Birth Care Gaps in the Childbirth Options, Information, and Person-Centered Explanation (CHOICEs) Measure.

PURPOSE: The objective of this study was to revise and improve the intrapartum items of the shared decision-making (SDM) measure, CH ildbirth O ptions, I nformation and person- C entered E xplanation (CHOICEs). STUDY DESIGN AND METHODS: Methodological sequential triangulation was used to select a purposive sample of 29 people who gave birth in the United States between August 2019 and June 2021. A qualitative descriptive approach was used to analyze and interpret the data. We used an interview guide with questions related to the nine intrapartum items in CHOICEs to address the question: How did decision-making occur during your most recent birth? RESULTS: Four major themes were identified: provider told me what to do ; communication about interventions during labor and birth ; preferences overlooked ; multiple team members . Under the theme of provider told me what to do , there was one sub-theme of induction of labor . CLINICAL IMPLICATIONS: Participants noted lack of shared decision-making, poor communication, and obstetric violence. We found the need for perinatal providers to improve communication with birthing people on topics such as fetal monitoring, induction of labor, and multiple team members who may participate in their care. Revisions of CHOICEs will include seven new items to further address birth preferences, feeling heard, and multiple team members.

Communication Between Pregnant People of Color and Prenatal Care Providers in the United States: An Integrative Review.

INTRODUCTION: Racism and discrimination negatively affect patient-provider communication. Yet, pregnant people of color consistently report being discriminated against, disrespected, and ignored. The purpose of this integrated review was to identify studies that examined communication between pregnant people of color and their prenatal care providers and evaluate the factors and outcomes arising from communication. METHODS: We searched the PubMed, Embase, CINAHL, and PsychINFO databases for studies published between 2001 and 2023. Articles were eligible for inclusion if they reported on primary research conducted in the United States, were written in English, and focused on patient-provider communication with a sample that included pregnant people of color, defined as those who self-identified as Black, African American, Hispanic, Latina/x/e, Indigenous, American Indian, Asian, Asian American, Native Hawaiian, and/or Pacific Islander American. Twenty-six articles were included in the review. Relevant data were extracted and compiled into an evidence table. We then applied the rating scale of the Johns Hopkins Evidence-Based Practice model to assess the level of evidence and quality of the studies. Themes were identified using a memoing technique and organized into 3 a priori categories: factors, outcomes, and recommendations. RESULTS: Two overarching themes emerged from our analysis: racism/discrimination and unmet information needs. Subthemes were then identified as factors, outcomes, or recommendations. Factors included provider behaviors, language barriers, structural barriers, provider type, continuity of care, and fear. Outcome themes were disrespect, trust, decision-making power, missed appointments, and satisfaction with care. Lastly, culturally congruent care, provider training, and workforce development were categorized as recommendations. DISCUSSION: Inadequate communication between prenatal care providers and pregnant people of color continues to exist. Improving access to midwifery education for people of color can contribute to delivering perinatal care that is culturally and linguistically aligned. Further research about digital prenatal health communication is necessary to ensure equitable prenatal care.

A systematic review of the management of postoperative scars with silicone gel-based products in randomized controlled trials.

Although postoperative scarring may be considered a cosmetic concern, it can greatly impact a patient's quality of life. This extends beyond psychosocial burden influenced by hypertrophic scars and keloids, as patients also experience discomfort and pain. This systematic review evaluates the efficacy of silicone gel (SG)-based products in preventing postoperative abnormal scar formation. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a PubMed search was performed to find randomized, controlled trials investigating the effect of SG-based products on postoperative wound healing. The search yielded 359 publications, but only 30 studies published between 1991-2022 were found to fit the inclusion criteria. Outcomes were extracted from the literature and subsequent quality and risk of bias assessments were performed. Most studies indicated improvement of at least one quality of the scar with the use of SG-based products. The greatest potential variable increasing bias was an inadequate control group. Studies also suffered from small sample sizes, use of unvalidated scar assessment scales, lack of double-blinding, and short follow-up periods. Overall, SG-based products demonstrated potential in preventing abnormal scar formation during postoperative healing, but further studies are required to validate the results of current literature.

Clinical factors and surgical decision-making when managing premenopausal women with adnexal torsion.

PURPOSE: The primary objective of this study is to identify if and which clinical factors may influence surgical decision-making when managing premenopausal women who present emergently with adnexal torsion (AT). METHODS: This retrospective cohort study was conducted at a single tertiary hospital. Medical records for all admissions for AT between 1 January 2010 and 30 June 2020 were reviewed and data regarding patient demographics, history of torsion, and the index admission were collected. Conservative surgery was defined as detorsion only or detorsion with cyst decompression. Interventional surgery was defined as ovarian cystectomy, salpingectomy, oophorectomy or salpingo-oopherectomy. RESULTS: 126 women were included for final analysis. Of the 109 women diagnosed with AT at emergency surgery, 12 were postmenopausal (all had interventional surgery). In the 97 premenopausal women, 50 (52%) underwent conservative surgery. Pregnant women were more likely to undergo conservative surgery than non-pregnant women (Relative Risk [RR] 0.20, 95% confidence interval [CI] 0.5, 0.75, p = 0.001). Women having laparoscopies were also more likely to undergo conservative surgery (RR 0.08, 95% CI 0.01, 0.53, p = 0.001) than if they had laparotomies. Although not reaching statistical significance, women were more likely to undergo laparotomy if they were febrile or if a senior gynecology consultant was involved in their care. History of torsion, age, parity and ovarian size did not alter the risk of interventional surgery. CONCLUSION: This study identified that premenopausal women who presented emergently with AT were significantly more likely to have conservative surgery if they were pregnant or if they underwent laparoscopic surgery.

Day 1 to day 4 serum hCG change in predicting single-dose methotrexate treatment failure for tubal ectopic pregnancies.

OBJECTIVE: To determine if changes in Day 1 to Day 4 serum human chorionic gonadotropin (hCG) levels can predict treatment failure of single-dose methotrexate (MTX) in medical management of tubal ectopic pregnancies (EP). STUDY DESIGN: This retrospective cohort study was conducted at a tertiary level hospital. Files were reviewed for all women who received at least one dose of 50 mg/m2 intramuscular MTX for treatment of ultrasound-confirmed tubal EPs between 2013 and 2018. "Treatment failure" is defined as needing additional MTX or surgery to manage the EP. The primary purpose is to establish a threshold percentage change in Day 1 to Day 4 (Day 1/4) hCG that best predicts treatment failure, with clinically and statistically significant sensitivity and specificity, based on receiver-operator characteristic (ROC) analysis. RESULTS: 252 files were reviewed, with 108 included for final analysis. 17% of cases required a second dose of MTX and 12% required surgery to manage the EP. Women in the treatment failure group had significantly higher median hCG levels on Day 1, 4 and 7, but were otherwise similar to women who were successful in age, parity, history of previous EP, and EP size. ROC curve analysis of Day 1/4 hCG demonstrates that ≥5% rise best predicts treatment failure with sensitivity 68% (95% confidence interval [CI] 49-83%), specificity 69% (95%CI 56-78%), and AUC 0.77 (95%CI 0.68-0.86, p < 0.001). The positive predictive value is 46% (95%CI 36-56%) and negative predictive value is 84% (95%CI 75-90%). In comparison, ROC analysis of Day 4 to Day 7 hCG demonstrates that a drop of ≤17% best predicted failure, with sensitivity 83% (95%CI 64-94%), specificity 82% (95%CI 71-90%), and AUC 0.90 (95%CI 0.84-0.96), p < 0.001. CONCLUSION: This study suggests that ≥5% rise in Day 1/4 serum hCG levels could potentially predict treatment failure of single-dose MTX for tubal EPs, and that conversely, <5% rise or any drop in Day 1/4 hCG levels can reliably predict treatment success. Clinicians could consider factoring-in Day 1/4 hCG changes during the course of medically managing patients. They must bear in mind, however, that acting on the Day 1/4 hCG change would lead to increased interventions.

Comparison of surgical outcomes using Gyrus PKS™ vs LigaSure™ in total laparoscopic hysterectomy: A randomised controlled trial.

BACKGROUND: Advanced vessel sealing devices are widely used in laparoscopic surgery. However, there remains a lack of adequately powered trials comparing laparoscopic advanced vessel sealing devices in the clinical setting, especially in gynaecology. AIMS: This single-blinded randomised controlled trial aims to compare the surgical outcomes of total laparoscopic hysterectomy (TLH) using either the Gyrus PKS™ LYONS dissecting forceps or the LigaSure™ Maryland jaw vessel sealer/divider. MATERIALS AND METHODS: Women who required TLHs for benign indications were randomised to having their surgeries performed using either Gyrus PKS™ or LigaSure™. Time to haemostasis (from initial skin incision to detachment of the uterus with secured haemostasis) was the primary outcome; a 20% difference in time was considered clinically significant. Secondary outcomes measured were intra-operative blood loss, complications, conversions, post-operative analgesia use, and length of stay. This study was registered with the Australia New Zealand Clinical Trials Registry ACTRN12615000639516. RESULTS: Sixty-four women were included in the study - 33 and 31 in the Gyrus PKS™ and LigaSure™ arms, respectively. TLHs performed by LigaSure™ had statistically significantly shorter time to haemostasis compared to Gyrus PKS™ by 10.6 min (95% CI 1.3-2.0, P = 0.03). There were no differences in any of the other secondary outcomes measured. CONCLUSIONS: This trial suggests there is no difference between using either device. TLHs performed using LigaSure™ have statistically significantly shorter time to haemostasis than those using Gyrus PKS™; however, the difference is not considered clinically significant as it was only 14.2%. No other differences in surgical outcomes were detected.

Outcomes of high-risk obstetric transfers in New South Wales and the Australian Capital Territory: The High-Risk Obstetric Transfer Study.

BACKGROUND: In New South Wales and the Australian Capital Territory, in utero transfers to manage maternal or neonatal risks are highly challenging owing to geography and centralisation of tertiary perinatal care. AIMS: The study aims to document the outcomes of high-risk obstetric transfers. MATERIALS AND METHODS: A prospective observational study was conducted from 2010 to 2011 documenting urgent requests for obstetric transfers to tertiary centres across NSW/ACT for pregnancies 20 weeks' gestation or greater. Outcomes of transfers were allocated apriori to 'delivered at the receiving hospital', 'failed/delayed transfer' or 'discharged/transferred undelivered'. Our hypothesis is that each outcome has a specific group of associated clinical factors. RESULTS: Of the 249 transfer requests included in the study, 40% delivered at the receiving hospital, 7% were failed/delayed transfers, and 45% were discharged/transferred undelivered. Cases delivering at the receiving hospital were significantly associated with older mothers, twin pregnancies, pregnancy induced hypertension (PIH) or premature rupture of membranes (PROM) with/without threatened preterm labour (TPL) as the indications for transfer and having three indications for transfer. Cases that were discharged/transferred undelivered were significantly associated with singleton pregnancies, TPL and/or antepartum haemorrhage (APH) as the indication for transfer and having one indication for transfer. There were no significantly associated factors for failed/delayed transfers. CONCLUSIONS: The study confirms the hypothesis that particular transfer outcomes are associated with different factors. The findings also show that less than half of urgent obstetric transfers result in delivery at the receiving hospital, suggesting that there exists significant opportunities for further research into predicting preterm delivery, thereby improving the care of women with high-risk pregnancies.

Distributed probing of chromatin structure in vivo reveals pervasive chromatin accessibility for expressed and non-expressed genes during tissue differentiation in C. elegans.

BACKGROUND: Tissue differentiation is accompanied by genome-wide changes in the underlying chromatin structure and dynamics, or epigenome. By controlling when, where, and what regulatory factors have access to the underlying genomic DNA, the epigenome influences the cell's transcriptome and ultimately its function. Existing genomic methods for analyzing cell-type-specific changes in chromatin generally involve two elements: (i) a source for purified cells (or nuclei) of distinct types, and (ii) a specific treatment that partitions or degrades chromatin by activity or structural features. For many cell types of great interest, such assays are limited by our inability to isolate the relevant cell populations in an organism or complex tissue containing an intertwined mixture of other cells. This limitation has confined available knowledge of chromatin dynamics to a narrow range of biological systems (cell types that can be sorted/separated/dissected in large numbers and tissue culture models) or to amalgamations of diverse cell types (tissue chunks, whole organisms). RESULTS: Transgene-driven expression of DNA/chromatin modifying enzymes provides one opportunity to query chromatin structures in expression-defined cell subsets. In this work we combine in vivo expression of a bacterial DNA adenine methyltransferase (DAM) with high throughput sequencing to sample tissue-specific chromatin accessibility on a genome-wide scale. We have applied the method (DALEC: Direct Asymmetric Ligation End Capture) towards mapping a cell-type-specific view of genome accessibility as a function of differentiated state. Taking advantage of C. elegans strains expressing the DAM enzyme in diverse tissues (body wall muscle, gut, and hypodermis), our efforts yield a genome-wide dataset measuring chromatin accessibility at each of 538,000 DAM target sites in the C. elegans (diploid) genome. CONCLUSIONS: Validating the DALEC mapping results, we observe a strong association between observed coverage by nucleosomes and low DAM accessibility. Strikingly, we observed no extended regions of inaccessible chromatin for any of the tissues examined. These results are consistent with "local choreography" models in which differential gene expression is driven by intricate local rearrangements of chromatin structure rather than gross impenetrability of large chromosomal regions.

Managing patients with cutaneous squamous cell carcinoma metastatic to the axilla or groin lymph nodes.

Cutaneous squamous cell carcinoma accounts for 20% of all non-melanoma skin cancer with a minority arising on the trunk and extremities. A small proportion will develop metastases to regional nodes of the axilla or groin. We performed a retrospective review of patients with metastatic cutaneous squamous cell carcinoma to the axilla and groin treated at Westmead Hospital, Sydney. The purpose of this study was to document the treatment and outcome of these patients. We identified 18 men and 8 women with a median age of 73 years. Median follow-up was 18.5 months. Median lesion size was 27 mm (range 3-130 mm) and median thickness was 7 mm (range 3-32 mm). Nine patients developed metastases to the groin, 14 to the axilla, 1 in the epitrochlear, and 2 to both the epitrochlear and axillary lymph nodes. All patients were treated with surgery +/- radiotherapy. Recurrence developed in seven patients (27%) with most developing distant metastases. Most (6/7) patients with recurrence died. Predicting patients that may develop nodal metastatic non-head and neck cutaneous squamous cell carcinoma is difficult. Following diagnosis, surgery remains the primary treatment and select patients with unfavourable features, such as extranodal spread, may benefit from the addition of adjuvant radiotherapy.