The effect of cervical pessary on increasing gestational age at delivery in twin pregnancies with asymptomatic short cervix: a systematic review and meta-analysis of randomized controlled trials.

Objective: The incidence of preterm delivery is much higher in twin pregnancies than in singletons and even higher if a short cervical length is detected in the second trimester. Studies are contradictory regarding the efficacy of a cervical pessary to decrease preterm birth in twin pregnancies and short cervical length. To conduct a systematic review and meta-analysis investigating the efficacy of cervical pessary in prolonging gestation, preventing preterm birth, and reducing adverse neonatal outcomes in twin pregnancies with an asymptomatic short cervix. Data sources: PubMed, Scopus, Web of Science, and ClinicalTrials.org were searched for randomized controlled trials from inception to June 2023. Study eligibility criteria: In this study, randomized controlled trials comparing the cervical pessary to expectant management in the pregnant population with twin gestations and asymptomatic short cervix were included. Methods: The Cochrane risk-of-bias-2 tool for randomized controlled trials was used for the evaluation of the risk of bias in included studies. A meta-analysis was performed by calculating risk ratio and mean difference with their 95% confidence interval using the random effects model or fixed effect model on the basis of heterogeneity and accounting for potential covariates among the included randomized controlled trials. Results: A total of 6 randomized controlled trials were included in the analysis. Cervical pessary did not significantly increase the gestational age at delivery in twin pregnancies with asymptomatic patients (mean difference, 0.36 weeks [-0.27 to 0.99]; P=.270; I2=72.0%). Moreover, the cervical pessary use did not result in a reduction of spontaneous or all-preterm birth before 37 weeks of gestation (risk ratio, 0.88 [0.77-1.00]; P=.061; I2=0.0%). There was no statistically significant difference in the composite neonatal adverse outcomes (risk ratio, 1.001 [0.86-1.16]; P=.981; I2=20.9%), including early respiratory morbidity, intraventricular hemorrhage, necrotizing enterocolitis, and confirmed sepsis. Conclusion: The use of cervical pessary in twin pregnancies with asymptomatic short cervix does not seem to be effective in increasing the gestational age at delivery, preventing preterm birth, or reducing adverse neonatal outcomes. This indicates that alternative interventions should be sought for the management of this patient population.

Divergent growth of the transient brain compartments in fetuses with nonsyndromic isolated clefts involving the primary and secondary palate.

Cleft lip/palate is a common orofacial malformation that often leads to speech/language difficulties as well as developmental delays in affected children, despite surgical repair. Our understanding of brain development in these children is limited. This study aimed to analyze prenatal brain development in fetuses with cleft lip/palate and controls. We examined in utero MRIs of 30 controls and 42 cleft lip/palate fetal cases and measured regional brain volumes. Cleft lip/palate was categorized into groups A (cleft lip or alveolus) and B (any combination of clefts involving the primary and secondary palates). Using a repeated-measures regression model with relative brain hemisphere volumes (%), and after adjusting for multiple comparisons, we did not identify significant differences in regional brain growth between group A and controls. Group B clefts had significantly slower weekly cerebellar growth compared with controls. We also observed divergent brain growth in transient brain structures (cortical plate, subplate, ganglionic eminence) within group B clefts, depending on severity (unilateral or bilateral) and defect location (hemisphere ipsilateral or contralateral to the defect). Further research is needed to explore the association between regional fetal brain growth and cleft lip/palate severity, with the potential to inform early neurodevelopmental biomarkers and personalized diagnostics.

Mammalian target of rapamycin inhibitors: A new-possible approach for in-utero medication therapy.

The mammalian/mechanistic target of rapamycin (mTOR) is a protein kinase that plays a crucial role in regulating cellular growth, metabolism, and survival. Although there is no absolute contraindication for the use of mTOR inhibitors during pregnancy, the specific fetal effects remain unknown. Available data from the past 2 decades have examined the use of mTOR inhibitors during pregnancy in patients with solid organ transplantation, showing no clear link to fetal complications or structural abnormalities. Recently, a handful of case reports and series have described transplacental therapy of mTOR inhibitors to control symptomatic and complicated pathologies in the fetus. The effect of these agents includes a significant reduction in lesion size in the fetus and a reduced need for mechanical ventilation in neonates. In this context, we delve into the potential of mTOR inhibitors as in-utero therapy for fetal abnormalities, with a primary focus on lymphatic malformation (LM) and cardiac rhabdomyoma (CR). While preliminary reports underscore the efficacy of mTOR inhibitors for the treatment of fetal CR and fetal brain lesions associated with tuberous sclerosis complex, chylothorax, and LMs, additional investigation and clinical trials are essential to comprehensively assess the safety and efficacy of these medications.

Delivery outcomes in the subsequent pregnancy following the conservative management of placenta accreta spectrum disorder: a systematic review and meta-analysis.

OBJECTIVE: Cesarean hysterectomy is generally presumed to decrease maternal morbidity and mortality secondary to placenta accreta spectrum disorder. Recently, uterine-sparing techniques have been introduced in conservative management of placenta accreta spectrum disorder to preserve fertility and potentially reduce surgical complications. However, despite patients often expressing the intention for future conception, few data are available regarding the subsequent pregnancy outcomes after conservative management of placenta accreta spectrum disorder. Thus, we aimed to perform a systematic review and meta-analysis to assess these outcomes. DATA SOURCES: PubMed, Scopus, and Web of Science databases were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA: We included all studies, with the exception of case studies, that reported the first subsequent pregnancy outcomes in individuals with a history of placenta accreta spectrum disorder who underwent any type of conservative management. METHODS: The R programming language with the "meta" package was used. The random-effects model and inverse variance method were used to pool the proportion of pregnancy outcomes. RESULTS: We identified 5 studies involving 1458 participants that were eligible for quantitative synthesis. The type of conservative management included placenta left in situ (n=1) and resection surgery (n=1), and was not reported in 3 studies. The rate of placenta accreta spectrum disorder recurrence in the subsequent pregnancy was 11.8% (95% confidence interval, 1.1-60.3; I2=86.4%), and 1.9% (95% confidence interval, 0.0-34.1; I2=82.4%) of participants underwent cesarean hysterectomy. Postpartum hemorrhage occurred in 10.3% (95% confidence interval, 0.3-81.4; I2=96.7%). A composite adverse maternal outcome was reported in 22.7% of participants (95% confidence interval, 0.0-99.4; I2=56.3%). CONCLUSION: Favorable pregnancy outcome is possible following successful conservation of the uterus in a placenta accreta spectrum disorder pregnancy. Approximately 1 out of 4 subsequent pregnancies following conservative management of placenta accreta spectrum disorder had considerable adverse maternal outcomes. Given such high incidence of adverse outcomes and morbidity, patient and provider preparation is vital when managing this population.

Atypical fetal brain development in fetuses with non-syndromic isolated musculoskeletal birth defects (niMSBDs).

Non-syndromic, isolated musculoskeletal birth defects (niMSBDs) are among the leading causes of pediatric hospitalization. However, little is known about brain development in niMSBDs. Our study aimed to characterize prenatal brain development in fetuses with niMSBDs and identify altered brain regions compared to controls. We retrospectively analyzed in vivo structural T2-weighted MRIs of 99 fetuses (48 controls and 51 niMSBDs cases). For each group (19-31 and >31 gestational weeks (GW)), we conducted repeated-measures regression analysis with relative regional volume (% brain hemisphere) as a dependent variable (adjusted for age, side, and interactions). Between 19 and 31GW, fetuses with niMSBDs had a significantly (P < 0.001) smaller relative volume of the intermediate zone (-22.9 ± 3.2%) and cerebellum (-16.1 ± 3.5%,) and a larger relative volume of proliferative zones (38.3 ± 7.2%), the ganglionic eminence (34.8 ± 7.3%), and the ventricles (35.8 ± 8.0%). Between 32 and 37 GW, compared to the controls, niMSBDs showed significantly smaller volumes of central regions (-9.1 ± 2.1%) and larger volumes of the cortical plate. Our results suggest there is altered brain development in fetuses with niMSBDs compared to controls (13.1 ± 4.2%). Further basic and translational neuroscience research is needed to better visualize these differences and to characterize the altered development in fetuses with specific niMSBDs.

Achieving herd immunity in South America.

South America, once an epicenter of COVID-19, has stayed on the road of continued management of the pandemic. The region initially struggled to cope with the pandemic as it experienced spiraling numbers of infections and overwhelmed public health systems. South America has risen in its pandemic response to be the region with the highest global vaccination rate. The region posed a strong vaccination drive, with over 76% of its population fully vaccinated with the initial protocol. South America leveraged its deeply rooted vaccination culture and public health confidence among its population. Herd immunity is an integral concept in population infectious disease management. Attaining herd immunity is presently not feasible with available vaccines, but the high vaccination rate in the region depicts the acceptance of vaccination as a strategy for population protection. The availability of effective transmission-blocking vaccines, the continuous implementation of strategies that will enable the undisrupted supply of the vaccines, equity in access to the vaccines, improved vaccine acceptance, and trust in the vaccination and public health systems will help shepherd the region towards herd immunity. Local vaccine production backed with investment in infrastructure and international collaboration for research and knowledge development will also drive population safety.

Perinatal outcomes of twin-to-twin transfusion syndrome associated with evidence of twin anemia polycythemia using different standardized definitions.

OBJECTIVES: To evaluate the survival of twin-to-twin transfusion syndrome (TTTS) and concomitant twin anemia polycythemia sequence (TAPS) compared to TTTS without TAPS at the time of fetoscopic laser photocoagulation (FLP). METHODS: TTTS pregnancies undergoing FLP were divided to three groups including (i) traditional TAPS definition of middle cerebral artery (MCA) peak systolic velocity (PSV) < 1 multiple of the median (MoM) in recipient and > 1.5 MoM in the donor fetus, (ii) delta MCA-PSV > 0.5 MoM and (iii) delta MCA-PSV > 1.0 MoM. RESULTS: A total of 353 monochorionic twins underwent FLP for TTTS. Based on the traditional definition, 335 (94.9 %) had TTTS only and 18 (5.1 %) had TTTS + TAPS. There were 245 (69.4 %) TTTS only and 108 (30.6 %) TTTS + TAPS considering delta MCA-PSV > 0.5 MoM and 339 (96 %) TTTS only and 14 (4 %) TTTS + TAPS considering delta MCA-PSV > 1.0 MoM. No significant differences in survival were noted at birth or 30-days after delivery between TTTS and TTTS with TAPS patients using the traditional definition, delta > 0.5 MoM or delta > 1.0 MoM. CONCLUSION: The rate of neonatal survival at birth or at 30-days of life following FLP for TTTS only and TTTS with TAPS were not different based on any of the clinically used TAPS definitions.

COVID-19: National Pandemic Management Strategies and their Efficacies and Impacts on the Number of Secondary Cases and Prognosis: A Systematic Review.

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for an acute respiratory disease designated COIVD-19, which has spread throughout the world. Despite all the struggles with this virus, still, the majority of societies are affected by COVID-19, which raises many questions such as are these ways of management enough, which is crucial in order to contain the virus spread, and which is not effective. In this systemic review, we tried to summarize the data on different ways of managing COVID-19 outbreaks. Through understanding the efficacy and downsides of different approaches to manage COVID-19, public health officials, governing bodies, and health care administrators may be better equipped with the tools necessary to best manage COVID-19 and pandemics. Methods: This systematic review was carried out by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Articles were selected using several databases PubMed, ScienceDirect, and Google Scholar, all peer-reviewed and published articles from December 1, 2019 to April 23, 2020 that met the inclusion criteria were selected. Results: The majority of the included articles were mathematical modeling, cohort studies (n = 9), cross-sectional (n = 6), and one case series. Most articles originated from China and then Singapore. The measures that have been practiced in these articles consisted of close contact tracing and case isolation, quarantine, strict surveillance, lockdown, and travel surveillance. Conclusions: The most effective approach is at least the combination of case detection and isolation, and contact tracing or containment measures. In the literature, travel controls seem to be ineffective, personal hygiene should be tough and emphasized.

Afghan Health Related Concerns Following the US Withdrawal: Results of a Survey Given via Social Media.

Background: The United States Armed Forces completed their withdrawal from Afghanistan on August 30th, 2021, ending 20 years of war in Afghanistan. This rapid timeline from announcement to withdrawal and subsequent power transfer had profound consequences on the Afghan people, particularly in the domains of health and healthcare. Methods: On 15 September 2021, we posted an anonymous online cross-sectional survey on social media (Twitter, Facebook, and WhatsApp groups) to collect data about respondents from Afghanistan. Questions focused on COVID-19 symptoms, concerns, and individual care with a focus on changes related to the United States (US) withdrawal from Afghanistan. The form was composed of 17 questions which included multiple choice, single choice, and numeric options. All questions were optional including demographic data. Results: Our survey yielded 1,074 responses from the Farsi version and 572 responses from the Pashto version for a total of 1,646 responses. 1,286 (80%) of respondents were in Afghanistan at the time of survey submission. Concerning the US withdrawal from Afghanistan, 26% (412) respondents were extremely concerned and 12% (181) were moderately concerned. A majority of respondents report concerns regarding mental health due to the US withdrawal. 27% (418) report extreme concern, 12% (186) report moderate concern, and 15% (229) report a little concern. There is a significant difference in the proportions of concern (for US withdrawal generally, as well as physical and mental health) across gender. 49% of Female respondents report extreme concern regarding the US withdrawal compared to 22% of Male respondents (P < 0.001). With respect to physical health concerns 36% of Females report extreme concern compared to 16% of Males (P < 0.001). Finally on the mental health concerns, 54% of Females report extreme concern compared to 22% of Males (P < 0.001). Conclusion: The results from this survey are susceptible to the possibility of internal validity and/or external validity. However, we are accepting of those possibilities considering this survey wasn't designed to be bulletproof, but rather serve as a voice for those who can't be heard and to inform the public of the hardships occurring across the globe due to a steadfast retraction of the US footprint from their soil. Our findings indicate salient changes and public health concerns among Afghans following the US withdrawal from the region. These concerns varied across gender and ethnic groups. Our findings may serve as the first step in addressing the health concerns of Afghans following two decades of US military presence. The results should be understood through the limitations associated with a survey study design. Future research and policy aimed at tackling short and long-term health and social concerns in Afghanistan should consider the role of US withdrawal.

Women's sexual function before and during COVID-19 pandemic: A systematic review and meta-analysis.

BACKGROUND: To systematically review and summarize the available literature regarding the women's sexual function during COVID-19 pandemic and compare it to pre-pandemic period. METHODS: We searched PubMed and Embase from the inception of the databases until 15th April 2021. Data regarding the sexual function, measured by female sexual function index (FSFI), of adult sexually active women were extracted from the eligible studies and compared between the before and during the COVID-19 pandemic. The secondary outcome was the frequency of intercourse during pandemic time. The random-effect model was used to pool the mean differences and corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 value. RESULTS: Our search resulted in a sample of six eligible studies, which involved 1114 female participants. The total FSFI score among study participants during pandemic was 22.93 (95% CI: 19.26-26.59), which indicated a significant decrease in sexual function of women during pandemic as compared to pre-pandemic time (mean difference = -3.80, 95% CI: -6.48 to -1.12, p = 0.005, I2  = 96%). We also conducted a meta-analysis of individual FSFI domains. During pandemic, women had problems with arousal (p < 0.0001), orgasm (p = 0.0008), satisfaction (p = 0.0009), and pain (p = 0.009). No significant difference in frequency of intercourse was observed between pre- and during pandemic (p = 0.80). Furthermore, no significant publication bias was present among included studies. CONCLUSION: Overall, there was a significant decrease in sexual function of sexually active adult women during COVID-19 pandemic. The most affected areas of sexual function were arousal, orgasm, pain, and satisfaction. Physicians must be aware of COVID-19 impact on sexual life of women and provide proper counseling.

War Experience, Daily Stressors and Mental Health Among the Inter-taliban Generation Young Adults in Northern Afghanistan: A Cross-Sectional School-Based Study.

Objectives: The specific objectives of the study are to examine the mental health (depression and anxiety) of the first generation of post-Taliban government and compare these measures with its preceding generation, and to assess war experience of the first generation of post-Taliban government. We also wanted to assess the daily stressors and their contribution to the mental health, and to assess mental health as a result of war experiences and daily stressors with respect to demographic measures such as sex, marital status, age, mother's age, birth order, and ethnicities. Methods: In a cross-sectional design, 621 high school students, were randomly selected to participate in the study to assess war experience, daily stressors, and mental health among the first generation of young adults under post-Taliban government. Results: The participants had 17.37 ± 0.9 mean years of ages, 94.8% of them were unmarried. Poor mental health was significantly associated with higher exposure to war, but not with the age of participants (P = 0.08). There was no association between war experiences and the age and ethnicity of our participants (p = 0.9, p = 0.7). Age differences were negligible for daily stressors too (P = 0.07). Daily stressors scores were higher for female than male students (P = 0.02). The majority of young adults surveyed, declared themselves in agreement with statements such as the security situation in Afghanistan makes me frustrated (56%), air pollution as a concern (41%), and not having anyone to talk about what is in their heart (28.8%). Gender differences were highly significant for mental health, as appraised by both The Hopkins Symptoms Checklist (HSCL) -depression and HSCL-anxiety. Girls presented higher rates of depression, anxiety, and daily stressors than boys, and boys presented higher rates of war experiences than girls. Conclusion: War experience, daily stressors, and mental health were irrelevant with age, ethnicity and marital status. Factor such as being the first-born child of the family, higher reported war experiences, and daily stressors all negatively impact mental health. Alongside war and its direct effects, the existing socio-cultural context must be considered as a potential factor mediating the mental health of girls in Afghanistan.

Vaginal bleeding as a sign of Crimean-Congo hemorrhagic fever infection: a case report.

BACKGROUND: Crimean-Congo hemorrhagic fever is a severe vector-borne viral hemorrhagic fever with considerable mortality in humans. This disease is endemic in Afghanistan, and its incidence rate has rapidly increased in recent years. This infection can cause a broad range of hemorrhage manifestations including epistaxis, petechial or purpuric rashes, hematemesis, and melena; however, vaginal bleeding is also reported as a rare manifestation. CASE PRESENTATION: We report the case of a previously healthy 30-year-old Afghan female of shepherding occupation, with a sudden onset of fever, generalized body pain, epistaxis, and vaginal bleeding. She was admitted to the hospital after 7 days of symptom manifestation, with predominant signs being high fever, vaginal bleeding, and elevated liver enzymes. The serological test result for Crimean-Congo hemorrhagic fever was positive. She was treated with oral ribavirin and discharged with normal parameters. CONCLUSIONS: People in high-risk professions in endemic areas should be informed that vaginal bleeding is a serious symptom and requires immediate action and, therefore, might be attributed to nongynecologic disorders.

The daunting task of fighting HIV in Afghanistan: Current evidence and future recommendations.

The human immunodeficiency virus (HIV), like any other disease, has created great worry in Afghanistan. The country's slew of issues has paved the way for HIV to spread and go unchecked. International groups have banded together to stop the virus's spread since the first case was confirmed in Afghanistan. The cumulative effects of international collaboration have aided in the reduction of cases and improved awareness. Because of their injection use, a large portion of the country's population has been classified as a vulnerable category for HIV infection. Awareness campaigns and international collaboration should be implemented to further limit the spread of HIV.

Prevalence and determinants of self-medication with antibiotics among general population in Afghanistan.

OBJECTIVE: Self-medication with antibiotics (SMA) is a common cause of antibiotic resistance, a major public health problem. This research aimed to identify the prevalence of SMA and explore reasons for practicing SMA among people living in Kabul, Afghanistan. METHODS: A community-based cross-sectional study was conducted from May to November 2017 in 12 community pharmacies operating across Kabul, Afghanistan. Multivariable logistic regression was conducted to identify the factors associated with the use of SMA. RESULTS: Out of 385 participants, 282 (73.2%) practiced SMA during the last year. Overall, 241 (62.6%) were 'very concerned' about the use of SMA, and 156 (40.5%) highlighted it is bad to practice SMA. The top three antibiotics used for self-medication were penicillin (ATC class: J01C), metronidazole (ATC: P01AB01), and ceftriaxone (ATC: J01DD04). Economic problems, lack of time to visit doctors, and ease of use were cited as the main reasons for practicing SMA. Furthermore, female participants were less likely to practice SMA compared to male counterparts. CONCLUSION: While efforts should be directed to enforce strict drug regulations system and awareness programs, priority should be given to provide accessible, affordable, and quality health care services to increase citizen's compliance to appropriate drug prescriptions.