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https://doi.org/10.17085/apm.2019.14.4.371
Coagulation abnormalities and bleeding in pregnancy: an anesthesiologist's perspective
Anesth Pain Med 2019;14(4):371-9
Published online October 31, 2019
© 2019 Korean Society of Neuroscience in Anesthesiology and Critical Care.
Hea-Jo Yoon
Department of Anesthesiology and Pain Medicine, Ilsan Jeil Hospital, Goyang, Korea
Correspondence to: Hea-Jo Yoon, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Ilsan Jeil Hospital, 174 Jangbaek-ro, Ilsandong-gu, Goyang 10414, Korea Tel: 82-31-900-2000 Fax: 82-31-900-2014 E-mail: heajo7890@daum.net
Received September 10, 2019; Accepted October 1, 2019.
Abstract Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
During pregnancy, the procoagulant activity increases (manifested by elevation in factor VII, factor VIII, factor X, and fibrinogen levels), while the anticoagulant activity decreases (characterized by reduction in fibrinolysis and protein S activity), resulting in hypercoagulation. Standard coagulation tests, such as prothrombin time or activated partial thromboplastin time, are still used despite the lack of evidence supporting its accuracy in evaluating the coagulation status of pregnant women. Thromboelastography and rotational thromboelastometry, which are used to assess the function of platelets, soluble coagulation factors, fibrinogen, and fibrinolysis, can replace standard coagulation tests. Platelet count and function and the effect of anticoagulant treatment should be assessed to determine the risk of hematoma associated with regional anesthesia. Moreover, anesthesiologists should monitor patients for postpartum hemorrhage (PPH), and attention should be paid when performing rapid coagulation tests, transfusions, and prohemostatic pharmacotherapy. Transfusion of a high ratio of plasma and platelets to red blood cells (RBCs) showed high hemostasis success and low bleeding-related mortality rates in patients with severe trauma. However, the effects of high ratios of plasma and platelets and the ratio of plasma to RBCs and platelets to RBCs in the treatment of massive PPH were not established. Intravenous tranexamic acid should be administered immediately after the onset of postpartum bleeding. Pre-emptive treatment with fibrinogen for PPH is not effective in reducing bleeding. If fibrinogen levels of less than 2 g/L are identified, 2–4 g of fibrinogen or 5–10 ml/kg cryoprecipitate should be administered.
Key Words : Blood transfusion; Conduction anesthesia; Fibrinogen; Postpartum hemorrhage; Tranexamic acid.
INTRODUCTION Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
The physiology of coagulation in pregnant women differs from that in men or in women who are not pregnant. Pregnant women frequently develop physiological anemia and experience changes in the levels of coagulation factors that alter the balance between coagulation and bleeding in preparation for bleeding during birth. Anesthesiologists should understand both physiological changes in the coagulation system and diseaseand medication-induced pathophysiological changes during pregnancy and increase the safety of regional anesthesia for painless delivery and cesarean section. According to Vandermeulen et al. [1], spinal hematoma following the administration of regional anesthesia was associated with coagulation abnormalities in 68% of cases. In addition, obstetrical bleeding is the major cause of maternal mortality [2]. Although much progress has been made in the management of massive bleeding after conducting vigorous research, most study participants were trauma patients rather than pregnant women [3]. Massive bleeding caused by trauma and postpartum hemorrhage (PPH) differ in terms of the gender and coagulation mechanisms of the subjects; therefore, PPH requires an evidence-based treatment from the perspective of internal medicine, which is different from that used for treating bleeding caused by trauma [4].
This study takes an anesthesiologist's perspective to examine the changes in coagulation-related factors. It also aims to determine the risk for coagulation during pregnancy, incidence of hereditary or acquired coagulation disorders in pregnant women, risk for regional anesthesia administration in pregnant women with coagulation abnormalities, rate of transfusion in women with PPH, and pharmacological treatment for pregnant women with coagulation disorders under special circumstances such as intrauterine fetal death.
CHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCY Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
During pregnancy, the levels of factor VII, factor VIII, and factor X increase along with fibrinogen, while fibrinolysis and the activity of protein S decrease, resulting in hypercoagulation [5]. The level of fibrinogen increases significantly from the 28th week of pregnancy and is two times higher (350–650 mg/dl) than that in non-pregnant women (200–400 mg/ dl) at the end of pregnancy [4]. D-dimer level also increases throughout pregnancy; at the end of pregnancy, the level exceeds the level used to diagnose thromboembolism in nonpregnant population [4].
TESTS FOR COAGULATION STATUS Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
Standard (traditional) coagulation test
Prothrombin time/international normalized ratio or activated partial thromboplastin time has been used to diagnose coagulation disorders and to assess coagulation disorder correction or hemostasis. Haas et al. [6] reviewed 11 mass transfusion or perioperative bleeding management guidelines and 64 studies that examined the efficacy of standard coagulation tests. They could not identify well-founded and well-designed studies that demonstrated the usefulness of standard coagulation tests in the diagnosis of coagulation disorders and hemostasis [6].
Although the prothrombin time/international normalized ratio and activated partial thromboplastin time are suitable methods for evaluating the coagulation status in patients receiving warfarin and heparin treatment, respectively, it is difficult to properly evaluate the coagulation status in patients with clinical bleeding [7]. Moreover, the results of standard coagulation tests are usually obtained 1 h after [8]. Nevertheless, results of traditional standard coagulation tests are still used as a basis to determine the need for blood transfusions, as new standard tests to measure coagulation status are not yet established [9].
A few studies have reported fibrinogen as an important predictor of PPH [10,11]. Fibrinogen level less than 2 g/L can predict PPH with 100% positive predictability and 99.3% specificity and is an independent variable that predicts the need for invasive techniques such as artery ligation, embolization, and hysterectomy [10–12]. When fibrinogen level exceeded 4 g/L, the outcome of PPH was good, with 79% negative predictability [10].
Thromboelastography (TEG)/rotational thromboelastometry (ROTEM)
TEG or ROTEM can replace the standard coagulation test by measuring the overall process of hemostasis in whole blood [13]. These tests are used to measure platelet, soluble coagulation factor, and fibrinogen levels and determine the role of fibrinolysis [13]. As fibrinogen is recognized as a predictor of severe PPH, the need for rapid testing for hypofibrinogenemia is becoming apparent [10]. TEG and ROTEM are gaining attention because they can be used to diagnose hypofibrinogenemia and verify the effectiveness of fibrinogen supplement therapy while being the only test that can detect excessive fibrinolysis [13,14]. By measuring the amplitude of FIBTEM, which is a type of ROTEM that measures fibrinogen levels, the level of fibrinogen can be estimated within 5 min [14]. In addition, FIBTEM amplitude is an independent variable for predicting massive bleeding (> 2,500 ml), the need for transfusion of red blood cells, and the duration of ICU stay [15]. However, only a few studies have reported the accuracy of TEG and ROTEM in predicting the development of hematomas during regional anesthesia [16]. Hydroxyethyl starch (HES) can cause coagulation disorder and may have an effect on coagulation tests [17]. The use of HES in patients undergoing cesarean section can extend the clot reaction time and kinetic time of TEG, although the values are still within the normal range [18].
The 2019 Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) PPH guidelines recommend monitoring the coagulation status of PPH patients and using laboratory tests including traditional standard tests (platelets, prothrombin time, international normalized ratio, activated partial thromboplastin time, and fibrin level) or TEG/ROTEM to determine the need for goaloriented transfusion strategies and administering hemostasis-inducing drugs [9].
HEREDITARY COAGULATION DISORDERS Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
Von Willebrand disease or hemophilia (carrier) is a representative hereditary disorder in pregnant women. Regional anesthesia and normal vaginal delivery are possible in patients with hereditary coagulation disorders [8]. In the case of a severe coagulation disorder, the blood coagulation factor levels should be maintained within normal range for 3–5 days following an uncomplicated vaginal delivery or 5–7 days following a cesarean section [19]. Moreover, tranexamic acid, 1-desamino-9-d-arginine vasopressin (DDAVP), recombinant protein, and plasma or cryoprecipitate can be used to treat coagulation disorders [8]. After treating the coagulation disorders, the use of anticoagulants should be considered to prevent deep thrombosis [8].
ACQUIRED COAGULATION DISORDERS Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
Platelet disease
Platelet abnormalities are the most common blood disorder during pregnancy and can be categorized into platelet count and platelet function disorders [8]. Platelet count of 150 × 109/L or less is used as a criterion for diagnosing thrombocytopenia during pregnancy [20]. Ninety-nine percent of thrombocytopenia cases during pregnancy are associated with hypertensive diseases such as preeclampsia, gestational thrombocytopenia, or idiopathic thrombocytopenic purpura [8]. In addition, platelet count should be evaluated to help in the diagnosis of premature placental detachment and determine if the patient recently received an anticoagulant therapy [21].
The platelet level in pregnant women with gestational thrombocytopenia or idiopathic thrombocytopenic purpura is usually stable and within normal range [8,22]. On the contrary, the platelet count in patients with preeclampsia changes rapidly, requiring continuous platelet measurement; and the platelet function in severe preeclampsia patients may be reduced [22]. Pregnant women with mild or moderate preeclampsia may receive regional anesthesia based on the platelet count and coagulation test results obtained within 6 h [21]. However, in patients with severe preeclampsia, preeclampsia, and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, platelet counts and coagulation tests should be performed immediately prior to the administration of regional anesthesia, as the platelet count may decrease rapidly [21]. The incidence of spinal hematoma associated with the use of epidural anesthesia in preeclamptic pregnant women with thrombocytopenia is very low, and only one case was reported [23].
The plasma platelet levels that are associated with a high incidence of hematoma after the administration of regional anesthesia were not, even if agreed upon by experts, reported in clinical trials; hence, it is difficult to mention a specific value, but reference platelet levels have been suggested in several studies [8,21]. In healthy pregnant women, the risk for hematoma does not increase in patients with a platelet count of 100 × 109/L or above, and the level does not decrease at a platelet count of 75 × 109/L; hence, regional anesthesia can be administered in pregnant women with these values in the absence of other risk factors [21,24]. Thrombocytopenia occurring in pregnant women with preeclampsia can be accompanied by other coagulation disorders, and a coagulation disorder test should be performed when platelet count is below 100 × 109/L [21]. If the result of the coagulation disorder test is normal, regional anesthesia may be administered in pregnant women with a platelet count of 75 × 109/L, taking into account the rate at which platelet decreases [25]. In idiopathic thrombocytopenic purpura and gestational thrombocytopenia, regional anesthesia can be administered if the platelet count is greater than 50 × 109/L and stable [21]. Referring to the report that hematologists have performed lumbar puncture without sequelae using a needle that is thicker than the needle for spinal anesthesia used in obstetric anesthesia, spinal anesthesia may be administered in pregnant women with a platelet count of 50 × 109/L or less [21]. In addition, spinal anesthesia can be safely administered, even if the platelet count is less than 40 × 109/L, in the absence of other coagulation disorders [21,26].
Pregnant women who use anticoagulants
Caution is required for pregnant women who use drugs that affect coagulation. Table 1 summarizes the time required after injection of regional anesthetics (basically neuraxial anesthesia in pregnant women with normal kidney function), drug injected during epidural catheterization, and anticoagulant injected after regional anesthesia or catheter removal in pregnant women who use anticoagulants.
Recommendations related to Drug Use that Affect Coagulation
Acceptable time after drug for block performance
Administration of drug while spinal or epidural catheter in place
Acceptable time after block performance or catheter removal for next drug dose
UFH sc prophylaxis 4 h or normal aPTT Caution 1 h
UFH iv treatment 4 h or normal aPTT Caution 4 h
LMWH sc prophylaxis 12 h Caution 4 h
LMWH sc treatment 24 h Not recommended 4 h
Antiplatelet drugs
NSAIDs No additional precautions No additional precautions No additional precautions
Aspirin No additional precautions No additional precautions No additional precautions
Clopidogrel 7 days Not recommended 6 h
Prasugrel 7 days Not recommended 6 h
Oral anticoagulants
Warfarin INR ≤ 1.4 Not recommended After catheter removal
Rivaroxaban prophylaxis (CrCl > 30 ml/min) 18 h Not recommended 6 h
Thrombolytic drugs
Alteplase, anistreplase, reteplase, and streptokinase 10 days Not recommended 10 days
UFH: unfractionated heparin, sc: subcutaneous, aPTT: activated partial thromboplastin time, iv: intravenous, LMWH: low molecular weight heparin, NSAIDs: non-steroidal anti-inflammatory drugs, INR: international normalized ratio, CrCl: creatinine clearance. Modified from the article of Harrop- Griffiths et al. Anaesthesia 2013;68:966-72 [21].
RELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCK Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
The likelihood of developing hematoma after administering regional anesthesia or peripheral nerve block decreases in the following order: the risk increases after epidural anesthesia with catheterization, while the risk decreases after administering epidural anesthesia without catheterization, spinal anesthesia, paravertebral block, deep block (celiac plexus block, stellate ganglion block, etc.), superficial perivascular blocks (popliteal sciatic block, femoral nerve block, etc.), fascia block (ilio-inguinal block, Ilio-hypogastric block, etc.), superficial block (brachial nerve block, Bier's block, etc.), and regional anesthesia [21]. Catheterization is more dangerous than one-time injection, and there is a risk for catheter removal [21]. Ultrasound-guided regional anesthesia can reduce vascular rupture, thereby reducing the risk of clavicle block in patients with coagulation disorders [21].
RISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
The relative risks of spinal cord compression and permanent injury due to vertebral hematoma during the administration of neuraxial anesthesia in pregnant women with coagulation disorders are listed in Table 2.
Relative Risks associated with Neuraxial Blocks in Obstetric Patients with Coagulation Abnormalities
Normal risk
Very high risk
LMWH – prophylactic dose > 12 h 6–12 h < 6 h < 6 h
LMWH – therapeutic dose > 24 h 12–24 h 6–12 h
UFH – infusion Stopped > 4 h and APPT ≤ 1.4 APPT above normal range
UFH – prophylactic bolus dose Last given > 4 h Last given < 4 h
NSAID + aspirin Without LMWH With LMWH dose 12–24 h With LMWH dose < 12 h
Warfarin INR ≤ 1.4 INR 1.4–1.7 INR 1.7–2.0 INR > 2.0
General anesthesia Starved, not in labor, antacids given Full stomach or in labor
Preeclampsia Platelets > 100 × 109/L within 6 h of block Platelets 75–100 × 109/L (stable) and normal coagulation tests Platelets 75–100 × 109/L (decreasing) and normal coagulation tests Platelets < 75 × 109/L or abnormal coagulation tests with indices ≥ 1.5 or HELLP syndrome
Idiopathic thrombocytopenia Platelets > 75 × 109/L within 24 h of block Platelets 50–75 × 109/L Platelets 20–50 × 109/L Platelets < 20 × 109/L
Intra-uterine fetal death FBC and coagulation tests normal No clinical problems but no investigation results available With abruption or overt sepsis
Cholestasis INR ≤ 1.4 within 24 h No other clinical problems but no investigation results available
LMWH: low molecular weight heparin, UFH: unfractionated heparin, aPTT: activated partial thromboplastin time, INR: international normalized ratio. Modified from the article of Harrop-Griffiths et al. Anaesthesia 2013;68:966-72 [21].
RISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCES Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
After intrauterine fetal death (particularly 2 weeks after fetal death), there is a high likelihood of developing coagulation abnormalities and sepsis [27]. Coagulation abnormalities occur in 3% of patients who experienced uncomplicated intrauterine fetal death and in 13% of patients with placental detachment or uterine perforation [27]. The timing of onset for coagulation disorders varies and can progress rapidly; hence, it is important to know the patients' coagulation status to determine the risk for intrauterine fetal death [21].
Because trauma can cause coagulation disorders due to shock, hemodilution, hypothermia, acidemia, and inflammation, it is advisable to identify the coagulation status before administering regional anesthesia in patients with severe traumas [21]. Severe sepsis is a contraindication to regional anesthesia, as it can lead to coagulation disorders as well as consumptive coagulopathy and can increase the incidence of epidural abscess or meningitis [21]. In severe cases of uremia, platelet count and function tests are required, and platelet function may be improved by administering DDAVP [21]. The residual effects of anticoagulants should be assessed in dialysis patients receiving heparin, and the heparin effect should be reversed, if necessary [21,28]. If heparin was administered in dialysis patients who received regional anesthesia, caution must be taken during catheter removal to prevent bleeding [21] As all coagulation factors except for coagulation factor VIII are synthesized in the liver, liver failure is associated with coagulation disorders and coagulation tests should be performed before administering regional anesthesia [21,28]. In addition, hypersplenism may result in platelet count decrease and platelet dysfunction [21,28]. In mass transfusions, coagulation disorders may occur due to dilution and consumption of coagulation factors, and platelet function should be assessed if the patient has a history of platelet transfusion as this can lead to platelet dysfunction [21,29]. Disseminated coagulation disorders are consumptive coagulopathies, contraindicated in regional anesthesia, and should be blocked where they can be compressed with peripheral nerve blocks [21].
MEDICAL TREATMENT OF PPH Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
Obstetrical bleeding is a major cause of uterine atony, but it can also be caused by premature placenta detachment, placenta accrete, amniotic embolism, and consumptive coagulopathy [30]. Anesthesiologists and physicians are advised to actively intervene when there is massive bleeding or if early bleeding occurs in patients with severe PPH, even in the absence of cardiovascular instability [9]. The main components of the medical treatment of PPH are rapid testing of coagulation disorders, transfusion therapy, and prohemostatic pharmacotherapy as adjuvant therapies [17].
A large-scale cohort study conducted among patients with massive bleeding from trauma reported that a higher ratio of plasma and platelets to red blood cells during transfusion reduced the rate of mortality within 24 hours after hospitalization [31]. A four-year retrospective study of 142 patients reported a reduction in the incidence of interventional procedures when blood transfusions were performed with a serum to erythrocyte ratio of 1:2 or higher [32]. In addition, a randomized study of 680 patients with severe trauma published in JAMA in 2015 had the following conclusion. Patients with severe trauma and massive bleeding did not show a difference in the overall 24-h and 30-day mortalities when transfusion was performed with plasma, platelet, and erythrocyte ratio of 1:1:1 and 1:1:2. However, hemostasis success rate was higher in the patient group with 1:1:1 ratio and had a lower bleeding-related mortality rate within 24 h [33]. However, in the absence of a large, well-designed, randomized study of PPH patients, it is difficult to determine the appropriate plasma, platelet, and erythrocyte ratios for transfusions in pregnant women with PPH. The guidelines for the management of coagulation disorders related to PPH in the International Society of Thrombosis and Haemostasis are against the 1:1:1-ratio transfusions of plasma, platelet, and erythrocytes and recommended fibrinogen supplementation (cryoprecipitates or fibrinogen concentrate transfusion) and platelet transfusion if it is difficult to obtain coagulation test results after transfusing 8 units of red blood cells and fresh frozen plasma [34]. Some studies have shown that vascular endothelial glycocalyx, which protects the blood vessels, is damaged in patients with traumatic bleeding, and that plasma transfusions have been reported to reduce glycocalyx degradation, autoheparinization, and bleeding [35,36]. These studies emphasize that blood transfusions not only replenish plasma components but also protect the blood vessels [36]. The vascular endothelium in pregnant women, especially those with HELLP syndrome, has damaged glycocalyx; therefore, the plasma components may be expected to play a protective role in pregnant women [37].
NATA guidelines recommend a restrictive erythrocyte transfusion policy that considers erythrocyte transfusion only if hemoglobin levels are less than 7 g/dl for PPH unless in cases of massive bleeding, and 15 to 20 ml/kg plasma transfusion for coagulation abnormality in pregnant women with severe PPH NATA [9].
Pharmacologic treatment of coagulation abnormalities caused by PPH
Antifibrinolytic therapy
Antifibrinolytic agents such as tranexamic acid inhibit fibrinase activity and stabilize fibrin clots [17]. Tranexamic acid reduces perioperative bleeding by interfering with fibrin degradation by plasmin without any special side effects [38]. In their meta-analysis, Ferrer et al. [39] reported that preadministration of tranexamic acid in patients who underwent cesarean sections or vaginal delivery can reduce bleeding.
A randomized study was conducted in 20,000 individuals to examine the effects of early administration of tranexamic acid [40]. This study was performed in patients with a clinical diagnosis of PPH after cesarean section or vaginal delivery. If postpartum bleeding occurred, 1 g of tranexamic acid was given as an intravenous (IV) injection; if postpartum bleeding continued for 30 min or if bleeding re-occurred within 24 h, an additional 1 g was injected intravenously. Tranexamic acid reduced PPH mortality. Previous studies suggested that tranexamic acid should be administered as soon as the bleeding begins (within 3 h after delivering the fetus). The incidence of thromboembolism was not correlated with the administration of tranexamic acid [40].
The NATA guidelines recommended the IV injection of 0.5 to 1.0 g of tranexamic acid along with oxytocin if there is a high likelihood of PPH upon cesarean section and the IV injection of 1 g of tranexamic acid as soon as postpartum bleeding begins within 3 h, with an additional 1 g of tranexamic acid as via IV injection if postpartum bleeding continues after 30 min [9].
Fibrinogen supplementation
Low fibrinogen levels in the early stages of PPH have been associated with excessive bleeding and transfusion in several observational studies [10,11]. Cryoprecipitates and fibrinogen concentrates can be used to supplement fibrinogen, both of which contain more fibrinogen than plasma [17]. Fibrinogen concentrate differs from cryoprecipitates in that it contains less germs and can be used within 10 to 15 min (cryoprecipitates take more than 30 min to thaw) [41]. Cryoprecipitates, however, has von Willebrand factor, coagulation factor VIII, and coagulation factor XIII as well as fibrinogen [41]. Although fibrinogen concentrates are widely used to correct hypofibrinolysis, it remains unclear whether fibrinogen concentrates reduce bleeding [42,43].
In a randomized study conducted in patients with severe PPH (blood loss of at least 1 L after vaginal delivery or at least 0.5 L after placenta removal in vaginal delivery, and blood loss of at least 1 L during cesarean section) who had normal fibrinogen level prior to PPH but whose plasma fibrinogen level was not identified, the administration of 2 g of fibrinogen concentrate as a treatment for PPH could not reduce the frequency of transfusions although it did increase the level of plasma fibrinogen [44]. Therefore, it is advisable to assess the plasma level of fibrinogen and administer 2–4 g of fibrinogen or 5–10 ml/kg of cryoprecipitates only when fibrinogen level is 2 g/L (or ROTEM FIBTEM A5 < 12 mm or TEG FF MA < 14 mm) [9].
Prevention of thromboembolism
Correction of coagulation abnormality is important in severe PPH, but care must also be taken to prevent thromboembolism; the NATA guidelines recommend that prevention of thromboembolism be initiated if bleeding stabilizes after severe PPH and transfusion [9].
CONCLUSION Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
Regional anesthesia is often used in pregnant women. Therefore, when anesthesia is administered in pregnant women with coagulation disorders or in those using heparin and antiplatelet agents, the anesthesiologists should accurately identify the coagulation status of individual patients according to the procedure or the processes involved in the procedure (e.g., catheter removal after epidural anesthesia administration). Compared with traditional standard laboratory tests, field tests such as TEG and ROTEM can quickly diagnose a wider range of coagulation disorders [13]. In addition, anesthesiologists should be actively involved as part of a multidisciplinary team from the onset of PPH. In patients with severe PPH, the active use of plasma, platelets, and fibrinogen should be considered, and tranexamic acid, which is currently the most justified treatment, should be administered [9,40].
SUPPLEMENTARY MATERIALS Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
APM-14-371_suppl.pdf
CONFLICTS OF INTEREST Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
References Other SectionsAbstractINTRODUCTIONCHANGES IN COAGULATION-RELATED FACTORS DURING PREGNANCYTESTS FOR COAGULATION STATUSHEREDITARY COAGULATION DISORDERSACQUIRED COAGULATION DISORDERSRELATIVE RISK OF REGIONAL ANESTHESIA AND PERIPHERAL NERVE BLOCKRISK ASSOCIATED WITH REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERSRISK OF REGIONAL ANESTHESIA IN PREGNANT WOMEN WITH COAGULATION DISORDERS UNDER SPECIAL CIRCUMSTANCESMEDICAL TREATMENT OF PPHCONCLUSIONSUPPLEMENTARY MATERIALSCONFLICTS OF INTERESTReference
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De Pietri L, Bianchini M, Montalti R, De Maria N, Di Maira T, and Be-gliomini B et al. Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy:A randomized, controlled trial. Hepatology 2016;63:566-73.
Ducloy-Bouthors AS, Susen S, Wong CA, Butwick A, Vallet B, and Lockhart E. Medical advances in the treatment of postpartum hemorrhage. Anesth Analg 2014;119:1140-7.
Butwick A, and Carvalho B. The effect of colloid and crystalloid preloading on thromboelastography prior to Cesarean delivery. Can J Anaesth 2007;54:190-5.
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Harrop-Griffiths W, Cook TM, Gill H, Hill D, Ingram M, and Makris M et al. Regional anaesthesia and patients with abnormalities of coagulation:the Association of Anaesthetists of Great Britain &Ireland The Obstetric Anaesthetists'Association Regional Anaesthesia UK. Anaesthesia 2013;68:966-72.
Davies JR, Fernando R, and Hallworth SP. Hemostatic function in healthy pregnant and preeclamptic women:an assessment using the platelet function analyzer (PFA-100) and thromboelastograph. Anesth Analg 2007;104:416-20.
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Sharma SK, Philip J, Whitten CW, Padakandla UB, and Landers DF. Assessment of changes in coagulation in parturients with preeclampsia using thromboelastography. Anesthesiology 1999;90:385-90.
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Maslow AD, Breen TW, Sarna MC, Soni AK, Watkins J, and Oriol NE. Prevalence of coagulation abnormalities associated with intrauterine fetal death. Can J Anaesth 1996;43:1237-43.
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Mhyre JM, Shilkrut A, Kuklina EV, Callaghan WM, Creanga AA, and Kaminsky S et al. Massive blood transfusion during hospitalization for delivery in New York State 1998-2007. Obstet Gynecol 2013;122:1288-94.
Holcomb JB, del Junco DJ, Fox EE, Wade CE, Cohen MJ, and Schreiber MA et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study:comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg 2013;148:127-36.
Pasquier P, Gayat E, Rackelboom T, La Rosa J, Tashkandi A, and Tes-niere A et al. An observational study of the fresh frozen plasma:red blood cell ratio in postpartum hemorrhage. Anesth Analg 2013;116:155-61.
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, and Podbielski JM et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma:the PROPPR randomized clinical trial. JAMA 2015;313:471-82.
Collins P, Abdul-Kadir R, and Thachil J. Management of coagulopathy associated with postpartum hemorrhage:guidance from the SSC of the ISTH. J Thromb Haemost 2016;14:205-10.
Johansson PI, Stensballe J, Rasmussen LS, and Ostrowski SR. A high admission syndecan-1 level, a marker of endothelial glycocalyx degradation, is associated with inflammation, protein C depletion, fibrinolysis, and increased mortality in trauma patients. Ann Surg 2011;254:194-200.
Ostrowski SR, and Johansson PI. Endothelial glycocalyx degradation induces endogenous heparinization in patients with severe injury and early traumatic coagulopathy. J Trauma Acute Care Surg 2012;73:60-6.
Hofmann-Kiefer KF, Knabl J, Martinoff N, Schiessl B, Conzen P, and Rehm M et al. Increased serum concentrations of circulating glycocalyx components in HELLP syndrome compared to healthy pregnancy:an observational study. Reprod Sci 2013;20:318-25.
Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, and Fergusson DA et al. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2011;3:CD001886.
Ferrer P, Roberts I, Sydenham E, Blackhall K, and Shakur H. Antifibrinolytic agents in post partum haemorrhage:a systematic review. BMC Pregnancy Childbirth 2009;9:29.
WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN):an international, randomised, double-blind, placebo-controlled trial. Lancet 2017;389:2105-16.
Levy JH, Welsby I, and Goodnough LT. Fibrinogen as a therapeutic target for bleeding:a review of critical levels and replacement therapy. Transfusion 2014;54:1389-405.
Butwick AJ. Postpartum hemorrhage and low fibrinogen levels:the past, present and future. Int J Obstet Anesth 2013;22:87-91.
Park SW. Diagnosis and management of postpartum hemorrhage. Anesth Pain Med 2013;8:209-15.
Wikkelsø AJ, Edwards HM, Afshari A, Stensballe J, Langhoff-Roos J, and Albrechtsen C et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage:randomized controlled trial. Br J Anaesth 2015;114:623-33.
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Q: Sqlalchemy how to handle multiple related many-to-many relationships I'm building a fastapi API with sqlalchemy as ORM and posgtres as db server.
I have multiple many-to-many relationships consider this setup:
Organization can have many Employee(s) and Employee can be in many Organization(s) so it is many-to-many relationship.
Employee can have many EmployeeRole(s) and EmployeeRole can be in many Employee(s) so it is another many-to-many relationship.
I want to achieve EmployeeRole depends on Organization where Employee listed.
Here is the diagram to visualize the whole setup:

Here is what I have now:
Models.py
class Organization(Base):
    """A model representing a organization."""

    __tablename__ = 'organizations'

    id = Column(UUID(as_uuid=True), primary_key=True, index=True, default=uuid.uuid4)
    title = Column(String(length=OrgamizationModelConstants.CHAR_SIZE_512.value), unique=True)
    description = Column(String(length=OrgamizationModelConstants.CHAR_SIZE_8192.value))
    email = Column(String(length=OrgamizationModelConstants.CHAR_SIZE_256.value), unique=True)
    phone_number = Column(String(length=OrgamizationModelConstants.CHAR_SIZE_128.value), unique=True)
    created_at = Column(DateTime, default=datetime.now())

    employees = relationship('Employee', secondary='organization_employee_association', lazy='subquery')

    __mapper_args__ = {'eager_defaults': True}

    def __repr__(self):
        return f'Organization id={self.id}, title={self.title}, created_at={self.created_at}'

class Employee(Base):
    """A model representing a employee."""

    __tablename__ = 'employees'

    id = Column(UUID(as_uuid=True), primary_key=True, index=True, default=uuid.uuid4)
    user_id = Column(UUID(as_uuid=True), ForeignKey('users.id'), nullable=False, unique=True)
    created_at = Column(DateTime, default=datetime.now())
    user = relationship('User', back_populates='employee', uselist=False, lazy='subquery')

    __mapper_args__ = {'eager_defaults': True}

    def __repr__(self):
        return f'Employee id={self.id}, user_id={self.user_id}, created_at={self.created_at}'

class EmployeeRole(Base):
    """A model representing a employee role."""

    __tablename__ = 'employee_roles'

    id = Column(UUID(as_uuid=True), primary_key=True, index=True, default=uuid.uuid4)
    name = Column(String(length=EmployeeRoleModelConstants.CHAR_SIZE_256.value), unique=True)
    created_at = Column(DateTime, default=datetime.now())

    __mapper_args__ = {'eager_defaults': True}

    def __repr__(self):
        return f'EmployeeRole id={self.id}, name={self.name}, created_at={self.created_at}'

class OrganizationEmployeeRoleAssociation(Base):
    """Many-to-Many table for OrganizationEmployeeAssociation and EmployeeRole models association."""

    __tablename__ = 'organization_employee_role_association'
    __table_args__ = (
        UniqueConstraint('organization_employee_id', 'role_id', name='_organization_employee_role_uc'),
    )

    id = Column(UUID(as_uuid=True), primary_key=True, index=True, default=uuid.uuid4)
    organization_employee_id = Column(
        UUID(as_uuid=True), ForeignKey('organization_employee_association.id', ondelete='CASCADE'), nullable=False,
    )
    role_id = Column(UUID(as_uuid=True), ForeignKey('employee_roles.id', ondelete='CASCADE'), nullable=False)
    created_at = Column(DateTime, default=datetime.now())

    __mapper_args__ = {'eager_defaults': True}

    def __repr__(self):
        return (
            f'OrganizationEmployeeRoleAssociation: organization_employee_id={self.organization_employee_id}, '
            f'role_id={self.role_id}, created_at={self.created_at}'
        )

class OrganizationEmployeeAssociation(Base):
    """Many-to-Many table for Organization and Employee models association."""

    __tablename__ = 'organization_employee_association'
    __table_args__ = (
        UniqueConstraint('organization_id', 'employee_id', name='_organization_employee_uc'),
    )

    id = Column(UUID(as_uuid=True), primary_key=True, index=True, default=uuid.uuid4)
    organization_id = Column(UUID(as_uuid=True), ForeignKey('organizations.id', ondelete='CASCADE'), nullable=False)
    employee_id = Column(UUID(as_uuid=True), ForeignKey('employees.id', ondelete='CASCADE'), nullable=False)
    created_at = Column(DateTime, default=datetime.now())

    roles = relationship(
        'EmployeeRole',
        secondary='organization_employee_role_association',
        lazy='subquery',
    )

    __mapper_args__ = {'eager_defaults': True}

    def __repr__(self):
        return (
            f'OrganizationEmployeeAssociation: organization_id={self.organization_id}, employee_id={self.employee_id}, '
            f'created_at={self.created_at}'
        )

Here is how I getting an organization with loaded relationships by id:
async def _get_organization_by_id_with_relationships(self, id_: UUID) -> Organization | None:
        roles_subquery = (
            select(EmployeeRole, OrganizationEmployeeAssociation).join(
                OrganizationEmployeeRoleAssociation, OrganizationEmployeeRoleAssociation.role_id == EmployeeRole.id
            ).join(
                OrganizationEmployeeAssociation,
                OrganizationEmployeeAssociation.id == OrganizationEmployeeRoleAssociation.organization_employee_id
            ).subquery()
        )
        EmployeeRoleAlias = aliased(EmployeeRole, roles_subquery)
        Employee.roles = relationship(EmployeeRoleAlias, primaryjoin=Employee.id == roles_subquery.c.employee_id)
        q = select(Organization).where(Organization.id == id_).options(
            subqueryload(Organization.employees).subqueryload(Employee.roles),
        )
        result = await self.session.execute(q)
        return result.scalars().one_or_none()

Examples
In current setup the problem is that Employee roles showing without the regard of the organization where Employee listed.
Example how it is working now:
# GET /organizations
{
    "status_code": 200,
    "data": [
        {
            "title": "Organization Title 1",
            "description": "Organization description 1.",
            "phone_number": "+111222333444",
            "email": "Organization1@totalynotemail.com",
            "id": "1",
            "employees": [
                {
                    "first_name": "bob",
                    "id": "1",
                    "roles": [
                        {
                            "id": "1",
                            "name": "supervisor"
                        }
                    ]
                },
                {
                    "first_name": "bob2",
                    "id": "2",
                    "roles": [
                        {
                            "id": "2",
                            "name": "manager"
                        }
                    ]
                }
            ]
        },
        {
            "title": "Organization Title 2",
            "description": "Organization description 2.",
            "phone_number": "+222555333444",
            "email": "Organization2@totalynotemail.com",
            "id": "2",
            "employees": [
                {
                    "first_name": "bob2",
                    "id": "2",
                    "roles": [
                        {
                            "id": "1",
                            "name": "supervisor"
                        },
                        {
                            "id": "2",
                            "name": "manager"
                        }
                    ]
                }
            ]
        }
    ],
    "errors": []
}

When we creating an organization we adding user as an Employee with role supervisor to this organization.
Notice How bob_2 who were added as 'manager' on Org_1 and now created Org_2, his roles in Org_2 'manager' and 'supervisor', but he is 'manager' only in Org_1 !
I want it to work this way:
# GET /organizations
{
    "status_code": 200,
    "data": [
        {
            "title": "Organization Title 1",
            "description": "Organization description 1.",
            "phone_number": "+111222333444",
            "email": "Organization1@totalynotemail.com",
            "id": "1",
            "employees": [
                {
                    "first_name": "bob",
                    "id": "1",
                    "roles": [
                        {
                            "id": "1",
                            "name": "supervisor"
                        }
                    ]
                },
                {
                    "first_name": "bob2",
                    "id": "2",
                    "roles": [
                        {
                            "id": "2",
                            "name": "manager"
                        }
                    ]
                }
            ]
        },
        {
            "title": "Organization Title 2",
            "description": "Organization description 2.",
            "phone_number": "+222555333444",
            "email": "Organization2@totalynotemail.com",
            "id": "2",
            "employees": [
                {
                    "first_name": "bob2",
                    "id": "2",
                    "roles": [
                        {
                            "id": "1",
                            "name": "supervisor"
                        }
                    ]
                },
                                {
                    "first_name": "bob",
                    "id": "1",
                    "roles": [
                        {
                            "id": "2",
                            "name": "manager"
                        }
                    ]
                },
            ]
        }
    ],
    "errors": []
}

Where Employee role depends on Organization where employee listed.
Questions

*

*How to build such relationship, where Employee role separated and based on Organization where the Employee listed?

*Where to store logic of joins, relationships etc? Should it be stored in Models, or in business logic layer?

*What is proper way to add Employee to Organization?

*What is proper way to add EmployeeRole to Employee?

redpajama_set_name: RedPajamaStackExchange


text:
Fragile Things (Mass Market)
Short Fictions and Wonders
Harper, 9780060515232, 400pp.
Digital Audiobook (11/6/2006)
Paperback (10/2/2007)
CD-Audio (5/11/2010)
Hardcover (9/26/2006)
Compact Disc (9/26/2006)
MP3 CD (10/1/2006)
Compact Disc (10/1/2006)
"A prodigiously imaginative collection."
—New York Times Book Review, Editor's Choice
"Dazzling tales from a master of the fantastic."
—Washington Post Book World
Fragile Things is a sterling collection of exceptional tales from Neil Gaiman, multiple award-winning (the Hugo, Bram Stoker, Newberry, and Eisner Awards, to name just a few), #1 New York Times bestselling author of The Graveyard Book, Anansi Boys, Coraline, and the groundbreaking Sandman graphic novel series. A uniquely imaginative creator of wonders whose unique storytelling genius has been acclaimed by a host of literary luminaries from Norman Mailer to Stephen King, Gaiman's astonishing powers are on glorious displays in Fragile Things. Enter and be amazed!
Praise For Fragile Things: Short Fictions and Wonders…
"[Gaiman] is a one-man story engine. . . . Fragile Things is a delightful compendium . . . [Gaiman] is indeed a national treasure."
— Washington Post Book World
"The tales of Fragile Things are nibbles and bits of Gaiman's immensely satisfying inner landscape. They are fiercely playful and very grim, wisps of whimsy and wonder buoyed by the happy heart of a tragic poet."
— USA Today
"Charming, at times creepy, and good fun. . . . Well-worth adding to any collection; highly recommended."
"A prodigiously imaginative collection . . . The best of these clever fantasy metafictions explore the mysteries of artistic inspiration."
— New York Times Book Review, Editor's Choice
"Strange, or sweet, or eerie, or heartfelt stories . . . wonderfully peculiar . . . Gaiman relishes the sacred act of telling stories."
— Entertainment Weekly
"A powerful and oddly unified collection, a perfect introduction to Gaiman's work for new readers and a thrilling reminder to his long-time fans . . . [T]he shorter prose form allows Gaiman a greater freedom of whimsy and provocation than even his graphic work, with stunning results."
— Toronto Star
"Those with a taste for inventive idiosyncracy will find themselves fully rewarded."
— San Francisco Chronicle Book Review
"One delight after another."
— Booklist (starred review)
"Lush prose...and a winning faith in the enchantment of stories. Expect the unexpected. Then savor the chills."
— Kirkus Reviews, starred review
"FRAGILE THINGS is a delightful compendium...[Gaiman] is indeed a national treasure."
"Fiercely playful and very grim, wisps of whimsy and wonder buoyed by the happy heart of a tragic poet."
"Readers will be reminded most in these stories of that master craftsman...Ray Bradbury...Gothic tales of high caliber."
— Baltimore Sun
"A prodigiously imaginative collection...The best of these clever fantasy metafictions explore the mysteries of artistic inspiration."

redpajama_set_name: RedPajamaCommonCrawl


text:
Claude Servais Mathias Pouillet (* 16. Februar 1790 in Cusance, Département Doubs; † 14. Juni 1868 in Paris) war ein französischer Physiker.

Pouillet besuchte ab 1811 die École normale supérieure in Paris, an der er bald Repetent und Maître de conférences wurde. Er erhielt dann den Lehrstuhl für Physik am Collège royal de Bourbon und wurde 1829 zum zweiten Direktor des Konservatoriums der Künste und Gewerbe ernannt. 1831 ernannte man ihn zum Leiter dieser Einrichtung.

Als Pouillet-Effekt benannt wurde die physikalische exotherme Reaktion, die eintritt, wenn Pulver durch eine Flüssigkeit benetzt wird. Zuerst 1802 von Leslie an trockenem Sand und Wasser beobachtet, beschrieb Pouillet 1822 dieses Phänomen.

Als ein Anhänger der Julimonarchie gehörte Pouillet auch zu den Vertretern der Deputierten, die die ministerielle Politik unterstützten. Nach der Februarrevolution von 1848 zog er sich aus dem politischen Leben zurück und legte nach dem Staatsstreich vom 2. Dezember 1851 auch seine übrigen Ämter nieder.

Seit 1837 war Pouillet Mitglied der Akademie der Wissenschaften in Paris. Er bearbeitete vor allem optische, thermodynamische und elektrische Fragestellungen. Berühmt ist sein Lehrbuch Éléments de physique expérimentale et de météorologie (2 Bde., Paris 1827 bis 1830), das in der deutschen Ausgabe von Johann Heinrich Jacob Müller (ab 1842/43) als Müller-Pouillet zahlreiche Auflagen erlebte und in der 11. Auflage ab 1925 bei Vieweg erschien. Von ihm stammt auch das Lehrbuch Notions générales de physique et de météorologie (Paris 1850).

Pouillet misst 1838 mit dem von ihm erfundenen "Pyrheliometer" die von der Sonne abgestrahlte Wärmemenge. Sein Instrument wandelt die Strahlungsenergie in Wärmeenergie um. Diese lässt sich thermometrisch messen und daraus kann indirekt die Solarkonstante ermittelt werden. Pouillet ermittelte 1337 "Wärmeeinheiten pro Sekunde", was dem korrekten Wert der Solarkonstanten von 1,36 Kilowatt/m² gut entspricht. Da die korrekten Stahlungsgesetze zu dieser Zeit noch nicht bekannt waren, weicht der von Pouillet berechnete Wert für die Oberflächentemperatur der Sonne (1700 °C) stark vom tatsächlichen Wert (6058 °C) ab.

Einzelnachweise

Literatur

 Felix R. Paturi, Chronik der Technik, Chronik-Verlag in der Harenberg Kommunikation Verlags- und Mediengesellschaft mbH & Co. KG, Dortmund, 1988

Physiker (19. Jahrhundert)
Politiker (Frankreich)
Mitglied der Académie des sciences
Franzose
Geboren 1790
Gestorben 1868
Mann

redpajama_set_name: RedPajamaWikipedia


A study using National Cancer Database data has shown that the number of metastatic nodes is a primary independent factor associated with an increased mortality risk in patients with hypopharyngeal and laryngeal cancers. The study was reported in JAMA Oncology by Allen S. Ho, MD, of the Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, and colleagues.
The study involved 8,351 patients (78% male) with squamous cell carcinoma of the larynx or hypopharynx undergoing upfront surgical resection with curative intent at U.S. hospitals between 2004 and 2013. Neck dissection of a minimum of 10 nodes was required. Among these patients, 4,710 had metastatic nodes, and 3,641 had no metastatic nodes.
Ho AS, et al: JAMA Oncol. November 30, 2017 (early release online).


text:
numpy.random.Generator.pareto¶
random.Generator.pareto(a, size=None)¶
Draw samples from a Pareto II or Lomax distribution with specified shape.
The Lomax or Pareto II distribution is a shifted Pareto distribution. The classical Pareto distribution can be obtained from the Lomax distribution by adding 1 and multiplying by the scale parameter m (see Notes). The smallest value of the Lomax distribution is zero while for the classical Pareto distribution it is mu, where the standard Pareto distribution has location mu = 1. Lomax can also be considered as a simplified version of the Generalized Pareto distribution (available in SciPy), with the scale set to one and the location set to zero.
The Pareto distribution must be greater than zero, and is unbounded above. It is also known as the "80-20 rule". In this distribution, 80 percent of the weights are in the lowest 20 percent of the range, while the other 20 percent fill the remaining 80 percent of the range.
afloat or array_like of floats
Shape of the distribution. Must be positive.
Output shape. If the given shape is, e.g., (m, n, k), then m * n * k samples are drawn. If size is None (default), a single value is returned if a is a scalar. Otherwise, np.array(a).size samples are drawn.
outndarray or scalar
Drawn samples from the parameterized Pareto distribution.
scipy.stats.lomax
probability density function, distribution or cumulative density function, etc.
scipy.stats.genpareto
The probability density for the Pareto distribution is
\[p(x) = \frac{am^a}{x^{a+1}}\]
where \(a\) is the shape and \(m\) the scale.
The Pareto distribution, named after the Italian economist Vilfredo Pareto, is a power law probability distribution useful in many real world problems. Outside the field of economics it is generally referred to as the Bradford distribution. Pareto developed the distribution to describe the distribution of wealth in an economy. It has also found use in insurance, web page access statistics, oil field sizes, and many other problems, including the download frequency for projects in Sourceforge [1]. It is one of the so-called "fat-tailed" distributions.
Francis Hunt and Paul Johnson, On the Pareto Distribution of Sourceforge projects.
Pareto, V. (1896). Course of Political Economy. Lausanne.
Reiss, R.D., Thomas, M.(2001), Statistical Analysis of Extreme Values, Birkhauser Verlag, Basel, pp 23-30.
Wikipedia, "Pareto distribution", https://en.wikipedia.org/wiki/Pareto_distribution
Draw samples from the distribution:
>>> a, m = 3., 2.  # shape and mode
>>> s = (np.random.default_rng().pareto(a, 1000) + 1) * m
Display the histogram of the samples, along with the probability density function:
>>> count, bins, _ = plt.hist(s, 100, density=True)
>>> fit = a*m**a / bins**(a+1)
>>> plt.plot(bins, max(count)*fit/max(fit), linewidth=2, color='r')
>>> plt.show()


text:
"Ruth Is Stranger Than Richard" by Robert Wyatt - album review
Robert plays keyboards and sings on this one, backed by a core group of Bill MacCormick (bass), Laurie Allan (drums), George Khan (sax), Gary Windo (sax) and Brian Eno (guitar, synth, direct inject anti-jazz ray gun). It starts quite well with "Soup Song", a chipper pub-rock number of all things, before continuing the surprise with the reggae-styled "Sonia". Immediately, the saxophone boys are earning their corn, and the guesting South African trumpeter, Mongezi Feza, contributes greatly. Robert had recently lent his vocals to Phil Manzanera for his "Frontera" track, and the favour is returned here as they reinterpret the piece as "Team Spirit", a somewhat progressive piece in which Eno's direct inject anti-jazz ray gun fails to load. I was expecting much more of this LP after the brilliance of the preceding "Rock Bottom", but it proves to be somewhat anti-climactic for me, especially on side two which harks back to projects previous, primarily his short soundtrack for the 1973 film "Solar Flares" by Arthur Johns. In that context, I guess side two makes some degree of sense, but by and large it fails to stimulate my senses, drifting away unremarkably.
A1 [04:03] Robert Wyatt - Soup Song (Brian Hopper, Robert Wyatt) Cerebral Pop
A2 [04:18] Robert Wyatt - Sonia (Mongezi Feza) Reggae
A3 [08:33] Robert Wyatt - Team Spirit (Bill MacCormick, Phil Manzanera, Robert Wyatt) Jazz
A4 [03:42] Robert Wyatt - Song For Che (Charlie Haden) Latin
B1 [00:49] Robert Wyatt - Muddy Mouse (a) (Fred Frith, Robert Wyatt) Songwriter
B2 [05:36] Robert Wyatt - Solar Flares (Robert Wyatt) Prog
B3 [00:50] Robert Wyatt - Muddy Mouse (b) (Fred Frith, Robert Wyatt) Songwriter
B4 [05:00] Robert Wyatt - 5 Black Notes And 1 White Note (Jacques Offenbach, Robert Wyatt) Prog
B5 [06:15] Robert Wyatt - Muddy Mouse (c) (Fred Frith, Robert Wyatt) Songwriter


I should probably work all of this out in therapy, but that's expensive and time consuming and I don't know if my insurance even covers it.
When the pain first started, I was bitter that it had happened to me but then I got pretty decent treatments that helped manage it well and at the time, I could still keep up with most of my hobbies like triathlons and knitting and I was just training for my first half-marathon.
When the fibromyalgia started, it was subtle at first and then suddenly I could barely get out of bed for days at a time because of the muscle pain and fatigue. And with it came the loss of all of the activities that kept me sane dealing with constant, unrelenting pain. I couldn't do the marathon or triathlon training because walks around the block would leave me fatigued for the rest of the day.
I remember one weekend where I went to training, before I had a definitive diagnosis, and after completing an eight-mile walk/run I couldn't get out of bed for almost a week due to the fatigue.
Now when I knit my hands and arms tire quickly and the pain sets in almost immediately. I've completed only a handful of projects in there four years since I was officially diagnosed.
Losing all of these activities along with the fact that even household chores leave me in extra pain and fatigue makes me angry. For the rest of my life and my kids' lives we will never be the same because I can't do all the things I used to do.
And it didn't have to be this way. With the appropriate workplace accommodations I would have been better able to manage the existing pain so it didn't have to develop into fibro.
Patients with an existing pain condition are more likely to develop fibro because their neural pathways are already screwed up.
One in fifty Americans have fibro. One in four suffers from chronic pain and it is the most common cause for those going on disability. More people have chronic pain than cancer, diabetes and heart disease combined.
We have a lot to be angry about. There aren't many effective treatments for pain other than opioid pain medication and it's not very trendy for research dollars.


text:
US declines to supply coronavirus vaccine to Pakistan in first phase
As Pakistan is grappling with the second wave of coronavirus, the United States has told Islamabad that the coronavirus vaccine cannot be provided in the first phase, reported 24NewsHD TV channel on Wednesday.
Sources say the company involved in developing the much-awaited coronavirus vaccine will meet the domestic needs of the United States first and only then it is going to export the item around the world in the second phase.
According to a letter sent by the Pakistan Embassy in Washington to the Foreign Office in Islamabad, Johnson and Johnson – a pharmaceutical giant – is currently conducting clinical trials and facing some complications in the process.
The Pakistani diplomatic mission, which shared the US response, says it is making efforts for obtaining the vaccine and has been in contact with different companies working on the remedy to counter the deadly virus with an aim to ensure advance booking of consignments.
After receiving the letter from Pakistan's embassy, the Foreign Office shared the US response with the Ministry of National Health Services, Regulation and Coordination.
Earlier on Tuesday, 24NewsHD reported that Prime Minister Imran Khan had approved the suggestion to ensure advance booking of the vaccine.
Confirming the reports, Dr Nausheen Hamid – who is the parliamentary secretary for health ministry – said contacts had been made with two of the vaccine producers for advance booking.
Expressing her confidence that Pakistan would be able to achieve the goal, she said the government was taking steps to ensure the availability of the possible vaccine.
In this connection, sources say the proposal for this move was presented by the health ministry to the prime minister last month.
According to the ministry, the coronavirus vaccine should be booked for 10 million people with the allocation of $100 million for the purpose. The first phase, it is said, will cover the health workers and old citizens.
Dozens of pharmaceutical giants and research institutes are currently working on developing vaccines to fight the coronavirus which has crippled the entire globe.
On Monday, an important breakthrough was announced by Moderna – a US biotechnology company – which said early data showed that a new anti-coronavirus vaccine was nearly 95 percent effective.
This vaccine is to be administered in two doses with a gap of four weeks and requires storage at -20 degrees Celsius with a life of six months.
It is a very reassuring sign as the vaccine being developed by Pfizer has stated to have 90 percent effectiveness. But the biggest problem with Pfizer's product is storage. Its vaccine will have to be stored at -75 degrees Celsius which would be a near-impossible task for the poor and developing nations.
Just like Moderna, the vaccine developed by Pfizer requires two injections but with a gap of three weeks.
Categories : Featured News, Pakistan, National
coronavirus vaccine,
supply,
Imran Khan declines to accept Asim Saleem Bajwa's resignation
Posted 04:24 PM, 4 Sep, 2020
Pakistani doctor forgives $650,000 in medical bills for his US cancer patients
US offers to try mastermind behind Daniel Pearl murder
Posted 10:48 AM, 30 Dec, 2020
Last heir to Ottoman throne passes away at 90
Munnu Bhai's second death anniversary marked
Actress Reema Khan receives shot of coronavirus vaccine in US
Milan Men's Fashion Week longs for a bright winter
Tiger Shroff expresses his wish to play Spiderman
PTI govt's failures on foreign, local fronts a lesson for electorate
Why are student unions important for Pakistan?
Muhammad Saad Atif
Pakistan women players return to international cricket on Wednesday
India hero Pant hails 'dream series' after Australia upset
Defiant Paine wants to lead Australia to South Africa
Nora Fatehi's new video of playing with fire in Dubai goes viral
PAFEC, UNICEF hold training workshop on COVID-19


text:
Q: Bigquery - create surrogate keys on migrated data We are doing a migration from AWS Redshift to GCP BigQuery.
Problem statement:
We have a Redshift table that uses the IDENTITY column functionality to issue an internal EDW surrogate key (PK) for natural/business keys.  These natural keys are from at least 20 different source systems for customers.  We need a method to identify them in case natural keys are somehow duplicated (because we have so many source systems).  In BigQuery, the functionality of the Redshift IDENTITY column does not exist.  How can I replicate this in BQ?
We cant use GENERATE_UUID() because all our downstream clients have been using a BIGINT for the last 4 years.  All history is based on BIGINT and too much would need to change for a VARCHAR.
Does anyone have any ideas, recommendations or suggestions?
Some considerations I have made:
1. load the data into Spark and keep it in memory and use scala or python functions to issue the surrogate key.
2. use a nosql data store (but this does not seem likely as a use case).
Any ideas are welcome!

A: In these cases, the idea is generally to identify an injective/bijective function, which can map to some unique space.
How about you try something like: SELECT UNIX_MICROS(current_timestamp()) + x as identity where x is a numeral that you can somehow manage (using case statements or if conditions) based on the business name or something?
You can also eliminate x from this formula if you intend to process things linearly in some order, like one business entity at a time.
Hope it helps.


The Irvine City Council Tuesday voted 3-1 to hire a special counsel to review whether votes by individual members of city commissions on a high-density apartment project should be invalidated after a lobbyist's email indicated they had pre-committed to their decisions.
Mary Ann Gaido, a Democrat who serves on the planning commission and is running for city council in next month's election, voted Oct. 16 to approve a 280-unit project in the Irvine Business Complex called 360° Fusion. Meanwhile, Community Services Commissioner Melissa Fox, also a Democratic council candidate, voted in August for a park plan attached to the development.
The Republican council majority criticized the votes as contradicting the candidates' campaign pledge for a moratorium on approving new development. But Councilman Jeffrey Lalloway goes even further, stating that the project approvals could have been improper.
A planning commission's consideration of development projects is considered a "quasi-judicial" decision, which means commissioners are required under state law to follow strict due process guidelines and maintain an impartial stance until they cast their votes.
It is unclear whether community services commissioners operate under the same guidelines. But even if they don't, Lalloway says an inquiry is needed to determine whether Fox's vote could be seen as a quid-pro-quo.
For evidence, Lalloway points to an Aug. 26 email from lobbyist Pam Sapetto. In the email, which was first reported on by OC Weekly, Sapetto tells developers that, despite campaign promises from Gaido, Fox and Democratic council incumbent Larry Agran to oppose new development, the three candidates have assured her they would continue to support projects in the Irvine Business Complex.
The email goes on to encourage developers to make campaign contributions under $250, which is the maximum amount allowed under the state's Levine Act to individuals and organizations that have projects pending before council.
Agran, the only member of council to vote against the decision, said his Republican colleagues were engaging in an election-season political attack. He tried to show a presentation detailing campaign contributions from developers to Lalloway and other Republicans on council, but the council majority prevented him from showing it.
"It is so obviously a political effort to have yet another special counsel out there spending hundreds of thousands of dollars," Agran said.
Sapetto's attorney, Ed Connor, said that Lalloway's move was hypocritical because he received a campaign contribution from Sapetto and should therefore have recused himself from the discussion.
Lalloway called Connor's statement "absurd" because he hadn't voted on the project.
When asked for a response to allegations that Sapetto's email could be evidence of a quid-pro-quo, she briefly denied it and said she had to leave for another appointment.
The council directed the city to hire one of three firms: Richards, Watson & Gershon, Burke, Williams & Sorensen, LLP, or Woodruff, Spradlin & Smart.
Irvine residents now will have 12 days to study regular agendas for the City Council, Planning Commission and other city bodies after the Council voted Tuesday to strengthen its transparency ordinance.
The Irvine Planning Commission wants to send the City Council as fast as possible all available environmental reports and any potential development contracts in or near the Great Park that could affect development of a veterans cemetery.


text:
Q: html font size max value What is the max value of the font-size in pixel which browsers accept? Is it possible to get this value (depending on browser) using javascript?
Example:

1) formattedText.css('fontSize', 200);
           Result: formattedText.height() = 201
2) formattedText.css('fontSize', 2000);
           Result: formattedText.height() = 2001
3) formattedText.css('fontSize', 20000);
           Result: formattedText.height() = 2001


text:
Q: Hadoop: MapReduce: Node selection I have three rack servers each having five nodes from node 1 to node 15, I've written a file file.txt which is separated into four data blocks A,B,C,D and is stashed in node 1 (containing blocks A,B) and node 11 (containing blocks C,D). The job tracker provides the task tracker of the node 1 and 11 with the code to perform map task in its local blocks.
My Question is :

*

*How does the job tracker decide in which node the reduce job has to be performed. Is it because of the rack awareness?

*Out of node 2, node 6 and node 12 which would be most optimal node to perform the reduce task, let's assume the nodes are currently not occupied by any task?

*Can the reduce task be performed on any of node 1 or node 11 after the map task is over on the nodes.
Thanks in Advance.

A: 1) Job Tracker may choose Node1 or Node 11 to perform Reduce operation, It may choose the nodes where less data transfer is required.
2) Either of Node2 or Node12
3) Yes. For the Reduce operation to start, all the map outputs need to be copied to node where reduce operation is going to perform. So once Node 1 and Node 11 map functions completed, job tracker may start the reduce operation on Node1 or Node11.
Hope this helps.


where i can find device serial number?
You can find the device serial number in the Asset Management section in the Management Console.
Once in the Asset Management Tab click on "Devices" tab select the computer and expand the row.
On the right side under the "Hardware" category, the serial number, if available from the motherboard will be shown.
We show the serial number for HDD/SSD.


text:
Virtual training gives real results in the first course of the crew chief
Air Education and Training Command is becoming the digital realm to teach maintainers about their aircraft in a new program that is based on virtual reality.
Named "Transformation of Technical Training" or T3, the effort seeks to attract maintenance students in new ways, without the typical limitations of issues such as aircraft availability. Ultimately, it could help speed up the time it takes to eliminate maintainers and give them the experience they need to step up to the middle and upper levels more quickly.
Sheppard will host two full-fledged VR courses on crew chief basics and logistics planning next year, the Air Force said.
"Students come out on the line more capable and more comfortable in their role," said Major Jesse Johnson, who oversees T3 as commander of an AETC detachment at San Antonio, Texas Joint Base. "I definitely see it as a force multiplier."
The T3 initiative was launched over two months during the summer of 2020 as part of previous "Maintenance Next" experiments focused on AETC technology. Twenty-nine students in the core crew course at Air Force Base in Sheppard, Texas, used VR headsets to examine tools, repair simulated planes, and learn other trade tricks.
The Air Force spent between $ 5,000 and $ 6,000 for every 30 virtual reality gaming systems for the initial pilot program. As technology has improved, cheaper and smaller, the service has been reduced to headphones like Facebook's Oculus models or HTC's Vive models to several hundred dollars each.
To test the technology, students completed the usual three-week course in the classroom and then tested the VR version of the class for two weeks while waiting to move on to the next base. It took students about half the time to learn the same basics in the digital course compared to the regular version.
Their scores were comparable between the two methods, the Air Force said.
"Each student has their own classroom in mind. This allows all students to see their own plane and everyone can work on that plane for themselves, "explains Tech. Sergeant Kyle Ingram, a supervising instructor in the 362nd Aircraft Training Squadron Sheppard told reporters Tuesday.
Students can see their instructors inside the headphones and ask for help outside the virtual environment. The approach also avoids unnecessary damage to the aircraft caused by inexperienced maintainers who don't know what they're doing, Ingram said.
Earlier this summer, the team began testing artificially intelligent characters who can answer students 'questions and classify their work within headphones. These avatars are based on interviews with technical sergeants or master sergeants who have gained craft-level experience in the field, possibly freeing their real-life counterparts from working in aircraft.
The Air Force withdrew criticism that virtual training will not work as well as hands-on training because it fails to build the same type of muscle memory. Digital repetition of an advanced task reinforces an aviator's understanding and skill in real-world work, Johnson said.
"This will help the quality of the training we offer students, getting them more preparation for the flight line before they get to the flight line," Ingram added.
Future improvements will provide a way to track a student's degree of learning and what they have achieved, Johnson said. He hopes that over time the data can be used to further personalize the education of aviators based on their learning style and where they fall short.
While team advocates want to spread virtual reality tools throughout the service (which has begun to use them in limited cases for pilot training), they recognize that there are obstacles that could take years to erase. -se.
The challenges range from high technology to everyday life: even for commercially manufactured hardware and software that are ready to buy, aviators would still need wireless internet access at the grassroots, widespread enough and enough fast to support virtual reality images. Air Force facilities also need more electrical outlets to connect the systems, Johnson added.
"Our infrastructure is not built to manage it and we haven't trained people so they can create adaptive and immersive content," he said. "I think we could come up with a fully capable and available system that allows students to do that in the next two years."
Rachel Cohen joined the Air Force Times as a senior reporter in March 2021. Her work has appeared in Air Force Magazine, Inside Defense, Inside Health Policy, the Frederick News-Post (Md.), The Washington Post And others.


text:
Breaking it all Down
Dissecting Everything Since 2008
A Statement of Principles
Twitch Stream Embed
The Warhound and the World's Pain: Book Review
Michael Moorcock's Eternal Champion series is interesting to discuss. Some stories have direct analogies to and inversions of Robert E. Howard's work, like Elric. Others, like Hawkmoon, go in radically different directions. The first Von Bek novel probably falls more into the former camp – feeling like something of an inversion of Solomon Kaine, in multiple respects.
The Warhound and the World's Pain is, unlike the Moorcock material I've covered to date, set in Earth's past, instead of a possible future or different world, and follows Ulrich Von Bek. Bek is a mercenary and free thinker in the Thirty Years War, whose company has recently been wiped out in a previous battle. In his travels he ends up in a seemingly abandoned home, only to discover that it is the dwelling of Lucifer. As in the Lightbringer. Morningstar.
Ya' know – Satan.
Old Scratch has a job for Ulrich – he needs him to find the Holy Grail. It seems that The Devil has, after all this time, come to the realization that maybe he was in the wrong, and he'd like to patch things up with Jehovah. Obtaining the Grail, and with it the Cure for the World's Pain, would allow him to do that. However, he can't do it himself, so he needs assistance from Von Bek.
Lucifer feels that as a learned free thinker, a courageous warrior, and a man of integrity, Von Bek has what it takes to do the job. And, as a hardened veteran of the Thirty Years' War, with all that entails, Von Bek is absolutely damned to Hell, which gives Lucifer the leverage he needs to persuade Ulrich to take on the job – the ability to avoid Hell. And if he needs further incentive, Von Bek falls head over heels in love for a woman who is another damned soul, and the feeling is reciprocated – so if Von Bek succeeds, her soul is saved too.
This leads to our grand quest, which takes Ulrich Von Bek, along with a companion he picks up along the way, throughout Europe, both the real and supernatural forms, in order to retrieve the Grail. All in just one, actually pretty short, book.
That's my actual complaint actually – something as big as, an actual Grail Quest should be feel bigger, more eventful. Certainly, things happen over the course of this story, but a lot more events are things we are told about but never shown. Maybe it's because the idea sounded better then the actual execution was. Maybe Moorcock's editor said he needed to prune this down a bit and didn't feel it was worth fighting over. Maybe the deadline was coming up and he figured he'd revisit it in a later story, or collection of short stories, like he did with Elric. I don't know.
In any case, it makes for a bunch of stories where, as a reader, I'm going "Hang on, you can't just leave us with one or two sentences. You'd need to expand on that concept a little."
The rest of the story is… okay. It's not helped by Ulrich's companion, a Kazakh swordsman, who starts out racist and anti-Semitic, and never really changes in that regard. It comes up less, but he's still a character who basically excuses himself from a scene to rape a young girl who is staying with a hermit because the girl is a virgin. The rape is not on camera, but it absolutely happens, and outside from the statement that it happened it is generally not commented upon.
On the one hand, I get it, Von Bek has seen some shit over the course of his travels, and the Thirty Years War was utterly horrific, both in terms of the way the war was fought, and the toll it took on the population caught in the middle of it, in a lot of respects. However, say what you will about the scenes of sexual assault in Game of Thrones, or Berserk, and whether or not they actually need to be there or if they could be replaced with something else, they do serve a purpose. This, not so much.
It's a shame, because otherwise the book is fine. The finale of the book is really interesting, and I think comments better on the relationship between God, the Devil, and human religion better than, say, Go Nagai's Devilman does. It's just the route the book takes to get there is kind of "eh". And when you're telling a story about a quest, especially a Grail Quest, that journey is pretty important.
If you do want to pick this up, it's available from Amazon.com as part of Gollancz' Von Bek collection. Buying anything through that link will help support the site.
If you prefer to support an independent bookstore you can find it from other bookstores on Alibris.
Eternal Champion
on August 16, 2020 August 10, 2020 </a	by Alexander Case
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text:
Carmageddon or Lameageddon? Billion Dollar Project Isn't Apocalyptic After All
Reason Staff | 7.18.2011 9:00 AM
Did you hear about Carmageddon? It turns out the apocalyptic shutdown of the nation's busiest freeway, the 405, wasn't apocalyptic at all.
Media hyped the billion dollar construction project for weeks, claiming it could "back up traffic as much as 64 miles," and politicians blunted told constituents, "Stay the hell away from the 405." But none of the predictions about a Carmageddon came true.
Instead we found politicians ready to sing the praises of the newly added carpool lane and teardown of the Mulholland Bridge (Including an exclusive interview with Mayor of Los Angeles, Antonio Villaraigosa). We also found Angelenos skeptical that the project would actually alleviate traffic.
Written and Produced by Paul Detrick.
About 3:30 minutes.
Scroll down for downloadable versions and subscribe to Reason.tv's YouTube Channel to receive automatic notifications when new material goes live.
NEXT: 3 Reasons Why The Debt-Ceiling Debate is Full of Malarkey
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text:
Cette page dresse une liste de personnalités mortes au cours de l'année 1153 :

 6 janvier : Macaire l'Écossais, moine bénédictin allemand d'origine irlandaise.
 10 février : Taira no Tadamori, samouraï du clan Taira, père de Taira no Kiyomori et membre du Kebiishi (forces de police impériales).
 24 mai : David , prince de Cumbria puis roi d'Écosse.
 12 juin : Roger de Beaumont (2e comte de Warwick).
 29 juin : Olaf  de Man, roi de l'île de Man et des îles.
 juillet : Bernard de Rennes, cardinal français.
 8 juillet : Eugène III, pape.
 août : Simon II de Senlis, comte de Northampton et de Huntingdon.
 16 août : Bernard de Tramelay  Grand Maître des Templiers.
 20 août : Bernard de Clairvaux (Saint Bernard), moine français, réformateur de la vie religieuse. La congrégation cistercienne compte alors 345 monastères.
 14 octobre : Henri Murdac, abbé de Vauclair, abbé de Fountains puis archevêque d'York.
 Novembre : Shahrastani penseur et théologien musulman. Il classe les philosophes dans des sectes extérieures à l'islam.
 novembre ou décembre : Philippe de Mahdia, amiral du royaume normand de Sicile.
 16 décembre : Ranulph de Gernon, comte de Chester et vicomte d'Avranches et du Bessin.

 Gampopa, maître historique de la lignée Kagyüpa et plus particulièrement de la branche appelée « Karma-kagyu ». Disciple de Milarépa et initié au kadampa et au mahamudra, il est considéré comme le fondateur de la lignée-mère Dhagpo Kagyu, et l'ancêtre des « quatre grandes écoles » de la tradition kagyu du bouddhisme tibétain.
 Gregorio, cardinal.
 Heinrich  Felix von Harburg, archevêque et prince-électeur de Mayence et archichancelier du Saint-Empire romain germanique.
 Muhammad al-Shahrastani, philosophe musulman, perse, théologien.
 Pierre II de Béarn, vicomte de Béarn, de Gabardan et de Brulhois.
 Richard de Subligny, évêque d'Avranches.
 Theodwin, cardinal de Sainte-Ruffine.
 Vladimirko de Galicie, prince de Galicie.
 Piotr Włostowic, grand magnat très riche de Silésie, palatin et héros national de Pologne.

 date incertaine (vers 1153)
 Anne Comnène, historienne byzantine.

Notes et références

Crédit d'auteurs

Année du XIIe siècle


U.S. stock index futures are flat this morning ahead of a key statement by the Federal Reserve today which is expected to provide clues on the next monetary policy move by the U.S. central bank.
China's central bank is injecting a combined 500 billion yuan ($81.35 billion) of liquidity into the country's top banks, according to media reports, a sign that authorities are stepping up efforts to shore up a faltering economy.
U.S. consumer prices fell for the first time in nearly 1-1/2 years in August and underlying inflation pressures were muted, which could lessen the urgency for the Federal Reserve to raise interest rates.
The S&P posted its best performance in a month Tuesday and the Dow industrials set a record intraday high amid wavering expectations regarding the Fed's stance.
U.S.-traded shares of Sony Corp fell 10.6% in premarket trading after it estimated a bigger loss and said it would not pay a dividend this fiscal year for the first time since it listed in 1958.
Shares of Rackspace Hosting slumped 20.5% a day after the cloud management services provider said it would not sell itself.
Endo International Plc made an unsolicited offer to buy Auxilium Pharmaceuticals Inc for about $2.2 billion, which analysts said could complicate Auxilium's buyout of Canadian eye drug maker QLT Inc .
Pipeline operator TransCanada Corp is likely to haul Canadian oil sands crude by rail whether or not its embattled Keystone XL pipeline project is finally approved by Washington, the company's chief executive said on Tuesday.
Recent Canadian economic data has been encouraging, particularly on exports, Bank of Canada Governor Stephen Poloz said on Tuesday, but he pointed to a substantial amount of slack in the job market.