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Greenberg JT, Cross SN, Raab CA, Pettker CM, Illuzzi JL. Adherence to Definitions of Labor Arrest Influence on Primary Cesarean Delivery Rate. Am J Perinatol 2024; 41:618-627. [PMID: 35045572 DOI: 10.1055/a-1745-1570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The cesarean delivery rate in the United States is 31.9%. One of the leading indications for primary cesarean delivery is labor arrest. A modern understanding of the labor curve supports more time prior to the diagnosis of labor arrest. We conducted this study to examine the impact of adherence to the modern criteria for labor arrest and failed induction on rates of primary cesarean delivery and to identify predictors of meeting these criteria. STUDY DESIGN We analyzed rates of primary cesarean deliveries overall and primary cesarean deliveries occurring due to arrest of dilation, arrest of descent, and failed induction among the 17,877 live births at a large academic center from 2010 through 2013. Multiple logistic regression modeling identified predictors of meeting the new criteria for these indications based on guidelines published by the 2012 National Institute of Child Health and Human Development. RESULTS The primary cesarean delivery rate decreased from 23.5 to 21.1% (p = 0.026) from 2010 to 2013. Primary cesarean delivery rate for labor arrest and failed induction decreased from 8.5 to 6.7% (p = 0.005). The percentage of primary cesarean deliveries meeting the 2012 criteria for labor arrest increased from 18.8 to 34.9% (p = 0.002), and the rate of primary cesarean deliveries due to arrest of dilation decreased from 5.1 to 3.4% (p < 0.0005). The percentage of cases meeting the 2012 criteria for arrest of descent increased from 57.8 to 71.0% (p < 0.007), while primary cesarean delivery rate due to arrest of descent remained relatively unchanged, 3.1 to 2.6% (p = 0.330). CONCLUSION A decrease in the primary cesarean rate was attributable to a decrease in cesarean for arrest of dilation in the setting of a significant increase in meeting the 2012 criteria for arrest of dilation. At the end of the study period, 65.2% of cesareans still did not meet the criteria for arrest of dilation. Greater rates of adherence to these guidelines may yield further reductions in the cesarean rate. KEY POINTS · Primary cesarean delivery for labor arrest was decreased.. · Meeting criteria for labor arrest increased.. · A hospitalist provider increased odds of meeting criteria..
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Affiliation(s)
- Jessica T Greenberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
- Department of Obstetrics and Gynecology, Stamford Hospital, Stamford, Connecticut
| | - Sarah N Cross
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
- Department of Obstetrics, Gynecology, and Women's Health, University of Minnesota, Minneapolis, Minnesota
| | - Cheryl A Raab
- Women's Service, Yale New Haven Hospital, New Haven, Connecticut
| | - Christian M Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Jessica L Illuzzi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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2
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Metz TD, Clifton RG, Gallagher R, Gross RS, Horwitz LI, Jacoby VL, Martin-Herz SP, Peralta-Carcelen M, Reeder HT, Beamon CJ, Chan J, Chang AA, Costantine MM, Fitzgerald ML, Foulkes AS, Gibson KS, Güthe N, Habli M, Hackney DN, Hoffman MK, Hoffman MC, Hughes BL, Katz SD, Laleau V, Mallett G, Mendez-Figueroa H, Monzon V, Palatnik A, Palomares KTS, Parry S, Pettker CM, Plunkett BA, Poppas A, Reddy UM, Rouse DJ, Saade GR, Sandoval GJ, Schlater SM, Sciurba FC, Simhan HN, Skupski DW, Sowles A, Thaweethai T, Thomas GL, Thorp JM, Tita AT, Weiner SJ, Weigand S, Yee LM, Flaherman VJ. Researching COVID to enhance recovery (RECOVER) pregnancy study: Rationale, objectives and design. PLoS One 2023; 18:e0285351. [PMID: 38128008 PMCID: PMC10734909 DOI: 10.1371/journal.pone.0285351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 10/10/2023] [Indexed: 12/23/2023] Open
Abstract
IMPORTANCE Pregnancy induces unique physiologic changes to the immune response and hormonal changes leading to plausible differences in the risk of developing post-acute sequelae of SARS-CoV-2 (PASC), or Long COVID. Exposure to SARS-CoV-2 during pregnancy may also have long-term ramifications for exposed offspring, and it is critical to evaluate the health outcomes of exposed children. The National Institutes of Health (NIH) Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC aims to evaluate the long-term sequelae of SARS-CoV-2 infection in various populations. RECOVER-Pregnancy was designed specifically to address long-term outcomes in maternal-child dyads. METHODS RECOVER-Pregnancy cohort is a combined prospective and retrospective cohort that proposes to enroll 2,300 individuals with a pregnancy during the COVID-19 pandemic and their offspring exposed and unexposed in utero, including single and multiple gestations. Enrollment will occur both in person at 27 sites through the Eunice Kennedy Shriver National Institutes of Health Maternal-Fetal Medicine Units Network and remotely through national recruitment by the study team at the University of California San Francisco (UCSF). Adults with and without SARS-CoV-2 infection during pregnancy are eligible for enrollment in the pregnancy cohort and will follow the protocol for RECOVER-Adult including validated screening tools, laboratory analyses and symptom questionnaires followed by more in-depth phenotyping of PASC on a subset of the overall cohort. Offspring exposed and unexposed in utero to SARS-CoV-2 maternal infection will undergo screening tests for neurodevelopment and other health outcomes at 12, 18, 24, 36 and 48 months of age. Blood specimens will be collected at 24 months of age for SARS-CoV-2 antibody testing, storage and anticipated later analyses proposed by RECOVER and other investigators. DISCUSSION RECOVER-Pregnancy will address whether having SARS-CoV-2 during pregnancy modifies the risk factors, prevalence, and phenotype of PASC. The pregnancy cohort will also establish whether there are increased risks of adverse long-term outcomes among children exposed in utero. CLINICAL TRIALS.GOV IDENTIFIER Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT05172011.
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Affiliation(s)
- Torri D. Metz
- Department of Obstetrics and Gynecology, University of Utah Health Hospitals and Clinics, Salt Lake City, UT, United States of America
| | - Rebecca G. Clifton
- Biostatistics Center, The George Washington University, Washington, DC, United States of America
| | - Richard Gallagher
- Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, NY, United States of America
| | - Rachel S. Gross
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Leora I. Horwitz
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Vanessa L. Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Susanne P. Martin-Herz
- Department of Pediatrics, Division of Developmental Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Myriam Peralta-Carcelen
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Harrison T. Reeder
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, United States of America
| | - Carmen J. Beamon
- Department of Maternal Fetal Medicine, WakeMed Health and Hospitals, Raleigh, NC, United States of America
| | - James Chan
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, United States of America
| | - A. Ann Chang
- Women’s Health Research Clinical Center, University of California, San Francisco, San Francisco, CA, United States of America
| | - Maged M. Costantine
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Megan L. Fitzgerald
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Andrea S. Foulkes
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kelly S. Gibson
- Department of Obstetrics and Gynecology, The MetroHealth System, Cleveland, OH, United States of America
| | - Nick Güthe
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Mounira Habli
- Division Maternal Fetal Medicine, Trihealth Good Samaritan Hospital Maternal Fetal Medicine, Cincinnati, OH, United States of America
| | - David N. Hackney
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center: UH Cleveland Medical Center, Cleveland, OH, United States of America
| | - Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, DE, United States of America
| | - M. Camille Hoffman
- Department of Obstetrics & Gynecology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Brenna L. Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, United States of America
| | - Stuart D. Katz
- Department of Medicine, New York University School of Medicine, New York City, NY, United States of America
| | - Victoria Laleau
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Gail Mallett
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas McGovern Medical School: The University of Texas Health Science Center at Houston John P. and Katherine G. McGovern Medical School, Houston, TX, United States of America
| | - Vanessa Monzon
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Kristy T. S. Palomares
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Peter’s University Hospital, New Brunswick, NJ, United States of America
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Christian M. Pettker
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States of America
| | - Beth A. Plunkett
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL, United States of America
| | - Athena Poppas
- Division of Cardiology, Brown University Warren Alpert Medical School, Providence, RI, United States of America
| | - Uma M. Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York City, NY, United States of America
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, RI, United States of America
| | - George R. Saade
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Grecio J. Sandoval
- Biostatistics Center, The George Washington University, Rockville, MD, United States of America
| | - Shannon M. Schlater
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States of America
| | - Frank C. Sciurba
- Department of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Hyagriv N. Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Daniel W. Skupski
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, United States of America
| | - Amber Sowles
- Department of Obstetrics and Gynecology, University of Utah Health Hospitals and Clinics, Salt Lake City, UT, United States of America
| | - Tanayott Thaweethai
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, United States of America
| | - Gelise L. Thomas
- Clinical and Translational Science Collaborative of Cleveland, Case Western Reserve University, Cleveland, OH, United States of America
| | - John M. Thorp
- Department of Obstetrics and Gynecology, UNC: The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Alan T. Tita
- Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Steven J. Weiner
- Biostatistics Center, The George Washington University, Washington, DC, United States of America
| | - Samantha Weigand
- Department of Obstetrics and Gynecology, Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America
| | - Lynn M. Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Valerie J. Flaherman
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States of America
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3
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Denoble AE, Pettker CM. Hypertension Screening in Pregnancy: Remembering the Basics, Charting the Future. JAMA 2023; 330:1040-1041. [PMID: 37721621 DOI: 10.1001/jama.2023.15088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Affiliation(s)
- Anna E Denoble
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Christian M Pettker
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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4
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Pettker CM, Turrentine MA, Simhan HN. The Limits of Viability. Obstet Gynecol 2023; 142:725-726. [PMID: 37535950 PMCID: PMC10424821 DOI: 10.1097/aog.0000000000005280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/15/2023] [Accepted: 05/25/2023] [Indexed: 08/05/2023]
Abstract
The distinction between “pregnancy viability” and “fetal viability” indicates the need for care and clarity when using the term “viability” in clinical practice and guidance.
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Affiliation(s)
- Christian M Pettker
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut; the Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; and the Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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5
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Horwitz LI, Thaweethai T, Brosnahan SB, Cicek MS, Fitzgerald ML, Goldman JD, Hess R, Hodder SL, Jacoby VL, Jordan MR, Krishnan JA, Laiyemo AO, Metz TD, Nichols L, Patzer RE, Sekar A, Singer NG, Stiles LE, Taylor BS, Ahmed S, Algren HA, Anglin K, Aponte-Soto L, Ashktorab H, Bassett IV, Bedi B, Bhadelia N, Bime C, Bind MAC, Black LJ, Blomkalns AL, Brim H, Castro M, Chan J, Charney AW, Chen BK, Chen LQ, Chen P, Chestek D, Chibnik LB, Chow DC, Chu HY, Clifton RG, Collins S, Costantine MM, Cribbs SK, Deeks SG, Dickinson JD, Donohue SE, Durstenfeld MS, Emery IF, Erlandson KM, Facelli JC, Farah-Abraham R, Finn AV, Fischer MS, Flaherman VJ, Fleurimont J, Fonseca V, Gallagher EJ, Gander JC, Gennaro ML, Gibson KS, Go M, Goodman SN, Granger JP, Greenway FL, Hafner JW, Han JE, Harkins MS, Hauser KSP, Heath JR, Hernandez CR, Ho O, Hoffman MK, Hoover SE, Horowitz CR, Hsu H, Hsue PY, Hughes BL, Jagannathan P, James JA, John J, Jolley S, Judd SE, Juskowich JJ, Kanjilal DG, Karlson EW, Katz SD, Kelly JD, Kelly SW, Kim AY, Kirwan JP, Knox KS, Kumar A, Lamendola-Essel MF, Lanca M, Lee-lannotti JK, Lefebvre RC, Levy BD, Lin JY, Logarbo BP, Logue JK, Longo MT, Luciano CA, Lutrick K, Malakooti SK, Mallett G, Maranga G, Marathe JG, Marconi VC, Marshall GD, Martin CF, Martin JN, May HT, McComsey GA, McDonald D, Mendez-Figueroa H, Miele L, Mittleman MA, Mohandas S, Mouchati C, Mullington JM, Nadkarni GN, Nahin ER, Neuman RB, Newman LT, Nguyen A, Nikolich JZ, Ofotokun I, Ogbogu PU, Palatnik A, Palomares KTS, Parimon T, Parry S, Parthasarathy S, Patterson TF, Pearman A, Peluso MJ, Pemu P, Pettker CM, Plunkett BA, Pogreba-Brown K, Poppas A, Porterfield JZ, Quigley JG, Quinn DK, Raissy H, Rebello CJ, Reddy UM, Reece R, Reeder HT, Rischard FP, Rosas JM, Rosen CJ, Rouphael NG, Rouse DJ, Ruff AM, Saint Jean C, Sandoval GJ, Santana JL, Schlater SM, Sciurba FC, Selvaggi C, Seshadri S, Sesso HD, Shah DP, Shemesh E, Sherif ZA, Shinnick DJ, Simhan HN, Singh U, Sowles A, Subbian V, Sun J, Suthar MS, Teunis LJ, Thorp JM, Ticotsky A, Tita ATN, Tragus R, Tuttle KR, Urdaneta AE, Utz PJ, VanWagoner TM, Vasey A, Vernon SD, Vidal C, Walker T, Ward HD, Warren DE, Weeks RM, Weiner SJ, Weyer JC, Wheeler JL, Whiteheart SW, Wiley Z, Williams NJ, Wisnivesky JP, Wood JC, Yee LM, Young NM, Zisis SN, Foulkes AS. Researching COVID to Enhance Recovery (RECOVER) adult study protocol: Rationale, objectives, and design. PLoS One 2023; 18:e0286297. [PMID: 37352211 PMCID: PMC10289397 DOI: 10.1371/journal.pone.0286297] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/12/2023] [Indexed: 06/25/2023] Open
Abstract
IMPORTANCE SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis. METHODS RECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms. DISCUSSION RECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options. REGISTRATION NCT05172024.
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Affiliation(s)
- Leora I. Horwitz
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Tanayott Thaweethai
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Shari B. Brosnahan
- Division of Pulmonary Critical Care and Sleep Medicine, NYU Langone Health, New York, New York, United States of America
| | - Mine S. Cicek
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Megan L. Fitzgerald
- Patient Led Research Collaboration on COVID-19, Washington, DC, United States of America
| | - Jason D. Goldman
- Division of Infectious Diseases, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Rachel Hess
- Department of Population Health Sciences and Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - S. L. Hodder
- Department of Medicine, West Virginia University, Morgantown, West Virginia, United States of America
| | - Vanessa L. Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Michael R. Jordan
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Medford, Massachusetts, United States of America
| | - Jerry A. Krishnan
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Adeyinka O. Laiyemo
- Department of Medicine, Howard University, Washington, DC, United States of America
| | - Torri D. Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, United States of America
| | - Lauren Nichols
- Body Politic COVID-19 Support Group, Boston, Massachusetts, United States of America
| | - Rachel E. Patzer
- Department of Medicine and Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Anisha Sekar
- Patient Led Research Collaboration on COVID-19, Washington, DC, United States of America
| | - Nora G. Singer
- Department of Medicine and Rheumatology, The MetroHealth Medical Center, Cleveland, Ohio, United States of America
| | - Lauren E. Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, United States of America
| | - Barbara S. Taylor
- Department of Medicine, Division of Infectious Diseases and Infectious Diseases, Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
| | - Shifa Ahmed
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Heather A. Algren
- Swedish Center for Research and Innovation, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Khamal Anglin
- Department of Epidemiology and Biostatistics, University of California at San Francisco Institute of Global Health Sciences, San Francisco, San Francisco, California, United States of America
| | - Lisa Aponte-Soto
- College of Science and Health, Department of Health Sciences, DePaul University, Chicago, Illinois, United States of America
| | - Hassan Ashktorab
- Department of Medicine, Howard University, Washington, DC, United States of America
| | - Ingrid V. Bassett
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brahmchetna Bedi
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Nahid Bhadelia
- Center for Emerging Infectious Diseases Policy and Research, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Christian Bime
- Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Marie-Abele C. Bind
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Lora J. Black
- Department of Clinical Research, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Andra L. Blomkalns
- Department of Emergency Medicine, Stanford University, Stanford, California, United States of America
| | - Hassan Brim
- Department of Pathology, Howard University, Washington, DC, United States of America
| | - Mario Castro
- Division of Pulmonary and Critical Care, University of Kansas Medical Center, Kansas City, Kansas City, United States of America
| | - James Chan
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Alexander W. Charney
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Benjamin K. Chen
- Division of Infectious Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Li Qing Chen
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Peter Chen
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - David Chestek
- Department of Emergency Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Lori B. Chibnik
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Dominic C. Chow
- Department of Medicine, University of Hawaii at Manoa John A. Burns School of Medicine, Honolulu, Hawaii, United States of America
| | - Helen Y. Chu
- Department of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Rebecca G. Clifton
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Shelby Collins
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Maged M. Costantine
- Department of Obstetrics and Gynecology, The Ohio State University Hospital, Columbus, Ohio, United States of America
| | - Sushma K. Cribbs
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Steven G. Deeks
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - John D. Dickinson
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Sarah E. Donohue
- Department of Research Services, University of Illinois College of Medicine, Peoria, Illinois, United States of America
| | - Matthew S. Durstenfeld
- Department of Medicine, Division of Cardiology at Zuckerberg San Francisco General, University of California San Francisco, San Francisco, California, United States of America
| | - Ivette F. Emery
- MaineHealth Institute for Research, MaineHealth, Scarborough, Maine, United States of America
| | - Kristine M. Erlandson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Julio C. Facelli
- Department of Biomedical Informatics and Clinical and Translational Science Institute, University of Utah, Salt Lake City, Utah, United States of America
| | - Rachael Farah-Abraham
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Aloke V. Finn
- Department of Pathology, CVPath Institute, Gaithersburg, Maryland, United States of America
| | - Melinda S. Fischer
- Department of Medicine, Division of Infectious Diseases and Infectious Diseases, Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
| | - Valerie J. Flaherman
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Judes Fleurimont
- Mile Square Health Center, University of Illinois Chicago, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Vivian Fonseca
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Emily J. Gallagher
- Department of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente of Georgia, Atlanta, Georgia, United States of America
| | - Maria Laura Gennaro
- Public Health Research Institute and Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, United States of America
| | - Kelly S. Gibson
- Department of Obstetrics and Gynecology, MetroHealth System, Cleveland, Ohio, United States of America
| | - Minjoung Go
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Steven N. Goodman
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Joey P. Granger
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Frank L. Greenway
- Clinical Trials, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - John W. Hafner
- Department of Emergency Medicine, OSF Saint Francis Medical Center, Peoria, Illinois, United States of America
| | - Jenny E. Han
- Department of Pulmonary and Critical Care, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Michelle S. Harkins
- Department of Internal Medicine University of New Mexico, Health Science Center, Albuquerque, New Mexico, United States of America
| | - Kristine S. P. Hauser
- Clinical Research Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - James R. Heath
- Department of Bioengineering, Institute for Systems Biology, Seattle, Washington, United States of America
| | - Carla R. Hernandez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
| | - On Ho
- Seattle Children’s Therapeutics, Seattle, Washington, United States of America
| | - Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health Services, Newark, Delaware, United States of America
| | - Susan E. Hoover
- Department of Clinical Research, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Carol R. Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Harvey Hsu
- Department of Internal Medicine, University of Arizona, Phoenix, Arizona, United States of America
| | - Priscilla Y. Hsue
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Brenna L. Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, United States of America
| | - Prasanna Jagannathan
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Judith A. James
- Department of Arthritis & Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, United States of America
| | - Janice John
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America
| | - Sarah Jolley
- Department of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - S. E. Judd
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Joy J. Juskowich
- Department of Medicine, Division of Infectious Diseases, West Virginia School of Medicine, Morgantown, West Virginia, United States of America
| | - Diane G. Kanjilal
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Elizabeth W. Karlson
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Stuart D. Katz
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - J. Daniel Kelly
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Sara W. Kelly
- Department of Pediatrics & Department of Research Services, University of Illinois College of Medicine, Peoria, Illinois, United States of America
| | - Arthur Y. Kim
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - John P. Kirwan
- Department Integrated Physiology and Molecular Medicine, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - Kenneth S. Knox
- Department of Internal Medicine, University of Arizona, Phoenix, Arizona, United States of America
| | - Andre Kumar
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | | | - Margaret Lanca
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Joyce K. Lee-lannotti
- Department of Internal Medicine and Neurology, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, United States of America
| | - R. Craig Lefebvre
- Communications Practice Area, RTI International, Research Triangle Park, North Carolina, United States of America
| | - Bruce D. Levy
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Janet Y. Lin
- Department of Emergency Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Brian P. Logarbo
- Tulane Center for Clinical Research, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Jennifer K. Logue
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Michele T. Longo
- Tulane Center for Clinical Neurosciences, Tulane School of Medicine, New Orleans, Louisiana, United States of America
| | - Carlos A. Luciano
- Department of Neurology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico, United States of America
| | - Karen Lutrick
- Department of Family & Community Medicine, University of Arizona, College of Medicine – Tucson, Tucson, Arizona, United States of America
| | - Shahdi K. Malakooti
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Gail Mallett
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, United States of America
| | - Gabrielle Maranga
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Jai G. Marathe
- Department of Medicine, Section of Infectious Diseases, Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Vincent C. Marconi
- Department of Medicine, Infectious Diseases and Department of Global Health, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Gailen D. Marshall
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Christopher F. Martin
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Jeffrey N. Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Heidi T. May
- Department of Cardiology, Intermountain Medical Center, Salt Lake City, Utah, United States of America
| | - Grace A. McComsey
- Department of Medicine, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Dylan McDonald
- Department of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Lucio Miele
- Department of Genetics, Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
| | - Murray A. Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sindhu Mohandas
- Department of Infectious Diseases, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California, United States of America
| | - Christian Mouchati
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Janet M. Mullington
- Department of Neurology and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Girish N. Nadkarni
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Erica R. Nahin
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - Robert B. Neuman
- Division of Cardiology, Kaiser Permanente of Georgia, Atlanta, Georgia, United States of America
| | - Lisa T. Newman
- Department of Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, North Carolina, United States of America
| | - Amber Nguyen
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Janko Z. Nikolich
- Department of Immunobiology, University of Arizona College of Medicine, Tucson, Arizona, United States of America
| | - Igho Ofotokun
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Princess U. Ogbogu
- Division of Pediatric Allergy, Immunology, and Rheumatology, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, United States of America
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Kristy T. S. Palomares
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Peter’s University Hospital, New Brunswick, New Jersey, United States of America
| | - Tanyalak Parimon
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Sairam Parthasarathy
- Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Thomas F. Patterson
- Department of Medicine, Department of Infectious Disease, University of Texas Health, San Antonio, Texas, United States of America
| | - Ann Pearman
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Michael J. Peluso
- Division of HIV, Infectious Disease, and Global Medicine, University of California, San Francisco, California, United States of America
| | - Priscilla Pemu
- Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia, United States of America
| | - Christian M. Pettker
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Beth A. Plunkett
- Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois, United States of America
| | - Kristen Pogreba-Brown
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, United States of America
| | - Athena Poppas
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - J. Zachary Porterfield
- Department of Internal Medicine, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky, United States of America
| | - John G. Quigley
- Department of Medicine, Division of Hematology/Oncology, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Davin K. Quinn
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Hengameh Raissy
- Department of Pediatrics, University of New Mexico, Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Candida J. Rebello
- Department of Nutrition and Chronic Disease, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - Uma M. Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, United States of America
| | - Rebecca Reece
- Department of Medicine, Division of Infectious Diseases, West Virginia School of Medicine, Morgantown, West Virginia, United States of America
| | - Harrison T. Reeder
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Franz P. Rischard
- Department of Pulmonary and Critical Care, University of Arizona, Tucson, Arizona, United States of America
| | - Johana M. Rosas
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - Clifford J. Rosen
- MaineHealth Institute for Research, MaineHealth, Scarborough, Maine, United States of America
| | - Nadine G. Rouphael
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island, United States of America
| | - Adam M. Ruff
- Division of Pulmonary and Critical Care, University of Kansas Medical Center, Kansas City, Kansas City, United States of America
| | - Christina Saint Jean
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Grecio J. Sandoval
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Jorge L. Santana
- Department of Medicine, University of Puerto Rico, San Juan, Puerto Rico, United States of America
| | - Shannon M. Schlater
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Frank C. Sciurba
- Department of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Caitlin Selvaggi
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sudha Seshadri
- Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Sciences Center San Antonio, San Antonio, Texas, United States of America
| | - Howard D. Sesso
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Dimpy P. Shah
- Department of Population Health Sciences, Mays Cancer Center, University of Texas Health, San Antonio, Texas, United States of America
| | - Eyal Shemesh
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Zaki A. Sherif
- Department of Biochemistry & Molecular Biology, Howard University College of Medicine, Washington, DC, United States of America
| | - Daniel J. Shinnick
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Hyagriv N. Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Upinder Singh
- Department of Internal Medicine, Stanford University, Stanford, California, United States of America
| | - Amber Sowles
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, United States of America
| | - Vignesh Subbian
- Department of Biomedical Engineering, Department of Systems and Industrial Engineering, University of Arizona College of Engineering, Tucson, Arizona, United States of America
| | - Jun Sun
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Mehul S. Suthar
- Department of Pediatrics, Emory Vaccine Center, Emory University, Atlanta, Georgia, United States of America
| | - Larissa J. Teunis
- Health Services Research Center, Emory University, Atlanta, Georgia, United States of America
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Amberly Ticotsky
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America
| | - Alan T. N. Tita
- Department of Obstetrics and Gynecology and Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Robin Tragus
- Department of Medicine, University of Texas Health Science Center, San Antonio, Texas, United States of America
| | - Katherine R. Tuttle
- Department of Medicine, Division of Nephrology, University of Washington School of Medicine, Spokane, Washington, United States of America
| | - Alfredo E. Urdaneta
- Department of Emergency Medicine, Stanford University, Stanford, California, United States of America
| | - P. J. Utz
- Department of Internal Medicine, Stanford University, Stanford, California, United States of America
| | - Timothy M. VanWagoner
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Andrew Vasey
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Suzanne D. Vernon
- Department of Research, Bateman Horne Center, Salt Lake City, Utah, United States of America
| | - Crystal Vidal
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Tiffany Walker
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Honorine D. Ward
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - David E. Warren
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Ryan M. Weeks
- Department of Microbiology, Immunology, and Molecular Genetics, University of Kentucky, Lexington, Kentucky, United States of America
| | - Steven J. Weiner
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Jordan C. Weyer
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jennifer L. Wheeler
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sidney W. Whiteheart
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, Kentucky, United States of America
| | - Zanthia Wiley
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Natasha J. Williams
- Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Juan P. Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - John C. Wood
- Department of Pediatrics and Radiology, Children’s Hospital of Los Angeles, Los Angeles, California, United States of America
| | - Lynn M. Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Natalie M. Young
- Swedish Center for Research and Innovation, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Sokratis N. Zisis
- Department of Medicine, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Andrea S. Foulkes
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Thaweethai T, Jolley SE, Karlson EW, Levitan EB, Levy B, McComsey GA, McCorkell L, Nadkarni GN, Parthasarathy S, Singh U, Walker TA, Selvaggi CA, Shinnick DJ, Schulte CCM, Atchley-Challenner R, Alba GA, Alicic R, Altman N, Anglin K, Argueta U, Ashktorab H, Baslet G, Bassett IV, Bateman L, Bedi B, Bhattacharyya S, Bind MA, Blomkalns AL, Bonilla H, Bush PA, Castro M, Chan J, Charney AW, Chen P, Chibnik LB, Chu HY, Clifton RG, Costantine MM, Cribbs SK, Davila Nieves SI, Deeks SG, Duven A, Emery IF, Erdmann N, Erlandson KM, Ernst KC, Farah-Abraham R, Farner CE, Feuerriegel EM, Fleurimont J, Fonseca V, Franko N, Gainer V, Gander JC, Gardner EM, Geng LN, Gibson KS, Go M, Goldman JD, Grebe H, Greenway FL, Habli M, Hafner J, Han JE, Hanson KA, Heath J, Hernandez C, Hess R, Hodder SL, Hoffman MK, Hoover SE, Huang B, Hughes BL, Jagannathan P, John J, Jordan MR, Katz SD, Kaufman ES, Kelly JD, Kelly SW, Kemp MM, Kirwan JP, Klein JD, Knox KS, Krishnan JA, Kumar A, Laiyemo AO, Lambert AA, Lanca M, Lee-Iannotti JK, Logarbo BP, Longo MT, Luciano CA, Lutrick K, Maley JH, Marathe JG, Marconi V, Marshall GD, Martin CF, Matusov Y, Mehari A, Mendez-Figueroa H, Mermelstein R, Metz TD, Morse R, Mosier J, Mouchati C, Mullington J, Murphy SN, Neuman RB, Nikolich JZ, Ofotokun I, Ojemakinde E, Palatnik A, Palomares K, Parimon T, Parry S, Patterson JE, Patterson TF, Patzer RE, Peluso MJ, Pemu P, Pettker CM, Plunkett BA, Pogreba-Brown K, Poppas A, Quigley JG, Reddy U, Reece R, Reeder H, Reeves WB, Reiman EM, Rischard F, Rosand J, Rouse DJ, Ruff A, Saade G, Sandoval GJ, Schlater SM, Shepherd F, Sherif ZA, Simhan H, Singer NG, Skupski DW, Sowles A, Sparks JA, Sukhera FI, Taylor BS, Teunis L, Thomas RJ, Thorp JM, Thuluvath P, Ticotsky A, Tita AT, Tuttle KR, Urdaneta AE, Valdivieso D, VanWagoner TM, Vasey A, Verduzco-Gutierrez M, Wallace ZS, Ward HD, Warren DE, Weiner SJ, Welch S, Whiteheart SW, Wiley Z, Wisnivesky JP, Yee LM, Zisis S, Horwitz LI, Foulkes AS. Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection. JAMA 2023; 329:1934-1946. [PMID: 37278994 PMCID: PMC10214179 DOI: 10.1001/jama.2023.8823] [Citation(s) in RCA: 152] [Impact Index Per Article: 152.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/01/2023] [Indexed: 06/07/2023]
Abstract
Importance SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals. Objective To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections. Design, Setting, and Participants Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling. Exposure SARS-CoV-2 infection. Main Outcomes and Measures PASC and 44 participant-reported symptoms (with severity thresholds). Results A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months. Conclusions and Relevance A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.
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Affiliation(s)
- Tanayott Thaweethai
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Bruce Levy
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Lisa McCorkell
- Patient-Led Research Collaborative, Calabasas, California
| | | | | | - Upinder Singh
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mario Castro
- University of Kansas Medical Center, Kansas City
| | | | | | - Peter Chen
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Helen Y Chu
- University of Washington School of Medicine, Seattle
| | | | | | | | | | | | | | | | | | | | | | | | - Cheryl E Farner
- The University of Texas Health Science Center at San Antonio
| | | | | | - Vivian Fonseca
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | | | | | | | | | | | | | - Minjoung Go
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | - John Hafner
- University of Illinois Chicago College of Medicine
| | - Jenny E Han
- Emory University School of Medicine, Atlanta, Georgia
| | | | - James Heath
- Institute for Systems Biology, Seattle, Washington
| | | | - Rachel Hess
- University of Utah Schools of the Health Sciences, Salt Lake City
| | - Sally L Hodder
- West Virginia Clinical and Translational Science Institute, Morgantown
| | | | | | | | | | | | - Janice John
- Cambridge Health Alliance, Cambridge, Massachusetts
| | | | - Stuart D Katz
- New York University Grossman School of Medicine, New York
| | | | | | - Sara W Kelly
- University of Illinois College of Medicine at Peoria
| | | | - John P Kirwan
- Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | | | | | - Jerry A Krishnan
- University of Illinois Hospital and Health Sciences System, Chicago
| | - Andre Kumar
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | | | | | | | | | - Jason H Maley
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Yuri Matusov
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Alem Mehari
- Howard University College of Medicine, Washington, DC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jan E Patterson
- The University of Texas Health Science Center at San Antonio
| | | | | | | | | | | | - Beth A Plunkett
- Harvard Medical School, Boston, Massachusetts
- NorthShore University HealthSystem, Evanston, Illinois
| | | | - Athena Poppas
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Uma Reddy
- Columbia University Irving Medical Center, New York, New York
| | - Rebecca Reece
- West Virginia University School of Medicine, Morgantown
| | | | - W B Reeves
- Department of Medicine, The University of Texas Health Science Center at San Antonio
| | | | | | | | | | - Adam Ruff
- The University of Kansas Medical Center, Kansas City
| | | | - Grecio J Sandoval
- Milken Institute of Public Health, The George Washington University, Washington, DC
| | | | | | - Zaki A Sherif
- Howard University College of Medicine, Washington, DC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Steven J Weiner
- The George Washington University Biostatistics Center, Rockville, Maryland
| | | | | | | | | | - Lynn M Yee
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - Andrea S Foulkes
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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7
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Metz TD, Clifton RG, Gallagher R, Gross RS, Horwitz LI, Jacoby VL, Martin-Herz SP, Peralta-Carcelen M, Reeder HT, Beamon CJ, Bind MA, Chan J, Chang AA, Chibnik LB, Costantine MM, Fitzgerald ML, Foulkes AS, Gibson KS, Güthe N, Habli M, Hackney DN, Hoffman MK, Hoffman MC, Hughes BL, Katz SD, Laleau V, Mallett G, Mendez-Figueroa H, Monzon V, Palatnik A, Palomares KT, Parry S, Peralta-Carcelen M, Pettker CM, Plunkett BA, Poppas A, Reddy UM, Rouse DJ, Saade GR, Sandoval GJ, Schlater SM, Sciurba FC, Simhan HN, Skupski DW, Sowles A, Thaweethai T, Thomas GL, Thorp JM, Tita AT, Weiner SJ, Weigand S, Yee LM, Flaherman VJ. Researching COVID to enhance recovery (RECOVER) pregnancy study: Rationale, objectives and design. medRxiv 2023:2023.04.24.23289025. [PMID: 37162923 PMCID: PMC10168506 DOI: 10.1101/2023.04.24.23289025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Importance Pregnancy induces unique physiologic changes to the immune response and hormonal changes leading to plausible differences in the risk of developing post-acute sequelae of SARS-CoV-2 (PASC), or Long COVID. Exposure to SARS-CoV-2 during pregnancy may also have long-term ramifications for exposed offspring, and it is critical to evaluate the health outcomes of exposed children. The National Institutes of Health (NIH) Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC aims to evaluate the long-term sequelae of SARS-CoV-2 infection in various populations. RECOVER- Pregnancy was designed specifically to address long-term outcomes in maternal-child dyads. Methods RECOVER-Pregnancy cohort is a combined prospective and retrospective cohort that proposes to enroll 2,300 individuals with a pregnancy during the COVID-19 pandemic and their offspring exposed and unexposed in utero, including single and multiple gestations. Enrollment will occur both in person at 27 sites through the Eunice Kennedy Shriver National Institutes of Health Maternal-Fetal Medicine Units Network and remotely through national recruitment by the study team at the University of California San Francisco (UCSF). Adults with and without SARS-CoV-2 infection during pregnancy are eligible for enrollment in the pregnancy cohort and will follow the protocol for RECOVER-Adult including validated screening tools, laboratory analyses and symptom questionnaires followed by more in-depth phenotyping of PASC on a subset of the overall cohort. Offspring exposed and unexposed in utero to SARS-CoV-2 maternal infection will undergo screening tests for neurodevelopment and other health outcomes at 12, 18, 24, 36 and 48 months of age. Blood specimens will be collected at 24 months of age for SARS-CoV-2 antibody testing, storage and anticipated later analyses proposed by RECOVER and other investigators. Discussion RECOVER-Pregnancy will address whether having SARS-CoV-2 during pregnancy modifies the risk factors, prevalence, and phenotype of PASC. The pregnancy cohort will also establish whether there are increased risks of adverse long-term outcomes among children exposed in utero. Registration NCT05172024.
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Affiliation(s)
- Torri D. Metz
- Department of Obstetrics and Gynecology, University of Utah Health Hospitals and Clinics, Salt Lake City, UT, USA
| | - Rebecca G. Clifton
- Biostatistics Center, The George Washington University, Washington, DC, USA
| | - Richard Gallagher
- Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
| | - Rachel S. Gross
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, USA
| | - Leora I. Horwitz
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Vanessa L. Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Susanne P. Martin-Herz
- Department of Pediatrics, Division of Developmental Medicine, University of California San Francisco, San Francisco, CA, San Francisco, CA, USA
| | | | - Harrison T. Reeder
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Carmen J. Beamon
- Department of Maternal Fetal Medicine, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Marie-Abele Bind
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - James Chan
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - A. Ann Chang
- Women’s Health Research Clinical Center, University of California San Francisco, San Francisco, CA, USA
| | - Lori B. Chibnik
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Maged M. Costantine
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Megan L. Fitzgerald
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Andrea S. Foulkes
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Kelly S. Gibson
- Department of Obstetrics and Gynecology, The MetroHealth System, Cleveland, OH, USA
| | - Nick Güthe
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Mounira Habli
- Division Maternal Fetal Medicine, Trihealth Good Samaritan Hospital Maternal Fetal Medicine, Cincinnati, OH, USA
| | - David N. Hackney
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center: UH Cleveland Medical Center, Cleveland, OH, USA
| | - Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, DE, USA
| | - M. Camille Hoffman
- Department of Obstetrics & Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brenna L. Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - Stuart D. Katz
- Department of Medicine, New York University School of Medicine, New York City, NY, USA
| | - Victoria Laleau
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Gail Mallett
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas McGovern Medical School: The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX, USA
| | - Vanessa Monzon
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kristy T.S. Palomares
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Peter’s University Hospital, New Brunswick, NJ, USA
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Christian M. Pettker
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Beth A. Plunkett
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL, USA
| | - Athena Poppas
- Division of Cardiology, Brown University Warren Alpert Medical School, PROVIDENCE, RI, USA
| | - Uma M. Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York City, NY, USA
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, RI, USA
| | - George R. Saade
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Grecio J. Sandoval
- Biostatistics Center, The George Washington University, Rockville, MD, USA
| | - Shannon M. Schlater
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, USA
| | - Frank C. Sciurba
- Department of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh, pittsburgh, PA, USA
| | - Hyagriv N. Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Daniel W. Skupski
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Amber Sowles
- Department of Obstetrics and Gynecology, University of Utah Health Hospitals and Clinics, Salt Lake City, UT, USA
| | - Tanayott Thaweethai
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Gelise L. Thomas
- Clinical and Translational Science Collaborative of Cleveland, Case Western Reserve University, Cleveland, Ohio, Cleveland, OH, USA
| | - John M. Thorp
- Department of Obstetrics and Gynecology, UNC: The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alan T. Tita
- Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Steven J. Weiner
- Biostatistics Center, The George Washington University, Washington, DC, USA
| | - Samantha Weigand
- Department of Obstetrics and Gynecology, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Lynn M. Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Valerie J. Flaherman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
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8
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Sangal RB, Venkatesh AK, Cahill J, Pettker CM, Peaper DR. Choice Architecture to Assist Clinicians with Appropriate COVID-19 Test Ordering. J Appl Lab Med 2023; 8:98-105. [PMID: 36610419 DOI: 10.1093/jalm/jfac104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/03/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Despite improving supplies, SARS-CoV-2 nucleic acid amplification tests remain limited during surges and more so given concerns around COVID-19/influenza co-occurrence. Matching clinical guidelines to available supplies ensures resources remain available to meet clinical needs. We report a change in clinician practice after an electronic health record (EHR) order redesign to impact emergency department (ED) testing patterns. METHODS We included all ED visits between December 1, 2021 and January 18, 2022 across a hospital system to assess the impact of EHR order changes on provider behavior 3 weeks before and after the change. The EHR order redesign included embedded symptom-based order guidance. Primary outcomes were the proportion of COVID-19 + flu/respiratory syncytial virus (RSV) testing performed on symptomatic, admitted, and discharged patients, and the proportion of COVID-19 + flu testing on symptomatic, discharged patients. RESULTS A total of 52 215 ED visits were included. For symptomatic, discharged patients, COVID-19 + flu/RSV testing decreased from 11.4 to 5.8 tests per 100 symptomatic visits, and the rate of COVID-19 + flu testing increased from 7.4 to 19.1 before and after the intervention, respectively. The rate of COVID-19 + flu/RSV testing increased from 5.7 to 13.1 tests per 100 symptomatic visits for symptomatic patients admitted to the hospital. All changes were significant (P < 0.0001). CONCLUSIONS A simple EHR order redesign was associated with increased adherence to institutional guidelines for SARS-CoV-2 and influenza testing amidst supply chain limitations necessitating optimal allocation of scarce testing resources. With continually shifting resource availability, clinician education is not sufficient. Rather, system-based interventions embedded within exiting workflows can better align resources and serve testing needs of the community.
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Affiliation(s)
- Rohit B Sangal
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA.,Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Justin Cahill
- Department of Emergency Medicine, Bridgeport Hospital, Bridgeport, CT, USA
| | - Christian M Pettker
- Quality and Safety, Yale New Haven Health, New Haven, CT, USA.,Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - David R Peaper
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
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Fan LL, Sheth SS, Pettker CM. Pilot Implementation of a Health Equity Checklist to Improve the Identification of Equity-Related Adverse Events. Obstet Gynecol Surv 2023. [DOI: 10.1097/01.ogx.0000912592.42410.a6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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10
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Deshmukh US, Lundsberg LS, Pettker CM, Rouse DJ, Reddy UM. Neonatal outcomes by delivery indication after administration of antenatal late preterm corticosteroids. AJOG Global Reports 2022; 2:100097. [PMID: 36536839 PMCID: PMC9758401 DOI: 10.1016/j.xagr.2022.100097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Background Antenatal corticosteroids, specifically betamethasone, administered to patients at risk for late preterm delivery have been associated with reduced rates of neonatal respiratory complications. However, whether these risks vary by delivery indication among betamethasone-exposed, late-preterm infants is not known. Objective This study aimed to evaluate if spontaneous preterm labor or preterm prelabor rupture of membranes, compared with indicated late preterm delivery, is associated with better neonatal respiratory outcomes after accounting for betamethasone administration in the late preterm period. Study Design This was a secondary analysis of the Antenatal Late Preterm Steroids trial, a multicenter, placebo-controlled trial in which patients with singleton pregnancies at risk for delivery at 34 0/7 to 36 5/7 weeks of gestation were randomized to a single course of antenatal corticosteroids (betamethasone) or placebo. Patients were eligible if they had spontaneous preterm labor, preterm prelabor rupture of membranes, or if they were undergoing indicated late preterm delivery. The primary outcome was a composite of need for respiratory support, stillbirth, or neonatal death within 72 hours after delivery. Secondary outcomes included individual neonatal morbidities. Bivariate analyses were performed, and multivariable logistic regression models were used to control for potential confounders. Using the indicated preterm delivery group as the reference group, adjusted odds ratios and 95% confidence intervals were calculated for the outcomes by delivery indication. Subgroup analyses separately examined the treatment and placebo groups to determine the odds of the primary outcome by delivery indication. Results Of 2827 participants at high risk for late preterm delivery, 1427 (50.5%) received betamethasone. There were 790 (27.9%) infants born after preterm labor, 620 (21.9%) born after preterm prelabor rupture of membranes, and 1417 (50.1%) born after indicated preterm delivery. Compared with indicated preterm delivery, the odds of the primary outcome were lower among those born after preterm labor (7.3% vs 16.4%; adjusted odds ratio, 0.57; 95% confidence interval, 0.40-0.82) and among those born after preterm prelabor rupture of membranes (12.4% vs 16.4%; adjusted odds ratio, 0.49; 95% confidence interval, 0.35-0.69). Preterm labor had lower odds of all neonatal complications except feeding problems, and preterm prelabor rupture of membranes had lower odds of all neonatal complications except newborn intensive care unit admission for ≥3 days when compared with indicated preterm delivery. For the placebo group, the odds of the primary outcome were lower for the preterm labor group (8.2% vs 18.5%; adjusted odds ratio, 0.55; 95% confidence interval, 0.34-0.91) and the preterm prelabor rupture of membranes group (13.2% vs 18.5%; adjusted odds ratio, 0.46; 95% confidence interval, 0.29-0.73) than for the indicated preterm delivery group. For those exposed to betamethasone, the odds of the primary outcome remained lower for the preterm labor group (6.5% vs 14.3%; adjusted odds ratio, 0.58; 95% confidence interval, 0.34-0.99) and the preterm prelabor rupture of membranes group (11.7% vs 14.3%, adjusted odds ratio, 0.56; 95% confidence interval, 0.34-0.91) than for the indicated preterm delivery group. Conclusion Compared with indicated preterm delivery, preterm labor and preterm prelabor rupture of membranes were associated with reduced odds of neonatal respiratory complications irrespective of betamethasone exposure in the late preterm period.
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11
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Chaguza C, Coppi A, Earnest R, Ferguson D, Kerantzas N, Warner F, Young HP, Breban MI, Billig K, Koch RT, Pham K, Kalinich CC, Ott IM, Fauver JR, Hahn AM, Tikhonova IR, Castaldi C, De Kumar B, Pettker CM, Warren JL, Weinberger DM, Landry ML, Peaper DR, Schulz W, Vogels CBF, Grubaugh ND. Rapid emergence of SARS-CoV-2 Omicron variant is associated with an infection advantage over Delta in vaccinated persons. Med 2022; 3:325-334.e4. [PMID: 35399324 PMCID: PMC8983481 DOI: 10.1016/j.medj.2022.03.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/25/2021] [Accepted: 03/29/2022] [Indexed: 11/30/2022]
Abstract
Background The SARS-CoV-2 Omicron variant became a global concern due to its rapid spread and displacement of the dominant Delta variant. We hypothesized that part of Omicron's rapid rise was based on its increased ability to cause infections in persons that are vaccinated compared to Delta. Methods We analyzed nasal swab PCR tests for samples collected between December 12 and 16, 2021, in Connecticut when the proportion of Delta and Omicron variants was relatively equal. We used the spike gene target failure (SGTF) to classify probable Delta and Omicron infections. We fitted an exponential curve to the estimated infections to determine the doubling times for each variant. We compared the test positivity rates for each variant by vaccination status, number of doses, and vaccine manufacturer. Generalized linear models were used to assess factors associated with odds of infection with each variant among persons testing positive for SARS-CoV-2. Findings For infections with high virus copies (Ct < 30) among vaccinated persons, we found higher odds that they were infected with Omicron compared to Delta, and that the odds increased with increased number of vaccine doses. Compared to unvaccinated persons, we found significant reduction in Delta positivity rates after two (43.4%-49.1%) and three vaccine doses (81.1%), while we only found a significant reduction in Omicron positivity rates after three doses (62.3%). Conclusion The rapid rise in Omicron infections was likely driven by Omicron's escape from vaccine-induced immunity. Funding This work was supported by the Centers for Disease Control and Prevention (CDC).
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Affiliation(s)
- Chrispin Chaguza
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Andreas Coppi
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Rebecca Earnest
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - David Ferguson
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Nicholas Kerantzas
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Frederick Warner
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - H Patrick Young
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Mallery I Breban
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Kendall Billig
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Robert Tobias Koch
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Kien Pham
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Chaney C Kalinich
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Isabel M Ott
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Joseph R Fauver
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anne M Hahn
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Irina R Tikhonova
- Yale Center for Genome Analysis, Yale University, New Haven, CT, USA
| | | | - Bony De Kumar
- Yale Center for Genome Analysis, Yale University, New Haven, CT, USA
| | - Christian M Pettker
- Quality and Safety, Yale New Haven Health, New Haven, CT, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Joshua L Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Daniel M Weinberger
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Marie L Landry
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
- Section of Infectious Diseases, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Clinical Virology Laboratory, Yale New Haven Hospital, New Haven, CT, USA
| | - David R Peaper
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Wade Schulz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Chantal B F Vogels
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nathan D Grubaugh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA
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12
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Chaguza C, Coppi A, Earnest R, Ferguson D, Kerantzas N, Warner F, Young HP, Breban MI, Billig K, Koch RT, Pham K, Kalinich CC, Ott IM, Fauver JR, Hahn AM, Tikhonova IR, Castaldi C, De Kumar B, Pettker CM, Warren JL, Weinberger DM, Landry ML, Peaper DR, Schulz W, Vogels CBF, Grubaugh ND. Rapid emergence of SARS-CoV-2 Omicron variant is associated with an infection advantage over Delta in vaccinated persons. Med 2022; 3:325-334.e4. [PMID: 35399324 DOI: 10.1101/2022.01.22.22269660] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/25/2021] [Accepted: 03/29/2022] [Indexed: 05/22/2023]
Abstract
BACKGROUND The SARS-CoV-2 Omicron variant became a global concern due to its rapid spread and displacement of the dominant Delta variant. We hypothesized that part of Omicron's rapid rise was based on its increased ability to cause infections in persons that are vaccinated compared to Delta. METHODS We analyzed nasal swab PCR tests for samples collected between December 12 and 16, 2021, in Connecticut when the proportion of Delta and Omicron variants was relatively equal. We used the spike gene target failure (SGTF) to classify probable Delta and Omicron infections. We fitted an exponential curve to the estimated infections to determine the doubling times for each variant. We compared the test positivity rates for each variant by vaccination status, number of doses, and vaccine manufacturer. Generalized linear models were used to assess factors associated with odds of infection with each variant among persons testing positive for SARS-CoV-2. FINDINGS For infections with high virus copies (Ct < 30) among vaccinated persons, we found higher odds that they were infected with Omicron compared to Delta, and that the odds increased with increased number of vaccine doses. Compared to unvaccinated persons, we found significant reduction in Delta positivity rates after two (43.4%-49.1%) and three vaccine doses (81.1%), while we only found a significant reduction in Omicron positivity rates after three doses (62.3%). CONCLUSION The rapid rise in Omicron infections was likely driven by Omicron's escape from vaccine-induced immunity. FUNDING This work was supported by the Centers for Disease Control and Prevention (CDC).
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Affiliation(s)
- Chrispin Chaguza
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Andreas Coppi
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Rebecca Earnest
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - David Ferguson
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Nicholas Kerantzas
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Frederick Warner
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - H Patrick Young
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Mallery I Breban
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Kendall Billig
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Robert Tobias Koch
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Kien Pham
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Chaney C Kalinich
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Isabel M Ott
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Joseph R Fauver
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anne M Hahn
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Irina R Tikhonova
- Yale Center for Genome Analysis, Yale University, New Haven, CT, USA
| | | | - Bony De Kumar
- Yale Center for Genome Analysis, Yale University, New Haven, CT, USA
| | - Christian M Pettker
- Quality and Safety, Yale New Haven Health, New Haven, CT, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Joshua L Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Daniel M Weinberger
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Marie L Landry
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
- Section of Infectious Diseases, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Clinical Virology Laboratory, Yale New Haven Hospital, New Haven, CT, USA
| | - David R Peaper
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Wade Schulz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Chantal B F Vogels
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nathan D Grubaugh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA
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Combs CA, Goffman D, Pettker CM, Pettker C. Society for Maternal-Fetal Medicine Special Statement: A critique of postpartum readmission rate as a quality metric. Am J Obstet Gynecol 2022; 226:B2-B9. [PMID: 34838802 DOI: 10.1016/j.ajog.2021.11.1355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Hospital readmission is considered a core measure of quality in healthcare. Readmission soon after hospital discharge can result from suboptimal care during the index hospitalization or from inadequate systems for postdischarge care. For many conditions, readmission is associated with a high rate of serious morbidity and potentially avoidable costs. In obstetrics, for postpartum care specifically, hospitals and payers can easily track the rate of maternal readmission after childbirth and may seek to incentivize obstetricians, maternal-fetal medicine specialists, or provider groups to reduce the rate of readmission. However, this practice has not been shown to improve outcomes or reduce harm. There are major concerns with incentivizing providers to reduce postpartum readmissions, including the lack of a standardized metric, a baseline rate of 1% to 2% that is too low to accurately discriminate between random variation and controllable factors, the need for risk adjustment that greatly complicates rate calculations, the potential for bias depending on the duration of the follow-up interval, the potential for the "gaming" of the metric, the lack of evidence that obstetrical providers can influence the rate, and the potential for unintended harm in the vulnerable postpartum population. Until these problems are adequately addressed, maternal readmission rate after a childbirth hospitalization currently has limited utility as a metric for quality or performance improvement or as a factor to adjust provider reimbursement.
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14
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Roberts SC, Peaper DR, Sussman LS, Martinello RA, Pettker CM. Utility of Mass SARS-CoV-2 Testing of Asymptomatic Patients Before Ambulatory and Inpatient Preplanned Procedures Requiring Moderate Sedation or General Anesthesia. JAMA Netw Open 2021; 4:e2114526. [PMID: 34170307 PMCID: PMC8233702 DOI: 10.1001/jamanetworkopen.2021.14526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Scott C. Roberts
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David R. Peaper
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut
| | - L. Scott Sussman
- Clinical Redesign, Yale New Haven Health, New Haven, Connecticut
| | | | - Christian M. Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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15
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Roberts SC, Peaper DR, Thorne CD, Sussman LS, Murray TS, Choi SJ, Pettker CM, Russi MB, Martinello RA. Mass severe acute respiratory coronavirus 2 (SARS-CoV-2) testing of asymptomatic healthcare personnel. Infect Control Hosp Epidemiol 2021; 42:625-626. [PMID: 33487206 PMCID: PMC7853752 DOI: 10.1017/ice.2021.9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/18/2022]
Abstract
Mass asymptomatic SARS-CoV-2 nucleic acid amplified testing of healthcare personnel (HCP) was performed at a large tertiary health system. A low period-prevalence of positive HCP was observed. Of those who tested positive, half had mild symptoms in retrospect. HCP with even mild symptoms should be isolated and tested.
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Affiliation(s)
- Scott C. Roberts
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | - David R. Peaper
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Craig D. Thorne
- Occupational and Environmental Medicine Program, Yale School of Medicine, New Haven, Connecticut
| | - L. Scott Sussman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical Redesign, Yale New Haven Health, New Haven, Connecticut
| | - Thomas S. Murray
- Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Steven J. Choi
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Quality and Safety, Yale New Haven Health, New Haven, Connecticut
| | - Christian M. Pettker
- Quality and Safety, Yale New Haven Health, New Haven, Connecticut
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Mark B. Russi
- Occupational and Environmental Medicine Program, Yale School of Medicine, New Haven, Connecticut
| | - Richard A. Martinello
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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16
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Lappen JR, Pettker CM, Louis JM, Louis JM. Society for Maternal-Fetal Medicine Consult Series #54: Assessing the risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021; 224:B2-B15. [PMID: 33309560 DOI: 10.1016/j.ajog.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.
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Affiliation(s)
| | | | | | - Judette M Louis
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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17
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Lee RH, Mara Greenberg, Metz TD, Pettker CM, Pettker CM. Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy: Replaces Consult #13, April 2011. Am J Obstet Gynecol 2021; 224:B2-B9. [PMID: 33197417 DOI: 10.1016/j.ajog.2020.11.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Intrahepatic cholestasis of pregnancy is a hepatic disorder characterized by pruritus and an elevation in serum bile acid levels. Although intrahepatic cholestasis of pregnancy poses little risk for women, this condition carries a significant risk for the fetus, including complications such as preterm delivery, meconium-stained amniotic fluid, and stillbirth. The purpose of this Consult is to review the current literature on intrahepatic cholestasis of pregnancy and provide recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend measurement of serum bile acid and liver transaminase levels in patients with suspected intrahepatic cholestasis of pregnancy (GRADE 1B); (2) we recommend that ursodeoxycholic acid be used as the first-line agent for the treatment of maternal symptoms of intrahepatic cholestasis of pregnancy (GRADE 1A); (3) we suggest that patients with a diagnosis of intrahepatic cholestasis of pregnancy begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal fetal testing results or at the time of diagnosis if the diagnosis is made later in gestation (GRADE 2C); (4) we recommend that patients with total bile acid levels of ≥100 μmol/L be offered delivery at 36 0/7 weeks of gestation, given that the risk of stillbirth increases substantially around this gestational age (GRADE 1B); (5) we recommend delivery between 36 0/7 and 39 0/7 weeks of gestation for patients with intrahepatic cholestasis of pregnancy and total bile acid levels of <100 μmol/L (GRADE 1C); (6) we recommend administration of antenatal corticosteroids for fetal lung maturity for patients delivering before 37 0/7 weeks of gestation if not previously administered (GRADE 1A); (7) we recommend against preterm delivery at <37 weeks of gestation in patients with a clinical diagnosis of intrahepatic cholestasis of pregnancy without laboratory confirmation of elevated bile acid levels (GRADE 1B).
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Affiliation(s)
| | | | | | | | - Christian M Pettker
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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18
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Abstract
Though much of routine healthcare pauses in a public health emergency, childbirth continues uninterrupted. Crises like COVID-19 put incredible strains on healthcare systems and require strategic planning, flexible adaptability, clear communication, and judicious resource allocation. Experiences from obstetric units affected by COVID-19 highlight the importance of developing new teams and workflows to ensure patient and healthcare worker safety. Additionally, adapting a strategy that combines units and staff from different areas and hospitals can allow for synergistic opportunities to provision care appropriately to manage a structure and workforce at maximum capacity.
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Affiliation(s)
- Katherine H. Campbell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine and Yale New Haven Hospital, 333 Cedar Street, P.O. Box 208063, New Haven, CT 06520-8063, United States,Corresponding author
| | - Christian M. Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine and Yale New Haven Hospital, 333 Cedar Street, P.O. Box 208063, New Haven, CT 06520-8063, United States
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, United States
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19
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Grechukhina O, Greenberg V, Lundsberg LS, Deshmukh U, Cate J, Lipkind HS, Campbell KH, Pettker CM, Kohari KS, Reddy UM. Coronavirus disease 2019 pregnancy outcomes in a racially and ethnically diverse population. Am J Obstet Gynecol MFM 2020; 2:100246. [PMID: 33047100 PMCID: PMC7539936 DOI: 10.1016/j.ajogmf.2020.100246] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 12/19/2022]
Abstract
Background Older age and medical comorbidities are identified risk factors for developing severe coronavirus disease 2019. However, there are limited data on risk stratification, clinical and laboratory course, and optimal management of coronavirus disease 2019 in pregnancy. Objective Our study aimed to describe the clinical course of coronavirus disease 2019, effect of comorbidities on disease severity, laboratory trends, and pregnancy outcomes of symptomatic and asymptomatic severe acute respiratory syndrome coronavirus 2–positive pregnant women. Study Design This is a case series of pregnant and postpartum women who received positive test results for severe acute respiratory syndrome coronavirus 2 between March 3, 2020, and May 11, 2020, within 3 hospitals of the Yale New Haven Health delivery network. Charts were reviewed for basic sociodemographic and prepregnancy characteristics, coronavirus disease 2019 course, laboratory values, and pregnancy outcomes. Results Of the 1567 tested pregnant and postpartum women between March 3, 2020, and May 11, 2020, 9% (n=141) had a positive severe acute respiratory syndrome coronavirus 2 result. Hispanic women were overrepresented in the severe acute respiratory syndrome coronavirus 2–positive group (n=61; 43.8%). In addition, Hispanic ethnicity was associated with a higher rate of moderate and severe diseases than non-Hispanic (18% [11/61] vs 3.8% [3/78], respectively; odds ratio, 5.5; 95% confidence interval, 1.46–20.7; P=.01). Of note, 44 women (31.2%) were asymptomatic, 37 of whom (26.2%) were diagnosed on universal screening upon admission for delivery. Moreover, 59% (n=83) were diagnosed before delivery, 36% (n=51) upon presentation for childbirth, and 5% (n=7) after delivery. Severe disease was diagnosed in 6 cases (4.3%), and there was 1 maternal death. Obese women were more likely to develop moderate and severe diseases than nonobese women (16.4% [9/55] vs 3.8% [3/79]; odds ratio, 4.96; 95% confidence interval, 1.28–19.25; P=.02). Hypertensive disorders of pregnancy were diagnosed in 22.3% of women (17/77) who delivered after 20 weeks’ gestation. Higher levels of C-reactive protein during antepartum coronavirus disease 2019–related admission were more common in women with worse clinical course; however, this association did not reach statistical significance. Conclusion Coronavirus disease 2019 in pregnancy may result in severe disease and death. Hispanic women were more likely to receive a positive test result for severe acute respiratory syndrome 2 than other ethnic groups. Obesity and Hispanic ethnicity represent risk factors for moderate and severe diseases.
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Affiliation(s)
- Olga Grechukhina
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
| | - Victoria Greenberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
| | - Uma Deshmukh
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
| | - Jennifer Cate
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
| | - Heather S Lipkind
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
| | - Katherine H Campbell
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
| | - Christian M Pettker
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
| | - Katherine S Kohari
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
| | - Uma M Reddy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT
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20
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Hosier H, Farhadian SF, Morotti RA, Deshmukh U, Lu-Culligan A, Campbell KH, Yasumoto Y, Vogels CB, Casanovas-Massana A, Vijayakumar P, Geng B, Odio CD, Fournier J, Brito AF, Fauver JR, Liu F, Alpert T, Tal R, Szigeti-Buck K, Perincheri S, Larsen C, Gariepy AM, Aguilar G, Fardelmann KL, Harigopal M, Taylor HS, Pettker CM, Wyllie AL, Cruz CD, Ring AM, Grubaugh ND, Ko AI, Horvath TL, Iwasaki A, Reddy UM, Lipkind HS. SARS-CoV-2 infection of the placenta. J Clin Invest 2020; 130:4947-4953. [PMID: 32573498 PMCID: PMC7456249 DOI: 10.1172/jci139569] [Citation(s) in RCA: 318] [Impact Index Per Article: 79.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/10/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUNDThe effects of the novel coronavirus disease 2019 (COVID-19) in pregnancy remain relatively unknown. We present a case of second trimester pregnancy with symptomatic COVID-19 complicated by severe preeclampsia and placental abruption.METHODSWe analyzed the placenta for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through molecular and immunohistochemical assays and by and electron microscopy and measured the maternal antibody response in the blood to this infection.RESULTSSARS-CoV-2 localized predominantly to syncytiotrophoblast cells at the materno-fetal interface of the placenta. Histological examination of the placenta revealed a dense macrophage infiltrate, but no evidence for the vasculopathy typically associated with preeclampsia.CONCLUSIONThis case demonstrates SARS-CoV-2 invasion of the placenta, highlighting the potential for severe morbidity among pregnant women with COVID-19.FUNDINGBeatrice Kleinberg Neuwirth Fund and Fast Grant Emergent Ventures funding from the Mercatus Center at George Mason University. The funding bodies did not have roles in the design of the study or data collection, analysis, and interpretation and played no role in writing the manuscript.
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MESH Headings
- Abortion, Therapeutic
- Abruptio Placentae/etiology
- Abruptio Placentae/pathology
- Abruptio Placentae/virology
- Adult
- Betacoronavirus/genetics
- Betacoronavirus/isolation & purification
- Betacoronavirus/pathogenicity
- COVID-19
- Coronavirus Infections/complications
- Coronavirus Infections/pathology
- Coronavirus Infections/virology
- Female
- Humans
- Microscopy, Electron, Transmission
- Pandemics
- Phylogeny
- Placenta/pathology
- Placenta/virology
- Pneumonia, Viral/complications
- Pneumonia, Viral/pathology
- Pneumonia, Viral/virology
- Pre-Eclampsia/etiology
- Pre-Eclampsia/pathology
- Pre-Eclampsia/virology
- Pregnancy
- Pregnancy Complications, Infectious/etiology
- Pregnancy Complications, Infectious/pathology
- Pregnancy Complications, Infectious/virology
- Pregnancy Trimester, Second
- RNA, Viral/genetics
- RNA, Viral/isolation & purification
- SARS-CoV-2
- Viral Load
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Affiliation(s)
- Hillary Hosier
- Department of Obstetrics, Gynecology, and Reproductive Sciences
| | | | | | - Uma Deshmukh
- Department of Obstetrics, Gynecology, and Reproductive Sciences
| | | | | | - Yuki Yasumoto
- Department of Comparative Medicine, Yale School of Medicine
| | - Chantal B.F. Vogels
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and
| | | | | | - Bertie Geng
- Department of Obstetrics, Gynecology, and Reproductive Sciences
| | | | - John Fournier
- Section of Infectious Diseases, Department of Medicine
| | - Anderson F. Brito
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and
| | - Joseph R. Fauver
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and
| | | | - Tara Alpert
- Department of Molecular Biophysics and Biochemistry, Yale University, New Haven, Connecticut, USA
| | - Reshef Tal
- Department of Obstetrics, Gynecology, and Reproductive Sciences
| | | | | | | | | | | | | | | | - Hugh S. Taylor
- Department of Obstetrics, Gynecology, and Reproductive Sciences
| | | | - Anne L. Wyllie
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and
| | - Charles Dela Cruz
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | | | - Nathan D. Grubaugh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and
| | - Albert I. Ko
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and
| | | | | | - Uma M. Reddy
- Department of Obstetrics, Gynecology, and Reproductive Sciences
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21
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Campbell KH, Tornatore JM, Lawrence KE, Illuzzi JL, Sussman LS, Lipkind HS, Pettker CM. Prevalence of SARS-CoV-2 Among Patients Admitted for Childbirth in Southern Connecticut. JAMA 2020; 323:2520-2522. [PMID: 32453390 PMCID: PMC7251498 DOI: 10.1001/jama.2020.8904] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study describes the prevalence of positive SARS-CoV-2 test results among asymptomatic pregnant women presenting for labor and delivery at Yale New Haven health system hospitals.
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Affiliation(s)
- Katherine H. Campbell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Jean M. Tornatore
- Department of Obstetrics and Gynecology, Bridgeport Hospital, Bridgeport, Connecticut
| | - Kirsten E. Lawrence
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Jessica L. Illuzzi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - L. Scott Sussman
- Clinical Redesign, Yale New Haven Health, New Haven, Connecticut
| | - Heather S. Lipkind
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Christian M. Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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22
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Blackwell S, Louis JM, Norton ME, Lappen JR, Pettker CM, Kaimal A, Landy U, Edelman A, Teal S, Landis R. Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning. Am J Obstet Gynecol 2020; 222:B2-B18. [PMID: 32252942 DOI: 10.1016/j.ajog.2019.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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23
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Hehir MP, Friedman AM, Andrikopoulou M, D'Alton ME, DiVito M, Havens S, Huang Y, Jain JA, Mehlhaff KM, Pettker CM, Seligman NS, Walden B, Berkowitz RL. 156: Clinical management of deliveries resulting in hypoxic ischemic encephalopathy. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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24
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Mehlhaff KM, Pettker CM, Hosier H, Lipkind HS, Reddy UM, Tomlinson M, Ball B, Lundsberg LS, Raab C. 545: Putting teamwork to the test: a randomized trial of collaboration in electronic fetal monitoring (EFM). Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Feinberg J, Shaw S, Kashyap N, Illuzzi J, Campbell K, Hsiao AL, Pettker CM. Evaluating the Impact of a New Smartphone Texting Tool on Patient Care in Obstetrics, an Emergent Healthcare Setting. Appl Clin Inform 2019; 10:879-887. [PMID: 31747710 DOI: 10.1055/s-0039-1700868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Hospitals across the country are investing millions of dollars to adopt new Health Insurance Portability and Accountability Act (HIPAA)-compliant secure text messaging systems. However, in nearly all cases, these implementations are occurring without evaluation of their impact on patient care. OBJECTIVE To evaluate perceived impact on patient care and workflow of new text messaging system implemented in obstetrics at Yale-New Haven Hospital and to inform guidelines for future implementations in emergent settings. METHODS A new HIPAA-compliant texting system was implemented in obstetrics in 2016. Before implementation of the new system, residents and nurses were surveyed on perceived effect of communication system (pagers with text receiving, service mobile phones, personal cell phones) on clinical workflow and patient care using 5-point Likert scale and open-ended questions. Following roll-out (1 and 6 months), both teams were surveyed with same questions. Results were compared using Wilcoxon-Mann-Whitney test (0-1 months and then 0-6 months). Open-ended question results were qualitatively compared for recurrent unifying themes. RESULTS In both nursing and resident domains, 1 month after implementation, the new communication system was perceived to significantly improve efficiency and patient care across all metrics. After 6 months, this effect decayed in nearly all categories (including efficiency, real-time communication, and knowledge of covering provider). The exception was nurse's knowledge of which resident to contact and resident's timely evaluation of patient, for which we observed sustained improvements. System shortcomings identified included interrupted connection (i.e., dropped calls), dysfunctional and inaccurate alert system, and unclear identification of the covering provider. CONCLUSION A new text-messaging-based communication system may improve efficiency and patient care in emergent settings, but system shortcomings can substantially erode potential benefits over time. We recommend implementers evaluate new systems for a set of specific functional requirements to increase probability of sustained improvement and decrease risk of poor patient outcomes.
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Affiliation(s)
- Jacqueline Feinberg
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Sara Shaw
- Yale New Haven Hospital, New Haven, Connecticut, United States
| | - Nitu Kashyap
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Jessica Illuzzi
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Katherine Campbell
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Allen L Hsiao
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Christian M Pettker
- Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, Connecticut, United States
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26
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Schoen CN, Keefe KW, Berghella V, Sciscione A, Pettker CM. Blown out of proportion? Induction Foley balloon ruptures associated with overinflation. Am J Obstet Gynecol MFM 2019; 1:100026. [PMID: 33345790 DOI: 10.1016/j.ajogmf.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/13/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Larger volume Foley catheters are occasionally used for labor induction. In some instances the balloon is overinflated to obtain this volume. Neither the risk or rate of rupture are known for this practice. OBJECTIVE The purpose of this study was to evaluate the use of overinflated Foley catheter balloons and the rate of rupture in prospective trials and to describe rupture events in our institutions. STUDY DESIGN Clinical trials and prospective cohorts were identified through a search of MEDLINE from 2000 through May 1, 2017; prospective studies were examined for the use of overinflated Foley catheters. Reports of overinflated balloons were then reviewed in detail to determine if rupture occurred and to record any reported maternal, neonatal, or gynecologic outcomes. Internal reports to the Obstetric Safety Report System were used to describe the local cases at our institutions. RESULTS We reviewed 296 abstracts. Seventeen prospective cohorts or randomized trials used larger balloon volumes (≥50 mL), of which 12 abstracts confirmed routine overinflation of the balloon. Within these studies, 19 patients who underwent cervical ripening with overinflated Foley catheters experienced balloon rupture during use. The incidence of rupture in these studies was 0.9%. No adverse maternal or fetal effects were noted. Internal safety reporting yielded an additional case. One gynecologic case was identified internally. The patient had an overinflated Foley catheter balloon used to tamponade excessive uterine bleeding after uterine evacuation. Balloon rupture was noted, and hysteroscopy was needed to remove fragments of the balloon. CONCLUSION Overinflation of Foley catheter balloons in obstetric and gynecologic applications may cause rupture. Because of possible underreporting, the extent of complications that may result from balloon rupture is unknown.
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Affiliation(s)
- Corina N Schoen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Massachusetts-Baystate, Springfield, MA.
| | - Kimberly W Keefe
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Anthony Sciscione
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Christiana Care Health Systems, Newark, DE
| | - Christian M Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
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Campbell KH, Illuzzi JL, Lee HC, Lin H, Lipkind HS, Lundsberg LS, Pettker CM, Xu X. Optimal maternal and neonatal outcomes and associated hospital characteristics. Birth 2019; 46:289-299. [PMID: 30251270 DOI: 10.1111/birt.12400] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aims to examine hospital variation in both maternal and neonatal morbidities and identify institutional characteristics associated with hospital performance in a combined measure of maternal and neonatal outcomes. METHODS Using the California Linked Birth File containing data from birth certificate and hospital discharge records, we identified 1 322 713 term births delivered at 248 hospitals during 2010-2012. For each hospital, a risk-standardized rate of severe maternal morbidities and a risk-standardized rate of severe newborn morbidities were calculated after adjusting for patient clinical risk factors. Hospitals were ranked based on combined information on their maternal and newborn morbidity rates. RESULTS Risk-standardized severe maternal and severe newborn morbidity rates varied substantially across hospitals (10th to 90th percentile range = 67.5-148.2 and 141.8-508.0 per 10 000 term births, respectively), although there was no significant association between the two (P = 0.15). Government hospitals (non-Federal) were more likely than other hospitals to be in worse rank quartiles (P value for trend = 0.004), whereas larger volume was associated with better rank among hospitals in the first three quartiles (P = 0.004). The most prevalent morbidities that differed progressively across hospital rank quartiles were severe hemorrhage, disseminated intravascular coagulation, and heart failure during procedure/surgery for mothers, and severe infection, respiratory complication, and shock/resuscitation for neonates. CONCLUSIONS Hospitals with low maternal morbidity rates may not have low neonatal morbidity rates and vice versa, highlighting the importance of assessing joint maternal-newborn outcomes in order to fully characterize a hospital's obstetrical performance. Hospitals with smaller volume and government ownership tend to have less desirable outcomes and warrant additional attention in future quality improvement efforts.
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Affiliation(s)
- Katherine H Campbell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Jessica L Illuzzi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Henry C Lee
- Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Haiqun Lin
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Heather S Lipkind
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Christian M Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Xu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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Cross SN, Greenberg JT, Pettker CM, Raab CA, Illuzzi JL. Indications contributing to the decreasing cesarean delivery rate at an academic tertiary center. Am J Obstet Gynecol MFM 2019; 1:165-172. [PMID: 33345822 DOI: 10.1016/j.ajogmf.2019.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/27/2019] [Accepted: 05/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Evaluating trends in indications may identify targets to safely reduce the primary cesarean delivery rate. OBJECTIVE The purpose of this study was to examine physician-documented indications for cesarean delivery to identify specific factors that contribute to a decreasing cesarean delivery rate. STUDY DESIGN We analyzed rates of primary and repeat cesarean deliveries, which included indications for the procedure, among 22,265 live births at an academic tertiary center from 2009-2013. Time trends for each indication were modeled to estimate the absolute and cumulative annualized relative risk of cesarean delivery by indication over time and the relative contribution of each indication to the overall decrease in primary cesarean delivery rate. RESULTS From 2009-2013, the cesarean delivery rate decreased from 36.5-31.4%; 74% of the decrease was attributable to a decrease in primary cesarean deliveries, which decreased from 21.7-17.6%. Among documented indications for primary cesarean delivery, labor arrest, abnormal or indeterminate fetal heart rate, and preeclampsia decreased significantly over time (P<.001), whereas malpresentation, multiple gestation, maternal-fetal, macrosomia, and other obstetric and elective/maternal requests did not change (P>.05). Labor arrest was responsible for the largest proportion of the decrease in the primary cesarean delivery rate (44%), followed by abnormal or indeterminate fetal heart rate (23%) and preeclampsia (13%). CONCLUSION Primary cesarean births accounted for 74% of the decreasing cesarean delivery rate. Reductions in the diagnosis of labor arrest and abnormal fetal heart rate led to a decreased cesarean delivery rate at a major academic institution. Contemporaneous changes in definitions of labor arrest and approaches to fetal monitoring that were adopted at our institution may have considerable effect on the cesarean delivery rate.
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Affiliation(s)
- Sarah N Cross
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT.
| | | | - Christian M Pettker
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | | | - Jessica L Illuzzi
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT
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Xu X, Lee HC, Lin H, Lundsberg LS, Campbell KH, Lipkind HS, Pettker CM, Illuzzi JL. Hospital variation in utilization and success of trial of labor after a prior cesarean. Am J Obstet Gynecol 2019; 220:98.e1-98.e14. [PMID: 30278176 DOI: 10.1016/j.ajog.2018.09.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/20/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Trial of labor after cesarean delivery is an effective and safe option for women without contraindications. OBJECTIVES The objective of the study was to examine hospital variation in utilization and success of trial of labor after cesarean delivery and identify associated institutional characteristics and patient outcomes. STUDY DESIGN Using linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with 1 prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized utilization and success rates of trial of labor after cesarean delivery were estimated for each hospital after accounting for differences in patient case mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of trial of labor after cesarean delivery and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals' utilization and success rates of trial of labor after cesarean delivery. RESULTS In the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals, with a median of 35.2% (10th to 90th percentile range: 10.2-67.1%) and 40.5% (10th to 90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of trial of labor after cesarean delivery demonstrated an inverted U-shaped relationship such that low or excessively high use of trial of labor after cesarean delivery was associated with lower success rate. Compared with other births, those delivered at hospitals with above-the-median utilization and success rates of trial of labor after cesarean delivery had a higher risk for uterine rupture (adjusted risk ratio, 2.74, P < .001), severe newborn respiratory complications (adjusted risk ratio, 1.46, P < .001), and severe newborn neurological complications/trauma (adjusted risk ratio, 2.48, P < .001), but they had a lower risk for severe newborn infection (adjusted risk ratio, 0.80, P = .003) and overall severe unexpected newborn complications (adjusted risk ratio, 0.86, P < .001) as well as shorter length of stays (adjusted mean ratio, 0.948 for mothers and 0.924 for newborns, P < .001 for both). Teaching status, system affiliation, larger volume, higher neonatal care capacity, anesthesia availability, higher proportion of midwife-attended births, and lower proportion of Medicaid or uninsured patients were positively associated with both utilization and success of trial of labor after cesarean delivery. However, rural location and higher local malpractice insurance premium were negatively associated with the utilization of trial of labor after cesarean delivery, whereas for-profit ownership was associated with lower success rate. CONCLUSION Utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals. Strategies to promote vaginal birth should be tailored to hospital needs and characteristics (eg, increase availability of trial of labor after cesarean delivery at hospitals with low utilization rates while being more selective at hospitals with high utilization rates, and targeted support for lower capacity hospitals).
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Abstract
OBJECTIVES We sought to report the frequency of, circumstances surrounding, and outcomes of newborn falls in our hospital. We evaluated the impact of specific interventions on the frequency of newborn falls and the time between falls. METHODS We performed a retrospective study of newborn falls reported on our postpartum unit over a 13-year period. Demographic information and circumstances of falls were collected via an electronic event reporting system and medical record review. RESULTS There were 63 633 births and 29 newborn falls, yielding an average of 4.6 falls per 10 000 live births (median: 2 per year; range 0-5 per year). Newborns who sustained a fall were exclusively breastfeeding (75.9%), 24 to 48 hours of age at the time of the fall (58.6%), and had first-time parents (62.1%). At the time of the fall, most newborns were with the mother compared with being with the father or both parents (65.5% vs 34.5%); in the mother's bed compared with being elsewhere, such as on a couch or chair, with a parent, or in the parent's arms (62.1% vs 37.9%); and feeding at the time of the fall versus not (79.3% vs 20.7%). All newborns were monitored after the fall, with no adverse outcomes. Despite interventions, we continued to see cases of newborn falls, although the overall trend revealed decreasing falls per 10 000 patient-days and longer time between falls over the study period. CONCLUSIONS Newborn falls in our hospital are infrequent but continue to occur despite preventive efforts, highlighting the importance of continuous awareness and education.
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Affiliation(s)
| | - Christian M Pettker
- Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut; and
| | | | | | - Heather S Lipkind
- Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut; and
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Lundsberg LS, Lee HC, Dueñas GV, Gregory KD, Grossetta Nardini HK, Pettker CM, Illuzzi JL, Xu X. Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California. Obstet Gynecol 2018; 131:214-223. [PMID: 29324608 PMCID: PMC7020098 DOI: 10.1097/aog.0000000000002437] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices. METHODS Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests. RESULTS Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P≤.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04). CONCLUSION Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.
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Affiliation(s)
- Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut; the Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, California; the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California; and Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut
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Krenitsky N, Desai AN, Johnson AW, Pettker CM. 454: Counsel confidently: Reliability of bedside EFW to predict survival at periviability. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Xu X, Lee HC, Lin H, Lundsberg LS, Pettker CM, Lipkind HS, Illuzzi JL. Hospital variation in cost of childbirth and contributing factors: a cross-sectional study. BJOG 2017; 125:829-839. [PMID: 29090498 DOI: 10.1111/1471-0528.15007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine hospital variation in cost of childbirth hospitalisations and identify factors that contribute to the variation. DESIGN Cross-sectional analysis of linked birth certificate and hospital discharge data. SETTING Two hundred and twenty hospitals in California delivering ≥ 100 births per year. POPULATION A total of 405 908 nulliparous term singleton vertex births during 2010-2012. METHODS Cost of childbirth hospitalisations was compared across hospitals after accounting for differences in patient clinical risk factors. Relative contributions of patient sociodemographic, obstetric intervention, birth attendant and institutional characteristics to variation in cost were assessed by further adjusting for these factors in hierarchical generalised linear models. MAIN OUTCOME MEASURES Cost of childbirth hospitalisation. RESULTS Median risk-standardised cost of childbirth was $7149 among the hospitals (10th -90th percentile range: $4760-$10,644). Maternal sociodemographic characteristics and type of birth attendant did not explain hospital variation in cost. Adjustment for obstetric interventions overall reduced within-hospital variance by 15.8% (P < 0.001), while adjusting for caesarean delivery alone reduced within-hospital variance by 14.4% (P < 0.001). However, obstetric interventions did not explain between-hospital variation in cost. In contrast, adjustment for institutional characteristics reduced between-hospital variance by 30.3% (P = 0.002). Hospital type of ownership, teaching/urban-rural status, neonatal care capacity and geographic region were most impactful. Risk-standardised cost was positively correlated with risk-standardised rate of severe newborn morbidities (correlation coefficient 0.22, P = 0.001), but not associated with risk-standardised rate of severe maternal morbidities. CONCLUSIONS Cost of childbirth hospitalisations varied widely among hospitals in California. Institutional characteristics significantly contributed to this variation. Higher-cost hospitals did not have better outcomes, suggesting potential opportunities to enhance value in care. TWEETABLE ABSTRACT Hospitals vary in cost of childbirth. Institutional characteristics significantly contribute to the variation.
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Affiliation(s)
- X Xu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - H C Lee
- Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - H Lin
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - L S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - C M Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - H S Lipkind
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - J L Illuzzi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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Abstract
The critical arm of improvement and change comes after events are identified and classified. Getting and making things right when things go wrong defines a successful safety program. This article reviews the important tasks that should be familiar to any team approaching a serious event on an obstetrics unit. Root cause analysis is a critical, but often misunderstood, tool for dissecting the contributing factors leading to an adverse event. Successful root cause analyses have a standardized approach that result in meaningful action plans. Disclosure to the patient of the event and error, if applicable, is a new concept that is gaining traction in medicine. The review of a structured disclosure program can help programs adopt a method that has successfully gained the trust of patients and families with very few complications. Second victim support through coordinated debriefing of the individuals and teams who worked during the event is a final important measure that is important to prevent burnout or identification and classification is just the beginning to having a systematic approach to adverse events. The critical arm to improvement and change comes in the analysis and response to these events, which includes root cause analysis, corrective action plans, error disclosure, and second victim support.
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Affiliation(s)
- Christian M Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, Yale New Haven Hospital, 333 Cedar St, P.O. Box 208063, New Haven, CT 06520-8063.
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Affiliation(s)
- Christian M Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, P.O. Box 208063, New Haven, CT 06520-8063.
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215
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Abstract
Despite our best intentions to improve health when a patient presents for care, adverse events are ubiquitous in medical practice today. Known complications related to the course of a patient's illness or condition or to the characteristics of the treatment have been an openly stated part of taking care of patients for centuries. However, it is only in the past decade that preventable adverse events, instances of harm related to error and deviations in accepted practice have become a primary part of these conversations. Human and system errors are an innate part of working in a complex environment like health care and we are now well aware of this burden in medicine. Now, we are building ways to react to adverse events from error in systematic ways. A systematic approach to identifying and classifying events is a critical part of any safety program, let alone an obstetric safety program. This article reviews the various systems that are used to identify adverse events, in particular sentinel events, state reportable events, and the significant local adverse "trigger" events in obstetrics. These events typically become identified through robust reporting systems where staff can report adverse, near-miss events, or precursor safety events. After events are reported, a system for classifying events, including a structured tracking and reporting system with built in accountability, is necessary. The concept of the "serious safety event," and how these differ from known complications or unpreventable events, and how this is classified are also reviewed.
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Affiliation(s)
- Christian M Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, Yale New Haven Hospital, 333 Cedar St, P.O. Box 208063, New Haven, CT 06520-8063.
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Silvestri MT, Pettker CM, Raney JH, Xu X, Ross JS. Frequency and Importance of Incomplete Screening Fetal Anatomic Sonography in Pregnancy. J Ultrasound Med 2016; 35:2665-2673. [PMID: 27821652 DOI: 10.7863/ultra.16.01084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 02/20/2016] [Accepted: 03/22/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine (1) how often routine screening fetal anatomic sonography fails to completely visualize fetal anatomy; (2) the proportion of women with incomplete ultrasound examinations who are recommended for repeat screening and then undergo repeat sonography; and (3) how often abnormal fetal anatomy is detected on repeat sonography. METHODS We conducted a retrospective cohort study at a high-volume academic obstetric ultrasound center. Participants were 16,300 women at 17 through 21 weeks' gestation with a singleton pregnancy presenting for screening anatomic sonography between January 2009 and December 2013. Main outcome measures were (1) incomplete visualization of anatomy at initial screening sonography; (2) among women with incomplete but otherwise normal initial screening ultrasound examinations, recommendation for and performance of repeat sonography; and (3) among women undergoing repeat sonography, discovery of abnormal fetal anatomy within anatomic components that were previously incompletely visualized. RESULTS The mean maternal age ± SD was 30.8 ± 6.3 years, and the mean gestational age was 18.8 ± 1.0 weeks. Among 16,300 initial screening ultrasound examinations, 2157 (13.2%) had incomplete visualization of fetal anatomy. Of those women eligible for follow-up, 91.5% were recommended for repeat screening, of whom 92.8% had a subsequent examination. Of 1560 repeat screening ultrasound examinations, 8 (0.5%) showed an abnormality in the components of anatomy that were previously visualized incompletely. CONCLUSIONS In this large single-center study, incomplete visualization was common in screening fetal anatomic ultrasound examinations. Recommendations for repeat imaging were nearly universal, but abnormal fetal anatomy was infrequently discovered on repeat screening.
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Affiliation(s)
- Mark T Silvestri
- Robert Wood Johnson Foundation Clinical Scholars Program, New Haven, Connecticut USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, Connecticut USA
| | - Christian M Pettker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, Connecticut USA
| | | | - Xiao Xu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, Connecticut USA
| | - Joseph S Ross
- Robert Wood Johnson Foundation Clinical Scholars Program, New Haven, Connecticut USA
- Department of Internal Medicine, New Haven, Connecticut USA
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Archabald KL, Buhimschi IA, Bahtiyar MO, Dulay AT, Abdel-Razeq SS, Pettker CM, Lipkind HS, Hardy JT, McCarthy ME, Zhao G, Bhandari V, Buhimschi CS. Limiting the Exposure of Select Fetuses to Intrauterine Infection/Inflammation Improves Short-Term Neonatal Outcomes in Preterm Premature Rupture of Membranes. Fetal Diagn Ther 2016; 42:99-110. [PMID: 27794570 DOI: 10.1159/000450997] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 09/16/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND To improve neonatal outcomes in pregnancies at heightened risk for early-onset neonatal sepsis (EONS), there is a need to identify fetuses that benefit from expectant management as opposed to early delivery. Detectable haptoglobin and haptoglobin-related protein (Hp&HpRP switch-on status) in cord blood has been proposed as a biomarker of antenatal exposure to intra-amniotic infection and/or inflammation (IAI), an important determinant of EONS. SUBJECTS AND METHODS We analyzed 185 singleton newborns delivered secondary to preterm premature rupture of membranes (PPROM). In 123 cases, amniocentesis was performed to exclude amniotic fluid (AF) infection. Delivery was indicated for 61 cases with confirmed infection. Women without AF infection (n = 62) and those without amniocentesis (n = 62) were managed expectantly. Interleukin 6 and Hp&HpRP switch-on status were evaluated by ELISA and Western blot. Newborns were followed prospectively for short-term outcomes until hospital discharge or death. RESULTS Newborns exposed antenatally to IAI had an increased risk of adverse neonatal outcome [OR: 3.0 (95% CI: 1.15-7.59)]. Increasing gestational age [OR: 0.61 (95% CI: 0.52-0.70)] and management with amniocentesis [OR: 0.37 (95% CI: 0.14-0.95)] lowered the newborn's risk of developing adverse outcomes. DISCUSSION In the setting of PPROM and IAI, early delivery benefits a select subgroup of fetuses that have not yet progressed to Hp&HpRP switch-on status.
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Affiliation(s)
- Karen L Archabald
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Conn., USA
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Xu X, Gariepy A, Lundsberg LS, Sheth SS, Pettker CM, Krumholz HM, Illuzzi JL. Wide Variation Found In Hospital Facility Costs For Maternity Stays Involving Low-Risk Childbirth. Health Aff (Millwood) 2015; 34:1212-9. [DOI: 10.1377/hlthaff.2014.1088] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Xiao Xu
- Xiao Xu is an assistant professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, in New Haven, Connecticut
| | - Aileen Gariepy
- Aileen Gariepy is an assistant professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine
| | - Lisbet S. Lundsberg
- Lisbet S. Lundsberg is an associate research scientist in the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine
| | - Sangini S. Sheth
- Sangini S. Sheth is an assistant professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine
| | - Christian M. Pettker
- Christian M. Pettker is an associate professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine
| | - Harlan M. Krumholz
- Harlan M. Krumholz is the Harold H. Hines Jr. Professor of Medicine and Epidemiology and Public Health at the Yale School of Medicine
| | - Jessica L. Illuzzi
- Jessica L. Illuzzi is an associate professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine
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Shorten A, Fagerlin A, Illuzzi J, Kennedy HP, Lakehomer H, Pettker CM, Saran A, Witteman H, Whittemore R. Developing an Internet-Based Decision Aid for Women Choosing Between Vaginal Birth After Cesarean and Planned Repeat Cesarean. J Midwifery Womens Health 2015; 60:390-400. [DOI: 10.1111/jmwh.12298] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Han CS, Herrin MA, Pitruzzello MC, Mulla MJ, Werner EF, Pettker CM, Flannery CA, Abrahams VM. Glucose and metformin modulate human first trimester trophoblast function: a model and potential therapy for diabetes-associated uteroplacental insufficiency. Am J Reprod Immunol 2014; 73:362-71. [PMID: 25394884 DOI: 10.1111/aji.12339] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/10/2014] [Indexed: 12/28/2022] Open
Abstract
PROBLEM Diabetes confers an increased risk of preeclampsia, but its pathogenic role in preeclampsia is poorly understood. The objective of this study was to elucidate the effects of excess glucose on trophoblast function and whether any changes could be reversed by metformin. METHOD OF STUDY The human first trimester trophoblast cell line (Sw.71) was treated with glucose at 5, 10, 25, and 50 mm, in the presence and absence of metformin. Trophoblast migration was quantified and supernatant cytokine, chemokine, and angiogenic factors measured. RESULTS Increasing concentrations of glucose significantly increased trophoblast secretion of the inflammatory cytokines/chemokines: IL-1β, IL-6, IL-8, GRO-α, RANTES, and G-CSF; significantly increased trophoblast secretion of the anti-angiogenic factors sFlt-1 and sEndoglin; and significantly decreased trophoblast migration. Excess glucose-induced trophoblast IL-1β production was inhibited by disabling the Nalp3/ASC inflammasome. Metformin partially reduced the glucose-induced inflammatory response, but had no effect on the anti-angiogenic or antimigratory response. CONCLUSION Excess glucose induced a pro-inflammatory, anti-angiogenic, and antimigratory state in first trimester trophoblast cells. Glucose-induced trophoblast IL-1β secretion was mediated by the inflammasome. Glucose-induced inflammation was partially reversed by metformin. These findings demonstrate the pleiotropic effects of hyperglycaemia on the trophoblast, providing potential explanations for the strong link between diabetes and preeclampsia.
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Affiliation(s)
- Christina S Han
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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Pettker CM, Thung SF, Lipkind HS, Illuzzi JL, Buhimschi CS, Raab CA, Copel JA, Lockwood CJ, Funai EF. A comprehensive obstetric patient safety program reduces liability claims and payments. Am J Obstet Gynecol 2014; 211:319-25. [PMID: 24925798 DOI: 10.1016/j.ajog.2014.04.038] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/21/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022]
Abstract
Begun in 2003, the Yale-New Haven Hospital comprehensive obstetric safety program consisted of measures to standardize care, improve teamwork and communication, and optimize oversight and quality review. Prior publications have demonstrated improvements in adverse outcomes and safety culture associated with this program. In this analysis, we aimed to assess the impact of this program on liability claims and payments at a single institution. We reviewed liability claims at a single, tertiary-care, teaching hospital for two 5-year periods (1998-2002 and 2003-2007), before and after implementing the safety program. Connecticut statute of limitations for professional malpractice is 36 months from injury. Claims/events were classified by event-year and payments were adjusted for inflation. We analyzed data for trends as well as differences between periods before and after implementation. Forty-four claims were filed during the 10-year study period. Annual cases per 1000 deliveries decreased significantly over the study period (P < .01). Claims (30 vs 14) and payments ($50.7 million vs $2.9 million) decreased in the 5-years after program inception. Compared with before program inception, median annual claims dropped from 1.31 to 0.64 (P = .02), and median annual payments per 1000 deliveries decreased from $1,141,638 to $63,470 (P < .01). Even estimating the monetary awards for the 2 remaining open cases using the median payments for the surrounding 5 years, a reduction in the median monetary amount per case resulting in payment to the claimant was also statistically significant ($632,262 vs $216,815, P = .046). In contrast, the Connecticut insurance market experienced a stable number of claims and markedly increased cost per claim during the same period. We conclude that an obstetric safety initiative can improve liability claims exposure and reduce liability payments.
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Olmedo B, Miranda E, Cordon O, Pettker CM, Funai EF. Improving maternal health and safety through adherence to postpartum hemorrhage protocol in Latin America. Int J Gynaecol Obstet 2014; 125:162-5. [PMID: 24548891 DOI: 10.1016/j.ijgo.2013.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/14/2013] [Accepted: 01/17/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine provider compliance with protocols for the prevention of postpartum hemorrhage and provider characteristics associated with adherence and non-adherence. METHODS A multicenter descriptive study was conducted involving 78 direct observations of provider-implemented protocols and 52 interviews with Peruvian maternal healthcare providers at 4 Peruvian clinical sites representing the local, regional, and national levels of care. Parturient participants planning a normal vaginal delivery were 17-49 years of age and 34-42 weeks pregnant. Primary outcomes were compared using χ2 testing, while quantitative survey data were evaluated using means, standard deviations, and Student t test or analysis of variance for statistical significance. RESULTS There were 3 significant differences between the national, regional, and local levels of care: adherence to all 3 interventions (P<0.001); professional experience (P<0.04); and retention of healthcare providers (P<0.001). There were no differences in provider training (P<0.097), and the retention of experienced healthcare providers was not associated with greater adherence to protocols. There were no significant differences in parturient characteristics. CONCLUSION Individual characteristics and institutional beliefs may have more influence than experience or training on adherence to protocols for prevention of postpartum hemorrhage; addressing these biases may improve patient safety in Peru and throughout Latin America.
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Affiliation(s)
- Benjamin Olmedo
- Yale Physician Associate Program, Yale University School of Medicine, New Haven, USA.
| | - Eva Miranda
- US Agency for International Development, USAID|Peru|Quality Health Care, Lima, Peru
| | - Oscar Cordon
- US Agency for International Development, USAID|Peru|Quality Health Care, Lima, Peru
| | - Christian M Pettker
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, USA
| | - Edmund F Funai
- Department of Obstetrics and Gynecology, Ohio State University College of Medicine, Columbus, USA
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Martin DK, Bulmer SM, Pettker CM. Childbirth expectations and sources of information among low- and moderate-income nulliparous pregnant women. J Perinat Educ 2014; 22:103-12. [PMID: 24421603 DOI: 10.1891/1058-1243.22.2.103] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This article explores the childbirth expectations and sources of information of first-time mothers using a qualitative descriptive method. A purposive sample of low- to moderate-income nulliparous women (N = 7) from an urban area in Connecticut were interviewed in their third trimester of pregnancy. The themes that emerged touched on mode of birth, supportive resources, emotional and physical expectations, control, and health of the baby. No one participated in childbirth education classes, and instead cited mostly informal sources of information such as family, friends, the Internet, and television. In light of advanced technology and increased access to on-demand information, the results of this study should remind health-care providers to discuss childbirth expectations and the sources of information with patients.
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Nayeri UA, Werner EF, Han CS, Pettker CM, Funai EF, Thung SF. Antenatal lamivudine to reduce perinatal hepatitis B transmission: a cost-effectiveness analysis. Am J Obstet Gynecol 2012; 207:231.e1-7. [PMID: 22939730 DOI: 10.1016/j.ajog.2012.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 04/22/2012] [Accepted: 06/01/2012] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study aimed to determine whether administration of lamivudine to pregnant women with chronic hepatitis B in the third trimester is a cost-effective strategy in preventing perinatal transmission. STUDY DESIGN We developed a decision analysis model to compare the cost-effectiveness of 2 management strategies for chronic hepatitis B in pregnancy: (1) expectant management or (2) lamivudine administration in the third trimester. We assumed that lamivudine reduced perinatal transmission by 62%. RESULTS Our Markov model demonstrated that lamivudine administration is the dominant strategy. For every 1000 infected pregnant women treated with lamivudine, $337,000 is saved and 314 quality-adjusted life-years are gained. For every 1000 pregnancies with maternal hepatitis B, lamivudine prevents 21 cases of hepatocellular carcinoma and 5 liver transplants in the offspring. The model remained robust in sensitivity analysis. CONCLUSION Antenatal lamivudine administration to pregnant patients with hepatitis B is cost-effective, and frequently cost-saving, under a wide range of circumstances.
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Affiliation(s)
- Unzila A Nayeri
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
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Erekson EA, Brousseau EC, Dick-Biascoechea MA, Ciarleglio MM, Lockwood CJ, Pettker CM. Maternal postoperative complications after nonobstetric antenatal surgery. J Matern Fetal Neonatal Med 2012; 25:2639-44. [PMID: 22735069 DOI: 10.3109/14767058.2012.704445] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Our primary objective is to estimate the occurrence of major maternal 30 day postoperative complications after nonobstetric antenatal surgery. METHODS We analyzed the 2005-2009 data files from the American College of Surgeons National Surgical Quality Improvement Program to assess outcomes for pregnant women undergoing nonobstetric antenatal surgery during any trimester of pregnancy as classified by CPT-4 codes. t Tests, χ(2), logistic regression and other tests were used to calculate composite 30-day major postoperative complications and associations of preoperative predictors with 30 day postoperative morbidity. RESULTS The most common nonobstetric antenatal surgical procedure among the 1969 included women was appendectomy (44.0%). The prevalence of composite 30-day major postoperative complications was 5.8% (n = 115). This included (not exclusive categories): return to the surgical operating room within 30 days of surgery 3.6%, infectious morbidity 2.0%, wound morbidity 1.4%, 30 day respiratory morbidity 2.0%, venous thromboembolic event morbidity 0.5%, postoperative blood transfusion 0.2%, and maternal mortality 0.25%. CONCLUSION Major maternal postoperative complications following nonobstetric antenatal surgery were low (5.8%). Maternal postoperative mortality was rare (0.25%).
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Affiliation(s)
- Elisabeth A Erekson
- Yale University School of Medicine, Department of Obstetrics, Gynecology, & Reproductive Sciences, New Haven, CT 06520–8063, USA.
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Werner EF, Pettker CM, Zuckerwise L, Reel M, Funai EF, Henderson J, Thung SF. Screening for gestational diabetes mellitus: are the criteria proposed by the international association of the Diabetes and Pregnancy Study Groups cost-effective? Diabetes Care 2012; 35:529-35. [PMID: 22266735 PMCID: PMC3322683 DOI: 10.2337/dc11-1643] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) recently recommended new criteria for diagnosing gestational diabetes mellitus (GDM). This study was undertaken to determine whether adopting the IADPSG criteria would be cost-effective, compared with the current standard of care. RESEARCH DESIGN AND METHODS We developed a decision analysis model comparing the cost-utility of three strategies to identify GDM: 1) no screening, 2) current screening practice (1-h 50-g glucose challenge test between 24 and 28 weeks followed by 3-h 100-g glucose tolerance test when indicated), or 3) screening practice proposed by the IADPSG. Assumptions included that 1) women diagnosed with GDM received additional prenatal monitoring, mitigating the risks of preeclampsia, shoulder dystocia, and birth injury; and 2) GDM women had opportunity for intensive postdelivery counseling and behavior modification to reduce future diabetes risks. The primary outcome measure was the incremental cost-effectiveness ratio (ICER). RESULTS Our model demonstrates that the IADPSG recommendations are cost-effective only when postdelivery care reduces diabetes incidence. For every 100,000 women screened, 6,178 quality-adjusted life-years (QALYs) are gained, at a cost of $125,633,826. The ICER for the IADPSG strategy compared with the current standard was $20,336 per QALY gained. When postdelivery care was not accomplished, the IADPSG strategy was no longer cost-effective. These results were robust in sensitivity analyses. CONCLUSIONS The IADPSG recommendation for glucose screening in pregnancy is cost-effective. The model is most sensitive to the likelihood of preventing future diabetes in patients identified with GDM using postdelivery counseling and intervention.
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Affiliation(s)
- Erika F Werner
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
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Abdel-Razeq SS, Buhimschi IA, Trotta K, Zhao G, Bahtiyar MO, Pettker CM, Buhimschi CS. 51: Evidence for the presence of super-interleukin-6 (superIL-6) trans-signaling complex in amniotic fluid (AF) and its participation in the intraamniotic inflammatory response to infection. Am J Obstet Gynecol 2012. [DOI: 10.1016/j.ajog.2011.10.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Werner EF, Pettker CM, Reel M, Zuckerwise LC, Funai EF, Thung SF. 250: Long term diabetes risk reduction necessary for gestational diabetes screening to be cost effective. Am J Obstet Gynecol 2012. [DOI: 10.1016/j.ajog.2011.10.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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