Implementation and clinical impact of a guideline for standardized, evidence-based induction of labor

OBJECTIVE

To assess the impact of implementation of an induction of labor (IOL) guideline on IOL length and utilization of evidence-based practices.

STUDY DESIGN

We conducted a quality improvement project to increase utilization of three evidence-based IOL practices: combined agent ripening, vaginal misoprostol, and early amniotomy. Singletons with intact membranes and cervical dilation ≤2 cm admitted for IOL were included. Primary outcome was IOL length. Secondary outcomes included cesarean delivery and practice utilization. We compared pre-implementation (PRE; November 1, 2021 through January 31, 2022) to post-implementation (POST; March 1, 2022 through April 30, 2022) with sensitivity analyses by self-reported race and ethnicity. Cox proportional hazards models and logistic regression were used to test the association between period and outcomes.

RESULTS

Among 495 birthing people (PRE, n=293, POST, n=202), IOL length was shorter POST (22.0 vs. 18.3 hours, P=.003), with faster time to delivery (aHR 1.38, 95% CI 1.15-1.66), more birthing people delivered within 24 hours (57% vs. 68.8%, aOR 1.90 [95% CI 1.25-2.89]), and no difference in cesarean. Utilization of combined agent ripening (31.1% vs. 42.6%, P=.009); vaginal misoprostol (34.5% vs. 68.3%, P<.001); and early amniotomy (19.1% vs. 31.7%, P=.001) increased POST.

CONCLUSION

Implementation of an evidence-based IOL guideline is associated with shorter induction time. Additional implementation efforts to increase adoption of practices are needed to optimize outcomes after IOL.

Experiences of the Flint Water Crisis Among Reproductive-Age Michigan Women in Communities Outside of Flint: Differences by Race and Ethnicity

We sought to understand how women in Michigan communities outside of Flint experienced the Flint water crisis, an avoidable public health disaster widely attributed to structural racism. Using survey data from 950 Michigan women aged 18-45 from communities outside of Flint, we examined racial and ethnic differences in personal connections to Flint, perceived knowledge about the water crisis, and beliefs about the role of anti-Black racism in the water crisis factors that could contribute to poor health via increased psychological stress. We found that White (OR = 0.32; 95% CI: 0.22, 0.46) and Hispanic (OR = 0.21; 95% CI: 0.09, 0.49) women had lower odds than Black women of having family or friends who lived in Flint during the water crisis. Compared to Black women, White women were less likely to be moderately or very knowledgeable about the water crisis (OR = 0.58; 95% CI: 0.41, 0.80). White women (OR = 0.26; 95% CI: 0.18, 0.37), Hispanic women (OR = 0.38; 95% CI: 0.21, 0.68), and women of other races (OR = 0.28; 95% CI: 0.15, 0.54) were less likely than Black women to agree that the water crisis happened because government officials wanted to hurt Flint residents. Among those who agreed, White women (OR = 0.47; 95% CI: 0.30, 0.74) and women of other races (OR = 0.33; 95% CI: 0.12, 0.90) were less likely than Black women to agree that government officials wanted to hurt people in Flint because most residents are Black. We conclude that the Flint water crisis was a racialized stressor, with potential implications for the health of reproductive-age Black women.

Out-of-Pocket Costs for Colposcopy Among Commercially Insured Women From 2006 to 2019

Out-of-pocket costs for women who undergo colposcopy are common, significant, and have increased over time.

Increasing Influenza Vaccination Rates in a Busy Urban Clinic

Influenza infection is the cause of thousands of hospitalizations and deaths each year; infection during pregnancy results in increased morbidity and mortality. Underserved women are particularly susceptible to not receiving recommended vaccinations. This project explored the effect of a simple paper based prompt on the influenza vaccination rate in a resident continuity clinic for the underserved. Using this reminder to providers to discuss the influenza vaccination with their patients, we were able to increase vaccination rates in our clinic from 2.2% to 14.2%. This implementation of a simple, low cost, low tech prompt to providers increased the rate of influenza vaccination in our clinic and we present this approach as an easy to implement method of improving vaccination rates. We also suggest this method as an alternative to an alert in the electronic medical record in situations where the electronic medical record may not be accessed during every patient encounter.

Safety and pharmacokinetics of aciclovir in women following release from a silicone elastomer vaginal ring

OBJECTIVES

Systemic aciclovir and its prodrug valaciclovir are effective in treating and reducing recurrences of genital herpes simplex virus (HSV) and reducing transmission. Local aciclovir delivery, if it can achieve and maintain comparable intracellular genital tract levels, may be equally effective in the treatment and suppression of genital HSV. Intravaginal ring (IVR) delivery of aciclovir may provide pre-exposure prophylaxis against HSV acquisition.

METHODS

Tolerability and pharmacokinetics were evaluated in six HIV-negative women with recurrent genital HSV who switched their daily oral valaciclovir suppression to an aciclovir IVR for 7 days (n = 3) or 14 days (n = 3). Blood and cervicovaginal lavage (CVL) were collected after oral and IVR dosing to measure aciclovir concentrations and genital swabs were obtained to quantify HSV shedding by PCR.

RESULTS

The rings were well tolerated. Median plasma aciclovir concentrations were 110.2 ng/mL (IQR, 85.9-233.5) 12-18 h after oral valaciclovir. Little or no drug was detected in plasma following IVR dosing. Median (IQR) CVL aciclovir levels were 127.3 ng/mL (21-660.8) 2 h after oral valaciclovir, 154.4 ng/mL (60.7-327.5) 12-18 h after oral valaciclovir and 438 ng/mL (178.5-618.5) after 7 days and 393 ng/mL (31.6-1615) after 14 days of aciclovir ring use. Median CVL aciclovir levels 2 h after oral dosing were similar to levels observed 7 (P = 0.99) and 14 (P = 0.75) days after ring use. HSV DNA was not detected in genital swabs and there was no significant change in inflammatory mediators.

CONCLUSIONS

This first-in-human study demonstrated that an IVR could safely deliver mucosal levels of aciclovir similar to oral valaciclovir without systemic absorption. More intensive site-specific pharmacokinetic studies are needed to determine whether higher local concentrations are needed to achieve optimal drug distribution within the genital tract.

Characterizing community-based asthma knowledge in Chicago and its high risk neighborhoods

The goal of this study was to characterize asthma knowledge in high risk neighborhoods compared to a random sample of residents in the Chicago area. The Chicago Community Asthma Survey-32 (CCAS-32) was administered to 1006 Chicago-area residents and 388 residents in 4 high-risk Chicago inner-city neighborhoods. There was a significant difference in asthma knowledge between groups. The general Chicago-area respondents have an average desirable response rate of 71.6% versus 64.7% for respondents in high-risk communities (p < 0.0001). For some aspects of asthma knowledge, e.g., nocturnal cough, cockroach allergen, and vaporizer use, general knowledge was similarly low. For other aspects, such as the need for asymptomatic asthma visits and chest tightness, there were larger gaps between residents of high risk communities and the general community. High-risk neighborhoods in Chicago had lower asthma knowledge compared to the general Chicago community. This discrepancy may be contributing to the disparities seen in asthma morbidity. Public health efforts to increase asthma knowledge in these high risk minority communities may help reduce these disparities. Important misconceptions exist about asthma triggers, signs and symptoms, especially among lower income African American communities, that should be addressed by physicians.

Acute and chronic hemodynamic effects of enhanced external counterpulsation in patients with angina pectoris

BACKGROUND

Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for patients with angina pectoris. However, the hemodynamic effects of EECP are still unknown and have been theorized to simulate the clinical use of the intra-aortic balloon pump, enhancing cardiac output, stroke volume, and retrograde aortic diastolic flow.

METHODS

Twelve hemodynamic parameters were measured, using the BioZ System (CardioDynamics International Corporation, San Diego, Calif) after 1 hour (n=22) and after 35 hours (n=16) of EECP treatment compared with baseline. The BioZ System noninvasively measures hemodynamic parameters using the thoracic electrical bioimpedance method.

RESULTS

One hour of EECP treatment revealed a significant decrease in cardiac output, stroke volume, contractility, afterload, preload, and myocardial energy production, but systolic time ratios and thoracic fluid content were unchanged. However, after 35 hours of therapy, stroke volume (P < or = 0.05), index of contractility (P < or = 0.05), and thoracic fluid content (P < or = 0.01) were decreased.

CONCLUSIONS

The acute reduction in contractility, preload, and concurrent bradycardia may have favorable hemodynamic effects for patients with angina pectoris. Further studies are needed to elucidate the mechanism of EECP therapy and its efficacy for patients with angina pectoris.