The birth center model of care: Staffing, business characteristics, and core clinical outcomes.

OBJECTIVES: Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes. METHODS: This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission. RESULTS: The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations. CONCLUSIONS FOR PRACTICE: Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.

Emerging Antimicrobial Resistance.

The burden of emerging antimicrobial resistance (AMR) in the United States is significant and even greater worldwide. Mitigation efforts have decreased the incidence and deaths from antimicrobial-resistant organisms in the United States. Yet more than 2.8 million antimicrobial-resistant infections occur every year and more than 35,000 patients die as a result. Infection prevention and control, data tracking, antimicrobial stewardship, vaccines, therapeutics, diagnostics, and sanitation are all required to decrease AMR threats. In 2019, in the second version of the Centers for Disease Control and Prevention (CDC) report on antibiotic-resistant threats, the agency categorized AMR threats as urgent, serious, concerning, or to be watched. This review will discuss the following aspects of each bacterium in the CDC report: estimated numbers of cases and deaths, identify the better known and impactful mechanisms of resistance, diagnostic testing and its limitations, and current and possible future therapies. This review also presents anatomical pathology case examples that highlight the altered morphology of antibiotic partially treated bacteria in tissues.

Disseminated Tuberculosis Involving Lung, Peritoneum, and Endometrium in an Immunocompetent 17-Year-Old Patient.

A 17-year-old Guatemalan female with a recent history of spontaneous abortion requiring dilation and curettage at 16 weeks' gestation presented two weeks post-procedure to a pediatric hospital for three days of worsening generalized abdominal pain, diarrhea, fevers, and cough. The patient's vital signs showed hypoxia, tachypnea, tachycardia, and hypotension; she was alert and oriented with a thin body habitus and suprapubic abdominal tenderness without rebound, guarding, or hepatosplenomegaly. She had no crackles, rales, or wheezing on lung examination. Labs revealed neutrophilic leukocytosis, acute kidney injury, transaminitis, and coagulopathy. Pelvic ultrasound demonstrated a septated pelvic fluid collection with an endometrial thickening. CT abdomen and pelvis showed significant nodular omental thickening and ascites. CT angiogram of the chest demonstrated an apical lung cavity and bilateral micro-nodularity without lymphadenopathy. Due to concern for septic shock secondary to endometritis, the patient was started on broad-spectrum antibiotics and intubated for acute hypoxic respiratory failure. Repeat dilation and evacuation revealed degenerative first trimester products of conception and necrotizing granulomatous endometritis with Mycobacterium tuberculosis (M. tuberculosis) bacteria. Paracentesis indicated tuberculosis (TB) in ascites fluid, and bronchoalveolar lavage (BAL) showed pulmonary TB. Human immunodeficiency virus (HIV) screen and serum QuantiFERON®-TB Gold testing were negative. Rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy was initiated alongside piperacillin-tazobactam for the treatment of both disseminated TB and septic abortion. She was extubated with hemodynamic stability, but fevers persisted. Repeat fallopian tube fluid sampling after five weeks of RIPE indicated numerous acid-fast bacilli. The patient's septic clinical picture clouded her TB diagnosis as it appeared unusual that a healthy 17-year-old would concurrently have a septic abortion and disseminated TB; the lack of lymphadenopathy on CT scan also contributed to diagnostic uncertainty. Among patients from endemic regions, TB is a cause of spontaneous abortion. Conversely, during pregnancy, progesterone suppresses the T-helper 1 (Th1) proinflammatory response and increases susceptibility to TB. Peripartum women are at higher risk for disseminated TB, and postpartum women are twice as likely to experience reactivation of latent TB than nonpregnant women. Disseminated TB must be considered in pregnant adolescents presenting with appropriate clinical characteristics and imaging findings.

Applying time series modeling to assess the dynamics and forecast monthly reports of abuse, neglect and/or exploitation involving a vulnerable adult.

BACKGROUND: Application of time series modeling to predict reports related to maltreatment of vulnerable adults can be helpful for efficient early planning and resource allocation to handle a high volume of investigations. The goal of this study is to apply: (1) autoregressive integrated moving average (ARIMA) time series modeling to fit and forecast monthly maltreatment reports accepted for assessment reported to adult protective services (APS), and (2) interrupted time series analysis to test whether the implementation of intake hubs have a significant impact in the number of maltreatment reports after the implementation period. METHODS: A time series analysis on monthly APS intake reports was conducted using administrative data from SC Child and Adult Protective Services between January 2014 and June 2018. Monthly APS data were subjected to ARIMA modeling adjusting for the time period when intake hubs were implemented. The coefficient of determination, normalized SBC, AIC, MSE, and Ljung-Box Q-test were used to evaluate the goodness-of-fit of constructed models. The most parsimonious model was selected to predict the monthly APS intakes from July to December 2018. Poisson regression was fit to examine the association of the implementation of the hubs and the number of intake reports received to APS, adjusting for confounders. RESULTS: Over 24,000 APS intakes accepted for investigation were identified over a period of four calendar years with an increase in the monthly average of APS intakes between 2014 and 2017. An increase in the number of monthly APS intakes was found after the intake hubs were implemented in 2015 (Phase-1) and 2017 (Phase-2). Of all the models tested, an ARIMA (12), 1, 1 model was found to work best after evaluating all fit measures for both models. For Phase-1, the optimum model predicted an average of 488 APS intake reports between July and December 2018, representing a 9% increase from January-June 2018 (median = 445). For Phase-2, the percent increase was 32%. CONCLUSIONS: The implementation of the intake hubs has a significant impact in the number of reports received after the implementation period. ARIMA time series is a valuable tool to predict future reports of maltreatment of vulnerable adults, which could be used to allow appropriate planning and resource allocation to handle a high volume of monthly intake reports.

Rapid Development and Validation of a Novel Laboratory-Derived Test for the Detection of SARS-CoV-2.

OBJECTIVES: To increase testing capability for SARS-CoV-2 during a rapidly evolving public health emergency, we aimed to deploy a validated laboratory-developed real-time reverse transcription polymerase chain reaction (RT-PCR) diagnostic test for SARS-CoV-2 on an accelerated timeline and using reagent supply chains that were not constrained. METHODS: A real-time RT-PCR assay that detects the structural envelope (E) gene of SARS-CoV-2 was developed and validated on the Roche cobas 6800 instrument platform with the omni Utility channel reagents, which performs automated nucleic acid extraction and purification, PCR amplification, and detection. In silico analysis was performed for both inclusivity of all SARS-CoV-2 variants and cross reactivity with other pathogenic organisms. Positive control material was used to determine the Limit of Detection (LOD) and patient samples (positive and negative) confirmed by another authorized assay were used for clinical validation. Experiments were carried out at the Christiana Care Health System's Molecular Diagnostics Laboratory (Newark, DE) between April 1 and April 4, 2020. RESULTS: A real-time RT-PCR assay for SARS-Cov-2 was developed and validated in just two weeks. For all oligonucleotides, 100% homology to the available SARS-CoV-2 sequences was observed. Greater than 80% homology between one or more oligonucleotides was observed for SARS-Cov (Urbani strain) and Influenza A, however risk of cross reactivity was deemed to be low. The limit of detection (LOD) of the assay was 250 copies/mL. The assay identified 100% of positive patient samples (30/30) and 100% of negative patient samples (29/29 patient negatives and 1/1 saline). Up to 92 samples can be run on a single plate and analysis takes approximately 3.5 hours. CONCLUSIONS: In this work, we demonstrate the development and validation of a single target laboratory-developed test for SARS-CoV-2 in two weeks. Key considerations for complementary supply chains enabled development on an accelerated timeline and an increase in testing capability.

Case report: Atypical, 'symplastic' leiomyoma recurring as leiomyosarcoma in the vagina.

•Leiomyosarcoma in the vagina is rare.•Atypical fibroids recurring as leiomyosarcoma•Leiomyomas should be classified based on recurrence risk.

Risk for suicidal ideation and suicide attempts associated with co-occurring depression and conduct problems in early adolescence.

This study investigates the early manifestation of co-occurring depression and conduct problems as a predictor of heightened risk for later suicidal ideation and behavior in a community sample of 521 adolescents. Self-reported symptoms of depression and conduct problems were evaluated in early 6th grade. Suicidal thoughts and behaviors were tracked through multiple assessments carried out over the middle school years. Compared to adolescents with depression symptoms only, conduct problem symptoms only, or low psychopathology, those with co-occurring depression and conduct problem symptoms had the highest risk for subsequent suicidal ideation, recurrent suicidal behaviors, and suicide attempts.

The Family Health and Birth Center--a nurse-midwife-managed center in Washington, DC.

The Family Health and Birth Center (FHBC) is a family- and community-centered collaborative partnership designed to address the needs of women and families in the geographic area known as Ward 5 in Washington, DC. This community is predominantly low-income and African American; however, in recent years, a growing Latina and middle-income white population have sought out FHBC's services. Based on the midwifery model, FHBC provides prenatal care and midwifery-supported and -attended births in the freestanding birth center or at the nearby Washington Hospital Center. Through the collaborative partnership housed in a former supermarket and known as the Developing Families Center (DFC), FHBC works closely with the Healthy Babies Project and the United Planning Organization's Early Childhood Development Center. The aim of these partnerships is to provide midwifery-supported prenatal and birthing care within a framework of understanding the social context of health care. Together, the DFC/FHBC collaborative partnership provides a comprehensive system of health care for this predominantly underserved population. The purpose of this article is to highlight the FHBC--our perspective on the history of the founding of this center as a nurse-midwife-led model of care. Included in this issue is a comparative case study conducted by Palmer et al at the Urban Institute that systematically contrasts the care provided by three different models of maternity care serving low-income African American women in Washington, DC. Using qualitative methodology, the study analyzes the content and delivery of care, and the cost-effectiveness of FHBC as compared to a large city hospital and a federally qualified health care center. Study findings indicate that the combined elements of nurse-midwife-led maternal and child care with a focus on the social and educational context of pregnancy, birth, and infant/toddler better meet the needs of the population than do the comparison models.

Thoughts of death and suicide in early adolescence.

The prevalence and persistence of thoughts of death and suicide during early adolescence were estimated in a community-based cohort. A latent class approach was used to identify distinct subgroups based on endorsements to depression items administered repeatedly over 24 months. Two classes emerged, with 75% in a low ideation class across four assessments. Less than 2% persisted in the high ideation class over three or more assessments. African American and Asian American adolescents were more likely than European Americans to belong to the high ideation class. No members of the low ideation class endorsed "thought about killing myself," while "thoughts of death and dying" was endorsed by members of both classes. Implications for interpreting meanings of death and suicide ideation in early adolescence are discussed.

Necrotizing cervical and uterine infection in the postpartum period caused by group A streptococcus.

BACKGROUND: Group A Streptococcus, once the most common causes of puerperal sepsis, is now a rare cause of postpartum fever. CASE: A term 27-year-old woman presented after spontaneous membrane rupture. After an uncomplicated vaginal delivery, she became febrile without a source of infection. Despite two different antibiotic regimens, she remained febrile for 3 days. A computed tomography scan showed a wedge-shaped discontinuity in the anterior uterus suggesting uterine infection with early abscess formation. The patient underwent exploratory laparotomy and hysterectomy, with an uneventful postoperative course. Uterine pathology revealed a necrotizing infection within the uterus and cervix from Group A Streptococcus. CONCLUSION: Puerperal sepsis from Group A Streptococcus can be a cause of necrotizing infection following delivery. Physicians should be aware of the resurgence of this potentially fatal pathogen.

Prospective relations between rejection and depression in young adolescents.

The purpose of this longitudinal study was to examine the relations between rejection and depression across 3 years in young adolescents who varied with regard to their risk for depression. The sample consisted of 240 adolescents who were assessed in grades 6, 7, and 8. The assessment of rejection was based on adolescent-, mother-, and teacher-report, and depression assessment was based on adolescent- and mother-report and clinician ratings. Structural equation modeling indicated that rejection prospectively predicted depression. The authors did not find that depression prospectively predicted rejection, but such a relation cannot be ruled out because of strong cross-sectional correlations between depression and rejection.