Contributors: Habelitz, Stefan, Marshall, Grayson, Nurrohman, Hamid
... Abstract Mineralized and sound dentin matrices contain inactive preforms of proteolytic enzymes that may be activated during the demineralization cycle. In this study, we tested the hypothesis that protease inhibitors (PI) preserve demineralized collagen fibrils and other constituents of the dentin matrix and thereby affect the potential for remineralization. Artificial carious lesions with lesion depths of 140 µm were created with acetate buffer (pH=5.0, 66 hours), and remineralized using a polymer-induced-liquid-precursor (PILP) process (pH=7.4, 14 days) containing poly(aspartic acid) (pAsp) as the process-directing agent. De- and remineralizing procedures were performed in the presence or absence of PI. Ultrastructure and mechanical recovery of demineralized dentin following PILP remineralization were examined and measured in water with atomic force microscopy (AFM) and nanoindentation. Nanomechanical properties of hydrated artificial lesions had a low elastic modulus (ER <0.4 GPa) extending about 100 µm into the lesion, followed by a sloped region of about 140 µm depth where values reached those of normal dentin (18.0–20.0 GPa). Mapping of mineral content by both micro-FTIR and micro x-ray computed tomography correlated well with modulus profiles obtained by nanoindentation. Tissue demineralized in the presence of PI exhibited higher elastic moduli (average 2.8 GPa) across the lesion and comprised a narrow zone in the outer lesion with strongly increased modulus (up to 8 GPa; p < 0.05), which might be related to the preservation of non-collagenous proteins that appear to induce calcium phosphate mineral formation even under demineralizing physical-chemical conditions. However, mechanical aspects of remineralization through the elastic modulus change, and the micromorphological aspects with SEM and TEM observation were almost identical with PILP treatments being conducted in the presence or absence of PI. Thus, the application of the protease inhibitors (PI) seemed to be less effective in promoting the remineralization of demineralized dentin.
Contributors: Upadhyay, Ushma, Kimport, Katrina, Belusa, Elise, Johns, Nicole, Laube, Douglas, Roberts, Sarah
... Abstract Background Since mid-2013, Wisconsin abortion providers have been legally required to display and describe pre-abortion ultrasound images. We aimed to understand the impact of this law. Methods We used a mixed-methods study design at an abortion facility in Wisconsin. We abstracted data from medical charts one year before the law to one year after and used multivariable models, mediation/moderation analysis, and interrupted time series to assess the impact of the law, viewing, and decision certainty on likelihood of continuing the pregnancy. We conducted in-depth interviews with women in the post-law period about their ultrasound experience and analyzed them using elaborative and modified grounded theory. Results A total of 5342 charts were abstracted; 8.7% continued their pregnancies pre-law and 11.2% post-law (p=0.002). A multivariable model confirmed the law was associated with a higher odds of continuing pregnancy (aOR=1.23, 95% CI: 1.01-1.50). Decision certainty (aOR=6.39, 95% CI: 4.72-8.64) and having to pay fully out of pocket (aOR=4.98, 95% CI: 3.86-6.41) were most strongly associated with continuing pregnancy. Viewing fully mediated the relationship between the law and continuing pregnancy. Interrupted time series analyses found no significant effect of the law but may have been underpowered to detect such a small effect. Nineteen of twenty-three women interviewed viewed their ultrasound image. Most reported no impact on their abortion decision; five reported a temporary emotional impact or increased certainty about choosing abortion. Two women reported viewing helped them decide to continue the pregnancy; both also described preexisting decision uncertainty. Conclusions This law caused an increase in viewing rates and a statistically significant but small increase in continuing pregnancy rates. However, the majority of women were certain of their abortion decision and the law did not change their decision. Other factors were more significant in women’s decision-making, suggesting evaluations of restrictive laws should take account of the broader social environment.
Contributors: Rodriguez, Robert, Mower, William
... Abstract Background Clinicians, afraid of missing intracranial injuries, liberally obtain computed tomographic (CT) head imaging in blunt trauma patients. Prior work suggests that clinical criteria (NEXUS Head CT decision instrument) can reliably identify patients with important injuries, while excluding injury, and the need for imaging in many patients. Methods We conducted a prospective observational study of the NEXUS Head CT decision instrument (DI) that requires patients to meet eight criteria to achieve “low-risk” classification. We examined the instrument’s performance in identifying patients requiring neurological intervention from among a cohort of 11,770 blunt head injury patients. Results The NEXUS Head CT DI assigned high-risk status to 420 of 420 patients requiring neurological intervention (sensitivity, 100.0% [95% confidence interval [CI]: 99.1% – 100.0%]). The instrument assigned low-risk status to 2,823 of 11,350 patients who did not require neurological intervention (specificity, 24.9% [95% CI: 24.1% - 25.7%]). None of the 2,823 low-risk patients required neurological intervention (NPV, 100.0% [95% CI: 99.9% - 100.0%]). The DI assigned high-risk status to 759 of 767 patients with significant intracranial injuries (sensitivity, 99.0% [95% CI: 98.0% - 99.6%]). The instrument assigned low-risk status to 2,815 of 11,003 patients who did not have significant injuries (specificity, 25.6% [95% CI: 24.8% - 26.4%]). Significant injuries were absent in 2,815 of the 2,823 patients assigned low-risk status (NPV, 99.7% [95% CI: 99.4% - 99.9%]). Conclusions The NEXUS Head CT DI reliably identifies blunt trauma patients who require head CT imaging, and could significantly reducing the use of CT imaging. Methods Prospective multicenter
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Contributors: Smith, Jennifer, Sturrock, Hugh
... Abstract Data from a prospective case-control study conducted between January 2013 and August 2014 in Ohangwena and Omusati regions in north central Namibia. Patients attending health facilities who tested positive by malaria rapid diagnostic test (RDT) (index cases) were traced back to their home. All occupants of index case households (n = 116 households) and surrounding households (n = 225) were screened for Plasmodium infection with a rapid diagnostic test (RDT) and loop mediated isothermal amplification (LAMP) and interviewed. A comparison group of 286 randomly-selected control households was also screened, to compare infection levels of RACD and non-RACD households and their neighbours.
Gut Microbiota from Multiple Sclerosis patients triggers spontaneous autoimmune encephalomyelitis in mice --16S data--
Contributors: Wekerle, Hartmut, Berer, Kerstin, Gerdes, Lisa Ann, Cekanaviciute, Egle, Jia, Sherman, Xiao, Liang, Xia, Zhongkui, Liu, Chuan, Klotz, Luisa, Stauffer, Uta
... Abstract The commensal microbiota has emerged as a key factor influencing human health and has been associated with several diseases, including those of the central nervous system (CNS). To investigate the role of the microbiome in multiple sclerosis (MS), a complex autoimmune disorder shaped by a multitude of genetic and environmental factors, we recruited a cohort of 34 monozygotic twin pairs discordant for MS, and compared their gut microbial composition by 16S ribosomal RNA sequencing of stool samples. While no major differences in the microbial profiles between MS-affected twins and their healthy co-twins were detected, a significant increase in some taxa (including Akkermansia) was seen in affected untreated subjects. To search for possible functional differences, we used a transgenic mouse model, in which spontaneous anti-CNS autoimmunity is dependent on the commensal gut flora. Germ-free mice colonized with microbiota from MS-affected twins, developed the MS-like disease with a significantly higher incidence than mice colonized with healthy twin-derived microbiota. Although alpha diversity was reduced compared to human donors, the microbial profiles of the colonized mice showed high intraindividual, remarkable temporal stability and a high transfer rate,. Analysis of the transplanted mouse microbiome at the level of individual taxa revealed several differences, including a significantly reduced abundance of the potentially autoimmune-protective genus Sutterella in mice colonized with MS-twin-derived microbiota. These findings provide first evidence that MS-derived microbiota contain factors that precipitate an MS-like autoimmune disease in a transgenic mouse model. This model lends itself to identify protective and pathogenic microbial component in human MS. Methods Study design. MZ twins were recruited by launching a national televised appeal as well as internet notification in Germany with support from the German Multiple Sclerosis Society (DMSG). Inclusion criteria for study participation were met for MZ twins with an MS diagnosis according to the revised McDonald criteria or clinically isolated syndrome (CIS) in one twin only. Exclusion criteria were antibiotic, glucocorticosteroidal or immunosuppressive treatment, gastrointestinal infection or diet irregularities in the 3 months prior to study entry. In total, 34 pairs (see Table 1) visited the outpatient department at the Institute of Clinical Neuroimmunology in Munich for a detailed interview on past and present medical, family and social history, a neurological examination as well as a nutrition questionnaire. To confirm the MS diagnosis, medical records including MRI scans were obtained and reviewed. Fecal samples were either directly collected in hospital or taken at home, stored at -20°C and transferred to the hospital in cooling bags. Finally, all samples were stored at -80°C. Of all participants buccal swabs for zygosity testing were taken. The study was approved by the local Ethics Committee of the Ludwig-Maximilians University Munich and all participants gave written informed consent. 16S rRNA Sequencing and Analysis. The V3-V5 region of bacterial 16S rRNA gene was amplified using the universal forward (5’-CCGTCAATTCMTTTGAGTTT-3’) and reverse primer (5’-ACTCCTA CGGGAGGCAGCAG-3’) incorporating the FLX Titanium adapters and a unique barcode sequence. PCR products were sequenced on a 454 GS FLX titanium pyrosequencer (454 Life Sciences, Branford, CT, USA) at BGI-Shenzhen. Analysis was performed using QIIME v1.9 as described (1). Essentially, amplicon sequences were quality-filtered and grouped to operational taxonomic units (OTUs) using SortMeRNA method (2) using GreenGenes version 13.8 97% dataset for closed reference. Sequences that did not match reference sequences in the GreenGenes database were dropped from the analysis. Taxonomy was assigned to the retained OTUs based on the GreenGenes reference sequence and the GreenGenes tree was used for all downstream phylogenetic community comparisons. Samples were filtered to at least 10000 sequences per sample and OTUs were filtered to retain only OTUs present in at least 5% of samples, covering at least 0.01% of total reads. After filtering, human samples were rarefied to 10975 sequences, while mouse samples were rarefied to 8137 sequences per sample, which were the lowest number of sequences per sample, respectively. For comparison between human and mouse samples, the human and mouse datasets were combined before OTU filtering and rarefaction. The resulting OTUs were filtered as described above and samples were rarefied to 6200 sequences per sample. Alpha diversity was calculated using phylogenetic diversity index method (3). For analysis of beta diversity, pairwise distance matrices were generated by phylogenetic metric of weighted UniFrac (4) and used for PCoA. For comparison of individual taxa, samples were not rarefied. Instead, OTU abundances were normalized using variance-stabilizing transformation and taxa distributions were compared using the Wald negative binomial test from the R software package DESeq2 (as described in (4, 5) with Benjamini-Hochberg correction for multiple comparisons. All statistical analyses of differences between individual bacterial species were performed using QIIME v.1.9 or R (packages DESeq2 and phyloseq). Other Two files are uploaded. The dataset contains both human and mice samples. Max_Planck_Twin_metadata.txt: Contains the sample metadata Max_Planck_Twin_OTU_table.txt: contains the normalized OTU abundances for each individual OTU abundances were normalized using variance-stabilizing transformation and taxa distributions were compared using the Wald negative binomial test from the R software package DESeq2 (as described in (4, 5) with Benjamini-Hochberg correction for multiple comparisons.
Contributors: Yu, Shengyang, Tward, Aaron, Knox, Sarah
... Abstract Isolated Lacrimal gland for Single Cell RNA sequence data from E16 and P4 mice. These are the raw read count matrices along side the barcode for the cells and genes that span the sparse matrix. These results are published in Development: Defining epithelial cell dynamics and lineage relationships in the developing lacrimal gland. Abstract: The tear producing lacrimal gland is a tubular organ that protects and lubricates the ocular surface. While the lacrimal gland possesses many features that make it an excellent model to understand tubulogenesis, the cell types and lineage relationships that drive lacrimal gland formation are unclear. Using single cell sequencing and other molecular tools, we reveal novel cell identities and epithelial lineage dynamics that underlie lacrimal gland development. We show that the lacrimal gland from its earliest developmental stages is composed of multiple subpopulations of immune, epithelial, and mesenchymal cell lineages. The epithelial lineage exhibits the most substantiative cellular changes, transitioning through a series of unique transcriptional states to become terminally differentiated acinar, ductal and myoepithelial cells. Furthermore, lineage tracing in postnatal and adult glands provides the first direct evidence of unipotent KRT5+ epithelial cells in the lacrimal gland. Finally, we show conservation of developmental markers between the developing mouse and human lacrimal gland, supporting the use of mice to understand human development. Together, our data reveal critical features of lacrimal gland development that have broad implications for understanding epithelial organogenesis. Methods Gathered via 10x Genomics Cell Ranger pipeline for scRNA seq. These are the count matrices. Other Any programming language can load the matrix. We would recommend using the Seurat R package to load and process this data.
Gut bacteria from multiple sclerosis patients modulate human T cells and exacerbate symptoms in mouse models
Contributors: Baranzini, Sergio, US Department of Defense, Valhalla Charitable foundation, National multiple sclerosis Foundation
... Abstract The gut microbiota regulates T cell functions throughout the body. We hypothesized that intestinal bacteria impact the pathogenesis of multiple sclerosis (MS), an autoimmune disorder of the central nervous system, and thus analyzed the microbiomes of 71 MS patients not undergoing treatment and 71 healthy controls. Although no major shifts in microbial community structure were found, we identified specific bacterial taxa that were significantly associated with MS. Akkermansia muciniphila and Acinetobacter calcoaceticus, both increased in MS patients, induced pro-inflammatory responses in human PBMCs and in mono-colonized mice. In contrast, Parabacteroides distasonis, which was reduced in MS patients, stimulated anti-inflammatory interleukin-10 (IL-10)-expressing human CD4+CD25+ T cells, and IL-10+FoxP3+ regulatory T cells (Tregs) in mice. Finally, microbiota transplants from MS patients into germ-free mice resulted in more severe symptoms of experimental autoimmune encephalomyelitis (EAE) and reduced proportions of IL-10+ Tregs compared to mice “humanized” with microbiota from healthy controls. This study identifies specific human gut bacteria that regulate adaptive autoimmune responses, suggesting therapeutic targeting of the microbiota as a novel treatment for MS. Methods Human fecal sample collection Fecal samples were collected from 71 adult patients with relapsing-remitting multiple sclerosis that had not received treatment for at least 3 months prior to the time of collection and 71 controls without autoimmune disorders at the University of California, San Francisco (UCSF) and the Icahn School of Medicine at Mt Sinai (New York, NY). The inclusion criteria specified no use of antibiotics or cancer therapeutics in 3 months prior to the study. Detailed patient information is available in Supplementary Table 1. Samples were collected using culture swabs (BD #220135) and stored at -80C until DNA extraction or bacterial isolation. 16S rRNA amplicon sequencing and computational analysis of human and mouse microbiome samples DNA was extracted from samples using MoBio Power Fecal DNA extraction kit (MoBio #12830) and amplicons of V4 region of the prokaryotic 16S rRNA gene were sequenced using the Earth Microbiome Project standard protocol (1). Analysis was performed using QIIME v1.9 as described (2). Essentially, amplicon sequences were quality-filtered and grouped to “species-level” OTUs using SortMeRNA method (3) using GreenGenes version 13.8 97% dataset for closed reference. Sequences that did not match reference sequences in the GreenGenes database were dropped from the analysis. Taxonomy was assigned to the retained OTUs based on the GreenGenes reference sequence, and the GreenGenes tree was used for all downstream phylogenetic community comparisons. Samples were filtered to at least 10000 sequences per sample, and OTUs were filtered to retain only OTUs present in at least 5% of samples and covering at least 100 total reads. After filtering samples were rarefied to 10000 sequences per sample. We identified 129 total genera and 1462 total operational taxonomic units (OTUs) in our samples. We systematically compared relative abundances of individual microbial taxa between MS patients and controls at the genus and OTU levels by negative binomial Wald test using Benjamini-Hochberg correction for multiple comparisons (4). Alpha diversity was calculated using the Chao1 method (5). For analysis of beta diversity, pairwise distance matrices were generated using the phylogenetic metric unweighted UniFrac (6) and used for principal coordinate analysis (PCoA). For comparison of individual taxa, samples were not rarefied. Instead, OTU abundances were normalized using variance-stabilizing transformation and taxa distributions were compared using Wald negative binomial test from R software package DESeq2 as described previously (4, 7) with Benjamini-Hochberg correction for multiple comparisons. All statistical analyses of differences between individual bacterial species were performed using QIIME v.1.9 or R (packages DESeq2 and phyloseq). Other Two files are uploaded. The dataset contains both human and mice samples. 5set_map_for_EBI.txt: Contains the sample metadata 5set_otus_for_EBI.txt: contains the normalized OTU abundances for each individual OTU abundances were normalized using variance-stabilizing transformation and taxa distributions were compared using the Wald negative binomial test from the R software package DESeq2 (as described in (4, 5) with Benjamini-Hochberg correction for multiple comparisons.
Gut Microbiota from Multiple Sclerosis patients triggers spontaneous autoimmune encephalomyelitis in mice --shotgun data--
Contributors: Wekerle, Hartmut, Berer, Kerstin, Gerdes, Lisa Ann, Cekanaviciute, Egle, Jia, Sherman, Xiao, Liang, Xia, Zhongkui, Liu, Chuan, Klotz, Luisa, Stauffer, Uta
... Abstract There is emerging evidence that the commensal microbiota has a role in the pathogenesis of multiple sclerosis (MS), a putative autoimmune disease of the central nervous system. Here, we compared the gut microbial composition of 34 monozygotic twin pairs discordant for MS. While there were no major differences in the overall microbial profiles, we found a significant increase in some taxa such as Akkermansia in untreated MS twins. Furthermore, most notably, when transplanted to a transgenic mouse model of spontaneous brain autoimmunity, MS twin-derived microbiota induced a significantly higher incidence of autoimmunity than the healthy twin-derived microbiota. The microbial profiles of the colonized mice showed a high intra-individual and remarkable temporal stability with several differences, including Sutterella, an organism shown to induce a protective immunoregulatory profile in vitro. Immune cells from mouse recipients of MS-twin samples produced less IL-10 compared to immune cells from mice colonized with healthy twin samples. IL-10 may have a regulatory role in spontaneous CNS autoimmunity, as neutralization of the cytokine in mice colonized with healthy twin fecal samples increased disease incidence. These findings provide first evidence that MS-derived microbiota contain factors that precipitate an MS-like autoimmune disease in a transgenic mouse model. They hence encourage the detailed search for protective and pathogenic microbial components in human MS. Methods Study design. MZ twins were recruited by launching a national televised appeal as well as internet notification in Germany with support from the German Multiple Sclerosis Society (DMSG). Inclusion criteria for study participation were met for MZ twins with an MS diagnosis according to the revised McDonald criteria or clinically isolated syndrome (CIS) in one twin only. Exclusion criteria were antibiotic, glucocorticosteroidal or immunosuppressive treatment, gastrointestinal infection or diet irregularities in the 3 months prior to study entry. In total, 34 pairs (see Table 1) visited the outpatient department at the Institute of Clinical Neuroimmunology in Munich for a detailed interview on past and present medical, family and social history, a neurological examination as well as a nutrition questionnaire. To confirm the MS diagnosis, medical records including MRI scans were obtained and reviewed. Fecal samples were either directly collected in hospital or taken at home, stored at -20°C and transferred to the hospital in cooling bags. Finally, all samples were stored at -80°C. Of all participants buccal swabs for zygosity testing were taken. The study was approved by the local Ethics Committee of the Ludwig-Maximilians University Munich and all participants gave written informed consent. Metagenomic analysis of human and mouse samples We performed metagenomic sequencing of the gut microbiome in 16 pairs of identical twins, each composed of a sibling affected by MS and one unaffected sibling. In addition, stool samples from 25 germ-free mice that were colonized with four twin pair samples also underwent metagenomic sequencing. Each human and mouse fecal sample produced at least 30 million paired-end DNA reads of length 100 base pairs. Sequence quality, evaluated using FastQC, was high in the majority of sequences across all samples. We used the HMP Unified Metabolic Analysis Network (HUMAnN2) tool to calculate the relative abundance of specific microbes, gene families, and metabolic pathways. This software pipeline uses MetaPhlAn2 to obtain a list of abundant organisms by aligning sequences to genes unique to known bacterial species. DNA sequences are subsequently aligned to genomes of the identified organisms using the Bowtie 2 aligner and an annotated pangenome database, ChocoPhlAn. Unmapped DNA reads undergo translated alignment to the bacterial proteome using the software Diamond and a large protein database, UniRef50. The product of sequence alignment is a quantitative relative abundance of specific protein families. The HUMAnN2 software subsequently uses this information to determine the number complete copies of specific metabolic pathways using MetaCyc, a database mapping metabolic reactions to pathways. After obtaining quantitative measurements of gut bacterial abundance, gene families, and metabolic pathways, we performed an association testing to identify pathogenic and protective factors in multiple sclerosis. We calculated the pairwise sum of absolute differences of microbial relative abundance between two individuals to determine if gut bacterial flora is more similar between twins with discordant phenotype compared to pairs unrelated individuals. We used logistic regression (adjusting for twin pair and number of genome equivalents sequenced per sample) to examine associations between each gut bacterial variable with MS phenotype. We corrected for multiple comparisons, and adjusted p-values using a false discovery rate of 5%. We applied the same rigorous statistical approach to mouse samples, and also adjusted for the twin pair from which mice were colonized. Colonization of germ-free RR mice with human MS-twin-derived fecal samples. For the human to mouse fecal transfer experiments we selected a subgroup of 5 discordant twin pairs, mainly based on pragmatic criteria such as relatively young age (20-40 yrs), female sex and either no treatment or only treatment with interferon-beta (Table S1). One gram of human fecal material was suspended in 15 ml pre-reduced PBS (PBS supplemented with 0.1% L-Cysteine hydrochloride monohydrate) and vortexed at room temperature for 5 min. Large insoluble particles were allowed to settle by gravity for 5 min. Supernatant was transferred to an anaerobic crimped tube (Sigma-Aldrich). Pre-reduced glycerol (containing 0.1% L-Cysteine hydrochloride monohydrate) was added to a final concentration of 20% and tubes were frozen at -80°C. Tubes were sprayed thoroughly with Virkon (V.P. Produkte) before being transferred to the gnotobiotic isolators. Germ-free RR mice were gavaged with approximately 300 µl of fecal bacterial suspension. In addition, mice colonized with healthy twin fecal material were injected with 250 µg anti-IL-10 (JES5-2A5; BioXcell) or isotype control antibodies weekly once. All animal procedures were in accordance with the guidelines of the Committee on Animals of the Max Planck Institute of Neurobiology and the Max Planck Institute of Immunobiology and Epigenetics with a license from the Regierung von Oberbayern as well as the Regierungspräsidium Freiburg. Other Two zipped files have been uploaded (one of human and one for mice). Each zipped file contains 10 individual files. Bacterial relative abundance at the genus (1), species (2), and all taxonomic classifications (3): 1. humann2_metaphlan_bugs_list.genus.tsv 2. humann2_metaphlan_bugs_list.species.tsv 3. humann2_metaphlan_bugs_list.tsv Bacterial gene family relative abundance across all bacteria (4) and for each bacteria (5): 4. humann2_genefamilies_community.tsv 5. humann2_genefamilies.tsv Bacterial metabolic pathway abundance across all bacteria (6) and for each bacteria (7), and bacterial metabolic pathway coverage across all bacteria (8) and for each bacteria (9): 6. humann2_pathabundance_community.tsv 7. humann2_pathabundance.tsv 8. humann2_pathcoverage_community.tsv 9. humann2_pathcoverage.tsv Sample IDs, phenotype, twin pair, and genome equivalents calculated using MicrobeCensus (https://github.com/snayfach/MicrobeCensus): 10. metagenomic_ids_genome_equivalents.tsv Note: A description of HUMAnN2 output files is here: https://bitbucket.org/biobakery/humann2/wiki/Home#markdown-header-output-files
Contributors: Miller, Suellen, El Ayadi, Alison, El Ayadi, Alison
... Abstract This dataset includes clinical data for 958 women comprising pre-intervention/control participants from four studies conducted by the Safe Motherhood Program at the University of California, San Francisco that evaluated the effectiveness of the non-pneumatic anti-shock garment (NASG) to reduce adverse maternal outcomes for women with hypovolemic shock secondary to severe obstetric hemorrhage: Egypt 2004 (n=158), Egypt 2006-2008 (n=430), Nigeria 2004-2007 (n=179) and Zambia and Zimbabwe 2007-2012 (n=191) and were not missing data on vital signs or death. Three of these studies, based at the tertiary level, followed a quasi-experimental design where a pre-intervention period was temporally followed by an NASG intervention period, and one was a cluster-randomized control trial (CRCT) of NASG application at the primary health clinic (PHC) level, prior to transport to tertiary facility for definitive treatment. The pre-intervention/control participants in all studies received standardized evidence-based hemorrhage and shock management. Women in all trials were eligible for study participation if they reached a threshold estimated blood loss and one or more of the following: SBP 100 BPM. In the tertiary facility studies in Egypt and Nigeria, the threshold estimated blood loss was >750ml, while in the Zambia and Zimbabwe PHC-enrolled study the threshold EBL was >500 mL. The majority of facilities were under-staffed, under-resourced, and characterized by long delays in obtaining definitive care (surgery, blood transfusions). Initial study protocols, including informed consent procedures, were approved by institutional review boards at the University of California, San Francisco, and for each study, respectively, by the following institutions: University of Zambia, Lusaka Research Ethics Committee; Medical Research Council of Zimbabwe; Department of Reproductive Health and Research of the World Health Organization Ethics Review Committee; National Reproductive Health Research Committee of the Nigerian Federal Ministry of Health, El Galaa Maternity Teaching Hospital; Assiut University Women’s Health Center; Alexandria University Teaching Hospital; and Al Minya University Teaching Hospital. All women provided written or thumbprint (if illiterate) informed consent for study participation; all ethics committees provided a waiver of consent from women who were unconscious or confused at time of admission until they recovered or written consent was obtained from a relative as proxy. Methods Data captured included participant vital sign values at the measurement interval with the highest shock index (pulse/SBP) within the first hour after study entry: pulse, systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP= (2 x DBP + SBP)/3), SI (pulse/SBP), and pulse pressure (SBP-DBP). Severe shock at study entry was defined as MAP less than 60 mmHg, below which perfusion of vital organs has been proposed to be inadequate. BP was measured via an automated blood pressure device or auscultatory technique with mercury sphygmomanometer. Outcomes comprised any severe adverse maternal event related to obstetric hemorrhage, and included organ system dysfunction-based criteria and intervention-based criteria. Although the outcomes for the original trials were determined prior to the development of the WHO “Near-Miss” criteria, they are very similar. The original outcomes for the studies were maternal mortality; end-organ system failure morbidity defined as clinically-diagnosed major organ failure (respiratory, renal, neurological, cardiac) lasting for 24 hours post-resuscitation; and the intervention variables ICU admission, blood transfusion, and emergency hysterectomy for intractable uterine atony. These outcomes were selected because in the majority of our study sites, laboratory-based criteria (e.g., determining DIC by platelets), were not consistently available. For the purposes of the present analysis we used the WHO maternal near-miss indicators for our outcomes. We evaluated maternal status as 1) death or 2) severe maternal outcome (SMO), a composite indicator of death or severe end-organ failure maternal morbidity. Finally we combined SMO with the WHO intervention-based near-miss criteria ICU admission, blood transfusion ≥5 units and emergency hysterectomy (uterine atony diagnoses only). WHO labels these as “critical interventions”; therefore, to be consistent with WHO criteria, we called our composite indicator of SMO and the critical interventions SMO-CI. Other Data were created with funding from the Bill & Melinda Gates Foundation under grant OPP1086183. Other Data were created with funding from the MacArthur Foundation under grant 05-84956-000-GSS. Other Data were created with funding from the National Institutes of Health under grant R01HD053129. Other Data were created with funding from the Bill & Melinda Gates Foundation under grant 48541.
Contributors: Yukawa, Michi, Gansky, Stuart, O'Sullivan, Patricia, Feldman, Mitchell, Nishimura, Holly, Teherani, Arianne, Yukawa, Michi
... Methods Prospective survey study Other Data were created with funding from the none under grant none.