Reviewing past and present consent practices in unplanned obstetric interventions: an eye towards the future.

Many first-time mothers (primiparous) within UK National Health Service (NHS) settings require an obstetric intervention to deliver their babies safely. While the antepartum period allows time for conversations about consent for planned interventions, such as elective caesarean section, current practice is that, in emergencies, consent is addressed in the moments before the intervention takes place. This paper explores whether there are limitations on the validity of consent offered in time-pressured and emotionally charged circumstances, specifically concerning emergency obstetric interventions. Using the legal framework of the Mental Capacity Act, Montgomery v. Lanarkshire Health Board (2015) and McCulloch v Forth Valley Health Board (2023), we argue that while women have the capacity to consent during labour, their autonomy is best supported by providing more information about instrumental delivery (ID) during the antepartum period. This conclusion is supported by some national guidelines, including those developed by the Royal College of Obstetricians and Gynaecologists, but not all. Further, we examine the extent to which these principles are upheld in modern-day practice. Data suggest there is relatively little antepartum information provision regarding ID within NHS settings, and that primiparous women do not report a thorough understanding of ID before labour. Based on these results, and bearing in mind the pressures under which NHS obstetric services currently operate, we recommend further research into patient and clinician perceptions of the consent process for ID. Pending these results, we discuss possible modes of information delivery in future practice.

Birth "outside of guidance"-An exploration of a Birth Choices Clinic in the United Kingdom.

BACKGROUND: Decision-making around birthplace is complex and multifactorial. The role of clinicians is to provide unbiased, evidence-based information to support women and birthing people to make decisions based on what matters to them. Some decisions may fall outside of clinical guidance and recommendations. Birth Choices Clinics can provide an opportunity for extended discussion and personalized birthplace planning. This study aimed to explore the rationale behind choosing birthplace "outside of guidance" and examine the outcomes for women who attended a Birth Choices Clinic. METHODS: The study was descriptive using data extracted from clinical documentation and consultation. The data included demographic information, maternal characteristics, reason for choosing a midwifery-led birth setting, birthplace preference, and outcome. RESULTS: Eighty-two women used the Birth Choices Clinic between April 2022 and February 2023 in one large maternity unit in the UK. Reasons for choosing birth in a midwifery-led setting included having access to a birthing pool, to reduce the chance of obstetric interventions and pragmatic reasons. Sixty-five percent of women experienced a spontaneous vaginal birth, 10% experienced an assisted vaginal birth, and 23% experienced a cesarean birth. Of the 33 women who ultimately commenced labor care in a midwifery-led setting, 76% (n = 25/33) birthed in this setting without complications. Transfer rates in labor were similar to those in a "low-risk" pregnant population. DISCUSSION: Birth choice clinics may facilitate an understanding of material risk and support individualizing birth planning. There is evidence that women changed their planned birthplace, possibly in recognition of a move along the risk spectrum.

Impact of a resident and student-led video visitation navigation program.

BACKGROUND: Many institutions implemented telehealth initiatives to provide social support for patients during the SARS-CoV-2 (COVID-19) pandemic. Little is known about the impact of these programs on patient support persons and the trainees who facilitated them. OBJECTIVE: To assess perceptions of a resident physician and medical student-driven video visit program. METHODS: We designed and implemented a trainee-led video visit navigation program across three affiliated urban hospitals to facilitate video visits between patients and their support persons. We used descriptive statistics to understand the patient population served by the program and employed surveys for support persons and trainees to assess attitudes on the program. RESULTS: From April to June 2020, a total of 443 video visits were completed. Surveys were conducted for 101 out of 184 (54.9%) support persons and 39 out of 65 (60.0%) of medical trainees. Surveys demonstrated that video visits helped alleviate the stress and anxiety of support persons having a hospitalized loved one they could not visit. For trainees, facilitating these connections helped mitigate stress and provided a mechanism to contribute to the pandemic response. CONCLUSION: Telehealth navigation programs provide high levels of connection for patients and their support persons during the COVID-19 pandemic and potentially beyond. Residents and medical students involved in these initiatives mobilized telehealth modalities to improve experiences with care delivery.

Increased endothelial sclerostin caused by elevated DSCAM mediates multiple trisomy 21 phenotypes.

Trisomy 21 (T21), a recurrent aneuploidy occurring in 1:800 births, predisposes to congenital heart disease (CHD) and multiple extracardiac phenotypes. Despite a definitive genetic etiology, the mechanisms by which T21 perturbs development and homeostasis remain poorly understood. We compared the transcriptome of CHD tissues from 49 patients with T21 and 226 with euploid CHD (eCHD). We resolved cell lineages that misexpressed T21 transcripts by cardiac single-nucleus RNA sequencing and RNA in situ hybridization. Compared with eCHD samples, T21 samples had increased chr21 gene expression; 11-fold-greater levels (P = 1.2 × 10-8) of SOST (chr17), encoding the Wnt inhibitor sclerostin; and 1.4-fold-higher levels (P = 8.7 × 10-8) of the SOST transcriptional activator ZNF467 (chr7). Euploid and T21 cardiac endothelial cells coexpressed SOST and ZNF467; however, T21 endothelial cells expressed 6.9-fold more SOST than euploid endothelial cells (P = 2.7 × 10-27). Wnt pathway genes were downregulated in T21 endothelial cells. Expression of DSCAM, residing within the chr21 CHD critical region, correlated with SOST (P = 1.9 × 10-5) and ZNF467 (P = 2.9 × 10-4). Deletion of DSCAM from T21 endothelial cells derived from human induced pluripotent stem cells diminished sclerostin secretion. As Wnt signaling is critical for atrioventricular canal formation, bone health, and pulmonary vascular homeostasis, we concluded that T21-mediated increased sclerostin levels would inappropriately inhibit Wnt activities and promote Down syndrome phenotypes. These findings imply therapeutic potential for anti-sclerostin antibodies in T21.

Outcomes among adult survivors of total cavopulmonary Fontan palliation for single ventricle.

OBJECTIVE: This tertiary centre study aims to identify factors associated with adverse outcomes in adult survivors with total cavopulmonary connection (TCPC) Fontan palliation for single ventricle. METHODS: This retrospective review of medical records identified adult (≥18 years) survivors of TCPC Fontan palliation who were followed at a single tertiary centre between 1 January 2000 and 1 July 2019. Adverse outcomes were defined as arrhythmia, pacemaker/implantable cardioverter defibrillator placement, liver cirrhosis, protein losing enteropathy, hospitalisation for heart failure, thromboembolic complication and/or death. RESULTS: 160 adult TCPC patients met the inclusion criteria: 117 (73.1%) extracardiac and 43 (26.9%) lateral tunnel. The median (IQR) duration of follow-up since TCPC palliation was 17.5 (11.8-21.3) years. An adverse outcome occurred in 87 (54.4%) patients. Adverse outcome-free survival rates at 10, 20 and 25 years post TCPC were 89% (95% CI 82% to 93%), 60% (95% CI 50% to 69%) and 24% (95% CI 15% to 35%), respectively. On multivariate analysis, extracardiac Fontan (HR 2.21, 95% CI 1.20 to 4.08, p=0.011) was observed to be an independent risk factor for adverse outcomes after adjusting for age, race, morphology of the systemic ventricle and history of fenestration. CONCLUSIONS: In this single-centre retrospective study of adult survivors of TCPC palliation, extracardiac Fontan was associated with an increased hazard for adverse outcomes. This finding could guide clinicians in developing risk modification strategies and management decisions to improve long-term outcomes in these patients.

Renal Recovery and Mortality Risk among Patients with Hepatorenal Syndrome Receiving Chronic Maintenance Dialysis.

Background: Kidney replacement therapy is controversial for patients with hepatorenal syndrome who may not be liver transplant candidates. Data surrounding the likelihood of recovery of kidney function and mortality after outpatient dialysis initiation in patients with dialysis-requiring hepatorenal syndrome could inform discussions between patients and providers. Methods: We performed a retrospective cohort study of patients with hepatorenal syndrome who were registered in the United States Renal Data System between 1996 and 2015 (n=7830) as receiving maintenance dialysis. We characterized patients with hepatorenal syndrome by recovery of kidney function using Fine and Gray models. We also examined hazard of recovery of kidney function and death among those with hepatorenal syndrome versus those with acute tubular necrosis (n=48,861) using adjusted Fine-Gray and Cox models, respectively. Results: Of the patients with hepatorenal syndrome, 11% recovered kidney function. Those with higher likelihood of recovery were younger, non-Hispanic White, and had a history of alcohol use. Compared with patients with acute tubular necrosis, patients with hepatorenal syndrome as the attributed cause of kidney disease had a lower hazard of recovery (HR, 0.22; 95% CI, 0.21 to 0.24) and higher hazard of death within 1 year (HR, 3.10; 95% CI, 2.99 to 3.23) in fully adjusted models. Conclusions: Patients with hepatorenal syndrome receiving chronic maintenance dialysis had a lower likelihood of recovery of kidney function and higher mortality risk compared with patients with acute tubular necrosis. Among patients with hepatorenal syndrome, those most likely to recover kidney function were younger, had a history of alcohol use, and lacked comorbid conditions. These data may inform prognosis and discussions surrounding treatment options when patients with hepatorenal syndrome need chronic maintenance dialysis therapy.

Lessons From Learners: Adapting Medical Student Education During and Post COVID-19.

In response to the COVID-19 pandemic, many medical schools suspended clinical clerkships and implemented newly adapted curricula to facilitate continued educational progress. While the implementation of these new curricula has been described, an understanding of the impact on student learning outcomes is lacking. In 2020, the authors followed Kern's 6-step approach to curricular development to create and evaluate a novel COVID-19 curriculum for medical students at the University of California San Francisco School of Medicine and evaluate its learning outcomes. The primary goal of the curriculum was to provide third- and fourth-year medical students an opportunity for workplace learning in the absence of clinical clerkships, specifically for students to develop clerkship-level milestones in the competency domains of practice-based learning and improvement, professionalism, and systems-based practice. The curriculum was designed to match students with faculty-mentored projects occurring primarily in virtual formats. A total of 126 students enrolled in the curriculum and completed a survey about their learning outcomes (100% response rate). Of 35 possible clerkship-level milestones, there were 12 milestones for which over half of students reported development in competency domains including practice-based learning and improvement, professionalism, and interpersonal and communication skills. Thematic analysis of students' qualitative survey responses demonstrated 2 central motivations for participating in the curriculum: identity as physicians-in-training and patient engagement. Six central learning areas were developed during the curriculum: interprofessional teamwork, community resources, technology in medicine, skill-building, quality improvement, and specialty-specific learning. This analysis demonstrates that students can develop competencies and achieve rich workplace learning through project-based experiential learning, even in virtual clinical workplaces. Furthermore, knowledge of community resources, technology in medicine, and quality improvement was developed through the curriculum more readily than in traditional clerkships. These could be considered as integral learning objectives in future curricular design.

Circadian regulation of mitochondrial uncoupling and lifespan.

Because old age is associated with defects in circadian rhythm, loss of circadian regulation is thought to be pathogenic and contribute to mortality. We show instead that loss of specific circadian clock components Period (Per) and Timeless (Tim) in male Drosophila significantly extends lifespan. This lifespan extension is not mediated by canonical diet-restriction longevity pathways but is due to altered cellular respiration via increased mitochondrial uncoupling. Lifespan extension of per mutants depends on mitochondrial uncoupling in the intestine. Moreover, upregulated uncoupling protein UCP4C in intestinal stem cells and enteroblasts is sufficient to extend lifespan and preserve proliferative homeostasis in the gut with age. Consistent with inducing a metabolic state that prevents overproliferation, mitochondrial uncoupling drugs also extend lifespan and inhibit intestinal stem cell overproliferation due to aging or even tumorigenesis. These results demonstrate that circadian-regulated intestinal mitochondrial uncoupling controls longevity in Drosophila and suggest a new potential anti-aging therapeutic target.

Healthcare professionals' attitudes, knowledge and self-efficacy levels regarding the use of self-hypnosis in childbirth: A prospective questionnaire survey.

OBJECTIVE: to examine healthcare professionals' attitudes, knowledge and levels of self-efficacy regarding the use of self-hypnosis in childbirth. DESIGN: a prospective survey. SETTING: two large maternity units in London, England. PARTICIPANTS: healthcare professionals (n=129) involved in the care of childbearing women (anaesthetists, midwives and obstetricians). METHODS: online questionnaire assessing healthcare professionals' experience, knowledge, attitudes and self-efficacy relating to self-hypnosis in childbirth. MAIN OUTCOME MEASURES: attitude, self-efficacy and knowledge. FINDINGS: over half of the participants surveyed (56%) reported they had minimal or no knowledge of hypnosis. Higher levels of knowledge were associated with higher levels of self-efficacy (p<0.001) and also with more positive attitudes (p<.001). Midwives reported significantly higher levels of knowledge, more positive attitudes (7.25, 95% CI: 4.60-9.89) and higher levels of self-efficacy (3.48, 95% CI: 1.46-5.51) than doctors. Midwives also reported more exposure to/experience of hypnosis than doctors, and more exposure was significantly associated with higher levels of self-efficacy (midwives p<.001; doctors p=.001). Professionals who would plan to use self-hypnosis in their own or partners' births had significantly higher self-efficacy scores (p<.001). KEY CONCLUSIONS: if healthcare professionals are to effectively support women using self-hypnosis in childbirth, they need to be confident in their ability to facilitate this method. Previous research has established that self-efficacy is a strong indicator of performance. IMPLICATIONS FOR PRACTICE: Professionals with more knowledge of self-hypnosis are also more confident in supporting women using this technique in childbirth. Multi-disciplinary staff training which aims to increase knowledge, and which includes exposure to hypnosis in labour, may be beneficial in assisting staff to support women choosing to use self-hypnosis in labour.

A Drosophila model of Fragile X syndrome exhibits defects in phagocytosis by innate immune cells.

Fragile X syndrome, the most common known monogenic cause of autism, results from the loss of FMR1, a conserved, ubiquitously expressed RNA-binding protein. Recent evidence suggests that Fragile X syndrome and other types of autism are associated with immune system defects. We found that Drosophila melanogaster Fmr1 mutants exhibit increased sensitivity to bacterial infection and decreased phagocytosis of bacteria by systemic immune cells. Using tissue-specific RNAi-mediated knockdown, we showed that Fmr1 plays a cell-autonomous role in the phagocytosis of bacteria. Fmr1 mutants also exhibit delays in two processes that require phagocytosis by glial cells, the immune cells in the brain: neuronal clearance after injury in adults and the development of the mushroom body, a brain structure required for learning and memory. Delayed neuronal clearance is associated with reduced recruitment of activated glia to the site of injury. These results suggest a previously unrecognized role for Fmr1 in regulating the activation of phagocytic immune cells both in the body and the brain.