European Association of Perinatal Medicine (EAPM), European Board and College of Obstetricians and Gynaecologists (EBCOG), European Midwives Association (EMA). Joint position statement: Substandard and disrespectful care in labour - because words matter

Substandard or disrespectful care during labour should be of serious concern for healthcare professionals, as it can affect one of the most important events in a woman's life. Substandard care refers to the use of interventions that are not considered best-practice, to the inadequate execution of interventions, to situations where best-practice interventions are withheld from patients, or there is lack of adequate informed consent. Disrespectful care refers to forms of verbal and non-verbal communication that affect patients' dignity, individuality, privacy, intimacy, or personal beliefs. There are many possible underlying causes for substandard and disrespectful care in labour, including difficulties in modifying behaviours, judgmental or paternalistic attitudes, personal interests and individualism, and a human tendency to make less arduous, less difficult, or less stressful clinical decisions. The term "obstetric violence" is used in some parts of the world to describe various forms of substandard and disrespectful care in labour, but suggests that it is mainly carried out by obstetricians and is a serious form of aggression, carried out with the intent to cause harm. We believe that this term should not be used, as it does not help to identify the underlying problem, its causes, or its correction. In addition, it is generally seen by obstetricians and other healthcare professionals as an unjust and offensive term, generating a defensive and less collaborative mindset. We reach out to all individuals and institutions sharing the common goal of improving women's experience during labour, to work together to address the underlying causes of substandard and disrespectful care, and to develop common strategies to deal with this problem, based on mutual comprehension, trust and respect.

Sensitization to genuine markers of timothy grass pollen (Phleum pratense) in the North-Central region of Portugal

Summary

Background. Pollen is the main cause of respiratory allergy and its prevalence is increasing. Timothy grass (Phleum pratense) is one of the most common pollen sources, and one of the best characterized allergenic grasses. The major allergens Phl p1, Phl p2, Phl p5 and Phl p6 are considered markers of genuine grass pollen sensitization. Methods. Retrospective study. IgE levels of Phl p1 and Phl p5 in patients living in the North-Central region of Portugal were analyzed, considering age and area of residence (inland or costal). Results. Among the 188 patients with IgE results for Phl p1 and Phl p5, sensitization to Phl p1 and Phl p5b was observed in 97.87% and 63.83%, respectively. The majority demonstrated co-sensitization to both Phl p1 and Phl p5b, while 68 patients were monosensitized to Phl p1 and 4 patients were monosensitized to Phl p5b. Either patients living in costal or inland areas showed IgE levels of Phl p1 higher than Phl p5b. Conclusions. Regarding genuine grass pollen sensitization, Phl p1 sensitization is more prevalent than Phl p5b in the North-Central region of Portugal.

EUROPEAN ASSOCIATION OF PERINATAL MEDICINE (EAPM) Position statement: Use of appropriate terminology for situations related to inadequate fetal oxygenation in labor

In high-resource countries, adverse perinatal outcomes are currently rare in term, non-malformed fetuses, undergoing labor, but they remain a leading cause of medico-legal dispute. Precise terminology is important to describe situations related to inadequate fetal oxygenation in labor, to ensure appropriate communication between healthcare professionals and adequate transmission of information to parents. This position statement provides consensus definitions from European perinatologists and midwives regarding the most appropriate terminology to describe situations related to inadequate fetal oxygenation in labor: suspected fetal hypoxia, severe newborn acidemia, newborn metabolic acidosis, and hypoxic-ischemic encephalopathy. It also identifies terms that are imprecise or nonspecific to this situation, and should therefore be avoided by healthcare professionals: fetal well-being, fetal stress, fetal distress, non-reassuring fetal state, and birth asphyxia.

Expression of IL-17RA in Innate Cells of Patients with Common Variable Immunodeficiency (CVID) and its Clinical Implications

Summary

Background. Common Variable Immunodeficiency (CVID) is a primary immunodeficiency disorder characterized by B-cell dysfunction and immunoglobulin production deficiency. Dysregulation of interleukin-17 (IL-17) and its receptor IL-17RA have been reported in various immune disorders. This study aimed to investigate the expression of IL-17RA in innate immune cells of CVID patients and its correlation with clinical manifestations. Methods. A cross-sectional study included 22 CVID patients and 14 age- and sex-matched healthy controls. IL-17RA expression was assessed in various immune cell subsets using flow cytometry. Demographic and clinical data were collected, and statistical analysis was performed. Results. CVID patients had elevated IL-17RA expression in neutrophils, non-classical monocytes, and dendritic cells compared to healthy controls. Patients with a history of intestinal microbial colonization, particularly with Campylobacter jejuni and Giardia intestinalis, showed significantly higher IL-17RA expression in innate cells. Elevated IL-17RA expression in monocytes and dendritic cells also correlated with higher fecal calprotectin levels in CVID patients, regardless of microbial colonization. Conclusions. The study suggests that despite previous reports of reduced circulating Th17 cells and IL-17 levels in CVID patients, IL-17RA expression in innate cells may be elevated, potentially indicating altered IL-17 signaling. This heightened IL-17RA expression could contribute to a persistent pro-inflammatory state, possibly due to microbial translocation or other inflammatory factors. The association of IL-17RA expression with gastrointestinal microbial colonization and its correlation with fecal calprotectin underscores the complexity of IL-17RA's role in CVID pathophysiology. Further research in larger cohorts could elucidate the implications of IL-17RA expression in both infectious and non-infectious inflammatory aspects of CVID.

Influence of preconception body mass index on perinatal outcomes after metabolic and bariatric surgery

INTRODUCTION

Metabolic and bariatric surgery (MBS) is a very effective weight loss intervention, although does not invariably reverses the obesity status. Our aim was to evaluate whether despite successful weight loss after MBS, persistence of obesity at time of conception still carries additional risks of adverse perinatal pregnancy outcomes.

METHODS

Retrospective study comparing pregnancy outcomes of women previously submitted to MBS with a preconception (PC) body mass index BMI < 30 kg/m2 or PC BMI ≥ 30 kg/m2.

RESULTS

Eighty pregnancies (n = 80) were included, 49 from women with a PC BMI < 30 kg/m2 and 31 with a PC BMI ≥ 30 kg/m2. Gestational weight gain was significantly lower (9.72 ± 7.10 vs. 13.81 ± 7.16 respectively; p = 0.01) and neonatal intensive care unit admissions were significantly higher (5% vs. 0% respectively; p = 0.02) in women with PC BMI ≥ 30 kg/m2 as compared to those with PC BMI < 30 kg/m2. There were no statistically significant differences in gestational diabetes, anemia, fetal growth restriction, prematurity rate, mode of delivery or birth weight between groups.

CONCLUSION

Perinatal outcomes of pregnancies after MBS may be significantly influenced by PC BMI. The benefits of MBS induced weight loss on obesity-associated adverse pregnancy outcomes can be maximized if the obesity status can be reverted before pregnancy.

FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery

FIGO is actively contributing to the global effort to reduce maternal morbidity, mortality, and disability worldwide. Cesarean delivery rates are increasing globally, without signs of slowing down. Bleeding associated with cesarean delivery has become an important cause of hemorrhage-related maternal deaths in many low- and middle-income countries. Correct surgical techniques to improve safety and reduce complications of cesarean delivery is of the utmost importance. This article presents FIGO's good practice recommendations for effective surgical techniques to reduce cesarean complications. Evidence-based information is included where data are available. An expanded WHO Surgical Safety Checklist for maternity cases is suggested. Different incision techniques through the layers of the abdominal wall with appropriate indications are discussed. Hysterotomy through a transverse incision is described, as are indications for low vertical and classical incisions. Important precautions when extracting the fetus are explained. Uterine closure includes a safe method ensuring adequate reapproximation of the upper segment if a vertical incision is made. The paper concludes with the management of two common bleeding problems following delivery of the placenta.

Machine learning models based on clinical indices and cardiotocographic features for discriminating asphyxia fetuses—Porto retrospective intrapartum study

Introduction

Perinatal asphyxia is one of the most frequent causes of neonatal mortality, affecting approximately four million newborns worldwide each year and causing the death of one million individuals. One of the main reasons for these high incidences is the lack of consensual methods of early diagnosis for this pathology. Estimating risk-appropriate health care for mother and baby is essential for increasing the quality of the health care system. Thus, it is necessary to investigate models that improve the prediction of perinatal asphyxia. Access to the cardiotocographic signals (CTGs) in conjunction with various clinical parameters can be crucial for the development of a successful model.

Objectives

This exploratory work aims to develop predictive models of perinatal asphyxia based on clinical parameters and fetal heart rate (fHR) indices.

Methods

Single gestations data from a retrospective unicentric study from Centro Hospitalar e Universitário do Porto de São João (CHUSJ) between 2010 and 2018 was probed. The CTGs were acquired and analyzed by Omniview-SisPorto, estimating several fHR features. The clinical variables were obtained from the electronic clinical records stored by ObsCare. Entropy and compression characterized the complexity of the fHR time series. These variables' contribution to the prediction of asphyxia perinatal was probed by binary logistic regression (BLR) and Naive-Bayes (NB) models.

Results

The data consisted of 517 cases, with 15 pathological cases. The asphyxia prediction models showed promising results, with an area under the receiver operator characteristic curve (AUC) &gt;70%. In NB approaches, the best models combined clinical and SisPorto features. The best model was the univariate BLR with the variable compression ratio scale 2 (CR2) and an AUC of 94.93% [94.55; 95.31%].

Conclusion

Both BLR and Bayesian models have advantages and disadvantages. The model with the best performance predicting perinatal asphyxia was the univariate BLR with the CR2 variable, demonstrating the importance of non-linear indices in perinatal asphyxia detection. Future studies should explore decision support systems to detect sepsis, including clinical and CTGs features (linear and non-linear).

Designing a Nurse-Led Program for Self-Management of Substance Addiction Consequences: A Modified e-Delphi Study

Therapeutic interventions for people with problematic use of psychoactive substances can help tackle specific needs related to substance addiction consequences. This modified e-Delphi study aimed to establish consensus on a training program for self-management of substance addiction consequences. The study was conducted between February and April 2022, with an experts' sample of 28 participants in the first round and 24 in the second. A priori consensus criteria were defined for each round. The results revealed a very strong consensus was achieved on the structure of the program and on clinical areas, such as the problematic use of substances, general health knowledge, health-seeking behavior and adherence, self-knowledge and well-being, social role and personal dignity, and family process. Additionally, over 80% participant consensus was achieved on an extensive number of interventions categorized as psychoeducational, psychotherapeutic, socio therapeutic, brief interventions, social skills training, problem solving techniques, relaxation techniques, and counseling. These findings may be able to fulfill a gap concerning structured treatment approaches for people with problematic use of psychoactive substances. Supporting self-management of the consequences of substance addiction and its application can change nurses' interventions.

Structured programs for the self-management of substance addiction consequences in outpatient services: A scoping review

Structured intervention programs are an important resource for supporting people with substance addiction. Although evidence suggests that they improve health outcomes, such as specific symptoms, less is known about their impact on patients’ ability to self-manage the consequences of substance addiction. The aim of this review is to scope outpatient intervention programs focused on the self-management of substance addiction consequences. Approach. This review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews. MEDLINE and CINAHL (through Ebsco), Psychology & Behavioral Sciences Collection (including PsycINFO) and Web of Science were screened to identify articles published in the last 10 years. Only primary research was included. Out of 891 records, 19 were eligible for this review—12 randomized controlled trials (RCT), 6 quasi-experimental study and 1 observational study. Those studies reported group interventions (10), individual interventions (8) and 1 mixed approach. The most common interventions were based on motivational strategies, relapse prevention and definition of active plans for risky situations. 10 studies reported positive effects. The identification of structured programs may support the development of new approaches focused on empowerment and quality of life of people with substance addiction. Programs to empower patients for self-management of substance addiction consequences are often complex and rely on health professionals’ commitment. Nevertheless, they are a feasible approach that seems to benefit patients managing chronic conditions associated with substance addiction.

Compressive Neuropathy: A Consequence of Mal-Positioning during Labour?

N/a.

Rare case of interstitial nephritis in a young adult under IgG therapy

Immunoglobulin replacement therapy is an important therapeutic approach used in different diseases, such as immunodeficiency diseases. We report a case of a 19-year-old female patient with suspected common variable immunodeficiency who started replacement therapy with IgG. During the follow-up, she developed interstitial nephritis and the subsequent workup excluded other diseases or triggers except IgG therapy.

Physical exercise in pregnancy: benefits, risks and prescription

OBJECTIVES

The aim of this article is to provide a comprehensive literature review, gathering the strongest evidence about the risks and benefits and the prescription of physical exercise during pregnancy.

CONTENT

Regular physical exercise during pregnancy is associated with numerous benefits. In general women are not adequately advised on this matter. Along with their concerns regarding the potential associated risks, it contributes to the abandonment or refusal to start exercising during pregnancy. A systematic review was conducted in MEDLINE including articles considered to have the highest level of scientific evidence. Fifty-seven articles, including 32 meta-analysis, 9 systematic reviews and 16 randomized controlled trials were included in the final literature review.

SUMMARY

Exercise can help preventing relevant pregnancy related disorders, such as gestational diabetes, excessive gestational weight gain, hypertensive disorders, urinary incontinence, fetal macrosomia, lumbopelvic pain, anxiety and prenatal depression. Exercise is not related with an increased risk of maternal or perinatal adverse outcomes. Compliance with current guidelines is sufficient to achieve the main benefits, and exercise type and intensity should be based on woman's previous fitness level.

OUTLOOK

Exercise in pregnancy is safe for both mother and fetus, contributing to prevent pregnancy related disorders. Exercise type and intensity should be adapted to woman's previous fitness level, medical history and characteristics of the ongoing pregnancy.

The influence of cognitive reserve in the protection of the cognitive status after an acquired brain injury: A systematic review

BACKGROUND

Cognitive Reserve (CR) hypothesis was introduced to account for the variability in cognitive performance of patients with similar degrees of brain injury or pathology. The individual variability of CR is modulated by the interaction of innate capacities and exposures throughout life, which can act as protectors against neuropathology's clinical effects. Individuals with higher CR appear to have better cognitive performance after a brain injury. The present review aimed to identify and map the scientific evidence available in literature regarding CR's influence in protecting the cognitive status after an Acquired Brain Injury (ABI).

METHOD

A systematic review was performed for published studies until October 2020 in PubMed, Scopus, and CINAHL electronic databases. Studies regarding CR's influence in protecting the cognitive status after an ABI were included in this review. The Newcastle-Ottawa Scale was used to assess risk of bias in the included studies. This systematic review was recorded in the International Prospective Register of Systematic Reviews (PROSPERO) under the number CRD42021236594.

RESULTS

Twenty-one studies published between 2003 and 2020 were selected and analyzed. The literature analysis showed that CR has a positive effect on cognitive status after an ABI. Various proxies were used to estimate CR, including estimated premorbid IQ, education, occupation attainment, socioeconomic status, leisure activities, bilingualism, and social integration. CR proxies constitute a set of variables that may have a significant influence on cognitive status. Higher CR levels were associated with lower cognitive impairment after an ABI.

CONCLUSIONS

Although more research is necessary for a complete understanding of CR's impact on cognition, the synthesis of these studies confirmed that there is evidence on the beneficial impact of CR on cognitive status after an ABI. These findings support CR's cognitive status role following an ABI and may provide additional information for prognosis and rehabilitation plans.

OUP accepted manuscript

During germination, the seed releases nutrient-rich exudates into the spermosphere, thereby fostering competition between resident microorganisms. However, insight into the composition and temporal dynamics of seed-associated bacterial communities under field conditions is currently lacking. This field study determined the temporal changes from 11 to 31 days after sowing in the composition of seed-associated bacterial communities of winter wheat as affected by long-term soil fertilization history, and by introduction of the plant growth-promoting microbial inoculants Penicillium bilaiae and Bacillus simplex. The temporal dynamics were the most important factor affecting the composition of the seed-associated communities. An increase in the relative abundance of genes involved in organic nitrogen metabolism (ureC and gdhA), and in ammonium oxidation (amoA), suggested increased mineralization of plant-derived nitrogen compounds over time. Dynamics of the phosphorus cycling genes ppt, ppx and cphy indicated inorganic phosphorus and polyphosphate cycling, as well as phytate hydrolysis by the seed-associated bacteria early after germination. Later, an increase in genes for utilization of organic phosphorus sources (phoD, phoX and phnK) indicated phosphorus limitation. The results indicate that community temporal dynamics are partly driven by changed availability of major nutrients, and reveal no functional consequences of the added inoculants during seed germination.

Fetal Heart Rate Fragmentation

Intrapartum fetal monitoring's primary goal is to avoid adverse perinatal outcomes related to hypoxia/acidosis without increasing unnecessary interventions. Recently, a set of indices were proposed as new biomarkers to analyze heart rate (HR), termed HR fragmentation (HRF). In this work, the HRF indices were applied to intrapartum fetal heart rate (FHR) traces to evaluate fetal acidemia. The fragmentation method produces four indices: PIP-Percentage of inflection points; IALS-Inverse of the average length of acceleration/deceleration segments; PSS-Percentage of short segments; PAS-Percentage of alternating segments. On the other hand, the symbolic approach studied the existence of different patterns of length four. We applied the measures to 246 selected FHR recordings sampled at 4 and 2 Hz, where 39 presented umbilical artery's pH ≤ 7.15. When applied to the 4 Hz FHR, the PIP, IASL, and PSS showed significantly higher values in the traces from acidemic fetuses. In comparison, the percentage of "words"W 1 h andW 2 s showed lower values for those traces. Furthermore, when using the 2 Hz, only IASL, W 0, andW 2 m achieved significant differences between traces from both acidemic and normal fetuses. Notwithstanding, the ideal sampling frequency is yet to be established. The fragmentation indices correlated with Sisporto variability measures, especially short-term variability. Accordingly, the fragmentation indices seem to be able to detect pathological patterns in FHR tracings. These indices have the advantage of being suitable and straightforward to apply in real-time analysis. Future studies should combine these indexes with others used successfully to detect fetal hypoxia, improving the power of discrimination in a larger dataset.

European Guidelines on Perinatal Care - Oxytocin for induction and augmentation of labor[Formula: see text]

OF RECOMMENDATIONS1. Oxytocin for induction or augmentation of labor should not be started when there is a previous scar on the body of the uterus (such as previous classical cesarean section, uterine perforation or myomectomy when uterine cavity is reached) or in any other condition where labor or vaginal delivery are contraindicated. (Moderate quality evidence +++-; Strong recommendation).2. Oxytocin should not be started before at least 1 h has elapsed since amniotomy, 6 h since the use of dinoprostone (30 min if vaginal insert) and 4 h since the use of misoprostol (Low quality evidence ++- -; Moderate recommendation).3. Cardiotocography (CTG) should be performed and a normal pattern without tachysystole should be documented for at least 30 min before oxytocin is used. Continuous CTG, with adequate monitoring of both fetal heart rate and uterine contractions, should be maintained for as long as oxytocin is used, and thereafter until delivery (Low ++- - to moderate +++- quality evidence; Strong recommendation).4. For labor induction, at least 1-h should be allowed after amniotomy before oxytocin infusion is started, to evaluate whether adequate uterine contractility has meanwhile ensued. For augmentation of labor, if the membranes are intact and there are conditions for a safe amniotomy, the latter should be considered before oxytocin is started (Very low quality evidence +- --; Weak recommendation).5. Oxytocin should be administered intravenously using the following regimen: 5 IU oxytocin diluted in 500 mL of 0.9% normal saline (NaCl) (each mL contains 10 mIU of oxytocin), in an infusion pump at increasing rates, as shown in Table 1, until a frequency of 3-4 contractions per 10 min is reached, a non-reassuring CTG pattern ensues, or maximum rates are reached (Low quality evidence ++ - -; Strong recommendation). If the frequency of contractions exceeds 5 in 10 min, the infusion rate should be reduced, even if a normal CTG pattern is present. With a non-reassuring CTG pattern, urgent clinical assessment by an obstetrician is indicated, and strong consideration should be given to reducing or stopping the oxytocin infusion. The minimal effective dose of oxytocin should always be used. (Low ++- - to Moderate +++- - quality evidence; Strong recommendation).[Table: see text]6. Use of oxytocin for induction and augmentation of labor should be regularly audited (Low quality evidence ++--; Strong recommendation).

A Seasonal Cause of Encephalitis: Influenza Virus A (H3N1) Infection

Influenza virus infection can have a range of presentations, from asymptomatic to life-threatening disease. We present the case of a 57-year-old woman with a known history of schizophrenia (controlled with medication) who presented to our emergency department in a coma after experiencing a seizure. She had reported flu-like symptoms in the previous week, which evolved to dyspnoea and altered mental status culminating in seizures and coma. Influenza virus A (H3N1) was identified in the cerebrospinal fluid. Although a rare cause of encephalitis, the influenza virus should be considered in the differential diagnosis, especially during epidemics.

LEARNING POINTS

Influenza virus encephalitis should be considered in some specific settings, such as during pandemics or seasonal epidemics.Altered mental status in a patient with a history of mental disease may be easily dismissed as secondary to prior disease or medication.Although rare, extrapulmonary manifestations of influenza virus infection can be serious and fatal.

Benzodiazepine Use in Opioid Maintenance Treatment Programme: Risks and Clinical Outcomes

INTRODUCTION

The co-association of benzodiazepines and opioids is associated with an increased risk of overdose, death, and poorer psychosocial prognosis. The aim of this study is to characterize the prevalence, pattern of use, and primary clinical outcomes in benzodiazepines users in a public opioid maintenance treatment unit.

MATERIAL AND METHODS

We conducted a cross-sectional study involving 236 patients treated with opioid substitutes (methadone and buprenorphine). We conducted a descriptive, bivariable, and multivariable analysis to determine clinical differences between benzodiazepines users and non-users.

RESULTS

The prevalence of consumption of benzodiazepines was 25.4% (60). The benzodiazepines were obtained with a medical prescription (49.8%) or on the black market (42.6%). The most prescribed benzodiazepine was diazepam (29.1%), and the main reasons were to relieve insomnia (27.7%) or anxiety (26.9%) and to enhance the psychoactive effects of other drugs (19.7%). Regarding the clinical outcomes, we highlight: a very high prevalence of hepatitis C (51.7%); severe ongoing consumption of psychoactive drugs (73.7%); and a high rate of depression and anxiety (> 60%), significantly higher in the benzodiazepines-user group. In the multivariable analysis of benzodiazepine use, we found alcohol consumption (OR 0.482; IC 95% 0.247, 0.238) had a negative association and having hepatitis C (OR 2.544, IC 95% 1.273, 5.084) or anxiety symptoms (OR 5.591; IC 95% 2.345, 13.326) had positive associations.

DISCUSSION

Our results suggest the BZD users had a complex drug addiction problem and underline the importance of adequately addressing BZD use, contemplating psychological and psychiatric approach in this particular population.

CONCLUSION

Past or current use of benzodiazepines is associated with poor clinical and psychiatric outcomes. A multidisciplinary approach with a focus on infectious diseases and mental health is critical in order to enhance the treatment effectiveness and overall prognosis.

Systematic Review of Intrapartum Fetal Heart Rate Spectral Analysis and an Application in the Detection of Fetal Acidemia

It is fundamental to diagnose fetal acidemia as early as possible, allowing adequate obstetrical interventions to prevent brain damage or perinatal death. The visual analysis of cardiotocography traces has been complemented by computerized methods in order to overcome some of its limitations in the screening of fetal hypoxia/acidemia. Spectral analysis has been proposed by several studies exploring fetal heart rate recordings while referring to a great variety of frequency bands for integrating the power spectrum. In this paper, the main goal was to systematically review the spectral bands reported in intrapartum fetal heart rate studies and to evaluate their performance in detecting fetal acidemia/hypoxia. A total of 176 articles were reviewed, from MEDLINE, and 26 were included for the extraction of frequency bands and other relevant methodological information. An open-access fetal heart rate database was used, with recordings of the last half an hour of labor of 246 fetuses. Four different umbilical artery pH cutoffs were considered for fetuses' classification into acidemic or non-acidemic: 7.05, 7.10, 7.15, and 7.20. The area under the receiver operating characteristic curve (AUROC) was used to quantify the frequency bands' ability to distinguish acidemic fetuses. Bands referring to low frequencies, mainly associated with neural sympathetic activity, were the best at detecting acidemic fetuses, with the more severe definition (pH ≤ 7.05) attaining the highest values for the AUROC. This study shows that the power spectrum analysis of the fetal heart rate is a simple and powerful tool that may become an adjunctive method to CTG, helping healthcare professionals to accurately identify fetuses at risk of intrapartum hypoxia and to implement timely obstetrical interventions to reduce the incidence of related adverse perinatal outcomes.

Computer-based intrapartum fetal monitoring and beyond: A review of the 2nd Workshop on Signal Processing and Monitoring in Labor (October 2017, Oxford, UK)

The second Signal Processing and Monitoring in Labor workshop gathered researchers who utilize promising new research strategies and initiatives to tackle the challenges of intrapartum fetal monitoring. The workshop included a series of lectures and discussions focusing on: new algorithms and techniques for cardiotocogoraphy (CTG) and electrocardiogram acquisition and analyses; the results of a CTG evaluation challenge comparing state-of-the-art computerized methods and visual interpretation for the detection of arterial cord pH <7.05 at birth; the lack of consensus about the role of intrapartum acidemia in the etiology of fetal brain injury; the differences between methods for CTG analysis "mimicking" expert clinicians and those derived from "data-driven" analyses; a critical review of the results from two randomized controlled trials testing the former in clinical practice; and relevant insights from modern physiology-based studies. We concluded that the automated algorithms performed comparably to each other and to clinical assessment of the CTG. However, the sensitivity and specificity urgently need to be improved (both computerized and visual assessment). Data-driven CTG evaluation requires further work with large multicenter datasets based on well-defined labor outcomes. And before first tests in the clinic, there are important lessons to be learnt from clinical trials that tested automated algorithms mimicking expert CTG interpretation. In addition, transabdominal fetal electrocardiogram monitoring provides reliable CTG traces and variability estimates; and fetal electrocardiogram waveform analysis is subject to promising new research. There is a clear need for close collaboration between computing and clinical experts. We believe that progress will be possible with multidisciplinary collaborative research.

The effect of acetate on population heterogeneity in different cellular characteristics of Escherichia coli in aerobic batch cultures

Acetate as the major by-product in industrial-scale bioprocesses with Escherichia coli is found to decrease process efficiency as well as to be toxic to cells, which has several effects like a significant induction of cellular stress responses. However, the underlying phenomena are poorly explored. Therefore, we studied time-resolved population heterogeneity of the E. coli growth reporter strain MG1655/pGS20PrrnBGFPAAV expressing destabilized green fluorescent protein during batch growth on acetate and glucose as sole carbon sources. Additionally, we applied five fluorescent stains targeting different cellular properties (viability as well as metabolic and respiratory activity). Quantitative analysis of flow cytometry data verified that bacterial populations in the bioreactor are more heterogeneous in growth as well as stronger metabolically challenged during growth on acetate as sole carbon source, compared to growth on glucose or acetate after diauxic shift. Interestingly, with acetate as sole carbon source, significant subpopulations were found with some cells that seem to be more robust than the rest of the population. In conclusion, following batch cultures population heterogeneity was evident in all measured parameters. Our approach enabled a deeper study of heterogeneity during growth on the favored substrate glucose as well as on the toxic by-product acetate. Using a combination of activity fluorescent dyes proved to be an accurate and fast alternative as well as a supplement to the use of a reporter strain. However, the choice of combination of stains should be well considered depending on which population traits to aim for.

Long-term soil metal exposure impaired temporal variation in microbial metatranscriptomes and enriched active phages

BACKGROUND

It remains unclear whether adaptation and changes in diversity associated to a long-term perturbation are sufficient to ensure functional resilience of soil microbial communities. We used RNA-based approaches (16S rRNA gene transcript amplicon coupled to shotgun mRNA sequencing) to study the legacy effects of a century-long soil copper (Cu) pollution on microbial activity and composition, as well as its effect on the capacity of the microbial community to react to temporal fluctuations.

RESULTS

Despite evidence of microbial adaptation (e.g., iron homeostasis and avoidance/resistance strategies), increased heterogeneity and richness loss in transcribed gene pools were observed with increasing soil Cu, together with an unexpected predominance of phage mRNA signatures. Apparently, phage activation was either triggered directly by Cu, or indirectly via enhanced expression of DNA repair/SOS response systems in Cu-exposed bacteria. Even though total soil carbon and nitrogen had accumulated with increasing Cu, a reduction in temporally induced mRNA functions was observed. Microbial temporal response groups (TRGs, groups of microbes with a specific temporal response) were heavily affected by Cu, both in abundance and phylogenetic composition.

CONCLUSION

Altogether, results point toward a Cu-mediated "decoupling" between environmental fluctuations and microbial activity, where Cu-exposed microbes stopped fulfilling their expected contributions to soil functioning relative to the control. Nevertheless, some functions remained active in February despite Cu, concomitant with an increase in phage mRNA signatures, highlighting that somehow, microbial activity is still happening under these adverse conditions.

Legacy Effects on the Recovery of Soil Bacterial Communities from Extreme Temperature Perturbation

The type and frequency of disturbances experienced by soil microbiomes is expected to increase given predicted global climate change scenarios and intensified anthropogenic pressures on ecosystems. While the direct effect of multiple disturbances to soil microbes has been explored in terms of function, their effect on the recovery of microbial community composition remains unclear. Here, we used soil microcosm experiments and multiple model disturbances to explore their short-term effect on the recovery of soil microbiota after identical or novel stresses. Soil microcosms were exposed to a heat shock to create an initial effect. Upon initial community recovery (25 days after stress), they were subjected to a second stress, either a heat or a cold shock, and they were monitored for additional 25 days. To carefully verify the bacterial response to the disturbances, we monitored changes in community composition throughout the experiment using 16S rRNA gene transcript amplicon sequencing. The application of a heat shock to soils with or without the initial heat shock resulted in similar successional dynamics, but these dynamics were faster in soils with a prior heat shock. The application of a cold shock had negligible effects on previously undisturbed soils but, in combination with an initial heat shock, caused the largest shift in the community composition. Our findings show that compounded perturbation affects bacterial community recovery by altering community structure and thus, the community's response during succession. By altering dominance patterns, disturbance legacy affects the microbiome's ability to recover from further perturbation within the 25 days studied. Our results highlight the need to consider the soil's disturbance history in the development of soil management practices in order to maintain the system's resilience.

Autogenic succession and deterministic recovery following disturbance in soil bacterial communities

The response of bacterial communities to environmental change may affect local to global nutrient cycles. However the dynamics of these communities following disturbance are poorly understood, given that they are often evaluated over macro-ecological time scales and end-point measurements. In order to understand the successional trajectory of soil bacterial communities following disturbances and the mechanisms controlling these dynamics at a scale relevant for these organisms, we subjected soil microcosms to a heat disturbance and followed the community composition of active bacteria over 50 days. The disturbance imposed a strong selective pressure that persisted for up to 10 days, after which the importance of stochastic processes increased. Three successional stages were detected: a primary response in which surviving taxa increased in abundance; a secondary response phase during which community dynamics slowed down, and a stability phase (after 29 days), during which the community tended towards its original composition. Phylogenetic turnover patterns indicated that the community experienced stronger deterministic selection during recovery. Thus, soil bacterial communities, despite their extreme diversity and functional redundancy, respond to disturbances like many macro-ecological systems and exhibit path-dependent, autogenic dynamics during secondary succession. These results highlight the role of autogenic factors and successional dynamics in microbial recovery.

SisPorto 4.0 - computer analysis following the 2015 FIGO Guidelines for intrapartum fetal monitoring

SisPorto 4.0 is the most recent version of a program for the computer analysis of cardiotocographic (CTG) signals and ST events, which has been adapted to the 2015 International Federation of Gynaecology and Obstetrics (FIGO) guidelines for intrapartum foetal monitoring. This paper provides a detailed description of the analysis performed by the system, including the signal-processing algorithms involved in identification of basic CTG features and the resulting real-time alerts.

Computer analysis of foetal monitoring signals

Five systems for computer analysis of foetal monitoring signals are currently available, incorporating the evaluation of cardiotocographic (CTG) or combined CTG with electrocardiographic ST data. All systems have been integrated with central monitoring stations, allowing the simultaneous monitoring of several tracings on the same computer screen in multiple hospital locations. Computer analysis elicits real-time visual and sound alerts for health care professionals when abnormal patterns are detected, with the aim of prompting a re-evaluation and subsequent clinical action, if considered necessary. Comparison between the CTG analyses provided by the computer and clinical experts has been carried out in all systems, and in three of them, the accuracy of computer alerts in predicting newborn outcomes was evaluated. Comparisons between these studies are hampered by the differences in selection criteria and outcomes. Two of these systems have just completed multicentre randomised clinical trials comparing them with conventional CTG monitoring, and their results are awaited shortly. For the time being, there is limited evidence regarding the impact of computer analysis of foetal monitoring signals on perinatal indicators and on health care professionals' behaviour.

Differences between external and internal fetal heart rate monitoring during the second stage of labor: a prospective observational study

OBJECTIVE

To compare fetal heart rate (FHR) signals acquired simultaneously by an external ultrasound probe and a scalp electrode during the second stage of labor.

METHODS

This was a prospective observational study in a labor ward of a tertiary care university hospital. The population was women in labor with uneventful singleton pregnancies at term. Simultaneous external and internal FHR monitoring was performed in 67 consecutively recruited women during the second stage of labor. Cases were subsequently excluded if the trace length was under 40 min, cesarean birth occurred, or the interval between trace-end and birth exceeded 5 min, leaving a total of 33 traces for analysis. The last 40-60 min of these traces were analyzed by a computer system (Omniview-SisPorto 3.5; Speculum, Lisbon, Portugal) to quantify cardiotocographic parameters. Paired sample t-test and Bland-Altman limits of agreement (LoA) were used for statistical analysis, setting significance at 0.05. The main outcome measures were signal loss, FHR baseline, periodic events, and percentage of periodic events coinciding with contractions.

RESULTS

A higher signal loss was observed with external monitoring [10% vs. 4%; P<0.001, LoA=(-6, 18)]. No differences were found in mean FHR baseline [129 bpm vs. 130 bpm, P=0.245, LoA=(-15, 12)], but more accelerations [12 vs. 8, P<0.001, LoA=(-5, 13)] and less decelerations [8 vs. 10, P<0.001, LoA=(-8, 4)] were detected with external monitoring. With this method there were also more accelerations (66% vs. 55%, P=0.036) and less decelerations (68% vs. 81%, P=0.017) coinciding with contractions.

CONCLUSIONS

External FHR monitoring during the second stage of labor results in higher signal loss, increased number of accelerations, and decreased number of decelerations when compared with internal monitoring.

Prolonged saltatory fetal heart rate pattern leading to newborn metabolic acidosis

PURPOSE

The saltatory pattern, characterized by wide and rapid oscillations of the fetal heart rate (FHR), remains a controversial entity. The authors sought to evaluate whether it could be associated with an adverse fetal outcome.

MATERIAL AND METHODS

The authors report a case series of four saltatory patterns occurring in the last 30 minutes before birth in association with cord artery metabolic acidosis, obtained from three large databases of internally acquired FHR tracings. The distinctive characteristics of this pattern were evaluated with the aid of a computer system.

RESULTS

All cases were recorded in uneventful pregnancies, with normal birthweight singletons, born vaginally at term. The saltatory pattern lasted between 23 and 44 minutes, exhibited a mean oscillatory amplitude of 45.9 to 80.0 beats per minute (bpm) and a frequency between four and eight cycles per minute.

CONCLUSIONS

A saltatory pattern exceeding 20 minutes can be associated with the occurrence of fetal metabolic acidosis.

Preliminary toxicological assessment of phthalate esters from drinking water consumed in Portugal

This paper reports, for the first time, the concentrations of selected phthalates in drinking water consumed in Portugal. The use of bottled water in Portugal has increased in recent years. The main material for bottles is polyethylene terephthalate (PET). Its plasticizer components can contaminate water by leaching, and several scientific studies have evidenced potential health risks of phthalates to humans of all ages. With water being one of the most essential elements to human health and because it is consumed by ingestion, the evaluation of drinking water quality, with respect to phthalate contents, is important. This study tested seven commercial brands of bottled water consumed in Portugal, six PET and one glass (the most consumed) bottled water. Furthermore, tap water from Lisbon and three small neighbor cities was analyzed. Phthalates (di-n-butyl phthalate ester (DnBP), bis(2-ethylhexyl) phthalate ester (DEHP), and di-i-butyl phthalate ester (DIBP)) in water samples were quantified (PET and glass) by means of direct immersion solid-phase microextraction and ionic liquid gas chromatography associated with flame ionization detection or mass spectrometry due to their high boiling points and water solubility. The method utilized in this study showed a linear range for target phthalates between 0.02 and 6.5 μg L(-1), good precision and low limits of detection that were between 0.01 and 0.06 μg L(-1), and quantitation between 0.04 and 0.19 μg L(-1). Only three phthalates were detected in Portuguese drinking waters: dibutyl (DnBP), diisobutyl (DIBP), and di(ethylhexyl) phthalate (DEHP). Concentrations ranged between 0.06 and 6.5 μg L(-1) for DnBP, between 0.02 and 0.16 μg L(-1) for DEHP, and between 0.1 and 1.89 μg L(-1) for DIBP. The concentration of DEHP was found to be up to five times higher in PET than in glass bottled water. Surprisingly, all the three phthalates were detected in glass bottled water with the amount of DnBP being higher (6.5 μg L(-1)) than in PET bottled water. These concentrations do not represent direct risk to human health. Regarding potable tap water, only DIBP and DEHP were detected. Two of the cities showed concentration of all three phthalates in their water below the limits of detection of the method. All the samples showed phthalate concentrations below 6 μg L(-1), the maximum admissible concentration in water established by the US Environmental Protection Agency. The concentrations measured in Portuguese bottled waters do not represent any risk for adult's health.

Effects of gamma radiation on raspberries: safety and quality issues

There is an ever-increasing global demand from consumers for high-quality foods with major emphasis placed on quality and safety attributes. One of the main demands that consumers display is for minimally processed, high-nutrition/low-energy natural foods with no or minimal chemical preservatives. The nutritional value of raspberry fruit is widely recognized. In particular, red raspberries are known to demonstrate a strong antioxidant capacity that might prove beneficial to human health by preventing free radical-induced oxidative stress. However, food products that are consumed raw, are increasingly being recognized as important vehicles for transmission of human pathogens. Food irradiation is one of the few technologies that address both food quality and safety by virtue of its ability to control spoilage and foodborne pathogenic microorganisms without significantly affecting sensory or other organoleptic attributes of the food. Food irradiation is well established as a physical, nonthermal treatment (cold pasteurization) that processes foods at or nearly at ambient temperature in the final packaging, reducing the possibility of cross contamination until the food is actually used by the consumer. The aim of this study was to evaluate effects of gamma radiation on raspberries in order to assess consequences of irradiation. Freshly packed raspberries (Rubus idaeus L.) were irradiated in a (60)Co source at several doses (0.5, 1, or 1.5 kGy). Bioburden, total phenolic content, antioxidant activity, physicochemical properties such as texture, color, pH, soluble solids content, and acidity, and sensorial parameters were assessed before and after irradiation and during storage time up to 14 d at 4°C. Characterization of raspberries microbiota showed an average bioburden value of 10(4) colony-forming units (CFU)/g and a diverse microbial population predominantly composed of two morphological types (gram-negative, oxidase-negative rods, 35%, and filamentous fungi, 41%). The inactivation studies on the raspberries mesophilic population indicated a one log reduction of microbial load (95% inactivation efficiency for 1.5 kGy), in the surviving population mainly constituted by filamentous fungi (79-98%). The total phenolic content of raspberries indicated an increase with radiation doses and a decrease with storage time. The same trend was found for raspberries' antioxidant capacity with storage time. Regarding raspberries physicochemical properties, irradiation induced a significant decrease in firmness compared with nonirradiated fruit. However, nonirradiated and irradiated fruit presented similar physicochemical and sensory properties during storage time. Further studies are needed to elucidate the benefits of irradiation as a raspberries treatment process.

Effect of temozolomide on the U-118 glioma cell line

Glioblastomas (GBM) are the most lethal subtype of astrocytomas, with a mean patient survival rate of 12 months after diagnosis. The gold standard treatment of GBM, which includes surgery followed by the combination of radiotherapy and chemotherapy with temozolomide (TMZ), increases the survival rate to 14.6 months. The success of TMZ appears to be limited by the occurrence of chemoresistance that allows glioma cells to escape from death signaling pathways. However, the mechanism of TMZ action is yet to be clarified although some controversial results have been reported. Therefore, our aim was to evaluate the occurrence of apoptosis and autophagy in glioma cells treated with TMZ and to correlate TMZ action with the survival pathways Pi3K/Akt and ERK1/2 MAP kinase. Cell proliferation was evaluated by incorporation of bromodeoxyuridine. Apoptosis was studied by flow cytometry as well as by fluorescence confocal microscopy in order to evaluate the sub G0/G1 percentage of cells and chromatin condensation. The expression of the autophagy-associated protein, LC3, as well as Akt and ERK1/2 was performed by Western blotting. In TMZ-treated GBM cells the expression of LC3, the autophagy-associated protein was increased and only a reduced percentage of cells underwent apoptosis. In addition, we showed that the phosphorylation status of Pi3K/Akt and ERK1/2 MAP kinase was maintained during the treatment with TMZ, suggesting that glioma cells escape from TMZ-induced cell death due to these signaling pathways. The chemoresistance of U-118 cells to TMZ was partially eradicated when cells were simultaneously treated with specific inhibitors of Pi3K/Akt and ERK1/2 MAP kinase signaling pathways and TMZ. Therefore, we hypothesized that in order to induce glioma cell death it is essential to evaluate the activation of the survival pathways and establish a combined therapy using TMZ and inhibitors of those signaling pathways.

Paucisalibacillus globulus gen. nov., sp. nov., a Gram-positive bacterium isolated from potting soil

A Gram-positive bacterium, designated B22(T), was isolated from potting soil produced in Portugal. This organism is a catalase-positive, oxidase-negative, motile, spore-forming, aerobic rod that grows optimally at 37 degrees C and pH 8.0-8.5. Optimal growth occurs in media containing 1 % (w/v) NaCl, although the organism can grow in 0-8 % NaCl. The cell wall peptidoglycan is of the A4alpha type with a cross-linkage containing d-Asp. The major respiratory quinone is menaquinone 7 and the major fatty acids are anteiso-15 : 0, anteiso-17 : 0 and iso-15 : 0. The DNA G+C content is 37.9 mol%. Phylogenetic analysis of 16S rRNA gene sequences revealed that strain B22(T) formed a new branch within the family Bacillaceae. The novel isolate is phylogenetically closely related to members of genera of moderately halophilic bacilli and formed a coherent cluster with species of the genera Salinibacillus, Virgibacillus, Oceanobacillus and Lentibacillus, supported by bootstrap analysis at a confidence level of 71 %. Strain B22(T) exhibited 16S rRNA gene pairwise sequence similarity values of 94.7-94.3 % with members of the genus Salinibacillus, 95.1-92.8 % with members of the genus Virgibacillus, 94.7-93.2 % with members of the genus Oceanobacillus and 93.1-92.3 % with members of the genus Lentibacillus. On the basis of phylogenetic analysis and physiological and biochemical characteristics, it is proposed that strain B22(T) represents a novel species in a new genus, Paucisalibacillus globulus gen. nov., sp. nov. Strain B22(T) (=LMG 23148(T)=CIP 108857(T)) is the type strain of Paucisalibacillus globulus.

Host-defense mechanism of the ocular surfaces

The defense of the ocular surfaces presents an unique challenge in that not only must integrity be maintained against microbial, inflammatory and physical assault, but it must be done while minimizing the risk of loss of corneal transparency. This puts severe limitations on the degree to which scarring or neovascularization can occur in the cornea secondary to any infectious, inflammatory, immunological or wound healing process. Moreover, this defense system must be equally effective under two extremes of conditions: those found in the open eye and the closed eye environments. It is our contention that these constraints have resulted in the evolution of a highly complex fail-safe defense system that utilizes distinctly different strategies in open and closed eye conditions. The extraordinary effectiveness of this system is evidenced by the fact that despite continued exposure to a microbe rich environment, the external ocular surfaces maintain a very low microbial titer and are highly resistant to breaching by all but a few pathogens. It is the intent of this review to provide a working model of this defense system as it operates under both open and closed eye conditions, to provide evidence in support of this model as well as highlight some of the many areas of uncertainty.