A Randomized Controlled Trial of Innovative Postpartum Care Model for Mother-Baby Dyads

Objective

To evaluate the efficacy, safety, and maternal satisfaction of a newly established integrative postpartum community-based clinic providing comprehensive support for mothers during the first month after discharge from the hospital. Our primary interests were breastfeeding rates, readmission and patient satisfaction.

Methods

A randomized controlled trial was conducted in Ottawa, Canada, where 472 mothers were randomized via a 1:2 ratio to either receive standard of care (n = 157) or to attend the postpartum breastfeeding clinic (n = 315). Outcome data were captured through questionnaires completed by the participants at 2, 4, 12 and 24 weeks postpartum. Unadjusted and adjusted logistic regression models were conducted to determine the effect of the intervention on exclusive breastfeeding at 12 weeks (primary outcome). Secondary outcomes included breastfeeding rate at 2, 4 and 24 weeks, breastfeeding self-efficacy scale, readmission rate, and satisfaction score.

Results

More mothers in the intervention group (n = 195, 66.1%) were exclusively breastfeeding at 12 weeks compared to mothers in the control group (n = 81, 60.5%), however no statistically significant difference was observed (OR = 1.28; 95% CI:0.84–1.95)). The rate of emergency room visits at 2 weeks for the intervention group was 11.4% compared to the standard of care group (15.2%) (OR = 0.69; 95% CI: 0.39–1.23). The intervention group was significantly more satisfied with the overall care they received for breastfeeding compared to the control group (OR = 1.96; 95% CI: 3.50–6.88)).

Conclusion

This new model of care did not significantly increase exclusive breastfeeding at 12 weeks. However, there were clinically meaningful improvements in the rate of postnatal problems and satisfaction that support this new service delivery model for postpartum care. A community-based multidisciplinary postpartum clinic is feasible to implement and can provide appropriate and highly satisfactory care to mother-baby dyads. This model of care may be more beneficial in a population that is not already predisposed to breastfeed.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT02043119","term_id":"NCT02043119"}}NCT02043119     

Predicting low testosterone in aging men: a systematic review

Background:Physicians diagnose and treat suspected hypogonadism in older men by extrapolating from the defined clinical entity of hypogonadism found in younger men. We conducted a systematic review to estimate the accuracy of clinical symptoms and signs for predicting low testosterone among aging men.Methods:We searched the MEDLINE and Embase databases (January 1966 to July 2014) for studies that compared clinical features with a measurement of serum testosterone in men. Three of the authors independently reviewed articles for inclusion, assessed quality and extracted data.Results:Among 6053 articles identified, 40 met the inclusion criteria. The prevalence of low testosterone ranged between 2% and 77%. Threshold testosterone levels used for reference standards also varied substantially. The summary likelihood ratio associated with decreased libido was 1.6 (95% confidence interval [CI] 1.3–1.9), and the likelihood ratio for absence of this finding was 0.72 (95% CI 0.58–0.85). The likelihood ratio associated with the presence of erectile dysfunction was 1.5 (95% CI 1.3–1.8) and with absence of erectile dysfunction was 0.83 (95% CI 0.76–0.91). Of the multiple-item instruments, the ANDROTEST showed both the most favourable positive likelihood ratio (range 1.9–2.2) and the most favourable negative likelihood ratio (range 0.37–0.49).Interpretation:We found weak correlation between signs, symptoms and testosterone levels, uncertainty about what threshold testosterone levels should be considered low for aging men and wide variation in estimated prevalence of the condition. It is therefore difficult to extrapolate the method of diagnosing pathologic hypogonadism in younger men to clinical decisions regarding age-related testosterone decline in aging men.Male hypogonadism is defined as the presence of low serum testosterone and spermatozoa levels, accompanied by clinical signs and symptoms.¹ The Endocrine Society divides the symptoms and signs of androgen deficiency into 2 groups, based on expert consensus.¹ The first group, which is considered more specific, includes incomplete or delayed sexual development; eunuchoidism; reduced sexual desire (libido); erectile dysfunction; gynecomastia; decreased axillary, facial and pubic hair; small testes (i.e., volume < 5 mL); infertility: low-trauma fracture; low bone mineral density; and hot flushes.¹ The second group includes less specific signs and symptoms, such as decreased energy and motivation, depressed mood, poor concentration and memory, sleep disturbance, mild anemia, reduced muscle bulk and strength, increased body fat or body mass index, and diminished physical performance. ¹ Similar definitions have recently been developed by the Canadian Men’s Health Foundation Multidisciplinary Guidelines Task Force on Testosterone Deficiency.²In young men, hypogonadism is more commonly characterized by signs and symptoms from the first group, such as reduced libido and erectile dysfunction. This condition is most often caused by testicular or pituitary pathology, including hyperprolactinemia, pituitary or hypothalamic disorders, testicular disease, radiation exposure or genetic diseases such as Klinefelter syndrome.³ Testosterone replacement is indicated in these cases of “classic hypogonadism,” as it ameliorates the clinical symptoms.⁴In contrast, although these entities exist in older men too, they are less frequent causes of low testosterone than age-related changes. There is evidence that testosterone levels decline with age in all men, regardless of symptoms, at an estimated rate of 1%–3% per year.^5,6 One study found that serum testosterone levels were below the normal range in 20% of men in their 60s and in close to 50% of men in their 80s.⁷ However, the prevalence of symptomatic low testosterone (hypogonadism) is estimated by some to be much lower in this population, at about 2%.⁸ Given the high prevalence of low testosterone and more limited correlation with symptoms in aging men, it is uncertain to what extent this represents a physiologic or pathologic event.^6,7 Moreover, symptoms typically associated with low testosterone are less specific in older men and may be caused by other comorbidities. For example, erectile dysfunction can be the result of vascular insufficiency, neurologic impairment, psychogenic causes or substance use.⁹ Conditions such as diabetes mellitus and atherosclerosis are more common in older men, with up to 40% of men over 50 years of age having evidence of vascular insufficiency as the primary cause of their erectile dysfunction.¹⁰ Low libido similarly can result from psychiatric or medical conditions that are more common in older men.¹¹Currently, many clinicians diagnose hypogonadism in older men on the basis of low serum testosterone levels, with or without symptoms, largely on the assumption that this is a pathologic condition requiring treatment. The purpose of this study was to systematically review the available literature to estimate the accuracy and operating characteristics of signs and symptoms for predicting low testosterone in aging men.     

Acanthamoeba polyphaga resuscitates viable non-culturable Legionella pneumophila after disinfection

Amoebae are the natural hosts for Legionella pneumophila and play essential roles in bacterial ecology and infectivity to humans. When L. pneumophila colonizes an aquatic installation, it can persist for years despite repeated treatments with disinfectants. We hypothesized that freshwater amoebae play an important role in bacterial resistance to disinfectants, and in subsequent resuscitation of viable non-culturable (VNC) L. pneumophila that results in re-emergence of the disease-causing strain in the disinfected water source. Our work showed that in the absence of Acanthamoeba polyphaga, seven L. pneumophila strains became non-culturable after treatment by 256 p.p.m. of sodium hypochlorite (NaOCl). In contrast, intracellular L. pneumophila within A. polyphaga was resistant to 1024 p.p.m. of NaOCl. In addition, L. pneumophila-infected A. polyphaga exhibited increased resistance to NaOCl. When chlorine-sterilized water samples were co-cultured with A. polyphaga, the non-culturable L. pneumophila were resuscitated and proliferated robustly within A. polyphaga. Upon treatment by NaOCl, uninfected amoebae differentiated into cysts within 48 h. In contrast, L. pneumophila-infected A. polyphaga failed to differentiate into cysts, and L. pneumophila was never detected in cysts of A. polyphaga. We conclude that amoebic trophozoites protect intracellular L. pneumophila from eradication by NaOCl, and play an essential role in resuscitation of VNC L. pneumophila in NaOCl-disinfected water sources. Intracellular L. pneumophila within trophozoites of A. polyphaga block encystation of the amoebae, and the resistance of both organisms to NaOCl is enhanced. To ensure long-term eradication and complete loss of the VNC state of L. pneumophila, we recommend that Legionella-protozoa co-culture should be an important tool to ensure complete loss of the VNC state of L. pneumophila.     

Hairy math: insights into hair-follicle spacing and orientation

Hair follicles in the skin have a characteristic spacing and orientation. Two recent papers (Sick et al., 2006 and Wang et al., 2006) report the use of contrasting mathematical models and experimental manipulations to gain insight into the mechanisms underlying patterns of hair-follicle distribution and orientation.     

TIME FOR COFFEE encodes a nuclear regulator in the Arabidopsis thaliana circadian clock

The plant circadian clock is required for daily anticipation of the diurnal environment. Mutation in Arabidopsis thaliana TIME FOR COFFEE (TIC) affects free-running circadian rhythms. To investigate how TIC functions within the circadian system, we introduced markers for the evening and morning phases of the clock into tic and measured evident rhythms. The phases of evening clock genes in tic were all advanced under light/dark cycles without major expression level defects. With regard to morning-acting genes, we unexpectedly found that TIC has a closer relationship with LATE ELONGATED HYPOCOTYL (LHY) than with CIRCADIAN CLOCK ASSOCIATED1, as tic has a specific LHY expression level defect. Epistasis analysis demonstrated that there were no clear rhythms in double mutants of tic and evening-acting clock genes, although double mutants of tic and morning-acting genes exhibited a similar free-running period as tic. We isolated TIC and found that its mRNA expression is continuously present over the diurnal cycle, and the encoded protein appears to be strictly localized to the nucleus. Neither its abundance nor its cellular distribution was found to be clock regulated. We suggest that TIC encodes a nucleus-acting clock regulator working close to the central oscillator.     

Identification of intra- and intermolecular disulphide bonding in the plant mitochondrial proteome by diagonal gel electrophoresis

Redox active proteins in plant mitochondria were examined using 2-D oxidant/reductant diagonal-SDS-PAGE to separate and identify proteins with intermolecular or intramolecular disulphide bonds using diamide in the first dimension and DTT in the second dimension. Eighteen proteins spots were resolved either above or below the diagonal and these were in-gel digested and identified by MS/MS. This analysis revealed intermolecular disulphide bonds in alternative oxidase, O-acetylserine (thiol) lyase, citrate synthase and between subunits of the ATP synthase. Intramolecular disulphide bonds were observed in a range of mitochondrial dehydrogenases, elongation factor Tu, adenylate kinase and the phosphate translocator. Many of the soluble proteins found were known glutaredoxin/thioredoxin targets in other plants, but the membrane proteins were not found by these methods nor were the nature of the disulphides able to be investigated. The accessibility of thiols involved in disulphide bonds to modification by a lipid derived aldehyde gave an insight into the potential impact of Cys modification on redox-functions in mitochondria during lipid peroxidation. Comparison of the protein sequences of the identified proteins with homologs from other species has identified specific Cys residues that may be responsible for plant-specific redox modulations of mitochondrial proteins.     

Enantiomers of fuscumol acetate comprise the aggregation‐sex pheromone of the South American cerambycid beetle Psapharochrus maculatissimus,and likely pheromones of the cerambycids Eupromerella plaumanni and Hylettus seniculus

There is increasing evidence that pheromone chemistry within the large coleopteran family Cerambycidae is often highly conserved, with numerous related species sharing the same pheromone components. As a result, traps containing these components can attract multiple cerambycid species simultaneously. In the present study, we exploited this concept in the identification of the male‐produced aggregation‐sex pheromone of the South American species Psapharochrus maculatissimus (Bates) (Coleoptera: Cerambycidae, subfamily Lamiinae, tribe Acanthoderini). Initially, live adults of both sexes were caught using a trap baited with a lure containing a blend of known cerambycid pheromone components. Headspace volatiles were collected from live beetles and analyzed by coupled gas chromatography‐mass spectrometry. Males of P. maculatissimus sex‐specifically produced a 1:38 blend of (R)‐fuscumol acetate ([2R,5E]‐6,10‐dimethylundeca‐5,9‐dien‐2‐yl acetate) and (S)‐fuscumol acetate, which were both components of the pheromone lures to which they had been attracted. In more focused field trials, traps baited with the (S)‐enantiomer, or a blend approximating the natural 1:38 ratio of (R)‐ to (S)‐enantiomers, attracted adults of both sexes in approximately equal numbers. During bioassays, adults of the lamiine species Eupromerella plaumanni (Fuchs) (tribe Acanthoderini) and Hylettus seniculus (Germar) (Acanthocinini) also were attracted, but to different lures, with E. plaumanni being attracted to the racemic mixture of the two enantiomers of fuscumol acetate, whereas H. seniculus was attracted specifically to (R)‐fuscumol acetate. Our results suggest that differences between these sympatric species in the stereochemistry of fuscumol acetate impart species‐specificity to pheromone communication channels, similar to what has been found recently with lamiine species from other continents.