bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Type of Opioid Use on Methadone Dose at Delivery in Pregnant Women [13L]
Authors: Rosenthal Emily , Cruz Yury , Reyes Andres , Roman Amanda , Hand Dennis
Published: May 2019

INTRODUCTION:

In our institution, the methadone initiation protocol for treatment of opioid use disorder (OUD) in pregnancy does not differentiate between heroin use and use of prescribed or diverted prescription opioids. We sought to determine whether there is a difference in methadone dose at delivery when comparing these two groups.

METHODS:

This is a retrospective cohort study of pregnant women with OUD treated with methadone at our institution from 2012-2017. The primary outcome was methadone dose at delivery. We compared women with prior heroin use to women with prior prescribed or diverted prescription opioid use alone.

RESULTS:

There were 335 patients identified. Of these, 254 reported heroin use, and 81 reported prescription opioid use alone. There were differences in baseline characteristics. A higher proportion of patients with prior heroin use were white (87 vs. 63%, p<.0001). A lower proportion were multiparous. Patients with prior heroin use had a lower mean initial BMI (25.70 vs. 27.15, p=.039). Prior to adjustment, there was a significant difference in methadone dose at delivery between the two groups (144.4 mg vs. 123.2 mg, p=0.013). After adjustment for covariates, this was no longer significant. In the adjusted model, only race was significant, with non-white women receiving significantly lower doses (107.59 mg vs. 145.75 mg, p<0.001).

CONCLUSION:

After adjusting for race, parity and initial BMI, there is no significant difference in methadone dose at delivery between women with prior heroin use vs. prescription opioid use. Women of non-white race have significantly lower methadone dose at delivery compared to white women.
Impact of Uterine Closure Technique at Time of Cesarean Section on Development of Abnormally-Invasive Placentation [14L]
Authors: Leovic Michael Phillip , Perlow Jordan Hugh
Published: May 2019

INTRODUCTION:

Uterine closure technique at time of cesarean section has been extensively studied with regard to risk of operative bleeding, infectious morbidity, development of wedge defects, and risk of uterine rupture in subsequent pregnancy. Only one study has evaluated subsequent risk of abnormally-invasive placentation (AIP). We seek to describe AIP risk based on hysterotomy closure characteristics at the time of prior cesarean delivery.

METHODS:

A review of participants delivered at a single, large, tertiary care center from 12/15/2011-08/22/2017 was performed. Records were reviewed and data was abstracted pertaining to demographics, pregnancy characteristics, obstetric history, suture use, and tissue pathology. Data was summarized using SAS software, version 9.4.

RESULTS:

Of the 169 cases of AIP, 154 (91.1%) had a history of cesarean section. Information detailing prior hysterotomy closure was available for 48 (31.2%) patients, 9 (39.6%) with single-layer closure and 29 (60.4%) were closed in two layers. There was a statistically-significant difference observed in incidence of AIP among patients with double-layer closures (93.1% vs 41.4%, p 0.035). Closures were performed with Vicryl (n = 32, 20.8%), Monocryl (n = 5, 3.2%), PDS (n = 6, 3.9%), and chromic (n = 4, 2.6%) suture. The incidence of AIP for each group was 81.3%, 100%, 83.3%, and 50%, respectively (p 0.97). Larger suture caliber was associated with an increased incidence of AIP (p 0.032).

CONCLUSION:

Our data suggests that risk of AIP may be influenced by double- vs single-layer hysterotomy closure. Future large, randomized trials are warranted to adequately assess this relationship.
Implementation of a Preterm Labor Evaluation Algorithm in a Multi-State Health System [15L]
Authors: Girardi Gerald J. , Garpiel Susan , Mancuso Sarah , Frame Elizabeth A. , Ruma Michael S.
Published: May 2019

INTRODUCTION:

To determine the effect of implementing a standardized preterm labor (PTL) algorithm in a multiple hospital health system.

METHODS:

We performed a prospective evaluation of patients presenting with PTL at 34 hospitals within the Trinity Health System. Prior to implementation of a PTL algorithm, patients presenting with PTL symptoms were assessed in a manner determined by the clinician. After training, a PTL evaluation algorithm was implemented system-wide as a quality improvement project. The algorithm detailed the use of sterile speculum examination (SSE), fetal fibronectin (fFN) collection and transvaginal ultrasound cervical length (TVCL). Pre- and post-implementation data were compared using Chi-Square tests. Negative predictive value (NPV) was calculated for fFN and/or TVCL testing.

RESULTS:

1,826 women (557 pre- and 1,269 post-implementation) were included in the quality improvement project. The rate of SSE (pre: 51%, post: 68%; P<.0001) and fFN performance (pre: 23%, post: 36%; P<.0001) increased after utilization of the algorithm, while the rate of TVCL remained unchanged (pre: 13%, post: 14%; P>.05). Maternal admission rates decreased with algorithm utilization (pre: 21%, post: 15%; P<.01). Women presenting with PTL symptoms who were not evaluated by fFN or TVCL delivered within 2 weeks at a rate of 24%, while those who received either fFN, TVCL, or both had a rate of 6% (P<.0001). NPV for fFN and/or TVCL diagnostic testing for delivery within 2 weeks is 96.8%.

CONCLUSION:

Use of the PTL algorithm improved the clinical evaluation of patients in our health system and decreased the maternal admission rate.
Increasing Convalescent Leave Duration Has No Effect on Postpartum Physical Fitness [24L]
Authors: Sitler Collin A. , DeGroot David , Langan Kelly L. , Penberthy Sean , Hauret Keith , Gehrich Alan P.
Published: May 2019

INTRODUCTION:

Army Directive 2016-09, effective 2 Feb 2016, increased postpartum convalescent leave from 6 to 12 weeks. While this change is beneficial for Army families, the impact on the mother's ability to meet physical fitness standards postpartum is unknown. Therefore the purpose of this study was to determine the changes in Army Physical Fitness Test (APFT) performance before and after the implementation of the new policy.

METHODS:

Primigravid active duty Army women who delivered at Tripler Army Medical Center between 1 Jan 2011 and 31 March 2017 were eligible for inclusion in the study. APFT data were obtained from the Digital Training Management System; the last test prior to and the first test after pregnancy were used for analysis. Data were analyzed with repeated measures ANOVA and Fisher exact test.

RESULTS:

There were 167 women in the old leave policy cohort and 64 in the new policy cohort. Push-up and sit-up repetitions decreased and run time increased postpartum (33.9±11.2 vs 39.3±11.5 reps, 60.9±14.4 vs 68.1±11.3 reps, 17.8±2.9 vs 16.9±2.2 min, P<.01 for all). There were no significant differences in APFT performance between convalescent leave groups, pre- or postpartum. The proportion of passed APFTs decreased postpartum (pre-pregnancy group 1: 96.3%, group 2: 98.4%; postpartum group 1: 86.2%, group 2: 84.4%) however there was no difference between groups that failed the post-partum APFT, P=0.62.

CONCLUSION:

Our data indicate that the new Army postpartum convalescent leave policy does not adversely affect performance on the APFT, however poorer postpartum APFT performance remains.
Induction Compared to Expectant Management for Women With Gestational Diabetes at Term [26L]
Authors: Nau Christopher Thomas , Has Phinnara , Kole Martha Brown , Rouse Dwight J. , Russo Melissa Lauren , Werner Erika F.
Published: May 2019

INTRODUCTION:

To evaluate the risk of cesarean delivery by gestational week of induction versus expectant management in women with gestational diabetes mellitus (GDM).

METHODS:

We conducted a retrospective cohort study of term women with a singleton gestation and GDM who underwent a trial of labor and delivered between January 2016 and July 2018 at a tertiary care center. Outcomes were compared between women who underwent induction versus expectant management during a given gestational week. The primary outcome was mode of delivery. Maternal and pregnancy characteristics were compared between women in each group.

RESULTS:

Of 401 women with GDM, women induced during the 37th, 38th, and 39th weeks had greater body mass index than those who were expectantly managed and women induced during the 37th and 38th weeks were more likely to have hypertensive disorders of pregnancy. At all gestational ages, women who were induced were less likely to be diet-controlled. Overall, induction during the 39th week was associated with a lower rate of cesarean delivery, 14% compared to 28% with expectant management (P<0.01). This remained statistically significant when women with diet controlled GDM (n=216) were examined separately (11% vs 27%, P=0.02). Induction during the 39th week continued to be associated with a reduced risk of cesarean after adjusting for differences between each group; aOR 0.4 (95% CI 0.2-0.8) for all women with GDM and aOR 0.3 (95% CI 0.1-0.8) for women with diet-controlled GDM.

CONCLUSION:

For women with GDM, labor induction at 39 weeks is associated with a lower rate of cesarean delivery than expectant management.
Influence of Hypertensive Disorders of Pregnancy on Phenotype and Recovery in Peripartum Cardiomyopathy [27L]
Authors: Sangtani Ajleeta , Alrahmani Layan , Parikh Pavan
Published: May 2019

INTRODUCTION:

Peripartum cardiomyopathy (PPCM) and cardiomyopathy secondary to hypertensive disorders of pregnancy (HDP) are considered to represent distinct cardiac entities (i.e. dilated vs hypertrophic cardiomyopathy). The goal of this systematic review and meta-analysis was to determine if HDP alters the odds of recovery and if baseline left ventricle characteristics are significantly different.

METHODS:

Ovid Medline, EMBASE, CENTRAL and Scopus were searched for combinations of the following: hypertension, preeclampsia, cardiomyopathy, peripartum, postpartum or puerperium. Articles describing initial left ventricular ejection fraction (LVEF), odds of recovery (EF >50%) or end diastolic diameter (EDD) amongst those with PPCM were included. Two raters analyzed abstracts and full text to determine eligibility and risk of bias. Risk of bias was determined using the Newcastle-Ottawa scale and the DerSimonian-Laird method was used to combine odds ratios.

RESULTS:

1838 articles were identified and 148 full text articles were reviewed for eligibility, with 11 observational studies meeting criteria. There was substantial agreement for selection (K: 0.817) and for risk of bias (K: 0.633) between raters. There was no significant difference (mean: 1.837%, 95% CI-4.882, 1.282) in baseline LVEF or EDD (1.837 cm, 95% CI-1.104, 4.778) between patients who developed PPCM +/- HDP. Further, recovery rates between groups were similar with OR of 1.870 (95% CI 0.854, 4.094) and a moderate degree of heterogeneity.

CONCLUSION:

Counseling regarding eventual recovery of LVEF after PPCM should not be altered due to the presence of HDP; it is unlikely that a phenotypic difference exists in the cardiomyopathy induced by HDP compared to idiopathic PPCM.
Institutional Experience Using FIGO Protocol 2017 for First Trimester Miscarriages [28L]
Authors: Sepúlveda Rivera Cintia María , Mora Galván Jessica Aideé , Araujo Osvaldo Miranda , Ramírez Santés Victor Hugo
Published: May 2019

INTRODUCTION:

A prospective study, conducted at Instituto Nacional de Perinatología (Mexico) from March to September 2018. Main objective was to evaluate the efficacy of misoprostol according to the International Federation of Gynecology and Obstetrics (FIGO) protocol 2017 in the management of first trimester miscarriages.

METHODS:

All patients first attending at urgency room diagnosed with first trimester miscarriages were given misoprostol according to FIGO protocol 2017. Via of administration varied according to physician. Efficacy was defined as complete uterine evacuation demonstrated by transvaginal scan on 7th day after misoprostol administration; if it was incomplete, an additional course was administrated.

RESULTS:

76 patients were diagnosed with first trimester miscarriage and were treated based on FIGO 2017 protocol. Via of administration was vaginal 36.8%, buccal 30.2%, sublingual 21%, combined 9.2% and oral 2.6%. Main indications were 66.6% missed abortion, 2.5% incomplete abortion and 1.7% anembryonic pregnancy. Mean gestational age was 7.9 weeks. Main comorbidities were myomatosis 9.2%, diabetes mellitus 6.5%, human papillomavirus infection 5.2%, hypothyroidism 3.9%, recurrent gestational loss 2.6% and others 7.8%. Most frequent effects were 72.3% transvaginal bleeding plus pelvic pain, 11.8% isolated transvaginal bleeding, 2.6% slight pain pelvic and 13.1% were asymptomatic. About the efficacy, 93.4% had complete uterine evacuation with one course, 6% required a second course. One patient required manual vacuum aspiration after the second course.

CONCLUSION:

Use of misoprostol according to FIGO 2017 protocol is effective for treating first trimester miscarriage. Via of administration do not affect effectiveness. Patient should receive counselling, follow up and must sign inform consent.
Intrapartum Group B Streptococcus Antibiotic Prophylaxis in Penicillin Allergic Pregnant Women [29L]
Authors: Desravines Nerlyne , Venkatesh Kartik , Hopkins Austin Mitchell , Grant Megan , McGuire Colleen , Boggess Kim A.
Published: May 2019

INTRODUCTION:

To estimate the prevalence of inadequate intrapartum GBS antibiotic prophylaxis in penicillin-allergic pregnant women and identify potentially modifiable risk factors.

METHODS:

We conducted a retrospective cohort study of pregnant women within a medical center healthcare network from 01/1/2014-12/31/2017. Women were included if they 1) were GBS-colonized, defined as a positive urine or rectovaginal culture; 2) delivered at > 37 weeks' gestation, and 3) reported a penicillin/cephalosporin allergy. We excluded women with chorioamnionitis in labor, cesarean delivery without labor, or with incomplete data. Inadequate GBS prophylaxis was defined per CDC guidelines as the use of intrapartum antibiotics other than penicillin, ampicillin, or cefazolin. Multivariable logistic regression models adjusting for race and susceptibility testing were used to predict inadequate GBS antibiotic prophylaxis.

RESULTS:

Of 190 identified women, 5% reported anaphylaxis, 43% hives/shortness of breath/swelling, and 59% rash/itching/urticaria (not mutually exclusive). 63% of women received inadequate antibiotic prophylaxis. In adjusted analyses, non-white race (adjusted odds ratio (aOR): 2.42; 95% CI: 1.19-4.94) and reported reaction of hives/shortness of breath/swelling (aOR: 3.00; 95% CI: 1.54-5.83) were associated with higher odds of inadequate GBS antibiotic prophylaxis compared to those with mild or severe allergies. Those with a reported reaction of rash/itching/urticaria were less likely to receive inadequate prophylaxis (aOR: 0.39; 95 CI%: 0.20-0.77) compared to those with severe allergy.

CONCLUSION:

Inadequate intrapartum GBS antibiotic prophylaxis is frequent among term, penicillin/cephalosporin-allergic women. Efforts to confirm the severity of prior antibiotic allergic reactions and perform penicillin skin testing could potentially increase compliance with CDC guidelines.
Is Incision to Delivery Time Associated With Poor Neonatal Neurological Outcomes in Women With Class 3 Obesity? [31L]
Authors: Varvoutis Megan , Feldman Chelsea , Reiff Emily , Hughes Brenna L. , Grotegut Chad
Published: May 2019

INTRODUCTION:

Morbid obesity has been associated with adverse neonatal outcome. We sought to determine factors associated with adverse outcome, specifically whether incision to delivery time (IDT) was an independent risk factor for poor neonatal outcome in a morbidly obese patient.

METHODS:

Secondary analysis of the MFMU Cesarean Registry. Inclusion criteria were singleton pregnancy, >37 weeks EGA and BMI >40 undergoing cesarean section. Patients were stratified into 2 groups: cesarean for fetal (fetal CS) and non-fetal (non-fetal CS) indications. The primary outcome was a neonatal composite of seizure, CPR <24 hrs, death, ventilatory support >2 d, HIE, pH <7.1 and APGAR 5 <5. Multivariate logistic regression was performed to assess impact of IDT and additional risk factors.

RESULTS:

The primary outcome was observed in 543 and 106 neonates (total n=6325) in the non-fetal CS and fetal CS subgroups respectively. Median IDT was 14.1 m for the non-fetal CS and 7.7 m for the fetal CS respectively. Women with poor neonatal outcome were more likely to be black race, affected by hypertensive diseases of pregnancy, higher BMI, have attempted labor, and have failed a VBAC attempt (Table 1). In the regression model, IDT>90th was not associated with adverse outcomes in the non-fetal CS group and was significantly associated with normal outcomes in the fetal CS group (Table 2).

CONCLUSION:

In the non-fetal CS subgroup, IDT >90th percentile was not associated with adverse outcomes. In the fetal CS subgroup, women with IDT >90th percentile were not associated with an increased risk of morbidity. Black race was associated with poor outcomes in both subgroups.
Counseling for Lubricant Use: The Importance of Sexual Activity and Product Specific Selection [37L]
Authors: Krychman Michael L.
Published: May 2019

INTRODUCTION:

For the woman who suffers from genitourinary syndrome of menopause (GSM) moisturizers and lubricants remain the initial self-directed choice of intervention. There are a plethora of choices and appropriate product selection is often confusing, cumbersome and time-consuming. Lubricants choice differs with respect to characteristics and sexual activity.

METHODS:

An in-office survey was conducted in a random sampling of heterosexual women who attended a community sexual medicine clinic. Participants were anonymous and not financially compensated.

RESULTS:

Thirty women with a mean age of 46 (range 25-67) who were all users of lubricant were surveyed. Ninety-six (96%) of subjects reported improved comfort during coitus, and 87% report improved sexual enhancement whereas 97% reported improved overall sexual pleasure. No adverse effects were reported. Most (75%) preferred silicone over water based products. Many women who used flavored water lubricants said they enhanced sexual playfulness and enjoyment. On a Likert scale of 1-10 where (1 was completely dissatisfied with silicone as a lubricant and 10 most satisfied), participants rated silicone lubricant on average tat 9.1/10. Fifty percent of this sample engage in anal sex where as 70% engage in sexual intimacy in the bath/hot tub or shower and used silicone lubricant for these sexual events.

CONCLUSION:

Lubricant remains an important option for sexual play. Silicone lubricant offers an excellent choice for a variety of sexual situations, and has high patient acceptability, with noted improved sexual enhancement, pleasure and overall satisfaction. Water based lubes that have flavors may offer some dynamic sexual enjoyment for the couple.
Implementation of the Human Papillomavirus Vaccine in the Postpartum Period [39L]
Authors: Plisko Alexandra Marie , Hoyson Jessica Rose
Published: May 2019

INTRODUCTION:

The human papillomavirus (HPV) is the most common sexually transmitted infection, with a lifetime prevalence of 80%. The Food and Drug Administration approved the HPV vaccine in 2006 which through research was found to prevent 95-100% of cervical, vaginal, and vulvar neoplasms as well as anogenital condylomatas in women naïve to HPV. Despite the data, vaccination rates remain low. We hypothesized that the implementation of a comprehensive protocol for the HPV vaccine postpartum would result in improved rates of vaccination in eligible women.

METHODS:

We performed a retrospective chart review of the OBGYN resident clinic patients. The pre-intervention data was collected from March 1, 2017 to August 31, 2017 and post-intervention data from October 1, 2017 to March 31, 2018.

RESULTS:

In the post-protocol group, the rate of HPV vaccination on the postpartum unit was 11.5%, while no patients received the vaccination in the pre-protocol group (P=.06). The percentage of post-protocol patients who received the HPV vaccination at the postpartum visit was 8% vs 2.6% for the pre-protocol patients (P=0.56).19.2% of post-protocol patients compared to 2.6% pre-protocol patients received the vaccination on the postpartum unit or at the postpartum visit (P=.036). Final vaccination rates were 18.4% for the pre-protocol patients and 53.8% for the post-protocol patients (P=.003). The percentage of patients who discussed the HPV vaccination was significantly higher in the post-protocol group with 61.5% vs the pre-protocol group with 0% (P<.001).

CONCLUSION:

Implementation of a comprehensive HPV vaccination protocol resulted in increased discussion of HPV vaccination and postpartum vaccination rates.
A Data-Driven Evaluation of the Size and Content of Expanded Carrier Screening Panels [1M]
Authors: Ben-Shachar Rotem , Svenson Ashley , Muzzey Dale
Published: May 2019

INTRODUCTION:

The American College of Obstetricians and Gynecologists (ACOG) proposed seven criteria for expanded carrier screening (ECS) panel design. To ensure that screening for a condition is sufficiently sensitive to identify carriers and reduce residual risk of non-carriers, one criterion requires a per-condition carrier rate greater than 1-in-100. However, it is unestablished whether this threshold corresponds with a loss of clinical detection. The manner in which these criteria are interpreted and implemented could have an appreciable effect on the ability of ECS to detect at-risk couples. Yet, there has been no data-driven evaluation of the impact of these criteria.

METHODS:

Carrier rates and at-risk couple rates were calculated in 56,281 patients who underwent a 176-condition ECS and evaluated for panels satisfying various criteria. Condition-specific clinical sensitivity was estimated via simulation. This study was exempt from IRB oversight.

RESULTS:

Different interpretations of the 1-in-100 criterion have variable impact: a compliant panel would include between 3 and 38 conditions, identify 11%-81% fewer at-risk couples, and detect 36%-79% fewer carriers than a 176-condition panel. We found no conspicuous change in the ratio of the marginal panel carrier rate relative to the marginal at-risk couple rate that would motivate a 1-in-100 carrier-rate threshold. Simulations suggest that the clinical detection rate remains >84% for conditions with carrier rates as low as 1-in-1000, with detection rates sensitive to condition-specific variant-frequency distributions, which we have compiled.

CONCLUSION:

The 1-in-100 criterion should be reconsidered because it limits at-risk couple detection without substantially easing the burden of testing partners of carriers.
Effectiveness of a Digital Fertility Awareness-Based App for Contraception in the United States [4M]
Authors: Rowland Simon , Kallner Helena Kopp , Gemzell-Danielsson Kristina , Trussell James , Scherwitzl Elina Berglund , Scherwitzl Raoul
Published: May 2019

INTRODUCTION:

There is an unmet need for effective, non-hormonal methods of contraception. Natural Cycles is a digital fertility awareness-based method of contraception delivered in the form of a mobile app. The aim of this study was to assess the effectiveness of the app in a cohort of women from the United States (US).

METHODS:

Data from 18,304 users registered between August 2014 and November 2017 were included in the analysis. Participants were included if they were between 18 and 45 years of age and had at least 20 daily data entries. Questions addressing key characteristics (age, body mass index (BMI) and previous hormonal contraception) were mandatory for onboarding into the app. Other demographics were assessed through in-app messaging. Contraceptive effectiveness during typical use was calculated as both a 13-cycle cumulative probability of pregnancy from a life-table analysis and as a one-year Pearl Index (PI). (EPN, Stockholm, diary number 2017/563-31).

RESULTS:

The mean age of users of the application was 29 years and mean BMI was 22. The majority of the cohort had a university degree or higher (74.8%) and reported being in a stable relationship (85.7%). The 13-cycle failure rate was 6.2% ± 0.5 and the one-year PI was 5.9 ± 0.2.

CONCLUSION:

In this real-world observational study, this digital fertility awareness-based method of contraception had a 13-cycle failure rate of 6.2% in a cohort of users from the US. This is in-line with the typical-use failure rates of Natural Cycles users globally.
Evaluation of a Rapid Urine Test for Preeclampsia in an Antenatal Triage Population [7M]
Authors: Fryer Hugh J.L. , Rood Kara M. , Davis Wendy L. , Buhimschi Catalin Sorin , Buhimschi Irina A.
Published: May 2019

INTRODUCTION:

Preeclampsia-associated morbidity and mortality is most often due to a delay or misdiagnosis Recent studies showed misfolded proteins can be detected in urine of preeclamptic women. The previous research assay has been transitioned to a manufacturable diagnostic device. Here we present the clinical accuracy of the in vitro diagnostic device (GV-CR) intended as an aid in the diagnosis of preeclampsia.

METHODS:

We evaluated 346 frozen urine samples from a prospective study of women referred to a L&D triage center for rule-out preeclampsia. 89 (26%) patients were diagnosed with preeclampsia by expert adjudication with reference to the ACOG 2013 Guidelines. Results were visually scored at 3 minutes after urine was applied to the test device. The user was blinded to case diagnoses. Test results were compared to the adjudicated diagnosis. IRB approval was obtained.

RESULTS:

The cohort comprised 52% multiparous, 91% overweight/obese, 38% early preterm, 31% late preterm, and 31% at term women. Cases were particularly challenging and ambiguous to at least one physician who referred for rule-out preeclampsia. Results showed an 84.1% (95% CI: 75.1-90.3) sensitivity, 76.8% (95% CI: 71.0-81.7) specificity, and a negative predictive value of 93% for the device compared to the adjudicated diagnosis.

CONCLUSION:

This 3-minute urine test demonstrated strong correlation with an adjudicated diagnosis of preeclampsia in this cohort of complex cases referred with an uncertain diagnosis and holds promise as an aid in the diagnosis of preeclampsia. Multicenter clinical studies are warranted.
Nursing Students’ Professional Value Development: Can We Do Better?
Authors: Feller Lisa M. , Fisher MaryDee , Larson June , Schweinle William
Published: May 2019

AIM

The purpose of this study was to identify whether differences exist in nursing professional values based on program type and/or geographic location.

BACKGROUND

Deliberate inclusion of values formation is critical to nursing education and high-quality nursing care. There is limited research comparing professional values development among students in all types of prelicensure RN programs and no research comparing students’ professional values between geographic regions.

METHOD

A secondary analysis was completed of original data collected in three descriptive studies using the Nursing Professional Value Scale-Revised®.

RESULTS

Findings indicate prelicensure nursing students are educated with the values integrated within the American Nurses Association Code of Ethics. Significant differences (p < .05) were found when comparing geographic locations, program types, and Nursing Professional Value Scale-Revised factor scores.

CONCLUSION

Additional research is needed to identify best practices for overall values formation in all program types.
Underrepresentation of Racial Diversity in Simulation: An International Study
Authors: Foronda Cynthia , Prather Susan L. , Baptiste Diana , Townsend-Chambers Colette , Mays Linda , Graham Crystal
Published: May 2019

AIM

The purpose of this study was to: 1) examine the presence of racial diversity in simulation centers globally and 2) determine the opinion of the simulation community related to incorporation of a diversity component into international simulation standards.

BACKGROUND

Leading organizations in nursing education recommend improved efforts toward diversity and inclusion. Research suggests a lack of diversity in simulation-based education.

METHOD

This study employed a mixed-methods design.

RESULTS

Quantitative results demonstrated an underrepresentation of racial diversity in manikins, body parts/task trainers, standardized patients, and simulation facilitators. Two thirds of respondents indicated that international simulation standards should recommend a diversity component. Qualitative findings indicated categories of: 1) challenges of purchasing, realism, and availability; 2) importance of diversity in simulation; 3) representation of the regional population; 4) more diversity considerations needed; and 5) presence of diversity.

CONCLUSION

There is a continued need for diversity advocacy efforts in nursing education.
Therapeutic approach of anaphylaxis
Authors: Tanno Luciana Kase , Alvarez-Perea Alberto , Pouessel Guillaume
Published: May 2019

Purpose of review

Anaphylaxis is a recognized cause of death in all ages, which requires prompt recognition and treatment. We here propose to review the current and new pharmacological treatment of anaphylaxis in the view of the new knowledge in the field that can support the quality practice and empower allergists and health professionals with new tools that can be used to treat symptoms and prevent anaphylaxis.

Recent findings

The recent description of phenotypes provides new insight and understanding into the mechanisms and causes of anaphylaxis through a better understanding of endotypes and application of precision medicine. Several biologic therapies and new devices are emerging as potential preventive treatment for anaphylaxis.

Adrenaline (epinephrine) is still the first-line treatment for any type of anaphylaxis and is recognized as the only medication documented to prevent hospitalizations, hypoxic sequelae and fatalities. β2-adrenergic agonists and glucagon remains as the second-line treatment of anaphylaxis, meanwhile glucocorticoids and antihistamines should be used only as third-line treatment. Their administration should never delay adrenaline injection in anaphylaxis. More intuitive adrenaline autoinjectors design and features are required as well as a worldwide availability of adrenaline autoinjectors. Biological drugs, such as omalizumab, have been used as therapeutic adjuvants as a preventive treatment of anaphylaxis, but cost-effectiveness should be considered individually. Understanding the specifications of underlying mechanisms can potentially support improvements in the patients’ allergological work-up and open the opportunity of developments of potential new drugs, such as biological agents. Expanding knowledge with regard to the presentation, causes, and triggers for anaphylaxis among healthcare providers will improve its diagnosis and management, increase patient safety, and decrease morbidity and mortality.
Serum Biomarkers for the Early Detection of the Early-Onset Neonatal Sepsis
Authors: Ahmed Ali Mahmoud , Mohammed Abdelrahman Tarek , Bastawy Samah , Attalla Hams Ahmed , Yousef Aly Abdelrahman , Abdelrazek MennatAllah Sayed , Fransawy Alkomos Mina , Ghareeb Ahmed
Published: May 2019

Background:

Reducing the hazards of the early-onset neonatal sepsis (EONS) is a priority justifying the further investigation for potential biomarkers for its early diagnosis.

Purpose:

We aimed to investigate the diagnostic value of presepsin, procalcitonin, lactoferrin, interleukin (IL)-6, and IL-8 for the early diagnosis of EONS.

Methods:

A prospective comparative study, including 30 cases with highly suspected EONS and 30 matched controls, was conducted. Besides the complete blood count and blood culture, C-reactive protein, procalcitonin, presepsin, IL-6, IL-8, and lactoferrin were measured at the admission and after 72 hours.

Results:

At the time of the admission, presepsin, procalcitonin, C-reactive protein, and IL-8 were significantly higher in the sepsis group. The levels of presepsin, procalcitonin, and IL-8 significantly decreased after 72 hours of the admission. Presepsin, procalcitonin, IL-8, and IL-6 showed a high diagnostic ability for sepsis at admission with area under the curve of 0.934, 0.798, 0.775, and 0.751, respectively. The cutoff values of presepsin, procalcitonin, IL-8, and IL-6 were 821 pg/mL, 2.3 ng/mL, 54 pg/mL, and 24 pg/mL, with a sensitivity of 88.9%, 72.2%, 83.3%, and 94.4% and specificity of 85.7%, 80.9%, 71.4%, and 52.4%, respectively. Lactoferrin had the lowest diagnostic ability with area under the curve of 0.558.

Implications for Practice:

Presepsin was the most accurate biomarker followed by procalcitonin, IL-8, and IL-6 regarding the early diagnosis and management of EONS. The combination between these biomarkers is highly recommended.

Implications for Research:

Further studies are needed to investigate the diagnostic ability of the combination of these biomarkers.
Predicting disease severity and remission in juvenile idiopathic arthritis: are we getting closer?
Authors: Guzman Jaime , Oen Kiem , Loughin Thomas
Published: May 2019

Purpose of review

To summarize current research on the prediction of severe disease or remission in children with juvenile arthritis, and define further steps needed towards developing prediction tools with sufficient accuracy for clinical use.

Recent findings

High disease activity, poor patient-reported outcomes, ankle or wrist involvement, and a longer time from onset to the start of treatment herald a severe disease course and a low chance of remission. Other studies confirmed that age less than 7 years and positive ANA are the strongest predictors of uveitis development. Preliminary evidence suggests ultrasound findings may predict flare in patients with clinically inactive disease, and several new biomarkers show promise. A few prediction tools that combine predictors to estimate the chance of remission or a severe disease course in the medium-term to long-term have shown good accuracy when internally validated in the population in which they were developed.

Promising candidate tools for predicting disease severity and long-term remission in juvenile arthritis are now available. These tools need external validation in other populations, and ideally formal trials to assess whether their use in practice improves patient outcomes. We are definitively getting closer, but we are not there yet.
Curative-dose Chemoradiotherapy Versus Total Laryngectomy For Stage T3-T4 Squamous Cell Carcinoma of the Larynx
Authors: Bates James E. , Amdur Robert J. , Morris Christopher M. , Hitchcock Kathryn E. , Dziegielewski Peter T. , Boyce Brian J. , Silver Natalie L. , Shaw Christiana , Mendenhall William M.
Published: May 2019

Objective:

Chemoradiotherapy (cRT) and total laryngectomy (TL) are acceptable treatments for locally advanced laryngeal squamous cell carcinoma (LSSC). We aimed to compare the outcomes in patients receiving full-dose treatment.

Methods:

We identified 11,237 patients in the National Cancer Database treated 2004 to 2015 for T3-4N0-3 LSCC with either TL (with 60 to 80 Gy of adjuvant RT) or cRT (70 to 80 Gy). We evaluated differences in overall survival (OS) using Kaplan-Meier and Cox proportional hazards modeling.

Results:

For patients with T3 disease, there was no difference in OS regardless of N stage (N0: hazard ratio [HR]=0.94,P=0.38; N+: HR=0.92,P=0.19). TL was associated with improved OS in patients with T4 disease (N0: HR=1.39,P<0.001; N+: HR=1.22,P=0.001).

Conclusion:

In patients who receive optimal therapy, both TL and cRT offer similar outcomes in T3 but not T4a disease.
Patient Advocacy in Plastic Surgery: An Underutilized Tool
Authors: Mullens Cody L. , Nathan Shelby L. , Kozak Geoffrey M. , Fischer John P. , Greco Gregory A. , Ueno Cristiane M.
Published: May 2019

Healthcare advocacy is an important tool in the plastic surgeon’s arsenal that stands the potential to improve both patient care and the profession. However, many physicians underestimate the importance and influence that healthcare advocacy has on the profession and feel that they lack the leverage and knowledge to advocate on behalf of themselves, their practices, their patients, and their profession, all of which are untrue. Plastic surgeons are uniquely positioned to advocate based on their clinical acumen, personal experiences with patient care, and their position in the healthcare ecosystem value chain. This article aims to equip plastic surgeons with a general framework of knowledge regarding policy and advocacy. Additionally, the article outlines and discusses recent advocacy efforts related to plastic surgery, and efforts that are on the horizon to provide some context to the relevance of advocacy related to plastic surgery. Finally, we aim to empower plastic surgeons to step into the policy advocacy arena for the betterment of our patients and the professional practice of plastic surgery.
Surgical Excision of Keloids Followed by In-office Superficial Radiation Therapy: Prospective Study Examining Clinical Outcomes
Authors: Jones Michael E. , Ganzer Christine A. , Bennett Deanne , Finizio Andrea
Published: May 2019

Background:

Keloids are benign proliferative scars that often occur among individuals of color, and are thought to be the result of excessive collagen deposition that occurs after injury to the skin. The treatment of these scars is difficult with often poor outcomes. This study aimed to evaluate the effectiveness of surgical excision followed by in-office superficial radiation therapy (SRT) as a method to improve keloid remission.

Methods:

Participants for this study were recruited from June 2016 through February 2017 with 48 subjects enrolled and completed this study. All keloids were surgically resected and participants received 3 consecutive days of a customized dose of SRT, with a maximum cumulative dosage of 18 Gy. Patients were followed over the course of 12 months to monitor outcomes.

Results:

In this cohort, we found 39 (81%) to have achieved successful remission with 9 (19%) being classified as refractory. There were no adverse effects or medical complications reported as a part of this study.

Conclusion:

Study outcomes support the clinical benefits of surgical excision followed by SRT as a practical and efficient treatment for keloids.
Hyaluronic Acid Accelerates Re-epithelialization and Alters Protein Expression in a Human Wound Model
Authors: Nyman Erika , Henricson Joakim , Ghafouri Bijar , Anderson Chris D. , Kratz Gunnar
Published: May 2019

Background:

Hyaluronic acid (HA), a large glycosaminoglycan involved in proliferation, migration, and tissue repair, is suggested to be an important factor for keratinocyte activation and re-epithelialization. The experimental hypothesis of this study was that HA accelerates re-epithelialization, and we aimed to investigate the effect of exogenous intradermal HA during deep dermal, incisional wound healing in vivo in humans, the primary endpoint being re-epithelialization.

Methods:

A total of 8 standardized deep dermal incisional wounds (depth 1.6 mm, width 1.8 mm) per subject were induced in 10 healthy volunteers. Two of the wound sites per subject were pretreated with injections of HA and 2 with saline solution. At 2 time points (24 hours and 14 days), 2 biopsies for each treatment group (one for histology and one for proteomics) were taken. Skin erythema was measured at 24-hour intervals for 14 days as a surrogate measurement of inflammation.

Results:

At 24 hours, 8 of 9 wounds pretreated with HA showed complete re-epithelization, whereas none of the wounds pretreated with saline had re-epithelized. Wounds pretreated with HA also showed a 10-fold regulation of 8 identified proteins involved in wound healing compared to wounds treated with saline solution. No difference in inflammation, as measured as erythema, could be seen between any of the groups.

Conclusions:

We conclude that HA accelerates re-epithelialization and stimulates an altered protein expression in vivo in human deep dermal incisional skin wounds, but has no effect on the inflammation process as measured by erythema.
Cranial Suture Measurement by 2-point Method in Ultrasound Screening of Craniosynostosis
Authors: Okamoto Toyoko , Nuri Takashi , Harada Atsuko , Kyutoku Shigeo , Ueda Koichi
Published: May 2019

Background:

Diagnostic imaging for craniosynostosis currently relies entirely on radiation images, but it has been estimated that a risk of cancer from diagnostic x-rays may exist. Use of ultrasound imaging has been reported, but very little has been written on normal findings of the cranial suture. Also, ultrasound diagnostic methods have not been established. To obtain images for the diagnosis of abnormal sutures in craniosynostosis, we investigated the normal ultrasonographic appearance of the suture. To establish screening methods for craniosynostosis, we prepared a 2-point method for simple evaluation and confirmed its usefulness.

Methods:

Ultrasonography was performed in infants with normal head, deformational plagiocephaly, and craniosynostosis. We focused on the measurement indices and decided on the order for making our observations. Furthermore, we developed an evaluation method (2-point method) and recorded our finding in a useful table.

Results:

We could clearly judge whether the cranial suture was patent or closed and were able to measure the suture width. Even for 2-year-old children, the width of the sutures at the points measured exceeded the echocardiographic resolution. By using the 2-point evaluation method, all the sutures could be inspected in about 2 minutes. Sensitivity was 100% and specificity was 95.1%.

Conclusions:

Our present studies showed that normal or abnormal suture can be clearly distinguished by ultrasound. By evaluating the fixed points instead of the whole line, it was possible to shorten the inspection time. Ultrasound screening by applying the 2-point method is very useful.
Hand Function in Apert Syndrome
Authors: Raposo-Amaral Cassio Eduardo , Denadai Rafael , do Monte Lameiro Thais Miguel , de Oliveira Yuri Moresco , Raposo-Amaral Cesar Augusto
Published: May 2019

Background:

The Michigan Hand Questionnaire is widely used to assess hand outcomes in congenital hand deformities. The purpose of the present study is to compare Apert syndrome hand outcomes according to Upton hand type and age stratification with age-matched unaffected controls.

Methods:

The Brief Michigan Hand Questionnaire was administered to 39 Apert patients after completion of the digit separation surgical regimen, and 140 age-matched unaffected controls. Patients were divided into 3 groups according to age. In group 1 (from 4 months to 7 years of age), responses were provided by parents of Apert patients, and in group 2 (from 8 to 17 years of age), patients responded with assistance from their parents, and in group 3 (18 years of age or older), responses were provided by the patients themselves. Groups were substratified according to Upton hand type (type I, II, and III). Comparisons were made among groups, subgroups, and controls.

Results:

Comparisons of hand types for intragroups 1, 2, and 3, did not demonstrate any statistically significant differences (P > 0.05) between hand outcomes according to Upton hand type, regardless of patient age. Comparisons between Apert patients and their age-matched controls demonstrated statistically significant differences (P < 0.05), as the control group had higher outcome scores.

Conclusions:

Similar hand outcomes scores were achieved by all Apert patients regardless of hand type. Following completion of the digit separation regimen, Apert patients presented hand outcome scores that were lower than those of the patients in the normative control group.
The Influence of Surgical Specialty on Oncoplastic Breast Reconstruction
Authors: Blankensteijn Louise L. , Crystal Dustin T. , Egeler Sabine A. , Varkevisser Rens R.B. , Ibrahim Ahmed M.S. , Sharma Ranjna , Lee Bernard T. , Lin Samuel J.
Published: May 2019

Background:

The integration of oncological surgery with reconstructive techniques has gained popularity in the treatment of breast cancer. oncoplastic reconstruction after partial mastectomy can be performed by the breast surgeon or in cooperation with a consulted plastic surgeon. This study aims to objectively assess the differences in outcomes for partial mastectomy and subsequent oncoplastic reconstruction performed by either general surgery alone or in combination with a plastic and reconstructive surgery team.

Methods:

Unilateral oncoplastic breast reconstruction cases were extracted from the National Surgical Quality Improvement Program databases from 2005 to 2017. Outcomes of cases performed by the general surgery team alone were compared with those in which the partial mastectomy was performed by the general surgeon with subsequent reconstruction performed by plastic surgeons. To account for cohort baseline differences, propensity score-matched analysis was performed.

Results:

In total, 4,350 patients were included in this study; 3,759 procedures were performed by general surgery alone versus 591 combined with plastic surgery. The analysis of propensity score-matched cohorts, comprising 490 patients each, showed no statistical difference in the risk for postoperative complications when surgery was performed by either of the 2 specialty services. A longer operative time and length of stay were found in the group reconstructed by plastic surgeons.

Conclusions:

This study found no significant differences in adverse postoperative outcomes for oncoplastic reconstructions after partial mastectomy between the 2 groups. The data may indicate collaboration between both surgical specialties in oncoplastic breast care was not associated with increased morbidity in these patients.
Inspiratory Muscle Training After Heart Valve Replacement Surgery Improves Inspiratory Muscle Strength, Lung Function, and Functional Capacity
Authors: Cargnin Camila , Karsten Marlus , Guaragna João Carlos Vieira da Costa , Dal Lago Pedro
Published: May 2019

Purpose:

The aim of this study was to analyze the effects of inspiratory muscle training (IMT) as a therapeutic strategy after heart valve replacement surgery (HVRS).

Methods:

A double-blind, randomized, clinical trial that included patients undergoing elective HVRS, without post-operative complications, were allocated to 2 groups: IMT group (IMT-G) and IMT placebo group (IMT-PG). The IMT started 3 d after surgery and was performed twice daily for 4 wk. Lung function, maximum inspiratory pressure (MIP) as a measure of inspiratory muscle strength, functional capacity, and quality of life were assessed pre-operatively and at the end of training.

Results:

The IMT-G recovered pre-operative MIP and lung function values after 4 wk of training. This group also increased the distance walked during the 6-min walk test (6MWD). In the IMT-PG, the values of MIP were below those found pre-operatively, with impairment of lung function and lower 6MWD in the final evaluation. At the end of IMT, MIP was correlated with the 6MWD and with the spirometry variables.

Conclusions:

IMT performed for 4 wk after HVRS was effective in restoring the values of inspiratory muscle strength and lung function to the pre-operative level and increasing the functional capacity assessed by the 6MWD. Furthermore, an association between lung function and functional capacity was observed, demonstrating the clinical relevance of the use of IMT in the rehabilitation process of these patients.