International Emergency Medical Teams Training Workshop Special Report.

The World Health Organization's (WHO; Geneva, Switzerland) Emergency Medical Team (EMT) Initiative created guidelines which define the basic procedures to be followed by personnel and teams, as well as the critical points to discuss before deploying a field hospital. However, to date, there is no formal standardized training program established for EMTs before deployment. Recognizing that the World Association of Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA) Congress brings together a diverse group of key stakeholders, a pre-Congress workshop was organized to seek out collective expertise and to identify key EMT training competencies for the future development of training programs and protocols. The future of EMT training should include standardization of curriculum and the recognition or accreditation of selected training programs. The outputs of this pre-WADEM Congress workshop provide an initial contribution to the EMT Training Working Group, as this group works on mapping training, competencies, and curriculum. Common EMT training themes that were identified as fundamental during the pre-Congress workshop include: the ability to adapt one's professional skills to low-resource settings; context-specific training, including the ability to serve the needs of the affected population in natural disasters; training together as a multi-disciplinary EMT prior to deployment; and the value of simulation in training. AlbinaA, ArcherL, BoivinM, CranmerH, JohnsonK, KrishnarajG, ManeshiA, OddyL, Redwood-CampbellL, RussellR. International Emergency Medical Teams training workshop special report. Prehosp Disaster Med. 2018;33(3):335-338.

Effect of Borderline Personality Disorder on Obstetrical and Neonatal Outcomes.

BACKGROUND: Borderline personality disorder (BPD) is a serious mental disorder commonly associated with functional impairments and adverse health outcomes. Very little is known about BPD in pregnant women; hence, our study objective was to evaluate the effect of BPD on obstetrical and neonatal outcomes. METHODS: We carried out a retrospective cohort study using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample from 2003 to 2012. We identified births using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes and classified women by BPD status. Multivariate logistic regression was used to evaluate the effect of BPD on obstetrical and neonatal outcomes, adjusted for subject baseline characteristics. FINDINGS: During the study period, there were 989 births to women with BPD with an overall incidence of 11.65 in 100,000 births. Women with BPD were more likely younger, of lower socioeconomic status, smoked or used drugs, and had an underlying mental disorder. Unadjusted models revealed that BPD was associated with an increased risk of almost all adverse maternal and fetal outcomes we examined, the exception being post partum hemorrhage and instrumental delivery, which both had a null association with BPD, and induction of labor, which was negatively associated with BPD. Upon full adjustment, BPD was found to be associated with the following obstetrical and neonatal outcomes: gestational diabetes (odds ratio [OR], 1.45; 95% CI, 1.13-1.85), premature rupture of the membranes (OR, 1.40; 95% CI, 1.07-1.83), chorioamnionitis (OR, 1.65; 95% CI, 1.14-2.39), venous thromboembolism (OR, 2.11; 95% CI, 1.12-3.96), caesarian delivery (OR, 1.44; 95% CI, 1.26-1.64), and preterm birth (OR, 1.54; 95% CI, 1.29-1.83). CONCLUSION: BPD is associated with several adverse obstetrical and neonatal outcomes. Hence, pregnant women who suffer from BPD should be monitored closely by a multidisciplinary health care team both before and during their pregnancies. This oversight would allow for the receipt of treatment for BPD and also interventions to help them to cease tobacco and drug use, which may ultimately decrease the incidence of poor obstetrical and neonatal outcomes.

Motor vehicle collision-related accidents in pregnancy.

AIM: Motor vehicle accidents (MVA) are a major contributor of worldwide morbidity and mortality; however, relatively little is known about the incidence and consequences of traffic accidents on pregnant women. Our aim is to compare rates and outcomes of motor vehicle collision-related accidents in pregnant women. MATERIAL AND METHODS: We conducted a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2003 to 2011. The risk of different MVA and injuries were compared among pregnant and non-pregnant subjects using conditional logistic regression. RESULTS: We identified 5936 cases of collision-related MVA in pregnancy and age-matched them at a 1:10 ratio to 59,360 non-pregnant women with collision-related MVA. As compared to non-pregnant women, pregnant women who were admitted after an MVA suffered less severe injuries and consequently required fewer therapeutic interventions and a shorter hospital stay. Pregnant women who had a collision-related MVA were, however, at increased risk of requiring genitourinary surgery (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.24-1.69). When restricted to women with a fracture, pregnant women were even more likely to require genitourinary surgery (OR, 2.93; 95%CI, 2.32-3.71) as well as require a blood transfusion (OR, 1.21; 95%CI, 1.01-1.44). CONCLUSION: Pregnant women admitted to hospital after a collision-related MVA tend to sustain less severe injuries compared to non-pregnant women. However, the influence of admissions for fetal monitoring, rather than maternal injury, could not be determined from our dataset. Pregnant women who experienced a collision-related MVA also required less surgical intervention, with the exception of genitourinary surgery, which may be indicative of more cesarean deliveries.

Incidence of maternal and neonatal outcomes in pregnancies complicated by ovarian masses.

PURPOSE: The purpose of our study is to estimate the incidence of adnexal mass and ovarian cancers during pregnancy and to evaluate their effects on obstetrical and fetal outcomes. METHODS: We conducted a population-based cohort study using data from The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. Cases of ovarian mass during delivery were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Women were categorized into subgroups of malignant and benign masses. Logistic regression analysis was used to evaluate maternal and fetal outcomes. RESULTS: There were 7,785,583 deliveries between 2003 and 2011, of which 19,591 were diagnosed with ovarian masses during delivery, representing 0.25 % of all deliveries. Among these, 1:200 were malignant. The overall malignancy rate was 0.12/10,000 deliveries. Apart from the increased rate of cesarean section, OR 5.92 (95 % CI 4.12-8.40), and the risk of thrombosis, OR 5.52 (95 % CI 1.96-15.53), there was no significant increase in maternal morbidity or mortality. Prematurity, OR 2.24 (95 % CI 1.48-3.40), was the only significant newborn risk in women with malignant ovarian tumors. Newborns of women with an ovarian mass had comparable risks of intrauterine growth restriction, preterm rupture of membrane and intrauterine death. CONCLUSION: The diagnosis of ovarian mass is rare during pregnancy and it is associated with an extremely low malignancy rate. Pregnant woman with a confirmed malignant ovarian tumor should be counseled regarding risks of prematurity, thrombosis and hysterectomy.

Incidence and determinants of sudden infant death syndrome: a population-based study on 37 million births.

BACKGROUND: The objective of our study is to measure the incidence of sudden infant death syndrome (SIDS), estimate the birth to death interval, and identify associated maternal and infant risk factors. METHODS: We carried out a population-based cohort study on 37 418 280 births using data from the Centers for Disease Control and Prevention's "Linked Birth-Infant Death" and "Fetal Death" data files from 1995 to 2004. Descriptive statistics and cox-proportional hazard models were used to estimate the adjusted effect of maternal and newborn characteristics on the risk of SIDS. RESULTS: There were 24 101 cases of SIDS identified for an overall 10-year incidence of 6.4 cases per 10 000 births. Over the study period, the incidence decreased from 8.1 to 5.6 per 10 000 and appeared to be most common among infants aged 2-4 months. Risk factors included maternal age <20 years, black, non-Hispanic race, smoking, increasing parity, inadequate prenatal care, prematurity and growth restriction. CONCLUSIONS: While the incidence of SIDS in the US has declined, it currently remains the leading cause of post-neonatal mortality, highlighting an important public health priority. Educational campaigns should be targeted towards mothers at increased risk in order to raise their awareness of modifiable risk factors for SIDS such as maternal smoking and inadequate prenatal care.

Obstetrical and neonatal outcomes in renal transplant recipients.

OBJECTIVE: To measure the incidence and outcomes of pregnancies in renal transplant (RT) patients and to identify risk factors of adverse pregnancy outcomes. METHODS: We conducted a population-based retrospective cohort study using the United States Nationwide Inpatient Sample from 2003-2010. The incidence of pregnancies in women with RT was measured and logistic regression analysis was used to estimate the adjusted effect of RT on maternal and fetal outcomes. RESULTS: We identified 375 deliveries in patients with a RT among 7094300 births for an overall incidence of 5.3 cases per 100000 births over 8 years. Maternal complications, including preeclampsia OR=9.87 (7.76, 12.55) and blood transfusion OR=2.29 (1.69, 3.12) were more common in women with RT as compared to in women without. RT pregnancies were also complicated by an increased risk of preterm birth OR=4.65 (3.72, 5.81), intrauterine fetal death OR=3.67 (1.89, 7.15) and fetal congenital anomalies OR=5.28 (2.81, 9.90). Among women with RT and pre-existing hypertension, the risk of intrauterine growth restriction (IUGR) was considerably increased from 4.3% to 21.8%, OR=3.79 (1.67, 8.62). CONCLUSION: Pregnancies in RT patients are associated with an increased risk of maternal and fetal morbidities. Among women with RT, pre-existing hypertension strongly increases the risk of IUGR.

Pregnancy outcomes in Marfan syndrome: a retrospective cohort study.

OBJECTIVE: Marfan syndrome (MFS) is a rare connective tissue disease with significant risk for adverse cardiovascular outcomes. Our objective was to evaluate pregnancy and cardiovascular outcomes in pregnant women with MFS. STUDY DESIGN: We conducted a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS) database from 2003 to 2010. We used unconditional regression analyses to compare maternal and fetal outcomes among pregnancies in women with and without MFS. RESULTS: Out of the 7,094,400 births in our cohort, 339 deliveries were to women with MFS. There was one maternal death and six aortic dissections among women with MFS. Births to women with MFS were more likely to be premature, odds ratio (OR) 2.15 (1.60-2.89), have intrauterine growth restricted and small for gestational age infants, OR 2.06 (1.24-3.43). Women with MFS were more likely to deliver by cesarean section, OR 1.91 (1.53-2.38) and were at higher risk of major morbidities including cardiac arrhythmias, OR 10.64 (5.49-20.61) and pneumothorax, OR 51.95 (6.18, 437.10). CONCLUSION: Pregnant women with MFS are at a particularly high risk of adverse pregnancy and cardiovascular events. Preconception counseling should take these risks into consideration and appropriate pregnancy care in tertiary centers should be considered.

Sarcoidosis and pregnancy: obstetrical and neonatal outcomes in a population-based cohort of 7 million births.

OBJECTIVES: Data on sarcoidosis in pregnancy is sparse and limited to a few case reports and series. Our aim is to determine the prevalence of sarcoidosis at delivery, and related maternal and newborn outcomes. STUDY DESIGN: Using the United States Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) from 2003 to 2010, we conducted a population-based retrospective cohort study to compare women with and without sarcoidosis at delivery. We calculated the prevalence of sarcoidosis in pregnancy and used logistic regression analyses to estimate the associated risks of maternal and neonatal outcomes. RESULTS: There were 678 cases of sarcoidosis in 7,094,400 births over an 8-year period for an overall prevalence of nine and six-tenths cases per 100,000 births. Compared with controls, women with sarcoidosis were older, more likely to be African American and to report being smokers. Women with sarcoidosis were more likely to have preeclampsia odds ratio (OR) 1.62 (95% CI 1.18-2.22), eclampsia OR 5.27 (95% CI 1.69-16.40), deep vein thrombosis OR 4.92 (95% CI 1.58-15.33), pulmonary embolism OR 6.68 (95% CI 3.99-11.21), and premature delivery OR 1.73 (95% CI 1.40-2.15). There was also an increased risk of cesarean deliveries and postpartum hemorrhages. There were no cases of maternal death reported. CONCLUSIONS: Sarcoidosis in pregnancy is a rare disease associated with an increased risk of adverse obstetrical outcomes. Women with sarcoidosis can carry out successful pregnancies, however should be made aware of the higher risk of adverse events. Given the higher risk of venous thromboembolic events, consideration should be given to thromboprophylaxis in pregnancy.

Perspectives on reproductive healthcare delivered through a basic package of health services in Afghanistan: a qualitative study.

BACKGROUND: Contracting-out non-state providers to deliver a minimum package of essential health services is an increasingly common health service delivery mechanism in conflict-affected settings, where government capacity and resources are particularly constrained. Afghanistan, the longest-running example of Basic Package of Health Services (BPHS) contracting in a conflict-affected setting, enables study of how implementation of a national intervention influences access to prioritised health services. This study explores stakeholder perspectives of sexual and reproductive health (SRH) services delivered through the BPHS in Afghanistan, using Bamyan Province as a case study. METHODS: Twenty-six in-depth interviews were conducted with health-system practitioners (e.g. policy/regulatory, middle management, frontline providers) and four focus groups with service-users. Inductive thematic coding used the WHO Health System Framework categories (i.e. service delivery, workforce, medicines, information, financing, stewardship), while allowing for emergent themes. RESULTS: Improvements were noted by respondents in all health-system components discussed, with significant improvements identified in service coverage and workforce, particularly improved gender balance, numbers, training, and standardisation. Despite improvements, remaining weaknesses included service access and usage - especially in remote areas, staff retention, workload, and community accountability. CONCLUSIONS: By including perspectives on SRH service provision and BPHS contracting across health-system components and levels, this study contributes to broader debates on the effects of contracting on perceptions and experiences among practitioners and service-users in conflict-affected countries.

Sickle cell disease and pregnancy outcomes: population-based study on 8.8 million births.

OBJECTIVE: To estimate the prevalence of sickle cell disease (SCD) in pregnancy, and to measure risk factors, morbidity, and mortality among women with SCD with and without crisis at the time of birth. METHODS: We conducted a population-based, retrospective cohort study on all births in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) from 1999 to 2008. Births to SCD with and without crisis were identified using ICD-9 codes. Adjusted effects of risk factors and outcomes were estimated using logistic regression analyses. Effect of hemoglobin variants among women with SCD was analyzed as a predictor of crisis. RESULTS: There were 4262 births to women with SCD for an overall prevalence of 4.83 per 10,000 deliveries. 28.5% of women with SCD developed crisis at the time of delivery. The maternal mortality rate was 1.6 per 1000 deliveries in women with SCD, compared to 0.1 per 1000 in women without SCD. Pregnant women with SCD had a higher risk of developing preeclampsia, eclampsia, venous thromboembolism, cardiomyopathy, intrauterine fetal demise, and intrauterine growth restriction. Cesarean delivery rates were higher in women with SCD. Among the 1898 SCD women with identified hemoglobin variants, homozygous SS was the greatest risk factor for sickle cell crisis, accounting for 89.8% of all women who developed crisis. CONCLUSION: Pregnant women with SCD have a high risk of morbidity and mortality. Developing acute sickle cell crisis worsened perinatal outcomes.