Changes in use of 17-OHPC after the PROLONG trial: a physician survey.

OBJECTIVES: To determine if 17α-hydroxyprogesterone caproate (17OHPC) or vaginal progesterone use for patients at risk for preterm birth has changed since the publication of the 17-OHPC to Prevent Recurrent Preterm Birth in Singleton Gestations (PROLONG) trial, and to assess which organizations' (Food and Drug Administration's [FDA], American College of Obstetrics and Gynecology's [ACOG] or Society of Maternal Fetal Medicine's [SMFM]) statements most influenced change. METHODS: Through a vignette-based physician survey, we sought to measure (by Likert scale) how counseling tendencies regarding 17OHPC and vaginal progesterone have changed since the PROLONG trial publication. Participants were also asked which organizations' statements most influenced change. RESULTS: With response rate of 97 % (141/145), a pre-to-post PROLONG trial comparison revealed significant changes in counseling for progesterone. Respondents were less likely to recommend 17OHPC (p<0.001) and more likely to recommend vaginal (p<0.001). The FDA statement most influenced the decision not to recommend 17OHPC for the prevention of preterm birth (r=-0.23, p=0.005). CONCLUSIONS: Providers have made significant changes in their counseling regarding progesterone use for patients at risk for preterm birth after the publication of the PRLONG trial.

COVID-19 Vaccine Hesitancy in an Underrepresented Minority Community.

To assess factors influencing acceptability of COVID-19 vaccine in a population of predominantly indigent, minority, pregnant and non-pregnant people of reproductive age. Cross-sectional survey using a modified Health Belief model administered between January 2021 and January 2022 at four hospitals in Brooklyn. Participants included English-speaking reproductive aged persons attending clinics at the participating sites. Descriptive and univariate data analyses were used for analysis. 283 eligible reproductive persons were approached of whom 272 completed the survey (96%). Three quarters said they would take the vaccine under certain circumstances ("as soon as it is ready" [28.6%], "when my doctor recommends it" [21.3%] or "when enough people have received it to know if it works" [25%]), while 25% said they would never take the vaccine. When comparing persons that would take it under certain circumstances to those that never would, the "never" group was significantly more likely to note that, "they would not trust any COVID vaccine" (71.4% vs. 28.5%; p ≤ 0.0001). This greater level of distrust extended to greater distrust of doctors, government, family, newspapers, and media. However, 36% said they would be influenced by their doctor's recommendation. Pregnant participants were significantly more likely to wait until their doctor recommended it (17.6% of pregnant persons compared to 3.7% of non-pregnant p < 0.0001). Despite mistrust and other discouraging factors, many persons, under appropriate circumstances (e.g., reassurance about vaccine safety) may be motivated to take the vaccine. Even those who claimed that they wouldn't take the vaccine under any circumstance may be influenced by their health care providers.

Histologic and Immunohistochemical Evaluation of 65 Placentas From Women With Polymerase Chain Reaction-Proven Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection.

CONTEXT.­: Coronavirus disease 2019 (COVID-19) has been shown to have effects outside of the respiratory system. Placental pathology in the setting of maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remains a topic of great interest because earlier studies have shown mixed results. OBJECTIVE.­: To ascertain whether maternal SARS-CoV-2 infection is associated with any specific placental histopathology, and to evaluate the virus's propensity for direct placental involvement. DESIGN.­: Placentas from 65 women with polymerase chain reaction-proven SARS-CoV-2 infection underwent histologic evaluation using Amsterdam consensus group criteria and terminology. Another 85 placentas from women without SARS-CoV-2 constituted the negative control group. A total of 64 of the placentas from the SARS-CoV-2-positive group underwent immunohistochemical staining for SARS-CoV-2 nucleocapsid protein. RESULTS.­: Pathologic findings were divided into maternal vascular malperfusion, fetal vascular malperfusion, chronic inflammatory lesions, amniotic fluid infection sequence, increased perivillous fibrin, intervillous thrombi, increased subchorionic fibrin, meconium-laden macrophages (M-LMs) within fetal membranes, and chorangiosis. There was no statistically significant difference in prevalence of any specific placental histopathology between the SARS-CoV-2-positive and SARS-CoV-2-negative groups. There was no immunohistochemical evidence of SARS-CoV-2 virus in any of the 64 placentas that underwent staining for viral nucleocapsid protein. CONCLUSIONS.­: Our study results and a literature review suggest that there is no characteristic histopathology in most placentas from women with SARS-CoV-2 infection. Likewise, direct placental involvement by SARS-CoV-2 is a rare event.

The effects of alcohol on coagulation in trauma patients: interpreting thrombelastography with caution.

BACKGROUND: The effects of alcohol on coagulation after trauma remain unclear. In vitro studies show that alcohol may decrease clot strength and inhibit fibrinolysis. Observational data indicate that alcohol leads to altered thrombelastography (TEG) parameters indicative of impaired clot formation. Clinical studies have been inconclusive to date. METHODS: Longitudinal plasma samples were prospectively collected from 415 critically injured trauma patients at a single Level 1 trauma center and were matched with demographic and outcome data. Citrated kaolin TEG and standard coagulation measures were performed in parallel. Univariate and group comparisons were performed by alcohol status, with subsequent linear and logistic regression analysis. RESULTS: A total of 264 patients (63.6%) had detectable blood alcohol levels (EtOH, >10 mg/dL). These patients were primarily male (87% vs. 79%), were bluntly injured (77% vs. 59%), and had lower median Glasgow Coma Scale (GCS) score (9.5 vs. 14, all p < 0.05) than the EtOH-negative patients. There were no notable differences in pH (7.29 vs. 7.31, p = nonsignificant) or injury severity (median Injury Severity Score [ISS], 11 vs. 14; p = nonsignificant) between the groups. The alcohol-positive patients had a prolonged TEG citrated kaolin R-time (reaction time), or time to initial clot formation (5.91 minutes vs. 4.43 minutes, p = 0.013), prolonged K-time (kinetics time), or time to fixed level of clot strength (1.77 minutes vs. 1.43 minutes, p = 0.036), and decreased α angle (66.5 degrees vs. 70.2 degrees, p = 0.001). In multiple linear regression, for every 10-mg/dL increase in EtOH, R-time was prolonged by 3.84 seconds (p = 0.015), and α angle decreased by 0.11 degrees (p = 0.013). However, in multiple logistic regression analyses, EtOH was a negative predictor of coagulopathy by international normalized ratio (>1.3) and was not predictive of transfusion requirements or early or late mortality. CONCLUSION: Patients with elevated EtOH present with impaired clot formation as assayed by TEG, but this does not correlate with standard measures of coagulopathy or with outcome. Reliance on TEG for determining coagulopathy in intoxicated trauma patients may lead to a misperceived hypocoagulable state and inappropriate transfusion. TEG appears to be affected by EtOH in a previously unreported way, warranting further investigation. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Hospital-based violence intervention: risk reduction resources that are essential for success.

INTRODUCTION: Hospital-based violence intervention programs (VIPs) aim to reduce violent injury and recidivism. The aim of this study was to determine the most significant risk reduction variables associated with success in our VIP. We hypothesized that our recidivism rate declined since VIP's inception and that we could identify risk reduction variables that were independent determinants of program success. METHODS: We analyzed our prospectively collected data for 2005-2011 from our VIP database. Success was defined as more than 50% needs met without recidivism or attrition. Impact and outcome evaluation was performed per a model promoted by the Centers for Disease Control. Rates of risk reduction and injury recidivism were calculated. Case management time spent per client (dose) was defined as low (0-1 hours per week), medium (1-3 hours per week), moderate (3-6 hours per week), and high (>6 hours per week). Correlation coefficients and logistic regression were used to examine associations between variables and success in the VIP. RESULTS: Two hundred fifty-four clients received services. Meeting needs in mental health (odds ratio, 5.97; 95% confidence interval, 2.72-13.07) and employment (odds ratio, 4.41:95% confidence interval, 1.56-12.46) proved significantly associated with success (p < 0.005). The 6-year program recidivism rate was 4% versus historical control of 16% (p < 0.05). Moderate and high exposure to intensive case management in the first 3 months was also significantly associated with success (p < 0.05). Success in our VIP was not associated with age, gender, education level, previous incarceration, probation status, or length of time in program. DISCUSSION: For 6 years, our recidivism rate has decreased fourfold compared with the rate before VIP inception. For startup and maintenance of a VIP, it is essential to know where to focus collaborative efforts in communities to target the most critical risk reduction resources. This study provides guidance-securing mental health care and employment for our clients appears to be predictive of success. The value of early "high-dose" intensive case management is also essential for reducing recidivism. LEVEL OF EVIDENCE: Care management study, level III.