Patient-reported outcome measures evaluating postpartum maternal health and well-being: a systematic review and evaluation of measurement properties.

OBJECTIVE: This study aimed to systematically review and evaluate postpartum health and well-being using patient-reported outcome measures across all domains of postpartum health using the COnsensus-based Standards for the selection of health Measurement INstruments guidelines. DATA SOURCES: Based on a preprepared published protocol, a systematic search of PubMed, Embase, and CINAHL was undertaken to identify patient-reported outcome tools. The protocol was registered with the International Prospective Register of Systematic Reviews (registration number CRD42021283472), and this work followed the COnsensus-based Standards for the selection of health Measurement INstruments guidelines for systematic reviews. STUDY ELIGIBILITY CRITERIA: Studies eligible for inclusion included those that assessed a patient-reported outcome measure examining postpartum women's health and well-being with no limitation on the domain. The included studies aimed to evaluate one or more measurement properties of the patient-reported outcome measure. METHODS: Data extraction and the methodological assessment of the quality of the patient-reported outcome measure were assessed by 2 reviewers independently based on content validity, structural validity, internal consistency, cross-cultural validity or measurement invariance, reliability, measurement error, hypotheses testing for construct validity, and responsiveness, as defined by the COnsensus-based Standards for the selection of health Measurement INstruments. The standard used for content validity were the domains of importance to women in postpartum health and well-being proposed by the International Consortium for Health Outcomes Measurement. The outcome domains for patient-reported health status include mental health, health-related quality of life, incontinence, pain with intercourse, breastfeeding, and motherhood role transition. The quality of the methods was rated an overall rating of results, awarded a level of evidence, and assessed using the Grading of Recommendations, Assessment, Development, and Evaluations assessment tool, and a level of recommendation was awarded for each tool. RESULTS: There were 10,324 studies identified in the initial search, of which 29 tools were identified from 41 eligible studies included in the review. Moreover, 21 tools were awarded an "A" grading of recommendation for use as a patient-reported outcome measure in postpartum women following the COnsensus-based Standards for the selection of health Measurement Instruments standards. Of the "A"-rated tools, 17 (80%) examined the domain of mental health, 5 examined health-related quality of life, 4 examined breastfeeding, and 6 represented role transition. No "A"-recommended tool examined postpartum incontinence or pain with intercourse. Of note, 3 tools did not cover domains as recommended by the International Consortium for Health Outcomes Measurement, and 5 tools were awarded a "B" rating, requiring more research before their recommendation for use. Here, most tools were awarded very low-moderate Recommendations, Assessment, Development, and Evaluations level of evidence. Moreover, the highest quality tool identified that covered multiple domains of postpartum health and well-being was the women's Postpartum Quality-of-Life Questionnaire. CONCLUSION: This systematic review identified the best performing patient-reported outcome measures to assess postpartum health and well-being. No individual tool covers all 6 domains of postpartum health and well-being. Here, the highest quality tool found that covered multiple domains of postpartum health and well-being was the Postpartum Quality-of-Life Questionnaire. The Postpartum Quality-of-Life Questionnaire captures 4 of 6 domains of importance to women, with domains of incontinence and sexual health unevaluated. The domain of urinary incontinence was represented by the International Consultation on Incontinence Questionnaire Short Form, which requires further psychometric analysis before its recommended use. Postpartum sexual health, not represented by any tool, necessitates the development of a patient-reported outcome measure. A postpartum patient-reported outcome measure would be best provided by a combination of tools; however, further research is required before its implementation.

Contiguous Low Oxygen Waters between the Continental Shelf Hypoxia Zone and Nearshore Coastal Waters of Louisiana, USA: Interpreting 30 Years of Profiling Data and Three-Dimensional Ecosystem Modeling.

The multidecadal expansion of northern Gulf of Mexico continental shelf hypoxia is a striking example of the adverse effects of anthropogenic nutrient enrichment on coastal oceans. Increased nutrient inputs and widespread shelf hypoxia have resulted in numerous dissolved oxygen (DO) water quality problems in nearshore coastal waters of Louisiana. A large hydrographic dataset compiled from research programs spanning 30 years and the three-dimensional hydrodynamic-biogeochemical model CGEM (Coastal Generalized Ecosystem Model) were integrated to explore the interconnections of low DO waters across the continental shelf to nearshore coastal waters of Louisiana. Cross-shelf vertical profiles showed contiguous low DO bottom waters extending from the shelf to coastal waters nearly every year in the 30+ year time series, which were concurrent with strong cross-shelf pycnoclines. A threshold Brunt-Väisälä frequency of 40 cycles h-1 was critical to maintaining the cross-shelf subpycnocline layers and facilitating the formation of a contiguous low DO water mass. Field observations and model simulations identified periods of wind-driven bottom water upwelling lasting between several days to several weeks, resulting in both physical advection of oxygen-depleted offshore waters to the nearshore and enhanced nearshore stratification. Both the upwelling of low DO bottom waters and in situ respiration were of sufficient temporal and spatial extent to drive DO below Louisiana's DO water quality criteria. Basin-wide nutrient management strategies aimed at reducing nutrient inputs and shelf hypoxia remain essential to improving the nearshore coastal water quality across the northern Gulf of Mexico.

The impact of alternative nutrient kinetics and computational grid size on model predicted primary production and hypoxic area in the northern Gulf of Mexico.

Model structure uncertainty is seldom calculated because of the difficulty and time required to perform such analyses. Here we explore how a coastal model using the Monod versus Droop formulations and a 6 km × 6 km versus 2 km 2 × km computational grid size predict primary production and hypoxic area in the Gulf of Mexico. Results from these models were compared to each other and to observations, and sensitivity analyses were performed. The different models fit the observations almost equally well. The 6k-model calculated higher rates of production and settling, and especially a larger hypoxic area, in comparison to the 2k-model. The Monod-based model calculated higher production, especially close to the river delta regions, but smaller summer hypoxic area, than the model using the Droop formulation. The Monod-based model was almost twice as sensitive to changes in nutrient loads in comparison to the Droop model, which can have management implications.

Characterizing light attenuation within Northwest Florida Estuaries: Implications for RESTORE Act water quality monitoring.

Water Quality (WQ) condition is based on ecosystem stressor indicators (e.g. water clarity) which are biogeochemically important and critical when considering the Deepwater Horizon oil spill restoration efforts under the 2012 RESTORE Act. Nearly all of the proposed RESTORE projects list restoring WC as a goal, but 90% neglect water clarity. Here, dynamics of optical constituents impacting clarity are presented from a 2009-2011 study within Pensacola, Choctawhatchee, St. Andrew and St. Joseph estuaries (targeted RESTORE sites) in Northwest Florida. Phytoplankton were the smallest contribution to total absorption (at-wPAR) at 412nm (5-11%), whereas colored dissolved organic matter was the largest (61-79%). Estuarine at-wPAR was significantly related to light attenuation (KdPAR), where individual contributors to clarity and the influence of climatic events were discerned. Provided are conversion equations demonstrating interoperability of clarity indicators between traditional State-measured WQ measures (e.g. secchi disc), optical constituents, and even satellite remote sensing for obtaining baseline assessments.

Comparative toxicity of eight oil dispersants, Louisiana sweet crude oil (LSC), and chemically dispersed LSC to two aquatic test species.

The present study describes the acute toxicity of eight commercial oil dispersants, South Louisiana sweet crude oil (LSC), and chemically dispersed LSC. The approach used consistent test methodologies within a single laboratory in assessing the relative acute toxicity of the eight dispersants, including Corexit 9500A, the predominant dispersant applied during the DeepWater Horizon spill in the Gulf of Mexico. Static acute toxicity tests were performed using two Gulf of Mexico estuarine test species, the mysid shrimp (Americamysis bahia) and the inland silversides (Menidia beryllina). Dispersant-only test solutions were prepared with high-energy mixing, whereas water-accommodated fractions of LSC and chemically dispersed LSC were prepared with moderate energy followed by settling and testing of the aqueous phase. The median lethal concentration (LC50) values for the dispersant-only tests were calculated using nominal concentrations, whereas tests conducted with LSC alone and dispersed LSC were based on measured total petroleum hydrocarbon (TPH) concentrations. For all eight dispersants in both test species, the dispersants alone were less toxic (LC50s: 2.9 to >5,600 µl/L) than the dispersant-LSC mixtures (0.4-13 mg TPH/L). Louisiana sweet crude oil alone had generally similar toxicity to A. bahia (LC50: 2.7 mg TPH/L) and M. beryllina (LC50: 3.5 mg TPH/L) as the dispersant-LSC mixtures. The results of the present study indicate that Corexit 9500A had generally similar toxicity to other available dispersants when tested alone but was generally less toxic as a mixture with LSC.

Multiple regression models for hindcasting and forecasting midsummer hypoxia in the Gulf of Mexico.

A new suite of multiple regression models was developed that describes relationships between the area of bottom water hypoxia along the northern Gulf of Mexico and Mississippi-Atchafalaya River nitrate concentration, total phosphorus (TP) concentration, and discharge. Model input variables were derived from two load estimation methods, the adjusted maximum likelihood estimation (AMLE) and the composite (COMP) method, developed by the U.S. Geological Survey. Variability in midsummer hypoxic area was described by models that incorporated May discharge, May nitrate, and February TP concentrations or their spring (discharge and nitrate) and winter (TP) averages. The regression models predicted the observed hypoxic area within +/-30%, yet model residuals showed an increasing trend with time. An additional model variable, Epoch, which allowed post-1993 observations to have a different intercept than earlier observations, suggested that hypoxic area has been 6450 km2 greater per unit discharge and nutrients since 1993. Model forecasts predicted that a dual 45% reduction in nitrate and TP concentration would likely reduce hypoxic area to approximately 5000 km2, the coastal goal established by the Mississippi River/Gulf of Mexico Watershed Nutrient Task Force. However, the COMP load estimation method, which is more accurate than the AMLE method, resulted in a smaller predicted hypoxia response to any given nutrient reduction than models based on the AMLE method. Monte Carlo simulations predicted that five years after an instantaneous 50% nitrate reduction or dual 45% nitrate and TP reduction it would be possible to resolve a significant reduction in hypoxic area. However, if nutrient reduction targets were achieved gradually (e.g., over 10 years), much more than a decade would be required before a significant downward trend in both nutrient concentrations and hypoxic area could be resolved against the large background of interannual variability. The multiple regression models and statistical approaches applied provide improved capabilities for evaluating dual nutrient management strategies to address Gulf hypoxia and a clearer perspective on the strengths and limitations of approaching the problem using regression models.