Using conflict negativity to index psychological tension between impartiality and status-upholding principles

People often endorse the moral principle that all human lives are equally valuable. At the same time, people often privilege high-status individuals over low-status individuals. These two inclinations come into conflict in a scenario involving the potential killing of a high-status person to save the lives of multiple low-status people. In the present study, participants viewed a series of sacrificial dilemmas in which the social status of the victims and beneficiaries was varied. We measured participants' choice (sacrifice vs. don't sacrifice), response time, and electroencephalographic activity, with an emphasis on conflict negativity (CN). Overall, we found no effects of victim/beneficiaries status on choice and response time. However, participants displayed a more pronounced CN effect when contemplating a high-status victim/low-status beneficiaries tradeoff than a low-status-victim/high-status beneficiaries tradeoff. Further analyses revealed that this effect was primarily driven by participants who endorsed deontological principles (e.g., "Some rules must never be broken, no matter the consequences"). In contrast, those who endorsed utilitarian principles displayed equivalent levels of conflict negativity, regardless of the social status of victims and beneficiaries. These findings shed light on the role of conflict in the phenomenology of moral decision making.

Anger and Sadness as Moral Signals

Three studies examined the relationship between emotions and moral judgment from an interpersonal perspective. In Studies 1 and 2, participants justified their decisions in sacrificial dilemmas to an imagined interlocutor. Linguistic analyses revealed that Don’t Sacrifice justifications contained more anger-related language than sadness-related language, whereas Sacrifice justifications contained roughly equal proportions of anger and sadness language. In Study 3, participants made character inferences about an actor who chose to/refused to sacrifice one person to save multiple people. We manipulated the actor’s ratio of anger to sadness. Participants rated the Don’t Sacrifice actor more negatively when they displayed high anger relative to sadness but rated the Sacrifice actor negatively whenever they exhibited high anger (independent of sadness). These data highlight novel ways in which actors and observers use emotions to complement the substance of a moral argument.

Prenatal Diet and Child Growth at 18 Months

OBJECTIVE

Our objective was to evaluate the effect of an antenatal dietary and lifestyle intervention in pregnant women who are overweight or obese on child outcomes at age 18 months.

METHODS

We conducted a follow-up study of children at 18 months of age who were born to women who participated in the Limiting Weight Gain in Overweight and Obese Women during Pregnancy to Improve Health Outcomes randomized trial. The primary follow-up study outcome was prevalence of child BMI z scores >85th percentile. Secondary study outcomes included a range of anthropometric measures, neurodevelopment, general health, and child feeding. Intention to treat principles were used in analyses, according to the treatment group allocated at randomization.

RESULTS

A total of 1602 children were assessed at age 18 months (lifestyle advice, n = 816; standard care, n = 786), representing 75.0% of the eligible sample (n = 2136). There were no statistically significant differences in the prevalence of child BMI z scores >85th percentile for children born to women in the lifestyle advice group, compared with the standard care group (lifestyle advice, 505 [47.11%] versus standard care, 483 [45.36%]; adjusted relative risk: 1.04; 95% confidence interval: 0.94 to 1.16; P = .45). There was no evidence of effects on child growth, adiposity, neurodevelopment, or dietary and physical activity patterns.

CONCLUSIONS

There is no evidence that providing pregnant women who were overweight or obese with an antenatal dietary and lifestyle intervention altered 18-month child growth and adiposity.

Disgust and Deontology: Trait Sensitivity to Contamination Promotes a Preference for Order, Hierarchy, and Rule-Based Moral Judgment

Models of moral judgment have linked generalized emotionality with deontological moral judgment. The evidence, however, is mixed. Other research has linked the specific emotion of disgust with generalized moral condemnation. Here too, the evidence is mixed. We suggest that a synthesis of these two literatures points to one specific emotion (disgust) that reliably predicts one specific type of moral judgment (deontological). In all three studies, we found that trait disgust sensitivity predicted more extreme deontological judgment. In Study 3, with deontological endorsement and consequentialist endorsement operationalized as independent constructs, we found that disgust was positively associated with deontological endorsement but was unrelated to consequentialist endorsement. Across studies, the disgust–deontology link was mediated by individual difference variables related to preference for order (right-wing authoritarianism and intolerance for ambiguity). These data suggest a more precise model of emotion and moral judgment that identifies specific emotions, specific types of moral judgment, and specific motivational pathways.

Nonlinear Ultrafast Spin Scattering in the Skyrmion Phase of Cu_{2}OSeO_{3}

Ultrafast x-ray scattering studies of the topological Skyrmion phase in Cu_{2}OSeO_{3} show the dynamics to be strongly dependent on the excitation energy and fluence. At high photon energies, where the electron-spin scattering cross section is relatively high, the excitation of the topological Skyrmion phase shows a nonlinear dependence on the excitation fluence, in contrast to the excitation of the conical phase which is linearly dependent on the excitation fluence. The excitation of the Skyrmion order parameter is nonlinear in the magnetic excitation resulting from scattering during electron-hole recombination, indicating different dominant scattering processes in the conical and Skyrmion phases.

Proximal and Distal Intent: Toward a New Folk Theory of Intentional Action

Inferences regarding actors’ intentions play an important role in social and moral cognition. Numerous studies have operationalized intentionality in a binary fashion (i.e., an act is either “intentional” or “unintentional”). The authors suggest, however, that when determining the degree to which an act was intentional, lay observers consider two independent dimensions: proximal intent (the actor's focus on the means) and distal intent (the actor's focus on the end). They describe how the proximal intent/distal intent (PIDI) approach allows researchers to understand observers’ intent-related judgments with greater precision. The authors review studies highlighting a range of variables that lead perceivers to prioritize either proximal intent or distal intent in their social and moral judgment. They describe how previous findings in the literature may be reinterpreted in light of the PIDI framework. Finally, they suggest ways in which the PIDI framework implies novel directions for future research on moral cognition.

Vaginal progesterone pessaries for pregnant women with a previous preterm birth to prevent neonatal respiratory distress syndrome (the PROGRESS Study): A multicentre, randomised, placebo-controlled trial

BACKGROUND

Neonatal respiratory distress syndrome, as a consequence of preterm birth, is a major cause of early mortality and morbidity. The withdrawal of progesterone, either actual or functional, is thought to be an antecedent to the onset of labour. There remains limited information on clinically relevant health outcomes as to whether vaginal progesterone may be of benefit for pregnant women with a history of a previous preterm birth, who are at high risk of a recurrence. Our primary aim was to assess whether the use of vaginal progesterone pessaries in women with a history of previous spontaneous preterm birth reduced the risk and severity of respiratory distress syndrome in their infants, with secondary aims of examining the effects on other neonatal morbidities and maternal health and assessing the adverse effects of treatment.

METHODS

Women with a live singleton or twin pregnancy between 18 to <24 weeks' gestation and a history of prior preterm birth at less than 37 weeks' gestation in the preceding pregnancy, where labour occurred spontaneously or in association with cervical incompetence or following preterm prelabour rupture of the membranes, were eligible. Women were recruited from 39 Australian, New Zealand, and Canadian maternity hospitals and assigned by randomisation to vaginal progesterone pessaries (equivalent to 100 mg vaginal progesterone) (n = 398) or placebo (n = 389). Participants and investigators were masked to the treatment allocation. The primary outcome was respiratory distress syndrome and severity. Secondary outcomes were other respiratory morbidities; other adverse neonatal outcomes; adverse outcomes for the woman, especially related to preterm birth; and side effects of progesterone treatment. Data were analysed for all the 787 women (100%) randomised and their 799 infants.

FINDINGS

Most women used their allocated study treatment (740 women, 94.0%), with median use similar for both study groups (51.0 days, interquartile range [IQR] 28.0-69.0, in the progesterone group versus 52.0 days, IQR 27.0-76.0, in the placebo group). The incidence of respiratory distress syndrome was similar in both study groups-10.5% (42/402) in the progesterone group and 10.6% (41/388) in the placebo group (adjusted relative risk [RR] 0.98, 95% confidence interval [CI] 0.64-1.49, p = 0.912)-as was the severity of any neonatal respiratory disease (adjusted treatment effect 1.02, 95% CI 0.69-1.53, p = 0.905). No differences were seen between study groups for other respiratory morbidities and adverse infant outcomes, including serious infant composite outcome (155/406 [38.2%] in the progesterone group and 152/393 [38.7%] in the placebo group, adjusted RR 0.98, 95% CI 0.82-1.17, p = 0.798). The proportion of infants born before 37 weeks' gestation was similar in both study groups (148/406 [36.5%] in the progesterone group and 146/393 [37.2%] in the placebo group, adjusted RR 0.97, 95% CI 0.81-1.17, p = 0.765). A similar proportion of women in both study groups had maternal morbidities, especially those related to preterm birth, or experienced side effects of treatment. In 9.9% (39/394) of the women in the progesterone group and 7.3% (28/382) of the women in the placebo group, treatment was stopped because of side effects (adjusted RR 1.35, 95% CI 0.85-2.15, p = 0.204). The main limitation of the study was that almost 9% of the women did not start the medication or forgot to use it 3 or more times a week.

CONCLUSIONS

Our results do not support the use of vaginal progesterone pessaries in women with a history of a previous spontaneous preterm birth to reduce the risk of neonatal respiratory distress syndrome or other neonatal and maternal morbidities related to preterm birth. Individual participant data meta-analysis of the relevant trials may identify specific women for whom vaginal progesterone might be of benefit.

TRIAL REGISTRATION

Current Clinical Trials ISRCTN20269066.

Paternal obesity modifies the effect of an antenatal lifestyle intervention in women who are overweight or obese on newborn anthropometry

The contribution of paternal obesity to pregnancy outcomes has been little described. Our aims were to determine whether the effect of an antenatal maternal dietary and lifestyle intervention among women who are overweight or obese on newborn adiposity, was modified by paternal obesity. We conducted a secondary analysis of a multicenter randomised trial. Pregnant women with BMI ≥25 kg/m² received either Lifestyle Advice or Standard Care. Paternal anthropometric measures included height, weight, BMI; waist, hip, calf and mid-upper arm circumferences; biceps and calf skinfold thickness measurements (SFTM); and percentage body fat. Newborn anthropometric outcomes included length; weight; head, arm, abdominal, and chest circumferences; biceps, triceps, subscapular, suprailiac, thigh, and lateral abdominal wall SFTM; and percentage body fat. The effect of an antenatal maternal dietary and lifestyle intervention among women who were overweight or obese on neonatal anthropometric measures, was significantly modified by paternal BMI ≥35.0 kg/m², with a significantly smaller infant triceps, suprailiac, and thigh SFTM, and percent fat mass, compared with that observed in offspring of lean fathers. Further research is required to determine whether our observed associations are causal, and whether paternal weight loss prior to conception is a potential strategy to reduce the intergenerational effects of obesity.

The effect of an antenatal lifestyle intervention in overweight and obese women on circulating cardiometabolic and inflammatory biomarkers: secondary analyses from the LIMIT randomised trial

BACKGROUND

Maternal overweight and obesity during pregnancy is associated with insulin resistance, hyperglycaemia, hyperlipidaemia and a low-grade state of chronic inflammation. The aim of this pre-specified analysis of secondary outcome measures was to evaluate the effect of providing antenatal dietary and lifestyle advice on cardiometabolic and inflammatory biomarkers.

METHODS

We conducted a multicentre trial in which pregnant women who were overweight or obese were randomised to receive either Lifestyle Advice or Standard Care. We report a range of pre-specified secondary maternal and newborn cardiometabolic and inflammatory biomarker outcomes. Maternal whole venous blood was collected at trial entry (mean 14 weeks gestation; non-fasting), at 28 weeks gestation (fasting), and at 36 weeks gestation (non-fasting). Cord blood was collected after birth and prior to the delivery of the placenta. A range of cardiometabolic and inflammatory markers were analysed (total cholesterol, triglycerides, non-esterified fatty acids, high-density lipoprotein cholesterol, insulin, glucose, leptin, adiponectin, C-reactive protein, granulocyte macrophage-colony stimulating factor, interferon gamma, TNF-α, and interleukins 1β, 2, 4, 5, 6, 8, and 10). Participants were analysed in the groups to which they were randomised, and were included in the analyses if they had a measure at any time point.

RESULTS

One or more biological specimens were available from 1951 women (989 Lifestyle Advice and 962 Standard Care), with cord blood from 1174 infants (596 Lifestyle Advice and 578 Standard Care). There were no statistically significant differences in mean cardiometabolic and inflammatory marker concentrations across pregnancy and in infant cord blood between treatment groups. Estimated treatment group differences were close to zero, with 95% confidence intervals spanning a range of differences that were short of clinical relevance. There was no evidence to suggest that the intervention effect was modified by maternal BMI category.

CONCLUSIONS

Despite our findings, it will be worth considering potential relationships between cardiometabolic and inflammatory markers and clinical outcomes, including longer-term infant health and adiposity.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ( ACTRN12607000161426 ; Date Registered 09/03/2007).

The effect of antenatal lifestyle advice for women who are overweight or obese on secondary measures of neonatal body composition: the LIMIT randomised trial

OBJECTIVE

To evaluate the effect of providing antenatal dietary and lifestyle advice on neonatal anthropometry, and to determine the inter-observer variability in obtaining anthropometric measurements.

DESIGN

Randomised controlled trial.

SETTING

Public maternity hospitals across metropolitan Adelaide, South Australia.

POPULATION

Pregnant women with a singleton gestation between 10(+0) and 20(+0) weeks, and body mass index (BMI) ≥25 kg/m(2).

METHODS

Women were randomised to either Lifestyle Advice (comprehensive dietary and lifestyle intervention over the course of pregnancy including dietary, exercise and behavioural strategies, delivered by a research dietician and research assistants) or continued Standard Care. Analyses were conducted using intention-to-treat principles.

MAIN OUTCOME MEASURES

Secondary outcome measures for the trial included assessment of infant body composition using body circumference and skinfold thickness measurements (SFTM), percentage body fat, and bio-impedance analysis of fat-free mass.

RESULTS

Anthropometric measurements were obtained from 970 neonates (488 Lifestyle Advice Group, and 482 Standard Care Group). In 394 of these neonates (215 Lifestyle Advice Group, and 179 Standard Care Group) bio-impedance analysis was also obtained. There were no statistically significant differences identified between those neonates born to women receiving Lifestyle Advice and those receiving Standard Care, in terms of body circumference measures, SFTM, percentage body fat, fat mass, or fat-free mass. The intra-class correlation coefficient for SFTM was moderate to excellent (0.55-0.88).

CONCLUSIONS

Among neonates born to women who are overweight or obese, anthropometric measures of body composition were not modified by an antenatal dietary and lifestyle intervention.

Effects of Culture and Gender on Judgments of Intent and Responsibility

Do different cultures hold different views of intentionality? In four studies, participants read scenarios in which the actor’s distal intent (a focus on a broader goal) and proximal intent (a focus on the mechanics of the act) were manipulated. In Studies 1–2, when distal intent was more prominent in the actor’s mind, North Americans rated the actor more responsible than did Chinese and South Asian participants. When proximal intent was more prominent, Chinese and South Asian participants, if anything, rated the actor more responsible. In Studies 3–4, when distal intent was more prominent, male Americans rated the actor more responsible than did female Americans. When proximal intent was more prominent, females rated the actor more responsible. The authors discuss these findings in relation to the literatures on moral reasoning and cultural psychology.

The effect of anaemia on hospital length of stay in lumbar decompression and fusion procedures

Ways of reducing the length of hospital stay have received increased attention in recent years. Both preoperative and postoperative anaemia have been implicated as causative agents in increasing postoperative length of stay (LOS). In a retrospective study, 317 patients that underwent lumbar decompression and fusion surgery were assessed. Two separate block multivariate linear regression analyses were performed to evaluate the impact of preoperative anaemia, postoperative anaemia, and the degree of perioperative haemoglobin drop on LOS. Other anaemia related factors were also assessed. Preoperative anaemia, postoperative anaemia, and the amount of perioperative haemoglobin drop were all shown to prolong the length of hospitalisation and therefore to increase overall healthcare costs. Following strict anaemia corrective maneuvers could reasonably be expected to reduce expenditure.

The effect of antenatal dietary and lifestyle advice for women who are overweight or obese on emotional well-being: the LIMIT randomized trial

INTRODUCTION

Our aim was to evaluate the effect of dietary and lifestyle advice given to women who were overweight or obese during pregnancy on maternal quality of life, anxiety and risk of depression, and satisfaction with care.

MATERIAL AND METHODS

We conducted a randomized trial, involving pregnant women with body mass index ≥25 kg/m(2) , recruited from maternity units in South Australia. Women were randomized to Lifestyle Advice or Standard Care, and completed questionnaires assessing risk of depression (Edinburgh Postnatal Depression Scale), anxiety (Spielberger State-Trait Anxiety Inventory), and quality of life (SF-36) at trial entry, 28 and 36 weeks' gestation, and 4 months postpartum. Secondary trial outcomes assessed for this analysis were risk of depression, anxiety, maternal quality of life, and satisfaction with care.

RESULTS

One or more questionnaires were completed by 976 of 1108 (90.8%) women receiving Lifestyle Advice and 957 of 1104 (89.7%) women receiving Standard Care. The risk of depression [adjusted risk ratio 1.01; 95% confidence interval (CI) 0.82-1.24; p = 0.95], anxiety (adjusted risk ratio 1.09; 95% CI 0.93-1.27; p = 0.31), and health-related quality of life were similar between the two groups. Women receiving Lifestyle Advice reported improved healthy food choice [Lifestyle Advice 404 (68.9%) vs. Standard Care 323 (51.8%); p < 0.0001], and exercise knowledge [Lifestyle Advice 444 (75.8%) vs. Standard Care 367 (58.8%); p < 0.0001], and reassurance about their health [Lifestyle Advice 499 (85.3%) vs. Standard Care 485 (77.9%); p = 0.0112], and health of their baby [Lifestyle Advice 527 (90.2%) vs. Standard Care 545 (87.6%); p = 0.0143].

CONCLUSION

Lifestyle advice in pregnancy improved knowledge and provided reassurance without negatively impacting well-being.

Imaging Molecular Motion: Femtosecond X-Ray Scattering of an Electrocyclic Chemical Reaction

Structural rearrangements within single molecules occur on ultrafast time scales. Many aspects of molecular dynamics, such as the energy flow through excited states, have been studied using spectroscopic techniques, yet the goal to watch molecules evolve their geometrical structure in real time remains challenging. By mapping nuclear motions using femtosecond x-ray pulses, we have created real-space representations of the evolving dynamics during a well-known chemical reaction and show a series of time-sorted structural snapshots produced by ultrafast time-resolved hard x-ray scattering. A computational analysis optimally matches the series of scattering patterns produced by the x rays to a multitude of potential reaction paths. In so doing, we have made a critical step toward the goal of viewing chemical reactions on femtosecond time scales, opening a new direction in studies of ultrafast chemical reactions in the gas phase.

Construal level and free will beliefs shape perceptions of actors' proximal and distal intent

Two components of lay observers' calculus of moral judgment are proximal intent (the actor's mind is focused on performing the action) and distal intent (the actor's mind is focused on the broader goal). What causes observers to prioritize one form of intent over the other? The authors observed whether construal level (Studies 1–2) and beliefs about free will (Studies 3–4) would influence participants' sensitivity to the actor's proximal vs. distal intent. In four studies, participants read scenarios in which the actor's proximal and distal intent were independently manipulated. In Study 1, when only distal intent was present in the actor's mind, participants rated the psychologically distant actor more responsible than the psychologically near actor. In Study 2, when only distal intent was in the actor's mind, participants with a chronic high level of action identification rated the actor more responsible than did those with a low level of action identification. In both studies, when only proximal intent was in the actor's mind, construal level did not predict judgments of responsibility. In Study 3, when only proximal intent was present in the actor's mind, the more participants believed in free will, the more they rated the actor responsible. When only distal intent was in the actor's mind, free will belief did not influence ratings of responsibility. In Study 4, the same pattern emerged when free will/determinism beliefs were manipulated and the actor performed a positive (life-saving) act. The authors discuss how these results shed new light on the literatures on moral reasoning and psycho-legal theory.

The cost-effectiveness of providing antenatal lifestyle advice for women who are overweight or obese: the LIMIT randomised trial

Background

Overweight and obesity during pregnancy is common, although robust evidence about the economic implications of providing an antenatal dietary and lifestyle intervention for women who are overweight or obese is lacking.

We conducted a health economic evaluation in parallel with the LIMIT randomised trial. Women with a singleton pregnancy, between 10⁺⁰-20⁺⁰ weeks, and BMI ≥25 kg/m² were randomised to Lifestyle Advice (a comprehensive antenatal dietary and lifestyle intervention) or Standard Care. The economic evaluation took the perspective of the health care system and its patients, and compared costs encountered from the additional use of resources from time of randomisation until six weeks postpartum. Increments in health outcomes for both the woman and infant were considered in the cost-effectiveness analysis. Mean costs and effects in the treatment groups allocated at randomisation were compared, and incremental cost effectiveness ratios (ICERs) and confidence intervals (95%) calculated. Bootstrapping was used to confirm the estimated confidence intervals, and to generate acceptability curves representing the probability of the intervention being cost-effective at alternative monetary equivalent values for the outcomes avoiding high infant birth weight, and respiratory distress syndrome. Analyses utilised intention to treat principles.

Results

Overall, the increase in mean costs associated with providing the intervention was offset by savings associated with improved immediate neonatal outcomes, rendering the intervention cost neutral (Lifestyle Advice Group $11261.19±$14573.97 versus Standard Care Group $11306.70±$14562.02; p=0.094). Using a monetary value of $20,000 as a threshold value for avoiding an additional infant with birth weight above 4 kg, the probability that the antenatal intervention is cost-effective is 0.85, which increases to 0.95 when the threshold monetary value increases to $45,000.

Conclusions

Providing an antenatal dietary and lifestyle intervention for pregnant women who are overweight or obese is not associated with increased costs or cost savings, but is associated with a high probability of cost effectiveness. Ongoing participant follow-up into childhood is required to determine the medium to long-term impact of the observed, short-term endpoints, to more accurately estimate the value of the intervention on risk of obesity, and associated costs and health outcomes.

Trials registration

Australian and New Zealand Clinical Trials Registry (ACTRN12607000161426).

Nonlinear lattice dynamics as a basis for enhanced superconductivity in YBa2Cu3O6.5

Terahertz-frequency optical pulses can resonantly drive selected vibrational modes in solids and deform their crystal structures. In complex oxides, this method has been used to melt electronic order, drive insulator-to-metal transitions and induce superconductivity. Strikingly, coherent interlayer transport strongly reminiscent of superconductivity can be transiently induced up to room temperature (300 kelvin) in YBa2Cu3O6+x (refs 9, 10). Here we report the crystal structure of this exotic non-equilibrium state, determined by femtosecond X-ray diffraction and ab initio density functional theory calculations. We find that nonlinear lattice excitation in normal-state YBa2Cu3O6+x at above the transition temperature of 52 kelvin causes a simultaneous increase and decrease in the Cu-O2 intra-bilayer and, respectively, inter-bilayer distances, accompanied by anisotropic changes in the in-plane O-Cu-O bond buckling. Density functional theory calculations indicate that these motions cause drastic changes in the electronic structure. Among these, the enhancement in the character of the in-plane electronic structure is likely to favour superconductivity.

The effects of antenatal dietary and lifestyle advice for women who are overweight or obese on maternal diet and physical activity: the LIMIT randomised trial

BACKGROUND

Overweight and obesity is a significant health concern during pregnancy. Our aim was to investigate the effect of providing antenatal dietary and lifestyle advice to women who are overweight or obese on components of maternal diet and physical activity.

METHODS

We conducted a randomised controlled trial, in which pregnant women with a body mass index≥25 kg/m2, and singleton gestation between 10(+0) to 20(+0) weeks were recruited and randomised to Lifestyle Advice (involving a comprehensive dietary and lifestyle intervention over their pregnancy) or Standard Care. Within the intervention group, we conducted a nested randomised trial in which a subgroup of women were further randomised to receive access to supervised group walking sessions in addition to the standard information presented during the intervention contacts (the Walking group) or standard information only. The outcome measures were maternal dietary intake, (including food groups, macronutrient and micronutrient intake, diet quality (using the Healthy Eating Index; HEI), dietary glycaemic load, and glycaemic index) and maternal physical activity. Women completed the Harvard Semi-Structured Food Frequency Questionnaire, and the Short Questionnaire to Assess Health-enhancing Physical Activity (SQUASH), at trial entry, 28 and 36 weeks' gestational age, and 4 months postpartum. Analyses were performed on an intention-to-treat basis, using linear mixed effects models with adjustment for the stratification variables.

RESULTS

Women randomised to Lifestyle Advice demonstrated a statistically significant increase in the number of servings of fruit and vegetables consumed per day, as well as increased consumption of fibre, and reduced percentage energy intake from saturated fats (P<0.05 for all). Maternal HEI was significantly improved at both 28 (73.35±6.62 versus 71.86±7.01; adjusted difference in means 1.58; 95% CI 0.89 to 2.27; P<0.0001) and 36 (72.95±6.82 versus 71.17±7.69; adjusted difference in means 1.77; 95% CI 1.01 to 2.53; P<0.0001) weeks. There were no differences in dietary glycaemic index or glycaemic load. Women randomised to Lifestyle Advice also demonstrated greater total physical activity (adjusted difference in means 359.76 metabolic equivalent task units (MET) minutes/week; 95% CI 74.87 to 644.65; P=0.01) compared with women receiving Standard Care. The supervised walking group was poorly utilised.

CONCLUSIONS

For women who are overweight or obese, antenatal lifestyle advice improves maternal diet and physical activity during pregnancy. Please see related articles: http://www.biomedcentral.com/1741-7015/12/163 and http://www.biomedcentral.com/1741-7015/12/201.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ( ACTRN12607000161426).

The effects of antenatal dietary and lifestyle advice for women who are overweight or obese on neonatal health outcomes: the LIMIT randomised trial

BACKGROUND

Overweight and obesity during pregnancy represents a considerable health burden. While research has focused on interventions to limit gestational weight gain, there is little information describing their impact on neonatal health. Our aim was to investigate the effect on a range of pre-specified secondary neonatal outcomes of providing antenatal dietary and lifestyle advice to women who are overweight or obese.

METHODS

We report a range of pre-specified secondary neonatal outcomes from a large randomised trial in which antenatal dietary and lifestyle advice was provided to women who were overweight or obese. Pregnant women were eligible for participation with a body mass index of 25 kg/m(2) or over, and singleton gestation between 10(+0) and 20(+0) weeks. Outcome measures included gestational age at birth; Apgar score below 7 at 5 minutes of age; need for resuscitation at birth; birth weight above 4.5 kg or below 2.5 kg; birth weight, length and head circumference (and Z-scores); admission to the nursery; respiratory distress syndrome; and postnatal length of stay. Data relating to the primary outcome (large for gestational age infants defined as birth weight above the 90th centile) and birth weight above 4 kg have been reported previously. Analyses used intention-to-treat principles.

RESULTS

In total, 2,142 infants were included in the analyses. Infants born to women following lifestyle advice were significantly less likely to have birth weight above 4.5 kg (2.15% versus 3.69%; adjusted risk ratio (aRR)=0.59; 95% confidence interval (CI) 0.36 to 0.98; P=0.04), or respiratory distress syndrome (1.22% versus 2.57%; aRR=0.47; 95% CI 0.24 to 0.90; P=0.02), particularly moderate or severe disease, and had a shorter length of postnatal hospital stay (3.94±7.26 days versus 4.41±9.87 days; adjusted ratio of means 0.89; 95% CI 0.82 to 0.97; P=0.006) compared with infants born to women who received Standard Care.

CONCLUSIONS

For women who are overweight or obese, antenatal dietary and lifestyle advice has health benefits for infants, without an increase in the risk of harm. Continued follow-up into childhood will be important to assess the longer-term effects of a reduction in high infant birth weight on risk of child obesity. Please see related articles: http://www.biomedcentral.com/1741-7015/12/161 and http://www.biomedcentral.com/1741-7015/12/201 .

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ( ACTRN12607000161426 ).

Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial

OBJECTIVE

To determine the effect of antenatal dietary and lifestyle interventions on health outcomes in overweight and obese pregnant women.

DESIGN

Multicentre randomised trial. We utilised a central telephone randomisation server, with computer generated schedule, balanced variable blocks, and stratification for parity, body mass index (BMI) category, and hospital.

SETTING

Three public maternity hospitals across South Australia.

PARTICIPANTS

2212 women with a singleton pregnancy, between 10+0 and 20+0 weeks' gestation, and BMI ≥ 25.

INTERVENTIONS

1108 women were randomised to a comprehensive dietary and lifestyle intervention delivered by research staff; 1104 were randomised to standard care and received pregnancy care according to local guidelines, which did not include such information.

MAIN OUTCOME MEASURES

Incidence of infants born large for gestational age (birth weight ≥ 90th centile for gestation and sex). Prespecified secondary outcomes included birth weight >4000 g, hypertension, pre-eclampsia, and gestational diabetes. Analyses used intention to treat principles.

RESULTS

2152 women and 2142 liveborn infants were included in the analyses. The risk of the infant being large for gestational age was not significantly different in the two groups (lifestyle advice 203/1075 (19%) v standard care 224/1067 (21%); adjusted relative risk 0.90, 95% confidence interval 0.77 to 1.07; P=0.24). Infants born to women after lifestyle advice were significantly less likely to have birth weight above 4000 g (lifestyle advice 164/1075 (15%) v standard care 201/1067 (19%); 0.82, 0.68 to 0.99; number needed to treat (NNT) 28, 15 to 263; P=0.04). There were no differences in maternal pregnancy and birth outcomes between the two treatment groups.

CONCLUSIONS

For women who were overweight or obese, the antenatal lifestyle advice used in this study did not reduce the risk delivering a baby weighing above the 90th centile for gestational age and sex or improve maternal pregnancy and birth outcomes.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12607000161426).

Hypnosis antenatal training for childbirth: a randomised controlled trial

OBJECTIVE

To determine the use of pharmacologic analgesia during childbirth when antenatal hypnosis is added to standard care.

DESIGN

Randomised controlled clinical trial, conducted from December 2005 to December 2010.

SETTING

The largest tertiary referral centre for maternity care in South Australia.

POPULATION

A cohort of 448 women at >34 weeks of gestation, with a singleton pregnancy and cephalic presentation, planning a vaginal birth. Exclusions were: the need for an interpreter; pre-existing pain; psychiatric illness; younger than 18 years; and previous experience of hypnosis for childbirth.

METHODS

All participants received usual care. The group of women termed Hypnosis + CD (hypnotherapist guided) were offered three antenatal live hypnosis sessions plus each session's corresponding audio CD for further practise, as well as a final fourth CD to listen to during labour. The group of women termed CD only (nurse administered) were played the same antenatal hypnosis CDs as group 1, but did not receive live hypnosis training. The control group participants were given no additional intervention or CDs.

MAIN OUTCOME MEASURE

Use of pharmacological analgesia during labour and childbirth.

RESULTS

No difference in the use of pharmacological analgesia during labour and childbirth was found comparing hypnosis + CD with control (81.2 versus 76.2%; relative risk, RR 1.07; 95% confidence interval, 95% CI 0.95-1.20), or comparing CD only with control (76.9 versus 76.2%, RR 1.01, 95% CI 0.89-1.15).

CONCLUSIONS

Antenatal group hypnosis using the Hypnosis Antenatal Training for Childbirth (HATCh) intervention in late pregnancy does not reduce the use of pharmacological analgesia during labour and childbirth.

Australasian randomised trial to evaluate the role of maternal intramuscular dexamethasone versus betamethasone prior to preterm birth to increase survival free of childhood neurosensory disability (A*STEROID): study protocol

BACKGROUND

Both dexamethasone and betamethasone, given to women at risk of preterm birth, substantially improve short-term neonatal health, increase the chance of the baby being discharged home alive, and reduce childhood neurosensory disability, remaining safe into adulthood. However, it is unclear which corticosteroid is of greater benefit to mother and child.This study aims to determine whether giving dexamethasone to women at risk of preterm birth at less than 34 weeks' gestation increases the chance of their children surviving free of neurosensory disability at two years' corrected age, compared with betamethasone.

METHODS/DESIGN

Design randomised, multicentre, placebo controlled trial.Inclusion criteria women at risk of preterm birth at less than 34 weeks' gestation with a singleton or twin pregnancy and no contraindications to the use of antenatal corticosteroids and who give informed consent.Trial entry & randomisation at telephone randomisation eligible women will be randomly allocated to either the dexamethasone group or the betamethasone group, allocated a study number and corresponding treatment pack.Study groups women in the dexamethasone group will be administered two syringes of 12 mg dexamethasone (dexamethasone sodium phosphate) and women in the betamethasone group will be administered two syringes of 11.4 mg betamethasone (Celestone Chronodose). Both study groups consist of intramuscular treatments 24 hours apart.Primary study outcome death or any neurosensory disability measured in children at two years' corrected age.Sample size a sample size of 1449 children is required to detect either a decrease in death or any neurosensory disability from 27.0% to 20.1% with dexamethasone compared with betamethasone, or an increase from 27.0% to 34.5% (two-sided alpha 0.05, 80% power, 5% loss to follow up, design effect 1.2).

DISCUSSION

This study will provide high-level evidence of direct relevance for clinical practice. If one drug clearly results in significantly fewer deaths and fewer disabled children then it should be used consistently in women at risk of preterm birth and would be of great importance to women at risk of preterm birth, their children, health services and communities.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

ACTRN12608000631303.

Real-time manifestation of strongly coupled spin and charge order parameters in stripe-ordered La(1.75)Sr(0.25)NiO(4) nickelate crystals using time-resolved resonant x-ray diffraction

We investigate the order parameter dynamics of the stripe-ordered nickelate, La(1.75)Sr(0.25)NiO(4), using time-resolved resonant x-ray diffraction. In spite of distinct spin and charge energy scales, the two order parameters' amplitude dynamics are found to be linked together due to strong coupling. Additionally, the vector nature of the spin sector introduces a longer reorientation time scale which is absent in the charge sector. These findings demonstrate that the correlation linking the symmetry-broken states does not unbind during the nonequilibrium process, and the time scales are not necessarily associated with the characteristic energy scales of individual degrees of freedom.

Phosphorus flux from wetland ditch sediments

The accumulation of phosphorus (P) in the bottom sediment of field drainage ditches poses a threat to the ecology both of the ditch water and downstream water courses. We investigated the amounts, forms and internal loading of sediment-bound P along two drainage ditches that regulate water levels in a basin fen (~200 ha) supporting a mixture of restored wetland and drained agricultural fields. Water levels in the Lady's Drove Rhyne are currently managed to enhance the biodiversity of the wetland (Catcott Lows Reserve - an area formerly cultivated for arable crop production); whereas, the East Ditch is managed to drain adjoining land that remains under arable and livestock production. Laboratory-based chemical fractionation schemes were used to characterise the forms and potential mobility of the sediment-bound P, whilst pore-water equilibrators were employed in situ to evaluate the diffusive flux of P through the sediment-water column, and to characterise the corresponding redox conditions. Along both ditches, sediment pore-water profiles indicated conditions ranging from weakly to very reducing conditions with increasing depth, and net fluxes of P from the sediment to overlying water. P flux values ranged from 0.33 to 1.30 mg m(-2) day(-1). Both the degree of P saturation (DPS) of the sediment and NaOH extractable (Fe/Al-bound) P correlated significantly (P<0.05) with P flux. Both in the wetland and agricultural ditches, by far the highest values for P flux were recorded at sites closest to points of drainage water entry from the corresponding, adjoining land. Although the P flux data were obtained from only a single sampling event, this study highlights the contribution of historical as well as ongoing agricultural land use on the sustained elevated P status of ditch sediments in lowland catchments.

The IDEAL study: investigation of dietary advice and lifestyle for women with borderline gestational diabetes: a randomised controlled trial - study protocol

BACKGROUND

The Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) showed that treatment of pregnant women with mild gestational diabetes mellitus is beneficial for both women and their infants. It is still uncertain whether there are benefits of similar treatment for women with borderline gestational diabetes.This trial aims to assess whether dietary and lifestyle advice and treatment given to pregnant women who screen for borderline gestational diabetes reduces neonatal complications and maternal morbidities.

METHODS/DESIGN

DESIGN

Multicentre, randomised controlled trial.

INCLUSION CRITERIA

Women between 240 and 346 weeks gestation with a singleton pregnancy, a positive oral glucose challenge test (venous plasma glucose ≥7.8 mmol/L) and a normal oral 75 gram glucose tolerance test (fasting venous plasma glucose <5.5 mmol/L and a 2 hour glucose <7.8 mmol/L) with written, informed consent.Trial entry and randomisation: Women with an abnormal oral glucose tolerance test (fasting venous plasma glucose ≥5.5 mmol/L or 2 hour glucose ≥7.8 mmol/L) will not be eligible and will be offered treatment for gestational diabetes, consistent with recommendations based on results of the ACHOIS trial. Eligible women will be randomised into either the 'Routine Care Group' or the 'Intervention Group'.Study groups: Women in the 'Routine Care Group' will receive routine obstetric care reflecting current clinical practice in Australian hospitals. Women in the 'Intervention Group' will receive obstetric care, which will include dietary and lifestyle advice, monitoring of blood glucose and further medical treatment for hyperglycaemia as appropriate.Primary study outcome: Incidence of large for gestational age infants.

SAMPLE SIZE

A sample size of 682 women will be sufficient to show a 50% reduction in the risk of large for gestational age infants (alpha 0.05 two-tailed, 80% power, 4% loss to follow up) from 14% to 7% with dietary and lifestyle advice and treatment.

DISCUSSION

A conclusive trial outcome will provide reliable evidence of relevance for the care of women with borderline glucose intolerance in pregnancy and their infants.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry - ACTRN12607000174482.

Reduced corticomotor excitability and motor skills development in children born preterm

The mechanisms underlying the altered neurodevelopment commonly experienced by children born preterm, but without brain lesions, remain unknown. While individuals born the earliest are at most risk, late preterm children also experience significant motor, cognitive and behavioural dysfunction from school age, and reduced income and educational attainment in adulthood. We used transcranial magnetic stimulation and functional assessments to examine corticomotor development in 151 children without cerebral palsy, aged 10-13 years and born after gestations of 25-41 completed weeks. We hypothesized that motor cortex and corticospinal development are altered in preterm children, which underpins at least some of their motor dysfunction. We report for the first time that every week of reduced gestation is associated with a reduction in corticomotor excitability that remains evident in late childhood. This reduced excitability was associated with poorer motor skill development, particularly manual dexterity. However, child adiposity, sex and socio-economic factors regarding the child's home environment soon after birth were also powerful influences on development of motor skills. Preterm birth was also associated with reduced left hemisphere lateralization, but without increasing the likelihood of being left handed per se. These corticomotor findings have implications for normal motor development, but also raise questions regarding possible longer term consequences of preterm birth on motor function.

Invited review article: technology for attosecond science

We describe a complete technological system at Imperial College London for Attosecond Science studies. The system comprises a few-cycle, carrier envelope phase stabilized laser source which delivers sub 4 fs pulses to a vibration-isolated attosecond vacuum beamline. The beamline is used for the generation of isolated attosecond pulses in the extreme ultraviolet (XUV) at kilohertz repetition rates through laser-driven high harmonic generation in gas targets. The beamline incorporates: interferometers for producing pulse sequences for pump-probe studies; the facility to spectrally and spatially filter the harmonic radiation; an in-line spatially resolving XUV spectrometer; and a photoelectron spectroscopy chamber in which attosecond streaking is used to characterize the attosecond pulses. We discuss the technology and techniques behind the development of our complete system and summarize its performance. This versatile apparatus has enabled a number of new experimental investigations which we briefly describe.

Elective birth at 37 weeks of gestation versus standard care for women with an uncomplicated twin pregnancy at term: the Twins Timing of Birth Randomised Trial

OBJECTIVE

To evaluate whether for women with an uncomplicated twin pregnancy, elective birth at 37 weeks of gestation was associated with reduced risk of death or serious outcomes for babies, without increasing harm.

DESIGN

Randomised controlled trial.

SETTING

Maternity hospitals across Australia, New Zealand and Italy.

POPULATION

A total of 235 women with an uncomplicated twin pregnancy at 36(+6) weeks of gestation, with no contraindication to continuing their pregnancy.

METHODS

Using a computer-generated, central telephone randomisation service, 235 women were randomised to Elective Birth (birth at 37 weeks; n=116) or Standard Care (continued expectant management, with birth planned from 38 weeks; n=119). Outcome assessors were masked to treatment allocation.

MAIN OUTCOME MEASURE

A composite of serious adverse outcome for the infant.

RESULTS

For women with an uncomplicated twin pregnancy, elective birth at 37 weeks of gestation was associated with a significant reduction in risk of serious adverse outcome for the infant (Elective Birth 11/232 [4.7%] versus Standard Care 29/238 [12.2%]; risk ratio [RR] 0.39; 95% CI 0.20-0.75; P=0.005), reflecting a reduction in birthweight less than the third centile using singleton gestational age-specific charts (Elective Birth 7/232 [3.0%] versus Standard Care 24/238 [10.1%]; RR 0.30; 95% CI 0.13-0.67; P=0.004). In a post hoc analysis using twin gestational age-specific charts, there was evidence of a trend towards a reduction in the primary composite of serious adverse infant outcome (Elective Birth Group 4/232 [1.7%] versus Standard Care Group 12/238 [5.0%]; RR 0.34; 95% CI 0.11 to 1.05; P=0.06).

CONCLUSION

The findings of our study support recommendations for women with an uncomplicated twin pregnancy to birth at 37 weeks of gestation.

Placental restriction reduces insulin sensitivity and expression of insulin signaling and glucose transporter genes in skeletal muscle, but not liver, in young sheep

Poor growth before birth is associated with impaired insulin sensitivity later in life, increasing the risk of type 2 diabetes. The tissue sites at which insulin resistance first develops after intrauterine growth restriction (IUGR), and its molecular basis, are unclear. We have therefore characterized the effects of placental restriction (PR), a major cause of IUGR, on whole-body insulin sensitivity and expression of molecular determinants of insulin signaling and glucose uptake in skeletal muscle and liver of young lambs. Whole-body insulin sensitivity was measured at 30 d by hyperinsulinaemic euglycaemic clamp and expression of insulin signaling genes (receptors, pathways, and targets) at 43 d in muscle and liver of control (n = 15) and PR (n = 13) lambs. PR reduced size at birth and increased postnatal growth, fasting plasma glucose (+15%, P = 0.004), and insulin (+115%, P = 0.009). PR reduced whole-body insulin sensitivity (-43%, P < 0.001) and skeletal muscle expression of INSR (-36%), IRS1 (-28%), AKT2 (-44%), GLUT4 (-88%), GSK3α (-35%), and GYS1 (-31%) overall (each P < 0.05) and decreased AMPKγ3 expression in females (P = 0.030). PR did not alter hepatic expression of insulin signaling and related genes but increased GLUT2 expression (P = 0.047) in males. Whole-body insulin sensitivity correlated positively with skeletal muscle expression of IRS1, AKT2, HK, AMPKγ2, and AMPKγ3 in PR lambs only (each P < 0.05) but not with hepatic gene expression in control or PR lambs. Onset of insulin resistance after PR and IUGR is accompanied by, and can be accounted for by, reduced expression of insulin signaling and metabolic genes in skeletal muscle but not liver.

Planned vaginal birth or elective repeat caesarean: patient preference restricted cohort with nested randomised trial

BACKGROUND

Uncertainty exists about benefits and harms of a planned vaginal birth after caesarean (VBAC) compared with elective repeat caesarean (ERC). We conducted a prospective restricted cohort study consisting of a patient preference cohort study, and a small nested randomised trial to compare benefits and risks of a planned ERC with planned VBAC.

METHODS AND FINDINGS

2,345 women with one prior caesarean, eligible for VBAC at term, were recruited from 14 Australian maternity hospitals. Women were assigned by patient preference (n = 2,323) or randomisation (n = 22) to planned VBAC (1,225 patient preference, 12 randomised) or planned ERC (1,098 patient preference, ten randomised). The primary outcome was risk of fetal death or death of liveborn infant before discharge or serious infant outcome. Data were analysed for the 2,345 women (100%) and infants enrolled. The risk of fetal death or liveborn infant death prior to discharge or serious infant outcome was significantly lower for infants born in the planned ERC group compared with infants in the planned VBAC group (0.9% versus 2.4%; relative risk [RR] 0.39; 95% CI 0.19-0.80; number needed to treat to benefit 66; 95% CI 40-200). Fewer women in the planned ERC group compared with women in the planned VBAC had a major haemorrhage (blood loss ≥ 1,500 ml and/or blood transfusion), (0.8% [9/1,108] versus 2.3% [29/1,237]; RR 0.37; 95% CI 0.17-0.80).

CONCLUSIONS

Among women with one prior caesarean, planned ERC compared with planned VBAC was associated with a lower risk of fetal and infant death or serious infant outcome. The risk of major maternal haemorrhage was reduced with no increase in maternal or perinatal complications to time of hospital discharge. Women, clinicians, and policy makers can use this information to develop health advice and make decisions about care for women who have had a previous caesarean.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53974531

Fetal Growth and the Fetal Origins Hypothesis in Twins — Problems and Perspectives

Although there is substantial evidence from studies of singletons that small size at birth is linked with long-term adverse health effects, until recently little was known as to whether these associations extend to twins. A review of published studies suggests that at present there is little consistent evidence that birthsize in twins is associated with increased morbidity or morality. While, these findings may reflect methodological limitations, it is also argued that they arise as a consequence of the substantially different biology of fetal growth in twins.

Limiting weight gain in overweight and obese women during pregnancy to improve health outcomes: the LIMIT randomised controlled trial

Background

Obesity is a significant global health problem, with the proportion of women entering pregnancy with a body mass index greater than or equal to 25 kg/m² approaching 50%. Obesity during pregnancy is associated with a well-recognised increased risk of adverse health outcomes both for the woman and her infant, however there is more limited information available regarding effective interventions to improve health outcomes.

The aims of this randomised controlled trial are to assess whether the implementation of a package of dietary and lifestyle advice to overweight and obese women during pregnancy to limit gestational weight gain is effective in improving maternal, fetal and infant health outcomes.

Methods/Design

Design: Multicentred randomised, controlled trial.

Inclusion Criteria: Women with a singleton, live gestation between 10⁺⁰-20⁺⁰ weeks who are obese or overweight (defined as body mass index greater than or equal to 25 kg/m²), at the first antenatal visit.

Trial Entry & Randomisation: Eligible, consenting women will be randomised between 10⁺⁰ and 20⁺⁰ weeks gestation using a central telephone randomisation service, and randomisation schedule prepared by non-clinical research staff with balanced variable blocks. Stratification will be according to maternal BMI at trial entry, parity, and centre where planned to give birth.

Treatment Schedules: Women randomised to the Dietary and Lifestyle Advice Group will receive a series of inputs from research assistants and research dietician to limit gestational weight gain, and will include a combination of dietary, exercise and behavioural strategies.

Women randomised to the Standard Care Group will continue to receive their pregnancy care according to local hospital guidelines, which does not currently include routine provision of dietary, lifestyle and behavioural advice.

Outcome assessors will be blinded to the allocated treatment group.

Primary Study Outcome: infant large for gestational age (defined as infant birth weight ≥ 90^th centile for gestational age).

Sample Size: 2,180 women to detect a 30% reduction in large for gestational age infants from 14.40% (p = 0.05, 80% power, two-tailed).

Discussion

This is a protocol for a randomised trial. The findings will contribute to the development of evidence based clinical practice guidelines.

Trial Registration

Australian and New Zealand Clinical Trials Registry ACTRN12607000161426

Stressful life events, social health issues and low birthweight in an Australian population-based birth cohort: challenges and opportunities in antenatal care

BACKGROUND

Investment in strategies to promote 'a healthy start to life' has been identified as having the greatest potential to reduce health inequalities across the life course. The aim of this study was to examine social determinants of low birthweight in an Australian population-based birth cohort and consider implications for health policy and health care systems.

METHODS

Population-based survey distributed by hospitals and home birth practitioners to >8000 women six months after childbirth in two states of Australia. Participants were women who gave birth to a liveborn infant in Victoria and South Australia in September/October 2007. Main outcome measures included stressful life events and social health issues, perceived discrimination in health care settings, infant birthweight.

RESULTS

4,366/8468 (52%) of eligible women returned completed surveys. Two-thirds (2912/4352) reported one or more stressful life events or social health issues during pregnancy. Women reporting three or more social health issues (18%, 768/4352) were significantly more likely to have a low birthweight infant (< 2500 grams) after controlling for smoking and other socio-demographic covariates (Adj OR = 1.77, 95% CI 1.1-2.8). Mothers born overseas in non-English speaking countries also had a higher risk of having a low birthweight infant (Adj OR = 1.85, 95% CI 1.2-2.9). Women reporting three or more stressful life events/social health issues were more likely to attend antenatal care later in pregnancy (OR = 2.06, 95% CI 1.3-3.1), to have fewer antenatal visits (OR = 2.17, 95% CI 1.4-3.4) and to experience discrimination in health care settings (OR = 2.69, 95% CI 2.2-3.3).

CONCLUSIONS

There is a window of opportunity in antenatal care to implement targeted preventive interventions addressing potentially modifiable risk factors for poor maternal and infant outcomes. Developing the evidence base and infrastructure necessary in order for antenatal services to respond effectively to the social circumstances of women's lives is long overdue.

Maternal and perinatal health outcomes by body mass index category

AIMS

To determine the effect of increasing maternal body mass index (BMI) during pregnancy on maternal and infant health outcomes.

METHODS

The South Australian Pregnancy Outcome Unit's population database, 2008 was accessed to determine pregnancy outcomes according to maternal BMI. Women with a normal BMI (18.5-24.9 kg/m(2) ) formed a reference population, to which women in other BMI categories were compared utilising risk ratios and 95% confidence intervals.

RESULTS

Overweight and obese women had an increased risk of gestational diabetes, hypertension and iatrogenic preterm birth. Labour was more likely to be induced, and the risk of caesarean birth was increased. Infants were more likely to require resuscitation at birth and to have birth weight in excess of 4 kg. The risk increased with increasing maternal BMI.

CONCLUSIONS

There is a well-documented increased risk of maternal and perinatal health complications for women who are overweight or obese during pregnancy.

Timing of birth for women with a twin pregnancy at term: a randomised controlled trial

Background

There is a well recognized risk of complications for both women and infants of a twin pregnancy, increasing beyond 37 weeks gestation. Preterm birth prior to 37 weeks gestation is a recognized complication of a twin pregnancy, however, up to 50% of twins will be born after this time.

The aims of this randomised trial are to assess whether elective birth at 37 weeks gestation compared with standard care in women with a twin pregnancy affects the risk of perinatal death, and serious infant complications.

Methods/Design

Design: Multicentred randomised trial.

Inclusion Criteria: women with a twin pregnancy at 36⁶ weeks or more without contraindication to continuation of pregnancy.

Trial Entry & Randomisation: Following written informed consent, eligible women will be randomised from 36⁺⁶ weeks gestation. The randomisation schedule uses balanced variable blocks, with stratification for centre of birth and planned mode of birth. Women will be randomised to either elective birth or standard care.

Treatment Schedules: Women allocated to the elective birth group will be planned for elective birth from 37 weeks gestation. Where the plan is for vaginal birth, this will involve induction of labour. Where the plan is for caesarean birth, this will involve elective caesarean section. For women allocated to standard care, birth will be planned for 38 weeks gestation or later. Where the plan is for vaginal birth, this will involve either awaiting the spontaneous onset of labour, or induction of labour if required. Where the plan is for caesarean birth, this will involve elective caesarean section (after 38 and as close to 39 weeks as possible).

Primary Study Outcome: A composite of perinatal mortality or serious neonatal morbidity.

Sample Size: 460 women with a twin pregnancy to show a reduction in the composite outcome from 16.3% to 6.7% with adjustment for the clustering of twin infants within mothers (p = 0.05, 80% power).

Discussion

This is a protocol for a randomised trial, the findings of which will contribute information about the optimal time of birth for women with an uncomplicated multiple pregnancy at and beyond 37 weeks gestation.

Clinical Trial Registration

Current Controlled Trials ISRCTN15761056

Placental restriction increases adipose leptin gene expression and plasma leptin and alters their relationship to feeding activity in the young lamb

Low birth weight and catch-up growth predict increased adiposity in children and adults. This may be due in part to leptin resistance, as adults who were born small exhibit increased plasma leptin concentration relative to adiposity. Placental restriction (PR), a major cause of intrauterine growth restriction, reduces size at birth and increases feeding activity and adiposity by 6 wk in sheep. We hypothesized that PR would increase plasma leptin concentration and alter its relationship with feeding activity and adiposity in young lambs. Body size, plasma leptin, feeding activity, adiposity, leptin, and leptin receptor gene expression in adipose tissue were measured (12 control, 12 PR). PR reduced size at birth and increased adiposity. Plasma leptin concentration decreased with age, but to a lesser extent after PR and correlated positively with adiposity similarly in control and PR. PR increased plasma leptin concentration and perirenal adipose tissue leptin expression. Feeding activity correlated negatively with plasma leptin concentration in controls, but positively after PR. PR increases adipose tissue leptin expression and plasma leptin concentration, however, this increased abundance of peripheral leptin does not inhibit feeding activity (suckling event frequency), suggesting PR programs resistance to appetite and energy balance regulation by leptin, leading to early onset obesity.

Effect of treatment of gestational diabetes mellitus on obesity in the next generation

OBJECTIVE

Gestational diabetes mellitus (GDM) may cause obesity in the offspring. The objective was to assess the effect of treatment for mild GDM on the BMI of 4- to 5-year-old children.

RESEARCH DESIGN AND METHODS

Participants were 199 mothers who participated in a randomized controlled trial of the treatment of mild GDM during pregnancy and their children. Trained nurses measured the height and weight of the children at preschool visits in a state-wide surveillance program in the state of South Australia. The main outcome measure was age- and sex-specific BMI Z score based on standards of the International Obesity Task Force.

RESULTS

At birth, prevalence of macrosomia (birth weight >or=4,000 g) was 5.3% among the 94 children whose mothers were in the intervention group, and 21.9% among the 105 children in the routine care control group. At 4- to 5-years-old, mean (SD) BMI Z score was 0.49 (1.20) in intervention children and 0.41 (1.40) among controls. The difference between treatment groups was 0.08 (95% CI -0.29 to 0.44), an estimate minimally changed by adjustment for maternal race, parity, age, and socio-economic index (0.08 [-0.29 to 0.45]). Evaluating BMI >or=85th percentile rather than continuous BMI Z score gave similarly null results.

CONCLUSIONS

Although treatment of GDM substantially reduced macrosomia at birth, it did not result in a change in BMI at age 4- to 5-years-old.

Review: Placental programming of postnatal diabetes and impaired insulin action after IUGR

Being born small due to poor growth before birth increases the risk of developing metabolic disease, including type 2 diabetes, in later life. Inadequate insulin secretion and decreasing insulin sensitivity contribute to this increased diabetes risk. Impaired placental growth, development and function are major causes of impaired fetal growth and development and therefore of IUGR. Restricted placental growth (PR) and function in non-human animals induces similar changes in insulin secretion and sensitivity as in human IUGR, making these valuable tools to investigate the underlying mechanisms and to test interventions to prevent or ameliorate the risk of disease after IUGR. Epigenetic changes induced by an adverse fetal environment are strongly implicated as causes of later impaired insulin action. These have been well-characterised in the PR rat, where impaired insulin secretion is linked to epigenetic changes at the Pdx-1 promotor and reduced expression of this transcription factor. Present research is particularly focussed on developing intervention strategies to prevent or reverse epigenetic changes, and normalise gene expression and insulin action after PR, in order to translate this to treatments to improve outcomes in human IUGR.

Progesterone after previous preterm birth for prevention of neonatal respiratory distress syndrome (PROGRESS): a randomised controlled trial

BACKGROUND

Neonatal respiratory distress syndrome, as a consequence of preterm birth, is a major cause of early mortality and morbidity during infancy and childhood. Survivors of preterm birth continue to remain at considerable risk of both chronic lung disease and long-term neurological handicap. Progesterone is involved in the maintenance of uterine quiescence through modulation of the calcium-calmodulin-myosin-light-chain-kinase system in smooth muscle cells. The withdrawal of progesterone, either actual or functional is thought to be an antecedent to the onset of labour. While there have been recent reports of progesterone supplementation for women at risk of preterm birth which show promise in this intervention, there is currently insufficient data on clinically important outcomes for both women and infants to enable informed clinical decision-making. The aims of this randomised, double blind, placebo controlled trial are to assess whether the use of vaginal progesterone pessaries in women with a history of previous spontaneous preterm birth will reduce the risk and severity of respiratory distress syndrome, so improving their infant's health, without increasing maternal risks.

METHODS

DESIGN

Multicentered randomised, double blind, placebo-controlled trial.

INCLUSION CRITERIA

pregnant women with a live fetus, and a history of prior preterm birth at less than 37 weeks gestation and greater than 20 weeks gestation in the immediately preceding pregnancy, where onset of labour occurred spontaneously, or in association with cervical incompetence, or following preterm prelabour ruptured membranes. Trial Entry & Randomisation: After obtaining written informed consent, eligible women will be randomised between 18 and 23+6 weeks gestation using a central telephone randomisation service. The randomisation schedule prepared by non clinical research staff will use balanced variable blocks, with stratification according to plurality of the pregnancy and centre where planned to give birth. Eligible women will be randomised to either vaginal progesterone or vaginal placebo. Study Medication & Treatment Schedules: Treatment packs will appear identical. Woman, caregivers and research staff will be blinded to treatment allocation. Primary Study Outcome: Neonatal Respiratory Distress Syndrome (defined by incidence and severity).

SAMPLE SIZE

of 984 women to show a 40% reduction in respiratory distress syndrome from 15% to 9% (p = 0.05, 80% power).

DISCUSSION

This is a protocol for a randomised trial.

Ideal waveform to generate the maximum possible electron recollision energy for any given oscillation period

We present the perfect waveform which, during a strong field interaction, generates the maximum possible electron recollision energy for any given oscillation period, over 3 times as high as that for a pure sinusoidal wave. This ideal waveform has the form of a linear ramp with a dc offset. A genetic algorithm was employed to find an optimized practically achievable waveform composed of a longer wavelength field, to provide the offset, in addition to higher frequency components. This second waveform is found to be capable of generating electron recollision energies as high as those for the perfect waveform while retaining the high recollision amplitudes of a pure sinusoidal wave. Calculations of high harmonic generation demonstrate this enhancement, by increasing the cutoff energy by a factor of 2.5 while maintaining the harmonic yield, providing an enhanced tool for attosecond science.

Impaired beta-cell function and inadequate compensatory increases in beta-cell mass after intrauterine growth restriction in sheep

Poor growth before birth increases the risk of non-insulin-dependent diabetes mellitus (NIDDM) and impairs insulin secretion relative to sensitivity. We investigated the effects of intrauterine growth restriction in sheep on insulin secretion, beta-cell mass, and function from before birth to young adulthood and its molecular basis. Pancreas was collected from control and placentally restricted sheep as fetuses (d 143 gestation), lambs (aged 42 d), and young adults (aged 556 d), following independent measures of in vivo insulin secretion and sensitivity. beta-Cells and islets were counted after immunohistochemical staining for insulin. In lambs, gene expression was measured by RT-PCR and expressed relative to 18S. beta-Cell mass correlated positively with fetal weight but negatively with birth weight in adult males. Glucose-stimulated insulin disposition and beta-cell function correlated negatively with fetal weight but positively with birth weight in adult males. Placental restriction increased pancreatic expression of IGF-II and IGF-I but decreased that of voltage-gated calcium channel, alpha1D subunit (CACNA1D) in lambs. In male lambs, pancreatic IGF-II and insulin receptor expression correlated strongly and positively with beta-cell mass and CACNA1D expression with glucose-stimulated insulin disposition. Restricted growth before birth in the sheep does not impair insulin secretion, relative to sensitivity, before birth or in young offspring. IGF-II and insulin receptor are implicated as key molecular regulators of beta-cell mass compensation, whereas impaired expression of the voltage-gated calcium channel may underlie impaired beta-cell function after intrauterine growth restriction. With aging, the insulin secretory capacity of the beta-cell is impaired in males, and their increases in beta-cell mass are inadequate to maintain adequate insulin secretion relative to sensitivity.

Dietary and lifestyle interventions to limit weight gain during pregnancy for obese or overweight women: a systematic review

BACKGROUND

To assess the benefits and harm of dietary and lifestyle interventions during pregnancy to improve maternal and infant outcomes for pregnant women who are overweight or obese.

METHODS

Randomized controlled trials comparing any form of dietary or lifestyle intervention during pregnancy for women who are overweight or obese with no treatment to improve maternal and infant health were considered. The Cochrane Controlled Trials Register (CENTRAL), PUBMED and the Australian and International Clinical Trials Registry were searched (date of last search November 2007).

RESULTS

Two published trials were identified with no statistically significant differences identified between the intervention and standard care groups for maternal or infant health outcomes.

CONCLUSION

There is limited information available assessing the benefits and harm associated with dietary and lifestyle interventions for overweight and obese pregnant women. Further evaluation through randomized trials with adequate power is required.

Dynamic two-center interference in high-order harmonic generation from molecules with attosecond nuclear motion

We report a new dynamic two-center interference effect in high-harmonic generation from H2, in which the attosecond nuclear motion of H2+ initiated at ionization causes interference to be observed at lower harmonic orders than would be the case for static nuclei. To enable this measurement we utilize a recently developed technique for probing the attosecond nuclear dynamics of small molecules. The experimental results are reproduced by a theoretical analysis based upon the strong-field approximation which incorporates the temporally dependent two-center interference term.

The pars intermedia and the fetal pituitary-adrenal axis

The increased production of cortisol by the fetal adrenal gland at term acts as the trigger for parturition in some species. The fetal pituitary controls fetal adrenal function. However, ACTH is only one of a family of closely related peptides which derive from a common precursor and we have shown that although ACTH is the dominant form in the adult pituitary, the expression of the "family trees' is altered in the fetus. In the sheep, it is large-molecular-weight precursors and, in the primate, the smaller peptides such as alpha-MSH, CLIP, beta-MSH and beta-endorphin that predominate in fetal life and which may be responsible for fetal adrenal function. It is still unclear what causes the developmental change in the ACTH "family tree'. Since it may result from a change in pituitary function - from the peptides of the pars intermedia, in the fetus, to those of pars anterior, in the adult - we have studied these two lobes separately in pituitaries taken from adult and fetal sheep and monkeys. Our preliminary results suggest that the change may occur in the neurointermediate lobe in the primate, but that in the sheep the developmental changes occur in the anterior lobe.