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Human pregnancies contain large amounts of water in several compartments, including the fetal body, the placenta and membranes, and the amniotic fluid (AF). This water circulates within the conceptus and also between fetus and mother. Normal acquisition and circulation of water is critical to fetal health and development, and abnormal amounts of water, evidenced as insufficient (oligohydramnios) or excessive (polyhydramnios) amounts of AF, are associated with impaired fetal outcome, even in the absence of structural fetal abnormalities. This chapter will review the current understanding of water flow to the fetus and into and out of the amniotic cavity, and the evidence suggesting that the fetus may regulate AF volume.
The rocky shores of the north-east Atlantic have been long studied. Our focus is from Gibraltar to Norway plus the Azores and Iceland. Phylogeographic processes shape biogeographic patterns of biodiversity. Long-term and broadscale studies have shown the responses of biota to past climate fluctuations and more recent anthropogenic climate change. Inter- and intra-specific species interactions along sharp local environmental gradients shape distributions and community structure and hence ecosystem functioning. Shifts in domination by fucoids in shelter to barnacles/mussels in exposure are mediated by grazing by patellid limpets. Further south fucoids become increasingly rare, with species disappearing or restricted to estuarine refuges, caused by greater desiccation and grazing pressure. Mesoscale processes influence bottom-up nutrient forcing and larval supply, hence affecting species abundance and distribution, and can be proximate factors setting range edges (e.g., the English Channel, the Iberian Peninsula). Impacts of invasive non-native species are reviewed. Knowledge gaps such as the work on rockpools and host–parasite dynamics are also outlined.
A finitely presented 1-ended group
has semistable fundamental group at infinity if
acts geometrically on a simply connected and locally compact ANR
having the property that any two proper rays in
are properly homotopic. This property of
captures a notion of connectivity at infinity stronger than “1-ended”, and is in fact a feature of
, being independent of choices. It is a fundamental property in the homotopical study of finitely presented groups. While many important classes of groups have been shown to have semistable fundamental group at infinity, the question of whether every
has this property has been a recognized open question for nearly forty years. In this paper we attack the problem by considering a proper but non-cocompact action of a group
on such an
would typically be a subgroup of infinite index in the geometrically acting over-group
; for example
might be infinite cyclic or some other subgroup whose semistability properties are known. We divide the semistability property of
-part and a “perpendicular to
” part, and we analyze how these two parts fit together. Among other things, this analysis leads to a proof (in a companion paper) that a class of groups previously considered to be likely counter examples do in fact have the semistability property.
On October 1, 2017, a gunman fired on a festival in Las Vegas, Nevada, killing 58 people and wounding over 500. Multiple casualties were received at two nearby hospitals that sponsor residency programs: Sunrise Hospital and Medical Center and University Medical Center.
To evaluate the impact of the most lethal mass-shooting event in US history on graduate medical education (GME) at the involved hospitals.
Anonymized surveys were sent to 210 physicians at SMC and 110 physicians at UMC. Surveys incorporated 4 validated instruments: The Post Traumatic Growth Inventory (PTGI), The Impact of Events Scale-Revised (IES-R), The Multidimensional Scale of Perceived Social Support (MSPSS), and The Team Cohesion Factor (TCF).
Sixty-six physicians completed the surveys (38 attendings; 17 residents). 10% of physicians scored in the likely posttraumatic stress disorder (PTSD) range and 15% found themselves avoiding or struggling with managing similar patients, though overall survey response rate was low. The majority of physicians did not believe the event impacted their specific GME activities. No attending physician rated the event as negative in terms of global impact on GME, and 34% rated it as positive. However, 12 of 17 residents rated the event as a hurdle in its GME impact. A regression model predicting the IES-R score demonstrated a trend that those with higher pre-event stress and lower social support reported more adverse impact (p<0.06).
We believe our study is the first to examine the impact of mass casualty traumatic events on graduate medical education. Attendings and residents differ in their global perception of the impact, with attendings viewing it as a positive event and residents as a challenge. Pre-event level of stress and perceived social support predicted the impact of the event and may partially explain these results if residents and attendings vary on these parameters.
Balloon atrial septostomy is performed in infants with dextro-transposition of the great arteries to improve oxygenation before surgery. It is performed in the catheterisation laboratory with fluoroscopy or at the bedside using echocardiography. It is unclear whether procedural safety and efficacy is superior in one location versus the other, although the bedside procedure may improve resource utilisation and present an opportunity for reducing cost. This study compares safety and efficacy of atrial septostomy performed at the patient’s bedside versus the catheterisation laboratory.
Neonates with dextro-transposition of the great arteries who underwent balloon atrial septostomy from October, 2000 to January, 2014 were included. Medical and procedural records, echocardiograms, and catheterisation data were reviewed. Comparisons between the two procedural locations included patient demographics, pre- and post-procedure oxygen saturations, and outcomes. Complications reviewed included bleeding, arrhythmia, cardiac trauma, stroke, and death. Coronary artery evaluations were recorded. T-tests were used for continuous variables, and Fisher’s exact tests were used for all categorical variables. Wilcoxon rank sum and analysis of covariance modelling were used for time variables and oxygen saturation, respectively.
A total of 88 infants met the inclusion criteria. Among them, 53 underwent septostomy at the bedside and 35 underwent septostomy in the catheterisation laboratory. No safety or outcome benefit was identified between the two procedural locations.
Septostomy performed at the bedside and in the catheterisation laboratory had similar outcomes and efficacy. Further, bedside septostomy has the advantage of no radiation exposure, and obviating risks with patient transfer from the ICU to the catheterisation laboratory.
Hospitalized older adults are at high risk of falling. The HELPER system is a ceiling-mounted fall detection system that sends an alert to a smartphone when a fall is detected. This article describes the performance of the HELPER system, which was pilot tested in a geriatric mental health hospital. The system’s accuracy in detecting falls was measured against the hospital records documenting falls. Following the pilot test, nurses were interviewed regarding their perceptions of this technology. In this study, the HELPER system missed one documented fall but detected four falls that were not documented. Although sensitivity (.80) of the system was high, numerous false alarms brought down positive predictive value (.01). Interviews with nurses provided valuable insights based on the operation of the technology in a real environment; these and other lessons learned will be particularly valuable to engineers developing this and other health and social care technologies.
To integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs).
Design, Setting, and Participants
This 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015.
Phase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication.
Overall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3·85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9·06 in phase 1 to 1·65 in phase 4 (relative risk [RR], 0·182; 95% confidence interval [CI], 0·153–0·216; P<·001). New catheters per 1,000 patient days declined from 53·4 in phase 1 to 39·5 in phase 4 (RR, 0·740; 95% CI, 0·730; P<·001), and catheter days per 1,000 patient days decreased from 194·5 in phase 1 to 140·7 in phase 4 (RR, 0·723; 95% CI, 0·719–0·728; P<·001). The reinsertion rate declined from 3·66% in phase 1 to 3·25% in phase 4 (RR, 0·894; 95% CI, 0·834–0·959; P=·0017).
The phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.
This research aims to explore the submerged landscapes of the Pilbara of western Australia, using predictive archaeological modelling, airborne LiDAR, marine acoustics, coring and diver survey. It includes excavation and geophysical investigation of a submerged shell midden in Denmark to establish guidelines for the underwater discovery of such sites elsewhere.