Estimating the cost of Rh testing and prophylaxis in early pregnancy: A time-driven activity-based costing study.

OBJECTIVE: To estimate the cost of Rhesus (Rh) testing and prophylaxis for first-trimester vaginal bleeding in the ambulatory setting. STUDY DESIGN: We used time-driven, activity-based costing to analyze tasks associated with Rh testing and prophylaxis of first-trimester vaginal bleeding at one hospital-based outpatient and two independent reproductive health clinics. At each site, we observed 10 patients undergoing Rh-typing and two patients undergoing Rh prophylaxis. We computed the costs of blood Rh-typing by both fingerstick and phlebotomy, cost of locating previous blood type in the electronic health record (available for 69.8% of hospital-based patients), and costs associated with Rh immune globulin prophylaxis. All costs are reported in 2021 US dollars. RESULTS: The hospital-based clinic reviewed the electronic health record to confirm Rh-status (cost, $26.18 per patient) and performed a phlebotomy, at $47.11 per patient, if none was recorded. The independent clinics typed blood by fingerstick, at a per-patient cost of $4.07. Rh-immune globulin administration costs, including the medication, were similar across facilities, at a mean of $145.66 per patient. Projected yearly costs for testing and prophylaxis were $55,831 for the hospital-based clinic, which was the lowest-volume site, $47,941 for Clinic A, which saw 150 patients/month, and $185,654 for Clinic B, which saw 600 patients/month. CONCLUSIONS: Rh testing and prophylaxis for first-trimester vaginal bleeding generates considerable costs for outpatient facilities, even for Rh-positive patients with a prior blood type on record. IMPLICATIONS: Rh testing and prophylaxis for first-trimester bleeding generate considerable costs even for Rh-positive patients and those with a previously known blood type. These findings highlight the need to reconsider this practice, which is no longer supported by evidence and already safely waived in multiple medical settings in the United States and around the world.

Homelessness in Pregnancy and Increased Risk of Adverse Outcomes: A Retrospective Cohort Study.

Limited data indicates that homelessness during pregnancy is linked to adverse outcomes for both mothers and newborns, but there is an information gap surrounding pregnant individuals struggling with homelessness. In a landscape of increasing healthcare disparities, housing shortages and maternal mortality, information on this vulnerable population is fundamental to the creation of targeted interventions and outreach. The current study investigates homelessness as a risk factor for adverse obstetrical, neonatal, and postpartum outcomes. We reviewed more than 1000 deliveries over 1 year at a large public hospital in New York City, comparing homeless subjects to a group of age-matched, stably housed controls. Multiple outcomes were assessed regarding obstetrical, neonatal, and postpartum outcomes along with social stressors. Homeless pregnant individuals were more likely to experience numerous adverse outcomes, including cesarean delivery and preterm delivery. Their neonates were more likely to undergo an extended stay in the intensive care unit and evaluation by the Administration for Children's Services, suggesting that they may be at an increased risk for family separation. After delivery, patients were less likely to exclusively breastfeed or return for their postpartum visit. Regarding personal history, they were more likely to endorse a history of violence or abuse, use illicit substances, and carry a psychiatric diagnosis. These findings indicate that homelessness is linked to numerous adverse obstetrical, neonatal, and postpartum outcomes that worsen health indices and exacerbate pre-existing disparities. Initiatives must focus on improved outreach and care delivery for homeless pregnant individuals.

Diagnosis and Management of an Intramyometrial Ectopic Pregnancy Within a Septate Uterus.

BACKGROUND: An intramyometrial pregnancy is a rare form of ectopic pregnancy, making up an estimated 1% of all ectopic pregnancies. Previously described management options have included surgical excision in the emergency setting. CASE: A 32-year-old woman, gravida 4 para 0, at 6 0/7 weeks of gestation by last menstrual period, was noted to have a gestational sac implanted entirely within the uterine myometrium. Ultrasonography and magnetic resonance imaging confirmed the presence of an intramyometrial ectopic pregnancy within a septate uterus. The patient's abnormal pregnancy was successfully treated with multidose methotrexate. CONCLUSION: Intramyometrial pregnancy is a rare entity that should be considered when it is suggested by ultrasonography or if an intrauterine pregnancy is surgically inaccessible from the endometrial cavity. In a stable patient, multidose systemic methotrexate may be a feasible management strategy.

Feasibility and acceptability of virtual group contraceptive counseling prior to abortion care.

OBJECTIVES: This study aimed to evaluate the feasibility and acceptability of virtual group contraceptive counseling in the abortion care setting. STUDY DESIGN: Patients seeking abortion care at an urban university hospital were invited to participate in this cohort study. Prior to their clinical appointments, groups of two to six patients participated in 45-minute virtual contraceptive counseling visits facilitated by study staff. Contraceptive method use, effectiveness, and side effects were reviewed according to group interest. Participant satisfaction scores were collected immediately following the sessions. After their appointments, providers estimated the time spent on contraceptive counseling during the clinical visit. RESULTS: Of 195 patients approached, 86 (44%) were enrolled. Fifty-seven (66%) enrolled patients completed a session. The most common reason for declining enrollment was concern about the time commitment. Most (93%) participants reported being "satisfied" or "very satisfied" overall, and 96% would recommend group contraceptive counseling to a friend. Providers reported that compared to typical counseling, participants required a shorter amount of time during the clinical visit than nonparticipants (time spent <5 minutes: 74% vs 54%). CONCLUSIONS: Virtual group contraceptive counseling for patients seeking abortion was feasible and acceptable in this study. Group virtual visits may reduce provider time burden, add value when virtual care delivery is desired or required, and deserve further study. IMPLICATIONS: Family planning clinics can consider incorporating virtual group counseling as a person-centered and efficient approach to contraceptive counseling at the time of abortion care.

How the geometry and mechanics of bighorn sheep horns mitigate the effects of impact and reduce the head injury criterion.

Male bighorn sheep (Ovis canadensis) participate in seasonal ramming bouts that can last for hours, yet they do not appear to suffer significant brain injury. Previous work has shown that the keratin-rich horn and boney horncore may play an important role in mitigating brain injury by reducing brain cavity accelerations through energy dissipating elastic mechanisms. However, the extent to which specific horn shapes (such as the tapered spiral of bighorn sheep) may reduce accelerations post-impact remains unclear. Thus, the goals of this work were to (a) quantify bighorn sheep horn shape, particularly the cross-sectional areal properties related to bending that largely dictate post-impact deformations, and (b) investigate the effects of different tapered horn shapes on reducing post-impact accelerations in an impact model with finite element analysis. Cross-sectional areal properties indicate bighorn sheep horns have a medial-lateral bending preference at the horn tip (p= 0.006), which is likely to dissipate energy through medial-lateral horn tip oscillations after impact. Finite element modeling showed bighorn sheep native horn geometry reduced the head injury criterion (HIC15) by 48% compared to horns with cross-sections rotated by 90° to have a cranial-caudal bending preference, and by 125% compared to a circular tapered spiral model. These results suggest that the tapered spiral horn shape of bighorn sheep is advantageous for dissipating energy through elastic mechanisms following an impact. These findings can be used to broadly inform the design of improved safety equipment and impact systems.

A noninferiority randomized controlled trial to compare transabdominal and transvaginal sonography for eligibility assessment prior to medical abortion.

OBJECTIVES: To compare transabdominal sonography (TAS) to transvaginal sonography (TVS) in medical abortion eligibility assessment, specifically to measure how often clinicians chose to order additional testing for eligibility assessment following TAS and TVS, and to look for differences by patient and clinician characteristics. Also, to compare patient acceptability between the two modalities. STUDY DESIGN: This pragmatic multisite randomized noninferiority trial compared TAS to TVS at 10 New York City and New Jersey health centers that provide medical abortion. Women seeking medical abortion were randomized 1:1 to receive TAS or TVS. Following the study ultrasound examination, clinicians determined whether participants were eligible for medical abortion based on these results or warranted further testing. All participants completed an acceptability questionnaire. We compared additional testing and acceptability between TAS and TVS. RESULTS: Of those randomized to TAS, 63/317 (19.9%) received additional testing compared to 15/312 (4.8%) randomized to TVS. After TAS, most additional testing consisted of a same-day TVS. Other tests included ß-hCG testing, scheduled repeat sonography or return visit. After TAS, 13.4% seen by physicians and 27.6% seen by advanced practice nurses (APNs) received additional testing (p<.01). Additional testing was more common in early gestational ages for both groups. We enrolled too few women with a body mass index (BMI) >35 kg/m2 to make comparisons. Participants found TAS more acceptable than TVS, and two thirds preferred TAS for future care. CONCLUSIONS: TAS provided sufficient information for clinicians to assess medical abortion eligibility without additional tests for most patients. However, the frequency of additional testing was exceedingly close to our predefined noninferiority boundary. Why APNs ordered substantially more additional testing than physicians is unclear. TAS was more acceptable to patients than TVS. IMPLICATIONS: TVS use requires high-level disinfection, which is resource-intensive and thus can be a barrier to care. Instead, TAS can be first-line for most women, reducing resources needed to provide medical abortion. Further research could help to establish gestational age and BMI thresholds beyond which TVS would be a more informative first test. We also need to evaluate whether additional training in using TAS would decrease additional testing.

Sleep-related violence and sexual behavior in sleep: a systematic review of medical-legal case reports.

OBJECTIVE: To review systematically medical-legal cases of sleep-related violence (SRV) and sexual behavior in sleep (SBS). SEARCH METHODS: We searched Pubmed and PsychINFO (from 1980 to 2012) with pre-specified terms. We also searched reference lists of relevant articles. SELECTION CRITERIA: Case reports in which a sleep disorder was purported as the defense during a criminal trial and in which information about the forensic evaluation of the defendant was provided. DATA EXTRACTION AND ANALYSIS: Information about legal issues, defendant and victim characteristics, circumstantial factors, and forensic evaluation was extracted from each case. A qualitative-comparative assessment of cases was performed. RESULTS: Eighteen cases (9 SRV and 9 SBS) were included. The charge was murder or attempted murder in all SRV cases, while in SBS cases the charge ranged from sexual touching to rape. The defense was based on sleepwalking in 11 of 18 cases. The trial outcome was in favor of the defendant in 14 of 18 cases. Defendants were relatively young males in all cases. Victims were usually adult relatives of the defendants in SRV cases and unrelated young girls or adolescents in SBS cases. In most cases the criminal events occurred 1-2 hours after the defendant's sleep onset, and both proximity and other potential triggering factors were reported. The forensic evaluations widely differed from case to case. CONCLUSION: SRV and SBS medical-legal cases did not show apparent differences, except for the severity of the charges and the victim characteristics. An international multidisciplinary consensus for the forensic evaluation of SRV and SBS should be developed as an urgent priority.

Factors associated with nurses' opinions and practices regarding information and consent.

This cross-sectional survey aimed to investigate nurses' opinions and practices regarding information and consent in the context of a large Italian teaching hospital and to explore potential influences of gender, age, university education, length of professional experience, and care setting. A questionnaire was administered to 282 nurses from six different care settings (Emergency Room, Emergency Medicine, Surgery, Hematology-Oncology, Geriatrics, and Internal Medicine). Overall, 84% (n = 237) of nurses returned the questionnaire (men: 24%; mean age: 36.2 ± 8 years; university degree: 35%; mean length of professional experience: 12 ± 8.2 years). Most respondents regularly informed patients about medications and nursing procedures and asked for consent prior to invasive procedures, but some provided information to relatives instead of patients. Lack of time or opportunity was the main difficulty in informing patients. The work setting was the foremost factor significantly associated with participants' opinions and practices. Further investigations are needed to confirm these findings in similar and other care settings.