Eshetu Tefera

The Effect of Centering Pregnancy versus Traditional Prenatal Care Models on Improved Adolescent Health Behaviors in the Perinatal Period.

STUDY OBJECTIVE To determine if the CenteringPregnancy model of prenatal care improves maternal health behaviors in adolescent pregnancy. DESIGN We conducted a retrospective chart review comparing 150 pregnant adolescents who received prenatal care between 2008 to 2012 with CenteringPregnancy to those receiving care in traditional prenatal care models with either multiprovider or single-provider visits. Outcome measures included weight gain during pregnancy, compliance to prenatal care appointments, infant feeding method, postpartum follow up and contraceptive use postpartum. A χ(2) analysis was used to compare outcomes between the 3 groups at a 2-tailed α of .05. RESULTS Fifty individuals were evaluated in each group. Adolescents in the CenteringPregnancy group were more likely to comply with prenatal and postpartum visits and to meet the 2009 Institute of Medicine gestational weight guidelines for weight gain in pregnancy than were adolescents in either multiprovider (62.0% vs 38.0%, P = .02) or single-provider (62.0% vs 38.0%, P = .02) groups. The CenteringPregnancy group was also more likely to solely breastfeed compared with adolescents in the multiprovider group (40.0% vs 20.0%, P = .03) and include breastfeeding in addition to bottle-feeding compared with both multiprovider (32.0% vs 14.0%, P = .03) and single-provider (32.0% vs 12.0%, P = .03) patient groups. Additionally, the CenteringPregnancy group had increased uptake of long-acting reversible contraception and were less likely to suffer from postpartum depression. CONCLUSIONS CenteringPregnancy Prenatal Care program aids in compliance to prenatal visits, appropriate weight gain, increased uptake of highly effective contraception, and breastfeeding among adolescent mothers.

Prevalence and Etiology of Hypogonadism in Young Men With Chronic Spinal Cord Injury: A Cross-Sectional Analysis From Two University-Based Rehabilitation Centers

Spinal cord injury (SCI) triggers an “accelerated aging” process that may include development of hypogonadism, even among younger men with SCI; however, few studies have investigated the prevalence or etiology of hypogonadism in men with SCI. Young men with SCI also are at increased risk for developing metabolic dysfunction after injury, which may be exacerbated by concomitant testosterone (T) deficiency, thus identifying the prevalence and risk factors for T deficiency in men with SCI is important for their long‐term health.

Transvaginal Versus Transabdominal Placement of Synthetic Mesh at Time of Sacrocolpopexy

Objectives Our primary aim was to compare mesh-related complications at the time of total vaginal hysterectomy with laparoscopic sacrocolpopexy (TVH-LSC) versus laparoscopic placement of sacrocolpopexy mesh at time of laparoscopic supracervical hysterectomy (LSH-LSC). Our secondary aim was to compare operative time, intraoperative and postoperative complications, as well as subjective and objective success between these groups. Methods We performed a retrospective cohort study with prospective follow-up for patients with uterovaginal prolapse who underwent TVH-LSC or LSH-LSC from June 2008 to July 2012. We collected baseline demographics, mesh-related complications, intraoperative and postoperative complications, and pelvic organ prolapse quantification data. We contacted patients postoperatively for telephone interviews and to request a return to the office for repeat examination. Results One hundred eighty-two patients were included: 123 TVH-LSC and 59 LSH-LSC. There was no difference in the rate of mesh-related complications (1.6% [2/123]; 95% confidence interval, 0–3.86% vs 1.7% [1/59]; 95% confidence interval, 0–4.99%; P = 1.0). Median examination follow-up was similar between groups (9 (2–17) months TVH-LSC vs 9 (2–17) months LSH-LSC, P = 1.0). The TVH-LSC was associated with a significantly shorter operative time (256 ± 53 vs 344 ± 81 minutes; P < 0.01). There were no differences in intraoperative or postoperative complications or subjective and objective success between groups. Conclusions There was no difference in mesh-related complications between groups (1.6% TVH-LSC vs 1.7% LSH-LSC; P = 1.0). Vaginal mesh attachment during TVH-LSC decreased operative time by over 1 hour with no differences in intraoperative complications, reoperation for recurrent prolapse, and subjective or objective outcomes compared to LSH-LSC.

Fetal biometry: does patient ethnicity matter?

Abstract Objective: To determine if fetal biometry varies according to race. Methods: We performed a retrospective chart review of prenatal ultrasounds completed in our Perinatal Center from January 2009 to December 2010. Singleton pregnancies 17 to 22.9 weeks were included. Pregnancies complicated by IUGR, fetal anomalies, chronic maternal diseases, or dated by an ultrasound after the first trimester were excluded. Biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), and humerus length (HL) were compared between African Americans (AA), Caucasians, and Hispanics using ANOVA and Student t-test. Results: Included were 1327 AA, 147 Caucasian, and 86 Hispanic subjects. The AC was significantly smaller in AA than Caucasians (p = 0.008). There was no difference between AA and Caucasians in BPD, HC, FL, or HL. There were no differences between Hispanics and either Caucasians or AA in any of the biometries evaluated. Conclusions: A single fetal growth curve is not applicable across all ethnicities. AA fetuses have smaller AC then Caucasian fetuses from 17 to 22.9 weeks, which is typically the period when anatomic surveys are performed. Because AC contributes heavily to estimated fetal weight calculations, physicians may be over estimating growth restriction in AA patients. Ethnicity-specific fetal growth curves are indicated to limit unnecessary follow up.

Accuracy of rapid sequence intubation medication dosing in obese patients intubated in the ED.

OBJECTIVE There are limited data regarding appropriateness of sedative and paralytic dosing of obese patients undergoing rapid sequence intubation (RSI) in the emergency department. The goal of this study was to compare rates of appropriate succinylcholine and etomidate doses in obese and nonobese patients. METHODS Retrospective review using a database of endotracheally intubated patients using RSI in an urban, tertiary care academic emergency department, from November 2009 to June 2011. Dosing for succinylcholine and etomidate was calculated as milligrams per kilogram of total body weight (TBW) for each patient, defining appropriate dosing as succinylcholine 1-1.5 mg/kg TBW and etomidate 0.2-0.4 mg/kg TBW. Logistic regression analysis was used to estimate the association between appropriate dosing and World Health Organization body mass index classification. RESULTS A total of 440 patients were included in the study, 311 (70.7%) classified as nonobese and 129 (29.3%) as obese. two hundred thirty-three (56%) received an inappropriate succinylcholine dose and 107 (24%) received an inappropriate etomidate dose. Obese patients were more likely to be underdosed with succinylcholine (odds ratio [OR], 63.7; 95% confidence interval [CI], 17.8-228.1) and etomidate (OR, 178.3; 95% CI, 37.6-844.7). Nonobese patients were more likely to be overdosed with succinylcholine (OR, 62.5; 95% CI, 17.9-250) and etomidate (OR, 166.7; 95% CI, 37.0-1000). CONCLUSION Obese patients were more likely to be underdosed during RSI compared with nonobese patients, whereas nonobese patients were more likely to be overdosed with RSI medications. Most obese and nonobese patients were inappropriately dosed with RSI medications, suggesting that physicians are not dosing these medications based on weight.

Utilizing Technology in Assessment of Lower Urinary Tract Symptoms: A Randomized Trial of Electronic Versus Paper Voiding Diaries.

Objectives The aim of this study was to compare a Web app developed by the American Urogynecologic Society, called “BladderTrakHer,” to the traditional paper voiding diary (PVD) for reliability and satisfaction. Methods Women presenting to our urogynecology practice with lower urinary tract symptom and access to an iPhone/iPad were randomized to a 3-day electronic voiding diary (EVD), using the BladderTrakHer Web app or PVD. Participants then completed a second voiding diary using the alternate format. Estimated fluid intake and output, number of voids, and episodes of incontinence were compared between formats. Patient and practitioner surveys assessed ease of use, ease of data interpretation, time to data entry, and overall satisfaction. Results Thirty-one of 122 patients completed both diary formats and the survey. The EVD and PVD showed good test-retest reliability. Patients recorded a higher number of entries for both voids and leaks while using the PVD (28.0 vs 25.5 [P = 0.03] and 4.5 vs 2.8 [P = 0.02], respectively). There was no significant difference in time to data entry among diary formats; 51.6% of patients preferred the EVD, and 78% of patients would prefer an electronic format if the app were improved. Four of 6 practitioners found the PVD easier to interpret, but all stated a preference for an EVD if the data were presented in a more organized fashion. Conclusions The use of an EVD is acceptable and reliable in our population of adult female patients with lower urinary tract symptom. Electronic voiding diary and PVD have good test-retest reliability, although the number of voids and leaks entered is slightly lower for the EVD.

Video intervention increases participation of black breast cancer patients in therapeutic trials

There is a striking racial and ethnic disparity in incidence and mortality of cancer yet minorities remain markedly underrepresented in clinical trials. This pilot study set out to determine the impact of a 15-min culturally tailored educational video on three outcomes relating to clinical trials: likely participation, attitudes (assessed based on six barriers), and actual enrollment. Breast cancer patients with Stage I-III, if diagnosed within previous 6 months, or metastatic disease who self-identified as black or African American were invited to participate. The primary outcome measure was the decision to participate in a therapeutic clinical trial after the intervention. Patients’ intention to enroll on a therapeutic clinical trial and the change in attitudes toward clinical trials were measured by the previously developed Attitudes and Intention to Enroll in Therapeutic Clinical Trials (AIET) questionnaire. Of the 200 patients that participated, 39 (19.5%) patients signed consent to participate in a therapeutic clinical trial; 27 (13.5%) patients enrolled, resulting in a 7.5% increase from our baseline comparison of 6% clinical trial enrollment rate in black cancer patients (p < .001). Pre-test versus post-test assessment demonstrated the proportion of patients expressing likelihood to enroll in a therapeutic trial following the intervention increased by 14% (p < .001). Among 31 AIET items, 25 (81%) showed statistically significant and positive change post-intervention. The findings suggest the promising utility of a culturally tailored video intervention for improving black patients’ attitudes regarding clinical trial participation and resultant enrollment. Future efforts should continue to target facilitators of population-specific recruitment, enrollment, and retention in therapeutic and non-therapeutic clinical trials.Educational video boosts trial enrollment among black patients with breast cancerA culturally tailored educational video can boost participation among black patients in clinical trials of new breast cancer treatments. A US team led by Sandra Swain from Georgetown University Medical Center in Washington, DC, created a 15-min video designed to address six of the concerns commonly cited by blacks about human subjects research. The researchers showed the video to 200 black patients, and saw a large bump in the number of women willing to sign up for a therapeutic trial. On average, only 6% of black cancer patients typically enroll in clinical trials. But in the video intervention study, 19.5% agreed to participate and then 13.5% went ahead with a trial. Video watchers also reported a positive change in their attitude toward clinical research. The study points to the need for population-specific recruitment efforts.

Third trimester ultrasound for fetal macrosomia: optimal timing and institutional specific accuracy

Abstract Purpose: To determine the performance of third trimester ultrasound in women with suspected fetal macrosomia. Materials and methods: We performed a retrospective cohort study of fetal ultrasounds from January 2004 to December 2014 with estimated fetal weight (EFW) between 4000 and 5000 g. We determined accuracy of birth weight prediction for ultrasound performed at less than and greater than 38 weeks, accounting for diabetic status and time between ultrasound and delivery. Results: There were 405 ultrasounds evaluated. One hundred and twelve (27.7%) were performed at less than 38 weeks, 293 (72.3%) at greater than 38 weeks, and 91 (22.5%) were performed in diabetics. Sonographic identification of EFW over 4000 g at less than 38 weeks was associated with higher correlation between EFW and birth weight than ultrasound performed after 38 weeks (71.5 versus 259.4 g, p < .024). EFW to birth weight correlation was within 1.7% of birth weight for ultrasound performed less than 38 weeks and within 6.5% of birth weight for ultrasound performed at greater than 38 weeks. Conclusions: Identification of EFW with ultrasound performed less than 38 weeks has greater reliability of predicting fetal macrosomia at birth than measurements performed later in gestation. EFW to birth weight correlation was more accurate than previous reports.

Fetal Macrosomia Prediction in Diabetic Gravidas: The Reliability of Third Trimester Ultrasound [27M]

INTRODUCTION: Conflicting evidence exists regarding the reliability of third trimester ultrasound for guiding delivery management for fetal macrosomia. Our objective was to determine the performance of third trimester ultrasound in diabetic and non-diabetic women with fetal macrosomia. METHODS: We performed a retrospective cohort study of fetal ultrasounds from 2004–2014 with estimated fetal weight (EFW) above 4,000 grams (gm). We determined accuracy of birth weight prediction for ultrasound performed at less than and greater than 38 weeks, in non-diabetic and diabetic women. We used student t test, Wilcoxon rank sum test, chi-square, Fisher exact test, and multivariate logistic regression. RESULTS: There were 405 fetal ultrasounds with EFW above 4,000 gm. 112 (27.7%) were performed at less than 38 weeks, 293 (72.3%) at greater than 38 weeks, and 91 (22.5%) in diabetics. Sonographic identification of EFW over 4000 gm at less than 38 weeks was associated with higher birth weight (4183 gm vs 4019 gm, P=.001) and higher correlation between EFW and birth weight than ultrasound performed after 38 weeks (71.5 gm vs 259.4 gm, P<.001). EFW to birthweight correlation was within 1.7% of EFW for ultrasound performed less than 38 weeks. Diabetics had larger birth weight then non-diabetics (4198 gm vs 4022 g, P<.001) but the correlation between EFW and birth weight was the same after adjusting for gestational age at ultrasound (102gm vs 252 gm, P=.103). In all cohorts, average EFW overestimated average birth weight. CONCLUSION: Identification of fetal weight over 4000 gm in patients with ultrasound performed less than 38 weeks has greater reliability of predicting fetal macrosomia at birth than measurements performed greater than 38 weeks.

Vigorous Neonates With Acidemia at Term

INTRODUCTION: The objective of this study was to compare outcomes among vigorous neonates (5-minute Apgar score 7 or greater) with acidemia (arterial cord pH less than 7) at birth with vigorous neonates without acidemia (arterial cord pH 7.1 or greater). METHODS: A retrospective case–control study was performed using the Medstar PeriBirth labor database. Universal cord gas analysis was adopted at Medstar Washington Hospital Center in 2009. All singleton term deliveries between 37.0 and 42.0 weeks of gestation with arterial cord pH 7.0 or less and 5-minute Apgar score 7 or greater from 2010 to 2012 (cases, n=170) were matched one-to-one by gestational age and mode of delivery with those in a control group with arterial cord pH 7.1 or greater and 5-minute Apgar score 7 or greater (controls, n=170). Outcomes included mode of delivery, neonatal intensive care unit (NICU) admission, and type of acidosis. Statistical significance was defined as P⩽.05. RESULTS: Of 4,107 term, singleton deliveries in which cord blood gas analysis was available, 170 vigorous, acidemic neonates were delivered (incidence of 4.1%). There were no significant differences in identified obstetric or medical risk factors between the two groups. Those in the case group and those in the control group did not differ in the National Institute of Child Health and Human Development category of fetal heart tracing with the majority of tracings classified as category II. Neonates in the case group were more likely to be delivered by emergent cesarean delivery compared with those in the control group (25.5% compared with 14.7%, P=.004). Case neonates had an increased odds for NICU admission (odds ratio 2.68 95% confidence interval 1.6–4.5). CONCLUSION: Vigorous neonates with acidemia are at increased risk for NICU admission compared with nonacidemic neonates. Close observation may be warranted in neonates with acidemia irrespective of 5-minute Apgar scores.