Premarurity's voices : relevant themes and meanings in the communication between health professionals and patients

Orientadores: Rodolfo de Carvalho Pacagnella, Maria José Martins Duarte OsisDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: No mundo todo, a cada 10 bebês nascidos vivos, um nasce prematuro; no Brasil a prematuridade representa 12% dos nascimentos. O pré-natal é o único momento para avaliar riscos, antecipar situações ruins e prevenir ou reduzir desfechos adversos. E a primeira forma de prevenção ocorre por meio do diálogo em consulta: ouvindo, orientando e esclarecendo. Quando há uma interrupção abrupta da gestação, seus efeitos são traumáticos para todos os envolvidos, e as consequências de um parto pré-termo pode influenciar a saúde futura da criança comprometendo a vida de toda a família. Partindo do pressuposto de que as informações médicas sobre a prematuridade são negligenciadas durante o pré-natal, esse estudo buscou ouvir os pais de crianças nascidas prematuras e os profissionais de saúde que lidam com bebês prematuros e assim, compreender quais são essas lacunas e investigar seus significados. Método: Foi realizado um estudo exploratório com delineamento qualitativo utilizando a técnica de Grupos Focais. Para a formação dos Grupos Focais foram convidados os pais de recém-nascidos prematuros cujos filhos estavam internados na Unidade de Terapia Intensiva Neonatal e todos os profissionais de saúde que trabalhavam na mesma Unidade Intensiva durante o período do estudo. As reuniões foram realizadas com cada grupo separadamente, em datas diferentes. Todos os participantes receberam o termo de consentimento e após a assinatura e o aceite, iniciamos os debates a partir de perguntas disparadoras. Para adequado registro, os debates foram gravados. Foi feita análise temática de conteúdo, gerando categorias que se referiram às necessidades de informações e as lacunas na comunicação. Resultados: A principal questão trazida foi a ausência de informações médicas sobre a prematuridade. Durante o pré-natal não há orientações a respeito dos sinais e sintomas de alerta para o parto pré-termo mesmo nas pacientes de risco. Durante o trabalho de parto a comunicação entre as equipes que atuam juntas no Centro Obstétrico é pequena e as gestantes não recebem informações adequadas sobre sua saúde e de seus filhos. Tais problemas na comunicação erguem barreiras durante a internação do bebê na Unidade de Terapia Intensiva Neonatal que resultam na dificuldade de compreensão das condutas durante a internação e no sentimento de despreparo das mães no acompanhamento dos filhos após a alta hospitalar. Conclusão: Nossos achados apontam uma dissonância entre a percepção das mães de bebês prematuros e de profissionais de saúde quanto à comunicação acerca da prematuridade, gerando insegurança nas mães e distanciamento entre elas e as equipes de saúde. Essa falha na comunicação se mantém permeada por relações de poder e dificultada pelo processo atual de cuidado no pré-natal, parto e internação na Unidade de Terapia Intensiva NeonatalAbstract: Worldwide, for every 10 live-born babies, one is born prematurely. In Brazil, prematurity represents 12% of births. Prenatal care is an important moment to evaluate risks, and looking for conditions to prevent or reduce adverse outcomes. And dialogue in the consultation is crucial: with listening, and advice, and clarify any information. When there is sudden interruption of pregnancy, the effects are traumatic for all involved, and the consequences of prematurity can influence the future health of the child and compromising the life of entire family. Based on the assumption that medical information on prematurity is neglected during prenatal care, this study sought to listen to the parents of preterm infants and health professionals dealing with preterm infants and to understand what these gaps are and to investigate their meanings. Method: An exploratory study with a qualitative design using the Focal Groups technique. For the Focus Groups, the parents of premature newborns whose children were in the Neonatal Intensive Care Unit and all the health professionals who worked in the same Intensive Unit during the study period of the study. For meetings with the Focal Groups, we reserve one room to make sure the privacy of the topics covered. The meetings were held with each group separately and on different dates. All the participants received consent in participate and after signing and accepting the consent form, we began the debates from startling questions. The discussions were recorded. The thematic content analysis involved generating categories that referred to information needs and communication gaps. Results: The main question was the lack of medical information on prematurity. During the prenatal period, there is no information about warning signs and symptoms or risks for preterm delivery. During childbirth there is no communication between the teams that work together at the delivery room and pregnant women do not receive adequate information about their health and their child. Such failures create barriers in communication during hospitalization in neonatal intensive care unit that resulted in the misunderstandings during hospitalization and the feeling of unpreparedness of the mothers in the follow-up of their children after hospital discharge. Conclusion: Our findings point out to a dissonance between the perception of mothers of preterm infants and health professionals regarding the communication about prematurity, generating insecurity for the mothers and distancing between them and health professionals. This lack of communication is permeated by power in relationships and by the current process of prenatal care, delivery and hospitalization in the Neonatal Intensive Care UnitMestradoSaúde Materna e PerinatalMestra em Ciências da SaúdeCAPE

The food patterns of a multicenter cohort of Brazilian nulliparous pregnant women

Assessment of human nutrition is a complex process, in pregnant women identify dietary patterns through mean nutrient consumption can be an opportunity to better educate women on how to improve their overall health through better eating. This exploratory study aimed to identify a posteriori dietary patterns in a cohort of nulliparous pregnant women. The principal component analysis (PCA) technique was performed, with Varimax orthogonal rotation of data extracted from the 24-h dietary recall, applied at 20 weeks of gestation. We analysed 1.145 dietary recalls, identifying five main components that explained 81% of the dietary pattern of the sample. Dietary patterns found were: Obesogenic, represented by ultra-processed foods, processed foods, and food groups rich in carbohydrates, fats and sugars; Traditional, most influenced by natural, minimally processed foods, groups of animal proteins and beans; Intermediate was similar to the obesogenic, although there were lower loads; Vegetarian, which was the only good representation of fruits, vegetables and dairy products; and Protein, which best represented the groups of proteins (animal and vegetable). The obesogenic and intermediate patterns represented over 37% of the variation in food consumption highlighting the opportunity to improve maternal health especially for women at first mothering

Profile of calories and nutrients intake in a Brazilian multicenter study of nulliparous women

Objective: To assess the calorie intake and nutritional content of the maternal diet in regions with different culinary traditions and typical foods, and to understand the nutritional profile so as to provide information about the consumption of this population and promote maternal and perinatal health. Methods: From a cohort of 1145 pregnant women with diverse socio-backgrounds we analyzed the dietary characteristics profile according to three guidelines and compared the differences between regions of Brazil. Results: Women from the northeast had the lowest level of income, occupation, education, and age (P < 0.001). Intakes of unprocessed/minimally processed foods and processed foods were more prevalent in women from the northeast than in southern/southeastern women (P < 0.001). The consumption of dairy products and vegetables was less than the recommended intake, with lower intake in southern/southeastern women (P < 0.001). This study showed a lower consumption of dairy and vegetables, with a shortfall of vitamins K and D, iron, calcium, folate, magnesium, and chromium from natural and fortified foods. We observed a greater consumption of unprocessed or minimally processed food in women from the northeast of Brazil. Conclusion: Our findings indicate the importance of differentiating the source of calorie intake between regional nutritional guidance and the diversity of local cuisine

Proposal of MUAC as a fast tool to monitor pregnancy nutritional status : results from a cohort study in Brazil

Objective: In Brazil, although the assessment of maternal nutritional status is recommended using body mass index (BMI), this is only possible in settings adequately prepared. Midupper arm circumference (MUAC) is another biological variable identified as a tool for rapid assessment of nutritional status that is correlated with BMI. Therefore, we aim to surrogate BMI by MUAC cut-offs for rapid screening of maternal nutritional status starting at midpregnancy. Design: Analysis of the multicentre cohort study entitled ‘Preterm SAMBA’ using an approach of validation of diagnostic test. Setting: Outpatient prenatal care clinics from five tertiary maternity hospitals from three different Brazilian regions. Participants: 1165 pregnant women attending prenatal care services from 2015 to 2018 and with diverse ethnic characteristics who were enrolled at midpregnancy and followed in three visits at different gestational weeks. Primary and secondary outcome measures: Sensitivity, specificity, positive and negative predictive values, likelihood ratio and accuracy of MUAC being used instead of BMI for the assessment of nutritional status of women during pregnancy. Results: We found a strong correlation between MUAC and BMI, in the three set points analysed (r=0.872, 0.870 and 0.831, respectively). Based on BMI categories of nutritional status, we estimated the best MUAC cut-off points, finding measures according to each category: underweight 30.15 cm (19–21 weeks), >30.60 cm (27–29 weeks) and >30.25 cm (37–39 weeks) per gestational week. Therefore, we defined as adequate between 25.75–28.10 cm (19–21 weeks), 25.75–28.70 cm (27–29 weeks) and 25.75–29.45 cm (37–39 weeks) of MUAC. Conclusion: We conclude that MUAC can be useful as a surrogate for BMI as a faster screening of nutritional status in pregnant women

Head circumference as an epigenetic risk factor for maternal nutrition

Nutrition indicators for malnutrition can be screened by many signs such as stunting, underweight or obesity, muscle wasting, and low caloric and nutrients intake. Those deficiencies are also associated with low socioeconomic status. Anthropometry can assess nutritional status by maternal weight measurements during pregnancy. However, most studies have focused primarily on identifying changes in weight or Body Mass Index (BMI), and their effects on neonatal measures at present time. Whereas head circumference (HC) has been associated with nutrition in the past. When the mother was exposed to poor nutrition and unfavorable social conditions during fetal life, it was hypothesized that the intergenerational cycle was potentially mediated by epigenetic mechanisms. To investigate this theory, maternal head circumference (MHC) was associated with neonatal head circumference (NHC) in pregnant women without preexisting chronic conditions, differentiated by sociodemographic characteristics. A multiple linear regression model showed that each 1 cm-increase in MHC correlated with a 0.11 cm increase in NHC (β95% CI 0.07 to 0.15). Notwithstanding, associations between maternal and neonatal anthropometrics according to gestational age at birth have been extensively explained. Path analysis showed the influence of social status and the latent variable was socioeconomic status. A model of maternal height and head circumference was tested with effects on neonatal HC. The social variable lacked significance to predict neonatal HC in the total sample (p = 0.212) and in the South/Southeast (p = 0.095), in contrast to the Northeast (p = 0.047). This study highlights the potential intergenerational influence of maternal nutrition on HC, suggesting that maternal nutrition may be more relevant in families with major social vulnerability

Large expert-curated database for benchmarking document similarity detection in biomedical literature search

Document recommendation systems for locating relevant literature have mostly relied on methods developed a decade ago. This is largely due to the lack of a large offline gold-standard benchmark of relevant documents that cover a variety of research fields such that newly developed literature search techniques can be compared, improved and translated into practice. To overcome this bottleneck, we have established the RElevant LIterature SearcH consortium consisting of more than 1500 scientists from 84 countries, who have collectively annotated the relevance of over 180 000 PubMed-listed articles with regard to their respective seed (input) article/s. The majority of annotations were contributed by highly experienced, original authors of the seed articles. The collected data cover 76% of all unique PubMed Medical Subject Headings descriptors. No systematic biases were observed across different experience levels, research fields or time spent on annotations. More importantly, annotations of the same document pairs contributed by different scientists were highly concordant. We further show that the three representative baseline methods used to generate recommended articles for evaluation (Okapi Best Matching 25, Term Frequency-Inverse Document Frequency and PubMed Related Articles) had similar overall performances. Additionally, we found that these methods each tend to produce distinct collections of recommended articles, suggesting that a hybrid method may be required to completely capture all relevant articles. The established database server located at https://relishdb.ict.griffith.edu.au is freely available for the downloading of annotation data and the blind testing of new methods. We expect that this benchmark will be useful for stimulating the development of new powerful techniques for title and title/abstract-based search engines for relevant articles in biomedical research.Peer reviewe

Increased serum miR-193a-5p during non-alcoholic fatty liver disease progression: diagnostic and mechanistic relevance

Background & Aims: Serum microRNAs (miRNAs) levels are known to change in non-alcoholic fatty liver disease (NAFLD) and may serve as useful biomarkers. This study aimed to profile miRNAs comprehensively at all NAFLD stages.Methods: We profiled 2,083 serum miRNAs in a discovery cohort (183 NAFLD cases representing the complete NAFLD spectrum and 10 population controls). MiRNA libraries generated by HTG EdgeSeq were sequenced by Illumina NextSeq. Selected serum miRNAs were profiled in 372 additional NAFLD cases and 15 population controls by quantitative reverse transcriptase-polymerase chain reaction.Results: Levels of 275 miRNAs differed between cases and population controls. Fewer differences were seen within individual NAFLD stages but miR-193a-5p consistently the showed increased levels in all comparisons. Relative to NAFL/NASH with mild fibrosis (stage 0/1), three miRNAs (miR-193a-5p, miR-378d and miR378d) were increased in cases with NASH and clinically significant fibrosis (stage 2-4), seven (miR193a-5p, miR-378d, miR-378e, miR-320b, c, d & e) increased in cases with NAFLD Activity Score (NAS) 5-8 compared with lower NAS, and three (miR-193a-5p, miR-378d, miR-378e) increased but one (miR-19b-3p) decreased in steatosis, activity, and fibrosis "activity" (SAF-A) score 2-4 compared with lower SAF-A. The significant findings for miR-193a-5p were replicated in the additional NAFLD cohort. Studies in Hep G2 cells showed that following palmitic acid treatment, miR-193a-5p expression decreased significantly. Gene targets for miR-193a-5p were investigated in liver RNAseq data for a case subgroup (n=80); liver GPX8 levels correlated positively with serum miR-193a-5p. Conclusions: Serum miR-193a-5p levels correlate strongly with NAFLD activity grade and fibrosis stage. MiR-193a-5p may have a role in the hepatic response to oxidative stress and is a potential clinically tractable circulating biomarker for progressive NAFLD

A randomized controlled trial on the use of pessary plus progesterone to prevent preterm birth in women with short cervical length (P5 trial)

Background: Preterm birth is the leading cause of mortality and disability in newborn and infants. Having a short cervix increases the risk of preterm birth, which can be accessed by a transvaginal ultrasound scan during the second trimester. In women with a short cervix, vaginal progesterone and pessary can both reduce this risk, which progesterone more established than cervical pessary. The aim of this study is to compare the use of vaginal progesterone alone versus the association of progesterone plus pessary to prevent preterm birth in women with a short cervix. Methods: This is a pragmatic open-label randomized controlled trial that will take place in 17 health facilities in Brazil. Pregnant women will be screened for a short cervix with a transvaginal ultrasound between 18 0/7 until 22 6/7 weeks of gestational age. Women with a cervical length below or equal to 30mm will be randomized to the combination of progesterone (200 mg) and pessary or progesterone (200 mg) alone until 36 + 0 weeks. The primary outcome will be a composite of neonatal adverse events, to be collected at 10 weeks after birth. The analysis will be by intention to treat. The sample size is 936 women, and a prespecified subgroup analysis is planned for cervical length (= 25 mm). Categorical variables will be expressed as a percentage and continuous variables as mean with standard deviation. Time to delivery will be assessed with Kaplan-Meier analysis and Cox proportional hazard analysis. Discussion: In clinical practice, the combination of progesterone and pessary is common however, few studies have studied this association. The combination of treatment might act in both the biochemical and mechanical routes related to the onset of preterm birth. Trial registration: Brazilian Clinical Trial Registry (ReBec) RBR-3t8prz, UTN: U1111–1164-2636, 2014/11/18.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Bill & Melinda Gates Foundation [OPP1107597], the Brazilian Ministry of Health, and the Brazilian National Council for Scientific and Technological Development (CNPq) [401615/20138]

Maternal Nutrition Status Associated with Pregnancy-Related Adverse Outcomes

Although maternal nutrition has an impact on fetal development and gestational outcome, tracking maternal nutrition in outpatient practice is still complex and involves proper technical capacitation in this area. Nevertheless, the association between nutritional variables may broaden the ability to predict the occurrence of gestational disorders and prevention management. We aimed to identify factors that could indicate the probability of adverse outcomes in mid-pregnancy. From a cohort of 1165 nulliparous pregnant women without any previous disease, the nutritional status was assessed by body mass index (BMI) and mid-upper arm circumference (MUAC), associated with dietary patterns and sociodemographic characteristics. Two predictive models with nutritional status for screening the occurrence of adverse outcomes of preterm birth, gestational diabetes mellitus, small-for-gestational-age newborns and preeclampsia were developed. The odds of adverse outcomes were higher in non-white (p &lt; 0.05) obese women and with high protein consumption. There was no significant difference between the models, with an overall accuracy of 63% for both models and a probability of success in predicting adverse outcomes (BMI = 61%, MUAC = 52%). This study of Brazilian pregnant nulliparous women offers two possible options for early tracking of adverse gestational outcomes that should be further externally validated