Gestational diabetes in twin pregnancies-a pathology requiring treatment or a benign physiological adaptation?

There is level-1 evidence that screening for and treating gestational diabetes in singleton pregnancies reduce maternal and neonatal morbidity. However, similar data for gestational diabetes in twin pregnancies are currently lacking. Consequently, the current approach for the diagnosis and management of gestational diabetes in twin pregnancies is based on the same diagnostic criteria and glycemic targets used in singleton pregnancies. However, twin pregnancies have unique physiological characteristics, and many of the typical gestational diabetes-related complications are less relevant for twin pregnancies. These differences raise the question of whether the greater increase in insulin resistance observed in twin pregnancies (which is often diagnosed as diet-treated gestational diabetes) should be considered physiological and potentially beneficial in which case alternative criteria should be used for the diagnosis of gestational diabetes in twin pregnancies. In this review, we summarize the most up-to-date evidence on the epidemiology, pathophysiology, and clinical consequences of gestational diabetes in twin pregnancies and review the available data on twin-specific screening and diagnostic criteria for gestational diabetes. Although twin pregnancies are associated with a higher incidence of diet-treated gestational diabetes, diet-treated gestational diabetes in twin pregnancies is less likely to be associated with adverse outcomes and accelerated fetal growth than in singleton pregnancies and may reduce the risk for intrauterine growth restriction. In addition, there is currently no evidence that treatment of diet-treated gestational diabetes in twin pregnancies improves outcomes, whereas preliminary data suggest that strict glycemic control in such cases might increase the risk for intrauterine growth restriction. Overall, these findings provide support to the hypothesis that the greater transient increase in insulin resistance observed in twin pregnancies is merely a physiological exaggeration of the normal increase in insulin resistance observed in singleton pregnancies (that is meant to support 2 fetuses) rather than a pathology that requires treatment. These data illustrate the need to develop twin-specific screening and diagnostic criteria for gestational diabetes to avoid overdiagnosis of gestational diabetes and to reduce the risks associated with overtreatment of diet-treated gestational diabetes in twin pregnancies. Although data on twin-specific screening and diagnostic criteria are presently scarce, preliminary data suggest that the optimal screening and diagnostic criteria in twin pregnancies are higher than those currently used in singleton pregnancies.

Plasma soluble fms-like tyrosine kinase 1 to placental growth factor ratio of 11.5 multiples of median predicts preeclampsia with severe features within 2 weeks of testing.

BACKGROUND: Angiogenic imbalances, characterized by an excess of antiangiogenic factors (soluble fms-like tyrosine kinase 1) and reduced angiogenic factors (vascular endothelial growth factor and placental growth factor), contribute to the mechanisms of disease in preeclampsia. The ratio of soluble fms-like tyrosine kinase 1 to placental growth factor has been used as a biomarker for preeclampsia, but the cutoff values may vary with gestational age and assay platform. OBJECTIVE: This study aimed to compare multiples of the median of the maternal plasma soluble fms-like tyrosine kinase 1 to placental growth factor ratio, soluble fms-like tyrosine kinase 1, placental growth factor, and conventional clinical and laboratory values in their ability to predict preeclampsia with severe features. STUDY DESIGN: We conducted a cohort study across 18 United States centers involving hospitalized individuals with hypertension between 23 and 35 weeks' gestation. Receiver operating characteristic curve analyses of maternal plasma biomarkers, highest systolic or diastolic blood pressures, and laboratory values at enrollment were performed for the prediction of preeclampsia with severe features. The areas under the curve were compared, and quasi-Poisson regression models were fitted to estimate relative risks. The primary outcome was preeclampsia with severe features within 2 weeks of enrollment. Secondary outcomes were a composite of severe adverse maternal outcomes (elevated liver enzymes, low platelets count, placental abruption, eclampsia, disseminated intravascular coagulation, and pulmonary edema) and a composite of severe adverse perinatal outcomes (birth weight below the third percentile, very preterm birth [<32 weeks' gestation], and fetal or neonatal death). RESULTS: Of the 543 individuals included in the study, preeclampsia with severe features within 2 weeks was observed in 33.1% (n=180) of them. A receiver operating characteristic curve-derived cutoff of 11.5 multiples of the median for the soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio provided good sensitivity (90.6%), specificity (76.9%), positive predictive value (66.0%), negative predictive value (94.3%), positive likelihood ratio (3.91), negative likelihood ratio (0.12), and accuracy (81.4%) for preeclampsia with severe features within 2 weeks. This cutoff was used to compare test positive cases (≥ cutoff) and test negative cases (< cutoff). Preeclampsia with severe features (66.0% vs 5.7%; P<.001) and composites of severe adverse maternal (8.11% vs 2.7%; P=.006) or perinatal (41.3% vs 10.14%; P=.001) outcomes within 2 weeks were more frequent in test positive cases than in test negative cases. A soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio ≥11.5 multiples of the median was independently associated with preeclampsia with severe features (adjusted incidence rate ratio, 9.08; 95% confidence interval, 6.11-14.06; P<.001) and a composite of severe adverse perinatal outcomes (adjusted incidence rate ratio, 9.42; 95% confidence interval, 6.36-14.53; P<.001) but not with a composite of severe adverse maternal outcomes (adjusted incidence rate ratio, 2.20; 95% confidence interval, 0.95-5.54; P=.08). The area under the curve for the soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio in multiples of the median (0.91; 95% confidence interval, 0.89-0.94) for preeclampsia with severe features within 2 weeks was significantly higher (P<.001 for all comparisons) than either plasma biomarker alone or any other parameter with the exception of absolute soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio values. CONCLUSION: A soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio ≥11.5 multiples of the mean among hospitalized patients with hypertension between 23 and 35 week's gestation predicts progression to preeclampsia with severe features and severe adverse perinatal outcomes within 2 weeks.

A data-driven approach to multiple-stressor impact assessment for a marine protected area.

The coastal environment is not managed in a way that considers the impact of cumulative threats, despite being subject to threats from all realms (marine, land, and atmosphere). Relationships between threats and species are often nonlinear; thus, current (linear) approaches to estimating the impact of threats may be misleading. We developed a data-driven approach to assessing cumulative impacts on ecosystems and applied it to explore nonlinear relationships between threats and a temperate reef fish community. We used data on water quality, commercial fishing, climate change, and indicators of recreational fishing and urbanization to build a cumulative threat map of the northern region in New South Wales, Australia. We used statistical models of fish abundance to quantify associations among threats and biophysical covariates and predicted where cumulative impacts are likely to have the greatest impact on fish. We also assessed the performance of no-take zones (NTZs), to protect fish from cumulative threats across 2 marine protected area networks (marine parks). Fishing had a greater impact on fish than water quality threats (i.e., percent increase above the mean for invertivores was 337% when fishing was removed and was 11% above the mean when water quality was removed inside NTZs), and fishing outside NTZs affected fish abundances inside NTZs. Quantifying the spatial influence of multiple threats enables managers to understand the multitude of management actions required to address threats.

Una estrategia basada en datos para la evaluación de impacto de múltiples estresores en un área marina protegida Resumen Los ambientes costeros no se manejan de manera que se considere el impacto de las amenazas acumulativas, a pesar de que se enfrentan a amenazas de todos los entornos (marinas, terrestres y atmosféricas). Las relaciones entre las amenazas y las especies casi siempre son no lineales; por lo tanto, las estrategias actuales (lineales) para estimar el impacto de las amenazas pueden ser engañosas. Desarrollamos una estrategia basada en datos para evaluar el impacto acumulativo sobre los ecosistemas y la aplicamos para explorar las relaciones no lineales entre las amenazas y la comunidad de peces de arrecifes templados. Usamos datos de la calidad del agua, pesca comercial, cambio climático e indicadores de pesca recreativa y urbanización para construir un mapa acumulativo de amenazas de la región norte de Nueva Gales del Sur, Australia. Usamos modelos estadísticos de la abundancia de peces para cuantificar las asociaciones entre las amenazas y las covarianzas biofísicas y pronosticamos en dónde es probable que los impactos acumulativos sean mayores sobre los peces. También evaluamos el desempeño de las zonas de veda para así proteger a los peces de las amenazas acumulativas en dos redes de áreas marinas protegidas (parques marinos). La pesca tuvo un mayor impacto que la calidad del agua sobre los peces (es decir, el incremento del porcentaje por encima de la media de depredadores de invertebrados fue de 337% cuando se eliminó la pesca y fue de 11% por encima de la media cuando se eliminó la calidad del agua dentro de las zonas de veda) y la pesca fuera de las zonas de veda afectó la abundancia de los peces dentro de ellas. La cuantificación de la influencia espacial de las múltiples amenazas permite que los gestores entiendan la multitud de acciones de manejo que se requieren para abordar las amenazas.

Antenatal corticosteroids and newborn respiratory outcomes in twins: A regression discontinuity study.

OBJECTIVE: To estimate the effect of antenatal corticosteroids on newborn respiratory morbidity in twins. DESIGN: Regression discontinuity applied to population-based birth registry data. SETTING: British Columbia, Canada, 2008-2018. POPULATION: Twin pregnancies admitted for birth between 31+0 and 36+6 weeks of gestation. METHODS: During our study period, Canadian clinical practice guidelines recommended antenatal corticosteroid administration for imminent preterm birth up to 33+6 weeks. We used a logistic model to compare the predicted risks of our outcomes among pregnancies admitted for birth immediately before this clinical cut-point (higher probability of exposure to antenatal corticosteroids) versus immediately after it (lower probability). MAIN OUTCOME MEASURES: Our primary outcome was a composite of newborn respiratory distress or in-hospital death. Our secondary outcome was a composite of newborn respiratory intervention or in-hospital death. RESULTS: Among 2524 pregnancies (5035 liveborn twins), 47% of admissions before 34+0 weeks of gestation were exposed to antenatal corticosteroids but only 4.2% of admissions after this cut-point were exposed. The risk of newborn respiratory distress or in-hospital mortality increased abruptly at 34+0 weeks, corresponding to a protective effect of treatment (risk ratio [RR] 0.69, 95% CI 0.53-0.90; risk difference [RD] -12 cases per 100 births, 95% CI -20 to -4.1). There was no clear evidence for or against an effect on newborn respiratory intervention or in-hospital death (RR 0.89, 95% CI 0.70-1.13; RD -4.2 per 100, 95% CI -13 to +4.2). CONCLUSIONS: Our findings provide evidence for the effectiveness of antenatal corticosteroids in preventing adverse newborn respiratory outcomes in twins.

The outcome of reduced and non-reduced triplet pregnancies managed in a tertiary hospital during a 15-year-period - a retrospective cohort study.

OBJECTIVES: Triplet pregnancies involve several complications, the most important being prematurity as virtually all triplets are born preterm. We conducted this study to compare the outcomes of reduced vs. non-reduced triplet pregnancies managed in the largest tertiary hospital in Finland. METHODS: This was a retrospective cohort study in the Helsinki University Hospital during 2006-2020. Data on the pregnancies, parturients and newborns were collected from patient records. The fetal number, chorionicity and amnionicity were defined in first-trimester ultrasound screening. The main outcome measures were perinatal and neonatal mortality of non-reduced triplets, compared to twins and singletons selectively reduced of triplet pregnancies. RESULTS: There were 57 initially triplet pregnancies and 35 of these continued as non-reduced triplets and resulted in the delivery of 104 liveborn children. The remaining 22 cases were spontaneously or medically reduced to twins (9) or singletons (13). Most (54.4 %) triplet pregnancies were spontaneous. There were no significant differences in gestational age at delivery between triplets (mean 33+0, median 34+0) and those reduced to twins (mean 32+5, median 36+0). The survival at one week of age was higher for triplets compared to twins (p<0.00001). CONCLUSIONS: Most pregnancies continued as non-reduced triplets, which were born at a similar gestational age but with a significantly higher liveborn rate compared to those reduced to twins. There were no early neonatal deaths among cases reduced to singletons. Prematurity was the greatest concern for multiples in this cohort, whereas the small numbers may explain the lack of difference in gestational age between these groups.

Risks and pregnancy outcome after fetal reduction in dichorionic twin pregnancies: a Danish national retrospective cohort study.

BACKGROUND: Twin pregnancies carry a higher risk of congenital and structural malformations, and pregnancy complications including miscarriage, stillbirth, and intrauterine fetal death, compared with singleton pregnancies. Carrying a fetus with severe malformations or abnormal karyotype places the remaining healthy fetus at an even higher risk of adverse outcome and pregnancy complications. Maternal medical conditions or complicated obstetrical history could, in combination with twin pregnancy, cause increased risks for both the woman and the fetuses. To our knowledge, no previous studies have evaluated and compared the outcomes of all dichorionic twin pregnancies and compared the results of reduced twins with those of nonreduced and primary singletons in a national cohort. These data are important for clinicians when counseling couples about fetal reduction and its implications. OBJECTIVE: This study aimed to describe and compare the risks of adverse pregnancy outcomes, including the risk of pregnancy loss, in a national cohort of all dichorionic twins-reduced, nonreduced, and primary singletons. In addition, we examined the implications of gestational age at fetal reduction on gestational age at delivery. STUDY DESIGN: This was a retrospective cohort study of all Danish dichorionic twin pregnancies, including pregnancies undergoing fetal reduction and a large proportion of randomly selected primary singleton pregnancies with due dates between January 2008 and December 2018. The primary outcome measures were adverse pregnancy outcomes (defined as miscarriage before 24 weeks, stillbirth from 24 weeks, or single intrauterine fetal death in nonreduced twin pregnancies), preterm delivery, and obstetrical pregnancy complications. Outcomes after fetal reduction were compared with those of nonreduced dichorionic twins and primary singletons. RESULTS: In total, 9735 dichorionic twin pregnancies were included, of which 172 (1.8%) were reduced. In addition, 16,465 primary singletons were included. Fetal reductions were performed between 11 and 23 weeks by transabdominal needle-guided injection of potassium chloride, and outcome data were complete for all cases. Adverse pregnancy outcome was observed in 4.1% (95% confidence interval, 1.7%-8.2%) of reduced twin pregnancies, and 2.4% (95% confidence interval, 0.7%-6.1%) were delivered before 28 weeks, and 4.2% (95% confidence interval, 1.7%-8.5%) before 32 weeks. However, when fetal reduction was performed before 14 weeks, adverse pregnancy outcomes occurred in only 1.4% (95% confidence interval, 0.0%-7.4%), and delivery before 28 and 32 weeks diminished to 0% (95% confidence interval, 0.0%-5.0%) and 2.8% (95% confidence interval, 0.3%-9.7%), respectively. In contrast, 3.0% (95% confidence interval, 2.7%-3.4%) of nonreduced dichorionic twins had an adverse pregnancy outcome, and 1.9% (95% confidence interval, 1.7%-2.1%) were delivered before 28 weeks, and 7.3% (95% confidence interval, 6.9%-7.7%) before 32 weeks. Adverse pregnancy outcomes occurred in 0.9% (95% confidence interval, 0.7%-1.0%) of primary singletons, and 0.2% (95% confidence interval, 0.1%-0.3%) were delivered before 28 weeks, and 0.7% (95% confidence interval, 0.6%-0.9%) before 32 weeks. For reduced twins, after taking account of maternal factors and medical history, it was demonstrated that the later the fetal reduction was performed, the earlier the delivery occurred (P<.01). The overall risk of pregnancy complications was significantly lower among reduced twin pregnancies than among nonreduced dichorionic twin pregnancies (P=.02). CONCLUSION: In a national 11-year cohort including all dichorionic twin pregnancies, transabdominal fetal reduction by needle guide for fetal or maternal indication was shown to be safe, with good outcomes for the remaining co-twin. Results were best when the procedure was performed before 14 weeks.

Triple trouble: uncovering the risks and benefits of early fetal reduction in trichorionic triplets in a large national Danish cohort study.

BACKGROUND: Triplet pregnancies are high risk for both the mother and the infants. The risks for infants include premature birth, low birthweight, and neonatal complications. Therefore, the management of triplet pregnancies involves close monitoring and may include interventions, such as fetal reduction, to prolong the pregnancy and improve outcomes. However, the evidence of benefits and risks associated with fetal reduction is inconsistent. OBJECTIVE: This study aimed to compare the outcomes of trichorionic triplet pregnancies with and without fetal reduction and with nonreduced dichorionic twin pregnancies and primary singleton pregnancies. STUDY DESIGN: All trichorionic triplet pregnancies in Denmark, including those with fetal reduction, were identified between 2008 and 2018. In Denmark, all couples expecting triplets are informed about and offered fetal reduction. Pregnancies with viable fetuses at the first-trimester ultrasound scan and pregnancies not terminated were included. Adverse pregnancy outcome was defined as a composite of miscarriage before 24 weeks of gestation, stillbirth at 24 weeks of gestation, or intrauterine fetal death of 1 or 2 fetuses. RESULTS: The study cohort was composed of 317 trichorionic triplet pregnancies, of which 70.0% of pregnancies underwent fetal reduction to a twin pregnancy, 2.2% of pregnancies were reduced to singleton pregnancies, and 27.8% of pregnancies were not reduced. Nonreduced triplet pregnancies had high risks of adverse pregnancy outcomes (28.4%), which was significantly lower in triplets reduced to twins (9.0%; difference, 19.4%, 95% confidence interval, 8.5%-30.3%). Severe preterm deliveries were significantly higher in nonreduced triplet pregnancies (27.9%) than triplet pregnancies reduced to twin pregnancies (13.1%; difference, 14.9%, 95% confidence interval, 7.9%-21.9%). However, triplet pregnancies reduced to twin pregnancies had an insignificantly higher risk of miscarriage (6.8%) than nonreduced twin pregnancies (1.1%; difference, 5.6%; 95% confidence interval, 0.9%-10.4%). CONCLUSION: Triplet pregnancies reduced to twin pregnancies had significantly lower risks of adverse pregnancy outcomes, severe preterm deliveries, and low birthweight than nonreduced triplet pregnancies. However, triplet pregnancies reduced to twin pregnancies were potentially associated with a 5.6% increased risk of miscarriage.

Ecological momentary assessment of postpartum outcomes in mothers of multiples: lower maternal-infant bonding, higher stress, and more disrupted sleep.

Research on mental health in mothers of multiples has neglected important outcomes like postpartum bonding and relationship satisfaction and is limited by reliance on single-administration, retrospective measures. This study fills these gaps by assessing previously unexamined variables and using ecological momentary assessment (EMA), wherein participants answer repeated, brief surveys to measure real-world, real-time outcomes. This online study recruited 221 women and compared outcomes in those who birthed multiples (n = 127, 57.47%) vs. singletons (n = 94, 42.53%). When recruited, participants were either 6-12 (n = 129, 58.37%) or 18-24 (n = 83, 37.56%) weeks postpartum. All 221 participants completed baseline measures of self-reported depression, anxiety, stress, sleep, relationship satisfaction, and maternal-infant bonding. One hundred thirty participants (58.82%) engaged in 7 days of EMA assessing self-reported momentary mood, stress, fatigue, bonding, and sleep. Data were analyzed using two-by-two ANOVAs and hierarchical linear modeling. Mothers of multiples reported more baseline parenting stress and less maternal-infant bonding than mothers of singletons (ps < .05). Mothers of multiples who were 6-12 weeks postpartum reported the lowest bonding (p = .03). Mothers of multiples also reported more momentary stress, overwhelm, nighttime awakenings, and wake time after sleep onset (ps < .05). The latter two variables positively correlated with momentary fatigue, stress, and worse mood (ps < .05). Mothers of multiples experienced worse postpartum bonding, more stress, and more interrupted sleep than mothers of singletons. This population may benefit from tailored postpartum interventions to decrease stress, increase bonding, and improve sleep.

Recurrence risk and risk factors for monozygotic twin and triplet birth in over 65,000 single-embryo transfers.

PURPOSE: To determine the recurrence risk and risk factors for monozygotic splitting after elective single-embryo transfers (eSET). METHODS: A retrospective cohort study was performed investigating 65,664 eSET cycles that resulted in a clinical pregnancy as reported in the Society for Assisted Reproductive Technology (SART) Clinical Outcomes Reporting System (CORS) between 2004 and 2017. Monozygosity was defined as more than one fetal heart tone by the first-trimester ultrasound and concordant sex at live birth. The primary outcome was recurrence risk, with recurrence defined as one patient having two or more cycles of eSET resulting in monozygotic multiples. The secondary objective was to identify factors associated with smonozygotic splitting, using a multivariable logistic regression model and a stepwise purposeful model selection. RESULTS: There were 1355 (2.05%) pregnancies that resulted in two or more fetal heart tones after SET, including 840 monozygotic twins and triplets at birth. Recurrence occurred in two cases-0.0001% of patients with multiple eSET cycles. One case resulted from embryos created from a single cohort with intracytoplasmic sperm injection (ICSI), assisted hatching (AH), and blastocyst transfers. The second case resulted from donor egg embryos with ICSI and blastocyst transfers. Risk factors associated with monozygotic live birth were blastocyst transfer (OR 1.23, 95% CI 1.04-1.47, P = 0.0176) and AH (OR 1.23, 95% CI 1.05-1.44, P = 0.0081). CONCLUSION: Recurrence of monozygotic live births in eSET was very rare. Blastocyst transfer and AH were confirmed to be risk factors for monozygotic live births, while ICSI, PGT, and FET do not appear to be associated.

Convolutional Neural-Network-Based Reverse-Time Migration with Multiple Reflections.

Reverse-time migration (RTM) has the advantage that it can handle steep dipping structures and offer high-resolution images of the complex subsurface. Nevertheless, there are some limitations to the chosen initial model, aperture illumination and computation efficiency. RTM has a strong dependency on the initial velocity model. The RTM result image will perform poorly if the input background velocity model is inaccurate. One solution is to apply least-squares reverse-time migration (LSRTM), which updates the reflectivity and suppresses artifacts through iterations. However, the output resolution still depends heavily on the input and accuracy of the velocity model, even more than for standard RTM. For the aperture limitation, RTM with multiple reflections (RTMM) is instrumental in improving the illumination but will generate crosstalks because of the interference between different orders of multiples. We proposed a method based on a convolutional neural network (CNN) that behaves like a filter applying the inverse of the Hessian. This approach can learn patterns representing the relation between the reflectivity obtained through RTMM and the true reflectivity obtained from velocity models through a residual U-Net with an identity mapping. Once trained, this neural network can be used to enhance the quality of RTMM images. Numerical experiments show that RTMM-CNN can recover major structures and thin layers with higher resolution and improved accuracy compared with the RTM-CNN method. Additionally, the proposed method demonstrates a significant degree of generalizability across diverse geology models, encompassing complex thin layers, salt bodies, folds, and faults. Moreover, The computational efficiency of the method is demonstrated by its lower computational cost compared with LSRTM.

Parent Descriptions of the Active Play Behaviors of Their Twins and Triplets With Autism.

Children with autism engage in active play in different ways than children who are neurotypical, but their active play behaviors are not well understood. Research with twins and triplets with autism offers a unique opportunity to gain a clear picture of the play behaviors of children with autism because twins and triplets share many similarities (age, access to toys, etc.). Through semistructured interviews, this descriptive phenomenological study aimed to describe the active play behaviors of 19 twins and triplets with autism from the perspective of their parents (N = 9). The interviews revealed two main themes: (a) parents' descriptions of active play and (b) parents' descriptions of social play. The results reveal the diverse active and social play behaviors of twins and triplets with autism; parents described their children's play behavior when engaging in sensory, indoor, outdoor, and organized play. These results suggest that children with autism may be meeting the definition of active play in nontraditional ways.

Laboratory surveillance of invasive Haemophilus influenzae disease in Argentina, 2011-2019.

The incorporation of Haemophilus influenzae type b (Hib) vaccine into the Argentine National Immunization Program in 1998 resulted in a dramatic decrease in the incidence of invasive disease due to this serotype. We assessed 1405 H. influenzae (Hi) isolates causing invasive infections referred to the National Reference Laboratory between 2011 and 2019. Non-encapsulated Hi were the most common strains (44.5%), followed by types b (41.1%) and a (10.0%). Significant increase in the proportion of type b was observed, from 31.2% in 2011, to 50% in 2015, correlating with the peak incidence rate, later decreasing to 33.6% by 2019. We compared the genetic relationship between clones circulating during the period of increased Hib incidence (2011-2015) and those of the prevaccination-transition period (1997-1998). Four pulsotypes predominated in both periods, G, M, P and K, G being the most common. Multi-locus sequence typing revealed that the 4 pulsotypes belonged to ST6, or one of its simple or double locus variants. Isolates from fully vaccinated individuals did not differ from those of the rest of the population studied. After ruling out aspects associated with emergence of specific clones, we concluded that factors such as low booster coverage rates, delayed vaccination schedules and use of different vaccines may have contributed to the reemergence of Hib infections.

Partial excision of schwannomatosis with fascicular invasion occurring in the ulnar nerve above the elbow: A 1-year follow-up study.

Although not as common as solitary lesions, multiple schwannomas do occur, even in single nerve lesions. We report a rare case of a 47-year-old female patient who presented with multiple schwannomas with inter-fascicular invasion in the ulnar nerve above the cubital tunnel. Preoperative MRI revealed a 10-cm multilobulated tubular mass along the ulnar nerve above the elbow joint. During excision under 4.5° loupe magnification, we separated three ovoid yellow-colored neurogenic tumors of different sizes, but there were still remaining lesions as it was difficult to completely separate lesions from the ulnar nerve due to the risk of iatrogenic nerve ulnar nerve injury. The operative wound was closed. Postoperative biopsy confirmed the diagnosis of the three schwannomas. During the follow-up, the patient recovered without neurological symptom or limitations in range of motion, and there were no neurological abnormalities. At 1year after surgery, small lesions remained in the most proximal part. However, the patient had no clinical symptoms and was satisfied with the surgical results. Although a long-term follow-up is necessary for this patient, we were able to obtain good clinical and radiological results.

Leptomeningeal enhancement on post-contrast FLAIR images for early diagnosis of Susac syndrome.

BACKGROUND: Leptomeningeal enhancement (LME) is a key feature of Susac syndrome (SuS) but is only occasionally depicted on post-contrast T1-weighted images (T1-WI). OBJECTIVE: As post-contrast fluid-attenuated inversion recovery (FLAIR) may be more sensitive, our aim was to assess LME in SuS on this sequence. METHODS: From 2010 to 2020, 20 patients with definite SuS diagnosis were retrospectively enrolled in this multicentre study. Two radiologists independently assessed the number of LME on post-contrast FLAIR and T1-WI acquisitions performed before any treatment. A chi-square test was used to compare both sequences and the interrater agreement was calculated. RESULTS: Thirty-five magnetic resonance imagings (MRIs) were performed before treatment, including 19 post-contrast FLAIR images in 17 patients and 25 post-contrast T1-WI in 19 patients. In terms of patients, LME was observed on all post-contrast FLAIR, contrary to post-contrast T1-WI (17/17 (100%) vs. 15/19 (79%), p < 0.05). In terms of sequences, LME was observed on all post-contrast FLAIR, contrary to post-contrast T1-WI (19/19 (100%) vs. 16/25 (64%), p < 0.005). LME was disseminated at both supratentorial (19/19) and infratentorial (18/19) levels on post-contrast FLAIR, contrary to post-contrast T1-WI (3/25 and 9/25, respectively). Interrater agreement was excellent for post-contrast FLAIR (κ = 0.95) but only moderate for post-contrast T1-WI (κ = 0.61). CONCLUSION: LME was always observed and easily visible on post-contrast FLAIR images prior to SuS treatment. In association with other MRI features, it is highly indicative of SuS.

Relation of sensorimotor and cognitive cerebellum functional connectivity with brain structural damage in patients with multiple sclerosis and no disability.

BACKGROUND AND PURPOSE: To investigate the relationship between the functional connectivity (FC) of the sensorimotor and cognitive cerebellum and measures of structural damage in patients with multiple sclerosis (MS) and no physical disability. METHODS: We selected 144 relapsing-remitting MS patients with an Expanded Disability Status Scale score of ≤1.5 and 98 healthy controls from the Italian Neuroimaging Network Initiative database. From multimodal 3T magnetic resonance imaging (MRI), including functional MRI at rest, we calculated lesion load, cortical thickness, and white matter, cortical gray matter, and caudate, putamen, thalamic, and cerebellar volumes. Voxel-wise FC of the sensorimotor and cognitive cerebellum was assessed with seed-based analysis, and multiple regression analysis was used to evaluate the relationship between FC and structural damage. RESULTS: Whole brain, white matter, caudate, putamen, and thalamic volumes were reduced in patients compared to controls, whereas cortical gray matter was not significantly different in patients versus controls. Both the sensorimotor and cognitive cerebellum showed a widespread pattern of increased and decreased FC that were negatively associated with structural measures, indicating that the lower the FC, the greater the tissue loss. Lastly, among multiple structural measures, cortical gray matter and white matter volumes were the best predictors of cerebellar FC alterations. CONCLUSIONS: Increased and decreased cerebellar FC with several brain areas coexist in MS patients with no disability. Our data suggest that white matter loss hampers FC, whereas, in the absence of atrophy, cortical volume represents the framework for FC to increase.

The role of maternal age on the risk of preterm birth among singletons and multiples: a retrospective cohort study in Lombardy, Norther Italy.

BACKGROUND: All over the world, especially in the developed countries, maternal age at birth is rising. This study aimed to assess the role of maternal age on the occurrence of preterm birth (PTB) in a large birth cohort of Lombardy Region, Northern Italy. METHODS: This population-based study used data from regional healthcare utilization databases of Lombardy to identify women who delivered between 2007 and 2017. PTBs were defined as births before 37 completed weeks of gestation and considered according to the gestational age (two categories: < 32 weeks and 32 to 36 weeks). Six maternal age groups were defined (< 20, 20-24, 25-29, 30-34, 35-39, ≥40 years). Logistic regression models were fitted to estimate the crude and adjusted odds ratio (aOR) and the corresponding 95% confidence interval (CI) for PTB among different maternal age groups. Analyses were separately performed according to type of pregnancy (singletons and multiples). Reference group was the age group with the lowest frequency of PTB. RESULTS: Overall, 49,759 (6.6%) PTBs were observed, of which 41,807 were singletons and 7952 were multiples. Rates of PTB were lowest in the women aged 25-29 years among singletons and in the 30-34 years old group among multiples. Our results described a U-shaped association between maternal age and risk of PTB. In particular, the risk of a singleton PTB between 32 and 36 weeks was significantly higher for women aged less than 20 years (aOR = 1.16, CI 95%: 1.04-1.30) and more than 40 years (aOR = 1.62 CI 95%: 1.54-1.70). The highest risk of a multiple delivery between 32 and 36 weeks was observed among women aged less than 25 years and more than 40 years (aOR = 1.79, CI 95%: 1.01-3.17, aOR = 1.47, CI 95%: 1.16-1.85 and aOR = 1.36, CI 95%: 1.19-1.55 respectively for < 20, 20-24 and > 40 age categories). PTB before 32 completed weeks occurred more frequently in the same age categories, except that among multiples no association with advanced maternal age emerged. CONCLUSION: Our study suggested that, after adjustment for potential confounders, both advance and young maternal age were associated with an increased risk of PTB.

Geology-dependent impacts of forest conversion on stream fish diversity.

Forest conversion is one of the greatest global threats to biodiversity, and land-use change and subsequent biodiversity declines sometimes occur over a variety of underlying geologies. However, how forest conversion and underlying geology interact to alter biodiversity is underappreciated, although spatial variability in geology is considered an integral part of sustaining ecosystems. We aimed to examine the effects of forest conversion to farmland, the underlying geology, and their interaction on the stream fishes' diversity, evenness, and abundance in northeastern Japan. We disentangled complex pathways between abiotic and biotic factors with structural equation modeling. Species diversity of stream fishes was indirectly shaped by the interaction of land use and underlying geology. Diversity declined due to nutrient enrichment associated with farmlands, which was mainly the result of changes in evenness rather than by changes in species richness. This impact was strongest in streams with volcanic geology with coarse substrates probably because of the differential responses of abundant stream fishes to nutrient enrichment (i.e., dominance) and the high dependency of these fishes on large streambed materials during their life cycles. Our findings suggest that remediation of deforested or degraded forest landscapes would be more efficient if the interaction between land use and underlying geology was considered. For example, the negative impacts of farmland on evenness were larger in streams with volcanic geology than in other stream types, suggesting that riparian forest restoration along such streams would efficiently provide restoration benefits to stream fishes. Our results also suggest that land clearing around such streams should be avoided to conserve species evenness of stream fishes.

Impactos Geológicamente Dependientes de la Conversión de Bosques sobre la Diversidad de Peces de Arroyo Resumen La conversión de los bosques es una de las mayores amenazas para la biodiversidad mundial y el cambio en el uso de suelo y las declinaciones subsecuentes de la biodiversidad a veces ocurren a lo largo de una variedad de geologías subyacentes. Sin embargo, la manera en que interactúan la conversión del bosque y la geología subyacente está subestimada a pesar de que la variabilidad espacial en la geología es considerada una parte integral del mantenimiento de un ecosistema. Fijamos como objetivo examinar los efectos de la conversión del bosque a tierras de cultivo, la geología subyacente y sus interacciones sobre la diversidad, uniformidad y abundancia de peces de arroyo en el noreste de Japón. Para esto, desentrañamos las vías complejas entre los factores bióticos y abióticos con modelados de ecuación estructural. La diversidad de especies de los peces de arroyo estuvo formada indirectamente por la interacción del uso de suelo y la geología subyacente. La diversidad declinó debido al enriquecimiento de nutrientes asociado con las tierras de cultivo, lo cual fue principalmente resultado de los cambios en la uniformidad de especies en lugar de cambios en la riqueza de especies. Este impacto fue más fuerte en los arroyos con geología volcánica y sustratos ásperos, probablemente debido a las respuestas diferenciales de los peces abundantes en el arroyo al enriquecimiento de nutrientes (es decir, dominancia) y la alta dependencia de estos peces por los grandes materiales del lecho durante su ciclo de vida. Nuestros hallazgos sugieren que la reparación de los paisajes de bosque deforestados o degradados sería más eficiente si se considera la interacción entre el uso de suelo y la geología subyacente. Por ejemplo, los impactos negativos de las tierras de cultivo sobre la uniformidad fueron mayores en los arroyos con geología volcánica que en otros tipos de arroyo, lo que sugiere que la restauración de los bosques ribereños a lo largo de dichos arroyos proporcionaría eficientemente los beneficios de restauración a los peces del arroyo. Nuestros resultados sugieren que el desmonte de tierras alrededor de dichos arroyos debería evitarse para conservar la uniformidad de especies de los peces de arroyo.

Pregnancy and birth characteristics of Aboriginal twins in two Australian states: a data linkage study.

INTRODUCTION: Perinatal outcomes for singleton pregnancies are poorer, on average, for Aboriginal people than non-Aboriginal people, but little is known about Aboriginal multifetal pregnancies. Yet multifetal pregnancies and births are often more complicated and have poorer outcomes than singleton pregnancies. We describe the pregnancies, births and perinatal outcomes for Aboriginal twins born in Western Australia (WA) and New South Wales (NSW) with comparisons to Aboriginal singletons in both states and to non-Aboriginal births in NSW. MATERIALS AND METHODS: Whole-population birth records and birth and death registrations were linked for all births during 2000-2013 (WA) and 2002-2008 (NSW). Hospital records and the WA Register of Developmental Anomalies - Cerebral Palsy were linked for all WA births and hospital records for a subset of NSW births. Descriptive statistics are reported for maternal and child demographics, maternal health, pregnancy complications, births and perinatal outcomes. RESULTS: Thirty-four thousand one hundred twenty-seven WA Aboriginal, 32,352 NSW Aboriginal and 601,233 NSW non-Aboriginal births were included. Pregnancy complications were more common among mothers of Aboriginal twins than Aboriginal singletons (e.g. 17% of mothers of WA twins had hypertension/pre-eclampsia/eclampsia vs 8% of mothers of singletons) but similar to mothers of NSW non-Aboriginal twins. Most Aboriginal twins were born in a principal referral, women's or large public hospital. The hospitals were often far from the mother's home (e.g. 31% of mothers of WA Aboriginal twins gave birth at hospitals located more than 3 h by road from their home). Outcomes were worse for Aboriginal liveborn twins than Aboriginal singletons and non-Aboriginal twins (e.g. 58% of NSW Aboriginal twins were preterm compared to 9% of Aboriginal singletons and 49% non-Aboriginal twins). CONCLUSIONS: Mothers of Aboriginal twins faced significant challenges during the pregnancy, birth and the postnatal period in hospital and, in addition to accessible specialist medical care, these mothers may need extra practical and psychosocial support throughout their journey.

Patient experience data as enacted: Sociomaterial perspectives and 'singular-multiples' in health care quality improvement research.

Over the last three decades, sociomaterial approaches to the study of health care practices have made an important contribution to the sociology of health care. Significant attention has been paid to the role of technology and artefacts in health care and the operation of actor-networks but less space has been given to questions of ontological multiplicity in health care practices. In this paper, we draw upon our study of patient experience data in five acute hospitals in England to illustrate how treating patient experience data as 'singular-multiples' can enable useful insights into patient experience data work in health care organisations. Our data was generated during 12 months of fieldwork at five participating hospitals and included organisational documents, field notes, informal and formal interviews with frontline and managerial staff and patient representatives at the study sites. We use the examples of the Friends and Family Test (FFT) and the National Cancer Patient Experience Survey (NCPES) in England to consider the multiple nature of data as it is enacted in practice and the work data does when coordinated as an entity in the singular. We argue that, and discuss how, the sociomaterial insights we discuss here are relevant to health care quality and improvement research and practice.

Perceptions of Portuguese parents about the acceptability of a multicomponent intervention targeted at behavioral inhibition during early childhood.

High and stable behavioral inhibition during early childhood is a risk factor for later anxiety disorders. The few available interventions targeted at behavioral inhibition have not yet been implemented in European countries. Evaluating intervention acceptability is essential when introducing interventions in new cultures. This study aimed to explore the perceptions of parents about the acceptability of the multicomponent Turtle Program in Portugal. Participants were 12 parents (from seven families) of children with a positive screening on the Behavioral Inhibition Questionnaire and no diagnoses of developmental disorders/selective mutism. Children's mean age was 55.86 months and most children were female and first-born. Parents and children participated in the eight-sessions Turtle Program. After each session, parents completed weekly satisfaction checklists. Following completion of the full intervention, parents were invited to participate in individual qualitative in-depth interviews. The thematic analysis revealed that both parents perceived the intervention objectives and contents as relevant. Both parents suggested the introduction of follow-up sessions, the discussion of practical experiences, the need to be sensitive to cultural differences in positive language, and the provision of more feedback about children's activities. These findings support prior research on the acceptability and cultural tailoring needed for parenting and child socioemotional learning interventions.

Una alta y estable conducta de inhibición durante la temprana niñez es un factor de riesgo para posteriores trastornos de ansiedad. Las pocas intervenciones disponibles que se enfocan en la inhibición de la conducta no se han implementado aún en países europeos. Evaluar el nivel de aceptación de la intervención es esencial cuando las intervenciones se introducen en nuevas culturas. Este estudio se propuso explorar las percepciones de los progenitores acerca del nivel de aceptación del multi-compuesto Programa Tortuga en Portugal. Los participantes fueron 12 progenitores (de siete familias) de niños con una positiva detección en el Cuestionario de Inhibición de la Conducta y sin diagnóstico de trastornos de desarrollo/mutismo selectivo. La edad promedio de los niños fue 55.86 meses y la mayoría eran niñas y primogénitas. Los progenitores y los niños participaron en las ocho sesiones del Programa Tortuga. Después de cada sesión, los progenitores completaron listas semanales de chequeo de la satisfacción. Luego de completar la intervención en su totalidad, se invitó a los progenitores a participar en entrevistas cualitativas individuales para profundizar. Los análisis temáticos revelaron que ambos progenitores percibieron como relevantes los objetivos y el contenido de la intervención. Ambos progenitores sugirieron introducir sesiones de seguimiento, la discusión de experiencias prácticas, la necesidad de mostrarse sensible a las diferencias culturales en lenguaje positivo y la provisión de más información sobre las actividades de los niños. Estos resultados apoyan la investigación anterior sobre el nivel de aceptación y la adaptación cultural necesarias en las intervenciones sobre la crianza y el aprendizaje socioemocional del niño.

L'inhibition comportementale élevée et stable durant la petite enfance est un facteur de risque pour des troubles de l'anxiété plus tard. Quelques interventions disponibles ciblant l'inhibition comportementale n'ont pas encore été mises en œuvre dans les pays européens. Evaluer l'acceptabilité de l'intervention est essentiel lorsqu'on introduit des interventions dans de nouvelles cultures. Cette étude s'est donnée pour but d'explorer les perceptions des parents à propos de l'acceptabilité du Programme Tortue à composants multiples au Portugal. Les participants ont consisté en 12 parents (de sept familles) d'enfants ayant eu un dépistage positif au Questionnaire d'Inhibition Comportementale et aucun diagnostic de troubles développementaux / mutisme sélectif. L'âge moyen des enfants était de 55,86 mois et la plupart des enfants étaient des filles et des premières nées. Les parents et les enfants ont participé au Programme Tortue de huit séances. Après chaque séance les parents ont rempli des checklists de satisfaction hebdomadaires. Après avoir terminé l'intervention totale les parents ont été invité à participer à des entretiens individuels en profondeur et qualitatifs. L'analyse thématique a révélé que les deux parents percevaient les objectifs d'intervention et les contenus comme étant pertinents. Les deux parents ont suggéré l'introduction de séances de suivi, la discussion d'expériences pratiques, le besoin d'être sensible aux différences culturelles dans le langage positif et le besoin de plus de commentaires sur les activités des enfants. Ces résultats soutiennent les recherches précédentes sur l'acceptabilité et l'adaptation culturelle nécessaire pour le parentage et les interventions pour le développement socioémotionnel de l'enfant.