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Human immunodeficiency virus (HIV) infection can weaken the immune system causing its inability to combat opportunistic infections. Managing the complexity of these opportunistic infections has created a challenge for healthcare professionals. Our knowledge on the aetiological agents causing opportunistic infections in immunocompromised hosts has increased over the last decade. Diarrhoeal diseases are frequent complications associated with HIV-infected patients. For most of the causes of diarrhoea, the clinical signs are non-specific, and the laboratory diagnostic workup is neither easy nor fast. This review provides data on aetiological approaches of common diarrhoeal diseases including viral, microbacterial, parasitic, bacterial and fungal infections, and HIV enteropathy; diagnostic evaluation; and treatment of diarrhoea in HIV-infected patients. This article will be helpful for those who are in the practice of managing diarrhoea in such patients. [ABSTRACT FROM AUTHOR]

Present study assessed the growth of two plant species and ion uptake by them grown on different proportion of industrial solid waste and garden soil. The industrial waste having high concentration of chemicals were used with garden soil at different proportion i.e. 0% (T0), 5% (T1), 10% (T2), 15% (T3) and 20% (T4). Two species namely Conocarpus erectus (alien plant) and Dodonaea viscosa (indigenous) were used as test plants in pot study. Different parameters including growth, physiology, and anatomy of plants and concentration of cations (Na + , K + , Ca 2+ , and Mg 2+ ) in the plant shoot and root were measured at different time duration (initial, 1 st , 2 nd , 3 rd and 4 th month). The key objective of the study was to use these plants to establish their plantations on the barren lands where industrial solid wastes were being disposed of. C. erectus showed better growth than D. viscosa, as well as more uptake of ions. A significant increase in plant growth was observed in fourth month in T1, where plant height reached 24.5% and 46% for C. erectus and D. viscosa, respectively. At harvest, in C. erectus, no significant difference in the fresh (65-78 g) and dry weight (24-30 g) of the shoot was observed across treatments compared to the control. In D. viscosa, at the time of harvest, the fresh and dry weights of the root and shoot showed a strong, significantly decreasing pattern across T1, T2, and T3, leading to the death of the plant at T3 and T4. Further, optimum ratio of waste soil to garden soil was found as 10:90 and 20:80 to establish the plantations of D. viscosa and C. erectus, respectively in areas where such solid waste from industries are disposed. Findings can be used for the restoration of such solid waste for the sustainable management of industrial areas and their associated ecosystems., (© 2024. The Author(s).)

Salt stress is one of the significant abiotic stress factors that exert harmful effects on plant growth and yield. In this study, five cultivars of mung bean ( Vigna radiata L.) were treated with different concentrations of NaCl and also inoculated with a salt-tolerant bacterial strain to assess their growth and yield. The bacterial strain was isolated from the saline soil of Sahiwal District, Punjab, Pakistan and identified as Bacillus pseudomycoides . Plant growth was monitored at 15-days interval and finally harvested after 120 days at seed set. Both sodium and potassium uptake in above and below-ground parts were assessed using a flame photometer. Fresh and dry mass, number of pods, seeds per plant, weight of seeds per plant and weight of 100 seeds reduced significantly as the concentration of NaCl increased from 3 to 15 dSm -1 . There was a significant reduction in the growth and yield of plants exposed to NaCl stress without bacterial inoculum compared to the plants with bacterial inoculum. The latter plants showed a significant increase in the studied parameters. It was found that the cultivar Inqelab mung showed the least reduction in growth and yield traits among the studied cultivars, while Ramzan mung showed the maximum reduction. Among all the cultivars, maximum Na + uptake occurred in roots, while the least uptake was observed in seeds. The study concludes that NaCl stress significantly reduces the growth and yield of mung bean cultivars, but Bacillus pseudomycoides inoculum alleviates salt stress. These findings will be helpful to cultivate the selected cultivars in soils with varying concentrations of NaCl., Competing Interests: The authors declare that they have no competing interests., (© 2024 Bilal et al.)

Background: Accurate and precise diagnosis is central to treating central nervous system (CNS) tumors, yet tissue diagnosis is often a neglected focus in low- and middle-income countries (LMICs). Since 2016, the WHO classification of CNS tumors has increasingly incorporated molecular biomarkers into the diagnosis of CNS tumors. While this shift to precision diagnostics promises a high degree of diagnostic accuracy and prognostic precision, it has also resulted in increasing divergence in diagnostic and management practices between LMICs and high-income countries (HICs). Pathologists and laboratory professionals in LMICs lack the proper training and tools to join the molecular diagnostic revolution. We describe the impact of a 7-year long twinning program between Canada and Pakistan on pathology services., Methods: During the study period, 141 challenging cases of pediatric CNS tumors initially diagnosed at Aga Khan University Hospital (AKUH), Karachi, were sent to the Hospital for Sick Children in Toronto, Canada (SickKids), for a second opinion. Each case received histologic review and often immunohistochemical staining and relevant molecular testing. A monthly multidisciplinary online tumor board (MDTB) was conducted to discuss the results with pathologists from both institutions in attendance., Results: Diagnostic discordance was seen in 30 cases. Expert review provided subclassification for 53 cases most notably for diffuse gliomas and medulloblastoma. Poorly differentiated tumors benefited the most from second review, mainly because of the resolving power of specialized immunohistochemical stains, NanoString, and targeted gene panel next-generation sequencing. Collaboration with expert neuropathologists led to validation of over half a dozen immunostains at AKUH facilitating diagnosis of CNS tumors., Conclusions: LMIC-HIC Institutional twinning provides much-needed training and mentorship to pathologists and can help in infrastructure development by adopting and validating new immunohistochemical stains. Persistent unresolved cases indicate that molecular techniques are indispensable in for diagnosis in a minority of cases. The development of affordable alternative molecular techniques may help with these histologically unresolved cases., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Gilani, Mushtaq, Shakir, Altaf, Siddiq, Bouffet, Tabori, Hawkins and Minhas.)

Water stored in trunk sapwood is vital for the canopy to maintain its physiological function under high transpiration demands. Little is known regarding the anatomical properties that contribute to the hydraulic capacitance of tree trunks and whether trunk capacitance is correlated with the hydraulic and gas exchange traits of canopy branches. We examined sapwood capacitance, xylem anatomical characteristics of tree trunks, embolism resistance, the minimal xylem water potential of canopy branches, leaf photosynthesis and stomatal conductance in 22 species from a tropical seasonal rainforest and savanna. The results showed that the mean trunk sapwood capacitance did not differ between the two biomes. Capacitance was closely related to the fiber lumen fraction and fiber wall reinforcement and not to the axial and ray parenchyma fractions. Additionally, it was positively correlated with the theoretical hydraulic conductivity of a trunk and the specific hydraulic conductivity of branches, and showed a trade-off with branch embolism resistance. Species with a high trunk sapwood capacitance maintained less negative canopy water potentials in the dry season, but higher leaf photosynthetic rates and stomatal conductance in the wet season. This study provides a functional link among trunk sapwood capacitance, xylem anatomy, canopy hydraulics and photosynthesis in tropical trees., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Introduction: The recently updated World Health Organization classification of central nervous system (CNS) tumors, 5th edition, (CNS5) reclassifies pediatric tumors according to their distinct molecular drivers, recognizing a new entity-infant-type hemispheric glioma (IHG). Defined by its unique epigenetic signature, and/or genomic fusions in ALK, ROS1, NTRK, or MET gene, IHG subsumes many cases previously classified as congenital glioblastoma (cGBM). Histologic features of IHG are still poorly defined with known overlap with a clinic radiologically similar entity-desmoplastic infantile ganglioglioma/astrocytoma (DIG)., Methods: We revisited our cohort of cGBMs and DIGs, now reclassifying them according to CNS5 and compared the clinical, radiologic, molecular and histologic features between the two., Results: 3/6 cases of cGBM that underwent targeted NGS fusion mutation panel were positive for ALK fusions (involving MAP4, MZT2Bex2, and EML4 genes as fusion partners), and 1/6 showed GOPC:ROS1 fusion. Interestingly, GOPC:ROS1 fusion was also shared by 1/5 cases of histologically defined DIG. DNA methylation profiling using the Heidelberg classifier (v12.3) recategorized 2/5 DIG cases as IHG (including the case with ROS1 alteration)., Conclusion: In conclusion, histology alone is insufficient to distinguish IHG from DIG, necessitating epigenomic and genomic testing for the diagnosis of early-life gliomas., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Within vascular plants, the partitioning of hydraulic resistance along the soil-to-leaf continuum affects transpiration and its response to environmental conditions. In trees, the fractional contribution of leaf hydraulic resistance (R leaf ) to total soil-to-leaf hydraulic resistance (R total ), or fR leaf (=R leaf /R total ), is thought to be large, but this has not been tested comprehensively. We compiled a multibiome data set of fR leaf using new and previously published measurements of pressure differences within trees in situ. Across 80 samples, fR leaf averaged 0.51 (95% confidence interval [CI] = 0.46-0.57) and it declined with tree height. We also used the allometric relationship between field-based measurements of soil-to-leaf hydraulic conductance and laboratory-based measurements of leaf hydraulic conductance to compute the average fR leaf for 19 tree samples, which was 0.40 (95% CI = 0.29-0.56). The in situ technique produces a more accurate descriptor of fR leaf because it accounts for dynamic leaf hydraulic conductance. Both approaches demonstrate the outsized role of leaves in controlling tree hydrodynamics. A larger fR leaf may help stems from loss of hydraulic conductance. Thus, the decline in fR leaf with tree height would contribute to greater drought vulnerability in taller trees and potentially to their observed disproportionate drought mortality., (© 2022 John Wiley & Sons Ltd.)

Heavy metals like chromium (Cr) are hazardous pollutants for aquatic life in water bodies. Similarly, lithium (Li) is also an emerging contaminant in soil and water which later is taken up by plants. The aim of the present study is to evaluate the removal rate of Cr and Li by Eichhornia crassipes . The rate of the removal of Cr and Li by roots, stems, and leaves of E. crassipes were evaluated. The translocation factor (TF) and bioaccumulation factor (BAF) were also estimated. Roots of E. crassipes accumulated higher concentrations of Cr and Li as compared to the stems and leaves. BAF for Cr and Li showed that E. crassipes effectively accumulated the Cr and Li in the roots as compared to the stems and leaves. Statistical analysis showed that E. crassipes removed significant concentrations of Cr and Li ( p ≤ 0.05). Thus, this study recommends that Cr and Li can be effectively removed by E. crassipes . High concentrations of Cr and Li could also be removed by E. crassipes . This technology could be used for the cleanup of the environment because it is eco-friendly and cost-effective.

A high amount of CO 2 causes numerous health effects, including headaches, restlessness, difficulty in breathing, increased heart rate, high blood pressure, asphyxia, and dizziness. This issue of increasing atmospheric CO 2 can only be solved via above-ground and below-ground carbon sequestration (CS). This study was designed to determine the relationship between CS with the crown area (CA), diameter at breast height (DBH), height (H), species richness (SR), and elevation in different forest types of Pakistan with the following specific objectives: (1) to quantify the direct and indirect relationship of carbon sequestration with CA, DBH, H, and SR in various natural forest types and (2) to evaluate the effect of elevation on the trees functional traits and resultant CS. We used the linear structural equation model (SEM) for each conceptual model. Our results confirmed that the highest CS potential was recorded for dry temperate conifer forests (DTCF) i.e., 52.67%, followed by moist temperate mix forests (MTMF) and sub-tropical broad-leaved forests (STBLF). The SEM further described the carbon sequestration variation, i.e., 57, 32, 19, and 16% under the influence of CA (β = 0.90 and P -value < 0.001), H (β = 0.13 and p -value = 0.05), DBH (β = 0.07 and p -value = 0.005), and SR (β = -0.55 and p -value = 0.001), respectively. The individual direct effect of SR on carbon sequestration has been negative and significant. At the same time, the separate effect of CA, DBH, and H had a positive and significant effect on carbon sequestration. The remaining 20% of CS variations are indirectly influenced by elevation. This means that elevation affects carbon sequestration indirectly through CA, DBH, H, and SR, i.e., β = 0.133 and P -value < 0.166, followed by β = 0.531 and P -value < 0.001, β = 0.007 and P -value < 0.399, and β = -0.32 and P -value < 0.001, respectively. It is concluded that abiotic factors mainly determined carbon sequestration in forest ecosystems along with the elevation gradients in Pakistan. Quantifying the role of various forest types in carbon dioxide (CO 2 ) reduction leads to improved air quality, which positively impacts human health. This is an imperative and novel study that links the dynamics of the biosphere and atmosphere., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Ali, Khan, Ahmad, Siddiq, Ullah, Yoo, Han and Raposo.)

Crop irrigation with untreated wastewater is a routine practice in developing countries that causes multiple human health consequences. A comparative study was performed to regulate total Cr and Pb stress in soil and Solanum melongena L. plant. For this purpose, 0.2% chitosan polymerized silica gel (CP-silica gel), 1.5% zinc-enriched biochar (ZnBc), and three bacterial species such as Trichococcus sp. (B1), Pseudomonas alcaligenes (B2), and Bacillus subtilis (B3) were selected. Initially, a biosorption trial was conducted to test the heavy metal removal efficiency of three bacterial species B1, B2, and B3 for 24 h. Hence, B3 showed maximum Cr and Pb removal efficiency among the studied bacterial isolates. Then, a pot study was conducted with 12 different treatments having three replicates. After harvesting, different growth and biochemical parameters such as chlorophyll concentration, proteins, phenolics, reactive oxygen species, and antioxidant enzymes were analyzed. The results demonstrated that wastewater application significantly ( p ≤ 0.01) reduced the fresh and dry weights of the root, stem, and leaves due to high total Cr and Pb toxicity. However, CP-silica gel and ZnBc treatments performed best when applied in combination with B3. The concentration of leaf total Cr was significantly decreased (91 and 85%) with the application of ZnBc + B3 and CP-Silica gel + B3, respectively, as compared to control. There was a reduction in stem hydrogen peroxide (87%) and malondialdehyde (81%) recorded with CP-silica gel + B3 treatment due to enhanced activities of antioxidant enzymes viz. ascorbate peroxidase (6-folds) and catalase (7-folds) relative to control. Similarly, leaf total phenolics (3-folds) and protein (6-folds) contents were enhanced with CP silica gel+B3 application relative to control. Overall, CP-silica gel and ZnBc with B3 application proved to be the most appropriate treatments and can be used in developing countries to limit the deleterious effects of total Cr and Pb pollution., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Rabiya, Ali, Farooq, Siddiq, Alamri, Siddiqui and Khan.)

Palynological features of tribe Astagaleae L. have been observed with scanning electron microscopy (SEM), to assess features that can be used to re-examine the placement and taxonomic position of tribe. The palynomorph attributes of 10 species included in three genera of Astragaleae (Astragalus L., Glycyrrhiza L., and Oxytropis DC.) are investigated. The assignment of genus Oxytropis in tribe Astragaleae was also reevaluated based on pollen characters. Pollen appear to be prolate, prolate-spheroidal, and subprolate. Polar axis size (P) varies from 31.3 μm ±1 to 17.5 μm ±1.4 and equatorial axis size (E) varies from 22.2 μm ±1.8 to 13.1 μm ±0.9. Prominent apertures found consistently dispersed along the surface of pollen. Three kinds of ornamentation pattern were recorded, that is, reticulate or reticulate-perforate and perforate. The studied species display variation in equatorial and polar diameter, aperturation and sculpturing pattern, exine thickness, and pollen shape. On the basis of descriptive pollen features, a dichotomous taxonomic key and UPGMA analysis has been made for effortless and quick identification. The study concluded that disparities of the entire features are typically unrelenting and concerned with the species and shows potential systematic significance. The combination of palynological attributes in association with additional traits has prospective for systematic identification at species and genus level., (© 2021 Wiley Periodicals LLC.)

Objective: This study aimed to assess risk for fetal acidemia, low Apgar scores, and hypoxic ischemic encephalopathy based on decision-to-incision time interval in the setting of emergency cesarean delivery., Study Design: This unplanned secondary analysis of the Maternal-Fetal Medicine Units prospective observational cesarean registry dataset evaluated risk for hypoxic ischemic encephalopathy, umbilical cord pH ≤7.0, and Apgar score ≤4 at 5 minutes based on decision-to-incision time for emergency cesarean deliveries. Cesarean occurring for nonreassuring fetal heart rate monitoring, bleeding previa, nonreassuring antepartum testing, placental abruption, or cord prolapse was classified as emergent. Decision-to-incision time was categorized as <10 minutes, 10 to <20 minutes, 20 to <30 minutes, 30 to <50 minutes, or ≥50 minutes. As secondary outcomes umbilical cord pH ≤7.1, umbilical artery pH ≤7.0, and Apgar score ≤5 at 5 minutes were analyzed., Results: Of 5,784 women included in the primary analysis, 12.4% had a decision-to-incision interval ≤10 minutes, 20.2% 11 to 20 minutes, 14.9% 21 to 30 minutes, 18.2% 31 to 50 minutes, and 16.5% >50 minutes. Risk for umbilical cord pH ≤7.0 was highest at ≤10 and 11 to 20 minutes (10.2 and 7.9%, respectively), and lowest at 21 to 30 minutes (3.9%), 31 to 50 minutes (3.9%), and >50 minutes (3.5%) ( p  < 0.01). Risk for Apgar scores ≤4 at 5 minutes was also higher with decision-to-incision intervals ≤10 and 11 to 20 minutes (4.3 and 4.4%, respectively) compared with intervals of 21 to 30 minutes (1.7%), 31 to 50 minutes (2.1%), and >50 minutes (2.0%) ( p  < 0.01). Hypoxic ischemic encephalopathy occurred in 1.5 and 1.0% of women with decision-to-incision intervals of ≤10 and 11 to 20 minutes compared with 0.3 and 0.5% for women with decision-to-incision intervals of 21 to 30 minutes and 31 to 50 minutes ( p  = 0.04). Risk for secondary outcomes was also higher with shorter decision-to-incision intervals., Conclusion: Shorter decision-to-incision times were associated with increased risk for adverse outcomes in the setting of emergency cesarean., Key Points: · Shorter intervals likely occur with higher risk cases.. · Shorter intervals were associated with higher neonatal risk.. · Shorter intervals were associated with low cord pH.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: This study aimed to evaluate temporal trends in opioid use disorder (OUD) during antepartum and postpartum hospitalizations., Study Design: This repeated cross-sectional analysis analyzed data from the National (Nationwide) Inpatient Sample. Women aged 15 to 54 years admitted antepartum or postpartum were identified. The presence of OUD was determined based on a diagnosis of opioid abuse, opioid dependence, or opioid overdose. Temporal trends in OUD were evaluated using the Rao-Scott chi-square test. Temporal trends in opioid overdose were additionally evaluated., Results: An estimated 7,336,562 antepartum hospitalizations and 1,063,845 postpartum readmissions were included in this analysis. The presence of an OUD diagnosis during antepartum hospitalizations increased from 0.7% of patients in 1998 to 1999 to 2.9% in 2014 ( p  < 0.01) and during postpartum hospitalizations increased from 0.8% of patients in 1998 to 1999 to 2.1% of patients in 2014 ( p  < 0.01). Risk of overdose diagnoses increased significantly for both antepartum hospitalizations, from 22.7 per 100,000 hospitalizations in 1998 to 2000 to 70.3 per 100,000 hospitalizations in 2013 to 2014 ( p  < 0.001), and postpartum hospitalizations, from 18.8 per 100,000 hospitalizations in 1998 to 2000 to 65.2 per 100,000 hospitalizations in 2013 to 2014 ( p  = 0.02)., Discussion: Risk of OUD diagnoses and overdoses increased over the study period for both antepartum and postpartum hospitalizations., Competing Interests: J.D.W. has served as a consultant for Tesaro and Clovis Oncology. The other authors did not report any potential conflicts of interest., (Thieme. All rights reserved.)

Objective: The objective of this study was to assess how race is associated with adverse maternal outcomes in the setting of preeclampsia. Study design: This retrospective cohort study utilized the National (Nationwide) Inpatient Sample (NIS) from the Agency for Health care Research and Quality for the years 2012-2014. Women aged 15-54 with a diagnosis of preeclampsia were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. The overall risk for severe morbidity based on Centers for Disease Control and Prevention criteria was analyzed along with the risk for specific outcomes such as stroke, acute heart failure or pulmonary edema, eclampsia, and acute renal failure. The risk for severe morbidity was stratified by comorbid risk and compared by race. Log-linear regression models were created to assess risk for severe morbidity with risk ratios and associated 95% confidence intervals as measures of effect. Results: A total of 101,741 women with preeclampsia from 2012 to 2014 were included in this analysis. The risk for severe morbidity was significantly higher among non-Hispanic black women (9.8%) than non-Hispanic white, Hispanic, and all other women, respectively (6.1, 7.7, and 7.5%, respectively, p  < .01). For non-Hispanic black compared to non-Hispanic white, Hispanic, and all other women, risk was higher for stroke (17.1 versus 6.5, 12.7, and 9.3 per 10,000 deliveries, respectively, p  < .01) and pulmonary edema or heart failure (56.2 versus 32.7, 30.2, and 38.4 per 10,000 deliveries, respectively, p  < .01). Non-Hispanic black women were also more likely than non-Hispanic white women to experience renal failure (136.4 versus 60.4 per 10,000 deliveries, p  < .01). Adjusting for comorbidity, black women remained at higher risk for severe morbidity ( p  < .01). The risk for death was higher for black compared to non-black women (121.8 per 100,000 deliveries, 95% CI 69.7-212.9 versus 24.1 per 100,000 deliveries, 95% CI 14.6-39.8, respectively, p  < .01) Conclusion: Black women were at higher risk for severe morbidity and mortality associated with preeclampsia.

Objective: This study aimed to determine the receipt of short-acting opioid medications during vaginal delivery hospitalizations., Study Design: The Perspective database was analyzed to evaluate patterns of short-acting oral opioid use during vaginal delivery hospitalizations from January 2006 to March 2015. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating use of opioids. Hospital-level rates of opioid use were evaluated. Opioid receipt among women with opioid abuse or dependence was evaluated based on overall hospital rates of opioid use., Results: Of 3,785,396 vaginal delivery hospitalizations from 2006 to 2015, 1,720,899 (45.5%) women received an oral opioid for pain relief. Opioid use varied significantly among the 458 hospitals included in the analysis, with one-third of hospitals providing opioids to <38% of patients, one-third to 38 to <59% of patients, and one-third to ≥59% of patients. When hospitals were stratified by overall opioid administration rates, women with opioid abuse or dependence were less likely to be given opioids in hospitals with low overall opioid rates., Discussion: The use of opioid pain medications during vaginal delivery hospitalizations varied significantly among hospitals, suggesting that standardization of pain management practices could reduce opioid use., Competing Interests: J.D.W. has served as a consultant for Tesaro and Clovis Oncology. The other authors did not report any potential conflicts of interest., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Subtropical scrub forests in Pakistan have diminished by about 75% over the last hundred years, mainly due to indiscriminate exploitation and invasion by exotics species. Lack of initiatives, awareness, and research in utilizing the techniques used for accelerating natural forest succession is resulting in further degradation of the remaining forests. To promote active restoration with local communities and governmental authorities, a restoration scheme was piloted between 2010 and 2016 to examine enrichment population effects. Over 4,000 saplings of two woody climax species, Acacia modesta and Olea ferruginea, raised from seeds of local provenance, were planted in three subjectively selected trial plots representing various stages of degradation, covering a total area of about 4 ha. The results showed an overall 46% survival rate, accompanied by natural regeneration. Comparative analyses of the trial plots have shown variations which were strongly site specific, in addition, it also helped in gauging compliance of the site coordinators in implementing restoration measures as an effective management tool. This study provided an opportunity to appreciate the differences in terms of interventions used for implementing ecological restoration across landscape in the degraded scrub forests.

This was the first comprehensive pollen micromorphological investigation of lactiferous flora (Apocynaceae) of District Rawalpindi, Pakistan. The pollen morphology of 10 species of the family Apocynaceae was observed and documented using light microscopy and scanning electron microscopy. Pollen was found subspheroidal in shape in most of the species, however peroblate shape was noted in Vinca major. Exine sculpturing patterns (psilate, rugulate, scabrate, and microreticulate) were observed. The result indicated that exine ornamentation of Apocynaceae taxa is systematically informative at generic and species levels. Most of the species have tricolporate type pollen but tetraporate pollen was also observed in Trachelospermum jasminoides and tetracolpate in V. major. Minimum equatorial diameter was noted in Carissa edulis (27.13 μm) and maximum in V. major (108.25 μm). Similarly, maximum exine thickness was found in Cascabela thevetia (9.5 μm). In the present findings, the pollen morphological data are compared with available other pollen studies to evaluate the taxonomic value of pollen traits in Apocynaceae taxa by using multiple microscopic techniques. Furthermore, molecular and phylogenetic studies were recommended to strengthen the systematics of Apocynaceae taxa., (© 2019 Wiley Periodicals, Inc.)

Objective: The objective of this study was to characterize morbidity, acuity, and maternal risks associated with preeclampsia across hospitals with varying obstetric volumes., Methods: This retrospective cohort analysis used a large administrative data source, the Perspective database, to characterize the risk for preeclampsia from 2006 to 2015. Hospitals were classified as having either low (≤1000), moderate (1001-2000), or high (≥2000) delivery volume. The primary outcomes included preeclampsia, antihypertensive administration, comorbidity, and related severe maternal morbidity. Severe maternal morbidity was estimated using criteria from the Centers for Disease Control and Prevention. Comorbidity was estimated using an obstetric comorbidity index. Univariable comparisons were made with Chi-squared test. Adjusted log linear regression models were fit to assess factors associated with severe morbidity with risk ratios with 95% confidence intervals as the measures of effect. Population weights were applied to create national estimates., Results: Of 36,985,729 deliveries included, 1,414,484 (3.8%) had a diagnosis of preeclampsia. Of these, 779,511 (2.1%) had mild, 171,109 (0.5%) superimposed, and 463,864 (1.3%) severe preeclampsia. The prevalence of mild, superimposed, and severe preeclampsia each increased over the study period with severe and superimposed preeclampsia as opposed to mild preeclampsia increasing the most proportionately (53.2 and 102.5 versus 10.8%, respectively). The use of antihypertensives used to treat severe range hypertension increased with use of intravenous labetalol increasing 31.5%, 43.2%, and 36.1% at low-, medium-, and high-volume hospitals. Comorbid risk also increased across hospital volume settings as did risk for severe maternal morbidity., Conclusions: Preeclampsia is increasing across obstetric care settings with preeclamptic patients demonstrating increasing comorbid risk, increased risk for severe morbidity, and more frequent need for treatment of acute hypertension.

As a global biodiversity hotspot, the subtropical evergreen broadleaved forest (SEBF) in southern China is strongly influenced by the humid monsoon climate, with distinct hot-wet and cool-dry seasons. However, the hydraulic strategies of this forest are not well understood. Branch and leaf hydraulic safety margins (HSMbranch and HSMleaf, respectively), as well as seasonal changes in predawn and midday leaf water potential (Ψpd and Ψmd), stomatal conductance (Gs), leaf to sapwood area ratio (AL/AS) and turgor loss point (Ψtlp), were examined for woody species in a mature SEBF. For comparison, we compiled these traits of tropical dry forests (TDFs) and Mediterranean-type woodlands (MWs) from the literature because they experience a hot-dry season. We found that on average, SEBF showed larger HSMbranch and HSMleaf than TDF and MW. During the dry season, TDF and MW species displayed a significant decrease in Ψpd and Ψmd. However, SEBF species showed a slight decrease in Ψpd but an increase in Ψmd. Similar to TDF and MW species, Gs was substantially lower in the dry season for SEBF species, but this might be primarily because of the low atmospheric temperature (low vapor pressure deficit). On the other hand, AL/AS and Ψtlp were not significant different between seasons for any SEBF species. Most SEBF species had leaves that were more resistant to cavitation than branches. Additionally, species with stronger leaf-to-branch vulnerability segmentation tended to have smaller HSMleaf but larger HSMbranch. Our results suggest that SEBF is at low hydraulic risk under the current climate., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The medicinal plants are utilized globally considering the cheap and chemical free source, but their correct identification and authentication is prerequisite for safety and efficacy of plant-based medicines. The present study encompassed traded medicinal plants (16) with high therapeutic value from diverse families like Brassicaceae, Berberidaceae, Malvaceae, Salicaceae, Myrtaceae, Papilionaceae, Ascelpiadaceae, Colchicaceae, Violaceae, and Vitaceae for detailed microscopic study of characters that is, morphology, pollen shape and sizes, P/E ratio, pore length and width, spine length, colpi dimensions, and exine sculpture pattern. The plants showed noteworthy differences in microscopy of Wattakaka volubilis having pollinia, translator and corpusculum like structures while pores were visible in Colchicum luteum, Alcea rosea, and Hibiscus syriacus. The spines were observed in Centipeda minima, A. rosea, and H. syriacus being dimorphic spines in A. rosea and monomorphic in H. syriacus. The exine sculpturing pattern was reticulate in mostly studied plants however distinctive exine pattern was noted in Berberis aristata and Berberis lyceum. The highest polar diameter, equatorial diameter and exine thickness among studied plants were observed in H. syriacus (161 μm), C. luteum (50 μm) and Vitis jacquemontii (1.10), respectively. Thus, microscopy of medicinal plants in addition to other taxonomic evidence offers a supportive skill in authentication, consequently utilization by local consumers and pharmaceutical industries., (© 2019 Wiley Periodicals, Inc.)

Tree trunks not only provide physical support for canopy leaves but also supply and store water for transpiration. However, the relationships between trunk hydraulic properties and canopy leaf physiology in tropical trees are not well-understood. In this study we concurrently measured morning and midday canopy leaf photosynthesis (A), stomatal conductance (g s ), and leaf water potentials (Ψ L ) in 40 tropical trees representing 14 species at the beginning of the rainy season in Xishuangbanna, Southwest China. We also measured trunk sapwood capacitance (C), wood density, and sap flux density to assess their association with canopy leaf physiology. Among the 14 studied species, only three and four species did not show a significant midday reduction in A and g s respectively. The diurnally maximum A and g s were significantly positively related to sapwood hydraulic capacitance, maximum sap flux density (midday), and sap flux density at 11:00. Those species with lower wood density and higher C showed a lower reduction in Ψ L at midday, whereas, species with high C, and large values of maximum sap flux density also showed high carbon assimilation at midday. Our results provide new insights into the close coordination between canopy physiology and trunk sapwood hydraulic properties in tropical trees., (Copyright © 2019. Published by Elsevier Masson SAS.)

Background: Maternal race may be an important risk factor for postpartum readmissions and associated adverse outcomes., Objective: To determine the association of race with serious complications during postpartum readmissions., Study Design: This repeated cross-sectional analysis used the National (Nationwide) Inpatient Sample from the Healthcare Cost and Utilization Project from 2012 to 2014. Women ages 15-54 readmitted postpartum after a delivery hospitalization were identified by Centers for Disease Control and Prevention criteria. Race and ethnicity were characterized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific islander, Native American, other, and unknown. Overall risk for readmission by race was determined. Risk for severe maternal morbidity during readmissions by race was analyzed. Individual outcomes including pulmonary edema/acute heart failure and stroke also were analyzed by race. Log-linear regression models including demographics, hospital factors, and comorbid risk were used to analyze risk for severe maternal morbidity during postpartum readmissions., Results: Of 11.3 million births, 207,730 (1.8%) women admitted postpartum from 2012 to 2014 were analyzed, including 96,670 white, 47,015 black, and 33,410 Hispanic women. Compared with non-Hispanic white women, non-Hispanic black women were at 80% greater risk of postpartum readmission (95% confidence interval, 79%-82%) whereas Hispanic women were at 11% lower risk of readmission (95% confidence interval, 10%-12%). In unadjusted analysis, compared with non-Hispanic white women, non-Hispanic black women admitted postpartum were at 27% greater risk of severe maternal morbidity (95% confidence interval, 24%-30%) whereas Hispanic women were at 10% lower risk (95% confidence interval, 7%-13%). In the adjusted model, non-Hispanic black women were at 16% greater risk for severe maternal morbidity during readmission than non-Hispanic white women (95% confidence interval, 10%-22%), whereas Hispanic women were at 7% lower risk (95% confidence interval, 1%-12%). Differences in severe maternal morbidity risk between other racial groups and non-Hispanic white women were not significant. In addition to overall morbidity, non-Hispanic black women were at significantly greater risk for eclampsia, acute respiratory distress syndrome, and renal failure than other racial groups (P<.05 all). Black women were at 126% greater risk for pulmonary edema/acute heart failure than white women (95% confidence interval, 117%-136%)., Conclusion: Black women were more likely (1) to be readmitted postpartum, (2) to suffer severe maternal morbidity during readmission, and (3) to suffer life threatening complications such as pulmonary edema/acute heart failure. At-risk women including black women with cardiovascular risk factors may benefit from short-term postpartum follow-up., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Foliar epidermal features were based on the micromorphology of trichomes types, epidermal cells and stomatal complex. Even though each feature has its own limited taxonomic value but collectively these characteristics may be systematically important especially for the discrimination and identification of complex and problematic taxa. The systematics significance of nonglandular (NGTs) and glandular trichomes (GTs), stomatal complex and epidermal cells of Lamiaceous flora were analyzed by using the light microscopy (LM) and scanning electron microscopy (SEM). Variations on the observed epidermal appendages were divided into two basic types: glandular and nonglandular. GTs can be divided into subtypes: sessile capitate, subsessile capitate, and barrel and sunken. NGTs were also divided into subtypes: dendritic, stellate, conical, falcate, simple and 1-6 cells long having granulate and smooth surface ornamentation. NGTs were the most dominant features of both adaxial and abaxial surfaces of all observed taxa. Vitex negundo, Isodon rugosus, Colebrookea oppositifolia, and Marrubium vulgare could be demarked because of their twisted like appearance of NGTs at the abaxial surface. The Lamiaceae had both hypostomatic and amphistomatic leaf. Stomata were observed as diacytic, anisocytic, and anomocytic. Epidermal cells were found to be irregular, isodiametric, and rectangular. Based on these characters a taxonomic key was developed to delimit the closely related taxa. Distribution and morphology of the foliar epidermal trichomes through SEM highlight an important taxonomic tool used by the taxonomists as an aid to the correct identification of problematic Lamiaceae taxa., (© 2019 Wiley Periodicals, Inc.)

Objective: The objective of this study was to characterize the risk for severe maternal morbidity and other pregnancy complications by maternal age during delivery hospitalizations., Study Design: This retrospective cohort analysis used the Perspective database to characterize the risk for adverse maternal outcomes from 2006 to 2015 based on maternal age. Women were divided into 7 categories based on maternal age: 15-17, 18-24, 25-29, 30-34, 35-39, 40-44, and 45-54 years of age. The primary outcome of this study was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Secondary outcomes included (1) overall comorbid risk; (2) risk for pregnancy complications such as postpartum hemorrhage, gestational diabetes, preeclampsia, and cesarean delivery; and (3) risk for individual severe morbidity diagnoses such as stroke, embolism, eclampsia, and hysterectomy. Adjusted models were fitted to assess factors associated with severe morbidity with adjusted risk ratios (aRRs) and 95% confidence intervals (CI) as measures of effect. Population weights were applied to create national estimates., Results: Of 36,944,292 deliveries included, 2.5% occurred among women aged 15-17 years (n = 921,236), 29.1% to women aged 18-24 years (n = 10,732,715), 28.6% to women aged 25-29 years (n = 10,564,850), 24.9% to women aged 30-34 years (n = 9,213,227), 12.1% to women aged 35-39 years (n = 4,479,236), 2.6% to women aged 40-44 years (n = 974,289), and 0.2% to women aged 45-54 years (n = 58,739). In unadjusted analyses, severe morbidity was more than 3 times higher (risk ratio [RR], 3.33, 95% confidence interval [CI], 3.03-3.66) for women 45-54 years compared with women 25-29 years. Women aged 40-44, 35-39, and 15-17 years were also at increased risk (RR, 1.83, 95% CI, 1.77-1.89; RR, 1.36, 95% CI, 1.33-1.39; RR, 1.39, 95% CI, 1.34-1.45, respectively). In the adjusted model, the 45-54 year old group was associated with the highest relative risk (aRR, 3.46, 95% CI, 3.15-3.80) followed by the 40-44 year old group (aRR 1.90, 95% CI, 1.84-1.97), the 35-39 year old group (aRR, 1.43, 95% CI, 1.40-1.47), and the 15-17 year old group (aRR, 1.20, 95% CI, 1.15-1.24). Cesarean delivery, preeclampsia, postpartum hemorrhage, and gestational diabetes were most common among women aged 45-54 years, as were thrombosis and hysterectomy., Conclusion: While differential risk was noted across maternal age categories, women aged 45 years old and older were at highest risk for a broad range of adverse outcomes during delivery hospitalizations., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To assess trends in use of long-acting opioids during delivery hospitalizations., Methods: The Perspective database, an administrative inpatient database that includes medication receipt, was analyzed to evaluate patterns of long-acting opioid use during delivery hospitalizations from January 2006 through March 2015. Medications evaluated included methadone, formulations including buprenorphine and extended-release formulations of oxycodone, morphine, fentanyl, and other opioids. Temporal trends in use of these medications were determined. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating both use of these medications and risk for severe morbidity. Risk for severe morbidity was determined based on Centers for Disease Control and Prevention criteria., Results: Our analysis included 2,994,630 delivery hospitalizations meeting study criteria. Over the entire study period, use of long-acting opioids increased significantly from 457 to 844 per 100,000 deliveries. Although buprenorphine and methadone use increased, use of other long-acting opioids decreased. In 2006, methadone and buprenorphine accounted for less than one third of all long-acting opioids used during delivery hospitalizations. By 2015, buprenorphine and methadone represented 73.5% of long-acting opioids used. In adjusted and unadjusted models, risk for severe morbidity was significantly lower with buprenorphine or methadone compared with other long-acting opioids. Restricting the cohort to only women with drug abuse or dependence, risk for severe morbidity was lower with methadone and buprenorphine than without any long-acting opioids., Conclusion: Increased use of methadone and buprenorphine in this study supports the feasibility of use of these medications during pregnancy and uptake of clinical recommendations for women with opioid use disorder. Use of methadone and buprenorphine is associated with decreased maternal morbidity, although causation cannot be presumed from this study model.

Objective: To clarify how race is associated with adverse maternal outcomes and risk for women aged 40 years or older., Methods: This retrospective cohort study used the Nationwide Inpatient Sample for the years 1998-2014. Women aged 40-54 years were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. Temporal trends in severe maternal morbidity and overall comorbid risk by race in women aged 40 years or older were evaluated as were common pregnancy complications including preeclampsia, gestational diabetes, and cesarean delivery. Adjusted models were created to assess factors associated with severe morbidity., Results: A total of 1,724,694 deliveries were included in this analysis. Severe maternal morbidity increased over the study period from 1.6% in 1998-2000 to 3.0% from 2013 to 2014. Black women had the highest rates of severe morbidity at both the beginning (2.4% in 1998-2000) and the end (4.9% in 2013-2014) of the study period. During this same period, comorbid risk based on medical conditions and other factors increased overall and individually by race. Black women also experienced the absolute largest increase from 1998-2003 to 2010-2014 in risk for acute renal failure, disseminated intravascular coagulation, transfusion, and hysterectomy. Pregnancy complications including preeclampsia, cesarean delivery, and gestational diabetes were more common at the end compared with the beginning of the study for black, white, and Hispanic women. The adjusted risk ratio for overall severe morbidity for black compared with white race was 1.81 (95% CI 1.76-1.87). Black women had a substantially higher risk of death than white women (risk ratio 4.71, 95% CI 3.36-6.61), and Hispanic women had more than twice the risk of death (risk ratio 2.13, 95% CI 1.48-3.07) as white women., Conclusion: Although black women older than 40 years were at increased risk for adverse outcomes and severe morbidity, this differential was of smaller magnitude than reported mortality risk.

Background: How race is associated with adverse outcomes in the setting of postpartum hemorrhage is not well characterized., Objective: The objective of this study was to assess how race is associated with adverse maternal outcomes in the setting of postpartum hemorrhage., Study Design: This retrospective cohort study utilized the National (Nationwide) Inpatient Sample (NIS) from the Agency for Healthcare Research and Quality for the years 2012-2014. Women aged 15-54 years with a diagnosis of postpartum hemorrhage were included. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, Native American, other, and unknown. Overall risk for severe morbidity based on Centers for Disease Control and Prevention criteria was analyzed along with risk for specific outcomes such as disseminated intravascular coagulation, hysterectomy, transfusion, and maternal death. Risk for severe morbidity was stratified by comorbid risk and compared by race. Weights were applied to create population estimates. Log-linear regression models were created to assess risk for severe morbidity with risk ratios and associated 95% confidence intervals as measures of effect., Results: A total of 360,370 women with postpartum hemorrhage from 2012 to 2014 were included in this analysis. Risk for severe morbidity was significantly higher among non-Hispanic black women (26.6%) than non-Hispanic white, Hispanic, or Asian or Pacific Islander women (20.7%, 22.5%, and 21.4%, respectively, P < .01). For non-Hispanic black compared with non-Hispanic white, Hispanic, and Asian or Pacific Islander women risk was higher for disseminated intravascular coagulation (8.4% vs 7.1%, 6.8%, and 6.8%, respectively, P < .01) and transfusion (19.4% vs 13.9%, 16.1%, and 15.8%, respectively, P < .01). Black women were also more likely than non-Hispanic white women to undergo hysterectomy (2.4% vs 1.9%, P < .01), although Asian or Pacific Islander women were at highest risk (2.9%). Adjusting for comorbidity, black women remained at higher risk for severe morbidity (P < .01). Risk for death for non-Hispanic black women was significantly higher than for nonblack women (121.8 per 100,000 deliveries, 95% confidence interval, 94.7-156.8 vs 24.1 per 100,000 deliveries, 95% confidence interval, 19.2-30.2, respectively, P < .01)., Conclusion: Black women were at higher risk for severe morbidity and mortality associated with postpartum hemorrhage., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To estimate whether the diagnosis of asthma is associated with the use of specific uterotonic and antihypertensive medications during delivery hospitalizations., Methods: We used Perspective, an administrative database, to determine whether women hospitalized for delivery complicated by postpartum hemorrhage or preeclampsia received uterotonics and antihypertensive medications differentially based on the absence or presence of asthma from 2006 to 2015. Given that carboprost and intravenous (IV) labetalol may be associated with asthma exacerbation, adjusted models for receipt of these medications were created with adjusted risk ratios with 95% CIs as measures of effect. Risk for status asthmaticus based on receipt of carboprost and IV labetalol was analyzed., Results: Over the study period, a total of 5,691,178 women were analyzed, of whom 239,915 (4.2%) had preeclampsia and 139,841 postpartum hemorrhage (2.5%). Carboprost was used less frequently in patients with asthma compared with patients with no asthma (11.4% vs 18.0%) in comparison with IV labetalol, which was used more commonly when a diagnosis of asthma was present (18.5% vs 16.7%). In unadjusted analysis, the presence of asthma was associated with a 37% decrease in likelihood of carboprost use and an 11% increase in likelihood of labetalol use. In adjusted analysis, the presence of asthma was associated with a 32% decrease in likelihood of carboprost use (adjusted risk ratio 0.68, 95% CI 0.62-0.74) compared with a 7% decrease in labetalol use (adjusted risk ratio 0.93, 95% CI 0.90-0.97). Risk for status asthmaticus was significantly increased with use of IV labetalol compared with other antihypertensive medications (6.5 vs 1.7/1,000 delivery hospitalizations, P<.01)., Conclusion: There may be an opportunity to reduce use of β-blockers and carboprost among patients with asthma. Given their association with status asthmaticus, these drugs should be used cautiously in women with asthma.

Introduction: The rate of heparin-induced thrombocytopenia (HIT) on a population basis is unknown. The objective of this study was to characterize the risk for HIT during antepartum, delivery, and postpartum hospitalizations in the United States., Materials and Methods: A large administrative database was used to determine the risk of HIT in hospitalized obstetric patients who received unfractionated heparin (UFH) or low molecular weight heparin (LMWH). Patients were presumed to have HIT if they were exposed to UFH or LMWH, received a diagnosis of HIT, and were administered a medication for the treatment of HIT including bivalirudin, argatroban, fondaparinux, or lepirudin. We queried severe complications of HIT including arterial thrombosis, limb amputation, heart failure, and death., Results: We identified 66,468 antepartum hospitalizations, 66,741 delivery hospitalizations, and 16,325 postpartum readmissions where women received pharmacologic prophylaxis. Of these, 10 antepartum admissions, 1 delivery admission, and 14 postpartum readmissions involved a diagnosis of HIT with treatment of bivalirudin, argatroban, fondaparinux, or lepirudin. There were no deaths and no diagnoses of arterial thrombosis, limb amputation, heart failure, and death., Conclusion: Risk for HIT among hospitalized obstetric patients is low. In this cohort, no cases of death or severe complications were noted in relation to the diagnosis., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Cesarean delivery has increased steadily in the United States over recent decades with significant downstream health consequences. The World Health Organization has endorsed the Robson 10-Group Classification System as a global standard to facilitate analysis and comparison of cesarean delivery rates., Objective: Our objective was to apply the Robson 10-Group Classification System to a nationwide cohort in the United States over a 10-year period., Study Design: This population-based analysis applied the Robson 10-Group Classification System to all births in the United States from 2005 through 2014, recorded in the 2003 revised birth certificate format. Over the study 10-year period, 27,044,217 deliveries met inclusion criteria. Five parameters (parity including previous cesarean, gestational age, labor onset, fetal presentation, and plurality), identifiable on presentation for delivery, were used to classify all women included into 1 of 10 groups., Results: The overall cesarean rate was 31.6%. Group-3 births (singleton, term, cephalic multiparas in spontaneous labor) were most common, while group-5 births (those with a previous cesarean) accounted for the most cesarean deliveries increasing from 27% of all cesareans in 2005 through 2006 to >34% in 2013 through 2014. Breech pregnancies (groups 6 and 7) had cesarean rates >90%. Primiparous and multiparous women who had a prelabor cesarean (groups 2b and 4b) accounted for over one quarter of all cesarean deliveries., Conclusion: Women with a previous cesarean delivery represent an increasing proportion of cesarean deliveries. Use of the Robson criteria allows standardized comparisons of data and identifies clinical scenarios driving changes in cesarean rates. Hospitals and health organizations can use the Robson 10-Group Classification System to evaluate quality and processes associated with cesarean delivery., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to characterize risk for and temporal trends in postpartum hemorrhage across hospitals with different delivery volumes., Study Design: This study used the Nationwide Inpatient Sample (NIS) to characterize risk for postpartum hemorrhage from 1998 to 2011. Hospitals were classified as having either low, moderate or high delivery volume (≤1000, 1001 to 2000, >2000 deliveries per year, respectively). The primary outcomes included postpartum hemorrhage, transfusion, and related severe maternal morbidity. Adjusted models were created to assess factors associated with hemorrhage and transfusion., Results: Of 55,140,088 deliveries included for analysis 1,512,212 (2.7%) had a diagnosis of postpartum hemorrhage and 361,081 (0.7%) received transfusion. Risk for morbidity and transfusion increased over the study period, while the rate of hemorrhage was stable ranging from 2.5 to 2.9%. After adjustment, hospital volume was not a major risk factor for transfusion or hemorrhage., Discussion: While obstetric volume does not appear to be a major risk factor for either transfusion or hemorrhage, given that transfusion and hemorrhage-related maternal morbidity are increasing across hospital volume categories, there is an urgent need to improve obstetrical care for postpartum hemorrhage. Those risk factors are able to discriminate women at increased risk supports routine use of hemorrhage risk assessment.

Objective: To evaluate temporal trends in use of antihypertensive medications during delivery hospitalizations complicated by preeclampsia and risk of maternal stroke over the same time period., Methods: The Perspective database was used to perform a retrospective cohort study evaluating antihypertensive drugs dispensed during delivery hospitalizations complicated by preeclampsia from 2006 to the first quarter of 2015. Medications evaluated included nifedipine, hydralazine, and oral and intravenous labetalol. Adjusted models for receipt of antihypertensive agents accounting for demographic and hospital factors were created. Hospital-level rates of antihypertensive administration for women with severe preeclampsia were analyzed. Risk of stroke during delivery hospitalization was evaluated., Results: A total of 239,454 patients with preeclampsia were included in the analysis including 126,595 women with mild, 31,628 with superimposed, and 81,231 with severe preeclampsia. Overall, 105,409 women received a hypertensive agent. From 2006 to 2014, for all patients with preeclampsia, receipt of oral labetalol increased from 20.3% to 31.4%, intravenous labetalol from 13.3% to 21.4%, hydralazine from 12.8% to 16.9%, nifedipine from 15.0% to 18.2%, and more than one medication from 16.5% to 25.8%. The proportion of patients with preeclampsia receiving any antihypertensive medication rose from 37.8% in 2006 to 49.4% in 2015. In adjusted models, temporal trends retained significance. Rates of antihypertensive administration for severe preeclampsia varied significantly by hospital. For severe preeclampsia, the risk for stroke decreased from 13.5 per 10,000 deliveries in 2006-2008 (n=27) to 9.7 in 2009-2011 (n=25) to 6.0 in 2012-2014 (n=20) (P=.02)., Conclusion: Use of multiple antihypertensive agents to treat preeclamptic women increased over the study period for women with mild, superimposed, and severe preeclampsia. There was substantial hospital variation in use of antihypertensive agents. This trend was associated with decreased risk of maternal stroke.

Objective: To characterize probabilities of vaginal delivery based on second-stage duration along with maternal and neonatal risks for women undergoing labor after cesarean delivery., Methods: This unplanned secondary analysis of the Maternal-Fetal Medicine Units Cesarean Registry, a prospective observational cohort, assessed outcomes in women with a prior uterine scar and included women with a previous cesarean delivery without prior vaginal delivery who reached the second stage of labor. The primary outcome was mode of delivery by second-stage duration. Secondary outcomes included assessment of individual adverse maternal (chorioamnionitis, atony, endometritis, hysterectomy, uterine rupture or dehiscence, and red cell transfusion) and neonatal (cord pH less than 7.10, Apgar score less than 6 at 5 minutes, neonatal intensive care unit admission, and ventilatory support) outcomes., Results: Of 4,579 women with a previous cesarean delivery who reached the second stage of labor, 4,147 (90.6%) delivered vaginally. As second stage increased, successful vaginal delivery rates decreased: 97.3% at less than 1 hour (95% CI 96.6-97.9%), 91.5% at 1 to less than 2 hours (95% CI 89.8-93.1%), 78.5% at 2 to less than 3 hours (95% CI 74.5-82.1%), 62.3% at 3 to less than 4 hours (95% CI 55.2-69.1%), and 45.6% at 4 hours or greater (95% CI 37.7-53.7%). Risk of all adverse maternal outcomes increased with the length of the second stage. Specifically, risk of uterine rupture or dehiscence increased with second-stage length from less than 1 hour (0.7%), 1 to less than 2 hours (1.4%), 2 to less than 3 hours (1.5%), to 3 hours or greater (3.1%) (P<.001 for differential risk across the second stage). Risk of neonatal outcomes did not differ significantly by second-stage length., Conclusion: Although many women with a longer second stage (greater than 3 hours) will achieve successful vaginal delivery, these patients may be at increased risk for adverse maternal outcomes and should have close observation of fetal heart rate monitoring, maternal vital signs, and symptoms suggestive of uterine rupture or dehiscence.

Objective: The objectives of this study were to determine temporal trends in forceps and vacuum delivery and factors associated with operative vaginal delivery., Design: Retrospective cohort., Setting: Population-based study of US birth records., Population: US births from 2005 to 2013., Methods: This study evaluated forceps and vacuum extraction during vaginal delivery in live-born, non-anomalous singleton gestations from ≥ 36 to < 42 weeks of gestation. The primary outcomes were vacuum, forceps and overall operative delivery. Obstetric, medical and demographic characteristics associated with operative vaginal delivery were analysed. Multivariable logistic regression models were developed to determine factors associated with forceps/vacuum use., Results: A total of 22 598 971 vaginal deliveries between 2005 and 2013 were included in the analysis. In all, 1 083 318 (4.8%) were vacuum-assisted and 237 792 (1.1%) were by forceps. Both vacuum and forceps deliveries decreased over the study period; vacuum deliveries decreased from 5.8% in 2005 to 4.1% in 2013, and forceps deliveries decreased from 1.4% to 0.9% during the same period. The adjusted odds ratio for forceps delivery was 0.70 (95% CI 0.69-0.72) in 2013 with 2005 as a reference. For vacuum delivery the odds ratio was 0.68 (95% CI 0.67-0.69) comparing the same years., Conclusion: Forceps and vacuum deliveries decreased during the study period. Low rates of operative delivery pose a challenge for resident education and may limit the degree to which women have access to alternatives to caesarean delivery. Initiatives that allow future generations of obstetricians to develop expertise in performing operative deliveries in the setting of decreased volume are an urgent resident education priority., Tweetable Abstract: Forceps and vacuum delivery decreased significantly in the USA from 2005 to 2013., (© 2017 Royal College of Obstetricians and Gynaecologists.)

Objective: To characterize the use of venous thromboembolism prophylaxis during antepartum and postpartum hospitalizations in the United States., Methods: A retrospective cohort study using the Perspective database was performed to analyze temporal trends of mechanical and pharmacologic venous thromboembolism prophylaxis for patients hospitalized for antepartum and postpartum indications between 2006 and 2015. Delivery hospitalizations were excluded. The association between use of prophylaxis and medical and obstetric risk factors as well as patient demographic and hospital characteristics was evaluated with unadjusted and adjusted models accounting for demographic, hospital and medical, and obstetric risk factors., Results: A total of 622,740 antepartum and 105,361 postpartum readmissions were identified and included in the analysis. Between 2006 and 2015, use of venous thromboembolism prophylaxis increased from 18.5% to 38.7% for antepartum admissions (adjusted risk ratio [RR] 1.94, 95% CI 1.88-2.01) and from 22.5% to 30.6% for postpartum readmissions (adjusted RR 1.31, 95% CI 1.21-1.43). Among women readmitted postpartum, 56.4% of prophylaxis was pharmacologic and 43.6% was mechanical. For antepartum admissions, 87.2% of prophylaxis was mechanical and 12.8% was pharmacologic. Significant regional and hospital-level variation was noted with prophylaxis most common in the South. In both unadjusted and unadjusted analyses, use of venous thromboembolism prophylaxis was more common for women with thrombophilia, ovarian hyperstimulation syndrome, a history of venous thromboembolism, and prolonged hospitalization. Factors associated with decreased rates of prophylaxis included hyperemesis and postpartum endometritis., Conclusion: Although antepartum and postpartum venous thromboembolism prophylaxis is becoming increasingly common, particularly in the setting of medical or obstetric risk factors, use of prophylaxis varies regionally and on a hospital level. Some risk factors for venous thromboembolism were associated with lower rates of prophylaxis. The heterogeneity of clinical approaches to venous thromboembolism prophylaxis for these patient populations may represent an opportunity to perform outcomes research to further clarify best practices.

Background: There are limited data on how maternal age is related to twin pregnancy outcomes., Objective: The purpose of this study was to assess the relationship between maternal age and risk for preterm birth, fetal death, and neonatal death in the setting of twin pregnancy., Study Design: This population-based study of US birth, fetal death, and period-linked birth-infant death files from 2007-2013 evaluated neonatal outcomes for twin pregnancies. Maternal age was categorized as 15-17, 18-24, 25-29, 30-34, 35-39, and ≥40 years of age. Twin live births and fetal death delivered at 20-42 weeks were included. Primary outcomes included preterm birth (<34 weeks and <37 weeks), fetal death, and neonatal death at <28 days of life. Analyses of preterm birth at <34 and <37 weeks were adjusted for demographic and medical factors, with maternal age modeled with the use of restricted spline transformations., Results: A total of 955,882 twin live births from 2007-2013 were included in the analysis. Preterm birth rates at <34 and <37 weeks gestation were highest for women 15-17 years of age, decreased across subsequent maternal age categories, nadired for women 35-39 years old, and then increased slightly for women ≥40 years old. Risk for fetal death generally decreased across maternal age categories. Risk for fetal death was 39.9 per 1000 live births for women 15-17 years old, 24.2 for women 18-24 years old, 17.8 for women 25-29 years old, 16.4 for women 30-34 years old, 17.2 for women 35-39 years old, and 15.8 for women ≥40 years old. Risk for neonatal death at <28 days was highest for neonates born to women 15-17 years old (10.0 per 1,000 live births), decreased to 7.3 for women 18-24 years old and 5.5 for women 25-29 years old and ranged from 4.3-4.6 for all subsequent maternal age categories. In adjusted models, risk for preterm birth at <34-<37 weeks gestation was not elevated for women in their mid-to-late 30s; however, risk was elevated for women <20 years old and increased progressively with age for women in their 40s., Conclusion: Although twin pregnancy is associated with increased risk for most adverse perinatal outcomes, this analysis did not find advanced maternal age to be an additional risk factor for fetal death and infant death. Preterm birth risk was relatively low for women in their late 30s. Risks for adverse outcomes were higher among younger women; further research is indicated to improve outcomes for this demographic group. It may be reasonable to counsel women in their 30s that their age is not a major additional risk factor for adverse obstetric outcomes in the setting of twin pregnancy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The coordination between minor vein density (MVD) and stomatal density (SD) has been found in many plants. However, we still know little about the influence of leaf node on this correlation relationship. Here, we devised the new functional trait 'stomatal number per minor vein length' (SV). By measuring leaflet area (LA), MVD, SD, and SV, we demonstrated the significance of this functional trait in Arachis hypogaea (peanut) grown under different light regimes and in sun leaves of Dalbergia odorifera and Desmodium renifolium. We found that SV did not change significantly with leaflet node or with LA within each light treatment, while shading caused a significant decrease in SV. The positive correlation between SD and MVD was found in peanut under each light regime. Sun leaves of D. odorifera and D. renifolium also had stable SV along the leaflet node, with a positive correlation between MVD and SD. We conclude that under a certain light regime, a stable SV similar to the positive correlation between MVD and SD can also indicate the coordination between leaf water supply and demand. Our findings highlight the significance of SV and provide new insight into the coordination between stomatal number and minor vein length.

Background: While research has demonstrated increasing risk for severe maternal morbidity in the United States, risk at lower volume hospitals remains poorly characterized. More than half of all obstetric units in the United States perform <1000 deliveries per year and improving care at these hospitals may be critical to reducing risk nationwide., Objective: We sought to characterize maternal risk profiles and severe maternal morbidity at low-volume hospitals in the United States., Study Design: We used data from the Nationwide Inpatient Sample to evaluate trends in severe maternal morbidity and comorbid risk during delivery hospitalizations in the United States from 1998 through 2011. Comorbid maternal risk was estimated using a comorbidity index validated for obstetric patients. Severe maternal morbidity was defined as the presence of any 1 of 15 diagnoses representative of acute organ injury and critical illness., Results: A total of 2,300,279 deliveries occurred at hospitals with annual delivery volume <1000, representing 20% of delivery hospitalizations overall. There were 7849 cases (0.34%) of severe morbidity in low-volume hospitals and this risk increased over the course of the study from 0.25% in 1998 through 1999 to 0.49% in 2010 through 2011 (P < .01). The risk in hospitals with ≥1000 deliveries increased from 0.35-0.62% during the same time periods. The proportion of patients with the lowest comorbidity decreased, while the proportion of patients with highest comorbidity increased the most. The risk of severe morbidity increased across all women including those with low comorbidity scores. Risk for severe morbidity associated with obstetric hemorrhage, infection, hypertensive diseases of pregnancy, and medical conditions all increased during the study period., Conclusion: Our findings demonstrate increasing maternal risk at hospitals performing <1000 deliveries per year broadly distributed over the patient population. Rates of morbidity in centers with ≥1000 deliveries have also increased. These findings suggest that maternal safety improvements are necessary at all centers regardless of volume., (Copyright © 2016 Elsevier Inc. All rights reserved.)