Physical exercise in pregnancy: benefits, risks and prescription.

OBJECTIVES: The aim of this article is to provide a comprehensive literature review, gathering the strongest evidence about the risks and benefits and the prescription of physical exercise during pregnancy. CONTENT: Regular physical exercise during pregnancy is associated with numerous benefits. In general women are not adequately advised on this matter. Along with their concerns regarding the potential associated risks, it contributes to the abandonment or refusal to start exercising during pregnancy. A systematic review was conducted in MEDLINE including articles considered to have the highest level of scientific evidence. Fifty-seven articles, including 32 meta-analysis, 9 systematic reviews and 16 randomized controlled trials were included in the final literature review. SUMMARY: Exercise can help preventing relevant pregnancy related disorders, such as gestational diabetes, excessive gestational weight gain, hypertensive disorders, urinary incontinence, fetal macrosomia, lumbopelvic pain, anxiety and prenatal depression. Exercise is not related with an increased risk of maternal or perinatal adverse outcomes. Compliance with current guidelines is sufficient to achieve the main benefits, and exercise type and intensity should be based on woman's previous fitness level. OUTLOOK: Exercise in pregnancy is safe for both mother and fetus, contributing to prevent pregnancy related disorders. Exercise type and intensity should be adapted to woman's previous fitness level, medical history and characteristics of the ongoing pregnancy.

Different Effects of Soil Fertilization on Bacterial Community Composition in the Penicillium canescens Hyphosphere and in Bulk Soil.

This study investigated the effects of long-term soil fertilization on the composition and potential for phosphorus (P) and nitrogen (N) cycling of bacterial communities associated with hyphae of the P-solubilizing fungus Penicillium canescens Using a baiting approach, hyphosphere bacterial communities were recovered from three soils that had received long-term amendment in the field with mineral or mineral plus organic fertilizers. P. canescens hyphae recruited bacterial communities with a decreased diversity and an increased abundance of Proteobacteria relative to what was observed in soil communities. As core bacterial taxa, Delftia and Pseudomonas spp. were present in all hyphosphere samples irrespective of soil fertilization. However, the type of fertilization showed significant impacts on the diversity, composition, and distinctive taxa/operational taxonomic units (OTUs) of hyphosphere communities. The soil factors P (Olsen method), exchangeable Mg, exchangeable K, and pH were important for shaping soil and hyphosphere bacterial community compositions. An increased relative abundance of organic P metabolism genes was found in hyphosphere communities from soil that had not received P fertilizers, which could indicate P limitation near the fungal hyphae. Additionally, P. canescens hyphae recruited bacterial communities with a higher abundance of N fixation genes than found in soil communities, which might imply a role of hyphosphere communities for fungal N nutrition. Furthermore, the relative abundances of denitrification genes were greater in several hyphosphere communities, indicating an at least partly anoxic microenvironment with a high carbon-to-N ratio around the hyphae. In conclusion, soil fertilization legacy shapes P. canescens hyphosphere microbiomes and their functional potential related to P and N cycling.IMPORTANCE P-solubilizing Penicillium strains are introduced as biofertilizers to agricultural soils to improve plant P nutrition. Currently, little is known about the ecology of these biofertilizers, including their interactions with other soil microorganisms. This study shows that communities dominated by Betaproteobacteria and Gammaproteobacteria colonize P. canescens hyphae in soil and that the compositions of these communities depend on the soil conditions. The potential of these communities for N and organic P cycling is generally higher than that of soil communities. The high potential for organic P metabolism might complement the ability of the fungus to solubilize inorganic P, and it points to the hyphosphere as a hot spot for P metabolism. Furthermore, the high potential for N fixation could indicate that P. canescens recruits bacteria that are able to improve its N nutrition. Hence, this community study identifies functional groups relevant for the future optimization of next-generation biofertilizer consortia for applications in soil.

Use of Oak and Cherry Wood Chips during Alcoholic Fermentation and the Maturation Process of Rosé Wines: Impact on Phenolic Composition and Sensory Profile.

There is a lack of knowledge about the use of different wood species on rosé wine production. Thus, this work focused on the impact of the addition of wood chips from oak and cherry trees during the alcoholic fermentation and maturation process on rosé wine characteristics. Therefore, phenolic composition and sensory characteristics were monitored during the rosé wines' production. The use of wood chips during alcoholic fermentation induced a significant increase of phenolic content in rosé musts. During rosé wine maturation, the wood chip contact induced significantly higher values of colored anthocyanins, color intensity, and polymeric pigments, and significantly lower values of color hue in the corresponding rosé wines. In terms of sensory profile, a tendency for lower scores of "overall appreciation" were attributed to control rosé wine, while significantly higher scores for "color intensity" descriptor were attributed to all rosé wines matured in contact with wood chips. For the majority of phenolic parameters and individual phenolic compounds quantified, a clear and specific influence of the use of oak and cherry wood chips was not detected, except for (+)-catechin, where the rosé wines produced in contact with cherry chips showed the highest values. This study provides relevant information for winemakers about the impact of the use of wood chips on rosé wine quality.

Complexity of Cardiotocographic Signals as A Predictor of Labor.

Prediction of labor is of extreme importance in obstetric care to allow for preventive measures, assuring that both baby and mother have the best possible care. In this work, the authors studied how important nonlinear parameters (entropy and compression) can be as labor predictors. Linear features retrieved from the SisPorto system for cardiotocogram analysis and nonlinear measures were used to predict labor in a dataset of 1072 antepartum tracings, at between 30 and 35 weeks of gestation. Two groups were defined: Group A-fetuses whose traces date was less than one or two weeks before labor, and Group B-fetuses whose traces date was at least one or two weeks before labor. Results suggest that, compared with linear features such as decelerations and variability indices, compression improves labor prediction both within one (C-Statistics of 0.728) and two weeks (C-Statistics of 0.704). Moreover, the correlation between compression and long-term variability was significantly different in groups A and B, denoting that compression and heart rate variability look at different information associated with whether the fetus is closer to or further from labor onset. Nonlinear measures, compression in particular, may be useful in improving labor prediction as a complement to other fetal heart rate features.

Computer-based intrapartum fetal monitoring and beyond: A review of the 2nd Workshop on Signal Processing and Monitoring in Labor (October 2017, Oxford, UK).

The second Signal Processing and Monitoring in Labor workshop gathered researchers who utilize promising new research strategies and initiatives to tackle the challenges of intrapartum fetal monitoring. The workshop included a series of lectures and discussions focusing on: new algorithms and techniques for cardiotocogoraphy (CTG) and electrocardiogram acquisition and analyses; the results of a CTG evaluation challenge comparing state-of-the-art computerized methods and visual interpretation for the detection of arterial cord pH <7.05 at birth; the lack of consensus about the role of intrapartum acidemia in the etiology of fetal brain injury; the differences between methods for CTG analysis "mimicking" expert clinicians and those derived from "data-driven" analyses; a critical review of the results from two randomized controlled trials testing the former in clinical practice; and relevant insights from modern physiology-based studies. We concluded that the automated algorithms performed comparably to each other and to clinical assessment of the CTG. However, the sensitivity and specificity urgently need to be improved (both computerized and visual assessment). Data-driven CTG evaluation requires further work with large multicenter datasets based on well-defined labor outcomes. And before first tests in the clinic, there are important lessons to be learnt from clinical trials that tested automated algorithms mimicking expert CTG interpretation. In addition, transabdominal fetal electrocardiogram monitoring provides reliable CTG traces and variability estimates; and fetal electrocardiogram waveform analysis is subject to promising new research. There is a clear need for close collaboration between computing and clinical experts. We believe that progress will be possible with multidisciplinary collaborative research.

Grieving With Humor: A Correlational Study on Sense of Humor and Professional Grief in Palliative Care Nurses.

The aim of this study was to explore the relationship between humor and professional grief. Findings confirm that these are not independent phenomena. Using humor as a coping mechanism emerged as a response to death-related work. Likewise, positive attitudes toward humor seem to alleviate the distress associated with end-of-life care.

Omalizumab in Chronic Spontaneous Urticaria: A Brazilian Real-Life Experience.

BACKGROUND: Current guidelines on chronic spontaneous urticaria (CSU) suggest a treatment based on a 3-step approach that aims at total symptom control, starting with H1-antihistamines. However, a significant number of patients present an antihistamine-resistant urticaria that must be treated with an alternative third-line therapy such as omalizumab. METHODS: Patients with a history of CSU who did not respond to treatment with high doses of modern antihistamines were treated with 150 or 300 mg of omalizumab every 4 weeks. The response to treatment was recorded as complete (CR), partial (PR) or no response. A dose adjustment was proposed according to response. RESULTS: We treated 47 CSU patients with omalizumab (40 females), of whom 39.5% had evidence of autoimmunity. The average number of treatments was 11.4 (range 2-87). All patients had been refractory to high-dose modern antihistamines. A CR was seen in 84.6% of patients who started with 300 mg and in 60% of those who started with 150 mg. Only 1 patient had no response to both the 150- and 300-mg doses. In 6 of the PR patients with 150 mg, a higher dose of 300 mg was proposed and 4 had a CR. Four patients discontinued the treatment. No severe adverse events were reported in the patients who finished the study. DISCUSSION: Although good results were seen in both groups, CR rates were higher in those under a high-dose initial treatment. Our data strongly suggest that the therapy should be individualized.

Differences between external and internal fetal heart rate monitoring during the second stage of labor: a prospective observational study.

OBJECTIVE: To compare fetal heart rate (FHR) signals acquired simultaneously by an external ultrasound probe and a scalp electrode during the second stage of labor. METHODS: This was a prospective observational study in a labor ward of a tertiary care university hospital. The population was women in labor with uneventful singleton pregnancies at term. Simultaneous external and internal FHR monitoring was performed in 67 consecutively recruited women during the second stage of labor. Cases were subsequently excluded if the trace length was under 40 min, cesarean birth occurred, or the interval between trace-end and birth exceeded 5 min, leaving a total of 33 traces for analysis. The last 40-60 min of these traces were analyzed by a computer system (Omniview-SisPorto 3.5; Speculum, Lisbon, Portugal) to quantify cardiotocographic parameters. Paired sample t-test and Bland-Altman limits of agreement (LoA) were used for statistical analysis, setting significance at 0.05. The main outcome measures were signal loss, FHR baseline, periodic events, and percentage of periodic events coinciding with contractions. RESULTS: A higher signal loss was observed with external monitoring [10% vs. 4%; P<0.001, LoA=(-6, 18)]. No differences were found in mean FHR baseline [129 bpm vs. 130 bpm, P=0.245, LoA=(-15, 12)], but more accelerations [12 vs. 8, P<0.001, LoA=(-5, 13)] and less decelerations [8 vs. 10, P<0.001, LoA=(-8, 4)] were detected with external monitoring. With this method there were also more accelerations (66% vs. 55%, P=0.036) and less decelerations (68% vs. 81%, P=0.017) coinciding with contractions. CONCLUSIONS: External FHR monitoring during the second stage of labor results in higher signal loss, increased number of accelerations, and decreased number of decelerations when compared with internal monitoring.

Gestational Diabetes Risk and Low Birth Weight After Metabolic Bariatric Surgery: a Complex Interplay to be Balanced.

INTRODUCTION: Metabolic bariatric surgery (MBS) is known to improve the obstetric outcomes of women with obesity and to prevent gestational diabetes (GD). To what extent does MBS decreases GD, without incurring at additional risks is a matter of concern. METHODS: A retrospective case-control study to compare the pregnancy outcomes of women previously submitted to MBS to those of age and preconception body mass index (PC BMI) matched non-operated controls. RESULTS: Pregnancies of women after MBS (n = 79) and matched controls (n = 79) were included. GD was significantly less frequent after MBS (7.6% vs. 19%; p = 0.03). Fasting blood glucose (76.90 ± 0.77 vs 80.37 ± 1.15 mg/dl, p < 0.05; 70.08 ± 1.34 vs. 76.35 ± 0.95 mg/dl; p < 0.05, first and second trimesters respectively) and birth weight (2953.67 ± 489.51 g vs. 3229.11 ± 476.21 g; p < 0.01) were significantly lower after MBS when compared to controls. The occurrence of small-for-gestational-age (SGA) was more frequent after MBS (22.8% vs. 6.3%; p < 0.01), but no longer significant after controlling for smoking habits (15.5% vs. 6%, p = 0.14). There were no significant differences in gestational weight gain, prematurity rate nor mode of delivery between groups. CONCLUSION: MBS was associated with a lower prevalence of GD than observed in non-operated women with the same age and BMI. After controlling for smoking, this occurred at the expense of a lower birth weight. Our data reinforces the hypothesis that MBS has body weight independent effects on glucose kinetics during pregnancy with distinctive impacts for mother and offspring, which need to be balanced.

Influence of preconception body mass index on perinatal outcomes after metabolic and bariatric surgery.

INTRODUCTION: Metabolic and bariatric surgery (MBS) is a very effective weight loss intervention, although does not invariably reverses the obesity status. Our aim was to evaluate whether despite successful weight loss after MBS, persistence of obesity at time of conception still carries additional risks of adverse perinatal pregnancy outcomes. METHODS: Retrospective study comparing pregnancy outcomes of women previously submitted to MBS with a preconception (PC) body mass index BMI < 30 kg/m2 or PC BMI ≥ 30 kg/m2. RESULTS: Eighty pregnancies (n = 80) were included, 49 from women with a PC BMI < 30 kg/m2 and 31 with a PC BMI ≥ 30 kg/m2. Gestational weight gain was significantly lower (9.72 ± 7.10 vs. 13.81 ± 7.16 respectively; p = 0.01) and neonatal intensive care unit admissions were significantly higher (5% vs. 0% respectively; p = 0.02) in women with PC BMI ≥ 30 kg/m2 as compared to those with PC BMI < 30 kg/m2. There were no statistically significant differences in gestational diabetes, anemia, fetal growth restriction, prematurity rate, mode of delivery or birth weight between groups. CONCLUSION: Perinatal outcomes of pregnancies after MBS may be significantly influenced by PC BMI. The benefits of MBS induced weight loss on obesity-associated adverse pregnancy outcomes can be maximized if the obesity status can be reverted before pregnancy.

EUROPEAN ASSOCIATION OF PERINATAL MEDICINE (EAPM) Position statement: Use of appropriate terminology for situations related to inadequate fetal oxygenation in labor.

In high-resource countries, adverse perinatal outcomes are currently rare in term, non-malformed fetuses, undergoing labor, but they remain a leading cause of medico-legal dispute. Precise terminology is important to describe situations related to inadequate fetal oxygenation in labor, to ensure appropriate communication between healthcare professionals and adequate transmission of information to parents. This position statement provides consensus definitions from European perinatologists and midwives regarding the most appropriate terminology to describe situations related to inadequate fetal oxygenation in labor: suspected fetal hypoxia, severe newborn acidemia, newborn metabolic acidosis, and hypoxic-ischemic encephalopathy. It also identifies terms that are imprecise or nonspecific to this situation, and should therefore be avoided by healthcare professionals: fetal well-being, fetal stress, fetal distress, non-reassuring fetal state, and birth asphyxia.

European Association of Perinatal Medicine (EAPM), European Board and College of Obstetricians and Gynaecologists (EBCOG), European Midwives Association (EMA). Joint position statement: Substandard and disrespectful care in labour - because words matter.

Substandard or disrespectful care during labour should be of serious concern for healthcare professionals, as it can affect one of the most important events in a woman's life. Substandard care refers to the use of interventions that are not considered best-practice, to the inadequate execution of interventions, to situations where best-practice interventions are withheld from patients, or there is lack of adequate informed consent. Disrespectful care refers to forms of verbal and non-verbal communication that affect patients' dignity, individuality, privacy, intimacy, or personal beliefs. There are many possible underlying causes for substandard and disrespectful care in labour, including difficulties in modifying behaviours, judgmental or paternalistic attitudes, personal interests and individualism, and a human tendency to make less arduous, less difficult, or less stressful clinical decisions. The term "obstetric violence" is used in some parts of the world to describe various forms of substandard and disrespectful care in labour, but suggests that it is mainly carried out by obstetricians and is a serious form of aggression, carried out with the intent to cause harm. We believe that this term should not be used, as it does not help to identify the underlying problem, its causes, or its correction. In addition, it is generally seen by obstetricians and other healthcare professionals as an unjust and offensive term, generating a defensive and less collaborative mindset. We reach out to all individuals and institutions sharing the common goal of improving women's experience during labour, to work together to address the underlying causes of substandard and disrespectful care, and to develop common strategies to deal with this problem, based on mutual comprehension, trust and respect.

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus.

OBJECTIVE: There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth. DESIGN: Systematic review and three-stage modified Delphi expert consensus. SETTING: International. POPULATION: Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance. OUTCOME MEASURES: Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth. RESULTS: Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach. CONCLUSION: These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

Pediatric allergy and immunology in Brazil.

The subspecialty of pediatric allergy and immunology in Brazil is in its early years and progressing steadily. This review highlights the research developed in the past years aiming to show the characteristics of allergic and immunologic diseases in this vast country. Epidemiologic studies demonstrated the high prevalence of asthma in infants, children, and adolescents. Mortality rates and average annual variation of asthma hospitalization have reduced in all pediatric age groups. Indoor aeroallergen exposure is excessively high and contributes to the high rates of allergy sensitization. Prevalence of food allergy has increased to epidemic levels. Foods (35%), insect stings (30%), and drugs (23%) are the main etiological agents of anaphylaxis in children and adolescents. Molecular diagnosis of primary immunodeficiencies (PID) showed a high incidence of fungal infections including paracoccidioidomycosis in X-linked hyper-IgM syndrome, and the occurrence of BCG adverse reactions or other mycobacterial infections in patients with chronic granulomatous disease. Education in pediatric allergy and immunology is deficient for medical students, but residency programs are effective in training internists and pediatricians for the practice of allergy. The field of PID requires further training. Last, this review is a tribute to Prof. Dr. Charles Naspitz, one of the pioneers of our specialty in Brazil.

FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery.

FIGO is actively contributing to the global effort to reduce maternal morbidity, mortality, and disability worldwide. Cesarean delivery rates are increasing globally, without signs of slowing down. Bleeding associated with cesarean delivery has become an important cause of hemorrhage-related maternal deaths in many low- and middle-income countries. Correct surgical techniques to improve safety and reduce complications of cesarean delivery is of the utmost importance. This article presents FIGO's good practice recommendations for effective surgical techniques to reduce cesarean complications. Evidence-based information is included where data are available. An expanded WHO Surgical Safety Checklist for maternity cases is suggested. Different incision techniques through the layers of the abdominal wall with appropriate indications are discussed. Hysterotomy through a transverse incision is described, as are indications for low vertical and classical incisions. Important precautions when extracting the fetus are explained. Uterine closure includes a safe method ensuring adequate reapproximation of the upper segment if a vertical incision is made. The paper concludes with the management of two common bleeding problems following delivery of the placenta.

Machine learning models based on clinical indices and cardiotocographic features for discriminating asphyxia fetuses-Porto retrospective intrapartum study.

Introduction: Perinatal asphyxia is one of the most frequent causes of neonatal mortality, affecting approximately four million newborns worldwide each year and causing the death of one million individuals. One of the main reasons for these high incidences is the lack of consensual methods of early diagnosis for this pathology. Estimating risk-appropriate health care for mother and baby is essential for increasing the quality of the health care system. Thus, it is necessary to investigate models that improve the prediction of perinatal asphyxia. Access to the cardiotocographic signals (CTGs) in conjunction with various clinical parameters can be crucial for the development of a successful model. Objectives: This exploratory work aims to develop predictive models of perinatal asphyxia based on clinical parameters and fetal heart rate (fHR) indices. Methods: Single gestations data from a retrospective unicentric study from Centro Hospitalar e Universitário do Porto de São João (CHUSJ) between 2010 and 2018 was probed. The CTGs were acquired and analyzed by Omniview-SisPorto, estimating several fHR features. The clinical variables were obtained from the electronic clinical records stored by ObsCare. Entropy and compression characterized the complexity of the fHR time series. These variables' contribution to the prediction of asphyxia perinatal was probed by binary logistic regression (BLR) and Naive-Bayes (NB) models. Results: The data consisted of 517 cases, with 15 pathological cases. The asphyxia prediction models showed promising results, with an area under the receiver operator characteristic curve (AUC) >70%. In NB approaches, the best models combined clinical and SisPorto features. The best model was the univariate BLR with the variable compression ratio scale 2 (CR2) and an AUC of 94.93% [94.55; 95.31%]. Conclusion: Both BLR and Bayesian models have advantages and disadvantages. The model with the best performance predicting perinatal asphyxia was the univariate BLR with the CR2 variable, demonstrating the importance of non-linear indices in perinatal asphyxia detection. Future studies should explore decision support systems to detect sepsis, including clinical and CTGs features (linear and non-linear).

Designing a Nurse-Led Program for Self-Management of Substance Addiction Consequences: A Modified e-Delphi Study.

Therapeutic interventions for people with problematic use of psychoactive substances can help tackle specific needs related to substance addiction consequences. This modified e-Delphi study aimed to establish consensus on a training program for self-management of substance addiction consequences. The study was conducted between February and April 2022, with an experts' sample of 28 participants in the first round and 24 in the second. A priori consensus criteria were defined for each round. The results revealed a very strong consensus was achieved on the structure of the program and on clinical areas, such as the problematic use of substances, general health knowledge, health-seeking behavior and adherence, self-knowledge and well-being, social role and personal dignity, and family process. Additionally, over 80% participant consensus was achieved on an extensive number of interventions categorized as psychoeducational, psychotherapeutic, socio therapeutic, brief interventions, social skills training, problem solving techniques, relaxation techniques, and counseling. These findings may be able to fulfill a gap concerning structured treatment approaches for people with problematic use of psychoactive substances. Supporting self-management of the consequences of substance addiction and its application can change nurses' interventions.

Exploring new antiviral targets for influenza and COVID-19: Mapping promising hot spots in viral RNA polymerases.

Influenza and COVID-19 are infectious respiratory diseases that represent a major concern to public health with social and economic impact worldwide, for which the available therapeutic options are not satisfactory. The RdRp has a central role in viral replication and thus represents a major target for the development of antiviral approaches. In this study, we focused on Influenza A virus PB1 polymerase protein and the betacoronaviruses nsp12 polymerase protein, considering their functional and structural similarities. We have performed conservation and druggability analysis to map conserved druggable regions, that may have functional or structural importance in these proteins. We disclosed the most promising and new targeting regions for the discovery of new potential polymerase inhibitors. Conserved druggable regions of putative interaction with favipiravir and molnupiravir were also mapped. We have also compared and integrated the current findings with previous research.