Management of late-onset fetal growth restriction: pragmatic approach

OBJECTIVES

There is limited prospective evidence to guide the management of late-onset fetal growth restriction (FGR) and its differentiation from small-for-gestational age. The aim of this study was to assess prospectively a novel protocol in which ultrasound criteria were used to classify women with suspected late FGR into two groups: those at low risk, who were managed expectantly until the anticipated date of delivery, and those at high risk, who were delivered soon after 37 weeks of gestation. We also compared the outcome of this prospective cohort with that of a historical cohort of women presenting similarly with suspected late FGR, in order to evaluate the impact of the new protocol.

METHODS

This was a prospective study of women with a non-anomalous singleton pregnancy at ≥ 32 weeks' gestation attending a tertiary hospital in London, UK, between February 2018 and September 2019, with estimated fetal weight (EFW) ≤ 10th centile, or EFW > 10th centile in addition to a decrease in fetal abdominal circumference of ≥ 50 centiles compared with a previous scan, umbilical artery Doppler pulsatility index > 95th centile or cerebroplacental ratio < 5th centile. Women were classified as low or high risk based on ultrasound and Doppler criteria. Women in the low-risk group were delivered by 41 weeks of gestation, unless they subsequently met high-risk criteria, whereas women in the high-risk group (EFW < 3rd centile, umbilical artery Doppler pulsatility index > 95th centile or EFW between 3rd and 10th centiles (inclusive) with abdominal circumference drop or abnormal Dopplers) were delivered at or soon after 37 weeks. The primary outcome was adverse neonatal outcome and included hypothermia, hypoglycemia, neonatal unit admission, jaundice requiring treatment, suspected infection, feeding difficulties, 1-min Apgar score < 7, hospital readmission and any severe adverse neonatal outcome (perinatal death, resuscitation using inotropes or mechanical ventilation, 5-min Apgar score < 7, metabolic acidosis, sepsis, and cerebral, cardiac or respiratory morbidity). Secondary outcomes were adverse maternal outcome (operative delivery for abnormal fetal heart rate) and severe adverse neonatal outcome. Women managed according to the new protocol were compared with a historical cohort of 323 women delivered prior to the implementation of the new protocol, for whom management was guided by individual clinician expertise.

RESULTS

Over 18 months, 321 women were recruited to the prospective cohort, of whom 156 were classified as low risk and 165 were high risk. Adverse neonatal outcome was significantly less common in the low-risk compared with the high-risk group (45% vs 58%; adjusted odds ratio (aOR), 0.6 (95% CI, 0.4-0.9); P = 0.022). There was no significant difference in the rate of adverse maternal outcome (18% vs 24%; aOR, 0.7 (95% CI, 0.4-1.2); P = 0.142) or severe adverse neonatal outcome (3.8% vs 8.5%; aOR, 0.5 (95% CI, 0.2-1.3); P = 0.153) between the low- and high-risk groups. Compared with women in the historical cohort classified retrospectively as low risk, low-risk women managed under the new protocol had a lower rate of adverse neonatal outcome (45% vs 58%; aOR, 0.6 (95% CI, 0.4-0.9); P = 0.026).

CONCLUSIONS

Appropriate risk stratification to guide management of late FGR was associated with a reduced rate of adverse neonatal outcome in low-risk pregnancies. In clinical practice, a policy of expectantly managing women with a low-risk late-onset FGR pregnancy at term could improve neonatal and long-term development. Randomized controlled trials are needed to assess the effect of an evidence-based conservative management protocol for late FGR on perinatal morbidity and mortality and long-term neurodevelopment. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Disentangling age-dependent DNA methylation: deterministic, stochastic, and nonlinear

DNA methylation variability arises due to concurrent genetic and environmental influences. Each of them is a mixture of regular and noisy sources, whose relative contribution has not been satisfactorily understood yet. We conduct a systematic assessment of the age-dependent methylation by the signal-to-noise ratio and identify a wealth of "deterministic" CpG probes (about 90%), whose methylation variability likely originates due to genetic and general environmental factors. The remaining 10% of "stochastic" CpG probes are arguably governed by the biological noise or incidental environmental factors. Investigating the mathematical functional relationship between methylation levels and variability, we find that in about 90% of the age-associated differentially methylated positions, the variability changes as the square of the methylation level, whereas in the most of the remaining cases the dependence is linear. Furthermore, we demonstrate that the methylation level itself in more than 15% cases varies nonlinearly with age (according to the power law), in contrast to the previously assumed linear changes. Our findings present ample evidence of the ubiquity of strong DNA methylation regulation, resulting in the individual age-dependent and nonlinear methylation trajectories, whose divergence explains the cross-sectional variability. It may also serve a basis for constructing novel nonlinear epigenetic clocks.

Sonographers' self-reported visualization of normal postmenopausal ovaries on transvaginal ultrasound is not reliable: results of expert review of archived images from UKCTOCS

OBJECTIVE

In the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), self-reported visualization rate (VR) of the ovaries by the sonographer on annual transvaginal sonographic (TVS) examinations was a key quality control (QC) metric. The objective of this study was to assess self-reported VR using expert review of a random sample of archived images of TVS examinations from UKCTOCS, and then to develop software for measuring VR automatically.

METHODS

A single expert reviewed images archived from 1000 TVS examinations selected randomly from 68 931 TVS scans performed in UKCTOCS between 2008 and 2011 with ovaries reported as 'seen and normal'. Software was developed to identify the exact images used by the sonographer to measure the ovaries. This was achieved by measuring caliper dimensions in the image and matching them to those recorded by the sonographer. A logistic regression classifier to determine visualization was trained and validated using ovarian dimensions and visualization data reported by the expert.

RESULTS

The expert reviewer confirmed visualization of both ovaries (VR-Both) in 50.2% (502/1000) of the examinations. The software identified the measurement image in 534 exams, which were split 2:1:1 providing training, validation and test data. Classifier mean accuracy on validation data was 70.9% (95% CI, 70.0-71.8%). Analysis of test data (133 exams) provided a sensitivity of 90.5% (95% CI, 80.9-95.8%) and specificity of 47.5% (95% CI, 34.5-60.8%) in detecting expert confirmed visualization of both ovaries.

CONCLUSIONS

Our results suggest that, in a significant proportion of TVS annual screens, the sonographers may have mistaken other structures for normal ovaries. It is uncertain whether or not this affected the sensitivity and stage at detection of ovarian cancer in the ultrasound arm of UKCTOCS, but we conclude that QC metrics based on self-reported visualization of normal ovaries are unreliable. The classifier shows some potential for addressing this problem, though further research is needed. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Early detection of cancer in the general population: a blinded case-control study of p53 autoantibodies in colorectal cancer

Background:

Recent reports from cancer screening trials in high-risk populations suggest that autoantibodies can be detected before clinical diagnosis. However, there is minimal data on the role of autoantibody signatures in cancer screening in the general population.

Methods:

Informative p53 peptides were identified in sera from patients with colorectal cancer using an autoantibody microarray with 15-mer overlapping peptides covering the complete p53 sequence. The selected peptides were evaluated in a blinded case–control study using stored serum from the multimodal arm of the United Kingdom Collaborative Trial of Ovarian Cancer Screening where women gave annual blood samples. Cases were postmenopausal women who developed colorectal cancer following recruitment, with 2 or more serum samples preceding diagnosis. Controls were age-matched women with no history of cancer.

Results:

The 50 640 women randomised to the multimodal group were followed up for a median of 6.8 (inter-quartile range 5.9–8.4) years. Colorectal cancer notification was received in 101 women with serial samples of whom 97 (297 samples) had given consent for secondary studies. They were matched 1 : 1 with 97 controls (296 serial samples). The four most informative peptides identified 25.8% of colorectal cancer patients with a specificity of 95%. The median lead time was 1.4 (range 0.12–3.8) years before clinical diagnosis.

Conclusion:

Our findings suggest that in the general population, autoantibody signatures are detectable during preclinical disease and may be of value in cancer screening. In colorectal cancer screening in particular, where the current need is to improve compliance, it suggests that p53 autoantibodies may contribute towards risk stratification.

Systems biology and longevity: an emerging approach to identify innovative anti-aging targets and strategies

Human aging and longevity are complex and multi-factorial traits that result from a combination of environmental, genetic, epigenetic and stochastic factors, each contributing to the overall phenotype. The multi-factorial process of aging acts at different levels of complexity, from molecule to cell, from organ to organ systems and finally to organism, giving rise to the dynamic "aging mosaic". At present, an increasing amount of experimental data on genetics, genomics, proteomics and other -omics are available thanks to new high-throughput technologies but a comprehensive model for the study of human aging and longevity is still lacking. Systems biology represents a strategy to integrate and quantify the existing knowledge from different sources into predictive models, to be later tested and then implemented with new experimental data for validation and refinement in a recursive process. The ultimate goal is to compact the new acquired knowledge into a single picture, ideally able to characterize the phenotype at systemic/organism level. In this review we will briefly discuss the aging phenotype in a systems biology perspective, showing four specific examples at different levels of complexity, from a systemic process (inflammation) to a cascade-process pathways (coagulation) and from cellular organelle (proteasome) to single gene-network (PON-1), which could also represent targets for anti-aging strategies.

Stochastic suppression of gene expression oscillators under intercell coupling

This paper examines the dynamics of an ensemble of hysteresis-based genetic relaxation oscillators, focusing on the influence of noise and cell-to-cell coupling on the appearance of new dynamical regimes. In particular, we show that control of the coupling strength and noise can effectively change the dynamics of the system leading to behaviors such as clustering, synchronous and asynchronous oscillations, and suppression. Moreover, under certain conditions an optimal amount of noise can lead to increased order in the system. The results obtained are correlated with relevant biological processes that occur in living organisms.

Inherent multistability in arrays of autoinducer coupled genetic oscillators

Rhythm generation mechanisms are very important for genetic network functions as well as for the design of synthetic genetic circuits. A significant attention to date has been focused on the synchronization of communicating genetic units, which results in the production of an unified rhythm. In contrast to this we address the question: what mechanisms of intercell communication can be responsible for multirhythmicity in globally coupled genetic units? Here, we show that an autoinducer intercell communication system that provides coupling between synthetic genetic oscillators will inherently lead to multirhythmicity and the appearance of several coexisting dynamical regimes, if the time evolution of the genetic network can be split in two well-separated time scales. We investigate in detail a variety of dynamical regimes in a genetic population and show the possibility for multiple element distributions between clusters, as well as the possibility of generating complex oscillations with different return times in one limit cycle.

Noise-induced excitability in oscillatory media

A noise-induced phase transition to excitability is reported in oscillatory media with FitzHugh-Nagumo dynamics. This transition takes place via a noise-induced stabilization of a deterministically unstable fixed point of the local dynamics, while the overall phase-space structure of the system is maintained. Spatial coupling is required to prevent oscillations through suppression of fluctuations (via clustering in the case of local coupling). Thus, the joint action of coupling and noise leads to a different type of phase transition and results in a stabilization of the system. The resulting regime is shown to display characteristic traits of excitable media, such as stochastic resonance and wave propagation. This effect thus allows the transmission of signals through an otherwise globally oscillating medium.

Experimental evidence, numerics, and theory of vibrational resonance in bistable systems

We consider an overdamped bistable oscillator subject to the action of a biharmonic force with very different frequencies, and study the response of the system when the parameters of the high-frequency force are varied. A resonantlike behavior is obtained when the amplitude or the frequency of this force is modified in an experiment performed by means of an analog circuit. This behavior, confirmed by numerical simulations, is explained on the basis of a theoretical approach.

Doubly stochastic coherence via noise-induced symmetry in bistable neural models

The generation of coherent dynamics due to noise in an activator-inhibitor system describing bistable neural dynamics is investigated. We show that coherence can be induced in deterministically asymmetric regimes via symmetry restoration by multiplicative noise, together with the action of additive noise which induces jumps between the two stable steady states. The phenomenon is thus doubly stochastic, because both noise sources are necessary. This effect can be understood analytically in the frame of a small-noise expansion and is confirmed experimentally in a nonlinear electronic circuit. Finally, we show that spatial coupling enhances this coherent behavior in a form of system-size coherence resonance.

Bone modeling and structural measures of complexity

We test sensitivity and powerfulness of recently suggested Structure Measures of Complexity (SMC) with simulated test objects, represented by simple structures or modelled on the basis of a real bone image. We check how these SMC reflect the local and global disordering processes, as well as a deterioration of the bone structure. We show that applications of SMC provide additional information about any changes of the bone structure in comparison to bone mineral density (BMD), and that they can be potentially helpful in the diagnosis of osteoporosis.

System size resonance in coupled noisy systems and in the Ising model

We consider an ensemble of coupled nonlinear noisy oscillators demonstrating in the thermodynamic limit an Ising-type transition. In the ordered phase and for finite ensembles stochastic flips of the mean field are observed with the rate depending on the ensemble size. When a small periodic force acts on the ensemble, the linear response of the system has a maximum at a certain system size, similar to the stochastic resonance phenomenon. We demonstrate this effect of system size resonance for different types of noisy oscillators and for different ensembles---lattices with nearest neighbors coupling and globally coupled populations. The Ising model is also shown to demonstrate the system size resonance.

Additive noise in noise-induced nonequilibrium transitions

We study different nonlinear systems which possess noise-induced nonequlibrium transitions and shed light on the role of additive noise in these effects. We find that the influence of additive noise can be very nontrivial: it can induce first- and second-order phase transitions, can change properties of on-off intermittency, or stabilize oscillations. For the Swift-Hohenberg coupling, that is a paradigm in the study of pattern formation, we show that additive noise can cause the formation of ordered spatial patterns in distributed systems. We show also the effect of doubly stochastic resonance, which differs from stochastic resonance, because the influence of noise is twofold: multiplicative noise and coupling induce a bistability of a system, and additive noise changes a response of this noise-induced structure to the periodic driving. Despite the close similarity, we point out several important distinctions between conventional stochastic resonance and doubly stochastic resonance. Finally, we discuss open questions and possible experimental implementations. (c) 2001 American Institute of Physics.

An active-medium model of organic substance transformation in soil and its dynamic properties

An analysis of the behaviour of the soil system considered as an active medium with distributed energy sources was undertaken. This approach enabled the authors to build a heuristic model of soil which accounts for processes of organic substance production, migration and utilisation. The soil body is presented as a spatially distributed trophic chain with non-linear interactions of adjacent links. The level of this non-linearity appears to be the key parameter determining the dynamic behaviour of the model system in one-, two- and three-dimensional cases. The conditions for the existence of pulse-generating and autowave modes in this system were determined by computer simulations. Of particular interest is the behaviour of damaged soil, especially its self-regeneration potential. Inoculation autowave was proven to restore the initial state of the soil if two adjacent or separated trophic links fall out. Possible ways of the further development of the proposed model are also discussed.