A Cross-Sectional Study Examining Differences in Indication for Cesarean Delivery by Race/Ethnicity

(1) Background: There are persistent racial/ethnic disparities in cesarean delivery in the United States (U.S.), yet the causes remain unknown. One factor could be provider bias. We examined medical indications for cesarean delivery that involve a greater degree of physician discretion (more subjective) versus medical indications that involve less physician discretion (more objective) to better understand factors contributing to the higher rate among Micronesian, one of the most recent migrant groups in the state, compared to White women in Hawai‘i. (2) Methods: A retrospective chart review was conducted to collect data on 620 cesarean deliveries (N = 296 White and N = 324 Micronesian) at the state’s largest maternity hospital. Multivariate regression models were used to examine associations between maternal and obstetric characteristics and (1) subjective indication defined as non-reassuring fetal heart tracing (NRFHT) and arrest of labor disorders, and (2) objective indication defined as all other indications (e.g., malpresentation). (3) Results: We found that Micronesian women had significantly higher odds of cesarean delivery due to a subjective indication compared to White women (aOR: 4.17; CI: 2.52-6.88; P < 0.001; N = 619) after adjusting for multiple covariates. (4) Conclusion: These findings suggest unmeasured factors, possibly provider bias, may influence cesarean delivery recommendations for Micronesian women in Hawai‘i.

Perspectives and Experiences of Obstetricians Who Provide Labor and Delivery Care for Micronesian Women in Hawai'i: What Is Driving Cesarean Delivery Rates?

Access to cesarean delivery is vital for quality obstetrical care, but the procedure can increase maternal mortality, morbidity, and complications in subsequent deliveries. The objective of this study was to describe obstetrician-gynecologists' (OB-GYNs) perspectives on labor and delivery care for Micronesian women in Hawai'i and possible factors contributing to higher cesarean delivery rates among that racial/ethnic group. The Framework Method guided the analysis of 13 semi-structured interviews with OB-GYNs. Study results indicated that OB-GYNs were more likely to attribute racial/ethnic differences in mode of delivery to challenges resulting from nonmedical factors, particularly communication and negative attitudes toward Micronesian patients, than to medical risk factors. In this study, we explored aspects of care that cannot be captured in medical charts or clinical data, but may impact health outcomes for this population. The findings could help improve care for Micronesian women, with lessons applicable to other racial/ethnic minority groups.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

FRI0450 MEASURES OF DISEASE SEVERITY PREDICT DISABILITY AND QUALITY OF LIFE DIFFERENTLY IN RHEUMATOID ARTHRITIS AND CHRONIC CHIKUNGUNYA DISEASE

Background:

Chronic rheumatological manifestations similar to those of rheumatoid arthritis (RA) have been described after chikungunya virus infection. However, the clinical significance of the symptoms and disease severity in the two conditions has not been directly compared.

Objectives:

To compare, using identical measures of disease severity and patient outcomes, the impact of disease severity measures and symptoms on outcomes in RA and chronic chikungunya disease.

Methods:

Forty patients with chronic chikungunya arthralgia two years post-infection and 40 matched patients with RA were enrolled in Roraima, Brazil. Twenty-eight joints were assessed for tenderness and swelling, a pain intensity visual analogue scale, musculoskeletal stiffness questionnaire, modified Health Assessment Questionnaire and the EuroQol EQ5D-5L quality of life assessment were completed. The importance of the various measures of disease severity were analysed using Spearman’s rank correlation and regression analysis.

Results:

Tender and swollen joint counts, pain and stiffness were all predictive of the HAQ disability index in RA, but only stiffness was significantly associated with disability in chikungunya patients (Table 1). Tender and swollen joint counts, pain and stiffness were predictive for all EQ5D quality of life domains (except anxiety/depression) in RA patients. In contrast, in chikungunya disease, tender joint counts were predictive only of usual daily activities; pain was predictive of impaired mobility, self-care and discomfort, while stiffness was predictive for the mobility and anxiety/depression domains (Figure 1). Swollen joint counts were not associated with any of the patient outcomes in chikungunya disease. Linear regression analysis confirmed (p=0.003) that the effect of swollen joint count on the HAQ disability index depends on the underlying disease.

Table 1.

Association of disease severity with HAQ disability index in rheumatoid and CHIKV+ arthritis

Severity measureRheumatoid arthritisCHIKV+ arthritisr (p)r (p)Tender joint count0.56 (0.0002)0.24 (0.14)Swollen joint count0.60 (<0.0001)0.002 (0.99)Joint pain (VAS)0.55 (0.0002)0.29 (0.07)Stiffness severity0.57 (0.0001)0.38 (0.02)Figure 1.

Association of disease severity with quality of life domains in rheumatoid and CHIKV+ arthritis

Conclusion:

The value of all the disease severity measures tested in RA were confirmed, but tender joint counts may have more limited value in the assessment of chronic chikungunya disease. Joint swelling appears to have little impact for chikungunya patients, while stiffness appears to be an important metric to quantify chikungunya arthritis disease severity.

Disclosure of Interests:

Hugh Watson Shareholder of: Sanofi, Employee of: Sanofi, Ramão Luciano Nogueira-Hayd: None declared, Maony Rodrigues-Moreno: None declared, Felipe Naveca: None declared, Giulia Calusi: None declared, Richard Amdur: None declared, Karol Suchowiecki: None declared, Gary S. Firestein: None declared, Gary Simon: None declared, Aileen Chang: None declared

0303 Heart Rate and Systolic Blood Pressure Increase During Experimental Sleep Restriction

Introduction

Experimental sleep restriction is associated with elevated daytime cardiac activity, including heart rate (HR) and blood pressure (BP). However, some studies have found changes in systolic (SBP) but not diastolic blood pressure (DBP) or found changes in neither. Although findings are mixed, there may be a dose-response effect of cumulative sleep loss on daytime cardiac activity, such that HR and BP increase above basal levels with additional nights of insufficient sleep. This study examined changes in cardiac activity during experimental sleep restriction.

Methods

We used multilevel models with random effects for individuals to analyze data from 15 healthy males (M=22.3 years old, SD=2.8) in an 11-day inpatient protocol consisting of three nights of 10-hour/night baseline sleep opportunity, five nights of sleep restriction (5-hour/night sleep opportunity), and then two recovery nights (10-hour/night sleep opportunity). HR and BP were measured approximately every two hours during wake.

Results

HR increased 0.75 beats/minute with each successive night of sleep restriction (SE=0.18, p&lt;0.001). HR was 5.13 beats/minute higher during the recovery condition than during baseline or sleep restriction (SE=1.05, p&lt;0.001). During sleep restriction only, HR was lower in the later morning and evening compared to the earliest morning timepoint of the day, F(10, 743)=10.44, p&lt;0.001. SBP increased 0.33 mmHg following each successive night of sleep restriction (SE=0.16, p=0.041); however, SBP was only marginally higher during the sleep restriction condition than during baseline (b=1.90, SE=1.09, p=0.082).

Conclusion

Our findings suggest that HR and SBP increase with each additional day of experimental sleep restriction, even after accounting for diurnal effects on HR and SBP. HR did not recover to baseline levels following a night of recovery sleep, suggesting that longer recovery sleep may be necessary to recover from a week of sleep restriction.

Support

Grant UL1TR000127 (Chang PI), Clinical and Translational Science Institute; College of Health and Human Development at Pennsylvania State University.

0296 Less Self-Reported Alertness and Motivation During Sleep Restriction are Associated with Decreased Attentional Performance

Introduction

Some individuals demonstrate more performance decrements on the psychomotor vigilance task (PVT) after sleep restriction (SR). We investigated whether individuals who reported less alertness and/or less motivation after SR demonstrated poorer performance on the PVT.

Methods

Fifteen healthy men (22.3±2.8 years) participated in a 10-night inpatient protocol with three nights of 10-hour baseline time in bed (TIB), five nights of SR (5-hour TIB), then two recovery (10-hour TIB) nights. Participants completed the 10-minute PVT (Joggle Research® battery) approximately every two hours during wake. Outcomes included number of false starts (&lt;100 ms reaction time, RT) and number of lapses (≥500 ms RT). Participants reported alertness and motivation levels after each PVT. Median splits were used to characterize changes in alertness (“sleepy,” n=8, versus “alert,” n=7) and motivation (“unmotivated,” n=7, versus “motivated,” n=8) from the last day of baseline to the last day of SR. Outcomes were analyzed in mixed models with the predictor day*alertness or day*motivation, excluding the first three baseline days to preclude practice effects.

Results

There were significant interactions between day and alertness (p=.025) and day and motivation (p=.043) for false starts. False starts followed a quadratic inverted-U shape across days in sleepy (b=-0.16, p=.003) and unmotivated (b=-0.16, p=.004) participants, but not in alert or motivated participants (p&gt;.05). There was a significant interaction between day and alertness for lapses (p=.008); lapses followed a quadratic inverted-U shape across days with a stronger effect in sleepy (b=-0.43, p&lt;.001) versus alert (b=-0.15, p=.031) participants. There was no interaction between day and motivation for lapses.

Conclusion

Participants reporting less alertness were more likely to make both false starts and lapses after SR; those reporting less motivation were more likely to make false starts, but not lapses. Findings suggest greater motivation is sufficient to preserve inhibitory control but not vigilance after sleep restriction. In contrast, greater alertness despite sleep restriction was sufficient to preserve inhibitory control and resulted in lower vigilance decrements.

Support

This study was funded by grant UL1TR000127 from the Clinical and Translational Science Institute and the College of Health and Human Development at the Pennsylvania State University (Chang PI).

0085 Vulnerability to Sleep Restriction is Associated with Decreased Working Memory Performance

Introduction

We investigated whether individuals with more lapses on the psychomotor vigilance task (PVT) after sleep restriction (SR) demonstrated poorer working memory compared to those with fewer PVT lapses.

Methods

Fifteen healthy men (22.3±2.8 years) participated in a 10-night inpatient protocol with three nights of 10-hour baseline time in bed (TIB), five nights of SR (5-hour TIB), then two recovery (10-hour TIB) nights. Participants completed the Visual Object Learning Task (VOLT) and Fractal 2-Back (F2B; visual n-back) measuring working memory and the PVT (Joggle Research® battery) approximately every two hours during wake. During the VOLT, participants indicated whether presented images had been shown previously. Outcomes included number of misses and false alarms. During the F2B, participants tapped the screen when an image appeared that had been shown 2 images previously. Outcomes included sensitivity and specificity. Median split of mean PVT lapses after the last night of SR was used to categorize participants into “vulnerable” (n=8) versus “resistant” (n=7) groups. Outcomes were analyzed in mixed models with the predictor day*vulnerability, excluding the first three baseline days to preclude practice effects.

Results

There was a significant interaction between day and attentional vulnerability for VOLT misses (p&lt;.001); misses increased linearly across days in vulnerable (b=.18, p&lt;.001) but not resistant (p=.956) participants. There was no interaction between day and vulnerability for VOLT false alarms, which did not change across days. There was a significant interaction between day and attentional vulnerability for F2B sensitivity (p=.002); sensitivity increased linearly across days in resistant (b=.02, p&lt;.001) but not in vulnerable (p=.273) participants. There was no interaction between day and vulnerability for F2B specificity, which did not change across days.

Conclusion

Performance on the VOLT decreased in vulnerable participants only; performance on the F2B improved in resistant participants likely due to practice effects not seen in vulnerable participants. Findings indicate vulnerability to attentional lapses after SR is a marker of vulnerability to working memory decrements.

Support

This study was funded by grant UL1TR000127 from the Clinical and Translational Science Institute (Chang PI) and the College of Health and Human Development at the Pennsylvania State University.

Recruitment and retention of US South Asians for an epidemiologic cohort: Experience from the MASALA study

INTRODUCTION

There are few longitudinal studies about South Asians (SAs) and little information about recruitment and retention approaches for this ethnic group.

METHODS

We followed 906 SAs enrolled in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort for 5 years. Surviving participants were invited for a second clinical exam from 2015 to 2018. A new wave of participants was recruited during 2017-2018. We assessed the yields from different methods of recruitment and retention.

RESULTS

A total of 759 (83%) completed the second clinical exam, and 258 new participants were enrolled. Providing a nearby community hospital location for the study exam, offering cab/shared ride reimbursement, and conducting home visits were the most effective methods for enhancing retention. New participant recruitment targeted women and individuals with lower socioeconomic status, and we found that participant referrals and active community engagement were most effective. Mailing invitational letters to those identified by electronic health records had very low yield.

CONCLUSION

Recruitment and retention strategies that address transportation barriers and increase community engagement will help increase the representation of SAs in health research.