Risk Factors Associated with Congenital Syphilis, Georgia, 2008-2015.

Background: Congenital syphilis (CS) is associated with significant perinatal morbidity and mortality. The study objectives were to compare risk factors among women with syphilis infection whose pregnancies did and did not result in CS cases and to evaluate other geographic and socioeconomic characteristics of county of residence as a measure of healthcare inequity. Methods: This study linked maternal and congenital syphilis data from the Georgia Department of Public Health (DPH), 2008-2015. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline was followed. Demographic, behavioral, and case characteristics were compared among women with syphilis infection who did and did not have an infant with CS. Chi-square, Fisher's exact, and multivariate regression analyses were performed using STATA 14.2 (College Station, TX). Results: Of 505 women with syphilis infection, 23% had an infant with CS, while 77% did not. After adjusting for race/ethnicity, factors associated with CS outcome were age greater than 35 years (adjusted odds ratio (aOR) 3.88; 95% confidence interval (CI) 1.01-14.89), hospital/emergency department diagnosis of syphilis (aOR 3.43; 95% CI 1.54-7.62), and high-risk behaviors such as exchanging sex for money or drugs (aOR 3.25; 95% CI 1.18-8.98). There were no associations between characteristics of county of residence and CS outcome. Conclusions: This study highlights risk factors that may be associated with CS incidence and the adverse pregnancy outcomes associated with CS. Further work is needed to study improved data collection systems, contributing factors related to CS as well as prevention measures in the United States.

Substance Use Disorder-Related Deaths and Maternal Mortality in New Mexico, 2015-2019.

BACKGROUND: In recent decades, maternal mortality has increased across the U.S. Experiences of pregnant and postpartum people with Substance Use Disorder (SUD)-related deaths have not been previously evaluated in New Mexico. The aim of this study was to analyze risk factors related to substance use and explore substance use patterns among pregnancy-associated deaths in New Mexico from 2015 to 2019. METHODS: We conducted an analysis of pregnancy-associated deaths to assess the association between demographics, pregnancy factors, circumstances surrounding death, treatment of mental health conditions, and experiences with social stressors among Substance Use Disorder (SUD)-related and non-SUD-related deaths. We performed univariate analyses of risk factors using chi-square tests to assess the differences between SUD-related and non-SUD-related deaths. We also examined substance use at time of death. RESULTS: People with SUD-related deaths were more likely to die 43-365 days postpartum (81% vs. 45%, p-value = 0.002), have had a primary cause of death of mental health conditions (47% vs 10%, p < 0.001), have died of an overdose (41% vs. 8%, p-value = 0.002), have had experienced any social stressors (86% vs 30%, p < 0.001) compared to people with non-SUD-related deaths, and received treatment for SUD at any point before, during, or after pregnancy (49% vs. 2%, p < 0.001). The substances most used at time of death were amphetamines (70%), and most cases engaged in polysubstance use (63%). CONCLUSIONS FOR PRACTICE: Providers, health departments, and community organizations must prioritize supporting people using substances during and after pregnancy to prevent death and improve quality of life for pregnant and postpartum people.

Effectiveness of a question formulation rubric with second-year medical students: a randomized controlled trial.

Objective: The FAC (Focus, Amplify, Compose) rubric for assessing medical students' question formulation skills normally accompanies our Evidence Based Practice (EBP) training. The combined training and assessment rubric have improved student scores significantly. How much does the rubric itself contribute to improved student scores? This study sought to measure student improvement using the rubric either with or without a linked 25-minute training session. Methods: Randomized Controlled Trial. The authors tested the hypothesis that a 25-minute training session combined with use of a rubric would lead to higher scores than a brief explanation of this rubric alone. All 72 participating second-year medical students had a question formulation rubric briefly explained to them following a pre-test. Students in the intervention groups were taught how to formulate EBP questions for 25 minutes using the rubric followed with another 30 minutes of EBP search training. Students in the control group only received the 30 minutes of EBP search training in their small group labs. All 72 students took the post-test in which they formulated a question in response to a clinical vignette. Statistical analysis to test the hypothesis consisted of a two-sample paired t-test to measure between-group differences. Discussion: Both the intervention and control groups performed significantly better on the post-test for question formulation skills than on the pre-test. When analyzed by extent of individual improvement between pre- and post-tests using a two-sample paired t-test for between group differences, the control group students receiving only a brief explanation of the rubric performed the same statistically (intervention 37.7 versus 37.4 control) as the intervention group students who received the same brief explanation followed by a 25-minute active learning training session. Thus, the results provided no support of the hypothesis that the extra 25-minute training improved post-test scores. The rubric itself contributed similarly to the intervention groups students' improvement as the combined rubric and training for control group students. This finding could potentially save scarce curricular time. Key Messages: The FAC question formulation rubric and training significantly improves medical students' EBP question quality. The FAC rubric coupled with only a 5-minute explanation can be effective. In a crowded medical school curriculum, the rubric and brief explanation might save valued time for other purposes.

Birth Outcomes and Rehospitalizations Among Pregnant Women With Rheumatoid Arthritis and Systemic Lupus Erythematosus and Their Offspring.

OBJECTIVE: To compare obstetric/birth outcomes and rehospitalization among women with and without rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) and their infants. METHODS: This population-based retrospective cohort study identified women with RA (n = 1,223) and SLE (n = 1,354) and unexposed women with singleton births 1987-2014 in Washington State in linked vital hospital discharge records. Outcomes, including cause-specific hospitalizations <2 years postpartum, were compared by estimating adjusted relative risks (RRs) and cause-specific rehospitalization hazard ratios (HRs) with 95% confidence intervals (95% CIs). RESULTS: We observed increased risks of several adverse outcomes; RRs were often greatest for SLE. Women with RA/SLE more often required rehospitalization, most notably at <6 months postpartum (RA: 4% versus 2%; RR 2.22 [95% CI 1.62-3.04]; SLE: 6% versus 2%; RR 2.78 [95% CI 2.15-3.59]). Maternal postpartum rehospitalization was greatest for musculoskeletal conditions (RA: HR 19.1 [95% CI 13.6-26.8]; SLE: HR 29.8 [95% CI 22.1-40.1]). Infants of women with SLE more often had malformations (9% versus 6%; RR 1.46 [95% CI 1.21-1.75]), and increased mortality at <2 years (RR 2.11 [95% CI 1.21-3.67]). Infants of women with SLE also experienced more frequent rehospitalizations in their first year of life. CONCLUSION: Women with RA or SLE and their infants experienced adverse outcomes, particularly infants of women with SLE. Maternal/infant rehospitalization was more common; most marked in the early months postpartum. Close follow-up during these time periods is crucial to minimize adverse outcomes.

Morbidity and rehospitalization postpartum among women with epilepsy and their infants: A population-based study.

OBJECTIVE: We compared the relative occurrence of selected pregnancy outcomes and postpartum rehospitalizations among women with and without epilepsy and their infants. Using linked vital-hospital discharge records of women with deliveries in Washington State 1987-2014, comparisons were made overall, by epilepsy type, and by time periods related to antiepileptic drug (AED) marketing changes. METHODS: This population-based retrospective cohort study identified women with, and without epilepsy per diagnosis codes in the hospital discharge record from among all deliveries during 1987-2014 to examine maternal and infant outcomes, rehospitalization and mortality <2 years postpartum. Relative risks (RRs) and 95 % confidence intervals (CI) overall, and by epilepsy type were calculated using Poisson regression. We assessed the validity of epilepsy identification based on diagnosis codes by conducting a medical chart review for a sample of women. RESULTS: Women with epilepsy had increased risks of preeclampsia (RR 1.23; 95 % CI 1.08-1.41) and gestational diabetes (RR 1.18; 95 % CI 1.02-1.36). Their infants had increased malformation (RR 1.23; 95 % C: 1.08-1.42) and small for gestational age (SGA, RR 1.39; 95 % CI 1.25-1.54) risks, and were nearly three times as likely to not be breastfed. Affected mothers (RR 5.25; 95 % CI 2.46-11.23) and their infants (RR 1.64, 95 % CI 1.41-1.89) required more ICU admissions during the delivery hospitalizations, and more postpartum rehospitalization, with greatest risk in the first six months. Maternal mortality < 2 years after delivery was increased (RR 7.11; 95 % CI 2.47-20.49). Increased risks were observed for all epilepsy subtypes for nearly all outcomes examined. Risks of preterm delivery and low birthweight increased over time (p <.05). Suggestive, but not statistically significant temporal decreases in risks of gestational diabetes and malformations and increased risk of preterm labor were noted. We observed high sensitivity of diagnosis codes for identifying pregnant women with epilepsy. CONCLUSION: These population-based results emphasize the need for frequent postpartum monitoring of women with epilepsy. Increases in risks of low birthweight and preterm delivery over time are of concern. Possible temporal changes in other outcomes warrant further investigation.

Increased length of active labor is associated with adverse perinatal outcomes among nulliparous women undergoing labor induction.

OBJECTIVE: Evaluate the association between current recommendations for active labor duration in nulliparous women undergoing labor induction and adverse perinatal outcomes. STUDY DESIGN: Retrospective cohort study from 2012 to 2015. Subjects were nulliparous, 18-44 years, cephalic, singleton ≥37 weeks undergoing labor induction who reached active labor. We created three subgroups, defined by active labor duration from 6 to 10cm as < the median, median-95th percentile, and >95th percentile based on contemporary labor curves. We evaluated the association between subgroups and cesarean delivery, chorioamnionitis, blood loss (EBL), 5-minute Apgar score < 7, and neonatal intensive care unit (NICU) admission using logistic regression. RESULTS: Among 356 women, 34.8% had an active labor duration < median, 43.3% were between the median-95th percentile, and 21.9% were >95th percentile. The risk of cesarean delivery increased with longer active labor duration; 1.8-fold (95%CI = 1.1-3.1) and 4.0-fold (95%CI = 2.5-6.5) for women whose active labors were between the median-95th percentile and >95th percentile, respectively. Chorioamnionitis increased by 3.9-fold (95%CI = 1.2-13.2) in the >95th percentile subgroup. Active labor length was not associated with EBL, Apgar scores, or NICU admission. CONCLUSIONS: Cesarean delivery and chorioamnionitis increased significantly as induced active labor duration exceeded the median. This study provides a better understanding regarding the risks of longer active labor as defined by contemporary labor curves.

The Association Between Risk Behaviors and Vaping Among Youth in New Mexico.

CONTEXT: Electronic-cigarette use, or vaping, among youth has increased substantially in recent years. Tobacco smoking shows a strong association with other risk behaviors, but the association between vaping and other risk behaviors has rarely been explored. We examine the relationship between youth vaping and substance use, risky driving behaviors, and lack of bicycle helmet use. PROGRAM: Data from the 2015 and 2017 New Mexico Youth Risk and Resiliency Survey were analyzed to evaluate the association between the use of e-cigarettes and other youth risk behaviors. Study participants were high school students, grades 9 to 12. Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI). EVALUATION: A majority of students reported ever using e-cigarettes (54%). In 2015, e-cigarette users were more likely than nonusers to be Hispanic (65% vs 54%, P ≤ .001) and 16 years of age or older (58% vs 42%, P = .018). We found strong, statistically significant associations between e-cigarette use and not wearing a bicycle helmet (OR = 2.62, 95% CI: 1.95-3.51), texting while driving (OR = 2.18, 95% CI: 1.79-2.66), driving after drinking (OR = 2.95, 95% CI: 1.61-5.40), current marijuana use (OR = 6.38, 95% CI: 4.65-8.76), current painkiller use (OR = 2.47, 95% CI: 1.63-3.77), and current heroin use (OR = 0.15, 95% CI: 0.06-0.33). Driving after drinking was not significantly associated with e-cigarette use in 2017. DISCUSSION: E-cigarette use is associated with multiple other risk behaviors among youth. Further research should focus on environmental and policy efforts to reduce access to e-cigarettes by youth as well as interventions that address the underlying causes of the constellation of risk behaviors.

Question formulation skills training using a novel rubric with first-year medical students.

OBJECTIVE: The authors used an assessment rubric to measure medical students' improvement in question formulation skills following a brief evidence-based practice (EBP) training session conducted by a health sciences librarian. METHOD: In a quasi-experimental designed study, students were assessed using a rubric on their pre-instructional skills in formulating answerable EBP questions, based on a clinical scenario. Following their training, they were assessed using the same scenario and rubric. Student pre- and post-test scores were compared using a paired t-test. RESULTS: Students demonstrated statistically significant improvement in their question formulation skills on their post-instructional assessments. The average score for students on the pre-test was 45.5 (SD 11.1) and the average score on the post-test was 65.6 (SD 5.4) with an average increase of 20.1 points on the 70-point scale, p<0.001. CONCLUSION: The brief instructional session aided by the rubric improved students' performance in question formulation skills.

Pregnancy outcomes among visually impaired women in Washington State, 1987-2014.

BACKGROUND: Women with visual impairment may have reduced ability to access standard care resources, however, information on their pregnancy and neonatal outcomes is limited. OBJECTIVE: To assess risk of adverse pregnancy and neonatal outcomes among visually impaired women in Washington State from 1987 to 2014. METHODS: We conducted a retrospective cohort study using linked Washington State birth/fetal death hospital discharge records to compare outcomes among women with and without visual impairment noted at their delivery hospitalization. Pregnancy conditions and outcomes evaluated included gestational diabetes, pre-eclampsia, labor induction and cesarean delivery. Neonatal outcomes included preterm delivery and birth weight <2500 g. We assessed length of maternal and infant delivery hospitalization. We performed Poisson regression to estimate relative risks (RR) and 95% confidence intervals (CIs) for each outcome, adjusting for year of delivery, maternal age, and parity. RESULTS: Most adverse pregnancy and neonatal outcomes were similar for visually impaired (N = 232) and comparison women (N = 2362). However, visually impaired women had increased risks of severe pre-eclampsia (RR 3.77, 95% CI 1.69-8.43), labor induction (RR 1.33, 95% CI 1.10-1.61) and preterm delivery (RR 1.60, 95% CI 1.06-2.42). They were also more likely to have delivery hospitalizations of 3 or more days following a vaginal (RR 1.86, 95% CI 1.41-2.47). Among cesarean deliveries, infants of visually impaired women had increased risk (RR 1.24, 95% CI 1.02-1.51) of hospitalization for 3 or more days postpartum. CONCLUSION: Our findings may be useful for obstetric providers in counseling their visually impaired patients.

Assessment of the Accuracy of Identification of Selected Disabilities and Conditions in Hospital Discharge Data for Pregnant Women.

BACKGROUND: Linked birth certificate-hospital discharge records are a valuable resource for examining pregnancy outcomes among women with disability conditions. Few studies relying on these data have been able to assess the accuracy of identification of preexisting disability conditions. We assessed the accuracy of International Classification of Diseases version 9 (ICD9) codes for identifying selected physical, sensory, and intellectual conditions that may result in disability. As ICD9 codes were utilized until recently in most states, this information is useful to inform analyses with these records. METHODS: We reviewed 280 of 311 (90%) medical records of pregnant women with disabilities based on ICD9 codes and 390 of 8,337 (5%) records of pregnant women without disabilities who had deliveries at a large university medical center. We estimated sensitivity, specificity, and positive predictive values (PPV) using the medical record as gold standard. We adjusted for verification bias using inverse probability weighting and imputation. RESULTS: The estimated sensitivity of ICD9 codes to identify women with disabilities with deliveries 2009-2012 was 44%; PPV was 98%, improving over time. Although sensitivity was <50% for some conditions, PPVs were 87%-100% for all conditions except intellectual disability (67%). Many physical conditions had complete verification and no underreporting. CONCLUSIONS: These results are helpful for new studies using historical data comparing outcomes among women with and without these conditions and to inform interpretation of results from earlier studies. Assessment of the accuracy of disabilities as identified by ICD version 10 codes is warranted.

Educating Obstetrics and Gynecology Residents on Transgender Patients: A Survey of Program Directors.

OBJECTIVE: To describe education on transgender health provided by obstetrics and gynecology residency programs and to identify the facilitators and barriers to providing this training. METHODS: We conducted a cross-sectional survey to evaluate transgender health education in residency among a representative sample of 100 of the 236 obstetrics and gynecology residency programs listed in the 2015 Electronic Residency Application Service catalogue. We compared programs that did and did not offer transgender education on demographics, presence and type of transgender education offered, and reasons for and barriers to offering transgender health education using χ or Fisher's exact testing. RESULTS: We found that 31 out of 61 (51%, 95% CI 38-64%) programs completing the survey offered transgender health education in residency. Compared with programs that offered no education, residency programs offering education were more likely to report that transgender health education was very important (19/31, 61% [95% CI 42-78%] vs 7/30, 23% [95% CI 9-42%]), resident interest (20/31, 64% [95% CI 45-81%] vs 11/30, 37% [95% CI 20-56%]), and the presence of a transgender population requesting services (28/31 or 90% [95% CI 74-98%] vs 16/30 or 53% [95% CI 34-72%]). Among the 31 programs that offered transgender health education, 30 (97%; 95% CI 83-99%) provided formal didactic sessions and 20 (64%; 95% CI 45-81%) offered health screening for both male-to-female and female-to-male transgender patients, but 17 (55%; 95% CI 36-73%) did not offer gender-affirming hormone therapy. Among the 30 programs that did not currently offer transgender health education, 24 (80%; 95% CI 61-92%) planned to establish a transgender education program in the next year. CONCLUSION: Our survey of obstetrics and gynecology residency programs highlights the interest in transgender health education for a systemically underserved population of patients.

Pregnancy Outcomes in Women with Spinal Cord Injuries: A Population-Based Study.

BACKGROUND: Pregnant women with congenital or acquired spinal cord injury face challenges due to compromised neurologic function and mobility, factors that may also affect fetal/infant health. Few studies have examined pregnancy course and longer-term outcomes in this population. OBJECTIVE: To assess pregnancy outcomes among women with spinal cord injury, paralysis, or spina bifida using population-based data. DESIGN: Retrospective cohort study. SETTING: Washington state linked birth-hospital discharge records. PARTICIPANTS: All women (N = 529) with spinal cord injury, paralysis, or spina bifida with singleton live birth deliveries 1987-2012, and a comparison group of women without disabilities (N = 5282). METHODS: Diagnosis codes were screened to identify cases and a 10:1 random sample of comparison women. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated overall and separately for each condition using multivariable regression. Subsequent hospitalizations or death were identified via linkage to hospital discharge/death records for 2 years after delivery. MAIN OUTCOME MEASUREMENTS: Pregnancy course (weight gain, gestational diabetes, preeclampsia, infection, venous thromboembolism), delivery/labor characteristics, infant characteristics (birthweight/size, gestational age), and longer-term outcomes (occurrence/reasons for maternal/infant rehospitalization, mortality). RESULTS: Women with these spinal conditions had increased adjusted risks of prenatal urinary tract infection/pyelonephritis (RR 26.43, 95% CI 13.97-49.99), venous thromboembolism (RR 9.16, 95% CI 2.17-38.60), preterm rupture of membranes (RR 2.15, 95% CI 1.18-3.90), and cesarean delivery (RR 1.88, 95% CI 1.70-2.09). They had longer hospitalizations and increased rehospitalization (RR 1.54, 95% CI 1.28-1.87), including for postpartum depression (RR 8.15, 4.29-15.48) or injury (RR 13.05, 95% CI 6.60-25.81). Their infants were more often small for gestational age (RR 1.65, 95% CI 1.33-2.06), but had no increased risk of rehospitalization or death. CONCLUSIONS: We observed no increased long-term morbidity among infants of women with these conditions. Possible increased maternal morbidities during the first postpartum years indicate areas for intervention. LEVEL OF EVIDENCE: III.

Pregnancy course, infant outcomes, rehospitalization, and mortality among women with intellectual disability.

BACKGROUND: Pregnant women with intellectual disability (ID) may have greater levels of comorbidity and decreased care access, social support, or ability to monitor their status and communicate needs, but few studies have examined their pregnancy course and outcome, and little is known about their longer-term maternal and infant health. OBJECTIVE: We compared pre-pregnancy characteristics, pregnancy outcomes, and rehospitalization <2 years after delivery among women with and without ID. METHOD: We identified all women with ID and randomly selected a 10:1 comparison group of women without ID with singleton live birth deliveries in Washington State population-based linked birth-hospital discharge data 1987-2012. Multivariable regressions estimated adjusted odds ratios comparing pre-pregnancy characteristics. In cohort analyses, we estimated relative risks (RR) and 95% confidence intervals (CI) for outcomes. RESULTS: Women with ID (N = 103) more often had gestational diabetes (RR 3.39, 95% CI 1.81-6.37), preeclampsia (RR 1.88, 95% CI 1.03-3.42), and inadequate prenatal care (RR 2.48, 95% CI 1.67-3.70). Their infants more often were small for gestational age (RR 1.78, 95% CI 1.10-2.89). Need for rehospitalization postpartum was not increased among women with ID or their infants. CONCLUSION: Reasons for increased preeclampsia and gestational diabetes among pregnant women with ID are unclear. Barriers to inadequate prenatal care are multifactorial and warrant further study, with consideration that wellness during pregnancy and other times involves social, familial and clinical support systems responsive to each woman's needs.

Duration of Spontaneous Active Labor and Perinatal Outcomes Using Contemporary Labor Curves.

OBJECTIVE: Evaluate the association between spontaneous active labor duration utilizing contemporary labor curves and risk of adverse outcomes. MATERIALS AND METHODS: This is a retrospective cohort study from January 2012 to January 2015. Subjects were nulliparous, 18 to 44 years, with a cephalic, singleton ≥37 weeks in spontaneous labor. Subjects were placed into three subgroups, defined by active labor duration from 6 to 10 cm as less than the median, the median-95th, and >95th percentile based on contemporary labor curves published by Zhang et al. We evaluated the association between subgroups and cesarean delivery, chorioamnionitis, estimated blood loss, Apgar score < 7 at 5 minutes, and neonatal intensive care unit admission using logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Six-hundred forty two women met the inclusion criteria. Compared with women whose active labor was less than the median, the risk of cesarean was higher in the median-95th percentile ([adjusted OR, aOR] 3.1, 95% CI 1.8-5.5) and the >95th percentile ([aOR] 6.8, 95% CI 3.9-11.7) subgroups. There was an increased odds of chorioamnionitis in the median-95th percentile subgroup ([aOR] 2.5, 95% CI 1.1-5.9). CONCLUSION: Chorioamnionitis and cesarean delivery increased significantly as labor duration exceeded the median. This study provides a better understanding regarding the potential risk of cesarean and chorioamnionitis using contemporary labor curves.

Robotic, Laparoscopic, or Open Hysterectomy: Surgical Outcomes by Approach in Endometrial Cancer.

STUDY OBJECTIVES: To compare patient outcomes by surgical approach in the management of endometrial cancer (EC) in Washington State from 2008 to 2013. DESIGN: Population-based retrospective cohort study (Canadian Task Force classification II-2). SETTING: Washington State. PATIENTS: EC patients treated with robotic-assisted surgery (RAS), laparoscopy (LS), or laparotomy (XLAP). INTERVENTIONS: Comprehensive Hospital Abstract Reporting System to identify patients and assess the association of surgical approach with length of stay, readmissions, and perioperative complications. MEASUREMENTS AND RESULTS: We identified 3712 cases of EC managed with either RAS, LS, or XLAP. Mean length of stay was not clinically different for RAS (1.5 days) and LS (1.6 days) but was 2.31 days longer for XLAP compared with LS (p < .001). Odds of any readmission did not differ for either RAS or XLAP compared with LS; however, early readmissions were half as likely for RAS compared with LS (p = .014). Complications were more than 2.5 times as likely for XLAP versus LS (p < .001), whereas complications did not differ for RAS versus LS (p = .931). CONCLUSIONS: RAS is as an alternative to LS in the treatment of EC and is preferable to XLAP. The use of RAS resulted in fewer early readmissions compared with LS and resulted in an increased proportion of cases via minimally invasive surgery.

What are the risk factors associated with hospital birth among women planning to give birth in a birth center in Washington State?

BACKGROUND: Few studies have evaluated risk factors associated with hospital birth among women planning to give birth in a birth center in the United States. This study describes the obstetrical risk factors for hospital birth among women intending to deliver in a birth center in Washington State. METHODS: We performed a retrospective cohort study of Washington State birth certificate data for women with singleton, term pregnancies planning to give birth at a birth center from 2004 to 2011. We assessed risk factors for hospital birth including demographic, obstetrical, and medical characteristics. We used multivariable logistic regression to estimate the odds ratio (OR) and 95% confidence interval (CI) of the association between risk factors and hospital birth. RESULTS: Among the 7118 women planning to give birth at a birth center during the study period, 7% (N = 501) had a hospital birth, and 93% delivered at a birth center (N = 6617). The strongest risk factors for hospital transfer included nulliparity (OR 7.2 [95% CI 5.3-9.8]), maternal age >40 years (OR 3.7 [95% CI 2.1-6.7]), inadequate prenatal care (OR 3.7 [95% CI 2.7-5.0]), body mass index ≥30 (OR 2.1 [95% CI 1.6-3.0]), government health insurance (OR 9.3 [95% CI 5.0-17.1]), and hypertension (10.1 [95% CI 5.7-18.1]). Among nulliparous women, all of these demographic and obstetrical factors remained strongly associated with hospital birth. CONCLUSIONS: This information may be useful for counseling women who plan a birth center birth about the risk of hospital birth.

Randomized Trial of Smartphone-Based Evaluation for an Obstetrics and Gynecology Clerkship.

OBJECTIVE: We hypothesized that compared to paper evaluations, a smartphone-based quick response (QR) evaluation tool would improve timeliness of feedback, enhance efficacy of giving and receiving feedback, and be as easy to use. DESIGN: We performed a randomized controlled trial of student and instructor experience with two evaluation tools in the OB/GYN clerkship at University of Washington School of Medicine (UWSOM). Sites were randomized to the QR or paper tool; students at QR sites received individualized QR codes at the beginning of the clerkship. Instructors and students completed postintervention surveys regarding the evaluation tool and associated feedback. We compared responses between groups using chi-squared tests. SETTING: Participating clerkship sites included primary, tertiary, private practice and institutional settings affiliated with the University of Washington in the Washington, Wyoming, Alaska, Montana and Idaho region. PARTICIPANTS: Of the 29 OB/GYN UWSOM clerkship sites, 18 agreed to participate and were randomized. Of 29 eligible instructors, 25 (86%) completed the survey, with n = 18 using QR and n = 7 using paper. Of 161 eligible students, 102 (63%) completed the survey, with n = 54 using QR and n = 48 using paper. RESULTS: Compared to those using paper evaluations, instructors using QR evaluations were significantly more likely to agree that the evaluation tool was easy to understand (100% QR vs 43% paper, p = 0.002), the tool was effective in providing feedback (78% QR vs 29% paper, p = 0.002), and they felt comfortable approaching students with the tool (89% QR vs 43% paper, p = 0.002). Compared to those using paper evaluations, students using QR evaluations were less likely to agree the tool was effective in eliciting feedback (QR 43% vs paper 55%, p = 0.042). CONCLUSION: Instructors found QR evaluations superior to paper evaluations for providing feedback to medical students, whereas students found QR evaluations less effective for feedback.

Bits and Pieces: A Crowd-Sourced Series of 54 Cases of Fractured Hormonal Implants.

STUDY OBJECTIVE: The fracture of hormonal implants, including Implanon, Nexplanon (both from Merck & Co, Inc), and histrelin acetate is rare. Our aim was to describe patient demographic characteristics, mechanisms, and consequences of fractured implants by surveying physicians' experience via listservs and social media. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We developed a Research Electronic Data Capture survey for physicians regarding their experience with implant fracture, including patient characteristics, mechanism of fracture, changes in menstrual bleeding patterns, time from insertion to fracture, and time from fracture to seeking care. We distributed the survey to providers in listservs for the North American Society for Pediatric and Adolescent Gynecology, the Family Planning Fellowship, the Ryan Program, and the Facebook Physician Moms Group and Facebook OB-GYN Mom Group. We performed descriptive analyses. RESULTS: We received 42 survey responses, representing 54 discrete implant fractures of which 70% (n=14) were Nexplanon, 26% (n=38) were Implanon, and 4% (n=2) were histrelin acetate. Mechanisms of implant fracture included patient manipulation (23%, n=12), unintentional trauma (11%, n=6), interpersonal violence (8%, n=4), lifting/carrying (6%, n=3), fracture with removal (6%, n=3), and unknown (47%, n=25). Bleeding pattern was not altered in 78% (n=42) of cases. Time interval between placement and fracture was less than 2 years for 63% (n=34) of cases. Thirty-nine percent (n=21) of patients presented for care more than 1 month from the time of fracture. CONCLUSION: Patients should be counseled about potential for hormonal implant fracture, advised against excessive manipulation of implants, and counseled to present for care immediately upon noticing an implant fracture. Surveying physicians through listervs and social media is an effective strategy to increase the reporting of rare complications and events.

Risk Factors for Lower Extremity Overuse Injuries in Female Youth Soccer Players.

BACKGROUND: Youth soccer injuries are common and of increasing concern, with sport specialization occurring at younger ages. Limited research is available regarding overuse injuries and risk factors in young female athletes. PURPOSE: To identify the number and rate of overuse injuries in female soccer players (ages 12-15 years), describe the anatomic location and type of injury, and evaluate contributing risk factors. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 351 female youth soccer players, ages 12 to 15 years, from Washington State were evaluated from 2008 to 2012. Players with lower extremity overuse injuries were identified through weekly emails and were interviewed by telephone to obtain data on injury type and body region. We evaluated the association between overuse injuries and preseason risk factors, including joint hypermobility, hip and knee muscle strength, and jump biomechanics, using Poisson regression to estimate relative risk (RR) and 95% CIs. RESULTS: The incidence rate for first-time lower extremity overuse injuries was 1.7 per 1000 athlete-exposure hours (AEH; 95% CI, 1.4-2.2), and that for repeat injuries was 3.4 per 1000 AEH (95% CI, 2.1-5.6). Knee injuries accounted for 47% of overuse injuries. Increased valgus was associated with a 3.2-fold increased risk (95% CI, 1.52-6.71) for knee injury. A 1-standard deviation (SD) increase in hamstring strength was associated with a 35% decreased risk (RR, 0.65; 95% CI, 0.46-0.91) for overuse knee injuries, and a 1-SD increase in quadriceps strength was associated with a 30% decreased risk (RR, 0.70; 95% CI, 0.50-0.98). A 1-SD increase in hip flexor strength was associated with a 28% decreased risk (RR, 0.72; 95% CI, 0.51-1.00) for overuse knee injuries, and a 1-SD increase in external rotation strength was associated with a 35% decreased risk (RR, 0.65; 95% CI, 0.46-0.91). Playing on more than 1 soccer team was associated with a 2.5-fold increased risk (95% CI, 1.08-5.35) for overuse knee injuries, and participating in other physical activities was associated with a 61% decreased risk (odds ratio, 0.39; 95% CI, 0.15-0.81). CONCLUSION: In this study, lower extremity overuse injuries in female youth soccer players affected primarily the knee. Lower knee separation distance, decreased lower extremity strength, and playing on more than 1 soccer team increased injury risk.

Hospital trauma level's association with outcomes for injured pregnant women and their neonates in Washington state, 1995-2012.

BACKGROUND: Trauma occurs in 8% of all pregnancies. To date, no studies have evaluated the effect of the hospital's trauma designation level as it relates to birth outcomes for injured pregnant women. METHODS: This population-based, retrospective cohort study evaluated the association between trauma designation levels and injured pregnancy birth outcomes. We linked Washington State Birth and Fetal Death Certificate data and the Washington State Comprehensive Hospital Abstract Recording System. Injury was identified using the International Classification of Diseases, Ninth Revision injury diagnosis and external causation codes. The association was analyzed using logistic regression to estimate odds ratios and 95% confidence intervals (CIs). RESULTS: We identified 2492 injured pregnant women. Most birth outcomes studied, including placental abruption, induction of labor, premature rupture of membranes, cesarean delivery, maternal death, gestational age <37 weeks, fetal distress, fetal death, neonatal respiratory distress, and neonatal death, showed no association with trauma hospital level designation. Patients at trauma Level 1-2 hospitals had a 43% increased odds of preterm labor (95% CI: 1.15-1.79) and a 66% increased odds of meconium at delivery (95% CI: 1.05-2.61) compared to those treated at Level 3-4 hospitals. Patients with an injury severity score >9, treated at trauma Level 1-2 hospitals, had an aOR of low birth weight, <2500 g, of 2.52 (95% CI: 1.12-5.64). CONCLUSIONS: The majority of birth outcomes for injured patients had no association with hospitalization at a Level 1-2 compared to a Level 3-4 trauma center.