Assimilation of cholesterol by Lactobacillus acidophilus

Considerable variation was found among strains of Lactobacillus acidophilus isolated from the fecal flora of pigs with regard to the ability to grow well in the presence of bile and to assimilate cholesterol from a laboratory growth medium. The uptake of cholesterol occurred only when the culture(s) was growing in the presence of bile under anaerobic conditions. Consumption of L. acidophilus RP32, which was selected for its ability to grow well in the presence of bile and to assimilate cholesterol from the laboratory medium, significantly inhibited increases in serum cholesterol levels of pigs (P less than 0.05) fed a high-cholesterol diet. Consumption of L. acidophilus P47, which was selected for its ability to grow in the presence of bile and lack of ability to remove cholesterol from the growth medium, failed to have a similar effect. This indicates that certain strains of L. acidophilus act directly on cholesterol in the gastrointestinal tract, and thus may be beneficial in reducing serum cholesterol levels.

Sensitivity and accuracy of the visual analogue scale: a psycho-physical classroom experiment

1 Twenty-seven intelligent volunteers took part in a classroom experiment on two occasions to assess subjectively, ordinally related volumes of sound (offered in random sequence), using the visual analogue scale. 2 It was simple to use and largely acceptable. Big differences were significant by parametric tests but small ones were sometimes significant only with ordinal ones. Within-subject comparisons were more accurate and more sensitive than those between-subjects. The t-test was very robust. 3 Five out of 49 results were erroneously significant; they remained so no matter how the data were handled. It was concluded that this was due to a shift in either perception, cognition or scoring between the two sessions. 4 Arcsine transformations made little difference. The mechanism of these is fully discussed. A conversion to proportional scores resulted in very much improved sensitivity. 5 It is recommended that authors using the visual analogue scale: have valid reason in their own setting for using a transformation; present the distribution, or at least the medians and ranges of their raw scores; also use a simple but different measure so as to demonstrate internal consistency between them.

A gene cluster for secondary metabolism in oat: implications for the evolution of metabolic diversity in plants

The evolution of the ability to synthesize specialized metabolites is likely to have been key for survival and diversification of different plant species. Oats (Avena spp.) produce antimicrobial triterpenoids (avenacins) that protect against disease. The oat beta-amyrin synthase gene AsbAS1, which encodes the first committed enzyme in the avenacin biosynthetic pathway, is clearly distinct from other plant beta-amyrin synthases. Here we show that AsbAS1 has arisen by duplication and divergence of a cycloartenol synthase-like gene, and that its properties have been refined since the divergence of oats and wheat. Strikingly, we have also found that AsbAS1 is clustered with other genes required for distinct steps in avenacin biosynthesis in a region of the genome that is not conserved in other cereals. Because the components of this gene cluster are required for at least four clearly distinct enzymatic processes (2,3-oxidosqualene cyclization, beta-amyrin oxidation, glycosylation, and acylation), it is unlikely that the cluster has arisen as a consequence of duplication of a common ancestor. Although clusters of paralogous genes are common in plants (e.g., gene clusters for rRNA and specific disease resistance), reports of clusters of genes that do not share sequence relatedness and whose products contribute to a single selectable function are rare [Gierl, A. & Frey, M. (2001) Planta 213, 493-498]. Taken together, our evidence has important implications for the generation of metabolic diversity in plants.

Designing a broad-spectrum integrative approach for cancer prevention and treatment

Targeted therapies and the consequent adoption of "personalized" oncology have achieved notable successes in some cancers; however, significant problems remain with this approach. Many targeted therapies are highly toxic, costs are extremely high, and most patients experience relapse after a few disease-free months. Relapses arise from genetic heterogeneity in tumors, which harbor therapy-resistant immortalized cells that have adopted alternate and compensatory pathways (i.e., pathways that are not reliant upon the same mechanisms as those which have been targeted). To address these limitations, an international task force of 180 scientists was assembled to explore the concept of a low-toxicity "broad-spectrum" therapeutic approach that could simultaneously target many key pathways and mechanisms. Using cancer hallmark phenotypes and the tumor microenvironment to account for the various aspects of relevant cancer biology, interdisciplinary teams reviewed each hallmark area and nominated a wide range of high-priority targets (74 in total) that could be modified to improve patient outcomes. For these targets, corresponding low-toxicity therapeutic approaches were then suggested, many of which were phytochemicals. Proposed actions on each target and all of the approaches were further reviewed for known effects on other hallmark areas and the tumor microenvironment. Potential contrary or procarcinogenic effects were found for 3.9% of the relationships between targets and hallmarks, and mixed evidence of complementary and contrary relationships was found for 7.1%. Approximately 67% of the relationships revealed potentially complementary effects, and the remainder had no known relationship. Among the approaches, 1.1% had contrary, 2.8% had mixed and 62.1% had complementary relationships. These results suggest that a broad-spectrum approach should be feasible from a safety standpoint. This novel approach has potential to be relatively inexpensive, it should help us address stages and types of cancer that lack conventional treatment, and it may reduce relapse risks. A proposed agenda for future research is offered.

The clinical and immunologic responses of normal human volunteers to low dose hookworm (Necator americanus) infection

Five normal human volunteers were exposed to approximately 50 infective larvae of Necator americanus and were observed for the development of clinical signs or symptoms and for changes in blood eosinophil levels, IgG antibody titers, total and parasite-specific IgE, and lymphocyte blastogenic responses for 6-10 weeks. Bronchoalveolar lavage was performed on four subjects prior to infection and at times when larval migration through the pulmonary tree was likely. Eggs were demonstrated in the stools of four volunteers who remained untreated for more than 6 weeks; one volunteer had to be treated at day 40 because of severe gastrointestinal symptoms. All others also complained of abdominal pain and flatulence between days 35-40. All volunteers developed marked blood eosinophilia which peaked between days 38-64 and ranged from 1,350-3,828 eosinophils/mm3. Small increases in total and parasite-specific IgE and IgG were noted in some volunteers. One volunteer showed a significant lymphocyte blastogenic response. With the exception of mucosal erythema, bronchoalveolar lavage results were unremarkable. Our data indicate that a single small inoculum of hookworm larvae is capable of producing significant transient gastrointestinal morbidity and marked blood eosinophilia but does not induce other prominent T cell- and B cell-dependent immune responses.

CBF measured by Xe-CT: approach to analysis and normal values

Normal reference values and a practical approach to CBF analysis are needed for routine clinical analysis and interpretation of xenon-enhanced computed tomography (CT) CBF studies. We measured CBF in 67 normal individuals with the GE 9800 CT scanner adapted for CBF imaging with stable Xe. CBF values for vascular territories were systematically analyzed using the clustering of contiguous 2-cm circular regions of interest (ROIs) placed within the cortical mantle and basal ganglia. Mixed cortical flows averaged 51 +/- 10ml.100g-1.min-1. High and low flow compartments, sampled by placing 5-mm circular ROIs in regions containing the highest and lowest flow values in each hemisphere, averaged 84 +/- 14 and 20 +/- 5 ml.100 g-1.min-1, respectively. Mixed cortical flow values as well as values within the high flow compartment demonstrated significant decline with age; however, there were no significant age-related changes in the low flow compartment. The clustering of systematically placed cortical and subcortical ROIs has provided a normative data base for Xe-CT CBF and a flexible and uncomplicated method for the analysis of CBF maps generated by Xe-enhanced CT.

The pig as a potential organ donor for man. A study of potentially transferable disease from donor pig to recipient man

Ten pigs, reared in an unmodified laboratory animal house environment, have been investigated to ascertain the incidence of diseases or disorders, including infection, neoplasia, or metabolic abnormalities, that might preclude the transplantation of major organs from the pig to man. Noninvasive studies were performed in the second month of life (study 1) and repeated after an interval that varied between 3 and 5 1/2 months (study 2). Necropsy was then performed as a means of assessing the accuracy of the 2 screening examinations. A total of 150 tests were performed on each pig. At both studies the feces contained cysts and/or trophozoites of several parasites, all of which were considered commensals. No other organisms potentially infective for man were identified either at study or at necropsy. Neither congenital anomalies nor malignant neoplasia was found at necropsy. However, in 2 pigs a vasculitis of uncertain etiology was present in the kidneys on microscopic examination, and in one of these the same condition affected the heart. This pathology was suspected neither from the screening examinations nor from the macroscopic appearance of these organs. Biopsy and microscopic examination would therefore appear to be essential before any organ is transplanted into a human.

Multi-country field trials comparing wash-resistance of PermaNet and conventional insecticide-treated nets against anopheline and culicine mosquitoes

Insecticide-treated bednets (ITNs) are commonly used as a means of personal protection from malaria transmission by anopheline mosquitoes (Diptera: Culicidae). Long-lasting insecticidal nets (LLINs) have special treatments intended to remain effective after many washes. The present trials assessed the efficacy and wash-resistance of several production batches of PermaNet (polyester net coated with polymer resin containing pyrethroid insecticide deltamethrin 55 mg ai/m2) against malaria vectors in Pakistan, Iran and Tanzania compared to ITNs conventionally treated with alphacypermethrin 15 or 20 mg ai/m2, or deltamethrin 25 or 50 mg ai/m2. Insecticidal efficacy of the nets before and after repeated washing (using W.H.O. recommended and traditional local washing procedures) was monitored through contact bioassays with Anopheles and by experimental hut and outdoor platform tests. Local washing regimes gradually reduced the insecticidal efficacy of conventionally treated nets, but they were not exhausted, even after 21 washes. Using a more rigorous laboratory washing method, insecticide was more readily stripped from conventionally treated nets. PermaNet retained high efficacy after 21 washes, giving more than 97% mortality of Anopheles in contact bioassays with 3-min exposure. Using the more sensitive bioassay criterion of 'median time to knockdown', PermaNet showed no loss of insecticidal activity against Anopheles after washing repeatedly in 2 out of 6 trials; whereas in a further three trials knockdown activity of PermaNet and conventional ITNs declined at comparable rates. Higher mortality levels of Anopheles in contact bioassays did not always translate to superiority in experimental hut or enclosed platform trials. In only one of four comparative field trials did PermaNet out-perform conventional ITNs after washing: this was in the trial of PermaNet 2.0--the product with improved quality assurance. Because PermaNet and conventionally treated nets were both quite tolerant of local washing procedures, it is important in field trials to compare LLINs with conventional ITNs washed an equivalent number of times. Our comparison of PermaNet 2.0 against conventionally treated deltamethrin nets (CTDN) in Pakistan demonstrated superior performance of the LLIN after 20 washes in phase I and phase II bioassays, and this was corroborated by chemical assays of residual deltamethrin. Although PermaNet 2.0 has received WHOPES interim recommendation for malaria control purposes, its performance should be monitored in everyday use throughout its lifespan in various cultural settings to assess its durability and long-term effectiveness for malaria prevention and control. As many millions of conventionally treated nets are already in routine use, and these will require regular re-treatment, programme strategies should be careful to preserve the effectiveness of ITNS before and after establishing the reliability of LLINs in long-term use.

Bronchoalveolar lavage fluid from asthmatic subjects is mitogenic for human airway smooth muscle

Airway smooth muscle proliferation may contribute to the airway wall remodeling seen in asthma. In this study we tested for the presence of airway smooth muscle mitogenic activity in bronchoalveolar lavage (BAL) fluid obtained from 12 atopic asthmatics before and serially after segmental allergen challenge, and from four normal subjects who did not undergo allergen challenge. Mitogenic effect was assessed by coincubating BAL fluid with human airway smooth muscle cells, and measuring its effect on (3)[H]thymidine incorporation and cell number. Induction of ERK phosphorylation and cyclin D(1) protein abundance were also assessed. Compared with serum-free medium alone, BAL fluid obtained from normal subjects increased thymidine incorporation, cell number, ERK phosphorylation, and cyclin D(1) abundance. BAL fluid from asthmatic subjects prior to allergen challenge induced even greater increases in all measures, except for cell number, which was similar to that observed with normal subjects' BAL fluid. Incubation with lavage fluid obtained 48 h after segmental allergen challenge in atopic asthmatics caused yet further increases in thymidine incorporation, cell number, and cyclin D(1) protein abundance. Molecular sieving of prechallenge BAL fluid from three asthmatic subjects demonstrated that mitogenic activity was present exclusively in the > 10 kD fraction. These results provide the first direct demonstration that fluid lining the airways of asthmatics contains excess mitogenic activity for human airway smooth muscle, and that this activity increases further after allergen challenge.

Bi-potential Behaviour of Cytotrophoblasts in First Trimester Chorionic Villi

Murine trophoblast stem (TS) cells express fibroblast growth factor receptor 2 (FGFR2) and are maintained in their proliferative state by fibroblast growth factor 4 (FGF4). We show in this report that in the first trimester human placenta FGFR2 expression is similarly found in a subset of villous cytotrophoblast and in proximal anchoring columns. Western analysis demonstrated declining FGFR2 protein expression as gestation advanced, suggesting a similar role for FGF in early human trophoblast proliferation. Mouse TS cell differentiation is known to occur along two distinct transcriptionally-regulated pathways; extravillous trophoblast (EVT) cells invade the uterine wall to promote maternal blood flow whilst syncytiotrophoblast lines chorionic villi in the labyrinth. Similar differentiation steps occur in the human placenta though the fate of human trophoblast stem cells is presently unknown. To investigate the mechanisms underlying human cytotrophoblast differentiation we have developed a novel cultured floating first trimester villous explant model in which denuded first trimester villi spontaneously regenerate syncytiotrophoblast following 48 h of culture. Addition of FGF4 and heparin inhibited syncytiotrophoblast regeneration in favor of forming clumps of cytotrophoblast. Proximal cells in these clumps were FGFR2 immuno-reactive and proliferative, intermediate parts expressed alpha5beta1-integrin, while the distal portion expressed HLA-G and the invasive integrin alpha1beta1 indicating differentiation to the EVT phenotype. In contrast, non-denuded villi exposed to FGF4 exhibited similar proliferation of the cytotrophoblast; however, these cells did not express any of the invasive EVT markers. We conclude that FGFR2-positive chorionic cytotrophoblasts exhibit bi-potential behaviour, being capable of forming either syncytiotrophoblast or EVT. We suggest bipotential trophoblast progenitor cells persist during first trimester human placental development.

Can we safely recommend gestational weight gain below the 2009 guidelines in obese women? A systematic review and meta-analysis

A systematic review was conducted to determine the risk of adverse pregnancy outcomes with gestational weight gain (GWG) below the 2009 Institute of Medicine guidelines compared with within the guidelines in obese women. MEDLINE, Embase, Cochrane Register, CINHAL and Web of Science were searched from 1 January 2009 to 31 July 2014. Quality was assessed using a modified Newcastle-Ottawa scale. Three primary outcomes were included: preterm birth, small for gestational age (SGA) and large for gestational age (LGA). Eighteen cohort studies were included. GWG below the guidelines had higher odds of preterm birth (adjusted odds ratio [AOR] 1.46; 95% confidence interval [CI] 1.07-2.00) and SGA (AOR 1.24; 95% CI 1.13-1.36) and lower odds of LGA (AOR 0.77; 95% CI 0.73-0.81) than GWG within the guidelines. Across the three obesity classes, the odds of SGA and LGA did not show any notable gradient and remained unexplored for preterm birth. Decreased odds were noted for macrosomia (AOR 0.64; 95% CI 0.54-0.77), gestational hypertension (AOR, 0.70; 95% CI 0.53-0.93), pre-eclampsia (AOR 0.90; 95% CI 0.82-0.99) and caesarean (AOR 0.87; 95% CI 0.82-0.92). GWG below the guidelines cannot be routinely recommended but might occasionally be individualized for certain women, with caution, taking into account other known risk factors.

YB-1 evokes susceptibility to cancer through cytokinesis failure, mitotic dysfunction and HER2 amplification

Y-box binding protein-1 (YB-1) expression in the mammary gland promotes breast carcinoma that demonstrates a high degree of genomic instability. In the present study, we developed a model of premalignancy to characterize the role of this gene during breast cancer initiation and early progression. Antibody microarray technology was used to ascertain global changes in signal transduction following the conditional expression of YB-1 in human mammary epithelial cells (HMEC). Cell cycle associated proteins were frequently altered with the most dramatic being LIM Kinase 1/2 (LIMK1/2). Consequently, the misexpression of LIMK1/2 was associated with cytokinesis failure that acted as a precursor to centrosome amplification. Detailed investigation revealed that YB-1 localized to the centrosome in a phosphorylation-dependent manner where it complexed with pericentrin and γ-tubulin. This was found to be essential in maintaining the structural integrity and microtubule nucleation capacity of the organelle. Prolonged exposure to YB-1 led to rampant acceleration toward tumourigenesis with the majority of cells acquiring numerical and structural chromosomal abnormalities. Slippage through the G₁/S checkpoint due to overexpression of cyclin E promoted continued proliferation of these genomically compromised cells. As malignancy further progressed, we identified a subset of cells harbouring HER2 amplification. Our results recognize YB-1 as a cancer susceptibility gene with the capacity to prime cells for tumourigenesis.

Hospital organizational response to the nuclear accident at Three Mile Island: implications for future-oriented disaster planning

The 1979 nuclear accident at Three Mile Island (TMI) near Harrisburg, Pennsylvania, caused severe organizational problems for neighboring health care institutions. Dauphin County, just north of TMI, contained four hospitals ranging in distance from 9.5 to 13.5 miles from the stricken plant. Crash plans put into effect within 48 hours of the initial incident successfully reduced hospital census to below 50 per cent of capacity, but retained bedridden and critically ill patients within the risk-zone. No plans existed for area-wide evacuation of hospitalized patients. Future-oriented disaster planning should include resource files of host institution bed capacity and transportation capabilities for the crash evacuation of hospitalized patients during non-traditional disasters.

On the ecophysiology of the Clusiaceae in Trinidad: expression of CAM in Clusia minor L. during the transition from wet to dry season and characterization of three endemic species

A study was made of photosynthesis and expression of crassulacean acid metabolism (CAM) in naturally exposed and shaded populations of Clusia minor L. during the transition from wet to dry season in Trinidad (mid-February to mid-April, 1990). At the start of the dry season, plants from exposed and shaded habitats showed a capacity for CAM either through the fixation of external or internal (respiratory) CO₂ . Exposed plants showed continuous uptake of CO₂ over 24 h although dark fixation accounted for only a small proportion of CO₂ fixed over the day. The expression of CAM was considerably enhanced as the dry season progressed with substantial increases in the overnight accumulation of titratable acidity, particularly in leaves of exposed plants. This was accompanied by a reduction in day-time photosynthesis and an increase in dark fixation, with shaded plants showing only night-time fixation of CO₂ . The magnitude of CAM in C. minor was substantial with a maximum ΔH⁺ of 1410 mol m^-3 measured in leaves from exposed branches. Both malic and citric acids were accumulated overnight. The highest citric:malic acid ratios were found in young leaves from exposed plants with 250 mol m^-3 malic and 125 mol m^-3 citric acid accumulated near the time of maximum CAM activity. Photosynthetic efficiency, measured as light responses of O₂ evolution, also varied on a daily basis dependent on the incident photosynthetic photon flux density (PPFD). Apparent quantum yield and photosynthetic capacity showed marked reductions depending on the degree of exposure, suggesting that photoinhibitory responses are important under natural conditions. An analysis of three members of the Clusiaceae endemic to Trinidad showed that each had the capacity to induce CAM activity, despite being found in a narrow range of habitats which have higher rainfall than those of C. minor. However, despite the variable expression of CAM activity, carbon isotope composition suggested that when integrated throughout the year, carbon accumulation is predominantly mediated via the C₃ pathway in all the species studied.

Aurora A kinase RNAi and small molecule inhibition of Aurora kinases with VE-465 induce apoptotic death in multiple myeloma cells

The expression of RHAMM and other centrosome-associated genes are known to correlate with the extent of centrosome amplification in multiple myeloma, and with poor prognosis. RHAMM has a significant interaction with TPX2, a protein which regulates the localization and action of Aurora A kinase (AURKA) at the spindle poles. AURKA is known to be a central determinant of centrosome and spindle function and is a target for cancer therapy. Given these observations, we investigated the role of Aurora kinases as therapeutic targets in myeloma. Here we report that AURKA is expressed ubiquitously in myeloma, to varying degrees, in both cell lines and patients' bone marrow plasma cells. siRNA targeting AURKA induces apoptotic cell death in myeloma cell lines. The Aurora kinase inhibitor VE-465 also induces apoptosis and death in myeloma cell lines and primary myeloma plasma cells. The combination of VE-465 and dexamethasone improves cell killing compared with the use of either agent alone, even in cells resistant to the single agents. The phenotype of myeloma cells treated with VE-465 is consistent with published reports on the effects of Aurora kinase inhibition. Aurora kinase inhibitors should be pursued as potential treatments for myeloma.

Malaria and anaemia at different altitudes in the Muheza district of Tanzania: childhood morbidity in relation to level of exposure to infection

Parallel monthly surveys of children aged 6-71 months were conducted in the Muheza district of Tanzania. The aim was to compare highland villages, where the mean, annual entomological inoculation rate (EIR) for malaria is 34 and mean annual prevalences of parasitaemia range from 33%-76%, with culturally similar villages of the lowlands, where the mean EIR is 405 and prevalences of parasitaemia range from 80%-84%. The total survey population could be divided into six geographical subgroups, which can be arranged in order of increasing prevalence of parasitaemia. The prevalences of dense parasitaemia, of febrile malaria, and of anaemia all increased in the same order across this series of groups, the trends being statistically significant. The results of previous studies have indicated a paradoxical effect whereby children in regions with a lower exposure to malarial infection suffer, in the long term, a higher incidence of severe attacks of malaria. In the present study there was no sign of any such paradoxical inverse relationship between the level of exposure and the prevalence of malarial illness or anaemia. However, child mortality rates are similar in the highlands and lowlands, as are the median ages of children admitted to hospital. Overall, the present findings indicate that, for the populations studied, an artificial reduction in EIR would be beneficial, even in the long term, with regard to the chronic effects of malaria. This does not necessarily conflict with previous studies reporting opposite conclusions with regard to the incidence of severe,acute effects.

Risky heterosexual practices amongst women over 30: gender, power and long term relationships

Statistics suggest that older and younger people are about equally at risk for HIV infection, yet existing research on heterosexuality and safer sexual practices has tended to focus on people under the age of 25. The present qualitative study investigates risk behaviours and the practice of safer sex in older populations. Group discussions comprising women over the age of 30 (n = 23) targeted two issues: the gendered power dimension of heterosexuality and safer sex in long term relationships. Cohort issues were also discussed. The discussion groups revealed that the imbalance of power between men and women which has been shown by previous research to constrain younger women's choices with regard to safer sex, continues to affect older women's decisions. Many of the group participants still found it difficult to assert themselves in sexual relationships and even those who were able to challenge overt pressures to engage in unsafe sex were still susceptible to internalized social pressures. In addition, it seems that risks for older age groups are increased by difficulties in continuing to use condoms in long term relationships where monogamy cannot be taken for granted. It was also apparent that there are difficulties in changing sexual behaviours which were established before HIV became an issue.

YB-1 transforms human mammary epithelial cells through chromatin remodeling leading to the development of basal-like breast cancer

There is growing evidence that cancer-initiation could result from epigenetic changes. Y-box binding protein-1 (YB-1) is a transcription/translation factor that promotes the formation of tumors in transgenic mice; however, the underlying molecular events are not understood. To explore this in a human model system, YB-1 was expressed in mammary epithelial cells under the control of a tetracycline-inducible promoter. The induction of YB-1 promoted phenotypes associated with malignancy in three-dimensional breast acini cultures. This was attributed to YB-1 enhancing the expression and activity of the histone acetyltransferase p300 leading to chromatin remodeling. Specifically, this relaxation of chromatin allowed YB-1 to bind to the BMI1 promoter. The induction of BMI1 engaged the Polycomb complex resulting in histone H2A ubiquitylation and repression of the CDKN2A locus. These events manifested functionally as enhanced self-renewal capacity that occurred in a BMI1-dependent manner. Conversely, p300 inhibition with anacardic acid prevented YB-1 from binding to the BMI1 promoter and thereby subverted self-renewal. Despite these early changes, full malignant transformation was not achieved until RSK2 became overexpressed concomitant with elevated human telomerase reverse transcriptase (hTERT) activity. The YB-1/RSK2/hTERT expressing cells formed tumors in mice that were molecularly subtyped as basal-like breast cancer. We conclude that YB-1 cooperates with p300 to allow BMI1 to over-ride p16(INK4a) -mediated cell cycle arrest enabling self-renewal and the development of aggressive breast tumors.

Pregnancy and COVID-19: pharmacologic considerations

In this review, we summarize evidence regarding the use of routine and investigational pharmacologic interventions for pregnant and lactating patients with coronavirus disease 2019 (COVID-19). Antenatal corticosteroids may be used routinely for fetal lung maturation between 24 and 34 weeks' gestation, but decisions in those with critical illness and those < 24 or > 34 weeks' gestation should be made on a case-by-case basis. Magnesium sulfate may be used for seizure prophylaxis and fetal neuroprotection, albeit cautiously in those with hypoxia and renal compromise. There are no contraindications to using low-dose aspirin to prevent placenta-mediated pregnancy complications when indicated. An algorithm for thromboprophylaxis in pregnant patients with COVID-19 is presented, which considers disease severity, timing of delivery in relation to disease onset, inpatient vs outpatient status, underlying comorbidities and contraindications to the use of anticoagulation. Nitrous oxide may be administered for labor analgesia while using appropriate personal protective equipment. Intravenous remifentanil patient-controlled analgesia should be used with caution in patients with respiratory depression. Liberal use of neuraxial labor analgesia may reduce the need for emergency general anesthesia which results in aerosolization. Short courses of non-steroidal anti-inflammatory drugs can be administered for postpartum analgesia, but opioids should be used with caution due to the risk of respiratory depression. For mechanically ventilated pregnant patients, neuromuscular blockade should be used for the shortest duration possible and reversal agents should be available on hand if delivery is imminent. To date, dexamethasone is the only proven and recommended experimental treatment for pregnant patients with COVID-19 who are mechanically ventilated or who require supplemental oxygen. Although hydroxycholoroquine, lopinavir/ritonavir and remdesivir may be used during pregnancy and lactation within the context of clinical trials, data from non-pregnant populations have not shown benefit. The role of monoclonal antibodies (tocilizumab), immunomodulators (tacrolimus), interferon, inhaled nitric oxide and convalescent plasma in pregnancy and lactation needs further evaluation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Maternal pre-gravid body mass index and obstetric outcomes in twin gestations

OBJECTIVE

The aim of this study is to evaluate the impact of maternal pre-gravid and/or first trimester overweight and obesity, and the adverse obstetrics outcome in twin pregnancies.

STUDY DESIGN

This is a retrospective study of women who delivered viable twins after 23 weeks of gestation with available prepregnancy body mass index (BMI) and/or were at their earliest visit during the first trimester of pregnancy in the period 2007-2011. The patients were divided into four subgroups according to their BMI (underweight, normal weight, overweight and obese) according to the WHO classification and their outcomes were compared. Obstetrical outcomes of interest including gestational diabetes, gestational hypertension, preterm birth, antepartum hemorrhage, intrahepatic cholestasis of pregnancy, method of delivery and neonatal intensive care unit (NICU) admission were all studied and compared.

RESULT

Electronic records of 1228 pregnant subjects who delivered twins were abstracted. Five hundred and four patients with twin gestations with available BMI were identified (underweight BMI<18.5% (n=22), normal weight BMI 18.5-24.9% (n=260), overweight 25-29.9% (n=114) and obese ⩾30% (n=108)). Obstetric complications occurred more often in the overweight and obese groups as compared with the normal weight group. There was an increased risk of gestational diabetes in overweight and obese women (odds ratio (OR), 3.3; 95% confidence interval (CI) 1.52-7.3; P=0.001) and (OR, 3.2; 95% CI, 1.41-7.1; P=0.002), respectively. There was an increased risk of gestational hypertension in the obese group compared with the normal weight group (OR, 2.29; 95% CI, 1.1-4.7; P=0.02) but not in the overweight group (OR, 1.71; 95% CI, 0.8-3.6; P=0.1). In addition, an increased risk of very preterm delivery (<32 weeks) in the overweight group and obese groups was seen when compared with the normal weight group (OR, 2.2; 95% CI, 1.18-4.20; P=0.014 and OR, 2; 95% CI, 1.024-3.91; P=0.04, respectively). Increased rate of cesarean section in the obese group was seen when compared with the normal weight group (OR, 2; 95% CI, 1.2-3.4; P=0.006). Risks of antepartum hemorrhage, intrahepatic cholestasis and NICU admission were similar between the groups.

CONCLUSION

In addition to the known obstetrics complications associated with twin gestations, the pregnancy outcomes in twins are further adversely influenced by increased maternal prepregnancy BMI.

No HLA-DR specificity is associated with endometriosis

Thirty-one patients with endometriosis were typed for HLA-A, B and DR antigens. No association was found between the disease and any DR specificity, which may be taken as evidence against an autoimmune aetiology.

Daily Context for Abusive and Neglectful Behavior in Family Caregiving for Dementia

BACKGROUND AND OBJECTIVES

The purpose of this study was to identify risk and protective factors for abusive and neglectful behavior in the context of daily caregiving.

RESEARCH DESIGN AND METHODS

Family caregivers who co-reside with a care recipient with Alzheimer's disease and related dementia, recruited from social media, completed 21-days of diaries. Multilevel modeling with days (n = 831) nested within caregivers (N = 50) was used to evaluate relationships between hypothesized risk and protective factors and the odds of an abusive or neglectful behavior on a given day.

RESULTS

Disruptions in the daily routine and stress of the caregiver related to behavioral symptoms of the care recipient are significant risk factors for abusive and neglectful behavior. Participating in a meaningful activity with the care recipient when it occurs twice in a day is a significant protective factor against use of a neglect behavior (OR = 0.19; CI 0.06-0.64; p = .01), but not for abusive behavior. Hypotheses that spending the full day together would increase risk, and that receipt of instrumental support and caregiver participation in self-care would decrease risk, were not supported.

DISCUSSION AND IMPLICATIONS

Findings demonstrate that risk of an abusive or neglectful behavior varies from day-to-day in the presence and absence of contextual factors, and that the majority of the variance in the odds an abusive or neglectful behavior occurring is related to day-level factors. Findings demonstrate that diary surveys are critical to identifying ecologically valid modifiable risk and protective factors for abusive and neglectful behaviors that can be targeted in future interventions.