Timing of Intrauterine Balloon Tamponade for Postpartum Haemorrhage After Vaginal Delivery Among Women With Moderate Bleeding: Exploratory Analysis of a Randomised Trial

ABSTRACT Objective A randomised controlled trial found no significant reduction in severe postpartum haemorrhage (≥ 3 packed red blood cell units and/or total blood loss > 1000 mL) when intrauterine balloon tamponade and second‐line uterotonics were used simultaneously compared with balloon use after failure of second‐line uterotonics. However, one quarter of participants had already lost more than 1000 mL at randomisation, increasing heterogeneity and coagulopathy risk. This may have obscured a potential benefit in women with moderate bleeding (500–1000 mL). We aimed to assess the effect of early versus later balloon use in this subgroup. Design Exploratory analysis of a randomised controlled trial. Setting Maternity units across France. Population Women with 500–1000 mL of blood loss at the time of second‐line uterotonic administration after vaginal delivery ( n  = 264). Methods Outcomes were compared between women randomised to early intrauterine balloon tamponade ( n  = 128) and those who received balloon after failure of second‐line uterotonics ( n  = 136). Risk ratios were estimated using multivariate Poisson regression with robust variance. Main Outcome Measures Severe postpartum haemorrhage (≥ 3 packed red blood cell units and/or total blood loss > 1000 mL). Results Severe postpartum haemorrhage occurred in 57.8% of the early group and 70.6% of the later group (adjusted risk ratio 0.83; 95% CI 0.69–1.01; p  = 0.06). Conclusions Early intrauterine balloon tamponade was not associated with a statistically significant reduction in severe haemorrhage among women with moderate bleeding; estimates are compatible with a modest benefit and should be considered hypothesis‐generating.

A Core Outcome Set for Studies of Intrahepatic Cholestasis of Pregnancy: Results of International e‐Delphi and Consensus Processes

ABSTRACT Objective To define standardised outcomes, the Core Outcome Set (COS) for reporting in studies of Intrahepatic Cholestasis of Pregnancy (ICP). Design e‐Delphi survey and consensus process. Setting International. Population 155 individuals from Asia, Europe, Oceania, North and South America: 31 patients (20%), 121 clinicians (78%), and 3 researchers (2%). Methods Maternal and perinatal outcomes reported in studies of ICP were collated. Stakeholders in ICP research and clinical care scored the importance of each outcome using a 9‐point Likert scale over three rounds; short‐listed outcomes were ranked during face‐to‐face consensus meetings. The final COS was agreed by the Study Steering Committee. The study was registered prospectively with Core Outcome Measures in Effectiveness Trials. Ethical approval was granted by the King's College London Research Ethics Committee (KCL MRA‐23/24‐39574). Main Outcome Measures From 54 manuscripts, 97 individual clinical outcomes were attributed to ICP. Twenty three outcomes were shortlisted by the e‐Delphi surveys, the ranking of which enabled selection of 10 core outcomes. Results Maternal core outcomes comprise: total maternal bile acid (BA) concentration (maximum), gestational age at peak BA concentration, and itch impact on maternal wellbeing. Birth core outcomes comprise: stillbirth, gestational age at birth, and spontaneous preterm birth versus induced preterm birth. Neonatal core outcomes comprise: perinatal death within 7 days of birth, perinatal asphyxia, neonatal unit admission, and mechanical ventilation. Conclusions Given the heterogeneity of reported outcomes, we have confirmed the need for a COS in ICP, standardising the minimum reported outcomes to reduce outcome reporting bias and research wastage.

A survey of SEN practitioners' experiences of identifying and supporting exam access arrangements

Abstract Exam access arrangements aim to support students to demonstrate their knowledge in high‐stakes examinations. This study aimed to capture the experiences of practitioners providing this support. The sample comprised 134 SEN practitioners (SENCos and Exam Access Arrangements Assessors) based in secondary schools across England. Participants completed a survey asking about identification and monitoring the need for an access arrangement, they rated their confidence in these processes, and identified any challenges experienced. The findings highlighted inconsistencies in when students are being identified for access arrangements and a lack of processes in place to monitor the support being offered. Confidence to support provision was generally high, but SENCos rated themselves as less confident than those that had the assessor qualification. Thematic analysis of open‐text responses elicited three key themes: (1) Lack of time to fulfill duties; (2) Poor understanding of access arrangements raises further challenges; and (3) Meeting the increase in demands puts a strain on resources. The findings suggest that senior leaders ought to reflect on the roles of their SEN team, as well as equipping them with the training, resources and staffing to support the provision of access arrangements.

Semen extraction efficiency and recovery before and after washing from reusable period underwear

Abstract When sexual assault evidence kits do not yield biological evidence demonstrating sexual contact, clothing such as undergarments is evaluated for the presence of semen. Menstrual underwear is a new type of undergarment and feminine product encountered as evidence in sexual assaults. They are composed of absorbent and leak‐proof layers and can be washed and re‐worn multiple times. The objective of this work was to determine a best practice for semen and DNA recovery from reusable menstrual underwear. Simulated postcoital samples were deposited on three different brands of menstrual underwear, and alternate light source evaluation failed for two of the three brands tested, though acid phosphatase testing was positive for all three brands tested. Testing of individual layers versus cuttings of a portion of the stain found that a full‐depth cutting results in optimal biological sample recovery. Mock postcoital deposits were then washed once or twice and subjected to serological and DNA workflows, with varying results in acid phosphatase and P30 testing after washing once or twice between brands. However, sperm recovery was successful in all samples, and complete short tandem repeat (STR) profiles were obtained from both sperm and nonsperm fractions from all samples, regardless of washing status. With these findings, while sperm recovery has the highest likelihood of success with a full‐thickness cutting, forensic scientists should be cautious in depending on ALS for stain location. Additionally, biological materials remain in these brands of menstrual underwear after washing, and therefore, biological material from previous sexual contact could remain and be detectable.

Tracking Australian students’ participation in senior secondary geography: Trends and implications for geography’s future

Abstract This study examines trends in senior secondary geography participation in Australia from 1998 to 2023, using data from the Longitudinal Surveys of Australian Youth and published senior secondary data. The research reveals a significant decline in geography enrolment nationally, with the proportion of Year 12 students studying geography falling from 8.1% (1998–2017) to 6.2% (2012–2023). Substantial variations exist across jurisdictions, with Western Australia maintaining the highest participation rates and the Australian Capital Territory the lowest. The study also explores demographic characteristics, finding that independent schools have higher participation rates, and gender balance varies by state. The decline in geography enrolment is contextualised within broader educational trends and compared with selected international patterns. The paper concludes by discussing the implications of these trends for the future of geography education in Australia, highlighting the need for targeted interventions to address the subject’s declining popularity and ensure its continued relevance in the curriculum.

Impersonating predators and prey to study trophic interactions through real‐life simulations

Abstract Predator–prey interactions are a fundamental aspect of ecology that has generated sustained research interests. Progress in the field stems from a diverse range of approaches, from highly controlled yet simplified mathematical and agent‐based models, to grounded but data‐limited field studies. As a compromise between mathematical and observation‐oriented methods, we introduce an original approach based on an outdoor game. In this game, biologged human players follow simple rules to impersonate predators and prey in a natural landscape augmented with synthetic resource patches and refuges. We investigated the behaviour, movement, functional response and spatial organization of over 25 players simultaneously monitored during nine simulations to determine whether the game could replicate realistic predator–prey dynamics. Results derived from our real‐life simulations were consistent with ecological patterns expected in natural systems. We found that (a) predator and prey movements were driven by risk and reward trade‐offs, (b) predators took advantage of linear features to travel at higher speed, making these areas risky for prey, (c) prey had nonlinear and risk‐sensitive functional responses and (d) consumer–resource interactions were spatially modular and defined by players' movement rates and landscape features. Moreover, the comprehensive dataset generated through the game allowed for the exploration of phenomena that are challenging to study in natural settings, such as spatial memory and the influence of satiety on resource acquisition rates. The approach offers a simple, computationally accessible and genuinely amusing way to explore the complex ramifications of predator–prey interactions and test otherwise data‐deficient hypotheses. The strength and originality of the method lies in the use of living agents—players—making decisions in a real‐world setting. This aspect alleviates the computational and empirical burden of defining and estimating decision‐related parameters needed to build simulators, while generating extensive datasets in a flexible experimental framework that is generally out of reach for empirical studies. It also offers immersive insights into predator–prey interactions, making it an engaging pedagogical tool that encourages creative thinking. The numerous possible scenarios that can be explored are only constrained by the investigator's creativity in adapting game rules and the players' desire to win.

A Novel Longitudinal Proteomic Aging Index Predicts Mortality, Multimorbidity, and Frailty in Older Adults

ABSTRACT Previous studies have developed proteomic aging clocks to estimate biological age and predict mortality and age‐related diseases. However, these earlier clocks were based on cross‐sectional data, capturing only the cumulative aging burden at a single time point but were unable to reflect the dynamic trajectory of biological aging over time. We constructed a longitudinal proteomic aging index (LPAI) using data from 4684 plasma proteins measured by the SomaScan 5K Array across three visits in the Atherosclerosis Risk in Communities (ARIC) study (ages 67–90 at last visit). Our two‐step approach applied functional principal component analysis (FPCA) to capture protein‐level change patterns over time, followed by elastic net penalized Cox regression for protein selection. LPAI was constructed in a randomly selected training set of ARIC participants ( N  = 2954), tested among the remaining ARIC participants ( N  = 1267), and validated externally in Multi‐Ethnic Study of Atherosclerosis (MESA) participants ( N  = 3726, ages 53–94 at last exam). Using Cox proportional hazards model, higher LPAI was associated with increased all‐cause mortality (HR = 2.50, 95% CI: [2.15, 2.92] per SD), CVD mortality (HR = 1.79, 95% CI: [1.34, 2.39] per SD), and cancer mortality (HR = 1.96, 95% CI: [1.45, 2.64] per SD) risk in ARIC, with statistically significant and directionally consistent associations also observed in MESA. Additionally, higher LPAI was associated with increased multimorbidity and frailty. This study demonstrates the feasibility of developing biological aging measures from longitudinal proteomics data and supports LPAI as a biomarker for aging‐related health risks.

Barriers to Enrolling Mental Health Emergency Patients in a Quality Improvement Study

Pregnancy Outcomes in Women Diagnosed With Attention‐Deficit/Hyperactivity Disorder: A Population‐Based Register Study

ABSTRACT Background Maternal attention‐deficit/hyperactivity disorder (ADHD) has been associated with various pregnancy outcomes, but the degree to which that association is explained by concomitant mental disorders and smoking during pregnancy remains unclear. Objective To investigate the association between maternal ADHD and pregnancy outcomes. Methods Through the Swedish Medical Birth Register, we identified 977,266 women who gave birth to a live singleton between January 1, 2006, and December 1, 2020 (1,617,121 pregnancies). Of these, 1.3% (12,553 women; 17,434 pregnancies) had an ADHD diagnosis prior to pregnancy. The primary outcome was preterm birth (< 37 weeks), with secondary outcomes being postterm birth (> 41 weeks), small for gestational age, large for gestational age, birth weight (≤ 2500, 2501–3500, > 4500 g), acute and planned cesarean section, assisted vaginal delivery, preeclampsia, and gestational diabetes. Generalized linear mixed‐effects models adjusted for maternal age, year of childbirth, maternal education, comorbid mental disorders, and smoking during pregnancy. Results There were 1089 (6.6%) preterm births among women with ADHD, and 73,423 (4.9%) preterm births among women without an ADHD diagnosis, corresponding to a crude OR of 1.33 (95% CI 1.25, 1.42). This association attenuated to nonsignificance after adjusting for maternal age, year of childbirth, maternal education, and comorbid mental disorders (adjOR = 1.06, 95% CI: 0.99, 1.13). Fully adjusted models revealed that ADHD was associated with an increased risk of having a large for gestational age baby (adjOR = 1.16, 95% CI: 1.06, 1.26) and undergoing a planned caesarean section (adjOR = 1.16, 95% CI: 1.06, 1.26). Sensitivity analyses using a broader ADHD definition suggested associations with preterm birth (adjOR = 1.09, 95% CI: 1.04, 1.15) and acute caesarean section (adjOR = 1.09, 95% CI: 1.04, 1.13). Conclusions After adjustments for comorbid mental disorders and smoking during pregnancy, maternal ADHD was not associated with preterm birth. An increased risk of delivering large for gestational age babies and undergoing planned caesarean sections was found in women with ADHD.

Associations between county‐level e‐cigarette‐inclusive Tobacco 21 law population coverage and e‐cigarette use behaviors among United States adolescents in Monitoring the Future

Abstract Background and aims In the United States (US), Tobacco 21 (T21) laws set the minimum legal sale age for all tobacco products to 21 years. This study aimed to examine whether e‐cigarette‐inclusive T21 laws were associated with e‐cigarette use behaviors and related disparities among US adolescents. Design We used nationally representative, repeated cross‐sectional Monitoring the Future data to compare self‐reported current e‐cigarette use (2014–2022) and first e‐cigarette initiation (2015–2022) among adolescents in counties with 100% ('full') versus <100% ('partial or no') e‐cigarette‐inclusive T21 law population coverage using modified Poisson regression, examining differences by sex, race and ethnicity, parental educational attainment and college educational expectations through interactions. Setting United States. Participants 8th, 10th and 12th graders. Measurements County‐level e‐cigarette‐inclusive T21 law population coverage was determined using Tobacco 21 Population Coverage Database and US Census Bureau population data. Current e‐cigarette use was defined as any past 30‐day use among the entire sample. First e‐cigarette initiation was defined as first use in the current grade among adolescents who had not initiated use prior to the current grade. Findings Compared with 8th, 10th and 12th graders in counties with partial or no e‐cigarette‐inclusive T21 law coverage, 8th [marginal effect (ME) = −1.8%, 95% confidence interval (CI) = −3.1% to −0.6%], 10th (ME = −2.6%, 95% CI = −4.6% to −0.6%) and 12th graders (ME = −2.7%, 95% CI = −5.2% to −0.1%) in counties with full coverage had a lower current e‐cigarette use prevalence. For current e‐cigarette use, we also observed statistically significant interactions by sociodemographic factors. Across all grades, full [8th: predicted prevalence (PP) = 5.9%, 95% CI = 4.7%–7.1%; 10th: PP = 11.8%, 95% CI = 10.2%–13.4%; 12th: 18.1%, 95% CI = 15.6%–20.6%] versus partial or no coverage (8th: PP = 7.5%, 95% CI = 6.2%–8.8%; 10th: PP = 16.3%, 95% CI = 15.0%–17.6%; 12th: 23.4%, 95% CI = 21.9%–24.8%) was associated with lower current e‐cigarette use among males but not females. By race and ethnicity, associations were statistically significant across all grades, but the magnitude and direction of these associations varied by subgroup and grade. Among 12th graders, full (PP = 16.1%, 95% CI = 13.9%–18.3%) versus partial or no coverage (PP = 20.5%, 95% CI = 19.0%–22.1%) was associated with lower current e‐cigarette use among those who said they ‘probably will’ graduate from a four‐year college but not among those with other educational expectations. We did not find sufficient evidence to support an association between e‐cigarette‐inclusive T21 law coverage and first e‐cigarette initiation overall or across sociodemographic subgroups. Conclusions E‐cigarette‐inclusive Tobacco 21 laws appear to be associated with lower current e‐cigarette use among US adolescents. However, we lacked sufficient evidence to support an association with first e‐cigarette use initiation. We also observed sociodemographic differences in these associations for current e‐cigarette use.