Background Disruption of critical cell cycle regulators is a potential therapeutic target for brain tumors in children and adolescents. The aim of this study was to determine the maximum tolerated dose (MTD) and describe toxicities related to palbociclib, a selective cyclin dependent kinase 4/6 (CDK4/6) inhibitor in pediatric patients with progressive/refractory brain tumors with intact retinoblastoma protein. Methods Palbociclib was administered orally starting at 50 mg/m2 daily for the first 21 days of a 28 day course. Dose escalation was according to the Rolling-6 statistical design in less heavily (Stratum I) and heavily pretreated (Stratum II) patients, and MTD was determined separately for each group. Pharmacokinetic studies were performed during the first course, and pharmacodynamic studies were conducted to evaluate relationships between drug levels and toxicities. Pharmacogenetic analyses were based on pre-treatment samples. Results A total of 21 patients were enrolled on Stratum I and 14 patients on Stratum II. The MTD for both strata was 75 mg/m2. Palbociclib absorption (mean Tmax between 4.9 and 6.6 h) and elimination (mean half-life between 11.3 and 19.5 h) were assessed. The most common toxicity was myelosuppression. Higher palbociclib exposure was associated with grade 3/4 neutropenia and leukopenia. No patients had an objective response to palbociclib therapy. Conclusions Palbociclib was safely administered to children and adolescents at a dosage of 75 mg/m2 for 21 consecutive days followed by 7 days of rest in both strata. Future studies will be required to establish its optimal utilization in pediatric patients with brain tumors.

Comment on: Langerhans cell histiocytosis with BRAF p.N486_P490del or MAP2K1 p.K57_G61del treated by the MEK inhibitor trametinib1Paige Vicenzi, OMS-IV, 2Anish Ray, MD1Texas College of Osteopathic Medicine, University of North Texas Health Science Center2Department of Pediatric Hematology/Oncology, Cook Children’s Health Care SystemCorresponding Author:Anish Ray, MD1500 Cooper St., 5th floor,Fort Worth, TX 76104Phone: [email protected] Count: 513Number of Tables: 0Number of Figures: 0Running Title: Langerhans cell histiocytosis treated by trametinibKeywords: Langerhans cell histiocytosis, MAP2K1, trametinib, pediatricThe authors have no financial support or conflicts of interest.Langerhans cell histiocytosis (LCH) is a rare but heterogenous myeloid malignancy. The discovery of mitogen-activated protein kinase (MAPK) pathway activating mutations as key oncogenic drivers offered only equivocal implications at best; the promise of targeted therapy was often eclipsed by a more severe clinical course, risk organ involvement, poorer response to standard therapy, and higher risk of relapse.1 There is, however, mounting evidence in support of MAPK pathway inhibition for patients with BRAF V600E mutations. A recent report outlines rapid and durable response of relapsed, multisystemic LCH with either BRAF p.N486_P490 or MAP2K1 p.K57_G61 deletion to MEK inhibitor trametinib.2 Two of the three patients achieved nonactive disease, including a 2-year-old male with MAP2K1 deletion who, despite reports attributing trametinib resistance to MAP2K1 mutations3, continues to thrive. We take this opportunity to describe an analogous experience treating a relapsed LCH patient with trametinib at Cook Children’s Medical Center from early 2020 to present.Our patient is a 4-year-old male who presented in March 2017 with new onset central diabetes insipidus (DI) and skin rash; skin biopsy provided diagnosis of LCH, but skeletal survey was negative for bone involvement. He was treated with twelve cycles of cytarabine (100 milligram (mg)/m2 intravenous daily for five days, every four weeks) and DDAVP for DI. At the completion of cytarabine, a second skin biopsy revealed recurrence of LCH, which warranted treatment with hydroxyurea (20 mg/kilogram (Kg) daily) and methotrexate (2.5 mg at 0.12 mg/Kg twice a week). This was continued for 52 weeks despite a brief interruption of methotrexate due to dermatitis. Three months following completion of this therapy, brain MRI revealed a 7 mm lesion of the skull. Curettage by neurosurgery confirmed relapse of LCH in January 2020. Genetic testing of this sample was negative forBRAF mutation, but positive for a mutation in the MAP2K1 gene, specifically a point mutation resulting in a substitution of Q56P. Shortly after his biopsy, the patient developed a soft tissue swelling on his skull. Due to these results and his multiple relapses, the patient was started on trametinib (2.5 mg daily) in February 2020 with rapid resolution of skull swelling and transient but dramatic reduction of his desmopressin dose from 3.2 mg twice a day to 0.2 mg twice a day. He has not experienced toxicity and continues to tolerate the drug well.Though trametinib presents a promising treatment for high-risk, relapsed LCH, it is not without limitations. In 2020, we also treated a 15-year-old male with relapsed LCH and BRAF V600E with trametinib monotherapy. Due to skin rash (Grade II), the patient became noncompliant. Despite stopping altogether after a month of treatment, he has yet to experience disease recurrence. But as stated in the aforementioned report, sufficient dose and treatment length to attain MAPK pathway suppression merits further investigation. In our similar experience treating a young child with multisystemic LCH and MAP2K1 mutation, we remain encouraged that MEK inhibition via trametinib monotherapy is a viable treatment option. In the context of genomic landscaping, we hope to incite further exploration of targeted therapy, and consequently, greater consensus on LCH management.

We introduced a simple technique to eliminate electromagnetic interference between a left ventricular assist device (LVAD) and an implantable cardioverter-defibrillator (ICD). A 43-year-old male with heart failure and a reduced ejection fraction (HFrEF) who had an ICD presented with decompensated heart failure and received an LVAD as a bridge to transplant. Remote monitoring showed persistent atrial fibrillation causing an inappropriate ICD shock leading to a decision to disable shock therapies. However, an in-office interrogation was unsuccessful due to electromagnetic interference. Patient was instructed to extend his arm above his head on the ipsilateral side of the ICD, thus increasing the distance between LVAD and ICD, eliminating the interaction to allow reprogramming of the device.

In this paper, we establish existence and finite time blow up of weak solutions of a parabolic equation of p(x)-Laplacian type with the Dirichlet boundary condition. Moreover, we obtain upper and lower bounds for the blow up time of solutions, by employing concavity method and differential inequality technique respectively.

Background: Although catheter ablation (CA) is an effective treatment for patients with AF and LVSD, the efficacy of an initial cryo-ablation strategy is unknown. This study evaluated long term outcomes of patients with an initial cryo-ablation strategy for AF and LV systolic dysfunction (LVSD). Methods: Outcomes of patients undergoing index cryoablation for AF from January 2008 until March 2018, with documented pre-ablation LVEF45% were evaluated for long term freedom from AF and change in ventricular function from baseline. Results: 76 patients met inclusion criteria. Patients were predominantly male (80%), aged 63 11yrs, with an average CHADS2 VASc score of 2.66  1.40, baseline LVEF 34  8.7% (ischaemic in 37%) and NYHA class 2.37  0.72. Repeat procedures were performed in 13%. The single procedure success was 70% at 1 year (81% for paroxysmal AF, 65% for persistent AF, 29% for long-standing persistent AF) and at 28  13 months follow up was 43% (50%, 41% and 21% respectively), increasing to 59% allowing for subsequent redo procedure with RF ablation (64%, 57%, and 50% respectively). At follow up, LVEF significantly improved to 46  16% (p<0.001), and NYHA reduced to 1.51  0.66 (p<0.001). Conclusion: An initial strategy of cryoablation in patients with AF and LVSD is an effective approach in the treatment of patients with concurrent AF and LVSD. Larger, randomised prospective studies are required to confirm these findings.

Monoclonal antibodies are high value agents used for disease therapy (‘biologic drugs’) or as diagnostic tools which are widely used in the health care sector. They are generally manufactured in mammalian cells, in particular Chinese hamster ovary (CHO) cells cultured in defined media, and are harvested from the medium. Rheb is a small GTPase which, when bound to GTP, activates mechanistic target of rapamycin complex 1 (mTORC1), a protein kinase that drives anabolic processes including protein synthesis and ribosome biogenesis. Here we show that certain constitutively-active mutants of Rheb drive faster protein synthesis in CHO cells and increase the expression of proteins involved in the processing of secreted proteins via the endoplasmic reticulum, which expands in response to expression of Rheb. Active Rheb mutants, in particular Rheb[T23M], drive increased cell number under serum-free conditions similar to those used in the biotechnology industry. Rheb[T23M] also enhances the expression of the reporter protein luciferase and, especially strongly, the secreted Gaussia luciferase. Moreover, Rheb[T23M] markedly (2-3 fold) enhances the amount of this luciferase and of a model immunoglobulin into the medium. Our data clearly demonstrate that expressing Rheb[T23M] in CHO cells provides a simple approach to promoting cell growth in defined medium and the production of secreted proteins of high commercial value

Yellow fever (YF) is a life-threatening viral disease endemic in large areas of Africa and Latin America. Although there is a very efficacious vaccine since the 1930s, YF still causes 29,000-60,000 annual deaths. During recent YF outbreaks there were issues of vaccine shortage due to limited supply of the current egg-derived vaccine; rare but fatal vaccine adverse effects occurred; and cases were imported to Asia, where the mosquito vector circulates and where local transmission could potentially start. In this work, we investigated the production of YF virus-like particles (VLPs) using suspension-adapted stably-transfected HEK293 cells. In order to develop an intensified process, we combined two strategies: the use of sequential FACS rounds to enrich the stable cell pool in terms of high producers, and the use of perfusion processes. At first, shaken tube experiments revealed that FACS enrichment of the cell pool allowed doubling VLP production, and that in pseudoperfusion cultures (with daily medium exchange) lasting 14 days VLP production increased by 8.3 fold as compared to batch cultures lasting 11 days. When true perfusion cultures were carried out in bioreactors, the use of an inclined cell settler as cell retention device showed operational advantages as compared to an ATF system.

Dapsone had been used for leprosy but now used in dermatological conditions. The medical emergency team saw a patient on Dapsone with low oxygen saturation despite 8L/min O2 and elevated methaemoglobin level. After diagnosising dapsone related methaemoglobinaemia dapsone was ceased and Vitamin C given intravenously for 4 days

Understanding genetic variation and structure, adaptive genetic variation and its relationship with environmental factors is of great significance to understand how plants adapt to climate change and design effective conservation and management strategies. The objective of this study was to (I) investigate the genetic diversity and structure by AFLP markers in 36 populations of R. aureum from northeast China, (Ⅱ) reveal the relative contribution of geographical and environmental impacts on the distribution and genetic differentiation of R. aureum; (Ⅲ) identify outlier loci under selection and evaluate the association between outlier loci and environmental factors and (Ⅳ) exactly calculate development trend of population of R. aureum，as it is confronted with severe climate change and to provide information for designing effective conservation and management strategies. We found high genetic variation (I = 0.584) and differentiation among populations (ΦST = 0.711) and moderate levels of genetic diversity within populations of R. aureum. A significant relationship between genetic distance and environmental distance was identified, which suggested that the differentiation of different populations was the caused by environmental factors. Using BayeScan and Dfdist, 42 outlier loci identified and most of the outlier loci are associated with climate or relief factors, suggesting that these loci are linked to genes that are involved in the adaptability of R. aureum to environment. Species distribution models (SDM) showed that climate warming will cause a significant reduction of suitable area for R. aureum especially under the RCP 85 scenario. Our results help to understand the potential response of R. auruem to climatic changes, and provide new perspectives for R. auruem resource management and conservation strategies.

How and why species range size varies along spatial gradients is fundamental yet controversial topics in biogeography. To advance our understanding on these questions and to provide insight into biological conservation, we assessed the elevational variations in vascular plants range size for different life form and biogeographical affinities, and explored the main drivers underlying above variations in the longest valley in China's Himalayas---the Gyirong Valley. Elevational range sizes of vascular plants were documented by 96 sampling plots along 12 elevational bands of 300-m ranging from 1800 to 5400 m above sea level. We assessed the elevational variations in range size by averaging the range size of all species within each elevational band. We then related range size to climate, disturbance, competition factors and the mid-domain effect, and explored the relative importance of aforementioned factors in explaining the range size variations using the Random Forest model. Total 545 vascular plants were documented by our sampling plots along the elevational gradient. Out of 545 plants, 158, 387, 337 and 112 were woody, herbaceous, temperate and tropical species respectively. Range size of each groups of vascular plants shown uniform increasing trends along the elevational gradient which are in accordance with the prediction of Rapoport's rule. Climate was the main driver for the increasing trends of vascular plants range size in the Gyirong Valley. Climate variability hypothesis and mean climate condition hypothesis were both supported to jointly explain such climate-range size relationship. Our results reinforce previous notion that Rapoport's rule applies to where the influence of climate is most pronounced, and call for close attention to the impact of climate change in order to prevent range contraction and even extinction under global warming.

In this investigation we have used NG-QTAIM to fully quantity the response to the four IR-active modes of all the bonding in benzene in terms of bond-flexing, bond-torsion and bond-anharmonicity that includes the tendencies towards IR-responsivity and IR-non-responsivity. Bond-anharmonicity is found to be lacking for the C-C bonds comprising the lowest frequency mode (721.57 cm-1) measured as the absence of bond critical point (BCP) sliding. Additionally, bond-flexing was absent for this mode harmonic-like variation of the profile of the variation of the wrapping (torsion) of the {p,p’} path-packet, referred to as the Precession K, along the conventional QTAIM bond-path, the remaining three IR-active mode possessed step-like variations in the K profiles. The presence of non-nuclear attractors was detected for the IR-active mode with frequency 1573.93 cm-1 with C-C K profiles that most closely resemble those of the relaxed benzene. We quantified the C-H bonds in terms of bond-flexing and bond-anharmonicity and IR-responsivity and IR-non-responsivity.

Understanding community restoration state and the corresponding assembly mechanism is helpful to assess the restoration measures and predict community dynamics. We collected plots by shrub cover (low, medium and high) in three Caragana mircophylla shrub-encroached grasslands which were fenced since 1979, 1983, and 2003 (fencing duration) in the northern China, to explore the effect of fencing duration and shrub cover on the community restoration by vegetation investigation and phylogenetic approach. There were significant differences in community composition among different fencing duration or shrub cover treatments. Species richness in the site of fencing since 1979 or in the plots of high shrub cover was relatively higher than that in any other sites or plots. By phylogenetic analysis, functional traits were phylogenetically convergent. Based on the standardized effect sizes of mean pairwise distance (SESMPD) ranged from -1.96 to 1.96 in six out of nine plots, which suggested that stochastic processes dominated community assembly. SESMPD were lower than -1.96 in the rest three plots which indicated that competitive exclusion drove community assembly. These results indicated that the increase of fencing duration or shrub cover could enhance competitive exclusion. The present findings highlighted the importance of shrub in influencing the community composition and community assembly, supporting that shrub-encroached grassland is another stable state in the semi-arid northern China. Therefore, it is essential to distinct shrub-encroached grassland from degraded grasslands when formulating relevant conservation and management measures in the semi-arid regions.

ABSTRACT ¬ Rationale, aims and objectives: Physician consultations are a limited resource. Anesthesiologists provide anesthesia during surgery and procedures, prepare patients for surgery in preoperative clinics, and provide postoperative care. This study sought to evaluate current consultation usage patterns, with an aim to determine possible opportunities for efficiency. Method: A retrospective comprehensive population-based cohort study was performed, evaluating all hospitals in the Canadian province of Ontario from 2002-2018. The main outcome measures were American Society of Anesthesiologists (ASA) classification of the patients, and whether the patients underwent surgery within 3 months following the anesthesia consultation. Results: A cohort of 2,023,499 patients, and a total of 2,920,100 preoperative anesthesia consultations was obtained. The number of consults per year doubled between 2003 (112,983/year) and 2017 (246,427/year). Each year, an average of 19.32% of the consults (range: 17.69-20.49%) were for patients that did not progress to having surgery. Of those that did have surgery following the anesthesia consult, 37.23% were ASA Classification I or II. The most common surgical procedures (percent of total) following anesthesia consult were: Knee implantation of internal device (9.46%), hip implantation of internal device (5.84%), cataract excision (4.09%), repair of muscle of chest/abdomen (3.31%), uterus excision (2.76%), and gallbladder excision (2.67%). Conclusions: This study reveals data on utilization and trends over time of preoperative anesthesia consultations. Potential opportunities for optimization were found, including patients who did not proceed to surgery, and healthier patients undergoing low to moderate risk surgery that may not require consultation.

Motion capture and analysis techniques are emerging in the surgical education and surgical education research literature as viable ways to augment the assessment of technical skills. In particular, these methods provide an opportunity to reveal objective information about the efficiency of surgical procedures, above and beyond the accuracy of procedural outcomes. One assessment that is very prevalent in the literature are counts of the number of movements a surgeon makes in completing a technical performance. In this commentary, the number of movements metric is explored from kinesiology and engineering perspectives; two disciplines that have contributed heavily to the development of rigorous motion analysis methods. Furthermore, the assumption that skill efficiency improves linearly as a learner progresses along the continuum of expertise is challenged. While movement efficiency does certainly improve, this assumption does not necessarily capture the way that learners flexibly prioritize particular aspects of performance in the intermediate stages of skill learning. By way of this commentary, important a priori decisions that should proceed effective motion capture and analysis are highlighted, a call for the standardization of procedures is made, and an opportunity to better understand the way that computerized movement analysis techniques may contribute (or be detrimental) to competency constructs in surgical education and assessment is realized.

Dear Editor, We really appreciate MN van IJsselmuiden et al. for their efforts in conducting the first ever multicenter randomized controlled trial to compare laparoscopic sacrohysteropexy (LSH) with sacrospinous hysteropexy (SSHP).1 However, I have some questions regarding the methodology and results of this trial. What are the reasons for including patients with histories of previous pelvic floor or prolapse surgery in the exclusion criteria? Would randomly and equally allocating these patients into two surgical groups affect the study result or design? Nevertheless, we are really interested in the conduct of anterior or posterior colporrhaphy through the laparoscopic method.Patients presented with anterior vaginal wall prolapse are higher in number: POP-Q stage- Aa or Ba > 0 (LSH group:81%; SSHP group:72.6%) than those presented with apical prolapse (LSH group:46.6%; SSHP:45.6%) in Table 1. The majority of study population appears to have combined anterior and apical compartment prolapse rather than apical prolapse alone. Furthermore, Table 2 shows that the overall anterior compartment failure rates are 50.9% and 56.9% in the LSH and SSHP groups, respectively, in a 1 year follow-up interval. The failure rate is extraordinarily high compared with that in a previous study.2 Hysteropexy surgery is beneficial for patients with apical prolapse. It is not beneficial for patients with combined anterior and apical compartment prolapse with prominent cystocele. Most patients are satisfied with the 1 year surgical results and would recommend surgery to someone else (LSH: 87.7%; SSHP: 89.7%) despite the high recurrence rate of anterior wall prolapse in a 1 year follow-up.In the statistical analysis section, additional anterior vaginal wall repairs are significantly higher in the SSHP group than those in the LSH group (SSHP: n = 61, 98.4%; LSH: n = 55, 85.9%, P = 0.010). I would like to know how this small number difference (61 − 55 = 6) in these groups can cause significant difference in P value and how this P value is calculated. This trial assumes a failure rate of 3% on the basis of the outcomes of SSHP in a previous prospective study. However, the data population is relatively small, and the non-inferiority margin was set at 10%.The primary outcome is defined as a composite outcome of the surgical failure of the apical compartment after 12 months of follow-up and as the recurrence of uterine prolapse (POP-Q ≥ stage 2). Surgical success is defined as the absence of prolapse beyond the hymen. In the POP-Q stage system, POP-Q stage 2 is defined as the most distal prolapse between 1 cm above and 1 cm beyond the hymen.3 The most prominent prolapse, which descends beyond hymen, is the stage 2 prolapse. It elicits clinical controversy and conflicts with regard to the definitions of surgical failure and success. We hope that this letter will deliver the message that precise preoperative patient selection and study design are crucial, as they may have substantial impacts on clinical outcomes and treatment success.Min-syuan Huang,2, 3 Zi-Xi Loo,1Kun- Ling Lin,1, 2 Cheng-Yu Long1, 21 Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan2 Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan3 Department of Obstetrics and Gynecology, Kuo General Hospital, Tainan, Taiwan

IgE, the key molecule in atopy has been shown to bind two receptors, FcRI, the high affinity receptor and FcεRII (CD23), mostly found on B cells and that binds IgE with lower affinity. Whereas cross-linking of IgE on FcRI triggers allergic reaction, binding of IgE to CD23 is known to play an important role in both IgE synthesis and presentation. Thus, targeting IgE-immune complexes on B cells has shown to enhance antibody and T cell responses in mice and humans. However, the mechanisms that regulate the targeting of the two receptors and the respective function of the two pathways in inflammation or homeostasis are still matter of debate. Here, we discuss several mechanisms related to IgE and IgE binding to both receptors, as well as the influence of the antigen binding on different immune cells expressing the receptors. One recent paper has shown that free IgE preferentially binds to FcRI whereas IgE immune complexes (IgE-ICs) are preferentially captured by CD23. Binding of IgE-ICs to CD23 on B cells can on one hand regulate serum IgE and prevent effector cell activation and on the other hand facilitate the antigen presentation by delivering antigen to dendritic cells. The data suggest that CD23 play a multifunctional role in regulating the allergic response pathway.

Background: Breastfeeding is associated with long-term health benefits, such as a lower incidence of allergy, asthma, diabetes or celiac disease. However, little is known regarding how the maternal and neonatal immune systems interact after parturition when the neonate receives nutrition from maternal breastmilk. Methods: We undertook a comparative analysis of immune repertoire and function at birth and 3 weeks of age in a cohort of 38 term neonates born by caesarean section grouped according to feeding method (breastmilk versus formula). We used flow cytometry to study the immune phenotype in neonatal and maternal blood samples and mixed lymphocyte reactions to establish the proliferation response of neonatal versus maternal lymphocytes and vice versa. The microbiome of neonatal stool samples was also investigated using 16S rRNA sequencing. Results: We show that the proportion of regulatory T cells (Tregs) increases in this period and is nearly two-fold higher in exclusively breastfed neonates compared to those who received formula milk only. Moreover, breastfed neonates show a specific and Treg-dependent reduction in proliferative T cell responses to non-inherited maternal antigens (NIMA), associated with a reduction in inflammatory cytokine production. Conclusions: These data indicate that exposure of the neonate to maternal cells through breastfeeding acts to drive the maturation of Tregs and ‘tolerizes’ the neonate towards NIMA.

Dear Sir, Whilst the primary focus of our commentary was to reflect upon the multitude of clinical and institutional changes prompted by COVID-19 to help adopt a more streamlined approach to healthcare,1we thank Herron et al for highlighting the importance of partner support during labour.2 However, we note that even during the peak of the first wave of infections, the Royal College of Obstetricians and Gynaecologists (RCOG) continued to advocate the presence of a single birth partner throughout labour. Many obstetric units, including our own, managed to successfully adhere to this practice throughout the pandemic. However, guidance from the RCOG for women attending antenatally, for face to face clinic appointments or ultrasound scans, was to attend alone. This was subsequently implemented in most hospitals in order to reduce the number of visitors.1 Whilst necessary during the initial fear and uncertainty surrounding COVID-19, moving forward it is important to consider the potential negative impact of partner non-attendance antenatally, as well as intrapartum. Partners often positively encourage women to seek care and prepare for birth complications, thereby preventing delay in treatment and helping to manage expectations, which have been shown to positively impact outcomes.3 Whilst undoubtedly an exciting time for many, pregnancy and the prospect of motherhood is daunting to others. Partners provide support and facilitate decision making throughout the antenatal process, particularly in difficult circumstances such as following the diagnosis of a missed miscarriage, during counselling for pregnancies affected by genetic abnormalities, or after an intrauterine death. The restrictions on partner attendance may therefore inadvertently prevent a number of women seeking care during pregnancy, for fear of having to face procedures or receiving bad news alone. Evidence from a London hospital supports this notion after demonstrating a significant increase in stillbirth rate during the pandemic compared to pre-pandemic (9.31 per 1000 births Vs 2.38 per 1000 births; p=0.01). Of significance, no cases were affected by COVID-19, nor were there any post-mortem findings suggestive of the virus.4The utilisation of remote consultations with a woman and her partner offers a suitable option in appropriately triaged cases.1 Even in remote consultations where inadvertent difficult decisions arise, the presence and support of their partner facilitates collaborative decision making. Ironically, those with high risk enough pregnancies to warrant in person consultations, where additional support could offer significant value, are those whereby partners are not permitted. Prior to the pandemic, partners often reported feeling excluded, fearful of the uncertainty of pregnancy and labour and frustrated by perceived lack of support from healthcare professionals.5 This may subsequently negatively impact their relationship because of the inability to adequately support their partners. Their exclusion from the majority of antenatal care therefore, may not only negatively impact psychological wellbeing of women which may in turn result in suboptimal outcomes, but also negatively impact their future relationship. As such, we agree with Herron et al and support their notion that attempts should be made towards delivering individualised patient centred care both antenatally and intrapartum.Lorraine S Kasaven1,2, Srdjan Saso1,2, Jen Barcroft1,2, Joseph Yazbek1,2, Karen Joash1, Catriona Stalder1, Jara Ben Nagi,2 J Richard Smith,1,2 Christoph Lees1,2, Tom Bourne1,2, Benjamin P Jones1,21 Queen Charlotte’s and Chelsea Hospital, Department of Cancer and Surgery, Imperial College NHS Trust, W12 0HS London, UK.2 Imperial College London, Department of Cancer and Surgery, London W12 0NN, UK.