Understanding what patients and physicians need to improve their decision-making about antenatal corticosteroids in late preterm gestation: a qualitative framework analysis.

BACKGROUND: It is unclear whether the benefits of administration of antenatal corticosteroids in late preterm gestation outweigh its harms. We sought to understand whether patients and physicians need increased support to decide whether to administer antenatal corticosteroids in late preterm gestation, and their informational needs and preferences for decision-making roles related to this intervention; we also wanted to know if creation of a decision-support tool would be useful. METHODS: We conducted individual, semistructured interviews with pregnant people, obstetricians and pediatricians in Vancouver, Canada, in 2019. Using a qualitative framework analysis method, we coded, charted and interpreted interview transcripts into categories that formed an analytical framework. RESULTS: We included 20 pregnant participants, 10 obstetricians and 10 pediatricians. We organized codes into the following categories: informational needs to decide whether to administer antenatal corticosteroids; preferences for decision-making roles regarding this treatment; the need for support to make this treatment decision; and the preferred format and content of a decision-support tool. Pregnant participants wanted to be involved in decision-making about antenatal corticosteroids in late preterm gestation. They wanted information on the medication, respiratory distress, hypoglycemia, parent-neonate bonding and long-term neurodevelopment. There was variation in physician counselling practices, and in how patients and physicians perceived the balance of treatment harms and benefits. Responses suggested a decision-support tool may be useful. Participants desired clear descriptions of risk magnitude and uncertainty. INTERPRETATION: Pregnant people and physicians would likely benefit from increased support to consider the harms and benefits of antenatal corticosteroids in late preterm gestation. Creation of a decision-support tool may be useful.

Technical Update No. 439: Antenatal Corticosteroids at Late Preterm Gestation.

OBJECTIVE: To update recommendations for administration of antenatal corticosteroids in the late preterm period. TARGET POPULATION: Pregnant individuals at risk of preterm birth from 340 to 366 weeks gestation. OPTIONS: Administration or non-administration of a single course of antenatal corticosteroids at 340 to 366 weeks gestation. OUTCOMES: Neonatal morbidity (respiratory distress, hypoglycemia), long-term neurodevelopment, and other long-term outcomes (growth, cardiac/metabolic, respiratory). BENEFITS, HARMS, AND COSTS: Administration of antenatal corticosteroids from 340 to 366 weeks gestation decreases the risk of neonatal respiratory distress but increases the risk of neonatal hypoglycemia. The long-term impacts of antenatal corticosteroid administration from 340 to 366 weeks gestation are uncertain. EVIDENCE: For evidence on the neonatal effects of antenatal corticosteroid administration at late preterm gestation, we summarized evidence from the 2020 Cochrane review of antenatal corticosteroids and combined this with evidence from published randomized trials identified by searching Ovid MEDLINE from January 1, 2020, to May 11, 2022. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on neurodevelopmental outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on neurodevelopmental outcomes using the following sources: (1) the 2020 Cochrane review; and (2) evidence obtained by searching Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to January 5, 2022. We did not apply date or language restrictions. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on other long-term outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on other long-term outcomes by combining findings from the 2020 Cochrane review with evidence obtained by searching Ovid MEDLINE for observational studies related to long-term cardiometabolic, respiratory, and growth effects of antenatal corticosteroids from inception to October 22, 2021. We reviewed reference lists of included studies and relevant systematic reviews for additional references. See Appendix A for search terms and summaries. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Maternity care providers, including midwives, family physicians, and obstetricians. SUMMARY STATEMENTS: RECOMMENDATIONS.

Labor and delivery outcomes by delivery method in term deliveries in occiput posterior position: a population-based retrospective cohort study.

BACKGROUND: Occiput posterior is the most common malposition in labor. Deliveries in occiput posterior position have been shown to have higher rates of adverse short-term maternal and neonatal outcomes compared with deliveries in occiput anterior position. There are no guidelines providing recommendations nor summarizing risks of adverse outcomes by delivery method to inform the decision-making process in occiput posterior delivery management. Population-based studies examining the outcomes associated with various management processes of occiput posterior position at the time of labor or delivery are lacking. OBJECTIVE: This study aimed to describe the current management of term singleton occiput posterior deliveries in British Columbia, Canada and to examine the association between different management strategies and adverse outcomes by describing the rates of: occiput posterior malposition; and spontaneous vaginal delivery, operative vaginal delivery, and cesarean delivery from occiput posterior malposition. We also analyzed the rates of adverse labor and delivery outcomes stratified by fetal position and delivery mode, and the interaction effect of occiput posterior position and delivery mode on the rates of adverse outcomes. STUDY DESIGN: This was a retrospective cohort study of cephalic term singleton deliveries in British Columbia from 2004 to 2020, using the British Columbia Perinatal Data Registry. The obstetrical adverse outcome index (a composite of 10 adverse maternal or neonatal events), adverse outcome index subcomponent rates, and adverse outcome index-derived weighted scores were compared between deliveries stratified by fetal position at delivery (occiput posterior or occiput anterior) and occiput posterior deliveries stratified by delivery method. Multivariable log-binomial logistic regression was used to model the adverse outcome index score. RESULTS: Of 306,237 term births, 19% had occiput posterior position during labor, 37% of which persisted in occiput posterior position at delivery. Among occiput posterior deliveries, 27% were spontaneous vaginal deliveries, 8% vacuum, 5% forceps, 1% mixed vacuum-forceps, and 59% were cesarean delivery; this distribution differed from that of occiput anterior deliveries (P<.0001). Overall, adverse outcome index scores were significantly higher in persistent occiput posterior deliveries (8.8% had ≥1 adverse outcomes; adjusted rate ratio, 1.07 [1.01-1.14]) than in occiput posterior labors that rotated to occiput anterior deliveries; the most frequent adverse outcome was third- or fourth-degree lacerations. Neonatal adverse outcomes were also more frequent in occiput posterior delivery (4.3% vs 3.3%; adjusted rate ratio, 1.21 [1.10-1.35]), whereas maternal outcomes were similar between groups (4.8% vs 6.0%; adjusted rate ratio, 1.04 [0.96-1.13]). Among persistent occiput posterior deliveries, spontaneous vaginal delivery and cesarean delivery had the lowest proportion of deliveries with ≥1 adverse outcomes (6.1% and 6.2%), whereas forceps deliveries had the highest (38.1%); the largest contributor to the adverse outcomes were third- or fourth-degree lacerations. Among occiput posterior deliveries with any adverse outcome, cesarean delivery had the highest Severity Index score, due in part to the inclusion of third- or fourth-degree tears (which are assigned a comparatively low score) as the most common adverse event in the other vaginal delivery modes, and because of outcomes with a higher severity score being associated with cesarean delivery, such as uterine rupture (a reason for cesarean delivery) and intensive care unit admission (an outcome following cesarean delivery). Overall, in a multivariable regression model, delivery mode and the interaction between delivery mode and occiput posterior position were significant predictors of a delivery with ≥1 adverse outcomes, whereas occiput posterior position itself was not. CONCLUSION: One in five singleton deliveries at term gestation had occiput posterior position in labor; most of these rotated to occiput anterior by delivery, which had better outcomes than persistent occiput posterior deliveries. Among the latter, spontaneous vaginal delivery and cesarean delivery had the lowest frequency of adverse outcomes, whereas forceps deliveries had the highest. This study provides a robust updated analysis of birth outcomes following different occiput posterior management strategies, which can inform provider decision-making and counseling. Its observational design may limit its use for direct recommendations for management of occiput posterior malposition, yet the study helps to define the risks associated with different modes of delivery in the setting of occiput posterior malposition. With additional studies examining success rates of intermediate occiput posterior-occiput anterior rotation, other delivery management steps, and long-term outcomes, this study helps to define safe management of occiput posterior delivery.

Making sense of harms and benefits: Assessing the numeric presentation of risk information in ACOG obstetrical clinical practice guidelines.

OBJECTIVE: To assess the presentation of risk information in American College of Obstetricians and Gynecologists (ACOG) obstetrical Practice Bulletins. METHODS: We reviewed B- and C-graded recommendations in Practice Bulletins published from January 2017 to March 2020. We calculated the proportion of recommendations and outcomes that were presented numerically and, of these, the proportion that were presented in accordance with best practices of risk communication - in absolute formats, or as absolute changes in risk from baseline risks. We categorized outcomes as harms or benefits to compare their risk presentation. RESULTS: In 21 obstetrical Practice Bulletins, there were 125 recommendations, with 46 (37%) describing risks numerically. Sixteen of these 46 recommendations (35%) presented an absolute change in risk from a baseline risk. For harms, 65% were presented as absolute risks and 25% as relative risks. For benefits, this was 55% and 48% respectively. CONCLUSION: Most recommendations do not present numeric risk information. Of those that do, most do not use absolute risk measures. PRACTICE IMPLICATIONS: Obstetrical practice guidelines should present numerical risk information wherever possible to support recommendations, increasing the use of absolute risk formats and absolute changes from baseline risks to increase risk comprehension.

Subjective and objective vestibular changes that occur following paediatric cochlear implantation: systematic review and meta-analysis.

OBJECTIVE: Cochlear implantation can result in post-operative vestibular dysfunction of unknown clinical significance. The objective of this study was to characterize the presence, magnitude, and clinical significance of vestibular dysfunction that occurs after pediatric cochlear implantation. DATA SOURCES: The databases Embase, Medline (OvidSP), and PubMed were used. Only articles published in English were included. Grey literature and unpublished sources were also reviewed. STUDY SELECTION: Articles published from 1980 until the present which documented pre-operative and post-operative vestibular testing on children under the age of 18 were used. DATA EXTRACTION: Parameters that were assessed included number of patients, pre- and post-operative vestibular-evoked myogenic potentials (VEMPs), head impulse testing (HIT), calorics, and posturography, timing of pre- and post-operative testing, symptomatology, and other demographic data such as etiology of the hearing loss. DATA SYNTHESIS: Ten articles were included. Relative risk values evaluating the effect of cochlear implantation on vestibular function were calculated for VEMPs and caloric testing due to the availability of published data. I2 values were calculated and 95% confidence intervals were reported. Separate analyses were conducted for each individual study and a pooled analysis was conducted to yield an overall relative risk. Assessment on risk of bias in individual studies and overall was performed. CONCLUSION: Pediatric cochlear implantation is associated with a statistically significant decrease in VEMP responses post-operatively (RR 1.8, p < 0.001, I2 91.86, 95%CI 1.57-2.02). Similar results are not seen in caloric testing. Insufficient data is available for analysis of HIT and posturography. Further studies are necessary to determine the effect of cochlear implantation on objective vestibular measures post-operatively and whether any changes seen are clinically relevant in this population.

Validation of the Ankle Osteoarthritis Scale Instrument for Preoperative Evaluation of End-Stage Ankle Arthritis Patients Using Item Response Theory.

BACKGROUND:: Significant ankle arthritis results in functional limitations and patient morbidity. There is a need to measure symptoms and the impact of interventions on patient's quality of life using valid and reliable patient-reported measurement instruments. The objective of this research was to validate the Ankle Osteoarthritis Scale instrument in the preoperative setting using factor analysis, item response theory, and differential item function methods. METHODS:: This research is based on secondary analysis of patients scheduled for ankle arthrodesis or total ankle replacement in Vancouver, Canada. Participants completed the instrument between September 2014 and August 2017. Item response theory was used to estimate item difficulty and discrimination parameters, controlling for study participants' underlying level of ankle function. Differential item function was examined for sex, age group, and surgery. There were 88 participants. RESULTS:: Modification indices suggested that item 10, "walking around the house," would better fit the pain domain rather than the disability domain. Items in the pain domain displayed a range of discrimination and difficulty. Items in the disability domain exhibited a range of discrimination, though the disability domain had low difficulty. Differential item functioning for sex, age group, and ankle arthrodesis or total ankle replacement appeared to be ignorable. CONCLUSION:: This evaluation of the Ankle Osteoarthritis Scale found the instrument to be a strong measure of the effect of pain and dysfunction among patients with end-stage ankle arthritis, even when removing items 7 and 8, supporting its prior use in numerous clinical studies. LEVEL OF EVIDENCE:: Level II, prospective comparative study.

Shared decision making and decisional conflict in the Management of Vestibular Schwannoma: a prospective cohort study.

BACKGROUND: Patients with vestibular schwannomas (VS) are faced with complex management decisions. Watchful waiting, surgical resection, and radiation are all viable options with associated risks and benefits. We sought to determine if patients with VS experience decisional conflict when deciding between surgery or non-surgical management, and factors influencing the degree of decisional conflict. METHODS: A prospective cohort study in two tertiary ambulatory skull-base clinics was performed. Patients with newly diagnosed or newly growing vestibular schwannomas were recruited. Patients were given a demographic form and the decisional conflict scale (DCS), a validated measure to assess the degree of uncertainty when making medical decisions. The degree of shared decision making (SDM) experienced by the patient and physician were assessed via the SDM-Q-10 and SDM-Q-Doc questionnaires, respectively. Non-parametric statistics were used. Questionnaires and demographic information were correlated with DCS using Spearman correlation coefficient and Mann-Whitney U. Logistic regression was performed to determine factors independently associated with DCS scores. RESULTS: Seventy-seven patients participated (55% female, aged 37-81 years); VS ranged in size from 2 mm-50 mm. Significant decisional conflict (DCS score 25 or greater) was experienced by 17 (22%) patients. Patients reported an average SDM-Q-10 score of 86, indicating highly perceived level of SDM. Physician and patient SDM scores were weakly correlated (p = 0.045, Spearman correlation coefficient 0.234). DCS scores were significantly negatively correlated with a decision to pursue surgery, presence of a trainee, and higher SDM-Q-10 score. DCS was higher with female gender. Using logistic regression, the SDM-Q-10 score was the only variable associated with significantly reduced DCS. CONCLUSIONS: About one fifth of patients deciding how to manage their vestibular schwannoma experienced a significant degree of decisional conflict. Involving the patients in the process through shared decision-making significantly reduced the degree of uncertainty patients experienced.