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Abstract The purpose of this study is to investigate whether smart administrative governance (SAG) and smart technical governance (STG) affect sustainable development (SD). Importantly, it explores the moderating effect of human capital training and development (HCTD) on the relationship of SAG and STG to SD. To this end, data was gathered from a sample of 318 respondents from Nonprofit organizations in Saudi Arabia and analyzed using PLS-SEM via SmartPLS. The findings demonstrated that SAG positively affects SD, while STG has no effect on SD. Moreover, HCTD directly and favorably affects SD. Importantly, HCTD negatively moderates the relationship between STG and SD. In contrast, HCTD does not moderate the relationship between STG and SD. Overall, this study contributes to the literature by providing a nuanced understanding of how to enhance SD in nonprofit organizations by highlighting the distinct roles of SAG and STG. Hence, this study enriches the literature on governance and sustainability and has implications for both practitioners and policymakers.

The set Si,n={0,1,2,…,n−1,n}\{i}{S}_{i,n}=\left\{0,1,2,\ldots ,n-1,n\right\}\setminus \left\{i\right\}, 1⩽i⩽n1\leqslant i\leqslant n, is called Laplacian realizable if there exists an undirected simple graph whose Laplacian spectrum is Si,n{S}_{i,n}. The existence of such graphs was established by Fallat et al. (On graphs whose Laplacian matrices have distinct integer eigenvalues, J. Graph Theory 50 (2005), 162–174). In this article, we consider graphs whose Laplacian spectra have the form S{i,j}nm={0,1,2,…,m−1,m,m,m+1,…,n−1,n}\{i,j},0

Artificial intelligence (AI) has emerged as a transformative force in various sectors, including medicine and healthcare. Large language models like ChatGPT showcase AI’s potential by generating human-like text through prompts. ChatGPT’s adaptability holds promise for reshaping medical practices, improving patient care, and enhancing interactions among healthcare professionals, patients, and data. In pandemic management, ChatGPT rapidly disseminates vital information. It serves as a virtual assistant in surgical consultations, aids dental practices, simplifies medical education, and aids in disease diagnosis. A total of 82 papers were categorised into eight major areas, which are G1: treatment and medicine, G2: buildings and equipment, G3: parts of the human body and areas of the disease, G4: patients, G5: citizens, G6: cellular imaging, radiology, pulse and medical images, G7: doctors and nurses, and G8: tools, devices and administration. Balancing AI’s role with human judgment remains a challenge. A systematic literature review using the PRISMA approach explored AI’s transformative potential in healthcare, highlighting ChatGPT’s versatile applications, limitations, motivation, and challenges. In conclusion, ChatGPT’s diverse medical applications demonstrate its potential for innovation, serving as a valuable resource for students, academics, and researchers in healthcare. Additionally, this study serves as a guide, assisting students, academics, and researchers in the field of medicine and healthcare alike.

The set Si,n = {0, 1, 2, …, i − 1, i + 1, …, n − 1, n}, 1 ⩽ i ⩽ n, is called Laplacian realizable if there exists a simple connected undirected graph whose Laplacian spectrum is Si,n. The existence of such graphs was established by S. Fallat et all. In the present paper, we find the Laplacian energy and first Zagreb index of graphs whose Laplacian spectrum is Si,n.

Through reduction of thickness value in nanostructures, the features of surface elasticity become more prominent due to having a high surface-to-volume ratio. The main aim of this research work was to examine the surface residual stress effect on the three-dimensional nonlinear stability characteristics of geometrically perfect and imperfect cylindrical shells at nanoscale under axial compression. To do so, an unconventional three-dimensional shell model was established via combination of the three-dimensional shell formulations and the Gurtin–Murdoch theory of elasticity. The silicon material is selected as a case study, which is the most utilized material in the design of micro-electromechanically systems. Then, the moving Kriging meshfree approach was applied to take numerically into account the surface free energy effects and the initial geometrical imperfection in the three-dimensional nonlinear stability curves. Accordingly, the considered cylindrical shell domain was discretized via a set of nodes together using the quadratic polynomial type of basis shape functions and an appropriate correlation function. It was found that the surface stress effects lead to an increase the critical axial buckling load of a perfect silicon nanoshell about 82.4%82.4 \% for the shell thickness of 2nm2{\rm{nm}}, about 32.4%32.4 \% for the shell thickness of 5nm5{\rm{nm}}, about 15.8%15.8 \% for the shell thickness of 10nm10{\rm{nm}}, and about 7.5%7.5 \% for the shell thickness of 20nm20{\rm{nm}}. These enhancements in the value of the critical axial buckling load for a geometrically imperfect silicon nanoshell become about 92.9%92.9 \% for the shell thickness of 2nm2{\rm{nm}}, about 36.5%36.5 \% for the shell thickness of 5nm5{\rm{nm}}, about 17.7%17.7 \% for the shell thickness of 10nm10{\rm{nm}}, and about 8.8%8.8 \% for the shell thickness of 20nm20{\rm{nm}}.

تحددت أهمية البحث في إمكانية المزج بين تمرينات البلانك وأسلوب الهيبوكسيك على الافراد الممارسين للنشاط البدني. اذ هدف البحث في العمل على إعداد تمرينات بأسلوب الهيبوبلانك للأفراد الممارسين للنشاط البدني من أجل الصحة فئة الرجال وبأعمار 35-40 سنة. وتم استخدام المنهج التجريبي بتصميم المجموعة الواحدة ذات الاختبار القبلي والبعدي. وتكون مجتمع البحث من الرجال الممارسين للنشاط البدني من اجل الصحة في مراكز اللياقة البدنية في محافظة بغداد-منطقة العامرية والبالغ عددهم 130 فرداً. وتم استخدام مجموعة اختبارات بدنية منها اختبار مطاوعة القوة للذراعين واختبار مطاولة القوة للبطن واختبار مطاول القوة للجذع واختبار ركض (1000) متر. وبعد جمع المعلومات ومعالجتها احصائياً، بينت النتائج وجود فروق معنوية لصالح المجموعة التجريبية في متغيرات مطاولة القوة للذراعين ومطاولة القوة لعضلات البطن ومطاولة القوة لعضلات الظهر واختبار ركض 1000م

Reactive arthritis (ReA) is commonly associated with gastroenteritis by Yersinia, Salmonella, Shigella, Campylobacter, and Clostridium difficile and genitourinary infections by Chlamydia trachomatis and Neisseria gonorrhea. Urinary tract infection (UTI) with Escherichia coli is rarely associated with ReA. Failure to screen for UTI, especially in patients with asymptomatic bacteriuria, can lead to delayed diagnosis and inappropriate treatment. A 31-year-old homemaker, who had been diagnosed with pulmonary TB 1 month back and had completed 1 month of successful anti-TB therapy, presented with pain and swelling of the right knee and fever of 1-week duration. She had healing erythema nodosum on both her thighs. Her right knee had pain and swelling that lead to restriction of movements. X-ray of the right knee showed joint effusion with no joint destruction. Work up for autoimmune arthritis was negative. Synovial fluid studies ruled out septic arthritis, crystal arthropathies, and tuberculous arthritis. Urinalysis suggested UTI and urine culture isolated E. coli. Hence, we made the diagnosis of ReA due to UTI with E. coli. She received oral nonsteroidal anti-inflammatory drugs and a course of ciprofloxacin. She had a complete recovery.

Use of transdermal patches can evade many issues associated with oral drug delivery, such as first-pass hepatic metabolism, enzymatic digestion attack, drug hydrolysis and degradation in acidic media, drug fluctuations, and gastrointestinal irritation. This article reviews various transdermal patches available in the market, types, structural components, polymer role, and the required assessment tools. Although transdermal patches have medical applications for smoking cessation, pain relief, osteoporosis, contraception, motion sickness, angina pectoris, and cardiac disorders, advances in formulation development are ongoing to make transdermal patches capable of delivering more challenging drugs. Transdermal patches can be tailored and developed according to the physicochemical properties of active and inactive components, and applicability for long-term use. Therefore, a number of chemical approaches and physical techniques for transdermal patch development are under investigation.

The problem of the research lies in women wanting to lose weight yet unable to maintain a healthy nutritional program along with the physical program. The research aimed at designing a nutritional – physical program for obese women as well as identifying its effect on health-related fitness development and losing weight in obese women. The researchers used the experimental program on (6) obese women aged (25 – 35) years old from the nutritional researchers’ institute in the specialized clinic for treating obesity. The training program lasted for three sessions per week for two months to conclude that the program has a positive effect on improving health relate fitness and losing weight. Finally, the researchers recommended decreasing calories and increasing training load gradually through repetitions in future athletic programs.

In the present study, berries of two different species of Solanaceae family, Withania somnifera (WS) and Solanum nigrum (SN), were extracted in methanol and then fractionated with solvents, ranging from non-polar to polar, for their phytochemical profiling and investigation of antioxidant and tyrosinase enzyme inhibition capacity. The methanolic extract and n-hexane, ethyl acetate (WSEA, SNEA) and aqueous fractions were chemically analyzed and evaluated for biological activity. Total flavonoids and total phenolics were quantified in WSEA (96.91 ± 1.56 μg QE mg-1 sample and 178.45 ± 2.78 μg GAE mg-1 s ample, r esp.) and S NEA (89.58 ± 0.98 μg QE mg-1 sample and 120.15 ± 2.33 μg GAE mg-1 sample, resp.). HPLC-DAD analysis of ethyl acetate fractions of WS and SN measured 13.74 and 5.34 μg GAE mg-1 dry fraction and 3.72 and 3.41 μg QE mg-1 dry fraction, resp. WSEA and SNEA fractions showed the highest 2,2-diphenyl-2-picryl hydrazyl (DPPH) radical scavenging, total antioxidant capacity and iron reducing power activity. The highest inhibition of tyrosinase enzyme was also exhibited by WSEA and SNEA (59.6 and 58.7 %) resp. This investigation justifies the medicinal value of W. somnifera and S. nigrum berry extracts as potential and readily available sources of natural antioxidants. Marked tyrosinase enzyme inhibition activity and antioxidant activity of both plant extracts might be due to polyphenols and flavonoids.

Mitral stenosis is one of the more commonly seen valve lesions encountered in pregnancy. The pathophysiologic implications, management strategies, and a comprehensive review of literature over the past 20 years for optimal timing of catheter balloon commissurotomy during pregnancy are discussed. Mechanical relief of obstruction is indicated for cases of severe symptomatic mitral stenosis in pregnancy refractory to medical therapy. Catheter balloon commissurotomy is the procedure of choice in a select group of these patients with suitable valve morphology. [ABSTRACT FROM AUTHOR]

Curcumin is a natural product with enormous biological potential. In this study, curcumin synthesis was revisited using different reaction solvents, a catalyst (n-butylamine) and a water scavenger [(n-BuO)3B], to develop the optimal procedure for its rapid acquisition. During synthesis, solvent choice was found to be an important parameter for better curcumin yield and high purity. In a typical reaction, acetyl acetone was treated with boron trioxide, followed by condensation with vanillin in the presence of tri-n-butyl borate as water scavenger and n-butylamine as catalyst at 80 °C in ethyl acetate to afford curcumin. Moreover, curcumin was also extracted from turmeric powder and spectroscopic properties such as IR, MS, 1H NMR and 13C NMR with synthetic curcumin were established to identify any impurity. The purity of synthetic and extracted curcumin was also checked by TLC and HPLC-DAD. To computationally assess its therapeutic potential against cyclin dependent kinases (CDKs), curcumin was docked in different isoforms of CDKs. It was observed that it did not dock at the active sites of CDK2 and CDK6. However, it could enter into weak interactions with CDK4 protein.

Pb(Zrx,Ti1-x)O3 (PZT) powder was prepared via solid-state reaction and deposited on glass by Pulsed Laser Deposition (PLD). X-ray diffraction (XRD) analysis carried out to investigate the phase structure, it was found that PZT thin films with x=0.7 are polycrystalline with many peaks, and the results of Atomic Force Microscopy (AFM) used to studied the samples topographic indicated the film have grain size around 100 nm decrease to around 70 nm after annealing to 723 K. The optiical properties of PZT films with x=0.7 studied at RT and 723 K. The absorbance and transmittance spectra have been registered in the wavelength range (390-1100) nm so as to examine the optical properties at vis-IR wavelengths. It was investigated that the optical energy gap (Eg) increase when annealing temperature (Ta) increase. An extinction coefficient, refractive index, real and imaginary dielectric constant were sensitive to the change in temperature. Fourier Transform Infra-Red (FTIR) to know the identity and to study the vibrational frequencies between the bonds of atoms for synthesized (PZT) Nanoparticles which found stretching at (3477.66 cm-1) after annealing to 723 K. the interferometer used to determine the thickness of the deposited film, it found of about 200 nm.

Pb(Zrx,Ti1-x)O3 (PZT) powder was prepared via solid-state reaction and deposited on n-type silicon wafers ( Pb(Zrx,Ti1-x)O3/n-Si ) and on n-type porous silicon ( Pb(Zrx,Ti1-x)O3/n-PS ) of (111) orientation and (0.015 Ω.cm) resistivity by (PLD). We used the photoelectrochemical etching cell for creation the porosity layers on the silicon wafers. Using thermal evaporation system to evaporate Al on the back of the wafer to make an ohmic contact thick film. Spectral measurements ( responsivity, quantum efficiency, detectivity and noise equivalent power ) for Pb(Zrx,Ti1-x)O3 /n-Si and Pb(Zrx,Ti1-x)O3 /n-PS devices show ( 1.2482, 0.4422% , 2.207×1010 and 0.45×10-10 ) and ( 1.5695, 0.5561%, 2.618×1010 and 0.36×10-10 ) respectively. the favorite x content of Zr is 0.5 for all samples. spectral parameters for devices assign to the stable behavior of the samples after etching procedure and its values are larger than that for without porous

Background: Acute respiratory distress syndrome (ARDS) is seen in critically ill patients. Its etiological spectrum in India is expected to be different from that seen in western countries due to the high prevalence of tropical infections. Aim: To study the epidemiological profile of ARDS patients. Setting: A tertiary care hospital in Karnataka, India. Materials and Methods: Retrospective analysis of 150 out of the 169 ARDS patients diagnosed during 2010–2012. Data collected included the clinical features and severity scoring parameters. Results: The mean age of the study population was 42.92 ± 13.91 years. The causes of ARDS included pneumonia (n = 35, 23.3%), scrub typhus (n = 33, 22%), leptospirosis (n = 11, 7.3%), malaria (n = 6, 4%), influenza (H1N1) (n = 10, 6.7%), pulmonary tuberculosis (n = 2, 1.3%), dengue (n = 1, 0.7%), abdominal sepsis (n = 16, 10.7%), skin infection (n = 3, 2%), unknown cause of sepsis (n = 18, 12%), and nonseptic causes (n = 15, 10%). A total of 77 (51.3%) patients survived, 66 (44%) expired, and 7 (4.7%) were discharged against medical advice (AMA). Preexisting comorbidities (46) were present in 13 survivors, 19 nonsurvivors, and four discharged AMA. History of surgery prior to the onset of ARDS was present in one survivor, 13 nonsurvivors, and one discharge AMA. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, and Sequential Organ Failure Assessment scores in survivors were 9.06 ± 4.3, 49.22 ± 14, and 6.43 ± 2.5 and in nonsurvivors 21.11 ± 7, 86.45 ± 23.5, and 10.6 ± 10, respectively. Conclusion: The most common cause of ARDS in our study was pneumonia, but a large percentage of cases were due to the tropical infections. Preexisting comorbidity, surgery prior to the onset of ARDS, higher severity scores, and organ failure scores were more frequently observed among nonsurvivors than survivors.

Background: Leukotriene modifiers have an established role in the management of chronic asthma but their role in acute asthma is still under evaluation. Objective: To study and compare the effects of oral montelukast with oral zileuton in acute asthma. Materials and Methods: This study included 120 asthmatics and was conducted from September 2012 to March 2014. Patients were randomized into three different groups to receive montelukast or zileuton or placebo in addition to standard treatment for asthma exacerbation. Peak expiratory flow rate (PEFR) values, details of rescue medication and vital signs were recorded at 6 h, 12 h, 24 h, and 48 h of drug or placebo administration and at discharge. Additional recording was done in the morning (8-10 am) following admission. The primary endpoint was the mean PEFR of each group at these time points; the secondary end point being the need for rescue medications. Results: The mean PEFR recordings of the three study groups - placebo, montelukast, and zileuton - respectively, at various time points were as follows: at 6 h (223.25 ± 90.40, 199.00 ± 82.52, 233.75 ± 84.05; P = 0.240); at 12 h (271.00 ± 109.38, 251.50 ± 101.44, 309.50 ± 129.63; P = 0.048); at 24 h (288.25 ± 114.26, 269.00 ± 107.51, 324.50 ± 127.88; P = 0.080); and at 48 h (295.00 ± 114.80, 293.50 ± 113.24, 344.75 ± 119.91; P = 0.015); discharge (305.00 ± 118.56, 305.25 ± 119.51, 361.25 ± 119.70; P = 0.010). The mean PEFR for the three study groups at 8-10 am on the morning following admission was 268.75 ± 111.43, 252.50 ± 99.99, 306.75 ± 114.44; P = 0.047. Total rescue doses needed were 10, 1, and 0, respectively (P = 0.049). Conclusion: Zileuton is better than montelukast as an additional drug in acute asthma and results in significant improvement in lung function, and reduction in the need for rescue medications.

الكايتوسان الذي يمكن الحصول عليه بعد ازالة مجاميع الاستيل من الكايتين، هو سكر متعدد يتشكل اساسا من وحدات متعددة من الدي كلوكوز امين. هو بوليمر حيوي متعدد الاستعمالات واظهر خصائص بايولوجية مختلفة فريدة من نوعها ولذلك له تطبيقات واسعة في الغذاء والطب الحيوي والصناعات الكيميائية. هدفت هذه الدراسة الى تحديد الظروف المثلى لأنتاج الكايتوسان من الفطر Aspergillus oryzae SU-B2 اظهرت النتائج أن أفضل تلك الظروف تتمثل بأستخدام سكر الكلوكوز بتركيز 2% كمصدر للكربون وكلا من كبريتات الامونيوم بتركيز %0. 5 ومستخلص الخميرة بتركز 0. 1% والببتون بتركيز1% كمصدر للنتروجين والرقم الهيدروجيني 5.5 ودرجة الحرارة 30م ومدة 120ساعة وحجم اللقاح 15 مل محتويا على 710x1 بوغ/ مل وبسرعة تهوية 150دورة/ دقيقة حيث بلغت انتاجية الكايتوسان 10200 ملغم/ لتر وبمعدل زيادة بلغت207.2 %.

Image matching techniques play an essential role in many real world applications such as content based image retrieval (CBIR), computer vision, and near duplicate images. The state of the art methods are generally assumed that the content of images is not private. This reduces the utilization of these methods to work within only environments where images are publicly access. Essentially, this assumption limits more practical applications, e.g., image matching between two security agencies, where images are confidential. This paper addresses the problem of privacy-preserving image matching between two parties where images should not be revealed to each other. The descriptor set of the queried party needs to be generated and encrypted properly using a secret key at the queried party side before being transferred to the other party. We have developed a secure scheme to measure the cosine similarity between two descriptor sets without decryption. Several experiments are conducted to investigate the performance of the proposed scheme.

هدفت هذه الدراسة الى تحديد الظروف المثلى لانتاج انزيمL- asparaginase من عزلة محلية من بكتريا Erwinia Caratovora AH88 (تم الحصول عليها من دراسة سابقة) وباستخدام تقنية المزارع المغمورة. أظهرت نتائج هذه الدراسة ان الظروف المثلى لانتاج انزيم L- asparaginas من العزلة المحلية المذكورة اعلاه تضمنت استخدام اللاكتوز بتركيز 1% مصدرا للكاربون وخلاصة الخميرة بتركيز 1 % مصدرا للنتروجين فضلا عن وجود الاسبارجين كمادة حاثة وبتركيز%0.19 . كما ان الرقم الهيدروجيني الامثل لوسط الانتاج هو 7 ودرجة الحرارة المثلى 30مْ وسرعة التهوية 150 دورة / دقيقة وان حجم اللقاح الامثل كان مساويا الى 2 % (محتويا على 3x 10 6 وحدة تكوين مستعمرة / مل) وفترة الحضن المثلى كانت 24 ساعة. وتحت الظروف المثلى لانتاج انزيم L- asparaginase فان الفعالية الانزيمية والنوعية للانزيم بلغت 71.0 وحدة / مل و17 وحدة / ملغم على التوالي.

Diagnosis of diseases depends on histology using formaldehyde-fixed paraffin embedded tissue .The polymerase chain reaction (PCR)helps the pathologists to confirm the diagnosis of many disease including mycotic infections. Aborted placentas from 40 ewes were formalin fixed, paraffin embedded and sectioned. Tissue sections were stained with haematoxylin and eosine, and periodic acid Schiff (PAS) for histopathology examination. Fresh tissue parts were cultivated ,subjected to DNA extraction for the purpose of real-time PCR amplification. Histopathological examination of placental tissue revealed extensive necrotizing placentitis with the presence of spherule of CoccidioidesPosadasiiin the necrotic area. Only eight samples gave positive growth for coccidioidesPosadasii out of forty aborted placental samples. DNA amplification by real-time PCR revealed positive amplification for the eight samples which confirmed the detection of coccidiodesposadasii.

Brucellosis is one of the common bacterial zoonosis in the worldwide caused by organisms belong to the genus Brucella, However, animal Brucellosis is a serious problem worldwide and is endemic globally and disease of sexually matured animals and commonly transmitted to other animals by direct or indirect contact with infected animals or discharges such as: aborted fetuses, placental membranes or fluids. Fifty samples from internal organ of aborted fetus and the same number of aborted placenta were collected from aborted ewes positive to Rose Bengal test. For isolation and identification of Brucella from placenta and stomach contents , the standard procedures (Alton et al., 1988) were followed. The isolates were further confirmed by molecular techniques. The results showed that Br.melitensis was isolated from all animals that expressed Rose Bengal and serum agglutination test positive .The agglutination with monospecific A and M antisera were performed and these test revealed that the bacterial isolates expressed three Biovar as following ,Biovar 1(M,50%),Biovar 2 (A,26%) and Biovar 3 (0,24%). The number of this Biovar were varied according to collect area of the samples, high percentage (44%) was seen in the ALmanitherh ,,followed by AL Shabeka (30%) and AL Kuzweenah (26%) The results of PCR assay explained that 22 bacterial isolates showed a single amplified DNA product (44%) ,two bands at the level of 273 and 680 bp were seen in 8 isolates (16% ) and four bands at 273,680,750 and 850 bp were reported in 20 isolates(40%).

Abstract Background In recent times the basic understanding, perceptions and CAM use among undergraduate health sciences students have become a topic of interest. This study was aimed to investigate the understanding, perceptions and self-use of CAM among pharmacy students in Malaysia. Methods This cross-sectional study was conducted on 500 systematically sampled pharmacy students from two private and one public university. A validated, self-administered questionnaire comprised of seven sections was used to gather the data. A systematic sampling was applied to recruit the students. Both descriptive and inferential statistics were applied using SPSS® version 18. Results Overall, the students tend to disagree that complementary therapies (CM) are a threat to public health (mean score = 3.6) and agreed that CMs include ideas and methods from which conventional medicine could benefit (mean score = 4.7). More than half (57.8%) of the participants were currently using CAM while 77.6% had used it previously. Among the current CAM modalities used by the students, CM (21.9%) was found to be the most frequently used CAM followed by Traditional Chinese Medicine (TCM) (21%). Most of the students (74.8%) believed that lack of scientific evidence is one of the most important barriers obstructing them to use CAM. More than half of the students perceived TCM (62.8%) and music therapy (53.8%) to be effective. Majority of them (69.3%) asserted that CAM knowledge is necessary to be a well-rounded professional. Conclusions This study reveals a high-percentage of pharmacy students who were using or had previously used at least one type of CAM. Students of higher professional years tend to agree that CMs include ideas and methods from which conventional medicine could benefit.

Abstract Lipoid proteinosis is a rare autosomal recessive disease characterized by cutaneous and mucosal lesions and hoarseness appearing in early childhood that is caused by homozygous or compound heterozygous mutations in the ECM1 gene located on chromosome 1q21. The aim of the study was to investigate the molecular genetic defect underlying lipoid proteinosis in a consanguineous Pakistani family. Methods Genotyping of seven members of the family was performed by amplifying microsatellite markers, tightly linked to the ECM1 gene. To screen for mutations in the ECM1 gene, all of its exons and splice junctions were PCR amplified from genomic DNA and analyzed by SSCP and sequenced directly in an ABI 3130 genetic analyzer. Results The results revealed linkage of the LP family to the ECM1 locus. Sequence analysis of the coding exons and splice junctions of the ECM1 gene revealed a novel homozygous mutation (c.616C > T) in exon 6, predicted to replace glutamine with stop codon (p.Q206X) at amino acid position 206. Conclusions The finding of a novel mutation in Pakistani family extends the body of evidence that supports the importance of ECM1 gene for the development of lipoid proteinosis.

Abstract Background Avian influenza virus (AIV) infections have caused heavy economic losses to the poultry industry in Pakistan as well as numerous other regions worldwide. The first introduction of H7N3 AIV to Pakistan occurred during 1995, since then H7N3, H9N2 and H5N1 AIVs have each been sporadically isolated. This report evaluates the genetic origin of the H7N3 viruses from Pakistan collected 1995-2004 and how they disseminated within the country. To accomplish this we produced whole genome sequences for 6 H7N3 viruses and data for the HA and NA genes of an additional 7 isolates. All available sequence from H7N3 AIV from Pakistan was included in the analysis. Results Phylogenetic analysis revealed that there were two introductions of H7 into Pakistan and one N3 introduction. Only one of the H7 introductions appears to have become established in poultry in Pakistan, while the other was isolated from two separate outbreaks 6 years apart. The data also shows that reassortment has occurred between H7N3 and H9N2 viruses in the field, likely during co-infection of poultry. Also, with the exception of these few reassortant isolates, all 8 genes in the predominant H7N3 virus lineage have evolved to be phylogenetically distinct. Conclusions Although rigorous control measures have been implemented in commercial poultry in Pakistan, AIV is sporadically transmitted to poultry and among the different poultry industry compartments (broilers, broiler breeders, table egg layers). Since there is one primary H7 lineage which persists and that has reassorted with the H9N2 AIV in poultry, it suggests that there is a reservoir with some link commercial poultry. On a general level, this offers insight into the molecular ecology of AIV in poultry where the virus has persisted despite vaccination and biosecurity. This data also illustrates the importance of sustained surveillance for AIVs in poultry.

The United States has the highest maternal mortality rate among developed countries, with cardiovascular disease (CVD) being one of the leading causes of maternal deaths. Diagnosing CVD during pregnancy may be challenging as symptoms of normal pregnancy overlap with those of CVD. Delays in recognition and response to the diagnosis of CVD is a missed opportunity for timely intervention to improve maternal outcomes. Implementing universal CVD risk assessment for all pregnant and postpartum patients across clinical care settings presents a pivotal opportunity to address this issue. Integrating a validated risk assessment tool into routine obstetric care, clinicians, including obstetricians, primary care, and emergency healthcare providers, can enhance awareness of cardiovascular risk and facilitate early CVD diagnosis. Consensus among stakeholders underscores the importance of screening and education on cardiovascular health strategies for pregnant and postpartum patients to reduce CVD-related maternal mortality. This comprehensive approach offers a pathway to identify at-risk individuals and intervene promptly, potentially saving lives and advancing maternal healthcare equity., Competing Interests: This initiative was funded by the 10.13039/100000936Gordon and Betty Moore Foundation, Diagnostic Excellence Initiative, award GBMF9055.01, and from the 10.13039/100000071National Institute of Child Health and Human Development Study #5R21HD101783. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Maternal Cardiovascular Health Post-DobbsPregnancy is associated with increasing morbidity and mortality in the United States. In the post-Dobbs era, many pregnant patients at highest risk no longer have access to abortion, which has been a crucial component of standard medical care.

Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum., (Copyright © 2023. Published by Elsevier Inc.)

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified., (Copyright © 2023 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Ultrasound is the hallmark imaging modality traditionally used by obstetricians for fetal diagnosis and surveillance. The COVID-19 pandemic highlighted the role of point of care ultrasound for expeditious assessment of the maternal cardiopulmonary status. The familiarity of obstetricians with ultrasound, coupled with the availability of ultrasound equipment without the need to transport the patient, make point of care ultrasound particularly valuable in the labor and delivery unit. The rising contribution of cardiopulmonary disorders to maternal morbidity and mortality carves out many potential applications for point of care ultrasound during labor and delivery. Obstetricians have access to the technology and the skills to obtain the basic views required to assess for the presence of pulmonary edema, ventricular dysfunction, or intra-abdominal free fluid. Point of care ultrasound can be used routinely for the evaluation of pulmonary complaints or in the assessment of hypotension and may play an essential role in the diagnosis and management of life-threatening emergencies such as shock, an amniotic fluid embolism, or cardiac arrest. We reviewed the currently established point of care ultrasound protocols for the evaluation of cardiopulmonary complaints through the lens of the obstetrician. We call on educators and academic leaders to incorporate maternal point of care ultrasound teachings into existing curricula. Point of care ultrasound is of enormous value for providers with limited access to diagnostic imaging or subspecialty providers. With the growing complexity of the obstetrical population, acquiring the clinical skills to meet these evolving needs is a requisite step in the ongoing efforts to reduce maternal morbidity and mortality., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.

Cardiac conditions are the leading cause of pregnancy-related deaths and disproportionately affect non-Hispanic Black people. Multidisciplinary maternal mortality review committees have found that most people who died from cardiac conditions during pregnancy or postpartum were not diagnosed with a cardiovascular disease before death and that more than 80% of all pregnancy-related deaths, regardless of cause, were preventable. In addition, other obstetric complications, such as preeclampsia and gestational diabetes, are associated with future cardiovascular disease risk. Those with cardiac risk factors and those with congenital and acquired heart disease require specialized care during pregnancy and postpartum to minimize risk of preventable morbidity and mortality. This bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people with cardiac conditions and to respond to cardio-obstetric emergencies. This bundle is one of several core patient safety bundles developed by the Alliance for Innovation on Maternal Health that provide condition- or event-specific clinical practices for implementation in appropriate care settings. The Cardiac Conditions in Obstetric Care bundle is organized into five domains: 1) Readiness , 2) Recognition and Prevention , 3) Response , 4) Reporting and Systems Learning , and 5) Respectful Care . This bundle is the first by the Alliance to be developed with the fifth domain of Respectful Care . The Respectful Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into elements in each domain., Competing Interests: Financial Disclosure Alison Haddock reports receiving payment from Baylor College of Medicine and the American College of Emergency Physicians. The other authors did not report any potential conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Cardiovascular disease (CVD) is the leading cause of maternal mortality in the United States, accounting for over one-third of all pregnancy-related deaths. Contributing factors such as lack of recognition and delayed diagnosis of CVD are primarily due to the overlap of signs and symptoms of a normal pregnancy with those of CVD., Objectives: This study aimed to demonstrate the feasibility of introducing CVD risk assessment into clinical practice using the California Maternal Quality Care Collaborative algorithm to detect CVD during pregnancy and postpartum periods., Methods: We implemented the CVD risk assessment algorithm into electronic health records at 3 large hospital networks serving over 14,000 patients at 23 sites. We determined the percentage of pregnant and/or postpartum patients who were screened for CVD risk and the follow-up rate for patients in whom the tool recommended a follow-up assessment. Rates were stratified according to clinical site characteristics. We obtained clinician feedback regarding the feasibility and acceptability of the tool., Results: The rate of patients screened for CVD risk in the 3 hospital networks was 57.1%, 71.5%, and 98.7%. For those with a positive screen, follow-up rates were 65.8%, 72.5%, and 55.9% in the 3 networks. The rates of screening and follow-up varied based on the clinic size and specialty. Clinician-identified barriers were busy clinics, competing priorities, and the type of clinical practice., Conclusions: This innovative population-based approach for universal CVD risk assessment during pregnancy is feasible and may be a helpful strategy to decrease CVD-related maternal morbidity and mortality., Competing Interests: This research is funded by the 10.13039/100000936Gordon and Betty Moore Foundation, Diagnostic Excellence Initiative, award GBMF9055.01. All statements in this report, including its findings and conclusions, are solely those of the authors. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2023 The Authors.)

Cardiac biomarkers are widely used in the nonpregnant population when acute cardiovascular (CV) pathology is suspected; however, the behavior of these biomarkers in the context of pregnancy is less well understood. Pregnant individuals often have symptoms that mimic those of cardiac dysfunction, and complications of pregnancy may include CV disease. This paper will summarize our current knowledge on the use of cardiac biomarkers in pregnancy and provide suggestions on how to use these tools in clinical practice based on the available evidence. Natriuretic peptides and troponin should not be measured routinely in uncomplicated pregnancy, where values should remain low as in the nonpregnant population. In the context of pre-existing or suspected CV disease, these biomarkers retain their negative predictive value. Elevations of both natriuretic peptides and troponin may occur without clear clinical significance in the immediate postpartum period. Elevations of these markers should always prompt further investigation into possible CV pathology., Competing Interests: Dr Sarma has received the CRICO patient safety award and the MGH Department of Medicine Innovation grant. Dr Januzzi has received the Hutter Family Professorship; is a trustee of the American College of Cardiology; is a board member of Imbria Pharmaceuticals; has received grant support from 10.13039/100014386Abbott Diagnostics, Applied Therapeutics, Innolife, and 10.13039/100004336Novartis; has received consulting income from Abbott Diagnostics, Boehringer Ingelheim, Jana Care, Janssen, Novartis, Prevencio, and Roche Diagnostics; and participates in clinical end point committees/data safety monitoring boards for AbbVie, Siemens, Takeda, and Vifor. Dr Quesada has received support from the 10.13039/100000002NIH (K23-HL151867). Dr Briller is an unpaid consultant for the Illinois Maternal Mortality Committee; and is on the Steering committee for the REBIRTH trial of bromocriptine in Peripartum Cardiomyopathy (NCT05180773). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2022 The Authors.)

Cardiovascular complications are frequently present in coronavirus-2019 (COVID-19) infection. These include microvascular and macrovascular thrombotic complications such as arterial and venous thromboembolism, myocardial injury or inflammation resulting in infarction, heart failure, and arrhythmias. Data suggest increased risk of adverse outcomes in pregnant compared with nonpregnant women of reproductive age with COVID-19 infection, including need for intensive care unit admission, mechanical ventilation, and extracorporeal membrane oxygenation utilization. Current statements addressing COVID-19-associated cardiac complications do not include pregnancy complications that may mimic COVID-19 complications such as peripartum cardiomyopathy, spontaneous coronary artery dissection, and preeclampsia. Unique to pregnancy, COVID-19 complications can result in preterm delivery and modify management of the pregnancy. Moreover, pregnancy has often been an exclusion criterion for enrollment in research studies. In this review, we summarize what is known about pregnancy-associated COVID-19 cardiovascular complications., Competing Interests: Dr Quesada has received external funding of 10.13039/100000002NIH, United States K23HL151867 award for investigation on hypertensive disorders of pregnancy. Drs Malhamé and Gibson McDonald hold Fonds de Recherche du Quebec-Santé (FRQS), Canada Career awards. Dr Gibson McDonald is a site investigator and member of steering committee for the ATTACC study. The sponsors for the ATTACC study had no role in interpretation of data for this study. Dr Briller is on the steering committee and a site investigator for the REBIRTH trial. All other authors have reported they have no relationships relevant to the content of this paper to disclose., (© 2022 The Authors.)

Maternal mortality in the United States has been on the rise. Every year, about 700 women die from pregnancy-related complications. Cardiovascular disease (CVD) accounts for a large majority of pregnancy-related deaths driven by the lack of recognition and delays in diagnosis due to the overlap of normal pregnancy symptoms with those of CVD. Risk factors for CVD including race, advanced maternal age, hypertension, diabetes, obesity, socioeconomic status, and geographic region play an important role in CVD-related deaths. Several risk assessment models are available to stratify women with a known diagnosis of CVD. However, most women who die from CVD during pregnancy or the postpartum period do not have a prior diagnosis of CVD, and cardiomyopathy is an important contributor. The California Maternal Quality Care Collaborative (CMQCC) developed an algorithm to screen all pregnant and postpartum women to allow stratification into low or high risk for CVD. The algorithm has been validated in diverse patient populations. We propose universal CVD screening for all women in the antepartum and postpartum period to identify women at risk and to provide education and awareness for both patients and healthcare providers. This screening tool would work to reduce the increasing rates of severe maternal mortality and morbidity while having a significant impact on healthcare costs in the United States.

Severe hypertension in pregnancy is a medical emergency. Although expeditious treatment within 30 to 60 minutes is recommended to reduce the risk of maternal death or severe morbidity, treatment is often delayed by >1 hour. In this statement, we propose a quality metric that facilities can use to track their rates of timely treatment of severe hypertension. We encourage facilities to adopt this metric so that future reports from different facilities will be based on a uniform definition of timely treatment., (Copyright © 2021. Published by Elsevier Inc.)

The United States has the highest maternal mortality rates among developed countries, and cardiovascular disease is the leading cause. Therefore, the American Heart Association has a unique role in advocating for efforts to improve maternal health and to enhance access to and delivery of care before, during, and after pregnancy. Several initiatives have shaped the time course of major milestones in advancing maternal and reproductive health equity in the United States. There have been significant strides in improving the timeliness of data reporting in maternal mortality surveillance and epidemiological programs in maternal and child health, yet more policy reforms are necessary. To make a sustainable and systemic impact on maternal health, further efforts are necessary at the societal, institutional, stakeholder, and regulatory levels to address the racial and ethnic disparities in maternal health, to effectively reduce inequities in care, and to mitigate maternal morbidity and mortality. In alignment with American Heart Association's mission "to be a relentless force for longer, healthier lives," this policy statement outlines the inequities that influence disparities in maternal outcomes and current policy approaches to improving maternal health and suggests additional potentially impactful actions to improve maternal outcomes and ultimately save mothers' lives.

Objective: The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy., Study Design: This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 ( n  = 2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m 2 ) was classified as normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities., Results: The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births ( n  = 320). Unadjusted ORs were 1.32 (95% CI: 1.01-1.74) for women with overweight BMI and 2.03 (95% CI: 1.57-2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95-1.66) for overweight women and 1.38 (95% CI: 1.04-1.84) for women with obesity. The ORs suggested a dose-response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00., Conclusion: Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period., Key Points: · Pre-pregnancy obesity affects maternal health.. · Effects may extend to peripartum cardiomyopathy.. · The risk includes peripartum cardiomyopathy that emerges postpartum.., Competing Interests: None declared., (Thieme. All rights reserved.)

Importance: Prior studies on COVID-19 and pregnancy have reported higher rates of cesarean delivery and preterm birth and increased morbidity and mortality. Additional data encompassing a longer time period are needed., Objective: To examine characteristics and outcomes of a large US cohort of women who underwent childbirth with vs without COVID-19., Design, Setting, and Participants: This cohort study compared characteristics and outcomes of women (age ≥18 years) who underwent childbirth with vs without COVID-19 between March 1, 2020, and February 28, 2021, at 499 US academic medical centers or community affiliates. Follow-up was limited to in-hospital course and discharge destination. Childbirth was defined by clinical classification software procedural codes of 134-137. A diagnosis of COVID-19 was identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis of U07.1. Data were analyzed from April 1 to April 30, 2021., Exposures: The presence of a COVID-19 diagnosis using ICD-10., Main Outcomes and Measures: Analyses compared demographic characteristics, gestational age, and comorbidities. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, intensive care unit (ICU) admission, mechanical ventilation, and discharge status. Continuous variables were analyzed using t test, and categorical variables were analyzed using χ2., Results: Among 869 079 women, 18 715 (2.2%) had COVID-19, and 850 364 (97.8%) did not. Most women were aged 18 to 30 years (11 550 women with COVID-19 [61.7%]; 447 534 women without COVID-19 [52.6%]) and were White (8060 White women [43.1%] in the COVID-19 cohort; 499 501 White women (58.7%) in the non-COVID-19 cohort). There was no significant increase in cesarean delivery among women with COVID-19 (6088 women [32.5%] vs 273 810 women [32.3%]; P = .57). Women with COVID-19 were more likely to have preterm birth (3072 women [16.4%] vs 97 967 women [11.5%]; P < .001). Women giving birth with COVID-19, compared with women without COVID-19, had significantly higher rates of ICU admission (977 women [5.2%] vs 7943 women [0.9%]; odds ratio [OR], 5.84 [95% CI, 5.46-6.25]; P < .001), respiratory intubation and mechanical ventilation (275 women [1.5%] vs 884 women [0.1%]; OR, 14.33 [95% CI, 12.50-16.42]; P < .001), and in-hospital mortality (24 women [0.1%] vs 71 [<0.01%]; OR, 15.38 [95% CI, 9.68-24.43]; P < .001)., Conclusions and Relevance: This retrospective cohort study found that women with COVID-19 giving birth had higher rates of mortality, intubation, ICU admission, and preterm birth than women without COVID-19.

Cardiovascular disease (CVD) has surpassed the traditional causes of pregnancy-related mortality, including hemorrhage and thromboembolism in the United States. CVD accounts for ~15.5% of all pregnancy-related deaths. Pregnancy is a "natural cardiovascular stress test" for a woman. The physiological changes in the maternal hemodynamics that are geared to accommodate the growing needs of the fetal-placental unit may also lead to symptoms that are indistinguishable from those of CVD, especially in the third trimester of pregnancy. It is imperative that an obstetric provider is able to differentiate symptoms of normal pregnancy from those of a pathologic process.

Pregnancy in women with pregestational diabetes mellitus (type 1 and type 2) carries increased risks of both maternal and neonatal complications due to maternal hyperglycemia and underlying chronic conditions and comorbidities. To reduce the risk of pregnancy complications or to mitigate their effects, numerous interventions are recommended at various times during pregnancy. Since 2016, the Society for Maternal-Fetal Medicine has posted a Diabetes Antepartum Checklist on its website. An updated version of this checklist is presented here, along with suggestions for implementation into the standard antenatal care of patients with type 1 and type 2 diabetes mellitus., (Copyright © 2020. Published by Elsevier Inc.)

There are many organizations in the United States concerned with the improvement of patient safety and healthcare quality. In this overview, we provide a synopsis of the major entities whose work is relevant to maternal healthcare. For each organization, we summarize its mission, vision, major programs, and relationships with other entities. We include 13 entities with broad scope covering all types of healthcare; 9 organizations whose focus is maternal-child health; 6 women's health professional organizations with committees on patient safety, quality, or both; 12 organizations that offer accreditation, certification, or special distinction based on quality; and 5 organizations that rate, rank, or report quality metrics., (Copyright © 2020. Published by Elsevier Inc.)

Congenital heart defects are a leading cause of neonatal morbidity and mortality. Accurate prenatal diagnosis of congenital heart defects can reduce morbidity and mortality by improving prenatal care, facilitating predelivery pediatric cardiology consultation, and directing delivery to facilities with resources to manage the complex medical and surgical needs of newborns with congenital heart defects. Unfortunately, less than one half of congenital heart defect cases are detected prenatally, resulting in lost opportunities for counseling, shared decision-making, and delivery at an appropriate facility. Quality improvement initiatives to improve prenatal congenital heart defects detection depend on the ability to measure the rate of detection at the level of providers, facilities, or populations, but no standard metric exists for measuring the detection of congenital heart defects at any level. The need for such a metric was recognized at a Cooperative Workshop held at the 2016 Annual Meeting of the Society for Maternal-Fetal Medicine, which recommended the development of a quality metric to assess the rate of prenatal detection of clinically significant congenital heart defects. In this paper, we propose potential quality metrics to measure prenatal detection of critical congenital heart defects, defined as defects with a high rate of morbidity or mortality or that require surgery or tertiary follow-up. One metric is based on a retrospective approach, assessing whether postnatally diagnosed congenital heart defects had been identified prenatally. Other metrics are based on a prospective approach, assessing the sensitivity and specificity of prenatal diagnosis of congenital heart defects by comparing prenatal ultrasound findings with newborn findings. Potential applications, limitations, challenges, barriers, and value for both approaches are discussed. We conclude that future development of these metrics will depend on an expansion of the International Classification of Diseases system to include specific codes that distinguish fetal congenital heart defects from newborn congenital heart defects and on the development of record systems that facilitate the linkage of fetal records (in the maternal chart) with newborn records., (Copyright © 2020. Published by Elsevier Inc.)