bluuebunny/crossref_metadata_2025_split huggingface dataset:
Should Penicillin Allergy Be Confirmed During Pre-operative Testing? [38T]
Authors: Lozo Svjetlana , Wagner Daniel , Goldberg Roger , Shah Nirav , Silver Richard Karl , Solomonides Toni 
Published: May 2019

INTRODUCTION:
Documentation of a penicillin allergy often results in use of broad-spectrum antibiotics for surgical site infection prophylaxis which can contribute to antibiotic resistance and higher medical cost. The primary aim of our study is to prospectively determine the true prevalence of penicillin allergy in patients undergoing urogynecological surgeries so that the use of alternative antibiotics could be curtailed when appropriate.

METHODS:
This study was undertaken as the practicum project in an institutional Patient Safety and Quality Fellowship. In phase I, retrospective chart review of patients' allergies and surgical site infection prophylaxis medication was performed (2017). Subsequently (Phase II; 1/18-9/18), penicillin allergy testing was offered as part of pre-operative evaluation to at-risk patients and results were used to modify care as appropriate.

RESULTS:
In 2017, 51% of patients with penicillin allergies received broad-spectrum antibiotics for surgical site infection prophylaxis. In 2018, 44 patients had a history of penicillin allergy (28 reported rash, 6 had hives and 10 could not recall their reaction); all were offered testing; 28 accepted, and 26 (93%) had negative results. These 26 women (60%) were able to receive recommended prophylaxis via cefazolin without complication.

CONCLUSION:
Our findings support penicillin allergy testing for at-risk urogynecology patients as part of pre-operative assessment. This strategy has the potential to promote antibiotic stewardship, improve care, and reduce cost. We cannot extrapolate to other surgical cohorts without considering patient age, gender differences and other factors, but confirming penicillin allergy in other surgical groups seems warranted.
Use of Hormonal Contraception in Women Suffering From Migraine [6S]
Authors: Johnson Amy , Tilden Elizabeth , Newmark Alexis , Grosberg Brian , O'Sullivan David 
Published: May 2019

INTRODUCTION:
Migraine is a common condition in reproductive age women, with menses as a frequent trigger. The use of continuous combined hormonal contraception (CHC) has been shown to reduce the frequency of estrogen-associated migraine by as much as 80%. With newer low-dose estrogen formulas, the Centers for Disease Control and Prevention (CDC) re-categorized CHC as acceptable for women with migraine without aura. The International Headache Society Task Force concluded that low-risk patients may benefit from CHC regardless of the presence of aura. We hypothesized that CHC is underutilized in appropriate candidates despite recent guidelines.

METHODS:
An IRB-approved retrospective chart review was performed to assess the use of hormonal suppression in women with migraine. Electronic medical records were reviewed over two years for women age 18-50 suffering from migraine. Patient data extracted included demographics, medical history, and medications.

RESULTS:
A total of 7,451 female migraine suffers were identified, the majority (n=6,404, 85.9%) without aura. 18.9% of all patients were identified as having at least one risk factor for CHC use, primarily smoking or hypertension. There was no statistically significant difference in hormone utilization based on headache type; 22% of patients without aura (20.4% pills, 1.4% ring, 0.2% patch) and 19.8% of those with aura (18.1% pills, 1.6% ring and 0.1% patch). There also was no difference among those identified specifically as menstrual migraine (27.3% pill, 1% ring).

CONCLUSION:
The majority of patients with migraine are low risk for CHC and potential candidates for hormonal suppression.
Trends in Abortions Performed in Georgia Following Partial Enactment of a 22-Week Ban [4S]
Authors: Redd Sara , Berry-Bibee Erin , Hartwig Sophie , Lathrop Eva , Haddad Lisa , Cwiak Carrie 
Published: May 2019

INTRODUCTION:
We investigated trends in abortions performed in Georgia before and after partial enactment of House Bill 954 (HB954) in January 2013, which bans abortions at 22 weeks from last menstrual period.

METHODS:
Using publicly available data from Georgia Department of Public Health's state-mandated Induced Termination of Pregnancy forms, we estimated changes in the numbers of abortions provided before (2009-2012) and after (2013-2016) the law went into partial effect, stratified by gestational age, state of residence, and year.

RESULTS:
From 2009 to 2016, 257,161 abortions were performed in Georgia, including 131,655 pre- and 125,506 post-law; 88% were among Georgia residents and 4% occurred ≥20 weeks gestation. Following HB954, the number of ≥20-week abortions among in-state residents declined 22% (9% for 20-23 weeks, 74% for ≥24 weeks). Among out-of-state residents, abortions occurring ≥20 weeks declined 41% (14% for 20-23 weeks, 92% for ≥24 weeks). By year, abortions occurring 20-23 weeks declined steadily among in-state residents (549 in 2013 to 409 in 2016), but among out-of-state residents temporarily increased in 2013 (443) and 2014 (497), then sharply declined in 2015 (321) and 2016 (248). Trends in ≥24-week abortions were similar for in- and out-of-state residents, spiking from ∼0 in 2013 and 2014 to 138 in 2015.

CONCLUSION:
Following HB954, abortions occurring ≥20 weeks gestation declined in Georgia, though differential trends were found across study years and residence. We are continuing to evaluate the impact of the 22-week ban, which went into full effect in October 2015, on reproductive health access, outcomes, and systems across the Southeast.
Trends in Utilization of Brachytherapy in Cervical Cancer in a Single Military Medical Center [37R]
Authors: Kucera Calen W. , Miller Caela 
Published: May 2019

INTRODUCTION:
Standard of care (SOC) treatment for locally advanced cervical cancer consists of chemotherapy, external beam radiation and brachytherapy. Despite significant survival benefits, there is a national decline in utilization of brachytherapy in recent years. Currently only 44% of US patients with locally advanced cervical cancer receive brachytherapy. We believe military medicine and our military medical center has avoided this trend and correctly administers SOC treatment for locally advanced non-operable cervical cancer.

METHODS:
We utilized the Brooke Army Medical Center Tumor Registry to identify women with locally advanced cervical cancer between January 1997 and March 2018. We reviewed medical records to determine if they received SOC treatment as well as potential associated demographic factors. Data was then analyzed using logistic regression models. (IRB approval was obtained).

RESULTS:
We found that of the 147 patients with cervical cancer, 36 had locally advanced cervical cancer, 28 (77.8%) met SOC treatment. We found no statistically significant associated factors to include race, rank, duty status, or stage. Reasons for not completing SOC treatment included vesico-vaginal and recto-vaginal fistulas, declining treatment, and rare histologies.

CONCLUSION:
Our military institution has nearly double the rate of SOC brachytherapy compared to national use. Although we have a small sample size we expect that these trends would be consistent across military medical centers. The contribution of economic and social factors that decrease use of brachytherapy nationwide may be mitigated by the equal access to care provided by military medicine, and the decrease in out of pocket expenses by military beneficiaries at military facilities.
Risk of Cancer and Performance of Ultrasound in Postmenopausal Women Who Failed Endometrial Biopsy [36R]
Authors: Doulaveris Georgios , Chen Alice , Orfanelli Theofano , Escobar Pamela , Dar Pe'er , Rotenberg Ohad 
Published: May 2019

INTRODUCTION:
To assess the risk of endometrial cancer or hyperplasia (EmCH) and the performance of transvaginal ultrasound (TVS) in postmenopausal women who had a failed endometrial biopsy (EMB).

METHODS:
Retrospective study of all women, aged 55 and older, who underwent EMB between 1997 and 2008. Failed EMB was defined as “absent” or “insufficient” endometrial tissue. Patients' data was collected until 2015 for long term surveillance. We assessed TVS utilization, the ability of TVS to provide adequate measurement of the endometrial echo (EE) and performance of TVS for detection of EmCH. For the performance of TVS we used EE cutoff of ≥5 mm.

RESULTS:
1808 postmenopausal women underwent EMB during the study period. In 269 (14.9%), endometrial sampling failed to obtain tissue. Of these cases, 16/269 (5.9%) had a final diagnosis of EmCH. 125/269 (46.5%) of women had concurrent TVS to assess their endometrium. EE could be adequately visualized in 111/125 (88.8%). Mean EE was significantly thicker in women eventually diagnosed with EmCH compared to those with benign diagnosis (17.4 mm vs 10.2 mm, p= 0.01). In women who had insufficient EMB and had accessible EE measurements via TVS, endometrial thickening had a sensitivity of 100%, specificity of 46.1%, NPV of 100% and PPV of 11.1% in diagnosis of EmCH.

CONCLUSION:
EMB failed to obtain tissue in 14.9% of postmenopausal women of which 5.9% had EmCH. TVS provided adequate EE measurement in 88.8% of these cases. Thick endometrium had 100% sensitivity and 100% NPV in the diagnosis of EmCH but with low specificity and PPV.
Protocol Management of Cholestasis of Pregnancy [32R]
Authors: Shepard Sarah Therese , Brost Brian , Stark Craig , Alkis Mallory 
Published: May 2019

INTRODUCTION:
Intrahepatic Cholestasis of Pregnancy (ICP) is associated with intrauterine fetal demise (IUFD) and severity of disease is associated with higher rates of IUFD. Antepartum management of (ICP) is highly variable. Consensus in clinical practice is to encourage delivery at 37 weeks regardless of severity. We evaluated if standardizing the management of ICP based on bile acid level would affect maternal and neonatal outcomes.

METHODS:
Women diagnosed with ICP and delivered at our hospital were prospectively followed from 01/02/2012-01/01/2018. Maternal and neonatal outcomes were evaluated before and after institution of a standardized management protocol. A 6 month wash-out period was utilized. Statistical methods performed included the Chi Square test, Fischer exact probability test and the two sample t-test. IRB approval was obtained and standards upheld.

RESULTS:
Ninety-two patients were included in the analysis. The bile acid level was higher in the post guideline group 69 umol/L vs the pre guideline group 30 umol/L (p =0.002). No difference was noted in the cesarean rate (p=0.56), NICU admissions (p=0.075), or 5 minute APGAR (p=0.609). The rate of composite neonatal respiratory morbidity was higher in the post guideline group (p=0.0023). There was one IUFD in the post-guideline group that occurred at 28 weeks in the setting of a twin pregnancy and bile acids of 264.

CONCLUSION:
Induction at 39 weeks for pregnancies with bile acids 20 or less did increase composite neonatal respiratory morbidity. Guidelines and standardization of care for cholestasis of pregnancy would help reduce variability between providers and deliveries prior to 39 weeks.
Prelabor Rupture of Membranes at Term: When Should We Recommend Induction? [31R]
Authors: Teal Elizabeth Nicole , Lewkowitz Adam , Tran Carol , Koser Sarah , Gaw Stephanie 
Published: May 2019

INTRODUCTION:
Prelabor rupture of membranes (PROM) affects approximately 8% of pregnancies. The TermPROM Study demonstrated that immediate induction of labor (IOL) versus expectant management for up to four days result in similar rates of cesarean and neonatal infection but increased maternal infection. ACOG endorses IOL for PROM but states expectant management may be considered. However, guidelines on the safest duration of expectant management are lacking. This study aims to determine whether there is an optimal time from PROM to IOL initiation.

METHODS:
This retrospective cohort study included nulliparous women with non-anomalous, singleton, cephalic pregnancies who underwent IOL for PROM at a tertiary-care academic hospital from January 2015 to April 2017. Primary outcome was vaginal delivery (VD) rate. Secondary outcomes were IOL duration, infection, hemorrhage, and NICU admission. The data were analyzed using the Kruskal-Wallis test and logistic regression.

RESULTS:
The 246 patients were divided into groups by time from PROM to IOL initiation: <12 h (n=116, 47.2%), 12-24 h, (n=96, 39.0%), and >24 h (n=34, 13.8%). There was no difference in VD rate, IOL duration, infection, or NICU admission amongst groups. There was an increased odds of hemorrhage with IOL greater than 24 hours after PROM (aOR 2.74, CI 1.18 - 6.33). There were no differences in NICU admission.

CONCLUSION:
In this cohort, expectant management up to 24 hours was not associated with increased maternal or fetal risks. Expectant management beyond 24 hours was associated with increased risk of hemorrhage. This suggests that patients with PROM can be safely offered expectant management for up to 24 hours.
Pregnancy Related Emergency Department Visits in a Clinic Population: A Quality Improvement Review [28R]
Authors: Gilroy Laura Claire , Tomczyk Setul Ram 
Published: May 2019

INTRODUCTION:
For many women in the United States, their local emergency department (ED) is the only option for medical care. As the number of uninsured and underinsured patients increases, there is a mounting burden on emergency departments to care for patients with both urgent and non-urgent complaints. We looked to assess patients initiating care at a resident-run clinic who already presented to our local emergency department with pregnancy-related complaints.

METHODS:
A retrospective chart review was performed of patients who received prenatal care in the resident-run clinic over 6 months. This was cross referenced with hospital records to identify those patients who presented to the emergency department prior their initial prenatal visit.

RESULTS:
Two hundred and twenty three patients were seen at the clinic over 6 months. 59 (26.5%) presented to the ED prior to initiating prenatal care. The patients presenting to the ED were significantly younger (mean age 28.6 versus 30.6 years (p=0.034). The mean gestational age at first ED presentation was 9 weeks and 1 day. The majority of patients had pain (37%) or bleeding (27%) as their presenting complaint. There was no significant difference in wait time for an initial OB appointment between those consulted by the Gynecology service in the ED versus those seen by an ED physician (3.65 versus 4.65 weeks, p=0.152).

CONCLUSION:
Our data suggest visiting the ED does not significantly improve early pregnancy care for clinic patients. There is potential for improving this system in a way that will benefit patients and lower institutional costs.
Postpartum Severe Maternal Morbidity Among Mothers of Neonatal Intensive Care Unit Infants [20R]
Authors: Stuebe Alison M. , Tucker Christine , Ferrari Renee , Verbiest Sarah , Pate Virginia , Jonsson-Funk Michele 
Published: May 2019

INTRODUCTION:
To reduce maternal mortality, it is critical to identify women at increased risk of postpartum complications.

METHODS:
We conducted a retrospective cohort study of mothers delivering liveborn infants at North Carolina Women's Hospital between 7/1/2014 and 6/30/2016. NICU mothers were defined as women with ≥1 infant admitted to the Neonatal Critical Care Unit. We used data from the UNC Health System Epic Electronic Medical Record to ascertain hospital visits between discharge and 12 weeks postpartum. We used Alliance for Innovation on Maternal Health (AIM) criteria to define postpartum severe maternal morbidity (PSMM). We used Fisher's exact tests to compare rates of PSMM among mothers of well babies (MWB), compared with NICU mothers.

RESULTS:
Among 6849 women in our cohort, there were 488 emergency department visits, 239 OB triage visits, 62 hospitalizations for observation, and 171 inpatient admissions at the North Carolina Women's Hospital within the first 12 weeks postpartum. There were no postpartum maternal deaths. NICU mothers were more likely to have at least one hospital visit than MWB (173/1081, 15.6% vs. 517/5768, 9.0%, p<.0001). PSMM by AIM criteria was experienced by 33/6849 women (0.48%). NICU mothers were more likely to experience SMM than MWB (1.2% vs. 0.38%, Fisher's Exact p = 0.01, OR 2.69, 95% CI 1.30-5.56).

CONCLUSION:
About 0.5% of mothers were readmitted with PSMM. Actual rates of PSMM are likely higher, as we only ascertained encounters within the UNC Health System. The risk of PSMM was higher among NICU mothers than among mothers of well babies.
Peripartum Intensive Care: Experience in an Urban Hospital Setting [17R]
Authors: Upadhyay Ruchi , Elkafrawi Deena , Sultana Carmen , Gaither Kecia 
Published: May 2019

INTRODUCTION:
As women with co-morbid conditions become pregnant, it is not surprising that the rate of peripartum ICU admissions reflect this occurrence. Critically ill peripartum patients present a unique population, as the presence of a fetus, in conjunction with altered maternal physiology and a co-existing disease entity makes their care challenging. The purpose of this study is to describe the clinical characteristics of peripartum patients requiring intensive care in an urban hospital center.

METHODS:
IRB approved retrospective chart review of women admitted to the ICU between the first trimester of pregnancy through six weeks postpartum, from January 2014 through January 2017. Data collected on age, ethnicity, BMI, presence/absence of prenatal care, substance abuse and attendant co-morbidities for antepartum and postpartum patients.

RESULTS:
Seventy three patients were admitted to the ICU. The majority of the antepartum patients admitted lacked prenatal care, were noted to be tobacco/substance abusers; sepsis, DKA and respiratory dysfunction were the predominant morbidities. Conversely, the majority of the postpartum patients had prenatal care, and were morbidly obese; preeclampsia, cardiomyopathy and postpartum hemorrhage were the predominant morbidities.

CONCLUSION:
There exists a paucity of studies relating to peripartum intensive care--and of those, most focus on the postpartum aspect. The findings of this study are interesting in that both antepartum and postpartum patients were analyzed. Obesity confers a number of associated outcomes inclusive of hypertensive disorders and cardiac dysfunction. Our findings suggest that outreach programs directed to encouraging early prenatal care with screening for evidence of cardiac dysfunction/preeclampsia risk would be of benefit.
The Search for Vaginal Candida Resistant Infections, A Descriptive Study [15R]
Authors: Tiran-Saucedo Jose , Garza Humberto , Leon Yvette , Godinez-Burgos Jesus Alfonso 
Published: May 2019

INTRODUCTION:
An increase in the prevalence of drug-resistant candida species has been observed due to the free sale of antifungal agents, which has also led to changes in vaginal colonization by other species with greater resistance such as C. krusei or C. glabrata. The purpose of the study was to identify candida species isolated in vaginal cultures and to determine their sensitivity and resistance to antifungals.

METHODS:
The research was conducted at the Mexican Institute of Infectious Diseases Gynecology and Obstetrics (IMIGO). The culture and microbial susceptibility were performed using VITEK®2 AST-YST system and then classified as sensitive, intermediate or resistant to the use of Flucytosine, Fluconazole, Voriconazole, Amphotericin, Caspofungin and Micafungin. We included women with symptoms of vaginal candidiasis regardless of their age and previous treatments.

RESULTS:
A total of 90 positive cultures were obtained. The isolated microorganisms were C. albicans 68%, C. glabrata 19%, and C. krusei, C. tropicalis and C. parapsilosis 1%. C. albicans was classified as 15% resistant and 9% intermediate resistant with Fluconazole, in addition 6% resistant and 12% intermediate resistant to Voriconazole. C. glabrata was classified as 42% intermediate resistant to Fluconazole, and 5% intermediate resistant to Voriconazole, Amphotericin B and Micafungin.

CONCLUSION:
There is an important increase in the diagnosis of C. glabrata compared to that reported in the literature where the predominance by species is C. albicans. In addition, higher resistance was found in the C. albicans and C. glabrata species to anti-fungal of the triazole family, specifically Fluconazole and Voriconazole.
Streptococcal Non-Menstrual Toxic Shock Syndrome [14R]
Authors: Zimmer Zoe Clark , Schexnayder Brian , O'Neill Shea 
Published: May 2019

INTRODUCTION:
Case report.

METHODS:
Case Study: We describe the case of a 21-year old gravida 0 with history of substance abuse and genital herpes who presented to the hospital with fever and malaise of several days duration. On examination she exhibited cervical motion tenderness concerning for pelvic inflammatory disease and severe maculopapular rash accompanied by an episode of hypotension. The patient was transferred to the intensive care unit, where her clinic picture met the CDC case definition for probable toxic shock syndrome. Streptococcal disease was suspected due to elevated anti-DNAse B titers. She underwent treatment with antibiotics and intravenous immunoglobulin and discharged home after one week of hospitalization. At discharge she exhibited characteristic desquamation of the palms and soles. The incidence of non-menstrual toxic shock syndrome has remained stable despite the decline in menstrual toxic shock associated with high-absorbency tampon use. While the CDC's case definition is useful in defining a case, a patient is often resuscitated and treated-to their benefit--before criteria can be met to confirm diagnosis. In discussion of this case we review the epidemiology, pathophysiology, and management of this life threatening illness, and reaffirm the importance of maintaining a high index of suspicion for patients with a similar presentation. Informed consent was granted by the patient. She understands that no personally identifying information would be included in the report and that every effort for anonymity would be made, but could not be guaranteed. The patient was offered the opportunity to read the manuscript and associated materials.

CONCLUSION:
Case report.
Partial Molar Gestation Presenting as Hypertensive Emergency [33Q]
Authors: Montanez Kathleen R. , DeSouza Nelson , Talise Paul C. 
Published: May 2019

INTRODUCTION:
The reported incidence of partial hydatidiform is 23 to 1,299 per 100,000 pregnancies. Women present with early pregnancy complications such as bleeding, pelvic discomfort, or hyperemesis. The diagnosis is often made on pathologic evaluation after treatment for a presumed missed abortion. If the pregnancy continues past the first trimester, intrauterine growth restriction and oligohydramnios are common. Partial molar gestations continuing into the second trimester may present with hypertensive emergency or thyrotoxicosis.

METHODS:
A 29-year-old G3P1 at 18 weeks and 3 days gestational age presented to the emergency room for acute onset headache. Severe range blood pressures up to 231/125, serum beta-hCG of 638,645 and an abnormal appearing placenta on bedside ultrasound were concerning for partial molar gestation. She was admitted to the intensive care unit for a nicardipine drip due to refractory hypertension. The patient refused uterine evacuation at this time due to presence of a fetal heart rate. On hospital day four, she had severe range blood pressures despite two oral agents and consented to delivery. Prior to placement of laminaria, she started hemorrhaging after rupture of membranes prompting an emergent dilation and evacuation. She refused packed red cells due to religious concerns but consented to other blood products. She received three units of fresh frozen plasma and one pack of platelets. She was discharged home on postoperative day three. Her human chorionic gonadotropin was followed appropriately.

CONCLUSION:
Second trimester partial molar gestations are rare and may present with severe sequalae requiring emergent evacuation of the uterus.