Processes and the Electronic Health Record: Challenges and Difficulties Faced when Creating an OB Quality Dashboard.

Healthcare quality as defined by the National Academy of Medicine is "the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes [1]". While building QI dashboard data quality to improve the maternal health of our patient population issues were discovered that hindered that the progress of the project. This paper will discuss the challenges and difficulties faced while creating an OB quality dashboard at a regional perinatal.

What Is the Failure Rate After Arthroscopic Repair of Bucket-Handle Meniscal Tears? A Systematic Review and Meta-analysis.

BACKGROUND: Meniscal repair has become the treatment of choice for meniscal tears, especially in the subset of bucket-handle meniscal tears (BHMTs). However, a comprehensive estimate of the corresponding failure rate is not available, thus maintaining doubts about the healing potential of these tears. Furthermore, a wide range of factors to predict high failure rates have been reported but with conflicting evidence. PURPOSE: To determine the failure rate after arthroscopic repair of BHMTs as reported in the literature, compare this with the failure rate of simple meniscal tears extracted from the same studies, and analyze the influence of factors previously reported to be predictive of meniscal repair failure. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: A systematic search was conducted by 2 independent reviewers using principal bibliographic databases (PubMed, Scopus, Cochrane Library, and EMBASE). After a stepwise exclusion process, 38 articles met the inclusion criteria. Failure rate data were analyzed with a random-effects proportional meta-analysis (weighted for individual study size), and forest plots were constructed to determine any statistically significant differences between BHMTs versus simple tears (longitudinal, radial, or horizontal), medial versus lateral BHMTs, isolated procedures versus repairs with concomitant anterior cruciate ligament reconstruction, and tears in red-red versus red-white zones. Moreover, a meta-regression analysis was conducted to evaluate the effect of patient age and sex, suture technique (in-out or all-inside), time from injury to surgery, mean number of stitches, and length of follow-up on failure rates. RESULTS: The pooled failure rate was 14.8% (95% CI, 11.3%-18.3%; I2 = 77.2%). A total of 17 studies provided failure rates of both BHMT repairs (46/311 repairs) and simple tear repairs (54/546 repairs), demonstrating a significantly higher failure rate for BHMT repairs (risk ratio [RR] = 1.50; 95% CI, 1.05-2.15; I2 = 0%; P = .03). Medial BHMT repairs (RR = 1.94; 95% CI, 1.25-3.01; I2 = 0%; P = .003) and isolated repairs (RR = 1.77; 95% CI, 1.15-2.72; I2 = 0%; P = .009) had statistically higher risk of failure, but no statistically significant difference was found between tears in red-red versus red-white zones. Among the other factors evaluated with meta-regression, only the mean number of stitches showed a statistically significant effect on failure rates. CONCLUSION: Based on the currently available literature, this systematic review provides a reasonably comprehensive analysis of failure rate after arthroscopic BHMT repair; failure is estimated to occur in 14.8% of cases. Medial tears and isolated repairs were the 2 major predictors of failure.

The impact of COVID-19 prevention measures on epidemiology of orthopedic injuries: the outbreak ages fractures!

BACKGROUND: The application of stringent prevention measures for contrasting COVID-19 spread generated changes not only in the outbreak course, but also in epidemiology of traumatic fractures. The aim of this study was to report the epidemiologic characteristics of surgically-treated fractures during the COVID-19 outbreak over a six-month period, and to describe the variation in volumes and types of injuries, by comparing them with fractures which occurred during the same period in 2019. METHODS: We retrospectively analyzed all surgically-treated fractures which were admitted from the January 1st 2020 to June 30th 2020, and compared these data to those of the corresponding timeframe in 2019. The collected data of interest included demographics, such as age and gender, fracture location, time lapse between presentation at Emergency Department and admission in the ward, length of stay. RESULTS: A total of 117 patients were admitted with a diagnosis of facture and surgically treated, with no cases of COVID-19 positive patients. In the corresponding period of 2019, the number of patients admitted for the same reasons was 129. This decrease was more significant in the period between March and April (-30.6%), during which time prevention measures were more stringent. The only statistically significant discrepancy between the two study groups was the mean age, which was significantly higher in 2020. The location of examined injuries were similar in the two study groups, with proximal femur fractures representing the most frequent injuries. CONCLUSIONS: This study demonstrated significant changes of epidemiologic patterns of fractures during COVID-19 outbreak. These data should provide support for clinicians and government to evaluate the management and prevention strategies of traumatic not only during outbreak but also in non-outbreak period.

Three single loops enhance the biomechanical behavior of the transtibial pull-out technique for posterior meniscal root repair.

PURPOSE: To investigate the effect of applying an additional suture to enhance the biomechanical behavior of the suture-meniscus construct used during the transtibial pull-out repair technique. METHODS: A total of 20 fresh-frozen porcine tibiae with intact medial menisci were used. In one half of all specimens (N = 10), two non-absorbable sutures were passed directly over the meniscal root from the tibia side of the meniscus to the femoral side (2SS). In other ten specimens, three sutures were passed over the meniscal root (3SS). All specimens were subjected to cyclic loading followed by load-to-failure testing. Displacement of the construct was recorded at 100, 500, and 1000 cycles. Further, stiffness (500-1000 cycles) and ultimate load and modes of failure of the suture-meniscus construct were also recorded. RESULTS: There was no statistically significant difference between the Group 2SS and Group 3SS at the 1st (1.6 ± 0.7 vs 1.4 ± 0.4 mm) and the 100th cycle (2 ± 0.7 vs 1.8 ± 0.4 mm). At 500 and 1000 cycles, the 2SS fixation technique resulted in significantly more displacement than the 3SS fixation technique (2.8 ± 0.6 vs 2.3 ± 0.5 mm; 3.1 ± 0.7 vs 2.5 ± 0.5 mm) (p < 0.05). No differences between two groups were noted concerning ultimate load to failure and stiffness (500-1000 cycles). CONCLUSION: Three single sutures technique provided superior biomechanical properties compared with the two single sutures technique during the conducted fatigue tests. CLINICAL RELEVANCE: Applying three simple stitches during meniscal root repair might be beneficial for healing of the posterior meniscal root, potentially reducing the post-operative immobilization time.

A randomized controlled trial comparing two types of retractors at caesarean delivery.

The aim of this study was to determine if the use of a self-retaining, symmetrical retractor (OB/Mobius®) during caesarean delivery is associated with differences in post-operative pain experience. Consenting women undergoing caesarean delivery were randomly assigned to OB/Mobius® versus conventional retraction instruments. Women were blinded to retractor type and filled out surgical pain surveys each post-operative day. Additional outcome variables were collected through a provider survey and chart review. Of the 154 randomised women, 144 completed the study. There was no difference in the symmetry, quality or intensity of postoperative pain based on the method of retraction. The OB/Mobius® retractor did not confer an improvement in the quality or intensity of post-caesarean discomfort in the first three days following delivery. Nor did the groups differ in operative times, blood loss or pain medication usage. However, the retractor may offer improved visualisation and retraction in obese women. Impact statement Use of a plastic sheath self-retaining retractor has been minimally studied in caesarean deliveries. Recently it was found that the use of such a retractor reduced wound infection, but another study in obese women did not show improved rates of infection (Hinkson et al. 2016 ; Scolari Childress et al. 2016 ). The study of sheath self-retaining retractors to decrease post-operative pain has not been reported previously. This study offers an investigation into a generalisable population of parturients who undergo caesarean delivery and if the primary use of a self-retaining retractor versus sole use of traditional hand-held retractors decreased post-operative pain while in the hospital. Although this study did not show an improvement in post-operative pain, provider experience reports demonstrated some improvement in visualisation, particularly in the obese population with the use of this novel retractor, thus making it an option for providers who do caesarean deliveries without an assistant and find hand-held retractors inadequate.

Surgical time for graft preparation using different suture techniques.

BACKGROUND: The purpose of the present study was to compare the operative time for graft preparation using different techniques for graft suturing. MATERIAL AND METHODS: Flexor profundus tendons were harvested from fresh pig hind-leg trotters. Three different suture techniques were investigated: the Krackow stitch (K), the Whipstitch (W), and the Modified Finger-Trap suture (MFT). Tendons were sutured starting at 10 mm from the distal free end of the tendon. The suture configurations of the Krackow stitch and Whipstitch were completed with five suture throws. According to the MFT technique, the suture was wrapped five times around the tendon over a distance of 30 mm. The time required to perform a complete suture on each tendon was measured. Five independent examiners of different levels of training measured the time required for graft preparation during 3 separate occasions to determine intraobserver repeatability and interobserver reproducibility. RESULTS: The mean time required for graft preparation following the Krackow technique was 69.1 seconds ± 18.3 SD (range 31.8-120). The Whipstitch technique took an average of 59.9 seconds ± 21.2 SD (range 27-93). The MFT suture required a mean of 29.3 seconds ± 11.4 SD for completing the suture (range 21.6-33). In all examiners the time required to complete the MFT suture was significantly less than the other suture techniques (p < 0.05). Intraobserver intraclass correlation coefficients for each examiner ranged from 0.72 to 0.83. CONCLUSION: Low graft preparation time is required to complete a MFT suture in a porcine tendon model. Further, time required for graft preparation using the MFT was shorter than other suturing techniques such as the Krackow and Whipstitch techniques. CLINICAL RELEVANCE: The MFT suture could be used for graft set-up with the main advantage of reducing the time required in comparison with other suture techniques.

How to avoid collision between PCL and MCL femoral tunnels during a simultaneous reconstruction.

PURPOSE: The purpose of the present study was to assess the risk of femoral tunnel collisions between the medial collateral ligament (MCL) and the posterior cruciate ligament (PCL) tunnels during a simultaneous PCL and MCL reconstruction. METHODS: Fourth generation medium and large synthetic femur bones were used. On each femur, a MCL tunnel and a PCL tunnel were reamed. The MCL tunnel was drilled at 0°, 20° and 40° of axial and coronal angulations. The PCL femoral tunnel was reamed to simulate two different tunnel directions that could be obtained through an inside-out and outside-in technique. Tunnels were filled with epoxy resin augmented with BaSO4, and a multidetector CT examination of each specimen was performed. RESULTS: High rate of tunnel collision (62.5 %) was found when the MCL femoral tunnel was reamed with a coronal angulation of 0° and 20°. The rate of tunnel collision significantly decreased (0 %) when the MCL tunnel was reamed proximally with a coronal angulation of 40°. No differences were found between the two PCL tunnel directions in terms of tunnel collision. CONCLUSION: The results of this study can help surgeons to better direct the femoral MCL tunnel in order to avoid a collision between femoral tunnels during a combined MCL and PCL reconstruction. In order to minimize such potential complications, the MCL tunnel should be created limiting the axial angulation and it should be drilled with a proximal angulation from 20° to 40°, depending on the medial condyle width.

Multistate Collaboration to Confidentially Review Unanticipated Perinatal Outcomes: Lessons Learned.

This commentary describes the development of The Northern New England Perinatal Quality Improvement Network's Confidential Review and Improvement Board and its lessons learned from reviewing cases of unanticipated perinatal outcomes between 2010 and 2013. The Confidential Review and Improvement Board is a multistate mechanism for rigorous and confidential case review of unanticipated perinatal outcomes among unaffiliated academic medical centers, community hospitals, and home birth midwives. We performed semistructured interviews with key individuals participating in the Confidential Review and Improvement Board since its inception and used inductive content analysis to analyze 22 consecutive case reviews. The Confidential Review and Improvement Board's case reviews involved five key clinical situations: second stage of labor management with neonatal depression, obstetric hemorrhage, uterine rupture, fetal demise, and maternal sepsis. A recurrent theme was failure to differentiate maternal from fetal heart rate associated with the birth of severely compromised newborns. Analysis of the Confidential Review and Improvement Board cases revealed opportunities for improvement in the following categories: 1) timely application of best practice, 2) documentation, and 3) communication. The Confidential Review and Improvement Board's evidence-based recommendations centered on strengthening multidisciplinary training through simulation, improving documentation and communication systems, and developing and implementing guidelines with appropriate tools. The Confidential Review and Improvement Board demonstrates that collaboration among unaffiliated rural perinatal providers--who are often direct market competitors--is possible and catalyzes regional improvement efforts.

Maternal circulating angiogenic factors in twin and singleton pregnancies.

OBJECTIVE: The purpose of this study was to compare longitudinally sampled maternal angiogenic proteins between singleton and twin pregnancies. STUDY DESIGN: Placental growth factor (PlGF), soluble feline McDonough sarcoma (fms)-like tyrosine kinase (sFlt)-1, and soluble endoglin from healthy pregnant women were quantified at 10, 18, 26, and 35 weeks' gestation (n=91), and during the third trimester (31-39 weeks) and at delivery (33-41 weeks; n=41). Geometric means and 95% confidence intervals were calculated for gestational age-adjusted angiogenic protein concentrations and compared between matched twin and singleton pregnancies. RESULTS: Maternal sFlt-1 concentrations and the sFlt-1/PlGF ratio were higher in twins than singletons across pregnancy and at delivery, with the greatest differences at week 35 (sFlt-1: 36,916 vs 10,151 pg/mL; P<.0001; sFlt-1/PlGF: 168.4 vs 29.0; P<.0001). Maternal concentrations of soluble endoglin also were higher in the third trimester and delivery. Maternal PlGF concentrations were lower in twin than singleton pregnancies at week 35 only (219.2 vs 350.2 pg/mL; P<.0001). Placental weight appeared to be inversely correlated with maternal sFlt-1/PlGF ratio at the end of pregnancy in both twins and singletons. CONCLUSION: Higher maternal antiangiogenic proteins in twin than singleton pregnancies does not appear to be due to greater placental mass in the former, and may be one explanation for the increased risk of preeclampsia in women carrying multiple gestations. Determining whether women with a history of multiple gestations have an altered cardiovascular disease and breast cancer risk, like those with a history of preeclampsia, is warranted.

Intensity and unpleasantness of pain following vaginal and cesarean delivery: a prospective evaluation.

BACKGROUND: To date, most studies evaluating pain associated with cesarean birth have focused on delivery procedures or postoperative pain control methods rather than on the nature or severity of the pain experience of women, despite the increasing incidence and maternal requests for cesarean delivery. The objective in this study was to evaluate sensory, affective, and laterality aspects of pain after cesarean delivery and vaginal delivery. METHODS: A prospective cohort study using a seven-item visual analog scale assessed pain at rest and with activity, and the unpleasantness and location of pain on postpartum days 1 and 2. Chart review identified demographic and clinical factors influencing pain. Multivariable regression and propensity score analyses were used to evaluate patient-level outcomes. RESULTS: Of 126 consenting women, 48 underwent cesarean delivery and 78 had vaginal delivery. No statistically significant differences in pain at rest and pain unpleasantness were found between groups on postpartum day 1, but women undergoing cesarean delivery reported more pain with activity than those who had a vaginal delivery (p < 0.0002). On postpartum day 2, cesarean delivery women reported significantly more pain when compared with those with a vaginal delivery (p < 0.04), and more cesarean delivery women reported lateralized pain (p < 0.0001). In multivariate regression analyses, cesarean delivery was the most significant predictor of activity-related pain on postpartum day 1 (p < 0.00001), followed by current substance abuse (p < 0.01). Women undergoing cesarean delivery required twice the dosage of analgesics on postpartum day 1 and four times greater amounts on postpartum day 2 relative to those with a vaginal delivery (p < 0.01 and p < 0.001). CONCLUSIONS: Cesarean delivery was associated with higher levels of pain, more unpleasant pain, more lateralized pain, and greater narcotic use than vaginal delivery. Evaluation of factors associated with postpartum pain can help practitioners to counsel women better about their delivery alternatives and can promote improved management of women undergoing both types of delivery experiences.

Why VBAC in Northern New England is still viable: the Northern New England perinatal quality improvement network.

Under the strong leadership of Maternal-Fetal Medicine specialists and the support of the tertiary care centers serving the region, Northern New England (NNE) initiated a collaborative project to improve the availability and safety of trial of labor after cesarean delivery. The project involved over 250 individuals from over 30 organizations and resulted in a strong regional guideline that has been implemented by institutions across the nation. The availability of trial of labor after cesarean in NNE has increased. The work led to the creation of the NNE Perinatal Quality Improvement Network, whose work has improved regional outcomes.

Newborn care and safety: the black box of obstetric practices and residency training.

Certain causes of newborn mortality such as sudden unexpected infant death, which includes sleep-related infant death and sudden unexplained infant death syndrome, are potentially preventable. Obstetricians are uniquely positioned to counsel new parents about safe practices regarding newborn sleep, feeding, and transportation. Patients often do not develop a relationship with their pediatricians until the neonate has been discharged, and the newborn period is a time of particular vulnerability. Newborn safety should be routinely taught in obstetric curricula, and the American College/Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics (AAP) should partner to disseminate updated literature and guidelines to health care providers regarding newborn safety. Current guidelines from the Academy of Pediatrics Task Force on Sudden Infant Syndrome are summarized in this article.

Mifepristone versus laminaria: a randomized controlled trial of cervical ripening in midtrimester termination.

BACKGROUND: Mifepristone was compared with laminaria for cervical ripening in second-trimester induction of labor (IOL). STUDY DESIGN: We performed a randomized, controlled, open-label study of women undergoing second-trimester IOL for fetal demise, aneuploidy or anomalies at a single tertiary care center from January 2004 to May 2006. Main outcome measures were induction-to-delivery time and pain with cervical ripening. RESULTS: Of 50 eligible women, 37 were enrolled in the study, of whom 33 completed the study: 16 were randomized to laminaria and 17 to mifepristone. Induction-to-delivery time was significantly shorter in the mifepristone arm (mean=10 h vs. 16 h, p=.01; median=7.5 h vs. 13.4 h, p=.01). Pain with cervical ripening was also significantly less in the mifepristone group than in the laminaria group (median=1 vs. 6 on an 11-point visual analogue scale, p<.001). Maternal age, parity, gestational age, fetal demise prior to induction, need for postpartum curettage, blood loss, pain during induction, delivery and at the time of discharge were not significantly different between the two groups. CONCLUSION: Mifepristone shortens the induction-to-delivery time and decreases pain with cervical ripening when compared with laminaria for second-trimester induction.

Clinical impact of systematic genetic sonogram screening in a low-risk population.

OBJECTIVE: To determine the clinical impact of a genetic sonogram (GS) on a population at low risk for trisomy 21 (T21). STUDY DESIGN: A GS evaluating common major and minor markers was created and prospectively applied to consecutive women at 15-20 weeks' gestation presenting for routine ultrasound and at low T21 risk. Prenatal diagnosis (PND) referral occurred if 1 major marker, 2 minor markers, major malformation or choroid plexus cysts (CPCs) were seen. Neonatal outcomes were determined by chart review for neonates born at our institution and by letter for those born elsewhere. Using an ultrasound database, a similar population was identified prior to study inception and the GS retrospectively applied. PND referrals in both periods were confirmed by chart review. The rates of isolated minor marker (IMM), positive GS and PND referrals were compared using chi2 analysis. RESULTS: IMM detection was unchanged (43 of 434, 10.1%) in the study vs. (23 of 243, 9.5%) control group. Excluding CPCs, 6 of 18 (33.3%) subjects of vs. 2 of 28 (7.1%) controls with IMM were referred for prenatal diagnosis (p < 0.03). The frequency of positive GS was unchanged: 14 of 434 (3.2%) subjects vs. 5 of 243 (2.1%) controls. CONCLUSION: Currently no prospectively studied, effective ultrasound models exist for screening low-risk populations at 15-20 weeks. A GS with clear criteria for counseling on an increased T21 risk decreased inappropriate referrals without increasing positive screens.

Pathologic uterine ring associated with fetal head trauma and subsequent cerebral palsy.

BACKGROUND: Pathologic uterine rings, also called Bandl's ring, are historically associated with obstructed labor and good neonatal outcomes. CASE: Two cases are presented involving a pathologic uterine ring identified at cesarean delivery, which led to fetal cranial trauma. At delivery, pathologic uterine rings were found to encompass the heads of both fetuses, with gross features of traumatic head deformity. Radiologic studies demonstrated intracranial hemorrhage predating delivery. Both infants developed cerebral palsy, which was initially attributed to hypoxic-ischemic encephalopathy from delivery despite normal umbilical arterial pH. Further investigation linked the intracranial bleeding to compressive trauma from the uterine rings. CONCLUSION: Although rare, pathologic uterine rings may cause traumatic cranial deformity and subsequent cerebral palsy.

Potentially avoidable maternity complications: an indicator of access to prenatal and primary care during pregnancy.

OBJECTIVE: We identified Potentially Avoidable Maternity Complications (PAMCs). Used with hospital discharge data, PAMCs may indicate lack of prenatal care access. METHODS: A research team of two obstetrician/gynecologists and three health services researchers developed the PAMC indicator, which was verified by external review. AIM 1 used the National Maternal and Infant Health Survey, with prenatal care information and 8,661 pregnancy hospitalizations, to examine associations between prenatal care, risk factors, and PAMCs. AIM 2 used the 1997 Nationwide Inpatient Sample (NIS), with 895,259 pregnancy-related hospitalizations, to examine PAMC risks for groups likely to have prenatal care access problems. RESULTS: In AIM 1, adequate prenatal care reduced PAMC risks by 57% (p < .01). Compared to nonsmokers, the odds of a PAMC for smokers were 86% higher (p < .01). Cocaine use increased PAMC risk notably (odds ratio 3.35, p < .0001). In the multivariate analyses of AIM 2, African Americans, the uninsured, and Medicaid beneficiaries had high PAMC risks (all p < .0001). CONCLUSIONS: Findings suggest adequate prenatal care may reduce PAMC risks. Results for groups with less prenatal care access were consistent with previous research using less refined indicators, such as low birth weight. PAMCs improve on earlier measures, and readily permit adjustments for mothers' ages and comorbidities.