bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Effect Of Oral Anticoagulation Agents On Hemoglobin Levels in Reproductive Age Women [7D]
Authors: Gonzalez Aaron Herrera , Stough Alexandra , Palacio Danica , Palvia Vijay , Anasti James 
Published: April 2018

INTRODUCTION:
Oral anticoagulation in reproductive age women is not uncommon. Some studies have reported increased incidence of abnormal uterine bleeding and heavy menstrual bleeding in those receiving anticoagulation. However, studies comparing the effect of different oral anticoagulants on hemoglobin levels on menstruating women are lacking.

METHODS:
We retrospectively reviewed charts of reproductive age women on oral direct activated Factor X inhibitors (FXaI), vitamin K antagonist (vKa), or aspirin (ASA). Demographics and indication for anticoagulation were recorded. Hemoglobin before and 6 to 12 months after initiation of oral anticoagulation were recorded. Pre and post treatment hemoglobin values were compared using paired t-test for each individual anticoagulant and ANOVA was employed to compare initial Hemoglobin levels and pre and post treatment Hemoglobin differences.

RESULTS:
FXaI, vKa, ASA groups included 91, 73 and 68 patients, respectively. They did not differ in mean age (44.2 ± 6.2 yrs) or BMI (32.5 ± 8.1 kg/m2). Indications for FXaI were Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) (64/91), Atrial fibrillation (Afib) (8/91) or antiphospholipid syndrome(7/91). vKa was used for DVT/PE (28/73), stroke (12/73), or Afib (10/73). ASA indications included stroke (27/68), DVT/PE (11/68), or Factor V Leiden (10/68). Post treatment Hemoglobin values were less than 2% lower than pretreatment Hemoglobin levels in all groups. This was not clinically or statistically significant. Differences in Hemoglobin were similar between groups.

CONCLUSION:
There was no clinically significant decrease in Hemoglobin levels in menstruating women receiving oral anticoagulants at 6 to 12 months post initiation of oral anticoagulation.
Evaluation of Obstetric Telephone Triage: A Quality Improvement Project [14D]
Authors: Miller Michael , Magann Everett , Moody Heather , Schmidt Melissa , Butler Patricia , Lutgendorf Monica 
Published: April 2018

INTRODUCTION:
Obstetric telephone triage is commonly used when patients call with questions or seek advice for various medical concerns. Prompt and accurate telephone triage is imperative to ensure high quality and accessible care while maintaining healthcare efficiency. We sought to determine the current accuracy of obstetric telephone triage on a labor and delivery unit compared to a standardized obstetric telephone triage call center.

METHODS:
This is an approved quality improvement project. We collected telephone triage logs for patients calling Labor and Delivery. Calls were reviewed by experienced nurses from the ANGELS call center at the University of Arkansas using standardized obstetric triage algorithms. Differences were categorized by concordant advice vs. discordant advice/less urgent and discordant advice/more urgent.

RESULTS:
We reviewed 101 calls over a 3 month period. 55% were >34 weeks, 27% were 20-34 weeks, and 2% were <20 weeks gestational age. Caller complaints included: contractions (38%), discharge/bleeding (10%), leaking fluid (10%), decreased fetal movement (6%), fever/nausea/vomiting/diarrhea (4%), and other complaints (30%). Of these calls, 80% (n = 81) were assessed with concordant advice. Of the discordant advice calls, 9% (n = 9) were less urgent, and 8% (n = 8) were more urgent. Three records (3%) were not marked with a disposition in the telephone triage log book.

CONCLUSION:
In an L&D setting, 80% of documented telephone triage advice was concordant with standardized telephone triage protocols. This presents opportunity for education and standardized obstetric telephone triage protocols to improve patient care.
Effects of Weight Gain on Delivery Outcomes in an Obese Pregnant Population [17D]
Authors: Ratan Bani M. , Sellner Allison A. , Garbarino Abigail H. , Miao Di , Hollier Lisa M. 
Published: April 2018

INTRODUCTION:
The 2009 Institute of Medicine guidelines recommend 11-20 pounds weight gain for all pregnant women with a BMI ≥30. This study examines the effect of weight gain/loss on delivery outcomes in relation to class of obesity.

METHODS:
A retrospective cohort of 1,440 women receiving care at a large Medicaid clinic from 2013-2016 with pre-gravid BMI ≥30 was reviewed. Eligible women were non-smokers with a singleton pregnancy initiating care prior to 20 weeks. Multinomial logistic regression analysis compared gestational weight change to primary outcome of birth-weight percentile and secondary outcome of delivery type.

RESULTS:
Inclusion criteria were met by 889 women, with 485 in Class 1 (BMI 30-34.9), 218 in Class 2 (BMI 35-39.9), and 186 in Class 3 (BMI ≥40). Class 1 patients that lost weight were more likely to have a small-for-gestational-age (SGA) infant (P=.040) compared to Class 1 patients who had recommended weight gain. Class 2 and 3 patients had no statistically significant increase in SGA infants with weight loss or weight gain below recommendations. Class 2 patients that gained above recommendations were more likely to have a C-section during labor (P<.001) while Class 3 patients that gained above recommendations were more likely to have a scheduled C-section (P=.010).

CONCLUSION:
Class 2 and Class 3 mothers may benefit from less weight gain than current recommendations without increasing their risk of SGA infants. Further research is needed to ascertain if weight gain recommendations should be stratified based on obesity class.
Caesarean Sections in a National Referral Hospital in Addis Ababa, Ethiopia: Trends, Predictors and Outcomes [27D]
Authors: Kuzma Tamara 
Published: April 2018

INTRODUCTION:
The objective of this study was to analyze Caesarean section (CS) rate trends and maternal and perinatal outcomes in an Ethiopian hospital using Robson criteria groups and subdividing further based on urgency.

METHODS:
This was a retrospective study of deliveries at a national referral hospital between 2002/01/01 and 2006/13/05 (Ethiopian calendar) using cluster sampling of deliveries of gestational age ≥28 weeks. (N=4,816). Women were categorized into 10 Robson groups (RGs) with CS deliveries further classified by urgency. Perinatal mortality and neonatal distress rates were used to characterize perinatal outcomes. Maternal morbidity rate was used to characterize maternal outcomes.

RESULTS:
The total CS rate rose from 24.5% to 32.8% (p=0.001). The only RG showing a significant change in CS rate was RG1 (15.9% - 24.1%; p= 0.02), which experienced a 51% relative increase. RG1 contributed most to the total CS rate in all 5 years (7.8%), followed by RG3 and RG5. The “Scheduled” urgency subgroup was largest within the majority of RGs. Neonatal outcomes did not significantly change over time. Overall maternal morbidity rate increased from 3.5% to 4.1% (p=0.02).

CONCLUSION:
The threshold for medically indicated CS has decreased in this publicly funded hospital, especially in low-risk women. We did not see increased complications, but CS without medical indication can result in harm and strain on already limited resources. As primary CS rates increase, more women will require repeat CS. Evidence-based interventions to reduce primary and repeat CS should be studied and implemented at this Ethiopian hospital.
Non-invasive Prenatal Testing (NIPT): The Probability of a Redraw Following a No-call [6E]
Authors: Martin Kimberly A. , Demko Zachary , Benn Peter , Valenti Elizabeth , Shah Shailen , Hedriana Herman 
Published: April 2018

INTRODUCTION:
NIPT detects fetal aneuploidy with high accuracy provided the cell-free DNA fetal fraction (FF) is sufficient. For samples not receiving a result, referral for discussion of invasive testing has been suggested as the most appropriate “next step.” Alternatively, precise estimation of the success rate of a redraw NIPT sample could allow a more comprehensive discussion of management options between provider and patient.

METHODS:
We reviewed FF, maternal weight (MW), gestational age (GA), and the interval between draws (IBD) for 3,116 women whose initial single-nucleotide polymorphism (SNP)-based NIPT sample resulted in a no-call due to low FF and who submitted a second sample. Parameter correlations and redraw success rates were calculated.

RESULTS:
The overall redraw success rate was 63.4%. Initial FF and IBD were positively correlated, MW inversely correlated, and GA not correlated with redraw success. The average increase in FF between draws was 1.2%. Women with initial FF below 2%, between 2% and 3%, and above 3% had redraw success rates of <30%, 55%, and >70%, respectively. Women with <200 or >200 pounds MW had 78.3% and 54.7% redraw success rates, respectively. Over the first three weeks, the redraw success rate increased by approximately 15% per week.

CONCLUSION:
Women who do not receive a result on their SNP-based NIPT may have a good chance (>60%) for a successful redraw; further, waiting to redraw may increase the likelihood of redraw success. Women with high MW or especially low FF may benefit from referral for further evaluation and discussion of other options, including invasive testing.
Outcomes of Second-line Therapies for Stage 3 Postpartum Hemorrhage at a Tertiary Care Center [25E]
Authors: Clure Cara , Ernst Amanda , Vogel Rachel Isaksson , Bojan Katelyn , Das Kamalini 
Published: April 2018

INTRODUCTION:
Postpartum hemorrhage (PPH) remains a major worldwide cause of maternal morbidity and mortality. Second-line interventions including uterine tamponade, dilation and curettage, uterine artery embolization (UAE), compression or hemostatic sutures, or hysterectomy, are often required to manage severe PPH. Our study sought to evaluate the success rates and complications of second-line therapies used to treat stage 3 PPH, defined as an estimated blood loss of greater than 1500 mL by the California Maternal Quality Care Collaborative.

METHODS:
This retrospective cohort study examined all deliveries at a tertiary care center between 2007 and 2015 complicated by a stage 3 primary PPH. The timing, order, and success rates of interventions performed and the subsequent complications were evaluated. Complications examined included ICU admission, hemorrhagic shock, disseminated intravascular coagulopathy (DIC), and endometritis.

RESULTS:
Of 21,067 deliveries, 267 (1.26%) were complicated by stage 3 PPH. Second-line therapies were used in 116/267 (44%). The highest success rates were found with UAE (94%, n=18), compression sutures (73%, n=29) and balloon tamponade (72%, n=68). Patients undergoing dilation and curettage as an initial second-line management were most likely to require additional intervention (54%). Endometritis and DIC were the most common complications (8%). Endometritis was most common after successful treatment with compression sutures (29%). The use of multiple interventions was associated with a higher incidence of complications.

CONCLUSION:
For the treatment of severe PPH, the use of uterine tamponade and UAE have high success rates and low complication rates. Our results can help inform management of stage 3 PPH, as it is less standardized.
Decreasing Opiate Prescriptions on Labor and Delivery: An Exercise in Culture Change [38E]
Authors: Ulrich Nicole , Nakahara Angela , Gala Rajiv 
Published: April 2018

INTRODUCTION:
Louisiana is one of the worst states in regards to the opioid epidemic (average 98.1 prescriptions per 100 persons). We aimed to change the culture around opiate prescribing practices on Labor and Delivery with the goal of making this a system-wide initiative.

METHODS:
This QI project started with educating the prescribers, nurses, and patients about postpartum narcotic expectations. The primary outcome was patient initiated encounters for pain in the postpartum period (ED/office visits, phone calls, emails). Demographics and medication use were collected via chart review. Phone calls made 1-2 weeks after delivery included a short 5 question survey evaluating pain control satisfaction. Paired T-test was used to compare each of our 4 PDSA cycle outcomes to baseline data from the two months prior to cycle 1. We continued PDSA cycles until a plateau was reached.

RESULTS:
Baseline data from 192 patients were collected. The 4 PDSA cycles included 144 combined patients. There was no difference in the number of postpartum pain encounters after the prescribing changes (p=0.604). Amount of morphine milligram equivalents (MME) prescribed upon discharge significantly decreased (84% among patients with no lacerations, 64% in those with a first degree, and 79% in those with a second degree) (p<0.0001). Patients included in the PDSA cycles maintained very high satisfaction with pain control while hospitalized and after discharge.

CONCLUSION:
We demonstrated that we can significantly reduce the amount of narcotics introduced into our community without increasing postpartum encounters for pain or decreasing patient satisfaction.
Provision of the Contraceptive Implant for Adolescents Among Primary Care Residents [8M]
Authors: Hein Julie D. W. , Stoddard Amy M. 
Published: April 2018

INTRODUCTION:
The contraceptive implant is highly effective and safe for adolescents yet under-used by this population. Provision of the contraceptive implant should be within the scope of practice of primary care providers who care for teenagers, including pediatricians and family physicians. This study aims to assess the attitudes, knowledge, and provision of the contraceptive implant by pediatric and family medicine residents.

METHODS:
Researchers emailed a web-based survey to program directors or coordinators for 204 pediatric and 498 family medicine programs, with a request to forward the survey to residents in each program. Responses were recorded, and relationships between participants’ demographics, knowledge, and experience regarding contraceptive implants were assessed using chi-squared analyses.

RESULTS:
Among 665 participants, 81.2% recommended the contraceptive implant to adolescents, yet 73.2% had never inserted an implant in this population. 68.5% had received lectures and 52.0% had received hands-on training regarding contraceptive implants. Compared to pediatric residents, more family medicine residents had received lectures (80.1% vs 49.0%, P<.00001) and hands-on training (77.8% vs 19.2%, P<.00001). More family medicine residents had placed one or more implants than pediatric residents (40.5% vs 9.2%, P<.00001). Most participants correctly answered three knowledge-based questions about the contraceptive implant (66.0%, 72.5%, 85.6% correct). Reported setbacks to provision of contraceptive implants included lack of training or experience, lack of patient interest, and lack of implant availability at clinical sites.

CONCLUSION:
The provision of contraceptive implants for adolescents by primary care residents is low, particularly among pediatric residents. Primary care residency programs should focus more on contraceptive implant training.
Knowledge Assessment and Screening Barriers for Breast Cancer in the Arab American Community [17M]
Authors: Ayyash Mariam , Blackwood R. Alexander , Hassouneh Samar , Hamade Hiam , Ayyash Marwa , Bahroloomi Sheena 
Published: April 2018

INTRODUCTION:
Breast cancer is the most common malignancy afflicting women, with an estimated 1 out in 8 U.S. women diagnosed during their lifetime. Screening for breast cancer can reduce mortality through early cancer detection. Lack of knowledge is an important barrier leading to low screening rates. Given that the Arab American population has grown approximately 47% since 2000, this study was designed to assess breast cancer knowledge and screening barriers in an Arab American community.

METHODS:
Following (Not Regulated/Exempt) determination by the Institutional Review Board (Michigan) a survey was distributed through ACCESS, Arab Community Center for Economic and Social Services, in Dearborn, MI.

RESULTS:
175 Arab American adults participated in the study: 100 healthy women, 50 breast cancer women survivors and 25 healthy men. Deficiencies were noted in knowledge around cancer presentation and racial and ethnic differences in relative risk of disease. 72% of healthy women had a high level of knowledge, compared to 58% in survivors and 48% in men. Additionally we noted that 56% of healthy women controls over the age of 40 have not had a screening mammogram in the past 2 years with leading causes being: lack of health insurance, absence of family history and absence of symptoms.

CONCLUSION:
With the growing presence of Arabs in American communities, it is important that local physicians are aware in their medical knowledge gap to better serve this population. This study highlights some of these deficiencies especially the failure to adequately educate patients and their families while they are going through treatment.
Cervical Cancer Attitudes and Prevention in Rural Nicaragua [20M]
Authors: Wood Nicole , Pargas Anaisy , Romero Stephanie 
Published: April 2018

INTRODUCTION:
In Nicaragua, cervical cancer is the leading cause of cancer-related deaths, with an estimated 18.43 deaths per 100,000 females in 2011. Prevention of cervical cancer is largely dependent on Pap testing; however, access is difficult in many Latin American countries due to limited health education and socioeconomic and cultural barriers. The objective of this study was to evaluate the epidemiology and perceptions regarding cervical cancer prevention and awareness in a rural Hispanic community.

METHODS:
Investigators evaluated a rural Nicaraguan community’s perceptions of HPV, Pap tests, and cervical cancer, measured through survey (n=40). A chart review was performed at the main local clinic, which addresses the majority of women’s health needs for the population, in order to gauge baseline community Pap test adherence and cervical cancer rates (n=564).

RESULTS:
Preliminary survey data found that 82% of women had previous knowledge of HPV, but basic questions about the disease were answered incorrectly greater than 50% of the time. Baseline chart review data indicated that 88.3% of eligible women had no Pap test data on file, and of those that did, 3% had an abnormal result possibly indicative of malignancy.

CONCLUSION:
The collected data indicates a significant deficit in both knowledge regarding cervical cancer and complete screening coverage in this community. Based on these findings, increased community health promotion would be valuable to educate women in prevention strategies and encourage greater Pap testing rates.
Shoulder Dystocia Simulation Training Improves Attending Physician Communication and Technical Skills [32M]
Authors: Chuang Meleen , Lee Yuo-yu , Friedman Frederick , Frieden Faith , Atallah Fouad , Bernstein Peter 
Published: April 2018

INTRODUCTION:
Simulation has been widely adopted for resident training. The purpose of this study was to determine if an innovative shoulder dystocia simulation training program for attending physicians can improve performance.

METHODS:
Five academic medical centers with the same malpractice insurance company mandated all attending physicians to complete standardized simulation training for the management of shoulder dystocia. Baseline and post-training performance of communication and technical skills were compared in the simulated environment.

RESULTS:
288 attending physicians completed simulation training between 4/1/2016-6/22/2017. Most participants were female (69%) and had >11 years of experience (63%). Improvements in provider communication were noted in the following areas: Instructs patient (52.6% to 77.9%, P<0.001), provides explanation (49.1% to 84.2%, P<0.0001), notes time (26.7% to 47%, P<0.0001), requests rapid response (81.2% to 97%, P>0.0001), and calls for: Nursing (72.6% to 92.6%, P<0.0001), Pediatrics (70.5% to 93.7%, P<0.0001), Second OB (73.3% to 92.6%, P<0.0001), and Anesthesia (64.9% to 92.3%, P<0.0001). Provider performance of maneuvers were also noted to improve: McRobert's (93.7% to 97.5% P=0.0266), suprapubic pressure (63.2% to 93.9%, P<0.0001), rotational maneuvers (71.5% to 90.5%, P<0.0001), and posterior arm delivery (59.6% to 89.4%, P<0.0001). Significant improvements were also seen with the trainer's overall assessment of the provider's management of the emergency (66% to 95.1% P<0.0001).

CONCLUSION:
A simulation program for shoulder dystocia can improve attending performance in caring for this infrequent obstetric emergency. What remains to be demonstrated is whether this will translate into improved patient outcomes.
Therapist Guided Exposure Treatment for Vaginismus: Simulation and Immersive Learning Applications [36M]
Authors: Solone Michelle , Lynd Kelsey , Williams Katherine E. , May Margaret , Nemecek Pamela , Weitlauf Julie 
Published: April 2018

INTRODUCTION:
Efficacious and cost-efficient non-pharmacologic treatments, i.e., therapist guided exposure therapy for penetration disorders (GET-PEN), are available and in widespread use outside of the U.S. While therapists commonly provide guided desensitization therapy for other phobias, the GET-PEN treatment has not yet been implemented within the U.S.- largely due to a lack of medical education and training opportunities and appropriate supervisory resources. Simulation based immersive learning techniques may offer an innovative mechanism for bridging this educational gap.

METHODS:
We developed a brief simulation-based/immersive learning protocol designed to train a cohort of interdisciplinary teams (i.e., gynecology + mental health) to correctly implement GET-PEN. Next, we piloted this training protocol with our selected clinical teams who then implemented the protocol with professional simulators (PSs). All teams were evaluated on the implementation of GET-PEN by an international team of instructors. Three core outcomes were emphasized: self-efficacy for communicating with patients about sexual pain disorders, adherence to the treatment protocol, and quality of sexual education provided in response to PS’s questions.

RESULTS:
Teams showed significant pre-post training skill gains in communication self-efficacy (p < .05), quality of sexual education (p < .05), and fidelity ratings of > 85%. However, not all teams trained to adequate fidelity ratings at the same rate, and those that required additional training repeated the simulation to achieve proficiency.

CONCLUSION:
Simulation based/immersive learning techniques are an efficient mechanism for training interdisciplinary teams to implement GET-PEN. Our next steps include implementation and evaluation of this treatment in U.S. patients presenting with vaginismus.