Association of pain catastrophizing with labor pain and analgesia consumption in obstetrical patients.

INTRODUCTION: Pain catastrophizing is an exaggerated negative orientation to painful stimuli which in obstetric patients is associated with fear of overwhelming labor pain and negative pain-related outcomes. This study aimed to quantitatively examine the association of pain catastrophizing with maternal labor pain outcomes. METHODS: We conducted a prospective observational study of women admitted for a vaginal trial of labor. Subjects completed the 13-item Pain Catastrophizing scale (PCS) questionnaire (scored 0 to 52, higher scores representing greater catastrophizing). Pain was assessed at baseline and at request for neuraxial labor analgesia. Labor and postpartum pain intensity was assessed as the average area under the pain intensity by time curve. Pain at request for analgesia, labor pain, postpartum pain, analgesic consumption, and quality of recovery was compared between high (PCS ≥ 17) and low catastrophizing groups. RESULTS: Data from 138/157 (88%) subjects were included in the analysis. Median (IQR) pain scores at request for analgesia were 9 (8,10) and 8 (6,9), a difference of 1 (95% CI 0 to 2.5, P = 0.008) in high-catastrophizing and in low-catastrophizing groups, respectively. Adjusted pain during labor, postpartum pain and opioid analgesic use were not significantly different. High-catastrophizers reported less comfort, ability to mobilize and less control during hospitalization. Post-discharge there were no differences in pain or analgesic use. CONCLUSION: We did not observe greater labor or post-delivery pain or increased analgesic use in high-catastrophizing parturients. High catastrophizers reported greater pain when requesting analgesia, which is consistent with the role of catastrophizing in intensifying the experience of pain.

A survey of United States obstetric anesthesiologists' perceived value of obstetric anesthesiology fellowship.

INTRODUCTION: Subspecialty training in obstetric anesthesiology is associated with improved patient outcomes and reduced anesthesia-related morbidity and mortality. Despite this, the demand for fellowship-trained obstetric anesthesiologists far exceeds the supply. This survey study aimed to evaluate the perceived value of obstetric anesthesiology subspecialty training on career trajectory, job satisfaction, quality of life, and job autonomy. METHODS: After Institutional Review Board approval, we conducted a cross-sectional study of fellowship-trained obstetric anesthesiologists in the United States of America. In March and April 2022, program directors of obstetric anesthesiology fellowships distributed an electronic survey link containing 29 multiple-choice questions to their program alumni. Survey content included respondent demographic characteristics, practice models, career information, and perceived value of an obstetric anesthesiology fellowship. RESULTS: We surveyed 217/502 (43%) fellowship-trained obstetric anesthesiologists with a response rate of 158/217 (73%). Most worked in urban, academic, and level IV perinatal health centers. The majority believed an obstetric anesthesiology fellowship was "extremely beneficial" (77%), enhanced quality of life (84%), improved the quality of patient care (99%), and was influential in helping obtain their first post-training job (86%). The perceived value of the fellowship included an enhanced career trajectory, a sense of purpose, improved job satisfaction, a sense of work community, lower burnout, involvement in maternal health initiatives, increased mentorship, and departmental leadership. CONCLUSION: In this survey study, fellowship-trained obstetric anesthesiologists perceived a positive impact of fellowship training on career trajectory, job protection and autonomy, quality of life, and job satisfaction. This information may be meaningful to trainees considering pursuing a fellowship and a career in obstetric anesthesiology.

Critical limb ischaemia in the time of COVID-19: establishing ambulatory service provision.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic enforced changes to healthcare services at a pace and extent not seen previously in the NHS. The Royal Devon and Exeter provides regional vascular surgery services. A consultant-led urgent 'hot clinic' was established, providing patients with ambulatory care. We aim to describe the service for critical limb ischaemia (CLI) before and during the COVID-19 pandemic, and evaluate this against recommended best practice. METHODS: Retrospective review of electronic databases and records of patients with CLI during a non-COVID vs COVID-19 period. Primary outcome measures were those established by guidance from the Vascular Society of Great Britain and Ireland. RESULTS: Non-COVID vs COVID-19: total patients n=97 vs 96, of which CLI patients n=29 vs 21. Median length of stay 15 vs 0 days (p<0.001); median time from referral to specialist review 0 vs 3 days (p<0.001); multidisciplinary team meeting (MDT) recorded 3% vs 29%; median time to intervention 6 vs 8 days; conservative management 52% vs 67%; endovascular 28% vs 10%; open surgery 21% vs 24%; 30-day survival 79% vs 76%. CONCLUSION: COVID-19 imposed a major change to the service for patients with CLI with a focus on ambulatory care pathways for diagnosis and intervention. We observe a significant reduction in overall length of stay with no clinically significant change in time to consultant review, time to imaging, overall management strategy or outcomes. The results of this study show that patients with CLI can be managed safely and effectively on an ambulatory basis in accordance with established best practice.

An exploration of the impact of SARS-CoV-2 (COVID-19) restrictions on marginalised groups in the UK.

BACKGROUND: To contain the spread of COVID-19 within the UK over the past year, there have been a series of local and national lockdowns. These restrictions are likely to have impacted upon the health and well-being of marginalised groups who rely on now closed social and community support services to stay healthy. An understanding of the experiences of marginalised people is important; therefore, this study aimed to explore the impact of the COVID-19 restrictions on the health and well-being of marginalised groups in the UK. METHODS: In summer 2020, a rapid telephone survey was conducted by trained, trusted volunteers with 76 participants who were from marginalised groups. As part of this survey, 64 participants consented to describe their experience of lockdown. These case studies were thematically analysed to identify patterns of meaning. RESULTS: Findings indicate that lockdown led to the deterioration of health of participants, impacted adversely on their socio-economic positions and affected access to food and essential supplies. In addition, government public health messaging was considered confusing and inadequate. CONCLUSIONS: This study highlights the need for pathways into services which support marginalised groups to remain accessible during periods of restrictions and essential supplies and food to be mapped and protected for marginalised individuals within our local communities.

Hockey: a pain in the butt! Isolated superior gluteal artery rupture following blunt pelvic trauma - an unusual case.

Superior gluteal artery rupture is a rare complication of trauma but a significant one with potential for substantial morbidity and mortality. This case demonstrates the importance of early diagnosis and treatment of this injury pattern. Endovascular embolisation has become the most effective treatment for pelvic haemorrhage. Acknowledgement of this rare injury as a differential diagnosis is vital to facilitate rapid diagnosis and appropriate treatment.

Underwater channel estimation exploiting multipath feature morphology.

Real-time accurate channel estimation has been an ongoing challenge because of diverse oceanic events that cause rapid fluctuations of high-energy multipath activity across the delay spread. This work leverages current compressed sensing and sparse optimization techniques with topological signal processing to improve estimation time and localize channel estimation to salient parts of the delay spread. This work improves the estimation time by tracking the channel as a union of overlapping multipath and other scattering events, which are modeled as "feature braids" in the delay-time domain. A channel feature braid may be intuitively visualized as the topologically connected trajectory of a group of channel delay taps, which represent the support of dominant or persistent scattering events, e.g., surface bounce multipath scattering. We present algorithms that harness support-constrained mixed norm optimization techniques to track the evolving support of channel feature braids. We validate our channel feature tracking algorithm independently in experimental field data as well as BELLHOP channel simulations across a diversity of oceanic conditions. This work shows that braiding used in estimation can improve estimation time and track high-energy events that develop within the delay vs time channel representation.

Effect of companion presence on maternal satisfaction during neuraxial catheter placement for labor analgesia: a randomized clinical trial.

BACKGROUND: Neuraxial labor analgesia is frequently achieved after placing an epidural catheter under sterile conditions. There is no consensus on the risk versus benefit of allowing a parturient's companion to remain during the procedure. We sought to assess the effect of the presence of a companion on maternal satisfaction and anxiety during neuraxial catheter placement for labor analgesia. METHODS: Healthy nulliparous parturients planning to receive neuraxial labor analgesia after admission to labor, and who had a companion with them at the time of interview, were randomized to having a companion present or not present in the labor and delivery room during neuraxial catheter placement. Participants completed questionnaires to assess maternal anxiety, pain catastrophizing and health literacy. Satisfaction was scored on 5-point Likert scale (1- highly dissatisfied, 2- dissatisfied, 3- neutral, 4- satisfied, 5- highly satisfied). RESULTS: A total of 143 participants completed the study. The Wilcoxon-Mann-Whitney odds ratio for a random pair of satisfaction scores for a woman with her companion present compared with companion not present was 1.93 (95% CI 1.30 to 2.81, P=0.001). Anxiety scores were decreased following the procedure (P=0.39) in both groups. Eighty-nine percent of women randomized to companion not present would have preferred to have a companion present (P <0.001) compared with only one with their companion present who would have preferred her companion to be not present (P=0.99). CONCLUSION: Maternal satisfaction can be improved with the presence of a companion in the labor and delivery room at the time of neuraxial catheter placement for labor analgesia.

Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study.

BACKGROUND: Consensus regarding the safest mode of delivery and anesthetic management for parturients with Arnold Chiari malformation-I (ACM-I) remains controversial. This study assessed their anesthetic management and reported anesthetic complications during hospitalization for delivery. METHODS: This was a multicenter, retrospective, cohort study of patients with ACM-I undergoing vaginal or cesarean delivery. Data were obtained from the electronic databases of four United States academic institutions using International Classification of Diseases (ICD) codes from 2007-2017 at three sites and 2004-2017 at one site. The primary outcome was anesthetic complications. RESULTS: Data were analyzed for 185 deliveries in 148 patients. Diagnosis of ACM-I was made prior to delivery in 147 (80%) cases. Pre-delivery neurosurgical consultation for management of ACM-I was performed in 53 (36%) patients. Pre-existing symptoms were recorded for 89 (48%) of the deliveries. Vaginal deliveries occurred in 80 (43%) cases, and 62 women (78%) received neuraxial labor analgesia. Cesarean delivery was performed in 105 (57%) cases, of which 70 women (67%) had neuraxial anesthesia and 34 (32%) received general anesthesia. Post-dural puncture headache was reported in three (2%) patients who had neuraxial anesthesia, and in two (12%) patients with syringomyelia. There was one (3%) reported case of aspiration pneumonia with general anesthesia. CONCLUSIONS: The findings suggest that anesthetic complications occur infrequently in patients with ACM-I regardless of the anesthetic management. Although institutional preference in anesthetic and obstetric care appears to drive patient management, the findings suggest that an individualized approach has favorable outcomes in this population.

Prophylactic mesh used in ileal conduit formation following radical cystectomy: a retrospective cohort.

PURPOSE: Given the difficulty of durable repairs, there is continued interest in hernia prevention. One emerging prevention technique for parastomal hernias is prophylactic mesh placement, whereby mesh is inserted during the index procedure as hernia prophylaxis. We evaluated our experience using prophylactic mesh when creating an ileal conduit. METHODS: We retrospectively reviewed patients undergoing robotic cystectomy with ileal conduit from 6/2010 to 8/2017. Patient demographics and operative/perioperative outcomes were documented. We evaluated hernia recurrence using postoperative computed tomography scanning or physical exam. Prophylactic mesh was inserted at the operating surgeon's discretion using a synthetic resorbable or biologic mesh. RESULTS: During the study period, 38 patients underwent robotic-assisted cystectomy with ileal conduit formation. Average patient age was 68 years, with 28 (74%) male and 35 (92%) Caucasian patients. Three patients (8%) required conversion to open, and one patient (3%) had a concomitant colorectal resection. Thirty-one (88%) patients had postoperative computed tomography scanning. Prophylactic mesh was used in 18 patients (47%) in a retrorectus position. Of these, 15 (83%) patients had synthetic resorbable mesh and 3 (17%) patients had biologic mesh. At average follow-up of 21 months, one hernia recurred (5%) in a patient without mesh placement at the time of ileal conduit. At an average follow-up of 11 months, there have been no recurrences and no mesh-related complications in the prophylactic mesh group. CONCLUSIONS: Using prophylactic mesh in ileal conduit, creation is feasible and may decrease the parastomal hernia formation rate. Further study of using synthetic resorbable and biologic meshes for hernia prophylaxis is warranted.

Language abnormality in deaf people with schizophrenia: a problem with classifiers.

INTRODUCTION: Although there is evidence for language abnormality in schizophrenia, few studies have examined sign language in deaf patients with the disorder. This is of potential interest because a hallmark of sign languages is their use of classifiers (semantic or entity classifiers), a reference-tracking device with few if any parallels in spoken languages. This study aimed to examine classifier production and comprehension in deaf signing adults with schizophrenia. METHOD: Fourteen profoundly deaf signing adults with schizophrenia and 35 age- and IQ-matched deaf healthy controls completed a battery of tests assessing classifier and noun comprehension and production. RESULTS: The patients showed poorer performance than the healthy controls on comprehension and production of both nouns and entity classifiers, with the deficit being most marked in the production of classifiers. Classifier production errors affected handshape rather than other parameters such as movement and location. CONCLUSIONS: The findings suggest that schizophrenia affects language production in deaf patients with schizophrenia in a unique way not seen in hearing patients.

Neuraxial labor analgesia is not an independent predictor of perineal lacerations after vaginal delivery of patients with intrauterine fetal demise.

INTRODUCTION: The role of neuraxial labor analgesia in perineal trauma following live births is controversial, and no studies have assessed the association in women delivering an intrauterine fetal demise. We evaluated the relationship between neuraxial labor analgesia and perineal laceration in these patients. METHODS: This was a retrospective case-control study of women with a diagnosis of fetal death after 20weeks of gestation, a vaginal delivery, and an Apgar score of 0 at delivery, during the period from January 2007 through December 2015. The presence of a perineal laceration and its severity, graded from grade I to IV based on the 2014 American College of Obstetricians and Gynecologists guidelines, was recorded. RESULTS: A total of 329/422 (78%) patients received neuraxial, and 93/422 (22%) non-neuraxial, labor analgesia. A perineal laceration occurred in 23% in the neuraxial versus 10% in the non-neuraxial analgesia group, a difference of 13% (95% CI of difference 4% to 20%, P=0.005). After adjusting for confounder bias, greater birthweight (OR 4.22, 95% CI 3.00 to 5.92, P<0.001) and lower parity (OR 0.44, 95% CI 0.24 to 0.82, P=0.009), but not neuraxial analgesia (OR 1.29, 95% CI 0.47 to 3.57, P=0.61) were independent predictors of perineal laceration. The maintenance concentration of bupivacaine did not affect the rate of perineal injury. CONCLUSIONS: Neuraxial labor analgesia does not appear to be an independent risk for a perineal laceration in patients with intrauterine fetal demise. Our data suggests that the use of neuraxial analgesia should not raise concern about increased rates of perineal injury.

Factors influencing the choice of treatment modality for individual patients with varicose veins.

INTRODUCTION There is evidence of effectiveness for a range of different treatment modalities for varicose veins but limited information about factors that influence treatment choice for individual patients. METHODS A postal survey was sent to 438 UK members of the Vascular Society of Great Britain and Ireland. RESULTS Overall, 251 responses were received (response rate 57%). A total of 222 respondents treated varicose veins using conventional surgery (84%), endothermal ablation (82%) and foam sclerotherapy (68%). The clinical pattern of veins appeared to have the greatest influence on treatment choice. This was followed by guidance from the National Institute for Health and Care Excellence, patient expectations, facilities, cost and whether treatment was carried out in the public or private sector. Respondents were asked to indicate whether each of 13 clinical 'scenarios' (eg very extensive varicose veins in both legs) would influence them towards or against using specified treatment modalities. 'Consensus' was defined as ≥80% of responses either towards or against any treatment modality; and disagreement as 41-59% both towards and against any modality (i.e. ∼50:50 split). There was consensus towards using endothermal ablation for truncal reflux, towards UGFS for localised varicose veins and towards conventional surgery for large, extensive, bilateral veins. There was consensus against UGFS for large truncal veins, and against surgery for obese patients and those with a history of venous thromboembolism. There were important disagreements about the influence of large or extensive veins, about whether patients were obese or slim and about a prior history of venous thromboembolism. CONCLUSIONS Conventional surgery is still widely available in the UK. Disagreements about treatment choice in different clinical scenarios suggest substantial variation in the treatments patients are offered. Attention to identifying subgroups in trials would help to guide treatment choice for individual patients.

TRIM28 interacts with EZH2 and SWI/SNF to activate genes that promote mammosphere formation.

Histone methyl transferase EZH2 (Enhancer of Zeste Homolog 2) is generally associated with H3K27 methylation and gene silencing, as a member of the polycomb repressor 2 (PRC2) complex. Immunoprecipitation and mass spectrometry of the EZH2-protein interactome in estrogen receptor positive, breast cancer-derived MCF7 cells revealed EZH2 interactions with subunits of chromatin remodeler SWI/SNF complex and TRIM28, which formed a complex with EZH2 distinct from PRC2. Unexpectedly, transcriptome profiling showed that EZH2 primarily activates, rather than represses, transcription in MCF7 cells and with TRIM28 co-regulates a set of genes associated with stem cell maintenance and poor survival of breast cancer patients. TRIM28 depletion repressed EZH2 recruitment to chromatin and expression of this gene set, in parallel with decreased CD44hi/CD24lo mammosphere formation. Mammosphere formation, inhibited by EZH2 depletion, was rescued by ectopic expression of EZH2 but not by TRIM28 expression or by EZH2 mutated at the region (pre-SET domain) of TRIM28 interaction. These results support PRC2-independent functions of EZH2 and TRIM28 in activation of gene expression that promotes mammary stem cell enrichment and maintenance.

Segmental spinal dysgenesis: a report of early surgical intervention and outcome in a 14-month-old child.

Segmental spinal dysgenesis is a rare spinal deformity that is the result of failure of formation resulting in some cases spondyloptosis and neurological dysfunction usually at the thoracolumbar junction. There is little known concerning surgical intervention and timing in these patients. The goal of this case report is to present a case involving 14 months old diagnosed with segmental spinal dysgenesis with stenosis at the thoracolumbar junction soon after birth, treated with definitive posterior spinal fusion and subsequent follow-up.

Standardised versus Individualised Parenteral Nutrition. Further Food for Thought.

Parenteral Nutrition may be prescribed as a standard PN (SPN) formulation or as an individualised PN (IPN) formulation. SPN may have advantages in terms of rapid availability, less prescription errors, decreased risk of infection and cost savings but IPN, specifically tailored to an infants needs, may achieve better outcomes in terms of nutrient intake and weight gain. The aim of our study was to determine if VLBW infants in our NICU benefited from receiving IPN over currently available SPN solutions. Our findings were that VLBW infants prescribed IPN received significantly more amino acid (28%), glucose (6%), energy (11%) and calcium (8%) from the aqueous phase of PN than had they received a similar volume of SPN. The benefits were seen over all the days for which PN was administered. In conclusion, IPN was found to offer significant benefits to our VLBW infants. Modifications to currently available SPN would result in better SPN formulations. Our study also supported the recent recommendation to reduce the calcium:phosphate ratio in PN solutions to avoid early hypophosphataemia.