Culinary continuity in central Japan across the transition to agriculture.

Rice and millet arrived in Western Japan from Korea around 3,000 years ago and spread eastwards across the archipelago in the next 700 years. However, the extent to which agriculture transformed traditional Jomon hunter-gatherer-fisher communities is debated. Central Japan is a key area of study as remodelling of radiocarbon dates shows a slowdown in the dispersal rate of rice agriculture in this area. Here, we examine and compare the use of pottery by Final Jomon and Early to Middle Yayoi communities in the Tokai and the Central Highland regions of central Japan, using lipid residue analysis. Although the identification of specific biomarkers for rice remains elusive, an increase in the ratio of E/H C18 APAAs with the arrival of rice and millet indicates a potential change in plant processing and consumption. We were also able to identify biomarkers for broomcorn millet (miliacin) in both Final Jomon and Yayoi pottery. However, evidence for millet consumption is sparse and in all cases was likely mixed with wild hunted and foraged foods. We conclude therefore that, despite the introduction of rice and millet agriculture in central Japan, pre-existing diets and culinary habits of Jomon hunter-gatherers remain important. Supplementary Information: The online version contains supplementary material available at 10.1007/s12520-024-01992-9.

Alkylresorcinol detection and identification in archaeological pottery using ultra-high-performance liquid chromatography-quadrupole/Orbitrap mass spectrometry.

RATIONALE: Alkylresorcinols (AR) are cereal-specific biomarkers and have recently been found in archaeological pots. However, their low concentrations and high susceptibility to degradation make them difficult to detect using conventional gas chromatography mass spectrometry (GC/MS). Here we describe the development of a more sensitive liquid chromatography mass spectrometry (LC/MS) method to detect these compounds. METHOD: A method based on the use of ultra-high-performance liquid chromatography (UHPLC) coupled to an Orbitrap mass analyser was established and validated for the detection of low-concentration ARs in pottery. During the preliminary experiments, UHPLC-Q/Orbitrap MS (ultra-high-performance liquid chromatography-quadrupole/Orbitrap mass spectrometry) was demonstrated to be more sensitive, and a wide range of AR homologues in cereal extracts were detected, unlike UHPLC-QTOFMS (ultra-high-performance liquid chromatography-quadrupole time-of-flight mass spectrometry) and GC/MS. The developed method was utilised to profile AR homologue distribution in modern cereal samples and reanalyse AR-containing pots from the archaeological site of Must Farm. RESULTS: A highly sensitive LC/MS method with a limit of detection (LOD) of 0.02 µg/g and a limit of quantification (LOQ) of 0.06 µg/g was used to profile ARs in five modern cereal grains. The obtained LOD is 250 times lower than that obtained using the conventional GC/MS approach. AR 21:0 was the most abundant homologue in all four Triticum spp.-einkorn, emmer, Khorasan wheat and common wheat. Meanwhile, AR 25:0 was the predominant homologue in barley, potentially enabling differentiation between wheat and barley. The developed LC/MS-based method was successfully used to analyse ARs extracted from Must Farm potsherds and identified the cereal species most likely processed in the pots-emmer wheat. CONCLUSION: The described method offers an alternative and more sensitive approach for detecting and identifying ARs in ancient pottery. It has been successfully utilised to detect AR homologues in archaeological samples and discriminate which cereal species-wheat and barley-were processed in the pots.

Genus Erica: An identification aid version 4.00.

Species identification is fundamental to all aspects of biology and conservation. The process can be challenging, particularly in groups including many closely related or similar species. The problem is confounded by the absence of an up-to-date taxonomic revision, but even with such a resource all but professional botanists may struggle to recognise key species, presenting a substantial barrier to vital work such as surveys, threat assessments, and seed collection for ex situ conservation. Genus Erica: An Identification Aid is a tool to help both amateurs and professionals identify (using a limited number of accessible characteristics) and find information about the 851 species and many subspecific taxa of the genus Erica. We present an updated version 4.00, with new features including integrating distribution data from GBIF and iNaturalist, links to taxonomic resources through World Flora Online, and a probability function for identifications, that is freely available for PCs. It remains a work in progress: We discuss routes forward for collaboratively improving this resource.

Limb, sex, but not acute dietary capsaicin, modulate the near-infrared spectroscopy-vascular occlusion test estimate of muscle metabolism.

The downward slope during the near-infrared spectroscopy (NIRS)-vascular occlusion test (NIRS-VOT) is purported as a simplified estimate of metabolism. Whether or not the NIRS-VOT exhibits sex- or limb-specificity or may be acutely altered remains to be elucidated. Thus, we investigated if there is limb- or sex specificity in tissue desaturation rates (DeO2) during a NIRS-VOT, and if acute dietary capsaicin may alter this estimate of muscle metabolism. Young healthy men (n = 25, 21 ± 4 years) and women (n = 20, 20 ± 1 years) ingested either placebo or capsaicin, in a counterbalanced, single-blind, crossover design after which a simplified NIRS-VOT was conducted to determine the DeO2 (%/s), as an estimate of oxidative muscle metabolism, in both the forearm (flexors) and thigh (vastus lateralis). There was a significant limb effect with the quadriceps having a greater DeO2 than the forearm (-2.31 ± 1.34 vs. -1.78 ± 1.22%/s, p = 0.007, ηp 2 = 0.19). There was a significant effect of sex on DeO2 (p = 0.005, ηp 2 = 0.203) with men exhibiting a lesser DeO2 than women (-1.73 ± 1.03 vs. -2.36 ± 1.32%/s, respectively). This manifested in significant interactions of limb*capsaicin (p = 0.001, ηp 2 = 0.26) as well as limb*capsaicin*sex on DeO2 (p = 0.013, ηp 2 = 0.16) being observed. Capsaicin does not clearly alter O2-dependent muscle metabolism, but there was apparent limb and sex specificity, interacting with capsaicin in this NIRS-derived assessment.

Do antibody CDR loops change conformation upon binding?

Antibodies have increasingly been developed as drugs with over 100 now licensed in the US or EU. During development, it is often necessary to increase or reduce the affinity of an antibody and rational attempts to do so rely on having a structure of the antibody-antigen complex often obtained by modeling. The antigen-binding site consists primarily of six loops known as complementarity-determining regions (CDRs), and an open question has been whether these loops change their conformation when they bind to an antigen. Existing surveys of antibody-antigen complex structures have only examined CDR conformational change in case studies or small-scale surveys. With an increasing number of antibodies where both free and complexed structures have been deposited in the Protein Data Bank, a large-scale survey of CDR conformational change during binding is now possible. To this end, we built a dataset, AbAgDb, that currently includes 177 antibodies with high-quality CDRs, each of which has at least one bound and one unbound structure. We analyzed the conformational change of the Cα backbone of each CDR upon binding and found that, in most cases, the CDRs (other than CDR-H3) show minimal movement, while 70.6% and 87% of CDR-H3s showed global Cα RMSD ≤ 1.0Å and ≤ 2.0Å, respectively. We also compared bound CDR conformations with the conformational space of unbound CDRs and found most of the bound conformations are included in the unbound conformational space. In future, our results will contribute to developing insights into antibodies and new methods for modeling and docking.

Barriers and facilitators to establishing a clinical academic career in clinical education research in the UK: A focus group study.

In a rapidly changing healthcare environment, we need a robust evidence base to inform effective education and training. This study aimed to examine factors perceived to determine career progression in clinical education research in the UK. Six online focus groups were conducted, with 35 participants from a range of medical, dental, nursing, and allied health professions who identified as aspiring or early career clinical education researchers. Transcripts underwent thematic analysis. Two themes and associated subthemes were constructed to illustrate perceived factors impacting on career development: (1) A cultural challenge from clinical norms. Challenges included differences between the epistemological assumptions of biomedical and clinical research, and the underlying philosophy of education research, which is more closely aligned with the knowledge generation of the social sciences. This led to difficulty communicating the impact of education research to patient care. There were also blurred boundaries between education delivery and research, with the latter lacking a clearly defined group identity. (2) Structures, systems and relationships for career progression. Practical considerations included time and funding (or lack thereof), the opportunity to undertake formal training, networking and role models. This research highlights a number of systemic barriers and facilitators to careers in clinical education research and offers targets of intervention to enable a sustainable academic workforce in clinical education research.

Binding kinetics drive G protein subtype selectivity at the ß1-adrenergic receptor.

G protein-coupled receptors (GPCRs) bind to different G protein α-subtypes with varying degrees of selectivity. The mechanism by which GPCRs achieve this selectivity is still unclear. Using 13C methyl methionine and 19F NMR, we investigate the agonist-bound active state of ß1AR and its ternary complexes with different G proteins in solution. We find the receptor in the ternary complexes adopts very similar conformations. In contrast, the full agonist-bound receptor active state assumes a conformation differing from previously characterised activation intermediates or from ß1AR in ternary complexes. Assessing the kinetics of binding for the agonist-bound receptor with different G proteins, we find the increased affinity of ß1AR for Gs results from its much faster association with the receptor. Consequently, we suggest a kinetic-driven selectivity gate between canonical and secondary coupling which arises from differential favourability of G protein binding to the agonist-bound receptor active state.

Exploring the Bob Ross effect: A psychophysiological investigation.

Watching news broadcasts is known to elicit psychological stress. Conversely, the iconic painter Bob Ross (BR) has risen to pop culture status and amassed a following, as many find the messages and sounds of BR to be soothing and relaxing. Though, it has yet to be directly tested if such exposure can confer psychological or physiological benefit. The purpose of this study was to compare the effects of watching BR versus streaming news on markers of cardiovascular health and profile of mood states (POMS). It was hypothesized that watching BR would increase POMS scores and heart rate variability (HRV). It was also hypothesized that watching the news would increase blood pressure (BP), vascular stiffness (VS), and heart rate (HR). METHODS: In a randomized, controlled, crossover design, 18 young (21 ± 1 yrs, 9 female, 9 male) healthy participants (172.6 ± 9.9 cm, 69 ± 18 kg) were assessed for BP, VS, HR, HRV, and POMS before and after watching an episode of BR or the News matched for time (∼27 mins). RESULTS: A significant interaction effect on POMS scores were observed for, anxiety (p = 0.01), anger (p = 0.008), depression (p = 0.003), fatigue (p = 0.001), and confusion (p = 0.01) domains after watching BR. The LF/HF ratio, an HRV marker of sympathovagal balance, was significantly lower after watching BR (p = 0.04). There were no significant time, condition, or interaction effects on systolic BP, mean arterial pressure, and diastolic BP. CONCLUSION: The "Bob Ross Effect" reduces overall mood disturbance, though appears to exert little influence on the cardiovascular system in this acute paradigm.

Transport and barrier mechanisms that regulate ciliary compartmentalization and ciliopathies.

Primary cilia act as cell surface antennae, coordinating cellular responses to sensory inputs and signalling molecules that regulate developmental and homeostatic pathways. Cilia are therefore critical to physiological processes, and defects in ciliary components are associated with a large group of inherited pleiotropic disorders - known collectively as ciliopathies - that have a broad spectrum of phenotypes and affect many or most tissues, including the kidney. A central feature of the cilium is its compartmentalized structure, which imparts its unique molecular composition and signalling environment despite its membrane and cytosol being contiguous with those of the cell. Such compartmentalization is achieved via active transport pathways that bring protein cargoes to and from the cilium, as well as gating pathways at the ciliary base that establish diffusion barriers to protein exchange into and out of the organelle. Many ciliopathy-linked proteins, including those involved in kidney development and homeostasis, are components of the compartmentalizing machinery. New insights into the major compartmentalizing pathways at the cilium, namely, ciliary gating, intraflagellar transport, lipidated protein flagellar transport and ciliary extracellular vesicle release pathways, have improved our understanding of the mechanisms that underpin ciliary disease and associated renal disorders.

Erica L. (Ericaceae): homonyms amongst published names for African species and proposed replacement names.

In support of ongoing taxonomic work on the large and complex flowering plant genus Erica (Ericaceae), we document nineteen pairs of homonyms representing currently used illegitimate names. We provide replacements for thirteen names and new typifications for five. We relegate five names to synonymy: Ericaaemula Guthrie & Bolus under Ericadistorta Bartl.; Ericaarmata Klotzsch ex Benth. under Ericaumbrosa H. A. Baker; Ericacapensis T.M. Salter under Ericaturbiniflora Salisb.; Ericalanata Andrews under Ericaflaccida Link; and Ericatomentosa Salisb. under Ericavelutina Bartl. Finally, we suggest conservation of Ericaaristata Andrews. The new names are: Ericaadelopetala E.C. Nelson & E.G.H. Oliv. replacing Ericainsignis E.G.H. Oliv.; Ericabombycina E.C. Nelson & Pirie replacing Ericaniveniana E.G.H. Oliv.; Ericaconcordia E.C. Nelson & E.G.H. Oliv. replacing Ericaconstantia Nois. ex Benth.; Ericadidymocarpa E.C. Nelson & E.G.H. Oliv. replacing Ericarugata E.G.H. Oliv.; Ericagalantha E.C. Nelson & E.G.H. Oliv. replacing Ericaperlata Benth.; Ericamallotocalyx E.C. Nelson & E.G.H. Oliv. replacing Ericaflocciflora Benth.; Ericanotoporina E.C. Nelson & E.G.H. Oliv. replacing E.autumnalis L.Bolus; Ericaoliveranthus E.C. Nelson & Pirie replacing Ericatenuis Salisb.; Ericaoraria E.C. Nelson & E.G.H. Oliv. replacing Ericaspectabilis Klotzsch ex Benth.; Ericaoresbia E.C. Nelson & E.G.H. Oliv. replacing Ericademissa Klotzsch ex Benth.; Ericapoculiflora E.C. Nelson & E.G.H. Oliv. replacing Ericastenantha Klotzsch ex Benth.; Ericarhodella E.C. Nelson & E.G.H. Oliv. replacing Ericarhodantha Guthrie & Bolus; Ericasupranubia E.C. Nelson & Pirie replacing Ericapraecox Klotzsch.

A Deep Learning Approach to Classify Surgical Skill in Microsurgery Using Force Data from a Novel Sensorised Surgical Glove.

Microsurgery serves as the foundation for numerous operative procedures. Given its highly technical nature, the assessment of surgical skill becomes an essential component of clinical practice and microsurgery education. The interaction forces between surgical tools and tissues play a pivotal role in surgical success, making them a valuable indicator of surgical skill. In this study, we employ six distinct deep learning architectures (LSTM, GRU, Bi-LSTM, CLDNN, TCN, Transformer) specifically designed for the classification of surgical skill levels. We use force data obtained from a novel sensorized surgical glove utilized during a microsurgical task. To enhance the performance of our models, we propose six data augmentation techniques. The proposed frameworks are accompanied by a comprehensive analysis, both quantitative and qualitative, including experiments conducted with two cross-validation schemes and interpretable visualizations of the network's decision-making process. Our experimental results show that CLDNN and TCN are the top-performing models, achieving impressive accuracy rates of 96.16% and 97.45%, respectively. This not only underscores the effectiveness of our proposed architectures, but also serves as compelling evidence that the force data obtained through the sensorized surgical glove contains valuable information regarding surgical skill.

Chemical analysis of pottery reveals the transition from a maritime to a plant-based economy in pre-colonial coastal Brazil.

Understanding long-term dynamics of past socio-ecological systems is essential for their future management. The southern Atlantic Forest coast of Brazil with its biodiverse littoral zone and artisanal fishing communities, is a priority for conservation. Traditional maritime knowledge is thought to have a deep-history and indeed, marine exploitation can be traced back to the middle Holocene. As part of one of South America's largest diasporas, Guarani groups reached the southern Brazilian coast at around 1000 years ago. Their impact on the long-standing coastal economy is unknown, due to poor preservation of organic remains. Through the first organic residue study on Guarani pottery, we show that maize rather than aquatic foods was the most dominant product in pottery at this time. By developing a mixing model based on carbon isotope values of saturated and mono-unsaturated fatty acids we propose new criteria for the identification of maize, opening up avenues for future research. Our data confirms the importance of maize to the pre-colonial Guarani, even in a highly productive coastal environment. The Guarani occupation of this region marks a significant departure from previous socio-economic systems, potentially leading to loss of traditional knowledge and alleviating anthropogenic pressure, albeit temporarily, on the marine environment.

Surfactant amplifies yield-stress effects in the capillary instability of a film coating a tube.

To assess how the presence of surfactant in lung airways alters the flow of mucus that leads to plug formation and airway closure, we investigate the effect of insoluble surfactant on the instability of a viscoplastic liquid coating the interior of a cylindrical tube. Evolution equations for the layer thickness using thin-film and long-wave approximations are derived that incorporate yield-stress effects and capillary and Marangoni forces. Using numerical simulations and asymptotic analysis of the thin-film system, we quantify how the presence of surfactant slows growth of the Rayleigh-Plateau instability, increases the size of initial perturbation required to trigger instability and decreases the final peak height of the layer. When the surfactant strength is large, the thin-film dynamics coincide with the dynamics of a surfactant-free layer but with time slowed by a factor of four and the capillary Bingham number, a parameter proportional to the yield stress, exactly doubled. By solving the long-wave equations numerically, we quantify how increasing surfactant strength can increase the critical layer thickness for plug formation to occur and delay plugging. The previously established effect of the yield stress in suppressing plug formation [Shemilt et al., J. Fluid Mech., 2022, vol. 944, A22] is shown to be amplified by introducing surfactant. We discuss the implications of these results for understanding the impact of surfactant deficiency and increased mucus yield stress in obstructive lung diseases.

Parallel worlds and mixed economies: multi-proxy analysis reveals complex subsistence systems at the dawn of early farming in the northeast Baltic.

The transition from foraging to farming was a key turning point in ancient socio-economies. Yet, the complexities and regional variations of this transformation are still poorly understood. This multi-proxy study provides a new understanding of the introduction and spread of early farming, challenging the notions of hierarchical economies. The most extensive biological and biomolecular dietary overview, combining zooarchaeological, archaeobotanical, dietary stable isotope and pottery lipid residue analyses is presented, to unravel the nature and extent of early farming in the 3rd millennium cal BCE in the northeast Baltic. Farming was introduced by incoming Corded Ware cultural groups (CWC), but some dietary segregation existed within these communities, with some having more access to domesticates, others incorporating more wild resources into their diet. The CWC groups coexisted in parallel with local hunter-fisher-gatherers (HFG) without any indication of the adoption of domesticates. There was no transition from foraging to farming in the 3rd millennium cal BCE in the NE Baltic. Instead, we see a complex system of parallel worlds with local HFGs continuing forager lifeways, and incoming farmers practising mixed economies, with the continuation of these subsistence strategies for at least a millennium after the first encounter with domesticated animals.

The impact of farming on prehistoric culinary practices throughout Northern Europe.

To investigate changes in culinary practices associated with the arrival of farming, we analysed the organic residues of over 1,000 pottery vessels from hunter-gatherer-fisher and early agricultural sites across Northern Europe from the Lower Rhine Basin to the Northeastern Baltic. Here, pottery was widely used by hunter-gatherer-fishers prior to the introduction of domesticated animals and plants. Overall, there was surprising continuity in the way that hunter-gatherer-fishers and farmers used pottery. Both aquatic products and wild plants remained prevalent, a pattern repeated consistently across the study area. We argue that the rapid adaptation of farming communities to exploit coastal and lagoonal resources facilitated their northerly expansion, and in some cases, hunting, gathering, and fishing became the most dominant subsistence strategy. Nevertheless, dairy products frequently appear in pottery associated with the earliest farming groups often mixed with wild plants and fish. Interestingly, we also find compelling evidence of dairy products in hunter-gatherer-fisher Ertebølle pottery, which predates the arrival of domesticated animals. We propose that Ertebølle hunter-gatherer-fishers frequently acquired dairy products through exchange with adjacent farming communities prior to the transition. The continuity observed in pottery use across the transition to farming contrasts with the analysis of human remains which shows substantial demographic change through ancient DNA and, in some cases, a reduction in marine consumption through stable isotope analysis. We postulate that farmers acquired the knowledge and skills they needed to succeed from local hunter-gatherer-fishers but without substantial admixture.

How to define clinical education research terminology: A glossary.

Clinical education research (ClinEdR) utilises diverse terminology, which can lead to confusion. A common language is essential for enhancing impact. An expert panel drawn from various workstreams within the National Institute for Health and Care Research (NIHR) Incubator for Clinical Education Research was tasked with reviewing an initial list of terms for the development of a glossary of terms in the field of ClinEdR. The glossary was populated with terms, definitions and foundational papers by the authors and peer-reviewed for accuracy. The glossary of terms developed for ClinEdR should enable researchers to use a common language, promoting consistency and improving communication. We anticipate this will be useful for ClinEdR students and early career researchers. The glossary could be integrated into educational research methods courses in ClinEdR, and through critical and reflective use, enhance the quality and subsequent impact of ClinEdR.

Modeling collagen fibril self-assembly from extracellular medium in embryonic tendon.

Collagen is a key structural component of multicellular organisms and is arranged in a highly organized manner. In structural tissues such as tendons, collagen forms bundles of parallel fibers between cells, which appear within a 24-h window between embryonic day 13.5 (E13.5) and E14.5 during mouse embryonic development. Current models assume that the organized structure of collagen requires direct cellular control, whereby cells actively lay down collagen fibrils from cell surfaces. However, such models appear incompatible with the time and length scales of fibril formation. We propose a phase-transition model to account for the rapid development of ordered fibrils in embryonic tendon, reducing reliance on active cellular processes. We develop phase-field crystal simulations of collagen fibrillogenesis in domains derived from electron micrographs of inter-cellular spaces in embryonic tendon and compare results qualitatively and quantitatively to observed patterns of fibril formation. To test the prediction of this phase-transition model that free protomeric collagen should exist in the inter-cellular spaces before the formation of observable fibrils, we use laser-capture microdissection, coupled with mass spectrometry, which demonstrates steadily increasing free collagen in inter-cellular spaces up to E13.5, followed by a rapid reduction of free collagen that coincides with the appearance of less-soluble collagen fibrils. The model and measurements together provide evidence for extracellular self-assembly of collagen fibrils in embryonic mouse tendon, supporting an additional mechanism for rapid collagen fibril formation during embryonic development.

Molecular evidence for new foodways in the early colonial Caribbean: organic residue analysis at Isla de Mona, Puerto Rico.

Ceramic objects account for over 90% of the cultural material recovered from archaeological sites in the Caribbean. However, little research has been conducted on molecular evidence for past food production from these same vessels. Forty ceramic sherds from Isla de Mona have been analysed by GC-MS and GC-C-IRMS in order to address questions surrounding foodways in the Greater Antilles prior to and post European arrival. We evaluate evidence for dietary changes to illuminate aspects of cultural exchange between Indigenous populations and the first generations of Spanish colonists. Here, we show that plant residues are found in a variety of pottery forms, with some evidence for non-ruminant and ruminant fats. The dearth of marine biomarkers is curious given the volume of fish bones found in archaeological contexts on Isla de Mona and may offer evidence for spit-roasting, pit-roasting, or the use of a 'barbacoa' to cook fish on the island. The ubiquity of plant residues in a variety of pottery forms may relate to the large-scale cultivation and export of cassava (Manihot esculenta) from the island. A Spanish olive jar revealed evidence of wine residues, which may constitute the earliest detection of wine residues in pottery found in the Americas. Supplementary information: The online version contains supplementary material available at 10.1007/s12520-023-01771-y.

Effectiveness of dinoprostone gel, misoprostol vaginal insert and dinoprostone vaginal insert for induction of labour in twin pregnancies.

OBJECTIVES: To compare the effectiveness and safety of Dinoprostone Gel (DG), Misoprostol Vaginal Insert (MVI) and Dinoprostone Vaginal Insert (DVI) for induction of labour (IOL) in twin pregnancies. STUDY DESIGN: Retrospective cohort study of twin pregnancies > 34 + 0 weeks gestation that underwent induction of labour (IOL) with DG, MVI or DVI between December 2016 and November 2019 in a Tertiary NHS hospital, North West England, UK. Delivery characteristics, maternal complications and neonatal outcomes were compared between the three groups. RESULTS: A total of 87 twin pregnancies were included for analysis. 27 women received DG, 34 received MVI and 26 DVI. The MVI cohort had a higher proportion of nulliparous women (55.9%) compared to the DG and DVI cohorts, 29.6% and 38.5% respectively. No other differences amongst demographic characteristics were considered clinically significant. DG demonstrated a significantly quicker time to delivery (minutes) compared to DVI (1021 ± 556 versus 1649 ± 852; P = 0.0026). Significantly fewer women required terbutaline for hyperstimulation/tachysystole in the DG group compared to MVI (0% vs 32%; RR 0.05; 95% CI 0.003-0.88). Both DG and MVI groups required significantly less oxytocin following artificial rupture of membranes compared to DVI (33% vs 65%; RR 0.51; 95% CI 0.28-0.93) and (29% vs 65%; RR 0.45; 95% CI 0.25-0.81). There were no significant differences in mode of delivery, maternal complications and neonatal outcomes. CONCLUSION: Our data suggests that for women with a twin pregnancy considering a planned labour that induction with DG, MVI and DVI appear to be equally safe and effective IOL methods. These results should be interpreted with caution due to the study being underpowered to detect significant adverse outcomes. In order to determine the optimal method of IOL in twins, direct randomised comparison is needed.

Comparison of international guidelines on the management of twin pregnancy.

OBJECTIVES: To review current international clinical guidelines on the antenatal and intrapartum management of twin pregnancies, examining areas of consensus and conflict. METHODS: We conducted a database search using Medline, Pubmed, Scopus, Academic Search Complete, CINAHL and ERCI Guidelines website. Guidelines were screened for eligibility using our inclusion and exclusion criteria. Those deemed eligible were quality assessed using the AGREE II tool and relevant data was extracted. RESULTS: We identified 21 relevant guidelines from 16 countries including two international society guidelines. There was consensus in determination of chorionicity and amnionicity within the first trimester, fetal anomaly scan between 18 and 22 weeks and the recommended screening for twin-to-twin transfusion syndrome (TTTS). For those that provided intrapartum guidance, there was agreement in recommending caesarean section to deliver monochorionic monoamniotic (MCMA) twins, epidural anaesthesia for intrapartum analgesia and the use of cardiotocography (CTG) for intrapartum fetal monitoring. The main areas of conflict included cervical length screening, frequency of ultrasound surveillance, timing of delivery of dichorionic twin pregnancies and circumstances for recommending vaginal delivery. There was a lack of advice on intrapartum management. CONCLUSIONS: This review has highlighted the need for unified international guidance on the management of twin pregnancy. Comparisons of current guidance demonstrates a lack of confidence in the management of labour in twin pregnancies. Further evidence on intrapartum care of twin pregnancies is needed to inform practice guidelines and improve both short and long term maternal and fetal outcomes.