bluuebunny/crossref_metadata_2025 huggingface dataset:
Pregnancy Basics
Authors: Mathiesen Amber , Roy Kali
Published: May 2018

This chapter provides background on pregnancy concepts that are essential to understand when working in the perinatal setting. Topics include pregnancy timeline and duration, the difference between gestational and embryonic age, methods for establishing an expected due date, and tools for assisting with pregnancy dating, including pregnancy wheels and online tools. General pregnancy care topics are also addressed, including types of obstetric providers; common lab tests including the complete blood count, blood type, antibody testing, and HbA1C; and imaging including the first-, second-, and third-trimester ultrasounds as well as specialized evaluations such as a nuchal translucency and fetal magnetic resonance imaging (MRI). Last, there is a explanation with examples of how to document a pregnancy history by gravidity and parity.
Prenatal Screening
Authors: Mathiesen Amber , Roy Kali
Published: May 2018

This chapter provides information about a genetic counselor’s role in prenatal screening, including discussing and offering options to a patient, interpreting and providing results, or managing referrals based on abnormal results. It discusses how a screen is evaluated using sensitivity, specificity, positive predictive value, negative predictive value, and personal utility. It provides a detailed description of both maternal serum screening and cell-free DNA testing. The maternal serum screening discussion includes information on multiples of median, calculating risk, timing, pattern association, limitations, and follow-up. The review of cell-free DNA testing includes fetal fraction, methodology, test performance, limitations and considerations for testing, and follow-up. This chapter also provides a list of additional resources to use for cell-free DNA testing.
Pain Management
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Adequate pain control has a high priority. In any acute neurologic pain syndrome it must be assumed that pain management is possible, effective, and simple; unfortunately, most patients in pain have been poorly managed. The pharmacopeia of pain management is growing and changing and several trends have been noted. Pain is underreported in the intensive care unit and should be treated when indicated. Acetaminophen is often the first agent used in pain management. Next are weak narcotic analgesics which could have less severe side effects than stronger opioid analgesics. This chapter discusses types of pain in the neurosciences intensive care unit and specific pharmacologic approaches.
Osmotic Therapy
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Osmotic drugs are ubiquitously used in neurocritically ill patients. Mannitol and hypertonic saline are readily available in emergency departments and intensive care units to reduce intracranial pressure. Mannitol depletes and hypertonic saline expands the volume status. Hyperosmolar fluids increase the intravascular osmolality, draw water from the brain, reduce or temporize shift, and reduce globally increased intracranial pressure from any cause. These osmotic fluids change fluid compartments and cannot be used indiscriminately. Particularly when they are administered regularly, close monitoring is needed and target goals should be set. This chapter discusses triggers for the use of these osmotic agents, how to judge their effect, and how to dose adequately.
Anticoagulation and Reversal Drugs
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Management of anticoagulation, is a common practice. This chapter discusses best approaches, heparin choices, and safety issues. Anticoagulation is required in immobilized patients in the neurosciences intensive care unit to prevent deep venous thrombosis and the more consequential pulmonary embolus. There are very few strong indications for anticoagulation in ischemic stroke and exceptions are discussed. Reversal of anticoagulation is also needed in some patients and certainly in patients with recent significant trauma or spontaneous hemorrhages. Current reversal protocols require intravenous vitamin K, fresh-frozen plasma, and more often, prothrombin complex concentrate. Reversal of the effect of the direct oral anticoagulants is more difficult but options are discussed.
Antifibrinolytics and Thrombolytics
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

There is a balance between activation of the coagulation cascade leading to thrombin and the fibrinolytic system dissolving clots. Antifibrinolytic drugs and fibrinolytic drugs are commonly used in the neurosciences intensive care unit. Antifibrinolytics, mostly tranexamic acid, are used to prevent rebleeding of recently ruptured intracranial aneurysms because fibrinolysis is considered the main mechanism of rebleeding. Drugs resulting in fibrinolysis are commonly used in vascular medicine and in cardiology. In acute ischemic stroke with disability, intravenous alteplase is the main fibrinolytic drug, and there is proof of its benefit. Both fibrinolytic and antifibrinolytic drugs are frequently initiated in the emergency department where patients are seen first. The current use, mechanisms, and targets of these medications are reviewed in this chapter.
Immunosuppression and Immunotherapy
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Immune modulation in the neurosciences intensive care unit mostly involves high-dose corticosteroids, plasma exchange, and immunoglobulin. Corticosteroids are frequently used in patients with neurologic complications of cancer. Neurosurgeons typically use corticosteroids after performing a craniectomy to reduce cerebral edema. Corticosteroids are the established initial treatment modality of choice for patients with acute metastatic epidural spinal cord compression. Therapeutic apheresis or immunoglobulin is generally used as supportive therapy in patients with Guillain-Barré syndrome, myasthenia crisis, and autoimmune encephalitis. Immune modulation has been considered essential in autoimmune encephalitis despite lack of controlled clinical trials. In these now better characterized disorders, a combination of corticosteroids, intravenous immune globulin (IVIG), plasma exchange, rituximab, or cyclophosphamide are used. The use of acute immunotherapy and precautionary measures are discussed in this chapter.
Vasopressors and Inotropes
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Vasopressors and inotropes are used in the neurosciences intensive care unit to treat hypotension and to augment blood pressure. Hypotension can be attributed to abnormal cardiac output, abnormal intravascular volume or abnormal systemic vascular resistance. Vasopressors are needed to manage hemodynamic augmentation in patients with severe cerebral vasospasm and aneurysmal subarachnoid hemorrhage, in patients with critical carotid or basilar artery stenosis producing marginal blood flow, or when patients are maintained in drug-induced comas. The main incentive is to maintain adequate perfusion pressure to the brain and vital organs, particularly the kidneys. This chapter provides the essentials of management of these complex drugs and how to avoid unintended side effects.
Drugs to Correct Electrolyte Disorders
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Critically ill patients develop electrolyte imbalances, and replacement orders are daily practice. Knowing how to manage sodium imbalances in both neurocritical care and neurosurgical practices is imperative. Changes in serum sodium values are very common in acute neurocritical illness, and these derangements are important not only because the patient’s level of consciousness may change but because they may signal a neurologic change. This chapter discusses how to replace common electrolyte replacements and offers more detailed information about the management of disorders of sodium and water homeostasis, including the use of vaptans, which are reserved for patients with difficult-to-manage euvolemic or hypervolemic hyponatremia.
Antidotes with Overdose
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

In contrast to general intensive care units, the neurosciences ICU admits fewer cases of incidental overdoses with illicit or prescribed drugs than cases of adverse drug effects. Overdoses of illicit drugs can be seen in conjunction with traumatic brain injury and anoxic-ischemic injury. In fact, the illegal drug is often the main culprit in the acute brain injury. Alcohol intoxication remains frequent and the intoxication signs depressing brain function may merge with clinical signs of an acute structural brain injury. This chapter discusses toxins causing laboratory abnormalities, first treatment considerations, and antidotes, including commonly used drugs for detoxification. When available, antidotes for toxidromes are provided. The chapter also summarizes the neurology of drug overdose.
Drugs Used to Treat Withdrawal Syndromes
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

This chapter covers the treatment of withdrawal syndromes associated with alcohol, opioids, stimulants, baclofen, and nicotine. The approach to refractory withdrawal delirium is discussed, as well as the management of serious withdrawal syndromes that are neurology-specific, such as baclofen withdrawal. Withdrawal syndromes are serious and may require extensive pharmacotherapy. The safety of the patient must be balanced against the risks and side effects of the medications administered to control the agitation. Prior alcoholism accounts for the overwhelming proportion of patients with withdrawal syndromes. The drugs used for treatment of alcohol withdrawal syndrome include benzodiazepines, dexmedetomidine, and propofol. The prevalence of opioid withdrawal is increasing.
Treatment of Brain Injury-Associated Symptoms and Signs
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Acute neurologic disease results in a myriad of minor and major symptoms, some of which are partly specific to the nature of the illness. Symptom relief for acutely ill neurologic patients requires medication orders. Treatment of these symptoms is not without adverse effects, and regular use of opioids to treat severe headaches may very often lead to opioid-induced constipation, which may progress to adynamic ileus. This chapter focuses on, nausea and vomiting, hiccups, secretion control, constipation, fever and shivering, and rhabdomyolysis. Large volumes of emesis or secretions can easily cause aspiration and mucus plugging of large bronchial branches. Drug regimens are discussed in detail.
Drugs Used in Neurorehabilitation
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Neurologic rehabilitation arguably starts in the neurosciences intensive care unit. Specialized care is often needed in acute spinal cord injury, particularly if long-term care appears imminent. Much of neurorehabilitation is done without pharmaceuticals, but good options are available in patients with persistent disorders of consciousness, spasticity, and early depression after stroke. Disorders of consciousness are major concerns in neurorehabilitation centers because they obviate traditional rehabilitation programs. Improvement can be achieved with a neurostimulant which would improve attention span to therapy This chapter discusses dopaminergic agents and other neurostimulants for disorders of consciousness and long-term drugs for spasticity to improve outcomes.
The Madness of Fear
Authors: Shorter Edward , Fink Max
Published: May 2018

This is the first history of the psychiatric illness called catatonia, virtually forgotten by medicine yet often present in severely ill patients. The main symptoms of catatonia affect movement and thought, including staring, stupor, mutism, food refusal, negativism, and even psychosis. These symptoms are age-old, but they were brought together in the single term “catatonia” by German psychiatrist Karl Kahlbaum in 1874. Yet, 30 years later, catatonia disappeared from view as an independent illness, turned into a “subtype” of dementia praecox (schizophrenia). There, catatonia remained submerged from view for almost a century, rediscovered again as a disease of its own in the 1990s. Today, catatonic symptoms are seen in around one in ten admissions to a psychiatric emergency department. Untreated, catatonia may have a fatal outcome. Interest today has been increasing because of the discovery that, unlike schizophrenia, catatonia responds readily to therapy, with the symptoms vanishing without a trace. The authors argue that catatonia may be a response to fear and alarm triggered by trauma; during a stupor, patients often experience terrifying images and thoughts. Edward Shorter is a medical historian who has written widely about psychiatry. Max Fink is a clinician whose writings on melancholia, catatonia, and convulsive therapy have been internationally recognized.
Catatonia Before Kahlbaum
Authors: Shorter Edward , Fink Max
Published: May 2018

The symptoms of catatonia—stupor, staring, mutism, food refusal, grimacing, negativism, odd movements, rigidity, posturing, “waxy flexibility,” and stereotypies—have always existed. But they were described under different terms, such as catalepsy, acute delirium, hysteria, and “homesickness” and were not linked together as part of the same disorder. People once had a terrible fear of being buried alive, for example, dreading that stuporous catatonia might be misrecognized as death. Yet what people considered “demonic possession” has almost always been viewed in medicine as a group of legitimate illnesses—different illnesses with different treatments, such as catalepsy, ecstasy, stupor, tics, chorea, and melancholia.
Emil Kraepelin
Authors: Shorter Edward , Fink Max
Published: May 2018

Emil Kraepelin, professor of psychiatry first in Heidelberg then Munich, originated modern psychiatric diagnosis. So it was a fateful error when, in 1899, Kraepelin made catatonia a “subtype” of schizophrenia (which Kraepelin called “dementia praecox”). He did so on the basis of what Kraepelin considered a downhill course and outcome. Catatonia thus disappeared into the schizophrenia tent and ceased to be an independent disease entity. There it remained for the next century. It was because of Kraepelin’s immense prestige that his disease classification has survived virtually until the present. Kraepelin thus saved catatonia from extinction as a diagnosis, but at the cost of ensuring that it would be diagnosed only in “schizophrenics.” Clinicians who did not think their patients had schizophrenia would miss the catatonia diagnosis.
Psychology
Authors: Shorter Edward , Fink Max
Published: May 2018

In a debate about a possible psychology of catatonia, those who argued that patients’ minds were blank during stupor vied against those who saw that stuporous patients were filled with fear and apprehension. The latter won out. It became clear that sometimes a fearful or traumatic event itself sufficed to trigger catatonia. The “blank slate” school were led by Karl Kleist in Frankfurt and a group of German neurologists. Karl Leonhard, an acolyte of this school, authored an elaborate classification of catatonia. The “fear and apprehension school” were led by a number of psychologically minded psychiatrists in Germany and France. A wide international variety of clinical observations confirm the role of fear, including the formation of catatonic symptoms in people experiencing extreme stress.
Symptoms and Diagnoses
Authors: Shorter Edward , Fink Max
Published: May 2018

Even as researchers became aware that the neuroleptic drug–induced neurotoxic syndrome was best treated as catatonia, signs of catatonia were found more often among depressed and manic populations than among the schizophrenic. Catatonia as a sign of schizophrenia was challenged, with calls for catatonia to be recognized as a systemic independent syndrome. In 1987, James Lohr and Alexander Wisniewski laid a heavy thumb on the independent-disease side of the scales in a book, citing evidence that catatonia represents a distinct entity, but that it should be diagnosed on the basis of motor signs alone. These challenges questioned the connection of catatonia to schizophrenia. The increasing reports of deaths as a consequence of treating catatonia with potent neuroleptics stimulated interest in effective treatments and forced the separation of catatonia from schizophrenia.
Biologics registries
Authors: Isenberg David , Zink Angela
Published: May 2018

Double-blind controlled trials undertaken over the past two decades have established the short-term effectiveness and side-effect profile of biologic drugs for patients with rheumatoid arthritis and related diseases. However, the development of biologics registers to capture ’real-life experience’ and explore long-term effectiveness and complications is equally important. In this chapter, we demonstrate how these registers have identified long-term joint benefits, a reduction in cardiovascular mortality, reassurance concerning fears about cancer development, and a balanced view of the risk of infection.
Fungal arthritis
Authors: Kemper Carol A. , Deresinski Stanley C.
Published: May 2018

Fungal infections of the musculoskeletal system are uncommon and diagnosis is often delayed. Infection is more common in the immunocompromised patient. The most important infections are due to candida species, Histoplasmosis capsulatum, Blastomycosis dermatiditis, and Coccidioides immitis. Amphotericin B remains the initial therapeutic agent of choice for many serious fungal infections, especially for those who are severely immunosuppressed, have life-threatening or central nervous system disease, or who have failed azole therapy.
Anti-phospholipid antibody syndrome
Authors: Khamashta Munther A. , Hughes Graham R. V. , Ruiz-Irastorza Guillermo
Published: May 2018

The anti-phospholipid syndrome (APS) described almost 30 years ago, is now recognized as a major cause of deep vein thrombosis, stroke, and heart attacks in young people (<45 years of age). It is also the commonest treatable cause of recurrent miscarriages and a major cause of late fetal death. Other clinical manifestations are cardiac valvular disease, livedo reticularis, renal thrombotic microangiopathy, thrombocytopenia, haemolytic anaemia, epilepsy, and cognitive impairment.
The presence of anti-phospholipid antibodies (aPL) has been closely related to the development of thrombosis and complications in pregnancy. However, not all patients with aPL will develop the clinical features. Lupus anticoagulant is generally thought to be more strongly associated with the risk of clinical manifestations of APS than anticardiolipin and anti ?2-glycoprotein I antibodies.
The exact pathogenic mechanisms leading to thrombosis and/or pregnancy morbidity are poorly understood. Therapy of thrombosis is based on long-term oral anti-coagulation and patients with arterial events should be treated aggressively. Obstetric care is based on combined medical-obstetric high-risk management and treatment with aspirin and heparin.
Sjögren’s syndrome—management
Authors: Ng Wan-Fai , Vissink Arjan , Theander Elke , Figueiredo Francisco
Published: May 2018

Management of Sjögren’s syndrome (SS) encompasses confirmation of diagnosis, disease assessment, and treatment of glandular and systemic manifestations including special situations such as pregnancy and SS-related lymphoma. The American European Consensus Group (AECG) classification criteria 2002 are the current gold standard for the diagnosis of SS. Salivary gland sialometry, sialochemistry, and ultrasound and tear osmolarity may be useful adjuncts. Recently, preliminary classification criteria of the American College of Rheumatology have been introduced as an alternative to the AECG criteria. Symptoms of SS are non-specific and must be actively explored. When assessing patients with SS, it is important to consider not only objective parameters such as abnormalities in blood tests and changes in tear and salivary flow, but also patient-reported outcome measures and impact on quality of life. Current management of patients with SS is hampered by the lack of evidence-based strategies. The symptoms experienced by patients with SS are often not fully appreciated by clinicians, which may contribute to the suboptimal management of the condition. Management of fatigue remains a major challenge and a holistic, multidisciplinary approach is recommended. Factors that may contribute to fatigue should be fully addressed. Recent advances in the understanding of the pathogenic mechanisms of SS have informed more targeted therapeutic strategies with some promising data. Optimal management of SS requires expertise from different disciplines. Combined clinics with rheumatology, oral medicine, and ophthalmology input will improve care and communications as well as reduce the number of clinic visits for patients and healthcare-related cost. Effective link between pSS specialists, dentists, opticians, and general practitioners will facilitate early diagnosis and reduce risk of long-term disability of SS.
Hard state neutron star and black hole X-ray binaries in the radio:X-ray luminosity plane
Authors: Gallo Elena , Degenaar Nathalie , van den Eijnden Jakob
Published: May 2018

Motivated by the large body of literature around the phenomenological properties of accreting black hole (BH) and neutron star (NS) X-ray binaries in the radio:X-ray luminosity plane, we carry out a comparative regression analysis on 36 BHs and 41 NSs in hard X-ray states, with data over 7 dex in X-ray luminosity for both. The BHs follow a radio to X-ray (logarithmic) luminosity relation with slope β = 0.59 ± 0.02, consistent with the NSs’ slope ($\beta =0.44^{+0.05}_{-0.04}$) within 2.5σ. The best-fitting intercept for the BHs significantly exceeds that for the NSs, cementing BHs as more radio loud, by a factor ∼22. This discrepancy cannot be fully accounted for by the mass or bolometric correction gap, or by the NS boundary layer contribution to the X-rays, and is likely to reflect physical differences in the accretion flow efficiency, or the jet powering mechanism. Once importance sampling is implemented to account for the different luminosity distributions, the slopes of the non-pulsating and pulsating NS subsamples are formally inconsistent (>3σ), unless the transitional millisecond pulsars (whose incoherent radio emission mechanism is not firmly established) are excluded from the analysis. We confirm the lack of a robust partitioning of the BH data set into separate luminosity tracks.
Simulating the Role of the Parent: Promoting Family-Centered Nursing Care
Authors: Zimmermann Elizabeth , Alfes Celeste M.
Published: May 2018

Parents of hospitalized children need support to diminish their own fear and anxiety and provide safe and loving care for the child. Baccalaureate nursing students, who are rarely parents themselves, often find it difficult to understand the needs of parents. An innovative simulation strategy was created to enhance students’ understanding of the parent’s role and its effect on family-centered care. This article describes the development of pediatric simulation experiences that actively incorporate the role of a parent. Portraying the parent during the simulation increases students’ ability to be empathetic while providing safe family-centered care.
Variation in Neonate Swaddling Techniques
Authors: Fletcher Laura , Pham Tammy , Bar Sari , Li Diana , Spinazzola Regina , Papaioannou Helen , Milanaik Ruth
Published: May 2018

Background:

It is common practice for healthcare practitioners to swaddle infants in newborn nursery and neonatal intensive care unit settings. Despite the widespread use of this practice, the American Academy of Pediatrics neither bans nor recommends swaddling. To date, there has been no standard protocol developed for either healthcare professionals or parents to establish optimal swaddling techniques in terms of infant arm positioning, infant leg positioning, and tightness of wrap.

Purpose:

To evaluate the variability in swaddling techniques used for infants in the newborn nursery and neonatal intensive care unit.

Methods:

Across 2 pediatric hospitals, the swaddling positioning of each open-crib infant in the newborn nursery and neonatal intensive care unit was examined. For each infant, the following data were collected: gender, left and right arm position, left and right leg position, and tightness of wrap.

Results:

In total, 132 swaddle observations were recorded. There was significant variability in swaddling positioning of arms and legs. The most common combination of arm/leg positioning was “mixed arm positioning” and “both legs flexed” (25.0% of all observations). In 9.1% of cases, tightness of wrap around chest was “tight,” and in 30.3% of cases, tightness of wrap around legs was “tight.”

Implications for Practice:

There was a large variability in swaddling positioning of both arms and legs. For such a widespread practice, the lack of medical guidelines results in inconsistent, and potentially harmful, positioning. Parents and healthcare professionals would benefit from specific, research-driven guidelines regarding proper swaddling techniques.

Implications for Research:

Different variations on swaddling should be evaluated for consideration of best practice swaddling.
Management of Labor and Delivery After Fetoscopic Repair of an Open Neural Tube Defect
Authors: Kohn Jaden R. , Rao Vibha , Sellner Allison A. , Sharhan Dina , Espinoza Jimmy , Shamshirsaz Alireza A. , Whitehead William E. , Belfort Michael A. , Sanz Cortes Magdalena
Published: May 2018

OBJECTIVE:

To report labor, delivery, and neonatal outcomes in a cohort of women delivering neonates who had undergone fetoscopic neural tube defect repair.

METHODS:

We conducted a retrospective cohort study from April 2014 to January 2018. All patients met Management of Myelomeningocele Study eligibility criteria. We included patients with completed second-trimester fetoscopic neural tube defect repair (laparotomy, uterine exteriorization, and minimally invasive access through two or three uterine ports) followed by standardized management of labor and delivery at our institution. Outcomes included rates of vaginal delivery, term delivery, and intrapartum cesarean delivery as well as obstetric and neonatal outcomes after oxytocin. Complications of interest included preterm prelabor rupture of membranes, chorioamnionitis, uterine dehiscence or rupture, 5-minute Apgar score less than 7, and neonatal acidosis (umbilical artery pH less than 7.15).

RESULTS:

Thirty-four patients had fetoscopic repair, followed by 17 vaginal deliveries (50%, 95% CI 32–68%). Median gestational age was 38 1/7 weeks at vaginal delivery (range 26 0/7–40 2/7 weeks of gestation) and 37 1/7 weeks of gestation at cesarean delivery (range 25 5/7–40 5/7 weeks of gestation); 62% of deliveries occurred at term. Eight patients had prelabor cesarean delivery: three nonurgent and five urgent (for nonreassuring fetal heart tracings). Twenty-six patients labored; six were induced and 20 labored spontaneously. Of the latter, five were augmented. Of 26 laboring patients, 17 delivered vaginally and nine underwent urgent cesarean delivery (35%, 95% CI 17–56%; seven nonreassuring fetal heart tracings and two breech). There were no cases of uterine rupture or dehiscence. Most (94%, 95% CI 80–99%) had normal 5-minute Apgar scores; one neonate (3%, 95% CI 0–15%) had acidosis but normal Apgar scores.

CONCLUSION:

Our data regarding trial of labor, use of low-dose oxytocin, and vaginal delivery after prenatal fetoscopic neural tube defect repair are reassuring. Importantly, fetoscopic repair may permit delivery at advanced gestational ages.
Decreased Surgical Site Infection Rate in Hysterectomy
Authors: Andiman Sarah E. , Xu Xiao , Boyce John M. , Ludwig Elizabeth M. , Rillstone Heidi R. W. , Desai Vrunda B. , Fan Linda L.
Published: May 2018

OBJECTIVE:

We implemented a hysterectomy-specific surgical site infection prevention bundle after a higher-than-expected surgical site infection rate was identified at our institution. We evaluate how this bundle affected the surgical site infection rate, length of hospital stay, and 30-day postoperative readmission rate.

METHODS:

This is a quality improvement study featuring retrospective analysis of a prospectively implemented, multidisciplinary team-designed surgical site infection prevention bundle that consisted of chlorhexidine-impregnated preoperative wipes, standardized aseptic surgical preparation, standardized antibiotic dosing, perioperative normothermia, surgical dressing maintenance, and direct feedback to clinicians when the protocol was breached.

RESULTS:

There were 2,099 hysterectomies completed during the 33-month study period. There were 61 surgical site infections (4.51%) in the pre–full bundle implementation period and 14 (1.87%) in the post–full bundle implementation period; we found a sustained reduction in the proportion of patients experiencing surgical site infection during the last 8 months of the study period. After adjusting for clinical characteristics, patients who underwent surgery after full implementation were less likely to develop a surgical site infection (adjusted odds ratio [OR] 0.46, P=.01) than those undergoing surgery before full implementation. Multivariable regression analysis showed no statistically significant difference in postoperative days of hospital stay (adjusted mean ratio 0.95, P=.09) or rate of readmission for surgical site infection-specific indication (adjusted OR 2.65, P=.08) between the before and after full-bundle implementation periods.

CONCLUSION:

The multidisciplinary implementation of a gynecologic perioperative surgical site infection prevention bundle was associated with a significant reduction in surgical site infection rate in patients undergoing hysterectomy.
Obstetric Management of Loeys-Dietz Syndrome
Authors: Russo Melissa L. , Sukhavasi Neelima , Mathur Veena , Morris Shaine A.
Published: May 2018

BACKGROUND:

Loeys-Dietz syndrome is associated with arterial tortuosity and aortic dissection. Pregnancy may be a period of increased risk for aortic dissection.

CASE:

A 16-year-old primigravid girl was referred to our center with a family history of aortic dissection. Loeys-Dietz syndrome was suspected, and genetic testing confirmed the TGFβ2 (c.988C>T) mutation. A cesarean delivery was performed at 36 weeks of gestation, with no cardiovascular complications. In this case, the uterine vessels were significantly tortuous; this may be an additional finding in Loeys-Dietz syndrome.

CONCLUSION:

Women with Loeys-Dietz syndrome warrant special consideration in obstetric management secondary to the risk for aortic dissection. It is recommended that a multidisciplinary team with knowledge about connective tissue disorders and expertise in aortic surgery coordinate maternal obstetric and cardiovascular care.
Patterns of von Willebrand Disease Screening in Girls and Adolescents With Heavy Menstrual Bleeding
Authors: Jacobson Amanda E. , Vesely Sara K. , Koch Terah , Campbell Janis , O'Brien Sarah H.
Published: May 2018

OBJECTIVE:

To estimate the frequency of von Willebrand disease screening and factors that affect screening frequency in a national sample of girls and adolescents with heavy menstrual bleeding.

METHODS:

In this retrospective cohort study, we used a national claims database for privately and publicly insured patients between 2011 and 2013 for girls aged 10–17 years. Diagnostic criteria of heavy menstrual bleeding were the presence of one inpatient or two outpatient International Classification of Diseases, 9th Revision codes for heavy menstrual bleeding. We defined severe heavy menstrual bleeding as heavy menstrual bleeding plus an inpatient stay for menstrual bleeding, iron deficiency anemia, or blood transfusion. To assess whether patient- or facility-level characteristics affected screening, we performed logistic regression analysis including patient age, health care provider type seen at first visit for menorrhagia, patient residence in a metropolitan statistical area (proxy for urban vs rural inhabitance), and approximate travel time to the nearest hemophilia treatment center.

RESULTS:

We identified 23,888 postpubertal girls and adolescents with heavy menstrual bleeding (986 with severe heavy menstrual bleeding). Von Willebrand disease screening was performed in 8% of females with heavy menstrual bleeding and 16% with severe heavy menstrual bleeding. Younger age at diagnosis, commercial insurance, and living within a metropolitan statistical area were associated with higher screening rates. Patients who underwent testing for iron deficiency anemia had the highest likelihood of undergoing screening (odds ratio 7.08, 95% CI 6.32–7.93). Among patients living in a metropolitan statistical area, those 60 minutes or more from a hemophilia treatment center were less likely to undergo screening.

CONCLUSION:

Despite recommendations by the American College of Obstetricians and Gynecologists for more than 15 years, fewer than 20% of postpubertal girls and adolescents with heavy menstrual bleeding underwent screening for von Willebrand disease in this cohort. Increased clinician awareness and adherence to recommended screening recommendations may increase diagnosis of von Willebrand disease.
Variation in the Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rate
Authors: Pasko Daniel N. , McGee Paula , Grobman William A. , Bailit Jennifer L. , Reddy Uma M. , Wapner Ronald J. , Varner Michael W. , Thorp John M. , Leveno Kenneth J. , Caritis Steve N. , Prasad Mona , Saade George , Sorokin Yoram , Rouse Dwight J. , Blackwell Sean C. , Tolosa Jorge E. ,   for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network
Published: May 2018

OBJECTIVE:

To estimate the contributions of patient and health care provider–hospital characteristics to the variation in the frequency of nulliparous, term, singleton, vertex cesarean delivery in a multi-institutional U.S. cohort.

METHODS:

We performed a secondary analysis of the multicenter Assessment of Perinatal Excellence cohort of 115,502 mother and neonatal pairs who were delivered at 25 hospitals between March 2008 and February 2011. Women met inclusion criteria if they were nulliparous and delivered a singleton in vertex presentation at term. Hospital ranks for nulliparous, term, singleton, vertex cesarean delivery frequency were determined after risk adjustment. The fraction of variation in nulliparous, term, singleton, vertex cesarean delivery frequency attributable to patient and health care provider–hospital characteristics was assessed using hierarchical logistic regression.

RESULTS:

Of the 115,502 deliveries in the initial cohort, 38,275 nulliparous, term, singleton, vertex deliveries met inclusion criteria. The median hospital nulliparous, term, singleton, vertex cesarean delivery frequency was 25.3% with a range from 15.0% to 35.2%. The majority of hospitals (16/25) changed rank quintiles after risk adjustment; overall the changes in rank were not statistically significant (P=.53). Patient characteristics accounted for 24% of the nulliparous, term, singleton, vertex cesarean delivery variation. The analyzed health care provider–hospital characteristics were not significantly associated with cesarean delivery frequency.

CONCLUSION:

Although patient characteristics accounted for some of the variation in nulliparous, term, singleton, vertex cesarean delivery frequency and accounting for case mix had implications for hospital cesarean delivery rankings, the majority of the variation was not explained by the characteristics evaluated. These findings emphasize the importance of continued efforts to understand aspects of obstetric care, including case mix, that contribute to cesarean delivery variation.
Clinical Comparison of Surgical Constructs for Anterior Cervical Corpectomy and Fusion in Patients With Cervical Spondylotic Myelopathy or Ossified Posterior Longitudinal Ligament
Authors: Niedzielak Timothy R. , Palmer Joseph , Malloy John P.
Published: May 2018

Study Design:

This is a systematic review and meta-analysis.

Objective:

To examine the differences in outcomes among current constructs and techniques for anterior cervical corpectomy and fusion (ACCF) in patients with single or multiple level cervical myelopathy (CM) secondary to cervical spondylosis or ossified posterior longitudinal ligament.

Summary of Background Data:

The natural history of CM can be a progressive disease process. In such cases, where surgical decompression is indicated to halt the progression, ACCF is typically chosen for pathology located posterior to the vertebral body. Numerous studies have shown that decompression with appropriate stabilization not only halts progression, but also improves patient outcomes. However, several constructs are available for this procedure, all with variable outcomes.

Materials and Methods:

A systematic review was conducted using Cochrane Database, Medline, and PubMed. Only studies with a minimum patient population of 10, reporting on CM because of cervical spondylosis or ossified posterior longitudinal ligament were included; a minimum follow-up period of 12 months and 1 clinical and/or radiographic outcome were required. Studies examining patients with cervical trauma/fracture, tumor, and infection or revision cases were excluded. Data analysis was carried out with Microsoft Excel.

Results:

A total of 30 studies met the inclusion criteria for qualitative analysis, while 26 studies were included for quantitative analysis. Constructs that were reported in these studies included titanium mesh cages, nano-hydroxyapatite/polyamide 66 composite struts, bone graft alone, expandable corpectomy cages, and polyetheretherketone cages. Clinical outcomes included Japanese Orthopaedic Association and modified Japanese Orthopaedic Association scores, Visual Analog Scale scores, Neck Disability Index scores, and Nurick grades. Radiographic outcomes included C2–C7 and segmental Cobb angles and pseudarthrosis rates. Each construct type had variable and unique benefits and shortcomings.

Conclusions:

ACCF is a common surgical option for CM, despite carrying certain risks expected of any anterior cervical approach. Several constructs are available for ACCF, all with variable clinical and radiographic outcomes.
Cardiac Arrest in Patients Managed for Convulsive Status Epilepticus: Characteristics, Predictors, and Outcome
Authors: Legriel Stephane , Bresson Edouard , Deye Nicolas , Grimaldi David , Sauneuf Bertrand , Lesieur Olivier , Lascarrou Jean-Baptiste , Argaud Laurent , Chelly Jonathan , Beuret Pascal , Schnell David , Chateauneuf Anne-Laure , Holleville Mathilde , Perier François , Lemiale Virginie , Bruel Cedric , Cronier Pierrick , Pichon Nicolas , Mongardon Nicolas , de-Prost Nicolas , Dumas Florence , Cariou Alain
Published: May 2018

Objectives:

Cardiac arrest is a catastrophic event that may arise during the management of convulsive status epilepticus. We aimed to report the clinical characteristics, outcomes, and early predictors of convulsive status epilepticus–related cardiac arrest.

Design:

Retrospective multicenter study.

Setting:

Seventeen university or university affiliated participating ICUs in France and Belgium.

Patients:

Consecutive patients admitted to the participating ICUs for management of successfully resuscitated out-of-hospital cardiac arrest complicating the initial management of convulsive status epilepticus between 2000 and 2015. Patients were compared with controls without cardiac arrest identified in a single-center registry of convulsive status epilepticus patients, regarding characteristics, management, and outcome.

Interventions:

None.

Measurements and Main Results:

We included 49 cases with convulsive status epilepticus–cardiac arrest and 235 controls. In the cases, median time from medical team arrival to cardiac arrest was 25 minutes (interquartile range, 5–85 min). First recorded rhythm was asystole in 25 patients (51%) and pulseless electrical activity in 13 patients (27%). A significantly larger proportion of patients had a favorable 1-year outcome (Glasgow Outcome Scale score of 5) among controls (90/235; 38%) than among cases (10/49; 21%; p = 0.02). By multivariate analysis, independent predictors of cardiac arrest were pulse oximetry less than 97% on scene (odds ratio, 2.66; 95% CI, 1.03–7.26; p = 0.04), drug poisoning as the cause of convulsive status epilepticus (odds ratio, 4.13; 95% CI, 1.27–13.53; p = 0.02), and complications during early management (odds ratio, 11.98; 95% CI, 4.67–34.69; p < 0.0001). Having at least one comorbidity among cardiac, respiratory, and neurologic (other than epilepsy) conditions predicted absence of cardiac arrest (odds ratio, 0.28; 95% CI, 0.10–0.80; p = 0.02).

Conclusions:

In patients managed for convulsive status epilepticus, relative hypoxemia, on-scene management complications, and drug poisoning as the cause of convulsive status epilepticus were strong early predictors of cardiac arrest, suggesting areas for improvement.
Spiritual care in cancer patients: a need or an option?
Authors: Ripamonti Carla I. , Giuntoli Federico , Gonella Silvia , Miccinesi Guido
Published: May 2018

Purpose of review

Because of cancer is generally perceived as a life-threatening illness, patients often develop spiritual needs upon the diagnosis. Spirituality impacts patient quality of life (QoL) and provides a context in which to derive hope and meaning to cope with illness. The goal of this review is to give an overview of the most relevant studies with a focus on the relationship between spiritual well being, QoL and hope in patients with cancer, in addition to exploring the importance of spiritual issues both for patients and healthcare professionals.

Recent findings

Spiritual well being with its dimensions of faith, meaning, and peace is a central component for the overall QoL. A strong spiritual well being decreases symptom severity, the level of hopelessness and the desire for hastened death in cancer patients. However, in the medical setting the provision of spiritual care remains poor, although patients, especially at the end of life, would like their spiritual needs to be addressed as part of the global care.

Care for cancer patients goes beyond just caring for the person's body. The assessment of spiritual/religious needs can be considered the first step in designing needs-tailored interventions.
Serum exosomal microRNAs as potent circulating biomarkers for melanoma
Authors: Tengda Li , Shuping Long , Mingli Gu , Jie Guo , Yun Liu , Weiwei Zhang , Anmei Deng
Published: May 2018

Exosomes are small homogenous membrane vesicles that derive from the exocytosis process of cells and can contain DNA, microRNAs (miRNAs), and/or proteins. Characterization of the content profile of exosomes may reflect the state of the cells that release them, and this could be predictive of disease. In this study, to explore the potential biomarkers for melanoma, we isolated serous exosomes from 30 patients with melanoma and 30 healthy individuals using the ultracentrifugation method. Five miRNAs were subsequently detected in each sample by quantitative reverse transcription-PCR: miRNA-532-5p, miRNA-106b, miRNA-200c, miRNA-199a-5p, and miRNA-210. Only the levels of exo-miRNA-532-5p and exo-miRNA-106b differed between the two groups (Z=−4.17 and −4.57, respectively, P<0.0001). When these two miRNAs were evaluated individually and in combination in 95 melanoma patients and 95 healthy individuals serum samples, the area under the receiver operating characteristic curve values were 0.867, 0.820, and 0.936, respectively. Furthermore, in blinded tests of samples from 25 melanoma patients and 25 healthy individuals, this panel of miRNAs identified 23/25 patients with melanoma (92.0% sensitivity) and 22/25 healthy individuals (88.0% sensitivity). Our exo-miRNA panel also distinguished patients with metastasis from those without metastasis, patients with stage I–II disease from those with stage III–IV disease, and patients who had received pembrolizumab treatment from those who were untreated. Overall, these results indicate that serum exosomal miRNAs, especially exo-miRNA-532-5p and exo-miRNA-106b, have the potential to be used for monitoring and/or a diagnosis of melanoma in a clinical setting.
Vemurafenib in BRAF-mutant metastatic melanoma patients in real-world clinical practice: prognostic factors associated with clinical outcomes
Authors: Schouwenburg Maartje G. , Jochems Anouk , Leeneman Brenda , Franken Margreet G. , van den Eertwegh Alfons J.M. , Haanen John B.A.G. , van Zeijl Michiel C.T. , Aarts Maureen J. , van Akkooi Alexander C.J. , van den Berkmortel Franchette W.P.J. , Blokx Willeke A.M. , de Groot Jan Willem B. , Hospers Geke A.P. , Kapiteijn Ellen , Koornstra Rutger H. , Kruit Wim H. , Louwman Marieke W.J. , Piersma Djura , van Rijn Rozemarijn S. , Suijkerbuijk Karijn P.M. , ten Tije Albert J. , Vreugdenhil Gerard , Wouters Michel W.J.M. , van der Hoeven Jacobus J.M.
Published: May 2018

The aim of this population-based study was to identify the factors associated with clinical outcomes in vemurafenib-treated patients and to evaluate outcomes across subgroups of patients with different risk profiles. Data were retrieved from the Dutch Melanoma Treatment Registry. Time to next treatment (TTNT) and overall survival (OS) of all metastatic melanoma patients who received vemurafenib between 2012 and 2015 were assessed using Kaplan–Meier estimates. A risk score was developed on the basis of all prognostic factors associated with TTNT and OS derived from multivariable Cox regression analyses. Patients were stratified according to the presence of prognostic risk factors by counting the number of factors, ranging from 0 to 6. A total of 626 patients received vemurafenib with a median follow-up of 35.8 months. The median TTNT and OS were 4.7 months [95% confidence intervals (CI): 4.4–5.1] and 7.3 months (95% CI: 6.6–8.0). The strongest prognostic factors were serum lactate dehydrogenase (LDH) level, Eastern Cooperative Oncology Group performance score, number of organ sites involved and brain metastases. Patients with a favourable risk profile (no risk factors) had a median TTNT and OS of 7.1 (95% CI: 5.8–8.5) and 15.4 months (95% CI: 10.0–20.9). The median OS more than halved for patients with greater than or equal to 2 risk factors compared with patients with no risk factors. The clinical outcomes of vemurafenib in metastatic melanoma patients with a favourable risk profile are comparable with the results of the trials. Combining prognostic factors into a risk score could be valuable to stratify patients into favourable and poor-prognosis groups.