Expanding access to hepatitis C virus treatment--Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care.

The Extension for Community Healthcare Outcomes (ECHO) Model was developed by the University of New Mexico Health Sciences Center as a platform to deliver complex specialty medical care to underserved populations through an innovative educational model of team-based interdisciplinary development. Using state-of-the-art telehealth technology, best practice protocols, and case-based learning, ECHO trains and supports primary care providers to develop knowledge and self-efficacy on a variety of diseases. As a result, they can deliver best practice care for complex health conditions in communities where specialty care is unavailable. ECHO was first developed for the management of hepatitis C virus (HCV), optimal management of which requires consultation with multidisciplinary experts in medical specialties, mental health, and substance abuse. Few practitioners, particularly in rural and underserved areas, have the knowledge to manage its emerging treatment options, side effects, drug toxicities, and treatment-induced depression. In addition, data were obtained from observation of ECHO weekly clinics and database of ECHO clinic participation and patient presentations by clinical provider. Evaluation of the ECHO program incorporates an annual survey integrated into the ECHO annual meeting and routine surveys of community providers about workplace learning, personal and professional experiences, systems and environmental factors associated with professional practice, self-efficacy, facilitators, and barriers to ECHO. The initial survey data show a significant improvement in provider knowledge, self-efficacy, and professional satisfaction through participation in ECHO HCV clinics. Clinicians reported a moderate to major benefit from participation. We conclude that ECHO expands access to best practice care for underserved populations, builds communities of practice to enhance professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence.

Noninvasive and Highly Multiplexed Five-Color Tumor Imaging of Multicore Near-Infrared Resonant Surface-Enhanced Raman Nanoparticles In Vivo.

In vivo multiplexed imaging aims for noninvasive monitoring of tumors with multiple channels without excision of the tissue. While most of the preclinical imaging has provided a number of multiplexing channels up to three, Raman imaging with surface-enhanced Raman scattering (SERS) nanoparticles was suggested to offer higher multiplexing capability originating from their narrow spectral width. However, in vivo multiplexed SERS imaging is still in its infancy for multichannel visualization of tumors, which require both sufficient multiplicity and high sensitivity concurrently. Here we create multispectral palettes of gold multicore-near-infrared (NIR) resonant Raman dyes-silica shell SERS (NIR-SERRS) nanoparticle oligomers and demonstrate noninvasive and five-plex SERS imaging of the nanoparticle accumulation in tumors of living mice. We perform the five-plex ratiometric imaging of tumors by varying the administered ratio of the nanoparticles, which simulates the detection of multiple biomarkers with different expression levels in the tumor environment. Furthermore, since this method does not require the excision of tumor tissues at the imaging condition, we perform noninvasive and longitudinal imaging of the five-color nanoparticles in the tumors, which is not feasible with current ex vivo multiplexed tissue analysis platforms. Our work surpasses the multiplicity limit of previous preclinical tumor imaging methods while keeping enough sensitivity for tumor-targeted in vivo imaging and could enable the noninvasive assessment of multiple biological targets within the tumor microenvironment in living subjects.

Consequences of routine delivery at 38 weeks for A-2 gestational diabetes.

OBJECTIVE: To report our intrapartum experience with routine delivery at 38 weeks of gestation of A-2 diabetic pregnancies requiring primarily oral hypoglycemic therapy. METHODS: This retrospective study consisted of 143 consecutive women with gestational diabetes not controlled with diet alone (A-2). Each underwent a routine trial of labor at 38 weeks of gestation. The preinduction condition of the cervix, need for oxytocin, and primary cesarean rates were primary endpoints. For comparison, a control group during that same period consisted of 137 consecutive diet-controlled diabetic (A-1) pregnancies with the same eligibility criteria who underwent expectant management at 38 weeks. RESULTS: The study group was more likely to have an unfavorable cervix (75% versus 45%; p < 0.001) and to require oxytocin (76% versus 56%; p < 0.001). Early onset meconium was less common in the study group (3.5% versus 13.1%; p < 0.01). Primary cesarean rates were low and not different between the study and control groups (12.7% versus 11.7%; p < 0.8). The only stillbirth was in the control group and was associated with a tight double nuchal cord encirclement. Mean birth weights and the frequency of birth weights > 4000 g were not different between groups. Shoulder dystocia, low Apgar scores, and admissions to the special care nursery were infrequent in either group. No respiratory difficulties requiring resuscitation or prolonged nursery care were encountered. CONCLUSION: Routine delivery at 38 weeks in an A-2 diabetic population is not associated with additional intrapartum morbidity or a greater need for cesarean delivery.

Symptoms of postpartum depression and breastfeeding.

Despite important health benefits, the presence of depressive symptoms may decrease the prevalence of breastfeeding. The current study assessed the relationship between depressive symptoms and breastfeeding at 6 and 12 weeks postpartum. Participants were recruited from a cohort completing a clinical trial of calcium for prevention of preeclampsia. At 6 weeks postpartum, the Edinburgh Postnatal Depression Scale (EPDS) was completed by mail. At 12 weeks postpartum, the EPDS was completed at an outpatient visit. There was an inverse relationship between depressive symptoms and breastfeeding at 6 weeks postpartum (P<.001) but not at 12 weeks. This relationship persisted even after controlling for prior history of depression, increased life stress, and current psychoactive medication. The results suggest that depressive symptoms early in the postpartum period may lower the prevalence of breastfeeding.

The effects of amnioinfused solutions for meconium-stained amniotic fluid on neonatal plasma electrolyte concentrations and pH.

OBJECTIVE: To determine if amnioinfused normal saline or lactated Ringer's solution in cases of meconium-stained amniotic fluid is associated with significant changes on neonatal plasma electrolyte concentrations or pH. STUDY DESIGN: This was a prospective randomized study using normal saline or lactated Ringer's solution for amnioinfusion in women with thick meconium in the amniotic fluid. The control group was composed of women with clear amniotic fluid not receiving amnioinfusion. Cord blood arterial sampling was analyzed for sodium, potassium, and chloride plasma concentrations and pH. The sample sizes allowed for an alpha of 0.05 and power of 0.80. RESULTS: We evaluated 61 cases (20 normal saline solution, 20 lactated Ringer's solution, and 21 control). No significant differences in cord blood arterial plasma concentrations of sodium (p=0.43), potassium (p=0.21), chloride (p=0.68), and pH (p=0.11) were noted. CONCLUSION: Use of normal saline or lactated Ringer's solution for amnioinfusion in meconium-stained amniotic fluid is not associated with changes on neonatal plasma electrolyte concentrations or pH.

Effect of labor induction on cesarean section rates in diabetic pregnancies.

OBJECTIVE: To determine if induced labor increases the incidence of cesarean delivery in pregnancies complicated by diabetes. STUDY DESIGN: This retrospective cohort study of pregnancies complicated with diabetes involved data from birth certificates reported to the New Mexico Department of Health between January 1996 and December 1999. RESULTS: There were 108,487 births, with 3,392 (3.1%) in women with diabetes. As compared to those without diabetes, this group had an almost twofold-increased risk of primary cesarean delivery (20.3% versus 11.3%; OR 2.00; 95% CI 1.83, 2.19). The risk of primary cesarean delivery in diabetic women was lower in the presence than in the absence of induced labor (17.7% versus 21.9%; OR .77; 95% CI .50, 0.89). This association continued after controlling for birth weight > or = 4,000 g, breech presentation, twins, maternal age > 35 and gestational age > 42 weeks. CONCLUSION: Induction of labor was not an independent risk factor that could explain the higher cesarean delivery rate in diabetic pregnancies.

Metformin compared with glyburide in gestational diabetes: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of metformin with glyburide for glycemic control in gestational diabetes. METHODS: Patients with gestational diabetes who did not achieve glycemic control on diet were randomly assigned to metformin (n=75) or glyburide (n=74) as single agents. The primary outcome was glycemic control. Secondary outcomes were drug failure rate and neonatal and obstetric complications. RESULTS: In the patients who achieved adequate glycemic control, the mean fasting and 2-hour postprandial blood glucose levels were not statistically different between the two groups. However, 26 patients in the metformin group (34.7%) and 12 patients in the glyburide group (16.2%) did not achieve adequate glycemic control and required insulin therapy (P=.01). CONCLUSION: In this study, the failure rate of metformin was 2.1 times higher than the failure rate of glyburide when used in the management of gestational diabetes (95% confidence interval 1.2-3.9). CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00965991. LEVEL OF EVIDENCE: I.

Smoking before pregnancy and risk of gestational hypertension and preeclampsia.

OBJECTIVE: Our purpose was to determine whether smoking before pregnancy reduces the risk of gestational hypertension or preeclampsia. STUDY DESIGN: The trial of Calcium for Preeclampsia Prevention (CPEP) was a randomized study of 4589 nulliparous women conducted in 5 US medical centers during the years 1992 through 1995. Women were classified into 4 exposure groups by smoking history obtained at study enrollment (13-21 weeks' gestation): (1) never smoked, (2) smoked but quit before the last menstrual period (LMP), (3) smoked but quit after LMP but before enrollment, and (4) smoked and still smoking at enrollment. RESULTS: After adjustments were made for maternal age, race, body mass index, type of health insurance, and clinical center, women smoking at enrollment had a reduced risk of hypertension (relative risk = 0.8; 95% CI, 0.6-0.9). Women who quit smoking before the LMP did not have reduced risk (relative risk = 1.1; 95% CI, 0.9-1.3). Results were similar for gestational hypertension and preeclampsia examined separately. CONCLUSION: Women who smoke but quit before becoming pregnant do not have a reduced risk for gestational hypertension or preeclampsia.

Increased risk of preeclampsia among nulliparous pregnant women with idiopathic hematuria.

OBJECTIVE: Our purpose was to determine the risk of preeclampsia and gestational hypertension among nulliparous pregnant women with idiopathic hematuria. STUDY DESIGN: We conducted a prospective cohort study using data from the trial of Calcium for Preeclampsia Prevention (CPEP). Participants were followed up from screening and enrollment (gestational weeks 11-21) throughout pregnancy. Our analysis was limited to women who had been followed up to at least 20 weeks' gestation, had outcome information available, and were not suspected to have had urolithiasis. Surveillance for hematuria was conducted with dipsticks on clean-catch urine specimens obtained at research clinic visits. Idiopathic hematuria was defined as hematuria identified at regularly scheduled clinic visits in the absence of urinary tract infection and before the onset of labor. Logistic regression was used to estimate the risk of preeclampsia among women with hematuria compared with women without hematuria. RESULTS: Among the 4307 women available for analysis, 132 (3%) had idiopathic hematuria during pregnancy. Idiopathic hematuria was associated with an almost 2-fold increased odds for development of preeclampsia (adjusted odds ratio [aOR] = 1.89, 95% CI 1.12- 3.18) but not with increased odds of gestational hypertension (aOR = 0.78, 95% CI 0.46-1.32). CONCLUSIONS: Idiopathic hematuria identified during pregnancy is associated with greater risk of preeclampsia but not gestational hypertension.