Introduction
To examine whether there is a threshold of oxytocin exposure at which the risk for primary cesarean increases among women who are nulliparous with a term, singleton, vertex fetus (NTSV) ...and how oxytocin interacts with other risk factors to contribute to this outcome.
Methods
This was a secondary analysis of the Consortium on Safe Labor data set that used a retrospective cohort study design. Women who met the criteria for NTSV who were not admitted for a prelabor cesarean and for whom oxytocin data were available, were included in the sample. Robust logistic regression was used to examine the association of oxytocin exposure with primary cesarean birth, while controlling for demographic and clinical risk factors and clustering by provider.
Results
The sample comprised 17,331 women who were exposed to oxytocin during labor. The women were predominantly white non‐Hispanic (59.2%) with an average (SD) gestational age of 39.4 (1.1) weeks and an 18.5% primary cesarean rate. Exposure to greater than 11,400‐milliunits (mU) of oxytocin resulted in 1.6 times increased odds of primary cesarean birth compared with less than 11,400 mU (95% CI 1.01‐2.6).
Discussion
Exposure to greater than 11,400 mU of oxytocin in labor was associated with an increased odds of primary cesarean birth in NTSV women.
To determine the extent to which newborns with neonatal abstinence syndrome (NAS) are concentrated in some hospitals as compared with newborns without NAS and whether care quality and safety differed ...among these hospitals. We hypothesized that newborns with NAS would be cared for in poorer-quality hospitals.
Secondary analysis of 3 2016 data sets: (1) the panel study of effects of changes in nursing on patient outcomes-US survey of hospital registered nurses regarding work conditions and safety, (2) inpatient discharge abstracts, and (3) the American Hospital Association annual survey. Newborns in 266 hospitals from the 4 states where the panel study of effects of changes in nursing on patient outcomes was conducted were included. We used Lorenz curves to determine if newborns with NAS were concentrated in different hospitals than newborns without NAS and whether care quality and safety differed among those hospitals. Quality and safety were assessed by staff nurses by using standard survey questions.
Of the 659 403 newborns in this study, 3130 were diagnosed with noniatrogenic NAS. We found that newborns with NAS were cared for in different hospitals compared with newborns without NAS (Gini coefficient 0.62, 95% confidence interval, 0.56-0.68) and that the hospitals in which they received care were rated as having poorer quality and safety (Gini coefficient 0.12, 95% confidence interval, 0.01-0.23).
Newborns with NAS are cared for in poorer-quality hospitals than other newborns. Our findings are of concern because poorer-quality care is linked to patient outcomes. As stakeholders seek to address the opioid epidemic and improve outcomes of newborns with NAS, our findings suggest the importance of examining hospital factors.
Behavior change theories and models, validated within the field of dietetics, offer systematic explanations for nutrition-related behavior change. They are integral to the nutrition care process, ...guiding nutrition assessment, intervention, and outcome evaluation. The American Dietetic Association Evidence Analysis Library Nutrition Counseling Workgroup conducted a systematic review of peer-reviewed literature related to behavior change theories and strategies used in nutrition counseling. Two hundred fourteen articles were reviewed between July 2007 and March 2008, and 87 studies met the inclusion criteria. The workgroup systematically evaluated these articles and formulated conclusion statements and grades based upon the available evidence. Strong evidence exists to support the use of a combination of behavioral theory and cognitive behavioral theory, the foundation for cognitive behavioral therapy (CBT), in facilitating modification of targeted dietary habits, weight, and cardiovascular and diabetes risk factors. Evidence is particularly strong in patients with type 2 diabetes receiving intensive, intermediate-duration (6 to 12 months) CBT, and long-term (>12 months duration) CBT targeting prevention or delay in onset of type 2 diabetes and hypertension. Few studies have assessed the application of the transtheoretical model on nutrition-related behavior change. Little research was available documenting the effectiveness of nutrition counseling utilizing social cognitive theory. Motivational interviewing was shown to be a highly effective counseling strategy, particularly when combined with CBT. Strong evidence substantiates the effectiveness of self-monitoring and meal replacements and/or structured meal plans. Compelling evidence exists to demonstrate that financial reward strategies are not effective. Goal setting, problem solving, and social support are effective strategies, but additional research is needed in more diverse populations. Routine documentation and evaluation of the effectiveness of behavior change theories and models applied to nutrition care interventions are recommended.
Introduction
Poor communication is a leading root cause of preventable maternal mortality in the United States. Communication challenges are compounded with the presence of biases, including racism. ...Hospital administrators and clinicians are often aware that communication is a problem, but understanding where to intervene can be difficult to determine. While clinical leadership routinely reviews incident reports and acts on them to improve care, we hypothesized that reviewing incident reports in a systematic way might reveal thematic patterns, providing targeted opportunities to improve communication in direct interaction with patients and within the healthcare team itself.
Methods
We ed incident reports from the Women's Health service and linked them with patient charts to join patient's race/ethnicity, birth outcome, and presence of maternal morbidity and mortality to the incident report. We conducted a qualitative content analysis of incident reports using an inductive and deductive approach to categorizing communication challenges. We then described the intersection of different types of communication challenges with patient race/ethnicity and morbidity outcomes.
Results
The use of incident reports to conduct research on communication was new for the health system. Conversations with health system‐level stakeholders were important to determine the best way to manage data. We developed a thematic codebook based on prior research in healthcare communication. We found that we needed to add codes that were equity focused, as this was missing from the existing codebook. We also found that clinical and contextual expertise was necessary for conducting the analysis—requiring more resources to conduct coding than initially estimated. We shared our findings back with leadership iteratively during the work.
Conclusions
Incident reports represent a promising source of health system data for rapid improvement to transform organizational practice around communication. There are barriers to conducting this work in a rapid manner, however, that require further iteration and innovation.
Understanding the process by which research is translated into practice is limited. This study sought to examine how interventions change during implementation.
Data were collected from July 2005 to ...September 2007. A real-time and cross-case comparison was conducted, examining ten interventions designed to improve health promotion in primary care practices in practice-based research networks. An iterative group process was used to analyze qualitative data (survey data, interviews, site visits, and project diary entries made by grantees approximately every 2 weeks) and to identify intervention adaptations reported during implementation.
All interventions required changes as they were integrated into practice. Modifications differed by project and by practice, and were often unanticipated. Three broad categories of changes were identified and include modifications undertaken to accommodate practices' and patients' circumstances as well as personnel costs. In addition, research teams played a crucial role in fostering intervention uptake through their use of personal influence and by providing motivation, retraining, and instrumental assistance to practices. These efforts by the research teams, although rarely considered an essential component of the intervention, were an active ingredient in successful implementation and translation.
Changes are common when interventions are implemented into practice settings. The translation of evidence into practice will be improved when research design and reporting standards are modified to help quality-improvement teams understand both these adaptations and the effort required to implement interventions in practice.
Congenital diaphragmatic hernia (CDH) is a relatively common and genetically heterogeneous structural birth defect associated with high mortality and morbidity. We describe eight unrelated families ...with an X-linked condition characterized by diaphragm defects, variable anterior body-wall anomalies, and/or facial dysmorphism. Using linkage analysis and exome or genome sequencing, we found that missense variants in plastin 3 (PLS3), a gene encoding an actin bundling protein, co-segregate with disease in all families. Loss-of-function variants in PLS3 have been previously associated with X-linked osteoporosis (MIM: 300910), so we used in silico protein modeling and a mouse model to address these seemingly disparate clinical phenotypes. The missense variants in individuals with CDH are located within the actin-binding domains of the protein but are not predicted to affect protein structure, whereas the variants in individuals with osteoporosis are predicted to result in loss of function. A mouse knockin model of a variant identified in one of the CDH-affected families, c.1497G>C (p.Trp499Cys), shows partial perinatal lethality and recapitulates the key findings of the human phenotype, including diaphragm and abdominal-wall defects. Both the mouse model and one adult human male with a CDH-associated PLS3 variant were observed to have increased rather than decreased bone mineral density. Together, these clinical and functional data in humans and mice reveal that specific missense variants affecting the actin-binding domains of PLS3 might have a gain-of-function effect and cause a Mendelian congenital disorder.
In eight families where males are affected by congenital diaphragmatic hernia, we found variants in PLS3 on the X chromosome. This gene was initially associated with severe osteoporosis in males. Different molecular mechanisms are at play to explain that these two diseases are associated with the same gene.
Abstract Purpose We wanted to examine how coordinated care is implemented in primary care practices to address patients' health behavior change needs. Methods Site visit notes, documents, interviews, ...and online implementation diaries were collected from July 2005 to September 2007 from practice-based research networks (PBRNs) participating in Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks (P4H). An iterative group process was used to conduct a cross-case comparative analysis of 9 interventions. Published patient outcomes reports from P4H interventions were referenced to provide information on intervention effectiveness. Results In-practice health risk assessment (HRA) and brief counseling, coupled with referral and outreach to a valued and known counseling resource, emerged as the best way to consistently coordinate and encourage follow-through for health behavior counseling. Findings from published P4H outcomes suggest that this approach led to improvement in health behaviors. Automated prompts and decision support tools for HRA, brief counseling and referral, training in brief counseling strategies, and co-location of referral with outreach facilitated implementation. Interventions that attempted to minimize practice or clinician burden through telephone and Web-based counseling systems or by expanding the medical assistant role in coordination of health behavior counseling experienced difficulties in implementation and require more study to determine how to optimize integration in practices. Conclusions Easy-to-use system-level solutions that have point-of-delivery reminders and decision support facilitate coordination of health behavior counseling for primary care patients. Infrastructure is needed if broader integration of health behavior counseling is to be achieved in primary care.
Many coastal marine populations persist across gradients in benthic productivity. In the New Zealand fjords there is a sharp gradient in available biomass between the wave-washed outer coasts, ...dominated by kelps, and the quiescent inner fjords, where estuarine seaweeds and terrestrial inputs predominate. In Doubtful Sound we found significant variation in abundance of macroalgal groups, the grazing sea urchinEvechinus chloroticusand the detritivorous sea cucumberStichopus mollis, and in δ15N and δ13C of the macroalgae and consumers among 5 study sites across this gradient. Analysis of δ15N and δ13C from tissue of the 2 consumers relative to the primary carbon source pools with a mass balance model indicated that diet was primarily influenced by composition and quality of macroalgal food, except at the innermost sites, where there was evidence for terrestrial inputs. These results demonstrate that it is important to resolve relative abundance of food sources and specific isotopic variation to resolve spatial patterns in diet from stable isotope analysis across environmental gradients. Isotopic analysis ofE. chloroticusstomach contents from the innermost sites provided strong evidence that terrestrial detritus was being assimilated via microbial recycling (δ15N, –5‰ and δ13C, –37‰). Differences in δ13C of stomach contents versus those of tissues provided a basis to measure assimilation. There was a strong correlation between this proxy for assimilation with growth parameters among study sites across the ecotone. This analysis indicates a strong bottom-up influence on vital rates ofE. chloroticuswithin the fjord, with links to the source–sink structure of the population.
Background. Many trials have been carried out to determine the effectiveness of antimicrobial agents in treating skin and soft tissue infections. The results of these studies are often utilized to ...make determinations about the use of these antimicrobials against other types of infections. Despite the importance of these trials in determining clinical care, we hypothesized that many of these studies failed to include a variety of infections of significant enough severity to effectively draw objective conclusions about antimicrobial efficacy. Methods. We conducted a modified PubMed search to identify studies of antimicrobial agents in treating soft tissue infections that were published from 1998 through 2008. We then evaluated these trials for specific recommended study criteria, which were based on published US Food and Drug Administration guidelines for the conduct of trials of antimicrobials for soft tissue infection. Results. Seventeen studies were identified for inclusion in the trial. Upon review, only 30% of trials required both local and systemic signs of infection for inclusion in the trial. One trial stratified results on the basis of operative intervention, less than half reported patient comorbidities, and only 53% provided a specific definition for “cure.” Conclusions. Our meta-analysis of current trials evaluating antimicrobial therapy for skin and soft tissue infections revealed substantial shortcomings in the design of most of these trials. These data provide evidence for the importance of designing specialist panels to objectively evaluate studies and photographs of included infections to ensure that conclusions drawn from these trials concerning clinical practice are justified.
PDF
