Identifying causes and associated factors of stillbirths using autopsy of the fetus and placenta.

PURPOSE: The study aimed to evaluate the causes of death and associated factors in cases of stillbirth, using post-mortem examination and applying a rigorous, evidence-based holistic approach. METHODS: Our retrospective observational study included cases of autopsy following stillbirth that occurred at our tertiary medical center during a period of 8 years. Detailed up-to-date criteria that incorporate clinical reports, medical history, prenatal imaging, and histopathological findings were used to evaluate the cause of death and associated factors. RESULTS: After applying our proposed methodology, 138 cases of stillbirth were classified into eight categories based on the causes of death. A definitive cause of death was observed in 100 (72%) cases, while 38 (28%) cases were considered unexplained. The leading cause of death was placental lesions (n = 39, 28%) with maternal vascular malperfusion (MVM) lesions being the most common (54%). Ascending infection was the second most common cause of fetal death (n = 24, 17%) and was often seen in the setting of preterm labor and cervical insufficiency. CONCLUSION: The largest category of cause of death was attributed to placental pathology. Using rigorous detailed up-to-date criteria that incorporate pathological and clinical factors may help in objectively classifying the cause of death.

Disparities Between Prenatal Ultrasound and Autopsy Findings in Pregnancies Resulting in Fetal Loss.

OBJECTIVES: This retrospective study aimed to assess disparities between prenatal ultrasound and autopsy findings in pregnancies that resulted in fetal loss, and to evaluate the diagnostic performance of prenatal ultrasound using postmortem examinations as a gold standard. METHODS: Our study included 136 autopsy cases following a fetal loss that occurred at our tertiary medical center for 8 years. A comparison between the prenatal ultrasound and autopsy findings was made, and all cases were classified according to the degree of agreement. The diagnostic performance of prenatal ultrasound was calculated at the level of organ system and specific malformations. RESULTS: The primary sonographic diagnosis was confirmed in 91.9% of the cases (n = 125). General agreement was highest among central nervous system (CNS), cardiovascular and musculoskeletal systems (85.7%, n = 36, 18, and 12, respectively) and lowest among facial, multiple anomalies, genitourinary and gastrointestinal systems (50.0%, 74.3%, 78.6%, and 80.0%, n = 2, 26, 11, and 4, respectively). The sensitivity of ultrasound was highest in the CNS (93.2%) and musculoskeletal (87.0%) and lowest in the facial (32.3%) and pulmonary (13.0%) systems. Specifically, low diagnostic rates were noted in detecting ventriculomegaly, valvular anomalies, renal dysplasia, spleen and adrenal anomalies, and digital and facial defects. CONCLUSIONS: Our study observed an overall high agreement between prenatal ultrasound and autopsy while contributing to our comprehensive understanding of its strengths and limitations across various types of organ systems and specific malformations.

First-Phase Ejection Fraction and Long-Term Survival in Patients Who Underwent Transcatheter Aortic Valve Implantation.

Early recognition of deteriorating left ventricular function plays a key prognostic role in patients with aortic stenosis (AS). First-phase ejection fraction (EF1), the ejection fraction (EF) up to time of maximal contraction, has been suggested for detection of early left ventricular dysfunction in patients with AS with preserved EF. This work aims to evaluate the predictive value of EF1 for assessment of long-term survival in patients with symptomatic severe AS and preserved EF who undergo transcatheter aortic valve implantation (TAVI). We included 102 consecutive patients (median age 84 years [interquartile range 80 to 86 years]) who underwent TAVI between 2009 and 2011. Patients were retrospectively stratified into tertiles by EF1. Device success and procedural complications were defined according to the Valve Academic Research Consortium-3 criteria. Mortality data were retrieved from a computerized interface of the Israeli Ministry of Health. Baseline characteristics, co-morbidities, clinical presentation, and echocardiographic findings were similar among groups. The groups did not differ significantly regarding device success and in-hospital complications. During a potential follow-up period of >10 years, 88 patients died. Kaplan-Meier analysis (log-rank p = 0.017) followed by multivariable Cox regression analysis showed that EF1 predicted long-term mortality independently, either as continuous variable (hazard ratio 1.04, 95% confidence interval 1.01 to 1.07, p = 0.012) or for each decrease in tertile group (hazard ratio 1.40, 95% confidence interval 1.05 to 1.86, p = 0.023). In conclusion, low EF1 is associated with a significant decrease in adjusted hazard for long-term survival in patients with preserved EF who undergo TAVI. Low EF1 might delineate a population at great risk who would benefit from prompt intervention.

Cardiologic Manifestations in Omicron-Type Versus Wild-Type COVID-19: A Systematic Echocardiographic Study.

Background Information about the cardiac manifestations of the Omicron variant of COVID-19 is limited. We performed a systematic prospective echocardiographic evaluation of consecutive patients hospitalized with the Omicron variant of COVID-19 infection and compared them with similarly recruited patients were propensity matched with the wild-type variant. Methods and Results A total of 162 consecutive patients hospitalized with Omicron COVID-19 underwent complete echocardiographic evaluation within 24 hours of admission and were compared with propensity-matched patients with the wild-type variant (148 pairs). Echocardiography included left ventricular (LV) systolic and diastolic, right ventricular (RV), strain, and hemodynamic assessment. Echocardiographic parameters during acute infection were compared with historic exams in 62 patients with the Omicron variant and 19 patients with the wild-type variant who had a previous exam within 1 year. Of the patients, 85 (53%) had a normal echocardiogram. The most common cardiac pathology was RV dilatation and dysfunction (33%), followed by elevated LV filling pressure (E/e' ≥14, 29%) and LV systolic dysfunction (ejection fraction <50%, 10%). Compared with the matched wild-type cohort, patients with Omicron had smaller RV end-systolic areas (9.3±4 versus 12.3±4 cm2; P=0.0003), improved RV function (RV fractional-area change, 53.2%±10% versus 39.7%±13% [P<0.0001]; RV S', 12.0±3 versus 10.7±3 cm/s [P=0.001]), and higher stroke volume index (35.6 versus 32.5 mL/m2; P=0.004), all possibly related to lower mean pulmonary pressure (34.6±12 versus 41.1±14 mm Hg; P=0.0001) and the pulmonary vascular resistance index (P=0.0003). LV systolic or diastolic parameters were mostly similar to the wild-type variant-matched cohort apart from larger LV size. However, in patients who had a previous echocardiographic exam, these LV abnormalities were recorded before acute Omicron infection, but not in the wild-type cohort. Numerous echocardiographic parameters were associated with higher in-hospital mortality (LV ejection fraction, stroke volume index, E/e', RV S'). Conclusions In patients with Omicron, RV function is impaired to a lower extent compared with the wild-type variant, possibly related to the attenuated pulmonary parenchymal and/or vascular disease. LV systolic and diastolic abnormalities are as common as in the wild-type variant but were usually recorded before acute infection and probably reflect background cardiac morbidity. Numerous LV and RV abnormalities are associated with adverse outcome in patients with Omicron.

Post-operative pain following percutaneous nephrolithotripsy- clinical correlates.

OBJECTIVES: Management of postoperative pain following percutaneous nephrolithotripsy (PCNL) is a significant goal. We sought to identify risk factors and clinical correlates of postoperative pain in order to improve perioperative management and patient satisfaction. MATERIALS AND METHODS: A single-center, retrospective analysis, from a prospectively maintained database, of all consecutive patients who underwent PCNL for renal calculi between January 2011 and August 2018. Postoperative pain was assessed using the visual analog scale (VAS) and analgesic use. We considered VAS score above 4 as meaningful. Pain management was standardized according to patirnt reported VAS scores. Multivariable logistic regression was performed to identify risk factors and clinical correlates. RESULTS: A total of 496 patients were analyzed. Younger age was associated with VAS above 4 on the operative day and the first postoperative following PCNL (p = 0.003 and p < 0.001, respectively). Female gender was associated with VAS above 4 in the first 2 days following the operation (p < 0.001). CONCLUSIONS: Younger age and female gender would most likely benefit from pre-emptive improved pain management protocols following PCNL.

Systematic lung ultrasound in Omicron-type vs. wild-type COVID-19.

AIMS: Preliminary data suggested that patients with Omicron-type-Coronavirus-disease-2019 (COVID-19) have less severe lung disease compared with the wild-type-variant. We aimed to compare lung ultrasound (LUS) parameters in Omicron vs. wild-type COVID-19 and evaluate their prognostic implications. METHODS AND RESULTS: One hundred and sixty-two consecutive patients with Omicron-type-COVID-19 underwent LUS within 48 h of admission and were compared with propensity-matched wild-type patients (148 pairs). In the Omicron patients median, first and third quartiles of the LUS-score was 5 [2-12], and only 9% had normal LUS. The majority had either mild (≤5; 37%) or moderate (6-15; 39%), and 15% (≥15) had severe LUS-score. Thirty-six percent of patients had patchy pleural thickening (PPT). Factors associated with LUS-score in the Omicron patients included ischaemic-heart-disease, heart failure, renal-dysfunction, and C-reactive protein. Elevated left-filling pressure or right-sided pressures were associated with the LUS-score. Lung ultrasound-score was associated with mortality [odds ratio (OR): 1.09, 95% confidence interval (CI): 1.01-1.18; P = 0.03] and with the combined endpoint of mortality and respiratory failure (OR: 1.14, 95% CI: 1.07-1.22; P < 0.0001). Patients with the wild-type variant had worse LUS characteristics than the matched Omicron-type patients (PPT: 90 vs. 34%; P < 0.0001 and LUS-score: 8 [5, 12] vs. 5 [2, 10], P = 0.004), irrespective of disease severity. When matched only to the 31 non-vaccinated Omicron patients, these differences were attenuated. CONCLUSION: Lung ultrasound-score is abnormal in the majority of hospitalized Omicron-type patients. Patchy pleural thickening is less common than in matched wild-type patients, but the difference is diminished in the non-vaccinated Omicron patients. Nevertheless, even in this milder form of the disease, the LUS-score is associated with poor in-hospital outcomes.

Recurrent hospitalizations with moderate to severe hyponatremia in older adults and its associated mortality.

BACKGROUND: Recurrent hospitalizations with hyponatremia are commonly encountered in older adults admitted to Internal Medicine wards. However, the incidence and the prognostic implication of this phenomenon have never been studied. METHODS: Medical charts of all older adults (≥75 years) admitted to Internal Medicine wards at a tertiary medical center during 2009-2010 with symptomatic moderate to severe hyponatremia (blood sodium ≤130 meq/l) upon admission were reviewed. The study group included patients with one or more hospitalizations with hyponatremia in the year following the first hospitalization with hyponatremia. The control group included patients with a single hospitalization with hyponatremia. Mortality rates were studied one year following the second hospitalization with hyponatremia in the study group and one year following the single hospitalization with hyponatremia in the control group. Regression analysis was used to study the association between recurrent hospitalizations with hyponatremia and 1-year mortality while controlling for demographics, chronic co-morbidities, albumin serum levels, and the number of hospitalizations. RESULTS: The cohort included 431 older adults: 301 (69.8%) women; mean age of 84.6±5.6 years. Overall, 120 (27.8%) patients had recurrent hospitalizations with hyponatremia and 125 (29.0%) patients died within a year. 1-Year mortality rates were higher in patients with recurrent hospitalizations with hyponatremia than in patients with a single hospitalization with hyponatremia (42.5% vs. 23.8%; p<0.0001). Regression analysis showed that recurrent hospitalizations with hyponatremia were independently associated with 1-year mortality (odds ratio 1.9; 95% confidence interval 1.1-3.2; p=0.018). CONCLUSIONS: Recurrent hospitalizations with hyponatremia in older adults are common and associated with 1-year mortality.