Hemostatic assessment, treatment strategies, and hematology consultation in massive postpartum hemorrhage: results of a quantitative survey of obstetrician-gynecologists.

OBJECTIVE: To assess potential diagnostic and practice barriers to successful management of massive postpartum hemorrhage (PPH), emphasizing recognition and management of contributing coagulation disorders. STUDY DESIGN: A quantitative survey was conducted to assess practice patterns of US obstetrician-gynecologists in managing massive PPH, including assessment of coagulation. RESULTS: Nearly all (98%) of the 50 obstetrician-gynecologists participating in the survey reported having encountered at least one patient with "massive" PPH in the past 5 years. Approximately half (52%) reported having previously discovered an underlying bleeding disorder in a patient with PPH, with disseminated intravascular coagulation (88%, n=23/26) being identified more often than von Willebrand disease (73%, n=19/26). All reported having used methylergonovine and packed red blood cells in managing massive PPH, while 90% reported performing a hysterectomy. A drop in blood pressure and ongoing visible bleeding were the most commonly accepted indications for rechecking a "stat" complete blood count and coagulation studies, respectively, in patients with PPH; however, 4% of respondents reported that they would not routinely order coagulation studies. Forty-two percent reported having never consulted a hematologist for massive PPH. CONCLUSION: The survey findings highlight potential areas for improved practice in managing massive PPH, including earlier and more consistent assessment, monitoring of coagulation studies, and consultation with a hematologist.

Dance Based Music on Piano

According to the Merriam-Webster dictionary, the definition of dance is “to move your body in a way that goes with the rhythm and style of music that is being played.” As you can see in that definition, these two important ways of expressing human feelings, music and dance, are very closely related. Countless pieces of music have been composed for dance, and are still being composed. It is impossible and useless to count how many kinds of dances exist in the world. Different kinds of dances have been developed according to their purposes, cultures, rhythm and tempo. For this reason, the field of dance-related music necessarily expanded significantly. A great deal of dance music has been written for orchestras, small ensembles, or vocals. Along with them, keyboard music also has a huge repertoire of dance pieces. For example, one of the most famous form in Baroque period was suites. Suites usually include 5 or more dance movements in the same key, such as Minuet, Allemende, Courant, Sarabande, Gigue, Bourree, Gavotte, Passepied, and so on. Nationalistic dances like waltz, polonaise, mazurka, and tarantella, were wonderful sources for composers like Chopin, Brahms, and Tchaikovsky. Dance-based movements were used for Mozart and Beethoven’s piano sonatas, chamber works and concertos. Composers have routinely traveled around the world to collect folk and dance tunes from places they visit. For example, Bartok and Balakirev's pieces that are based on folk dances from where they had traveled became famous and are still thought to be valuable for studying and performing today. For these reasons, it is clear that dance-related music is a very important part of keyboard music. In three dissertation recitals, to expand my performing repertoire and to understand dance-related music deeper, I tried to explore many different styles of dances, and compare interpretations between composers. This program note contains information about each pieces’ composers, related dances, and backgrounds. I hope this will be helpful for a future performer who’s seeking an effective dance based keyboard piece.

Dolutegravir plus Abacavir-Lamivudine for the treatment of HIV-1 infection

BACKGROUND: Dolutegravir (S/GSK1349572), a once-daily, unboosted integrase inhibitor, was recently approved in the United States for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in combination with other antiretroviral agents. Dolutegravir, in combination with abacavir-lamivudine, may provide a simplified regimen. METHODS: We conducted a randomized, double-blind, phase 3 study involving adult participants who had not received previous therapy for HIV-1 infection and who had an HIV-1 RNA level of 1000 copies per milliliter or more. Participants were randomly assigned to dolutegravir at a dose of 50 mg plus abacavir-lamivudine once daily (DTG-ABC-3TC group) or combination therapy with efavirenz-tenofovir disoproxil fumarate (DF)-emtricitabine once daily (EFV-TDF-FTC group). The primary end point was the proportion of participants with an HIV-1 RNA level of less than 50 copies per milliliter at week 48. Secondary end points included the time to viral suppression, the change from baseline in CD4+ T-cell count, safety, and viral resistance. RESULTS: A total of 833 participants received at least one dose of study drug. At week 48, the proportion of participants with an HIV-1 RNA level of less than 50 copies per milliliter was significantly higher in the DTG-ABC-3TC group than in the EFV-TDF-FTC group (88% vs. 81%, P = 0.003), thus meeting the criterion for superiority. The DTG-ABC-3TC group had a shorter median time to viral suppression than did the EFV-TDF-FTC group (28 vs. 84 days, P<0.001), as well as greater increases in CD4+ T-cell count (267 vs. 208 per cubic millimeter, P<0.001). The proportion of participants who discontinued therapy owing to adverse events was lower in the DTG-ABC-3TC group than in the EFV-TDF-FTC group (2% vs. 10%); rash and neuropsychiatric events (including abnormal dreams, anxiety, dizziness, and somnolence) were significantly more common in the EFV-TDF-FTC group, whereas insomnia was reported more frequently in the DTG-ABC-3TC group. No participants in the DTG-ABC-3TC group had detectable antiviral resistance; one tenofovir DF-associated mutation and four efavirenz-associated mutations were detected in participants with virologic failure in the EFV-TDF-FTC group. CONCLUSIONS: Dolutegravir plus abacavir-lamivudine had a better safety profile and was more effective through 48 weeks than the regimen with efavirenz-tenofovir DF-emtricitabine. Copyright © 2013 Massachusetts Medical Society.

Characterization of immunoregulatory T lymphocytes during ageing by monoclonal antibodies.

Monoclonal antibodies of the OKT series were used to identify T lymphocytes (OKT3+) and their inducer (OKT4+) and suppressor-cytotoxic (OKT8+) subsets in the peripheral blood mononuclear cells (PBMC) of 32 healthy old-aged people more than 70 years old (16 men and 16 women) compared to 47 adults (29 men, 18 women) less than 40 years old. The absolute lymphocyte count in the peripheral blood was not significantly influenced by age or sex. Both the proportions and the absolute numbers of T3+ and T4+ cells were significantly lower in aged than in young participants. The proportions but not the absolute counts of OKT8+ cells were higher in the elderly. Most interesting is the influence of sex and these parameters. Old women have normal numbers and proportions of T3+, T4+ and T8+ cells when compared to young women. The latter have a significantly higher proportion of T8+ cells than young adult males. Old men have a striking reduction of both the numbers and proportions of OKT3+ and OKT4+ cells when compared with young men and with women. In addition, old men have an elevated proportion, but a normal absolute number, of OKT8+ cells. The responses of PBMC to phytohaemagglutinin extent (PHA), concanavalin A (Con A) and pokeweed mitogen (PWM) are reduced to the same extent in ageing male and female subjects when compared to young adults. In the older group, the magnitude of the lymphocyte response to PHA and Con A but not to PWM is negatively correlated with the proportions of OKT8+ cells. Surprisingly, these correlations are observed only in old women but not in old men. The latter finding excludes the possibility that the age-associated decline of the lymphocyte response to T cell mitogens is secondary to an imbalance between T4+ and T8+ lymphocytes.

LPS-binding protein and IL-6 Mark paradoxical tuberculosis immune reconstitution inflammatory syndrome in HIV patients

Background: Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) remains a poorly understood complication in HIV-TB co-infected patients initiating antiretroviral therapy (ART). The role of the innate immune system in TB-IRIS is becoming increasingly apparent, however the potential involvement in TB-IRIS of a leaky gut and proteins that interfere with TLR stimulation by binding PAMPs has not been investigated before. Here we aimed to investigate the innate nature of the cytokine response in TB-IRIS and to identify novel potential biomarkers. Methods: From a large prospective cohort of HIV-TB co-infected patients receiving TB treatment, we compared 40 patients who developed TB-IRIS during the first month of ART with 40 patients matched for age, sex and baseline CD4 count who did not. We analyzed plasma levels of lipopolysaccharide (LPS)-binding protein (LBP), LPS, sCD14, endotoxin-core antibody, intestinal fatty acid-binding protein (I-FABP) and 18 pro-and anti-inflammatory cytokines before and during ART. Results: We observed lower baseline levels of IL-6 (p = 0.041), GCSF (p = 0.036) and LBP (p = 0.016) in TB-IRIS patients. At IRIS event, we detected higher levels of LBP, IL-1RA, IL-4, IL-6, IL-7, IL-8, G-CSF (p ≤ 0.032) and lower I-FABP levels (p = 0.013) compared to HIV-TB co-infected controls. Only IL-6 showed an independent effect in multivariate models containing significant cytokines from pre-ART (p = 0.039) and during TB-IRIS (p = 0.034). Conclusion: We report pre-ART IL-6 and LBP levels as well as IL-6, LBP and I-FABP levels during IRIS-event as potential biomarkers in TB-IRIS. Our results show no evidence of the possible contribution of a leaky gut to TB-IRIS and indicate that IL-6 holds a distinct role in the disturbed innate cytokine profile before and during TB-IRIS. Future clinical studies should investigate the importance and clinical relevance of these markers for the diagnosis and treatment of TB-IRIS. Copyright: © 2013 Goovaerts et al.

Antigen-specific interferon-gamma responses and innate cytokine balance in TB-IRIS.

Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) remains a poorly understood complication in HIV-TB patients receiving antiretroviral therapy (ART). TB-IRIS could be associated with an exaggerated immune response to TB-antigens. We compared the recovery of IFNγ responses to recall and TB-antigens and explored in vitro innate cytokine production in TB-IRIS patients.

Are the reference values of B cell subpopulations used in adults for classification of common variable immunodeficiencies appropriate for children?

Detailed phenotypic characterization of B cell subpopulations is of utmost importance for the diagnosis and management of humoral immunodeficiencies, as they are used for classification of common variable immunodeficiencies. Since age-specific reference values remain scarce in the literature, we analysed by flow cytometry the proportions and absolute values of total, memory, switched memory and CD21(-/low) B cells in blood samples from 168 healthy children (1 day to 18 years) with special attention to the different subpopulations of CD21(low) B cells. The percentages of total memory B cells and their subsets significantly increased up to 5-10 years. In contrast, the percentages of immature CD21(-) B cells and of immature transitional CD21(low)CD38(hi) B cells decreased progressively with age, whereas the percentage of CD21(low) CD38(low) B cells remained stable during childhood. Our data stress the importance of age-specific reference values for the correct interpretation of B cell subsets in children as a diagnostic tool in immunodeficiencies.

Cross-sectional study of 168 patients with hepatorenal tyrosinaemia and implications for clinical practice

Background: Hepatorenal tyrosinaemia (Tyr 1) is a rare inborn error of tyrosine metabolism. Without treatment, patients are at high risk of developing acute liver failure, renal dysfunction and in the long run hepatocellular carcinoma. The aim of our study was to collect cross-sectional data. Methods. Via questionnaires we collected retrospective data of 168 patients with Tyr 1 from 21 centres (Europe, Turkey and Israel) about diagnosis, treatment, monitoring and outcome. In a subsequent consensus workshop, we discussed data and clinical implications. Results: Early treatment by NTBC accompanied by diet is essential to prevent serious complications such as liver failure, hepatocellular carcinoma and renal disease. As patients may remain initially asymptomatic or develop uncharacteristic clinical symptoms in the first months of life newborn mass screening using succinylacetone (SA) as a screening parameter in dried blood is mandatory for early diagnosis. NTBC-treatment has to be combined with natural protein restriction supplemented with essential amino acids. NTBC dosage should be reduced to the minimal dose allowing metabolic control, once daily dosing may be an option in older children and adults in order to increase compliance. Metabolic control is judged by SA (below detection limit) in dried blood or urine, plasma tyrosine (<400 μM) and NTBC-levels in the therapeutic range (20-40 μM). Side effects of NTBC are mild and often transient. Indications for liver transplantation are hepatocellular carcinoma or failure to respond to NTBC. Follow-up procedures should include liver and kidney function tests, tumor markers and imaging, ophthalmological examination, blood count, psychomotor and intelligence testing as well as therapeutic monitoring (SA, tyrosine, NTBC in blood). Conclusion: Based on the data from 21 centres treating 168 patients we were able to characterize current practice and clinical experience in Tyr 1. This information could form the basis for clinical practice recommendations, however further prospective data are required to underpin some of the recommendations.

Predicting optimal process conditions for flip-chip aassembly using copper column bumped dies

Recently, research has been carried out to test a novel bumping method which omits the under bump metallurgy (UBM) forming process by bonding copper columns directly onto the Al pads of the silicon dies. This bumping method could be adopted to simplify the flip chip assembly process, increase the productivity and achieve a higher I/O count. Computer modelling methods are used to predict the shape of solder joints and response of the flip chip to thermal cyclic loading. The accumulated plastic strain energy at the comer solder joints is used as the damage indicator. Models with a range of design parameters have been compared for their reliability. The ranking of the relative importance of these parameters is given. Results from these analyses are being used by our industrial and academic partners to identify optimal design conditions.

Computer modelling of the reliability of flip chips with metal column bumping

Recently, research has been carried out to test a novel bumping method which omits the under bump metallurgy forming process by bonding copper columns directly onto the Al pads of the silicon dies. This bumping method could be adopted to simplify the flip chip manufacturing process, increase the productivity and achieve a higher I/O count. This paper describes an investigation of the solder joint reliability of flip-chips based on this new bumping process. Computer modelling methods are used to predict the shape of solder joints and response of flip chips to thermal cyclic loading. The accumulated plastic strain energy at the comer solder joints is used as the damage indicator. Models with a range of design parameters have been compared for their reliability. The parameters that have been investigated are the copper column height, radius and solder volume. The ranking of the relative importance of these parameters is given. For most of the results presented in the paper, the solder material has been assumed to be the lead-free 96.5Sn3.5Ag alloy but some results for 60Sn40Pb solder joints have also been presented.

Shear strength analysis of ball grid array (BGA) solder interfaces

Ball shear test is the most common test method used to assess the reliability of bond strength for ball grid array (BGA) packages. In this work, a combined experimental and numerical study was carried out to realize of BGA solder interface strength. Solder mask defined bond pads on the BGA substrate were used for BGA ball bonding. Different bond pad metallizations and solder alloys were used. Solid state aging at 150degC up to 1000 h has been carried out to change the interfacial microstructure. Cross-sectional studies of the solder-to-bond pad interfaces was conducted by scanning electron microscopy (SEM) equipped with an energy dispersive X-ray (EDX) analyzer to investigate the interfacial reaction phenomena. Ball shear tests have been carried out to obtain the mechanical strength of the solder joints and to correlate shear behaviour with the interfacial reaction products. An attempt has been taken to realize experimental findings by Finite Element Analysis (FEA). It was found that intermetallic compound (IMC) formation at the solder interface plays an important role in the BGA solder bond strength. By changing the morphology and the microchemistry of IMCs, the fracture propagation path could be changed and hence, reliability could be improved

A modelling approach for coupling numerical analytical techniques applied in microsystems

In this paper, a method for the integration of several numerical analytical techniques that are used in microsystems design and failure analysis is presented. The analytical techniques are categorized into four groups in the discussion, namely the high-fidelity analytical tools, i.e. finite element (FE) method, the fast analytical tools referring to reduced order modeling (ROM); the optimization tools, and probability based analytical tools. The characteristics of these four tools are investigated. The interactions between the four tools are discussed and a methodology for the coupling of these four tools is offered. This methodology consists of three stages, namely reduced order modeling, deterministic optimization and probabilistic optimization. Using this methodology, a case study for optimization of a solder joint is conducted. It is shown that these analysis techniques have mutual relationship of interaction and complementation. Synthetic application of these techniques can fully utilize the advantages of these techniques and satisfy various design requirements. The case study shows that the coupling method of different tools provided by this paper is effective and efficient and it is highly relevant in the design and reliability analysis of microsystems

For the record

Discusses her film, For the Record, the making of which was funded by the Arts and Humanities Research Council. The research material used in the making of FOR THE RECORD consists of official records, private diaries, personal testimony, historical expert interviews and archive footage - all related to the Internment period 1956-1960 in Northern Ireland. Through the use of clips from the film and footage that did not make it into the final cut, this talk examines how selected material is used and to what purpose. FOR THE RECORD is a film about a daughter documenting a period in her father's life and centres on PJ McClean's prison diary, secretly written on the inside of envelopes during the first 30 days in his cell. This brings the viewer into the intimate space of personal testimony. This intimacy is also reflected in the interviews between father and daughter. Throughout the film the diaries are illustrated by experimental Super8 and 16mm footage shot by the filmmaker, over a period of 10 years, of home life. The film unravels the complex story of internment; the why, the how and the ‘for what’? Official records obtained from the Public Records Office Northern Ireland (which have been closed to the public for the past fifty years) combine with archive footage of the then Northern Irish Prime Minister, Basil Brookeborough, to give a wider political perspective to this personal testament. FOR THE RECORD deals with memory, memorabilia and the question of testimony in a complex political landscape. [From the Author]

Decadal basin-scale changes in diatoms, dinoflagellates, and phytoplankton color across the North Atlantic

The Continuous Plankton Recorder (CPR) survey has been used to characterize phytoplankton and zooplankton space-time dynamics in the North Sea since 1931 and in the North Atlantic since 1939. Phytoplankton biomass is assessed from these samples by visual assessment of the green color of the silk mesh, the Phytoplankton Color Index (PCI), and the total count of diatoms and dinoflagellates. Species with a frequency of occurrence greater than 1% in the samples are used as indicator species of the community. We investigated (1) long-term fluctuations of phytoplankton biomass, total diatoms, and total dinoflagellates; (2) geographical variation of patterns; (3) the relationship between phytoplankton and climate forcing in the North Atlantic CPR samples; (4) the relative contribution of diatoms and dinoflagellates to the PCI; and (5) the fluctuations of the dominant species over the period of survey to provide more information on the processes linking climate to changes in the phytoplankton community. As a result of the differences in microscopic analysis methods prior to 1958, our analyses were conducted for the period ranging from 1958 to 2002. The North Atlantic was divided into six regions identified through bathymetric criteria and separated along a North-South axis. Based on 12 monthly time series, we demonstrate increasing trends in PCI and total dinoflagellates and a decrease in total diatoms.

Statistical Procedure For Estimating Grey Seal Pup Production From A Single Census

The variable start and duration of the Grey seal breeding season makes the estimation of total pup production from a single census very difficult. Classifying the count into morphological age classes enables the form and timing of the birth rate curve and estimates of pup mortality rates to be elucidated. A simulation technique is described which enables the duration of each morphological stage to be determined from a series of such classified counts taken over one season. A further statistical technique uses these estimates to calculate the mean timing and duration of the breeding season from a single classified count taken from similar populations in subsequent years. This information allows total pup production to be calculated for any appropriate breeding colony. Some guidance is given as to the optimal timing of that single census which would yield the best estimate of production, although the precise date is not critical to the success of the technique. Results from single census estimates obtained in this way are compared with known production data from more detailed surveys for a number of different colonies.