Maternal morbidity and mortality: an iceberg phenomenon.

OBJECTIVE: To apply the iceberg model, quantifying absolute and relative incidence, to the four main causes of maternal morbidity and mortality in Ireland: haemorrhage, hypertension, sepsis and thrombosis. DESIGN: Secondary analysis of national data on maternal morbidity and mortality. SETTING: Republic of Ireland. POPULATION OR SAMPLE: Approximately 715 000 maternities, 1 200 000 maternal hospitalisations, 2138 cases of severe maternal morbidity (SMM) and 54 maternal deaths. METHODS: Incidence rates and case-fatality ratios were calculated. MAIN OUTCOME MEASURES: Maternal death, SMM and hospitalisation. RESULTS: At the 'tip of the iceberg', the incidence of maternal death per 10 000 maternities was 0.09 (95% CI 0.03-0.20) due to thrombosis and 0.03 (95% CI 0-0.11) due to haemorrhage, hypertension disorders or sepsis. For one death due to thrombosis there were 35 cases of pulmonary embolism and 257 thrombosis hospitalisations. For one death due to eclampsia, there were 58 eclampsia cases, 13 040 hospitalisations with pre-existing hypertension and 40 781 hospitalisations with gestational hypertension. For one death due to pregnancy-related sepsis, there were 92 cases of septicaemic shock and 9005 hospitalisations with obstetric sepsis. For one maternal death due to haemorrhage, there were 1029 cases of major obstetric haemorrhage and 53 715 maternal hospitalisations with haemorrhage. For every 100 maternities, there were approximately 16 hospitalisations associated with haemorrhage, 12 associated with hypertension disorders, three with sepsis and 0.2 with thrombosis. CONCLUSIONS: Haemorrhage and hypertension disorders are leading causes of maternal morbidity in Ireland but they have very low case fatality. This indicates that these morbidities are managed effectively but their prevention requires more focus. TWEETABLE ABSTRACT: Study shows that haemorrhage and hypertension are main causes of #maternalmorbidity in Ireland. Timely interventions for #maternalhealth and focus on prevention of severe and non-severe morbidities are needed. @NPEC #maternityservices #clinicalaudit #qualityimprovement.

Irish Inquiry Reports Relating to Perinatal Deaths and Pregnancy Loss Services.

Aims External inquiries are carried out following specific adverse events in healthcare, many in maternity care; to identify issues and make recommendations to improve standards of care. Methods Ten publically-available national inquiry reports published between 2005-2018 relating to pregnancy loss services, were reviewed by 2 clinicians, separately, examining the content and recommendations from each report. Results A total of 258 recommendations were made in 9 reports (90%). Five inquiries (50%) clearly stated that affected families were involved and four (40%) involved affected clinical staff. In 9 reports (90%) recommendations included: increase workforce staffing and/or training, strengthen clinical governance, enhance adverse incident management and comprehensive data collection e.g. maternity outcomes. Only two inquiry reports (20%) stated that feedback was sought from key stakeholders prior to publication. Conclusion A collaborative and standardised inquiry process involving and supporting all persons affected as well as key stakeholders would ensure that all relevant issues are identified, recommendations are implemented and essential lessons are learned.

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study.

BACKGROUND: Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls. METHODS: The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources. CONCLUSIONS: The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

Wiki as a tool for microbiology teaching, learning and assessment.

INTRODUCTION: Evidence suggests that cooperative learning and peer-assessment fosters students' ability to work with others and may lead to better cognitive outcomes and higher achievement. This work aimed to assess the use of an online collaborative tool for the teaching/learning and assessment of Microbiology. MATERIALS AND METHODS: A total of 144 students were grouped and assigned to create wiki entries as well as to peer review wikis created by colleagues (peer-assessment process) using the Wiki module from Moodle Virtual Learning Environment (MVLE). MVLE actions log was used for tracking students' activity. RESULTS: The number of student's actions within wiki did not present a strong correlation with wiki scores, so it should not be used as a heavy evaluation parameter. The amount of work developed between members of the same group differed significantly, suggesting that final scores should be attributed individually. When peer-assessment process was implemented, the number of editing actions increased, suggesting that the peer-assessment strategy encourages the development of a better work. The vast majority of students execute the work in the last 10% of the period assigned for task development, which can be counter-productive for a truly collaborative work. CONCLUSIONS: Wiki revealed to be a useful tool for Microbiology teaching/learning and assessment, promoting collaborative work, promoting virtual mobility and facilitating the real-time monitoring of the students' work. This pedagogical project promoted also the involvement of students in their assessment process, encouraging their critical sense and quest for Excellency.

Spatially multiplexed single-molecule translocations through a nanopore at controlled speeds.

In current nanopore-based label-free single-molecule sensing technologies, stochastic processes influence the selection of translocating molecule, translocation rate and translocation velocity. As a result, single-molecule translocations are challenging to control both spatially and temporally. Here we present a method using a glass nanopore mounted on a three-dimensional nanopositioner to spatially select molecules, deterministically tethered on a glass surface, for controlled translocations. By controlling the distance between the nanopore and glass surface, we can actively select the region of interest on the molecule and scan it a controlled number of times and at a controlled velocity. Decreasing the velocity and averaging thousands of consecutive readings of the same molecule increases the signal-to-noise ratio by two orders of magnitude compared with free translocations. We demonstrate the method's versatility by assessing DNA-protein complexes, DNA rulers and DNA gaps, achieving down to single-nucleotide gap detection.

Zooplankton exposure to microplastic contamination in a estuarine plume-influenced region, in Northeast Brazil.

This work describes the spatio-temporal distribution of suspected plastic and microplastic (MP) particles in estuarine plumes and analyzes the microplastic/zooplankton ratio. Subsurface hauls with a conical-cylindrical net were deployed in the coastal area of Tamandare (Pernambuco, Brazil), covering the plume of two rivers and a bay adjacent to coral reefs. A total of 2079 suspected plastic particles were detected, mostly fibers and fragments (>60%). Organic matter digestion was made using a 30% hydrogen peroxide solution, of which approximately 50% of suspected particles were validated as MPs. The average MP abundance was significantly higher during the high rainfall season (53.8 ± 89.6 and 18.8 ± 32.3 particles/m³, respectively), with higher values registered in the plume area (108.9 ± 158.5 and 44.6 ± 55.5 particles/m³). Polymer identification using FT-IR confirmed that suspected particles were mainly polypropylene, polyamide, and polyurethane. These results confirm the hypothesis of a temporal transport variation of MPs from the river to the coastal environments, particularly since the plume influences debris input. Eleven animal phyla were identified, and the subclass Copepoda was predominant (90%), particularly the nauplius stage (70%). Over 70% of verified MPs range between 20 and 2000 µm, equivalent to the most common size of zooplanktonic organisms. Results support that coastal areas near estuarine plumes are exposed to microplastic contamination, affecting species dependent on zooplankton in marine coastal food webs.

Healthcare professionals and students' knowledge on termination of pregnancy legislation and clinical practice: A systematic review.

BACKGROUND: Legal and safe termination of pregnancy (TOP) has long been recognised as an important public health issue internationally. Healthcare professionals (HCPs) and students have a key role within TOP services, and it is crucial that they have sufficient understanding of laws, guidelines and clinical practice to facilitate safe and effective care. The current systematic review aims to study the level of knowledge of both HCPs and students on TOP legislation, methods and procedures and potential associated complications. METHODS: PubMed, Embase, Scopus and EBSCOhost were searched for peer-reviewed studies published until July 2020. After initial selection, 239 articles were screened in full and 31 studies (qualitative and quantitative) were included. A narrative review and synthesis of the findings was completed. MAIN FINDINGS: Poor knowledge on TOP legislation and clinical practice was reported for HCPs and students. The main issues identified included limited awareness of specific circumstances for legal TOP and poor understanding of methods and medical regimens recommended. Overall, education/training, experience in provision of TOP and receiving reminders of legislation were the main factors associated with increased levels of knowledge. CONCLUSION: HCPs must be fully aware of the clinical practice and circumstances in which TOP is legal in their country/region so adequate provision of this service is ensured. This study highlighted the importance of involving and promoting participation of HCPs and students in the provision of TOP services. A clear need and desire for staff education and training on TOP was shown. Adequate training allows preparation of current and future HCPs to provide respectful and compassionate care.

Genomic and phenotypic characterization of Escherichia coli isolates recovered from the uterus of puerperal dairy cows.

The role of Escherichia coli in the pathogenesis of the puerperal uterine infection of the cow is largely unknown. It is proposed that E. coli favors the persistence of Arcanobacterium pyogenes and gram-negative bacteria that are pivotal to the establishment of the infection. Here, we report the genomic and phenotypic characteristics of 72 E. coli isolates recovered from the uterus of dairy cows with normal puerperium (n = 12; 35 isolates) or clinical metritis (n = 18; 37 isolates), in an attempt to identify characteristics that are related to the establishment of uterine infection. We evaluated DNA fingerprints generated by repetitive element sequence-based PCR, phylogenetic grouping, the presence of 15 virulence factor genes, in vitro biofilm formation and its relationship to curli fimbriae expression, and cellulose production. We found a wide genetic diversity (40 clonal types), including types common to normal puerperium and clinical metritis cows (n = 6), as well as types specific to normal puerperium (n = 14) or clinical metritis (n = 20) cows. Isolates were assigned to phylogenetic groups B1 (58%), A (31%), and D (11%). Only 4 virulence factor genes were detected (hlyE, hlyA, iuc, and eaeA). In vitro biofilm formation was significantly affected by culture medium and incubation temperature. Curli fimbriae expression and cellulose production, although related to biofilm formation, were not required for it. None of the evaluated E. coli characteristics were significantly related to the establishment of the uterine infection. In conclusion, data presented in this paper indicate that E. coli isolates recovered from the uterus of puerperal cows present a wide genetic diversity, do not belong to a known pathogenic group, and have a low potential of virulence and persistence. This corroborates the putative role of the bacterium in the pathogenesis of the puerperal uterine infection of the cow.

Prostaglandin synthesis genes are differentially transcripted in normal and pyometra endometria of bitches.

Pro-inflammatory stimuli, such as endotoxins released by Gram-negative bacteria, are potent stimulators of prostaglandin (PG) synthesis. The aim of this study was to evaluate the gene transcription pattern of PG synthesis enzymes in normal (anestrous, n = 6 and diestrous, n = 8) and pyometra (n = 7) endometria of bitches. Uteri were collected during routine ovariohysterectomy, processed for histopathological evaluation and uterine contents cultured. Gene transcription of COX-1, COX-2, mPGES-1 and PGF-synthase (PGFS) were evaluated by relative real-time PCR and normalized with the ribosomal protein L27 (RPL27) housekeeping gene. Normal uteri had no histological abnormalities and were negative for bacteriology. All pyometra uteri were hyperplasic and Escherichia coli was the only isolated bacterium. Except for COX-1, gene transcription was significantly higher in pyometra than in normal endometria. No significant differences in gene transcription were observed between normal diestrous and anestrous endometria. COX-2 gene transcription was 19 and 69 times higher in pyometra than in diestrous and anestrous endometria (p < 0.001), while PGFS gene transcription had a 3- and 600-fold increase in pyometra endometria compared to normal diestrous and anestrous endometria (p < 0.001). Gene transcription of mPGES-1 was 9 times higher in pyometra than in normal uteri (p < 0.01). Based on these results, we suggest that pyometra-associated E. coli endotoxin release stimulates the up-regulation of COX-2 PGFS and mPGES-1 gene transcription in the endometrium.

Genomic characterization of Arcanobacterium pyogenes isolates recovered from the uterus of dairy cows with normal puerperium or clinical metritis.

Arcanobacterium pyogenes is considered to be the most relevant bacterium involved in the establishment of puerperal uterine infection in cattle due to its persistence in utero, resistance to treatment and synergic action with Gram negative anaerobes. Once the infection is established, A. pyogenes is responsible for the persistence of the infection. The objective of this study was to characterize A. pyogenes field isolates recovered from the uterus of cows with either normal puerperium or clinical metritis, in an attempt to identify factors that might be associated with the establishment and persistence of the disease. This characterization was based on BOX-PCR typing and on screening of eight virulence factor genes (plo, nanP, nanH, cbpA, fimA, fimC, fimE, fimG) by conventional PCR. Finally, a relationship between clonal types, virulence factors and presence of disease was investigated. A. pyogenes clonal types identified from isolates recovered from the uterus of postpartum dairy cows differed among herds. Although some clonal types were strictly associated with the development of clinical metritis, others were identified from isolates recovered from normal puerperium and clinical metritis cows. Moreover, the presence of the eight virulence factor genes was not related with the ability to induce clinical metritis, suggesting that the type of A. pyogenes may not be a determinant factor in the development of the disease. We suggest that host intrinsic factors, the synergism between A. pyogenes and other bacteria and the differential gene expression of virulence factor genes may play a more relevant role in the establishment of puerperal uterine infections.

Blood COX-2 and PGES gene transcription during the peripartum period of dairy cows with normal puerperium or with uterine infection.

In the dairy cow, puerperal uterine intra-luminal concentrations of PGE(2) are related to the establishment and severity of uterine infections. Here we evaluated whether the blood concentrations of PGE(2) and the gene transcription profiles of enzymes involved in its synthesis (cyclooxygenase-2 and prostaglandin E synthase) could be used as markers of predisposition and/or presence of puerperal uterine infections. We also studied the relationship between the endocrine status and the leukocyte profiles around parturition and the transcription patterns of the genes. Finally, we have characterized the in vitro gene transcription and expression response to a challenge of LPS. Gene transcription profiles, quantified by real-time PCR, were similar in normal puerperium and metritis/endometritis cows, indicating that they are not suitable markers of predisposition to/presence of puerperal uterine infections. Transcription decreased from 2 weeks before parturition until parturition, when a minimum was attained, and then increased during the first week postpartum. The lowest gene transcription, at parturition, was coincidental with the highest total leukocytes, polymorphonuclear neutrophils and CD14 positive cell numbers. It is suggested that by this mechanism, a large number of PMN can be recruited into the uterus after parturition, avoiding an excessive acute inflammatory response. The lowest gene transcription was also coincidental with the surge in cortisol concentrations, indicating that this hormone plays a main immunomodulatory role around parturition. Gene transcription was significantly greater after stimulation with LPS than in non-stimulated blood. We suggest that this PGE(2) producing cells might arrive to the uterine lumen, contributing to the local PGE(2) concentrations and mediating the inflammatory response.

Heterogeneous growth fingerlings of the Nile tilapia Oreochromis niloticus: effects of density and initial size variability.

In this study, the effect of initial heterogeneity of weight and density on heterogeneous growth (HetG) evaluated by the coefficient of the variation of weight in the young Nile tilapia Oreochromis niloticus of the territorial species was tested. Fish were maintained in a glass aquarium (8 and 2 L of water) with two levels of initial heterogeneity of weight: low and high, under two density conditions: low and high, thus constituting four conditions (six replications for each). Initially, the weights of the animals were taken after 8, 16, 22 and 30 days (end of experiment). The results, evaluated by the non-parametric test of Kruskal- Wallis, demonstrated that in the groups where the animals were stored under high initial HetG, there was a reduction of the same and that in the groups where the animals were stored under high density, there was exacerbation or maintained high values of HetG. High density in association with high initial heterogeneity caused more exacerbation of HetG in such a way that the density appeared to be a determining factor for exacerbation or the maintenance of high values of HetG, whereas the initial heterogeneity of the weight could be a secondary factor.

Cladocerans (Branchiopoda) of a tropical estuary in Brazil.

The study was conducted in the Capibaribe river estuary in Recife (Brazil) to assess the role played by cladocerans in a eutrophic environment. Samplings were carried out monthly at 4 fixed stations along the estuary from July 1987 to June 1988. Collections were made with a plankton net of 65 micrometers mesh size. Six cladocerans species were registered: Penilia avirostris, Diaphanosoma spinulosum, Chlydorus barroisi, Ceriodaphnia rigaudi, Ilyocryptus spinifer, and Moina micrura. The most frequent species was Moina micrura with 49%. The only true marine species was Penilia avirostris, which was registered at station 1 (close to the river mouth), during high and low tide and in the dry season. The Cladocera average density decreased from 329 ind.m'3 (August 1987, high tide) to 2 ind.m(-3) (March 1988, high tide) due to the high load of organic and chemical pollution received by the estuary. At all stations, D. spinulosum, M. micrura, and C. barroisi occurred with a wide distribution, mainly during the rainy season. C. rigaudi and I. spinifer were rare, occurring only during the rainy season. Cladocerans played an important role in the food webs of the plankton community of the Capibaribe tropical estuary and the dominance of a few small species indicated a hypereutrophic environment. A high level of disturbance was indicated by the decline in diversity of specialized species and the increase in abundance of opportunistic species like M. micrura.

Ecdysteroids from two Brazilian Vitex species.

A new ecdysteroid, 26-hydroxypinnatasterone (1), together with 20-hydroxyecdysone, was isolated from the stem barks of Vitex cymosa. 20-Hydroxyecdysone, ajugasterone C, ajugasterone C monoacetonide and turkesterone were isolated from the branches of V. polygama. The structure of 1 was determined by spectroscopic methods.

3,4-seco-Lupanes and other constituents from Platypodium elegans.

The isolation and NMR data of seco-lupane triterpenes and coumarins from Platypodium elegans are reported.

Anti-inflammatory and analgesic activity of Bouchea fluminensis.

Dried leaves extract from Bouchea fluminensis was assessed in anti-inflammatory (mouse paw edema) and analgesic models (acetic acid-induced writhings and hot plate). Oral pretreatment of animals with a crude mixture (IG) and a purified mixture of ursolic, oleanolic and micromeric acids (IG-59) at doses ranging from 1 to 30 mg/kg, significantly inhibited carrageenin-induced edema formation. At the same doses, IG and IG-59 also exhibited peripheral and central analgesic activity. It seems that B. fluminensis triterpenes develop their analgesic effect through central opioid receptors, due to the observation that naloxone reverted analgesic activity on the hot plate model.

Phytoplankton nyctemeral variation at a tropical river estuary (Itamaracá-Pernambuco-Brazil).

The Botafogo estuary is of socio-economical importance for Pernambuco State. It is located at the north of Santa Cruz Channel, Itamaracá, Pernambuco, Brazil (07 degrees 42' 50 "S and 34 degrees 52' 10" W). There is a critical need to understand its functioning because of the rate at which this area is being converted to land uses. The phytoplankton dynamics was studied to enhance the knowledge of and verify the possible changes which have occurred in this ecosystem. Sampling was carried out with a plankton net 65 micrometers mesh size for qualitative data, and a Van Dorn bottle for quantitative data. Concurrent hydrological and chlorophyll-a data were collected. Samplings were made in one fixed station in July 1996 (rainy season) and December 1996 (dry season), at 3-hour intervals during 24 hours. Eighty-seven specific and infra-specific taxa were identified from net plankton samples. Diatoms were most frequent, mainly Coscinodiscus centralis and Odontella regia in the rainy and dry seasons, respectively. Phytoplankton density varied from 205,000 to 1,210,000 cell.L-1 in the dry season, and from 230,000 to 2,510,000 cell.L-1 in the rainy season, indicating eutrophic conditions. Most numerically abundant were the diatoms Cyclotella meneghiniana and Cylindrotheca closterium and the phytoflagellates. The ecosystem is polluted, and deleterious effects are minimized by the marine influence which allows periodic water renewal.

Distribution of the planktonic shrimp Lucifer (Thompson, 1829) (Decapoda, Sergestoidea) off the Amazon.

Lucifer faxoni (BORRADAILE, 1915) and L. typus (EDWARDS, 1837) are species first identified in the neritic and oceanic waters off the Amazon. Samplings were made aboard the vessel "Antares" at 22 stations in July and August, 2001 with a bongo net (500-µm mesh size). Hydrological data were taken simultaneously for comparative purposes. L. faxoni was present at thirteen of the fourteen neritic stations analysed, as well as at five of the eight oceanic stations. L. typus was present at three of the fourteen neritic stations and in one of the eight oceanic stations. The highest density of L. faxoni in the neritic province was 7,000 ind.m(-3) (St. 82) and 159 ind.m(-3) (St. 75) in the oceanic area. For L. typus, the highest density observed was 41 ind.m(-3) (St. 64) in the neritic province. In the oceanic province, the highest single density value was recorded at station 75 (5 ind.m(-3)). Overall, L. faxoni typically presented the highest densities.