Medical or surgical treatment before embryo transfer improves outcomes in women with abnormal endometrial BCL6 expression.

PURPOSE: To evaluate the effect of medical or surgical treatment prior to embryo transfer in women with elevated endometrial BCL6 expression and suspected endometriosis in a prospective, cohort study design at a university-associated infertility clinic. METHODS: All subjects had at least 1 year of unexplained infertility (UI) and each prospectively underwent endometrial biopsy and immunostaining for the oncogene BCL6, prior to embryo transfer during an assisted reproductive technology (ART) cycle. To be included, subjects had to have an abnormal BCL6 result, defined by elevated HSCORE ≥ 1.4. Women that were pre-treated with laparoscopy or medical suppression with GnRH agonist (depot leuprolide acetate; Lupron®, Abbvie, Inc., Chicago, IL) for 2 months were compared to a group that went untreated (controls). Endpoints included implantation rate (IR), clinical pregnancy rate (CPR), and live birth rate (LBR), and as well as cycle characteristics. Miscarriage rate were also compared between treatment and control group. RESULTS: Women in each group had similar characteristics. Those treated by medical suppression and those undergoing laparoscopy for endometriosis had a significantly higher LBR, (5/10; 50%; 95%CI 23.7 to 76.3%) and (11/21; 52.4%; 95%CI 32.4 to 71.7), respectively, compared to controls (4/54; 7.4%; 95%CI 2.9 to 17.6). An absolute benefit of 44.2% (16/31; 95%CI 24.6 to 61.2) and a number need to treat of 3 for those that received treatment (medical suppression and laparoscopy), compared to no treatment. Miscarriages were significantly more common in the control group. CONCLUSIONS: Women with suspected endometriosis and aberrant endometrial BCL6 expression have worse reproductive outcomes following embryo transfer, including a high miscarriage rate, poor IR, and low LBR and CPR compared to cycles pre-treated with medical and surgical management.

Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. STUDY DESIGN: Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days. RESULTS: A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups. CONCLUSIONS: NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.

Temporal changes in the prehospital management of trauma patients: 2014-2021.

INTRODUCTION: Aggressive prehospital interventions (PHI) in trauma may not improve outcomes compared to prioritizing rapid transport. The aim of this study was to quantify temporal changes in the frequency of PHI performed by EMS. METHODS: Retrospective chart review of adult patients transported by EMS to our trauma center from January 1, 2014 to 12/31/2021. PHI were recorded and annual changes in their frequency were assessed via year-by-year trend analysis and multivariate regression. RESULTS: Between the first and last year of the study period, the frequency of thoracostomy (6% vs. 9%, p â€‹= â€‹0.001), TXA administration (0.3% vs. 33%, p â€‹< â€‹0.001), and whole blood administration (0% vs. 20%, p â€‹< â€‹0.001) increased. Advanced airway procedures (21% vs. 12%, p â€‹< â€‹0.001) and IV fluid administration (57% vs. 36%, p â€‹< â€‹0.001) decreased. ED mortality decreased from 8% to 5% (p â€‹= â€‹0.001) over the study period. On multivariate regression, no PHI were independently associated with increased or decreased ED mortality. CONCLUSION: PHI have changed significantly over the past eight years. However, no PHI were independently associated with increased or decreased ED mortality.

Barriers to Breastfeeding During Surgery Residency.

OBJECTIVE: Breastfeeding is a highly demanding experience, especially for surgical residents who pump after returning to work. We believe that there are obstacles to pumping and opportunities exist to improve support for this group. The objective of this study was to understand the experience of breastfeeding surgery residents and find opportunities for increased support. DESIGN: Surveys were sent out through the Association of Program Directors in Surgery for distribution among current residents. A survey was also conducted in a private group of surgeon mothers to identify those who had previously been breastfeeding during residency. SETTING: All surveys were performed online with results collected in a REDCap web-based application. PARTICIPANTS: Participants were those who gave birth during their surgical residency. RESULTS: 67% of the 246 survey respondents stated that they did not have adequate time for pumping and 56% rarely had access to a lactation room. 69% of mothers reported a reduction in milk supply and 64% stated that the time constraints of residency shortened the total duration they breastfed. 59% of women did not feel comfortable asking to pump. CONCLUSIONS: Surgical residents reported a lack of space, resources, and dedicated time for pumping. These deficiencies contribute to shorter breastfeeding duration. It is crucial to provide lactation rooms and to foster a supportive culture.

Is Chest X-Ray a Reliable Screening Tool for Blunt Thoracic Aortic Injury? Results from the American Association for the Surgery of Trauma/Aortic Trauma Foundation Prospective Blunt Thoracic Aortic Injury Registry.

BACKGROUND: Traditional teaching continues to espouse the value of initial trauma chest x-ray (CXR) as a screening tool for blunt thoracic aortic injury (BTAI). The ability of this modality to yield findings that reliably correlate with grade of injury and need for subsequent treatment, however, requires additional multicenter prospective examination. We hypothesized that CXR is not a reliable screening tool, even at the highest grades of BTAI. STUDY DESIGN: The Aortic Trauma Foundation/American Association for the Surgery of Trauma prospective BTAI registry was used to correlate initial CXR findings to the Society for Vascular Surgery injury grade identified with computed tomographic angiography. RESULTS: We analyzed 708 confirmed BTAI injuries with recorded CXR findings and subsequent computed tomographic angiography injury characterization from February 2015 to August 2021. The presence of any of the classic CXR findings was observed in only 57.6% (408 of 708) of injuries, with increasing presence correlating with advanced Society for Vascular Surgery BTAI grade (39.1% [75 of 192] of grade 1; 55.6% [50 of 90] of grade 2; 65.2% [227 of 348] of grade 3; and 71.8% [56 of 78] of grade 4). The most consistent single finding identified was widened mediastinum, but this was only present in 27.7% of all confirmed BTAIs and only 47.4% of G4 injuries (7.8%% of grade 1, 23.3%, of grade 2, 35.3% of grade 3, and 47.4% of grade 4). CONCLUSIONS: CXR is not a reliable screening tool for the detection of BTAI, even at the highest grades of injury. Further investigations of specific high-risk criteria for screening that incorporate imaging, mechanism, and physiologic findings are warranted.