Racial and Ethnic Disparities in Epidural Blood Patch Utilization Among Obstetric Patients in the United States: A Nationwide Analysis, 2016-2020.

Racial and ethnic disparities in health care delivery can lead to inadequate peripartum pain management and associated adverse maternal outcomes. An epidural blood patch (EBP) is the definitive treatment for moderate to severe postdural puncture headache (PDPH), a potentially debilitating neuraxial anesthesia complication associated with significant maternal morbidity if undertreated. In this nationwide study, we examine the racial and ethnic disparities in the inpatient utilization of EBP after obstetric PDPH in the United States. In this retrospective observational study, we used the National Inpatient Sample, a nationally representative database of discharge records for inpatient admissions in the United States, from 2016 to 2020. We analyzed delivery hospitalizations of women of childbearing age (15-49 years) diagnosed with PDPH. Adjusting for maternal and hospitalization characteristics as confounders, we used a multilevel mixed-effects logistic regression model to compare the rates of EBP utilization by race and ethnicity. Secondarily, among hospitalizations with an EBP, we examined the association between race and ethnicity and the timing of the EBP procedure. We analyzed 49,300 delivery hospitalizations with a diagnosis of PDPH. An EBP was performed in 24,075 (48.8%; 95% confidence interval [CI], 47.8%-49.9%) of these hospitalizations. EBP was performed in 52.7% (95% CI, 51.3%-54.1%) of White non-Hispanic patients with PDPH. Compared to White non-Hispanic patients, Black non-Hispanic (adjusted odds ratio [aOR] = 0.69; 99% CI, 0.56-0.84), Hispanic (aOR = 0.80, 99% CI, 0.68-0.95), and Asian or Pacific Islander patients (aOR = 0.74, 99% CI, 0.58-0.96) were less likely to receive an EBP. The median (interquartile range [IQR]) time to perform an EBP was 2 (1-3) days after admission, with 90% of EBP procedures completed within 4 days of admission. There was no significant association between race and ethnicity and the timing of EBP placement. In this nationwide analysis of delivery hospitalizations from 2016 to 2020 in the United States with a diagnosis of PDPH, we identified racial and ethnic disparities in the utilization of EBP. Minoritized patients identified as Black non-Hispanic, Hispanic, or Asian or Pacific Islander were less likely to receive an EBP for the treatment of PDPH compared to White non-Hispanic patients. Suboptimal treatment of PDPH may be associated with adverse long-term outcomes such as postpartum depression, posttraumatic stress disorder, and chronic headaches. Racial and ethnic disparities in EBP utilization should be further investigated to ensure equitable health care delivery.

Potnuru PP ，Jonna S ，Orlando B ，Nwokolo OO ... -  《-》

Examining racial and ethnic disparities in diagnosis and access to care in infantile atopic dermatitis in the United States: a retrospective cohort study.

Atopic dermatitis (AD) is an inflammatory skin disorder that is common in children and associated with medical and psychosocial comorbidities. Previous studies have shown that there exist significant racial disparities in healthcare utilization in children with AD; however, literature on disparities in dermatology access is limited. The primary aim of this study was to identify differences in diagnosis of AD and access to dermatologic care by race and ethnicity in infants with AD. We conducted a retrospective chart review of infants diagnosed with AD at Boston Children's Hospital from January 1, 2015 - December 31, 2019. Race and ethnicity were categorized as Native American or Alaska Native, Asian, non-Hispanic Black, Hispanic, Native Hawaiian or Other Pacific Islander, non-Hispanic white, and other. Outcomes included time to diagnosis and dermatology visit from rash onset and were analyzed utilizing a Kruskal-Wallis test. Severity of presentation at first dermatology visit, presentation to the emergency department (ED), medications prescribed, and follow up were analyzed using Chi-squared tests. Significantly more non-Hispanic white infants received a prescription by their pediatrician for AD than Hispanic infants (p = 0.002). Non-Hispanic Black and Asian infants waited longer to see a dermatologist after receiving a prescription for AD by their pediatrician compared to non-Hispanic white patients (p < 0.001; p = 0.007). Significantly more non-Hispanic Black and Hispanic infants presented to the ED for AD within the first year of life than non-Hispanic white patients (p < 0.001; p = 0.003). Our study suggests disparities in diagnosis and access to care for non-Hispanic Black and Hispanic infants with AD, with differences in prescriptions, time to see a dermatologist, and presentation to the ED compared to non-Hispanic white infants.

Servattalab SE ，Lee M ，Hlobik M ，Song H ，Huang J ... -  《-》

Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling.

Elwenspoek MM ，Thom H ，Sheppard AL ，Keeney E ，O'Donnell R ，Jackson J ，Roadevin C ，Dawson S ，Lane D ，Stubbs J ，Everitt H ，Watson JC ，Hay AD ，Gillett P ，Robins G ，Jones HE ，Mallett S ，Whiting PF ... -  《-》

Cervical mucus patterns and the fertile window in women without known subfertility: a pooled analysis of three cohorts.

What is the normal range of cervical mucus patterns and number of days with high or moderate day-specific probability of pregnancy (if intercourse occurs on a specific day) based on cervical mucus secretion, in women without known subfertility, and how are these patterns related to parity and age? The mean days of peak type (estrogenic) mucus per cycle was 6.4, the mean number of potentially fertile days was 12.1; parous versus nulliparous, and younger nulliparous (<30 years) versus older nulliparous women had more days of peak type mucus, and more potentially fertile days in each cycle. The rise in estrogen prior to ovulation supports the secretion of increasing quantity and estrogenic quality of cervical mucus, and the subsequent rise in progesterone after ovulation causes an abrupt decrease in mucus secretion. Cervical mucus secretion on each day correlates highly with the probability of pregnancy if intercourse occurs on that day, and overall cervical mucus quality for the cycle correlates with cycle fecundability. No prior studies have described parity and age jointly in relation to cervical mucus patterns. This study is a secondary data analysis, combining data from three cohorts of women: 'Creighton Model MultiCenter Fecundability Study' (CMFS: retrospective cohort, 1990-1996), 'Time to Pregnancy in Normal Fertility' (TTP: randomized trial, 2003-2006), and 'Creighton Model Effectiveness, Intentions, and Behaviors Assessment' (CEIBA: prospective cohort, 2009-2013). We evaluated cervical mucus patterns and estimated fertile window in 2488 ovulatory cycles of 528 women, followed for up to 1 year. Participants were US or Canadian women age 18-40 years, not pregnant, and without any known subfertility. Women were trained to use a standardized protocol (the Creighton Model) for daily vulvar observation, description, and recording of cervical mucus. The mucus peak day (the last day of estrogenic quality mucus) was used as the estimated day of ovulation. We conducted dichotomous stratified analyses for cervical mucus patterns by age, parity, race, recent oral contraceptive use (within 60 days), partial breast feeding, alcohol, and smoking. Focusing on the clinical characteristics most correlated to cervical mucus patterns, linear mixed models were used to assess continuous cervical mucus parameters and generalized linear models using Poisson regression with robust variance were used to assess dichotomous outcomes, stratifying by women's parity and age, while adjusting for recent oral contraceptive use and breast feeding. The majority of women were <30 years of age (75.4%) (median 27; IQR 24-29), non-Hispanic white (88.1%), with high socioeconomic indicators, and nulliparous (70.8%). The mean (SD) days of estrogenic (peak type) mucus per cycle (a conservative indicator of the fertile window) was 6.4 (4.2) days (median 6; IQR 4-8). The mean (SD) number of any potentially fertile days (a broader clinical indicator of the fertile window) was 12.1 (5.4) days (median 11; IQR 9-14). Taking into account recent oral contraceptive use and breastfeeding, nulliparous women age ≥30 years compared to nulliparous women age <30 years had fewer mean days of peak type mucus per cycle (5.3 versus 6.4 days, P = 0.02), and fewer potentially fertile days (11.8 versus 13.9 days, P < 0.01). Compared to nulliparous women age <30 years, the likelihood of cycles with peak type mucus ≤2 days, potentially fertile days ≤9, and cervical mucus cycle score (for estrogenic quality of mucus) ≤5.0 were significantly higher among nulliparous women age ≥30 years, 1.90 (95% confidence interval (CI) 1.18, 3.06); 1.46 (95% CI 1.12, 1.91); and 1.45 (95% CI 1.03, 2.05), respectively. Between parous women, there was little difference in mucus parameters by age. Thresholds set a priori for within-woman variability of cervical mucus parameters by cycle were examined as follows: most minus fewest days of peak type mucus >3 days (exceeded by 72% of women), most minus fewest days of non-peak type mucus >4 days (exceeded by 54% of women), greatest minus least cervical mucus cycle score >4.0 (exceeded by 73% of women), and most minus fewest potentially fertile days >8 days (found in 50% of women). Race did not have any association with cervical mucus parameters. Recent oral contraceptive use was associated with reduced cervical mucus cycle score and partial breast feeding was associated with a higher number of days of mucus (both peak type and non-peak type), consistent with prior research. Among the women for whom data were available (CEIBA and TTP), alcohol and tobacco use had minimal impact on cervical mucus parameters. We did not have data on some factors that may impact ovulation, hormone levels, and mucus secretion, such as physical activity and body mass index. We cannot exclude the possibility that some women had unknown subfertility or undiagnosed gynecologic disorders. Only 27 women were age 35 or older. Our study participants were geographically dispersed but relatively homogeneous with regard to race, ethnicity, income, and educational level, which may limit the generalizability of the findings. Patterns of cervical mucus secretion observed by women are an indicator of fecundity and the fertile window that are consistent with the known associations of age and parity with fecundity. The number of potentially fertile days (12 days) is likely greater than commonly assumed, while the number of days of highly estrogenic mucus (and higher probability of pregnancy) correlates with prior identifications of the fertile window (6 days). There may be substantial variability in fecundability between cycles for the same woman. Future work can use cervical mucus secretion as an indicator of fecundity and should investigate the distribution of similar cycle parameters in women with various reproductive or gynecologic pathologies. Funding for the three cohorts analyzed was provided by the Robert Wood Johnson Foundation (CMFS), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (TTP), and the Office of Family Planning, Office of Population Affairs, Health and Human Services (CEIBA). The authors declare that they have no conflict of interest. N/A.

Najmabadi S ，Schliep KC ，Simonsen SE ，Porucznik CA ，Egger MJ ，Stanford JB ... -  《-》

The effectiveness of school-based family asthma educational programs on the quality of life and number of asthma exacerbations of children aged five to 18 years diagnosed with asthma: a systematic review protocol.

Walter H ，Sadeque-Iqbal F ，Ulysse R ，Castillo D ，Fitzpatrick A ，Singleton J ... -  《-》