Surgical-site infection in multifetal cesarean delivery.

PURPOSE: The relationship between multifetal cesarean delivery and surgical-site infection (SSI) is unclear. If SSI is more common in multifetal cesareans, adjustment of practices such as antibiotic dosing could be warranted. The purpose of this study was to determine whether patients undergoing multifetal cesarean delivery are more likely to experience SSI than those undergoing singleton cesarean delivery. METHODS: This was a retrospective cohort study including all cesarean deliveries at a tertiary hospital from 10/1/2009 to 12/28/2018. The primary outcome was rate of SSI in women after multifetal cesarean delivery as compared to those who underwent singleton cesarean delivery. Univariable analysis and multivariable logistic regression were used to assess independent clinical factors associated with SSI in multifetal cesarean deliveries. RESULTS: 34,340 women underwent cesarean delivery during this period. 33,211 were singletons (96.7%), and 1,129 were multifetal (3.3%). There was no difference in the rate of SSI in multifetal gestations (15/1,129, 1.3%) as compared to singletons (493/33,211, 1.5%) (p = 0.670, OR 0.89 [95% CI 0.53, 1.50], aOR 1.06 [95% CI 0.61, 1.84]). Limiting analysis to multifetal deliveries, prolonged rupture of membranes (p < 0.004, OR 5.43 [95% CI 1.49, 19.88]), labor augmentation (p < 0.001, OR 15.84 [1.74, 144.53]), and chorioamnionitis (p < 0.001, OR 15.43 [95% CI 3.11, 76.62]) were more common in women with SSI. DISCUSSION: SSI is not increased in multifetal cesarean delivery as compared to singleton cesarean delivery. In multifetal cesareans, chorioamnionitis, prolonged rupture of membranes, and labor augmentation were associated with increased odds of SSI.

Intrapartum trends of NT-proBNP and hs-cTnT in patients with severe features of preeclampsia.

BACKGROUND: Preeclampsia with severe features (SPE) is a multisystem syndrome associated with long-term cardiovascular morbidity. Serum concentrations of N-terminal B-type natriuretic peptide (NT-proBNP) and high sensitivity cardiac troponin-T (hs-cTnT) are sensitive markers of cardiac stretch and ischemia, respectively. OBJECTIVE: Our aim was to examine NT-proBNP and hs-cTnT in patients with SPE during labor. We hypothesized that patients with severe preeclampsia would have increased serum concentrations of these analytes as compared with normotensive laboring patients. STUDY DESIGN: This was a prospective cohort study of intrapartum patients with SPE and normotensive controls. Patients were recruited at the time of SPE diagnosis or admission to the labor unit, and those with medical conditions that could predispose to baseline cardiac dysfunction were excluded. Serum from venous blood was collected for NT-proBNP and hs-cTnT measurement at three time points: 0-2 h, 4 h, and 12 h after admission. A mixed random effects regression model was used to compare analyte levels at each time point and to compare trends over time. The primary outcome was NT-proBNP concentration at each collection time point in patients with severe preeclampsia as compared to normotensive controls. Power analysis yielded a goal sample of 25 patients with a 12 h and at least 1 other sample in each arm. Two-tailed P values less than 0.05 were considered statistically significant. P value adjustment for multiple comparisons was performed. RESULTS: Of 78 patients analyzed, 36 had severe preeclampsia and 42 were normotensive controls with 25 in each cohort having a 12 h and at least 1 other sample. The NT-proBNP trend was significantly different in the two cohorts (P < 0.001). After adjustment for multiple comparisons, the mean serum concentration of NT-proBNP was elevated in the severe preeclampsia group at 0-2 and 4 h, but not at 12 h. After similar adjustment, detectable serum concentrations of hs-cTnT were more frequent in patients with severe preeclampsia at all three timepoints. CONCLUSION: Intrapartum serum concentrations of NT-proBNP were elevated nearly twofold in patients with SPE when compared with normotensive controls, with the most pronounced differences found during early labor. Detectable but low serum concentrations of hs-cTnT were more common in women with severe preeclampsia as compared with normotensive controls. These findings suggest cardiac dysfunction with SPE may be present at the time of admission and contribute to features of maternal cardiovascular morbidity and mortality.

Patterns of relating between physicians and medical assistants in small family medicine offices.

PURPOSE: The clinician-colleague relationship is a cornerstone of relationship-centered care (RCC); in small family medicine offices, the clinician-medical assistant (MA) relationship is especially important. We sought to better understand the relationship between MA roles and the clinician-MA relationship within the RCC framework. METHODS: We conducted an ethnographic study of 5 small family medicine offices (having <5 clinicians) in the Cincinnati Area Research and Improvement Group (CARInG) Network using interviews, surveys, and observations. We interviewed 19 MAs and supervisors and 11 clinicians (9 family physicians and 2 nurse practitioners) and observed 15 MAs in practice. Qualitative analysis used the editing style. RESULTS: MAs' roles in small family medicine offices were determined by MA career motivations and clinician-MA relationships. MA career motivations comprised interest in health care, easy training/workload, and customer service orientation. Clinician-MA relationships were influenced by how MAs and clinicians respond to their perceptions of MA clinical competence (illustrated predominantly by comparing MAs with nurses) and organizational structure. We propose a model, trust and verify, to describe the structure of the clinician-MA relationship. This model is informed by clinicians' roles in hiring and managing MAs and the social familiarity of MAs and clinicians. Within the RCC framework, these findings can be seen as previously undefined constraints and freedoms in what is known as the Complex Responsive Process of Relating between clinicians and MAs. CONCLUSIONS: Improved understanding of clinician-MA relationships will allow a better appreciation of how clinicians and MAs function in family medicine teams. Our findings may assist small offices undergoing practice transformation and guide future research to improve the education, training, and use of MAs in the family medicine setting.