Vitamin B12 deficiency presenting with a pancytopenia in pregnancy.

Vitamin B12 deficiency is a significant public health problem globally. Although it is a well-known cause of macrocytic anaemia and in advanced cases, pancytopenia, there remains a relative paucity of cases reported in pregnancy. It is associated with an increased risk of pregnancy complications and adverse birth outcomes such as neural tube defects, preterm birth, low birth weight, neurological sequelae and intrauterine death. It has a predilection for individuals aged >60 years. It has been implicated in a spectrum of neuropsychiatric disorders and it may also exert indirect cardiovascular effects. Severe vitamin B12 deficiency may present with haematological abnormalities that mimic thrombotic microangiopathy such as HELLP syndrome (haemolysis, elevated liver enzymes and low platelets) or it may present as pseudothrombotic microangiopathy (Moschcowitz syndrome) characterised by anaemia, thrombocytopenia and schistocytosis. It can also closely mimic thrombotic thrombocytopenia purpura, hence posing a diagnostic challenge to the unwary physician. Serological measurement of vitamin B12 levels confirms the diagnosis. Oral supplementation with vitamin B12 remains a safe and effective treatment. The authors describe the case of a multiparous woman in her late 20s presenting with a plethora of non-specific symptoms at 29+5 weeks' gestation. Her haemoglobin was 45 g/L, platelets 32×109/L, vitamin B12 <150 ng/L and serum folate <2 µg/L. She was not a vegetarian, but her diet lacked nutrition. Following parenteral B12 supplementation, her haematological parameters improved. The pregnancy was carried to term. Due to the plethora of non-specific symptoms, the diagnosis can be challenging to establish. Adverse maternal or fetal outcomes may occur. Folic acid supplementation may mask an occult vitamin B12 deficiency and further exacerbate or initiate neurological disease.

Solution-processed double-layered hole transport layers for highly-efficient cadmium-free quantum-dot light-emitting diodes.

The search for heavy-metal-free quantum-dot light-emitting diodes (QD-LEDs) has greatly intensified in the past few years because device performance still falls behind that of CdSe-based QD-LEDs. Apart from the effects of nanostructures of the emitting materials, the unbalanced charge injection and transport severely affects the performance of heavy-metal-free QD-LEDs. In this work, we presented solution-processed double hole transport layers (HTLs) for improving the device performance of heavy-metal-free Cu-In-Zn-S(CIZS)/ZnS-based QD-LEDs, in which N,N'-Bis(3-methylphenyl)-N,N'-bis(phenyl)benzidine (TPD) as an interlayer was incorporated between the emitting layer and the HTL. Through optimizing the thickness of poly(9,9-dioctylfluorene-co-N-(4-butylphenyl)diphenyl-amine (TFB) and TPD layers, a maximum external quantum efficiency (ηEQE) of 3.87% and a current efficiency of 9.20 cd A-1 were achieved in the solution-processed QD-LEDs with double-layered TFB/TPD as the HTLs, which were higher than those of the devices with pristine TFB, TPD and TFB:TPD blended layers. The performance enhancement could be attributed to the synergistic effects of the reduction of the hole injection barrier, the increase of the hole mobility and suppressed charge transfer between the HTL and the emitting layer. Furthermore, the best ηEQE of 5.61% with a mean ηEQE of 4.44 ± 0.73% was realized in the Cu-In-Zn-S-based QD-LEDs by varying the annealing temperature of TPD layer due to the more balanced charge injection and transport as well as smooth surface of TPD layer.

A systematic review on the use of new anticoagulants in pregnancy.

New anticoagulants such as direct factor Xa inhibitors and direct thrombin inhibitors have been recently developed, but their experience in pregnancy is limited. This review therefore aims to systematically search for studies on the use of these newer anticoagulants in pregnancy and the puerperal period. Searches were performed on electronic databases MEDLINE (from 1966), EMBASE (from 1974) and the Cochrane Library, until October 2011 using terms of 'pregnancy', 'puerperium', 'breastfeeding' and names of specific anticoagulants. The search yielded 561 citations and 11 studies (10 on fondaparinux, 1 on ximelagatran) were included. Newer anticoagulants (fondaparinux, hirudin and argatroban) on the limited evidence appear not to have adverse pregnancy outcomes, but there is currently no experience of new oral anticoagulants (rivaroxaban, apixaban, betrixaban or dabigatran) use in pregnancy. There is a need for reporting on new oral anticoagulation use in pregnancy to provide more information about the safety and risks to the fetus in utero.

A feasibility trial of screening women with idiopathic recurrent miscarriage for high uterine natural killer cell density and randomizing to prednisolone or placebo when pregnant.

STUDY QUESTION: Is it feasible to screen women with idiopathic recurrent miscarriage (RM) for high uterine natural killer (uNK) cell density and then randomize them to prednisolone or placebo when pregnant? SUMMARY ANSWER: It was feasible to recruit women with idiopathic RM into a 'screen and treat' trial despite their desire for active medication. WHAT IS KNOWN ALREADY: Clinical trials of immunotherapy in women with idiopathic RM have failed to substantiate efficacy in preventing miscarriage. Preimplantation uNK cell density is higher in women with RM and can be reduced with prednisolone. STUDY DESIGN, SIZE, DURATION: In a pilot RCT, 160 eligible women were screened with an endometrial biopsy and those with high uNK cell density were invited to return when pregnant for randomization to prednisolone (20 mg for 6 weeks, 10 mg for 1 week, 5 mg for 1 week) or identical placebo tablets. Randomization was by random number generation and patients, clinicians and outcome assessors were blinded to allocation. The study size and duration was determined by funding, which was for a feasibility trial, for 2 years, sufficient to screen 150 women and randomize 40 women. The outcome measures were recruitment rate, women's perspectives, compliance, live birth and miscarriage rates and pregnancy complications. PARTICIPANTS/MATERIALS, SETTING, METHODS: The trial was advertised nationally in the UK. Women who attended research clinics run by one consultant (SQ) with three or more consecutive idiopathic miscarriages were included. Women's perspectives of the trial were sought through a questionnaire. The endometrium was sampled 5-9 days after the LH surge, stained using immunohistochemistry for CD56 and the sub-epithelial region analysed with image analysis. Women with a high uNK cell density (>5%) were invited to contact the clinic at 4-6 weeks gestation for randomization. Compliance with medication was assessed using a daily log, and side effects recorded by the women in a diary and on a structured proforma completed in the clinic at the end of the first trimester. All women had ultrasound scans every 2 weeks until 14 weeks' gestation and growth scans at 28 and 34 weeks' gestation in addition to routine antenatal care and a follow-up in person or by telephone 6 weeks after delivery. MAIN RESULTS AND THE ROLE OF CHANCE: Despite the fact that 85% of women said they would prefer the active treatment, the trial recruitment occurred at the planned rate. Eligible women (n = 160) attended the research clinics and had the uNK test, 72 were screen positive and 40 returned when pregnant for randomization. Compliance with medication was reported to be 100%. The active treatment was associated with side effects of insomnia and flushing. The live birth rate was 12/20 (60%) with prednisolone and 8/20 (40%) with placebo (Risk Ratio 1.5, 95% confidence interval (CI) 0.79-2.86, absolute difference 20% CI-10%, +50%), and hence, this was not significant. There were no pregnancy complications or serious adverse fetal outcomes. LIMITATIONS, REASONS FOR CAUTION: This was a feasibility trial so of insufficient size to assess efficacy or safety. There was inconsistency in the start date of the trial medication and this may have affected the outcome in the active treatment group. WIDER IMPLICATIONS OF THE FINDINGS: It was feasible to recruit women with idiopathic RM into a 'screen and treat' trial despite their desire for active medication. Our data also suggest that in future trials the primary outcome measure is live birth rate after 24 weeks gestation.

A rapid, reliable method for uNK cell density estimation.

Interest in uterine NK cell density as a diagnostic or screening tool in reproductive disorders is growing. However, current methods of analysis are time consuming. In this study, 997 images from 100 women were analysed both by the currently used method combining manual and computer aided counting, and by using colour splitting combined with area measurement as an estimate of positively stained cells. Good correlation was found between both methods (r(2)=0.92) centred around the line of equality, with no systematic differences observed in Bland Altman plots. The area measurement was significantly faster and thus is a useful screening method.

Poly-l-lysine assisted synthesis of core-shell nanoparticles and conjugation with triphenylphosphonium to target mitochondria.

In this paper, we report a facile route to synthesize mitochondria-targeted core-shell nanoparticles (NPs). Firstly, PLL-coated NPs are prepared by a one-step reprecipitation-encapsulation method assisted by positively charged poly-l-lysine (PLL). The effect of the molecular weight of PLL on the formation of particles is studied in terms of morphology, size and zeta potential, and medium-sized PLL (MH-PLL) is proved to be the optimum one. By means of crosslinking with different amounts of glutaraldehyde, amino groups in MH-PLL-NPs are characterized by zeta potential and fluorescamine assay, respectively. The results indicate that in the PLL shell, only a small portion of amino groups (surface amino groups, SAGs) are available for conjugation, while the other groups exclusively contribute to zeta potential. Subsequently, a known mitochondriotropic ligand, triphenylphosphonium (TPP), is conjugated with SAG via a carbodiimide reaction, which is evaluated by NMR and absorption spectra, respectively. The TPP-MH-PLL-NPs exhibit a low cytotoxic effect tested by the MTT method, as well as efficient cellular uptake microscopically observed after a fluorescent dye, coumarin 6, is incorporated. Most importantly, the TPP-conjugated NPs can selectively target mitochondria, demonstrated by the merged z-stacked images in co-localization experiments with MitoTracker-stained mitochondria. Given that many hydrophobic species could be loaded into the particle core, TPP-MH-PLL-NPs are very promising as mitochondria-targeted nanocarriers for imaging or anti-cancer therapies.

Endometrial cell counts in recurrent miscarriage: a comparison of counting methods.

AIMS: Studies of uterine natural killer (uNK) cells require reliable measurements of uNK cell density among diverse endometrial tissue. The aim of this study was to compare cell counting manually with two computer-aided methods based on a public domain software package, ImageJ. METHODS AND RESULTS: Immunohistochemistry (IHC) of CD56(+) uNK cells was performed on endometrium from recurrent miscarriage patients. Numbers of stromal cells per high-power field (HPF) were counted by two observers using: (i) manual tally counter and graticule; (ii) ImageJ 'point picker' tool; and (iii) ImageJ 'particle analysis' tool. Coefficients of variation (CV) and Bland-Altman plots were used to evaluate interobserver differences. Evaluation of %uNK using ImageJ particle analysis for stromal cell counts and point picker tool for uNK counts was undertaken. Point picker and particle analysis were significantly better than manual counting [interobserver CVs mean (standard deviation) 6.1% (3.3%); 4.7% (3.9%), 8.2% (6.5%), respectively]. Mean inter- and intra-observer CVs for %uNK were 10.3% (6.6%), 8.5% (4.9%) and 6.8% (4.3%), respectively. Bland-Altman analysis revealed no systematic differences in cell counts with the number of cells in the image for each method. CONCLUSIONS: Compared to manual cell counting, computer-aided image analysis yields more reproducible results for the assessment of uNK cells density using IHC.

Recent thoughts on management and prevention of recurrent early pregnancy loss.

PURPOSE OF REVIEW: To provide an overview of the latest views and evidence available to clinicians managing couples with recurrent early pregnancy loss (RPL). RECENT FINDINGS: RPL is a heterogeneous condition associated with many pathologies, none of which is found in more than 50% of couples after routine investigations. The recommended treatment of low-dose aspirin and heparin in women with antiphospholipid syndrome has a weak evidence base. Recent randomized controlled trials (RCTs) of low-dose aspirin and heparin have failed to find an improvement in live birth rates, even in the presence of thrombophilia. Although parental karyotypic abnormalities are associated with RPL, conservative management of such couples may be optimal. Observational studies of hysteroscopic metroplasty have promising results, but evidence from RCTs is awaited. Progestogen therapy may improve pregnancy outcomes, but further RCTs are needed. Immunological factors are thought to be important in idiopathic RPL. Research is focused on natural killer cells and cytokines in influencing implantation as potential therapeutic treatments. Currently, RCTs have not substantiated a benefit for immunotherapy. SUMMARY: Management of RPL remains challenging, with many controversial issues regarding the underlying pathophysiology. Improvements in live birth rates in subsequent pregnancies have not been found in RCTs of treatment for most of the associated conditions. All women can be offered supportive care in subsequent pregnancies. Empirical treatment is widely used in idiopathic RPL. A better option may be to encourage women to participate in high-quality and methodologically sound studies to guide optimal management.

Prednisolone Trial: Study protocol for a randomised controlled trial of prednisolone for women with idiopathic recurrent miscarriage and raised levels of uterine natural killer (uNK) cells in the endometrium.

BACKGROUND: Idiopathic recurrent miscarriage is defined as 3 consecutive pregnancy losses with no contributing features found on investigations. At present there are no treatments of proven efficacy for idiopathic recurrent miscarriage. Uterine natural killer (uNK) cells, the most predominant leucocyte in the endometrium are adjacent to foetal trophoblast cells and thought to be involved in implantation. The exact mechanisms of how uNK cells affect implantation are not clear but are probably through the regulation of angiogenesis. Multiple studies have shown an association between high density of uterine natural killer cells and recurrent miscarriage. We have shown that prednisolone reduces the number of uNK cells in the endometrium. The question remains as to whether reducing the number of uNK cells improves pregnancy outcome. METHODS: We propose a randomised, double-blind, placebo controlled trial of prednisolone with a pilot phase to assess feasibility of recruitment, integrity of trial procedures, and to generate data to base future power calculations. The primary aim is to investigate whether prednisolone therapy during the first trimester of pregnancy is able to improve live birth rates in patients with idiopathic recurrent miscarriage and raised uNK cells in the endometrium. Secondary outcomes include conception rate, karyotype of miscarriage, miscarriages (first and second trimester), stillbirths, pregnancy complications, gestational age at delivery, congenital abnormality and side effects of steroids. The trial has 2 stages: i) screening of non-pregnant women and ii) randomisation of the pregnant cohort. All patients who fit the inclusion criteria (<40 years old, > or =3 consecutive miscarriages with no cause found and no contraindications to prednisolone therapy) will be asked to consent to an endometrial biopsy in the mid-luteal phase to assess their levels of uNK cells. Women with high levels of uNK cells (> or =5%), will be randomised to either prednisolone or placebo when a pregnancy is confirmed. Follow-up includes 2 weekly ultrasound scans in the first trimester, an anomaly scan at 20 weeks gestation, growth scans at 28 and 34 weeks gestation and a postnatal follow-up at 6 weeks. TRIAL REGISTRATION: Current Controlled Trials ISRCTN28090716.

A case-control study of CYP1A1, GSTT1 and GSTM1 gene polymorphisms, pregnancy smoking and fetal growth restriction.

OBJECTIVES: To determine the role of maternal CYP1A1, GSTT1, and GSTM1 metabolic gene polymorphisms in modulating the association between pregnancy smoking exposure and fetal growth restriction. STUDY DESIGN: A case-control study was conducted to investigate if the association of pregnancy smoking and birth outcome was modulated by maternal gene polymorphisms. A total of 90 mothers with an IUGR baby (cases) and 180 mothers without IUGR (controls) were enrolled. RESULTS: Almost half of smokers who carried a CYP1A1 variant (51.3%), GSTT1 null (43.6%), or GSTM1 null genotypes (64.1%) delivered a baby with IUGR. Smokers with the variant CYP1A1 "aa" genotype had babies with lower mean birthweight than non-smokers with the same genotype (p=0.004). An interaction test showed increased prevalence of IUGR in smokers with the CYP1A1 (Aa/aa) variant (adjusted OR, 1.9; 95% CI, 1.4-5.5, p=0.01), or with the GSTT1 null (AOR, 1.5; 1.1-3.1, p=0.001), or GSTM1 null genotypes (AOR, 1.5; 1.2-3.7, p=0.001). CONCLUSIONS: Risk of fetal growth restriction in mothers who smoked during pregnancy was modulated by maternal metabolic gene polymorphisms. The genetic control of the conversion of toxic metabolites of tobacco smoke to less damaging substances is important for maternal and fetal health.

[Investigation on electroluminescence of MEH-PPV/ZnSe nanocomposite device].

ZnSe nanocrystals were synthesized in aqueous solution by using mercapto-acetate acid as stabilizer. Products were characterized by X-ray diffraction patterns (XRD) and X-ray photoelectron spectra (XPS). A surfactant was used to transfer the nanocrystals from the aqueous solution to organic solvent, so that ZnSe and MEH-PPV could be mixed sufficiently and were used as an emitting layer in a multilayered electroluminescence device: Glass/ITO/MEH-PPV : ZnSe /BCP/Alq3/LiF/Al. A comparison between absorption spectra and photoluminescence spectra of ZnSe nanocrystals and MEH-PPV thin film exhibits an effective energy transfer from ZnSe nanocrystals to MEH-PPV, which is one reason for the existing difference between photoluminescence spectrum and electroluminescence spectrum of MEH-PPV : ZnSe nanocomposite film. The recombination mechanism of the nanocomposite film under photoexcitation and electric injection was discussed respectively. The authors investigated the photo- and electroluminescence properties of the device, and found that the EL intensity of ZnSe nanocrystals increased with the applied voltages. The I-V characteristic of this device is similar to that of a classic diode.

Synthesis and optical properties of L-cysteine hydrochloride-stabilized CdSe nanocrystals in a new alkali system.

Water-soluble CdSe nanocrystals were synthesized in a new alkali system at lower temperatures by using L-cysteine hydrochloride as a stabilizer and Na2SeSO3 as a selenium source to enable the synthesis of CdSe nanocrystals in a wider range of pH values. The CdSe nanocrystal powder was characterized by X-ray powder diffraction, X-ray photoelectron spectroscopy, Fourier transform infrared spectroscopy, and transmission electron microscopy. We systematically investigated the effect of synthesis conditions on the optical properties of the L-cysteine hydrochloride-stabilized CdSe nanocrystals, and found that different sizes of CdSe nanocrystals can be obtained by changing the pH value, the molar ratio of L-cysteine hydrochloride to Cd2+, or the refluxing time. The emission maxima of the obtained CdSe nanocrystals can be tuned in a wider range from 477 to 575 nm by changing the pH value from 7 to 13. We observed an obvious blue-shift of the absorption and photoluminescence peak position by varying the molar ratio of L-Cys to Cd2+ from 3.5:1 to 2:1 at the same pH value. The size of the obtained nanocrystals increased and the full width at half maximum became narrower as reflux time increased. Transmission electron microscopy images indicate that the as-prepared CdSe nanocrystals have a good dispersion, which means that L-cysteine hydrochloride can control the grouping of CdSe nanocrystals excellently as a stabilizer in the new alkali system.

[Investigation on the photoconductive properties of MEH-PPV/CdSe nanocomposite devices].

Photoconductive properties of the composite devices made up of cadmium selenide nanocrystals and polymer poly[2-methoxy-5-(2'-ethylhexyloxy-p-phenylenevinylene)] (MEH-PPV) were investigated. The photocurrent action spectrum for a nanocomposite device corresponded to the absorption of MEH-PPV and CdSe nanocrystals, indicating that the absorption of the CdSe nanocrystals and MEH-PPV contributed to the photocurrent. The photocurrent was attributed to the exciton dissociation and charge transfer between the interface of CdSe nanocrystals and MEH-PPV. The photocurrent action spectra of the nanocomposite device was wider than that of the pure MEH-PPV device, and the photocurrent was enhanced in comparison with the pure MEH-PPV device due to the introduction of CdSe nanocrystals.

[Study of water-sol core-shell CdSe/CdS quantum dots].

Water-sol core/shell CdSe/CdS quantum dots (QDs) were synthesized in aqueous solution by using mercapto-acetate acid as stabilizer. The UV-Vis absorption and emission spectra were studied. The size of the SdSe-core was about 2 nm estimated by absorption edge and X-ray powder diffraction(XRD). The structure was also characterized by X-ray photoelectron spectroscopy(XPS). The intensity of luminescence of the quantum dots was greatly enhanced after the surface was modified with CdS shell. Red shift of the peak was shown in both the emission and absorption spectra.