Severe maternal morbidity during delivery hospitalisation in a large international administrative database, 2008-2013: a retrospective cohort.

OBJECTIVE: This study utilized the Dr. Foster Global Comparators database to identify pregnancy complications and associated risk factors that led to severe maternal morbidity during delivery hospitalisations in large university hospitals based in the USA, Australia, and England. DESIGN: Retrospective cohort. SETTING: Births in the USA, England and Australia from 2008 to 2013. SAMPLE: Data from delivery hospitalisations between 2008 and 2013 were examined using the Dr. Foster Global Comparators database. METHODS: We identified delivery hospitalisations with life-threatening diagnoses or use of life-saving procedures, using algorithms for severe maternal morbidity from the Center for Disease Control. Frequency of severe maternal morbidity was calculated for each country. MAIN OUTCOME MEASURES: Multivariable analysis was used to examine the association between morbidity and socio-demographic and clinical characteristics within each country. Chi-square tests assessed differences in covariates between countries. RESULTS: From 2008 to 2013, there were 516 781 deliveries from a total of 18 hospitals: 24.5% from the USA, 57.0% from England and 18.4% from Australia. Overall severe maternal morbidity rate was 8.2 per 1000 deliveries: 15.6 in the USA, 5.0 in England, and 8.2 in Australia. The most common codes identifying severe morbidity included transfusion, disseminated intravascular coagulation, acute renal failure, cardiac events/procedures, ventilation, hysterectomy, and eclampsia. Advanced maternal age, hypertension, diabetes, and substance abuse were associated with severe maternal morbidity in all three countries. CONCLUSION: Rates of severe maternal morbidity differed by country. Identification of geographical, socio-demographic, and clinical differences can help target modifications of practice and potentially reduce severe maternal morbidity. TWEETABLE ABSTRACT: Rates of severe maternal morbidity vary, but risk factors associated with adverse outcomes are similar in developed countries.

Is the Relationship between Short Interpregnancy Interval and Preterm Birth Related to a Short Cervix?

Objective Our objective was to determine if the relationship between interpregnancy interval (IPI) and preterm delivery was related to cervical shortening. Methods This is a secondary analysis of a prospective cohort study designed to assess the relationship between cervical length (CL) and preterm delivery. Multiparous patients, who had transvaginal CLs obtained at 22 to 24 weeks and complete pregnancy outcome data available were included. The women were divided into two groups: Group 1 with an IPI of ≤ 1 year and Group 2 with an IPI of > 1 year. The primary outcome was short cervix (CL < 2.5 cm) at 24 weeks. The secondary outcome was the incidence of preterm delivery < 37 weeks. Interaction between short cervix and IPI was examined in a regression model. Results There were 155 women in Group 1 and 328 women in Group 2. There was no difference in the incidence of short cervix between groups (10.0% in Group 1 and 12.9% in Group 2, p = 0.35). In a logistic regression model, short IPI and short cervix were independently associated with preterm birth. Conclusion The relationship between short IPI and preterm birth is not explained by a short cervix. They remain independent risk factors for preterm birth.

Trends in operative vaginal delivery, 2005-2013: a population-based study.

OBJECTIVE: The objectives of this study were to determine temporal trends in forceps and vacuum delivery and factors associated with operative vaginal delivery. DESIGN: Retrospective cohort. SETTING: Population-based study of US birth records. POPULATION: US births from 2005 to 2013. METHODS: This study evaluated forceps and vacuum extraction during vaginal delivery in live-born, non-anomalous singleton gestations from ≥ 36 to < 42 weeks of gestation. The primary outcomes were vacuum, forceps and overall operative delivery. Obstetric, medical and demographic characteristics associated with operative vaginal delivery were analysed. Multivariable logistic regression models were developed to determine factors associated with forceps/vacuum use. RESULTS: A total of 22 598 971 vaginal deliveries between 2005 and 2013 were included in the analysis. In all, 1 083 318 (4.8%) were vacuum-assisted and 237 792 (1.1%) were by forceps. Both vacuum and forceps deliveries decreased over the study period; vacuum deliveries decreased from 5.8% in 2005 to 4.1% in 2013, and forceps deliveries decreased from 1.4% to 0.9% during the same period. The adjusted odds ratio for forceps delivery was 0.70 (95% CI 0.69-0.72) in 2013 with 2005 as a reference. For vacuum delivery the odds ratio was 0.68 (95% CI 0.67-0.69) comparing the same years. CONCLUSION: Forceps and vacuum deliveries decreased during the study period. Low rates of operative delivery pose a challenge for resident education and may limit the degree to which women have access to alternatives to caesarean delivery. Initiatives that allow future generations of obstetricians to develop expertise in performing operative deliveries in the setting of decreased volume are an urgent resident education priority. TWEETABLE ABSTRACT: Forceps and vacuum delivery decreased significantly in the USA from 2005 to 2013.

Extraocular muscle is defined by a fundamentally distinct gene expression profile.

Skeletal muscle fibers are defined by patterned covariation of key traits that determine contractile and metabolic characteristics. Although the functional properties of most skeletal muscles result from their proportional content of a few conserved muscle fiber types, some, typically craniofacial, muscles exhibit fiber types that appear to lie outside the common phenotypic range. We analyzed gene expression profiles of three putative muscle classes, limb, masticatory, and extraocular muscle (EOM), in adult mice by high-density oligonucleotide arrays. Pairwise comparisons using conservative acceptance criteria identified expression differences in 287 genes between EOM and limb and/or masticatory muscles. Use of significance analysis of microarrays methodology identified up to 400 genes as having an EOM-specific expression pattern. Genes differentially expressed in EOM reflect key aspects of muscle biology, including transcriptional regulation, sarcomeric organization, excitation-contraction coupling, intermediary metabolism, and immune response. These patterned differences in gene expression define EOM as a distinct muscle class and may explain the unique response of these muscles in neuromuscular diseases.

Extraocular muscle is spared despite the absence of an intact sarcoglycan complex in gamma- or delta-sarcoglycan-deficient mice.

Models of the dystrophin-glycoprotein complex do not reconcile the novel sparing of extraocular muscle in muscular dystrophy. Extraocular muscle sparing in Duchenne muscular dystrophy implies the existence of adaptive properties in these muscles that may extend protection to other neuromuscular diseases. We studied the extraocular muscle morphology and dystrophin-glycoprotein complex organization in murine targeted deletion of the gamma-sarcoglycan (gsg(-/-)) and delta-sarcoglycan (dsg(-/-)) genes, two models of autosomal recessive limb girdle muscular dystrophy. In contrast to limb and diaphragm, the principal extraocular muscles were intact in gsg(-/-) and dsg(-/-) mice. However, central nucleated, presumptive regenerative, fibers were seen in the accessory extraocular muscles (retractor bulbi, levator palpebrae superioris) of both strains. Skeletal muscles of gsg(-/-) mice exhibited in vivo Evans Blue dye permeability, while the principal extraocular muscles did not. Disruption of gamma-sarcoglycan produced secondary displacement of alpha- and beta-sarcoglycans in the extraocular muscles. The intensity of immunofluorescence for dystrophin and alpha- and beta-dystroglycan also appeared to be slightly reduced. Utrophin localization was unchanged. The finding that sarcoglycan disruption was insufficient to elicit alterations in extraocular muscle suggests that loss of mechanical stability and increased sarcolemmal permeability are not inevitable consequences of mutations that disrupt the dystrophin-glycoprotein complex organization and must be accounted for in models of muscular dystrophy.

A quadripotential mesenchymal progenitor cell isolated from the marrow of an adult mouse.

Adult marrow contains mesenchymal progenitor cells (MPCs) that have multiple differentiation potentials. A conditionally immortalized MPC clone, BMC9, has been identified that exhibits four mesenchymal cell phenotypes: chondrocyte, adipocyte, stromal (support osteoclast formation), and osteoblast. The BMC9 clone, control brain fibroblasts and another marrow-derived clone, BMC10, were isolated from a transgenic mouse (H-2Kb-tsA58) containing a gene for conditional immortality. To test for chondrogenic potential, cells were cultured in defined medium containing 10 ng/ml transforming growth factor beta and 10-7 M dexamethasone in 15-ml polypropylene tubes ("aggregate cultures"). Adipogenic potential was quantitated by flow cytometry of Nile Red-stained cells cultured for 1 and 2 weeks in medium containing isobutyl methylxanthine, indomethacin, insulin, and dexamethasone. Support of osteoclast formation was measured by quantitating multinucleated tartrate-resistant acid phosphatase-positive cells in spleen cell cocultures of test clones (immortomouse clones and positive control ST2 cells) cultured in the presence of 10-7 M vitamin D3 and 150 mM ascorbate-2-phosphate. In vivo osteogenic potential was assayed by histologic examination of bone formation in subcutaneous implants, into athymic mouse hosts, of a composite of cells combined with porous calcium phosphate ceramics. The bone marrow-derived clone BMC9 has the potential to express each of the four mesenchymal characteristics tested, while brain fibroblasts, tested under identical conditions, did not exhibit any of these four mesenchymal characteristics. BMC10 cells exhibited osteogenic and chondrogenic phenotypes, but showed only minimal expression of adipocytic or osteoclast-supportive phenotypes. Clone BMC9 is, minimally, a quadripotential MPC isolated from the marrow of an adult mouse that can differentiate into cartilage and adipose, support osteoclast formation, and form bone. The BMC9 clone is an example of an adult-derived multipotential progenitor cell that is situated early in the mesenchymal lineage.

Characterization of the collagen phenotype of rabbit proximal tubule cells in culture.

Studies were performed to characterize the collagen phenotype of cultured rabbit proximal tubule (RPT) epithelial cells grown on plastic and on the reconstituted basement membrane preparation, Matrigel. When grown on a plastic substratum, RPT cells display a cobblestone appearance characteristic of glomerular epithelial cells. While initially forming an interlocking network of cells after subculture on Matrigel, this pattern of culture morphology rapidly develops into one characterized by isolated, organized groups of cells. Notwithstanding the effects of Matrigel on culture morphology, total cellular proliferation was reduced only 25% when RPT cells were grown on this substrate. Greater than 90% of the collagen synthesized by RPT cells grown on plastic was secreted into the culture medium. Qualitative analysis by SDS-PAGE revealed components exhibiting electrophoretic mobilities corresponding to the chains present in type IV and type I collagens. Quantitative analysis by CM-Trisacryl chromatography established that approximately 2/3 of the total collagen synthesized by RPT cells grown on plastic was type IV and approximately 1/3 type I. Quantitative analysis of the collagens produced by RPT cells grown on Matrigel again indicated the synthesis of only type IV and type I molecules but in a slightly more equal ratio of both collagen types and in the ratio of secreted to cell-associated molecules. However, the total amount of collagen synthesized by RPT cells grown on Matrigel was reduced to approximately 1% of the level synthesized by the cells grown on plastic. On plastic, approximately 3/4 of the type I collagen produced was recovered as the type I homotrimer, but on Matrigel type I homotrimers represented only approximately 55% of the total type I collagen synthesized. On Matrigel, the majority of the type IV collagen was recovered as heterotrimers containing alpha1(IV) and alpha2(IV) chains. In contrast, RTP cells grown on plastic predominantly produced type IV homotrimers containing only the alpha1(IV) chain. These data represent the initial report describing the collagens produced by nonimmortalized cultured proximal tubule cells. The finding that a significant amount of the total collagen synthesized was type IV (basement membrane) collagen, regardless of culture substrate, suggests that the RPT cells have maintained a significant degree of differentiation in culture, and thus establishes RPT cells as an appropriate model for investigating ECM changes in proximal tubule cells that occur in kidney disease. Finally, the observation that culture of RPT cells on a reconstituted basement membrane preparation results in a significant reduction in total collagen production and alterations in the molecular forms of type IV and type I molecules synthesized indicates that integrity of the tubular basement membrane may represent an important component in preventing the development of tubulointerstitial fibrosis.

Efficient gas-phase generation of coherent vacuum ultraviolet radiation.

We report the demonstration of a pulsed atomic lead (Pb) vapor-based vacuum ultraviolet frequency converter from 233 to 186 nm with unity photon-conversion efficiency. This conversion is attained without phase matching.

Effectiveness of attention training in schizophrenia.

This study assessed the impact of attention training on information processing in schizophrenia. Fifty-four inpatients with chronic schizophrenia were randomly assigned to two groups after baseline assessment with the Continuous Performance Test (CPT). Patients in the experimental group participated in individual sessions of computerized attention remediation, while patients in the control group participated in individual sessions during which they viewed video documentaries. After 18 sessions, reassessment with the CPT showed that patients in the experimental group had made significantly more improvement than the control group, which made no significant change. Brief Psychiatric Rating Scale assessments before and after the study phase indicated that both groups improved on the total score but the experimental group made significantly more improvement. These results suggest that it is feasible to use practice and behavioral learning to remediate a core attention deficit in chronic schizophrenia.

Efficient self-seeding of a pulsed Ti3+:Al2O3 laser.

We describe the design considerations and operating characteristics of a compact, widely tunable, narrow-linewidth, megawatt-class pulsed laser system based on Ti(3+):Al(2)O(3) (Ti:sapphire) pumped by the second harmonic of a 1.06-microm Nd:YAG laser. The system delivers 10 mJ in a 5-ns near-transform-limited single-longitudinal-mode (SLM) pulse with a threshold of 20 mJ and a slope efficiency greater than 40%. By the technique of self-seeding, in which a portion of the gain medium's spontaneous fluorescence is coupled back to the laser cavity, SLM operation may be obtained across the entire gain profile of Ti:sapphire with a minimum number of optical components and without external seeding.

Headache and cortisol responses to m-chlorophenylpiperazine are highly correlated.

The serotonin receptor agonist m-chlorophenylpiperazine (m-CPP) stimulates the release of cortisol and prolactin, and induces migraine-like headaches. We have studied the neuroendocrine and headache responses to m-CPP in 8 subjects with migraine and 10 normal subjects. Each subject underwent two challenge tests, one with 0.25 mg/kg PO of m-CPP and the other with placebo, administered in a double-blind crossover format. Serial measurements of serum cortisol, prolactin, and m-CPP levels were made at 30-min intervals for 210 min following ingestion of the medication. The incidence and severity of headache was assessed by a structured telephone interview after each test. We confirmed that m-CPP stimulates the release of cortisol and prolactin, and may induce headache, in both migraine subjects and normal controls. The cortisol response as well as ratings of headache severity and duration directly correlated with plasma levels of m-CPP. There were highly significant associations between the cortisol response and both headache severity and duration, independent of m-CPP plasma levels. We did not find statistically significant differences between the migraine and normal subjects in terms of their neuroendocrine or headache responses to m-CPP.

The neuropsychological sequelae of attempted hanging.

Only one report on the neuropsychological sequelae of attempted hanging exists in the English language. Two cases of attempted hanging with subsequent isolated memory deficits are reported. Possible mechanisms for induction of this amnesia are discussed. In these two cases it is most likely that circulatory disturbance produced by the ligatures caused ischaemic hippocampal damage, which in turn led to amnesia.

Neuroradiological facets of cognitive abnormality in schizophrenia.

Cognitive abnormality has long been regarded as a core feature of schizophrenia, but its nature and etiopathology have been poorly understood. Predicated on new tests that characterize fundamental cognitive impairments, we investigated their relationship to four neuroradiological markers that have been previously implicated in schizophrenia: choroid plexus calcification, cerebellar atrophy, third ventricle enlargement, and pineal calcification. Twenty-three chronic schizophrenic inpatients meeting RDC and DSM-III diagnostic criteria were stabilized on chlorpromazine and assessed independently on a cognitive battery and on CT scan. The results indicated that all four neuroradiological variables were independent of one another and of demographic, historical, and general intellectual measures. The neuroradiological assessments, however, correlated significantly with different cognitive parameters, implying separate pathophysiological bases for distinct profiles of cognitive abnormality. The findings support a "dual-process model" of cognitive dysfunction that posits developmental and arousal-related components which may, more generally, underlie the positive-negative dimension of schizophrenia.

Atrophy of the cerebellar vermis: relevance to the symptoms of schizophrenia.

Degeneration of the cerebellar vermis is a common pathological and neuroradiological feature of chronic schizophrenia, but its relationship to symptoms of the disease are poorly understood. We investigated the relationship of vermal cerebellar atrophy on CT scan to features of positive (productive) and negative (defect) dimensions of schizophrenia as well as to symptoms of general psychopathology in a sample of 23 chronic schizophrenic patients. For comparison, we also studied the relationship of third ventricular width (TVW), which reflects periventricular and diencephalic atrophy, to these features of schizophrenic symptomatology. Vermal cerebellar atrophy was found in 43.5% of patients and correlated significantly with general psychopathology and, more specifically, with feelings of guilt and disturbance of volition. It was unrelated to global positive or negative features of schizophrenia. By contrast, TVW was uniquely associated with global negative syndrome. These observations indicate that degeneration of the cerebellar vermis and enlargement of the third ventricle are integral aspects of schizophrenia, and that each contributes independently to specific clinical aspects of the disease.