bluuebunny/crossref_metadata_2025 huggingface dataset:
GCT Cut-Off in Women With GDM Based on Pre-pregnancy BMI [20K]
Authors: Angras Kajal , Young Amanda , Mackeen Awathif D.
Published: May 2019

INTRODUCTION:

A universal cut-off for the 1-hour 50-g glucose challenge test (GCT) does not take into consideration pre-pregnancy body mass index (BMI). Our objective was to determine the optimal GCT cut-off for the screening of gestational diabetes mellitus (GDM) based on pre-pregnancy BMI.

METHODS:

An-IRB approved retrospective cohort analysis of singleton pregnancies at Geisinger between January 2003-December 2017 was performed. GCT > 20 weeks was used. Using receiver operator curve (ROC), we sought to determine the optimal GCT cut-off for each BMI category that would predict the development of GDM. ROC curve was generated by calculating the sensitivity and specificity for the GCT value in each BMI category. Youden Index was used for cut-point analysis.

RESULTS:

22,266 women with a GCT were identified. Of those, 1,027 were diagnosed with GDM. 312 with BMI <25 kg/m2, 282 overweight, 215 class I obese, 133 class II obese, and 85 class III obese women were diagnosed with GDM. Gestational diabetes was predicted at GCT cut-off of 131 mg/dL and an area under the curve (AUC) of 0.93 (BMI < 25), 131 mg/dL and an AUC of 0.92 (overweight BMI), 133 mg/dL and an AUC of 0.88 (class I BMI), 130 mg/dL and an AUC of 0.88 (class II BMI), and 134 mg/dL and an AUC of 0.85 (class III BMI).

CONCLUSION:

AUC ranged from 0.85 to 0.93 with 85% or greater sensitivity for GCT cut-off for each of the BMI categories. The findings support a GCT cut-off of 130 mg/dL for GDM screening regardless of BMI.
Glycemic Efficacy With U-500 Insulin in Pregnancy: A Retrospective Cross-Over Study [21K]
Authors: Vasquez Bertha A. , Sarumi Mojirayo , Shultz Lori , Bedell James , Gherman Robert , Johnson Mary Jo
Published: May 2019

INTRODUCTION:

Pre-gestational diabetes, one of the most challenging complications of pregnancy, may require over 200 units per day in patients with severe insulin resistance, resulting in compliance and absorption issues. The purpose of this study was to determine if conversion to U-500 led to improved glycemic efficacy in pregnancies complicated by severe insulin resistance.

METHODS:

A retrospective review of pregnant patients managed with (Humulin R) U-500 from 2014 to 2018 was conducted. Maternal and neonatal demographics were abstracted. Primary objective was to compare fasting and postprandial glycemic efficacy, insulin injections per day and number of hypoglycemic episodes pre- and post- conversion to U-500 assessments. Wilcoxon two tailed signed ranks tests was used for the qualitative data analysis, P value <.05 was considered statistically significant.

RESULTS:

Ten patients were identified. Mean gestational age was 24 weeks (16.2 to 33.4) and mean insulin dose was 301.8 U (64 to 522) at time of conversion to U-500. Post-conversion to U-500, a decrease in the percent-above-range fasting glucose levels (65.61% vs 51.56%, P=.047) and insulin injections per day (4.8 vs 3.5 P <.01) was noted. An increase in percent-above-range postprandial glucose levels was noted post-conversion (45.26% vs 54.42%, P=.114). A trend towards decreased number of hypoglycemic episodes was noted (7.50 vs 3.80, P=.089).

CONCLUSION:

U-500 insulin use is associated with improved fasting glycemic efficacy with decreased number of injections per day in pregnancies complicated by pre-gestational diabetes. Additional experience with U-500 in pregnancy is warranted to determine its safety profile in terms of maternal and neonatal outcomes.
Hydralazine Versus Labetalol for Acute Hypertension in the Peripartum Patient [26K]
Authors: Scholl Jessica , Chan-Akeley Rosalyn , Leizer Julie , Skupksi Daniel
Published: May 2019

INTRODUCTION:

Women in the peripartum period with acute severe hypertension require urgent antihypertensive therapy. First-line management with either intravenous (IV) Labetalol or IV Hydralazine has been endorsed by ACOG, with the choice of antihypertensive left to the discretion of the clinician. Our objective was to assess whether IV Labetalol or IV Hydralazine has better efficacy in treating acute severe hypertension in the peripartum period.

METHODS:

This was a retrospective cohort study including patients from 2013 to 2018. We identified peripartum patients presenting with severe acute hypertension, defined as systolic blood pressure (BP) greater than or equal to 160 mmHg or diastolic BP greater than or equal to 110 mmHg. Records were reviewed for patient characteristics, treatment used, and BP effect after the initial medication dose.

RESULTS:

There were 170 patients included. In 142 cases IV Labetalol was used, and in 28 cases IV Hydralazine was used. Patient characteristics were similar between the groups, with the exceptions of a greater presence of chronic hypertension in the Labetalol group, and greater percentage of postpartum patients in the Hydralazine group. The use of Hydralazine was successful in achieving the target BP more frequently than Labetalol (71% vs 50%, P=0.04), with greater median decrease in systolic BP (18.5 mm Hg vs 11.5 mm Hg, P=0.03). There were no differences in the success of decreasing diastolic BP or mean arterial pressure.

CONCLUSION:

IV Hydralazine may provide better efficacy in BP control for the peripartum patient compared to IV Labetalol. We advocate for the conduction of a randomized controlled trial.
Hyponatremia in Patients With Intrapartum Hospital Transfer After Planning an Out-of-Hospital Birth [28K]
Authors: Kjos Kari , Stephenson-Famy Alyssa , Eschenbach David Arthur , Chandrasekaran Suchitra
Published: May 2019

INTRODUCTION:

Most intrapartum transfers after planned out-of-hospital birth (“midwife transfers”) are for labor complications. Hyponatremia can be a consequence of prolonged labor and excessive oral hydration, and is associated with adverse maternal-neonatal outcomes. We sought to evaluate the association between obstetrical outcomes and maternal sodium levels in midwife transfers.

METHODS:

We performed a retrospective cohort study evaluating all singleton, term, midwife-transfers in labor at a single tertiary care academic medical center from 2009-2015. Maternal demographic data, sodium levels, obstetrical and neonatal outcomes were collected. Categorical variables were compared using chi-square or Fisher's exact score, and continuous variables were compared using ANOVA or Kruskal -Wallis tests.

RESULTS:

For 374 intrapartum midwife-transfers, the mean gestational age was 40 weeks, 5% (n=17) had previous cesarean section, mean duration of membrane rupture was 19 hours, and 39% (n=145) had meconium stained amniotic fluid. Ten percent (n=41) had a sodium nadir ≤130 mEq/L, 22% (n=82) had a sodium nadir >130 mEq/L and 67% (n=251) did not have a sodium level recorded. Complications in this cohort included high rates of cesarean section (50%, n=187), postpartum hemorrhage (12%, n=44), chorioamnionitis (16%, n=59), and neonatal demise (0.8%, n=3). While hyponatremia (sodium ≤130 mEq/L) was not associated with significant increase in maternal or neonatal morbidity, two symptomatic women with sodium <120 mEq/L required intensive care.

CONCLUSION:

In our cohort, midwife transfers represent a high-risk obstetrical group regardless of sodium level. Sodium levels in midwife-transfers should be obtained in those with neurologic symptoms.
Impact of CALM Initiative and Timing of AROM on NTSV Cesarean Section Rate [30K]
Authors: Gallagher Kristen , Wahl Geneva , Takhsh Eden , Lombard Emily , Reynolds Peyton , Davies Jeffrey
Published: May 2019

INTRODUCTION:

Nulliparous, term, singleton, vertex (NTSV) cesarean section rate is an AHRQ (Agency for Healthcare Quality and Research) quality indicator and Healthy People 2020 has set a target of 23.9% for this measure. Our institution adopted this target with a goal of decreasing our rate by implementing the “Consistent Approach to Labor Management” (CALM) initiative in 2017. As part of this initiative, an effort was made to limit interventions in early labor including delay of amniotomy until 4cm dilation.

METHODS:

Action plans were developed with inspiration from the California Maternal Quality Care Collaborative (CMQCC) initiatives. Data was collected from 2016, prior to the institution of our CALM initiative, and compared to 2017. Primary outcome measurements included artificial rupture of membranes (AROM) versus spontaneous rupture of membranes (SROM) and cesarean section rate.

RESULTS:

NTSV cesarean section rate in 2016 was 31.6% and 24.4% in 2017. Cesarean section rate was 39.0% in the AROM group in 2016 versus 23.8% in 2017. Rate of cesarean section in the SROM group in 2016 and 2017 were 22.6% and 22.8%, respectively. In 2017, the cesarean section rate was 41.7% if AROM was performed prior to 4cm cervical dilation and 19.4% if performed after 4cm cervical dilation. These respective rates for 2016 were 48.7% and 23.8%. The percentage of patients that had AROM prior to 4cm was decreased by 42.8% between 2016 and 2017.

CONCLUSION:

Delayed AROM until after 4cm dilation, as part of the CALM initiative implementation, resulted in a 39% decrease in NTSV cesarean section rate.
Comparison of Embryo Transfer Techniques in Assisted Reproductive Technology (ART) Cycles [35K]
Authors: Ligon Sarah , Chaffin Kimberly Ann , Pier Bruce D. , Levy Gary
Published: May 2019

INTRODUCTION:

Different transfer techniques have been developed to optimize the embryo transfer process and maximize the probability of pregnancy after transfer. The purpose of this study is to compare the afterload (AL) embryo transfer technique and the post-mock (PM) embryo transfer technique.

METHODS:

We designed a retrospective cohort study which included women who underwent an autologous, fresh or cryopreserved embryo transfer (ET) between 01 July 2013 and 01 September 2016 at our academic center. Embryo transfer was performed with either the afterload technique (AL) or the immediate post-mock (PM) transfer technique. The primary outcome of interest was ongoing pregnancy rate (OPR) defined as fetal cardiac activity on first trimester ultrasound. This study was approved by the Tripler Army Medical Center Department of Clinical Investigation Scientific Review Committee and Institutional Review Board.

RESULTS:

There was no significant difference in OPR between patients that underwent AL transfers and PM transfers (AL 51%, PM 57%; P=.378). Ongoing pregnancy rate for frozen embryo transfers was superior for AL transfers compared to PM transfers (AL 68%, PM 31%; P=.005). Ongoing pregnancy rate was superior with the PM technique for fresh embryo transfers (AL 43%, PM 63%; P=.002). Ongoing pregnancy rate decreased with age in the AL cohort, but not in the PM cohort (P=.004).

CONCLUSION:

There appears to be no overall difference in OPR between AL and PM transfer technique. However, with vitrified embryos, the AL technique demonstrated a higher OPR, and with fresh embryos, the PM technique resulted in a superior OPR.
Inappropriate Use of Antibiotics in Benign Gynecologic Surgery [2L]
Authors: Chu Amanda , Disturco Mariella , Ahn Seungjun
Published: May 2019

INTRODUCTION:

Preoperative antibiotic overuse contributes to unnecessary healthcare costs, harmful drug reactions and the creation of drug resistant bacteria. Study objective was to examine inappropriate antibiotic use among laparoscopic gynecologic surgeries and evaluate for targetable trends.

METHODS:

This is a single center retrospective cohort study. We examined all laparoscopic gynecologic surgeries performed at Lenox Hill Hospital from 2016-2017. There were a total of 1269 cases performed by 63 gynecologists. Cases where antibiotics were indicated were excluded; 794 cases were studied. The two sample t-test was used for continuous variables and a Fisher's exact test or chi-square test were used to compare categorical variables between groups. Results were statistically significant if p < 0.05. Analysis was conducted using SAS v. 9.4.

RESULTS:

Antibiotics were inappropriately given in 80.3% of all procedures that met criteria. Myomectomies and endometriosis surgeries were more likely to receive antibiotics than adnexal surgeries. Faculty physicians were more likely to appropriately withhold antibiotics than voluntary staff (39.7% vs 11.4%, p < 0.001), oncologists were more likely than benign gynecologists to withhold antibiotics (36.3% vs. 17.5%, p < 0.001) and low volume surgeons were more likely than high volume to withhold antibiotics (35.8% vs. 12.4%, p < 0001). Diabetes and smoking status were both examined and did not appear to influence the decision to administer antibiotics. Low rates of 30 day complications (<1%) were seen among both groups.

CONCLUSION:

Future directions are to correct the high use of inappropriate antibiotics at our institution and target the groups most at risk.
Can the New ACGME RRC Hysterectomy Requirements Be Fulfilled at Inner City Academic Centers? [3L]
Authors: Sidduri Nishanth , Ackroyd Sarah , Rose Marisa
Published: May 2019

INTRODUCTION:

The ACGME and ACOG promote the use of minimally invasive approaches for hysterectomy when feasible. In 2018, the ACGME Residency Review Committee increased the number of minimally invasive (MIS) hysterectomies required for trainees to graduate residency.

METHODS:

Retrospective cohort study using the 2016 hysterectomy-specific National Surgical Quality Improvement Program (NSQIP) database. Demographics, comorbidities and surgical characteristics were examined by hysterectomy type. The association between race and hysterectomy type was investigated using one and two-way analysis of variance (ANOVA).

RESULTS:

20,770 hysterectomies for benign indications were identified. Across all races, 25.7% underwent abdominal hysterectomy, 57.4% underwent laparoscopic hysterectomy and 16.9% underwent vaginal hysterectomy. Black women were more likely to undergo abdominal hysterectomy than white women (41.4% vs 20.1%, respectively, p<0.001), and less likely to undergo both laparoscopic and vaginal hysterectomy (47.5% vs 61.9% and 11.1% vs 18.0%, respectively, p<0.001). After adjusting for uterine weight (0-100g, 100-250g, and >250g), black women were still more likely to undergo abdominal hysterectomy compared to other races (p<0.001). Additionally, when adjusting for history of prior abdominal or pelvic surgeries, black women were more likely to undergo abdominal hysterectomy compared to other races (p<0.001).

CONCLUSION:

African American women disproportionately undergo higher rates of abdominal hysterectomy compared to other racial groups. Trainees at academic medical centers with high-risk and higher proportion of African American patients may experience difficulty fulfilling the number of minimally invasive hysterectomies required for graduation. Further efforts to identify the etiology of racial disparities in route of hysterectomy should be pursued.
Development and Validation of Diagnostic Hysteroscopy Simulation Curriculum [9L]
Authors: Porter Anne , Fuller Tobi , Lupo Andrew , Walsh Teresa , Kho Kimberly
Published: May 2019

INTRODUCTION:

Hysteroscopy is a cornerstone operative skill for gynecologists. As with other technical skills, simulation training may improve performance in the OR. Cavitary foods (e.g. bell pepper) have been used as models but these have the limitation of being inflexible and short lived. We have developed a low-fidelity, reusable and reproducible training model using a clear plastic bottle for hysteroscopic simulation. This purpose of this study is to test the face and construct validity of that model.

METHODS:

This is a prospective observational study. In 2017 and 2018 first year residents in Obstetrics and Gynecology at UT Southwestern completed the curriculum, including instructional videos, pre-test and post-test surveys and a the simulation task. Expert faculty administered an objective structured assembly of technical skills (OSATS) and recorded times required to assemble the hysteroscope and perform the simulation. Residents were given 6 weeks for independent practice with the model after which the OSATS and performance times were collected again.

RESULTS:

36 first year residents and 4 faculty experts completed the simulation. Following independent practice, resident OSAT scores improved by 11 points (SD ± 8, out of 39 potential total points) on assembly of hysteroscope and 9 points (SD ± 3.5, out of 15 potential points) on simulation tasks. Resident OSATS scores improved significantly (p<0.005) between pre-test and post-test. Experts scored significantly higher than the residents on the OSATS overall (p < .001).

CONCLUSION:

Our study supports the use of our reusable hysteroscopic training model as a way to improve resident performance in a simulation environment.
Impact of Maternal Obesity on Outcomes in Late Preterm Prelabor Rupture of Membranes [11L]
Authors: Lynch Tara A. , Colihan Sarah , Malshe Amol , Varlamov Anna , Soto-Torres Eleazar , Olson-Chen Courtney
Published: May 2019

INTRODUCTION:

Morbidity associated with preterm prelabor rupture of membranes (PPROM) is primarily related to infectious complications and gestational age at delivery. Obesity is a known risk factor for adverse pregnancy outcomes. There is no data on the impact of obesity on outcomes in pregnancies with PPROM after 34 weeks.

METHODS:

Secondary analysis of a multicenter retrospective cohort study of singletons with PPROM from January 2011-April 2017. Women with a delivery BMI of ≥30 kg/m2 (obese) were compared to women with a delivery BMI of <30 kg/m2 (non-obese). Pregnancies were also stratified based on hospital delivery policies of expectant management (EM) until 35 weeks versus immediate delivery (ID) ≥34 weeks. The primary outcome was neonatal ventilation. Univariate and general estimating equations models were used with p<0.05 level of significance.

RESULTS:

259 mother-infant dyads were included and 122 (47%) women were obese. Pregnancies complicated by obesity had increased need for neonatal ventilation as compared to non-obese pregnancies (15.4% in obese versus 8.2% in non-obese, adjusted p<0.001). Obesity was also associated with increased neonatal supplemental oxygen administration, surfactant administration and neonatal antibiotic use >72 hours. However, when stratified by delivery practice and obesity only neonatal antibiotic use >72 hours was significantly lower in obese pregnancies with ID (5.9%) as compared to obese pregnancies with EM (25.0%, p=0.004).

CONCLUSION:

Pregnancies complicated by PPROM and obesity have an increased risk for neonatal respiratory and infectious morbidity. These findings suggest that obesity and delivery timing impact perinatal outcomes in pregnancies with late PPROM.
Impact of Regional Variation and Practitioner Bias on Infant Mortality Rate: A Survey Study [12L]
Authors: Polen-De Clarissa , Kamath-Rayne Beena , Goyal Neera , DeFranco Emily A.
Published: May 2019

INTRODUCTION:

Periviable birth is a primary driver of IMR in the US and varies significantly among regions. We measured practice variation in how periviable pregnancy outcomes are categorized and how this impacts reported regional IMRs.

METHODS:

We distributed a 28-item questionnaire to practitioners associated with US birth hospitals. Five clinical scenarios were included to identify how participants classify birth outcomes from 15-22 weeks. Practice characteristics potentially affecting reporting of birth outcomes were assessed. IRB approval was obtained.

RESULTS:

Of 1024 questionnaires distributed, 237 were completed (23% response rate). Responses were compared among US census regions; 8.4% from the Northeast, 56.1% Midwest, 13.9% South, 5.4% West; 16% did not disclose. Despite >90% participants classifying a 14-week loss without signs of life as a miscarriage, 19% would provide a certificate of fetal death. 51% who would not initially provide a certificate would give one upon request, yielding a potential fetal death reporting rate of 32% for a 14-week pregnancy loss. Likewise, 32% would provide a certificate of live birth for a 16-week loss with signs of life, with notable regional variation in classifying this as a live birth (41% Northeast, 44% Midwest, versus 13% South, 18% West, p=0.003).

CONCLUSION:

Practice variation in recording birth outcomes at periviable gestational ages was noted in our study. This may contribute to significant misrepresentation of the frequency of miscarriage, stillbirth and live births and could influence regional variation in reported birth outcomes.
Implementation of an Electronic Pain Management Order Set and the Effect on Postpartum Pain Control [16L]
Authors: Parsanian Lucineh Cristina , Gedeon Myrlande , Clare Camille Angela , Shilkrut Alexander G.
Published: May 2019

INTRODUCTION:

The purpose of this project was to determine whether the implementation of an electronic pain management order set will have an effect on postpartum pain control.

METHODS:

In this IRB exempt quality improvement project, a standardized pain medication order set was implemented and an electronic version placed in the electronic medical record at New York City Health + Hospitals/Metropolitan in March 2016. A retrospective review of randomly selected charts from the postpartum unit was performed from January to December 2016, and pain management satisfaction and the completeness of a pain medication order set were recorded, pre- and post-implementation. The outcomes of the study were pain order completeness on chart review and patients' survey-reported pain management satisfaction scores.

RESULTS:

A total of 209 patient surveys and 292 charts were reviewed. 16.3% of the charts had completed pain medication entry pre-implementation of the order set compared with 78% post-implementation (p<0.0001). After the implementation of the order set, 98.4% of patients answered that pain medication was given immediately after being requested, and 96.7% of patients answered that the pain medication they received relieved their pain compared to 86.2% and 88.5%, respectively, prior to March 2016 (p<0.005 and p<0.0098). Patient pain management satisfaction in the Press Ganey HCAHPS survey was noted to increase from an average of 56% in 2013-2015 to 71.5% in 2016 (p=0.018).

CONCLUSION:

The implementation of a standardized pain management order set is associated with the increased completeness of pain management orders, as well as the improved perception of a patient's pain management satisfaction.
Incidence and Predictors of Psychiatric Illness During Pregnancy and After Delivery Among TRICARE Beneficiaries [23L]
Authors: Ranjit Anju , Androtti Tomas , Jiang Wei , Lutgendorf Monica Ann , Robinson Julian Norman , Haider Adil H.
Published: May 2019

INTRODUCTION:

To determine the incidence and predictors of psychiatric illnesses during pregnancy and within one year after delivery.

METHODS:

This was an IRB approved protocol using TRICARE claims data to identify mothers (without previous psychiatric illness up to two years before pregnancy) who delivered between 2009-2013. The incidence of any psychiatric illness (including peripartum onset depression) during pregnancy and within one year of delivery were identified using ICD-9 codes. Predictors for the development of new psychiatric illness were determined using step-wise logistic regression models adjusted for demographic/clinical characteristics.

RESULTS:

A total of 104,866 women met the inclusion criteria. Among them, 85.4% were 20-34 years of age, 57.4% were White, 12.4% African-American, and 21.5% were active duty women. Among all, 15,636 (14.9%) and 20,566 (19.6%) were diagnosed with at least one psychiatric illness during pregnancy and within one year of delivery, respectively. In multivariable adjusted models, African-American race (aOR [CI]: 1.16 [1.10-1.22]), active duty status (aOR [CI]:1.18 [1.13-1.24]), and severe maternal morbidity during delivery (aOR [CI]: 1.16 [1.02-1.32]) were significantly associated with occurrence of any psychiatric illness within one year of delivery. Active duty women were twice as likely to be diagnosed with post-traumatic stress disorder (aOR [CI]: 2.31 [1.83-2.90]) during pregnancy or after delivery.

CONCLUSION:

In military beneficiaries, development of psychiatric conditions in pregnancy and within a year of delivery is common, and may be associated with race, active duty status and complicated births. Future studies should explore these relationships to assess timing of development of new psychiatric conditions and risk factors for screening and intervention.
Indications for Preterm Birth Stratified by Gestational Age [25L]
Authors: Haddad Andrew , Mokhtari Neggin Bayat , Iqbal Sara Naeem , Fries Melissa H.
Published: May 2019

INTRODUCTION:

Preventive interventions such as 17 alpha hydroxyprogesterone caproate are available to decrease preterm deliveries (PTD); however the rate remains high. In order to identify other opportunities to decrease PTD, we sought to examine the indications that lead to these deliveries.

METHODS:

This was a retrospective cohort study of all PTD from June 1, 2016 to March 31, 2018. IRB number 2018-214 was approved. Causes of PTD were categorized by gestational age (GA) at delivery: category I (23 0/7-27 6/7), II (28 0/6-31 6/7), III (32 0/7-33 6/7), and IV (34 0/7-36 6/7 weeks). The causes were characterized as either fetal anomalies, fetal conditions (intrauterine growth restriction, oligohydramnios, non-reassuring status) or maternal conditions (rupture of membranes, preeclampsia, preterm labor, stillbirth). Multivariable logistic regression analyses were performed to calculate adjusted odds ratios (aOR) with 95% confidence intervals (95% CI), controlling for age, race/ethnicity, parity and body mass index. Category IV was considered as reference.

RESULTS:

Of 694 PTD, 85.6% were due to maternal causes and 14.4% to fetal causes. The rates of fetal causes were higher in category I (36.8%) compared to category IV (10.3%), P<.001. PTD in category I was associated with fetal conditions (aOR 2.24 (95% CI 1.15-4.36) and stillbirth (aOR 7.18 (95% CI 2.28-22.60), whereas PTD in categories II and III was more associated with preeclampsia (aOR 2.61 (95% CI 1.50-4.54) and aOR 1.87 (95% CI 1.09-3.20), respectively)).

CONCLUSION:

While PTD prevention currently focuses on maternal conditions, further studies that focus on fetal indications are required to decrease PTD at earlier gestational ages.
Is First Trimester Maternal Serum Alpha Fetoprotein Predictive of Adverse Pregnancy Outcomes? [30L]
Authors: Dinglas Cheryl , Afsar Nur , Davis Jay , Kim Sara , Herrera Kimberly , Chavez Martin
Published: May 2019

INTRODUCTION:

While elevated second trimester maternal serum alpha fetoprotein (msAFP) has been associated with adverse pregnancy outcomes, the utility of first trimester msAFP (AFP1) in predicting these outcomes is not known. Our objective was to determine the association between AFP1 and ischemic placental disease (a composite of preeclampsia, fetal growth restriction and/or placental abruption). Secondary outcomes included correlation with second trimester msAFP (AFP2), in addition to the association of AFP1 with preterm birth, fetal demise, and spontaneous abortion.

METHODS:

An IRB-approved multi-site retrospective cohort study was performed including all patients with AFP1 as part of routine first trimester aneuploidy screening over from April 2015-August 2016. Pregnancies with multiple gestations and known structural or chromosomal abnormalities were excluded. Delivery records were reviewed for adverse pregnancy outcomes. Spearman correlation coefficient assessed the relationship between AFP1 and AFP2. Fisher exact test and Odds Ratios were used to determine the association between AFP1 and adverse pregnancy outcomes.

RESULTS:

Of 968 patients with AFP1, 847 had complete records available for review (87.5%). There was a positive correlation between AFP1 and AFP2 (rho =0.57, P<.001). There was a significant association between elevated AFP1 (> 2.0 MoM) and ischemic placental disease, 18.9% vs 8.2% (OR 2.6, 95% CI 1.4-4.9). Additionally, there was a significant association between high AFP1 and early onset preeclampsia <34 weeks, spontaneous preterm birth and overall preterm birth.

CONCLUSION:

Elevated first trimester msAFP is associated with ischemic placental disease and preterm birth and may help to identify at risk pregnancies as early as the first trimester of pregnancy.
Is There a Correlation Between Elevated Healthy Start Screen Scores and Development of Postpartum Depression? [32L]
Authors: Roussos-Ross Dikea , Padilla Mikela , Goodin Amie
Published: May 2019

INTRODUCTION:

The incidence of postpartum depression is 15-20%. ACOG currently recommends pregnant women be assessed for depression at least once during the perinatal period. The Healthy Start Screen (HSS), a mandated screening tool of all pregnant women during initial prenatal care in Florida, assesses women at risk for adverse pregnancy related outcomes. HSS scores >6 (maximum score of 14) trigger referrals for additional services. Our aim was to determine whether elevated prenatal HSS scores correlate with elevated postpartum Edinburgh Postnatal Depression Scale (EPDS) scores, thus identifying women at risk for developing postpartum depression (PPD).

METHODS:

A retrospective chart review of 2,816 pregnant women seen within the Department of OBGYN between January 1, 2016 and March 1, 2018 was completed. Patients who had both a HSS and a postpartum EPDS were included (total n=1,738). A HSS score >6 was considered positive, identifying the patient as at-risk. An EPDS score >12 was considered positive for postpartum depression. Logistic regression estimated the relationship between HSS and EPDS.

RESULTS:

An elevated HSS score at the initial prenatal screening was significantly associated with an elevated EPDS score at postnatal assessment (P<0.001). Each additional point on the HSS, regardless of the total HSS score, resulted in a 13% increase in likelihood of having a positive EPDS (OR 1.13; 95% CI 1.09-1.17).

CONCLUSION:

The HSS is a useful tool to identify women at risk for postpartum depression. At-risk women could be screened more frequently, and depression identified earlier, leading to more timely evaluation and treatment. Future studies are warranted.
Current Practices of Obstetrics & Gynecology Providers Regarding Menstrual Health Management During Clinic Visits [36L]
Authors: Espinal Mariana , Trant Amelia A. , Redman Shelby , Kebede Nardos , Sheth Sangini Shah , Fan Linda L.
Published: May 2019

INTRODUCTION:

Menstrual health management (MHM) has gained attention internationally given the relationship between lack of access to menstrual products and absenteeism, poor school or work performance, and increased risk of urogenital infections. There is a dearth of information on how Ob/Gyn providers in the United States address MHM. This study seeks to describe Ob/Gyn providers' MHM practices in a low income clinic population and to assess willingness to recommend reusable menstrual products.

METHODS:

A cross-sectional study of Ob/Gyn providers from private and hospital outpatient women's health practices at Yale New Haven Hospital conducted with a 17-item anonymous questionnaire to assess counseling practices regarding menstrual products. Descriptive statistics were used for analysis.

RESULTS:

Among the 52 providers who responded (response rate 69%): 38.4% sometimes ask patients about their choice of menstrual products, 21.2% always ask, 15.4% ask only when patients bring it up, 17.3% don't usually ask and 7.7% never ask. While most providers (88.5%) were familiar with the menstrual cup and 36.5% think that the menstrual cup would work well for some patients, only 13.5% have recommended it. One-quarter would not recommend the menstrual cup and 42.3% would appreciate more information about the menstrual cup prior to recommending it.

CONCLUSION:

The menstrual cup is a reusable alternative that remains underutilized. There is great need for guidelines to encourage and educate providers regarding MHM that may improve patients' quality of life. Ob/Gyn providers could play an essential role in the improvement of MHM if menstrual products use and patient needs were addressed in clinic visits.
Bleeding Patterns With a 1-Year, Segesterone Acetate/Ethinyl Estradiol Contraceptive Vaginal System [3M]
Authors: Nelson Anita L. , Vieira Carolina Sales , Fraser Ian , Burke Anne E. , Gilliam Melissa , Brache Vivian
Published: May 2019

INTRODUCTION:

A segesterone acetate (SA) 0.015 mg/ethinyl estradiol (EE) and 0.013 mg (per day) contraceptive vaginal system (CVS) can be used for up to 1 year. We analyzed bleeding patterns with CVS use and factors associated with unscheduled bleeding/spotting.

METHODS:

We pooled results from two multicenter, single-arm, open-label, pivotal, phase 3 studies of the SA/EE CVS conducted in 17 US and 7 international sites. Participants followed a 21/7 day in/out schedule of CVS use for up to 13 cycles, and recorded vaginal bleeding daily in paper diaries. Scheduled and unscheduled bleeding/spotting were summarized by cycle. We used multiple logistic regression to identify factors associated with unscheduled bleeding/spotting. To avoid bias from varying study participation lengths, we analyzed the first 4 cycles of CVS use.

RESULTS:

Data from 2070 participants were analyzed. Scheduled bleeding/spotting was documented by 97.9% of women with a mean of 4.6-5.2 scheduled bleeding/spotting days/cycle. Any unscheduled bleeding/spotting ranged from 13.2% to 21.7% of women/cycle; with a mean of 3.4-5.1 days/cycle for those women. Absence of scheduled bleeding/spotting was 5%-8% of women/cycle; absence of any bleeding/spotting (complete amenorrhea) was 2.6%-4.9% of women/cycle. Few women (1.7%) discontinued early due to unacceptable bleeding. Compared with White women, Black/African-American women were more likely to report unscheduled bleeding/spotting (OR 1.49; 95% CI, 1.14-1.94). Body mass index did not influence bleeding patterns.

CONCLUSION:

Participants using the SA/EE CVS up to 13 cycles experienced good cycle control. Discontinuations due to unacceptable bleeding were low. Further research into demographic/other differences with reported bleeding is warranted.
Endometrial Safety With a 1-Year Segesterone Acetate/Ethinyl Estradiol Contraceptive Vaginal System [5M]
Authors: Archer David F. , Barnhart Kurt , Creinin Mitchell D. , Jensen Jeffrey T. , Thomas Michael , Creasy George W.
Published: May 2019

INTRODUCTION:

A new contraceptive vaginal system (CVS) for 13 cycles of use has been developed that releases a daily mean of segesterone acetate (SA) 0.15 mg and ethinyl estradiol (EE) 0.013 mg. We evaluated endometrial safety during use of the SA/EE CVS for up to 13 cycles.

METHODS:

In this multicenter, open-label, phase 3 study, 2308 women used the SA/EE CVS on a 21-day in/7-day out regimen for up to 13 cycles. Women could choose to participate in an endometrial safety sub-study at 5 study sites. Three blinded pathologists histologically examined endometrial biopsies at screening, at cycle 6 in the first 25 women reaching 6 cycles, and at the end of study (cycle 12/13) or early study termination in the remainder. Women with endometrial hyperplasia or cancer at baseline were excluded. We evaluated histologic changes in women with both screening and follow-up biopsies.

RESULTS:

Of the 156 women who participated, 83 had follow-up biopsies. Pathologists identified no cases of endometrial hyperplasia or carcinoma at cycle 6 (n=24), cycles 12/13 (n=30) or other end of therapy times (n=29). The most frequent histologic diagnoses were atrophic/inactive or secretory: atrophic/inactive (29%, 27% and 28%, respectively), secretory (29%, 37%, and 45%, respectively), proliferative (17%, 7%, and 21%, respectively), mixed (17%, 10% and 3%, respectively), menstrual (4%, 7%, and 0%, respectively), or insufficient/no tissue (0%, 10%, and 3%, respectively).

CONCLUSION:

Use of the SA/EE CVS for up to 13 cycles did not result in any unexpected endometrial safety effects based on endometrial histology.
Effect of Daytime Versus Night-time on Outcome in Patients Undergoing Emergent Neurosurgical Procedures
Authors: Qadri Ali H. , Sproule Stephanie , Girling Linda , West Michael , Cappellani Ronald , Chowdhury Tumul
Published: May 2019

Background:

Timing of neurosurgical procedures is controversial. Challenges identified with night-time surgeries include physician fatigue and sleep deprivation, and fewer staff and resources compared with daytime surgery. These might contribute to medical errors and complications, and, hence, worse patient outcomes.

Methods:

This single center retrospective study of 304 patients who underwent emergent neurosurgical procedures between January 1, 2010 and December 31, 2016 included 2 groups based on the timing of surgery: daytime (7:00 amto 6:59 pm) and night-time (7:00 pmto 6:59 am) surgery groups. Patient demographics, diagnosis, surgical characteristics, complications, and neurological outcome were obtained from the medical records.

Results:

There was no difference in patient demographics, intraoperative complications, and length of surgery between the 2 groups. Although there was no statistically significant difference in neurological outcome between the 2 groups at hospital discharge and 1 month postdischarge, there was a higher proportion of patients in the night-time surgical group with unfavorable neurological outcome (Glasgow Outcome Score 1 to 3) at both these times. There were differences in hospital length of stay, location of postoperative management (postanesthesia care unit or intensive care unit), midline shift, baseline Glasgow Coma Scale score, and acuity of surgery between the 2 groups. Logistic regression analysis showed that age, baseline Glasgow Coma Scale score, surgery acuity status, procedure type, and intraoperative complications influenced neurological outcome.

Conclusions:

This study found no difference in the rate of unfavorable neurological outcome in patients undergoing emergent neurosurgical procedures during the daytime and night-time. However, our findings cannot exclude the possibility of an association between timing of surgery and outcome given its limitations, including small sample size and omission of potentially confounding variables. Further well-designed prospective trials are warranted to confirm our findings.
Language Monitoring in Brain Surgery Under General Anesthesia
Authors: Martin Jennifer , Tyrand Rémi , Lopez Ursula , Bernasconi Pertusio Françoise , Lysakowski Christopher , Laganaro Marina , Schaller Karl , Boëx Colette
Published: May 2019

Background:

Awake surgeries for cerebral lesion resection have several limitations including patient fear, discomfort, or pain. This study aimed to determine whether components of language function could be measured under general anesthesia. In this study, the occurrence of mismatch negativity (MMN) was searched in evoked potentials for phonological sounds.

Materials and Methods:

Five normal hearing, French native speaker, awake volunteers participated in evaluating the phonological task (4 females and 1 male). Eleven normal-hearing, French native speaker patients (6 left and 5 right hemisphere lesions) participated at the time of their tumor neurosurgery (3 females and 8 males). Repetitions of the standard syllable /pa/ with the insertion of 1 deviant /po/ were presented through earphones. The difference between averaged epochs of standards and deviants syllables determined the MMN. During surgery, total intravenous anesthesia was performed with propofol and synthetic opioid sufentanil. The bispectral index was targeted (40 to 60).

Results:

The MMN was found in all awake volunteers and validated by an N250 component. In the patient group, the electroencephalogram analysis was not possible in 4 of 11 patients because of anesthesia being too deep, burst suppression, or a high level of noise (>40 μV). Significant N250 response was obtained in 5 of 7 (71.4%) patients under general anesthesia. The 2 other patients also showed MMN which did not reach significance.

Conclusions:

To our knowledge, this is the first demonstration that phonological processing can be measured during brain surgery under general anesthesia, suggesting that some language processing persists under the condition of unconsciousness. These results encourage further study of language processing under general anesthesia with the goal of making intraoperative neuromonitoring.
Outcomes of a Nontraditional Dual Incision Approach for Lisfranc Trauma, Fractures, and Osteoarthritis
Authors: Blazek Cody D. , Patel Neil , Burns Patrick R.
Published: May 2019

Background:

Numerous surgical approaches and treatments for Lisfranc pathology have been described and vary across physicians and surgical specialties. Many incisions to access the tarsometatarsal (TMT) joint complex have been described including single and dual longitudinal as well as transverse. The aim of this study was to retrospectively review and compare complication and fusion rates in patients with a Lisfranc open reduction and internal fixation or arthrodesis utilizing a nontraditional dual incision approach. Incisions were performed dorsal medial to the first TMT and dorsal along the second interspace just medial to the third TMT.

Materials and Methods:

The medical records of 1 foot and ankle surgeon were reviewed of patients who underwent Lisfranc surgery utilizing a dual incision approach for both elective and traumatic procedures. The study period encompassed January 2006 through December 2016. Statistical analysis was performed using information collected from chart-review as well as radiograph evaluation to examine predictors of complications and fusion rates.

Results:

Sixty-eight patients reviewed had the nontraditional dual dorsal incisions, 61 with TMT fusions for arthritis or injury, and 7 open reduction and internal fixation for TMT injuries. In total, 180 joint fusions were performed on the first, second, or third TMTs during arthrodesis. Four of 68 patients were revisions of previously failed fusions. All 68 patients (100%) healed soft tissue without complication. Of the 180 joints that underwent arthrodesis 170 (94.4%) fused successfully. Hardware removal occurred in 10 patients (14.7%) due to discomfort.

Conclusions:

This nontraditional dual incision dorsal approach for Lisfranc surgery has a low wound healing complication rate, in fact none were reported in this sample size of 68 patients. This approach is reproducible for either traumatic or elective procedures of the Lisfranc complex allowing excellent visualization of the medial and central tarsometatarsal joints while removing risk to the neurovascular structures inherent in the more traditional incisions.

Level of Evidence:

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting
Authors: Pinkney Sonia J. , Fan Mark , Koczmara Christine , Trbovich Patricia L.
Published: May 2019

Objectives:

Assess interventions’ impact on preventing IV infusion identification and disconnection mix-ups.

Design:

Experimental study with repeated measures design.

Setting:

High fidelity simulated adult ICU.

Subjects:

Forty critical care nurses.

Interventions:

Participants had to correctly identify infusions and disconnect an infusion in four different conditions: baseline (current practice); line labels/organizers; smart pump; and light-linking system.

Measurements and Main Results:

Participants identified infusions with significantly fewer errors when using line labels/organizers (0; 0%) than in the baseline (12; 7.7%) and smart pump conditions (10; 6.4%) (p < 0.01). The light-linking system did not significantly affect identification errors (5; 3.2%) compared with the other conditions. Participants were significantly faster identifying infusions when using line labels/organizers (0:31) than in the baseline (1:20), smart pump (1:29), and light-linking (1:22) conditions (p < 0.001). When disconnecting an infusion, there was no significant difference in errors between conditions, but participants were significantly slower when using the smart pump than all other conditions (p < 0.001).

Conclusions:

The results suggest that line labels/organizers may increase infusion identification accuracy and efficiency.
Complete Pocket Resection with Regional Flap Closure for Treatment of Cardiac Implantable Device Infections
Authors: Hansalia Riple , Rose Michael I. , Martins Catarina P. , Rossi Kristie
Published: May 2019

Background:

Cardiac implantable electronic device infections are associated with substantial morbidity and mortality. There are varied recommendations in the literature about treatment of the wound after extraction of all hardware, but only conservative, time-consuming approaches such as open packing and negative-pressure therapy along with a long interval before reimplanting any hardware have generally been recommended for the treatment.
1–4

Methods:

A retrospective review was performed of 42 patients treated at Jersey Shore University Medical Center for implantable cardioverter defibrillator and permanent pacemaker infections between July 2010 and April 2018 with an aggressive, multidisciplinary approach utilizing an invasive cardiologist and a plastic surgeon. Clinical and demographic data were collected, and a descriptive analysis was conducted.

Results:

A total of 42 patients, with a median age of 76 years, were selected for our treatment of pacemaker pocket infection. Patients underwent removal of all hardware followed by debridement and flap closure of the wound soon after extraction. Reimplantation was performed when indicated typically within a week after initial extraction and typically on the contralateral side. There were no reports of reinfection and no mortality in all 42 patients treated.

Conclusion:

We found that the aggressive removal of all hardware and excisional debridement of the entire capsule followed by flap coverage and closure of the wound allowed for a shortened interval to reimplantation with no ipsilateral or contralateral infections during the follow-up period.
Polytrauma Transitional Rehabilitation in the Veterans Administration: Implementing the Principles of Person-Centered, Participation-Oriented Rehabilitation
Authors: Malec James F.
Published: May 2019

Objective:

To review principles of person-centered, participation-oriented (PCPO) rehabilitation and introduce their implementation in Veterans Administration (VA) Polytrauma Transitional Rehabilitation Programs (PTRPs).

Background:

Post–hospital rehabilitation for individuals with acquired brain injury (ABI) has evolved toward PCPO rehabilitation, an approach that makes participation goals identified by the person served and his or her significant others the primary focus of rehabilitation. Goals to reduce impairments and increase activities contribute to the achievement of primary participation goals. Research, primarily in the nonveteran population, confirms the effectiveness of PCPO rehabilitation.

Overview:

In the civilian sector, PCPO programs are generally provided locally or regionally in outpatient or community settings to individuals with moderate-severe ABI associated with other traumatic injuries and comorbidities. Because of the geographical dispersion of veterans, the VA provides these services in residential centers serving larger geographical areas. The group of veterans served more often has sustained milder traumatic ABI associated with neuropsychiatric comorbidities, particularly posttraumatic stress disorder and depression. Measuring progress and outcome is important to establish a feedback loop for process improvement. VA PTRPs use state-of-the-science standardized outcome measures and methods for identifying successful cases, that is, the minimal clinically important difference. Vocational reintegration is an important element of PCPO rehabilitation. Articles in this special section detail the development and effectiveness of PTRPs.