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Background: In neonatal chylothorax, thoracic lymphatic drainage is ineffective. The resultant effusions often require drainage, leading to a loss of immune components. Affected infants can be managed with formula or defatted human milk feedings low in long-chain triglycerides to decrease lymph production. We hypothesized that there is no significant difference in the immunological profile or antibacterial effect of full-fat and defatted human milk., Methods: Milk from lactating mothers was divided into 1 aliquot that was defatted via centrifugation with the full-fat aliquot as control. Macronutrient content was analyzed with mid-infrared spectroscopy. Flow cytometry was used to measure immune cell populations. Lactoferrin, lysozyme, immunoglobulin (Ig)A, and IgG values were determined using enzyme-linked immunosorbent assay. The antibacterial properties were determined by inoculating paired full-fat and defatted milk samples with Escherichia coli or Streptococcus pneumoniae bacteria and performing colony counts., Results: Compared with full-fat milk, defatted milk demonstrated decreased total energy and fat and increased carbohydrate concentrations. Defatted milk demonstrated a significant decrease in all immune cell populations. There was no difference in IgA, IgG, lysozyme, or lactoferrin concentrations. Both aliquots demonstrated equivalent growth inhibition of E. coli and S. pneumoniae., Conclusions: Unexpectedly, defatted human milk contained significantly less leukocytes than full-fat milk. IgA, IgG, lysozyme, and lactoferrin concentrations were preserved. The ability of defatted milk to inhibit bacterial growth was unaffected, suggesting that the antibacterial benefits of human milk remain after the defatting process. Further investigation regarding the clinical effect of leukocyte loss in defatted milk is warranted., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Background: A key reason for premature cessation of breastfeeding is inadequate support from healthcare providers. Most physicians and nurses do not feel confident in their ability to support families with breastfeeding initiation or maintenance. Increasing health professional confidence in clinical lactation skills is key to improving maternal and child health outcomes. High-fidelity (realistic) simulators encourage learner engagement, resulting in increased clinical skills competency, confidence, and transfer to patient care. Lactation educators teach with low-fidelity cloth and single breast models. There are no high-fidelity breast simulators for health professional education in clinical lactation. DEVELOPMENT AND EVALUATION OF A HIGH-FIDELITY LACTATION SIMULATION MODEL: In this commentary we describe the development of a high-fidelity Lactation Simulation Model (LSM) and how physician residents, nurse-midwifery students, and clinical lactation experts provided feedback on LSM prototypes., Limitations: The user-testing described in this commentary does not represent comprehensive validation of the LSM due to small sample sizes and the significant conflict of interest., Conclusion: For breastfeeding rates to improve, mothers need support from their nurses, midwives, pediatricians, obstetricians and gynecologists, and all healthcare staff who interact with pregnant and lactating women. Clinical education with high-fidelity breastfeeding simulators could be the ideal learning modality for trainees and hospital staff to build confidence in clinical lactation skills. The ability of a high-fidelity breastfeeding simulator to increase a learner's lactation knowledge and psychomotor skills acquisition, retention, and transfer to patient care still needs to be tested.

Background: Postpartum mothers express and store breast milk using a hospital-grade pump and manufacturer-specific kit (flanges, bottles, tubing, valves, and membranes). After hospital discharge, mothers may attempt to interchange kits from different manufacturers. The objective of this study is to determine whether pump performance is affected by the use of a different manufacturer's kit. Materials and Methods: Suction pressure was tested using kits and six pumps from three manufacturers (Ameda, Medela, and Spectra). Pump settings (speed and vacuum strength) simulated maximum, minimum, and commonly used median settings. Suction pressure (mmHg) was measured using an analog gauge and repeated six times for each pump-kit combination. Measurements were compared using repeated measures analysis of covariance (ANCOVA) to determine whether kit was an independent predictor of suction pressure. Results: The kit type was a significant independent predictor ( p  < 0.05) of suction pressure for all at medium vacuum strength and many at maximum and minimum vacuum strengths. Upon further analysis interchanging kits resulted in both significantly increased and decreased suction pressures compared to the manufacturer-specific kit. Conclusion: Breast pump kits generate variable suction pressures when interchanged between pumps from different manufacturers. Interchanging combinations of kits and breast pumps could potentially lead to low milk expression due to ineffective suction pressure or increased discomfort from excessive pressure. The results of this study emphasize the importance of maternal education regarding the use of manufacturer-specific kits and breast pumps.

Optimal glycaemic control before and during pregnancy improves both maternal and fetal outcomes. This article summarizes the recently published guidelines on the management of glycaemic control in pregnant women with diabetes on obstetric wards and delivery units produced by the Joint British Diabetes Societies for Inpatient Care and available in full at www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. Hyperglycaemia following steroid administration can be managed by variable rate intravenous insulin infusion (VRIII) or continuous subcutaneous insulin infusion (CSII) in women who are willing and able to safely self-manage insulin dose adjustment. All women with diabetes should have capillary blood glucose (CBG) measured hourly once they are in established labour. Those who are found to be higher than 7 mmol/l on two consecutive occasions should be started on VRIII. If general anaesthesia is used, CBG should be monitored every 30 min in the theatre. Both the VRIII and CSII rate should be reduced by at least 50% once the placenta is delivered. The insulin dose needed after delivery in insulin-treated Type 2 and Type 1 diabetes is usually 25% less than the doses needed at the end of first trimester. Additional snacks may be needed after delivery especially if breastfeeding. Stop all anti-diabetes medications after delivery in gestational diabetes. Continue to monitor CBG before and 1 h after meals for up to 24 h after delivery to pick up any pre-existing diabetes or new-onset diabetes in pregnancy. Women with Type 2 diabetes on oral treatment can continue to take metformin after birth., (© 2018 Diabetes UK.)

Objectives: To compare the cost-effectiveness (CE) of the National Institute for Health and Care Excellence (NICE) 2015 and the WHO 2013 diagnostic thresholds for gestational diabetes mellitus (GDM)., Setting: The analysis was from the perspective of the National Health Service in England and Wales., Participants: 6221 patients from four of the Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study centres (two UK, two Australian), 6308 patients from the Atlantic Diabetes in Pregnancy study and 12 755 patients from UK clinical practice., Primary and Secondary Outcome Measures Planned: The incremental cost per quality-adjusted life year (QALY), net monetary benefit (NMB) and the probability of being cost-effective at CE thresholds of £20 000 and £30 000 per QALY., Results: In a population of pregnant women from the four HAPO study centres and using NICE-defined risk factors for GDM, diagnosing GDM using NICE 2015 criteria had an NMB of £239 902 (relative to no treatment) at a CE threshold of £30 000 per QALY compared with WHO 2013 criteria, which had an NMB of £186 675. NICE 2015 criteria had a 51.5% probability of being cost-effective compared with the WHO 2013 diagnostic criteria, which had a 27.6% probability of being cost-effective (no treatment had a 21.0% probability of being cost-effective). For women without NICE risk factors in this population, the NMBs for NICE 2015 and WHO 2013 criteria were both negative relative to no treatment and no treatment had a 78.1% probability of being cost-effective., Conclusion: The NICE 2015 diagnostic criteria for GDM can be considered cost-effective relative to the WHO 2013 alternative at a CE threshold of £30 000 per QALY. Universal screening for GDM was not found to be cost-effective relative to screening based on NICE risk factors., Competing Interests: Competing interests: MJAM, KS, AD and RWB received travel expenses from the National Institute for Health and Care Excellence for attending clinical guideline development meetings., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: In patients with type 1 diabetes who are not pregnant, closed-loop (automated) insulin delivery can provide better glycemic control than sensor-augmented pump therapy, but data are lacking on the efficacy, safety, and feasibility of closed-loop therapy during pregnancy., Methods: We performed an open-label, randomized, crossover study comparing overnight closed-loop therapy with sensor-augmented pump therapy, followed by a continuation phase in which the closed-loop system was used day and night. Sixteen pregnant women with type 1 diabetes completed 4 weeks of closed-loop pump therapy (intervention) and sensor-augmented pump therapy (control) in random order. During the continuation phase, 14 of the participants used the closed-loop system day and night until delivery. The primary outcome was the percentage of time that overnight glucose levels were within the target range (63 to 140 mg per deciliter [3.5 to 7.8 mmol per liter])., Results: The percentage of time that overnight glucose levels were in the target range was higher during closed-loop therapy than during control therapy (74.7% vs. 59.5%; absolute difference, 15.2 percentage points; 95% confidence interval, 6.1 to 24.2; P=0.002). The overnight mean glucose level was lower during closed-loop therapy than during control therapy (119 vs. 133 mg per deciliter [6.6 vs. 7.4 mmol per liter], P=0.009). There were no significant differences between closed-loop and control therapy in the percentage of time in which glucose levels were below the target range (1.3% and 1.9%, respectively; P=0.28), in insulin doses, or in adverse-event rates. During the continuation phase (up to 14.6 additional weeks, including antenatal hospitalizations, labor, and delivery), glucose levels were in the target range 68.7% of the time; the mean glucose level was 126 mg per deciliter (7.0 mmol per liter). No episodes of severe hypoglycemia requiring third-party assistance occurred during either phase., Conclusions: Overnight closed-loop therapy resulted in better glucose control than sensor-augmented pump therapy in pregnant women with type 1 diabetes. Women receiving day-and-night closed-loop therapy maintained glycemic control during a high proportion of the time in a period that encompassed antenatal hospital admission, labor, and delivery. (Funded by the National Institute for Health Research and others; Current Controlled Trials number, ISRCTN71510001.).

Left ventricular non-compaction (LVNC) is a rare form of cardiomyopathy. This case reviews a woman with familial LVNC (EF 45%, NYHA class I, evidence of non-sustained ventricular tachycardia pre-pregnancy) who had significant decompensation with heart failure in the third trimester that required early delivery. Deterioration in symptoms and LV function 7 days after delivery required further hospitalization and aggressive treatment. Suppression of lactation with bromocriptine, together with standard heart failure management, has allowed recovery and return to full activities and work. Acknowledged adverse risk factors in LVNC are considered, and pre-pregnancy risk assessment is reviewed. There is no specific treatment for LVNC in pregnancy besides the usual management of dilated cardiomyopathy. This is the ninth case report of LVNC in pregnancy reported in the literature.

Objective: Anal incontinence occurs as a result of damage to pelvic floor and the anal sphincter. In women, vaginal delivery has been recognized as the primary cause. To date, figures quoted for overt third degree anal sphincter tear vary between 0% and 26.9% of all vaginal deliveries and the prevalence of anal incontinence following primary repair vary between 15% and 61%. Our aim was to analyse the long-term (minimum 10 years post primary repair) anorectal function and quality of life in a cohort of women who suffered a third degree tear (Group 1) and compare the results with a cohort of women who underwent an uncomplicated vaginal delivery (Group 2) or an elective caesarean delivery (Group 3)., Method: In all, 107 patients who suffered a third degree tear between 1981 and 1993 were contacted with a validated questionnaire. The two control groups comprised of 125 patients in each category. Those who responded to the questionnaire were invited for anorectal physiology studies and endoanal ultrasound., Results: Of the total number contacted, 54, 71 and 54 women from the three groups returned the completed questionnaire. In the three groups, a total of 28 (53%), 13 (19%) and six (11%) complained of anal incontinence (P < 0.0001) respectively. Comparison of quality of life scores between the groups showed a poorer quality of life in those who suffered a tear (P < 0.0001). In addition, in spite of primary repair, 13 (59%) patients in group 1 showed a persistent sphincter defect compared to one (4%) occult defect in Group 2 and none in Group 3., Conclusion: Our study indicates that long-term results of primary repair are not encouraging. It therefore emphasizes the importance of primary prevention and preventing further sphincter damage in those who have already suffered an injury (during subsequent deliveries).

Background: Anal pressure vectography is an anorectal physiology study that evaluates the radial pressures in the anal canal from which a symmetry index that indicates the anatomical integrity of the anal sphincter can be calculated. However, there are conflicting opinions of its validity. Since endoanal ultrasonography (EAUS) has been recognized as the gold standard for detecting anal sphincter disruption, the aim of this pilot study was to observe whether a vector symmetry index (VSI) determined at the level of injury shown in EAUS has a better sensitivity than the overall VSI in detecting anal sphincter disruption., Methods: A group of 11 women in whom EAUS had shown defects in both the internal and the external anal sphincters underwent anorectal manometry using a water-perfused vector manometry catheter, and the overall VSI and the VSI at the level of sphincter disruption (shown on EAUS) were calculated., Results: Overall VSI at rest indicated internal sphincter injury in 7 women (64%) but the VSI at the level of disruption indicated internal sphincter injury in all 11 women (100%, p=0.0137). Similarly, the overall VSI at squeeze indicated external sphincter injury in 6 women (55%), but the VSI at the level of disruption indicated external sphincter injury in 10 women (91%, p=0.0049)., Conclusions: Our pilot study showed that EAUS and VSI are equally sensitive in diagnosing a localized anal sphincter defect, provided a segment-for-segment comparison is carried out.

Nitric oxide (NO) is a vasodilator produced from L-arginine (L-Arg) by NO synthase (NOS). Gene therapy for hypertensive disorders has been proposed using the inducible isoform of NOS (iNOS). L-Arg also can be metabolized to urea and L-ornithine (L-Orn) by arginase, and L-Orn can be metabolized to proline and/or polyamines, which are vital for cellular proliferation. To determine the effect of iNOS gene transfer on arginase, we transfected bovine pulmonary arterial endothelial cells (bPAEC) with an adenoviral vector containing the gene for iNOS (AdiNOS). As expected, NO production in AdiNOS bPAEC was substantially greater than in control bPAEC. Although urea production was significantly less in the AdiNOS bPAEC than in the control bPAEC, despite similar levels of arginase I protein, AdiNOS transfection of bPAEC had no effect on the uptake of L-Arg. Inhibiting NO production with Nomega-nitro-L-arginine methyl ester increased urea production, and inhibiting urea production with L-valine increased nitrite production, in AdiNOS bPAEC. The addition of L-Arg to the medium increased urea production by AdiNOS bPAEC in a concentration-dependent manner. Thus, in these iNOS-transfected bPAEC, the transfected iNOS and native arginase compete for a common intracellular pool of L-Arg. This competition for substrate resulted in impaired proliferation in the AdiNOS-transfected bPAEC. These findings suggest that the use of iNOS gene therapy for pulmonary hypertensive disorders may not only be beneficial through NO-mediated pulmonary vasodilation but also may decrease vascular remodeling by limiting L-Orn production by native arginase.

Objective: To assess the distribution of cord blood insulin in an unselected population, and examine its relation to birthweight centiles., Setting: District General Hospital in Nottinghamshire., Subjects: 209 unselected singleton births., Mean Outcome Measure: Cord blood insulin; cord blood C-peptide; birthweight centiles., Results: Hyperinsulinaemic babies (greater than 97th centile for cord insulin) were found at all birthweight centiles. 15% of high birthweight babies were hyperinsulinaemic. For low birthweight babies, the distribution of cord insulin/C-peptide was skewed indicating a high number of low values. Hypoinsulinaemic babies were present up to the 50th centile for birthweight., Conclusions: Abnormalities of fetal insulinisation may be found in babies of all birthweights.

Survival and cold hardiness declined gradually when cold-hardened Fredrick winter wheat (Triticum aestivum L.) was maintained at -6 degrees C for several weeks. Moisture content of crown and root tissue did not change significantly during this period. Uptake of O(2) and accumulation of (86)Rb by root tissue declined abruptly upon exposure to -6 degrees C, whereas a concomitant negative effect of freezing on these metabolic processes was not observed in crown tissue. Electron spin resonance spectroscopic analysis of microsomal membrane preparations from crown tissue revealed no evidence of gross changes in the physical properties of the bulk lipids even when seedlings were killed. The results provide biochemical evidence that seedling damage due to prolonged exposure to a mild freezing stress is due to disruption of key metabolic process in the root while cells within the crown remain viable.