Emergence of Long-Range Angular Correlations in Low-Multiplicity Proton-Proton Collisions

This Letter presents the measurement of near-side associated per-trigger yields, denoted ridge yields, from the analysis of angular correlations of charged hadrons in proton-proton collisions at sqrt[s]=13  TeV. Long-range ridge yields are extracted for pairs of charged particles with a pseudorapidity difference of 1.4<|Δη|<1.8 and a transverse momentum of 1 Collapse

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Association of fetal growth restriction and stillbirth in twin compared with singleton pregnancies

OBJECTIVE

Twin pregnancies are at an increased risk of stillbirth compared to singletons. Fetal growth restriction (FGR) is a leading cause of perinatal mortality and morbidity, in both singleton and multiple pregnancies. Whether the contribution of FGR to stillbirth in twin pregnancies differs from that in singletons is yet to be determined. The main aim of this study was to determine the association between FGR and stillbirth in twin compared to singleton pregnancies. The secondary objectives include an assessment of the contribution of FGR to stillbirths, stratified by gestational age at delivery. Furthermore, we aimed to compare the association between FGR and stillbirth in twin pregnancies using the twin-specific versus singleton birthweight charts, stratified by chorionicity.

METHODS

This was a cross-sectional study including pregnancies receiving obstetric care and birth at St George's Hospital, London. The exclusion criteria included triplet and higher order pregnancies, those resulting in miscarriage or livebirths at or prior to 23+6 weeks, or had a termination of pregnancy, or with missing data on the gestational age at birth. FGR and small for gestational age (SGA) were defined as birthweight <5th and <10th centile, respectively. While standard logistic regression was used for singleton pregnancies, the association of FGR and SGA designation with stillbirth in twin pregnancies was investigated with mixed-effects logistic regression models. For twin pregnancies, intercepts were allowed to vary for twin pairs to account for inter-twin dependency. Analyses were stratified by gestational age at delivery and chorionicity.

RESULTS

The study included 95,342 singleton and 3,576 twin pregnancies. There were 494 (0.52%) stillbirths in singleton and 41 (1.15%) stillbirths in twin pregnancies (17 dichorionic and 24 monochorionic). FGR and SGA were significantly associated with stillbirth in singleton pregnancies, across all gestational ages at delivery (before 32 weeks- SGA: OR 2.36; 95% CI 1.78-3.13, p<0.001 and FGR: OR 2.67; 95% CI 2.02- 3.55, p<0.001; between 32-36 weeks- SGA: OR 2.70; 95% CI 1.71-4.31, p<0.001 and FGR: OR 2.82; 95% CI 1.78- 4.47, p<0.001; above 36 weeks- SGA: OR 3.85; 95% CI 2.83 - 5.21, p<0.001 and FGR: OR 4.43; 95% CI 3.16 - 6.12, p<0.001) A greater proportion of fetuses from twin pregnancies were diagnosed as SGA and FGR when singleton compared to the twin-specific chart was used (48.43% vs. 9.12%, and 36.73% vs. 6.23%, respectively). When stratified by gestational age at delivery, both SGA and FGR determined by the twin-specific charts were associated with significantly increased odds of having a stillbirth for those delivered before 32 weeks (SGA: OR 3.87; 95% CI 1.56-9.50, p=0.003 and FGR: OR 5.26; 95% CI 2.11-13.01, p<0.001), those delivered between 32-36 weeks (SGA: OR 6.67; 95% CI 2.11-20.41, p=0.001 and FGR: OR 9.54; 95% CI 3.01-29.40, p<0.001) and those delivered beyond 36 weeks (SGA: OR 12.68 95% CI 2.47-58,15, p=0.001 and FGR: OR 23.84; 95% CI 4.62-110.25, p<0.001), whereas the association of stillbirth with either SGA or FGR was inconsistent when analysed using singleton charts (before 32 weeks- SGA: p=0.014 and FGR: p=0.005; between 32-36 weeks- SGA: p=0.036 and FGR: p=0.008; above 36 weeks- SGA: p=0.080 and FGR: p=0.063). For dichorionic twins delivered before 32 weeks, the odds of an SGA or FGR fetus having a stillbirth was increased when analysed using twin-specific charts. In contrast, monochorionic twins delivered before 32 weeks showed lower and non-significant associations with stillbirth for both SGA and FGR cases using either twin-specific or singleton charts. In dichorionic twin pregnancies delivered between 32-36 weeks, the OR for stillbirth of SGA using twin birthweight chart was 6.70 (95% CI 0.80-56.46, p=0.059), and using singleton chart was 0.92 (95% CI 0.11-7.71, p=0.934) and statistically non-significant. Similarly, the OR for stillbirth of FGR using twin birthweight chart and singleton chart was 9.59 (95% CI 1.14-81.06, p=0.025), and 1.40 (95% CI 0.17-11.76, p=0.735), respectively. On the other hand, in monochorionic twin pregnancies delivered between 32-36 weeks, the OR for stillbirth of SGA and FGR using twin birthweight chart was 9.37 (95% CI 2.20- 37.72, p=0.001), and 13.55 (95% CI 3.12 - 55.94 p < 0.001) respectively.

CONCLUSIONS

Our study demonstrates a significant association between SGA, particularly for FGR, with increased odds of stillbirths in singleton pregnancies across all gestational ages. For twin pregnancies, when twin-specific charts were used, SGA and in particular FGR were associated with a significantly increased risk of stillbirth, across all gestational ages at delivery. This article is protected by copyright. All rights reserved.

First Measurement of the |t| Dependence of Incoherent J/ψ Photonuclear Production

The first measurement of the cross section for incoherent photonuclear production of J/ψ vector mesons as a function of the Mandelstam |t| variable is presented. The measurement was carried out with the ALICE detector at midrapidity, |y|<0.8, using ultraperipheral collisions of Pb nuclei at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=5.02  TeV. This rapidity interval corresponds to a Bjorken-x range (0.3-1.4)×10^{-3}. Cross sections are given in five |t| intervals in the range 0.04<|t|<1  GeV^{2} and compared to the predictions by different models. Models that ignore quantum fluctuations of the gluon density in the colliding hadron predict a |t| dependence of the cross section much steeper than in data. The inclusion of such fluctuations in the same models provides a better description of the data.

Storylines of family medicine II: foundational building blocks-context, community and health

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'II: foundational building blocks-context, community and health', authors address the following themes: 'Context-grounding family medicine in time, place and being', 'Recentring community', 'Community-oriented primary care', 'Embeddedness in practice', 'The meaning of health', 'Disease, illness and sickness-core concepts', 'The biopsychosocial model', 'The biopsychosocial approach' and 'Family medicine as social medicine.' May readers grasp new implications for medical education and practice in these essays.

Storylines of family medicine X: standing up for diversity, equity and inclusion

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'X: standing up for diversity, equity and inclusion', authors address the following themes: 'The power of diversity-why inclusivity is essential to equity in healthcare', 'Medical education for whom?', 'Growing a diverse and inclusive workforce', 'Therapeutic judo-an inclusive approach to patient care', 'Global family medicine-seeing the world "upside down"', 'The inverse care law', 'Social determinants of health as a lens for care', 'Why family physicians should care about human rights' and 'Toward health equity-the opportunome'. May the essays that follow inspire readers to promote change.

Selective fetal growth restriction in dichorionic diamniotic twin pregnancy: systematic review and meta-analysis of pregnancy and perinatal outcomes

OBJECTIVE

Most of the published literature on selective fetal growth restriction (sFGR) has focused on monochorionic twin pregnancies. The aim of this systematic review was to report on the outcome of dichorionic diamniotic (DCDA) twin pregnancies complicated by sFGR.

METHODS

MEDLINE, EMBASE and The Cochrane Library databases were searched. The inclusion criteria were DCDA twin pregnancies complicated by sFGR. The outcomes explored were intrauterine death (IUD), neonatal death and perinatal death (PND), survival of at least one and both twins, preterm birth (PTB) (either spontaneous or iatrogenic) prior to 37, 34, 32 and 28 weeks' gestation, pre-eclampsia (PE) or gestational hypertension, neurological, respiratory and infectious morbidity, Apgar score < 7 at 5 min, necrotizing enterocolitis, retinopathy of prematurity and admission to the neonatal intensive care unit (NICU). A composite outcome of neonatal morbidity, defined as the occurrence of respiratory, neurological or infectious morbidity, was also evaluated. Random-effects meta-analysis was used to analyze the data, and results are reported as pooled proportion or odds ratio (OR) with 95% CI.

RESULTS

Thirteen studies reporting on 1339 pregnancies with sFGR and 6316 pregnancies without sFGR were included. IUD occurred in 2.6% (95% CI, 1.1-4.7%) of fetuses from DCDA pregnancies with sFGR and 0.6% (95% CI, 0.3-9.7%) of those from DCDA pregnancies without sFGR, while the respective values for PND were 5.2% (95% CI, 3.5-7.3%) and 1.7% (95% CI, 0.1-5.7%). Spontaneous or iatrogenic PTB before 37 weeks complicated 84.1% (95% CI, 55.6-99.2%) of pregnancies with sFGR and 69.1% (95% CI, 45.4-88.4%) of those without sFGR. The respective values for PTB before 34, 32 and 28 weeks were 18.4% (95% CI, 4.4-38.9%), 13.0% (95% CI, 9.5-17.1%) and 1.5% (95% CI, 0.6-2.3%) in pregnancies with sFGR and 10.2% (95% CI, 3.1-20.7%), 7.8% (95% CI, 6.8-9.0%) and 1.8% (95% CI, 1.3-2.4%) in those without sFGR. PE or gestational hypertension complicated 19.9% (95% CI, 12.4-28.6%) of pregnancies with sFGR and 12.8% (95% CI, 10.4-15.4%) of those without sFGR. Composite morbidity occurred in 28.2% (95% CI, 7.8-55.1%) of fetuses from pregnancies with sFGR and 13.9% (95% CI, 6.5-23.5%) of those from pregnancies without sFGR. When stratified according to the sFGR status within a twin pair, composite morbidity occurred in 39.0% (95% CI, 11.1-71.5%) of growth-restricted fetuses and 29.9% (95% CI, 3.5-65.0%) of appropriately grown fetuses (OR, 1.9 (95% CI, 1.7-3.1)), while the respective values for PND were 3.0% (95% CI, 1.8-4.5%) and 1.6% (95% CI, 0.9-2.6%) (OR, 2.1 (95% CI, 1.0-4.1)). On risk analysis, DCDA pregnancies complicated by sFGR had a significantly higher risk of IUD (OR, 5.2 (95% CI, 3.2-8.6)) and composite morbidity or admission to the NICU (OR, 3.2 (95% CI, 1.9-5.6)) compared to those without sFGR, while there was no difference in the risk of PTB before 34 weeks (P = 0.220) or PE/gestational hypertension (P = 0.210).

CONCLUSIONS

DCDA twin pregnancies complicated by sFGR are at high risk of perinatal morbidity and mortality. The findings of this systematic review are relevant for counseling and management of complicated DCDA twin pregnancies, in which twin-specific, rather than singleton, outcome data should be used. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Neurodevelopmental outcome in complicated twin pregnancy: prospective observational study

OBJECTIVE

Twin pregnancy is associated with increased perinatal mortality and morbidity, but long-term neurodevelopmental outcome remains underinvestigated. The primary objective of this study was to investigate the incidence of adverse neurodevelopment after 1 year of age in complicated monochorionic diamniotic (MCDA) twin pregnancies compared with uncomplicated twin pregnancies.

METHODS

This was a prospective cohort study conducted at St George's University Hospital NHS Foundation Trust, London, UK. Women with a twin pregnancy culminating in at least one surviving child, aged between 12 and 60 months (corrected for prematurity) at the time of assessment, were invited to complete the relevant Ages and Stages Questionnaire® version 3 (ASQ-3) test. The two study groups were: (1) complicated MCDA twin pregnancies, including those with twin-twin transfusion syndrome, twin anemia-polycythemia sequence, selective fetal growth restriction, twin reversed arterial perfusion sequence and/or single intrauterine demise; and (2) uncomplicated MCDA and dichorionic diamniotic twin pregnancies. The primary outcome measure was an abnormal ASQ-3 score, defined as a score of more than 2 SD below the mean in any one of the five domains. Mixed-effects multivariable logistic regression analysis was performed to determine whether a complicated MCDA twin pregnancy was associated independently with an abnormal ASQ-3 score.

RESULTS

The study included 174 parents who completed the questionnaire for one or both twins; therefore, 327 ASQ-3 questionnaires were available for analysis. Of those, 117 (35.8%) were complicated MCDA twin pregnancies and 210 (64.2%) were controls. The overall rate of an abnormal ASQ-3 score in children born of a complicated MCDA twin pregnancy was nearly double that of those from uncomplicated twin pregnancies (14.5% vs 7.6%; P = 0.056). Children born of a complicated MCDA twin pregnancy had a significantly higher rate of impairment in the gross-motor domain compared with the control group (8.5% vs 2.9%; P = 0.031). Complicated MCDA twin pregnancies that underwent prenatal intervention had a significantly higher rate of abnormal ASQ-3 score compared with those that did not undergo prenatal intervention (28.1% vs 1.7%; P < 0.001). On multilevel logistic regression analysis, complicated MCDA twin pregnancy was an independent predictor of abnormal ASQ-3 score (adjusted odds ratio, 3.28 (95% CI, 3.27-3.29); P < 0.001).

CONCLUSIONS

This study demonstrates that survivors of complicated MCDA twin pregnancies have a higher rate of adverse neurodevelopmental outcome, independently of prematurity. Long-term neurodevelopmental follow-up in these pregnancies can ensure timely and optimal management of those affected. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

ψ(2S) Suppression in Pb-Pb Collisions at the LHC

The production of the ψ(2S) charmonium state was measured with ALICE in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV, in the dimuon decay channel. A significant signal was observed for the first time at LHC energies down to zero transverse momentum, at forward rapidity (2.5 Collapse

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Experimental Analysis of Energy Transfers between a Quantum Emitter and Light Fields

Energy can be transferred between two quantum systems in two forms: unitary energy-that can be used to drive another system-and correlation energy-that reflects past correlations. We propose and implement experimental protocols to access these energy transfers in interactions between a quantum emitter and light fields. Upon spontaneous emission, we measure the unitary energy transfer from the emitter to the light field and show that it never exceeds half the total energy transfer and is reduced when introducing decoherence. We then study the interference of the emitted field and a coherent laser field at a beam splitter and show that the nature of the energy transfer quantitatively depends on the quantum purity of the emitted field.

Measurements of Groomed-Jet Substructure of Charm Jets Tagged by D^{0} Mesons in Proton-Proton Collisions at sqrt[s]=13 TeV

Understanding the role of parton mass and Casimir color factors in the quantum chromodynamics parton shower represents an important step in characterizing the emission properties of heavy quarks. Recent experimental advances in jet substructure techniques have provided the opportunity to isolate and characterize gluon emissions from heavy quarks. In this Letter, the first direct experimental constraint on the charm-quark splitting function is presented, obtained via the measurement of the groomed shared momentum fraction of the first splitting in charm jets, tagged by a reconstructed D^{0} meson. The measurement is made in proton-proton collisions at sqrt[s]=13  TeV, in the low jet transverse-momentum interval of 15≤p_{T}^{jet ch}<30  GeV/c where the emission properties are sensitive to parton mass effects. In addition, the opening angle of the first perturbative emission of the charm quark, as well as the number of perturbative emissions it undergoes, is reported. Comparisons to measurements of an inclusive-jet sample show a steeper splitting function for charm quarks compared with gluons and light quarks. Charm quarks also undergo fewer perturbative emissions in the parton shower, with a reduced probability of large-angle emissions.

Innovative Approaches to Improve COVID-19 Case Investigation and Contact Tracing Among Refugees, Immigrants, and Migrants: Lessons Learned from a Newly Established National Resource Center

Effective COVID-19 case investigation and contact tracing (CICT) among refugee, immigrant, and migrant (RIM) communities requires innovative approaches to address linguistic, cultural and community specific preferences. The National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM) is a CDC-funded initiative to support state and local health departments with COVID-19 response among RIM communities, including CICT. This note from the field will describe NRC-RIM and initial outcomes and lessons learned, including the use of human-centered design to develop health messaging around COVID-19 CICT; training developed for case investigators, contact tracers, and other public health professionals working with RIM community members; and promising practices and other resources related to COVID-19 CICT among RIM communities that have been implemented by health departments, health systems, or community-based organizations.

The Impact of Chronic Pulmonary Aspergillosis Co-infection on the Health-Related Quality of Life of Patients with Pulmonary Tuberculosis in Uganda

BACKGROUND

Both pulmonary tuberculosis (PTB) and chronic pulmonary aspergillosis (CPA) significantly affect health-related quality of life (HR-QoL). We aimed to determine the impact of CPA co-infection on the HR-QoL of Ugandans with PTB.

METHODS

We conducted a prospective study as part of a larger study among participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020 and June 2021. HR-QoL was assessed using St. George Respiratory Questionnaire (SGRQ) at enrollment and at the end of PTB treatment (4 months apart). SGRQ scores range from 0 to 100, with higher score representing a poorer HR-QoL.

RESULTS

Of the 162 participants enrolled in the larger study, 32 (19.8%) had PTB + CPA and 130 (80.2%) had PTB. The baseline characteristics of the two groups were comparable. Regarding overall health, a higher proportion of the PTB group rated their HR-QoL as "very good" compared to those who had PTB + CPA (68 [54.0%] versus 8 [25.8%]). At enrollment, both groups had comparable median SGRQ scores. However, at follow up, the PTB group had statistically significantly better SGRQ scores (interquartile range); symptoms (0 [0-12.4] versus 14.4 [0-42.9], p < 0.001), activity ((0 [0-17.1] versus 12.2 [0-35.5], p = .03), impact (0 [0-4.0] versus 3.1 [0-22.5], p = 0.004), and total scores ((0 [0-8.5] versus 7.6[(0-27.4], p = 0.005).

CONCLUSION

CPA co-infection impairs HR-QoL of people with PTB. Active screening and management of CPA in patients with PTB is recommended to improve HR-QoL of these individuals.

Measurement of the Lifetime and Λ Separation Energy of _{Λ}^{3}H

The most precise measurements to date of the _{Λ}^{3}H lifetime τ and Λ separation energy B_{Λ} are obtained using the data sample of Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV collected by ALICE at the LHC. The _{Λ}^{3}H is reconstructed via its charged two-body mesonic decay channel (_{Λ}^{3}H→^{3}He+π^{-} and the charge-conjugate process). The measured values τ=[253±11(stat)±6(syst)]  ps and B_{Λ}=[102±63(stat)±67(syst)]  keV are compatible with predictions from effective field theories and confirm that the _{Λ}^{3}H structure is consistent with a weakly bound system.

Outcome following laser surgery of twin-twin transfusion syndrome complicated by selective fetal growth restriction: systematic review and meta-analysis

OBJECTIVE

The published literature reports mostly on the outcome of twin pregnancies complicated by twin-twin transfusion syndrome (TTTS) without considering whether the pregnancy is also complicated by another pathology, such as selective fetal growth restriction (sFGR). The aim of this systematic review was to report on the outcome of monochorionic diamniotic (MCDA) twin pregnancies undergoing laser surgery for TTTS that were complicated by sFGR and those not complicated by sFGR.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched. The inclusion criteria were studies reporting on MCDA twin pregnancies with TTTS undergoing laser therapy that were complicated by sFGR and those not complicated by sFGR. The primary outcome was the overall fetal loss following laser surgery, defined as miscarriage and intrauterine death. The secondary outcomes included fetal loss within 24 h after laser surgery, survival at birth, preterm birth (PTB) prior to 32 weeks of gestation, PTB prior to 28 weeks, composite neonatal morbidity, neurological and respiratory morbidity, and survival free from neurological impairment. All outcomes were explored in the overall population of twin pregnancies complicated by sFGR vs those not complicated by sFGR in the setting of TTTS and in the donor and recipient twins separately. Random-effects meta-analysis was used to combine data and the results are reported as pooled odds ratios (OR) with 95% CI.

RESULTS

Five studies (1710 MCDA twin pregnancies) were included in the qualitative synthesis and four in the meta-analysis. The overall risk of fetal loss after laser surgery was significantly higher in MCDA twin pregnancies with TTTS complicated by sFGR (20.90% vs 14.42%), with a pooled OR of 1.6 (95% CI, 1.3-1.9) (P < 0.001). The risk of fetal loss was significantly higher in MCDA twin pregnancies with TTTS and sFGR for the donor but not for the recipient twin. The rate of live twins was 79.1% (95% CI, 72.6-84.9%) in TTTS pregnancies with sFGR and 85.6% (95% CI, 81.0-89.6%) in those without sFGR (pooled OR, 0.6 (95% CI, 0.5-0.8)) (P < 0.001). There was no significant difference in the risk of PTB prior to 32 weeks of gestation (P = 0.308) or prior to 28 weeks (P = 0.310). Assessment of short- and long-term morbidity was affected by the small number of cases. There was no significant difference in the risk of composite (P = 0.506) or respiratory (P = 0.531) morbidity between twins complicated by TTTS with vs those without sFGR, while the risk of neurological morbidity was significantly higher in those with TTTS and sFGR (pooled OR, 1.8 (95% CI, 1.1-2.9)) (P = 0.034). The risk of neurological morbidity was significantly higher for the donor twin (pooled OR, 2.4 (95% CI, 1.1-5.2)) (P = 0.029) but not for the recipient twin (P = 0.361). Survival free from neurological impairment was observed in 70.8% (95% CI, 45.0-91.0%) of twin pregnancies with TTTS complicated by sFGR and in 75.8% (95% CI, 51.9-93.3%) of those not complicated by sFGR, with no difference between the two groups.

CONCLUSIONS

sFGR in MCDA pregnancies with TTTS represents an additional risk factor for fetal loss following laser surgery. The findings of this meta-analysis may be useful for individualized risk assessment of twin pregnancy complicated by TTTS and tailored counseling of the parents prior to laser surgery. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A systematic review on efficacy, safety and cost-effectiveness of office-based laryngeal biopsy

OBJECTIVE

Laryngeal cancer is the second most prevalent head and neck malignancy in the USA. With recent advances in technology, this procedure is increasingly performed under local anaesthesia. This study aimed to identify the efficacy, safety and cost-effectiveness of laryngeal biopsy in out-patients by conducting a systematic review.

METHOD

A literature search was conducted using PubMed, Medline, Google Scholar and Embase over a 20-year period. Inclusion criteria were: studies performed on out-patient diagnostic biopsy procedures of the larynx. Exclusion criteria included all therapeutic procedures. The outcome measures were sensitivity and specificity, complication rate and cost-savings.

RESULTS

Thirty-five studies were included in the analysis. The sensitivity and specificity varied from 60 to 100 per cent with a low complication rate and cost savings.

CONCLUSION

Office-based laryngeal biopsies are increasingly used in the diagnosis of laryngeal cancers, resulting in earlier diagnosis and commencement of treatment. The barrier to undertaking this procedure is low sensitivity.

First-trimester choroid-plexus-to-lateral-ventricle disproportion and prediction of subsequent ventriculomegaly

OBJECTIVE

Ventriculomegaly can be associated with long-term neurodevelopmental impairment. Prenatal diagnosis of ventriculomegaly is most commonly made at the routine second-trimester anomaly scan. The value of first-trimester ultrasound has expanded to early diagnosis and screening of fetal abnormalities. The objective of this study was to assess the predictive accuracy of first-trimester choroid-plexus-to-lateral-ventricle-or-head ratios for development of ventriculomegaly at a later gestational age.

METHODS

This was a case-control study of fetuses with isolated ventriculomegaly diagnosed after 16 weeks' gestation and a control group of normal fetuses (without ventriculomegaly). The exclusion criteria included aneuploidy, genetic syndrome and/or other brain abnormality. Stored two-dimensional first-trimester ultrasound images were analyzed blindly offline and fetal biometry was performed in the axial view of the fetal head. The ratios of choroid plexus area (PA) to lateral ventricular area (VA), choroid plexus length (PL) to lateral ventricular length (VL), choroid plexus diameter (PD) to lateral ventricular diameter (VD) and PA to biparietal diameter (BPD) were measured at 11 + 0 to 13 + 6 weeks' gestation. Intra- and interobserver variability of measurement of these fetal head biometric parameters at 11 + 0 to 13 + 6 weeks' gestation were assessed in 20 normal fetuses using intraclass correlation coefficients with 95% CI. The accuracy of first-trimester biometric measurements for prediction of ventriculomegaly was assessed using the area under the receiver-operating-characteristics curves (AUC).

RESULTS

The analysis included 683 singleton pregnancies, of which 102 fetuses were diagnosed with ventriculomegaly. Ventriculomegaly was mild in 86 (84.3%) cases and severe in the other 16 (15.7%). All first-trimester fetal choroid-plexus-to-lateral-ventricle/head ratios were significantly lower in cases with ventriculomegaly compared with controls (P < 0.001), with good inter- and intraobserver agreement (≥ 0.95) for the majority of the fetal head biometric parameters assessed. On adjusting for crown-rump length, optimism-adjusted AUC values obtained after cross-validation showed that both PL/VL ratio (AUC, 0.87 (95% CI, 0.73-0.98)) and PA/VA ratio (AUC, 0.90 (95% CI, 0.82-0.98)) had good predictive accuracy for severe ventriculomegaly. The PA/BPD ratio (AUC, 0.73 (95% CI, 0.54-0.90)) had modest predictive ability, which was significantly lower compared with that of the PA/VA ratio and PL/VL ratio (P = 0.003 and P = 0.001, respectively). The predictive accuracy of PD/VD ratio was low with an AUC of 0.65 (95% CI, 0.47-0.84). Optimism-adjusted AUC values obtained after cross-validation showed that PA/VA ratio offered the highest predictive accuracy for mild ventriculomegaly with an AUC of 0.84 (95% CI, 0.79-0.89), followed by PL/VL ratio (AUC, 0.82 (95% CI, 0.76-0.88)), PA/BPD ratio (AUC, 0.76 (95% CI, 0.69-0.82)) and PD/VD ratio (AUC, 0.75 (95% CI, 0.67-0.81)). Calibration plots showed that both PA/VA and PL/VL ratios had good calibration.

CONCLUSION

First-trimester prediction of ventriculomegaly using ratios of fetal choroid plexus to lateral ventricle/head appears promising. Future prospective studies are needed to validate the predictive accuracy of these ultrasound markers as a screening tool for ventriculomegaly. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Measurement of the J/ψ Polarization with Respect to the Event Plane in Pb-Pb Collisions at the LHC

We study the polarization of inclusive J/ψ produced in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV at the LHC in the dimuon channel, via the measurement of the angular distribution of its decay products. We perform the study in the rapidity region 2.5 Collapse

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First Measurement of Antideuteron Number Fluctuations at Energies Available at the Large Hadron Collider

The first measurement of event-by-event antideuteron number fluctuations in high energy heavy-ion collisions is presented. The measurements are carried out at midrapidity (|η|<0.8) as a function of collision centrality in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV using the ALICE detector. A significant negative correlation between the produced antiprotons and antideuterons is observed in all collision centralities. The results are compared with a state-of-the-art coalescence calculation. While it describes the ratio of higher order cumulants of the antideuteron multiplicity distribution, it fails to describe quantitatively the magnitude of the correlation between antiproton and antideuteron production. On the other hand, thermal-statistical model calculations describe all the measured observables within uncertainties only for correlation volumes that are different with respect to those describing proton yields and a similar measurement of net-proton number fluctuations.

Enhanced Deuteron Coalescence Probability in Jets

The transverse-momentum (p_{T}) spectra and coalescence parameters B_{2} of (anti)deuterons are measured in p-p collisions at sqrt[s]=13  TeV for the first time in and out of jets. In this measurement, the direction of the leading particle with the highest p_{T} in the event (p_{T}^{lead}>5  GeV/c) is used as an approximation for the jet axis. The event is consequently divided into three azimuthal regions, and the jet signal is obtained as the difference between the toward region, that contains jet fragmentation products in addition to the underlying event (UE), and the transverse region, which is dominated by the UE. The coalescence parameter in the jet is found to be approximately a factor of 10 larger than that in the underlying event. This experimental observation is consistent with the coalescence picture and can be attributed to the smaller average phase-space distance between nucleons in the jet cone as compared with the underlying event. The results presented in this Letter are compared to predictions from a simple nucleon coalescence model, where the phase-space distributions of nucleons are generated using pythia8 with the Monash 2013 tuning, and to predictions from a deuteron production model based on ordinary nuclear reactions with parametrized energy-dependent cross sections tuned on data. The latter model is implemented in pythia8.3. Both models reproduce the observed large difference between in-jet and out-of-jet coalescence parameters, although the almost flat trend of the B_{2}^{Jet} is not reproduced by the models, which instead give a decreasing trend.

A pragmatic approach to equitable global health partnerships in academic health sciences

Global partnerships offer opportunities for academic departments in the health sciences to achieve mutual benefits. However, they are often challenged by inequities in power, privilege and finances between partners that have plagued the discipline of global health since its founding. In this article, a group of global health practitioners in academic medicine offer a pragmatic framework and practical examples for designing more ethical, equitable and effective collaborative global relationships between academic health science departments, building on the principles laid out by the coalition Advocacy for Global Health Partnerships in the Brocher declaration.

Effectiveness and safety of prenatal valacyclovir for congenital cytomegalovirus infection: systematic review and meta-analysis

OBJECTIVE

Universal screening for cytomegalovirus (CMV) infection in pregnancy is not recommended in most countries. One of the major deterrents is the lack of effective prenatal therapy. The role of valacyclovir therapy in reducing the risk of vertical transmission, symptomatic congenital CMV infection and adverse outcome is controversial. The main aim of this systematic review and meta-analysis was to investigate the safety and effectiveness of prenatal valacyclovir therapy in pregnancies with maternal CMV infection.

METHODS

MEDLINE, EMBASE and Cochrane databases and ClinicalTrials.gov were searched. The inclusion criteria were pregnancy with confirmed maternal CMV infection, treated or untreated with valacyclovir. The primary outcome was the incidence of congenital CMV infection confirmed by a positive CMV polymerase chain reaction result of the amniotic fluid. The secondary outcomes were symptomatic and asymptomatic infection, perinatal death, termination of pregnancy, anomalies detected on follow-up ultrasound, on fetal magnetic resonance imaging or at birth, severe and mild-to-moderate symptoms due to congenital CMV infection, neurological, visual and hearing symptoms, and adverse events related to valacyclovir. Risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) or Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool, as appropriate. Head-to-head meta-analyses were used to compare the risk of each of the explored outcomes according to whether pregnancies with maternal CMV infection were treated with prenatal valacyclovir therapy.

RESULTS

Eight studies (620 women) were included. Pregnancies treated with valacyclovir had a significantly lower risk of congenital CMV infection compared with those not receiving valacyclovir (three studies; 325 fetuses; pooled odds ratio (OR), 0.37 (95% CI, 0.21-0.64); I2  = 0%; P < 0.001). When stratifying the analysis according to gestational age at maternal infection, the risk of vertical transmission was significantly lower in pregnancies receiving valacyclovir following first-trimester maternal infection (three studies; 184 fetuses; pooled OR, 0.34 (95% CI, 0.15-0.74); I2  = 20.9%; P = 0.001), while there was no significant difference between the two groups in those acquiring CMV infection in the periconceptional period or in the third trimester of pregnancy. Only one study reported on the risk of vertical transmission in women infected in the second trimester, demonstrating a lower risk of congenital infection in women taking valacyclovir, although this was based on a small number of cases. Pregnancies treated with valacyclovir therapy had an increased likelihood of asymptomatic congenital CMV infection compared with those not receiving valacyclovir (two studies; 132 fetuses; pooled OR, 2.98 (95% CI, 1.18-7.55); I2  = 0%; P = 0.021), while there was no significant difference between the two groups in the risk of perinatal death (P = 0.923), termination of pregnancy (P = 0.089), anomalies detected at follow-up imaging assessment during pregnancy or at birth (P = 0.934) and symptoms due to CMV infection in the newborn (P = 0.092). The occurrence of all adverse events in pregnant individuals taking valacyclovir was 3.17% (95% CI, 1.24-5.93%) (six studies; 210 women), with 1.71% (95% CI, 0.41-3.39%) experiencing acute renal failure, which resolved after discontinuation of the drug. On GRADE assessment, the quality of evidence showing that valacyclovir reduced the risk of congenital CMV infection and adverse perinatal outcome was very low.

CONCLUSIONS

Prenatal valacyclovir administration in pregnancies with maternal CMV infection reduces the risk of congenital CMV infection. Further evidence is needed to elucidate whether valacyclovir can affect the course of infection in the fetus and the risk of symptomatic fetal or neonatal infection. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Determining the gluonic gravitational form factors of the proton

The proton is one of the main building blocks of all visible matter in the Universe¹. Among its intrinsic properties are its electric charge, mass and spin². These properties emerge from the complex dynamics of its fundamental constituents-quarks and gluons-described by the theory of quantum chromodynamics^3-5. The electric charge and spin of protons, which are shared among the quarks, have been investigated previously using electron scattering². An example is the highly precise measurement of the electric charge radius of the proton⁶. By contrast, little is known about the inner mass density of the proton, which is dominated by the energy carried by gluons. Gluons are hard to access using electron scattering because they do not carry an electromagnetic charge. Here we investigated the gravitational density of gluons using a small colour dipole, through the threshold photoproduction of the J/ψ particle. We determined the gluonic gravitational form factors of the proton^7,8 from our measurement. We used a variety of models^9-11 and determined, in all cases, a mass radius that is notably smaller than the electric charge radius. In some, but not all cases, depending on the model, the determined radius agrees well with first-principle predictions from lattice quantum chromodynamics¹². This work paves the way for a deeper understanding of the salient role of gluons in providing gravitational mass to visible matter.

Is tranexamic acid associated with decreased need for blood transfusion in percutaneous nephrolithotomy: a systematic review and meta-analysis

INTRODUCTION

Bleeding is a common complication after percutaneous nephrolithotomy (PNL) for renal stone disease. Tranexamic acid (TXA) has been found to reduce mortality and blood transfusion in surgical and trauma patients. This review aimed to assess the safety and efficacy of TXA in patients undergoing PNL.

METHODS

A systematic literature review was performed to recognise all randomised controlled trials (RCTs) comparing the use of TXA in PNL. The primary outcome of the study was to compare the need for blood transfusion with and without TXA.

FINDINGS

Six RCTs with 1,323 patients were included in this review. Haemoglobin fall was lower in the TXA group compared with the control group, and the need for blood transfusion was reduced by 67% (odds ratio (OR) 0.33, confidence interval (CI) (0.21, 0.52), p<0.00001). However, blood loss was comparable for the two groups (mean difference -116.9, CI (-244.5,10.7) p=0.07). Length of stay and duration of surgery was significantly shorter with TXA. Furthermore, both minor and major complications were lower in the TXA group. Stone-free rate was higher with the TXA group. No thromboembolic complications were noted in the TXA group.

CONCLUSIONS

TXA is safe and efficacious for PNL with a reduction in need for blood transfusion and without an attending increase in complication rates.

The Impact of Chronic Pulmonary Aspergillosis Co-infection on the Health-Related Quality of Life of Patients with Pulmonary Tuberculosis in Uganda

Background Both pulmonary tuberculosis (PTB) and chronic pulmonary aspergillosis (CPA) significantly affect health-related quality of life (HR-QoL). We aimed to determine the impact of CPA co-infection on the HR-QoL of Ugandans with PTB. Methods We conducted a prospective study among participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020 and June 2021. HR-QoL was assessed using St. George Respiratory Questionnaire (SGRQ) at enrollment and at the end of PTB treatment (4 months apart). SGRQ scores range from 0 to 100, with higher score representing a poorer HR-QoL. Results Of the 162 participants enrolled, 32 (19.8%) had CPA + PTB and 130 (80.2%) had PTB only. The baseline characteristics of the two groups were comparable. Regarding overall health, a higher proportion of the PTB only group rated their HR-QoL as "very good" compared to those who had both TB and CPA (68 (54.0%) versus 8 (25.8%)). At enrollment, both groups had comparable median SGRQ scores. However, at follow up, the PTB only group had statistically significantly better SGRQ scores (interquartile range); symptoms (0 (0 - 12.4) versus 14.4 (0 - 42.9), p < 0.001), activity ((0 (0 - 17.1) versus 12.2 (0 - 35.5), p = .03), impact (0 (0 - 4.0) versus 3.1 (0 - 22.5), p = 0.004), and total scores ((0 (0 - 8.5) versus 7.6 (0 - 27.4), p = 0.005). Conclusion CPA co-infection impairs HR-QoL of people with PTB. Active screening and management of CPA in patients with PTB is recommended to improve HR-QoL of these individuals.

Anorexia in Medicare Fee-for-Service Beneficiaries: A Claims-Based Analysis of Epidemiology and Mortality

OBJECTIVES

Loss of appetite in older adults can lead to malnutrition, weight loss, frailty, and death, but little is known about its epidemiology in the United States (US). The objective of this study was to estimate the annual prevalence and incidence of anorexia in older adults with Medicare fee-for-service (FFS) health insurance.

DESIGN

Retrospective and observational analysis of administrative health insurance claims data.

SETTING

This study included Medicare FFS claims from all settings (eg, hospital inpatient/outpatient, office, assisted living facility, skilled nursing facility, hospice, rehabilitation facility, home).

PARTICIPANTS

This study included all individuals aged 65 to 115 years old with continuous Medicare FFS medical coverage (Parts A and/or B) for at least one 12-month period from October 1, 2015, to September 30, 2021 (ie, approximately 30 million individuals each year).

INTERVENTION

Not applicable.

MEASUREMENTS

Anorexia was identified using medical claims with the ICD-10 diagnosis code "R63.0: Anorexia". This study compared individuals with anorexia to a control group without anorexia with respect to demographics, comorbidities using the Charlson Comorbidity Index (CCI), Claims-based Frailty Index (CFI), and annual mortality. The annual prevalence and incidence of anorexia were estimated for each 12-month period from October 1, 2015, to September 30, 2021.

RESULTS

The number of individuals with anorexia ranged from 317,964 to 328,977 per year, a mean annual prevalence rate of 1.1%. The number of individuals newly diagnosed with anorexia ranged from 243,391 to 281,071 per year, a mean annual incidence rate of 0.9%. Individuals with anorexia had a mean (±standard deviation) age of 80.5±8.7 years (vs 74.9±7.5 years without anorexia; p<.001), 64.4% were female (vs 53.8%; p<.001), and 78.4% were White (vs 83.2%; p<.001). The most common CCI comorbidities for those with anorexia were chronic pulmonary disease (39.4%), dementia (38.3%), and peripheral vascular disease (38.0%). Median (interquartile range [IQR]) CCI with anorexia was 4 [5] (vs 1 [3] without anorexia; p<.001). The annual mortality rate among those with anorexia was 22.3% (vs 4.1% without anorexia; relative risk 5.49 [95% confidence interval, 5.45-5.53]).

CONCLUSION

Approximately 1% of all adults aged 65-115 years old with Medicare FFS insurance are diagnosed with anorexia each year based on ICD-10 codes reported in claims. These individuals have a higher comorbidity burden and an increased risk of annual mortality compared to those without a diagnosis of anorexia. Further analyses are needed to better understand the relationship between anorexia, comorbidities, frailty, mortality, and other health outcomes.

Protocol for Clinical GLP-1 Receptor PET/CT Imaging with [68Ga]Ga-NODAGA-Exendin-4

Imaging with radiolabeled exendin enables detection and characterization of glucagon-like peptide 1 receptors (GLP-1Rs) in vivo with high specificity. The novel radiotracer [⁶⁸Ga]Ga-NODAGA-exendin-4 forms a stable complex after a simple and fast labeling procedure. Beta-cell mass in the islets of Langerhans can be visualized using [⁶⁸Ga]Ga-NODAGA-exendin-4, which is promising for research into diabetes mellitus (DM) pathophysiology. Furthermore, this radiotracer enables very sensitive detection of insulinomas, resulting from vast overexpression of GLP-1Rs, and seems promising for the detection of focal lesions in congenital hyperinsulinism (CHI). Here, we describe the procedures involved in [⁶⁸Ga]Ga-NODAGA-exendin-4 positron emission tomography (PET)/computed tomography (CT) imaging including the radiolabeling of the NODAGA-exendin conjugate with ⁶⁸Ga, quality controls, and PET/CT.

Characteristics of International Rotations for Undergraduate Medical Education at United States Medical Schools: A National Study

OBJECTIVE

Medical education is criticized that it does not prepare students to serve in an increasingly globalized society. Evidence that global educational experiences can alleviate these concerns have contributed to the rise in international medical education experiences. This study explores surrounding characteristics and institutional support for international rotations across medical schools in the US.

METHODS

The authors conducted a sequential mixed methods exploratory national survey of international rotation coordinators at 185 US medical schools and 15 semi-structured interviews in fall 2018. Quantitative data were analyzed with descriptive statistics and qualitative data were coded and analyzed using interpretive description to identify themes across data.

RESULTS

There were 57 responses to the survey for an overall response rate of 31%, with 77% percent of respondents (n = 44) indicating that their medical school offered international rotations. Fifteen individuals representing 13 medical schools were identified as interviewees for the second stage of the study. International rotation coordinators described components of international rotations, including partnerships with host communities, use of third-party organizations, and supporting administrative and academic structures.

CONCLUSION

Although international rotations are common in medical education, they are not positioned as core academic programming within medical schools. This leads to challenges in planning, implementation, and evaluation, and immense variation in rotation components across medical programs. Future research should explore best practices for pre-departure preparation, post-travel debriefing, and evaluation of student activity as well as impact on the host site. Additional research should include exploration of unique benefits of international versus domestic sites, and aspects of sustainable partnerships between medical schools and host communities.

Social vulnerability during the COVID-19 pandemic in Peru

The COVID-19 pandemic has demanded governments and diverse organizations to work on strategies to prepare and help communities. Increasing recognition of the importance of identifying vulnerable populations has raised a demand for better tools. One of these tools is the Social Vulnerability Index (SVI). The SVI was created in 2011 to identify and plan assistance for socially vulnerable populations during hazardous events, by providing disaster management personnel information to target specific areas. We aimed to evaluate and determine the social vulnerability in different provinces and districts of Peru in the context of the COVID-19 pandemic using an adapted version of the SVI index. Ecological, observational, and cross-sectional study was conducted. We adapted the SVI and collected indicators related to COVID-19. We organized and analyzed the population data of the 196 provinces of Peru, using data from government institutions. We found a distribution of high and very high SVI in the mountainous areas of Peru. High and very high social vulnerability indexes, due to the presence of some or all the variables were predominantly distributed in the provinces located in the southern and highlands of the country. The association between mortality rate and social SVI-COVID19 was inverse, the higher the vulnerability, the lower the mortality. Our results identify that the provinces with high and very high vulnerability indexes are mostly located in rural areas nearby the Andes Mountains, not having a direct correlation with COVID-19 mortality.

Rethinking our Rigor Mortis: Creating space for more adaptive and inclusive truth-seeking in community-based global health research in Kenya

As global health researchers, we have long embraced the conviction that the answers to complex problems of poverty and disease will reveal themselves if only we apply enough scientific rigor. Yet, at the community level, our group of American and Kenyan investigators has begun to question whether our veneration of rigor is itself contributing to the intractability of certain types of global health problems. Here, we illustrate examples from our experience among the remote island communities of Lake Victoria, Kenya, and join a chorus of emerging voices, to examine how our culture of control as global health scientists may marginalise truth-seekers and change-makers within communities we seek to serve. More broadly, we seek to acknowledge the limitations of control over truth that rigorous academic research affords. We suggest that by relinquishing this pervasive illusion of control, we can more fully appreciate complementary modes of answering important questions that rely upon the intrinsic resourcefulness and creativity of community-based enterprises taking place across sub-Saharan Africa. While such inquiries may never solve all problems facing the diverse populations of the continent, we advocate for a deeper appreciation of the inherent capacity of adaptive, locally contextualised investigations to identify meaningful and enduring solutions.

Lipid parameters in the blood of coronary artery diseases patients depending on age and dietary components: a case study

Coronary artery disease (CAD) is the major cause of mortality worldwide and is defined as an elevated level of atherogenic cholesterol and low levels of HDL cholesterol. However, very few studies have been conducted in India on the association of blood lipid profile with age and diet. The study aims to estimate lipid parameters in the blood of CAD patients aged 40-70 years on different diets. Lipid parameters were analyzed by enzymatic method on EM-200 fully automated Biochemistry analyzer. The data obtained showed that the majority of patients who suffered from CAD were between the age group of 51-60 years. Patients with CAD had altered lipid profiles, with higher levels of serum TGs, total cholesterol and low levels of HDL. Vegetarians have been found to have reduced lipid risk factors for coronary heart disease compared to patients on a mixed diet. Keywords: age, cholesterol, coronary artery disease, dietary components, HDL, triglycerides

Evaluation of immunogenicity and reactogenicity of COVID-19 vaccines in pregnant women

OBJECTIVE

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy is associated with increased risk of adverse maternal and perinatal outcomes. Vaccines are highly effective at preventing severe coronavirus disease 2019 (COVID-19), but there are limited data on COVID-19 vaccines in pregnancy. This study aimed to investigate the reactogenicity and immunogenicity of COVID-19 vaccines in pregnant women when administered according to the 12-week-interval dosing schedule recommended in the UK.

METHODS

This was a cohort study of pregnant women receiving COVID-19 vaccination between April and September 2021. The outcomes were immunogenicity and reactogenicity after COVID-19 vaccination. Pregnant women were recruited by phone, e-mail and/or text and were vaccinated according to vaccine availability at their local vaccination center. For immunogenicity assessment, blood samples were taken at specific timepoints after each dose to evaluate nucleocapsid protein (N) and spike protein (S) antibody titers. The comparator group comprised non-pregnant female healthcare workers in the same age group who were vaccinated as part of the national immunization program in a contemporaneous longitudinal cohort study. Longitudinal changes in serum antibody titers and association with pregnancy status were assessed using a two-step regression approach. Reactogenicity assessment in pregnant women was undertaken using an online questionnaire. The comparator group comprised non-pregnant women aged 18-49 years who had received two vaccine doses in primary care. The association of pregnancy status with reactogenicity was assessed using logistic regression analysis.

RESULTS

Overall, 67 pregnant women, of whom 66 had received a mRNA vaccine, and 79 non-pregnant women, of whom 50 had received a mRNA vaccine, were included in the immunogenicity study. Most (61.2%) pregnant women received their first vaccine dose in the third trimester, while 3.0% received it in the first trimester and 35.8% in the second trimester. SARS-CoV-2 S-antibody geometric mean concentrations after mRNA vaccination were not significantly different at 2-6 weeks after the first dose but were significantly lower at 2-6 weeks after the second dose in infection-naïve pregnant compared with non-pregnant women. In pregnant women, prior infection was associated with higher antibody levels at 2-6 weeks after the second vaccine dose. Reactogenicity analysis included 108 pregnant women and 116 non-pregnant women. After the first dose, tiredness and chills were reported less commonly in pregnant compared with non-pregnant women (P = 0.043 and P = 0.029, respectively). After the second dose, feeling generally unwell was reported less commonly (P = 0.046) in pregnant compared with non-pregnant women.

CONCLUSIONS

Using an extended 12-week interval between vaccine doses, antibody responses after two doses of mRNA COVID-19 vaccine were found to be lower in pregnant compared with non-pregnant women. Strong antibody responses were achieved after one dose in previously infected women, regardless of pregnancy status. Pregnant women reported fewer adverse events after both the first and second dose of vaccine. These findings should now be addressed in larger controlled studies. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Utility of advanced echocardiographic deformation measures to delineate cause of pathological left ventricular hypertrophy: value of a multiparametric approach

Background

Early diagnosis of cardiac amyloidosis (CA) is warranted to initiate specific treatment and improve outcomes. Conventional echocardiography is unable to reliably differentiate CA from other causes of increased left ventricular (LV) wall thickness.

Purpose

To demonstrate the value of a multiparametric approach utilising both standard and advanced echocardiographic measures to distinguish CA from other pathological causes of increased LV wall thickness.

Results

Patients with HCM had the highest septal thickness, maximum LV wall thickness, septum/posterior wall (Sep/PW) thickness ratio and left ventricular outflow tract (LVOT) gradient and lowest PW thickness (p&lt;0.0001) among all groups. Patients with CA had the lowest global longitudinal strain (GLS), tissue Doppler-derived myocardial systolic and diastolic velocities and LV ejection fraction (EF) (p&lt;0.0001). EF strain ratio (EFSR=LVEF/GLS) and LV longitudinal strain (apex/base) ratio were highest (largest number) in CA patients (p&lt;0.0001). Multivariate linear regression identified 5 independent predictors (PW thickness, Sep/PW thickness ratio, LVOT gradient, LV longitudinal strain (apex/base) ratio and GLS) that discriminated CA from other causes of increased LV wall thickness. A regression equation (using multivariate linear regression) {CA prediction value = (0.230*LS apex/base) − (0.002*LVOT gradient) − [0.068*(Sep/PW ratio)] + (0.007*PW thickness) + (0.022*GLS) + 0.189; r=0.667)} was derived which allowed reliable distinction of CA with a sensitivity of 92.3% and specificity of 91.2% at the optimal cut-off.

Conclusion

PW thickness, Sep/PW thickness ratio, LVOT gradient, LV longitudinal strain (apex/base) ratio and GLS are independent predictors of CA. We developed a multiparametric regression equation which allowed discrimination of CA from other causes of increased LV wall thickness. Future studies involving larger cohorts are required to validate these findings.

Funding Acknowledgement

Type of funding sources: None.

Use of advanced echocardiographic modalities to discriminate preclinical HCM mutation carriers from non-carriers

Background

It is a challenging goal to identify which family members of patients with hypertrophic cardiomyopathy (HCM) will subsequently develop HCM. Previous studies evaluating the utility of two-dimensional conventional Doppler echocardiography in HCM families with a known pathogenic variant identified on genetic testing have been unable to reliably distinguish preclinical genotype-positive, phenotype-negative (G+P−) individuals from their healthy genotype-negative, phenotype-negative (G−P−) relatives.

Purpose

To determine if advanced echocardiographic modalities can discriminate preclinical HCM mutation carriers (G+P−) from non-carriers (G−P−).

Methods

A total of 199 participants who had undergone genetic testing from HCM families with a known pathogenic variant were included in the study: 39 G−P−; 58 G+P− and 102 overt HCM patients (G+P+). Speckle tracking echocardiography (STE) and colour M-mode were performed on all participants and longitudinal, circumferential and radial strain, and torsion were compared.

Results

Patients with overt HCM had the highest septal, posterior wall thickness, septum/posterior wall (Sep/PW) thickness ratio and left ventricular outflow tract (LVOT) gradient and lowest global longitudinal, circumferential and radial strain, and tissue Doppler-derived myocardial systolic and diastolic velocities. Comparing G−P− and G+P− individuals, there were no significant differences in LV cavity size, wall thickness, LVOT gradient, LVEF and tissue Doppler-derived myocardial systolic and diastolic velocities. However, G+P− individuals had significantly higher peak apical rotation, peak twist and colour M-mode flow propagation velocity (Vp). Multivariate linear regression identified two independent predictors (peak apical rotation and Vp), and a regression equation (using multivariate linear regression) {Mutation carrier prediction value = (0.210×peak apical rotation) − (0.002×Vp) + 0.156; r=0.655)} was derived which allowed reliable discrimination of G+P- individuals with a sensitivity of 95.2% and specificity of 94.1% at the optimal cut-off.

Conclusion

In HCM family members without overt HCM, peak apical rotation and Vp provide good sensitivity and specificity for identifying mutation carriers and may be a clinically useful early marker of HCM before the onset of hypertrophy. Future longitudinal studies involving larger cohorts are required to validate these findings.

Funding Acknowledgement

Type of funding sources: None.

Building the foundation for universal healthcare: Academic family medicine’s ability to train family medicine practitioners to meet the needs of their community across the globe

Background

The Declaration of Astana marked a revived global interest in investing in primary care as a means to achieve universal healthcare. Family medicine clinicians are uniquely trained to provide high-quality, comprehensive primary care throughout the lifespan. Yet little focus has been placed on understanding the needs of family medicine training programs.

Aim

This study aims to assess broad patterns of strengths and resource challenges faced by academic programs that train family medicine clinicians.

Methods

An anonymous online survey was sent to family medicine faculty using World Organization of Family Doctors (WONCA) listservs.

Results

Twenty-nine representatives of academic family medicine programs from around the globe answered the survey. Respondents cited funding for the program and/or individual trainees as one of either their greatest resources or greatest limitations. Frequently available resources included quality and quantity of faculty and reliable clinical training sites. Frequently noted limitations included recruitment capacity and social capital. Over half of respondents reported their program had at some point faced a disruption or gap in its ability to recruit or train, most often because of loss of government recognition. Reflecting on these patterns, respondents expressed strong interest in partnerships focusing on faculty development and research collaboration.

Lessons learnt

This study provides a better understanding of the challenges family medicine training programs face and how to contribute to their sustainability and growth, particularly in terms of areas for investment, opportunities for government policy and action and areas of collaboration.

Keywords

family medicine; primary care; medical education; global health; community medicine.

Maternal and perinatal outcomes of SARS-CoV-2 infection in unvaccinated pregnancies during Delta and Omicron waves

OBJECTIVE

There is little evidence related to the effects of the Omicron severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant on pregnancy outcomes, particularly in unvaccinated women. This study aimed to compare pregnancy outcomes of unvaccinated women infected with SARS-CoV-2 during the pre-Delta, Delta and Omicron waves.

METHODS

This was a retrospective cohort study conducted at two tertiary care facilities: Sancaktepe Training and Research Hospital, Istanbul, Turkey, and St George's University Hospitals NHS Foundation Trust, London, UK. Included were women who tested positive for SARS-CoV-2 by real-time reverse-transcription polymerase chain reaction (RT-PCR) during pregnancy, between 1 April 2020 and 14 February 2022. The cohort was divided into three periods according to the date of their positive RT-PCR test: (i) pre-Delta (1 April 2020 to 8 June 2021 in Turkey, and 1 April 2020 to 31 July 2021 in the UK), (ii) Delta (9 June 2021 to 27 December 2021 in Turkey, and 1 August 2021 to 27 December 2021 in the UK) and (iii) Omicron (after 27 December 2021 in both Turkey and the UK). Baseline data collected included maternal age, parity, body mass index, gestational age at diagnosis and comorbidities. The primary outcome was the need for oxygen supplementation, classified as oxygen support via nasal cannula or breather mask, non-invasive mechanical ventilation with continuous positive airway pressure (CPAP) or high-flow oxygen, mechanical ventilation with intubation, or extracorporeal membrane oxygenation (ECMO). Inferences were made after balancing of confounders, using an evolutionary search algorithm. Selected confounders were maternal age, body mass index and gestational age at diagnosis of infection.

RESULTS

During the study period, 1286 unvaccinated pregnant women with RT-PCR-proven SARS-CoV-2 infection were identified, comprising 870 cases during the pre-Delta period, 339 during the Delta wave and 77 during the Omicron wave. In the confounder-balanced cohort, infection during the Delta wave vs during the pre-Delta period was associated with increased need for nasal oxygen support (risk ratio (RR), 2.53 (95% CI, 1.75-3.65); P < 0.001), CPAP or high-flow oxygen (RR, 2.50 (95% CI, 1.37-4.56); P = 0.002), mechanical ventilation (RR, 4.20 (95% CI, 1.60-11.0); P = 0.003) and ECMO (RR, 11.0 (95% CI, 1.43-84.7); P = 0.021). The maternal mortality rate was 3.6-fold higher during the Delta wave compared to the pre-Delta period (5.3% vs 1.5%, P = 0.010). Infection during the Omicron wave was associated with a similar need for nasal oxygen support (RR, 0.62 (95% CI, 0.25-1.55); P = 0.251), CPAP or high-flow oxygen (RR, 1.07 (95% CI, 0.36-3.12); P = 0.906) and mechanical ventilation (RR, 0.44 (95% CI, 0.06-3.45); P = 0.438) with that in the pre-Delta period. The maternal mortality rate was similar during the Omicron wave and the pre-Delta period (1.3% vs 1.3%, P = 0.999). The need for nasal oxygen support during the Omicron wave was significantly lower compared to the Delta wave (RR, 0.26 (95% CI, 0.11-0.64); P = 0.003). Perinatal outcomes were available for a subset of the confounder-balanced cohort. Preterm birth before 34 weeks' gestation was significantly increased during the Delta wave compared with the pre-Delta period (15.4% vs 4.9%, P < 0.001).

CONCLUSIONS

Among unvaccinated pregnant women, SARS-CoV-2 infection during the Delta wave, in comparison to the pre-Delta period, was associated with increased requirement for oxygen support (including ECMO) and higher maternal mortality. Disease severity and pregnancy complications were similar between the Omicron wave and pre-Delta period. SARS-CoV-2 infection of unvaccinated pregnant women carries considerable risks of morbidity and mortality regardless of variant, and vaccination remains key. Miscommunication of the risks of Omicron infection may impact adversely vaccination uptake among pregnant women, who are at increased risk of complications related to SARS-CoV-2. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Myocardial fibrosis predicts ventricular arrhythmias and sudden death after cardiac electronic device implantation

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted educational grants

Background

Increasing evidence supports a link between myocardial fibrosis (MF) and ventricular arrhythmias. We sought to determine whether presence of MF on visual assessment (MFVA) and gray zone fibrosis (GZF) mass predicts SCD and ventricular fibrillation / sustained ventricular tachycardia after cardiac implantable electronic device (CIED) implantation.

Methods

In this prospective study, total fibrosis and GZF mass, quantified using cardiovascular magnetic resonance, was assessed in relation to the primary endpoint of sudden cardiac death (SCD) and the secondary, arrhythmic endpoint of SCD or ventricular arrhythmias after CIED implantation.

Results

Among 700 patients (age 68.0 ± 12.0yrs [mean ± SD]), 27 (3.85%) experienced a SCD and 121 (17.3%) met the arrhythmic endpoint over 6.93 yrs (median; interquartile range 5.82-9.32). MFVA predicted SCD (hazard ratio [HR]: HR:26.3 [95% confidence interval [CI] 3.70-3337]; negative predictive value: 100%). In competing risks analyses, MFVA also predicted the arrhythmic endpoint (subdistribution [sHR]: 19.9 [95% CI 6.40-61.9]; negative predictive value:98.6%). Compared with no MFVA, a GZF mass measured with the 5SD method (GZF5SD) &gt; 17 g was associated with highest risk of SCD (HR: 44.6;95% CI 6.12-5685) and the arrhythmic endpoint (sHR: 30.3 [95% CI 9.60-95.8]). Adding GZF5SD mass to MFVA led to reclassification of 39% for SCD and 50.2% for the arrhythmic endpoint. In contrast, LVEF did not predict either endpoint.

Conclusions

In CIED recipients, MFVA excluded patients at risk of SCD and virtually excluded ventricular arrhythmias. Quantified GZF5SD mass added predictive value in relation to SCD and the arrhythmic endpoint.

Chronic pulmonary aspergillosis in patients with active pulmonary tuberculosis with persisting symptoms in Uganda

BACKGROUND

The occurrence of chronic pulmonary aspergillosis (CPA) among drug sensitive pulmonary tuberculosis (PTB) patients on optimal therapy with persistent symptoms was investigated.

METHODS

We consecutively enrolled participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020, and June 2021. CPA was defined as a positive Aspergillus-specific IgG/IgM immunochromatographic test (ICT), a cavity with or without a fungal ball on chest x-ray (CXR), and compatible symptoms >3 months.

RESULTS

We enrolled 162 participants (median age 30 years; IQR: 25 - 40), 97 (59.9%) were male, 48 (29.6%) were HIV-infected, and 15 (9.3%) had prior PTB. Thirty-eight (23.4%) sputum samples grew A. niger and 13 (8.0%) A. fumigatus species complexes. Six (3.7%) participants had intra-cavitary fungal balls, and 52 (32.1%) had cavities. Overall, 32 (19.8%) participants had CPA. CPA was associated with prior PTB (adjusted odds ratio (aOR): 6.61, 95% CI: 1.85 - 23.9, p=0.004), and far advanced CXR changes (aOR: 4.26, 95%CI: 1.72 - 10.52, p=0.002). The Aspergillus IgG/IgM ICT was positive in 10 (31.3%) participants with CPA.

CONCLUSIONS

CPA may cause persistent respiratory symptoms in up to one-fifth of patients after intensive treatment for PTB. The Aspergillus IgG/IgM ICT positivity rate was very low and may not be used alone for the diagnosis of CPA in Uganda.

Strengthening global health security by improving disease surveillance in remote rural areas of low-income and middle-income countries

The COVID-19 pandemic has underscored the need to strengthen national surveillance systems to protect a globally connected world. In low-income and middle-income countries, zoonotic disease surveillance has advanced considerably in the past two decades. However, surveillance efforts often prioritise urban and adjacent rural communities. Communities in remote rural areas have had far less support despite having routine exposure to zoonotic diseases due to frequent contact with domestic and wild animals, and restricted access to health care. Limited disease surveillance in remote rural areas is a crucial gap in global health security. Although this point has been made in the past, practical solutions on how to implement surveillance efficiently in these resource-limited and logistically challenging settings have yet to be discussed. We highlight why investing in disease surveillance in remote rural areas of low-income and middle-income countries will benefit the global community and review current approaches. Using semi-arid regions in Kenya as a case study, we provide a practical approach by which surveillance in remote rural areas can be strengthened and integrated into existing systems. This Viewpoint represents a transition from simply highlighting the need for a more holistic approach to disease surveillance to a solid plan for how this outcome might be achieved.

DeepUCT: Complex cascaded deep learning network for improved ultrasound tomography

Ultrasound computed tomography is an inexpensive and radiation-free medical imaging technique used to quantify the tissue acoustic properties for advanced clinical diagnosis. Image reconstruction in ultrasound tomography is often modeled as an optimization scheme solved by iterative methods like full-waveform inversion. These iterative methods are computationally expensive, while the optimization problem is ill-posed and nonlinear. To address this problem, we propose to use deep learning to overcome the computational burden and ill-posedness, and achieve near real-time image reconstruction in ultrasound tomography. We aim to directly learn the mapping from the recorded time-series sensor data to a spatial image of acoustical properties. To accomplish this, we develop a deep learning model using two cascaded convolutional neural networks with an encoder–decoder architecture. We achieve a good representation by first extracting the intermediate mapping-knowledge and later utilizing this knowledge to reconstruct the image. This approach is evaluated on synthetic phantoms where simulated ultrasound data are acquired from a ring of transducers surrounding the region of interest. The measurement data is acquired by forward modeling the wave equation using the k-wave toolbox. Our simulation results demonstrate that our proposed deep-learning method is robust to noise and significantly outperforms the state-of-the-art traditional iterative method both quantitatively and qualitatively. Furthermore, our model takes substantially less computational time than the conventional full-wave inversion method.