Should I vote-by-mail or in person? The impact of COVID-19 risk factors and partisanship on vote mode decisions in the 2020 presidential election.

While the evidence is clear that 2020 voters shifted away from Election Day voting in favor of vote-by-mail and early voting, we know very little about how health risk versus party polarization around risk assessment influenced how and when to vote. We rely on individual-level observational data in the form of high-quality official voter administrative records from the State of New Mexico to ask how pandemic-related risk factors, especially voter age along with partisanship influenced voter decision-making. To identify causal factors, we use a difference-in-differences design and hazard model that compare 2020 general election and primary voter behavior to 2018 and 2016. We find that age and party were large factors in vote mode decisions in 2020, but not in 2016 or 2018. We consider the implications of our findings on how health risk and partisanship interact to influence decision-making.

What Is New in Cesarean Delivery?: Best Articles From the Past Year.

This month we focus on current research in cesarean delivery. Dr. Hansen discusses eight recent publications, which are concluded with a "bottom-line" that is the take-home message. A complete reference for each can be found on on this page along with direct links to abstracts.

Evolving Practice Patterns in Imaging Pregnant Patients With Acute Abdominal and Pelvic Conditions.

OBJECTIVE: The purpose of our study was to determine the current practice patterns of U.S. radiologists in imaging pregnant or potentially pregnant patients with acute abdominal and pelvic conditions. MATERIALS AND METHODS: After obtaining an Institutional Review Board waiver, all members of the Association of University Radiologists, the Association of Program Directors in Radiology, and the Society of Radiologists in Ultrasound were invited via e-mail to take a 23-question online survey on radiology practices and clinical scenarios about acute abdominal and pelvic imaging of pregnant patients. RESULTS: Comparisons were made with previously published surveys. A total of 225 responses were received. Areas of high consensus included pregnancy assessment (97%) and obtaining informed consent (87%) before imaging, having a written policy on imaging pregnant patients (79%), modification of computed tomography (CT) protocols (74%), avoiding gadolinium contrast in magnetic resonance imaging (MRI) (74%), using ultrasound for initial imaging in some scenarios, and using CT in trauma cases after inconclusive ultrasound. Areas of emerging consensus compared to 2007 included the use of serum or urine testing to confirm pregnancy status (59.4%; previously 14%) and the use of MRI in suspected appendicitis after an inconclusive ultrasound (73% in first trimester and 67% in third trimester; previously 46% and 29%, respectively). Areas without clear consensus included policy development, additional modifications to MRI protocols, choice of imaging modality, radiation dose, and the use of contrast agents in some scenarios. CONCLUSION: In conclusion, high or increasing consensus exists in some areas of imaging pregnant patients with acute abdominal and pelvic conditions, but has yet to emerge in other areas.

Autoantibodies to two novel peptides in seronegative and early rheumatoid arthritis.

OBJECTIVES: Despite recent progress in biomarker discovery for RA diagnostics, still over one-third of RA patients-and even more in early disease-present without RF or ACPA. The aim of this study was to confirm the presence of previously identified autoantibodies to novel Hasselt University (UH) peptides in early and seronegative RA. METHODS: Screening for antibodies against novel UH peptides UH-RA.1, UH-RA.9, UH-RA.14 and UH-RA.21, was performed in two large independent cohorts. Peptide ELISAs were developed to screen for the presence of antibodies to UH-RA peptides. First, 292 RA patients (including 39 early patients), 90 rheumatic and 97 healthy controls from UH were studied. Antibody reactivity to two peptides (UH-RA.1 and UH-RA.21) was also evaluated in 600 RA patients, 309 patients with undifferentiated arthritis and 157 rheumatic controls from the Leiden Early Arthritis Clinic cohort. RESULTS: In both cohorts, 38% of RA patients were seronegative for RF and ACPA. Testing for autoantibodies to UH-RA.1 and UH-RA.21 reduced the serological gap from 38% to 29% in the UH cohort (P = 0.03) and from 38% to 32% in the Leiden Early Arthritis Clinic cohort (P = 0.01). Furthermore, 19-33% of early RA patients carried antibodies to these peptides. Specificities in rheumatic controls ranged from 82 to 96%. Whereas antibodies against UH-RA.1 were related to remission, anti-UH-RA.21 antibodies were associated with inflammation, joint erosion and higher tender and swollen joint counts. CONCLUSION: This study validates the presence of antibody reactivity to novel UH-RA peptides in seronegative and early RA. This might reinforce current diagnostics and improve early diagnosis and intervention in RA.

Multimodality imaging of pancreatic arteriovenous malformation.

Arteriovenous malformation of the pancreas (PAVM) is a very rare entity, although it may be increasingly diagnosed with the expanding use of cross-sectional imaging of the abdomen. PAVM is characterized by a network of tangled vasculature within and surrounding all or part of the pancreas, resulting in the shunting of the arteries of the pancreas directly into the portal venous system. Here, we present a patient with chronic abdominal pain and pancreatitis found to have PAVM, based on the findings of computed tomography, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography, and angiography. Differential considerations are discussed. Although PAVM is uncommon, it should be considered in the differential of patients with recurrent abdominal pain or gastrointestinal bleeding.

The use of digital peripheral artery tonometry to detect endothelial dysfunction in pregnant women who smoke.

OBJECTIVE: We hypothesized that, as has been shown outside of pregnancy, endothelial dysfunction would be seen in a dose-dependent fashion among women who smoke in the midtrimester of pregnancy. STUDY DESIGN: Endothelial function in women with singleton pregnancies between 16 and 23 weeks was analyzed utilizing the Endo-PAT2000 device (Itamar Medical Ltd., Caesarea, Israel) and expressed as a reactive hyperemia ratio (RHI). Serum was drawn to check cotinine and high-sensitivity C-reactive protein (CRP) levels. SAS 9.2 (SAS Institute, Cary, NC) was used to perform statistical tests including Student t test, analysis of variance, Fisher exact test, and Pearson coefficient. RESULTS: Endothelial function was noninvasively examined in 29 smokers and 31 nonsmokers. Demographics including age, race, and parity were similar between groups. Mean RHI was not significantly different between smokers and nonsmokers (1.43 ± 0.32 versus 1.53 ± 0.39, p = 0.27). No correlation was noted when cotinine values were plotted against RHI or CRP values in smokers (rho = 0.24, p = 0.21 and rho = 0.26, p = 0.18, respectively). RHI did correlate with diastolic blood pressure (rho = -0.40, p = 0.002), systolic blood pressure (rho = -0.35, p = 0.006), and heart rate (rho = -0.37, p = 0.004). CONCLUSION: We did not find an association between smoking status and endothelial dysfunction in the midtrimester utilizing a noninvasive methodology.

A real-time PCR-based semi-quantitative breakpoint to aid in molecular identification of urinary tract infections.

This study presents a novel approach to aid in diagnosis of urinary tract infections (UTIs). A real-time PCR assay was used to screen for culture-positive urinary specimens and to identify the causative uropathogen. Semi-quantitative breakpoints were used to screen for significant bacteriuria (presence of ≥ 10(5) CFU/ml of uropathogens) or low-level bacteriuria (containing between 10(3) and 10(4) CFU/ml of uropathogens). The 16S rDNA-based assay could identify the most prevalent uropathogens using probes for Escherichia coli, Pseudomonas species, Pseudomonas aeruginosa, Staphylococcus species, Staphylococcus aureus, Enterococcus species and Streptococcus species. 330 urinary specimens were analysed and results were compared with conventional urine culture. Using a PCR Ct value of 25 as semi-quantitative breakpoint for significant bacteriuria resulted in a sensitivity and specificity of 97% and 80%, respectively. In 78% of the samples with monomicrobial infections the assay contained probes to detect the bacteria present in the urine specimens and 99% of these uropathogens was correctly identified. Concluding, this proof-of-concept approach demonstrates that the assay can distinguish bacteriuria from no bacteriuria as well as detect the involved uropathogen within 4 hours after sampling, allowing adequate therapy decisions within the same day as well as drastically reduce consequent urine culturing.

Up-regulation of oxytocin receptor expression at term is related to maternal body mass index.

BACKGROUND: The likelihood of cesarean is in part related to maternal body mass index (BMI). Myometrial changes may be responsible. METHODS: Myometrial biopsies were collected from the upper edge of the hysterotomy from women undergoing scheduled cesarean with term, singleton gestations. Oxytocin receptor and connexin-43 mRNA protein expression was quantified with real-time polymerase chain reaction and Western blot. RESULTS: Twenty subjects were recruited: 13 repeat and 7 primary cesareans. Oxytocin receptor mRNA was associated with BMI among women undergoing primary (r = 0.75; p = 0.05) but not repeat cesarean (p > 0.05). Controlling for gestational age, this association strengthened (p = 0.004). Receptor protein expression showed a linear correlation with BMI in the primary cesarean group (p = 0.002). Connexin-43 mRNA expression was not related to BMI in women undergoing primary (r = -0.14, p = 0.76) or repeat (r = -0.01, p = 0.86) cesarean. CONCLUSIONS: Oxytocin receptor, but not connexin-43, expression is related to BMI, suggesting an alteration in oxytocin receptor expression or function related to obesity.

Intervención domiciliaria y variables predictoras para reingreso hospitalario en la enfermedad pulmonar obstructiva crónica agudizada / Home Intervention and Predictor Variables for Rehospitalization in Chronic Obstructive Pulmonary Disease Exacerbations

Introducción: La enfermedad pulmonar obstructiva crónica (EPOC) agudizada aumenta la mortalidad y los recursos asociados con la hospitalización. Se estudia si un control domiciliario precoz disminuye la tasa de reingresos y si existen variables que puedan predecirlo. Pacientes y métodos: Se realiza un estudio prospectivo, controlado en grupos paralelos en pacientes ingresados por EPOC. Los pacientes que residían a menos de 15km del hospital fueron asignados a un grupo de intervención (visita domiciliaria por una enfermera en las 48-72h tras el alta) y los restantes a un grupo de cuidados habituales. Se compararon en ambos grupos la tasa de reingresos hospitalarios en el primer mes y las variables capaces de predecirlo. Resultados: Fueron incluidos 71 enfermos, 35 en el grupo de cuidados convencionales y 36 en el grupo de intervención; en este último se modificó el tratamiento en 13 sujetos (36% de los enfermos). La tasa de reingreso fue del 17%, siendo similar en ambos grupos (p=0,50). Por cada aumento de 5 años en la edad, el riesgo de reingreso fue de 2,54 (IC95%, 1,06 a 5,07) y por cada incremento de 10mmHg en la PaCO2, el riesgo de reingreso fue de 8,34 (IC95%, 2,43 a 18,55). Conclusiones: El control domiciliario precoz no disminuyó la tasa de reingresos durante el primer mes. Una mayor edad y una PaCO2 elevada son factores que identifican a un grupo con elevado riesgo de reingreso(AU)

Background: Chronic obstructive pulmonary disease (COPD) exacerbation increases mortality and resources used associated with hospitalization. We studied whether early home monitoring reduces the rate of readmission and if there are any predictor variables. Patients and methods: We performed a prospective, controlled, parallel-group study in patients who were hospitalized for COPD. Patients whose residence was within less than 15km from the hospital were assigned to an interventional group (home visits by nurses about 48-72hours after discharge), the remainder were assigned to a conventional care group. The rate of rehospitalization within the first month was compared between the two groups, as well as those variables that showed a predictive capability. Results: Seventy one patients were included: 35 in the conventional care group and 36 in the interventional group. In the latter, the treatment was modified in 13 patients (36%). The hospital readmission rate was 17%, which was similar in both groups (P=.50). For every 5-year increase in age, the risk for readmission was 2.54 (95%CI, 1.06-5.07) and for each increase of 10mmHg in PaCO2, the risk of readmission was 8.34 (95%CI, 2.43-18.55). Conclusions: Early home monitoring did not decrease the readmission rate during the first month. Older age and high PaCO2 are factors that identify the group with a high risk for rehospitalization(AU)

Pre-analytical sample treatment and DNA extraction protocols for the detection of bacterial pathogens from whole blood.

Molecular diagnostics is an increasing popular approach for the direct detection and identification of pathogenic bacteria in clinical samples. Conventional culture techniques are time-consuming and therefore causing a delay in the diagnosis of the patient. Alternative techniques based on nucleic acid amplification offer a shorter turn-around-time and the ability to identify fastidious and non-cultivable organisms. However, molecular detection of bacteria in blood, by for example PCR, RT-PCR, or sequencing of the 16S rDNA genes is often complicated by the presence of PCR-inhibitory compounds. Here we describe several different methods for the extraction of bacterial DNA from whole blood samples. The methods differ regarding costs, hands-on time as well as regarding sensitivity. In combination with a model PCR the detection limits that can be reached using the different methods range from 1,000 to 50 cfu/ml.

Headache and neurological disease in pregnancy.

A review of the approach in pregnancy to a very commonly encountered neurological disorder (headache), along with less commonly encountered neurological entities that none the less deserve the obstetrician's attention. Definitions of specific disorders and differential diagnoses are reviewed, along with treatment options and pregnancy-associated morbidities. Headache is reviewed first including the common primary headaches migraine and tension-type headache. The disabling neurological disorders-multiple sclerosis, cerebral palsy, and spinal cord injury are grouped due to common morbidities affecting pregnancy. Finally, Bell palsy is also reviewed.

One-day workflow scheme for bacterial pathogen detection and antimicrobial resistance testing from blood cultures.

Bloodstream infections are associated with high mortality rates because of the probable manifestation of sepsis, severe sepsis and septic shock(1). Therefore, rapid administration of adequate antibiotic therapy is of foremost importance in the treatment of bloodstream infections. The critical element in this process is timing, heavily dependent on the results of bacterial identification and antibiotic susceptibility testing. Both of these parameters are routinely obtained by culture-based testing, which is time-consuming and takes on average 24-48 hours(2, 4). The aim of the study was to develop DNA-based assays for rapid identification of bloodstream infections, as well as rapid antimicrobial susceptibility testing. The first assay is a eubacterial 16S rDNA-based real-time PCR assay complemented with species- or genus-specific probes(5). Using these probes, Gram-negative bacteria including Pseudomonas spp., Pseudomonas aeruginosa and Escherichia coli as well as Gram-positive bacteria including Staphylococcus spp., Staphylococcus aureus, Enterococcus spp., Streptococcus spp., and Streptococcus pneumoniae could be distinguished. Using this multiprobe assay, a first identification of the causative micro-organism was given after 2 h. Secondly, we developed a semi-molecular assay for antibiotic susceptibility testing of S. aureus, Enterococcus spp. and (facultative) aerobe Gram-negative rods(6). This assay was based on a study in which PCR was used to measure the growth of bacteria(7). Bacteria harvested directly from blood cultures are incubated for 6 h with a selection of antibiotics, and following a Sybr Green-based real-time PCR assay determines inhibition of growth. The combination of these two methods could direct the choice of a suitable antibiotic therapy on the same day (Figure 1). In conclusion, molecular analysis of both identification and antibiotic susceptibility offers a faster alternative for pathogen detection and could improve the diagnosis of bloodstream infections.

Extreme morbid obesity and labor outcome in nulliparous women at term.

We examined the prevalence of cesarean delivery (CD) among women with morbid obesity and extreme morbid obesity. Using Kentucky birth certificate data, a cross-sectional analysis of nulliparous singleton gestations at term was performed. We examined the prevalence of CD by body mass index (BMI; in kg/m2) using the National Institutes of Health/World Health Organization schema and a modified schema that separates extreme morbid obesity (BMI ≥ 50) from morbid obesity (BMI ≥ 40 to < 50). Bivariate and multivariate analyses were performed. Multivariate modeling controlled for maternal age, estimated gestational age, birth weight, diabetes, and hypertensive disorders. Overall, 83,278 deliveries were analyzed. CD was most common among women with a prepregnancy BMI ≥ 50 (56.1%, 95% confidence interval 50.9 to 61.4%). Extreme morbid obesity was most strongly associated with CD (adjusted odds ratio 4.99, 95% confidence interval 4.00 to 6.22). Labor augmentation decreased the likelihood of CD among women with extreme morbid obesity, but this failed to reach statistical significance. We speculate a qualitative or quantitative deficiency in the hormonal regulation of labor exists in the morbidly obese parturient. More research is needed to better understand the influence of morbid obesity on labor.

Violence against women and postpartum depression.

BACKGROUND: Violence against women (VAW), including intimate partner violence (IPV) in its various forms (sexual, physical, or stalking), and childhood violence (sexual or physical) are common and are associated with depressive symptoms. We examined the association between these violence exposures and self-reported history of postpartum depression (PPD). METHODS: Women from the Kentucky Women's Health Registry (KWHR) who reported at least one live birth were included in this study. Individual IPV and child abuse histories were examined for association with self-reported history of PPD. Multivariate regression analysis estimated adjusted risk ratios (aRR) and 95% confidence intervals (95% CI), controlling for age, obstetrical history, and substance abuse history. RESULTS: The 5380 women in the KWHR reporting at least one live birth were included in this study. Of these women, 2508 (46.6%) reported a history of any VAW. A history of adult VAW was associated with a history of PPD (aRR 1.48, 95% CI 1.12-1.95). Physical IPV (aRR 1.48, 95% CI 1.12-1.95) and stalking IPV (aRR 1.39, 95% CI1.03-1.87) were individually associated with PPD. Other types of violence were not individually associated with a history of PPD. The strength of association increased with each additional type of violence experienced (aRR1.17, 95% CI 1.06-1.30). CONCLUSIONS: Adult VAW is associated with self-reported history of PPD. With an increase in the number of types of abuse experienced, this association became stronger. Our findings highlight the need for thorough VAW screening in obstetrical populations.

Molecular probes for diagnosis of clinically relevant bacterial infections in blood cultures.

Broad-range real-time PCR and sequencing of the 16S rRNA gene region is a widely known method for the detection and identification of bacteria in clinical samples. However, because of the need for sequencing, such identification of bacteria is time-consuming. The aim of our study was to develop a more rapid 16S real-time PCR-based identification assay using species- or genus-specific probes. The Gram-negative bacteria were divided into Pseudomonas species, Pseudomonas aeruginosa, Escherichia coli, and other Gram-negative species. Within the Gram-positive species, probes were designed for Staphylococcus species, Staphylococcus aureus, Enterococcus species, Streptococcus species, and Streptococcus pneumoniae. The assay also included a universal probe within the 16S rRNA gene region for the detection of all bacterial DNA. The assay was evaluated with a collection of 248 blood cultures. In this study, the universal probe and the probes targeting Pseudomonas spp., P. aeruginosa, E. coli, Streptococcus spp., S. pneumoniae, Enterococcus spp., and Staphylococcus spp. all had a sensitivity and specificity of 100%. The probe specific for S. aureus showed eight discrepancies, resulting in a sensitivity of 100% and a specificity of 93%. These data showed high agreement between conventional testing and our novel real-time PCR assay. Furthermore, this assay significantly reduced the time needed for identification. In conclusion, using pathogen-specific probes offers a faster alternative for pathogen detection and could improve the diagnosis of bloodstream infections.

Evaluation of new preanalysis sample treatment tools and DNA isolation protocols to improve bacterial pathogen detection in whole blood.

Two novel preanalysis sample treatment tools were evaluated in combination with four DNA extraction kits for the selective isolation of bacterial DNA from whole blood. The combination of performing a preanalysis sample treatment and using a larger sample volume increased the detection limit to 50 CFU per ml.

Factors associated with substance use during pregnancy: results from a national sample.

OBJECTIVE: To examine the prevalence and correlates of substance use during pregnancy among women in the United States. METHODS: We analyzed data from pregnant (n=1800) and non-pregnant women (n=37,527) aged 15-44 years who participated in the 2002 or 2003 National Survey on Drug Use and Health, a nationally representative epidemiologic survey. Study variables included demographics, any substance use in the prior 30 days, and possible current psychopathology. Data were analyzed using weighted chi-square and multiple logistic regressions that accounted for the complex survey design. RESULTS: The overall prevalence of any past month substance use during pregnancy was 25.8%; the prevalence rates of past month illicit drug, cigarette and alcohol use were 4.7%, 18.9% and 10%, respectively. Compared to the prevalence of substance use among women in their first trimester, use was significantly lower among women in their second or third trimesters. Women who reported using substances during pregnancy were significantly more likely to meet the criteria for possible current psychopathology and be White. Additionally, women who were employed, married, and in their second or third trimester compared to the first were significantly less likely to have used any substance during pregnancy, adjusting for age, ethnicity and income. CONCLUSIONS: Although the prevalence of substance use among pregnant women was significantly lower than non-pregnant women, some groups of women remain vulnerable to continued use, including those who are unemployed, unmarried, and experiencing possible current psychopathology. Prevention and intervention programs aimed at high-risk populations are warranted to reduce the deleterious effects of substance use on pregnancy outcomes.

Sonographic findings of trisomy 18 in the second trimester of pregnancy.

OBJECTIVE: The purpose of this study was to examine the sonographic findings in fetuses with trisomy 18 in the second trimester of pregnancy. METHODS: A retrospective review of the cytogenetic laboratory databases at 6 tertiary referral centers identified all cases of trisomy 18. The prenatal sonographic studies in fetuses at 15 to 21 weeks' gestation, done before invasive testing for the karyotype, were reviewed for anatomic and biometric findings. We defined abnormal fetal biometric findings as a biometric measurement (biparietal diameter, abdominal circumference, or femur length) below the fifth percentile in the second trimester. RESULTS: Of 98 fetuses with trisomy 18, 95 (97%) were detected sonographically; an anomaly was found in 92 (94%). A biometric measurement below the fifth percentile was noted in 50 (51%). Cardiac (63%) and central nervous system (34%) anomalies were most frequently detected. Although choroid plexus cysts were commonly seen, no fetuses with trisomy 18 and isolated choroid plexus cysts were found. CONCLUSIONS: Targeted sonography identified abnormal fetal anatomy or abnormal biometric findings in 97% of fetuses with trisomy 18 in the second trimester. A biometric measurement below the fifth percentile was noted in half of the cases in the second trimester.

Tonic shock induces detachment of Giardia lamblia.

BACKGROUND: The parasite Giardia lamblia must remain attached to the host small intestine in order to proliferate and subsequently cause disease. However, little is known about the factors that may cause detachment in vivo, such as changes in the aqueous environment. Osmolality within the proximal small intestine can vary by nearly an order of magnitude between host fed and fasted states, while pH can vary by several orders of magnitude. Giardia cells are known to regulate their volume when exposed to changes in osmolality, but the short-timescale effects of osmolality and pH on parasite attachment are not known. METHODOLOGY AND PRINCIPAL FINDINGS: We used a closed flow chamber assay to test the effects of rapid changes in media osmolality, tonicity, and pH on Giardia attachment to both glass and C2(Bbe)-1 intestinal cell monolayer surfaces. We found that Giardia detach from both surfaces in a tonicity-dependent manner, where tonicity is the effective osmolality experienced by the cell. Detachment occurs with a characteristic time constant of 25 seconds (SD = 10 sec, n = 17) in both hypo- and hypertonic media but is otherwise insensitive to physiologically relevant changes in media composition and pH. Interestingly, cells that remain attached are able to adapt to moderate changes in tonicity. By exposing cells to a timed pattern of tonicity variations and adjustment periods, we found that it is possible to maximize the tonicity change experienced by the cells, overcoming the adaptive response and resulting in extensive detachment. CONCLUSIONS AND SIGNIFICANCE: These results, conducted with human-infecting Giardia on human intestinal epithelial monolayers, highlight the ability of Giardia to adapt to the changing intestinal environment and suggest new possibilities for treatment of giardiasis by manipulation of tonicity in the intestinal lumen.