Multiethnic Growth Standards for Fetal Body Composition and Organ Volumes Derived from 3D Ultrasonography.

BACKGROUND: A major goal of contemporary obstetrical practice is to optimize fetal growth and development throughout pregnancy. To date, fetal growth during prenatal care is assessed by performing ultrasonographic measurement of two-dimensional fetal biometry to calculate an estimated fetal weight. Our group previously established two-dimensional fetal growth standards using sonographic data from a large cohort with multiple sonograms. A separate objective of that investigation involved the collection of fetal volumes from the same cohort. OBJECTIVE: The Fetal 3D Study was designed to establish standards for fetal soft tissue and organ volume measurements by three-dimensional ultrasonography and compare growth trajectories with conventional two-dimensional measures where applicable. STUDY DESIGN: The NICHD Fetal 3D Study included research-quality images of singletons collected in a prospective, racially and ethnically diverse, low-risk cohort of pregnant individuals at 12 U.S. sites, with up to five scans per fetus (N=1,730 fetuses). Abdominal subcutaneous tissue thickness was measured from two-dimensional images and fetal limb soft tissue parameters extracted from three-dimensional multiplanar views. Cerebellar, lung, liver and kidney volumes were measured using virtual organ computer aided analysis (VOCAL). Fractional arm and thigh total volumes, and fractional lean limb volumes were measured, with fractional limb fat volume calculated by subtracting lean from total. For each measure, weighted curves (5th, 50th, 95th percentiles) were derived from 15-41 weeks' using linear mixed models for repeated measures with cubic splines. RESULTS: Subcutaneous thickness of the abdomen, arm, and thigh increased linearly, with slight acceleration around 27-29 weeks. Fractional volumes of the arm, thigh, and lean limb volumes increased along a quadratic curvature, with acceleration around 29-30 weeks. In contrast, growth patterns for two-dimensional humerus and femur lengths demonstrated a logarithmic shape, with fastest growth in the 2nd trimester. The mid-arm area curve was similar in shape to fractional arm volume, with an acceleration around 30 weeks, whereas the curve for the lean arm area was more gradual. The abdominal area curve was similar to the mid-arm area curve with an acceleration around 29 weeks. The mid-thigh and lean area curves differed from the arm areas by exhibiting a deceleration at 39 weeks. The growth curves for the mid arm and thigh circumferences were more linear with some decelerations. Cerebellar two-dimensional diameter increased linearly, whereas cerebellar three-dimensional volume growth gradually accelerated until 32 weeks and then decelerated. Lung, kidney, and liver volumes all demonstrated gradual early growth followed by a linear acceleration beginning at 25 weeks for lungs, 26-27 weeks for kidneys, and 29 weeks for liver. CONCLUSION: Growth patterns and timing of maximal growth for three-dimensional lean and fat measures, limb and organ volumes differed from patterns revealed by traditional two-dimensional growth measures, suggesting these parameters reflect unique facets of fetal growth. Growth in these three-dimensional measures may be altered by genetic, nutritional, metabolic or environmental influences and pregnancy complications, in ways not identifiable using corresponding two-dimensional measures. Further investigation into the relationships of these three-dimensional standards to abnormal fetal growth, adverse perinatal outcomes, and health status in postnatal life is warranted.

Nutritional Intake in Dichorionic Twin Pregnancies: A Descriptive Analysis of a Multisite United States Cohort.

INTRODUCTION: Twin gestations have greater nutritional demands than singleton gestations, yet dietary intakes of women with twin gestations have not been well described. METHODS: In a prospective, multi-site US study of 148 women with dichorionic twin gestations (2012-2013), we examined longitudinal changes in diet across pregnancy. Women completed a food frequency questionnaire during each trimester of pregnancy. We examined changes in means of total energy and energy-adjusted dietary components using linear mixed effects models. RESULTS: Mean energy intake (95% CI) across the three trimesters was 2010 kcal/day (1846, 2175), 2177 kcal/day (2005, 2349), 2253 kcal/day (2056, 2450), respectively (P = 0.01), whereas the Healthy Eating Index-2010 was 63.9 (62.1, 65.6), 64.5 (62.6, 66.3), 63.2 (61.1, 65.3), respectively (P = 0.53). DISCUSSION: Women with twin gestations moderately increased total energy as pregnancy progressed, though dietary composition and quality remained unchanged. These findings highlight aspects of nutritional intake that may need to be improved among women carrying twins.

Comparing Fetal Ultrasound Biometric Measurements to Neonatal Anthropometry at the Extremes of Birthweight.

OBJECTIVE: Error in birthweight prediction by sonographic estimated fetal weight (EFW) has clinical implications, such as avoidable cesarean or misclassification of fetal risk in labor. We aimed to evaluate optimal timing of ultrasound and which fetal measurements contribute to error in fetal ultrasound estimations of birth size at the extremes of birthweight. STUDY DESIGN: We compared differences in head circumference (HC), abdominal circumference (AC), femur length, and EFW between ultrasound and corresponding birth measurements within 14 (n = 1,290) and 7 (n = 617) days of birth for small- (SGA, <10th percentile), appropriate- (AGA, 10th-90th), and large-for-gestational age (LGA, >90th) newborns. RESULTS: Average differences between EFW and birthweight for SGA neonates were: -40.2 g (confidence interval [CI]: -82.1, 1.6) at 14 days versus 13.6 g (CI: -52.4, 79.7) at 7 days; for AGA, -122.4 g (-139.6, -105.1) at 14 days versus -27.2 g (-50.4, -4.0) at 7 days; and for LGA, -242.8 g (-306.5, -179.1) at 14 days versus -72.1 g (-152.0, 7.9) at 7 days. Differences between fetal and neonatal HC were larger at 14 versus 7 days, and similar to patterns for EFW and birthweight, differences were the largest for LGA at both intervals. In contrast, differences between fetal and neonatal AC were larger at 7 versus 14 days, suggesting larger error in AC estimation closer to birth. CONCLUSION: Using a standardized ultrasound protocol, SGA neonates had ultrasound measurements closer to actual birth measurements compared with AGA or LGA neonates. LGA neonates had the largest differences between fetal and neonatal size, with measurements 14 days from delivery showing 3- to 4-fold greater differences from birthweight. Differences in EFW and birthweight may not be explained by a single fetal measurement; whether estimation may be improved by incorporation of other knowable factors should be evaluated in future research. KEY POINTS: · Ultrasound measurements may be inadequate to predict neonatal size at birth.. · Birthweight estimation error is higher for neonates >90th percentile.. · There is higher error in AC closer to birth..

Combination of Fundal Height and Ultrasound to Predict Small for Gestational Age at Birth.

OBJECTIVE: The objective of the study was to determine whether adding longitudinal measures of fundal height (FH) to the standard cross-sectional FH to trigger third trimester ultrasound estimated fetal weight (EFW) would improve small for gestational age (SGA) prediction. STUDY DESIGN: We developed a longitudinal FH calculator in a secondary analysis of a prospective cohort study of 1,939 nonobese pregnant women who underwent serial FH evaluations at 12 U.S. clinical sites. We evaluated cross-sectional FH measurement ≤ -3 cm at visit 3 (mean: 32.0 ± 1.6 weeks) versus the addition of longitudinal FH up to and including visit 3 to trigger an ultrasound to diagnose SGA defined as birth weight <10th percentile. If the FH cut points were not met, the SGA screen was classified as negative. If FH cut points were met and EFW was <10th percentile, the SGA screen was considered positive. If EFW was ≥10th percentile, the SGA screen was also considered negative. Sensitivity, specificity, and positive predictive value (PPV) and negative predictive value (NPV) were computed. RESULTS: In a comparison of methods, 5.8% of women were classified as at risk of SGA by both cross-sectional and longitudinal classification methods; cross-sectional FH identified an additional 4.0%, and longitudinal fundal height identified a separate, additional 4.5%.Using cross-sectional FH as an ultrasound trigger, EFW had a PPV and NPV for SGA of 69 and 92%, respectively. After adding longitudinal FH, PPV increased to 74%, whereas NPV of 92% remained unchanged; however, the number of women who underwent triggered EFW decreased from 9.7 to 5.7%. CONCLUSION: An innovative approach for calculating longitudinal FH to the standard cross-sectional FH improved identification of SGA birth weight, while simultaneously reducing the number of triggered ultrasounds. As an essentially free-of-charge screening test, our novel method has potential to decrease costs as well as perinatal morbidity and mortality (through better prediction of SGA). KEY POINTS: · We have developed an innovative calculator for fundal height trajectory.. · Longitudinal fundal height improves detection of SGA.. · As a low cost screening test, the fundal height calculator may decrease costs and morbidity through better prediction of SGA..

A return to responsibility: A critique of the single actor strategic model of CSR.

Any functional utility gained through corporate social responsibility (CSR) depends on "responsibility" as the governing principle between "corporate" and "social" interests. We argue that Porter and Kramer's highly popularised notion of "shared value" has been pivotal to the erosion of responsibility as a moderating concept in CSR. Under this approach, "strategic" CSR becomes an instrument to leverage corporate advantage, rather than fulfil social responsibilities and address business-related harms. In mining, this approach has supported shallow, derivative ideas including the wellknown CSR artefact: "social license to operate" (SLTO). We argue that CSR, and the related concept corporate social irresponsibility (CSI), suffer from the single actor problem, where the corporation too easily becomes the exclusive focus of analysis. We advocate for a reinvigorated debate about mining and social responsibility in which the corporation is but one actor in the (ir)responsibility landscape.

Early outcomes from a national Train-the-Trainer Interprofessional Team Development Program.

The imperative need to train health professions faculty (educators and clinicians) to lead interprofessional education efforts and promote interprofessional team-based care is widely recognized. This need stems from a growing body of research that suggests collaboration improves patient safety and health outcomes. This short report provides an overview of a Train-the-Trainer Interprofessional Team Development Program (T3 Program) that equips faculty leaders with the skills to lead interprofessional education and interprofessional collaborative practice across the learning continuum. We also describe the history, approach, and early outcomes of this innovative program.

Fetal Growth Biometry as Predictors of Shoulder Dystocia in a Low-Risk Obstetrical Population.

OBJECTIVE: This study aimed to evaluate fetal biometrics as predictors of shoulder dystocia (SD) in a low-risk obstetrical population. STUDY DESIGN: Participants were enrolled as part of a U.S.-based prospective cohort study of fetal growth in low-risk singleton gestations (n = 2,802). Eligible women had liveborn singletons ≥2,500 g delivered vaginally. Sociodemographic, anthropometric, and pregnancy outcome data were abstracted by research staff. The diagnosis of SD was based on the recorded clinical impression of the delivering physician. Simple logistic regression models were used to examine associations between fetal biometrics and SD. Fetal biometric cut points, selected by Youden's J and clinical determination, were identified to optimize predictive capability. A final model for SD prediction was constructed using backward selection. Our dataset was randomly divided into training (60%) and test (40%) datasets for model building and internal validation. RESULTS: A total of 1,691 women (98.7%) had an uncomplicated vaginal delivery, while 23 (1.3%) experienced SD. There were no differences in sociodemographic or maternal anthropometrics between groups. Epidural anesthesia use was significantly more common (100 vs. 82.4%; p = 0.03) among women who experienced SD compared with those who did not. Amniotic fluid maximal vertical pocket was also significantly greater among SD cases (5.8 ± 1.7 vs. 5.1 ± 1.5 cm; odds ratio = 1.32 [95% confidence interval: 1.03,1.69]). Several fetal biometric measures were significantly associated with SD when dichotomized based on clinically selected cut-off points. A final prediction model was internally valid with an area under the curve of 0.90 (95% confidence interval: 0.81, 0.99). At a model probability of 1%, sensitivity (71.4%), specificity (77.5%), positive (3.5%), and negative predictive values (99.6%) did not indicate the ability of the model to predict SD in a clinically meaningful way. CONCLUSION: Other than epidural anesthesia use, neither sociodemographic nor maternal anthropometrics were significantly associated with SD in this low-risk population. Both individually and in combination, fetal biometrics had limited ability to predict SD and lack clinical usefulness. KEY POINTS: · SD unpredictable in low-risk women.. · Fetal biometry does not reliably predict SD.. · Epidural use associated with increased SD risk.. · SD prediction models clinically inefficient..

Evaluation of the Induced Membrane for Neurotrophic Factors.

PURPOSE: Despite gaining popularity as a bridge for small and moderate nerve gaps, an acellular nerve allograft (ANA) lacks many of the neurotrophic characteristics of a nerve autograft. Pseudomembranes induced to form around temporary skeletal spacers are rich in growth factors. Induced membranes may have beneficial neurotrophic factors which could support ANA. METHODS: Twenty-two male Sprague-Dawley rats underwent resection of 2 cm of the sciatic nerve. A silicone rod was inset in the defect of 11 experimental rats, and marking sutures only were placed in the nerve stumps of the remaining 11 control rats. After allowing 4 weeks for tissue maturation, tissue samples harvested from the induced membrane (experimental group) and the tissue bed (control group) were analyzed using Luminex multiplex assay to quantify differences in detectable levels of the following neurotrophic factors: nerve growth factor, glial-derived nerve factor, vascular endothelial growth factor, and transforming growth factor ß (TGF-ß) 1, 2, and 3, interleukin-1ß, and monocyte chemoattractant protein 1. RESULTS: No difference was detected between the control and experimental groups in levels of vascular endothelial growth factor. Higher levels of TGF-ß1, TGF-ß2, TGF-ß3, glial-derived nerve factor, nerve growth factor, monocyte chemoattractant protein 1, and interleukin-1ß were detected in the experimental group. CONCLUSIONS: In the setting of peripheral nerve injury, an induced membrane has higher levels of several neurotrophic factors that may support nerve regeneration compared to wound bed cicatrix. CLINICAL RELEVANCE: This investigation provides impetus for further study examining the utility of using a staged induced membrane technique in conjunction with delayed nerve grafting in reconstruction of some peripheral nerve defects.

Data harmonisation for information fusion in digital healthcare: A state-of-the-art systematic review, meta-analysis and future research directions.

Removing the bias and variance of multicentre data has always been a challenge in large scale digital healthcare studies, which requires the ability to integrate clinical features extracted from data acquired by different scanners and protocols to improve stability and robustness. Previous studies have described various computational approaches to fuse single modality multicentre datasets. However, these surveys rarely focused on evaluation metrics and lacked a checklist for computational data harmonisation studies. In this systematic review, we summarise the computational data harmonisation approaches for multi-modality data in the digital healthcare field, including harmonisation strategies and evaluation metrics based on different theories. In addition, a comprehensive checklist that summarises common practices for data harmonisation studies is proposed to guide researchers to report their research findings more effectively. Last but not least, flowcharts presenting possible ways for methodology and metric selection are proposed and the limitations of different methods have been surveyed for future research.

Automated Solid-Phase Microextraction and Negative Chemical Ionization GC-MS for the Measurement of Synthetic Pyrethroids.

Synthetic pyrethroids are frequently detected as trace contaminants in sediment and natural waters. Because of the importance of measuring both total and freely available concentrations for ecotoxicity evaluations, solid-phase microextraction (SPME) combined with gas chromatography-mass spectrometry using negative chemical ionization (NCI-GC-MS) was investigated as an analytical technique. Automated SPME-NCI-GC-MS quantification of freely dissolved (and thus potentially bioavailable) pyrethroids in aqueous samples containing dissolved organic matter (DOM) was successfully applied. The introduction of stable isotope-labeled pyrethroid calibration standards into the water sample allows for the simultaneous determination of total concentrations. Because pyrethroids adsorb rapidly to container walls (especially in calibration standard solutions without DOM) it was necessary to develop a technique to minimize the resulting time-dependent losses from calibration standard solutions in autosampler vials as they await analysis. A staggered preparation of these analytical calibration standards immediately prior to analysis was shown to ameliorate this problem. The developed method provides accurate and reproducible results for aqueous samples containing a range of dissolved organic matter concentrations (e.g., sediment pore water or sediment/water mixtures) and yields practical benefits in comparison to conventional analysis methods, such as reduced sample volume requirements, reduced solvent consumption, and fewer sample manipulations, and makes simultaneous measurements of freely dissolved/bioavailable pyrethroids and total pyrethroids possible.

Global Scan of Disruptions to the Mine Life Cycle: Price, Ownership, and Local Impact.

Criticality and supply risk models seek to address concerns of potential disruption to global metal supply. These models need to incorporate disruption events that arise from within the mining industry's market structure. In this paper, we review what we refer to as events of "mine life cycle disruption". These include project abandonments, premature closures, care and maintenance, and ownership changes. Life cycle disruptions not only cause production disruptions but also embed social and environmental risks in global metal markets. They arise from the highly variable business environment in which the resources sector operates. Changing commodity prices directly influence mining revenues and drive decisions on whether to halt or push forward a project. While some disruptions are involuntary and induced by external economic conditions, others are purposefully triggered by certain mining companies that use them to their advantage. We examine the frequency of these disruptions based on a contemporary global inventory of 35,000 mining projects and present the findings against recent developments in the research literature. We conclude that life cycle disruption events are an important consideration in balancing the demand for metals and the social and environmental impacts of mining and propose pathways for managing these events and their effects.

Electrochemistry from first-principles in the grand canonical ensemble.

Progress in electrochemical technologies, such as automotive batteries, supercapacitors, and fuel cells, depends greatly on developing improved charged interfaces between electrodes and electrolytes. The rational development of such interfaces can benefit from the atomistic understanding of the materials involved by first-principles quantum mechanical simulations with Density Functional Theory (DFT). However, such simulations are typically performed on the electrode surface in the absence of its electrolyte environment and at constant charge. We have developed a new hybrid computational method combining DFT and the Poisson-Boltzmann equation (P-BE) capable of simulating experimental electrochemistry under potential control in the presence of a solvent and an electrolyte. The charged electrode is represented quantum-mechanically via linear-scaling DFT, which can model nanoscale systems with thousands of atoms and is neutralized by a counter electrolyte charge via the solution of a modified P-BE. Our approach works with the total free energy of the combined multiscale system in a grand canonical ensemble of electrons subject to a constant electrochemical potential. It is calibrated with respect to the reduction potential of common reference electrodes, such as the standard hydrogen electrode and the Li metal electrode, which is used as a reference electrode in Li-ion batteries. Our new method can be used to predict electrochemical properties under constant potential, and we demonstrate this in exemplar simulations of the differential capacitance of few-layer graphene electrodes and the charging of a graphene electrode coupled to a Li metal electrode at different voltages.

Micro-CT yields high image quality in human fetal post-mortem imaging despite maceration.

BACKGROUND: Current clinical post-mortem imaging techniques do not provide sufficiently high-resolution imaging for smaller fetuses after pregnancy loss. Post-mortem micro-CT is a non-invasive technique that can deliver high diagnostic accuracy for these smaller fetuses. The purpose of the study is to identify the main predictors of image quality for human fetal post-mortem micro-CT imaging. METHODS: Human fetuses were imaged using micro-CT following potassium tri-iodide tissue preparation, and axial head and chest views were assessed for image quality on a Likert scale by two blinded radiologists. Simple and multivariable linear regression models were performed with demographic details, iodination, tissue maceration score and imaging parameters as predictor variables. RESULTS: 258 fetuses were assessed, with median weight 41.7 g (2.6-350 g) and mean gestational age 16 weeks (11-24 weeks). A high image quality score (> 6.5) was achieved in 95% of micro-CT studies, higher for the head (median = 9) than chest (median = 8.5) imaging. The strongest negative predictors of image quality were increasing maceration and body weight (p < 0.001), with number of projections being the best positive imaging predictor. CONCLUSIONS: High micro-CT image quality score is achievable following early pregnancy loss despite fetal maceration, particularly in smaller fetuses where conventional autopsy may be particularly challenging. These findings will help establish clinical micro-CT imaging services, addressing the need for less invasive fetal autopsy methods.

Mid-Trimester Cervical Length Screening: Effect of Poorly Developed Lower Uterine Segment on Pregnancy Outcome.

OBJECTIVES: To identify whether a poorly developed lower uterine segment (PDLUS) observed during cervical length (CL) screening affects the duration of gestation in women with no prior spontaneous preterm birth (sPTB). MATERIALS AND METHODS: A retrospective cohort study of women with a singleton gestation and no prior sPTB, who underwent transvaginal CL screening at our institution. We excluded women with progesterone exposure, major anomalies, and women delivering elsewhere. Women with PDLUS were compared to those with a measured (normal) CL ≥25 mm. PRIMARY OUTCOME: birth gestational age (GA). SECONDARY OUTCOMES: sPTB <35 and 37 weeks, hospital evaluation for preterm labor without delivery, delivery indication, and mode. A Cox proportional-hazards survival model considered time from CL scan to delivery. We powered the study to detect a one-half week difference in birth GA. RESULTS: We included 270 women with PDLUS and 985 women with normal CL. Mean birth GA was 38.9 ± 2.0 weeks with PDLUS versus 38.7 ± 2.4 weeks with normal CL (p = .10). Women with PDLUS were less likely to experience sPTB <37 weeks (1.1% vs 3.6%; p = 0.04). There was no difference in sPTB <35 weeks (0.8% vs 1.7%; p = .25). Hospital evaluation for preterm labor (17% vs 19%; p = .54), delivery indication, and mode were not different. The hazard ratio for earlier birth in women with PDLUS was 0.67 (95% CI 0.46, 0.98; p = .04). CONCLUSIONS: We observed no difference in mean GA at birth; however, PDLUS was protective against sPTB <37 weeks and was associated with a lower hazard ratio for earlier birth.

Pragmatic Experience with Risk-based versus Universal Hepatitis C Screening in Pregnancy: Detection of Infection and Postpartum Linkage to Care.

OBJECTIVE: Despite the Centers for Disease Control and Prevention (CDC) and U.S. Preventive Services Task Force (USPSTF) recommending universal hepatitis C virus (HCV) screening in pregnancy Society for Maternal-Fetal Medicine (SMFM) and American College of Obstetricians and Gynecologists (ACOG) continue to endorse risk-based screening for HCV in pregnancy. We hypothesized that universal screening is associated with increased HCV diagnosis and postpartum linkage to HCV care compared with risk-based screening. STUDY DESIGN: This retrospective cohort study included pregnant women screened for HCV at a single tertiary-care center. We defined two cohorts: women managed with risk-based (January 2014-October 2016) or universal HCV screening (November 2016-December 2018). Screening was performed with ELISA antibody testing and viremia confirmed with HCV ribonucleic acid (RNA) polymerase chain reaction (PCR). Primary outcomes were the rate of HCV screen positivity and postpartum linkage to care. RESULTS: From 2014 to 2018, 16,489 women delivered at our institution, of whom 166 screened positive for HCV. A total of 7,039 pregnant women were screened for HCV: 266 with risk-based and 6,773 with universal screening; 29% (76/266) were positive HCV antibody screening (HCVAb + ) in the risk-based cohort and 1.3% (90/6,773) in the universal cohort. HCVAb+ women in the risk-based cohort were more likely to have a positive drug screen. Only 69% (62/90) of HCVAb+ women in the universal cohort met the criteria for risk-based testing. Of the remaining 28 women, 6 (21%) had active viremia (HCV RNA+). Of the 166 HCVAb+ women, 64% (103/166) were HCV RNA+-51 of 266 (19%) in the risk-based and 52 of 6,773 (0.8%) in the universal cohort. Of HCVAb+ women, 75% (125/166) were referred postpartum for HCV evaluation and 27% (34/125) were linked to care. Only 9% (10/103) of women with viremia initiated treatment within 1 year of delivery. CONCLUSION: Universal HCV screening in pregnancy identified an additional 31% of HCVAb+ women compared with risk-based screening. Given low rates of HCV follow-up and treatment regardless of screening modality, further studies are needed to address barriers to postpartum linkage to care. KEY POINTS: · Ideal screening for HCV in pregnancy is unknown.. · We explore screening strategies in pregnancy to linkage to HCV care.. · Regardless of screening strategy there is low rates of postpartum linkage to HCV care..

A Biomechanical Comparison of the Effect of Baseplate Design and Bone Marrow Fat Infiltration on Tibial Baseplate Pullout Strength.

BACKGROUND: Early clinical results of a new total knee arthroplasty (TKA) implant design show promise for improved outcomes and patellofemoral function scores. However, reports of early tibial component-cement interface debonding requiring revision have been published. This study investigated the biomechanical properties of three different tibial baseplates to understand potential causes of failure. METHODS: PFC Sigma (control), Attune (1st generation) and Attune S+ (2nd generation) tibial baseplates were implanted into 4th generation sawbone tibia models using a standardized technique. Three of each baseplate were cemented with and without additional bovine bone marrow fat. All models were tested to failure with measured axial distraction force. Implant type, presence or absence of bovine marrow and load to failure were all recorded and compared. Two-way ANOVA followed by post-hoc pairwise comparisons were used to determine statistical significance, which was set to P < .05. RESULTS: The 2nd generation tibial baseplates required significantly more force to failure. The presence of bovine marrow significantly reduced the pullout force of the implant designs overall. No significant difference was detected between the 1st generation and control baseplates. Failure mode for each model was also noted to be different irrespective of the presence or absence of bone marrow fat. CONCLUSION: The 2nd generation baseplates required significantly more force to failure compared with older designs. The presence of bone marrow during cementation of a tibial base plate significantly decreased axial pullout strength of a tibial baseplate in this laboratory model. All 1st generation baseplates exhibited debonding at the cement-implant interface.

Governing deep sea mining in the face of uncertainty.

Progress towards deep sea mining (DSM) is driven by projected demands for metals and the desire for economic development. DSM remains controversial, with some political leaders calling for a moratorium on DSM pending further research into its impacts. This paper highlights the need for governance architectures that are tailored to DSM. We conceptualise DSM as a type of complex orebody, which encompasses the breadth of environmental, social and governance (ESG) risks that make a mineral source complex. Applying a spatial overlay approach, we show that there are significant data gaps in understanding the ESG risks of DSM. Such uncertainties are compounded by fact that there are no extant commercial DSM projects to function as a precedent - either in terms of project design, or the impacts of design on environment and people. Examining the legislation of the Cook Islands and International Seabed Authority, we demonstrate how regulators are defaulting to terrestrial mining governance architectures, which cannot be meaningfully implemented until a fuller understanding of the ESG risk landscape is developed. We argue that DSM be approached as a distinct extractive industry type, and governed with its unique features in frame.

Intrauterine growth discordance across gestation and birthweight discordance in dichorionic twins.

BACKGROUND: Although intertwin size difference is an important measure of fetal growth, the appropriate cut point to define discordance is unclear. Few studies have assessed intertwin differences in estimated fetal weight longitudinally or in relation to size differences at birth. OBJECTIVES: The objectives of the study were to estimate the magnitude of percentage differences in estimated fetal weight across gestation in dichorionic twins in relation to a fixed discordance cut point and compare classification of aberrant fetal growth by different measures (estimated fetal weight differences, birthweight discordance, small for gestational age). STUDY DESIGN: Women aged 18-45 years from 8 US centers with dichorionic twin pregnancies at 8 weeks 0 days to 13 weeks 6 days gestation planning to deliver in participating hospitals were recruited into the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies-Dichorionic Twins study and followed through delivery (n = 140; 2012-2013). Ultrasounds were conducted at 6 targeted study visits to obtain fetal biometrics and calculate estimated fetal weight. Percent estimated fetal weight and birthweight differences were calculated: ([weightlarger - weightsmaller]/weightlarger)*100; discordance was defined as ≥18% for illustration. Birth sizes for gestational age (both, 1, or neither small for gestational age) were determined; twins were categorized into combined birthweight plus small for gestational age groups: birthweight discordance ≥18% (yes, no) with both, 1, or neither small for gestational age. Linear mixed-models estimated percentiles of estimated fetal weight percent differences across gestation and compared estimated fetal weight differences between combined birthweight discordance and small for gestational age groups. A Fisher exact test compared birthweight discordance and small for gestational age classifications. RESULTS: Median estimated fetal weight percentage difference increased across gestation (5.9% at 15.0, 8.4% at 38.0 weeks), with greater disparities at higher percentiles (eg, 90th percentile: 15.6% at 15.0, 26.3% at 38.0 weeks). As gestation advanced, an increasing percentage of pregnancies were classified as discordant using a fixed cut point: 10% at 27.0, 15% at 34.0, and 20% at 38.0 weeks. Birthweight discordance and small for gestational age classifications differed (P = .002); for birthweight discordance ≥18% vs <18%: 44% vs 71% had neither small for gestational age; 56% vs 18% had 1 small for gestational age; no cases (0%) vs 11% had both small for gestational age, respectively. Estimated fetal weight percent difference varied across gestation by birthweight discordance plus small for gestational age classification (P = .040). Estimated fetal weight percentage difference increased with birthweight discordance ≥18% (neither small for gestational age: 0.46%/week [95% confidence interval, 0.08-0.84]; 1 small for gestational age: 0.57%/week [95% confidence interval, 0.25-0.90]) but less so without birthweight discordance (neither small for gestational age: 0.17%/week [95% confidence interval, 0.06-0.28]; 1 small for gestational age: 0.03%/week [95% confidence interval, -0.17 to 0.24]); both small for gestational age: 0.10%/week [95% confidence interval, -0.15 to 0.36]). CONCLUSION: The percentage of dichorionic pregnancies exceeding a fixed discordance cut point increased over gestation. A fixed cut point for defining twin discordance would identify an increasing percentage of twins as discordant as gestation advances. Small for gestational age and percentage weight differences assess distinct aspects of dichorionic twin growth. A percentile cut point may be more clinically useful for defining discordance, although further study is required to assess whether any specific percentile cut point correlates to adverse outcomes.

Maceration determines diagnostic yield of fetal and neonatal whole body post-mortem ultrasound.

OBJECTIVES: To determine factors in nondiagnostic fetal and neonatal post-mortem ultrasound (PMUS) examinations. METHODS: All fetal and neonatal PMUS examinations were included over a 5-year study period (2014-2019). Nondiagnostic image quality by body parts (brain, spine, thorax, cardiac, and abdomen) was recorded and correlated with patient variables. Descriptive statistics and logistic regression analyses were performed to identify significant factors for nondiagnostic studies. RESULTS: Two hundred sixty-five PMUS examinations were included, with median gestational age of 22 weeks (12-42 wk), post-mortem weight of 363 g (16-4033 g), and post-mortem interval of 8 days (0-39 d). Diagnostic imaging quality was achieved for 178/265 (67.2%) studies. It was high for abdominal (263/265, 99.2%), thoracic (264/265, 99.6%), and spine (265/265, 100%) but lower for brain (210/265, 79.2%) and cardiac imaging (213/265, 80.4%). Maceration was the best overall predictor for nondiagnostic imaging quality (P < .0001). Post-mortem fetal weight was positively associated with cardiac (P = .0133) and negatively associated with brain imaging quality (P = .0002). Post-mortem interval was not a significant predictor. CONCLUSIONS: Fetal maceration was the best predictor for nondiagnostic PMUS, particularly for brain and heart. Fetuses with marked maceration and suspected cardiac or brain anomalies should be prioritised for post-mortem MRI.

The Effect of Intramuscular 17α-Hydroxyprogesterone in Women Screened for Shortened Cervical Length.

OBJECTIVE: This article assesses the effect of weekly intramuscular 17α-hydroxyprogesterone caproate (17P) on midtrimester cervical length (CL) in patients with prior spontaneous preterm birth. STUDY DESIGN: Retrospective cohort study of all singletons that underwent CL screening at a single institution from 2011 to 2016. The timing of 17P exposure was assessed. The primary outcome was shortest midtrimester CL. Secondary outcomes included gestational age at delivery, rate of short cervix, cerclage, preterm labor admission, and preterm premature rupture of the membranes (PROM). Multivariable regression analysis was used to model the relationship between 17P exposure and shortest CL, controlling for selected covariates. RESULTS: Of 409 women who underwent screening, 211 received and 198 did not receive 17P prior to the last CL. Rates of short cervix and cerclage were similar between groups. After adjusting for covariates, the shortest CL was significantly shorter in the 17P group. In a secondary analysis, those who received any 17P (n = 293) versus those who did not (n = 116) had higher rates of preterm PROM, preterm labor admission, and cerclage. After controlling for covariates, gestational age at delivery was significantly lower in those receiving 17P. CONCLUSION: In high-risk patients undergoing CL screening for ultrasound-indicated cerclage, 17P did not prevent midtrimester cervical shortening or prolong gestation.