The Laborist trend: its implications.

PURPOSE: To offer obstetrical practitioners a current perspective about an important contemporary practice model which has implications that may not have been adequately recognized. METHODS: A description of individual past professional experience. RESULTS: A resultant perspective from decades of professional obstetric practice. CONCLUSION: A description of potential clinical impact on patients and practitioners alike.

Clinical Value of 3-Dimensional Ultrasound in Gynecology.

This report provides examples of using 3-dimensional ultrasound diagnostically in gynecology. The cost efficiency it provides and the wide range of applications it has support the routine use of this ultrasound technology in the practice of gynecology.

Prospective evaluation of a new protocol for the provisional use of perfusion imaging with exercise stress testing.

PURPOSE: Previous literature suggests that myocardial perfusion imaging (MPI) adds little to the prognosis of patients who exercise >10 metabolic equivalents (METs) during stress testing. With this in mind, we prospectively tested a provisional injection protocol in emergency department (ED) patients presenting for the evaluation of chest pain in which a patient would not receive an injection of radioisotope if adequate exercise was achieved without symptoms and a negative ECG response. METHODS: All patients who presented to the ED over a 5-year period who were referred for stress testing as part of their ED evaluation were included. Patients considered for a provisional protocol were: exercise stress, age <65 years, no known coronary artery disease, and an interpretable rest ECG. Criteria for not injecting included a maximal predicted heart rate ≥85%, ≥10 METs of exercise, no anginal symptoms during stress, and no ECG changes. Groups were compared based on stress test results, all-cause and cardiac mortality, follow-up cardiac testing, subsequent revascularization, and cost. RESULTS: A total of 965 patients were eligible with 192 undergoing exercise-only and 773 having perfusion imaging. After 41.6 ± 19.6 months of follow-up, all-cause mortality was similar in the exercise-only versus the exercise plus imaging group (2.6% vs. 2.1%, p = 0.59). There were no cardiac deaths in the exercise-only group. At 1 year there was no difference in the number of repeat functional stress tests (1.6% vs. 2.1%, p = 0.43), fewer angiograms (0% vs. 4.0%, p = 0.002), and a significantly lower cost ($65 ± $332 vs $506 ± $1,991, p = 0.002; values are in US dollars) in the exercise-only group. The radiation exposure in the exercise plus imaging group was 8.4 ± 2.1 mSv. CONCLUSIONS: A provisional injection protocol has a very low mortality, few follow-up diagnostic tests, and lower cost compared to standard imaging protocols. If adopted it would decrease radiation exposure, save time and decrease health-care costs without jeopardizing prognosis.

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department.

BACKGROUND: Recent studies have compared CTA to stress testing and MPI using older Na-I SPECT cameras and traditional rest-stress protocols, but are limited by often using optimized CTA protocols but suboptimal MPI methodology. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT cameras and stress-first protocols in an ED population. METHODS: In a retrospective, non-randomized study, all patients who underwent CTA or stress testing (ETT or Tc-99m sestamibi SPECT MPI) as part of their ED assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their disposition from the ED (admission vs discharge, length of time to disposition), subsequent visits to the ED and diagnostic testing (within 3 months), and radiation exposure. CTA was performed using a 64-slice scanner (GE Lightspeed VCT) and MPI was performed using a CZT SPECT camera (GE Discovery 530c). Data were obtained from prospectively acquired electronic medical records and effective doses were calculated from published conversion factors. A propensity-matched analysis was also used to compare outcomes in the two groups. RESULTS: A total of 1,458 patients underwent testing in the ED with 192 CTAs and 1,266 stress tests (327 ETTs and 939 MPIs). The CTA patients were a lower-risk cohort based on age, risk factors, and known heart disease. A statistically similar proportion of patients was discharged directly from the ED in the stress testing group (82% vs 73%, P = .27), but their time to disposition was longer (11.0 ± 5 vs 20.5 ± 7 hours, P < .0001). There was no significant difference in cardiac return visits to the ED (5.7% CTA vs 4.3% stress testing, P = .50), but more patients had follow-up studies in the CTA cohort compared to stress testing (14% vs 7%, P = .001). The mean effective dose of 12.6 ± 8.6 mSv for the CTA group was higher (P < .0001) than 5.0 ± 4.1 mSv for the stress testing group (ETT and MPI). A propensity score-matched cohort showed similar results to the entire cohort. CONCLUSIONS: Stress testing with ETT, high-efficiency SPECT MPI, and stress-only protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA with similar cardiac return visits. CTA had a shorter time to disposition, but there was a trend toward more revascularization than with stress testing.

A simple scoring tool for the evaluation of patients in an emergency department chest pain unit.

BACKGROUND: There are multiple risk scores to determine the prognosis of high-risk patients presenting with acute coronary syndromes (ACS) to emergency departments (ED) and chest pain units (CPU), however, there are few options for patients without ACS (no diagnostic ST-segment deviation or positive biomarkers). OBJECTIVES: To derive a clinical risk score for the management of lower-risk patients seen in ED CPUs. METHODS: We evaluated all patients triaged through the Mount Sinai ED CPU over a 76-month period who underwent stress testing after negative serial biomarkers and ECGs. Primary and secondary endpoints of hospital admission and coronary revascularization were retrospectively obtained. Variables associated with admission at P < 0.1 level were entered into a multivariable model. Each variable was assigned an integer score based on the beta coefficients in the final model. RESULTS: A total of 4,666 patients were evaluated and 738 (15.8%) had an abnormal stress test, 575 (12.3%) were admitted to the hospital, and 133 (2.9%) underwent coronary revascularization. A score consisting of age > 55 years, gender, chest pain quality (typical vs atypical), known coronary artery disease, shortness of breath, diabetes, smoking, and abnormal ECG demonstrated strong correlation between observed vs predicted hospital admission. The clinical score showed good ability to predict admission with a receiver operating characteristic (ROC) area of 0.72, which improved to 0.81 when the results of stress testing were added. CONCLUSIONS: This new clinical risk score is simple to use, predicts a clinically relevant outcome to ED physicians, and the results of noninvasive testing are additive.

The expanding role of sonography for the diagnosis of deep infiltrating endometriosis: Results of a large case series.

OBJECTIVE: To investigate the value of the sonographic identification of deep infiltrating endometriosis (DIE) in women presenting with complaints suggestive of DIE. Sonography findings were correlated with subsequent surgical exploration, and histologic verification. METHODS: A retrospective observational case series was investigated to document the ability of the use of sonography to accurately detect the presence of deep infiltrating endometriosis. The clinical observations were performed consistent with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations for observational studies. Recognizing the real-world office setting for this may introduce the importance of the practical clinical aspects of diagnostic procedures in general. RESULTS: Three-dimensional transvaginal sonography was able to accurately identify deep invasive endometriosis in 92% of the 100 women subjectively complaining of the associated symptoms of endometriosis, who underwent sonography, surgical exploration, and pathologic analysis. Additional sonographic evidence of pelvic pathology was found during the course of this investigation, perhaps complementing other means for diagnosing endometriosis. CONCLUSION: Three-dimensional transvaginal sonography is a diagnostic tool that can effectively identify deep infiltrating endometriosis, which may otherwise go undetected and untreated. These findings should encourage the use of sonography for the detection of this subtype of endometriosis.

A hypothetical protocol for the provisional use of perfusion imaging with exercise stress testing.

BACKGROUND: Previous literature suggests that the results of myocardial perfusion imaging (MPI) add little to the prognosis of patients who exercise >10 metabolic equivalents (METS) during stress testing. With this in mind, we attempted to determine if a provisional injection protocol could be developed in which a patient would not receive an injection of radioisotope if adequate exercise was achieved without symptoms and a negative ECG response. This protocol would save a substantial amount of time, radiation exposure, and cost. METHODS: All patients who underwent a stress SPECT MPI over a 6.5-year period from 2004 to 2010 were included. Patients who would have been considered for a standby injection protocol were: exercise stress, age < 65, no known coronary artery disease (CAD), and an interpretable ECG. Patients were retrospectively divided into two groups based on whether they would have received radioisotope or not. Criteria for not injecting included a maximal predicted heart rate ≥ 85%, ≥10 METS of exercise, no symptoms of chest pain or shortness of breath, and no ECG changes (ST depression or arrhythmia). The two groups were then compared based on MPI results and all-cause mortality derived from the Social Security Death Index. RESULTS: A total of 24,689 patients underwent SPECT MPI during this period, and 5,352 would have been eligible for a provisional injection protocol. There were 3,791 (70.8%), who would have been injected and 1,561 (29.2%), who would not have been. Perfusion results were abnormal in 5.9% of non-injected group compared to 14.4% in those who would have been injected. After a mean follow-up of 60.6 ± 21.4 months, 1.1% had died in the non-injected cohort compared to 2.2% in the injected group. CONCLUSION: A provisional injection protocol defined as age < 65, normal rest ECG, no history of CAD, and high level exercise with a negative ECG response and no symptoms has a very low 5-year all-cause mortality and low yield of MPI. If adopted it would decrease radiation exposure and save time and health care costs without jeopardizing prognosis.

Diagnosis and management of intramural ectopic pregnancy.

Intramural pregnancy, a gestation completely surrounded by the myometrium located within the uterine wall with separation from the uterine cavity, is an extremely unusual form of pregnancy. Complications resulting from intramural pregnancy include inevitable uterine rupture with resultant hemorrhage and possible hysterectomy if diagnosis is not made early and treatment is not initiated. An asymptomatic patient was initially diagnosed with a missed abortion at approximately 6 weeks of gestation after a routine ultrasound. Suction curettage was performed approximately 1 month after the initial diagnosis. The pathology specimen failed to reveal placental villi. Ultimately, the diagnosis of intramural pregnancy was made via ultrasound and a computed tomography scan. She was treated with a single dose of systemically administered methotrexate. Over a period of 4 months, ß-human chorionic gonadotropin levels trended downward; however, the intramural pregnancy failed to resolve completely, and a persistent mass remained. The intramural pregnancy was removed using the da Vinci laparoscopic procedure (Intuitive Surgical, Sunnyvale, CA). If the diagnosis of intramural ectopic pregnancy is made sufficiently early, conservative measures can be taken, which can preserve a patient's future fertility.

Race and Ethnic Categories: A Brief Review of Global Terms and Nomenclature.

Terminology regarding descriptors of race and ethnicity have been constantly evolving. Due to differences in terminology, data collection, demographics, and group identity, there are numerous challenges in determining what descriptors are suitable and acceptable to all individuals. The National Institutes of Health (NIH) has defined six racial and ethnic categories that should be used for reporting purposes. This review gives a historical background of the definition of the different racial and ethnic categories. This review also aims to define acceptable categories of race and ethnicity to provide guidelines for reports and best practices.

Outcomes of Combined Heart and Kidney Transplantation Under the New Heart Allocation Policy: A United Organ Network for Organ Sharing Database Analysis.

BACKGROUND: The impact of the new heart allocation policy, which prioritizes acutely ill patients on temporary mechanical circulatory support and provides broader sharing of donor organs, on patient and graft survival in combined heart and kidney transplantation (HKT) is unknown. METHODS: In the United Network for Organ Sharing data, patients were divided in groups before and after the policy change (OLD, January 1, 2015 to October 17, 2018, N=533; and NEW, October 18, 2018 to December 31, 2020, N=370). Propensity score matching was performed utilizing recipient characteristics (283 pairs). The median follow-up was 1099 days. RESULTS: The annual volume of HKT increased approximately 2-fold during this period (N=117 in 2015 and N=237 in 2020), predominantly among patients not on hemodialysis at time of transplantation. Ischemic times for heart (OLD, 2.94 versus NEW, 3.37 hours; P<0.001) and kidney grafts (14.1 versus 16.0 hours; P<0.001) were longer under the new policy, as was the travel distance (47 versus 183 miles; P<0.001). In the matched cohort, 1-year overall survival (OLD, 91.1% versus NEW, 84.8%; P<0.001), and freedom from heart and kidney graft failure rate were worse under the new policy. Patients not on hemodialysis at time of HKT demonstrated worse survival and a higher risk of kidney graft failure under the new policy compared with the old policy. In multivariate Cox proportional-hazards analysis, the new policy was associated with an increased risk of mortality (hazard ratio, 1.81; P=0.007), and graft failure among HKT recipients (heart, hazard ratio, 1.81; P=0.007; and kidney, hazard ratio, 1.83; P=0.002). CONCLUSIONS: The new heart allocation policy was associated with worse overall survival and decreased freedom from heart and kidney graft failure in HKT recipients.

A model for the prediction of a successful stress-first Tc-99m SPECT MPI.

BACKGROUND: Stress-only Tc-99m MPI saves time, radiation exposure, and a normal study has a benign prognosis. However, a stress-first protocol is relatively labor intensive requiring pre-test screening for suitability and early post-stress image review to determine the need for rest imaging. The purpose of this study was to develop a simple clinical score used prior to a patient's myocardial perfusion imaging (MPI) study to determine if they should undergo a stress-first protocol. METHODS: We reviewed all patients who underwent Tc-99m SPECT MPI over a 27-month period and divided them into derivation and validation cohorts. Patients were categorized as having a successful stress-first protocol based on a summed stress score ≤1, with or without attenuation correction. We generated a multivariable model from the derivation cohort to identify demographic and clinical correlates of successful stress-first imaging. Two validation cohorts using a CZT and a conventional SPECT camera were then used to test the performance of the model. RESULTS: The derivation cohort included 1,996 patients and the validation cohort consisted of 1,005 CZT SPECT patients and 2,430 conventional SPECT patients. The following variables were associated with unsuccessful (i.e., abnormal) stress-first imaging: age >65 years (1 point), diabetes (2 points), typical chest pain (2 points), congestive heart failure (3 points), abnormal ECG (4 points), male gender (4 points), and documented CAD (5 points). Emergency Department location (-2 points) was negatively associated with an unsuccessful protocol. An increasing score showed a strong association with an unsuccessful stress-first protocol in both the derivation and the validation cohorts (P < .0001) and dividing the cohorts into low (<5), intermediate (≥5 and <10), and high (≥10) risk scores accurately stratified patients based on their frequencies of unsuccessful stress-first imaging. ROC curve analysis showed excellent prediction in both the derivation and the validation cohorts with an area under the curve of 0.82 and 0.75-0.83, respectively. CONCLUSIONS: This pre-test scoring tool accurately identifies patients who can successfully undergo a stress-first imaging protocol without the need for rest imaging and may allow for wider adoption of stress-first imaging protocols.

The prognosis of a normal Tl-201 stress-only SPECT MPI study.

BACKGROUND: Stress-only Tc-99m SPECT myocardial perfusion imaging (MPI) decreases test time and patient radiation exposure with a proven benign prognosis of a normal study. The imaging sequence of Tl-201 MPI always starts with the stress portion; therefore, no pre-test decisions are needed regarding the imaging sequence. The recent intermittent Tc-99m shortage afforded the unique opportunity to study an unselected group of patients undergoing Tl-201 imaging. METHODS: We retrospectively reviewed all the patients who had SPECT MPI with Tc-99m or Tl-201 over a 1-year period. When Tc-99m was not available, patients received Tl-201. All stress Tl-201 images were routinely processed, and if normal, rest imaging was not done. When Tc-99m was used, patients with lower pre-test probability were selected for a stress-first protocol. We compared the all-cause mortality of patients with normal Tl-201 studies to those with normal stress-only and rest-stress Tc-99m studies using the Social Security Death Index. Unadjusted and risk-adjusted survival analysis was performed. Specific causes of death (cardiac or non-cardiac) were determined by medical record review and contact with treating physicians. RESULTS: A total of 3,658 patients underwent stress MPI during this time period. Of the 1,215 patients who had Tl-201 MPI, 716 (67%) had a normal stress-only study. Out of 2,443 patients who underwent Tc-99m MPI, 70% had normal perfusion with 1,098 normal stress-only studies and 493 normal rest-stress studies. The average follow-up was 23.3 ± 5.3 months. Unadjusted all-cause mortality at the end of follow-up was 7.1% in the Tl-201 stress-only group, 6.3% for Tc-99m stress-only patients, and 4.3% in the Tc-99m rest-stress cohort. After controlling for confounding variables, survival was similar in the three groups (HR 1.07, 95% CI 0.62-1.82, P = .82 for normal Tl-201 stress-only compared to normal Tc-99m rest-stress). The risk-adjusted 1-year survival was between 98.5 and 98.8% in the three groups. CONCLUSIONS: Normal stress-only Tl-201 SPECT MPI study has a similarly benign prognosis when compared to Tc-99m rest-stress and Tc-99m stress-only normal SPECT MPI studies. The stress-first design allowed for early triage of over 60% of patients and marked improvement in laboratory efficiency due to shortened test time.