Contrasting Regional Carbon Cycle Responses to Seasonal Climate Anomalies Across the East-West Divide of Temperate North America.

Across temperate North America, interannual variability (IAV) in gross primary production (GPP) and net ecosystem exchange (NEE) and their relationship with environmental drivers are poorly understood. Here, we examine IAV in GPP and NEE and their relationship to environmental drivers using two state-of-the-science flux products: NEE constrained by surface and space-based atmospheric CO2 measurements over 2010-2015 and satellite up-scaled GPP from FluxSat over 2001-2017. We show that the arid western half of temperate North America provides a larger contribution to IAV in GPP (104% of east) and NEE (127% of east) than the eastern half, in spite of smaller magnitude of annual mean GPP and NEE. This occurs because anomalies in western ecosystems are temporally coherent across the growing season leading to an amplification of GPP and NEE. In contrast, IAV in GPP and NEE in eastern ecosystems is dominated by seasonal compensation effects, associated with opposite responses to temperature anomalies in spring and summer. Terrestrial biosphere models in the MsTMIP ensemble generally capture these differences between eastern and western temperate North America, although there is considerable spread between models.

How Much Greater is Obstetric Intervention in Women with Medical Disorders in Pregnancy When Compared to the General Population?

Introduction The purpose of this study was to compare obstetric and neonatal outcomes between women attending a specialised maternal medicine service and the general obstetric population. Methods Women attending from January 2011 to December 2016 were identified from the clinic database. Medical diagnosis, demographics, obstetric and neonatal outcomes were compared with data from hospital annual report 2014. Results 1873 women were compared with 8632 women who delivered at the hospital in 2014. Delivery before 34 weeks [82 (4.5%) vs 189 (2.2%)], induction of labour [761 (40.6%) vs 2664 (30.9%)] and delivery by Caesarean Section (CS) [664 (35%) vs 2479 (29%)] were higher p<0.001; but elective CS [334 (18%) vs 1425 (17%), p=0.18] did not differ between the two groups. Neonatal outcomes were similar. Conclusion Premature delivery, induction of labour and CS rates are higher in women with medical disorders in pregnancy. Encouragingly, 77% of women attempting vaginal birth in this group were successful.

Inequalities in Implementation and Different Outcomes During the Growth of Laparoscopic Colorectal Cancer Surgery in England: A National Population-Based Study from 2002 to 2012.

AIM: Laparoscopic colorectal cancer surgery has developed from unproven technique to mainstay of treatment. This study examined the application and relative outcomes of laparoscopic and open colorectal cancer surgery over time, as laparoscopic uptake and experience have grown. METHODS: Adults undergoing elective laparoscopic and open colorectal cancer surgery in the English NHS during 2002-2012 were included. Age, sex, Charlson Comorbidity Index and Index of Multiple Deprivation were compared over time. Post-operative 30-day mortality, length of stay, failure to rescue reoperation and the associated mortality rate were examined. RESULTS: Laparoscopy rates rose from 1.1 to 50.8%. Patients undergoing laparoscopic surgery had lower comorbidity by 0.24 points (95% confidence intervals (CI) 0.20-0.27) and lower socioeconomic deprivation by 0.16 deciles (95% CI 0.12-0.20) than those having open procedures. Overall mortality fell by 48.0% from 2002-2003 to 2011-2002 and was 37.8% lower after laparoscopic surgery. Length of stay and mortality after surgical re-intervention also fell. However, re-intervention rates were higher after laparoscopic procedures by 7.8% (95% CI 0.9-15.2%). CONCLUSIONS: There was clear and persistent inequality in the application of laparoscopic colorectal cancer surgery during this study. Further work must explore and remedy inequalities to maximise patient benefit. Higher re-intervention rates after laparoscopy are unexplained and differ from randomized controlled trials. This may reflect differences in surgeons and practice between research and usual care settings and should be further investigated.

Characterization of spaC-type Erysipelothrix sp. isolates causing systemic disease in ornamental fish.

Since 2012, low-to-moderate mortality associated with an Erysipelothrix sp. bacterium has been reported in ornamental fish. Histological findings have included facial cellulitis, necrotizing dermatitis and myositis, and disseminated coelomitis with abundant intralesional Gram-positive bacterial colonies. Sixteen Erysipelothrix sp. isolates identified phenotypically as E. rhusiopathiae were recovered from diseased cyprinid and characid fish. Similar clinical and histological changes were also observed in zebrafish, Danio rerio, challenged by intracoelomic injection. The Erysipelothrix sp. isolates from ornamental fish were compared phenotypically and genetically to E. rhusiopathiae and E. tonsillarum isolates recovered from aquatic and terrestrial animals from multiple facilities. Results demonstrated that isolates from diseased fish were largely clonal and divergent from E. rhusiopathiae and E. tonsillarum isolates from normal fish skin, marine mammals and terrestrial animals. All ornamental fish isolates were PCR positive for spaC, with marked genetic divergence (<92% similarity at gyrB, <60% similarity by rep-PCR) between the ornamental fish isolates and other Erysipelothrix spp. isolates. This study supports previous work citing the genetic variability of Erysipelothrix spp. spa types and suggests isolates from diseased ornamental fish may represent a genetically distinct species.

Transcriptome assessment of the Pompe (Gaa-/-) mouse spinal cord indicates widespread neuropathology.

Pompe disease, caused by deficiency of acid alpha-glucosidase (GAA), leads to widespread glycogen accumulation and profound neuromuscular impairments. There has been controversy, however, regarding the role of central nervous system pathology in Pompe motor dysfunction. We hypothesized that absence of GAA protein causes progressive activation of neuropathological signaling, including pathways associated with cell death. To test this hypothesis, genomic data (Affymetrix Mouse Gene Array 2.0ST) from the midcervical spinal cord in 6 and 16 mo old Pompe (Gaa-/-) mice were evaluated (Broad Institute Molecular Signature Database), along with spinal cord histology. The midcervical cord was selected because it contains phrenic motoneurons, and phrenic-diaphragm dysfunction is prominent in Pompe disease. Several clinically important themes for the neurologic etiology of Pompe disease emerged from this unbiased genomic assessment. First, pathways associated with cell death were strongly upregulated as Gaa-/- mice aged, and motoneuron apoptosis was histologically verified. Second, proinflammatory signaling was dramatically upregulated in the Gaa-/- spinal cord. Third, many signal transduction pathways in the Gaa-/- cervical cord were altered in a manner suggestive of impaired synaptic function. Notably, glutamatergic signaling pathways were downregulated, as were "synaptic plasticity pathways" including genes related to neuroplasticity. Fourth, many genes and pathways related to cellular metabolism are dysregulated. Collectively, the data unequivocally confirm that systemic absence of GAA induces a complex neuropathological cascade in the spinal cord. Most importantly, the results indicate that Pompe is a neurodegenerative condition, and this underscores the need for early therapeutic intervention capable of targeting the central nervous system.

Pharmacokinetic indices for cefovecin after single-dose administration to adult sea otters (Enhydra lutris).

Seven sea otters received a single subcutaneous dose of cefovecin at 8 mg/kg body weight. Plasma samples were collected at predetermined time points and assayed for total cefovecin concentrations using ultra-performance liquid chromatography and tandem mass spectrometry. The mean (±SD) noncompartmental pharmacokinetic indices were as follows: CMax (obs) 70.6 ± 14.6 µg/mL, TMax (obs) 2.9 ± 1.5 h, elimination rate constant (kel ) 0.017 ± 0.002/h, elimination half-life (t1/2kel) 41.6 ± 4.7 h, area under the plasma concentration-vs.-time curve to last sample (AUClast) 3438.7 ± 437.7 h·µg/mL and AUC extrapolated to infinity (AUC0→∞ ) 3447.8 ± 439.0 h·µg/mL. The minimum inhibitory concentrations (MIC) for select isolates were determined and used to suggest possible dosing intervals of 10 days, 5 days, and 2.5 days for gram-positive, gram-negative, and Vibrio parahaemolyticus bacterial species, respectively. This study found a single subcutaneous dose of cefovecin sodium in sea otters to be clinically safe and a viable option for long-acting antimicrobial therapy.

Comparison of blood transfusion and surgical complications in peripartum hysterectomy when anticipated and unanticipated.

The aim of the study was to determine the incidence and aetiology of peripartum hysterectomy (PH) for major obstetric haemorrhage (MOH) in our population and to compare estimated blood loss (EBL), blood transfusion, surgical complications and duration of hospital stay in PH that was anticipated and PH that was unanticipated. 26 cases of MOH requiring PH were identified from 50,548 women who delivered between 1 January 2006 and 31 December 2011 (0.5/1000). PH was anticipated in 17 and unanticipated in 9 cases. When compared, the anticipated group was more likely to have placenta accreta 15/17 (88%) vs 4/9 (44%): p = 0.03 and a gynaecological oncologist as the principal operator 15/17 (88%) vs 3/9 (33%): p = 0.007. The EBL 5.5 ± 3.7 SD vs 6.6 ± 3.9 SD l; p = 0.5, units of red cell concentrate or RCC transfused 7 ± 5 SD vs 9 ± 5 SD: p = 0.3, and mean operating time 134 ± 60 SD vs 190 ± 96 SD min: p = 0.07 were less in the anticipated than the unanticipated group, but not significantly so. The intraoperative complication rate 7/17 (41%) vs 3/9 (33%): p = 1.0 and the mean duration of hospital stay 7 ± 1 SD vs 8 ± 3 SD days: p = 0.27 were similar in both groups. PH is associated with a large volume of blood loss and significant surgical complications regardless of whether the procedure is anticipated or not.

Helical piles: an innovative foundation design option for offshore wind turbines.

Offshore wind turbines play a key part in the renewable energy strategy in the UK and Europe as well as in other parts of the world (for example, China). The majority of current developments, certainly in UK waters, have taken place in relatively shallow water and close to shore. This limits the scale of the engineering to relatively simple structures, such as those using monopile foundations, and these have been the most common design to date, in UK waters. However, as larger turbines are designed, or they are placed in deeper water, it will be necessary to use multi-footing structures such as tripods or jackets. For these designs, the tension on the upwind footing becomes the critical design condition. Driven pile foundations could be used, as could suction-installed foundations. However, in this paper, we present another concept-the use of helical pile foundations. These foundations are routinely applied onshore where large tension capacities are required. However, for use offshore, a significant upscaling of the technology will be needed, particularly of the equipment required for installation of the piles. A clear understanding of the relevant geotechnical engineering will be needed if this upscaling is to be successful.

Laser Capture Microdissection of Feline Streptomyces spp Pyogranulomatous Dermatitis and Cellulitis.

Suspected Streptomyces spp infections were identified in 4 cats at UC Davis Veterinary Medical Teaching Hospital between 1982 and 2011. Three had ulcerated, dark red mycetomas involving the dermis, subcutis, and fascia with fistulous tracts and/or regional lymphadenopathy. One cat had pyogranulomatous mesenteric lymphadenitis. Granulomatous inflammation in all cats contained colonies of Gram-positive, non-acid-fast organisms. All 4 cats failed to respond to aggressive medical and surgical treatment and were euthanized. Laser capture microdissection (LCM) was used to selectively harvest DNA from the affected formalin-fixed, paraffin-embedded (FFPE) tissues. Cloned amplicons from LCM-derived tissue confirmed the presence of Streptomyces spp in the dermatitis cases. Amplicons from the remaining cat with peritoneal involvement aligned with the 16S ribosomal RNA gene for Actinomycetales. Usually considered a contaminant, Streptomyces spp can be associated with refractory pyogranulomatous dermatitis and cellulitis in cats with outdoor access. LCM is useful in the diagnosis of bacterial diseases where contamination may be an issue.

Musculoskeletal Health, Kidney and Liver Function in Retired Jockeys.

The long-term implications of making-weight daily on musculoskeletal health and functioning of the kidney and liver remain unknown. This study aimed to investigate musculoskeletal health and kidney and liver function in a group of retired jockeys. 28 retired male jockeys (age 50-70 years) provided fasting blood samples for markers of bone metabolism and kidney and liver function. A dual-energy x-ray absorptiometry (DXA) scan was performed for the assessment of bone mineral density (BMD). Established reference ranges were used for interpretation of results. Comparisons were made between retired jockeys based on the professional racing licence held: Flat, National Hunt or Dual. Mean whole-body osteopenia was reported, with no differences between groups. Bone markers, micronutrients, electrolytes and associated hormones, and markers for kidney and liver function were within clinical normative ranges. No differences existed between groups. Results indicate the retired jockeys in this study do not demonstrate compromised bone health or kidney and liver function. However, the retired jockeys may not have undergone chronic weight cycling in the extreme manner evident in present-day jockeys, indicating the next generation of jockeys may face more of a problem. Jockeys should be tracked longitudinally throughout their racing career and beyond.

A retrospective cohort study evaluating pregnancy outcomes in women with MIDD.

AIMS: The most common pathogenic mitochondrial mutation associated with mitochondrial disease is m.3243A>G. Increased obstetric complications, such as spontaneous abortion, gestational diabetes (GDM), preterm delivery, and preeclampsia, have been reported in women carrying this mutation. We aimed to determine the fetal and maternal outcomes in pregnant women with mitochondrial disease. METHODS: We retrospectively studied the obstetric and perinatal outcomes in 88 pregnancies of 26 women with genetically confirmed mitochondrial disease (m.3243A>G in the MTTL1 gene (n = 25); m.12258C>A in the MT-TS2 gene (n = 1)). Outcomes included pregnancy related complications, mode of delivery, gestational age at delivery and birthweight. RESULTS: Mean heteroplasmy rate was 18%. The miscarriage rate was higher than background at 25%. 21 pregnancies (24%) were complicated by GDM; 9 pregnancies (13.6%) had a preterm delivery and 2 of them (3%) an extreme premature delivery < 32 weeks. One woman had preeclampsia and one had a postpartum hemorrhage. The caesarean section (CS) rate was 20%. For every unit increase in maternal heteroplasmy levels there was a 26% increased risk of undergoing an assisted operative vaginal delivery (OR 1.26, 95% CI 1.04-1.53, P = 0.002, Bonferroni corrected P = 0.005) and an 18% increased risk of undergoing a CS (OR 1.18, 95% CI 1.01-1.39, P = 0.01, Bonferroni corrected P = 0.03) compared to a spontaneous vaginal delivery. There was a statistical significant correlation between maternal and offspring heteroplasmy levels. Spearman correlation rho = 0.96, 95% CI 0.78-0.99, P = 0.0002. CONCLUSION: Women with mitochondrial disease appear to have more frequent obstetric complications including miscarriage and GDM. Pre-pregnancy diagnosis of m.3243A>G will enable the counseling of women and increase awareness of possible obstetric complications.

Population-based cohort study comparing 30- and 90-day institutional mortality rates after colorectal surgery.

BACKGROUND: Surgical mortality results are increasingly being reported and published in the public domain as indicators of surgical quality. This study examined how mortality outlier status at 90 days after colorectal surgery compares with mortality at 30 days and subsequent intervals in the first year after surgery. METHODS: All adults undergoing elective and emergency colorectal resection between April 2001 and February 2007 in English National Health Service (NHS) Trusts were identified from administrative data. Funnel plots of postoperative case mix-adjusted institutional mortality rate against caseload were created for 30, 90, 180 and 365 days. High- or low-mortality unit status of individual Trusts was defined as breaching upper or lower third standard deviation confidence limits on the funnel plot for 90-day mortality. RESULTS: A total of 171 688 patients from 153 NHS Trusts were included. Some 14 537 (8·5 per cent) died within 30 days of surgery, 19 466 (11·3 per cent) within 90 days, 23 942 (13·9 per cent) within 180 days and 31 782 (18·5 per cent) within 365 days. Eight institutions were identified as high-mortality units, including all four units with high outlying status at 30 days. Twelve units were low-mortality units, of which six were also low outliers at 30 days. Ninety-day mortality correlated strongly with later mortality results (rs = 0·957, P < 0·001 versus 180-day mortality; rs = 0·860, P < 0·001 versus 365-day mortality). CONCLUSION: Extending mortality reporting to 90 days identifies a greater number of mortality outliers when compared with the 30-day death rate. Ninety-day mortality is proposed as the preferred indicator of perioperative outcome for local analysis and public reporting.

Serotypes and virulence profiles of atypical enteropathogenic Escherichia coli (EPEC) isolated from bovine farms and abattoirs.

AIMS: The objective of this study was to examine the prevalence of enteropathogenic Escherichia coli (EPEC) on beef and dairy farms and in beef abattoirs and to characterize the isolates in terms of serogroup and virulence markers. METHODS AND RESULTS: Bovine faecal samples (n = 1200), farm soil samples (n = 600), hide samples (n = 450) and carcass samples (n = 450) were collected from 20 farms and three abattoirs throughout Ireland over a 12-month period. After selective enrichment, samples testing positive for the intimin gene (eae) using PCR screening were cultured, and colonies were examined for the presence of the eae, vt(1) and vt(2) genes. Colonies that were positive for the intimin gene and negative for the verotoxin genes were further screened using PCR for a range of virulence factors including tir, espA, espB katP, espP, etpD, saa, sab, toxB, iha, lpfA(O157/OI-141) , lpfA(O113) and lpfA(O157/OI-154) . PCR screening was also used to screen for variations in the intimin gene (eae). Of the 2700 source samples analysed, 3.9% (47 of 1200) of faecal, 2% (12 of 600) of soil, 6.4% (29 of 450) of hide and 0.7% (3 of 450) of carcass samples were PCR positive (for the presence of the eae gene). All 140 isolates obtained were atypical EPEC (aEPEC), while θ and ß intimin types were common. The virulence factors hlyA, tir, lpfA (O113) , lpfA (O157/OI-154) , and iha were frequently detected, while lpfA(O157/OI-141) , saa, espA, espB and toxB were also present but to a lesser extent. CONCLUSIONS: It was concluded that cattle are a source of aEPEC, many of which have the virulence machinery necessary to be pathogenic to humans. SIGNIFICANCE AND IMPACT OF THE STUDY: These findings suggest the need for increased research on aEPEC with particular emphasis on food safety and public health risk.

Unselected rectal cancer patients undergoing low anterior resection with defunctioning ileostomy can be safely managed within an Enhanced Recovery Programme.

BACKGROUND: An increasing body of evidence supports the application of the Enhanced Recovery Programme (ERP) to colorectal surgery. Some institutions have reported an association between ERP failure and low rectal cancer surgery. We present the results that we achieved by applying the ERP to low anterior resections for tumours within 6 cm of the anal verge, with a view to determining the validity and safety of applying the ERP to this patient group. METHODS: A multimodal ERP, based on Kehlet's model, was introduced in January 2007 and applied to all patients undergoing elective resections. Patients having a low anterior resection for a rectal cancer less than 6 cm from the anal verge between January 2007 and August 2011 were retrospectively identified from a prospectively maintained database. Individual patient record review was performed. RESULTS: Twenty consecutive patients (12 males) were identified. Median total postoperative length of stay (LOS), including readmission, was 8 days (mean 10.7, range 4-47 days), with 2 readmissions and no deaths. When surgery was uncomplicated, median LOS was 5 days (mean 5.8, range 4-12 days, n = 11), whereas LOS increased when a complication occurred, with a median of 12 days (mean 16.6, range 8-47 days, n = 9) [p = 0.001]. CONCLUSIONS: The ERP can safely be applied to this high-risk patient group. When no complication occurs, LOS of 5 days can be expected. When a complication is encountered, LOS is prolonged (12 days), but this is acceptable compared with the current national median LOS in the United Kingdom of 11 days for all rectal cancer surgery (at any height) with a stoma.

Pharmacokinetics of ceftiofur crystalline free acid after single and multiple subcutaneous administrations in healthy alpacas (Vicugna pacos).

Six adult male alpacas received one subcutaneous administration of ceftiofur crystalline free acid (CCFA) at a dosage of 6.6 mg/kg. After a washout period, the same alpacas received three subcutaneous doses of 6.6 mg/kg CCFA at 5-day intervals. Blood samples collected from the jugular vein before and at multiple time points after each CCFA administration were assayed for ceftiofur- and desfuroylceftiofur-related metabolite concentrations using high-performance liquid chromatography. Pharmacokinetic disposition of CCFA was analyzed by a noncompartmental approach. Mean pharmacokinetic parameters (± SD) following single-dose administration of CCFA were Cmax (2.7 ± 0.9 µg/mL); Tmax (36 ± 0 h); area under the curve AUC0→∞ (199.2 ± 42.1 µg·h/mL); terminal phase rate constant λz (0.02 ± 0.003/h); and terminal phase rate constant half-life t1/2λz (44.7 h; harmonic). Mean terminal pharmacokinetic parameters (±SD) following three administrations of CCFA were Cmax (2.0 ± 0.4 µg/mL); Tmax (17.3 ± 16.3 h); AUC0→∞ (216.8 ± 84.5 µg·h/mL); λz (0.01 ± 0.003/h); and t1/2λz (65.9 h; harmonic). The terminal phase rate constant and the Tmax were significantly different between single and multiple administrations. Local reactions were noted in two alpacas following multiple CCFA administrations.

Severe maternal morbidity trends over 20 years in a tertiary referral stand-alone maternity unit.

OBJECTIVE: Severe maternal morbidity (SMM) is a better indicator of quality of care than maternal mortality, which is a rare event. Risk factors such as advanced maternal age, caesarean section (CS) and obesity are increasing. The aim of this study was to examine the rate and trends in SMM at our hospital over a 20-year period. STUDY DESIGN: Retrospective review was performed of cases of SMM from January 1st 2000 to December 31st 2019. Yearly rates for SMM and Major Obstetric Haemorrhage (MOH) were calculated (per 1000 maternities) and linear regression analysis was used to model the trends over time. Average SMM and MOH rates were also calculated for the periods 2000-2009 and 2010-2019 and compared using a chi-square test. The patient demographics of the SMM group were compared to the background population delivered at our hospital using a chi-square test. RESULTS: 702 women with SMM were identified out of 162,462 maternities over the study period yielding an incidence of 4.3 per 1000 maternities. When the two time periods (2000-2009 and 2010-2019) are compared, the rate of SMM increased 2.4 vs 6.2 (p < 0.001), largely due to an increase in MOH 1.72 vs 3.86 (p < 0.001) and pulmonary embolus (PE) also increased 0.2 vs 0.5 (p = 0.012). Intensive-care unit (ICU) transfer rates more than doubled 0.19 vs 0.44 (p = 0.006). Eclampsia rates decreased 0.3 vs 0.1 (p = 0.047) but the rate of peripartum hysterectomy 0.39 vs 0.38 (p = 0.495), uterine rupture 0.16 vs 0.14 (p = 0.867), cardiac arrest (0.04 vs 0.04) and cerebrovascular accidents (CVA) (0.04 vs 0.04) remained unchanged. Maternal age > 40 years 9.7% vs 5% (p = 0.005), previous CS 25.7% vs 14.4%; p < 0.001 and multiple pregnancy 8 vs 3.6% (p = 0.002) were more prevalent in the SMM cohort compared to the hospital population. CONCLUSIONS: Overall, rates of SMM have increased threefold and transfer for ICU care has doubled over 20 years in our unit. The main driver is MOH. The rate of eclampsia has decreased and peripartum hysterectomy, uterine rupture, CVA and cardiac arrest remain unchanged. Advanced maternal age, previous caesarean delivery and multiple pregnancy were more prevalent in the SMM cohort compared to the background population.

Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study.

OBJECTIVE: To derive nationally representative incidence rates of postpartum haemorrhage (PPH), and to investigate trends associated with method of delivery, blood transfusion and morbidly adherent placenta (accreta, percreta and increta). DESIGN: Population-based retrospective cohort study. SETTING: Republic of Ireland. POPULATION: Childbirth hospitalisations during the period 1999-2009. METHODS: International Classification of Diseases (ICD)-9-CM and ICD-10-AM diagnostic codes from hospital discharge records were used to identify cases of PPH. Significant temporal trends in PPH incidence were determined using Cochrane-Armitage tests for trend. Log-binomial regression was conducted to assess annual changes in the risk of PPH diagnosis, with adjustment for potential confounding factors. MAIN OUTCOME MEASURES: PPH, uterine atony, blood transfusion and morbidly adherent placenta. RESULTS: A total of 649,019 childbirth hospitalisations were recorded; 2.6% (n = 16,909) included a diagnosis of PPH. The overall PPH rate increased from 1.5% in 1999 to 4.1% in 2009; atonic PPH rose from 1.0% in 1999 to 3.4% in 2009. Significant increasing trends in atonic PPH rates were observed across vaginal, instrumental, and emergency and elective caesarean deliveries (P < 0.001). The rate of atonic PPH co-diagnosed with blood transfusion also significantly increased (P < 0.001). Relative to 1999, the risk of atonic PPH in 2009 was three-fold increased (adjusted RR 3.03; 95% CI 2.76-3.34). Women diagnosed with a morbidly adherent placenta had a markedly higher risk of total PPH (unadjusted RR 13.14; 95% CI 11.43-15.11). CONCLUSIONS: Increasing rates of atonic PPH highlight the pressing need for research and for clinical audit focusing on aetiological factors, preventative measures and quality of care, to guide current clinical practice.