Historical (retrospective) cohort studies and other epidemiologic study designs in perinatal research

Prenatal Cannabis Exposure and Executive Function and Aggressive Behavior at Age 5 Years

Importance

Cannabis use during pregnancy is increasingly common in the US and may affect the development and behavior of preschool-aged children.

Objective

To prospectively investigate the association of prenatal cannabis exposure with executive function and aggressive behavior at age 5 years.

Design, Setting, Participants

This cohort study was conducted from 2016 through 2020. Data analysis was conducted from 2022 through 2024. Patients aged 16 through 50 years who were able to communicate in English and intended to deliver at the Ohio State University Wexner Medical Center were enrolled in a pregnancy research repository. Participants (n = 355) who gave consent for future contact and whose child(ren) was presumed to be alive were invited to participate again at child age 5 years (children born May 25, 2010, through February 7, 2016) and 250 children participated (70%).

Exposure

Cannabis exposure was measured prospectively by urine toxicology, maternal self-report, and obstetric record abstraction.

Main Outcomes and Measures

Executive function and aggressive behavior, measured via multimodal assessment by staff masked to exposure status. Outcomes were chosen a priori.

Results

Of 250 children, 80 were exposed to cannabis (32%). Use of tobacco, other drugs, and alcohol during pregnancy was common (22% to 39% each). Most families were living in poverty. There were 155 children who were Black/African American, non-Hispanic (62%); 11 were Hispanic (4%); 34 indicated more than one race or another race, non-Hispanic (14%); and 50 were White, non-Hispanic (20%). Age-corrected standard scores for children's attention and inhibitory control (National Institutes of Health Toolbox) were about 0.4 SDs lower for those exposed to cannabis compared with unexposed (β = -6.1 points; 95% CI, -10.8 to -1.4), following propensity score weighting and adjustment for confounders. Exposed children also exhibited poorer task-based planning ability and more observed aggression. Caregiver ratings of executive function and behavior and laboratory assessments of other aspects of executive functioning showed no differences by exposure status.

Conclusions and Relevance

Results from this contemporary US cohort where prenatal cannabis exposure was common and indicated that exposed children exhibited some differences in aspects of executive function and behavior relevant to long-term academic success and adaptive functioning. These results may be considered in refining clinical recommendations regarding cannabis use during pregnancy.

Infection and Sepsis Trends during United States' Delivery Hospitalizations from 2000 to 2020

OBJECTIVE

 This study aimed to evaluate trends, risk factors, and outcomes associated with infections and sepsis during delivery hospitalizations in the United States.

STUDY DESIGN

 The 2000-2020 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of patients aged 15 to 54 with and without infection and sepsis were identified. Common infection diagnoses during delivery hospitalizations analyzed included (i) pyelonephritis, (ii) pneumonia/influenza, (iii) endometritis, (iv) cholecystitis, (v) chorioamnionitis, and (vi) wound infection. Temporal trends in sepsis and infection during delivery hospitalizations were analyzed. The associations between sepsis and infection and common chronic health conditions including asthma, chronic hypertension, pregestational diabetes, and obesity were analyzed. The associations between clinical, demographic, and hospital characteristics, and infection and sepsis were determined with unadjusted and adjusted logistic regression models with unadjusted odds ratio (OR) and adjusted odds ratios with 95% confidence intervals as measures of association.

RESULTS

 An estimated 80,158,622 delivery hospitalizations were identified and included in the analysis, of which 2,766,947 (3.5%) had an infection diagnosis and 32,614 had a sepsis diagnosis (4.1 per 10,000). The most common infection diagnosis was chorioamnionitis (2.7% of deliveries) followed by endometritis (0.4%), and wound infections (0.3%). Infection and sepsis were more common in the setting of chronic health conditions. Evaluating trends in individual infection diagnoses, endometritis and wound infection decreased over the study period both for patients with and without chronic conditions, while risk for pyelonephritis and pneumonia/influenza increased. Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Risks for adverse outcomes including mortality, severe maternal morbidity, the critical care composite, and acute renal failure were all significantly increased in the presence of sepsis and infection.

CONCLUSION

 Endometritis and wound infections decreased over the study period while risk for sepsis increased. Infection and sepsis were associated with chronic health conditions and accounted for a significant proportion of adverse obstetric outcomes including severe maternal morbidity.

KEY POINTS

· Sepsis increased over the study period for deliveries with and without chronic condition diagnoses.. · Endometritis and wound infection decreased over the study period.. · Infection and sepsis accounted for a significant proportion of adverse obstetric outcomes..

Immunomodulatory Treatment Versus Systemic Steroids in Inflammatory Choroidal Neovascularization Secondary to Idiopathic Multifocal Choroiditis

PURPOSE

To evaluate the influence of immunomodulatory therapy (IMT) on visual and treatment outcomes of inflammatory choroidal neovascularization (iCNV) in patients affected by multifocal choroiditis (MFC), and to compare them to patients treated with steroids as needed.

DESIGN

Multicenter retrospective matched cohort study.

METHODS

Patients affected by MFC with iCNV were divided into a IMT group and a "steroids as needed" group and matched according to the time between diagnosis and beginning of systemic treatment. Visual acuity (VA), number of anti-vascular endothelial growth factor (VEGF) intravitreal injections, and number of iCNV reactivations during 2 years of follow-up after treatment initiation were compared between the 2 groups.

RESULTS

A total of 66 eyes of 58 patients were included, equally divided into the 2 groups. Patients in the IMT group had a lower relative risk (RR) of iCNV reactivation (0.64, P = .04) and of anti-VEGF intravitreal injection retreatment (0.59, P = .02). Relapses of MFC-related inflammation were independently associated with a higher RRs of iCNV reactivation (1.22, P = .003). Final VA was higher in the IMT compared to the steroids as needed group (mean [SD], 69.1 [15.1] vs 77.1 [8.9] letters, P = .01), and IMT was associated with greater VA gains over time (+2.5 letters per year, P = .04).

CONCLUSIONS

IMT was associated with better visual and treatment outcomes in MFC complicated by iCNV compared to steroids as needed. The better outcomes of the IMT group and the association between MFC-related inflammation and iCNV reactivations highlight the need for tighter control of inflammation to prevent iCNV relapses and visual loss.

Association between onychomycosis and ulcerative complications in patients with diabetes: a longitudinal cohort study in Dutch general practice

INTRODUCTION

Diabetic foot ulcers are feared complications of diabetes mellitus (DM), requiring extensive treatment and hospital admissions, ultimately leading to amputation and increased mortality. Different factors contribute to the development of foot ulcers and related complications. Onychomycosis, being more prevalent in patients with diabetes, could be an important risk factor for developing ulcers and related infections. However, the association between onychomycosis and diabetic complications has not been well studied in primary care.

RESEARCH DESIGN AND METHODS

To determine the impact of onychomycosis on ulcer development and related complications in patients with diabetes in primary care, a longitudinal cohort study was carried out using routine care data from the Extramural Leiden University Medical Center Academic Network. Survival analyses were performed through Cox proportional hazards models with time-dependent covariates.

RESULTS

Data from 48 212 patients with a mean age of 58 at diagnosis of DM, predominantly type 2 (87.8%), were analysed over a median follow-up of 10.3 years. 5.7% of patients developed an ulcer. Onychomycosis significantly increased the risk of ulcer development (HR 1.37, 95% CI 1.13 to 1.66), not affected by antimycotic treatment, nor after adjusting for confounders (HR 1.23, 95% CI 1.01 to 1.49). The same was found for surgical interventions (HR 1.54, 95% CI 1.35 to 1.75) and skin infections (HR 1.48, CI 95% 1.28 to 1.72), again not affected by treatment and significant after adjusting for confounders (HR 1.32, 95% CI 1.16 to 1.51 and HR 1.27, 95% CI 1.10 to 1.48, respectively).

CONCLUSIONS

Onychomycosis significantly increased the risk of ulcer development in patients with DM in primary care, independently of other risk factors. In addition, onychomycosis increased the risk of surgeries and infectious complications. These results underscore the importance of giving sufficient attention to onychomycosis in primary care and corresponding guidelines. Early identification of onychomycosis during screening and routine care provides a good opportunity for timely recognition of increased ulcer risk.

Trends in and outcomes of delivery hospitalizations with lupus and antiphospholipid syndrome

OBJECTIVE

To assess trends and outcomes associated with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) during US delivery hospitalizations.

STUDY DESIGN

The National Inpatient Sample from 2000 to 2019 was used for this repeated cross-sectional analysis. We identified delivery hospitalizations with and without SLE. Temporal trends in SLE during delivery hospitalizations were determined using joinpoint regression. Adjusted logistic regression models accounting for demographic, clinical, and hospital factors were used to determine adjusted odds ratios (aORs) for adverse outcomes based on the presence or absence of SLE.

RESULTS

Of an estimated 76 698 775 delivery hospitalizations identified in the NIS, 79386 (0.10%) had an associated diagnosis of SLE. Over the study period, SLE increased from 6.7 to 14.6 cases per 10 000 delivery hospitalizations (average annual percent change 4.5%, 95% CI 4.0-5.1). Deliveries with SLE had greater odds of non-transfusion severe morbidity (aOR 2.21, 95% CI 2.00, 2.44) and underwent a larger absolute increase in morbidity risk over the study period. SLE was associated with a range of other adverse outcomes including preterm delivery, eclampsia, cesarean delivery, and blood transfusion.

CONCLUSION

The proportion of deliveries to women with SLE has increased over time in the US, and SLE and APS are associated with a broad range of adverse outcomes.

Performance of tunnelled, non-cuffed central venous catheters in infants: A scoping review

AIM

To summarise and critique existing knowledge and evidence relating to the utility, and post-insertion complications surrounding tunnelled non-cuffed central venous catheters (tncCVCs) in infants.

METHODS

A scoping review of original research studies reporting the use of, and post-insertion complications associated with, tncCVCs in infants was completed. MeSH terms were used to formulate a systematic search, and data were extracted using a customised data extraction form. Data were analysed descriptively across key themes based on the research questions. Study quality was evaluated using the Mixed Methods Appraisal Tool.

RESULTS

The systematic search generated 3994 studies, of which 9 studies met final inclusion criteria. Studies included 644 tncCVCs in infants based in the USA, Europe and Australia. Most studies were retrospective cohort studies. The most common vein of insertion, where individually specified, was the internal jugular (n = 177). Tunnel length, where reported, was 2.5-5 cm. Infection rates were most commonly reported (eight studies), with results ranging from 0 to 12.8%, and device dislodgements of up to 20% reported. Participant follow-up and definition of complications varied greatly between studies. Study quality across all papers was sound.

CONCLUSIONS

This review has identified only a small number of studies, with small participant numbers, reporting the performance of tncCVCs in infants. Definitions of complications measured varied significantly between studies, and vastly different patient follow-up protocols were reported. Further larger-scale studies on the performance of tncCVC, employing internationally recognised reporting standards is warranted to ensure clinicians can make informed choices for medication and infusion delivery.

Clinical Outcomes of Unicompartmental Knee Arthroplasty in Patients with Full-versus Partial-Thickness Cartilage Loss: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of the study was to compare postoperative patient-reported outcomes and reoperation rates following unicompartmental knee arthroplasty (UKA) between patients with full-thickness cartilage loss (FTCL) and partial-thickness cartilage loss (PTCL).

DESIGN

Multiple databases, including PubMed, Embase, Cochrane Library, and CNKI, were searched until October 2019 for studies comparing the Oxford Knee Score (OKS), American Knee Society (AKS) score, and reoperation rates between patients with FTCL and PTCL following UKA. Data analysis was performed using Review Manager software.

RESULTS

A total of 613 UKA cases from 5 retrospective cohort studies were included. The mean difference in postoperative OKSs was significantly higher by 2.92 in FTCL group than in PTCL group (95% confidence interval [CI] = -5.29 to -0.55; P = 0.02). Improvement in OKS was significantly higher by 2.69 in FTCL group than in PTCL group (95% CI = -4.79 to -0.60; P = 0.01). However, the differences in OKSs were not clinically significant. The mean difference in AKS knee scores was similar between the 2 groups (95% CI = -9.14 to -3.34; P = 0.36), whereas the pooled mean difference in AKS function scores was higher by 5.63 in FTCL group than in PTCL group (95% CI = -9.27 to -1.98; P = 0.002), which was clinically relevant. The reoperation rates were statistically higher in PTCL group than in FTCL group (odds ratio = 2.24; 95% CI = 1.15 to 4.38; P = 0.02).

CONCLUSIONS

Patients with FTCL achieved superior postoperative patient-reported outcomes and lower reoperation rates following UKA compared with those with PTCL. Thus, we believe this procedure should only be applied to end-stage medial osteoarthritis of the knee joint.

Opioid Use Disorder and Overdose in the First Year Postpartum: A Rapid Scoping Review and Implications for Future Research

OBJECTIVE

Opioid overdose is a leading cause of maternal mortality, yet limited attention has been given to the consequences of opioid use disorder (OUD) in the year following delivery when most drug-related deaths occur. This article provides an overview of the literature on OUD and overdose in the first year postpartum and provides recommendations to advance maternal opioid research.

APPROACH

A rapid scoping review of peer-reviewed research (2010-2021) on OUD and overdose in the year following delivery was conducted in PubMed, PsycINFO, and Web of Science databases. This article discusses existing research, remaining knowledge gaps, and methodological considerations needed.

RESULTS

Seven studies were included. Medication for OUD (MOUD) was the only identified factor associated with a reduction in overdose rates. Key literature gaps include the role of mental health disorders and co-occurring substance use, as well as interpersonal, social, and environmental contexts that may contribute to postpartum opioid problems and overdose.

CONCLUSION

There remains a limited understanding of why women in the first year postpartum are particularly vulnerable to opioid overdose. Recommendations include: (1) identifying subgroups of women with OUD at highest risk for postpartum overdose, (2) assessing opioid use, overdose, and risks throughout the first year postpartum, (3) evaluating the effect of co-occurring physical and mental health conditions and substance use disorders, (4) investigating the social and contextual determinants of opioid use and overdose after delivery, (5) increasing MOUD retention and treatment engagement postpartum, and (6) utilizing rigorous and multidisciplinary research methods to understand and prevent postpartum overdose.

Developing a triage predictive model for access to a spinal surgeon using clinical variables and natural language processing of radiology reports

PURPOSE

To utilize natural language processing (NLP) of MRI reports and various clinical variables to develop a preliminary model predictive of the need for surgery in patients with low back and neck pain. Such a model would be beneficial for informing clinical practice decisions and help reduce the number of unnecessary surgical referrals, streamlining the surgical process.

METHODS

A historical cohort study was conducted using de-identified data from patients referred to a spine assessment clinic. Various demographic, clinical, and radiological variables were included as potential predictors. Full-text radiology reports of patients' MRI findings were vectorized using NLP before applying machine learning algorithms to develop models predicting who underwent surgery. Outputs from these models were then entered into a logistic regression model with clinical variables to develop a preliminary model predictive of surgical recommendations.

RESULTS

Of the 398 patients assessed, 71 underwent spine surgery. NLP variables were significant predictors in univariate analysis but did not remain in the final logistic regression model. An outcome of receiving surgery was predicted by a primary symptom of low back and leg pain (adjusted odds ratio 2.81), distal pain indicated by a pain diagram (adjusted odds ratio 2.49) and self-reported difficulties walking (adjusted odds ratio 2.73).

CONCLUSION

A logistic regression model was created to predict which patients may require spine surgery. Simple clinical variables appeared more predictive than variables created using NLP. However, additional research with more data samples is needed to validate this model and fully evaluate the usefulness of NLP for this task.

Demographic trends associated with substance use disorder and risk for adverse obstetric outcomes with cannabis and opioid use disorders

BACKGROUND

Substance use disorders (SUDs) are increasing in the obstetric population, vary with demographic characteristics, and are associated with adverse pregnancy outcomes. Cannabis use disorder and opioid use disorder are two of the most common SUDs during pregnancy.

OBJECTIVE

This study had two objectives. The first objective was to assess trends in any SUD diagnosis during delivery hospitalizations from 2000 to 2018 by maternal age, ZIP code income quartile, and hospital location and teaching status. The second objective was to determine risk for adverse pregnancy outcomes during delivery hospitalizations specifically in the presence of cannabis and opioid use disorder diagnoses.

STUDY DESIGN

We conducted a serial cross-sectional analysis of the 2000-2018 National Inpatient Sample. Delivery hospitalizations to women aged 15-54 years with substance use disorder diagnoses were identified. SUD included (i) cannabis use disorder; (ii) opioid use disorder; (iii) alcohol use disorder; and (iv) other drug use disorder. We used joinpoint regression to estimate the average annual percent change (AAPC) in any substance use disorder diagnoses with 95% confidence intervals (CIs) by (i) ZIP code income quartile, (ii) hospital location and teaching status, and (iii) maternal age. We used unadjusted and adjusted log-linear regression to evaluate the relationship between cannabis use disorder and opioid use disorder several adverse maternal outcomes. We report unadjusted and adjusted risk ratios (aRRs) as measures of effect.

RESULTS

From 2000 to 2018, trends analyses broadly demonstrated increasing risk for SUD across demographic categories. In trends analyses stratified by ZIP code-income quartile, the proportion of deliveries with any SUD diagnosis increased across each income quartile with significant increases in the lowest income quartile (AAPC 4.6%, 95% CI 0.4%, 8.9%), second lowest quartile (AAPC 6.3%, 95% CI 5.3%, 7.4%), second highest quartile (AAPC 5.4%, 95% CI 4.1%, 6.8%), and highest quartile (AAPC 4.4%, 95% CI 2.1%, 6.8%). A larger increasing AAPC for SUD was present for deliveries in rural hospitals (AAPC 12.3%, 95% CI 9.8%, 14.9%) as compared to teaching (AAPC 5.7%, 95% CI 5.2%, 6.3%) and non-teaching urban hospitals (AAPC 7.0%, 95% CI 5.9%, 8.1%). By maternal age group, there was a significant larger AAPC for SUD for women aged 15-19 years (AAPC 8.5%, 95% CI 6.6%, 10.4%), 20-24 years (AAPC 9.0%, 95% CI 6.9%, 11.1%) and 25-29 years (AAPC 9.8%, 95% CI 9.1%, 10.6%) than women ≥30 years of age. Cannabis use disorder was associated with increased adjusted risk for preterm delivery (aRR 1.44, 95% CI 1.43, 1.45) and abruption and antepartum hemorrhage (aRR 1.77, 95% CI 1.75, 1.80). Opioid use disorder was associated with risk for non-transfusion severe maternal morbidity (aRR 1.73, 95% CI 1.67, 1.79), preterm delivery (aRR 1.75, 95% CI 1.74, 1.77), and abruption and antepartum hemorrhage (aRR 2.15, 95% CI 2.11, 2.19).

CONCLUSION

While substance use disorders are increasing in pregnancy across rural and urban settings, age groups, and income quartiles, several populations are associated with higher increased risks and trends. These findings support that SUDs are likely to continue to be of public health significance in diverse geographic and demographic settings.

Delivery outcomes associated with maternal congenital heart disease, 2000-2018

PURPOSE

To characterize temporal trends and outcomes of delivery hospitalization with maternal congenital heart disease (CHD).

MATERIALS AND METHODS

For this repeated cross-sectional analysis, deliveries to women aged 15-54 years with maternal CHD were identified in the 2000-2018 National Inpatient Sample. Temporal trends in maternal CHD were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. The relationship between maternal CHD and several adverse maternal outcomes was analyzed with log-linear regression models. Risk for adverse outcomes in the setting of maternal CHD was further characterized based on additional diagnoses of cardiac comorbidity including congestive heart failure, arrhythmia, valvular disease, pulmonary disorders, and history of thromboembolism.

RESULTS

Of 73,109,790 delivery hospitalizations, 51,841 had a diagnosis of maternal CHD (7.1 per 10,000). Maternal CHD rose from 4.2 to 10.9 per 10,000 deliveries (AAPC 4.8%, 95% CI 4.2%, 5.4%). Maternal CHD deliveries with a cardiac comorbidity diagnosis also increased from 0.6 to 2.6 per 10,000 from 2000 to 2018 (AAPC 8.4%, 95% CI 6.3%, 10.6%). Maternal CHD was associated with severe maternal morbidity (adjusted risk ratios [aRR] 4.97, 95% CI 4.75, 5.20), cardiac severe maternal morbidity (aRR 7.65, 95% CI 7.14, 8.19), placental abruption (aRR 1.30, 95% 1.21, 1.38), preterm delivery (aRR 1.47, 95% CI 1.43, 1.51), and transfusion (aRR 2.28, 95% CI 2.14, 2.42). Risk for severe morbidity (AAPC 4.7%, 95% CI 2.5%, 6.9%) and cardiac severe morbidity (AAPC 4.7%, 95% CI 2.5%, 6.9%) increased significantly among women with maternal CHD over the study period. The presence of cardiac comorbidity diagnoses was associated with further increased risk.

CONCLUSION

Maternal CHD is becoming more common among US deliveries. Among deliveries with maternal CHD, risk for severe morbidity is increasing. These findings support that an increasing burden of risk from maternal CHD in the obstetric population.

Trends and outcomes for deliveries with hypertensive disorders of pregnancy from 2000 to 2018: A repeated cross-sectional study

OBJECTIVE

To analyse trends, risk factors, and outcomes related to hypertensive disorders of pregnancy (HDP).

DESIGN

Repeated cross-sectional.

SETTING

US delivery hospitalisations.

POPULATION

Delivery hospitalisations in the 2000-2018 National Inpatient Sample.

METHODS

US hospital delivery hospitalisations with HDP were analysed. Several trends were analysed: (i) the proportion of deliveries by year with HDP, (ii) the proportion of deliveries with HDP risk factors and (iii) adverse outcomes associated with HDP including maternal stroke, acute renal failure and acute liver injury. Risk ratios were determined using regression models with HDP as the exposure of interest.

MAIN OUTCOME MEASURES

Prevalence of HDP, risk factors for HDP and associated adverse outcomes.

RESULTS

Of 73.1 million delivery hospitalisations, 7.7% had an associated diagnosis of HDP. Over the study period, HDP doubled from 6.0% of deliveries in 2000 to 12.0% in 2018. The proportion of deliveries with risk factors for HDP increased from 9.6% in 2000 to 24.6% in 2018. In adjusted models, HDP were associated with increased stroke (aRR [adjusted risk ratio] 15.9, 95% CI 14.8-17.1), acute renal failure (aRR 13.8, 95% CI 13.5-14.2) and acute liver injury (aRR 1.2, 95% CI 1.2-1.3). Among deliveries with HDP, acute renal failure and acute liver injury increased; in comparison, stroke decreased.

CONCLUSION

Hypertensive disorders of pregnancy increased in the setting of risk factors for HDP becoming more common, whereas stroke decreased.

TWEETABLE ABSTRACT

While hypertensive disorders of pregnancy increased from 2000 to 2018, stroke appears to be decreasing.

Outcomes during delivery hospitalisations with inflammatory bowel disease

OBJECTIVE

To characterise inflammatory bowel disease (IBD) trends and associated risk during delivery hospitalisations.

DESIGN

Cross-sectional.

SETTING

US delivery hospitalisations.

POPULATION

Delivery hospitalisations in the 2000-2018 National Inpatient Sample.

METHODS

This study analysed a nationally representative hospital discharge database based on the presence of IBD. Temporal trends in IBD were analysed using joinpoint regression to estimate the average annual percent change (AAPC). IBD severity was characterised by the presence of diagnoses such as penetrating and stricturing disease and history of bowel resection. Risks for adverse outcomes were analysed based on presence of IBD. Poisson regression models were performed with unadjusted and adjusted risk ratios (aRR) as measures of effect.

MAIN OUTCOME MEASURE

Prevalence of IBD and associated adverse outcomes.

RESULTS

Of 73 109 790 delivery hospitalisations, 89 965 had a diagnosis of IBD. IBD rose from 0.06% in 2000 to 0.21% in 2018 (AAPC 7.3%, 95% CI 6.7-7.9%). Among deliveries with IBD, IBD severity diagnoses increased from 4.1% to 8.1% from 2000 to 2018. In adjusted analysis, IBD was associated with increased risk for preterm delivery (aRR 1.50, 95% CI 1.47-1.53), severe maternal morbidity (aRR 1.93, 95% CI 1.83-2.04), venous thrombo-embolism (aRR 2.76, 95% CI 2.39-3.18) and surgical injury during caesarean delivery hospitalisation (aRR 5.03, 95% CI 4.76-5.31). In the presence of a severe IBD diagnosis, risk was further increased for all adverse outcomes.

CONCLUSION

IBD is increasing in the obstetric population and is associated with adverse outcomes. Risk is increased in the presence of a severe IBD diagnosis.

TWEETABLE ABSTRACT

Deliveries among women with inflammatory bowel disease are increasing. Disease severity is associated with adverse outcomes.

Deliveries Among Patients Aged 11-19 Years and Risk for Adverse Pregnancy Outcomes

OBJECTIVE

To characterize delivery hospitalization trends of patients aged 11-19 years and associated comorbidities and outcomes.

METHODS

For this repeated cross-sectional analysis, deliveries to patients aged 11-54 years were identified in the 2000-2018 National Inpatient Sample. Temporal trends in deliveries to patients aged 11-14 years and 15-19 years were analyzed using joinpoint regression to estimate average annual percent change with 95% CIs. The association of deliveries among patients aged 11-19 years with other comorbid conditions was analyzed. The relationship between delivery among patients aged 11-19 years and adverse maternal outcomes was analyzed with unadjusted and adjusted logistic regression models, with unadjusted and adjusted odds ratios (aORs) as measures of effect.

RESULTS

An estimated 73,198,153 delivery hospitalizations from 2000 to 2018 were included, of which 88,363 were to patients aged 11-14 years and 6,359,331 were to patients aged 15-19 years. The proportion of delivery hospitalizations among patients aged 11-14 years decreased from 2.1 to 0.4 per 1,000 from 2000 to 2018 (average annual percent change -7.8%, 95% CI -8.5% to -7.2%). Deliveries to patients aged 15-19 years decreased from 2000 to 2018, from 11.5% to 4.8% of all deliveries (average annual percent change -4.9%, 95% CI -5.6% to -4.3%). For deliveries among patients aged 11-19 years, rates of obesity, mental health conditions, substance use disorder, asthma, and pregestational and gestational diabetes all significantly increased over the study period. From 2000 to 2018, rates of severe maternal morbidity (average annual percent change 2.4%, 95% CI 1.6-3.1%), postpartum hemorrhage (average annual percent change 2.4%, 95% CI 1.4-3.4%), cesarean delivery (average annual percent change 1.3%, 95% CI 0.9-1.7%), and hypertensive disorders of pregnancy (average annual percent change 3.3%, 95% CI 2.8-3.8%) all increased significantly among deliveries to patients aged 11-19 years. Compared with deliveries to patients aged 20-54 years, deliveries to patients aged 11-14 years were associated with increased risk for severe maternal morbidity (aOR 1.73, 95% CI 1.49-2.00), hypertensive disorders of pregnancy (aOR 1.79, 95% CI 1.71-1.88), and postpartum hemorrhage (aOR 1.37, 95% CI 1.27-1.49).

CONCLUSION

Deliveries among patients aged 11-19 years have decreased, but both comorbidity and risk for adverse outcomes increased among this age group.

Accurate identification of cohort study designs in perinatal research: a practical guide

Study designs are often mischaracterized in the obstetrics literature; in particular, the designation of studies as retrospective (historical) cohorts is frequently in error to describe studies that are prospective cohorts. This is especially true for studies based on electronic health records, which often should be properly considered as prospective cohorts. Epidemiologic study designs were developed in earlier eras of research and healthcare when researchers directly contacted study participants or relied on data from paper medical records. Accordingly, standard epidemiologic study design definitions are difficult to apply to digitized data, which have become common in the modern era of healthcare and computing. In this article, we briefly review the characteristics of the 3 main types of cohort studies. Afterward, we build on existing definitions by proposing several subdesignations of prospective cohort studies that we believe will reduce the confusion in terminology. We provide illustrative examples from obstetrics to concretely demonstrate connections and distinctions among study designs. First, a prospective cohort study can be "active" (participants are deliberately and explicitly enrolled in a prospective research study) or "passive" (participants are followed up in real time for some nonresearch activity, such as clinical care or quality improvement). An active prospective cohort study never stops being a prospective cohort study; however, when reused to answer a new, secondary question, we propose that this should be called a "reused (active) prospective cohort." The de novo cohort study that answered the original question should be considered an "intended (active) prospective cohort." Lastly, when a randomized controlled trial is reused to study some new questions where the randomization variable is not under study, this is also a subtype of a prospective cohort study, a "repurposed randomized controlled trial." The use of more detailed descriptors to describe prospective cohort studies will enable more accurate identification of this study design going forward. It is likely that further refinements will be needed in the future, given the ongoing evolution of how we engage with patients or participants and how data are collected, stored, and linked.

Trends in and complications associated with mental health condition diagnoses during delivery hospitalizations

BACKGROUND

Mental health conditions during delivery hospitalizations are not well characterized.

OBJECTIVE

This study aimed to characterize the prevalence of maternal mental health condition diagnoses and associated risk during delivery hospitalizations in the United States.

STUDY DESIGN

The 2000 to 2018 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of women aged 15 to 54 years with and without mental health condition diagnoses, including depressive disorder, anxiety disorder, bipolar spectrum disorder, and schizophrenia spectrum disorder, were identified. Temporal trends in mental health condition diagnoses during delivery hospitalizations were determined using the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% confidence intervals. The trends in chronic conditions associated with mental health condition diagnoses, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, were analyzed. The association between mental health conditions and the following adverse outcomes was determined: (1) severe maternal morbidity, (2) preeclampsia or gestational hypertension, (3) preterm delivery, (4) postpartum hemorrhage, (5) cesarean delivery, and (6) maternal mortality. Regression models for each outcome were performed with unadjusted and adjusted risk ratios as measures of effects.

RESULTS

Of 73,109,791 delivery hospitalizations, 2,316,963 (3.2%) had ≥1 associated mental health condition diagnosis. The proportion of delivery hospitalizations with a mental health condition increased from 0.6% in 2000 to 7.3% in 2018 (average annual percent change, 11.4%; 95% confidence interval, 10.3%-12.6%). Among deliveries in women with a mental health condition diagnosis, chronic health conditions, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, increased from 14.9% in 2000 to 38.5% in 2018. Deliveries to women with a mental health condition diagnosis were associated with severe maternal morbidity (risk ratio, 1.88; 95% confidence interval, 1.86-1.90), preeclampsia and gestational hypertension (risk ratio, 1.59; 95% confidence interval, 1.58-1.60), preterm delivery (risk ratio, 1.35; 95% confidence interval, 1.35-1.36), postpartum hemorrhage (risk ratio, 1.37; 95% confidence interval, 1.36-1.38), cesarean delivery (risk ratio, 1.20; 95% confidence interval, 1.20-1.20), and maternal death (risk ratio, 1.31; 95% confidence interval, 1.12-1.56). The increased risk was retained in adjusted models.

CONCLUSION

The proportion of delivery hospitalizations with mental health condition diagnoses increased significantly throughout the study period. Mental health condition diagnoses were associated with other underlying chronic health conditions and a modestly increased risk of a range of adverse outcomes. The findings suggested that mental health conditions are an important risk factor in adverse maternal outcomes.

Trends in Venous Thromboembolism and Associated Risk Factors During Delivery Hospitalizations From 2000 to 2018

OBJECTIVE

To characterize trends in and risk factors for venous thromboembolism (VTE) during delivery hospitalizations in the United States.

METHODS

The 2000-2018 National Inpatient Sample was used for this repeated cross-sectional analysis. Venous thromboembolism (including deep vein thrombosis [DVT] and pulmonary embolism) during delivery hospitalizations for women aged 15 to 54 years was determined by year. Temporal trends in VTE were characterized using joinpoint regression with estimates presented as the average annual percent change. Temporal trends in common VTE risk factors were also analyzed. The proportion of vaginal and cesarean deliveries by year that had VTE risk factors was determined, and average annual percent changes with 95% CIs were calculated. The relationship between risk factors and the likelihood of VTE events was determined with adjusted and unadjusted logistic regression models.

RESULTS

Of 73,109,789 delivery hospitalizations, 48,546 VTE events occurred (6.6/10,000 deliveries), including 37,312 DVT diagnoses and 12,487 pulmonary embolism diagnoses. Rates increased significantly for vaginal (average annual percent change 2.5%, 95% CI 1.5-3.5%) but not for cesarean delivery hospitalizations (average annual percent change 0.3%, 95% CI -1.0 to 1.6%) over the study period. Pulmonary embolism increased for both vaginal delivery (average annual percent change 8.7%, 95% CI 6.0-11.5%) and cesarean delivery (average annual percent change 4.9%, 95% CI 3.6-6.2%). The proportion of cesarean deliveries with at least one VTE risk factor increased from 27.2% in 2000 to 43.6% in 2018 (average annual percent change 2.6%, 95% CI 2.2-3.1%) and for vaginal deliveries, from 17.7% to 31.4% (average annual percent change 3.4%, 95% CI 2.3-4.4%). The 5.9% of deliveries with at least two VTE risk factor diagnoses accounted for 25.4% of VTE diagnoses. Factors with the highest VTE risk included transfusion (adjusted odds ratio [aOR] 4.1, 95% CI 3.7-4.5), infection (aOR 5.8, 95% CI 5.3-6.3), history of VTE (aOR 7.2, 95% CI 6.2-8.4), and thrombophilias (aOR 9.6, 95% CI 8.5-11.0).

CONCLUSION

Both risk factors for VTE and rate of pulmonary embolism increased over the study period. Deep vein thrombosis increased during vaginal delivery hospitalizations but not during cesarean delivery hospitalizations.

Sigmoidoscopic extent of ulcerative colitis and associated factors in Pakistani population

OBJECTIVES

To determine the extent of ulcerative colitis and associated factors in patients who underwent sigmoidoscopy at Liver Center, Jail Road, Lahore, Pakistan.

METHODS

In this retrospective cohort study, patients who underwent sigmoidoscopy from July 2013 to July 2020 at Liver Clinic, Jail Road, Lahore, were categorized into two cohorts: who had ulcerative colitis confirmed on histology and who had no ulcerative colitis. Extent and severity of the disease as well as coexisting pathologies were also noted. SPSS version 25 was used. Independent sample T-test was applied to compare quantitative variables like age and weight, and chi-square test to compare qualitative variables with two cohorts. The p-value less than 0.05 was opted as significant. Odd ratio with 95% confidence interval (CI) were also computed for each association.

RESULTS

About 11.55% patients (165 out of 1428) had ulcerative colitis, whose mean age and mean weight were 38.27 ± 14.15 years and 74.08 ± 13.20 Kg respectively. Among ulcerative colitis patients, 18.2% had proctitis, 22.4% had proctosigmoiditis, 27.7% had left-sided colitis, and 31.5% had extensive colitis. May endoscopic severity score was found 0,1,2, and 3 in 12.1%, 23.6%, 31.5%, and 32.7% patients respectively. Ulcerative colitis cohort had significant association with younger age (p<0.01), female gender (p<0.01), non or former smoking (p=0.02) and presentation with bloody diarrhea (p<0.01), and no association with body weight (p=0.311), presence of diabetes mellitus (p=0.311) and family history of IBD (P=0.368).

CONCLUSION

Endoscopic extent and severity of ulcerative colitis is high in our studied population. Ulcerative colitis is more prevalent in younger age and female gender patients who presented with bloody diarrhea, while the presence of active smoking has negative association with finding the ulcerative colitis. However, presence of family history of IBD, diabetes mellitus and body weight of the patient has no statistical correlation with finding ulcerative colitis during sigmoidoscopic examination in our patients.

Trends in and Maternal Outcomes of Delivery Hospitalizations of Patients With an Asthma Diagnosis

OBJECTIVE

To characterize asthma prevalence and outcomes during U.S. delivery hospitalizations.

METHODS

For this repeated cross-sectional analysis, deliveries to women aged 15-54 years with asthma were identified in the 2000-2018 National Inpatient Sample, which approximates a 20% stratified sample of all hospitalizations nationally. Temporal trends in asthma were analyzed using joinpoint regression to estimate the average annual percent change with 95% CIs. The association of asthma with other comorbid conditions was analyzed. The relationship between asthma and several adverse maternal outcomes was analyzed with unadjusted and adjusted logistic regression models, with unadjusted odds ratios and adjusted odds ratios (aORs) as measures of effect. Risk for and trends in a composite of rare, but severe, respiratory complications also were analyzed.

RESULTS

An estimated 73,109,790 delivery hospitalizations from 2000 to 2018 were included in the analysis, of which 2,221,644 (3.0%) had a diagnosis of asthma. (Unweighted, the study sample included 15,213,024 deliveries, of which 462,276 [3.0%] had a diagnosis of asthma.) Asthma diagnoses rose from 1.2% in 2000 to 5.3% in 2018, representing an average annual percent change of 8.3% (95% CI 7.4-9.2%). Asthma was more common among women with obesity and chronic hypertension. In adjusted analyses, asthma was associated with severe maternal morbidity (aOR 1.50, 95% CI 1.45-1.55), preeclampsia and gestational hypertension (aOR 1.29, 95% CI 1.26-1.30), postpartum hemorrhage (aOR 1.21, 95% CI 1.19-1.24), cesarean delivery (aOR 1.16, 95% CI 1.15-1.18), gestational diabetes (aOR 1.20, 95% CI 1.18-1.21), venous thromboembolism (aOR 1.79, 95% CI 1.65-1.95), and preterm delivery (aOR 1.27, 95% CI 1.25-1.29). From 2000 to 2018, severe respiratory complications decreased from 72 per 10,000 deliveries with asthma to 14 per 10,000 deliveries with asthma (average annual percent change -9.4%, 95% CI -13.3% to -5.3%). This decreasing risk was offset on a population level by an increase in the risk of asthma.

CONCLUSION

Asthma is increasing during deliveries, is associated with adverse maternal outcomes, and is associated with comorbid conditions. Severe respiratory complications are decreasing proportionately among deliveries with asthma, but are stable on a population basis.

Delivery risks and outcomes associated with grand multiparity

BACKGROUND

There is limited recent US national data on risk for adverse outcomes associated with grand multiparity.

OBJECTIVE

To examine the association between grand multiparity and severe maternal morbidity (SMM) and other adverse outcomes during delivery hospitalizations in the United States.

METHODS

This repeat cross-sectional study evaluated delivery hospitalizations from 2000 through the third quarter of 2015 to women aged 15-54 in the National (Nationwide) Inpatient Sample database. Temporal trends in deliveries to women with grand multiparity were analyzed using the Cochran-Armitage trend test. The primary outcome studied was SMM, a composite of adverse outcomes defined by the Centers for Disease Control and Prevention. The exposure of interest was grand multiparity diagnosis during delivery hospitalization. Other adverse outcomes analyzed included placental abruption, preterm delivery, postpartum hemorrhage, disseminated intravascular coagulation, shock, hysterectomy, pulmonary edema and acute heart failure, transfusion of blood or blood products, hypertensive diseases of pregnancy, cesarean delivery, eclampsia, and acute renal failure. Log linear regression models were performed to determine the relationship between grand multiparity and adverse outcomes with measures of association demonstrated as unadjusted (RR) and adjusted risk ratios (aRR) with 95%CIs.

RESULTS

From 2000 to 2015, there were an estimated 62,672,862 hospital deliveries with 386,019 deliveries in the setting of grand multiparity. The number of deliveries with a grand multiparity diagnosis increased over the study period from 4.2 per 1000 deliveries in 2000 to 8.6 per 1000 in 2015 (p < .01). Women with grand multiparity were more likely to be older, have comorbidities, be Hispanic or non-Hispanic Black, be from a lower ZIP code income quartile, have Medicaid insurance, and present to an urban teaching hospital for delivery (p < .01 for all). On univariable analysis, grand multiparity was associated with SMM (RR 1.27, 95%CI 1.23-1.32). However, in adjusted analyses accounting for hospital, clinical, and demographic factors, women with grand multiparity were at lower risk of SMM (aRR 0.93, 95%CI 0.89, 0.96). On analysis of individual adverse outcomes, grand multiparity was associated with a higher risk of placental abruption (RR 1.28, 95%CI 1.24-1.31), preterm delivery (RR 1.17, 95%CI 1.16-1.18), postpartum hemorrhage (RR 1.30, 95%CI 1.28-1.32), disseminated intravascular coagulation (RR 1.23, 95%CI 1.16-1.31), shock (RR 2.50, 95%CI 2.20-2.85), hysterectomy (RR 3.20, 95%CI 3.30, 3.41), pulmonary edema and acute heart failure (RR 1.33, 95%CI 1.24-1.42), and transfusion of blood or blood products (RR 1.74, 95%CI 1.70-1.79). Conversely, grand multiparity was associated with a lower risk of hypertensive diseases of pregnancy (RR 0.85, 95%CI 0.84-0.86), cesarean delivery (RR 0.96, 95%CI 0.95-0.96), and eclampsia (RR 0.69, 95%CI 0.60-0.79). There was no significant association between grand multiparity and acute renal failure.

CONCLUSIONS

Delivery hospitalizations with a grand multiparity diagnosis were not associated with increased risk for SMM in adjusted analysis. Grand multiparity was associated with increased risk for hysterectomy and shock although absolute increased risk for these complications was small.

Racial and Ethnic Disparities in Peripartum Hysterectomy Risk and Outcomes

OBJECTIVE

This study aimed to determine whether race and ethnicity contribute to risks associated with peripartum hysterectomy.

STUDY DESIGN

This retrospective cross-sectional study utilized the 2000-2014 Nationwide Inpatient Sample to analyze risk of peripartum hysterectomy and associated severe maternal morbidity, mortality, surgical injury, reoperation, surgical-site complications, and mortality by maternal race and ethnicity. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, other, and unknown. Multivariable log-linear regression models including patient, clinical, and hospital risk factors were performed with adjusted risk ratios (aRRs) and 95% confidence intervals (CIs).

RESULTS

Of 59,854,731 delivery hospitalizations, there were 45,369 peripartum hysterectomies (7.6 per thousand). Of these, 37.8% occurred among non-Hispanic white, 13.9% among non-Hispanic black, and 22.8% among Hispanic women. In adjusted analyses, non-Hispanic black (aRR: 1.21, 95% CI: 1.17-1.29) and Hispanic women (aRR: 1.25, 95% CI: 1.22-1.29) were at increased risk of hysterectomy compared with non-Hispanic white women. Risk for severe morbidity was increased for non-Hispanic black (aRR: 1.25, 95% CI: 1.19-1.33), but not for Hispanic (aRR: 1.02, 95% CI: 0.97-1.07) women. Between these three groups, risk for intraoperative complications was highest among non-Hispanic white women, risk for reoperation was highest among Hispanic women, and risk for surgical-site complications was highest among non-Hispanic black women. Evaluating maternal mortality, non-Hispanic black women (RR: 3.83, 95% CI: 2.65-5.53) and Hispanic women (RR: 2.49, 95% CI: 1.74-3.59) were at higher risk than non-Hispanic white women.

CONCLUSION

Peripartum hysterectomy and related complications other than death differed modestly by race. In comparison, mortality differentials were large supporting that differential risk for death in the setting of this high-risk scenario may be an important cause of disparities.

KEY POINTS

· Peripartum hysterectomy and related complications differed modestly by race.. · Mortality differentials in the setting of peripartum hysterectomy were large.. · Failure to rescue may be an important cause of peripartum hysterectomy disparities..

Services and payer mix of Black-serving hospitals and related severe maternal morbidity

BACKGROUND

Black-serving hospitals are associated with increased maternal risk. However, prior administrative data research on maternal disparities has generally included limited hospital factors. More detailed evaluation of hospital factors related to obstetric outcomes may be important in understanding disparities.

OBJECTIVE

To examine detailed characteristics of Black-serving hospitals and how these characteristics are associated with risk for severe maternal morbidity (SMM).

METHODS

This serial cross-sectional study linked the 2010-2011 Nationwide Inpatient Sample and the 2013 American Hospital Association Annual Survey Databases. Delivery hospitalizations occurring to women 15-54 years of age were identified. The proportions of non-Hispanic Black patients within a hospital was categorized into quartiles, and hospital factors such as specialized medical, surgical and safety-net services as well as payer mix were compared across these quartiles. A series of models was performed evaluating risk for SMM with Black-serving hospital quartile as the primary exposure. Log linear regression models with a Poisson distribution (and robust variance) were performed with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CIs) as measures of effect.

RESULTS

Overall 965,202 deliveries from 430 hospitals met inclusion criteria and were included in the analysis. By quartile, non-Hispanic Black patients accounted for 1.3%, 5.4%, 13.4%, and 33.8% of patients. Many services were significantly less common in the lowest compared to the highest Black-serving hospital quartile including cardiac intensive care (48.9% versus 74.5%), neonatal intensive care (28.9% versus 64.9%), pediatric intensive care (20.0% versus 45.7%), pediatric cardiology (29.6% versus 44.7%), and HIV/AIDS services (36.3% versus 71.3%) (p≤0.01 for all). Indigent care clinics, crisis prevention, and enabling services (p≤0.01 for all) were more common at Black-serving hospitals as was Medicaid payer. Following adjustments for detailed hospital factors, the lowest Black serving hospital quartile carried the lowest risk for SMM. However, SMM risks were similar across the 2^nd (aRR 1.31, 95% CI 1.08, 1.59), 3^rd (aRR 1.27, 95% 1.05, 1.55), and 4^th (aRR 1.29, 95% CI 1.07, 1.55) quartiles.

CONCLUSION

Black-serving hospitals were more likely to provide a range of specialized medical, surgical, and safety-net services and to have a higher Medicaid burden. Payer mix and unmeasured confounding may account for some of the maternal risk associated with Black-serving hospitals.

The impact of the catheter to vein ratio on peripheral intravenous cannulation success, a post-hoc analyses

Background

Intravenous cannulation is usually the first procedure performed in modern healthcare, although establishing peripheral intravenous access is challenging in some patients. The impact of the ratio between venous diameter and the size of the inserted catheter (catheter to vein ratio, CVR) on the first attempt success rate can be of added value in clinical. This study tries to give insight into the consideration that must be made when selecting the target vein and the type of catheter, and proved the null hypothesis that an optimal CVR would not be associated with increased first attempt cannulation success.

Methods

This was a post-hoc analyses on adult patients admitted for peripheral intravenous cannulation. Intravenous cannulation was performed according to practice guidelines, by applying the traditional landmark approach. The CVR was calculated afterwards for each individual patient by dividing the external diameter of the inserted catheter by the diameter of the target vein, which was multiplied by 100%.

Results

In total, 610 patients were included. The median CVR was 0.39 (0.15) in patients with a successful first attempt, whereas patients with an unsuccessful first attempt had a median CVR of 0.55 (0.20) (P<0.001). The optimal cut-off point of the CVR was 0.41. First attempt cannulation was successful in 92% of patients with a CVR<0.41, whereas as those with a CVR>0.41 had a first attempt success rate of 65% (P<0.001).

Conclusion

This first introduction of the CVR in relation to cannulation success should be further investigated. Although, measuring the venous diameter or detection of a vein with a specific diameter prior to cannulation may increase first attempt cannulation success.

Risk for and temporal trends in cesarean surgical complications

OBJECTIVE

It is possible that in the setting of increasing patient comorbidity and obesity, risk for surgical injury and need for reoperation is increasing. It is also possible that with differential uptake of evidence-based recommendations and increasing prevalence of risk factors such as obesity, risk for surgical site complications is increasing. The objective of this study was to evaluate trends in, risk factors for, and racial disparities related to cesarean complications.

METHODS

This repeated cross-sectional study evaluated cesarean deliveries in the 2002-2014 National Inpatient Sample for women age 15-54. The primary outcome was a cesarean surgical complication composite including (i) surgical injuries, (ii) reoperation, and (iii) surgical site complications. Surgical injuries, reoperation, and surgical site complications were additionally evaluated individually as outcomes. Univariable and multivariable log linear regression models including demographic, clinical, and hospital factors were performed to assess risk for outcomes with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CI) as measures of association. Temporal trends were estimated using average annual percentage change from a joinpoint regression model. A stratified analysis was performed restricted to non-Hispanic black women. Data was weighted to provide national estimates.

RESULTS

A total of 16.2 million estimated cesarean deliveries (3.2 million unweighted cesarean deliveries) from 2002 to 2014 were included in this analysis. The prevalence of the cesarean surgical complication composite was 1.14%, surgical site complications occurred in 0.60%, surgical injuries in 0.49%, and reoperations in 0.10%. Comparing the end of the study (2012-2014) to the beginning of the study (2002-2003), adjusted risk for the composite was similar (aRR 0.93, 95% CI 0.92, 0.95). In comparison, surgical site complication risk was lower at the end of the study (aRR 0.77, 95% CI 0.75, 0.79) while risks for surgical injury (aRR 1.18, 95% CI 1.15, 1.22) and reoperation (1.18, 95% CI 1.10, 1.26) were higher. Non-Hispanic black women were at increased risk for surgical site complications (aRR 1.83, 95% CI 1.80, 1.87) and reoperation (aRR 1.44, 95% CI 1.37, 1.51), but not surgical injury (aRR 0.99, 95% CI 0.97, 1.02). In analyses stratified for non-Hispanic black women, there was a reduction in risk for surgical site complications at the end of the study period compared to the beginning similar to the primary analysis (aRR 0.76, 95% 0.72, 0.81) with a modest decrease in overall risk for the composite outcome (aRR 0.85, 95% CI 0.81, 0.89).

CONCLUSION

A decrease in risk for surgical site complications was offset by slightly increased risk for surgical injury and reoperation in adjusted analyses. Among non-Hispanic black women, surgical site complication risk decreased proportionately with this group still at significantly higher overall risk.

Robot-assisted partial nephrectomy versus standard laparoscopic partial nephrectomy for renal hilar tumor: A prospective multi-institutional study

OBJECTIVE

To investigate whether robot-assisted partial nephrectomy compared with laparoscopic partial nephrectomy is effective for renal hilar tumor removal.

METHODS

This was a prospective, multicenter, single-arm, open-label trial with a 2-year enrollment period. A total of 22 academic hospitals in Japan participated in the present study. Comparison with historical control values from reported studies of laparoscopic partial nephrectomy was carried out. The warm ischemia time and positive surgical margin rate were set as primary perioperative and oncological outcomes. In the historical control group, these were 27.7 min and 13%, respectively.

RESULTS

The analysis population included 105 participants. The mean warm ischemia time was 20.2 (95% confidence interval 16.7-21.8; P < 0.0001 vs 27.7). Two of 103 participants (1.9%) had a positive surgical margin (95% confidence interval 0.5-6.8%). Both results satisfy the prespecified decision criteria for the superiority of robot-assisted partial nephrectomy over the historical control of laparoscopic partial nephrectomy. Resected weight and preoperative estimated glomerular filtration rate were predictive factors of functional loss of the partially nephrectomized kidney after robot-assisted partial nephrectomy.

CONCLUSION

Robot-assisted partial nephrectomy for clinical T1 renal hilar tumors results in shorter warm ischemia time than and comparable positive surgical margin rate to those reported for laparoscopic partial nephrectomy.

Postpartum health risks among women with hypertensive disorders of pregnancy, California 2008-2012

OBJECTIVES

The aim of this study was to understand the associations between hypertensive disorders of pregnancy (HDP) and postpartum complications throughout the newly defined 12-week postpartum transition.

STUDY DESIGN

We conducted a retrospective cohort study of the associations of HDP (any/subtype) with postpartum complications among 2.5 million California births, 2008-2012. We identified complications from discharge diagnoses from maternal hospital encounters (emergency department visits and readmissions) in the 12 weeks after giving birth. We compared rates of complications, overall and by diagnostic category, between groups defined by HDP. In survival analyses, we calculated the adjusted hazard ratios of postpartum complications associated with HDP. We adjusted for maternal age, race/ethnicity, prepregnancy obesity, chronic diabetes, gestational diabetes, insurance, delivery mode, gestational age and birth outcome (term and size).

RESULTS

Among women with and without HDP, 12.8 and 7.7%, respectively, had a hospital encounter within 12 weeks of giving birth [adjusted hazard ratio 1.5, 95% confidence interval (95% CI): 1.5-1.5]. HDP was associated with increased risk across all major categories of complications: hypertension-related, adjusted hazard ratio 11.8 (95% CI: 11.2-12.3); childbirth-related, 1.4 (1.3-1.4); and other, 1.4 (1.4-1.4). Risk of any complication differed by hypertensive subtype: chronic hypertension with super-imposed preeclampsia, adjusted hazard ratio 1.8 (95% CI: 1.7-1.8); chronic hypertension, 1.6 (1.6-1.7); preeclampsia/eclampsia, 1.3 (1.3-1.4); and gestational hypertension, 1.2 (1.2-1.3). Over a quarter (28.9%) of maternal hospital encounters occurred more than 6 weeks after giving birth; this did not differ substantially by HDP status.

CONCLUSION

Women with HDP are at an increased risk for virtually all postpartum complications, including those not related to hypertension, and may benefit from enhanced and comprehensive postpartum care.

Retrospective study of bacterial and fungal causes of abortion in domestic ruminants in northern regions of South Africa (2006-2016)

This initial retrospective study presents information on bacterial and fungal causes of abortion in domestic ruminants in South Africa over 10 years (2006-2016). A complete set of data was collected at the Faculty of Veterinary Science through a keyword search of pathology and bacteriology laboratory registers. Additional electronic data were received from an external laboratory. A total of 288 cases were recorded from six provinces. Overall diagnostic rate was 35.1%. In 14.6% of cases, histological evidence of an infectious process was found, but no aetiological agent was detected. Several cases did not include aetiological diagnoses because applicable diagnostic techniques were not available or not applied when necessary. Increased submission of placenta, as well as additional conventional and molecular diagnostic methods, can contribute to an improved diagnostic rate. In addition, the study highlights the superior significance of Brucella abortus as a major bovine pathogen in South Africa.

Lifestyle and Early Achievement in Families (LEAF) study: Design of an ambidirectional cohort study of prenatal marijuana exposure and child development and behaviour

BACKGROUND

Marijuana is the most-used illicit substance during pregnancy in the USA, but only two cohort studies, begun over 30 years ago, were specifically established to assess the association of pregnancy use with childhood outcomes. They found use to be associated with specific deficits in executive function at 8+ years, but did not focus on these outcomes earlier in life when intervention may be more successful. Two general purpose cohorts found increased aggression in exposed female toddlers and increased behavioural problems and tic disorders in exposed school-age children.

OBJECTIVES

The Lifestyle and Early Achievement in Families (LEAF) study assesses the association of in utero marijuana exposure, documented prospectively by biomarker, self-report, and medical records, with executive function and aggression at age 3½-7 years.

METHODS

This ambidirectional cohort (historical cohort with continued follow-up) includes women enrolled in the Perinatal Research Repository during prenatal care at Ohio State University Wexner Medical Center and their children, recontacted 3½-7 years post-birth. Children complete 1-2 study visits including cognitive testing, behavioural observation, and maternal and teacher report of behaviour. Family and social environmental factors are assessed.

RESULTS

Child follow-up began in September 2016; visits continue through August 2020. There are 362 eligible children; 32% had mothers who used marijuana during pregnancy, 10% of mothers completed college, and 23% did not complete high school. Mean maternal age at study registration in pregnancy was 26.4 years, and 63% of mothers were African American. To date, 268 children have completed at least 1 study visit.

CONCLUSIONS

The LEAF Study will document the association of prenatal marijuana exposure with development and behaviour in the current era when marijuana is more potent than when previous cohorts were studied. The results may inform policy and interventions to counsel reproductive-aged women about the risks of use during pregnancy and guide prevention and treatment of adverse effects among children.

How to choose your study design

Research designs are broadly divided into observational studies (i.e. cross-sectional; case-control and cohort studies) and experimental studies (randomised control trials, RCTs). Each design has a specific role, and each has both advantages and disadvantages. Moreover, while the typical RCT is a parallel group design, there are now many variants to consider. It is important that both researchers and paediatricians are aware of the role of each study design, their respective pros and cons, and the inherent risk of bias with each design. While there are numerous quantitative study designs available to researchers, the final choice is dictated by two key factors. First, by the specific research question. That is, if the question is one of 'prevalence' (disease burden) then the ideal is a cross-sectional study; if it is a question of 'harm' - a case-control study; prognosis - a cohort and therapy - a RCT. Second, by what resources are available to you. This includes budget, time, feasibility re-patient numbers and research expertise. All these factors will severely limit the choice. While paediatricians would like to see more RCTs, these require a huge amount of resources, and in many situations will be unethical (e.g. potentially harmful intervention) or impractical (e.g. rare diseases). This paper gives a brief overview of the common study types, and for those embarking on such studies you will need far more comprehensive, detailed sources of information.

Payment for Contraceptive Services in Safety Net Clinics: Roles of Affordable Care Act, Title X, and State Programs

OBJECTIVES

We describe payor for contraceptive visits 2013-2014, before and after Medicaid expansion under the Affordable Care Act (ACA), in a large network of safety-net clinics. We estimate changes in the proportion of uninsured contraceptive visits and the independent associations of the ACA, Title X, and state family planning programs.

METHODS

Our sample included 237 safety net clinics in 11 states with a common electronic health record. We identified contraception-related visits among women aged 10-49 years using diagnosis and procedure codes. Our primary outcome was an indicator of an uninsured visit. We also assessed payor type (public/private). We included encounter, clinic, county, and state-level covariates. We used interrupted time series and logistic regression, and calculated multivariable absolute predicted probabilities.

RESULTS

We identified 162,666 contraceptive visits in 219 clinics. There was a significant decline in uninsured contraception-related visits in both Medicaid expansion and nonexpansion states, with a slightly greater decline in expansion states (difference-in-difference: -1.29 percentage points; confidence interval: -1.39 to -1.19). The gap in uninsured visits between expansion and nonexpansion states widened after ACA implementation (from 2.17 to 4.1 percentage points). The Title X program continues to fill gaps in insurance in Medicaid expansion states.

CONCLUSIONS

Uninsured contraceptive visits at safety net clinics decreased following Medicaid expansion under the ACA in both expansion and nonexpansion states. Overall, levels of uninsured visits are lower in expansion states. Title X continues to play an important role in access to care and coverage. In addition to protecting insurance gains under the ACA, Title X and state programs should continue to be a focus of research and advocacy.

An Inventory of European Birth Cohorts

Many birth cohorts have been carried out. We performed a review of European birth cohorts to see the countries involved, provide a panorama of the current research topics and design, and, more generally, provide input for those creating collaborations and laying out guidelines aimed at unifying cohort methodologies to enable data merging and maximize knowledge acquisition. We searched PubMed and Embase for articles referring to longitudinal, prospective European birth cohorts and searched online cohort inventories. We found references to 111 birth cohorts, 45 of which began enrolment at birth. These cohorts began between 1921 and 2015 and represented 19 countries, with varying sample sizes (236 to 21,000 children). As of 5 January 2020, were still recruiting. The main areas addressed were allergic diseases (14 cohorts) and environmental exposure (f12 cohorts) and most cohorts were publicly funded. Given the large costs of running cohorts and the importance of long follow-up periods in identifying the risk factors for disorders thought to have a perinatal/early life etiology, current cohorts must be designed to answer research questions considering several aspects, from genetic ones to psychological, social, and environmental ones. Furthermore, universally recognized methodological aspects are needed to permit the comparison and merging of cohort data.

Use of Uterine Tamponade and Interventional Radiology Procedures During Delivery Hospitalizations

OBJECTIVE

To characterize use of uterine tamponade and interventional radiology procedures.

METHODS

This retrospective study analyzed uterine tamponade and interventional radiology procedures in a large administrative database. The primary outcomes were temporal trends in these procedures 1) during deliveries, 2) by hospital volume, and 3) before hysterectomy for uterine atony or delayed postpartum hemorrhage. Three 3-year periods were analyzed: 2006-2008, 2009-2011, and 2012-2014. Risk of morbidity in the setting of hysterectomy with uterine tamponade and interventional radiology procedures as the primary exposures was additionally analyzed in adjusted models.

RESULTS

The study included 5,383,486 deliveries, which involved 6,675 uterine tamponade procedures, 1,199 interventional radiology procedures, and 1,937 hysterectomies. Interventional radiology procedures increased from 16.4 to 25.7 per 100,000 delivery hospitalizations from 2006-2008 to 2012-2014 (P<.01), and uterine tamponade increased from 86.3 to 158.1 (P<.01). Interventional radiology procedures use was highest (45.0/100,000 deliveries, 95% CI 41.0-48.9) in the highest and lowest (8.9/100,000, 95% CI 7.1-10.7) in the lowest volume quintile. Uterine tamponade procedures were most common in the fourth (209.8/100,000, 95% CI 201.1-218.5) and lowest in the third quintile (59.8/100,000, 95% CI 55.1-64.4). Interventional radiology procedures occurred before 3.3% of hysterectomies from 2006 to 2008 compared with 6.3% from 2012 to 2014 (P<.05), and uterine tamponade procedures increased from 3.6% to 20.1% (P<.01). Adjusted risks for morbidity in the setting of uterine tamponade and interventional radiology before hysterectomy were significantly higher (adjusted risk ratio [aRR] 1.63, 95% CI 1.47-1.81 and aRR 1.75 95% CI 1.51-2.03, respectively) compared with when these procedures were not performed.

CONCLUSION

This analysis found that uterine tamponade and interventional radiology procedures became increasingly common over the study period, are used across obstetric volume settings, and in the setting of hysterectomy may be associated with increased risk of morbidity, although this relationship is not necessarily causal.