bluuebunny/crossref_metadata_2025_split huggingface dataset:
Use of Massive Transfusion Protocol: Maternal Outcomes in Patients With Severe Obstetric Hemorrhage [22K]
Authors: Lepic Molly , Greer Danielle M. , Kram Jessica J. F. , Nijhawan Niraj , Cicero Andra 
Published: April 2018

INTRODUCTION:
Obstetrical hemorrhage represents the single-most significant cause of maternal mortality. As hemorrhage rates increase, Massive Transfusions Protocols (MTP) have been adopted for maternal resuscitation. We explored maternal outcomes associated with MTP utilization.

METHODS:
We retrospectively studied women who delivered with Class III-IV hemorrhage (estimated blood loss [EBL] ≥1,500 mL) at either an urban teaching-hospital serving high-risk patients (HOSP1) or a suburban hospital serving average-risk patients (HOSP2) during 2012–2015. Patient groups included: 1) no transfusion, 2) transfusion without MTP, and 3) transfusion via MTP (implemented at HOSP1 only). Between-group differences in maternal characteristics and outcomes by year and hospital were described.

RESULTS:
Women totaled 109 at HOSP1 (no transfusion: 30 [28%], transfusion: 56 [51%], MTP: 23 [21%]) and 42 at HOSP2 (no transfusion: 18 [43%], transfusion: 24 [57%]). Transfusion reactions (n=2) occurred in the transfusion group only, and no maternal deaths occurred. No statistically significant patterns were detected in length of stay (LOS) or renal, hematologic, or coagulation indices. However, notable patterns were observed at HOSP1 in mean EBL (no transfusion: 1,720 mL, transfusion: 2,048 mL, MTP: 3,417 mL) and postpartum LOS (no transfusion: 3.0 days, transfusion: 3.2 days, MTP: 4.3 days). Thrombocytopenia improved annually with MTP. Total units transfused were greater with MTP (Total 10.2, PRBC 6.6, FFP 2.6, Platelet 0.9) than transfusion (Total 3.6, PRBC 3.0, FFP 0.4, Platelet 0.1). MTP accounted for the only wasted units (mean 0.52, range 0–4).

CONCLUSION:
MTP uses more blood products. However, in class III–IV hemorrhages, MTP use may be beneficial without significant adverse outcome.
The Correlation of Involvement in Resident Education and Episiotomy Rates [28K]
Authors: Neace Sasha , Crisp Catrina , Devaiah Ganga , Marcotte Michael , Voss Deward , Holbert Michael 
Published: April 2018

INTRODUCTION:
Nationally, there exists large variation in episiotomy rates among organizations and providers. The Leapfrog group has set a national goal of reducing episiotomy rates to less than 5%. The purpose of this study was to compare rates of episiotomy for providers during their private deliveries who participated in obstetric resident supervision to the rates for providers who did not supervise residents.

METHODS:
This is a retrospective study examining all private vaginal deliveries performed by physicians at an academic institution from July 1, 2015 to June 30, 2016. Deliveries with shoulder dystocia were excluded. Physician demographic information and delivery attributes were collected and analyzed.

RESULTS:
There were 3,785 private vaginal deliveries performed by 68 physicians during the study period: 31 provided resident coverage. Those providing resident supervision performed 1,578 private deliveries compared to 2,207 private deliveries among the 37 physicians not providing resident supervision. Physicians providing resident supervision performed half as many episiotomies compared to the group not involved in resident supervision, 7.5% versus 14.5% (OR 0.477, P<.001, 95% CI 0.382–0.595). There was no significant difference in physician demographics or operative vaginal delivery rates between the two groups.

CONCLUSION:
At our organization, there exists a difference in episiotomy rates among physicians that provide and do not provide resident supervision. Although causality cannot be inferred from this retrospective study, physician involvement in obstetric resident training is associated with reduced episiotomy rates reflecting an improved quality of obstetric care based on one of the Leapfrog group's metrics.
Impact of Prior History of Intrahepatic Cholestasis of Pregnancy on Current Pregnancy [33K]
Authors: Kohari Katherine , Rekawek Patricia , Lipkind Heather S. , Ferrara Lauren 
Published: April 2018

INTRODUCTION:
The purpose of this study was to determine the impact of a prior history of intrahepatic cholestasis of pregnancy (ICP) on current pregnancy course and outcome in women with subsequent ICP.

METHODS:
This is a retrospective cohort study, comparing multiparous patients with ICP who had a history of ICP in a prior pregnancy to those patients without a prior history. Data was collected from a single hospital between 2005 and 2013. All patients with a diagnosis of ICP were identified. Data collected included maternal demographics, ICP management, delivery and neonatal outcomes. Logistic regression was used to evaluate the overall odds of an adverse neonatal outcome for those with and without a history of ICP.

RESULTS:
We identified 529 multiparous pregnancies with ICP during this time, 420 (79.5%) had no prior history of ICP and 109 (20.5%) had a prior history. There were no differences in demographics between the groups. Women with a history of ICP were diagnosed 6 days sooner and were more likely to be treated with ursodiol. There were lower birthweights, higher rates of RDS, and meconium in those with a history of ICP. When adjusting for maternal demographics, prior ICP, and gestational or other diabetes, a history of ICP was not significantly associated with any adverse neonatal outcomes.

CONCLUSION:
Patients with a history of ICP have earlier diagnosis. There is a significantly higher rate of meconium, lower birthweight and a higher rate of RDS. This may be driven by delivery timing which serves as valuable information when counseling patients on pregnancy expectations.
Smoking Cessation Patterns Among Pregnant Women Who Smoke [12L]
Authors: Halpin Delaney , Spencer Noelle , Neuhoff Ronica , Turner Kielah , Rothenberger Scott , Chang Judy 
Published: April 2018

INTRODUCTION:
The objective of this study was to assess smoking cessation and reduction patterns among pregnant smokers. One in ten women in the United States will continue to smoke during their pregnancy. Smoking continuation during pregnancy is one of the most preventable causes of negative health outcomes for both the mother and baby.

METHODS:
We used data from a prior study of 468 pregnant patients. In this study, participants self-identified as tobacco smokers during the visit. Data was abstracted from all obstetrics visit(s) to assess cessation or continuation of smoking. For patients who reported quitting, we noted gestational age when quit was first documented. We also assessed whether cessation was sustained through documentation in subsequent progress notes. We performed descriptive statistics using SPSS.

RESULTS:
From 468 total study patients, 167 patients (36%) admitted to smoking tobacco during the first obstetric visits. Fifty-three (31.7%) patients quit during their pregnancy. Of these 53 patients, 41.5% quit during the first trimester, 47.2% during the second trimester, and 11.3% during the third trimester. Additionally, 11 of the 53 (20.8%) had remained quit at their postpartum visit where 4 of the 53 (7.5%) claimed to have started smoking again postpartum. The remaining 38 (72%) either did not come to their postpartum visit or were not asked about their smoking status at the visit.

CONCLUSION:
Less than a third of pregnant smokers quit smoking during their pregnancy. Those that quit were more likely to do so earlier in the pregnancy. Efforts for smoking cessation should target early pregnancy visits.
Operative Vacuum Vaginal Delivery: Effect of Compliance With Recommended Checklist [19L]
Authors: Pintucci Armando , Ghidini Alessandro , Consonni Sara , Lambicchi Laura , Incerti Maddalena , Locatelli Anna 
Published: April 2018

INTRODUCTION:
Rules for optimal placement and use of vacuum have not been tested in a clinical setting. We evaluated the effect of the adherence to the recommended checklist for vacuum delivery (VD) on maternal and perinatal outcomes.

METHODS:
Retrospective cohort study including all VD over 4 years. Kiwi Omni Cup was used in all cases and the operators were encouraged to follow 3 rules: recording of fetal head station and position, performing no more than 4 tractions, and no more than 3 cup applications. A checklist to record the procedure was also introduced.

RESULTS:
The overall rates of VD and cesarean delivery (CD) were respectively 4.4% and 17.9%. Cases in which the 3 rules were respected had lower incidence of III–IV degree perineal lacerations after controlling for episiotomy, nulliparity, and indication for the procedure (P=.025), but similar rates of failure of vacuum extraction (2.1% versus 2.2%, P=1) and adverse neonatal composite outcome (10.8% versus 11.7%, P=.71). Introduction of the checklist for VD resulted in an increase in the compliance to the rules (83.8% versus 62.8%, P=.000). Neither failure of vacuum nor adverse maternal or neonatal outcomes was related to occiput posterior position or high station of the head in cases respecting rules.

CONCLUSION:
Compliance with the recommended rules in VD results in a lower rate of severe perineal lacerations but it does not affect success of OVD or neonatal outcome. A continuous training program is a main factor to reach a successful procedure and reduce adverse outcome, even in cases of occiput posterior delivery.
Hyperemesis Gravidarum: Can Factors Predict Risk of Readmission? [21L]
Authors: White Sarah , Byrne John , McIntire Donald D. , Nelson David B. 
Published: April 2018

INTRODUCTION:
Hyperemesis gravidarum is one of the most common indications for admission in pregnancy. Because some women require re-hospitalization, we hypothesized that the risk for readmission could be identified. The aim of this study was to use patient characteristics and index admission features to determine the risk for readmission.

METHODS:
This was a retrospective cohort study of women admitted with hyperemesis gravidarum at our hospital. Hyperemesis gravidarum was defined as intractable nausea and vomiting with either electrolyte derangement, >10 lb weight loss, or persistent ketonuria suggesting dehydration. Women with alternative etiologies for persistent nausea and vomiting were excluded. Women requiring more than one hospitalization for hyperemesis gravidarum were compared to those with one admission to determine if any factors were associated with readmission during the same pregnancy.

RESULTS:
Between 2009 and 2014, a total of 144 women were admitted with hyperemesis gravidarum that comprised 247 hospital admissions. Fifty-one (35%) women required more than one hospitalization for hyperemesis gravidarum. Factors examined included maternal age, race, parity, habitus, substance use, smoking, and psychiatric illness. None of these features including length of initial hospitalization were found to be associated with the need for readmission. Of those delivered at our hospital, readmission was not associated with differing perinatal outcomes.

CONCLUSION:
More than one-third of women with hyperemesis gravidarum required readmission at our hospital. Factors associated with need for readmission did not include maternal demographic features, substance use, or psychiatric illness. The length of hospitalization for the initial admission also was not associated with later readmission.
Prenatal Dexamethasone to Prevent Newborn Virilization From Fetal CAH: A Cost-Effectiveness Analysis [29L]
Authors: Gabo Virginia , Skeith Ashley E. , Sargent James , Caughey Aaron B. 
Published: April 2018

INTRODUCTION:
Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency can cause virilization in affected females, potentially requiring post-natal surgical correction. Prenatal dexamethasone administration has been shown to reduce incidence and severity of virilization in newborn females. However, diagnostic information regarding fetal CAH status is not available until after critical embryological stages have passed, limiting the effectiveness of the intervention. We designed a model to examine the cost-effectiveness of empiric dexamethasone administration in pregnancies at high-risk for fetal CAH.

METHODS:
A cost-effectiveness model was built using TreeAge Pro and incorporated probabilities, costs, and utilities from the literature. In pregnancies at-risk for CAH, we compared three strategies: empiric initiation of dexamethasone at 6 weeks gestation, conditional dexamethasone administration following a CVS at 10 weeks gestation, and no dexamethasone intervention. The cost-effectiveness threshold was set to $100,000 per quality-adjusted life year (QALY). The model's robustness was assessed with sensitivity analyses.

RESULTS:
In a theoretical cohort of 1,000 women, empiric dexamethasone at 6 weeks gestation lead to 26 fewer affected female neonates requiring surgical intervention. This strategy lead to lower costs and higher QALYs when compared to dexamethasone administration at 10 weeks and no dexamethasone intervention. Because dexamethasone administration was associated with decreased severity and frequency of virilization, it was the cost-effective strategy across a broad range of sensitivity analyses.

CONCLUSION:
In pregnancies at-risk for fetal virilization secondary to CAH, initiation of empiric dexamethasone before 6 weeks gestation was the cost-effective strategy resulting in fewer affected female infants, and fewer surgical corrections.
Pregnancy Outcomes in Women With Current or Previous Cerebrovascular Accident [35L]
Authors: Bushman Elisa T. , Gibbins Karen J. , Silver Robert M. 
Published: April 2018

INTRODUCTION:
To describe presence of cerebrovascular accident (CVA) risk factors and obstetric outcomes in women with pregnancy associated stroke (PAS), and to describe management and outcomes of subsequent pregnancies in women with history of CVA.

METHODS:
In a population of 948,074 births women with history of CVA during pregnancy or followed by subsequent pregnancy were identified by ICD-9 and 10 codes. CVA types were categorized as ischemic, hemorrhagic, and transient ischemic event. Major CVA and known pregnancy risk factors for PAS were abstracted. Use of thromboprophylaxis, pregnancy outcomes, and presence of recurrent CVA were abstracted.

RESULTS:
Sixty-one patients were identified with PAS; 51% antepartum and 78% ischemic CVA predominance was found. Thrombophilia was present in 6%, and 27% had concomitant gestational hypertensive disease. Sixty-nine percent of women delivered at term. One hundred two patients were identified with history of CVA (88 patients) or PAS (14 patients) who underwent subsequent pregnancy. Women with previous PAS were more likely to be Hispanic (25% versus 10% P=.024). Thirty-one percent of women with history of PAS received thromboprophylaxis in subsequent pregnancies compared to 61% of women with previous CVA (P=.069). There were six cases of recurrent CVA giving a 5.7% risk of recurrence.

CONCLUSION:
PAS is most commonly ischemic (78%) and is concomitant with hypertensive disease of pregnancy in 27% of cases. Pregnancy outcomes are overall positive if extreme prematurity is avoided. Recurrent CVA occurs in 5.7% of women who pursue future pregnancy, and thus management of these pregnancies remains high risk.
Pregnancy Outcomes in Patients Without Gestational Diabetes Stratified by Maternal Age [39L]
Authors: Hickok Ruth A. , Waites Bethany T. , Walker Allison R. , Caughey Aaron B. 
Published: April 2018

INTRODUCTION:
To compare pregnancy outcomes and rates of complications in women without gestational diabetes stratified by maternal age.

METHODS:
We designed a retrospective cohort analysis using data compiled from singleton, non-anomalous gestations in the United States. Using multivariate regression and χ2 tests, we examined maternal and neonatal outcomes stratified by maternal age at time of delivery. Women ages 20–25 severed as reference values. Outcomes examined included preterm delivery, birth weight >4,000 g, small for gestational age, intrauterine fetal demise, neonatal death, cesarean section, abruption, chorioamnionitis, and post-partum hemorrhage. P-value less than 0.05 was considered statistically significant.

RESULTS:
In a population of 1.85 million non-anomalous singleton deliveries, 1,718,481 women without gestational diabetes were identified. Women ≤20 year old had higher rates of preterm deliveries <32 w (OR 1.28; 95% CI 1.20–1.25) compared to women ≥40 (OR 0.95; 95% CI 1.11–1.28). Women 35–40 had increased IUFD (OR 1.68; 95% CI 1.40–2.02). Women 35–40 and ≥40 had higher cesarean section (OR 1.60; 95% CI 1.59–1.62 and OR 1.29; 95% CI 1.26–1.31) and post-partum hemorrhage (OR 1.09; 95% CI 1.05–1.12 and OR 1.10; 95% CI 1.04–1.16) rates. Women ≤20 had lower rates of placental abruption rates (OR 0.98; 95% CI 0.81–0.93) and chorioamnionitis (OR 0.74; 95% CI 0.72–0.77).

CONCLUSION:
Among women without gestational diabetes, younger maternal age is associated with lower risk of cesarean section, placental abruption and chorioamnionitis. Women of advanced maternal age face increased risk for SGA, IUFD, cesarean sections and post-partum hemorrhage. Women at extremes of maternal age have greater risk of preterm delivery and neonatal death.
Continuous Negative Abdominal Pressure Reduces Ventilator-induced Lung Injury in a Porcine Model
Authors: Yoshida Takeshi , Engelberts Doreen , Otulakowski Gail , Katira Bhushan , Post Martin , Ferguson Niall D. , Brochard Laurent , Amato Marcelo B. P. , Kavanagh Brian P. 
Published: April 2018

Abstract

Background
In supine patients with acute respiratory distress syndrome, the lung typically partitions into regions of dorsal atelectasis and ventral aeration (“baby lung”). Positive airway pressure is often used to recruit atelectasis, but often overinflates ventral (already aerated) regions. A novel approach to selective recruitment of dorsal atelectasis is by “continuous negative abdominal pressure.”

Methods
A randomized laboratory study was performed in anesthetized pigs. Lung injury was induced by surfactant lavage followed by 1 h of injurious mechanical ventilation. Randomization (five pigs in each group) was to positive end-expiratory pressure (PEEP) alone or PEEP with continuous negative abdominal pressure (−5 cm H2O via a plexiglass chamber enclosing hindlimbs, pelvis, and abdomen), followed by 4 h of injurious ventilation (high tidal volume, 20 ml/kg; low expiratory transpulmonary pressure, −3 cm H2O). The level of PEEP at the start was ≈7 (vs. ≈3) cm H2O in the PEEP (vs. PEEP plus continuous negative abdominal pressure) groups. Esophageal pressure, hemodynamics, and electrical impedance tomography were recorded, and injury determined by lung wet/dry weight ratio and interleukin-6 expression.

Results
All animals survived, but cardiac output was decreased in the PEEP group. Addition of continuous negative abdominal pressure to PEEP resulted in greater oxygenation (Pao
2/fractional inspired oxygen 316 ± 134 vs. 80 ± 24 mmHg at 4 h, P = 0.005), compliance (14.2 ± 3.0 vs. 10.3 ± 2.2 ml/cm H2O, P = 0.049), and homogeneity of ventilation, with less pulmonary edema (≈10% less) and interleukin-6 expression (≈30% less).

Conclusions
Continuous negative abdominal pressure added to PEEP reduces ventilator-induced lung injury in a pig model compared with PEEP alone, despite targeting identical expiratory transpulmonary pressure.
Epithelial Recurrent Erosion Dystrophy Secondary to COL17A1 c.3156C>T Mutation in a Non-white Family
Authors: Vahedi Farnoosh , Chung Doug D. , Gee Katherine M. , Chuephanich Pichaya , Aldave Anthony J. 
Published: April 2018

Purpose:
To report the identification of the collagen, type XVII, alpha 1 (COL17A1) c.3156C>T mutation associated with epithelial recurrent erosion dystrophy (ERED) in a Thai family.

Methods:
Slit-lamp examination was performed to determine the affected status of each member of a Thai family, with multiple members demonstrating scattered Bowman layer opacities. After genomic deoxyribonucleic acid (DNA) was isolated from saliva, polymerase chain reaction (PCR) amplification and Sanger sequencing were performed to screen COL17A1 and exons 4 and 12 of the transforming growth factor β–induced gene.

Results:
The 67-year-old proband and her 4 siblings were examined by slit-lamp biomicroscopy, which identified bilateral subepithelial opacities in the proband and in one of the 4 siblings. In both the proband and the affected sister, screening of the COL17A1 gene identified a heterozygous c.3156C>T synonymous mutation that has been previously demonstrated to introduce a cryptic splice donor site, likely leading to aberrant splicing of COL17A1. This mutation was not identified in the unaffected siblings, and no mutations were identified in exons 4 and 12 of the transforming growth factor β–induced gene in any of the screened family members.

Conclusions:
ERED associated with a COL17A1 mutation has been previously reported in only 6 families, all white. Identification of the c.3156C>T mutation, previously identified in 5 of these 6 families, in the Thai family we report indicates conservation of the genetic basis of ERED across different races and underscores the importance of ophthalmologists around the globe being familiar with ERED, which has only recently become a recognized corneal dystrophy.
Outcomes of Thermal Pulsation Treatment for Dry Eye Syndrome in Patients With Sjogren Disease
Authors: Godin Morgan R. , Stinnett Sandra S. , Gupta Preeya K. 
Published: April 2018

Purpose:
To evaluate the clinical outcomes of thermal pulsation treatment in patients with meibomian gland dysfunction (MGD) and dry eye secondary to Sjogren disease.

Methods:
Twenty-four eyes from 13 patients with previously diagnosed Sjogren disease who presented to our institution with dry eye symptoms and had thermal pulsation treatment were prospectively followed up. Patients underwent comprehensive slit-lamp examination, including MGD grading, gland oil flow, corneal and conjunctival staining scores, and tear break-up time (TBUT). Tear osmolarity was tested before and after treatment.

Results:
The average patient age was 62.4 years (range, 31–78 yrs); 12 were women and 1 a man. The average meibomian gland oil flow score showed an increase from pretreatment 0.71 to 1.75 at 1 year posttreatment (range 9–15 months) (P = 0.001). The average corneal staining score decreased from a pretreatment grade of 1.04 to a posttreatment grade of 0.36 (P < 0.001). The average conjunctival staining score decreased from a pretreatment grade of 1.5 to a posttreatment grade of 0.48 (P < 0.001). The average tear break-up time improved from 3.8 seconds before treatment to 7.5 seconds after thermal pulsation treatment (P < 0.001). There was no statistically significant change in the tear osmolarity or Ocular Surface Disease Index score.

Conclusions:
Our findings suggest that MGD is an important contributor to dry eye disease in patients with Sjogren disease and should not be overlooked when considering treatment options. Thermal pulsation is a therapeutic option for patients with Sjogren disease who have MGD and dry eye symptoms. After a single treatment, patients exhibited increased oil flow and tear break-up time with an associated decrease in corneal and conjunctival staining.