Published by Copernicus Publications on behalf of the European Geosciences Union. A. Baklanov et al.: Online coupled regional meteorology chemistry models in EuropeAbstract. Online coupled mesoscale meteorology atmospheric chemistry models have undergone a rapid evolution in recent years. Although mainly developed by the air quality modelling community, these models are also of interest for numerical weather prediction and regional climate modelling as they can consider not only the effects of meteorology on air quality, but also the potentially important effects of atmospheric composition on weather. Two ways of online coupling can be distinguished: online integrated and online access coupling. Online integrated models simulate meteorology and chemistry over the same grid in one model using one main time step for integration. Online access models use independent meteorology and chemistry modules that might even have different grids, but exchange meteorology and chemistry data on a regular and frequent basis. This article offers a comprehensive review of the current research status of online coupled meteorology and atmospheric chemistry modelling within Europe. Eighteen regional online coupled models developed or being used in Europe are described and compared. Topics discussed include a survey of processes relevant to the interactions between atmospheric physics, dynamics and composition; a brief overview of existing online mesoscale models and European model developments; an analysis on how feedback processes are treated in these models; numerical issues associated with coupled models; and several case studies and model performance evaluation methods. Finally, this article highlights selected scientific issues and emerging challenges that require proper consideration to improve the reliability and usability of these models for the three scientific communities: air quality, numerical meteorology modelling (including weather prediction) and climate modelling. This review will be of particular interest to model developers and users in all three fields as it presents a synthesis of scientific progress and provides recommendations for future research directions and priorities in the development, application and evaluation of online coupled models.

IMPORTANCE Health apps in low-income countries are emerging tools with the potential to improve quality of health care services, but few apps undergo rigorous scientific evaluation.OBJECTIVE To determine the effects of the safe delivery app (SDA) on perinatal survival and on health care workers' knowledge and skills in neonatal resuscitation. DESIGN, SETTING, AND PARTICIPANTSIn a cluster-randomized clinical trial in 5 rural districts of Ethiopia, 73 health care facilities were randomized to the mobile phone intervention or to standard care (control). From September 1, 2013, to February 1, 2015, 3601 women in active labor were included at admission and followed up until 7 days after delivery to record perinatal mortality. Knowledge and skills in neonatal resuscitation were assessed at baseline and at 6 and 12 months after the intervention among 176 health care workers at the included facilities. Analyses were performed based on the intention-to-treat principle.INTERVENTIONS Health care workers in intervention facilities received a smartphone with the SDA. The SDA is a training tool in emergency obstetric and neonatal care that uses visual guidance in animated videos with clinical instructions for management. MAIN OUTCOMES AND MEASURESThe primary outcome was perinatal death. Secondary outcomes included the knowledge and clinical management of neonatal resuscitation (skills) of health care workers before the intervention and after 6 and 12 months. RESULTSThe analysis included 3601 women and 176 health care workers. Use of the SDA was associated with a nonsignificant lower perinatal mortality of 14 per 1000 births in intervention clusters compared with 23 per 1000 births in control clusters (odds ratio, 0.76; 95% CI, 0.32-1.81). The skill scores of intervention health care workers increased significantly compared with those of controls at 6 months (mean difference, 6.04; 95% CI, 4.26-7.82) and 12 months (mean difference, 8.79; 95% CI, 7.14-10.45) from baseline, corresponding to 80% and 107%, respectively, above the control level. Knowledge scores also significantly improved in the intervention compared with the control group at 6 months (mean difference, 1.67; 95% CI, 1.02-2.32) and at 12 months (mean difference, 1.54; 95% CI, 0.98-2.09), corresponding to 39% and 38%, respectively, above the control level. CONCLUSIONS AND RELEVANCEThe SDA was an effective method to improve and sustain the health care workers' knowledge and skills in neonatal resuscitation as long as 12 months after introduction. Perinatal mortality was nonsignificantly reduced after the intervention. The results are highly relevant in low-income countries, where quality of care is challenged by a lack of continuing education. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01945931

Objectives To assess urinary and reproductive health and quality of life following surgical repair of obstetric fistula.Design Follow-up study.Setting A newly established fistula clinic (2004) at Gimbie Adventist Hospital, a 71-bedded district general hospital in West Wollega Zone, in rural Western Ethiopia.Population Thirty-eight women (86%) of 44 who had undergone fistula repair were identified in their community.Methods Community-based structured interviews 14-28 months following fistula repair, using a customised questionnaire addressing urinary health, reproductive health and quality of life.Main outcome measures Urinary health at follow up was assessed as completely dry, stress or urge incontinence, or fistula. King's Health Questionnaire was modified and used for the quality-oflife assessment.Results At follow up, 21 women (57%) were completely dry, 13 (35%) suffered from stress or urge incontinence and three (8%) had a persistent fistula. Surgery improved quality of life and facilitated social reintegration to a level comparable to that experienced before fistula development for both women who were dry and those with residual incontinence (P = 0.001). For women still suffering from fistula no change was seen (P = 0.1). Four women became pregnant following their surgery, among which there was one maternal death, three stillbirths and one re-occurrence of fistula.Conclusion Community-based, long-term follow up after fistula repair succeeded in Western rural Ethiopia. Despite one-third still suffering stress or urge incontinence, the women reported improved quality of life and social reintegration after fistula closure.Keywords Quality of life, long term follow-up, obstetric fistula, outcomes.Please cite this paper as: Nielsen H, Lindberg L, Nygaard U, Aytenfisu H, Johnston O, Sørensen B, Rudnicki M, Crangle M, Lawson R, Duffy S. A community-based long-term follow up of women undergoing obstetric fistula repair in rural Ethiopia.

Objective To audit the quality of obstetric management preceding emergency caesarean sections for prolonged labour.Design A quality assurance analysis of a retrospective criterionbased audit supplemented by in-depth interviews with hospital staff.Setting Two Tanzanian rural mission hospitals.Population Audit of 144 cases of women undergoing caesarean sections for prolonged labour; in addition, eight staff members were interviewed.Methods Criteria of realistic best practice were established, and the case files were audited and compared with these. Hospital staff were interviewed about what they felt might be the causes for the audit findings.Main outcome measures Prevalence of suboptimal management and themes emerging from an analysis of the transcripts.Results Suboptimal management was identified in most cases. Non-invasive interventions to potentially avoid operative delivery were inadequately used. When deciding on caesarean section, in 26% of the cases labour was not prolonged, and in 16% the membranes were still intact. Of the women with genuine prolonged labour, caesarean sections were performed with a fully dilated cervix in 36% of the cases. Vacuum extraction was not considered. Amongst the hospital staff interviewed, the awareness of evidence-based guidelines was poor. Word of mouth, personal experience, and fear, especially of HIV transmission, influenced management decisions. ConclusionThe lack of use and awareness of evidence-based guidelines led to misinterpretation of clinical signs, fear of simple interventions, and an excessive rate of emergency caesarean sections.

The simulation of the coupled evolution of atmospheric dynamics, pollutant transport, chemical reactions and atmospheric composition is one of the most challenging tasks in environmental modelling, climate change studies, and weather forecasting for the next decades as they all involve strongly integrated processes. Weather strongly influences air quality (AQ) and atmospheric transport of hazardous materials, while atmospheric composition can influence both weather and climate by directly modifying the atmospheric radiation budget or indirectly affecting cloud formation. Until recently, however, due to the scientific complexities and lack of computational power, atmospheric chemistry and weather forecasting have developed as separate disciplines, leading to the development of separate modelling systems that are only loosely coupled.

The continuous increase in computer power has now reached a stage that enables us to perform online coupling of regional meteorological models with atmospheric chemical transport models. The focus on integrated systems is timely, since recent research has shown that meteorology and chemistry feedbacks are important in the context of many research areas and applications, including numerical weather prediction (NWP), AQ forecasting as well as climate and Earth system modelling. However, the relative importance of online integration and its priorities, requirements and levels of detail necessary for representing different processes and feedbacks can greatly vary for these related communities: (i) NWP, (ii) AQ forecasting and assessments, (iii) climate and earth system modelling. Additional applications are likely to benefit from online modelling, e.g.: simulation of volcanic ash or forest fire plumes, pollen warnings, dust storms, oil/gas fires, geo-engineering tests involving changes in the radiation balance.

The COST Action ES1004 – European framework for online integrated air quality and meteorology modelling (EuMetChem) – aims at paving the way towards a new generation of online integrated atmospheric chemical transport and meteorology modelling with two-way interactions between different atmospheric processes including dynamics, chemistry, clouds, radiation, boundary layer and emissions. As its first task, we summarise the current status of European modelling practices and experience with online coupled modelling of meteorology with atmospheric chemistry including feedback mechanisms and attempt reviewing the various issues connected to the different modules of such online coupled models but also providing recommendations for coping with them for the benefit of the modelling community at large

A considerable number of the audited emergency cesarean sections were performed on doubtful indications. In the light of the rising trend in global cesarean section rates, there seems to be a need to ensure quality of management preceding cesarean sections. This is particularly called for in rural sub-Saharan Africa where cesarean rates are still low and health risks of emergency surgery not negligible.

The risk for several maternal and perinatal complications increased with the diagnostic threshold for 2-h glucose. Large-scale blinded studies are needed to clarify the question of a clinically meaningful diagnosis of gestational diabetes mellitus. Until these results are available, a 2-h threshold level of 9.0 mmol/l after a 75-g oral glucose tolerance test seems acceptable.

A two-day ALSO training course can significantly improve staff performance and reduce the incidence of PPH, at least as evaluated by short-term effects.