The Adelaide Facial Bone Rule: A simple prediction model and clinical guideline for the presence of facial fractures using CT brain scans in victims of minor trauma

BACKGROUND

Facial fractures bleed, resulting in high-density fluid in the sinuses (haemosinus) on computed tomography (CT) scans. A CT brain scan includes most maxillary sinuses in the scan field, which should allow detection of haemosinus as an indirect indicator of a facial fracture without the need for an additional CT facial bone scan, yet no robust evidence for this exists in the literature. The aim of this study was to determine whether the presence of haemosinus on a CT brain scan, alone or in combination with other clinical information, can predict the presence of facial fractures.

METHODS

1231 adult patients, who had both brain and facial CT scans performed on the same day, were selected from a seven year period. Patients were eligible if scans were requested for trauma. Brain and facial scans were reviewed separately for the presence of facial fractures, haemosinus, emphysema and intra-cranial haemorrhage. Prediction modelling was used to assess whether findings from brain scans could be used to identify patients requiring further CT scanning.

FINDINGS

The full prediction model included four predictors and showed excellent discrimination (AUROC 0.982; 95 % CI 0.971 - 0.993). A simplified model, more suitable for clinical implementation, used only facial fractures and haemosinus as predictors. This model showed only marginally poorer discrimination (AUROC 0.964; 95 % CI 0.945 - 0.983) and excellent performance on other measures.

CONCLUSION

Based on the excellent performance of the simplified prediction model, we present the Adelaide Facial Bone Rule: The absence of blood in the sinuses or facial fractures on a CT brain scan means a CT facial bone scan does not need to be routinely performed in the setting of clinically-determined minor trauma.

Fetal Growth and Adiposity of Infants Born Large for Gestational Age in Three Harmonized Randomized Trials

OBJECTIVE

 Infants born large for gestational age (LGA) are at an increased risk of short- and longer-term adverse outcomes. Understanding fetal growth and adiposity and their trajectories may help inform interventions to prevent birth of LGA infants. We aimed to compare fetal growth and adiposity measures of infants born LGA with those born not LGA, to determine whether the discrepancy at birth was primarily due to larger size throughout gestation, or instead to different trajectories of fetal growth.

STUDY DESIGN

 This was a secondary analysis of secondary outcomes of fetal growth and adiposity from three harmonized randomized trials-the LIMIT, GRoW, and Optimise randomized trials. These trials recruited women in early pregnancy, and a singleton gestation, from three major public metropolitan Adelaide maternity hospitals. Maternal body mass index (BMI) ranged from 18.5 to ≥40.0 kg/m2. Data were obtained from enrolled women who underwent research ultrasounds at 28 and 36 weeks' gestation. Outcome measures were ultrasound measures of fetal biometry and adiposity.

RESULTS

 Infants born LGA had larger fetal biometry measures, and higher growth trajectories, from 20 weeks' gestation. Fetal adiposity measures were consistently larger among infants born LGA and these differences increased over time. We did not find evidence that the differences in biometry and adiposity measurements varied according to maternal BMI.

CONCLUSION

 Infants born LGA had larger fetal biometry measures at all time points from 20 weeks' gestation, compared with infants born not LGA suggesting any interventions to prevent LGA likely need to commence earlier in pregnancy or prior to conception.

KEY POINTS

· Infants born LGA had larger fetal biometry measures from 20 weeks' gestation.. · Infants born LGA had larger fetal adiposity measures.. · Interventions to prevent LGA need to start earlier in pregnancy or prior to conception..

Effects of an antenatal dietary intervention in women with obesity or overweight on child outcomes at 8-10 years of age: LIMIT randomised trial follow-up

BACKGROUND

The LIMIT randomised controlled trial looked at the effect of a dietary and lifestyle intervention compared with routine antenatal care for pregnant women with overweight and obesity on pregnancy outcomes. While women in the intervention group improved diet and physical activity with a reduction of high birth weight, other outcomes were similar. We have followed the children born to women in this study at birth, 6 and 18 months and 3-5 years of age and now report follow-up of children at 8-10 years of age.

METHODS

Children at 8-10 years of age who were born to women who participated in the LIMIT randomised trial, and whose mother provided consent to ongoing follow-up were eligible for inclusion. The primary study endpoint was the incidence of child BMI z-score > 85th centile for child sex and age. Secondary study outcomes included a range of anthropometric measures, neurodevelopment, child dietary intake, and physical activity. Analyses used intention to treat principles according to the treatment group allocated in pregnancy. Outcome assessors were blinded to the allocated treatment group.

RESULTS

We assessed 1,015 (Lifestyle Advice n = 510; Standard Care n = 505) (48%) of the 2,121 eligible children. BMI z-score > 85th percentile was similar for children of women in the dietary Lifestyle Advice Group compared with children of women in the Standard Care Group (Lifestyle Advice 479 (45%) versus Standard Care 507 (48%); adjusted RR (aRR) 0.93; 95% CI 0.82 to 1.06; p = 0.302) as were secondary outcomes. We observed that more than 45% of all the children had a BMI z-score > 85th percentile, consistent with findings from follow-up at earlier time-points, indicating an ongoing risk of overweight and obesity.

CONCLUSIONS

Dietary and lifestyle advice for women with overweight and obesity in pregnancy has not reduced the risk of childhood obesity, with children remaining at risk of adolescent and adult obesity. Other strategies are needed to address the risk of overweight and obesity in children including investigation of preconception interventions to assess whether this can modify the effects of maternal pre-pregnancy BMI. The LIMIT randomised controlled trial was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12607000161426).

Review of outpatient procedural sedation clinics in a tertiary paediatric hospital in South Australia

AIM

Procedures, such as immunisation and venepuncture, can be distressing for paediatric patients, especially those with needle phobia and neurodevelopmental disorders. Procedural sedation helps provide access to equitable health care in this population. The aim of this study was to evaluate the pilot outpatient procedural sedation clinics at the Women's and Children's Hospital and the impact on patient care and outcomes.

METHODS

A prospective review was undertaken between July 2021 and May 2022 on all patients who attended the procedural sedation clinics at the Women's and Children's Hospital. These clinics were the COVID Specialist Immunisation Sedation Clinic (SISC) and Paediatric Sedation Clinic (PSC).

RESULTS

There were 182 visits in a total of 110 children with a 92% primary procedure success rate. Sixty-three per cent of patients had neurodevelopmental disorders with autism spectrum disorder being most common. There was a significant reduction in anxiety scores pre- and post-sedation and a reduction in anxiety scores if patients were to return without the use of sedation.

CONCLUSIONS

Outpatient procedural sedation is beneficial for a specific cohort of the paediatric population. This can also have a significant positive impact on patient care and potentially, long-term outcomes.

Comparison of effect of CTG + STan with CTG alone on emergency Cesarean section rate: STan Australian Randomized controlled Trial (START)

OBJECTIVE

To investigate whether use of ST analysis of the fetal electrocardiogram (STan) as an adjunct to continuous cardiotocography (CTG) reduces the rate of emergency Cesarean section (EmCS) compared with CTG alone.

METHODS

This was a randomized controlled trial of patients with a singleton fetus in cephalic presentation at ≥ 36 weeks' gestation, requiring continuous electronic fetal monitoring during labor at a tertiary maternity hospital in Adelaide, Australia, between January 2018 and July 2021. Participants were randomized to undergo CTG + STan or CTG alone. The calculated sample size was 1818 participants. The primary outcome was EmCS. Secondary outcomes included metabolic acidosis, a composite adverse perinatal outcome, and other maternal and neonatal morbidity and safety outcomes.

RESULTS

The present study enrolled 970 women, of whom 967 were included in the primary analysis. EmCS occurred in 107/482 (22.2%) deliveries in the CTG + STan arm and in 107/485 (22.1%) in the CTG arm (adjusted relative risk, 1.02 (95% CI, 0.81-1.27); P = 0.89). There was no difference in the rate of adverse maternal or neonatal outcomes between arms.

CONCLUSIONS

The addition of STan as an adjunct to continuous CTG did not reduce the EmCS rate. The smaller-than-anticipated sample size meant that this study was underpowered to detect absolute differences of ≤ 5% and, therefore, this negative finding could be due to a Type-2 error. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Handling misclassified stratification variables in the analysis of randomised trials with continuous outcomes

Many trials use stratified randomisation, where participants are randomised within strata defined by one or more baseline covariates. While it is important to adjust for stratification variables in the analysis, the appropriate method of adjustment is unclear when stratification variables are affected by misclassification and hence some participants are randomised in the incorrect stratum. We conducted a simulation study to compare methods of adjusting for stratification variables affected by misclassification in the analysis of continuous outcomes when all or only some stratification errors are discovered, and when the treatment effect or treatment-by-covariate interaction effect is of interest. The data were analysed using linear regression with no adjustment, adjustment for the strata used to perform the randomisation (randomisation strata), adjustment for the strata if all errors are corrected (true strata), and adjustment for the strata after some errors are discovered and corrected (updated strata). The unadjusted model performed poorly in all settings. Adjusting for the true strata was optimal, while the relative performance of adjusting for the randomisation strata or the updated strata varied depending on the setting. As the true strata are unlikely to be known with certainty in practice, we recommend using the updated strata for adjustment and performing subgroup analyses, provided the discovery of errors is unlikely to depend on treatment group, as expected in blinded trials. Greater transparency is needed in the reporting of stratification errors and how they were addressed in the analysis.

Validation of RAH VQ SPECT/CT lobar quantification program using a modified version of GE Q lung

OBJECTIVE

The value of ventilation-perfusion (VQ) single photon emission tomography/computed tomography (SPECT/CT) lobar quantification for pre-operative assessment of lobectomy and lung volume reduction is known. Our in-house developed software, RAH ventilation perfusion SPECT/CT quantification (RAHVQSQ) has been shown to be able to identify the target lobe for collapse in bronchoscopic lung volume reduction (BLVR) for advanced emphysema. We have proven inter and intra observer reproducibility but are yet to validate the accuracy of our program. This study aims to validate the accuracy of our quantitative program through comparison with a modified version of GE Q lung which is a commercial program certified for clinical use.

SUBJECTS AND METHODS

Ventilation-perfusion SPECT/CT data of 19 subjects from our previous study using RAHVQSQ for BLVR assessment were re-analysed using Q lung by 2 technologists independently and in a blinded fashion to determine lobar differential ventilation, perfusion and volume percentages. The data were from GE Hawkeye 4 and external CT, thus a modified version of Q lung was used. To determine interobserver variation in the 3 parameters between the 3 assessors, intraclass correlation coefficient (ICC) and Bland-Altman limits of agreement (LoA) were generated.

RESULTS

Paired comparisons between the 3 assessors had high ICC (range for ventilation: 0.69-0.97; perfusion: 0.69-0.97; volume: 0.63-0.97) and means of LoA differences close to zero (range for ventilation: -0.04 - 0.10; perfusion: 0.00-0.02; volume: -0.12 - 0.09) were noted indicative of good concordance for all parameters.

CONCLUSION

Using VQ SPECT/CT data of participants with advanced airway disease, our study has found a close concordance of estimated differential lobar ventilation, perfusion and volume percentages using RAHVQSQ when compared with a duplicated blinded assessment using Q lung. The good concordance supports the validity of our quantitative methodology.

Cardiovascular disease, associated risk factors, and risk of dementia: An umbrella review of meta-analyses

Introduction

Cardiovascular diseases (CVDs) have been associated with an increased risk of dementia; yet the evidence is mixed. This review critically appraises and synthesises current evidence exploring associations between dementia risk and CVD and their risk factors, including coronary heart disease, heart failure, atrial fibrillation, hypertension, hyperlipidaemia, and arterial stiffness.

Methods

MEDLINE, Embase, PsycINFO, and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews with meta-analyses investigating the association between at least one of the CVDs of interest and dementia risk. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews was used to assess methodological quality.

Results

Twenty-five meta-analyses published between 2007 and 2021 were included. Studies largely consisted of cohorts from North America and Europe. Findings were variable, with coronary heart disease, heart failure, and atrial fibrillation consistently associated with increased risk for all-cause dementia, but results were inconsistent for Alzheimer's disease. Hypertension was more frequently associated with dementia during mid-life compared to late life. Findings concerning cholesterol were complex, and while results were inconsistent for low-density lipoprotein cholesterol and total cholesterol, there appeared to be no associations between triglycerides and high-density lipoprotein cholesterol. All meta-analyses investigating hypercholesterolaemia showed significant increases in dementia risk. There was a paucity of research on the association between arterial stiffness and dementia risk.

Conclusion

Targeted CVD dementia prevention strategies could reduce dementia prevalence. Future research should determine the underpinning mechanisms linking heart and brain health to determine the most effective strategies for dementia risk reduction in CVD populations.

Data processing choices can affect findings in differential methylation analyses: an investigation using data from the LIMIT RCT

Objective

A wide array of methods exist for processing and analysing DNA methylation data. We aimed to perform a systematic comparison of the behaviour of these methods, using cord blood DNAm from the LIMIT RCT, in relation to detecting hypothesised effects of interest (intervention and pre-pregnancy maternal BMI) as well as effects known to be spurious, and known to be present.

Methods

DNAm data, from 645 cord blood samples analysed using Illumina 450K BeadChip arrays, were normalised using three different methods (with probe filtering undertaken pre- or post- normalisation). Batch effects were handled with a supervised algorithm, an unsupervised algorithm, or adjustment in the analysis model. Analysis was undertaken with and without adjustment for estimated cell type proportions. The effects estimated included intervention and BMI (effects of interest in the original study), infant sex and randomly assigned groups. Data processing and analysis methods were compared in relation to number and identity of differentially methylated probes, rankings of probes by p value and log-fold-change, and distributions of p values and log-fold-change estimates.

Results

There were differences corresponding to each of the processing and analysis choices. Importantly, some combinations of data processing choices resulted in a substantial number of spurious 'significant' findings. We recommend greater emphasis on replication and greater use of sensitivity analyses.

Childhood follow-up of the GRoW randomized trial: Metformin in addition to dietary and lifestyle advice for pregnant women with overweight or obesity

BACKGROUND

Metformin for women with overweight or obesity during pregnancy has been evaluated in randomized trials to reduce adverse pregnancy and birth outcomes. The effect on longer-term child health remains of interest.

OBJECTIVES

To evaluate the effect of in-utero exposure to metformin on child health compared with no exposure.

METHODS

We assessed children born to 513 women who participated in the Metformin in addition to dietary and lifestyle advice for pregnant women with overweight or obesity: the GRoW randomized trial, where women were randomized to receive either metformin or placebo during pregnancy. Child weight, height, anthropometry, diet, physical activity and neurodevelopment were assessed at six and 18 months and three to five years of age. The main outcome was BMI z-score > 85th centile for age and sex.

RESULTS

The number of children with BMI >85th centile was similar between treatment groups at all time points. At 18 months and three to five years of age, more than half of the children had a BMI z-score > 85th centile, indicating a high risk of childhood obesity.

CONCLUSIONS

We did not show evidence of the benefit of metformin for children of women with overweight or obesity during pregnancy adding to the growing literature on the lack of effect of pregnancy interventions in reducing longer-term risks of childhood obesity.

Maternal overweight and obesity during pregnancy: strategies to improve outcomes for women, babies, and children

INTRODUCTION

Women with overweight and obesity, and their children, are at increased risk of adverse pregnancy, birth, and longer term health outcomes, believed to be compounded by excessive gestational weight gain (GWG). Research to date has focused on interventions to reduce excessive GWG through changes to maternal diet and/or lifestyle.

AREAS COVERED

Current clinical recommendations for GWG vary according to a woman's early pregnancy body mass index, based on assumptions that associations between GWG and adverse pregnancy outcomes are causal in nature, and modifiable. While there are small differences in GWG following pregnancy interventions, there is little evidence for clinically relevant effects on pregnancy, birth, and longer term childhood outcomes. This review considers interventional studies targeting women with overweight or obesity to reduce GWG in an effort to improve maternal and infant health, and the current evidence for interventions prior to conception.

EXPERT OPINION

GWG is not modifiable via diet and lifestyle change, and continued efforts to find the 'right' intervention for women with overweight and obesity during pregnancy are unjustified. Researchers should focus on gathering evidence for interventions prior to pregnancy to optimize maternal health and weight to improve pregnancy, birth, and longer term health outcomes associated with obesity.

Effect of an antenatal diet and lifestyle intervention and maternal BMI on cord blood DNA methylation in infants of overweight and obese women: The LIMIT Randomised Controlled Trial

Background

To investigate the effect of an antenatal diet and lifestyle intervention, and maternal pre-pregnancy overweight or obesity, on infant cord blood DNA methylation.

Methods

We measured DNA methylation in 645 cord blood samples from participants in the LIMIT study (an antenatal diet and lifestyle intervention for women with early pregnancy BMI ≥25.0 kg/m2) using the Illumina 450K BeadChip array, and tested for any differential methylation related to the intervention, and to maternal early pregnancy BMI. We also analysed differential methylation in relation to selected candidate genes.

Results

No CpG sites were significantly differentially methylated in relation to either the diet and lifestyle intervention, or with maternal early pregnancy BMI. There was no significant differential methylation in any of the selected genes related to the intervention, or to maternal BMI.

Conclusion

We found no evidence of an effect of either antenatal diet and lifestyle, or of maternal early pregnancy BMI, on cord blood DNA methylation.

Clinical trials registration

ACTRN12607000161426

No evidence for clinical efficacy of adjunctive celecoxib with vortioxetine in the treatment of depression: A 6-week double-blind placebo controlled randomized trial

Given the role of low-grade inflammation in the pathophysiology of major depressive disorder (MDD), anti-inflammatory strategies may improve treatment outcomes in some patients. However, it is controversial whether they can be used as adjunctive treatments and whether pre-treatment levels of inflammation can predict treatment outcomes. This study was conducted to measure the efficacy of anti-inflammatory augmentation of antidepressant treatment in MDD patients; and to investigate whether treatment response was dependent on baseline inflammation levels. This parallel-group randomised, double-blind, placebo-controlled trial was conducted at the University of Adelaide (Australia). Participants with MDD were randomised to receive vortioxetine with celecoxib or vortioxetine with placebo for six weeks, and baseline blood high sensitivity C reactive protein levels were measured. Primary outcome was change in depressive symptoms (Montgomery-Åsberg Depression Rating Scale) and secondary outcomes included change in cognition (THINC-integrated tool - Codebreaker task) and functioning (Functioning Assessment Short Test) over 6 weeks. There was no evidence of superior efficacy of celecoxib augmentation over placebo on depressive symptom severity, response and remission rates, cognition and psychosocial functioning. There was also no evidence that pre-treatment inflammation levels modified the effect of celecoxib augmentation versus placebo. This observed lack of efficacy of celecoxib add-on does not support the use of celecoxib augmentation of antidepressants in the treatment of MDD in a cohort that mostly comprises treatment-resistant individuals. Additionally, C-reactive protein may not be suitable to predict treatment selection and response in MDD. The study was registered on the Australian New Zealand Clinical Trials Registry: ACTRN12617000527369 (www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000527369p).

The effects of dietary and lifestyle interventions among pregnant women with overweight or obesity on early childhood outcomes: an individual participant data meta-analysis from randomised trials

BACKGROUND

The impact of maternal obesity extends beyond birth, being independently associated with an increased risk of child obesity. Current evidence demonstrates that women provided with a dietary intervention during pregnancy improve their dietary quality and have a modest reduction in gestational weight gain. However, the effect of this on longer-term childhood obesity-related outcomes is unknown.

METHODS

We conducted an individual participant data meta-analysis from RCTs in which women with a singleton, live gestation between 10⁺⁰ and 20⁺⁰ weeks and body mass index (BMI) ≥ 25 kg/m² in early pregnancy were randomised to a diet and/or lifestyle intervention or continued standard antenatal care and in which longer-term maternal and child follow-up at 3-5 years of age had been undertaken. The primary childhood outcome was BMI z-score above the 90th percentile. Secondary childhood outcomes included skinfold thickness measurements and body circumferences, fat-free mass, dietary and physical activity patterns, blood pressure, and neurodevelopment.

RESULTS

Seven primary trials where follow-up of participants occurred were identified by a systematic literature search within the International Weight Management in Pregnancy (i-WIP) Collaborative Group collaboration, with six providing individual participant data. No additional studies were identified after a systematic literature search. A total of 2529 children and 2383 women contributed data. Approximately 30% of all child participants had a BMI z-score above the 90th percentile, with no significant difference between the intervention and control groups (aRR 0.97; 95% CI 0.87, 1.08; p=0.610). There were no statistically significant differences identified for any of the secondary outcome measures.

CONCLUSIONS

In overweight and obese pregnant women, we found no evidence that maternal dietary and/or lifestyle intervention during pregnancy modifies the risk of early childhood obesity. Future research may need to target the pre-conception period in women and early childhood interventions.

TRIAL REGISTRATION

PROSPERO, CRD42016047165.

Associations between diet, the gut microbiome and short chain fatty acids in youth with islet autoimmunity and type 1 diabetes

AIM

We aimed to characterize associations between diet and the gut microbiome and short chain fatty acid (SCFA) products in youth with islet autoimmunity or type 1 diabetes (IA/T1D) in comparison with controls.

RESEARCH DESIGN AND METHODS

Eighty participants (25 diagnosed with T1D, 17 with confirmed IA, 38 sibling or unrelated controls) from the Australian T1D Gut Study cohort were studied (median [IQR] age 11.7 [8.9, 14.0] years, 43% female). A Food Frequency Questionnaire characterized daily macronutrient intake over the preceding 6 months. Plasma and fecal SCFA were measured by gas chromatography; gut microbiome composition and diversity by 16S rRNA gene sequencing.

RESULTS

A 10 g increase in daily carbohydrate intake associated with higher plasma acetate in IA/T1D (adjusted estimate +5.2 (95% CI 1.1, 9.2) μmol/L p = 0.01) and controls (adjusted estimate +4.1 [95% CI 1.7, 8.5] μmol/L p = 0.04). A 5 g increase in total fat intake associated with lower plasma acetate in IA/T1D and controls. A 5% increase in noncore (junk) food intake associated with reduced richness (adjusted estimate -4.09 [95%CI -7.83, -0.35] p = .03) and evenness (-1.25 [95% CI -2.00, -0.49] p < 0.01) of the gut microbiome in IA/T1D. Fiber intake associated with community structure of the microbiome in IA/T1D.

CONCLUSIONS

Modest increments in carbohydrate and fat intake associated with plasma acetate in all youth. Increased junk food intake associated with reduced diversity of the gut microbiome in IA/T1D alone. These associations with the gut microbiome in IA/T1D support future efforts to promote SCFA by using dietary interventions.

A multi-centre, open label, randomised, parallel-group, superiority Trial to compare the efficacy of URsodeoxycholic acid with RIFampicin in the management of women with severe early onset Intrahepatic Cholestasis of pregnancy: the TURRIFIC randomised trial

BACKGROUND

Severe early onset (less than 34 weeks gestation) intrahepatic cholestasis of pregnancy (ICP) affects 0.1% of pregnant women in Australia and is associated with a 3-fold increased risk of stillbirth, fetal hypoxia and compromise, spontaneous preterm birth, as well as increased frequencies of pre-eclampsia and gestational diabetes. ICP is often familial and overlaps with other cholestatic disorders. Treatment options for ICP are not well established, although there are limited data to support the use of ursodeoxycholic acid (UDCA) to relieve pruritus, the main symptom. Rifampicin, a widely used antibiotic including in pregnant women, is effective in reducing pruritus in non-pregnancy cholestasis and has been used as a supplement to UDCA in severe ICP. Many women with ICP are electively delivered preterm, although there are no randomised data to support this approach.

METHODS

We have initiated an international multicentre randomised clinical trial to compare the clinical efficacy of rifampicin tablets (300 mg bd) with that of UDCA tablets (up to 2000 mg daily) in reducing pruritus in women with ICP, using visual pruritus scores as a measuring tool.

DISCUSSION

Our study will be the first to examine the outcomes of treatment specifically in the severe early onset form of ICP, comparing "standard" UDCA therapy with rifampicin, and so be able to provide for the first-time high-quality evidence for use of rifampicin in severe ICP. It will also allow an assessment of feasibility of a future trial to test whether elective early delivery in severe ICP is beneficial.

TRIAL IDENTIFIERS

Australian New Zealand Clinical Trials Registration Number (ANZCTR): 12618000332224p (29/08/2018). HREC No: HREC/18/WCHN/36. EudraCT number: 2018-004011-44. IRAS: 272398. NHMRC registration: APP1152418 and APP117853.

Skin and subcutaneous fascia closure at caesarean section to reduce wound complications: the closure randomised trial

BACKGROUND

Wound infection is a common complication following caesarean section. Factors influencing the risk of infection may include the suture material for skin closure, and closure of the subcutaneous fascia. We assessed the effect of skin closure with absorbable versus non-absorbable suture, and closure versus non-closure of the subcutaneous fascia on risk of wound infection following Caesarean section.

METHODS

Women undergoing caesarean birth at an Adelaide maternity hospital were eligible for recruitment to a randomised trial using a 2 × 2 factorial design. Women were randomised to either closure or non-closure of the subcutaneous fascia and to subcuticular skin closure with an absorbable or non-absorbable suture. Participants were randomised to each of the two interventions into one of 4 possible groups: Group 1 - non-absorbable skin suture and non-closure of the subcutaneous fascia; Group 2 - absorbable skin suture and non-closure of the subcutaneous fascia; Group 3 - non-absorbable skin suture and closure of the subcutaneous fascia; and Group 4 - absorbable skin suture and closure of the subcutaneous fascia. The primary outcomes were reported wound infection and wound haematoma or seroma within the first 30 days after birth.

RESULTS

A total of 851 women were recruited and randomised, with 849 women included in the analyses (Group 1: 216 women; Group 2: 212 women; Group 3: 212 women; Group 4: 211 women). In women who underwent fascia closure, there was a statistically significant increase in risk of wound infection within 30 days post-operatively for those who had skin closure with an absorbable suture (Group 4), compared with women who had skin closure with a non-absorbable suture (Group 3) (adjusted RR 2.17; 95% CI 1.05, 4.45; p = 0.035). There was no significant difference in risk of wound infection for absorbable vs non-absorbable sutures in women who did not undergo fascia closure.

CONCLUSION

The combination of subcutaneous fascia closure and skin closure with an absorbable suture may be associated with an increased risk of reported wound infection after caesarean section.

TRIAL REGISTRATION

Prospectively registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12608000143325 , on the 20th March, 2008.

The effect of advanced recovery room care on postoperative outcomes in moderate-risk surgical patients: a multicentre feasibility study

Postoperative complications are common and may be under-recognised. It has been suggested that enhanced postoperative care in the recovery room may reduce in-hospital complications in moderate- and high-risk surgical patients. We investigated the feasibility of providing advanced recovery room care for 12-18 h postoperatively in the post-anaesthesia care unit. The primary hypothesis was that a clinical trial of advanced recovery room care was feasible. The secondary hypothesis was that this model may have a sustained impact on postoperative in-hospital and post-discharge events. This was a multicentre, prospective, feasibility before-and-after trial of moderate-risk patients (predicted 30-day mortality of 1-4%) undergoing non-cardiac surgery and who were scheduled for postoperative ward care. Patients were managed using defined assessment checklists and goals of care in an advanced recovery room care setting in the immediate postoperative period. This utilised existing post-anaesthesia care unit infrastructure and staffing, but extended care until the morning of the first postoperative day. The advanced recovery room care trial was deemed feasible, as defined by the recruitment and per protocol management of > 120 patients. However, in a specialised cancer centre, recruitment was slow due to low rates of eligibility according to narrow inclusion criteria. At a rural site, advanced recovery room care could not be commenced due to logistical issues in establishing a new model of care. A definitive randomised controlled trial of advanced recovery room care appears feasible and, based on the indicative data on outcomes, we believe this is warranted.

Effect of metformin in addition to an antenatal diet and lifestyle intervention on fetal growth and adiposity: the GRoW randomised trial

BACKGROUND

The infants born to women who are overweight or obese in pregnancy are at an increased risk of being born macrosomic or large for gestational age. Antenatal dietary and lifestyle interventions have been shown to be ineffective at reducing this risk. Our aim was to examine the effects of metformin in addition to a diet and lifestyle intervention on fetal growth and adiposity among women with a BMI above the healthy range.

METHODS

Women who had a body mass index ≥25 kg/m² in early pregnancy, and a singleton gestation, were enrolled in the GRoW trial from three public maternity hospitals in metropolitan Adelaide. Women were invited to have a research ultrasounds at 28 and 36 weeks' gestation at which ultrasound measures of fetal biometry and adiposity were obtained. Fetal biometry z-scores and trajectories were calculated. Measurements and calculations were compared between treatment groups. This secondary analysis was pre-specified.

RESULTS

Ultrasound data from 511 women were included in this analysis. The difference in femur length at 36 weeks' gestation was (0.07 cm, 95% CI 0.01-0.14 cm, p = 0.019) and this was was statistically significant, however the magnitude of effect was small. Differences between treatment groups for all other fetal biometry measures, z-scores, estimated fetal weight, and adiposity measures at 28 and 36 weeks' gestation were similar.

CONCLUSIONS

The addition of metformin to dietary and lifestyle advice in pregnancy for overweight and obese women has no clinically relevant effect on ultrasound measures of fetal biometry or adiposity.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ( ACTRN12612001277831 ).

Pancreas size and exocrine function is decreased in young children with recent-onset Type 1 diabetes

AIMS

To measure pancreatic area and exocrine function in young children with recent-onset Type 1 diabetes to determine whether the exocrine pancreas is also affected in the pathophysiology of early childhood diabetes.

METHODS

Thirty-two children (14 boys) aged 5.5 (4.5, 7.3) median (IQR) years presenting with recent-onset Type 1 diabetes and 90 controls (44 boys) of similar age had ultrasound imaging of the pancreas. Children with Type 1 diabetes were receiving insulin and were without ketosis. Transverse and longitudinal areas of the pancreas were measured by digitalized outline. Pancreatic faecal elastase-1 was analysed using an enzyme-linked immunosorbent assay kit in recent-onset Type 1 diabetes and 38 first-degree relative control children.

RESULTS

Pancreatic area and exocrine function were reduced in Type 1 diabetes. Mean transverse area (SD) in Type 1 diabetes was 6.82 cm² (1.61) vs. 8.31 cm² (1.74) in controls, adjusted estimate (95% CI) 1.45 (-2.12, -0.79), P < 0.001; longitudinal area was 1.28 cm² (0.44) vs. 1.55 cm² (0.43), adjusted estimate (95% CI) -0.27 (-0.45, -0.09), P = 0.003. Faecal elastase-1 levels in Type 1 diabetes were 455 (323, 833) ug/g, median (IQR) vs. 1408 μg/g (1031, 1989) in controls, P < 0.001.

CONCLUSION

Pancreatic area and accompanying subclinical exocrine function were reduced in very young children with recent-onset Type 1 diabetes. This supports changes in the exocrine pancreas in the pathophysiology of Type 1 diabetes presenting in early life.

A Randomised Trial to Optimise Gestational Weight Gain and Improve Maternal and Infant Health Outcomes through Antenatal Dietary, Lifestyle and Exercise Advice: The OPTIMISE Randomised Trial

There are well-recognised associations between excessive gestational weight gain (GWG) and adverse pregnancy outcomes, including an increased risk of pre-eclampsia, gestational diabetes and caesarean birth. The aim of the OPTIMISE randomised trial was to evaluate the effect of dietary and exercise advice among pregnant women of normal body mass index (BMI), on pregnancy and birth outcomes. The trial was conducted in Adelaide, South Australia. Pregnant women with a body mass index in the healthy weight range (18.5–24.9 kg/m²) were enrolled in a randomised controlled trial of a dietary and lifestyle intervention versus standard antenatal care. The dietitian-led dietary and lifestyle intervention over the course of pregnancy was based on the Australian Guide to Healthy Eating. Baseline characteristics of women in the two treatment groups were similar. There was no statistically significant difference in the proportion of infants with birth weight above 4.0 kg between the Lifestyle Advice and Standard Care groups (24/316 (7.59%) Lifestyle Advice versus 26/313 (8.31%) Standard Care; adjusted risk ratio (aRR) 0.91; 95% confidence interval (CI) 0.54 to 1.55; p = 0.732). Despite improvements in maternal diet quality, no significant differences between the treatment groups were observed for total GWG, or other pregnancy and birth outcomes.

Maternal cardiometabolic markers are associated with fetal growth: a secondary exploratory analysis of the LIMIT randomised trial

BACKGROUND

To determine the association between maternal cardiometabolic and inflammatory markers with measures of fetal biometry and adiposity.

METHODS

Women included in this exploratory analysis were randomised to the 'Standard Care' group (N = 911) from the LIMIT randomised trial involving a total of 2212 pregnant women who were overweight or obese (ACTRN12607000161426, Date of registration 9/03/2007, prospectively registered). Fetal biometry including abdominal circumference (AC), estimated fetal weight (EFW), and adiposity measurements (mid-thigh fat mass, subscapular fat mass, abdominal fat mass) were obtained from ultrasound assessments at 28 and 36 weeks' gestation. Maternal markers included C reactive protein (CRP), leptin and adiponectin concentrations, measured at 28 and 36 weeks' gestation and fasting triglycerides and glucose concentrations measured at 28 weeks' gestation.

RESULTS

There were negative associations identified between maternal serum adiponectin and fetal ultrasound markers of biometry and adiposity. After adjusting for confounders, a 1-unit increase in log Adiponectin was associated with a reduction in the mean AC z score [- 0.21 (- 0.35, - 0.07), P = 0.004] and EFW [- 0.23 (- 0.37, - 0.10), P < 0.001] at 28 weeks gestation. Similarly, a 1-unit increase in log Adiponectin was association with a reduction in the mean AC z score [- 0.30 (- 0.46, - 0.13), P < 0.001] and EFW [- 0.24 (- 0.38, - 0.10), P < 0.001] at 36 weeks gestation. There were no consistent associations between maternal cardiometabolic and inflammatory markers with measurements of fetal adiposity.

CONCLUSION

Adiponectin concentrations are associated with measures of fetal growth. Our findings contribute to further understanding of fetal growth in the setting of women who are overweight or obesity.

Epidemiological trends of dermal sarcoma in Australia

Background: Sarcomas comprise a heterogenous group of malignant tumours of mesenchymal origin and can arise in the skin. Definitive management of skin sarcoma usually entails surgical resection with wide margins, often requiring reconstruction. The incidence and demographics of these neoplasms in Australia are poorly understood. Method: Incidence, gender and age distribution data for skin sarcomas for the period 1982–2009 were obtained from the Australian Cancer Database (ACD). Morphology and topographical region coding via the International Classification of Diseases for Oncology third edition (ICD-O-3)1 were used to identify the data.Results: A total of 5453 cases of skin sarcoma in the Australian population were identified over the 28-year period. Anatomically, 1610 cases (29%) occurred on the limbs, 1416 (26%) on the head and neck area, 957 (18%) on the trunk and 1470 (27%) had an unspecified skin origin. Overall incidence was 2.09 per 100,000 population. Males were more commonly affected (70%), most commonly in the 30–49 years and 70+ years age groups. The most common pathological subtypes were fibromatous sarcoma (including dermatofibrosarcoma protuberans), Kaposi’s sarcoma and pleomorphic dermal sarcoma.Conclusion: The Australian Cancer Database data used to describe the pattern and epidemiological trends for skin sarcoma in Australia demonstrated variation from international trends and highlight the need for further research into the aetiology of these tumours.

In overweight and obese women, fetal ultrasound biometry accurately predicts newborn measures

INTRODUCTION

The aim of this study was to evaluate the association between fetal ultrasound and newborn biometry and adiposity measures in the setting of maternal obesity.

MATERIAL AND METHODS

The study population involved 845 overweight or obese pregnant women, who participated in the Standard Care Group of the LIMIT randomised trial (ACTRN12607000161426, 9/03/2007). At 36 weeks gestation, fetal biometry, estimated fetal weight (EFW) and adiposity measures including mid-thigh fat mass (MTFM), subscapular fat mass (SSFM), and abdominal fat mass (AFM) were undertaken using ultrasound. Neonatal anthropometric measurements obtained after birth included birthweight, head circumference (HC), abdominal circumference (AC) and skinfold thickness measurements (SFTM) of the subscapular region and abdomen.

RESULTS

At 36 weeks gestation, every 1 g increase in EFW was associated with a 0.94 g increase in birthweight (95% CI 0.88-0.99; P < 0.001). For every 1 mm increase in the fetal ultrasound measure, there was a 0.69 mm increase in birth HC (95% CI 0.63-0.75, P < 0.001) and 0.69 mm increase in birth AC (95% CI 0.60-0.79, P < 0.001). Subscapular fat mass in the fetus and the newborn (0.29 mm, 95% CI 0.20-0.39, P < 0.001) were moderately associated, but AFM measurements were not (0.06 mm, -0.03 to 0.15, P = 0.203). There is no evidence that these relationships differed by maternal body mass index.

CONCLUSION

In women who are overweight or obese, fetal ultrasound accurately predicts neonatal HC and AC along with birthweight.

Contact force and ablation assessment of surgical bipolar radiofrequency clamps in the treatment of atrial fibrillation

OBJECTIVES

Atrial fibrillation is treated surgically by creating conduction block lesions. Radiofrequency (RF) lesions have reduced efficacy compared to 'cut-and-sew'. Catheter ablation studies demonstrate a relationship between lesion depth and contact force. We hypothesized that contact force and lesion depth are dependent on design of the bipolar surgical RF clamps.

METHODS

Hinged and parallel jaw style RF clamps were studied. Muscle samples were clamped with pressure-sensitive film at increasing tissue thicknesses. Films were analysed determining clamp pressure profiles. A sheep model was utilized for ablation testing using each clamp style until the device indicated transmurality. Separate muscle areas had 1, 2 or 3 burns applied. The muscle was excised, sectioned every 1 cm and stained for lesion depth and fat thickness analysis.

RESULTS

Pressure profiling comparing the proximal and distal segments of each clamp style demonstrated only one statistically significant difference in the parallel clamp; the hinged clamp had statistically significant differences (P ≤ 0.03) for all tissue thicknesses. There was no evidence for differences in the proximal lesion depth of both clamps (P = 0.13) but deeper distally in the parallel clamp (10.17 mm vs 8.02 mm, P = 0.003). The logistic regression analysis demonstrated increased odds of transmurality with parallel clamps at 1, 2 or 3 burns (P = 0.03, P = 0.003 and P = 0.002). Every 1 mm increase in overlying fat decreased likelihood of transmurality by 11% (P < 0.05).

CONCLUSIONS

The parallel and hinged clamps have different pressure profiles with higher likelihood of transmurality using the parallel clamp. Fat reduces the ability of RF to deliver a transmural lesion. These findings have implications for optimal surgical RF ablation technique.

Effect of metformin in addition to dietary and lifestyle advice for pregnant women who are overweight or obese: the GRoW randomised, double-blind, placebo-controlled trial

BACKGROUND

Maternal overweight and obesity are associated with well recognised pregnancy complications. Antenatal dietary and lifestyle interventions have a modest effect on gestational weight gain without affecting pregnancy outcomes. We aimed to assess the effects on maternal and infant outcomes of antenatal metformin given in addition to dietary and lifestyle advice among overweight and obese pregnant women.

METHODS

GRoW was a multicentre, randomised, double-blind, placebo-controlled trial in which pregnant women at 10-20 weeks' gestation with a BMI of 25 kg/m² or higher were recruited from three public maternity units in Adelaide, SA, Australia. Women were randomly assigned (1:1) via a computer-generated schedule to receive either metformin (to a maximum dose of 2000 mg per day) or matching placebo. Participants, their antenatal care providers, and research staff (including outcome assessors) were masked to treatment allocation. All women received an antenatal dietary and lifestyle intervention. The primary outcome was the proportion of infants with birthweight greater than 4000 g. Secondary outcomes included measures of maternal weight gain, maternal diet and physical activity, maternal pregnancy and birth outcomes, maternal quality of life and emotional wellbeing, and infant birth outcomes. Outcomes were analysed on an intention-to-treat basis (including all randomly assigned women who did not withdraw consent to use their data, and who did not have a miscarriage or termination of pregnancy before 20 weeks' gestation, or a stillbirth). The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12612001277831.

FINDINGS

Of 524 women who were randomly assigned between May, 28 2013 and April 26, 2016, 514 were included in outcome analyses (256 in the metformin group and 258 in the placebo group). Median gestational age at trial entry was 16·29 weeks (IQR 14·43-18·00) and median BMI was 32·32 kg/m² (28·90-37·10); 167 (32%) participants were overweight and 347 (68%) were obese. There was no significant difference in the proportion of infants with birthweight greater than 4000 g (40 [16%] with metformin vs 37 [14%] with placebo; adjusted risk ratio [aRR] 0·97, 95% CI 0·65 to 1·47; p=0·899). Women receiving metformin had lower average weekly gestational weight gain (adjusted mean difference -0·08 kg, 95% CI -0·14 to -0·02; p=0·007) and were more likely to have gestational weight gain below recommendations (aRR 1·46, 95% CI 1·10 to 1·94; p=0·008). Total gestational weight gain, pregnancy and birth outcomes, maternal diet and physical activity, and maternal quality of life and emotional wellbeing did not differ significantly between groups. Similar numbers of women in both treatment groups (76% [159/208] in the metformin group and 73% [144/196] in the placebo group) reported side-effects including nausea, diarrhoea, and vomiting. Two stillbirths (placebo group) and one neonatal death (metformin group) occurred; none of the perinatal deaths were determined to be attributable to participation in the trial.

INTERPRETATION

For pregnant women who are overweight or obese, metformin given in addition to dietary and lifestyle advice initiated at 10-20 weeks' gestation does not improve pregnancy and birth outcomes.

FUNDING

Australian National Health and Medical Research Council.

Can the Bayley Scales of Infant Development at 18 months predict child behaviour at 7 years?

AIM

Infants born preterm (<37 weeks' gestation) are at risk of poor neurodevelopmental outcomes; hence, many neonatal centres routinely follow up infants using the Bayley Scales of Infant Development (BSID), although the predictive validity of the BSID for children born preterm is questionable. Our objective is to evaluate the predictive capacity of the BSID for behavioural functioning at school age of children born preterm.

METHODS

Children (n = 657 children born <33 weeks' gestation) were enrolled at birth from five neonatal centres around Australia. A psychologist assessed child development at 18 months using the BSID-II. When children were 7 years (corrected age) of age, parents completed the Strengths and Difficulties Questionnaire, the Behavior Rating Inventory of Executive Function and the Conners 3rd Edition Attention Deficit Hyperactivity Disorder Index. We explored associations between BSID-II at 18 months and behaviour scores at 7 years and examined the interaction effect of the use of an allied health service between the BSID-II and behaviour assessments.

RESULTS

For every one-point increase on the BSID-II Mental Development Index, behaviour scores decreased by 0.07 points for the Strengths and Difficulties Questionnaire Total Difficulties (95% confidence interval (CI) -0.10, -0.03), 0.12 points for the Behavior Rating Inventory of Executive Function Global Executive Composite (95% CI -0.21, -0.04) and 0.16 points for the Conners 3rd Edition Attention Deficit Hyperactivity Disorder Index (95% CI -0.26, -0.05).

CONCLUSION

The BSID-II at 18 months was weakly associated with parent-reported behaviour at 7 years in children born preterm.

The effect of maternal obesity on fetal biometry, body composition, and growth velocity

Introduction: The aim of this secondary analysis was to investigate the relationship between maternal body mass index (BMI) and fetal biometry, body composition, and velocity measurements at 28 and 36 weeks gestation.Materials and methods: The current analysis involves 911 overweight or obese women who were randomized to the Standard Care group of the LIMIT randomized trial.Results: The fetus of women with Class 3 obesity (BMI ≥ 40.0) showed the greatest increase in all biometry z-scores, abdominal area (AA), and abdominal fat mass (AFM) compared with women classified as overweight (BMI 25.0-29.9). In women with Class 3 obesity, AA velocity was increased by 0.035 cm² (0.004, 0.066, p = .029) and the z-score velocity was increased by 0.238 (0.022, 0.453, p = .03). Estimated fetal weight (EFW) velocity for women with Class 3 obesity was higher than that of overweight women by 2.028 g per day (0.861, 3.196, p<.001) and the z-score velocity was also higher by 0.441 per day (0.196, 0.687, p < .001).Conclusions: Maternal obesity is associated with an increase in fetal abdominal circumference, AFM and area along with EFW velocity over time. Women with Class 3 obesity (BMI ≥ 40.0) may represent a higher risk group for perpetuating the intergenerational transmission of obesity to their offspring.

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.

In Overweight or Obese Pregnant Women, Maternal Dietary Factors are not Associated with Fetal Growth and Adiposity

The aim of our study was to evaluate associations between maternal dietary factors and fetal growth and adiposity in overweight and obese women. Women randomised to the ‘Standard Care’ group of the LIMIT trial were included. Maternal dietary factors including Healthy Eating Index, total energy, fat, carbohydrates, protein, glycaemic load and index were measured using the Harvard semi-quantitative Food Frequency questionnaire at time of study entry, 28 and 36 weeks’ gestation. Fetal ultrasound measurements of biometry and adiposity were obtained at 28 and 36 weeks’ gestation. Linear regression models were used to associate between dietary factors and fetal growth and adiposity measurements. There were 721 women included in this exploratory analysis. A 10 unit increase in the log total energy was associated with a reduction in mid-thigh lean mass by 4.94 mm at 28 weeks (95% CI −9.57 mm, −0.32 mm; p = 0.036) and 7.02 mm at 36 weeks (95% CI −13.69 mm, −0.35 mm; p = 0.039). A 10 unit increase in Healthy Eating Index score was associated with a reduced mean subscapular skin fold measure at 28 weeks by 0.17 mm (95% CI −0.32 mm, −0.03 mm; p = 0.021). We did not identify consistent associations between maternal diet and measures of fetal growth and adiposity in overweight and obese women.

The mediating effects of gestational diabetes on fetal growth and adiposity in women who are overweight and obese: secondary analysis of the LIMIT randomised trial

OBJECTIVE

To describe the mediating effect of maternal gestational diabetes on fetal biometry and adiposity measures among overweight or obese pregnant women.

DESIGN

Secondary analysis of the LIMIT randomised trial.

SETTING

Public hospitals, metropolitan Adelaide, South Australia.

POPULATION

Pregnant women with body mass index (BMI) ≥25 kg/m² and singleton gestation.

METHODS

Fetal ultrasound measures at 36 weeks of gestation and baseline BMI from women randomised to the LIMIT trial Standard Care group (n = 912 women) were used to conduct causal mediation analyses using regression-based methods.

MAIN OUTCOMES MEASURES

Ultrasound measures of fetal biometry and adiposity at 36 weeks of gestation.

RESULTS

Increased maternal BMI was associated with increased measures of fetal head circumference [direct (unmediated) effect 0.18 (95% CI: 0.05-0.31), P = 0.005; total effect 0.17 (95% CI: 0.02-0.31), P = 0.018], abdominal circumference [direct effect 0.26 (95% CI: 0.11-0.41), P = 0.001; total effect 0.26 (95% CI: 0.11-0.42), P = 0.001] and estimated fetal weight [direct effect 0.22 (95% CI: 0.08-0.35), P = 0.002; total effect 0.22 (95% CI: 0.08-0.35), P = 0.002], with no evidence of mediation by treated gestational diabetes. There was no apparent association between maternal BMI and fetal adiposity measures, or mediation by treated gestational diabetes.

CONCLUSIONS

We show an important association between increased maternal BMI and fetal growth, not mediated by treated gestational diabetes. There was no association between increased maternal BMI and fetal adiposity measures, or mediation by treated gestational diabetes. Whether these findings represent 'saturation' in the effect of maternal BMI on fetal growth or the effect of treatment of GDM is unclear.

FUNDING

This project was funded by a 4-year project grant from the National Health and Medical Research Council (NHMRC), Australia (ID 519240); The Channel 7 Children's Research Foundation, South Australia; and the US National Institutes of Health (R01 HL094235-01).

TWEETABLE ABSTRACT

Increased fetal growth associated with maternal obesity is not mediated by gestational diabetes.

Fetal middle cerebral artery Doppler to time intrauterine transfusion in red-cell alloimmunization: a randomized trial

OBJECTIVES

To evaluate whether Doppler measurement of middle cerebral artery peak systolic velocity (MCA-PSV) for timing subsequent intrauterine transfusions (IUTs) in fetuses that had undergone one IUT for anemia secondary to red-cell alloimmunization is non-inferior to timing based on expected decrease in fetal hematocrit (Hct) or fetal hemoglobin level, without compromising infant hemoglobin at birth.

METHODS

This was an international, pragmatic multicenter randomized controlled trial. Women with a pregnancy complicated by fetal anemia secondary to red-cell alloimmunization (due to any antibody alone or in combination), as indicated by the need to undergo a single IUT, were eligible for inclusion. Women were randomized to the determination of timing of further transfusion(s) by Doppler measurement of MCA-PSV (MCA-PSV Group), with a serial upward trend of values >1.5 multiples of the median considered indicative of the need for another IUT, or timing of transfusion by a decrease in fetal Hct (fetal Hct Group), with subsequent IUTs timed according to an estimated fall in fetal Hct of 1% per day or fetal hemoglobin of 0.3 g/dL per day, to maintain fetal hemoglobin level between 7 and 10 g/dL. The primary outcome was infant hemoglobin level measured at birth.

RESULTS

A total of 71 women were randomized, 36 to the MCA-PSV Group and 35 to the fetal Hct Group. Median gestational age at randomization was 30.3 weeks, the majority of women were Caucasian and non-smokers, 9.9% of women had Kell alloimmunization, and 14% of fetuses were hydropic at their first IUT. No statistically significant differences between the two treatment groups were observed with regard to mean hemoglobin levels at birth (MCA-PSV Group, 10.36 ± 3.82 g/dL vs fetal Hct Group, 12.03 ± 3.14 g/dL; adjusted mean difference -1.56 g/dL (95% CI, -3.24 to 0.13 g/dL); P = 0.070), or the number of IUTs performed after randomization (MCA-PSV Group, 1.75 ± 1.79 vs fetal Hct Group 1.80 ± 1.32; adjusted relative risk 0.88 (95% CI, 0.61-1.26); P = 0.474). There was no statistically significant difference between the two groups with respect to the risk of adverse infant outcomes related to alloimmunization or procedure-related complications.

CONCLUSION

Both Doppler measurement of MCA-PSV and estimation of the decrease in fetal Hct or hemoglobin can be used to determine the timing of second and subsequent IUTs in fetuses with red-cell alloimmunization. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Optimising gestational weight gain and improving maternal and infant health outcomes through antenatal dietary, lifestyle and physical activity advice: the OPTIMISE randomised controlled trial protocol

INTRODUCTION

Obesity represents a significant health burden, and WHO recognises the importance of preventing weight gain and subsequent development of obesity among adults who are within the healthy weight range. Women of reproductive age have demonstrated high rates of weight gain during pregnancy placing them at risk of becoming overweight or obese. We will evaluate the effects of dietary and physical activity advice on maternal, fetal and infant health outcomes, among pregnant women of normal body mass index (BMI).

METHODS AND ANALYSIS

We will conduct a randomised controlled trial, consenting and randomising women with a live singleton pregnancy between 10⁺⁰ and 20⁺⁰ weeks and BMI 18.5-24.9 kg/m² at first antenatal visit, from a tertiary maternity hospital. Women randomised to the Lifestyle Advice Group will receive three face-to-face sessions (two with a research dietitian and one with a trained research assistant) and three telephone calls over pregnancy, in which they will be provided with dietary and lifestyle advice and encouraged to make change using a SMART goals approach. Women randomised to the Standard Care Group will receive routine antenatal care. The primary outcome is infant birth weight >4 kg. Secondary outcomes will include adverse infant and maternal outcomes, maternal weight change, maternal diet and physical activity changes, maternal quality of life and emotional well-being, fetal growth and costs of healthcare. We will recruit 624 women to detect a reduction from 8.72% to 3.87% (alpha 0.05 (two-tailed); power 70%) in infants with birth weight >4 kg. Analyses will be intention to treat with estimates reported as relative risks and 95% CIs.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Women's and Children's Hospital ethics committee. Findings will be disseminated widely via journal publication and conference presentation(s), and participants informed of results.

TRIAL REGISTRATION NUMBER

ACTRN12614000583640.

Evaluation of a smartphone nutrition and physical activity application to provide lifestyle advice to pregnant women: The SNAPP randomised trial

Our objective was to evaluate the impact of a smartphone application as an adjunct to face-to-face consultations in facilitating dietary and physical activity change among pregnant women. This multicentre, nested randomised trial involved pregnant women with a body mass index ≥18.5 kg/m2 , with a singleton pregnancy between 10 and 20 weeks' gestation, and participating in 2 pregnancy nutrition-based randomised trials across metropolitan Adelaide, South Australia. All women participating in the SNAPP trial received a comprehensive dietary, physical activity, and behavioural intervention, as part of the GRoW or OPTIMISE randomised trials. Women were subsequently randomised to either the "Lifestyle Advice Only Group," where women received the above intervention, or the "Lifestyle Advice plus Smartphone Application Group," where women were additionally provided access to the smartphone application. The primary outcome was healthy eating index (HEI) assessed by maternal food frequency questionnaire completed at trial entry, and 28 and 36 weeks' gestation. Analyses were performed using intention-to-treat principles, with statistical significance at p = .05. One hundred sixty-two women participated: 77 allocated to the Lifestyle Advice plus Smartphone Application Group and 85 to the Lifestyle Advice Only Group. Mean difference in HEI score at 28 weeks of pregnancy was 0.01 (CI [-2.29, 2.62]) and at 36 weeks of pregnancy -1.16 (CI [-4.60, 2.28]). There was no significant additional benefit from the provision of the smartphone application in improving HEI score (p = .452). Although all women improved dietary quality across pregnancy, use of the smartphone application was poor. Our findings do not support addition of the smartphone application.

Randomized controlled trial assessing the efficacy of a reusable fish-shaped iron ingot to increase hemoglobin concentration in anemic, rural Cambodian women

Background: Anemia affects 45% of women of childbearing age in Cambodia. Iron supplementation is recommended in populations in which anemia prevalence is high. However, there are issues of cost, distribution, and adherence. A potential alternative is a reusable fish-shaped iron ingot, which, when added to the cooking pot, leaches iron into the fluid in which it is prepared.Objective: We sought to determine whether there was a difference in hemoglobin concentrations in rural Cambodian anemic women (aged 18-49 y) who cooked with the iron ingot or consumed a daily iron supplement compared with a control after 1 y.Design: In Preah Vihear, 340 women with mild or moderate anemia were randomly assigned to 1) an iron-ingot group, 2) an iron-supplement (18 mg/d) group, or 3) a nonplacebo control group. A venous blood sample was taken at baseline and at 6 and 12 mo. Blood was analyzed for hemoglobin, serum ferritin, and serum transferrin receptor. Hemoglobin electrophoresis was used to detect structural hemoglobin variants.Results: Anemia prevalence was 44% with the use of a portable hemoglobinometer during screening. At baseline, prevalence of iron deficiency was 9% on the basis of a low serum ferritin concentration. There was no significant difference in mean hemoglobin concentrations between the iron-ingot group (115 g/L; 95% CI: 113, 118 g/L; P = 0.850) or iron-supplement group (115 g/L; 95% CI: 113, 117 g/L; P = 0.998) compared with the control group (115 g/L; 95% CI: 113, 117 g/L) at 12 mo. Serum ferritin was significantly higher in the iron-supplement group (73 μg/L; 95% CI: 64, 82 μg/L; P = 0.002) than in the control group at 6 mo; however, this significance was not maintained at 12 mo (73 μg/L; 95% CI: 58, 91 μg/L; P = 0.176).Conclusions: Neither the iron ingot nor iron supplements increased hemoglobin concentrations in this population at 6 or 12 mo. We do not recommend the use of the fish-shaped iron ingot in Cambodia or in countries where the prevalence of iron deficiency is low and genetic hemoglobin disorders are high. This trial was registered at clinicaltrials.gov as NCT02341586.

The effect of a lifestyle intervention on pregnancy and postpartum dietary patterns determined by factor analysis

OBJECTIVE

Optimizing maternal diet during pregnancy improves maternal and infant health. This study assessed the effect of an antenatal lifestyle intervention for women with overweight or obesity on dietary patterns during pregnancy and post partum.

METHODS

This study is a secondary analysis of a randomized controlled trial in which pregnant women (BMI ≥ 25 kg/m² ) received lifestyle advice (n = 943) or standard care (n = 924). Dietary pattern analysis was undertaken using factor analysis with comparisons between trial entry and 28 weeks, 36 weeks, and 4 months post partum.

RESULTS

The dietary pattern analysis revealed two distinct patterns: "prudent" and "Western." There was a significant difference between groups in the change over time for both patterns (P < 0.001). For the prudent score, the lifestyle group had higher scores at all times after trial entry compared with standard care, while for the Western score, the lifestyle group had a lower score at 28 weeks. The intervention effect differed based on trial entry BMI (P =  0.043) and smoking (P = 0.019), with higher prudent scores for women with obesity compared with overweight and smokers compared with nonsmokers.

CONCLUSIONS

The provision of an antenatal lifestyle intervention for women with overweight and obesity was associated with an improvement in dietary patterns that persisted post partum. This has important implications for the future consideration of optimal dietary intervention components to include in antenatal lifestyle interventions.

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.

Growth patterns during the first 12 months of life: post-hoc analysis for South Australian Aboriginal and Caucasian infants in a randomised controlled trial of formula feeding

BACKGROUND AND OBJECTIVES

To compare growth characteristics of Aboriginal and Caucasian formula-fed in-fants in the first 12 months of life.

METHODS AND STUDY DESIGN

We conducted post-hoc data analysis of infants who were part of a previous randomised controlled trial comparing infants randomly assigned to cow or goat milk-based infant formulae. Weight, height, and body composition were assessed at serial time points between study entry (~1-2 weeks of age) and 12 months. There was no growth difference between the randomised groups so the two groups were combined and the data were used to conduct a non-randomised comparison of the growth between Aboriginal (n=11) and Caucasian formula-fed (n=169) infants.

RESULTS

Aboriginal formula-fed infants had significantly higher mean z-scores for weight (0.65 difference, [95% CI 0.11, 1.18], p=0.018) and weight-for-length (0.82 difference [95% CI 0.20, 1.44], p=0.010) at 2 months, and all time points onward compared with Caucasian formula-fed infants. Mean length z-scores and the overall growth trajectory across time did not differ between Aboriginal and Caucasian formula-fed infants. Concordant with the weight and weight-for-length z-scores, Aboriginal infants had increased fat mass at 2 months (292 g difference [95% CI 56, 528], p=0.015), and all time points onward compared to Caucasian infants. There was no difference in fat free mass.

CONCLUSIONS

Though there was only a small number of Aboriginal infants for comparison, our data indicate Aboriginal formu-la-fed infants were heavier and had a larger increase in fat mass over time compared with Caucasian formula-fed infants. Further studies using a larger cohort are needed to substantiate these findings.

The effects of dietary and lifestyle interventions among pregnant women who are overweight or obese on longer-term maternal and early childhood outcomes: protocol for an individual participant data (IPD) meta-analysis

BACKGROUND

The aim of this individual participant data meta-analysis (IPDMA) is to evaluate the effects of dietary and lifestyle interventions among pregnant women who are overweight or obese on later maternal and early childhood outcomes at ages 3-5 years.

METHODS/DESIGN

We will build on the established International Weight Management in Pregnancy (i-WIP) IPD Collaborative Network, having identified researchers who have conducted randomised dietary and lifestyle interventions among pregnant women who are overweight or obese, and where ongoing childhood follow-up of participants has been or is being undertaken. The primary maternal outcome is a diagnosis of maternal metabolic syndrome. The primary childhood outcome is BMI above 90%. We have identified 7 relevant trials, involving 5425 women who were overweight or obese during pregnancy, with approximately 3544 women and children with follow-up assessments available for inclusion in the meta-analysis.

DISCUSSION

The proposed IPDMA provides an opportunity to evaluate the effect of dietary and lifestyle interventions among pregnant women who are overweight or obese on later maternal and early childhood health outcomes, including risk of obesity. This knowledge is essential to effectively translate research findings into clinical practice and public health policy.

SYSTEMATIC REVIEW REGISTRATION

This IPD has been prospectively registered (PROSPERO), ID number CRD42016047165 .

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).

Metformin and dietary advice to improve insulin sensitivity and promote gestational restriction of weight among pregnant women who are overweight or obese: the GRoW Randomised Trial

Background

Obesity is a significant global health problem, with approximately 50% of women entering pregnancy having a body mass index greater than or equal to 25 kg/m². Obesity during pregnancy is associated with a well-recognised increased risk of adverse health outcomes both for the woman and her infant. Currently available data from large scale randomised trials and systematic reviews highlight only modest effects of antenatal dietary and lifestyle interventions in limiting gestational weight gain, with little impact on clinically relevant pregnancy outcomes. Further information evaluating alternative strategies is required.

The aims of this randomised controlled trial are to assess whether the use of metformin as an adjunct therapy to dietary and lifestyle advice for overweight and obese women during pregnancy is effective in improving maternal, fetal and infant health outcomes.

Methods

Design: Multicentre 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 an online computer randomisation system, 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 Metformin Group will receive a supply of 500 mg oral metformin tablets. Women randomised to the Placebo Group will receive a supply of identical appearing and tasting placebo tablets. Women will be instructed to commence taking one tablet daily for a period of one week, increasing to a maximum of two tablets twice daily over four weeks and then continuing until birth. Women, clinicians, researchers and outcome assessors will be blinded to the allocated treatment group.

All women will receive three face-to-face sessions (two with a research dietitian and one with a trained research assistant), and three telephone calls over the course of their pregnancy, in which they will be provided with dietary and lifestyle advice, and encouraged to make change utilising a SMART goals approach.

Primary Study Outcome: infant birth weight >4000 grams.

Sample Size: 524 women to detect a difference from 15.5% to 7.35% reduction in infants with birth weight >4000 grams (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 ACTRN12612001277831, prospectively registered 10^th of December, 2012.

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.

International Mobile-Health Intervention on Physical Activity, Sitting, and Weight: The Stepathlon Cardiovascular Health Study

BACKGROUND

Although proof-of-concept for mobile health (mHealth) life-style programs targeting physical inactivity and overweight/obesity has been established in randomized trials, the feasibility and effect of a globally distributed, large-scale, mass-participation mHealth implementation has not been investigated.

OBJECTIVES

The purpose of this study was to determine the effect of Stepathlon, an international, low-cost, mass-participation mHealth intervention, on physical activity, sitting, and weight.

METHODS

We prospectively collected cohort data from participants completing Stepathlon, an annual 100-day global event in 2012, 2013, and 2014. Participants were organized in worksite-based teams, issued pedometers, and encouraged to increase daily steps and physical activity as part of the team-based race. The program was conducted via an interactive multiplatform application available on mobile devices and the Internet. Analysis was performed according to a pre-specified plan.

RESULTS

A total of 69,219 subjects participated (481 employers, 1,481 cities, 64 countries, all populated continents, age 36 ± 9 years, 23.9% female, 8.0% high-income countries, and 92.0% lower-middle income countries). After Stepathlon completion, participants recorded improved step count (+3,519 steps/day; 95% confidence interval [CI]: 3,484 to 3,553 steps/day; p < 0.0001), exercise days (+0.89 days; 95% CI: 0.87 to 0.92 days; p < 0.0001), sitting duration (-0.74 h; 95% CI: -0.78 to -0.71 h; p < 0.0001) and weight (-1.45 kg; 95% CI: -1.53 to -1.38 kg; p < 0.0001). Improvements occurred in women and men, in all geographic regions, and in both high and lower-middle income countries, and the results were reproduced in 2012, 2013, and 2014 cohorts. Predictors of weight loss included step increase, sitting duration decrease, and increase in exercise days (all p < 0.0001).

CONCLUSIONS

Distributed mHealth implementation of a low-cost life-style intervention is associated with short-term, reproducible, large-scale improvements in physical activity, sitting, and weight. (Effect of the Stepathlon Pedometer Program on Physical Activity, Weight and Well-Being; ACTRN12615001310550).