Prescriptive and proscriptive lessons for managing shoulder dystocia: a technical and videographical tutorial.

This tutorial of the intrapartum management of shoulder dystocia uses drawings and videos of simulated and actual deliveries to illustrate the biomechanical principles of specialized delivery maneuvers and examine missteps associated with brachial plexus injury. It is intended to complement haptic, mannequin-based simulation training. Demonstrative explication of each maneuver is accompanied by specific examples of what not to do. Positive (prescriptive) instruction prioritizes early use of direct fetal manipulation and stresses the importance of determining the alignment of the fetal shoulders by direct palpation, and that the biacromial width should be manually adjusted to an oblique orientation within the pelvis-before application of traction to the fetal head, the biacromial width is manually adjusted to an oblique orientation within the pelvis. Negative (proscriptive) instructions includes the following: to avoid more than usual and/or laterally directed traction, to use episiotomy only as a means to gain access to the posterior shoulder and arm, and to use a 2-step procedure in which a 60-second hands-off period ("do not do anything") is inserted between the emergence of the head and any initial attempts at downward traction to allow for spontaneous rotation of the fetal shoulders. The tutorial presents a stepwise approach focused on the delivering clinician's tasks while including the role of assistive techniques, including McRoberts, Gaskin, and Sims positioning, suprapubic pressure, and episiotomy. Video footage of actual deliveries involving shoulder dystocia and permanent brachial plexus injury demonstrates ambiguities in making the diagnosis of shoulder dystocia, risks of improper traction and torsion of the head, and overreliance on repeating maneuvers that prove initially unsuccessful.

Nitrogen deposition suppresses ephemeral post-fire plant diversity.

Fire is a dominant force shaping patterns of plant diversity in Mediterranean-type ecosystems. In these biodiversity hotspots, including California's endangered coastal scrub, many species remain hidden belowground as seeds and bulbs, only to emerge and flower when sufficient rainfall occurs after wildfire. The unique adaptations possessed by these species enable survival during prolonged periods of unfavorable conditions, but their continued persistence could be threatened by nonnative plant invasion and environmental change. Furthermore, their fleeting presence aboveground makes evaluating these threats in situ a challenge. For example, nitrogen (N) deposition resulting from air pollution is a well-recognized threat to plant diversity worldwide but impacts on fire-following species are not well understood. We experimentally evaluated the impact of N deposition on post-fire vegetation cover and richness for three years in stands of coastal sage scrub that had recently burned in a large wildfire in southern California. We installed plots receiving four levels of N addition that corresponded to the range of N deposition rates in the region. We assessed the impact of pre-fire invasion status on vegetation dynamics by including plots in areas that had previously been invaded by nonnative grasses, as well as adjacent uninvaded areas. We found that N addition reduced native forb cover in the second year post-fire while increasing the abundance of nonnative forbs. As is typical in fire-prone ecosystems, species richness declined over the three years of the study. However, N addition hastened this process, and native forb richness was severely reduced under high N availability, especially in previously invaded shrublands. An indicator species analysis also revealed that six functionally and taxonomically diverse forb species were especially sensitive to N addition. Our results highlight a new potential mechanism for the depletion of native species through the suppression of ephemeral post-fire bloom events.

Differences in root phenology and water depletion by an invasive grass explains persistence in a Mediterranean ecosystem.

PREMISE: Flexible phenological responses of invasive plants under climate change may increase their ability to establish and persist. A key aspect of plant phenology is the timing of root production, how it coincides with canopy development and subsequent water-use. The timing of these events within species and across communities could influence the invasion process. We examined above- and belowground phenology of two species in southern California, the native shrub, Adenostoma fasciculatum, and the invasive perennial grass, Ehrharta calycina to investigate relative differences in phenology and water use. METHODS: We used normalized difference vegetation index (NDVI) to track whole-canopy activity across the landscape and sap flux sensors on individual chaparral shrubs to assess differences in aboveground phenology of both species. To determine differences in belowground activity, we used soil moisture sensors, minirhizotron imagery, and stable isotopes. RESULTS: The invasive grass depleted soil moisture earlier in the spring and produced longer roots at multiple depths earlier in the growing season than the native shrub. However, Adenostoma fasciculatum produced longer roots in the top 10 cm of soil profile in May. Aboveground activity of the two species peaked at the same time. CONCLUSIONS: The fact that Ehrharta calycina possessed longer roots earlier in the season suggests that invasive plants may gain a competitive edge over native plants through early activity, while also depleting soil moisture earlier in the season. Depletion of soil moisture earlier by E. calycina suggests that invasive grasses could accelerate the onset of the summer drought in chaparral systems, assuring their persistence following invasion.

Potential vulnerability of 348 herbaceous species to atmospheric deposition of nitrogen and sulfur in the United States.

Atmospheric nitrogen and sulfur pollution increased over much of the United States during the twentieth century from fossil fuel combustion and industrial agriculture. Despite recent declines, nitrogen and sulfur deposition continue to affect many plant communities in the United States, although which species are at risk remains uncertain. We used species composition data from >14,000 survey sites across the contiguous United States to evaluate the association between nitrogen and sulfur deposition and the probability of occurrence for 348 herbaceous species. We found that the probability of occurrence for 70% of species was negatively associated with nitrogen or sulfur deposition somewhere in the contiguous United States (56% for N, 51% for S). Of the species, 15% and 51% potentially decreased at all nitrogen and sulfur deposition rates, respectively, suggesting thresholds below the minimum deposition they receive. Although more species potentially increased than decreased with nitrogen deposition, increasers tended to be introduced and decreasers tended to be higher-value native species. More vulnerable species tended to be shorter with lower tissue nitrogen and magnesium. These relationships constitute predictive equations to estimate critical loads. These results demonstrate that many herbaceous species may be at risk from atmospheric deposition and can inform improvements to air quality policies in the United States and globally.

Simulation of Shoulder Dystocia for Skill Acquisition and Competency Assessment: A Systematic Review and Gap Analysis.

STATEMENT: Mastery of shoulder dystocia management skills acquired via simulation training can reduce neonatal brachial plexus injury by 66% to 90%. However, the correlation between simulation drills and reduction in clinical injuries has been inconsistently replicated, and establishing a causal relationship between simulation training and reduction of adverse clinical events from shoulder dystocia is infeasible due to ethical limitations. Nevertheless, professional liability insurance carriers increasingly are mandating simulation-based rehearsal and competency assessment of their covered obstetric providers' shoulder dystocia management skills-a high-stakes demand that will require rapid scaling up of access to quality shoulder dystocia simulation. However, questions remain about differing simulation training schemes and instructional content used among clinically effective and ineffective educational interventions. This review of original research compares curricular content of shoulder dystocia simulation and reveals several critical gaps: (1) prescriptive instruction prioritizing maneuvers shown to decrease strain on the brachial plexus is inconsistently used. (2) Proscriptive instruction to avoid placing excessive and laterally directed traction on the head or to observe a brief hands-off period before attempting traction is infrequently explicit. (3) Neither relative effectiveness nor potential interaction between prescriptive and proscriptive elements of instruction has been examined directly. (4) Reliability of high-fidelity mannequins capable of objective measurement of clinician-applied traction force as compared with subjective assessment of provider competence is unknown. Further study is needed to address these gaps and inform efficient and effective implementation of clinically translatable shoulder dystocia simulation.

High N, dry: Experimental nitrogen deposition exacerbates native shrub loss and nonnative plant invasion during extreme drought.

Hotter, longer, and more frequent global change-type drought events may profoundly impact terrestrial ecosystems by triggering widespread vegetation mortality. However, severe drought is only one component of global change, and ecological effects of drought may be compounded by other drivers, such as anthropogenic nitrogen (N) deposition and nonnative plant invasion. Elevated N deposition, for example, may reduce drought tolerance through increased plant productivity, thereby contributing to drought-induced mortality. High N availability also often favors invasive, nonnative plant species, and the loss of woody vegetation due to drought may create a window of opportunity for these invaders. We investigated the effects of multiple levels of simulated N deposition on a Mediterranean-type shrubland plant community in southern California from 2011 to 2016, a period coinciding with an extreme, multiyear drought in the region. We hypothesized that N addition would increase native shrub productivity, but that this would increase susceptibility to drought and result in increased shrub loss over time. We also predicted that N addition would favor nonnatives, especially annual grasses, leading to higher biomass and cover of these species. Consistent with these hypotheses, we found that high N availability increased native shrub canopy loss and mortality, likely due to the higher productivity and leaf area and reduced water-use efficiency we observed in shrubs subject to N addition. As native shrub cover declined, we also observed a concomitant increase in cover and biomass of nonnative annuals, particularly under high levels of experimental N deposition. Together, these results suggest that the impacts of extended drought on shrubland ecosystems may be more severe under elevated N deposition, potentially contributing to the widespread loss of native woody species and vegetation-type conversion.

Recurrent Shoulder Dystocia: Risk Factors and Counseling.

A prior history of delivery complicated by shoulder dystocia confers a 6-fold to nearly 30-fold increased risk of shoulder dystocia recurrence in a subsequent vaginal delivery, with most reported rates between 12% and 17%. Whereas prevention of shoulder dystocia in the general population is neither feasible nor cost-effective, directing intervention efforts at the particular subgroup of women with a prior history of shoulder dystocia has merit. Potentially modifiable risk factors and individualized management strategies that may reduce shoulder dystocia recurrence and its associated significant morbidities are reviewed.

Conditional vulnerability of plant diversity to atmospheric nitrogen deposition across the United States.

Atmospheric nitrogen (N) deposition has been shown to decrease plant species richness along regional deposition gradients in Europe and in experimental manipulations. However, the general response of species richness to N deposition across different vegetation types, soil conditions, and climates remains largely unknown even though responses may be contingent on these environmental factors. We assessed the effect of N deposition on herbaceous richness for 15,136 forest, woodland, shrubland, and grassland sites across the continental United States, to address how edaphic and climatic conditions altered vulnerability to this stressor. In our dataset, with N deposition ranging from 1 to 19 kg N⋅ha(-1)⋅y(-1), we found a unimodal relationship; richness increased at low deposition levels and decreased above 8.7 and 13.4 kg N⋅ha(-1)⋅y(-1) in open and closed-canopy vegetation, respectively. N deposition exceeded critical loads for loss of plant species richness in 24% of 15,136 sites examined nationwide. There were negative relationships between species richness and N deposition in 36% of 44 community gradients. Vulnerability to N deposition was consistently higher in more acidic soils whereas the moderating roles of temperature and precipitation varied across scales. We demonstrate here that negative relationships between N deposition and species richness are common, albeit not universal, and that fine-scale processes can moderate vegetation responses to N deposition. Our results highlight the importance of contingent factors when estimating ecosystem vulnerability to N deposition and suggest that N deposition is affecting species richness in forested and nonforested systems across much of the continental United States.

Linking Medicaid Expansion and Cuts to Disproportionate-Share Hospitals: Will Safety Nets Survive?

The predominant mechanism by which the health care reforms of the Patient Protection and Affordable Care Act of 2010 are to be financed is through the government's simultaneous defunding of major portions of Medicare and Medicaid, including the reduction of up to 75% of federal payments to disproportionate-share hospitals. The justification for curtailment of other public programs is that after Medicaid expansion under the Affordable Care Act, the decrease in the proportion of uninsured among the U.S. population will render disproportionate-share hospital payments extraneous and unnecessary. Such justification was reiterated in the recent American College of Obstetricians and Gynecologists Committee Opinion No. 627, entitled Health Care for Unauthorized Immigrants. Herein, the soundness of the Committee Opinion's proposed policy is evaluated by reviewing available literature on the potential effect of Medicaid disproportionate-share hospital cuts with and without concomitant Medicaid expansion. Limitations of Medicaid expansion efforts before and under the Affordable Care Act, the disproportionate-share hospital payment program, and other legislation providing safety net hospitals with (some) relief of financial burdens related to uncompensated care are explicated. Findings raise concern that acceptance of cuts of up to 75% of federal disproportionate-share hospital funds on the premise that nationwide state expansion of Medicaid will offset the difference may be overly optimistic. Indeed, foregoing disproportionate-share hospital payments undercuts the otherwise laudable intent of Committee Opinion No. 627, namely to advocate for universal health care for all women, including undocumented immigrants.

Extractable nitrogen and microbial community structure respond to grassland restoration regardless of historical context and soil composition.

Grasslands have a long history of invasion by exotic annuals, which may alter microbial communities and nutrient cycling through changes in litter quality and biomass turnover rates. We compared plant community composition, soil chemical and microbial community composition, potential soil respiration and nitrogen (N) turnover rates between invaded and restored plots in inland and coastal grasslands. Restoration increased microbial biomass and fungal : bacterial (F : B) ratios, but sampling season had a greater influence on the F : B ratio than did restoration. Microbial community composition assessed by phospholipid fatty acid was altered by restoration, but also varied by season and by site. Total soil carbon (C) and N and potential soil respiration did not differ between treatments, but N mineralization decreased while extractable nitrate and nitrification and N immobilization rate increased in restored compared with unrestored sites. The differences in soil chemistry and microbial community composition between unrestored and restored sites indicate that these soils are responsive, and therefore not resistant to feedbacks caused by changes in vegetation type. The resilience, or recovery, of these soils is difficult to assess in the absence of uninvaded control grasslands. However, the rapid changes in microbial and N cycling characteristics following removal of invasives in both grassland sites suggest that the soils are resilient to invasion. The lack of change in total C and N pools may provide a buffer that promotes resilience of labile pools and microbial community structure.

Minimal intervention dentistry and older patients part 2: minimally invasive operative interventions.

UNLABELLED: As described in the first paper of this two part series, the expansion of our older population and the concomitant reduction in levels of edentulism will result in an increase in the number of patients presenting in general practice with complex restorative challenges. The application of the concepts of minimal intervention dentistry and minimally invasive operative techniques may offer a powerful armamentarium to the general dentist to provide ethical and conservative treatment to older patients. CLINICAL RELEVANCE: When it is unavoidable, operative intervention should be as minimally invasive as practicable in older patients to preserve the longevity of their natural dentition.

Minimal intervention dentistry and older patients. Part 1: Risk assessment and caries prevention.

Ten million people in the UK today are aged over 65. The latest projections estimate that there will be 5 1/2 million more people aged 65 and older in the next 20 years. This projected pattern of population ageing will have profound consequences for dentistry. Minimal intervention dentistry (MID) is a modern evidence-based approach to caries management in dentate patients that uses the 'medical model' whereby disease is controlled by the 'oral physician'. This approach offers considerable benefits over conventional dentistry for older patients. It encourages patients to be responsible for their oral health through the provision of both knowledge and motivation. MID encompasses risk assessment for dental disease, early detection and control of disease processes, and minimally invasive treatment. Clinical Relevance: Risk assessment tools can aid the general dental practitioner and the patient to develop a suitable caries prevention programme for that individual and reduce the need for future operative intervention.

Above- and belowground responses to nitrogen addition in a Chihuahuan Desert grassland.

Increased available soil nitrogen can increase biomass, lower species richness, alter soil chemistry and modify community structure in herbaceous ecosystems worldwide. Although increased nitrogen availability typically increases aboveground production and decreases species richness in mesic systems, the impacts of nitrogen additions on semiarid ecosystems remain unclear. To determine how a semiarid grassland responds to increased nitrogen availability, we examined plant community structure and above- and belowground net primary production in response to long-term nitrogen addition in a desert grassland in central New Mexico, USA. Plots were fertilized annually (10 g N m(-2)) since 1995 and NPP measured from 2004 to 2009. Differences in aboveground NPP between fertilized and control treatments occurred in 2004 following a prescribed fire and in 2006 when precipitation was double the long-term average during the summer monsoon. Presumably, nitrogen only became limiting once drought stress was alleviated. Belowground NPP was also related to precipitation, and greatest root growth occurred the year following the wettest summer, decreasing gradually thereafter. Belowground production was unrelated to aboveground production within years and unrelated to nitrogen enrichment. Species richness changed between years in response to seasonal precipitation variability, but was not altered by nitrogen addition. Community structure did respond to nitrogen fertilization primarily through increased abundance of two dominant perennial grasses. These results were contrary to most nitrogen addition studies that find increased biomass and decreased species richness with nitrogen fertilization. Therefore, factors other than nitrogen deposition, such as fire or drought, may play a stronger role in shaping semiarid grassland communities than soil fertility.

Oxidative and inflammatory status in Type 2 diabetes patients with periodontitis.

AIM: To determine the impact of periodontitis on oxidative/inflammatory status and diabetes control in Type 2 diabetes. MATERIALS AND METHODS: A comparative study of 20 Type 2 diabetes patients with periodontitis [body mass index (BMI) 31+5], 20-age/gender-matched, non-periodontitis Type 2 diabetes controls (BMI 29+6) and 20 non-diabetes periodontitis controls (BMI 25+4) had periodontal examinations and fasting blood samples collected. Oxidative stress was determined by plasma small molecule antioxidant capacity (pSMAC) and protein carbonyl levels; inflammatory status by total/differential leucocytes, fibrinogen and high sensitivity C-reactive protein (hsCRP); diabetes status by fasting glucose, HbA1c, lipid profile, insulin resistance and secretion. Statistical analysis was performed using SPSS. RESULTS: pSMAC was lower (p=0.03) and protein carbonyls higher (p=0.007) in Type 2 diabetes patients with periodontitis compared with those without periodontitis. Periodontitis was associated with significantly higher HbA1c (p=0.002) and fasting glucose levels (p=0.04) and with lower ß-cell function (HOMA-ß; p=0.01) in diabetes patients. Periodontitis had little effect on inflammatory markers or lipid profiles, but Type 2 diabetes patients with periodontitis had higher levels of hsCRP than those without diabetes (p=0.004) and the lowest levels of HDL-cholesterol of all groups. CONCLUSION: Periodontitis is associated with increased oxidative stress and compromised glycaemic control in Type 2 diabetes patients.

Can resource-use traits predict native vs. exotic plant success in carbon amended soils?

Productivity in desert ecosystems is primarily limited by water followed by nitrogen availability. In the deserts of southern California, nitrogen additions have increased invasive annual plant abundance. Similar findings from other ecosystems have led to a general acceptance that invasive plants, especially annual grasses, are nitrophilous. Consequently, reductions of soil nitrogen via carbon amendments have been conducted by many researchers in a variety of ecosystems in order to disproportionately lower invasive species abundance, but with mixed success. Recent studies suggest that resource-use traits may predict the efficacy of such resource manipulations; however, this theory remains largely untested. We report findings from a carbon amendment experiment that utilized two levels of sucrose additions that were aimed at achieving soil carbon to nitrogen ratios of 50:1 and 100:1 in labile sources. Carbon amendments were applied once each year, for three years, corresponding with the first large precipitation event of each wet season. Plant functional traits measured on the three invasive and 11 native herbaceous species that were most common at the study site showed that exotic and native species did not differ in traits associated with nitrogen use. In fact, plant abundance measures such as density, cover, and biomass showed that carbon amendments were capable of decreasing both native and invasive species. We found that early-germinating species were the most impacted by decreased soil nitrogen resulting from amendments. Because invasive annuals typically germinate earlier and exhibit a rapid phenology compared to most natives, these species are expected to be more competitive than native annuals yet more susceptible to early-season carbon amendments. However, desert annual communities can exhibit high interannual variability in species composition and abundance. Therefore, the relative abundance of native and invasive species at the time of application is critical to the success of carbon amendments at our study site. For land management purposes, carbon amendments remain relatively impractical and may only be useful at small scales or in conjunction with other invasive species removal techniques.

The cost-effectiveness of supportive periodontal care: a global perspective.

AIM: To evaluate the cost-effectiveness of supportive periodontal care (SPC) provided in generalist and periodontal specialist practices under publicly subsidized or private dental care. MATERIAL AND METHODS: SPC cost data and the costs of replacing teeth were synthesized with estimates of the effectiveness of SPC in preventing attachment and tooth loss and adjusted for differences in clinician's time. Incremental cost-effectiveness ratios were calculated for both outcomes assuming a time horizon of 30 years. RESULTS: SPC in specialist periodontal practice provides improved outcomes but at higher costs than SPC provided by publicly subsidized or private systems. SPC in specialist periodontal practice is usually more cost-effective than in private dental practice. For private dental practices in Spain, United Kingdom and Australia, specialist SPC is cost-effective at modest values of attachment loss averted. Variation in the threshold arises primarily from clinician's time. CONCLUSION: SPC in specialist periodontal practice represents good value for money for patients (publicly subsidized or private) in the United Kingdom and Australia and in Spain if they place relatively modest values on avoiding attachment loss. For patients in Ireland, Germany, Japan and the United State, a higher valuation on avoiding attachment loss is needed to justify SPC in private or specialist practices.

Nitrogen deposition effects on Mediterranean-type ecosystems: an ecological assessment.

We review the ecological consequences of N deposition on the five Mediterranean regions of the world. Seasonality of precipitation and fires regulate the N cycle in these water-limited ecosystems, where dry N deposition dominates. Nitrogen accumulation in soils and on plant surfaces results in peaks of availability with the first winter rains. Decoupling between N flushes and plant demand promotes losses via leaching and gas emissions. Differences in P availability may control the response to N inputs and susceptibility to exotic plant invasion. Invasive grasses accumulate as fuel during the dry season, altering fire regimes. California and the Mediterranean Basin are the most threatened by N deposition; however, there is limited evidence for N deposition impacts outside of California. Consequently, more research is needed to determine critical loads for each region and vegetation type based on the most sensitive elements, such as changes in lichen species composition and N cycling.