The role of healthcare professionals in encouraging parents to see and hold their stillborn baby: a meta-synthesis of qualitative studies.

Background: Globally, during 2013 there were three million recorded stillbirths. Where clinical guidelines exist some recommend that professionals do not encourage parental contact. The guidance is based on quantitative evidence that seeing and holding the baby is not beneficial for everyone, but has been challenged by bereaved parents' organisations. We aim to inform future guideline development through a synthesis of qualitative studies reporting data relevant to the research question; how does the approach of healthcare professionals to seeing and holding the baby following stillbirth impact parents views and experiences? Methods/Findings: Using a predetermined search strategy of PubMed and PsychINFO we identified robust qualitative studies reporting bereaved parental views and/or experiences relating to seeing and holding their stillborn baby (final search 24 February, 2014). Eligible studies were English language, reporting parental views, with gestational loss >20weeks. Quality was independently assessed by three authors using a validated tool. We used meta-ethnographic techniques to identify key themes and a line of argument synthesis. We included 12 papers, representing the views of 333 parents (156 mothers, 150 fathers, and 27 couples) from six countries. The final themes were: "[Still]birth: Nature of care is paramount", "Real babies: Perfect beauties, monsters and spectres", and "Opportunity of a lifetime lost." Our line-of-argument synthesis highlights the contrast between all parents need to know their baby, with the time around birth being the only time memories can be made, and the variable ability that parents have to articulate their preferences at that time. Thus, we hypothesised that how health professionals approach contact between parents and their stillborn baby demands a degree of active management. An important limitation of this paper is all included studies originated from high income, westernised countries raising questions about the findings transferability to other cultural contexts. We do not offer new evidence to answer the question "Should parents see and hold their stillborn baby?", instead our findings advance understanding of how professionals can support parents to make appropriate decisions in a novel, highly charged and dynamic situation. Conclusions: Guidelines could be more specific in their recommendations regarding parental contact. The role of healthcare professionals in encouraging parents to see and hold their stillborn baby is paramount. Parental choice not to see their baby, apprehension, or uncertainty should be continuously revisited in the hours after birth as the opportunity for contact is fleeting and final

Molecular Physics of Elementary Processes relevant to Hypersonics: atom-molecule, molecule-molecule and atom-surface processes.

In the present chapter some prototype gas and gas-surface processes occurring within the hypersonic flow layer surrounding spacecrafts at planetary entry are discussed. The discussion is based on microscopic dynamical calculations of the detailed cross sections and rate coefficients performed using classical mechanics treatments for atoms, molecules and surfaces. Such treatment allows the evaluation of the efficiency of thermal processes (both at equilibrium and nonequilibrium distributions) based on state-to-state and state specific calculations properly averaged over the population of the initial states. The dependence of the efficiency of the considered processes on the initial partitioning of energy among the various degrees of freedom is discussed

Pathology of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a relatively rare non-resolving chronic liver disease, which mainly affects women. It is characterized by hypergammaglobulinemia, circulating autoantibodies, interface hepatitis on liver histology and a favourable response to immunosuppression. The putative mechanism for the development of autoimmune hepatitis is thought to be the interaction between genetic predisposition, environmental triggers and failure of the native immune system. AIH still remains a major diagnostic and therapeutic challenge, mainly because it is a very heterogeneous disease. Prompt and timely diagnosis is crucial since, if left untreated, AIH has a high mortality rate. Histological demonstration of hepatitis is required for the diagnosis of AIH and, therefore, liver biopsy is mandatory in the initial diagnostic work-up, before treatment. In this review, we summarize the histological features of AIH with the main aim of highlighting the most important clinical-pathological hallmarks useful in the routine diagnostic practice

Reductions in co-contraction following neuromuscular re-education in people with knee osteoarthritis

Background Both increased knee muscle co-contraction and alterations in central pain processing have been suggested to play a role in knee osteoarthritis pain. However, current interventions do not target either of these mechanisms. The Alexander Technique provides neuromuscular re-education and may also influence anticipation of pain. This study therefore sought to investigate the potential clinical effectiveness of the AT intervention in the management of knee osteoarthritis and also to identify a possible mechanism of action. Methods A cohort of 21 participants with confirmed knee osteoarthritis were given 20 lessons of instruction in the Alexander Technique. In addition to clinical outcomes EMG data, quantifying knee muscle co-contraction and EEG data, characterising brain activity during anticipation of pain, were collected. All data were compared between baseline and post-intervention time points with a further 15-month clinical follow up. In addition, biomechanical data were collected from a healthy control group and compared with the data from the osteoarthritis subjects. Results: Following AT instruction the mean WOMAC pain score reduced by 56% from 9.6 to 4.2 (P<0.01) and this reduction was maintained at 15 month follow up. There was a clear decrease in medial co-contraction at the end of the intervention, towards the levels observed in the healthy control group, both during a pre-contact phase of gait (p<0.05) and during early stance (p<0.01). However, no changes in pain-anticipatory brain activity were observed. Interestingly, decreases in WOMAC pain were associated with reductions in medial co-contraction during the pre-contact phase of gait. Conclusions: This is the first study to investigate the potential effectiveness of an intervention aimed at increasing awareness of muscle behaviour in the clinical management of knee osteoarthritis. These data suggest a complex relationship between muscle contraction, joint loading and pain and support the idea that excessive muscle co-contraction may be a maladaptive response in this patient group. Furthermore, these data provide evidence that, if the activation of certain muscles can be reduced during gait, this may lead to positive long-term clinical outcomes. This finding challenges clinical management models of knee osteoarthritis which focus primarily on muscle strengthening

Conservation actions for restoring the coastal lagoon habitats: Strategy and multidisciplinary approach of LIFE Lagoon Refresh

The Habitat Directive of European Union lists Costal Lagoons (habitat code 1150*) among priority habitats because they are in danger of disappearance. Natural ecosystems may recover from anthropogenic perturbations; however, the recovery can follow natural restoration or it can be redirected through ecological restoration by anthropogenic intervention. Accordingly, by collecting the available theoretical indications for restoration of estuarine and coastal areas, a methodological approach was detailed andit can be summarised into five issues: (i) Environmental context from which it began; (ii) Desired state to be achieved; (iii) Policies and socio-economic context; (iv) Typology of recovery and/or improvement of habitats and ecosystems; and (v) Methods for monitoring the impact of the project. The project strategy, management and measures of LIFE Lagoon Refresh were also presented and discussed, as a case study for the implementation of the multidisciplinary approach for restoration ecology in transitional waters. The project takes place in the northern Venice Lagoon (Italy), started in 2017 and it lasts 5 years. In the Venice Lagoon, since the 20th century, strong reductions of the typical salinity gradient of buffer areas between lagoon and mainland, and of reedbed extensions have occurred due to historic human interventions, with negative consequences on coastal lagoon habitats. To improve the conservation status of habitats and biodiversity of the area, the LIFE Lagoon Refresh project included several conservative actions, which are (i) the diversion of a freshwater flow from the Sile River into the lagoon; (ii) the restoration of intertidal morphology, through biodegradable structures; (iii) the reed and aquatic angiosperm transplantations with the involvement of local fishermen and hunters, and (iv) the reduction of hunting and fishing pressures in the intervention area. To achieve the restoration of the lagoon environment, the strategy of the project covered a combination of different aspects and tools, such as planning activities, through the involvement of local Institutions and communities; stakeholder's involvement to increase awareness of environment conservation and socioeconomic value improvement; an ecological engineering approach; numerical models as supporting tool for planning and managing of conservation actions; environmental monitoring performed before and after the conservation actions

A New Multi-Index Method for the Eutrophication Assessment in Transitional Waters: Large-Scale Implementation in Italian Lagoons

Eutrophication represents one of the most impacting threats for the ecological status and related ecosystem services of transitional waters; hence, its assessment plays a key role in the management of these ecosystems. A new multi-index method for eutrophication assessment, based on the ecological index MaQI (Macrophyte Quality Index), the trophic index TWQI (Transitional Water Quality Index), and physicochemical quality elements (sensu Dir. 2000/60/EC), was developed including both driver and impact indicators. The study presents a large-scale implementation of the method, which included more than 100 Italian lagoon sites, covering a wide variability of lagoon typologies and conditions. Overall, 35% of sites resulted in eutrophic status, 45% in mesotrophic, and 25% in oligotrophic status

Conservation actions for restoring the coastal lagoon habitats: Strategy and multidisciplinary approach of LIFE Lagoon Refresh

The Habitat Directive of European Union lists Costal Lagoons (habitat code 1150*) among priority habitats because they are in danger of disappearance. Natural ecosystems may recover from anthropogenic perturbations; however, the recovery can follow natural restoration or it can be redirected through ecological restoration by anthropogenic intervention. Accordingly, by collecting the available theoretical indications for restoration of estuarine and coastal areas, a methodological approach was detailed andit can be summarised into five issues: (i) Environmental context from which it began; (ii) Desired state to be achieved; (iii) Policies and socio-economic context; (iv) Typology of recovery and/or improvement of habitats and ecosystems; and (v) Methods for monitoring the impact of the project. The project strategy, management and measures of LIFE Lagoon Refresh were also presented and discussed, as a case study for the implementation of the multidisciplinary approach for restoration ecology in transitional waters. The project takes place in the northern Venice Lagoon (Italy), started in 2017 and it lasts 5 years. In the Venice Lagoon, since the 20th century, strong reductions of the typical salinity gradient of buffer areas between lagoon and mainland, and of reedbed extensions have occurred due to historic human interventions, with negative consequences on coastal lagoon habitats. To improve the conservation status of habitats and biodiversity of the area, the LIFE Lagoon Refresh project included several conservative actions, which are (i) the diversion of a freshwater flow from the Sile River into the lagoon; (ii) the restoration of intertidal morphology, through biodegradable structures; (iii) the reed and aquatic angiosperm transplantations with the involvement of local fishermen and hunters, and (iv) the reduction of hunting and fishing pressures in the intervention area. To achieve the restoration of the lagoon environment, the strategy of the project covered a combination of different aspects and tools, such as planning activities, through the involvement of local Institutions and communities; stakeholder’s involvement to increase awareness of environment conservation and socioeconomic value improvement; an ecological engineering approach; numerical models as supporting tool for planning and managing of conservation actions; environmental monitoring performed before and after the conservation actions

An economic evaluation of Alexander Technique lessons or acupuncture sessions for patients with chronic neck pain : A randomized trial (ATLAS)

OBJECTIVES: To assess the cost-effectiveness of acupuncture and usual care, and Alexander Technique lessons and usual care, compared with usual GP care alone for chronic neck pain patients. METHODS: An economic evaluation was undertaken alongside the ATLAS trial, taking both NHS and wider societal viewpoints. Participants were offered up to twelve acupuncture sessions or twenty Alexander lessons (equivalent overall contact time). Costs were in pounds sterling. Effectiveness was measured using the generic EQ-5D to calculate quality adjusted life years (QALYs), as well as using a specific neck pain measure-the Northwick Park Neck Pain Questionnaire (NPQ). RESULTS: In the base case analysis, incremental QALY gains were 0.032 and 0.025 in the acupuncture and Alexander groups, respectively, in comparison to usual GP care, indicating moderate health benefits for both interventions. Incremental costs were £451 for acupuncture and £667 for Alexander, mainly driven by intervention costs. Acupuncture was likely to be cost-effective (ICER = £18,767/QALY bootstrapped 95% CI £4,426 to £74,562) and was robust to most sensitivity analyses. Alexander lessons were not cost-effective at the lower NICE threshold of £20,000/QALY (£25,101/QALY bootstrapped 95% CI -£150,208 to £248,697) but may be at £30,000/QALY, however, there was considerable statistical uncertainty in all tested scenarios. CONCLUSIONS: In comparison with usual care, acupuncture is likely to be cost-effective for chronic neck pain, whereas, largely due to higher intervention costs, Alexander lessons are unlikely to be cost-effective. However, there were high levels of missing data and further research is needed to assess the long-term cost-effectiveness of these interventions

Lipid Accumulation in Hearts Transplanted From Nondiabetic Donors to Diabetic Recipients

Background: Early pathogenesis of diabetic cardiomyopathy (DMCM) may involve lipotoxicity of cardiomyocytes in the context of hyperglycemia. There are many preclinical studies of DMCM pathogenesis, but the human evidence is still poorly understood. Objectives: By using a nondiabetic mellitus (non-DM) heart transplanted (HTX) in diabetes mellitus (DM) recipients, this study conducted a serial study of human heart transplant recipients evaluating cardiac effects of diabetic milieu (hyperglycemia and insulin resistance) on lipotoxic-mediated injury. We evaluated cardiomyocyte morpho-pathology by seriated biopsies of healthy implanted hearts in DM recipients during 12-month follow-up from HTX. Because metformin reduces ectopic lipid accumulation, we evaluated the effects of the drug in a nonrandomized subgroup. Methods: The DMCM-AHEAD (Diabetes and Lipid Accumulation and Heart Transplant) prospective ongoing study (NCT03546062) evaluated 158 first HTX recipients (82 non-DM, 76 DM of whom 35 [46%] were receiving metformin). HTX recipients were undergoing clinical standard evaluation (metabolic status, echocardiography, coronary computed tomography angiography, and endomyocardial biopsies). Biopsies evaluated immune response, Oil Red-O staining, ceramide, and triacylglycerol levels. Lipotoxic factors and insulin resistance were evaluated by reverse transcriptase–polymerase chain reaction. Results: There was a significant early and progressive cardiomyocyte lipid accumulation in DM but not in non-DM recipients (p = 0.019). In the subgroup receiving metformin, independently from immunosuppressive therapy that was similar among groups, lipid accumulation was reduced in comparison with DM recipients not receiving the drug (hazard ratio: 6.597; 95% confidence interval: 2.516 to 17.296; p &lt; 0.001). Accordingly, lipotoxic factors were increased in DM versus non-DM recipients, and, relevantly, metformin use was associated with fewer lipotoxic factors. Conclusions: Early pathogenesis of human DMCM started with cardiomyocyte lipid accumulation following HTX in DM recipients. Metformin use was associated with reduced lipid accumulation independently of immunosuppressive therapy. This may constitute a novel target for therapy of DMCM

Lipid Accumulation in Hearts Transplanted From Nondiabetic Donors to Diabetic Recipients

Background: Early pathogenesis of diabetic cardiomyopathy (DMCM) may involve lipotoxicity of cardiomyocytes in the context of hyperglycemia. There are many preclinical studies of DMCM pathogenesis, but the human evidence is still poorly understood. Objectives: By using a nondiabetic mellitus (non-DM) heart transplanted (HTX) in diabetes mellitus (DM) recipients, this study conducted a serial study of human heart transplant recipients evaluating cardiac effects of diabetic milieu (hyperglycemia and insulin resistance) on lipotoxic-mediated injury. We evaluated cardiomyocyte morpho-pathology by seriated biopsies of healthy implanted hearts in DM recipients during 12-month follow-up from HTX. Because metformin reduces ectopic lipid accumulation, we evaluated the effects of the drug in a nonrandomized subgroup. Methods: The DMCM-AHEAD (Diabetes and Lipid Accumulation and Heart Transplant) prospective ongoing study (NCT03546062) evaluated 158 first HTX recipients (82 non-DM, 76 DM of whom 35 [46%] were receiving metformin). HTX recipients were undergoing clinical standard evaluation (metabolic status, echocardiography, coronary computed tomography angiography, and endomyocardial biopsies). Biopsies evaluated immune response, Oil Red-O staining, ceramide, and triacylglycerol levels. Lipotoxic factors and insulin resistance were evaluated by reverse transcriptase–polymerase chain reaction. Results: There was a significant early and progressive cardiomyocyte lipid accumulation in DM but not in non-DM recipients (p = 0.019). In the subgroup receiving metformin, independently from immunosuppressive therapy that was similar among groups, lipid accumulation was reduced in comparison with DM recipients not receiving the drug (hazard ratio: 6.597; 95% confidence interval: 2.516 to 17.296; p < 0.001). Accordingly, lipotoxic factors were increased in DM versus non-DM recipients, and, relevantly, metformin use was associated with fewer lipotoxic factors. Conclusions: Early pathogenesis of human DMCM started with cardiomyocyte lipid accumulation following HTX in DM recipients. Metformin use was associated with reduced lipid accumulation independently of immunosuppressive therapy. This may constitute a novel target for therapy of DMCM