Mir, Hassan R.

Abstract Aims Although cardiovascular disease (CVD) screening and preventive care in the early postpartum are recommended for women with prior gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP), certain barriers limit access to such services. We conducted a scoping review to summarize evidence on the barriers and facilitators of CVD prevention services among women with prior GDM or HDP. Methods and results A comprehensive search strategy was used to search articles published in three databases (Ovid Medline, CINAHL, Embase). Studies published in English or French that investigated and reported barriers or facilitators to postpartum CVD screening and preventive care among women with previous GDM and HDP were included. Out of 18 565 studies we screened, 29 studies (12 qualitative, 17 quantitative) were included. Main individual level barriers including lack of knowledge, health, and emotional factors were identified. Competing priorities, lack of family/friend support, and mistrust of healthcare providers were the most reported interpersonal level barriers, while gaps in communication were the most significant organizational barrier, and gaps in insurance coverage was the most reported system barrier. Individual level facilitators included a personal desire for better health and availability of postpartum programmes, and the most reported interpersonal facilitator was women's commitment to modelling a healthy lifestyle for their children. Organizational level facilitators were access to primary care providers and follow-up visit reminders, and programme availability in native languages. Conclusion Women with prior GDM or HDP face significant barriers to accessing postpartum CVD prevention services. These barriers ranged from individual-level knowledge gaps to system-level healthcare disparities.

Objectives: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. Design: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage. Setting: Fourteen level-1 trauma centers across the United States. Patients: Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage. Intervention: Delay definitive fixation and flap coverage in tibial type III fractures. Main Outcome Measurements: (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding. Results: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001). Conclusion: Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.