Postpartum hemorrhage is common and can occur in patients without risk factors for hemorrhage. Active management of the third stage of labor should be used routinely to reduce its incidence. Use of ...oxytocin after delivery of the anterior shoulder is the most important and effective component of this practice. Oxytocin is more effective than misoprostol for prevention and treatment of uterine atony and has fewer adverse effects. Routine episiotomy should be avoided to decrease blood loss and the risk of anal laceration. Appropriate management of postpartum hemorrhage requires prompt diagnosis and treatment. The Four T's mnemonic can be used to identify and address the four most common causes of postpartum hemorrhage (uterine atony Tone; laceration, hematoma, inversion, rupture Trauma; retained tissue or invasive placenta Tissue; and coagulopathy Thrombin). Rapid team-based care minimizes morbidity and mortality associated with postpartum hemorrhage, regardless of cause. Massive transfusion protocols allow for rapid and appropriate response to hemorrhages exceeding 1,500 mL of blood loss. The National Partnership for Maternal Safety has developed an obstetric hemorrhage consensus bundle of 13 patient- and systems-level recommendations to reduce morbidity and mortality from postpartum hemorrhage.
Tropical reef systems are transitioning to a new era in which the interval between recurrent bouts of coral bleaching is too short for a full recovery of mature assemblages. We analyzed bleaching ...records at 100 globally distributed reef locations from 1980 to 2016. The median return time between pairs of severe bleaching events has diminished steadily since 1980 and is now only 6 years. As global warming has progressed, tropical sea surface temperatures are warmer now during current La Niña conditions than they were during El Niño events three decades ago. Consequently, as we transition to the Anthropocene, coral bleaching is occurring more frequently in all El Niño-Southern Oscillation phases, increasing the likelihood of annual bleaching in the coming decades.
During 2015-2016, record temperatures triggered a pan-tropical episode of coral bleaching, the third global-scale event since mass bleaching was first documented in the 1980s. Here we examine how and ...why the severity of recurrent major bleaching events has varied at multiple scales, using aerial and underwater surveys of Australian reefs combined with satellite-derived sea surface temperatures. The distinctive geographic footprints of recurrent bleaching on the Great Barrier Reef in 1998, 2002 and 2016 were determined by the spatial pattern of sea temperatures in each year. Water quality and fishing pressure had minimal effect on the unprecedented bleaching in 2016, suggesting that local protection of reefs affords little or no resistance to extreme heat. Similarly, past exposure to bleaching in 1998 and 2002 did not lessen the severity of bleaching in 2016. Consequently, immediate global action to curb future warming is essential to secure a future for coral reefs.
An integrated understanding of therapeutic plasma exchange (TPE) effects on immunoglobulins, autoantibodies, and natural or acquired (vaccine) protective antibodies in patients with autoimmune ...myasthenia gravis (MG) is lacking. Prior studies measured TPE effects in healthy volunteers or heterogeneous autoimmune disease populations. We prospectively profiled plasma IgA, IgM, IgG, IgG subclasses (IgG1-4), acetylcholine receptor autoantibodies (AChR+), and protective antibodies in patients with AChR + MG receiving TPE for an exacerbation. TPE was performed according to institutional practice and patients were profiled for up to 12 weeks. Ten patients were enrolled (median age = 72.9 years; baseline MG-Composite = 21; median TPE treatments = 6 during their first course) and all improved. The maximum decrease in all immunoglobulins, including AChR autoantibodies, was achieved on the final day of the first TPE course (∼60-70% reduction). Three weeks post-TPE, mean AChR autoantibody, total IgG, IgG1, and IgG2 titers were below the reference range and had not recovered within 20% of baseline, whereas other measured immunoglobulins approached baseline values. We did not generally observe an "overshoot" of immunoglobulins above pre-TPE levels or accelerated recovery of pathologic AChR autoantibodies. Protective antibody profiles showed similar patterns as other IgGs and were detectable at levels associated with protection from infection. A slow return to baseline for IgGs (except IgG3) was observed, and we did not observe any obvious effect of concomitant medications on this recovery. Collectively, these findings enhance our understanding of the immunological effects of TPE and further support the concept of rapid immunoglobulin depletion for the treatment of patients with MG.
To be considered an effective pollinator, a floral visitor must not only be able to remove pollen but also transfer this pollen to a receptive conspecific stigma. While studies of diurnal pollination ...are commonplace, our understanding of the effectiveness of nocturnal pollinators is limited largely because of the difficulties of doing these studies at night. As a result of this, the way in which moths transfer pollen between flowers has been understudied globally, despite many authors suggesting they could be significant contributors to pollination. Here, we tested whether moths are capable of transferring pollen between flowers under experimental conditions using a fluorescent pollen-tracker powder. A flower-feeding taxon (Noctuidae: Ichneutica plena) and non-feeding taxon (Hepialidae: Wiseana spp.) were contained overnight with flowering shoots of putatively moth-pollinated Leptospermum scoparium and Pimelea prostrata (I. plena only), and putatively bird-pollinated Crocosmia × crocosmiiflora. Moths were able to transfer pollen tracker between flowers for both of the putatively mothpollinated species, while no pollen tracker was removed from putatively bird-pollinated flowers. Both the feeding and non-feeding moth taxa were able to transfer pollen tracker between flowers; however, the feeding taxon could be considered a more effective pollinator because of the greater proportion of individuals both carrying and transferring pollen tracker compared with the non-feeding taxon. This study provides experimental evidence that moths may contribute to the pollination of L. scoparium and P. prostrata, and suggests a reassessment of the pollination ecology for these species is warranted.
Military unit cohesion has been shown to correlate with physical and psychological outcomes. However, little is known about the development of cohesion in the early days of military service during ...Basic Combat Training (BCT) and how it relates to positive support and the negative stressors of training. The current study assessed the development of unit cohesion across the 10-week BCT period (N = 1,939), and the relation of cohesion to stress, resilience, mental health measures, and BCT outcomes (graduation, passing the Army Physical Fitness Test, and final Basic Rifle Marksmanship scores). The sample was primarily male (62%), under age 25 (88%), and unmarried (88%). All putative mediators showed significant change over time. Unit cohesion increased over time (slope 0.22; p < .001), and these increases were associated with decreases in psychological distress (p < .001), sleep problems (p < .001), and tolerance of BCT stressors (p < .001), as well as increases in resilience (p < .001), confidence managing stress reactions (p < .001), and positive states of mind (p < .001). Unit cohesion was indirectly associated with successful graduation and passing the Army Physical Fitness Test through cohesion-related improvement in psychological distress, resilience, and confidence managing reactions to stress. Sleep problems also mediated BCT graduation. Cohesion effects on the Basic Rifle Marksmanship scores were mediated by psychological distress and tolerance of BCT stressors only. These results suggest that unit cohesion may play a key role in the development of psychological health among new soldiers.
Postpartum hemorrhage, the loss of more than 500 mL of blood after delivery, occurs in up to 18 percent of births and is the most common maternal morbidity in developed countries. Although risk ...factors and preventive strategies are dearly documented, not all cases are expected or avoidable. Uterine atony is responsible for most cases and can be managed with uterine massage in conjunction with oxytocin, prostaglandins, and ergot alkaloids. Retained placenta is a less common cause and requires examination of the placenta, exploration of the uterine cavity, and manual removal of retained tissue. Rarely, an invasive placenta causes postpartum hemorrhage and may require surgical management. Traumatic causes include lacerations, uterine rupture, and uterine inversion. Coagulopathies require dotting factor replacement for the identified deficiency. Early recognition, systematic evaluation and treatment, and prompt fluid resuscitation minimize the potentially serious outcomes associated with postpartum hemorrhage.
The detection of low levels of pharmaceuticals in rivers and streams, drinking water, and groundwater has raised questions as to whether these levels may affect human health. This report presents ...human health risk assessments for 26 active pharmaceutical ingredients (APIs) and/or their metabolites, representing 14 different drug classes, for which environmental monitoring data are available for the United States. Acceptable daily intakes (ADIs) are derived using the considerable data that are available for APIs. The resulting ADIs are designed to protect potentially exposed populations, including sensitive sub-populations. The ADIs are then used to estimate predicted no effect concentrations (PNECs) for two sources of potential human exposure: drinking water and fish ingestion. The PNECs are compared to measured environmental concentrations (MECs) from the published literature and to maximum predicted environmental concentrations (PECs) generated using the P
hATE model. The P
hATE model predictions are made under conservative assumptions of low river flow and no depletion (i.e., no metabolism, no removal during wastewater or drinking water treatment, and no instream depletion). Ratios of MECs to PNECs are typically very low and consistent with PEC to PNEC ratios. For all 26 compounds, these low ratios indicate that no appreciable human health risk exists from the presence of trace concentrations of these APIs in surface water and drinking water.
Cellular damage from ionizing radiation (IR) is in part due to DNA damage and reactive oxygen species, which activate DNA damage response (DDR) and cytokine signaling pathways, including the ataxia ...telangiectasia mutated (ATM) and transforming growth factor (TGF)β/Smad pathways. Using classic double-strand breaks (DSBs) markers, we studied the roles of Smad proteins in DDR and the crosstalk between TGFβ and ATM pathways. We observed co-localization of phospho-Smad2 (pSmad2) and Smad7 with DSB repair proteins following low and high linear energy transfer (LET) radiation in human fibroblasts and epithelial cells. The decays of both foci were similar to that of γH2AX foci. Irradiation with high LET particles induced pSmad2 and Smad7 foci tracks indicating the particle trajectory through cells. pSmad2 foci were absent in S phase cells, while Smad7 foci were present in all phases of cell cycle. pSmad2 (but not Smad7) foci were completely abolished when ATM was depleted or inactivated. In contrast, a TGFβ receptor 1 (TGFβR1) inhibitor abrogated Smad7, but not pSmad2 foci at DSBs sites. In summary, we suggest that Smad2 and Smad7 contribute to IR-induced DSB signaling in an ATM or TGFβR1-dependent manner, respectively.
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