BACKGROUND:Case-based learning (CBL) is a useful pedagogical approach, for which learner experience has been well researched. The experience of faculty is less known. CBL was integrated into the first year of a new pre-licensure medical curriculum, so the faculty experience of transition from large group teaching to structured CBL was investigated. METHODOLOGY:Interpretative phenomenological analysis (IPA) was undertaken to explore the facilitator lived experience through reflective inquiry. Ten CBL facilitators were purposively selected from a diverse pool of faculty using maximum variation; faculty were involved in patient care, research, and education, and were a mix of ages, ethnicities and genders. Semi-structured interviews were conducted and analysed according to the IPA structure. RESULTS:Overall experiences were positive. Facilitators repeatedly expressed the enjoyment felt from closer student interaction. They reported that CBL afforded an authentic and active teaching approach. Other themes included: initial uncertainty regarding their role, anxiety around standardisation of the student experience and concerns regarding the level of content expertise required. However, confidence generally improved with experience facilitating. CONCLUSION:These insights provide a deeper understanding of faculty perceptions of the CBL facilitator's role and will better inform future faculty development initiatives, as well as the iterative design of the CBL teaching resources.

gradient bottom PMS 1815C C13 M96 Y81 K54 on dark backgrounds on light backgrounds standard no gradients watermark stacked logo (for sharing only) standard no gradients watermark stacked logo (for sharing only) white WHITE C0 M0 Y0 K0

gradient bottom PMS 1815C C13 M96 Y81 K54 on dark backgrounds on light backgrounds standard no gradients watermark stacked logo (for sharing only) standard no gradients watermark stacked logo (for sharing only) white WHITE C0 M0 Y0 K0

PUFA modulate immune function and have been associated with the risk of childhood atopy and asthma. We investigated the effect of maternal fat intake in mice on PUFA status, elongase and desaturase gene expression, inflammatory markers and lung function in the offspring. C57BL/6J mice (n 32) were fed either standard chow (C, 20·4 % energy as fat) or a high-fat diet (HFD, 39·9 % energy as fat) for 4 weeks prior to conception and during gestation and lactation. At 21 d of age, offspring were weaned onto either the HFD or C, generating four experimental groups: C/C, C/HF, HF/C and HF/HF. Plasma and liver fatty acid composition were measured by GC and gene expression by quantitative PCR. Lung resistance to methacholine was assessed. Arachidonic acid concentrations in offspring plasma and liver phospholipids were increased by HFD; this effect was greater in the post-natal HFD group. DHA concentration in offspring liver phospholipids was increased in response to HFD and was higher in the post-natal HFD group. Post-natal HFD increased hepatic fatty acid desaturase (FADS) 2 and elongation of very long-chain fatty acid 5 expression in male offspring, whereas maternal HFD elevated expression of FADS1 and FADS2 in female offspring compared with males. Post-natal HFD increased expression of IL-6 and C-C motif chemokine ligand 2 (CCL2) in perivascular adipose tissue. The HFD lowered lung resistance to methacholine. Excessive maternal fat intake during development modifies hepatic PUFA status in offspring through regulation of gene expression of enzymes that are involved in PUFA biosynthesis and modifies the development of the offspring lungs leading to respiratory dysfunction.

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council OnBehalf BICeP Study Group Background Prompt, effective bystander cardiopulmonary resuscitation (CPR) is the single most important factor determining survival from out of hospital cardiac arrest (OHCA), increasing survival up to 4-fold. However only 35%-45% of people trained in CPR actually attempt it when required. This study uses psychological theory and behaviour change techniques (BCTs) to increase the proportion of bystanders who attempt CPR in a real emergency. Design Intervention development study Methods Intervention content was informed by two recent systematic reviews, which identified barriers to bystander CPR and BCTs within existing training programmes (PROSPERO CRD42018117438; CRD42019126745) and a qualitative study exploring participants’ views (n = 12) of draft text messages. A lay bystander user-involvement panel (n = 7) and an expert advisory group (comprising representatives from CPR training organisations) worked with the research team to co-produce the final intervention and agree the schedule for text message delivery. BCT content was assessed by two independent experts. A framework analysis of interviews was undertaken. Results Recognising and addressing fears, and helping people to better prepare for real-life situations were identified to be important to participants. Short, simple texts from a credible source and with a positive tone were strongly preferred, there was a strong aversion to anything "guilt-inducing". Pictures and personalisation were important, rewards less so. Regarding frequency: participants varied but around 1/week was considered adequate by most. A total of n = 35 text-messages with verified BCT content were co-developed with participants. Conclusions A text message intervention incorporating BCTs, which is acceptable to intended users and CPR trained individuals has been produced and will be subject to future evaluation.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

gradient bottom PMS 1815C C13 M96 Y81 K54 on dark backgrounds on light backgrounds standard no gradients watermark stacked logo (for sharing only) standard no gradients watermark stacked logo (for sharing only) white WHITE C0 M0 Y0 K0

The placental microvasculature is a conduit for fetal blood allowing solute exchange between the mother and the fetus. Serial block‐face scanning electron microscopy (SBF SEM) allows ultrastructure to be viewed in three dimensions and provides a new perspective on placental anatomy. This study used SBF SEM to study endothelial cells within the human placental microvasculature from uncomplicated pregnancies. Term human placental villi were aldehyde‐fixed and processed for imaging by SBF SEM. Manual segmentation was carried out on a terminal villous capillary and an intermediate villous arteriole and venule. Twenty‐seven SBF SEM stacks from terminal villi were analysed using stereological approaches to determine the volumes of microvascular components and the proportions of pericyte coverage. SBF SEM analysis of capillary endothelial cells revealed the presence of interendothelial protrusions (IEPs) originating from the donor cell at the endothelial junction and forming deep thin projections up to 7 μm into the adjacent endothelial cells. IEP density was estimated to be in the order of 35 million cm –3 placental tissue. Pericytes cover 15% of the fetal capillary surface area in terminal villi. In comparison, the cytotrophoblast covered 24% of the syncytiotrophoblast basal membrane. A trans‐endothelial channel was observed in a region of the vasculo‐syncytial capillary. Pericyte coverage was extensive in both arteriole and venule. Three‐dimensional imaging of the placental microvasculature identified novel ultrastructural features and provided an insight into factors that may influence capillary permeability and placental function. We hypothesise that the IEPs may allow mechanosensing between adjacent endothelial cells to assist in the maintenance of vessel integrity. The numbers of endothelial junctions, the presence of trans‐endothelial channels and the extent of pericyte coverage all provide an insight into the factors determining capillary permeability.

It has been 30 years since David Barker and colleagues published their first work on the association between in utero environment and cardiovascular disease in later life (Barker et al. 1989). Since that time, there has been a huge amount of research carried out on the impact of sub-optimal developmental environments and future disease risk. Using population cohorts and various animal models the impact of maternal undernutrition, overnutrition, hypoxia and stress has been shown to be linked to adverse outcomes in the offspring across a range of systems including cardiometabolic, respiratory and reproduction among others (Hanson & Gluckman, 2014). Yet, despite this large body of work, research has mostly focused on the maternal environment and role of the father has been relatively ignored. This though is starting to change, and a paper published in this issue of The Journal of Physiology by Morgan et al. (2020) provides some insight into how paternal transmission of disease risk can occur between generations. In their paper, Morgan et al. (2020) have used a model of protein restriction that has previously been shown to have repeated effects on embryo development, blood pressure control and transmission of effects to the second generation, via the maternal line (Torrens et al. 2008; Watkins et al. 2008). In focusing on the paternal influence, Morgan et al. (2020) can separate out any such programming into that which reflects a primary effect on the developing embryo/fetus and that which is a consequence of altered maternal environment. Although there is no change in maternal dietary composition, the seminal plasma is capable of altering the immediate uterine environment (Sharkey et al. 2012). One of the strengths of the work of Morgan et al. (2020) is that, to combat this effect, they have sought to independently investigate the effect of paternal low protein diet on the sperm alone, on the seminal plasma alone or both sperm and plasma together. The period of protein restriction that the male mice were exposed to had a negligible impact on their cardiovascular or reproductive function. However, it did have a quantifiable impact on their offspring. Importantly, as discussed above, the effect was dependent on whether the sperm, the seminal plasma or both came from protein restricted males. As well as changes in ACE activity in the offspring, there was also an increased expression of Ace1, Ace2 and the type 1 angiotensin-receptor in both the male and female offspring, suggesting overall cardiovascular dysregulation (Paul et al. 2006). These changes in the F1 offspring were associated with vascular dysfunction in isolated mesenteric arteries, evident as either an overall decrease in the endothelial-dependent relaxation or in the relative contributions of nitric oxide (NO) or endothelial-derived hyperpolarising factor (EDH) to this. Such changes have been observed in the offspring of maternally protein restricted dams (Torrens et al. 2008; Watkins et al. 2008) and it would appear that similar effects are seen following paternal programming. A key finding of the work presented by Morgan et al. (2020) is that the effect of paternal protein restriction is still apparent in the second-generation offspring (F2). Furthermore, these effects are present in the absence of an additional dietary challenge in the first (F1) generation. Like the F1 before them, the F2 generation also show altered ACE activity and RAS regulation. Helpfully, the authors provide a mechanism for this transgenerational impact in their analysis of the epigenetic status of the testes in the F1 generation. Here they show altered expression of genes involved in histone modifications and methylation, as well as an overall change in DNA methylation, and similar changes have been shown to persist down the maternal lineage from P0 to F2 (Burdge et al. 2007). In summary, the study by Morgan and colleagues highlights the importance of the paternal nutrition and environment around the time of conception for the health and development of subsequent offspring. Current antenatal advice tends to ignore prospective fathers, and as such they may be forgiven for thinking their environment is unimportant. This work shows, however, that if fathers are not careful, their sins will be visited on to their children and grandchildren. The author has no conflicts of interests to disclose. Sole author. None.

Pregnancy is associated with a number of structural and functional cardiovascular adaptations that ensure the fetus is adequately supplied with nutrients throughout all phases of growth and development. Failure to meet the increased metabolic demands can lead to significant maternal and fetal morbidity. Maternal hypertension, either pre-existing or developing during pregnancy, is complicated by the limitations of our current anti-hypertensive medication. The mainstays of anti-hypertensive treatment, such as angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor antagonists/blockers (ARBs/Sartans) and thiazide diuretics are associated with an increased risk of congenital abnormalities to the developing fetus (NICE, 2019). As such, there remains a need to increase the available options for treatment of hypertension in pregnancy. Nitric oxide (NO), derived from the oxidative metabolism of l-arginine by the enzyme nitric oxide synthase (NOS), plays an important role in lowering peripheral vascular resistance critical to the maternal adaption to pregnancy (Hata et al. 1998). A decrease in NO bioavailability is also associated with poor maternal adaptation and fetal growth restriction (Kusinski et al. 2012). Dietary nitrate can be reduced in the body to nitrite (and possibly further to NO) in a NOS-independent manner, and an increased dietary nitrate consumption has been shown to decrease blood pressure (Kapil et al. 2010; Kerley et al. 2018). Beetroot juice is known to be a rich source of nitrate. In their paper published in The Journal of Physiology, Tropea et al. (2020) have investigated whether this juice can improve endothelial function in pregnant eNOS−/− knock-out mice, and importantly whether this is actually due to nitrate. The eNOS−/− knock-out mouse model has been shown to have elevated blood pressure, endothelial dysfunction and fetal growth restriction (Kusinski et al. 2012), and similar responses were seen by Tropea et al. (2020). For 6 days in the second-half of pregnancy (day 12.5–18.5, term 19.5 days) mice received either water, beetroot juice or a placebo beetroot juice, with a significantly reduced nitrate content. Maternal plasma nitrate concentrations were raised only in the beetroot juice supplemented animals, while maternal plasma nitrite was only raised in the eNOS−/− mice on beetroot juice. The placebo beetroot juice did not affect the maternal plasma concentrations of either nitrate or nitrite. Despite this differential effect on circulating nitrate concentrations, both the placebo and the beetroot juice significantly decreased blood pressure and improved isolated uterine artery endothelial function in the eNOS−/− mice. However, despite this increase in uterine artery reactivity, neither peak systolic velocity nor fetal growth improved with either beetroot juice or placebo. An important feature of this work is the use of the appropriate controls. With the development of nitrate-depleted beetroot juice (Gilchrist et al. 2014) this would seem to be the ideal ‘placebo control’ and surely more relevant than just providing mice with regular drinking water. However, this also implies nitrate is the only bioactive constituent of beetroot juice, and yet the effect size of a beetroot juice intervention has been shown to be lower when compared to a placebo that is a nitrate-depleted beetroot juice than when compared to another control (Bahadoran et al. 2017). Indeed, in their paper, Tropea et al. (2020) show positive effects on blood pressure and vascular reactivity in both beetroot juice groups, irrespective of whether nitrate was present or not. Had the nitrate-depleted, placebo juice been the only control, it would have appeared that there was no effect of supplementation at all. The importance of maternal endothelial dysfunction and a loss of NO bioavailability in fetal growth restriction is evident when experimental models such as the eNOS−/− knock out mice are used (Kusinski et al. 2012). In some models, the pharmacological amelioration of endothelial dysfunction has been shown to prevent growth restriction (Sekimoto et al. 2020). Supplementation with beetroot juice (either with or without nitrate) was shown to improve vascular reactivity of isolated uterine arteries in this mouse model and has also been shown to improve microvascular function in humans with Raynaud's disease (Shepherd et al. 2019). Taken together with the growing literature on dietary nitrate and beetroot juice in particular, the study by Tropea et al. (2020) suggests that beetroot juice may produce a favourable cardiovascular outcome in a manner that is independent of its nitrate content. While the reduction in blood pressure did not translate into an increase in late gestation fetal size, it had no negative impact on fetal growth either. In a condition like hypertension in pregnancy, where treatment options are limited because of potential risk to mother and fetus, a dietary supplement that is both safe and effective could be hard to beet. None. Both authors have approved the final version of the manuscript and agree to be accountable for all aspects of the work. All persons designated as authors qualify for authorship, and all those who qualify for authorship are listed. None.

OBJECTIVES:Despite robust evidence on health inequalities in adulthood, less attention has been paid to inequalities in adolescence. The aim of this overview was to examine systematic review (SR) evidence on the equity impact of population-level interventions intended to improve health, happiness and wellbeing for adolescents. STUDY DESIGN:An overview (review of systematic reviews). METHODS:Eleven electronic databases were systematically searched to identify SRs of population-level interventions for adolescent health. A secondary data analysis of socioeconomic inequality was conducted to identify whether SRs reported on primary studies in terms of disadvantage, by measures of socioeconomic status (SES) and by differential effects. RESULTS:35,310 review titles were screened; 566 full texts were retrieved and 140 SRs met the predefined selection criteria. Differential intervention effects were considered in 42/140 (30%) SRs, 18/140 (13%) reported primary studies using an SES measure and 16/140 (11%) explicitly reported differential effects. 15/140 SRs (11%) explicitly focused on socioeconomic inequalities; of these 4/15 reported differential intervention effects in more detail, 7/15 concluded there was insufficient primary evidence to identify the impact of interventions on socioeconomic inequalities and 4/15 planned to examine differential effects by SES, but this was not reported further. CONCLUSIONS:Our overview identifies that there is limited SR evidence on the equity impact of population-level interventions for adolescent health. Strengthening the evidence on whether interventions narrow or widen inequalities for adolescents must be a priority for public health research.

Bicuspid aortic valve (BAV) disease remains the most common congenital cardiac disease and is associated with an increased risk of potentially fatal aortopathy including aortic aneurysm and dissection. Mutations in the NOTCH1 gene are one of only a few genetic anomalies identified in BAV disease; however evidence for defective NOTCH signaling, and its involvement in the characteristic histological changes of VSMC apoptosis and differentiation in ascending aortae of BAV patients is lacking. This review scrutinizes the evidence for the interactions of NOTCH signaling, cellular differentiation and apoptosis in the context of aortic VSMCs and provides focus for future research efforts in the diagnosis of BAV aortopathy and prevention of catastrophic complications through NOTCH signaling manipulation.

gradient bottom PMS 1815C C13 M96 Y81 K54 on dark backgrounds on light backgrounds standard no gradients watermark stacked logo (for sharing only) standard no gradients watermark stacked logo (for sharing only) white WHITE C0 M0 Y0 K0 black BLACK

Background Type 2 diabetes mellitus (T2DM) has been established as an important independent risk factor for aortic stenosis. T2DM patients present with a higher degree of valve calcification and left ventricular dysfunction compared to patients without diabetes. This may be due to an increase in incidence and severity of myocardial fibrosis. Currently, there is no reliable method of determining the optimal timing of intervention for a patient with asymptomatic aortic stenosis or predicting when a patient will become symptomatic. Research into serum biomarkers to predict subclinical onset and track progression of aortic stenosis is hampered by the multimodal nature of the pathological processes ultimately responsible for aortic stenosis. Objective The aim of this study is to prove that an approach using a combination of serum biomarkers and the echocardiographic parameter global longitudinal strain (GLS) can be used to establish baseline status of fibrocalcific aortic valve disease, predict rate of progression, and quantitatively assess any regression of these processes following aortic valve replacement in patients with T2DM. Methods Validated serum biomarkers for the separate processes of calcification, inflammation, oxidative stress and fibrosis can be used to quantify onset and rate of progression of aortic stenosis. This, in combination with the echocardiographic parameter GLS, can be compared with other objective investigations of calcification and fibrosis with the aim of developing a quick, noninvasive one-stop assessment of aortic stenosis in patients with T2DM. The serum biomarkers BNP (B-type natriuretic peptide), Gal-3 (Galectin-3), GDF-15 (growth differentiation factor-15), sST2 (soluble suppression of tumorigenicity 2), OPG (osteoprotegerin), and microRNA 19b and 21 will be sampled from patients undergoing aortic valve replacement (with and without T2DM), patients with T2DM but without aortic valve disease and healthy volunteers. These patients will also undergo computed tomography (CT) scans for calcium scoring, magnetic resonance imaging (MRI) to quantify myocardial fibrosis, and myocardial strain imaging with speckle-tracking echocardiography. Samples of calcified native aortic valve and a biopsy of ventricular myocardium will be examined histologically to determine the quantity and distribution of calcification and fibrosis, and the secretome of these tissue samples will also be analyzed for levels of the same biomarkers as in the serum samples. All patients will be followed up with in 3 months and 12 months for repeat blood sampling, echocardiography, and CT and MRI imaging to assess disease progression or regression. The results of tissue analysis and CT and MRI scanning will be used to validate the findings of the serum biomarkers and echocardiographic assessment. Results Using all of the information gathered throughout the study will yield a ranking scale for use in the clinic, which will provide each patient with a fibrocalcific profile. This can then be used to recommend an optimal time for intervention. Conclusion A reliable, validated set of serum biomarkers combined with an inexpensive bedside echocardiographic examination can now form the basis of a one-stop outpatient-based assessment service, which will provide an accurate risk assessment in patients with aortic stenosis at first contact. International Registered Report Identifier (IRRID) PRR1-10.2196/13186

OBJECTIVES:Bicuspid aortic valve disease is common and is associated with ascending aortic aneurysms. Vascular smooth muscle cell (VSMC) apoptosis is characteristic of the ascending aorta of bicuspid patients, and NOTCH1 gene mutations have also been linked to the disease. NOTCH signalling is a fundamental cell signalling pathway, which dictates cell fate decisions including apoptosis. Our objective was to elucidate the role of NOTCH signalling in VSMC apoptosis and differentiation in bicuspid aortopathy.METHODS:Ascending aortic biopsies were obtained from 19 bicuspid and 12 tricuspid aortic valve patients and were sub-classified into 4 groups according to the maximum ascending aortic diameter (aneurysmal  ≥45 mm). Apoptotic VSMCs were counted by light microscopy using a TUNEL assay. Gene expression of key regulators of NOTCH signalling (NOTCH1 and HES1), apoptosis (BAX and BCL-2) and VSMC differentiation (MYH11, CNN1 and MYH10) were quantified using quantitative real-time PCR. Primary VSMCs were cultured from 2 tricuspid aortic valve and 2 bicuspid aortic valve patients, NOTCH signalling was inhibited with N-[N-(3,5-Difluorophenacetyl)-l-alanyl]-S-phenylglycine t-butyl ester, and the gene expression was again quantified.RESULTS:The apoptotic cell count was significantly higher in bicuspid aortic valve patients (3.2 cells/50 000 μm2 vs 1.1 cells/50 000 μm2; P = 0.033). There was a trend towards lower apoptotic cell count in the aneurysmal versus non-aneurysmal tricuspid and bicuspid groups and an increased ratio of proapoptotic gene expression, which was not statistically significant. This was associated with a 2.8-fold increase in contractile gene expression (P = 0.026) and a 2.0-fold increase in NOTCH signalling gene expression in bicuspid versus tricuspid aortic valve patients (P = 0.022). NOTCH inhibition in cultured VSMCs induced a similar pattern of increased proapoptotic and procontractile gene expressions.CONCLUSIONS:This preliminary study suggests that NOTCH activation in the non-aneurysmal bicuspid aortas may underlie aortopathy by influencing VSMC apoptosis and differentiation. NOTCH signalling manipulation may provide a therapeutic target for preventing aneurysms in bicuspid patients. Further studies with larger sample sizes are needed to substantiate the present findings.

Placental function is essential for fetal development and establishing the foundations for lifelong health. The placental villous stroma is a connective tissue layer that supports the fetal capillaries and villous trophoblast. All the nutrients that cross the placenta must also cross the stroma, and yet little is known about this region. This study uses high‐resolution three‐dimensional imaging to explore the structural complexity of this region within the placental villi. Serial block‐face scanning electron microscopy and confocal microscopy were used to image the placental villous stroma in three‐dimensions. Transmission electron microscopy (TEM) was used to generate high resolution two‐dimensional images. Stereological approaches were used to quantify volumes of stromal constituents. Three‐dimensional imaging identified stromal extracellular vesicles, which constituted 3.9% of the villous stromal volume. These stromal extracellular vesicles were ovoid in shape, had a median length of 2750 nm (range 350–7730 nm) and TEM imaging confirmed that they were bounded by a lipid bilayer. Fifty‐nine per cent of extracellular vesicles were in contact with a fibroblast‐like stellate cell and these vesicles were significantly larger than those where no contact was observed. These stellate cells formed local networks with adherent junctions observed at contact points. This study demonstrates that the villous stroma contains extracellular macrovesicles which are considerably larger than any previously described in tissue or plasma. The size and abundance of these macrovesicles in the villous stroma highlight the diversity of extracellular vesicle biology and their roles within connective tissues.

Intrahepatic cholestasis of pregnancy (ICP) causes increased transfer of maternal bile acids to the fetus and an increased incidence of sudden fetal death. Treatment includes ursodeoxycholic acid (UDCA), but it is not clear if UDCA protects the fetus. This study explores the placental transport of the bile acid taurocholate (TC) by the organic anion-transporting polypeptide, (OATP)4A1, its effects on the placental proteome and vascular function, and how these are modified by UDCA. Various methodological approaches including placental villous fragments and Xenopus laevis oocytes were used to investigate UDCA transport. Placental perfusions and myography investigated the effect of TC on vasculature. The effects of acute TC exposure on placental tissue were investigated using quantitative proteomics. UDCA inhibited OATP4A1 activity in placental villous fragments and oocytes. TC induced vasoconstriction in placental and rat vasculature, which was attenuated by UDCA. Quantitative proteomic analysis of villous fragments showed direct effects of TC on multiple placental pathways, including oxidative stress and autophagy. The effects of TC on the placental proteome and vasculature demonstrate how bile acids may cause fetal distress in ICP. UDCA inhibition of OATP4A1 suggests it will protect the mother and fetus against the vascular effects of TC by inhibiting its cellular uptake. UDCA may protect the fetus in ICP by inhibiting OATP4A1-mediated bile acid transfer and TC-induced placental vasoconstriction. Understanding the physiologic mechanisms of UDCA may allow better therapeutic interventions to be designed specifically for the fetus in the future.-Lofthouse, E. M., Torrens, C., Manousopoulou, A., Nahar, M., Cleal, J. K., O'Kelly, I. M., Sengers, B. G., Garbis, S. D., Lewis, R. M. Ursodeoxycholic acid inhibits uptake and vasoconstrictor effects of taurocholate in human placenta.