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Breastfeeding rates in many Global North countries are low. Qualitative research highlights that breastfeeding in public is a particular challenge, despite mothers often having the legal right to do so. To identify barriers and facilitators, we systematically searched the qualitative research from Organisation for Economic Co-operation and Development countries relating to breastfeeding in public spaces from 2007 to 2021. Data were analysed using the Thematic Synthesis technique. The review was registered with PROSPERO (registration number: CRD42017081504). Database searching identified 3570 unique records. In total, 74 papers, theses, or book chapters, relating to 71 studies, were included, accounting for over 17,000 mothers. Overall, data quality was high. Our analysis identified that five core factors influenced mothers' thought processes and their breastfeeding in public behaviour: legal system; structural (in)equality; knowledge; beliefs and the social environment. Macro-level factors relating to legislation and inequality urgently require redress if breastfeeding rates are to be increased. Widespread culture change is also required to enhance knowledge, change hostile beliefs and thus the social environment in which mother/infant dyads exist. In particular, the sexualisation of breasts, disgust narratives and lack of exposure among observers to baby-led infant feeding patterns resulted in beliefs which created a stigmatising environment. In this context, many mothers felt unable to breastfeed in public; those who breastfed outside the home were usually highly self-aware, attempting to reduce their exposure to conflict. Evidence-based theoretically informed interventions to remove barriers to breastfeeding in public are urgently required.

Breastfeeding support is a key component in meeting the public health responsibility of increasing breastfeeding rates, with access to individualised, convenient and linked support across services central to improved outcomes. With the rise of new technology and the COVID-19 pandemic, social media (SM) support for breastfeeding has become increasingly popular and it is important to understand how and why mothers access such support, and from whom, to optimise services and to meet mothers' needs. Increasing research is building on women's use and experience of SM for breastfeeding, although there is a paucity of UK data. This systematic review aimed to understand the impacts of SM support for breastfeeding, including benefits and challenges, to establish the evidence for wider provision within maternity services. The search was limited to studies published in English and focused on the self-directed use of social media groups for breastfeeding (defined as platforms that facilitate group support via interactivity, allowing for user-generated content and subsequent responses). Of 327 papers retrieved, 13 studies were included for review. The six themes identified were: breastfeeding context, including factors impacting women's decision making; the relational impact of belonging to an online community; increased self-efficacy; critiques of SM; the nature and types of support commonly sought and received; and breastfeeding duration as an outcome. The findings confirm that mothers value SM groups for community support, which normalises breastfeeding and provides the support they attribute to improved outcomes, and highlight that UK research focused on provision linked to wider services is needed.

Aims Eating disorders are serious psychiatric disorders with high rates of morbidity and mortality. Early intervention can improve treatment outcomes and reduce disruption to psychosocial development. However, early intervention is not well established in the eating disorder field. First episode rapid early intervention for eating disorders (FREED) was developed to address barriers to early, effective eating disorder treatment in emerging adults aged 16 to 25 years. Since 2014, FREED has progressed from a single-site research project to an evidence-based care approach in nine eating disorder services. This paper aims to summarize key learning from the scaling of FREED to date, with attention to how this learning may generalizes to other models of care. Methods We describe the development, scaling and implementation of FREED with reference to the RE-AIM (reach; effectiveness/efficacy; adoption; implementation; maintenance) framework. We also summarize challenges and learning in each of the RE-AIM domains. Results FREED has demonstrated real-world validity across diverse clinical contexts, geographical regions and populations. Key outcomes are seen for each of the RE-AIM domains. Conclusions FREED provides an example of effective, non-commercial scaling of an early intervention eating disorder care pathway. This work is likely to be particularly relevant to others looking to scale-up early intervention models and for those working in secondary and tertiary mental health settings.

Background Access to donor human milk (DHM) has primarily been based on the health and development outcomes of premature infants but there has been little examination of the broader impact of an infant receiving it upon parental mental health. Breastfeeding and mental health are closely tied with women who experience breastfeeding difficulties or are unable to meet their own breastfeeding goals often experiencing feelings of guilt, sadness and anger, alongside an increased risk of postnatal depression. The aim of the current study was to explore how experience of receiving DHM for their baby affected the wellbeing of parents. Methods UK parents of infants aged 0 – 12 months who had received screened DHM from a milk bank (typically on the neonatal unit or in some cases in the community) completed an online questionnaire exploring their experiences. The questionnaire included Likert scale items examining perceived impact upon infant health, own wellbeing and family functioning alongside open-ended questions exploring perceptions of how receiving DHM affected wellbeing. Results Almost all of the 107 participants (women = 102) agreed that receiving DHM had a positive impact upon infant health and development, their own mental and physical health, and their family’s wellbeing. Parents felt relieved that their infant was receiving DHM for health reasons but also due to the experience of being listened to, supported and having their infant feeding decisions facilitated. Receiving DHM helped mothers to process some of their emotions at not being able to breastfeed, in part because knowing their baby was being fed gave them the space to focus on recovery and bonding with their baby. Some parents did experience challenges, feeling guilty at receiving DHM, insecure that another woman was able to feed their baby when they could not, or negative reactions from family. Although the impact of receiving DHM upon breastfeeding was not measured, some women who were working to build their own milk supply noted that it helped motivate them to continue. Conclusions DHM may play an important role not only in protecting infant health and development but in supporting the mental health and wellbeing of mothers for whom their infant receiving human milk is important.

Low breastfeeding rates are driven by multiple bio-psycho-social factors. Experience of breastfeeding is known to differ by maternal demographic factors (age, education and ethnicity) but there is less recognition of factors such as neurodivergence. This review, prospectively registered with PROSPERO (registration number: CRD42021271465), systematically identified qualitative research, commentaries and personal accounts related to Autistic mothers and infant feeding. Database searching identified 1225 records, with thematic synthesis undertaken on 22 (eight peer-reviewed studies and 14 grey literature) pieces. Our analysis identified that maternity and infant feeding services were built on a lack of understanding of Autistic needs, and were often inaccessible at a time when Autistic mothers already felt a loss of control and lack of social support. Specifically relating to breastfeeding, knowledge and determination were often high, and a minority of mothers reported positive breastfeeding experiences. However, sensory challenges, pain and interoceptive differences (exacerbated by a lack of support) made breastfeeding impossible for some. Infant formula was viewed as second-best to breastmilk, but a minority of mothers found the ritual of preparing bottles of formula positive. There is an urgent need for maternity and infant feeding services to accommodate the needs of Autistic mothers, including service design and staff training.Lay abstractWhat is already known about the topic? Mothers are encouraged to breastfeed their babies due to known health benefits for both babies and mothers. However, although breastfeeding is ‘natural’, that does not make it easy and many women experience challenges. Autistic women may face additional barriers to breastfeeding when compared to neurotypical women. What this paper adds? We reviewed all existing evidence on Autistic mothers’ infant feeding experiences (22 pieces) and found that although many Autistic women wanted to breastfeed, breastfeeding was difficult for Autistic mothers for three key reasons. First, maternity and infant feeding services were inaccessible and unsupportive to Autistic mothers, meaning they did not receive help when needed. Second, becoming a mother was challenging because of exhaustion, loss of control over routines and a lack of social support. Third, when breastfeeding Autistic mothers experienced sensory challenges, such as ‘being touched out’, and pain, which could feel unbearable. Despite these difficulties, many Autistic mothers had done a lot of reading about breastfeeding and were determined to breastfeed their babies; some mothers found breastfeeding positive. Infant formula was often viewed as second-best compared to breastmilk, but some mothers found the ritual of preparing bottles of formula to be calming. Implications for practice, research or policy The findings of this work show that Autistic mothers urgently need better support from health professionals to help meet their breastfeeding goals, including how to remove or reduce the extra barriers being Autistic brings to breastfeeding.

Exclusive breastfeeding for the first 6 months and then alongside solid food for the first 2 years and beyond is the gold standard in young child nutrition. There is an abundance of literature relating to the preventative nature of breastmilk and breastfeeding against many infectious diseases and chronic conditions. However, despite medically complex infants and children being a group that could benefit most from continued breastfeeding, breastfeeding duration and exclusivity are lower among more complex paediatric populations. The reasons for this are not well known, and there is a paucity of data relating to supporting infants who have acute or chronic illness, disability or congenital anomaly to breastfeed. This systematic review aimed to understand the challenges of breast/chestfeeding the medically complex child and to establish the gaps in healthcare provision that act as barriers to optimal infant and young child feeding. The search was limited to studies published in English, focused on breastfed sick infants in hospital, with no date limits as there is no previous systematic review. Of 786 papers retrieved, 11 studies were included for review, and seven themes identified. Themes included practical and psychological challenges of continuing to breastfeed in a hospital setting, complications of the condition making breastfeeding difficult, lack of specialist breastfeeding support from hospital staff and a lack of availability of specialist equipment to support complex breastfeeding. The findings affirm the lack of consistent high‐quality care for lactation support in paediatric settings and reinforce the need for further focused research in this area.

There are several options for real-time prostate monitoring during radiation therapy including fiducial markers (FMs) and transperineal ultrasound (TPUS). However, the patient experience for these procedures is very different. This study aimed to determine patient preferences around various aspects of prostate image-guidance, focusing on FMs and TPUS.A discrete choice experiment (DCE) was conducted, describing the image-guidance approach by: pain, cost, accuracy, side effects, additional appointments, and additional time. Participants were males with prostate cancer (PCa) and from the general Australian population. A DCE survey required participants to make hypothetical choices in each of 8 choice sets. Multinomial logit modelling and Latent Class Analysis (LCA) were used to analyse the responses. Marginal willingness to pay (mWTP) was calculated.476 respondents completed the survey (236 PCa patients and 240 general population). The most important attributes for both cohorts were pain, cost and accuracy (p 0.01). PCa patients were willing to pay more to avoid the worst pain than the general population, and willing to pay more for increased accuracy. LCA revealed 3 groups: 2 were focused more on the process-related attributes of pain and cost, and the third was focused on the clinical efficacy attributes of accuracy and side effects.Both cohorts preferred less cost and pain and improved accuracy, with men with PCa valuing accuracy more than the general population. In addition to the clinical and technical evidence, radiation oncology centres should consider the preferences of patients when considering choice of image-guidance techniques.

STUDY OBJECTIVE To compare the parenting and career patterns of female and male gynecology subspecialists. DESIGN Cross-sectional survey study (Canadian Task Force classification II-3). SETTING Survey administered electronically in February 2015 to physician members of the Society of Gynecologic Oncology, the American Society for Reproductive Medicine, and the American Urogynecologic Society. PARTICIPANTS All physician members of the 3 national gynecology subspecialty organizations listed above. MEASUREMENTS AND MAIN RESULTS There were 75 questions in 4 domains: demographics, mentoring issues, work-life balance, and caregiving responsibilities. Data were analyzed for survey sampling weights. Six hundred seventy-seven physicians completed the survey, 62% of whom were women (n = 420; 20.2% response rate). Sixty-four percent were aged 36 to 55 years. Eighty-two percent of respondents had at least 1 child, and men had more children than women (42% of men had 3 or more children compared with 20% of women, p

Failure to predict and understand the causes of preterm birth, the leading cause of neonatal morbidity and mortality, have limited effective interventions and therapeutics. From a cohort of 2000 pregnant women, we performed a nested case control study on 107 well-phenotyped cases of spontaneous preterm birth (sPTB) and 432 women delivering at term. Using innovative Bayesian modeling of cervicovaginal microbiota, seven bacterial taxa were significantly associated with increased risk of sPTB, with a stronger effect in African American women. However, higher vaginal levels of β-defensin-2 lowered the risk of sPTB associated with cervicovaginal microbiota in an ethnicity-dependent manner. Surprisingly, even in Lactobacillus spp. dominated cervicovaginal microbiota, low β-defensin-2 was associated with increased risk of sPTB. These findings hold promise for diagnostics to accurately identify women at risk for sPTB early in pregnancy. Therapeutic strategies could include immune modulators and microbiome-based therapeutics to reduce this significant health burden., Here, Elovitz et al. investigate associations between cervicovaginal microbiota (CVM) and spontaneous preterm birth (sPTB) in a large cohort of African American and non-African American women, and find that CVM and local immune response early in pregnancy are associated with sPTB in an ethnicity-dependent manner.

Survivorship care plan (SCP) comprising a treatment summary and plan for follow-up care is recommended by various organizations to address long-term needs of an increasing number of breast cancer survivors. Although there have been previous systematic reviews of SCPs in cancer, none has focused on breast cancer exclusively. This systematic review evaluates the use and impact of SCP in breast cancer survivors. Randomized (RCTs) and non-randomized (non-RCT) studies evaluating health care and patient-related outcomes after implementation of SCPs for survivors were identified by searching databases (MEDLINE, EMBASE, CINHAL, and Scopus). Data were extracted, quality assessed, and summarized on the basis of qualitative synthesis. Ten non-RCTs and 14 RCTs met the inclusion criteria. Although the overall quality of RCTs was superior to non-RCTs with mean quality score of 81.5% vs 64.3%, two mixed-methods non-RCTs which were individualized and included both provider and patient perspectives had comparable scores like RCTs. Several models of SCP were evaluated (paper based/online, oncologist/nurse/primary-care physician-delivered, and different templates). Descriptive information from non-RCTs suggests improvement in survivorship knowledge, satisfaction with care, and improved communication with providers. Findings from RCTs were variable. Potential gaps existed in content of SCP including unclear recommendation on frequency and ownership of follow-up. Levels of survivor satisfaction with, and self-reported understanding of, their SCP were high. Distal outcomes like health care delivery measures including costs and efficiency were mostly mixed, but heterogeneous study designs make interpretation difficult. Existing research provides positive impact of SCPs on more proximal outcomes of patient experience and care delivery but mixed results for health outcomes in breast cancer survivors. Future research should focus on better defining SCP content and ensuring follow-up recommendations are acted upon, and provider feedback is included and use of novel tools to empower stakeholders.

Breastfeeding and human milk (HM) are critically important to maternal, infant and population health. This paper summarizes the proceedings of a workshop that convened a multidisciplinary panel of researchers to identify key priorities and anticipated breakthroughs in breastfeeding and HM research, discuss perceived barriers and challenges to achieving these breakthroughs and propose a constructive action plan to maximize the impact of future research in this field. Priority research areas identified were as follows: (1) addressing low breastfeeding rates and inequities using mixed methods, community partnerships and implementation science approaches; (2) improving awareness of evidence‐based benefits, challenges and complexities of breastfeeding and HM among health practitioners and the public; (3) identifying differential impacts of alternative modes of HM feeding including expressed/pumped milk, donor milk and shared milk; and (4) developing a mechanistic understanding of the health effects of breastfeeding and the contributors to HM composition and variability. Key barriers and challenges included (1) overcoming methodological limitations of epidemiological breastfeeding research and mechanistic HM research; (2) counteracting ‘breastfeeding denialism’ arising from negative personal breastfeeding experiences; (3) distinguishing and aligning research and advocacy efforts; and (4) managing real and perceived conflicts of interest. To advance research on breastfeeding and HM and maximize the reach and impact of this research, larger investments are needed, interdisciplinary collaboration is essential, and the scientific community must engage families and other stakeholders in research planning and knowledge translation.

The importance of support to breastfeeding success is well established, as are the difficulties many mothers face in accessing the support they need. With the majority of UK mothers now accessing social media for support, Breastfeeding Support Facebook (BSF) groups have increased exponentially. BSF groups vary in type (local or national/international) and in moderation—overseen by breastfeeding mothers and by midwives or trained lactation specialists. Some groups aimed at supporting mothers in a specific geographical area also have associated face‐to‐face groups, facilitated as either professional or peer support. Little is currently known about these specific local groups, their prevalence, impact or value to mothers. This paper examines mothers' experiences of using local BSF groups and why they value them as part of a larger study exploring the impact of midwife moderation on these groups. An online survey consisting of open and closed questions was completed by 2028 mothers. Findings identified that local BSF groups are widely used and highly valued for their connection with local face‐to‐face services and other mothers. They offer access to expertise and shared experience in a format mothers find convenient and timely, improving confidence and self‐efficacy. Local BSF groups enable the formation of support networks and development of breastfeeding knowledge that mothers credit with increased well‐being, motivation and breastfeeding duration. As such, they have the potential to add value to local face‐to‐face services and improve breastfeeding experiences and knowledge in communities. The findings have important implications to support the development of integrated online interventions to improve public health.

BackgroundIn order to manage the COVID-19 systemic inflammatory response, it is important to identify clinicopathological characteristics across multiple cohorts.MethodsElectronic patient records for 2 consecutive cohorts of patients admitted to two urban teaching hospitals with COVID-19 during two 7-week periods of the COVID-19 pandemic in Glasgow, U.K. (cohort 1: 17th March 2020 – 1st May 2020) and (cohort 2: 18th May 2020 – 6th July 2020) were examined for routine clinical, laboratory and clinical outcome data.ResultsCompared with cohort 1, cohort 2 were older (pConclusionIn addition to the 4C mortality score, frailty score and a low albumin were strongly independently associated with 30-day mortality in two consecutive cohorts of patients admitted to hospital with COVID-19.Article summaryIn two consecutive cohorts of patients with COVID-19 infection admitted to two urban teaching hospitals in Glasgow, UK, there were variations in a number of clinicopathological characteristics despite similar mortality (23 and 22%).In these two cohorts, in a multivariate analysis that included the 4C mortality score, clinical frailty score >3, low serum albumin concentration (145 mmol/L) remained independently associated with 30-day mortality.

Background: Predicting relapses of post-operative complications in obese patients who undergo cardiac surgery is significantly complicated by persistent metabolic maladaptation associated with obesity. Despite studies supporting the linkages of increased systemic branched-chain amino acids (BCAAs) driving the pathogenesis of obesity, metabolome wide studies have either supported or challenged association of circulating BCAAs with cardiovascular diseases (CVDs). Objective: We interrogated whether BCAA catabolic changes precipitated by obesity in the heart and adipose tissue can be reliable prognosticators of adverse outcomes following cardiac surgery. Our study specifically clarified the correlation between BCAA catabolizing enzymes, cellular BCAAs and branched-chain keto acids (BCKAs) with the severity of cardiometabolic outcomes in obese patients pre and post cardiac surgery. Methods: Male and female patients of ages between 44 and 75 were stratified across different body mass index (BMI) (non-obese = 17, pre-obese = 19, obese class I = 14, class II = 17, class III = 12) and blood, atrial appendage (AA), and subcutaneous adipose tissue (SAT) collected during cardiac surgery. Plasma and intracellular BCAAs and BC ketoacids (BCKAs), tissue mRNA and protein expression and activity of BCAA catabolizing enzymes were assessed and correlated with clinical parameters. Results: Intramyocellular, but not systemic, BCAAs increased with BMI in cardiac surgery patients. In SAT, from class III obese patients, mRNA and protein expression of BCAA catabolic enzymes and BCKA dehydrogenase (BCKDH) enzyme activity was decreased. Within AA, a concomitant increase in mRNA levels of BCAA metabolizing enzymes was observed, independent of changes in BCKDH protein expression or activity. BMI, indices of tissue dysfunction and duration of hospital stay following surgery correlated with BCAA metabolizing enzyme expression and metabolite levels in AA and SAT. Conclusion: This study proposes that in a setting of obesity, dysregulated BCAA catabolism could be an effective surrogate to determine cardiac surgery outcomes and plausibly predict premature re-hospitalization.

Background The aim was to determine outcomes in the first year of school of a population-delivered parenting program to prevent internalising problems in temperamentally inhibited preschool children and predictors of engagement in parenting groups. Method Design: Randomised controlled trial. Setting 307 preschool services across eight socio-economically diverse government areas in Melbourne, Australia. Participants 545 parents of inhibited 4-year-old children; 469 (86%) retained at two-year follow-up. Intervention Cool Little Kids program. Primary outcomes were child internalising symptoms and anxiety disorders. Secondary outcomes were parenting, parent well-being and engagement. Trial registration ISRCTN30996662 http://www.isrctn.com/ISRCTN30996662. Results In the first year of school (M (SD) age 6.7 (0.4) years), child anxiety symptoms were reduced in the intervention versus control arm (PAS-R M (SD): total 36.2 (17.2) versus 39.4 (18.5); adjusted difference -3.26, 95% CI -6.46 to -0.05, p = .047; specific fears 9.1 (6.2) versus 10.7 (6.8), adjusted difference -1.53; 95% CI -2.69 to -0.38, p = .009). However, there was little difference in broader child internalising (CMFWQ M (SD): 2.2 (0.5) versus 2.3 (0.6); adjusted difference -0.03, 95% CI -0.13 to 0.06, p = .489) or anxiety disorders (37.6% vs. 42.6%; adjusted OR 0.79, 95% CI 0.53 to 1.18, p = .242). Lower income, younger mothers, less educated and more culturally diverse fathers engaged less with the intervention. Continued skills practice was less frequent for parents of girls and in advantaged neighbourhoods. Conclusions There were population effects of Cool Little Kids in the first year of school for anxiety symptoms but not disorders. Considering motivation techniques to engage subgroups of families would be helpful in translation research.

Infant feeding experiences are important for the development of healthy weight gain trajectories. Evidence surrounding milk feeding and timing of introduction to solids is extensive; however, the impact of the method of introducing solids on infant growth has been relatively underexplored. Baby‐led weaning (where infants self‐feed family foods) is proposed to improve appetite regulation, leading to healthier weight gain and a reduced risk of obesity. However, the evidence is mixed and has methodological inconsistencies. Furthermore, despite milk being a large part of the infant diet during the period infants are introduced to solid foods, its influence and interaction with introductory style have not been considered. The aim of this study was to explore growth among infants aged 3–12 months according to both style of introduction to solid foods and milk feeding; 269 infants were weighed and measured, and body mass index (BMI) computed. The results showed that overall, infants who were spoon‐fed (compared with self‐fed) at introduction to complementary feeding (CF) had greater length (but not weight or BMI). However, when milk feeding was accounted for, we found that infants who were both spoon‐fed and fully formula fed had greater weight compared with spoon‐fed, breastfed infants. There was no significant difference in weight among self‐fed infants who were breastfed or formula fed. The results highlight the importance of considering infant feeding as a multicomponent experience in relation to growth, combining both milk feeding and method of CF. This relationship may be explained by differences in maternal feeding style or diet consumed.

Prenatal inflammation is associated with poor neurobehavioral outcomes in exposed offspring. A common route of exposure for the fetus is intrauterine infection, which is often associated with preterm birth. Hippocampal development may be particularly vulnerable to an inflammatory insult during pregnancy as this region remains highly neurogenic both prenatally and postnatally. These studies sought to determine if intrauterine inflammation specifically altered hippocampal neurogenesis and migration of newly produced granule neurons during the early postnatal period. Microglial and astroglial cell populations known to play a role in the regulation of postnatal neurogenesis were also examined. We show that intrauterine inflammation significantly reduced hippocampal neurogenesis between postnatal days 7 (P7) and P14 as well as decreased granule cell density at P28. Ectopic migration of granule cells was observed in LPS-exposed mice at P14, but not at P28. Intrauterine inflammation had no effect on hippocampal astrocyte or microglia density or on apoptosis rate at the postnatal time points examined. Thus, exposure to intrauterine inflammation disrupts early postnatal neurogenesis and leads to aberrant migration of newly born granule cells.

Background Baby-led weaning (BLW) where infants self-feed family foods during the period that they are introduced to solid foods is growing in popularity. The method may promote healthier eating patterns, although concerns have been raised regarding its safety. The present study therefore explored choking frequency amongst babies who were being introduced to solid foods using a baby-led or traditional spoon-fed approach. Methods In total, 1151 mothers with an infant aged 4–12 months reported how they introduced solid foods to their infant (following a strict BLW, loose BLW or traditional weaning style) and frequency of spoon-feeding and puree use (percentage of mealtimes). Mothers recalled if their infant had ever choked and, if so, how many times and on what type of food (smooth puree, lumpy puree, finger food and specific food examples). Results In total, 13.6% of infants (n = 155) had ever choked. No significant association was found between weaning style and ever choking, or the frequency of spoon or puree use and ever choking. For infants who had ever choked, infants following a traditional weaning approach experience significantly more choking episodes for finger foods (F2,147 = 4.417, P = 0.014) and lumpy purees (F2,131 = 6.46, P = 0.002) than infants following a strict or loose baby-led approach. Conclusions Baby-led weaning was not associated with increased risk of choking and the highest frequency of choking on finger foods occurred in those who were given finger foods the least often. However, the limitations of noncausal results, a self-selecting sample and reliability of recall must be emphasised.

Exposure to inflammation during pregnancy has been linked to adverse neurodevelopmental consequences for the offspring. One common route through which a developing fetus is exposed to inflammation is with intrauterine inflammation. To that end, we utilized an animal model of intrauterine inflammation (IUI; intrauterine lipopolysaccharide (LPS) administration, 50 µg, E15) to assess placental and fetal brain inflammatory responses, white matter integrity, anxiety-related behaviors (elevated zero maze, light dark box, open field), microglial counts, and the CNS cytokine response to an acute injection of LPS in both males and females. These studies revealed that for multiple endpoints (fetal brain cytokine levels, cytokine response to adult LPS challenge) male IUI offspring were uniquely affected by intrauterine inflammation, while for other endpoints (behavior, microglial number) both sexes were similarly affected. These data advance our understanding of sex-specific effects of early life exposure to inflammation in a translationally- relevant model.

Abstract Background The World Health Organisation recommends women have at least four antenatal care visits (ANC) during a low risk pregnancy. However, in Saudi Arabia, many mothers miss these appointments, placing their health and that of their baby at risk. Limited research which has explored why this is happening has focused on low maternal education or personal barriers such as lack of transport. The aim of the current research was therefore to understand what factors at the individual and healthcare systems level were associated with missing antenatal care in Saudi Arabia. Methods Two hundred and forty-two pregnant women in their third trimester completed a questionnaire examining their care attendance (appointments missed, planned future attendance, timing of first appointment) alongside barriers to attending care. These included maternal demographic background, health literacy, personal barriers, health care system factors and staff communication). Results Over half of women surveyed had missed at least one appointment and a third had delayed their care. Mothers who had missed or delayed appointments blamed health care system factors such as poor clinic facilities and waiting times. Attending care was not associated with maternal education or literacy, although mothers with a lower level of literacy were more likely to delay care. However, perceptions of staff communication, consistency and care were lower amongst mothers who had missed at least one appointment. Conclusions Although in previous research health professionals believe it is maternal education that leads to poor attendance, in our sample at least, perceptions of staff communication and clinic facilities were instead associated with attendance. Making changes at the health care level e.g. through adapting clinic times and investing in staff training may increase antenatal care attendance in Saudi Arabia.

BACKGROUND: Angiopoietin 1 and 2 regulate angiogenesis and vascular remodelling by interacting with the tyrosine kinase receptor Tie2, and inhibition of angiogenesis has shown promise in the treatment of ovarian cancer. We aimed to assess whether trebananib, a peptibody that inhibits binding of angiopoietin 1 and 2 to Tie2, improved progression-free survival when added to carboplatin and paclitaxel as first-line therapy in advanced epithelial ovarian, primary fallopian tube, or peritoneal cancer in a phase 3 clinical trial. METHODS: TRINOVA-3, a multicentre, multinational, phase 3, double-blind study, was done at 206 investigational sites (hospitals and cancer centres) in 14 countries. Eligible patients were aged 18 years or older with biopsy-confirmed International Federation of Gynecology and Obstetrics (FIGO) stage III to IV epithelial ovarian, primary peritoneal, or fallopian tube cancers, and an ECOG performance status of 0 or 1. Eligible patients were randomly assigned (2:1) using a permuted block method (block size of six patients) to receive six cycles of paclitaxel (175 mg/m2) and carboplatin (area under the serum concentration-time curve 5 or 6) every 3 weeks, plus weekly intravenous trebananib 15 mg/kg or placebo. Maintenance therapy with trebananib or placebo continued for up to 18 additional months. The primary endpoint was progression-free survival, as assessed by the investigators, in the intention-to-treat population. Safety analyses included patients who received at least one dose of study treatment. This trial is registered with ClinicalTrials.gov, number NCT01493505, and is complete. FINDINGS: Between Jan 30, 2012, and Feb 25, 2014, 1164 patients were screened and 1015 eligible patients were randomly allocated to treatment (678 to trebananib and 337 to placebo). After a median follow-up of 27·4 months (IQR 17·7-34·2), 626 patients had progression-free survival events (405 [60%] of 678 in the trebananib group and 221 [66%] of 337 in the placebo group). Median progression-free survival did not differ between the trebananib group (15·9 months [15·0-17·6]) and the placebo group (15·0 months [12·6-16·1]) groups (hazard ratio 0·93 [95% CI 0·79-1·09]; p=0·36). 512 (76%) of 675 patients in the trebananib group and 237 (71%) of 336 in the placebo group had grade 3 or worse treatment-emergent adverse events; of which the most common events were neutropenia (trebananib 238 [35%] vs placebo 126 [38%]) anaemia (76 [11%] vs 40 [12%]), and leucopenia (81 [12%] vs 35 [10%]). 269 (40%) patients in the trebananib group and 104 (31%) in the placebo group had serious adverse events. Two fatal adverse events in the trebananib group were considered related to trebananib, paclitaxel, and carboplatin (lung infection and neutropenic colitis); two were considered to be related to paclitaxel and carboplatin (general physical health deterioration and platelet count decreased). No treatment-related fatal adverse events occurred in the placebo group. INTERPRETATION: Trebananib plus carboplatin and paclitaxel did not improve progression-free survival as first-line treatment for advanced ovarian cancer. The combination of trebananib plus carboplatin and paclitaxel did not produce new safety signals. These results show that trebananib in combination with carboplatin and paclitaxel is minimally effective in this patient population. FUNDING: Amgen. ispartof: LANCET ONCOLOGY vol:20 issue:6 pages:862-876 ispartof: location:England status: published

Recent human clinical studies have identified Mobiluncus mulieris, a fastidious strict anaerobic bacterium present in the cervicovaginal (CV) space, as being strongly associated with spontaneous preterm birth (sPTB). However, the molecular mechanisms that underlie this association remain unknown. As disruption of the cervical epithelial barrier has been shown to contribute to the premature cervical remodeling that precedes sPTB, we hypothesize that M. mulieris, a microbe strongly associated with sPTB in humans, has the ability to alter cervical epithelial function. We investigated if bacteria-free supernatants of M. mulieris were able to disrupt the cervical epithelial barrier through immunological and epigenetic based mechanisms in an in vitro model system. Ectocervical cells were treated with supernatant from cultured M. mulieris and epithelial cell permeability, immune cytokines and microRNAs (miRNAs) were investigated. M. mulieris supernatant significantly increased cell permeability and the expression of two inflammatory mediators associated with cervical epithelial breakdown, IL-6 and IL-8. Moreover, treatment of the ectocervical cells with the M. mulieris supernatant also increased the expression of miRNAs that have been associated with either sPTB or a shorter gestational length in humans. Collectively, these results suggest that M. mulieris induces molecular and functional changes in the cervical epithelial barrier thought to contribute to the pathogenesis of sPTB, which allows us to hypothesize that targeting CV bacteria such as M. mulieris could provide a therapeutic opportunity to reduce sPTB rates.

AIM We describe 2-year outcomes of a novel first episode early intervention service for young adults with a recent onset eating disorder (FREED). Outcomes in FREED patients with anorexia nervosa (AN) were compared with those from patients previously seen in our service [treatment as usual (TAU) cohort], matched for age, illness duration and diagnosis. METHODS Electronic case records of FREED-AN (n = 22) and TAU-AN patients (n = 35) were examined to identify service utilisation and clinical outcomes over 24 months. RESULTS Outpatient service utilisation was similar in both groups, but FREED-AN patients needed intensive (in- or day-patient) treatment less frequently than TAU-AN (23% vs 32%). FREED-AN patients had a higher estimated mean body mass index [19.2 kg/m2 ; 95% CI (18.21, 20.16)] than TAU patients [18.0 kg/m2 ; 95% CI (16.90, 19.15)] at last contact. CONCLUSION Introduction of FREED led to a more complete recovery in patients with AN at 24 months.

Problem Exposure to intrauterine inflammation (IUI) has been shown to induce fetal brain injury and increase the risk of acquiring a neurobehavioral disorder. The trafficking of the inflammatory mediator, lipopolysaccharide (LPS), in the pregnant female reproductive tract in the setting of IUI and the precise mechanisms by which inflammation induces fetal brain injury are not fully understood. Method of study FITC‐labeled LPS was utilized to induce IUI on E15, tissues were collected, and fluorescence was visualized via the Spectrum IVIS. Embryo transfer was utilized to create divergent maternal and fetal genotypes. Wild‐type (WT) embryos were transferred into TLR4−/− pseudopregnant dams (TLR4−/−mat/WTfet). On E15, TLR4−/−mat/WTfet dams or their WT controls (WTmat/WTfet) received an intrauterine injection of LPS or phosphate‐buffered saline (PBS). Endotoxin and IL‐6 levels were assessed in amniotic fluid, and cytokine expression was measured via QPCR. Results Lipopolysaccharide trafficked to the uterus, fetal membranes, placenta, and the fetus and was undetectable in other tissues. Endotoxin was present in the amniotic fluid of all animals exposed to LPS. However, the immune response was blunted in TLR4−/−mat/WTfet compared with WT controls. Conclusion Intrauterine administered LPS is capable of accessing the entire feto‐placental unit with or without a functional maternal TLR4. Thus, bacteria or bacterial byproducts in the uterus may negatively impact fetal development regardless of the maternal genotype or endotoxin response. Despite the blunted immune response in the TLR4‐deficient dams, an inflammatory response is still ignited in the amniotic cavity and may negatively impact the fetus., IL‐6 protein expression in the amniotic fluid of WTmat/WTfet and TLR4‐/‐mat/WTfet Pregnant females were treated with an intrauterine dose of LPS (250 μg) or PBS on E15. LPS injection resulted in significantly increased IL‐6 protein in WT animals (*, P = 0.0017) compared to controls. LPS did not significantly elevate IL‐6 levels in the TLR4‐/‐mat/WTfet animals. The WTmat/WTfet dams had a significantly higher immune response compared to their TLR4‐/‐mat/WTfet counterparts (#, P = 0.015).

Background: This 2016 study aimed to investigate the training in contraception and preconception counseling received by cardiovascular science fellows. Method: The authors surveyed current adult and pediatric cardiology fellows in the United States. Questions assessed the availability of family planning counseling training within their training program, current practices of contraception and preconception counseling, and use of available tools for risk stratification of patients. Bivariate logistic regressions were utilized to predict demographic variables associated with survey responses, and associations between hours of training or perceived preparedness and clinical use of training. Results: There were 101 survey responses. Most participating fellows disagreed that their fellowship training had prepared them to counsel patients on contraception (69%) and preconception planning (62%). Sixty-one percent of participants do not routinely discuss contraception options and 55% do not routinely discuss preconception counseling with reproductive-age female patients at routine visits. Having more than 1 hour of training was predictive of more consistent counseling for both contraception and preconception counseling. Approximately 40% of participants routinely refer patients to an OB/Gyn for contraception or preconception counseling. Conclusion: This study highlights the need for increased training in contraceptive and preconception counseling within adult and pediatric cardiology fellowship programs.

Objective Effective antenatal care is important for the health and wellbeing of pregnant women and infants. However, in Saudi Arabia, attendance rates are low, increasing the risk of negative birth outcomes. The aim of this research is to understand the beliefs of pregnant women and health professionals about the factors leading to these low attendance rates. Methodology A qualitative exploratory study-using semi structured face-to-face interviews. Interviews were conducted exploring (a) attitudes to the use of antenatal care by pregnant Saudi women, (b) beliefs of women regarding the value of antenatal care and (c) perceived barriers to attendance. Setting Data were collected from three hospitals in two regions of Saudi Arabia. Participants Women at any stage of their pregnancy attending for antenatal care or ultrasound, women attending postnatal clinic, and health professionals (obstetricians) who support women during pregnancy and birth. Findings Although mothers viewed antenatal care as important for maternal and infant health, several barriers to attending care were identified by mothers and professionals. These factors were classified into three themes: physical barriers (e.g., lack of transport), low maternal education, and inadequate healthcare facilities (including negative staff attitudes and poor communication). These factors were exacerbated by the beliefs of partners and family. Notably, the theme of low maternal education was raised only by health professionals, whilst the theme of staff attitudes and communication was raised only by mothers. Key conclusions Barriers to antenatal care exist at the personal, social, socioeconomic and health services level. Some health professionals may be unaware of the importance of their communication style. Interventions to improve attendance must be multifaceted rather than focussing on individual women alone. Implications for practice Barriers for women attending antenatal healthcare must be addressed in order to increase attendance rates. Specific practice-based interventions may involve changing the time or location of services and exploring changes to staff communication with women.

Baby care books that promote strict infant care routines are popular, but little research has considered their impact upon maternal infant care behaviours. We explored whether mothers who have read these books guide their infant care behaviours based on their concepts and how this is associated with infant feeding, night-time care, and response to infant's needs. Three hundred and fifty-four U.K. mothers with a baby aged 0-12 months completed an online questionnaire exploring use of baby care books, motivations for use, whether guidance was followed, and infant care behaviours. Mothers who read the books were drawn to them for information about how to settle their infant, infant sleep, and infant feeding behaviour. Those who read the books were less likely to breastfeed, feed responsively, have their infant sleep in the same room, cuddle their infant to sleep, or respond promptly to infant cries. Although the causality between reading these books and care cannot be determined through this study design, and is likely bidirectional with some reading the books to confirm existing preferences, around 25-40% of mothers noted the information determined their care decisions. Regardless of specific causal pathways, there is an association between these books and behaviours that go against infant feeding and responsive care recommendations. Understanding what drives mothers to follow these books and increasing support for new mothers in these areas is important. The findings will be important for those supporting mothers in the perinatal period in starting conversations around responsive infant care.

Breastfeeding support is integral to many women's successful breastfeeding experiences. However, cuts to professional and peer support services, distance from family, and a predominant formula‐feeding culture mean that many women in the United Kingdom do not receive the support they need. Turning to online support is an increasingly popular means of gaining both informational and emotional support, but research into online breastfeeding support groups is sparse in the United Kingdom. Data from Australia and the United States tend to focus on the positives: Women value such groups, finding information, reassurance, and a feeling of belonging. This study explored 14 women's experiences of using online support for breastfeeding in the United Kingdom, using semistructured interviews to understand their motivations and positive and negative experiences. Mothers were drawn to online support due to a lack of professional, familial, and partner support. Online support was reassuring, empathetic, and available around the clock and less daunting than attending a face‐to‐face group. Many attributed their continued breastfeeding to the support they received. However, women also experienced negativities: judgement for using formula, polarised debate, and a lack of regulation, meaning that unhelpful information was sometimes posted. The findings have important implications for those working to support mothers. These groups provide a safe space for breastfeeding mothers, but moderation is needed of such groups to ensure information is accurate and debate respectful. Online support groups are currently plugging a gap in funded support; they should be in addition not in replacement to professional and trained peer support services.

Objectives Thirty-day readmission is used as a quality measure for patient care and Medicare-based hospital reimbursement. The primary study objective was to describe the 30-day readmission rate to an academic gynecologic oncology service. Secondary objectives were to identify risk factors and costs related to readmission. Methods This was a retrospective, concurrent cohort study of all surgical admissions to an academic, high volume gynecologic oncology service during a two-year period (2013–2014). Data were collected on patient demographics, medical comorbidities, psychosocial risk factors, and results from a hospital discharge screening survey. Mixed logistic regression was used to identify factors associated with 30-day readmission and costs of readmission were assessed. Results During the two-year study period, 1605 women underwent an index surgical admission. Among this population, a total of 177 readmissions (11.0%) in 135 unique patients occurred. In a surgical subpopulation with >1 night stay, a readmission rate of 20.9% was observed. The mean interval to readmission was 11.8days (SD 10.7) and mean length of readmission stay was 5.1days (SD 5.0). Factors associated with readmission included radical surgery for ovarian cancer (OR 2.87) or cervical cancer (OR 4.33), creation of an ostomy (OR 11.44), a Charlson score of ≥5 (OR 2.15), a language barrier (OR 3.36), a median household income in the lowest quartile (OR 6.49), and a positive discharge screen (OR 2.85). The mean cost per readmission was $25,416 (SD $26,736), with the highest costs associated with gastrointestinal complications at $32,432 (SD $32,148). The total readmission-related costs during the study period were $4,523,959. Conclusions Readmissions to a high volume gynecologic oncology service were costly and related to radical surgery for ovarian and cervical cancer as well as to medical, socioeconomic and psychosocial patient variables. These data may inform interventional studies aimed at decreasing unplanned readmissions in gynecologic oncology surgical populations.

Objective poor body image during pregnancy is a growing issue. Similarly, emerging evidence is suggesting that social media use may increase the risk of poor well-being e.g. depression, anxiety and body image concerns amongst users. Research has not examined how social media use may influence women during pregnancy. The aim of this study was to therefore to explore the relationship between body image during pregnancy and Facebook use. Design a cross sectional self-report questionnaire. Participants two hundred and sixty nine pregnant women. Setting community groups and online forums. Measurements a self-report questionnaire exploring maternal body image, use of Facebook and how mothers perceived Facebook affected their body image. Descriptive statistics were used to explore body image perceptions. Partial correlations (controlling for maternal age, education, parity and gestation) were used to explore the association between Facebook use and body image during pregnancy. Results negative body image was common in the sample, increased with gestation and was unrelated to pre pregnancy weight. Mothers with a Facebook account had higher body image concerns than those without a Facebook account. Of those with an account, increased Facebook use was associated with increased body image dissatisfaction, particularly in terms of postnatal concerns for how their body would look with 56.5% reporting that they frequently compared their pregnant body to other pregnant women on the site. Facebook access was frequent with 85% of participants checking it at least once per day and the average participant spending over an hour per day on the site. Key conclusion although causality cannot be fully explained, Facebook use may increase mother's risk of poor body image dissatisfaction during pregnancy. Mothers with already poor body image may also be drawn to the site in order to make comparisons of their appearance. Implications for practice the potential impact of Facebook on increasing the risk of, or promoting existing poor body image is an important message for those working to support mothers during pregnancy and the postnatal period. Care should be taken when directing mothers to use the site.

Gender has an impact on the expectations and the outcomes of orthopedic procedures. The data examining the effect of gender on total shoulder arthroplasty (TSA) are limited but suggest that women may have worse outcomes. We performed a prospective comparison between men and women with regard to expectations and midterm functional outcomes for TSA.The study prospectively enrolled 63 patients receiving a TSA with a minimum of 3 years of follow-up. The cohort included 36 men and 27 women with a mean age of 60.8 years for men (range, 37-79 years) and 66.4 years (P = .01) for women (range, 52-77 years.) Each patient was given a preoperative survey in which patients were asked to select 3 expectations they most hoped to gain from surgery. Functional outcomes were measured with American Shoulder and Elbow Surgeons and 12-Item Short Form Health Survey scores.There were differences in expectations between the genders. Men chose exercise or participation in sports (24/36) whereas women chose to maintain daily routine and chores (18/27) (P .01) as their top expectation. Both, however, chose to sleep through the night similarly as the next most important expectation. Each achieved their expectations at similar and high rates. American Shoulder and Elbow Surgeons and 12-Item Short Form Health Survey scores, respectively, increased significantly but did not differ between genders.TSA results in excellent improvement of functional outcomes for both men and women without a significant difference at midterm follow-up. Men, on average, are younger and value participation in sports. Women hope to improve their ability to do their daily routine and chores. Both value sleeping through the night.

Promoting breastfeeding is a strategic priority, but breastfeeding rates remain low in the United Kingdom. Women value breastfeeding promotion and education, but a different strategy may be needed to continue to raise breastfeeding rates. New mothers, as the experts, are best placed to inform these changes. The current study explored new mothers' attitudes toward breastfeeding education and promotion, evaluating experiences and examining ideas for change.One thousand one hundred thirty mothers with a baby aged 0-2 years old who had planned to breastfeed at birth completed a questionnaire consisting of both closed and open-ended questions exploring their attitudes to breastfeeding promotion and support.Overall, the findings showed that mothers valued breastfeeding information, but believed that changes needed to be made to current messages. Key themes included a move away from the perception that breastfeeding is best (rather than normal), emphasis on wider values other than the health benefits of breastfeeding, and a message that every feed, rather than just 6 months exclusive breastfeeding, matters. Mothers also highlighted the need for promotion and education to target family members and wider society rather than simply mothers themselves, all of whom influenced both directly or indirectly maternal decision and ability to breastfeed. Mothers suggested ideas for promotional campaigns or how specific groups or methods could be used to increase support, including education for children, TV adverts, and using established online sources of breastfeeding information.The findings are important both for those supporting new mothers to breastfeed and those involved in breastfeeding policy and promotional messages.

BACKGROUND: Spontaneous preterm birth (sPTB) is a major contributor to infant mortality and its etiology remains poorly understood. Host immunity and maternal stress may play a role in the pathogenesis of sPTB but mechanisms are poorly delineated. Antimicrobial proteins in the cervicovaginal space, such as beta defensins, modulate immune responses to bacteria and have been shown to modulate the risk of sPTB from non-optimal microbiota. While stress is known to induce immunological changes, no study has examined the interplay between maternal stress and the immune response in association with sPTB. OBJECTIVES: Our objectives were to determine whether psychosocial stress was associated with a mediator of the immune system in the cervicovaginal space, beta defensin-2, and to examine the combined impact of high stress and low cervicovaginal beta defensin-2 levels on the odds of sPTB. STUDY DESIGN: From the Motherhood & Microbiome cohort study (n=2000), we performed a secondary, nested case-control study, frequency matched by race/ethnicity, of 519 pregnant women (110 sPTB and 409 term). Stress and cervicovaginal beta defensin-2 levels were measured at 16–20 weeks of gestation. Stress was dichotomized at a score of 30 on Cohen’s Perceived Stress Scale (PSS-14). We measured cervicovaginal beta defensin-2 levels with ELISA and dichotomized at the median. We modeled associations of high stress and low cervicovaginal beta defensin-2 levels using multivariable logistic regression. We also compared the proportion of women with high stress and low cervicovaginal beta defensin-2 levels among women with spontaneous preterm and term births using Chi-Square tests. We modeled adjusted associations of stress and cervicovaginal beta defensin-2 levels with odds of sPTB using logistic regression. RESULTS: The majority of the study population was non-Hispanic black (72.8%), insured by Medicaid (51.1%), and had a PSS-14 score < 30 (80.2%). High stress was associated with reduced adjusted odds of low beta defensin-2 levels (aOR 0.63, 95% CI: 0.38 −0.99). In a model adjusted for race and smoking, both high stress (aOR 1.72, 95% CI: 1.03–2.90) and low beta defensin-2 (aOR 1.58, 95% CI: 1.004–2.49) were associated with increased odds of sPTB. We then built a model of the four possible combinations of low and high stress and low and high beta defensin-2 levels with the odds of sPTB. Women with either high stress (aOR 1.37, 95% CI: 0.68 – 2.78) or low beta defensin-2 (aOR 1.40, 95% CI: 0.83–2.34), had slightly elevated but not significantly increased odds of sPTB compared to women with neither exposure. However, women with both high stress and low beta defensin-2 had significantly elevated odds of sPTB compared to women with neither exposure (aOR 3.16, 95 % CI: 1.46 – 6.84). CONCLUSION: High perceived stress and low cervicovaginal beta defensin-2 levels are associated with higher odds of sPTB, and when present concurrently, they result in the highest odds of sPTB in a largely non-Hispanic black cohort. Our findings warrant further work to examine social determinants of health and the host cervicovaginal immune responses that may modulate the pathogenesis of sPTB.

Electronic nicotine delivery systems and vaping devices are now the most commonly used forms of tobacco consumed by youth and young adults. A variety of chemicals and toxicants released during inhalation have harmful systemic effects and effects on the lung. The known and potential health consequences are particularly alarming. There is concern that use of these devices will create a new generation of life-long smokers with nicotine and polysubstance addiction. Beyond the concerning chronic health effects of regular use, there is a recent epidemic of severe, acute lung disease termed e-cigarette, or vaping product use-associated lung injury, (EVALI), associated with high morbidity and mortality. These issues demand immediate public health attention. Healthcare providers play key roles in limiting the exposure of youth and young adults to these products by providing evidence-based counseling to patients and families, and by advocating for regulations to protect against childhood initiation and continuation of use.

Background Baby-led weaning (BLW) is a method of introducing solid foods to infants, which centres around the infant self-feeding family foods. BLW has grown in popularity over the last 10 years; however, although research is starting to build around the safety and impact of the method, research examining intake is sparse. This is important because concerns have been raised by healthcare providers regarding the nutrient and energy sufficiency of BLW. The present study aimed to invstigate exposure to different food types based on different weaning approaches. Methods One hundred and eighty parents completed a 24-h recall of the foods given to their babies aged 6-12 months. Respondents were split into those following strict BLW, loose BLW and traditional spoon-feeding. Recalls were examined to ascertain the number of times in 24 h infants were given different types of foods, including iron-containing foods. The results were then compared between different weaning groups and age groups. Results Several significant differences were found between the frequency of foods eaten by different weaning and age groups: in the youngest age group, strict BLW infants were more likely to be exposed to vegetables (P = 0.000) and protein (P = 0.002) than traditionally weaned babies, whereas, at all age groups, the traditionally weaned group had the highest exposure to composite meals. However, no significant differences were found in reported exposure to iron-containing foods between weaning groups at any age. Maternal age, education and milk feeding method were controlled for throughout the analyses. Conclusions The findings add to a growing body of evidence that suggest a BLW approach may be safe and sufficient.

Objective High levels of childbirth interventions are known to increase risk of health complications for mother and infant, alongside having a negative impact upon maternal wellbeing. However less is understood about how childbirth experience may affect infant behaviour (e.g. how calm or unsettled an infant is). This study explores maternity care provider perceptions of how and why childbirth experience may affect infant behaviour. Design A qualitative semi-structured interview study. Setting Bristol, Swansea and West Wales, UK. Participants 18 maternity care providers. Measurements and findings A semi-structured interview schedule was developed to explore maternity care providers' perceptions of how maternal experience of childbirth could influence infant behaviour. Findings highlighted how maternity care providers perceived childbirth experience to sometimes impact positively or negatively on infant behaviour. A calmer birth and postnatal experience was believed to lead to a calmer infant, whilst physical and emotional stress was associated with more challenging infant behaviours such as crying and being unsettled. Pathways were perceived to be direct (pain and stress during birth might physiologically affect the infant) and indirect (birth was perceived to affect maternal wellbeing and subsequently her interactions with her baby). However, postnatal factors such as skin to skin, postnatal environment and emotional support were believed to mediate these impacts. Key conclusions Birth experience was considered to affect infant behaviour. Promoting as positive a birth experience as possible, including postnatal care, was viewed as significant in supporting positive infant behaviours. Maternity care providers believed this could help facilitate bonding, attachment, and mother–infant wellbeing in the postnatal period. Implications for practice The findings highlight maternity care providers' views concerning supporting normal birth and protecting emotional wellbeing during birth and postnatally. Where interventions are necessary, ensuring a calm environment, and enabling normal postnatal behaviours such as skin to skin and breastfeeding were perceived as important. Midwives, it was claimed, need time to nurture mothers alongside providing physical care. Limitations Participants were self-selecting and might therefore have been biased.

Background: Exposure to intrauterine inflammation during pregnancy is linked to brain injury and neurobehavioral disorders in affected children. Innate immunity, specifically Toll-like receptor (TLR) signaling pathways are present throughout the reproductive tract as well as in the placenta, fetal membranes, and fetus. The TLR pathways are mechanistically involved in host responses to foreign pathogens and may lead to brain injury associated with prenatal inflammation. Objective: We aimed to determine whether the activation of the TLR4 signaling pathway, in the mother and fetus, is critical to fetal brain injury in the setting of intrauterine inflammation. Methods: A mini-laparotomy was performed on time pregnant C57B6 mice and 2 knockout mouse strains lacking the function of the Tlr4 and Myd88 genes on embryonic day 15. Intrauterine injections of Escherichia coli lipopolysaccharide or saline were administered as described previously. Dams were killed 6 hours postsurgery, and placental, amniotic fluid, and fetal brain tissue were collected. To assess brain injury, quantitative polymerase chain reaction (qPCR) analysis was performed on multiple components of the NOTCH signaling pathway, including Hes genes. Interleukin (IL) IL6, IL1β, and CCL5 expression was assessed using qPCR and enzyme-linked immunosorbent assay. Results: Using an established mouse model of intrauterine inflammation, we demonstrate that the abrogation of TLR4 signaling eliminates the cytokine response in mother and fetus and prevents brain injury associated with increased expression of transcriptional effectors of the NOTCH signaling pathway, Hes1 and Hes5. Conclusions: These data show that the activation of the TLR4 signaling pathway is necessary for the development of fetal brain injury in response to intrauterine inflammation.

Background In total, 81% of women in the UK start breastfeeding, but fewer than half continue beyond 6 weeks. Peer support in the early postnatal period may encourage women to breastfeed for longer. Objective To develop a breastfeeding peer-support intervention based on motivational interviewing (MI) for breastfeeding maintenance and to test the feasibility of delivering it to mothers in areas with high levels of social deprivation. Design Intervention development and a non-randomised multisite feasibility study. Setting Community maternity services in three areas with high levels of social deprivation and low breastfeeding initiation rates in England and Wales. Participants Pregnant women considering breastfeeding. Women who did not plan to breastfeed, who had a clinical reason that precluded breastfeeding continuation or who were unable to consent were excluded. Intervention The intervention Mam-Kind was informed by a survey of infant feeding co-ordinators, rapid literature review, focus groups with service users and peer supporters and interviews with health-care professionals and a Stakeholder Advisory Group. It consisted of face-to-face contact at 48 hours after birth and proactive one-to-one peer support from the Mam-Kind buddy for 2 weeks, followed by mother-led contact for a further 2–6 weeks. Main outcome measures Recruitment and retention of Mam-Kind buddies, uptake of Mam-Kind by participants, feasibility of delivering Mam-Kind as specified and of data collection methods, and acceptability of Mam-Kind to mothers, buddies and health-care professionals. Results Nine buddies were recruited to deliver Mam-Kind to 70 participants (61% of eligible women who expressed an interest in taking part in the study). Participants were aged between 19 and 41 years and 94% of participants were white. Intervention uptake was 75% and did not vary according to age or parity. Most contacts (79%) were initiated by the buddy, demonstrating the intended proactive nature of the intervention and 73% (n = 51) of participants received a contact within 48 hours. Follow-up data were available for 78% of participants at 10 days and 64% at 8 weeks. Data collection methods were judged feasible and acceptable. Data completeness was > 80% for almost all variables. Interviews with participants, buddies and health service professionals showed that the intervention was acceptable. Buddies delivered the intervention content with fidelity (93% of intervention objectives were met), and, in some cases, developed certain MI skills to a competency level. However, they reported difficulties in changing from an information-giving role to a collaborative approach. These findings were used to refine the training and intervention specification to emphasise the focus of the intervention on providing mother-centric support. Health-care professionals were satisfied that the intervention could be integrated with existing services. Conclusions The Mam-Kind intervention was acceptable and feasible to deliver within NHS maternity services and should be tested for effectiveness in a multicentre randomised controlled trial. The feasibility study highlighted the need to strengthen strategies for birth notification and retention of participants, and provided some insights on how this could be achieved in a full trial. Limitations The response rate to the survey of infant feeding co-ordinators was low (19.5%). In addition, the women who were recruited may not be representative of the study sites. Funding The National Institute for Health Research Health Technology Assessment programme.

An uncontrolled study with process evaluation was conducted in three U.K. community maternity sites to establish the feasibility and acceptability of delivering a novel breastfeeding peer‐support intervention informed by motivational interviewing (MI; Mam‐Kind). Peer‐supporters were trained to deliver the Mam‐Kind intervention that provided intensive one‐to‐one peer‐support, including (a) antenatal contact, (b) face-to‐face contact within 48 hr of birth, (c) proactive (peer‐supporter led) alternate day contact for 2 weeks after birth, and (d) mother‐led contact for a further 6 weeks. Peer‐supporters completed structured diaries and audio‐recorded face‐to‐face sessions with mothers. Semi-structured interviews were conducted with a purposive sample of mothers, health professionals, and all peer‐supporters. Interview data were analysed thematically to assess intervention acceptability. Audio‐recorded peer‐support sessions were assessed for intervention fidelity and the use of MI techniques, using the MITI 4.2 tool. Eight peer‐supporters delivered the Mam‐Kind intervention to 70 mothers in three National Health Service maternity services. Qualitative interviews with mothers (n = 28), peer‐supporters (n = 8), and health professionals (n = 12) indicated that the intervention was acceptable, and health professionals felt it could be integrated with existing services. There was high fidelity to intervention content; 93% of intervention objectives were met during sessions. However, peer‐supporters reported difficulties in adapting from an expert‐by‐experience role to a collaborative role. We have established the feasibility and acceptability of providing breastfeeding peer‐support using a MI‐informed approach. Refinement of the intervention is needed to further develop peer‐supporters' skills in providing mother‐centred support. The refined intervention should be tested for effectiveness in a randomised controlled trial.

Introduction: The Queensland Remote Chemotherapy Supervision (QReCS) model enables rural nurses to administer chemotherapy in smaller rural towns under supervision by health professionals from larger centers using telehealth. Its implementation began in North Queensland, Australia (population, 650,000), in 2014 between two regional cancer centers (Townsville and Cairns as primary sites) and six rural sites (125 to 1,000 kilometers from primary sites). Our study examined the implementation processes, feasibility, and safety of this model. Methods: Details of implementation and patients’ clinical details for the period of 2014 to 2016 for descriptive analysis were extracted from telechemotherapy project notes and oncology information systems of North Queensland, respectively. Results: After a successful pilot study in Townsville Cancer Centre, statewide rural and cancer networks of Queensland Health, in collaboration with clinicians and managers across the state of Queensland, developed the QReCS model and a guide for operationalizing it. QReCS was implemented at six sites from 2014 to 2016. Main enablers across North Queensland included collaboration among clinicians and managers, availability of common electronic medical records, funding from Queensland Health, and installation of telehealth infrastructure by statewide telehealth services. Main barriers included turnover of senior management and nursing staff at two rural towns. Sixty-two patients received 327 cycles of low- to medium-risk chemotherapy agents. Rates of treatment delays, adverse events, and hospital admissions were similar to those in face-to-face care. Conclusion: Implementation of the QReCS model across a large geographic region is feasible with acceptable safety profiles. Leadership by and collaboration among clinicians and managers, adequacy of resources and common governance are key enablers.

Background Nonresponsive maternal child-feeding interactions, such as restricting, pressurising and emotional feeding, can affect the ability of a child to self-regulate intake and increase the risk of becoming overweight. However, despite findings that South Asian and Black children living in the UK are more likely to be overweight, UK research has not considered how maternal child-feeding style might differ between ethnic groups. The present study aimed to explore variations in maternal child-feeding style between ethnic groups in the UK, taking into account associated factors such as deprivation and parenting style. Methods Six hundred and fifty-nine UK mothers with a child who was aged 5-11 years old completed a questionnaire. Items included ethnicity and demographic data, as well as copies of the Child Feeding Questionnaire, Parental Feeding Styles Questionnaire and Parenting Styles and Dimensions Questionnaire. Results Significant differences in perceived responsibility (P = 0.002), restriction (P = 0.026), pressure to eat (P = 0.045), instrumental feeding (P = 0.000) and emotional feeding (P = 0.000) were found between the groups. Mothers from South Asian backgrounds reported higher levels of pressure to eat, emotional feeding and indulgent feeding styles, whereas mothers from Chinese backgrounds reported greater perceived responsibility and restriction. Mothers from Black and White British backgrounds were not significantly higher with respect to any behaviour. Maternal child-feeding style was also associated with deprivation and parenting style, although these did not fully explain the data. Conclusions Understanding cultural factors behind maternal child-feeding style, particularly around pressurising and indulgent feeding behaviours, may play an important part in reducing levels of children who are overweight and obese in the UK.

This pilot study assesses the impact of FREED (First Episode Rapid Early Intervention for Eating Disorders [ED]), a novel transdiagnostic service for emerging adults with recent ED onset, on clinical outcomes. Data were collected from 56 patients and 19 carers for 12 months following enrolment. FREED patients showed significant improvements in ED and other symptoms across time. Carers also showed psychological improvements. For FREED anorexia nervosa (AN) patients, body mass index (BMI) at initial clinical assessment was similar to that of comparable patients (audit cohort) seen in our service before (16.4 vs 16.1 kg/m2 ). By start of treatment, because of their shorter wait, FREED-AN had gained weight whereas audit patients had lost (16.7 vs 15.8 kg/m2 ). This difference continued throughout treatment, and at 12 months, nearly 60% FREED-AN patients returned to a BMI of 18.5 or greater. FREED shows promise as a service model for emerging adults with EDs.

Background Many women in the UK stop breastfeeding before they would like to, and earlier than is recommended by the World Health Organization (WHO). Given the potential health benefits for mother and baby, new ways of supporting women to breastfeed for longer are required. The purpose of this study was to develop and characterise a novel Motivational Interviewing (MI) informed breastfeeding peer-support intervention. Methods Qualitative interviews with health professionals and service providers (n = 14), and focus groups with mothers (n = 14), fathers (n = 3), and breastfeeding peer-supporters (n = 15) were carried out to understand experiences of breastfeeding peer-support and identify intervention options. Data were audio-recorded, transcribed, and analysed thematically. Consultation took place with a combined professional and lay Stakeholder Group (n = 23). The Behaviour Change Wheel (BCW) guided intervention development process used the findings of the qualitative research and stakeholder consultation, alongside evidence from existing literature, to identify: the target behaviour to be changed; sources of this behaviour based on the Capability, Opportunity and Motivation (COM-B) model; intervention functions that could alter this behaviour; and; mode of delivery for the intervention. Behaviour change techniques included in the intervention were categorised using the Behaviour Change Technique Taxonomy Version 1 (BCTTv1). Results Building knowledge, skills, confidence, and providing social support were perceived to be key functions of breastfeeding peer-support interventions that aim to decrease early discontinuation of breastfeeding. These features of breastfeeding peer-support mapped onto the BCW education, training, modelling and environmental restructuring intervention functions. Behaviour change techniques (BCTTv1) included social support, problem solving, and goal setting. The intervention included important inter-personal relational features (e.g. trust, honesty, kindness), and the BCTTv1 needed adaptation to incorporate this. Conclusions The MI-informed breastfeeding peer-support intervention developed using this systematic and user-informed approach has a clear theoretical basis and well-described behaviour change techniques. The process described could be useful in developing other complex interventions that incorporate peer-support and/or MI. Electronic supplementary material The online version of this article (10.1186/s12884-018-1725-1) contains supplementary material, which is available to authorized users.

The role of the cervicovaginal (CV) microbiome in regulating cervical function during pregnancy is poorly understood. Gardnerella vaginalis (G. vaginalis) is the most common bacteria associated with the diagnosis of bacterial vaginosis (BV). While BV has been associated with preterm birth (PTB), clinical trials targeting BV do not decrease PTB rates. It remains unknown if G. vaginalis is capable of triggering molecular, biomechanical and cellular events that could lead to PTB. The objective of this study was to determine if cervicovaginal colonization with G. vaginalis, in pregnant mice, induced cervical remodeling and modified cervical function. CD-1 timed-pregnant mice received a 5X108 CFU/mL intravaginal inoculation of G. vaginalis or control on embryonic day 12 (E12) and E13. On E15, the mice were sacrificed and cervicovaginal fluid (CVF), amniotic fluid (AF), cervix, uterus, placentas and fetal membranes (FM) were collected. Genomic DNA was isolated from the CVF, placenta, uterus and FM and QPCR was performed to confirm colonization. IL-6 was measured in the CVF and AF and soluble e-cadherin (seCAD) was assessed in the CVF by ELISA. RNA was extracted from the cervices to evaluate IL-10, IL-8, IL-1β, TNF-α, Tff-1, SPINK-5, HAS-1 and LOX expression via QPCR. Mucicarmine and trichrome staining was used to assess cervical mucin and collagen. Biomechanical properties of the cervix were studied using quasi-static tensile load-to-failure biomechanical tests. G. vaginalis successfully colonized the CV space. This colonization induced immune responses (increased IL-6 levels in CVF and AF, increased mRNA expression of cervical cytokines), altered the epithelial barrier (increased seCAD in the CVF), induced cervical remodeling (increased mucin production, altered collagen) and altered cervical biomechanical properties (a decrease in biomechanical modulus and an increase in maximum strain). The ability of G. vaginalis to induce these molecular, immune, cellular and biomechanical changes suggests that this bacterium may play a pathogenic role in premature cervical remodeling leading to PTB.

Objective The objective was to determine if women with symptoms of preterm labor who ultimately have a spontaneous preterm birth (sPTB) have a distinct cervicovaginal (CV) metabolome compared with women who deliver at term. Study Design A nested case–control study of women presenting with symptoms of preterm labor was performed. CV fluid was collected from women between 22 and 336/7 weeks' gestation. The CV metabolome was compared between women with sPTB (n = 20) and women who delivered at term (n = 30). Global biochemical profiles were determined using ultraperformance liquid chromatography/tandem mass spectrometry. Welch's two-sample t-test was used to identify metabolites that differed significantly. Level of significance was defined as p ≤ 0.05. Results Eighty-eight percent of women were African-American and none had a prior history of sPTB. A total of 301 metabolites were identified in CV fluid. Thirty metabolites were significantly different in women with preterm birth compared with term birth. Two metabolites (mannitol and methyl phosphate) were significantly upregulated, and the remaining 28 metabolites were significantly downregulated and consisted of medium chain-fatty acids and collagen degradation markers. Conclusion The CV metabolome is significantly altered among women who present with preterm labor symptoms and ultimately have a sPTB.

The cervix is a unique organ able to dramatically change its shape and function by serving as a physical barrier for the growing fetus and then undergoing dramatic dilation allowing for delivery of a term infant. As a result, the cervix endures changing mechanical forces from the growing fetus. There is an emerging concept that the cervix may change or remodel “early” in many cases of spontaneous preterm birth (sPTB). However, the mechanical role of the cervix in both normal and preterm birth remains unclear. Therefore, the primary objective of this study was to determine the mechanical and structural responses of murine cervical tissue throughout a normal gestational time course. In this study, both tissue structural and material properties were determined via a quasi-static tensile load-to-failure test, while simultaneously obtaining dynamic collagen fiber re-alignment via cross-polarization imaging. This study demonstrated that the majority of the mechanical properties evaluated decreased at midgestation and not just at term, while collagen fiber re-alignment occurred earlier in the loading curve for cervices at term. This suggests that although structural changes in the cervix occur throughout gestation, the differences in material properties function in combination with collagen fiber re-alignment as mechanical precursors to regulate term gestation. This work lays a foundation for investigating cervical biomechanics and the role of the cervix in preterm birth.

Objective Endometrial cancer can be diagnosed early and cured, yet cases that recur portend a very poor prognosis with over 10,000 women succumbing to the disease every year. In this study we addressed the question of how to recognize cases likely to recur early in the course of therapy using dysregulation of tumor microRNAs (miRNAs) as predictors. Methods Using the tissue collection from Gynecologic Oncology Group Study-210, we selected and analyzed expression of miRNAs in 54 recurrent and non-recurrent cases. The three most common histologic types, endometrioid adenocarcinoma (EEA), serous adenocarcinoma (ESA) and carcinosarcoma (UCS), were analyzed as three independent sets and their miRNA expression profiles compared. Results Only one miRNA was statistically different between recurrent and non-recurrent cases, and in only one histologic type: significant down-regulation of miR-181c was observed in EEA recurrence. Using several well-known databases to assess miR-181c targets, one target of particular relevance to cancer, NOTCH2, was well supported. Using The Cancer Genome Atlas and our validation tumor panel from the GOG-210 cohort, we confirmed that NOTCH2 is significantly over-expressed in EEA. In the most relevant endometrial adenocarcinoma cell model, Ishikawa H, altering miR-181c expression produces significant changes in NOTCH2 expression, consistent with direct targeting. Conclusions Our findings suggest that increased NOTCH2 via loss of miR-181c is a significant component of EEA recurrence. This presents an opportunity to develop miR-181c and NOTCH2 as markers for early identification of high risk cases and the use of NOTCH inhibitors in the prevention or treatment of recurrent disease.

Objective:To analyze the oral motor, speech, and language phenotype in 20 children and adults with Dravet syndrome (DS) associated with mutations in SCN1A.Methods:Fifteen verbal and 5 minimally verbal DS patients with SCN1A mutations (aged 15 months-28 years) underwent a tailored assessment battery.Results:Speech was characterized by imprecise articulation, abnormal nasal resonance, voice, and pitch, and prosody errors. Half of verbal patients had moderate to severely impaired conversational speech intelligibility. Oral motor impairment, motor planning/programming difficulties, and poor postural control were typical. Nonverbal individuals had intentional communication. Cognitive skills varied markedly, with intellectual functioning ranging from the low average range to severe intellectual disability. Language impairment was congruent with cognition.Conclusions:We describe a distinctive speech, language, and oral motor phenotype in children and adults with DS associated with mutations in SCN1A. Recognizing this phenotype will guide therapeutic intervention in patients with DS.

Introduction Exposure to prenatal inflammation is associated with diverse adverse neurobehavioral outcomes in exposed offspring. The mechanism by which inflammation negatively impacts the developing brain is poorly understood. Metabolomic profiling provides an opportunity to identify specific metabolites, and novel pathways, which may reveal mechanisms by which exposure to intrauterine inflammation promotes fetal and neonatal brain injury. Therefore, we investigated whether exposure to intrauterine inflammation altered the metabolome of the amniotic fluid, fetal and neonatal brain. Additionally, we explored whether changes in the metabolomic profile from exposure to prenatal inflammation occurs in a sex-specific manner in the neonatal brain. Methods CD-1, timed pregnant mice received an intrauterine injection of lipopolysaccharide (50 μg/dam) or saline on embryonic day 15. Six and 48 hours later mice were sacrificed and amniotic fluid, and fetal brains were collected (n = 8/group). Postnatal brains were collected on day of life 1 (n = 6/group/sex). Global biochemical profiles were determined using ultra performance liquid chromatography/tandem mass spectrometry (Metabolon Inc.). Statistical analyses were performed by comparing samples from lipopolysaccharide and saline treated animals at each time point. For the P1 brains, analyses were stratified by sex. Results/conclusions Exposure to intrauterine inflammation induced unique, temporally regulated changes in the metabolic profiles of amniotic fluid, fetal brain and postnatal brain. Six hours after exposure to intrauterine inflammation, the amniotic fluid and the fetal brain metabolomes were dramatically altered with significant enhancements of amino acid and purine metabolites. The amniotic fluid had enhanced levels of several members of the (hypo) xanthine pathway and this compound was validated as a potential biomarker. By 48 hours, the number of altered biochemicals in both the fetal brain and the amniotic fluid had declined, yet unique profiles existed. Neonatal pups exposed to intrauterine inflammation have significant alterations in their lipid metabolites, in particular, fatty acids. These sex-specific metabolic changes within the newborn brain offer an explanation regarding the sexual dimorphism of certain psychiatric and neurobehavioral disorders associated with exposure to prenatal inflammation.

Background Lysophosphatidic acid (LPA) receptor signaling has been implicated in cardiovascular and obesity-related metabolic disease. However, the distribution and regulation of LPA receptors in the myocardium and adipose tissue remain unclear. Objectives This study aimed to characterize the mRNA expression of LPA receptors (LPA1-6) in the murine and human myocardium and adipose tissue, and its regulation in response to obesity. Methods LPA receptor mRNA levels were determined by qPCR in i) heart ventricles, isolated cardiomyocytes, and perigonadal adipose tissue from chow or high fat-high sucrose (HFHS)-fed male C57BL/6 mice, ii) 3T3-L1 adipocytes and HL-1 cardiomyocytes under conditions mimicking gluco/lipotoxicity, and iii) human atrial and subcutaneous adipose tissue from non-obese, pre-obese, and obese cardiac surgery patients. Results LPA1-6 were expressed in myocardium and white adipose tissue from mice and humans, except for LPA3, which was undetectable in murine adipocytes and human adipose tissue. Obesity was associated with increased LPA4, LPA5 and/or LPA6 levels in mice ventricles and cardiomyocytes, HL-1 cells exposed to high palmitate, and human atrial tissue. LPA4 and LPA5 mRNA levels in human atrial tissue correlated with measures of obesity. LPA5 mRNA levels were increased in HFHS-fed mice and insulin resistant adipocytes, yet were reduced in adipose tissue from obese patients. LPA4, LPA5, and LPA6 mRNA levels in human adipose tissue were negatively associated with measures of obesity and cardiac surgery outcomes. This study suggests that obesity leads to marked changes in LPA receptor expression in the murine and human heart and white adipose tissue that may alter LPA receptor signaling during obesity.