Predominant approaches to measuring pregnancy-related anxiety in Sub-saharan Africa: a scoping review.

BACKGROUND: Pregnancy-related anxiety significantly impacts maternal and fetal health in low- and middle-income countries (LMICs), including those within Sub-Saharan Africa (SSA). Most studies conducted to evaluate pregnancy-related anxiety in LMICs have utilized scales developed in high-income countries, despite significant variations in pregnancy-related anxiety due to socioeconomic and cultural contexts. This review surveyed existing literature in order to identify which scales have been used to measure pregnancy-related anxiety in SSA. METHODS: A systematic search was conducted in PubMed, Health and Psychosocial Instruments, and APA PsycNet for relevant studies published in the English language up to March 22, 2023. Eligible studies focused on anxiety in pregnant populations within SSA, using validated scales or tools. Screening followed PRIMSA guidelines, with blinded review at the abstract/title level and subsequent full-text review. Data was extracted and analyzed to identify trends and characteristics of the screening tools used. RESULTS: From 271 articles, 37 met inclusion criteria, identifying 24 different tools used to measure anxiety in pregnant women in SSA. The most common tools were the Generalized Anxiety Disorder 7-item scale (seven uses), State-Trait Anxiety Inventory (five uses), and the Self-Reporting Questionnaire 20 (five uses). Seven tools were pregnancy-specific, with only two designed specifically for SSA: the Risk Factor Assessment (RFA), and the 4-Item Screening Tool. Studies were most frequently conducted in South Africa, followed by Tanzania, Ethiopia, Nigeria, and Ghana. CONCLUSIONS: This scoping review illustrates that only two tools (the RFA and 4-item Screening Tool) were created to assess pregnancy-related anxiety specifically in SSA. This highlights the need for more culturally sensitive tools tailored to the specific contexts of pregnant populations in SSA.

Evaluation of neuroretina following i.v. or intra-CSF AAV9 gene replacement in mice with MPS IIIA, a childhood dementia.

BACKGROUND: Sanfilippo syndrome (mucopolysaccharidosis type IIIA; MPS IIIA) is a childhood dementia caused by inherited mutations in the sulfamidase gene. At present, there is no treatment and children with classical disease generally die in their late teens. Intravenous or intra-cerebrospinal fluid (CSF) injection of AAV9-gene replacement is being examined in human clinical trials; evaluation of the impact on brain disease is an intense focus; however, MPS IIIA patients also experience profound, progressive photoreceptor loss, leading to night blindness. AIM: To compare the relative efficacy of the two therapeutic approaches on retinal degeneration in MPS IIIA mice. METHODS: Neonatal mice received i.v. or intra-CSF AAV9-sulfamidase or vehicle and after 20 weeks, biochemical and histological evaluation of neuroretina integrity was carried out. RESULTS: Both treatments improved central retinal thickness; however, in peripheral retina, outer nuclear layer thickness and photoreceptor cell length were only significantly improved by i.v. gene replacement. Further, normalization of endo-lysosomal compartment size and microglial morphology was only observed following intravenous gene delivery. CONCLUSIONS: Confirmatory studies are needed in adult mice; however, these data indicate that i.v. AAV9-sulfamidase infusion leads to superior outcomes in neuroretina, and cerebrospinal fluid-delivered AAV9 may need to be supplemented with another therapeutic approach for optimal patient quality of life.

"Nobody gave me information": Hospital experiences of Ghanaian families after maternal mortalities.

Background: Rates of maternal mortality are highest in low-resource settings. Family members are often involved in the critical periods surrounding a maternal death, including transportation to health centers and financial and emotional support during hospital admissions. Maternal death has devastating impacts on surviving family members, which are often overlooked and understudied. Objective: Our study aimed to explore the hospital experiences of family members surrounding a maternal death, and to define their access to and need for institutional and psychosocial support. Study Design: This mixed methods cross-sectional study was conducted at an urban tertiary hospital in Ghana. Maternal mortalities from June 2019 to December 2020 were identified using death certificates. Participants, defined as husbands or other heads of households in families affected by maternal mortality, were purposively recruited. An interview guide was developed using grounded theory. In-person semi-structured interviews were conducted in English or Twi to explore impacts of maternal mortality on family members, with a focus on hospital experiences. Surveys were administered on types of and needs for institutional support. Interviews were audio recorded, translated, transcribed, coded with an iteratively-developed codebook, and thematically analyzed. Survey data was descriptively analyzed. Results: Fifty-one participants included 26 husbands of the deceased woman, 5 parents, 12 siblings, and 8 second-degree relatives. Interviews revealed an overall negative hospital experience for surviving family members, who expressed substantial dissatisfaction and distress. Four themes regarding the hospital experience emerged from the interviews: 1) poor communication from healthcare workers and hospital personnel, which contributed to 2) limited understanding of the patient's clinical status, hospital course, and cause of death; 3) maternal death perceived as avoidable; and 4) maternal death perceived as unexpected and shocking. Survey data revealed that only 10% of participants were provided psychosocial support following the maternal death event, yet 93.3% of those who did not receive support desired this resource. Conclusion: The hospital experience was overall negative for family members and a lack of effective communication emerged as the root cause of this negative perception. Strategies to improve communication between healthcare providers and families are essential. In addition, there is an unmet need for formal mental health resources for families who experience a maternal death.

Respiratory Health Associated With Systemic Metal Exposure in Post-9/11 Veterans in the Department of Veterans Affairs Toxic Embedded Fragment Registry.

OBJECTIVE: Adverse respiratory outcomes in post-9/11 veterans with elevated urinary metal measures and enrolled in the VA's Toxic Embedded Fragment registry were compared to those without elevated urinary metals. METHODS: Veterans completed questionnaires, underwent pulmonary physiology tests (pulmonary function and oscillometry), and provided urine samples for analysis of 13 metals. Respiratory symptoms, diagnoses, and physiology measures were compared in veterans with ≥1 urine metal elevation to those without metal elevations, adjusted for covariates, including smoking. RESULTS: Among 402 study participants, 24% had elevated urine metals, often just exceeding upper limits of reference values. Compared to veterans without elevated metals, those with elevated metals had had higher FEV 1 values but similar frequencies of respiratory symptoms and diagnoses and abnormalities on pulmonary physiology tests. CONCLUSIONS: Mild systemic metal elevations in post-9/11 veterans are not associated with adverse respiratory health outcomes.

Mass spectrometry imaging protocol for spatial mapping of lipids, N-glycans and peptides in murine lung tissue.

RATIONALE: The application of matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI) to murine lungs is challenging due to the spongy nature of the tissue. Lungs consist of interconnected air sacs (alveoli) lined by a single layer of flattened epithelial cells, which requires inflation to maintain its natural structure. Therefore, a protocol that is compatible with both lung instillation and high spatial resolution is essential to enable multi-omic studies on murine lung disease models using MALDI-MSI. METHODS AND RESULTS: To maintain the structural integrity of the tissue, murine lungs were inflated with 8% (w/v) gelatin for lipid MSI of fresh frozen tissues or 4% (v/v) paraformaldehyde neutral buffer for N-glycan and peptide MSI of FFPE tissues. Tissues were sectioned and prepared for enzymatic digestion and/or matrix deposition. Glycerol-free PNGase F was applied for N-glycan MSI, while Trypsin Gold was applied for peptide MSI using the iMatrixSpray and ImagePrep Station, respectively. For lipid, N-glycan and peptide MSI, α-cyano-4-hydroxycinnamic acid matrix was deposited using the iMatrixSpray. MS data were acquired with 20 µm spatial resolution using a timsTOF fleX MS instrument followed by MS fragmentation of lipids, N-glycans and peptides. For lipid MSI, trapped ion mobility spectrometry was used to separate isomeric/isobaric lipid species. SCiLS™ Lab was used to visualize all MSI data. For analyte identification, MetaboScape®, GlycoMod and Mascot were used to annotate MS fragmentation spectra of lipids, N-glycans and tryptic peptides, respectively. CONCLUSIONS: Our protocol provides instructions on sample preparation for high spatial resolution MALDI-MSI, MS/MS data acquisition and lipid, N-glycan and peptide annotation and identification from murine lungs. This protocol will allow non-biased analyses of diseased lungs from preclinical murine models and provide further insight into disease models.

Mucopolysaccharidosis (MPS IIIA) mice have increased lung compliance and airway resistance, decreased diaphragm strength, and no change in alveolar structure.

Mucopolysaccharidosis type IIIA (MPS IIIA) is characterized by neurological and skeletal pathologies caused by reduced activity of the lysosomal hydrolase, sulfamidase, and the subsequent primary accumulation of undegraded heparan sulfate (HS). Respiratory pathology is considered secondary in MPS IIIA and the mechanisms are not well understood. Changes in the amount, metabolism, and function of pulmonary surfactant, the substance that regulates alveolar interfacial surface tension and modulates lung compliance and elastance, have been reported in MPS IIIA mice. Here we investigated changes in lung function in 20-wk-old control and MPS IIIA mice with a closed and open thoracic cage, diaphragm contractile properties, and potential parenchymal remodeling. MPS IIIA mice had increased compliance and airway resistance and reduced tissue damping and elastance compared with control mice. The chest wall impacted lung function as observed by an increase in airway resistance and a decrease in peripheral energy dissipation in the open compared with the closed thoracic cage state in MPS IIIA mice. Diaphragm contractile forces showed a decrease in peak twitch force, maximum specific force, and the force-frequency relationship but no change in muscle fiber cross-sectional area in MPS IIIA mice compared with control mice. Design-based stereology did not reveal any parenchymal remodeling or destruction of alveolar septa in the MPS IIIA mouse lung. In conclusion, the increased storage of HS which leads to biochemical and biophysical changes in pulmonary surfactant also affects lung and diaphragm function, but has no impact on lung or diaphragm structure at this stage of the disease.NEW & NOTEWORTHY Heparan sulfate storage in the lungs of mucopolysaccharidosis type IIIA (MPS IIIA) mice leads to changes in lung function consistent with those of an obstructive lung disease and includes an increase in lung compliance and airway resistance and a decrease in tissue elastance. In addition, diaphragm muscle contractile strength is reduced, potentially further contributing to lung function impairment. However, no changes in parenchymal lung structure were observed in mice at 20 wk of age.

Facilitators and barriers to home blood pressure monitoring among pregnant women in Ghana: a mixed-methods analysis of patient perspectives.

BACKGROUND: The benefit of home blood pressure monitoring during pregnancy and in low-resource settings is incompletely understood. The objective of this study was to explore the experiences, barriers, and facilitators of home blood pressure monitoring among pregnant women in Ghana. METHODS: This concurrent triangulation mixed-methods study was conducted at an urban tertiary hospital in Ghana. Participants were recruited from adult pregnant women presenting for routine antenatal care. Upon enrollment, participants' demographics and history were collected. At the next study visit, participants received audiovisual and hands-on training on using an automatic blood pressure monitor; they then monitored and logged their blood pressure daily at home for 2-4 weeks. At the final study visit, verbally administered surveys and semi-structured interviews assessed participant's experiences. Quantitative data were analyzed using R version 4.2.2, and frequencies and descriptive statistics were calculated. Qualitative data were imported into DeDoose 9.0.78 for thematic analysis. RESULTS: Of 235 enrolled participants, 194 completed surveys; of those, 33 completed in-depth interviews. Participants' mean age was 31.6 (SD 5.3) years, 32.1% had not previously given birth, and 31.1% had less than a senior high school education. On a 4-point Likert scale, the majority reported they "definitely" were able to remember (n = 134, 69.1%), could find the time (n = 124, 63.9%), had the energy (n = 157, 80.9%), could use the blood pressure monitor without problems (n = 155, 79.9%), and had family approval (n = 182, 96.3%) while engaging in home blood pressure monitoring. 95.88% (n = 186) believed that pregnant women in Ghana should monitor their blood pressure at home. Qualitative thematic analysis demonstrated that most participants liked home blood pressure monitoring because of increased knowledge of their health during pregnancy. While most participants found measuring their blood pressure at home doable, many faced challenges. Participants' experiences with five key factors influenced how easy or difficult their experience was: 1) Time, stress, and daily responsibilities; 2) Perceived importance of BP in pregnancy; 3) Role of family; 4) Capability of performing monitoring; 5) Convenience of monitoring. CONCLUSIONS: Among pregnant women in urban Ghana, home blood pressure monitoring was perceived as positive, important, and doable; however, challenges must be addressed.

"If You Need a Psychiatrist, It's BAD": Stigma Associated with Seeking Mental Health Care Among Obstetric Providers in Ghana.

Purpose: Globally, the COVID-19 pandemic has brought attention to the impact of negative patient outcomes on healthcare providers. In Ghana, obstetric providers regularly face maternal and neonatal mortality, yet limited research has focused on provision of mental health support for these providers. This study sought to understand how obstetric providers viewed seeking mental health support after poor clinical outcomes, with a focus on the role of mental health stigma. Patients and Methods: Participants were 52 obstetric providers (20 obstetrician/gynecologists and 32 midwives) at two tertiary care hospitals in Ghana. Five focus groups, led by a trained facilitator and lasting approximately two hours, were conducted to explore provider experiences and perceptions of support following poor maternal and neonatal outcomes. Discussions were audiotaped and transcribed verbatim, then analyzed qualitatively using grounded theory methodology. Results: Most participants (84.3%, N=43) were finished with training, and 46.2% (N=24) had been in practice more than 10 years. Emerging themes included pervasive stigma associated with seeking mental health care after experiencing poor clinical outcomes, which was derived from two overlapping dimensions. First, societal-level stigma resulted from a cultural norm to keep emotions hidden, and the perception that psychiatry is equated with severe mental illness. Second, provider-level stigma resulted from the belief that healthcare workers should not have mental health problems, a perception that mental health care is acceptable for patients but not for providers, and a fear about lack of confidentiality. Despite many providers acknowledging negative mental health impacts following poor clinical outcomes, these additive layers of stigma limited their willingness to engage in formal mental health care. Conclusion: This study demonstrates that stigma creates significant barriers to acceptance of mental health support among obstetric providers. Interventions to support providers will need to respect provider concerns without reinforcing the stigma associated with seeking mental health care.

Impact of antenatal care on severe maternal and neonatal outcomes in pregnancies complicated by preeclampsia and eclampsia in Ghana.

OBJECTIVES: To explore how specific measures of antenatal care utilization are associated with outcomes in pregnancies complicated by preeclampsia and eclampsia in Ghana. STUDY DESIGN: Participants were adult pregnant women with preeclampsia or eclampsia at a tertiary hospital in Ghana. Antenatal care utilization measures included timing of first visit, total visits, facility and provider type, and referral status. Antenatal visits were characterized by former and current World Health Organization recommendations, and by gestational age-based adequacy. MAIN OUTCOME MEASURES: Composites of maternal complications and poor neonatal outcomes. Multivariate logistic regressions identified associations with antenatal care factors. RESULTS: Among 1176 participants, median number of antenatal visits was 5.0 (IQR 3.0-7.0), with 72.9% attending ≥4 visits, 19.4% attending ≥8 visits, and 54.9% attending adequate visits adjusted for gestational age. Care was most frequently provided in a government polyclinic (n = 522, 47.2%) and by a midwife (n = 704, 65.1%). Odds of the composite maternal complications were lower in women receiving antenatal care at a tertiary hospital (aOR 0.47, p = 0.01). Odds of poor neonatal outcomes were lower in women receiving antenatal care at a tertiary hospital (aOR 0.56, p < 0.001), by a specialist Obstetrician/Gynecologist (aOR 0.58, p < 0.001), and who attended ≥8 visits (aOR 0.67, p = 0.04). Referred women had twice the odds of a maternal complication (aOR 2.12, p = 0.007) and poor neonatal outcome (aOR 1.68, p = 0.002). CONCLUSIONS: Fewer complications are seen after receiving antenatal care at tertiary facilities. Attending ≥8 visits reduced poor neonatal outcomes, but didn't impact maternal complications. Quality, not just quantity, of antenatal care is essential.

Close-kin mark-recapture informs critically endangered terrestrial mammal status.

Reliable information on population size is fundamental to the management of threatened species. For wild species, mark-recapture methods are a cornerstone of abundance estimation. Here, we show the first application of the close-kin mark-recapture (CKMR) method to a terrestrial species of high conservation value; the Christmas Island flying-fox (CIFF). The CIFF is the island's last remaining native terrestrial mammal and was recently listed as critically endangered. CKMR is a powerful tool for estimating the demographic parameters central to CIFF management and circumvents the complications arising from the species' cryptic nature, mobility, and difficult-to-survey habitat. To this end, we used genetic data from 450 CIFFs captured between 2015 and 2019 to detect kin pairs. We implemented a novel CKMR model that estimates sex-specific abundance, trend, and mortality and accommodates observations from the kin-pair distribution of male reproductive skew and mate persistence. CKMR estimated CIFF total adult female abundance to be approximately 2050 individuals (95% CI (950, 4300)). We showed that on average only 23% of the adult male population contributed to annual reproduction and strong evidence for between-year mate fidelity, an observation not previously quantified for a Pteropus species in the wild. Critically, our population estimates provide the most robust understanding of the status of this critically endangered population, informing immediate and future conservation initiatives.

Ability and accuracy of patient-performed blood pressure monitoring among pregnant women in urban Ghana.

BACKGROUND: Patient-performed blood pressure monitoring in pregnancy is rarely performed in low- and middle-income country settings, including Ghana. The clinical efficacy of home blood pressure monitoring relies on a pregnant patient being able to independently execute the correct steps to position and use a blood pressure monitor and to achieve accurate blood pressure measurements. OBJECTIVE: This study aimed to (1) assess whether pregnant women can correctly use an automatic blood pressure monitor to check their blood pressure before and after a brief training and (2) determine whether blood pressure values measured by pregnant women using an automatic monitor are similar to values measured by a healthcare provider using a standard clinic monitor. STUDY DESIGN: This was a cross-sectional study conducted at the Korle Bu Teaching Hospital, a tertiary hospital in Accra, Ghana. Participants were adult pregnant women presenting for their first prenatal care visit. Data collection was performed by 2 Ghanaian physicians. Information on demographics, obstetrical history, and past medical history was collected. A brief training was provided on the correct use of the blood pressure monitor, including a verbal script, annotated photographs, and a hands-on demonstration. Pre- and posttraining assessments using a 9-item checklist of correct preparation, position, and use of an automatic blood pressure monitor were performed. Following a modified British Hypertension Society protocol, a series of 4 blood pressure measurements were taken, alternating between provider performed using a clinic monitor and patient performed using an automatic monitor intended for individual use and validated in pregnancy. RESULTS: Among 176 participants, the mean age was 31.5 years (±5.6), and 130 (73.9%) were multiparous. Regarding socioeconomic characteristics, 128 (72.7%) were married, 171 (97.2%) had public insurance, and 87 (49.7%) had completed ≤9 years of formal education. Regarding clinical blood pressure issues, 19 (10.9%) had a history of a hypertensive disorder in a previous pregnancy, and 6 (3.4%) had chronic hypertension. Before receiving any training, 21 participants (12.1%) performed all 9 steps correctly to prepare, position, and use the automatic blood pressure monitor. Comparing pretraining vs posttraining ability, statistically significant increases were seen in the correct performance of each step and the mean number of steps performed correctly (6.1±1.8 vs 9.0±0.2, respectively; P<.001) and proportion performing all 9 steps correctly (12.1% vs 96.6%, respectively; P<.001). The mean difference between doctor-performed and patient-performed blood pressure measurements was 5.6±4.8 mm Hg for systolic blood pressure values and 3.4±3.08 mm Hg for diastolic blood pressure values, with most differences within 5 mm Hg for both systolic blood pressure values (102/176 [58.0%]) and diastolic blood pressure values (141/176 [80.1%]). CONCLUSION: After a brief training, pregnant women in Ghana demonstrated that they are able to use an automatic blood pressure monitor to check their blood pressure correctly and accurately.

Implications of past and present genetic connectivity for management of the saltwater crocodile (Crocodylus porosus).

Effective management of protected species requires information on appropriate evolutionary and geographic population boundaries and knowledge of how the physical environment and life-history traits combine to shape the population structure and connectivity. Saltwater crocodiles (Crocodylus porosus) are the largest and most widely distributed of living crocodilians, extending from Sri Lanka to Southeast Asia and down to northern Australia. Given the long-distance movement capabilities reported for C. porosus, management units are hypothesised to be highly connected by migration. However, the magnitude, scale, and consistency of connection across managed populations are not fully understood. Here we used an efficient genotyping method that combines DArTseq and sequence capture to survey ≈ 3000 high-quality genome-wide single nucleotide polymorphisms from 1176 C. porosus sampled across nearly the entire range of the species in Queensland, Australia. We investigated historical and present-day connectivity patterns using fixation and diversity indices coupled with clustering methods and the spatial distribution of kin pairs. We inferred kinship using forward simulation coupled with a kinship estimation method that is robust to unspecified population structure. The results demonstrated that the C. porosus population has substantial genetic structure with six broad populations correlated with geographical location. The rate of gene flow was highly correlated with spatial distance, with greater differentiation along the east coast compared to the west. Kinship analyses revealed evidence of reproductive philopatry and limited dispersal, with approximately 90% of reported first and second-degree relatives showing a pairwise distance of <50 km between sampling locations. Given the limited dispersal, lack of suitable habitat, low densities of crocodiles and the high proportion of immature animals in the population, future management and conservation interventions should be considered at regional and state-wide scales.

Challenges to diagnosing and managing preeclampsia in a low-resource setting: A qualitative study of obstetric provider perspectives from Ghana.

Preeclampsia is a leading cause of global maternal morbidity and mortality. The greatest burden of disease is in low- and middle-income countries where healthcare providers face significant, understudied, challenges to diagnosing and managing preeclampsia. This qualitative study used semi-structured interviews to explore the challenges of diagnosing and managing preeclampsia from the perspectives of obstetric doctors. Participants were doctors who provide obstetric care at the Korle Bu Teaching Hospital, an urban tertiary hospital in Ghana. Purposive sampling identified doctors with meaningful experience in managing patients with preeclampsia. Thematic saturation of data was used to determine sample size. Interviews were audio recorded, transcribed verbatim, coded using an iteratively-developed codebook, and thematically analyzed. Interviews were conducted with 22 participants, consisting of 4 house officers, 6 junior obstetrics/gynecology residents, 8 senior obstetrics/gynecology residents, and 4 obstetrics/gynecology consultants. Doctors identified critical challenges faced at the patient, provider, and systems levels in detecting and managing preeclampsia, each of which mediates the health outcomes of a pregnancy complicated by preeclampsia. Challenges centered around three overarching global themes: (1) low education levels and health literacy among women, (2) insufficient number of healthcare providers highly trained in obstetric care, and (3) inadequate health infrastructure to support critically ill patients with preeclampsia. Recognizing and addressing root challenges to preeclampsia care has great potential to improve outcomes in pregnancies complicated by preeclampsia in low-resource settings.

Benefits and barriers of home blood pressure monitoring in pregnancy: perspectives of obstetric doctors from a Ghanaian tertiary hospital.

BACKGROUND: Delayed diagnosis of preeclampsia contributes to maternal morbidity and mortality. Patient-performed home blood pressure monitoring facilitates more frequent monitoring and earlier diagnosis. However, challenges may exist to implementation in low- and middle income-countries. METHODS: This cross-sectional mixed methods study evaluated obstetric doctors' perspectives on the benefits of and barriers to the implementation of home blood pressure monitoring among pregnant women in Ghana. Participants were doctors providing obstetric care at Korle Bu Teaching Hospital. Electronic surveys were completed by 75 participants (response rate 49.3%), consisting of demographics and questions on attitudes and perceived benefits and challenges of home BP monitoring. Semi-structured interviews were completed by 22 participants to expand on their perspectives. RESULTS: Quantitative and qualitative results converged to highlight that the current state of blood pressure monitoring among pregnant women in Ghana is inadequate. The majority agreed that delayed diagnosis of preeclampsia leads to poor health outcomes in their patients (90.6%, n = 68) and earlier detection would improve outcomes (98.7%, n = 74). Key qualitative benefits to the adoption of home blood pressure monitoring were patient empowerment and trust of diagnosis, more quantity and quality of blood pressure data, and improvement in systems-level efficiency. The most significant barriers were the cost of monitors, lack of a communication system to convey abnormal values, and low health literacy. Overall, doctors felt that most barriers could be overcome with patient education and counseling, and that benefits far outweighed barriers. The majority of doctors (81.3%, n = 61), would use home BP data to inform their clinical decisions and 89% (n = 67) would take immediate action based on elevated home BP values. 91% (n = 68) would recommend home BP monitoring to their pregnant patients. CONCLUSION: Obstetric doctors in Ghana strongly support the implementation of home blood pressure monitoring, would use values to inform their clinical management, and believe it would improve patient outcomes. Addressing the most significant barriers, including cost of blood pressure monitors, lack of a communication system to convey abnormal values, and need for patient education, is essential for successful implementation.

Aberrant protein expression of Appl1, Sortilin and Syndecan-1 during the biological progression of prostate cancer.

Diagnosis and assessment of patients with prostate cancer is dependent on accurate interpretation and grading of histopathology. However, morphology does not necessarily reflect the complex biological changes occurring in prostate cancer disease progression, and current biomarkers have demonstrated limited clinical utility in patient assessment. This study aimed to develop biomarkers that accurately define prostate cancer biology by distinguishing specific pathological features that enable reliable interpretation of pathology for accurate Gleason grading of patients. Online gene expression databases were interrogated and a pathogenic pathway for prostate cancer was identified. The protein expression of key genes in the pathway, including adaptor protein containing a pleckstrin homology (PH) domain, phosphotyrosine-binding (PTB) domain, and leucine zipper motif 1 (Appl1), Sortilin and Syndecan-1, was examined by immunohistochemistry (IHC) in a pilot study of 29 patients with prostate cancer, using monoclonal antibodies designed against unique epitopes. Appl1, Sortilin, and Syndecan-1 expression was first assessed in a tissue microarray cohort of 112 patient samples, demonstrating that the monoclonal antibodies clearly illustrate gland morphologies. To determine the impact of a novel IHC-assisted interpretation (the utility of Appl1, Sortilin, and Syndecan-1 labelling as a panel) of Gleason grading, versus standard haematoxylin and eosin (H&E) Gleason grade assignment, a radical prostatectomy sample cohort comprising 114 patients was assessed. In comparison to H&E, the utility of the biomarker panel reduced subjectivity in interpretation of prostate cancer tissue morphology and improved the reliability of pathology assessment, resulting in Gleason grade redistribution for 41% of patient samples. Importantly, for equivocal IHC-assisted labelling and H&E staining results, the cancer morphology interpretation could be more accurately applied upon re-review of the H&E tissue sections. This study addresses a key issue in the field of prostate cancer pathology by presenting a novel combination of three biomarkers and has the potential to transform clinical pathology practice by standardising the interpretation of the tissue morphology.

Maternal Mortality in Low and Middle-Income Countries.

Despite a 38% decrease in global maternal mortality during the last decade, rates remain unacceptably high with greater than 800 maternal deaths occurring each day. There exists significant regional variation among rates and causes of maternal mortality, and the vast majority occurs in low-income and middle-income countries. The leading causes of direct maternal mortality are hemorrhage, hypertensive disorders of pregnancy, sepsis, complications of abortion, and thromboembolism. Eliminating preventable maternal mortality hinges on improving clinical management of these life-threatening obstetric conditions, as well as addressing the complex social and economic barriers that pregnant women face to access quality care.