Geriatrics fellowship during COVID-19: expanding impact, using innovation and maintaining balance.

The COVID-19 pandemic provided an opportunity for geriatricians, especially geriatrics fellows, to demonstrate leadership in a crisis that has significantly affected the 65 and older demographic. Given their expertise in care delivery to complex, multimorbid patients, as well as their ability to navigate different healthcare settings, geriatrics fellows became a valuable resource during the pandemic, particularly at one large, urban academic health system. Their training in patient-centered, value-based care helped determine the best course of action for patients not only in the hospital, but also in the community. Utilizing innovative strategies such as a newly developed Palliative Care Hotline (PATCH-24 line), telehealth, and community paramedicine, fellows delivered services to complex patients in community settings. In addition to providing direct patient care, geriatrics fellows also taught their skills to frontline physicians of other specialties. Strong support from the fellowship program's leadership, as well as an ongoing focus on clinician wellbeing and resilience, have been central factors in the success of geriatrics fellows during the COVID-19 crisis.

The Third Stage of Labour in the Extremely Obese Parturient.

BACKGROUND: Maternal obesity has been associated with an increased risk for an abnormal progression of labour; however, less is known about the length of the third stage of labour and its relation to maternal obesity. OBJECTIVE: To determine if the length of the third stage of labour is increased in extremely obese women and its possible correlation with an increased risk for postpartum hemorrhage. STUDY DESIGN: This was a retrospective cohort study of deliveries from January 2008 to December 2015 at our university hospital. Women with a BMI ≥40 and a vaginal delivery were compared with the next vaginal delivery of a woman with a BMI <30. There were 147 women with a BMI ≥40 compared with 157 with a BMI <30. Outcomes evaluated the length of the third stage of labour and the risk for postpartum hemorrhage and included antepartum, intrapartum, and perinatal complications. RESULTS: Subjects in the extreme obese group were more likely to be African American, older, diabetic (pregestational and gestational), hypertensive, pre-eclamptic, had a preterm delivery, and underwent an induction of labour. The overall length of the third stage of labour was significantly longer in the extreme obese group, 5 minutes (3, 8 [25th and 75th percentiles]) compared with 4 minutes (3,7) (P = 0.0374) in the non-obese group. Postpartum hemorrhage occurred more often in the extreme obese group (N = 16/147; 11%) compared with the non-obese group (N = 5/157; 3%) (P = 0.01). There were no differences between groups in respect to the following: gravidity, parity, length of the second stage of labour, birth weight, GA at delivery, Apgar score, cord blood gases, hematocrit change, need for postpartum transfusion, operative delivery, and development of chorioamnionitis. After an adjustment for ethnicity, maternal age, diabetes, preeclampsia, preterm labour, hypertension, and induction/augmentation, the analysis failed to show a significant difference in estimated blood loss and postpartum hemorrhage between the groups. CONCLUSIONS: The length of the third stage of labour is longer in the extreme obese parturient. Postpartum hemorrhage also occurs more often, but after adjustments for confounding variables, it is no longer significant.

Radiographic indices for the diagnosis of atlantoaxial instability in toy breed dogs [corrected].

Toy breed dogs are overrepresented for atlantoaxial instability. Radiography is a standard diagnostic test, however published toy breed-specific radiographic measurements are lacking and diagnosis remains largely subjective. Aims of this retrospective, diagnostic accuracy study were to describe normal values and determine whether some quantitative radiographic criteria strongly support a diagnosis of atlantoaxial instability specific to toy breed dogs. Neutral lateral and ventrodorsal radiographs of 102 toy breed dogs (92 control, 10 affected) were reviewed. The median C1-C2 overlap (the distance of overlap between the C2 spinous process and the dorsal arch of C1) was +4.65 mm in control dogs and -5.00 mm in atlantoaxial instability cases. A C1-C2 overlap ≤ +1.55 mm was the most sensitive (100%) and specific (94.5%) radiographic measurement in the diagnosis of atlantoaxial instability. Three relative measurements were performed: the ventral atlantodental interval to dorsal atlantodental interval ratio, the dens/C2 ratio, and the C1-C2 angle. These three relative measurements had good specificity (94.5, 86.9, and 98.9%, respectively), lower sensitivity (80.0, 66.7, and 60.0%, respectively), and were not influenced by body weight (P > 0.05). Absolute measurements (including absolute dens length and atlantoaxial distance) were significantly correlated with body weight (P < 0.05) diminishing their utility in the diagnosis of atlantoaxial instability. Decreased C1-C2 overlap strongly supports atlantoaxial instability. The ventral atlantodental interval/dorsal atlantodental interval ratio, dens/C2 ratio, and C1-C2 angle may provide further support but may be normal in individual cases.

The effect of impedance cardiography directed antihypertensive therapy on fetal growth restriction rates and perinatal mortality in women with chronic hypertension.

OBJECTIVES: We sought to determine the effect of impedance cardiography directed medical antihypertensive therapy on fetal growth restriction and perinatal mortality in women with chronic hypertension. STUDY DESIGN: A retrospective study was conducted on 958 women referred to the Maternal Hypertension Center at Cabell Huntington Hospital between 2005 and 2014 for the indication of chronic hypertension. MAIN OUTCOME MEASURES: Serial assessments of maternal hemodynamics were obtained using non-invasive impedance cardiography. Vasodilators were initiated for increased systemic vascular resistance. Elevated cardiac output was treated with beta blockade. RESULTS: Blood pressure at initial visit was used to stratify patients into five groups. Initial blood pressure of <130 systolic or <80 diastolic had 24 cases of growth restriction (6.8%) and 6 perinatal deaths (1.7%), 130-139 systolic or 80-89 diastolic resulted in 29 cases of growth restriction (9.3%) and 9 perinatal deaths (2.9%), 140-149 systolic or 90-99 diastolic 14 cases of growth restriction (6.5%) and 3 perinatal deaths (1.4%), 150-159 systolic or 100-109 diastolic had 5 cases of growth restriction (8.6%) and 4 perinatal deaths (6.89%), and >160 systolic or >110 diastolic 3 cases of growth restriction (13%) with no perinatal deaths. There were no differences in growth restriction (p = .59) or perinatal death (p = .15) between the groups. CONCLUSION: The rates of IUGR and perinatal mortality did not increase even with increasing severity of maternal hypertension. This low cost and non-invasive test should be considered for optimizing rates of growth restriction and perinatal mortality in pregnancies complicated by chronic hypertension.

Placental changes in diabetic pregnancies and the contribution of hypertension.

OBJECTIVE: To evaluate placental abnormalities in pregnancies affected by diabetes compared to unaffected pregnancies from a single academic center. METHODS: This is a retrospective cohort study of women with singleton gestations delivered at the University of Arkansas for Medical Sciences from 2007 to 2016. Pathologic examination of placentas from pregestational and gestational diabetic pregnancies were compared to placentas from patients without diabetes using 12 histologic elements. Maternal and neonatal outcomes were extracted from the medical record and compared between groups. Findings were adjusted for hypertensive disorders of pregnancy. Placental lesions were also correlated with diabetic control. RESULTS: Pathology reports of 590 placentas along with corresponding medical records were reviewed. The diabetic group (N = 484) consisted of 188 patients with pregestational diabetes and 296 patients with gestational diabetes. The nondiabetic group consisted of 106 patients. The diabetic group was older, had a higher average BMI, and more hypertensive disorders (p < .0001). Out of the 12 histologic elements investigated, accelerated villous maturation (aOR = 8.45, 95%CI (1.13-62.95)) and increased placental weight (aOR = 3.131, 95% CI (1.558-6.293)) were noted to be significantly increased in placentas from diabetic pregnancies after controlling for hypertension. Intervillous thrombi were not significantly increased in pregnancies affected by diabetes. Neonates of the diabetic group were more likely to be large for gestational age (p < .0001) and had a higher rate of preterm delivery (p < .0001). CONCLUSIONS: Accelerated villous maturation was found to be more frequent in pregnancies complicated by pregestational diabetes, even after controlling for hypertension. In pregnancies complicated by gestational diabetes, the placental findings were not significant after controlling for hypertension. In contrast with prior studies, there was no increase in thrombotic lesions of the placenta in patients with diabetes.

A resident-led initiative to improve patient safety event reporting in an internal medicine residency program.

BACKGROUND: Despite the Clinical Learning Environment Review's recommendations of their use, patient safety event reporting systems are underutilized by residents. OBJECTIVE: We aimed to identify perceived barriers to event reporting amongst internal medicine residents and implement a targeted quality improvement initiative to address the identified barriers and increase overall resident event report rates. METHODS: A total of 94 Internal Medicine (IM) residents participated in the educational intervention in 2018. We measured residents' perception of barriers to event reporting and employed the results of the questionnaire to create a skill-based educational workshop. We conducted the plan-do-study-act model to test a structured educational intervention and its effectiveness on pre-post IM residents' event report rates and compared it to report rates of Non-Internal Medicine (Non-IM) residents. Additionally, we assessed pre-post intervention knowledge, skills, and attitudes in event reporting. RESULTS: 94/94 (100%) of IM residents had a significantly higher median percent of patient safety event reporting when compared to pre-intervention (23.6% compared to 5.88%, p-value = 0.0030) and when compared to Non-IM residents (23.6% compared to 5.31%, p-value = 0.0002). Residents performed better on the post-test compared to the pre-test (90% compared to 30%, p-value = 0.0001) for knowledge. 100% of the critical action items were completed and 90% of participants reported their perception of the event reporting process improved. CONCLUSIONS: By elucidating common reasons why residents are not reporting patient safety events, a specific intervention can be created to target the identified impediments and improve resident event reporting. ABBREVIATIONS: IM: Internal Medicine IM; Non-IM: Non-Internal Medicine; IOM: Institute of Medicine I; ACGME CLER: Accreditation Council for Graduate Medical Education Clinical Learning Environment Review; GME: Graduate Medical Education; IRB: Institutional Review Board; PDSA: Plan, Do, Study, Act.

Duration of the Third Stage of Labor and Estimated Blood Loss in Twin Vaginal Deliveries.

Objective The main aim of this study was to characterize the duration of the third stage of labor and estimated blood loss in twin vaginal deliveries. Study Design This was a retrospective case-control study. The data was collected from deliveries at the University of Arkansas for Medical Sciences in Little Rock, Arkansas, from January 2013 to June 2017. Women were identified who had twin gestation, were delivered vaginally, and whose maternal age was greater than 18 years old. Women were excluded if they had an intrauterine fetal demise, delivered either/both fetuses via cesarean, history of a previous cesarean or a fetus with a congenital anomaly. If a subject met criteria to be included in the study, the next normal singleton vaginal delivery was used as the control subject. Results There were 132 singleton vaginal deliveries and 133 twin vaginal deliveries analyzed. There was no significant difference in the length of the third stage of labor between twin and singleton vaginal deliveries except in the 95th percentile of the distribution. Mothers delivering twins had an increase in third-stage duration by 7.618 minutes (95% confidence interval [CI]: 0.73, 14.50; p = 0.03) compared with those who delivered singletons. The twin group had a higher estimated blood loss than singleton deliveries. The increase in blood loss in the twin group was 149.02 mL (95% CI: 100.2, 197.8), 257.01 mL (95% CI: 117.9, 396.1), and 381.53 mL (95% CI: 201.1, 562.1) at the 50th, 90th, and 95th percentiles, respectively. When the third stage of labor was at the 90th percentile or less in twin pregnancy (14 minutes), estimated blood loss was less than 1000 mL. Conclusion Twin pregnancy is a known risk factor for postpartum hemorrhage. As the duration of the third stage prolongs, the risk for hemorrhage also increases. We recommend delivery of the placenta in twin pregnancies by 15 minutes to reduce this risk. Key Points The third stage is longer in twin pregnancy at extremes.Twin placentas should be delivered by 15 minutes.Manually extract the placenta when third stage is prolonged.

Recurrence of Citrobacter koseri-associated Intra-abdominal Infection 2 Years after Spilled Gallstones during Laparoscopic Cholecystectomy.

Spilled gallstones during laparoscopic cholecystectomy (LC) are common. Lost gallstones can lead to complications such as intra-abdominal abscesses, which can occur days, months, or even years after the procedure. Citrobacter koseri belongs to the family of Enterobacteriaceae. It is a low-virulence pathogen; however, it is linked to infections of the urinary tract and abdomen. We report the case of a 70-year-old diabetic male who presented with C. koseri- associated subhepatic abscess. Two years prior, he had emphysematous cholecystitis and liver abscess caused by C. koseri. During his LC, gallstones were spilled in the abdominal cavity and every effort was made to retrieve them. However, 2 years later, an aspiration of the subhepatic abscess revealed cholesterol fragments. We hypothesize that dislodged cholesterol gallstones and bile, contaminated with C. koseri, were the culprits for the appearance of the subhepatic abscess with the same organism 2 years after the LC.

Fish Parasites: A Growing Concern During Pregnancy.

Intestinal parasitic worms affect more than 2 billion people worldwide according to the World Health Organization. Fish-borne parasitic infections are becoming more common with the increasing popularity of sushi, sashimi, Carpaccio, tartare, gefilte, and ceviche. The ingestion of these parasites can cause serve anemia, malabsorption, severe abdominal pain, nausea, vomiting, strong allergic reactions, and gastric ulcers. Knowledge about fish parasites and pregnancy is limited. A literature search on PubMed and Web of Science used the search terms "fish parasites" OR "diphyllobothrium" OR "anisakiasis" OR "pseudoterranova" OR ("food borne parasites" AND "fish") AND "pregnancy" OR "maternal" OR "fetus" OR "fetal" OR "newborn" OR "neonatal" OR "childbirth." No limit was put on the number of years searched. There were 281 publications identified. The abstracts of all of these publications were read. After exclusion of the articles that were not relevant to pregnancy, pregnancy outcome, and fish parasites, there were 24 articles that became the basis of this review. The pathophysiology, altered maternal immunity related to the infection, limited information about fish-borne parasitic infections and pregnancy, and treatments are discussed. The main impact of a fish-borne parasitic infection on pregnant women is anemia and altered immunity, which may increase the risk of a maternal infection. The primary fetal effects include intrauterine growth restriction and preterm delivery.

Timing of manual placenta removal to prevent postpartum hemorrhage: is it time to act?

OBJECTIVE: The length of the third stage of labor is an important risk factor for postpartum hemorrhage (PPH). Current practice recommends manual placenta removal, if not delivered spontaneously, within 30 min. The review reexamines the evidence to determine the optimal length of the third stage of labor. METHODS: A MEDLINE search that associated the length of the third stage of labor with the risk of PPH was undertaken. RESULTS: A retrospective cohort study revealed the risk of a PPH became significant at 10 min (odds ratio = 2.1, 95% confidence interval: 1.6-2.6), and had doubled by 20 min (odds ratio = 4.3, 95% confidence interval: 3.3-5.5). A receiver operator curve determined the optimal length of the third stage of labor to prevent PPH was 18 min. A follow up randomized controlled trial showed that hemodynamic compromise secondary to a PPH can be reduced with manual placenta removal at 10 compared to 15 min (6.4 versus 19.2%, p = 0.001). CONCLUSION: The time interval of 15 min may be a more appropriate time interval to recommend placental removal to prevent PPH.

Resource limitation alters the consequences of co-infection for both hosts and parasites.

Most animals are concurrently infected with multiple parasite species and live in environments with fluctuating resource availability. Resource limitation can influence host immune responses and the degree of competition between co-infecting parasites, yet its effects on individual health and pathogen transmission have not been studied for co-infected hosts. To test how resource limitation affects immune trade-offs and co-infection outcomes, we conducted a factorial experiment using laboratory mice. Mice were given a standard or low protein diet, dosed with two species of helminths (alone and in combination), and then challenged with a microparasite. Using a community ecology trophic framework, we found that co-infection influenced parasite survival and reproduction via host immunity, but the magnitude and direction of responses depended on resources and the combination of co-infecting parasites. Our findings highlight that resources and their consequence for host defenses are a key context that shapes the magnitude and direction of parasite interactions.