Novel concepts in every day practice

The concept that one could replace a body part from another of the (autograft) or even person (homograft) has been around for millennia. In fact, autogenous skin flaps were carried out as far back sixteenth century. But it is only in 20th century better understanding immunology clarified reasons observation homograft failure, due to groundbreaking work Billingham, Brent, and Medawar. Using an identical twin donor allowed first truly successful human kidney transplant, undertaken Boston 1954. However, reducing immune response overcome genetic barrier transplantation was needed allow more widespread use. Initially this using radiation, while investigations drug-based immunosuppression substitute radiation followed. pioneers advances are too many mention, I recommend excellent review by Watson Dark those interested delve deeper into subject (British Journal Anaesthesia, 108, 2012, i29–i42; https://doi.org/10.1093/bja/aer384). Landmarks included prolongation mercaptopurine, azathioprine steroids, addition ciclosporin, use monoclonal antibodies, tacrolimus eventually low-dose maintenance clinical transplants. These also increasingly good results with heart, liver, lung pancreatic transplantation. methods much reduced side-effects, called ‘almost’ ‘prope tolerance’ have had important impact our field: online version issue, Scientific Impact paper on Uterine Transplantation (page e51) discusses how technique now able give opportunity women uterine factor infertility achieve pregnancy, at least based fact ‘the burden immunosuppressive medications offset improvement quality life’. surprised read such affects 1 500 childbearing age, about 1.5 million worldwide. Paper summarises existing studies, highlights alternatives proposes framework establishing sustainable programme, discussing issues potential recipients donors. This exciting years development, yet remains under investigation. On hand offers possibility alternative option other associated significant morbidity, requirement repeat surgery risks immunosuppression. As consequence, than 70 procedures performed (and 23 live births reported following technique), merit careful consideration, authors report should be commended their efforts collecting all available data – including reports media. They make point novel therapies interventions demand robust governance structures, safety monitoring well long-term registration follow-up. After particularly complex decision timing removal uterus, maximising time pregnancy but limiting recipient–graft time. Not surprisingly, given novelty procedure, no guidelines address decisions whether retain transplanted uterus second undergo ‘graft hysterectomy’. page 1610 Liza Johannesson share experience Dallas Uterus Transplant Study (DUETS) need multifaceted counselling - support psychologists order reach balanced decision-making considers recipient/couple preference regarding pregnancy; complications rejection; maternal complications; obstetrical What clear these papers transition practice just starting, will remain highly specialised foreseeable future. BJOG issue contains whole series articles inform every day care. study Williamson et al 1635) deals intrahepatic cholestasis defined pruritus elevated total serum bile acids (TSBA). elegant show diurnal variations TSBA. face suggests difficulty determining clinically appropriate diagnostic thresholds. Very practically, argue that, since adverse perinatal outcomes peak concentrations TSBA, measurement non-fasting levels greatest relevance. suggest postprandial required identify high-risk pregnancies threshold ≥19 μmol/l would improve accuracy, essence changing thresholds pregnancy. Large studies databases consistently significantly lower rates obstetric anal sphincter injuries when episiotomy during operative vaginal delivery. At same time, difficulties encountered conducting randomised trials field. therefore great interest Ankarcrona 1663). takes advantage large scale Swedish Medical Birth Register, process propensity scoring emulate controlled trial. association between reduction nulliparous delivered vacuum extraction, compared episiotomy. Also sure thoughtful accompanying mini-commentary Sultan deLeeuw 1672), who guide us through evidence ask really assess performance Finally, like highlight anaemia global problem increased mortality, Caesarean section, low birth weight, small-for-gestational preterm birth, neonatal mortality [Ohuma al, EClinicalMedicine, Volume 29, 100660]. Globally 40% pregnant anaemia, highest prevalence South-East Asia Africa; among 15–49 age relevance UN Sustainable Development Goals WHO nutrition targets. Hull 1674) studied South Africa, where there not high very HIV infection Through analysis trajectories haemoglobin confirmed iron-deficiency after iron supplementation started, recovery 0.1 g/dl per week slower average positive negative women. reminds interplay nutrition, infection, socioeconomic status. It shows therapy possible positive, start early reason engage antenatal