Sponsors asked the IOM's Food and Nutrition Board and the Division of Behavioral and Social Sciences and Education Board on Children, Youth, and Families to review and update the IOM (1990) recommendations for weight gain during pregnancy and recommend ways to encourage their adoption through consumer education, strategies to assist practitioners, and public health strategies.The committee was asked to address the following tasks: 1. Review evidence on the relationship between weight gain patterns before, during, and after pregnancy and maternal and child health outcomes, with particular attention to the prevalence of maternal obesity racial/ethnic and age differences, components of GWG, and implications of weight during pregnancy on postpartum weight retention, maternal and child obesity, and later child health. 2. Within a life-stage framework consider factors in relation to GWG that are associated with maternal health outcomes such as lactation performance, postpartum weight retention, cardiovascular disease, metabolic processes including glucose and insulin-related issues, and risk of other chronic diseases; for infants and children, in addition to low birth weight, consider early developmental impacts and obesity-related consequences (e.g., mental health, diabetes). 3. Recommend revisions to the existing guidelines, where necessary, including the need for specific pregnancy weight guidelines for underweight, normal weight, and overweight and obese women and adolescents and women carrying twins or higher-order multiples. 4. Consider a range of approaches to promote appropriate weight gain, including: individual (behavior), psychosocial, community, health care, and health systems; timing and components of interventions; and ways to enhance awareness and adoption of the guidelines, including interdisciplinary approaches, consumer education to men and women, strategies to assist practitioners to use the guidelines, and public health strategies. 5. Identify gaps in knowledge and recommend research priorities.

/pdf/weight-gain-during-pregnancy-reexamining-the-guidelines-54naat6auf.pdf

Weight Gain During Pregnancy: Reexamining the Guidelines

Simple and complex carbohydrates (glycans) have long been known to play major metabolic, structural and physical roles in biological systems. Targeted microbial binding to host glycans has also been studied for decades. But such biological roles can only explain some of the remarkable complexity and organismal diversity of glycans in nature. Reviewing the subject about two decades ago, one could find very few clear-cut instances of glycan-recognition-specific biological roles of glycans that were of intrinsic value to the organism expressing them. In striking contrast there is now a profusion of examples, such that this updated review cannot be comprehensive. Instead, a historical overview is presented, broad principles outlined and a few examples cited, representing diverse types of roles, mediated by various glycan classes, in different evolutionary lineages. What remains unchanged is the fact that while all theories regarding biological roles of glycans are supported by compelling evidence, exceptions to each can be found. In retrospect, this is not surprising. Complex and diverse glycans appear to be ubiquitous to all cells in nature, and essential to all life forms. Thus, >3 billion years of evolution consistently generated organisms that use these molecules for many key biological roles, even while sometimes coopting them for minor functions. In this respect, glycans are no different from other major macromolecular building blocks of life (nucleic acids, proteins and lipids), simply more rapidly evolving and complex. It is time for the diverse functional roles of glycans to be fully incorporated into the mainstream of biological sciences.

/pdf/biological-roles-of-glycans-zowb8sw07y.pdf

Biological Roles of Glycans

Table 1. Classes of recommendation

Table 2. Levels of evidence

Table 3. Estimated fetal and maternal effective doses for various diagnostic and interventional radiology procedures

Table 4. Predictors of maternal cardiovascular events and risk score from the CARPREG study

Table 5. Predictors of maternal cardiovascular events identified in congential heart diseases in the ZAHARA and Khairy study

Table 6. Modified WHO classification of maternal cardiovascular risk: principles

Table 7. Modified WHO classification of maternal cardiovascular risk: application

Table 8. Maternal predictors of neonatal events in women with heart disease

Table 9. General recommendations

Table 10. Recommendations for the management of congenital heart disease

Table 11. Recommendations for the management of aortic disease

Table 12. Recommendations for the management of valvular heart disease

Table 13. Recommendations for the management of coronary artery disease

Table 14. Recommendations for the management of cardiomyopathies and heart failure

Table 15. Recommendations for the management of arrhythmias

Table 16. Recommendations for the management of hypertension

Table 17. Check list for risk factors for venous thrombo-embolism

Table 18. Prevalence of congenital thrombophilia and the associated risk of venous thrombo-embolism during pregnancy

Table 19. Risk groups according to risk factors: definition and preventive measures

Table 20. Recommendations for the prevention and management of venous thrombo-embolism in pregnancy and puerperium

Table 21. Recommendations for drug use

ABPM
: ambulatory blood pressure monitoring
ACC
: American College of Cardiology
ACE
: angiotensin-converting enzyme
ACS
: acute coronary syndrome
AF
: atrial fibrillation
AHA
: American Heart Association
aPTT
: activated partial thromboplastin time
ARB
: angiotensin receptor blocker
AS
: aortic stenosis
ASD
: atrial septal defect
AV
: atrioventricular
AVSD
: atrioventricular septal defect
BMI
: body mass index
BNP
: B-type natriuretic peptide
BP
: blood pressure
CDC
: Centers for Disease Control
CHADS
: congestive heart failure, hypertension, age (>75 years), diabetes, stroke
CI
: confidence interval
CO
: cardiac output
CoA
: coarction of the aorta
CT
: computed tomography
CVD
: cardiovascular disease
DBP
: diastolic blood pressure
DCM
: dilated cardiomyopathy
DVT
: deep venous thrombosis
ECG
: electrocardiogram
EF
: ejection fraction
ESC
: European Society of Cardiology
ESH
: European Society of Hypertension
ESICM
: European Society of Intensive Care Medicine
FDA
: Food and Drug Administration
HCM
: hypertrophic cardiomyopathy
ICD
: implantable cardioverter-defibrillator
INR
: international normalized ratio
i.v.
: intravenous
LMWH
: low molecular weight heparin
LV
: left ventricular
LVEF
: left ventricular ejection fraction
LVOTO
: left ventricular outflow tract obstruction
MRI
: magnetic resonance imaging
MS
: mitral stenosis
NT-proBNP
: N-terminal pro B-type natriuretic peptide
NYHA
: New York Heart Association
OAC
: oral anticoagulant
PAH
: pulmonary arterial hypertension
PAP
: pulmonary artery pressure
PCI
: percutaneous coronary intervention
PPCM
: peripartum cardiomyopathy
PS
: pulmonary valve stenosis
RV
: right ventricular
SBP
: systolic blood pressure
SVT
: supraventricular tachycardia
TGA
: complete transposition of the great arteries
TR
: tricuspid regurgitation
UFH
: unfractionated heparin
VSD
: ventricular septal defect
VT
: ventricular tachycardia
VTE
: venous thrombo-embolism
WHO
: World Health Organization

Guidelines summarize and evaluate all available evidence, at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes but are complements for textbooks and cover the European Society of Cardiology (ESC) Core Curriculum topics. Guidelines and recommendations should help the …

/pdf/esc-guidelines-on-the-management-of-cardiovascular-diseases-3xh319x7m6.pdf

ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC).

https://www.cardioatrio.com/index.php/guias-esc?download=107:manejo-cardiopatas-en-embarazo-ehj-2011-embarazo

ESC Guidelines on the management of cardiovascular diseases during pregnancy The Task Force on the Management of Cardiovascular Diseases

ContextMentoring, as a partnership in personal and professional growth and development, is central to academic medicine, but it is challenged by increased clinical, administrative, research, and other educational demands on medical faculty. Therefore, evidence for the value of mentoring needs to be evaluated.ObjectiveTo systematically review the evidence about the prevalence of mentorship and its relationship to career development.Data SourcesMEDLINE, Current Contents, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, PsycINFO, and Scopus databases from the earliest available date to May 2006.Study Selection and Data ExtractionWe identified all studies evaluating the effect of mentoring on career choices and academic advancement among medical students and physicians. Minimum inclusion criteria were a description of the study population and availability of extractable data. No restrictions were placed on study methods or language.Data SynthesisThe literature search identified 3640 citations. Review of abstracts led to retrieval of 142 full-text articles for assessment; 42 articles describing 39 studies were selected for review. Of these, 34 (87%) were cross-sectional self-report surveys with small sample size and response rates ranging from 5% to 99%. One case-control study nested in a survey used a comparison group that had not received mentoring, and 1 cohort study had a small sample size and a large loss to follow-up. Less than 50% of medical students and in some fields less than 20% of faculty members had a mentor. Women perceived that they had more difficulty finding mentors than their colleagues who are men. Mentorship was reported to have an important influence on personal development, career guidance, career choice, and research productivity, including publication and grant success.ConclusionsMentoring is perceived as an important part of academic medicine, but the evidence to support this perception is not strong. Practical recommendations on mentoring in medicine that are evidence-based will require studies using more rigorous methods, addressing contextual issues, and using cross-disciplinary approaches.

Mentoring in academic medicine: a systematic review.

Attitudes and Practices of Obstetrician–Gynecologists Regarding Influenza Vaccination in Pregnancy

Gum is an unusual food that presents significant challenges to animals that feed on it. Gum is limited in availability; trees generally secrete it only in response to damage. Gum is a β-linked complex polysaccharide, and as such is resistant to mammalian digestive enzymes and requires fermentation by gut microbes. It contains little or no lipid, low amounts of protein, and no appreciable levels of vitamins. As a food, gum can be characterized as difficult to obtain, potentially limited in quantity, difficult to digest, and primarily a source of energy and minerals. Despite these drawbacks, many primates feed extensively on gums. Among mammals, gum-feeding largely appears to be a primate dietary adaptation. Why are there so many primate gum-feeders and what adaptations have allowed them to make a living on such a problematic food? This is the central question of this book. This chapter examines digestive and nutritional aspects of gum. Specific examples of biological adaptations found in common and pygmy marmosets (Callithrix jacchus and Cebuella pygmaea), small New World primate gum-feeding specialists, will be examined. These marmoset species have many similarities in their behavior, morphology and metabolism, but also some instructive differences in their digestive function. C. pygmaea is the smallest of the marmosets but has the slowest passage rate of digesta. This might represent an adaptation to retain difficult-to-digest material, such as gum, within the gut to allow fermentation. In contrast, C. jacchus has a rapid passage rate. Passage rate in C. jacchus appears adapted more for rapidly excreting indigestible material (e.g., seeds) than for retaining gum within the gut to enable more complete digestion. Fruit is a rare component of C. pygmaea’s diet; hence any constraint on feeding caused by filling the gut with ingested seeds is greatly relaxed, apparently enabling digestive kinetics that favor digestive efficiency over maximizing food intake. Interestingly, however, these marmosets share an ability to digest gum despite their differences in gum kinetics. In captivity both species have been shown to be more able to digest Acacia gum than related species that feed less often on gum in the wild.

Nutritional and Digestive Challenges to Being a Gum-Feeding Primate

The generalization that anthropoid primates produce dilute milks that are low in protein and energy is based primarily on data from large monkeys of the families Cebidae and Cercopithecidae, as well as humans. The marmosets and tamarins (Callitrichidae) are not only much smaller in body size, but also typically raise multiple offspring during a relatively brief lactation. We hypothesized that selection for small body size and high reproductive rate might favor secretion of milk of higher energy and protein concentrations. To test this hypothesis, 46 milk samples collected from 10 common marmosets (Callithrix jacchus, ca. 350 g) were assayed for dry matter (DM), crude protein (CP), fat, and sugar; and gross energy (GE) was calculated from these constituents. We also assayed five samples collected from three golden lion tamarins (Leontopithecus rosalia, ca. 700 g) and six samples collected from a single pygmy marmoset (Cebuella pygmaea, ca. 150 g) over two lactation periods. All samples were collected between days 10 and 57 post partum, representing mid lactation for these species. The milks of these three species were similar, containing 14.0%, 16.1%, and 13.7% DM; 2.7%, 2.6%, and 2.9% CP; 3.6%, 5.2%, and 3.7% fat; 7.4%, 7.2%, and 7.8% sugar; and 0.76, 0.90, and 0.82 kcal/g for common marmosets, golden lion tamarins, and the pygmy marmoset, respectively. These species produced milks with energy values that were within the range reported for large anthropoids, albeit with slightly higher protein concentration. However, milk composition did vary substantially among individual common marmoset females, especially in the proportion of milk energy derived from fat. In contrast, CP as expressed as a percent of GE was remarkably constant among common marmoset females. Callitrichid milk appeared to be similar to that of larger anthropoid primates in GE, but was higher in CP and in the proportion of GE from CP. However, the small sample sizes for the golden lion tamarin and the pygmy marmoset, and the wide variation in milk composition found among common marmoset females cautions against definitively characterizing the milks of callitrichids from these data.

Does the milk of Callitrichid monkeys differ from that of larger anthropoids

Corticotropin-releasing hormone (CRH) is an ancient regulatory molecule. The CRH hormone family has at least four ligands, two receptors, and a binding protein. Its well-known role in the hypothalamic-pituitary-adrenal (HPA) axis is only one of many. The expression of CRH and its related peptides is widespread in peripheral tissue, with important functions in the immune system, energy metabolism, and female reproduction. For example, CRH is involved in the implantation of fertilized ova and in maternal tolerance to the fetus. An apparently unique adaptation has evolved in anthropoid primates: placental expression of CRH. Placental CRH stimulates the fetal adrenal zone, an adrenal structure unique to primates, to produce dehydroepiandrosterone sulfate (DHEAS), which is converted to estrogen by the placenta. Cortisol induced from the fetal and maternal adrenal glands by placental CRH induces further placental CRH expression, forming a positive feedback system that results in increasing placental production of estrogen. In humans, abnormally high placental expression of CRH is associated with pregnancy complications (e.g., preterm labor, intrauterine growth restriction (IUGR), and preeclampsia). Within anthropoid primates, there are at least two patterns of placental CRH expression over gestation: monkeys differ from great apes (and humans) by having a midgestational peak in CRH expression. The functional significance of these differences between monkeys and apes is not yet understood, but it supports the hypothesis that placental CRH performs multiple roles during gestation. A clearer understanding of the diversity of patterns of placental CRH expression among anthropoid primates would aid our understanding of its role in human pregnancy.

Functions of corticotropin-releasing hormone in anthropoid primates: from brain to placenta.

The developmental origins of health and disease (DOHaD) is a paradigm for understanding metabolic diseases of modern humans. Vulnerability to disease is linked to perturbations in development during critical time periods in fetal and neonatal life. These perturbations are caused by environmental signals, often generated or transduced by the mother. The regulation of mammalian development depends to a large extent on maternal biochemical signals to her offspring. We argue that this adaptation is ancient, and originated with the evolution of lactation. Lactation evolved earlier than live birth and before the extensive placental development of modern eutherian mammals. Milk contains a host of signaling molecules including nutrients, immunoglobulins, growth factors and metabolic hormones. As evidenced by marsupials, lactation originally served to supply the biochemical factors for growth and development for what is essentially a fetus to a weanling transitioning to independent existence. In placental mammals maternal signaling in earliest life is accomplished through the maternal-placental-fetal connection, with more of development shifted to in utero life. However, significant development occurs postpartum, supported by milk. Mothers of all taxa provide biochemical signals to their offspring, but for non-mammalian mothers the time window is short. Developing mammals receive maternal biochemical signals over an extended period. These signals serve to guide normal development, but also can vary in response to environmental conditions. The ancient adaptation of lactation resulted in a lineage (mammals) in which maternal regulation of offspring development evolved to a heightened degree, with the ability to modify development at multiple time points. Modern metabolic diseases may arise due to a mismatch between maternal regulation and eventual circumstances of the offspring, and due to a large proportion of mothers that exceed past evolutionary norms in body fat and pregnancy weight gain such that maternal signals may no longer be within the adaptive range.

Michael L. Power

Papers

Attitudes and Practices of Obstetrician–Gynecologists Regarding Influenza Vaccination in Pregnancy

Nutritional and Digestive Challenges to Being a Gum-Feeding Primate

Does the milk of Callitrichid monkeys differ from that of larger anthropoids

Functions of corticotropin-releasing hormone in anthropoid primates: from brain to placenta.

Maternal regulation of offspring development in mammals is an ancient adaptation tied to lactation