Respiratory Syncytial Virus During the COVID-19 Pandemic Compared to Historic Levels: A Retrospective Cohort Study of a Health System.

BACKGROUND: Surveillance in 2020-2021 showed that seasonal respiratory illnesses were below levels seen during prior seasons, with the exception of interseasonal respiratory syncytial virus (RSV). METHODS: Electronic health record data of infants aged <1 year visiting the Duke University Health System from 4 October 2015 to 28 March 2020 (pre-COVID-19) and 29 March 2020 to 30 October 2021 (COVID-19) were assessed. International Classification of Diseases-Tenth Revision (ICD-10) codes for RSV (B97.4, J12.1, J20.5, J21.0) and bronchiolitis (RSV codes plus J21.8, J21.9) were used to detail encounters in the inpatient (IP), emergency department (ED), outpatient (OP), urgent care (UC), and telemedicine (TM) settings. RESULTS: Pre-COVID-19, 88% of RSV and 92% of bronchiolitis encounters were seen in ambulatory settings. During COVID-19, 94% and 93%, respectively, occurred in ambulatory settings. Pre-COVID-19, the highest RSV proportion was observed in December-January (up to 38% in ED), while the peaks during COVID-19 were seen in July-September (up to 41% in ED) across all settings. RSV laboratory testing among RSV encounters was low during pre-COVID-19 (IP, 51%; ED, 51%; OP, 41%; UC, 84%) and COVID-19 outside of UC (IP, 33%; ED, 47%; OP, 47%; UC, 87%). Full-term, otherwise healthy infants comprised most RSV encounters (pre-COVID-19, up to 57% in OP; COVID-19, up to 82% in TM). CONCLUSIONS: With the interruption of historical RSV epidemiologic trends and the emergence of interseasonal disease during COVID-19, continued monitoring of RSV is warranted across all settings as the changing RSV epidemiology could affect the distribution of health care resources and public health policy.

Traveling for rights: Abortion trends in New Mexico after passage of restrictive Texas legislation.

OBJECTIVES: To determine the proportion of abortions provided to patients from Texas in New Mexico before and after the 2013 enactment of Texas House Bill 2 (HB2), an omnibus bill of abortion restrictions, and to compare the gestational ages at which Texans presented for abortion in New Mexico before and after HB2. STUDY DESIGN: We conducted a chart review of Texas and New Mexico patients obtaining an abortion in New Mexico abortion clinics before HB 2 was signed and implemented (time period 1: January 1, 2012 to December 31, 2012) and after HB 2 went into effect (time period 2: May 1, 2014 to April 30, 2015). We used random sampling of corresponding 7-day periods (by week number during the one-year sample) to obtain data until we reached the desired sample of at least 300 patients. We compared proportions of individuals from Texas obtaining abortions and the gestational age at which they presented in the two time periods. RESULTS: We abstracted data from 350 and 300 Texas and New Mexico patients, respectively. The proportion of procedures provided to women from Texas increased from 10 (3%) pre-HB2 to 43 (14%) post-HB2 (p < 0.0001). The proportion of procedures in Texas patients at 13 to ≤24 weeks increased from 1 of 29 (3%) pre-HB2 to 10 of 38 (26%) post-HB2 (p = 0.012). CONCLUSION: The proportion of Texans scheduling abortions in New Mexico within the first 24 weeks of gestation increased after passage of HB2. Restrictive legislation may force more people to travel across state lines to obtain abortion care. IMPLICATIONS: Patients residing in Texas and seeking abortion care in Texas experienced barriers to abortion care, likely related to restrictions imposed by HB2.

Women's experiences with immediate postpartum intrauterine device insertion: a mixed-methods study.

OBJECTIVE: To describe women's pain and experiences with immediate postpartum intrauterine device (IUD) insertion (IPPI) following vaginal delivery using a ring forceps insertion technique. STUDY DESIGN: This observational mixed-methods study included women who underwent successful IPPI using ring forceps, with and without epidural analgesia. To describe women's pain during the procedure, we recruited women during antenatal care and at the time of admission for delivery until we collected at least 30 sets of pain scores at two time points (preprocedure and immediately postprocedure) in both groups using two instruments: 100-mm visual analogue scale (VAS) and a 4-point Likert verbal rating scale (VRS) (0=none, 1=mild, 2=moderate, 3=severe). After placing the IUD, physicians rated ease of IUD insertion. A subset of participants in both groups underwent semistructured interviews prior to hospital discharge. Our goal was to explore women's (a) decisional influences and prior contraception experience, (b) experience during IPPI and (c) decisional regret. We conducted iterative analysis of interview content until thematic saturation was reached in both groups. Interviewees provided recall pain scores and rated satisfaction with IPPI. RESULTS: We collected 30 pain scores in the no-epidural group and 36 in the epidural group. At both time points, the VAS data exhibited very low pain scores in the epidural group and a uniform distribution in the no-epidural group; standard deviations were large. The majority of women in both groups reported "none-mild" pain on the VRS. Physicians reported minimal difficulty with IUD insertion in most cases. We conducted interviews with 12 women who had an epidural and 9 who did not. Both groups offered similar comments across all domains. Convenience was the primary motivation to undergo IPPI, and women recognized the barriers to obtaining effective contraception remote from delivery. The majority of interviewees, even those with high pain scores, characterized their procedural pain as less than expected, and IUD insertion pain was less than or similar to labor pain. Interviewees' recall pain scores were similar to those reported at the time of IUD insertion. An unanticipated theme that emerged was an ineffective informed consent process; women could not recall most procedural risks or how IPPI was accomplished. All interviewees endorsed IPPI, expressing a high degree of satisfaction; none regretted undergoing the procedure. CONCLUSION: The distributions of our VAS scores did not reveal useful summary statistics in either group. The VRS scores were a more informative representation of women's pain during IPPI; most women reported little pain. Convenience of obtaining highly effective contraception immediately postpartum was the key motivator for undergoing IPPI. All women voiced favorable experiences, even those who had high pain scores. IMPLICATIONS: Women in our study overwhelmingly described less pain than anticipated with IPPI and also reported a high degree of satisfaction. Our study offers valuable patient-centered guidance to inform antenatal contraceptive counseling with respect to IPPI and lays the groundwork for ongoing research towards optimizing women's experiences with the procedure.

Differentiating giant cell tumor of bone from patellofemoral syndrome: a case study.

Balancing the assessment of musculoskeletal dysfunctions with a high level of suspicion for non-mechanical origins can be a challenge for the clinician examining a sports injury. Without timely diagnosis, non-mechanical complaints could result in surgery or loss of limb. This case describes the discovery of a Giant Cell Tumor of Bone (GCTB) following the re-evaluation of an athlete who had undergone five years of conservative management for patellofemoral pain syndrome (PFPS). Knee injuries account for 32.6% of sports injuries with PFPS being the most common and most likely diagnosis for anterior knee pain. GCTB is a benign aggressive bone tumor with a predilection for the juxta-articular region of the knee, comprising up to 23% of all benign bone tumors, and commonly occurs in the second to fourth decades. This case report illustrates the difficulty in accurately diagnosing healthy athletes, reviews common differentials for knee complaints and explores helpful diagnostic procedures.

Trouver le bon équilibre entre l'évaluation des dysfonctionnements musculo-squelettiques et un niveau élevé de suspicion d'origines non mécaniques peut présenter un défi pour un clinicien qui examine une blessure sportive. Sans un diagnostic rapide, les plaintes non mécaniques pourraient nécessiter la chirurgie ou aboutir à la perte d'un membre. Ce cas décrit la découverte d'une tumeur à cellules géantes (TCG) de l'os à la suite de la réévaluation d'un athlète qui avait subi cinq ans de traitement conservateur du syndrome fémoro-rotulien douloureux (SFP). Les blessures au genou représentent 32,6 % des blessures sportives, et le SFP est le diagnostic le plus fréquent et le plus probable pour la douleur de la partie antérieure du genou. La TCG est une tumeur osseuse bénigne agressive avec une prédilection pour la région juxta-articulaire du genou, comprenant jusqu'à 23 % de toutes les tumeurs osseuses bénignes et généralement se produisant au cours de la deuxième, troisième et quatrième décennie. Cette étude de cas montre la difficulté du diagnostic précis des athlètes en bonne santé, examine les écarts communs pour les plaintes liées au genou et explore les procédures utiles de diagnostic.

Safety of the progesterone-releasing vaginal ring (PVR) among lactating women: A systematic review.

CONTEXT: Lactation causes a delay in ovulation in the postpartum period, and therefore a delay in the resumption of menses. However, return to fertility is variable in the postpartum period and is contingent upon numerous factors. The postpartum period is therefore a critical time to initiate effective contraception in order to support the numerous beneficial health outcomes of optimal pregnancy spacing. Breastfeeding women have an unmet need for highly effective birth control methods that do not interfere with lactation and that are safe for their infants. The progesterone-releasing vaginal ring (PVR) releases a natural progesterone that suppresses ovulation and is specifically designed for breastfeeding women in the first postpartum year. OBJECTIVE: To review the published peer-reviewed literature regarding the safety and effectiveness of the PVR used for contraception among lactating women, as well as the safety for their infants. Results of this review informed the decisions of the Guideline Development Group to include recommendations on contraceptive eligibility for the PVR within the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 5th Edition. METHODS: We searched the PubMed, Popline, and LILACS bibliographic databases for articles published in any language from database inception through October 1, 2014. We reviewed the literature for evidence regarding the safety of the PVR among breastfeeding women using the method, as well as for their infants. The US Preventive Services Task Force system was applied to assess the quality of the evidence. RESULTS: Seven articles met our criteria for inclusion in this review. All studies were of a prospective cohort design. All studies consistently showed that use of the PVR among breastfeeding women compares favorably to other methods of contraception with regard to effectiveness, does not compromise a woman's breastfeeding performance, and does not adversely affect infant growth during the first year postpartum. CONCLUSION: The PVR is a safe and highly effective method of contraception for use among breastfeeding women. It should be offered to women who plan to breastfeed in the context of postpartum contraceptive counseling.

A randomized controlled trial of nitrous oxide for intrauterine device insertion in nulliparous women.

OBJECTIVE: To evaluate the effectiveness of inhaled nitrous oxide for pain management among nulliparous women undergoing intrauterine device (IUD) insertion. METHODS: A double-blind, randomized controlled trial was conducted among nulliparous women aged 13-45years who underwent IUD insertion at a US center between October 1, 2013, and August 31, 2014. Using a computer-generated randomization sequence, participants were randomly assigned to inhale either oxygen (O2) or a mixture of 50% nitrous oxide and 50% oxygen (N2O/O2) through a nasal mask for 2minutes before insertion. Only the person administering the inhalation agent was aware of group assignment. The primary outcome was maximum pain assessed 2minutes after insertion via a 100-mm visual analog scale. Analyses were by intention to treat. RESULTS: Forty women were assigned to each group. Mean maximum pain score at the time of insertion was 54.3±24.8mm for the N2O/O2 group and 55.3±20.9mm for the O2 group (P=0.86). Adverse effects were reported for 6 (15%) women in the N2O/O2 group and 7 (18%) in the O2 group (P=0.32). CONCLUSION: N2O/O2 did not reduce the pain of IUD insertion among nulliparous women. ClinicalTrials.gov: NCT02391714.

Nitrous oxide for pain management of first trimester surgical abortion -- a randomized controlled pilot study.

OBJECTIVE: The objective was to determine feasibility of a study comparing mean pain scores between women randomized to nitrous oxide/oxygen (NO) versus oxygen+oral analgesics for trimester surgical abortion. STUDY DESIGN: Pilot randomized controlled trial comparing NO (n=10) versus oxygen+oral analgesics (n=10). Feasibility of subject recruitment, and pain and satisfaction scores on a visual analog scale were evaluated. RESULTS: Fifty-seven percent of eligible women participated. Mean pain scores were similar between groups, and mean satisfaction scores were higher for the NO group (77.5 vs. 46.7, P=.048). CONCLUSIONS: The majority of eligible women agreed to participate in this study evaluating an uncommon pain control intervention.

Intrauterine devices and pelvic inflammatory disease among adolescents.

Adolescents may be ideal candidates for intrauterine device (IUD) use, given high rates of unintended pregnancy and less successful use of short-acting contraceptive methods. Concerns about elevated risks of pelvic inflammatory disease in adolescents, with the consequences of infertility, ectopic pregnancy, and pelvic pain, prevent many clinicians from inserting IUDs in adolescents. The body of evidence examining risks of pelvic infection related to IUD use specifically in adolescents is limited, but is reassuring that the absolute risk of pelvic infection is small and that the benefits of IUD use likely outweigh the risks.