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Natural barriers against viral infections include (a) the acidity of the stomach treatment lice generic norpace 150 mg without a prescription, (b) the alkalinity of the small intestine treatment statistics discount norpace 100 mg, and (c) secretory enzymes found in the saliva and pancreatic secretions medications you cant take with grapefruit purchase norpace american express. Intestinal mucus and secretory IgA antibodies are important and offer partial protection to the intestinal tract. Enveloped viruses usually fail to establish infection in the gastrointestinal tract, because these are destroyed by bile secreted in the gastrointestinal tract. Replication of viruses at the primary sites may be accompanied by clinical symptoms. Some viruses, on the other hand, may disseminate to other tissues through blood stream, lymphatic system, and neurons (secondary sites) and cause a systemic infection. Chapter 51 Replication of Virus and Spread to Secondary Site the viruses are spread in the body mainly by the blood stream and the lymphatic system. After multiplication in the lymph nodes, the virus enters the blood stream, resulting in primary viremia. In the blood stream, the virus may exist either free in the plasma or it may be ingested by the lymphocytes or macrophages. In macrophages, the viruses may die or replicate or may be carried by the mononuclear phagocytic system to the spleen and liver. Replication of the viruses in macrophages, in the endothelial lining of blood vessels, or in the spleen and liver results in production of viruses in large numbers. This leads to massive spillover of the virus into the blood stream, causing secondary viremia. Subsequently, it is carried by blood stream to reach target organs (skin, brain, liver, etc. Viruses enter the brain or central nervous system (a) through the blood stream, (b) through the infected cerebrospinal fluid or meninges, and/or (c) through the infection of the peripheral and sensory (olfactory) neurons. Cytopathic effects of viruses Cytopathic effects Cell death Cell fusion Transformation Destruction of T cells Inclusion bodies in nucleus Inclusion bodies in nucleus Inclusion bodies in cytoplasm (negri bodies) Inclusion bodies in cytoplasm and nucleus Manifestations of the Viral Diseases the clinical manifestations of viral diseases depend on the complex interaction of virus and host factors. The outcome of the infection, that is, the disease manifestation depends on the: Age, general health, and immune status of the person, Dose of the infective virus, and Genetics of the host and the virus. After the host is infected by the virus, the immune status of the host plays an important role and determines the outcome of viral infection whether it will be an asymptomatic infection, a benign disease, or a life-threatening disease. Moreover, the outcome of infection is determined by the properties of the virus and the cell. These cellular changes may be caused (a) by viral takeover of macromolecular synthesis of proteins and enzymes by viruses instead of host cell, (b) by accumulation of virus proteins or particles, or (c) by alteration or disruption of cellular structure. The accumulation of large amounts of viral proteins or particles in the infected cells may lead to the modification or disruption of the cellular architecture. At the cellular level, depending on the nature of the virus and the cell infected, the virus infection in a cell can produce any of the three infections. Infection without cell death (persistent viral infection) A permissive cell is a cell that allows replication of a particular type of strain of virus by providing biosynthesis compounds, such as transcriptional factors and posttranslational enzymes. A nonpermissive cell does not provide any biosynthesis compound, hence does not support replication of the viruses. Chapter 51 Abortive Infection Some viruses cause failed or abortive infections in which those viruses do not multiply, therefore disappear from the cell. Replication of virus in cell may cause a broad spectrum of effects, ranging from nonapparent cellular damage to rapid cell destruction. This occurs due to replication of virus in infected cell, which kills the target cell. The cellular injury caused by viruses may be due to combination of several factors. Viruses adopt different mechanisms (Table 51-2) for preventing cellular growth and causing cell death as follows: Some viruses may cause cell death or even cell lysis. For example, polioviruses cause death of cells (cytocidal effect) and even lysis of the cells (cytolysis), molluscum contagiosum cause proliferation of cells, and oncogenic viruses cause malignant transformation of cells. In some conditions, viruses infect cells and replicate independently within the cells without causing any cellular injury to the infected cells. Fusion from without: In this type, cell fusion occurs in the absence of new protein synthesis. Cell fusion Infections of cells with certain viruses cause the cells to fuse, resulting in the production of giant multinucleated cells. Infection by paramyxoviruses, herpes viruses, and retroviruses results in the expression of glycoproteins on the cell surface. This triggers the fusion of neighboring cells, resulting in the formation of large multinucleated giant cells called syncytia. Formation of syncytia facilitates spread of the virus from cellto-cell and allows the virus to escape from the lytic effect of antibodies. The cell-to-cell fusion of infected cells is of two types: Certain viruses cause alterations in the cytoplasm of infected cells, or lead to expression of virus-coded antigens on the surface of infected cells. For example, respiratory syncytial virus causes fusion of adjacent cell membrane, resulting in polykaryocytosis or formation of syncytia. For example, infection by influenza virus results in the appearance of viral hemagglutinin on infected cell surfaces, leading to hemadsorption or adsorption of erythrocytes to the cell surface. Apoptosis is a process leading to cellular suicide that facilitates the release of viruses from the cell. Certain viral infections produce characteristic changes in the properties and appearance of target cells. For example, measles viruses, mumps viruses, adenoviruses, cytomegaloviruses, and varicella viruses cause chromosomal aberrations and degradations. Infection of cells with certain viruses causes transformation of normal cells to malignant cells. The viruses that stimulate uncontrolled cell growth causing the transformation of immortalization of the cell are known as oncogenic viruses. Loss of P53 gene makes the cell more susceptible to mutation, thus releasing the mechanisms that inhibit the cell growth. It encodes a protein (tax) that transactivates gene expression, including genes for interleukin-2 and other growth-stimulating lymphokines. Inclusion bodies: Inclusion bodies are the characteristic histological feature in virus-infected cells reflecting the change in the appearance of the target cells. They may result from virus-induced changes in the membrane or chromosomal structure. They also represent the sites of viral replication or accumulation of viral capsids. Inclusion bodies are the structures with distinct size, shape, location, and staining properties that are found in virus-infected cells. Cowdry type A inclusion bodies are of variable size, and are produced by infection with herpes virus and yellow fever virus. Cowdry type B inclusion bodies are often multiple and more circumscribed, and are produced by adenovirus and poliovirus infection. These inclusion bodies may be acidophilic, which appear as pink structures when stained with Giemsa or eosin methylene blue stains. They may be basophilic as produced by some viruses, such as adenovirus (Table 51-3).
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The process is called hemagglutination and it forms the basis of hemagglutination inhibition test used in the viral serology medicine bow national forest 100mg norpace free shipping. The structural components of envelope remain biologically active only in aqueous solutions and are readily destroyed by drying or on treatment with acids natural pet medicine 100 mg norpace mastercard, detergents symptoms 8 dpo bfp buy norpace 100 mg visa, and solvents, such as ether, leading to inactivation of virus. They are rapidly killed in stomach due to sensitivity of enveloped components Three types of symmetry are observed depending on the arrangement of the capsid around the nucleic acid core (genome). They are the pentagonal capsomeres or the vertices (pentons) and hexagonal capsomeres making up the facets (hexons). There are always 12 pentons, but the number of hexons varies with the virus group. Each penton has fivefold symmetry (pentamer or pentagon) in the shape of an equilateral triangle. This pentamer symmetry is found in simple viruses, such as the picornaviruses and parvoviruses. In picornaviruses, each pentamer is made up of five protomers, each of which is composed of three subunits of four different proteins. The hexamer symmetry is usually found in large capsid virions, such as herpesviruses and adenoviruses. Hexons are made up of certain structurally distinct capsomeres between the pentons at the vertices. The adenovirus nucleocapsid has 12 pentons and 240 hexons, whereas the herpesvirus nucleocapsid has 12 pentons and 150 hexons surrounded by an envelope. Capsomeres (protein) is in several separate segments, each segment encoding an individual gene. The total amount of nucleic acid may vary from a few thousand nucleotides to as many as 250,000 nucleotides. Viral proteins and lipids Helical symmetry: the nucleic acid and the capsomeres are wound together to form a spherical or spiral tube. The tubular nucleocapsid structure may be rigid as in tobacco mosaic virus, but may be pliable and may be coiled on itself in case of some other animal viruses. Complex symmetry: Some viruses may not exhibit either icosahedral or helical symmetry but instead may exhibit a complex symmetry. The viral protein protects the nucleic acid as well as determines the antigenic specificity of the virus. In addition, the enveloped viruses contain lipids, which are derived from the host cell membrane. Susceptibility to Physical and Chemical Agents Chapter 50 Disinfectants Shape Most of the enveloped viruses are round or pleomorphic with exception of poxvirus and rhabdovirus. The oxidizing agents, such as hydrogen peroxide, potassium permanganate, hypochlorite, and organic iodine compounds, are most active antiviral disinfectants. Formaldehyde and -propiolactone are also active virucidal agents, which are commonly used for preparation of killed viral vaccines. The chlorination of drinking water is useful for killing most of the common viruses with exception of hepatitis A and polioviruses. They are inactivated within seconds at 56°C, within minutes at 37°C, and within days at 4°C. The viruses such as influenza, measles, and mumps are very labile and may survive outside the host only for a few hours. Other viruses, such as polio and hepatitis A, are relatively much stable and may survive for many days, weeks, or even months in the environment. Attachment Attachment or adsorption is the first event in the infection of the cell by a virus. The viruses have attachment sites that attach to the complementary receptor sites on the host cell surface. For example, in influenza virus these receptor proteins are the spikes present on the surface of the envelope, whereas in adenovirus these receptor proteins are small fibers present at the corner of the icosahedron. The attachment sites of the virus bind specifically to the complementary receptors on the surface of the host (Table 50-5). These receptor sites on the cell vary depending on the nature of the virus: the viruses are stable at low temperature. Rhinoviruses are very susceptible to acidic pH, while enteroviruses are highly resistant. Lipid solvents Ether, chloroform, and detergents are active against enveloped viruses but are not active against nonenveloped, naked viruses. Influenza virus binds specifically to sialic acid residue of glycoprotein receptor sites on the surface of respiratory epithelium. Susceptibility of the host to virus infection, therefore, depends upon the presence or absence of receptors on the cell surface. Replication of Viruses the replication of viruses in the host cell depends upon the synthesis mechanism of the host cell for manufacture of different viral components. The genetic information for viral multiplication is present in the viral nucleic acid. Multiplication of viruses follows the basic pattern of bacteriophage multiplication, but has several important differences (Box 50-1). In some other viruses, uncoating is caused exclusively by enzymes present in the host cell cytoplasm. However, they synthesize their capsid and other proteins in the cytoplasm by using host cell enzymes. Poxvirus is an exception, because all of its components are synthesized in the cytoplasm. Chapter 50 Penetration Depending on their nature, whether enveloped or nonenveloped, the viruses penetrate into cell by different mechanisms: A nonenveloped virus enters the cell by a process known as endocytosis. The endocytosis is an active process by which nutrients and other molecules are brought into a cell. The enveloped viruses enter the cell by an alternate method called fusion, in which the viral envelope fuses with the plasma membrane and releases the capsid into the cell cytoplasm. Uncoating Uncoating is the process of separation of viral nucleic acid from its protein core. This process apparently varies depending on the nature of the virus causing infection: Maturation the assembly of the protein capsid is the first step in viral maturation. During maturation, the envelope protein is encoded by the viral genes and is incorporated into the plasma membrane of the infected host cell. In contrast, the envelope lipids and carbohydrates are encoded by host cell genes, but not by viral genes, and are present in the plasma membrane. The assembly of various viral components into virions may take place in the nucleus. The nonenveloped viruses are present intracellularly as fully developed viruses, but in case of enveloped viruses, only the nucleocapsid is complete. Subsequently, nucleocapsid is surrounded by an envelope, which is derived from the host cell membrane during the process of budding.
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Key Facts about Infant Mortality in South Carolina Despite recent improvements symptoms 0f diabetes order 150 mg norpace visa, the infant mortality rate in South Carolina continues to medicine 19th century buy 100 mg norpace overnight delivery exceed the national rate symptoms torn meniscus 150mg norpace with visa. Despite marked improvement between 2013 and 2014, a significant racial disparity in infant mortality rates remains (blacks 2. These professionals can provide oral health education and counseling, as well as link women to dental care during the perinatal period. Explain that dental care during pregnancy is safe and effective and is essential for the pregnant woman and her fetus. Reassure women that diagnosis (including necessary dental X-rays) and dental treatment for conditions requiring immediate attention are safe during the first trimester of pregnancy. Inform women that needed treatment can be provided throughout the remainder of the pregnancy; however, the time period between the 14th and 20th week is the best time to provide dental care. Advise women that delaying necessary treatment could result in significant risk to the mother and indirectly to the fetus (Kumar J, Samelson R, eds. Include an oral health assessment that identifies problems and offers recommendations on patient intake forms. Key Oral Health Messages for Pregnant Women · Brush teeth twice daily with a fluoride toothpaste and floss daily. Suggestions for Pregnant Women with Nausea and Vomiting Instruct pregnant women who are experiencing morning sickness to: · Eat small amounts of nutritious food throughout the day. Moreover, prenatal periodontal therapy is associated with the improvement of maternal oral health. This assessment should include interviewing the patient using the following protocol. Ask Oral Health Questions the following two interview questions are recommended for incorporation into the initial prenatal visit. Advise Pregnant Women On the Need for Oral Health Care · If the last dental visit took place more than six months ago or if any oral problems. Refer Pregnant Women for Dental Care · Dental Referrals: Provide referrals as needed. Summary Doc Referral form for Pregnant women to receive oral health care) · Dental Referral Network: Provide a list of dentists in the community, including those who accept Medicaid and other public insurance programs. Medical history should be taken and evaluated to identify predisposing conditions that may affect treatment, patient management, and outcomes. Such conditions include, but are not limited to, diabetes, hypertension, pregnancy, smoking, substance abuse and medications, or other existing conditions that impact traditional dental therapy (Kumar J, Samelson R, eds. Topics to cover: (National Consensus Statement) · When and where was your last dental visit? Determine Weeks of Gestation (due date) · First trimester, defined as starting at the first day of the last menstrual period and continuing until 13 weeks and six days, is when organogenesis, development of the organs, takes place. Technically, the conceptus is called an embryo until the ninth week, when it becomes a fetus. It is during the embryonic period when the risk of teratogenicity, the ability to cause birth defects, exists. Performing dental care during early pregnancy has never been reported to increase the rate of malformations in infants. Criteria for prescribing antibiotics for bacterial endocarditis are the same for pregnant women as they are for all individuals (Wilson et al, 2007). Oral Assessment For adults there are a number of factors that contribute to caries risk such as: · Visible cavities · Many multi surface restorations · Exposed root surfaces · Deep pits/fissures on teeth · Radiographic lesions · Visible heavy plaque on teeth · Saliva reducing factors (medications/radiation/systemic) · Dietary history that includes frequent exposures to carbohydrates and frequent snacking and acidic beverages such as soda. Utilizing historical and clinical findings gathered in a caries risk assessment will aid the dental professional in identifying risk factors in order to develop an individualized preventive approach. Protective factors include: access to fluoridated water, use of fluoridated toothpaste, adequate salivary flow, use of fluoride mouth rinse, and use of xylitol gum/mints (Featherstone, 2007). Community Water Fluoridation the consumption of fluoridated water is a recognized protective factor for preventing dental decay. Hypertensive Disorders of Pregnancy Dental professionals should be knowledgeable of hypertensive disorders because of increased riskof bleeding during procedures and should consult the prenatal care provider before initiating dental procedures in women with uncontrolled severe hypertension (Kumar J, Samelson R, eds. This evolving paradigm in the treatment of chronic diseases, such as periodontal diseases, not only identifies the existence of disease and its severity, but also considers factors that may influence future progression of the disease. The challenge of periodontal disease is that it can progress silently, often without pain or overt symptoms that would alert the patient to its presence. Therefore, a key component of the clinical exam is a complete periodontal probing, which measures the crevice depth around each tooth. If it is determined that treatment is needed, several key factors need to be considered in the development of a treatment plan. These include: · Chief complaint (if any) · Medical history · History of tobacco, alcohol or other substance abuse · Findings from the clinical evaluation, including the gingival and periodontal examination · Findings from radiographs when needed · Restorative dental service options · Safe administration of drugs In some cases diagnostic X-rays need to be used during pregnancy as part of the treatment plan. Current evidence suggests that there is not increased risk to the fetus with regard to congenital malformation, growth retardation or abortion from ionizing radiation at a dose of less than five rad. Steps should include: · Develop a plan for treatment of dental needs, maintenance of optimal health, and prevention strategies based on benefits, risks and alternatives · Provide a timeline to complete all necessary dental procedures prior to delivery · Provide for emergency care any time during pregnancy as indicated by oral condition · Develop strategies to reduce maternal cariogenic bacterial load. Possible strategies include: Use fluoride toothpaste and mouth rinse depending upon access to a public fluoridated water system Use of chlorhexidine mouth rinse and fluoride varnish as appropriate Use of chewing gum or mints that contain xylitol Treatment of periodontal disease · Recommend tobacco cessation. Choices from these groups provide important nutrients for the mother and developing baby. An excellent resource for eating healthy during pregnancy is available at the March of Dimes Website. Most medications prescribed for common diseases can be used with relative safety (with a few notable exceptions like thalidomide and aspirin) because there have been few adverse drug reports. Moreover, the untreated disease or condition itself may pose more serious risks to both mother and fetus than any unsubstantiated risks from the medications. Antibiotics and Analgesics Dentists typically use antibiotics and analgesics for treating infection and controlling pain. Pharmaco-therapeutics should not be a substitute for appropriate and timely dental procedures. Drugs such as aspirin, aspirin containing products, erythromycin estolate and tetracycline should be avoided during pregnancy. May be used during pregnancy Avoid During Pregnancy Never Use During Pregnancy Always use for indicated medical conditions and with appropriate supervision. Acetaminophen Acetaminophen with codeine, May be used during pregnancy hydrocodone, or oxycodone Oral pain can often be managed with non-opioid Codeine medication. If opioids are used, prescribe the lowest dose Hydrocodone for the shortest duration (usually less than 3 days), and avoid issuing refills to reduce risk for dependency. Meperidine Morphine Aspirin Ibuprofen Naproxen May be used in short duration during pregnancy; 48 to 72 hours. Avoid in 1st and 3rd trimester Adapted, with permission, from Oral Health During Pregnancy Expert Work Group. Lidocaine with epinephrine prolongs the length of anesthesia because the drug is absorbed slowly. No scientific studies, however, could be found to confirm this effect in pregnant women.
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The disease epidemic typhus is much more common among people living in crowded and unhygienic conditions symptoms quadriceps tendonitis purchase norpace without prescription, which facilitate spread of the body lice from one person to medications given to newborns order norpace 100mg free shipping another symptoms 5 days before missed period generic norpace 100mg line. Such condition is commonly seen during wars, famines, and natural disasters as people live closely together. Recrudescent typhus this condition was seen in some patients treated with antibiotics and has been apparently cured of the disease. Improper or incomplete antibiotic therapy, poor general health, and malnutrition are some of the risk factors that may predispose a person to recrudescence. The presentation of this disease is less severe and mortality is much lower than the epidemic typhus. Culture Chapter 48 Rickettsiae are highly infectious pathogens; therefore, isolation of these pathogens from clinical specimens is carried out only in the laboratory equipped with high safety provision. Key Points Rickettsiae isolation is carried out in male guinea pigs or mice by inoculating the clinical specimen intraperitoneally (Table 48-2). The response of animals to different rickettsial infections may vary: Epidemiology Epidemic typhus is a disease known since ancient times. Geographical distribution Epidemic typhus is present in Central and South America, Africa (Ethiopia and Nigeria), Northern China, and in India. Rickettsia causing rocky mountain spotted fever causes fever and scrotal necrosis in guinea pigs. Smears from peritoneum, tunica, and spleen of the infected animals may be stained by Giemsa and Gimenez methods to detect these pathogens. Reservoir, source, and transmission of infection Humans are the primary reservoir of the epidemic typhus and are the sources of infection. The rickettsiae in these infected cell lines are identified by immunofluorescence, using group-specific and strain-specific monoclonal antibodies. Isolation of rickettsia in the eggs or chick embryos is usually not followed for primary isolation of rickettsia from clinical specimens. Tetracycline and chloramphenicol are the drugs of choice for the treatment of epidemic typhus. Antibiotic therapy in combination with treatment of louse infestation of the human host is effective. Serodiagnosis WeilFelix test: this is a heterologous agglutination test used since long for diagnosis of rickettsial infections. The test detects antirickettsial antibodies that cross-react with O antigens of certain nonmotile strains of Proteus. Reactions of WeilFelix test in other rickettsial infections are summarized in Table 48-3. Complement fixation test, indirect hemagglutination, indirect immunofluorescence, latex agglutination, and enzyme immunoassay are the other tests, which employ rickettsial antigens for demonstration of rickettsial antibodies for diagnosis of rickettsial infections including R. Properties of the Bacteria and Pathogenesis and Immunity the morphology, cultural characteristics, and pathogenesis of the disease caused by R. The condition has a sudden onset of symptoms with fever, headache, malaise, and myalgia. The rash is typically present on the chest and abdomen but may spread to palms and soles. The endemic typhus differs from epidemic in being a mild illness of shorter duration, associated with few complications and case fatality rate less than 1%. The control measures are essentially based on the control of rodent population and flea population in the area endemic for disease. Epidemiology the murine typhus occurs in many parts of the world particularly in subtropical temperate coastal areas. Rat flea (Xenopsylla cheopis) or cat flea (Ctenocephalides felis) are the main vectors responsible for the transmission of disease. Endemic or flea-borne murine typhus is transmitted from rats to rats by a rat flea and accidentally to humans by the feces of infected fleas. These infected fleas may subsequently transmit the disease to humans during act of biting. During bite, they transmit the disease by direct inoculation or indirect inoculation of the infected feces into the site of the bite. The infection can also be transmitted by inoculation or inhalation of aerosolized infectious specimens. The infection may also be transmitted by ingestion and food contaminated with infected rat urine or flea feces. Spotted Fever Group Spotted fever group of rickettsial diseases include: Rocky Mountain spotted fever caused by Rickettsia rickettsiae, Rickettsial pox caused by R. They also multiply in the nucleus as well as in the cytoplasm of the infected cells. A total of 12 species of rickettsiae have been associated with humans causing spotted fever and seven species have been isolated from arthropod vectors. A single titer of 1:128 or a fourfold rise in antibody titer in paired sera is diagnostic of the disease. Rocky Mountain spotted fever was the first among the spotted fever group to be described. This disease was earlier called as Mediterranean disease and later boutonneuse fever by Connor who described this condition for the first time in 1910. Chapter 48 Key Points Neil Mooser or tunica reaction Properties of the Bacteria Morphology, culture, biochemical reactions, and other properties of R. They are small intracellular bacteria, which multiply in the cytoplasm of the infected cells. The animal is observed for the development of fever and a characteristic scrotal inflammation. In a positive test, the scrotum becomes enlarged and the testis cannot be pushed back into the layer of tunica vaginalis. The condition progresses to hypoalbunemia, hyponatremia, and hypovolemia due to loss of plasma into the tissues. Treatment Tetracycline, doxycycline, and chloramphenicol are highly effective in the treatment of endemic typhus. The condition is characterized by development of fever, severe headache, chills, and myalgia. A rash may develop after three or more days and typically appears initially on wrist, ankles, and palms and soles and then spreads to the trunk. The rash is maculopapular early in the disease but may later become petechial and hemorrhagic. This is a serious disease associated with many complications, such as respiratory failure, encephalitis, and renal failure. Direct detection of rickettsial antigen Reservoir, source, and transmission of infection Ticks are the natural hosts, reservoirs, and vectors of R. Different tick hosts are associated with the infection in different parts of the world. These vectors include the wood tick (Dermacentor andersoni) in the western United States and western Canada, the American dog tick (Dermacentor variabilis) in the eastern Canada and eastern United States, and Lone star tick (Amblyomma americana) in the southwestern United States. Rickettsia multiplies in these ticks and is transmitted transovarially to the next generation.
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Low labor and delivery volumes are a barrier to medicine journals impact factor purchase genuine norpace online analyzing and interpreting quality and performance measures among small and rural hospitals medicine 50 years ago order generic norpace. Funding relationships and participation incentives provided by the California Healthcare Foundation medications when pregnant purchase norpace 100 mg with mastercard, Blue Shield of California, California Medicaid, Healthcare Management Associates, the Yellow Chair Foundation, and the Robert Wood Johnson Foundation have also been essential to the sustainability of the program. Furthermore, the closest maternal-fetal medicine specialist was over four hours away. To address the diminishing access, Kearny County Hospital sought opportunities to expand its maternal health services, particularly for labor and delivery. The hospital leveraged several strategies to improve access to this care, including: · Building the cross-discipline maternal health workforce. Many of these providers were recruited after their residencies at Kearny County Hospital. The hospital also trains and utilizes mid-level providers to deliver care up to 32 weeks. This specialist not only provides care to pregnant women, he also provides ongoing training and support to local providers to improve their ability to care for high-risk pregnancies. Harvard providers donated their time for this training and the Kearny providers received continuing education credits. The hospital has also focused on reaching out to the surrounding immigrant populations, which include immigrants and refugees from Somalia, Ethiopia, El Salvador, Ecuador, Guatemala, Haiti, Burma, Vietnam, China, and Kenya. Kearny County Hospital has employed multiple strategies to engage women within the region in perinatal care. The hospital received a $100,000 grant from Tyson Foods to place care coordinators in its plants to better engage patients, including pregnant women who need prenatal care. The hospital is also collaborating with the Kansas Department of Health and Environment and the March of Dimes to implement group prenatal care modeled after the Becoming a Mom program. The hospital has implemented virtual support programs for women in their prenatal and postpartum periods using Facebook, and weight management coaching through the National Diabetes Prevention Program Improving Access to Maternal Health Care in Rural Communities Issue Brief 41 using Zoom Meetings. Results As a result of these efforts to improve its maternal health services, Kearny County Hospital has experienced the following results: · Increased volume of births from 100 deliveries a year to 300350 deliveries a year, which indicates the successful provision of labor and delivery care to women from nearby counties · Reduction in births of babies that were large for gestational age from 28% to 17% · Increase in breastfeeding rates by 30% Barriers Kearny County Hospital had consistently experienced barriers related to financial sustainability of its services. In 2018 the hospital was able to turn a profit, although its maternal health services were not a strong contributor to this financial turnaround. Hospital representatives noted that the Critical Access Hospital model creates a disincentive for the hospital to provide maternity services because it cannot include maternity-related costs in its Medicare Cost Report. Costs related to training and support for labor and delivery nurses also have to be included on a separate ledger from the Medicare Cost Report. Telemedicine and Other Innovations · Establish mechanisms or funding opportunities to support partnerships between academic medical centers and rural providers to conduct training via telemedicine. CenteringPregnancy of South Carolina · Location: Multiple locations in South Carolina · Organization Type: Technical Assistance Program for Group Prenatal Care · Community Characteristics: Population: 4,625,364 in 2010 (1,557,555 in rural communities); Largest Industry: Aerospace and Aviation, Automotive Manufacturing Description of the Program or Practice CenteringPregnancy of South Carolina is a subset of the larger Centering Healthcare Institute that provides a group prenatal care model for pregnancy. The South Carolina implementation of CenteringPregnancy began in 2012 at the Greenville Health System and has expanded to 24 sites (22 sites are currently operating) across South Carolina. CenteringPregnancy leveraged several strategies to improve access to this care, including: · Providing technical assistance and creating a collaboration network in South Carolina. Using grant funding from the March of Dimes, the program coordinator can provide training, technical assistance, and materials to rural implementation sites free of charge. The coordinator has also hosted CenteringPregnancy convenings for the participating sites to share challenges and best practices in person, although these meetings have recently been less frequent due to challenges in scheduling time for a large group of providers. Because many rural implementation sites experience lower volumes of pregnant women than recommended for a robust experience, several sites have structured their cohorts to include women with due dates across two months rather than just one. Among these cohorts, providers have experimented with creating smaller groups of women with closer due dates, although this is not consistent with the traditional CenteringPregnancy model. To address this barrier, the March of Dimes is working with the Centering Healthcare Institute to design another model of group prenatal care that may be more effective with rural women. CenteringPregnancy of South Carolina has worked with organizations like the Georgia Health Policy Center and the University of South Carolina to collect, analyze, and publish data related to the impacts of the CenteringPregnancy model on maternal health outcomes in South Carolina. However, because of the low volume of women participating in rural sites, these findings cannot be dissected by urban and rural distinctions. Improving Access to Maternal Health Care in Rural Communities Issue Brief 43 Results As a result of these efforts to improve maternal health services in South Carolina, CenteringPregnancy has experienced the following results: · Improved maternal health outcomes, including lower rates of preterm birth, low-weight babies, caesarian deliveries, and gestational diabetes. Barriers CenteringPregnancy faces significant barriers to sustainability in South Carolina. Low volumes of pregnant women within rural communities make it difficult to achieve the required number of women (812) within each CenteringPregnancy cohort. Furthermore, some women have voiced concerns with engaging in a group model for prenatal care, due to stigma and privacy concerns, and would prefer to retain care with their individual provider despite enhanced outcomes documented for the Centering model. Additionally, implementing and maintaining the CenteringPregnancy program requires immense buy-in from leaders and providers, which is often difficult to achieve and sustain in rural areas because of provider turnover. Enhanced reimbursements provided by Medicaid and Blue Cross Blue Shield often do not cover the costs of implementing the program, particularly lost provider time, costs of maintaining a group classroom, and costs of providing materials, refreshments, and incentives. Furthermore, providers that already receive an enhanced payment for being a Rural Health Center or Critical Access Hospital must choose between receiving their enhanced payments for rural designation or an enhanced CenteringPregnancy payment. CenteringPregnancy of South Carolina has also experienced barriers in trying to modify its program to meet the needs of rural providers. Telemedicine solutions are not yet feasible for this program because of push-back in adoption by providers and reduced engagement among participants. One site aims to implement the program across multiple locations, including provider clinics that will initiate prenatal care in early and late gestational ages, while the hospital provides care during CenteringPregnancy visits in the second and parts of the third trimester. There are concerns related to reimbursement and continuity of care throughout the prenatal period. Facilitators CenteringPregnancy of South Carolina relies on its partnership with and funding from the March of Dimes to support training, technical assistance, and materials for the program. Achieving enhanced payments through South Carolina Medicaid and Blue Cross Blue Shield of South Carolina has made the program more sustainable among providers. Improving Access to Maternal Health Care in Rural Communities Issue Brief 44 For one site in Dillon, South Carolina, facilitators for their program include providing incentives. The residency program aims to increase access to maternal health services by: · Increasing training and education opportunities related to rural disparities among medical students. The addition of the rural training track has improved exposure to and understanding of the barriers that rural communities experience in accessing maternal health services. In addition, the medical school is offering a one-month health disparities course for all students, which includes an examination of rural/urban disparities. Many residents not specifically assigned to rural locations are opting to have one of their rotations held in a rural hospital. By placing medical residents in rural training institutions, both the residents and the rural providers obtain access to maternal-fetal medicine specialists based within the medical school. The program has used telemedicine to care for highrisk obstetric patients in rural settings, and in the future, the department is going to host a Thursday morning didactic with rural providers and residents on maternal morbidity and mortality using telemedicine technologies. Other partnerships with the Wisconsin Health Collaborative, Medical College of Wisconsin, and Aurora University have also improved collaboration and sharing of best practices among workforce training programs. Nevertheless, the residency program has achieved the following: · Increased interest among medical students to participate in a rural training track, as either a rotation or residency location.
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Information to symptoms yeast infection women 150 mg norpace pregnant women would need to symptoms whiplash order cheap norpace line focus on early reporting to medicine used to treat chlamydia buy norpace 100 mg on-line a health facility at the first signs of pregnancy complications such as preterm uterine contractions, premature rupture of membranes and symptoms of preeclampsia or any other complication. In case the drug is to be given, safe injection practices for administrating injections should be followed. If the mother is in true labour give recommended prereferral dose of steroids as given in the flow chart* 2. In case the referral is not possible complete the course of antenatal steroid and contact the nearest health facility 4. In case the delivery is imminent prepare for delivery and resuscitation of the baby 5. If possible delay labour for at least 24 hours for Dexamethasone to have effect or for a period in which the fetus gets maximum benefit of antenatal steroids (within 7 days). Tocolysis (Delaying the labour) is to be done if gestation is more than 24 weeks upto 34 weeks after excluding risk factors like frank infection, pre-eclampsia and diabetes. Labour is allowed to progress in conditions where delay in delivery may worsen the maternal medical status. The service provider must ensure all findings related to maternal morbidities are mentioned on the case sheet or on the referral slip if the patient is being referred to a higher facility. While referring a preterm newborn the service provider must ensure the full documentation both in the case sheet and referral slip. The provider also requires to be aware of the following important aspects of referral: Provide relevant, immediate information regarding referral to parents/relatives in simple and practical language which may require repetition for the parents to understand. The ambulance (102/108) should have the following requirements if using transport incubator: Secure fixation for the transport incubator, oxygen and air tanks, monitoring power source and necessary adapters for power source to supplement equipment etc. Independent equipment batteries to ensure uninterrupted operation of the equipment. If between 24-34 weeks then Check whether the pregnant woman is in true preterm labour using the table* given below: If the pregnant woman is in true labour Delivery imminent Give one dose of Injection Dexamethasone as described in the box** and prepare for delivery and neonatal resuscitation If the pregnant woman is not in true labour Observe for the symptoms, discharge if the symptoms resolve with advice to report immediately if danger signs appear. If symptoms do not resolve, treat her as in true preterm labour and follow the chart. Tocolysis (delay of uterine contractions) is to be done under medical supervision. Arrange for delivery, resuscitation and care of preterm baby **Dexamethasone protocol Dose/injection Route Interval No. Felt first in the lower back and sweeps around to the abdomen in a wave pattern 3. Role of antenatal corticosteroids in reducing morbidity and mortality in preterm births is well established 2. A single course comprising of four doses of Injection Dexamethasone to be given to all pregnant women going into preterm labour (24-34 weeks gestation) 4. Dose: Injection Dexamethasone 6 mg intramuscular repeated every 12 hours x 4 doses 5. Chorioamnionitis is an absolute contraindication to administer antenatal corticosteroids 6. Quality antenatal care, skilled attendance at birth, Kangaroo mother care for preterm and low birth weight babies will continue to contribute towards reducing the morbidity and mortality. State level orientation for all the stakeholders including private partners regarding the guidelines for use of Antenatal Corticosteroids to be organized. Ensure Injection Dexamethasone is listed in the essential drug list and is available at the facilities. The states must ensure regular procurement and availability of Injection Dexamethasone at all delivery points including sub-centres. The services of the members/trainers may be utilized for Capacity building/Mentoring at the facilities if needed. Ensure emphasizing on the key messages of the guidelines during teaching and trainings. During these meetings a feedback on the usage of the drug will also be taken once it gets implemented. Regular monitoring of supplies to avoid any stock out situations and corrective actions to be taken if such a situation arises. The state and the districts within, must ensure that all the high caseload delivery points especially Medical Colleges, District Hospitals and Sub District Hospitals are oriented towards these guidelines first as they will be catering to a large population and will also be serving as training centres. Safe injection practices and bio medical waste management are to be an integral part of the teaching. Logistics the states to ensure the supplies of Injection Dexamethasone at all the delivery points up to the sub-centre level. The drug does not require refrigeration and can be easily stored at room temperature. The supply of drug is to be estimated for 10% of all the deliveries conducted at the delivery point. Ensure regular monitoring of stocks to provide timely feedback to districts to avoid stock out situations. The message to ensure availability in the drug tray of the labour room should be communicated. The key indicators described below should be compiled at the district level on monthly basis to measure the effective implementation of the guideline. Data will be compiled at the state level quarterly and reviewed before sharing at the national level. Antenatal Corticosteroids to Reduce Neonatal Morbidity (Green-top 7) Royal College of Obstetricians and Gynaecologists. According to these criteria, the diagnosis could be made using the combination of at least one of the clinical criteria and the biological presence of an anti-phospholipid antibody using a reference method. At clinical level · · Thrombosis: One or more symptomatic episodes of arterial or venous thrombosis or thrombosis in the vessel of any tissue/organ. Obstetric manifestations: One or more unexplained morphologically normal fetal deaths after at least week 10 of gestation; one or many premature births of a morphologically normal newborn before week 34 of gestation following an eclampsia or known signs of placental deficiency or at least three consecutive spontaneous miscarriages before week 10 of gestation without any anatomical or maternal hormonal causes and without maternal or paternal chromosomal causes. The therapeutic option was a combination of acetyl salicylic acid and low molecular weight heparin. The success rate of the treatment was 97% full-term pregnancies against 12% without treatment. They are found usually in low quantities in 5 to 10% of the general population and up to 50% among the elderly. At such low rates these antibodies are rarely associated with clinical manifestations. Several studies showed that the presence of antiphospholipid antibodies is associated with an increase risk of miscarriage or fetal death [2-4]. Indeed, the impact of the presence of anti-phospholipid antibodies varies from 10 to 20% in women with a history of at least two spontaneous miscarriages with no apparent causes. Pregnant women who have anti-phospholipid antibodies and a history of fetal loss or repeated miscarriage are at very high risks of recurrence. There are two theoretical therapeutic approaches: elimination of the antiphospholipid antibodies and/or impediment of their thrombogenicactivity .
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In the second or third trimester medications affected by grapefruit cheap 100mg norpace with visa, the patient should lay on her left side to 10 medications that cause memory loss buy generic norpace avoid compression of the inferior vena cava by the gravid uterus medicine 2 order norpace 150mg online. Hypotension should be avoided as it may result in decrease perfusion to the fetus. The goal of desensitization protocols is to allow these individuals to be transplanted using a donor kidney that would otherwise not be usable due to the high likelihood of graft loss. Allograft rejection has traditionally focused on T cell mediated process causing cellular rejection. Recipients at higher risk include those with previous transplant and high panel-reactive antibodies. Current management/treatment New immunosuppressive drugs are continually being developed to prevent and treat acute renal allograft rejection, and to decrease antibody titers. The optimal regimen has yet to be defined but include the use of cyclosporine, tacrolimus, mycophenolate mofetil, azathioprine, and antithymocyte globulin. In addition, some case series use other immunosuppressives such bortezomib (proteasome inhibitor). Immunosuppressive drugs, such as rituximab, glucocorticsteroids, mycophenolate mofetil, and tacrolimus, are initiated at the start of the protocol. These antibodies can be removed with plasma exchange, double filtration plasmapheresis, lymphoplasmapheresis, and immunoabsorbtion. Therapeutic apheresis is always in combination with other immunosuppressive drugs, such as antithymocyte globulin glucocorticosteroids, rituximab, and intravenous immunoglobulin. Case series since 1985 have shown improvement when plasma exchange is used in patients with acute vascular rejection in combination with a variety of anti-rejection medications. The most characteristic feature is an inflammatory synovitis, usually involving peripheral joints in a symmetric distribution. Current management/treatment the goals of therapy are relief of pain, reduction of inflammation, protection of articular structures, maintenance of function, and control of systemic involvement. The current therapeutic interventions are palliative, not curative, and are aimed primarily at relieving signs and symptoms of the disease. There is clinical improvement and frequently an improvement in serologic evidence of disease activity. In intent-to treat analysis of all 99 patients who were randomized, the corresponding response rates were 29% and 11%. Thus, the precise mechanism of action remains unclear and is probably multifactorial. Plasma is treated by perfusion through the column and then reinfused with the flow rate not exceeding 20 mL/min. Common adverse effects include fatigue, chills, low-grade fever, musculoskeletal pain, hypotension, nausea, vomiting and short-term flare in joint pain and swelling following treatment. Serious adverse events reported were cutaneous vasculitis or rash which necessitates temporary discontinuation of the procedures until it is resolved. Volume treated: 1,200 mL plasma Replacement fluid: not applicable Duration and discontinuation/number of procedures Frequency: once a week for 12 weeks In most studies, clinical improvement was delayed for up to few weeks after completing the procedures. The severity of visceral disease determines survival as it affects critical organs [e. A state of chronic ischemia caused by an injury to endothelial cells in small arteries, arterioles, and capillaries precedes fibrosis. D-Penicillamine is the most widely used drug and has been shown in a retrospective study to improve the skin thickening and survival of patients, when compared to no treatment. In rapidly progressive disease, corticosteroids, azathioprine, methotrexate, cyclophosphamide, and other immunosuppressants have been used. However, no medications appear to be truly effective in patients with aggressive disease. A clinical benefit was observed in total of 46 patients who underwent high dose chemotherapy followed by autologous hematopoietic progenitor cell salvage. There is no known circulating factor, pivotal in pathogenesis of this disease, which could be easily identified and removed. Nevertheless, there are several controlled trials as well as case series spanning over the last 20 years. A controlled trial of 23 patients randomized to no apheresis, plasma exchange, or lymphoplasmapheresis was reported in 1987 as an abstract. Both treatment groups showed statistically significant improvement in skin score, physical therapy assessment, and patient and physician global assessment. All serological markers improved in comparison to the control group; however, there was no difference in clinical outcomes between the groups. Severe gastrointestinal symptoms were ameliorated in 4 patients, severe polymyositis was largely reversed in 2 patients, and pulmonary and cardiac function was improved in others. A course of six procedures over the course of 23 weeks should constitute a sufficient therapeutic trial. The incidence of sepsis has increased over the last two decades with an unchanged mortality rate of 2850%. Signs and symptoms consist of fever or hypothermia, tachycardia, hyperventilation, and leukocytosis or leukopenia. Risk factors include age extremes, chronic medical conditions, immune compromise, indwelling catheters and devices, and disruption of natural defense barriers. Production of a wide variety of inflammatory molecules can lead to organ dysfunction or an anti-inflammatory response resulting in an immunocompromised state. Current management/treatment Management includes antimicrobial agents and control of the source of the infection, hemodynamic support including volume and vasopressors, oxygenation and ventilatory support, and avoidance of complications. These therapies seek to interrupt the cascade of inflammation and anti-inflammatory response. Rationale for therapeutic apheresis Attempts to block or remove single mediators of sepsis have been somewhat successful. When differences between the control and experimental groups were considered using multiple logistic regression, the significance of the treatment variable on mortality was p50. A trial by Reeves et al using continuous plasmafiltration examined 22 adults and 8 children. No difference in mortality was seen between the control group and those treated with plasmafiltration. This resulted in the trial being stopped early due to the interim analysis showing significant improvement in the treatment group. In the presence of severe coagulopathy, plasma alone is indicated as a replacement fluid. Because these patients are severely ill with hypotension and cardiovascular instability, treatment should be performed in an appropriate setting, such as an intensive care unit, and the patients monitored closely. A randomized trial of 70 patients found a 54% survival in the treatment arm compared to a 36% survival in the control arm. A case series of 99 patients, survival of 66% was seen compared to an expected survival of 20%. These patients received treatments lasting two hours though the frequency and total volume treated were not given. While infection is the most common cause of death in children, pulmonary hypertension is the most common cause of death in adults.
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Many American Indian and Alaska Native women seek care from the Indian Health Service or tribal health centers medications januvia buy norpace 100 mg fast delivery, which often do not offer the full range of maternal health services 5 medications discount norpace 150mg with amex, in some cases medicine 014 generic 150mg norpace with amex, due to challenges related to recruiting and retaining maternal health care providers. Addressing these needs may not be sufficient to eliminate racial and ethnic disparities experienced by women of color living in rural communities. As demonstrated by the National Healthcare Quality and Disparities Report, issued annually by the Agency for Healthcare Research and Quality, improvements in health care quality do not always result in reductions of racial and ethnic disparities. Improving Access to Maternal Health Care in Rural Communities Issue Brief 23 It is essential that federal, states, regional, and local organizations engage a cross-section of stakeholders from the community to inform the development and implementation of programs and policies aimed at maternal health care for women living in rural areas. It is also essential for systems to evaluate their programs in an effort to build the evidence base, and for evidence-based or evidenceinformed strategies to be tested in rural contexts. Unfortunately, communities of color and tribal communities are frequently left out of the conversations related to rural America. This resource helps health systems improve their data collection, staff training, and patient, family, and community engagement to address racial and ethnic disparities among their populations. These measures are provider-level in contrast to the current state-level Medicaid Core set. The Maternal Mortality Review Data System has included a set of contextual measures (termed socio-spatial indicators) related to the health service environment, reproductive and behavioral health, and social and economic factors that are intended to demonstrate the link between maternal mortality and health equity within individual communities. There are promising community-driven initiatives that could be employed and tested in rural areas. The case studies address several of the factors contributing to problems accessing maternal health care in rural communities, including workforce shortages and access to care challenges associated with social determinants of health. They illustrate efforts to stabilize rural hospital obstetrical services, regionalization and coordination of care, quality improvement initiatives, training and guideline development, provider recruitment and retention strategies, and expansion of care models. The experience of these organizations highlights policy and structural changes that could be adopted to improve access to maternal health services in rural communities. Most of these organizations reported difficulty recruiting and retaining maternal health providers, low patient volume for maternal services, and disincentives or barriers related to reimbursement of maternal health services. Yet they overcame these barriers with unique strategies, such as partnering with community or state associations, collaborating with urban or academic providers, or using telehealth and other innovations. High-level summaries of the case studies follow in the narrative below with full profiles provided in Appendix C. A summary of which barriers each organization aimed to address is included in Table 2. Summary of Barriers Addressed in Each Case Study Social Determinants of Health X X 25 Insurance Coverage Workforce Supply and Distribution Hospital Closures Case Study Summary Matsu Midwifery. Birth center, family health center, and functional medical clinic with flexible schedules and multiple services to accommodate patients and families. State-based program aimed at improving access to and the quality of maternal health services within Arkansas. Multistakeholder collaboratives specifically designed to improve the quality of maternal health services through quality improvement activities and a maternal health e-learning platform for provider professional development. X X X X X X X X Improving Access to Maternal Health Care in Rural Communities Issue Brief Health Disparities X X X Access to Care Quality Case Study Summary Kearny County Hospital. Education to family medicine providers in the provision of perinatal care, including labor and delivery services; partnerships with foundations and universities in training and quality improvement activities; inperson and virtual prenatal care. Rural residency program aimed at expanding the maternal health workforce in rural Wisconsin. Matsu Midwifery is a birth center, family health center, and functional medical clinic located in Wasilla, Alaska, that provides services to women across a large area. With a 150-mile catchment area, the center has implemented several strategies to improve access to and engagement in perinatal care. While most of the surrounding Alaska Native population seeks care at a nearby hospital dedicated to this population, Matsu Midwifery aims to address disparities among the patients who choose to seek care from the birth center by actively supporting patients at risk for perinatal depression. As a result of these efforts, Matsu Midwifery reduced perinatal anxiety, postpartum depression, and feelings of isolation among its patients; and facilitated quick and successful transfers from the birth center to the local hospital during emergencies. It has established incentives programs for organizations that participate in quality improvement activities and provided a maternal health e-learning platform for provider professional development. It also aims to improve its data collection to better understand experiences of bias in health care settings and perception of health care among communities of color, namely Black women. As multiple hospitals surrounding Lakin, Kansas, closed their obstetric units, women in the nearby counties had less access to prenatal care and labor and delivery services. At the same time, this population also had high rates of gestational diabetes (approximately twice the national average), and type 2 diabetes after birth. To address these issues, Kearny County Hospital has provided continued education to family medicine providers in the provision of perinatal care, including labor and delivery services; partnered with foundations and universities in training and quality improvement activities; and increased access to in-person and virtual prenatal care. It also established relationships via targeted programming with local refugee communities to build trust among these populations. All these efforts resulted in an increased volume of births, reduction in births of babies that were large for gestational age, and an increase in breastfeeding initiation. CenteringPregnancy of South Carolina is a subset of the larger Centering Health care Institute that provides a group prenatal care model for pregnant women. Implementation of CenteringPregnancy of South Carolina began in 2012 at the Greenville Health System and has expanded to 24 sites (22 sites are currently operating) across the state. Rural sites, in particular, tend to experience more challenges in program implementation, especially in engaging and retaining rural women due to barriers such as transportation, education about the importance of prenatal care, and limited provider capacity in smaller clinics or hospitals. CenteringPregnancy leveraged several strategies to improve access to maternal health care across each of these sites, including providing technical assistance and creating a collaboration network in South Carolina, establishing enhanced payments for CenteringPregnancy services, designing alternative versions of CenteringPregnancy to increase sustainability among rural programs, and fostering maternal health research in South Carolina. As a result of these efforts to improve maternal health services in South Carolina, CenteringPregnancy has experienced improved maternal health outcomes including lower rates of preterm birth, low-weight babies, cesarean sections, and gestational diabetes; higher rates of breastfeeding initiation among participants; and implementation, sustainment, and collaboration among 22 CenteringPregnancy sites across the state, including urban and rural communities. In 2017, the University of Wisconsin Department of Obstetrics and Gynecology established a rural residency program aimed at expanding the maternal health workforce in rural Wisconsin. In its two years of existence, the program has seen an increased interest among medical students to participate in a rural training track as either a rotation or residency position, increased interest from rural hospitals and providers to serve as preceptors for rural residents, and increased collaboration among rural providers and academic medical institutions for consultations and continued education. These access disparities result in worse health outcomes for rural women and their babies, with American Indian and Alaska Native women and women of color suffering disproportionately. To directly address these challenges, stakeholders across the health system and in rural communities have developed creative solutions to address some of the gaps in maternal health care. Improving maternal health and health care in rural communities will require cross-sector efforts at the federal, regional, state, and local levels. Such a system will ensure that all women and their babies have access to the maternal health services they need and have better outcomes. Closure of Hospital Obstetric Services Disproportionately Affects LessPopulated Rural Counties. The case studies illustrate efforts to stabilize rural hospital obstetrical services, regionalization and coordination of care, quality improvement initiatives, training and guideline development, provider recruitment and retention strategies, and expansion of care models. It includes a midwifery clinic, family health center, and functional medicine clinic. The birth center leveraged several strategies to improve access to its care, including: · Establishing a flexible schedule and providing multiple services to accommodate patients and families. The providers also do their best to coordinate with families so that all members.