Thirty-Day Outcomes after Elective Percutaneous or Open Endovascular Repair of Abdominal Aortic Aneurysms.

BACKGROUND: Percutaneous endovascular aneurysm repair (PEVAR) has become accepted as a suitable alternative to open EVAR (OEVAR) in the treatment of abdominal aortic aneurysms (AAAs). Direct comparisons between the 2 techniques have been infrequently reported and have predominantly focused on immediate procedural outcomes. The objective of this study was to compare contemporary 30-day postoperative outcomes between successfully completed elective PEVAR and OEVAR. METHODS: The 2012 National Surgical Quality Improvement Program database was queried for all elective primary AAA repairs. Procedures on ruptured AAAs and those involving adjunctive thoracic, abdominal, or extremity procedures were excluded. Cases completed with at least one surgical exposure of the femoral artery for access (OPEN) were compared with those completed without such exposure (PERC). Preoperative, intraoperative, and 30-day postoperative variables were compared using appropriate univariate statistical tests. A P value of ≤0.05 was considered significant for all comparisons. RESULTS: A total of 1,589 (51%) OPEN and 1,533 (49%) PERC cases met inclusion and exclusion criteria. Preoperative characteristics did not differ between groups. OPEN cases took significantly longer (150 ± 69 min) than PERC cases (134 ± 65 min, P < 0.001). No significant differences were found between the groups in any postoperative occurrence, but the rate of venous thromboembolism twice as high in OPEN (16, 1.0%) than PERC cases (7, 0.5%, P = 0.07). In addition, wound complications (36, 2.3% OPEN vs. 23, 1.3% PERC, P = 0.11) were more common in OPEN cases but were diagnosed a week sooner on average in PERC cases (19 days OPEN and 12 days PERC). Median postoperative length of stay was 2 days among OPEN cases versus 1 day in PERC cases (P = 0.11). Female gender and obesity predicted wound complications in the OPEN group but not in the PERC group. CONCLUSIONS: Successfully completed PEVAR and OEVAR have similar rates of overall complications. Female gender and obesity predict wound complications in OEVAR but not in PEVAR, which appears to be a safe alternative to OEVAR. PEVAR has the advantage of shorter operative time and the potential for a shorter postoperative stay, and may offer the advantage of fewer wound complications in females and obese patients.

Development of a capillary electrophoresis-based heteroduplex tracking assay to measure in-host genetic diversity of initial and recurrent Plasmodium vivax infections in Cambodia.

A heteroduplex tracking assay used to genotype Plasmodium vivax merozoite surface protein 1 was adapted to a capillary electrophoresis format, obviating the need for radiolabeled probes and allowing its use in settings where malaria is endemic. This new assay achieved good allelic discrimination and detected high multiplicities of infection in 63 P. vivax infections in Cambodia. More than half of the recurrent parasitemias sampled displayed identical or highly related genotypes compared to the initial genotype, suggesting that they represented relapses.

Clinical Update on Uses for Mifepristone in Obstetrics and Gynecology.

Importance: Mifepristone (RU-486) is a selective progesterone receptor modulator that has antagonist properties on the uterus and cervix. Mifepristone is an effective abortifacient, prompting limitations on its use in many countries. Mifepristone has many uses outside of induced abortion, but these are less well known and underutilized by clinicians because of challenges in accessing and prescribing this medication. Objectives: To provide clinicians with a history of the development of mifepristone and mechanism of action and safety profile, as well as detail current research on uses of mifepristone in both obstetrics and gynecology. Evidence Acquisition: A PubMed search of mifepristone and gynecologic and obstetric conditions was conducted between January 2018 and December 2021. Other resources were also searched, including guidelines from the American College of Obstetricians and Gynecologists and the Society of Family Planning. Results: Mifepristone is approved by the Food and Drug Administration for first-trimester medication abortion but has other off-label uses in both obstetrics and gynecology. Obstetric uses that have been investigated include management of early pregnancy loss, intrauterine fetal demise, treatment of ectopic pregnancy, and labor induction. Gynecologic uses that have been investigated include contraception, treatment of abnormal uterine bleeding, and as an adjunct in treatment of gynecologic cancers. Conclusions and Relevance: Mifepristone is a safe and effective medication both for its approved use in first-trimester medication abortion and other off-label uses. Because of its primary use as an abortifacient, mifepristone is underutilized by clinicians. Providers should consider mifepristone for other indications as clinically appropriate.

Considerations and Recommendations for Pregnancy and Postpartum Care for People Living With Human Immunodeficiency Virus.

Considerable strides have been made in reducing the rate of perinatal human immunodeficiency virus (HIV) transmission within the United States and around the globe. Despite this progress, preventable perinatal HIV transmission continues to occur. Adherence to HIV screening and treatment recommendations preconception and during pregnancy can greatly reduce the risk of perinatal HIV transmission. Early and consistent usage of highly active antiretroviral therapy (ART) can greatly lower the HIV viral load, thus minimizing HIV transmission risk. Additional intrapartum interventions can further reduce the risk of HIV transmission. Although the current standard is to recommend abstinence from breastfeeding for individuals living with HIV in settings where there is safe access to breast milk alternatives (such as in the United States), there is guidance available on counseling and risk-reduction strategies for individuals on ART with an undetectable viral load who elect to breastfeed.

Preterm birth among pregnant women living in areas with high social vulnerability.

BACKGROUND: Communities and individuals widely vary in their resources and ability to respond to external stressors and insults. To identify vulnerable communities, the Centers for Disease Control and Prevention developed the Social Vulnerability Index, an integrated tool to assess community resources and preparedness; it is based on 15 factors and includes individual scores in the following 4 themes: socioeconomic status (theme 1), household composition and disability (theme 2), minority status and language (theme 3), and housing type and transportation (theme 4) and an overall composite score. Several Social Vulnerability Index components have been independently associated with an increased risk of preterm birth. OBJECTIVE: We sought to investigate the association of the Social Vulnerability Index for each patient's residence during pregnancy, personal clinical risk factors, and preterm birth. STUDY DESIGN: This was a retrospective cohort study of women carrying nonanomalous singleton or twin gestations delivering at a large university health system from April 2014 to January 2020. Women at high risk of spontaneous and medically indicated preterm birth were assigned to a census tract based on their geocoded home address, and a Social Vulnerability Index score was assigned to each individual by linking each patient's home address at the census tract level. Higher scores indicate greater social vulnerability. The primary outcome was preterm birth at <37 weeks' gestation; secondary outcomes were preterm birth at <34 and <28 weeks' gestation and composite major neonatal morbidity before initial hospital discharge (death, intraventricular leukomalacia or intraventricular hemorrhage, necrotizing enterocolitis, or bronchopulmonary dysplasia). Data were analyzed using the chi-square test, t test, and backward stepwise logistic regression. In addition, because race is a social construct, we conducted regression models omitting Black race. For all regression models, independent variables with a P value of <.20 remained in the final models. RESULTS: Overall, 15,364 women met the inclusion criteria, of which 18.5%, 6.5%, 2.1% of women delivered at <37, <34, and <28 weeks' gestation, respectively, and 3.1% of neonates were diagnosed with major composite morbidity. Women delivering before term at <37, <34, and <28 weeks' gestation were more likely to live in an area with a higher overall Social Vulnerability Index and higher social vulnerability in each Social Vulnerability Index theme. In regression models, the adjusted odds ratio of preterm birth increased with increasing Social Vulnerability Index scores (across all themes and the composite value); these effects were the greatest at the earliest gestational ages (eg, for the composite Social Vulnerability Index: adjusted odds ratio of preterm birth at <37 weeks' gestation for models, including Black race, 1.32 [95% confidence interval, 1.14-1.53]; adjusted odds ratio at <34 weeks' gestation, 1.60 [95% confidence interval, 1.27-2.01]; adjusted odds ratio at <28 weeks' gestation, 2.21 [95% confidence interval, 1.50-3.25]; adjusted odds ratio for composite major neonatal morbidity, 2.30 [95% confidence interval, 1.67-3.17]). Similar trends were seen for each Social Vulnerability Index theme. In addition, an increased adjusted odds ratio of composite major neonatal morbidity was recognized for each Social Vulnerability Index theme. Results were similar when Black race was removed from the models. CONCLUSION: The Social Vulnerability Index is a valuable tool that may further identify communities and individuals at the highest risk of preterm birth and may enable clinicians to integrate information regarding the local home environment of their patients to further refine preterm birth risk assessment.

Exposure to toxic metals and per- and polyfluoroalkyl substances and the risk of preeclampsia and preterm birth in the United States: a review.

Preeclampsia and preterm birth are among the most common pregnancy complications and are the leading causes of maternal and fetal morbidity and mortality in the United States. Adverse pregnancy outcomes are multifactorial in nature and increasing evidence suggests that the pathophysiology behind preterm birth and preeclampsia may be similar-specifically, both of these disorders may involve abnormalities in placental vasculature. A growing body of literature supports that exposure to environmental contaminants in the air, water, soil, and consumer and household products serves as a key factor influencing the development of adverse pregnancy outcomes. In pregnant women, toxic metals have been detected in urine, peripheral blood, nail clippings, and amniotic fluid. The placenta serves as a "gatekeeper" between maternal and fetal exposures, because it can reduce or enhance fetal exposure to various toxicants. Proposed mechanisms underlying toxicant-mediated damage include disrupted placental vasculogenesis, an up-regulated proinflammatory state, oxidative stressors contributing to prostaglandin production and consequent cervical ripening, uterine contractions, and ruptured membranes and epigenetic changes that contribute to disrupted regulation of endocrine and immune system signaling. The objective of this review is to provide an overview of studies examining the relationships between environmental contaminants in the US setting, specifically inorganic (eg, cadmium, arsenic, lead, and mercury) and organic (eg, per- and polyfluoroalkyl substances) toxicants, and the development of preeclampsia and preterm birth among women in the United States.

Preclinical Labor-and-Delivery Shadowing: The Impact on Medical Students' Perceptions of Obstetrics and Gynecology.

Objective We sought to determine the impact of preclinical exposure (shadowing) to labor and delivery (L&D) on medical students' perceptions of obstetrics and gynecology (OB/GYN). Study Design We administered a written survey to rising third-year medical students at a single center prior to any clerkship. We described motivation/deterrents for shadowing among students, and experiences/perceptions of those students who shadowed. Results In total, 119/136 (86%) students completed the survey. Of those, 29% participated in shadowing on L&D. Participating students were more likely to be female (79 vs. 21%; p < 0.01) and in their first year (85%). Ninety-one percent participated because they wanted more exposure to OB/GYN, whereas only 53% they were interested in OB/GYN. Students who did not shadow indicated not having enough time as the main reason. After participation, 82% had more perspective on OB/GYN than prior to shadowing. Ninety-seven percent felt that the experience was worthwhile; 62% stated based on their experience that they were likely to consider a career in OB/GYN. All students who participated stated that they would opt to shadow again if given the opportunity. Conclusion Students who have L&D shadowing exposure report very positive experiences and express desire for increased opportunities. OB/GYN departments may consider increasing availability of L&D shadowing opportunities for preclinical medical students.

Minimizing the Risk of Perinatal Human Immunodeficiency Virus Transmission.

IMPORTANCE: There are approximately 284,500 adolescent and adult women living with human immunodeficiency virus (HIV) in the United States. It is estimated that approximately 8500 of these women give birth annually. While the rate of perinatal transmission in the United States has decreased by more than 90% since the early 1990s, potentially preventable HIV transmission events still occur and cause significant morbidity and mortality. OBJECTIVE: The aim of this review was to summarize the current data regarding perinatal HIV transmission timing and risk factors, current management recommendations, and implications of timing of transmission on patient management. EVIDENCE ACQUISITION: Literature review. RESULTS: This review reiterates that the risk of perinatal HIV transmission can be reduced to very low levels by following current recommendations for screening for HIV in all pregnant women and properly treating HIV-infected mothers, as well as using evidence-based labor management practices. CONCLUSIONS AND RELEVANCE: Familiarity with the pathogenesis of HIV transmission is important for obstetric care providers to appropriately manage HIV-infected women in pregnancy, intrapartum, and the postpartum period.

Complication profile, failure to rescue, and mortality following elective endovascular aortic aneurysm repair.

INTRODUCTION: Understanding the relationship between patient risk factors, postoperative complications, and morbidity and mortality is important when considering elective endovascular aortic aneurysm repair (E-EVAR) performed to prevent aneurysm rupture mortality. We aimed to stratify complications in E-EVAR and explore their relationship with postoperative death. METHODS: E-EVAR cases from 2012 NSQIP were identified. 30-day complications were categorized as major (MAJCX) or minor (MINCX) using the Clavien-Dindo classification. Failure to rescue (FTR) was defined as death following a complication. Univariate and multivariate analyses were performed to identify associations between patient risk factors, complications, and mortality. Significance set at P < 0.05. RESULTS: 3344 E-EVAR's were analyzed, with 155 (4.6%) MINCX, 106 (3.2%) MAJCX, and 39 (1.2%) mortality. Significant univariate risk factors differed between MINCX (preoperative dyspnea 27% vs 19%, COPD 32% vs19%, HTN 87% vs 79%, functional dependence 9% vs 3%) and MAJCX (female sex 33% vs 18%, preoperative diabetes 30% vs 17%, dyspnea 40% vs 19%, COPD 46% vs 20%, anticoagulant use 20% vs 11%, and functional dependence 13% vs 3%). 24 of 39 (62%) of deaths were preceded by a complication. FTR was more frequent following MAJCX than MINCX (16% vs 4.5%, P = 0.002), and occurred most commonly after renal failure with dialysis (33% mortality with complication), cardiac arrest (33%), septic shock (22%), and reintubation (22%). Independent predictors of MAJCX included female sex (OR 2, P = 0.001), COPD (OR 2, P = 0.009), and anticoagulant use (OR 2, P = 0.001). Mortality was independently predicted by MAJCX (OR 29, P < 0.001), MINCX (OR 8, P < 0.001), and preoperative renal failure (OR 11.6, P < 0.001). CONCLUSION: The majority of deaths within 30 days following E-EVAR are preceded by a complication; both MAJCX and MINCX predict mortality. FTR is more common after MAJCX; prevention efforts should take this into account. Identified risk factors should be taken into consideration when considering E-EVAR.