The Hospital-Physician Relationship: Hospital Responsibiity for Malpractice of Physicians

Since 1957 the courts in most states have moved rapidly toward imposing vicarious liability on a hospital for the torts of employee-physicians. In 1965 the Illinois Supreme Court held that a hospital could be liable for the malpractice of a nonemployee-physician. This comment attempts to describe these trends, to delineate the new rules the courts are applying and to determine the rationale for adopting these new rules. The comment assumes the patient has established that the physician committed malpractice; the only issue addressed is whether the patient can recover from the hospital for his or her injuries. The scope is further limited to the liability of a private hospital; thus governmental immunity, peculiar to state or federally owned hospitals, is not discussed

The Most Massive Ultra-Compact Dwarf Galaxy in the Virgo Cluster

We report on the properties of the most massive ultra-compact dwarf galaxy (UCD) in the nearby Virgo Cluster of galaxies using imaging from the Next Generation Virgo Cluster Survey (NGVS) and spectroscopy from Keck/DEIMOS. This object (M59-UCD3) appears to be associated with the massive Virgo galaxy M59 (NGC 4621), has an integrated velocity dispersion of 78 km/s, a dynamical mass of $3.7\times10^8 M_\odot$, and an effective radius ($R_e$) of 25 pc. With an effective surface mass density of $9.4\times10^{10} M_\odot/kpc^2$, it is the densest galaxy in the local Universe discovered to date, surpassing the density of the luminous Virgo UCD, M60-UCD1. M59-UCD3 has a total luminosity of $M_{g'}=-14.2$ mag, and a spectral energy distribution consistent with an old (14 Gyr) stellar population with [Fe/H]=0.0 and [$\alpha$/Fe]=+0.2. We also examine deep imaging around M59 and find a broad low surface brightness stream pointing towards M59-UCD3, which may represent a tidal remnant of the UCD progenitor. This UCD, along with similar objects like M60-UCD1 and M59cO, likely represents an extreme population of tidally stripped galaxies more akin to larger and more massive compact early-type galaxies than to nuclear star clusters in present-day dwarf galaxies.Comment: 6 pages, 4 figures, 1 table, accepted for publication in ApJ Letter

Rosetta-Alice Observations of Exospheric Hydrogen and Oxygen on Mars

The European Space Agency's Rosetta spacecraft, en route to a 2014 encounter with comet 67P/Churyumov-Gerasimenko, made a gravity assist swing-by of Mars on 25 February 2007, closest approach being at 01:54UT. The Alice instrument on board Rosetta, a lightweight far-ultraviolet imaging spectrograph optimized for in situ cometary spectroscopy in the 750-2000 A spectral band, was used to study the daytime Mars upper atmosphere including emissions from exospheric hydrogen and oxygen. Offset pointing, obtained five hours before closest approach, enabled us to detect and map the HI Lyman-alpha and Lyman-beta emissions from exospheric hydrogen out beyond 30,000 km from the planet's center. These data are fit with a Chamberlain exospheric model from which we derive the hydrogen density at the 200 km exobase and the H escape flux. The results are comparable to those found from the the Ultraviolet Spectrometer experiment on the Mariner 6 and 7 fly-bys of Mars in 1969. Atomic oxygen emission at 1304 A is detected at altitudes of 400 to 1000 km above the limb during limb scans shortly after closest approach. However, the derived oxygen scale height is not consistent with recent models of oxygen escape based on the production of suprathermal oxygen atoms by the dissociative recombination of O2+.Comment: 17 pages, 8 figures, accepted for publication in Icaru

Habituated, Tolerant, or Salt-conditioned Mountain Goats and Human Safety

Interactions between humans and wildlife include a number of consumptive and non-consumptive forms. In some cases, the increased demand for wildlife viewing can precipitate new human–wildlife conflicts. Mountain goats (Oreamnos americanus; goats) are native to a number of North American mountain ranges from southeastern Alaska to southwestern Montana, USA. Goat habitat typically consists of steep terrain and cold weather habitats, which has left them particularly vulnerable to climate change. Their alpine environments also make them vulnerable to disturbance by aircraft and land-based motorized human activity. We reviewed and characterized situations in which goats in close proximity to humans on foot may become a nuisance or dangerous to people. We identify how such interactions might occur, focusing on the array of intensity observed in different settings. We summarize and evaluate interventions that have been attempted and may warrant additional research. Goats that tolerate people along hiking trails, perhaps through a habituation-like process, can typically be kept at a safe distance simply by shouting, clapping hands, or vigorous gestures. Goats that have learned to associate people with a salt reward (e.g., typically urine deposited on the ground, less frequently sweat obtained directly by licking) are more likely to be successfully hazed by tossing small stones, hitting the animal in the flank or rear. Salt-conditioned goats sometimes come within touching distance of humans; we strongly advise against prodding or poking these animals with sharp objects such as trekking poles. The recreating public that ventures into goat habitat is the ultimate source of these conflicts. Education, compliance, and possibly some infrastructure improvements can lessen the potential for conflicts and provide new and safer opportunities to view goats

Evaluation of the Arabin cervical pessary for prevention of preterm birth in women with a twin pregnancy and short cervix (STOPPIT-2):An open-label randomised trial and updated meta-analysis

BackgroundPreterm-labour-associated preterm birth is a common cause of perinatal mortality and morbidity in twin pregnancy. We aimed to test the hypothesis that the Arabin pessary would reduce preterm-labour-associated preterm birth by 40% or greater in women with a twin pregnancy and a short cervix.Methods and findingsWe conducted an open-label randomised controlled trial in 57 hospital antenatal clinics in the UK and Europe. From 1 April 2015 to 14 February 2019, 2,228 women with a twin pregnancy underwent cervical length screening between 18 weeks 0 days and 20 weeks 6 days of gestation. In total, 503 women with cervical length ≤ 35 mm were randomly assigned to pessary in addition to standard care (n = 250, mean age 32.4 years, mean cervical length 29 mm, with pessary inserted in 230 women [92.0%]) or standard care alone (n = 253, mean age 32.7 years, mean cervical length 30 mm). The pessary was inserted before 21 completed weeks of gestation and removed at between 35 and 36 weeks or before birth if earlier. The primary obstetric outcome, spontaneous onset of labour and birth before 34 weeks 0 days of gestation, was present in 46/250 (18.4%) in the pessary group compared to 52/253 (20.6%) following standard care alone (adjusted odds ratio [aOR] 0.87 [95% CI 0.55-1.38], p = 0.54). The primary neonatal outcome-a composite of any of stillbirth, neonatal death, periventricular leukomalacia, early respiratory morbidity, intraventricular haemorrhage, necrotising enterocolitis, or proven sepsis, from birth to 28 days after the expected date of delivery-was present in 67/500 infants (13.4%) in the pessary group compared to 76/506 (15.0%) following standard care alone (aOR 0.86 [95% CI 0.54-1.36], p = 0.50). The positive and negative likelihood ratios of a short cervix (≤35 mm) to predict preterm birth before 34 weeks were 2.14 and 0.83, respectively. A meta-analysis of data from existing publications (4 studies, 313 women) and from STOPPIT-2 indicated that a cervical pessary does not reduce preterm birth before 34 weeks in women with a short cervix (risk ratio 0.74 [95% CI 0.50-1.11], p = 0.15). No women died in either arm of the study; 4.4% of babies in the Arabin pessary group and 5.5% of babies in the standard treatment group died in utero or in the neonatal period (p = 0.53). Study limitations include lack of power to exclude a smaller than 40% reduction in preterm labour associated preterm birth, and to be conclusive about subgroup analyses.ConclusionsThese results led us to reject our hypothesis that the Arabin pessary would reduce the risk of the primary outcome by 40%. Smaller treatment effects cannot be ruled out.Trial registrationISRCTN Registry ISRCTN 02235181. ClinicalTrials.gov NCT02235181

The Arabin pessary to prevent preterm birth in women with a twin pregnancy and a short cervix:the STOPPIT 2 RCT

Background: Preterm birth is common in twins and accounts for significant mortality and morbidity. There are no effective preventative treatments. Some studies have suggested that, in twin pregnancy complicated by a short cervix, the Arabin pessary, which fits around the cervix and can be inserted as an outpatient procedure, reduces preterm birth and prevents neonatal morbidity. Objective: STOPPIT 2 aimed to evaluate the clinical utility of the Arabin cervical pessary in preventing preterm birth in women with a twin pregnancy and a short cervix. Design: STOPPIT 2 was a pragmatic, open label, multicentre randomised controlled trial with two treatment group – the Arabin pessary plus standard care (intervention) and standard care alone (control). Participants were initially recruited into the screening phase of the study, when cervical length was measured. Women with a measured cervical length of ≤ 35 mm were then recruited into the treatment phase of the study. An economic evaluation considered cost-effectiveness and a qualitative substudy explored the experiences of participants and clinicians. Setting: Antenatal clinics in the UK and elsewhere in Europe. Participants: Women with twin pregnancy at < 21 weeks’ gestation with known chorionicity and gestation established by scan at ≤ 16 weeks’ gestation. Interventions: Ultrasound scan to establish cervical length. Women with a cervical length of ≤ 35 mm at 18+ 0–20+ 6 weeks’ gestation were randomised to standard care or Arabin pessary plus standard care. Randomisation was performed by computer and accessed through a web-based browser. Main outcome measures: Obstetric – all births before 34+ 0 weeks’ gestation following the spontaneous onset of labour; and neonatal – composite of adverse outcomes, including stillbirth or neonatal death, periventricular leukomalacia, early respiratory morbidity, intraventricular haemorrhage, necrotising enterocolitis or proven sepsis, all measured up to 28 days after the expected date of delivery. Results: A total of 2228 participants were recruited to the screening phase, of whom 2170 received a scan and 503 were randomised: 250 to Arabin pessary and 253 to standard care alone. The rate of the primary obstetric outcome was 18.4% (46/250) in the intervention group and 20.6% (52/253) in the control group (adjusted odds ratio 0.87, 95% confidence interval 0.55 to 1.38; p = 0.54). The rate of the primary neonatal outcome was 13.4% (67/500) and 15.0% (76/506) in the intervention group and control group, respectively (adjusted odds ratio 0.86, 95% confidence interval 0.54 to 1.36; p = 0.52). The pessary was largely well tolerated and clinicians found insertion and removal ‘easy’ or ‘fairly easy’ in the majority of instances. The simple costs analysis showed that pessary treatment is no more costly than standard care. Limitations: There was the possibility of a type II error around smaller than anticipated benefit. Conclusions: In this study, the Arabin pessary did not reduce preterm birth or adverse neonatal outcomes in women with a twin pregnancy and a short cervix. The pessary either is ineffective at reducing preterm birth or has an effect size of < 0.4. Future work: Women with twin pregnancy remain at risk of preterm birth; work is required to find treatments for this. Trial registration: Current Controlled Trials ISRCTN98835694 and ClinicalTrials.gov NCT02235181. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 44. See the NIHR Journals Library website for further project information