Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum.

Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.

Society for Maternal-Fetal Medicine Special Statement: Telemedicine in obstetrics-quality and safety considerations.

The frequency of telemedicine encounters has increased dramatically in recent years. This review summarizes the literature regarding the safety and quality of telemedicine for pregnancy-related services, including prenatal care, postpartum care, diabetes mellitus management, medication abortion, lactation support, hypertension management, genetic counseling, ultrasound examination, contraception, and mental health services. For many of these, telemedicine has several potential or proven benefits, including expanded patient access, improved patient satisfaction, decreased disparities in care delivery, and health outcomes at least comparable to those of traditional in-person encounters. Considering these benefits, it is suggested that payers should reimburse providers at least as much for telemedicine as for in-person services. Areas for future research are considered.

Society for Maternal-Fetal Medicine Special Statement: Quality metric for timely postpartum follow-up after severe hypertension.

Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality. Because postpartum exacerbation of severe hypertension is common, the American College of Obstetricians and Gynecologists recommends that patients with severe hypertension during the childbirth hospitalization be seen within 72 hours after discharge. In this statement, the Society for Maternal-Fetal Medicine proposes a uniform metric reflecting the rate of timely postpartum follow-up of patients with severe hypertension. The metric is designed to be measured using automated calculations based on billing codes derived from claims data. The metric can be used in quality improvement projects to increase the rate of timely follow-up in patients with severe hypertension during the childbirth hospitalization. Suggested steps for implementing such a project are outlined.

Two-photon uncaging of bioactive thiols in live cells at wavelengths above 800 nm.

Photoactivatable protecting groups (PPGs) are useful for a broad range of applications ranging from biology to materials science. In chemical biology, induction of biological processes via photoactivation is a powerful strategy for achieving spatiotemporal control. The importance of cysteine, glutathione, and other bioactive thiols in regulating protein structure/activity and cell redox homeostasis makes modulation of thiol activity particularly useful. One major objective for enhancing the utility of photoactivatable protecting groups (PPGs) in living systems is creating PPGs with longer wavelength absorption maxima and efficient two-photon (TP) absorption. Toward these objectives, we developed a carboxyl- and dimethylamine-functionalized nitrodibenzofuran PPG scaffold (cDMA-NDBF) for thiol photoactivation, which has a bathochromic shift in the one-photon absorption maximum from λmax = 315 nm with the unfunctionalized NDBF scaffold to λmax = 445 nm. While cDMA-NDBF-protected thiols are stable in the presence of UV irradiation, they undergo efficient broad-spectrum TP photolysis at wavelengths as long as 900 nm. To demonstrate the wavelength orthogonality of cDMA-NDBF and NDBF photolysis in a biological setting, caged farnesyltransferase enzyme inhibitors (FTI) were prepared and selectively photoactivated in live cells using 850-900 nm TP light for cDMA-NDBF-FTI and 300 nm UV light for NDBF-FTI. These experiments represent the first demonstration of thiol photoactivation at wavelengths above 800 nm. Consequently, cDMA-NDBF-caged thiols should have broad applicability in a wide range of experiments in chemical biology and materials science.

Synthesis, Characterization, and Electron-Transfer Properties of Ferrocene-BODIPY-Fullerene Near-Infrared-Absorbing Triads: Are Catecholopyrrolidine-Linked Fullerenes a Good Architecture to Facilitate Electron-Transfer?

A series of covalent ferrocene-BODIPY-fullerene triads with the ferrocene groups conjugated to the BODIPY π-system and the fullerene acceptor linked at the boron hub by a common catecholpyrrolidine bridge were prepared and characterized by 1D and 2D NMR, UV/Vis, steady-state fluorescence spectroscopy, high-resolution mass spectrometry, and, for one of the derivatives, X-ray crystallography. Redox processes of the new compounds were investigated by electrochemical (CV and DPV) methods and spectroelectrochemistry. DFT calculations indicate that the HOMO in all triads was delocalized between ferrocene and BODIPY π-system, the LUMO was always fullerene-centered, and the catechol-centered occupied orbital was close in energy to the HOMO. TDDFT calculations were indicative of the low-energy, low-intensity charge-transfer bands originated from the ferrocene-BODIPY core to fullerene excitation, which explained the similarity of the UV/Vis spectra of the ferrocene-BODIPY dyads and ferrocene-BODIPY-fullerene triads. Photophysical properties of the new triads as well as reference BODIPY-fullerene and ferrocene-BODIPY dyads were investigated by pump-probe spectroscopy in the UV/Vis and NIR spectral regions following selective excitation of the BODIPY-based antenna. Initial charge transfer from the ferrocene to the BODIPY core was shown to outcompete sub-100 fs deactivation of the excited state mediated by the catechol bridge. However, no subsequent electron transfer to the fullerene acceptor was observed. The initial charge separated state relaxes by recombination with a time constant of 150-380 ps.

Photodetachment, electron cooling, and recombination, in a series of neat aliphatic room temperature ionic liquids.

Transient absorption following photodetachment of a series of neat methyl-alkyl-pyrrolidinium bis(trifluoromethylsulfonyl)amides at 6.20 eV was measured with sub-picosecond time resolution in the visible and near-IR portions of the spectrum. This series spans the onset of structuring in the liquids in the form of polarity alternation. Excitation promotes the electron into a delocalized state with a very large reactive radius. Strong transient absorption is observed in the visible spectrum with a ∼700 fs lifetime, and much weaker, long-lived absorption is observed in the near-IR spectrum. Absorption in the visible is shown to be consistent with the hole, and absorption in the near-IR is assigned to the free solvated electron. Yield of free electrons is estimated at ∼4%, is insensitive to the size of the cation, and is determined in less than 1 ps. Solvation of free electrons depends strongly on the size of the cation and correlates well with the viscosity of the liquid. In addition to radiolytic stability of the aliphatic cations, ultrafast, efficient recombination of separated charge in NTf2 (-) based ionic liquids following photo-excitation near the band-gap may prevent subsequent reactive damage associated with anions.

Irrelevant events affect voters' evaluations of government performance.

Does information irrelevant to government performance affect voting behavior? If so, how does this help us understand the mechanisms underlying voters' retrospective assessments of candidates' performance in office? To precisely test for the effects of irrelevant information, we explore the electoral impact of local college football games just before an election, irrelevant events that government has nothing to do with and for which no government response would be expected. We find that a win in the 10 d before Election Day causes the incumbent to receive an additional 1.61 percentage points of the vote in Senate, gubernatorial, and presidential elections, with the effect being larger for teams with stronger fan support. In addition to conducting placebo tests based on postelection games, we demonstrate these effects by using the betting market's estimate of a team's probability of winning the game before it occurs to isolate the surprise component of game outcomes. We corroborate these aggregate-level results with a survey that we conducted during the 2009 NCAA men's college basketball tournament, where we find that surprising wins and losses affect presidential approval. An experiment embedded within the survey also indicates that personal well-being may influence voting decisions on a subconscious level. We find that making people more aware of the reasons for their current state of mind reduces the effect that irrelevant events have on their opinions. These findings underscore the subtle power of irrelevant events in shaping important real-world decisions and suggest ways in which decision making can be improved.

Protected areas reduced poverty in Costa Rica and Thailand.

As global efforts to protect ecosystems expand, the socioeconomic impact of protected areas on neighboring human communities continues to be a source of intense debate. The debate persists because previous studies do not directly measure socioeconomic outcomes and do not use appropriate comparison groups to account for potential confounders. We illustrate an approach using comprehensive national datasets and quasi-experimental matching methods. We estimate impacts of protected area systems on poverty in Costa Rica and Thailand and find that although communities near protected areas are indeed substantially poorer than national averages, an analysis based on comparison with appropriate controls does not support the hypothesis that these differences can be attributed to protected areas. In contrast, the results indicate that the net impact of ecosystem protection was to alleviate poverty.

Development of a Maternal Equity Safety Bundle to Eliminate Racial Inequities in Massachusetts.

OBJECTIVE: The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative. METHODS: Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle. RESULTS: Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle. CONCLUSION: Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes.

Photodetachment and electron reactivity in 1-methyl-1-butyl-pyrrolidinium bis(trifluoromethylsulfonyl)amide.

The transient absorption spectrum in the range 500 nm-1000 nm was measured with ultrafast time resolution on a flowing neat, aliphatic, room-temperature ionic liquid following anion photodetachment. In this region the spectrum was shown to be a combination of absorption from the electron and the hole. Spectrally-resolved electron quenching determined a bimodal shape for the hole spectrum in agreement with recent computational predictions on a smaller aliphatic ionic liquid [Margulis et al., J. Am. Chem. Soc. 133, 20186 (2011)]. For time delays beyond 15 ps, spectral evolution qualitatively agrees with recent radiolysis experiments [Wishart et al., Faraday Discuss. 154, 353 (2012)]. However, the shape of the spectrum is different, reflecting the contrast in ionization energy between the two methods. Previously unobserved reactivity of the electron was found with a time constant of 300 fs. The results demonstrate solvent control of the rate coefficient for reaction between the electron and proton, with a rapid decline in the rate within the first picosecond.

Hyperosmolar therapy for intracranial hypertension.

The use of hyperosmolar agents for intracranial hypertension was introduced in the early 20th century and remains a mainstay of therapy for patients with cerebral edema. Both animal and human studies have demonstrated the efficacy of two hyperosmolar agents, mannitol and hypertonic saline, in reducing intracranial pressure via volume redistribution, plasma expansion, rheologic modifications, and anti-inflammatory effects. However, because of physician and institutional variation in therapeutic practices, lack of standardized protocols for initiation and administration of therapy, patient heterogeneity, and a paucity of randomized controlled trials have yielded little class I evidence on which clinical decisions can be based, most current evidence regarding the use of hyperosmolar therapy is derived from retrospective analyses (class III) and case series (class IV). In this review, we summarize the available evidence regarding the use of hyperosmolar therapy with mannitol or hypertonic saline for the medical management of intracranial hypertension and present a comprehensive discussion of the evidence associated with various theoretical and practical concerns related to initiation, dosage, and monitoring of therapy.

The Effect of Cervical and Lumbar Decompression Surgery for Spinal Stenosis on Erectile Dysfunction.

STUDY DESIGN: Observational study. OBJECTIVES: To evaluate the prevalence of erectile dysfunction and evaluate the effects of decompressive surgery on erectile dysfunction in cervical spinal stenosis and lumbar canal stenosis patients. METHODS: This observational, prospective analysis enrolled patients aged 18-80 with cervical spinal stenosis and/or lumbar canal stenosis that underwent respective decompressive surgery. The IIEF-5 questionnaire was administered preoperatively, and at 6- and 12-months postoperatively to assess erectile dysfunction severity. The EPIC database was queried to determine any postoperative complications and document prominent erectile dysfunction risk factors. RESULTS: Of 79 patients included in the analysis, 42 (53.2%) completed the IIEF-5 at 6 months, and 62 (78.5%) completed it at 12 months. Eighteen had cervical stenosis only, 54 had lumbar stenosis only, and 7 had both. 72% (18/25) of cervical stenosis patients and 83.6% (51/61) of lumbar stenosis patients had erectile dysfunction preoperatively according to IIEF-5 responses. The average preoperative IIEF-5 score indicated significant presence of erectile dysfunction for both the cervical and lumbar stenosis groups. No significant differences were identified in IIEF-5 score deltas from pre- to both postoperative periods. The presence of erectile dysfunction in both the cervical and lumbar stenosis groups was not significantly associated with the presence of any documented risk factors. CONCLUSIONS: Our results suggest no significant improvement in overall erectile function postoperatively for patients with preoperative erectile dysfunction. This is important to address during patient counseling for decompression surgery candidates with cervical spinal stenosis and/or lumbar canal stenosis to manage expectations.

Outsourcing Intersystem Crossing without Heavy Atoms: Energy Transfer Dynamics in PyridoneBODIPY-C60 Complexes.

The excited state dynamics in two fully characterized pyridoneBODIPY-fullerene complexes were investigated using time-resolved spectroscopy. Photoexcitation was initially localized on the pyridoneBODIPY chromophore. The energy was rapidly transferred to the fullerene, which subsequently underwent ISC to form a triplet state and returned the energy to the pyridoneBODIPY via triplet-triplet energy transfer. This ping-pong energy transfer mechanism resulted in efficient (>85%) overall conversion of the excited state pyridoneBODIPY constituent despite a complete lack of ISC in the pyridoneBODIPY in the absence of the fullerene partner. The small difference in attachment chemistry for the fullerene did not impact the initial singlet energy transfer. However, the N-methylpyrrolidine bridge did slow both the triplet-triplet energy transfer and the ultimate relaxation rate of the final triplet state when compared to an isoxazole-based bridge. The rates of each step were quantified, and computational predictions were used to complement the proposed mechanism and energetics. The result demonstrated efficient triplet sensitization of a strong chromophore that lacks significant spin-orbit coupling.

Association of gestational weight gain with cesarean delivery rate after labor induction.

OBJECTIVE: To evaluate the association of gestational weight gain with the cesarean delivery (CD) rate in term women undergoing induction of labor (IOL). STUDY DESIGN: This is a retrospective cohort study of 2,495 consecutive term women from May 2005 to June 2008 admitted for IOL between 37 and 42 completed weeks of gestation. Labor induction ending in cesarean delivery was defined as a binary outcome. Weight gain during pregnancy was calculated by subtracting prepregnancy weight from weight recorded at delivery. Multiple gestation, malpresentation, stillbirth, planned CD and women with prior CD were excluded. Maternal and obstetric characteristics were examined as predictors of CD using multivariable logistic regression analyses. RESULTS: The risk of CD increased by 13% (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.05-1.23) for each 5 kg increase in gestational weight gain. Other factors associated with an increased risk of CD included maternal age (OR per year 1.05, 95% CI 1.03-1.06), neonatal birth weight (OR 1.06 per 100 g, 95% CI 1.03-1.08), nulliparity (OR 9.13, 95% CI 7.00-11.90), Bishop score at admission < or = 5 (OR 2.3, 95% CI 1.90-2.90), male infant (OR 1.37, 95% CI 1.10-1.70) and unit increase in prepregnancy body mass index (OR 1.08, 95% CI 1.06-1.10). CONCLUSION: The CD rate following labor induction increases significantly with increasing gestational weight gain even after controlling for possible confounding variables.

Sprengel Deformity with Omovertebral Bone Encroaching the Spinal Canal Causing Progressive Cervical Myelopathy: A Technical Case Report.

An adult with Sprengel deformity and Klippel-Feil syndrome associated with an omovertebral bone has rarely been reported in literature. The omovertebral bone is an abnormal cartilaginous connection between the scapula and the cervical spine. Limited cases have previously been reported in the literature describing surgical intervention when neurologic deficits such as cervical myelopathy or radiculopathy are present. In the present case, an omovertebral bone extended into the cervical lamina resulting in cervical myeloradiculopathy requiring resection of the bony anomaly and cervicothoracic fusion. The omovertebral bone as an etiology for radiculopathy or myelopathy is rarely seen in an adult population, and surgical decompression and fusion should be considered with this constellation of anomalies.

Fully Conjugated Pyrene-BODIPY and Pyrene-BODIPY-Ferrocene Dyads and Triads: Synthesis, Characterization, and Selective Noncovalent Interactions with Nanocarbon Materials.

Several pyrene-boron-dipyrromethene (BODIPY) and pyrene-BODIPY-ferrocene derivatives with a fully conjugated pyrene fragment appended to the α-position(s) of the BODIPY core have been prepared by Knoevenagel condensation reaction and characterized by one-dimensional (1D) and two-dimensional (2D) nuclear magnetic resonance (NMR), UV-vis, fluorescence spectroscopy, high-resolution mass spectrometry as well as X-ray crystallography. The redox properties of new donor-acceptor BODIPY dyads and triads were studied by electrochemical (cyclic voltammetry (CV) and differential pulse voltammetry (DPV)) and spectroelectrochemical approaches. Formation of weakly bonded noncovalent complexes between the new pyrene-BODIPYs and nanocarbon materials (C60, C70, single-walled carbon nanotube (SWCNT), and graphene) was studied by UV-vis, steady-state fluorescent, and time-resolved transient absorption spectroscopy. UV-vis and fluorescent spectroscopy are indicative of the much stronger and selective interaction between new dyes and (6,5)-SWCNT as well as graphene compared to that of C60 and C70 fullerenes. In agreement with these data, transient absorption spectroscopy provided no evidence for any significant change in excited-state lifetime or photoinduced charge transfer between pyrene-BODIPYs and C60 or C70 fullerenes when the pyrene-BODIPY chromophores were excited into the lowest-energy singlet excited state. Density functional theory (DFT) and time-dependent DFT (TDDFT) calculations suggest that the pyrene fragments are fully conjugated into the π-system of BODIPY core, which correlates well with the experimental data.

Ultrafast dynamics in helium nanodroplets probed by femtosecond time-resolved EUV photoelectron imaging.

The dynamics of electronically excited helium nanodroplets are studied by femtosecond time-resolved photoelectron imaging. EUV excitation into a broad absorption band centered around 23.8 eV leads to an indirect photoemission process that generates ultraslow photoelectrons. A 1.58 eV probe pulse transiently depletes the indirect photoemission signal for pump-probe time delays <200 fs and enhances the signal beyond this delay. The depletion is due to suppression of the indirect ionization process by the probe photon, which generates a broad, isotropically emitted photoelectron band. Similar time scales in the decay of the high energy photoelectron signal and the enhancement of the indirect photoemission signal suggest an internal relaxation process that populates states in the range of a lower energy droplet absorption band located just below the droplet ionization potential (IP approximately 23.0 eV). A nearly 70% enhancement of the ultraslow photoelectron signal indicates that interband relaxation plays a more dominant role for the droplet de-excitation mechanism than photoemission.

Probing Electronic Communication and Excited-State Dynamics in the Unprecedented Ferrocene-Containing Zinc MB-DIPY.

The electronic communication between two ferrocene groups in the electron-deficient expanded aza-BODIPY analogue of zinc manitoba-dipyrromethene (MB-DIPY) was probed by spectroscopic, electrochemical, spectroelectrochemical, and theoretical methods. The excited-state dynamics involved sub-ps formation of the charge-separated state in the organometallic zinc MB-DIPYs, followed by recovery of the ground state via charge recombination in 12 ps. The excited-state behavior was contrasted with that observed in the parent complex that lacked the ferrocene electron donors and has a much longer excited-state lifetime (670 ps for the singlet state). Much longer decay times observed for the parent complex without ferrocene confirm that the main quenching mechanism in the ferrocene-containing 4 is reflective of the ultrafast ferrocene-to-MB-DIPY core charge transfer (CT).

Treatment of osteoblastoma at C7: a multidisciplinary approach. A case report and review of the literature.

Osteoblastoma is a rare benign bone tumor that presents with back pain and occurs in the spine approximately 40% of the time. The time from onset of symptoms to diagnosis is typically several months because it is a rare entity and radiographic studies are often negative early in the course of the disease. These highly vascular and locally aggressive tumors require complete and precise resection. The patient presented is a 15-year-old boy with a 14-month history of right-sided neck and shoulder pain. Computerized tomography and magnetic resonance imaging demonstrated a lesion in the posterior elements of C7 which extended through the pedicle and into the body. Preoperative angiography confirmed a hypervascular lesion which was successfully embolized. He subsequently underwent piecemeal tumor resection and instrumented fusion. Immediate postoperative imaging demonstrated complete resection. At 18 months follow up the patient has maintained resolution of preoperative symptoms and demonstrates evidence of solid fusion on CT. This multidisciplinary approach markedly decreased blood loss and improved visualization to help achieve complete surgical resection and resolution of clinical symptoms.