Near-miss and maternal sepsis mortality: A qualitative study of survivors and support persons.

BACKGROUND: Prior studies have shown that maternal deaths due to sepsis occur due to delays in recognition, treatment, and escalation of care through medical chart reviews. This study was conducted to obtain the patient perspective for near-miss and maternal mortality cases due to sepsis. OBJECTIVE: To identify quality improvement opportunities for improving maternal sepsis through patient and support person experiences. STUDY DESIGN: Twenty semi-structured interviews and three follow-up focus groups with patients who experienced critical illness from maternal sepsis in the United States and their support persons (when available) were conducted from May 23, 2022, through October 14, 2022. In this qualitative study, data were analyzed using inductive thematic analysis. RESULTS: In this qualitative study of patients with maternal sepsis and their support persons, four main quality improvement themes were identified. The themes were the following: (1) participants reported a lack of awareness of pregnancy-related warning signs and symptoms of when to seek care, (2) many of the presenting symptoms participants experienced were not typical of expected warning signs of maternal sepsis, such as severe pain, overwhelming tiredness, and lack of fever (3) participant concerns were met with dismissal leading to delays in diagnosis, (4) participants experienced long-term sequelae but had difficulty receiving screening and referrals for treatment. CONCLUSIONS: The findings of this study suggest that standardized patient education about the warning signs of maternal sepsis and provider education about the presentation of maternal sepsis, improved listening to patients, and follow-up for sequalae of sepsis are needed.

Chronic Hypertension During Pregnancy: Prevalence and Treatment in the United States, 2008-2021.

BACKGROUND: Treatment of chronic hypertension during pregnancy has been shown to reduce the risk of adverse perinatal outcomes. In this study, we examined the prevalence and treatment of chronic hypertension during pregnancy and assessed changes in these outcomes following the release of the updated 2017 hypertension guidelines of the American College of Cardiology and American Heart Association. METHODS: We analyzed the MerativeTM Marketscan® Research Database of United States commercial insurance claims from 2007 to 2021. We assessed the prevalence of chronic hypertension during pregnancy and oral antihypertensive medication use over time. We then performed interrupted time series analyses to evaluate changes in these outcomes. RESULTS: The prevalence of chronic hypertension steadily increased from 1.8% to 3.7% among 1 900 196 pregnancies between 2008 and 2021. Antihypertensive medication use among pregnant individuals with chronic hypertension was relatively stable (57%-60%) over the study period. The proportion of pregnant individuals with chronic hypertension treated with methyldopa or hydrochlorothiazide decreased (from 29% to 2% and from 11% to 5%, respectively), while the proportion treated with labetalol or nifedipine increased (from 19% to 42% and from 9% to 17%, respectively). The prevalence or treatment of chronic hypertension during pregnancy did not change following the 2017 American College of Cardiology and American Heart Association hypertension guidelines. CONCLUSIONS: The prevalence of chronic hypertension during pregnancy doubled between 2008 and 2021 in a nationwide cohort of individuals with commercial insurance. Labetalol replaced methyldopa as the most commonly used antihypertensive during pregnancy. However, only about 60% of individuals with chronic hypertension in pregnancy were treated with antihypertensive medications.

The relative impact of labor induction versus improved labor management: Before and after the ARRIVE (a randomized trial of induction vs. expectant management) trial.

OBJECTIVE: To evaluate the association of labor induction on cesarean delivery and other maternal and neonatal outcomes in low-risk, full-term patients in community hospitals during a period of concerted effort to safely prevent cesarean delivery. METHODS: We performed a retrospective cohort study using the California Maternal Data Center comprised linked discharge diagnoses and birth certificate data for all low-risk, nulliparous, term, singleton, vertex (NTSV) individuals between 39 and 41 weeks from three Sacramento Valley community hospitals from 2016 to 2022 (N = 10,821) during a period of state-wide efforts to safely reduce cesarean rates. Logistic regression was used to calculate odds ratios (ORs) and adjusted odds ratios (aORs) after labor induction in two time periods before and after the ARRIVE trial. RESULTS: During the study period, labor induction increased from 14.7% to 23.1%. Controlling for maternal age, pre-pregnancy BMI, birthweight, maternal race and ethnicity, birthplace, English language, gestational age, Medicaid status, delivery year, and labor induction was associated with an increased aOR of 1.67 (95% CI 1.48-1.89) for cesarean delivery. We found a trend toward increased aOR of chorioamnionitis but no differences in blood transfusion, severe maternal morbidity, unexpected newborn complications, chorioamnionitis, operative vaginal delivery, maternal lacerations, and shoulder dystocia with labor induction. A decrease aOR of cesarean delivery was observed comparing all births in 2019-2021 to 2016-2018. CONCLUSION: Labor induction was associated with an increased aOR for cesarean delivery both before and after the ARRIVE trial. A decreased aOR for cesarean delivery was observed during the period of statewide efforts to safely reduce cesarean delivery both with and without labor induction.

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus.

OBJECTIVE: There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth. DESIGN: Systematic review and three-stage modified Delphi expert consensus. SETTING: International. POPULATION: Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance. OUTCOME MEASURES: Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth. RESULTS: Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach. CONCLUSION: These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

Rotational Stability of Toric Intraocular Lenses by Lens Model and Haptic Design: A Systematic Review and Single-Arm Meta-Analysis.

Rotational stability is key for optimizing postoperative visual outcomes as even a small degree of rotation of a toric intraocular lens (IOL) from its target axis can result in a significant reduction of astigmatic correction. This systematic review and meta-analysis evaluated the rotational stability of toric IOLs of different lens models and haptic designs. All published studies and clinical trials that investigate postoperative rotation of toric IOLs were searched and evaluated. Quality of studies was assessed using the Methodological Index for Nonrandomized Studies (MINORS) scale. A single-arm meta-analysis was performed in R4.3.1 software with subgroup analysis performed based on lens model and haptic design. Fifty-one published studies of 4863 eyes were included in the meta-analysis. The pooled mean absolute rotation of all toric IOLs was 2.36° (95% CI: 2.08-2.64). Postoperative rotation is dependent on many aspects of lens material and design. Modern commercially available toric IOLs exhibit exceptional rotational stability.

Bedside physician led US-guided supra-clavicular lymph node biopsy and ROSE (rapid on-site evaluation): SVC obstruction swift management in lung cancer.

Superior vena cava obstruction (SVCO) is an oncological emergency and can often be linked to an underlying lung malignancy. Due to the potential life-threatening risks associated with SVCO, it necessitates urgent diagnosis and management. In this report, we discuss 3 case studies where the use of ultrasound-guided supraclavicular lymph node biopsy was used to obtain a biopsy from patients with SVCO, followed by rapid on-site evaluation (ROSE). The benefits of this technique ensure a more rapid histological diagnosis, while also involving a less invasive procedure for the patient. The histological diagnosis is essential in improving patient outcomes when treating those with SVCO as the recommended treatments vary depending on the underlying type of lung malignancy. Having this information can help the clinician swiftly employ the optimal treatment pathway for the patient.

Exploring the spatial variation of mercury in the Gulf of St. Lawrence using northern gannets as fish samplers.

Mercury (Hg) is a ubiquitous and pervasive environmental contaminant with detrimental effects on wildlife, which originates from both natural and anthropogenic sources. Its distribution within ecosystems is influenced by various biogeochemical processes, making it crucial to elucidate the factors driving this variability. To explore these factors, we employed an innovative method to use northern gannets (Morus bassanus) as biological samplers of regurgitated fish in the Gulf of St. Lawrence. We assessed fish total Hg (THg) concentrations in relation to their geographical catch location as well as to pertinent biotic and anthropogenic factors. In small fish species, trophic position, calculated from compound-specific stable nitrogen isotopes in amino acids, emerged as the most influential predictor of THg concentrations. For large fish species, THg concentrations were best explained by δ13C, indicating higher concentrations in inshore habitats. No anthropogenic factors, such as pollution, shipping traffic, or coastal development, were significantly related to THg concentrations in fish. Moreover, previously published THg data in mussels sampled nearby were positively linked with THg concentrations in gannet prey, suggesting consistent mercury distribution across trophic levels in the Gulf of St. Lawrence. Our findings point to habitat-dependent variability in THg concentrations across multiple trophic levels. Our study could have many potential uses in the future, including the identification of vulnerability hotspots for fish populations and their predators, or assessing risk factors for seabirds themselves by using biologically relevant prey.

The Need for Laboratory Medicine in the Undergraduate Medical Education Curriculum: A White Paper from the Association of Pathology Chairs.

Considering laboratory results are used to make medical decisions, a fundamental understanding of laboratory medicine is paramount to enhance patient care, optimize health care cost containment, and prevent legal repercussions. With increasing laboratory testing complexity, this education is needed now more than ever. This article is a call to action to have medical schools adequately incorporate practical laboratory medicine content into their undergraduate medical education (UME) curricula. The authors discuss the definition of laboratory medicine, what it encompasses, who uses it and why it matters, and propose that a core laboratory medicine curriculum is a necessary part of UME.

Characterizing Chronic Pain and Adverse Childhood Experiences in the Lesbian, Gay, Bisexual, Transgender, or Queer Community.

BACKGROUND: Childhood adversity is associated with chronic pain in adulthood. Additionally, individuals identifying as lesbian, gay, bisexual, transgender, or queer (LGBTQ+) report a greater prevalence of chronic pain and increased adverse childhood experiences (ACEs). While the LGTBQ+ community has a disproportionately high chronic disease burden, limited research has been conducted on the associations between chronic pain conditions or intensity and childhood adversity in this population. METHODS: In this cross-sectional study, participants were 18 years or older, LGBTQ+ identifying, and reported chronic pain. Surveys were electronically distributed from August to November 2022 via LGBTQ+ organization email listservs and social media platforms. The survey included demographics and validated questionnaires measuring chronic pain (The Chronic Pain Questionnaire) and childhood adversity (ACE score). In analysis, ACE scores of 4 or more were defined as high. RESULTS: Responses from 136 individuals (average age of 29 ± 7.4 years) were analyzed. The mean for participants' average pain rating in the last 6 months was 5.9 of 10. Participants' worst pain was rated at least a 7 of 10 for 80% of respondents. Half (47%) had high ACE scores, and high ACE scores were significantly associated with higher average pain scores (6.27 ± 1.79, mean difference = -2.22, P = .028, 95% confidence interval [CI], -1.2 to -0.0), and higher perceived current pain ratings (4.53 ± 2.16, mean difference = -2.78, P = .007, 95% CI, -1.9 to -0.3). Transgender and gender diverse (TGD) participants (n = 75) had higher ACE scores (3.91 ± 1.78) and current pain scores compared to cisgender individuals (3.9 ± 1.8 vs 3.0 ± 1.9, P = .009, 95% CI, 0.0-0.3). History of any sexual trauma was prevalent in 36.7% and was associated with chronic pain located in the pelvic region (P = .016, effect size estimate 0.21). Specific histories of forced sexual and touch encounters were associated with a specific diagnosis of fibromyalgia (P = .008, effect size estimate 0.31 and P = .037, effect size estimate 0.31, respectively). CONCLUSIONS: Childhood adversity and chronic pain's dose-dependent relationship among our LGBTQ+ sample indicates a need to explore trauma's role in perceived pain. Given sexual trauma's association with pain location and diagnosis, type of trauma may also be crucial in understanding chronic pain development. Research into the relationships between childhood adversity, sexuality, gender identity, and chronic pain could improve chronic pain prevention and management for the LGBTQ+ community.

Validity of Birth Certificate Data Compared With Hospital Discharge Data in Reporting Maternal Morbidity and Disparities.

A growing number of studies are using birth certificate data, despite data-quality concerns, to study maternal morbidity and associated disparities. We examined whether conclusions about the incidence of maternal morbidity, including Black-White disparities, differ between birth certificate data and hospitalization data. Using linked birth certificate and hospitalization data from California and Michigan for 2018 (N=543,469), we found that maternal morbidity measures using birth certificate data alone are substantially underreported and have poor validity. Furthermore, the degree of underreporting in birth certificate data differs between Black and White individuals and results in erroneous inferences about disparities. Overall, Black-White disparities were more modest in the birth certificate data compared with the hospitalization data. Birth certificate data alone are inadequate for studies of maternal morbidity and associated racial disparities.

Performance Characteristics of Sepsis Screening Tools During Delivery Admissions.

OBJECTIVE: To evaluate the screening performance characteristics of existing tools for the diagnosis of sepsis during delivery admissions. METHODS: This was a case-control study using electronic health record data, including vital signs and laboratory results, for all delivery admissions of patients with sepsis from 59 nationally distributed hospitals. Patients with sepsis were matched by gestational age at delivery in a 1:4 ratio with patients without sepsis to create a comparison group. Patients with chorioamnionitis and sepsis were compared with a complete cohort of patients with chorioamnionitis without sepsis. Multiple screening criteria for sepsis were evaluated: the CMQCC (California Maternal Quality Care Collaborative), SIRS (Systemic Inflammatory Response Syndrome), the MEWC (the Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System), and the MEWT (Maternal Early Warning Trigger Tool). Sensitivity, false-positive rates, and C-statistics were reported for each screening tool. Analyses were stratified into cohort 1, which excluded patients with chorioamnionitis-endometritis, and cohort 2, which included those patients. RESULTS: Delivery admissions at 59 hospitals were extracted for patients with sepsis. Cohort 1 comprised 647 patients with sepsis, including 228 with end-organ injury, matched with a control group of 2,588 patients without sepsis. Cohort 2 comprised 14,591 patients with chorioamnionitis-endometritis, of whom 1,049 had sepsis and 238 had end-organ injury. In cohort 1, the CMQCC and the UKOSS pregnancy-adjusted criteria had the lowest false-positive rates (6.9% and 9.6%, respectively) and the highest C-statistics (0.92 and 0.91, respectively). Although other screening criteria, such as SIRS and the MEWC, had similar sensitivities, it was at the cost of much higher false-positive rates (21.3% and 38.3%, respectively). In cohort 2, including all patients with chorioamnionitis-endometritis, the highest C-statistics were again for the CMQCC (0.67) and UKOSS (0.64). All screening tools had high false-positive rates, but the false-positive rates for the CMQCC and UKOSS were substantially lower than those for SIRS and the MEWC. CONCLUSION: During delivery admissions, the CMQCC and UKOSS pregnancy-adjusted screening criteria have the lowest false-positive results while maintaining greater than 90% sensitivity rates. Performance of all screening tools was degraded in the setting of chorioamnionitis-endometritis.

Trends and Disparities in Severe Maternal Morbidity Indicator Categories during Childbirth Hospitalization in California from 1997 to 2017.

OBJECTIVE: Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization. STUDY DESIGN: We analyzed California birth cohort data on all live and stillbirths ≥ 20 weeks' gestation from 1997 to 2017 (n = 10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven nonmutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression. RESULTS: SMM occurred in 1.16% of births and nontransfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over 3-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717 and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, U.S.-born Hispanic, and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial. CONCLUSION: Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities, and potential needs for intervention. KEY POINTS: · By SMM subgroup, trends and racial and ethnic disparities varied yet Black individuals consistently had highest rates.. · Hemorrhage, renal, respiratory, and sepsis SMM significantly increased over time.. · Disparities increased for respiratory SMM among Black, U.S.-born Hispanic and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals..

In ovo administration of the Marek's disease vaccine in conjunction with 25-hydroxyvitamin D3 and its subsequent effects on the performance and immunity-related characteristics of Ross 708 broiler hatchlings1,2,3.

The combined effects of the in ovo injection of commercial Marek's disease vaccine (MDV) and various levels of 25-hydroxyvitamin D3 (25OHD3) on the hatch variables, immunological measurements, and gene expression of Ross 708 hatchling broilers were investigated. A total of 5 in ovo injection treatments that were applied at 18 d of incubation (doi) included: 1) noninjected (control); or a 50 µL solution volume of 2) MDV alone; or MDV combined with 3) 0.6 µg of 25OHD3; 4) 1.2 µg of 25OHD3; or 5) 2.4 µg of 25OHD3. At hatch, hatchability of set and live embryonated eggs, hatchling body weight, hatch residue analysis, serum IgY and alpha-1 acid glycoprotein (AGP) concentrations, and the expression of genes related to immunity (INFα, INFß, INFγ, TLR-3, and TLR-21) and vitamin D3 activity (1 α-hydroxylase, 24 hydroxylase, and vitamin D receptor) were determined. No significant treatment differences were observed for hatchability of set and live embryonated eggs, or for serum IgY and AGP concentrations. However, hatchling body weight was higher when MDV was combined with either 1.2 or 2.4 µg of 25OHD3 than when MDV was provided alone or in combination with 0.6 µg of 25OHD3. Also, in comparison to the noninjected treatment group, the expression of the genes for 1 α-hydroxylase and 24 hydroxylase was improved when MDV was combined with either 1.2 or 2.4 µg of 25OHD3. Lastly, expression of the genes linked to viral detection (TLR-3) and antibody production (INF-ß) was increased in those treatments that contained any level of 25OHD3. These results indicate that in comparison to controls, the effects of MDV were observed to be greater on hatchling BW and splenic gene expression when it was administered in combination with the 1.2 or 2.4 µg doses of 25OHD3. Further research is needed to determine the posthatch effects of the administration of various levels of 25OHD3 in combination with MDV.

C-L Case Conference: Insomnia Disorder.

We present the case of a 67-year-old male with a history of major depressive disorder, panic disorder, treatment refractory hypertension, dyslipidemia, benign prostatic hypertrophy, and environmental allergies who was initially brought to medical attention following an unwitnessed fall. He subsequently developed symptoms of insomnia disorder. Experts in consultation-liaison psychiatry and sleep medicine provide guidance for this clinical scenario based on their experience and a review of current literature, exploring the epidemiology of insomnia disorder and comorbidities in relation to this case. Furthermore, we offer a review of current treatment for insomnia disorder, including non-pharmacologic methods such as cognitive behavioral therapy for insomnia and pharmacotherapy.

Perinatal Care Measures Are Incomplete If They Do Not Assess The Birth Parent-Infant Dyad As A Whole.

Measures of perinatal care quality and outcomes often focus on either the birth parent or the infant. We used linked vital statistics and hospital discharge data to describe a dyadic measure (including both the birth parent and the infant) for perinatal care during the birth hospitalization. In this five-state cohort of 2010-18 births, 21.6 percent of birth parent-infant dyads experienced at least one complication, and 9.6 percent experienced a severe complication. Severe infant complications were eight times more prevalent than severe birth parent complications. Among birth parents with a severe complication, the co-occurrence of a severe infant complication ranged from 2 percent to 51 percent, whereas among infants with a severe complication, the co-occurrence of a severe birth parent complication was rare, ranging from 0.04 percent to 5 percent. These data suggest that measures, clinical interventions, public reporting, and policies focused on either the birth parent or the infant are incomplete in their assessment of a healthy dyad. Thus, clinicians, administrators, and policy makers should evaluate dyadic measures, incentivize positive outcomes for both patients (parent and infant), and create policies that support the health of the dyad.

Effects of the in ovo injection of an Escherichia coli vaccine on the hatchability and quality characteristics of commercial layer hatchlings.

In the commercial egg industry, avian pathogenic Escherichia coli (APEC) can lead to significant economic loss. The Poulvac E. coli vaccine (PECV) is a commercially available attenuated live vaccine commonly applied via spray or drinking water to protect against losses associated with colibacillosis. The PECV has not been tested in layer hatching eggs using in ovo injection. Therefore, the purpose of this experiment was to determine the effects of injecting 50 µL of different doses of the PECV into Hy-Line W-36-layer hatching eggs on the hatchability and quality characteristics of hatchlings. At 18 d of incubation (DOI), treatments included 1 noninjected and 1 diluent-injected control. Furthermore, PECV treatments included a full dose (4.4 × 108E. coli CFU) or serial dilutions of the full dose to produce 4.4 × 106, 4.4 × 104, or 4.4 × 102 CFU doses of E. coli. In ovo injections targeted the amnion. Percent hatchability of live embryonated eggs (HI), percent residue eggs, hatchling mortality, and female chick whole and yolk-free BW, relative yolk sac weight, and body length were among the variables examined. Treatment significantly (P < 0.0001) affected HI, with HI being highest in the control groups (97.3% in the noninjected and 94.2% in the diluent-injected), and with HI values being 89.0, 88.9, 84.4, and 71.2% in the 4.4 × 102, 4.4 × 104, 4.4 × 106, and 4.4 × 108 CFU E. coli dose treatments, respectively. The percentage of live embryos that did not complete hatch but that pipped internally (P = 0.024) or externally (P < 0.0001) were significantly affected by treatment, with percentages being highest in the 4.4 × 108 CFU treatment. Female chick body length was significantly (P < 0.0001) affected by treatment and was longer in both control groups and in the 1 × 102 CFU E. coli treatment in comparison to all other treatments. Yolk-free female chick BW was significantly (P = 0.034) affected by treatment and was lower in the 4.4 × 106 CFU and 4.4 × 108 CFU treatments when compared to the diluent-injected control group. An increase in the E. coli concentration administered in the amnion of embryonated layer hatching eggs at 18 DOI decreased hatch success and female chick yolk-free BW and body length.

Chronic Hypertension in Pregnancy and Racial-Ethnic Disparities in Complications.

OBJECTIVE: To evaluate whether there are individual- and population-level associations between chronic hypertension and pregnancy complications, and to assess differences across seven racial-ethnic groups. METHODS: This population-based study used linked vital statistics and hospitalization discharge data from all live and stillbirths in California (2008-2018), Michigan (2008-2020), Oregon (2008-2020), Pennsylvania (2008-2014), and South Carolina (2008-2020). We used multivariable log-binomial regression models to estimate risk ratios (RRs) and population attributable risk (PAR) percentages with 95% CIs for associations between chronic hypertension and several obstetric and neonatal outcomes, selected based on prior evidence and pathologic pathways. We adjusted models for demographic factors (race and ethnicity, payment method, educational attainment), age, body mass index, obstetric history, delivery year, and state, and conducted analyses stratified across seven racial-ethnic groups. RESULTS: The study included 7,955,713 pregnancies, of which 168,972 (2.1%) were complicated by chronic hypertension. Chronic hypertension was associated with several adverse obstetric and neonatal outcomes, with the largest adjusted PAR percentages observed for preeclampsia with severe features or eclampsia (22.4; 95% CI 22.2-22.6), acute renal failure (13.6; 95% CI 12.6-14.6), and pulmonary edema (10.7; 95% CI 8.9-12.6). Estimated RRs overall were similar across racial-ethnic groups, but PAR percentages varied. The adjusted PAR percentages (95% CI) for severe maternal morbidity-a widely used composite of acute severe events-for people who were American Indian or Alaska Native, Asian, Black, Latino, Native Hawaiian or Other Pacific Islander, White, and Multiracial or Other were 5.0 (1.1-8.8), 3.7 (3.0-4.3), 9.0 (8.2-9.8), 3.9 (3.6-4.3), 11.6 (6.4-16.5), 3.2 (2.9-3.5), and 5.5 (4.2-6.9), respectively. CONCLUSION: Chronic hypertension accounts for a substantial fraction of obstetric and neonatal morbidity and contributes to higher complication rates, particularly for people who are Black or Native Hawaiian or Other Pacific Islander.

Emerging technology in agriculture: Opportunities and considerations for occupational safety and health researchers.

INTRODUCTION: A variety of factors are driving the development of robotics and automation in the agriculture industry including the nature of work, workforce shortages, and a variety of economic, climatic, technologic, political, and social factors. While some new robotics and automated machines are available commercially, most are still being developed. This provides occupational safety and health researchers an unprecedented opportunity to mitigate risks and benefit the health and safety of agriculture workers. METHOD: The NIOSH Office of Agriculture Safety and Health (OASH) is working to better understand how the advancements in automation and robotics is affecting workers. OASH is coordinating with the NIOSH Center of Occupational Robotics Research (CORR) to help to increase the understanding of human/machine interactions; improve the ability to identify injuries and fatalities involving automation/ robotics; and provide guidance on working safely with automation/ robotics. OASH also joined a small team of academics and industry to organize the SAfety For Emerging Robotics and Autonomous aGriculture or (SAFER AG) Workshop to identify gaps in knowledge and research needs that connect to issues related to risks and regulations/standards, occupational safety research, and impacts on workforce and society. This workshop was sponsored by USDA NIFA. PRACTICAL APPLICATIONS: Occupational safety and health experts need to engage and collaborate with developers of technology. It is also increasingly important for occupational safety and health researchers and practitioners to not only become familiar with existing manufacturing safety standards, but also the lengthy standards development process. Joining consensus standards groups to help shape new standards for emerging technologies may help to mitigate adverse worker impacts. NIOSH's Office of Agriculture Safety and Health will continue to identify research gaps, support new research projects, education, outreach efforts and the development of best practices with our partners.