bluuebunny/crossref_metadata_2025 huggingface dataset:
Development and Validation of a Clinical Grading Scale to Assess the Vulvar Region: The Vulvar Architecture Severity Scale
Authors: Almadori Aurora , Zenner Nicole , Boyle Deborah , Swale Victoria , Reid Wendy , Maclean Allan , Butler Peter E M
Published: May 2020

Background

The vulva is composed of aesthetic units that can be affected differently by vulvar conditions. A reliable, comprehensive, and quick-to-use clinical scoring system is required to assess the disease extent in the vulvar area.

Objectives

The aim of this study was to develop and validate a grading scale based on the aesthetic unit principle to evaluate the extent of vulvar lichen sclerosus (VLS).

Methods

After reviewing photographs of 100 patients affected by VLS, the authors targeted the aesthetic units most frequently affected. The disease signs were recorded and graded in 4 levels of severity (none, mild, moderate, severe) taking into account the vulvar architecture and skin involvement. To validate the scale, 14 observers were asked to apply it to photographs of 25 VLS patients on 2 different occasions. Intra- and inter-observer reliabilities were determined employing Pearson’s and intraclass correlation coefficients.

Results

A 6-region, 4-point grading system was designed and identified as the Vulvar Architecture Severity Scale (VASS). In all 6 areas, the Pearson’s r was greater than 0.9 (mean, 0.994; 95% confidence interval [CI] = 0.992), indicating that the intra-observer reliability of the VASS was consistent over time (P < 0.001). Intraclass correlation at time 1 was 0.928 (95% CI = 0.910, 0.943) and at time 2 was 0.944 (95% CI = 0.931, 0.996), indicating a high reliability level among different observers.

Conclusions

The VASS is a reliable scale to assess the severity of VLS, and it might be considered as an outcome measure in future VLS trials.

Level of Evidence: 4
The Parkinson’s Disease Comprehensive Response (PDCORE): a composite approach integrating three standard outcome measures
Authors: Luz Matthias , Whone Alan , Bassani Niccolò , Wyse Richard K , Stebbins Glenn T , Mohr Erich
Published: May 2020

There is an increasing need for improved endpoints to assess clinical trial effects in Parkinson’s disease. We propose the Parkinson’s Disease Comprehensive Response as a novel weighted composite endpoint integrating changes measured in three established Parkinson’s outcomes, including: OFF state Movement Disorder Society Unified Parkinson’s Disease Rating Scale Motor Examination scores; Motor Experiences of Daily Living scores; and total good-quality ON time per day. The data source for the initial development of the composite described herein was a recent Phase II trial of glial cell line-derived neurotrophic factor. A wide range of clinically derived relative weights was assessed to normalize for differentially scoring base rates with each endpoint component. The Parkinson’s disease comprehensive response, in contrast to examining practically defined OFF state Unified Parkinson’s Disease Rating Scale Motor Examination scores alone, showed stability over 40 weeks in placebo patients, and all 432 analyses in this permutation exercise yielded significant differences in favour of glial cell line-derived neurotrophic factor. The findings were consistent with results obtained employing three different global statistical test methodologies and with patterns of intra-patient change. Based on our detailed analyses, we conclude it worth prospectively evaluating the clinical utility, validity and regulatory feasibility of using clinically supported final Parkinson’s disease comprehensive response formulas (for both the Unified Parkinson’s Disease Rating Scale-based and Movement Disorders Society-Unified Parkinson’s Disease Rating Scale-based versions) in future disease-modifying Parkinson’s trials. Whilst the data source employed in the initial development of this weighted composite score is from a recent Phase II trial of glial cell line-derived neurotrophic factor, we wish to stress that the results are not described to provide post hoc evidence of the efficacy of glial cell line-derived neurotrophic factor but rather are presented to further the debate of how current regulatory approved rating scales may be combined to address some of the recognized limitations of using individual scales in isolation.
Disease and Treatment Patterns Among Patients With Pouch-related Conditions in a Cohort of Large Tertiary Care Inflammatory Bowel Disease Centers in the United States
Authors: Barnes Edward L , Raffals Laura , Long Millie D , Syal Gaurav , Kayal Maia , Ananthakrishnan Ashwin , Cohen Benjamin , Pekow Joel , Deepak Parakkal , Colombel Jean-Frederic , Herfarth Hans H , Sandler Robert S
Published: May 2020

Background

Gaps exist in our understanding of the clinical course of pouch-related disorders.

Methods

We evaluated baseline disease activity and longitudinal treatment patterns among patients with inflammatory conditions of the pouch.

Results

Among 468 patients with an ileal pouch-anal anastomosis (IPAA), 94 (20%) had acute pouchitis, 96 (21%) had chronic pouchitis, and 192 (41%) had Crohn disease of the pouch. Following an IPAA, 38% of patients were treated with a biologic and 11% underwent inflammatory bowel disease- or bowel-related surgery.

Conclusions

Treatment patterns after IPAA indicate that pouch-related disorders have a significant impact on individual patients and the healthcare system.
Novel coronavirus 19 (COVID-19) associated sinus node dysfunction: a case series
Authors: Peigh Graham , Leya Marysa V , Baman Jayson R , Cantey Eric P , Knight Bradley P , Flaherty James D
Published: May 2020

Background

Novel coronavirus-19 disease (COVID-19) is associated with significant cardiovascular morbidity and mortality. To date, there have not been reports of sinus node dysfunction (SND) associated with COVID-19. This case series describes clinical characteristics, potential mechanisms, and short-term outcomes of COVID-19 patients who experience de novo SND.

Case summary

We present two cases of new-onset SND in patients recently diagnosed with COVID-19. Patient 1 is a 70-year-old female with no major past medical history who was intubated for acute hypoxic respiratory failure secondary to COVID-19 pneumonia and developed new-onset sinus bradycardia without a compensatory increase in heart rate in response to relative hypotension. Patient 2 is an 81-year-old male with a past medical history of an ascending aortic aneurysm, hypertension, and obstructive sleep apnoea who required intubation for COVID-19-induced acute hypoxic respiratory failure and exhibited new-onset sinus bradycardia followed by numerous episodes of haemodynamically significant accelerated idioventricular rhythm. Two weeks following the onset of SND, both patients remain in sinus bradycardia.

Discussion

COVID-19-associated SND has not previously been described. The potential mechanisms for SND in patients with COVID-19 include myocardial inflammation or direct viral infiltration. Patients diagnosed with COVID-19 should be monitored closely for the development of bradyarrhythmia and haemodynamic instability.
Toward an Understanding of the Welfare Effects of Nudges: Evidence from a Field Experiment in the Workplace
Authors: Bulte Erwin , List John A , van Soest Daan
Published: May 2020

Social scientists have recently explored how framing of gains and losses affects productivity. We conducted a field experiment in peri-urban Uganda, and compared output levels across 1,000 workers over isomorphic tasks and incentives, framed as either losses or gains. We find that loss aversion can be leveraged to increase the productivity of labour. The estimated welfare costs of using the loss contract are quite modest—perhaps because the loss contract is viewed as a (soft) commitment device.
Undoing Gender with Institutions: Lessons from the German Division and Reunification
Authors: Lippmann Quentin , Georgieff Alexandre , Senik Claudia
Published: May 2020

Using the 41-year division of Germany as a natural experiment, we show that the German Democratic Republic’s gender-equal institutions created a culture that has undone the male breadwinner norm and its consequences. Since reunification, East Germany still differs from West Germany not only because of its higher female contribution to household income, but also because East German women can earn more than their husbands without having to increase their number of housework hours, put their marriage at risk or withdraw from the labour market. By contrast, the norm of higher male income, and its consequences, are still prevalent in West Germany.
Genotypic and phenotypic characterization of food-associated Lactobacillus plantarum isolates for potential probiotic activities
Authors: Prete Roberta , Long Sarah L , Joyce Susan A , Corsetti Aldo
Published: May 2020

Lactic acid bacterium, Lactobacillus plantarum, has been applied, for centuries, for food and drink fermentations. Given the benefits associated with fermented products, Lb. plantarum strains have captured considerable industrial and scientific interest, so that they are included as fundamental components of functional foods. Indeed, some strains are marketed as probiotics. In the present study, food- and gut-associated Lb. plantarum isolates were genetically characterized by multilocus sequence typing (MLST) and phenotypically characterized for properties that could influence their probiotic potential. MLST and phylogenetic analysis stratified 22 Lb. plantarum isolates into six lineages. The isolates were further phenotypically characterized by an in vitro assay to assess their potential gut community influence via a limited number of assays including acidification activity, strain displacement activity and their intrinsic range of antibiotic resistance. Given growing recognition of the benefits of fermented foods, and the prevalence of Lb. plantarum in these applications, this study highlights analysis of a subset of preliminary important strain-specific features. These features are of interest to all stakeholders, to inform isolate comparison and selection for current functional food associations, and that can serve as a basis for future strain and food-microbe fermentation product development.
Spotlight on: BCS Canada
Authors: Haisley Andrew
Published: May 2020

Our international hubs are located across Europe, North America, Asia and Africa, supporting our member communities in these areas with a platform for networking, professional development and debate. Andrew Haisley CITP, Chair of the Canada International Section completes the ITNOW Q&A about the group.
The Rise of Fraud in Loyalty Schemes
Authors: Umar Assad
Published: May 2020

There has been a sharp rise in loyalty card fraud, with both companies and consumers missing out on the benefits they were designed to deliver. Assad Umar, Consultant at Consult Hyperion, explores the history and where these schemes are going in the future.
Architecting Change
Authors: Smith Jonathon
Published: May 2020

Jonathon Smith MBCS discusses best practice for connecting systems together in his role as Solution Architect at National Grid.
Sir Clive Sinclair Innovator Extraordinaire
Authors: Abram Tom
Published: May 2020

Mention the name Sinclair to a technologist of a certain age and expect a lively response — writes Tom Abram, Editor in Chief of the Archives of IT — always nostalgic and tinged with either enthusiasm or frustration.
10 Critical Considerations When Developing an AI
Authors: Oatridge Nic
Published: May 2020

Concerns about the dangers of AI are older than the field itself, dating at least as far back as Isaac Asimov’s 1942 Three Laws of Robotics, writes Nic Oatridge MSc MBCS.
Cybersecurity in the Space Age
Authors: Hamilton Johanna
Published: May 2020

Graham Wright CBE, Senior Vice President for Security and Cyber at Inmarsat, talks to Johanna Hamilton AMBCS at the Cyber Security Connect UK conference — about satellites, security and paving the way for those new to the cyber profession.
Voter Turnout and City Performance: Evidence from Italian Municipalities
Authors: Lo Prete Anna , Revelli Federico
Published: May 2020

Using data on mayoral elections in large Italian cities during the 2000s, we investigate whether and how voter turnout affects city performance across a number of dimensions. To address the issue of voter turnout endogeneity and identify the transmission mechanism, we exploit exogenous variation in participation rates in mayoral elections due to anticipated shocks (concurrence of local and national elections) and unanticipated shocks (bad weather on the day of the election) to the cost of voting. The results consistently point to a negative impact of voter turnout rates on indicators of urban environmental performance, life quality, and administrative efficiency. Interestingly, though, we find that only anticipated shocks to turnout affect the quality of elected mayors measured on a number of competence dimensions, compatibly with the hypothesis of a selection mechanism whereby parties choose candidates to maximize their chances of winning the elections based on their expectations on voter turnout rates (JEL D72, H72, C26).
Anterior tibialis artery pseudoaneurysm after minimally invasive plate osteosynthesis in the proximal tibia: a case report
Authors: Beaton Comulada David , Hernández-Rodríguez Saul , Rivera Lenny , Zierenberg Charles , Lojo-Sojo Luis
Published: May 2020

Tibial plateau fractures are common fractures associated with high-energy trauma. The treatment of these fractures remains a challenge today. Recent management of fractures has moved from open surgery toward minimally invasive surgery to reduce complications and improve functional outcomes. Nevertheless, such a minimalistic approach makes visualization of neurovascular structures difficult, placing them at risk. We report the case of a 39-year-old male who developed a pseudoaneurysm of the anterior tibial artery following minimally invasive plate osteosynthesis of the right proximal tibia. Diagnosis was made through noninvasive duplex ultrasound and was referred to endovascular service. Understanding of the anatomy of the surgical site is vital to minimize complications. In addition, proper postsurgical patient evaluation is important to monitor the insurgence of such complications.
Racial demographics and COVID-19 confirmed cases and deaths: a correlational analysis of 2886 US counties
Authors: Mahajan Uma V , Larkins-Pettigrew Margaret
Published: May 2020

Background

Recent news reports state that racial minority groups, such as African–Americans, are experiencing a greater COVID-19 burden, as measured by confirmed cases and deaths. Limited racial data is available on a national level.

Methods

We conducted the first nationwide analysis to examine COVID-19 and race on a county level. We obtained datasets on COVID-19 cases and deaths, and racial population totals, by US county. We examined if correlations exist between the racial percentages and percentages of confirmed COVID-19 cases and deaths by county.

Results

A positive correlation existed between percentages of African–Americans living in a county and who have COVID-19 (r = 0.254, P < 0.0001), who have died from COVID-19 (r = 0.268, P < 0.0001), and case mortality (r = 0.055, P = 0.003). Positive correlations also existed between percentages of Asian–Americans living in counties and these factors. Negative correlations existed between percentages of Whites living in counties and these factors.

Conclusions

A weak, albeit very significant, positive relationship exists between the percentage of African–Americans living in a county and the percentage of COVID-19 confirmed cases, confirmed deaths and case mortality in the county. This is in support of many city and statewide analyses, and we urge for targeted resources towards work that further examine these racial associations.
Hydrogen gas (XEN) inhalation ameliorates airway inflammation in asthma and COPD patients
Authors: Wang S -T , Bao C , He Y , Tian X , Yang Y , Zhang T , Xu K -F
Published: May 2020

Background

Hydrogen was proven to have anti-oxidative and anti-inflammation effects to various diseases.

Aim

We wish to investigate the acute effects of inhaled hydrogen on airway inflammation in patients with asthma and chronic obstructive pulmonary disease (COPD).

Design

Prospective study.

Methods

In total, 2.4% hydrogen containing steam mixed gas (XEN) was inhaled once for 45 min in 10 patients with asthma and 10 patients with COPD. The levels of granulocyte-macrophage colony stimulating factor, interferon-γ, interleukin-1β (IL-1β), IL-2, IL-4, IL-6 and so on in peripheral blood and exhaled breath condensate (EBC) before and after ‘XEN’ inhalation were measured.

Results

45 minutes ‘XEN’ inhalation once decreased monocyte chemotactic protein 1 level in both COPD (564.70–451.51 pg/mL, P = 0.019) and asthma (386.39–332.76 pg/mL, P = 0.033) group, while decreased IL-8 level only in asthma group (5.25–4.49 pg/mL, P = 0.023). The level of EBC soluble cluster of differentiation-40 ligand in COPD group increased after inhalation (1.07–1.16 pg/mL, P = 0.031), while IL-4 and IL-6 levels in EBC were significantly lower after inhalation in the COPD (0.80–0.64 pg/mL, P = 0.025) and asthma (0.06–0.05 pg/mL, P = 0.007) group, respectively.

Conclusions

A single inhalation of hydrogen for 45 min attenuated inflammatory status in airways in patients with asthma and COPD.
A telehealth program to perform medical screening examinations
Authors: Laghezza Matthew , Sharma Rahul , Hsu Hanson , Greenwald Peter , Sullivan Robert , Eid Dona Alma Bou
Published: May 2020

The importance of a timely medical screening examination on ED throughput, efficiency, and patient safety cannot be underestimated. This article describes a telemedicine program based on the provider in triage model that uses physician assistants and NPs to improve patient door-to-diagnostic evaluation times in the ED.
The new nurse manager survival guide, part II
Authors: Cathcart Eloise Balasco
Published: May 2020

Leading in a time of crisis
Changing How Race Is Portrayed in Medical Education: Recommendations From Medical Students
Authors: Nieblas-Bedolla Edwin , Christophers Briana , Nkinsi Naomi T. , Schumann Paul D. , Stein Elizabeth
Published: May 2020

The medical community has been complicit in legitimizing claims of racial difference throughout the history of the United States. Unfortunately, a rigorous examination of the role medicine plays in perpetuating inequity across racial lines is often missing in medical school curricula due to time constraints and other challenges inherent to medical education. The imprecise use of race—a social construct—as a proxy for pathology in medical education is a vestige of institutionalized racism. Recent examples are presented that illustrate how attributing outcomes to race may contribute to bias and unequal care. This paper proposes the following recommendations for guiding efforts to mitigate the adverse effects associated with the use of race in medical education: emphasize the need for incoming students to be familiar with how race can influence health outcomes; provide opportunities to hold open conversations about race in medicine among medical school faculty, students, and staff; craft and implement protocols that address and correct the inappropriate use of race in medical school classes and course materials; and encourage a large cultural shift within the field of medicine. Adoption of an interdisciplinary approach that taps into many fields, including ethics, history, sociology, evolutionary genetics, and public health is a necessary step for cultivating more thoughtful physicians who will be better prepared to care for patients of all racial and ethnic backgrounds.
Naloxone-induced Peripheral Edema: A Case Report
Authors: Taylor Shawn R. , Gustafson Benjamin D. , Hough Daniel S.
Published: May 2020

Introduction:

Despite a low bioavailability, sublingual naloxone does reach systemic circulation as evidenced by pharmacokinetic studies. As observed in clinical practice, patients receiving sublingual naloxone in combination with buprenorphine occasionally experience adverse reactions that resolve when naloxone alone is discontinued suggesting potential for naloxone-induced reactions. According to postmarketing data, peripheral edema is one of the most common adverse drug events related to sublingual buprenorphine/naloxone.

Case:

A case of potential naloxone-induced peripheral edema in a 69-year-old woman. The patient experienced peripheral edema over the course of several months after the initiation of sublingual buprenorphine/naloxone despite numerous attempts at pharmacological diuresis. Within 1 month of omitting naloxone from her regimen and continuing buprenorphine monotherapy, the patient’s edema resolved.

Conclusions:

Given pharmacokinetic studies and evidence of systemic absorption, adverse drug reactions from sublingual naloxone are possible. Mindfulness of appropriate candidates for combination sublingual buprenorphine/naloxone formulations and monitoring for naloxone-induced peripheral edema is prudent.
Evaluation of the Efficacy of Prolonged Pregabalin Administration Before and After Surgery in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Repair
Authors: Tobias Alexandro F. , Moura Ed C.R. , Honda Claudio A.d.O. , Pereira Emanuel C. , de Oliveira Caio M.B. , Leal Plinio d.C. , Sakata Rioko K.
Published: May 2020

Context and Objective:

Reconstruction of the knee ligament causes postoperative pain and delayed rehabilitation.

Objective:

The primary objective of this study was to evaluate the effect of a prolonged preoperative and postoperative pregabalin use for arthroscopic anterior cruciate ligament repair.

Materials and Methods:

Group 1 (N=25) patients received pregabalin 75 mg/d, and group 2 (N=25) received placebo, 7 days before and 7 days after surgery. Spinal anesthesia was performed using 0.5% hyperbaric bupivacaine (15 mg). The following were evaluated: pain intensity immediately after the surgery, and 12 hours, 24 hours, 1 week, 2 weeks, 1 month, and 2 months after the surgery using a Numerical Rating Scale; dose of postoperative supplementary analgesic for 2 months; time to first analgesic requirement; and side effects during 2 months. For supplementation, the participants received 1 g dipyrone; if there was no pain control, 100 mg ketoprofen was administered; if there was no effect, 100 mg tramadol was administered; and if there was no pain control, 5 mg intravenous morphine was administered until pain control.

Results:

There was no difference between the groups with regard to pain intensity (P=0.077). In the pregabalin group, morphine consumption was lower at 12 hours (P=0.039) and 24 hours (P=0.044) after surgery, and the consumption of tramadol and ketoprofen was lower 24 hours after surgery. There was no significant difference in the incidence of nausea and vomiting. Dizziness was higher in the pregabalin group (group 1=12 patients; group 2=3 patients; P=0.005).

Discussion:

A prolonged preoperative and postoperative pregabalin prescription for anterior cruciate ligament repair decreased the need for supplementary analgesics during the first 24 postoperative hours but increased dizziness.
Psychological Predictors of Perceived Age and Chronic Pain Impact in Individuals With and Without Knee Osteoarthritis
Authors: Booker Staja Q. , Sibille Kimberly T. , Terry Ellen L. , Cardoso Josue S. , Goodin Burel R. , Sotolongo Adriana , Staud Roland , Redden David T. , Bradley Laurence A. , Fillingim Roger B. , Bartley Emily J.
Published: May 2020

Objective:

Chronological age is a risk factor in chronic pain; however, aging research supports the premise that physical and psychological health may better predict perceived age. Given the lack of evidence on perceived age in the context of chronic pain, the current study presents novel findings about the relationship between perceived age, chronic pain impact, and psychological function in adults with and without knee osteoarthritis.

Methods:

This secondary analysis was part of an ongoing multisite observational cohort study to understand the progression of knee pain and disability. Community-dwelling adults (N=227) ages 45+ completed measures of trait resilience, trait positive and negative affect, pain catastrophizing, subjective perceptions of age, and the Graded Chronic Pain Scale.

Results:

On average, participants reported feeling 10 years younger than their chronological age; however, this effect was attenuated in individuals reporting high-impact pain. Lower perceived age was associated with lower pain impact (low pain/low disability), while higher perceived age correlated with higher pain impact (high pain/high disability) and more adverse psychological effects. Using hierarchical linear regression, high-impact pain and positive affect emerged as statistically significant predictors of perceived age, whereas no differences were observed among trait resilience, negative affect, or pain catastrophizing.

Discussion:

These findings highlight the importance of a biopsychosocial approach in understanding the intersection between psychological and physical factors associated with chronic pain. Addressing negative self-perceptions of aging, while simultaneously augmenting positive affect, through psychological therapies may mitigate pain and disability.
Conceptually Redefining Neonatal Palliative Care
Authors: Kain Victoria J. , Chin Susan D.
Published: May 2020

Background:

First defined in 2002 by Catlin and Carter, neonatal palliative care (NPC) is a relatively new model of care in neonatal pediatrics, first appearing in the medical literature in the early 1980s.

Purpose:

The purpose of this article is to suggest a conceptual definition of NPC that encompasses all the essential concepts as a way of moving NPC forward by having a consistent approach.

Methods:

Following a review of the NPC literature, a thematic analysis as a method for identifying, analyzing, and interpreting patterns of meaning in the definitions (“themes”) within the literature was undertaken.

Findings:

The major themes identified included philosophies of care, support, culture and spirituality, the team, and clinical management.

Implications for Research:

At the heart of NPC is the primacy of maintaining quality of life, while providing ethical and humane care that supports a “good death.” The extensive elements presented in this article are considered essential to a comprehensive and conceptual definition of NPC proposed here.
Implementation of a Perinatal Hospice Program
Authors: Falke Megan , Rubarth Lori Baas
Published: May 2020

Background:

In 2017, the Nebraska Unicameral passed legislative bill 506, which required physicians to inform patients carrying fetuses diagnosed with a life-limiting anomaly of the option to enroll in a comprehensive perinatal hospice program. The bill also required the Department of Health & Human Services to provide information about statewide hospice programs. Families enrolled in hospice programs are better prepared for the birth and death of their child. This large academic medical center was listed on the registry but did not have a formal perinatal hospice program.

Purpose:

Implementation of a comprehensive perinatal hospice program.

Methods:

The program was designed and implemented, beginning with the formation of an interdisciplinary team. Guidelines were developed for program referral, care conferences, team communication, and family follow-up. The team was educated. Electronic record documentation and order set were implemented. A data collection process was developed to track referrals and critical data points.

Results:

The perinatal hospice program has been accepting referrals but has not had any qualifying referrals.

Implications for Practice:

The development of an evidence-based guideline for referral that can improve referral consistency. While trisomy 13 and 18 diagnosis was historically considered life-limiting, these families now have the option of full intervention and transfer for specialists.

Implications for Research:

Future research will include collecting data from patients who could have benefited from hospice, including infants who were born 20 to 22 weeks, or for maternal reasons. Future research will evaluate the experience after bereavement, the hospice team's experience, and the effectiveness of the referral process.
Profile of Reported Alcohol, Tobacco, and Recreational Drug Use in Nulliparous Women
Authors: Haas David M. , Mahnke Brianna , Yang Ziyi , Guise David , Daggy Joanne , Simhan Hyagriv N. , Silver Robert M. , Grobman William A. , Wapner Ronald J. , Makhoul Joshua , Parry Samuel , Mercer Brian M. , Saade George R.
Published: May 2020

OBJECTIVE:

To estimate alcohol, tobacco, and recreational drug use during pregnancy among nulliparous women.

METHODS:

In a cohort of nulliparous women followed through pregnancy from the first-trimester nuMoM2b (Nulliparous Outcomes in Pregnancy: Monitoring Mothers to be) study, self-reported use of alcohol, tobacco, and drugs was chronicled longitudinally at four study visits in this secondary analysis. Rates of use before pregnancy, in each trimester (visit 1, visit 2, visit 3, approximating each trimester), and at the time of delivery (visit 4) were recorded. The amount of alcohol, tobacco, and drug exposure were recorded using validated measures, and trends across pregnancy were analyzed.

RESULTS:

Of the 10,038 study participants, 10,028 had information regarding alcohol, tobacco, and drug use at visit 1, 9,412 at visit 2, 9,217 at visit 3, and 7,167 at visit 4. The rates of drinking alcohol, which had been 64.6% in the 3 months before pregnancy, were lower in pregnancy (3.9% at visit 1, 5.6% at visit 2, 7.0% at visit 3, and 6.1% at visit 4, P<.001 for all). Rates later in pregnancy were all greater than in the first trimester (P<.01). The rate of smoking in the 3 months before pregnancy, which was 17.8%, also declined at visit 1 (5.9%), and continued to decline through pregnancy (5.3% at visit 2, 4.7% at visit 3, and 3.9% at visit 4, with all rates lower than that of visit 1 [P<.01]). Although recreational drug use was relatively common in the months before pregnancy (33.8%), it also declined during pregnancy (1.1% at visit 2, 0.7% at visit 3, 0.4% at visit 4).

CONCLUSIONS:

In this geographically and ethnically diverse cohort of nulliparous women, rates of self-reported alcohol, smoking, and recreational drug use were all significantly lower during than before pregnancy. Nonetheless, rates of alcohol use rose as pregnancy progressed, highlighting the need for continued counseling throughout all trimesters of pregnancy.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT01322529.
Antenatal Corticosteroids and Outcomes in Preterm Twins
Authors: Ushida Takafumi , Kotani Tomomi , Sadachi Ryo , Hirakawa Akihiro , Hayakawa Masahiro , Moriyama Yoshinori , Imai Kenji , Nakano-Kobayashi Tomoko , Kikkawa Fumitaka ,   for the Neonatal Research Network of Japan
Published: May 2020

OBJECTIVE:

To estimate whether improvement in outcomes from antenatal corticosteroid treatment in extremely and very preterm twins is similar to that observed in singletons, and to investigate whether antenatal corticosteroid treatment has different effects according to chorionicity or birth order.

METHODS:

This population-based study was based on an analysis of data collected by the Neonatal Research Network of Japan from 2003 to 2015 of neonates weighing 1,500 g or less at birth, from gestational ages of 24 0/7 to 31 6/7 weeks of gestation. After propensity score matching, univariate logistic and interaction analyses were performed to compare short-term (neonatal period) and medium-term (3 years of age) outcomes of the children of mothers who received antenatal corticosteroids with those of children of mothers who did not receive antenatal corticosteroids. We focused on differences between singletons and twins, between monochorionic and dichorionic twins and between the first and second twin.

RESULTS:

The study comprised 23,502 singletons and 6,546 twins. Antenatal corticosteroid treatment was associated with significant decreased short-term neurologic outcomes in both singletons and twins. However, antenatal corticosteroid treatment was associated with significantly decreased mortality (odds ratio [OR] 0.61; 95% CI 0.53–0.70), respiratory distress syndrome (OR 0.71, 95% CI 0.67–0.76), and cerebral palsy (OR 0.85, 95% CI 0.72–0.99) in singletons but not in twins (OR 0.89, 95% CI 0.68–1.17; OR 0.99, 95% CI 0.87–1.12; and OR 0.82, 95% CI 0.61–1.11, respectively). No association was found between chorionicity and the efficacy of antenatal corticosteroid treatment on outcomes. Further, no association was found between birth order and the efficacy of antenatal corticosteroid treatment on outcomes, except for periventricular leukomalacia and necrotizing enterocolitis (interaction: P=.02 and P=.04, respectively).

CONCLUSION:

Antenatal corticosteroid treatment in twins was associated with a beneficial effect on short-term neurologic outcomes only, without improvement in other short-term and medium-term outcomes. There was no difference related to chorionicity.
Tuberculosis in Pregnancy
Authors: Miele Kathryn , Bamrah Morris Sapna , Tepper Naomi K.
Published: May 2020

Tuberculosis (TB) in pregnancy poses a substantial risk of morbidity to both the pregnant woman and the fetus if not diagnosed and treated in a timely manner. Assessing the risk of having Mycobacterium tuberculosis infection is essential to determining when further evaluation should occur. Obstetrician–gynecologists are in a unique position to identify individuals with infection and facilitate further evaluation and follow up as needed. A TB evaluation consists of a TB risk assessment, medical history, physical examination, and a symptom screen; a TB test should be performed if indicated by the TB evaluation. If a pregnant woman has signs or symptoms of TB or if the test result for TB infection is positive, active TB disease must be ruled out before delivery, with a chest radiograph and other diagnostics as indicated. If active TB disease is diagnosed, it should be treated; providers must decide when treatment of latent TB infection is most beneficial. Most women will not require latent TB infection treatment while pregnant, but all require close follow up and monitoring. Treatment should be coordinated with the TB control program within the respective jurisdiction and initiated based on the woman's risk factors including social history, comorbidities (particularly human immunodeficiency virus [HIV] infection), and concomitant medications.
Traumatic Hip Fracture and Primary Elective Total Hip Patients are Not the Same: A Comparison of Comorbidity Burden, Hospital Course, Postoperative Complications, and Cost of Care Analysis
Authors: Lowe Jason , Mitchell Sean M. , Agarwal Sumit , Jones Clifford B.
Published: May 2020

Objectives:

To compare patient admission comorbidity profiles, length of stay, readmission rate, postoperative complications, mortality rate, and cost of care between acute geriatric hip fractures (HF) and elective total hip arthroplasties (THA).

Methods:

Retrospective cohort.

Setting:

Multicenter health care system.

Patients:

Eighteen thousand forty-two geriatric HF treated with operative fixation or arthroplasty and 8761 elective total hip patients were reviewed.

Main Outcome Measurements:

Charlson Comorbidity Index, length of stay, ICU admission, readmission rate, postoperative complications, mortality rates, and cost of care.

Results:

Medical comorbidities: chronic pulmonary disease, chronic kidney disease, coronary artery disease, heart failure, liver cirrhosis, and cerebrovascular disease were higher in HF patients as was mean Charlson Comorbidity Index (P < 0.001). Albumin was lower and HgbA1c higher in HF patients (P < 0.001). Average length of stay was 5.0 versus 2.6 days (P < 0.001) with 8.5% of HF patients being managed in the ICU versus 1.8% of THA patients. Readmission rates for HF and THA patients were 21.4% and 6.2%, respectively (P < 0.001). Minor and major complications were higher in the HF cohort (P < 0.001), as were 30-day (1.97% vs. 0.17%) and 1-year mortality rates (3.49% vs. 0.40%) (P < 0.001). Mean hospital cost of care was nearly 15,000 US dollars more expensive in HF patients when compared to the elective THA cohort (P < 0.001).

Conclusions:

HF patients have increased comorbidity burdens, lengths of stay, ICU admissions, readmission rates, complications, mortality, and costs of care than patients with elective total hip arthroplasty. In the era of pay for quality performance, health systems must reconcile the difference between these 2 patient cohorts.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Increased Microvessel and Arteriole Density in the Contracted Side of the Relapsed Clubfoot
Authors: Novotny Tomas , Eckhardt Adam , Knitlova Jarmila , Doubkova Martina , Ostadal Martin , Uhlik Jiri , Musilkova Jana
Published: May 2020

Background:

Clubfoot deformity (pes equinovarus) is one of the most common birth defects, and its etiology is still unknown. Initial clubfoot treatment is based on the Ponseti method throughout most of the world. Despite the effectiveness of this therapy, clubfoot may relapse. Recent studies confirm the theory of active fibrotic remodeling processes in the extracellular matrix of the affected tissue. The aim of this study was to clarify whether relapses in clubfoot therapy are associated with altered angiogenesis and to suggest possible regulatory pathways of this pathologic process.

Methods:

We compared microvessel density, arteriole density, and concentration of angioproliferative-related proteins found between tissues in the contracted, that is, the medial side (M-side), and noncontracted, that is, the lateral side (L-side) of the relapsed clubfeet. Tissue samples from 10 patients were analyzed. Histopathologic analysis consisted of immunohistochemistry and image analysis. Real-time polymerase chain reaction was used to study mRNA expression.

Results:

An increase in microvessel and arteriole density was noted in contracted, relapsed clubfoot tissue. This was accompanied by a significant increase in the levels of the vascular endothelial growth factor, vascular endothelial growth factor receptor 2, β catenin and active β catenin. Vascular endothelial growth factor, vascular endothelial growth factor receptor 2, and CD31 overexpression was also seen with mRNA analysis.

Conclusions:

Increased microvessel and arteriole density in the contracted side of the relapsed clubfoot was noted. These processes are mediated by specific proangiogenic proteins that are overexpressed in the contracted tissue. These findings contribute to the etiology and the development of relapses in the treatment of clubfoot.

Level of Evidence:

Level II—analytical and prospective.
Intraoperative Prone Radiographs During Scheuermann Kyphosis Correction Closely Estimate Standing Thoracic and Lumbar Parameters at 2 Years
Authors: Greenhill Dustin A. , Poppino Kiley F. , Jo Chan-Hee , Sucato Daniel J.
Published: May 2020

Background:

In patients with Scheuermann kyphosis (SK) undergoing posterior spinal fusion with instrumentation (PSFI), intraoperative lateral radiographs assess deformity correction in the prone position. The relationship between thoracic and (partially un-instrumented) lumbar parameters on prone intraoperative versus standing postoperative radiographs is unknown.

Methods:

Forty-five consecutive patients with SK who underwent PSFI between 2007 and 2014 were reviewed. Thoracic kyphosis (TK), lumbar lordosis (LL), instrumented level kyphosis [upper instrumented vertebrae (UIV)-lower instrumented vertebrae (LIV)], and traditional sagittal parameters were recorded from preoperative standing, intraoperative prone, first outpatient standing, and >2-year standing radiographs and time periods were compared. Exclusion criteria included reduction modification after intraoperative radiographs and postoperative construct revision prohibiting comparison to initial intraoperative radiographs.

Results:

Twenty-five patients averaging 16 (12 to 20) years old during surgery with 3.1 (2 to 7) years follow-up met inclusion criteria. Average surgical variables included: 13±1 fusion levels, UIV at T2, LIV at L3, 3.8±1.6 osteotomies per patient, and 43±9% correction of TK. Preoperative TK and LL measured 82 and 76 degrees, respectively. TK on intraoperative (47 degrees), 6-week (49 degrees), and >2-year (50 degrees) radiographs changed significantly only between intraoperative and >2-year radiographs (P=0.03) by just 3 degrees. LL increased 5 degrees from intraoperative prone to 6-week standing radiographs (51 to 56 degrees, P=0.01) without further significant change at >2 years (59 degrees, P=0.09). Instrumented levels (UIV-LIV) had increased kyphosis at 6 weeks (32 to 35 degrees, P=0.01) without further change at >2 years (36 degrees, P=0.06).

Conclusions:

TK on intraoperative prone radiographs during PSFI for SK should match the standing TK ∼6 weeks later. Intraoperative prone LL only slightly increases on early standing radiographs. Assuming a routine postoperative course, intraoperative radiographs slightly underestimate TK (by 3 degrees) and LL (by 8 degrees) on >2-year standing radiographs. These parameters (TK, LL, UIV-LIV) are visualized during surgery and should be used in future studies to predict long-term outcomes.

Level of Evidence:

Level IV—retrospective study.
Modified Woodward Technique for Sprengel Deformity and a Modification of the Cavendish Classification
Authors: Öner Ali , Köksal Alper , Çimen Osman , Kargin Deniz , Albayrak Akif , Akman Yunus E.
Published: May 2020

Introduction:

Sprengel deformity (SD) is the most common congenital anomaly of the shoulder. Surgery is required for moderate and severe forms. The modified Woodward procedure is the most widely used procedure for the surgical treatment.

Methods:

SD patients who applied to our institution between 2005 and 2018 were retrospectively reviewed. A modification of the Cavendish classification was used for preoperative and postoperative evaluations.

Results:

Eighteen shoulders of 17 (mean age: 8.5 y, range: 2 to 18 y, 5 males and 12 females) patients were included. The right, left, and bilateral shoulders were affected in 9, 7, and 1 cases, respectively. The mean follow-up time was 62.9 months (12 to 161 mo). Preoperatively, 3 shoulders were type 2, 12 shoulders were type 3, and 3 shoulders were type 4 according to the Cavendish classification and 2 shoulders were type 0, 6 shoulders were type 1, and 10 shoulders were type 2 postoperatively.

Conclusions:

Periscapular congenital malformations play a significant role in range of motion limitation. The modified Woodward procedure is a viable alternative in the surgical treatment of SD and the proposed modification of Cavendish classification (grade 0) is functional.
Distraction-to-stall Versus Targeted Distraction in Magnetically Controlled Growing Rods
Authors: Dragsted Casper , Fruergaard Sidsel , Jain Mohit J. , Deveza Lorenzo , Heydemann John , Ohrt-Nissen Søren , Andersen Thomas , Gehrchen Martin , Dahl Benny
Published: May 2020

Background:

Consensus is lacking regarding the lengthening procedures in magnetically controlled growing rods (MCGR), and no studies have compared the outcome between different distraction principles. The purpose of the present study was to compare distraction-to-stall with targeted distraction and identify variables associated with achieved distraction.

Methods:

We performed a 2-center retrospective study of all children treated with MCGR from November 2013 to January 2019, having a minimum of 1-year follow-up and undergoing a minimum of 3 distractions. Exclusion criteria were single-rod constructs and conversion cases. In group 1 (21 patients), we used a distraction-to-stall (maximum force) principle where each rod was lengthened until the internal magnetic driver stopped (clunking). In group 2 (18 patients), we used a targeted distraction principle, where the desired distraction was entered the remote control before distraction. In both groups we aimed for maximal distraction and curve correction at index surgery. Achieved distraction was measured on calibrated radiographs and compared between the 2 groups using a linear mixed effects model. Univariate and multivariate analyses were performed to identify variables associated with achieved distraction within the first year.

Results:

Mean age at surgery was 9.5±2.0 years. Etiology of the deformity was congenital/structural (n=7), neuromuscular (n=9), syndromic (n=3), or idiopathic (n=20). Demographics and preoperative characteristics including spinal height (T1T12 and T1S1) did not differ significantly between the groups (P≥0.13). Time interval between distractions were mean 18 days (95% confidence interval: 10-25) shorter in group 1. Implant-related complications occurred in 10/39 patients, 5 in each group. We found no difference in achieved distraction between the groups in the linear mixed effects model. In the multivariate analysis, preoperative major curve angle was the only independent variable associated with achieved distraction.

Conclusions:

In 2 comparable and consecutive cohorts of patients treated with MCGR, we found no difference in achieved distraction between a distraction-to-stall and a targeted distraction principle. Preoperative major curve angle was the only independent predictor of achieved distraction.

Level of Evidence:

Level III—retrospective comparative study.
Management of Paronychia in Patients With Apert Syndrome
Authors: Kim Justine S. , Block Lisa M. , Zhu Xiao , Davit Alexander J.
Published: May 2020

Apert syndrome is a complex congenital syndrome that includes bicoronal craniosynostosis, craniofacial dysmorphologies, cleft palate, hearing loss, spina bifida occulta, cardiac anomalies, and affects the upper and lower extremities—producing complex syndactyly in these patients. Management of the hands yields several challenges and mandates close follow-up to balance repair of complex polysyndactyly with other pressing interventions, such as posterior cranial vault distraction and surgical management of the airway. Our goals of therapy for the hands are to preserve 10 digits, provide sufficient soft tissue coverage, optimize hand function, and minimize the number of surgical interventions. Ideally, surgical management of the hand differences occurs between the ages of 9 months and 2 years, to optimize neurocognitive development. In complex syndactyly observed in patients with Apert syndrome, there are broad, conjoined nail plates that overlie the fused digits, and paronychia occurs frequently. Suppurative infections can delay definitive surgical intervention for the patient’s complex syndactyly, and resolution of paronychia is critical. This study aims to propose an effective and safe technique to manage paronychia when it occurs in patients with Apert complex syndactyly and to mitigate the length of delay to definitive polysyndactyly reconstruction. In the context of these patients’ need for multiple surgical interventions within the first few years of life, this strategy for preventing or mitigating paronychia can play an important role in streamlining their complex surgical management while avoiding multiple cancellations.