Use of Postpartum Hemorrhage Checklist during Vaginal Deliveries: A Quality Improvement Study.

OBJECTIVE: Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. STUDY DESIGN: This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. RESULTS: During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. CONCLUSION: This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. KEY POINTS: · Our study showed sustainability of PPH checklist use over a 20-month period.. · PPH checklist use was associated with increased use of interventions known to reduce blood loss.. · Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes..

Disparities in menopausal care in the United States: A systematic review.

Effective menopausal care constitutes a continuum of symptom management and optimization of medical health, including cardiovascular, bone, and mental health. Menopausal knowledge and prescribing patterns changed significantly after the publication of the Women's Health Initiative. A systematic review was conducted to address three key questions about disparities in menopausal care: 1) What differences in menopausal care are experienced by specific populations? 2) What disparities are there in access to preventive care and symptomatic treatment? 3) What interventions reduce disparities in menopause management? PubMed, PsychInfo, SCOPUS, and EMBASE were queried to identify relevant articles published in the United States between 2002 and 2023. Twenty-eight articles met the review criteria; these included quantitative and qualitative analyses. Symptomatic menopausal patients utilize a range of therapies. Racial and ethnic minorities, veterans, women living with HIV, incarcerated individuals, patients with surgical menopause, and nursing home residents represent specifically studied populations that demonstrate differences in menopausal care. Healthcare professionals may impact access to certain therapeutics, possibly driven by lack of content knowledge or implicit bias. Insurance status and geographic location may also affect menopause management or access to care. Few interventions exist to address disparities in menopausal care. There is an urgent need to understand how patients and providers make menopausal treatment decisions and intervene to mitigate health disparities in menopausal care.

Targeted deletion of the zebrafish obscurin A RhoGEF domain affects heart, skeletal muscle and brain development.

Obscurin is a giant structural and signaling protein that participates in the assembly and structural integrity of striated myofibrils. Previous work has examined the physical interactions between obscurin and other cytoskeletal elements but its in vivo role in cell signaling, including the functions of its RhoGTPase Exchange Factor (RhoGEF) domain have not been characterized. In this study, morpholino antisense oligonucleotides were used to create an in-frame deletion of the active site of the obscurin A RhoGEF domain in order to examine its functions in zebrafish development. Cardiac myocytes in the morphant embryos lacked the intercalated disks that were present in controls by 72 and, in the more severely affected embryos, the contractile filaments were not organized into mature sarcomeres. Neural abnormalities included delay or loss of retinal lamination. Rescue of the phenotype with co-injection of mini-obscurin A expression constructs demonstrated that the observed effects were due to the loss of small GTPase activation by obscurin A. The immature phenotype of the cardiac myocytes and the retinal neuroblasts observed in the morphant embryos suggests that obscurin A-mediated small GTPase signaling promotes tissue-specific cellular differentiation. This is the first demonstration of the importance of the obscurin A-mediated RhoGEF signaling in vertebrate organogenesis and highlights the central role of obscurin A in striated muscle and neural development.

Laparoscopic hysterectomy to manage uterine rupture due to placenta percreta in the first trimester: A case report.

Placenta percreta causing uterine rupture is a rare complication of pregnancy. It is most commonly diagnosed after the second trimester and can lead to significant morbidity necessitating abdominal hysterectomy of a gravid or immediately postpartum uterus. We describe a patient who presented with abdominal pain at 13 weeks of gestation and was diagnosed with placenta percreta during laparoscopy for presumed appendicitis. Intraoperatively, placenta was seen perforating the uterine fundus and 1 l of hemoperitoneum was evacuated. However, the uterus was hemostatic and the patient was stable, so the procedure was terminated. The patient was then transferred to a tertiary care center, where she ultimately underwent an uncomplicated laparoscopic gravid hysterectomy. We conclude that placenta percreta can occur in the first trimester even in patients without traditional risk factors. In stable patients, it is appropriate to consider minimally invasive hysterectomy with utilization of specific techniques to minimize intraoperative blood loss.

Capnocytophaga bacteremia precipitating severe thrombocytopenia and preterm labor in an asplenic host.

Capnocytophaga species are gram-negative bacilli that inhabit mammalian oral surfaces and can cause opportunistic infection, especially in asplenic patients. The species Capnocytophaga canimorsus is particularly associated with dog bites and is known to cause endocarditis, meningitis, and sepsis in the general population. In pregnant patients, infections tied to Capnocytophaga species from human flora have been associated with preterm labor, chorioamnionitis, and neonatal septicemia. There is little known about the effects of zoonotically-acquired Capnocytophaga infection in pregnant patients. In this case report, we present a patient with Capnocytophaga bacteremia acquired after a dog bite associated with profound thrombocytopenia and preterm labor. Dog bites are common in the United States, and we present basic recommendations for management of dog bites in pregnant patients in order to avoid morbidity associated with delay in time to antibiotic treatment of infection as described in this case.

Discharge Medical Complexity, Change in Medical Complexity and Pediatric 30-day Readmission.

BACKGROUND: While medical complexity is associated with pediatric readmission risk, less is known about how increases in medical complexity during hospitalization affect readmission risk. METHODS: We conducted a five-year retrospective, case-control study of pediatric hospitalizations at a tertiary care children's hospital. Cases with a 30-day unplanned readmission were matched to controls based on admission seasonality and distance from the hospital. Complexity variables included the number of medications prescribed at discharge, medical technology, and the need for home healthcare services. Change in medical complexity variables included new complex chronic conditions and new medical technology. We estimated odds of 30-day unplanned readmission using adjusted conditional logistic regression. RESULTS: Of 41,422 eligible index hospitalizations, we included 595 case and 595 control hospitalizations. Complexity: Polypharmacy after discharge was common. In adjusted analyses, being discharged with ≥2 medications was associated with higher odds of readmission compared with being discharged without medication; children with ≥5 discharge medications had a greater than four-fold higher odds of readmission. Children assisted by technology had higher odds of readmission compared with children without technology assistance. Change in complexity: New diagnosis of a complex chronic condition (Adjusted Odds Ratio (AOR) = 1.75; 1.11-2.75) and new technology (AOR = 1.84; 1.09-3.10) were associated with higher risk of readmission when adjusting for patient characteristics. However, these associations were not statistically significant when adjusting for length of stay. CONCLUSION: Polypharmacy and use of technology at discharge pose a substantial readmission risk for children. However, added technology and new complex chronic conditions do not increase risk when accounting for length of stay.

Body fat composition assessment using analytic morphomics predicts infectious complications after bowel resection in Crohn's disease.

BACKGROUND: Decisions between medical and surgical management of Crohn's disease (CD) incorporate risk assessments for potential complications of each therapy. Analytic morphomics is a novel method of image analysis providing quantifiable measurements of body tissue composition, characterizing body fat more comprehensively than body mass index alone. The aim of this study was to determine the risk factors associated with postoperative complications in CD, incorporating fat composition analysis using analytic morphomics. METHODS: We performed a retrospective review of adults undergoing bowel resection for CD between 2004 and 2011 at a single center. Computed tomography obtained within 30 days prior to surgery underwent morphomic analysis for fat characterization. Postoperative infectious complications were defined as the need for a postoperative abdominal drain, intravenous antibiotics, or reoperation within 30 days. Bivariate and multivariate analyses using logistic regression were used to generate a prediction model of infectious complications. RESULTS: A total of 269 subjects met selection criteria; 27% incurred postoperative infectious complications. Bivariate analysis showed hemoglobin, albumin, surgical urgency, high-dose prednisone use, and subcutaneous-to-visceral fat volume distribution as predictors of complications. Body mass index, anti-tumor necrosis factor alpha therapies, and immunomodulator use were not predictors of complication. Multivariate modeling demonstrated a c-statistic of 0.77 and a negative predictive value of 81.1% with surgical urgency (odds ratio = 2.78; 95% confidence interval, 1.46-6.02; P = 0.004), subcutaneous-to-visceral fat distribution (odds ratio = 2.01; 95% confidence interval, 1.20-3.19; P = 0.006), and hemoglobin (odds ratio = 0.69; 95% confidence interval, 0.55-0.85; P = 0.001) as predictors of infectious complication. CONCLUSIONS: Fat subtype and distribution are predictive of postoperative infectious complications after bowel resection for CD. Analytic morphomics provides additional body composition detail not captured by body mass index.