Morbidity Criteria Research Articles

Beyond Morbidity and Mortality Conference: How Do We Learn From Special Cases?

Physicians experience scary cases in the course of usual medical practice. Cases of near misses, legal and ethical dilemmas, or unique clinical challenges are great sources of education. However, there is no format for presentation and dissemination of cases that do not meet criteria for morbidity and mortality (M&M) conferences. The Scary Cases Conference is an innovative educational forum for scrutiny and analysis of these challenging clinical cases. Scary Cases differs from traditional Morbidity and Mortality conferences as it explores outcomes beyond the scope of medical or surgical errors. From 2011 to 2021: 11 regional and 10 national "Otolaryngology Scary Cases" conferences and mini-seminars were held. The cases presented were analyzed for case specialty, area of management deemed troublesome, and compared to M&M conference criteria. 187 cases were presented. 62% percent of cases included traditional medical problems, whereas 21% involved legal issues, and 17% focused on ethical dilemmas. For the cases with medical problems, 31% involved airway obstruction, 17% nerve injuries, and 17% malignancy. 49% of cases would have met criteria for presentation at traditional M&M conferences. Of all the "scary cases," 25% were near misses and 26% represented ethical or legal dilemmas which would not be classified as morbitidy, mortality, or near miss. The Scary Cases provides a forum conducive to learning amongst peers and experts. It allows medical and surgical specialties to share the cases deemed most impactful. The M&M conference would only include half of such cases, but could be expanded beyond the traditional scope in the future.

How to Find Correct Transection Plane in Laparoscopic Right Hepatectomy Extended to S1 for Bismuth IIIa Perihilar Cholangiocarcinoma.

Perihilar cholangiocarcinoma (pCCA) is one of the most challenging tumours for hepatic surgeons. To reach radical resection, it is mandatory to extend the hepatectomy to segment 1 and biliary tract. With the advent of minimally invasive techniques, an increasing number of centres have begun to treat this tumour using robotic or laparoscopic approaches, demonstrating the ability to maintain oncological standards as well as morbidity and mortality criteria. This video presents a case of a 79-year-old man with pCCA Bismuth type IIIa, undergoing right hepatectomy extended to segment 1 and biliary tract after preoperative optimization including biliary drainage and portal vein and right hepatic vein embolization. Unlike conventional right hepatectomy, extending transection to include segment 1 requires identifying the plane defined by the Arantius duct. To reach this plane, we suggest using three approaches, previously described in other hepatectomies, were employed: dorsal and caudal approaches to the middle hepatic vein (MHV) and an extraglissonian intrahepatic approach to the left portal pedicle. With this method, we achieved oncologically radical resection of pCCA using minimally invasive surgical techniques.

Increased dicentric chromosome in peripheral lymphocytes is related to acute skin toxicity induced by radiotherapy in cancer patients

ObjectiveTo investigate the impacts of radiotherapy (RT) on dicentric chromosomes in peripheral blood lymphocytes of cancer patients, in order to explore the relationship between dicentric chromosomes and RT-induced adverse reactions. MethodsA total of 33 cancer patients after postoperative RT in a tertiary hospital from October 2021 to May 2022 were enrolled in this study. These patients were grouped according to the grade of acute skin and marrow toxicities determined based on the scoring criteria for acute morbidity developed by the Radiation Therapy Oncology Group (RTOG). Peripheral blood samples were collected from each patient before and after RT, followed by whole-blood lymphocyte culture and chromosome analysis. Dicentric chromosomes were searched automatically using a high-throughput chromosome analysis system and were then confirmed manually. Finally, the relationships of the frequency of dicentric chromosomes (also referred to as the dic frequency) with acute skin and marrow toxicities were assessed. ResultsAfter RT, the mean counts of white blood cells (WBCs), lymphocytes, and platelets significantly decreased, while the red blood cells (RBCs) and hemoglobin notably increased (P ​< ​0.001), while the dic frequency was elevated remarkably, significantly higher in patients with higher-grade (>1) acute skin toxicities compared to those with lower-grade (=1) acute skin toxicities (Z ​= ​−1.985, P ​= ​0.047). However, no significant relationship was observed between the dic frequency and acute marrow toxicity after RT (P ​> ​0.05). Logistic regression showed that radiosensitivity denoted by the post-RT dic frequency in peripheral blood lymphocytes produced insignificant impacts on the severity of RT-induced acute skin toxicities (P ​= ​0.060). ConclusionThe elevated dic frequency in peripheral blood lymphocytes of cancer patients with higher-grade acute skin toxicities suggests enhanced radiosensitivity of peripheral blood lymphocytes, which is associated with the occurrence of RT-induced adverse reactions.

Passive second stage of labor: Does a fourth hour increase maternal morbidity in nulliparous patients at term with epidural?

ObjectivesProlonging the passive second stage of labor could increase vaginal birth rate, but the data concerning maternal and fetal morbidity are contradictory. The French guidelines did not specify a maximum duration of the passive second stage. Our objective was to assess if allowing a 4th hour after full dilatation before pushing increased maternal morbidity, compared to 3 h after full dilatation. Study designThis single-center, retrospective, observational cohort study took place from January 1–December 31, 2020, in a tertiary maternity unit. All consecutive term nulliparous women who delivered under epidural anesthesia and without pathological fetal heart rate and reaching a second-stage passive phase of labor lasting at least 3 h were included. We compared 2 groups according to the duration of the passive second stage: “3-hour group” and “4-hour group”. In the "3-hour group," featuring a second-stage passive phase of up to 3 h, pushing is initiated for favorable conditions, while a cesarean section is performed if conditions are deemed unfavorable. In the "4-hour group", obstetric conditions not justifying immediate pushing after three hours, and the obstetric team believed that an additional hour of expectant management could lead to a successful vaginal delivery. The principal endpoint was a composite criterion of maternal morbidity including obstetric anal sphincter injuries, postpartum hemorrhage, transfusion and intrauterine infection. ResultsWe included 111 patients in the “4-hour group” and 349 in the “3-hour group”. Composite maternal morbidity did not increase in the “4-hour group” compared to the “3-hour group” (21 (18.9 %) versus 61 (17.5 %); p = 0.73). Neonatal morbidity was similar between the two groups. In the “4-hour group, 91 (82 %) patients had vaginal deliveries”, 62 (55,9 %) by spontaneous vaginal delivery and 29 (26,1 %) with instrumental assistance. ConclusionFor selected patients, waiting for 4 h at full dilation can be beneficial due to the high rate of vaginal delivery and low incidence of maternal and fetal complications.

Extreme prematurity: Factors associated with perinatal management and morbi-mortality in western Normandy, France

BackgroundExtreme prematurity (birth before 26 weeks of gestation), presents complex challenges and can lead to various complications. Survival rates of extremely preterm infants are lower in France than in other countries. The choice between active and palliative care is decisive in managing these births. ObjectiveTo conduct an observational study focused on factors associated with perinatal management, mortality, and morbidity outcomes among extremely preterm births in a regional perinatal network. MethodsWe undertook a retrospective, multicenter study within the western Normandy perinatal network, encompassing live births between 230/6 and 256/6 weeks from 2015 to 2019. Data were extracted from the perinatal network database and medical records. ResultsOne hundred and seven infants born from 94 women were included. In the antenatal period, 79 were exposed to corticosteroids, 66 to magnesium sulfate, and 67 to antibiotics. Active care at birth was provided to 84 neonates of whom 42 survived. In total, 65 infants died. Among the 42 surviving neonates, 9 experienced no severe morbidity, 29 displayed one and 4 exhibited two criteria of severe morbidity. Active care was associated with gestational age. Neonatal survival was correlated with antenatal exposure to antibiotics and magnesium sulfate as well as with postnatal corticosteroids. We found no significant association between mortality and gestational age at birth. ConclusionPrognostic factors must be weighed to discuss active antenatal care which is crucial for survival of extremely preterm neonates. Cooperation between obstetricians and neonatal caregivers is a cornerstone on a regional perinatal network scale.

Ten-Year Outcomes of Hypofractionated (45 Gy in 9 Fractions) Intensity Modulated Radiotherapy for Localized Prostate Cancer.

We reported 10-year outcomes of localized prostate cancers treated with hypofractionated intensity-modulated radiotherapy of 45 Gy in 9 consecutive fractions. From October 2011 to April 2017, thirty patients with localized prostate cancer were enrolled in this prospective trial. The median age of the patients was 72.5 years. According to NCCN recurrence risk criteria, eight patients were at low-risk group, 17 at intermediate risk group, 5 at high-risk group. All patients were treated with hypofractionated intensity-modulated radiotherapy (IMRT) of 45 Gy in 9 consecutive fractions to their prostate with or without seminal vesicles. Before radiotherapy, three gold fiducials were implanted into the prostate. In order to reduce the rectal high dose irradiation volume, an inflated rectal balloon was placed in the rectum at simulation and every treatment and patients were treated with comfortable full bladder. Static Intensity-modulated radiotherapy (SIMRT) was applied in 1 patient, Volumetric Modulated Arc Therapy (VMAT) in 27 patients, and tomotherapy in 2 patients. Image guided radiotherapy (IGRT) with gold fiducial registration was adopted. Twenty-six patients also received androgen deprivation therapy (ADT). The median time of ADT was 6 months. Progression⁃free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier analysis. All grade ≥1 genitourinary (GU) and gastrointestinal (GI) toxicities were recorded using Common Terminology Criteria for Adverse Event version 5.0 (CTCAE 5.0) and Radiation Therapy Oncology Group (RTOG) late morbidity criteria, and GU and GI toxicities were cumulatively calculated. After a median follow-up of 102 months (65∼131 months), the 10-year OS was 90.0% (95% confidence interval, 83.3%-96.7%), and the 10-year PFS was 86.5% (95% confidence interval, 79.1%-93.9%). According to CTCAE 5.0, grade 1 acute gastrointestinal (GI) toxicity developed in 12 patients, grade 2 in 2 patients, grade 3 in 2 patients, and grade 1 acute genitourinary (GU) toxicity developed in 12 patients, grade 2 in 2 patients, and no grade 3 or higher toxicity occurred. According to RTOG late morbidity criteria, late (≥3 months after radiotherapy) grade 1 GI toxicity developed in 4 patients (13.3%), grade 2 in 1 (3.3%), grade 3 in 1 (3.3%), and late grade 1 GU toxicity occurred in 1 patient (3.3%), grade 2 in 1 (3.3%), grade 3 in 1 (3.3%). No grade 4 or higher GI and GU toxicities developed. Only one grade 3 GI and one grade 2 GU toxicities were observed for the maximum toxicity at the last follow-up. The potency was not evaluated. The 10-year oncologic outcomes of this shortened hypofractionated IMRT regimen for mainly low/intermediate risk prostate cancer patients is favorable with acceptable acute and late toxicities.

Meconium-stained amniotic fluid and neonatal morbidity in nulliparous patients with prolonged pregnancy.

Our objective was to study the strength of the association between meconium-stained amniotic fluid and severe morbidity among neonates of nulliparas with prolonged pregnancies. This was a secondary analysis of the NOCETER randomized trial that took place between 2009 and 2012 in which 11 French maternity units included 1373 nulliparas at 41+0 weeks of gestation onwards with a single live fetus in cephalic presentation. This analysis excluded patients with a cesarean delivery before labor and those with bloody amniotic fluid or of unreported consistency. The principal end point was a composite criterion of severe neonatal morbidity (neonatal death, 5-minute Apgar <7, convulsions in the first 24 h, meconium aspiration syndrome, mechanical ventilation ≥24 h, or neonatal intensive care unit admission for 5 days or more). The neonatal outcomes of pregnancies with thin or thick meconium-stained amniotic fluid were compared with those with normal amniotic fluid. The association between the consistency of the amniotic fluid and neonatal morbidity was tested by univariate and then multivariate analysis adjusted for gestational age at birth, duration of labor, and country of birth. This study included 1274 patients: 803 (63%) in the group with normal amniotic fluid, 196 (15.4%) in the thin amniotic fluid group, and 275 (21.6%) in the thick amniotic fluid group. The neonates of patients with thick amniotic fluid had higher rates of neonatal morbidity than those of patients with normal amniotic fluid (7.3% vs. 2.2%; p < 0.001; adjusted relative risk [aRR] 3.3, 95% confidence interval [CI] 1.7-6.3), but those of patients with thin amniotic fluid did not (3.1% vs. 2.2%; p = 0.50; aRR 1.0, 95% CI, 0.4-2.7). Among nulliparas at 41+0 weeks onwards, only thick meconium-stained amniotic fluid is associated with a higher rate of severe neonatal morbidity.

Ten-year outcomes of hypofractionated (45 Gy in 9 fractions) intensity-modulated radiotherapy for localized prostate cancer.

e17100 Background: We reported 10-year outcomes of localized prostate cancers treated with hypofractionated intensity-modulated radiotherapy of 45 Gy in 9 consecutive fractions. Methods: From October 2011 to April 2017, thirty patients with localized prostate cancer were enrolled in this prospective trial. The median age of the patients was 72.5 years. According to NCCN recurrence risk criteria, eight patients were at low risk group, 17 at intermediate risk group, 5 at high risk group. All patients were treated with hypofractionated intensity-modulated radiotherapy (IMRT) of 45 Gy in 9 consecutive fractions to their prostate with or without seminal vesicles. Before radiotherapy, three gold fiducials were implanted into the prostate. In order to reduce the rectal high dose irradiation volume , an inflated rectal balloon was placed in the rectum at simulation and every treatment and patients were treated with comfortable full bladder. Static Intensity-modulated radiotherapy (SIMRT) was applied in 1 patient, Volumetric Modulated Arc Therapy (VMAT) in 27 patients, and tomotherapy in 2 patients. Image guided radiotherapy (IGRT) with gold fiducial registration was adopted. Twenty-six patients also received androgen deprivation therapy (ADT). The median time of ADT was 6 months. Progression⁃free survival(PFS) and overall survival(OS) were analyzed using Kaplan-Meier analysis. All grade ≥1 genitourinary (GU) and gastrointestinal (GI) toxicities were recorded using Common Terminology Criteria for Adverse Event version 5.0 (CTCAE 5.0) and Radiation Therapy Oncology Group (RTOG) late morbidity criteria , and GU and GI toxicities were cumulatively calculated. Results: After a median follow-up of 102 months (65~131 months), the 10-year OS was 90.0%(95% confidence interval, 83.3%-96.7%), and the 10-year PFS was 86.5% (95% confidence interval, 79.1%-93.9%). According to CTCAE 5.0, grade 1 acute gastrointestinal (GI) toxicity developed in 12 patients, grade 2 in 2 patients, grade 3 in 2 patients, and grade 1 acute genitourinary (GU) toxicity developed in 12 patients, grade 2 in 2 patients, and no grade 3 or higher toxicity occurred. According to RTOG late morbidity criteria, late (≥3 months after radiotherapy) grade 1 GI toxicity developed in 4 patients (13.3%), grade 2 in 1 (3.3%), grade 3 in 1 (3.3%), and late grade 1 GU toxicity occurred in 1 patient (3.3%), grade 2 in 1 (3.3%), grade 3 in 1 (3.3%). No grade 4 or higher GI and GU toxicities developed. Only one grade 3 GI and one grade 2 GU toxicities were observed for the maximum toxicity at the last follow-up. The potency was not evaluated. Conclusions: The 10-year oncologic outcomes of this shortened hypofractionated IMRT regimen for mainly low/intermediate risk prostate cancer patients is favorable with acceptable acute and late toxicities.

The Conceptualization of Pregnancy-Associated Maternal Morbidity in Research Studies: A Scoping Review [ID: 1376717

INTRODUCTION: This study aimed to review the clinical literature to understand how maternal morbidity has been conceptualized. METHODS: We conducted a scoping review wherein we searched four databases until May 2022 for studies on maternal morbidity. We screened abstracts in duplicate and extracted data on the study scope, terms used to describe maternal morbidity, and conditions included. Results were presented descriptively. RESULTS: We identified 8,178 titles, of which 589 studies from 1986 to 2022 were included in the final analysis. Included studies used 73 terms to describe maternal morbidity. While 217 (37%) studies described maternal morbidity in the context of the general pregnant population, others described more specific contexts, for example, hypertensive disorders of pregnancy (43 studies, 7%), obesity (38 studies, 6%), and gestational and pregestational diabetes (31 studies, 5%). In terms of component outcomes, 156 (26%) studies utilized the World Health Organization criteria for maternal near miss and potentially life-threatening conditions or the Centers for Disease Control and Prevention criteria for severe maternal morbidity, while others included between one and 45 outcomes, the most frequent of which were intensive care unit admission, preeclampsia, eclampsia, hemorrhage, uterine rupture, hysterectomy, and blood transfusion. Notably, 36 (6%) studies included fetal or neonatal outcomes when describing maternal morbidity. CONCLUSION: Although maternal morbidity is reported in a large number of pregnancy studies, there is no consistency in what outcomes are included in its definition. There is need for a standardized definition of maternal morbidity that embodies the perspectives of persons with lived experience of pregnancy.

Application of the Modified Early Obstetrical Warning System (MEOWS) in postpartum patients in the emergency department.

Over the last two decades, there has been a steady rise in severe maternal morbidity and pregnancy-related deaths in Canada and the USA. The Modified Early Obstetric Warning System (MEOWS) is a risk stratification tool designed to predict severe maternal morbidity and mortality and has been validated for use in obstetrical wards. The objective of this study was to determine if MEOWS could accurately identify patients at risk of severe maternal morbidity and mortality in the ED setting. This was a chart review of patients presenting to an academic tertiary care centre (annual ED census 65,000) with a postpartum complaint within 6 weeks of delivery between May 2020 and March 2022. The exposure was the presence of a trigger, defined as one severely abnormal (red) or two mildly abnormal (yellow) physiological measurements during the ED visit. The diagnostic accuracy of the tool to identify patients at risk of severe maternal morbidity severe maternal morbidity or mortality was estimated by calculating the sensitivity, specificity, positive predictive value and negative predictive value. Two hundred and sixty-seven patients were included, of which 21 (7.9%) met the criteria for severe maternal morbidity. There were no maternal deaths. Overall, the sensitivity of the MEOWS tool was 85.7% (95% CI 63.7-97.0%), specificity was 67.9% (95% CI 61.7-73.7%), positive predictive value was 18.6% (95% CI 15.1-22.7%), and negative predictive value was 98.2% (95% CI 95.1-99.4%). Severe preeclampsia and eclampsia were the most common outcome category of severe maternal morbidity, representing 16 (76.2%) cases. Most patients (86.5%) were discharged directly from the ED, and 90.0% did not return within 30days. This study is the first to explore the utility of MEOWS in postpartum ED patients. The presence of a MEOWS trigger at ED triage or the first ED nursing assessment was associated with severe maternal morbidity. Thus, MEOWS may be a valuable tool to identify postpartum patients at risk of severe outcomes early in an ED visit.

Observed Versus Expected Distribution of Patient Self-Reported Race and Ethnicity in Quality Improvement Review Processes at a Single Safety Net Academic Institution.

Background While there is a plethora of evidence describing racial and ethnic disparities in obstetric care and outcomes, little has been published evaluating potential inequities in departmental Patient Safety and Quality Improvement (PSQI) processes. Objective The study aims to describe the distribution of patient-reported race or ethnicity for safety events at a single safety net teaching hospital. We hypothesized that the observed versus expected case distribution for each racial or ethnic group would be similar, signifying proportional representation in the PSQI reporting and review process. Study design We performed a cross-sectional study including all Safety Intelligence (SI) events filed on obstetric and gynecologic patients and all cases reviewed at monthly PSQI multidisciplinary departmental meetings from May 2016 to December 2021. We compared the distribution of patients' self-reported race or ethnicity as documented in the medical record to our patient population's expected race or ethnicity distribution based on historical institutional data. Results Two thousand and fiveSI events were filed on obstetric and gynecologic patients. Of those, 411 cases were selected for review by the departmental multidisciplinary PSQI committee, which meets once monthly. Of the 411 cases reviewed by the PSQI committee, 132 met Severe Maternal Morbidity (SMM) criteria defined by the American College of Obstetricians and Gynecologists (ACOG). Fewer SI reports were filed on Asian patients and those who declined to provide race or ethnicity (observed 4.3% versus expected 5.5%, p=0.0088 and 2.9% versus expected 1%, p<0.0001, respectively). For cases reviewed by the departmental PSQI committee and for those which met SMM criteria, there was no significant difference in race/ethnicity distribution. Conclusions There was a disparity between fewer safety events filed for Asian patients and those not reporting race/ethnicity. It was reassuring that our process did not identify other racial/ethnic disparities. However, given the widespread systemic inequities in healthcare, further evaluation of our PSQI process, and PSQI processes beyond our institution, is needed.

Maternal and Neonatal Prognosis of Childbirth Among 14 to 19 Years Teenage Girls at the Ordre De Malte Hospital of Djougou, Benin

<i>Introduction</i>: Despite advances in clinical care, teenage childbirth is still feared both medically and socially. Because of their immature bodies, teenage girls are more prone to complications during pregnancy and delivery. Objective: This study aimed to investigate maternal and neonatal prognosis of childbirth among 14 to 19 years teenage girls at the Ordre de Malte hospital of Djougou (HZ-OMD) in 2021.<i> Method</i>: For descriptive and analytical purposes, we conducted a prospective study in the gynecology and obstetrics section of the Ordre de Malte hospital of Djougou (HZ-OMD), from January 1 to May 31, 2021 (5 months). The study population consisted of all parturients admitted into the gynecology and obstetrics section of the HZ-OMD throughout the study period. Data were collected through a face-to-face interview using a pre-designed and tested questionnaire, as well as through physical checkup. Pearson's chi-square and Fisher's exact tests have been used as appropriate to determine correlation between variables. <i>Result</i>: A total of 240 participants were included in this study. The teenage girls childbirths rate in the HZ-OMD was 18.3%. Deliveries were vaginal (63.7%) and vaginal (36.3%). The dystocia noted during vaginal delivery were mechanical (15.2%) and dynamic (11%). High blood pressure was found in 28.6% and was complicated by eclampsia in 16.4% of cases. No maternal deaths were recorded. Preterm births and low birthweight represented 21% and 33.33% of these births respectively. Acute fetal distress was noted in 13.75%. The neonatal mortality rate was 106 per 1000 live births. Irregular fetal heart rate and a generally narrowed pelvis were associated 5.14 and 5.86 times respectively with the risk of delivering through cesarean section (p=0.001; p=0.033). Fifth minute Apgar <7, a criteria of fetal morbidity, was significantly associated with low birthweight (p=0.01), preterm delivery (p=0.021), and acute fetal distress (p 0.001). Newborns were 5 times more likely to die when they are of low birthweight (p=0.001). <i>Conclusion</i>: Teenage girls’ childbirth presents huge risks due to the immaturity of their bodies and the poor follow-up of their pregnancies in our settings.

The deep inferior epigastric artery perforator flap: a narrative review on its various uses in non-breast reconstruction.

The deep inferior epigastric artery perforator (DIEP) flap was first described by Koshima and Soeda in 1989 and is now well-established as the gold standard in breast reconstruction. Lately, this issue has been explored in the context of head and neck reconstruction, highlighting growing interest in the use of the DIEP flap beyond breast reconstruction, but its usage in other anatomical regions appears elusive. Nevertheless, DIEP flap reconstruction may be a viable choice for complex, three-dimensional head and neck deformities while upholding the criteria of minimal donor site morbidity, according to a recent review. To determine whether the DIEP flap may be used successfully in other types of reconstruction, we conducted a review on the use, applications, and outcomes of the DIEP flap in non-breast reconstruction. This is, as far as we are aware, the first comprehensive analysis of all applications of the DIEP flap other than for breast reconstruction. A literature review was performed using PubMed to include all relevant articles in English or French published up to February 2022. Keywords included "DIEP flap" and "deep inferior epigastric perforator flap". A total of 1,299 articles were identified with 105 on the use of the DIEP flap in non-breast reconstruction. This suggests increasing recognition of the DIEP flap as a feasible option for reconstruction of most anatomical regions, especially in lower limb and head and neck reconstruction, followed by gynecological reconstruction. The DIEP flap was also utilized in the reconstruction of upper limb, thigh and hip defects. Less commonly, it has been used for penoscrotal, groin, sternal, buttock and abdomen reconstruction. The scientific body of evidence showed the robustness and versatility of the DIEP flap in non-breast reconstruction, with its relative pros and cons at different anatomical regions.

Implementation and outcomes of a system-wide women’s health ‘team goal’ to reduce maternal morbidity for black women: a prospective quality improvement study

ObjectiveIn response to the unacceptable racial disparities in US obstetric outcomes, our health system established a formal goal to reduce maternal morbidity for black women. Here, we describe our process...

Аналітичний огляд результатів моніторингових епідеміологічних досліджень та інфекційної захворюваності у Кіровоградській області

Objective: The aim of the work is to develop approaches to improving the information and analytical support for monitoring epidemiological studies and infectious diseases in the activities of public health institutions. Materials and methods: The studies were carried out on the basis of a retrospective review of long-term monitoring of epidemiological observations of infectious morbidity and indicators of microbiological and chemical pollution of environmental factors, performed by the state institution «Kirovohrad Regional Center for Disease Control and Prevention of the Ministry of Health of Ukraine». In this case, the following methods were used: dialectical - to determine the essence of information and analytical support for the activities of public health institutions; functional, comparative analysis - to analyze the activities of the state institution "Kirovohrad Regional Center for Disease Control and Prevention of the Ministry of Health of Ukraine"; model, integrated approaches - to develop a model of information and analytical support for the activities of public health institutions and measures for its implementation in practice; methods of statistical analysis - to determine the characteristics of the study of environmental objects and the dynamics of infectious diseases in the population. Results: According to monitoring observations of environmental objects in medical institutions, preschool and general educational institutions, social security institutions of the Kirovohrad region for 2020, which included data from 4196 studies, it was found that almost 15% of them do not meet the requirements of regulatory documents. At the same time, microbiological studies included 1207 samples and measurements, of which 117 samples (9.7%) were inappropriate, sanitary-chemical studies amounted to 2989 samples, of which 146 samples were inappropriate (4.9%) exceeding the permissible standards. The largest number of samples that do not comply with regulatory documents and pose a threat to human health were found in non-centralized water supply 77 samples. The analysis of the infectious morbidity of the population in the Kirovohrad region covered the period of 2018-2020, the dynamic review of which showed that, according to the criterion of general morbidity, the number of cases of infectious diseases is growing over time, while the incidence of infectious diseases in children tends to decrease. A number of shortcomings in accounting and data processing have been identified. Conclusions: The expediency of improving the methodological, software and technological support of the information and analytical direction of the functioning of the state institution "Kirovohrad Regional Center for Disease Control and Prevention of the Ministry of Health of Ukraine" is shown. This will improve the efficiency and quality of the implementation of monitoring studies, as well as the processing and analysis of the obtained data on the state of the environment and public health and the adoption of timely management decisions on its conservation.

Every maternal near-miss counts: Need for a national audit in South Africa? A mixed-methods study.

To improve maternal health, studies of maternal morbidity are increasingly being used to evaluate the quality of maternity care, in addition to studies of mortality. While South Africa (SA) has a well-established confidential enquiry into maternal deaths, there is currently no structure in place to systematically collect and analyse maternal near-misses (MNMs) at national level. To synthesise MNM indicators and causes in SA by performing a systematic literature search, and to investigate perceived needs for data collection related to MNMs and determine whether the MNM tool from the World Health Organization (WHO-MNM) would require adaptations in order to be implemented. The study used a mixed-methods approach. A systematic literature search was conducted to find all published data on MNM audits in SA. Semi-structured interviews were conducted virtually with maternal health experts throughout the country who had been involved in studies of MNMs, and main themes arising in the interviews were synthesised. A method for MNM data collection for SA use was discussed with these experts. The literature search yielded 797 articles, 15 of which met the WHO-MNM or Mantel et al. severe acute maternal morbidity criteria. The median (interquartile range) MNM incidence ratio in SA was 8.4/1 000 (5.6 - 8.7) live births, the median maternal mortality ratio was 130/100 000 (71.4 - 226) live births, and the median mortality index was 16.6% (11.7 - 18.8). The main causes of MNMs were hypertensive disorders of pregnancy and obstetric haemorrhage. Eight maternal health experts were interviewed from May 2020 to February 2021. All participants focused on the challenges of implementing a national MNM audit, yet noted the urgent need for one. Recognition of MNMs as an indicator of quality of maternity care was considered to lead to improved management earlier in the chain of events, thereby possibly preventing mortality. Obtaining qualitative information from women with MNMs was perceived as an important opportunity to improve the maternity care system. Participants suggested that the WHO-MNM tool would have to be adapted into a simplified tool with more clearly defined criteria and a number of specific diagnoses relevant to the SA setting. This 'Maternal near-miss: Inclusion criteria and data collection form' is provided as a supplementary file. Adding MNMs to the existing confidential maternal death enquiry could potentially contribute to a more robust audit with data that may inform health systems planning. This was perceived by SA experts to be valuable, but would require context-specific adaptations to the WHO-MNM tool. The available body of evidence is sufficient to justify moving to implementation.

Maternal early warning criteria predict postpartum severe maternal morbidity and mortality after delivery hospitalization discharge: a case–control study

The predictors of postpartum severe maternal morbidity and mortality have not been well-described using patient-level data. This study aimed to evaluate the application of maternal early warning criteria in the postpartum period and generate a preliminary predictive model for severe maternal morbidity and mortality occurring after delivery hospitalization discharge until 42 days postpartum. A retrospective case-control study was conducted from January 2013 to September 2020. Cases were identified from electronic medical records using the International Classification of Diseases, Tenth Revision codes for Centers for Disease Control and Prevention-defined severe maternal morbidity. Patients meeting the criteria for severe maternal morbidity and mortality from delivery hospitalization discharge until 42 days postpartum were matched for delivery hospital and year with the controls in an approximate 1:2 fashion. The objective was to identify the demographic and clinical risk factors during the antepartum through postpartum periods for postpartum severe maternal morbidity and mortality. Multivariable logistic regression was performed to estimate the risks, and a receiver operating characteristic curve was derived to evaluate the model. Ninety cases of postpartum severe maternal morbidity and mortality that occurred following delivery hospitalization discharge were identified. These were matched with 175 controls. Women with postpartum severe maternal morbidity and mortality had more postpartum assessments (mean: 1.7 vs 1.4, P=.005) and a higher frequency of maternal early warning criteria (58% [52/90] vs 2% [3/175]; P<.001) preceding the diagnosis of severe maternal morbidity and mortality than controls. Black women had higher odds of postpartum severe maternal morbidity and mortality than White women (odds ratio, 1.93; 95% confidence interval, 1.14-3.27). Women with maternal early warning criteria during postpartum assessments were more likely to experience subsequent postpartum severe maternal morbidity and mortality (odds ratio, 67.2; 95% confidence interval, 21.3-211.6) than women with no maternal early warning criteria. Although the point estimate was different in Black women (odds ratio, 161.8; 95% confidence interval, 8.9 to >999) than White women (odds ratio, 47.9; 95% confidence interval, 13.8-167.1), the effect modification between the maternal early warning criteria and race was not statistically significant (P=.93). In a multivariable model, race, body mass index, cesarean delivery, and maternal early warning criteria at postpartum assessments were associated with subsequent severe maternal morbidity and mortality, with an area under the curve of 0.905 (95% confidence interval, 0.864-0.946). Maternal early warning criteria are associated with increased odds of postpartum severe maternal morbidity and mortality. A straightforward model that includes race, body mass index, cesarean delivery, and presence of maternal early warning criteria appears to be a promising tool to identify those at risk for postpartum severe maternal morbidity and mortality following delivery hospitalization discharge. This is an important first step in improving the ability to recognize and respond to conditions preceding postpartum severe maternal morbidity. These findings should be validated in a prospective cohort.

The prevalence of psychiatric illness among cannabis users

This study was conducted in a tertiary hospital's psychiatry unit. Legal edible cannabis (bhang) users for more than a year who attended the OPD and IPD during the study period and met the inclusion criteria (age 18 to 60, no history of physical or psychiatric illness) were included in the investigation with their informed consent. 171 patients were recruited after being assured of the study's confidentiality. Special tests evaluated cannabis dependence and psychiatric conditions. (1) CUDIT-R and (2) DSM-5 updated psychiatric morbidity criteria. Population demographics. Patients with CUDs ranged in age from 18 to 60. The majority were age 21 to 30 (49.7%), followed by 31 to 40 (29.8%), 41 to 50 (12.9%), 20 (5.8%), and 51 to 60. (1.8 percent). Male (93.1%) and female patients were roughly evenly split (7.0 percent). 103 of 171 study patients were married (60.2%), compared to 66 unmarried patients (38.6%) who used bhang more often. 1,2% were divorced. The study considered patients' education levels. Middle schoolers had the highest percentage (22.2%), followed by illiterates and graduates (17.5%), high school (12.9%), and postgraduates (0.6 percent). Lower middle class (40.9%) had the most participants, and upper class had the fewest (2.3 percent).

Characterization of Hepatic Dysfunction in Subjects Diagnosed With Chronic GVHD by NIH Consensus Criteria

Hepatic chronic graft-versus-host disease (cGVHD) causes morbidity and current diagnostic criteria are nonspecific. An accurate diagnosis is imperative because overdiagnosis can lead to unnecessary treatment with immunosuppressive agents and raising the risk of opportunistic infections. We aim to characterize different patterns of liver injury and cytokine profiles associated with hepatic dysfunction in cGVHD, to evaluate the accuracy of the NIH Consensus Criteria (NCC) for hepatic cGVHD and to explore predictors for hepatic cGHVD. Patients were evaluated in this prospective cross-sectional study of patients with cGVHD recruited under a natural history protocol. Laboratory tests and cytokines were measured. The cGVHD were diagnosed and scored based on NCC. Clinically indicated liver biopsy specimens or autopsies were reviewed by an expert hepatopathologist (D.E.K.). Comparisons were made between groups, and univariable and multivariable logistic regression were calculated. Of the 302 patients enrolled, 151 fulfilled hepatic cGVHD based on NCC; however, 69% had at least 1 abnormal liver test result. Abnormal alanine aminotransferase (ALT) and aspartate aminotransferase were associated with lower platelets, higher total bilirubin (TB), total cholesterol, serum amyloid A, and IL 15. Abnormal ALP and gamma-glutamyl transpeptidase were associated with higher cholesterol, and IL7. Lower platelet count was associated with higher ALT, TB, and triglycerides and lower albumin. Of the 27 with liver tissue, 16 had histologic features of GVHD, only eight met clinical criteria for hepatic GVHD. Sensitivity and specificity of NCC in identifying hepatic GVHD were 50% and 27% (Kappa=-0.23). Only 6 had only hepatic GVHD, whereas 10 had hepatic GVHD with either iron overload, nodular regenerative hyperplasia, or steatosis. Multivariable logistic regression showed that ALP and total cholesterol were associated with hepatic GVHD and total cholesterol >220 mg/dL increased the sensitivity for histologic hepatic GVHD. In conclusion, abnormal liver enzymes in cGVHD are nonspecific and have poor correlation with histologic evidence for hepatic GVHD, highlighting the importance of histology. Cytokines provide insight into the pathogenesis of hepatic cGVHD. Decreased platelet count was associated with factors associated with liver disease including portal vein diameter, which may suggest progression of liver disease. This highlights the need of incorporating these factors in natural history study and using liver biopsy to understand the development of liver dysfunction in hematopoietic stem cell transplantation and to develop better instruments to decreased hepatic cGVHD related morbidity and mortality. The study was registered with a ClinicalTrials.gov identifier NCT00092235.

Neonatal morbidity and mortality for preterm in breech presentation regarding the onset mode of labor.

To assess severe neonatal morbidity and mortality in induced labor in preterm breech deliveries, compared to spontaneous labor. This is a retrospective study conducted in a tertiary university center in France. Women with single live breech pregnancy between 28 + 0 and 36 + 6weeks gestation were included. We excluded situations with medical contraindication to vaginal delivery and fetal malformations. We compared women with an unfavorable cervix, who had an indication for deliver and could receive cervical ripening to induce labor, to women in spontaneous labor. The primary outcome was a composite criterion of severe neonatal morbidity and mortality including perinatal death, traumatic event during delivery, Apgar score at 5-min < 4, moderate or severe encephalopathy, seizures within the first 24h, Intra-Ventricular Hemorrhage grade 3 or 4, necrotizing enterocolitis grade 2 or 3. We included 212 patients: 64 in the induced labor group and 136 in the spontaneous labor group. In the induced labor group, 45.3% of patients delivered vaginally, and 86% in spontaneous labor group. The neonatal morbidity and mortality rate were similar in both groups: 4.7% in the induced labor group, and 5.2% in the spontaneous labor group, p = 0.889, aOR = 1.5 (0.28-8.28). Nearly half of the patient who received induction of labor delivered vaginally. The onset mode of labor does not appear to have an effect on severe neonatal morbidity and mortality in preterm breech fetuses. Induction of labor could be an option for patients in this setting.