SummaryBackgroundPost-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.MethodsIn this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283.FindingsBetween March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus ...

Purpose There are growing signs that the COVID‐19 virus has started to spread to rural areas and can impact the rural health care system that is already stretched and lacks resources. To aid in the legislative decision process and proper channelizing of resources, we estimated and compared the county‐level change in prevalence rates of COVID‐19 by rural‐urban status over 3 weeks. Additionally, we identified hotspots based on estimated prevalence rates. Methods We used crowdsourced data on COVID‐19 and linked them to county‐level demographics, smoking rates, and chronic diseases. We fitted a Bayesian hierarchical spatiotemporal model using the Markov Chain Monte Carlo algorithm in R‐studio. We mapped the estimated prevalence rates using ArcGIS 10.8, and identified hotspots using Gettis‐Ord local statistics. Findings In the rural counties, the mean prevalence of COVID‐19 increased from 3.6 per 100,000 population to 43.6 per 100,000 within 3 weeks from April 3 to April 22, 2020. In the urban counties, the median prevalence of COVID‐19 increased from 10.1 per 100,000 population to 107.6 per 100,000 within the same period. The COVID‐19 adjusted prevalence rates in rural counties were substantially elevated in counties with higher black populations, smoking rates, and obesity rates. Counties with high rates of people aged 25‐49 years had increased COVID‐19 prevalence rates. Conclusions Our findings show a rapid spread of COVID‐19 across urban and rural areas in 21 days. Studies based on quality data are needed to explain further the role of social determinants of health on COVID‐19 prevalence.

Despite the consequences of night-shift work, the diet of night-shift workers has not been widely studied. To date, there are no studies related to food intake among emergency healthcare workers (HCWs). We performed a prospective observational study to assess the influence of night work on the diet of emergency HCWs. We monitored 24-h food intake during a day shift and the consecutive night, and during night work and the daytime beforehand. We analyzed 184 emergency HCWs’ food intakes. Emergency HCWs had 14.7% lower (−206 kcal) of their 24-h energy intake during night shifts compared to their day-shift colleagues (1606.7 ± 748.2 vs. 1400.4 ± 708.3 kcal, p = 0.049) and a 16.7% decrease in water consumption (1451.4 ± 496.8 vs. 1208.3 ± 513.9 mL/day, p = 0.010). Compared to day shifts, night-shift had 8.7% lower carbohydrates, 17.6% proteins, and 18.7% lipids. During the night shift the proportion of emergency HCWs who did not drink for 4 h, 8 h and 12 h increased by 20.5%, 17.5%, and 9.1%, respectively. For those who did not eat for 4 h, 8 h and 12 h increased by 46.8%, 27.7%, and 17.7%, respectively. A night shift has a huge negative impact on both the amount and quality of nutrients consumed by emergency healthcare workers.

Background Psychological distress and self-rated health status may create additional complexities in patients already diagnosed with breast cancer. This study aims to assess the association of self-report-based assessment of psychological distress and self-rated health on survival times among women with breast cancer diagnoses. Methods Seventeen-year data from the Integrated Public Use Microdata Series—National Health Interview Survey (IPUMS-NHIS) were pooled and analyzed. Women who were aged 30 to 64 years old, with breast cancer diagnosis were selected (n = 2,819). The outcome variable was time to death. The independent variables were self-reported assessment of psychological distress and self-rated health. Psychological distress was defined using the Kessler-6 scale while self-rated health was measured on a 3-point Likert scale: Poor, Fair, and Good-to-Excellent (referred to as good for brevity). We computed unadjusted and adjusted hazard ratios (HR) using Cox-Proportional Hazard regression models with sociodemographic characteristics and measures of health care access used as potential confounders. Significance was set at alpha = 0.05. Results Women with breast cancer assessed as having psychological distress had 46% (Adjusted HR: 1.46; 95% CI: 1.02–2.09) increased risks of mortality. Also, women who rated their health as poor or fair had a significantly elevated mortality risk (Poor Health: Adjusted HR: 3.05; 95% CI: 2.61–4.69; Fair Health: Adjusted HR: 1.83; 95% CI: 1.43–2.35) as compared to women with good health status. Conclusions Self-reported psychological distress and fair and poor self-rated health are associated with reduced survival times among women with breast cancer diagnoses.