RESUMEN
PURPOSE OF REVIEW: Healthcare workers experience a disproportionate frequency of workplace violence. Identifying commonalities among incidents of workplace violence provides an opportunity for change to prevent and mitigate future violence. RECENT FINDINGS: Despite a continued decline in overall workplace violence, the rate of violence in the healthcare sector is steadily rising. While healthcare workers make up 13% of the workforce, they experience 60% of all workplace assaults. Environmental, structural, and staffing issues may all contribute to the increased rates of workplace violence affecting healthcare workers. SUMMARY: Comprehensive proactive workplace violence prevention programs can significantly reduce the frequency of violence and the negative impact on employees and institutions. Analyzing the factors that contribute to violence in the healthcare workplace provides the potential to mitigate these risks and reduce episodes of violence.
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Personal de Salud , Violencia Laboral , Lugar de Trabajo , Humanos , Violencia Laboral/estadística & datos numéricos , Violencia Laboral/prevención & control , Femenino , Salud LaboralAsunto(s)
Retardo del Crecimiento Fetal , Resultado del Embarazo , Humanos , Embarazo , Femenino , Recién Nacido , Adulto , Ultrasonografía PrenatalRESUMEN
Second- and third-trimester obstetrical ultrasound examinations include an amniotic fluid volume assessment. Professional organizations' clinical guidance recommends using semiquantitative techniques, such as the single deepest vertical pocket or amniotic fluid index, for this purpose. The single deepest vertical pocket is described as the preferred method of assessing amniotic fluid volume based on fewer oligohydramnios diagnoses and labor inductions with no demonstrable difference in pregnancy outcomes compared with the amniotic fluid index. We offer an alternative interpretation of the evidence for this advice, drawn from 6 randomized clinical trials and 2 meta-analyses comparing the single deepest vertical pocket to the amniotic fluid index. Individually and collectively, these reports are underpowered to detect significant differences in maternal and perinatal outcomes by study group. Moreover, randomized clinical trials comparing maternal and perinatal outcomes resulting from a policy of labor induction at or beyond 37 weeks of gestation vs expectant care consistently favor labor induction, the very intervention paradoxically cited as favoring the single deepest vertical pocket vs the amniotic fluid index. We conclude that the amniotic fluid index should be considered a reasonable method for third-trimester amniotic fluid assessment and diagnosing oligohydramnios.
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Oligohidramnios , Líquido Amniótico/diagnóstico por imagen , Femenino , Humanos , Oligohidramnios/diagnóstico por imagen , Embarazo , Resultado del Embarazo , Tercer Trimestre del Embarazo , Ultrasonografía Prenatal/métodosRESUMEN
OBJECTIVES: To compare maternal and perinatal outcomes in pregnancies with transient and persistent idiopathic polyhydramnios to those with normal amniotic fluid volume. METHODS: This retrospective cohort study included subjects delivering a singleton pregnancy between January 1, 2015, and June 30, 2020, with sonography ≥26 weeks' gestation demonstrating transient or persistent idiopathic polyhydramnios (amniotic fluid index [AFI] ≥24.0 cm) or normal AFI (referent group). The primary maternal outcome was a composite of spontaneous preterm delivery <37 weeks, cesarean delivery for malpresentation, abnormal labor progress, or nonreassuring fetal status, operative vaginal delivery, hemorrhage requiring transfusion, and umbilical cord prolapse. The primary perinatal outcome was a composite of birthweight >4500 g, fetal or neonatal death, 5-minute Apgar score <7, and neonatal intensive care unit admission for >24 hours. RESULTS: Patients with transient polyhydramnios (n = 259) exhibited maternal outcomes similar to those of the referent group (n = 435) but had significantly increased odds for the primary perinatal outcome (odds ratio [OR] 1.70, 95% confidence interval [CI] 1.15-2.53; P = .008) and for birthweight ≥4500 g (OR 8.70, 95% CI 1.89-40.0; P = .005). Persistent polyhydramnios (n = 176) was significantly associated with both the primary maternal (OR 1.93, 95% CI 1.27-2.95, P = .002) and primary perinatal outcome (OR 2.15, 95% CI 1.40-3.30; P < .001), and individually with cesarean delivery for abnormal labor (OR 3.22, 95% CI 1.55-6.68; P = .002) and birthweight ≥4500 g (OR 8.97, 95% CI 1.84-43.6; P = .007). CONCLUSIONS: Transient idiopathic polyhydramnios does not impact maternal outcomes but is associated with increased odds of newborn birthweight >4500 g. Persistent polyhydramnios is associated with both adverse maternal and perinatal outcomes.
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Polihidramnios , Embarazo , Recién Nacido , Femenino , Humanos , Polihidramnios/diagnóstico por imagen , Peso al Nacer , Resultado del Embarazo , Estudios Retrospectivos , Líquido AmnióticoRESUMEN
BACKGROUND: The frequency with which physicians are injured or killed in acute care hospital shootings has more than tripled during the past two decades. Moreover, physicians may be exposed to firearm violence outside of hospital settings. OBJECTIVE: To characterize physician-involved workplace-related firearms violence to inform risk identification and mitigation strategies. METHODS: Quantitative content analysis of physician-involved workplace-related firearm violence resulting in injury or death. Two investigators independently abstracted web-based reports for each year from 2008-2017 with differences resolved by consensus. Data were summarized using descriptive statistics, and analyzed using chi-square, Fisher exact, or Kruskal Wallis test, as appropriate. RESULTS: Twenty-six incidents, 10 (38.5%) perpetrated by physicians and 16 (61.5%) perpetrated by nonphysicians, resulted in 83 casualties. All physician-perpetrated shootings represented either type III or IV violence motivated by grudges. Significantly more crimes perpetrated by nonphysicians were type II violence (11/16, 68.8%), Pâ<â.001, most representing grudges related to medical or surgical outcomes (7/16, 43.8%), Pâ=â.003. Physician perpetrated shootings occurred significantly more often in the victim's home (5/11, 45.4%), compared to nonphysician perpetrated attacks which more often occurred at a hospital or physician office (14/16, 87.5%), Pâ=â.03. Urologists (4/26, 15.4%) were disproportionately targeted. CONCLUSIONS: These data may inform practical education and training to identify potential perpetrators before a work-related attack occurs by or on a physician.
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Armas de Fuego , Médicos , Violencia Laboral , Heridas por Arma de Fuego , Hospitales , Humanos , Estados Unidos , Heridas por Arma de Fuego/epidemiologíaRESUMEN
Acute urinary retention rarely occurs in women, and is only infrequently caused by a pelvic mass. We describe a case of acute urinary retention caused by a large ovarian mucinous cystadenoma. Point of care ultrasound characterized and localized the lesion, while computerized tomography demonstrated the anatomic distortions resulting in urinary retention. The patient's symptoms resolved immediately following a laparoscopic right salpingo-oophorectomy with complete tumor removal.
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Cistoadenoma Mucinoso/complicaciones , Neoplasias Ováricas/complicaciones , Retención Urinaria/etiología , Enfermedad Aguda , Femenino , Humanos , Ultrasonografía , Retención Urinaria/diagnóstico por imagenAsunto(s)
Gastrectomía , Obesidad Mórbida , Femenino , Humanos , Obesidad Mórbida/cirugía , EmbarazoRESUMEN
OBJECTIVES: We sought to study potential diagnostic criteria for marginal placental cord insertions as determined by associations with obstetric outcomes. METHODS: This single-center retrospective cohort investigation included singleton gestations delivering from January 1, 2012, to December 31, 2016, and having a standard or detailed fetal ultrasound examination from 18 weeks to 21 weeks 6 days. Cord insertion-to-placental edge distances were used to create a referent comparison group and 3 patient groups: greater than 3.0 cm (comparison); greater than 2.0 to 3.0 cm (group 1); greater than 1.0 to 2.0 cm (group 2); and 1.0 cm or less (group 3). The primary outcome consisted of any one of spontaneous delivery before 37 weeks, fetal growth restriction, oligohydramnios, placental abruption, or intrauterine fetal demise. RESULTS: The numbers of participants and mean distances ± SDs for the comparison group and groups 1 to 3, respectively, were 628 and 4.68 ± 1.17 cm, 106 and 2.52 ± 0.26 cm, 131 and 1.60 ± 0.29 cm, and 77 and 0.36 ± 0.37 cm, respectively. The primary outcome was significantly associated only with cord insertion-to-placental edge distances of 1.0 cm or less (adjusted odds ratio, 3.05; 95% confidence interval, 1.73-5.38). CONCLUSIONS: Marginal cord insertions may be diagnosed when the cord insertion-to-placental edge distance is 1.0 cm or less.
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Placenta/diagnóstico por imagen , Ultrasonografía Prenatal/métodos , Cordón Umbilical/diagnóstico por imagen , Adulto , Femenino , Humanos , Placenta/anomalías , Embarazo , Resultado del Embarazo , Segundo Trimestre del Embarazo , Estudios Retrospectivos , Cordón Umbilical/anomalíasRESUMEN
BACKGROUND: Healthcare workers experience a disproportionately high frequency of workplace assaults. Incidents involving firearms are of particular concern. OBJECTIVE: To provide detailed characterizations of recent hospital shootings to better inform prevention and mitigation strategies. METHODS: Quantitative content analysis of reports involving hospital shootings resulting in casualties derived from web searches for each year from 2012-2016. Data were abstracted independently by two investigators, with differences resolved by consensus. Data were compared between subgroups by chi-square test, Fisher's exact test, or Kruskal-Wallis test, as appropriate. RESULTS: Eighty-eight shootings occurred in 86 hospitals resulting in 121 firearms-related casualties, including 54 victims and 67 perpetrators. Case fatality rates were 55.6% (nâ=â30) and 70.1% (nâ=â47), respectively. The most frequent sites involved were the emergency department, (nâ=â27, 30.3%), patient room (nâ=â19, 21.3%), and parking lot (nâ=â13, 14.6%). Grudge (nâ=â17, 19.3%), suicide (nâ=â14, 15.9%), and mental instability (nâ=â13, 14.8%) were the most common explanations for these shootings. Four inadvertent discharges occurred and were more likely to involve a female perpetrator (pâ=â0.03). Shootings were most frequent during summer (pâ=â0.03) and winter (pâ=â0.04). CONCLUSIONS: Out study findings on location and seasonal patterns can guide the development or improvement of prevention and mitigations strategies for hospital shootings.
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Hospitales/estadística & datos numéricos , Violencia Laboral/estadística & datos numéricos , Heridas por Arma de Fuego/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Armas de Fuego , Humanos , Masculino , Trastornos Mentales , Persona de Mediana Edad , Traumatismos Ocupacionales/epidemiología , Habitaciones de Pacientes/estadística & datos numéricos , Estaciones del Año , Suicidio/estadística & datos numéricos , Estados Unidos/epidemiología , Heridas por Arma de Fuego/mortalidadRESUMEN
Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial-myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Although ultrasound evaluation is important, the absence of ultrasound findings does not preclude a diagnosis of placenta accreta spectrum; thus, clinical risk factors remain equally important as predictors of placenta accreta spectrum by ultrasound findings. There are several risk factors for placenta accreta spectrum. The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries. Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. In addition, established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place, and access to a blood bank capable of employing massive transfusion protocols should help guide decisions about delivery location.
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Placenta Accreta/diagnóstico , Diagnóstico Prenatal , Cesárea , Femenino , Ginecología , Humanos , Histerectomía , Obstetricia , Placenta Accreta/cirugía , Embarazo , Sociedades Médicas , Estados UnidosRESUMEN
The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.
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Competencia Clínica/normas , Ginecología/educación , Obstetricia/educación , Mejoramiento de la Calidad , Ultrasonido/educación , Ultrasonografía Prenatal/normas , Curriculum/normas , Femenino , Humanos , Embarazo , Estados UnidosRESUMEN
OBJECTIVES: To evaluate perinatal outcomes in singleton and twin pregnancies with pathologically confirmed velamentous cord insertion without vasa previa. METHODS: This retrospective case-control study included all nonanomalous singleton and twin pregnancies with pathologically confirmed velamentous cord insertion delivered in a single institution between January 1, 2005, and July 1, 2015, and having an ultrasound examination by maternal-fetal medicine. For each case, the next 2 consecutive deliveries matched for gestational age at delivery ± 1 week and, in twins, amnionicity and chorionicity served as controls. Primary outcomes included surgical delivery for a nonreassuring intrapartum fetal heart rate tracing, umbilical arterial cord pH of less than 7.2, 5-minute Apgar score of less than 7, birth weight below the 10th percentile, neonatal intensive care unit admission, fetal or neonatal death, and cord avulsion necessitating manual placental extraction. RESULTS: Outcomes were available for 53 singletons with 103 matched controls and 33 twin pregnancies with 65 matched controls. In singletons, velamentous cord insertion was associated with cord pH of less than 7.2 (odds ratio [OR] 3.5; 95% confidence interval [CI], 1.1-11.2; P = .039), 5-minute Apgar score of less than 7 (OR, 5.3; 95% CI, 0.99-28.1; P = .045), and cord avulsion requiring manual placental extraction (7.5% versus 0%; P = .012). Associations were suggested with increased surgical delivery for a nonreassuring intrapartum fetal heart rate tracing (OR, 2.4; 95% CI, 0.9-6.9; P = .14), birth weight below the 10th percentile (OR, 2.1; 95% CI, 0.8-5.9; P = .21), and fetal or neonatal death (3.8% versus 0%; P = .11). Velamentous cord insertions were also associated with placental abruption in singletons (7.5% versus 0%; P = .013). Among twins, velamentous cord insertion was associated with fetal or neonatal death (9.1% versus 0%; P = .036). CONCLUSIONS: Isolated confirmed velamentous cord insertion is associated with adverse perinatal outcomes in singleton and twin gestations.
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Resultado del Embarazo , Ultrasonografía Prenatal/métodos , Cordón Umbilical/diagnóstico por imagen , Vasa Previa/diagnóstico por imagen , Adulto , Estudios de Casos y Controles , Femenino , Humanos , Embarazo , Embarazo Gemelar , Estudios RetrospectivosRESUMEN
Endocervical varices are a rare cause of obstetrical hemorrhage. Usually presenting in the second and third trimesters, bleeding varices often require pregnancy termination or indicated preterm birth via cesarean delivery. Our patient experienced variceal hemorrhage at 12 weeks' gestation in a dichorionic twin pregnancy conceived through in vitro fertilization. A low-lying placenta resolved at 19 weeks followed by variceal regression at 22 weeks' gestation. Endocervical varices causing first-trimester hemorrhage may regress with resolution of a coexisting low placental implantation, permitting planned vaginal delivery, despite progressive hemodynamic changes of pregnancy. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:218-221, 2018.
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Cuello del Útero/irrigación sanguínea , Complicaciones del Embarazo/diagnóstico por imagen , Ultrasonografía Prenatal/métodos , Enfermedades del Cuello del Útero/diagnóstico por imagen , Hemorragia Uterina/etiología , Várices/complicaciones , Adulto , Cuello del Útero/diagnóstico por imagen , Femenino , Humanos , Embarazo , Primer Trimestre del Embarazo , Embarazo Gemelar , Várices/diagnóstico por imagenRESUMEN
The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.
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Competencia Clínica , Internado y Residencia , Obstetricia/educación , Garantía de la Calidad de Atención de Salud , Mejoramiento de la Calidad , Ultrasonografía Prenatal , Acreditación , Femenino , Humanos , Embarazo , Estados UnidosRESUMEN
When administered inappropriately, first-trimester misoprostol management of induced or spontaneous abortion can result in loss or damage of a continuing pregnancy. Despite these serious consequences, such misoprostol exposures continue to occur. Unfortunately, contributing factors and preventive measures receive little attention. We describe the cases of 4 women in whom misoprostol was inappropriately administered during management of induced and presumed spontaneous abortion. In each case, careful adherence to published clinical guidance could have avoided the exposures.
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Abortivos no Esteroideos/administración & dosificación , Aborto Inducido , Aborto Espontáneo , Adhesión a Directriz , Errores Médicos/prevención & control , Misoprostol/administración & dosificación , Abortivos no Esteroideos/efectos adversos , Adulto , Femenino , Humanos , Lactante , Muerte del Lactante , Misoprostol/efectos adversos , Embarazo , Primer Trimestre del Embarazo , Ultrasonografía Prenatal/métodos , Adulto JovenRESUMEN
Preterm birth is the leading cause of perinatal morbidity and mortality in developed nations. The heterogeneous causes of spontaneous preterm birth make prediction and prevention difficult. The primary importance of transvaginal cervical sonography and cervicovaginal fetal fibronectin lies in their high negative predictive values in assessing risk for preterm birth. Cervical length may be useful in identifying women who are candidates for cervical cerclage or progesterone therapy for preterm birth prevention. Together, cervical length and fibronectin can be used in the triaging of women symptomatic for preterm labor.
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Medición de Longitud Cervical/métodos , Cuello del Útero/diagnóstico por imagen , Fibronectinas/metabolismo , Trabajo de Parto Prematuro/diagnóstico , Nacimiento Prematuro/diagnóstico por imagen , Diagnóstico Prenatal/métodos , Cerclaje Cervical , Femenino , Fibronectinas/análisis , Humanos , Trabajo de Parto Prematuro/prevención & control , Valor Predictivo de las Pruebas , Embarazo , Resultado del Embarazo , Riesgo , Medición de Riesgo , Factores de RiesgoRESUMEN
PURPOSE: To determine the relationship between the first-trimester chorionic bump and fetal aneuploidy. METHODS: This retrospective cohort study included all singleton pregnancies with chromosomal analysis and sonographic examination performed between 5 0/7 and 13 6/7 weeks from January 1, 2010 through August 15, 2015. Interobserver and intraobserver agreement for identifying a chorionic bump was evaluated by the Kappa statistic. Pregnancies with and without a chorionic bump were compared regarding patient characteristics and fetal karyotypes. RESULTS: Six hundred ninety subjects were included, 16 (2.3%) having a bump. The kappa coefficients for interobserver agreement were 0.88 (95% confidence interval [CI]: 0.71-1.00) and 0.94 (95% CI: 0.82-1.00); those for intraobserver agreement were 0.81 (95% CI: 0.61-1.00) and perfect agreement. One hundred seventeen fetuses (16.9%) were aneuploid, of which five (4.3%) had a bump. The odds of aneuploidy in the presence of a chorionic bump were higher than those in the absence of a chorionic bump, although this difference was not statistically significant (odds ratio [OR] 2.3, 95% CI: 0.8-6.7). In subgroup analyses, odds of aneuploidy were four times higher in the bump group than in the no bump group among those with a sonographically isolated bump (OR 4.5, 95% CI: 1.5-13.5) and 15 times higher among those with an isolated bump and increased first-trimester aneuploidy risk (OR 15.0, 95% CI 2.4-93.3). CONCLUSIONS: Agreement in identifying chorionic bumps is near-perfect. A sonographically nonisolated chorionic bump is not associated with significant additional aneuploidy risk, whereas a sonographically isolated chorionic bump confers a significantly increased likelihood of aneuploidy in high-risk fetuses. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:3-7, 2017.