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The orphans at Grace Field House lead a comfortable life under the care of \"Mom,\" but Emma and Norman uncover a dark truth that is going to change their lives completely.

Objective To determine the risks of stillbirth and neonatal complications by gestational age in uncomplicated monochorionic and dichorionic twin pregnancies.Design Systematic review and meta-analysis.Data sources Medline, Embase, and Cochrane databases (until December 2015). Review methods Databases were searched without language restrictions for studies of women with uncomplicated twin pregnancies that reported rates of stillbirth and neonatal outcomes at various gestational ages. Pregnancies with unclear chorionicity, monoamnionicity, and twin to twin transfusion syndrome were excluded. Meta-analyses of observational studies and cohorts nested within randomised studies were undertaken. Prospective risk of stillbirth was computed for each study at a given week of gestation and compared with the risk of neonatal death among deliveries in the same week. Gestational age specific differences in risk were estimated for stillbirths and neonatal deaths in monochorionic and dichorionic twin pregnancies after 34 weeks’ gestation.Results 32 studies (29 685 dichorionic, 5486 monochorionic pregnancies) were included. In dichorionic twin pregnancies beyond 34 weeks (15 studies, 17 830 pregnancies), the prospective weekly risk of stillbirths from expectant management and the risk of neonatal death from delivery were balanced at 37 weeks’ gestation (risk difference 1.2/1000, 95% confidence interval −1.3 to 3.6; I2=0%). Delay in delivery by a week (to 38 weeks) led to an additional 8.8 perinatal deaths per 1000 pregnancies (95% confidence interval 3.6 to 14.0/1000; I2=0%) compared with the previous week. In monochorionic pregnancies beyond 34 weeks (13 studies, 2149 pregnancies), there was a trend towards an increase in stillbirths compared with neonatal deaths after 36 weeks, with an additional 2.5 per 1000 perinatal deaths, which was not significant (−12.4 to 17.4/1000; I2=0%). The rates of neonatal morbidity showed a consistent reduction with increasing gestational age in monochorionic and dichorionic pregnancies, and admission to the neonatal intensive care unit was the commonest neonatal complication. The actual risk of stillbirth near term might be higher than reported estimates because of the policy of planned delivery in twin pregnancies.Conclusions To minimise perinatal deaths, in uncomplicated dichorionic twin pregnancies delivery should be considered at 37 weeks’ gestation; in monochorionic pregnancies delivery should be considered at 36 weeks.Systematic review registration PROSPERO CRD42014007538.

Abstract In this paper, the authors present the design of a new pair of 8 × 8 S-boxes over the residue classes of Gaussian integers $$\\:Z{\\left[i\\right]}_{h}$$ and their usage for the encryption of multiple RGB images using a three-stage Substitution-Permutation Network (SPN). In the present work, the S-boxes are constructed using the properties of Gaussian Integers and inverse of affine then affine maps, where first S-box holds the roles of substitution layer and the second S-box looks after the permutation layer. The modulation is nonlinear by means of operating the Gaussian integer residue classes through modular arithmetic, which will greatly benefit from strong diffusion and confusion properties that are critical for cryptographic security. For even greater complexity an exclusive XOR operation on the two S-boxes is made to produce a third S-box. The third S-box is deployed in the encryption process in such manner which offers superior diffusion over all RGB image channels. When the proposed SPN framework is utilized for a set of multiple RGB images, the mappings employed involves substitution-permutation-XOR operations that are severe nonlinear functions for differential or linear attacks. The incorporation of these Gaussian-integer-based S-boxes into the SPN scheme makes it possible for each image channel to be transformed independently but mutually connected to produce a secure and efficient encryption function. The analysis of outcomes proves the efficiency of the developed method; the viability of its application for multi-image encryption with high entropy, low correlation and increased resistance to a variety of attacks. This ability to consider it as an effective tool in the sphere of secure multimedia communication.

Prior to this intervention, multiple infection control strategies in addition to those routine in our facilities had been implemented in response to the COVID-19 pandemic: (1) symptom and exposure screening of all patients with implementation of immediate isolation if symptom screen is positive and testing for SARS-Cov-2, (2) universal masking of employees, patients, and visitors on facility premises,3 (3) daily employee symptom attestation with exclusion from work and referral for testing if symptom screen positive; and (4) deferral of all nonessential in-person visits and elective procedures. Among asymptomatic women, 9 of 618 (1.5%) tested positive (Fig. 1). [...]9 of 20 patients positive for SARS-CoV-2 at admission (45%) had no symptoms of COVID-19 at presentation. Notably, the 1%–2% incidence of asymptomatic infection in our population more closely mirrors asymptomatic infection rates in other areas.4,5 Several theories may explain the lower prevalence of asymptomatic infection in Boston compared to New York City: (1) we began testing >30 days after physical distancing orders were placed by the state and hence were sampling at a time with declining community transmission, (2) the overall population density of greater Boston is lower than New York City, perhaps leading to less community-based transmission, and (3) some New York hospitals transiently stopped or considered stopping birth partners from attending deliveries, which could have led to some women underreporting symptoms.

Impaired or suboptimal fetal growth is associated with an increased risk of perinatal morbidity and mortality. By utilizing readily available clinical data on the relative size of the fetus at multiple points in pregnancy, including delivery, future epidemiological research can improve our understanding of the impacts of maternal, fetal, and environmental factors on fetal growth at different windows during pregnancy. This study presents mean and standard deviation ultrasound measurements from a clinically representative US population that can be utilized for creating Z-scores to this end. Between 2006 and 2012, 18, 904 non-anomalous pregnancies that received prenatal care, first and second trimester ultrasound evaluations, and ultimately delivered singleton newborns at Brigham and Women's hospital in Boston were used to create the standard population. To illustrate the utility of this standard, we created Z-scores for ultrasound and delivery measurements for a cohort study population and examined associations with factors known to be associated with fetal growth. In addition to cross-sectional regression models, we created linear mixed models and generalized additive mixed models to illustrate how these scores can be utilized longitudinally and for the identification of windows of susceptibility. After adjustment for a priori confounders, maternal BMI was positively associated with increased fetal size beginning in the second trimester in cross-sectional models. Female infants and maternal smoking were associated with consistently reduced fetal size in the longitudinal models. Maternal age had a non-significant association with increased size in the first trimester that was attenuated as gestation progressed. As the growth measurements examined here are widely available in contemporary obstetrical practice, these data may be abstracted from medical records by investigators and standardized with the population means presented here. This will enable easy extension of clinical data to epidemiologic studies investigating novel maternal, fetal, and environmental factors that may impact fetal growth.

ObjectiveTo determine the relative effects of patient and hospital factors on a hospital’s postpartum readmission rate.Study designThis retrospective cohort study was conducted using State Inpatient Databases from California, Florida, and New York between 2004 and 2013. We compared patient and hospital characteristics among hospitals with low and high readmission rates using χ2 tests. Risk-adjusted 30-day readmission rates were calculated for patient, delivery, and hospital characteristics to understand factors affecting readmission using fixed and random effects models.ResultsPatients in hospitals with low readmission rates were more likely to be white, to have private insurance and higher incomes, and to have fewer comorbidities. The patient comorbidities with the highest risk-adjusted readmission rates included hypertension (range, 2.14–3.04%), obesity (1.78–2.94%), preterm labor/delivery (2.50–2.60%), and seizure disorder (1.78–3.35%). Delivery complications were associated with increased risk-adjusted readmission rates. Compared to patient characteristics, hospital characteristics did not have a profound impact on readmission risk.ConclusionObstetric readmissions were more attributable to patient and demographic characteristics than to hospital characteristics. Readmission metric-based incentives may ultimately penalize hospitals providing high-quality care due to patient characteristics specific to their catchment area.

ObjectivesTo explore provider perspectives surrounding national guidelines proposing regionalization of maternal care.MethodsAn 18-item survey focused on provider attitudes and practices surrounding regionalized maternity care was administered to a national sample of practicing obstetricians. We classified respondants reporting less than 500 annual deliveries at their hospital as low-volume providers and those practicing at hospitals performing 500 or more annual deliveries as high-volume providers. We compared responses according to hospital delivery volume using univariate analysis.ResultsOf the 497 physicians surveyed, 278 people responded (56%) with 229 currently practicing obstetrics. The median annual delivery volume amongst respondents was 200 (interquartile range 100–1900) with 146 (63.7%) practicing in low-volume delivery centers. The need for medical or surgical expertise was the most commonly reported indication for maternal transfer (19.7%) and independent of practice setting. Ninety-six percent of providers agreed with the concept of regionalization, but respondents in high-volume centers reported higher familiarity with the levels of maternal care paradigm compared to their low-volume counterparts (81.9% v. 62.3%, p < 0.01). Financial factors (60.3%), geography (48.9%), and access to care (43.2%) were the most cited major barriers to regionalization. High-volume providers endorsed geography as a major barrier more often than low-volume providers (57.8% v. 43.8%, p = 0.04).Conclusions for PracticeObstetricians may agree with the concept of regionalized maternity care but also identify significant barriers to its implementation. Early and frequent engagement of providers reflecting the diversity of delivery centers in a region is a simple but necessary step in any attempts to designate levels of maternal care.

Fetal health is critically dependent on placental function, especially placental transport of oxygen from mother to fetus. When fetal growth is compromised, placental insufficiency must be distinguished from modest genetic growth potential. If placental insufficiency is present, the physician must trade off the risk of prolonged fetal exposure to placental insufficiency against the risks of preterm delivery. Current ultrasound methods to evaluate the placenta are indirect and insensitive. We propose to use Blood-Oxygenation-Level-Dependent (BOLD) MRI with maternal hyperoxia to quantitatively assess mismatch in placental function in seven monozygotic twin pairs naturally matched for genetic growth potential. In-utero BOLD MRI time series were acquired at 29 to 34 weeks gestational age. Maps of oxygen Time-To-Plateau (TTP) were obtained in the placentas by voxel-wise fitting of the time series. Fetal brain and liver volumes were measured based on structural MR images. After delivery, birth weights were obtained and placental pathological evaluations were performed. Mean placental TTP negatively correlated with fetal liver and brain volumes at the time of MRI as well as with birth weights. Mean placental TTP positively correlated with placental pathology. This study demonstrates the potential of BOLD MRI with maternal hyperoxia to quantify regional placental function in vivo .

Animal studies have demonstrated the therapeutic potential of polyphenol-rich pomegranate juice. We recently reported altered white matter microstructure and functional connectivity in the infant brain following in utero pomegranate juice exposure in pregnancies with intrauterine growth restriction (IUGR). This double-blind exploratory randomized controlled trial further investigates the impact of maternal pomegranate juice intake on brain structure and injury in a second cohort of IUGR pregnancies diagnosed at 24–34 weeks’ gestation. Ninety-nine mothers and their eligible fetuses ( n  = 103) were recruited from Brigham and Women’s Hospital and randomly assigned to 8 oz pomegranate ( n  = 56) or placebo ( n  = 47) juice to be consumed daily from enrollment to delivery. A subset of participants underwent fetal echocardiogram after 2 weeks on juice with no evidence of ductal constriction. 57 infants ( n  = 26 pomegranate, n  = 31 placebo) underwent term-equivalent MRI for assessment of brain injury, volumes and white matter diffusion. No significant group differences were found in brain volumes or white matter microstructure; however, infants whose mothers consumed pomegranate juice demonstrated lower risk for brain injury, including any white or cortical grey matter injury compared to placebo. These preliminary findings suggest pomegranate juice may be a safe in utero neuroprotectant in pregnancies with known IUGR warranting continued investigation. Clinical trial registration: NCT04394910, https://clinicaltrials.gov/ct2/show/NCT04394910 , Registered May 20, 2020, initial participant enrollment January 16, 2016.

Coding theory is the study of the properties of codes and their respective fitness for specific applications. Codes are used for data compression, cryptography, error detection, error correction, data transmission, and data storage. Codes are studied by various scientific disciplines, such as information theory, electrical engineering, mathematics, linguistics, and computer science, to design efficient and reliable data transmission methods. Many authors in the previous literature have discussed codes over finite fields, Gaussian integers, quaternion integers, etc. In this article, the author defines octonion integers, fundamental theorems related to octonion integers, encoding, and decoding of cyclic codes over the residue class of octonion integers with respect to the octonion Mannheim weight one. The comparison of primes, lengths, cardinality, dimension, and code rate with respect to Quaternion Integers and Octonion Integers will be discussed.