Obstetric Anesthesia Workforce Surveys were conducted in 1981, 1992, and 2001, and the 10-year update was conducted in 2012. Anesthesia providers from US hospitals were surveyed to identify the ...methods used to provide obstetric anesthesia. Our primary hypothesis was that the provision of obstetric anesthesia services has changed in the past 10 years.
A sample of hospitals was generated based on the number of births per year and US census region. Strata were defined as follows: I ≥ 1500 annual births (n = 341), II ≥ 500 to 1499 annual births (n = 438), and III < 500 annual births (n = 414). Contact email information for the anesthesia provider in charge of obstetric services was obtained by phone call. Electronic questionnaires were sent through email.
Administration of neuraxial (referred to as "regional" in previous surveys) labor analgesia was available 24 hours per day in all stratum I hospitals responding to the survey. Respondents across all strata reported high rates of in-house coverage, with 86.3% (95% confidence interval CI = 82.7%-90%) of stratum I providers reporting that they provided in-house anesthesiology services for obstetrics. The use of patient-controlled epidural analgesia in stratum I hospitals was reported to be 35% in 2001 and 77.6% (95% CI = 73.2%-82.1%) in this survey. Independent Certified Registered Nurse Anesthetists were reported to provide obstetric anesthesia services in 68% (95% CI = 57.9%-77.0%) of stratum III hospitals. Although 76% (95% CI = 71.2%-80.3%) of responding stratum I hospitals allow postpartum tubal ligations, 14% report inadequate staffing to provide anesthesia either always or at off-hours.
Since 2001, there have been significant changes in how responding hospitals provide obstetric anesthesia care and staff the labor and delivery ward. Obstetric anesthesia surveys, updated every 10 years, continue to provide information about changes in obstetric anesthesia practice.
The “39-Week Rule” was adopted by the American College of Obstetricians and Gynecologists in 2009 to eliminate nonmedically indicated (elective) deliveries before 39 weeks in an effort to improve ...neonatal outcomes.
Our primary objective was to quantify the effect of this policy change on adverse neonatal outcomes among a cohort of term births in South Carolina.
Deidentified data from all births in the state of South Carolina from 2000 to 2008 (before the 39-week rule) and from 2013 to 2017 (after statewide implementation and enforcement of the rule) were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic data and International Statistical Classification of Diseases and Related Health Problems Ninth/Tenth Revision codes were obtained for each birth. Our primary outcome was admission to a neonatal intensive care unit. Our secondary outcomes were respiratory morbidities (including respiratory distress syndrome and transient tachypnea of the newborn), hypoxic–ischemic encephalopathy, seizure, sepsis, birth injuries, hyperbilirubinemia, hypoglycemia, and feeding difficulties. Propensity score analysis was used to control for maternal age, body mass index, race, gestational hypertension, infection, placental abruption, and gestational and pregestational diabetes mellitus. After stratification by propensity score, the Cochran-Mantel-Haenszel test was used to compare groups.
A total of 620,121 infants were liveborn at term during the 2 study periods. After implementation of the 39-week rule, there was a significant reduction in early-term deliveries. In adjusted analyses, neonatal intensive care unit admission was significantly more common in the postimplementation period. Respiratory morbidities were also significantly more common postimplementation. In contrast, there were significant reductions in birth injuries and hyperbilirubinemia in the postimplementation period.
Implementation of the 39-week rule was associated temporally with an increase in adverse neonatal outcomes. The outcomes intended to be reduced by the 39-week rule, including neonatal intensive care unit admission and respiratory morbidity, seem to have increased in incidence despite adherence to the proposed guidelines.
The “39-week rule,” adopted by the American College of Obstetricians and Gynecologists circa 2009, discouraged routine elective induction of labor in early-term gestations (37 weeks 0 days–38 weeks 6 ...days) to decrease the risk of adverse neonatal outcomes. However, little research exists regarding any unintended adverse pregnancy outcomes associated with this policy shift.
This study aimed to quantify the difference in incidence of adverse pregnancy outcomes before and after the implementation of the 39-week rule.
Deidentified data from all births in the state of South Carolina from 2000 to 2008 (before the 39-week rule) and from 2013 to 2017 (after statewide implementation and enforcement of the rule) were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic data and International Classification of Diseases 9/10 codes were obtained for each birth. Our primary outcome was the incidence of any of the following adverse pregnancy outcomes: cesarean delivery, hypertensive disorders, chorioamnionitis, postpartum hemorrhage, high-degree lacerations, placental abruption, and intensive care unit admission. Propensity score analysis was used to control for age, body mass index, and race. After stratification by propensity score, the Cochran–Mantel–Haenszel test was used to compare the prerule and postrule groups.
A total of 633,985 births were eligible for inclusion—412,632 from 2000 to 2008, and 221,353 from 2013 to 2017. There was a significant increase in the primary outcome in the postrule period (39.94% pre vs 42.76% post; P<.01). The incidence of all hypertensive disorders was significantly increased in the postrule period compared with the prerule period (7.75% pre vs 10.1% post; P<.01). The incidence of chorioamnionitis and cesarean delivery also increased in the postrule period (1.45% pre vs 1.92% post; P<.01; 29.6% pre vs 31.82% post; P<.01; respectively).
There was a significant increase in the primary outcome following the implementation of the 39-week rule. Although the policy shift was driven by a desire to decrease adverse neonatal outcomes, aggregate benefit was not observed for pregnancy outcomes.
Studies have demonstrated an association of the BRAF(V600E) mutation and microRNA (miR) expression with aggressive clinicopathologic features in papillary thyroid cancer (PTC). Analysis of ...BRAF(V600E) mutations with miR expression data may improve perioperative decision making for patients with PTC, specifically in identifying patients harboring central lymph node metastases (CLNM).
Between January 2012 and June 2013, 237 consecutive patients underwent total thyroidectomy and prophylactic central lymph node dissection (CLND) at four endocrine surgery centers. All tumors were tested for the presence of the BRAF(V600E) mutation and miR-21, miR-146b-3p, miR-146b-5p, miR-204, miR-221, miR-222, and miR-375 expression. Bivariate and multivariable analyses were performed to examine associations between molecular markers and aggressive clinicopathologic features of PTC.
Multivariable logistic regression analysis of all clinicopathologic features found miR-146b-3p and miR-146b-5p to be independent predictors of CLNM, while the presence of BRAF(V600E) almost reached significance. Multivariable logistic regression analysis limited to only predictors available preoperatively (molecular markers, age, sex, and tumor size) found miR-146b-3p, miR-146b-5p, miR-222, and BRAF(V600E) mutation to predict CLNM independently. While BRAF(V600E) was found to be associated with CLNM (48% mutated in node-positive cases vs. 28% mutated in node-negative cases), its positive and negative predictive values (48% and 72%, respectively) limit its clinical utility as a stand-alone marker. In the subgroup analysis focusing on only classical variant of PTC cases (CVPTC), undergoing prophylactic lymph node dissection, multivariable logistic regression analysis found only miR-146b-5p and miR-222 to be independent predictors of CLNM, while BRAF(V600E) was not significantly associated with CLNM.
In the patients undergoing prophylactic CLNDs, miR-146b-3p, miR-146b-5p, and miR-222 were found to be predictive of CLNM preoperatively. However, there was significant overlap in expression of these miRs in the two outcome groups. The BRAF(V600E) mutation, while being a marker of CLNM when considering only preoperative variables among all histological subtypes, is likely not a useful stand-alone marker clinically because the difference between node-positive and node-negative cases was small. Furthermore, it lost significance when examining only CVPTC. Overall, our results speak to the concept and interpretation of statistical significance versus actual applicability of molecular markers, raising questions about their clinical usefulness as individual prognostic markers.
Background: The prevalence of foot and ankle conditions varies among different ethnic groups. It is not known if this difference is due to any distinctive skeletal morphological characteristics of ...the foot. The purpose of this study was to determine if ethnic differences exist in the morphometric measurements on radiographs of the weightbearing foot. Materials and Methods: A morphometric study of weightbearing radiographs of feet was performed prospectively. Radiographic parameters were measured on digital monitors using digital tools. These were the hallux valgus angle (HVA), intermetatarsal angle (IMA), talonavicular angle (TNA), talonavicular coverage angle (TNCovA), metatarsal span (MS) on anteroposterior (AP) radiographs and talo-first metatarsal angle (T-1stMTA), calcaneal pitch (CP), and lateral talocalcaneal angle (LTCA) on lateral radiographs. Results: A total of 237 feet in 126 patients (45 African Americans, 59 Caucasians, and 22 Hispanics) were studied. Statistically significant differences were found in the CP, LTCA, and MS. African Americans have significantly lower CP than Caucasians (p < 0.0001). African Americans have significantly lower CP than Hispanics (p < 0.0016). Caucasians have significantly higher TCA than African Americans (p < 0.0004). Males have a larger MS than females (p < 0.0001). Conclusion: There are differences in the radiographic morphology of feet among different ethnic groups. A larger prospective community-based study of morphological differences is needed for better understanding of the genetic and environmental factors influencing the prevalence of foot and ankle conditions. Clinical Relevance: The clinical relevance between having a lower CP angle and a higher incidence of flat feet in African Americans warrants further investigation. It is not known if there is a relationship between posterior tibialis insufficiency and low CP.
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