Challenges of Developing Robust AI for Intrapartum Fetal Heart Rate Monitoring.

Background: CTG remains the only non-invasive tool available to the maternity team for continuous monitoring of fetal well-being during labour. Despite widespread use and investment in staff training, difficulty with CTG interpretation continues to be identified as a problem in cases of fetal hypoxia, which often results in permanent brain injury. Given the recent advances in AI, it is hoped that its application to CTG will offer a better, less subjective and more reliable method of CTG interpretation. Objectives: This mini-review examines the literature and discusses the impediments to the success of AI application to CTG thus far. Prior randomised control trials (RCTs) of CTG decision support systems are reviewed from technical and clinical perspectives. A selection of novel engineering approaches, not yet validated in RCTs, are also reviewed. The review presents the key challenges that need to be addressed in order to develop a robust AI tool to identify fetal distress in a timely manner so that appropriate intervention can be made. Results: The decision support systems used in three RCTs were reviewed, summarising the algorithms, the outcomes of the trials and the limitations. Preliminary work suggests that the inclusion of clinical data can improve the performance of AI-assisted CTG. Combined with newer approaches to the classification of traces, this offers promise for rewarding future development.

Enablers and barriers to physical activity in overweight and obese pregnant women: an analysis informed by the theoretical domains framework and COM-B model.

BACKGROUND: Obesity during pregnancy is associated with increased risk of gestational diabetes mellitus (GDM) and other complications. Physical activity is a modifiable lifestyle factor that may help to prevent these complications but many women reduce their physical activity levels during pregnancy. Interventions targeting physical activity in pregnancy are on-going but few identify the underlying behaviour change mechanisms by which the intervention is expected to work. To enhance intervention effectiveness, recent tools in behavioural science such as the Theoretical Domains Framework (TDF) and COM-B model (capability, opportunity, motivation and behaviour) have been employed to understand behaviours for intervention development. Using these behaviour change methods, this study aimed to identify the enablers and barriers to physical activity in overweight and obese pregnant women. METHODS: Semi-structured interviews were conducted with a purposive sample of overweight and obese women at different stages of pregnancy attending a public antenatal clinic in a large academic maternity hospital in Cork, Ireland. Interviews were recorded and transcribed into NVivo V.10 software. Data analysis followed the framework approach, drawing on the TDF and the COM-B model. RESULTS: Twenty one themes were identified and these mapped directly on to the COM-B model of behaviour change and ten of the TDF domains. Having the social opportunity to engage in physical activity was identified as an enabler; pregnant women suggested being active was easier when supported by their partners. Knowledge was a commonly reported barrier with women lacking information on safe activities during pregnancy and describing the information received from their midwife as 'limited'. Having the physical capability and physical opportunity to carry out physical activity were also identified as barriers; experiencing pain, a lack of time, having other children, and working prevented women from being active. CONCLUSION: A wide range of barriers and enablers were identified which influenced women's capability, motivation and opportunity to engage in physical activity with "knowledge" as the most commonly reported barrier. This study is a theoretical starting point in making a 'behavioural diagnoses' and the results will be used to inform the development of an intervention to increase physical activity levels among overweight and obese pregnant women.

A Mixed-Methods Exploration of the Needs of People Living with HIV (PLWH) Enrolled in Access to Care, a National HIV Linkage, Retention and Re-Engagement in Medical Care Program.

Competing needs pose barriers to engagement in HIV medical care. Mixed methods were used to explore and describe the needs of participants enrolled in Access to Care, a national HIV linkage, retention and re-engagement in care (LRC) program that served people living with HIV who knew their status but were not engaged in care. When asked to prioritize their most urgent needs, participants reported housing or shelter (31%), HIV medical services (24%), and employment (8%). When we assessed the HIV continuum of care by needs status, we found no significant differences in linkage, retention, or viral suppression between participants with and without basic needs. Qualitative interviews with program staff contextualized the barriers to HIV medical care faced by participants and explored the strategies used by LRC programs to address participant needs. Study findings will be of use to future programs and have implications for HIV policy, in particular the implementation of the National HIV/AIDS Strategy (2015-2020).

Investigating the Perceived Benefits, Barriers and Beliefs towards Physical Activity in Pregnancy among Women with Gestational Diabetes Mellitus.

Gestational Diabetes Mellitus (GDM) is a growing concern and poses serious health risks to both mother and child1. The current study explores the psychological determinants of exercise behaviour in a sample of pregnant women with GDM. A cross-sectional survey design was employed to examine exercise behaviour, illness perceptions, perceived barriers and benefits, exercise beliefs, and exercise self-efficacy using validated questionnaires. A sample of 46 pregnant women was recruited from University College Hospital Galway, Letterkenny General Hospital, Cork University Hospital and Mayo General Hospital in Castlebar. Participant's varied; age (22-44 years), body mass index (19-41). High mean scores for Personal Control (24.5) and Treatment Control (30.2) subscales indicated strongly held positive beliefs in relation to controllability of the illness. Total MET-min/week score was not related to any psychological variables. Analysis of the IPQ-R data revealed 'diet' (n=37, 80.4%) as the most referred to cause of diabetes. Exercise belief data identified "managing weight gain" (n= 21, 45.7%), and "losing baby weight" (n= 31, 67.4%) as the most frequent beliefs for engaging in physical activity during pregnancy and post pregnancy. Further research on the psychological determinants of physical activity behaviour among this population group is needed in order to create successful intervention strategies.

Access to diagnostics in primary care and the impact on a primary care led health service.

We undertook a postal survey of GPs to establish their current access to radiological and endoscopic tests. More than one fifth of GPs do not have direct access to abdominal (n = 42, 21.4%) or pelvic (n = 49, 24.6%) ultrasound in the public system. Where access is available public patients have an average 14 week waiting period. In stark contrast in the private system virtually all GPs have direct access (n = 159, 99.2% and n = 156, 98.8% respectively for abdominal and pelvic ultrasound) with an average wait of just over four days. Direct access to CT scan in the public system is available to the minority of GPs, e.g. n = 31, 18.4% for chest scan, in the public system; even where available, there is an average 12 week wait for this. In comparison 151 (88.6%) GPs have access to CT chest scanning in the private sector with an average waiting time of 5.4 working days. Such limited access to diagnostics impacts on the delivery of a quality service.

Traffic Light: prognosis-based eligibility for clinical trials of hematopoietic SCT in adults with sickle cell anemia.

Estimating prognosis in sickle cell anemia (SCA) assumes greater importance as intensive treatments, such as hematopoietic SCT (HSCT), are being tested. Here we estimate the mortality risk from the walk-PHaSST (Sildenafil Therapy for Pulmonary Hypertension and Sickle Cell Disease) trial of homozygous SCA patients with suspected pulmonary hypertension (19/468 deaths; 10 centers in the US and UK). Parallel investigations were also undertaken in the Cooperative Study of Sickle Cell Disease (CSCCD) and a contemporary urban sickle cell disease population (Case Western Reserve University-University Hospitals (CWRU-UH), Cleveland, OH, USA). One- and two-value positive predictive values for 2-year mortality (from study entry) are calculated using factors that include demographics, laboratory values and clinical evaluations. We define high-, intermediate-, and low-risk SCA as > 15%, 10-15% and < 10% 2-year mortality. In walk-PHaSST, no single factor qualifies as high-risk SCA, although several combinations of two factors (that is, both age > 35 years and history of chronic transfusion) do. Either elevated white blood cell count (> 13.5 × 10(3) cells/mcL, 7/70 deaths) or elevated Tricuspid Regurgitant Jet Velocity (⩾ 3.0 m/s, 8/67 deaths) was individually associated with intermediate-risk disease, as were many two-factor combinations. N-terminal pro-brain natriuretic peptide > 160 ng/L, lactate dehydrogenase > 600 IU/L, history of chronic transfusion, sepsis or age > 35 years are individually associated with low-risk SCA, as are many two-factor combinations. SCA risk was integrated with estimated donor type-associated risk from HSCT to form 'Traffic Light' eligibility criteria for clinical trials of HSCT. This method is adaptable to evolutions in clinical care.

The impact of economic recession on infection prevention and control.

The economic recession that began in 2007 led to austerity measures and public sector cutbacks in many European countries. Reduced resource allocation to infection prevention and control (IPC) programmes is impeding prevention and control of tuberculosis, HIV and vaccine-preventable infections. In addition, higher rates of infectious disease in the community have a significant impact on hospital services, although the extent of this has not been studied. With a focus on quick deficit reduction, preventive services such IPC may be regarded as non-essential. Where a prevention programme succeeds in reducing disease burden to a low level, its very success can undermine the perceived need for the programme. To mitigate the negative effects of recession, we need to: educate our political leaders about the economic benefits of IPC; better quantify the costs of healthcare-associated infection; and evaluate the effects of budget cuts on healthcare outcomes and IPC activities.

Methylxanthine use for apnea of prematurity among an international cohort of neonatologists.

BACKGROUND: A recent multinational clinical trial in preterm infants has demonstrated pulmonary and neurodevelopmental benefits from caffeine therapy. Indications for caffeine use in that study were predominantly for treatment of apnea and facilitation of extubation rather than prophylaxis. There are no recent studies that describe current practice of neonatologists and regional differences in regards to indications for starting, monitoring and discontinuing methylxanthine therapy in premature infants. OBJECTIVE: To characterize the spectrum of current practice and demonstrate the extent to which methylxanthine therapy varies by location. METHODS: A cross-sectional survey of all neonatologists in Thailand, Lebanon, Australia, and a representative sample in the USA regarding management of apnea of prematurity. RESULTS: The response rate was 50% (342/681). The methylxanthine of choice varied greatly across study locations. Prophylactic methylxanthine use is common (62%) among neonatologists in all four study locations. Significant variation exists in almost all aspects of apnea pharmacotherapy practice among neonatologists in different international locations. CONCLUSIONS: Prophylactic use of methylxanthine therapy for apnea of prematurity is widespread. We speculate that this expanded use is possibly attributed to the beneficial effects of caffeine therapy in the Caffeine for Apnea of Prematurity (CAP) Trial.

A randomized trial of the Vein Viewer versus standard technique for placement of peripherally inserted central catheters (PICCs) in neonates.

OBJECTIVE: Peripherally inserted central catheters are important but can be difficult to place in neonates. Therefore, we compared a near-infrared device, the Vein Viewer, to determine if its use would increase successful line placement, with standard techniques. STUDY DESIGN: Randomized controlled trial in preterm and term neonates in a level 3 Neonatal Intensive Care Unit. RESULT: In all, 115 subjects were enrolled with 59 randomized to the Vein Viewer group and 56 to the control group. Overall, use of the Vein Viewer showed a trend to more successful placement 86 versus 75%; unadjusted odds ratio 2.33 (0.90, 6.04; P=0.08). Infants randomized to the Vein Viewer were more mature (30 ± 2 weeks gestational age (GA) versus 28 ± 2 weeks GA; P=0.08). After adjusting for GA, use of the Vein Viewer was significantly more likely to lead to successful line placement (adjusted odds ratio 3.05 (1.10, 1.82)). CONCLUSION: The Vein Viewer improved successful placement with the most benefit seen in infants of greater GA.

The maximal cytoprotective function of the heat shock protein 27 is dependent on heat shock protein 70.

Endogenous heat shock proteins (HSPs) 70 and 25/27 are induced in renal cells by injury from energy depletion. Transfected over-expression of HSPs 70 or 27 (human analogue of HSP25), provide protection against renal cell injury from ATP deprivation. This study examines whether over-expressed HSP27 depends on induction of endogenous HSPs, in particular HSP70, to afford protection against cell injury. LLC-PK1 cells transfected with HSP27 (27OE cells) were injured by ATP depletion for 2h and recovered for 4h in the presence of HSF decoy, HSP70 specific siRNA (siRNA-70) and their respective controls. Injury in the presence of HSF decoy, a synthetic oligonucleotide identical to the heat shock element, the nuclear binding site of HSF, decreased HSP70 induction by 80% without affecting the over-expression of transfected HSP27. The HSP70 stress response was completely ablated in the presence of siRNA-70. Protection against injury, provided by over-expression of HSP27, was reduced by treatment with HSF decoy and abolished by treatment with siRNA-70. Immunoprecipitation studies demonstrated association of HSP27 with actin that was not affected by either treatment with HSF decoy or siRNA. Therefore, HSP27 is dependent on HSP70 to provide its maximal cytoprotective effect, but not for its interaction with actin. This study suggests that, while it has specific action on the cytoskeleton, HSP 25/27 must have coordinated activity with other HSP classes, especially HSP70, to provide the full extent of resistance to injury from energy depletion.

An unusual case of small bowel obstruction post caesarean section.

Small bowel obstruction (SBO) is a very rare complication post-caesarean section (CS). Herniation of small bowel through the rectus muscle with an intact sheath is extremely rare. We present a case of SBO after an uncomplicated c-section and an uneventful early postoperative course.

Analysis of postural stability following posterior spinal fusion in adolescents with idiopathic scoliosis.

This study uses experimental data acquired from adolescents with idiopathic scoliosis to assess their postural control during quiet standing before and after posterior spinal fusion. Statistically significant differences were seen when comparing the pre- and post-surgical measures of balance calculated from data for three different test conditions.

The NRPB era.

Some 40 years ago, in May 1970, the Radiological Protection Bill was passed by the parliament of the United Kingdom. This legislation created the National Radiological Protection Board (NRPB). It lasted 35 years until absorbed by the Health Protection Agency in 2005. During that period, the NRPB discharged its basic duty of protecting the people from radiation hazards.

Relationships among depressive symptoms, sexually transmitted infections, and pregnancy in African-American adolescent girls.

STUDY OBJECTIVE: To explore relationships among depressive symptoms, sexually transmitted infections (STI), and pregnancy in African-American adolescent girls. DESIGN: Retrospective chart review. SETTING: A hospital-based outpatient practice serving primarily African-American patients. PARTICIPANTS: A total of 126 female patients ages 13-19 years who had ligase chain reaction (LCR) for N. gonorrhoeae and C. trachomatis. METHODS: Charts were reviewed for history of STI, history of pregnancy, LCR results, and a history of depressive symptoms as indicated by standardized provider notes and patient self-administered questionnaire. Data are compared using Fisher's exact test. RESULTS: Mean age was 16.6 years (+/-1.6 years); 19.8% of participants had a history of depressive symptoms, 40.5% had a history of STI, 8.7% had a prior pregnancy, and 18.2% had a positive LCR. Of patients with a history of depressive symptoms, 64% had a history of STI compared to 34.6% of those without depressive symptoms (P = 0.01). A positive LCR was found in 20% of patients with a history of depressive symptoms and 17.8% of patients without (P = 0.78). Of patients with a history of depressive symptoms, 12% had a prior pregnancy compared to 7.9% without such history (P = 0.45). CONCLUSIONS: African-American adolescent females in our clinic with a history of depressive symptoms were more likely to have a history of STI. A greater percentage of patients with a history of depressive symptoms also had prior pregnancies and/or current STI. Sexually active adolescent girls should be screened for depressive symptoms as part of their evaluation for sexual risk behaviors.

Prevalence of suboptimal vitamin D status during pregnancy.

Low maternal vitamin D status has been associated with reduced intrauterine long bone growth and shorter gestation, decreased birth weight, as well as reduced childhood bone-mineral accrual. Despite data from other countries indicating low maternal vitamin D status is common during pregnancy, there is a dearth of information about vitamin D status during pregnancy in the Irish female population. Therefore, we prospectively assessed vitamin D nutritive status and the prevalence of suboptimal vitamin D status in a cohort of Irish pregnant women. The mean (SD) daily intake of vitamin D by the group of pregnant women was 3.6 (1.9) microg/day. None of the women achieved the recommended daily vitamin D intake value for Irish pregnant women (10 microg/day). Taking all three trimesters collectively, 14.3-23.7% and 34.3-52.6% of Irish women had vitamin D deficiency (serum 25 (OH) D <25 nmol/l) and insufficiency (serum 25 (OH) D 25-50 nmol/l), respectively during pregnancy. Both the levels of serum 25 (OH) D and the prevalence of vitamin D deficiency/adequacy were dramatically influenced by season, with status being lowest during the extended winter period and best during the extended summer period. These findings show that inadequate vitamin D status is common in Irish pregnant women.

Patient outcomes and economics of once-daily tacrolimus in renal transplant patients: results of a modeling analysis.

PURPOSE: The objective of this study was to model patient outcomes and treatment costs over a 5-year horizon time for renal transplant patients comparing twice-daily tacrolimus to once-daily extended-release tacrolimus as a primary immunosuppressive agent. METHODS: We constructed a stochastic state-transition model to simulate the incidence of acute rejection, graft loss and subsequent return to dialysis, retransplantation, and mortality among transplanted patients, as well as their associated costs. The two immunosuppressive treatment arms analyzed were twice-daily tacrolimus plus mycophenolate mofetil (MMF) and once-daily extended-release tacrolimus plus MMF. Estimates for the current rate of adherence to twice-daily medication, as well as the improvement in adherence expected in a once-daily medication, were taken from literature reviews. Sensitivities around these estimates were analyzed. Cost data for medical procedures and hospitalization were obtained from Medicare and the United States Renal Data System (USRDS). Medicare ASP prices from July 2006 were used to price pharmaceutical products. Once-daily extended-release tacrolimus was assumed to have the same daily cost as twice-daily tacrolimus. RESULTS: Patient outcomes included a decrease in acute rejections, increase in graft survival, and a corresponding decrease in number of patients on dialysis. Using once-daily extended-release tacrolimus increased graft survival at 5 years from 63.0% to 69.1% an absolute increase of 6.1 percentage points. Overall cost savings averaged $9411 per patient over the 5-year treatment using a 5% discount rate. Total costs, including initial transplantation, were $238,144 for twice-daily tacrolimus and $228,734 for once-daily extended-release tacrolimus.