Specific Maneuvers Research Articles

Delivering Urgent Care Using Telemedicine: Insights from Experienced Clinicians at Academic Medical Centers

BackgroundCare delivered using telemedicine has been steadily growing in the USA but represented a small fraction of overall visits before the COVID-19 pandemic as few clinicians had been providing care using telemedicine. Understanding how experienced clinicians have practiced telemedicine can help guide today’s exponential adoption of telemedicine.ObjectiveThe objective of this study was to explore barriers and facilitators to providing effective, high-quality urgent care using telemedicine (“tele-urgent care”) from the perspective of clinicians experienced in telemedicine.ApproachWe conducted semi-structured interviews between July 2018 and March 2019 of clinicians who had been providing tele-urgent care services to patients as a part of their routine clinical practice. Themes were identified using content analysis with a constant comparative coding approach.Key ResultsAmong the 20 clinicians interviewed, the majority were female (90%) and nurse practitioners (65%). We identified four themes related to barriers and facilitators to providing effective, high-quality tele-urgent care. Workplace factors such as a strong information technology (IT) infrastructure, real-time IT support, an electronic health record, and a collegial work environment, often virtual, were necessary standards. Communication and exam techniques from in-person encounters were adapted to tele-urgent care including active listening skills and teaching patients to conduct specific exam maneuvers virtually. The convenience of tele-urgent care should be preserved to support improvements in access to care. Finally, patients and clinicians occasionally had mismatched expectations about what could or would be provided during a tele-urgent care encounter. Managing the added tension that can occur during a telemedicine encounter was important.ConclusionAs telemedicine becomes an integral part of the care continuum, incorporating and accounting for these key insights when we train and support clinicians will be necessary to provide effective, high-quality care to patients in the future.

Parameter influence analysis in an optimized fuzzy stability control for a four-wheel independent-drive electric vehicle

This paper presents an optimized fuzzy logic control (FLC) applied to four-wheel independent-drive electric vehicles (FWID-EVs). The controller is developed to act as an Electronic Differential (ED), which changes the in-wheel motors torques to correct the vehicle trajectory during some specific maneuvers. The simulation determines the rotation, the lateral and longitudinal displacement of the vehicle, in which the nonlinear Magic Formula is applied to define the tires slip, associated with the load transfer during curves or drive/break situations and with the steering input. According to the literature, several parameters are used to provide stability controls of similar vehicles, for example, the sideslip angle and yaw rate. Therefore, a parameter influence analysis is carried out to find out the most relevant parameters to be monitored in the investigated FWID-EV. Once the relevant input parameters are defined, an optimum ED FLC is developed by means of a genetic algorithm multi-objective optimization with the objective of minimizing the trajectory error of the FWID-EV under a combination of the Sine with Dwell and constant steering standard maneuvers. The results show the best control configuration is a combination of steer and sideslip angles, with a reduced number of rules and less processing time (0.71 s). Besides, the proposed control presents a reduction in the trajectory error, improvement up to 95.1%, emphasizing that the parameter influence analysis allows finding an optimum, more efficient, and time-saving control solution. Therefore, a simple adjustment in the variables inputs can decrease the control process, without overshadowing the dynamic behavior.

Passengers’ acceptance and perceptions of risk while riding in an automated vehicle on open, public roads

Automated vehicles are an emerging technology that operate with differing levels of automatic control (SAE levels). The current study explored participants’ acceptance of a conditional (Level 3) automated vehicle (AV) before and after riding as a passenger for 10 min on open, public roads in uncontrolled traffic. Additionally, participants were asked to rate the riskiness (perceived risk) of a variety of vehicle maneuvers, such as turning, accelerating, and braking when approaching an intersection. We predicted that participants would report higher acceptance ratings and lower perceived risk ratings after experiencing the AV compared to pre-trip ratings. Further, we predicted that participants riding in the front-passenger seat would report higher ratings for risk compared to participants sitting in the rear-passenger or rear-driver seats. Sixty participants from South-East Queensland, Australia (aged 21–82 years; Mage = 45.78; 23 female) took part in the study. Compared to pre-trip responses, participants reported statistically higher ratings for acceptance, as well as statistically lower ratings for perceived risk with respect to specific vehicle maneuvers performed while in automated mode. Differences were detected between seats for perceived risk, but these results were less clear. Increases in acceptance and decreases in risk were also detected as the number of false hazards detected by the vehicle increased. Overall, these findings suggest that acceptance towards AVs may increase, and expectations of risk related to AV maneuvers may decrease, after participants have experienced the vehicles firsthand, on an open, public road in an uncontrolled traffic environment.

A calibration method of DVL in integrated navigation system based on particle swarm optimization

In the underwater SINS/DVL integrated navigation system, the calibration problem between SINS and DVL sensors is one of the critical factors affecting the accuracy of integrated navigation. Traditional calibration methods usually require long-term filter estimation or require the vehicle to operate specific maneuvers, which have limitations. In this paper, a DVL calibration algorithm using a particle swarm optimization (PSO) algorithm is proposed. The SINS/GPS integrated navigation velocity and DVL output velocity are constructed into two point sets, thereby converting the calibration problem into a Wahba problem and using the particle swarm optimization algorithm to solve the optimal rotation matrix. Simulation experiments and semi-physical experiments show that the proposed calibration method can quickly and accurately estimate the scale factor and installation misalignment angle between SINS and DVL sensors, and the integrated navigation accuracy after calibration is significantly improved. Compared with the conventional calibration approaches, the calibration performance of the proposed method is better.

Survey of Occupational Therapy Driver Assessors' Rehabilitation Interventions With Older Drivers.

The rehabilitation strategies used by occupational therapy driver assessors with older drivers with age-related decline or health conditions are not well understood. The objective of the study was to describe driver rehabilitation interventions used by Australian driver assessors, identify factors that guide rehabilitation choices, and identify barriers and facilitators encountered. An online survey was emailed to 300 driver assessors. Descriptive statistics were used to summarize and to rank order participant responses. A total of 148 respondents selected from a combined total of 655 interventions. The four most common rehabilitation methods were (a) graded driving (18%, n = 118), (b) practicing specific maneuvers (17.7%, n = 116), (c) using a modified vehicle (16.9%, n = 111), and (d) graded driving in local areas only (15.1%, n = 99). The most common barrier limiting driver rehabilitation was cost (M = 2.92, SD = 1.24). The most frequently used driver rehabilitation method was on-road training. Practice can be enhanced by collating and evaluating resources, and ensuring effective interventions are more accessible.

Prospective study to evaluate the value of Identification of nerves crossing inguinal canal during inguinal mesh hernioplasty

Abstract Background Long-term morbidity associated with open inguinal hernia repair mainly consists of postoperative chronic pain. The mechanism responsible for the development of this postoperative pain is thought to be the entrapment, inflammation, and fibrotic reactions of the nerve around the mesh. Aim of the Work To analyse and provide comprehensive data on their incidence (identification rates), anatomical characteristics, and possible sources of heterogenecity, to decrease the risk of iatrogenic injury/ entrapment to these nerves during inguinal hernioplasty. Patients and Methods This study identified 40 patients who underwent inguinal hernia repairs with either routine repair or nerve identification and preservation. As several studies point out, a nerve-recognizing procedure is a logical step for minimizing postoperative groin pain. Such an approach can be advocated for two reasons: identification of the nerves for preservation or for performing standard neurectomy in case of interference with the position of the mesh. Results In the present study, there was no difference in pain scorings at one or 3-months after repair between different surgical techniques in patients undergoing open repair of a primary inguinal hernia. In present work, in addition to identifying and preserving all neural structures, specific maneuvers have been adopted for preventing postherniorrhaphy inguinodynia Conclusion The results indicated that routine nerve identification and preservation was associated with a significantly lower incidence of postoperative neuralgia compared with no nerve identification.

MEMS Vaporazing Liquid Microthruster: A Comprehensive Review

The interest in developing efficient nano and pico-satellites has grown in the last 20 years. Secondary propulsion systems capable of serving specific maneuvers are an essential part of these small satellites. In particular, Micro-Electro-Mechanical Systems (MEMS) Vaporizing Liquid Microthrusters (VLM), using water as a propellant, represent today a smart choice in terms of simplicity and cost. In this paper, we first propose a review of the international literature focused on MEMS VLM development, reviewing the different geometries and heating solutions proposed in the literature. Then, we focus on a critical aspect of these micro thrusters: the presence of unstable phenomena. In particular, the boiling instabilities and reverse channel flow substantially impact the MEMS VLMs’ performance and limit their applicability. Finally, we review the research focused on the passive and active control of the boiling instabilities, based on VLM geometry optimization and active heating strategies, respectively. Today, these ones represent the two principal research axes followed by the scientific community to mitigate the drawbacks linked to the use of MEMS VLMs.

Low Back Pain In A Basketball Player

HISTORY: 16 year old basketball player presenting with low back pain for 1 year, worsening for 1 month, with night pain for 1 week. No acute injury. Pain at low back and sacrum, worse with flexion. Denies radicular symptoms in lower extremities, bowel/bladder incontinence, gait instability, saddle anesthesia. Recently developed fatigue, anorexia, and urinary hesitancy - requires bladder pressure for voiding. ED eval with neg x-rays; PCP eval with urgent referral to Ortho clinic. PHYSICAL EXAMINATION: Neuro: CN II-XII grossly intact. Normal muscle bulk/tone, slightly guarded gait. MSK: Lumbar spine/Sacrum/Coccyx. Inspection: No ecchymosis or deformity. Palpation: TTP at L2-L5 spinous processes, sacrum, coccyx. No TTP at SI joints, iliac crests, thoracic spine. ROM: 40 deg flexion with pain, 20 deg extension, 20 deg lat bending, 20 deg lat rotation. Neurovascular: Distally NVI, brisk pulses, 2 sec cap refill, sensation intact. 2+ DTRs bilateral patellar and Achilles tendons. No clonus. Special maneuvers: Neg Hyperextension test in prone, Neg SLR test. Neg Slump test. Neg FABER test. Hip ROM full, pain free. Anal sphincter tone normal, perineum sensation intact per PCP. DIFFERENTIAL DIAGNOSIS: 1. Spondylolysis/Spondylolisthesis 2. Syringomyelia 3. Ewing Sarcoma/Osteosarcoma TEST AND RESULTS: XR Sacrum/Coccyx: No visible fracture or malalignment. No significant abnormality in visualized portion of the lumbar spine. Soft tissues radiographically normal. MRI Pelvis: Intradural mass extending at S2-S4 level (measures 1.3 x 2.9 x 5.5 cm), likely impinging cauda equine roots at these levels. Mass causes scalloping of posterior aspects of S3-S4 vertebral bodies. Mass heterogeneous on T1/T2 with peripheral enhancement, but no definite centralenhancement. No definite extension through sacral ala. May represent filum terminale (myxopapillary) ependymoma. Meningioma or nerve sheath tumors less likely, given lack of central enhancement. FINAL WORKING DIAGNOSIS: Ewing Sarcoma TREATMENT AND OUTCOMES: 1. Admission to Neurosurgery. Sacral laminectomy/resection of intradural extramedullary spine tumor 2. Radiation therapy complete (5 mos) 3. Chemotherapy complete (10 mos) 4. Pediatric Urology: urinary hesitancy resolved 5. Surveillance q 3 months with serial imaging 6. Return to activity as tolerated

The value of listening and listening for values in conservation

Abstract Listening is a pervasive and significant act of conservation research and praxis, mattering greatly for the realisation of conservation agendas, not least its ambitions to be outward looking and inclusive in approach. Yet, the value and role of listening has been barely explored in a sustained and reflexive way. This paper is a preliminary schematic of what it might mean to attend to the act of listening, set within the context of a larger field of listening scholarship as well as more specific manoeuvres to embed relational approaches into the study of people and nature interactions. We explore what it means to 'listen well' within the context of conservation, highlighting the importance of recognising listening as a relationship and our positions and power within those relationships; the need to care for the relationship through respect and empathy; and the building of inclusive relationships of listening by attending to how space and time influences understanding. We offer examples of how researchers and practitioners can create spaces for listening, illustrating our discussion with personal reflections about listening practices gained through our various conservation and research careers. We provide approaches and ideas which help the reader—academic and practitioner—to both understand and articulate the value of listening in conservation and relational values of nature. We hope to inspire the wider use of listening‐based approaches in conservation research and practice, and the recognition and support from senior managers and funders of what is needed to promote long‐term and meaningful relationships between people and nature. A free Plain Language Summary can be found within the Supporting Information of this article.

Increase of the clivus-canal angle in patients with basilar invagination, without atlantoaxial displacement, treated with a simple maneuver of indirect decompression of the odontoid with the head clamp, during posterior occipitocervical arthrodesis.

Background: Basilar invagination (BI) can be defined as the insinuation of the content of the craniovertebral junction through the foramen magnum toward the posterior fossa. BI is a prevalent condition in Northeast Brazil. The present study describes the changes in the clivus-canal angle (CCA) in the postoperative period in patients with symptomatic BI operated by a posterior approach, using a simple technique of indirect reduction of the odontoid associated with occipitocervical fixation.Methods: Patients underwent radiological evaluations by magnetic resonance imaging in the pre and postoperative periods, where the height of the odontoid tip was measured in relation to the Chamberlain line and the ACC. All patients underwent posterior occipitocervical fixation with specific maneuvers of distraction and extension of the cephalic segment with the aid of a head clamp with three fixation points for anterior reduction of the odontoid.Results: Among the 8 patients evaluated in the series, all had increased ACC in the postoperative period, with a mean of 14.81 ± 1.54°, and statistically significant difference between the pre and postoperative periods (P < 0.05).Conclusion: The indirect surgical reduction of the odontoid process by a posterior approach through the manipulation (distraction-extension) of a “Mayfield” type of head clamp followed by occipitocervical fixation proved to be effective in improving the ACC, being easily reproducible.

House mice in human habitats are street-smart

I remember the first time I took the New York City subway. The station was vibrant with a mix of passengers waiting for their train and a few subway rodents scurrying away with discarded food. Does living in an urban environment make such animals better at solving challenging tasks to find food? Researchers Lara Vrbanec, Vanja Matijević and Anja Guenther from the Max Planck Institute for Evolutionary Biology, Germany, studied the problem-solving abilities of three subspecies of house mice that have lived in human-altered environments for different evolutionary periods.The house mouse, Mus musculus, has been living with humans for around 13,000 years. During this time, it has evolved into three subspecies: M. m. domesticus (western house mouse) appeared 11,000–13,000 years ago, M. m. musculus evolved 8000 years ago, and then M. m. castaneus turned up approximately 3000 years ago. Although we know the ecological impacts of humans on house mice, our influence on the intelligence of mice was unknown. Animals that can adapt their behaviour to novel circumstances are likely to be more successful in changing environments. So, the scientists wondered whether the mice subspecies that have lived in close proximity with humans the longest are better at solving problems, and can invent novel behaviours or reuse pre-existing ones, than the newer arrivals.To test their idea, the researchers tested laboratory-based colonies of all three subspecies, which had lived in captivity for several generations after sharing their homes with humans for thousands of years. The researchers set the mice seven tests where they had to access a mealworm reward in different contexts by performing specific manoeuvres, such as pushing, pulling or digging. The scientists found that the captive western house mice were most likely to solve the food extraction tasks, followed by M. m. musculus and M. m. castaneus. As there were no recent differences in the animals’ lifestyles, their different aptitudes could only be accounted for by the amount of time they had spent sharing their homes with humans in the past. The better problem-solving ability of western house mice is probably a result of sharing their living space with humans for the longest time.However, the team needed convincing that the impressive abilities of the western house mouse are due to their proximity to people and not to some other factor, such as their general inquisitiveness. To test whether any other aspects of their lives drove the animals’ increased intelligence, the researchers connected a cage containing unfamiliar objects to the cages of individual mice and measured how long it took each one to enter the unfamiliar environment. They thought that if the subspecies differed in their motivation to enter the unknown environment, their curiosity could be a possible explanation for why the mice vary in their problem-solving abilities. But they found that the three subspecies did not differ in their inquisitiveness or motivation to explore novel objects, confirming that the western house mouse is better at solving challenging tasks likely owing to its longer cohabitation with humans.Whether you are a New Yorker or a mouse that evolved in an urban or human habitat, problem-solving is key for survival. The human environment may act as a filter in which individuals with certain behaviour types are more likely to thrive. So, the subspecies of mice that has co-existed longest with humans have adapted well to their new, man-made environment through better problem-solving abilities than subspecies that have lived in our shadow for shorter times. So be warned, it may not be long before some mice learn how to extract cheese successfully from your mousetrap without getting squished.

A novel decision support methodology for oceangoing vessel collision avoidance

The wider use of electronic devices in shipping has led to the introduction of new navigation control systems and decision support tools for collision avoidance. The application of these systems improves the data utilisation and allows for the prediction of ship's performance in various operational conditions. In this study, a decision support methodology for collision avoidance of ocean going vessels is developed, taking into account both the ship's manoeuvrability and propulsion system performance whilst employing a new formulation for the estimation of the collision probability indicator. An integrated model that simulates the ship's manoeuvrability and propulsion system performance is employed to predict the required ship's hull and propulsion plant dynamic response. The integrated model couples a 3-DOF manoeuvring model with a mean value engine model, providing a fast but accurate prediction of ship and her propulsion system characteristics during specific manoeuvring scenarios. The derived ship trajectories populate a database that is employed as input to the developed decision support for investigating various encounter situations depending on the target ship's initial position, approach angle, trajectory and speed. The developed decision support provides the collision probability indicator as function of the ordered rudder angle and engine speed as the available control options to avoid the collision. This study provides support to the officer of the watch to make decisions on the ship and propulsion system control parameters during encountering situations, thus contributing to the safer maritime operations.

State-of-the-Art Methods to Improve Energy Efficiency of Ships

Generating energy efficiency through behavioural change requires not only understanding and empathy with user interests and needs but also the fostering of energy saving awareness, a technique and framework that supports operators and ship owners. There is strong potential to make use of different technical solutions to increase energy efficiency, but many cost-efficient solutions relate to carrot-and-stick incentives for operators to minimise energy consumption. These incentives range from voyage planning with weather routing eco-driving bonus, to torque limitations and changes in company policies, all of which demonstrate that the operators’ on-board importance for the energy consumption has been identified. Data collection will allow operators to make better decisions in the lifecycle of the ship from knowledge-driven design to operation, redesign and lifetime extension. Various systems are available for data acquisition, storage and analysis, some of which are delivered by well-known marine suppliers while others are stand-alone systems. The lack of standardization for data capture, transmission and analysis is a challenge, so systematic improvement is required in shipping companies to achieve energy savings. When these are achieved, they will be the result of customer requirements, cost pressure or individual driving forces in the companies. The potential energy savings, brought up in interviews, shows up to 35% on specific routes and up to 60% in specific maneuvers. These savings will be made feasible by operators and crews being involved in the decision-making process.

BPPV Simulation: A Powerful Tool to Understand and Optimize the Diagnostics and Treatment of all Possible Variants of BPPV.

BPPV is a mechanical disorder caused by the displacement of otolith debris into the semicircular canals. The treatment involves different repositioning maneuvers to bring the debris back into the utricle. This study aims to show how dynamic simulation models based on fluid dynamics and MRI, can help to visualize and understand the movement of the debris within the canals during head movement in 3D as a function of time. The user can define the rotation angle and plane at each step of the maneuver and then the model visualizes the canal and the otoconial movement in 3D. The simulation developed also allows alteration of various parameters like the rotational head acceleration, the duration of each step of the maneuver, the initial position of the otoconial debris in the canal, the size and the number of the particles and fluid dynamics of endolymph. The clod movement is visualized in such a way that it allows a better understanding of the impact and efficacy of various liberation maneuvers and why certain maneuvers might fail when not applied properly in the clinic. The model allows simulation of multi-canal BPPV. In this paper we demonstrate the power of the model applied on the maneuvers of Semont and Yacovino when executed in different ways. The model aims to provide a visual explanation for the need of specific maneuvers for each type of BPPV. The simulator presented here can be used to test the efficacy of existing maneuvers and help in the development of new maneuvers to treat different BPPV variants.

Drivers’ Psychomotor Reaction Times Tested with a Test Station Method

The article presents the standard method of the evaluation of car drivers’ psychomotor reaction times. A characteristic feature of this method is the ability to conduct tests using real vehicles equipped with mobile measuring apparatus. Measurements are carried out on people whose task is to initiate specific maneuvers (such as: a braking or turning maneuver, a combined braking and turning maneuver, as well as e.g., the use of an audio signal) in response to external stimuli coming from different directions. The sources of the stimuli are light signals emitted by variable message signs placed around the vehicle. The developed control and measurement equipment allows us to realize various and complex test scenarios. It generates stimulus sequences, assesses the correctness of the driver’s response and measures its time. This method allows us to obtain sets of results from tests carried out under different conditions and variable test durations. The possibility of testing a large number of participants in a relatively short time and in repetitive conditions allows for reliable statistical inference. The paper presents examples of research results obtained on the basis of few thousand tests carried out on a large group of respondents. The registered data was statistically processed and referred to the literature. A high degree of correlation between the analyzed results and the literature reports proves that the presented method may be a source of data for the analysis of phenomena related to the time of the driver’s response, especially the influence of various factors affecting its values.

METHOD FOR DETERMINING THE MISALIGNMENT OF OPTICAL-ELECTRONIC AND INERTIAL ORIENTATIONS HELICOPTER SYSTEMS

A unique method for determining the misalignment of the orientation of the instrumental coordinate systems of different posts of the optical-electronic system of a helicopter with each other and with an inertial navigation system is proposed. The method does not require preflight preparation, and is based on processing video information streams generated by thermal imaging and television channels of the optical-electronic system, and using information from an inertial navigation system. The method involves the helicopter performing a special maneuver, which is a rotation of the helicopter at a low altitude. This maneuver can be automated. When the helicopter rotates, trajectories of characteristic points of the underlying surface and airfield infrastructure are formed on the images. In general, the trajectories of these points are hyperbolas, which are approximated by straight lines. The parameters of these straight lines are determined using the least squares method. The angle of inclination of straight lines in the screen coordinate system determines the position of the angular velocity vector in the instrument coordinate systems. Since all the posts of the optical-electronic system measure the same vector, it is possible to determine their mismatch in roll between themselves and with the inertial navigation system. Preliminary modeling showed high potentialities of the proposed method. The method can be considered as an integral part of a more general method for coordinating coordinate systems in roll, pitch and course based on processing video streams of optical-electronic systems. When the method is used in real conditions, the errors in estimating the angular misalignment of the optical-electronic and inertial systems of a helicopter can be in units of arc minutes.

Aerodynamic Parameter Estimation Using Reconstructed Turbulence Measurements

A classical flow-vane approach for reconstructing translational gust velocities from air data and inertial sensor measurements was improved and implemented for real-time computation. The reconstructed turbulence measurements were then included in a system identification analysis to estimate nondimensional stability and control derivatives in a longitudinal short period model using the maximum likelihood equation-error method in the frequency domain with Fourier-transform data. Flight-test results using 44 maneuvers from a subscale transport-type airplane showed that the power spectra for the reconstructed vertical gusts resembled standard Dryden or von Kármán turbulence models. Flight data in moderate and severe turbulence exhibited a decorrelation of the modeling data. In particular, pitch rate and angle-of-attack rate derivatives could both be identified from flight data about straight and level flight without special maneuvers or prior information.

Posterior Shoulder Instability in the Throwing Athlete

Posterior capsulolabral injuries are common problems faced by athletes, especially throwing athletes. Posterior shoulder instability can occur as a result of multiple mechanisms, including acute traumatic events, or a more insidious process of repetitive throwing. An understanding of the pathomechanics and pathoanatomy of posterior instability in the throwing shoulder is essential in order to effectively manage throwing athletes. Athletes will more commonly complain of shoulder pain and difficulty with throwing rather than of shoulder instability. A thorough physical examination to identify potential underlying causes as well as specific maneuvers to elicit posterior instability are important in the evaluation and workup of the throwing athlete. Appropriate imaging, including with plain radiographs and advanced imaging assist in decision-making. Treatment options include both nonoperative intervention with a heavy reliance on physical therapy and surgical intervention consisting of arthroscopic posterior labral repair. Recent advancements in our understanding of shoulder biomechanics and posterior shoulder instability, improvements in diagnostic abilities via examination, imaging, and intraoperative evaluation, as well as advancements in arthroscopic techniques have allowed surgeons to better identify and appropriately manage posterior capsulolabral pathology in athletes.

536 Association of neonatal birthweight with shoulder dystocia management

To evaluate maneuvers associated with shoulder dystocia resolution in patients delivering neonates with a birthweight >4000g compared to <4000g This is a retrospective cohort of patients who delivered between September 2014 and August 2018 at a tertiary care center whose delivery was complicated by shoulder dystocia. The proportion of patients who underwent a maneuver beyond McRoberts was compared between patients who delivered neonates with birthweight >4000g vs <4000g. Secondary outcomes included total number of maneuvers, specific maneuvers performed, final maneuver prior to delivery, maternal trauma, dystocia length and neonatal morbidity. Continuous and categorical variables were evaluated using Wilcoxon rank sum and Fisher’s exact test. Relative risks were calculated with a confidence interval (CI) of 95% being considered significant. Of the 481 patients meeting study criteria, 9 were excluded due to lack of informative data. Patients with a neonate weighing >4000g (n=156, 33.0%), compared to those with a neonate weighing 35 (42.2% vs 30.1%) and less likely to undergo operative delivery (4.5% vs 10.8%). Patients with a neonate weighing >4000g were more likely to undergo a maneuver beyond McRoberts (RR 1.24, CI 1.08-1.42); and remained so after adjusting for BMI, diabetes and operative delivery (aRR 1.26, CI 1.06-1.41). Patients with a neonate weighing >4000g were more likely to have a 3rd/4th degree laceration (RR 2.62, CI 1.43-4.79), have a dystocia lasting >90 seconds (RR 1.63, CI 1.12-2.37) and had a higher mean total of maneuvers performed (2.2 vs 1.9 p=value 0.004). Neonates weighing >4000g were more likely to have brachial plexus injury (RR 5.1, CI 1.62-15.94) and clavicular fracture (RR 3.77, CI 1.54-9.27). Patients with neonates weighing >4000g, as compared to <4000g, are more likely to undergo a maneuver beyond McRoberts during shoulder dystocia. Further data is needed to evaluate if shoulder dystocia management should be guided by suspected fetal weight.

Increased colonic K+ excretion through inhibition of the H,K-ATPase type 2 helps reduce plasma K+ level in a murine model of nephronic reduction

Hyperkalemia is frequently observed in patients at the end-stage of chronic kidney disease (CKD), and has possible harmful consequences on cardiac function. Many strategies are currently used to manage hyperkalemia, one consisting of increasing fecal K+ excretion through the administration of cation-exchange resins. In this study, we explored another more specific method of increasing intestinal K+ secretion by inhibiting the H,K-ATPase type 2 (HKA2), which is the main colonic K+ reabsorptive pathway. We hypothetised that the absence of this pump could impede the increase of plasma K+ levels following nephronic reduction (N5/6) by favoring fecal K+ secretion. In N5/6 WT and HKA2KO mice under normal K+ intake, the plasma K+ level remained within the normal range, however, a load of K+ induced strong hyperkalemia in N5/6 WT mice (9.1 ± 0.5 mM), which was significantly less pronounced in N5/6 HKA2KO mice (7.9 ± 0.4 mM, p < 0.01). This was correlated to a higher capacity of HKA2KO mice to excrete K+ in their feces. The absence of HKA2 also increased fecal Na+ excretion by inhibiting its colonic ENaC-dependent absorption. We also showed that angiotensin-converting-enzyme inhibitor like enalapril, used to treat hypertension during CKD, induced a less severe hyperkalemia in N5/6 HKA2KO than in N5/6 WT mice. This study therefore provides the proof of concept that the targeted inhibition of HKA2 could be a specific therapeutic maneuver to reduce plasma K+ levels in CKD patients.