The obstetrical emergency department: need, rationale, and guide to implementation.

The past 2 decades have seen dramatic growth in the number of obstetrics and gynecology hospitalists, and many hospitals have created obstetrical-specific emergency departments. The goals of an obstetrics emergency department are to provide safe and efficient care to the pregnant dyad and postpartum patient, while generating revenue for emergency services provided. In an obstetrics emergency department, all patients must be evaluated in person by a licensed practitioner, whereas historically they may have been evaluated in person by nursing staff or a trainee. We make the argument that formation of an obstetrics emergency department has the potential to improve the safety and quality of patient care. In addition, the financial benefits to institutions are substantial and can subsidize the cost of maintaining obstetrician presence all the time in the hospital. There are various regulatory requirements to become certified, accredited, and licensed as an emergency department. In addition, there are many operational and systems issues that institutions should consider before implementation. We provide a guide for healthcare systems considering creating an obstetrics emergency department.

Use of Obstetric and Gynecologic Hospitalists Is Associated With Decreased Severe Maternal Morbidity in the United States.

OBJECTIVES: This study aimed to evaluate the prevalence of obstetric and gynecologic (Ob/Gyn) hospitalists and determine if an association exists between the presence of Ob/Gyn hospitalists and severe maternal morbidity (SMM). METHODS: This observational study included data from hospitals listed in the USA TODAY 's 2019 article titled, "Deadly deliveries: Childbirth complication rates at maternity hospitals." Telephone and email surveys of staff in these hospitals identified the presence or absence of continuous providers in the hospital 24 hours, 7 days a week (24/7 coverage) and the types of providers who are employed, then compared these responses with the SMM cited by USA TODAY . RESULTS: Eight hundred ten hospitals were contacted, with participation from 614 labor and delivery units for a response rate of 75.8%. Fifty-seven percent of units were staffed with 24/7 coverage, with 46% of hospitals' coverage primarily provided by an Ob/Gyn hospitalist and 54% primarily by a nonhospitalist OB/Gyn provider. The SMM and presence of 24/7 coverage increased with the level of neonatal care and delivery volume. Of hospitals with 24/7 coverage, those that primarily used Ob/Gyn hospitalists had a lower SMM for all mothers (1.7 versus 2.0, P = 0.014) and for low-income mothers (1.9 versus 2.30, P = 0.007) than those who primarily used nonhospitalist OB/Gyn providers. CONCLUSIONS: Severe maternal morbidity increases with delivery volume, level of neonatal care, and 24/7 coverage. Of hospitals with 24/7 coverage, units that staff with Ob/Gyn hospitalists have lower levels of SMM than those that use nonhospitalist Ob/Gyn providers.

Bipolar disorder and eating disorders in sport: a case of comorbidity and review of treatment principles in an elite athlete.

OBJECTIVES: There is overlap between the typical age of onset of bipolar disorder (BD) and the age of peak athletic success. Additionally, eating disorders (EDs) are prevalent psychiatric disorders in athletes. Despite the relevance of both disorders in this population, there remains a need for treatment guidelines, especially when present as comorbidities given the complex interplay between them. METHODS: This report provides background information and utilizes a case report to explore the presentation and treatment of BD comorbid with an ED in an athlete. It specifically highlights the case of an elite female long-distance runner utilizing a multidisciplinary approach specific to the patient's unique needs as an athlete. RESULTS: Treatment of this elite athlete utilized strategic pharmacotherapy taking into consideration her training and competition cycles. At 16 week follow-up, the patient was psychiatrically stable, experienced improvement in her running and felt confident in choosing to stay on medication and continue her running career. CONCLUSION: It is important for providers who work with high-level athletes to provide treatment choices that allow athletes to safely and successfully continue their sport while adequately treating their mental illness. Treatment guidelines that increasingly take into consideration complex psychiatric comorbidities and nuanced pharmacologic approaches are needed in order to advance the field of sports psychiatry.

A reconciled solution of Meltwater Pulse 1A sources using sea-level fingerprinting.

The most rapid global sea-level rise event of the last deglaciation, Meltwater Pulse 1A (MWP-1A), occurred ∼14,650 years ago. Considerable uncertainty regarding the sources of meltwater limits understanding of the relationship between MWP-1A and the concurrent fast-changing climate. Here we present a data-driven inversion approach, using a glacio-isostatic adjustment model to invert for the sources of MWP-1A via sea-level constraints from six geographically distributed sites. The results suggest contributions from Antarctica, 1.3 m (0-5.9 m; 95% probability), Scandinavia, 4.6 m (3.2-6.4 m) and North America, 12.0 m (5.6-15.4 m), giving a global mean sea-level rise of 17.9 m (15.7-20.2 m) in 500 years. Only a North American dominant scenario successfully predicts the observed sea-level change across our six sites and an Antarctic dominant scenario is firmly refuted by Scottish isolation basin records. Our sea-level based results therefore reconcile with field-based ice-sheet reconstructions.

Nonlinear landscape and cultural response to sea-level rise.

Rising sea levels have been associated with human migration and behavioral shifts throughout prehistory, often with an emphasis on landscape submergence and consequent societal collapse. However, the assumption that future sea-level rise will drive similar adaptive responses is overly simplistic. While the change from land to sea represents a dramatic and permanent shift for preexisting human populations, the process of change is driven by a complex set of physical and cultural processes with long transitional phases of landscape and socioeconomic change. Here, we use reconstructions of prehistoric sea-level rise, paleogeographies, terrestrial landscape change, and human population dynamics to show how the gradual inundation of an island archipelago resulted in decidedly nonlinear landscape and cultural responses to rising sea levels. Interpretation of past and future responses to sea-level change requires a better understanding of local physical and societal contexts to assess plausible human response patterns in the future.

An Efficient Ice Sheet/Earth System Model Spin-up Procedure for CESM2-CISM2: Description, Evaluation, and Broader Applicability.

Spinning up a highly complex, coupled Earth system model (ESM) is a time consuming and computationally demanding exercise. For models with interactive ice sheet components, this becomes a major challenge, as ice sheets are sensitive to bidirectional feedback processes and equilibrate over glacial timescales of up to many millennia. This work describes and demonstrates a computationally tractable, iterative procedure for spinning up a contemporary, highly complex ESM that includes an interactive ice sheet component. The procedure alternates between a computationally expensive coupled configuration and a computationally cheaper configuration where the atmospheric component is replaced by a data model. By periodically regenerating atmospheric forcing consistent with the coupled system, the data atmosphere remains adequately constrained to ensure that the broader model state evolves realistically. The applicability of the method is demonstrated by spinning up the preindustrial climate in the Community Earth System Model Version 2 (CESM2), coupled to the Community Ice Sheet Model Version 2 (CISM2) over Greenland. The equilibrium climate state is similar to the control climate from a coupled simulation with a prescribed Greenland ice sheet, indicating that the iterative procedure is consistent with a traditional spin-up approach without interactive ice sheets. These results suggest that the iterative method presented here provides a faster and computationally cheaper method for spinning up a highly complex ESM, with or without interactive ice sheet components. The method described here has been used to develop the climate/ice sheet initial conditions for transient, ice sheet-enabled simulations with CESM2-CISM2 in the Coupled Model Intercomparison Project Phase 6 (CMIP6).

Predicting marsh vulnerability to sea-level rise using Holocene relative sea-level data.

Tidal marshes rank among Earth's vulnerable ecosystems, which will retreat if future rates of relative sea-level rise (RSLR) exceed marshes' ability to accrete vertically. Here, we assess the limits to marsh vulnerability by analyzing >780 Holocene reconstructions of tidal marsh evolution in Great Britain. These reconstructions include both transgressive (tidal marsh retreat) and regressive (tidal marsh expansion) contacts. The probability of a marsh retreat was conditional upon Holocene rates of RSLR, which varied between -7.7 and 15.2 mm/yr. Holocene records indicate that marshes are nine times more likely to retreat than expand when RSLR rates are ≥7.1 mm/yr. Coupling estimated probabilities of marsh retreat with projections of future RSLR suggests a major risk of tidal marsh loss in the twenty-first century. All of Great Britain has a >80% probability of a marsh retreat under Representative Concentration Pathway (RCP) 8.5 by 2100, with areas of southern and eastern England achieving this probability by 2040.

Half-metre sea-level fluctuations on centennial timescales from mid-Holocene corals of Southeast Asia.

Sea-level rise is a global problem, yet to forecast future changes, we must understand how and why relative sea level (RSL) varied in the past, on local to global scales. In East and Southeast Asia, details of Holocene RSL are poorly understood. Here we present two independent high-resolution RSL proxy records from Belitung Island on the Sunda Shelf. These records capture spatial variations in glacial isostatic adjustment and paleotidal range, yet both reveal a RSL history between 6850 and 6500 cal years BP that includes two 0.6 m fluctuations, with rates of RSL change reaching 13±4 mm per year (2σ). Observations along the south coast of China, although of a lower resolution, reveal fluctuations similar in amplitude and timing to those on the Sunda Shelf. The consistency of the Southeast Asian records, from sites 2,600 km apart, suggests that the records reflect regional changes in RSL that are unprecedented in modern times.

Commentary on "Maternal immunization: clinical experiences, challenges, and opportunities in vaccine acceptance".

Immunization during pregnancy is an important and effective public health strategy. Obstetrician-gynecologists should start thinking of themselves as vaccinators and develop systems approaches to facilitate vaccination for women both during and outside of pregnancy. The importance of a strong provider recommendation is key.

Shifts in national rates of inpatient prolapse surgery emphasize current coding inadequacies.

OBJECTIVE: : This study aimed to assess national rates, types, and routes of inpatient surgery for pelvic organ prolapse in the United States in 1998 compared to those in 2007. METHODS: : We used the 1998 and 2007 Nationwide Inpatient Sample, which represents a stratified, random sample of discharge data from US hospitals. We included women 20 years and older who underwent surgery for prolapse based on diagnosis and procedure codes of the International Classification of Disease, 9th Revision, Clinical Modification. We calculated the number of women undergoing surgery each year and incidence rates. RESULTS: : The total number of women undergoing prolapse surgeries was 92,503 in 1998 versus 113,646 in 2007. The incidence rate of surgery increased slightly, from 90.8 to 100.9 per 100,000 women, respectively. The most common procedure was hysterectomy, representing approximately half of prolapse surgeries in 1998 and 2007. Suspension procedures accounted for 18.8% of procedures in 2007, an increase from 6.1% in 1998. Surgeries performed via a minimally invasive route increased from 4.8% in 1998 to 9.4% in 2007. However, it was difficult to determine the route for many procedures based on current ICD-9 codes. There were also no codes that specifically designated mesh kit procedures or minimally invasive sacrocolpopexies. CONCLUSIONS: : During the last decade, the rate of inpatient prolapse surgery has slightly increased. The proportion of suspension procedures has increased; however, it is difficult to determine the route of these procedures based on current ICD-9 codes. These findings emphasize that ICD-9 procedure codes have not kept up with changes in clinical practice.

Cancer attributions, distress, and health practices among gynecologic cancer survivors.

OBJECTIVE: Personal beliefs about one's medical condition have been related to health behaviors and psychological distress among individuals with serious illness. We examined whether beliefs about cause of cancer and prevention of recurrence were associated with health practices and distress in 134 long-term endometrial and cervical cancer survivors. METHODS: Participants completed questionnaires assessing depressive symptoms, anxiety, health behavior, and beliefs about factors that may have caused their cancer and prevented recurrence. RESULTS: Genetics/heredity was rated as the most important cancer cause, followed by stress, God's will, hormones, and environmental factors. Medical screening was rated as most important in preventing recurrence, followed by positive attitude and prayer. Stronger causal attributions were generally associated with elevated depressive symptomatology and anxiety, but women citing potentially controllable causes were more likely to be practicing healthy behaviors. Similarly, women citing health behaviors as important in preventing recurrence reported greater anxiety but were more likely to practice positive health behaviors. Health behavior and lifestyle attributions interacted with health practices in predicting distress. For example, among women who had not made positive dietary changes, rating lifestyle as important in preventing recurrence was associated with greater distress, whereas among women who had made a positive change in diet, this belief was associated with less distress. CONCLUSIONS: Results suggest that stronger attributions are associated with greater distress, but engaging in behavior believed to be important in preventing cancer or recurrence may ameliorate this distress.

Relationship of serotonin transporter gene polymorphisms and haplotypes to mRNA transcription.

The serotonin transporter (5HTT; chromosomal location 17q12) is an important regulator of serotonergic neurotransmission and is the site of action for a number of antidepressant medications. Sequence variation at a VNTR known as the 5HTTLPR, which is 1.4 kb upstream of the translation start of 5HTT, has been associated in some studies with increased vulnerability to depression, neuroticism, and autism. Support for these clinical observations has included laboratory findings that 5HTTLPR variation is associated with changes in 5HTT gene translation. We re-examined these earlier laboratory findings by directly measuring 5HTT mRNA levels and genotyping four loci spanning the 5HTT gene using RNA and DNA prepared from 85 independent lymphoblast cell lines. Using this data, haplotypes were inferred and the resulting single point and haplotypes data analyzed by univariate and regression analyses. Consistent with the original findings, we found a significant effect of the 5HTTLPR on mRNA production. In contrast to previous reports, the effect on 5HTT mRNA production appeared to be mediated through an additive, not dominant, mechanism. Neither genotype nor haplotype at three other 5HTT loci were associated with alterations in mRNA production, although the small number of samples homozygous for the three most common haplotypes limits these findings. We conclude that further examination of the role of 5HTT sequence variation in regulating 5HTT mRNA production is warranted.