North Atlantic subtropical mode water formation controlled by Gulf Stream fronts.

The North Atlantic Ocean hosts the largest volume of global subtropical mode waters (STMWs) in the world, which serve as heat, carbon and oxygen silos in the ocean interior. STMWs are formed in the Gulf Stream region where thermal fronts are pervasive and result in feedback with the atmosphere. However, their roles in STMW formation have been overlooked. Using eddy-resolving global climate simulations, we find that suppressing local frontal-scale ocean-to-atmosphere (FOA) feedback leads to STMW formation being reduced almost by half. This is because FOA feedback enlarges STMW outcropping, attributable to the mixed layer deepening associated with cumulative excessive latent heat loss due to higher wind speeds and greater air-sea humidity contrast driven by the Gulf Stream fronts. Such enhanced heat loss overshadows the stronger restratification induced by vertical eddies and turbulent heat transport, making STMW colder and heavier. With more realistic representation of FOA feedback, the eddy-present/rich coupled global climate models reproduce the observed STMWs much better than the eddy-free ones. Such improvement in STMW production cannot be achieved, even with the oceanic resolution solely refined but without coupling to the overlying atmosphere in oceanic general circulation models. Our findings highlight the need to resolve FOA feedback to ameliorate the common severe underestimation of STMW and associated heat and carbon uptakes in earth system models.

Effects of grid spacing on high-frequency precipitation variance in coupled high-resolution global ocean-atmosphere models.

High-frequency precipitation variance is calculated in 12 different free-running (non-data-assimilative) coupled high resolution atmosphere-ocean model simulations, an assimilative coupled atmosphere-ocean weather forecast model, and an assimilative reanalysis. The results are compared with results from satellite estimates of precipitation and rain gauge observations. An analysis of irregular sub-daily fluctuations, which was applied by Covey et al. (Geophys Res Lett 45:12514-12522, 2018. 10.1029/2018GL078926) to satellite products and low-resolution climate models, is applied here to rain gauges and higher-resolution models. In contrast to lower-resolution climate simulations, which Covey et al. (2018) found to be lacking with respect to variance in irregular sub-daily fluctuations, the highest-resolution simulations examined here display an irregular sub-daily fluctuation variance that lies closer to that found in satellite products. Most of the simulations used here cannot be analyzed via the Covey et al. (2018) technique, because they do not output precipitation at sub-daily intervals. Thus the remainder of the paper focuses on frequency power spectral density of precipitation and on cumulative distribution functions over time scales (2-100 days) that are still relatively "high-frequency" in the context of climate modeling. Refined atmospheric or oceanic model grid spacing is generally found to increase high-frequency precipitation variance in simulations, approaching the values derived from observations. Mesoscale-eddy-rich ocean simulations significantly increase precipitation variance only when the atmosphere grid spacing is sufficiently fine (< 0.5°). Despite the improvements noted above, all of the simulations examined here suffer from the "drizzle effect", in which precipitation is not temporally intermittent to the extent found in observations.

Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial.

OBJECTIVE: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS). SETTING: Twenty-eight UK NHS early pregnancy units. SAMPLE: A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. METHODS: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). RESULTS: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. TWEETABLE ABSTRACT: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

Swedish and Australian midwives' experiences of providing antenatal care for Somali-born women: A qualitative study.

BACKGROUND: Women from Somalia have increased risks of adverse pregnancy outcomes compared with destination country populations, but little is known about midwives' experiences of caring for Somali women in pregnancy, knowledge which might help to improve care and outcomes. This study aimed to explore how midwives in Melbourne and Stockholm experienced caring for Somali women. METHOD: Eight midwives in Stockholm and ten midwives in Melbourne, all working in antenatal care clinics, were interviewed about caring for Somali women and the interviews were analysed using thematic analysis. FINDINGS: Both the Swedish and Australian midwives highlighted lack of time and challenges in communication as impacting on their capacity to provide good care; and all wished they had a better understanding of Somali culture. Some differences in midwife attitudes and approaches to care were apparent in the two settings, particularly in how accepting of Somali women the midwives were and the flexibility with which care could be provided in order to meet the needs of the women. The Australian midwives appeared both more accepting and also more flexible. CONCLUSION: Differences in the culture of care were apparent between midwives in Sweden and Australia, particularly in how flexible care could be in order to meet the needs of migrant women and how accepting and responsive the midwives were. More attention in antenatal care on developing mutual understanding between midwives and Somali women would improve their care, and possibly also their outcomes.

The Global Sink of Available Potential Energy by Mesoscale Air-Sea Interaction.

The thermal component of oceanic eddy available potential energy (EPE) generation due to air-sea interaction is proportional to the product of anomalous sea surface temperature (SST) and net air-sea heat flux (SHF). In this study we assess EPE generation and its timescale and space-scale dependence from observations and a high-resolution coupled climate model. A dichotomy exists in the literature with respect to the sign of this term, that is, whether it is a source or a sink of EPE. We resolve this dichotomy by partitioning the SST and net heat flux into climatological mean, climatological seasonal cycle, and remaining transient contributions, thereby separating the mesoscale eddy variability from the forced seasonal cycle. In this decomposition the mesoscale air-sea SST-SHF feedbacks act as a 0.1 TW global sink of EPE. In regions of the ocean with a large seasonal cycle, for example, midlatitudes of the Northern Hemisphere, the EPE generation by the forced seasonal cycle exceeds the mesoscale variability sink, such that the global generation by seasonal plus eddy variability acts as a 0.8 TW source. EPE destruction is largest in the midlatitude western boundary currents due to mesoscale air-sea interaction and in the tropical Pacific where SST variability is due mainly to the El Niño-Southern Oscillation. The EPE sink in western boundary currents is spatially aligned with SST gradients and offset to the poleward side of currents, while the mean and seasonal generation are aligned with the warm core of the current. By successively smoothing the data in space and time we find that half of the EPE sink is confined to timescales less than annual and length scales less than 2°, within the oceanic mesoscale band.

Interprofessional provider attitudes toward the initiation of epidural analgesia in the laboring patient: are we all on the same page?

BACKGROUND: The timing of initiation of neuraxial labor analgesia should ultimately depend on patient preference although obstetricians, anesthesiologists and nurses may influence decision-making. We hypothesized that provider groups would have similar attitudes toward the timing of epidural placement, but some identifiable differences could be used to improve understanding and communication among providers. METHODS: Anesthesiologists, nurses and obstetricians completed a survey assessing their knowledge and attitudes on the timing of epidural placement in specified clinical circumstances. RESULTS: Anesthesiologists (100%) and nurses (86.2%) reported being more familiar with epidural management than obstetricians (43.3%, P <0.01). The willingness of providers to advocate epidural placement based on the magnitude of cervical dilation was similar, although at 10 cm dilatation obstetricians (73.3%) were significantly more likely to advocate neuraxial block compared to both nurses (27.6%, P <0.01) and anesthesiologists (36.7%, P <0.01). The impact of patient factors and clinical circumstances on the timing of neuraxial block placement showed significant differences among provider groups in five of 24 areas assessed, including patient desire for an epidural, primigravid patients without membrane rupture, oxytocin infusion initiated, labor epidural in a previous pregnancy, and a difficult airway. CONCLUSIONS: There were differences between providers in factors that may impact the timing of epidural placement and in their self-perceived familiarity with epidural management. These present an opportunity for furthering interprofessional education and collaboration.

Refined efficacy estimates of the Sanofi Pasteur dengue vaccine CYD-TDV using machine learning.

CYD-TDV is the first licensed dengue vaccine for individuals 9-45 (or 60) years of age. Using 12% of the subjects enroled in phase-2b and phase-3 trials for which baseline serostatus was measured, the vaccine-induced protection against virologically confirmed dengue during active surveillance (0-25 months) was found to vary with prior exposure to dengue. Because age and dengue exposure are highly correlated in endemic settings, refined insight into how efficacy varies by serostatus and age is essential to understand the increased risk of hospitalisation observed among vaccinated individuals during the long-term follow-up and to develop safe and effective vaccination strategies. Here we apply machine learning to impute the baseline serostatus for subjects with post-dose 3 titres but missing baseline serostatus. We find evidence for age dependence in efficacy independent of serostatus and estimate that among 9-16 year olds, CYD-TDV is protective against serotypes 1, 3 and 4 regardless of baseline serostatus.

Caesarean scar pregnancy in the UK: a national cohort study.

OBJECTIVE: To estimate the incidence of caesarean scar pregnancy (CSP) and to describe the management outcomes associated with this condition. DESIGN: A national cohort study using the UK Early Pregnancy Surveillance Service (UKEPSS). SETTING: 86 participating Early Pregnancy Units. POPULATION: All women diagnosed in the participating units with CSP between November 2013 and January 2015. METHODS: Cohort study of women identified through the UKEPSS monthly mailing system. MAIN OUTCOME MEASURES: Incidence, clinical outcomes and complications. RESULTS: 102 cases of CSP were reported, with an estimated incidence of 1.5 per 10 000 (95% CI 1.1-1.9) maternities. Full outcome data were available for 92 women. Management was expectant in 21/92 (23%), medical in 15/92 (16%) and surgical in 56/92 (61%). The success rates of expectant, medical and surgical management were 43% (9/21), 46% (7/15) and 96% (54/56), respectively. The complication rates were 15/21 (71%) with expectant, 9/15 (60%) with medical and 20/56 (36%) with surgical management. Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management. CONCLUSIONS: Surgical management appears to be associated with a high success rate, low complication rate and short post-treatment follow up. TWEETABLE ABSTRACT: Surgery for CSP appears to be successful, with low complication rates and short post-treatment follow up.

The value of embedding: integrated palliative care for patients with metastatic breast cancer.

PURPOSE: The American Society of Clinical Oncology recommends concurrent palliative care (PC) for patients with metastatic cancer. Recent data show benefits of early PC (at least 90 days before death). However, little is known about PC among patients who die from metastatic breast cancer. METHODS: Patients with metastatic breast cancer at a comprehensive cancer center. Analysis of medical records and clinician and patient surveys. Assess referral patterns and value to patients at the end of life (EOL) of a specialty PC service embedded in a breast oncology program; compare to a prior period of stand-alone PC. RESULTS: In the 18-month study period, oncologists referred for palliative care 105 of their 515 (20.4%) patients; 59 (11.5%) patients were seen by the PC physician. Of the 38 referred patients who died, 23 (60.5%) were seen by embedded PC and all 23 received PC within 90 days of death; 0 of 18 decedents with data available for analysis had ICU stays within 30 days of death. In an earlier 24-month period of stand-alone PC, 43 patients died after receiving PC, but only 11 (25.5%) received PC within 90 days of death (p < 0.01) and 7 of 43 had ICU stays within 30 days of death (p = 0.074). CONCLUSIONS: Embedded PC was well-received by patients and oncologists, increased early PC referrals, and improved EOL care. Avoidable, unnecessary health care utilization at the end of life, such as ICU stays in the last month of life, represent an important potential reduction in patient suffering and system costs.

Western boundary currents regulated by interaction between ocean eddies and the atmosphere.

Current climate models systematically underestimate the strength of oceanic fronts associated with strong western boundary currents, such as the Kuroshio and Gulf Stream Extensions, and have difficulty simulating their positions at the mid-latitude ocean's western boundaries. Even with an enhanced grid resolution to resolve ocean mesoscale eddies-energetic circulations with horizontal scales of about a hundred kilometres that strongly interact with the fronts and currents-the bias problem can still persist; to improve climate models we need a better understanding of the dynamics governing these oceanic frontal regimes. Yet prevailing theories about the western boundary fronts are based on ocean internal dynamics without taking into consideration the intense air-sea feedbacks in these oceanic frontal regions. Here, by focusing on the Kuroshio Extension Jet east of Japan as the direct continuation of the Kuroshio, we show that feedback between ocean mesoscale eddies and the atmosphere (OME-A) is fundamental to the dynamics and control of these energetic currents. Suppressing OME-A feedback in eddy-resolving coupled climate model simulations results in a 20-40 per cent weakening in the Kuroshio Extension Jet. This is because OME-A feedback dominates eddy potential energy destruction, which dissipates more than 70 per cent of the eddy potential energy extracted from the Kuroshio Extension Jet. The absence of OME-A feedback inevitably leads to a reduction in eddy potential energy production in order to balance the energy budget, which results in a weakened mean current. The finding has important implications for improving climate models' representation of major oceanic fronts, which are essential components in the simulation and prediction of extratropical storms and other extreme events, as well as in the projection of the effect on these events of climate change.

Transversus abdominis plane and ilioinguinal/iliohypogastric blocks for cesarean delivery in a patient with type II spinal muscular atrophy.

While neuraxial and general anesthetic techniques are most commonly utilized for cesarean delivery, there are rare instances in which alternative techniques may be considered. We report a patient with type II spinal muscular atrophy who had relative contraindications to both neuraxial and general anesthesia, and had experienced significant discomfort during two previous cesarean deliveries performed with local anesthetic infiltration. We describe the successful use of bilateral ultrasound-guided transversus abdominis plane and ilioinguinal/iliohypogastric blocks, in addition to intravenous sedation, for cesarean delivery anesthesia.

Dyspareunia and childbirth: a prospective cohort study.

OBJECTIVE: To investigate the relationship between mode of delivery, perineal trauma and dyspareunia. DESIGN: Prospective cohort study. SETTING: Six maternity hospitals in Melbourne, Australia. SAMPLE: A total of 1507 nulliparous women recruited in the first and second trimesters of pregnancy. METHOD: Data from baseline and postnatal questionnaires (3, 6, 12 and 18 months) were analysed using univariable and multivariable logistic regression. MAIN OUTCOME MEASURE: Study-designed self-report measure of dyspareunia at 18 months postpartum. RESULTS: In all, 1244/1507 (83%) women completed the baseline and all four postpartum questionnaires; 1211/1237 (98%) had resumed vaginal intercourse by 18 months postpartum, with 289/1211 (24%) women reporting dyspareunia. Compared with women who had a spontaneous vaginal delivery with an intact perineum or unsutured tear, women who had an emergency caesarean section (adjusted odds ratio [aOR] 2.41, 95% confidence interval [95% CI] 1.4-4.0; P = 0.001), vacuum extraction (aOR 2.28, 95% CI 1.3-4.1; P = 0.005) or elective caesarean section (aOR 1.71, 95% CI 0.9-3.2; P = 0.087) had increased odds of reporting dyspareunia at 18 months postpartum, adjusting for maternal age and other potential confounders. CONCLUSIONS: Obstetric intervention is associated with persisting dyspareunia. Greater recognition and increased understanding of the roles of mode of delivery and perineal trauma in contributing to postpartum maternal morbidities, and ways to prevent postpartum dyspareunia where possible, are warranted.

Particle diagrams and embedded many-body random matrix theory.

We present a method which uses Feynman-like diagrams to calculate the statistical quantities of embedded many-body random matrix problems. The method provides a promising alternative to existing techniques and offers many important simplifications. We use it here to find the fourth, sixth, and eighth moments of the level density of an m-body system with k fermions or bosons interacting through a random Hermitian potential (k ≤ m) in the limit where the number of possible single-particle states is taken to infinity. All share the same transition, starting immediately after 2k = m, from moments arising from a semicircular level density to Gaussian moments. The results also reveal a striking feature; the domain of the 2nth moment is naturally divided into n subdomains specified by the points 2k = m,3 k = m,...,nk = m.

Disparities in pre-eclampsia and eclampsia among immigrant women giving birth in six industrialised countries.

OBJECTIVE: To assess disparities in pre-eclampsia and eclampsia among immigrant women from various world regions giving birth in six industrialised countries. DESIGN: Cross-country comparative study of linked population-based databases. SETTING: Provincial or regional obstetric delivery data from Australia, Canada, Spain and the USA and national data from Denmark and Sweden. POPULATION: All immigrant and non-immigrant women delivering in the six industrialised countries within the most recent 10-year period available to each participating centre (1995-2010). METHODS: Data was collected using standardised definitions of the outcomes and maternal regions of birth. Pooled data were analysed with multilevel models. Within-country analyses used stratified logistic regression to obtain odds ratios (OR) with 95% confidence intervals (95% CI). MAIN OUTCOME MEASURES: Pre-eclampsia, eclampsia and pre-eclampsia with prolonged hospitalisation (cases per 1000 deliveries). RESULTS: There were 9,028,802 deliveries (3,031,399 to immigrant women). Compared with immigrants from Western Europe, immigrants from Sub-Saharan Africa and Latin America & the Caribbean were at higher risk of pre-eclampsia (OR: 1.72; 95% CI: 1.63, 1.80 and 1.63; 95% CI: 1.57, 1.69) and eclampsia (OR: 2.12; 95% CI: 1.61, 2.79 and 1.55; 95% CI: 1.26, 1. 91), respectively, after adjustment for parity, maternal age and destination country. Compared with native-born women, European and East Asian immigrants were at lower risk in most industrialised countries. Spain exhibited the largest disparities and Australia the smallest. CONCLUSION: Immigrant women from Sub-Saharan Africa and Latin America & the Caribbean require increased surveillance due to a consistently high risk of pre-eclampsia and eclampsia.

Somali women and their pregnancy outcomes postmigration: data from six receiving countries.

OBJECTIVE: This study aimed to investigate pregnancy outcomes in Somali-born women compared with those women born in each of the six receiving countries: Australia, Belgium, Canada, Finland, Norway and Sweden. DESIGN: Meta-analyses of routinely collected data on confinements and births. SETTING: National or regional perinatal datasets spanning 3-6 years between 1997 and 2004 from six countries. SAMPLE: A total of 10 431 Somali-born women and 2 168 891 receiving country-born women. METHODS: Meta-analyses to compare outcomes for Somali-born and receiving country-born women across the six countries. MAIN OUTCOME MEASURES: Events of labour (induction, epidural use and proportion of women using no analgesia), mode of birth (spontaneous vaginal birth, operative vaginal birth and caesarean section) and infant outcomes (preterm birth, birthweight, Apgar at 5 minutes, stillbirths and neonatal deaths). RESULTS: Compared with receiving country-born women, Somali-born women were less likely to give birth preterm (pooled OR 0.72, 95% CI 0.64-0.81) or to have infants of low birthweight (pooled OR 0.89, 95% CI 0.82-0.98), but there was an excess of caesarean sections, particularly in first births (pooled OR 1.41, 95% CI 1.25-1.59) and an excess of stillbirths (pooled OR 1.86, 95% CI 1.38-2.51). CONCLUSIONS: This analysis has identified a number of disparities in outcomes between Somali-born women and their receiving country counterparts. The disparities are not readily explained and they raise concerns about the provision of maternity care for Somali women postmigration. Review of maternity care practices followed by implementation and careful evaluation of strategies to improve both care and outcomes for Somali women is needed.

NeuN expression correlates with reduced mitotic index of neoplastic cells in central neurocytomas.

In the developing brain, neuronal differentiation is associated with permanent exit from the mitotic cycle. This raises the possibility that neuronal differentiation may suppress proliferative activity, even in neoplastic cells. As a first step towards understanding the relation between neuronal differentiation and mitotic cycling in brain tumours, we studied the expression of NeuN (a neuronal marker) and Ki-67 (a mitotic marker) by double-labelling immuno-fluorescence in 16 brain tumours with neuronal differentiation. The tumours included a series of 11 central neurocytomas, and five single cases of other tumour types. In the central neurocytomas, NeuN(+) cells had a 15-fold lower Ki-67 labelling index, on average, than did NeuN(-) cells (P < 0.01). In the other tumours (one extraventricular neurocytoma, one desmoplastic medulloblastoma, one olfactory neuroblastoma, one ganglioglioma and one anaplastic ganglioglioma), the Ki-67 labelling index was always at least fourfold lower in NeuN(+) cells than in NeuN(-) cells. These results indicate that neuronal differentiation is associated with a substantial decrease of proliferative activity in neoplastic cells of central neurocytomas, and suggest that the same may be true across diverse types of brain tumours. However, tumours with extensive neuronal differentiation may nevertheless have a high overall Ki-67 labelling index, if the mitotic activity of NeuN(-) cells is high. The correlation between NeuN expression and reduced mitotic activity in neurocytoma cells is consistent with the hypothesis that neuronal differentiation suppresses proliferation, but further studies will be necessary to determine causality and investigate underlying mechanisms.