Exposure of birds to radionuclides and other contaminants in Special Protection Areas (SPAs) in North-West England

There has been a decline in the population of some bird species at Morecambe Bay and the Solway Firth Special Protected Areas in North-West England during the last fifty years. It was suggested that the declines were caused, in part, by contaminants in the food and environment, primarily from the radioactive effluent discharge from the Sellafield Ltd nuclear fuel reprocessing plant in Cumbria. This study analysed bird feathers and tissues, vegetation and sediment for radionuclides, metals and persistent organic compounds. The non-radionuclide results were all low compared to relevant action limits. The ERICA model was used with field data to estimate the radiological dose to birds from exposure to (137)Cs and (241)Am with results between 1.26 to 3.83 microGy h(-1), below the ERICA screening level of 10 microGy h(-1) and within the IAEA 40 microGy h(-1) guideline value below which potential adverse impacts on biota are unlikely. The study showed no link between bird population decline and anthropogenic discharges to the SPAs.

Abstract 3443: Lymphangiogenic parameters in metastatic malignant melanoma: association with clinicopathological parameters and prognosis

Background and aims: Regional lymph node metastasis is one of the important indicators of malignant melanoma. Lymphatic or vascular systems are considered to provide a way whereby tumor cells can migrate to the lymph nodes either by direct invasion of surrounding tissue or spreading. Despite their clinical relevance, the mechanisms that guide the way of spreading are not well known. Recent studies have shown that Flt-4, a VEGF receptor, is activated by its ligand, VEGF-C. The resultant signaling pathway promotes angiogenesis and/or lymphangiogenesis, but the prognostic significance of these axes in malignant melanoma remains controversial. The aim of this study is to clarify therole of these factors and to evaluate the relationships between the VEGF-C/Flt-4 axis and lymphangiogenesis, lymph node metastasis, and prognosis in patients with metastatic malignant melanoma patients (MMM). The expressions of VEGF-C and VEGFR −3 were detected on 15 metastatic melanoma tumor by immunohistochemistry. Circulating form of VEGFC and Flt-4 were measured using ELISA assays in the sera of 90 patients with MMM in comparison to 50 healthy controls. Disease free Survival (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier method. Results: High expressions of VEGF-C and VEGFR-3 proteins were concomitantly detected in the cytoplasm of melanoma tumors. VEGF-C was associated with VEGFR-3 expression and was significantly correlated with lymph node metastasis. Pretreatment median levels of sVEGF-C and sFlt-4 were significantly higher in MMM patients as compared to healthy ones (p=0.005, p<0.00001). None of the studied markers correlated with gender, age or LDH levels. An inverse correlation between Flt-4 expression & its soluble form was noted (r=-0.33 p=0.040). A positive correlation between sVEGF-C & sFlat-4 was observed (r’=0.430, p=0.0014). Furthermore, high expression & levels of sVEGF-C, sFlat-4 correlated to high tumor burden (p=0.02, p=0.045). Only sVEGFC/sFlat-4 ratio showed a relationship with lymph node metastasis. Pretreatment sFlat-4 level was significantly different (p=0.0125) between R (n=40) & NR patients (n=50) but not sVEGF-C level. After treatment, no change in the median sFlat-4 level was observed. By contrast, sVEGF-C increased specifically in NR patients with high tumor burden. Only elevated level of sFlat-4 concentration exert a significantly unfavorable impact on disease free survival (X2= 3.855, p=0.045). Conclusions: This study suggests that both VEGF-C and VEGFR-3 expression as well as their soluble forms are involved in peritumoral lymphangiogenesis and lymphatic metastasis. Furthermore, the VEGF-C/Flt-4 axis enhances cancer cell invasiveness, contributes to the promotion of cancer cell metastasis and may be clinically useful indicators for prognostic evaluation in patients with metastatic malignant melanoma.

Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3443.

Relative efficiency of chlamydia screening in non-clinical settings in two California counties

We examined the relative efficiency of non-clinical sites to screen for chlamydia in youth and young adults. Chlamydia screening targeting youth (under 30 years of age) was performed at non-clinical sites in high-morbidity neighbourhoods of two California counties. Venues were subdivided into community outreach, schools, parenting centres and drug treatment/correctional facilities. Relative efficiency was estimated with multivariate Poisson regression using incidence of chlamydia per person-hours labour adjusting for strategy and county. Among the 1514 youths screened, the overall prevalence of chlamydia was 5.5%. By venue, the highest prevalence was in drug treatment/correction facilities at 11.1% followed by parenting centres at 6.3%, community outreach at 4.9% and schools at 4.6%. Drug treatment/correctional facilities were the most labour time efficient at 9.9 person-hours per chlamydia case. Schools and parenting centres had the lowest cost per screen at 0.9 person-hours per screen. Adjusted relative labour time efficiency (chlamydia cases per paid person-hour) was significantly higher in schools, 2.0 (95% confidence interval [CI] 1.0-4.2), parenting centres, 3.2 (95% CI 1.6-6.6) and drug treatment/correctional facilities, 2.9 (95% CI 1.0-7.8), compared with community outreach. In conclusion, parenting centres and drug treatment centres and correctional facilities are the most efficient venues for chlamydia screening.

Phenotypic approaches to gene mapping in platelet function disorders - identification of new variant of P2Y12, TxA2 and GPVI receptors

Platelet number or function disorders cause a range of bleeding symptoms from mild to severe. Patients with platelet dysfunction but normal platelet number are the most prevalent and typically have mild bleeding symptoms. The study of this group of patients is particularly difficult because of the lack of a gold-standard test of platelet function and the variable penetrance of the bleeding phenotype among affected individuals. The purpose of this short review is to discuss the way in which this group of patients can be investigated through platelet phenotyping in combination with targeted gene sequencing. This approach has been used recently to identify patients with mutations in key platelet activation receptors, namely those for ADP, collagen and thromboxane A2 (TxA2). One interesting finding from this work is that for some patients, mild bleeding is associated with heterozygous mutations in platelet proteins that are co-inherited with other genetic disorders of haemostasis such as type 1 von Willebrand's disease. Thus, the phenotype of mild bleeding may be multifactorial in some patients and may be considered to be a complex trait.

Clinical pathological and epidemiological assessment of morphologically and immunologically confirmed canine leukaemia

Traditionally, classification of leukaemia in dogs has relied on morphological examination and cytochemical staining patterns, but aberrant cellular morphology and stain uptake often curtails accurate categorization, and historical data based on this classification may be unreliable. Immunophenotyping is now the gold standard for classification of leukaemias. The purpose of this prospective study was to assess the clinical pathological and epidemiological features of a population of dogs with morphologically and immunologically confirmed leukaemia and to compare them within categories: acute and chronic lymphoid leukaemia (ALL and CLL), and acute and chronic myeloid leukaemia (AML and CML). There were 64 cases of morphologically and immunologically confirmed leukaemia: 25 cases of ALL, 17 cases of CLL and 22 cases of AML. Prevalence of B and T immunophenotypes in ALL and CLL was not statistically different. Dogs with AML were significantly younger than those with ALL at presentation (P = 0.04). Golden Retriever dogs in the study population were overrepresented in comparison with a control population of dogs (6/25 ALL cases, 8/64 leukaemia cases). No sex was overrepresented. Dogs with ALL had significantly more severe neutropenia (P = 0.001) and thrombocytopenia (P = 0.002) than those with CLL and had significantly more cytopenias. The severity and numbers of cytopenias seen in ALL and AML were not significantly different. Twenty-one of the leukaemia cases showed one cytopenia, fourteen had two cytopenias and twenty-one cases had pancytopenia. Anaemia was the most common cytopenia seen in isolation (17/21). No dogs had neutropenia without anaemia and/or thrombocytopenia. Total white blood cell counts were not different between the groups. The atypical cell counts within the peripheral blood were significantly higher in ALL than AML; both in isolation and as a percentage of the total white blood cell count (P = 0.03). This study strengthens the hypothesis that acute leukaemias give rise to more profound cytopenias, affecting more cell lines, than chronic leukaemias.

Systematically missing confounders in individual participant data meta-analysis of observational cohort studies

One difficulty in performing meta-analyses of observational cohort studies is that the availability of confounders may vary between cohorts, so that some cohorts provide fully adjusted analyses while others only provide partially adjusted analyses. Commonly, analyses of the association between an exposure and disease either are restricted to cohorts with full confounder information, or use all cohorts but do not fully adjust for confounding. We propose using a bivariate random-effects meta-analysis model to use information from all available cohorts while still adjusting for all the potential confounders. Our method uses both the fully adjusted and the partially adjusted estimated effects in the cohorts with full confounder information, together with an estimate of their within-cohort correlation. The method is applied to estimate the association between fibrinogen level and coronary heart disease incidence using data from 154 012 participants in 31 cohorts.† Copyright © 2009 John Wiley & Sons, Ltd.

Can abdominal bioelectrical impedance refine the determination of visceral fat from waist circumference?

Ryo et al (2005 Diabetes Care 28 451-3) reported a new method for measuring the visceral fat area (VFA) by combining abdominal bioelectrical impedance analysis (BIA) with measurement of waist circumference (WC), but very few methodological details were provided. Furthermore, the study did not test the use of WC alone as an indicator of VFA even though others had previously reported a strong correlation. We sought to determine the optimal measurement technique and analysis for measuring VFA by abdominal BIA and WC. 18 volunteers (age 23-64 years) underwent measurement of WC, abdominal impedance (Bodystat 500 four-electrode system) and a single cross-sectional CT scan at the umbilicus. VFA derived using WC(3) and measurements of abdominal impedance from electrode pairs sited at the flank predicted the value of VFA measured by CT with correlation r = 0.904 (p < 0.0001); the optimizing power of WC was 3.3 (r = 0.905). However, the use of WC(1.9) alone, without involving BIA at all, provided a similar correlation (r = 0.923). Our small preliminary study shows that abdominal BIA is potentially a practicable non-invasive technique for measurement of VFA but casts doubt on whether it adds any value to the use of WC alone. Larger studies are now required to test this finding.

Class II major histocompatibility complex genes of the sheep

The class II genes of the sheep major histocompatibility complex (MHC) have been cloned from two unrelated heterozygous sheep into cosmid vectors. By restriction mapping and hybridization with a number of class II probes of human and mouse origin, the cloned genetic material has been assigned to seven distinct alpha genes, 10 distinct beta genes and 14 beta-related sequences. It was difficult to identify homologues of specific HLA class II genes because of a tendency for the ovine genes to cross-hybridize between HLA probes representing different loci. Such cross-hybridization was especially marked among the beta genes. While DQ and DR homologues have been tentatively identified by several criteria, no genes corresponding to DP have been identified. Cosmids containing class II alpha and beta genes have been transfected into mouse LTK- cells, and surface expression of a sheep class II molecule has been obtained.

A role for CD81 on the late steps of HIV-1 replication in a chronically infected T cell line

BACKGROUND

HIV-1 uses cellular co-factors for virion formation and release. The virus is able to incorporate into the viral particles host cellular proteins, such as tetraspanins which could serve to facilitate HIV-1 egress. Here, we investigated the implication of several tetraspanins on HIV-1 formation and release in chronically infected T-lymphoblastic cells, a model that permits the study of the late steps of HIV-1 replication.

RESULTS

Our data revealed that HIV-1 Gag and Env structural proteins co-localized with tetraspanins in the form of clusters. Co-immunoprecipitation experiments showed that Gag proteins interact, directly or indirectly, with CD81, and less with CD82, in tetraspanin-enriched microdomains composed of CD81/CD82/CD63. In addition, when HIV-1 producing cells were treated with anti-CD81 antibodies, or upon CD81 silencing by RNA interference, HIV-1 release was significantly impaired, and its infectivity was modulated. Finally, CD81 downregulation resulted in Gag redistribution at the cell surface.

CONCLUSION

Our findings not only extend the notion that HIV-1 assembly can occur on tetraspanin-enriched microdomains in T cells, but also highlight a critical role for the tetraspanin CD81 on the late steps of HIV replication.

HIV-1 buds and accumulates in "nonacidic" endosomes of macrophages

Macrophages represent viral reservoirs in HIV-1-infected patients and accumulate viral particles within an endosomal compartment where they remain infectious for long periods of time. To determine how HIV-1 survives in endocytic compartments that become highly acidic and proteolytic and to study the nature of these virus-containing compartments, we carried out an ultrastructural study on HIV-1-infected primary macrophages. The endosomal compartments contain newly formed virions rather than internalized ones. In contrast to endocytic compartments free of viral proteins within the same infected cells, the virus containing compartments do not acidify. The lack of acidification is associated with an inability to recruit the proton pump vacuolar ATPase into the viral assembly compartment. This may prevent its fusion with lysosomes, since acidification is required for the maturation of endosomes. Thus, HIV-1 has developed a strategy for survival within infected macrophages involving prevention of acidification within a devoted endocytic virus assembly compartment.

Determination of suitable housekeeping genes for normalisation of quantitative real time PCR analysis of cells infected with human immunodeficiency virus and herpes viruses

The choice of an appropriate housekeeping gene for normalisation purposes has now become an essential requirement when designing QPCR experiments. This is of particular importance when using QPCR to measure viral and cellular gene transcription levels in the context of viral infections as viruses can significantly interfere with host cell pathways, the components of which traditional housekeeping genes often encode. In this study we have determined the reliability of 10 housekeeping genes in context of four heavily studied viral infections; human immunodeficiency virus type 1, herpes simplex virus type 1, cytomegalovirus and varicella zoster virus infections using a variety of cell types and virus strains. This provides researchers of these viruses with a shortlist of potential housekeeping genes to use as normalisers for QPCR experiments.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Residual capacitive coupling and the measurement of permittivity in magnetic induction tomography

In an ideal magnetic induction tomography (MIT) system, the coupling between the coils and the sample is entirely by the magnetic field. In a practical system, unwanted electric-field (capacitive) coupling can also exist and cause large errors in the MIT measurements unless the hardware is designed carefully. A series of tests was carried out to assess the magnitude of capacitive coupling present in a 10 MHz MIT system designed for biomedical use and other applications involving low-conductivity samples (<or=10 S m(-1)). The tests indicated that, even with the individual coils left unscreened, the signal contamination from capacitive coupling was very small compared with the true MIT signal. Because the contamination was small, it was demonstrated possible to derive the permittivity of the sample from the real part of the MIT signal. This was shown to work well when the conductivity of the sample was less than about 0.5 S m(-1), but for higher conductivities, when the skin depth became comparable with the width of the sample, the commonly used theoretical expression for the MIT signal began to break down. This implies that the measurement of permittivity (and permeability) in real biological tissues (which have conductivities of up to 2 S m(-1)) will require a more detailed derivation taking into account both the real and imaginary parts of the signals.

Tastes and odours in drinking water: where are we today?

This article gives a concise summary of the position reached by tastes and odours research in recent decades, and highlights nine key challenges for further investigation.

Interlaboratory comparison of geosmin and 2-methylisoborneol in municipal tap water

An interlaboratory comparison ("round-robin") for geosmin and 2-methylisoborneol (MIB) was carried out between six laboratories of the Ontario Water Works Research Consortium (OWWRC). Municipal tap water was found to be a suitable medium for distribution of samples. To test stability, geosmin and MIB were added to tap water and stored at 2-4 degrees C. Under these conditions, geosmin concentrations declined by approximately 5% per month for the first 2 months. MIB concentrations were stable over a 158-day period. Three round-robins were carried out individually in 2001, 2003 and 2004. Two levels of geosmin and MIB were used: nominally 10 and 100 ng/l. In 2003 the relative standard deviation for all six participating laboratories were 34, 21, 21 and 22% for low and high level MIB, and low and high level geosmin, respectively. For all but MIB at the low level, there was a marked improvement in agreement between laboratories from 2001 to 2004. However, we recommend use of common analytical standards in order to potentially further reduce interlaboratory variability.

Are burns photographs useful?

Routine photography of all patients admitted to the West of Scotland Regional Burns Unit was introduced in 2003. To date, there are few burns units to evaluate the usefulness of photographs taken.

AIM

To assess the usefulness of photographs of patients admitted to the burns unit to various members of the multidisciplinary team.

METHOD

A questionnaire was completed by hospital staff involved in the management of burns patients over a 3-month period. A total of 43 questionnaires were completed.

RESULTS

The majority of questionnaires were completed by nursing staff (55%) followed by medical staff (23%); physiotherapy (5%); anaesthetists (7%); theatre staff (5%); students (2%); dietician (2%). About 98% of respondents agreed that photographs were useful overall, particularly for teaching purposes. About 9% disagreed that photographs were useful for assessment due to difficulty in assessing depth of burn. About 72% agreed that the photographs were useful for patient management and improve patient care. About 88% agreed that all patients should have photographs available in future. Advantages of photographs include; moving and handling of patients; patient positioning in theatre; reviewing wound healing and complications. They are useful for assessing site, size and type of burn. Disadvantages include difficulty in assessing depth of burn, technical factors, and unavailability out of hours.

CONCLUSIONS

Photographs of burns patients are useful overall to all members of the multidisciplinary team.

Tiagabine in the treatment of acute affective episodes in bipolar disorder: efficacy and acceptability

BACKGROUND

Bipolar disorder is a common recurrent illness with high levels of chronicity. Treatment resistance persists despite the use of established medications, such as lithium and valproate. New medications are required for the treatment of refractory cases. Some open-label reports have suggested that the anticonvulsant tiagabine may be efficacious in bipolar disorder. There is a need to clarify the evidence available, in the form of randomised controlled trials, for its use in the treatment of acute affective episodes in bipolar disorder

OBJECTIVES

To review the evidence for the efficacy and acceptability of tiagabine in the treatment of acute mood episodes in bipolar disorder.

SEARCH STRATEGY

The following databases were searched on 13-10-2005. The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References),The Cochrane Controlled Clinical Trials Register (CCCTR),EMBASE,MEDLINE,LILACS,PsycLIT andPsyndex. Reference lists of relevant papers and major textbooks of mood disorder were searched. Handsearches were done (specialist journals and conference proceedings). Authors, other experts in the field and pharmaceutical companies were contacted for knowledge of suitable published or unpublished trials.

SELECTION CRITERIA

Randomised controlled trials, which compared tiagabine with placebo or with active agents in the treatment of any acute mood episodes in bipolar disorder, were selected. Studies of participants with bipolar disorder were to be included. Subjects could be of either sex and of all ages.

DATA COLLECTION AND ANALYSIS

Data extraction and methodological quality assessment were performed independently by two reviewers. For analysis, relative risk was used for binary efficacy outcomes and the weighted mean difference or standardised mean differerence was used for continuously distributed outcomes

MAIN RESULTS

We did not find any studies which fulfilled the Cochrane criteria of randomised controlled trials. However, one uncontrolled open label study and one case series were found. There were also three case reports/series of acute treatment which were continued into maintenance therapy, and one open non-randomised study with this design. The results of these studies are inconsistent.

AUTHORS' CONCLUSIONS

We found no randomised controlled trials of tiagabine in bipolar disorder. In the reported cases, a significant proportion of patients suffered episodes of syncope or seizure. There is a need for randomised controlled trials examining the efficacy and acceptability of tiagabine in the acute treatment of bipolar disorder, after the nature of these episodes has been clarified.

Comparison of red blood cell transfusion rates of epoetin alfa and darbepoetin alfa in an inpatient oncology setting

16002

Background: Epoetin alfa (EPO) and darbepoetin alfa (DARB) are used to treat cancer-related anemia and to reduce the requirements for blood transfusions. To date, limited information on the relative effectiveness of these agents in the inpatient setting is available. This analysis evaluated red blood cell (RBC) transfusion rates in cancer patients receiving EPO or DARB during hospitalization. Methods: An analysis of electronic inpatient hospital records from the Premier Perspective Comparative Hospital Database was conducted to compare RBC transfusion rates in cancer patients receiving EPO or DARB therapy. Study subjects were identified through hospitalizations recorded between 07/2002 and 03/2005 from over 500 hospitals nationwide. Patients were required to be ≥18 years old, have a primary admitting diagnosis of cancer and be treated with EPO or DARB during hospitalization. Patients who had received renal dialysis were excluded. To minimize effects of outliers, 5% of patients with extreme doses in each group were excluded from the dosing analysis. In addition to descriptive statistics on transfusion requirements, a multivariate logistic model was employed to isolate the effect of an individual erythropoietic agent on the risk of RBC transfusion after controlling for patient demographics, comorbidities, admission characteristics, use of IV or oral iron and hospitalization severity markers. Results: Among the 24,814 EPO and 2,990 DARB study patients, mean age and gender distribution at admission were similar (age: EPO 65.3 years, DARB 64.5 years; %women: EPO 53%, DARB 55%). Mean cumulative dose per inpatient stay was EPO 61,656 ± 50,274 Units and DARB 259 ± 340 mcg. RBC transfusions occurred in 37.9% of EPO patients compared to 39.8% of DARB patients (p=0.0404). Transfused EPO patients received a mean of 2.24 units versus 2.20 units for DARB patients (p=0.2111). After adjusting for covariates, the multivariate model confirmed that DARB treatment was associated with a higher risk of transfusion compared to EPO (odds ratio: 1.2, 95% CI: 1.1–1.3, p=0.0007). Conclusions: This analysis of inpatients with cancer indicates DARB treatment is associated with a higher risk of receiving RBC transfusion compared to treatment with EPO.

[Table: see text]

A role for voltage-gated, but not Ca2+-activated, K+ channels in regulating spontaneous contractile activity in myometrium from virgin and pregnant rats

The roles of voltage-gated (K(V)) and large conductance Ca2+-activated K+ (BK(Ca)) channels in regulating basal contractility in myometrial smooth muscle are unresolved. The aim of this study was to determine the effects of inhibition of these channels on spontaneous rhythmic contraction in myometrial strips from four groups of rats: nonpregnant and during early (day 7), mid- (day 14), and late (day 21) pregnancy. BK(Ca) channels were inhibited using iberiotoxin (1-100 nM), paxilline (1-10 microM) or penitrem A (1-500, or 3000 nM); K(V) channels were inhibited using tetraethylammonium (TEA; 1-10 mM) and/or 4-aminopyridine (4-AP; 1-5 mM). Contractility was assessed as mean integral tension (MIT). Time/vehicle controls were also performed. None of the selective BK(Ca) channel inhibitors significantly affected contractility in myometrial strips from either nonpregnant or pregnant animals. 4-AP caused concentration-dependent increases in MIT in myometrium in all four groups. TEA (5 and 10 mM) significantly increased MIT in myometrium from nonpregnant, and mid- and late pregnant rats, but not in myometrium from early pregnant rats. TEA and 4-AP still caused an increase in MIT following treatment with 3000 nM penitrem A or a combination of propranolol, phentolamine, atropine (all 1 microM) and capsaicin (10 microM) in myometrial strips from nonpregnant rats. These results indicate that whereas BK(Ca) channels play little or no part in controlling basal rhythmicity in rat myometrium, K(V) channels appear to play a crucial role in this regard, especially during mid- and late pregnancy.