Endometrial injury in women undergoing in vitro fertilisation (IVF)

BACKGROUND

Implantation of an embryo within the endometrial cavity is a critical step in the process of in vitro fertilisation (IVF). Previous research has suggested that endometrial injury (also known as endometrial scratching), defined as intentional damage to the endometrium, can increase the chance of pregnancy in women undergoing IVF.

OBJECTIVES

To assess the effectiveness and safety of endometrial injury performed before embryo transfer in women undergoing in vitro fertilisation (IVF) including intracytoplasmic sperm injection (ICSI) and frozen embryo transfer.

SEARCH METHODS

In June 2020 we searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, LILACS, DARE and two trial registries. We also checked the reference sections of relevant studies and contacted experts in the field for any additional trials.

SELECTION CRITERIA

Randomised controlled trials comparing intentional endometrial injury before embryo transfer in women undergoing IVF, versus no intervention or a sham procedure.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Two independent review authors screened studies, evaluated risk of bias and assessed the certainty of the evidence by using GRADE (Grading of Recommendation, Assessment, Development and Evaluation) criteria. We contacted and corresponded with study investigators as required. Due to the high risk of bias associated with many of the studies, the primary analyses of all review outcomes were restricted to studies at a low risk of bias for selection bias and other bias. Sensitivity analysis was then performed including all studies. The primary review outcomes were live birth and miscarriage.

MAIN RESULTS

Endometrial injury versus control (no procedure or a sham procedure) A total of 37 studies (8786 women) were included in this comparison. Most studies performed endometrial injury by pipelle biopsy in the luteal phase of the cycle before the IVF cycle. The primary analysis was restricted to studies at low risk of bias, and included eight studies. The effect of endometrial injury on live birth is unclear as the result is consistent with no effect, or a small reduction, or an improvement (odds ratio (OR) 1.12, 95% confidence interval (CI) 0.98 to 1.28; participants = 4402; studies = 8; I² = 15%, moderate-certainty evidence). This suggests that if the chance of live birth with IVF is usually 27%, then the chance when using endometrial injury would be somewhere between < 27% and 32%. Similarly, the effect of endometrial injury on clinical pregnancy is unclear (OR 1.08, 95% CI 0.95 to 1.23; participants = 4402; studies = 8; I² = 0%, moderate-certainty evidence). This suggests that if the chance of clinical pregnancy from IVF is normally 32%, then the chance when using endometrial injury before IVF is between 31% and 37%. When all studies were included in the sensitivity analysis, we were unable to conduct meta-analysis for the outcomes of live birth and clinical pregnancy due to high risk of bias and statistical heterogeneity. Endometrial injury probably results in little to no difference in chance of miscarriage (OR 0.88, 95% CI 0.68 to 1.13; participants = 4402; studies = 8; I² = 0%, moderate-certainty evidence), and this result was similar in the sensitivity analysis that included all studies. The result suggests that if the chance of miscarriage with IVF is usually 6.0%, then when using endometrial injury it would be somewhere between 4.2% and 6.8%. Endometrial injury was associated with mild to moderate pain (approximately 4 out of 10), and was generally associated with some minimal bleeding. The evidence was downgraded for imprecision due to wide confidence intervals and therefore all primary analyses were graded as moderate certainty. Higher versus lower degree of injury Only one small study was included in this comparison (participants = 129), which compared endometrial injury using two different instruments in the cycle prior to the IVF cycle: a pipelle catheter and a Shepard catheter. This trial was excluded from the primary analysis due to risk of bias. In the sensitivity analysis, all outcomes reported for this study were graded as very-low certainty due to risk of bias, and as such we were not able to interpret the study results.

AUTHORS' CONCLUSIONS

The effect of endometrial injury on live birth and clinical pregnancy among women undergoing IVF is unclear. The results of the meta-analyses are consistent with an increased chance, no effect and a small reduction in these outcomes. We are therefore uncertain whether endometrial injury improves the chance of live birth or clinical pregnancy in women undergoing IVF. Endometrial injury does not appear to affect the chance of miscarriage. It is a somewhat painful procedure associated with a small amount of bleeding. In conclusion, current evidence does not support the routine use of endometrial injury for women undergoing IVF.

Adolescent Bariatric Surgery: Racial Disparities in 30-Day Outcomes Using the MBSAQIP from 2015 to 2018

INTRODUCTION

Racial disparities exist in obesity prevalence and obesity-related comorbid conditions among youth. We hypothesized that non-White adolescents would have poorer 30-day outcomes after adolescent bariatric surgery.

METHODS

Adolescent patients 19 years or younger who had bariatric surgery from January 2015 to December 2018 were identified in the Metabolic and Bariatric Surgery Accreditation and Quality Initiative Program datafiles. Patient characteristics and 30-day perioperative outcomes were compared across racial groups. Trends in utilization of adolescent bariatric surgery were evaluated by race and procedure.

RESULTS

Bariatric surgery was performed in 3177 adolescents with a mean age of 17.9 years [standard deviation (SD) 1.1 years]. The majority of patients were White 71.5% (2,271), while only 16.4% (520) were Black, and 12.1% (386) were other. Black adolescents 42.7% (222) more commonly presented with a BMI >50kg/m² compared to 28.4% (645) White and 27.2% (105) other. Baseline hypertension and sleep apnea were more common among Black adolescents than other racial groups (P< 0.05). Black adolescents with LRYGB comprised 4.6% (48) of procedures in 2015 and only 1.5% (11) in 2018. Clavien-Dindo complications and all-cause readmission rates were similar among racial groups. Mean BMI decrease after 30 days was greatest for Black patients after Roux-en-Y gastric bypass, with a loss of 3.1 BMI points (SD 1.5).

CONCLUSIONS

Despite similar short-term outcomes, significant disparities exist for Black adolescents who qualify for bariatric surgery. Further investigation is warranted to better understand the racial differences that limit access and utilization of this safe and effective intervention.

Does prevention-focused dental care provision during recruit training reduce adverse dental outcomes in UK Armed Forces personnel? A retrospective cohort analysis

Background Dental emergencies experienced during military operations may render individuals unable to operate effectively. To minimise this risk, UK Armed Forces (UKAF) recruits receive a prevention-focused dental care intervention during military training (known as 'Project MOLAR') before their entry to the trained strength of the Armed Forces.Aim To evaluate whether Project MOLAR is effective in preventing future dental emergency events and subsequent oral disease in UKAF recruits.Methods This is a retrospective cohort analysis of UKAF recruits who enlisted between 1 January 2011 and 31 December 2011, conducted by analysing electronic primary dental care records. Adverse outcomes were defined as: i) incidence of dental emergency events during the five-year follow-up period; and ii) further oral disease at 18 months measured by an increase in Decayed, Missing and Filled Teeth (DMFT).Results In total, 7,361 recruits met the inclusion criteria. The total follow-up time for the cohort was 31,957 person-years (mean follow-up 4.3 years/recruit). Individuals whose treatment was completed under Project MOLAR were found to experience a 30% reduction in dental emergency incidence (RR: 0.70-95% CI: 0.63-0.76) (p <0.001) and a 64% reduction in the odds of DMFT increase at 18 months (OR: 0.36-95% CI: 0.28-0.47) (p <0.001) compared to individuals whose treatment was incomplete.Conclusions Defence dentistry's focus on delivering prevention-focused dentistry early in a recruit's military career confers a downstream benefit to personnel who complete the intervention, such that dental emergency occurrences and DMFT progression are significantly reduced.

Impact of lifestyle Intervention on branched-chain amino acid catabolism and insulin sensitivity in adolescents with obesity

Insulin resistance in adolescents with obesity associates with a sex‐dependent metabolic ‘signature’ comprising branched‐chain amino acids (BCAAs), glutamate and C3/C5 acylcarnitines (C3/C5), implicating altered flux through BCAA catabolic pathways. Here, we investigated the effects of lifestyle intervention on BCAA catabolism and insulin sensitivity. We hypothesized (1) weight reduction and improved insulin sensitivity associate with enhanced BCAA catabolism; (2) baseline BCAAs and their metabolic by‐products predict changes in weight and insulin sensitivity during lifestyle intervention.

COVID-19 Response Strategies at Large Institutes of Higher Education in the United States: A Landscape Analysis, Fall 2020

PURPOSE

To examine the pandemic response plans of institutes of higher education (i.e., colleges and universities), including COVID-19 prevention, enforcement, and testing strategies.

METHOD

Data from the largest public (n = 50) and private (n = 50) US institutes of higher education were collected from October 30 to November 20, 2020.

RESULTS

Most institutes of higher education (n = 93) offered some in-person teaching in the Fall 2020 semester; most adopted masking (100%) and physical distancing (99%) mandates. Other preventive strategies included on-campus housing de-densification (58%), classroom de-densification (61%), mandated COVID-19-related training (39%), and behavioral compacts (43%). Testing strategies included entry testing (65%), testing at regular intervals (32%), population sample testing (46%), and exit testing (15%). More private than public institutes implemented intercollegiate athletics bans, behavioral compacts, and suspension clauses for noncompliance.

CONCLUSIONS

Variability in COVID-19 prevention and testing strategies highlights the need for national recommendations and the equitable distribution of sufficient pandemic response resources to institutes of higher education.

Novel Fecal Biomarkers That Precede Clinical Diagnosis of Ulcerative Colitis

BACKGROUND & AIMS

Altered gut microbiota composition and function have been associated with inflammatory bowel diseases, including ulcerative colitis (UC), but the causality and mechanisms remain unknown.

METHODS

We applied 16S ribosomal RNA gene sequencing, shotgun metagenomic sequencing, in vitro functional assays, and gnotobiotic colonizations to define the microbial composition and function in fecal samples obtained from a cohort of healthy individuals at risk for inflammatory bowel diseases (pre-UC) who later developed UC (post-UC) and matched healthy control individuals (HCs).

RESULTS

Microbiota composition of post-UC samples was different from HC and pre-UC samples; however, functional analysis showed increased fecal proteolytic and elastase activity before UC onset. Metagenomics identified more than 22,000 gene families that were significantly different between HC, pre-UC, and post-UC samples. Of these, 237 related to proteases and peptidases, suggesting a bacterial component to the pre-UC proteolytic signature. Elastase activity inversely correlated with the relative abundance of Adlercreutzia and other potentially beneficial taxa and directly correlated with known proteolytic taxa, such as Bacteroides vulgatus. High elastase activity was confirmed in Bacteroides isolates from fecal samples. The bacterial contribution and functional significance of the proteolytic signature were investigated in germ-free adult mice and in dams colonized with HC, pre-UC, or post-UC microbiota. Mice colonized with or born from pre-UC-colonized dams developed higher fecal proteolytic activity and an inflammatory immune tone compared with HC-colonized mice.

CONCLUSIONS

We have identified increased fecal proteolytic activity that precedes the clinical diagnosis of UC and associates with gut microbiota changes. This proteolytic signature may constitute a noninvasive biomarker of inflammation to monitor at-risk populations that can be targeted therapeutically with antiproteases.

Defence dentistry: an occupationally focused health service with worldwide deployable capability

Oral disease can cause substantial disruption to service personnel, resulting in debilitation and reduced effectiveness while deployed on military operations. As such, Defence dentistry delivers an occupationally focused dental service that is deployable, agile and holistic, to ensure service personnel are dentally fit for operations and that the impact of dental morbidity is minimised.Defence dentists provide a unique service, balancing the needs of the individual while considering their operational role requirements. This enables the UK Armed Forces' oral health to be optimised by mitigating morbidity and maintaining operational capability while deployed.The aim of this paper is to highlight the key principles of Defence dentistry by discussing the public health values and occupational focus which underpin a patient-centred approach and the agility of the uniformed military dental workforce in providing a responsive and deployable care capability.

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review

OBJECTIVE

To estimate the incidence of avoidable significant harm in primary care in England; describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents.

DESIGN

Retrospective case note review. Patients with significant health problems were identified and clinical judgements were made on avoidability and severity of harm. Factors contributing to avoidable harm were identified and recorded.

SETTING

Primary care.

PARTICIPANTS

Thirteen general practitioners (GPs) undertook a retrospective case note review of a sample of 14 407 primary care patients registered with 12 randomly selected general practices from three regions in England (total list size: 92 255 patients).

MAIN OUTCOME MEASURES

The incidence of significant harm considered at least 'probably avoidable' and the nature of the safety incidents.

RESULTS

The rate of significant harm considered at least probably avoidable was 35.6 (95% CI 23.3 to 48.0) per 100 000 patient-years (57.9, 95% CI 42.2 to 73.7, per 100 000 based on a sensitivity analysis). Overall, 74 cases of avoidable harm were detected, involving 72 patients. Three types of incident accounted for more than 90% of the problems: problems with diagnosis accounted for 45/74 (60.8%) primary incidents, followed by medication-related problems (n=19, 25.7%) and delayed referrals (n=8, 10.8%). In 59 (79.7%) cases, the significant harm could have been identified sooner (n=48) or prevented (n=11) if the GP had taken actions aligned with evidence-based guidelines.

CONCLUSION

There is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.

Evaporation and Electrowetting of Sessile Droplets on Slippery Liquid-Like Surfaces and Slippery Liquid-Infused Porous Surfaces (SLIPS)

Sessile droplet evaporation underpins a wide range of applications from inkjet printing to coating. However, drying times can be variable and contact-line pinning often leads to undesirable effects, such as ring stain formation. Here, we show voltage programmable control of contact angles during evaporation on two pinning-free surfaces. We use an electrowetting-on-dielectric approach and Slippery Liquid-Infused Porous (SLIP) and Slippery Omniphobic Covalently Attached Liquid-Like (SOCAL) surfaces to achieve a constant contact angle mode of evaporation. We report evaporation sequences and droplet lifetimes across a broad range of contact angles from 105°-67°. The values of the contact angles during evaporation are consistent with expectations from electrowetting and the Young-Lippman equation. The droplet contact areas reduce linearly in time, and this provides estimates of diffusion coefficients close to the expected literature value. We further find that the total time of evaporation over the broad contact angle range studied is only weakly dependent on the value of the contact angle. We conclude that on these types of slippery surfaces, droplet lifetimes can be predicted and controlled by the droplet's volume and physical properties (density, diffusion coefficient, and vapor concentration difference to the vapor phase) largely independent of the precise value of contact angle. These results are relevant to applications, such as printing, spraying, coating, and other processes, where controlling droplet evaporation and drying is important.

IL-1α Modulates IFN-γ-Induced Production of CXCL9/MIG during Herpes Simplex Virus Type-1 Corneal Infection

PURPOSE

Investigating the modulation of neutrophil production of MIG and IP-10 during the inflammatory response to HSV-1 infection.

MATERIALS AND METHODS

An ex vivo model of human corneal infection by HSV-1 was used for this study. This model permits the study of cytokine production by human corneal buttons in the presence, or absence, of gradient purified human neutrophils, under conditions of HSV-1 infection. All experimental samples were stimulated with a baseline concentration of recombinant human IFN-γ at 1 ng/mL. The relative levels of production for 12 pro-inflammatory mediators were screened using a multi-analyte ELISA assay. Neutrophil production of chemokines MIG and IP-10, under conditions of IFN-γ and/or HSV-1 stimulation were measured by quantitative ELISA. Lastly, antibody neutralization (goat IgG anti-human IL-1α, 2 µg/mL) of de novo production of IL-1α by corneal tissue was performed to investigated the effect on MIG and IP-10 production in the ex vivo model for HSV-1 infection.

RESULTS

Four of the 12 pro-inflammatory mediators screened (IL-8, IL-6, IL-1α and IL-1β) demonstrated elevated levels of production during corneal cell infection with HSV-1 and communication with neutrophils. Neutrophils were demonstrated to produce significant levels of both MIG and IP-10 under conditions of IFN-γ stimulation, and production of MIG was further upregulated by co-stimulation with IFN-γ and HSV-1. Neutralization of de novo IL-1α production in the model resulted in increased production of the chemokine production MIG but had no observable effect on IP-10 production.

CONCLUSIONS

Our data provide evidence demonstrating the potential for expression patterns of MIG and IP-10 to be modulated by IL-1α, during the inflammatory response to HSV-1 corneal infection. Both corneal cells and neutrophils contribute to the production of T cell recruiting chemokines. However, IL-1α has the potential to upregulate MIG production by corneal cells while down-regulating MIG production by neutrophils.

Complex Clinical Decision-Making Process of Re-Irradiation

As patients live longer with their cancer as a result of more effective treatment, recurrences and second malignancies in a previously irradiated field are an increasing challenge. The technical advances that enable high-dose radiation to limited volumes, excluding critical normal tissues, have increased the use of re-irradiation for many tumour sites. Minimising the volume, selecting patients with good performance status, negative metastatic screening and longer disease-free intervals are important principles. Despite this there is a narrow therapeutic window, and careful consideration with open discussion, including the patient, of the probable benefit and the implications of potential toxicities will always be essential. In this overview we evaluate the various radiobiological factors that need to be considered for re-irradiation, tissue recovery and dose tolerances in the setting of re-irradiation and summarise the available literature to guide clinicians in their decision-making for re-irradiation to primary and metastatic site/s of disease.

Polypharmacy, benzodiazepines, and antidepressants, but not antipsychotics, are associated with increased falls risk in UK care home residents: a prospective multi-centre study

Aim

To explore the link between polypharmacy, psychotropic medications, and falls risk in a cohort of UK care home residents.

Findings

Polypharmacy and psychotropic drugs are predictive of falls in UK care home residents.

Message

Deprescribing interventions relating to psychotropic drugs should continue to be encouraged.

Purpose

Falls and polypharmacy are both common in care home residents. Deprescribing of medications in residents with increased falls risk is encouraged. Psychotropic medications are known to increase falls risk in older adults. These drugs are often used in care home residents for depression, anxiety, and behavioural and psychological symptoms of dementia. However, a few studies have explored the link between polypharmacy, psychotropic medications, and falls risk in care home residents.

Methods

This was a prospective cohort study of residents from 84 UK care homes. Data were collected from residents’ care records and medication administration records. Age, diagnoses, gender, number of medications, and number of psychotropic medications were collected at baseline and residents were monitored over three months for occurrence of falls. Logistic regression models were used to assess the effect of multiple medications and psychotropic medication on falls whilst adjusting for confounders.

Results

Of the 1655 participants, mean age 85 (SD 8.9) years, 67.9% female, 519 (31%) fell in 3 months. Both the total number of regular drugs prescribed and taking ≥ 1 regular psychotropic medication were independent risk factors for falling (adjusted odds ratio (OR) 1.06 (95% CI 1.03–1.09, p < 0.01) and 1.39 (95% CI 1.10–1.76, p < 0.01), respectively). The risk of falls was higher in those taking antidepressants (p < 0.01) and benzodiazepines (p < 0.01) but not antipsychotics (p > 0.05).

Conclusion

In UK care homes, number of medications and psychotropic medications (particularly antidepressants and benzodiazepines) predicted falls. This information can be used to inform prescribing and deprescribing decisions.

GM-CSF (granulocyte macrophage colony-stimulating factor) supplementation in culture media for women undergoing assisted reproduction

BACKGROUND

GM-CSF (granulocyte macrophage colony-stimulating factor) is a growth factor that is used to supplement culture media in an effort to improve clinical outcomes for those undergoing assisted reproduction. It is worth noting that the use of GM-CSF-supplemented culture media often adds a further cost to the price of an in vitro fertilisation (IVF) cycle. The purpose of this review was to assess the available evidence from randomised controlled trials (RCTs) on the effectiveness and safety of GM-CSF-supplemented culture media.

OBJECTIVES

To assess the effectiveness and safety of GM-CSF-supplemented human embryo culture media versus culture media not supplemented with GM-CSF, in women or couples undergoing assisted reproduction.

SEARCH METHODS

We used standard methodology recommended by Cochrane. We searched the Cochrane Gynaecology and Fertility Group Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, LILACS, DARE, OpenGrey, PubMed, Google Scholar, and two trials registers on 15 October 2019, checked references of relevant papers and communicated with experts in the field.

SELECTION CRITERIA

We included RCTs comparing GM-CSF (including G-CSF (granulocyte colony-stimulating factor))-supplemented embryo culture media versus any other non-GM-CSF-supplemented embryo culture media (control) in women undergoing assisted reproduction.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary review outcomes were live birth and miscarriage rate. The secondary outcomes were clinical pregnancy, multiple gestation, preterm birth, birth defects, aneuploidy, and stillbirth rates. We assessed the quality of the evidence using GRADE methodology. We undertook one comparison, GM-CSF-supplemented culture media versus culture media not supplemented with GM-CSF, for those undergoing assisted reproduction.

MAIN RESULTS

We included five studies, the data for three of which (1532 participants) were meta-analysed. We are uncertain whether GM-CSF-supplemented culture media makes any difference to the live-birth rate when compared to using conventional culture media not supplemented with GM-CSF (odds ratio (OR) 1.19, 95% confidence interval (CI) 0.93 to 1.52, 2 RCTs, N = 1432, I² = 69%, low-quality evidence). The evidence suggests that if the rate of live birth associated with conventional culture media not supplemented with GM-CSF was 22%, the rate with the use of GM-CSF-supplemented culture media would be between 21% and 30%. We are uncertain whether GM-CSF-supplemented culture media makes any difference to the miscarriage rate when compared to using conventional culture media not supplemented with GM-CSF (OR 0.75, 95% CI 0.41 to 1.36, 2 RCTs, N = 1432, I² = 0%, low-quality evidence). This evidence suggests that if the miscarriage rate associated with conventional culture media not supplemented with GM-CSF was 4%, the rate with the use of GM-CSF-supplemented culture media would be between 2% and 5%. Furthermore, we are uncertain whether GM-CSF-supplemented culture media makes any difference to the following outcomes: clinical pregnancy (OR 1.16, 95% CI 0.93 to 1.45, 3 RCTs, N = 1532 women, I² = 67%, low-quality evidence); multiple gestation (OR 1.24, 95% CI 0.73 to 2.10, 2 RCTs, N = 1432, I² = 35%, very low-quality evidence); preterm birth (OR 1.20, 95% CI 0.70 to 2.04, 2 RCTs, N = 1432, I² = 76%, very low-quality evidence); birth defects (OR 1.33, 95% CI 0.59 to 3.01, I² = 0%, 2 RCTs, N = 1432, low-quality evidence); and aneuploidy (OR 0.34, 95% CI 0.03 to 3.26, I² = 0%, 2 RCTs, N = 1432, low-quality evidence). We were unable to undertake analysis of stillbirth, as there were no events in either arm of the two studies that assessed this outcome.

AUTHORS' CONCLUSIONS

Due to the very low to low quality of the evidence, we cannot be certain whether GM-CSF is any more or less effective than culture media not supplemented with GM-CSF for clinical outcomes that reflect effectiveness and safety. It is important that independent information on the available evidence is made accessible to those considering using GM-CSF-supplemented culture media. The claims from marketing information that GM-CSF has a positive effect on pregnancy rates are not supported by the available evidence presented here; further well-designed, properly powered RCTs are needed to lend certainty to the evidence.

Botulinum toxin in the management of temporomandibular disorders: a systematic review

The aim of this review was to critically investigate and assess the evidence relating to the use and efficacy of botulinum toxin (BTX) in the management of temporomandibular joint disorders (TMD) and masticatory myofascial pain. A comprehensive search was conducted of PubMed, Scopus, Embase, and Cochrane CENTRAL, to find relevant studies from the last 30 years up to the end of July 2018. Seven were identified. Three showed a significant reduction in pain between the BTX and placebo groups and one showed a clinical, but not a significant, difference. In one that compared BTX with another novel treatment, myofascial pain reduced equally in both groups, and in the remaining two there was no significant difference in pain reduction between the BTX and control groups. Of the four studies that assessed mouth opening, two reported that BTX had resulted in a slight improvement; one reported no improvement, and the other a worsening of the condition. A meta-analysis was not possible because of the considerable variation in the studies' designs, the heterogeneity between the groups, and the different assessment tools used. Despite showing benefits, consensus on the therapeutic benefit of BTX in the management of myofascial TMD is lacking. Further randomised controlled trials with larger sample sizes, minimal bias, and longer follow-up periods are now needed.

A35 MICROBIAL PROTEOLYTIC SIGNATURE IN ULCERATIVE COLITIS INDUCES AN INFLAMMATORY SIGNATURE IN MICROBIOTA-HUMANIZED MICE

Background

Altered gut microbiota composition has been associated with inflammatory bowel diseases (IBD) including ulcerative colitis (UC), but causality and bacterially-driven mechanisms, are unclear. Proteases within the gastrointestinal tract play a critical role in maintaining homeostasis and are tightly regulated by anti-proteases. Host-derived proteolytic imbalances have been described in IBD, including UC, however, the role of intestinal microbiota as a source of proteases and anti-proteases has largely been ignored.

Aims

To study microbial proteolytic activity and intestinal microbiota profiles in a cohort of individuals at-risk for IBD, and in those individuals that develop UC at follow-up.

Methods

Fecal samples were collected from healthy individuals at-risk for IBD and who went on to develop UC (pre-UC; n=14) and again after UC diagnosis (post-UC, n=10). Fecal samples from matched at-risk individuals that did not develop UC were used as healthy controls (n=52). Overall fecal proteolytic and elastolytic activity was measured. We performed metagenomics sequencing in 4 UC subjects (pre and post) and 4 matched HC using Illumina Hi-Seq from stool DNA. To investigate bacterial origin and functional significance, pregnant germ-free (GF) mice were colonized with a fecal sample from a selected UC subject (pre and post) and a matched HC. Naturally colonized litters were followed for 12 weeks, after which proteolytic activities and signs of inflammation were measured.

Results

Fecal proteolytic and elastase activity was increased in pre- and post-UC samples compared to HCs. Metagenomics revealed over 20k genes were significantly different between HC and pre-UC samples, and of these, 440 related to proteases and peptidases. Increased fecal proteolytic activity, higher lipocalin levels, and increased colonic polymorphonuclear cells in colonic H&E sections was observed in pre- and post-UC colonized mice compared to HC colonized mice. Mice colonized with pre-UC microbiota showed increased mRNA expression of genes linked to immunological disease, antimicrobial and inflammatory responses (ie. Tlr2, Tlr5, Nod2, and Il1b) as compared to HC colonized mice.

Conclusions

These results suggest increased fecal proteolytic activity is observed prior to the onset and clinical diagnosis of UC in patients at-risk for IBD, and upon transfer to mice born from colonized GF dams, low-grade inflammation develops. These pathways could be developed as novel non-invasive biomarkers to monitor at-risk populations. Submitted on behalf of the CCC-GEM Project consortium. Supported by CCC GIA to EF Verdu

Funding Agencies

CCC

Clinician Identification of Birth Asphyxia Using Intrapartum Cardiotocography Among Neonates With and Without Encephalopathy in New Zealand

IMPORTANCE

Despite improvements in antenatal care and increasing cesarean delivery rates, birth asphyxia leading to neonatal encephalopathy (NE) continues to contribute to neonatal death and long-term neurodevelopmental disability. Cardiotocography (CTG) has been used in labor for several decades to detect a stressed fetus so that delivery can be expedited and NE avoided.

OBJECTIVE

To investigate whether experienced clinicians can detect and respond to abnormal readings from CTGs during the penultimate hour before birth in infants with moderate to severe NE but no acute peripartum event.

DESIGN, SETTING, AND PARTICIPANTS

This case-control study included 10 practicing obstetricians and midwives at maternity hospitals in New Zealand. Participants, who were masked to the perinatal outcome, were asked to assess CTG tracings from 35 neonates with NE and evidence of birth hypoxia (ie, cases) and 105 neonates without NE or birth hypoxia (ie, controls), all of whom were born in 2010 to 2011. Data analysis was conducted from May to December 2017.

EXPOSURES

Brief clinical details and 1 hour of CTG tracings from the penultimate hour before birth were provided for each baby. Clinicians assessed the CTG tracings and recommended a plan.

MAIN OUTCOMES AND MEASURES

Intra-assessor and interassessor agreement on CTG findings and action plans as well as sensitivity (ie, detection of NE) and specificity (ie, ruling out those without NE) for the assessment of abnormal CTG readings leading to immediate action (ie, fetal blood sample or immediate delivery) were reported.

RESULTS

A total of 35 infants (mean [SD] gestational age, 40 [1.4] weeks; 16 [45.7%] cesarean deliveries) were designated cases, and 105 infants (mean [SD] gestational age, 39.4 [1.2] weeks; 22 [21.0%] cesarean deliveries) were designated controls. No infants had congenital anomalies. The mean (range) sensitivity for detection of abnormal CTG results and for recommending immediate action for all assessors was 75% (63%-91%) and 41% (23%-57%), respectively, with a mean (range) specificity of 67% (53%-77%) and 87% (65%-99%), respectively. A sensitivity analysis including only assessors with 80% or more interassessor agreement only differed from the main analysis by 6% or less (mean [range] sensitivity for detection, 76% [63%-91%]; sensitivity for action plan, 36% [25%-49%]; specificity for detection, 71% [53%-77%]; and specificity for action plan, 93% [88%-99%]).

CONCLUSIONS AND RELEVANCE

Experienced clinicians detected 3 of 4 infants who were subsequently diagnosed with NE. Action to expedite delivery was recommended for more than 40% of infants with NE. These results indicate that CTG does not identify all infants at risk of NE, and that there is a need for further investment in new approaches to fetal surveillance in labor.

Weight-related quality of life and temperament as predictors and moderators of outcomes among treatment-seeking, low-income, ethnically diverse children with obesity

Within any childhood obesity treatment program, some children have better outcomes than others. Little is known about predictors or moderators of more positive outcomes. We aimed to identify whether child temperament and weight-related quality of life predict or moderate childhood obesity treatment outcomes at 6 months. From 2015 to 2016, children (n = 97) ages 5-11 years old with obesity were randomized to a clinic-community (Bull City Fit) or a clinic-only treatment program. Linear regression was used to explore whether dimensions of child temperament and weight-related quality of life predicted or moderated 6-month anthropometric and physical activity outcomes. Children who had more social avoidance due to their weight at baseline had significantly better improvements in body fat percent in the clinic-community model compared with the clinic-only model at 6 months. Across programs, better baseline social quality of life predicted greater increases in waist circumference; conversely, better physical quality of life predicted a decrease in percent of the 95th percentile. Also, children with longer attention spans had greater increases in physical activity. Our findings suggest that children who have social avoidance due to their weight may benefit most from comprehensive clinic-community treatment. Weight-related quality of life may influence outcomes across all treatments, and practitioners need to carefully counsel children experiencing weight negatively.

Body Mass Index Change Between Referral to and Enrollment in Pediatric Weight Management

This study describes changes in body mass index z score (BMIz) and percent of 95th percentile (P95) between referral to pediatric weight management (PWM) and initial PWM visit. We conducted a prospective cohort analysis among subjects (n = 77) aged 5 to 11 years referred to PWM and compared height and weight at time of referral versus initial PWM visit. Mean BMIz decreased by 0.05, and P95 decreased by 1.48 across all age groups (both P < .01) from time of referral to initial visit. Children 5 to 8 years old experienced a greater BMIz change than older children (-0.07 vs -0.02; P < .05). Interval BMIz change was greater for non-Hispanic White and Hispanic children compared with non-Hispanic Blacks (-0.10 vs -0.01; P < .001). There were no subgroup differences in P95. Interval BMI changes between referral and treatment approach half the effect reported by some PWM programs. Referral to PWM may motivate pretreatment lifestyle changes in some patients.