Expedient, regioselective C-H chalcogenation of 3,4-dihydro-1,4-benzoxazines using a palladium-copper catalyst.

The palladium-catalysed regioselective C-H chalcogenation of benzoxazines with disulfides and diselenides in air has been described. In this protocol, palladium acetate serves as the catalyst in conjunction with copper as an oxidizing agent. Through this approach, a wide array of sulfenylation and selenylation reactions of benzomorpholines have been effected, yielding results ranging from good to excellent. Thus, the established procedure demonstrates superb regioselectivity and a strong tolerance towards various functional groups and is suitable for gram-scale synthesis. Additionally, this synthetic approach offers a practical and convenient pathway for late-stage functionalization leading to the Rosenmund-von Braun reaction.

Synthesis and characterization of organoselenium based BODIPY and its application in living cells.

Phenylselenide based BODIPY probe was successfully synthesized and characterized by NMR spectroscopic techniques (1H, 13C and 77Se NMR), mass spectrometry and single crystal XRD. Surprisingly, crystal packing diagram of the probe showed formation of 1-D strip through intermolecular F---H interaction. The probe was screened with various Reactive Oxygen Species (ROS) and found to be selective for superoxide ion over other ROS via "turn-on" fluorescence response. The probe selectively and sensitively detects superoxide with a lower detection limit (43.34 nM) without interfering with other ROS. The quantum yield of the probe was found to increase from 0.091 % to 30.4 % (334-fold) after oxidation. Theoretical calculations (DFT and TD-DFT) were also performed to understand the sensing mechanism of the probe. The probe was able to effectively detect superoxide inside living cells without any toxic effect.

Efficient recall of SARS-CoV-2 variant-reactive B cells and T responses in the elderly upon heterologous mRNA vaccines as boosters.

Waning antibody levels against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the emergence of variants of concern highlight the need for booster vaccinations. This is particularly important for the elderly population, who are at a higher risk of developing severe coronavirus disease 2019 (COVID-19) disease. While studies have shown increased antibody responses following booster vaccination, understanding the changes in T and B cell compartments induced by a third vaccine dose remains limited. We analyzed the humoral and cellular responses in subjects who received either a homologous messenger RNA(mRNA) booster vaccine (BNT162b2 + BNT162b2 + BNT162b2; ''BBB") or a heterologous mRNA booster vaccine (BNT162b2 + BNT162b2 + mRNA-1273; ''BBM") at Day 0 (prebooster), Day 7, and Day 28 (postbooster). Compared with BBB, elderly individuals (≥60 years old) who received the BBM vaccination regimen display higher levels of neutralizing antibodies against the Wuhan and Delta strains along with a higher boost in immunoglobulin G memory B cells, particularly against the Omicron variant. Circulating T helper type 1(Th1), Th2, Th17, and T follicular helper responses were also increased in elderly individuals given the BBM regimen. While mRNA vaccines increase antibody, T cell, and B cell responses against SARS-CoV-2 1 month after receiving the third dose booster, the efficacy of the booster vaccine strategies may vary depending on age group and regimen combination.

Coordination Behavior of the Tellurium Incorporated Mercuraazametallamacrocycle and Investigation of d10 ⋠⋠⋠d10 Interactions between Closed Shell (Ag+ Hg2+ ) Metal Ions.

Herein, a new tellurium and mercury containing mercuraazametallamacrocycle has been prepared via (2+2) condensation of bis(o-aminophenyl)telluride and bis(o-formylphenyl)mercury(II). The isolated bright yellow solid of mercuraazametallamacrocycle has adopted unsymmetrical figure-of-eight conformation in the crystal structure. To study the metallophilic interactions between closed shell metal ions, the macrocyclic ligand has been treated with two equiv. of AgOTf (OTf=trifluoromethansulfonate) and AgBF4 , which afforded greenish-yellow bimetallic silver complexes. The isolated silver complexes displayed intramolecular Hg⋅⋅⋅Ag, Te⋅⋅⋅Ag interactions as well as intermolecular Hg⋅⋅⋅Hg interactions and formed an extended 1D molecular chain by directing six atoms to interact as TeII ⋅⋅⋅AgI ⋅⋅⋅HgII ⋅⋅⋅HgII ⋅⋅⋅AgI ⋅⋅⋅TeII in a non linear fashion. The Hg⋅⋅⋅Ag, Te⋅⋅⋅Ag interactions have also been studied in solution by 199 Hg, 125 Te NMR spectroscopy, absorption, and emission spectroscopy. In DFT calculations, the Atom in Molecule (AIM) analysis, non-covalent interactions (NCI), natural bonding orbital (NBO) analysis strongly supported for experimental evidences and revealed that the intermolecular Hg⋅⋅⋅Hg interaction is stronger than the intramolecular Hg⋅⋅⋅Ag interactions.

Pushing the Boundary of Covalency in Lanthanoid-Tellurium Bonds: Insights from the Synthesis, Molecular and Electronic Structures of Low-Coordinate, Monomeric Europium(II) and Ytterbium(II) Tellurolates.

Owing to the strict hard/soft dichotomy between the lanthanoids and tellurium atoms, and the strong affinity of lanthanoid ions for high coordination numbers, low-coordinate, monomeric lanthanoid tellurolate complexes have remained elusive as compared to the lanthanoid complexes with lighter group 16 elements (O, S, and Se). This makes the development of suitable ligand systems for low-coordinate, monomeric lanthanoid tellurolate complexes an appealing endeavor. In a first report, a series of low-coordinate, monomeric lanthanoid (Yb, Eu) tellurolate complexes were synthesized by utilizing hybrid organotellurolate ligands containing N-donor pendant arms. The reaction of bis[2-((dimethylamino)methyl)phenyl] ditelluride, 1 and 8,8'diquinolinyl ditelluride, 2 with Ln0 metals (Ln=Eu, Yb) resulted in the formation of monomeric complexes [LnII (TeR)2 (Solv)2 ] [R=C6 H4 -2-CH2 NMe2 ] [3: Ln=Eu, Solv=tetrahydrofuran; 4: Ln=Eu, Solv=acetonitrile; 5: Ln=Yb, Solv=tetrahydrofuran; 6: Ln=Yb, Solv=pyridine] and [EuII (TeNC9 H6 )2 (Solv)n ] (7: Solv=tetrahydrofuran, n=3; 8: Solv=1,2-dimethoxyethane, n=2), respectively. Complexes 3-4 and 7-8 represent the first sets of examples of monomeric europium tellurolate complexes. The molecular structures of complexes 3-8 are validated by single-crystal X-ray diffraction studies. The electronic structures of these complexes were investigated using Density Functional Theory (DFT) calculations, which revealed appreciable covalency between the tellurolate ligands and lanthanoids.

Disentangling the trajectories of maternal depressive symptoms and partnership problems in the transition to parenthood and their impact on child adjustment difficulties.

Maternal perinatal depression (PND) and partnership problems have been identified to influence the development of later child adjustment difficulties. However, PND and partnership problems are closely linked which makes it difficult to draw conclusions about the exact transmission pathways. The aim of the present study was to investigate to what extent PND symptoms and partnership problems influence each other longitudinally and to examine the influence of their trajectories on child adjustment difficulties at the age of three. Analyses were based on publicly available data from the German family panel "pairfam". N = 354 mothers were surveyed on depressive symptoms and partnership problems annually from pregnancy (T0) until child age three (T4). Child adjustment difficulties were assessed at age three. Results of latent change score modeling showed that partnership problems predicted change in PND symptoms at T0 and T3 while PND symptoms did not predict change in partnership problems. Child adjustment difficulties at age three were predicted by PND symptoms, but not by partnership problems. Partnership problems predicted externalizing, but not internalizing symptoms. Results underline the effects of family factors for the development of child adjustment difficulties and emphasize the importance of early interventions from pregnancy onwards.

Minimally invasive colectomies can be performed with similar outcomes to open counterparts for colorectal cancer emergencies: a propensity score matching analysis utilizing ACS-NSQIP.

PURPOSE: The safety and feasibility of minimally invasive surgery (MIS) in the setting of colorectal cancer emergencies have been debated. We sought to compare postoperative outcomes of MIS with open techniques in the setting of colorectal cancer emergencies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS: We included patients undergoing colectomy for colorectal cancer emergency between 2012 and 2019 "2012-2019" from the ACS-NSQIP dataset. We compared short-term morbidity, mortality, short-term oncological outcomes, and secondary outcomes for MIS vs open colectomies using propensity score matching. We then evaluated the trends of MIS versus open colectomies using linear regression analysis. RESULTS: We examined a total of 5544 patients (open n = 4070; MIS n = 1474) and included 1352 patients for our postoperative outcome analyses after propensity score matching 1:1 (open n = 676; MIS n = 676). Within the matched cohort, mortality was significantly higher in the open group (open 6.95% vs MIS 3.99%, OR 1.8, p = 0.023). Anastomotic leak rates were comparable between the  two groups (open 4.46% vs MIS 4.02%, OR 1.12, p = 0.787). Pulmonary complications were significantly higher after open surgery (open 10.06% vs MIS 4.73%, OR 2.25, p < 0.001). Rates of ileus were significantly higher amongst open patients (open 29.08% vs MIS 19.94%, p < 0.001). Patients stayed on average 1 day longer in the hospital after open surgery (p < 0.001). Rates of MIS for early tumors (N0 and T1/T2, n = 289) did not significantly change over 7 years (p = 0.597, rate = - 0.065%/year); however, utilization of MIS for late tumors (N1 or T3/T4, n = 4359) increased by 2.06% per year (p < 0.001). CONCLUSIONS: This study demonstrates that MIS was associated with superior postoperative outcomes compared to open surgery without compromising oncological outcomes in patients undergoing emergency colectomy for colon cancer. Within the matched cohort, MIS was associated with lower rates of mortality, pulmonary complications, ileus, and shorter postoperative length of stay.

Catalytic Acceptorless Dehydrogenation (CAD) of Secondary Benzylic Alcohols into Value-Added Ketones Using Pd(II)-NHC Complexes.

For the creation of adaptable carbonyl compounds in organic synthesis, the oxidation of alcohols is a crucial step. As a sustainable alternative to the harmful traditional oxidation processes, transition-metal catalysts have recently attracted a lot of interest in acceptorless dehydrogenation reactions of alcohols. Here, using well-defined, air-stable palladium(II)-NHC catalysts (A-F), we demonstrate an effective method for the catalytic acceptorless dehydrogenation (CAD) reaction of secondary benzylic alcohols to produce the corresponding ketones and molecular hydrogen (H2). Catalytic acceptorless dehydrogenation (CAD) has been successfully used to convert a variety of alcohols, including electron-rich/electron-poor aromatic secondary alcohols, heteroaromatic secondary alcohols, and aliphatic cyclic alcohols, into their corresponding value-added ketones while only releasing molecular hydrogen as a byproduct.

Shared Responsibility Decreases the Sense of Agency in the Human Brain.

Sharing responsibility in social decision-making helps individuals use the flexibility of the collective context to benefit themselves by claiming credit for good outcomes or avoiding the blame for bad outcomes. Using magnetoencephalography, we examined the neuronal basis of the impact that social context has on this flexible sense of responsibility. Participants performed a gambling task in various social contexts and reported feeling less responsibility when playing as a member of a team. A reduced magnetoencephalography outcome processing effect was observed as a function of decreasing responsibility at 200 msec post outcome onset and was centered over parietal, central, and frontal brain regions. Before outcome revelation in socially made decisions, an attenuated motor preparation signature at 500 msec after stimulus onset was found. A boost in reported responsibility for positive outcomes in social contexts was associated with increased activity in regions related to social and reward processing. Together, these results show that sharing responsibility with others reduces agency, influencing pre-outcome motor preparation and post-outcome processing, and provides opportunities to flexibly claim credit for positive outcomes.

Antibody Response of Heterologous vs Homologous Messenger RNA Vaccine Boosters Against the Severe Acute Respiratory Syndrome Coronavirus 2 Omicron Variant: Interim Results from the PRIBIVAC Study, a Randomized Clinical Trial.

BACKGROUND: Waning antibody levels post-vaccination and the emergence of variants of concern (VOCs) capable of evading protective immunity have raised the need for booster vaccinations. However, which combination of coronavirus disease 2019 (COVID-19) vaccines offers the strongest immune response against the Omicron variant is unknown. METHODS: This randomized, participant-blinded, controlled trial assessed the reactogenicity and immunogenicity of different COVID-19 vaccine booster combinations. A total of 100 BNT162b2-vaccinated individuals were enrolled and randomized 1:1 to either homologous (BNT162b2 + BNT162b2 + BNT162b2; "BBB") or heterologous messenger RNA (mRNA) (BNT162b2 + BNT162b2 + mRNA-1273; "BBM") booster vaccine. The primary end point was the level of neutralizing antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) wild-type and VOCs at day 28. RESULTS: A total of 51 participants were allocated to BBB and 49 to BBM; 50 and 48, respectively, were analyzed for safety and immunogenicity outcomes. At day 28 post-boost, mean SARS-CoV-2 spike antibody titers were lower with BBB (22 382 IU/mL; 95% confidence interval [CI], 18 210 to 27 517) vs BBM (29 751 IU/mL; 95% CI, 25 281 to 35 011; P = .034) as was the median level of neutralizing antibodies: BBB 99.0% (interquartile range [IQR], 97.9% to 99.3%) vs BBM 99.3% (IQR, 98.8% to 99.5%; P = .021). On subgroup analysis, significant higher mean spike antibody titer, median surrogate neutralizing antibody level against all VOCs, and live Omicron neutralization titer were observed only in older adults receiving BBM. Both vaccines were well tolerated. CONCLUSIONS: Heterologous mRNA-1273 booster vaccination compared with homologous BNT123b2 induced a stronger neutralizing response against the Omicron variant in older individuals. CLINICAL TRIALS REGISTRATION: NCT05142319.

Ergodicity-breaking reveals time optimal decision making in humans.

Ergodicity describes an equivalence between the expectation value and the time average of observables. Applied to human behaviour, ergodic theories of decision-making reveal how individuals should tolerate risk in different environments. To optimize wealth over time, agents should adapt their utility function according to the dynamical setting they face. Linear utility is optimal for additive dynamics, whereas logarithmic utility is optimal for multiplicative dynamics. Whether humans approximate time optimal behavior across different dynamics is unknown. Here we compare the effects of additive versus multiplicative gamble dynamics on risky choice. We show that utility functions are modulated by gamble dynamics in ways not explained by prevailing decision theories. Instead, as predicted by time optimality, risk aversion increases under multiplicative dynamics, distributing close to the values that maximize the time average growth of in-game wealth. We suggest that our findings motivate a need for explicitly grounding theories of decision-making on ergodic considerations.

Caesarean birth in women with infertility: population-based cohort study.

OBJECTIVE: Caesarean section (CS) is more common following infertility treatment (IT) but the reasons why remain unclear and confounded. The Robson 10-Group Classification System (TGCS) may further explain variation in CS rates. We assessed the association between mode of conception and CS across Robson groups. DESIGN: Population-based cohort study. SETTING: Ontario, Canada, in a public healthcare system. POPULATION: 921 023 births, 2006-2014. METHODS: Modified Poisson regression produced relative risks (RR) and 95% confidence intervals, comparing the risk of CS among women with (1) subfertility without IT, (2) non-invasive IT (OI, IUI) or (3) invasive IT (IVF)-each relative to (4) spontaneous conception (SC). MAIN OUTCOME MEASURES: CS rate according to one of four modes of conception, overall and stratified by each of the TGCS groups. RESULTS: Relative to SC (26.9%), the risk of CS increased in those with subfertility without IT (RR 1.17, 95% CI 1.16-1.18), non-invasive IT (RR 1.21, 95% CI 1.18-1.24) and invasive IT (RR 1.39, 95% CI 1.36-1.42). Within each Robson group, similar patterns of RRs were seen, but with markedly differing rates. For example, in Group 1 (nulliparous, singleton, cephalic at ≥37 weeks, with spontaneous labour), the respective rates were 15.0, 19.4, 18.7 and 21.9%; in Group 2 (nulliparous, singleton, cephalic at ≥37 weeks, without spontaneous labour), the rates were 35.9, 44.4, 43.2 and 54.1%; and in Group 8 (multiple pregnancy), they were 55.9, 67.5, 65.0 and 69.3%, respectively. CONCLUSIONS: CS is relatively more common in women with subfertility and those receiving IT, an effect that persists across Robson groups. TWEETABLE ABSTRACT: Caesarean delivery is more common in women with infertility independent of demographics and prenatal conditions.

Appropriateness of inpatient dosing of direct oral anticoagulants for atrial fibrillation.

Direct oral anticoagulant (DOAC) use for stroke prevention in atrial fibrillation (AF) has dose reduction criteria including age, weight, serum creatinine, and creatinine clearance. There is a paucity of data for rates of inappropriate inpatient DOAC dosing in Australia. The objective was to determine the rates of inappropriate inpatient DOAC dosing in AF and identifying its associated underlying factors. We conducted a retrospective cross-sectional study from December 2013 to November 2019 across six South Australian public hospitals utilising a centralised electronic health record. Multivariate analysis was used to identify factors associated with underdosing of patients prescribed apixaban. Of 1882 inpatients, 544 (28.9 %) were inappropriately dosed. Underdosing was the most common form of inappropriate dosing with rates of 22.9 % (n = 295), 7.1 % (n = 7), and 25.1 % (n = 124) for apixaban, dabigatran, and rivaroxaban, respectively. Independent factors predictive of apixaban underdosing included higher age (adjusted odds ratio (aOR) 1.63 [95 % Confidence Interval (CI): 1.47-1.81]), higher serum creatinine (aOR 1.13 [95 % CI: 1.08-1.19]), higher total number of drugs on discharge (aOR 1.08 [95 % CI: 1.04-1.11]), and being already prescribed a DOAC on admission (aOR 1.63 [95 % CI: 1.12-2.38]). Nearly one quarter of all apixaban prescribing was inappropriately underdosed. Older patients with multimorbidity, frailty and polypharmacy present a challenge for clinicians in balancing risks of thromboembolism and bleeding. It is likely prescribers are more conservative in their apixaban dosing in this population. Clinicians should consider alternative drug regimens to avoid DOAC use at inappropriate doses at unknown safety and efficacy.

Added value of Joint ENT-Rheumatology clinic in the management of ANCA-associated vasculitis: One year's experience.

PURPOSE: ANCA-associated vasculitides (AAV) represent a group of diagnoses, including granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA). Most commonly, they present initially with ENT-associated symptomatology, and therefore they often pose a diagnostic challenge. We aim to present our one-year experience in the joint management of AAV in a multi-disciplinary setting. METHODS: We performed a retrospective analysis based on the records of 39 patients who were seen in the joint clinic, during a period of one year. RESULTS: After clinical assessment, 13 patients had changes made to their ENT treatment, 2 had some changes in their immunosuppression, while 11 had changes in both ENT and Rheumatology treatment. Six patients did not require any alterations to their therapeutic scheme. On average three separate appointments were reduced to a single appointment in the joint clinic where definitive treatment decisions were made. This led to significant cost reductions. CONCLUSIONS: Cost-effectiveness, patient satisfaction, rapid multi-disciplinary evaluation, avoidance of unnecessary immunosuppression, patient education and medical training are only a few of the many advantages of this proposed joint service.

Catalytic and highly regenerable aminic organoselenium antioxidants with cytoprotective effects.

Novel N-methylated ebselenamine antioxidants were prepared from the corresponding diselenides with iodomethane. All ebselenamines showed excellent chain-breaking and glutathione peroxidase (GPx)-like activities. They could also inhibit lipid peroxidation much more efficiently than α-tocopherol. They could also mimic the functions of the GPx-enzymes nearly two times better than ebselen in the coupled reductase assay. Also, they were found to scavenge the ROS produced at low concentration (10 µM) with low toxicity effects and could have therapeutic potential against autoxidation. It is anticipated that these compounds could potentially be used against several diseases caused by autoxidation, and thus provide protection from cell death to mammals.

Contribution of Massive Mitochondrial Fusion and Subsequent Fission in the Plant Life Cycle to the Integrity of the Mitochondrion and Its Genome.

Plant mitochondria have large genomes to house a small number of key genes. Most mitochondria do not contain a whole genome. Despite these latter characteristics, the mitochondrial genome is faithfully maternally inherited. To maintain the mitochondrial genes-so important for energy production-the fusion and fission of mitochondria are critical. Fission in plants is better understood than fusion, with the dynamin-related proteins (DRP 3A and 3B) driving the constriction of the mitochondrion. How the endoplasmic reticulum and the cytoskeleton are linked to the fission process is not yet fully understood. The fusion mechanism is less well understood, as obvious orthologues are not present. However, there is a recently described gene, MIRO2, that appears to have a significant role, as does the ER and cytoskeleton. Massive mitochondrial fusion (MMF or hyperfusion) plays a significant role in plants. MMF occurs at critical times of the life cycle, prior to flowering, in the enlarging zygote and at germination, mixing the cells' mitochondrial population-the so-called "discontinuous whole". MMF in particular aids genome repair, the conservation of critical genes and possibly gives an energy boost to important stages of the life cycle. MMF is also important in plant regeneration, an important component of plant biotechnology.

Undiagnosed type 2 diabetes during pregnancy is associated with increased perinatal mortality: a large population-based cohort study in Ontario, Canada.

AIM: To compare perinatal outcomes in women with undiagnosed diabetes with gestational diabetes alone, pre-existing diabetes and women without diabetes, and to identify risk factors which distinguish them from women with gestational diabetes alone. METHODS: This population-based cohort study included administrative data on all women who gave birth in Ontario, Canada, during 2002-2015. Maternal/neonatal outcomes were compared across groups using logistic regression, adjusting for confounders. A nested case control study compared women with undiagnosed type 2 diabetes with women with gestational diabetes alone to determine risk factors that would help identify these women. RESULTS: Among 995 990 women, 68 163 had gestational diabetes (6.8%) and, of those women with gestational diabetes,1772 had undiagnosed type 2 diabetes (2.6%). Those with undiagnosed type 2 diabetes were more likely to be older, from a lower income area, have parity > 3 and BMI ≥ 30 kg/m2 compared with gestational diabetes alone. Infants had a higher risk of perinatal mortality (OR 2.3 [1.6-3.4]), preterm birth (OR 2.6 [2.3-2.9]), congenital anomalies (OR 2.1 [1.7-2.5]), neonatal intensive care unit admission (OR 3.1 [2.8-3.5]) and neonatal hypoglycaemia (OR 406.0 [357-461]), which were similar to women with pre-existing diabetes. The strongest predictive risk factors included early gestational diabetes diagnosis, previous gestational diabetes and chronic hypertension. CONCLUSIONS: Women diagnosed with gestational diabetes who develop diabetes within 1 year postpartum are at higher risk of adverse pregnancy outcomes, including perinatal mortality. This highlights the need for earlier diagnosis, preferably pre-pregnancy, and more aggressive treatment and surveillance of suspected type 2 diabetes during pregnancy.

Single or two drug combination therapy as initial treatment for low risk, gestational trophoblastic neoplasia. A Canadian analysis.

INTRODUCTION: Low risk gestational trophoblastic neoplasia, WHO prognostic score of 0 to 6, is highly curable. There is no consensus on the optimal chemotherapy. Common regimens are q2wk actinomycin-D (ACT-D), weekly intramuscular methotrexate (MTX) or multi-day MTX. Combination MTX/ACT-D is rarely used. METHODS: A four centre, retrospective cohort study was carried out comparing commonly used regimens: weekly MTX, q2weekly ACT-D and q2 weekly MTX and ACT-D. RESULTS: 412 patients - 196 MTX/ACT-D, 107 MTX, 109 ACT-D - were treated between October 1994 and January 2019. Initial regimen failure (secondary to resistance or toxicity) occurred in 37% (MTX), 21% (ACT-D) and 5% (MTX/ACT-D). Relapse after completion of primary therapy (initial plus switch to another therapy if needed) was rare (0-5%). All eventually were cured. Mean number of cycles required to achieve remission were 10.1 (MTX), 7 (ACT-D) and 5.6 (MTX/ACT-D) with corresponding mean treatment durations of 3.12, 2.9 and 2.26 months. Dosage reductions occurred in 3% (MTX), 0% (ACT-D) and 29% (MTX/ACT-D). Higher failure rates occurred with WHO prognostic scores of 5 to 6 and HCG levels ≥10,000. SUMMARY: Initial regimen failure ie the need to switch to an alternative treatment was more common with MTX. ACT-D and MTX/ACT-D were similar within prognostic score 0-4 or HCG < 10,000. ACT-D then appears the better initial choice with its superior convenience. Above these levels primary failure rates are less with MTX/ACT-D, making it a better choice.

Increased maternal new-onset psychiatric disorders after delivering a child with a major anomaly: a cohort study.

BACKGROUND: The birth of a child with a major congenital anomaly may create chronic caregiving stress for mothers, yet little is known about their psychiatric outcomes. AIMS: To evaluate the association of the birth of a child with a major congenital anomaly with subsequent maternal psychiatric risk. METHODS: This Danish nationwide cohort study included mothers who gave birth to an infant with a major congenital anomaly (n = 19 220) between 1997 and 2015. Comparators were randomly selected mothers, matched on maternal age, year of delivery and parity (n = 195 399). The primary outcome was any new-onset psychiatric diagnosis. Secondary outcomes included specific psychiatric diagnoses, psychiatric in-patient admissions and redeemed psychoactive medicines. Cox models were used to estimate hazard ratios (HRs), adjusted for socioeconomic and medical variables. RESULTS: Mothers of affected infants had an elevated risk for a new-onset psychiatric disorder vs. the comparison group (adjusted HR, 1.16, 95% CI 1.11-1.22). The adjusted HR was particularly elevated during the first postpartum year (1.65, 95% CI 1.42-1.90), but remained high for years, especially among mothers of children with multiorgan anomalies (1.37, 95% CI 1.18-1.57). The risk was also elevated for most specific psychiatric diagnoses, admissions and medicines. CONCLUSIONS: Mothers who give birth to a child with a major congenital anomaly are at increased risk of new-onset psychiatric disorders, especially shortly after birth and for mothers of children with more severe anomalies. Our study highlights the need to screen for mental illness in this high-risk population, as well as to integrate adult mental health services and paediatric care.

Haemoglobin levels in early pregnancy and severe maternal morbidity: population-based cohort study.

OBJECTIVE: Data regarding low maternal haemoglobin concentration and severe maternal morbidity (SMM) are limited and potentially biased. This study evaluated the relation between early maternal haemoglobin concentration and SMM or maternal mortality. DESIGN: Population-based cohort study. SETTING: Ontario, Canada, in a public healthcare system. POPULATION: 737 393 births with a routine outpatient haemoglobin measured at a calculated gestational age of 2-16 weeks. METHODS: The relation between early-pregnancy outpatient blood haemoglobin concentration and each study outcome was expressed as adjusted relative risks (aRR) and absolute risk differences (aRD), with 95% confidence intervals (CI), generated by modified Poisson regression. MAIN OUTCOME MEASURES: The primary outcome was SMM or maternal mortality, from 23 weeks' gestation to 42 days postpartum. RESULTS: The mean (SD) haemoglobin concentration was 126.9 (9.3) g/l. Overall, SMM or death occurred in 13 514 pregnancies (1.8%). Relative to a haemoglobin level of 125-129 g/l, the aRR was 1.07 (95% CI 1.02-1.13) and aRD (0.09%, 95% CI 0.01-0.18) at 120-124 g/l; aRR 1.31 (95% CI 1.17-1.46) and aRD 0.47% (95% CI 0.24-0.69) at 105-109 g/l; and aRR 4.53 (95% CI 3.59-5.72) and aRD 5.94% (95% CI 4.12-7.76) at <90 g/l. In all, 5961 women (0.8%) required red cell transfusion, with significantly higher risks at all haemoglobin concentrations below 125-129 g/l, peaking at a haemoglobin level <90 g/l (aRR 11.82, 95% CI 9.30-15.03). CONCLUSION: There is a gradual increase in the risk of SMM or death, as well as red cell transfusion, starting from the lower level of the normal range of haemoglobin of non-pregnant women. TWEETABLE ABSTRACT: Women with low haemoglobin in early pregnancy are at higher future risk of morbidity, death and blood transfusion.