Extracellular vesicles as markers and mediators of pregnancy complications: gestational diabetes, pre-eclampsia, preterm birth and fetal growth restriction

In high income countries, approximately 10% of pregnancies are complicated by pre-eclampsia (PE), preterm birth (PTB), fetal growth restriction (FGR) and/or macrosomia resulting from gestational diabetes (GDM). Despite the burden of disease this places on pregnant people and their newborns, there are still few, if any, effective ways of preventing or treating these conditions. There are also gaps in our understanding of the underlying pathophysiologies and our ability to predict which mothers will be affected. The placenta plays a crucial role in pregnancy, and alterations in placental structure and function have been implicated in all of these conditions. As extracellular vesicles (EVs) have emerged as important molecules in cell-to-cell communication in health and disease, recent research involving maternal- and placental-derived EV has demonstrated their potential as predictive and diagnostic biomarkers of obstetric disorders.  This review will consider how placental and maternal EVs have been investigated in pregnancies complicated by PE, PTB, FGR and GDM and aims to highlight areas where further research is required to enhance the management and eventual treatment of these pathologies.

Neonatal outcomes following early fetal growth restriction: a subgroup analysis of the EVERREST study

OBJECTIVE

To quantify the risks of mortality, morbidity and postnatal characteristics associated with extreme preterm fetal growth restriction (EP-FGR).

DESIGN

The EVERREST (Do e s v ascular endothelial growth factor gene therapy saf e ly imp r ove outcome in seve r e e arly-onset fetal growth re st riction?) prospective multicentre study of women diagnosed with EP-FGR (singleton, estimated fetal weight (EFW) <3rd percentile, <600 g, 20+0-26+6 weeks of gestation). The UK subgroup of EP-FGR infants (<36 weeks) were sex-matched and gestation-matched to appropriate for age (AGA) infants born in University College London Hospital (1:2 design, EFW 25th-75th percentile).

SETTING

Four tertiary perinatal units (UK, Germany, Spain, Sweden).

MAIN OUTCOMES

Antenatal and postnatal mortality, bronchopulmonary dysplasia (BPD), sepsis, surgically treated necrotising enterocolitis (NEC), treated retinopathy of prematurity (ROP).

RESULTS

Of 135 mothers recruited with EP-FGR, 42 had a stillbirth or termination of pregnancy (31%) and 93 had live births (69%). Postnatal genetic abnormalities were identified in 7/93 (8%) live births. Mean gestational age at birth was 31.4 weeks (SD 4.6). 54 UK-born preterm EP-FGR infants (<36 weeks) were matched to AGA controls. EP-FGR was associated with increased BPD (43% vs 26%, OR 3.6, 95% CI 1.4 to 9.4, p=0.01), surgical NEC (6% vs 0%, p=0.036) and ROP treatment (11% vs 0%, p=0.001). Mortality was probably higher among FGR infants (9% vs 2%, OR 5.0, 95% CI 1.0 to 25.8, p=0.054). FGR infants more frequently received invasive ventilation (65% vs 50%, OR 2.6, 95% CI 1.1 to 6.1, p=0.03), took longer to achieve full feeds and had longer neonatal stays (median difference 6.1 days, 95% CI 3.8 to 8.9 and 19 days, 95% CI 9 to 30 days, respectively, p<0.0001).

CONCLUSIONS

Mortality following diagnosis of EP-FGR is high. Survivors experience increased neonatal morbidity compared with AGA preterm infants.

TRIAL REGISTRATION NUMBER

NCT02097667.

Patient empowerment improves follow-up data collection after fetal surgery for spina bifida: institutional audit

OBJECTIVES

To define and grade fetal and maternal adverse events following fetal surgery for spina bifida and to report on the impact of engaging patients in collecting follow-up data.

METHODS

This prospective single-center audit included 100 consecutive patients undergoing fetal surgery for spina bifida between January 2012 and December 2021. In our setting, patients return to their referring unit for further pregnancy care and delivery. On discharge, referring hospitals were requested to return outcome data. For this audit, we prompted patients and referring hospitals to provide data in cases of missing outcomes. Outcomes were categorized as missing, returned spontaneously or returned following additional request, by the patient and/or referring center. Postoperative maternal and fetal complications until delivery were defined and graded according to Maternal and Fetal Adverse Event Terminology (MFAET) and the Clavien-Dindo classification.

RESULTS

There were no maternal deaths, but severe maternal complications occurred in seven women (anemia in pregnancy, postpartum hemorrhage, pulmonary edema, lung atelectasis, urinary tract obstruction and placental abruption). No cases of uterine rupture were reported. Perinatal death occurred in 3% of fetuses and other severe fetal complications in 15% (perioperative fetal bradycardia/cardiac dysfunction, fistula-related oligohydramnios, chorioamnionitis and preterm prelabor rupture of membranes (PPROM) before 32 weeks). PPROM occurred in 42% of patients and, overall, delivery took place at a median gestational age of 35.3 weeks (interquartile range, 34.0-36.6 weeks). Information provided following additional request, from both centers and patients but mainly from the latter, reduced missing data by 21% for gestational age at delivery, 56% for uterine-scar status at birth and 67% for shunt insertion at 12 months. Compared with the generic Clavien-Dindo classification, the MFAET system ranked complications in a more clinically relevant way.

CONCLUSIONS

The nature and rate of severe complications following fetal surgery for spina bifida were similar to those reported in other large series. Spontaneous return of outcome data by referring centers was low, yet patient empowerment improved data collection. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Maternal PlGF and umbilical Dopplers predict pregnancy outcomes at diagnosis of early-onset fetal growth restriction

BACKGROUNDSevere, early-onset fetal growth restriction (FGR) causes significant fetal and neonatal mortality and morbidity. Predicting the outcome of affected pregnancies at the time of diagnosis is difficult, thus preventing accurate patient counseling. We investigated the use of maternal serum protein and ultrasound measurements at diagnosis to predict fetal or neonatal death and 3 secondary outcomes: fetal death or delivery at or before 28+0 weeks, development of abnormal umbilical artery (UmA) Doppler velocimetry, and slow fetal growth.METHODSWomen with singleton pregnancies (n = 142, estimated fetal weights [EFWs] below the third centile, less than 600 g, 20+0 to 26+6 weeks of gestation, no known chromosomal, genetic, or major structural abnormalities) were recruited from 4 European centers. Maternal serum from the discovery set (n = 63) was analyzed for 7 proteins linked to angiogenesis, 90 additional proteins associated with cardiovascular disease, and 5 proteins identified through pooled liquid chromatography and tandem mass spectrometry. Patient and clinician stakeholder priorities were used to select models tested in the validation set (n = 60), with final models calculated from combined data.RESULTSThe most discriminative model for fetal or neonatal death included the EFW z score (Hadlock 3 formula/Marsal chart), gestational age, and UmA Doppler category (AUC, 0.91; 95% CI, 0.86-0.97) but was less well calibrated than the model containing only the EFW z score (Hadlock 3/Marsal). The most discriminative model for fetal death or delivery at or before 28+0 weeks included maternal serum placental growth factor (PlGF) concentration and UmA Doppler category (AUC, 0.89; 95% CI, 0.83-0.94).CONCLUSIONUltrasound measurements and maternal serum PlGF concentration at diagnosis of severe, early-onset FGR predicted pregnancy outcomes of importance to patients and clinicians.TRIAL REGISTRATIONClinicalTrials.gov NCT02097667.FUNDINGThe European Union, Rosetrees Trust, Mitchell Charitable Trust.

A high-density 3-dimensional culture model of human glioblastoma for rapid screening of therapeutic resistance

Glioblastoma is among the most lethal cancers, with no known cure. A multitude of therapeutics are being developed or in clinical trials, but currently there are no ways to predict which patient may benefit the most from which drug. Assays that allow prediction of the tumor's response to anti-cancer drugs may improve clinical decision-making. Here, we present a high-density 3D primary cell culture model for short-term testing from resected glioblastoma tissue that is set up on the day of surgery, established within 7 days and viable for at least 3 weeks. High-density 3D cultures contain tumor and host cells, including microglia, and retain key histopathological characteristics of their parent tumors, including proliferative activity, expression of the marker GFAP, and presence of giant cells. This provides a proof-of-concept that 3D primary cultures may be useful to model tumor heterogeneity. Importantly, we show that high-density 3D cultures can be used to test chemotherapy response within a 2-3-week timeframe and are predictive of patient response to Temozolomide therapy. Thus, primary high-density 3D cultures could be a useful tool for brain cancer research and prediction of therapeutic resistance.

Foetal loss after chorionic villus sampling and amniocentesis in twin pregnancies: A multicentre retrospective cohort study

OBJECTIVE

We aimed to determine foetal losses for DCDA and MCDA twins following transabdominal CVS or amniocentesis performed <22+⁰  weeks.

METHODS

Retrospective cohort study conducted in the UK and Belgium 01/01/00-01/06/20. Cases with unknown chorionicity, monochorionic complications or complex procedures were excluded. Uncomplicated DCDA and MCDA twins without invasive procedures were identified as controls. We reported foetal losses <24+⁰  weeks and losses of genetically and structurally normal foetuses.

RESULTS

Outcomes were compared for DCDA foetuses; 258 after CVS with 3406 controls, 406 after amniocentesis with 3390 controls plus MCDA foetuses, 98 after CVS with 1124 controls, and 160 after amniocentesis with 1122 controls. There were more losses <24+⁰  weeks with both procedures in DCDA (CVS RR 5.54 95% CI 3.38-9.08, amniocentesis RR 2.36 95% CI 1.22-4.56) and MCDA twins (CVS RR 5.14 95% CI 2.51-10.54, amniocentesis RR 7.01 95% CI 3.86-12.74). Losses of normal foetuses were comparable to controls (DCDA CVS RR 0.39 95% CI 0.05-2.83, DCDA amniocentesis RR 1.16 95% CI 0.42-3.22, MCDA CVS RR 2.3 95% CI 0.71-7.56, and MCDA amniocentesis RR 1.93 95% CI 0.59-6.38).

CONCLUSIONS

This study indicates increased foetal losses for DCDA and MCDA twins following CVS and amniocentesis with uncertain risk to normal foetuses.

Evaluation of an Opioid-Free Anesthesia Protocol for Elective Abdominal Surgery in a Community Hospital

Utilization of opioids for acute pain control during surgical procedures is commonplace for anesthesia providers. Opioid use is associated with many undesirable side effects, including opioid use disorder. Opioid-free anesthesia for surgical procedures using a multimodal approach can reduce these side effects. This quality improvement project evaluated the implementation of an opioid-free anesthesia protocol for elective abdominal surgical procedures in a community hospital. The project had specific aims of detecting a reduction in opioid consumption in the operating room and the first 30 minutes in the post anesthesia recovery unit (PACU) while confirming pain relief comparable to that seen with opioid analgesia. Implementation of the quality improvement protocol resulted in a 79% reduction in the number of patients who received opioids during surgery and provided pain relief through the first 30 minutes in PACU comparable to anesthesia that included opioids. This project confirmed that an opioid-free anesthesia protocol could be successfully implemented within a community hospital for healthy adults undergoing elective abdominal surgery.

0110 Nap-Related Change in Memory Precision may be Related to Slow-Wave Sleep in Early Childhood

Introduction

In early childhood (3-5 years), naps comprise part of children’s 24-hr sleep. Naps support some types of learning (declarative, emotional), enhancing children’s ability to correctly identify previously seen items. During this time, children’s ability to form precise memories also improves, likely due to ongoing hippocampal development and maturation of processes allowing for pattern separation. Whether naps support the ability to form precise memory representations, allowing children to discriminate between previously seen vs. similar but novel items, is unclear. Here, we used a mnemonic similarity task to examine whether daytime naps support children’s recall of specific images more so than a period of wake. Further, we tested whether this nap-related improvement persists across overnight sleep. We hypothesized that task improvement would be associated with slow-wave sleep (SWS), as this stage has been shown to support episodic memory in preschool-aged children.

Methods

Participants (N=7, 4 females, Mage=56.1 mos) encoded items in the morning, verbally categorizing each image as something they would find “inside” or “outside”. They recalled items at three time points: immediately following encoding, after their nap/wake period, and the following morning after overnight sleep. Recall involved being shown a single image and responding whether it had been previously seen or not. Recall items included targets, foils, and lures. PSG was recorded during the nap and overnight sleep bouts.

Results

When controlling for age, children forgot fewer target items following a nap than a comparable period of wake (p=.05). Following a nap and overnight sleep, children also exhibited marginally less forgetting of target items than following a period of wake and overnight sleep (p=.102). Lure discrimination index (LDI; false alarm lures minus false alarm foils) did not differ between nap and wake conditions. Change in target recall following the nap was associated with SWS% during the nap (r=.96, p=.01), but not nap duration (p=.27).

Conclusion

Napping supported children’s ability to recall target items, but not to correctly reject lures, suggesting naps’ benefit towards more generalized memory. Nap SWS% was associated with less forgetting of target items, supporting its role in hippocampal-dependent memory consolidation. Analyses of overnight sleep data and inclusion of more participants may help better elucidate the relationship between preschool children’s sleep and memory development.

Support (If Any)

NSF BCS 1749280 NIH R21 HD094758 NIH R01 HL111695

0007 Temporal Associations Between Actigraphy-Measured Daytime Movement Behaviors and Daytime Sleep in Early Childhood

Introduction

Although napping in early childhood is associated with some cognitive and behavioral outcomes, less is known about relations with physical health measures. Lower levels of sedentary behavior and higher levels of physical activity have been beneficially associated with sleep measures in adults. Studies exploring sleep and daytime movement behaviors (sedentary time and physical activity) in young children have had inconsistent results and primarily focused on overnight sleep. The purpose of this micro-longitudinal analysis was to determine if: 1) daytime movement behaviors predicted the likelihood of napping the next day, 2) daytime movement behaviors predicted next-day nap duration, and 3) the occurrence of a nap predicted next-day movement behaviors.

Methods

In 240 children (age=50.8±9.8 months, 49.2% female) sedentary time (% of wake time), total physical activity (counts/min), and nap duration (min) were derived from wrist-based actigraphy (mean = 9.7 days), and occurrence of a nap was recorded daily. Multilevel logistic and linear models with lagged effects were used to examine temporal within-person relations between wake behaviors and nap sleep, and adjusted for night’s sleep duration of nights between days of interest (min), age (months), sex (male or female), and socioeconomic status (index). Preliminary models included interactions with nap habituality (rarely, sometimes, or frequent).

Results

Occurrence of a nap was not associated with next-day wake behaviors and previous-day wake behaviors did not predict nap duration. However, on days children napped, they were less sedentary (B=-2.09, p&lt;0.001) and more active (B=25.8, p&lt;0.001) the following day. Nap habituality did not moderate these associations.

Conclusion

Bidirectional associations between nap sleep and daytime wake behaviors were not evident. While daytime movement behaviors were not predictive of nap sleep, napping was beneficially associated with subsequent-day movement behaviors in preschool children. Further studies could explore specific nap sleep metrics in samples with more diverse sleep health, as well as consider the reason for daytime napping.

Support (If Any)

NIH R01 HL111695

Identifying self-report measures of emotion regulation and evaluating their psychometric properties: a protocol for a systematic review

INTRODUCTION

Successful emotion regulation (ER) is critical for psychological health. Disturbances in this ability are associated with several psychiatric disorders. There are several self-report questionnaires to assess ER. However, there are no studies synthesising the evidence on their psychometric properties. We aim to identify all available instruments addressing ER in adolescents or adults and to critically appraise, compare and summarise the quality of their psychometric properties. For this, we will use COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria.

METHOD AND ANALYSIS

The search process to identify eligible studies will be conducted in April 2021 including the ProQuest, PubMed, Scopus and Web of Science databases with no restriction in terms of publication date. Eligibility criteria include peer-reviewed research articles written in English or Spanish by means of patient-reported outcome measures focused on ER among participants of 13 years or older. We will assess the quality of measures according to the COSMIN Risk of Bias Checklist. The psychometric properties will be assessed by the COSMIN updated criteria for good measurement. The available evidence will be addressed by the Grading of Recommendations, Assessment, Development and Evaluations approach. Our findings will be synthesised independently for each measure, including information on their sample, theoretical model and psychometric properties when possible.

ETHICS AND DISSEMINATION

Ethical approval is not required, as this study does not involve any participants or collection of primary data. Results are expected to be published in a peer-reviewed journal in the field of youth mental health and presented at relevant meetings and conferences.

PROSPERO REGISTRATION NUMBER

CRD42021249498.

Mental Health Impacts of Climate Change on Women: a Scoping Review

Climate change is the largest threat to human health of the twenty-first century. Women are disproportionately affected by climate change. While the physical health impacts of climate change are an active area of research, works related to the mental health impacts are less developed. Furthermore, the mental health impacts of climate change on women are a particular area of interest due to women's disproportionately negative experiences with climate change and climate change-related events. Therefore, the purpose of this scoping review is to understand what is known from the existing literature regarding the mental health impacts of climate change on women. The methods for this review follow the Arksey and O'Malley framework for a scoping review. By searching databases for publications that discuss women, mental health, and climate change, and screening for relevant work, 20 studies that met inclusion criteria were included in the review. Themes derived from the reviewed studies include negative mental health outcomes, gender-based violence, burdens of care and responsibility, attachment to land and traditions, and the importance of intersectionality. From these findings, there is a clear need for climate policies on adaptation and mitigation to reflect women's unique needs to ensure their health and safety.

Multiple Fungi May Connect the Roots of an Orchid (Cypripedium reginae) and Ash (Fraxinus nigra) in Western Newfoundland

Showy lady's slipper (Cypripedium reginae Walter, Orchidaceae) and black ash (Fraxinus nigra Marshall, Oleaceae) often co-occur in close proximity in fens in western Newfoundland, Canada. Metabarcoding of DNA extracted from root samples of both species following surface sterilization, and others without surface sterilization was used to determine if there were shared fungal endophytes in the roots of both species that could form a common mycorrhizal network between them. A wide variety of fungi were recovered from primers amplifying the nuclear ribosomal internal transcribed spacer region (ITS2). Sixty-six fungal sequences were shared by surface-sterilized roots of both orchid and ash, among them arbuscular mycorrhizal fungi (Claroideoglomus, Dominikia, Glomus and Rhizophagus), ectomycorrhizal fungi (Inocybe and Tomentella), the broad-host root endophyte Cadophora orchidicola, along with root pathogens (Dactylonectria, Ilyonectria, Pyricularia, and Xylomyces) and fungi of unknown function. There appear to be multiple fungi that could form a common mycorrhizal network between C. reginae and F. nigra, which might explain their frequent co-occurrence. Transfer of nutrients or carbon between the orchid and ash via one or more of the shared fungal endophytes remains to be demonstrated.

Comparison of Efficiency and Function of Vascular Endothelial Growth Factor Adenovirus Vectors in Endothelial Cells for Gene Therapy of Placental Insufficiency

Severe fetal growth restriction (FGR) affects 1:500 pregnancies, is untreatable and causes serious neonatal morbidity and death. Reduced uterine blood flow (UBF) and lack of bioavailable VEGF due to placental insufficiency is a major cause. Transduction of uterine arteries in normal or FGR sheep and guinea pigs using an adenovirus (Ad) encoding VEGF isoforms A (Ad.VEGF-A₁₆₅) and a FLAG-tagged pre-processed short form D (D^ΔNΔC, Ad.VEGF-D^ΔNΔC-FLAG) increases endothelial nitric oxide expression, enhances relaxation and reduces constriction of the uterine arteries and their branches. UBF and angiogenesis are increased long term, improving fetal growth in utero. For clinical trial development we compared Ad.VEGF vector transduction efficiency and function in endothelial cells (ECs) derived from different species. We aimed to compare the transduction efficiency and function of the pre-clinical study Ad. constructs (Ad.VEGF-A₁₆₅, Ad.VEGF-D^ΔNΔC-FLAG) with the intended clinical trial construct (Ad.VEGF-D^ΔNΔC) where the FLAG tag is removed. We infected ECs from human umbilical vein, pregnant sheep uterine artery, pregnant guinea pig aorta and non-pregnant rabbit aorta, with increasing multiplicity of infection (MOI) for 24 or 48 hours of three Ad.VEGF vectors, compared to control Ad. containing the LacZ gene (Ad.LacZ). VEGF supernatant expression was analysed by ELISA. Functional assessment used tube formation assay and Erk-Akt phosphorylation by ELISA. VEGF expression was higher after Ad.VEGF-D^ΔNΔC-FLAG and Ad.VEGF-D^ΔNΔC transduction compared to Ad.VEGF-A₁₆₅ in all EC types (*p < 0.001). Tube formation was higher in ECs transduced with Ad.VEGF-D^ΔNΔC in all species compared to other constructs (***p < 0.001, *p < 0.05 with rabbit aortic ECs). Phospho-Erk and phospho-Akt assays displayed no differences between the three vector constructs, whose effect was, as in other experiments, higher than Ad.LacZ (***p < 0.001). In conclusion, we observed high transduction efficiency and functional effects of Ad.VEGF-D^ΔNΔC vector with comparability in major pathway activation to constructs used in pre-clinical studies, supporting its use in a clinical trial.

144 Temporal and Bidirectional Associations between Objectively Measured Physical Activity and Sleep in Preschoolers

Introduction

Physical activity (PA) and sleep contribute to overall health in early childhood. To explore the interactive relationships of these behaviors in older children and adults, previous studies have examined temporal between- and within-person associations through micro-longitudinal designs. However, such analyses have not been conducted in early childhood, when behaviors are guided by adult caregivers. The purpose of this analysis was to examine temporal and bidirectional associations between SED, PA, and sleep in preschool children.

Methods

Wake (activity counts/min and percent time in SED, light PA [LPA], and moderate-to-vigorous PA [MVPA]) and overnight sleep (sleep duration, sleep efficiency [SE], mid-sleep point [MSP]) were assessed via wrist-based actigraphy (mean = 10.4 days and 9.8 nights) and recorded as repeated (daily) measures. Multilevel models with lagged effects and AR(1) error covariance structure were used to examine the temporal associations between wake and sleep measures and adjusted for age, sex, socioeconomic status, and nap frequency.

Results

With PA measures as predictors, between-person associations were positive between activity counts and SE (p=0.004), SED and SE (p=0.004), LPA and sleep duration (p=0.005), and negative between LPA and MSP (p=0.039) and MVPA and SE (p=0.003). Within-person associations were positive between activity counts and sleep duration (p=0.010), activity counts and SE (p=0.018), MVPA and sleep duration (p=0.003), MVPA and SE (p=0.004), and negative between SED and SE (p=0.034) and LPA and sleep duration (p=0.045). With sleep measures as predictors, associations were positive between sleep duration and LPA (p&lt;0.001) and SE and SED (p=0.008), and negative between MSP and LPA (p=0.009), SE and activity counts (p=0.001), and SE and MVPA (p=0.003). Within-person associations were positive between SE and activity counts (p=0.001) and SE and MVPA (p=0.001), and negative between sleep duration and LPA (p=0.001) and SE and SED (p=0.012).

Conclusion

Generally, days with higher levels of activity or sleep were not associated with greater subsequent sleep or PA. Conversely, when participants obtained greater PA or sleep compared to their individual average, some beneficial associations were evident. These findings demonstrate some evidence of temporal associations between PA and sleep, although the bidirectional nature was not conclusive.

Support (if any)

NIH R01 HL111695

172 Sleep Disparities in Preschool-Aged Children

Introduction

Sleep is known to be associated with socioeconomic status (SES) in older children and adults with those from lower SES households often experiencing poorer sleep quality. Whether this disparity exists in early childhood is relatively unknown, despite being an important age marked by sleep transitions and the establishment of lifelong sleep habits. Furthermore, it is a critical period for cognitive development and learning, which are supported by sleep. Here, we explore associations between sleep and SES in a preschool population. We hypothesized that children from lower SES households would exhibit shorter overnight sleep, longer and more frequent naps, and shorter 24-hr sleep. Additionally, we considered racial and ethnic disparities in sleep which can be confounded with SES in some samples.

Methods

Child (n=441; M age=51.9mo; 45.4% female) sleep was measured objectively using actigraph watches, worn for 3-16 days (M=9.5 days). Caregivers reported child demographics and household data. Race/ethnicity of our sample was 72% White, 10.2% Black, 17.8% other or more than one race, and 28.4% identified as Hispanic. 20.1% of our sample was categorized as low SES. Effects of SES and race/ethnicity on continuous sleep measures were assessed using multiple regression models, with age and gender as covariates. Nap habituality was assessed using chi-square tests.

Results

Lower SES was associated with shorter nighttime sleep duration, longer nap duration, and shorter 24-hr sleep duration (p’s&lt;.001). Children from lower SES households were also more likely to nap habitually (p=.04) as were Hispanic children (p&lt;.001). Hispanic children also tended to have longer nap bouts (p=.002). Hispanic and Black children on average had shorter overnight sleep durations than White children (p’s&lt;.04), but their 24-hr sleep did not differ.

Conclusion

SES-related sleep disparities were present in this preschool population, with lower SES children exhibiting poorer sleep. When controlling for SES, Hispanic children tended to sleep less overnight which was compensated for by longer, more frequent naps. This underscores the necessity of naps for some children to achieve adequate sleep. Future directions will explore the relationship between parenting factors and sleep, such as bedtime routines and parent knowledge surrounding child sleep needs.

Support (if any)

NIH R01 HL111695

A rapid review of Indigenous boys' and men's sexual health in Canada

Indigenous boys and men in Canada face adverse social and structural circumstances that affect their ability to achieve and maintain sexual health. Research about Indigenous sexual health, however, is largely limited to matters relating to women and statistics on sexually transmitted infections. A rapid review of research was conducted to determine what is currently known about Indigenous boys' and men's sexual health in Canada. Given the prevalence of research documenting quantitative disparities, the current review included qualitative research only. Thirteen included studies explored a wide range of topics relating to sexual health and an overarching intersection between social conditions and individual health outcomes was observed. The results of this review reveal significant gaps in the literature relating to the holistic sexual health of Indigenous boys and men and highlight important domains of sexual health to consider in future research. Findings suggest that sexual health programmes that promote traditional Indigenous knowledge and intergenerational relationships may be effective for promoting sexual health among Indigenous boys and men.

Magnetic resonance imaging measurement of placental perfusion and oxygen saturation in early-onset fetal growth restriction

OBJECTIVE

We hypothesised that a multi-compartment magnetic resonance imaging (MRI) technique that is sensitive to fetal blood oxygenation would identify changes in placental blood volume and fetal blood oxygenation in pregnancies complicated by early-onset fetal growth restriction (FGR).

DESIGN

Case-control study.

SETTING

London, UK.

POPULATION

Women with uncomplicated pregnancies (estimated fetal weight [EFW] >10th centile for gestational age [GA] and normal maternal and fetal Doppler ultrasound, n = 12) or early-onset FGR (EFW <3rd centile with or without abnormal Doppler ultrasound <32 weeks GA, n = 12) were studied.

METHODS

All women underwent MRI examination. Using a multi-compartment MRI technique, we quantified fetal and maternal blood volume and feto-placental blood oxygenation.

MAIN OUTCOME MEASURES

Disease severity was stratified according to Doppler pulsatility index and the relationship to the MRI parameters was investigated, including the influence of GA at scan.

RESULTS

The FGR group (mean GA 27⁺⁵  weeks, range 24⁺² to 33⁺⁶  weeks) had a significantly lower EFW compared with the control group (mean GA 29⁺¹  weeks; -705 g, 95% CI -353 to -1057 g). MRI-derived feto-placental oxygen saturation was higher in controls compared with FGR (75 ± 9.6% versus 56 ± 16.2%, P = 0.02, 95% CI 7.8-30.3%). Feto-placental oxygen saturation estimation correlated strongly with GA at scan in controls (r = -0.83).

CONCLUSION

Using a novel multimodal MRI protocol we demonstrated reduced feto-placental blood oxygen saturation in pregnancies complicated by early-onset FGR. The degree of abnormality correlated with disease severity defined by ultrasound Doppler findings. Gestational age-dependent changes in oxygen saturation were also present in normal pregnancies.

TWEETABLE ABSTRACT

MRI reveals differences in feto-placental oxygen saturation between normal and FGR pregnancy that is associated with disease severity.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Digital methods to enhance the usefulness of patient experience data in services for long-term conditions: the DEPEND mixed-methods study

Background

Collecting NHS patient experience data is critical to ensure the delivery of high-quality services. Data are obtained from multiple sources, including service-specific surveys and widely used generic surveys. There are concerns about the timeliness of feedback, that some groups of patients and carers do not give feedback and that free-text feedback may be useful but is difficult to analyse.

Objective

To understand how to improve the collection and usefulness of patient experience data in services for people with long-term conditions using digital data capture and improved analysis of comments.

Design

The DEPEND study is a mixed-methods study with four parts: qualitative research to explore the perspectives of patients, carers and staff; use of computer science text-analytics methods to analyse comments; co-design of new tools to improve data collection and usefulness; and implementation and process evaluation to assess use of the tools and any impacts.

Setting

Services for people with severe mental illness and musculoskeletal conditions at four sites as exemplars to reflect both mental health and physical long-terms conditions: an acute trust (site A), a mental health trust (site B) and two general practices (sites C1 and C2).

Participants

A total of 100 staff members with diverse roles in patient experience management, clinical practice and information technology; 59 patients and 21 carers participated in the qualitative research components.

Interventions

The tools comprised a digital survey completed using a tablet device (kiosk) or a pen and paper/online version; guidance and information for patients, carers and staff; text-mining programs; reporting templates; and a process for eliciting and recording verbal feedback in community mental health services.

Results

We found a lack of understanding and experience of the process of giving feedback. People wanted more meaningful and informal feedback to suit local contexts. Text mining enabled systematic analysis, although challenges remained, and qualitative analysis provided additional insights. All sites managed to collect feedback digitally; however, there was a perceived need for additional resources, and engagement varied. Observation indicated that patients were apprehensive about using kiosks but often would participate with support. The process for collecting and recording verbal feedback in mental health services made sense to participants, but was not successfully adopted, with staff workload and technical problems often highlighted as barriers. Staff thought that new methods were insightful, but observation did not reveal changes in services during the testing period.

Conclusions

The use of digital methods can produce some improvements in the collection and usefulness of feedback. Context and flexibility are important, and digital methods need to be complemented with alternative methods. Text mining can provide useful analysis for reporting on large data sets within large organisations, but qualitative analysis may be more useful for small data sets and in small organisations.

Limitations

New practices need time and support to be adopted and this study had limited resources and a limited testing time.

Future work

Further research is needed to improve text-analysis methods for routine use in services and to evaluate the impact of methods (digital and non-digital) on service improvement in varied contexts and among diverse patients and carers.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 28. See the NIHR Journals Library website for further project information.

0122 Does Additional Training on an Implicit Motor Sequence Learning Task for Older Adults Improve Sleep-Dependent Memory Consolidation?

Introduction

Previous studies show sleep dependent consolidation (SDC) for motor sequence learning with regular training in younger adults, whereas, in older adults, this sleep benefit is missing. If hippocampal engagement underlies age-related differences in SDC, then enhanced training should result in significant SDC in older adults. Thus, this study aims to look at younger vs. older adults with regular training and older adults with regular training vs. overtraining to determine if older adults show evidence of SDC. Alternatively, regardless of initial learning, older adults may fail to exhibit SDC because the sleep mechanisms supporting consolidation are impaired.

Methods

Seven younger adults (M=22 years) and seven older adults (M=68.5 years) completed the train condition, while ten older adults (M=67.6 years) completed the overtrain condition. In the encoding phase, participants either completed 5 blocks (train) or 10 blocks (overtrain). Between immediate and delayed recall, participants either slept with Polysomnography (PSG) in the lab or remained awake, and subsequently, completed the alternate condition one week later. Actigraphy was collected for 14 days and PSG (32-electrode EasyCap) was recorded for overnight sleep.

Results

Older adults significantly improved their skill learning from immediate to delayed recall, in both the train (p=0.005) and overtrain (p=0.013) conditions, regardless of sleep or wake. Younger adults did not improve their skill learning in the train condition (p&gt;0.05). However, there was a trending main effect, with younger adults performing the task better compared to older adults in the train condition, at both time points (p=0.061). No other main effects or interactions were significant.

Conclusion

These results suggest the alternative hypothesis that, regardless of initial learning, older adults fail to exhibit SDC. This result is of interest as the age-related differences in sleep, such as sleep spindle characteristics may play a role. Future analysis will include more participants and further exploration into the PSG-recorded sleep architecture and actigraphy-recorded measures of habitual sleep.

Support

This work was funded by NIH R01 AG040133 (PI: Spencer)

0222 The Association of Habitual Physical Activity with 24-Hour Sleep Outcomes in Preschoolers

Introduction

Sedentary behavior, physical activity (PA), and sleep are health behaviors that contribute significantly to overall and early childhood health. Although interactive relationships of these behaviors have been reported in adults and school-aged children, there is limited evidence that PA is associated with sleep using objective measures in younger children and findings have been mixed. The purpose of this study was to determine if objectively measured PA and sleep behavior outcomes are associated in preschoolers.

Methods

Participants (n=77, age: 4.34±177;0.91 years; 55.8% female) were included in this cross-sectional study. Actiwatch Spectrum monitors (wrist-worn, triaxial accelerometers) were worn 24-hours for 16-days to measure PA (total PA counts, sedentary time [ST], light PA, and moderate-to-vigorous PA [MVPA]) and sleep (24-hour, nighttime, and nap sleep duration, bedtime, wake after sleep onset [WASO], and sleep efficiency).

Results

Multiple linear regression models adjusted for age and wear time during wake periods indicated that greater MVPA was associated with less nighttime sleep duration (β=-3.48, p&lt;0.001), less total 24-hour sleep duration (β=-3.38, p&lt;0.001), and a later bedtime (β=0.07, p&lt;0.001). Total PA counts were associated with less nighttime sleep duration (β=-0.0002, p=0.001), less total 24-hour sleep duration (β=-0.0002, p=0.001), and a later bedtime (β=4.83, p=0.001). Greater ST was associated with greater total 24-hour sleep duration (β=1.92, p=0.006) and an earlier bedtime (β=-0.36, p=0.02). Percent time spent in light PA was not associated with any sleep outcomes and no PA variables were associated with nap sleep duration, WASO, or sleep efficiency.

Conclusion

As these findings are in contrast to previous studies reporting null or beneficial associations, further analyses are warranted to examine potential mediators/effect modifiers (e.g., sleep timing, gender, body mass index, and socioeconomic status) and temporal relationships between these movement behaviors in young children.

Support

NIH R01 HL111695

Circulating mRNAs are differentially expressed in pregnancies with severe placental insufficiency and at high risk of stillbirth

BACKGROUND

Fetuses affected by placental insufficiency do not receive adequate nutrients and oxygenation, become growth restricted and acidemic, and can demise. Preterm fetal growth restriction is a severe form of placental insufficiency with a high risk of stillbirth. We set out to identify maternal circulating mRNA transcripts that are differentially expressed in preterm pregnancies complicated by very severe placental insufficiency, in utero fetal acidemia, and are at very high risk of stillbirth.

METHODS

We performed a cohort study across six hospitals in Australia and New Zealand, prospectively collecting blood from 128 pregnancies complicated by preterm fetal growth restriction (delivery < 34 weeks' gestation) and 42 controls. RNA-sequencing was done on all samples to discover circulating mRNAs associated with preterm fetal growth restriction and fetal acidemia in utero. We used RT-PCR to validate the associations between five lead candidate biomarkers of placental insufficiency in an independent cohort from Europe (46 with preterm fetal growth restriction) and in a third cohort of pregnancies ending in stillbirth.

RESULTS

In the Australia and New Zealand cohort, we identified five mRNAs that were highly differentially expressed among pregnancies with preterm fetal growth restriction: NR4A2, EMP1, PGM5, SKIL, and UGT2B1. Combining three yielded an area under the receiver operative curve (AUC) of 0.95. Circulating NR4A2 and RCBTB2 in the maternal blood were dysregulated in the presence of fetal acidemia in utero. We validated the association between preterm fetal growth restriction and circulating EMP1, NR4A2, and PGM5 mRNA in a cohort from Europe. Combining EMP1 and PGM5 identified fetal growth restriction with an AUC of 0.92. Several of these genes were differentially expressed in the presence of ultrasound parameters that reflect placental insufficiency. Circulating NR4A2, EMP1, and RCBTB2 mRNA were differentially regulated in another cohort destined for stillbirth, compared to ongoing pregnancies. EMP1 mRNA appeared to have the most consistent association with placental insufficiency in all cohorts.

CONCLUSIONS

Measuring circulating mRNA offers potential as a test to identify pregnancies with severe placental insufficiency and at very high risk of stillbirth. Circulating mRNA EMP1 may be promising as a biomarker of severe placental insufficiency.

Sexualized drug use in virtual space: A scoping review of how gay, bisexual and other men who have sex with men interact online

The purpose of this article is to review the scope of the current literature on sexualized drug use (SDU) among gay, bisexual and other men who have sex with men (GBMSM), particularly in online spaces. Over the last decade, there has been a rapid emergence of online venues for GBMSM to interact for sexual purposes. These spaces have also been infused with various substances that influence or shape the sexual interactions among GBMSM. Employing a scoping review methodology, we explored the interplay between GBMSM, SDU, and online dating and hookup apps. This scoping review presents four themes emerging from the literature: the connection between social networking apps (SNAs) and SDU, the planning and coordination of sex parties, accessing drugs through SNAs, and the coded language that emerges on SNAs. These findings synthesize the important relationship between GBMSM and SDUs, and identify the implications for health promotion.

P574Accuracy of wrist-worn heart rate monitors for chronotropic assessment in atrial fibrillation

Introduction

Wrist-worn fitness and heart rate (HR) monitors are increasingly popular. Previous studies in healthy participants with sinus rhythm (SR) have yielded variable results depending on HR, activity levels and device tested. A paucity of data exists on their accuracy in atrial fibrillation (AF) in ambulatory patients.

Purpose

We sought to assess the HR accuracy of 2 commercially available smart watches (Fitbit Charge HR [FB] and Apple Watch Series 3 [AW]) compared with Holter monitoring in an ambulant patient cohort.

Methods

Patients aged >18 years referred for 24-hour Holter monitoring were prospectively recruited. The Holter monitor was the criterion measure. Each patient was randomly allocated to either a FB or AW along with their Holter monitor. The study protocol was approved by the institutional review board.

Statistical analysis: Pearson (r) correlation coefficients and Bland-Altman comparison with 95% limits of agreement (LoA) were evaluated to assess criterion validity and agreement between the smart watch and Holter ECG-HR. Bias was the calculated mean difference between the smart watch and ECG-HR. A ± 10-beat different between Holter-HR and SW-HR was used as a clinically relevant range to establish the accuracy of HR estimation by SW.

Results

Across all devices, 53,288 hear rate values were recorded from 32 patients. Twenty six patients were in persistent AF and six were in SR. Twelve patients wore the FB while 20 wore the AW. In the FB arm, nice patient were in persistent AF and three in SR. In the AW arm, persistent AF was the rhythm in seventeen and SR in three. Patients in SR demonstrated overall strong agreement compared to Holter monitoring (Mean Bias <1 beat, LoA −11 to 11 beats) and a correlation coefficient of 0.87 (p<0.001). In AF, both devices underestimated HR measurements (Overall Bias −9 beats, LoA −41 to 23, r=0.60, p<0.001). The AW had lower bias and narrower LoA compared to FB (−5 beats vs −13 beats, LoA −31 to 21 beats vs −50 to 22 beats). Using a ± 10-beat range against ECG-HR for clinical accuracy, both the AW and FB performed satisfactorily in SR with 95.2% of AW and 92.2% of FB HR readings considered valid. In AF, however, the AW-HR readings were within the ± 10-beat threshold in 76.5% of the time compared with only 56.1% of FB readings.

Conclusion

In ambulatory patients, smart watches were accurate in HR estimation when compared to Holter monitor in SR; however tended to underestimate HR in AF. Further improvements in device technology are needed before the widespread consumer adoption of this nascent technology for chronotropic assessment in arrhythmias.

Pregnant women's experiences and perceptions of participating in the EVERREST prospective study; a qualitative study

Background

The EVERREST Prospective Study is a multicentre observational cohort study of pregnancies affected by severe early-onset fetal growth restriction. The study recruits women with singleton pregnancies where the estimated fetal weight is less than the 3rd centile and below 600 g, between 20 + 0 and 26 + 6 weeks of pregnancy, in the absence of a known chromosomal, structural or infective cause.

Method

The reported study was retrospective descriptive qualitative interview study of women who had participated in the EVERREST Prospective Study. The aim of this study was to explore the experiences and perceptions of pregnant women taking part in research during a pregnancy affected by severe early-onset fetal growth restriction. Audio-recorded semi-structured telephone interviews were conducted with a purposive sample of 12 women, at least 1 year after delivery of their baby. Two of these pregnancies had ended in stillbirth and one in neonatal death, reflecting the outcomes seen in the EVERREST Prospective Study. Participants gave informed consent, were 16 years or older and were interviewed in English. A topic guide was used to ensure a consistent approach. Questions focused on pregnancy experiences, involvement with the EVERREST study and potential involvement in future research. Recordings were transcribed verbatim for thematic analysis using NVivo10.

Results

Four broad themes were identified; ‘before joining the EVERREST Prospective Study’, ‘participating in research’, ‘information and support’ and ‘looking back and looking forwards’. Each broad theme incorporated several subthemes. All participants recalled their reaction to being told their baby was smaller than expected. The way this news was given had a lasting impact. A range of benefits of participation in the EVERREST Prospective Study were described and the participants were positive about the way it was conducted. As a consequence, they were receptive to participating in future research. However, the findings suggest that research teams should be sensitive when approaching families at a difficult time or when they are already participating in other research.

Conclusions

This study highlights the willingness of pregnant women to participate in research and identifies strategies for researchers to engage participants.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2277-8) contains supplementary material, which is available to authorized users.

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

BACKGROUND

Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.

METHODS

FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.

FINDINGS

Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months.

INTERPRETATION

Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.

FUNDING

UK Stroke Association and NIHR Health Technology Assessment Programme.

Factors Influencing the Implementation of Nutrition Policies in Schools: A Scoping Review

BACKGROUND

Although school nutrition policies (SNPs) have been highlighted as an important intervention to support childhood nutrition, their implementation and maintenance within real-word settings is complex. There is a need to understand the factors that influence implementation by consolidating existing research and identifying commonalities and differences.

AIMS

The purpose of this review is to determine what is known about the influence of broad and local system factors on the implementation of SNPs internationally.

METHOD

This scoping review involved identifying and selecting relevant literature that related SNP implementation in primary and secondary schools. Following the search process, 2,368 articles were screened and 59 articles were synthesized and charted and emerging themes were identified.

RESULTS

Across the final studies identified, factors emerged as barriers and facilitators to the implementation of SNPs, with system implications that related to five areas to support policy action: providing macro-level support may encourage policy implementation; addressing the financial implications of healthy food access; aligning nutrition and core school priorities; developing a common purpose and responsibility among stakeholders; recognition of school and community characteristics.

DISCUSSION

While SNPs can help to support childhood nutrition, strategies to address issues related to policy implementation need to be taken to help schools overcome persistent challenges.

CONCLUSION

The results of this review provide opportunities for action across multiple system levels to ensure synergy and coordinated action toward SNP goals to foster the creation supportive nutrition environments for children.

At-a-glance - "A tough sell": findings from a qualitative analysis on the provision of healthy foods in recreation and sports settings

Recreation and sport settings (RSS) typically promote health in the form of physical activity, but the healthfulness of their food environment is often neglected. We explored stakeholder perspectives on barriers to healthy food provision in RSS through telephone interviews with ten representatives from RSS across Nova Scotia. Three key barriers were identified: 1) cultural norms associated with food in RSS and the broader environment, 2) the persisting notion of personal choice and responsibility, and 3) financial implications of healthy food provision. These barriers challenge healthy food provision in RSS and require multi-faceted strategies to overcome social norms that undermine health behaviours.