Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight M, Acosta C, Brocklehurst P, Cheshire A, Fitzpatrick K, Hinton L, Jokinen M, Kemp B, Kurinczuk JJ, Lewis G, Lindquist A, Locock L, Nair M, Patel N, Quigley M, Ridge D, Rivero-Arias O, Sellers S, Shah A on behalf of the UKNeS coapplicant group. Background Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.

Diffusion de représentations d’itinéraires adaptées aux personnes à mobilité réduite selon les interfaces multimodales des appareils mobiles

L’accessibilité universelle est de nos jours très importante pour nos villes, car elle permet à toute personne, ayant des incapacités physiques ou non, de mener à bien ses activités socio-professionnelles. À travers le monde, plusieurs projets ont vu le jour comme AXS Map à New York ou AccesSIG en France. Au Canada, un projet multidisciplinaire nommé MobiliSIG ayant pour lieu d’expérimentation la ville de Québec a vu le jour en 2013. L’objectif du projet MobiliSIG est de concevoir et développer une application multimodale d’assistance au déplacement des personnes à mobilité réduite. Ce projet se concentre principalement sur la constitution d’une base de données d’accessibilité se référant au modèle PPH (Processus de Production du Handicap). Nos travaux visent à définir la diffusion d’itinéraires adaptés, adaptables et adaptatifs liés à des contextes multi-utilisateurs, multiplateformes, multimodaux (interfaces et transports) et multi-environnements. Après une revue de littérature et afin d’identifier et définir les besoins liés à cette diffusion des données de navigation, nous nous sommes attelés à la description de plusieurs scénarios pour mieux comprendre les besoins des utilisateurs : planification d’un déplacement et navigation dans le milieu urbain ; parcours multimodal ; recherche d’un point d’intérêt (toilettes accessibles). Cette démarche nous a permis également d’identifier les modes de communication et représentations souhaitées de l’itinéraire (carte, texte, image, parole, …) et de proposer une approche basée sur la transformation de l’itinéraire reçu de la base de données d’accessibilité. Cette transformation est effectuée en tenant compte des préférences de l’utilisateur, de son appareil et de son environnement. La diffusion de l’itinéraire se fait ensuite par un service web de diffusion conçu selon le standard du W3C sur les architectures multimodales (MMI) en combinaison avec le concept de la plasticité des interfaces. Le prototype développé a permis d’avoir comme résultat un système qui diffuse de façon générique l’information de navigation adaptée, adaptable et adaptative à l’utilisateur, à son appareil et à son environnement.

New morpho-bathymetric and tectono-stratigraphic data on Naples and Salerno gulfs (southern tyrrhenian sea, Italy) derived from bathymetric and seismic data analysis and integrated geological interpretation

New morpho-bathymetric and tectono-stratigraphic data on Naples and Salerno Gulfs, derived from bathymetric and seismic data analysis and integrated geologic interpretation are here presented. The CUBE(Combined Uncertainty Bathymetric Estimator) method has been applied to complex morphologies, such as the Capri continental slope and the related geological structures occurring in the Salerno Gulf.The bathymetric data analysis has been carried out for marine geological maps of the whole Campania continental margin at scales ranging from 1:25.000 to 1:10.000, including focused examples in Naples and Salerno Gulfs, Naples harbour, Capri and Ischia Islands and Salerno Valley. Seismic data analysis has allowed for the correlation of main morpho-structural lineaments recognized at a regional scale through multichannel profiles with morphological features cropping out at the sea bottom, evident from bathymetry.Main fault systems in the area have been represented on a tectonic sketch map, including the master fault located northwards to the Salerno Valley half graben. Some normal faults parallel to the master fault have been interpreted from the slope map derived from bathymetric data. A complex system of antithetic faults bound two morpho-structural highs located 20km to the south of the Capri Island. Some hints of compressional reactivation of normal faults in an extensional setting involving the whole Campania continental margin have been shown from seismic interpretation.

Synthesis, characterization and chemical vapor deposition of transition metal di(tert-butyl)amido compounds

Although the transition metal chemistry of many dialkylamido ligands has been well studied, the chemistry of the bulky di(tert-butyl)amido ligand has been largely overlooked. The di(tert-butyl)amido ligand is well suited for synthesizing transition metal compounds with low coordination numbers; such compounds may exhibit interesting structural, physical, and chemical properties. Di(tert-butyl)amido complexes of transition metals are expected to exhibit high volatilities and low decomposition temperatures, thus making them well suited for the chemical vapor deposition of metals and metal nitrides. Treatment of MnBr₂(THF)₂, FeI₂, CoBr₂(DME), or NiBr₂(DME) with two equivalents of LiN(t-Bu)2 in benzene affords the two-coordinate complex M[N(t-Bu)₂]₂, where M is Mn, Fe, Co, or Ni. Crystallographic studies show that the M-N distances decrease across the series: 1.9365 (Mn), 1.8790 (Fe), 1.845 (Co), 1.798 Å (Ni). The N-M- N angles are very close to linear for Mn and Fe (179.30 and 179.45°, respectively), but bent for Co and Ni (159.2 and 160.90°, respectively). As expected, the d⁵ Mn complex has a magnetic moment of 5.53 μΒ that is very close to the spin only value. The EPR spectrum is nearly axial with a low E/D ratio of 0.014. The d⁶ Fe compound has a room temperature magnetic moment of 5.55 μΒ indicative of a large orbital angular momentum contribution. It does not exhibit a Jahn-Teller distortion despite the expected doubly degenerate ground state. Applied field Mössbauer spectroscopy shows that the effective internal hyperfine field is unusually large, Hint = 105 T. The magnetic moments of Co[N(t-Bu)₂]₂ and Ni[N(t-Bu)₂]₂ are 5.24 and 3.02 μΒ respectively. Both are EPR silent at 4.2 K. Treatment of TiCl₄ with three equivalents of LiN(t-Bu)2 in pentane affords the briding imido compound Ti₂[μ-N(t-Bu)]₂Cl₂[N(t-Bu)₂]₂ via a dealkylation reaction. Rotation around the bis(tert-butyl)amido groups is hindered, with activation parameters of ΔH‡ = 12.8 ± 0.6 kcal mol-1 and ΔS‡ = -8 ± 2 cal K-1 ·mol-1, as evidenced by variable temperature 1H NMR spectroscopy. Treatment of TiCl₄ with two equivalents of HN(t-Bu)₂ affords Ti₂Cl₆[N(t-Bu)₂]₂. This complex shows a close-contact of 2.634(3) Å between Ti and the carbon atom of one of the CH₃ substituents on the tert-butyl groups. Theoretical considerations and detailed structural comparisons suggest this interaction is not agostic in nature, but rather is a consequence of interligand repulsions. Treatment of NiI₂(PPh3)₂ and PdCl₂(PPh₃)₂ with LiN(t-Bu)₂in benzene affords Ni[N(t-Bu)₂](PPh₃)I and Pd₃(μ₂-NBut₂)2(μ₂-PPh₂)Ph(PPh₃) respectively. The compound Ni[N(t-Bu)₂](PPh₃)I has distorted T-shape in geometry, whereas Pd₃(μ₂-NBut₂)₂(μ₂-PPh₂)Ph(PPh₃) contains a triangular palladium core. Manganese nitride films were grown from Mn[N(t-Bu)₂]₂ in the presence of anhydrous ammonia. The growth rate was several nanometers per minute even at the remarkably low temperature of 80⁰C. As grown, the films are carbon- and oxygen-free, and have a columnar morphology. The spacings between the columns become smaller and the films become smoother as the growth temperature is increased. The composition of the films is consistent with a stoichiometry of Mn₅N₂.