Associations between provider-assigned Apgar score and neonatal race.

BACKGROUND: For decades, the Apgar scoring system has been used to evaluate neonatal status and determine need for resuscitation or escalation in care, such as admission to a neonatal intensive care unit. However, the variation and accuracy of provider-assigned Apgar scores across neonatal racial groups have yet to be evaluated. OBJECTIVE: This study aimed to investigate how provider-assigned Apgar scores vary by neonatal race independently of clinical factors and umbilical cord gas values. STUDY DESIGN: We conducted a retrospective cohort study at an urban academic medical center. All live births at ≥23 weeks and 0 days of gestation from January 1, 2019 through December 31, 2019 with complete data available were included. Data were queried from the electronic medical record and included race, ethnicity, gestational age of neonate, umbilical cord gas values (umbilical artery pH and base deficit), admission to the neonatal intensive care unit, and presence of maternal-fetal complications. Primary outcome measures were neonates' Apgar scores at 1 and 5 minutes. Color Apgar score and admission to the neonatal intensive care unit served as secondary outcome measures. We performed 3 partially proportional ordinal regression models controlling for an increasing number of covariates, with Model 1, the baseline model, adjusted for gestational age, Model 2 additionally adjusted for umbilical cord gases, and Model 3 additionally adjusted for maternal medical conditions and pregnancy complications. RESULTS: A total of 977 neonates met selection criteria; 553 (56.6%) were Black. Providers assigned Black neonates significantly lower Apgar scores at 1 minute (odds ratio, 0.63; 95% confidence interval, 0.49-0.80) and 5 minutes (odds ratio, 0.64; 95% confidence interval, 0.47-0.87), when controlling for umbilical artery gases, gestational age, and maternal-fetal complications. This difference seemed related to significantly lower assigned color Apgar scores at 1 minute when controlling for all the above factors (odds ratio, 0.52; 95% confidence interval, 0.39-0.68). Providers admitted full-term Black neonates to the neonatal intensive care unit at higher rates than non-Black neonates when controlling for all factors (odds ratio, 1.29; 95% confidence interval, 0.94-1.77). Black neonates did not have more abnormal cord gas values (mean umbilical artery pH of 7.259 for Black vs 7.256 for non-Black neonates), which would have supported their admission to the neonatal intensive care unit. CONCLUSION: Providers applied inaccurate Apgar scores to Black neonates given that the umbilical cord gases were not in agreement with lower Apgar scores. These inaccuracies may be a factor in unnecessary admissions to neonatal intensive care units, and suggest that colorism and racial biases exist among healthcare providers.

Waterbirth: A Systematic Review and Meta-Analysis.

Despite patient interest, there is little evidence regarding waterbirth. This review sought to compare maternal and perinatal outcomes in waterbirth, compared with landbirth. This search was conducted using MEDLINE, Google Scholar, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and Cochrane Library from inception to November 15, 2021, with no language or geographic restrictions. Review was registered with PROSPERO under registration number: CRD42021288576. Selection criteria included randomized controlled trials of women with singleton cephalic gestations at ≥36 weeks comparing waterbirth to landbirth. The primary outcome was a perinatal composite outcome. Secondary outcomes included maternal and individual perinatal outcomes. Summary measures were reported as relative risk or mean difference with 95% confidence intervals using random effects model of DerSimonian and Laird. I 2 (Higgins I 2) > 0% was used to identify heterogeneity. Six trials including 706 patients were included. When reported, all patients were ≥ 37 weeks' gestation. Labor augmentation (41.7 vs. 84.7%, p < 0.0001) and neuraxial anesthesia (10.5 vs. 72.4%, p < 0.0001) were less common with waterbirth. Estimated blood loss, postpartum hemorrhage, perineal laceration, episiotomy, mode of delivery, and perinatal outcomes did not differ between groups. Chorioamnionitis and endometritis were not reported by any trial. Maternal satisfaction was higher (p = 0.01) and pain scores lower (p = 0.003) with waterbirth. Length of first stage (p < 0.00001), third stage (p = 0.02), and labor (p = 0.04) were shorter with waterbirth. The composite perinatal outcome could not be calculated due to lack of individual patient data. Compared with landbirth, waterbirth was associated with lower rates of neuraxial anesthesia and lower pain scores, with improved maternal satisfaction. KEY POINTS: · Data are limited regarding the safety and potential benefits of waterbirth.. · With waterbirth, maternal satisfaction was higher and pain scores lower. The first and third stages of labor and labor overall were shorter. No significant differences noted in other maternal outcomes, such as hemorrhage or laceration.. · Insufficient data are available regarding neonatal outcomes..

Communication and Palliation in Trauma Critical Care: Impact of Trainee Education and Mentorship.

BACKGROUND: Surgical residency training requires Advance Care Planning (ACP) and Palliative Care (PC) education. To meet education needs and align with American College of Surgeons guidelines, our Surgical Intensivists and PC faculty developed courses on communication and palliation for residents (2017-18) and fellows (2018-19). We hypothesized that education in ACP would increase ACP communication and documentation. METHODS: The trauma registry of an academic, level 1trauma center was queried for ICU admissions from 2016-2019, excluding incarcerated and pregnant patients. A retrospective chart review was performed, obtaining frequency of ACP documentation, ACP meetings, time from admission to documentation, and PC consultation. We collected ICU quality measures as secondary outcomes: ICU Length Of Stay (LOS), hospital LOS, ventilator days, invasive procedures, discharge disposition, and mortality. Comparisons were made between years prior to (Y 1) and following implementation (Y 2: residents, Y 3: fellows). RESULTS: For 1732 patients meeting inclusion criteria, patient demographics, injuries, and injury severity score were comparable. ACP documentation increased from 19.5% in Y 1 to 57.2% in Y 3 (P < 0.001). Time to ACP documentation was reduced from 47.6 to 13.1 h (P < 0.001) from time of admission. ICU LOS decreased from 6 to 4.8 d (P = 0.004). Patients in Y 3 had fewer tracheostomies and percutaneous endoscopic gastrostomies. PC consultations decreased. Mortality was unchanged. CONCLUSION: Following trainee education, we observed increases in ACP documentation, earlier communication and improvements in ICU quality measures. Our findings suggest that trainee education positively impacts ACP documentation, reduces LOS, and improves trauma critical care outcomes.

Differences in knowledge and attitudes toward the intrauterine device: Do age and race matter?

AIM: The intrauterine device (IUD) is highly effective birth control, but US IUD usage lags. Barriers to usage, including patient attitudes and lack of knowledge, are not well-characterized. This study sought to investigate how attitudes and knowledge about IUD vary by age and race. METHODS: A survey was distributed to all women in the outpatient obstetrics and gynecology office of a large, urban, academic medical center in Philadelphia. Exclusion criteria included inability to read English or age less than 14 years. Surveys queried participant demographics, knowledge about and opinions of IUD. The authors performed exploratory bi-variable analysis using t tests and chi-square testing to determine which outcomes differed by age and race. For those differing significantly, the authors performed regression analysis to assess for confounding by other factors. RESULTS: Of 1366 women approached, 521 completed the survey (38% response rate). After controlling for confounding, only responses to the statement 'Hormonal birth control is safe and effective' differed significantly by age. Knowledge about IUD did not differ significantly by race, but black women were significantly more likely to perceive that they had insufficient knowledge about IUD compared to white women (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.06-3.46). Black women had a more negative opinion of IUD safety (OR: 5.0; 95% CI: 2.35-10.66) and reliability (OR: 5.5; 95% CI: 2.20-14.13) than white women. CONCLUSION: Attitudes and knowledge about IUD do not differ significantly by age. While knowledge about IUD is similar between races, black women may have more negative opinions of IUD.

Maternal-Child Microbiome: Specimen Collection, Storage, and Implications for Research and Practice.

BACKGROUND: The maternal microbiome is a key contributor to the development and outcomes of pregnancy and the health status of both mother and infant. Significant advances are occurring in the science of the maternal and child microbiome and hold promise in improving outcomes related to pregnancy complications, child development, and chronic health conditions of mother and child. OBJECTIVES: The purpose of this study was to review site-specific considerations in the collection and storage of maternal and child microbiome samples and its implications for nursing research and practice. APPROACH: Microbiome sampling protocols were reviewed and synthesized. Precautions across sampling protocols were also noted. RESULTS: Oral, vaginal, gut, placental, and breast milk are viable sources for sampling the maternal and/or child microbiome. Prior to sampling, special considerations need to be addressed related to various factors including current medications, health status, and hygiene practices. Proper storage of samples will avoid degradation of cellular and DNA structures vital for analysis. DISCUSSION: Changes in the microbiome throughout the perinatal, postpartum, and childhood periods are dramatic and significant to outcomes of the pregnancy and the long-term health of mother and child. Proper sampling techniques are required to produce reliable results from which evidence-based practice recommendations will be built. Ethical and practical issues surrounding study design and protocol development must also be considered when researching vulnerable groups such as pregnant women and infants. Nurses hold the responsibility to both perform the research and to translate findings from microbiome investigations for clinical use.

Identifying Factors and Techniques to Decrease the Positive Margin Rate in Partial Mastectomies: Have We Missed the Mark?

Breast conservation therapy (BCT) has a reported incidence of positive margins ranging widely in the literature from 20% to 70%. Efforts have been made to refine standards for partial mastectomy and to predict which patients are at highest risk for incomplete excision. Most have focused on histology and demographics. We sought to further define modifiable risk factors for positive margins and residual disease. A retrospective study was conducted of 567 consecutive partial mastectomies by 21 breast and general surgeons from 2009 to 2012. Four hundred fourteen cases of neoplasm were reviewed for localization, intraoperative assessment, excision technique, rates, and results of re-excision/mastectomy. Histologic margins were positive in 23% of patients, 25% had margins 0.1-0.9 mm, and 7% had tumor within 1-1.9 mm. Residual tumor was identified at-in 61 cases: 38% (disease at margin), 21% (0.1-0.9 mm), and 14% (1-1.9 mm). Ductal carcinoma in situ (DCIS) was present in 85% of residual disease on re-excision and correlated to higher rates of re-excision (p = <0.001), residual disease, and subsequent mastectomy. The use of multiple needles to localize neoplasms was associated with 2-3 times the likelihood for positive margins than when a single needle was required. The removal of additional margins at initial surgery correlated with improved rates of complete excision when DCIS was present. Patients must have careful analysis of specimen margins at the time of surgery and may benefit from additional tissue excision or routine shaving of the cavity of resection. Surgeons should conduct careful patient selection for BCT, in the context of multifocal, and multicentric disease. Patients for whom tumor localization requires bracketing may be at higher risk for positive margins and residual disease and should be counseled accordingly.

Mutations in the leptin receptor gene associated with delayed onset of puberty are also associated with decreased ovulation and lambing rates in prolific Davisdale sheep.

The aim of this study was to determine if single nucleotide polymorphisms (SNPs) in the leptin receptor (LEPR) gene associated with delayed onset of puberty are associated with changes in other reproductive traits in adult ewes. The ovulation rate of ewes homozygous for the SNPs was ~15% lower (PPLEPR SNPs than their wild-type or heterozygous contemporaries. Partial failure of multiple ovulations was also increased (PLEPR had on average 0.2 fewer lambs at mid-pregnancy and at birth compared with the wild-type or heterozygous ewes (PLEPR were strongly associated with poorer reproductive performance in Davisdale ewes, which is likely to be linked to both a reduced number of ova available for fertilisation and an increased number of ewes failing to become pregnant. Increased partial failure of multiple ovulations in ewes with high ovulation rates (i.e. 3 or greater) may also contribute to the poor reproductive performance.

Maternal Microbiome and Pregnancy Outcomes That Impact Infant Health: A Review.

The maternal microbiome is recognized as a key determinant of a range of important maternal and child health outcomes, and together with perinatal factors influences the infant microbiome. This article provides a summary review of research investigating (1) the role of the maternal microbiome in pregnancy outcomes known to adversely influence neonatal and infant health, including preterm birth, cardiometabolic complications of pregnancy such as preeclampsia and gestational diabetes, and excessive gestational weight gain; (2) factors with an established link to adverse pregnancy outcomes that are known to influence the composition of the maternal microbiome; and (3) strategies for promoting a healthy maternal microbiome, recognizing that much more research is needed in this area.

Single-nucleotide polymorphisms in the LEPR gene are associated with divergent phenotypes for age at onset of puberty in Davisdale ewes.

Attainment of puberty is a key developmental event influenced by genetic and environmental factors. In examining age at attainment of puberty, we observed closely related rams from the Davisdale line whose daughters differed in age at which they attained puberty. A candidate gene approach was used to identify mutations that may underlie these observed differences. Four rams with divergent phenotypes for their daughter's age at onset of puberty were selected for whole-genome sequencing. The coding regions of genes with known roles in regulating reproductive function were searched for single-nucleotide polymorphisms (SNPs) that altered the amino acid sequence of the protein. Of interest were three SNPs in the leptin receptor gene (LEPR). A Sequenom assay was developed to determine the genotype of these SNPs in daughters of 17 sons of a founding sire. A higher percentage of ewe lambs homozygous for the LEPR mutations failed to undergo puberty before 1 yr of age, and those that did undergo puberty during the first breeding season on average were approximately 17 days older than homozygous wild-type ewes. Heterozygous ewes were intermediate for both measurements. Given the predicted change in protein function produced by the mutation in LEPR and the strong associations between the genotype and onset of puberty phenotypes, we propose that this mutation in LEPR underlies the observed difference in age at onset of puberty in the Davisdale line. Furthermore, these animals will likely provide a useful model to better understand the role of leptin in the regulation of puberty.

Individual placement and support focusing on employment and education for young people at clinical high risk of psychosis: A feasibility study.

OBJECTIVE: This study aimed to assess the feasibility of implementing Individual Placement and Support (IPS) with a focus on educational and employment goals, within a clinical service for the early detection of individuals at clinical high risk (CHR) of psychosis. METHOD: Between June 2019 and April 2021, participants were recruited and received up to 6 (± 2) months support. Primary outcome: Enrolled participants, attended sessions, and disengagement rates were analyzed to assess feasibility. SECONDARY OUTCOMES: Enrollment in mainstream education or/and employment, hours spent working or/and studying, salary, level of functioning, and self-efficacy at baseline and follow-up were compared. RESULTS: Thirty-one participants were recruited, 13 of whom were remotely recruited after the first COVID-19 lockdown. Dropout rates were relatively low (16.1%), and 26 participants (83.9%) completed the program. Each participant received on average nine sessions (M = 9.65; SD = 4.92). Secondary outcomes: At follow-up, 73.1% participants were employed, working on average more hours per week, t(25) = -2.725; p = .012, and were earning significantly more money, t(25) = -3.702; p = .001, compared to baseline. Gains in educational outcomes were less clear. Global Assessment of Functioning, t = 248.50; p = .001, and Social Occupational Functioning, t(25) = -3.273; p = .003, were significantly higher at 6-month follow-up compared to baseline. No differences were found in participants' self-efficacy. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Findings indicate that research procedures are appropriate and that IPS implementation within a CHR clinical team is feasible. Secondary outcomes also suggest that IPS may be a beneficial intervention for young people at CHR. A longer follow-up might be needed to assess its impact on educational outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Deaths After Readmissions are Mostly Attributable to Failure-to-Rescue in EGS Patients.

INTRODUCTION: We have recently shown that readmission after EGS procedures carries a 4-fold higher mortality rate when compared to those not readmitted. Understanding factors associated with death after readmission is paramount to improving outcomes for EGS patients. We aimed to identify risk factors contributing to failure-to-rescue (FTR) during readmission after EGS. We hypothesized that most post-readmission deaths in EGS are attributable to FTR. METHODS: A retrospective cohort study using the NSQIP database 2013-2019 was performed. Patients who underwent 1 of 9 urgent/emergent surgical procedures representing 80% of EGS burden of disease, who were readmitted within 30 days post-procedure were identified. The procedures were classified as low- and high-risk. Patient characteristics analyzed included age, sex, BMI, ASA score comorbidities, postoperative complications, frailty, and FTR. The population was assessed for risk factors associated with mortality and FTR by uni- and multivariate logistic regression. RESULTS: Of 312,862 EGS cases, 16,306 required readmission. Of those, 10,748 (3.4%) developed a postoperative complication. Overall mortality after readmission was 2.4%, with 90.6% of deaths attributable to FTR. Frailty, high-risk procedures, pulmonary complications, AKI, sepsis, and the need for reoperation increased the risk of FTR. DISCUSSION: Death after a complication is common in EGS readmissions. The impact of FTR could be minimized with the implementation of measures to allow early identification and intervention or prevention of infectious, respiratory, and renal complications.

The anterior deltoid's importance in reverse shoulder arthroplasty: a cadaveric biomechanical study.

BACKGROUND: Frequently, patients who are candidates for reverse shoulder arthroplasty have had prior surgery that may compromise the anterior deltoid muscle. There have been conflicting reports on the necessity of the anterior deltoid thus it is unclear whether a dysfunctional anterior deltoid muscle is a contraindication to reverse shoulder arthroplasty. The purpose of this study was to determine the 3-dimensional (3D) moment arms for all 6 deltoid segments, and determine the biomechanical significance of the anterior deltoid before and after reverse shoulder arthroplasty. METHODS: Eight cadaveric shoulders were evaluated with a 6-axis force/torque sensor to assess the direction of rotation and 3D moment arms for all 6 segments of the deltoid both before and after placement of a reverse shoulder prosthesis. The 2 segments of anterior deltoid were unloaded sequentially to determine their functional role. RESULTS: The 3D moment arms of the deltoid were significantly altered by placement of the reverse shoulder prosthesis. The anterior and middle deltoid abduction moment arms significantly increased after placement of the reverse prosthesis (P < .05). Furthermore, the loss of the anterior deltoid resulted in a significant decrease in both abduction and flexion moments (P < .05). CONCLUSION: The anterior deltoid is important biomechanically for balanced function after a reverse total shoulder arthroplasty. Losing 1 segment of the anterior deltoid may still allow abduction; however, losing both segments of the anterior deltoid may disrupt balanced abduction. Surgeons should be cautious about performing reverse shoulder arthroplasty in patients who do not have a functioning anterior deltoid muscle.

A comprehensive analysis of 30-day readmissions after emergency general surgery procedures: Are risk factors modifiable?

BACKGROUND: Modifiable risk factors associated with procedure-related 30-day readmission after emergency general surgery (EGS) have not been comprehensively studied. We set out to determine risk factors associated with EGS procedure-related 30-day unplanned readmissions. METHODS: A retrospective cohort study was conducted using the National Surgical Quality Improvement Project database (2013-2019). It included nine surgical procedures encompassing 80% of the burden of EGS diseases, performed on an urgent/emergent basis. The procedures were classified as low risk (open and laparoscopic appendectomy and laparoscopic cholecystectomy) and high risk (open cholecystectomy, laparoscopic and open colectomy, lysis of adhesions, perforated ulcer repair, small bowel resection, and exploratory laparotomy). Data on patient characteristics, admission status, procedure risk, hospital length of stay, and discharge disposition were analyzed by multivariate logistic regression. RESULTS: A total of 312,862 patients were included (16,306 procedure-related 30-day readmissions [5.2%]). Thirty-day readmission patients were older, had higher American Association of Anesthesiology scores, were more often underweighted or markedly obese, and were more frequently presented with sepsis. Risk factors associated with EGS procedure-related 30-day unplanned readmissions included age older than 40 years (adjusted odds ratio [AOR], 1.15), American Association of Anesthesiology ≥3 (AOR, 1.41), sepsis present at the time of surgery (AOR, 1.84), body mass index <18 kg/m 2 (AOR, 1.16), body mass index ≥40 kg/m 2 (AOR, 1.12), high-risk procedures (AOR, 1.51), LOS ≥4 d (AOR, 2.04), and discharge except to home (AOR, 1.33). Thirty-day readmissions following low-risk procedures occurred at a median of 5 days (interquartile range, 2-11 days) and 6 days (interquartile range, 3-11 days) after high-risk procedures. Surgical site infections, postoperative sepsis, wound disruption, and thromboembolic events were more prevalent in the 30-day readmission group. Mortality rate was fourfold higher in the 30-day readmission group (2.4% vs. 0.6%). CONCLUSION: We identified several unmodifiable patients and EGS disease-related factors associated with 30-day unplanned readmissions. Readmissions could be potentially reduced by the implementation of a postdischarge surveillance systems between hospitals and postdischarge destination facilities, leveraging telehealth and outpatient care. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Intimate Partner Violence and Pregnancy: Nationwide Analysis of Injury Patterns and Risk Factors.

BACKGROUND: Intimate partner violence (IPV) is a significant cause of injury, and in pregnant patients (PIPV) poses a risk to both mother and fetus. Characteristics and outcomes for PIPV patients have not been well described. We hypothesize that PIPV patients have higher admission rates and mortality than non-IPV pregnant trauma (PT) patients and nonpregnant female IPV patients of childbearing age. We also hypothesize differences exist between PIPV and PT patient injury patterns, allowing for targeted IPV screening. STUDY DESIGN: The Nationwide Emergency Department Sample database was queried from 2010 to 2014 to identify IPV in adult women patients by injury code E967.3. Patients were compared in 2 ways, PIPV vs PT and PIPV vs nonpregnant female IPV patients. Demographics, injury mechanisms, and National Trauma Data Standard injury diagnoses were surveyed. Primary outcomes were hospital admissions and mortality. Logistic regression was used to estimate risk factors of the outcomes of hospitalization and IPV victimization in pregnant injured patients. RESULTS: There were 556 PIPV patients, 73,970 PT patients, and 56,543 nonpregnant female IPV patients. When comparing PIPV to PT, more PIPV patients had Medicaid coverage or were self-pay. Suffocation, head injuries, face/neck/scalp contusions, multiple contusions, and abrasions/friction burns were more prevalent in PIPV patients. Mortality and hospital admissions were scarce among all cohorts. Predictors of IPV victimization among injured pregnant patients include multiple injuries, head injuries, face/neck/scalp contusions, abrasions/friction burns, contusions of multiple sites, and those with Medicaid or self-pay coverage. CONCLUSIONS: Among injured pregnant patients, those with multiple injuries, head injuries, contusions of the face/neck/scalp, abrasions/friction burns, and multiple contusions should undergo IPV screening. Admissions and mortality are low; therefore, prevention measures should be implemented in the emergency department to reduce repeat victimization.

Racial bias in cesarean decision-making.

BACKGROUND: Category II fetal heart tracing noted during continuous external fetal monitoring is a frequent indication for cesarean delivery in the United States despite its somewhat subjective interpretation. Black patients have higher rates of cesarean delivery and higher rates for this indication. Racial bias in clinical decision-making has been demonstrated throughout medicine, including in obstetrics. OBJECTIVE: We sought to examine if racial bias affects providers' decisions about cesarean delivery for an indication of category II fetal heart tracings. STUDY DESIGN: We constructed an online survey study consisting of 2 clinical scenarios of patients in labor with category II tracings. Patient race was randomized to Black and White; the vignettes were otherwise identical. Participants had the option to continue with labor or to proceed with a cesarean delivery at 3 decision points in each scenario. Participants reported their own demographics anonymously. This survey was distributed to obstetrical providers via email, listserv, and social media. Data were analyzed using chi-square tests at each decision point in the overall sample and in subgroup analyses by various participant demographics. RESULTS: A total of 726 participants contributed to the study. We did not find significant racial bias in cesarean delivery decision-making overall. However, in a scenario of a patient with a previous cesarean delivery, Fisher's exact tests showed that providers <40 years old (n=322; P=.01) and those with <10 years of experience (n=239; P=.050) opted for a cesarean delivery for Black patients more frequently than for White patients at the first decision point. As labor progressed in this scenario, the rates of cesarean delivery equalized across patient race. CONCLUSION: Younger providers and those with fewer years of clinical experience demonstrated racial bias in cesarean delivery decision-making at the first decision point early in labor. Providers did not show racial bias as labor progressed, nor in the scenario with a patient without a previous cesarean delivery. This bias may be the consequence of provider training with the Maternal-Fetal Medicine Unit Network Vaginal Birth After Cesarean Calculator, developed in 2007, and widely used to estimate the probability of successful vaginal birth after a cesarean delivery. This calculator used race as a predictive factor until it was removed in June 2021. Future studies should investigate if this bias persists following this change, while also focusing on interventions to address these findings.

Immersion in water during the second stage of labor: a randomized controlled trial.

BACKGROUND: Current obstetrical guidelines in the United States caution firmly against birth in water, but patients remain interested in this intervention. Limited data are available to evaluate the safety and efficacy of water immersion in the second stage of labor for patients and neonates. OBJECTIVE: This study aimed to ascertain the effects of water use during the second stage of labor on maternal outcomes. Second, it aimed to propose guidelines for midwives conducting the second stage of labor in water. STUDY DESIGN: A randomized, prospective design was used to evaluate the primary outcomes of maternal experience in labor and trauma to the birth canal and several secondary neonatal and maternal outcomes when participants delivered in water vs in a conventional setting. Participants were recruited at 2 academic state hospitals serving the same low- to middle-income group urban population in the midwestern suburbs of Johannesburg, South Africa over a period of 2 years. Individuals in active labor without exclusion criteria were asked to participate in the study. A total of 120 participants were enrolled, with 60 randomized to water birth and 60 to conventional birth. Outcomes were compared using the chi-square and Fisher exact tests. RESULTS: The use of water during birth significantly reduced the participants' perception of experienced pain than what they expected it to be (P=.006) and enhanced their satisfaction with their ability to cope with labor (P=.010). No differences were noted in trauma to the birth canal. No adverse maternal effects were noted. One early neonatal death occurred in the water group. The most likely cause of death was preexisting intrauterine fetal infection. CONCLUSION: Participants who delivered in water were significantly more satisfied with their birthing experience. The possible harmful effect of inhalation of fresh water by a baby is not resolved, and a large randomized controlled trial is recommended. It is recommended that immersion in water during the second stage of labor should only be offered by competent birth attendants who follow specific guidelines until clear evidence is available on the possible beneficial or harmful effects. Pending further evidence, we recommend adding salt to the bath to produce a physiological saline solution to reduce theoretical risks associated with fresh water inhalation by the neonate.

Management of choledocholithiasis in the elderly: Same-admission cholecystectomy remains the standard of care.

BACKGROUND: Current guidelines recommend that patients with choledocholithiasis undergo same-admission cholecystectomy. The compliance with this guideline is poor in elderly patients. We hypothesized that elderly patients treated with endoscopic retrograde cholangiopancreatography (ERCP) alone would have higher complication and readmission rates than the patients treated with cholecystectomy. METHODS: The Nationwide Readmissions Database was queried for all patients aged ≥65 years with admission for choledocholithiasis January to June 2016. The patients were divided based on index treatment received: (1) no intervention; (2) ERCP alone; or (3) cholecystectomy. Multivariate analyses identified predictors of cholecystectomy during index admission and of readmissions. RESULTS: A total of 16,121 patients with choledocholithiasis were admitted; 38.4% underwent cholecystectomy, 37.6% endoscopic retrograde cholangiopancreatography alone, and 24.0% no intervention. The patients not receiving a cholecystectomy were more likely to be older, female, have a higher Elixhauser score, do-not-resuscitate status, and at a teaching hospital (all P < .001). Emergency readmissions for recurrent biliary disease were lowest in patients undoing a cholecystectomy (2.2% vs 9.2% endoscopic retrograde cholangiopancreatography and 12.4% no intervention, P < .001), as were readmissions for complications (3.6% vs 5.5% and 7.8%, P < .001). Cholecystectomy reduced rates of readmissions for recurrent disease (odds ratio 0.168, P < .001), for complications (odds ratio 0.540, P < .001), and death during readmission (odds ratio 0.503, P = .007); endoscopic retrograde cholangiopancreatography alone reduced only rates of readmissions. Age was not a predictor of readmission or death. CONCLUSION: Index admission cholecystectomy is associated with a lower risk of readmission for biliary disease or complications, as well as death during readmission, in elderly patients. Age alone is not predictive of outcomes; surgical intervention should be guided by clinical condition, comorbidities, and patient preference.

Corrigendum: Case report: Persistence of residual antigen and RNA of the SARS-CoV-2 virus in tissues of two patients with long COVID.

[This corrects the article DOI: 10.3389/fimmu.2022.939989.].

Case report: Persistence of residual antigen and RNA of the SARS-CoV-2 virus in tissues of two patients with long COVID.

The World Health Organization has defined long COVID-19 (LC) as a condition that occurs in individuals with a history of SARS-CoV-2 infection who exhibit persistent symptoms after its acute phase that last for at least two months and cannot be explained by an alternative diagnosis. Since we had previously reported residual viral antigens in tissues of convalescent patients, we aimed to assess the presence of such antigens in long COVID tissues. Here, we established the presence of the residual virus in the appendix, skin, and breast tissues of 2 patients who exhibited LC symptoms 163 and 426 days after symptom onset. With multiplex immunohistochemistry, we detected viral nucleocapsid protein in all three tissues. The nucleocapsid protein was further observed to colocalize with macrophage marker CD68, suggesting that immune cells were direct targets of SARS-CoV-2. Additionally, using RNAscope, the presence of viral RNA was also detected. Our positive finding in the breast tissue is corroborated by the recent reports of immunocompromised patients experiencing LC symptoms and persistent viral replication. Overall, our findings and emerging LC studies raise the possibility that the gastrointestinal tract may function as a reservoir for SARS-CoV-2.