TReating Incontinence for Underlying Mental and Physical Health (TRIUMPH): a study protocol for a multicenter, double-blinded, randomized, 3-arm trial to evaluate the multisystem effects of pharmacologic treatment strategies for urgency-predominant urinary incontinence in ambulatory older women.

BACKGROUND: Urgency-type urinary incontinence affects one in four older community-dwelling women and overlaps with other common aging-associated health syndromes such as cognitive impairment, physical mobility impairment, and depression. Observational studies have raised concern about potentially higher rates of delirium and dementia in older adults taking anticholinergic bladder medications, but few prospective data are available to evaluate the effects of these and other pharmacologic treatments for urgency incontinence on cognition and other multisystem functional domains important to older women. METHODS: The TRIUMPH study is a randomized, double-blinded, 3-arm, parallel-group trial comparing the multisystem effects of anticholinergic versus beta-3-adrenergic agonist bladder therapy and versus no active bladder anti-spasmodic pharmacotherapy in older women with urgency incontinence. Women aged 60 years and older (target N = 270) who have chronic urgency-predominant urinary incontinence and either normal or mildly impaired cognition at baseline are recruited from the community by investigators based in northern California, USA. Participants are randomized in equal ratios to take identically encapsulated oral anticholinergic bladder therapy (in the form of tolterodine 2 mg extended release [ER]), oral beta-3 adrenergic agonist bladder therapy (mirabegron 25 mg ER), or placebo daily for 24 weeks, with the option of participant-directed dose titration (to tolterodine 4 mg ER, mirabegron 50 mg ER, or matching placebo daily). Participants also receive patient-oriented information and instructions about practicing first-line behavioral management strategies for incontinence. The primary outcome is change in composite cognitive function over 24 weeks assessed by a comprehensive battery of cognitive tests, with a secondary exploration of the persistence of change at 36 weeks. Secondary outcomes include changes over 24 and 36 weeks in domain-specific cognitive function; frequency, severity, and impact of urgency-associated urinary symptoms; physical function and balance; sleep quality and daytime sleepiness; psychological function; and bowel function. DISCUSSION: The TRIUMPH trial addresses the need for rigorous evidence to guide counseling and decision-making for older women who are weighing the potential multisystem benefits and risks of pharmacologic treatments for urgency incontinence in order to preserve their day-to-day functioning, quality of life, and independence in older age. TRIAL REGISTRATION: ClinicalTrials.gov NCT05362292. Registered on May 5, 2022.

Use of a rapid digital microfluidics-powered immunoassay for assessing measles and rubella infection and immunity in outbreak settings in the Democratic Republic of the Congo.

The Democratic Republic of the Congo (DRC) has a high measles incidence despite elimination efforts and has yet to introduce rubella vaccine. We evaluated the performance of a prototype rapid digital microfluidics powered (DMF) enzyme-linked immunoassay (ELISA) assessing measles and rubella infection, by testing for immunoglobulin M (IgM), and immunity from natural infection or vaccine, by testing immunoglobulin G (IgG), in outbreak settings. Field evaluations were conducted during September 2017, in Kinshasa province, DRC. Blood specimens were collected during an outbreak investigation of suspected measles cases and tested for measles and rubella IgM and IgG using the DMF-ELISA in the field. Simultaneously, a household serosurvey for measles and rubella IgG was conducted in a recently confirmed measles outbreak area. DMF-ELISA results were compared with reference ELISA results tested at DRC's National Public Health Laboratory and the US Centers for Disease Control and Prevention. Of 157 suspected measles cases, rubella IgM was detected in 54% while measles IgM was detected in 13%. Measles IgG-positive cases were higher among vaccinated persons (87%) than unvaccinated persons (72%). In the recent measles outbreak area, measles IgG seroprevalence was 93% overall, while rubella seroprevalence was lower for children (77%) than women (98%). Compared with reference ELISA, DMF-ELISA sensitivity and specificity were 82% and 78% for measles IgG; 88% and 89% for measles IgM; 85% and 85% for rubella IgG; and 81% and 83% for rubella IgM, respectively. Rubella infection was detected in more than half of persons meeting the suspected measles case definition during a presumed measles outbreak, suggesting substantial unrecognized rubella incidence, and highlighting the need for rubella vaccine introduction into the national schedule. The performance of the DMF-ELISA suggested that this technology can be used to develop rapid diagnostic tests for measles and rubella.

Impact of the COVID-19 Controlled Drugs and Substances Act exemption on pharmacist prescribing of opioids, benzodiazepines and stimulants in Ontario: A cross-sectional time-series analysis.

Background: Due to the coronavirus disease 2019 (COVID-19) pandemic, Health Canada issued an exemption to the Controlled Drugs and Substances Act (CDSA) on March 19, 2020, enabling pharmacists to act as prescribers of controlled substances to support continuity of care. Our study investigates utilization of the CDSA exemption by Ontario pharmacists with the intent to inform policy on pharmacist scope of practice and to improve future patient outcomes. Methods: We conducted a time-series analysis of pharmacist-prescribed opioid, benzodiazepine and stimulant claims data using Ontario Narcotics Monitoring System (NMS) data between January 2019 and December 2021. We used ARIMA modelling to measure the change to these classes of claims and to opioid claims containing quantities greater than a 30-day supply. Results: Postexemption, the average weekly number of pharmacist-prescribed opioid, benzodiazepine and stimulant claims rose by 146% (160 to 393 claims/week), 960% (49 to 515 claims/week) and 2150% (8 to 177 claims/week), respectively. There was a 2-week lag period between the time of announcement and the statistically significant increase in claims on April 5, 2020(p < 0.0001). The total number of claims for opioid quantities exceeding a 30-day supply decreased by 60%. Cumulative pharmacist-prescribed claims accounted for under 2% of the total NMS claims. Interpretation: Ontario pharmacists used the CDSA exemption but were prescribing at low rates. These findings suggest an effective change to pharmacy practice as the low rates show pharmacists used the exemption as a last line of defense. This may lead to further studies exploring treatment breaks during the COVID-19 pandemic and future changes to pharmacist scope to benefit patients.

Congenital Syphilis: A Case Report Demonstrating Missed Opportunities for Screening and Inadequate Treatment Despite Multiple Health Care Encounters During Pregnancy.

ABSTRACT: A case of congenital syphilis due to multiple missed opportunities, highlights the challenges of treating syphilis during pregnancy. Although cases are increasing in the United States, congenital syphilis, a disease with devastating consequences, is preventable.

A Cross-Sectional Study Examining Differences in Indication for Cesarean Delivery by Race/Ethnicity.

(1) Background: There are persistent racial/ethnic disparities in cesarean delivery in the United States (U.S.), yet the causes remain unknown. One factor could be provider bias. We examined medical indications for cesarean delivery that involve a greater degree of physician discretion (more subjective) versus medical indications that involve less physician discretion (more objective) to better understand factors contributing to the higher rate among Micronesian, one of the most recent migrant groups in the state, compared to White women in Hawai'i. (2) Methods: A retrospective chart review was conducted to collect data on 620 cesarean deliveries (N = 296 White and N = 324 Micronesian) at the state's largest maternity hospital. Multivariate regression models were used to examine associations between maternal and obstetric characteristics and (1) subjective indication defined as non-reassuring fetal heart tracing (NRFHT) and arrest of labor disorders, and (2) objective indication defined as all other indications (e.g., malpresentation). (3) Results: We found that Micronesian women had significantly higher odds of cesarean delivery due to a subjective indication compared to White women (aOR: 4.17; CI: 2.52-6.88; P < 0.001; N = 619) after adjusting for multiple covariates. (4) Conclusion: These findings suggest unmeasured factors, possibly provider bias, may influence cesarean delivery recommendations for Micronesian women in Hawai'i.

Perspectives and Experiences of Obstetricians Who Provide Labor and Delivery Care for Micronesian Women in Hawai'i: What Is Driving Cesarean Delivery Rates?

Access to cesarean delivery is vital for quality obstetrical care, but the procedure can increase maternal mortality, morbidity, and complications in subsequent deliveries. The objective of this study was to describe obstetrician-gynecologists' (OB-GYNs) perspectives on labor and delivery care for Micronesian women in Hawai'i and possible factors contributing to higher cesarean delivery rates among that racial/ethnic group. The Framework Method guided the analysis of 13 semi-structured interviews with OB-GYNs. Study results indicated that OB-GYNs were more likely to attribute racial/ethnic differences in mode of delivery to challenges resulting from nonmedical factors, particularly communication and negative attitudes toward Micronesian patients, than to medical risk factors. In this study, we explored aspects of care that cannot be captured in medical charts or clinical data, but may impact health outcomes for this population. The findings could help improve care for Micronesian women, with lessons applicable to other racial/ethnic minority groups.

Examining the validity of a predictive model for vaginal birth after cesarean.

Background The Maternal-Fetal Medicine Units (MFMU) vaginal birth after cesarean (VBAC) calculator, while accurate for candidates with high predicted success rates, is not as accurate for poor candidates. This study examines the calculator's validity in an understudied multiracial cohort with a high proportion of poor candidates. Methods This retrospective study examined women with one or two prior cesarean deliveries who attempted VBAC at a single institution. Subjects were placed into quartiles based on MFMU-predicted success rates. For each quartile, actual and predicted success rates were compared. The calculated area under the receiver operating characteristic curve (AUC) was compared to the original AUC. Results The study included 1604 women. Actual and predicted VBAC rates were similar in the lowest and highest quartile groups, 18.2% vs. 21.2% (n = 11, P > 0.99) and 87.1% vs. 88.5% (n = 1090, P = 0.14), respectively. In the 51-75% predicted success rate group, the actual VBAC rate was higher than the predicted rate, 69.9% vs. 65.5% (n = 394) but not statistically significant (P = 0.07). In the 25-50% predicted success rate group, the actual VBAC rate was significantly higher than the predicted rate 55.1% vs. 39.6% (n = 109, P = 0.002). The actual AUC was lower than the MFMU model, 0.72 [95% confidence interval (CI) 0.69-0.75] vs. 0.77 (95% CI 0.76-0.78) (P < 0.001). Conclusion The MFMU VBAC calculator's predicted success rates were comparable to actual success rates for candidates with predicted success rates >75%. As predicted success rates declined, the calculator was increasingly inaccurate and underestimated the success rate. Caution should be taken when using the MFMU VBAC calculator for poor candidates.

Recruitment and retention of US South Asians for an epidemiologic cohort: Experience from the MASALA study.

INTRODUCTION: There are few longitudinal studies about South Asians (SAs) and little information about recruitment and retention approaches for this ethnic group. METHODS: We followed 906 SAs enrolled in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort for 5 years. Surviving participants were invited for a second clinical exam from 2015 to 2018. A new wave of participants was recruited during 2017-2018. We assessed the yields from different methods of recruitment and retention. RESULTS: A total of 759 (83%) completed the second clinical exam, and 258 new participants were enrolled. Providing a nearby community hospital location for the study exam, offering cab/shared ride reimbursement, and conducting home visits were the most effective methods for enhancing retention. New participant recruitment targeted women and individuals with lower socioeconomic status, and we found that participant referrals and active community engagement were most effective. Mailing invitational letters to those identified by electronic health records had very low yield. CONCLUSION: Recruitment and retention strategies that address transportation barriers and increase community engagement will help increase the representation of SAs in health research.

Patient Perspectives in Comparing Hospitals for Childbirth: Insights from Hawai'i.

Childbirth is a national priority area for healthcare quality improvement. Patient perspectives are increasingly valued in healthcare, yet Asian American and Pacific Islander (AAPI) perspectives of healthcare quality are often understudied, particularly from individuals with limited English proficiency (LEP). Our study goal was to understand factors that consumers in Hawai'i, including AAPI and those with LEP, use to compare patient care in hospitals, especially for childbirth. A total of 400 women ages 18 years and older with a recent childbirth completed an in-person interview in English (n=291), Tagalog (n=42), Chinese (n=36), or Marshallese (n=31) on O'ahu, Hawai'i. Participants described if (yes/no), and how (open-ended), they believed hospitals in the state varied in providing patient care. Open-ended responses were coded by two independent raters using the framework approach. Respondents were 53.3% Asian, 30.8% Pacific Islander, 13.5% White, and 2.5% other race/ethnicity; 17.8% reported limited English proficiency. Overall, 66.8% of respondents affirmed that local hospitals varied in patient care; Marshallese, other Pacific Islanders, and non-English speakers were significantly less likely to say that Hawai'i hospitals varied in patient care. Among those who endorsed hospital variation, commonly reported themes about this variation were: (1) patient experience, (2) patient overall impression, (3) childbirth options (eg, waterbirths), (4) staff, (5) facilities (eg, "emergency capabilities"), (6) high-tech levels of care, and (7) the hospital's area of focus (eg, "women and children"). We provide insights into factors that diverse patients use to compare patient care in hospitals in Hawai'i to add value, relevance, and engagement to healthcare quality research and dissemination efforts.

Health Locus of Control Beliefs in Health Care Providers in the Pacific Basin.

As part of the strategic plan to improve preconception care, health care providers are advised to counsel women about developing a reproductive life plan. Women are asked think about whether they want to become pregnant and have children and if so, when they would like to do so. The utility of a reproductive life plan is based on the premise that an individual has control over their own health and reproduction. Less is known regarding the beliefs of health care providers which may be important for strategizing educational and training programs. We conducted this project to examine whether health care providers in the Pacific Basin region who are providing reproductive health care, believe they have control over their own health. The Multidimensional Health Locus of Control Scale was used to survey attendees of the Annual Title X Reproductive Health Conference in Saipan, Commonwealth of the Northern Marianas. The cohort of reproductive health care providers surveyed (n=21) showed high internal control scores with a mean of 29.9 (SD = 3.5) and a range of 21 to 36 (maximum score = 36) consistent with individuals who have a strong belief that their health is most influenced by their own behavior. Chance and "powerful others" scores were consistent with means noted in other studies of healthy individuals. Understanding providers' health beliefs can aid in designing and executing more effective interventions to improve reproductive health outcomes.

Understanding of Key Obstetric Quality Terminology by Asian and Pacific Islander Subgroups: Implications for Patient Engagement and Health Equity.

Introduction Comprehension of healthcare terminology across diverse populations is critical to patient education and engagement. Methods Women in Oahu, Hawai'i with a recent delivery were interviewed about their understanding of ten common obstetric terms. Health literacy was assessed by the rapid estimate of adult literacy in medicine (REALM). Multivariable models predicted total terms comprehended by demographic factors. Results Of 269 participants, self-reported primary race was 20.5% Japanese, 19.0% Native Hawaiian, 19.0% White, 16.7% Filipino, 11.5% other Asian, 9.7% other Pacific Islander, and 3.7% other race/ethnicity; 12.7% had low health literacy. On average, participants understood 6.0 (SD: 2.2) of ten common obstetric terms. Comprehension varied by term, ranging from 97.8% for "Breastfeeding" to 27.5% for "VBAC routinely available." Models showed (1) being Filipino, Japanese, Native Hawaiian, or other Pacific Islander (vs. white); (2) having low (vs. adequate) health literacy; (3) having a high school (vs. a college) degree; and (4) being under 25-years-old (vs. 35 +) were significantly associated with less comprehension. Discussion Participants were unfamiliar with common obstetrics terminology. Comprehension struggles were more common among populations with maternal health disparities, including Asian and Pacific Islander subgroups, and those with low health literacy.

Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism.

BACKGROUND: It may be possible to safely rule out pulmonary embolism (PE) in patients with low pretest probability (PTP) using a higher than standard D-dimer threshold. The YEARS criteria, which include three questions from the Wells PE score to identify low-PTP patients and a variable D-dimer threshold, was recently shown to decrease the need for imaging to rule out PE by 14% in a multicenter study in the Netherlands. However, the YEARS approach has not been studied in the United States. METHODS: This study was a prospective, observational study of consecutive adult patients evaluated for PE in 17 U.S. emergency departments. Prior to diagnostic testing, we collected the YEARS criteria: "Does the patient have clinical signs or symptoms of DVT?" "Does the patient have hemoptysis?" "Are alternative diagnoses less likely than PE?" with YEARS (+) being any "yes" response. A negative D-dimer was <1000 mg/dL for YEARS (-) patients and <500 mg/dL for YEARS (+) patients. We calculated test characteristics and used Fisher's exact test to compare proportions of patients who would have been referred for imaging and patients who would have had PE "missed." RESULTS: Of 1,789 patients, 84 (4%) had PE, 1,134 (63%) were female, 1,038 (58%) were white, and mean (±SD) age was 48 (±16) years. Using the standard D-dimer threshold, 940 (53%) would not have had imaging, with two (0.2%, 95% confidence interval [CI] = 0.02%-0.60%) missed PE. Using YEARS adjustment, 1,204 (67%, 95% CI = 65%-69%) would not have been referred for imaging, with six (0.5%, 95% CI = 0.18%-1.1%) missed PE, and using "alternative diagnoses less likely than PE" adjustment, 1,237 (69%, 95% CI = 67%-71%) would not have had imaging with six (0.49%, 95% CI = 0.18%-1.05%) missed PE. Sensitivity was 97.6% (95% CI = 91.7%-99.7%) for the standard threshold and 92.9% (95% CI = 85%-97%) for both adjusted thresholds. Negative predictive value (NPV) was nearly 100% for all approaches. CONCLUSIONS: D-dimer adjustment based on PTP may result in a reduced need for imaging to evaluate possible PE, with some additional missed PE but no decrease in NPV.

Phylogenetic patterns of trait and trait plasticity evolution: Insights from amphibian embryos.

Environmental variation favors the evolution of phenotypic plasticity. For many species, we understand the costs and benefits of different phenotypes, but we lack a broad understanding of how plastic traits evolve across large clades. Using identical experiments conducted across North America, we examined prey responses to predator cues. We quantified five life-history traits and the magnitude of their plasticity for 23 amphibian species/populations (spanning three families and five genera) when exposed to no cues, crushed-egg cues, and predatory crayfish cues. Embryonic responses varied considerably among species and phylogenetic signal was common among the traits, whereas phylogenetic signal was rare for trait plasticities. Among trait-evolution models, the Ornstein-Uhlenbeck (OU) model provided the best fit or was essentially tied with Brownian motion. Using the best fitting model, evolutionary rates for plasticities were higher than traits for three life-history traits and lower for two. These data suggest that the evolution of life-history traits in amphibian embryos is more constrained by a species' position in the phylogeny than is the evolution of life history plasticities. The fact that an OU model of trait evolution was often a good fit to patterns of trait variation may indicate adaptive optima for traits and their plasticities.

Key Factors in Obstetric Delivery Decision-Making among Asian and Pacific Islander Women by English Proficiency.

Childbirth is the most common reason women are hospitalized in the United States. Understanding (1) how expectant mothers gather information to decide where to give birth, and (2) who helps make that decision, provides critical health communication and decision-making insights. Diverse Asian American and Pacific Islander (AA/PI) perspectives on such topics are understudied, particularly among those with limited English proficiency (LEP). LEP is defined as having a limited ability to read, write, speak, or understand English. To address this research gap, we interviewed 400 women (18+ years) with a recent live birth on O'ahu, Hawai'i. Participants completed a 1-hour, in-person interview in English (n=291), Tagalog (n=42), Chinese (n=36), or Marshallese (n=31). Women were asked (1) what information was most important in deciding where to deliver and why; and (2) who participated in the decision-making and why. Responses were compared by LEP (n=71; 18%) vs English-proficient (n=329; 82%) in qualitative and quantitative analyses. Both LEP and English-proficient participants reported their obstetrician as the most important source of health information. Significantly more LEP participants valued advice from family or acquaintances as important sources of information compared to English-proficient participants. The top three health decision-makers for both those with LEP and English-proficient participants were themselves, their obstetrician, and their spouse, which did not differ significantly by language proficiency. These findings provide insights into health information sources and decision-making across diverse AA/PI populations, including those with LEP, and can help direct health interventions such as disseminating patient education and healthcare quality information.

Exome and genome sequencing of nasopharynx cancer identifies NF-κB pathway activating mutations.

Nasopharyngeal carcinoma (NPC) is an aggressive head and neck cancer characterized by Epstein-Barr virus (EBV) infection and dense lymphocyte infiltration. The scarcity of NPC genomic data hinders the understanding of NPC biology, disease progression and rational therapy design. Here we performed whole-exome sequencing (WES) on 111 micro-dissected EBV-positive NPCs, with 15 cases subjected to further whole-genome sequencing (WGS), to determine its mutational landscape. We identified enrichment for genomic aberrations of multiple negative regulators of the NF-κB pathway, including CYLD, TRAF3, NFKBIA and NLRC5, in a total of 41% of cases. Functional analysis confirmed inactivating CYLD mutations as drivers for NPC cell growth. The EBV oncoprotein latent membrane protein 1 (LMP1) functions to constitutively activate NF-κB signalling, and we observed mutual exclusivity among tumours with somatic NF-κB pathway aberrations and LMP1-overexpression, suggesting that NF-κB activation is selected for by both somatic and viral events during NPC pathogenesis.

Programmed Death-Ligand 1 Expression, Microsatellite Instability, Epstein-Barr Virus, and Human Papillomavirus in Nasopharyngeal Carcinomas of Patients from the Philippines.

Most nasopharyngeal carcinomas (NPCs) in a high-incidence population are driven by Epstein-Barr virus (EBV) infection. EBV-associated malignancies have increased expression of the programmed death-ligand 1 (PD-L1). Immunotherapy agents targeting the PD-1/PD-L1 pathway have achieved durable treatment effects in patients with various cancer types including EBV-associated malignancies. In this study, we sought to investigate PD-L1 expression in a cohort of patients with NPCs from the Philippines. Fifty-six NPCs were studied for PD-L1, p16, and DNA mismatch repair (MMR) deficiency by immunohistochemistry. One case with MMR deficiency was also assessed for microsatellite instability (MSI) by polymerase chain reaction. EBV and human papillomavirus (HPV) status were tested by in situ hybridization. All NPCs were p16 negative. Three of the 56 NPCs (5%) were EBV negative (EBV-) and HPV negative, while one NPC (1/56, 2%) was EBV positive and showed MSI (EBV+/MSI). Positive PD-L1 expression (PD-L1+), defined as membranous staining in ≥1% tumor cells, was seen in 64% (36/56) of NPCs. All three EBV- NPCs were PD-L1+ as was the EBV+/MSI NPC. PD-L1+ was seen significantly more often in NPCs from non-smokers than those from smokers (23/28, 82% vs 9/18, 50%; P = 0.047). PD-L1+ was not associated with pT, pN, distant metastasis, or clinical stage (P > 0.05). PD-L1+ was not associated with overall survival (P = 0.473). In summary, our results show frequent PD-L1 expression in NPCs regardless of EBV status and a preferential PD-L1 expression in non-smokers. MSI and HPV positivity are exceedingly rare in NPCs.

Correlational selection on personality and social plasticity: morphology and social context determine behavioural effects on mating success.

Despite a central line of research aimed at quantifying relationships between mating success and sexually dimorphic traits (e.g., ornaments), individual variation in sexually selected traits often explains only a modest portion of the variation in mating success. Another line of research suggests that a significant portion of the variation in mating success observed in animal populations could be explained by correlational selection, where the fitness advantage of a given trait depends on other components of an individual's phenotype and/or its environment. We tested the hypothesis that interactions between multiple traits within an individual (phenotype dependence) or between an individual's phenotype and its social environment (context dependence) can select for individual differences in behaviour (i.e., personality) and social plasticity. To quantify the importance of phenotype- and context-dependent selection on mating success, we repeatedly measured the behaviour, social environment and mating success of about 300 male stream water striders, Aquarius remigis. Rather than explaining individual differences in long-term mating success, we instead quantified how the combination of a male's phenotype interacted with the immediate social context to explain variation in hour-by-hour mating decisions. We suggest that this analysis captures more of the mechanisms leading to differences in mating success. Males differed consistently in activity, aggressiveness and social plasticity. The mating advantage of these behavioural traits depended on male morphology and varied with the number of rival males in the pool, suggesting mechanisms selecting for consistent differences in behaviour and social plasticity. Accounting for phenotype and context dependence improved the amount of variation in male mating success we explained statistically by 30-274%. Our analysis of the determinants of male mating success provides important insights into the evolutionary forces that shape phenotypic variation. In particular, our results suggest that sexual selection is likely to favour individual differences in behaviour, social plasticity (i.e., individuals adjusting their behaviour), niche preference (i.e., individuals dispersing to particular social conditions) or social niche construction (i.e., individuals modifying the social environment). The true effect of sexual traits can only be understood in interaction with the individual's phenotype and environment.

Working Toward a Competency-Based Preceptor Development Program.

Preceptorship programs are widely used in nursing education and transition to practice. This article describes a variety of improvements implemented in an academic health sciences center on the basis of findings from a study previously conducted with preceptors in the same institution. A long-standing preceptor preparation program was redesigned and expanded into two levels-an introductory workshop directed toward meeting the needs of new preceptors, and an advanced workshop for experienced preceptors. Organization-specific preceptor competencies were developed as a foundation for preceptor practice. The competencies also informed the revised preceptor development program that included selection, ongoing development, and evaluation. A more structured support system, a standardized performance feedback process, and additional recognition strategies were incorporated in the new competency-based preceptor program. J Contin Educ Nurs. 2016;47(9):427-432.

Cesarean delivery complications in women with morbid obesity.

OBJECTIVE: To compare cesarean complication rates between women with body mass index (BMI) 40-49.9 kg/m(2) and BMI ≥ 50 kg/m(2) and associations with surgical techniques. METHODS: This retrospective cohort study from 2009 to 2014 included women who underwent cesarean with delivery BMI ≥ 50 and an equal number with BMI 40-49.9. Wound infections and/or separations were compared. We also examined wound complication rates between skin closure techniques and self-retaining retractor use. RESULTS: Among 498 patients (249 with BMI ≥ 50 and 249 with BMI 40-49.9) there were no differences in estimated blood loss >1000 mL, blood transfusion, deep vein thrombosis or endometritis. Among those with outpatient follow-up (144 with BMI ≥ 50 and 162 with BMI 40-49.9), those with BMI ≥ 50 had a significantly higher rate of wound separations (p = 0.01) but not infections. There were no differences in wound complication rates between skin closure techniques or self-retaining retractor use, though the study was not powered for these comparisons. CONCLUSION: Wound complications, particularly separations, increase with BMI ≥ 50 compared to a lesser degree of morbid obesity. Skin closure techniques and self-retaining retractor use were not associated with cesarean wound complications in patients with morbid obesity.

Comparison of Primary Cesarean Delivery Rates Among Low-Risk Women in Urban and Rural Hospitals in Hawaii.

Objective The purpose of this study was to examine primary cesarean delivery rates among women with low risk pregnancies in urban and rural hospitals in Hawaii. Methods This is a retrospective study of all low-risk women (term, vertex, singleton) who had a primary cesarean delivery in any Hawaii hospital from 2010 to 2011 using a statewide health information database. Hospitals were divided into two categories: rural and urban. Results Of the 27,096 women who met criteria for this study, 7105 (26.2 %) delivered in a rural hospital. Low-risk women who delivered in a rural hospital had a primary cesarean delivery rate of 18.5 % compared to 11.8 % in the urban hospitals, p < .0001. Low-risk women who delivered at rural hospitals had significantly higher unadjusted and adjusted odds ratios for cesarean delivery. The association with rural hospital was stronger after adjusting for confounders, aOR 2.47 (95 % CI 2.23-2.73) compared to unadjusted OR 1.70 (95 % CI 1.58-1.83) for primary cesarean delivery. Conclusions on practice In a geographically isolated population, rates of primary cesarean delivery among low-risk women are significantly higher in rural hospitals. This disparity should be investigated further.