Sonographic Predictors of Antepartum Bleeding in Placenta Previa.

OBJECTIVE: To evaluate the association between sonographic features of placenta previa and vaginal bleeding (VB). STUDY DESIGN: Retrospective cohort study of women with placenta previa identified on ultrasound between 160/7 and 276/7 weeks gestation. Placental distance past the cervical os (DPO), placental thickness, edge angle, and cervical length (CL) were measured. The primary outcome was any VB and the secondary outcome was VB requiring delivery. Median values of the sonographic features were compared for each of the outcomes using the Mann-Whitney U test. Receiver operating characteristic curves were used to compare the predictive value of sonographic variables markers and to determine optimal cut points for each measurement. Logistic regression was used to estimate the association between each measure and the outcomes while controlling for confounders. RESULTS: Of 149 women with placenta previa, 37% had VB and 15% had VB requiring delivery. Women with VB requiring delivery had significantly more episodes of VB than those who did not require delivery for VB (1.5, interquartile range [IQR] [1-3] vs 1.0 [1-5]; p = 0.001). In univariate analysis, women with VB had decreased CL (3.9 vs. 4.2 cm; p < 0.01) compared with those without. Women with VB requiring delivery had increased DPO (2.6 cm IQR [1.7-3.3] vs. 1.5 cm [1.1-2.4], p = 0.01) compared with those without. After adjusting for confounders, only CL < 4 cm remained independently associated with increased risk of VB (adjusted odds ratio: 2.27, 95% confidence interval [1.12-4.58], p = 0.01). None of the measures were predictive of either outcome (area under the curve < 0.65). CONCLUSION: Decreased CL may be associated with risk of VB in placenta previa. KEY POINTS: · Placenta previa is associated with VB.. · Sonographic markers of placenta previa are associated with VB.. · CL is associated with VB in placenta previa, whereas placental DPO is associated with higher rates of bleeding leading to delivery..

Knowledge, Attitudes, Willingness to Pay, and Patient Preferences About Genetic Testing and Subsequent Risk Management for Cancer Prevention.

Knowledge, attitudes, and patient preferences about genetic testing and subsequent risk management for cancer prevention among average risk populations are understudied, especially among Hispanics. This study was to assess these items by conducting an in-person survey in this understudied population. We conducted in-person surveys using a self-administered, structured questionnaire among young women in 2017. Survey questions were adapted from other validated surveys. This study had 677 participants in the final analyses. Data were collected in 2017 and analyzed in 2018 and 2019. Participants had little knowledge about genes or breast cancer risk, but most felt that genetic testing for cancer prevention is "a good idea" (87.0%), "a reassuring idea" (84.0%), and that "everyone should get the test" (87.7%). Most (64.0%) of these women would pay up to $25 for the test, 29.3% would pay $25-$500, and < 10% would pay more than $500 for the test. When asked about a hypothetical scenario of high breast cancer risk, 34.2% Hispanics and 24.5% non-Hispanics would choose chemoprevention. Women would be less likely to choose risk reduction procedures, such as mastectomy (19.6% among Hispanics and 15.1% among non-Hispanics) and salpingo-oophorectomy (11.8% among Hispanics and 10.7% among non-Hispanics). In this low-income, mostly Hispanic population, knowledge about genetic testing and cancer risk is poor, but most have positive opinions about genetic testing for cancer prevention. However, their strong preference for chemoprevention and lesser preference for prophylactic surgeries in a hypothetical scenario underscore the importance of genetic counseling and education.

Feasting, not fasting: winter diets of cave hibernating bats in the United States.

Temperate bat species use extended torpor to conserve energy when ambient temperatures are low and food resources are scarce. Previous research suggests that migratory bat species and species known to roost in thermally unstable locations, such as those that roost in trees, are more likely to remain active during winter. However, hibernating colonies of cave roosting bats in the southeastern United States may also be active and emerge from caves throughout the hibernation period. We report what bats are eating during these bouts of winter activity. We captured 2,044 bats of 10 species that emerged from six hibernacula over the course of 5 winters (October-April 2012/2013, 2013/2014, 2015/2016, 2016/2017, and 2017/2018). Using Next Generation sequencing of DNA from 284 fecal samples, we determined bats consumed at least 14 Orders of insect prey while active. Dietary composition did not vary among bat species; however, we did record variation in the dominant prey items represented in species' diets. We recorded Lepidoptera in the diet of 72.2% of individual Corynorhinus rafinesquii and 67.4% of individual Lasiurus borealis. Diptera were recorded in 32.4% of Myotis leibii, 37.4% of M. lucifugus, 35.5% of M. sodalis and 68.8% of Perimyotis subflavus. Our study is the first to use molecular genetic techniques to identify the winter diet of North American hibernating bats. The information from this study is integral to managing the landscape around bat hibernacula for insect prey, particularly in areas where hibernating bat populations are threatened by white-nose syndrome.

The Hepatobiliary System: An Overview of Normal Function and Diagnostic Testing in Pregnancy.

Pregnancy is associated with physiological adaptions that affect every organ system. Changes in liver function in pregnancy have important effects on nutrient metabolism, protein synthesis, and the biotransformation of substances in preparation for excretion. A clear understanding of the anatomic and functional changes of the hepatobiliary system is necessary for the diagnosis and evaluation of disease, as well as understanding how these changes predispose women to pregnancy-specific hepatic conditions. In this review, the effect of gestational changes in hepatobiliary function on laboratory tests and the role of diagnostic imaging of the liver and gallbladder in pregnancy will be discussed.

Operating Room Guide for Confirmed or Suspected COVID-19 Pregnant Patients Requiring Cesarean Delivery.

We sought to provide a clinical practice protocol for our labor and delivery (L&D) unit, to care for confirmed or suspected COVID-19 patients requiring cesarean delivery. A multidisciplinary team approach guidance was designed to simplify and streamline the flow and care of patient with confirmed or suspected COVID-19 requiring cesarean delivery. A protocol was designed to improve staff readiness, minimize risks, and streamline care processes. This is a suggested protocol which may not be applicable to all health care settings but can be adapted to local resources and limitations of individual L&D units. Guidance and information are changing rapidly; therefore, we recommend continuing to update the protocol as needed. KEY POINTS: · Cesarean delivery for confirmed or suspected novel coronavirus disease 2019 (COVID-19) patients. · Team-based approach for streamline care. · Labor and delivery protocols for COVID-19 positive patients.

Obesity and laboratory aspirin resistance in high-risk pregnant women treated with low-dose aspirin.

BACKGROUND: Low-dose aspirin is used for preeclampsia prevention in high-risk women, but the precise mechanism and optimal dose are unknown. Evidence suggests that an imbalance in prostacyclin and thromboxane A2 (TXA2) plays a key role in the pathogenesis of preeclampsia. Aspirin has a dose-dependent effect blocking production of TXA2, a potent stimulator of platelet aggregation and promoter of vasoconstriction. Incomplete inhibition of platelet aggregation, designated aspirin resistance, can be reduced by increasing the aspirin dose. Evidence in the nonobstetric literature suggests that aspirin resistance may be more common among patients with a high body mass index. OBJECTIVE: To investigate the association of obesity on platelet-derived thromboxane inhibition in high-risk women treated with low-dose aspirin. MATERIALS AND METHODS: This was a secondary analysis of a prospective multi-centered study investigating the effect of low-dose aspirin (60-mg) administration in women at high risk for preeclampsia. Maternal serum TXB2 (an indirect measure of TxA2) levels were drawn at 3 time points: randomization (13-26 weeks' gestation), second trimester (at least 2 weeks after randomization and 24-28 weeks' gestation), and third trimester (34-38 weeks' gestation). Patients were included in the analysis if a TXB2 level was recorded at randomization and at least 1 time point thereafter. Patients were stratified by body mass index category and treatment arm. Median TXB2 levels were calculated at each time point, as well as rates of complete TXB2 inhibition (<0.01 ng/mL). A multivariate logistic regression analysis was performed to generate odds ratios (OR) for complete TXB2 inhibition by body mass index category, adjusting for maternal age, race, high-risk group at randomization, nulliparity, and rate of randomization less than 16 weeks' gestation. RESULTS: A total of 1002 patients were included in the analysis, 496 (49.5%) and 506 (50.5%) in the low-dose aspirin and placebo groups respectively. There were substantial decreases in TXB2 levels among low-dose aspirin-treated women in all body mass index categories. In contrast, women assigned to placebo did not show a marked decrease in TXB2 levels after randomization, and obese women had higher median TXB2 levels in both the second (16.5, interquartile range [IQR] 8.0-31.8 vs 14.0, IQR 6.9-26.7, ng/mL; P = .032) and third (15.7, IQR 7.6-28.5 vs 11.9, IQR 4.6-25.9, ng/mL; P = .043) trimesters. When comparing among stratified body mass index low-dose aspirin groups, women with class III obesity had the lowest odds of undetectable TXB2 levels in the second trimester (adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.15-0.72) and third trimester (aOR, 0.30; 95% CI, 0.11-0.78) as well as at both time points (aOR, 0.09; 95% CI, 0.02-0.41). CONCLUSION: High-risk obese women receiving low-dose aspirin for the prevention of preeclampsia have lower rates of complete inhibition of TXB2. These data suggest that an increase in aspirin dosing or frequency may be necessary in this population.

Predator-prey interaction reveals local effects of high-altitude insect migration.

High-altitude nocturnal insect migrations are ubiquitous and represent significant pulses of biomass, which impact large areas and multiple trophic levels, yet are difficult to study and poorly understood. Predation on migratory insects by high-flying bats provides potential for investigating flows of migratory insects across a landscape. Brazilian free-tailed bats, Tadarida brasiliensis, provide valuable ecosystem services by consuming migratory pests, and research suggests migratory insects are an important resource to bats in autumn. We sequenced insect DNA from bat feces collected during the 2010-2012 autumn migrations of insects over southern Texas, and tested the utility of predator-prey interactions for monitoring migratory insect populations by asking: 1) how extensively do bats consume migratory insects during autumn? (2) does the prey community reflect known drivers of insect migrations, e.g. cold fronts? and (3) are migratory insects increasingly important to bats when local food resources decline in autumn? Bats consumed at least 21 species of migratory insects and 44 species of agricultural pests. Prey community richness increased with cold front passage. Bats consumed migratory moths over the entire autumn season, and the proportion of migratory moths in the bat diet increased over the course of the autumn season in all 3 years. This study confirms extensive consumption of migratory insects by bats, links patterns in prey communities to mechanisms driving insect migration, and documents a novel approach to tracking patterns of migratory insect movement. As an important resource for T. brasiliensis in autumn, migratory insects provide stabilizing effects to the local animal community.

Full House: A Retrospective Analysis of High Sexually Transmitted Infection Prevalence among Adult Film Actors at a Singular Residence.

BACKGROUND: During a routine human immunodeficiency virus (HIV) investigation, Florida Department of Health staff identified a house (house A) in which over 150 individuals had resided at least briefly. Further investigation revealed that house A is used by the producer of a small adult film production company to board his actors. This report describes sexually transmitted infection (STI) prevalence among male actors in gay adult films residing in a common Florida residence. METHODS: LexisNexis Accurint was used to identify house A residents since October 2002 when the producer arrived. Information on STIs and interview data were obtained from Florida's STI surveillance system. An infection was considered to be associated with residence in house A if the date of diagnosis occurred 6 months before an individual's residence start date through 6 months after his residence end date. RESULTS: Excluding the producer, 150 men resided in house A starting from September 2003 to July 2015. Forty-six individuals had a reported case of HIV, syphilis, gonorrhea, and/or chlamydia with 92 infections total. Forty-two (46%) infections among 24 men were considered associated with residence in house A. CONCLUSIONS: LexisNexis Accurint was a useful tool for identifying house A residents, a highly mobile and highly sexually active population. There is a high prevalence of STIs among residents, but it is unclear where transmission is occurring. Settings like house A are good candidates for HIV pre-exposure prophylaxis and active STI screenings and may be an opportunity for public health officials to intervene in high-risk groups to reduce STI rates in the community.

An Audit of Nursing Documentation at Three Public Hospitals in Jamaica.

PURPOSE: Nursing documentation provides an important indicator of the quality of care provided for hospitalized patients. This study assessed the quality of nursing documentation on medical wards at three hospitals in Jamaica. METHODS: This cross-sectional study audited a multilevel stratified sample of 245 patient records from three type B hospitals. An audit instrument which assessed nursing documentation of client history, biological data, client assessment, nursing standards, discharge planning, and teaching facilitated data collection. Descriptive statistics were conducted using IBM SPSS, Version 19 (IBM Inc., Armonk, NY, USA). FINDINGS: Records from three hospitals (Hospital 1, n = 119, 48.6%; Hospital 2, n = 56, 22.9%; Hospital 3, n = 70, 28.6%) were audited. Documented evidence of the patient's chief complaint (81.6%), history of present illness (78.8%), past health (79.2%), and family health (11.0%) were noted; however, less than a third of the dockets audited recorded adequate assessment data (e.g., occupation or living accommodations of patients). The audit noted 90% of records had a physical assessment completed within 24 hr of admission and entries timed, dated, and signed by a nurse. Less than 5% of dockets had evidence of patient teaching, and 13.5% had documented evidence of discharge planning conducted within 72 hr of admission. CONCLUSIONS: This study highlights the weakness in nursing documentation and the need for increased training and continued monitoring of nursing documentation at the hospitals studied. Additional research regarding the factors that affect nursing documentation practice could prove useful. CLINICAL RELEVANCE: The study provides valuable information for the development of strategic risk management programs geared at improving the quality of care delivered to clients and presents an opportunity for nurse leaders to implement structured interventions geared at improving nursing documentation in Jamaica. In light of Jamaica's epidemiologic transition of chronic diseases, gaps in nurses' documentation of client assessment, patient teaching, and discharge planning should be addressed with urgency. Patient teaching and discharge planning enable the clients to participate more effectively in their health maintenance process.

Transient hypoxia drives soil microbial community dynamics and biogeochemistry during human decomposition.

Human decomposition in terrestrial ecosystems is a dynamic process creating localized hot spots of soil microbial activity. Longer-term (beyond a few months) impacts on decomposer microbial communities are poorly characterized and do not typically connect microbial communities to biogeochemistry, limiting our understanding of decomposer communities and their functions. We performed separate year-long human decomposition trials, one starting in spring, another in winter, integrating bacterial and fungal community structure and abundances with soil physicochemistry and biogeochemistry to identify key drivers of microbial community change. In both trials, soil acidification, elevated microbial respiration, and reduced soil oxygen concentrations occurred. Changes in soil oxygen concentrations were the primary driver of microbial succession and nitrogen transformation patterns, while fungal community diversity and abundance was related to soil pH. Relative abundance of facultative anaerobic taxa (Firmicutes and Saccharomycetes) increased during the period of reduced soil oxygen. The magnitude and timing of the decomposition responses were amplified during the spring trial relative to the winter, even when corrected for thermal inputs (accumulated degree days). Further, soil chemical parameters, microbial community structure, and fungal gene abundances remained altered at the end of 1 year, suggesting longer-term impacts on soil ecosystems beyond the initial pulse of decomposition products.

Severe Maternal Morbidity: The Impact of Race on Tricare Beneficiaries.

Maternal morbidity and mortality rates in the United States have increased in the last two decades with a disproportionate impact on women of color. While numerous factors contribute to the inequities in pregnancy-related mortality, access to health insurance is among the most significant. Military Tricare models universal health care access; however, in studies looking at births in military treatment facilities, disparities still exist for women of color. This study analyzed maternal delivery outcomes for all women with Tricare coverage, including deliveries in the civilian sector. We analyzed data from 6.2 million births in the Centers for Disease Control (CDC) Wide-ranging Online Data for Epidemiology Research (WONDER) Linked Birth/Infant Death Records for 2017-2019. Data included all-cause morbidity (transfusions, perineal lacerations, uterine rupture, unplanned hysterectomy, and ICU admissions), severe maternal morbidity (SMM) excluding lacerations, and SMM excluding transfusion. Risk ratios were calculated by comparing overall maternal morbidity rates between Tricare, Medicaid, self-pay, and private insurance. In addition, risk ratios were calculated between insurance types stratified by race. In conclusion, there is an increased risk for women identifying as racial minorities for SMM and SMM excluding transfusion. While Tricare coverage seems to decrease the risk, the decrease is not significant and disparities in outcomes persist among women identifying as minorities. The risk of severe maternal morbidity remains elevated for women of color despite access to Tricare health insurance.

Uterocervical angle in predicting spontaneous preterm birth: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to compare the uterocervical angles in term and spontaneous preterm birth cohorts and to compare the test characteristics of the uterocervical angle and cervical length in the prediction of spontaneous preterm birth. DATA SOURCES: A systematic search of published literature from January 1, 1945, to May 15, 2022, was performed using the following databases: PubMed, Cochrane Central Register of Controlled Trials, Embase, World Health Organization International Clinical Trials Registry Platform, Web of Science, and ClinicalTrials.gov. The search was not restricted. The references of all relevant articles were reviewed. STUDY ELIGIBILITY CRITERIA: Randomized control trials, nonrandomized control trials, and observational studies were evaluated for primary comparisons. Included studies compared the uterocervical angles in term and spontaneous preterm birth cohorts and compared the uterocervical angle with cervical length in the prediction of spontaneous preterm birth. METHODS: Of note, 2 researchers independently selected studies and evaluated the risk of bias with the Newcastle-Ottawa Scale for cohort and case-control studies. Mean differences and odds ratios were calculated using a random effects model for inclusion and methodological quality. The primary outcomes were uterocervical angle and successful prediction of spontaneous preterm birth. Moreover, posthoc analysis comparing the uterocervical angle and cervical length together was performed. RESULTS: A total of 15 cohort studies with 6218 patients were included. The uterocervical angle was larger in the spontaneous preterm birth cohorts (mean difference, 13.76; 95% confidence interval, 10.61-16.91; P<.00001; I2=90%). Sensitivity and specificity analyses demonstrated lower sensitivities with cervical length alone and uterocervical angle plus cervical length than with uterocervical angle alone. Pooled sensitivities for uterocervical angle and cervical length alone were 0.70 (95% confidence interval, 0.66-0.73; I2=90%) and 0.46 (95% confidence interval, 0.42-0.49; I2=96%), respectively. Pooled specificities for uterocervical angle and cervical length were 0.67 (95% confidence interval, 0.66-0.68; I2=97%) and 0.90 (95% confidence interval, 0.89-0.91; I2=99%), respectively. The areas under the curve for uterocervical angle and cervical length were 0.77 and 0.82, respectively. CONCLUSION: Uterocervical angle alone or with cervical length was not superior to cervical length alone in predicting spontaneous preterm birth.

Resident Trainee Access and Barriers to Routine Health Services in the Military Health System.

OBJECTIVE: Resident physician wellness has been a highly contentious topic in graduate medical education over the past 2 decades. Physicians, including residents and attending physicians, are more likely than other professionals to work through illness and delay necessary healthcare screening appointments. Potential reasons for underutilization of health care include-unpredictable work hours, limited time, concerns about confidentiality, poor support from training programs, and apprehension about the impact on their peers. The goal of this study was to evaluate access to health care amongst resident physicians within a large military training facility. DESIGN: This is an observational study using Department of Defense approved software to distribute an anonymous ten question survey on routine health care practices of residents. The survey was distributed to a total of 240 active-duty military resident physicians at a large tertiary military medical center. RESULTS: One hundred seventy-eight residents completed the survey with a 74% response rate. Residents from 15 specialty areas responded. Compared to male counterparts', female residents were more likely to miss routine scheduled health care appointments to include, behavioral health appointments (54.2% vs 28%, p < 0.01). Female residents were more likely to report that attitudes toward missing clinical duties for health care appointments impacted their decision to start or add to their family more than male coresidents (32.3% vs 18.3%, p = 0.03). Surgical residents are also more likely to miss routine screening appointments or scheduled follow ups than residents in nonsurgical training programs; (84.0-88% compared to 52.4%-62.8%) respectively. CONCLUSIONS: Resident health and wellness have long been an issue, with resident physical and mental health being negatively impacted during residency. Our study notes that residents in the military system also face barriers accessing routine health care. Female surgical residents being the demographic most significantly impacted. Our survey highlights cultural attitudes in military graduate medical education regarding the prioritization of personal health, and the negative impact that can have on residents' utilization of care. Our survey also raises concerns particularly amongst female surgical residents, that these attitudes may impact career advancement, as well as influence their decision to start or add to their families.

Military healthcare system mitigates racial disparities for severe maternal morbidity from preeclampsia.

BACKGROUND: In the United States, Black women die at 2.5 times the rate of White women and 3.5 times the rate of Hispanic women. These racial health care disparities have been largely attributed to access to health care and other social determinants of health. OBJECTIVE: We hypothesize that the Military healthcare system models universal health care access seen in other developed countries and should equalize these rates. STUDY DESIGN: Delivery data from 41 Military treatment facilities across the Department of Defense (Army, Air Force, and Navy) including over 36,000 deliveries from 2019 to 2020 were compiled in a convenience dataset through the National Perinatal Information Center. After aggregation, the parameters of percent of deliveries complicated by Severe Maternal Morbidity and percent of severe maternal morbidity secondary to pre-eclampsia with and without transfusion were calculated. Risk ratios were calculated by race for the resulting summary data. American Indian/Alaska Native were excluded because of limited total number deliveries preventing statistical analyses. RESULTS: Overall, the risk of severe maternal morbidity was increased among Black women compared to White women. The risk of severe maternal morbidity related to pre-eclampsia showed no significant difference among races with or without transfusion. When other races were set as reference group, there was a significant difference for White women, suggesting a protective effect. CONCLUSION: Although women of color still experience overall severe maternal morbidity at higher rates than their White counterparts, TRICARE may have equalized the risk of severe maternal morbidity for deliveries complicated by pre-eclampsia.

Mediastinal Mass Discovered in the Second Trimester, a Rare Presentation of Hodgkin's Lymphoma in Pregnancy.

Newly diagnosed malignancy during pregnancy is rare affecting approximately 1 in 1,000 pregnancies. Breast followed by hematologic malignancies are most common. Hodgkin's lymphoma (HL) is a lymphoid neoplasm which can present with lymphadenopathy or mediastinal mass and represents 6% of all malignancies diagnosed during pregnancy. Treatment involves a combination of chemotherapy with or without adjuvant radiation which poses significant challenges when diagnosed antepartum. We highlight a 28-year-old primigravida at 26 weeks gestation who presented to the emergency department in Japan with cough, dyspnea, and sore throat for 3-5 days. Initial chest radiography demonstrated a large perihilar mass with mediastinal shift. Follow-up CT chest revealed an anterior mediastinal mass measuring 8 cm × 19 cm × 16 cm with features concerning for aggressive lymphoma. The patient was subsequently transferred to a stateside tertiary care center for expedited workup. She underwent two core needle biopsies, both of which were non-diagnostic. Cardiothoracic surgery performed a cervical mediastinoscopy with excision of the enlarged right supraclavicular lymph node. Pathologic analysis revealed classical HL, nodular sclerosis subtype. Treatment was initiated with adriamycin, bleomycin, vinblastine, and dacarbazine with two cycles planned antepartum followed by additional cycles postpartum. The patient had an uncomplicated vaginal delivery at 38 weeks gestation. Diagnosis of HL in pregnancy is rare, and expedited diagnosis can be challenging as multiple diagnostic and treatment modalities may impact pregnancy. Management in pregnancy requires a multidisciplinary approach, and decisions regarding treatment and delivery timing should be weighed against risk to the fetus.

Increased maternal morbidity and mortality among Asian American and Pacific Islander women in the military health system.

BACKGROUND: Rates of maternal morbidity and mortality experienced by women in the United States have been shown to vary significantly by race, most commonly attributed to differences in access to healthcare and socioeconomic status. Recent data showed that Asian Pacific Islanders have the highest rate of maternal morbidity despite having a higher socioeconomic status. In the military, women of all races are granted equal access to healthcare, irrespective of socioeconomic class. We hypothesized that within the military, there would be no racial disparities in maternal outcomes because of universal healthcare. OBJECTIVE: This study aimed to evaluate if universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of racial or ethnic background. STUDY DESIGN: This was a retrospective cohort study of data from the National Perinatal Information Center reports obtained from participating military treatment facilities from April 2019 to March 2020 and included 34,025 deliveries. We compared racial differences in the incidence of each of the following 3 outcomes: postpartum hemorrhage, severe maternal morbidity among women with postpartum hemorrhage including transfusion, and severe maternal morbidity among women with postpartum hemorrhage excluding transfusion. RESULTS: A total of 41 military treatment facilities (a list of participating military treatment facilities are provided in the Appendix) provided data that were included. There was an increased rate of postpartum hemorrhage (relative risk, 1.73; 95% confidence interval, 1.45-2.07), severe maternal morbidity including transfusion (relative risk, 1.22; 95% confidence interval, 0.93-1.61), and severe maternal morbidity excluding transfusion (relative risk, 1.97; 95% confidence interval, 1.02-3.8) among Asian Pacific Islander women when compared with Black or White women. CONCLUSION: Even with equal access to healthcare in the military, Asian Pacific Islander women experience statistically significant increased rates of postpartum hemorrhage and severe maternal morbidity excluding transfusion when compared with Black or White women. The increased rates of severe maternal morbidity including transfusion were not statistically significant.

Peripartum cardiomyopathy and acute fatty liver of pregnancy: one patient with two zebras.

OBJECTIVE: Peripartum cardiomyopathy (PPCM) and acute fatty liver of pregnancy (AFLP) are rare complications of pregnancy affecting approximately 1/10,000 pregnancies each. We describe a patient who had biopsy-proven AFLP complicated by PPCM. METHODS: Chart review and literature search. RESULTS: The patient is a 22-year-old G5P1213 obese African-American female who presented at 30 weeks gestation with abdominal pain. She had normal blood pressures and mildly elevated liver enzymes. After completion of a 24 hour urine protein collection that was consistent with pre-eclampsia, an induction of labor with uncomplicated vaginal delivery was accomplished. Following delivery, a computed tomography scan of the abdomen revealed significant cardiomegaly. An echocardiogram revealed global dysfunction with an ejection fraction of 10%. Liver biopsy showed AFLP. Attempts to establish a unifying etiology were unrevealing. The PPCM was treated with diuretics and intravenous immunoglobulin. The patient's clinical status deteriorated, eventually requiring continuous dialysis, intubation, pharmacologic and mechanical inotropic support, and a feeding tube. The patient was discharged to a long-term care facility where she subsequently passed away from multiorgan failure. CONCLUSION: AFLP and PPCM are rare complications of pregnancy. We present a patient who had both. Both diseases carry a high mortality rate, and together, are likely fatal.

Breaking Barriers with Bread: Using the Sourdough Starter Microbiome to Teach High-Throughput Sequencing Techniques.

Widespread usage of high-throughput sequencing (HTS) in the LIFE SCIENCES has produced a demand for undergraduate and graduate institutions to offer classes exposing students to all aspects of HTS (sample acquisition, laboratory work, sequencing technologies, bioinformatics, and statistical analyses). Despite the increase in demand, many challenges exist for these types of classes. We advocate for the usage of the sourdough starter microbiome for implementing meta-amplicon sequencing. The relatively small community, dominated by a few taxa, enables potential contaminants to be easily identified, while between-sample differences can be quickly statistically assessed. Finally, bioinformatic pipelines and statistical analyses can be carried out on personal student laptops or in a teaching computer lab. In two semesters adopting this system, 12 of 14 students were able to effectively capture the sourdough starter microbiome, using the instructor's paired sample as reference.

Preterm vs term delivery in antenatally diagnosed gastroschisis: a systematic review and meta-analysis.

OBJECTIVE: To review the evidence regarding gestational age at birth, length of stay, sepsis incidence, days on mechanical ventilation, and mortality between preterm and term deliveries in pregnancies complicated by gastroschisis. DATA SOURCES: We conducted database searches of PubMed, Cochrane Central Register of Controlled Trials, Embase, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov without language restrictions through August 16, 2021. References of all relevant articles were reviewed. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, nonrandomized controlled trials, and observational studies were evaluated comparing length of stay, sepsis, days on mechanical ventilation, and mortality between either elective preterm delivery and expectant management (Group 1) or preterm gestational age and term gestational age (Group 2). METHODS: Two researchers independently selected studies and evaluated risk of bias with the Risk of Bias 2 tool for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. Mean differences and odds ratios were calculated using a random-effects model for inclusion and methodological quality. The primary outcome was length of stay. Secondary outcomes were incidence of sepsis, mortality, days on mechanical ventilation, and gestational age. RESULTS: Thirty studies with a total of 7409 patients were included in the systematic review, of which 25 were included in the analysis. Group 1 studies found no difference in length of stay or mortality and a trend toward fewer days on mechanical ventilation (mean difference, -0.40; 95% confidence interval, -0.89 to -0.10; P=.12; I2=35%). Subgroup analysis excluding premature delivery demonstrated lower sepsis incidence in elective preterm delivery (odds ratio, 0.46; 95% confidence interval, 0.25-0.84; P=.01; I2=0%). Group 2 studies found increased length of stay (mean difference, 15.44; 95% confidence interval, 8.44-21.83; P<.00001; I2=94%), sepsis (odds ratio, 1.69; 95% confidence interval, 1.15-2.50; P=.008; I2=51%), days on mechanical ventilation (mean difference, 1.38; 95% confidence interval, 0.10-2.66; P=.03; I2=66%), and mortality (odds ratio, 2.97; 95% confidence interval, 1.59-5.55; P=.0007; I2=0%). Gestational age was significantly lower in Group 2 studies than in Group 1 studies. CONCLUSION: Data continue to be conflicting, but subgroup analysis suggested a possible reduction in sepsis incidence and mean days on mechanical ventilation with elective early term delivery.

Interrupted versus continuous magnesium sulfate and blood loss at cesarean delivery.

OBJECTIVE: Magnesium sulfate is standard of care for prevention of eclampsia in women with preeclampsia with severe features. The American College of Obstetrics and Gynecology endorses its use throughout labor, delivery and the immediate postpartum period. Some providers pause magnesium sulfate infusion preoperatively due to concern for increased risk of uterine atony and postpartum hemorrhage. Using a non-inferiority analysis, we investigated the effect of interrupted versus continuous infusion of magnesium sulfate on postpartum hemorrhage in women with preeclampsia with severe features undergoing cesarean delivery. STUDY DESIGN: Retrospective non-inferiority cohort study of women with preeclampsia with severe features treated with magnesium sulfate undergoing cesarean delivery with singleton pregnancies at tertiary care hospital from 2013 to 2018. The primary outcome was postpartum hemorrhage. Secondary outcomes included estimated blood loss, change in hematocrit and a composite of postpartum hemorrhage severity, including transfusion of blood products, use of more than one uterotonic and additional surgical interventions. RESULTS: Of 249 women, magnesium sulfate infusion was interrupted in 171 (69%) and continued in 78 (31%). Women with interrupted magnesium sulfate infusion were more likely to be Caucasian (73% vs 67%, p = .024), have chronic hypertension (23% vs 1%, p < .001), labor prior to cesarean delivery (84% vs 55%, p < .001), undergo primary cesarean delivery (86% vs 67%, p = .005), and experience shorter surgical time (50 vs 55 min, p = .026). The rate of postpartum hemorrhage for those receiving interrupted magnesium sulfate infusion (9.9%) and continuous magnesium sulfate infusion (10.2%) was similar, falling within the non-inferiority margin (absolute difference 0.3%, 95% CI -7.8 to 8.4%, p = .88). There were no significant differences in the secondary outcomes. CONCLUSION: Interrupted magnesium sulfate infusion is non-inferior to continued magnesium sulfate infusion for rates of postpartum hemorrhage in women with preeclampsia with severe features undergoing cesarean delivery.