Low-dose aspirin and racial disparities in spontaneous preterm delivery in low-risk individuals

BACKGROUND

Preterm birth is a leading cause of perinatal morbidity and mortality. There are significant racial disparities in the rates of preterm delivery in the United States, with Black individuals at disproportionately higher risk than their White counterparts. Although low-dose aspirin is currently under investigation for reducing the rates of preterm delivery, limited data are available on how the use of low-dose aspirin might affect racial and ethnic disparities in the rates of preterm delivery.

OBJECTIVE

Our group and others have shown that low-dose aspirin decreases spontaneous preterm delivery in low-risk parturients. This study aimed to examine whether the relationship between low-dose aspirin and the risk of spontaneous preterm delivery is modified by race and ethnicity.

STUDY DESIGN

This was a secondary analysis of a randomized clinical trial examining low-dose aspirin for preeclampsia prevention in low-risk nulliparous individuals. The parent trial defined low risk as the absence of preexisting hypertension or other medical comorbidities. Participants received 60-mg aspirin or placebo between 13 and 25 weeks of gestation. Here, multiple pregnancies, fetal anomalies, terminations or abortions at <20 weeks of gestation, and participants with previous miscarriages were excluded. Our exposure, race and ethnicity, was self-reported in the parent trial and categorized as non-Hispanic White, Hispanic, non-Hispanic Black, and other. The primary outcome was spontaneous preterm delivery at <34 weeks of gestation; the secondary outcomes included spontaneous preterm delivery at <37 weeks of gestation and all preterm deliveries at <34 and <37 weeks of gestation. Fit logistic regression models were used to examine how the use of low-dose aspirin modified the relationship between race and ethnicity and preterm delivery, adjusting for confounders. Furthermore, sensitivity analyses were performed to compare the rates of preterm delivery by race and ethnicity.

RESULTS

Of note, 2528 of 3171 parent study participants were included in this analysis. Of the participants, 425 (16.8%) were White, 819 (32.4%) were Hispanic, 1265 (50%) were Black, and 19 (0.8%) were other. The baseline characteristics differed among racial and ethnic groups, including maternal age, body mass index, education level, marital status, tobacco and alcohol use, and pregnancy loss. The rate of spontaneous preterm delivery at <34 weeks of gestation was significantly higher in Black participants (2.8%) than in White (1.2%) and Hispanic (1.2%) participants (P=.04). Logistical regression analysis showed that Black race was no longer an independent risk factor for spontaneous preterm delivery at <34 weeks of gestation when controlling for low-dose aspirin (adjusted odds ratio, 1.71; 95% confidence interval, 0.67-4.40). A similar pattern was found for spontaneous preterm delivery at <37 weeks of gestation and preterm delivery at <34 and <37 weeks of gestation. In our sensitivity analyses, spontaneous preterm delivery at <34 weeks of gestation differed by race and ethnicity in the placebo group (P=.01) but did not differ in the low-dose aspirin group (P=.90).

CONCLUSION

The use of low-dose aspirin mitigated racial disparities in spontaneous preterm delivery at <34 weeks of gestation. Additional investigation is warranted to assess the reproducibility of our findings.

The Development of Normal Fetal External Genitalia Throughout Gestation

In this review, we describe normal development of fetal genitalia throughout gestation as well as the identification of normal male and female genitalia on ultrasound. We use abnormal and ambiguous genitalia as illustrative tools to assist with the identification of normal genitalia and recognition of some of the most common abnormalities in external genitalia development.

Jurisdictional Coordination of Integrated HIV Prevention and Patient Care Planning and Implementation

Jacksonville, Florida, provides services to persons living with the HIV. A federal call for integrated HIV prevention and treatment was published on June 19, 2015. This study unveils the principles that guided the local response to that call. Service providers have not systematically engaged in strategic planning for system improvement, the absence of which defines the boundaries and properties of the service system. Integration requires a unifying strategy as it draws leaders from their respective silos. Directed leadership, community-based participatory research, and action research provided a science-based framework for integration. Quantitatively, one-third of the planning implementation journey has elapsed, and 46% of the 75 planned activities have either reached fulfillment or are ongoing. Another one-fourth is in progress and slightly more than one-fourth (28%) are pending. Qualitatively, this study recorded 7 system-level changes. Progress to date is a harbinger of future system-level changes.

Utility of preoperative laboratory evaluation in low-risk patients undergoing hysterectomy for benign indications

OBJECTIVE

To evaluate whether preoperative laboratory tests are predictive of surgical complications in the first 30 days after benign hysterectomy.

STUDY DESIGN

Data was collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) of patients undergoing benign hysterectomy between 2014 and 2016. Patients with significant medical comorbidities were excluded except for current smoking and hypertension. Patients were stratified into those who did and did not undergo preoperative testing. Laboratory results were stratified into normal and abnormal values. The primary outcome was the composite complication rate between groups. Student'st-test, Fisher's exact test, and Wilcoxon Rank-Sum were used for statistical analysis where appropriate. Multivariable regression analysis was used to determine which variables were independently predictive of postoperative complications.

RESULTS

A total of 24,752 patients met all inclusion criteria. Of these, 92.5% had at least one preoperative test performed, and out of those 33.5% had an abnormal value. The most common test performed was a complete blood count, 92.5%, and the least common were coagulation studies, 16.1%. Patients who underwent testing were younger (45.9 vs 47.8 years, p < 0.001), more likely to smoke (15.3% vs 12.7%, p = 0.004) and less likely to have hypertension (18.9% vs 21.8%, p = 0.001). The most common abnormality was a low hematocrit, and the least common anomaly was an elevated international normalized ratio. The total complication rate was 9.2%, and there were no differences between groups (p = 0.07). The only lab value associated with an increased risk of complications was a hematocrit less than 34.9% (aOR 2.74, 95%CI 2.92-3.79) and WBC count >11 thousand per microliter (aOR 2.11, 95%CI 1.53-3.09).

CONCLUSION

Non-hematologic preoperative laboratory anomalies are uncommon in healthy women undergoing benign hysterectomy by any modality and furthermore non-hematologic abnormalities are not predictive of post-operative complications. On the other hand, hematologic abnormalities are fairly common and a WBC above 11 cells per uL and hematocrit below 34.9% are predictive of postoperative complications.

Self-esteem, behavior, and concerns surrounding epilepsy in siblings of children with epilepsy

Researchers document the emotional impact of epilepsy on the child with seizures. Minimal data are available examining the effects of epilepsy on the siblings of children with seizures. Twenty children whose siblings had either frequent seizures or infrequent seizures were matched by age, gender, and birth order to control subjects with no chronic illness. These three groups were compared. Self-esteem, behavioral and social functioning, and family stress were measured by the Piers-Harris Self-Concept Scale, Child Behavior Checklist, and Family Inventory of Life Events. The siblings of children with epilepsy completed the Sibling Concern About Seizure Scale to define and measure their concerns surrounding epilepsy. There is no statistical difference in self-esteem or social functioning among the three groups. There is a trend toward increased incidence of externalizing behavior in siblings of children with frequent seizures. Data indicate a trend toward siblings of children with frequent seizures having more concerns about epilepsy than siblings of children with infrequent seizures. There is significantly more stress in families of children with frequent seizures compared to families of children with infrequent seizures and families of children with no chronic illness. Although there were no significant differences in the self-esteem, behavior, socialization, and concerns between the siblings in the family when compared to the control group or to each other, there were trends in the results that may be of clinical significance. These issues, along with the level of family stress, should be considered when coordinating and providing care to families of children with intractable epilepsy.

Health care management of children with cognitive and physical disabilities: to treat or not to treat

Advanced medical technology has provided life support and maintenance for high risk infants. In dramatically increasing numbers, children surviving aggressive intervention as neonates and infants suffer from varying degrees of physical and mental disability. Once these children are stable and grow older difficult medical intervention decisions need to be made. As nurses, we are often in situations involving difficult treatment decisions made by the family and health care team. We need to be aware of our personal beliefs and ethical principles to effectively support family members and participate in decision making. Ethical principles serve as a guide to the decision making process.

Sexuality and related issues in the preadolescent and adolescent female with epilepsy

Multiple resources for the adult female with epilepsy are noted in the literature. Topics covered include pregnancy, epilepsy, contraception, anticonvulsant medications and issues of sexuality. Adolescence is a time of physiological and psychosocial change. The adolescent faces the usual challenges of this life stage along with the added stress of issues surrounding epilepsy. There is minimal information available for and about adolescents with epilepsy.

Treatment of nonepileptic psychogenic events in adolescent patients using the systems model for intervention

Nonepileptic psychogenic events in children, adolescents and adults can be difficult to treat. Using a systems framework intervention method resulted in significant reduction in nonepileptic psychogenic events. This method provides for a continuous flow of interaction, feedback and modification among the health care team, family and community. Common goals and plans are defined and implemented with a mechanism for feedback and modification. Using a systems model approach in educating the caregivers resulted in immediate and long-term reduction in nonepileptic psychogenic events.