Asian-white disparities in obstetric anal sphincter injury: Protocol for a systematic review and meta-analysis.

BACKGROUND: Obstetric anal sphincter injury (OASI) describes severe injury to the perineum and perineum and perianal muscles following birth and occurs in 4.4% to 6.0% of vaginal births in Canada. Studies from high-income countries have identified an increased risk of OASI in individuals who identify as Asian race versus those who identify as white. This protocol outlines a systematic review and meta-analysis which aims to determine the incidence of OASI in individuals living in high-income countries who identify as Asian versus those of white race/ethnicity. We hypothesize that the pooled incidence of OASI will be higher in Asian versus white birthing individuals. METHODS: We will search MEDLINE, OVID, Embase, Emcare and Cochrane databases from inception to 2022 for observational studies using keywords and controlled vocabulary terms related to race, ethnicity and OASI. Two reviewers will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and Meta-analysis of Observational Studies (MOOSE) recommendations. Meta-analysis will be performed using RevMan for dichotomous data using the random effects model and the odds ratio (OR) as effect measure with a 95% confidence interval (CI). Subgroup analysis will be performed based on Asian subgroups (e.g., South Asian, Filipino, Chinese, Japanese individuals). Study quality assessment will be performed using The Joanna Briggs Institute Critical Appraisal tools. DISCUSSION: The systematic review and meta-analysis that this protocol outlines will synthesize the extant literature to better estimate the rates of OASI in Asian and white populations in non-Asian, high-income settings and the relative risk of OASI between these two groups. This systematic summary of the evidence will inform the discrepancy in health outcomes experienced by Asian and white birthing individuals. If these findings suggest a disproportionate burden among Asians, they will be used to advocate for future studies to explore the causal mechanisms underlying this relationship, such as differential care provision, barriers to accessing care, and social and institutional racism. Ultimately, the findings of this review can be used to frame obstetric care guidelines and inform healthcare practices to ensure care that is equitable and accessible to diverse populations.

COVID-19 and neurodegeneration: The mitochondrial connection.

There is still a significant lack of knowledge regarding many aspects of the etiopathology and consequences of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in humans. For example, the variety of molecular mechanisms mediating this infection, and the long-term consequences of the disease remain poorly understood. It first seemed like the SARS-CoV-2 infection primarily caused a serious respiratory syndrome. However, over the last years, an increasing number of studies also pointed towards the damaging effects of this infection has on the central nervous system (CNS). In fact, evidence suggests a possible disruption of the blood-brain barrier and deleterious effects on the CNS, especially in patients who already suffer from other pathologies, such as neurodegenerative disorders. The molecular mechanisms behind these effects on the CNS could involve the dysregulation of mitochondrial physiology, a well-known early marker of neurodegeneration and a hallmark of aging. Moreover, mitochondria are involved in the activation of the inflammatory response, which has also been broadly described in the CNS in COVID-19. Here, we critically review the current bibliography regarding the presence of neurodegenerative symptoms in COVID-19 patients, with a special emphasis on the mitochondrial mechanisms of these disorders.

Prevalence And Impact of Medical Comorbidities in A Real-World Lung Cancer Screening Population.

BACKGROUND: Lung cancer screening trials generally enroll motivated, relatively healthy, and adherent populations. We therefore evaluated the prevalence and effects of comorbidities in a real-world population undergoing low-dose computed tomography (LDCT) scans. PATIENTS AND METHODS: We calculated the Charlson Comorbidity Index (CCI) of patients for whom an initial low-dose computed tomography (LDCT) for lung cancer screening was ordered between February 2017 and February 2019 in an integrated safety-net healthcare system. We examined the association between CCI and initial LDCT completion using multivariable logistic regression, assessed the association between specific medical comorbidity and LDCT completion using Chi-square test or Fisher's exact test as appropriate, and examined the association between CCI and LDCT Lung-RADS results using Fisher's exact test. RESULTS: A total of 1358 patients were included in the analysis. Mean age was 63 years, 57% were women, and 50% were Black. Patients had moderate comorbidity burden (median CCI 3) with chronic pulmonary disease the most common comorbidity. Overall, 943 LDCT (70%) were completed. There was no difference in 30-day, 90-day, or 1-year completion rates of initial LDCT according to CCI. However, 30-day LDCT completion rates did increase over time (P < .001). Lung-RADS scores were not associated with CCI. CONCLUSION: In a real-world setting, patients undergoing lung cancer screening have moderate comorbidity burden. The degree and type of medical comorbidity are not associated with initial screening completion or results. Timeliness of LDCT completion may improve as program experience increases.

Making good care essential: The impact of increased obstetric interventions and decreased services during the COVID-19 pandemic.

PROBLEM & BACKGROUND: Since the onset of the COVID-19 pandemic in Canada, policies have been implemented to limit interpersonal contact in clinical and community settings. The impacts of pandemic-related policies on experiences of pregnancy and birth are crucial to investigate and learn from. AIM: To examine the impact of pandemic policy changes on experiences of pregnancy and birth, thereby identifying barriers to good care; to inform understandings of medicalization, care, pregnancy, and subjectivity during times of crisis; and to critically examine the assumptions about pregnancy and birth that are sustained and produced through policy. METHODS: Qualitative descriptive study drawing on 67 in-depth interviews with people who were pregnant and/or gave birth in Canada during the pandemic. The study took a social constructionist standpoint and employed thematic analysis to derive meaning from study data. FINDINGS: The pandemic has resulted in an overall scaling back of perinatal care alongside the heavy use of interventions (e.g., induction of labour, cesarian section) in response to pandemic stresses and uncertainties. Intervention use here is an outcome of negotiation and collaboration between pregnant people and their care providers as they navigate pregnancy and birth in stressful, uncertain conditions. DISCUSSION: Continuity of care throughout pregnancy and postpartum, labour support persons, and non-clinical services and interventions for pain management are all essential components of safe maternal healthcare. However, pandemic perinatal care demonstrates that they are not viewed as such. CONCLUSION: The pandemic has provided an opportunity to restructure Canadian reproductive health care to better support and encourage out-of-hospital births - including midwife-assisted births - for low-risk pregnancies.

Sources of exposure identified through structured interviews of healthcare workers who test positive for severe acute respiratory coronavirus virus 2 (SARS-CoV-2): A prospective analysis at two teaching hospitals.

We interviewed 1,208 healthcare workers with positive SARS-CoV-2 tests between October 2020 and June 2021 to determine likely exposure sources. Overall, 689 (57.0%) had community exposures (479 from household members), 76 (6.3%) had hospital exposures (64 from other employees including 49 despite masking), 11 (0.9%) had community and hospital exposures, and 432 (35.8%) had no identifiable source of exposure.

Low Risk of Coronavirus Disease 2019 (COVID-19) Among Patients Exposed to Infected Healthcare Workers.

Many patients are fearful of acquiring coronavirus disease 2019 (COVID-19) in hospitals and clinics. We characterized the risk of COVID-19 among 226 patients exposed to healthcare workers with confirmed COVID-19. One patient may have been infected, suggesting that the risk of COVID-19 transmission from healthcare workers to patients is generally low.

Clinician-ordered peripheral blood smears have low reimbursement and variable clinical value: a three-institution study, with suggestions for operational efficiency.

BACKGROUND: Peripheral blood smears are performed to evaluate a variety of hematologic and non-hematologic disorders. At the authors' institutions, clinician requests for pathologist-performed blood smear reviews have increased in recent years. Blood smears may contribute significantly to pathologists' workloads, yet their clinical value is variable, and professional reimbursement rates are low. This study aimed to identify clinical scenarios in which smear review is likely to provide value beyond automated laboratory testing. METHODS: Blood smear review practices at three institutions were examined, and the indications for and interpretations of clinician-initiated smears were reviewed to determine the percentage of smears with potential added clinical value. A smear review was classified as having added clinical value if the pathologist's interpretation included a morphologic abnormality that had the potential to impact patient management, and that could not be diagnosed by automated complete blood count with white blood cell differential or automated iron studies alone. RESULTS: Among 515 consecutive clinician-requested smears performed during the study timeframes, 23% yielded interpretations with potential added clinical value. When sorted by indication, 25, 19, and 13% of smear reviews requested for white blood cell abnormalities, red blood cell abnormalities, and platelet abnormalities, respectively, had findings with potential added clinical value. The proportion of smears with potential clinical value differed significantly across these three categories (p = 0.0375). CONCLUSIONS: Smear review ordering practices across three institutions resulted in a minority of smears with potential added clinical value. The likelihood of value varied according to the indication for which the smear was requested. Given this, efforts to improve the utilization and efficiency of smear review are worthwhile. Solutions are discussed, including engaging laboratory staff, educating clinicians, and modifying technology systems.

COVID-19 infections among HCWs exposed to a patient with a delayed diagnosis of COVID-19.

We report on COVID-19 risk among HCWs exposed to a patient diagnosed with COVID-19 on day 13 of hospitalization. There were 44 HCWs exposed to the patient before contact and droplet precautions were implemented: of these, 2 of 44 (5%) developed COVID-19 potentially attributable to the exposure.

Narratives of responsibility: Maternal mortality, reproductive governance, and midwifery in Mexico.

This research highlights the malleability of Maternal Mortality Ratios (MMR) and the ways in which they accommodate a variety of narratives via their claims about women's access to reproductive health services. MMR plays an important role in determining fiscal and legislative priorities for women's health in Mexico and in the discursive practices that shape societal beliefs about appropriate birthing practices and birth attendants. This paper is based on ethnographic fieldwork conducted in Yucatán and Quintana Roo between 2009 and 2017 during Ministry of Health midwifery workshops and approximately fifty interviews with midwives, doctors, public health officials, and parents. It explores the mutability of MMR within the context of political struggles for midwifery in Mexico-both for and against its legality and existence. In Mexico, MMR is often used by bureaucrats and public health workers to reinforce the importance of biomedical obstetric services over midwifery. However, the same metrics are also employed by midwives in critiques of underfunded and often structurally-violent maternal health care services. While doctors attempt to use MMR to prove that birth is inherently dangerous and must take place in hospitals with access to obstetric technologies and interventions, midwives use MMR to demonstrate that birth in hospitals is risky precisely because of those technologies and their inappropriate use, and to draw international attention and funding in support of midwifery. In addition to examining the strategic use of MMR in health-related discourses, this paper interrogates techniques employed by the state to limit midwives' access to births in the name of monitoring and improving MMR. I contend that while discursive uses of MMR to advance professional and political goals are common in both midwifery and biomedicine, the asymmetric power relations of biomedicine vis-à-vis the Mexican state privilege interpretations of MMR that justify and legitimate enhanced bureaucratic surveillance of midwives.

Reluctance to Retire: A Qualitative Study on Work Identity, Intergenerational Conflict, and Retirement in Academic Medicine.

Purpose of the Study: Some professions foster expectations that individuals cultivate their work identity above all other aspects of life. This can be problematic when individuals are confronted with the expectation that they will readily terminate this identity in later-career stages as institutions seek to cycle in new generations. This study examines the relationship between work identity and retirement by examining multiple generations of academic physicians. Design and Methods: This study used a multimethod qualitative design that included document analysis, participant observation, focus groups, and in-depth interviews with academic physicians from one of the oldest departments of medicine in North America. Results: This study illustrates how participants were predisposed and then groomed through institutional efforts to embrace a career trajectory that emphasized work above all else and fostered negative sensibilities about retirement. Participants across multiple generations described a lack of work-life balance and a prioritization of their careers above nonwork commitments. Assertions that less experienced physicians were not as dedicated to medicine and implicit assumptions that later-career physicians should retire emerged as key concerns. Implications: Strong work identity and tensions between different generations may confound concerns about retirement in ways that complicate institutional succession planning and that demonstrate how traditional understandings of retirement are out of date. Findings support the need to creatively reconsider the ways we examine relations between work identity, age, and retirement in ways that account for the recent extensions in the working lives of professionals.

Clonal Lymphoproliferations in a Patient With Common Variable Immunodeficiency.

Common variable immunodeficiency (CVID) comprises a heterogeneous group of disorders of humoral immunity, characterized by marked deficiencies in serum immunoglobulins. Immune dysregulation causes susceptibility to recurrent bacterial infections, as well as autoimmune and lymphoproliferative disorders. Although the lymphoid cells comprising the atypical proliferations are often clonally related, their malignant potential and clinical significance differ from similar lesions in individuals with immunocompetence. Herein, we describe a Caucasian woman with CVID who over 7 years developed multiple clonal lymphoproliferative lesions, comprising a spectrum of morphologic characteristics. Many of the lesions harbored distinct clonal populations. Though a majority responded to conservative intervention, 1 lesion persisted, met the diagnostic criteria for diffuse large B-cell lymphoma, and responded well to conventional chemotherapeutic treatment. The patient subsequently developed additional lymphoproliferations, but the lesions were clonally distinct and responded to conservative therapy. The clinical course of this patient emphasizes the variable nature of lymphoproliferative lesions arising in patients with CVID and underscores an individualized approach to pathologic interpretation and diagnostic intervention.

Ideal citizens: the birthing of state truths and fictions in Quintana Roo.

Reducing the maternal mortality rate (MMR) is an important part of Mexico's commitment to the Millennium Development Goals, and the country has made great strides towards achieving this goal. However, researchers have questioned to what extent the focus on improved MMR and other indices of maternal health has contributed to an emphasis on improved statistics rather than quality care, and the effect this has had on the quality of reporting. While public health officials and hospital administrators alike agree that improved obstetric reporting is necessary, there is little discussion regarding the accuracy of the data that are submitted and the institutional pressures that may contribute to the production of inaccurate data. Using ethnographic research collected in Tulum, Quintana Roo, this paper explores how biomedical childbirth functions as a source of legitimization for the state while simultaneously providing the means for the presentation of an ideal subjecthood, one that situates birthing women and healthcare personnel as properly attenuated to the norms and needs of the modern Mexican state. By highlighting the point of disjuncture between women's experiences and the formal 'reality' created through hospital texts, this paper explores the place of biomedical birth as a producer of and legitimization for Mexican public health policy.

Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients.

OBJECT NSAIDs are effective perioperative analgesics. Many surgeons are reluctant to use NSAIDs perioperatively because of a theoretical increase in the risk for bleeding events. The authors assessed the effect of routine perioperative ketorolac use on intracranial hemorrhage in children undergoing a wide range of neurosurgical procedures. METHODS A retrospective single-institution analysis of 1451 neurosurgical cases was performed. Data included demographics, type of surgery, and perioperative ketorolac use. Outcomes included bleeding events requiring return to the operating room, bleeding seen on postoperative imaging, and the development of renal failure or gastrointestinal tract injury. Variables associated with both the exposure and outcomes (p < 0.20) were evaluated as potential confounders for bleeding on postoperative imaging, and multivariable logistic regression was performed. Bivariable analysis was performed for bleeding events. Odds ratios and 95% CIs were estimated. RESULTS Of the 1451 patients, 955 received ketorolac. Multivariate regression analysis demonstrated no significant association between clinically significant bleeding events (OR 0.69; 95% CI 0.15-3.1) or radiographic hemorrhage (OR 0.81; 95% CI 0.43-1.51) and the perioperative administration of ketorolac. Treatment with a medication that creates a known bleeding risk (OR 3.11; 95% CI 1.01-9.57), surgical procedure (OR 2.35; 95% CI 1.11-4.94), and craniotomy/craniectomy (OR 2.43; 95% CI 1.19-4.94) were associated with a significantly elevated risk for radiographically identified hemorrhage. CONCLUSIONS Short-term ketorolac therapy does not appear to be associated with a statistically significant increase in the risk of bleeding documented on postoperative imaging in pediatric neurosurgical patients and may be considered as part of a perioperative analgesic regimen. Although no association was found between ketorolac and clinically significant bleeding events, a larger study needs to be conducted to control for confounding factors, because of the rarity of these events.

Patterns of care for craniopharyngioma: survey of members of the american association of neurological surgeons.

BACKGROUND: Initial therapy for craniopharyngioma remains controversial. Population-based datasets indicate that traditional algorithms [gross total resection (GTR) vs. subtotal resection (STR) +/- radiation therapy (XRT)] are often not employed. We investigated neurosurgical practice patterns. METHODS: A ten-question survey was electronically distributed to members of the American Association of Neurological Surgeons. Responses were analyzed using standard statistical techniques. RESULTS: 102 responses were collected, with a median of 25 craniopharyngiomas managed per respondent. 36% estimated that their practice included ≥75% pediatric patients and 61% had an academic practice. 36% would recommend observation or XRT for a suspected craniopharyngioma in the absence of a tissue diagnosis, with 46% of these indicating this recommendation in ≥10% of the cases. Following STR, 35% always recommend XRT and 59% recommend it in over half of the cases. However, following STR or biopsy alone, 18 and 11% never recommend XRT. There was no association between the type of practice (i.e. academic or ≥75% pediatric patients) and practice patterns. CONCLUSIONS: This survey verifies that a deviation from established algorithms is common, underscoring the clinical complexity of these patients and recent secondary data analyses. This should influence clinical researchers to investigate outcomes for patients treated using alternative methods. It will lend insight into appropriate treatment options and contribute to quality of life outcomes studies for craniopharyngioma.

Pair bonding and lateral neck-resting preferences in captive Caribbean flamingos (Phoenicopterus ruber).

When flamingos rest, they typically lay their head on their back and curve their neck to either the right or left of their body, with both individual and population-level lateral preferences for rightward neck resting when preferences are tracked over time (Anderson, Williams, & O'Brien, 2009). The present study attempted to replicate these previous neck-resting preferences, to examine how they changed over time, and to examine the possibility of a relationship between lateral neck-resting preference and pair bonding in captive Caribbean flamingos (Phoenicopterus ruber) housed at the Philadelphia Zoo (Philadelphia, PA, USA). Results successfully replicated the individual- and population-level lateral preferences for rightward neck resting, and demonstrated that these preferences were stable over time. Moreover, individual flamingos that demonstrated stronger pair bond strengths tended to differ less from their partners in terms of neck-resting preference than did those birds displaying weaker pair bond strengths, suggesting a relationship between laterality and social cohesion.

Preferred neck-resting position predicts aggression in Caribbean flamingos (Phoenicopterus ruber).

When flamingos rest, they typically lay their heads along their backs. In order to achieve this positioning they curve their necks to either the right or left of their midline. Previously we have shown both individual and flock-level laterality of preferred neck-resting direction, with most birds preferring to rest their necks to their right (Anderson, Williams, & O'Brien, 2009). As laterality has been shown to play a role in social cohesion (e.g., Rogers & Workman, 1989) and aggression (e.g., Vallortigara, Cozzutti, Tommasi, & Rogers, 2001), here we attempted to determine whether a flamingo's preferred neck-resting direction could be used to predict involvement in aggressive encounters. Results replicated the earlier flock-level preference for neck resting towards the right, and indicated that those flamingos preferring the left were more likely to be involved in aggressive encounters.

Why do flamingos stand on one leg?

A series of observational studies of captive Caribbean flamingos Phoenicopterus ruber were conducted to determine why flamingos rest on one leg. While frequently asked by the general public, this basic question has remained unanswered by the scientific community. Here we suggest that the latency of flamingos to initiate forward locomotion following resting on one leg is significantly longer than following resting on two, discounting the possibility that unipedal resting reduces muscle fatigue or enhances predatory escape. Additionally, we demonstrate that flamingos do not display lateral preferences at the individual or group levels when resting on one leg, with each bird dividing its resting time across both legs. We show that while flamingos prefer resting on one leg to two regardless of location, the percentage of birds resting on one leg is significantly higher among birds standing in the water than among those on land. Finally, we demonstrate a negative relationship between temperature and the percentage of observed birds resting on one leg, such that resting on one leg decreases as temperature rises. Results strongly suggest that unipedal resting aids flamingos in thermoregulation.