Outcomes After Induction of Labor Compared With Dilation and Evacuation for the Management of Rupture of Membranes in the Second Trimester

Previable and periviable rupture of membranes is associated with significant morbidity for the pregnant patient. For those who have a choice of options and undergo active management, it is not known how the risks of induction of labor compare with those for dilation and evacuation (D&E). We performed a retrospective cohort study of patients with rupture of membranes between 14 0/7 and 23 6/7 weeks of gestation who opted for active management. Adverse events (52.2% vs 16.9%, P <.01) and time to uterine evacuation greater than 24 hours (26.7% vs 9.6%, P =.01) were more common among patients undergoing induction of labor. In a multivariable regression, induction of labor was an independent risk factor for complications (odds ratio 5.70, 95% CI, 2.35-13.82) compared with D&E. Severe complications were rare across both groups (4.4% for patients undergoing induction vs 2.6% for D&E, P =.63). Given the differing risks by termination method, access to D&E is an important treatment option for this patient population.

Perceptions of HIV risk screening strategies among patients seeking abortion, contraception, and pregnancy loss management in the United States

OBJECTIVES

Women make up nearly a fifth of new human immunodeficiency virus (HIV) infections yearly in the United States, more than half of which could have been prevented with broader use of HIV pre-exposure prophylaxis (PrEP). We aimed to qualitatively assess (1) acceptability of an HIV risk screening strategy and PrEP provision in a family planning setting, and (2) the influence of family planning visit type (abortion, pregnancy loss management, or contraception) on HIV risk screening acceptability.

STUDY DESIGN

Guided by the P3 (practice-, provider-, and patient-level) model for preventive care interventions, we conducted three focus group discussions including patients who had experienced induced abortion, early pregnancy loss (EPL), or contraception care. We developed a codebook of a priori and inductive concepts, and categorized themes by practice, provider, and patient considerations.

RESULTS

We included 24 participants. Practice-level considerations included overall positive feelings about being screened for PrEP eligibility during family planning visits, though some expressed reservations about screening during EPL visits. Provider-level themes included the concept of screening tools as entry points into conversation and education, and the importance of nonjudgment in discussing sexually transmitted infection (STI) prevention. Participants often had to initiate STI prevention discussions and felt that contraception was overemphasized by their providers compared with STI prevention and PrEP care. Patient-level themes included the stigma of STIs and oral PrEP, and the dynamic nature of STI risk.

CONCLUSIONS

Participants in our research had genuine interest in learning about PrEP during family planning visits. Findings from our research support the consistent inclusion of STI prevention education into family planning clinical practice using patient-centered STI screening methods.

IMPLICATIONS

Family planning encounters, including visits for contraception and abortion, are generally appropriate times to discuss HIV PrEP. Patient-centered conversations are an important adjunct to HIV risk screening tools.

A tailored COVID-19 vaccination pathway for children 5-11 years in Victoria, Australia

BACKGROUND

Procedural anxiety was anticipated in children 5-11 years during the COVID-19 vaccine rollout in Victoria, Australia, as children in this age group receive few routine vaccines. Therefore, the Victorian state government designed a tailored, child-friendly vaccine program. This study aimed to assess parental satisfaction with elements of the bespoke vaccination pathway.

METHODS

The Victorian government and state-run vaccination hubs in Victoria facilitated an online immunisation plan to help parents identify their child's support needs, and utilised experienced paediatric staff and additional supports for children with severe needle distress and/or disability. All parents/guardians of children 5-11 years who received a COVID-19 vaccine in a vaccination hub were sent a 16-item feedback survey via text message.

RESULTS

Between 9 February and 31 May 2022 there were 9203 responses; 865 children (9.4%) had a first language other than English, 499 (5.4%) had a disability or special needs, and 142 (1.5%) were Aboriginal or Torres Strait Islander. Most parents (94.4%; 8687/9203) rated their satisfaction with the program as very good or excellent. The immunisation plan was used by 13.5% (1244/9203) of respondents, with usage more common for Aboriginal or Torres Strait Islander children (26.1%; 23/88) or families with a first language other than English (23.5%; 42/179). The child-friendly staff (88.5%, 255/288) and themed environment (66.3%, 191/288) were the most valued measures for vaccination. Additional support measures were required by 1.6% (150/9203) of children in the general population and 7.9%, (17/261) of children with a disability and/or special needs.

CONCLUSION

A tailored COVID-19 vaccination program for children 5-11 years, with additional support for children with severe needle distress and/or disability, had high parental satisfaction. This model could be utilised for COVID-19 vaccination in pre-school children and for routine childhood vaccination programs to provide optimal support to children and their families.

Near real time monitoring and forecasting for COVID-19 situational awareness

In the opening months of the pandemic, the need for situational awareness was urgent. Forecasting models such as the Susceptible-Infectious-Recovered (SIR) model were hampered by limited testing data and key information on mobility, contact tracing, and local policy variations would not be consistently available for months. New case counts from sources like John Hopkins University and the NY Times were systematically reliable. Using these data, we developed the novel COVID County Situational Awareness Tool (CCSAT) for reliable monitoring and decision support. In CCSAT, we developed a retrospective seven-day moving window semantic map of county-level disease magnitude and acceleration that smoothed noisy daily variations. We also developed a novel Bayesian model that reliably forecasted county-level magnitude and acceleration for the upcoming week based on population and new case count data. Together these formed a robust operational update including county-level maps of new case rate changes, estimates of new cases in the upcoming week, and measures of model reliability. We found CCSAT provided stable, reliable estimates across the seven-day time window, with the greatest errors occurring in cases of anomalous, single day spikes. In this paper, we provide CCSAT details and apply it to a single week in June 2020.

Association of Social Distancing, Population Density, and Temperature With the Instantaneous Reproduction Number of SARS-CoV-2 in Counties Across the United States

IMPORTANCE

Local variation in the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) across the United States has not been well studied.

OBJECTIVE

To examine the association of county-level factors with variation in the SARS-CoV-2 reproduction number over time.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 211 counties, representing state capitals and cities with at least 100 000 residents and including 178 892 208 US residents, in 46 states and the District of Columbia between February 25, 2020, and April 23, 2020.

EXPOSURES

Social distancing, measured by percentage change in visits to nonessential businesses; population density; and daily wet-bulb temperatures.

MAIN OUTCOMES AND MEASURES

Instantaneous reproduction number (Rt), or cases generated by each incident case at a given time, estimated from daily case incidence data.

RESULTS

The 211 counties contained 178 892 208 of 326 289 971 US residents (54.8%). Median (interquartile range) population density was 1022.7 (471.2-1846.0) people per square mile. The mean (SD) peak reduction in visits to nonessential business between April 6 and April 19, as the country was sheltering in place, was 68.7% (7.9%). Median (interquartile range) daily wet-bulb temperatures were 7.5 (3.8-12.8) °C. Median (interquartile range) case incidence and fatality rates per 100 000 people were approximately 10 times higher for the top decile of densely populated counties (1185.2 [313.2-1891.2] cases; 43.7 [10.4-106.7] deaths) than for counties in the lowest density quartile (121.4 [87.8-175.4] cases; 4.2 [1.9-8.0] deaths). Mean (SD) Rt in the first 2 weeks was 5.7 (2.5) in the top decile compared with 3.1 (1.2) in the lowest quartile. In multivariable analysis, a 50% decrease in visits to nonessential businesses was associated with a 45% decrease in Rt (95% CI, 43%-49%). From a relative Rt at 0 °C of 2.13 (95% CI, 1.89-2.40), relative Rt decreased to a minimum as temperatures warmed to 11 °C, increased between 11 and 20 °C (1.61; 95% CI, 1.42-1.84) and then declined again at temperatures greater than 20 °C. With a 70% reduction in visits to nonessential business, 202 counties (95.7%) were estimated to fall below a threshold Rt of 1.0, including 17 of 21 counties (81.0%) in the top density decile and 52 of 53 counties (98.1%) in the lowest density quartile.2.

CONCLUSIONS AND RELEVANCE

In this cohort study, social distancing, lower population density, and temperate weather were associated with a decreased Rt for SARS-CoV-2 in counties across the United States. These associations could inform selective public policy planning in communities during the coronavirus disease 2019 pandemic.

A multi-method and multi-informant approach to assessing post-traumatic stress disorder (PTSD) in children

Trauma exposure is highly prevalent among children globally, and is associated with elevated rates of PTSD. The goal of this study was to systematically evaluate the effects of multiple informants and multiple screening measures on the identification of specific PTSD symptoms and rates of PTSD diagnoses. Participants in this study included 350 maltreated children from two cohorts, one recruited from Connecticut (n = 130), and the other from Vermont (n = 220). Both cohorts completed the Screen for Child Anxiety-Related Emotional Disorders (SCARED) before a PTSD self-report measure. The KSADS psychiatric interview was also completed with the Connecticut cohort, with best-estimate ratings generated using parent and child interview, child self-report, and teacher questionnaire data. In addition to the SCARED and PTSD self-report scale, parents of the Vermont cohort completed the Child Behavioural Checklist. Significant differences emerged between parent and child report of sleep, nightmares, concentration, and irritability problems, suggesting the need for multiple informants in PTSD screening. Children also under-reported nightmares when asked in the context of a trauma-specific screening tool. As child trauma is associated with a broad range of psychiatric sequelae, comprehensive assessment using both general symptomatology and trauma-specific measures is recommended, since children often shut down when completing trauma measures.

Manganese-enhanced MRI Offers Correlation with Severity of Spinal Cord Injury in Experimental Models

BACKGROUND

Spinal cord injuries (SCI) are clinically challenging, because neural regeneration after cord damage is unknown. In SCI animal models, regeneration is evaluated histologically, requiring animal sacrifice. Noninvasive techniques are needed to detect longitudinal SCI changes.

OBJECTIVE

To compare manganese-enhanced magnetic resonance imaging (MRI [MEMRI]) in hemisection and transection of SCI rat models with diffusion tensor imaging (DTI) and histology.

METHODS

Rats underwent T9 spinal cord transection (n=6), hemisection (n=6), or laminectomy without SCI (controls, n=6). One-half of each group received lateral ventricle MnCl₂ injections 24 hours later. Conventional DTI or T1-weighted MRI was performed 84 hours post-surgery. MEMRI signal intensity ratio above and below the SCI level was calculated. Fractional anisotropy (FA) measurements were taken 1 cm rostral to the SCI. The percentage of FA change was calculated 10 mm rostral to the SCI epicenter, between FA at the dorsal column lesion normalized to a lateral area without FA change. Myelin load (percentage difference) among groups was analyzed by histology.

RESULTS

In transection and hemisection groups, mean MEMRI ratios were 0.62 and 0.87, respectively, versus 0.99 in controls (P<0.001 and P<0.001, respectively); mean FA decreases were 67.5% and 40.1%, respectively, compared with a 6.1% increase in controls (P=0.002 and P=0.019, respectively). Mean myelin load decreased by 38.8% (transection) and 51.8% (hemisection) compared to controls (99.1%) (P<0.001 and P<0.001, respectively). Pearson's correlation coefficients were -0.94 for MEMRI ratio and FA changes and 0.87 for MEMRI and myelin load.

CONCLUSION

MEMERI results correlated to SCI severity measured by FA and myelin load. MEMRI is a useful noninvasive tool to assess neuronal damage after SCI.

RESPONSE OF DOSEMETERS IN FIELDS GENERATED BY LASER-ACCELERATED PROTONS

In laser-driven acceleration, ultra-short and intense laser pulses are focussed on targets to generate beams of ionising radiation. One of the most important issues to be addressed is personal monitoring. While traditional dosemeters were designed primarily for measurements in continuous fields, dosemeters for laser laboratories must be capable of working in pulsed fields of pulse length below 1 ps, in a single-shot regime up to the repetition rate of 1 kHz. Responses of conventional dosemeters (films, polyallyldiglycol carbonate, electronic personal dosemeter) to proton bunches of up to 30 MeV energy produced by South Korean PW laser system at the Advanced Photonics Research Institute, Gwangju Institute of Science and Technology were studied, both by means of Monte Carlo simulations and experimentally.

Chess, Cheerleading, Chopin: What Gets You Into College?

Do extracurricular activities increase students' likelihood of attending college, including prestigious institutions? Yes, but grades, test scores, and family background still matter more.

Quick-Wee: A Novel Non-Invasive Urine Collection Method for Infants in the Emergency Department

BACKGROUND: Urinary tract infection is one of the commonest paedi-atric infections, and important to diagnose or exclude in young children with fever. Limitations exist with all current urine collection methods, guidelines vary, and clinicians have different preferences. Clean catch urine (CCU) is a preferred non-invasive collection method and is convenient and painless compared to suprapubic aspirate and catheterisation. However, it can be unreliable and time-consuming, with high rates of sample contamination and collection failure. Only 12% void within 5 minutes based on recent data. An ideal method of urine collection would be fast, reliable and simple. Suprapubic stimulation may trigger involuntary parasympathetic detrusor contraction, inducing voiding via early childhood exteroceptive somato-bladder reflexes.

OBJECTIVES: We conducted a pilot study using a novel method (termed ‘Quick-Wee’) of gentle cutaneous suprapubic stimulation with saline-soaked gauze, to hasten voiding for non-invasive urine collection.

DESIGN/METHODS: Prospective pilot study of 40 pre-continent children age 1-24 months requiring CCU in a paediatric emergency department in Australia. Standard CCU was augmented by 5 minutes of suprapubic cutaneous stimulation (Quick-Wee method), with either cold (3 degrees Celsius) or room-temperature saline-soaked gauze. PRIMARY OUTCOME: Void &lt;5 minutes. SECONDARY OUTCOMES: Successful catch of sample (if voids), contamination rate, parental/clinician satisfaction with technique.

RESULTS:

Urine Clean Catch Collection in the Paediatric Emergency Department: Success, Time to Void and Contamination Rates

BACKGROUND: Young children frequently require investigation for urinary tract infection (UTI). Clean catch urine (CCU) is a common urine collection method in pre-continent children but can be time consuming or unsuccessful, and contaminated cultures may lead to an inability to diagnose or exclude UTI. There are few data available examining the success and time required for CCU and factors influencing contamination. We hypothesise that time taken to obtain CCU influences contamination, due to accidental contamination during collection.

OBJECTIVES: To determine the time taken to obtain CCU in pre-conti-nent children, and if time to collection is related to the contamination rate.

DESIGN/METHODS: Prospective observational study of CCU collection in pre-continent children aged 2-48 months at a paediatric emergency department in Australia. A standardised CCU collection protocol was used. Primary outcome was time to first void; secondary outcomes were success of obtaining (catching) CCU and contamination of urine cultures obtained. Contamination was defined as per hospital microbiology standards. Descriptive analysis of time to void included median and interquartile range (IQR). We performed a regression analysis of key factors possibly related to contamination, including age, sex and time to collection.

RESULTS: Of the 218 recruited patients, 61% were male, mean age 11.4 months (SD 8.5). The main indication for CCU was: 128 fever of unknown origin (59%), 31 vomiting (14%), 27 specifically suspected UTI (12%), 32 other reason (15%). From first CCU attempt, 174 voided (80%) of which 139 were successful catches (64%) and 34 were missed on voiding (16%). 44 first CCU attempts were stopped before voiding (20%), 26 patients had 2 attempts (12%), and 2 patients had 3 CCU attempts (1%). Median time to first void was 25 minutes (IQR 8 – 49). 27 children (12%) voided &lt;5 minutes, 33 (19%) voided &gt;1hr. Of the 130 patients who had urine culture results available, 50 were contaminated (38%). There was no significant difference in contamination rate by age, sex or time to sample collection. Of 218 patients where ED clinicians set out to collect CCU in the emergency department, only 80 (37%) resulted in a successful CCU attempt with an uncontaminated culture.

CONCLUSION: Contamination rates are high in clean catch urine, but not related to the time taken for sample collection. CCU attempts are often unsuccessful, and have a low diagnostic yield for investigation of UTI in young children in clinical practice.

Short communication: Field study of air ammonia concentrations in Ontario dairy calf housing microenvironments

Kaufman, J., Linington, M., Osborne, V. R., Wagner-Riddle, C. and Wright, T. C. 2015. Short Communication: Field study of air ammonia concentrations in Ontario dairy calf housing microenvironments. Can. J. Anim. Sci. 95: 539–542. The objective of this study was to measure the ammonia concentrations in the microenvironment of the calf housing area on a sample of commercial dairies in Ontario under typical management conditions. Two approaches were used to measure ammonia concentrations: (1) weekly on four farms for a period of 8 wk and (2) one-time samples were taken from the calf areas on 15 other farms. The results indicated that ammonia levels are managed below the existing maximum threshold provided in the national dairy code of practice.

Severe Acute Anemia After Liver Transplantation in an Elderly Jehovah's Witness Treated With High-dose Erythropoietin and Ferric Carboxymaltose: A Case Report

BACKGROUND

There is no standard treatment for patients with severe anemia who refuse blood transfusion or cannot receive red blood cells.

CASE REPORT

After an orthotopic liver transplantation, an elderly Jehovah's Witness who refused blood transfusion presented with severe acute anemia with hemorrhagic shock. The calculated red blood cell loss was near 70%. Associated with surgical treatment and supportive measures, the patient was treated with high-dose erythropoietin and ferric carboxymaltose.

RESULTS

The patient presented a rapid increase in hemoglobin concentration and reticulocyte count with resolution of hemorrhagic shock after the proposed pharmacologic treatment combined with local hemostatic measures. She was transferred to a low-risk unit 4 days after transplantation and was discharged from the hospital on day 10. The hemoglobin concentration was normal 35 days after the bleeding event.

CONCLUSION

This case demonstrated that a protocol with high-dose erythropoietin and ferric carboxymaltose may be an option for patients with severe anemia who refuse blood transfusion or cannot receive red blood cells.

Similar Outcomes for Two Anemia Treatment Strategies among Elderly Hemodialysis Patients with Diabetes

BACKGROUND/AIMS

To compare mortality and cardiovascular risk in elderly dialysis patients with diabetes under two clinical strategies of anemia correction: maintaining hematocrit (Hct) between 34.5 and < 39.0% (high Hct strategy), and between 30.0 and <34.5% (low Hct strategy) using intravenous alpha epoetin.

METHODS

Observational data were used to emulate a randomized trial in which diabetic patients who initiated hemodialysis in 2006-2008 were assigned to each anemia correction strategy. Inverse-probability weighting was used to adjust for measured time-dependent confounding.

RESULTS

Comparing high with low hematocrit strategy, the hazard ratio (95% confidence interval) was 1.07 (0.83, 1.38) for all-cause mortality and 1.00 (0.81, 1.24) for a composite mortality and cardiovascular endpoint.

CONCLUSIONS

Among a cohort of elderly hemodialysis patients with diabetes, no differences were found between the low and high hematocrit strategies. A lower target hematocrit - per current Food and Drug Administration (FDA) guidelines - appears to be as safe as higher targets among this population.

Development and first experimental tests of Faraday cup array

A new type of Faraday cup, capable of detecting high energy charged particles produced in a high intensity laser-matter interaction environment, has recently been developed and demonstrated as a real-time detector based on the time-of-flight technique. An array of these Faraday cups was designed and constructed to cover different observation angles with respect to the target normal direction. Thus, it allows reconstruction of the spatial distribution of ion current density in the subcritical plasma region and the ability to visualise its time evolution through time-of-flight measurements, which cannot be achieved with standard laser optical interferometry. This is a unique method for two-dimensional visualisation of ion currents from laser-generated plasmas. A technical description of the new type of Faraday cup is introduced along with an ad hoc data analysis procedure. Experimental results obtained during campaigns at the Petawatt High-Energy Laser for Heavy Ion Experiments (GSI, Darmstadt) and at the Prague Asterix Laser System (AS CR) are presented. Advantages and limitations of the used diagnostic system are discussed.

Adverse myocardial effects of B-vitamin therapy in subjects with chronic kidney disease and hyperhomocysteinaemia

BACKGROUND & AIMS

Hyperhomocysteinaemia (HHCY), a common finding in patients with chronic kidney disease (CKD), has been shown to contribute to adverse cardiac remodelling and failure. We hypothesised that in human subjects with CKD, HHCY would be associated with myocardial dysfunction, and that homocysteine (HCY)-lowering therapy would improve myocardial remodelling and heart-failure (HF) outcomes.

METHODS AND RESULTS

Post hoc analysis of the Homocysteinemia in Kidney and End Stage Renal Disease (HOST) trial (n=2056) was performed to determine if HCY-lowering therapy with high dose B vitamins affects HF outcomes in patients with CKD. In addition, effects on myocardial remodelling were assessed in a subgroup of 220 trial subjects who had transthoracic echocardiograms done before study randomisation and during the course of the study as part of their routine clinical care. HF outcomes were not significantly affected by treatment compared to the placebo. HCY levels were inversely correlated with diastolic function (R=-0.21; p=0.038). Vitamin therapy resulted in a significant increase in left atrial size (+0.15±0.8 cm vs. -0.13±0.07 cm; p=0.0095). No other echocardiographic parameters were significantly associated with baseline HCY levels or changes with vitamin therapy.

CONCLUSION

HHCY is associated with diastolic dysfunction in patients with CKD. However, B-vitamin therapy did not improve HF outcomes despite lowering of plasma HCY levels, and was associated with an increase in left atrial size, which is a surrogate for worsening left ventricular diastolic dysfunction. These findings suggest that high-dose B vitamin therapy may be harmful in patients with CKD.