Amy P Cohen
Harvard School of Public Health, Office for Educational Programs, Department Member
Objective. Epidural use has been associated with a higher rate of neonatal sepsis evaluation. Epidural-related fever explains some of the increase but not the excess of neonatal sepsis evaluations in afebrile women Methods. We studied... more
Objective. Epidural use has been associated with a higher rate of neonatal sepsis evaluation. Epidural-related fever explains some of the increase but not the excess of neonatal sepsis evaluations in afebrile women Methods. We studied 1109 women who had singleton term pregnancies and who presented in spontaneous labor and were afebrile during labor (<100.4°F). Neonatal sepsis evaluation generally was performed on the basis of the presence of 1 major or 2 minor criteria. Major criteria included rupture of membranes for >24 hours or sustained fetal heart rate of >160 beats per minute. Minor criteria included a maternal temperature of 99.6°F to 100.4°F, rupture of membranes for 12 to 24 hours, maternal admission white blood cell count of >15 000 cells/mL3, or an Apgar score of <7 at 5 minutes. Results. Infants of afebrile women with epidural analgesia were more likely to be evaluated for sepsis than infants of women without epidural (20.4% vs 8.9%), although not more likely to have neonatal sepsis. An increased risk of sepsis evaluation persisted in regression analysis (odds ratio: 3.1; 95% confidence interval: 2.0, 4.7) after controlling for confounders and was not explained by longer labors with epidural. Women with epidural were significantly more likely to have major and minor criteria for sepsis evaluation, including fetal tachycardia (4.4% vs 0.4%), rupture of membranes for >24 hours (6.2% vs 3.4%), low-grade fever of 99.6°F to 100.4°F (24.3% vs 5.2%), and rupture of membranes for 12 to 24 hours (21.4% vs 5.2%) than women without epidural. Conclusions. Epidural analgesia is associated with increased rates of major and minor criteria for neonatal sepsis evaluations in afebrile women.
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Pediatrics, Medicine, Pregnancy, Humans, Female, and 14 moreSepsis, Confidence intervals, Newborn Infant, Adult, Fever, Odds ratio, Neonatal Sepsis, Thoracic epidural analgesia, Confidence Interval, Apgar Score, Tachycardia, Psychology and Cognitive Sciences, Medical and Health Sciences, and leukocyte Count
Trial of labor after cesarean section has been an important strategy for lowering the rate of cesarean delivery in the United States, but concerns regarding its safety remain. The purpose of this study was to evaluate the outcome of... more
Trial of labor after cesarean section has been an important strategy for lowering the rate of cesarean delivery in the United States, but concerns regarding its safety remain. The purpose of this study was to evaluate the outcome of newborns delivered by elective repeat cesarean section compared to delivery following a trial of labor after cesarean. All low-risk mothers with 1 or 2 previous cesareans and no prior vaginal deliveries, who delivered at our institution from December 1994 through July 1995, were identified. Neonatal outcomes were compared between 136 women who delivered by elective repeat cesarean section and 313 women who delivered after a trial of labor. To investigate reasons for differences in outcome between these groups, neonatal outcomes within the trial of labor group were then compared between those mothers who had received epidural analgesia (n = 230) and those who did not (n = 83). Infants delivered after a trial of labor had increased rates of sepsis evaluation (23.3% vs 12.5%, p = 0.008); antibiotic treatment (11.5% vs 4.4%, p = 0.02); intubation to evaluate for the presence of meconium below the cords (11.5% vs 1.5%, p < 0.001); and mild bruising (8.0% vs 1.5%, p = 0.008). Within the trial of labor group, infants of mothers who received epidural analgesia were more likely to have received diagnostic tests and therapeutic interventions including sepsis evaluation (29.6% vs 6.0%, p = 0.001) and antibiotic treatment (13.9% vs 4.8%, p = 0.03) than within the no-epidural analgesia group. Infants born to mothers after a trial of labor are twice as likely to undergo diagnostic tests and therapeutic interventions than infants born after an elective repeat cesarean section, but the increase occurred only in the subgroup of infants whose mothers received epidural analgesia for pain relief during labor. The higher rate of intervention could relate to the well-documented increase in intrapartum fever that occurs with epidural use.
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... 5. Washington, DC: American College of Obstetricians and Gynecologists, 1998. Cited Here... 2. Callahan C, Chescheir N, Steiner BD. Safety and efficacy of attempted vaginal birth after cesarean beyond the estimated date of delivery.... more
... 5. Washington, DC: American College of Obstetricians and Gynecologists, 1998. Cited Here... 2. Callahan C, Chescheir N, Steiner BD. Safety and efficacy of attempted vaginal birth after cesarean beyond the estimated date of delivery. Reprod Med 1999;44:606-10. Cited Here... ...
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In an attempt to find more efficacious alternatives for the diagnosis of gestational diabetes mellitus, we evaluated whether (1) there is a glucose loading test value above which all glucose tolerance test results are positive, (2)... more
In an attempt to find more efficacious alternatives for the diagnosis of gestational diabetes mellitus, we evaluated whether (1) there is a glucose loading test value above which all glucose tolerance test results are positive, (2) omission of the third-hour plasma glucose measurement of the glucose tolerance test alters the sensitivity of the test, and (3) the presence of a fasting plasma glucose concentration >/=105 mg/dL suffices as a diagnostic standard after an abnormal glucose loading test result. The charts of 512 patients who underwent 3-hour glucose tolerance tests at our institution between January 1995 and December 1996 were reviewed. Only subjects for whom the glucose loading test yielded plasma glucose levels >/=140 mg/dL were selected. The positive predictive value of a glucose loading test result >/=185 mg/dL was calculated. Results of glucose tolerance tests of subjects with elevated fasting plasma glucose concentrations were then evaluated to determine the positive predictive value for gestational diabetes mellitus of an elevated fasting plasma glucose concentration. Among the subjects who underwent glucose tolerance tests, 22% (114/512) met positive test criteria for gestational diabetes mellitus. The positive predictive value for a glucose loading test result >/=185 mg/dL was 57% (25/44), whereas a glucose loading test result >199 mg/dL showed a positive predictive value of 69% (4/13). Omission of the third-hour glucose tolerance test value yielded a sensitivity of 87% (99/114). Among the 24 women with fasting plasma glucose concentrations >/=105 mg/dL, 96% had positive glucose tolerance test results. An elevated fasting plasma glucose concentration was highly associated with gestational diabetes mellitus necessitating insulin therapy (65%). An elevated glucose loading test result was associated with but not highly predictive of gestational diabetes mellitus. Omission of the 3-hour glucose tolerance test measurement resulted in failure to diagnose 13% of gestational diabetes mellitus cases. A fasting plasma glucose concentration >/=105 mg/dL was highly predictive of an abnormal glucose tolerance test result among patients with an elevated glucose loading test value.
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Endocrinology, Medicine, Gestational diabetes, Humans, Internal Medicine, and 15 moreBlood Glucose, Insulin, Fasting, Diabetes mellitus, Female, American, Adult, Parity, Glucose Tolerance Test, Positive predictive value, Fasting Blood Glucose, Cohort Studies, Plasma Glucose, Paediatrics and reproductive medicine, and gestational diabetes mellitus
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Family Medicine, Health Care, Cultural Competency, Cultural Competence, General Internal Medicine, and 15 moreEthnic minorities, Cultural Diversity, African American, General, Female, Data Collection, Graduate medical education, Feeling, Clinical Sciences, Ethnic Group, Health Beliefs, Ethnic Minorities, Clinical Competence, Distrust, and Healthcare system
: Background: Parents feel strongly about whether or not to learn the sex of their fetus. We sought to determine which factors are significantly associated with parents’ desire to know or not to know the fetal sex during a prenatal... more
: Background: Parents feel strongly about whether or not to learn the sex of their fetus. We sought to determine which factors are significantly associated with parents’ desire to know or not to know the fetal sex during a prenatal ultrasound. Methods: All women undergoing prenatal ultrasound examinations, except for those with suspected failed pregnancies, were invited to answer a questionnaire at an outpatient referral center for diagnostic ultrasound in obstetrics and gynecology in Boston, Massachusetts. The survey asked about demographic factors, current pregnancy, and past pregnancies, and an open‐ended question about whether and why the parents wished to learn, or did not learn, the sex of their fetus. Factors significantly associated with parents’ desire to learn the fetal sex prenatally were determined and analyzed. Results: A total of 1,340 questionnaires were completed. Overall, 761/1,302 (58%) of mothers and 747/1,295 (58%) of fathers learned or planned to learn the fetal sex before delivery. Factors most associated with wanting to learn the fetal sex were conceiving accidentally, finding out the sex in a previous pregnancy, not planning to breastfeed, influence of sex on future childbearing plans, planning a move or renovation dependent on sex, and specific parental sex preference. Demographic factors most associated with wanting to learn the fetal sex were father without full‐time job, lower household income, unwed mother, maternal age less than 22 or greater than 40 years, no college degree, race other than white, and religion other than Catholic. Conclusions: Specific demographic and socioeconomic characteristics predicted whether or not parents chose to know the sex of their unborn child. Families in which the pregnancy was unplanned, those in which fetal sex would influence living arrangements or future childbearing plans, and those of lower socioeconomic status wished to know the sex more frequently. Further study is needed to understand parents’ motivations underlying the desire to know or not know fetal sex before delivery.
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Obstetrics, Risk assessment, Medicine, Logistic Regression, Birth Weight, and 15 morePregnancy, Humans, Female, Obstetrics Gynecology, Adult, Maternal Age, Odds ratio, Retrospective Studies, Cesarean Section, Risk Assessment, Medical Records, Logistic Models, Confidence Interval, confounding, and Paediatrics and reproductive medicine
Few studies have directly examined the reasons for choices of pain relief during labor. The purpose of this study was to investigate if women's preferences for epidural analgesia in labor have an impact on the use of intrapartum... more
Few studies have directly examined the reasons for choices of pain relief during labor. The purpose of this study was to investigate if women's preferences for epidural analgesia in labor have an impact on the use of intrapartum epidural analgesia. Nulliparous women attending childbirth classes completed questionnaires about their antenatal preferences for the use of intrapartum epidural analgesia. Data on actual use of analgesia was obtained by chart review. The analysis included 303 women with either spontaneous or induced labor at term. The 185 women who planned to receive epidural analgesia had a markedly higher rate of epidural use (91%) than the 110 women who hoped to avoid it (57%) (p = 0.001). Of 237 epidurals administered, 169 (71%) were planned during the antenatal period. Among women receiving epidural analgesia, those planning to receive it tended to have more frequent early administration (< or = 3 cm cervical dilation) than women who unsuccessfully tried to avoid epidural use (54% vs. 24%, p = 0.003). In our population of nulliparas, a woman's antenatal plan to receive epidural analgesia is strongly associated with her likelihood of receiving it. Women who plan to receive epidural analgesia have earlier administration.
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Introduction: Faculty development in the clinical setting is challenging to implement and assess. This study evaluated an intervention (IG) to enhance bedside teaching in three content areas: critical thinking (CT), high-value care (HVC),... more
Introduction: Faculty development in the clinical setting is challenging to implement and assess. This study evaluated an intervention (IG) to enhance bedside teaching in three content areas: critical thinking (CT), high-value care (HVC), and health care equity (HCE). Methods: The Communities of Practice model and Theoretical Domains Framework informed IG development. Three multidepartmental working groups (WGs) (CT, HVC, HCE) developed three 2-hour sessions delivered over three months. Evaluation addressed faculty satisfaction, knowledge acquisition, and behavior change. Data collection included surveys and observations of teaching during patient care. Primary analyses compared counts of post-IG teaching behaviors per hour across intervention group (IG), comparison group (CG), and WG groups. Statistical analyses of counts were modeled with generalized linear models using the Poisson distribution. Results: Eighty-seven faculty members participated (IG n = 30, CG n = 28, WG n = 29). Sixty-eight (IG n = 28, CG n = 23, WG n = 17) were observed, with a median of 3 observation sessions and 5.2 hours each. Postintervention comparison of teaching (average counts/hour) showed statistically significant differences across groups: CT CG = 4.1, IG = 4.8, WG = 8.2; HVC CG = 0.6, IG = 0.9, WG = 1.6; and HCE CG = 0.2, IG = 0.4, WG = 1.4 (P < .001). Discussion: A faculty development intervention focused on teaching in the context of providing clinical care resulted in more frequent teaching of CT, HVC, and HCE in the intervention group compared with controls. WG faculty demonstrated highest teaching counts and provide benchmarks to assess future interventions. With the creation of durable teaching materials and a cadre of trained faculty, this project sets a foundation for infusing substantive content into clinical teaching.
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To the Editor: On reading the article by Frigoletto et al. re-garding the randomized controlled trial of active manage-ment of labor, we were pleased to note so many similarities between their findings and ours.1 With patients who... more
To the Editor: On reading the article by Frigoletto et al. re-garding the randomized controlled trial of active manage-ment of labor, we were pleased to note so many similarities between their findings and ours.1 With patients who fulfilled the criteria for active management at the ...
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OBJECTIVE To identify gaps and opportunities in complex care training for pediatric residents. METHODS Residents in an academic pediatric residency program were surveyed about: training experiences in complex care; self-entrustment in key... more
OBJECTIVE To identify gaps and opportunities in complex care training for pediatric residents. METHODS Residents in an academic pediatric residency program were surveyed about: training experiences in complex care; self-entrustment in key clinical activities in complex care; educational strategies that would increase preparedness; and recommendations for curriculum development. We used descriptive statistics for quantitative data and content analysis for free-text responses. RESULTS Of the 160 residents surveyed, 110 (69%) participated. Most participants reported prior clinical exposure to children with medical complexity (CMC) (106, 96%) during both inpatient (82, 75%) and outpatient (88, 80%) clinical rotations. Mean self-entrustment was at or below "somewhat confident" for all clinical activities in complex care, for residents in all postgraduate years. Clinical activities with highest reported self-entrustment included evaluating aspiration into the airway, nutritional issues, care coordination, and evaluating pain. Lowest self-entrustment was reported for facilitating transition to adult care, managing medical technologies, and safety/emergency planning. In terms of educational strategies, participants recommended inpatient encounters with an expert preceptor teaching about evaluating aspiration, pain/irritability and dysmotility (>50%); discussions with patients/families for advocacy, difficult discussions, and transition to adult care (>40%); and hands-on practice for medical technology care (>40%). CONCLUSIONS Pediatric residents report limited self-entrustment in performing key clinical activities in complex care, including for residents at the end of their last postgraduate year. Future curriculum development should prioritize direct observation of clinical encounters with CMC by expert preceptors, partnership with patients and families of CMC, and hands-on simulation.
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... Ellice Lieberman and Amy Cohen are from the Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School; Janet Lang is from the Department of Epidemiology and Biostatistics; Boston... more
... Ellice Lieberman and Amy Cohen are from the Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School; Janet Lang is from the Department of Epidemiology and Biostatistics; Boston University School of Public Health; and Fredric ...
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Background:There are limited training opportunities for pediatricians in caring for children with medical complexity (CMC) in the home and community. Prior studies have described a lack of comfort caring for CMC among pediatric... more
Background:There are limited training opportunities for pediatricians in caring for children with medical complexity (CMC) in the home and community. Prior studies have described a lack of comfort caring for CMC among pediatric residents.Objective:1) To evaluate the impact of participation in a virtual home visit curriculum on pediatric residents’ confidence, knowledge, and application of knowledge in complex care; 2) to explore changes in perspectives relating to the care of CMC after participation in the curriculum.Methods:This was a prospective pre-post intervention study in 2019 with first-year pediatric residents, using quantitative and qualitative methods. The intervention, co-created with a family partner, was an online video-based curriculum followed by an in-person seminar. Pre- and post-assessments were compared using paired t-tests. Follow-up interviews and focus groups were performed 5–8 weeks after training. Transcripts were analyzed using inductive thematic analysis.Results:Twenty-four residents (100%) participated. Residents reported increased confidence in all aspects of complex care presented in the curriculum, with significant increase in knowledge and application of knowledge (all p<0.001). Twelve residents (50%) participated in a follow-up interview or focus group. Four themes were identified: 1) recognizing prior attitudes toward complexity, 2) new mental framework for complex care at home, 3) drivers of behavior change, 4) commitment to change practice.Conclusions:Participation in this curriculum was associated with increased confidence, knowledge, and application of knowledge in complex care outside of the hospital. Qualitative findings align with transformative learning theory, lending insight into effective approaches to complex care training.
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Medicine, Linear models, Logistic Regression, Birth Weight, Humans, and 15 moreAfrican American, Female, American, Newborn Infant, Adult, Fever, European Continental Ancestry Group, Neonatal Intensive Care Unit, Linear Regression, Gestational Age, Logistic Models, Confidence Interval, Cohort Studies, confounding, and Obstetric Labor Premature
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Obstetrics, Medicine, Pregnancy, Humans, Hypertension, and 14 morePreeclampsia, Blood Pressure, Female, Risk factors, Black Women, African Americans, Adult, Retrospective Studies, European Continental Ancestry Group, Chi Square Distribution, Risk Factors, Gestational hypertension, Paediatrics and reproductive medicine, and chronic hypertension
Objectives. We evaluated whether “seminar blogs” enhanced learning in a large graduate-level introductory public health school class.Methods. Sixty students were divided into 6 online blog groups. Students posted their assignments (case... more
Objectives. We evaluated whether “seminar blogs” enhanced learning in a large graduate-level introductory public health school class.Methods. Sixty students were divided into 6 online blog groups. Students posted their assignments (case analyses, news commentaries), prompting comments from other students. Anonymous poll surveys of students were conducted at midpoint and at the end of the course.Results. Sixty percent reported that blog participation enriched their learning quite a bit, 34% a small amount, and 6% not at all; 54% said that the blogs provided opportunities to learn from classmates. When comparing writing on the blog to speaking in class, 60% found it easier, 30% about the same, and 10% harder. About 65% said that skills attained by participating in blogs were useful for current or future work. Major criticisms involved time issues.Conclusions. Small seminar blogs offer opportunities for increased student participation, interaction, and learning. To be most effective and appealing, assignments for postings need to allow sufficient time for commentary. This educational technology has potential to expand the classroom experience and is worthy of further development and testing.
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Psychology, Educational Technology, Problem Based Learning, Public Health, Group Processes, and 15 moreMedicine, Learning, Humans, Mental processes, American, Data Collection, Interpersonal Relations, Boston, Adult, Professional Competence, Competency Based Education, Cooperative Behavior, Internet, Medical and Health Sciences, and research and practice
Objective. To evaluate the National Violent Death Reporting System (NVDRS) as a surveillance system for homicides by law enforcement officers.Methods. We assessed sensitivity and positive predictive value of the NVDRS “type of death”... more
Objective. To evaluate the National Violent Death Reporting System (NVDRS) as a surveillance system for homicides by law enforcement officers.Methods. We assessed sensitivity and positive predictive value of the NVDRS “type of death” variable against our study count of homicides by police, which we derived from NVDRS coded and narrative data for states participating in NVDRS 2005 to 2012. We compared state counts of police homicides from NVDRS, Vital Statistics, and Federal Bureau of Investigation Supplementary Homicide Reports.Results. We identified 1552 police homicides in the 16 states. Positive predictive value and sensitivity of the NVDRS “type of death” variable for police homicides were high (98% and 90%, respectively). Counts from Vital Statistics and Supplementary Homicide Reports were 58% and 48%, respectively, of our study total; gaps varied widely by state. The annual rate of police homicide (0.24/100 000) varied 5-fold by state and 8-fold by race/ethnicity.Conclusions. NVDRS provides more complete data on police homicides than do existing systems.Policy Implications. Expanding NVDRS to all 50 states and making 2 improvements we identify will be an efficient way to provide the nation with more accurate, detailed data on homicides by law enforcement.
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Demography, Health Disparities, General Internal Medicine, Acculturation, Adolescent, and 15 moreDominican Republic, Humans, Hypertension, Diabetes mellitus, Country of Origin, Female, Male, Confidence intervals, Health Status, Clinical Sciences, Aged, Adult, Ethnic Group, Health surveys, and Logistic Models
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Introduction: Faculty development in the clinical setting is challenging to implement and assess. This study evaluated an intervention (IG) to enhance bedside teaching in three content areas: critical thinking (CT), high-value care (HVC),... more
Introduction: Faculty development in the clinical setting is challenging to implement and assess. This study evaluated an intervention (IG) to enhance bedside teaching in three content areas: critical thinking (CT), high-value care (HVC), and health care equity (HCE). Methods: The Communities of Practice model and Theoretical Domains Framework informed IG development. Three multidepartmental working groups (WGs) (CT, HVC, HCE) developed three 2-hour sessions delivered over three months. Evaluation addressed faculty satisfaction, knowledge acquisition, and behavior change. Data collection included surveys and observations of teaching during patient care. Primary analyses compared counts of post-IG teaching behaviors per hour across intervention group (IG), comparison group (CG), and WG groups. Statistical analyses of counts were modeled with generalized linear models using the Poisson distribution. Results: Eighty-seven faculty members participated (IG n = 30, CG n = 28, WG n = 29). ...
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ABSTRACTBackground The flipped classroom is a teaching approach with strong evidence for effectiveness in undergraduate medical education. Objective data for its implementation in graduate medical education are limited.Objective We... more
ABSTRACTBackground The flipped classroom is a teaching approach with strong evidence for effectiveness in undergraduate medical education. Objective data for its implementation in graduate medical education are limited.Objective We assessed the efficacy of the flipped classroom compared with standard approaches on knowledge acquisition and retention in residency education.Methods During academic year 2016–2017, 63 medical interns in a large academic internal medical residency program on their ambulatory block were randomized to a flipped classroom or standard classroom during a 6-hour cardiovascular prevention curriculum. The primary outcome was performance on a 51-question knowledge test at preintervention, immediate postintervention, and 3- to 6-month postintervention (delayed postintervention). Secondary outcomes included satisfaction with the instructional method and preparation time for the flipped classroom versus standard approach. We also examined feasibility and barriers to...
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Infants are at greatest risk for severe disease and death from pertussis; most acquire it from household contacts. Centers for Disease Control and Prevention guidelines recommend tetanus toxoid, reduced diphtheria toxoid, and acellular... more
Infants are at greatest risk for severe disease and death from pertussis; most acquire it from household contacts. Centers for Disease Control and Prevention guidelines recommend tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap) vaccination for infant caregivers, especially postpartum women who did not receive it during pregnancy. Our objective was to increase the percentage of women receiving Tdap vaccine before postpartum discharge. An interdisciplinary workgroup identified barriers to improvement of postpartum Tdap vaccination from which a 5-step intervention was created: (1) provide education on Tdap and pertussis; (2) offer Tdap throughout hospitalization; (3) create a Tdap standing order; (4) keep Tdap as floor stock; and (5) document administration. Pre- and postintervention data were collected from monthly chart reviews. Our main outcome measures were the proportion of postpartum women eligible for Tdap and the proportion of those eligible w...
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Long term recalls of dietary intake are frequently used in case-control studies, but their validity and reliability have not been established. In this study, 91 middle-aged adults (median age, 50 years) who were participants in the... more
Long term recalls of dietary intake are frequently used in case-control studies, but their validity and reliability have not been established. In this study, 91 middle-aged adults (median age, 50 years) who were participants in the Longitudinal Study of Child Health and Development at the Harvard School of Public Health in Boston, Massachusetts, starting in the early 1930s, were asked in 1984-1985 to report present food intake and to recall food intakes at ages 5-7 years. 18 years, and 30 years using food frequency questionnaires. Their recalled intakes were validated by comparison with historical records of intake collected during the earlier time periods. Recall of food intake in the distant past was a better predictor of historical intake than was current diet. However, correlations between recalled and historical consumption for individual foods and food groups were generally low, rarely exceeding 0.3. Current intakes exerted a powerful influence on accuracy of recall. The consideration of participant characteristics did not prove to be consistently useful in explaining variations in food item and food group-related recall. The authors conclude that recall of food intake in the distant past may be a sufficiently valid estimate of past intake to justify its collection.
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Identifying the source and specific type of gas used in suicides is difficult using most data systems owing to limitations in ICD-10 coding. The National Violent Death Reporting System (NVDRS), with its rich collection of both coded and... more
Identifying the source and specific type of gas used in suicides is difficult using most data systems owing to limitations in ICD-10 coding. The National Violent Death Reporting System (NVDRS), with its rich collection of both coded and free-text variables, has the potential to overcome these limitations. This study used a multipronged approach to identify gas-specific suicides in NVDRS and to track the incidence of these suicides over time. Using suicide cases from the 16 NVDRS states that participated throughout 2005-2012, free-text and code searches were conducted for four types of variables-incident narratives, coroner/medical examiner cause-of-death statements, cause-of-death codes, and substance names-to identify suicides by carbon monoxide, helium, hydrogen sulfide, and four other gases. All analyses were conducted in 2015. Approximately 4% (3,242 of 80,715) of suicides recorded in NVDRS over the study period were the result of gas inhalation. Of these, the majority (73%) wer...
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Background Multi-source evaluation has demonstrated value for trainees, but is not generally provided to residency or fellowship program directors (PDs). Objective To develop, implement, and evaluate a PD multi-source evaluation process.... more
Background Multi-source evaluation has demonstrated value for trainees, but is not generally provided to residency or fellowship program directors (PDs). Objective To develop, implement, and evaluate a PD multi-source evaluation process. Methods Tools were developed for PD evaluation by trainees, department chairs, and graduate medical education (GME) leadership. Evaluation questions were based on PD responsibilities, including Accreditation Council for Graduate Medical Education (ACGME) requirements. A follow-up survey assessed the process. Results Evaluation completion rates were as follows: trainees in academic year 2012–2013, 53% (958 of 1824), and in academic year 2013–2014, 42% (800 of 1898); GME directors in 2013–2014, 100% (95 of 95); and chairs/chiefs in 2013–2014, 92% (109 of 118). Results of a follow-up survey of PDs (66%, 59 of 90) and chairs (74%, 48 of 65) supports the evaluations' value, with 45% of responding PDs (25 of 56) and 50% of responding chairs (21 of 42)...
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To evaluate the National Violent Death Reporting System (NVDRS) as a surveillance system for homicides by law enforcement officers. We assessed sensitivity and positive predictive value of the NVDRS "type of death" variable... more
To evaluate the National Violent Death Reporting System (NVDRS) as a surveillance system for homicides by law enforcement officers. We assessed sensitivity and positive predictive value of the NVDRS "type of death" variable against our study count of homicides by police, which we derived from NVDRS coded and narrative data for states participating in NVDRS 2005 to 2012. We compared state counts of police homicides from NVDRS, Vital Statistics, and Federal Bureau of Investigation Supplementary Homicide Reports. We identified 1552 police homicides in the 16 states. Positive predictive value and sensitivity of the NVDRS "type of death" variable for police homicides were high (98% and 90%, respectively). Counts from Vital Statistics and Supplementary Homicide Reports were 58% and 48%, respectively, of our study total; gaps varied widely by state. The annual rate of police homicide (0.24/100 000) varied 5-fold by state and 8-fold by race/ethnicity. NVDRS provides more...
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Stroke care, admission through discharge, is a process that should lead to symptomatic improvement. Improvement or decline in conditions of patients with acute stroke during hospitalization can be measured by the National Institutes of... more
Stroke care, admission through discharge, is a process that should lead to symptomatic improvement. Improvement or decline in conditions of patients with acute stroke during hospitalization can be measured by the National Institutes of Health Stroke Scale (NIH Stroke Scale or NIHSS) at both admission and discharge and may indicate the overall quality of acute stroke care for a patient and the stability of care in the system. Shewhart control charts were analyzed for 98 patients with stroke admissions in a random sample at a tertiary care stroke center to determine the feasibility of examining the NIHSS score change to detect statistical control or identify excess variance in outcomes. The study sample showed a mean improvement of 1.33 points from admission to discharge on the NIHSS. Three statistical outliers were found. Excess statistical variation clustered within a specific stroke team's tenure suggested a need for targeted education and examination for process redesign. Usin...
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To the Editor .— We read the article by Goetzl et al1 with interest. While we agree that there is an association between epidural analgesia and increased maternal temperature,2 we would question that epidural analgesia in the mother per... more
To the Editor .— We read the article by Goetzl et al1 with interest. While we agree that there is an association between epidural analgesia and increased maternal temperature,2 we would question that epidural analgesia in the mother per se leads to increased screening for sepsis in the newborn whether the mother is febrile or afebrile after an epidural. At St Helier Hospital we have reviewed 461 consequent deliveries. In this audit we noted the following irrespective of whether the mothers received epidural analgesia or not: parity, mode of delivery, time from membrane rupture to birth, duration of first and second stage, maternal temperature on arrival in the delivery suite, maternal temperature during labor, if there was any other reason (eg, infection) to explain maternal pyrexia, infant’s temperature immediately after birth, if the infant received a sepsis screen, if the infant was prescribed antibiotics, and if the infant developed within the first 7 days after birth. At our institution women are also given the choice to choose epidural analgesia. Midwives and obstetricians may also recommend this option for a labor that seems more painful than normal or has an increased risk of surgical delivery or in the presence of certain medical disorders, such as preeclampsia. If they choose epidural analgesia they are given bupivacaine 0.1% with …
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The timing of fetal lung maturation is regulated, at least in part, by the fetal endocrine milieu, which in turn may be influenced by environmental factors. Infants of smoking mothers are at decreased risk of neonatal respiratory distress... more
The timing of fetal lung maturation is regulated, at least in part, by the fetal endocrine milieu, which in turn may be influenced by environmental factors. Infants of smoking mothers are at decreased risk of neonatal respiratory distress syndrome (RDS), a disease of lung immaturity. Therefore, we measured fetal lung maturity and cigarette smoke exposure to determine whether the lungs of smoke-exposed fetuses mature more quickly and whether changes in maturation are associated with alterations in amniotic fluid (AF) cortisol levels. Amniotic fluid lecithin-sphingomyelin ratio (L/S) and saturated phosphatidylcholine levels were used as measures of lung maturity, while smoke exposure was assessed by measuring AF cotinine, a stable nicotine metabolite. Lung maturity was more advanced in smoke-exposed fetuses as measured by saturated phosphatidylcholine (P = .02) and L/S ratio (P = .04). Smoke-exposed fetuses attained sufficient lung maturity to minimize the risk of RDS approximately 1 ...