Interprofessional obstetric simulation training improves postpartum haemorrhage management and decreases maternal morbidity: a before-and-after study.

OBJECTIVE: To determine the impact of the Obstetric Simulation Training and Teamwork (OB-STaT) curriculum on postpartum haemorrhage (PPH) rates and outcomes. DESIGN: Before-and-after study. SETTING: Maternity care hospitals within the USA. POPULATION: Patients who delivered between February 2018 and November 2019. METHODS: Interprofessional obstetric teamwork training (OB-STaT) conducted at each hospital. Electronic medical records for deliveries were reviewed for 6 months before and after conducting OB-STaT at participating hospitals. MAIN OUTCOME MEASURES: The PPH rate (blood loss of ≥1000 ml), uterotonic medications used, tranexamic acid use, blood product transfusion, hysterectomy, length of stay and composite maternal morbidity (postpartum haemorrhage, hysterectomy, transfusion of ≥4 units of blood products and intensive care unit admission for PPH). RESULTS: A total of 9980 deliveries were analysed: 5059 before and 4921 after OB-STaT. The PPH rates did not change significantly (5.48% before vs 5.14% after, p = 0.46). Composite maternal morbidity decreased significantly by 1.1% (6.35%-5.28%, p = 0.03), massive transfusions decreased by 57% (0.42%-0.18%, p = 0.04) and the mean postpartum length of stay decreased from 2.05 days (1.05 days SD) to 2.01 days (0.91 days SD) (p = 0.04). Following OB-STaT, haemorrhage medication use increased by 36% (14.8%-51.2%, p = 0.03), the use of tranexamic acid for PPH treatment almost doubled (2.7%-4.8%, p < 0.001) and the rate of hysterectomy significantly increased (0%-0.1%, p = 0.03). CONCLUSIONS: Although the PPH rates did not decrease, OB-STaT significantly improved maternal morbidity, decreased massive transfusions, and improved PPH management by increasing the utilization of uterotonic medications, tranexamic acid and hysterectomy.

Association of Pelvic Floor Disorders, Perceived Psychological Stress, and Military Service in U.S. Navy Servicewomen: A Cross-Sectional Survey.

IMPORTANCE: Pelvic floor disorders (PFDs) are linked to psychological stress and decreased work performance in civilian populations. Higher psychological stress is reported in female active-duty servicewomen (ADSW), which affects military readiness. OBJECTIVE: This study sought to associate PFDs, work-related challenges, and psychological stress in ADSW. STUDY DESIGN: We conducted a single-site, cross-sectional survey of ADSW seeking care in the urogynecology, family medicine, and women's health clinics between December 2018 and February 2020 using validated questionnaires to determine the prevalence of PFDs and the association with psychological stress, performance of military duties, and continued military service. RESULTS: One hundred seventy-eight U.S. Navy ADSW responded; most were seeking care for PFDs. The reported prevalence rates of PFDs were as follows: urinary incontinence, 53.7%; pelvic organ prolapse, 16.3%; fecal incontinence, 73.2%; and interstitial cystitis/bladder pain syndrome, 20.3%. Active-duty servicewomen with PFDs were more likely to have higher psychological stress scores (22.5 ± 3.7 vs 20.5 ± 4.2, P = 0.002) and body composition failures (22.0% vs 7.3%, P = 0.012), yet more strongly consider remaining on active service if they reported urinary incontinence (22.8% vs 1.8%) or interstitial cystitis/bladder pain syndrome (19.5% vs 1.8%; all P ≤ 0.001). No significant differences were noted in physical fitness failures or other military duties. CONCLUSIONS: For these U.S. Navy ADSW with PFDs, there was no significant difference in duty performance but reported psychological stress levels were higher. The presence of PFD was associated with women more strongly considering ongoing military service compared with other factors such as family, job, or career path.

Dissociating Fibroepithelioma of Pinkus From Internal Malignancy: A Single-Center Retrospective Study.

Fibroepithelioma of Pinkus (FeP) is a rare skin tumor with a clinical presentation similar to benign neoplasms such as acrochordons and seborrheic keratoses. Our study analyzed if there is an association between FeP and internal tumors, specifically gastrointestinal tract tumors. We retrospectively reviewed the medical records of patients with FeP for other tumors throughout their lives until 2020. Although the quality of documentation for each patient may have differed, this study suggests that the presence of FeP does not indicate the presence of gastrointestinal tract tumors, and there is no need for altered cancer screening recommendations for those with FeP.

Stretching and Self-Myofascial Release in Helicopter Aircrew to Reduce Neck and Back Pain (Phase 1).

INTRODUCTION: This prospective intervention study was designed to determine the efficacy of a standardized Preflight/Postflight Stretches (PPS) protocol to reduce subjective neck and back pain scores in helicopter aircrew. Aircrew transient back and neck pain is well documented, and there is currently no standardized preflight and postflight stretching protocol for Naval Aviation. METHODS: Subjects were recruited from two carrier air wing MH-60R squadrons at Naval Air Station Jacksonville. These carrier air wing squadrons were selected to control for size (number of aircrew), age, and operational tempo (number of flight hours). Subjects consisted of both pilots and enlisted aircrew. One squadron was designated as the control group, although the second squadron served as the intervention group. Subjects from both groups filled out the questionnaire. Only the intervention group completed the PPS protocol immediately after completing the questionnaire and before departing the squadron spaces for the aircraft outside. Upon landing, the aircrew completed a postflight debrief. Only the intervention group completed the PPS protocol after debrief. Both the intervention and control groups once again completed the questionnaire. Questionnaires were matched by using a generated anonymous subject ID. The amounts of change and pain levels were then compared using the Mann-Whitney test and the Fisher's exact test, respectively. RESULTS: The Kolmogorov-Smirnov test found the data to be nonparametric. The preflight and postflight overall (P ≤ .001), cervical (P ≤ .001), thoracic (P = .006), and lumbar (P = .004) differences between the control and intervention groups were found to be statistically significant when using the Mann-Whitney test. Preflight and postflight pain differences in the sacral region and "other" section were not found to be statistically significant (sacral, P = .618; others, P = .182). When evaluating the worsening of the pain level, 50 (92%) of the control flights in which PPS was not performed reported worse pain, compared to 21 (61.8%) in the intervention group where PPS was performed. The Fisher's exact test found the association between performing PPS and the worsening in pain to be statistically significant (P = .001) in the overall, cervical, thoracic, and lumbar regions. Therefore, the hypothesis was accepted in regard to overall pain, as well as in the cervical, thoracic, and lumbar regions. CONCLUSION: Aircrew back and neck pain because of flying is well documented. However, there is no standardized stretching protocol for aircrew to perform immediately preflight or postflight in U.S. Naval Aviation. This study demonstrated that PPS, a simple 5- to 7-min stretching routine, gives aircrew structure and can reduce postflight cervical, thoracic, lumbar, and overall pain. This phase proved to be safe as no adverse events were reported. The prehabilitation aspect could reduce conventional medical intervention, costly pharmacological management of neck and back pain, and be applied to other aviation populations in military and civilian communities.

Patient Handoff Processes: Implementation and Effects of Bedside Handoffs, the Teach-Back Method, and Discharge Bundles on an Inpatient Oncology Unit.

BACKGROUND: Bedside handoffs, the teach-back method, and discharge bundles have been shown to contribute to empowering patients to actively engage in their treatment. OBJECTIVES: The objectives were to identify patient activation scores, patient readmission rates, and nursing staff satisfaction before and after implementing bedside handoffs, the teach-back method, and discharge bundles on an inpatient oncology unit at a large military treatment facility. METHODS: A series of three cycles using the Plan-Do-Study-Act framework guided implementation of the multifaceted approach. Patient activation scores, readmission rates, staff satisfaction, and anecdotal feedback from patients and nursing staff were collected prior to and following implementation. FINDINGS: The sample of patients with cancer had high patient activation scores. After implementation of the multifaceted approach, readmission rates decreased from 32% to 25%, and staff satisfaction improved.

Complications of Sling Surgery for Stress Urinary Incontinence Among Female Military Beneficiaries.

BACKGROUND: Prior studies of complications after sling surgery excluded the large number of women in military treatment facilities (MTFs). OBJECTIVE: To characterize the postoperative complication rates after sling surgery for Stress urinary incontinence (SUI) within MTFs in the United States. MATERIALS AND METHODS: Retrospective cohort study of women aged 18 and older, with SUI, and who underwent either an outpatient or inpatient mid-urethral sling placement for SUI in any MTF in the United States between January 1, 2011 and December 31, 2012. RESULTS: During the study period, 348 surgeons performed 1632 slings. The average patient age was 47.2 years, and 22.4% of the patients had a concomitant pelvic organ prolapse procedure. Overall, 45.5% of subjects had at least one postoperative complication. Of the specific complications, urologic infectious complications were the most frequent, occurring in 25.2% of patients. Overall, only 0.9% of patients underwent a repeat incontinence procedure. In multivariate analyses, concomitant pelvic organ procedure was associated with an increased risk of bladder outlet obstruction and noninfectious urologic complications. Those with a Charlson comorbidity index score of 1 or more were more likely to have an infectious complication and a new diagnosis of pelvic pain. Women older than the median age were less likely than those below to experience treatment failure and a new diagnosis of pelvic pain. CONCLUSIONS: The population of women with SUI undergoing sling surgery at MTFs is a young population with postoperative complication rates lower than previously reported. However, the absolute overall complication rate is still high, specifically related to urinary tract infections, suggesting that significant opportunities exist for quality improvement.

Vape and Aviate: Electronic-Cigarette Use and Misuse in Naval Aviation.

Introduction: Electronic cigarettes (EC) are an emerging form of nicotine replacement that has had a discernible increase in prevalence in the general population. Little is known regarding EC use among different military demographic groups or the extent of influence that social determinants of health may have on the behavior. The purpose of this study was to assess the prevalence and correlates of EC use in a select population of active duty U.S. Naval personnel. This study is unique in that it allows for EC behavior comparison between a traditionally healthy demographic (aviators, a subset of aircrew) and a representative general military population sample. Materials and methods: Cross-sectional survey data were collected anonymously and analyzed in 2015-2016. Active duty Naval personnel (n = 977) were asked about ever trying ECs, frequency of use, and when was the last time an EC was used. Participants were assessed similarly regarding cigarette use. Descriptive and inferential statistics as well as multinomial logistic regression analyses were conducted using categorical and ordinal variables assigned to usage and demographic factors. This protocol was approved by the Institutional Review Board at Naval Hospital Portsmouth located in Portsmouth, Virginia. Results: Within the study population, 31.4% have tried ECs, 9.3% were current users, and only 3.8% were dual (EC and cigarettes) users. EC use was significantly associated with paygrade (enlisted), primary job duty (non-aircrew), and education (less than a bachelor degree, p < 0.001, p < 0.01, and p < 0.001, respectively). ECs were used at some point as a smoking cessation tool for 43.6% of current EC users (p < 0.001), 21.6% of current smokers, and only 5.6% of former smokers. Continued EC use after ever trying ECs (30.0%) was only slightly more prevalent as continued cigarette use after ever trying cigarettes (27.3%). Smokers were nearly five times more likely to currently use ECs compared with non-smokers. Trying cigarettes was associated with nearly 12 times the risk for trying ECs compared with those who never tried cigarettes. No significant misuse of ECs was noted; however, several cases of drinking, tasting, and touching EC fluid were reported. Conclusion: This study is unique in that it examines the use of electronic cigarettes among selected healthy and baseline groups within the active duty U.S. Navy population. The current prevalence of EC use among active duty personnel is much higher than previously thought. Continued use of ECs after ever trying them appears to exceed that of cigarettes even among healthy populations such as aircrew. The findings of increased risk of EC use among those with lower income and less than a bachelor's degree suggest social determinants of health implications. This study sheds new light on EC use, characteristics of use, addiction implications, and highlights concerns for a growing health risk behavior.

Military Surgeon Volume and Stress Incontinence Surgery Complications: A Retrospective Cohort Study.

STUDY OBJECTIVE: To compare 12-month postoperative complication rates in women who underwent sling procedures by high-volume versus low-volume surgeons at US military treatment facilities (MTFs). DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: US MTFs. PATIENTS: Female military beneficiaries enrolled in TRICARE. INTERVENTIONS: Sling surgery for stress urinary incontinence between January 1, 2011 and December 31, 2012. MEASUREMENTS AND MAIN RESULTS: The primary exposure was surgeon volume (high vs low). Surgeon volume was categorized as high or low based on the number of slings performed in the previous 2 years at US MTFs (January 1, 2009 to December 31, 2010). The primary outcome was a composite variable indicating at least 1 postoperative complication within 12 months. We used International Classification of Diseases, 9th revision and Current Procedural Terminology codes to identify postoperative complications that occurred in the 12 months after the index sling procedure. During the study period 348 gynecologic and urologic surgeons performed 1632 slings. The average patient age was 47.2 years. Based on our data distribution we classified surgeons as high volume (>12 slings/2 years) or low volume (<4 slings/2 years). High-volume surgeons operated on patients who were older, more likely to have comorbidities, and more likely to receive concomitant prolapse surgery. Using a cluster analysis the overall likelihood of at least 1 postoperative complication in 12 months for high-volume versus low-volume surgeons was 48.4% versus 42.2% (adjusted odds ratio, 1.24; 95% confidence interval, .99-1.54; p = .06). There were no differences between high- and low-volume surgeons in the rate of almost all other postoperative complications. CONCLUSION: No significant differences in 12-month complication rates after sling surgery, stratified by surgeon volume, were seen in a setting of overall low-volume military surgeons.

Surgical management of penetrating spinal cord injury primarily due to shrapnel and its effect on neurological outcome: a literature review and meta-analysis.

OBJECTIVE This study was performed to determine whether decompression of penetrating spinal cord injury (SCI) due to explosive shrapnel leads to greater neurological recovery than conservative management. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive literature search using PubMed/MEDLINE, Web of Science, Google Scholar, and the Defense Technical Information Center public site was conducted on May 2, 2016. Studies that described penetrating SCI with shrapnel as an etiology, included surgical and/or conservative management, and demonstrated admission and follow-up neurological status were eligible for inclusion in this study. Odds ratios were calculated for the overall effect of surgical treatment on neurological recovery. Funnel plots were used to evaluate publication bias. RESULTS Five case series (Level IV evidence) met the study criteria, and 2 of them had estimable odds ratios for use in the Forest plot analysis. Among the patients from all 5 studies, 65% were injured by shrapnel, 25% by high-velocity bullet, 8% by low-velocity bullet, and 2% by an unknown cause. A total of 288 patients were included in the overall odds ratio calculations. Patients were stratified by complete and incomplete SCI. The meta-analysis showed no significant difference in outcomes between surgical and conservative management in the complete SCI cohort or the incomplete SCI cohort. Overall rates of improvement for complete SCI were 25% with surgery and 27% with conservative treatment (OR 1.07, 95% CI 0.44-2.61, p = 0.88); for incomplete SCI, 70% with surgery and 81% with conservative treatment (OR 1.67, 95% CI 0.68-4.05, p = 0.26). CONCLUSIONS This study demonstrates no clear benefit to surgical decompression of penetrating SCI due predominantly to shrapnel. There is a considerable need for nonrandomized prospective cohort studies examining decompression and stabilization surgery for secondary and tertiary blast injuries.

Temporal artery and axillary thermometry comparison with rectal thermometry in children presenting to the ED.

BACKGROUND: Accurate temperature readings, often obtained rectally, are an important part of the initial evaluation of pediatric patients in the Emergency Department. Temporal artery thermometry (TAT) is one way to noninvasively measure temperature. We sought to compare the accuracy of axillary and temporal artery temperatures compared to rectal. METHODS: This prospective study included children age 0-36months presenting to the Emergency Department of a large military treatment facility. Rectal, axillary, and temporal artery temperatures were obtained. Test characteristics (sensitivity, specificity, NPV, PPV) were reported. The effect of cutoff values 99.9°F, 100.4°F, and 102.2°F on test characteristics were also evaluated. RESULTS: The sensitivities of axillary and temporal artery thermometry to detect rectal fever is 11.5% and 61.5% respectively. Cutoff values did not significantly alter test characteristics. In this study, temporal artery thermometry was 0.2°C lower than rectal temperature, axillary measurement was 0.9°C below the reference standard. Mean temperature difference in the febrile group between TAT and rectal thermometry was >0.5°C compared with a mean temperature difference 0.05°C in afebrile patients. CONCLUSION: The findings of our study do not support using axillary thermometry to screen pediatric patients for fever in the emergency department. TAT cannot be recommended as a rectal thermometry replacement where height and duration of fever are used in pediatric disease prediction models. TAT may have a role in screening for fever in the appropriate pediatric patient population like primary orthopedic or trauma presentations where the balance between device precision, data capture and patient comfort may favor use of TAT.

Patterns and perceptions of supplement use by U.S. Marines deployed to Afghanistan.

Dietary supplements are implicated in an increasing number of minor and serious adverse events, including death. A series of adverse events in deployed Marines using multiple supplements prompted medical officers to investigate the prevalence of supplement use among Marines stationed on Camp Leatherneck, Afghanistan. The investigators developed a survey to identify the types of supplements used, patterns of supplement use, reasons for taking supplements, perceived benefits from using supplements, and self-reported adverse effects. Marines were invited to complete an anonymous 17-question survey while visiting recreational and athletic facilities. A total of 329 active duty Marines completed the survey. The prevalence of supplement use was 72% for males and 42% for females (p = 0.009). Of the 12% of Marines reporting side effects, 79% were taking multiple supplements and 89% were using stimulants. Deployment was significantly associated with new supplement use (p < 0.001). Of users, 81% noted an improvement in physical performance. The majority of deployed Marines use multiple dietary supplements and perceive a high benefit. Given the high prevalence of supplement use and recent deaths associated with supplement use, recommendations are needed to guide the use of certain supplements by U.S. Marines in the deployed environment.

The implementation of interconception care in two community health settings: lessons learned.

PURPOSE: This study reports on an evaluation of the implementation of a pilot interconceptional care program (ICCP) in Chicago and the experiences of the participants in their first postpartum year. DESIGN: A longitudinal, multi-method approach was used to gather data to measure success in achieving project benchmarks and to gain insights into women's experiences after an adverse pregnancy outcome. SETTING: The ICCP interventions were provided in two different health care settings. SUBJECTS: Low-income African-American women with a prior adverse pregnancy outcome were recruited to participate. Data on services delivered are available for 220 women; linked interview data are also available for 99 of these women. INTERVENTION: The ICCP focused on the integration of social services, family planning, and medical care provided through a team approach. MEASURES: An interview questionnaire asked detailed information about interconceptional health status, attitudes, and behaviors. A services database documented all services delivered to each participant. Key informant interviews were conducted with the ICCP project staff. ANALYSIS: Simple frequencies were generated. Chi-square and t-tests were used to compare participants and benchmarks at the two different sites. RESULTS: The planned delivery of interventions based on women's unique interconceptional health needs was often replaced by efforts to address women's socioeconomic needs. Although medical care remained important, participants viewed themselves as healthy and did not view medical care as a priority. Women's perceptions of contraceptive effectiveness were not always in sync with clinical knowledge. CONCLUSIONS: Interconceptional care is a complex process of matching interventions and services to meet women's unique needs, including their socioeconomic needs.

Now what? Effects of on-site assessment on treatment entry after perinatal depression screening.

BACKGROUND: Depression is a frequent accompaniment of the perinatal period. Although screening improves detection of perinatal depression, it does not in itself improve mental health treatment entry and, therefore, does not improve outcomes. This study addresses the feasibility of incorporating diagnostic assessment for depression directly into perinatal care visits and the influence of doing so on entry into mental health treatment. METHODS: The Perinatal Depression Management Program was implemented in an urban community health center serving a predominantly Hispanic population. The Patient Health Questionnaire (PHQ-9) was administered during perinatal visits. Positive screens (scores ≥10) were followed within the same visit by brief diagnostic assessment and engagement strategies. Chart review was conducted to compare rates of screening, assessment, and treatment entry during a 3-month baseline period before implementation of the intervention (n=141) with a 1-year period after implementation of the intervention (n=400). RESULTS: Before the intervention, 65.2% of patients completed a PHQ-9, and 10% of patients with positive screens received on-site assessment. None of the patients with identified perinatal depression entered treatment. After model implementation, significantly more (93.5%) completed a PHQ-9, and of patients with positive screens, 84.8% received an on-site assessment. Among patients diagnosed with major depression and offered treatment, 90% entered treatment. CONCLUSIONS: It is feasible to implement diagnostic assessment for depression within perinatal clinic visits. Doing so may substantially increase entry into mental health treatment for women with perinatal major depression while reducing unnecessary mental health referral of patients with false positive screens.