Perinatal outcome of monochorionic triamniotic triplet pregnancy: multicenter cohort study.

OBJECTIVE: Monochorionic (MC) triplet pregnancies are extremely rare and information on these pregnancies and their complications is limited. We aimed to investigate the risk of early and late pregnancy complications, perinatal outcome and the timing and methods of fetal intervention in these pregnancies. METHODS: This was a multicenter retrospective cohort study of MC triamniotic (TA) triplet pregnancies managed in 21 participating centers around the world from 2007 onwards. Data on maternal age, mode of conception, diagnosis of major fetal structural anomalies or aneuploidy, gestational age (GA) at diagnosis of anomalies, twin-to-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS), twin reversed arterial perfusion (TRAP) sequence and or selective fetal growth restriction (sFGR) were retrieved from patient records. Data on antenatal interventions were collected, including data on selective fetal reduction (three to two or three to one), laser surgery and any other active fetal intervention (including amniodrainage). Data on perinatal outcome were collected, including numbers of live birth, intrauterine demise, neonatal death, perinatal death and termination of fetus or pregnancy (TOP). Neonatal data such as GA at birth, birth weight, admission to neonatal intensive care unit and neonatal morbidity were also collected. Perinatal outcomes were assessed according to whether the pregnancy was managed expectantly or underwent fetal intervention. RESULTS: Of an initial cohort of 174 MCTA triplet pregnancies, 11 underwent early TOP, three had an early miscarriage, six were lost to follow-up and one was ongoing at the time of writing. Thus, the study cohort included 153 pregnancies, of which the majority (92.8%) were managed expectantly. The incidence of pregnancy affected by one or more fetal structural abnormality was 13.7% (21/153) and that of TRAP sequence was 5.2% (8/153). The most common antenatal complication related to chorionicity was TTTS, which affected just over one quarter (27.6%; 42/152, after removing a pregnancy with TOP < 24 weeks for fetal anomalies) of the pregnancies, followed by sFGR (16.4%; 25/152), while TAPS (spontaneous or post TTTS with or without laser treatment) occurred in only 4.6% (7/152) of pregnancies. No monochorionicity-related antenatal complication was recorded in 49.3% (75/152) of pregnancies. Survival was apparently associated largely with the development of these complications: there was at least one survivor beyond the neonatal period in 85.1% (57/67) of pregnancies without antenatal complications, in 100% (25/25) of those complicated by sFGR and in 47.6% (20/42) of those complicated by TTTS. The overall rate of preterm birth prior to 28 weeks was 14.5% (18/124) and that prior to 32 weeks' gestation was 49.2% (61/124). CONCLUSION: Monochorionicity-related complications, which can impact adversely perinatal outcome, occur in almost half of MCTA triplet pregnancies, creating a challenge with regard to counseling, surveillance and management. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Detection of growth-restricted fetuses during pregnancy is associated with fewer intrauterine deaths but increased adverse childhood outcomes: an observational study.

OBJECTIVE: Exploring associations between antenatal detection of fetal growth restriction (FGR) and adverse outcome. DESIGN: Retrospective, observational, register-based study. SETTING: Zealand, Denmark. POPULATION OR SAMPLE: Children born from 1 September 2012 to 31 August 2015. METHODS: Diagnoses from birth until 1 January 2018 were retrieved from The National Patient Registry. Detection was defined as estimated fetal weight less than the 2.3rd centile. Cox regression was used to associate detection status with the hazard rate of adverse outcome, adjusted for fetal weight deviation, maternal age, ethnicity, body mass index and smoking. MAIN OUTCOME MEASURES: Adverse neonatal outcome, adverse neuropsychiatric outcome, respiratory disorders, endocrine disorders, gastrointestinal/urogenital disorders. RESULTS: A total of 2425 FGR children were included. An association was found for gastrointestinal/urogenital disorders (hazard ratio [HR] 1.68, 95% CI 1.26-2.23, P < 0.001) and respiratory disorders (HR 1.22, 95% CI 1.02-1.46, P = 0.03) in detected versus undetected infants. For adverse neuropsychiatric outcome, HR was 1.32 (95% CI 1.00-1.75, P = 0.05). There was no evidence of an association between detection and adverse neonatal outcome (HR 1.00, 95% CI 0.62-1.61, P = 0.99) and endocrine disorders (HR 1.39, 95% CI 0.88-2.19, P = 0.16). Detected infants were smaller (median -28% versus -25%, P < 0.0001), more often born preterm (odds ratio [OR] 4.15, 3.12-5.52, P < 0.0001) and more often born after induction or caesarean section (OR 5.19, 95% CI 4.13-6.51, P < 0.0001). Stillbirth risk was increased in undetected FGR fetuses (OR 2.63, 95% CI 1.37-5.04, P = 0.004). CONCLUSIONS: We found an association between detection of FGR and risk of adverse childhood conditions, possibly caused by prematurity. Iatrogenic prematurity may be inevitable in stillbirth prevention, but is accompanied by a risk of long-term childhood conditions. TWEETABLE ABSTRACT: Antenatal detection of growth-restricted fetuses is associated with adverse childhood outcomes but fewer intrauterine deaths.

Multicenter randomized trial exploring effects of simulation-based ultrasound training on obstetricians' diagnostic accuracy: value for experienced operators.

OBJECTIVE: To explore the effects of simulation-based ultrasound training on the accuracy of fetal weight estimation in the third trimester among obstetricians with different levels of clinical experience. METHODS: This was a multicenter, randomized pre-post-test practical trial conducted between March 2016 and January 2018. Obstetricians with different levels of clinical experience were randomized to either simulation-based ultrasound training focusing on fetal weight scans or no intervention. Participants completed two scans in pregnant women at term to establish baseline accuracy of fetal weight estimation. Another two scans were performed at follow-up. Accuracy was defined by the percentage difference between estimated fetal weight and actual birth weight. Ultrasound image quality was rated by two expert raters. RESULTS: Seventy participants with different levels of clinical experience completed the study. Adjusting for clinical experience, the intervention group demonstrated an improvement in measurement accuracy of 31.9% (95% CI, 6.9-50.1%) (P = 0.02), whereas the control group did not improve (relative difference, 13.1% (95% CI, -17.9 to 55.9%); P = 0.45). The change in accuracy was significantly different between the groups (P = 0.02) and independent of clinical experience (P = 0.54). Image-quality scores improved by a mean of 1.2 (95% CI, 0.4-2.1) (P < 0.01) in the intervention group, with no change in the control group (mean difference, 0.1 (95% CI, -0.8 to 1.0); P = 0.78). There was a strong negative correlation between time spent using the simulator and clinical experience (r = -0.70, P = 0.0001). CONCLUSION: Simulation-based ultrasound training improved accuracy and image quality when performing fetal weight estimation in women at term, independent of obstetricians' clinical experience. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Do chorionic villus samplings (CVS) or amniocenteses (AC) induce RhD immunisation? An evaluation of a large Danish cohort with no routine administration of anti-D after invasive prenatal testing.

OBJECTIVE: To evaluate the risk of inducing RhD immunisation in pregnancies of RhD-negative mothers with an RhD-positive fetus undergoing chorionic villus samplings (CVS) or amniocenteses (AC). DESIGN, SETTING AND POPULATION: Registry-based study in a Danish cohort which has not been given rhesus prophylaxis. METHODS: Data were retrieved from the Department of Clinical Immunology at Rigshospitalet. All RhD-negative women carrying an RhD-positive fetus with screen test results from weeks 8-12 and weeks 25-29 were linked to data from the Danish Fetal Medicine Database. Data were divided into cases where no invasive prenatal diagnostic procedure was performed, cases that had AC performed, and cases that had CVS performed. MAIN OUTCOME MEASURES: A comparison of the proportion of women who developed RhD immunisation between the two screen tests. RESULTS: The cohort consisted of 10 085 women: 9353 had no invasive procedures performed, 189 had AC and 543 had CVS performed. No women were immunised spontaneously or due to the procedure between the first and second screen test in the group with no procedure performed, or in the AC group. One woman was immunised in the CVS group. When comparing the proportion of women who was immunised in the CVS group with the no invasive test group a non-significant difference was found (P = 0.055). CONCLUSION: The RhD immunisation rate before gestational weeks 25-29 in RhD-negative women carrying an RhD-positive fetus is very low, even in women undergoing prenatal invasive testing without rhesus prophylaxis. TWEETABLE ABSTRACT: The RhD immunisation rate during pregnancy is very low even in women undergoing prenatal invasive testing.

Rapid quantification of casein in skim milk using Fourier transform infrared spectroscopy, enzymatic perturbation, and multiway partial least squares regression: Monitoring chymosin at work.

In this study, we introduce enzymatic perturbation combined with Fourier transform infrared (FTIR) spectroscopy as a concept for quantifying casein in subcritical heated skim milk using chemometric multiway analysis. Chymosin is a protease that cleaves specifically caseins. As a result of hydrolysis, all casein proteins clot to form a creamy precipitate, and whey proteins remain in the supernatant. We monitored the cheese-clotting reaction in real time using FTIR and analyzed the resulting evolution profiles to establish calibration models using parallel factor analysis and multiway partial least squares regression. Because we observed casein-specific kinetic changes, the retrieved models were independent of the chemical background matrix and were therefore robust against possible covariance effects. We tested the robustness of the models by spiking the milk solutions with whey, calcium, and cream. This method can be used at different stages in the dairy production chain to ensure the quality of the delivered milk. In particular, the cheese-making industry can benefit from such methods to optimize production control.

Collecting Validity Evidence for the Assessment of Mastery Learning in Simulation-Based Ultrasound Training.

PURPOSE: To collect validity evidence for the assessment of mastery learning on a virtual reality transabdominal ultrasound simulator. MATERIALS AND METHODS: We assessed the validity evidence using Messick's framework for validity. The study included 20 novices and 9 ultrasound experts who all completed 10 obstetric training modules on a transabdominal ultrasound simulator that provided automated measures of performance for each completed module (i. e., simulator metrics). Differences in the performance of the two groups were used to identify simulator metrics with validity evidence for the assessment of mastery learning. The novices continued to practice until they had attained mastery learning level. RESULTS: One-third of the simulator metrics discriminated between the two groups. The median simulator scores from a maximum of 40 metrics were 17.5 percent (range 0 - 45.0 percent) for novices and 90.0 percent (range 85.0 - 97.5) for experts, p < 0.001. Internal consistency was high, with a Cronbach's alpha value of 0.98. The test/retest reliability gave an intra-class correlation coefficient (ICC) of 0.62 for novices who reached the mastery learning level twice. Novices reached the mastery learning level within a median of 4 attempts (range 3 - 8) corresponding to a median of 252 minutes of simulator training (range 211 - 394 minutes). CONCLUSION: This study found that validity evidence for the assessment of mastery learning in simulation-based ultrasound training can be demonstrated and that ultrasound novices can attain mastery learning levels with less than 5 hours of training. Only one-third of the standard simulator metrics discriminated between different levels of competence.

Sustained effect of simulation-based ultrasound training on clinical performance: a randomized trial.

OBJECTIVE: To study the effect of initial simulation-based transvaginal sonography (TVS) training compared with clinical training only, on the clinical performance of residents in obstetrics and gynecology (Ob-Gyn), assessed 2 months into their residency. METHODS: In a randomized study, new Ob-Gyn residents (n = 33) with no prior ultrasound experience were recruited from three teaching hospitals. Participants were allocated to either simulation-based training followed by clinical training (intervention group; n = 18) or clinical training only (control group; n = 15). The simulation-based training was performed using a virtual-reality TVS simulator until an expert performance level was attained, and was followed by training on a pelvic mannequin. After 2 months of clinical training, one TVS examination was recorded for assessment of each resident's clinical performance (n = 26). Two ultrasound experts blinded to group allocation rated the scans using the Objective Structured Assessment of Ultrasound Skills (OSAUS) scale. RESULTS: During the 2 months of clinical training, participants in the intervention and control groups completed an average ± SD of 58 ± 41 and 63 ± 47 scans, respectively (P = 0.67). In the subsequent clinical performance test, the intervention group achieved higher OSAUS scores than did the control group (mean score, 59.1% vs 37.6%, respectively; P < 0.001). A greater proportion of the intervention group passed a pre-established pass/fail level than did controls (85.7% vs 8.3%, respectively; P < 0.001). CONCLUSION: Simulation-based ultrasound training leads to substantial improvement in clinical performance that is sustained after 2 months of clinical training. © 2015 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of performance measures and learning curves for use of a virtual-reality ultrasound simulator in transvaginal ultrasound examination.

OBJECTIVE: To assess the validity and reliability of performance measures, develop credible performance standards and explore learning curves for a virtual-reality simulator designed for transvaginal gynecological ultrasound examination. METHODS: A group of 16 ultrasound novices, along with a group of 12 obstetrics/gynecology (Ob/Gyn) consultants, were included in this experimental study. The first two performances of the two groups on seven selected modules on a high-fidelity ultrasound simulator were used to identify valid and reliable metrics. Performance standards were determined and novices were instructed to continue practicing until they attained the performance level of an expert subgroup (n = 4). RESULTS: All 28 participants completed the selected modules twice and all novices reached the expert performance level. Of 153 metrics, 48 were able to be used to discriminate between the two groups' performance. The ultrasound novices scored a median of 43.8% (range, 17.9-68.9%) and the Ob/Gyn consultants scored a median of 82.8% (range, 60.4-91.7%) of the maximum sum score (P < 0.001). The ultrasound novices reached the expert level (88.4%) within a median of five iterations (range, 5-6), corresponding to an average of 219 min (range, 150-251 min) of training. The test/retest reliability was high, with an intraclass correlation coefficient of 0.93. CONCLUSIONS: Competence in the performance of gynecological ultrasound examination can be assessed in a valid and reliable way using virtual-reality simulation. The novices' performance improved with practice and their learning curves plateaued at the level of expert performance, following between 3 and 4 h of simulator training.

Challenges in qualitative social pharmacy research: Reflections based on a conference workshop.

A methodological debate within social pharmacy is ongoing regarding how to apply a qualitative approach. This paper emanates from a workshop at the Nordic Social Pharmacy Conference in 2019, named 'How do we know it's good? A workshop on quality criteria in qualitative social and clinical pharmacy research', that addressed this debate. The aim of this paper is twofold (1) to present the main key points raised during the workshop and (2) based on these inputs to contribute to the ongoing discussion on qualitative methodology within social pharmacy research. This paper starts with what was discussed at the workshop and further elaborated are some of the challenges with conducting qualitative research within social pharmacy. These include methodological and disciplinary competence and insecurity, reflections on the consequences of that many social pharmacy researchers come from a natural science background and how this (possibly) shapes the practice of qualitative research within the field. For example, how concepts like transparency and saturation, together with checklists and quality criteria are understood and used. Finally, we make suggestions for the next step for qualitative research in social pharmacy.

Effects of text genre and verbal ability on adult age differences in sensitivity to text structure.

The present study examined the effects of verbal ability and text genre on adult age differences in sensitivity to the semantic structure of prose. Young and older adults of low or high verbal ability heard narrative and expository passages at different presentation rates. The results demonstrated that older adults recalled less than younger adults and that age differences in recall were larger for low-verbal adults and expository texts. However, subjects from all groups favored the main ideas in their recalls for both types of passages. The results indicated that adult age similarities in the ability to focus on the main ideas when processing prose was not compromised by the verbal ability of the subjects or the organization of the passages used. However, the results also demonstrate how the characteristics of the learner and the characteristics of the text modulate the size of the age differences observed.

Fluorescence of raw cane sugars evaluated by chemometrics.

In a fluorescence study of raw cane sugar samples, two-way and three-way chemometric methods have been used to extract information about the individual fluorophores in the sugar from fluorescence excitation-emission landscapes. A sample set of 47 raw sugar samples representing a varied selection was analyzed, and three individual fluorophores with (275, 350) nm, (340, 420) nm, and (390, 460) nm as their approximate excitation and emission maxima were found. The spectral profiles of the fluorophores were estimated with the three-way decomposition model PARAFAC. Two-way principal component analysis (PCA) of unfolded fluorescence landscapes confirmed the PARAFAC results and showed patterns of samples related to time of storage. Partial least squares (PLS) calibration models of color at 420 nm had a high model error due to the very high color range of the raw sugars, but variable selection performed on the fluorescence data revealed that all three fluorophores were correlated to color. The (275, 350) nm fluorophore is considered as a color precursor to the color developed on storage and the (340, 420) nm and (390, 460) nm fluorophores show colorant polymer characteristics.

Specific screening for color precursors and colorants in beet and cane sugar liquors in relation to model colorants using spectrofluorometry evaluated by HPLC and multiway data analysis.

A comparison was made of the fluorophores in beet thick juice and cane final evaporator syrup, which are comparable in the production of cane and beet sugar; that is, both represent the final stage of syrup concentration prior to crystallization of sugar. To further elucidate the nature of the color components in cane and beet syrup, a series of model colorants was also prepared, consisting of mildly alkaline-degraded fructose and glucose and two Maillard type colorants, glucose--glycine and glucose--lysine. Fluorescence excitation--emission landscapes resolved into individual fluorescent components with PARAFAC modeling were used as a screening method for colorants, and the method was validated with size exclusion chromatography using a diode array UV--vis detector. Fluorophores from the model colorants were mainly located at visible wavelengths. An overall similarity in chromatograms and absorption spectra of the four model colorant samples indicated that the formation of darker color was the distinguishing characteristic, rather than different reaction products. The fluorophores obtained from the beet and cane syrups consisted of color precursor amino acids in the UV wavelength region. Tryptophan was found in both beet and cane syrups. Tyrosine as a fluorophore was resolved in only beet syrup, reflecting the higher levels of amino acids in beet processing. In the visible wavelength region, cane syrup colorant fluorophores were situated at higher wavelengths than those of beet syrup, indicating formation of darker colorants. A higher level of invert sugar in cane processing compared to beet processing was suggested as a possible explanation for the darker colorants.

A multivariate chemometric approach to fluorescence spectroscopy.

A multivariate approach to the solution of problems often encountered in the spectrofluorometry of natural samples, utilising information from whole spectra is presented. (a) Piecewise direct standardisation is implemented and employed to transfer emission spectra measured with two different xenon lamps of different ages as if the spectra were measured with the same lamp. (b) It has been shown using a multivariate analysis approach that it is possible to use the raw data points instead of the smoothed data based on an algorithm included in the instrument software by the manufacturer. (c) It is documented that Raman scattering does not hamper the performance of multivariate calibration; on the contrary, in an experiment with sugar samples the concentration prediction errors become about five times lower by including the whole emission spectrum in the analysis instead of using a univariate calibration based on an emission wavelength that only reflects the analyte of interest. (d) An algorithm for variable selection is implemented and employed in the selection of optimal excitation wavelengths. Among 13 emission spectra recorded for a sugar sample at different excitation wavelengths, four of these are chosen that describe 98.51% of the total variance in the original data. (e) Finally the combination of fluorescence spectroscopy and multivariate calibration with conventional chemical data according to the near-infrared black box model is presented. The refined sugar quality parameter, the ash content and the fluorescence emission spectra are correlated by a partial least-squares regression model. Five experiments employing different monochromator slit widths and sugar concentrations are performed, and the best correlation obtained by full cross-validation of the 15 sugar samples is R = 0.98.

Spectrophotometric determination of mixtures of 2-, 3-, and 4-hydroxybenzaldehydes by flow injection analysis and uv/vis photodiode-array detection.

A multivariate approach to the quantitative determination of 2-hydroxybenzaldehyde (salicylaldehyde), 3-hydroxybenzaldehyde, and 4-hydroxybenzaldehyde in their mixtures is described. The method is based on second order data generated in a flow injection analysis system with a pH gradient and photodiode-array detection. Each injection gave rise to an 89 (times) x 101 (wavelength) matrix, containing both the acidic and the basic characteristics of the sample injected. A least-squares algorithm based on Lambert-Beers law was used for the prediction of concentrations in unknown samples. No assumptions concerning the qualitative mixture composition of the hydroxybenzaldehydes were necessary to perform concentration predictions. The following four data types were used in the least-squares modelling: (1) unfolded raw data, (2) acidic spectra, (3) basic spectra, and (4) first spectral derivative of the raw data. The prediction errors obtained were comparable to literature results. A graphic method, based on the model residuals for detecting erroneous samples, was developed.

Optimization of flow-injection systems for determination of substrates by means of enzyme amplification reactions and chemiluminescence detection.

A flow-injection system is described that incorporates a small column reactor containing two co-immobilized, synergistically operating oxidoreductases, allowing determination of minute amounts of substrates by means of enzyme amplification and subsequent chemiluminescence detection of the hydrogen peroxide generated in the repeated redox cycling. With lactate oxidase and lactate dehydrogenase, and taking advantage of the fact that the enzymatic degradation step and the ensuing detection step can be individually optimized, the FIA-system has been optimized by factorial experiments to yield an amplification factor of over 140 for each of the two substrates lactate and pyruvate. With a linear calibration range of 0-6muM, the limits of detection for the two species were 48 and 103nM, respectively, and the sampling rate was 50-60/hr. The optimized system has also been employed for assay of glucose by utilizing a column reactor with immobilized glucose oxidase and glucose dehydrogenase, but yielded amplification factors of only 3-4. The large discrepancy in the performance of the two enzyme systems is discussed.

The Fresno Asthma Project: a model intervention to control asthma in multiethnic, low-income, inner-city communities.

The Fresno Asthma Project targeted the entire low-income, inner-city, multiethnic population of Fresno, California. For 36 months following a 6-month planning phase, continuing education was provided to a high proportion of physicians, pharmacists, nurses/respiratory therapists, emergency medical technicians, school personnel, and allied health professionals involved in asthma care in Fresno, including virtually all those providing care/services to the target population. Small group patient education was made available and provided in age- and culturally appropriate formats to patients/families in clinics, hospitals, and schools. General and ethnic media and a Speakers Bureau were used to raise public awareness of asthma as a serious but controllable health problem. This community intervention model is particularly appropriate to multiethnic communities. It is relatively low cost (total direct costs were $140,000 per year), uses existing educational resources, and appears to have minimized counterproductive competition. Although morbidity and mortality trend data are not yet available to monitor program impact, penetration into the target community has been substantial: community physicians refer patients to asthma classes, asthma educator training is ongoing through the local American Lung Association chapter, hospitals and managed care systems serving low- income/MediCal patients offer asthma classes, and public schools and HeadStart are institutionalizing asthma awareness and self-management classes.

Analysis of polychlorinated dioxins and furans in samples of the toxic oil syndrome.

1 Polychlorinated dioxins (PCDDs) and furans (PCDFs) are known to produce a wide range of toxic effects. 2 PCDDs and PCDFs are typical contaminants of chlorinated phenols, and pentachlorophenol and related compounds have been shown to be widely distributed among selected oil samples taken from the 1981 Spanish toxic oil epidemic. 3 Six control and eight case oil samples were analysed using GC/MS for PCDDs and PCDFs. Only small concentrations, normally below 1 ng g-1, of the higher chlorinated PCDDs and PCDFs were detected. There were no statistical differences between the case and control oils. 4 These levels seem to be too low to elicit toxic effects, although they could be enough to potentiate the toxicity of other xenobiotics present in the oils. However, it is uncertain whether the levels of these compounds measured in 1990 reflect the levels present when the oils were consumed in 1981, or whether or not the levels measured in crude oils are representative of fried oils.

[Prolonged pregnancy. Labor induction versus intensified monitoring]. / Overbåren graviditet. Igangsaetning af fødsel kontra intensiveret overvågning.

This study was made in order to evaluate the effect of a policy of induction of labour at 42 weeks of gestation in post-term pregnancies. A group of 139 women with uncomplicated post-term pregnancies, who gave birth at the maternity ward at Herlev Hospital in 1993 was compared to a group of 145 women, who gave birth in 1996 at the same location. In 1993 spontaneous labour was awaited with twice weekly surveillance tests, and labour was only induced if there was evidence of foetal or maternal compromise, while in 1996 labour was induced at 42 weeks of gestation. There were at 20.1% inductions of labour in 1993 compared to 44.8% in 1996. The perinatal morbidity and birth complication rates were similar in the two groups.