Acute obstetric coagulopathy during postpartum hemorrhage is caused by hyperfibrinolysis and dysfibrinogenemia: an observational cohort study.

BACKGROUND: Postpartum hemorrhage (PPH) may be exacerbated by hemostatic impairment. Information about PPH-associated coagulopathy is limited, often resulting in treatment strategies based on data derived from trauma studies. OBJECTIVES: To investigate hemostatic changes associated with PPH. PATIENTS/METHODS: From a population of 11 279 maternities, 518 (4.6%) women were recruited with PPH ≥ 1000 mL or placental abruption, amniotic fluid embolism, or concealed bleeding. Routine coagulation and viscoelastometric results were collated. Stored plasma samples were used to investigate women with bleeds > 2000 mL or those at increased risk of coagulopathy defined as placenta abruption, amniotic fluid embolism, or need for blood components. Procoagulant factors were assayed and global hemostasis was assessed using thrombin generation. Fibrinolysis was investigated with D-dimer and plasmin/antiplasmin complexes. Dysfibrinogenemia was assessed using the Clauss/antigen ratio. RESULTS: At 1000 mL blood loss, Clauss fibrinogen was ≤2 g/L in 2.4% of women and 6/27 (22.2%) cases of abruption. Women with very large bleeds (>3000 mL) had evidence of a dilutional coagulopathy, although hemostatic impairment was uncommon. A subgroup of 12 women (1.06/1000 maternities) had a distinct coagulopathy characterized by massive fibrinolysis (plasmin/antiplasmin > 40 000 ng/mL), increased D-dimer, hypofibrinogenemia, dysfibrinogenemia, reduced factor V and factor VIII, and increased activated protein C, termed acute obstetric coagulopathy. It was associated with fetal or neonatal death in 50% of cases and increased maternal morbidity. CONCLUSIONS: Clinically significant hemostatic impairment is uncommon during PPH, but a subgroup of women have a distinct and severe coagulopathy characterized by hyperfibrinolysis, low fibrinogen, and dysfibrinogenemia associated with poor fetal outcomes.

Does Public Reporting of Staffing Ratios and Nursing Home Compare Ratings Matter?

OBJECTIVE: Public reporting is a policy to improve quality and increase data transparency. The objective was to examine the association between publicly available staffing ratios and the Five-Star Quality Ratings from Nursing Home Compare over time. DESIGN: Panel data analysis. SETTING AND PARTICIPANTS: About 146 nursing homes with complete quarterly data in New Jersey between January 1, 2012, and December 31, 2019. METHODS: Using data from the State of New Jersey Department of Health and Nursing Home Compare, staff-to-resident ratios were trended for registered nurses, licensed practical nurses, and certified nursing assistants by shift and over time. Panel data analysis was used to test the association between the ratios and the ratings. RESULTS: Compared to 2012, staffing ratios improved slightly for licensed practical nurses but not for registered nurses or certified nursing assistants in 2019 (P < .001). The number of residents assigned doubled at night for all personnel. During the day and evening shifts, registered nurse staffing was significantly associated with the Nursing Home Compare staffing rating (P < .01) but not the overall rating. CONCLUSIONS AND IMPLICATIONS: Decreasing the number of residents assigned to a registered nurse in NHs results in an increase in staffing ratings. Mandatory public reporting holds nursing homes accountable for quality outcomes but does not improve staffing ratios. Quality resident care is the cumulative result of multiple measures inclusive of staffing; therefore, administrators should continue to focus on improving quality in NHs, which may improve staffing ratios across shifts.

Determinants of participating in life after spinal cord injury - advice for health professionals arising from an examination of shared narratives.

PURPOSE: To explore the perceived determinants of participation in life after spinal cord injury and incorporate these into a framework for the promotion of participation suitable for use by rehabilitation professionals. METHOD: Four people with spinal cord injury and one health service researcher engaged in a process of sharing narratives of life after spinal cord injury over a period of one year. The narratives were distilled using thematic analysis. RESULTS: The relevant subset of data from the narratives categorized as This is what we think determines our participation in life was analyzed in depth to reveal nine themes (1) The world can be my friend or foe; (2) I am who I am; (3) It is a personal journey; (4) Some like to talk, others like to do; (5) We have the technology; (6) A support network is vital and it can be built; (7) Life involves tradeoffs; (8) Push; and (9) Be flexible. These themes were combined into a framework for the promotion of participation to be used by rehabilitation professionals. The collaboratively developed framework has three aspects - Help me, Encourage me and Accept. CONCLUSION: The proposed participation promotion framework is grounded in the narratives of the research group but needs to be tested before it can be endorsed for practice. Implications for Rehabilitation In order to promote participation in life after spinal cord injury rehabilitation professionals can help people with spinal cord injury to negotiate the world, build and maintain a support crew and access equipment and technology. Spinal cord injury rehabilitation professionals can encourage people with spinal cord injury to push themselves, be assertive and be flexible, as these attributes can assist participation in life after spinal cord injury. In the pursuit of participation goals, rehabilitation professionals must accept the individuality of each person with spinal cord injury, respect that they may or may not be willing to make tradeoffs to achieve participation goals and that they are on an ever changing life journey.

Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic considerations.

BACKGROUND: Writing therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched. DATA SOURCES: Databases, including MEDLINE, EMBASE, PsycINFO, Linguistics and Language Behaviour Abstracts, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature, were searched from inception to March 2013 (updated January 2015). REVIEW METHODS: Four TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk-of-bias tool. Unfacilitated and facilitated TW studies were analysed separately under International Classification of Diseases, Tenth Revision chapter headings. Meta-analyses were performed where possible using RevMan version 5.2.6 (RevMan 2012, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Costs were estimated from a UK NHS perspective and three cost-consequence case studies were prepared. Realist synthesis followed Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines. OBJECTIVES: To review the clinical effectiveness and cost-effectiveness of TW for people with long-term conditions (LTCs) compared with no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom. RESULTS: From 14,658 unique citations, 284 full-text papers were reviewed and 64 studies (59 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW; these were extremely heterogeneous with unclear or high risk of bias but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable or unreported quality. Overall, there was very little or no evidence of any benefit reported in the following conditions (number of studies): human immunodeficiency virus (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); and chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity [n = 191, standardised mean difference (SMD) -0.61, 95% confidence interval (CI) -0.96 to -0.26] in the short term on meta-analysis of four studies. For all other LTCs there were either no data, or sparse data with no or inconsistent, evidence of benefit. Meta-analyses conducted across all of the LTCs provided no evidence that unfacilitated emotional writing had any effect on depression at short- (n = 1563, SMD -0.06, 95% CI -0.29 to 0.17, substantial heterogeneity) or long-term (n = 778, SMD -0.04 95% CI -0.18 to 0.10, little heterogeneity) follow-up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, no studies reported cost-effectiveness and 12 studies reported resource use; and meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist synthesis findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW. LIMITATION: Difficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure. CONCLUSIONS: Overall, there is little evidence to support the therapeutic effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focused on facilitated TW in people with LTCs could be informative. STUDY REGISTRATION: This study is registered as PROSPERO CRD42012003343. FUNDING: The National Institute for Health Research Health Technology Assessment programme.