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Objective: Describe a model for incorporating campus-based Sexual Assault Nurse Examiner (SANE) services. Describe differences in patient satisfaction and utilization of follow-up resources between patients seeking SANE services at a university health center (UHC) compared to an emergency department (ED). Participants: Patients seeking SANE services at the UHC or ED of a large Midwestern university from January 2016-April 2018. Fifty-eight participants completed a satisfaction survey, including 28 students. Twenty-eight participants completed a follow-up survey, including 15 students. Methods: A Qualtrics survey assessed--(1) satisfaction following the SANE exam and (2) use of follow-up services 4-6 weeks later. Descriptive analyses, exact logistic regressions, and OLS regressions were calculated. Results: There were no differences in satisfaction, services received, or follow-up services accessed between patients at the UHC and ED, including between students. Conclusions: Campus-based SANE services meet the expectations of survivors and do not differ significantly from services at the ED.

Abstract Background Gout is the commonest inflammatory arthritis affecting around 1.4% of adults in Europe. It is predominantly managed in primary care and classically affects the joints of the foot, particularly the first metatarsophalangeal joint. Gout related factors (including disease characteristics and treatment) as well as comorbid chronic disease are associated with poor Health Related Quality of Life (HRQOL) yet to date there is limited evidence concerning gout in a community setting. Existing epidemiological studies are limited by their cross-sectional design, selection of secondary care patients with atypical disease and the use of generic tools to measure HRQOL. This 3 year primary care-based prospective observational cohort study will describe the spectrum of HRQOL in community dwelling patients with gout, associated factors, predictors of poor outcome, and prevalence and incidence of foot problems in gout patients. Methods Adults aged ≥ 18 years diagnosed with gout or prescribed colchicine or allopurinol in the preceding 2 years will be identified through Read codes and mailed a series of self-completion postal questionnaires over a 3-year period. Consenting participants will have their general practice medical records reviewed. Discussion This is the first prospective cohort study of HRQOL in patients with gout in primary care in the UK. The combination of survey data and medical record review will allow an in-depth understanding of factors that are associated with and lead to poor HRQOL and foot problems in gout. Identification of these factors will improve the management of this prevalent, yet under-treated, condition in primary care.

Abstract Background Polymyalgia Rheumatica (PMR) is the commonest inflammatory condition seen in older patients in primary care. To date, however, research has been focused on secondary care cohorts rather than primary care where many patients are exclusively managed. This two year prospective inception cohort study of PMR patients will enable us to understand the full spectrum of this condition. Methods Patients diagnosed with PMR in primary care will be identified via Read codes and mailed a series of postal questionnaires over a two-year period to assess their levels of pain, stiffness and functioning, as well as medication usage and other health-related and socio-demographic characteristics. In addition, participants will be asked for permission to link their survey data to their general practice electronic medical record and to national mortality and cancer registers. Discussion This will be the first large-scale, prospective, observational cohort of PMR patients in primary care. The combination of survey data with medical records and national registers will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting, in which the majority of patients are treated, but where little research on the treatment and outcome of consultation has been undertaken. This will provide information that may lead to improved primary care management of PMR.

Abstract Background Musculoskeletal conditions represent a common reason for consulting general practice yet with the exception of low back pain, relatively little is known about the prognosis of these disorders. Recent evidence suggests that common 'generic' factors may be of value when assessing prognosis, irrespective of the location of the pain. This study will test a generic assessment tool used as part of the general practice consultation to determine prognosis of musculoskeletal complaints. Methods/Design Older adults (aged 50 years and over) presenting to six general practices with musculoskeletal complaints will be assessed as part of the routine consultation using a generic assessment of prognosis. Participants will receive a self-completion questionnaire at baseline, three, six and 12 months post consultation to gather further data on pain, disability and psychological status. The primary outcome measure is participant's global rating of change. Discussion Prognosis is considered to be a fundamental component of scientific medicine yet prognostic research in primary care settings is currently neglected and prognostic enquiry is disappearing from general medical textbooks. This study aims to address this issue by examining the use of generic prognostic factors in a general practice setting.

Abstract Background There is evidence to suggest that human papillomavirus (HPV) can cross the placenta resulting in in-utero transmission. The goal of this study was to determine if HPV can be detected in amniotic fluid from women with intact amniotic membranes. Methods Residual amniotic fluid and cultured cell pellets from amniocentesis performed for prenatal diagnosis were used. PGMY09/11 L1 consensus primers and GP5+/GP6+ primers were used in a nested polymerase chain reaction assay for HPV. Results There were 146 paired samples from 142 women representing 139 singleton pregnancies, 2 twin pregnancies, and 1 triplet pregnancy. The women were 78% Caucasian, 5% African American, 14% Asian, and 2% Hispanic. The average age was 35.2 years with a range of 23–55 years. All samples were β-globin positive. HPV was not detected in any of the paired samples. Conclusion Given the age range, race, and ethnicity of the study population, one would anticipate some evidence of HPV if it could easily cross the placenta, but there was none.

Abstract Background Curcumin is the major yellow pigment extracted from turmeric, a commonly-used spice in India and Southeast Asia that has broad anticarcinogenic and cancer chemopreventive potential. However, few systematic studies of curcumin's pharmacology and toxicology in humans have been performed. Methods A dose escalation study was conducted to determine the maximum tolerated dose and safety of a single dose of standardized powder extract, uniformly milled curcumin (C3 Complex™, Sabinsa Corporation). Healthy volunteers were administered escalating doses from 500 to 12,000 mg. Results Seven of twenty-four subjects (30%) experienced only minimal toxicity that did not appear to be dose-related. No curcumin was detected in the serum of subjects administered 500, 1,000, 2,000, 4,000, 6,000 or 8,000 mg. Low levels of curcumin were detected in two subjects administered 10,000 or 12,000 mg. Conclusion The tolerance of curcumin in high single oral doses appears to be excellent. Given that achieving systemic bioavailability of curcumin or its metabolites may not be essential for colorectal cancer chemoprevention, these findings warrant further investigation for its utility as a long-term chemopreventive agent.

Objective This study aimed to assess the impact of implementation of an induction of labor (IOL) guideline on IOL length and utilization of evidence-based practices. Study Design We conducted a quality improvement project to increase utilization of three evidence-based IOL practices: combined agent ripening, vaginal misoprostol, and early amniotomy. Singletons with intact membranes and cervical dilation ≤2 cm admitted for IOL were included. Primary outcome was IOL length. Secondary outcomes included cesarean delivery and practice utilization. We compared preimplementation (PRE; November 1, 2021 through January 31, 2022) to postimplementation (POST; March 1, 2022 through April 30, 2022) with sensitivity analyses by self-reported race and ethnicity. Cox proportional hazards models and logistic regression were used to test the association between period and outcomes. Results Among 495 birthing people (PRE, n = 293; POST, n = 202), IOL length was shorter POST (22.0 vs. 18.3 h, p = 0.003), with faster time to delivery (adjusted hazard ratio [aHR] = 1.38, 95% CI: 1.15–1.66), more birthing people delivered within 24 hours (57 vs. 68.8%, adjusted odds ratio [aOR] = 1.90 [95% CI: 1.25–2.89]), and no difference in cesarean. Utilization of combined agent ripening (31.1 vs. 42.6%, p = 0.009), vaginal misoprostol (34.5 vs. 68.3%, p < 0.001), and early amniotomy (19.1 vs. 31.7%, p = 0.001) increased POST. Conclusion Implementation of an evidence-based IOL guideline is associated with shorter induction time. Additional implementation efforts to increase adoption of practices are needed to optimize outcomes after IOL. Key Points Implementation of an IOL guideline is associated with faster time to delivery. Evidence-based induction practices were used more often after guideline implementation. Adoption of evidence-based induction practices is variable even with a guideline. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic stress is associated with increases in preterm birth, low birth weight, and other perinatal complications. Yet the identification of patients with traumatic stress and intervention for traumatic stress prevention or treatment remain low. Locally in this university hospital‐based midwife clinic, a health records review found that trauma exposure was documented in 5% of patient records, and no records had a diagnosis of posttraumatic stress disorder (PTSD). This is lower than research‐based population estimates of 25% to 50% for trauma exposure and 8% for PTSD during pregnancy. The clinic staff did not screen for posttraumatic stress, and exposure screening was limited to intimate personal violence. Staff had not been trained in trauma‐informed care (TIC) as defined by the Substance Abuse and Mental Health Services Administration. The aim for this improvement project was to provide trauma screening and trauma‐related care planning, collectively referred to as trauma‐informed psychosocial care, to midwifery patients 85% of the time. Process: Interventions were implemented over 4 plan‐do‐study‐act (PDSA) cycles. These included staff training in TIC; written screening at the new prenatal, third trimester, and postpartum visits; verbal broad inquiry at every visit; and bidirectional trauma‐specific care planning emphasizing patient and provider input into treatment choice. The clinic flow was changed to create privacy for patient‐staff interaction at every visit. Field notes and data were analyzed every 2 weeks and iterative changes applied. Outcomes: Trauma disclosure increased from 5% to 30% and identification of PTSD from 0% to 7%. Bidirectional care plan documentation increased from 8% to 67%. Staff rated the workload as reasonable. Discussion: Redesigning psychosocial screening to align with TIC principles increased the discovery of trauma to levels consistent with research‐based population estimates. Gains were made in bidirectional care planning. This project illustrates practical methods of implementing TIC principles. [ABSTRACT FROM AUTHOR]

Background: Induction of labor (IOL) has been studied as a strategy to reduce rates of cesarean birth (CB). Midwifery care models are also associated with lower CB rates, even considering that midwives perform fewer IOLs. In this study, we examined childbirth outcomes among individuals undergoing IOL in certified nurse‐midwifery (CNM) care as compared to two categories of expectant management (EM). Methods: Data were from two CNM practices in the United States (2007‐2018). The sample was limited to term nulliparous, nondiabetic, singleton, vertex pregnancies. Individuals having an IOL in each week of gestation (37th, 38th, etc) were compared with those having EM. Two methods for defining EM were considered as each method when used alone limits interpretation. Inclusive EM included all births starting in the same week as IOL. The exclusive EM group was comprised of all births occurring in the next gestational age week relative to the IOL cases (ie, 39th week IOL versus all births occurring at 40 weeks or later). Adjusted regression models were used to examine differences in CB by IOL versus EM (inclusive or exclusive) at each week of gestation. Results: Among 4057 CNM‐attended pregnancies, the overall rate of IOL was 28.9% (95% CI 27.5%‐30.3%) and CB was 19.4% (95% CI 18.1%‐20.6%). Most IOLs involved obstetric indications. CB rates did not differ by IOL versus inclusive EM when performed between 37 and 40 weeks, though post hoc power calculations indicate these comparisons were low‐powered. In multivarable models, IOL in the 40th week was associated with lower odds for CB versus exclusive EM definition (ie, births occurring at 41 0/7 weeks or later, OR (95% CI) = 0.57 (0.36‐0.90)). This finding is explained by the large increase in CB rates after IOL during the 41st week (34.3%, up from 21.9% in the 40th week). Furthermore, the adjusted odds for CB in the 41st week were 55% higher relative to inclusive EM (all labors 41st week and later), OR (95% CI) = 1.55(1.11‐2.15). Neonatal outcomes (aside from macrosomia) did not differ by IOL/EM at any gestational age. Discussion: Outcomes for nulliparous individuals having IOL or EM in the context of a midwifery model of care include low overall use of CB and low frequency of IOL before 41 weeks. In this model, IOL in the 40th week may lower CB odds, especially in comparison to those who do not have spontaneous labor and later undergo an IOL in the 41st week. [ABSTRACT FROM AUTHOR]

Background: Hypertensive disorders of pregnancy are a leading cause of maternal mortality and morbidity. To address this, a large Midwestern hospital initiated a practice guideline. Practice guidelines should improve outcomes, but implementation of these remains challenging. At the time of initiation of the guideline, no implementation or evaluation plan was conceived. Objective: Evaluate the implementation and unit impact of a guideline for the management of hypertensive disorders of pregnancy in a large academic health system in the Midwest. Methods: Six objectives, guided by the constructs of the Ottawa Model of Research Utilization, were operationalized to evaluate the implementation and unit impact of the guideline. Results: The guideline implemented was consistent with national recommendations. Intervention education was inconsistent across provider types. A survey of staff revealed insight into a unit in the midst of practice change. A chart review revealed below-target management of patients with severe range blood pressures. Not following the guideline was associated with hospital readmission. Conclusions: Guideline implementation can be efficiently and holistically evaluated with a model-based framework, even in projects that were not initiated with such an approach. Implications for Nursing Practice: Nurses provide expertise in model-based approaches that result in comprehensive evaluations of quality improvement processes. [ABSTRACT FROM AUTHOR]

This retrospective descriptive analysis of 837 patients seeking postassault care at an academic hospital in the United States describes characteristics of sexual assault survivors from a sociocultural context, with a specific focus on describing survivors presenting for sexual assault nurse examiner (SANE) exams and confirming existing literature on assault characteristics, such as disabilities and alcohol and/or drug use. Assaults resulting in SANE exams increased over time. Drug and/or alcohol use at the time of the assault was reported in 44.8% of cases and 20.8% of survivors reported having a disability. Understanding the demographic and sexual assault characteristics of survivors is fundamental to providing sensitive and responsive care. [ABSTRACT FROM AUTHOR]

Introduction: In the United States, most women presenting in spontaneous labor undergo intravenous (IV) cannulation on admission to hospital labor and birth units. There is limited evidence for this routine practice in pregnant women at low risk for adverse outcomes during labor or birth. Methods: A retrospective, exploratory, descriptive study of an indication‐only practice of IV cannulation on admission for women presenting in spontaneous labor and cared for by a nurse‐midwife service was performed. Descriptive data included the timing of IV cannula placement (admission, during labor or postpartum period, or not at all) and indications for placement. Maternal outcomes of interest were estimated blood loss, postpartum hemorrhage rates, and management; neonatal outcome was 5‐minute Apgar scores. Results: Records for 1069 women cared for by nurse‐midwives who presented in spontaneous labor were reviewed. In this cohort, 445 (41.6%) had IV access established on admission, 325 (30.4%) had an IV cannula placed during labor or postpartum, and 299 (28%) never had IV access during their hospital stay. For the 325 women with IV cannulas placed after admission, 25 (7.7%) were placed urgently for excessive postpartum bleeding. Further analysis of the subset of women who had a postpartum hemorrhage after vaginal birth (defined as >500 mL estimated blood loss) indicated that urgent IV cannulation was not associated with a lower mean postpartum hemoglobin or hematocrit or an increase in blood transfusion rate when compared with women who had an IV cannula placed earlier in their labor course. Discussion: Indication‐only IV cannulation for women experiencing an uncomplicated labor and birth is a reasonable practice in settings where IV access can be established urgently if needed. [ABSTRACT FROM AUTHOR]

Background: Water immersion during labor is an effective comfort measure; however, outcomes for waterbirth in the hospital setting have not been well documented. Our objective was to report the outcomes from two nurse‐midwifery services that provide waterbirth within a tertiary care hospital setting in the United States. Methods: This study is a retrospective, observational, matched comparison design. Data were collected from two large midwifery practices in tertiary care centers using information recorded at the time of birth for quality assurance purposes. Land birth cases were excluded if events would have precluded them from waterbirth (epidural, meconium stained fluid, chorioamnionitis, estimated gestational age < 37 weeks, or body mass index > 40). Neonatal outcomes included Apgar score and admission to the neonatal intensive care unit. Maternal outcomes included perineal lacerations and postpartum hemorrhage. Results: A total of 397 waterbirths and 2025 land births were included in the analysis. There were no differences in outcomes between waterbirth and land birth for Apgar scores or neonatal intensive care admissions (1.8% vs 2.5%). Women in the waterbirth group were less likely to sustain a first‐ or second‐degree laceration. Postpartum hemorrhage rates were similar for both groups. Similar results were obtained using a land birth subset matched on insurance, hospital location, and parity using propensity scores. Discussion: In this study, waterbirth was not associated with increased risk to neonates, extensive perineal lacerations, or postpartum hemorrhage. Fewer women in the waterbirth group sustained first‐ or second‐degree lacerations requiring sutures. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The American Red Cross recently declared a national blood crisis. We aimed to evaluate the effect of a single-unit transfusion guideline on the transfusion rate. METHODS: An interdisciplinary quality improvement initiative to reduce blood transfusion for postpartum hemorrhage (PPH) was conducted in a tertiary obstetric hospital with approximately 5,000 births annually. Opportunities for improvement were prioritized including antepartum anemia treatment, early recognition and treatment of PPH, and blood stewardship. The baseline period was January 2019 to December 2020. The intervention period was July 2021 to April 2022. We recommended transfusions begin with an order for a single unit of blood ("Start with One"). Plan-do-check-act cycles were initiated. The clinical outcome was units of blood transfused per 1,000 deliveries. Relative risks, t tests, and control charts were used for analysis. The quality improvement project was IRB exempt (HUM00213652). RESULTS: Incidence of PPH decreased between baseline and intervention periods (relative risk 0.83, 95% CI 0.77–0.90). The baseline transfusion rate was 79.3 units of blood per 1,000 births. During the intervention period, this decreased by 32.8% to 53.2 units per 1,000 births (P =.004). Special cause variation was found after introduction of the "Start with One" campaign: 8 consecutive months in the intervention period have been above the mean proportion for single-unit transfusions. CONCLUSION: A single-unit transfusion guideline, as part of a multimodal strategy to reduce PPH, was associated with a significant decrease in red cell transfusion. The current national blood shortage should be a call to action for all obstetric providers to safely reduce the volume of blood transfusions. [ABSTRACT FROM AUTHOR]

This article explores the apparent paradoxes in representations of the British Jack Tar in order to reconsider the ways in which his figure came to embody idealised attributes of manliness in the period 1760–1860. Naval historians have revealed that images of sailors were closely related to ideas about class, sex, and nation, identifying distinctive types of Jack Tar such as the drunken carouser, the fatalistic, fearless but simple Tar, and the domesticated family man. Notions of heroism changed over the period too. The officer was the hero in the eighteenth and early nineteenth centuries and notions of valour only extended to the lower ranks by the mid-nineteenth century. Thus the picture is of the ordinary tar emerging as manly hero once his character was scrubbed clean of its less salubrious aspects. This article argues that there were not diverse and distinct Jack Tars successively climbing the ladder of morality over time. The tar was not sanitised and civilised, but was given feelings. In particular, tears identified the sailor as a man of feeling as well as a fearless fighter, stressing his tenderness, fidelity, duty, and self-sacrificing love for his brother sailor, his ‘Poll’, and his nation. But he still loved grog, dance, and girls. The Jack Tar was thus the everyman, which aided his popularity and democratised the manly hero. [ABSTRACT FROM PUBLISHER]