Improving energy efficiency in manufacturing processes is a critical global concern for the industry. Manufacturers strive to enhance energy efficiency across all manufacturing operations to remain competitive globally, aiming to reduce production times without compromising product quality. While there has been significant research characterizing energy efficiency and surface roughness in conventional processes like turning or milling, studies on unconventional manufacturing techniques are limited. This study focuses on optimizing a wire electrical discharge machining (WEDM) process to minimize energy consumption while maintaining surface roughness. Various cutting parameters, such as pulse on-time, pulse off-time, servo voltage, wire tension, wire speed, and wire voltage, were evaluated. Experiments were conducted using Taguchi’s methodology with a $L_{27}$ orthogonal array, employing AISI D2 steel plates of 19 mm and 25 mm thickness as the machining material. The research identified that optimal parameters for reducing energy consumption and improving surface roughness included a pulse on-time of 10 s, pulse off-time of 11 s, servo voltage of 44 V, wire tension of 50 g-force, wire speed of 7 m per minute, and wire voltage of 9 volts. This combination led to an 8% reduction in energy consumption and a 1% enhancement in surface roughness compared to baseline values. Full article

Polyvinyl chloride microplastics (PVC-MPs) are microplastic pollutants widely present in the environment, but their potential risks to human lung health and underlying toxicity mechanisms remain unknown. In this study, we systematically analyzed the effects of PVC-MPs on the transcriptome and metabolome of BEAS-2B cells using high-throughput RNA sequencing and untargeted metabolomics technologies. The results showed that exposure to PVC-MPs significantly reduced the viability of BEAS-2B cells, leading to the differential expression of 530 genes and 3768 metabolites. Further bioinformatics analyses showed that PVC-MP exposure influenced the expression of genes associated with fluid shear stress, the MAPK and TGF-β signaling pathways, and the levels of metabolites associated with amino acid metabolism. In particular, integrated pathway analysis showed that lipid metabolic pathways (including glycerophospholipid metabolism, glycerolipid metabolism, and sphingolipid metabolism) were significantly perturbed in BEAS-2B cells following PVC-MPs exposure. This study provides new insights and targets for a deeper understanding of the toxicity mechanism of PVC-MPs and for the prevention and treatment of PVC-MP-associated lung diseases. Full article

To improve the luminescent efficiency of and to design the color spectrum of phosphors, the comprehensive understanding of the correlation between physical parameters and luminescent properties is imperative, necessitating systematic experimental studies. However, unintentional variations across individually prepared samples impede the thorough investigation of the correlation. In this study, we investigate the possible sources of unintentional variation in the photoluminescence properties of phosphors during sample preparation using a solid-state reaction, explicitly focusing on the ball milling process. Based on the quantitative features of the photoluminescent properties and their associated statistical errors, we explore the impact of unintentional variation alongside intended systematic variation, highlighting its potential to obscure meaningful trends. Full article

Bisphenol A (BPA) and bisphenol B (BPB) are widely used in the production of plastics, and their potential adverse health effects, particularly on endocrine disruption and metabolic health, have raised concern. Peroxisome proliferator-activated receptor gamma (PPARγ) plays a pivotal role in metabolic regulation and adipogenesis, making it a target of interest in understanding the development of obesity and associated health impacts. In this study, we employ X-ray crystallography and molecular dynamics (MD) simulations to study the interaction of PPARγ with BPA and BPB. Crystallographic structures reveal the binding of BPA and BPB to the ligand binding domain of PPARγ, next to C285, where binding of partial agonists as well as antagonists and inverse agonists of PPARγ signaling has been previously observed. However, no interaction of BPA and BPB with Y437 in the activation function 2 site is observed, showing that these ligands cannot stabilize the active conformation of helix 12 directly. Furthermore, free energy analyses of the MD simulations revealed that I341 has a large energetic contribution to the BPA and BPB binding modes characterized in this study. Full article

The prediction of bankruptcy risk poses a formidable challenge in the fields of economics and finance, particularly within the healthcare industry, where it carries significant economic implications. The burgeoning field of healthcare electronic commerce, continuously evolving through technological advancements and changing regulations, introduces additional layers of complexity. We collected financial data from 1265 U.S. healthcare industries to predict bankruptcy based on 40 financial ratios using multi-class classification machine learning models across various industry subsectors and market capitalizations. The exceptionally high post-tuning accuracy rates, exceeding 90%, along with high-performance metrics solidified the robustness and exceptional predictive capability of the gradient boosting model in bankruptcy prediction. The results also demonstrate the power and sensitivity of financial ratios in predicting bankruptcy based on financial ratios. The Altman models highlight the return on investment (ROI) as the most important parameter for predicting bankruptcy risk in healthcare industries. The Ohlson model identifies return on assets (ROA) as an important ratio specifically for predicting bankruptcy risk within industry subsectors. Furthermore, it underscores the significance of both ROA and the enterprise value to earnings before interest and taxes (EV/EBIT) ratios as important parameters for predicting bankruptcy based on market capitalization. Recognizing these ratios enables proactive decision making that enhances resilience. Our findings contribute to informed risk management strategies, allowing for better management of healthcare industries in crises like those experienced in 2022 and even on a global scale. Full article

In this study, a top-down approach was employed for the fabrication of flame-retardant wood aerogels. The process involved the removal of lignin and the removal of hemicellulose utilizing NaOH concomitantly with the incorporation of ZnO and urea. Subsequently, an in situ reaction with boric acid was conducted to prepare flame-retardant wood aerogels. The morphology, chemical composition, thermal stability, and flame retardancy of the samples were studied. The results show that the NaOH treatment transformed the wood into a layered structure, and flame-retardant particles were uniformly distributed on the surface of the aerogel. The peak heat release rate (PHRR) and total heat release (THR) of the flame-retardant aerogel were significantly reduced compared with the control samples. Meanwhile, its vertical burning test (UL-94) rating reached the V-0 level, and the Limiting Oxygen Index (LOI) could exceed 90%. The flame-retardant wood aerogel exhibited excellent flame retardancy and self-extinguishing properties. Full article

In the Pistoia Nursery-Ornamental Rural District (Italy), a leader in Europe in ornamental nurseries covering over 5200 hectares with over 2500 different species of plant, plant-parasitic nematodes represent a serious concern. The potential efficacy of a pot cultivation system using commercial substrates to control plant-parasitic nematodes was assessed. On two different plant species, two different pot cultivation managements, potted plants, and potted plants previously cultivated in natural soil were compared to plants only cultivated in natural soil. The entire soil nematode structure with and without plants was evaluated. The relationship between soil properties and soil nematode community was investigated. All the studied substrates were free from plant-parasitic nematodes. Regarding free-living nematodes, Peat–Pumice showed nematode assemblage established by colonizer and extreme colonizer bacterial feeders, whereas Peat–Perlite included both bacterial and fungal feeders, and, finally, coconut fiber also included omnivores and predators. In farming, the substrates rich in organic matter such as coconut fiber could still play an important role in suppressing plant-parasitic nematodes because of the abundance of free-living nematodes. In fact, they are of crucial importance in both the mineralization of organic matter and the antagonistic control of plant-parasitic nematodes. Potting systems equally reduce virus-vector nematodes and improve the prey/predator ratio favoring natural control. Full article

This article argues that Pierre Bayle (1647–1706) is not merely a theorist of religious toleration but also a theorist of religious radicalization. By exploring how religious dissenters experienced religious conformity as a kind of mental and spiritual torture akin to conventional forms of corporeal punishment, I demonstrate that Bayle’s influential defense of toleration and liberty of conscience hinges on his account of the psychological mechanism of religious radicalization. Demands for religious conformity do not convince dissenters of their error but of their lack of zeal for their faith. Bayle’s plea for toleration, more broadly, urges us to reflect on the ways that we invite those who are different from us into dialogue or risk alienating them even further, an urgent concern today as extremist religious and nationalist views are on the rise across the globe. Full article

Background: Erectile dysfunction (ED) most often has vascular etiology and usually is the earliest symptom of vascular dysfunction. The aim of this study was to evaluate vascular dysfunction with the use of the Flow-Mediated Skin Fluorescence (FMSF) technique in men with and without ED. Methods: Included were 39 men (median age 53) with ED and 40 men (median age 41.5) without ED. Medical interview, physical examination, and anthropometrical measurements were performed for all participants. The serum total testosterone, LH, and SHBG determinations were performed in patients with ED, and the Free Testosterone Index (FTI) was calculated. The FMSF technique was used to measure the microcirculatory oscillations at the baseline and to determine the flowmotion (FM) and vasomotion (VM) parameters. The Normoxia Oscillatory Index (NOI) was calculated, which represents the contribution of the endothelial (ENDO) and neurogenic (NEURO) oscillations relative to all oscillations detected at low-frequency intervals (<0.15 Hz): NOI = (ENDO + NEURO)/(ENDO + NEURO + VM). Results: In men with ED were found significantly lower FM and VM parameters, but the NOI was significantly higher in comparison to men without ED. VM and FM correlated significantly positively with erectile function, orgasmic function, and general sexual satisfaction in the whole group and the FTI in the ED group. The thresholds of 53.5 FM (AUC = 0.7) and 8.4 VM (AUC = 0.7) were predictive values for discriminating men with ED. Conclusions: It was shown that the FMSF diagnostic technique may be helpful in the early diagnosis of microcirculation dysfunction due to impaired vasomotion caused by decreased testosterone activity. Full article

To date, life support systems on the International Space Center (ISS) or those planned for upcoming moon/Mars missions have not included biological reactors for wastewater treatment, despite their ubiquitous use for the treatment of terrestrial wastewaters. However, the new focus on partial gravity habitats reduces the required complexity of treatment systems compared with those operating in micro-gravity, and the likely addition of large-volume wastewaters with surfactant loads (e.g., laundry and shower) makes the current ISS wastewater treatment system inappropriate due to the foaming potential from surfactants, increased consumable requirements due to the use of non-regenerative systems (e.g., mixed adsorbent beds), the complexity of the system, and sensitivity to failures from precipitation and/or biological fouling. Hybrid systems that combine simple biological reactors with desalination (e.g., Reverse Osmosis (RO)) could reduce system and consumable mass and complexity. Our objective was to evaluate a system composed of a membrane-aerated bioreactor (MABR) coupled to a low-pressure commercial RO system to process partial gravity habitat wastewater. The MABR was able to serve as the only wastewater collection tank (variable volume), receiving all wastewaters as they were produced. The MABR treated more than 20,750 L of graywater and was able to remove more than 90% of dissolved organic carbon (DOC), producing an effluent with DOC < 14 mg/L and BOD < 12 mg/L and oxidizing >90% of the ammoniacal nitrogen into NOx₋. A single RO membrane (260 g) was able to process >3000 L of MABR effluent and produced a RO permeate with DOC < 5 mg/L, TN < 2 mg/L, and TDS < 10 mg/L, which would essentially meet ISS potable water standards after disinfection. The system has an un-optimized mass and volume of 128.5 kg. Consumables include oxygen (~4 g/crew-day), RO membranes, and a prefilter (1.7 g/crew-day). For a one-year mission with four crew, the total system + consumable mass are ~141 kg, which would produce ~15,150 kg of treated water, resulting in a pay-back period of 13.4 days (3.35 days for a crew of four). Given that the MABR in this study operated for 500 days, while in previous studies, similar systems operated for more than 3 years, the total system costs would be exceedingly low. These results highlight the potential application of hybrid treatment systems for space habitats, which may also have a direct application to terrestrial applications where source-separated systems are employed. Full article

Seroprevalence of lyssaviruses in certain bat species has been proven in the Republic of Croatia, but there have been no confirmed positive bat brain isolates or human fatalities associated with bat injuries/bites. The study included a retrospective analysis of bat injuries/bites, post-exposure prophylaxis (PEP) and geographic distribution of bat injuries in persons examined at the Zagreb Antirabies Clinic, the Croatian Reference Centre for Rabies. In the period 1995–2020, we examined a total of 21,910 patients due to animal injuries, of which 71 cases were bat-related (0.32%). Of the above number of patients, 4574 received rabies PEP (20.87%). However, for bat injuries, the proportion of patients receiving PEP was significantly higher: 66 out of 71 patients (92.95%). Of these, 33 received only the rabies vaccine, while the other 33 patients received the vaccine with human rabies immunoglobulin (HRIG). In five cases, PEP was not administered, as there was no indication for treatment. Thirty-five of the injured patients were biologists or biology students (49.29%). The bat species was confirmed in only one of the exposure cases. This was a serotine bat (Eptesicus serotinus), a known carrier of Lyssavirus hamburg. The results showed that the bat bites were rather sporadic compared to other human injuries caused by animal bites. All bat injuries should be treated as if they were caused by a rabid animal, and according to WHO recommendations. People who come into contact with bats should be strongly advised to be vaccinated against rabies. Entering bat habitats should be done with caution and in accordance with current recommendations, and nationwide surveillance should be carried out by competent institutions and in close collaboration between bat experts, epidemiologists and rabies experts. Full article

Introduction: Myasthenia gravis (MG), an immune disorder affecting nerve-muscle transmission, often necessitates tailored therapies to alleviate longitudinal symptom fluctuations. Here, we aimed to examine and compare the treatment cycle intervals and efficacy of efgartigimod in four patients. This case series mainly offers insights into personalized treatment cycle intervals and the efficacy of efgartigimod for patients with MG in our facility in Japan. Methods: We retrospectively analyzed four patients with MG (2 patients with early-onset, 1 with late-onset, and 1 with seronegative MG, mainly managed with oral immunosuppressants as prior treatments) who completed four or more cycles of efgartigimod treatment from January 2022 to September 2023. We focused on changes in serum immunoglobulin (IgG) level, acetylcholine receptor antibody (AChR-Ab) titer, and quantitative MG (QMG) score. Results: Efgartigimod, administered at a median of 5.0 [IQR 5.0, 7.5] weeks between cycles, led to decreased serum IgG levels in all patients and reduced AChR-Ab titers in seropositive patients. All patients showed sustained MG symptom improvement, with considerably reduced QMG scores before efgartigimod treatment. None of the patients required rescue medications or developed treatment-related adverse events. Conclusions: Customized efgartigimod administration intervals effectively enhanced clinical outcomes in patients with MG without notable symptom fluctuations, demonstrating the benefits of individualized treatment approaches and validating the safety of efgartigimod during the study period. Full article

In the context of open science, universities, research-performing and funding organizations and authorities worldwide are moving towards more responsible research assessment (RRA). In 2022, the European Coalition for Advancing Research Assessment (CoARA) published an agreement with ten commitments, including the recognition of the “diversity of contributions to, and careers in, research”, the “focus on qualitative evaluation for which peer review is central, supported by responsible use of quantitative indicators”, and the “abandon (of) inappropriate uses in research assessment of journal- and publication-based metrics”. Research assessment (RA) is essential for research of the highest quality. The transformation of assessment indicators and procedures directly affects the underlying research information management infrastructures (also called current research information systems) which collect and store metadata on research activities and outputs. This entry investigates the impact of RRA on these systems, on their development and implementation, their data model and governance, including digital ethics. Full article

Generative adversarial network (GAN) can generate diverse and high-resolution images for data augmentation. However, when GAN is applied to the synthetic aperture radar (SAR) dataset, the generated categories are not of the same quality. The unrealistic category will affect the performance of the subsequent automatic target recognition (ATR). To overcome the problem, we propose a reinforced constraint filtering with compensation afterwards GAN (RCFCA-GAN) algorithm to generate SAR images. The proposed algorithm includes two stages. We focus on improving the quality of easily generated categories in Stage 1. Then, we record the categories that are hard to generate and compensate by using traditional augmentation methods in Stage 2. Thus, the overall quality of the generated images is improved. We conduct experiments on the moving and stationary target acquisition and recognition (MSTAR) dataset. Recognition accuracy and Fréchet inception distance (FID) acquired by the proposed algorithm indicate its effectiveness. Full article

Background: Placenta accreta spectrum (PAS) can be the cause of major morbidity and its optimal management is still controversial. The aim of this study was to compare the traditional one-step surgery with a two-step surgical approach in which the placenta is left in situ and the second final operation is delayed to minimise blood loss. Methods: We conducted a single-centre retrospective cohort study including all patients managed for PAS between 2007 and 2023. The number of units of red blood cells (RBCs) needed during surgery was the primary outcome used to compare these two approaches. Results: A total of 43 cases were included in this analysis. Twenty of these were managed with the delayed two-step surgical approach, whereas 23 received one-step surgery. The median estimated blood loss during surgery was 2000 mL and 2800 mL for two-step and one-step surgery, respectively (p = 0.095). In the two-step surgical approach, the median number of RBC units transfused during surgery was significantly lower (p = 0.049) and the odds ratio for needing more than four units of RBCs was 0.28 (95%-CI: 0.08–0.98, p = 0.043). A longer interval between the caesarean section and the second operation showed a trend toward lower blood loss (p = 0.065) and was associated with a significantly lower number of RBC units needed during surgery (p = 0.019). Conclusions: Two-step surgery for the treatment of PAS was safe in our cohort and could lead to a reduction in blood transfusion. Leaving the placenta in situ and delaying the final operation represents a possible alternative to traditional caesarean hysterectomy. Full article

Pain is one of the most common symptoms in patients with cancer. Pain not only negatively affects the quality of life of patients with cancer, but it has also been associated with reduced survival. Pain management is therefore a critical component of cancer care. Prescription opioids remain the first-line approach for the management of moderate-to-severe pain associated with cancer. However, there has been increasing interest in understanding whether these analgesics could impact cancer progression. Furthermore, epidemiological data link a possible association between prescription opioid usage and cancer development. Until more robust evidence is available, patients with cancer with moderate-to-severe pain may receive opioids to decrease suffering. However, future studies should be conducted to evaluate the role of opioids and opioid receptors in specific cancers. Full article

In order to investigate the impact of moisture content on energy evolution, three types of rock samples with varying moisture contents were subjected to uniaxial compression tests. The study aimed to analyze the reasons behind the differences in energy during the deformation process of rocks with different moisture contents. The findings indicate that with increasing moisture content, the peak strength and elastic modulus of the samples decrease. However, the ratio of crack initiation strength σ_ci to peak strength σ_f shows little effect, primarily because the characteristic strength ratio σ_ci/σ_f is determined by external loads. The growth rate of elastic energy reaches its maximum value in the early stage of yield, while the proportion of elastic energy reaches its peak value in the later stage of yield. In the deformation and failure process of rocks with varying moisture contents, the increment in elastic performance is smallest in the initial compaction stage for saturated rocks, whereas it is the largest in the yield stage for dry rocks. Additionally, a damage evolution equation based on energy dissipation was established and validated. Full article

A comprehensive understanding of the mechanical characteristics of deep coalbed methane reservoir rocks (DCMRR) is crucial for the safe and efficient development of deep coalbed gas resources. In this study, the microstructural and mechanical features of the coal seam roof, floor, and the coal seam itself were analyzed through laboratory experiments. The impact mechanisms of drilling fluid and fracturing fluid hydration on the mechanical properties and failure behavior of coal seam rocks were investigated. The experimental results indicate that the main minerals in coal seams are clay and amorphous substances, with kaolinite being the predominant clay mineral component in coal seam rocks. The rock of the coal seam roof and floor exhibits strong elasticity and high compressive strength, while the rock in the coal seam section shows a lower compressive capacity with pronounced plastic deformation characteristics. The content of kaolinite shows a good correlation with the mechanical properties of DCMRR. As the kaolinite content increases, the strength of DCMRR gradually decreases, and deformability enhances. After immersion in drilling fluid and slickwater, the strength of coal seam rocks significantly decreases, leading to shear fracture zones and localized strong damage features after rock compression failure. The analysis of the mechanical properties of DCMRR suggests that the horizontal well trajectory should be close to the coal seam roof, and strong sealing agents should be added to drilling fluid to reduce the risk of wellbore collapse. Enhancing the hydration of slickwater is beneficial for the formation of a more complex fracture network in deep coalbed methane reservoir. Full article

To date, most studies examined the effects of cold water immersion (CWI) on neuromuscular control following exercise solely on measuring proprioception, no study explores changes in the brain and muscles. The aim of this study was to investigate the effects of CWI following exercise on knee neuromuscular control capacity, and physiological and perceptual responses. In a crossover control design, fifteen participants performed an exhaustion exercise. Subsequently, they underwent a 10 min recovery intervention, either in the form of passively seated rest (CON) or CWI at 15 °C. The knee proprioception, oxygenated cerebral hemoglobin concentrations (Δ[HbO]), and muscle activation during the proprioception test, physiological and perceptual responses were measured. CWI did not have a significant effect on proprioception at the post-intervention but attenuated the reductions in Δ[HbO] in the primary sensory cortex and posterior parietal cortex (p < 0.05). The root mean square of vastus medialis was higher in the CWI compared to the CON. CWI effectively reduced core temperature and mean skin temperature and improved the rating of perceived exertion and thermal sensation. These results indicated that 10 min of CWI at 15 °C post-exercise had no negative effect on the neuromuscular control of the knee joint but could improve subjective perception and decrease body temperature. Full article

Eco-industrial parks, as complex ecosystems at the regional scale, involve multi-dimensional interactions in terms of management, environment, economy, and society in their development. Given their complexity, it is difficult for a single indicator to comprehensively assess their sustainable development status. To promote sustainability and inclusive development of industrial parks, the World Bank Group published “the International Framework for Eco-Industrial Park” as a green evaluation benchmark. This paper examines the applicability of this framework in Chinese industrial parks, focusing on 17 cases in Jiangxi Province supported by the China-Jiangxi Eco-Industrial Parks Project. This study analyzes the indicator composition of the international EIP framework and compares it with the standardization system of eco-industrial parks in China. Through questionnaire surveys and dialogue interviews, this paper analyzed the compliance, practicality, and necessity of implementing the international EIP framework. Quantitative assessment using the analytic hierarchy process and the fuzzy comprehensive evaluation model revealed that the framework is well suited to Chinese conditions, scoring over 80, reaching the “applicability level”. This research provides a scientific basis for park management, advocating for international concepts in park development. It also underscores the importance of a comprehensive framework for park construction, intelligent management strategies, and enterprise empowerment, collectively contributing to sustainable park development and enhanced international competitiveness. Full article

Regulatory T cells (Tregs) are essential to maintain immune homeostasis by promoting self-tolerance. Reduced Treg numbers or functionality can lead to a loss of tolerance, increasing the risk of developing autoimmune diseases. An overwhelming variety of human Tregs has been described, based on either specific phenotype, tissue compartment, or pathological condition, yet the bulk of the literature only addresses CD25-positive and CD127-negative cells, coined by naturally occurring Tregs (nTregs), most of which express the transcription factor Forkhead box protein 3 (FOXP3). While the discovery of FOXP3 was seminal to understanding the origin and biology of nTregs, there is evidence in humans that not all T cells expressing FOXP3 are regulatory, and that not all Tregs express FOXP3. Namely, the activation of human T cells induces the transient expression of FOXP3, irrespective of whether they are regulatory or inflammatory effectors, while some induced T cells that may be broadly defined as Tregs (e.g., Tr1 cells) typically lack demethylation and do not express FOXP3. Furthermore, it is unknown whether and how many nTregs exist without FOXP3 expression. Several other candidate regulatory molecules, such as GITR, Lag-3, GARP, GPA33, Helios, and Neuropilin, have been identified but subsequently discarded as Treg-specific markers. Multiparametric analyses have uncovered a plethora of Treg phenotypes, and neither single markers nor combinations thereof can define all and only Tregs. To date, only the functional capacity to inhibit immune responses defines a Treg and distinguishes Tregs from inflammatory T cells (Teffs) in humans. This review revisits current knowledge of the Treg universe with respect to their heterogeneity in phenotype and function. We propose that it is unavoidable to characterize human Tregs by their phenotype in combination with their function, since phenotype alone does not unambiguously define Tregs. There is an unmet need to align the expression of specific markers or combinations thereof with a particular suppressive function to coin functional Treg entities and categorize Treg diversity. Full article

The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus. Dystocia describes the deviation from the limits that define a normal birth and is often used as a synonym for the term pathological birth. Shoulder dystocia, also known as the manual exit of the shoulders during vaginal delivery on cephalic presentation, is defined as the “failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head”. This means that obstetric interventions are necessary to deliver the fetus’s body after the head has been delivered, as gentle traction has failed. Abnormal labor (dystocia) is expressed and represented in partograms or by the prolongation of the latent phase or by slowing and pausing in the phases of cervical dilatation and fetal descent. While partograms are helpful in visualizing the progress of labor, regular use of them has not been shown to enhance obstetric outcomes considerably, and no partogram has been shown to be superior to others in comparative trials. Dystocia can, therefore, appear in any phase of the evolution of childbirth, so it is necessary to simultaneously assess all the factors that may contribute to its abnormal evolution, that is, the forces exerted, the weight, the shape, the presentation and position of the fetus, the integrity and morphology of the pelvis, and its relation to the fetus. When this complication occurs, it can result in an increased incidence of maternal morbidity, as well as an increased incidence of neonatal morbidity and mortality. Although several risk factors are associated with shoulder dystocia, it has proven impossible to recognize individual cases of shoulder dystocia in practice before they occur during labor. Various guidelines have been published for the management of shoulder dystocia, with the primary goal of educating the obstetrician and midwife on the importance of a preplanned sequence of maneuvers, thereby reducing maternal and neonatal morbidity and mortality. Full article