Positive Bubble Study But No Evidence of Interatrial Defect in a Patient with Recurrent Cryptogenic Stroke.

Pulmonary arteriovenous malformations (PAVMs) can be asymptomatic or result in a range of complications such as brain abscesses or cryptogenic emboli, which can contribute to morbidity and mortality if not diagnosed and treated in a timely manner. To date, there have been several reports of delayed diagnosis of PAVMs, which have been largely attributed to the misconception that PAVMs are too rare to be of clinical significance. Furthermore, because intracardiac shunting secondary to a patent foramen ovale (PFO) or atrial septal defect (ASD) also results in a positive saline contrast study with echocardiography, PAVM can be easily misdiagnosed as an intracardiac right-toleft shunt. However, there are unique echocardiographic features that differentiate between intracardiac shunting due to a PFO or ASD and extracardiac shunting such as in PAVM. This case details the course of a patient with recurrent cryptogenic strokes that was initially misattributed to a PFO and was only correctly diagnosed with multiple PAVMs after two failed attempts at PFO closure. This case serves as a reminder of an alternative etiology of right-to-left shunt and its presentation on imaging, which echocardiographers must be familiar with.

Procedural, Short-Term, and Intermediate-Term Outcomes in Propensity-Matched Patients With Severe Mitral Valve Regurgitation Undergoing Urgent Versus Elective MitraClip Percutaneous Mitral Valve Repair.

OBJECTIVE: The study authors sought to compare outcomes in patients with severe mitral valve regurgitation (MR) undergoing urgent, as compared to elective, mitral valve repair employing MitraClip. They hypothesized that, compared to elective cases, MitraClip procedures performed for urgent indications would be associated with increased intraoperative and postoperative complications but have similar long-term outcomes. DESIGN: A retrospective chart review with 3:1 propensity score matching of elective-to-urgent cases. SETTING: A single, large-volume tertiary care academic medical center. PARTICIPANTS: All consecutive patients with severe MR who underwent elective or urgent MitraClip procedures between December 15, 2015, and October 26, 2020. INTERVENTIONS: MR repair with MitraClip. MEASUREMENTS AND MAIN RESULTS: As expected, patients in the urgent MitraClip group required a higher level of preprocedural care, and there were significant differences in baseline demographic and clinical variables as compared to the elective group. To reduce baseline characteristics heterogeneity, propensity matching was performed for age, left ventricular systolic dysfunction, congestive heart failure, chronic obstructive pulmonary disease, and smoking histories, using the nearest-neighbor matching with a caliper of 0.2 and with replacement. The final study cohort included 89 urgent and 252 matched elective cases, with a suitable alignment between the treatment groups. Propensity-matched urgent MitraClip patients experienced a longer hospital length of stay (p < 0.001), increased intensive care unit admissions (19% v 4%, p < 0.001) and mechanical ventilation (6.7% v 1.6%, p = 0.023), postprocedural atrial fibrillation (11% v 4.4%, p = 0.036), pericardial effusion (10% v 2.4%, p = 0.005), and acute kidney injury (7.9% v 2%, p = 0.016). Furthermore, patients in the urgent cohort incurred significantly higher 30-day cardiovascular mortality (6.7% v 2%, p = 0.039), increased 30-day (16% v 5.6%, p = 0.006), and 1-year (33% v 20%, p = 0.021) readmission rates. However, there were no statistically significant differences in 30-day and 1-year overall and 1-year cardiovascular mortality. CONCLUSIONS: Urgent MitraClip repairs can be performed successfully, when needed, in critically ill patients with severe MR. Despite the procedural success, patients undergoing urgent MitraClip repair remain at high risk for adverse outcomes in the short- and intermediate-term and incur increased cardiovascular mortality and morbidity. Further efforts are required to develop strategies to optimize short and intermediate outcomes in this vulnerable group of patients.

Intra-incisional liposomal bupivacaine and its impact on postcesarean analgesia: a retrospective study.

PURPOSE: The efficacy of long-acting intraincisional bupivacaine in reducing postoperative opioid use among women who have undergone a cesarean is currently unknown. MATERIALS AND METHODS: This was a retrospective case-control study with a 1:1 allocation. We identified 40 patients in each group, for a total of 80. The treatment group was administered 266 mg of liposomal bupivacaine after completion of the cesarean and was compared to historical controls. Data regarding anesthesia administered, opioid consumption, nonsteroidal anti-inflammatory use, acetaminophen use, type of cesarean, reason for cesarean, and length of postoperative stay were recorded. RESULTS: The treatment group used 41.51 mg of morphine equivalents, while the control group consumed 69.90 mg (p < .001); multivariate analysis demonstrated a mean difference of 26.52 mg (95%CI 12.76-40.28). Univariate analysis demonstrated mean difference in intravenous (IV) ketorolac (40.77 mg, p < .001) and IV acetaminophen (1333.33 mg, p < .001) was different and greater in the treatment group; this was controlled for in the multivariate model. There was no difference in oral and IV ibuprofen or oral acetaminophen use between groups. There were no differences between the type of anesthesia, length of stay, reason for cesarean, and classical sections between groups. CONCLUSIONS: Incisional administration of liposomal bupivacaine may be an effective adjunct in reducing opioid use postoperatively and may be a useful adjunct within an enhanced recovery program.

Polyamine transporter in Streptococcus pneumoniae is essential for evading early innate immune responses in pneumococcal pneumonia.

Streptococcus pneumoniae is the most common bacterial etiology of pneumococcal pneumonia in adults worldwide. Genomic plasticity, antibiotic resistance and extreme capsular antigenic variation complicates the design of effective therapeutic strategies. Polyamines are ubiquitous small cationic molecules necessary for full expression of pneumococcal virulence. Polyamine transport system is an attractive therapeutic target as it is highly conserved across pneumococcal serotypes. In this study, we compared an isogenic deletion strain of S. pneumoniae TIGR4 in polyamine transport operon (ΔpotABCD) with the wild type in a mouse model of pneumococcal pneumonia. Our results show that the wild type persists in mouse lung 24 h post infection while the mutant strain is cleared by host defense mechanisms. We show that intact potABCD is required for survival in the host by providing resistance to neutrophil killing. Comparative proteomics analysis of murine lungs infected with wild type and ΔpotABCD pneumococci identified expression of proteins that could confer protection to wild type strain and help establish infection. We identified ERM complex, PGLYRP1, PTPRC/CD45 and POSTN as new players in the pathogenesis of pneumococcal pneumonia. Additionally, we found that deficiency of polyamine transport leads to up regulation of the polyamine synthesis genes speE and cad in vitro.

Management of gastroparesis-associated malnutrition.

Gastroparesis (GP) is a chronic debilitating dysmotility characterized by unrelenting nausea, vomiting, bloating, early satiety, postprandial fullness and abdominal pain. Patients with GP experience other associated conditions, including gastroesophageal reflux disease, gastric bezoars and small bowel bacterial overgrowth. Furthermore, GP is associated with poor quality of life, increased emergency room visits, hospitalizations and subsequent increased healthcare costs. Currently, the managements of GP consist of glycemic control, antiemetics, prokinetics and the use of gastric electrical stimulation. However, most GP patients are at risk for significant nutritional abnormalities. As such, it is essential to screen and diagnose malnutrition in these patients. Poor oral intake in such patients could be supplemented by enteral tube feeding. Parenteral nutrition, although a last resort, is associated with a number of complications and should be used only for the short term. In summary, a systematic approach including initial nutritional screening, diet recommendations, medical therapy, nutritional re-evaluation and enteral and parental nutrition should be considered in complex GP patients.

A modified and cost-effective method for hair cortisol analysis.

Hair cortisol may hold potential as a biomarker for assessment of chronic psychological stress. We report a modified and cost-effective method to prepare hair samples for cortisol assay. Hair samples were ground using an inexpensive ball grinder - ULTRA-TURRAX tube drive. Cortisol was extracted from the powder under various defined conditions. The data showed that the optimal conditions for this method include cortisol extraction at room temperature and evaporation using a stream of room air. These findings should allow more widespread research using economical technology to validate the utility of hair cortisol as a biomarker for assessing chronic stress status.

Impedance cardiography assessed treatment of acute severe pregnancy hypertension: a randomized trial.

OBJECTIVE: Using noninvasive bedside impedance cardiography (ICG), we compared the effectiveness and the hemodynamic impact of intravenous labetalol versus hydralazine for the reduction of acute-onset severe hypertension to ACOG-recommended blood pressure levels (ACOG Committee Opinion 514). STUDY DESIGN: In this prospective randomized pilot study of acutely severe systolic hypertension (≥160 mmHg), pregnant women received either labetalol (L) or hydralazine (H) intravenously and underwent thoracic ICG before and after treatment. Data analysis were performed using STATA software (StataCorp LP, College Station, TX); data are expressed as mean ± SD. RESULTS: About 29 patients completed the study. There was no significant difference in mean arterial pressure (MAP) between groups [H = 119.4 mmHg, L = 117.7 mmHg, mean difference (MD) = 1.73); the estimated MD between baseline and follow-up ICG was -9.17 (p = 0.001, 95% CI: -14.39 to -3.95). There were no significant differences in total peripheral resistance (TPR) between groups (H = 1771.3, L = 1976.97, MD = 205.62) or cardiac output (CO) between groups (H = 5.7, L = 5.1, MD = 0.64) or a significant MD between these at baseline and follow-up. CONCLUSION: Both drugs performed similarly to achieve ACOG-recommended initial blood pressure reduction safely without side effects or excessive acute hemodynamic profile correction toward normal pregnancy values.

Hair Cortisol Concentrations Are Associated with Hair Growth Rate.

There is a growing interest in hair cortisol concentrations as a valuable biomarker for the assessment of metabolic diseases and chronic psychological stress. Fifty-three volunteers were recruited, and hair segments proximal to the scalp were collected from each individual. A cost-effective ball mill was used for the preparation of hair samples, and ELISA was performed to analyze cortisol concentrations. Results indicate that the frequency of hair washing affects the hair cortisol concentration. The group that washed their hair every day had significantly lower cortisol concentrations than the group that washed it less often. However, no significant differences were detected between cosmetic-treated and nontreated hair samples. The study also shows that hair cortisol concentrations in the first 3 cm of hair segments proximal to the scalp corresponded to average hair growth rate based on 1 cm/month. Thus, hair cortisol concentrations of segments 3 cm proximal to the scalp may represent cumulative stress exposure over the previous 3 months. These findings will allow more widespread research to validate the utility of hair cortisol as a potential biomarker to assess chronic stress.

Burns During Pregnancy: Implications for Maternal-Perinatal Providers and Guidelines for Practice.

IMPORTANCE: When a major burn is suffered during pregnancy, the obstetric provider is challenged to respond on an evidence basis because personal experience usually is lacking. Currently, there is a paucity of publications to inform the obstetrician, guide practice, and impact early critical decision making. OBJECTIVE: The aims of this study were to summarize the available information on early management of burns during pregnancy and to identify components of best practices for optimal outcome. EVIDENCE ACQUISITION: The PubMed database was searched for relevant titles and abstracts involving pregnant patients suffering from second-/third-degree burns. Among these studies, the bibliographies were investigated for further relevant literature. A total of 114 studies were identified during the initial search, and only studies published in English and French were included for a total of 42. Variable data were available for 1141 patients, with complete data for 139 cases. Mediation and regression analysis were used for available data. Insufficient data were available to undertake a systematic review. RESULTS: Total body surface area of burns (TBSAB) was positively associated with maternal death, and the odds of maternal mortality increase by 1.08 per percentage increase of TBSAB (P < 0.001). Fetal survival depends on maternal survival (P ≤ 0.001). Maternal survival declines incrementally when TBSAB exceeds 55%, and inhalation injury further exacerbates maternal-perinatal risk. CONCLUSIONS: Emergent assessment of the pregnant burn victimincludes determination of gestational age, extent of TBSAB, presence of inhalation injury, and continuous fetal monitoring. If gestational age is 24 weeks or longer and TBSAB exceeds 55%, urgent cesarean delivery appears desirable for the mother and baby. RELEVANCE: A specific analysis of maternal-perinatal outcome based on TBSAB and gestational age is relevant to obstetric and emergency providers who provide care to pregnant burn patients.

Evaluating the performance of the focus HerpeSelect® HSV-2 IgG in veterans with chronic hepatitis C infection.

Epidemiologic links between chronic hepatitis C and herpes simplex type-2 infection have been suggested; however, type-specific tests for HSV-2 infection have not been validated in patients with chronic hepatitis C infection. The Focus HerpeSelect(®) HSV-2 IgG (Cypress, California) assay and the Biokit HSV-2 rapid assay (Biokit USA, Lexington, MA) were performed on serum samples obtained from 84 veterans with chronic hepatitis C who demonstrated a previously positive HSV-2 serologic test in their medical records. Using the Biokit HSV-2 as the comparator assay, the positive predictive value, and specificity for the HerpeSelect(®) HSV-2 assay were 62.1% (95%CI: 49.3-73.8) and 41.9% (95%CI: 27.0-57.9), respectively. Increasing the HerpeSelect(®) HSV-2 index value defining a positive test result from >1.1 to ≥2.89 increased the assay's specificity to 97.7% (95%CI: 87.7-99.6) and the positive predictive value to 94.1%(95%CI: 71.2-99.0). J. Med. Virol. 9999: 1-5, 2015. © 2015 Wiley Periodicals, Inc. In veterans with chronic hepatitis C infection, HerpeSelect(®) HSV-2 index values between 1.1 and 2.89 should be confirmed with an alternate test for HSV-2 infection.

State of the ART: Characteristics of HIV infected patients receiving care in Mississippi (MS), USA from the Medical Monitoring Project, 2009-2010.

BACKGROUND: Mississippi, the poorest state in the US, has a very high prevalence of HIV and among the highest HIV infection rates and AIDS-adjusted mortality rates in the country. African Americans, who suffer the worst health care disparities in the US, account for 76% of people with HIV in MS. The purpose of this study is to describe those in care for HIV and determine the factors associated with anti-retroviral treatment (ART) and viral suppression. METHODS: The CDC's Medical Monitoring Project collects surveillance data from 23 project areas in the US, including Mississippi, using annual probability sampling of persons in care for HIV. Data were collected from in-person interviews and medical record abstraction in 2009. The surveillance period was the 12 months prior to the interview date. RESULTS: 212 randomly selected participants represented a nationally representative weighted sample of 3190.4. Participants had a mean of 3.71 provider visits during the surveillance period. Geometric mean for CD4 count = 438.91 (95% CI 402.25-475.56). Overall 80.80% (95% CI 75.30%- 86.29%) were on ART, and 68.12% (95% CI 62.69%-73-56%) had undetectable viral load. Males (65.15%) were less likely to achieve undetectable viral load compared to females (78.30%) after controlling for individuals who were on ART (p = 0.01). Viral suppression was not associated with age, race or sexual risk factors. CONCLUSIONS: Although Mississippi has a high proportion of individuals out of HIV care, the majority in care is on ART and has suppressed viral loads. However, men are less likely to achieve virological suppression than females.

Gene polymorphisms of stress hormone and cytokine receptors associate with immunomodulatory profile and psychological measurement.

OBJECTIVE: We sought to identify whether stable single nucleotide polymorphisms (SNPs) of various endocrine and immune molecules could be used as biomarkers associated with specific immune alterations and chronic stress measures in normal humans. METHODS: A total of 207 volunteer participants answered stress questionnaire and gave peripheral blood cells for identification of SNPs in genes coding for glucocorticoid receptor (GR), beta 2 adrenergic receptor (B2AR), interferon-gamma receptors (IFNGR1, IFNGR2), and interleukin-4 receptor (IL4R). Immunoregulatory profiles were measured by flow cytometry and genotyping assays were performed by allelic discrimination real-time PCR. RESULTS: Several significant differences were revealed in associations between stress marker and immune indicators based on SNP categories. For instance, Th1 levels of the minor alleles of GR TthIIII (AA) and IFNGR2 Q64R (Arg/Arg) groups were positively associated with chronic stress (PSS) (p = 0.024 and 0.005, respectively) compared with wild type (WT) and negatively associated with PSS in the heterozygous genotypes of GR BclI and IL4R Ile50Val (p = 0.040 and p = 0.052, respectively). Treg levels of the minor alleles of BclI (GG) and IFNGR1 T-56C (CC) groups were positively associated with PSS (p = 0.045 and p = 0.010, respectively) and negatively associated in the minor allele (Val/Val) of IL4R Ile50Va and the heterozygous genotype of IL4R Q576R (p = 0.041 and p = 0.017, respectively) compared to WT. CONCLUSION: The data support the notion that gene polymorphisms from various components of the psychoneuroendocrine-immune network may be useful as biomarkers to categorize individual stress-associated immune responses.

Association between BVAB1 and high Nugent scores among women with bacterial vaginosis.

As part of a larger study using 454 pyrosequencing to investigate the vaginal microbiota of women with bacterial vaginosis (BV), we found an association between a novel BV-associated bacterium (BVAB1) and high Nugent scores and propose that BVAB1 is the curved Gram-negative rod traditionally identified as Mobiluncus spp. in vaginal Gram stains.

A pilot study examining the safety and tolerability of valacyclovir in veterans with hepatitis C virus/herpes simplex virus type 2 coinfection.

INTRODUCTION: We performed a pilot study examining the safety and tolerability of valacyclovir in veterans with herpes simplex virus type 2 and hepatitis C virus (HCV) coinfection. METHODS: We performed a randomized double-blind, placebo-controlled, crossover clinical trial in U.S. veterans with genotype 1 HCV/herpes simplex virus type 2 coinfection. Patients were randomized 1:1 in blocks of 10 to receive either 1 g twice-daily valacyclovir or matching placebo for 8 weeks followed by a 2-week washout phase with daily placebo. The alternate therapy (valacyclovir or placebo) was given for an additional 8-week period. Safety assessments were performed every 2 weeks. Changes in HCV RNA and alanine aminotransferase (ALT) were estimated using linear mixed models (SAS Proc Mixed). RESULTS: Thirty patients were enrolled. Valacyclovir was not associated with toxicity or adverse events. ALT levels declined 6% to 10%; mean HCV RNA levels were reduced 24% (1.3 million IU/mL [0.21 log10 IU/mL]) during the valacyclovir phase (P = 0.08) with no carryover effect observed (P = 0.21). CONCLUSIONS: Valacyclovir 1 g twice daily showed no evidence of hepatotoxicity in U.S. veterans with hepatitis C. A modest reduction in serum levels of ALT and plasma levels of HCV RNA was observed.

Validation of a genomics-based hypothetical adverse outcome pathway: 2,4-dinitrotoluene perturbs PPAR signaling thus impairing energy metabolism and exercise endurance.

2,4-dinitrotoluene (2,4-DNT) is a nitroaromatic used in industrial dyes and explosives manufacturing processes that is found as a contaminant in the environment. Previous studies have implicated antagonism of PPARα signaling as a principal process affected by 2,4-DNT. Here, we test the hypothesis that 2,4-DNT-induced perturbations in PPARα signaling and resultant downstream deficits in energy metabolism, especially from lipids, cause organism-level impacts on exercise endurance. PPAR nuclear activation bioassays demonstrated inhibition of PPARα signaling by 2,4-DNT whereas PPARγ signaling increased. PPARα (-/-) and wild-type (WT) female mice were exposed for 14 days to vehicle or 2,4-DNT (134 mg/kg/day) and performed a forced swim to exhaustion 1 day after the last dose. 2,4-DNT significantly decreased body weights and swim times in WTs, but effects were significantly mitigated in PPARα (-/-) mice. 2,4-DNT decreased transcript expression for genes downstream in the PPARα signaling pathway, principally genes involved in fatty acid transport. Results indicate that PPARγ signaling increased resulting in enhanced cycling of lipid and carbohydrate substrates into glycolytic/gluconeogenic pathways favoring energy production versus storage in 2,4-DNT-exposed WT and PPARα (-/-) mice. PPARα (-/-) mice appear to have compensated for the loss of PPARα by shifting energy metabolism to PPARα-independent pathways resulting in lower sensitivity to 2,4-DNT when compared with WT mice. Our results validate 2,4-DNT-induced perturbation of PPARα signaling as the molecular initiating event for impaired energy metabolism, weight loss, and decreased exercise performance.

Maternal hemodynamics by thoracic impedance cardiography for normal pregnancy and the postpartum period.

OBJECTIVE: To establish normative impedance cardiography values for the second half of pregnancy and up to 48 hours postpartum after either vaginal or cesarean delivery. METHODS: A single-center prospective observational institutional review board-approved study of normotensive women (n=168) using thoracic impedance cardiography performed at specific times during gestation. Antepartum testing was performed at three time periods: 20-27 weeks, 28-33 weeks, and 34-40 weeks of gestation. Postpartum testing was undertaken after the immediate puerperium at 6-23 hours and 24-48 hours after vaginal or cesarean delivery. Data analysis was performed using STATA software; data are expressed as mean±standard deviation. RESULTS: All seven of the patient groups studied were comparable with regard to demographic features; 80% of the study participants were African American. Group means obtained between 20 and 40 weeks of gestation and postpartum after vaginal and cesarean delivery fell within the "normal range" of the hemodynamic graph that was developed to associate mean arterial pressure and systemic vascular resistance. The thoracic fluid content group means in both vaginal and cesarean delivery groups were higher than the antepartum patient groups. The thoracic fluid content mean after cesarean delivery at 48 hours is significantly higher than the mean value recorded between 20 and 27 weeks of gestation (P<.05). The systemic vascular resistance systemic vascular resistance means in each of the postpartum groups were significantly higher than the late second-trimester group means recorded at 20-27 weeks of gestation (P<.05). CONCLUSION: The normative values reported in this investigation can be used to interpret and assess similarly tested patients with hypertensive or otherwise complicated pregnancy. LEVEL OF EVIDENCE: III.

Characterization of the vaginal microbiota among sexual risk behavior groups of women with bacterial vaginosis.

BACKGROUND: The pathogenesis of bacterial vaginosis (BV) remains elusive. BV may be more common among women who have sex with women (WSW). The objective of this study was to use 454 pyrosequencing to investigate the vaginal microbiome of WSW, women who have sex with women and men (WSWM), and women who have sex with men (WSM) with BV to determine if there are differences in organism composition between groups that may inform new hypotheses regarding the pathogenesis of BV. METHODS: Vaginal swab specimens from eligible women with BV at the Mississippi State Department of Health STD Clinic were used. After DNA extraction, 454 pyrosequencing of PCR-amplified 16S rRNA gene sequences was performed. Sequence data was classified using the Ribosomal Database Program classifer. Complete linkage clustering analysis was performed to compare bacterial community composition among samples. Differences in operational taxonomic units with an abundance of ≥ 2% between risk behavior groups were determined. Alpha and beta diversity were measured using Shannon's Index implemented in QIIME and Unifrac analysis, respectively. RESULTS: 33 WSW, 35 WSWM, and 44 WSM were included. The vaginal bacterial communities of all women clustered into four taxonomic groups with the dominant taxonomic group in each being Lactobacillus, Lachnospiraceae, Prevotella, and Sneathia. Regarding differences in organism composition between risk behavior groups, the abundance of Atopobium (relative ratio (RR)=0.24; 95%CI 0.11-0.54) and Parvimonas (RR=0.33; 95%CI 0.11-0.93) were significantly lower in WSW than WSM, the abundance of Prevotella was significantly higher in WSW than WSWM (RR=1.77; 95%CI 1.10-2.86), and the abundance of Atopobium (RR=0.41; 95%CI 0.18-0.88) was significantly lower in WSWM than WSM. Overall, WSM had the highest diversity of bacterial taxa. CONCLUSION: The microbiology of BV among women in different risk behavior groups is heterogeneous. WSM in this study had the highest diversity of bacterial taxa. Additional studies are needed to better understand these differences.

Bacterial vaginosis among African American women who have sex with women.

BACKGROUND: Bacterial vaginosis (BV) is a frequent cause of vaginal discharge that may be more common among women reporting sex with women (WSW). The objective of this study was to determine the prevalence of BV and predictors of infection among a sample of African American WSW. METHODS: African American WSW aged 18 years or older presenting to the Mississippi State Department of Health STD Clinic between 2009 and 2010 and reporting a history of sexual activity with a female partner during the preceding year were invited to participate. A survey on sexual history and sexual behavior characteristics was completed. Bacterial vaginosis was defined by Amsel criteria. Associations with participant characteristics were determined using logistic regression analysis. RESULTS: Bacterial vaginosis was diagnosed in 93 (47.4%) of 196 women. Bisexual identity (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.03-3.66; P = 0.04), douching within the past 30 days (OR, 1.93; 95% CI, 1.09-3.43; P = 0.02), age 18 years or less at first sexual encounter with a female partner (OR, 3.18; 95% CI, 1.16-8.71; P = 0.02), and report of more than 1 lifetime male sexual partners (OR, 1.94; 95% CI, 1.01-3.74; P = 0.04) were significant predictors of BV in bivariate analysis. Bacterial vaginosis was less common among women who reported more than 1 lifetime female sexual partner (OR, 0.26; 95% CI, 0.09-0.76; P = 0.01). In multivariable analysis, age 18 years or less at first sex with a female partner approached significance, while report of 1 lifetime female sexual partner remained strongly associated with BV. CONCLUSIONS: Bacterial vaginosis was common in this sample of African American WSW and significantly associated with report of 1 lifetime female sexual partner.

Hellp syndrome and composite major maternal morbidity: importance of Mississippi classification system.

OBJECTIVE: We explored the prevalence of Composite Major Maternal Morbidity (CMMM) for patients with severe preeclampsia (SPRE) and each class or category of HELLP syndrome. METHODS: In a retrospective cohort study from 2000 to 2010, we reviewed maternal charts of patients categorized with complete or partial HELLP syndrome. From 2005 to 2007, the maternal charts for every patient with a diagnosis of SPRE without HELLP syndrome were also evaluated for comparison. The CMMM for each patient group included cardiopulmonary; hematologic/coagulation, central nervous system/visual, hepatic or renal complications. During the study interval patients with class 1 and class 2 HELLP syndrome received Mississippi Protocol management. RESULTS: Four hundred and ninety-five mothers had a form of HELLP syndrome in years 2000-2010; 688 mothers experienced a non-HELLP severe form of preeclampsia during 2005-2007. The prevalence of CMMM for each patient group was: class 1 = 44%; class 2 = 13%; class 3 = 24%; partial HELLP = 20% and SPRE = 18%. CMMM for class 1 HELLP syndrome is significantly higher than all other groups (p < 0.001). CONCLUSIONS: Patients who develop class 1 HELLP syndrome have significantly higher CMMM. Avoiding this most advanced stage of HELLP syndrome and minimizing the development of new MMM becomes a measure of medical management effectiveness and a tool to assess overall quality of care.

A high LDH to AST ratio helps to differentiate pregnancy-associated thrombotic thrombocytopenic purpura (TTP) from HELLP syndrome.

OBJECTIVE: Differentiating between pre-eclampsia/HELLP syndrome and pregnancy-associated thrombotic thrombocytopenic purpura (TTP) is difficult but important in order to undertake timely and potentially life-saving plasma exchange (PEX) therapy for TTP recovery. We review our institutional experience with pregnancy-associated TTP and determine if the ratio of LDH to AST reliably distinguishes patients with TTP from those with HELLP syndrome. STUDY DESIGN: This is a retrospective case control study of all pregnant/puerperal patients with TTP from a single tertiary care center during 1986-2006. Laboratory findings in patients with TTP were compared to patients who met all criteria for class 1 or 2 HELLP syndrome within the first 24 hours of hospital admission during 2000-2007. RESULTS: Thirteen pregnant (n = 10) or puerperal (n = 3) patients with TTP were identified; 11 cases were primary, 2 were recurrent. TTP laboratory findings included LDH to AST ratios of 77 ± 42.17; Patients with HELLP syndrome (N = 83) had significantly lower LDH to AST ratios of 20.04 ± 2.13. Based on an ROC analysis, an LDH/AST ratio ≥ 22.12 discriminates well between TTP and antenatal HELLP subjects (AUC = 0.99). CONCLUSION: A high LDH to AST ratio >22.12 suggests that TTP is a more likely diagnosis than HELLP syndrome in the third trimester pregnant patient, presenting with findings that could be compatible with either diagnosis. In these circumstances, it is advisable to obtain hematology consultation and to consider PEX implementation.