Barriers to implementing good nutrition in pregnancy and early childhood: Creating equitable national solutions

Exposure to deleterious stressors in early life, such as poor nutrition, underlies most adult-onset chronic diseases. As rates of chronic disease continue to climb in the United States, a focus on good nutrition before and during pregnancy, lactation, and early childhood provides a potential opportunity to reverse this trend. This report provides an overview of nutrition investigations in pregnancy and early childhood and addresses racial disparities and health outcomes, current national guidelines, and barriers to achieving adequate nutrition in pregnant individuals and children. Current national policies and community interventions to improve nutrition, as well as the current state of nutrition education among healthcare professionals and students, are discussed. Major gaps in knowledge and implementation of nutrition practices during pregnancy and early childhood were identified and action goals were constructed. The action goals are intended to guide the development and implementation of critical nutritional strategies that bridge these gaps. Such goals create a national blueprint for improving the health of mothers and children by promoting long-term developmental outcomes that improve the overall health of the US population.

Performance Characteristics of Sepsis Screening Tools During Antepartum and Postpartum Admissions

OBJECTIVE

To evaluate the performance characteristics of existing screening tools for the prediction of sepsis during antepartum and postpartum readmissions.

METHODS

This was a case-control study using electronic health record data obtained between 2016 and 2021 from 67 hospitals for antepartum sepsis admissions and 71 hospitals for postpartum readmissions up to 42 days. Patients in the sepsis case group were matched in a 1:4 ratio to a comparison cohort of patients without sepsis admitted antepartum or postpartum. The following screening criteria were evaluated: the CMQCC (California Maternal Quality Care Collaborative) initial sepsis screen, the non-pregnancy-adjusted SIRS (Systemic Inflammatory Response Syndrome), the MEWC (Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System) obstetric SIRS, and the MEWT (Maternal Early Warning Trigger Tool). Time periods were divided into early pregnancy (less than 20 weeks of gestation), more than 20 weeks of gestation, early postpartum (less than 3 days postpartum), and late postpartum through 42 days. False-positive screening rates, C-statistics, sensitivity, and specificity were reported for each overall screening tool and each individual criterion.

RESULTS

We identified 525 patients with sepsis during an antepartum hospitalization and 728 patients with sepsis during a postpartum readmission. For early pregnancy and more than 3 days postpartum, non-pregnancy-adjusted SIRS had the highest C-statistics (0.78 and 0.83, respectively). For more than 20 weeks of gestation and less than 3 days postpartum, the pregnancy-adjusted sepsis screening tools (CMQCC and UKOSS) had the highest C-statistics (0.87-0.94). The MEWC maintained the highest sensitivity rates during all time periods (81.9-94.4%) but also had the highest false-positive rates (30.4-63.9%). The pregnancy-adjusted sepsis screening tools (CMQCC, UKOSS) had the lowest false-positive rates in all time periods (3.9-10.1%). All tools had the lowest C-statistics in the periods of less than 20 weeks of gestation and more than 3 days postpartum.

CONCLUSION

For admissions early in pregnancy and more than 3 days postpartum, non-pregnancy-adjusted sepsis screening tools performed better than pregnancy-adjusted tools. From 20 weeks of gestation through up to 3 days postpartum, using a pregnancy-adjusted sepsis screening tool increased sensitivity and minimized false-positive rates. The overall false-positive rate remained high.

Performance Characteristics of Sepsis Screening Tools During Delivery Admissions

OBJECTIVE

To evaluate the screening performance characteristics of existing tools for the diagnosis of sepsis during delivery admissions.

METHODS

This was a case-control study using electronic health record data, including vital signs and laboratory results, for all delivery admissions of patients with sepsis from 59 nationally distributed hospitals. Patients with sepsis were matched by gestational age at delivery in a 1:4 ratio with patients without sepsis to create a comparison group. Patients with chorioamnionitis and sepsis were compared with a complete cohort of patients with chorioamnionitis without sepsis. Multiple screening criteria for sepsis were evaluated: the CMQCC (California Maternal Quality Care Collaborative), SIRS (Systemic Inflammatory Response Syndrome), the MEWC (the Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System), and the MEWT (Maternal Early Warning Trigger Tool). Sensitivity, false-positive rates, and C-statistics were reported for each screening tool. Analyses were stratified into cohort 1, which excluded patients with chorioamnionitis-endometritis, and cohort 2, which included those patients.

RESULTS

Delivery admissions at 59 hospitals were extracted for patients with sepsis. Cohort 1 comprised 647 patients with sepsis, including 228 with end-organ injury, matched with a control group of 2,588 patients without sepsis. Cohort 2 comprised 14,591 patients with chorioamnionitis-endometritis, of whom 1,049 had sepsis and 238 had end-organ injury. In cohort 1, the CMQCC and the UKOSS pregnancy-adjusted criteria had the lowest false-positive rates (6.9% and 9.6%, respectively) and the highest C-statistics (0.92 and 0.91, respectively). Although other screening criteria, such as SIRS and the MEWC, had similar sensitivities, it was at the cost of much higher false-positive rates (21.3% and 38.3%, respectively). In cohort 2, including all patients with chorioamnionitis-endometritis, the highest C-statistics were again for the CMQCC (0.67) and UKOSS (0.64). All screening tools had high false-positive rates, but the false-positive rates for the CMQCC and UKOSS were substantially lower than those for SIRS and the MEWC.

CONCLUSION

During delivery admissions, the CMQCC and UKOSS pregnancy-adjusted screening criteria have the lowest false-positive results while maintaining greater than 90% sensitivity rates. Performance of all screening tools was degraded in the setting of chorioamnionitis-endometritis.

Delivery of a Fetus with a Non-Reassuring Status Is Associated with Significant Maternal Morbidity

OBJECTIVES

When a labor process is complicated by non-reassuring fetal status (NRFS), obstetricians focus on delivery to optimize neonatal status. We explored maternal morbidity in the setting of NRFS. Our hypothesis is that delivery of a live newborn with NRFS is associated with significant maternal morbidity. Design, Participants, Setting, and Methods: A large retrospective cohort study of 27,886 women who delivered between January 2013 and December 2016 in a single health system was studied. Inclusion criteria included (1) women over the age of 18 at the time of admission; (2) singleton pregnancy; (3) live birth; and (4) gestational age greater than or equal to 37 weeks at the time of admission. NRFS was defined as umbilical cord pH less than or equal to 7.00, fetal bradycardia, late decelerations, and/or umbilical artery base excess ≤-12. Univariate and multivariate logistic regression and propensity score analyses were performed, and propensity score adjusted odds ratios (AORPS) were derived. p values <0.05 were considered statistically significant. Primary outcomes are maternal blood transfusion, maternal readmission, maternal intensive care unit (ICU) admission, and cesarean delivery in relation to umbilical artery pH, fetal bradycardia, and late decelerations.

RESULTS

Umbilical artery pH less than or equal to 7 was associated with maternal blood transfusion (AORPS 6.83 [95% CI 2.22-21.0, p < 0.001]), maternal readmission (AORPS 12.6 [95% CI 2.26-69.8, p = 0.0039]), and cesarean delivery (AORPS 5.76 [95% CI 3.63-9.15, p < 0.0001]). Fetal bradycardia was associated with transfusion (AORPS 2.13 [95% CI 1.26-3.59, p < 0.005]) and maternal ICU admission (AORPS 3.22 [95% CI 1.23-8.46, p < 0.017]). Late decelerations were associated with cesarean delivery (AORPS 1.65 [95% CI 1.55-1.76, p < 0.0001]), clinical chorioamnionitis (AORPS 2.88 [95% CI 2.46-3.37, p < 0.0001]), and maternal need for antibiotics (AORPS 1.89 [95% CI 1.66-2.15, p < 0.0001]). Umbilical artery base excess less than or equal to -12 was associated with readmission (AORPS 6.71 [95% CI 2.22-20.3, p = 0.0007]), clinical chorioamnionitis (AORPS 1.89 [95% CI 1.24-2.89, p = 0.0031]), and maternal need for antibiotics (AORPS 1.53 [95% CI 1.03-2.26, p = 0.0344]).

LIMITATIONS

The retrospective design contributes to potential bias compared to the prospective design. However, by utilizing multivariate logistic regression analysis with a propensity score method, specifically inverse probability of treatment weighting, we attempted to minimize the impact of confounding variables. Additionally, only a portion of the data set had quantitative blood losses recorded, while the remainder had estimated blood losses.

CONCLUSION

NRFS is associated with significant maternal complications, in the form of increased need for blood transfusions, ICU admissions, and increased infection and readmission rates. Strategies for minimizing maternal complications need to be proactively considered in the management of NRFS.

Fetal effects of mild maternal COVID-19 infection: metabolomic profiling of cord blood

INTRODUCTION

The impact of maternal coronavirus disease 2019 (COVID-19) infection on fetal health remains to be precisely characterized.

OBJECTIVES

Using metabolomic profiling of newborn umbilical cord blood, we aimed to investigate the potential fetal biological consequences of maternal COVID-19 infection.

METHODS

Cord blood plasma samples from 23 mild COVID-19 cases (mother infected/newborn negative) and 23 gestational age-matched controls were analyzed using nuclear magnetic spectroscopy and liquid chromatography coupled with mass spectrometry. Metabolite set enrichment analysis (MSEA) was used to evaluate altered biochemical pathways due to COVID-19 intrauterine exposure. Logistic regression models were developed using metabolites to predict intrauterine exposure.

RESULTS

Significant concentration differences between groups (p-value < 0.05) were observed in 19 metabolites. Elevated levels of glucocorticoids, pyruvate, lactate, purine metabolites, phenylalanine, and branched-chain amino acids of valine and isoleucine were discovered in cases while ceramide subclasses were decreased. The top metabolite model including cortisol and ceramide (d18:1/23:0) achieved an Area under the Receiver Operating Characteristics curve (95% CI) = 0.841 (0.725-0.957) for detecting fetal exposure to maternal COVID-19 infection. MSEA highlighted steroidogenesis, pyruvate metabolism, gluconeogenesis, and the Warburg effect as the major perturbed metabolic pathways (p-value < 0.05). These changes indicate fetal increased oxidative metabolism, hyperinsulinemia, and inflammatory response.

CONCLUSION

We present fetal biochemical changes related to intrauterine inflammation and altered energy metabolism in cases of mild maternal COVID-19 infection despite the absence of viral infection. Elucidation of the long-term consequences of these findings is imperative considering the large number of exposures in the population.

Does Maternal SARS-CoV-2 Infection or SARS-CoV-2 Vaccination trigger an Inflammatory Response in The Fetus? A Prospective Cohort Study

BACKGROUND

SARS-CoV-2 infection triggers a significant maternal inflammatory response. There is a dearth of information regarding whether maternal SARS-CoV-2 infection at admission for delivery or SARS-CoV-2 vaccination triggers an inflammatory response in the fetus.

OBJECTIVE

This study aimed to evaluate fetal inflammatory response to maternal SARS-CoV-2 infection or SARS-CoV-2 vaccination compared to control group.

STUDY DESIGN

A prospective cohort study was performed with a total of 61 pregnant women who presented for delivery at a single medical center (William Beaumont Hospital, Royal Oak, MI). All mothers were tested for SARS-CoV-2 infection using polymerase chain reaction (PCR) on admission to Labor and Delivery unit. Three groups were evaluated: 22 pregnant with a positive SARS-CoV-2 test (case group), 23 pregnant women with a negative SARS-CoV-2 test (control group), and 16 pregnant women who had recent SAR-CoV-2 vaccination and a negative SARS-CoV-2 test (vaccine group). At delivery, cord blood was collected to determine the levels of IL-6, C-reactive protein (CRP), and SARS-CoV-2 Nucleocapsid IgG and IgM antibodies. In all cases, the newborn had a negative PCR test or showed no clinical findings consistent with SARS-CoV-2 infection.

RESULTS

Mean (SD) IL-6 level was not significantly different for the three groups: case group 9.00 +/- 3.340 pg/ml, control group 5.19 +/- 0.759 pg/ml, and vaccine group 7.11 +/- 2.468 pg/ml (p-value 0.855). Pairwise comparison also revealed no statistical difference for IL-6 concentrations with p-values for case versus control, case versus vaccine, and control versus vaccine = 0.57, 0.91, and 0.74, respectively. Similarly, there were no statistically significant difference in the frequency of elevated IL-6 (> 11 pg/ml) between groups (p-value 0.89). CRP levels across the three groups were not statistically significant different (p-value 0.634). Pairwise comparison of CRP levels among the different groups were also not statistically different. SARS-CoV-2 Nucleocaspid IgG was positive in 12 out of 22 cord blood samples in the case group, 2 out of 23 of the control group (indicating old resolved maternal infection), and 0 out of 16 of the vaccine group. SARS-CoV-2 Nucleocaspid IgM was negative in all cord blood samples of the case group, control group and vaccine group.

LIMITATIONS

A total number of 61 mothers enrolled in the study which represents a relatively small number of patients. Most patients with positive SARS-CoV-2 PCR were mainly asymptomatic. In addition, our vaccine group received the mRNA-based vaccines (mRNA1273 and BNT162b2). We did not study fetal response to other SARS-CoV-2 vaccines.

CONCLUSION

Neither IL-6 nor CRP indicated increased inflammation in the cord blood of newborns of vaccinated or SARS-CoV-2 infected mothers when the newborn was not infected.

Characterization and failure mode analyses of air plasma oxidized PDMS–PDMS bonding by peel testing

(a) Specimen geometry for peel test. (b) Specimen setup in Instron without loading (c) and under loading. (Units in mm. Dimensions not to scale.)

Sulci density map to aid in use of apparent diffusion coefficient for therapy evaluation

In order to more accurately asses variations in the apparent diffusion coefficient used for therapy evaluation, we have studied the variation in sulci density in the human brain. Sagittal, axial and coronal magnetic resonance imaging scans have been analyzed to determine the change of the coefficient of variance of pixel intensity as a function of position. In the sagittal direction, relative to the 50% most medial slices, we find an 11.0%+/-4.8% (S.D.) decrease in the next 25% (12.5% on each side) of the slices. The most lateral 25% of the slices had less of a decrease and more variation: 7.0%+/-12.2%. Similar variations were observed in axial and coronal scans.

Efficacy and safety of the perclose closer s device after neurointerventional procedures: prospective study and literature review

BACKGROUND AND PURPOSE

The purpose of this study was to examine the efficacy and safety of the 6F Closer S device (Perclose; Redwood City, CA) versus manual compression to close arteriotomy sites after neurointerventional procedures in both virgin vessels and those previously treated with the device.

METHODS

This single-center, multiple-operator, controlled, prospective study included 475 procedures (337 patients) with the device and 79 procedures (79 patients) with manual compression. A substantial number of patients receiving anticoagulation and/or antiplatelet medications were included. Efficacy and safety were evaluated on the basis of the rate of hemostatic success and the incidence of clinically significant complications. The literature was reviewed by using MEDLINE.

RESULTS

Overall success rates were 95% in the device group versus 96% in the manual-compression group (P = 0.78), and clinically relevant complication rates were 0.6% versus 2.5%, respectively (P = 0.15). Success rates significantly declined in vessels previously treated with the device three or more times. However, complication rates did not significantly change. Literature review yielded 12 articles reporting complication rates of 3.2-35% for the device and 2.3%-33.3% for manual compression.

CONCLUSION

The device was safe and effective for closing arteriotomy sites in patients undergoing neurointerventional procedures, including those receiving anticoagulation/antiplatelet therapy or those previously treated with the device one or two times.

125-TW Ti:sapphire/Nd:glass laser system

We have demonstrated a Ti:sapphire/Nd:glass laser system that produces up to 51 J of energy in 395-fs pulses (125TW). Focusing at f/3 to a 2.5-times diffraction-limited spot results in a peak irradiance greater than 10(20) W/cm(2) . Our 40-cm-diameter gold diffraction gratings have a damage threshold of 0.42 J/cm(2) for 320-fs pulses.

Molecular lesions associated with alleles of decapentaplegic identify residues necessary for TGF-beta/BMP cell signaling in Drosophila melanogaster

We have identified the molecular lesions associated with six point mutations in the Drosophila TGF-beta homologue decapentaplegic (dpp). The sites of these mutations define residues within both the pro and ligand regions that are essential for dpp function in vivo. While all of these mutations affect residues that are highly conserved among TGF-beta superfamily members, the phenotypic consequences of the different alleles are quite distinct. Through an analysis of these mutant phenotypes, both in cuticle preparations and with molecular probes, we have assessed the functional significance of specific residues that are conserved among the different members of the superfamily. In addition, we have tested for conditional genetic interactions between the different alleles. We show that two of the alleles are temperature sensitive for the embryonic functions of dpp, such that these alleles are not only embryonic viable as homozygotes but also partially complement other dpp hypomorphs at low temperatures. Our results are discussed with regard to in vitro mutagenesis data on other TGF-beta-like molecules, as well as with regard to the regulation of dpp cell signaling in Drosophila.

Genetic screens to identify elements of the decapentaplegic signaling pathway in Drosophila

Pathways for regulation of signaling by transforming growth factor-beta family members are poorly understood at present. The best genetically characterized member of this family is encoded by the Drosophila gene decapentaplegic (dpp), which is required for multiple events during fly development. We describe here the results of screens for genes required to maximize dpp signaling during embryonic dorsal-ventral patterning. Screens for genetic interactions in the zygote have identified an allele of tolloid, as well as two novel alleles of screw, a gene recently shown to encode another bone morphogenetic protein-like polypeptide. Both genes are required for patterning the dorsalmost tissues of the embryo. Screens for dpp interactions with maternally expressed genes have identified loss of function mutations in Mothers against dpp and Medea. These mutations are homozygous pupal lethal, engendering gut defects and severely reduced imaginal disks, reminiscent of dpp mutant phenotypes arising during other dpp-dependent developmental events. Genetic interaction phenotypes are consistent with reduction of dpp activity in the early embryo and in the imaginal disks. We propose that the novel screw mutations identified here titrate out some component(s) of the dpp signaling pathway. We propose that Mad and Medea encode rate-limiting components integral to dpp pathways throughout development.

Radiofrequency catheter ablation of the left and right ventricles: anatomic and electrophysiologic observations

Certain untoward effects associated with the use of direct-current electrical catheter ablation of the ventricular endomyocardium have been noted. We assessed the efficacy and safety of closed-chest catheter ablation of the left and right ventricles using radiofrequency (RF) energy (750 kHz) in six dogs. Mean RF energies between 93 and 123 joules (J) were randomly delivered to three left ventricular (LV) sites via two distal adjacent electrodes (bipolar configuration) using 6-7F USCI tripolar or quadripolar catheters with an interelectrode distance of 5-10 mm. Another 90-143 J were given to two right ventricular (RV) sites in single or multiple divided applications between a distal electrode and an external patch electrode (unipolar configuration). Ventricular arrhythmias were not observed during application of RF energy. Programmed ventricular stimulation before and after the procedure did not induce ventricular tachycardia (VT) or fibrillation except in one dog who had inducible VT prior to ablation. There were no significant changes in LV and RV effective refractory periods after the procedures. Occasional premature ventricular beats and rare episodes of non-sustained VT (3-12 beats) were observed in ambulatory electrocardiographic recordings (13-24 hrs) done immediately after ablation. Dogs were sacrificed after 4-5 days. Pathology showed well-demarcated round or ovoid lesions of varying sizes. Mural thrombus was found in one dog. Microscopic findings consisted of circumscribed areas of coagulation necrosis with a peripheral zone of cellular infiltration. Transmural necrosis without perforation was occasionally seen in the thin RV wall when higher energies were delivered. In conclusion, discrete areas of desiccation injury in the ventricles can be achieved by transcatheter bipolar or unipolar ablation using RF energy. The complications associated with this method appear to be minimal. Further experiments are needed to evaluate its potential for catheter ablation of ventricular tachycardia.