Browsing by Subject "Risk Factors"
Now showing 1 - 20 of 37
- Results Per Page
- Sort Options
Item Assessing Complications of Epiphysiodesis for Leg Length Discrepancy(2014-02-04) Terrill, Tyler A.; Dunn, Samuel H.; Birch, John; Makarov, MarinaINTRODUCTION: Leg length discrepancy in children and adolescents is a serious orthopedic problem that can cause leg and back problems due to abnormal gait. This condition may be congenital or caused by disease or trauma. One method to correct leg length discrepancies in children is to perform an epiphysiodesis. This surgical procedure removes one or more growth plates from the femur, tibia, or fibula. This operation slows down the growth of the long leg to allow the shorter leg to catch up, or at least prevent the discrepancy from increasing. As there has been no large study of epiphysiodesis patients in the literature, the rates for surgical complications and errors associated with this surgery are not well known. These complications may include infections, nerve damage, and incomplete epiphysiodesis, which often results in an angular deformity. Because of the lack of understanding for rate of complications and characteristics associated with these, we studied a large patient population to gain insight into these aspects of the procedure. METHODS: The patient population at Texas Scottish Rite Hospital for Children undergoing epiphysiodesis for the treatment of leg length discrepancy from 1980 to 2008 was examined by a retrospective review of both charts and radiographs, with a total of 755 patients included in the study. The information recorded in the study included the extent of leg length discrepancy, angular measurements of the joints, method of epiphysiodesis, postoperative development of angular deformities, underlying etiology, length correction prediction, and other clinical features. RESULTS: Of the 755 patients examined, 38 had surgical complications, (5%). Of these patients, 27 had incomplete epiphysiodesis, 6 had neurological problems, 3 had overcorrection of the leg length discrepancy, and 2 had other complications not specific to this procedure. Patients incurring complications had statistically significant risk factors that include greater leg length discrepancies at the time of epiphysiodesis, congenital defects instead of acquired ones, and younger age. There were also trends towards open curettage method, epiphysiodesis involving the femoral growth plate, and male gender as risk factors, though these did not achieve statistical significance. DISCUSSION: It is important that surgeons understand which populations of patients are at greater risk for complications during this procedure, so that extra caution may be taken to prevent harm. Also, parents should be aware that there is a 5% risk of surgical complication, so that they may be fully informed before committing to the procedure.Item Assessing Readiness to Change and Identifying Risk Factors Leading to an Alcohol-Related Injury(2006-08-11) Ladd, Gretchen Cora; Evans, Harry M.Alcohol use is a leading risk factor in injuries and accounts for nearly half of all patients in the emergency room. Brief interventions are conducted in the ER setting to target patients who are seeking medical attention and who screen positive for alcohol misuse. It is believed that providing treatment in alternative settings will more effectively reach patients with alcohol problems, thereby decreasing their risk of future injury. From May 2003 to May 2005, approximately 1,500 trauma patients at an urban hospital participated in a study to assess risk factors associated with alcohol-related injuries. The primary aim of this study was to assess factors associated with readiness to change for patients seeking medical attention due to an alcohol-related injury. Multivariate analysis demonstrated that older patients, patients with increased causal attribution, and patients reporting increased recent alcohol-related problems were significantly more likely to be ready to make a change in their alcohol use. Also of interest in the study were factors associated with acute intoxication and drinking beyond normal limits, patient's perception of the relationship between their alcohol use and subsequent injury, and ethnic influences on these variables. It was found that acutely intoxicated patients were more likely to not be employed for wages, have an intentional injury, and to have experienced more alcohol-related problems in the past 12 months compared to patients who drank beyond normal limits. It was further found that Hispanics, patients reporting having been a little bit, somewhat, and very affected by alcohol at the time they were injured, and patients reporting increased recent alcohol-related problems were significantly more likely to have increased causal attribution. Having an intentional injury and screening positive by either drinking beyond normal limits or on an alcohol questionnaire were negatively associated with causal attribution. Hispanics significantly differed from Whites and Blacks on causal attribution. These findings show that accounting for certain risk factors may facilitate treatment for alcohol problems by improved understanding of the patient's readiness to change.Item A Biopsychosocial Model of Attachment Styles and Adverse Birth Outcomes in High-Risk Pregnancies(2016-04-13) Cassedy, Hannah; Robinson, Richard C.; Frank, Blake; Bernstein, Ira; Evans, Harry M.; Stringer, Claude A.Because stress during pregnancy can contribute to preterm birth, low birth weight, and other adverse birth outcomes, there is a need for research on psychosocial factors that may mitigate this risk. Social support and attachment security have been shown to buffer the effects of stress in certain contexts. This study therefore evaluated the degree to which social support, attachment anxiety, and attachment avoidance affect stress-related birth outcomes in a sample of women with high-risk pregnancies. The study focused on women who had been hospitalized for pregnancy complications, as the population was identified as in need of further biopsychosocial research. The hypotheses were that women with more secure attachment would have greater social support, less stress, and therefore superior birth outcomes. Participants (N = 188) completed the 10-Item Perceived Stress Scale, Social Provisions Scale, and Experiences in Close Relationship Scale-Short Form, during their pregnancies. Birth outcome data (gestational age, birth weight, and Apgar scores) were extracted from their medical records after delivery. Biserial correlation analyses revealed that high stress levels were associated with more insecure attachment styles. Analysis of variance indicated that participants were more likely to have avoidant attachment if they were black, poorly educated, or unmarried. Hierarchical multiple regression analyses revealed that stress, social support, and attachment levels were not predictive of birth outcomes over and above the effects of physiological risk factors. This result diverges from research on low-risk pregnancies, where a clear link is observed between stress and adverse birth outcomes. By contrast, in this sample of high-risk pregnancies, psychosocial factors did not influence the profound effects of biological risk. In high-risk pregnancies, therefore, psychosocial interventions may be better suited to target psychosocial, rather than biological, outcomes. Furthermore, this study highlights a need for further research into demographic disparities in attachment styles, as well as the sociocultural factors that may impact them.Item Burden of Glaucoma: Adjunct Eye Disease(2014-02-04) Parikh, Kisan; Vu, Khiem; Markel, Nathan; Adams-Huet, Beverley; Li, Xilong; Kooner, KaranjitPURPOSE: The purpose of this study was to better understand the broad impact of primary open-angle glaucoma (POAG) by identifying eye conditions commonly associated with this multifactorial disease. METHODS: An IRB-approved retrospective chart study was conducted at a major academic institution. A total of 713 ethnically diverse patients met the inclusion criteria: 411 were diagnosed with POAG and 302 were controls with no glaucoma diagnosis. Information was collected on: demographics, refractive errors, and ocular ailments. Cochran-Mantel-Haenszel tests were used to compare eye disease prevalence between the two groups. RESULTS: The POAG group (mean age: 64.3, SD=13.3) was 44% female and the control group (mean age: 64.8, SD=12.3) was 47% female. The POAG group showed a higher prevalence of astigmatism (80% vs 60%,p<0.0001), myopia (66% vs 54%,p=0.0004), legal blindness (4.6% vs 1%,p= 0.004), pseudophakia (43% vs 35%,p=0.01), blepharitis (18% vs 12%,p=0.006), retinal detachment (4.1% vs 1.3%, p=0.03), central retinal vein occlusion (CRVO) (3.4% vs 0%,p=0.001), ptosis (12% v 4%,p=0.0001), and uveitis (2.4% vs 0.3%,p=0.02). DISCUSSION: The POAG group had an increased prevalence of astigmatism, myopia, legal blindness, pseudophakia, blepharitis, retinal detachment, CRVO, ptosis, and uveitis. Some of these results are explainable and expected. Glaucoma is the second leading cause of legal blindness in the United States. In addition, myopes have an increased risk of POAG and retinal detachment compared to emmetropes. The increased prevalence of blepharitis is likely due to side-effects of glaucoma medications. Another side effect is an increased risk of cataracts, which may explain the increased prevalence of pseudophakia. Lastly, glaucoma is a known risk factor for CRVO. The results involving uveitis and ptosis are more difficult to explain. CONCLUSIONS: This study has shown that patients with POAG have a host of other ocular diseases that may affect their quality of life. Awareness of these associations and their causes would be invaluable to clinicians as they screen for and treat ocular diseases. Future work to replicate the findings of this study and the elucidation of potential mechanisms underlying these associations are indicated.Item Cardiovascular Risk Factors Predict the Spatial Distribution of White Matter Hyperintensities(2014-02-04) Banerjee, Soham; King, Kevin; McColl, Roderick; Whittemore, Anthony; Hulsey, Keith; Peshock, Ronald M.PURPOSE: Increased volume of brain white matter hyperintensities (WMH) seen on MRI is associated with cardiovascular risk factors; however, WMH have also been attributed to normal aging. Recent studies have suggested that WMH in some brain regions are more strongly associated with specific risk factors. The purpose of this study was to create a map of every individual brain voxel that was significantly associated with risk factors (hypertension, diabetes, hyper-cholesterolemia) as compared to those without each risk factor. The aim of the study is to create a predictive model, which uses the WMH distribution to determine the associated underlying risk factor. METHODS: The MRI brain images used for analysis were obtained from 2066 participants in the Dallas Heart Study, a population based study. Each MRI brain was transformed onto a standard template that adjusts for participant variation in brain volume and shape, using the FSL SIENAX software. The participant's WMH distributions were then generated from their MRIs using an automated algorithm. For each risk factor, the subjects were divided into a case group and a control group. Each voxel of WMH was compared between the two groups using a two tailed nonparametric permutation test. A map of every voxel significantly associated with each risk factor was created. RESULTS: Of the total of 431891 voxels that comprise the distribution of WMH over the entire population, 26064 voxels (6%) were significantly associated with hypertension only. These hypertensive-associated voxels were prevalent anterior to the frontal horns of the lateral ventricles. Similarly, 22527 voxels (5%) were associated with diabetes only with a prevalence near the longitudinal cerebral fissure as well as lateral to the posterior horns of the lateral ventricles. 8088 voxels (2%) were associated with hyper-cholesterolemia only and were abundant posterior to the posterior horns of the lateral ventricles. 331588 voxels (77%) were not associated with a risk factor. CONCLUSIONS: For hypertension, diabetes, and hyper-cholesterolemia, certain voxels were significantly associated with a risk factor, and maps of these voxels were created. Knowing the WMH distribution significantly associated with each risk factor will improve the specificity for evaluating patients for risk factor associated white matter injury. Importantly, this approach makes no a priori assumptions which divide the brain into functional regions or vascular territories.Item Coronary heart disease in women: natural history and significance of lipids as risk factors(1991-10-17) Denke, Margo A.Item Donald W. Seldin, M.D., Research Symposium finalist presentations(2023-05-05) Eleazu, Ijeoma; Ramos, Lisandro Maya; Salcedo Betancourt, Juan; Singh, Sumitabh; Smith, AaronThis edition of the UT Southwestern Internal Medicine Grand Rounds features presentations by the six Foster Fellows selected as finalists from the Eighth Annual Donald W. Seldin, M.D. Research Symposium, which was held on April 28, 2023. These Foster Fellows presented work that spanned the breadth and depth of scholarly activity across the department, and at the close of Grand Rounds, one will be selected as the 2023 Seldin Scholar, in honor of Dr. Donald W. Seldin. The Grand Rounds presentation includes additional award presentations recognizing Clinical Vignettes, as well as the Award for Research in Quality of Care and Education at Parkland Hospital, the Social Impact Award, and the Award for Basic Science (non-GME).Item Epidemiological Risk Factors for Severe Plasmodium vivax Malaria in Peru(2016-01-19) Hamilton, Hayley; Stanley, AdriannaRecent investigation has produced a significant shift in the paradigm of Plasmodium vivax. No longer characterized as a mild and clinically benign disease, P. vivax can produce severe and life-threatening symptoms. While most of the recent literature seeks to address the clinical manifestations of severe P. vivax infection, we have chosen to examine the epidemiological risk factors in the progression to severe disease. We conducted an analysis based upon a prospective case-control study that took place between the years of 2012-2015 in the Peruvian Amazon Basin. The study population of 215 total patients with mono-infection of P. vivax consisted of 125 cases and 90 controls - as defined by the WHO guidelines for severe falciparum malaria. Men and women comprised 56% and 44% of the patients, respectively. Ages ranged from 4 to 88 years, including 20 children. Factors we found to be associated with severe malaria include sex, previous infection with malaria, and residence proximity to water. To determine significance, we performed chi-squared and logistic regression analyses and obtained odds ratios, p-values, and 95% confidence intervals using STATA software. Women were three times more likely to present with severe vivax malaria than men (p=0.0001). Patients with previous malaria infection(s) of any species were 4.16 times less likely to develop severe malaria (p=0.0003), suggesting that prior infection may be protective. Finally, we observed that study participants who lived near a source of water are 2.9 times more likely to present with severe infection (p=0.0005. Future studies should focus on identifying the relative contributions of innate host factor (immuno-tolerance and genetics) with differences associated with pathogen exposure (parasite load strain).Item Frequency, Versatility, and Duration of Nonsuicidal Self-Injury in Relation to Acquired Capability for Suicide among Adolescents(2015-08-31) Matney, Jacquelyn Deanna; Stewart, Sunita M.; Westers, Nicholas; Hughes, Jennifer L.Suicide is the 2nd leading cause of death among youth, and those who present to inpatient settings have been shown to have higher rates of suicidal behaviors (World Health Organization, 2012). Nonsuicidal self-injury (NSSI) is a leading risk factor for suicide. We propose that an increase in frequency, versatility, and/or duration of NSSI is associated with an increased risk for suicide attempt (SA) by means of the Acquired Capability for Suicide (ACS) proposed in Joiner's (2005) Interpersonal Psychological Theory of Suicide (IPTS) regardless of demographic or diagnostic factors. Preliminary results from this sample of inpatient adolescents (N = 150) were consistent with our proposed hypotheses. Yet, depressive symptoms appeared to interact with the association between these NSSI variables and ACS. These findings suggest that inpatient youth with greater NSSI versatility, frequency and duration, are at an increased risk for future SA by means of increased ACS. Consistent with the IPTS, the link between engagement in NSSI and history of SA appeared to be mediated by the ACS component. While limited by its cross-sectional design, the findings from this study have clinical implications regarding suicide risk assessment and prevention.Item Housing Quality as a Potential Risk Factor for Locally Acquired Malaria Infection in Swaziland(2016-01-19) Allen, Regan; Mkhonta, Nomcebo; Pindolia, Deepa; Ntshalintshali, Nyasatu; Novotny, Joseph; Dufour, Mi-suk Kang; Gosling, Roly; LeMenach, Amaud; Cohen, Justin; Midekisa, Alemayehu; Greenhouse, Bryan; Kunene, Simon; Hsiang, Michelle S.Poor housing quality may confer greater risk of malaria infection by means of increased mosquito exposure; however, evidence in low transmission settings is lacking. In this study, surveillance data was used to examine the relationship between housing quality and locally-acquired infection in the low transmission setting of Swaziland. A retrospective analysis was conducted utilizing data collected from passive and active surveillance. Subjects included malaria index cases diagnosed at health facilities as well as their household and community members screened in reactive case detection from August 2012 to March 2015. Subjects reporting travel in the past 8 weeks and/or residing beyond 500m from the index case were excluded. Using bivariate and multivariable logistic regression, adjusted for household-level clustering, the relationships between infection (testing positive by Rapid Diagnostic Test (RDT), microscopy, or loop-mediated isothermal amplification (LAMP)) and housing quality, as well as other epidemiological factors were analyzed. Housing quality was assessed by individual components (wall, roof and window type) as well as a composite housing quality index. Cases included 280 index cases and 131 RDT or LAMP positive individuals identified in active surveillance. These cases were compared to 8668 non-infected household members and neighbors of index cases. In the multivariable model, poor quality external wall was associated with higher infection odds (OR 4.59 95%CI 1.93-10.95). There was a trend in the association with both poor quality roof and windows. Using the composite housing index, compared to good quality housing, moderate quality housing was significantly associated with higher infection odds (OR 1.67 95%CI 1.09-2.57). There was a notable, yet non-significant trend in the association with poor quality housing (OR 2.05 95%CI 0.99-4.26). In the composite housing model, coverage of vector control interventions was independently associated with protection. Compared to no vector control (neither sleeping under an insecticide treated bed net (ITN) nor a sprayed structure), coverage with either an ITN or spraying conferred protection (OR 0.61 95%CI 0.40-0.94), as did coverage with both interventions (OR 0.10 95%CI 0.01-0.73). The findings of this study suggest that housing quality, especially wall material, is an important determinant of locally-acquired infection in Swaziland, suggesting improved housing as a potential control and elimination strategy in low transmission settings.Item Imapct [sic] of Pesticide Exposure on Motor Function and Mortality Among Patients with Parkinson's Disease in Southern Brazil(2020-05-01T05:00:00.000Z) Reddy, Sumanth Palvai; Dewey, Richard B., Jr.; Chang, Mary; Chitnis, ShilpaBACKGROUND: Multiple studies have suggested that various pesticides are associated with a higher risk of developing Parkinson's disease (PD). However, few studies have examined the impact of pesticide exposure on motor impairment and the risk of mortality among patients with PD. This study takes place in the context of growing pesticide use in Brazil as well as many other low- and middle-income countries around the world. OBJECTIVE: This study examines whether occupational pesticide exposure influences motor impairment and the risk of mortality among patients with PD in Southern Brazil, when accounting for socioeconomic status, disease-specific factors, nicotine exposure, and caffeine exposure. METHODS: 150 patients with idiopathic PD in Porto Alegre, Brazil were enrolled from 2008-2013 and followed until 2019. In addition to undergoing a detailed neurologic evaluation, patients completed surveys regarding environmental exposures. 105 of these patients also completed an additional survey regarding socioeconomic factors. The primary outcomes were whether occupational pesticide exposure was associated with motor impairment (as measured by linear regression with UPDRS-III score) and mortality (as determined by the log-rank test and Kaplan-Meier testing). Secondary analyses included models that accounted for relevant socioeconomic and disease specific characteristics (multiple linear regression for motor function, and multivariate cox proportionate hazards regressions for mortality). RESULTS: Of the 150 patients in this prospective cohort, 20 (13.3%) reported a history of occupational pesticide exposure, with an average duration of exposure of 14.3 years (SD = 10.6, median = 10). In the univariate analysis, occupational pesticide exposure was associated with a 16.10 point increase in the UPDRS-III (motor function) score (95% CI: [7.11, 25.02], p < 0.001). Similarly, in the multiple linear regression which controlled for several socioeconomic and disease-related covariates, pesticide exposure was associated with a 16.84 point increase in the UPDRS-III score (95% CI: [8.84, 24.85], p < 0.001). Patients with occupational pesticide exposure were more than two times as likely to die than their unexposed PD counterparts (HR = 2.32, 95% CI [1.15, 4.66], p = 0.22). This was significant when controlling for smoking history, caffeine intake, and socioeconomic factors such as historical monthly income, education, and a history of working predominately in agricultural professions. Patients with 10 or more years of occupational pesticide exposure had a significantly elevated risk of mortality (HR = 2.81, 95% CI [1.17, 6.73], p = 0.02), in contrast to patients with fewer than 10 years of exposure. CONCLUSION: In addition to providing a broad overview of the socioeconomic breakdown of a contemporary cohort of patients with PD in South America, this study implicates occupational pesticide exposure as an independent risk factor for poor motor function and mortality among patients with PD when controlling for disease-specific and socioeconomic confounding factors. This is especially important in the Brazilian market, and perhaps in other developing countries, where new pesticides continue to be introduced without the corresponding research output necessary to understand the impact on human health.Item Late Effects of Hypothalamic Radiation Exposure in Pediatric Brain Tumor Survivors(2015-03-31) Wu, Susan Y.; Bowers, Daniel C.; Vega, Gloria L.; Gargan, LynnBACKGROUND: Brain tumors are the second most common childhood malignancy and overall survival rates exceed 70%. Pediatric brain tumor survivors treated with hypothalamic radiation are at increased risk for developing components of metabolic syndrome, characterized by central obesity and two of the following: elevated triglycerides, low HDL, elevated blood pressure, or fasting hyperglycemia. These patients may also be at risk for developing decreased bone density, which is associated with pathologic fractures. OBJECTIVE: Our aim is to compare the prevalence of metabolic syndrome or concomitant cardiometabolic risk, bone density, and body composition among pediatric brain tumor survivors treated with and without hypothalamic radiation. METHODS: This study evaluated 146 survivors of childhood brain tumors (70 radiated, 76 non-radiated) between 5-20 years old (mean: 12.3 years, SD: 4.1 years, average survival time: 6 years). Patients underwent fasting lab assays (lipid panel, insulin, glucose, leptin, and adiponectin), anthropometric measurements (height, weight, and waist circumference), and Dual-energy X-ray Absorptiometry (DXA) scan. Insulin resistance was identified using the homeostasis model assessment of insulin resistance (HOMA-IR). Metabolic syndrome was diagnosed according to the International Diabetes Foundation criteria in children 10 years and older; children between 5-10 years of age who met 3 of 5 risk factors were classified as having concomitant cardiometabolic risk. RESULTS: Metabolic syndrome or concomitant cardiometabolic risk was more common in patients who received hypothalamic-pituitary axis (HPA) radiation (7/38, 18.4%) than those who did not (4/76, 5.3%) (p = 0.04). Patients who received HPA radiation were more likely to have elevated triglyceride levels (p = 0.02), low HDL levels (p = 0.04), and lower IGF-1 z-scores (p < 0.001). On DXA scan, patients exposed to HPA radiation had lower Bone Mineral Content (BMC) and Bone Mineral Density (BMD) z-scores (-1.3 vs. -0.3, p = 0.003 and -1.4 vs. -0.2, p < 0.001 respectively) and lower Fat Free Mass Index z-scores (-1.4 vs. -0.1, p = 0.001) despite no significant difference in BMI (21.7 vs. 22.2, p = 0.7) or percent body fat (35.5% vs. 32.8%, p = 0.11). There was no significant difference in leptin/kg fat and adiponectin/kg fat between patients who received HPA radiation and those who did not (p = 0.55 and p = 0.98 respectively). Patients with elevated HOMA-IR had elevated leptin levels (p = 0.001), lower adiponectin levels (p = 0.04), and elevated leptin:adiponectin ratios (p = 0.001). CONCLUSION: These results suggest that exposure to hypothalamic radiation may have significant subclinical consequences that include components of metabolic syndrome, decreased bone density, and altered body composition. These results highlight the need for stringent follow-up surveillance of these patients and suggest that screening for dyslipidemia may be a sensitive way to detect patients at risk for developing metabolic syndrome.Item Latex allergy: a growing risk for health care workers in the 1990's(1995-07-27) Gruchalla, Rebecca S.Item NAFLD and cardiovascular risk: translational implications for clinical practice(2023-05-12) VanWagner, LisaItem [News](1985-01-30) Bosler, Tommy JoyItem Nonalcoholic fatty liver disease (NAFLD) turns 38: what have we learned?(2018-10-05) Horton, Jay D.Item Peripheral artery disease: current insights into the disease, its diagnosis and management(2018-06-01) Banerjee, SubhashItem The Prevalence of Postpartum Depressive Symptoms in Women from a Public Maternity Hospital in Tucumán, Argentina at 4 Weeks Postpartum(2017-03-31) Pham, Diana; Doty, Meitra; Chi, Benjamin; Johnson, AndreaOBJECTIVE: The primary objective of our study is to investigate the prevalence of postpartum depression at 4 weeks postpartum in women from a public hospital in Tucuman, Argentina. Our secondary objective is to determine a relationship between postpartum depression and the associated sociodemographic, medical and obstetric factors. METHODS: We conducted an observational cross-sectional study that was carried out from March 17, 2016 to May 30, 2016 and from June 28, 2016 to July 29, 2016. There were 539 participants. Women were excluded if they: Were less than 18 years old, were located in the intensive care unit (ICU), gave birth to a stillborn or recent newborn that died during delivery, with a multiple gestation, had a recent newborn in the neonatal ICU, had a recent newborn with congenital abnormalities, or gave birth at gestational age less than 28 weeks old. RESULTS: Of the 539 participants, 167 (31.0%) had depressive symptoms. Important risk factors for developing PPD included employment status, education level, positive personal and family history of psychiatric illnesses, perceived social stresses such as poor patient-physician relationship or lack of childcare help, and giving birth to a female newborn. CONCLUSION: The high prevalence of postpartum depression (31.97%) in Tucuman demonstrates that the public sector is twice that of the private sector in Buenos Aires. This study results shows that postpartum depression is a serious public health issue and further study is needed about the cultural acceptance of mental health and how to provide adequate follow-up or treatment in a low-resource setting.Item Retrospective Review of Postpartum Hemorrhage Incidence, Risk Factors, and Maternal Morbidity(2020-05-01T05:00:00.000Z) Chu, Tina Meikei; Morgan, Jamie; Horsager-Boehrer, Robyn; Reed, W. GaryBACKGROUND: Postpartum hemorrhage (PPH) remains one of the most common causes of maternal mortality worldwide. In the US, PPH accounts for 2-3% of yearly maternal deaths and is also associated with serious morbidity including the need for blood transfusion, ICU admission, and hysterectomy. In the recent years, PPH risk assessment tools have been widely implemented in an attempt to identify woman at risk for hemorrhage and preemptively mobilize resources. The most commonly used trinary assessment tool from the California Maternal Quality Care Collaborative (CMQCC) assigns women to a low, medium or high-risk category; however, its utility has only been validated in relation to need for blood transfusion, which can be subjective. LOCAL PROBLEM: The American College of Obstetricians and Gynecologists (ACOG) recently released maternal safety bundles to reduce obstetric complications and rates of maternal morbidity and mortality. At UT Southwestern's Clements University Hospital (CUH), obstetricians and gynecologists recognized that a three-category approach to PPH risk stratification may hinder efficient PPH diagnosis and management. The Maternal-Fetal Medicine team developed a quality improvement project to identify hemorrhage risk factors and implement a PPH risk score in the labor and delivery unit. METHODS: Retrospective cohort review of all deliveries at CUH between January 1, 2018 and December 31, 2018 was conducted. Data on all antepartum and intrapartum hemorrhage risk factors using the trinary risk score developed by the CMQCC was analyzed and used to assign a risk category low, medium or high. A validated formula, utilizing maternal height, weight, ante- and post-partum hematocrits, was used to calculate each patient's blood loss. Calculated blood loss, need for intervention (uterotonic administration) and maternal morbidities (need for blood transfusion, intensive care unit (ICU) admission, and/or hysterectomy) were correlated to PPH risk categorization as well as to a developed numeric risk score. PPH was defined as blood loss exceeding 1,000 mL. Data was analyzed using standard methods of rates and proportions, Chi-square, and Wilcoxon rank-sum tests with p<0.05 considered significant. Quality improvement tools, including PDSA cycles, process maps, a SIPOC diagram, and FMEA were developed. INTERVENTIONS: A modified PPH risk assessment score that assigned a point value of 1 or 2 to hemorrhage risk factors based on their perceived potential to lead to PPH was developed. RESULTS: Of the 1855 deliveries, the median calculated blood loss was 879 mL. The overall PPH rate was 25.9%. The rates according to PPH risk groups were 19.5%, 36.6%, and 27.9%, respectively. The rate of PPH was significantly lower in the low risk group (p<0.001) but did not differ between the medium and high-risk groups (p= 0.11). The median blood loss was lowest in the low risk group (p<0.001). The transfusion rate correlated with risk stratification, with rates of 0.9%, 2.7% and 7% in the low, medium and high-risk groups, respectively. Overall, 178 women (9.5%) were treated with uterotonics, 38 (2.0%) required transfusion, 7 (0.4%) needed ICU admission and 12 (0.6%) underwent hysterectomy. Relative to low and medium-risk stratifications, women in the high-risk group were 2.3 times more likely to require uterotonic administration. Women in the low-risk group were 83% less likely to experience transfusion, ICU admission or hysterectomy compared to medium and high-risk women. Conversely, women in the high-risk group had a 4.1 fold increase in these same morbidities. CONCLUSION: Relative to the low and medium-risk stratifications, women classified as high risk for hemorrhage are indeed more likely to require uterotonic administration and also suffer disproportionately higher maternal morbidity. The trinary risk stratification tool commonly used to predict PPH distinguishes women at lower risk for hemorrhage compared to the general population. However, determining which women are most likely to hemorrhage at delivery evades prediction using current risk assessment tools. Though hypothesized that a numeric scoring system would better predict PPH and morbidity than the currently used trinary risk assessment, this was not substantiated by our data. More work needs to be conducted to understand which of the identified risk factors is most highly associated with hemorrhage, particularly in the low and medium risk groups, since women in these groups make up the majority of the obstetric population.Item Risk stratification of patients with acute myocardial infarction(1995-04-06) Willard, John E.