Cardio-Obstetrics de novo: A State-level, Evidence-based Approach for Addressing Maternal Mortality and Severe Maternal Morbidity in Georgia.

Georgia has a high rate of severe maternal morbidity and mortality when compared to the rest of the United States1-6. Evidence gained from the Georgia Maternal Mortality Review Committee identified areas of focus for high yield clinical initiatives for improvement in maternal health outcomes2,7,8. Cardiovascular disease, including cardiomyopathy, coronary conditions, and pre-eclampsia/eclampsia, is the most common cause of pregnancy-related death in non-Hispanic, Black women in Georgia9-11. Development of a Cardio-Obstetrics program is an initiative to advance health equity by decreasing cardiovascular morbidity and mortality. This report describes the following: (1) state-level advocacy for improving maternal health outcomes with funding gained through the legislative process and partnership with a governmental agency; (2) Cardio-Obstetrics program development based on evidence gained from the maternal mortality review process; and (3) implementation of a Cardio-Obstetrics service, beginning with a focused approach for capacity building and understanding barriers to care.

Mechanical Aortic Valve Thromboembolism During Pregnancy on Low Molecular Weight Heparin.

A 31-year-old pregnant woman with a mechanical aortic valve developed a thrombus on her mechanical aortic valve due to subtherapeutic low molecular weight heparin dosage. She received intravenous heparin followed by warfarin. low molecular weight heparin dosing in pregnancy should be individualized, considering weight, physiological changes, and adjusted based on levels.

Multidisciplinary Approach to Management of Hypertrophic Cardiomyopathy With Severe Left Ventricular Outflow Obstruction in Pregnancy.

Pregnancy can worsen symptoms of hypertrophic cardiomyopathy and increase the risk of complications. Severe left ventricular outflow tract obstruction with gradient >100 mm Hg poses a high risk of deterioration during pregnancy. We present a patient with hypertrophic obstructive cardiomyopathy in the third trimester of pregnancy with a left ventricular outflow tract gradient >100 mm Hg and discuss successful interdisciplinary management.

Value of D-Dimer in Risk Stratification for Thromboembolism in Patients With Atrial Fibrillation and Low CHA2DS2-VASc Score.

Atrial fibrillation (AF) can cause thrombi formation and subsequent emboli deposition in systemic arteries, leading to various organ ischemia and infarction. Anticoagulation therapy can reduce the risk of thrombus formation and embolization, and is initiated based on a patient's risk score, which is frequently estimated with the CHA2DS2-VASc score. We present a case of thromboembolism (TE) where a low CHA2DS2-VASc score suggested a low-moderate risk of systemic embolization, but an elevated plasma D-dimer value prompted further investigation which revealed an intracardiac thrombus with renal embolism. The patient is a 63-year-old male with past medical history of hypertension and AF treated with ablation 2 years prior presenting with sharp right flank pain of 5-hour duration. Primary workup and imaging were unrevealing at the time, and a low CHA2DS2-VASc score was suggestive of aspirin therapy. However, an elevated D-dimer of 289 ng/mL and a transient increase in creatinine pointed to possible etiology of embolic origin. The diagnosis was confirmed with computed tomography (CT) with contrast and transesophageal echocardiogram, revealing renal infarcts and the source of the emboli, respectively. The patient was treated with heparin and transitioned to apixaban prior to discharge with full resolution of symptoms. Through this case, we wish to show D-dimer's predictive value of TE, as well as its potential benefit in risk assessment in patients with AF.

Chemotherapy in Pregnancy: Assessing the Safety of Adriamycin Administration in Pregnancy Complicated by Breast Cancer.

Pregnancy-associated breast cancer is challenging to treat. Treatment with chemotherapeutic agents such as anthracyclines poses a risk of cardiotoxicity, despite being considered safe after the second trimester of pregnancy. Management requires multidisciplinary comanagement with cardio-obstetrics, cardiology-oncology, maternal-fetal medicine, and oncology.

Isolated accessory tricuspid valve leaflet in asymptomatic adult.

Accessory tricuspid valve (ATV) is a rare congenital anomaly that is often seen in complex congenital anomalies in children with very few reported cases in adults. We report a case of isolated ATV in an asymptomatic adult with no other congenital defects along with illustrative transesophageal echocardiographic 2D, 3D, high-resolution photo-realistic images.

Comparison of two drainage parameters on diuretic renogram in predicting the fate of prenatally detected pelvi-ureteric junction-like obstruction.

Introduction: In infants with suspected pelviureteric junction (PUJ) like obstruction, we compared the drainage patterns suggested by t 1/2 and normalized residual activity (NORA) to determine which parameter can differentiate obstructive from nonobstructive dilatation and thus predict the need for surgery. Materials and Methods: Infants presenting with prenatally detected PUJ-like obstruction from January 2014 to March 2020 were evaluated with ultrasonography. Diuretic renogram was performed using Tc99m ethylene dicysteine using the F0 protocol. Subjects with a differential renal function >40% were included in the study. The t ½ values were noted. NORA was calculated by dividing the tracer values at 60 min with the values at 2 min. The infants were followed using ultrasonography. Renogram was repeated if there was increase in hydronephrosis or after 6 months if hydronephrosis did not regress. The follow-up was continued till a decision for pyeloplasty was made or the hydronephrosis regressed. Pyeloplasty was advised if differential function dropped to below 40%. Results: 34 patients met the inclusion criteria. NORA and t ½ had very poor concordance in defining the drainage pattern. t ½ values did not correlate with the need for surgery or conservative management (P ≥ 0.05). Good drainage pattern by NORA was associated with regression of hydronephrosis (P ≤ 0.001). NORA predicted obstruction more accurately. Conclusion: NORA can define good drainage in a much larger subset of patients with PUJ-like obstruction who eventually do not need surgery. However, further multicenter studies are needed to confirm this.

Role of Macroscopic Image Enhancement in Diagnosis of Non-Muscle-Invasive Bladder Cancer: An Analytical Review.

Early diagnosis of non-muscle-invasive bladder cancer (NMIBC) is of paramount importance to prevent morbidity and mortality due to bladder cancer. Although white light imaging (WLI) cystoscopy has long been considered the gold standard in the diagnosis of bladder cancer, it can miss lesions in a substantial percentage of patients and is very likely to miss carcinoma in situ and dysplasia. Tumor margin detection by WLI can be inaccurate. Moreover, WLI could, sometimes, be inadequate in distinguishing inflammation and malignancy. To improve the diagnostic efficacy of cystoscopy, various optical image enhancement modalities have been studied. These image enhancement modalities have been classified as macroscopic, microscopic, or molecular. Photodynamic diagnosis (PDD), narrow band imaging (NBI), and Storz image 1 S enhancement (formerly known as SPIES) are macroscopic image enhancement modalities. A relevant search was performed for literature describing macroscopic image enhancement modalities like PDD, NBI, and image 1 S enhancement. The advantages, limitations, and usefulness of each of these in the diagnosis of bladder cancer were studied. Photodynamic diagnosis requires intravesical instillation of a photosensitizing agent and a special blue light cystoscope system. PDD has been shown to be more sensitive than WLI in the detection of bladder cancer. It is superior to WLI in the detection of flat lesions. Bladder tumor resection (TURBT) by PDD results in more complete resection and reduced recurrence rates. PDD-guided TURBT may have some role in reducing the risk of progression. Narrow band imaging provides increased contrast between normal and abnormal tissues based on neovascularization, thereby augmenting WLI. NBI requires a special light source. There is no need for intravesical contrast instillation. NBI is superior to WLI in the detection of bladder cancer. The addition of NBI to WLI improves the detection of flat lesions like carcinoma in situ. NBI is not useful in predicting invasive tumors or grades of tumors. NBI-directed TURBT reduces recurrence rates and recurrence free survival. But its efficacy in retarding progression is unproven. Image 1 S-enhancement utilizes software-based image enhancement modes without the need for a special light source or intravesical contrast instillation. This system provides high-quality images and identifies additional abnormal-looking areas. Another advantage of this system is simultaneous side-by-side visualization of WLI and enhanced image, providing WLI images as the control for comparison. As with PDD, S-enhancement produces a lower rate of a missed bladder cancer diagnosis. The system significantly improves the diagnosis of NMIBC. The sensitivity and negative predictive value of image 1 S enhancement increase with the increase in cancer grade. A negative test by S-enhancement effectively rules out NMIBC. All the image enhancement modalities have proven their utility in improving detection and short-term cancer control. But none of these modalities have proven their utility in delaying progression, or in long-term cancer control. Cancer progression and long-term control are governed by the biological nature of cancer cells. Early detection by optical enhancement may not be of utility in this regard. Well-designed studies are needed to establish the efficacy of these modalities in the evaluation of patients with bladder cancer. The last word, in this regard, is yet to be written.

Polar zwitterion/saccharide-based deep eutectic solvents for cellulose processing.

Liquid zwitterions are biocompatible cellulose solvents and have enabled successive ethanol production from plant biomass in the same reaction pot. However, only a few carboxylate-type liquid zwitterions have been reported since almost all zwitterions are solid. Here, we propose zwitterion-based deep eutectic solvents (DESs) to expand the choices of zwitterionic solvents for cellulose dissolution and the subsequent processing. Zwitterion-based DESs were prepared by mixing four types of saccharide at various ratios. Twenty-two combinations of zwitterion/saccharide mixtures formed DESs, that is, liquid state below 100 °C. Two of them, whose saccharide ratio were 5 wt%, successfully dissolved cellulose because the low saccharide load was sufficient for liquefaction but did not disrupt the intrinsic cellulose dissolution ability of zwitterions.

Renal cortical transit time in the evaluation of prenatally detected presumed pelvi ureteric junction like obstruction: A systematic review.

INTRODUCTION: Differentiating nonobstructive from obstructive dilatation of the kidney is a clinical dilemma in prenatally detected hydronephrosis. Many radionuclide renogram parameters have been used to differentiate obstructed from non-obstructed units, including cortical transit time (CTT). We evaluate the role of CTT in identifying obstruction through a systematic review. METHODS: A literature search of the MEDLINE, MEDLINE In-Process, and MEDLINE Epub Ahead of Print, EMBASE, Google scholar, Pub Med, and Cochrane Library was done using key words - radionuclide renogram, CTT, parenchymal transit time, cortical transit, renography to identify articles on the subject. The identified articles were assessed for appropriateness and reviewed. RESULTS: The initial search yielded a total of 1583 articles, after adding the articles from references and applying the inclusion and exclusion criteria a total of 28 articles were selected. CTT showed good inter observer agreement in identifying obstruction. The use of CTT as a single parameter for determining the need for surgery and to identify those kidneys which will have functional improvement after surgery has been evaluated and has been found to be useful. CTT is best used in conjunction with ultrasonography to make clinical decisions. CONCLUSION: The commonly used visual method of estimating the CTT, is a promising parameter for the evaluation of prenatally detected pelviureteric junction obstruction. Further well-designed multicenter prospective studies are needed to establish it as the most specific parameter to differentiate obstructive from nonobstructive dilatation of the pelvicalyceal system.

High loading of trimethylglycine promotes aqueous solubility of poorly water-soluble cisplatin.

Trimethylglycine (TMG) is a cheap, natural, and highly biocompatible compound. Therefore, it has been used in the fields of food and life sciences, but the application of solid TMG is limited to utilisation as an "additive". In the present study, we focussed on the high solubility of TMG in water, derived from the aprotic zwitterionic structure, and proposed TMG as the chemical accounting for a major portion of the aqueous solution (e.g., 50 wt%). High loading of TMG shifted the properties of water and enabled the dissolution of poorly water-soluble cisplatin, an anticancer agent, at high concentration (solubility of cisplatin: 0.15 wt% in water vs 1.7 wt% in TMG aqueous solution). For hepatic arterial infusion, this can reduce the amount of cisplatin administered from 40 to 4 mL. It enables simple injection using a syringe, without the need for catheters and automatic pumps, leading to critical alleviation of the risk to patients. Furthermore, we produced a dry powder from a cisplatin-containing TMG aqueous solution via freeze-drying. Powders can be conveniently stored and transported. Furthermore, cisplatin is often used as a mixture with other drugs, and cisplatin aqueous solutions are not preferred as they dilute the other drugs.

Evaluation of Spectra A and B Modes in Diagnosis of Suspicious Bladder Lesions.

Background: White light imaging (WLI) cystoscopy, a "gold standard" for diagnosis of nonmuscle invasive bladder cancer (NMIBC), can miss ∼25% of bladder cancers. Spectra A (SA) and Spectra B (SB) are virtual optical chromoendoscopy modes introduced by Storz. Objective: To evaluate whether SA and SB improve over WLI in diagnosis of NMIBC. Design, Setting, and Participants: Storz Professional Image Enhancement System (SPIES) modes allow side-by-side viewing of WLI and spectra images. Cystoscopy images of some patients with suspected NMIBC and some normal cystoscopy findings were cut in two parts: one WLI and the other SA or SB. Each individual image was sent to the 3721 members of Urological Society of India separately through online survey. Histologic diagnosis was considered final diagnosis. Intervention: The observers were asked whether they considered the image to be cancer; yes, no, or cannot say were the three response options. Outcome Measures and Statistical Analysis: Primary outcome measure was improved diagnosis of NMIBC. Diagnostic efficacy was analyzed through 2 × 2 tables, McNemar test, and Fleiss Kappa. Results and Limitations: A total of 273 observers participated in the study. The sensitivities of WLI, SA, and SB were 89.81, 91.15, and 88.81, respectively. The specificities were 73.18, 66.17, and 68.68, respectively. In patients with cancer, both SA and SB improved the diagnostic efficacy of WLI. SA added significantly to the diagnostic accuracy over WLI (χ2 = 12.23, p = 0.00046). SB also added significantly over WLI (χ2 = 11.76, p = 0.0006). With increasing cancer grade, the sensitivity and negative predictive value of all modes increased. The major limitation of this study is the online diagnosis based on still images. Conclusions: In patients with cancer, SA and SB significantly add to the diagnostic accuracy of WLI. As compared with the negative WLI, if SA and SB are negative, NMIBC would be less likely.