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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Shoe and Field Surface Risk Factors for Acute Lower Extremity Injuries Among Female Youth Soccer Players.

OBJECTIVE: To describe acute lower extremity injuries and evaluate extrinsic risk factors in female youth soccer. DESIGN: Nested case-control study. SETTING: Youth soccer clubs in Seattle, WA. PARTICIPANTS: Female soccer players (n = 351) ages 11 to 15 years randomly selected from 4 soccer clubs from which 83% of their players were enrolled with complete follow-up for 92% of players. INTERVENTIONS: Injured players were interviewed regarding injury, field surface, shoe type, and position. Uninjured controls, matched on game or practice session, were also interviewed. MAIN OUTCOME MEASURES: The association between risk factors and acute lower extremity injury using logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: One hundred seventy-three acute lower extremity injuries occurred involving primarily the ankle (39.3%), knee (24.9%), and thigh (11.0%). Over half (52.9%) recovered within 1 week, whereas 30.2% lasted beyond 2 weeks. During practices, those injured were approximately 3-fold (OR, 2.83; 95% CI, 1.49-5.31) more likely to play on grass than artificial turf and 2.4-fold (95% CI, 1.03-5.96) more likely to wear cleats on grass than other shoe and surface combinations. During games, injured players were 89% (95% CI, 1.03-4.17) more likely to play defender compared with forward. CONCLUSIONS: Half of the acute lower extremity injuries affected the ankle or knee. Grass surface and wearing cleats on grass increased training injuries. CLINICAL RELEVANCE: The majority, 64%, of female youth soccer players' acute injuries involve the ankle and knee and injury prevention strategies in this age group should target these areas. When considering playing surfaces for training, communities and soccer organizations should consider the third-generation artificial turf a safe alternative to grass.

Implementing the "Flipped Classroom" on a Gynecologic Oncology Service.

OBJECTIVE: To determine the impact of a new cur- riculum based on the "flipped classroom" model on the gynecologic oncology (gyn onc) section of the annual in-service examination for residents in obstetrics and gynecology. STUDY DESIGN: We intro- duced a curriculum focused on a weekly topic for teach- ing the residents on the gyn onc service in January of 2009. We compared the over- all mean gyn onc-specific percent-correct scores on the in-service examination be- fore (1999-2009) and after (2010-2011) the implemen- tation of the curriculum using linear regression to estimate the mean percentage point change and 95% confidence interval, adjusting for clustering by residents. RESULTS: Our analysis included 90 residents (73 females and 17 males), which yielded 295 scores for analysis. We found a significant increase of 6.5 per- centage points (95% CI 3.5-9.6) in the gyn .onc mean percent correct for all postgraduate year levels combined after initiation of our curriculum. During that same period the overall in-service examination percent-correct scores did not significantly change. CONCLUSION: Our curriculum,focusing on a weekly topic, resulted in improve- ment in in-service exam- ination scores. This type of curriculum could be applied to other areas of resident edu- cation within obstetrics and gynecology.

Beyond the Ivory Tower: A Comparison of Grades Across Academic and Community OB/GYN Clerkship Sites.

UNLABELLED: CONSTRUCT: Decentralized clinical education is the use of community facilities and community physicians to educate medical students. The theory behind decentralized clinical education is that academic and community sites will provide educational equivalency as determined by objective and subjective performance measures, while training more medical students and exposing students to rural or underserved communities. One of the major challenges of decentralized clinical education is ensuring site comparability in both learning opportunities and evaluation of students. BACKGROUND: Previous research has examined objective measures of student performance, but less is known about subjective performance measures, particularly in the field of obstetrics and gynecology (OB/GYN). This study explores the implications of clinical site on the adequacy of subjective and objective performance measures. APPROACH: This was a retrospective cohort study of 801 students in the University of Washington School of Medicine OB/GYN clerkship from 2008 to 2012. Academic sites included those with OB/GYN residency programs (n = 2) and community sites included those without residency programs (n = 29). The association between clerkship site and National Board of Medical Examiners (NBME) grade was assessed using linear regression and clinical and final grade using multinomial regression, estimating ß coefficient and relative risks (RR), respectively, and 95% confidence intervals (CIs), adjusting for gender, academic quarter of clerkship, and year of clerkship. RESULTS: There were no differences in NBME exam grades of students at academic sites (76.4 (7.3) versus 74.6 (8.0), ß = -0.11, 95% CI [1.35, 1.12] compared to community sites. For clinical grade, students at community sites were 2.4 times more likely to receive honors relative to high pass (RR 2.45), 95% CI [1.72, 3.50], and for final grade, students at community sites were 1.9 times more likely to receive honors relative to pass (RR 1.98), 95% CI [1.27, 3.09], and 1.6 times more likely to receive honors relative to high pass (RR 1.62), 95% CI [1.05, 2.50], compared to those at academic sites. CONCLUSIONS: Students at community sites receive higher clinical and final grades in the OB/GYN clerkship. This highlights a significant challenge in decentralized clinical education-ensuring site comparability in clinical grading, Further work should examine the differences in sites, as well as improve standardization of clinical grading. This also underscores an important consideration, as the final grade can influence medical school rank, nomination into honor societies, and ranking of residency applicants.

Labor and delivery outcomes among young adolescents.

OBJECTIVE: We sought to determine whether young adolescents aged 11-14 years and teens aged 15-17 and 18-19 years have an increased risk of cesarean or operative delivery, as well as maternal or neonatal delivery-related morbidity, compared to young adults aged 20-24 years. STUDY DESIGN: We conducted a retrospective population-based cohort study using Washington State birth certificate data linked to hospital records from 1987 through 2009 for 26,091 nulliparas with singleton gestations between 24-43 weeks. We compared young adolescents aged 11-14 years, young teens aged 15-17 years, and older teens aged 18-19 years to young adults aged 20-24 years. The primary outcome was method of delivery. Secondary outcomes included postpartum hemorrhage, shoulder dystocia, third- and fourth-degree perineal lacerations, chorioamnionitis, prolonged maternal length of stay, gestational age at delivery, birthweight, respiratory distress syndrome, neonatal length of stay, and death. We used multivariate regression to assess associations between age and delivery outcomes. RESULTS: Young adolescents aged 11-14 years had a lower risk of cesarean (risk ratio [RR], 0.73; 95% confidence interval [CI], 0.65-0.83) and operative vaginal (RR, 0.87; 95% CI, 0.78-0.97) delivery compared to young adults aged 20-24 years. Compared to young adults, young adolescents had an increased risk of prolonged length of stay for both vaginal and cesarean delivery (RR, 1.34; 95% CI, 1.20-1.49, and RR, 1.71; 95% CI, 1.38-2.12, respectively), with no significant differences in indication for cesarean delivery or other measures of maternal morbidity. Young adolescents had an increased risk of preterm delivery (RR, 2.11; 95% CI, 1.79-2.48), low and very low birthweight (RR, 2.08; 95% CI, 1.73-2.50, and RR, 3.25; 95% CI, 2.22-4.77, respectively), and infant death (RR, 3.90; 95% CI, 2.36-6.44) compared to young adults. CONCLUSION: Young adolescents have a decreased risk of cesarean and operative vaginal delivery compared to young adults; however, their neonates face higher risks of preterm delivery, low and very low birthweight, and death. This information can be used to inform clinical care for this population.

Leukocyte telomere length and age at menopause.

BACKGROUND: Telomere length is a marker of cellular aging that varies with the individual, is inherited, and is highly correlated across somatic cell types within persons. Interindividual variability of telomere length may partly explain differences in reproductive aging rates. We examined whether leukocyte telomere length was associated with menopausal age. METHODS: We evaluated the relationship between leukocyte telomere length and age at natural menopause in 486 white women ≥65 years of age. We fit linear regression models adjusted for age, income, education, body mass index, physical activity, smoking, and alcohol intake. We repeated the analysis in women with surgical menopause. We also performed sensitivity analyses excluding women (1) with unilateral oophorectomy, (2) who were nulliparous, or (3) reporting menopausal age <40 years, among other exclusions. RESULTS: For every 1-kb increase in leukocyte telomere length, average age at natural menopause increased by 10.2 months (95% confidence interval = 1.3 to 19.0). There was no association among 179 women reporting surgical menopause. In all but one sensitivity analysis, the association between leukocyte telomere length and age at menopause became stronger. However, when excluding women with menopausal age <40 years, the association decreased to 7.5 months (-0.4 to 15.5). CONCLUSIONS: Women with the longest leukocyte telomere length underwent menopause 3 years later than those with the shortest leukocyte telomere length. If an artifact, an association would likely also have been observed in women with surgical menopause. If these results are replicated, leukocyte telomere length may prove to be a useful predictor of age at menopause.

Evaluation of the Zachery Lystedt Law among female youth soccer players.

BACKGROUND: Despite recent increased awareness about sports concussions, few studies have evaluated the effect of concussion laws on concussion outcomes among young athletes. The purpose of our study was to evaluate the effect of the Washington State Zachery Lystedt Concussion Law on playing with concussion symptoms and being evaluated by a health care provider. METHODS: We performed a prospective cohort study of 351 elite female soccer players, aged 12 to 15 years, from 33 randomly selected youth soccer teams in the Puget Sound region of Washington State from 2008 to 2012. The Washington State Zachery Lystedt Concussion Law went into effect on July 1, 2009. Among concussed players (N = 59), we assessed the risk of playing with symptoms, the evaluation by a health care professional, and receiving a concussion diagnosis before and after the law was passed using logistic regression to estimate odds ratios and 95% CIs. RESULTS: The majority of concussed players (59.3%) continued to play with symptoms, and we found no statistically significant difference in the proportion of players who played with symptoms before and after the law was passed. Only 44.1% of concussed players were evaluated by a health care provider, with no difference before and after the law was passed. Among those evaluated by a health care professional, players were 2.1-fold (95% CI, 1.0-10.1) more likely to receive a concussion diagnosis after the law was passed. CONCLUSION: The majority of concussed female youth soccer players report playing with symptoms. Legislation mandating concussion education and evaluation prior to returning to play was not associated with an increase in concussion evaluations by health care providers.

Risk factors for concussive symptoms 1 week or longer in high school athletes.

OBJECTIVE: To identify risk factors for concussive symptoms ≥1 week. METHODS: Retrospective cohort study of concussions in the RIO™ database 2006-2009 (n = 1412) analysing risk factors for concussive symptoms ≥1 week. This study examined athlete's age, sex, weight, history of concussion, number of symptoms and specific symptoms. Data were stratified by football vs. non-football and analysed using Poisson regression to calculate relative risks and 95% confidence intervals. RESULTS: Presenting with four or more symptoms was associated with double the risk for concussive symptoms ≥1 week for both football (95% CI = 1.3-3.5) and non-football players (95% CI = 1.4-4.6). History of prior concussion was associated with double the risk for concussive symptoms ≥1 week in football players only (95% CI = 1.3-3.5). Several symptoms were associated with concussive symptoms ≥1 week in all athletes: drowsiness, nausea and concentration difficulties. Sensitivity to light and noise was associated with concussive symptoms ≥1 week in non-football players only. Amnesia was associated with concussive symptoms ≥1 week in males, but not females. Loss of consciousness was not significant. CONCLUSIONS: Risk factors for concussive symptoms ≥1 week are identifiable and can potentially be used to prognosticate for athletes and design evidence-based return-to-play guidelines.

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.

Population-based study of risk factors for severe maternal morbidity.

BACKGROUND: Severe maternal morbidity (SMM) is a serious health condition potentially resulting in death without immediate medical attention, including organ failure, obstetric shock and eclampsia. SMM affects 20000 US women every year; however, few population-based studies have examined SMM risk factors. METHODS: We conducted a population-based case-control study linking birth certificate and hospital discharge data from Washington State (1987-2008), identifying 9485 women with an antepartum, intrapartum or postpartum SMM with ≥3-day hospitalisation or transfer from another facility and 41 112 random controls. Maternal age, race, smoking during pregnancy, parity, pre-existing medical condition, multiple birth, prior caesarean delivery, and body mass index were assessed as risk factors with logistic regression to estimate odds ratios (OR) and 95% confidence intervals [CI], adjusted for education and delivery payer source. RESULTS: Older women (35-39: OR 1.65 [CI 1.52, 1.79]; 40+: OR 2.48 [CI 2.16, 2.81]), non-White women (Black: OR 1.82 [CI 1.64, 2.01]; American Indian: OR 1.52 [CI 1.32, 1.73]; Asian/Pacific Islander: OR 1.30 [CI 1.19, 1.41]; Hispanic: OR 1.17 [CI 1.07, 1.27]) and women at parity extremes (nulliparous: OR 1.83 [CI 1.72, 1.95]; parity 3+: OR 1.34 [CI 1.23, 1.45]) were at greater risk of SMM. Women with a pre-existing medical condition (OR 2.10 [CI 1.88, 2.33]), a multiple birth (OR 2.54 [CI 2.26, 2.82]) and a prior caesarean delivery (OR 2.08 [CI 1.93, 2.23]) were also at increased risk. CONCLUSION: The risk factors identified are not modifiable at the individual level; therefore, provider and system-level factors may be the most appropriate target for preventing SMM.

Adverse birth outcomes among Korean women compared to white women in the United States.

To evaluate the risk of adverse birth outcomes among US- and foreign-born Korean women compared to US-born white women, we used the 2004 US natality file to assess the risk of low birth weight (LBW), preterm delivery (PTD), and cesarean delivery (CD) among US-born (N = 943) and foreign-born Koreans (N = 11,974) compared to white women (N = 25,834). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated using regression models to assess the risk of these outcomes. US-born (aOR = 0.66, 95% CI 0.43-1.02) and foreign-born Korean women (aOR 0.86, 95% CI 0.70-1.06) exhibited a lowered risk of LBW than white women, although not statistically significant. The risks of PTD and CD among Korean women were similar to white women, regardless of Korean women's nativity status. Future research should focus on identifying the cultural factors and practices associated with decreased risk of LBW among Korean women.