Effects of Maternal Nutritional Supplements and Dietary Interventions on Placental Complications: An Umbrella Review,Meta-Analysis and Evidence Map

The placenta is a vital, multi-functional organ that acts as an interface between maternal and fetal circulation during pregnancy. Nutritional deficiencies during pregnancy alter placental development and function, leading to adverse pregnancy outcomes, such as pre-eclampsia, infants with small for gestational age and low birthweight, preterm birth, stillbirths and maternal mortality. Maternal nutritional supplementation may help to mitigate the risks, but the evidence base is difficult to navigate. The primary purpose of this umbrella review is to map the evidence on the effects of maternal nutritional supplements and dietary interventions on pregnancy outcomes related to placental disorders and maternal mortality. A systematic search was performed on seven electronic databases, the PROSPERO register and references lists of identified papers. The results were screened in a three-stage process based on title, abstract and full-text by two independent reviewers. Randomized controlled trial meta-analyses on the efficacy of maternal nutritional supplements or dietary interventions were included. There were 91 meta-analyses included, covering 23 types of supplements and three types of dietary interventions. We found evidence that supports supplementary vitamin D and/or calcium, omega-3, multiple micronutrients, lipid-based nutrients, and balanced protein energy in reducing the risks of adverse maternal and fetal health outcomes. However, these findings are limited by poor quality of evidence. Nutrient combinations show promise and support a paradigm shift to maternal dietary balance, rather than single micronutrient deficiencies, to improve maternal and fetal health. The review is registered at PROSPERO (CRD42020160887).     

Venetoclax ramp-up strategies for chronic lymphocytic leukaemia in the United Kingdom: a real world multicentre retrospective study

This retrospective, observational study evaluated patterns of inpatient versus outpatient tumour lysis syndrome (TLS) monitoring during venetoclax ramp-up in 170 patients with chronic lymphocytic leukaemia. The primary outcome was clinical/biochemical TLS. Two clinical and four biochemical TLS occurred (4.1%). Five of the six events occurred in high-risk patients, four occurred at 20 mg dose and three at the 6-h time-point. Inpatient versus outpatient TLS rates within the high-risk subgroup were 15% and 8%. Risk category was the only predictor of TLS events in multivariate analysis. Outpatient escalation did not associate with clinically meaningful TLS events, suggesting outpatient escalation has manageable associated TLS risks, including in high-risk cohorts. These observations require confirmation in larger studies.     

The feasibility of task-sharing the identification,emergency treatment,and referral for women with pre-eclampsia by community health workers in India

Background

Hypertensive disorders are the second highest direct obstetric cause of maternal death after haemorrhage, accounting for 14% of maternal deaths globally. Pregnancy hypertension contributes to maternal deaths, particularly in low- and middle-income countries, due to a scarcity of doctors providing evidence-based emergency obstetric care. Task-sharing some obstetric responsibilities may help to reduce the mortality rates. This study was conducted to assess acceptability by the community and other healthcare providers, for task-sharing by community health workers (CHW) in the identification and initial care in hypertensive disorders in pregnancy.

Methods

This study was conducted in two districts of Karnataka state in south India. A total of 14 focus group discussions were convened with various community representatives: women of reproductive age (N = 6), male decision-makers (N = 2), female decision-makers (N = 3), and community leaders (N = 3). One-to-one interviews were held with medical officers (N = 2), private healthcare OBGYN specialists (N = 2), senior health administrators (N = 2), Taluka (county) health officers (N = 2), and obstetricians (N = 4). All data collection was facilitated by local researchers familiar with the setting and language. Data were subsequently transcribed, translated and analysed thematically using NVivo 10 software.

Results

There was strong community support for home visits by CHW to measure the blood pressure of pregnant women; however, respondents were concerned about their knowledge, training and effectiveness. The treatment with oral antihypertensive agents and magnesium sulphate in emergencies was accepted by community representatives but medical practitioners and health administrators had reservations, and insisted on emergency transport to a higher facility. The most important barriers for task-sharing were concerns regarding insufficient training, limited availability of medications, the questionable validity of blood pressure devices, and the ability of CHW to correctly diagnose and intervene in cases of hypertensive disorders of pregnancy.

Conclusion

Task-sharing to community-based health workers has potential to facilitate early diagnosis of the hypertensive disorders of pregnancy and assist in the provision of emergency care. We identified some facilitators and barriers for successful task-sharing of emergency obstetric care aimed at reducing mortality and morbidity due to hypertensive disorders of pregnancy.

     

Hearing thresholds in newborns with a cleft palate assessed by auditory brain stem response.

OBJECTIVE: To objectively estimate the extent of hearing loss in infants with cleft palate and to measure the incidence of hearing loss. DESIGN: Retrospective consecutive case note review. SETTING: Tertiary institutional regional referral center for cleft lip and palate. PATIENTS, PARTICIPANTS: Consecutive cases of 90 infants with cleft palate who underwent auditory brain stem response (ABR) threshold estimation. INTERVENTIONS: ABR threshold estimation during natural sleep in infants with cleft palate under 2 months of age. MAIN OUTCOME MEASURES: Hearing level thresholds as estimated by auditory brain stem response and categorized as normal (< 25 < or = 35 dB nHL) , mild (> 35 < or = 45 dB nHL), moderate (> 45 < or = 65 dB nHL), severe (> 65 < or = 90 dB nHL), and profound (> 90 dB nHL) hearing loss. RESULTS: Hearing loss was present in 82% of the infants tested. Most of the hearing loss was conductive (89%), mild (86%), and bilateral (84%). Average age of ABR threshold estimation was 48.5 days. In 22% of infants there was an associated syndrome. The mean air conduction thresholds for the right and left ear were 40 and 39.7, respectively. CONCLUSION: The incidence of hearing loss in a cohort of cleft palate infants has been objectively estimated by auditory brain stem response thresholds and was found to be very high (82%).     

Auditory brainstem response threshold estimation: subjective threshold estimation by experienced clinicians in a computer simulation of the clinical test

Little research has been undertaken into the extent to which auditory brainstem response (ABR) threshold estimation varies between experienced professionals. In this paper, results are presented for 16 professionals who estimated ABR threshold for 12 sets of data in a computer simulation of the clinical test. The design differs from previous research in this area in that subjects had control over the creation of the set of traces from which they would estimate threshold, much as they would in the clinical situation. No agreement for threshold was found for any of the 12 sets of test data across the 16 subjects, and for nine of the sets, the difference between highest and lowest estimated threshold was 40 dB or greater. The maximum difference between highest and lowest estimated threshold was 60dB. It is argued that the variability is not accounted for by experimental design. The implications for clinical practice are discussed.     

Auditory brainstem response threshold estimation: subjective threshold estimation by experienced clinicians in a computer simulation of the clinical test

Little research has been undertaken into the extent to which auditory brainstem response (ABR) threshold estimation varies between experienced professionals. In this paper, results are presented for 16 professionals who estimated ABR threshold for 12 sets of data in a computer simulation of the clinical test. The design differs from previous research in this area in that subjects had control over the creation of the set of traces from which they would estimate threshold, much as they would in the clinical situation. No agreement for threshold was found for any of the 12 sets of test data across the 16 subjects, and for nine of the sets, the difference between highest and lowest estimated threshold was 40 dB or greater. The maximum difference between highest and lowest estimated threshold was 60 dB. It is argued that the variability is not accounted for by experimental design. The implications for clinical practice are discussed.