Development and deployment of tools for rapid response notification of Monkeypox exposure, exposure risk assessment and stratification, and symptom monitoring.

OBJECTIVES: Public health authorities recommend symptom monitoring of healthcare personnel (HCP) after defined exposures to monkeypox. We report on the rapid development and implementation of mobile responsive survey solutions for notification of possible exposure, exposure risk assessment and stratification, and symptom monitoring. SETTING: An academic health center in Boston, Massachusetts, after admission of first diagnosed case of monkeypox in the United States during the current global outbreak. PARTICIPANTS: Research Electronic Data Capture (REDCap) design and programmers, infection control, occupational health, and emergency preparedness specialists, and HCP with possible exposure to monkeypox. INTERVENTIONS: Design and deployment of REDCap tools to identify HCP with possible exposure to monkeypox, to perform exposure risk assessment and stratification for postexposure prophylaxis (PEP), and to conduct symptom monitoring during the exposure window. Project enhancements included dashboards for HCP tracking and short message service (SMS text) reminders for symptom monitoring. RESULTS: Tools to support the contact tracing and exposure investigation were deployed within 24 hours of identification of a patient with suspected monkeypox, with the full suite in production within 4 days of confirmation of the monkeypox diagnosis. Clinical follow-up of HCP was integrated into the design, and real-time versioning allowed for improvements in HCP symptom monitoring compliance and enhanced tracking. CONCLUSIONS: During the current monkeypox outbreak, timely and comprehensive evaluation of potential HCP exposures is necessary but presents logistical challenges. Rapid development of monkeypox-specific solutions using REDCap facilitated flexibility in design and approach, and integration of targeted clinical support enhanced functionality.

Renal artery Doppler studies in the assessment of monochorionic, diamniotic twin pregnancies with and without twin-twin transfusion syndrome.

BACKGROUND: In monochorionic, diamniotic twin pregnancies complicated by twin-twin transfusion syndrome, imbalanced fetofetal blood shunting and discordant activation of the renin-angiotensin system result in a hypovolemic, oliguric donor twin and a hypervolemic, polyuric recipient twin. Renal artery Doppler assessments have been reported to predict oligohydramnios in singleton pregnancies; however, their value in assessing monochorionic, diamniotic twin gestations, including pregnancies complicated by twin-twin transfusion syndrome, remains unstudied. OBJECTIVE: This investigation evaluated whether renal artery Doppler parameters are different between sets of monochorionic, diamniotic twins with and without twin-twin transfusion syndrome. STUDY DESIGN: We conducted a prospective study of women with monochorionic, diamniotic twin pregnancies complicated by twin-twin transfusion syndrome and women with gestational-age matched monochorionic, diamniotic twin control pregnancies without twin-twin transfusion syndrome. For each twin, renal artery Doppler assessment was performed from a coronal view of the fetus, and pulsatility index, resistive index, and peak systolic velocity were measured. In twin pairs complicated by twin-twin transfusion syndrome, renal artery Doppler pulsatility index, resistive index, and peak systolic velocity intertwin ratios were calculated by comparing paired recipient-to-donor values. Similar ratios were calculated for control twin pairs. We compared each measurement between donors and controls and between recipients and controls. Intertwin ratios were compared between twin-twin transfusion syndrome cases and monochorionic, diamniotic controls. Our primary outcome was a comparison of renal artery Doppler pulsatility index measurement between donor fetuses in twin-twin transfusion syndrome cases and matched control twins. Secondary outcomes included comparisons of other renal artery Doppler parameters between twin-twin transfusion syndrome donor twins and controls and between twin-twin transfusion syndrome recipients and controls and comparisons of the renal artery Doppler parameter ratios between twin-twin transfusion syndrome and non-twin-twin transfusion syndrome twin pair groups. Finally, we performed a subgroup analysis involving pregnancies with twin-twin transfusion syndrome that underwent fetoscopic laser therapy and resulted in twin survivors to evaluate if laser therapy influenced renal artery Doppler findings. RESULTS: We recruited 12 donors and 12 controls. Renal artery Doppler pulsatility index and resistive index did not differ between donors and controls. However, donor renal artery Doppler peak systolic velocity (median, 14.24 [11.51-15.36]) was significantly lower than that of controls (median, 24.79 [22.46-27.03]; P<.0004). When recipient twins were compared with controls, there was no difference in renal artery Doppler pulsatility index, renal artery Doppler resistive index, or renal artery Doppler peak systolic velocity. Renal artery Doppler peak systolic velocity ratios were significantly higher among cases with twin-twin transfusion syndrome (median, 1.70 [1.53-2.02]) than controls (median, 1.06 [1.03-1.15]; P=.002). Applying a renal artery Doppler peak systolic velocity ratio cutoff of >1.35 for the diagnosis of twin-twin transfusion syndrome correctly classified 11 of 12 cases with twin-twin transfusion syndrome and all 12 controls without twin-twin transfusion syndrome (92% sensitivity and 100% specificity). Among donors with twin-twin transfusion syndrome with double survivors after undergoing laser therapy (n=4), prelaser renal artery Doppler peak systolic velocity ratios (mean, 1.46; standard deviation, 0.37) were significantly higher than postlaser renal artery Doppler peak systolic velocity ratios (mean, 0.87; standard deviation=0.37; P=.02). Postlaser intertwin renal artery Doppler peak systolic velocity ratios did not differ from control twin pairs (P=.125). CONCLUSION: Renal artery Doppler peak systolic velocity ratios differ between monochorionic, diamniotic twins with twin-twin transfusion syndrome and those without twin-twin transfusion syndrome. This effect seems to be driven by altered donor twin renal artery Doppler peak systolic velocity. Laser therapy may normalize renal artery Doppler peak systolic velocity ratios and donor twin renal artery Doppler values to those observed in monochorionic, diamniotic twins without twin-twin transfusion syndrome. Further study is warranted to explore whether renal artery Doppler peak systolic velocity has utility as a tool for twin-twin transfusion syndrome prediction, diagnosis, or staging, and fetal response to laser therapy.

Adaptation of prenatal care and ultrasound.

In the spring of 2020, expeditious changes to obstetric care were required in New York as cases of COVID-19 increased and pandemic panic ensued. A reduction of in-person office visits was planned with provider appointments scheduled to coincide with routine maternal blood tests and obstetric ultrasounds. Dating scans were combined with nuchal translucency assessments to reduce outpatient ultrasound visits. Telehealth was quickly adopted for selected prenatal visits and consultations when deemed appropriate. The more sensitive cell-free fetal DNA test was commonly used to screen for aneuploidy in an effort to decrease return visits for diagnostic genetic procedures. Antenatal testing guidelines were modified with a focus on providing evidence-based testing for maternal and fetal conditions. For complex pregnancies, fetal interventions were undertaken earlier to avoid serial surveillance and repeated in-person hospital visits. These rapid adaptations to traditional prenatal care were designed to decrease the risk of coronavirus exposure of patients, staff, and physicians while continuing to provide safe and comprehensive obstetric care.

Telehealth Uptake into Prenatal Care and Provider Attitudes during the COVID-19 Pandemic in New York City: A Quantitative and Qualitative Analysis.

OBJECTIVE: This study aimed to (1) determine to what degree prenatal care was able to be transitioned to telehealth at prenatal practices associated with two affiliated hospitals in New York City during the novel coronavirus disease 2019 (COVID-19) pandemic and (2) describe providers' experience with this transition. STUDY DESIGN: Trends in whether prenatal care visits were conducted in-person or via telehealth were analyzed by week for a 5-week period from March 9 to April 12 at Columbia University Irving Medical Center (CUIMC)-affiliated prenatal practices in New York City during the COVID-19 pandemic. Visits were analyzed for maternal-fetal medicine (MFM) and general obstetrical faculty practices, as well as a clinic system serving patients with public insurance. The proportion of visits that were telehealth was analyzed by visit type by week. A survey and semistructured interviews of providers were conducted evaluating resources and obstacles in the uptake of telehealth. RESULTS: During the study period, there were 4,248 visits, of which approximately one-third were performed by telehealth (n = 1,352, 31.8%). By the fifth week, 56.1% of generalist visits, 61.5% of MFM visits, and 41.5% of clinic visits were performed via telehealth. A total of 36 providers completed the survey and 11 were interviewed. Accessing technology and performing visits, documentation, and follow-up using the telehealth electronic medical record were all viewed favorably by providers. In transitioning to telehealth, operational challenges were more significant for health clinics than for MFM and generalist faculty practices with patients receiving public insurance experiencing greater difficulties and barriers to care. Additional resources on the patient and operational level were required to optimize attendance at in-person and video visits for clinic patients. CONCLUSION: Telehealth was rapidly implemented in the setting of the COVID-19 pandemic and was viewed favorably by providers. Limited barriers to care were observed for practices serving patients with commercial insurance. However, to optimize access for patients with Medicaid, additional patient-level and operational supports were required. KEY POINTS: · Telehealth uptake differed based on insurance.. · Medicaid patients may require increased assistance for telehealth.. · Quick adoption of telehealth is feasible..

ACR Appropriateness Criteria® Assessment of Gravid Cervix.

Preterm birth remains the leading cause of perinatal morbidity and mortality. Although the greatest risk factor for preterm birth is a history of prior preterm birth, a short cervical length (≤25 mm) before 24 weeks' gestational age is also associated with increased risk of spontaneous preterm delivery. As such, cervical length assessment has become of particular interest in predicting those patients at risk for preterm birth. Other clinical scenarios (eg, preterm labor, induction of labor, and active labor) may arise, in which assessment of the cervix may be of interest. Ultrasound is the mainstay imaging modality for assessing the gravid cervix, with transvaginal ultrasound recommended in patients at high risk for preterm birth or suspected preterm labor. Transperineal ultrasound is an alternate approach in those cases where transvaginal ultrasound in contraindicated. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Telehealth for High-Risk Pregnancies in the Setting of the COVID-19 Pandemic.

As New York City became an international epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic, telehealth was rapidly integrated into prenatal care at Columbia University Irving Medical Center, an academic hospital system in Manhattan. Goals of implementation were to consolidate in-person prenatal screening, surveillance, and examinations into fewer in-person visits while maintaining patient access to ongoing antenatal care and subspecialty consultations via telehealth virtual visits. The rationale for this change was to minimize patient travel and thus risk for COVID-19 exposure. Because a large portion of obstetric patients had underlying medical or fetal conditions placing them at increased risk for adverse outcomes, prenatal care telehealth regimens were tailored for increased surveillance and/or counseling. Based on the incorporation of telehealth into prenatal care for high-risk patients, specific recommendations are made for the following conditions, clinical scenarios, and services: (1) hypertensive disorders of pregnancy including preeclampsia, gestational hypertension, and chronic hypertension; (2) pregestational and gestational diabetes mellitus; (3) maternal cardiovascular disease; (4) maternal neurologic conditions; (5) history of preterm birth and poor obstetrical history including prior stillbirth; (6) fetal conditions such as intrauterine growth restriction, congenital anomalies, and multiple gestations including monochorionic placentation; (7) genetic counseling; (8) mental health services; (9) obstetric anesthesia consultations; and (10) postpartum care. While telehealth virtual visits do not fully replace in-person encounters during prenatal care, they do offer a means of reducing potential patient and provider exposure to COVID-19 while providing consolidated in-person testing and services. KEY POINTS: · Telehealth for prenatal care is feasible.. · Telehealth may reduce coronavirus exposure during prenatal care.. · Telehealth should be tailored for high risk prenatal patients..

Obstetric and Gynecologic Ultrasound Curriculum and Competency Assessment in Residency Training Programs: Consensus Report.

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus-based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the task force expects that the criteria set forth in this document will evolve with time. The task force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency assessment process. Incorporating this training curriculum and the competency assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.

Obstetric and gynecologic ultrasound curriculum and competency assessment in residency training programs: consensus report.

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus-based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the task force expects that the criteria set forth in this document will evolve with time. The task force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency assessment process. Incorporating this training curriculum and the competency assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.

ACR Appropriateness Criteria Assessment of Fetal Well-Being.

Although there is limited evidence that antepartum testing decreases the risk for fetal death in low-risk pregnancies, women with high-risk factors for stillbirth should undergo antenatal fetal surveillance. The strongest evidence supporting antepartum testing pertains to pregnancies complicated by intrauterine fetal growth restriction secondary to uteroplacental insufficiency. The main ultrasound-based modalities to determine fetal health are the biophysical profile, modified biophysical profile, and duplex Doppler velocimetry. In patients at risk for cardiovascular compromise, fetal echocardiography may also be indicated to ensure fetal well-being. Although no single antenatal test has been shown to be superior, all have high negative predictive values. Weekly or twice-weekly fetal testing has become the standard practice in high-risk pregnancies. The timing for the initiation of assessments of fetal well-being should be tailored on the basis of the risk for stillbirth and the likelihood of survival with intervention. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.