Roberto Romero

Bio: Roberto Romero is an academic researcher from National Institutes of Health. The author has contributed to research in topics: Amniotic fluid & Chorioamnionitis. The author has an hindex of 151, co-authored 1516 publications receiving 108321 citations. Previous affiliations of Roberto Romero include University of Michigan & Weizmann Institute of Science.

Sonographic evaluation in the second stage of labor to improve the assessment of labor progress and its outcome

Abstract: Every pregnant woman in early spontaneous labor or admitted for induction of labor wishes to know if she will deliver vaginally, or if she will require an operative delivery. Will the energy, pain, and the effect of labor on the pelvic floor be worth a vaginal delivery? What are the consequences of a failed attempt at a vaginal delivery? It would be ideal if, before the onset of labor or in its early phases, we could accurately predict who will deliver vaginally spontaneously without complications, and who will require an operative delivery (abdominal or assisted). This information would reduce morbidity, improve safety, optimize utilization of resources, and improve satisfaction of women with the labor and/or delivery process. The results of a prospective observational study of 202 nulliparous women suggested that the mode of delivery could be predicted accurately in up to 87% of cases before the onset of labor, with a combination of clinical and historical factors as well as ultrasound findings.1 Sonographic examination has the potential to improve the predictive accuracy – such an improvement is highly desirable. The partogram was the crucial advance which allowed an objective mean to assess labor progress by plotting cervical dilatation and station as a function of time.2–15 (Figure 1) Before partograms, evaluation of labor progress was subjective and often monitored according to its duration. With the development of the partogram, in the middle part of the twentieth century, labor disorders were defined and classified (prolonged latent phase, protracted, and arrest disorders). The pelvic division of labor, which encompasses the phase of parturition during which the fetus descends through the birth canal, is defined by changes in station of the presenting part.16 It is noteworthy that descent begins before full dilation (Figure 1). The management of protracted descent (nulliparous: 1cm/hour or less; multiparous: 2cm/hour or less), arrest of descent (no change in station for 1 hour or more), or failure to descend (no change in the deceleration phase or the second stage)13 remain one of the most challenging problems of obstetrics. Indeed, the skill and judgment required to decide when and how to intervene have been defining factors of the art of obstetrics. Figure 1 Partogram developed by Emanuel Friedman which describes the relationship between time in the horizontal axis and two variables: cervical dilatation and station of the presenting part. Reproduced from: Friedman EA. Dysfunctional labor. In Management of ... Operative vaginal deliveries were introduced as a heroic measure to deal with obstructed labor. The feasibility of an abdominal delivery, its improved technique and safety, coupled with a concern for fetal and neonatal welfare have changed the components of the obstetrical equation to opt for a particular mode of delivery (vaginal operative delivery versus abdominal). Ultrasound has earned its role in obstetrics through the assessment of gestational age, fetal growth, detection of congenital anomalies, fetal well-being and cervical length. In this Editorial, we reaffirm the notion that ultrasound is superior to digital vaginal examinations in determining fetal position prior to operative delivery,17–26 and explore the concept that sonography brings objectivity in assessing the location of the presenting part (station), and may contribute substantially to the clinical management of the second stage of labor. This issue of the “Journal” contains several original contributions which support this view. A pioneering study by Antonio Barbera et al.27 (from Professor John Hobbins' group) reports the use of transperineal/translabial ultrasound,28 and describes that the angle between the symphysis pubis and the leading part of the fetal skull (“angle of progression”) can predict which patient would deliver vaginally and which one would be at risk for requiring an abdominal delivery. The concept was originally described in a DVD in 2003 (under the sponsorship of the American College of Obstetricians and Gynecologists).29 The study is now published in this issue of the Journal.27 An angle of progression of 120 degrees or more (Figure 2) was associated in all cases with a spontaneous vaginal delivery. The angle was also associated with the duration of the examination-to-delivery interval. The intra-observer and inter-observer variability of the angle of progression were low, and there was a good correlation between clinical assessment of progress and the angle of progression. Figure 2 “Angle of progression”. This is the angle formed between a line placed through the midline of the symphysis pubis, and a second line (in red) drawn from the inferior apex of the symphysis tangentially to the fetal skull. In this figure, ... This concept has been independently studied by Professor Karim Kalache at the Charite University Hospital in Berlin, in the Department of Professor Joachim Dudenhausen.30 Among 26 cases with an occiput anterior fetal position, an angle of progression of 120 degrees or more was associated with a probability of successful vaginal delivery of 90% (derived from logistic regression). Collectively, the evidence suggests that the simple determination of the angle of progression has important prognostic value. Since engagement of the fetal head is a major prognostic factor for the outcome of labor,31–33 and its diagnosis by clinical means has many shortcomings, ultrasound has been used to improve the accuracy of its diagnosis. “Engagement” is said to have occurred when the widest diameter of the fetal presenting part has passed beyond the plane of the maternal pelvic inlet.34 In a cephalic presentation, the head usually is engaged when the leading part of the skull is at or below the level of the maternal ischial spines. The diagnosis of engagement can be made clinically by transvaginal digital examination, or transabdominal examination (using the fourth Leopold maneuver and finding that two-fifths of the fetal head is palpable).35

The prognosis of pregnancy conceived despite the presence of an intrauterine device (IUD)

Abstract: OBJECTIVE—Intrauterine devices (IUDs) are used for contraception worldwide; however, the management of pregnancies with an IUD poses a clinical challenge. The purpose of this study was to determine the outcome of pregnancy in patients with an IUD. STUDY DESIGN—A retrospective cohort study (December 1997-June 2007) was conducted. The cohort consisted of 12,297 pregnancies, of which 196 had an IUD. Only singleton pregnancies were included. Logistic regression analysis was used to adjust for potential confounders between the groups. RESULTS—1) Pregnancies with an IUD were associated with a higher rate of late miscarriage, preterm delivery, vaginal bleeding, clinical chorioamnionitis, and placental abruption than those without an IUD; 2) among patients with available histologic examination of the placenta, the rate of histologic chorioamnionitis and/or funisitis was higher in patients with an IUD than in those without an IUD (54.2% vs. 14.7%; p<.001). Similarly, among patients who underwent an amniocentesis, the prevalence of microbial invasion of the amniotic cavity (MIAC) was also higher in pregnant women with an IUD than in those without an IUD (45.9% vs. 8.8%; p<.001); and 3) intra-amniotic infection caused by Candida species was more frequently present in pregnancies with an IUD than in those without an IUD (31.1% vs. 6.3%; p<.001). CONCLUSION—Pregnant women with an IUD are at a very high risk for adverse pregnancy outcomes. This finding can be attributed, at least in part, to the high prevalence of intra-amniotic infection and placental inflammatory lesions observed in pregnancies with an IUD.

limma powers differential expression analyses for RNA-sequencing and microarray studies

Abstract: limma is an R/Bioconductor software package that provides an integrated solution for analysing data from gene expression experiments. It contains rich features for handling complex experimental designs and for information borrowing to overcome the problem of small sample sizes. Over the past decade, limma has been a popular choice for gene discovery through differential expression analyses of microarray and high-throughput PCR data. The package contains particularly strong facilities for reading, normalizing and exploring such data. Recently, the capabilities of limma have been significantly expanded in two important directions. First, the package can now perform both differential expression and differential splicing analyses of RNA sequencing (RNA-seq) data. All the downstream analysis tools previously restricted to microarray data are now available for RNA-seq as well. These capabilities allow users to analyse both RNA-seq and microarray data with very similar pipelines. Second, the package is now able to go past the traditional gene-wise expression analyses in a variety of ways, analysing expression profiles in terms of co-regulated sets of genes or in terms of higher-order expression signatures. This provides enhanced possibilities for biological interpretation of gene expression differences. This article reviews the philosophy and design of the limma package, summarizing both new and historical features, with an emphasis on recent enhancements and features that have not been previously described.

STRING v11: protein-protein association networks with increased coverage, supporting functional discovery in genome-wide experimental datasets.

Abstract: Proteins and their functional interactions form the backbone of the cellular machinery. Their connectivity network needs to be considered for the full understanding of biological phenomena, but the available information on protein-protein associations is incomplete and exhibits varying levels of annotation granularity and reliability. The STRING database aims to collect, score and integrate all publicly available sources of protein-protein interaction information, and to complement these with computational predictions. Its goal is to achieve a comprehensive and objective global network, including direct (physical) as well as indirect (functional) interactions. The latest version of STRING (11.0) more than doubles the number of organisms it covers, to 5090. The most important new feature is an option to upload entire, genome-wide datasets as input, allowing users to visualize subsets as interaction networks and to perform gene-set enrichment analysis on the entire input. For the enrichment analysis, STRING implements well-known classification systems such as Gene Ontology and KEGG, but also offers additional, new classification systems based on high-throughput text-mining as well as on a hierarchical clustering of the association network itself. The STRING resource is available online at https://string-db.org/.

SPAdes, a new genome assembly algorithm and its applications to single-cell sequencing ( 7th Annual SFAF Meeting, 2012)

Abstract: The lion's share of bacteria in various environments cannot be cloned in the laboratory and thus cannot be sequenced using existing technologies. A major goal of single-cell genomics is to complement gene-centric metagenomic data with whole-genome assemblies of uncultivated organisms. Assembly of single-cell data is challenging because of highly non-uniform read coverage as well as elevated levels of sequencing errors and chimeric reads. We describe SPAdes, a new assembler for both single-cell and standard (multicell) assembly, and demonstrate that it improves on the recently released E+V-SC assembler (specialized for single-cell data) and on popular assemblers Velvet and SoapDeNovo (for multicell data). SPAdes generates single-cell assemblies, providing information about genomes of uncultivatable bacteria that vastly exceeds what may be obtained via traditional metagenomics studies. SPAdes is available online ( http://bioinf.spbau.ru/spades ). It is distributed as open source software.

Standards of Medical Care in Diabetes

Abstract: XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.