bluuebunny/crossref_metadata_2025_split huggingface dataset:
Incidence of Monozygotic Multiple Pregnancies After Single Embryo Transfer (SET): Review of SART Reported Outcomes [37K]
Authors: Peyser Alexandra , Blitz Matthew J. , Vohra Nidhi , Leung Tung Ming , Lesser Martin , Hershlag Avner 
Published: May 2019

INTRODUCTION:
To calculate the incidence and risk factors of monozygotic multiple pregnancies after SET.

METHODS:
A review of all SET cycles from 2005-2015 that resulted in more than one fetal heartbeat on ultrasound was conducted. Descriptive statistics were used to determine factors associated with an increased risk of multiple pregnancies after SET.

RESULTS:
67,884 SET cycles met inclusion criteria, resulting in 1,307 (1.9%) twin gestations and 36 (0.06%) triplet or higher-order multiples. Mean age and BMI of subjects was 35.7±5.4 years and 24.6±14.9 kg/m2, respectively. Majority of subjects were from the Northeast or from the southern U.S. Autologous oocytes accounted for 84.2% of the twin cases and 91.6% of the triplets or more. 63% of the twins and 72% of the triplets or more underwent a fresh cycle. Sperm source was from the partner in 96% of both twin and triplet cohorts.

CONCLUSION:
Risk of monozygotic twinning (MZT) in IVF is 1.9% which is 5 times the rate of MZT in natural conception. While the risk of identical triplets is low (0.06%), it is not negligible. The mechanism underlying this increased risk in IVF embryos is unclear and probably includes culture conditions as well as micromanipulation. It is unclear how a single embryo splits into three: Is it the result of two sequential monozygotic splitting? Prospective IVF patients should be informed of the risk of identical multiples even with SET. Patients who desire the transfer of two blastocyst should be warned of at least one embryo splitting, ending up with a triplet pregnancy.
Pregnancy Rates in In Vitro Fertilization Are Superior When Trophectoderm Biopsy Is Done Only on Hatching Embryos [40K]
Authors: Singh Sonali , Hobeika Elie , Traub Michael Lawrence 
Published: May 2019

INTRODUCTION:
In-vitro fertilization (IVF) with trophectoderm embryo biopsy and pre-implantation genetic screening (PGS) for aneuploidy, followed by elective single frozen embryo transfer (eSET) is becoming increasingly popular. However, embryos can be biopsied at various stages of blastocyst development. No studies to date have specifically investigated differences in pregnancy outcomes by timing of embryo biopsy.

METHODS:
Retrospective study of patients (n=363) at a single IVF center between January 1, 2013 and December 31, 2016 undergoing eSET with PGS. Embryo grading assessed at the time of biopsy and transfer. Pregnancy rates analyzed by embryo expansion, inner cell mass and trophectoderm grading. Statistical analyses performed by t-test, chi squared, Mann Whitney and Fischer exact tests. Interactions between embryo expansion, inner cell mass and trophectoderm grading were analyzed by 2-way ANOVA. IRB approval obtained.

RESULTS:
Implantation, clinical pregnancy and live birth rates improved significantly (P=.0001) and pregnancy loss decreased substantially (P<.001) with increased embryo expansion and if embryos were hatching at the time of embryo biopsy. For non-expanded or expanded embryos at biopsy, that later hatched at the time of eSET, pregnancy outcomes remained poor (live births 0% and 5.9%). Pregnancy rates from eSET with PGS where embryos were allowed to hatch, were far better than eSET of embryos without PGS.

CONCLUSION:
Embryos biopsied before they are hatching have extremely poor pregnancy outcomes regardless of how much they expand by the time of eSET. The embryo biopsy on a non-hatching embryo seems to significantly damage the embryo. IVF labs should wait until embryos hatch before performing trophectoderm biopsy.
Neutrophil/Lymphocyte Ratio: Predictive Biomarker for Outcomes of Early Pregnancy of Unknown Location [7L]
Authors: Arora Anubha , Menon Sharifa , Sanusi Ayodeji , Akinnawonu Kolawale Felix , Kumar Abhishek , Fuks Aleksandr 
Published: May 2019

INTRODUCTION:
Pregnancy of unknown location (PUL) (positive pregnancy test with no evidence of intrauterine or extrauterine pregnancy on Transvaginal sonogram) requires serial hCG levels and imaging till final location of pregnancy is ascertained. Inflammation plays part in pathogenesis of abnormal pregnancies. Neutrophil/lymphocyte ratio (NL) is a marker of inflammation and prognosis. We conducted the first study to investigate the role of NL as predictor of outcomes of PUL.

METHODS:
Retrospectively, 145 patients presenting to ER at tertiary care hospital from Jan 2011-Jan 2016 were included, with exclusion criteria of hemodynamic instability, intraperitoneal hemorrhage, underlying cancer or hematological disorder, infection, smoker. Study was IRB exempted. Demographics, parity, presenting symptoms, b-hCG levels and NL ratio at presentation were noted. Patients followed up in time and final outcomes classified as: Definite intrauterine pregnancy, Nonviable pregnancy, definite ectopic pregnancy, probable ectopic, spontaneously resolving PUL, treated persistent PUL. SPSS software was used for statistical analysis.

RESULTS:
NL for normal versus abnormal pregnancy (all other categories) was 1.868±0.12 vs 3.08±1.81 (P=.001). NL for intrauterine versus extrauterine pregnancies were compared = 2.077±1.11 vs 2.74±0.83 (P=.0058). For hCG levels less than 3500, NL for normal versus abnormal pregnancies were 1.93±0.25 vs 2.92±0.34 (P<.001). NLR > 1.83 had AUC =0.793, sensitivity 86.9%, specificity 62.3% (ROC). Binary regression analysis revealed NLR was statistically significant (beta= 2.83, P=.002).

CONCLUSION:
NL could triage patients with PUL. Larger studies are needed to confirm the utility of this test which could save multiple labs and imaging, and avoid catastrophes like administration of methotrexate to normal Intrauterine pregnancy.
Pulmonary Leiomyomatosis: A Case Report [10L]
Authors: Kailasam Aparna , Dubinskaya Alexandra , Roland Phillip Y. 
Published: May 2019

INTRODUCTION:
Benign metastasizing leiomyomatosis (BML) is a rare disorder, first characterized by Steiner in 1939, which manifests with extrauterine leiomyomata affecting areas such as the lung and bone. The clinical course is generally indolent, but patients can present with pulmonary symptoms.

METHODS:
CD is a 54 yo G4P2022 who presented to the emergency department with a 7 day complaint of moderate to severe chest pain radiating to her shoulder, exacerbated with movements. Surgical history included total hysterectomy at age 34 for uterine leiomyomata. Initial cardiac work up was negative. CT scan revealed fifteen pulmonary nodules and an ovarian mass. Transvaginal ultrasound showed two unilocular ovarian cysts. Laboratory results included CA-125 = 20.4 and FSH/LH = 14.5/11.3. CT guided biopsy of a pulmonary nodule demonstrated features of leiomyoma. Following this biopsy, the patient underwent VATS resection of the largest pleural nodule. The case was reviewed at the multidisciplinary tumor board. The final diagnosis was pulmonary benign metastasizing leiomyomatosis (BML). The left ovarian mass was felt to represent a benign ovarian neoplasm unrelated to BML. The patient was encouraged to undergo bilateral oophorectomy to limit the growth of her pulmonary leiomyomata. She elected for observation of her condition.

CONCLUSION:
The diagnosis of BML is rare and typically affects patients with a history of uterine leiomyomata s/p hysterectomy. Differentiating BML from malignant metastasis is important to avoid unnecessary procedures or delayed treatment. BML patients generally remain asymptomatic, though some patients may present with pulmonary symptoms. Anti-estrogenic, anti-hormonal therapies and surgical management have been suggested as treatment.
Implementation of Nitrous Oxide as an Analgesic Option on Our Labor and Delivery Unit [17L]
Authors: Canestraro Anthony John , Tussey Christina , Erickson Laurie Paullette 
Published: May 2019

INTRODUCTION:
Our institution initiated a pilot program to introduce nitrous oxide as an analgesic option during labor and delivery. Nitrous oxide has previously been proven to be safe and effective, but its use is limited by the need for technical equipment and trained staff to safely provide it. It proves useful in labor and delivery as it has quick onset to effective pain relief and is less invasive than neuraxial anesthesia.

METHODS:
Anesthesia and obstetric staff were trained on the nitrous oxide delivery system. We then assessed users' demographics, labor characteristics, pain scores, and outcomes through retrospective electronic medical record review from May 2017 to September 2017. Patient satisfaction surveys were also administered and evaluated.

RESULTS:
During rollout, 113 patients used nitrous oxide. Exclusive use was seen in 54 women (47.8%) with conversion to epidural in 58 women (51.8%). Indications varied with 109 (95.6%) citing pain management, 9 (7.9%) using during procedures, and 2 (1.9%) using due to epidural contraindication. Side effects reported included dizziness in 16 (14.4%) and nausea in 5 (4.5%). Timeliness of pain management and overall satisfaction with the birth experience were rated as 5 out of 5 points in 85% and 87% of patients, respectively.

CONCLUSION:
Nitrous oxide proved to be a useful analgesic option with promising patient satisfaction scores. Its ease of implementation, low side effect profile, versatility, and effectiveness support its adoption as a supplement to our analgesia options in labor and delivery.
Improving Compliance With Preeclampsia Guidelines Through an Electronic Health Record Alert [19L]
Authors: Spencer Nicole Marie , Gabra Martina , Bedell Sabrina M. , Scott Dana , Ananta Bangdiwala , Rauk Phillip N. 
Published: May 2019

INTRODUCTION:
Hypertensive disorders of pregnancy occur in 12-22% of all pregnancies and account for 17% of maternal mortality in the US. National guidelines for management of hypertensive disorders were developed by the American College of Obstetrics and Gynecology (ACOG) and the California Maternal Quality Care Collaborative (CMQCC). An electronic health record automated alert offers an opportunity to improve compliance with these guidelines.

METHODS:
A Blood Pressure Alert (BPA) was incorporated into an existing electronic health record to notify providers when a patient had a documented severe range blood pressure, defined as systolic blood pressure ≥-160 or diastolic blood pressure ≥110. Pre- and post-intervention data was collected via retrospective chart review. Compliance with national guidelines for administration of rapid-acting antihypertensive medication, IV magnesium for seizure prophylaxis, and initiation of oral antihypertensive medication postpartum was evaluated.

RESULTS:
Appropriate treatment of sustained severe-range blood pressure episodes with a rapid-acting antihypertensive medication within 1 hour of diagnosis improved after the implementation of the BPA (35% vs 54%, p<0.01), which was statistically significant. There was no significant change in the administration of IV magnesium sulfate (89% vs 80%, p=0.06) or prescription of oral antihypertensive medications at discharge (89% vs 93%, p=0.31).

CONCLUSION:
An automated electronic health record alert improved timely administration of rapid-acting anti-hypertensive medications for severe range blood pressures on an academic Labor and Delivery Unit and has the potential to improve overall compliance with ACOG and CMQCC preeclampsia guidelines. Increased adherence to these guidelines may improve maternal morbidity and mortality rates in the US.
How Well Do Patients Clearly Understand Invasive Prenatal Genetic Diagnostic Testing? [38L]
Authors: Davis Jay , Pastore Lisa , Milone Gina F. , Persad Malini D. , Diana Garretto  , Herrera Kimberly 
Published: May 2019

INTRODUCTION:
To determine patient clarity of the perceived benefits/drawbacks about invasive prenatal genetic diagnostic testing (PGDT).

METHODS:
Cross-sectional design. Voluntary, anonymous questionnaire (Q) assessing patient's decision making process in regards to invasive (CVS and/or amniocentesis) PGDT. Qs (paper and online options) were distributed between 2017 and 2018 to those recommended for PGDT in a university academic practice. Questions (5 items on clarity, 5-point Likert scale) were structured to evaluate patient decisional clarity, and were partly adapted from published validated Q's. Exclusion criteria: English or Spanish illiterate. Means, variances (SD), and ranges were tabulated.

RESULTS:
50 female patients returned the study; 38 (76%) completed it in entirety. 75% had equal PGDT decision making with their partner. Most were referred due to a positive carrier screen followed by positive cell free DNA result. Participants expressed high clarity of understanding advantages and disadvantages of PGDT (mean 3.28 on a 1=no clarity to 5=high clarity scale, SD 0.94).

CONCLUSION:
Patients have a clear understanding of PGDT; this may be attributable to in office counseling (MD and/or genetic counselors) done prior to decision making.
Improving Assessment and Documentation of Routine Prenatal Care Using a Standardized Template [40L]
Authors: Montgomery Holly , Duong Jennifer , Kauffman Kurt 
Published: May 2019

INTRODUCTION:
Routine prenatal care is a vital aspect of improving both maternal and infant morbidity. Standardizing clinical documentation, using templates and automatic alerts, can improve patient care by ensuring providers cover all aspects of routine prenatal care. The objective of this study was to evaluate improvement in the assessment and documentation of routine prenatal care after implementing a standardized electronic template.

METHODS:
This was a retrospective review of postpartum visits at a single obstetrical clinic affiliated with an obstetrics and gynecology residency program. A sample of fifty charts was reviewed before and after implementation of a standardized electronic prenatal care template. Charts were evaluated for provider counseling and documentation on the basic prenatal care recommended for all pregnant patients. Gestational age at the last prenatal visit and number of prenatal visits attended was collected. IRB committee approval was waived for this quality improvement project.

RESULTS:
Average gestational age at the last prenatal appointment and average number of prenatal visits was similar for both time periods. After implementing the template, there was an improvement in addressing and documenting the following topics: group prenatal classes (56%), genetics (10%), complete pregnancy ultrasound (4%), prenatal 2s (4%), early diabetes mellitus (10%), diabetes mellitus (88%), influenza (18%), GBS status (4%), contraception (24%), Varicella (72%), HPV vaccination (74%), breastfeeding (46%), safe sleep (76%), and Rh immunization (16%).

CONCLUSION:
Implementing a standardized template improved provider counseling and documentation of several key aspects of routine prenatal care, including improving discussion of important maternal health factors, vaccination, contraception, and intended postpartum care.
Adherence in a Phase 3 Trial of a Multipurpose Vaginal pH-Regulator vs Nonoxynol-9 [2M]
Authors: Creinin Mitchell D. , Howard Brandi , Culwell Kelly R. 
Published: May 2019

INTRODUCTION:
The multipurpose vaginal pH-regulator (MVP-R) is a water-based, petroleum-free vaginal gel which is acid-buffering and under investigation for prevention of pregnancy and sexually transmitted infections. We assessed treatment adherence in a phase 3 contraceptive trial comparing the MVP-R and nonoxynol-9 (N-9) spermicidal gel.

METHODS:
This randomized, open-label, non-inferiority study was conducted at 62 sites in the U.S. and Russia; all sites obtained IRB-approval and all subjects provided informed consent. The MVP-R (Amphora®, formerly known as Acidform) and N-9 were provided in pre-filled, single-use applicators. Women were instructed to use 1 applicator immediately before or up to 1 hour before vaginal intercourse, and to reapply product if more than 1 hour elapsed and for additional intercourse within 1 hour. Subjects recorded product use and coital activity on a daily diary.

RESULTS:
The 3,324 enrollees included 1,665 MVP-R and 1,659 N-9 subjects. Baseline characteristics were similar between treatment arms; characteristics of the overall Intent-to-Treat population included mean age 27.6±5.6 years, body mass index 27.8±8.0 kg/m2 (32.8% obese), 62.0% White, and 76.6% non-Hispanic. The study method was used as the only contraceptive method and used correctly in 85.6% of coital acts (85.9% MVP-R, 85.3% N-9). Overall, 61.5% of all subjects (63.0% MVP-R, 60.1% N-9) were adherent with the proper method use for ≥90% of coital acts. The most common reason for non-adherence was failure to reapply with additional acts of intercourse within 1 hour after application (390/2,935 [13.3%]).

CONCLUSION:
Most subjects used these on-demand, women-controlled products as directed. Adherence was similar between the two treatment groups.
Postmenopausal endometriosis, where are we now?
Authors: Ladanyi Camille , Boyd Sarah , Sticco Peter , Mohling Shanti 
Published: May 2019

Purpose of review
Postmenopausal endometriosis is a gynecologic disease, affecting 2–5% of postmenopausal woman. Current literature assessing the prevalence, pathogenesis, and treatment of this uncommon condition is limited, stressing the necessity for future research. This review examines the current literature on postmenopausal endometriosis to help inform clinical decision-making and point to novel approaches for treatment and management.

Recent findings
Although one unifying theory to explain the pathogenesis of endometriotic lesions has not been elucidated, estrogen dependence is central to the pathophysiological process. The total quantity of estrogen production is mediated by multiple enzymes in complex pathways. Recent studies have confirmed the presence of these necessary enzymes in endometriotic lesions thereby suggesting a local source of estrogen and a likely pathogenic contributor. More research is needed to fully elucidate the mechanism of local estrogen biosynthesis; however, the current data provide possible explanations for the presence of postmenopausal endometriosis in an otherwise systemically hypoestrogenic environment.

Summary
All suspected endometriosis lesions should be surgically excised for optimization of treatment and prevention of malignant transformation. If hormone replacement therapy is initiated, combined estrogen and progestin is recommended, even in the setting of previous hysterectomy, given the risk of disease reactivation and malignant transformation of endometriotic lesions. Further research is needed to understand the true prevalence, cause, and progression in this patient demographic. Histologic studies evaluating tissue lesions and peritoneal fluid for estrogen receptors, estrogen metabolizing enzymes, immune cells, and nerve fibers will aide in clinical management and treatment planning.
Vocational Rehabilitation in the Veterans Health Administration Polytrauma System of Care: Current Practices, Unique Challenges, and Future Directions
Authors: Ottomanelli Lisa , Bakken Shana , Dillahunt-Aspillaga Christina , Pastorek Nicholas , Young Cynthia 
Published: May 2019

Objective/Purpose:
Veterans and service members (V/SMs) with traumatic brain injury (TBI) and comorbid conditions are treated in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC). These V/SMs comprise a unique population with distinct needs for restoring community reintegration, including participation in meaningful employment. Low employment rates after TBI vary and are influenced by many factors. Employment is a central aspect of the VHA priority of facilitating adjustment, and addressing vocational needs alongside healthcare is critical to community reintegration. The purpose of this article is to outline current practices of addressing vocational rehabilitation in the PSC, discuss the unique challenges in serving Veterans with polytrauma, and outline future directions to improve vocational services and outcomes.

Methods:
Briefly review literature on V/SM with TBI and employment, describe the PSC and VHA vocational programs for V/SM with polytrauma, and synthesize proceedings on vocational rehabilitation from the 2017 VHA “Community Reintegration in the Polytrauma System of Care” meeting.

Conclusions:
To advance and expand vocational services the following guidelines were recommended: (1) designing flexible services based on individualized needs, (2) increasing access to vocational services through communication and collaboration, (3) promoting cross-disciplinary education and engagement in vocational care, and (4) systematically tracking employment outcomes.
A Prospective Analysis of iStent Inject Microstent Positioning: Schlemm Canal Dilatation and Intraocular Pressure Correlations
Authors: Gillmann Kevin , Bravetti Giorgio E. , Mermoud André , Mansouri Kaweh 
Published: May 2019

Précis:
A larger proportion of iStent inject microstents than suggested by gonioscopic examination could be entirely burrowed within the trabeculum (45.7%). The length of device protrusion within the anterior chamber is linked to postoperative intraocular pressure (IOP).

Introduction:
The iStent inject is a relatively new device designed to be implanted ab-interno through the trabecular meshwork. Although some preliminary studies have shown IOP-lowering potential, the full extent of the mechanisms through which IOP is reduced remains unconfirmed. The aim of this study was to use in vivo optical coherence tomography analysis of the anatomic and physiological effects of iStent inject device positioning on the structures of the iridocorneal angle and IOP.

Methods:
In total, 25 eyes of 19 subjects (mean age, 75.5±10.5 y) with mild to moderate open-angle glaucoma were enrolled in this prospective study. All patients underwent implantation of 2 iStent inject devices combined with cataract surgery. In the postoperative period, after IOP stabilized, anterior segment optical coherence tomography (AS-OCT) was performed and several measurements were made of the Schlemm canal (SC) and the devices’ positions. Thirteen unoperated fellow eyes served as control eyes.

Results:
Overall, 92% of devices were visible on AS-OCT versus 88% visible on gonioscopic examination. Of all visible devices, 54.3% had a protruding portion into the anterior chamber with a mean protruding length of 88.5 µm, and 72% of the devices’ heads were not positioned within the SC, with a mean shortest distance of 109.4 µm. In operated eyes, the average major diameter of SC was 308.7±197.4 µm (median, 303.8 µm) versus 126.9±60.3 µm in control eyes. Device protrusion and larger SC diameters were associated with lower postoperative IOP (r
s=−0.54; P=0.005 and r
s=−0.43; P=0.04, respectively), whereas the distance between the devices’ heads and SC was inversely associated with SC dilatation (r
s=−0.41; P=0.04).

Conclusions:
This study highlights the value of AS-OCT in exploring the positioning of trabecular bypass devices such as the iStent inject. Our study shows that more microstents than suggested by gonioscopy could be completely burrowed within the trabeculum. It also suggests that the surgical outcomes of cataract surgery combined with iStent inject implantation may be connected to the amplitude of device protrusion within the anterior chamber as well as the postoperative dimensions of the SC.