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A sustained increase in the maternal death rate in the U.S. remains one of the most challenging issues of the twenty-first century. Ten years ago, we investigated the major conditions contributing to the maternal death rate between the years 2000 and 2006. The leading causes of death in the U.S. at that time were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage and cardiac disease. Venous thromboembolism accounted for 9% of all maternal death, and an overall pregnancy-related mortality risk of 0.9 maternal deaths per 100,000 live births. VTE was the most common preventable cause of maternal death noted during that time period. In this paper, we will review and summarize changes in obstetric health care over the last ten years implemented to prevent VTE and its related morbidity. We will then examine opportunities for hospitals and hospital systems to improve VTE prophylaxis.

Superb Microvascular Imaging (SMI; Canon Medical Systems, Tustin, CA) uses clutter suppression to extract flow signals at rapid frame rates, which provides high-resolution vessel-branching details without the need for contrast agents. The potential diagnostic benefits of SMI, as described in other areas of medicine, requires further exploration during pregnancy. In this pictorial essay, we demonstrate the complementary use of SMI compared to conventional Doppler ultrasound and how it may improve our ability to characterize placental microvascular patterns without the need for ultrasound contrast agents.

Background Data are limited concerning rates of perinatal complications in women with a body mass index (BMI) ≥40 kg/m2 compared to women with other BMI classes when guidelines for the safe prevention of the primary cesarean delivery are applied. Objective The aim of the study is to evaluate labor guideline adherence by BMI class and to compare perinatal outcomes across BMI classes with guideline adherent management. Study Design This retrospective study included low-risk women admitted for delivery between April 2014 and April 2017 after the labor guidelines were implemented. BMI closest to delivery was used for analysis. Women with cesarean for nonreassuring fetal status were excluded. Results Guideline adherence decreased with increasing BMI, with 93% adherence among women of normal weight compared to 81% for class III obese women (p Conclusion There were no differences in adverse perinatal outcomes with increasing BMI.

A national shift in educational policies has been underway that is focused on increasing STEM integration in K-12 classrooms. Yet, what constitutes STEM still remains ambiguous and needs to be explicitly defined and agreed upon. Is STEM simply each associated field or it is a more complex entity that integrates the field disciplines? The state of Indiana has responded to this national call for increased STEM by integrating it increasingly within the K-12 settings in STEM certified schools. To become STEM certified is a lengthy and multiple step process. We decided to investigate how these STEM certified schools publicly portray themselves on three levels: how, what, and who is being portrayed with regard to STEM. We used content analysis of each schools publicly available school websites and twitter feeds, if available. Results varied greatly for how STEM is portrayed across both grade level and cohort of certification. Twitter across all grades was the most frequently utilized media source for showing STEM school activities. The STEM certified elementary schools were the only grade level to have “STEM specialists”. Thus, even within the state of Indiana, which has a rigorous process by which schools become STEM certified, the portrayal of STEM across and within grade bands is highly variable.

What is the nature of mathematics and what should students learn about it? This chapter will contrast the fallibilist and absolutist perspectives to provide an elaboration of the nature of mathematics. Three aspects of the nature of mathematics are identified that K-12 math students should become familiar with. First, they should understand mathematics is a way of knowing. Second, they should recognize that mathematics is tentative, because claims in mathematics are based on assumptions made. Third, mathematics is a creative endeavor. Examples of how each of these three aspects connect to the work of K-12 teachers are described, and considerations for how the nature of mathematics connects to nature of STEM are discussed.

The integrated disciplinary approach STEM education offers may be useful in preparing students to understand and ultimately address environmental challenges. For this to occur, however, teachers need the content and pedagogical knowledge to foster E-STEM literacy. Unfortunately, most teachers have had little direct experience with STEM education and there is a dearth of research into pre-service teachers E-STEM learning experiences. This chapter describes an action research study designed to explore our efforts in regard to E-STEM education, and subsequently use the understandings to improve those efforts. The process was guided by two questions: 1) How does our E-STEM intervention influence pre-service teachers’ understanding of STEM? And, 2) what extent does our E-STEM intervention impact pre-service teachers’ notion of environmental issues? The intervention consisted of exploring and designing new energy-efficient sources/technologies. In this chapter, we provide a description of the intervention/action, the findings associated with implementation, and subsequent revisions.

We have a wide variety of teaching experiences, from formal settings in elementary school (Valarie), high school (Alex, Taukir, and Meize), higher education (Steven), and teacher education (all) to...

Pregnancy-related deaths in the United States are increasing. Medical, social, economic, and cultural issues have all been implicated in this trend, but few data exist to differentiate the relative contributions of these various factors.The objective of the study was to examine trends in US pregnancy-related mortality by place of death and maternal race and age. We hypothesized that such an analysis may allow some distinction between deaths related to medical performance and those more closely related to social, cultural, or environmental issues.We conducted a retrospective, cross-sectional study for the years 2003-2016 using multiple cause-of-death mortality data provided by the Centers for Disease Control and Natality Data provided by National Vital Statistics System of the National Center for Health Statistics. Temporal trends analyses for the place of death, race/ethnicity, and age at the time of death were performed using joinpoint regression over the study period.Approximately one third of pregnancy-related deaths occurred outside a medical facility. The fraction of maternal deaths occurring in inpatient facilities fell by 20% over the study period, from 53% to 44% of all maternal deaths (P.0001). Maternal deaths in an outpatient facility or emergency room demonstrated a similar decline (24%) in relative frequency (P.0001). In contrast, there was a significant increase in the relative frequency of maternal mortality in other settings, particularly within the descendant's home, with a doubling over this time period. However, overall pregnancy-related deaths continued to increase in all settings. These increases were particularly striking in non-Hispanic black and white women and among women in the youngest and oldest age groups.Against a background of rising US pregnancy-related mortality, stratification of such deaths by place of death and maternal age and race highlights both the need for ongoing improvements in the quality of medical care and the potential contribution of events occurring outside a medical facility to the overall morality ratio. Current trends in pregnancy-related mortality in the United States are, in part, driven by social, cultural, and financial issues beyond the direct control of the medical community.

INTRODUCTION:Although there is evidence to suggest that obese women with a BMI ≥40 experience increased rates of perinatal complications, there is limited data concerning rates of these complications compared to women with other BMI classes when guidelines for the safe prevention of the primary cesa

Cystic hygroma (CH) is a relatively common malformation of the lymphatic system. It is important for clinicians to be familiar with the condition because it is one of the few developmental abnormalities that can be reliably diagnosed during the first-trimester sonogram. In addition to intrinsically contributing to fetal/neonatal morbidity and mortality, CH and other lymphatic malformations are associated with a dramatic increase in the risk for aneuploidy, other genetic abnormalities and syndromes, and other birth defects. This chapter will highlight the diagnosis and management of fetuses with CH and other lymphatic abnormalities.

Most people do not engage in recommended levels of physical activity. Social cognition research indicates that self-reported outcome expectancies (OEs) are associated with exercise behavior, but self-report assessments have limitations. We investigated whether reaction times (RTs) to endorse outcome expectancies would capture unique information about spontaneous cognitive processes associated with exercise behavior. Exercisers and sedentary participants were randomly assigned to complete an exercise test or to rest. Participants completed an OE questionnaire and RT task before and after the test/rest. On the RT task, exercisers endorsed exercise positive outcomes more rapidly than sedentary participants. Furthermore, reported OEs and RTs were independently associated with exercise status. RTs may afford a more comprehensive assessment of the cognitive processes associated with exercise behavior.

MSCs are considered to be the natural precursors to adipocyte development through the process of adipogenesis. A link has been established between decreased protective effects of EETs or HO-1 and their interaction in metabolic syndrome. Decreases in HO-1 or EET were associated with an increase in adipocyte stem cell differentiation and increased levels of inflammatory cytokines. EET agonist (AKR-I-27-28) inhibited MSC-derived adipocytes and decreased the levels of inflammatory cytokines. We further describe the role of CYP-epoxygenase expression, HO expression, and circulating cytokine levels in an obese mouse, ob/ob(-/-) mouse model. Ex vivo measurements of EET expression within MSCs derived from ob/ob(-/-) showed decreased levels of EETs that were increased by HO induction. This review demonstrates that suppression of HO and EET systems exist in MSCs prior to the development of adipocyte dysfunction. Further, adipocyte dysfunction can be ameliorated by induction of HO-1 and CYP-epoxygenase, i.e. EET.

HO-1 and EETs are functionally linked and their interactions influence body weight, insulin sensitivity, and serum levels of inflammatory cytokines in metabolic syndrome phenotype of HO-2 null mice. The HO-2 isozyme is essential for regulating physiological levels of ROS. Recent studies have suggested a potential role of EET in modifying adipocyte differentiation through up-regulation of HO-1-adiponectin-AkT signaling in human mesenchymal stem cells (MSCs). Our aim was to examine the consequences of HO deficiency on MSC-derived adipogenesis in vitro using MSC derived from HO-2 null and WT mice in vivo.Four-month-old HO-2 null (HO-2(-/-)) and B6/129SF2/J (WT) mice were divided into three groups (four mice/group): WT, HO-2(-/-), and HO-2(-/-) +CoPP. Adipogenesis was performed on purified MSC-derived adipocytes cultured in adipogenic differentiation media and an EET-agonist was added every 3 days.HO-2 depletion of MSC adipocytes resulted in increased adipogenesis (p0.01) and increased levels of inflammatory cytokines including (TNF)-alpha (p0.05), (MCP)-1 (p0.05), and (IL-1)-beta (p0.05). These results were accompanied by decreases in HO-1 (p0.05) and subsequently EET and HO activity (p0.05). Up-regulation of HO-1 resulted in decreased MSC-derived adipocyte differentiation, decreased production of TNF-alpha and MCP-1 and increased levels of adiponectin (p0.05). Cyp2J5 (p0.05), HO-1 (p0.05), and adiponectin mRNA levels (p0.05) were also decreased in visceral adipose tissue isolated from HO-2 null compared to WT mice. EET agonist stimulation of MSC adipocytes derived from HO-2 null mice yielded similar results.Increased levels of EET and HO-1 are essential for protection against the adverse effects of adipocyte hypertrophy and the ensuing metabolic syndrome. These results offer a portal into therapeutic approaches for the prevention of the metabolic syndrome.

Epoxygenase activity and synthesis of epoxyeicosatrienoic acids (EETs) have emerged as important modulators of obesity and diabetes. We examined the effect of the EET-agonist 12-(3-hexylureido)dodec-8(2) enoic acid on mesenchymal stem cell (MSC) derived adipocytes proliferation and differentiation. MSCs expressed substantial levels of EETs and inhibition of soluble epoxide hydrolase (sEH) increased the level of EETs and decreased adipogenesis. EET agonist treatment increased HO-1 expression by inhibiting a negative regulator of HO-1 expression, Bach-1. EET treatment also increased βcatenin and pACC levels while decreasing PPARγ C/EBPα and fatty acid synthase levels. These changes were manifested by a decrease in the number of large inflammatory adipocytes, TNFα, IFNγ and IL-1α, but an increase in small adipocytes and in adiponectin levels. In summary, EET agonist treatment inhibits adipogenesis and decreases the levels of inflammatory cytokines suggesting the potential action of EETs as intracellular lipid signaling modulators of adipogenesis and adiponectin.

Human mesenchymal stem cells (MSCs) expressed substantial levels of CYP2J2, a major CYP450 involved in epoxyeicosatrienoic acid (EET) formation. MSCs synthesized significant levels of EETs (65.8 ± 5.8 pg/mg protein) and dihydroxyeicosatrienoic acids (DHETs) (15.83 ± 1.62 pg/mg protein), suggesting the presence of soluble epoxide hydrolase (sEH). The addition of an sEH inhibitor to MSC culture decreased adipogenesis. EETs decreased MSC-derived adipocytes in a concentration-dependent manner, 8,9- and 14,15-EET having the maximum reductive effect on adipogenesis. We examined the effect of 12-(3-hexylureido)dodec-8(Z)-enoic acid, an EET agonist, on MSC-derived adipocytes and demonstrated an increased number of healthy small adipocytes, attenuated fatty acid synthase (FAS) levels (P

Adiponectin, an abundant adipocyte-derived plasma protein that modulates vascular function in type 2 diabetes, has been shown to provide cytoprotection to both pancreatic and vascular systems in diabetes. Therefore, we examined whether up-regulation of heme oxygenase (HO)-1 ameliorates the levels of inflammatory cytokines and influences serum adiponectin in Zucker fat (ZF) rats. ZF rats displayed a decrease in both HO activity and HO-1 and HO-2 protein levels and an increase in tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 compared with Zucker lean (ZL) rats. Treatment of ZF animals with 2 mg/kg cobalt protoporphyrin IX (CoPP) increased protein levels of HO-1 and HO activity, but HO-2 was unaffected. The increase in HO-1 was associated with a decrease in superoxide levels (p < 0.05) and an increase in plasma adiponectin (p < 0.005), compared with untreated ZF rats. CoPP treatment decreased visceral and s.c. fat content, and it reduced weight gain (p < 0.01). In addition, the inflammatory cytokines TNF-alpha and IL-6 were decreased (p < 0.04 and p < 0.008, respectively). Treatment of human bone marrow-derived adipocytes cultured with CoPP resulted in an increase in HO-1 and a decrease in superoxide levels. Up-regulation of HO-1 caused adipose remodeling, smaller adipocytes, and increased adiponectin secretion in the culture medium of human bone marrow-derived adipocytes. In summary, this study demonstrates that the antiobesity effect of HO-1 induction results in an increase in adiponectin secretion, in vivo and in vitro, a decrease in TNF-alpha and IL-6, and a reduction in weight gain. These findings highlight the pivotal role and symbiotic relationship of HO-1 and adiponectin in the modulation of the metabolic syndrome phenotype.

Background While unannounced standardized patients (USPs) have been used to assess physicians’ clinical skills in the ambulatory setting, they can also provide valuable information on patients’ experience of the health care setting beyond the physician encounter. This paper explores the use of USPs as a methodology for evaluating patient-centered care in the health care system. Methods USPs were trained to complete a behaviorally-anchored assessment of core dimensions of patient-centered care delivered within the clinical microsystem, including: 1) Medical assistants’ safe practices, quality of care, and responsiveness to patients; 2) ease of clinic navigation; and 3) the patient-centeredness of care provided by the physician. Descriptive data is provided on these three levels of patient-centeredness within the targeted clinical microsystem. Chi-square analyses were used to signal whether variations by teams within the clinical microsystem were likely to be due to chance or might reflect true differences in patient-centeredness of specific teams. Results Sixty USP visits to 11 Primary Care teams were performed over an eight-month period (mean 5 visits/team; range 2–8). No medical assistants reported detecting an USP during the study period. USPs found the clinic easy to navigate and that teams were functioning well in 60% of visits. In 30% to 47% of visits, the physicians could have been more patient-centered. Medical assistants’ patient safety measures were poor: patient identity was confirmed in only 5% of visits and no USPs observed medical assistants wash their hands. Quality of care was relatively high for vital signs (e.g. blood pressure, weight and height), but low for depression screening, occurring in only 15% of visits. In most visits, medical assistants greeted the patient in a timely fashion but took time to fully explain matters in less than half of the visits and rarely introduced themselves. Physicians tried to help patients navigate the system in 62% of visits. Conclusions USP assessment captured actionable, critical, behaviorally-specific information on team and system performance in an urban community clinic. This methodology provides unique insight into the patient-centeredness and quality of care in medical settings.

procedures such as blood tests, lumbar punctures, superficial suturing and the removal of sutures. However, the use of alternative therapies for children is less well documented than for adults. In 1992, a postal survey of non-physician practitioners of alternative medicine in England showed that two per cent of their clients were under 16 years of age. A more recent study of children attending a paediatric outpatient’s department in Bath revealed that 20 per cent of the children attending had previously received one or more forms of alternative therapy (Simpson et al 1998). This suggests that there is a small but significant acceptance and use of alternative and complementary therapies by parents/guardians for their children. This article compares the philosophy and practice of two complementary therapies: guided imagery and massage, which are now gaining support and recognition in the management of infants and children in many situations within the acute clinical setting.

Although the use of standardized patients (SPs) is widely used in assessment, the vast majority of SP exercises/exams involve announced encounters in which the learners know that they are interacting with a simulated patient. Objective structured clinical examinations (OSCEs) are considered a gold standard for assessing clinical skills, but their overtly contrived nature may limit their ability to capture the true behavior of medical professionals (Ozuah and Reznik 2007). The use of unannounced standardized patients (USPs) is a relatively new but increasingly used method for evaluating the competence of medical professionals (Glassman et al. 2000; Rethans et al. 2007). USP encounters do not have the artificial time constraints of OSCEs, and USPs can evaluate subjects in a real clinic setting.

Increases in visceral fat are associated with increased inflammation, dyslipidemia, insulin resistance, glucose intolerance, and vascular dysfunction. We examined the effect of the potent heme oxygenase (HO)-1 inducer, cobalt protoporphyrin (CoPP), on regulation of adiposity and glucose levels in both female and male obese mice. Both lean and obese mice were administered CoPP intraperitoneally (3 mg/kg once per week) for 6 weeks. Serum levels of adiponectin, tumor necrosis factor α (TNFa), interleukin (IL)-1β and IL-6, and HO-1, PPARγ, pAKT, and pAMPK protein expression in adipocytes and vascular tissue were measured. While female obese mice continued to gain weight at a rate similar to controls, induction of HO-1 slowed the rate of weight gain in male obese mice. HO-1 induction led to lowered blood pressure levels in obese male and female mice similar to that of lean male and female mice. HO-1 induction also produced a significant decrease in the plasma levels of IL-6, TNFα, IL-1β, and fasting glucose of obese females compared to untreated female obese mice. HO-1 induction increased the number and decreased the size of adipocytes of obese animals. HO-1 induction increased adiponectin, pAKT, pAMPK, and PPARγ levels in adipocyte of obese animals. Induction of HO-1 in adipocytes was associated with an increase in adiponectin and a reduction in inflammatory cytokines. These findings offer the possibility of treating not only hypertension, but also other detrimental metabolic consequences of obesity including insulin resistance and dyslipidemia in obese populations by induction of HO-1 in adipocytes.

This study tests the hypothesis that disparities of hypertension risk in African Americans is related to lead exposure, perceptions of racism, and stress, among urban (Roxbury, MA) and rural (Gadsden, FL) communities. Analysis of preliminary data from Phase I reveal 60% in Gadsden and 39% in Roxbury respondents self-reported having hypertension. In Gadsden 80% people did not know if their residence contained lead paint, compared to 45% in Roxbury. In Gadsden County, 58% of respondents reported experiencing racial discrimination in different settings compared with 72% in Roxbury. In regression analyses high cholesterol emerged as a significant predictors of hypertension in Gadsden County (OR=8.29, CI=1.4-49.3), whereas monthly household income (OR=0.15, CI=0.04- 0.7) and diabetes (OR=6.06, CI=1.4-26.17) were significant predictors of hypertension in Roxbury after adjusting for other covariates. These preliminary findings set the stage for initiating Phase II (Phase I continues recruitment), that entail biological marker measurements to rigorously test main hypothesis.