Factors affecting uptake of postmortem examination in the prenatal, perinatal and paediatric setting

Background

Postmortem examination is the single most useful investigation in providing information to parents about why their baby or child died. Despite this, uptake remains well below the recommended 75%.

Objective

To address the question ‘what are the barriers and motivators to perinatal, prenatal and paediatric PM examination?’

Search strategy

Key databases including Pubmed and CINAHL; Cochrane library, websites of relevant patient organisations, hand search of key journals, first and last authors and references.

Selection criteria

Peer‐reviewed qualitative, quantitative or mixed methods research examining factors affecting uptake or decline of perinatal or paediatric postmortem examination.

Data collection and analysis

Narrative synthesis; findings were compared across studies to examine interrelations.

Main results

Seven major themes describing barriers to postmortem uptake were identified: dislike of invasiveness, practicalities of the procedure, organ retention issues, protective parenting, communication and understanding, religion and culture and professional or organisational barriers. Six major themes related to factors which facilitated parental consent were identified: desire for information, contributing to research, coping and well‐being, respectful care, minimally invasive options, and policy and practice. There were a number of themes in the literature that reflected best practice.

Conclusion

Findings highlight the need for better health professional education and the fact some concerns may be mitigated if less invasive methods of postmortem were routinely available. New consent packages and codes of practice may have a positive impact on perception of examination after death. The landscape is changing; further research is necessary to assess the impact on postmortem uptake rates.

Tweetable abstract

Systematic review to explore the barriers and motivators to perinatal, prenatal and paediatric postmortem examination.

Systematic review to explore the barriers and motivators to perinatal, prenatal and paediatric postmortem examination.

Optimum dose of vitamin D for disease prevention in older people: BEST-D trial of vitamin D in primary care

This trial compared the effects of daily treatment with vitamin D or placebo for 1 year on blood tests of vitamin D status. The results demonstrated that daily 4000 IU vitamin D3 is required to achieve blood levels associated with lowest disease risks, and this dose should be tested in future trials for fracture prevention.

INTRODUCTION

The aim of this trial was to assess the effects of daily supplementation with vitamin D3 4000 IU (100 μg), 2000 IU (50 μg) or placebo for 1 year on biochemical markers of vitamin D status in preparation for a large trial for prevention of fractures and other outcomes.

METHODS

This is a randomized placebo-controlled trial in 305 community-dwelling people aged 65 years or older in Oxfordshire, UK. Outcomes included biochemical markers of vitamin D status (plasma 25-hydroxy-vitamin D [25[OH]D], parathyroid hormone [PTH], calcium and alkaline phosphatase), cardiovascular risk factors and tests of physical function.

RESULTS

Mean (SD) plasma 25(OH)D levels were 50 (18) nmol/L at baseline and increased to 137 (39), 102 (25) and 53 (16) nmol/L after 12 months in those allocated 4000 IU, 2000 IU or placebo, respectively (with 88%, 70% and 1% of these groups achieving the pre-specified level of >90 nmol/L). Neither dose of vitamin D3 was associated with significant deviation outside the normal range of PTH or albumin-corrected calcium. The additional effect on 25(OH)D levels of 4000 versus 2000 IU was similar in all subgroups except for body mass index, for which the further increase was smaller in overweight and obese participants compared with normal-weight participants. Supplementation with vitamin D had no significant effects on cardiovascular risk factors or on measures of physical function.

CONCLUSIONS

After accounting for average 70% compliance in long-term trials, doses of 4000 IU vitamin D3 daily may be required to achieve plasma 25(OH)D levels associated with lowest disease risk in observational studies.

The steroid metabolome in men with mood and anxiety disorders

The mood and behavior of individuals result from an orchestra of many factors. Among them steroids play an important role; however, only several common hormones have been investigated in this respect. It has been demonstrated that some steroid metabolites long considered merely the products of steroid hormone metabolism in fact possess considerable activity in the CNS. For this reason we studied the steroid metabolome including 50 analytes in 20 men with depression, 20 men with anxiety and 30 healthy controls. Significant differences were found not only between controls and men with either depression or anxiety, but also between men with depression and anxiety. Particularly striking were those steroids until now not generally associated with depression or anxiety, namely conjugated steroid forms, especially sulfates.

The role of steroid hormones in the development of intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a disorder of liver function, commonly occurring in the third trimester but sometimes also as soon as the end of the second trimester of pregnancy. Symptoms of this disorder include pruritus, plus abnormal values of bile acids and hepatic transaminases. After birth, symptoms disappear and liver function returns to normal. Though ICP is relatively non-complicated and often symptomatically mild from the point-of-view of the mother, it presents a serious risk to the fetus, making this disease the subject of great interest. The etiology and pathogenesis of ICP is multifactorial and as yet not fully elucidated. Hormonal factors likely play a significant role, along with genetic as well as exogenous factors. Here we summarize the knowledge of changes in steroid hormones and their role in the development of intrahepatic cholestasis of pregnancy. In addition, we consider the role of exogenous factors as possible triggers of steroid hormone changes, the relationship between metabolic steroids and bile acids, as well as the combination of these factors in the development of ICP in predisposed pregnant women.

The steroid spectrum during and after quitting smoking

Addiction to tobacco results in an imbalance of endocrine homeostasis in both sexes. This can also have impacts on fertility problems. The male reproductive system is less susceptible than that of females, with a worsening spermiogram in smokers, the most cited effect in the literature. However, the literature is inconsistent as to the effects of smoking on steroid hormone levels in men, and there is very little data on the effects of quitting smoking in men. In this study we followed 76 men before quitting smoking, and then after 6, 12, and 24 weeks and 1 year of abstinence. We measured basic anthropomorphic data and steroid hormone levels along with steroid neuroactive metabolites using GC-MS. We demonstrate lower androgen levels in men who smoke, and these changes worsened after quitting smoking. There was a drop in SHBG already in the first week of non-smoking, and levels continued to remain low. Male smokers have lower androgen levels compared to non-smokers. The lower the initial level of androgen, the lower the likelihood of success in quitting smoking. Changes in steroid hormones proved to be a promising marker for the prediction of success in quitting smoking.

Increased serum levels of C21 steroids in female patients with multiple sclerosis

Multiple sclerosis (MS) is one of the most common neurological diseases. This neurodegenerative autoimmune disease manifests as inflammatory and demyelinating impairment of the central nervous system (CNS). Although some studies demonstrated associations between altered steroidogenesis and pathophysiology of MS as well as the importance of steroids in the pathophysiology of MS, the knowledge concerning the steroid metabolome in female patients is limited. Hence, 51 steroids and steroid polar conjugates were measured in the serum of 12 women with MS, untreated with steroids and 6 age-corresponding female controls with the use of gas chromatography - mass spectrometry (GC-MS). The data were processed using age adjusted ANCOVA, receiver operating characteristics (ROC) analysis and orthogonal projections to latent structures (OPLS). Our data show higher levels of circulating C21 steroids including steroid modulators of ionotropic type A gamma-aminobutyric acid (GABA A) receptors and glutamate receptors. Furthermore, the levels of GABAergic androsterone and 5-androsten-3beta,7alpha,17beta-triol were also higher in the female MS patients. In conclusion, the data demonstrate higher levels of circulating C21 steroids and their polar conjugates and some bioactive C19 steroids in women with MS, which may influence neuronal activity and affect the balance between neuroprotection and excitotoxicity.

The impact of selected cytokines in the follow-up of normal pressure hydrocephalus

Cytokines are widely known mediators of inflammation accompanying many neurodegenerative disorders including normal pressure hydrocephalus (NPH). NPH is caused by impaired cerebrospinal fluid (CSF) reabsorption and treated by surgical shunt insertion. The diagnostics is still complicated and the shunt effect is not durable; after several years, dementia may develop. In the clinical practice, biomarkers support the diagnostics as well as the further time course of many neurodegenerative diseases. Until recently, no reliable biomarker for NPH was evaluated. The attempt of this review was to make a survey concerning cytokines as possible NPH markers. Among all reviewed cytokines, the most promising are CSF IL-10 and IL-33, enabling to follow-up the disease progression and monitoring the effectiveness of the shunt insertion.

Mediating the cultural boundaries between medicine, nursing and management - the central challenge in hospital reform

This paper documents the resilience of medical and nursing profession-based subcultures and the extent of the differences between them. Against this background, we assess the capacity and willingness of medical and nursing managers to promote changes that will extend the accountability of clinicians and engender more evidence-based, financially driven and output-oriented approaches to service delivery.

The effect of a vegetarian versus conventional hypocaloric diet on serum concentrations of persistent organic pollutants in patients with type 2 diabetes

BACKGROUND AND AIMS

The aim of this study was to explore the effect of a vegetarian versus conventional diet on the serum levels of persistent organic pollutants (POPs) in patients with T2D after 12 weeks of dietary intervention and to assess their relationships with metabolic parameters.

METHODS AND RESULTS

Men and women with T2D were randomly assigned to follow either a vegetarian diet without fish or meat (n = 37) or an isocaloric conventional antidiabetic diet (n = 37). Both diets were energy restricted (minus 500 kcal/day). All foods were provided to the participants. At randomization (week 0) and 12 weeks, the meal test was performed to assess the β-cell function and serum levels of 24 POPs. Dioxins and dioxin-like POPs were analyzed by isotope dilution high-resolution gas chromatography (HRGC) and mass spectrometry after cleanup of the silica and carbon columns. Non-dioxin-like POPs were analyzed by gas chromatography with an electron capture detector (GC-ECD). Statistical analyses used were repeated-measures analysis of variance (ANOVA), a multivariate regression model, and Pearson's correlations. We observed a statistically nonsignificant trend toward increases in the serum levels of most POPs in response to both hypocaloric diets with no differences between groups. In the groups combined, the change in serum concentrations of total POPs was correlated to changes in HbA1c (r = +0.34; p < 0.01), fasting plasma glucose (r = +0.41; p < 0.01) levels, and β-cell function measured as insulin secretion at a reference glucose level (r = -0.37; p < 0.01), independent of the changes in body weight and volume of visceral fat.

CONCLUSION

Short-term hypocaloric vegetarian and conventional diets did not reduce the POP levels, possibly due to mobilization of fat stores. Our findings support the relationship between POPs and diabetes, especially β-cell function.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT00883038, completed.

Steroid hormones related to 11beta-hydroxysteroid dehydrogenase type 1 in treated obesity

The local concentration of glucocorticoids is intensively regulated by 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD 1). Human 11beta-HSD 1 also reversibly catalyzes the inter-conversion of 7alpha-hydroxy- and 7beta-hydroxy-dehydroepiandrosterone (DHEA) into 7-oxo-DHEA. The cohort of 282 obese adolescents, 154 girls (median age 15.31 years, range 14.17-16.68 years) and 128 boys (median age 14.95 years, range 13.87-16.16 years), BMI (Body Mass Index) >90th percentile was examined. In samples collected before and after one month of reductive diet therapy, circulating levels of steroids were analyzed by liquid chromatography-tandem mass spectrometry and radioimmunoassay methods. The model of the treatment efficacy prediction was calculated. A significant reduction in circulating levels of cortisone, E2 and increased levels of 7beta-hydroxy-DHEA after the reductive treatment was observed. Levels of cortisol, DHEA, DHT sustained without any significant change. The predictive Orthogonal Projections to Latent Structures (OPLS) model explained 20.1 % of variability of BMI, z-score change by the basal levels of 7alpha-hydroxy-DHEA, DHEA, cortisol and E2 as the strongest predictors. Reduced levels of circulating cortisone and reduced ratios of oxygenated/reduced metabolites reflect increased reductase activity of 11beta-HSD 1 with reduced BMI, z-score. We hypothesize whether these changes can be attributed to the altered activity of 11beta-HSD 1 in the liver.

The rapid increase of circulating adiponectin in neonatal calves depends on colostrum intake

Adiponectin, an adipokine, regulates metabolism and insulin sensitivity. Considering that the transplacental transfer of maternal proteins of high molecular weight is hindered in ruminants, this study tested the hypothesis that the blood concentration of adiponectin in neonatal calves largely reflects their endogenous synthesis whereby the intake of colostrum might modify the circulating concentrations. We thus characterized the adiponectin concentrations in neonatal and young calves that were fed either colostrum or formula. Three trials were performed: in trial 1, 20 calves were all fed colostrum for 3 d, and then formula until weaning. Blood samples were collected on d 0 (before colostrum feeding), and on d 1, 3, 11, 22, 34, 43, 52, 70, 90, and 108 postnatum. In trial 2, 14 calves were studied for the first 4 d of life. They were fed colostrum (n=7) or formula (n=7), and blood samples were taken right after birth and before each morning feeding on d 2, 3, and 4. In trial 3, calves born preterm (n=7) or at term received colostrum only at 24 h postnatum. Blood was sampled at birth, and before and 2 h after feeding. Additionally, allantoic fluid and blood from 4 Holstein cows undergoing cesarean section were sampled. Adiponectin was quantified by ELISA. In trial 1, the serum adiponectin concentrations recorded on d 3 were 4.7-fold higher than before colostrum intake. The distribution of the molecular weight forms of adiponectin differed before and after colostrum consumption. In trial 2, the colostrum group had consistently greater plasma adiponectin concentrations than the formula group after the first meal. In trial 3, the preterm calves tended to have lower concentrations of plasma adiponectin than the term calves at birth and before and 2 h after feeding. Furthermore, the adiponectin concentrations were substantially lower in allantoic fluid than in the sera from neonatal calves and from cows at parturition. Our results show that calves are born with very low blood concentrations of adiponectin and placental transfer of adiponectin to the bovine fetus is unlikely. In conclusion, colostrum intake is essential for the postnatal increase of circulating adiponectin in newborn calves.

Scaling the yield of laser-driven electron-positron jets to laboratory astrophysical applications

We report new experimental results obtained on three different laser facilities that show directed laser-driven relativistic electron-positron jets with up to 30 times larger yields than previously obtained and a quadratic (∼E_{L}^{2}) dependence of the positron yield on the laser energy. This favorable scaling stems from a combination of higher energy electrons due to increased laser intensity and the recirculation of MeV electrons in the mm-thick target. Based on this scaling, first principles simulations predict the possibility of using such electron-positron jets, produced at upcoming high-energy laser facilities, to probe the physics of relativistic collisionless shocks in the laboratory.

Neurogenic inflammation and colliquative lymphadenitis with persistent orthopox virus DNA detection in a human case of cowpox virus infection transmitted by a domestic cat

Cowpox viruses are orthopoxviruses that may survive in the environment for years. Rodents are regarded as the primary hosts, but transmission to other species has been reported. This report describes a cowpox virus infection in a cat with subsequent transmission to its owner leading to protracted, atypical and severe clinical signs. A young cat presented with multiple crusts and plaques on the neck, muzzle and tail base. The owner developed an erythematous lesion with elevated margins, central necrosis and crust formation below the left breast, a neurogenic inflammation, enlarged regional lymph nodes, a colliquative lymphadenitis and concomitant flu-like symptoms. Cultures were taken at the first visit from the cat's lesional skin and the patient's skin, and polymerase chain reaction with sequencing of the haemagglutinin region of both were positive for cowpox virus. The patient was treated with various antibiotics and methylprednisolone and was in clinical remission after 7 months.

Steroid hormones in the development of postpartum depression

Postpartum depression affects 10-15 % women after childbirth. There is no currently generally accepted theory about the causes and mechanisms of postpartum mental disorders. The principal hypothesis concerns the association with sudden changes in the production of hormones affecting the nervous system of the mother and, on the other hand, with the ability of receptor systems to adapt to these changes. We observed changes in steroidogenesis in the period around spontaneous delivery. We collected three samples of maternal blood. The first sampling was 4 weeks prior to term; the second sampling was after the onset of uterine contractions (the beginning of spontaneous labour); the third sampling was during the third stage of labour (immediately after childbirth). Additionally, we collected mixed umbilical cord blood. The almost complete steroid metabolome was analyzed by gas chromatography-mass spectrometry followed by RIA for some steroids. Mental changes in women in the peripartum period were observed using the Hamilton Depression Rating Scale. The local Ethics Committee approved the study. We found already the changes in androgens levels correlating with postpartum mood disorders four weeks prior to childbirth. The strongest correlations between steroid and postpartum mood change were found in venous blood samples collected from mothers after childbirth and from umbilical cord blood. The main role played testosterone, possibly of maternal origin, and estrogens originating from the fetal compartment. These results suggest that changes in both maternal and fetal steroidogenesis are involved in the development of mental changes in the postpartum period. Descriptions of changes in steroidogenesis in relation to postpartum depression could help clarify the causes of this disease, and changes in some steroid hormones are a promising marker of mental changes in the postpartum period.

Dehydroepiandrosterone, its metabolites and ion channels

This review is focused on the physiological and pathophysiological relevance of steroids influencing the activities of the central and peripheral nervous systems with regard to their concentrations in body fluids and tissues in various stages of human life like the fetal development or pregnancy. The data summarized in this review shows that DHEA and its unconjugated and sulfated metabolites are physiologically and pathophysiologically relevant in modulating numerous ion channels and participate in vital functions of the human organism. DHEA and its unconjugated and sulfated metabolites including 5α/β-reduced androstane steroids participate in various physiological and pathophysiological processes like the management of GnRH cyclic release, regulation of glandular and neurotransmitter secretions, maintenance of glucose homeostasis on one hand and insulin insensitivity on the other hand, control of skeletal muscle and smooth muscle activities including vasoregulation, promotion of tolerance to ischemia and other neuroprotective effects. In respect of prevalence of steroid sulfates over unconjugated steroids in the periphery and the opposite situation in the CNS, the sulfated androgens and androgen metabolites reach relevance in peripheral organs. The unconjugated androgens and estrogens are relevant in periphery and so much the more in the CNS due to higher concentrations of most unconjugated steroids in the CNS tissues than in circulation and peripheral organs. This article is part of a Special Issue entitled "Essential role of DHEA".

Do plastic surgery division heads and program directors have the necessary tools to provide effective leadership?

BACKGROUND

Effective leadership is imperative in a changing health care landscape driven by increasing expectations in a setting of rising fiscal pressures. Because evidence suggests that leadership abilities are not simply innate but, rather, effective leadership can be learned, it is prudent for plastic surgeons to evaluate the training and challenges of their leaders because there may be opportunities for further growth and support.

OBJECTIVE

To investigate the practice profiles, education/training, responsibilities and challenges of leaders within academic plastic surgery.

METHODS

Following research ethics board approval, an anonymous online survey was sent to division heads and program directors from all university-affiliated plastic surgery divisions in Canada. Survey themes included demographics, education/training, job responsibilities and challenges.

RESULTS

A response rate of 74% was achieved. The majority of respondents were male (94%), promoted to their current position at a mean age of 48 years, did not have a leadership-focused degree (88%), directly manage 30 people (14 staff, 16 faculty) and were not provided with a job description (65%). Respondents worked an average of 65 h per week, of which 18% was devoted to their leadership role, 59% clinically and the remainder on teaching and research. A discrepancy existed between time spent on their leadership role (18%) and related compensation (10%). Time management (47%) and managing conflict (24%) were described as the greatest leadership challenges by respondents.

CONCLUSIONS

Several gaps were identified among leaders in plastic surgery including predominance of male sex, limitations in formal leadership training and requisite skill set, as well as compensation and human resources management (emotional intelligence). Leadership and managerial skills are key core competencies, not only for trainees, but certainly for those in a position of leadership. The present study provides evidence that academic departments, universities and medical centres may benefit by re-evaluating how they train, promote and support their leaders in plastic surgery.

Prediction of adrenocortical insufficiency after pituitary adenoma surgery using postoperative basal cortisol levels

Our aim was to analyze the correlation of early postoperative cortisol levels in patients after transsphenoidal pituitary adenoma surgery compared to the standard dose ACTH test and Insulin tolerance test (ITT) several months later. We retrospectively reviewed data from 94 patients operated for pituitary adenoma in years 2009-2012. The comparison of day 7 (median) postoperative basal cortisol levels and 3.6 months (median) after pituitary adenoma surgery stimulation test - standard dose 250 microg 1-24ACTH test in 83 patients or ITT in 11 patients were performed. All 16 patients with early postoperative cortisol levels >500 nmol/l proved a sufficient response in the stimulation tests. At basal cortisol levels of 370-500 nmol/l the sufficient response was found in 96 % (27/28) of patients. In the postoperative basal cortisol levels 200-370 nmol/l we found a preserved corticotroph axis later on in 88 % (28/32) of cases. Patients with basal cortisol levels 100-200 nmol/l had a maintained corticotroph axis function in 8/11 cases - 73 %. All patients with an early postoperative basal cortisol level above 500 nmol/l proved in the stimulation tests a preserved corticotroph axis function. The interval 370-500 nmol/l showed a minimal risk of postoperative adrenal insufficiency.

Do plastic surgery division heads and program directors have the necessary tools to provide effective leadership?

Background

Effective leadership is imperative in a changing health care landscape driven by increasing expectations in a setting of rising fiscal pressures. Because evidence suggests that leadership abilities are not simply innate but, rather, effective leadership can be learned, it is prudent for plastic surgeons to evaluate the training and challenges of their leaders because there may be opportunities for further growth and support.

Objective

To investigate the practice profiles, education/training, responsibilities and challenges of leaders within academic plastic surgery.

Methods

Following research ethics board approval, an anonymous online survey was sent to division heads and program directors from all university-affiliated plastic surgery divisions in Canada. Survey themes included demographics, education/training, job responsibilities and challenges.

Results

A response rate of 74% was achieved. The majority of respondents were male (94%), promoted to their current position at a mean age of 48 years, did not have a leadership-focused degree (88%), directly manage 30 people (14 staff, 16 faculty) and were not provided with a job description (65%). Respondents worked an average of 65 h per week, of which 18% was devoted to their leadership role, 59% clinically and the remainder on teaching and research. A discrepancy existed between time spent on their leadership role (18%) and related compensation (10%). Time management (47%) and managing conflict (24%) were described as the greatest leadership challenges by respondents.

Conclusions

Several gaps were identified among leaders in plastic surgery including predominance of male sex, limitations in formal leadership training and requisite skill set, as well as compensation and human resources management (emotional intelligence). Leadership and managerial skills are key core competencies, not only for trainees, but certainly for those in a position of leadership. The present study provides evidence that academic departments, universities and medical centres may benefit by re-evaluating how they train, promote and support their leaders in plastic surgery.

Quantitative proteomics of delirium cerebrospinal fluid

Delirium is a common cause and complication of hospitalization in older people, being associated with higher risk of future dementia and progression of existing dementia. However relatively little data are available on which biochemical pathways are dysregulated in the brain during delirium episodes, whether there are protein expression changes common among delirium subjects and whether there are any changes which correlate with the severity of delirium. We now present the first proteomic analysis of delirium cerebrospinal fluid (CSF), and one of few studies exploring protein expression changes in delirium. More than 270 proteins were identified in two delirium cohorts, 16 of which were dysregulated in at least 8 of 17 delirium subjects compared with a mild Alzheimer's disease neurological control group, and 31 proteins were significantly correlated with cognitive scores (mini-mental state exam and acute physiology and chronic health evaluation III). Bioinformatics analyses revealed expression changes in several protein family groups, including apolipoproteins, secretogranins/chromogranins, clotting/fibrinolysis factors, serine protease inhibitors and acute-phase response elements. These data not only provide confirmatory evidence that the inflammatory response is a component of delirium, but also reveal dysregulation of protein expression in a number of novel and unexpected clusters of proteins, in particular the granins. Another surprising outcome of this work is the level of similarity of CSF protein profiles in delirium patients, given the diversity of causes of this syndrome. These data provide additional elements for consideration in the pathophysiology of delirium as well as potential biomarker candidates for delirium diagnosis.