bluuebunny/crossref_metadata_2025 huggingface dataset:
Accuracy of Visual Estimation of Blood Loss in Obstetrics Using Clinical Reconstructions: An Observational Simulation Cohort Study
Authors: Athar M.W. , Abir G. , Seay R.C. , Guo N. , Butwick A. , Carvalho B.
Published: February 2023

(Int J Obstet Anesth. 2022;50:10359)

Postpartum hemorrhage accounts for 27% of worldwide maternal deaths and is defined as blood loss ≥1000 mL or blood loss accompanied by hypovolemia after birth. Visually estimated blood loss (EBL) following delivery remains the most common method of measurement despite it being largely inaccurate. Previous studies reported that accurate and timely hemorrhage diagnosis occurred in a minority (31%) of cases. While delivery mode, distribution or location of blood loss, the patient’s cardiovascular status, or experience may impact accuracy, these have not been tested. This study investigated the relationship between these factors, EBL and actual blood loss (ABL) and contributing factors between differences in EBL and ABL.
Obstetric Analgesia and Anaesthesia in SARS-CoV-2-positive Parturients Across 10 Maternity Units in the North-west of England: A Retrospective Cohort Study
Authors: Bhatia K.
Published: February 2023

(Anaesthesia. 2022;77:389–397)

At the onset of the COVID-19 pandemic, world health authorities recommended neuraxial (NA) over general anesthesia (GA) for infected parturients. The intent for risk reduction was 2-fold: to reduce the risks accompanying GA in parturients with acute respiratory symptoms, and to minimize SARS-CoV-2 exposure to health care teams. Initial retrospective studies have shown paradoxically both increased and decreased use of NA versus GA in different studies, but many having low numbers of participants. With no large-scale multi-center study of trends of labor analgesia in COVID-19-positive parturients, there is a need for understanding of these interventions and associated outcomes that can influence future recommendations.
COVID-19 Vaccination During Pregnancy: 2 for the Price of 1
Authors: Rasmussen S.A. , Jamieson D.J.
Published: February 2023

(N Engl J Med. 2022;387:178–179)

Studies have shown that maternal vaccination during pregnancy propagates the transfer of antibodies across the placenta to the infant. Coronavirus disease 2019 (COVID-19) is now being studied in this context. Safety recommendations have been encouraging the vaccination of pregnancy women to protect against COVID-19 based of historical trans-placenta benefits from vaccines during pregnancy.
Sleep-Disordered Breathing in High-risk Pregnancies is Associated With Elevated Arterial Stiffness and Increased Risk for Preeclampsia
Authors: Pahn K. , Pamidi S. , Gomez Y.H. , Gorgui J. , El-Messidi A. , Gagnon R. , Kimoff R.J. , Abenhaim H.A. , Daskalopoulou S.S.
Published: February 2023

(Am J Obstet Gynecol. 2022;226:833.e1–20)

Hormonal changes inherent in pregnancy can predispose women to sleep-disordered breathing that restrict airflow and can cause hypoxia. Snoring can be a sign of sleep-disordered breathing, and is also correlated with fetal growth restriction, gestational hypertension, and diabetes. Past studies have associated sleep-disordered breathing with preeclampsia, and arterial stiffness has been shown to be elevated in women who later develop preeclampsia, but prior studies have not studied the relationship. This study assessed the correlation between sleep-disordered breathing and arterial stiffness in women diagnosed with preeclampsia during pregnancy and investigated the association between sleep disordered breathing and preeclampsia.
Dural Puncture Epidural for Labor Analgesia: Is It Really an Improvement Over Conventional Labor Epidural Analgesia?
Authors: Segal S. , Pan P.H.
Published: February 2023

(Anesthesiology. 2022;136:667–669)

Continued innovations of the standard epidural technique have allowed for improvement of the quality of analgesia experienced by laboring women. The introduction of conventional neuraxial analgesia offered effective and safe pain relief to parturients, with relatively infrequent adverse outcomes, and is utilized in >73% of contemporary births in the United States. Procedural refinements over time have offered improvement in analgesia quality, including continuous local anesthetic infusions, optimizations of volume and concentrations of medications delivered, the addition of opioids to the injectate, timed bolus injections, and patient-controlled epidural analgesia. As protocol variations, both combined spinal-epidural and dural puncture epidural utilize a smaller spinal needle that is passed through the epidural needle. In combined spinal-epidural, small doses of opioid and local anesthetic are injected into the intrathecal (IT) space. With dural puncture epidural, the spinal needle is used to intentionally puncture the dura, but no drugs are injected. Initial evidence suggested improved analgesia with this technique over standard epidural and combined spinal-epidural, but the literature has produced mixed results since. In the same issue of this journal, Tan et al deliver results from a randomized clinical trial of obese parturients receiving dural puncture epidural vs conventional epidural to determine if analgesia quality is enhanced by dural puncture in this population at higher risk for epidural failure.
Labor Analgesia in Obese and Morbidly Obese Parturients: A Nationwide Register Analysis in Finland From 2004 to 2018
Authors: Kuitunen I. , Kekki M. , Ponkilainen V. , Huttunen T.
Published: February 2023

(Anaesthesia. 2022;77:351–353)

Maternal obesity rates are increasing, which is concerning for the short-term maternal and neonatal well-being during vaginal and cesarean delivery. A recent study found obese and morbidly obese parturients had increased use of neuraxial blocks compared to their nonobese counterparts (76% vs. 68%). Rates in Finland in 2018 were only 60%, so this study aimed to further analyze and report the use of labor analgesia in obese and morbidly obese parturients in Finland.
In-Hospital Opioid Consumption After the Previous Cesarean Delivery Weakly Predicts Opioid Consumption After Index Delivery: A Retrospective Cohort Study
Authors: Komatsu R. , Nash M. , Mandalia S. , Dinges E. , Kamal U. , Singh D. , El-Omrani H. , Anwar A. , Delgado C. , Ziga T.M. , Carvalho B.
Published: February 2023

(Anesth Analg. 2022;134:1280–1287)

Opioid administration is a common form of analgesia for breakthrough pain following cesarean deliveries when nonopioid medication is not sufficient. Pain severity can differ from patient to patient, so an individualized approach to care can be challenging. Predicting in-hospital opioid consumption following a repeat cesarean delivery requires study. The primary aim was to identify if prior opioid consumption 48 hours postoperatively following cesarean delivery correlates with patient opioid consumption following index cesarean delivery. The hypothesis was that an associated prediction would exist. Secondary aims included whether pain scores correlated and if obstetric and demographic variables improved prediction accuracy.
Non–immune-mediated Anaphylaxis to Synthetic Oxytocin During Labor
Authors: Srinivasan S.P.B. , Seth I. , Bulloch G. , Mills A. , Dhupar N.
Published: February 2023

(Int J Gynaecol Obstet. 2022;159:317–318)

Cases of non–immune-mediated anaphylaxis to synthetic oxytocin are exceedingly rare, occurring with an incidence of less than 1 in 20,000. Timely diagnosis and immediate coordinated interdisciplinary response are essential for favorable outcomes. Such a case is presented in the context of a patient with a family history of atopy undergoing vacuum-assisted birth with shoulder dystocia and postpartum hemorrhage (PPH).
Rethinking breastfeeding management
Authors: Scott Allison , Kirkland Tracie
Published: February 2023

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first 6 months of life. Nationally, however, breastfeeding rates are low, with Black infants among the least likely to be breastfed. The updated AAP breastfeeding policy guidelines emphasize an urgent need for a patient-centered approach to cultivate awareness of breastfeeding benefits and promote equitable care.
Sudden cardiac death in the young
Authors: Doucette Julianne , Rosenblum Ruth
Published: February 2023

NPs can identify risk for sudden cardiac death in children during physical exams to prevent tragedy. The updated American Academy of Pediatrics 2021 policy statement on this issue provides guidance on using a combination of elements to determine and manage risk, including the organization's own 4-question screening tool, the American Heart Association 14-Element Preparticipation Cardiovascular Screening of Young Competitive Athletes, personal history, family history, physical exam, ECG, and cardiology referral as indicated.
Vaccine hesitancy in prenatal women and mothers of newborns
Authors: Hallas Donna , Altman Susan , Mandel Elizabeth , Fletcher Jason
Published: February 2023

Introduction:

The purpose of this study was to determine the effectiveness of a web-based, vaccine resource-directed, interactive communication intervention for vaccine-hesitant prenatal women and mothers of newborns/infants to make informed decisions based on scientific evidence about vaccinating themselves and their newborns/infants, respectively.

Methods:

A prospective quasi-experimental design was used to determine the effectiveness of the intervention for vaccine-hesitant prenatal women (stage 1) and for mothers of newborns (stage 2). A survey was administered to prenatal women to determine attitudes about vaccines for themselves during pregnancy. A survey on parental attitudes about vaccination for their children was administered to mothers of newborns. The surveys were administered to determine levels of vaccine acceptance. Vaccine acceptors and vaccine-hesitant individuals were included in the study as control and intervention group participants, respectively; vaccine refusers were eliminated from the study.

Results:

Among prenatal vaccine-hesitant women, 82% had full prenatal vaccination coverage after receiving the intervention (χ2 = 7.2, P = .02). The majority of mothers of newborns/infants (74%) fully immunized their infants.

Discussion:

The interventions for prenatal vaccine-hesitant women were effective in changing their status from hesitant to acceptors. The mothers of newborns/infants who were initially hesitant had vaccination rates that exceeded the comparison group comprised of vaccine acceptors.
The Value of Ethics Education in Surgical Training
Authors: Angelos Peter
Published: February 2023

Although ethics is not a new concept in the surgical care of patients, the focused attention to ethics education in surgical education is a recent phenomenon. As more options have become available in the treatment armamentarium of surgery, the central question of surgical care has changed from “What can be done for this patient?” to the more modern question, “What should be done for this patient?” To answer this question, surgeons must attend to patients’ values and preferences. Surgical residents also spend much less time in the hospital today than they did several decades ago, increasing the necessity of focused attention to ethics education. Finally, with the shift to more outpatient care, surgical residents have fewer opportunities to engage in many of the important discussions about diagnosis and prognosis with patients. These factors have made ethics education in surgical training programs more important today than in previous decades.
Video-Based (Livestream) and In-Person Continuing Professional Development: Participant and Course Features Associated With Choice
Authors: Cook David A. , Pendl Aaron K. , Pankratz V. Shane
Published: February 2023

Purpose

Information on factors influencing learner choice between in-person and video-based continuing professional development (CPD) would help course leaders with planning and implementation. This study aimed to investigate how registration patterns differ between in-person and video-based offerings for the same CPD course.

Method

The authors obtained data from 55 CPD courses offered in-person (at various U.S. locations) and via livestreamed video, January 2020 to April 2022. Participants included physicians, advanced practice providers, allied health professionals, nurses, and pharmacists. Registration rates were compared by participant and course features including professional role, age, country of residence, distance to and perceived desirability of the in-person destination, and timing of registration.

Results

Analyses included 11,072 registrations, of which 4,336 (39.2%) were for video-based learning. There was significant heterogeneity in video-based registrations across courses, ranging 14.3% to 71.4%. Multivariable analysis showed higher video-based registrations for advanced practice providers (vs physicians; adjusted odds ratio [AOR] 1.80 [99% confidence interval, 1.55–2.10]), non-U.S. residents (AOR 3.26 [1.18–9.01]), longer distance (AOR 1.19 [1.16–1.23] for each doubling of distance), and courses in July–September 2021 (vs January–April 2022; AOR 1.59 [1.24–2.02]); video-based registrations were lower for current or former employees or trainees of our institution (AOR 0.53 [0.45–0.61]), destinations of moderate or high desirability (vs low; AOR 0.42 [0.34–0.51] and 0.44 [0.33–0.58], respectively), and early registration (AOR 0.67 [0.64–0.69] for each doubling of days between registration and course start). There was no significant difference by age (AOR 0.92 [0.82–1.05] for participants > 46 years old vs younger participants). The multivariable model correctly predicted actual registration 78.5% of the time.

Conclusions

Video-based livestreamed CPD is popular (chosen by nearly 40% of participants), although choices varied widely by course. Professional role, institutional affiliation, distance traveled, location desirability, and registration timing have small but statistically significant associations with choice of video-based vs in-person CPD.
The Bucksbaum Institute for Clinical Excellence and the Doctor–Patient Relationship: Origins, Programs, and Future Directions
Authors: Sorrentino Matthew , Krapec Joni , Cifu Adam S. , Pace-Moody Angela , Siegler Mark
Published: February 2023

The Bucksbaum Institute for Clinical Excellence at the University of Chicago was established in 2011 with the mission to improve patient care, strengthen the doctor–patient relationship, enhance communication and decision making in health care, and reduce health care disparities. The Bucksbaum Institute supports the development and activities of medical students, junior faculty, and senior clinicians who devote themselves to improving doctor–patient communication and clinical decision making. The institute seeks to enhance the skills of physicians as advisers, counselors, and navigators to help patients make informed decisions when facing complex treatment choices. To achieve its mission, the institute recognizes and supports the activities of physicians who excel in clinical care, supports an array of educational programs, and funds research into the doctor–patient relationship. As the Bucksbaum Institute enters a second decade, its focus will begin to extend beyond the University of Chicago, leveraging alumni and other relationships to improve patient care everywhere.
Strengthening Doctor–Patient Relationships Through Hospital-Based Violence Interventions
Authors: Cosey-Gay Franklin , Johnson Dwayne , Perez Ernestina , Milkovich Rachel , Robles Carlos , Rogers Selwyn O.
Published: February 2023

Problem

Violence in Chicago has been persistently high in low-income communities of color. Recent attention has focused on how structural inequities weaken protective factors that help keep communities healthy and safe. Spikes in community violence seen in Chicago since the COVID-19 pandemic further expose the lack of social service, health care, economic, and political safety nets in low-income communities and the apparent dearth of faith in those systems.

Approach

The authors contend that a comprehensive, collaborative approach to violence prevention that prioritizes treatment and community partnerships is needed to address social determinants of health and structural characteristics that often provide the context for interpersonal violence. One strategy to address decreasing faith in systems like hospitals is foregrounding frontline paraprofessional prevention workers who possess cultural capital based on their experiences navigating interpersonal and structural violence. Hospital-based violence intervention programs help professionalize these prevention workers by providing a framework for patient-centered crisis intervention and assertive case management. The authors describe how the Violence Recovery Program (VRP), a multidisciplinary hospital-based violence intervention model, leverages the cultural capital of credible messengers to use teachable moments to promote trauma-informed care to violently injured patients, assess their immediate risk for reinjury and retaliation, and connect them to wrap-around services to help aid comprehensive recovery.

Outcomes

Violence recovery specialists have engaged over 6,000 victims of violence since the program’s launch in 2018. Three-quarters of patients expressed social determinants of health needs. Over the past year, specialists have connected over one-third of engaged patients to mental health referrals and community-based social services.

Next Steps

High violence rates in Chicago limited case management opportunities in the emergency room. In fall 2022, the VRP began to establish collaborative agreements with community-based street outreach programs and medical–legal partnerships to address structural determinants of health.
Introducing a Sexual Wellness Clinic to an At-Risk Population Through the Emergency Department
Authors: Hazra Aniruddha , Stanford Kimberly , Schneider John , Davis Andrew
Published: February 2023

Rates of sexually transmitted infections (STIs) in the United States have continued to increase for nearly a decade as state and local health departments across the country have divested from sexual health services. The resulting closure of municipal STI clinics has led many uninsured and underinsured patients to rely on emergency departments for their sexual health needs. The authors describe the creation of the novel Sexual Wellness Clinic at University of Chicago Medicine in February 2019.

The clinic provides comprehensive sexual health care to establish linkage to pre-exposure prophylaxis (PrEP) for HIV, primary care, and other essential services to patients presenting to the emergency department for STI care. Since operationalization, the Sexual Wellness Clinic has served 560 unique patients; 50.5% (n = 283) were cisgender male and 49.5% (n = 277) were cisgender female. The majority of patients were African American (93.4%, n = 523), non-Hispanic or Latinx (96.1%, n = 538), between 18 and 29 years old (62.3%, n = 350), and had Medicaid or were uninsured (84.3%, n = 472). New syphilis diagnoses were identified in 23.5% (132/560) of patients; gonococcal and chlamydial infections were confirmed in 14.6% (82/560) and 13.4% (75/560) of patients, respectively. Same-day PrEP was initiated for 16.1% (90/560) of patients, of which 56.7% were cisgender female.

The Sexual Wellness Clinic identified unique candidates for PrEP, notably a large proportion of Black cisgender women; however, further work is needed to support the ongoing PrEP cascade. Identifying these new populations with untreated STIs and other HIV risk factors for targeted, innovative interventions is integral to HIV elimination and STI control efforts.
Exploring the Impact of Entrustable Professional Activities on Feedback Culture: A Qualitative Study of Anesthesiology Residents and Attendings
Authors: Berger Sabine , Stalmeijer Renee E. , Marty Adrian P. , Berendonk Christoph
Published: February 2023

Purpose

Entrustable professional activities (EPAs) were introduced as a potential way to optimize workplace-based assessments. Yet, recent studies suggest that EPAs have not yet overcome all of the challenges to implementing meaningful feedback. The aim of this study was to explore the extent to which the introduction of EPAs via mobile app impacts feedback culture as experienced by anesthesiology residents and attending physicians.

Method

Using a constructivist grounded theory approach, the authors interviewed a purposive and theoretical sample of residents (n = 11) and attendings (n = 11) at the Institute of Anaesthesiology, University Hospital of Zurich, where EPAs had recently been implemented. Interviews took place between February and December 2021. Data collection and analysis were conducted iteratively. The authors used open, axial, and selective coding to gain knowledge and understanding on the interplay of EPAs and feedback culture.

Results

Participants reflected on a number of changes in their day-to-day experience of feedback culture with the implementation of EPAs. Three main mechanisms were instrumental in this process: lowering the feedback threshold, change in feedback focus, and gamification. Participants felt a lower threshold to feedback seeking and giving and that the frequency of feedback conversations increased and tended to be more focused on a specific topic and shorter, while feedback content tended to focus more on technical skills and more attention was given to average performances. Residents indicated that the app-based approach fostered a game-like motivation to “climb levels,” while attendings did not perceive a game-like experience.

Conclusions

EPAs may offer a solution to problems of infrequent occurrence of feedback and invite attention to average performances and technical competencies, but may come at the expense of feedback on nontechnical skills. This study suggests that feedback culture and feedback instruments have a mutually interacting influence on each other.
Does the Doctor–Patient Relationship Affect Enrollment in Clinical Research?
Authors: Soo Jackie , Jameson Jacob , Flores Andrea , Dubin Lisa , Perish Emily , Afzal Azka , Berry Grace , DiMaggio Vinny , Krishnamoorthi V. Ram , Porter Justin , Tang Joyce , Meltzer David
Published: February 2023

Purpose

Recruiting patients for clinical research is challenging, especially for underrepresented populations, and may be influenced by patients’ relationships with their physicians, care experiences, and engagement with care. This study sought to understand predictors of enrollment in a research study among socioeconomically diverse participants in studies of care models that promote continuity in the doctor–patient relationship.

Method

A study of the effects of vitamin D levels and supplementation on COVID-19 risk and outcomes was implemented from 2020 to 2022 within 2 studies of care models at the University of Chicago that promoted continuity of inpatient and outpatient care from the same physician. Hypothesized predictors of vitamin D study enrollment included patient-reported measures of the care experience (quality of relationship with the doctor and their staff, timely receipt of care), engagement in care (scheduling and completing outpatient visits), and engagement with these “parent” studies (follow-up survey completion). The authors used univariate tests and multivariable logistic regression to examine the association of these predictors with enrollment in the vitamin D study among participants in the parent study intervention arms.

Results

Among 773 eligible participants, 351/561 (63%) in the parent study intervention arms enrolled in the vitamin D study, versus 35/212 (17%) in the control arms. Among intervention arm participants, vitamin D study enrollment was not associated with reported quality of communication with or trust in the doctor, or helpful/respectful office staff, but was associated with report of receiving timely care, more completed clinic visits, and higher parent study follow-up survey completion.

Conclusions

Study enrollment may be high in care models with high levels of continuity in the doctor–patient relationship. Rates of clinic involvement, parent study engagement, and experience of receiving timely access to care may better predict enrollment than quality of the doctor–patient relationship.
BREAST-Q Patient-reported Outcomes in Different Types of Breast Reconstruction after Fat Grafting
Authors: Retchkiman Meir , Elkhatib Arij , Efanov Johnny I. , Gagnon Alain , Bou-Merhi Joseph , Danino Michel Alain , Bernier Christina
Published: February 2023

Background:

Breast reconstruction after mastectomy improves patient quality of life. Independently of the type of reconstruction, ancillary procedures are sometimes necessary to improve results. Fat grafting to the breast is a safe procedure with excellent results. We report patient-reported outcomes using the BREAST-Q questionnaire after autologous fat grafting in different types of reconstructed breasts.

Methods:

We performed a single-center, prospective, comparative study that compared patient-reported outcomes using the BREAST-Q in patients after different types of breast reconstruction (autologous, alloplastic, or after breast conserving) who subsequently had fat grafting.

Results:

In total, 254 patients were eligible for the study, but only 54 (68 breasts) completed all the stages needed for inclusion. Patient demographic and breast characteristics are described. Median age was 52 years. The mean body mass index was 26.1 ± 3.9. The mean postoperative period at the administration of BREAST-Q questionnaires was 17.6 months. The mean preoperative BREAST-Q was 59.92 ± 17.37, and the mean postoperative score was 74.84 ± 12.48 (P < 0.0001). There was no significant difference when divided by the type of reconstruction.

Conclusion:

Fat grafting is an ancillary procedure that improves the outcomes in breast reconstruction independently of the reconstruction type and heightens patient satisfaction, and it should be considered an integral part of any reconstruction algorithm.
Patterns of Change in the Severity of Airway Obstruction with Robin Sequence in Early Infancy
Authors: Dede Belema D. , Robinson Paul D. , Castro Chenda , Waters Karen A.
Published: February 2023

Background:

Previous studies suggest that infants with Robin sequence show a pattern of steady improvement in the severity of airway obstruction, and of their treatment requirements, during infancy.

Methods:

Three infants with Robin sequence and severe obstructive sleep apnea were managed with nasal continuous positive airways pressure (CPAP). Multiple measures of airway obstruction were made during infancy, including CPAP pressure evaluations and sleep studies (screening and polysomnography studies). Parameters reported include obstructive apnea-hypopnea index, oxygen desaturation parameters, and CPAP pressures required for effective airway management.

Results:

CPAP pressure requirements increased in all three infants during their first weeks of life. Apnea indices on polysomnography did not track with the CPAP pressure requirements. Peak pressure requirements were at 5 and 7 weeks for two patients, with subsequent gradual decline and cessation of therapy CPAP at 39 and 74 weeks, respectively. The third patient had a complicated course, jaw distraction at 17 weeks, and biphasic CPAP pressure requirement (first peak at 3 weeks, but maximum pressure at 74 weeks), with cessation of CPAP at 75 weeks.

Conclusions:

The observed pattern of early increases in CPAP pressure requirements for infants with Robin sequence adds to the complexities of managing this disorder. Factors that may lead to this pattern of change in airway obstruction are discussed.
Chesapeake Regional Healthcare: Support from the Top for Impactful Relationships
Authors: Jackson Reese
Published: February 2023

When governing boards of healthcare organizations resolve to support their executive teams' commitments of time and money to create strategic action plans that meet their communities' environmental and social criteria—and when those healthcare organizations work with others that share their passion to measurably improve health—their communities can realize remarkable benefits.

For example, this case study describes Chesapeake Regional Healthcare's collaborative approach to a community health need that began with data from the hospital's emergency department. The approach included the development of intentional relationships with local health departments and nonprofits. The possibilities of such evidence-based collaborations are endless, but the support of a solid organizational structure is required as data collection identifies additional needs.
Clonal hematopoiesis: the nonhereditary genetics of age-associated cardiovascular disease
Authors: Sano Soichi , Thel Mark C. , Walsh Kenneth
Published: February 2023

Purpose of review

Somatic mutations, described as noninherited changes in DNA that arise and are passed on to descendant cells, are well known to cause cancers; however, it is increasingly appreciated that the propagation of somatic mutations within a tissue may have a role in causing nonneoplastic disorders and abnormalities in elderly individuals. The nonmalignant clonal expansion of somatic mutations in the hematopoietic system is termed clonal hematopoiesis. This review will briefly discuss how this condition has been linked to various age-related diseases outside the hematopoietic system.

Recent findings

Clonal hematopoiesis, resulting from leukemic driver gene mutations or mosaic loss of the Y chromosome in leukocytes, is associated with the development of various forms of cardiovascular disease, including atherosclerosis and heart failure, in a mutation-dependent manner.

Accumulating evidence shows that clonal hematopoiesis represents a new mechanism for cardiovascular disease and a new risk factor that is as prevalent and consequential as the traditional risk factors that have been studied for decades.
Pulmonary arterial hypertension in pregnancy
Authors: Vaidy Anika , Vaidya Anjali
Published: February 2023

Purpose of review

Although pregnancy in pulmonary arterial hypertension (PAH) is considered high risk and contraindicated, the incidence is rising. It is paramount to understand the pathophysiology and effective management strategies to ensure optimal outcomes for maternal and fetal survival.

Recent findings

In this review, we highlight the outcomes of recent case series of PAH patients in pregnancy, with a focus on proper risk assessment and target goals of PAH therapy. These findings support the notion that the pillars of PAH management, including pulmonary vascular resistance reduction resulting in right heart functional improvement, and widening of the cardiopulmonary reserve, should serve as a blueprint for PAH management in pregnancy.

Multidisciplinary and tailored management of PAH in pregnancy, with emphasis on optimizing right heart function prior to delivery, can result in excellent clinical outcomes in a referral pulmonary hypertension center.
Outcomes of Functional Testing Versus Invasive Cardiac Catheterization for the Evaluation of Intermediate Severity Coronary Stenosis Detected on Cardiac Computed Tomography Angiography
Authors: Bhagat Aditi A. , Fordham Matthew J. , Lohani Minisha , Teressa Getu
Published: February 2023

Introduction:

The aim of this study was to evaluate the effectiveness of functional testing in comparison to invasive coronary angiography (ICA) among acute chest pain patients whose first diagnostic modality was a coronary computed tomography angiogram (CCTA) and were found to have intermediate coronary stenosis, defined as 50%–70% luminal stenosis.

Methods:

We conducted a retrospective review of 4763 acute chest pain patients ≥18 years old who received a CCTA as the initial diagnostic modality. Of these, 118 patients met enrollment criteria and proceeded to either stress test (80/118) or directly to ICA (38/118). The primary outcome was 30-day major adverse cardiac event, consisting of acute myocardial infarction, urgent revascularization, or death.

Results:

There was no difference in 30-day major adverse cardiac event among patients who underwent initial stress testing versus directly referred to ICA (0% vs. 2.6%, P = 0.322) following CCTA. The rate of revascularization without acute myocardial infarction was significantly higher among those who underwent ICA versus stress test [36.8% vs. 3.8%, P < 0.0001; adjusted odds ratio: 9.6, 95% confidence interval, 1.8–49.6]. Patients who underwent ICA had a higher rate of catheterization without revascularization within 30 days of the index admission in comparison to those who underwent initial stress testing (55.3% vs. 12.5%, P < 0.0001; adjusted odds ratio: 26.7, 95% confidence interval, 6.6–109.5).

Conclusion:

Among patients with intermediate coronary stenosis on CCTA, a functional stress test compared with ICA may prevent unnecessary revascularization and improve cardiac catheterization yield without negatively affecting the 30-day patient safety profile.
Does the Electrocardiogram Machine Interpretation Affect the Ability to Accurately Diagnose ST-Elevation Myocardial Infarction by Emergency Physicians?
Authors: Paez Perez Yenisleidy , Rimm Sarah , Bove Joseph , Hochman Steven , Liu Tianci , Catapano Anthony , Shroff Ninad , Lim Jessica , Rimm Brian
Published: February 2023

Introduction:

An ST-elevation myocardial infarction (STEMI) can portend significant morbidity and mortality to the patient and therefore must be rapidly diagnosed by an emergency medicine (EM) physician. The primary aim of this study is to determine whether EM physicians are more or less likely to accurately diagnose STEMI on an electrocardiogram (ECG) if they are blinded to the ECG machine interpretation as opposed to if they are provided the ECG machine interpretation.

Methods:

We performed a retrospective chart review of adult patients over 18 years of age admitted to our large, urban tertiary care center with a diagnosis of STEMI from January 1, 2016, to December 31, 2017. From these patients’ charts, we selected 31 ECGs to create a quiz that was presented twice to a group of emergency physicians. The first quiz contained the 31 ECGs without the computer interpretations revealed. The second quiz, presented to the same physicians 2 weeks later, contained the same set of ECGs with the computer interpretations revealed. Physicians were asked “Based on the ECG above, is there a blocked coronary artery present causing a STEMI?”

Results:

Twenty-five EM physicians completed two 31-question ECG quizzes for a total of 1550 ECG interpretations. On the first quiz with computer interpretations blinded, the overall sensitivity in identifying a “true STEMI” was 67.2% with an overall accuracy of 65.6%. On the second quiz in which the ECG machine interpretation was revealed, the overall sensitivity was 66.4% with an accuracy of 65.8 % in correctly identifying a STEMI. The differences in sensitivity and accuracy were not statistically significant.

Conclusion:

This study demonstrated no significant difference in physicians blinded versus those unblinded to computer interpretations of possible STEMI.
Three-dimensional technologies in presurgical planning of bone surgeries: current evidence and future perspectives
Authors: Portnoy Yotam , Koren Jonathan , Khoury Amal , Factor Shai , Dadia Solomon , Ran Yuval , Benady Amit
Published: February 2023

Background:

The recent development of three-dimensional (3D) technologies introduces a novel set of opportunities to the medical field in general, and specifically to surgery. The preoperative phase has proven to be a critical factor in surgical success. Utilization of 3D technologies has the potential to improve preoperative planning and overall surgical outcomes. In this narrative review article, the authors describe existing clinical data pertaining to the current use of 3D printing, virtual reality, and augmented reality in the preoperative phase of bone surgery.

Methods:

The methodology included keyword-based literature search in PubMed and Google Scholar for original articles published between 2014 and 2022. After excluding studies performed in nonbone surgery disciplines, data from 61 studies of five different surgical disciplines were processed to be included in this narrative review.

Results:

Among the mentioned technologies, 3D printing is currently the most advanced in terms of clinical use, predominantly creating anatomical models and patient-specific instruments that provide high-quality operative preparation. Virtual reality allows to set a surgical plan and to further simulate the procedure via a 2D screen or head mounted display. Augmented reality is found to be useful for surgical simulation upon 3D printed anatomical models or virtual phantoms.

Conclusions:

Overall, 3D technologies are gradually becoming an integral part of a surgeon’s preoperative toolbox, allowing for increased surgical accuracy and reduction of operation time, mainly in complex and unique surgical cases. This may eventually lead to improved surgical outcomes, thereby optimizing the personalized surgical approach.
The Effects of Exercise on Sleep During Pregnancy: A Systematic Review and Meta-analysis
Authors: McCarthy Traci A. , Reddy Pranav S. , Spaeth Andrea M.
Published: February 2023

Background:

Sleep impairment during pregnancy can impact quality of life and lead to excessive gestational weight gain, gestational diabetes mellitus, postpartum depression, and delivery complications. In nonpregnant adults, exercise improves sleep quality, duration, and onset latency.

Purpose:

To determine whether exercise performed during pregnancy improves sleep outcomes.

Methods:

A systematic review was conducted from January 2021 to July 2022 using online databases and hand searching (PROSPERO registration number: CRD42021243477). Randomized controlled trials (RCTs) available in English were eligible if the sample included pregnant women, the intervention included exercise and was compared to a standard care group, and sleep was included as an outcome measure. Mean differences and standardized mean differences were calculated to compare sleep outcomes across studies. Heterogeneity of results was calculated using I
2 and risk of bias was assessed using the Cochrane Risk of Bias tool.

Results:

A total of 2578 articles were found using the search terms, and 7 studies met inclusion criteria (n = 839). Prenatal exercise reduced the amount of self-reported sleep disturbances (2 RCTs n = 115; instrumental variable [IV] −0.53, 95% confidence interval [CI] −0.90, −0.16, z = 2.79, P = .005) and improved sleep quality (3 RCTs n = 477; IV −0.48, 95% CI −0.61, −0.36) during pregnancy. Other sleep outcomes were not analyzed due to variability of measurements.

Conclusion:

Compared with not exercising, exercise during pregnancy improves sleep quality during pregnancy; however, the quality of existing evidence was low. Given the importance of sleep for health and well-being, more research is needed to determine the utility of exercise for improving sleep in pregnancy.
The Challenge of Intermediate-Risk Pulmonary Embolism
Authors: Weintraub Spencer F. , You Joseph , Wilson Sean , Galmer Andrew
Published: February 2023

Background:

Intermediate-risk pulmonary embolism is a common disease that is associated with significant morbidity and mortality; however, a standardized treatment protocol is not well-established.

Areas of Uncertainty:

Treatments available for intermediate-risk pulmonary embolisms include anticoagulation, systemic thrombolytics, catheter-directed therapies, surgical embolectomy, and extracorporeal membrane oxygenation. Despite these options, there is no clear consensus on the optimal indication and timing of these interventions.

Therapeutic Advances:

Anticoagulation remains the cornerstone of treatment for pulmonary embolism; however, over the past 2 decades, there have been advances in the safety and efficacy of catheter-directed therapies. For massive pulmonary embolism, systemic thrombolytics and, sometimes, surgical thrombectomy are considered first-line treatments. Patients with intermediate-risk pulmonary embolism are at high risk of clinical deterioration; however, it is unclear whether anticoagulation alone is sufficient. The optimal treatment of intermediate-risk pulmonary embolism in the setting of hemodynamic stability with right heart strain present is not well-defined. Therapies such as catheter-directed thrombolysis and suction thrombectomy are being investigated given their potential to offload right ventricular strain. Several studies have recently evaluated catheter-directed thrombolysis and embolectomies and demonstrated the efficacy and safety of these interventions. Here, we review the literature on the management of intermediate-risk pulmonary embolisms and the evidence behind those interventions.

Conclusions:

There are many treatments available in the management of intermediate-risk pulmonary embolism. Although the current literature does not favor 1 treatment as superior, multiple studies have shown growing data to support catheter-directed therapies as potential options for these patients. Multidisciplinary pulmonary embolism response teams remain a key feature in improving the selection of advanced therapies and optimization of care.
Spatial Distribution of Macrophage Subtypes Among Rejection Subtypes in Renal Transplant Biopsies by Dual Immunohistochemistry
Authors: Hurdogan Ozge , Karakus Fatmanur , Dirim Ahmet Burak , Aksu Bagdagul , Saygili Seha , Turkmen Aydin , Yilmaz Alev , Canpolat Nur , Solakoglu Seyhun , Kilicaslan Isin , Ozluk Yasemin
Published: February 2023

We performed dual immunohistochemistry for CD163/CD34 and CD68/CD34 in 108 renal transplant indication biopsies to investigate the presence and distribution of macrophages in various renal compartments. All Banff scores and diagnoses were revised according to the Banff 2019 classification. CD163 and CD68 positive cell counts (CD163pos and CD68pos) were evaluated in the interstitium, glomerular mesangium, and, within glomerular and peritubular capillaries. The diagnosis was antibody-mediated rejection (ABMR) in 38 (35.2%), T-cell mediated rejection (TCMR) in 24 (22.2%), mixed rejection in 30 (27.8%), and no rejection in 16 (14.8%). Banff lesion scores t, i, and ti were correlated with both CD163 and CD68 interstitial inflammation scores (r > 0.30; P < 0.05). Glomerular total CD163pos was correlated to Banff lesion scores g and cg (r > 0.30; P < 0.05). Glomerular total, mesangial, and intracapillary CD68pos were correlated with g (r > 0.30; P < 0.05). Both glomerular total and peritubular capillary CD68pos were correlated with peritubular capillaritis (r > 0.30; P < 0.05). Glomerular CD163pos were significantly higher in ABMR compared with no rejection, in mixed rejection compared with no rejection and TCMR. CD163pos in peritubular capillaries was significantly higher in mixed rejection compared with no rejection. Glomerular CD68pos was significantly higher in ABMR compared with no rejection. CD68pos per peritubular capillary was higher in mixed rejection, ABMR, and TCMR compared with no rejection. In conclusion, compared with CD68 positive macrophages, localization of CD163 positive macrophages in various renal compartments seems to be different among rejection subtypes and their glomerular infiltration seems to be more specific for the presence of ABMR component.
Long-Term Quality of Life in Congenital Heart Disease Surgical Survivors: Multicenter Retrospective Study of Surgical and ICU Explanatory Factors
Authors: Marino Bradley S. , Cassedy Amy , Brown Katherine L. , Franklin Rodney , Gaynor J. William , Cvetkovic Mirjana , Laker Simon , Levinson Katherine , MacGloin Helen , Mahony Lynn , McQuillan Annette , Mussatto Kathleen , O’Shea Deirdre , Newburger Jane , Sykes Michelle , Teele Sarah A. , Wernovsky Gil , Wray Jo
Published: February 2023

OBJECTIVES:

Greater congenital heart disease (CHD) complexity is associated with lower health-related quality of life (HRQOL). There are no data on the association between surgical and ICU factors and HRQOL in CHD survivors. This study assess the association between surgical and ICU factors and HRQOL in child and adolescent CHD survivors.

DESIGN:

This was a corollary study of the Pediatric Cardiac Quality of Life Inventory (PCQLI) Testing Study.

SETTING:

Eight pediatric hospitals participating in the PCQLI Study.

PATIENTS:

Patients in the study had the Fontan procedure, surgery for tetralogy of Fallot (TOF), and transposition of the great arteries (TGAs).

MEASUREMENTS AND MAIN RESULTS:

Surgical/ICU explanatory variables were collected by reviewing the medical records. Primary outcome variables (PCQLI Total patient and parent scores) and covariates were obtained from the Data Registry. General linear modeling was used to create the multivariable models. There were 572 patients included: mean ± sd of age 11.7 ± 2.9 years; CHD Fontan 45%, TOF/TGA 55%; number of cardiac surgeries 2 (1–9); and number of ICU admissions 3 (1–9). In multivariable models, lowest body temperature on cardiopulmonary bypass (CPB) was negatively associated with patient total score (p < 0.05). The total number of CPB runs was negatively associated with parent-reported PCQLI Total score (p < 0.02). Cumulative days on an inotropic/vasoactive drug in the ICU was negatively associated with all patient-/parent-reported PCQLI scores (p < 0.04). Neurological deficit at discharge was negatively associated with parent-reported PCQLI total score (p < 0.02). The variance explained by these factors ranged from 24% to 29%.

CONCLUSIONS:

Surgical/ICU factors, demographic, and medical care utilization variables explain a low-to-moderate amount of variation in HRQOL. Research is needed to determine whether modification of these surgical and ICU factors improves HRQOL, and to identify other factors that contribute to unexplained variability.
Endometrioid Adenocarcinoma Resembling Cutaneous Pilomatrix Carcinoma: A Case Report of an Aggressive Neoplasm in a Young Woman With Diffusely Aberrant Beta-catenin Expression and Associated Morular Metaplasia and Atypical Polypoid Adenomyoma–type Change
Authors: Keane Ellen , Floyd Ruairí , McDonnell Caoimhe , Beirne James P. , Ó’Riain Ciarán , Komanyane Lore
Published: February 2023

Endometrioid carcinoma with histopathologic resemblance to cutaneous pilomatrix carcinoma with mutations in the gene encoding beta-catenin, CTNNB1 are rare. There are minimal numbers of reports of high-grade tumors with this divergent differentiation in the literature. We report the case of a 29-yr-old female with an unusual presentation of endometrial cancer with overall histologic appearance indicative of a recently reported aggressive subtype of Federation of Gynecology and Obstetrics (FIGO) IVB grade 3 endometrioid carcinoma with features resembling cutaneous pilomatrix carcinoma. She was treated with a primary chemotherapy regimen with an initial significant response to treatment before developing symptomatic brain metastasis for which she underwent whole-brain radiotherapy. We discuss the unusual histologic and radiologic presentation as well as her individual management throughout this case report. The apparent association with morular metaplasia and atypical polypoid adenomyoma suggests that this rare carcinoma is within a spectrum of lesions associated with aberrant beta-catenin expression/beta-catenin mutation. Its aggressive nature highlights the importance of early recognition of this rare lesion.