bluuebunny/crossref_metadata_2025 huggingface dataset:
Baseline Cerebral Metabolic Rate Is a Critical Determinant of the Cerebral Vasodilating Potency of Volatile Anesthetic Agents
Authors: Drummond John C.
Published: April 2018

A Comparison of the Direct Cerebral Vasodilating Potencies of Halothane and Isoflurane in the New Zealand White Rabbit. By Drummond JC, Todd MM, Scheller MS, and Shapiro HM. Anesthesiology 1986; 65:462–7. Reprinted with permission.

Halothane is commonly viewed as a more potent cerebral vasodilator than isoflurane. It was speculated that the lesser vasodilation caused by isoflurane might be the result of the greater reduction in cerebral metabolic rate (CMR) that it causes, and that the relative vasodilating potencies of halothane and isoflurane would be similar if the two agents were administered in a situation that precluded volatile-agent–induced depression of CMR. To test this hypothesis, cerebral blood flow (CBF) and the cerebral metabolic rate for oxygen (CMRO2) were measured in two groups of rabbits before and after the administration of 0.75 MAC halothane or isoflurane. One group received a background anesthetic of morphine and N2O, which resulted in an initial CMRO2 of 3.21 ± 0.17 (SEM) ml · 100 g–1 · min–1; second group received a background anesthetic of high-dose pentobarbital, which resulted in an initial CMRO2 of 1.76 ± 0.16 ml · 100 g–1 · min–1. In rabbits receiving a background of morphine sulfate/N2O, halothane resulted in a significantly greater CBF (65 ± 10 ml · 100 g–1 · min–1) than did isoflurane (40 ± 5 ml · 100 g–1 · min–1). Both agents caused a reduction in CMRO2, but CMRO2 was significantly less during isoflurane administration. By contrast, with a background of pentobarbital anesthesia, CBF increased by significant and similar amounts with both halothane and isoflurane. With halothane, CBF increased from 22 ± 2 ml · 100 g–1 · min–1 in the control stage to 39 ± 3, and with isoflurane from 24 ± to 38 ± 2 ml · 100 g–1 · min–1. CMRO2 was not depressed further by either halothane or isoflurane. These results suggest that the relative effects of halothane and isoflurane on CBF are dependent on the CMR present prior to their administration. When the preexistent CMR is not markedly depressed, isoflurane decreases CMR and causes less cerebral vasodilation than does halothane. When initial CMR is depressed, halothane and isoflurane have similar vasodilating potencies.
Optimizing Blood Transfusion Practices Through Bundled Intervention Implementation in Patients With Gynecologic Cancer Undergoing Laparotomy
Authors: Wallace Sumer K. , Halverson Jessica W. , Jankowski Christopher J. , DeJong Stephanie R. , Weaver Amy L. , Weinhold Megan R. , Borah Bijan J. , Moriarty James P. , Cliby William A. , Kor Daryl J. , Higgins Andrew A. , Otto Hilary A. , Dowdy Sean C. , Bakkum-Gamez Jamie N.
Published: April 2018

OBJECTIVE:

To examine blood transfusion practices and develop a standardized bundle of interventions to address the high rate of perioperative red blood cell transfusion among patients with ovarian and endometrial cancer.

METHODS:

This was a retrospective cohort study. Our primary aim was to determine whether an implemented bundled intervention was associated with a reduction in perioperative red blood cell transfusions among cases of laparotomy for cancer. Secondary aims included comparing perioperative demographic, surgical, complication, and cost data. Interventions included blood transfusion practice standardization using American Society of Anesthesiologists guidelines, an intraoperative hemostasis checklist, standardized intraoperative fluid status communication, and evidence-based use of tranexamic acid. Prospective data from women undergoing laparotomy for ovarian or endometrial cancer from September 28, 2015, to May 31, 2016, defined the study cohort and were compared with historical controls (September 1, 2014, to September 25, 2015). Outcomes were compared in the full unadjusted cohorts and in propensity-matched cohorts.

RESULTS:

In the intervention and historical cohorts, respectively, 89 and 184 women underwent laparotomy for ovarian cancer (n=74 and 152) or advanced endometrial cancer (n=15 and 32). Tranexamic acid was administered in 54 (60.7%) patients. The perioperative transfusion rate was lower for the intervention group compared with historical controls (18.0% [16/89] vs 41.3% [76/184], P<.001), a 56.4% reduction. This improvement in the intervention group remained significant after propensity matching (16.2% [13/80] vs 36.2% [29/80], P=.004). The hospital readmission rate was also lower for the intervention group compared with historical controls (1.1% [1/89] vs 12.5% [23/184], P=.002); however, this improvement did not attain statistical significance after propensity matching (1.2% [1/80] vs 7.5% [6/80], P=.12). Cost analysis demonstrated that this intervention was cost-neutral during index hospitalization plus 30-day follow-up.

CONCLUSION:

Application of a standardized bundle of evidence-based interventions was associated with reduced blood use in our gynecologic oncology practice.
Opioid Detoxification During Pregnancy
Authors: Terplan Mishka , Laird Hollis J. , Hand Dennis J. , Wright Tricia E. , Premkumar Ashish , Martin Caitlin E. , Meyer Marjorie C. , Jones Hendrée E. , Krans Elizabeth E.
Published: April 2018

OBJECTIVE:

To systematically review maternal and neonatal outcomes associated with opioid detoxification during pregnancy.

DATA SOURCES:

PubMed, PsycINFO, EMBASE, Cochrane, and ClinicalTrials.gov databases were searched from January 1, 1966, to September 1, 2016.

METHODS OF STUDY SELECTION:

English-language studies that reported outcomes associated with opioid detoxification among pregnant women with opioid use disorder were included. Nonoriginal research articles (case reports, editorials, reviews) and studies that failed to report outcomes for detoxification participants were excluded. Bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias and quality was assessed using the U.S. Preventive Service Task Force Quality of Evidence scale.

TABULATION, INTEGRATION, AND RESULTS:

Of 1,315 unique abstracts identified, 15 met criteria for inclusion and included 1,997 participants, of whom 1,126 underwent detoxification. Study quality ranged from fair to poor as a result of the lack of a randomized control or comparison arm and high risk of bias across all studies. Only nine studies had a comparison arm. Detoxification completion (9–100%) and illicit drug relapse (0–100%) rates varied widely across studies depending on whether data from participants who did not complete detoxification or who were lost to follow-up were included in analyses. The reported rate of fetal loss was similar among women who did (14 [1.2%]) and did not undergo detoxification (17 [2.0%]).

CONCLUSIONS:

Evidence does not support detoxification as a recommended treatment intervention as a result of low detoxification completion rates, high rates of relapse, and limited data regarding the effect of detoxification on maternal and neonatal outcomes beyond delivery.
Access to Fertility Treatment for Mixed-Status Couples With Human Immunodeficiency Virus
Authors: Kawwass Jennifer F. , Haddad Lisa B. , Anderson Jean R. , Jamieson Denise J.
Published: April 2018

In an effort to place the recent Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report publications regarding conception options for mixed-status couples with human immunodeficiency virus (HIV) in perspective, we review the historical evolution of conception options for mixed-status couples with HIV with particular focus on the potential need for fertility treatment and the feasibility of accessing such treatment.
A Comparison of Methods for the Diagnosis of Fetal Growth Restriction Between the Royal College of Obstetricians and Gynaecologists and the American College of Obstetricians and Gynecologists
Authors: Blue Nathan R. , Beddow Meghan E. , Savabi Mariam , Katukuri Vivek R. , Mozurkewich Ellen L. , Chao Conrad R.
Published: April 2018

OBJECTIVE:

The Royal College of Obstetricians and Gynaecologists (RCOG) defines fetal growth restriction as ultrasound-estimated fetal weight less than the 10th percentile or abdominal circumference less than the 10th percentile; the American College of Obstetricians and Gynecologists (ACOG) defines fetal growth restriction as estimated fetal weight less than the 10th percentile alone. We compared each method's ability to predict small for gestational age (SGA) at birth.

METHODS:

For this retrospective study of diagnostic accuracy, we reviewed deliveries at the University of New Mexico Hospital from January 1, 2013, to March 31, 2017. We included mothers with singleton, well-dated pregnancies and nonanomalous fetuses undergoing indicated fetal growth restriction surveillance with an ultrasound-estimated fetal weight within 30 days of delivery. Estimated fetal weights and percentiles were calculated using the Hadlock intrauterine growth curve. Small for gestational age was defined as birth weight less than the 10th percentile based on a recent, sex-specific curve. We calculated the area under the curve, sensitivity, specificity, and positive and negative likelihood ratios for various approaches using abdominal circumference and estimated fetal weight to diagnose fetal growth restriction, including the definitions endorsed by ACOG and RCOG.

RESULTS:

We included 1,704 pregnancies with a mean ultrasonography-to-delivery interval of 14.0 days (±8.6). There were 235 SGA neonates (13.8%). The rate of fetal growth restriction was 13.6% when using ACOG's criteria and 16.9% according to RCOG's criteria (P=.007). The area under the curve of RCOG's diagnostic approach was 0.78 (95% CI 0.76–0.80), which was higher than ACOG's (0.76, 95% CI 0.74–0.78, P=.01). Sensitivities and specificities of the various methods were similar. Adopting estimated fetal weight or abdominal circumference less than the 10th percentile instead of estimated fetal weight alone to predict SGA at birth would correctly identify one additional case of SGA for each 14 patients assessed.

CONCLUSION:

The diagnostic approach endorsed by RCOG is a marginally better predictor of SGA at birth compared with the method endorsed by ACOG. Future research should consider the potential benefits and harms of the different methods in different populations.
Identifying Maternal Deaths in Texas Using an Enhanced Method, 2012
Authors: Baeva Sonia , Saxton Debra L. , Ruggiero Karen , Kormondy Michelle L. , Hollier Lisa M. , Hellerstedt John , Hall Manda , Archer Natalie P.
Published: April 2018

OBJECTIVE:

To more accurately estimate the 2012 maternal mortality ratio for Texas using an enhanced method for identifying maternal deaths.

METHODS:

This population-based descriptive study used both data matching and record review to verify pregnancy or delivery within 42 days for 147 deaths with obstetric cause-of-death codes, and used data matching alone to identify additional maternal deaths within the same timeframe. Crude maternal mortality ratios were calculated for confirmed maternal deaths overall, by race and ethnicity, and by age. These maternal mortality ratios were compared with maternal mortality ratios computed using obstetric cause-of-death codes alone (standard method).

RESULTS:

Fifty-six maternal deaths were confirmed to have occurred during pregnancy or within 42 days postpartum. Using our enhanced method, the 2012 maternal mortality ratio for Texas was 14.6 maternal deaths per 100,000 live births, less than half that obtained using the standard method (n=147). Approximately half (50.3%) of obstetric-coded deaths showed no evidence of pregnancy within 42 days, and a large majority of these incorrectly indicated pregnancy at the time of death. Insufficient information was available to determine pregnancy for 15 obstetric-coded deaths, which were excluded from the 2012 maternal mortality ratio estimate; however, had these deaths been included, the resulting maternal mortality ratio would still be significantly lower than that reported using the standard method.

CONCLUSION:

Relying solely on obstetric codes for identifying maternal deaths appears to be insufficient and can lead to inaccurate maternal mortality ratios. A method enhanced with data matching and record review yields more accurate ratios. Results likely have national implications, because miscoding of obstetric deaths with the standard method may affect the accuracy of other states' maternal mortality ratios.
Changing Patterns and Factors Associated With Mode of Delivery Among Pregnant Women With Human Immunodeficiency Virus Infection in the United States
Authors: Venkatesh Kartik K. , Morrison Leavitt , Livingston Elizabeth G. , Stek Alice , Read Jennifer S. , Shapiro David E. , Tuomala Ruth E.
Published: April 2018

OBJECTIVE:

To describe patterns and factors associated with mode of delivery among pregnant women with human immunodeficiency virus (HIV) infection in the United States in relation to evolving HIV-in-pregnancy guidelines.

METHODS:

We conducted an analysis of two observational studies, Pediatric AIDS Clinical Trials Group and International Maternal Pediatric Adolescent AIDS Clinical Trials Network Protocol P1025, which enrolled pregnant women with HIV infection from 1998 to 2013 at more than 60 U.S. acquired immunodeficiency syndrome clinical research sites. Multivariable analyses of factors associated with an HIV-indicated cesarean delivery (ie, for prevention of mother-to-child transmission) compared with other indications were conducted and compared according to prespecified time periods of evolving HIV-in-pregnancy guidelines: 1998–1999, 2000–2008, and 2009–2013.

RESULTS:

Among 6,444 pregnant women with HIV infection, 21% delivered in 1998–1999, 58% in 2000–2008, and 21% in 2009–2013; 3,025 (47%) delivered by cesarean. Cesarean delivery increased from 30% in 1998 to 48% in 2013. Of all cesarean deliveries, repeat cesarean deliveries increased from 16% in 1998 to 42% in 2013; HIV-indicated cesarean deliveries peaked at 48% in 2004 and then dropped to 12% by 2013. In multivariable analyses, an HIV diagnosis during pregnancy, initiation of antiretroviral therapy in the third trimester, a plasma viral load 500 copies/mL or greater, and delivery between 37 and 40 weeks of gestation increased the likelihood of an HIV-indicated cesarean delivery. In analyses by time period, an HIV diagnosis during pregnancy, initiation of antiretroviral therapy in the third trimester, and a plasma viral load of 500 copies/mL or greater were progressively more likely to be associated with an HIV-indicated cesarean delivery over time.

CONCLUSION:

Almost 50% of pregnant women with HIV infection underwent cesarean delivery. Over time, the rate of repeat cesarean deliveries increased, whereas the rate of HIV-indicated cesarean deliveries decreased; cesarean deliveries were more likely to be performed in women at high risk of mother-to-child transmission. These findings reinforce the need for both early diagnosis and treatment of HIV infection in pregnancy and the option of vaginal delivery after cesarean among pregnant women with HIV infection.
Intrauterine Device Insertion Before and After Mandated Health Care Coverage
Authors: Heisel Erica , Kolenic Giselle E. , Moniz Michelle M. , Kobernik Emily K. , Minadeo Leah , Kamdar Neil S. , Dalton Vanessa K.
Published: April 2018

OBJECTIVE:

To evaluate changes in out-of-pocket cost for intrauterine device (IUD) placement before and after mandated coverage of contraceptive services and to examine how changes in out-of-pocket cost influence IUD insertion as a function of baseline cost.

METHODS:

We conducted a cross-sectional pre–post analysis at the plan level using a large deidentified medical claims database to analyze our primary outcome, new IUD insertions among women enrolled in employer-sponsored health plans in 2009 and 2014, and our secondary outcome, out-of-pocket cost. Patient costs and utilization were aggregated by plan and year to conduct a plan-specific analysis. Plans were classified by mean out-of-pocket cost level: no out-of-pocket cost, low out-of-pocket cost (less than the 75th percentile), and high out-of-pocket cost (75th percentile or greater). A generalized estimating equation was used to evaluate average plan utilization of IUD services in 2009 and 2014 as a function of plan cost category and year.

RESULTS:

Overall, average plan utilization of IUD services demonstrated a significant increase between 2009 (12.5%, 95% CI 11.6–13.4%) and 2014 (13.8%, 95% CI 13.0–14.7%; P<.001). When plans were grouped by out-of-pocket cost level, significant differences in plan utilization over time were observed. Plans that went from high out-of-pocket cost in 2009 to no out-of-pocket cost in 2014 saw a higher average increase in the rate of plan IUD insertions over time (2.4%, 95% CI 0.04–4.5%) compared with plans with no out-of-pocket cost in both 2009 and 2014 (−1.0%, 95% CI −3.3 to 1.4%, P=.02). Among all women in all plans, the 75th percentile of out-of-pocket cost in 2009 was $368; this number dropped to $0 in 2014.

CONCLUSION:

Women in plans with the greatest reduction in out-of-pocket cost after mandated coverage of contraception had the greatest gains in IUD insertion. This suggests that baseline cost should be considered in evaluations of this policy and others that eliminate patient out-of-pocket cost.
An Evaluation of the Implementation of Pharmacist-Prescribed Hormonal Contraceptives in California
Authors: Batra Priya , Rafie Sally , Zhang Zhiwei , Singh Amay V. , Bird Chloe E. , Sridhar Aparna , Sullivan J. Greer
Published: April 2018

OBJECTIVE:

To evaluate the implementation of pharmacist-prescribed hormonal contraceptives in California after a recent expansion of pharmacists' scope of practice.

METHODS:

A probability sample of 480 licensed California retail pharmacies (stratified by nonrural or rural location and independent or chain status) was included in a cross-sectional “secret shopper” telephone survey assessing the availability of pharmacist-prescribed hormonal contraceptives and service details. Survey data were analyzed using weighted descriptive statistics, CIs, and Wald tests.

RESULTS:

Findings included data from 457 pharmacies (response rate 95.2%). Only 5.1% of pharmacies reported providing pharmacist-prescribed hormonal contraceptives (95% CI 2.9–7.2%). This proportion did not differ significantly between rural and nonrural pharmacies (P=.83) nor between independent and chain pharmacies (P=.40). Five of the 22 pharmacies that were providing pharmacist-prescribed hormonal contraceptives informed secret shoppers that all allowed hormonal methods were available; most of these pharmacies (77.3%) did proactively describe that a health history was required before receiving medications. Only half of pharmacies providing pharmacist-prescribed hormonal contraceptives would do so for minors although this was allowed by law.

CONCLUSION:

In the first year after statewide protocol implementation, only a small proportion of retail pharmacies across California has begun offering hormonal contraception services. In the absence of additional supportive legislation regarding reimbursement for pharmacist services, increases in scope of practice regulations to build a larger network of contraceptive providers may not be effective in increasing access to birth control.
Influenza Vaccination, Pregnancy Safety, and Risk of Early Pregnancy Loss
Authors: Sperling Rhoda S. , Riley Laura E. ,   on behalf of The Immunization and Emerging Infections Expert Work Group
Published: April 2018

Since 2004, the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists have recommended routine influenza vaccination for all pregnant women in any trimester. Maternal influenza vaccination has been shown to decrease the risk of influenza and its complications among pregnant women and their infants in the first 6 months of life. In a recent article published in Vaccine, Donahue and colleagues reported a possible association between influenza vaccination when given very early in the first trimester and spontaneous abortion. There are limited conclusions that should be drawn from this study given the case–control design as well as the small number of patients included in the subanalysis that is the basis for the report. A prior first-trimester safety study from this group, using a similar study design, had not observed any association with spontaneous abortion, and other reports of first-trimester vaccine safety have not observed an association. The lack of a biologically plausible mechanism for the suggested association between previous influenza vaccination and early pregnancy loss is of concern. The study's reported observation is not definitive and needs be replicated in appropriately designed studies before changing clinical practice. Pregnant women are at high risk for severe influenza-related complications, including death, and health care providers have an obligation to their patients to continue to recommend and provide influenza vaccinations.
Perinatal Outcomes in Women With a History of Chronic Hypertension but Normal Blood Pressures Before 20 Weeks of Gestation
Authors: Youngstrom Mallory , Tita Alan , Grant Janatha , Szychowski Jeff M. , Harper Lorie M.
Published: April 2018

OBJECTIVE:

To compare the perinatal outcomes of normotensive women with those of women with a history of chronic hypertension with normal blood pressures before 20 weeks of gestation, stratifying the latter by whether they were receiving antihypertensive medication.

METHODS:

We conducted a retrospective cohort study of all singletons with a history of chronic hypertension from 2000 to 2014. Exclusions were blood pressure greater than 140/90 mm Hg before 20 weeks of gestation, fetal anomalies, major medical problems other than hypertension, and diabetes. For the same time period, a randomly selected group without a diagnosis of chronic hypertension was chosen using the same exclusion criteria. Outcomes were compared among women without chronic hypertension, women with chronic hypertension on no antihypertensive medication but with blood pressures less than 140/90 mm Hg before 20 weeks of gestation, and women with chronic hypertension on antihypertensive medication with blood pressures less than 140/90 mm Hg before 20 weeks of gestation. The primary outcome was a perinatal composite of stillbirth, neonatal death, respiratory support at birth, arterial cord pH less than 7, 5-minute Apgar score 3 or less, and seizures. Secondary outcomes assessed were preterm birth before 37 and 34 weeks of gestation, small for gestational age, and preeclampsia.

RESULTS:

Of 830 women with chronic hypertension and blood pressures less than 140/90 mm Hg before 20 weeks of gestation, 212 (26%) were not taking antihypertensive medication and 618 (74%) were. These groups were compared with 476 women without chronic hypertension. Women with hypertension were more likely to be older and have baseline renal disease and diabetes compared with women in the no hypertension group. The perinatal composite was more common in both hypertensive groups: no antihypertensive medication (9.9%) and antihypertensive medication (14.6%) compared with women in the control group (2.9%) (adjusted odds ratio [OR] 2.9, 95% CI 1.21–6.85 no antihypertensive medications compared with no chronic hypertension; adjusted OR 5.0, 95% CI 2.38–10.54 antihypertensive medications vs no chronic hypertension). The risk of early preterm birth, small for gestational age, and preeclampsia was not significantly increased in women with chronic hypertension and no antihypertensive medications compared with women without chronic hypertension.

CONCLUSION:

Despite normal baseline blood pressures without medications before 20 weeks of gestation, women with chronic hypertension are at an increased risk of adverse perinatal outcomes compared with women without.
Transfer of Inhaled Cannabis Into Human Breast Milk
Authors: Baker Teresa , Datta Palika , Rewers-Felkins Kathleen , Thompson Heather , Kallem Raja R. , Hale Thomas W.
Published: April 2018

OBJECTIVE:

To evaluate the transfer of delta-9-tetrahydrocannabinol and its metabolites into human breast milk after maternal inhalation of 0.1 g cannabis containing 23.18% delta-9-tetrahydrocannabinol.

METHODS:

In this pilot pharmacokinetic study, breast milk samples were collected from mothers who regularly consumed cannabis, were 2–5 months postpartum, and exclusively breastfeeding their infants. Women were anonymously recruited for the study. After discontinuing cannabis for at least 24 hours, they were directed to obtain a baseline breast milk sample, then smoke a preweighed, analyzed, standardized strain of cannabis from one preselected dispensary, and collect breast milk samples at specific time points: 20 minutes and 1, 2, and 4 hours. Quantification of delta-9-tetrahydrocannabinol and its metabolites in these collected breast milk samples was performed by high-performance liquid chromatography tandem mass spectrometry.

RESULTS:

A total of eight women were enrolled. Most were occasional cannabis smokers and one a chronic user. Delta-9-tetrahydrocannabinol was detected at low concentrations at all the time points beyond time zero. No metabolites were detected at any time point. Delta-9-tetrahydrocannabinol was transferred into mother's milk such that exclusively breastfeeding infants ingested an estimated mean of 2.5% of the maternal dose (the calculated relative infant dose=2.5%, range 0.4–8.7%). The estimated daily infant dose was 8 micrograms per kilogram per day.

CONCLUSION:

This study documents inhaled delta-9-tetrahydrocannabinol transfer into the mother's breast milk. Low concentrations of delta-9-tetrahydrocannabinol were detected. The long-term neurobehavioral effect of exposure to delta-9-tetrahydrocannabinol on the developing brain is unclear. Mothers should be cautious using cannabis during pregnancy and breastfeeding.
Research in Obstetric Fistula
Authors: Pope Rachel
Published: April 2018

Although obstetric fistula has likely plagued women since the beginning of time, very little research proportionally exists. This article summarizes the most substantial research on the topic and delineates research gaps and future needs. Existing research demonstrates that access to care is the underlying cause of obstetric fistula and that the first attempt at closure holds the highest chance at success, ranging between 84% and 94%. For simple cases, 10 days of a catheter is sufficient, although what constitutes as simple is unclear. Circumferential fistulas are at high risk for ongoing urethral continence. Psychosocial programs are helpful for all women, but those who are “dry” tend to reintegrate into society, whereas those still leaking need additional support. Prenatal care and scheduled cesarean delivery are recommended to avoid another fistula. Gaps in research include accurate prevalence and incidence, interventions to improve access to care, surgical technique, especially for complex cases, and ways to prevent ongoing incontinence, among many others. In all areas, more rigorous research is needed.
Prescription and Other Medication Use in Pregnancy
Authors: Haas David M. , Marsh Derek J. , Dang Danny T. , Parker Corette B. , Wing Deborah A. , Simhan Hyagriv N. , Grobman William A. , Mercer Brian M. , Silver Robert M. , Hoffman Matthew K. , Parry Samuel , Iams Jay D. , Caritis Steve N. , Wapner Ronald J. , Esplin M. Sean , Elovitz Michal A. , Peaceman Alan M. , Chung Judith , Saade George R. , Reddy Uma M. ,   for the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) Study
Published: April 2018

OBJECTIVE:

To characterize prescription and other medication use in a geographically and ethnically diverse cohort of women in their first pregnancy.

METHODS:

In a prospective, longitudinal cohort study of nulliparous women followed through pregnancy from the first trimester, medication use was chronicled longitudinally throughout pregnancy. Structured questions and aids were used to capture all medications taken as well as reasons they were taken. Total counts of all medications taken including number in each category and class were captured. Additionally, reasons the medications were taken were recorded. Trends in medications taken across pregnancy and in the first trimester were determined.

RESULTS:

Of the 9,546 study participants, 9,272 (97.1%) women took at least one medication during pregnancy with 9,139 (95.7%) taking a medication in the first trimester. Polypharmacy, defined as taking at least five medications, occurred in 2,915 (30.5%) women. Excluding vitamins, supplements, and vaccines, 73.4% of women took a medication during pregnancy with 55.1% taking one in the first trimester. The categories of drugs taken in pregnancy and in the first trimester include the following: gastrointestinal or antiemetic agents (34.3%, 19.5%), antibiotics (25.5%, 12.6%), and analgesics (23.7%, 15.6%, which includes 3.6%; 1.4% taking an opioid pain medication).

CONCLUSION:

In this geographically and ethnically diverse cohort of nulliparous pregnant women, medication use was nearly universal and polypharmacy was common.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT01322529.
Ovarian Cancer Prevention and Screening
Authors: Menon Usha , Karpinskyj Chloe , Gentry-Maharaj Aleksandra
Published: April 2018

There has been much progress in ovarian cancer screening and prevention in recent years. Improved tools that combine genetic and epidemiologic factors to predict an individual's ovarian cancer risk are set to become available for tailoring preventive and screening approaches. The increasing evidence on tubal origins of a proportion of ovarian cancer has paved the way to use of opportunistic bilateral salpingectomy at tubal ligation and hysterectomy in the general population. Clinical trials are in progress to estimate the long-term effects on endocrine function. In women at high risk, risk reducing salpingo-oophorectomy remains the standard of care with the current focus on management of resulting noncancer outcomes, especially sexual dysfunction in younger women. This has led to evaluation of early bilateral salpingectomy and delayed oophorectomy in this population. Meanwhile, modeling suggests that BRCA mutation carriers should consider using the oral contraceptive pill for chemoprevention. In the general population, the largest ovarian cancer screening trial to date, the UK Collaborative Trial of Ovarian Cancer Screening reported a stage shift with annual multimodal screening using the longitudinal CA 125 Risk of Ovarian Cancer Algorithm but not with annual transvaginal ultrasound screening. There was no definitive mortality reduction with either screening strategy compared with no screening. Further follow-up until December 2018 in now underway. Stage shift and higher rates of optimal cytoreduction were also reported during 3- to 4-monthly multimodal screening in the United Kingdom and U.S. high-risk screening trials. Although all agree that there is not yet evidence to support general population screening, recommendations for high-risk screening vary between countries. A key finding from the screening trials has been the better performance of longitudinal algorithms compared with a single cutoff for CA 125. A major focus of ovarian cancer biomarker discovery work has been tumor DNA markers in both plasma and novel specimens such as cervical cytology samples.
Maternal Pyrexia and Villitis of Unknown Etiology
Authors: Graham Dorothy F. , Sung Eileen , Berry Bligh
Published: April 2018

BACKGROUND:

Villitis of unknown etiology is an inflammatory placental condition associated with adverse pregnancy outcomes, including fetal growth restriction and preterm birth.

CASE:

We describe maternal pyrexia with daily rigors in the third trimester of two consecutive pregnancies in the same woman. In her second pregnancy, we found no evidence of infection despite an extensive antenatal investigation (blood and urine cultures, serologies, chest X-ray, abdominal ultrasonogram, echocardiogram). The fetus was closely monitored for growth and well-being until spontaneous labor ensued at 36 weeks of gestation, followed by the birth of a vigorous female neonate who weighed 2.235 kg and was healthy. Placental pathology was consistent with villitis of unknown etiology and displayed more prominent abscess formation than is usually described. The patient's first pregnancy 4 years previously followed a similar but milder pattern, without preterm delivery but with similar placental pathology.

CONCLUSION:

Maternal pyrexia in both pregnancies was ultimately attributed to placental inflammation secondary to a maternal immunologic response to the fetal–placental unit. A placental origin for maternal pyrexia should be considered in cases in which a maternal cause cannot be identified and the pregnancy managed in light of the possible association with adverse fetal outcomes.
Pregnancy Exercise and Nutrition With Smartphone Application Support
Authors: Kennelly Maria A. , Ainscough Kate , Lindsay Karen L. , O'Sullivan Elizabeth , Gibney Eileen R. , McCarthy Mary , Segurado Ricardo , DeVito Giuseppe , Maguire Orla , Smith Thomas , Hatunic Mensud , McAuliffe Fionnuala M.
Published: April 2018

OBJECTIVE:

To evaluate the effect of a healthy lifestyle package (an antenatal behavior change intervention supported by smartphone application technology) on the incidence of gestational diabetes mellitus (GDM) in overweight and obese women.

METHODS:

Women with body mass indexes (BMIs) 25–39.9 were enrolled into this randomized controlled trial. The intervention consisted of specific dietary and exercise advice that addressed behavior change supported by a tailor-designed smartphone application. Women in the control group received usual care. The primary outcome was the incidence of GDM at 28–30 weeks of gestation. To reduce GDM from 15% to 7.2%, we estimated that 506 women would be required to have 80% power to detect this effect size at a significance of .05, that is, 253 in each group.

RESULTS:

Between March 2013 and February 2016, 565 women were recruited with a mean BMI of 29.3 and mean gestational age of 15.5 weeks. The incidence of GDM did not differ between the two groups, 37 of 241 (15.4%) in the intervention group compared with 36 of 257 (14.1%) in the control group (relative risk 1.1, 95% CI 0.71–1.66, P=.71).

CONCLUSIONS:

A mobile health-supported behavioral intervention did not decrease the incidence of GDM.

CLINICAL TRIAL REGISTRATION:

ISRCTN registry, https://www.isrctn.com/, ISRCTN29316280.
Direct Percutaneous Endoscopic Jejunostomy for the Management of Gastroparesis in Pregnancy
Authors: Rupani Sawan Vijay , Ergen William F. , Weber Frederick , Peter Shajan
Published: April 2018

BACKGROUND:

Providing meaningful nutrition in cases of refractory hyperemesis during pregnancy can be challenging; although intragastric enteral nutrition is the most common approach, it is contraindicated in certain cases and carries the risk of increased nausea and vomiting.

CASE:

A 36-year-old primigravid woman with a history of gastroparesis presented at 16 weeks of gestation with nausea and vomiting. With no improvement with conventional approaches and signs of malnutrition, a direct percutaneous endoscopic jejunostomy was placed. Her nutritional status improved, and the pregnancy ended in the delivery of a healthy neonate.

CONCLUSION:

Direct percutaneous endoscopic jejunostomy in pregnancy is an option in patients in whom intragastric feeding is contraindicated and may offer a more secure approach than percutaneous gastrojejunostomy.
Timing of Etonogestrel Implant Insertion After Dilation and Evacuation
Authors: Cowett Allison A. , Ali Rose , Cooper Mary A. , Evans Mark , Conzuelo Gabriel , Cremer Miriam
Published: April 2018

OBJECTIVE:

To compare the 6-month use rate of the etonogestrel implant placed immediately after dilation and evacuation (D&E) with placement 2–4 weeks postprocedure.

METHODS:

This is a randomized controlled trial of women seeking abortion between 14 0/7 and 23 5/7 weeks of gestation and desiring the etonogestrel contraceptive implant at an urban family planning clinic. Participants were randomized to device insertion immediately after the D&E compared with delayed insertion in 2–4 weeks. The primary outcome was implant use rate at 6 months after insertion and was determined by follow-up phone interviews. Secondary outcomes included repeat pregnancy rates and method satisfaction. The sample size of 120 participants was calculated based on a power of 0.80 to demonstrate a 20% difference in implant use rates between groups assuming 40% of women overall are not using the device 6 months after the procedure.

RESULTS:

Between November 2015 and October 2016, 148 participants were enrolled. Seventy-three participants (49.3%) were randomized to and underwent immediate implant insertion after D&E. The remaining 75 (50.6%) were randomized to delayed insertion. There were no significant differences in sociodemographic characteristics between the groups. Placement rate was 100% in the immediate group compared with 42.7% in the delayed group (P<.01). At 6 months, 40 of 43 (93%) women from the immediate group who completed follow-up continued use of the implant, whereas 19 of 30 (63.3%) women from the delayed group who completed follow-up were using the device (P=.002). Follow-up rates were low at 58.9% in the immediate group compared with 40.0% in the delayed group.

CONCLUSION:

Women were more likely to be using the etonogestrel implant at 6 months after D&E if they underwent immediate compared with delayed insertion. The very high loss to follow-up rate makes it difficult to draw conclusions about acceptability of the device and pregnancy rates.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, 02037919.
Disparities in Adherence to National Comprehensive Cancer Network Treatment Guidelines and Survival for Stage IB–IIA Cervical Cancer in California
Authors: Pfaendler Krista S. , Chang Jenny , Ziogas Argyrios , Bristow Robert E. , Penner Kristine R.
Published: April 2018

OBJECTIVE:

To evaluate the association of sociodemographic and hospital characteristics with adherence to National Comprehensive Cancer Network treatment guidelines for stage IB–IIA cervical cancer and to analyze the relationship between adherent care and survival.

METHODS:

This is a retrospective population-based cohort study of patients with stage IB–IIA invasive cervical cancer reported to the California Cancer Registry from January 1, 1995, through December 31, 2009. Adherence to National Comprehensive Cancer Network guideline care was defined by year- and stage-appropriate surgical procedures, radiation, and chemotherapy. Multivariate logistic regression, Kaplan-Meier estimate, and Cox proportional hazard models were used to examine associations between patient, tumor, and treatment characteristics and National Comprehensive Cancer Network guideline adherence and cervical cancer–specific 5-year survival.

RESULTS:

A total of 6,063 patients were identified. Forty-seven percent received National Comprehensive Cancer Network guideline–adherent care, and 18.8% were treated in high-volume centers (20 or more patients/year). On multivariate analysis, lowest socioeconomic status (adjusted odds ratio [OR] 0.69, 95% CI 0.57–0.84), low–middle socioeconomic status (adjusted OR 0.76, 95% CI 0.64–0.92), and Charlson-Deyo comorbidity score 1 or higher (adjusted OR 0.78, 95% CI 0.69–0.89) were patient characteristics associated with receipt of nonguideline care. Receiving adherent care was less common in low-volume centers (45.9%) than in high-volume centers (50.9%) (effect size 0.90, 95% CI 0.84–0.96). Death from cervical cancer was more common in the nonadherent group (13.3%) than in the adherent group (8.6%) (effect size 1.55, 95% CI 1.34–1.80). Black race (adjusted hazard ratio 1.56, 95% CI 1.08–2.27), Medicaid payer status (adjusted hazard ratio 1.47, 95% CI 1.15–1.87), and Charlson-Deyo comorbidity score 1 or higher (adjusted hazard ratio 2.07, 95% CI 1.68–2.56) were all associated with increased risk of dying from cervical cancer.

CONCLUSION:

Among patients with early-stage cervical cancer, National Comprehensive Cancer Network guideline-nonadherent care was independently associated with increased cervical cancer–specific mortality along with black race and Medicaid payer status. Nonadherence was more prevalent in patients with older age, lower socioeconomic status, and receipt of care in low-volume centers. Attention should be paid to increase guideline adherence.
What Is New in Sexually Transmitted Infections?
Authors: Ros Stephanie T.
Published: April 2018

This month we focus on current research in sexually transmitted infections. Dr. Ros discusses four 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.
Pelvic Incidence Is Associated With Sacral Curvature, Sacroiliac Joint Angulation, and Sacral Ala Width
Authors: Abola Matthew V. , Teplensky Jason R. , Cooperman Daniel R. , Bauer Jennifer M. , Liu Raymond W.
Published: April 2018

Study Design.

Cross-sectional anatomical study in dry cadaveric specimens.

Objective.

This study evaluates how the sacroiliac (SI) joint angulation, midsagittal sacral curvature, and sacral ala width relate to pelvic incidence (PI).

Summary of Background Data.

Numerous spinopelvic pathologies have been linked with pelvic incidence; however, the manner in which sacral morphology fits into this association is largely unknown.

Methods.

A total of 120 cadaveric sacra and corresponding innominate bones were obtained from an osteological collection. Pelvic incidence was measured in a previously validated method. To gauge ala width, calipers were used to measure the distance between the midpoint of the sacral endplate and the anterolateral aspect of the right and left ala. Sacral curvature was evaluated by measuring the difference of the direct distance and the curved bony distance from the sacral promontory to the inferior aspect of the fourth intervertebral foramen. Three separate angle measurements were made to quantify the angulation of the SI joint, which we divided into an upper and lower limb. Angle 1 approximated the relationship between the upper limb and the sacral endplate; angle 2 between the upper and lower limbs; angle 3 between the lower limb and a tangential line to the fourth sacral foramen.

Results.

Average age at death for all specimens was 31.9 ± 6.3 years with 63% representation of males and an equal distribution of Caucasian and African Americans. The mean PI of our study population was 45.1 ± 12.6°. Results from our regression showed statistically significant associations between our measured angles evaluating SI joint angulation (angles 1, 2, 3) and PI. Standardized beta for angle 1 was −0.421, angle 2 was 0.419, and angle 3 was −0.439 (all P < 0.001). Additionally, the average endplate-ala distance (beta = −0.254) and average difference between tape-caliper measurements, our measurement for sacral arc, (beta = 0.178) were significantly associated with PI (all P < 0.05).

Conclusion.

Our data supports the theory that increased PI is associated with a highly angulated and curved sacrum, with corresponding changes in the SI joint, and narrowed sacral alae.

Level of Evidence: N/A
An Open-Loop, Physiologic Model–Based Decision Support System Can Provide Appropriate Ventilator Settings
Authors: Karbing Dan Stieper , Spadaro Savino , Dey Nilanjan , Ragazzi Riccardo , Marangoni Elisabetta , Dalla Corte Francesca , Moro Federico , Lodahl David , Hansen Niklas Schurmann , Winding Robert , Rees Stephen Edward , Volta Carlo Alberto
Published: April 2018

Objectives:

To evaluate the physiologic effects of applying advice on mechanical ventilation by an open-loop, physiologic model–based clinical decision support system.

Design:

Prospective, observational study.

Setting:

University and Regional Hospitals’ ICUs.

Patients:

Varied adult ICU population.

Interventions:

Advice were applied if accepted by physicians for a period of up to 4–8 hours.

Measurements and Main Results:

Seventy-two patients were included for data analysis. Acceptance of advice was high with 95.7% of advice applied. In 41 patients in pressure support ventilation, following system advice led to significant decrease in PS, with PS reduced below 8 cm H2O in 15 patients (37%), a level not prohibiting extubation. Fraction of end-tidal CO2 values did not change, and increase in respiratory rate/VT was within clinical limits, indicating that in general, the system maintained appropriate patient breathing effort. In 31 patients in control mode ventilation, pressure control and tidal volume settings were decreased significantly, with tidal volume reduced below 8 mL/kg predicted body weight in nine patients (29%). Minute ventilation was maintained by a significant increase in respiratory rate. Significant reductions in Fio
2 were seen on elevated baseline median values of 50% in both support and control mode–ventilated patients, causing clinically acceptable reductions in oxygen saturation.

Conclusions:

The results indicate that during a short period, the clinical decision support system provided appropriate suggestions of mechanical ventilation in a varied ICU population, significantly reducing ventilation to levels which might be considered safe and beneficial.
Markedly Deranged Injury Site Metabolism and Impaired Functional Recovery in Acute Spinal Cord Injury Patients With Fever
Authors: Gallagher Mathew J. , Zoumprouli Argyro , Phang Isaac , Schwab Jan M. , Kopp Marcel A. , Liebscher Thomas , Papadopoulos Marios C. , Saadoun Samira
Published: April 2018

Objectives:

To characterize the effect of fever after acute, traumatic spinal cord injury on injury site metabolism and patient outcome.

Design:

Longitudinal cohort study. In 44 patients (London cohort), we determined the effect of fever on intrathecal injury site metabolism by analyzing 1,767 hours of intraspinal pressure and 759 hours of microdialysis data. We also determined the effect of fever burden, computed for the first 2 weeks in hospital, on neurologic outcome. A distinct cohort of 33 patients (Berlin cohort) was used to independently validate the effect of fever burden on outcome.

Setting:

ICUs in London and Berlin.

Patients:

Seventy-seven patients with acute, traumatic spinal cord injuries.

Interventions:

In the London patients, a pressure probe and a microdialysis catheter were placed intradurally on the surface of the injured cord for up to a week.

Measurements and Main Results:

Fever (> 37.5°C) occurs frequently (37% of the time) after spinal cord injury. High-grade fever (≥ 38°C) was associated with significantly more deranged metabolite levels than normothermia (36.5–37.5°C), that is, lower tissue glucose (median 2.0 vs 3.3 mM), higher lactate (7.8 vs 5.4 mM), higher glutamate (7.8 vs 6.4 µM), and higher lactate-to-pyruvate ratio (38.9 vs 29.3). High-grade fever was particularly detrimental on injury site metabolism when the peripheral leukocyte count was high. In the London and Berlin cohorts, high fever burden correlated with less neurologic improvement.

Conclusions:

Early after spinal cord injury, fever is associated with more deranged injury site metabolism than normothermia and worse prognosis.