mSep: investigating physiological and immune-metabolic biomarkers in septic and healthy pregnant women to predict feto-maternal immune health - a prospective observational cohort study protocol

INTRODUCTION

Maternal sepsis remains a leading cause of death in pregnancy. Physiological adaptations to pregnancy obscure early signs of sepsis and can result in delays in recognition and treatment. Identifying biomarkers that can reliably diagnose sepsis will reduce morbidity and mortality and antibiotic overuse. We have previously identified an immune-metabolic biomarker network comprising three pathways with a >99% accuracy for detecting bacterial neonatal sepsis. In this prospective study, we will describe physiological parameters and novel biomarkers in two cohorts-healthy pregnant women and pregnant women with suspected sepsis-with the aim of mapping pathophysiological drivers and evaluating predictive biomarkers for diagnosing maternal sepsis.

METHODS AND ANALYSIS

Women aged over 18 with an ultrasound-confirmed pregnancy will be recruited to a pilot and two main study cohorts. The pilot will involve blood sample collection from 30 pregnant women undergoing an elective caesarean section. Cohort A will follow 100 healthy pregnant women throughout their pregnancy journey, with collection of blood samples from participants at routine time points in their pregnancy: week 12 'booking', week 28 and during labour. Cohort B will follow 100 pregnant women who present with suspected sepsis in pregnancy or labour and will have at least two blood samples taken during their care pathway. Study blood samples will be collected during routine clinical blood sampling. Detailed medical history and physiological parameters at the time of blood sampling will be recorded, along with the results of routine biochemical tests, including C reactive protein, lactate and white blood cell count. In addition, study blood samples will be processed and analysed for transcriptomic, lipidomic and metabolomic analyses and both qualitative and functional immunophenotyping.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Wales Research Ethics Committee 2 (SPON1752-19, 30 October 2019).

TRIAL REGISTRATION NUMBER

NCT05023954.

Responding to the mental health needs of trafficked women

Background

Studies suggest a high prevalence of depression and PTSD among survivors of human trafficking in contact with shelter services. However, evidence for interventions to support the recovery of survivors of trafficking is lacking. The broader literature on PTSD and depression indicates that ongoing social stressors can exacerbate and perpetuate symptoms. Advocacy-based, or “casework”, interventions, which address current stressors and social support, may represent a promising avenue of enquiry. Objectives (1) Describe risk and protective factors for mental distress among trafficked people; (2) Present a preliminary theory of change describing how advocacy-based interventions may contribute to an improvement in mental health and wellbeing among survivors of human trafficking.

Methods

(1) Survey of adult male and female survivors of trafficking in contact with shelter services in England; symptoms of depression, anxiety, and post-traumatic stress disorder were measured using the PHQ-9, GAD-7, and PCL-C. (2) Theory of change workshop and review of intervention studies that assessed the effectiveness of casework, client support, or advocacy interventions delivered in health or community settings to survivors of trafficking or vulnerable migrants.

Results

150 survivors of trafficking participated in the survey, 98 women and 52 men. In multivariate analyses, psychological distress was associated with higher number of unmet needs and lacking a confidante, suggesting that practical and social support is important in facilitating mental health recovery. The theory of change identifies common components in advocacy interventions delivered to survivors of trafficking, and proposes pathways by which these components contribute to improved mental health.

Disclosure

No significant relationships.

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS

This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS

Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION

Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

Informal caregiving and intimate relationships: the experiences of spouses of UK military personnel

AIM

Currently, there is no research available on the experiences of spouses providing informal care to wounded, injured or sick (WIS) UK military personnel. The aim of this study was to fill this gap by investigating the relationship experiences of non-military partners caring for WIS UK military personnel.

METHODS

Spouses of WIS military personnel (n=25) completed telephone interviews with the research team. The data were transcribed and analysed using thematic analysis. The transcripts were cross-coded and checked for inter-rater reliability.

RESULTS

Six major themes were identified: (1) communication between couples, (2) adverse family environment, (3) reintegration, (4) intimacy, (5) financial uncertainty and (6) transition from partner to caregiver.

CONCLUSIONS

Partners caring for injured/ill military personnel appear to be at risk of experiencing personal distress caused by impaired relationship functioning, which may lead to diminished physical and mental well-being. Partners of WIS military personnel experience significant levels of distress and burden associated with caregiving in the form of arguments with the military partner, problems in reintegration and a lack of physical and emotional intimacy.

Suitability of measurements used to assess mental health outcomes in men and women trafficked for sexual and labour exploitation: a systematic review

Trafficking is a global human rights violation with multiple and complex mental health consequences. Valid and reliable mental health assessment tools are needed to inform health-care provision. We reviewed mental health assessment tools used in research with men and women trafficked for sexual and labour exploitation. We searched nine electronic databases (PsycINFO, Ovid Medline, PubMed, Embase, Assia, the Web of Science, Global Health, Google Scholar, and Open Grey) and hand-searched the reference lists of relevant identified studies. Seven studies were included in this Review. Six of the studies screened for post-traumatic stress disorder, depression, and anxiety; one study screened for harmful use or abuse of alcohol and used a diagnostic tool to assess post-traumatic stress disorder, depression, and anxiety. Two studies included men in their sample population. Although the reported prevalence of mental health problems was high, little information was provided about the validity, reliability, and cultural appropriateness of assessment tools. Further research is needed to determine which assessment tools are culturally appropriate, valid, and reliable for trafficked people.

Systematic review and meta-analysis of psychiatric disorder and the perpetration of partner violence

Backgrounds. The extent to which psychiatric disorders are associated with an increased risk of violence to partners is unclear. This review aimed to establish risk of violence against partners among men and women with diagnosed psychiatric disorders. Methods. Systematic review and meta-analysis. Searches of eleven electronic databases were supplemented by hand searching, reference screening and citation tracking of included articles, and expert recommendations. Results. Seventeen studies were included, reporting on 72 585 participants, but only three reported on past year violence. Pooled risk estimates could not be calculated for past year violence against a partner and the three studies did not consistently report increased risk for any diagnosis. Pooled estimates showed an increased risk of having ever been physically violent towards a partner among men with depression (odds ratio (OR) 2.8, 95% confidence intervals (CI) 2.5-3.3), generalized anxiety disorder (GAD) (OR 3.2, 95% CI 2.3-4.4) and panic disorder (OR 2.5, 95% CI C% 1.7-3.6). Increased risk was also found among women with depression (OR 2.4, 95% CI 2.1-2.8), GAD (OR 2.4, 95% CI 1.9-3.0) and panic disorder (OR 1.9, 95% CI 1.4-2.5). Conclusions. Psychiatric disorders are associated with high prevalence and increased odds of having ever been physically violent against a partner. As history of violence is a predictor of current violence, mental health professionals should ask about previous partner violence when assessing risk.

Prevalence of experiences of domestic violence among psychiatric patients: systematic review

BACKGROUND

Domestic violence has been linked with many mental disorders, including anxiety, depression, post-traumatic stress disorder, eating disorders and psychosis.

AIMS

To estimate the prevalence (adult lifetime and past year) of different types of domestic violence experienced by men and women receiving psychiatric treatment.

METHOD

In a systematic review, a search of 18 electronic databases was supplemented by hand searching, citation tracking and updating a recent systematic review of criminal victimisation in psychiatric populations. Two reviewers independently extracted data and appraised study quality.

RESULTS

Forty-two studies were included. The median prevalence of lifetime partner violence reported in high-quality papers was 30% (interquartile range (IQR) 26-39) among female in-patients and 33% (IQR 21-53) among female out-patients. Among male patients, one high-quality study reported a lifetime prevalence of 32% across mixed psychiatric settings. No study included a control group.

CONCLUSIONS

Psychiatric patients experience a high prevalence of domestic violence but there is limited information on family (non-partner) domestic violence, the prevalence of emotional abuse and the extent of risk compared with non-psychiatric controls.

High fat diet increases the weight of rat ventral prostate

BACKGROUND

Understanding the mechanisms by which diet influences the prostate may eventually lead to novel approaches for preventing prostate cancer. The objective of this research is to examine the impact of dietary fat, vitamin D, and genistein on prostate weight, serum and intraprostatic androgen levels, and the expression of several androgen-response genes.

METHODS

Sprague-Dawley rats were fed, beginning at 21 days of age, for 1 or 3 months of experimental diets with high saturated fat (32.2% calories from fat), low saturated fat (3.6% calories from fat), genistein plus (20 mg/kg), genistein deficient, vitamin D surplus (4,000 U/kg), or vitamin D deficient. The body weight, food intake, the weights of the ventral prostate and dorsolateral prostate, and the levels of testosterone and dihydrotestosterone (DHT) in the serum and in the prostate were determined. The expression of androgen-response genes was characterized by Northern blot analysis.

RESULTS

The pilot experiments showed that high dietary fat appeared to consistently increase the weight of the ventral prostate, while vitamin D or genistein did not have a consistent effect on prostate weight. Further analysis confirmed that the ventral prostate is 15% (P < 0.001) heavier in the rat on a high fat diet as compared to a low fat diet. Dietary fat had no significant influence on the levels of serum and intraprostatic androgens and the expression of androgen-response genes.

CONCLUSIONS

Our results suggested that the ventral prostate weight of the rat is increased without affecting the androgen axis by feeding the animals with high fat diet beginning at 21 days of age. This observation is potentially important since epidemiological data suggest that saturated fat consumption is a major risk factor associated with prostate cancer incidence rate.

Accidental intake of tritiated water: a cytogenetic follow-up case on translocation stability and dose reconstruction

PURPOSE

To examine by fluorescence in situ hybridization (FISH) chromosomal translocations in a person who, 11 years previously, had accidentally incorporated tritiated water. To compare the resultant estimate of radiation dose with contemporary dosimetry made by urine analysis and dicentric chromosome scoring.

MATERIALS AND METHODS

Blood lymphocytes were shared by two laboratories each performing the FISH analysis using different chromosome probe combinations. Doses were calculated by reference to an in vitro calibration curve produced in one of the laboratories.

RESULTS

Good agreement in translocation yields was found by the two laboratories. Comparing the yields with the dicentric frequency obtained shortly after the accident and with a translocation frequency measured 6 years post exposure showed good agreement between all measurements. This indicates essentially perfect stability for translocations over an 11 year period in this individual.

CONCLUSIONS

Dose reconstruction based on FISH-measured translocations showed good agreement with the dose estimated from initial dicentric measurements and from measurements of tritium in urine. Because of the extensive initial dosimetry performed on this individual, who received a uniform whole-body irradiation, the case serves as an excellent test for the use of FISH-measured translocations for retrospective biodosimetry.

Effect of nifedipine on exercise tolerance in angina pectoris

Nifedipine is a new antianginal drug, the calcium-antagonistic inhibitory action on excitation-contraction coupling apparently being so pronounced that, in therapeutic dosage, all other pharmacological properties are negligible. Its effect on exercise tolerance in angina was assessed by an exercise study involving 14 patients: single-stage exercise tests were chosen and the advantages of this are given. Our results suggest that the onset of action occurs after about 20 minutes, reaches a peak of activity at approximately one-half to two hours, and some effect may still be present at three hours. There was a significant improvement in exercise times with a mean rise of 50 per cent over placebo.

Asymmetric septal hypertrophy and propranolol treatment in a case of Ullrich-Noonan syndrome

A 4-year-old boy with the Ullrich-Noonan syndrome is described. Asymmetric septal hypertrophy was diagnosed by echocardiography and confirmed at cardiac catheterisation. The aortic subvalvar gradient was reduced from 56 mmHg to 10 mmHg with intravenous propranolol. Relatives of patients with the syndrome should be screened by echocardiography in the hope that the early detection of asymmetric septal hypertrophy and its treatment with propranolol may reduce the likelihood of sudden death.

Diagnosis of coronary artery disease by estimation of coronary sinus lactate

In an attempt to assess the value of coronary sinus lactate estimation before and during atrial pacing for the diagnosis of obstructive coronary artery disease, 70 patients with angina were investigated in this way and by selective coronary arteriography. Thirty-five had radiologically normal coronary arteries and 35 had coronary artery disease. When the change in coronary arteriovenous lactate difference was less than 0.09 mmol/l (0.8 mg/100 ml) between the control and the peak atrial pacing sample, the coronary arteries were normal except in one patient who had distal disease of a single vessel. When the change was greater than 0.22 mmol/l (2.0 mg/100 ml) coronary artery disease was always found, and when the change was greater than 0.39 mmol/l (3.5 mg/100 ml) there was always disease of two or three vessels. Unfortunately, the presence or absence of coronary artery disease could not be predicted when the change fell between 0.09 and 0.22 mmol/l (0.8 and 2.0 mg/100 ml). Estimation of coronary sinus lactate before and during atrial pacing can thus frequently distinguish patients with normal coronary arteries from those with coronary artery disease.

Occlusion of the subclavian vein associated with cephalic vein pacemaker electrodes

Thrombosis and occlusion of major veins have been described following the use of transvenous pacing electrodes for the establishment of permanent cardiac pacing. The frequency of such complications is, however, not well known. A series of 125 patients was therefore reviewed, all of whom had been paced with permanent transvenous electrodes through a cephalic vein. There was clinical and venographic evidence of subclavian vein occlusion in only 3 of these patients. A further 20 of these patients were also subjected to venography and showed no radiographic evidence of venous occlusion although minor thrombosis associated with the pacemaker electrode was found in one patient. It is concluded that the convenience of using the cephalic vein as a route for the insertion of transvenous pacing electrodes outweighs the small risk of major venous occlusion.

Reassessment of failed beta-blocker treatment in angina pectoris by peak-exercise heart rate measurements

Twenty-one patients with angina pectoris were treated with adrenergic beta-receptor antagonists. Previously the resting heart rate had been used as a guide to treatment, a reduction in the rate to 55-60 beats/min without symptomatic improvement indicating failure of medical treatment. These patients were re-evaluated before coronary arteriography using the peak-exercise heart rate as an index of adrenergic beta-receptor antagonism. The dose of beta-blocking drugs was increased to produce a peak-exercise heart rate of less than 100 beats/min or a consistent rate of 100-125 beats/min which would not lessen in spite of progressive dose increments. The resting heart rate was ignored. On these criteria 15 patients previously considered to have responded inadequately to beta-blockade responded satisfactorily and were therefore removed from the waiting list for coronary arteriography. They all remained well up to two years later. Six patients failed to respond and had coronary arteriography with a view to surgical treatment. Reliance on the resting heart rate as the index of optimum adrenergic beta-receptor antagonism is likely to lead to premature or unnecessary referral for surgery; the failure of beta-blockade in the treatment of angina pectoris can be determined simply and accurately by using peak-exercise heart rate.

Modification by propranolol of cardiovascular effects of induced hypoglycaemia

The cardiovascular effects of hypoglycaemia, with and without beta-blockade, were compared in fourteen healthy men. Eight received insulin alone, and eight, including two of the original insulin-only group, were given propranolol and insulin. In the insulin-group the period of hypoglycaemia was associated with an increase in heart-rate and a fall in diastolic blood-pressure. In the propranolol-insulin group there was a significant fall in heart-rate in most subjects and an increase in diastolic pressure. Typical S-T/T changes occurred in the insulin-group but in none of the propranolol-insulin group. Hypertension in diabetics prone to hypoglycaemia attacks should not be treated with beta-blockers because these drugs may cause a sharp rise in blood-pressure in such patients.

Double-blind comparison of tolamolol, propranolol, practolol, and placebo in the treatment of angina pectoris

Forty-two patients with angina pectoris have completed a randomized, double-blind trial comparing tolamolol 100 mg and 200 mg with propranolol 80 mg, practolol 100 mg, and placebo, all given three times a day. Tolamolol 200 mg thrice daily was found to be equivalent to propranolol 80 mg thrice daily in anti-anginal efficacy. Anginal attack rates and trinitrin consumption were significantly reduced by all active treatments as compared with the placebo but tolamolol and propranolol were the most effective. Tolamolol 200 mg thrice daily was most effective in reducing blood pressure, while propranolol was most effective in reducing the resting heart rate. All treatments except the placebo significantly increased the amount of exercise which could be performed before angina appeared (exercise work), while tolamolol 200 mg thrice daily significantly reduced Robinson's index when compared with all other active agents. The degree of S-T segment depression induced by exercise was significantly lessened by both tolamolol and propranolol but not by practolol or placebo. There was no difference in patient preference between tolamolol and propranolol but tolamolol at both dose levels was preferred to practolol. Both tolamolol and propranolol are potent adrenergic beta-receptor antagonists and equal in anti-anginal efficacy but tolamolol has the advantage of being cardioselective. It is superior to practolol.

Double-blind evaluation of verapamil, propranolol, and isosorbide dinitrate against a placebo in the treatment of angina pectoris

In the treatment of angina pectoris a double-blind evaluation of verapamil (Cordilox) at two dose levels-namely, 80 mg thrice daily and 120 mg thrice daily-propranolol (Inderal) 100 mg thrice daily, and isosorbide dinitrate (Vascardin) 20 mg thrice daily has been made against a placebo. The assessment was based on relief from daily attacks of angina on effort and the response to a whole-body exercise test. We can find no statistically significant difference between the effects of verapamil (120 mg three times a day) and propranolol (100 mg three times a day) in the treatment of angina of effort. Both of these preparations are more effective than a placebo both in the reduction of daily attacks (P < 0.01) and in the prolongation of exercise test (P < 0.05). Isosorbide dinitrate (20 mg three times a day) appears to be no more effective than a placebo in the treatment of angina on effort, but 14 out of 32 patients experienced headache of such severity that even when the dose was reduced to 10 mg thrice daily this drug therapy had to be withdrawn. Both propranolol (100 mg three times a day) and verapamil (120 mg three times a day) had a significant lowering effect on the diastolic blood pressure as measured with the patient standing (P < 0.01).

Mycotic aneurysms of coronary arteries

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Familial sinuatrial disorder

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Thromboembolic pulmonary hypertension of unusual cause in a teenager

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Evaluation of contrast media used in man for coronary arteriography

The electrocardiographic changes induced by the injection of four contrast media into the right and left coronary arteries of man are described. Comparisons have been made between the different media, the techniques used, and the individual coronary artery injected. We conclude that Hypaque 85 is the medium of choice for coronary arteriography, that injection into the right coronary artery is more hazardous than injection into the left, and that as far as safety is concerned there is nothing to choose between the Sones' and judkins' techniques.

Effect of respiratory obstruction on the arterial and venous circulation in animals and man

The glottis of man, which widens on inspiration, is a choked point on the airway, its lumen even when maximally open being less than that of the trachea. The glottis, however, is not the only point of obstruction, the nose being usually of greater significance, especially in carnivorous species. The nose does not change in calibre during respiration. Experiments were carried out in animals and man, consisting of measurements of intra-tracheal, intra-thoracic, femoral arterial, and right atrial pressures, to determine the effects of normal nasal obstruction of constant presence, increase in nasal resistance, rhythmic obstruction at the glottis, combined nasal and glottic obstruction, and of elimination of nasal resistance and elimination of glottic resistance. As a result of these experiments the early opinion that the pump action on the circulation was due mainly to obstruction at the glottis has proved incorrect, and the main point of resistance is the nose, which offers constant resistance, variable in wide periods of time but not so rapidly as the phases of respiration. It appears that the glottis is the point of fine adjustment.