Study Protocol for a Stepped-Wedge Cluster (Nested) Randomized Controlled Trial of Antenatal Colostrum Expression (ACE) Instruction in First-Time Mothers: The ACE Study.

BACKGROUND: Although many mothers initiate breastfeeding, supplementation with human-milk substitutes (formula) during the birth hospitalization is common and has been associated with early breastfeeding cessation. Colostrum hand expressed in the last few weeks before birth, known as antenatal colostrum expression (ACE), can be used instead of human-milk substitutes. However, evidence is lacking on the efficacy of ACE on breastfeeding outcomes and in non-diabetic mothers. METHODS AND PLANNED ANALYSIS: This multicenter stepped-wedge cluster (nested) randomized controlled trial aims to recruit 945 nulliparous pregnant individuals. The trial is conducted in two phases. During Phase 1, control group participants are under standard care. During Phase 2, participants are randomized to ACE instruction via a pre-recorded online video or a one-on-one session with a midwife. Adjusted logistic regression analysis will be used to examine the relationship between ACE instruction and breastfeeding outcomes. RESEARCH AIMS AND QUESTIONS: Primary aim: (1) Does advising pregnant individuals to practice ACE and providing instruction improve exclusive breastfeeding rates at 4 months postpartum? Secondary research questions: (2) Do individuals who practice ACE have higher rates of exclusive breastfeeding during the initial hospital stay after birth? (3) Is teaching ACE via an online video non-inferior to one-on-one instruction from a midwife? (4) Does expressing colostrum in pregnancy influence time to secretory activation, or (5) result in any differences in the composition of postnatal colostrum? DISCUSSION: Trial findings have important implications for maternity practice, with the online video providing an easily accessible opportunity for ACE education as part of standard antenatal care.

Waiting list eradication in secondary care psychology: Addressing a National Health Service blind spot.

OBJECTIVES: Waiting times for secondary care psychological therapy remain a 'blind spot' in serious mental illness (SMI) provision, and their reduction is a priority within the National Health Service (NHS) Five Year Forward View. The paper describes the eradication of waiting times within a community-based NHS service and the effectiveness of strategies whilst examining help-seeking behaviour, compliance and therapeutic need. METHODS: Analyses are reported for treatment compliance and therapeutic outcomes for 208 waiting-list cohort individuals seen by the SMI psychology service over an 18-month period between October 2014 and March 2016. RESULTS: No significant clinical or demographic differentiation between individuals who successfully completed therapy compared to those who disengaged was observed. Despite an average 2.20-year waiting time, this alone did not significantly impact engagement with psychological treatment and all psychological therapies provided led to a significant clinical improvement and no individuals who completed therapy required re-referral at 12-month follow-up. CONCLUSIONS: If imposed appropriately over a suitable time frame evidence-based practice coupled with effective operationalization can result in efficient needs-led psychological provision within SMI and secondary care. Potentially debilitating waiting times for service users and other referring professionals can be avoided, whilst psychology provision retains a flexible, formulation-based and person-centred approach.

Adnexal mass during pregnancy: a review.

OBJECTIVE: The purpose of this review was to determine the likelihood of malignancy or complications with ultrasonographic diagnosis of adnexal masses in pregnancy and to evaluate the obstetrical outcomes. Materials and METHODS: A review of literature was performed using keywords "adnexal mass and pregnancy" or "ovarian mass and pregnancy." RESULTS: Out of the 340 abstracts reviewed, 313 were excluded. The incidence of adnexal mass in pregnancy varied from 0.1 to 2.4%, with an average of 0.02%. Regarding the likelihood of malignancy, in seven publications, there were 557 women with 563 adnexal masses. Of these 563 masses, 48% were classified as simple and 52% as complex. Among the simple masses, 1% were malignant. Among the complex masses, 9% were malignant. When comparing laparoscopy and laparotomy, the rate of preterm contractions was found to be higher in patients undergoing laparotomy and this was statistically significant. Other measures, such as spontaneous abortion, vaginal bleeding, < 37 week delivery, and intrauterine fetal demise, were not found to have a significant difference. CONCLUSION: Adnexal masses in pregnancy occur infrequently and depending on whether the surgery was performed emergently or electively, via laparoscopy or laparotomy, the outcomes will vary.

An optimized duplex real-time PCR tool for sensitive detection of the quarantine oomycete Plasmopara halstedii in sunflower seeds.

Plasmopara halstedii, the causal agent of downy mildew of sunflower, is an oomycete listed as a quarantine pathogen. This obligate parasite resides in a quiescent state in seeds of sunflower and can be spread from seed production areas to areas of crop production by international seed trade. To prevent the spread or the introduction of potentially new genotypes or fungicide-tolerant strains, an efficient method to detect P. halstedii in sunflower seed is required. This work reports the optimization of a real-time detection tool that targets the pathogen within sunflower seeds, and provides statistically validated data for that tool. The tool proved to be specific and inclusive, based on computer simulation and in vitro assessments, and could detect as few as 45 copies of target DNA. A fully optimized DNA extraction protocol was also developed starting from a sample of 1,000 sunflower seeds, and enabled the detection of <1 infected seed/1,000 seeds. To ensure reliability of the results, a set of controls was used systematically during the assays, including a plant-specific probe used in a duplex quantitative polymerase chain reaction that enabled the assessment of the quality of each DNA extract.

A case of treatment refractory hyperemesis gravidarum in a patient with comorbid anxiety, treated successfully with adjunctive gabapentin: a review and the potential role of neurogastroentereology in understanding its pathogenesis and treatment.

Hyperemesis gravidarum occurs in 0.3 to 10 percent of pregnant women, with a 0.8 percent hospital admission rate. While older theories supported the psychosocial model as a cause for hyperemesis gravidarum, more recent studies have shown significant data to support a biological etiology. Hyperemesis gravidarum has serious complications including include increased risk for miscarriage, low birth weight infants, dehydration, Wernicke's encephalopathy, secondary depression, and negative attitudes toward a consecutive pregnancy. Because of these life-threatening complications and complexity of the disease, it is important to treat both somatic and psychosocial causes of hyperemesis gravidarum to provide the best care for the patient. This paper presents a case of a woman with anxiety symptoms who was experiencing severe nausea and vomiting since Week 2 of pregnancy, with minimal reduction of these symptoms on standard medications utilized in hyperemesis gravidarum. The patient had marked reduction of nausea and vomiting with adjunctive gabapentin. After a brief review of relevant neurogastroenterology, we discuss a possible mechanism for the added gabapentin.

Feeding experiences and growth status in a Rett syndrome population.

OBJECTIVES: Feeding difficulties in Rett syndrome are complex and multifactorial. In this study, we describe the feeding experiences in Rett syndrome and examine the factors affecting growth. MATERIALS AND METHODS: Using questionnaire data related to a population-based cohort, ages 2 to 29 years (n = 201), we measured the feeding experiences, growth, and factors affecting growth (enteral nutritional support, mutations, mobility, breath-holding, hyperventilation) in subjects with Rett syndrome. RESULTS: The mean weight, height, and body mass index z scores in subjects with Rett syndrome were below that of their age group and decreased steadily with age. Twenty percent of subjects had enteral nutrition support, and it was more common in the older age group. Those with truncating mutations had significantly less enteral nutrition support than the other mutation groups. Furthermore, those with low mobility had lower mean body mass index z scores than those with higher mobility, and increased frequency of breath-holding and hyperventilation also was associated with lower body mass index z scores. CONCLUSIONS: Routine monitoring of growth should continue to determine the severity of nutritional problems in Rett syndrome. Active nutritional management is recommended to ensure females affected with Rett syndrome have the best opportunity to reach their growth potential.

Tympanometry of a diverse group of preschool aged children.

OBJECTIVE: Ethnicity has been previously described as a risk factor for middle ear disease. Little data exist on the presence of middle ear disease based on tympanometry screening comparing Asian children and children of other races. METHODS: Two hundred and seventy children aged 3-5 were screened with tympanometry at six Head Start sites in St. Paul, Minnesota during the months of September and October of 2004. Gender, age, and race/ethnicity was recorded and entered into a database, along with values for canal volume, static admittance, peak pressure, and tympanometric width. RESULTS: Criteria for abnormal tympanometry were based on American Speech-Language Hearing Association (ASHA) recommendations for a failed tympanogram for 1-5 year olds (admittance <0.3 mmho or width >200 daPa). There were no statistically significant differences in failure rates between males and females. There were, however, more failures for Asian (predominantly Hmong) children compared to children of other races/ethnicities after adjusting for age and gender differences (OR=6.39, CI 3.65-11.2, p<0.001) and for children <4-years-old compared to children 4-5-years-old after adjusting for race and gender differences (OR=1.99, CI 1.03-3.84, p<0.05). CONCLUSIONS: Asian children were more than six times as likely to fail tympanometry as children of other races/ethnicities. The explanation for this difference is likely to be multifactorial, and further research is needed to characterize this difference.