Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action.

BACKGROUND: Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care. METHODS: We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility. FINDINGS: Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences. CONCLUSIONS: The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

Microbiological Food Safety for Vulnerable People.

Foodborne pathogens are more likely to cause infection and to result in serious consequences in vulnerable people than in healthy adults. People with some increase in susceptibility may form nearly 20% of the population in the UK and the USA. Conditions leading to increased susceptibility are listed. The main factors leading to foodborne disease caused by major pathogens are outlined and examples are given of outbreaks resulting from these factors. Measures to prevent foodborne disease include procedures based on Hazard Analysis Critical Control Point principles and prerequisite programmes and, especially for vulnerable people, the use of lower-risk foods in place of higher-risk products.

A possible route for foodborne transmission of Clostridium difficile?

Spores of toxigenic Clostridium difficile and spores of food-poisoning strains of Clostridium perfringens show a similar prevalence in meats. Spores of both species are heat resistant and can survive cooking of foods. C. perfringens is a major cause of foodborne illness; studies are needed to determine whether C. difficile transmission by a similar route is a cause of infection.

Microbiological food safety and a low-microbial diet to protect vulnerable people.

Low-microbial diets are advised by many institutions for people with neutropenia resulting from treatment with immunosuppressive drugs or medical conditions that increase their susceptibility to foodborne disease. In this article, the main microbiological hazards associated with foods are outlined, and a low-microbial diet in which higher-risk foods are replaced by lower-risk foods is described.

The occurrence and prevention of foodborne disease in vulnerable people.

In developed countries, such as the United Kingdom and the United States, between 15% and 20% of the population show greater susceptibility than the general population to foodborne disease. This proportion includes people with primary immunodeficiency, patients treated with radiation or with immunosuppressive drugs for cancer and diseases of the immune system, those with acquired immune-deficiency syndrome and diabetics, people suffering from liver or kidney disease or with excessive iron in the blood, pregnant women, infants, and the elderly. Malnutrition and use of antacids, particularly proton-pump inhibitors, also increase susceptibility. We review the occurrence of infection by foodborne pathogens in these groups of people and measures to prevent infection. The nature and use of low microbial diets to reduce the risk of foodborne disease in immunocompromised patients are very variable. Diets for vulnerable people in care should exclude higher-risk foods, and vulnerable people in the community should receive clear advice about food safety, in particular avoidance of higher-risk foods and substitution of safer, nutritious foods.

Effect of obesity on left ventricular mass and systolic function in patients with asymptomatic aortic stenosis (a Simvastatin Ezetimibe in Aortic Stenosis [SEAS] substudy).

Obesity and hypertension are associated with left ventricular (LV) hypertrophy. Whether an increased body mass index (BMI) affects LV hypertrophy in patients with asymptomatic aortic stenosis independent of hypertension is not known. We used the clinical blood pressure, BMI, and echocardiographic findings recorded at baseline of 1,703 patients with asymptomatic aortic stenosis (AS) participating in the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) study. The patient population was divided into 3 BMI classes: normal BMI, 18.5 to 24.9 kg/m(2); overweight, BMI 25.0 to 29.9 kg/m(2); and obese, BMI > or =30.0 kg/m(2). For the total study population, the average blood pressure was 145/82 +/- 20/10 mm Hg, age 67 +/- 10 years, BMI 26.9 +/- 4.3 kg/m(2), and peak transaortic velocity 3.1 +/- 0.5 m/s. The prevalence of hypertension increased with increasing BMI class (43% vs 51% and 63%, p <0.01). The LV mass and prevalence of LV hypertrophy increased with an increasing BMI (22% in normal, 38% in overweight, and 54% in obese patients). The LV ejection fraction and stress-corrected mid-wall fractional shortening decreased (p <0.01 vs normal-weight group). On multiple logistic regression analysis, the presence of LV hypertrophy was associated with a greater BMI (odds ratio 1.15, 95% confidence interval 1.12 to 1.18), independent of a history of hypertension, the severity of AS, older age, systolic blood pressure, and lower LV ejection fraction (all p <0.05). Valve regurgitation and gender had no independent association with the presence of LV hypertrophy. In conclusion, a greater BMI was associated with the presence of LV hypertrophy in patients with asymptomatic AS, independent of AS severity and the presence of hypertension.

Microbiological safety of food in hospitals and other healthcare settings.

Cases and outbreaks of foodborne infection in healthcare settings can result in serious illness, wastage of expensive medical treatments, spread of infection to other patients and staff and disruption of services. Providing nutritious meals for vulnerable people in healthcare settings involves a systematic approach to microbiological safety, as provided by hazard analysis and critical control point (HACCP) principles. The types of food served in healthcare settings should be selected to minimise the risk of foodborne infection.

Engaging patients for health information exchange.

Health information exchange (HIE) offers tremendous potential for the future, but its widespread adoption and sustainability depend upon engaging patients and earning their trust. Patients' willingness to allow their data to be shared will drive the usefulness of HIE and therefore the sustainability of regional health information organizations (RHIOs). The Massachusetts eHealth Collaborative (MAeHC) is one of a few organizations that have developed a successful community-based collaborative model, with more than a 90 percent opt-in rate among patients to participate in widespread electronic data sharing. Lessons learned from MAeHC's three pilot programs could be instructive for other HIE projects around the country.

Pasteurization of milk and the heat resistance of Mycobacterium avium subsp. paratuberculosis: a critical review of the data.

Mycobacterium avium subsp. paratuberculosis (M. paratuberculosis) causes Johne's disease in ruminants (including cattle, sheep and goats) and other animals, and may contribute to Crohn's disease in humans. This possibility, and the fact that M. paratuberculosis may be present in raw milk, make it important to ensure that the heat treatment specified for pasteurization of milk will give acceptable inactivation of this bacterium, with an adequate margin of safety. Published studies of the heat resistance of this bacterium in milk have given widely differing results. Possible reasons for these differences, and the technical problems involved in the work, are reviewed. It is concluded that there is a need (i) for the adoption of an agreed Performance Criterion for pasteurization of milk in relation to this bacterium, (ii) a need for definitive laboratory experiments to understand and determine the heat resistance of M. paratuberculosis, and (iii) a need for an assessment of whether the minimum heat treatments specified at present for pasteurization of milk (Process Criteria) will meet the Performance Criterion for M. paratuberculosis. Measures are also required to ensure that commercial processes deliver continually the specified heat treatment, and to ensure that post-pasteurization contamination is avoided.

Factors affecting growth from heat-treated spores of non-proteolytic Clostridium botulinum.

Heat treatment of spores of non-proteolytic Clostridium botulinum at 85°C for 120 min followed by enumeration of survivors on a medium containing lysozyme resulted in a 4.1 and 4.8 decimal reduction in numbers of spores of strains 17B (type B) and Beluga (type E), respectively. Only a small proportion of heated spores formed colonies on medium containing lysozyme; this proportion could be increased by treatments designed to increase the permeability of heated spores. The results indicate that the germination system in spores of non-proteolytic Cl. botulinum was destroyed by heating, that lysozyme could replace this germination system, and that treatments that increased the permeability of the spore coat could increase the proportion of heated spores that germinated on medium containing lysozyme. These results are important in relation to the assessment of heat-treatments required to reduce the risk of survival and growth of non-proteolytic Clostridium botulinum in processed (pasteurized) refrigerated foods for extended storage.

The effect of recovery medium on the estimated heat-inactivation of spores of non-proteolytic Clostridium botulinum.

Heating spores of non-proteolytic strains of Clostridium botulinum at 85°C, followed by enumeration of survivors on a highly nutrient medium indicated a 5 decimal kill in less than 2 min. The inclusion of lysozyme or egg yolk emulsion in the recovery medium substantially increased apparent spore heat-resistance, with as little as 0.1 µg lysozyme/ml sufficient to give an increase in the number of survivors. After heating at 85°C for 2 min between 0.1% and 1% of the spores of 11 strains (5 type B, 4 type E, 2 type F) formed colonies on medium containing 10 µg lysozyme/ml. Enumeration of survivors on a medium containing lysozyme showed that heating at 85°C for 5 min resulted in an estimated 2.6 decimal kill of spores of strain 17B (type B). These findings are important in the assessment of heat-treatments required to ensure the safety with respect to non-proteolytic Clostridium botulinum of processed (pasteurized) refrigerated foods for extended storage such as sous-vide foods.