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Objective  Congenital heart disease (CHD) is an important contributor to pediatric morbidity and mortality. Unfortunately, disparities in the diagnosis and treatment of CHD exist across racial and ethnic groups. The objective of this study was to share the experiences of Hispanic and Black families with CHD to better understand their needs. Study Design  This was a descriptive qualitative study involving two 2-part focus groups, one conducted in English and one in Spanish, consisting of parents of infants with CHD. Focus groups were audio recorded, transcribed, and analyzed via a conventional content analysis approach. Results  Six family members participated, representing a range of cardiac diagnoses. Two participants cited their identity as non-Hispanic Black and four as Hispanic. Three organizing themes emerged related to (1) communication, (2) psychosocial needs and processing, and (3) practical challenges associated with having a child with CHD. Together, these organizing themes supported a singular global theme: structural and socioemotional gaps in care exist for families of infants with CHD that need to be met in order to optimize care for patients and families. Conclusion  Societal and systems-level factors, including structural inequities, contribute to the care gaps experienced by racial and ethnic minority families of children with CHD. Key Points Poor communication around CHD diagnosis impairs provider-patient trust.Language barriers hinder accurate communication about CHD diagnosis and treatment.Parents of children with CHD have unmet mental health needs.Perinatal providers should champion health equity for CHD patients and their families., Competing Interests: Conflict of Interest M.S.M. reports support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) under award for Postdoctoral Training in Cardiovascular Clinical Research (5T32HL069749); J.C.R. and K.H. report support from the Duke Children's Health and Discovery Institute; M.E.L. reports grants from the NIH; BAND Foundation; Child Neurology Society., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Objectives: Many serious or life-threatening neurologic conditions are first diagnosed during the fetal period, often following a routine ultrasound or sonographic evaluation after an abnormal aneuploidy screen. Such conditions represent a worrisome or unexpected finding for expectant parents, making the perinatal period a critical time point to engage and empower families encountering complex neurologic clinical scenarios. This review covers the role of perinatal palliative care in these settings., Study Design: This study is a topical review RESULTS:  The prenatal identification of structural abnormalities of the brain or spinal cord, radiographic signs of hemorrhage or ischemic injury, or evidence of genetic or metabolic conditions should prompt involvement of a fetal palliative care team. The inherent prognostic uncertainty is challenging for prenatally diagnosed neurologic conditions which have difficult to predict short and long-term outcomes. While many of these conditions lead to the birth of an infant with neurodevelopmental challenges, few result in in utero demise. Palliative care beginning in the perinatal period provides an additional layer of support for families navigating complex decision-making during their pregnancy and provides continuity of care into the newborn period. Palliative care principles can help guide discussions around genetic and other diagnostic testing, fetal surgery, and birth planning. A multidisciplinary team can help support families with decision-making and through bereavement care in the setting of fetal or neonatal death., Conclusion: Early palliative care team involvement can provide a more holistic approach to counseling, facilitate planning, and ensure that a family's goals and wishes are acknowledged throughout an infant's care trajectory., Key Points: · Many serious or life-threatening neurologic conditions are diagnosed during the fetal period.. · Palliative care principles should be incorporated in the fetal period for affected patients.. · Palliative care clinicians can aid parents and clinicians in shared decision-making.. · Palliative care principles should be employed by all care providers in relevant cases.., Competing Interests: M.E.L. has received compensation for medicolegal work. Other authors report no conflict of interest., (Thieme. All rights reserved.)

Importance: For patients who present with prelabor rupture of membrane (PROM) in the late preterm period (34 to 36 6/7 weeks), management remains unclear due to lack of consensus. However, recent guidelines have suggested that shared decision-making may be used and expectant management can be considered up to 37 0/7 weeks., Objective: In this article, we review the contemporary studies comparing the risks and benefits of immediate delivery versus expectant management for patients with late preterm prelabor rupture of membranes (PPROM)., Evidence Acquisition: Original research articles, review articles, and guidelines on management of late PPROM., Results: Three randomized clinical trials and 2 meta-analyses comparing expectant management and immediate delivery outcomes in late PPROM showed no significant difference in neonatal sepsis rates between groups. Expectant management increased the likelihood that pregnancies reached term while decreasing the rate of cesarean delivery. However, data suggest an increased risk of antepartum hemorrhage among patients in the expectant management groups, as well as higher rates of histologic chorioamnionitis., Conclusions and Relevance: We recommend that clinicians offer expectant management as an alternative to immediate delivery in the setting of late PPROM through a shared decision-making process that clearly outlines the risks and benefits.

Objectives: Ultrasound users are advised to observe the ALARA (as low as reasonably achievable) principle, but studies have shown that most do not monitor acoustic output metrics. We developed an adaptive ultrasound method that could suggest acoustic output levels based on real-time image quality feedback using lag-one coherence (LOC)., Methods: Lag-one coherence as a function of the mechanical index (MI) was assessed in 35 healthy volunteers in their second trimester of pregnancy. While imaging the placenta or the fetal abdomen, the system swept through 16 MI values ranging from 0.15 to 1.20. The LOC-versus-MI data were fit with a sigmoid curve, and the ALARA MI was selected as the point at which the fit reached 98% of its maximum., Results: In this study, the ALARA MI values were between 0.35 and 1.03, depending on the acoustic window. Compared to a default MI of 0.8, the pilot acquisitions suggested a lower ALARA MI 80% of the time. The contrast, contrast-to-noise ratio, generalized contrast-to-noise ratio, and LOC all followed sigmoidal trends with an increasing MI. The R 2 of the fit was statistically significantly greater for LOC than the other metrics (P < .017)., Conclusions: These results suggest that maximum image quality can be achieved with acoustic output levels lower than the US Food and Drug Administration limits in many cases, and an automated tool could be used in real time to find the ALARA MI for specific imaging conditions. Our results support the feasibility of an automated, LOC-based implementation of the ALARA principle for obstetric ultrasound., (© 2020 American Institute of Ultrasound in Medicine.)

Objectives: Prenatal detection of congenital heart disease with obstetric screening remains at less than 50% in most population studies, far from what is thought to be achievable. We sought to identify barriers/facilitators for screening from the perspective of interpreting physicians and to understand how these barriers/facilitators may be associated with interpretation of screening images., Methods: Our mixed-methods studies included 4 focus groups in centers across the United States with obstetric, maternal-fetal medicine, and radiology providers who interpreted obstetric ultrasound studies. Themes around barriers/facilitators for fetal heart screening were coded from transcripts. A national Web-based survey was then conducted, which quantitatively measured reported barriers/facilitators and measured physicians' ability to interpret fetal heart-screening images. Multivariable generalized linear random-effect models assessed the association between barriers/facilitators and the accuracy of image interpretation at the image level., Results: Three main themes were identified in the focus groups: intrinsic barriers (ie, comfort with screening), external barriers (ie, lack of feedback), and organizational barriers (ie, study volumes). Among 190 physician respondents, 104 interpreted ultrasound studies. Perceptions of barriers varied by practice setting, with nontertiary providers having lower self-efficacy and perceived usefulness of cardiac screening. Facilitators associated with the odds of accurate interpretation of screening images were knowledge (odds ratio, 2.54; P = .002) and the volume of scans per week (odds ratio, 1.01 for every additional scan; P = .04)., Conclusions: Some of the main barriers to cardiac screening identified and prioritized by physicians across the United States were knowledge of screening and minimal volumes of scans. Targeting these barriers will aid in improving prenatal detection of congenital heart disease., (© 2019 by the American Institute of Ultrasound in Medicine.)

In this study, we evaluate the clinical utility of fetal short-lag spatial coherence (SLSC) imaging. Previous work has documented significant improvements in image quality with fetal SLSC imaging as quantified by measurements of contrast and contrast-to-noise ratio (CNR). The objective of this study was to examine whether this improved technical efficacy is indicative of the clinical utility of SLSC imaging. Eighteen healthy volunteers in their first and second trimesters of pregnancy were scanned using a modified Siemens SC2000 clinical scanner. Raw channel data were acquired for routinely examined fetal organs and used to generate fully matched raw and post-processed harmonic B-mode and SLSC image sequences, which were subsequently optimized for dynamic range and other imaging parameters by a blinded sonographer. Optimized videos were reviewed in matched B-mode and SLSC pairs by three blinded clinicians who scored each video based on overall quality, target conspicuity and border definition. SLSC imaging was highly favored over conventional imaging with SLSC scoring equal to (28.2 ± 10.5%) or higher than (63.9 ± 12.9%) B-mode for video pairs across all examined structures and processing conditions. Multivariate modeling revealed that SLSC imaging is a significant predictor of improved image quality with p ≤ 0.002. Expert-user scores for image quality support the application of SLSC in fetal ultrasound imaging., (Copyright © 2018 World Federation for Ultrasound in Medicine and Biology. Published by Elsevier Inc. All rights reserved.)

Fetal scanning is one of the most common applications of ultrasound imaging and serves as a source of vital information about maternal and fetal health. Visualization of clinically relevant structures, however, can be severely compromised in difficult-to-image patients due to poor resolution and the presence of high levels of acoustical noise or clutter. We have developed novel coherence-based beamforming methods called Short-Lag Spatial Coherence (SLSC) imaging and Harmonic Spatial Coherence imaging (HSCI), and applied them to suppress the effects of clutter in fetal imaging. This method is used to create images of the spatial coherence of the backscattered ultrasound as opposed to images of echo magnitude. We present the results of a patient study to assess the benefits of coherence-based beamforming in the context of first trimester fetal exams. Matched fundamental B-mode, SLSC, harmonic B-mode, and HSCI images were generated using raw radio frequency data collected on 11 volunteers in the first trimester of pregnancy. The images were compared for qualitative differences in image texture and target conspicuity as well as using quantitative imaging metrics such as signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and contrast. SLSC and HSCI showed statistically significant improvements across all imaging metrics compared with B-mode and harmonic B-mode, respectively. These improvements were greatest for poor quality B-mode images where contrast of anechoic targets was improved from 15 dB in fundamental B-mode to 27 dB in SLSC and 17 dB in harmonic B-mode to 30 dB in HSCI. CNR improved from 1.4 to 2.5 in the fundamental images and 1.4 to 3.1 in the harmonic case. These results exhibit the potential of coherence-based beamforming to improve image quality and target detectability, especially in high noise environments., (© The Author(s) 2014.)

Women (n = 15) who were pregnant after a traumatic late pregnancy loss (termination because of fetal death or serious anomalies) completed psychometric screening tests and scales, including the Perinatal Grief Scale (PGS), the Impact of Event Scale (IES), the Duke Depression Inventory (DDI), the Generalized Anxiety Disorder-7 (GAD), and the Hoge Scale for Intrinsic Religiosity (IR). Despite a mean elapsed time since the prior loss of 27 (range, 7-47) months, half (7/15, 47%) of the combined groups had high levels of grief on the PGS. Multiple positive scores on psychometric tests were frequent: Sixty percent (9/15) had high scores on the PGS Active Grief subscale or on the IES. Forty percent (6/15) had a high score on the DDI, and 17% (3/15) on the GAD. IR scores significantly and negatively correlated with scores on the Despair subscale of the PGS. The results from this pilot study suggest that high levels of grief and PTS symptoms are significant problems for pregnant women who have suffered late loss of a wanted pregnancy. Religiosity may play an important part in maternal coping during these stressful pregnancies.

We present a case of intracranial haemorrhage detected by ultrasound at 36 weeks gestation in a foetus who was ultimately diagnosed with severe factor V deficiency. An abnormality of the foetal heart rate, auscultated at a routine antenatal visit, prompted an investigation that led to an ultrasound examination and detection of an intracranial haemorrhage and low amniotic fluid volume. An intrauterine foetal demise was averted. The clinical scenario in this case raises the issue of how often a stillbirth with intracranial haemorrhage may result from unrecognized factor deficiency.

In response to iron deprivation, Bacillus subtilis secretes a catecholic siderophore, 2,3-dihydroxybenzoyl glycine, which is similar to the precursor of the Escherichia coli siderophore enterobactin. We isolated two sets of B. subtilis DNA sequences that complemented the mutations of several E. coli siderophore-deficient (ent) mutants with defective enterobactin biosynthesis enzymes. One set contained DNA sequences that complemented only an entD mutation. The second set contained DNA sequences that complemented various combinations of entB, entE, entC, and entA mutations. The two sets of DNA sequences did not appear to overlap. AB. subtilis mutant containing an insertion in the region of the entD homolog grew much more poorly in low-iron medium and with markedly different kinetics. These data indicate that (i) at least five of the siderophore biosynthesis genes of B. subtilis can function in E. coli, (ii) the genetic organization of these siderophore genes in B. subtilis is similar to that in E. coli, and (iii) the B. subtilis entD homolog is required for efficient growth in low-iron medium. The nucleotide sequence of the B. subtilis DNA contained in plasmid pENTA22, a clone expressing the B. subtilis entD homolog, revealed the presence of at least two genes. One gene was identified as sfpo, a previously reported gene involved in the production of surfactin in B. subtilis and which is highly homologous to the E. coli entD gene. We present evidence that the E. coli entD and B. subtilis sfpo genes are interchangeable and that their products are members of a new family of proteins which function in the secretion of peptide molecules.