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Clinical Rounds

doi: 10.1097/01.NURSE.0000580704.87026.95
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Night-shift work linked to adverse outcomes



To examine how shift work and longer working hours during pregnancy affect maternal and fetal health, researchers analyzed 62 observational studies involving 196,989 women who engaged in paid work during pregnancy. These studies contained information on many relevant factors, including work schedule (such as fixed day shift, rotating shifts, fixed night shifts, or longer working hours), and adverse pregnancy outcomes (such as preterm delivery, low birthweight, miscarriage, gestational hypertension, and gestational diabetes mellitus). Among the findings:

  • Working rotating shifts was associated with an increased odds of preterm delivery, an infant small for gestational age, preeclampsia, and gestational hypertension compared with working a fixed day shift.
  • Women working fixed night shifts were more likely to experience preterm delivery and miscarriage than women working days.
  • Women working more than 55.5 hours per week had a 10% increase in the odds of a preterm delivery compared with women working 40 hours per week.

The authors concluded, “Pregnant women who work rotating shifts, fixed night shifts, or longer hours have an increased risk of adverse pregnancy outcomes.”

Source: Cai C, Vandermeer B, Khurana R, et al. The impact of occupational shift work and working hours during pregnancy on health outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol. [e-pub ahead of print July 2, 2019.]

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In-hospital events may be underestimated

Prior studies have estimated a national incidence of 211,000 adult and 6,000 pediatric in-hospital cardiac arrests across the US, but figures are more than a decade old. For more contemporary estimates, researchers prospectively analyzed data from the Get With The Guidelines–Resuscitation registry between 2008 and 2017. They found that the public health burden of adult and pediatric in-hospital cardiac arrest is about 38% and 18% higher than previously reported, respectively, and that in-hospital cardiac arrest occurs with nearly the same frequency as out-of-hospital cardiac arrest. Based on the new data, about 292,000 adult in-hospital cardiac arrests and 15,200 pediatric in-hospital events requiring CPR occur in the US annually. The incidence of adult in-hospital cardiac arrests increased between 2008 and 2017, whereas the incidence of pediatric events remained more stable during that period.

Source: Holmberg MJ, Ross CE, Fitzmaurice GM, et al. Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019; 12:e005580.

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Video boosts HPV vaccine acceptance

Although the relationship between human papillomavirus (HPV) infection and cervical cancer is well documented, acceptance of HPV vaccination among young women is suboptimal. Researchers recently demonstrated that targeted educational interventions, particularly educational videos, can improve rates of HPV vaccination among girls and young women. After first investigating baseline acceptance of the prophylactic HPV vaccine and barriers to acceptance, they conducted a randomized controlled trial of female patients ages 12 to 26 at a single facility from March 2017 to August 2017. Participants were assigned to one of three study arms: educational handout (84 patients), educational video (87 patients), and control (85 patients). All patients completed a survey on demographics and HPV vaccine preferences and knowledge. Findings included the following:

  • About 52% of patients in the educational video arm reported willingness to accept the HPV vaccine, compared with 33% and 28%, respectively, of those in the educational handout and control arms.
  • Patients in the educational video and handout arms had higher median HPV vaccine knowledge scores than those in the control arm.
  • Both interventions were reported as helpful in learning, but the educational video arm was more likely to be helpful in deciding on vaccination (86% versus 70%).

The authors concluded that targeted educational interventions increased HPV vaccine acceptability and knowledge among young women, but more research is needed to determine whether these interventions would also increase rates of vaccine uptake (the proportion of the eligible population who receive a vaccine in a specified period) and series completion.

Source: Cory L, Cha B, Ellenberg S, et al. Effects of educational interventions on human papillomavirus vaccine acceptability: a randomized controlled trial. Obstet Gynecol. 2019;134(2):376-384.

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Is your bias showing?

A review of 42,991 Implicit Association Test (IAT) records and a cross-sectional study of 131 surgeons revealed that healthcare professionals have both implicit and explicit gender biases associating men with career and women with family. The IAT is a validated tool for measuring implicit biases, defined as mental associations outside of conscious awareness or control that influence one's interactions with others.

From January 1, 2006, through December 31, 2017, data were collected from self-identified healthcare professionals taking the Gender-Career IAT to explore gender bias. A novel Gender-Specialty IAT was also tested among 131 surgeons at a national surgical conference in October 2017.

Healthcare professionals taking the Gender-Career IAT (n = 42,991; 82% women; mean age, 32.7) held implicit and explicit biases associating men with career and women with family, and results were similar among surgeons. A broad consensus was found across social groups in implicit and explicit biases with one exception: Women in healthcare were less likely than men to explicitly associate men with career and surgery, or women with family and family medicine.

Implicit biases can sometimes lead people to act in ways that are not consistent with their explicit or conscious beliefs and values. Because awareness of bias is an important first step toward minimizing its effects, the authors call for more research to identify other psychological obstacles to women's success and explore effective interventions to reduce gender inequality.

Source: Salles A, Awad M, Goldin L, et al. Estimating implicit and explicit gender bias among health care professionals and surgeons. JAMA Netw Open. 2019;2(7):e196545.

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“Speak Up” campaign offers practical strategies

The Joint Commission has launched the latest version of its Speak Up To Prevent Falls campaign, which is designed to educate both patients and healthcare providers about preventing avoidable falls. Offering downloadable educational materials in English and Spanish, the campaign emphasizes four practical strategies to teach patients:

  • Pay attention to health; for example, by exercising, eating right, and getting regular healthcare checkups.
  • Take extra precautions, such as turning on lights when entering a room, using handrails on staircases, and wearing shoes with nonslip soles.
  • Make small changes at home, such as keeping regular pathways clear, installing timers and motion sensors on lights, and replacing rugs that can slip with rubber mats.
  • Ask for help in the hospital or nursing home. Encourage patients to use the call bell before they try to get out of bed.

For more information about this and other Speak Up campaigns, visit

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In October, celebrate

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Promising results for chronic stable angina



A randomized study conducted at five clinical facilities in China indicates that acupuncture is a safe and effective adjunctive therapy for patients with chronic stable angina. The study included 404 patients (mean age, 62.6) with chronic stable angina who were randomly assigned to four groups: those receiving acupuncture on the acupoints on the disease-affected meridian (DAM), those receiving acupuncture on the acupoints on the nonaffected meridian (NAM), those receiving sham acupuncture (SA), and those receiving no acupuncture (wait list or WL group).

All participants received antianginal therapies as recommended by clinical guidelines. In addition, patients in the DAM, NAM, and SA groups received acupuncture treatment three times weekly for 4 weeks, for a total of 12 sessions. Participants in the WL group did not receive acupuncture during the 16-week study period.

Patients recorded their symptoms in diaries during the study period. The primary outcome was the change in frequency of angina attacks every 4 weeks from baseline to week 16.

The results showed that at 16 weeks, mean changes in frequency of angina attacks differed significantly among the four groups, with a greater reduction of angina attacks in the DAM group versus the NAM group, in the DAM group versus the SA group, and in the DAM group versus the WL group. Sixteen patients reported acupuncture-related adverse reactions, such as subcutaneous hemorrhage, tingling at the acupuncture site, and sleeplessness. All these were mild or moderate, and none required treatment.

Source: Zhao L, Li D, Zheng H, et al. Acupuncture as adjunctive therapy for chronic stable angina: a randomized clinical trial. JAMA Intern Med. [e-pub ahead of print July 29, 2019.]

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Hearing implants can alter CSF shunt settings



The FDA has issued an alert to healthcare professionals about potential complications in patients with both implanted programmable cerebrospinal fluid (CSF) shunt systems and some hearing implants that contain magnets, such as cochlear implants, bone conduction hearing devices, or middle-ear hearing devices. When these devices are implanted close to each other, magnetic interactions may cause unintended changes to the programmable CSF shunt valve settings leading to over- or underdrainage of CSF. Signs and symptoms may include altered mental status, headaches, lethargy, irritability, vomiting, changes in vision, difficulty walking, loss of consciousness, seizures, hemorrhage, and even death.

Educate patients and caregivers about this potential risk and tell them to seek medical assistance immediately if they experience signs and symptoms associated with over- or underdrainage of CSF. After placement or adjustment of other devices that contain magnets, an appropriately trained clinician, such as a neurosurgeon, should check the CSF shunt valve setting and adjust the setting if necessary. For other guidelines and recommendations, visit and search for “programmable CSF shunts and magnetic interference.”

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