Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group

<p>Abstract</p> <p>Background</p> <p>Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Several recent publications have noted an increasing trend in incidence over time. The international PPH collaboration was convened to explore the observed trends and to set out actions to address the factors identified.</p> <p>Methods</p> <p>We reviewed available data sources on the incidence of PPH over time in Australia, Belgium, Canada, France, the United Kingdom and the USA. Where information was available, the incidence of PPH was stratified by cause.</p> <p>Results</p> <p>We observed an increasing trend in PPH, using heterogeneous definitions, in Australia, Canada, the UK and the USA. The observed increase in PPH in Australia, Canada and the USA was limited solely to immediate/atonic PPH. We noted increasing rates of severe adverse outcomes due to hemorrhage in Australia, Canada, the UK and the USA.</p> <p>Conclusion</p> <p><it>Key Recommendations</it></p> <p indent="1">1. Future revisions of the International Classification of Diseases should include separate codes for atonic PPH and PPH immediately following childbirth that is due to other causes. Also, additional codes are required for placenta accreta/percreta/increta.</p> <p indent="1">2. Definitions of PPH should be unified; further research is required to investigate how definitions are applied in practice to the coding of data.</p> <p indent="1">3. Additional improvement in the collection of data concerning PPH is required, specifically including a measure of severity.</p> <p indent="1">4. Further research is required to determine whether an increased rate of reported PPH is also observed in other countries, and to further investigate potential risk factors including increased duration of labor, obesity and changes in second and third stage management practice.</p> <p indent="1">5. Training should be provided to all staff involved in maternity care concerning assessment of blood loss and the monitoring of women after childbirth. This is key to reducing the severity of PPH and preventing any adverse outcomes.</p> <p indent="1">6. Clinicians should be more vigilant given the possibility that the frequency and severity of PPH has in fact increased. This applies particularly to small hospitals with relatively few deliveries where management protocols may not be defined adequately and drugs or equipment may not be on hand to deal with unexpected severe PPH.</p

Data Linkage: A powerful research tool with potential problems

Background: Policy makers, clinicians and researchers are demonstrating increasing interest in using data linked from multiple sources to support measurement of clinical performance and patient health outcomes. However, the utility of data linkage may be compromised by sub-optimal or incomplete linkage, leading to systematic bias. In this study, we synthesize the evidence identifying participant or population characteristics that can influence the validity and completeness of data linkage and may be associated with systematic bias in reported outcomes

Wirkbilanzen mit ökotoxikologischen Produktbilanzen: Ihre Bedeutung und Durchführung bei Ökobilanzen

Will die Ökobilanz ihrem operationalen Anspruch einer Abwägung der Auswirkungen menschlicher Aktivitäten auf verschiedene Umweltschutzgüter gerecht werden, so kommt der Wirkbilanz, d.h. der Klassifizierung der Einträge mit anschließender ökologischer Bewertung, eine zentrale Bedeutung zu: Eine sorgfältig durchgeführte Wirkbilanz ermöglicht erst die Beurteilung der Bedeutung eines Umwelteintrages in Hinblick auf eine Veränderung des betrachteten Schutzgutes - z.B. des Bodens oder der Erdatmosphäre. Durch die Ermittlung der Bedeutung sollte eine ökologisch begründete Skalierung des Umwelteintrages möglich werden. Durch diese Skalierung wiederum könnten verschiedene Umwelteinträge - zumindest teilweise - vergleichbar werden und geeignete Maßnahmen zum optimalen Umweltschutz ergriffen werden

Thematic maps for regional ecotoxicological risk assessment of pesticides

Frequently, decisions and/or recommendations on various regional scales on the application of pesticides have to be made by authorities, institutions and individual persons. Therefore, it is advisable to identify and rank the ecotoxicological risk of a pesticide under special consideration of the respective regional conditions. As a result thematic maps can be designed identifying and ranking different vulnerable regions with respect to groundwater contamination, permeable soils and areas at high risk for terrestrial and aquatic organisms. Also, different pesticides can be ranked with respect to their ecological risk for a specific area under consideration. Such a 'regionalization' of the ecological risk can be approached as follows: (1) Small-scale scenarios being representative for the regions under consideration have to be selected and characterized. The characterization has to comprise: soils (types, genesis, thickness, permeability to subsoils), topology (e.g., slope), climatic conditions, surface water (occurrence of ditches, ponds and creeks), portion of the drained area, portion of land under agricultural use, typical cultures and types of pesticides, application rates and frequency. (2) The representativity of the selected scenarios for the region under consideration has to be determined. (3) For the various regions predicted environmental concentrations (PEC) are assessed for the different paths of entry (mainly spraydrift and runoff), the different ecological systems, the different durations of the impact (fate consideration). If appropriate, sensible average values (e.g., for an average distance of the aquatic system from the target area) have to be agreed upon. (4) Determination of concentrations of no environmental concern (NEC). (5) Formation of risk quotients (PEC(i)/NEC(j)) for the each path of entry, ecological system and duration of the impact and subsequent aggregation of the quotients on a previously defined scale. The result is not an absolute risk, but the ranking of the regions as stated above can easily be performed