Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal.

BACKGROUND: Although clinicians have traditionally used the Finnegan Neonatal Abstinence Scoring Tool to assess the severity of neonatal opioid withdrawal, a newer function-based approach - the Eat, Sleep, Console care approach - is increasing in use. Whether the new approach can safely reduce the time until infants are medically ready for discharge when it is applied broadly across diverse sites is unknown. METHODS: In this cluster-randomized, controlled trial at 26 U.S. hospitals, we enrolled infants with neonatal opioid withdrawal syndrome who had been born at 36 weeks' gestation or more. At a randomly assigned time, hospitals transitioned from usual care that used the Finnegan tool to the Eat, Sleep, Console approach. During a 3-month transition period, staff members at each hospital were trained to use the new approach. The primary outcome was the time from birth until medical readiness for discharge as defined by the trial. Composite safety outcomes that were assessed during the first 3 months of postnatal age included in-hospital safety, unscheduled health care visits, and nonaccidental trauma or death. RESULTS: A total of 1305 infants were enrolled. In an intention-to-treat analysis that included 837 infants who met the trial definition for medical readiness for discharge, the number of days from birth until readiness for hospital discharge was 8.2 in the Eat, Sleep, Console group and 14.9 in the usual-care group (adjusted mean difference, 6.7 days; 95% confidence interval [CI], 4.7 to 8.8), for a rate ratio of 0.55 (95% CI, 0.46 to 0.65; P<0.001). The incidence of adverse outcomes was similar in the two groups. CONCLUSIONS: As compared with usual care, use of the Eat, Sleep, Console care approach significantly decreased the number of days until infants with neonatal opioid withdrawal syndrome were medically ready for discharge, without increasing specified adverse outcomes. (Funded by the Helping End Addiction Long-term (HEAL) Initiative of the National Institutes of Health; ESC-NOW ClinicalTrials.gov number, NCT04057820.).

The Influence of Mediators on the Relationship Between Antenatal Opioid Agonist Exposure and the Severity of Neonatal Opioid Withdrawal Syndrome.

OBJECTIVES: (1) To evaluate the direct (un-mediated) and indirect (mediated) relationship between antenatal exposure to opioid agonist medication as treatment for opioid use disorder (MOUD) and the severity of neonatal opioid withdrawal syndrome (NOWS), and (2) to understand the degree to which mediating factors influence the direct relationship between MOUD exposure and NOWS severity. METHODS: This cross-sectional study includes data abstracted from the medical records of 1294 opioid-exposed infants (859 MOUD exposed and 435 non-MOUD exposed) born at or admitted to one of 30 US hospitals from July 1, 2016, to June 30, 2017. Regression models and mediation analyses were used to evaluate the relationship between MOUD exposure and NOWS severity (i.e., infant pharmacologic treatment and length of newborn hospital stay (LOS)) to identify potential mediators of this relationship in analyses adjusted for confounding factors. RESULTS: A direct (un-mediated) association was found between antenatal exposure to MOUD and both pharmacologic treatment for NOWS (aOR 2.34; 95%CI 1.74, 3.14) and an increase in LOS (1.73 days; 95%CI 0.49, 2.98). Delivery of adequate prenatal care and a reduction in polysubstance exposure were mediators of the relationship between MOUD and NOWS severity and as thus, were indirectly associated with a decrease in both pharmacologic treatment for NOWS and LOS. CONCLUSIONS FOR PRACTICE: MOUD exposure is directly associated with NOWS severity. Prenatal care and polysubstance exposure are potential mediators in this relationship. These mediating factors may be targeted to reduce the severity of NOWS while maintaining the important benefits of MOUD during pregnancy.

Factors Related to Patients' Self-care and Self-care Confidence in Korean Patients With Heart Failure and Their Caregivers: A Cross-sectional, Correlational Study.

BACKGROUND: The relationships of patient factors and caregiver contribution to patients' self-care to different types of self-care have been rarely examined in Korean patients with heart failure. OBJECTIVE: The aim of this study was to examine patient (ie, age, depressive symptoms, and self-care confidence) and caregiver (ie, caregiver contribution to self-care maintenance and self-care management, and caregiver confidence in contributing to self-care) factors related to different types of self-care (ie, self-care maintenance, symptom perception, and self-care management) and self-care confidence in Korean patients with heart failure. METHODS: In this cross-sectional, correlational study, data from 41 pairs of patients (mean age, 68.0 years) and caregivers (mean age, 54.1 years) were collected and analyzed using multiple regression. RESULTS: Higher levels of self-care confidence in patients were related to higher levels of self-care maintenance in patients. Higher levels of self-care confidence in patients were related to higher levels of symptom perception. Higher levels of self-care confidence in patients and caregiver contribution to self-care maintenance were related to higher levels of self-care management. Less severe depressive symptoms in patients and higher levels of caregiver confidence in contributing to self-care were related to higher levels of self-care confidence. CONCLUSION: Different patient and caregiver factors were related to different types of self-care and self-care confidence in Korean patients, but patients' self-care confidence was related to all types of self-care. Clinicians and researchers need to develop and deliver effective interventions to both patients and their caregivers to improve patients' self-care confidence and, in turn, self-care, considering different factors associated with each type of self-care.

Assessing work role strain, burnout, and job satisfaction among remotely piloted aircraft operators: the moderating role of unit social support.

Utilizing the Job Demands-Resources (JD-R) theory as a guiding framework, the current study examined the relationships between job demands (work role strain) and occupational outcomes (burnout and job satisfaction) and assessed how job resources (team member social support and leader social support) mitigated the impact of high job demands for U.S. Air Force remotely piloted aircraft (RPA) operators. A total of 905 active duty U.S. Air Force RPA operators participated in a web-based occupational health assessment. Study findings confirmed that work role strain proved to be strongly related to negative occupational outcomes - increased burnout and reduced job satisfaction. Compelling evidence emerged suggesting that boosting job resources (i.e., team member and leader social support) may be a promising point of intervention to mitigate negative occupational outcomes. By investigating ongoing job demands that result in a higher incidence of burnout and job dissatisfaction, as well as job resources that protect against burnout and job dissatisfaction, researchers and practitioners can continue to introduce supportive resources at crucial points to alleviate the adverse consequences of occupational stress and burnout. Applying the JD-R theory to these findings highlights the importance of job resources for RPA operators and other employees working in high-risk, high-demand career fields. Implications and future directions are discussed.

Measuring and controlling medical record abstraction (MRA) error rates in an observational study.

BACKGROUND: Studies have shown that data collection by medical record abstraction (MRA) is a significant source of error in clinical research studies relying on secondary use data. Yet, the quality of data collected using MRA is seldom assessed. We employed a novel, theory-based framework for data quality assurance and quality control of MRA. The objective of this work is to determine the potential impact of formalized MRA training and continuous quality control (QC) processes on data quality over time. METHODS: We conducted a retrospective analysis of QC data collected during a cross-sectional medical record review of mother-infant dyads with Neonatal Opioid Withdrawal Syndrome. A confidence interval approach was used to calculate crude (Wald's method) and adjusted (generalized estimating equation) error rates over time. We calculated error rates using the number of errors divided by total fields ("all-field" error rate) and populated fields ("populated-field" error rate) as the denominators, to provide both an optimistic and a conservative measurement, respectively. RESULTS: On average, the ACT NOW CE Study maintained an error rate between 1% (optimistic) and 3% (conservative). Additionally, we observed a decrease of 0.51 percentage points with each additional QC Event conducted. CONCLUSIONS: Formalized MRA training and continuous QC resulted in lower error rates than have been found in previous literature and a decrease in error rates over time. This study newly demonstrates the importance of continuous process controls for MRA within the context of a multi-site clinical research study.

Detection of Fetal Anomalies by Remotely Directed and Interpreted Ultrasound (Teleultrasound): A Randomized Noninferiority Trial.

OBJECTIVE: To determine the accuracy and reliability of remotely directed and interpreted ultrasound (teleultrasound) as compared with standard in-person ultrasound for the detection of fetal anomalies, and to determine participants' satisfaction with teleultrasound. STUDY DESIGN: This was a single-center, randomized (1:1) noninferiority study. Individuals referred to the maternal-fetal medicine (MFM) ultrasound clinic were randomized to standard in-person ultrasound and counseling or teleultrasound and telemedicine counseling. The primary outcome was major fetal anomaly detection rate (sensitivity). All ultrasounds were performed by registered diagnostic medical sonographers and interpretations were done by a group of five MFM physicians. After teleultrasound was completed, the teleultrasound patients filled out a satisfaction survey using a Likert scale. Newborn data were obtained from the newborn record and statewide birth defect databases. RESULTS: Of 300 individuals randomized in each group, 294 were analyzed in the remotely interpreted teleultrasound group and 291 were analyzed in the in-person ultrasound group. The sensitivity of sonographic detection of 28 anomalies was 82.14% in the control group and of 20 anomalies in the telemedicine group, it was 85.0%. The observed difference in sensitivity was 0.0286, much smaller than the proposed noninferiority limit of 0.05. Specificity, negative predictive value, positive predictive value, and accuracy were more than 94% for both groups. Patient satisfaction was more than 95% on all measures, and there were no significant differences in patient satisfaction based on maternal characteristics. CONCLUSION: Teleultrasound is not inferior to standard in-person ultrasound for the detection of fetal anomalies. Teleultrasound was uniformly well received by patients, regardless of demographics. These key findings support the continued expansion of telemedicine services. KEY POINTS: · For detection of major anomalies, teleultrasound is comparable to standard ultrasound.. · Teleultrasound was well accepted by patients.. · Teleultrasound use should be expanded..

Examination of a Stillbirth Workup: A Rural Statewide Experience.

OBJECTIVE: The objective of our study was to determine whether recommended assessments were conducted on stillbirths delivered in our predominantly rural state. METHODS: This was a descriptive study of stillbirths delivered in a rural state and included in one site of the Birth Defects Study to Evaluate Pregnancy Exposures stillbirth study. Hospital and fetal death records were examined to determine whether the following areas were evaluated: genetic testing (noninvasive perinatal testing, quad screen, amniocentesis/chorionic villus sampling with karyotype, microarrays, fetal tissue specimen), placenta/membrane/cord sent for pathologic examination, examination of the stillbirth after delivery by the healthcare provider, and fetal autopsy was performed. RESULTS: From July 1, 2015 to June 30, 2020, there were 1108 stillbirths delivered in Arkansas. The most frequent assessments undertaken were placental pathology (72%), genetic testing (67%), fetal inspection (31%), and autopsy (13%). All four assessments were done in 2% of stillbirth cases, three assessments in 27%, two assessments in 47%, one assessment in 14%, and no assessment in 15%. There was no association between stillbirth assessment evaluation by gestational age (<28 weeks and > 28 weeks; P = 0.221); however, there was an overall association between hospital delivery volume with number of components completed (P < 0.0001). Hospitals with >2000 deliveries had a higher proportion of three or four completions compared with those hospitals with <1000 deliveries or 1000 to 2000 deliveries (P = 0.021 and P < 0.0001). CONCLUSIONS: Fetal stillbirth assessment is suboptimal in our rural state, with 15% of stillbirths having no assessment and only 2% having all four assessments. There is no association between stillbirth assessment and gestational age (<28 weeks vs >28 weeks), but there is a correlation between delivery volume and stillbirth assessment.

Peripartum Hypertensive Crisis Simulation and Education Initiative among Rural Emergency Departments.

OBJECTIVE: To determine whether the introduction of hypertensive bundles through simulation and education would result in the timely assessment and treatment of a simulated patient in a peripartum hypertensive crisis. METHODS: This prospective observational pilot study evaluates the use of simulation and education on hypertension bundled care for peripartum patients in eight rural hospitals. Unannounced simulation exercises were conducted at each hospital. Emergency department staff response was assessed with a checklist. Primary outcomes included time to first antihypertensive medication administered, time to registered nurse assessment, and time to physician assessment. After the initial simulation, nurse educators conducted an in-person didactic on the management of peripartum hypertensive crisis, providing each hospital with materials for local bundle initiation and implementation for hypertensive emergency. The nurse educators conducted the same simulation at the individual sites 3 to 4 months later. Time of intervention improvement pre- and posteducation training scores were analyzed for each of these using a paired t test followed by a Wilcoxon signed-rank test. The average time of intervention improvement among delivering hospitals versus nondelivering hospitals was compared. RESULTS: Eight training simulation and training sessions were conducted at four delivering and four nondelivering hospitals. Seventy-three healthcare workers attended training. The average time decreased from pre- to postsimulation at all of the hospitals (this was not statistically significant, however). The average reduction in time for first nurse assessment was 1.25 ± 10.05 minutes (P = 0.99). The average reduction in time to physician assessment was 4.88 ± 14.74 minutes (P = 0.45). The average reduction of time to administration of first hypertensive medication was 12.0 ± 25.79 minutes (P = 0.15). The average times for nurse or physician assessment and time to first hypertension medication administration were similar between delivering and nondelivering hospitals. CONCLUSIONS: Our study demonstrates a trend toward improved treatment of a peripartum hypertensive emergency through bundled care and simulation. The training reduced the time to first medication given and improved the selection process for the preferred hypertensive medication. The time from nurse care to physician assessment also was reduced. Education in bundled peripartum hypertension care may improve patient outcomes by decreasing hypertension-related maternal morbidity and mortality.

Placental location site and adverse antepartum pregnancy complications: a meta-analysis and review of the literature.

PURPOSE: The purpose to the study was to determine the relationship, if any, between the placental location site and antepartum complications of pregnancy. METHODS: A University research librarian conducted a comprehensive literature search using the search engines PubMed and Web of Science. The search terms were "placental location" AND "pregnancy complications" OR "perinatal complications. There were no limits put on the years of the search. RESULTS: The search identified 110 articles. After reviewing all the abstracts, relevant full articles, and references of full articles, there were 22 articles identified specific to antepartum complications. Central + fundal locations compared to all lateral were associated with a lower risk of hypertension during pregnancy RR = 0.47, 95% CI: 0.31-0.71]. Central location compared to all lateral was also associated with lower risk of hypertension during pregnancy [RR = 0.39, 95% CI: 0.26-0.59]. Placenta locations in the lower uterine segment were associated with greater risk of antepartum hemorrhage (APH) [RR = 2.99, 95% CI: 1.16-7.75] compared to above the lower uterine segment. No differences were observed in placental locations and gestational diabetes (GDM), preterm prelabor rupture of membranes (PPROM), preterm delivery (PTD) or on a placental abruption. CONCLUSION: Central and fundal location sites and central location alone decreased the risk of hypertension during pregnancy. Low uterine segment location sites increased the risk for APH. There were no effects of placenta location sites on the development of GDM, PPROM, PTD or abruption.

A neuromuscular-based analysis of the open payments program.

INTRODUCTION: In August 2013, the Centers for Medicare and Medicaid Services (CMS) Open Payments Program (OPP) made eligible payment information publicly available. Data about industry payments to neuromuscular neurologists are lacking. METHOD: Financial relationships were investigated between industry and US neuromuscular neurologists from January 2014 through December 2018 using the CMS OPP database. RESULTS: The total annual payments increased more than 6-fold during the study period. The top 10% of physician-beneficiaries collected 80% to 90% of total industry payments except in 2014. In 2018, the most common drugs associated with payments to neuromuscular neurologists were nusinersen, vortioxetine, eteplirsen, alglucosidase alpha, edaravone, and intravenous immunoglobulin. DISCUSSION: A substantial increase in the annual payments to neuromuscular physicians during the study period is likely due to the development of new treatments, including gene therapy.

Accuracy and Completion Rate of the Fetal Anatomic Survey in the Super Obese Parturient.

OBJECTIVE: To determine the completion rate of ultrasound in with a body mass index (BMI) ≥ 50 to women with BMI 18.5 to 29.9. STUDY DESIGN: This study was a retrospective cohort study. Women with a singleton pregnancy, age 18 to 45 with a BMI ≥50 that delivered between 2013-2016 were compared to women with a BMI 18.5 to 29.9 during that same time period to assess the accuracy and, as a second aim, the completion rate of the fetal anatomic survey. Data were analyzed using two-sample t test, chi-square test, or logistic regression as appropriate. RESULTS: Eighty-one cases with a BMI ≥50 were compared with 81 patients with a BMI 18.5 to 29.9. Maternal demographics and timing (gestational age) at the time of the ultrasound were similar between groups. In women with a BMI 18.5 to 29.9, completion of anatomy was 58% of the time with the first ultrasound, 81% with second ultrasound, and 84% with the third ultrasound. In women with BMI ≥50, completion of anatomy was 10% of the time with the first ultrasound, 33% with the second ultrasound, and 42% with the third ultrasound. Each time frame was statistically significant. Agreement level on the accuracy to detect fetal anomalies between groups were not statistically significant between the groups. CONCLUSION: In women with a BMI ≥50 compared to women with BMI of 18.8 to 29.9, more ultrasounds are needed to complete the anatomic survey although overall accuracy in fetal anomaly detection is similar.

Cesarean Delivery Management of Stillbirth: In-Depth Analysis of 75 Cases in a Rural State.

OBJECTIVE: To analyze the characteristics surrounding women who underwent cesarean delivery for stillbirth management in the rural, southern US state of Arkansas. METHODS: This was a planned secondary analysis of a retrospective descriptive study evaluating mode of delivery following the stillbirth of singleton pregnancies without anomalies or aneuploidy delivered in our state between July 2015 and June 2019. Data were extracted from a statewide reproductive health monitoring system and reviewed by the first three authors. Summary statistics were presented as means and standard deviations for continuous measures and frequencies and percentages for categorical variables. RESULTS: There were 861 patients diagnosed as having stillbirth between July 2015 and June 2019 in 44 hospitals in Arkansas. Seventy-five of those patients (8.7%) underwent cesarean delivery and are the basis for this analysis. Common indications for cesarean delivery were prior cesarean delivery (41%), malpresentation (18.7%), and abruption or hemorrhage (13.1%). Sixty-five percent of patients had a prior cesarean delivery. The most common complications were infection and hemorrhage, which accounted for 64.3% of known complications. The overall complication rate was 18.7% among stillbirths delivered via cesarean. CONCLUSIONS: This study demonstrates that cesarean delivery remains a common mode of delivery for management of stillbirth and that there is maternal morbidity associated with an abdominal delivery because 22.7% of the women undergoing a cesarean had an operative complication. It also highlights that prior cesarean delivery remains a common indication for a repeat abdominal delivery following a stillbirth despite the lack of fetal benefit.

Evidence for Prophylactic Transfusion during Pregnancy for Women with Sickle Cell Disease.

The objective of this study was to examine prior studies on maternal and neonatal outcomes with prophylactic compared with emergent blood transfusion in pregnant women with sickle cell disease. A review of the literature was performed. Twenty-one articles were identified and included in the analysis. A generalized linear mixed-effects model was used to analyze the outcomes. Pregnancy outcomes assessed were preeclampsia, pneumonia, pyelonephritis, pain crises, intrauterine growth restriction, neonatal death, perinatal death, and maternal mortality. Women who underwent emergent transfusion were more likely than women who underwent prophylactic transfusion to have the following adverse perinatal outcomes: preterm delivery (adjusted odds ratio [aOR 2.04], 95% confidence interval [CI] 1.14-3.63), pneumonia (aOR 2.98, 95% CI 1.44-6.15), pain crises (aOR 1.67, 95% CI 1.18-2.38), and perinatal death (aOR 1.84, 95% CI 1.06-3.07). Prophylactic transfusion should be reexamined as a potentially beneficial approach to the management of sickle cell disease in pregnancy.

Assessing the Feasibility of an Online Training Designed to Enable Community Health Workers to Deliver a Comprehensive, Evidence-Based Weight Loss Intervention for Rural African Americans of Faith.

Obesity is a critical modifiable risk factor in cancer prevention, control, and survivorship. Comprehensive weight loss interventions (e.g., Diabetes Prevention Program (DPP)) have been recommended by governmental agencies to treat obesity. However, their high implementation costs limit their reach, especially in underserved African American (AA) communities. Community health workers (CHWs) or trusted community members can help increase access to obesity interventions in underserved regions facing provider shortages. CHW-led interventions have increased weight loss. However, in-person CHW training can be costly to deliver and often requires extensive travel to implement. Web-based trainings have become common to increase reach at reduced cost. However, the feasibility of an online CHW training to deliver the DPP in AAs is unknown. The feasibility of an online CHW training to deliver the DPP adapted for AAs was assessed. The online training was compared to an in-person DPP training with established effectiveness. CHW effectiveness and satisfaction were assessed at baseline and 6 weeks. Nineteen participants (in-person n = 10; online n = 9) were recruited. At post-training, all scored higher than the 80% on a knowledge test required to deliver the intervention. All participants reported high levels of training satisfaction (88.9% of online participants and 90% of in-person participants rated the training as at least 6 on a 1-7 scale) and comfort to complete intervention tasks (78% of online participants and 60% of in-person participants scored at least 6 on a 1-7 scale). There were no significant differences in outcomes by arm. An online CHW training to deliver the DPP adapted for AAs faith communities produced comparable effectiveness and satisfaction to an evidence-based in-person CHW training. Further research is needed to assess the cost-effectiveness of different CHW training modalities to reduce obesity.

Associations of Advance Directive Knowledge, Attitudes, and Barriers/Benefits With Preferences for Advance Treatment Directives Among Patients With Heart Failure and Their Caregivers.

BACKGROUND: Patients with heart failure (HF) have not been considered as major beneficiaries of advance directives (ADs). We analyzed factors affecting the preferences for the adoption of ADs by patients with HF and their caregivers. METHODS AND RESULTS: Seventy-one patient (mean age: 68 years)-caregiver (mean age: 55 years) dyads were enrolled during clinic visits for routine care at a single institution and completed questionnaires during in-person visits. Cohen's kappa coefficients and generalized estimating equation models were used to analyze the data. The agreement on dyadic perspectives for aggressive treatments was poor or fair, whereas agreement relative to hospice care was moderate (k = 0.42, 95% confidence interval = 0.087-0.754). Both patients and caregivers demonstrated poor knowledge of ADs and similar levels of perceived benefits and barriers to advance care planning. However, the caregivers had more positive attitudes toward ADs than patients. Patients and caregivers who were older and/or males had greater odds of preferring aggressive treatments and/or hospice care. Further, those with depressive symptoms had lower odds of preferring hospice care. CONCLUSION: The dyadic agreement was moderately high only for hospice care preferences. Both patients and caregivers demonstrated knowledge of shortfalls regarding ADs. Timely AD discussions could increase dyadic agreement and enhance informed and shared decision-making regarding medical care.

Accuracy of the Ultrasound Estimate of the Amniotic Fluid Volume (Amniotic Fluid Index and Single Deepest Pocket) to Identify Actual Low, Normal, and High Amniotic Fluid Volumes as Determined by Quantile Regression.

OBJECTIVES: To identify abnormal amniotic fluid volumes (AFVs), normal volumes must be determined. Multiple statistical methods are used to define normal amniotic fluid curves; however, quantile regression (QR) is gaining favor. We reanalyzed ultrasound estimates in identifying oligohydramnios, normal fluid, and polyhydramnios using normal volumes calculated by QR. METHODS: Data from 506 dye-determined or directly measured AFVs along with ultrasound estimates were analyzed. Each was classified as low, normal, or high for both the single deepest pocket (SDP) and amniotic fluid index (AFI). A weighted κ statistic was used to assess the level of agreement between the AFI and SDP compared to actual AFVs by QR. RESULTS: The overall level of agreement for the AFI was fair (κ = 0.26), and that for the SDP was slight (κ = 0.19). Although not statistically significant (P = .792), the positive predictive value to classify a low volume using the AFI was lower compared to the SDP (35% vs 43%). The positive predictive value for a high volume was higher using the AFI compared to the SDP (55% versus 31%) but not statistically significant. The missed-call rate for high-volume identification by the SDP versus AFI was statistically significant (odds ratio, 5.5; 95% confidence interval, 2.04-14.97). The missed-call rate for low-volume identification by the AFI versus SDP was not statistically significant (odds ratio, 3.3; 95% confidence interval, 0.96-11.53). CONCLUSIONS: Both the AFI and SDP identify actual normal AFVs by QR, with sensitivity higher than 90%. The SDP is superior for identification of oligohydramnios, and the AFI superior for identification of polyhydramnios.

Hospital Annual Delivery Volume and Presence of Graduate Medical Education Influence Mode of Delivery after Stillbirth.

OBJECTIVES: To evaluate the statewide experience in mode of delivery for pregnancies complicated by stillbirth by annual delivery volume and presence of graduate medical education programs. METHODS: This is a descriptive study of all stillbirths without known congenital anomalies or aneuploidy born in our state from July 1, 2015 to June 30, 2019. Stillbirths were ascertained by the State Reproductive Health Monitoring System, a population-based surveillance system. Stillbirths were identified by the State Reproductive Health Monitoring System from medical facilities and fetal death certificates; trained staff abstracted records. All of the stillbirths with a gestational age of >20 weeks or a birth weight of >500 g if birth weight was unknown and without congenital anomalies or aneuploidy were eligible for this study. RESULTS: There were 861 stillbirths from July 2015 through June 2019, 75 (8.7%) of which were delivered by cesarean section. Low-volume hospitals (<1000 deliveries) experienced a higher proportion of their stillbirths delivered by cesarean compared with high-volume hospitals (>1000 deliveries; 13.4% vs 5.5%; P < 0.0001). Before adjusting for maternal characteristics, stillbirths delivered at high-volume hospitals had a 59% lower risk of delivery by cesarean section compared with those delivered at low-volume hospitals (relative risk [RR] 0.41, 95% confidence interval 0.20-0.86, P = 0.02). The cesarean cohort had a higher proportion of Black mothers (44% vs 31.3%, P = 0.025), greater parity (P < 0.0001), and greater gravidity (P < 0.0001) compared with the vaginal group. The gestational age at delivery for stillbirths delivered by cesarean was much higher compared with those who were delivered vaginally (34.8 weeks vs 28.6 weeks; P < 0.0001). The RR of the cesarean delivery of a stillbirth at teaching institutions compared with nonteaching institutions was significantly reduced (RR 0.45, 95% confidence interval 0.28-0.73, P = 0.0011). CONCLUSIONS: Annual hospital delivery volumes and residency teaching programs in obstetrics influence the mode of delivery in the management of stillbirth. Advancing gestational age, Black race, and parity are associated with an increased risk of cesarean delivery after stillbirth.

Prediction of Heart Failure Symptoms and Health-Related Quality of Life at 12 Months From Baseline Modifiable Factors in Patients With Heart Failure.

BACKGROUND: In patients with heart failure (HF), good health-related quality of life (HRQOL) is as valuable as, or more valuable than, longer survival. However, HRQOL is remarkably poor, and HF symptoms are strongly associated with poor HRQOL. Yet, the multidimensional, modifiable predictors have been rarely examined. OBJECTIVE: The aim of this study was to examine the baseline psychosocial, behavioral, and physical predictors of HF symptoms and HRQOL at 12 months and the mediator effect of HF symptoms in the relationship between depressive symptoms and HRQOL. METHODS: We collected data from 94 patients with HF (mean ± SD age, 58 ± 14 years). Data included sample characteristics, depressive symptoms, perceived control, social support, New York Heart Association (NYHA) functional class, medication adherence, sodium intake, self-care management, and HF symptoms at baseline, as well as HF symptoms and HRQOL at 12 months. Multiple regression analyses were performed to address the purpose. RESULTS: Baseline depressive symptoms (P < .001), medication adherence (P = .010), sodium intake (P = .032), and NYHA functional class (P = .040) significantly predicted 12-month HF symptoms, controlling for covariates (F = 7.363, R = 47%, P < .001). Baseline medication adherence (P = .001), NYHA functional class (P < .001), and HF symptoms (P = .013) significantly predicted 12-month HRQOL (F = 10.701, R = 59%, P < .001). Baseline HF symptoms fully mediated the relationship between baseline depressive symptoms and 12-month HRQOL. CONCLUSION: Symptoms of HF and HRQOL could be improved by targeting multidimensional, modifiable predictors, such as self-care, depressive symptoms, and NYHA functional class.

A hands-on resident umbilical cord blood educational curriculum compared to online education of post-residency obstetricians: comparison of the volume of collected cord blood units.

BACKGROUND: Umbilical cord blood unit (CBU) volume is a predictor of its later clinical utility. Many studies suggest the need to increase the volume of CBU collected, but most obstetrical providers receive no formal collection training. STUDY DESIGN AND METHODS: We designed and implemented an educational curriculum for obstetrics residents aimed at improving collection methods and increasing CBU volumes (CBUV). Residents were required to attend grand rounds and interactive didactic sessions on CBU collection followed by work with a simulated collection kit and then performed training collections under observation by a trained collector. Residents completed a self-assessment after each collection and received immediate personal feedback. Outside providers (non-UAMS physicians) received written instructional materials with the collection kits and had access to online training materials. They received feedback regarding their collection via standard mail. CBU donated to Cord Blood Bank of Arkansas for public use from 2014-2016 were analyzed. CBUV from residents were compared to those from outside providers. RESULTS: After adjusting for maternal age and race, infant gender, gestational age, and birth weight, the least-squared mean CBUV was 92.1 mL for UAMS collections and 65.5 mL for outside provider collections. The improved CBUV of UAMS providers is statistically significant (p < 0.0001). CONCLUSION: Our educational intervention was successful, and we believe that it can be replicated in other obstetrical residency programs. Cord blood collection education involving hands-on training with a model and immediate feedback improves CBUV, decreases kit waste, increases likelihood of CBU storage, and, therefore, inventory for transplantation.

Is There a Difference in Sonographic Estimation of Amniotic Fluid Volume When Measuring With the Probe Perpendicular to the Floor Compared With Perpendicular to the Uterine Contour?

OBJECTIVE: This study sought to determine whether there is a significant difference in amniotic fluid measurements when measuring perpendicular to the floor compared with perpendicular to the uterine contour using both amniotic fluid index and single deepest pocket. METHODS: This was a single-centre, prospective study of women with singleton gestation who were undergoing fetal ultrasound examination. A total of 240 women were enrolled, and single deepest pocket and amniotic fluid index were measured with both techniques. Correlation coefficient and intraclass correlation coefficient were used to assess the agreement between the values using the two methods of measurement (Canadian Task Force Classification II-2). RESULTS: A strong correlation was found between amniotic fluid index measurements (correlation coefficient 0.82; intraclass correlation coefficient 0.7). A strong correlation also was found between single deepest pocket measurements (correlation coefficient 0.7; intraclass correlation coefficient 0.6). CONCLUSION: The measurement of amniotic fluid index and single deepest pocket can be performed either perpendicular to the floor or perpendicular to the uterine contour. There is no significant difference between these measurements and they correlate well.