Increasing Prevalence of Diagnosed Gestational Diabetes in South Carolina: 2015-2021.

Objective: To examine trends with a focus on racial and ethnic disparities in reported gestational diabetes mellitus (GDM) and related outcomes (macrosomia, large for gestational age infants) before and during the COVID-19 pandemic in South Carolina (SC). Methods: A retrospective cohort study of pregnancies resulting in livebirths from 2015 through 2021 was conducted in SC. Statewide maternal hospital and emergency department discharge codes were linked to birth certificate data. GDM was defined by ICD-9-CM (i.e., 648.01-648.02, 648.81-648.82) or ICD-10-CM codes (i.e., O24.4, O24.1, O24.9), or indication of GDM on the birth certificate without evidence of diabetes outside pregnancy (ICD-9-CM: 250.xx; ICD-10-CM: E10, E11, O24.0, O24.1, O24.3). Results: Our study included 194,777 non-Hispanic White (White), 108,165 non-Hispanic Black (Black), 25,556 Hispanic, and 16,344 other race-ethnic group pregnancies. The relative risk for GDM associated with a 1-year increase was 1.01 (95% confidence interval [CI]: 1.01-1.02) before the pandemic and 1.12 (1.09-1.14) during the pandemic. While there were race-ethnic differences in the prevalence of GDM, increasing trends were similar across all race-ethnic groups before and during the pandemic. From quarter 1, 2020, to quarter 4, 2021, the prevalence of reported GDM increased from 8.92% to 10.85% in White, from 8.04% to 9.78% in Black, from 11.2% to 13.65% in Hispanic, and from 13.3% to 16.16% in other race-ethnic women. Conclusion: An increasing prevalence of diagnosed GDM was reported during the COVID-19 pandemic. Future studies are needed to understand the mechanisms underlying increasing trends, to develop interventions, and to determine whether the increasing trend continues in subsequent years.

Increasing Preterm Delivery and Small for Gestational Age Trends in South Carolina during the COVID-19 Pandemic.

Preterm delivery (PTD) complications are a major cause of childhood morbidity and mortality. We aimed to assess trends in PTD and small for gestational age (SGA) and whether trends varied between race-ethnic groups in South Carolina (SC). We utilized 2015-2021 SC vital records linked to hospitalization and emergency department records. PTD was defined as clinically estimated gestation less than (<) 37 weeks (wks.) with subgroup analyses of PTD < 34 wks. and < 28 wks. SGA was defined as infants weighing below the 10th percentile for gestational age. This retrospective study included 338,532 (243,010 before the COVID-19 pandemic and 95,522 during the pandemic) live singleton births of gestational age ≥ 20 wks. born to 260,276 mothers in SC. Generalized estimating equations and a change-point during the first quarter of 2020 helped to assess trends. In unadjusted analyses, pre-pandemic PTD showed an increasing trend that continued during the pandemic (relative risk (RR) = 1.04, 95% CI: 1.02-1.06). PTD < 34 wks. rose during the pandemic (RR = 1.07, 95% CI: 1.02-1.12) with a significant change in the slope. Trends in SGA varied by race and ethnicity, increasing only in Hispanics (RR = 1.02, 95% CI: 1.00-1.04) before the pandemic. Our study reveals an increasing prevalence of PTD and a rise in PTD < 34 wks. during the pandemic, as well as an increasing prevalence of SGA in Hispanics during the study period.

The Association of Hypertensive Disorders of Pregnancy with Infant Mortality, Preterm Delivery, and Small for Gestational Age.

Gestational hypertension, preeclampsia, eclampsia, and chronic hypertension (CHTN) are associated with adverse infant outcomes and disproportionately affect minoritized race/ethnicity groups. We evaluated the relationships between hypertensive disorders of pregnancy (HDP) and/or CHTN with infant mortality, preterm delivery (PTD), and small for gestational age (SGA) in a statewide cohort with a diverse racial/ethnic population. All live, singleton deliveries in South Carolina (2004-2016) to mothers aged 12-49 were evaluated for adverse outcomes: infant mortality, PTD (20 to less than <37 weeks) and SGA (<10th birthweight-for-gestational-age percentile). Logistic regression models adjusted for sociodemographic, behavioral, and clinical characteristics. In 666,905 deliveries, mothers had superimposed preeclampsia (HDP + CHTN; 1.0%), HDP alone (8.0%), CHTN alone (1.8%), or no hypertension (89.1%). Infant mortality risk was significantly higher in deliveries to women with superimposed preeclampsia, HDP, and CHTN compared with no hypertension (relative risk [RR] = 1.79, 1.39, and 1.48, respectively). After accounting for differing risk by race/ethnicity, deliveries to women with HDP and/or CHTN were more likely to result in PTD (RRs ranged from 3.14 to 5.25) or SGA (RRs ranged from 1.67 to 3.64). As CHTN, HDP and superimposed preeclampsia confer higher risk of adverse outcomes, prevention efforts should involve encouraging and supporting mothers in mitigating modifiable cardiovascular risk factors.

Hypertensive Disorders of Pregnancy and Pre-Pregnancy Hypertension with Subsequent Incident Venous Thromboembolic Events.

Hypertensive disorders of pregnancy (HDP) and pre-pregnancy hypertension contribute to maternal morbidity and mortality. We examined the association of HDP and pre-pregnancy hypertension with subsequent venous thromboembolic (VTE) events. The retrospective cohort study included 444,859 women with ≥1 live, singleton birth in South Carolina (2004-2016). Hospital and emergency department visit and death certificate data defined incident VTE, HDP, and pre-pregnancy hypertension. Birth certificate data also defined the exposures. Adjusted Cox proportional hazards methods modeled VTE events risk. Of the cohort, 2.6% of women had pre-pregnancy hypertension, 5.8% had HDP, 2.8% had both pre-pregnancy hypertension and HDP (both conditions), and 88.8% had neither condition. The risk of incident VTE events within one year of delivery was higher in women with HDP (hazard ratio [HR] = 1.62, 95% confidence interval [CI]: 1.15-2.29) and both conditions (HR = 2.32, 95% CI: 1.60-3.35) compared to those with neither condition as was the risk within five years for women with HDP (HR = 1.35, 95% CI: 1.13-1.60) and for women with both conditions (HR = 1.82, 95% CI: 1.50-2.20). One- and five-year risks did not differ in women with pre-pregnancy hypertension compared to women with neither condition. Compared to non-Hispanic White (NHW) women with neither condition, the incident VTE event risk was elevated within five years of delivery for NHW (HR = 1.29, 95% CI: 1.02-1.63; HR = 1.59, 95% CI: 1.16-2.17) and non-Hispanic Black (NHB; HR = 1.51, 95% CI: 1.16-2.96; HR = 2.08, 95% CI: 1.62-2.66) women with HDP and with both conditions, respectively, and for NHB women with pre-pregnancy hypertension (HR = 1.50, 95% CI: 1.09-2.07). VTE event risk was highest in women with HDP, and the event rates were higher in NHB women than in NHW women in the same exposure group.

A Machine Learning Approach with Human-AI Collaboration for Automated Classification of Patient Safety Event Reports: Algorithm Development and Validation Study.

BACKGROUND: Adverse events refer to incidents with potential or actual harm to patients in hospitals. These events are typically documented through patient safety event (PSE) reports, which consist of detailed narratives providing contextual information on the occurrences. Accurate classification of PSE reports is crucial for patient safety monitoring. However, this process faces challenges due to inconsistencies in classifications and the sheer volume of reports. Recent advancements in text representation, particularly contextual text representation derived from transformer-based language models, offer a promising solution for more precise PSE report classification. Integrating the machine learning (ML) classifier necessitates a balance between human expertise and artificial intelligence (AI). Central to this integration is the concept of explainability, which is crucial for building trust and ensuring effective human-AI collaboration. OBJECTIVE: This study aims to investigate the efficacy of ML classifiers trained using contextual text representation in automatically classifying PSE reports. Furthermore, the study presents an interface that integrates the ML classifier with the explainability technique to facilitate human-AI collaboration for PSE report classification. METHODS: This study used a data set of 861 PSE reports from a large academic hospital's maternity units in the Southeastern United States. Various ML classifiers were trained with both static and contextual text representations of PSE reports. The trained ML classifiers were evaluated with multiclass classification metrics and the confusion matrix. The local interpretable model-agnostic explanations (LIME) technique was used to provide the rationale for the ML classifier's predictions. An interface that integrates the ML classifier with the LIME technique was designed for incident reporting systems. RESULTS: The top-performing classifier using contextual representation was able to obtain an accuracy of 75.4% (95/126) compared to an accuracy of 66.7% (84/126) by the top-performing classifier trained using static text representation. A PSE reporting interface has been designed to facilitate human-AI collaboration in PSE report classification. In this design, the ML classifier recommends the top 2 most probable event types, along with the explanations for the prediction, enabling PSE reporters and patient safety analysts to choose the most suitable one. The LIME technique showed that the classifier occasionally relies on arbitrary words for classification, emphasizing the necessity of human oversight. CONCLUSIONS: This study demonstrates that training ML classifiers with contextual text representations can significantly enhance the accuracy of PSE report classification. The interface designed in this study lays the foundation for human-AI collaboration in the classification of PSE reports. The insights gained from this research enhance the decision-making process in PSE report classification, enabling hospitals to more efficiently identify potential risks and hazards and enabling patient safety analysts to take timely actions to prevent patient harm.

Social support in relation to posttraumatic stress disorder symptoms among patients with violent versus nonviolent injury.

OBJECTIVE: Violent injuries have become increasingly more common in the United States. Individuals experiencing violent injury are at increased risk for the development of posttraumatic stress disorder (PTSD) as compared to those experiencing nonviolent injury. Social support is touted as a protective factor against various psychiatric symptoms (i.e., PTSD), though little is known about the relation between PTSD symptoms and social support in traumatic injury populations. The aims of the present paper were twofold: (1) examine the prevalence of PTSD as a function of injury type (2) explore differences in levels of social support as a function of injury type and (3) explore the association between injury type and later PTSD symptoms as moderated by baseline social support. METHOD: Participants were 553 adults from a level-one trauma center in the Southeast United States who experienced a violent injury or nonviolent injury and completed measures of social support at baseline as well as PTSD symptoms at the 30-day follow-up timepoint. The study utilized data from both the baseline timepoint (i.e., upon admission to the trauma surgery unit), as well as a 30-day follow-up timepoint. RESULTS: Results demonstrated that those endorsing nonviolent injury reported lower levels of social support and PTSD symptoms. Social support predicted later PTSD symptoms until injury type was included as a covariate in the model. Social support did not moderate the relationship between injury type and later PTSD symptoms. CONCLUSIONS: Findings highlight the interrelatedness of key risk variables (i.e., injury type) with protective factors in influencing the trajectory of psychopathology postinjury. Violence intervention and interruption programs may have the capacity to fill patient needs when social support networks are insufficient. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports.

BACKGROUND: Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports. METHODS: The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated. RESULTS: Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54). CONCLUSION: Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

Hazard of substance abuse onset among adults diagnosed with epilepsy or migraine.

OBJECTIVE: We investigated adult-onset epilepsy as a risk factor for the development of substance use disorder (SUD) by comparing the rate of SUD diagnosis among adults diagnosed with epilepsy with presumably healthy controls with lower extremity fractures (LEF). For additional comparison, we investigated the risk for adults with migraine only. Epilepsy and migraine are both episodic neurological disorders and migraine is frequently comorbid with epilepsy. METHODS: We conducted a time-to-event analysis using a subset of surveillance data of hospital admissions, emergency department visits, and outpatient visits in South Carolina, USA from January 1, 2000, through December 31, 2011. Individuals aged 18 years or older were identified using the International Classification of Disease, 9thRevision Clinical Modification (ICD-9) with a diagnosis of epilepsy (n = 78,547; 52.7% female, mean age 51.3 years), migraine (n = 121,155; 81.5% female, mean age 40.0 years), or LEF (n = 73,911; 55.4% female, mean age 48.7 years). Individuals with SUD diagnosis following epilepsy, migraine, or LEF were identified with ICD-9 codes. We used Cox proportional hazards regression to model the time to SUD diagnosis comparing adults diagnosed with epilepsy, migraine, and LEF, adjusting for insurance payer, age, sex, race/ethnicity, and prior mental health comorbidities. RESULTS: Compared to LEF controls, adults with epilepsy were diagnosed with SUD at 2.5 times the rate [HR 2.48 (2.37, 2.60)] and adults with migraine only were diagnosed with SUD at 1.12 times the rate [HR 1.12 (1.06, 1.18)]. We found an interaction between disease diagnosis and insurance payer, with hazard ratios comparing epilepsy to LEF of 4.59, 3.48, 1.97, and 1.44 within the commercial payer, uninsured, Medicaid, and Medicare strata, respectively. SIGNIFICANCE: Compared to presumably healthy controls, adults with epilepsy had a substantially higher hazard of SUD, while adults with migraine only showed a small, but significant, increased hazard of SUD.

A Trial of Adding Lung Protective Strategies to Existing Enhanced Recovery After Surgery Protocols and Its Effect on Improving Postoperative Lung Function.

Background: With this rising popularization of enhanced recovery after surgery (ERAS) protocols, it is important to ask if the current and developing pathways are fully comprehensive for the patient's perioperative experience. Many current pathways discuss aspects of care including fluid management, pain management, and anti-emetic medication regiments, but few delineate recommendations for lung protective strategies. The hypothesis was that intraoperative lung protective strategies would results in improved postoperative lung function. Methods: One hundred patients at the Medical University of South Carolina undergoing hepatobiliary and colorectal surgeries were randomized to receive intraoperative lung protective techniques or a standard intraoperative ventilation management. Three maximum vital capacity breaths were recorded preoperatively, and postoperatively 30 min, 1 h, and 2 h after anesthesia stop time. Average maximum capacity breaths from all four data collection interactions were analyzed between both study and control cohorts. Results: There was no significant difference in the preoperative inspiratory capacity between the control and the ERAS group (2,043.3 ± 628.4 mL vs. 2,012.2 ± 895.2 mL; P = 0.84). Additional data analysis showed no statistically significant difference between ERAS and control groups: total average of the inspiratory capacity volumes (1,253.5 ± 593.7 mL vs. 1,390.4 ± 964.9 mL; P = 0.47), preoperative oxygen saturation (97.76±2.3% vs. 98.04±1.7%; P = 0.50), the postoperative oxygen saturation (98.51±1.4% vs. 96.83±14.2%; P = 0.40), and change in inspiratory capacity (95% confidence interval (CI) (-211.2 - 366.6); P = 0.60). Conclusions: No statistically significant difference in postoperative inspiratory capacities were seen after the implementation of intraoperative lung protective strategies. The addition of other indicators of postoperative lung function like pneumonia incidence or length of inpatient stay while receiving oxygen treatment could provide a fuller picture in future studies, but a higher power will be needed.

Inhaled nitric oxide for adults with pulmonary non-tuberculous mycobacterial infection.

QUESTION: There is an increasing prevalence of nontuberculous mycobacteria pulmonary disease (NTM-PD) in the US. Treatment of NTM-PD typically requires multiple medications, which can be associated with unpleasant morbidity and eradication of infection is difficult. Therefore, there is a critical need for novel effective and well-tolerated therapies. Recent in vitro data and case reports have suggested that nitric oxide, inhaled as a gas (gNO), has antimicrobial activity against NTM. We sought to investigate the effect of gNO in patients with NTM-PD in an open-label proof of concept trial. METHODS: Eligible participants had NTM-PD with persistently positive respiratory cultures for NTM even if on antibiotic treatment. Participants were treated with gNO for 50 min three times daily, five days per week, for three weeks (total of 15 treatment days). RESULTS: Ten participants, of whom nine were on long-term NTM antibiotic therapy, were enrolled. All participants completed the regimen without interruption or discontinuation. Small increases in methemoglobin were noted during treatment, and all resolved to baseline within 2 h. Four participants (40%) met the primary outcome measure of negative sputum cultures after three weeks of therapy. Following treatment discontinuation, three of these participants were again culture positive during the 3-month post-treatment monitoring period, although with measures suggesting low bacterial burden. ANSWER: Patients tolerated a 3-week regimen of gNO without safety concerns, and despite highly refractory disease four individuals completed the study with negative cultures, although three were again positive in subsequent months. These data support further investigation of gNO as a potential therapy for NTM-PD.

Anaesthesia cart standardisation expedites supply retrieval: A simulation study with patient safety implications.

BACKGROUND: Anaesthesia providers often work at a variety of perioperative and procedural locations. However, the layout of anaesthesia supplies and equipment is often inconsistent from operating theatre to operating theatre. This lack of standardisation may create delays in identification and retrieval of supplies. The primary goal of this study was to compare the duration of time required by anaesthesia providers to identify and retrieve a list of anaesthesia supplies prior to and after standardisation of the location for anaesthesia supplies. METHODS: In this observational simulation study, a pre-set list of ten items that may be rapidly needed when caring for patients was created. Volunteer anaesthesia providers were then timed retrieving these in two different operating theatres before and after anaesthesia cart standardisation. Cumulative time to retrieve all items was recorded in seconds. Participants were evaluated regarding mean time to compete the task before and after supply standardisation. Paired t-test were used to assess mean time to retrieve the ten items both before and after standardisation and between the two operating theatre locations. Providers were also evaluated on their familiarity with the operating theatre location, and this was assessed by chi-square tests of homogeneity. Multivariable generalised linear modelling was used to evaluate the impact of covariables on the change in time. RESULTS: Data from 18 anaesthesia providers was collected. Mean (95% confidence interval) time in seconds to retrieve items was decreased by 45% after supply standardisation (105.3 [88.6, 121.9 vs 57.1 [50.8, 63.5]; p < 0.001) with a mean (95% confidence interval) reduction of 48.1 seconds (30.6, 65.6; p < 0.001). Providers who worked primarily at that location also had faster times to complete the task. In a multivariable regression model that considered both the provider's familiarity with the location and the simulation attempt (Operating theatre 1 or Operating theatre 2), the mean time to retrieve all items remained reduced by 48.1 seconds (95% confidence interval: 31.9-64.4) after supply standardisation (p < 0.001). CONCLUSION: Standardisation of the location for anaesthesia supplies decreased the time for on-demand item retrieval. Retrieval times were most improved after standardisation for providers in an unfamiliar area. Supply standardisation of anaesthesia carts across perioperative and procedural sites could result in more timely interventions in patient care and efficiency.

Improving Patient Safety Event Report Classification with Machine Learning and Contextual Text Representation.

Adverse events caused by medical errors pose a significant threat to patient safety, with estimates of 251,454 deaths and a cost of $17.1 billion to the healthcare system annually in the United States. Patient safety event (PSE) reports play a vital role in identifying measures to prevent adverse events, but their utility is dependent on the accurate classification of PSE reports. Recent studies have used static natural language processing (NLP) and machine learning (ML) techniques to automate PSE report classification. However, the use of static NLP has limitations in differentiating the meaning of words in disparate contexts, which can lead to inferior classification results. Thus, this study proposes to utilize contextual text representation produced from neural NLP methods to improve the accuracy of PSE report classification. The results suggest that the contextual text representation can further improve the performance of PSE classifiers. The best-performing classifier, a support vector machine trained with contextual text representation (Roberta-base) reaches an accuracy of 0.75 and a ROCAUC score of 0.94, surpassing all ML classifiers trained with static text representations. Furthermore, the confusion matrix of the best classifier exposes latent deficiencies in the PSE reports' classification taxonomy, such as the multi-class nature of PSE and conceptually related event types. The study's findings can save time for PSE reclassification, enhance the learning capabilities of the reporting system, ultimately improve patient safety.

Racial and ethnic disparities in long-term contraception use among the birthing population at an academic hospital in the Southeastern United States.

Ensuring women and birthing people have access to the contraceptive of their choice is essential for patient-centered care, health equity, and reproductive justice. While trends in national data in the United States reveal racial disparities in long-term contraceptive use, health-system and hospital-level investigations are essential to understand disparities and encourage interventions. We used data from 5011 patients who delivered at a large academic hospital to determine the effect of race/ethnicity and social vulnerability index (SVI) on the odds of undergoing a long-term contraceptive procedure. Results indicate that SVI substantially affects the odds of long-term contraception for non-Hispanic White women and birthing people. In contrast, Hispanic and non-Hispanic Black women and birthing people have significantly higher odds of undergoing a long-term contraceptive procedure due to race/ethnicity. Contributions to these disparities may be based on factors including healthcare providers, organizational and external policies. Interventions at all levels of care are essential to address disparities in contraceptive care, outcomes, and patient experience.

Preoperative Quadratus Lumborum Block Reduces Initial Postoperative Opioid Consumption Following Hip Arthroscopy: A Retrospective Analysis.

Compare postoperative opioid consumption following hip arthroscopy in patients who received a preoperative, lateral quadratus lumborum block versus those who did not. Patients were retrospectively identified. The primary outcome was postoperative opioid consumption (IV morphine milligram equivalents) in patients with and without a block. Comparisons between groups were conducted with Chi-square tests and Fisher Exact Tests where appropriate. Continuous data were compared with two-sided t-tests and Wilcoxon rank-sum tests. Data were collected on 100 patients. Mean (95% confidence interval) postoperative opioid consumption was reduced in patients with a quadratus lumborum block compared to those without a block (6.6 [5.2 - 8.1] vs 11.8 [10.2 - 13.4]; p < 0.0001; respectively). Eleven percent of patients with a preoperative quadratus lumborum block did not consume any opioids in the post anesthesia care unit. Opioid consumption in the immediate postoperative period was significantly reduced in patients that received a preoperative quadratus lumborum block. Level of Evidence: Level III - Retrospective Cohort Study. (Journal of Surgical Orthopaedic Advances 31(1):017-021, 2022).

Hypertensive Disorders of Pregnancy With and Without Prepregnancy Hypertension Are Associated With Incident Maternal Kidney Disease Subsequent to Delivery.

BACKGROUND: Maternal morbidity and mortality are related to prepregnancy hypertensive disease and hypertensive disorders of pregnancy (HDP) including preeclampsia (41.1% of HDP), eclampsia (1.3% of HDP), and gestational hypertension (39.9% of HDP). Less information is available on the risk of maternal kidney disease and potential racial/ethnic differences following a hypertensive condition during pregnancy. Our objective was to examine the relationships between HDP and prepregnancy hypertension with maternal incident kidney disease subsequent to delivery (up to 3, 5, and 14 years) with consideration of racial/ethnic differences. METHODS: In a retrospective cohort study, 391 838 women 12 to 49 years of age had a live birth in South Carolina between 2004 and 2016; 35.1% non-Hispanic Black (NHB) and 64.9% non-Hispanic White (NHW). Hospitalization, emergency department, and birth certificate data defined prepregnancy hypertension and HDP. Hospitalization and death certificate data identified incident kidney disease. RESULTS: 317 006 (80.8%) women experienced neither condition, 1473 (0.4%) had prepregnancy hypertension, 64 050 (16.3%) had HDP, and 9662 (2.5%) had both conditions (prepregnancy hypertension with superimposed HDP, ie, preeclampsia). Five years after delivery, incident kidney disease risk was increased for NHB and NHW women with HDP (NHB: hazard ratio, 2.30 [95% CI, 1.94-2.73]; NHW: hazard ratio, 1.97 [95% CI, 1.64-2.37]) and with both conditions (NHB: hazard ratio, 3.88 [95% CI, 3.05-4.93]; NHW: hazard ratio, 1.86 [95% CI, 1.20-2.87]) compared with counterparts with neither condition after adjustment (P value for race/ethnicity interaction=0.003). CONCLUSIONS: Increased kidney disease risk 5 years after delivery was observed for women with HDP and with both compared with neither condition, with associated risk higher in NHB than NHW women.

Emergency Subglottic Airway Training and Assessment of Skills Retention of Attending Anesthesiologists With Simulation Mastery-Based Learning.

BACKGROUND: Although included within the American Society of Anesthesiologists difficult airway algorithm, the use of "invasive airway access" is rarely needed clinically. In conjunction with highly associated morbidity and liability risks, it is a challenge for the average anesthesiologist to develop and maintain competency. The advancement of high-fidelity simulators allows for practice of rarely encountered clinical scenarios, specifically those requiring invasive subglottic airway techniques. METHODS: Sixty board-certified academic anesthesiologists were enrolled and trained in dyads in a simulation-based, mastery-based learning (MBL) course directed at 2 emergency airway subglottic techniques: transtracheal jet ventilation (TTJV) and bougie cricothyrotomy (BC). Performance metrics included: pretest, posttest, specific skill step error tracking, and 15-month period retest. All were pretested and trained once on the Melker cricothyrotomy (MC) kit. All pretest assessment, training, posttesting, and 15-month retesting were performed by a single expert clinical and educational airway management faculty member. RESULTS: Initial testing showed a success rate of 14.8% for TTJV, 19.7% for BC, and 25% for MC. After mastery-based practice, all anesthesiologists achieved successful invasive airway placement with TTJV, BC, and MC. Repeated performance of each skill improved speed with zero safety breaches. BC was noted to be the fastest performed technique. Fifteen months later, retesting showed that 80.4% and 82.6% performed successful airway securement for TTJV and BC, respectively. For safety, average placement time and costs, MC was discarded after initial training results. CONCLUSIONS: We discovered that only ~20% of practicing anesthesiologists were able to successfully place an invasive airway in a simulated life or death clinical setting. Using mobile simulation (training performed in department conference room) during a 2.5-hour session using mastery-based training pedagogy, we increased our success rate of invasive airway placement to 100%, while also increasing the successful speed to ventilation (TTJV, 32 seconds average; BC, 29 seconds average). Finally, we determined that there was a 15-month 80% retention rate of the airway skills learned, indicating that skills last at least a year before retraining is required using this training methodology.

A Smartphone Application for Teamwork and Communication in Trauma: Pilot Evaluation "in the Wild".

OBJECTIVE: To evaluate the potential for a smartphone application to improve trauma care through shared and timely access to patient and contextual information. BACKGROUND: Disruptions along the trauma pathway that arise from communication, coordination, and handoffs problems can delay progress through initial care, imaging diagnosis, and surgery to intensive care unit (ICU) disposition. Implementing carefully designed and evaluated information distribution and communication technologies may afford opportunities to improve clinical performance. METHODS: This was a pilot evaluation "in the wild" using a before/after design, 3 month, and pre- post-intervention data collection. Use statistics, usability assessment, and direct observation of trauma care were used to evaluate the app. Ease of use and utility were assessed using the technology acceptance model (TAM) and system usability scale (SUS). Direct observation deployed measures of flow disruptions (defined as "deviations from the natural progression of an procedure"), teamwork scores (T-NOTECHS), and treatment times (total time in emergency department [ED]). RESULTS: The app was used in 367 (87%) traumas during the trial period. Usability was generally acceptable, with higher scores found by operating room (OR), ICU, and neuro and orthopedic users. Despite positive trends, no significant effects on flow disruptions, teamwork scores, or treatment times were observed. CONCLUSIONS: Pilot trials of a clinician-centered smartphone app to improve teamwork and communication demonstrate potential value for the safety and efficiency of trauma care delivery as well as benefits and challenges of "in-the-wild" evaluation.

Preoperative Quadratus Lumborum Block Reduces Opioid Requirements in the Immediate Postoperative Period Following Hip Arthroscopy: A Randomized, Blinded Clinical Trial.

PURPOSE: To examine acute postoperative opioid consumption in patients undergoing hip arthroscopy and randomized to either receive a preoperative lateral quadratus lumborum block or sham injection. METHODS: This trial randomized 46 subjects undergoing hip arthroscopy with a single surgeon to receive a preoperative lateral quadratus lumborum block (40 mL, ropivacaine 0.25%) or sham injection. The primary outcome was postoperative opioid consumption in patients with and without a block. All opioid medications were converted to morphine milligram equivalents for comparisons. Categorical data were compared with χ2 tests and Fisher exact tests where appropriate. Continuous data were compared with 2-sided t-test and Wilcoxon rank-sum tests. RESULTS: Forty-six subjects scheduled for elective hip arthroscopy were successfully consented and randomized. Demographic and clinical characteristics did not differ. Postoperative opioid consumption decreased 28.3% in patients who received a preoperative lateral quadratus lumborum block (P = .04). Total perioperative opioid consumption (intraoperative and postoperative combined) was reduced 20% in the block group; however, this did not achieve statistical significance (P = .05). Three subjects in the sham group (12.5%) required unblinding for a rescue block in the postoperative anesthetic care unit (PACU) for uncontrolled pain despite systemic analgesics. While cold sensation was decreased postoperatively over the abdomen (P < .001) and anterior thigh (P = .03) in the block group, other PACU variables did not differ, including VAS pain scores, motor function, side effects, PACU duration, and patient satisfaction. CONCLUSIONS: Opioid consumption was reduced in patients who received a preoperative lateral quadratus lumborum block combined with a standardized, multimodal protocol as compared with patients who did not receive a block. Our findings support the growing evidence that quadratus lumborum blocks are an effective component of multimodal analgesia options for patients undergoing elective hip arthroscopy. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Incident Heart Failure Within the First and Fifth Year after Delivery Among Women With Hypertensive Disorders of Pregnancy and Prepregnancy Hypertension in a Diverse Population.

Background Hypertensive disorders of pregnancy (HDP) and pre-pregnancy hypertension are associated with increased morbidity and mortality for the mother. Our aim was to investigate the relationships between HDP and pre-pregnancy hypertension with maternal heart failure (HF) within 1 and 5 years of delivery and to examine racial/ethnic differences. Methods and Results We conducted a retrospective cohort study in South Carolina (2004-2016) involving 425 649 women aged 12 to 49 years (58.9% non-Hispanic White [NHW], 31.5% non-Hispanic Black [NHB], 9.6% Hispanic) with a live, singleton birth. Incident HF was defined by hospital/emergency department visit and death certificate data. Pre-pregnancy hypertension and HDP (preeclampsia, eclampsia, or gestational hypertension) were based on hospitalization/emergency department visit and birth certificate data (i.e., gestational hypertension for HDP). The 425 649 women had pre-pregnancy hypertension without superimposed HDP (pre-pregnancy hypertension alone; 0.4%), HDP alone (15.7%), pre-pregnancy hypertension with superimposed HDP (both conditions; 2.2%), or neither condition in any pregnancy (81.7%). Incident HF event rates per 1000 person-years were higher in NHB than NHW women with HDP (HDP: 2.28 versus 0.96; both conditions: 4.30 versus 1.22, respectively). After adjustment, compared with women with neither condition, incident HF risk within 5 years of delivery was increased for women with pre-pregnancy hypertension (HR,2.55, 95% CI: 1.31-4.95), HDP (HR,4.20, 95% CI: 3.66-4.81), and both conditions (HR,5.25, 95% CI: 4.24-6.50). Conclusions Women with HDP and pre-pregnancy hypertension were at higher HF risk (highest for superimposed preeclampsia) within 5 years of delivery. NHB women with HDP had higher HF risk than NHW women, regardless of pre-pregnancy hypertension.