bluuebunny/crossref_metadata_2025 huggingface dataset:
North American Prodrome Longitudinal Study
Authors: Gupta Nikhil , Srihari Vinod H.
Published: May 2018

This chapter provides a summary of a landmark study on schizophrenia. The question studied was “In patients identified clinically to be at high risk for psychosis, which variables (or their combinations) best predict conversion to schizophrenia or another psychotic disorder?” Starting with that question, it describes the basics of the study, including funding, study location, who was studied, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. This study demonstrates that presence of some characteristics can better prognosticate conversion of a prodromal state to a psychotic disorder. Finally, the chapter briefly reviews other relevant studies and information, discusses implications, and concludes with a relevant clinical case.
Levomethadyl Acetate versus Buprenorphine versus Methadone for Opioid Dependence
Authors: Ross Robert , Fuehrlein Brian
Published: May 2018

This chapter provides a summary of a landmark study on substance use disorders. Which of the following is most effective for treatment of opioid dependence: levomethadyl acetate, buprenorphine, high-dose methadone, or low-dose methadone? Starting with that question, it describes the basics of the study, including funding, study location, who was studied, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, discusses implications, and concludes with a relevant clinical case. The study demonstrates that buprenorphine, high-dose methadone, and levomethadyl acetate are equally effective in the treatment of opiate use disorder. All three treatments are significantly more effective than low-dose methadone.
Antiplatelet Agents
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Antiplatelet agents are commonly used in vascular medicine and cardiology, but also in the pharmacologic management of patients with ischemic stroke. Aspirin alone remains the mainstay of therapy for secondary stroke prevention. Several landmark studies for the optimal duration and dose of antiplatelet therapy in stroke prevention are discussed. Dual antiplatelet therapy is needed after carotid artery stenting. Situations where antiplatelet agents also come into play are endovascular procedures associated with procedure-related thrombi. Antiplatelet agents have different mechanisms of action, and each will be discussed. Testing of platelet function and the issue of antiplatelet resistance and discontinuation of antiplatelet agents before procedures will be discussed in this Chapter.
Fluid Therapy
Authors: Wijdicks Eelco F. M. , Clark Sarah L.
Published: May 2018

Administration of intravenous fluids for maintenance and the more consequential fluid resuscitation are common therapeutic interventions in the neurosciences intensive care unit. Intravenous fluids are provided to ensure adequate hydration because acutely ill neurologic patients often cannot swallow safely. There is a reason to use certain types of fluids and certain measures to maintain an adequate fluid balance specifically in patients admitted to the neurosciences ICU. This chapter covers the regulation of fluid status and the effect of certain fluids on intravascular volume. Daily fluid requirements and the best methods of resuscitation are discussed. The chapter also outlines fluid solutions and the infusion rate associated with different techniques. The side effects of large-volume resuscitation are emphasized.
Introduction
Authors: Shorter Edward , Fink Max
Published: May 2018

Catatonia is a syndrome that is identifiable, verifiable, and eminently treatable, unlike other disorders in the roster of psychiatric diseases. Catatonia is not a form of “schizophrenia,” and, although it may “piggyback” on other diseases, it is also a disease in its own right. Today, catatonia is often not recognized; clinicians and the public are more familiar with the term as a subtype of “schizophrenia.” Failure to diagnose it is very common. This introduction documents the earliest descriptions of the disorder and its treatment and gives a brief history of the acceptance of the term “catatonia” by the psychiatric discipline. The authors emphasize the importance of recognizing the symptoms of catatonia and appreciating how straightforward its treatment is. Proper recognition is important because catatonia may be life-threatening, so diagnosing and treating it properly are matters of importance.
Polyarticular disease
Authors: Adebajo Ade , Dunkley Lisa
Published: May 2018

Polyarticular disease is a commonly encountered musculoskeletal problem which regularly confronts clinicians as a diagnostic dilemma. Polyarticular disease is a musculoskeletal presentation in which more than four joints are affected by the disease. The classical rheumatological condition which presents as polyarticular disease is rheumatoid arthritis, although even this condition can very occasionally present with a mono- or oligoarticular onset. Polyarticular disease includes a wide range of musculoskeletal conditions including such disorders as polyarticular gout, the seronegative spondyloarthropathies, rheumatic fever, and systemic lupus erythematosus. This chapter emphasizes how through a careful history, thorough clinical examination and appropriate investigations, a definitive diagnosis can be made in a patient presenting clinically with polyarticular disease. General management principles for patients with polyarticular disease are also provided.
Pain and fatigue
Authors: McCabe Candy , Haigh Richard , Cohen Helen , Hewlett Sarah
Published: May 2018

Pain and fatigue are the prominent problems for those with a rheumatic disease, and are often underestimated by clinicians. Symptoms may fluctuate in quality and intensity over time and commonly will vary over the course of a day. For pain, clinical signs and symptoms will be dependent on the source of the pain and whether causative underlying pathology is identifiable or not. Fatigue may range from mild effects to total exhaustion and may include cognitive and emotional elements, with a complex, probably multicausal, pathway. Theoretical knowledge of potential mechanistic pathways for pain and fatigue should be used to inform assessment and treatment approaches. Best practice recommends a multidisciplinary and holistic treatment approach with the patient an active participant in the planning of their care, and self-management. Many patients with chronic musculoskeletal conditions will not achieve a pain-free or fatigue-free status. Medication use must therefore balance potential benefit against short- and long-term side effects. Rheumatology centres should offer specific fatigue and pain self-management support as part of routine care. Emphasis should be given to facilitating self-management strategies for both pain and fatigue to help the patient optimize their quality of life over years or a lifetime of symptoms. Interventions should include behaviour change and cognitive restructuring of pain/fatigue beliefs, as well as access to relevant self-help groups and charitable organizations. Referral for specialist advice from regional or national clinics on pain relief and management should be considered if pain interferes significantly with function or quality of life despite local interventions.
Design of clinical trials in rheumatology
Authors: Strand Vibeke , Sokolove Jeremy , Chu Alvina D.
Published: May 2018

Development of new therapies for rheumatic diseases requires a series of randomized controlled trials (RCTs) progressing from phase 1, ’first-in-human’ to generate initial safety, pharmacokinetic (PK) and pharmacodynamic (PD) data; to phase 2, proof of concept for efficacy with safety and PK/PD data; and phase 3, designed to demonstrate definitive efficacy and safety to support regulatory approval. Important aspects of RCT designs include sample size estimations, treatment allocation, rescue, blinding, and statistical analyses of prespecified endpoints to preserve trial integrity. Over the past 15 years, significant progress has been made in the design of RCTs in rheumatoid arthritis (RA). Similarly, development and validation of composite outcome measures in psoriatic arthritis, ankylosing spondylitis, gout, and osteoarthritis have furthered trial design and treatment approvals. RCTs in systemic lupus erythematosus and other multisystem, heterogeneous diseases pose more challenges. Trial design will continue to evolve as promising therapies are introduced into the clinic.
Imaging in children
Authors: Gerety Emma , Johnson Karl
Published: May 2018

The radiological findings of the rheumatological conditions that occur in childhood, are in the majority of cases similar to those in the adult. However, there are some specific and unique features seen only in the paediatric population. Often these features reflect the immature nature of the child’s skeleton and the fact that growth is not yet complete. Radiology is important in helping to establish the diagnosis and in the long-term management of the child.
The most appropriate test, promptly performed and avoiding the child unnecessary discomfort, is the ideal. An understanding of the disease process, as well as the advantages and the limitations of each imaging modality, by both clinician and radiologist, is important. Collaboration between the requesting physician and radiologist will improve the quality of the service provided to the child.
Vaccination in immunocompromised children
Authors: Heijstek Marloes , Abinun Mario , Wulffraat Nico
Published: May 2018

Can immunocompromised children be safely and effectively vaccinated? This chapter discusses the recommendations from the European League Against Rheumatism (EULAR) for the immunization of immunocompromised patients. Patients with rheumatic or autoinflammatory diseases treated with high-dose glucocorticoids, high-dose disease-modifying antirheumatic drugs (DMARDs), or biologicals are considered immunocompromised. Safe and effective vaccination is crucial in these patients, given their increased risk of infection.
Safe vaccination implies that vaccination has no effect on disease activity and has only mild adverse effects. Effective vaccination denotes that patients are protected against infections after immunization. Particularly in severely immunosuppressed patients, concerns arise on the safety of (live-attenuated) vaccines and on the detrimental effect of immunosuppressive treatment on the immunogenicity of vaccines.
Overall, vaccinations do not increase disease activity and do not cause severe adverse events. It is recommended to withhold live-attenuated vaccines in patients on high-dose immunosuppressive drugs and biologicals, but booster vaccinations can be considered when essential.
Generally, immunogenicity of vaccines is good with some exceptions: responses are reduced in patients on high-dose glucocorticoids and rituximab; methotrexate reduces responses to (pneumococcal) polysaccharide vaccines; and tumour necrosis factor alpha (TNFα‎‎) may lower vaccine-induced antibody concentrations and may cause accelerated waning of immunity. Offering vaccination before immunosuppressive drugs and/or measuring antibodies after immunization is recommended.
Antirheumatic drugs in pregnancy and lactation
Authors: Marshall Tarnya , Abdulkader Rita , Sharma Poonam , Malpas Alice
Published: May 2018

Antirheumatic drugs in pregnancy and lactation are increasingly a common clinical dilemma. With the shift towards early, aggressive control of autoimmune diseases and with the advent of newer therapeutic agents, there is a need to understand the effects of these medicines in pregnancy and lactation, on fertility in both men and women, and on the process of spermatogenesis, in order to understand the risk of teratogenesis.
Although there are some limited data available for the use of antirheumatic drugs in pregnancy and lactation, much of our knowledge is derived from animal models and from limited clinical experience in human pregnancy.
The balance of therapeutic benefits and risks of harm to mother and fetus should always be carefully considered: it may vary between individuals and should be assessed on a case by case basis. Because of these issues, pregnancy should always be discussed and planned in advance, in part to reduce disease activity prior to conception but also to minimize risk to the fetus.
In this chapter we use the available evidence to discuss medicines which are commonly used in the treatment of rheumatological autoimmune diseases, and cover disease-modifying antirheumatic drugs (DMARDS) and biological agents.
Systemic lupus erythematosus—management
Authors: Dey Ida Dzifa , Isenberg David
Published: May 2018

Systemic lupus erythematosus (SLE) is an autoimmune rheumatic disease with varied presentation and a disease course characterized by remission and flares. Over the last 50 years the prognosis of SLE has improved considerably. The introductions of corticosteroids and later of cytotoxic drugs, dialysis, and renal transplantation were the major contributors to this improvement.
Nevertheless, the treatment and general management of lupus continues to present a challenge. While lupus may, for some patients, represent a relatively mild set of problems, many others require large doses of immunosuppressive drugs, which carry long-term concerns about side effects.
New immunotherapeutic drugs, with actions more closely targeted to the immune cells and molecules involved in the pathogenesis of SLE, are being introduced and the future looks promising. The role of early atherosclerosis and cardiovascular disease as a cause of death in patients with SLE is increasingly recognized and will present further challenges in the future.
Systemic sclerosis
Authors: Denton Christopher P. , Moinzadeh Pia
Published: May 2018

The term ’scleroderma’ describes a group of conditions in which the development of thickened, fibrotic skin is a cardinal feature. This includes localized forms of scleroderma (e.g. morphoea) and also systemic forms of the disease that are more correctly termed systemic sclerosis.
Systemic sclerosis (SSc) is a multiorgan, autoimmune disease that has a high clinical burden and mortality, due to affecting the skin as well as internal organs. As with other related diseases there is a female predominance and marked clinical diversity. The pathogenesis of SSc is not fully elucidated; it includes endothelial cell injury fibroblast activation and autoimmunity that lead to skin and internal organ manifestations. The majority of cases exhibit characteristic serum autoantibodies. Some of these antibodies are scleroderma-specific reactivities including anti-centromere (ACA), anti-topoisomerase-1 (ATA or Scl 70) or anti-RNA polymerase III antibodies. These anti-nuclear antibody (ANA) patterns are generally mutually exclusive and serve as useful clinical markers of disease subgroups. Additional subsetting of scleroderma cases, based on the extent of skin sclerosis, permits classification into limited and diffuse subsets. Because of the heterogeneity of the disease patients may suffer from different organ manifestations, such as lung fibrosis, hypertensive renal crisis, severe cardiac disease, gastrointestinal involvement, and pulmonary arterial hypertension. Although outcomes have improved recently, systemic sclerosis still has the highest case-specific mortality of any of the autoimmune rheumatic diseases and requires careful and systematic investigation, management and follow-up. Treatment includes symptomatic strategies with attention to each involved organ system; it is still an area where therapeutic progress and better understanding of pathogenesis is increasingly anticipated.
HealthStart: An Innovative Pilot Model Promoting Diversity in Nursing Education
Authors: Vignato Julie A. , Guinon Teresa
Published: May 2018

This article describes a pilot model for promoting diversity in prelicensure nursing education. The National League for Nursing calls on nursing education leadership to recruit, retain, and graduate diverse students to promote nursing diversity and decrease health disparities. Scaffolding contextualized learning through a learning community and “The Puente Project” bicultural and bilingual outreach guidelines were combined to create HealthStart. Retention rates increased by 23.5 percent in a predominately low socioeconomic, racially and ethnically diverse population. It was found that multiple modalities promote student success and diversity in prelicensure nursing education.
Implementing a Theoretical Debriefing Model in a Prelicensure BSN Program
Authors: Turrise Stephanie L. , Arms Tamatha , Jones Carolyn W. , White Patricia H.
Published: May 2018

The National League for Nursing and International Nursing Association for Clinical Simulation and Learning stress that debriefing fosters critical reflection and is essential to all educational settings. The call to action for nurse educators is to incorporate theory-based debriefing throughout the curriculum. This article reports on how one school of nursing implemented the theory-based model, Debriefing for Meaningful Learning©, into the prelicensure baccalaureate curriculum.
New Graduate Nurse Experiences in Clinical Judgment: What Academic and Practice Educators Need to Know
Authors: Lusk Monagle Janet , Lasater Kathie , Stoyles Sydnee , Dieckmann Nathan
Published: May 2018

AIM

The aim of the study was to determine if use of a structured reflection exercise using a clinical judgment framework would result in more practice-ready new graduate nurses (NGNs).

BACKGROUND

Clinical judgment is a critical skill for all nurses, yet it is identified as a deficit in NGNs.

METHOD

Seventy-four NGNs in two groups participated in this mixed-methods study in their first year in practice. Scores from two quantitative measures were collected for all participants. The Lasater Clinical Judgment Rubric framed the structured intervention.

RESULTS

Although the quantitative data showed no significant differences between the groups, use of the reflection exercise indicated a positive impact on NGNs. Qualitative data revealed four themes that present challenges for preparation of NGNs: enhancing communication, finding interprofessional support, responding to complexity of care, and appreciating the role of the nurse.

CONCLUSION

Implications provide guidance for academic and practice educators to smooth the transition into practice.
Interactive Versus Passive Distraction and Parent Psychoeducation as Pain Management Techniques During Pediatric Venepuncture
Authors: Newell Anna , Keane Jennifer , McGuire Brian E. , Heary Caroline , McDarby Vincent , Dudley Bernie , Moran Josh , Francis Kady , Caes Line
Published: May 2018

Objectives:

The aim of the current research was to compare the relative efficacy of interactive and passive distraction, with or without parental psychoeducation, on child pain and distress during a venepuncture. We also compared the effect of parental psychoeducation on parental distress, knowledge of distraction strategies, and engagement in distraction.

Materials and Methods:

This cross-sectional study included 213 children scheduled for a venepuncture, and one of their parents, who were randomly allocated to 1 of 4 conditions; interactive distraction, passive distraction, interactive distraction with parent psychoeducation, and passive distraction with parent psychoeducation. Analyses of covariances were used to investigate the impact of distraction type and the use of parent psychoeducation on child and parent pain-related outcome variables.

Results:

Statistical analyses revealed no significant differences between groups for child-reported pain and distress. The parents of children who received interactive distraction reported significantly higher levels of distress than the parents of children who received passive distraction. Parents who received parent psychoeducation had a significantly higher level of knowledge than parents who did not receive psychoeducation, but did not engage in more effective pain management behavior.

Conclusions:

The results indicated that distraction type did not have a significantly different influence on child pain-related outcome variables. In addition, while psychoeducation was demonstrated to be effective in increasing parental knowledge, it was not sufficient to change parental behavior.
Factor Structure and Psychometric Properties of the Neonatal Eating Assessment Tool—Bottle-Feeding (NeoEAT—Bottle-Feeding)
Authors: Pados Britt Frisk , Thoyre Suzanne M. , Estrem Hayley H. , Park Jinhee , McComish Cara
Published: May 2018

Background:

Feeding difficulties are common in infancy. There are currently no valid and reliable parent-report measures to assess bottle-feeding in infants younger than 7 months. The Neonatal Eating Assessment Tool (NeoEAT)—Bottle-feeding has been developed and content validated.

Purpose:

To determine the factor structure and psychometric properties of the NeoEAT—Bottle-feeding.

Methods:

Parents of bottle-feeding infants younger than 7 months were invited to participate. Exploratory factor analysis was used to determine factor structure. Internal consistency reliability was tested using Cronbach α. Test-retest reliability was tested between scores on the NeoEAT—Bottle-feeding completed 2 weeks apart. Construct validity was tested using correlations between the NeoEAT—Bottle-feeding, the Infant Gastroesophageal Reflux Questionnaire—Revised (I-GERQ-R), and the Infant Gastrointestinal Symptoms Questionnaire (IGSQ). Known-groups validation was tested by comparing scores between healthy infants and infants with feeding problems.

Results:

A total of 441 parents participated. Exploratory factor analysis revealed a 64-item scale with 5 factors. Internal consistency reliability (α= .92) and test-retest reliability (r = 0.90; P < .001) were both excellent. The NeoEAT—Bottle-feeding had construct validity with the I-GERQ-R (r = 0.74; P < .001) and IGSQ (r = 0.64; P < .001). Healthy infants scored lower on the NeoEAT—Bottle-feeding than infants with feeding problems (P < .001), supporting known-groups validity.

Implications for Practice:

The NeoEAT—Bottle-feeding is an available assessment tool for clinical practice.

Implications for Research:

The NeoEAT—Bottle-feeding is a valid and reliable measure that can now be used in feeding research.

Video Abstract Available at
https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.
Outcomes of Hysterectomy Performed by Very Low-Volume Surgeons
Authors: Ruiz Maria P. , Chen Ling , Hou June Y. , Tergas Ana I. , St. Clair Caryn M. , Ananth Cande V. , Neugut Alfred I. , Hershman Dawn L. , Wright Jason D.
Published: May 2018

OBJECTIVE:

To perform a population-based analysis to first examine the changes in surgeon and hospital procedural volume for hysterectomy over time and then to explore the association between very low surgeon procedural volume and outcomes.

METHODS:

All women who underwent hysterectomy in New York State from 2000 to 2014 were examined. Surgeons were classified based on the average annual procedural volume as very low-volume surgeons if they performed one procedure per year. We used multivariable models to examine the association between very low-volume surgeon status and morbidity, mortality, transfusion, length of stay, and cost.

RESULTS:

Among 434,125 women who underwent hysterectomy, very low-volume surgeons accounted for 3,197 (41.0%) of the surgeons performing the procedures and operated on 4,488 (1.0%) of the patients. The overall complication rates were 32.0% for patients treated by very low-volume surgeons compared with 9.9% for those treated by other surgeons (P<.001) (adjusted relative risk 1.97, 95% CI 1.86–2.09). Specifically, the rates of intraoperative (11.3% vs 3.1%), surgical site (15.1% vs 4.1%) and medical complications (19.5% vs 4.8%), and transfusion (38.5% vs 11.8%) were higher for very low-volume compared with higher volume surgeons (P<.001 for all). Patients treated by very low-volume surgeons were also more likely to have a prolonged length of stay (62.0% vs 22.0%) and excessive hospital charges (59.8% vs 24.6%) compared with higher volume surgeons (P<.001 for both). Mortality rate was 2.5% for very low-volume surgeons compared with 0.2% for higher volume surgeons (P<.001) (adjusted relative risk 2.89, 95% CI 2.32–3.61).

CONCLUSION:

A substantial number of surgeons performing hysterectomy are very low-volume surgeons. Performance of hysterectomy by very low-volume surgeons is associated with increased morbidity, mortality, and resource utilization.
A Simulator for Breech Extraction of the Second Twin
Authors: Birsner Meredith L.
Published: May 2018

BACKGROUND:

Breech extraction of a second twin is a skill useful for any health care provider planning on undertaking vaginal delivery of twins. However, training opportunities in this skill may be limited.

METHOD:

Using readily available supplies, a reusable model neoprene uterus can be constructed, as can a balloon model to simulate a fetus in the amniotic cavity.

EXPERIENCE:

The model allowed demonstration of skills expected of trainees and is easy to construct. A simulated vagina addition increased extraction difficulty and increased the probability of balloon (amniotic sac) rupture during simulation. A hysterotomy addition enhanced model applicability for use at simulated cesarean delivery of the breech fetus.

CONCLUSION:

This educational device for simulation of breech extraction realistically simulates a fetus suspended in an amniotic cavity and challenges learners to use tactile cues for prompt and proper identification, grasping, and delivery of the fetal foot or feet.
Delivery of the Nonpresenting Twin First
Authors: Weiner Eran , Barrett Jon , Ram Maya , Lipworth Hayley , Mizrachi Yossi , Bas Lando Maayan , Melamed Nir
Published: May 2018

OBJECTIVE:

To estimate the rate of delivery of the nonpresenting twin first and to identify risk factors for such an event by using a cohort of opposite-sex twins for whom the intrauterine order was well documented with ultrasonography before delivery.

METHODS:

We conducted a retrospective cohort study of all opposite-sex dichorionic twins in a single tertiary center between 2002 and 2016. Reports of ultrasonograms performed less than 2 weeks before birth were reviewed for information on twins' presenting order in relation to fetal sex. Intrauterine labeling was compared with labeling at the time of birth. Multivariable regression analysis was used to identify factors associated with delivery of the nonpresenting twin first.

RESULTS:

Of 1,746 women with dichorionic twin pregnancies, 942 (53.9%) had opposite-sex twins and 617 had recent data on ultrasonographic twin labeling. In 456 of 617 (73.9%) pregnancies, both twins were delivered by cesarean delivery and in 161 of 617 (26.1%) pregnancies, one or both twins were delivered vaginally. The overall rate of delivery of the nonpresenting twin first was 6.8% (95% CI 4.5–9.1%, 31/456) in the cesarean group; there were no deliveries (95% CI 0.0–2.3%, 0/161) of the nonpresenting twin first in the vaginal group (P=.001). The following factors were independently associated with delivery of the nonpresenting twin first at cesarean delivery: discordance greater than 25% in birth weights (17.5%, adjusted odds ratio [OR] 4.0, 95% CI 1.7–9.1), nonvertex presentation of the presenting twin (11.6%, adjusted OR 3.8, 95% CI 1.7–8.3), and gestational age less than 32 0/7 weeks (14.9%, adjusted OR 3.6, 95% CI 1.6–7.8).

CONCLUSIONS:

Delivery of the nonpresenting twin first in dichorionic, opposite-sex twins at the time of birth occurs in 6.8% of cesarean deliveries. Clinicians and researchers should be aware of this phenomenon because it has implications for neonatal care and long-term outcome.
Fetal Growth Patterns in Pregnancies With First-Trimester Bleeding
Authors: Bever Alaina M. , Pugh Sarah J. , Kim Sungduk , Newman Roger B. , Grobman William A. , Chien Edward K. , Wing Deborah A. , Li Hanyun , Albert Paul S. , Grantz Katherine L.
Published: May 2018

OBJECTIVE:

To assess the relationship between first-trimester vaginal bleeding and fetal growth patterns.

METHODS:

We conducted a secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies–Singletons, a prospective cohort study of low-risk, nonobese women with healthy lifestyles. Duration of bleeding was self-reported at enrollment (10 0/7 to 13 6/7 weeks of gestation) and categorized as 0, 1, or more than 1 day. Longitudinal measures of fetal biometrics were obtained in up to six study visits, and estimated fetal weight was computed. Growth trajectories were created for biometrics and estimated fetal weight. When global tests among groups was significant (P<.05), week-specific global and pairwise differences were tested. Birth weight and risk of a small-for-gestational-age (SGA) neonate were secondary outcomes. All analyses were adjusted for maternal age, weight, height, parity, and racial–ethnic group and neonatal sex in a sensitivity analysis.

RESULTS:

In 2,307 eligible women, 410 (17.8%) reported first-trimester bleeding, of whom 176 bled for 1 day and 234 bled for more than 1 day. Women with more than 1 day of bleeding demonstrated decreased fetal abdominal circumference from 34 to 39 weeks of gestation compared with women without bleeding. For women with more than 1 day of bleeding, compared with women without bleeding, estimated fetal weight was 68–107 g smaller from 35 to 39 weeks of gestation. Mean birth weight at term was 88 g smaller, confirming differences in calculated fetal weight, and SGA neonates were delivered to 148 (8.5%), 9 (5.7%), and 33 (15.7%) women in the no bleeding, 1 day, and more than 1 day of bleeding groups, respectively.

CONCLUSION:

More than 1 day of first-trimester vaginal bleeding was associated with smaller estimated fetal weight late in pregnancy driven by smaller abdominal circumference. The magnitude of decrease in birth weight was small, albeit comparable with observed decreases associated with maternal smoking. It remains unknown whether early pregnancy bleeding is associated with short-term or long-term morbidity and whether additional intervention would be of benefit.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT00912132.
Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use
Authors: Dickson Betsy , Mansfield Chanel , Guiahi Maryam , Allshouse Amanda A. , Borgelt Laura M. , Sheeder Jeanelle , Silver Robert M. , Metz Torri D.
Published: May 2018

OBJECTIVE:

To characterize recommendations given to pregnant women by Colorado cannabis dispensaries regarding use of cannabis products for nausea during the first trimester of pregnancy.

METHODS:

This was a statewide cross-sectional study in which advice about cannabis product use was requested using a mystery caller approach. The caller stated she was 8 weeks pregnant and experiencing morning sickness. Dispensaries were randomly selected from the Colorado Department of Revenue Enforcement Division website. The primary outcome was the proportion of marijuana dispensaries that recommended a cannabis product for use during pregnancy. We hypothesized that 50% of dispensaries would recommend use. A sample size of 400 was targeted to yield a two-sided 95% CI width of 10%. Secondary outcomes included the proportion endorsing cannabis use as safe during pregnancy, specific product recommendations, and encouraging discussion with a health care provider. Recommendations were compared by licensure type (medical, retail, or both) and location (rural vs urban).

RESULTS:

Of the 400 dispensaries contacted, 37% were licensed for medical sale (n=148), 28% for retail (n=111), and 35% for both (n=141). The majority, 69% (277/400), recommended treatment of morning sickness with cannabis products (95% CI 64–74%). Frequency of recommendations differed by license type (medical 83.1%, retail 60.4%, both 61.7%, P<.001). Recommendations for use were similar for dispensary location (urban 71% vs nonurban 63%, P=.18). The majority (65%) based their recommendation for use in pregnancy on personal opinion and 36% stated cannabis use is safe in pregnancy. Ultimately, 81.5% of dispensaries recommended discussion with a health care provider; however, only 31.8% made this recommendation without prompting.

CONCLUSION:

Nearly 70% of Colorado cannabis dispensaries contacted recommended cannabis products to treat nausea in the first trimester. Few dispensaries encouraged discussion with a health care provider without prompting. As cannabis legalization expands, policy and education efforts should involve dispensaries.
What Obstetrician–Gynecologists Should Know About Population Health
Authors: Jamieson Denise J. , Haddad Lisa B.
Published: May 2018

Although there is much discussion about population health in academic medical centers, managed care organizations, and a variety of disciplines, it is not always clear what this term means. Population health describes the health outcomes of a group of individuals including health disparities, social determinants of health, and policies and interventions that link health outcomes with and patterns of health determinants. We describe some of the successes and challenges to addressing reproductive health issues in Georgia from a population health perspective, focusing on efforts to reduce teenage pregnancy and improve maternal health.
A Call to Action to Address Gender Equity Within Our Specialty
Authors: Baecher-Lind Laura , Abbott Jodi , Atkins Katharyn Meredith , Nijjar J. Biba , Royce Celeste , Schiff Lauren , Ricciotti Hope A.
Published: May 2018

Although national attention has been focused on sexual harassment and gender inequity in the United States, leaders within the obstetrics and gynecology community have remained relatively silent. Sexual harassment and gender inequity remain pervasive in our specialty. This article serves as a call to action for leadership as well as physicians within obstetrics and gynecology to implement ethical and evidence-based approaches to reduce gender inequity and improve workplace culture within our specialty.
What Is New in Morbidly Adherent Placenta?
Authors: Dashe Jodi S.
Published: May 2018

This month we focus on current research in morbidly adherent placenta. Dr. Dashe discusses five recent publications, which are concluded with a “bottom line” that is a take-home message. A complete reference for each can be found in Box 1 on this page along with direct links to abstracts.
Anterolateral Complex Reconstruction: Another Fad or Method to Improve ACL Outcomes?
Authors: Wood Ryan , Marsh Jacquelyn , Getgood Alan
Published: May 2018

Anterolateral rotational laxity of the knee is a persistent problem following anterior cruciate ligament reconstruction (ACLR) that can lead to increased rates of graft failure. Renewed interest in the anterolateral complex of the knee has led to a resurgence in the use of adjunctive techniques such as lateral extra-articular tenodesis and anterolateral ligament reconstruction. Use of these techniques can restore normal knee kinematics and potentially thereby reduce the rate of graft failure. Historically, experience with modified ACLR techniques such as the double-bundle ACLR have shown that improved biomechanics is not always reflected in clinical outcome trials. Additional procedures also come with additional costs and further economic analysis needs to be performed to clarify whether these additional costs are offset by improved clinical and societal outcomes in the longer-term.
Optimizing Posterior Condylar Offset and Joint Line Restoration in Revision Total Knee Arthroplasty Using a Contemporary Implant System
Authors: Samson Anthony J. , Hamilton David F. , Loh Brian , MacPherson Gavin , Burnett Richard
Published: May 2018

We present a variation of the standard operative technique for the Triathlon total stabilized revision knee system that aims to facilitate recreation of an anatomic joint line, and increase the posterior condylar offset through flexion and posterior translation of the femoral component using short cemented intramedullary stems. We illustrate the technique with a sequential single-surgeon series of 29 patients undergoing total stabilized revision total knee arthroplasty. Joint line ratio is maintained and posterior condylar offset ratio increased from preoperative to postoperatively. Patient reported outcome scores (Oxford Knee Score) significantly improved by 15.6 points at 12 months (P<0.001) with an overall positive satisfaction outcome of 88%.
Changes in MicroRNA Expression Level of Circulating Platelets Contribute to Platelet Defect After Cardiopulmonary Bypass
Authors: Mukai Nobuhiro , Nakayama Yoshinobu , Ishi Sachiyo , Ogawa Satoru , Maeda Sachiko , Anada Natuki , Murakami Satoshi , Mizobe Toshiki , Sawa Teiji , Nakajima Yasufumi
Published: May 2018

Objectives:

Platelet defect mechanisms after cardiopulmonary bypass remain unclear. Our hypothesis microRNA expressions in circulating platelets significantly change between pre and post cardiopulmonary bypass, and consequent messenger RNA and protein expression level alterations cause postcardiopulmonary bypass platelet defect.

Design:

Single-center prospective observational study.

Setting:

Operating room of Kyoto Prefectural University of Medicine.

Patients:

Twenty-five adult patients scheduled for elective cardiac surgeries under cardiopulmonary bypass.

Interventions:

None.

Measurements and Main Results:

In the initial phase, changes in microRNA expression between pre and post cardiopulmonary bypass underwent next generation sequencing analysis (10 patients). Based on the results, we focused on changes in mir-10b and mir-96, which regulate glycoprotein 1b and vesicle-associated membrane protein 8, respectively, and followed them until messenger RNA and protein syntheses (15 patients) using quantitative polymerase chain reaction and Western blotting. Seven microRNAs including mir-10b and mir-96 exhibited significant differences in the initial phase. In the subsequent phase, mir-10b-5p and mir-96-5p overexpressions were confirmed, and glycoprotein 1b and vesicle-associated membrane protein 8 messenger RNA levels were significantly decreased after cardiopulmonary bypass: fold differences (95% CI): mir-10b-5p: 1.35 (1.05–2.85), p value equals to 0.01; mir-96-5p: 1.59 (1.06–2.13), p value equals to 0.03; glycoprotein 1b messenger RNA: 0.46 (0.32–0.60), p value of less than 0.001; and vesicle-associated membrane protein messenger RNA: 0.70 (0.56–0.84), p value of less than 0.001. Glycoprotein 1b and vesicle-associated membrane protein 8 were also significantly decreased after cardiopulmonary bypass: glycoprotein 1b: 82.6% (71.3–93.8%), p value equals to 0.005; vesicle-associated membrane protein 8: 79.0% (70.7–82.3%), p value of less than 0.001.

Conclusions:

Expressions of several microRNAs in circulating platelets significantly changed between pre and post cardiopulmonary bypass. Overexpressions of mir-10b and mir-96 decreased glycoprotein 1b and vesicle-associated membrane protein 8 messenger RNA as well as protein, possibly causing platelet defect after cardiopulmonary bypass.
Predictive Validity of Sepsis-3 Definitions and Sepsis Outcomes in Critically Ill Patients: A Cohort Study in 49 ICUs in Argentina
Authors: Estenssoro Elisa , Kanoore Edul Vanina S. , Loudet Cecilia I. , Osatnik Javier , Ríos Fernando G. , Vázquez Daniela N. , Pozo Mario O. , Lattanzio Bernardo , Pálizas Fernando , Klein Francisco , Piezny Damián , Rubatto Birri Paolo N. , Tuhay Graciela , Díaz Anatilde , Santamaría Analía , Zakalik Graciela , Dubin Arnaldo
Published: May 2018

Objectives:

The new Sepsis-3 definitions have been scarcely assessed in low- and middle-income countries; besides, regional information of sepsis outcomes is sparse. Our objective was to evaluate Sepsis-3 definition performance in Argentina.

Design:

Cohort study of 3-month duration beginning on July 1, 2016.

Settings:

Forty-nine ICUs.

Patients:

Consecutive patients admitted to the ICU with suspected infection that triggered blood cultures and antibiotic administration.

Interventions:

None.

Measurements and Main Results:

Patients were classified as having infection, sepsis (infection + change in Sequential Organ Failure Assessment ≥ 2 points), and septic shock (vasopressors + lactate > 2 mmol/L). Patients on vasopressors and lactate less than or equal to 2 mmol/L (cardiovascular dysfunction) were analyzed separately, as those on vasopressors without serum lactate measurement. Systemic inflammatory response syndrome was also recorded. Main outcome was hospital mortality. Of 809 patients, 6% had infection, 29% sepsis, 20% cardiovascular dysfunction, 40% septic shock, and 3% received vasopressors with lactate unmeasured. Hospital mortality was 13%, 20%, 39%, 51%, and 41%, respectively (p = 0.000). Independent predictors of outcome were lactate, Sequential Organ Failure Assessment score, comorbidities, prior duration of symptoms (hr), mechanical ventilation requirement, and infection by highly resistant microorganisms. Area under the receiver operating characteristic curves for mortality for systemic inflammatory response syndrome and Sequential Organ Failure Assessment were 0.53 (0.48–0.55) and 0.74 (0.69–0.77), respectively (p = 0.000).

Conclusions:

Increasing severity of Sepsis-3 categories adequately tracks mortality; cardiovascular dysfunction subgroup, not included in Sepsis-3, has distinct characteristics. Sequential Organ Failure Assessment score shows adequate prognosis accuracy―contrary to systemic inflammatory response syndrome. This study supports the predictive validity of Sepsis-3 definitions.
Delayed Cerebral Injury in Adults With Bacterial Meningitis: A Novel Complication of Adjunctive Steroids?*
Authors: Gallegos Cinthia , Tobolowsky Farrell , Nigo Masayuki , Hasbun Rodrigo
Published: May 2018

Objectives:

To report the prevalence of delayed cerebral injury in adults with bacterial meningitis and explore its association with adjunctive steroids.

Design:

Retrospective analysis of adults with bacterial meningitis between 2005 and 2016.

Setting:

Ten hospitals in the Greater Houston area.

Patients:

Consecutive subjects with culture proven community-acquired bacterial meningitis.

Intervention:

Subjects were categorized as receiving or not adjunctive steroids within 4 hours.

Measurements and Main Results:

A total of 120 patients were identified who were admitted with community-acquired bacterial meningitis. Delayed cerebral injury was seen in five of 120 patients (4.1%); all five patients had fever and abnormal neurologic examinations. Adjunctive steroids within 4 hours were more likely given to those with delayed cerebral injury (5/5,100% vs 43/115, 37.5%; p = 0.01). Of the patients who developed delayed cerebral injury, three had Streptococcus pneumoniae, one had methicillin-resistant Staphylococcus aureus, and one had Listeria monocytogenes isolated. We observed an adverse clinical outcome as defined by the Glasgow Outcome Scale in four of the five patients (80%).

Conclusions:

Delayed cerebral injury occurred in 4.1% of adults with bacterial meningitis, and it was associated with the use of adjunctive steroids. Future studies should explore the etiology and prevention of this devastating complication.
Ipilimumab/Nivolumab-related Opsoclonus-Myoclonus-Ataxia Syndrome Variant in a Patient with Malignant Pleural Mesothelioma
Authors: Maller Bradley , Peguero Edwin , Tanvetyanon Tawee
Published: May 2018

Introduction:

Ipilimumab and nivolumab are immune-checkpoint inhibitors commonly used for melanoma. The combination is being investigated for its efficacy against several types of cancer, including malignant pleural mesothelioma. Although immune-related adverse events have been reported in patients receiving immune-checkpoint inhibitors, opsoclonus-myoclonus-ataxia syndrome has never been previously described.

Case Presentation:

We describe a 74-year-old male with malignant pleural mesothelioma who presented with opsoclonus and marked truncal ataxia ∼10 weeks following immunotherapy with ipilimumab and nivolumab. No myoclonus was present. Oligoclonal bands were detected in cerebrospinal fluid. Treatment with methylprednisolone and intravenous immunoglobulin along with clonazepam and valproic acid resulted in a rapid clinical improvement. A follow-up visit 2 months afterward showed a resolution of opsoclonus and he was able to walk with cane.

Conclusions:

A variant of opsoclonus-myoclonus-ataxia syndrome may occur following treatment with ipilimumab and nivolumab.
The clinical significance of KIT mutations in melanoma: a meta-analysis
Authors: Gong Hui Z. , Zheng He Y. , Li Jun
Published: May 2018

This study aimed to evaluate the association of KIT mutations with clinicopathologic features of melanomas using a meta-analysis and to identify differences between Asian and White populations using subgroup analyses. We selected 32 studies from the literature including 5224 patients. The pooled data were combined, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Heterogeneity and publication bias were also determined. KIT mutations were reported in 497 (9.5%) of 5224 patients with melanomas, and were associated significantly with age, clinical melanoma subtype, anatomic location, and chronic sun-damage (CSD), but not with sex, histological type, Breslow thickness, ulceration, mitotic rate, or tumor stage. The incidence of KIT mutation was significantly higher in older individuals (OR=1.296, 95% CI: 1.025–1.641; P=0.031), and showed a positive association with mucosal melanoma (OR=1.363, 95% CI: 1.094–1.697; P=0.006), acral melanoma (OR=1.374, 95% CI: 1.123–1.682; P=0.02), and CSD (OR=1.880, 95% CI: 1.127–3.136; P=0.016), but a negative relationship with melanomas arising in non-CSD skin (OR=0.562, 95% CI: 0.392–0.805; P=0.002). The frequency of KIT mutations was associated negatively with melanomas located on the extremities. KIT mutations, which are critical in the genetic pathogenesis of melanomas, define a unique subtype of melanoma associated closely with older age, and acral, mucosal, or CSD sites, but not associated with any histological features or tumor stage. Although the KIT mutation rate is higher in White than Asian populations, no significant difference in clinical association with KIT mutations was detected between the two groups.