Different aspects of electronic fetal monitoring during labor

Background: Cardiotocography (CTG) is a tool to assess fetal well-being during labor and to detect early signs of fetal distress and thereby enable timely interventions to reduce neonatal morbidity and mortality. CTG is associated with shortcomings; poor reliability in interpretation, low specificity with a high proportion of false positive tracings indicating fetal distress when not accurate, no proven effect on rare severe outcomes such as mortality and cerebral palsy, but rather contributing to an increased risk of operative delivery. The aims of this thesis was to determine I) if an extended CTG education could lead to better reliability in interpretation compared to a national standard education, II) if a computerized algorithm could be developed with precision in detecting and quantitating decelerations on CTG, III) if deceleration area was a better predictor of fetal acidemia during labor than deceleration depth and duration, IV) the proportion of fetuses with undetected small for gestational age (SGA) in a low-risk population, comparing women that present with normal CTG at admission to labor (admCTG) to those with abnormal admCTG and to compare neonatal outcomes in the two groups stratified on SGA or non-SGA. Material and methods: The CTG tracings used in paper I-III were extracted from a previous cohort of women in labor, from Karolinska University Hospital, Sweden. All women had undergone fetal blood sampling (FBS) during labor due to suspicious CTG patterns. Six obstetricians from two different hospitals were used as observers in paper I. Inter- and intra-observer reliability using Cohen’s and Fleiss kappa was determined for different parameters assessed on CTG. In paper II two obstetricians visually analyzed CTG tracings with variable decelerations and specified duration, depth and area for each deceleration. The computerized algorithm analyzed and quantified the same CTG traces and was compared to the observers using intra-class correlation and Bland-Altman analysis. In paper III the predictive value of deceleration area, duration, and depth for fetal acidemia, measured as lactate concentration at FBS, was explored using receiver operating characteristics, area under curve (ROC AUC). In paper IV, a register-based study, the risk of SGA in relation to the result of admCTG, normal vs abnormal was assessed in low-risk pregnancies. Neonatal outcomes were also determined by multiple logistic regression analysis. Results: I) The inter- and intra-observer reliability was moderate to excellent at both departments, kappa 0.41-0.93. The department with extended education reached significantly higher interobserver agreement for two of six CTG parameters assessed. II) Computerized assessment of decelerations on CTG compared to visual observers reached excellent intraclass correlation (0.89-0.95) and low bias in Bland-Altman analysis, comparable to that between the two observers. III) The deceleration measures with the best prediction of fetal acidemia was cumulative deceleration area and duration, ROC AUC 0.682 and 0.683 respectively compared to deceleration depth 0.631. IV) The proportion of SGA was two-fold higher among neonates presenting with abnormal admCTG (18.6%) compared to normal admCTG (9.7%). The risk of composite severe adverse neonatal complications was substantially higher in the group with abnormal admCTG/SGA compared to normal admCTG/non-SGA, adjusted odds ratio 23.7 (95% confidence interval 9.8-57.3) Conclusion: Inter- and intra-observer agreement was better than expected at both departments studied and extended education might have an impact on interpretation reliability. A novel computerized algorithm for CTG assessment has high precision in detecting and quantifying decelerations. Cumulative deceleration area and duration are better predictors of fetal acidemia than deceleration depth. In presumed low-risk pregnancies there is a group of undetected SGA fetuses that more often present with abnormal admCTG and are at higher risks of neonatal complications

Emergency Medical Response in Mass Casualty Tunnel Incidents—with Emphasis on Prehospital Care

Responding to mass casualty incidents in a tunnel environment is problematic not least from a prehospital emergency medical services (EMS) perspective. The aim of this review was to 1) categorize preconditions for emergency response in tunnel environments based on Haddon’s matrix and 2) identify specific EMS knowledge of providing prehospital care. Twenty eight articles, reports and book chapters were selected for further analysis. Firstly, sorting the data from each included article was done according to Haddon’s matrix. The result covers human factors, technical factors, physical environmental factors and socioeconomic environmental factors all related to preconditions for emergency response. To describe the EMS’s knowledge the data was also sorted according to command and safety, communication, assessment, and triage treatment and transport, also known as CSCATT. Few studies, especially of high quality, actually provide detailed information regarding emergency response to tunnel incidents and those that do, often have a main focus on management by the rescue service. While many incidents studied were caused by fires in tunnels, thus requiring rescue service in action, the subsequent EMS response issues that have taken place appear to have been given limited attention. To optimize the survival rates and health of the injured, as well as to provide a safe and effective work environment for the emergency services, there is a need to explore the event phase

Seabed corrugations beneath an Antarctic ice shelf revealed by autonomous underwater vehicle survey: Origin and implications for the history of Pine Island Glacier

Ice shelves are critical features in the debate about West Antarctic ice sheet change and sea level rise, both because they limit ice discharge and because they are sensitive to change in the surrounding ocean. The Pine Island Glacier ice shelf has been thinning rapidly since at least the early 1990s, which has caused its trunk to accelerate and retreat. Although the ice shelf front has remained stable for the past six decades, past periods of ice shelf collapse have been inferred from relict seabed "corrugations" (corrugated ridges), preserved 340 km from the glacier in Pine Island Trough. Here we present high-resolution bathymetry gathered by an autonomous underwater vehicle operating beneath an Antarctic ice shelf, which provides evidence of long-term change in Pine Island Glacier. Corrugations and ploughmarks on a sub-ice shelf ridge that was a former grounding line closely resemble those observed offshore, interpreted previously as the result of iceberg grounding. The same interpretation here would indicate a significantly reduced ice shelf extent within the last 11 kyr, implying Holocene glacier retreat beyond present limits, or a past tidewater glacier regime different from today. The alternative, that corrugations were not formed in open water, would question ice shelf collapse events interpreted from the geological record, revealing detail of another bed-shaping process occurring at glacier margins. We assess hypotheses for corrugation formation and suggest periodic grounding of ice shelf keels during glacier unpinning as a viable origin. This interpretation requires neither loss of the ice shelf nor glacier retreat and is consistent with a "stable" grounding-line configuration throughout the Holocene

Mapping submarine glacial landforms using acoustic methods

The mapping of submarine glacial landforms is largely dependent on marine geophysical survey methods capable of imaging the seafloor and sub-bottom through the water column. Full global coverage of seafloor mapping, equivalent to that which exists for the Earth's land surface, has, to date, only been achieved by deriving bathymetry from radar altimeters on satellites such as GeoSat and ERS-1 (Smith & Sandwell 1997). The horizontal resolution is limited by the footprint of the satellite sensors and the need to average out local wave and wind effects, resulting in a cell size of about 15 km (Sandwell et al. 2001). A further problem in high latitudes is that the altimeter data are extensively contaminated by the presence of sea ice, which degrades the derived bathymetry (McAdoo & Laxon 1997). Consequently, the satellite altimeter method alone is not suitable for mapping submarine glacial landforms, given that their morphological characterization usually requires a much finer level of detail. Acoustic mapping methods based on marine echo-sounding principles are currently the most widely used techniques for mapping submarine glacial landforms because they are capable of mapping at a much higher resolution

Reply to: Towards solving the missing ice problem and the importance of rigorous model data comparisons

Our recent ice sheet reconstruction, PaleoMIST 1.0, was created on the basis of using near-field (i.e., ice sheet proximal) geological constraints. This was done so that it would be independent of far-field relative sea level observations, that are subject to uncertainties in the global distribution of ice, and deep sea proxy based global mean sea level reconstructions, which have large uncertainties due to temperature and salinity effects. We do not disagree with the interpretation of the far-field data highlighted by Yokoyama et al., but emphasise that near-field constraints should be the starting point for reconstructing ice sheets

Preparing medical first responders for crises: a systematic literature review of disaster training programs and their effectiveness.

BACKGROUND Adequate training and preparation of medical first responders (MFRs) are essential for an optimal performance in highly demanding situations like disasters (e.g., mass accidents, natural catastrophes). The training needs to be as effective as possible, because precise and effective behavior of MFRs under stress is central for ensuring patients' survival and recovery. This systematic review offers an overview of scientifically evaluated training methods used to prepare MFRs for disasters. It identifies different effectiveness indicators and provides an additional analysis of how and to what extent the innovative training technologies virtual (VR) and mixed reality (MR) are included in disaster training research. METHODS The systematic review was conducted according to the PRISMA guidelines and focused specifically on (quasi-)experimental studies published between January 2010 and September 2021. The literature search was conducted via Web of Science and PubMed and led to the inclusion of 55 articles. RESULTS The search identified several types of training, including traditional (e.g., lectures, real-life scenario training) and technology-based training (e.g., computer-based learning, educational videos). Most trainings consisted of more than one method. The effectiveness of the trainings was mainly assessed through pre-post comparisons of knowledge tests or self-reported measures although some studies also used behavioral performance measures (e.g., triage accuracy). While all methods demonstrated effectiveness, the literature indicates that technology-based methods often lead to similar or greater training outcomes than traditional trainings. Currently, few studies systematically evaluated immersive VR and MR training. CONCLUSION To determine the success of a training, proper and scientifically sound evaluation is necessary. Of the effectiveness indicators found, performance assessments in simulated scenarios are closest to the target behavior during real disasters. For valid yet inexpensive evaluations, objectively assessible performance measures, such as accuracy, time, and order of actions could be used. However, performance assessments have not been applied often. Furthermore, we found that technology-based training methods represent a promising approach to train many MFRs repeatedly and efficiently. These technologies offer great potential to supplement or partially replace traditional training. Further research is needed on those methods that have been underrepresented, especially serious gaming, immersive VR, and MR

Potential links between Baltic Sea submarine terraces and groundwater seeping

Submarine groundwater discharge (SGD) influences ocean chemistry, circulation, and the spreading of nutrients and pollutants; it also shapes sea floor morphology. In the Baltic Sea, SGD was linked to the development of terraces and semicircular depressions mapped in an area of the southern Stockholm archipelago, Sweden, in the 1990s. We mapped additional parts of the Stockholm archipelago, areas in Blekinge, southern Sweden, and southern Finland using high-resolution multibeam sonars and sub-bottom profilers to investigate if the sea floor morphological features discovered in the 1990s are widespread and to further address the hypothesis linking their formation to SGD. Sediment coring and sea floor photography conducted with a remotely operated vehicle (ROV) and divers add additional information to the geophysical mapping results. We find that terraces, with general bathymetric expressions of about 1 m and lateral extents of sometimes > 100 m, are widespread in the surveyed areas of the Baltic Sea and are consistently formed in glacial clay. Semicircular depressions, however, are only found in a limited part of a surveyed area east of the island of Asko, southern Stockholm archipelago. While submarine terraces can be produced by several processes, we interpret our results to be in support of the basic hypothesis of terrace formation initially proposed in the 1990s; i.e. groundwater flows through siltier, more permeable layers in glacial clay to discharge at the sea floor, leading to the formation of a sharp terrace when the clay layers above seepage zones are undermined enough to collapse. By linking the terraces to a specific geologic setting, our study further refines the formation hypothesis and thereby forms the foundation for a future assessment of SGD in the Baltic Sea that may use marine geological mapping as a starting point. We propose that SGD through the submarine sea floor terraces is plausible and could be intermittent and linked to periods of higher groundwater levels, implying that to quantify the contribution of freshwater to the Baltic Sea through this potential mechanism, more complex hydrogeological studies are required.Peer reviewe

Stratigraphic Occurrences of Sub-Polar Planktic Foraminifera in Pleistocene Sediments on the Lomonosov Ridge, Arctic Ocean

Turborotalita quinqueloba is a species of planktic foraminifera commonly found in the sub-polar North Atlantic along the pathway of Atlantic waters in the Nordic seas and sometimes even in the Arctic Ocean, although its occurrence there remains poorly understood. Existing data show that T. quinqueloba is scarce in Holocene sediments from the central Arctic but abundance levels increase in sediments from the last interglacial period [Marine isotope stage (MIS) 5, 71–120 ka] in cores off the northern coast of Greenland and the southern Mendeleev Ridge. Turborotalita also occurs in earlier Pleistocene interglacials in these regions, with a unique and widespread occurrence of the less known Turborotalita egelida morphotype, proposed as a biostratigraphic marker for MIS 11 (474–374 ka). Here we present results from six new sediment cores, extending from the central to western Lomonosov Ridge, that show a consistent Pleistocene stratigraphy over 575 km. Preliminary semi-quantitative assessments of planktic foraminifer abundance and assemblage composition in two of these records (LOMROG12-7PC and AO16-5PC) reveal two distinct stratigraphic horizons containing Turborotalita in MIS 5. Earlier occurrences in Pleistocene interglacials are recognized, but contain significantly fewer specimens and do not appear to be stratigraphically coeval in the studied sequences. In all instances, the Turborotalita specimens resemble the typical T. quinqueloba morphotype but are smaller (63–125 μm), smooth-walled and lack the final thickened calcite layer common to adults of the species. These results extend the geographical range for T. quinqueloba in MIS 5 sediments of the Arctic Ocean and provide compelling evidence for recurrent invasions during Pleistocene interglacials

Coastline changes and sedimentation related with the opening of an artificial channel: the Valo Grande Delta, SE Brazil

The role played by human activity in coastline changes indicates a general tendency of retreating coasts, especially deltaic environments, as a result of the recent trend of sea level rise as well as the blockage of the transfer of sediments towards the coast, especially due to the construction of dams. This is particularly important in deltaic environments which have been suffering a dramatic loss of area in the last decades. In contrast, in this paper, we report the origin and evolution of an anthropogenic delta, the Valo Grande delta, on the south-eastern Brazilian coast, whose origin is related to the opening of an artificial channel and the diversion of the main flow of the Ribeira de Iguape River. The methodology included the analysis of coastline changes, bathy metry and coring, which were used to determine the sedimentation rates and grain-size changes over time. The results allowed us to recognize the different facies of the anthropogenic delta and establish its lateral and vertical depositional trends. Despite not being very frequent, anthropogenic deltas represent a favorable environment for the record of natural and anthropogenic changes in historical times and, thus, deserve more attention from researchers of different subjects.Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP) [06/04344-2]info:eu-repo/semantics/publishedVersio

What have we learnt from palaeoclimate simulations?

There has been a gradual evolution in the way that palaeoclimate modelling and palaeoenvironmental data are used together to understand how the Earth System works, from an initial and largely descriptive phase through explicit hypothesis testing to diagnosis of underlying mechanisms. Analyses of past climate states are now regarded as integral to the evaluation of climate models, and have become part of the toolkit used to assess the likely realism of future projections. Palaeoclimate assessment has demonstrated that changes in large-scale features of climate that are governed by the energy and water balance show consistent responses to changes in forcing in different climate states, and these consistent responses are reproduced by climate models. However, state-of-the-art models are still largely unable to reproduce observed changes in climate at a regional scale reliably. While palaeoclimate analyses of state-of-the-art climate models suggest an urgent need for model improvement, much work is also needed on extending and improving palaeoclimate reconstructions and quantifying and reducing both numerical and interpretative uncertainties