The acceleration (or deceleration) of the aircraft along the flight path is indicated by the Flight Path Acceleration symbol. The flight path acceleration is made up of the total acceleration forces acting on the aircraft, including acceleration generated by both the aircraft in the form of thrust and acceleration generated by the air mass the aircraft is moving through. To avoid confusion in the control of aircraft thrust, the Flight Path Acceleration symbol is removed from the display when the HGS detects a low-level decreasing performance windshear. The deceleration rate index presented using the inertia caret indicates deceleration with respect to the airplane autobrake algorithms or other deceleration references familiar to the crew. The inertia caret algorithms run independently in the HGS computer and present an inertially derived deceleration indexed on the combiner.

The index on the combiner is presented with indices that represent their values that correlate to the airplane autobrake settings or other deceleration performance references useful to the crew. Early recognition of wind shear is identified by observing the erratic wind direction and wind velocity on the direction symbol and velocity symbol. The HGS/HUD will provide an intuitive and immediate identification of performance margin available to the pilot during a wind shear recovery by displaying the AoA limit symbol. The pilot maintains the flight path vector over the solid guidance cue and between the zero degree pitch line and the AoA limit symbol. The pilot is able to monitor the energy of the airplane via the inertia caret, which combined with the Speed Error Tape, can also provide indications of windshear conditions. To avoid confusion in the control of aircraft thrust, the Flight Path Acceleration symbol is removed from the display when the HGS detects a low-level decreasing performance windshear.

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This set of symbols allows the pilot to quickly and intuitively determine the inputs required to stabilize the airplane for engine-inoperative flight. The flight path displays the airplane's path referenced to the zero degree pitch line to establish a positive rate of climb, The AoA limit symbol provides the pilot a visual reference establishing the maximum ascent capability. The area displayed between the glideslope reference line and the AoA limit determines the performance margin available. The flight path also presents lateral position and when referenced to the slip/skid indicator intuitively provides guidance to the pilot to apply the appropriate rudder forces to stabilize the airplane laterally. The speed error tape presents precise speed control to maintain the designated speed or the engine-out condition. Since the speed the pilot must maintain can vary with when the engine failure occurred during the profile, the speed error tape can be a significant benefit to the pilot in establishing and maintains the desired speed. Surface Movement Guidance is a system that will help pilots navigate better on airport taxiways and runways.

The Surface Guidance System (SGS) uses an airport database to identify the centerline and edges of the current runway or taxiway the aircraft is operating on, and display virtual centerline, edges lines, signs and other symbols that overlay the actual airport taxiways, runways and signage will be able to maneuver on the ground with confidence and minimize runway incursions. This capability will utilize multiple technologies to provide accurate position information to ATC and other aircraft.

The reference setting for glideslope is indicated by the position of the Glideslope Reference Line relative to the Horizon Line. The Reference Glideslope value is also displayed digitally at both ends of the Glideslope Reference Line. The Glideslope Reference Line is a conformal display representing the glideslope value selected on the HCP or MCDU or received from the FMC, meaning that the Glideslope Reference Line overlaying a pointy on the ground indicates that the airplane position is at an angle equal to the glideslope reference point.

Adobe Flash Player is required to view this feature. If you are using an operating system that does not support Flash, we are working to bring you alternative formats. Original Article Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes Caroline A. Crowther, F.R.A.N.Z.C.O.G., Janet E. Hiller, Ph.D., John R. Moss, F.C.H.S.E., Andrew J.

McPhee, F.R.A.C.P., William S. Jeffries, F.R.A.C.P., and Jeffrey S. Robinson, F.R.A.N.Z.C.O.G., for the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group N Engl J Med 2005; 352:2477-2486 DOI: 10.1056/NEJMoa042973. Methods We randomly assigned women between 24 and 34 weeks' gestation who had gestational diabetes to receive dietary advice, blood glucose monitoring, and insulin therapy as needed (the intervention group) or routine care. Primary outcomes included serious perinatal complications (defined as death, shoulder dystocia, bone fracture, and nerve palsy), admission to the neonatal nursery, jaundice requiring phototherapy, induction of labor, cesarean birth, and maternal anxiety, depression, and health status. Results The rate of serious perinatal complications was significantly lower among the infants of the 490 women in the intervention group than among the infants of the 510 women in the routine-care group (1 percent vs. 4 percent; relative risk adjusted for maternal age, race or ethnic group, and parity, 0.33; 95 percent confidence interval, 0.14 to 0.75; P=0.01).

However, more infants of women in the intervention group were admitted to the neonatal nursery (71 percent vs. 61 percent; adjusted relative risk, 1.13; 95 percent confidence interval, 1.03 to 1.23; P=0.01).

Women in the intervention group had a higher rate of induction of labor than the women in the routine-care group (39 percent vs. 29 percent; adjusted relative risk, 1.36; 95 percent confidence interval, 1.15 to 1.62; P. Gestational diabetes mellitus occurs in 2 to 9 percent of all pregnancies and is associated with substantial rates of maternal and perinatal complications. The risk of perinatal mortality is not increased, but the risk of macrosomia is. Other perinatal risks include shoulder dystocia, birth injuries such as bone fractures and nerve palsies, and hypoglycemia.

Long-term adverse health outcomes reported among infants born to mothers with gestational diabetes include sustained impairment of glucose tolerance, subsequent obesity (although not when adjusted for size ), and impaired intellectual achievement. For women, gestational diabetes is a strong risk factor for diabetes. Although the risks associated with gestational diabetes are well recognized, it remains uncertain whether screening and treatment to reduce maternal glucose levels reduce these risks. Given this uncertainty, professional groups disagree on whether to recommend routine screening, selective screening based on risk factors for gestational diabetes, or no screening; some recommend screening, whereas others do not. There have been repeated calls for well-designed, randomized trials to determine the efficacy of screening, diagnosis, and management of gestational diabetes. We designed the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) trial to assess whether the treatment of gestational diabetes would reduce perinatal complications and to assess the effects of treatment on maternal outcome, mood, and quality of life.

Interventions Stratification was according to center and singleton or twin gestation. Randomization was performed centrally with the use of numbers generated by computer with variable block sizes of 6, 8, and 10. The full numerical results of the oral glucose-tolerance test were not released to the women or their providers until after birth, before discharge from the hospital. Women who were randomly assigned to the intervention group received ongoing care by the attending obstetrical team with a physician's support. Outcome Variables Primary outcomes among the infants were a composite measure of serious perinatal complications (defined as one or more of the following: death, shoulder dystocia, bone fracture, and nerve palsy), admission to the neonatal nursery, and jaundice requiring phototherapy.

The presence and severity of shoulder dystocia were assessed by means of a standardized checklist completed by the caregiver present at the birth. Primary clinical outcomes among the women were the need for induction of labor and cesarean section. Maternal health status was assessed by means of the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36), which assesses eight aspects of health status: general and mental health, physical and social functioning, physical and emotional role, pain, and vitality; scores on each scale can range from 0 (worst) to 100 (best).

Maternal psychological outcomes included measures of anxiety, depression, and health-related quality of life. Anxiety was assessed with the use of the short form of the Spielberger State–Trait Anxiety Inventory, a self-rating scale consisting of 6 items (scores below 15 are considered normal). The presence of depression was reflected by a score of more than 12 on the Edinburgh Postnatal Depression Scale. Questionnaires were mailed six weeks after study entry and at three months post partum to 916 women (92 percent of the total) recruited to the study after funding for this assessment became available.

Secondary outcomes among the infants included components of the composite primary outcome, gestational age at birth, birth weight, and other measures of health. Secondary outcomes among the women included the number of prenatal visits to a health professional, the mode of birth, weight gain during pregnancy, the number of antenatal admissions, and the presence or absence of pregnancy-induced hypertension (defined as a blood pressure of at least 140/90 mm Hg on two occasions four or more hours apart) and other complications. Statistical Analysis Statistical analyses were based on the intention to treat and used SAS software, version 8.2 (SAS Institute).

Analyses were adjusted for maternal age, race or ethnic group, and parity. Binary outcomes are presented as relative risks, with 95 percent confidence intervals; the number needed to treat to benefit (i.e., the number of patients who would need to be treated for a benefit in one patient) and the number needed to treat to harm (i.e., the number of patients who would need to be treated for harm to occur in one patient), with their 95 percent confidence intervals, are presented for primary clinical outcomes.

Relative risks were calculated with the use of log binomial regression. Continuous variables were analyzed by means of analysis of variance if they were normally distributed and by means of nonparametric tests if their distribution was not normal. The health state utility was calculated from the SF-36 according to the method of Brazier et al. With no evidence of increased variance owing to the small number of twins in the study, no adjustment was made for clustering of babies with the same mothers. A P value of 0.05 was considered to indicate statistical significance; all P values were two-sided. A step-down Sidak adjustment was made for analyses involving multiple primary clinical end points.

We estimated that we would need to enroll 1000 women for the study to have a statistical power of 80 percent (two-sided alpha value of 0.05) to detect a reduction in the risk of a serious perinatal outcome from 5.2 percent to 2.0 percent, using outcomes reported for all South Australian births and data from Women's and Children's Hospital in Adelaide. Data were reviewed once in January 1999 by our independent data-monitoring committee, whose members were unaware of the treatment assignments, after the enrollment of 460 women. The study protocol included a prespecified stopping rule for a difference in a major end point of at least 3 SD between the groups. Results Of the 1000 women enrolled in the study, 490 were assigned to the intervention group and 510 to the routine-care group ( Figure 1 Enrollment and Outcomes. Recruitment started in September 1993 and stopped in June 2003, after 1000 women had been enrolled. Clinical outcomes were obtained up to the time of hospital discharge for all women and their 1030 infants.

On the whole, the two groups were similar at entry. As compared with the women in the routine-care group, women in the intervention group were older and were less likely to be white or primiparous ( Table 1 Baseline Characteristics of the Women. Ninety-three percent of the women had been found to be at risk for gestational diabetes on the basis of the oral glucose-challenge test, and the remainder on the basis of risk factors. Primary Outcomes The rate of serious perinatal outcomes among the infants (defined by one or more of the following: death, shoulder dystocia, bone fracture, and nerve palsy) was significantly lower in the intervention group than the routine-care group (1 percent vs.

4 percent; P=0.01, adjusted for maternal age, race or ethnic group, and parity ( Table 2 Primary Clinical Outcomes among the Infants and Their Mothers. Thus, the number needed to treat to prevent a serious outcome in an infant was 34 (95 percent confidence interval, 20 to 103). A higher percentage of infants born to women in the intervention group than of infants born to women in the routine-care group were admitted to the neonatal nursery (71 percent vs. 61 percent, adjusted P=0.01). The length of stay in the neonatal nursery among the infants who were admitted did not differ significantly between groups (median of 1 day for both groups; interquartile range, 1 to 2 days in the intervention group and 1 to 3 days in the routine-care group; adjusted P=0.81). There was no significant difference in the percentage of infants who had jaundice requiring phototherapy in the two groups (adjusted P=0.72) ( ).

The induction of labor was significantly more common in the intervention group than in the routine-care group (39 percent vs. 29 percent; adjusted P. Secondary Outcomes No perinatal deaths occurred among the infants of mothers in the intervention group, but there were five perinatal deaths (three stillbirths and two neonatal deaths) among infants born to women in the routine-care group ( and ). Two stillbirths were unexplained intrauterine deaths at term of appropriately grown infants, and the other, at 35 weeks' gestation, was associated with preeclampsia and intrauterine growth restriction. One infant had a lethal congenital anomaly, and one infant died after an asphyxial condition during labor without antepartum hemorrhage. There was no significant difference in the rates of shoulder dystocia between the intervention and routine-care groups (1 percent and 3 percent, respectively) ( ).

No infant in the intervention group had a bone fracture or nerve palsy, whereas in the routine-care group, one infant had both a fractured humerus that was not related to a difficult birth and a radial-nerve palsy, one infant had Erb's palsy related to shoulder dystocia, and one infant had Erb's palsy alone ( ). Infants born to women in the intervention group had significantly lower mean birth weights than infants born to women in the routine-care group (P. Discussion In this randomized clinical trial, treatment of women with gestational diabetes — including dietary advice, blood glucose monitoring, and insulin therapy — reduced the rate of serious perinatal outcomes (defined as death, shoulder dystocia, bone fracture, and nerve palsy) from 4 percent to 1 percent. These benefits were associated with an increased use of induction of labor for the mother and an increased rate of admission to the neonatal nursery for the infant, both of which may be related to the knowledge of the diagnosis by the attending physician. The earlier gestational age at birth as a consequence of the induction of labor may have contributed to the reduction in serious perinatal outcomes. Others have reported an increased rate of cesarean delivery associated with the diagnosis and treatment of gestational diabetes.

In our study, the rate of cesarean delivery was similar in the two groups. We chose primary clinical outcomes to assess the effects of treatment for gestational diabetes on both the mothers and the infants. Differences between groups remained significant after adjustment for known confounders (maternal age, race or ethnic group, and parity) and for analyses involving multiple primary end points.

Infants born to mothers receiving intensive therapy had lower birth weights than those born to women receiving routine care, an observation that may be explained at least in part by the earlier gestational age at birth in this group, related to the increased use of induction of labor. Infants in this group were no more likely to be small for gestational age, but they were significantly less likely to be large for gestational age and to have macrosomia. Infants who are large for gestational age are prone to impaired glucose tolerance or diabetes in later life, and girls have an increased risk of gestational diabetes. Long-term follow-up is needed to assess whether the lower birth weights among the infants in the intervention group will translate into reduced rates of these later complications. Despite the increased rate of admission to the neonatal nursery in the intervention group, there were no significant differences between the groups of infants in secondary clinical outcomes, such as hypoglycemia requiring intravenous therapy.

As compared with the women in the routine-care group, the women in the intervention group made more visits to the medical clinic and were more likely to see a dietitian and diabetes educator. However, they made fewer antenatal clinic visits, a difference that was most likely related to their increased likelihood of induction and their infants' earlier gestational age at birth. The reduction in the risk of preeclampsia in the intervention group may be related to the earlier gestational age at birth. A potentially controversial aspect of our study design from an ethical standpoint was the fact that women were not informed of their diagnosis of “gestational diabetes” during the course of the study, after the change in the WHO criteria. However, despite changes in the nomenclature for gestational diabetes, there continued to be no conclusive evidence regarding the effects of treatment of gestational diabetes and there were wide variations in clinical practice during the time of this study. Women in the study received standard pregnancy care consistent with care in which screening for gestational diabetes is not routine. Our trial also revealed an improved health-related quality of life among women in the intervention group, both during the antenatal period and three months after birth, together with a reduction in the incidence of depression after birth.

These findings are contrary to reports suggesting a decline in women's perception of their own health after they receive a diagnosis of gestational diabetes. However, results for these outcomes should be interpreted with caution, since the analysis included only a subgroup of the women. There has been a lack of data from large randomized clinical trials on the effects of screening and treatment of women with gestational diabetes mellitus. An observational study is currently in progress to assess associations between maternal glucose levels and perinatal outcomes, and an ongoing randomized trial in the United States is addressing the effect of therapy for mild gestational diabetes, as did our study. Our results indicate that treatment of gestational diabetes in the form of dietary advice, blood glucose monitoring, and insulin therapy as required for glycemic control reduces the rate of serious perinatal complications, without increasing the rate of cesarean delivery. Appendix The following persons and institutions participated in the ACHOIS Trial Group: Coordinating Team: C. Robinson; Steering Group: C.

Robinson; Statistical Support: K. Willson; Data-Monitoring Committee: J. Lumley (chair), L. Watson; Writing Group: C. Robinson; Data Support: S. Bruggemann, P.

Moore; Hospitals (total number of women recruited at each hospital is given in parentheses): Blacktown District Hospital, New South Wales (79): D. Bradford; Bradford Royal Infirmary Maternity Unit, United Kingdom (0): D.

West; Caboolture Hospital, Queensland (28): M. Ratnapala, R. Armstrong, A. Heazelwood; Campbelltown Hospital, Sydney, New South Wales (1): H.

Grunstein, S. Marney; Flinders Medical Center, Adelaide, South Australia (43): K. Verco; General Infirmary, Leeds, United Kingdom (3): E. Lidelle-Johnson, J. Pearce; Hammersmith Hospital, London (2): M.

McCarthy; Hervey Bay Hospital, Queensland (24): A. Wickremachandran; Lyell McEwin Hospital, Adelaide, South Australia (125): G.

Kennedy-Andrews, N. Kretschmer, H. Mowbray; Modbury Hospital, Adelaide, South Australia (68): C. Sieben; Nambour General Hospital, Queensland (37): C. Rutherford, C.

Smith-Orr; Northern General Hospital, Sheffield, United Kingdom (41): S. Fraser; Queen Elizabeth Hospital, Adelaide, South Australia (29): B. Pridmore (deceased), W.

Torr; Royal North Shore Hospital, Sydney (198): G. George Hospital, Sydney (1): C.

Davis; Toowoomba Base Hospital, Queensland (11): P. Ratnapala; Townsville Hospital, Queensland (48): D. Whitehall, S. Lawrence; Women's and Children's Hospital, South Australia (261): C. Wilkinson, V. Coppinger, J. References • 1 Hoffman L, Nolan C, Wilson JD, Oats J, Simmons D.

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