Phinnara Has

Heroin use in adolescents and young adults admitted for drug detoxification

PURPOSE To examine heroin use and associated morbidity in young adults undergoing drug detoxification. METHODS A retrospective chart review of all persons (ages 18-25) admitted to either of the two state-funded detoxification facilities in Rhode Island was conducted between June 1998 and June 1999. Only those reporting heroin as a primary drug were included in this study (N=201). RESULTS Clients were largely male (64%), and white (79%), with a mean age of 22. Of those that reported heroin as their primary drug, 62% used primarily by injection. Mean age of initiation for heroin use was 18.3 years. Twenty-two percent reported a psychiatric diagnosis, and 80% reported a substance-abusing family member. Injection, previous overdose, and a mother with a history of substance use were associated with early initiation of heroin use. CONCLUSIONS The majority of young adults with heroin addiction undergoing detoxification began using heroin during late adolescence. Concurrence of psychiatric and medical diagnoses with heroin addiction was common, and may contribute to the severity of drug use. Efforts to identify risk factors for heroin and other injection drug use in adolescents and young adults will be critical for the design of effective interventions to prevent injection drug use and its associated morbidities.

Early Postpartum Glucose Testing in Women with Gestational Diabetes Mellitus.

Objective Given that most women with gestational diabetes mellitus (GDM) never undergo the recommended 6 to 12 weeks postpartum glucose tolerance test (GTT), we assessed the feasibility of performing GTTs on postpartum day 2. Study Design Women with abnormal postpartum day 2 results were similar to women with normal postpartum day 2 results except that more women with abnormal results required medicine to treat their GDM (Table 1). [corrected]. We assessed the feasibility of this GTT and compared the results to the standard of care GTT at 6 to 12 weeks postpartum. We also evaluated maternal and pregnancy characteristics of women who return for 6 to 12 weeks GTTs compared with those lost to follow-up. Results In this study, 98 of 106 participants (92%) completed the postpartum day 2 GTT; 59% had normal glucose values at that time. Only 49 women returned at 6 to 12 weeks postpartum. Among women who had testing at both time points, the 2 days postpartum GTT were 100% sensitive and 94% specific for diabetes mellitus but less sensitive and specific for milder forms of abnormal glucose. Women who did not return for testing at 6 to 12 weeks postpartum were more likely to have less education, have Medicaid, and to have GDM previously (Table 2). [corrected]. Conclusion Performing GTTs on postpartum day 2 is feasible and should be further investigated as an alternative postpartum testing regimen in GDM.

Use of Cefazolin for Group B Streptococci Prophylaxis in Women Reporting a Penicillin Allergy Without Anaphylaxis

OBJECTIVE: To estimate the proportion of group B streptococci (GBS)-colonized women with a reported penicillin allergy without anaphylaxis receiving appropriate intrapartum antibiotic prophylaxis. METHODS: We performed a retrospective cohort study of GBS-colonized, penicillin-allergic women delivering at term receiving intrapartum antibiotic prophylaxis during labor. Scheduled cesarean deliveries were excluded. The primary outcome was the proportion of women who received appropriate antibiotic coverage, defined as penicillin or cefazolin. Secondary outcomes included neonatal outcomes such as Apgar score, blood draws, antibiotic use, length of hospital stay, and composite morbidity. RESULTS: Of 165 women reporting a penicillin allergy without anaphylaxis, 73 (44.2%) received an appropriate antibiotic and 92 (55.8%) received an inappropriate antibiotic. Of those receiving an inappropriate antibiotic, 56 (60.9%) were given clindamycin, 1 (1.1%) erythromycin, and 35 (38.0%) vancomycin. Women reporting rash as a penicillin reaction were more likely to receive cefazolin than another antibiotic (44 [60.3%] compared with 24 [26.1%], respectively; P<.001), whereas women whose reaction was not documented were less likely to receive cefazolin (18 [24.7%] compared with 63 [68.5%], respectively; P<.001). Among neonates whose mothers received appropriate compared with inappropriate antibiotics, there were no differences in Apgar score, number of blood draws, antibiotic use, length of hospital stay, or composite morbidity. CONCLUSION: More than half of women allergic to penicillin without anaphylaxis received an antibiotic other than penicillin or cefazolin as prophylaxis, indicating poor adherence to national guidelines.

Choice of Trial of Labor after Cesarean and Association with Likelihood of Success

Objective To investigate whether the predicted chance of success is associated with the choice to undergo trial of labor after cesarean (TOLAC). Study Design Retrospective cohort study of women with a single prior nonelective cesarean delivering a term singleton in 2012 at a tertiary care hospital. A vaginal birth after cesarean (VBAC) score (likelihood of success) was estimated for each patient. The primary outcome was percentage of women choosing TOLAC among women with favorable (> 70% likelihood) and unfavorable VBAC scores. Other factors such as desired sterilization, provider type, and spontaneous labor were included in the analysis. Results In 2012, 434 women were eligible: 73 with VBAC score >70%, and 361 with score ≤70%. Of those with score >70%, 63% chose TOLAC, compared with 21% with score ≤70% (p < 0.01). In a multivariable analysis, spontaneous labor onset was highly associated with choosing TOLAC: adjusted odds ratio 26.7 (95% confidence interval 13.86‐51.29). The choice of TOLAC was also positively associated with resident provider and desired fertility. Conclusion Almost four in ten women with a history of nonelective primary cesarean and a very high predicted likelihood of VBAC choose elective repeat cesarean. Spontaneous labor was strongly associated with the choice to undergo TOLAC.

Prenatal Care Adherence and Neonatal Intensive Care Unit Admission or Stillbirth among Women with Gestational and Preexisting Diabetes Mellitus

Objective To determine if there was an association between prenatal care adherence and neonatal intensive care unit (NICU) admission or stillbirth, and adverse perinatal outcomes in women with preexisting diabetes mellitus (DM) and gestational DM (GDM). Materials and Methods This is a retrospective cohort study among women with DM and GDM at a Diabetes in Pregnancy Program at an academic institution between 2006 and 2014. Adherence with prenatal care was the percentage of prenatal appointments attended divided by those scheduled. Adherence was divided into quartiles, with the first quartile defined as lower adherence and compared with the other quartiles. Results There were 443 women with DM and 499 with GDM. Neonates of women with DM and lower adherence had higher rates of NICU admission or stillbirth (55 vs. 39%; p = 0.003). A multivariable logistic regression showed that the lower adherence group had higher likelihood of NICU admission (adjusted odds ratio: 1.61 [1.03‐2.5]; p = 0.035). Those with lower adherence had worse glycemic monitoring and more hospitalizations. Among those with GDM, most outcomes were similar between groups including NICU admission or stillbirth. Conclusion Women with DM with lower adherence had higher rates of NICU admission and worse glycemic control. Most outcomes among women with GDM with lower adherence were similar.

Outcomes of a Negative Rapid Influenza Diagnostic Test in Pregnant Women

Objective The objective of this study was to evaluate the negative predictive value (NPV) of a rapid influenza diagnostic test (RIDT) compared with polymerase chain reaction (PCR) in pregnant women. Study Design Retrospective cohort study of pregnant women with a negative RIDT followed by confirmatory PCR for influenza A, H1N1, and B during the influenza seasons from 2012 to 2015. Results The NPV of the RIDT was 85.4% (211 of 247), 93.5% (231 of 247), and 97.9% (242 of 247) for influenza A, H1N1, and B, respectively. Antiviral treatment was administered to 47.2% (17 of 36) of women with a false‐negative RIDT for influenza A compared with 9.0% (19 of 211) of women with a true‐negative RIDT (p < 0.001). Patients were more likely to receive antiviral treatment if they were feverish (adjusted odds ratio [aOR]: 6.05, 95% confidence interval [CI]: 1.83‐20.03), had cough (aOR: 6.43, 95% CI: 1.06‐39.26), dyspnea (aOR: 6.41, 95% CI: 1.63‐25.29), or had a subsequently positive PCR (aOR: 9.41, 95% CI: 3.13‐28.31). Conclusion Up to 14.5% of women with a negative RIDT in pregnancy had positive influenza A by PCR of whom more than half did not receive antiviral treatment.

Peripartum Morbidity after Cesarean Delivery for Arrest of Dilation at 4 to 5 cm Compared with 6 to 10 cm

Objective Given that recent consensus guidelines established to decrease cesarean delivery (CD) rates use 6 cm to define the onset of the active phase of labor, our objective was to evaluate maternal and neonatal outcomes after CD for the indication of arrest of dilation at 4 to 5 cm compared with ≥ 6 cm. Study Design We performed a secondary analysis using data from the Maternal Fetal‐Medicine Units Network Cesarean Registry. We included nulliparous women with term, singleton, vertex gestations who underwent primary CD for arrest of dilation. We compared those who reached a maximum cervical dilation of 4 to 5 cm with those of ≥6 cm. Our primary outcome was composite maternal morbidity that included chorioamnionitis, endometritis, transfusion, wound complication, operative injury, intensive care unit admission, or death. Results Of the 73,257 women in the dataset, 5,681 met the inclusion criteria. After adjusting for confounders, there was no difference in composite maternal (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 0.94‐1.52) or neonatal morbidity (aOR: 0.94; 95% CI: 0.79‐1.10) between the groups. Conclusion In this historical cohort, maternal and neonatal outcomes after CD for arrest of dilation ≥ 6 cm were comparable to those performed at 4 to 5 cm and support recent labor management guidelines.

Insulin Delivery Method and Admission for Glycemic Control in Pregnant Women with Type 1 Diabetes Mellitus

Abstract Objective To determine if there was a difference in glycemic control admissions or perinatal outcomes in women with type 1 diabetes mellitus (DM) treated with multiple daily injections (MDIs) versus continuous subcutaneous insulin infusion (CSII). Materials and Methods This was a retrospective cohort study of women with type 1 DM with a singleton gestation who delivered between 2006 and 2014 at a tertiary hospital and received care at a dedicated DM clinic. Women who used MDI were compared with those who used CSII. The primary outcome was glycemic control admission during pregnancy. Secondary outcomes included adverse perinatal outcomes. Results There were a total of 156 women; 107 treated with MDI and 49 with CSII. Women treated with MDI had higher rates of glycemic control admissions versus those treated with CSII (68.2 vs. 30.6%, p < 0.001). Adjusting for age, ethnicity, public insurer, duration of DM, first recorded hemoglobin A1c (HbA1c), and DM comorbidities, the likelihood of admission remained higher in women on MDI versus CSII (AOR 5.9 [1.7‐20.6]). Women treated with MDI had higher rates of postprandial hypoglycemia. Other perinatal outcomes were similar between the groups. Conclusion Women with type 1 DM treated with MDI were more likely to have glycemic control admissions and postprandial hypoglycemia than those treated with CSII.