Diagnostic terminology in Placenta Accreta Spectrum: a scoping review

BACKGROUND

Anaesthetic management strategies for Placenta Accreta Spectrum (PAS) remain diverse, and literature interpretation is complicated by a range of terminology. The International Federation for Gynaecology and Obstetrics (FIGO) published guidance in 2018 to improve PAS diagnosis and management by standardising definitions. We mapped the range, clarity and consistency of terminology in literature pertaining to both PAS and anaesthesia, and determined whether this changed followed FIGO guidance.

METHODS

A literature search of four medical databases was performed. Papers included had PAS (or any 'synonym') in the title, and mode of anaesthesia in the title or abstract. Narrative reviews, and papers not containing original data, were excluded. Diagnostic terms, and evidence supporting their use, were described.

RESULTS

Among 680 abstracts identified, 62 papers were included. Thirty distinct terms were used to describe PAS and subtypes. Terminology was clearly defined 46% of the time and used consistently within a paper 47% of the time. Nine papers (15%) provided no diagnostic evidence to support the terminology used. In 14 (23%) papers published after FIGO guidelines, 14 terms were used to describe PAS. Two papers (14%) specified the diagnostic criteria used. Six (43%) confirmed diagnoses using pathology. Four (29%) were consistent in use of terminology throughout the paper.

CONCLUSIONS

Despite international consensus criteria for reporting PAS, the language pertaining to PAS and anaesthesia remains heterogeneous, inconsistent and variably defined. Reporting of PAS should adhere to FIGO criteria to allow unambiguous interpretation of work, and generation of evidence that is transferrable into clinical practice.

Decentralized vitamin C & D dual biosensor chip: Toward personalized immune system support

Combating the ongoing COVID-19 pandemic has put the spotlight on nutritional support of the immune system through consumption of vitamins C and D. Accordingly, there are urgent demands for an effective on-the-spot multi-vitamin self-testing platform that monitors the levels of these immune-supporting micronutrients for guiding precision nutrition recommendations. Herein, we present a compact bioelectronic dual sensor chip aimed at frequent on-the-spot simultaneous monitoring of the salivary vitamin C and D dynamics. The new bioelectronic chip combines a new electrocatalytic vitamin C amperometric assay along with competitive vitamin D immunoassay on neighboring electrodes, to perform selective and cross-talk free detection of both vitamins in a 10-μL saliva sample within 25 min. The distinct vitamin C or D temporal profiles obtained for different individuals after vitamin supplementation indicate the potential of the new bioelectronic chip strategy for enhancing personalized nutrition towards guiding dietary interventions to meet individual nutrition needs and promote immune system health.

Problematic substance use: an assessment of workplace implications in midwifery

BACKGROUND

Problematic substance use (PSU) poses occupational, personal and professional risks. As an occupational group, midwives have been under-represented in research on PSU.

AIMS

The aim of this study was to assess self-reported occurrences of PSU, help-seeking behaviours and barriers, and perceptions of impairment in UK-based midwives.

METHODS

Self-selecting registered midwives were anonymously surveyed using the Tobacco, Alcohol, Prescription Medications, and Substance Use/Misuse (TAPS) tool, the Perceptions of Nursing Impairment Inventory (PNII) and open-ended/closed questions. Quantitative data were used to explore PSU, help-seeking and attitudes to impairment. Qualitative responses were used to provide richer understandings.

RESULTS

From 623 completed surveys, 28% (n = 176) self-reported PSU in response to work-related stress and anxiety, bullying, traumatic clinical incidents and maintenance of overall functioning. PSU was related to alcohol and a range of restricted drugs. While 11% of those affected indicated they had sought help, 27% felt they should seek help but did not. Reported barriers to help-seeking included fear of repercussions, shame, stigma, practicalities and a perceived lack of support either available or required. Perceptions of impairment were predominantly compassionate with a minority of stigmatizing attitudes displayed.

CONCLUSIONS

Overall, 10% of the sample reported they had attended work under the influence of alcohol, and 6% under the influence of drugs other than tobacco or those as prescribed to them. Furthermore, 37% indicated concern about a colleague's substance use. As stigmatizing attitudes and punitive actions can dissuade help-seeking, changed perceptions and policies which favour alternatives to discipline are suggested to reduce the risk overall.

Impact of Arachidonic and Docosahexaenoic Acid Supplementation on Neural and Immune Development in the Young Pig

Background: Human milk contains both arachidonic acid (ARA) and docosahexaenoic acid (DHA). Supplementation of infant formula with ARA and DHA results in fatty acid (FA) profiles, neurodevelopmental outcomes, and immune responses in formula-fed infants that are more like those observed in breastfed infants. Consequently, ARA and DHA have been historically added together to infant formula. This study investigated the impact of ARA or DHA supplementation alone or in combination on tissue FA incorporation, immune responses, and neurodevelopment in the young pig.

Methods: Male pigs (N = 48 total) received one of four dietary treatments from postnatal day (PND) 2–30. Treatments targeted the following ARA/DHA levels (% of total FA): CON (0.00/0.00), ARA (0.80/0.00), DHA (0.00/0.80), and ARA+DHA (0.80/0.80). Plasma, red blood cells (RBC), and prefrontal cortex (PFC) were collected for FA analysis. Blood was collected for T cell immunophenotyping and to quantify a panel of immune outcomes. Myelin thickness in the corpus callosum was measured by transmission electron microscopy and pig movement was measured by actigraphy.

Results: There were no differences in formula intake or growth between dietary groups. DHA supplementation increased brain DHA, but decreased ARA, compared with all other groups. ARA supplementation increased brain ARA compared with all other groups but did not affect brain DHA. Combined supplementation increased brain DHA levels but did not affect brain ARA levels compared with the control. Pigs fed ARA or ARA+DHA exhibited more activity than those fed CON or DHA. Diet-dependent differences in activity suggested pigs fed ARA had the lowest percent time asleep, while those fed DHA had the highest. No differences were observed for immune or myelination outcomes.

Conclusion: Supplementation with ARA and DHA did not differentially affect immune responses, but ARA levels in RBC and PFC were reduced when DHA was provided without ARA. Supplementation of either ARA or DHA alone induced differences in time spent asleep, and ARA inclusion increased general activity. Therefore, the current data support the combined supplementation with both ARA and DHA in infant formula and raise questions regarding the safety and nutritional suitability of ARA or DHA supplementation individually.

Epidermal Enzymatic Biosensors for Sweat Vitamin C: Toward Personalized Nutrition

Recent advances in wearable sensor technologies offer new opportunities for improving dietary adherence. However, despite their tremendous promise, the potential of wearable chemical sensors for guiding personalized nutrition solutions has not been reported. Herein, we present an epidermal biosensor aimed at following the dynamics of sweat vitamin C after the intake of vitamin C pills and fruit juices. Such skin-worn noninvasive electrochemical detection of sweat vitamin C has been realized by immobilizing the enzyme ascorbate oxidase (AAOx) on flexible printable tattoo electrodes and monitoring changes in the vitamin C level through changes in the reduction current of the oxygen cosubstrate. The flexible vitamin C tattoo patch was fabricated on a polyurethane substrate and combined with a localized iontophoretic sweat stimulation system along with amperometric cathodic detection of the oxygen depletion during the enzymatic reaction. The enzyme biosensor offers a highly selective response compared to the common direct (nonenzymatic) voltammetric measurements, with no effect on electroactive interfering species such as uric acid or acetaminophen. Temporal vitamin C profiles in sweat are demonstrated using different subjects taking varying amounts of commercial vitamin C pills or vitamin C-rich beverages. The dynamic rise and fall of such vitamin C sweat levels is thus demonstrated with no interference from other sweat constituents. Differences in such dynamics among the individual subjects indicate the potential of the epidermal biosensor for personalized nutrition solutions. The flexible tattoo patch displayed mechanical resiliency to multiple stretching and bending deformations. In addition, the AAOx biosensor is shown to be useful as a disposable strip for the rapid in vitro detection of vitamin C in untreated raw saliva and tears following pill or juice intake. These results demonstrate the potential of wearable chemical sensors for noninvasive nutrition status assessments and tracking of nutrient uptake toward detecting and correcting nutritional deficiencies, assessing adherence to vitamin intake, and supporting dietary behavior change.

Heterozygotes for ACAN dwarfism alleles in horses have reduced stature

Homozygous and compound heterozygous Miniature horses for ACAN alleles D1, D2, D3* and D4 exhibit chondrodysplastic dwarfism (OMIA 001271-9796). In a previous study, the carrier rate for these four alleles, combined, was 26.2%. The purpose of this study was to investigate whether carriers of these dwarfism-causing alleles had a shorter withers height than non-carriers. A total of 245 Miniature horses were tested for these four ACAN alleles and also were measured for withers height. Of these horses, 98 were carriers and 147 were non-carriers. A statistically significant difference of 1.43 inches was observed with the carriers being shorter (P = 1.72E - 11). The range of heights for the two groups overlapped, indicating that other factors, including genes, have an impact on withers height. However, the high carrier rate of these dwarfism-causing variants may be due to selection for decreased height.

Diagnosis of upper limb lymphedema: development of an evidence-based approach

BACKGROUND

The diagnosis of secondary upper limb lymphedema (LE) is complicated by the lack of an agreed-upon measurement tool and diagnostic threshold. The aim of this study was to determine which of the many commonly used and normatively determined clinical diagnostic thresholds has the best diagnostic accuracy of secondary upper limb LE, when compared to diagnosis by an appropriate reference standard, lymphoscintigraphy.

MATERIAL AND METHODS

The arms of women treated for breast cancer with and without a previous diagnosis of LE, as well as healthy controls, were assessed using lymphoscintigraphy, bioimpedance spectroscopy (BIS) and perometry. Dermal backflow score determined from lymphoscintigraphy imaging assessment (reference standard) was compared with diagnosis by both commonly used and normatively determined diagnostic thresholds for volume and circumference measurements as well as BIS.

RESULTS

For those with established dermal backflow, all commonly used and normatively determined diagnostic thresholds accurately identified presence of LE compared with lymphoscintigraphy diagnosis. In participants with mild to moderate changes in dermal backflow, only a normatively determined diagnostic threshold, set at two standard deviations above the norm, for arm circumference and full arm BIS were found to have both high sensitivity (81% and 76%, respectively) and specificity (96% and 93%, respectively). For this group, strong, and clinically useful, positive (23 and 10, respectively) and negative likelihood (0.2 and 0.3) ratios were found for both the circumference and bioimpedance diagnostic thresholds.

CONCLUSION

For the first time, evidence-based clinical diagnostic thresholds have been established for secondary LE. With mild LE, normatively determined circumference and BIS thresholds are superior to the commonly used thresholds.

Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth, a Cochrane systematic review

This paper compares the beneficial and harmful effects of paracetamol, ibuprofen and the novel combination of both in a single tablet for pain relief following the surgical removal of lower wisdom teeth. In this systematic review only randomised controlled double-blinded clinical trials were included. We calculated the proportion of patients with at least 50% pain relief at 2 and 6 hours post dosing, along with the proportion of participants using rescue medication at 6 and 8 hours. Adverse events were also analysed. Data was meta-analysed where possible. Seven studies were included with a total of 2,241 participants enrolled. Ibuprofen 400 mg is superior to 1,000 mg paracetamol with a risk ratio for at least 50% pain relief at 6 hours of 1.47 (95% confidence interval [CI] 1.28 to 1.69). For the combined drug, the risk ratio for at least 50% maximum pain relief over 6 hours is 1.77 (95% CI 1.32 to 2.39) based on total pain relief (TOTPAR) data. There is high quality evidence that ibuprofen is superior to paracetamol. The novel combination drug shows encouraging results when compared to the single drugs (based on two trials).

Erythrocyte fatty acid status in a convenience sample of residents of the Guatemalan Pacific coastal plain

We report the fatty acid composition, and in particular, the n-3 and n-6 long-chain polyunsaturated fatty acids (LCPUFA), in erythrocytes from a convenience sample of 158 women and 135 schoolchildren residing in the southern Pacific Coast of Guatemala. Erythrocyte fatty acids were analyzed by gas-liquid chromatography with flame ionization detection and the profiles were expressed as a weight percent; the Omega-3 Index values were also determined. Schoolchildren had significantly higher mean ARA and total n-6 fatty acid levels than the women. Women had significantly higher EPA fatty acid levels than schoolchildren, but the reverse was true for DHA. For mean total n-3 fatty acid concentration, women and schoolchildren had similar values. The red cell weight percentages of selected fatty acids were also similar in women and schoolchildren. As compared with erythrocyte fatty acid data from developed countries, Guatemalan women and schoolchildren had consistently lower LCPUFA values. The traditional diet of Guatemalans living in the Pacific coastal region provided a worse erythrocyte fatty acid profile than that typically obtained from a Western diet. Additional fatty acid composition studies with associated dietary intake data in other inland locations may be useful for the interpretation of the nutritional status of Guatemalan children and adults.

Genetics of swayback in American Saddlebred horses

Extreme lordosis, also called swayback, lowback or softback, can occur as a congenital trait or as a degenerative trait associated with ageing. In this study, the hereditary aspect of congenital swayback was investigated using whole genome association studies of 20 affected and 20 unaffected American Saddlebred (ASB) Horses for 48,165 single-nucleotide polymorphisms (SNPs). A statistically significant association was identified on ECA20 (corrected P=0.017) for SNP BIEC2-532523. Of the 20 affected horses, 17 were homozygous for this SNP when compared to seven homozygotes among the unaffected horses, suggesting a major gene with a recessive mode of inheritance. The result was confirmed by testing an additional 13 affected horses and 166 unaffected horses using 35 SNPs in this region of ECA20 (corrected P=0.036). Combined results for 33 affected horses and 287 non-affected horses allowed identification of a region of homozygosity defined by four SNPs in the region. Based on the haplotype defined by these SNPs, 80% of the 33 affected horses were homozygous, 21% heterozygous and 9% did not possess the haplotype. Among the non-affected horses, 15% were homozygous, 47% heterozygous and 38% did not possess the haplotype. The differences between the two groups were highly significant (P<0.00001). The region defined by this haplotype includes 53 known and predicted genes. Exons from three candidate genes, TRERF1, RUNX2 and CNPY3 were sequenced without finding distinguishing SNPs. The mutation responsible for swayback may lie in other genes or in regulatory regions outside exons. This information can be used by breeders to reduce the occurrence of swayback among their livestock. This condition may serve as a model for investigation of congenital skeletal deformities in other species.

Identification of equine major histocompatibility complex haplotypes using polymorphic microsatellites

A system for identifying equine major histocompatibility complex (MHC) haplotypes was developed based on five polymorphic microsatellites located within the MHC region on ECA 20. Molecular signatures for 50 microsatellite haplotypes were recognized from typing 353 horses. Of these, 23 microsatellite haplotypes were associated with 12 established equine leucocyte antigen (ELA) haplotypes in Thoroughbreds and Standardbreds. Five ELA serotypes were associated with multiple microsatellite subhaplotypes, expanding the estimates of diversity in the equine MHC. The strong correlations between serological and microsatellite typing demonstrated a linkage to known MHC class I protein polymorphisms and validated this assay as a useful supplement to ELA serotyping, and in some applications, a feasible alternative method for MHC genotyping in horse families and in population studies.

Dissemination of behavioural activation for depression to mental health nurses: training evaluation and benchmarked clinical outcomes

Depression causes significant distress, disability and cost within the UK. Behavioural activation (BA) is an effective single-strand psychological approach which may lend itself to brief training programmes for a wide range of clinical staff. No previous research has directly examined outcomes of such dissemination. A 5-day training course for 10 primary care mental health workers aiming to increase knowledge and clinical skills in BA was evaluated using the Training Acceptability Rating Scale. Depression symptom level data collected in a randomized controlled trial using trainees were then compared to results from meta-analysis of studies using experienced therapists. BA training was highly acceptable to trainees (94.4%, SD 6%). The combined effect size of BA was unchanged by the addition of the results of this evaluation to those of studies using specialist therapists. BA offers a promising psychological intervention for depression that appears suitable for delivery by mental health nurses following brief training.

Inbreeding in the Thoroughbred horse

Changes in the inbreeding coefficient, F, in the Thoroughbred horse over the past 45 years have been investigated by genotyping 467 Thoroughbred horses (born between 1961 and 2006) using the Illumina Equine SNP50 bead chip, which comprises 54,602 SNPs uniformly distributed across the equine genome. The Spearman rank correlation coefficient, r, between the year of birth and F was estimated. The results indicate that inbreeding in Thoroughbreds has increased over the past 40 years, with r = 0.24, P < 0.001 demonstrating that there is a highly significant, though relatively weak correlation between the year of birth and inbreeding coefficients. Interestingly, the majority of the increase in inbreeding is post-1996 and coincides with the introduction of stallions covering larger numbers of mares.

RT-qPCR comparison of mast cell populations in whole blood from healthy horses and those with laminitis

Inflammatory damage to the digital laminae, a structure responsible for suspension of the distal skeleton within the hoof capsule, results in a painful and often life-threatening disease in horses called laminitis. There can be many diverse causes of laminitis; however, previous work in the horse has suggested that in each case, the inflammation and resulting tissue damage is consistent with the action of mediators released from mast cells (MC), as well as the downstream consequences of their activation. The recent development of molecular genetics tools to characterize cells based on their transcriptional activity makes a new approach for measuring MCs possible. Healthy thoroughbred horses from a variety of age groups were used to assess the amount of variation in KIT (encoding mast cell growth factor receptor) and TPSB2 (encoding mast cell tryptase beta 2) gene expression present in the population and to establish "normal" values. Horses (n=9) with a wider range of body condition scores (3-8), because of a more lax management setting that could predispose them to laminitis, had significantly higher KIT expression in circulating peripheral blood cells than horses under individualized management conditions (n=10) that produced ideal body condition scores (4-6) (mean 2.573-fold, P<0.0005). Likewise, horses affected with acute laminitis (n=11) had elevated expression of TPSB2 (2.760-fold, P=0.0011) relative to control horses (n=15). These data suggest that investigation of MC-related genes KIT and TPSB2 may be effective to assay MC population and activity. More work is needed to refine the diagnostic criteria to better describe at what point MC activation occurs and illustrate the use of gene expression assays in clinical cases of laminitis. Additionally, MC activation is associated with inflammatory disease in several mammalian species and may prove a valuable therapeutic target in the horse.

The metabolism of glyoxylate by cell-free extracts of Pseudomonas sp

1. Extracts of Pseudomonas sp. grown on butane-2,3-diol oxidized glyoxylate to carbon dioxide, some of the glyoxylate being reduced to glycollate in the process. The oxidation of malate and isocitrate, but not the oxidation of pyruvate, can be coupled to the reduction of glyoxylate to glycollate by the extracts. 2. Extracts of cells grown on butane-2,3-diol decarboxylated oxaloacetate to pyruvate, which was then converted aerobically or anaerobically into lactate, acetyl-coenzyme A and carbon dioxide. The extracts could also convert pyruvate into alanine. However, pyruvate is not an intermediate in the metabolism of glyoxylate since no lactate or alanine could be detected in the reaction products and no labelled pyruvate could be obtained when extracts were incubated with [1-(14)C]glyoxylate. 3. The (14)C was incorporated from [1-(14)C]glyoxylate by cell-free extracts into carbon dioxide, glycollate, glycine, glutamate and, in trace amounts, into malate, isocitrate and alpha-oxoglutarate. The (14)C was initially incorporated into isocitrate at the same rate as into glycine. 4. The rate of glyoxylate utilization was increased by the addition of succinate, alpha-oxoglutarate or citrate, and in each case alpha-oxoglutarate became labelled. 5. The results are consistent with the suggestion that the carbon dioxide arises by the oxidation of glyoxylate via reactions catalysed respectively by isocitratase, isocitrate dehydrogenase and alpha-oxoglutarate dehydrogenase.

J-LEAPS vaccines initiate murine Th1 responses by activating dendritic cells

The Ligand Epitope Antigen Presentation System (LEAPS) converts a peptide containing a T cell epitope as small as 8 amino acids into an immunogen and directs the nature of the subsequent response. Tandem synthesis of the J peptide (a peptide from the beta-2-microglobulin) with peptides of 15 or 30 amino acids from HSV-1 or HIV made them immunogenic and promoted Th1 immune responses. Immunization of A/J or C57BL/6 mice with J-LEAPS heteroconjugates containing an epitope from the HSV-1 glycoprotein D (JgD) or an epitope from the HIV gag protein (JH) emulsified with Seppic ISA51 induced increased levels of IL-12p70 by day 3 and increased levels of interferon gamma (IFN-gamma) on days 10 and 24. Interestingly, levels of IL-10, TNF-alpha, and IL-6 did not change. Neither the H nor the gD peptides alone elicited responses and only weak responses followed immunization with the J peptide. Bone marrow (BM) cells became CD86 and CD11c positive within 48 h of treatment with JgD or JH. JH or JgD treatment promoted IL-12p70 production and expression of CD8 denoting the maturation and activation of a subclass of myeloid DCs. Pure cultures of immature myeloid DCs also responded to JgD treatment, forming clusters, developing dendrites, and producing IL-12p70 within 24 h. The JH or JgD treated bone marrow cells (JgD-DC) were necessary and sufficient to activate splenic T cells to produce IFN-gamma and the JgD-DC provided an antigen specific booster response to T cells from JgD immunized mice. Adoptive transfer of JgD-DC was also sufficient to initiate protective antigen specific immunity from lethal challenge with HSV-1. The J-LEAPS vaccines appear to act as an adjuvant and immunogen on DC precursors in a unique manner to promote activation and maturation into IL-12p70 producing DCs which then can initiate sufficient Th1 immune responses to elicit protection without production of acute phase cytokines.