Gas physical conditions and kinematics of the giant outflow Ou4

Ou4 is a recently discovered bipolar outflow with a projected size of more than one degree in the plane of the sky. It is apparently centred on the young stellar cluster -whose most massive representative is the triple system HR8119- inside the HII region Sh 2-129. The driving source, the nature, and the distance of Ou4 are not known. Deep narrow-band imagery of the whole nebula at arcsec resolution was obtained to study its morphology. Long-slit spectroscopy of the tips of the bipolar lobes was secured to determine the gas ionization mechanism, physical conditions, and line-of-sight velocities. An estimate of the proper motions at the tip of the south lobe using archival images is attempted. The existing multi-wavelength data for Sh 2-129 and HR 8119 are also comprehensively reviewed. The morphology of Ou4, its emission-line spatial distribution, line flux ratios, and the kinematic modelling adopting a bow-shock parabolic geometry, illustrate the expansion of a shock-excited fast collimated outflow. The radial velocities and reddening are consistent with those of Sh 2-129 and HR 8119. The improved determination of the distance to HR8119 (composed of two B0 V and one B0.5 V stars) and Sh 2-129 is 712 pc. We identify in WISE images a 5 arcmin-radius (1 pc at the distance above) bubble of emission at 22 micron emitted by hot (107 K) dust, located inside the central part of Ou4 and corresponding to several [O III] features of Ou4. The apparent position and the properties studied in this work are consistent with the hypothesis that Ou4 is located inside the Sh 2-129 HII region, suggesting that it was launched some 90 000 yrs ago by HR8119. The outflow total kinetic energy is estimated to be ~4e47~ergs. However, the alternate possibility that Ou4 is a bipolar planetary nebula, or the result of an eruptive event on a massive AGB or post-AGB star not yet identified, cannot be ruled out.Comment: Accepted for publication in Astronomy and Astrophysics. Also available at http://hal.archives-ouvertes.fr/hal-0102228

Can Consistent Benchmarking within a Standardized Pain Management Concept Decrease Postoperative Pain after Total Hip Arthroplasty? A Prospective Cohort Study including 367 Patients

Background: The number of total hip replacement surgeries has steadily increased over recent years. Reduction in postoperative pain increases patient satisfaction and enables better mobilization. Thus, pain management needs to be continuously improved. Problems are often caused not only by medical issues but also by organization and hospital structure. The present study shows how the quality of pain management can be increased by implementing a standardized pain concept and simple, consistent, benchmarking. Methods: All patients included in the study had undergone total hip arthroplasty (THA). Outcome parameters were analyzed 24 hours after surgery by means of the questionnaires from the German-wide project "Quality Improvement in Postoperative Pain Management" (QUIPS). A pain nurse interviewed patients and continuously assessed outcome quality parameters. A multidisciplinary team of anesthetists, orthopedic surgeons, and nurses implemented a regular procedure of data analysis and internal benchmarking. The health care team was informed of any results, and suggested improvements. Every staff member involved in pain management participated in educational lessons, and a special pain nurse was trained in each ward. Results: From 2014 to 2015, 367 patients were included. The mean maximal pain score 24 hours after surgery was 4.0 (+/- 3.0) on an 11-point numeric rating scale, and patient satisfaction was 9.0 (+/- 1.2). Over time, the maximum pain score decreased (mean 3.0, +/- 2.0), whereas patient satisfaction significantly increased (mean 9.8, +/- 0.4; p<0.05). Among 49 anonymized hospitals, our clinic stayed on first rank in terms of lowest maximum pain and patient satisfaction over the period. Conclusion: Results were already acceptable at the beginning of benchmarking a standardized pain management concept. But regular benchmarking, implementation of feedback mechanisms, and staff education made the pain management concept even more successful. Multidisciplinary teamwork and flexibility in adapting processes seem to be highly important for successful pain management

Psychological impact, support and information needs for women with an abnormal Pap smear: comparative results of a questionnaire in three European countries

<p>Abstract</p> <p>Background</p> <p>Extensive information on cervical cancer is currently available. Its effectiveness in reducing anxiety in women receiving abnormal Pap tests is not clear. We investigated current practices of communicating abnormal Pap results to evaluate women's reactions and determine the sources of information they use subsequently.</p> <p>Methods</p> <p>A self-administered questionnaire-based study was performed in 1475 women in France, Spain and Portugal who had received an abnormal Pap smear result in the 12 months prior to completing the questionnaire. Questions covered methods of communication of the result, emotional reactions, support received (from the physician and entourage), and information sources, using pre-specified check box options and rating scales. Data were analyzed by country.</p> <p>Results</p> <p>Pap test results were mostly communicated by phone to Spanish women (76%), while physician letters were common in France (59%) and Portugal (36%). Frequent reactions were anxiety, panic and stress, which were less common in Spanish women than their French and Portuguese counterparts. After discussing with their physician, half of the participants were worried, despite rating highly the psychological support received. Over 90% of women in each country discussed their results with family or friends. Partners provided a high level of support. Overall, the abnormal diagnosis and consequences had a low to medium impact on daily, professional and family life and their relationships with their partner. Impact was higher in Spanish women than the French or Portuguese. Information on the diagnosis and its treatment was rated average, and nearly 80% of participants wanted more information, notably French women. Preferred sources were the physician and the Internet.</p> <p>Conclusions</p> <p>Women expressed a strong wish for more information about cervical cancer and other HPV-related diseases, and that their physician play a major role in its provision and in support. There was a heavy reliance on the close entourage and the Internet for information, highlighting the need for dissemination of accurate material. Differences between countries suggest information management strategies may need to be tailored to different geographical regions.</p

Perinatal and 2-year neurodevelopmental outcome in late preterm fetal compromise: the TRUFFLE 2 randomised trial protocol

Introduction: Following the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late delivery are potentially important yet practice varies widely around the world, with abnormal findings from fetal heart rate monitoring invariably leading to delivery. Indices derived from fetal cerebral Doppler examination may guide such decisions although there are few studies in this area. We propose a randomised, controlled trial to establish the optimum method of timing delivery between 32 weeks and 36 weeks 6 days of gestation. We hypothesise that delivery on evidence of cerebral blood flow redistribution reduces a composite of perinatal poor outcome, death and short-term hypoxia-related morbidity, with no worsening of neurodevelopmental outcome at 2 years. Methods and analysis: Women with non-anomalous singleton pregnancies 32+0 to 36+6 weeks of gestation in whom the estimated fetal weight or abdominal circumference is &lt;10th percentile or has decreased by 50 percentiles since 18-32 weeks will be included for observational data collection. Participants will be randomised if cerebral blood flow redistribution is identified, based on umbilical to middle cerebral artery pulsatility index ratio values. Computerised cardiotocography (cCTG) must show normal fetal heart rate short term variation (≥4.5 msec) and absence of decelerations at randomisation. Randomisation will be 1:1 to immediate delivery or delayed delivery (based on cCTG abnormalities or other worsening fetal condition). The primary outcome is poor condition at birth and/or fetal or neonatal death and/or major neonatal morbidity, the secondary non-inferiority outcome is 2-year infant general health and neurodevelopmental outcome based on the Parent Report of Children's Abilities-Revised questionnaire. Ethics and dissemination: The Study Coordination Centre has obtained approval from London-Riverside Research Ethics Committee (REC) and Health Regulatory Authority (HRA). Publication will be in line with NIHR Open Access policy. Trial registration number: Main sponsor: Imperial College London, Reference: 19QC5491. Funders: NIHR HTA, Reference: 127 976. Study coordination centre: Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS with Centre for Trials Research, College of Biomedical &amp; Life Sciences, Cardiff University. IRAS Project ID: 266 400. REC reference: 20/LO/0031. ISRCTN registry: 76 016 200

Maternal Complications and Hemodynamic Changes Following Intrauterine Interventions for Twin-to-Twin Transfusion Syndrome in Monochorionic Diamniotic Twin Pregnancies

Twin-to-twin transfusion syndrome (TTTS) is a challenging complication in monochorionic diamniotic (MCDA) twins. Intrauterine interventions, such as fetoscopic laser ablation and cord occlusion followed by amniodrainage, are established treatments. Little is known about maternal complications and hemodynamics following these interventions. We performed a retrospective analysis of maternal procedure-related complications and the impact of such procedures on maternal hemodynamics and blood characteristics. Within the study period, 100 women with severe TTTS treated by fetoscopic laser ablation (FLA) or cord occlusion (CO) were identified. Clinically relevant maternal complications were reported in four (4%) cases. There was a significant decrease in hemoglobin, hematocrit, and albumin between admission and postoperative measurements (all p &lt; 0.001). Systolic and diastolic blood pressure, as well as maternal heart rate, decreased from time of skin suture to postoperative measurements (all p &lt; 0.001). Within a 24 h interval, there was a positive correlation between hematocrit (Spearman&rsquo;s rho 0.325; p = 0.003), hemoglobin (Spearman&rsquo;s rho 0.379; p &lt; 0.001), and albumin (Spearman&rsquo;s rho 0.360; p = 0.027), and the amount of amniodrainage during the intervention. Maternal procedure-related complications are relatively rare. Significant hemodynamic alterations and maternal hemodilution are common clinical findings following intrauterine interventions