BACKGROUND: Having twins is associated with more depressive symptoms than having singletons. However, the association between having twins and psychiatric morbidity requiring emergency department visit or inpatient hospitalization is less well known. OBJECTIVE: This study aimed to determine whether women have higher risk of having a psychiatric diagnosis at an emergency department visit or inpatient admission in the year after having twins vs singletons. STUDY DESIGN: This retrospective cohort study used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes within the Florida State Inpatient Database and State Emergency Department Database, which have an encrypted identifier allowing nearly all inpatient and emergency department encounters statewide to be linked to the medical record. The first delivery of Florida residents at the age of 13 to 55 years from 2005 to 2014 was included, regardless of parity; women with International Classification of Diseases, Ninth Revision, Clinical Modification coding for psychiatric illness or substance misuse during pregnancy or for stillbirth or higher-order gestations were excluded. The exposure was an International Classification of Diseases, Ninth Revision, Clinical Modification code during delivery hospitalization of live-born twins. The primary outcome was an International Classification of Diseases, Ninth Revision, Clinical Modification code during an emergency department encounter or inpatient admission within 1 year of delivery for a psychiatric morbidity composite (suicide attempt, depression, anxiety, post-traumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was drug or alcohol use or dependence within 1 year of delivery. We compared outcomes after delivery of live-born twins with singletons using multivariable logistic regression adjusting for socio-demographic and medical factors. We tested for interactions between independent variables in the primary model and conducted sensitivity analyses stratifying women by insurance type and presence of severe intrapartum morbidity or medical comorbidities. RESULTS: A total of 17,365 women who had live-born twins and 1,058,880 who had singletons were included. Within 1 year of birth, 1.6% of women delivering twins (n=270) and 1.6% of women delivering singletons (n=17,236) had an emergency department encounter or inpatient admission coded for psychiatric morbidity (adjusted odds ratio, 1.00; 95% confidence interval, 0.88-1.14). Coding for drug or alcohol use or dependence in an emergency department encounter or inpatient admission in the year after twin vs singleton delivery was also similar (n=96 [0.6%] vs n=6222 [0.6%]; adjusted odds ratio, 1.11; 95% confidence interval, 0.91-1.36). However, women with public health insurance were more likely to be coded for drug or alcohol use or dependence after twin than singleton delivery (n=75 [1.2%] vs n=4858 [1.0%]; adjusted odds ratio, 1.27; 95% confidence interval, 1.01-1.60). Women with >= 1 medical comorbidity, severe maternal morbidity, or low income also had an increased risk of psychiatric morbidity after twin delivery (comorbidities, n=7438 [42.8%]; adjusted odds ratio, 1.30; 95% confidence interval, 1.25-1.34; severe maternal morbidity, n=940 [5.4%]; adjusted odds ratio, 1.65; 95% confidence interval, 1.49-1.81; lowest income quartile, n=4409 [26.8%]; adjusted odds ratio, 1.31; 95% confidence interval, 1.23-1.40; second-lowest income quartile, n=4770 [29.0%]; adjusted odds ratio, 1.34; 95% confidence interval, 1.26-1.43). CONCLUSION: Overall, diagnostic codes for psychiatric illness or substance misuse in emergency department visits or hospital admissions in the year after twin vs singleton delivery are similar. However, women with who are low income or have public health insurance, comorbidities, or severe maternal morbidity are at an increased risk of postpartum psychiatric morbidity after twin vs singleton delivery.

Study Objective: Evaluate whether 30- and 90-day surgical complication and postoperative hospitalization rates after hysterectomy for benign conditions differ by race/ethnicity and whether the differences remain after controlling for patient, hospital, and surgical characteristics. Design: Retrospective cohort study using administrative data. The exposure was race/ethnicity. The outcomes included 5 different surgical complications/categories and posthysterectomy inpatient hospitalization, all identified through 30 and 90 days after hysterectomy hospital discharge, with the exception of hemorrhage/hematoma, which was only identified through 30 days. To examine the association between race/ethnicity and each outcome, we used logistic regression with clustering of procedures within hospitals, adjusting for patient and hospital characteristics and surgical approach. Setting: Multistate, including Florida and New York. Patients: Women aged >= 18 years who underwent hysterectomy for benign conditions using State Inpatient Databases and State Ambulatory Surgery Databases. Interventions: Hysterectomy for benign conditions. Measurements and Main Results: We included 183 697 women undergoing hysterectomy for benign conditions from January 2011 to September 2014. In analysis, adjusting for surgery route and other factors, black race was associated with increased risk of 30-day digestive system complications (multivariable adjusted odds ratio [aOR], 1.98; 95% confidence interval [CI], 1.78 & minus;2.21), surgical-site infection (aOR, 1.34; 95% CI, 1.18 & minus;1.53), posthysterectomy hospitalization (aOR, 1.31; 95% CI, 1.22 & minus;1.40), and urologic complications (aOR, 1.16; 95% CI, 1.01 & minus;1.34) compared with white race. Asian/ Pacific Islander race was associated with increased risk of 30-day urologic complications (aOR, 1.48; 95% CI, 1.08 & minus;2.03), intraoperative injury to abdominal/pelvic organs (aOR, 1.46; 95% CI, 1.23 & minus;1.75), and hemorrhage/hematoma (aOR, 1.33; 95% CI, 1.06 & minus;1.67) compared with white race. Hispanic ethnicity was associated with increased risk of 30-day posthysterectomy hospitalization (aOR, 1.11; 95% CI, 1.02 & minus;1.20) compared with white race. All findings were similar at 90 days. Conclusion: Black and Asian/Pacific Islander women had higher risk of some 30- and 90-day surgical complications after hysterectomy than white women. Black and Hispanic women had higher risk of posthysterectomy hospitalization. Intervention strategies aimed at identifying and better managing disparities in pre-existing conditions/comorbidities could reduce racial/ethnic differences in outcomes. Journal of Minimally Invasive Gynecology (2021) 28, 1022 & minus;1032. (c) 2021 AAGL. All rights reserved.

You have accessJournal of UrologyStone Disease: Medical & Dietary Therapy (MP43)1 Apr 2020MP43-01 EVALUATING HEALTHCARE UTILIZATION OF ALPHA-BLOCKER FOR MEDICAL EXPULSIVE THERAPY IN SYMPTOMATIC PATIENTS WITH URETERAL STONES Alexander Parker*, Alana Desai, Shilpa Argade, Joel Vetter, Matt Keller, Margaret Olsen, Alethea Paradis, and Ramakrishna Venkatesh Alexander Parker*Alexander Parker* More articles by this author , Alana DesaiAlana Desai More articles by this author , Shilpa ArgadeShilpa Argade More articles by this author , Joel VetterJoel Vetter More articles by this author , Matt KellerMatt Keller More articles by this author , Margaret OlsenMargaret Olsen More articles by this author , Alethea ParadisAlethea Paradis More articles by this author , and Ramakrishna VenkateshRamakrishna Venkatesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000898.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Alpha-blocker medical expulsive therapy (MET) is widely utilized in the treatment of ureteral stones though its effectiveness is questionable. With increasing burden of urolithiasis on US healthcare, the utilization effects of α-blocker therapy have not been elucidated. We studied the effects of α-blocker MET in reducing surgical intervention, imaging, adverse events, ER visits, and cost up to 3 months. METHODS: Patients were selected from a US national commercial claims database between 2011 and 2016 based on prescription of α-blocker for a primary diagnosis of ureteral stone in an emergency room (ER), urgent care, outpatient, or inpatient hospital setting. We identified 58568 patients with and 78653 patients without prescription for alpha-blocker. Evaluation was performed at 30 days and 90 days after diagnosis of a ureteral stone event to determine rate of surgical intervention, number and type of follow-up imaging studies, adverse events, ER visits, and total medical claims cost. Multivariable linear and logistic regression models were used to test associations between outcome variables and the use of MET. RESULTS: α-blockers were prescribed to 43% of patients with ureteral stones for median length of 14 days. At 30-days after index stone event, 20.6% MET vs. 20.1% non- MET (p<0.001, OR=1.07) underwent a surgical procedure, 40% MET vs. 32% non-MET (p<0.001, OR=1.46) had a follow-up imaging study (KUB, CT or US scan) and 20% MET vs. 16% non-MET (p<0.001, OR=1.36) presented to the ER. Total medical claims cost at 30 days was $3860 (IQR=$2117–7393) for MET compared to $3290 (IQR=$1395-6839) for non-MET patients (p<0.01). At 90-days after index stone event 24% MET vs. 23% non-MET (p < 0.001, OR = 1.08) underwent a surgical procedure, 46% MET vs. 38% non-MET (p < 0.001, OR = 1.417) had a follow-up imaging study, and 24% MET vs. 21% non-MET (p < 0.001, OR = 1.261) presented to the ER. 90-day total medical claims cost was $4597 (IQR=$2518-9519) for MET vs. $4137 (IQR= $1877-9112) for non-MET patients (p < 0.001). UTI and sepsis events were infrequent in both groups. CONCLUSIONS: In this largest cohort of patients who were prescribed α-blocker for ureteral stone treatment there was no reduction in the number of surgical procedures at 3 months. However, there was an increase in the subsequent ER visits, follow up imaging studies, and total cost to the health system. These results should be factored along with questionable efficacy of α-blocker for optimal utilization of resources for a common and expensive stone disease. Source of Funding: Midwest Stone Institute, St. Louis, MO © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e647-e647 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander Parker* More articles by this author Alana Desai More articles by this author Shilpa Argade More articles by this author Joel Vetter More articles by this author Matt Keller More articles by this author Margaret Olsen More articles by this author Alethea Paradis More articles by this author Ramakrishna Venkatesh More articles by this author Expand All Advertisement PDF downloadLoading ...

Background: Negative pressure wound therapy (NPWT) is commonly used to manage complex wounds in the pediatric population. With recently developed portable NPWT devices, providers have the opportunity to transition NPWT to the outpatient setting. However, there are no studies describing outpatient NPWT in pediatric patients. Therefore, the purpose of our study was to leverage a population-level analysis to advance our current knowledge about outpatient NPWT use in pediatric patients. Materials and methods: We analyzed the Truven Health Analytics MarketScan Commercial Claims Database from 2006 to 2014 to identify children treated with NPWT. We compared patient characteristics, indications, complications before and after NPWT, health care utilization within 30 d of NPWT initiation, and health care cost profile of patients treated with NPWT primarily as outpatients versus inpatients. Outpatient NPWT was defined as patients with 50% of NPWT coded during an inpatient hospitalization, whereas inpatient NPWT was defined as patients with 50% of NPWT. Results: We identified 3184 patients (1621 inpatients and 1563 outpatients) aged 0-17 y, who were treated with NPWT from 2006 to 2014. Outpatient NPWT was implemented across multiple ages, comorbidities, and indications, with a low complication rate (2.4%). After controlling for hematologic comorbidity and indications, outpatient NPWT was associated with lower risk of complications (odds ratio: 0.57, 95% confidence interval 0.38-0.86) and lower median total costs ($5602.03) compared with inpatient ($15,233.21) therapy. Conclusions: Outpatient NPWT management in pediatric patients was associated with low complication rates. Additional studies are necessary to determine the most overall costeffective treatment setting for NPWT in the pediatric population. (c) 2020 Elsevier Inc. All rights reserved.

The impact of severe maternal morbidity (SMM) on postpartum psychiatric health is unknown. We aimed to determine whether women without preexisting psychiatric illness have higher odds of developing severe psychiatric morbidity in the year after term, singleton livebirth with versus without SMM. This retrospective cohort study used the Florida State Inpatient and State Emergency Department (ED) Databases. The first delivery of all Florida residents aged 13 to 55 years old from 2005 to 2013 was included; women with pre-existing psychiatric illness were excluded. ICD-9-CM diagnosis codes identified SMM (per CDC composite) and psychiatric conditions from nine months prior to delivery (for exclusion) until one year after delivery. The primary outcome was presentation to the ED or hospital within a year of delivery for severe psychiatric morbidity (composite of suicide attempt, depression, anxiety, post-traumatic stress disorder, acute stress reaction, or adjustment disorder) or substance use (drug or alcohol use or dependence). Secondary outcomes included psychiatric morbidity with individual measures of the SMM composite. We compared outcomes after term, singleton liveborn delivery with SMM versus without SMM using multivariable logistic regression adjusting for mode of delivery and maternal age, race, health insurance type, and income quartile. 16,698 women with SMM and 1,190,882 without SMM were included. Within a year of delivery with SMM, 3.0% of women had severe psychiatric morbidity: the odds were over two times higher compared to delivery without SMM (adjusted odds ratio (aOR) 2.04 (95% Confidence Interval (CI) 1.86 – 2.24)). SMM was associated with significantly higher odds of having individual conditions within the psychiatric composite, particularly adjustment disorder (aOR 2.80 (95% CI 1.99 – 3.94)) & depression (aOR 2.22 (95% CI 1.95 – 2.53)). Within the SMM composite, having acute myocardial infarction, acute renal failure, conversion of cardiac arrhythmia, sepsis, sickle cell crisis, & tracheostomy each had more than four times higher odds of severe psychiatric morbidity within a year of delivery compared to women who did not have these conditions. SMM during term, singleton delivery is associated with increased risk of severe psychiatric illness in the following year, particularly for certain morbidities. Women who have SMM may benefit from additional psychosocial support for at least a year after delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

OBJECTIVE: To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge. METHODS: This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida's Healthcare Cost and Utilization Project's databases. The first liveborn singleton delivery from 2005 to 2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the Centers for Disease Control and Prevention. The primary outcome was ICD-9-CM codes in emergency department encounter or inpatient admission within 1 year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, post-traumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity with those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome. RESULTS: A total of 15,510 women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within 1 year of hospital discharge, 2.9% (n=452) of women with severe maternal morbidity had the primary outcome compared with 1.6% (n=19,279) of women without severe maternal morbidity, resulting in an adjusted odds ratio (aOR) 1.74 (95% CI 1.58-1.91). The highest risk interval was within 4 months of discharge (adjusted hazard ratio [adjusted HR] 2.53 [95% CI 2.05-3.12]). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 [1.1%] vs 6,861 [0.6%]; aOR 1.91 [95% CI 1.64-2.23]). CONCLUSION: Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to 4 months after hospital discharge.

To determine whether women without preexisting psychiatric conditions have higher odds of severe psychiatric morbidity in the year after stillbirth versus term, singleton livebirth. This retrospective cohort study used the Florida State Inpatient and State Emergency Department (ED) Databases. The first delivery of all Florida residents aged 13 to 55 years old from 2005 to 2013 was included; women with pre-existing psychiatric conditions were excluded. ICD-9-CM diagnosis codes identified birth type and psychiatric conditions from 9 months prior (for exclusion) to delivery until one year after delivery. The primary outcome was presentation to the ED or hospital within one year of delivery for management of severe psychiatric morbidity, measured via a composite including: suicide attempt, depression, anxiety, post-traumatic stress disorder (PTSD), acute stress reaction, or adjustment disorder. Secondary outcomes included individual measures of the composite and a substance use composite (drug or alcohol use or dependence). We compared outcomes after stillbirth ≥23 weeks to those after term, liveborn singletons using multivariable logistic regression to adjust for mode of delivery and maternal age, race, health insurance type, and income quartile. 8245 women with stillbirth and 1,207,280 with term, singleton livebirth were included. Within one year of stillbirth, 3.4% of women had severe psychiatric morbidity: the odds were 2.5 times higher compared to those with livebirth (adjusted odds ratio (aOR) 2.5 (95% confidence interval (CI) 2.22 – 2.82). With the exception of acute stress reaction, each condition within the psychiatric composite was associated with significantly higher odds of severe psychiatric morbidity in the year after delivery in women with stillbirth compared to livebirth, particularly for adjustment disorder (aOR 4.90 (95%CI 3.40 – 7.08)) and PTSD (aOR 4.31 (95% CI 2.29 – 8.10)). After stillbirth, women also had significantly higher odds of presenting to the ED or hospital for substance use (aOR 2.38 (95% CI 1.95 – 2.91)). Delivering a stillbirth is associated with increased risk of severe psychiatric morbidity and substance use in the following year, suggesting women who have a stillbirth may benefit from additional psycho-social support for up to a year after their delivery.

OBJECTIVE: To estimate whether stillbirth at 23 weeks of gestation or more is associated with increased risk of severe maternal morbidity compared with live birth, when stratified by maternal comorbidities. METHODS: This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes within the Healthcare Cost and Utilization Project's Florida State Inpatient Database. The first delivery of female Florida residents aged 13-54 years old from 2005 to 2014 was included. The exposure was an ICD-9-CM code of stillbirth at 23 weeks of gestation or more; the control was an ICD-9-CM code of singleton live birth. Deliveries were stratified by the presence of 1 or more conditions within a well-validated maternal morbidity composite using ICD-9-CM codes during delivery hospitalization. The primary outcome was an ICD-9-CM diagnosis or procedure code during delivery hospitalization of any indices within the Centers for Disease Control and Prevention's severe maternal morbidity composite. Multivariable analyses adjusted for maternal sociodemographic factors and delivery mode to compare outcomes after stillbirth with live-birth delivery. RESULTS: Nine thousand five hundred twenty-three women who delivered stillborn fetuses and 1,353,044 with liveborn neonates were included. Among 6,590 stillbirths and 935,913 live births without maternal comorbidities, severe maternal morbidity was significantly more common during stillbirth delivery (n=345 [5.2%]), corresponding to a seven-fold increased risk compared with live birth (n=8,318 [0.9]; adjusted odds ratio [aOR] 7.05 [95% CI 6.27-7.93]). Among 2,933 stillbirths and 417,131 live births with maternal comorbidities, severe maternal morbidity was significantly more common during stillbirth delivery (n=390 [13.3%]): the risk was more than six-fold higher comparatively (n=11,122 [2.7%]; aOR 6.21 [95% CI 5.54-6.96]). Most maternal comorbidities were individually associated with higher risk of severe maternal morbidity during stillbirth compared with live-birth delivery. CONCLUSION: Though severe maternal morbidity is overall uncommon, delivering a stillborn fetus 23 weeks of gestation or greater is associated with increased likelihood of severe maternal morbidity, particularly among women with comorbidities, suggesting health care providers must be vigilant about severe maternal morbidity during stillbirth delivery.

BACKGROUND: Stillbirth has been associated with emotional and psychologic symptoms. The association between stillbirth and diagnosed postpartum psychiatric illness is less well-known. OBJECTIVE: The purpose of this study was to determine whether women have a higher risk of experiencing clinician-diagnosed psychiatric morbidity in the year after stillbirth vs livebirth. STUDY DESIGN: This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes to identify participants, exposures, and outcomes within the Florida State Inpatient and State Emergency Department databases. The first delivery of female Florida residents aged 13-54 years old from 2005-2014 was included; women with International Classification of Diseases, 9th Revision, Clinical Modification coding for psychiatric illness or substance use during pregnancy were excluded. The exposure was an International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during delivery hospitalization of a stillbirth at >= 23 weeks gestation. The primary outcome was a primary or secondary International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during an Emergency Department encounter or inpatient admission within 1 year of delivery for a composite of psychiatric morbidity: suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder. The secondary outcome was a substance use composite of drug or alcohol use or dependence. We compared outcomes after delivery of stillbirth vs livebirth using multivariable logistic regression, adjusting for maternal sociodemographic factors, medical comorbidities, and severe intrapartum morbidity. We also used Cox proportional hazard models and tested for violation of the proportional hazard assumption to identify the highest risk time within the year after stillbirth delivery for the primary outcome, adjusting for the same factors and morbidities as in the logistic regression model. RESULTS: A total of 8292 women with stillborn singletons and 1,194,758 with liveborn singletons were included. Within 1 year of hospital discharge after stillbirth, 4.0% of the women (n=331) had an Emergency Department encounter or inpatient admission that was coded for psychiatric morbidity; the risk was nearly 2.5 times higher compared with livebirth (1.6%; n=19,746); adjusted odds ratio, 2.47; 95% confidence interval, 2.20-2.77). Women also had higher risk of having an Emergency Department encounter or inpatient admission coded for drug or alcohol use or dependence in the year after delivery of stillbirth vs livebirth (124 [1.5%] vs 7033 [0.6%]; adjusted odds ratio, 2.41; 95% confidence interval, 1.99-2.90). Cox proportional hazard modeling suggested that the highest risk interval for postpartum psychiatric illness was within 4 months of stillbirth delivery (adjusted hazard ratio, 3.26; 95% confidence interval, 2.63-4.04), although the risk remained high during the 4-12 months after delivery (adjusted hazard ratio, 2.42; 95% confidence interval, 2.13-2.76). CONCLUSION: Coding for psychiatric illness or substance misuse in Emergency Department visits or hospital admissions in the year after delivery of livebirths was not uncommon, corresponding to nearly 2 per 100 women. However, having a stillbirth was associated with increased risk of both psychiatric morbidity (corresponding to 1 per 25 women) and substance misuse (corresponding to 3 in 100 women), with the highest risk of postpartum psychiatric morbidity occurring from delivery until 4 months after delivery.

Stillbirth is associated with an increased rate of maternal blood transfusion. However, the association between stillbirth and other conditions within the Centers for Disease Control (CDC)'s severe maternal morbidity (SMM) composite remains unexamined. We aimed to determine whether stillbirth was associated with higher odds of having conditions within the SMM composite compared to livebirth. This retrospective cohort study used the Florida State Inpatient Database. The first delivery of all Florida residents aged 13 to 55 years old from 2005 to 2014 was included. ICD-9-CM diagnosis codes identified type of birth (stillbirth ≥23 weeks versus term, singleton liveborn) and presence of SMM during delivery hospitalization. The primary outcome was the CDC's composite of SMM, which includes 21 conditions ranging from acute myocardial infarction or blood transfusion to ventilation. Secondary outcomes included a SMM composite without blood transfusion and individual morbidities within the SMM composite. We compared outcomes after stillbirth ≥23 weeks to those after term, liveborn singletons using multivariable logistic regression to adjust for mode of delivery and maternal age, race, health insurance type, and income quartile. 9678 women with stillbirth and 1,356,107 with livebirth were included. During delivery, 7.6% of women with stillbirth had SMM including blood transfusion; the odds were more than 6.5 times higher compared to liveborn (adjusted odds ratio (aOR) 6.66 (95% confidence interval (CI) 6.16 – 7.21). Excluding transfusion, 2.5% of women with stillbirth had SMM; the odds were more than 5.5 times higher compared to women with livebirth (aOR 5.55 (95% CI 4.87 – 6.33)). With the exception of severe anesthetic complications, each condition within the composite had significantly higher odds during delivery hospitalization of stillbirth versus term livebirth, particularly for sepsis (0.9% vs 0.06%; aOR 18.95 (95%CI 15.10 – 23.80)), shock (0.5% vs 0.04%; aOR 16.39 (95% CI 11.94 – 22.48)), and acute renal failure (1.1% vs 0.09%; aOR 15.54 (95% CI 12.59 – 19.19)). Though blood transfusion is the most common SMM associated with stillbirth, these data suggest nearly all of the conditions within the CDC's SMM composite are significantly more common among women with stillbirth vs. livebirth. Providers and hospitals who deliver women with stillbirth ≥23 weeks must be prepared to manage all SMM, not only provide blood transfusion.

Cryptococcal disease (CD) often has an insidious presentation and can be difficult to recognize. However, delayed diagnosis can lead to increased morbidity and mortality. To estimate the potential number of missed opportunities for CD diagnosis we utilized the Healthcare Cost and Utilization Project State Inpatient Database from the Agency for Healthcare Research and Quality for the state of Florida from 2005 to 2014. We defined a missed opportunity as an admission with a new diagnosis of CD preceded by a hospitalization in the prior 90-days coded for an infection, respiratory, or central nervous system condition suggestive of CD. We performed descriptive statistics including mortality in each exposure group within one year after CD diagnosis. We identified 1,622 CD-related hospital discharges in Florida from April 2005 to December 2014. The median age of CD patients was 47 years, 30.6% were female, and 55.5% were coded for HIV/AIDS. Of those, 850/1,622 (52.4%) had meningitis. Five hundred sixty (34.5%) had a prior hospitalization within 90 days before the first hospitalization coded for CD. Of those, 50.9% (285/560) had a potentially missed opportunity to diagnose CD of whom 138/285 (48.4%) were HIV-positive. Of 560 patients, 49 (8.7%) were coded during a prior hospitalization with CNS conditions, 162 (28.9%) with respiratory conditions and 74 (13.2%) coded with both CNS and respiratory conditions. Patients who were coded for CNS diagnoses in a prior admission were more likely to be diagnosed with CD meningitis (P < 0.001). Of those with prior respiratory conditions 29/218 (13.3%) died during the CD admission, and 12.5% of those with prior CNS conditions died during the CD admission. Of those without a prior admission in the past 90 days, 110/1,062 (10.4%) died during the CD admission. Cryptococcosis is a deadly disease that affects patients with both competent and incompetent immune systems. Missed opportunities to diagnose CD are relatively commonmand may contribute to worse outcomes. All authors: No reported disclosures.

The impact of multiples on acute postpartum psychiatric illness is unclear. We aimed to determine whether women without preexisting psychiatric conditions or intrapartum severe maternal morbidity (SMM) have higher odds of developing severe psychiatric morbidity in the year after delivering multiples versus term singletons. This retrospective cohort study used the Florida State Inpatient and State Emergency Department (ED) Databases. The first delivery of all Florida residents aged 13 to 55 years old from 2005 to 2013 was included; women with pre-existing psychiatric conditions or intrapartum SMM as defined by the CDC were excluded. ICD-9- CM diagnosis codes identified number of infants delivered, intrapartum SMM, and psychiatric conditions from 9 months prior to delivery (for exclusion) until 1 year after delivery. The primary outcome was presentation to the ED or hospital within a year of delivery for severe psychiatric morbidity, measured via a composite including: suicide attempt, depression, anxiety, post-traumatic stress disorder (PTSD), acute stress reaction, or adjustment disorder. Secondary outcomes included individual measures of the composite and a substance use composite (drug or alcohol use or dependence). We compared outcomes after delivery of liveborn multiple gestation to those after liveborn term singletons using logistic regression to adjust for mode of delivery and maternal age, race, health insurance type, and income quartile. 15,964 women with multiples and 1,182,572 women with term singletons were included. Within a year of delivering multiples without SMM, 2.1% of women had severe psychiatric morbidity: the odds were more than 50% times higher compared to women with term singletons without SMM (adjusted odds ratio (aOR) 1.58 (95% Confidence Interval (CI) 1.41 – 1.76)). Within the psychiatric composite, the conditions with highest odds of presenting to the ED or hospital in the year after multiples were PTSD (aOR 2.93 (95% CI 1.64 – 5.23)) and adjustment disorder (aOR 2.25 (95% CI 1.45 – 3.47)). After having multiples without SMM, women also had significantly higher odds of presenting to the ED or hospital for substance use (aOR 1.35 (95% CI 1.16 – 1.71)). Delivering multiples is associated with increased risk of severe psychiatric morbidity and substance use in the following year. These data suggest women who have multiples may need additional psychosocial support in the year after delivery.

BACKGROUND:Although the safety and benefits of negative-pressure wound therapy (NPWT) have been clearly demonstrated in the adult population, studies evaluating the safety and describing the use of NPWT in the pediatric population have been limited. Given this paucity, the goals of this study were to (1) evaluate the literature dedicated to NPWT use in infants and children and (2) leverage a population-level analysis to describe the experience of NPWT use in the pediatric population. MATERIALS AND METHODS:We performed a literature review and analyzed the Truven Health Analytics MarketScan Commercial Claims Databases from 2006 to 2014 to identify infants and children treated with NPWT. We evaluated patient characteristics, indications, complications before and after NPWT placement, and health care utilization within 30 d of NPWT placement. RESULTS:We identified 457 articles, 11 of which fit our inclusion criteria. Most studies (65.2%) were case reports or series with less than 10 patients. In addition, we identified 3184 patients aged younger than of 18 y who were treated with NPWT between 2006 and 2014. Serious incident complications within 30 d after NPWT placement were rare (bleeding 0.6%, septicemia 0.5%, and sepsis 0.5%). CONCLUSIONS:Despite the lack of robust studies, NPWT is widely used for many indications and across different ages and providers. Given the low incidence of serious complications, we conclude that NPWT use in infants and children is safe and can be effectively used by different providers spanning surgical and nonsurgical disciplines.

PurposeThe distinction of patients with symptomatic multiple myeloma (MM) from those with smoldering MM poses a challenge for researchers who use administrative databases. Historically, researchers either have included all patients or used treatment receipt as the distinguishing factor; both methods have drawbacks. We present an algorithm for distinguishing between symptomatic and smoldering MM using ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes for the classic defining events of symptomatic MM commonly referred to as the CRAB criteria (hypercalcemia, renal impairment, anemia, and bone lesions).Patients and MethodsSEER-Medicare-linked data from 4,187 patients with MM diagnosed between 2007 and 2011 were used for this analysis.ResultsEighty-four percent had ICD-9-CM codes consistent with CRAB criteria, whereas only 57% received treatment. Overall survival of patients with symptomatic MM defined as receipt of treatment was 32.3 months versus 26.6 months for the overall population and 22.9 months for patients with symptomatic MM defined by CRAB criteria. Conceptually, removal of patients with smoldering MM should result in a reduction in overall survival; however, the cohort of patients who received treatment tended to be younger and healthier than the overall population, which could have skewed the results.ConclusionThe algorithm we present resulted in a larger and more representative sample than classification by treatment status and reduced potential bias that could result from including all patients with smoldering MM in the analysis. Although this study was performed using the SEER-Medicare database, the methodology was broad enough that the algorithm could be extended to additional claims-based data sets with relative ease.