Common Issues in Prenatal Care: First Trimester Bleeding.

Vaginal bleeding in the first trimester is a common concern during pregnancy. The amount of bleeding and associated symptoms, such as nausea and vomiting, can be of prognostic value. Timely evaluation with vital signs, physical examination, laboratory tests (eg, Rh factor, hemoglobin and possibly progesterone levels), and pelvic ultrasound (US) can distinguish among viable pregnancy, nonviable pregnancy, intrauterine pregnancy (IUP) of uncertain viability, and pregnancy of unknown location. Serial pelvic US can be obtained in patients with IUP of uncertain viability after 11 to 14 days, and in pregnancy of unknown location in as little as 48 hours. Quantitative human chorionic gonadotropin (hCG) levels are of minimal clinical utility after IUP is visualized on US. Serial quantitative hCG levels should be measured in patients with pregnancy of unknown location. After an early pregnancy loss has been identified, as long as the patient is hemodynamically stable, options include expectant, medical, and surgical management. The treatment plan can be guided by shared decision-making. Ectopic pregnancy can be managed surgically via laparoscopy, medically with methotrexate, or expectantly (in certain circumstances). Progesterone for patients with early pregnancy bleeding and no history of miscarriage likely is of no benefit.

Common Issues in Prenatal Care: Gestational Diabetes.

Two screening approaches are used to detect gestational diabetes, the 1-step and 2-step methods. The 1-step method is diagnostic and consists of a 75-g, 2-hour oral glucose tolerance test (OGTT). The 2-step method consists of a 50-g, 1-hour glucose challenge test, followed by a 100-g, 3-hr OGTT if initial test results are positive. All pregnant patients should be screened for gestational diabetes between 24 and 28 weeks' gestation unless pregestational diabetes is present. Lifestyle modifications are fundamental to management, and most patients are able to control blood glucose levels with these alone. Persistent hyperglycemia should be managed with drugs. Currently, insulin is the only drug approved by the Food and Drug Administration (FDA) for gestational diabetes management. Metformin or glyburide can be reasonable alternatives. For patients who require drugs, antepartum fetal surveillance is recommended starting at 32 weeks' gestation. The American College of Obstetricians and Gynecologists (ACOG) recommends delivery at 39 0/7 to 40 6/7 weeks' gestation for patients with gestational diabetes controlled with diet alone. Earlier delivery is recommended for patients with gestational diabetes controlled with drugs, at 39 0/7 to 39 6/7 weeks' gestation. Patients with gestational diabetes are at increased risk of type 2 diabetes later in life. These patients should be screened for prediabetes and diabetes between 4 and 12 weeks postpartum with a 75-g, 2-hour OGTT. Postpartum patients with a normal OGTT result should be screened every 1 to 3 years thereafter.

Common Issues in Prenatal Care: Fetal Growth Restriction.

Fetal growth restriction (FGR) is defined as an ultrasound (US)-determined estimated fetal weight or abdominal circumference less than the 10th percentile according to a population level reference curve. FGR affects up to 10% of pregnancies. Fetuses with FGR are at increased risk of intrauterine mortality and, postnatally, neonatal intraventricular hemorrhage, necrotizing enterocolitis, respiratory distress, hypoglycemia, and suboptimal neurologic, behavioral, and cognitive development. In early-onset FGR (ie, less than 32 weeks' gestation), a detailed US examination is recommended. When FGR is accompanied by polyhydramnios and/or fetal anomalies, genetic testing should be obtained, including chromosomal microarray analysis. The timing of delivery strategy should be based on the severity of growth restriction and findings on fetal tests of well-being (eg, nonstress testing, umbilical artery Doppler velocimetry). No routine prevention strategies are recommended. However, it has been shown that daily low-dose aspirin (ie, 81 mg/day) reduces the risk of FGR when taken by patients with a high risk of preeclampsia.

Common Issues in Prenatal Care: Antepartum Fetal Surveillance.

Patients at increased risk of stillbirth should be assessed with antepartum fetal surveillance (AFS) tests at regular intervals. In general, AFS should begin at the gestational age at which delivery would be considered. Most surveillance tests are performed weekly, but more frequent testing should be considered for patients with high-risk conditions. AFS tests include fetal movement monitoring, nonstress test, contraction stress test, biophysical profile, and modified biophysical profile. Umbilical artery Doppler velocimetry is used in the setting of fetal growth restriction. Abnormal test results should prompt additional assessment and consideration of delivery. Normal test results can provide reassurance about fetal well-being, but cannot predict the likelihood of acute incidents, such as placental abruption and umbilical cord infarction.

Cervical Cancer Screening Outcomes Among a Sample of Low-Income Uninsured Women: A Program-Based Study.

Background: Most studies examining cervical cancer screening outcomes have focused on either an age-specific diagnosis and outcomes of abnormal smears or frequency of abnormal outcomes among a sample of insured women. Thus, it is unclear what the distribution outcomes would be when other sociodemographic characteristics are considered. This study examines the variation in cervical cancer screening outcomes and sociodemographic characteristics (patients' age, marital status, race/ethnicity, rurality, and Papanicolaou [Pap] test screening history) within a sample of low-income and uninsured women. Materials and Methods: Our grant-funded program provided 751 Pap tests, 577 human papillomavirus (HPV) tests, and 262 colposcopies to 841 women between 2013 and 2019. Observed outcomes for each procedure type were cross-tabulated by patients' sociodemographic characteristics. Chi-squared and Fisher's exact tests were used to test the independence of screening outcomes and sociodemographic characteristics. Results: The overall positivity rate was 7.2% for Pap tests (n = 54/751), 3.6% for HPV tests (n = 21/577), and 44.7% for colposcopies (n = 117/262). Significance tests suggested that the Pap test and colposcopy outcomes we observed were independent of sociodemographic characteristics in all but one instance-Pap test outcomes were not independent of patient age (p = 0.009). Moreover, the Pap test positivity rate increased with patient age. Conclusions: Our findings support recommendations to discontinue screening for women older than 65 years at low risk for cervical cancer. Our ability to identify an association between cervical screening outcomes and other sociodemographic characteristics may have been limited by our small sample size. This highlights an important barrier to studying health outcomes within low-income and uninsured populations, which are often missing in larger research data sets (e.g., claims).

A case study of evaluating bilateral lung dose for VMAT treatment planning using a partial sagittal arc.

Radiation pneumonitis (RP) is a potential toxic side effect of thoracic radiotherapy. Optimal planning techniques must maintain tumor coverage while limiting dose to normal lung tissue to reduce the risk of patients developing RP. The addition of a noncoplanar arc may be beneficial by increasing treatment angles and providing an ideal dose distribution for tumor coverage while decreasing dose to organs at risk (OAR). The purpose of this research was to compare the effects on the normal bilateral lung tissue receiving 20 Gy, 10 Gy and 5 Gy (V20, V10, V5) and the mean lung dose (MLD) values when medial lung tumors are treated with 3 partial coplanar arcs vs 2 partial coplanar arcs combined with a partial sagittal arc. Researchers hypothesized that a beam arrangement of 2 partial coplanar arcs and 1 partial sagittal arc would reduce V20, V10, V5, and MLD values when compared to a 3 partial coplanar arc plan. In a retrospective study of 5 patients with bulky, medial right lung lesions without nodal involvement, cases were planned with both a noncoplanar and a coplanar arc geometry. Results were evaluated using a two-tailed t-test to determine the statistical significance (p < 0.05) of changes to total lung volume analyzation metrics when a noncoplanar sagittal arc was incorporated compared to the standard lung treatment using only coplanar arcs. Although some patient cases showed minor improvement in the V20, V10, V5, and MLD metrics, the study results were not statistically significant and showed no advantage with the introduction of an anterior sagittal arc over a coplanar beam arrangement.

The association between rurality, sociodemographic characteristics, and mammogram screening outcomes among a sample of low-income uninsured women.

Studies have found a positive association between adherence to mammography screening guidelines and early detection of breast cancer lesions, yet the proportion of women who get screened for breast cancer remains below national targets. Previous studies have found that mammography screening rates vary by sociodemographic factors including race/ethnicity, income, education, and rurality. It is less known whether sociodemographic factors are also related to mammography screening outcomes in underserved populations. Thus, with a particular interest in rurality, we examined the association between the sociodemographic characteristics and mammography screening outcomes within our sample of 1,419 low-income, uninsured Texas women who received grant-funded mammograms between 2013 and 2019 (n = 1,419). Screening outcomes were recorded as either negative (Breast Imaging Reporting and Data System (BI-RADS) classification 1-3) or positive (BI-RADS classification 4-6). When we conducted independency tests between sociodemographic characteristics (age, race/ethnicity, rurality, county-level risk, family history, and screening compliance) and screening outcomes, we found that none of the factors were significantly associated with mammogram screening outcomes. Similarly, when we regressed screening outcomes on age, race/ethnicity, and rurality via logistic regression, we found that none were significant predictors of a positive screening outcome. Though we did not find evidence of a relationship between rurality and mammography screening outcomes, research suggests that among women who do screen positive for breast cancer, rural women are more likely to present with later stage breast cancer than urban women. Thus, it remains important to continue to increase breast cancer education and access to routine cancer screening for rural women.

Suicide screening: How to recognize and treat at-risk adults.

Worsening nausea, vomiting, and dizziness for 2-months, resulting in a 20-pound weight loss. Pruritus. Ataxia. Mild hearing loss, with reoccurring episodes of falls.

Lower Gastrointestinal Conditions: Diverticular Disease.

Diverticular disease is a spectrum of conditions related to diverticulosis and includes symptomatic uncomplicated diverticular disease, segmental colitis associated with diverticulosis, diverticular bleeding, and diverticulitis. The spectrum of pathology contributes significantly to gastrointestinal comorbidities and increases in prevalence with age. Diverticulosis is associated with low dietary fiber intake, obesity, an inactive lifestyle, and family history. Patients with diverticulitis typically present with left lower quadrant pain and an elevated white blood cell count or C-reactive protein level. The diagnosis is made by clinical examination with or without imaging. Management of diverticulitis includes intravenous fluids and antibiotics, although recent studies have shown that the latter may be avoided in select patients with uncomplicated diverticulitis. The need for hospitalization is determined by patient presentation and complications identified on imaging. Surgery is indicated in patients with frank perforation, unsuccessful conservative management of an abscess, or lack of improvement with conservative therapy. Elective interval colectomy should be considered on an individual basis. Colonoscopy should be performed 4 to 8 weeks after resolution of diverticulitis to exclude colorectal cancer. For secondary prevention, a high-fiber diet and vigorous physical activity are recommended.

Effects of indoor environmental parameters related to building heating, ventilation, and air conditioning systems on patients' medical outcomes: A review of scientific research on hospital buildings.

The indoor environment of a mechanically ventilated hospital building controls infection rates as well as influences patients' healing processes and overall medical outcomes. This review covers the scientific research that has assessed patients' medical outcomes concerning at least one indoor environmental parameter related to building heating, ventilation, and air conditioning (HVAC) systems, such as indoor air temperature, relative humidity, and indoor air ventilation parameters. Research related to the naturally ventilated hospital buildings was outside the scope of this review article. After 1998, a total of 899 papers were identified that fit the inclusion criteria of this study. Of these, 176 papers have been included in this review to understand the relationship between the health outcomes of a patient and the indoor environment of a mechanically ventilated hospital building. The purpose of this literature review was to summarize how indoor environmental parameters related to mechanical ventilation systems of a hospital building are impacting patients. This review suggests that there is a need for future interdisciplinary collaborative research to quantify the optimum range for HVAC parameters considering airborne exposures and patients' positive medical outcomes.