Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study

Background: Previous research suggests that non-obstetric surgery is carried out in 1 – 2% of all pregnancies. However, there is limited evidence quantifying the associated risks. Furthermore, of the evidence available, none relates directly to outcomes in the UK, and there are no current NHS guidelines regarding non-obstetric surgery in pregnant women. Objectives: To estimate the risk of adverse birth outcomes of pregnancies in which non-obstetric surgery was or was not carried out. To further analyse common procedure groups. Data Source: Hospital Episode Statistics (HES) maternity data collected between 2002 – 3 and 2011 – 12. Main outcomes: Spontaneous abortion, preterm delivery, maternal death, caesarean delivery, long inpatient stay, stillbirth and low birthweight. Methods: We utilised HES, an administrative database that includes records of all patient admissions and day cases in all English NHS hospitals. We analysed HES maternity data collected between 2002 – 3 and 2011 – 12, and identified pregnancies in which non-obstetric surgery was carried out. We used logistic regression models to determine the adjusted relative risk and attributable risk of non-obstetric surgical procedures for adverse birth outcomes and the number needed to harm. Results: We identified 6,486,280 pregnancies, in 47,628 of which non-obstetric surgery was carried out. In comparison with pregnancies in which surgery was not carried out, we found that non-obstetric surgery was associated with a higher risk of adverse birth outcomes, although the attributable risk was generally low. We estimated that for every 287 pregnancies in which a surgical operation was carried out there was one additional stillbirth; for every 31 operations there was one additional preterm delivery; for every 25 operations there was one additional caesarean section; for every 50 operations there was one additional long inpatient stay; and for every 39 operations there was one additional low-birthweight baby. Limitations: We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Many spontaneous abortions will not be associated with a hospital admission and, therefore, will not be included in our analysis. A spontaneous abortion may be more likely to be reported if it occurs during the same hospital admission as the procedure, and this could account for the associated increased risk with surgery during pregnancy. There are missing values of key data items to determine parity, gestational age, birthweight and stillbirth. Conclusions: This is the first study to report the risk of adverse birth outcomes following non-obstetric surgery during pregnancy across NHS hospitals in England. We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Our observational study can never attribute a causal relationship between surgery and adverse birth outcomes, and we were unable to determine the risk of not undergoing surgery where surgery was clinically indicated. We have some reservations over associations of risk factors with spontaneous abortion because of potential ascertainment bias. However, we believe that our findings and, in particular, the numbers needed to harm improve on previous research, utilise a more recent and larger data set based on UK practices, and are useful reference points for any discussion of risk with prospective patients. The risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery is relatively low, confirming that surgical procedures during pregnancy are generally safe. Future work: Further evaluation of the association of non-obstetric surgery and spontaneous abortion. Evaluation of the impact of non-obstetric surgery on the newborn (e.g. neonatal intensive care unit admission, prolonged length of neonatal stay, neonatal death). Funding: The National Institute for Health Research Health Services and Delivery Research programme

EFFECT OF RECREATIONAL TRAIL TRAFFIC LEVEL ON EASTERN RED-BACKED SALAMANDER (PLETHODON CINEREUS) RELATIVE ABUNDANCE

The effects of roads and trails on terrestrial salamanders, primarily plethodontids, can be important. The abundance of terrestrial salamanders often increases with distance from roads. Less is known about the effects of recreational or hiking trails on terrestrial salamanders than is known about the effects of roads. We explored how low and high traffic trails in a suburban biological reserve affect the relative abundance of Eastern Red-backed Salamanders (Plethodon cinereus). We found more salamanders under cover objects next to low traffic trails compared to either high traffic trails or wooded areas without trails. At wooded sites, we found only striped morphs whereas at high traffic sites we found only unstriped morphs. Low traffic sites included a range of color morph frequencies. The proportion of females found in each site did not differ, nor did the mean size of the salamanders. Our results suggest that the impact of recreational walking trails needs to be examined more closely to see how and why the distributions of P. cinereus, and potentially other woodland salamanders, are affected and what trail characteristics are important in driving the apparent effects. Such information will contribute to the design and maintenance of walking trails in natural areas that minimize effects on terrestrial salamanders, and likely other organisms

The limitations of Slater's element-dependent exchange functional from analytic density functional theory

Our recent formulation of the analytic and variational Slater-Roothaan (SR) method, which uses Gaussian basis sets to variationally express the molecular orbitals, electron density and the one body effective potential of density functional theory, is reviewed. Variational fitting can be extended to the resolution of identity method,where variationality then refers to the error in each two electron integral and not to the total energy. It is proposed that the appropriate fitting functions be charge neutral and that all ab initio energies be evaluated using two-center fits of the two-electron integrals. The SR method has its root in the Slater's Xalpha method and permits an arbitrary scaling of the Slater-Gaspar-Kohn-Sham exchange-correlation potential around each atom in the system. Of several ways of choosing the scaling factors (Slater's exchange parameters), two most obvious are the Hartree-Fock (HF), alpha_HF, values and the exact atomic, alpha_EA, values. The performance of this simple analytic model with both sets for atomization energies of G2 set of 148 molecules is better than the local density approximation or the HF theory, although the errors in atomization energy are larger than the target chemical accuracy. To improve peformance for atomization energies, the SR method is reparametrized to give atomization energies of 148 molecules to be comparbale to those obtained by one of the most widely used generalized gradient approximations. The mean absolute error in ionization potentials of 49 atoms and molecules is about 0.5 eV and that in bond distances of 27 molecules is about 0.02 Angstrom. The overall good performance of the computationally efficient SR method using any reasonable set of alpha values makes it a promising method for study of large systems.Comment: 33 pages, Uses RevTex, to appear in The Journal of Chemical Physic

Model Atmospheres for Irradiated Stars in pre-Cataclysmic Variables

Model atmospheres have been computed for M dwarfs that are strongly irradiated by nearby hot companions. A variety of primary and secondary spectral types are explored in addition to models specific to four known systems: GD 245, NN Ser, AA Dor, and UU Sge. This work demonstrates that a dramatic temperature inversion is possible on at least one hemisphere of an irradiated M dwarf and the emergent spectrum will be significantly different from an isolated M dwarf or a black body flux distribution. For the first time, synthetic spectra suitable for direct comparison to high-resolution observations of irradiated M dwarfs in non-mass transferring post-common envelope binaries are presented. The effects of departures from local thermodynamic equilibrium on the Balmer line profiles are also discussed.Comment: Accepted for publication in ApJ; 12 pages, 10 figure

Developing a viva exam to assess clinical reasoning in pre-registration osteopathy students

Background: Clinical reasoning (CR) is a core capability for health practitioners. Assessing CR requires a suite of tools to encompass a wide scope of contexts and cognitive abilities. The aim of this project was to develop an oral examination and grading rubric for the assessment of CR in osteopathy, trial it with senior students in three accredited university programs in Australia and New Zealand, and to evaluate its content and face validity. Methods: Experienced osteopathic academics developed 20 cases and a grading rubric. Thirty senior students were recruited, 10 from each university. Twelve fourth year and 18 fifth year students participated. Three members of the research team were trained and examined students at an institution different from their own. Two cases were presented to each student participant in a series of vignettes. The rubric was constructed to follow a set of examiner questions that related to each attribute of CR. Data were analysed to explore differences in examiner marking, as well as relationships between cases, institutions, and different year levels. A non-examining member of the research team acted as an observer at each location. Results: No statistical difference was found between the total and single question scores, nor for the total scores between examiners. Significant differences were found between 4th and 5th students on total score and a number of single questions. The rubric was found to be internally consistent. Conclusions: A viva examination of clinical reasoning, trialled with senior osteopathy students, showed face and content validity. Results suggested that the viva exam may also differentiate between 4th and 5th year students’ capabilities in CR. Further work is required to establish the reliability of assessment, to further refine the rubric, and to train examiners before it is implemented as a high-stakes assessment in accredited osteopathy programs

Reforming the Veterans Health Administration-Beyond Palliation of Symptoms

The Veterans Health Administration (VHA) is one of the largest health care delivery systems in the United States, with 9.1 million enrollees, 20,000 physicians, 1600 facilities, 288,000 employees, and a $59 billion budget. In response to highly publicized concerns regarding delayed access to care, preventable deaths in patients awaiting care, and falsification of lists to make waiting times appear shorter, Congress passed and President Barack Obama signed the Veterans Access, Choice, and Accountability Act of 2014. In addition to expanding non-VHA treatment options for veterans, this law requires a comprehensive, independent assessment of 12 areas of VHA care delivery and management (see box). Eleven assessments were conducted under the Centers for Medicare and Medicaid Services Alliance to Modernize Healthcare, operated by the MITRE Corporation; the assessment of one area, “Access Standards,” was conducted by the Institute of Medicine. An independent blue-ribbon panel of experts was formed to examine and advise on all aspects of data collection and review, best practices, assessments, and recommendations. That panel, which we chaired, unanimously endorsed an integrated report, which was delivered to Secretary of Veterans Affairs Robert McDonald and Congress on September 1, 2015, and publicly released on September 18.

Understanding clinical reasoning in osteopathy: a qualitative research approach.

Background Clinical reasoning has been described as a process that draws heavily on the knowledge, skills and attributes that are particular to each health profession. However, the clinical reasoning processes of practitioners of different disciplines demonstrate many similarities, including hypothesis generation and reflective practice. The aim of this study was to understand clinical reasoning in osteopathy from the perspective of osteopathic clinical educators and the extent to which it was similar or different from clinical reasoning in other health professions. Methods This study was informed by constructivist grounded theory. Participants were clinical educators in osteopathic teaching institutions in Australia, New Zealand and the UK. Focus groups and written critical reflections provided a rich data set. Data were analysed using constant comparison to develop inductive categories. Results According to participants, clinical reasoning in osteopathy is different from clinical reasoning in other health professions. Osteopaths use a two-phase approach: an initial biomedical screen for serious pathology, followed by use of osteopathic reasoning models that are based on the relationship between structure and function in the human body. Clinical reasoning in osteopathy was also described as occurring in a number of contexts (e.g. patient, practitioner and community) and drawing on a range of metaskills (e.g. hypothesis generation and reflexivity) that have been described in other health professions. Conclusions The use of diagnostic reasoning models that are based on the relationship between structure and function in the human body differentiated clinical reasoning in osteopathy. These models were not used to name a medical condition but rather to guide the selection of treatment approaches. If confirmed by further research that clinical reasoning in osteopathy is distinct from clinical reasoning in other health professions, then osteopaths may have a unique perspective to bring to multidisciplinary decision-making and potentially enhance the quality of patient care. Where commonalities exist in the clinical reasoning processes of osteopathy and other health professions, shared learning opportunities may be available, including the exchange of scaffolded clinical reasoning exercises and assessment practices among health disciplines

Semiclassical charged black holes with a quantized massive scalar field

Semiclassical perturbations to the Reissner-Nordstrom metric caused by the presence of a quantized massive scalar field with arbitrary curvature coupling are found to first order in \epsilon = \hbar/M^2. The DeWitt-Schwinger approximation is used to determine the vacuum stress-energy tensor of the massive scalar field. When the semiclassical perturbation are taken into account, we find extreme black holes will have a charge-to-mass ratio that exceeds unity, as measured at infinity. The effects of the perturbations on the black hole temperature (surface gravity) are studied in detail, with particular emphasis on near extreme ``bare'' states that might become precisely zero temperature ``dressed'' semiclassical black hole states. We find that for minimally or conformally coupled scalar fields there are no zero temperature solutions among the perturbed black holes.Comment: 19 pages; 1 figure; ReVTe

Asplenium bird's nest ferns in rainforest canopies are climate-contingent refuges for frogs

Epiphytes are important for canopy dwelling organisms because they provide a cool and moist microhabitat in the relatively hot and dry canopy. Here we examine whether epiphytic Asplenium ferns act as important habitats for arboreal frogs. We conducted extensive fern and habitat surveys for frogs in the Philippines, and complimented these surveys with roaming day and night canopy surveys to identify the full extent of habitat use across the vertical strata. We artificially dried ferns of various sizes to identify relationships between water and temperature buffering. Ferns are the preferred diurnal microhabitat and breeding habitat for arboreal frogs. A strong positive relationship exists between fern size and frog usage and abundance. Our drying experiments show that large ferns buffer maximum temperatures and reduce variability in temperatures, and buffering is directly linked to their hydration. Frogs are likely using large ferns for their moist, cool, environments for breeding and daytime retreat, which supports the buffered microhabitat hypothesis—these plants promote species coexistence through habitat creation and amelioration of physical stress. However, drying experiments suggest that this buffering is contingent on regular rainfall. Altered rainfall regimes could lead to the unexpected loss of the functional capacity of these important fern habitats

Discovery of the Interstellar Chiral Molecule Propylene Oxide (CH3_3CHCH2_2O)

Life on Earth relies on chiral molecules, that is, species not superimposable on their mirror images. This manifests itself in the selection of a single molecular handedness, or homochirality, across the biosphere. We present the astronomical detection of a chiral molecule, propylene oxide (CH$_3$CHCH$_2$O), in absorption toward the Galactic Center. Propylene oxide is detected in the gas phase in a cold, extended molecular shell around the embedded, massive protostellar clusters in the Sagittarius B2 star-forming region. This material is representative of the earliest stage of solar system evolution in which a chiral molecule has been found