Differences in imaging and clinical characteristics are associated with higher rates of decompression-fusion versus decompression-alone in women compared to men for lumbar degenerative spondylolisthesis.

PURPOSE: The goals were to ascertain if differences in imaging/clinical characteristics between women and men were associated with differences in fusion for lumbar degenerative spondylolisthesis. METHODS: Patients had preoperative standing radiographs, CT scans, and intraoperative fluoroscopic images. Symptoms and comorbidity were obtained from patients; procedure (fusion-surgery or decompression-alone) was obtained from intraoperative records. With fusion surgery as the dependent variable, men and women were compared in multivariable logistic regression models with clinical/imaging characteristics as independent variables. The sample was dichotomized, and analyses were repeated with separate models for men and women. RESULTS: For 380 patients (mean age 67, 61% women), women had greater translation, listhesis angle, lordosis, and pelvic incidence, and less diastasis and disc height (all p ≤ 0.03). The rate of fusion was higher for women (78% vs. 65%; OR 1.9, p = 0.008). Clinical/imaging variables were associated with fusion in separate models for men and women. Among women, in the final multivariable model, less comorbidity (OR 0.5, p = 0.05), greater diastasis (OR 1.6, p = 0.03), and less anterior disc height (OR 0.8, p = 0.0007) were associated with fusion. Among men, in the final multivariable model, opioid use (OR 4.1, p = 0.02), greater translation (OR 1.4, p = 0.0003), and greater diastasis (OR 2.4, p = 0.0002) were associated with fusion. CONCLUSIONS: There were differences in imaging characteristics between men and women, and women were more likely to undergo fusion. Differences in fusion within groups indicate that decisions for fusion were based on composite assessments of clinical and imaging characteristics that varied between men and women.

Sex-Specific Postoperative Outcomes of Primary Total Hip Replacements: The Performance of Total Hip Replacement Procedures Leads to Worse Outcomes in Men.

INTRODUCTION: The demand for primary total hip arthroplasty (THA) is expected to increase significantly in the coming years, and women are expected to account for the greatest proportion of this increased demand. The purpose of this study was to determine, using a national database, the effect of sex on 90-day outcomes in primary THA patients while matching for confounding variables. Specifically, we evaluated: (1) in-hospital lengths of stay; (2) 90-day readmission rates; (3) 90-day medical complications; (4) and total global 90-day episode-of-care (EOC) costs in men and women. MATERIALS AND METHODS: Using the 100% Medicare Standard Analytical Files (SAF), a query from January 1, 2005 to March 31, 2014 from a nationwide database was performed to analyze patients who received a primary THA. The series was divided into two cohorts: men (n=436,737) and women (n=436,737). Male and female patients were matched according to age and Elixhauser-Comorbidity Index (ECI). Uni- and multi-variable regression analyses were performed to analyze the effects of sex on in-hospital lengths of stay, 90-day readmission rates, 90-day medical complications, and total global 90-day EOC costs. RESULTS: Men had greater overall 90-day medical complications compared to women following primary THA (1.28 vs. 1.19%, p<0.001). Men were found to have higher rates of acute kidney failure (0.12 vs 0.05%, p<0.0001), acute pancreatitis (0.02 vs. 0.01%, p<0.0001), cerebrovascular accidents (0.03 vs. 0.01%, p<0.0001), deep vein thromboses (0.06 vs. 0.04%, p<0.0001), and myocardial infarctions (0.02 vs. 0.01%, p<0.0001). Women were found to have higher rates of acute post-hemorrhagic anemiae (0.31 vs. 0.30%, p<0.001) and urinary tract infections (UTI; 0.40 vs. 0.28%, p<0.0001) compared to men. Men had shorter in-hospital lengths of stay (LOS) (3.42 vs. 3.54 days, p<0.001) but greater 90-day readmission rates (7.67 vs. 6.39% p<0.0001). Both cohorts had similar total global 90-day EOC costs ($14,869.85 ± $12,333.50 vs. $14,957.34 ± $10,915.61, p=0.36). CONCLUSION: Men undergoing THA have a greater number of overall 90-day medical complications and readmission rates while women have higher incidence of UTI, post-hemorrhagic anemia, and longer LOS. Understanding sex-based differences in complication rates and outcomes can help surgeons with preoperative counseling and targeted preoperative optimization.

Emerging Need for PROMs to Measure the Impact of Spine Disorders on Overall Health and Well-being: Measuring Expectations as an Example for Lumbar Degenerative Spondylolisthesis.

Background: Assessing the impact of spine disorders such as lumbar degenerative spondylolisthesis (LDS) on overall health is a component of quality of care that may not be comprehensively captured by spine-specific and single-attribute patient-reported outcome measures (PROMs). Purpose: We sought to compare PROMs to the Lumbar Surgery Expectations Survey ("Expectations Survey"), which addresses multiple aspects of health and well-being, and to compare the relevance of surgeon-selected versus survey-selected Patient-Reported Outcomes Measurement Information System (PROMIS) items to LDS. Methods: In a cross-sectional study, 379 patients with LDS preoperatively completed the Expectations Survey, Numerical Rating Pain Scales, Oswestry Disability Index (ODI), and PROMIS computer-adaptive physical function, pain, and mental health surveys. Expectations Survey scores were compared to PROMs with correlation coefficients (indicating strengths of relationships) and probability values (indicating associations by chance). Surgeons reviewed physical function questions to identify those particularly relevant to LDS. Results: Patients' mean age was 67 years, 64% were women, and 83% had single-level and 17% had multiple-level LDS. Probability values between the Expectations Survey and PROMs were reliable, but strengths of relationships were only mild to moderate, indicating PROMs did not comprehensively capture the impact of LDS. None of the surgeon-selected PROMIS physical function questions were posed to patients. Conclusion: This cross-sectional study found PROMs to be reliably associated but not strongly correlated with the Expectations Survey, which addresses the whole-patient impact of LDS. New measures that complement PROMIS and ODI should be developed to capture the whole-person effects of LDS and permit attribution of LDS treatments to overall health.

High preoperative expectations and postoperative fulfillment of expectations two years after decompression alone and decompression plus fusion for lumbar degenerative spondylolisthesis.

BACKGROUND CONTEXT: Fulfillment of expectations is a patient-centered outcome that has not been assessed based on fusion status for lumbar degenerative spondylolisthesis (LDS). PURPOSE: To compare preoperatively cited expectations and 2-year postoperative fulfillment of expectations between patients undergoing decompression alone (no-fusion) vs. decompression plus fusion (fusion) for LDS. STUDY DESIGN: Longitudinal cohort. PATIENT SAMPLE: A total of 357 patients. OUTCOME MEASURES: Postoperative version of Lumbar Spine Surgery Expectations Survey, Oswestry Disability Index (ODI), satisfaction with surgery. METHODS: Preoperatively patients completed the 20-item Expectations Survey measuring amount of 'improvement expected' for symptoms, physical function, and psychosocial well-being (score range 0-100); two years postoperatively patients completed the follow-up survey measuring 'improvement received'. The proportion of expectations fulfilled was calculated as 'improvement received' divided by 'improvement expected' (<1 some expectations fulfilled, >1 expectations surpassed). Patients also completed the ODI, SF-12 mental health subscale, satisfaction with surgery, and measures of comorbidity and psychosocial status, including social support (ie, help at home) and prior orthopedic surgery (ie, hip/knee arthroplasty). RESULTS: Patients' mean age was 67 years, 61% were women, 82% had single-level LDS, 73% had fusion, and mean follow-up was 26.2 months. Compared to patients with no-fusion, patients with fusion had more pain, spinal instability, use of opioids, disability, and greater preoperative Expectations Survey scores (69 vs 74, p=.008). The proportion of expectations fulfilled postoperatively was high and similar for both groups (.82 vs. .79, p=.40), but more variable for fusion (IQR .32 vs. .40). In multivariable analysis with the proportion as the dependent variable, fulfilled expectations was associated with better mental well-being (coeff=1.1, 95% CI 0.6-1.7, p=.0001) and more social support (coeff=3.3, 95% CI 1.1-5.6, p=.004) and unfulfilled expectations was associated with prior arthroplasty (coeff=-8.6, 95% CI -15.4-(-1.9), p=.01) and subsequent lumbar surgery (coeff=-15.6, 95% CI -25.2-(-6.0), p=.002). Similar associations were found for change in ODI and satisfaction. CONCLUSIONS: Patients had high preoperative expectations of surgery with greater expectations for decompression-fusion compared to decompression-alone. Although more variable for the fusion group, both groups had high proportions of expectations fulfilled. This study highlights the spectrum of clinical and psychosocial variables that impacts fulfillment of expectations for both decompression-alone and decompression-fusion for LDS surgery.

Instability Missed by Flexion-Extension Radiographs Subsequently Identified by Alternate Imaging in L4-L5 Lumbar Degenerative Spondylolisthesis.

STUDY DESIGN: Cross-sectional preoperative and intraoperative imaging study of L4-L5 lumbar degenerative spondylolisthesis (LDS). OBJECTIVE: To determine if alternate imaging modalities would identify LDS instability that did not meet the criteria for instability based on comparison of flexion and extension radiographs. SUMMARY OF BACKGROUND DATA: Pain may limit full flexion and extension maneuvers and thereby lead to underreporting of true dynamic translation and angulation in LDS. Alternate imaging pairs may identify instability missed by flexion-extension. MATERIALS AND METHODS: Consecutive patients scheduled for surgery for single-level L4-L5 LDS had preoperative standing radiographs in the lateral, flexion, and extension positions, supine computed tomography (CT) scans, and intraoperative fluoroscopic images in the supine and prone positions after anesthesia but before incision. Instability was defined as translation ≥3.5 mm or angulation ≥11° between the following pairs of images: (1) flexion-extension; (2) CT-lateral; (3) lateral-intraoperative supine; (4) lateral-intraoperative prone; and (5) intraoperative supine-prone. RESULTS: Of 240 patients (mean age 68 y, 54% women) 15 (6%) met the criteria for instability by flexion-extension, and 225 were classified as stable. Of these 225, another 84 patients (35% of total enrollment) were reclassified as unstable by comparison of CT-lateral images (21 patients) and by lateral-intraoperative images (63 patients). Nine of the 15 patients diagnosed with instability by flexion-extension had fusion (60%), and 68 of the 84 patients reclassified as unstable by other imaging pairs had fusion (81%) ( P =0.07). The 84 reclassified patients were more likely to undergo fusion compared with the 141 patients who persistently remained classified as stable (odds ratio=2.6, 95% CI: 1.4-4.9, P =0.004). CONCLUSIONS: Our study provides evidence that flexion and extension radiographs underreport the dynamic extent of LDS and therefore should not be solely relied upon to ascertain instability. These findings have implications for how instability should be established and the extent of surgery that is indicated.

Quantitative CT for Preoperative Assessment of Lumbar Degenerative Spondylolisthesis: The Unique Impact of L4 Bone Mineral Density on Single-Level Disease.

Background: Quantitative computed tomography (qCT) efficiently measures 3-dimensional vertebral bone mineral density (BMD), but its utility in measuring BMD at various vertebral levels in patients with lumbar degenerative spondylolisthesis (LDS) is unclear. Purpose: We sought to determine whether qCT could differentiate BMD at different levels of LDS, particularly at L4-L5, the most common single level for LDS. In addition, we sought to describe patterns of BMD for single-level and multiple-level LDS. Methods: We conducted a study of patients undergoing surgery for LDS who were part of a larger longitudinal study comparing preoperative and intraoperative images. Preoperative patients were grouped as single-level or multiple-level LDS, and qCT BMD was obtained for L1-S1 vertebrae. Mean BMD was compared with literature reports; in multivariable analyses, BMD of each vertebra was assessed according to the level of LDS, controlling for covariates and for BMD of other vertebrae. Results: Of 250 patients (mean age: 67 years, 64% women), 22 had LDS at L3-L4 only, 170 at L4-L5 only, 13 at L5-S1 only, and 45 at multiple levels. Compared with other disorders reported in the literature, BMD in our sample similarly decreased from L1 to L3 then increased from L4 to S1, but mean BMD per vertebra in our sample was lower. Nearly half of our sample met criteria for osteopenia. In multivariable analysis controlling for BMD at other vertebrae, lower L4 BMD was associated with LDS at L4-L5, greater pelvic incidence minus lumbar lordosis, and not having diabetes. In contrast, in similar multivariable analysis, greater L4 BMD was associated with LDS at L3-L4. Bone mineral density of L3 and L5 was not associated with LDS levels. Conclusion: In our sample of preoperative patients with LDS, we observed lower BMD for LDS than for other lumbar disorders. L4 BMD varied according to the level of LDS after controlling for covariates and BMD of other vertebrae. Given that BMD can be obtained from routine imaging, our findings suggest that qCT data may be useful in the comprehensive assessment of and strategy for LDS surgery. More research is needed to elucidate the cause-effect relationships among spinopelvic alignment, LDS, and BMD.

Association between SARS-CoV-2 Infection and Adverse Perinatal Outcomes in a Large Health Maintenance Organization.

OBJECTIVE: This study aimed to examine whether severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection during pregnancy is associated with increased odds of perinatal complications and viral transmission to the infant. STUDY DESIGN: A retrospective cohort study of women who delivered at Kaiser Permanente Southern California hospitals (April 6, 2020-February 28, 2021) was performed using data extracted from electronic health records (EHRs). During this time polymerize chain reaction (PCR)-based tests for SARS-CoV-2 was universally offered to all pregnant women at labor and delivery admission, as well as earlier in the pregnancy, if they were displaying symptoms consistent with SARS-CoV-2 infection or a possible exposure to the virus. Adjusted odds ratio (aOR) was used to estimate the strength of associations between positive test results and adverse perinatal outcomes. RESULTS: Of 35,123 women with a singleton pregnancy, 2,203 (6%) tested positive for SARS-CoV-2 infection with 596 (27%) testing positive during the first or second trimester and 1,607 (73%) during the third trimester. Women testing positive were younger than those who tested negative (29.7 [5.4] vs. 31.1 [5.3] years; mean [standard deviation (SD)]; p < .001). The SARS-CoV-2 infection tended to increase the odds of an abnormal fetal heart rate pattern (aOR: 1.10; 95% confidence interval [CI]: 1.00, 1.21; p = 0.058), spontaneous preterm birth (aOR: 1.28; 95% CI: 1.03, 1.58; p = 0.024), congenital anomalies (aOR: 1.69; 95% CI: 1.15, 2.50; p = 0.008), and maternal intensive care unit admission at delivery (aOR: 7.44; 95% CI: 4.06, 13.62; p < 0.001) but not preeclampsia/eclampsia (aOR: 1.14; 95% CI: 0.98, 1.33; p = 0.080). Eighteen (0.8%) neonates of mothers who tested positive also had a positive SARS-CoV-2 test after 24 hours of birth, but all were asymptomatic during the neonatal period. CONCLUSION: These findings suggest that prenatal SARS-CoV-2 infection increases the odds of some adverse perinatal outcomes. The likelihood of vertical transmission from the mother to the fetus was low (0.3%), suggesting that pregnancy complications resulting from SARS-CoV-2 infection pose more risk to the baby than transplacental viral transmission. KEY POINTS: · SARS-CoV-2 infection is associated with increased odds of adverse perinatal outcomes.. · The odds of specific adverse outcomes were greater when a mother was infected earlier in pregnancy.. · The proportion of vertical transmission from mother to fetus was 0.3%.

Proximal and distal reciprocal changes following cervical deformity malalignment correction.

OBJECTIVE: Hyperextension of C0-2 is a debilitating compensatory mechanism used to maintain horizontal gaze, analogous to high pelvic tilt in the lumbopelvic complex to maintain an upright posture. This study aims to investigate the impact of cervical deformity (CD) correction on this hyperextension. The authors hypothesize that correction of cervical sagittal malalignment allows for relaxation of C0-2 hyperextension and improved clinical outcomes. METHODS: A retrospective review was conducted of a multicenter database of patients with CD undergoing spinal realignment and fusion caudal to C2 and cephalad to the pelvis. Range of motion (ROM) and reserve of extension (ROE) were calculated across C2-7 and C0-2. The association between C2-7 correction and change in C0-2 ROE was investigated while controlling for horizontal gaze, followed by stratification into ΔC2-7 percentiles. RESULTS: Sixty-five patients were included (mean age 61.8 ± 9.6 years, 68% female). At baseline, patients had cervical kyphosis (C2-7, -11.7° ± 18.2°; T1 slope-cervical lordosis mismatch, 38.6° ± 18.6°), negative global alignment (sagittal vertical axis [SVA] -12.8 ± 71.2 mm), and hyperlordosis at C0-2 (mean 33.2° ± 11.8°). The mean ROM was 25.7° ± 17.7° and 21.3° ± 9.9° at C2-7 and C0-2, respectively, with an ROE of approximately 9° for each segment. Limited C0-2 ROM and ROE correlated with the Neck Disability Index (r = -0.371 and -0.394, p < 0.01). The mean number of levels fused was 7.0 ± 3.1 (24.6% anterior, 43.1% posterior), with 87.7% undergoing at least an osteotomy. At 1 year, mean C2-7 increased to 5.5° ± 13.4°, SVA became neutral (11.5 ± 54.8 mm), C0-2 hyperlordosis decreased to 27.8° ± 11.7°, and thoracic kyphosis (TK) increased to -49.4° ± 18.1° (all p < 0.001). Concurrently, mean C0-2 ROM increased to 27.6° ± 8.1° and C2-7 ROM decreased significantly to 9.0° ± 12.3° without a change in ROE. Controlling for horizontal gaze, change in C2-7 lordosis significantly correlated with increased TK (r = -0.617, p < 0.001), decreased C0-2 (r = -0.747, p < 0.001), and increased C0-2 ROE (r = 0.550, p = 0.002). CONCLUSIONS: CD correction can significantly impact cephalad and caudal compensation in the upper cervical and thoracic spine. Restoration of cervical alignment resulted in increased C0-2 ROE and TK and was also associated with improved clinical outcome.

Complication rate evolution across a 10-year enrollment period of a prospective multicenter database.

OBJECTIVE: Adult spinal deformity is a complex pathology that benefits greatly from surgical treatment. Despite continuous innovation, little is known regarding continuous changes in surgical techniques and the complications rate. The objective of the current study was to investigate the evolution of the patient profiles and surgical complications across a single prospective multicenter database. METHODS: This study is a retrospective review of a prospective, multicenter database of surgically treated patients with adult spinal deformity (thoracic kyphosis > 60°, sagittal vertical axis > 5 cm, pelvic tilt > 25°, or Cobb angle > 20°) with a minimum 2-year follow-up. Patients were stratified into 3 equal groups by date of surgery. The three groups' demographic data, preoperative data, surgical information, and complications were then compared. A moving average of 320 patients was used to visualize and investigate the evolution of the complication across the enrollment period. RESULTS: A total of 928/1260 (73.7%) patients completed their 2-year follow-up, with an enrollment rate of 7.7 ± 4.1 patients per month. Across the enrollment period (2008-2018) patients became older (mean age increased from 56.7 to 64.3 years) and sicker (median Charlson Comorbidity Index rose from 1.46 to 2.08), with more pure sagittal deformity (type N). Changes in surgical treatment included an increased use of interbody fusion, more anterior column release, and a decrease in the 3-column osteotomy rate, shorter fusion, and more supplemental rods and bone morphogenetic protein use. There was a significant decrease in major complications associated with a reoperation (from 27.4% to 17.1%) driven by a decrease in radiographic failures (from 12.3% to 5.2%), despite a small increase in neurological complications. The overall complication rate has decreased over time, with the lowest rate of any complication (51.8%) during the period from August 2014 to March 2017. Major complications associated with reoperation decreased rapidly in the 2014-2015. Major complications not associated with reoperation had the lowest level (21.0%) between February 2014 and October 2016. CONCLUSIONS: Despite an increase in complexity of cases, complication rates did not increase and the rate of complications leading to reoperation decreased. These improvements reflect the changes in practice (supplemental rod, proximal junctional kyphosis prophylaxis, bone morphogenetic protein use, anterior correction) to ensure maintenance of status or improved outcomes.

A double-blinded randomized controlled trial on the effects of increased intravenous hydration in nulliparas undergoing induction of labor.

BACKGROUND: Rates of labor induction are increasing, raising concerns related to increased healthcare utilization costs. High-dose intravenous fluid (250 cc/h) has been previously demonstrated to shorten the time to delivery in nulliparous individuals in spontaneous labor. Whether or not this relationship exists among individuals undergoing induction of labor is unknown. OBJECTIVE: Our study aimed to evaluate the effect of high-dose intravenous hydration on time to delivery among nulliparous individuals undergoing induction of labor. STUDY DESIGN: Nulliparous individuals presenting for induction of labor with a Bishop score of ≤6 (with and without rupture of membranes) were randomized to receive either 125 cc/h or 250 cc/h of normal saline. The primary outcome was length of labor (defined as time from initiation of study fluids to delivery). Both time to overall delivery and vaginal delivery were evaluated. Secondary outcomes included the lengths of each stage of labor, the percentage of individuals delivering within 24 hours, and maternal and neonatal outcomes, including cesarean delivery rate. RESULTS: A total of 180 individuals meeting inclusion criteria were enrolled and randomized. Baseline demographic characteristics were similar between groups; however, there was a higher incidence of diabetes mellitus in the group receiving 125 cc/h. Average length of labor was similar between groups (27.6 hours in 250 cc/h and 27.8 hours in 125 cc/h), as was the length of each stage of labor. Cox regression analysis did not demonstrate an effect of fluid rate on time to delivery. Neither the admission Bishop score, body mass index, nor other demographic characteristics affected time to delivery or vaginal delivery. There were no differences in maternal or neonatal outcomes, including overall cesarean delivery rate, clinically apparent iatrogenic intraamniotic infection, Apgar scores, need for neonatal phototherapy, or neonatal intensive care unit stay. CONCLUSION: There were no observed differences in the length of labor or maternal or neonatal outcomes with the administration of an increased rate of intravenous fluids among nulliparous individuals undergoing induction of labor.

The Influence of Intrapersonal, Interpersonal, and Community Protective Factors on Hong Kong Adolescents' Stress Arising from Political Life Events and Their Mental Health.

Precarious political circumstances can take a mental toll on young people. Adopting a socio-ecological perspective, this study investigated the influence of stress arising from political life events, intrapersonal factors (i.e., meaning in life, resilience), interpersonal factors (i.e., social support, associational social capital), and community factors (i.e., perceived empowerment in the community, perceived opportunities for civic engagement) on the mental health of youth in Hong Kong. Furthermore, it examined the moderating effects of these factors on the relationship between stress arising from political life events and mental health. A cross-sectional quantitative survey with a stratified purposive sampling data collection method was conducted. A total of 1330 secondary school students were recruited for this study. Multiple regression analysis was performed to examine both direct and moderation effects. The results indicate that high stress arising from political life events, low meaningfulness in life, low resilience, low social support, low youth empowerment in the community, and high civic engagement in the community were related to high mental distress. None of the presumed moderators moderated the relationship between stress due to political life events and mental distress. Assessing and addressing stress due to political life events would be potentially important in mental health programs for Hong Kong adolescents in precarious political situations.

Pregnancy Outcomes Associated With a Single Elevated Blood Pressure Before 20 Weeks of Gestation.

OBJECTIVE: To evaluate maternal and fetal outcomes among women with a single elevated blood pressure before 20 weeks of gestation. METHODS: We conducted a retrospective cohort study of women who delivered at Kaiser Permanente Southern California hospitals between January 1, 2008, and December 31, 2019. Participants were divided into two groups: normotensive (all systolic blood pressures lower than 130 mm Hg and diastolic pressures lower than 80 mm Hg) compared with single elevated blood pressure (single systolic pressure 130 mm Hg or higher, diastolic pressure 80 mm Hg or higher, or both). Women with chronic hypertension were excluded. Maternal comorbidities and maternal and neonatal outcomes were extracted from electronic health records using International Classification of Diseases codes. Adjusted odds ratios (aORs) derived from logistic regression were used to describe the magnitude of association. RESULTS: Of 303,689 women who delivered during the study period, 23% had a single elevated blood pressure. Rates of hypertensive disorders of pregnancy differed between the two groups (10.6% for single elevated blood pressure, 4.5% for normotensive group; aOR 2.06, 95% CI 2.00-2.13), as did iatrogenic preterm delivery (3.7% vs 2.7%, respectively; aOR 1.27, 95% CI 1.21-1.33). DISCUSSION: Women with a single elevated blood pressure before 20 weeks of gestation are at increased risk for hypertensive disorders of pregnancy and iatrogenic preterm delivery.

A Genome-Wide RNAi Screen for Enhancers of a Germline Tumor Phenotype Caused by Elevated GLP-1/Notch Signaling in Caenorhabditis elegans.

Stem cells are tightly controlled in vivo Both the balance between self-renewal and differentiation and the rate of proliferation are often regulated by multiple factors. The Caenorhabditis elegans hermaphrodite germ line provides a simple and accessible system for studying stem cells in vivo In this system, GLP-1/Notch activity prevents the differentiation of distal germ cells in response to ligand production from the nearby distal tip cell, thereby supporting a stem cell pool. However, a delay in germline development relative to somatic gonad development can cause a pool of undifferentiated germ cells to persist in response to alternate Notch ligands expressed in the proximal somatic gonad. This pool of undifferentiated germ cells forms a proximal tumor that, in adulthood, blocks the oviduct. This type of "latent niche"-driven proximal tumor is highly penetrant in worms bearing the temperature-sensitive weak gain-of-function mutation glp-1(ar202) at the restrictive temperature. At the permissive temperature, few worms develop tumors. Nevertheless, several interventions elevate the penetrance of proximal tumor formation at the permissive temperature, including reduced insulin signaling or the ablation of distal-most sheath cells. To systematically identify genetic perturbations that enhance proximal tumor formation, we sought genes that, upon RNAi depletion, elevate the percentage of worms bearing proximal germline tumors in glp-1(ar202) at the permissive temperature. We identified 43 genes representing a variety of functional classes, the most enriched of which is "translation". Some of these genes also influence the distal germ line, and some are conserved genes for which genetic interactions with Notch were not previously known in this system.

Universal SARS-Cov-2 Screening in Women Admitted for Delivery in a Large Managed Care Organization.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has created a need for data regarding the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnant women. After implementing universal screening for COVID-19 in women admitted for delivery, we sought to describe the characteristics of COVID-19 in this large cohort of women. STUDY DESIGN: An observational study of women admitted to labor and delivery units in Kaiser Permanente Southern California (KPSC) hospitals between April 6 and May 11, 2020 who were universally offered testing for SARS-CoV-2 infection (n = 3,963). Hospital inpatient and outpatient physician encounter, and laboratory records were used to ascertain universal testing levels, test results, and medical and obstetrical histories. The prevalence of SARS-CoV-2 infection was estimated from the number of women who tested positive during labor per 100 women delivered. RESULTS: Of women delivered during the study period, 3,923 (99.0%) underwent SARS-CoV-2 testing. A total of 17 (0.43%; 95% confidence interval: 0.23-0.63%) women tested positive, and none of them were symptomatic on admission. There was no difference in terms of characteristics between SARS-CoV-2 positive and negative tested women. One woman developed a headache attributed to COVID-19 3 days postpartum. No neonates had a positive test at 24 hours of life. CONCLUSION: The findings suggest that in pregnant women admitted for delivery between April 6 and May 11, 2020 in this large integrated health care system in Southern California, prevalence of SARS-CoV-2 test positive was very low and all patients were asymptomatic on admission. KEY POINTS: · The prevalence of SARS-CoV-2 infection in a large diverse cohort of term pregnant women was 0.43%.. · 99% of women accepted SARS-CoV-2 screening on admission to labor and delivery.. · All women with positive test results were asymptomatic at the time of testing..

Dextrose intravenous fluid therapy in labor reduces the length of the first stage of labor.

The aim of this systematic review with meta-analysis was to evaluate the effect on length of labor when patients receive IVF with or without dextrose. Searches were performed in electronic databases from inception of each database to May 2018. Trials comparing intrapartum IVF containing dextrose (i.e. intervention group) with no dextrose or placebo (i.e. control group) were included. Only trials examining low-risk pregnancies in labor at ≥36 weeks were included. Studies were included regardless of oral intake restriction. The primary outcome was the length of total labor from randomization to delivery. The meta-analysis was performed using the random effects model. Sixteen trials (n = 2503 participants) were included in the meta-analysis. Women randomized in the IVF dextrose group did not have a statistically significant different length of total labor from randomization to delivery compared to IVF without dextrose (MD -38.33 min, 95% CI -88.23 to 11.57). IVF with dextrose decreased the length of the first stage (MD -75.81 min, 95% CI -120.67 to -30.95), but there was no change in the second stage. In summary, use of IVF with dextrose during labor in low-risk women at term does not affect total length of labor, but it does shorten the first stage of labor.

Supplemental Oxygen Study: A Randomized Controlled Study on the Effect of Maternal Oxygen Supplementation during Planned Cesarean Delivery on Umbilical Cord Gases.

OBJECTIVE: The aim was to determine the fetal umbilical blood gas effects of supplemental maternal oxygenation compared with room air (RA) during term planned cesarean delivery. METHODS: This is a prospective randomized controlled study of singleton planned cesarean deliveries randomized to receive supplemental oxygen (O2) at 10 L per minute (L/min) via facemask or RA. Umbilical cord gases were collected. The primary outcome was umbilical arterial pH level. Secondary outcomes included umbilical cord values and maternal and neonatal outcomes. Data were expressed as median ± interquartile range (IQR). RESULTS: Seventy subjects in total were enrolled, with 65 subjects available for analysis. The median umbilical arterial pO2 was significantly increased in the supplemental O2 group (18 [13.5-20.5] mm Hg) versus RA group (16 [12-18] mm Hg), p = 0.04). The median umbilical venous pO2 was significantly increased in the supplemental O2 group (32 [26.5-36.0] mm Hg) versus RA group (28.5 [22-34.3] mm Hg), p = 0.04). There were no significant differences with other umbilical blood gas values and composite maternal or neonatal complications. CONCLUSION: Subjects with term singleton gestations receiving O2 at 10 L/min during cesarean delivery compared with RA demonstrated no significant change in umbilical cord pH values. There was a significant increase in umbilical cord arterial and venous O2 levels in those receiving O2.

Multiple sclerosis in pregnancy: prevalence, sociodemographic features, and obstetrical outcomes.

OBJECTIVE: We sought to describe the prevalence, sociodemographic features, and antenatal/peripartum outcomes of multiple sclerosis (MS) in pregnancy. STUDY DESIGN: A retrospective cohort study was performed using deliveries in California from 2001 to 2009. Cases of MS as well as other morbidities were identified via ICD-9-CM code. Logistic regression was performed to adjust for potential confounders. RESULTS: About 1185 out of 4,424,049 deliveries were complicated by MS. MS prevalence increased with maternal age, with Caucasians comprising a higher proportion of MS subjects. MS subjects were older and more likely to have private insurance. Women with MS were more likely to have preexisting medical conditions such as asthma, chronic hypertension, thyroid disease, or cardiac disease. However, no significant antepartum and peripartum morbidities were found to be increased in patients with MS. Urinary tract infection, cesarean delivery, and induction of labor were slightly increased in MS patients. CONCLUSIONS: MS is a rare condition which is more likely to affect older Caucasian women of higher socioeconomic status and is associated with several preexisting medical conditions. MS, however, does not appear to pose significant increases in adverse pregnancy outcome. This suggests that pregnant patients with MS may likely experience an uneventful pregnancy.

A randomized, double-blinded, controlled trial of the effects of fluid rate and/or presence of dextrose in intravenous fluids on the labor course of nulliparas.

BACKGROUND: Prolonged labor has been demonstrated to increase adverse maternal and neonatal outcome. A practice that may decrease the risk of prolonged labor is the modification of fluid intake during labor. OBJECTIVE: Several studies demonstrated that increased hydration in labor as well as addition of dextrose-containing fluids may be associated with a decrease in length of labor. The purpose of our study was to characterize whether high-dose intravenous fluids, standard-dose fluids with dextrose, or high-dose fluids with dextrose show a difference in the duration of labor in nulliparas. STUDY DESIGN: Nulliparous subjects with singletons who presented in active labor were randomized to 1 of 3 groups of intravenous fluids: 250 mL/h of normal saline, 125 mL/h of 5% dextrose in normal saline, or 250 mL/h of 2.5% dextrose in normal saline. The primary outcome was total length of labor from initiation of intravenous fluid in vaginally delivered subjects. Secondary outcomes included cesarean delivery rate and length of second stage of labor, among other maternal and neonatal outcomes. RESULTS: In all, 274 subjects who met inclusion criteria were enrolled. There were no differences in baseline characteristics among the 3 groups. There was no difference in the primary outcome of total length of labor in vaginally delivered subjects among the 3 groups. First stage of labor duration, second stage of labor duration, and cesarean delivery rates were also equivalent. There were no differences identified in other secondary outcomes including clinical chorioamnionitis, postpartum hemorrhage, blood loss, Apgar scores, or neonatal intensive care admission. CONCLUSION: There is no difference in length of labor or delivery outcomes when comparing high-dose intravenous fluids, addition of dextrose, or use of high-dose intravenous fluids with dextrose in nulliparous women who present in active labor.

Maternal and neonatal outcomes after antenatal corticosteroid administration for PPROM at 32 to 33 6/7 weeks gestational age.

BACKGROUND: Preterm Premature Rupture of Membranes (PPROM) precedes many deliveries and experts agree with expectant management until 34 weeks gestation. However, there is controversy regarding the gestational age (GA) for administration of corticosteroids. STUDY DESIGN: We performed a retrospective cohort study in the University of California Fetal Consortium (UCfC). We searched available charts of singleton pregnancies with PPROM between 32 and 33 6/7 weeks GA. Outcomes from the groups were analyzed. RESULTS: Of 191 women with PPROM at 32 to 33 6/7 weeks, 150 received corticosteroids. The median GA at admission was earlier for the exposed versus unexposed group (32 4/7 versus 33 0/7 weeks, respectively, p = 0.001). The mean GA at delivery in the exposed was 33 2/7 (32 0/7 to 35 0/7) weeks versus 33 5/7 (32 0/7 to 36 1/7) weeks in the unexposed (p = 0.001). There was no difference in chorioamnionitis or RDS. CONCLUSION: In women with PPROM at 32 to 33 6/7 weeks, our data suggests that corticosteroids are associated with similar outcomes despite earlier GA at delivery and no differences in major morbidities. A larger prospective study is needed to determine if the benefit of corticosteroids outweighs the potential risks in PPROM.

Effect of antenatal betamethasone on blood glucose levels in women with and without diabetes.

OBJECTIVE: To characterize the maternal glycemic response to betamethasone in subjects without diabetes compared to subjects with diabetes. STUDY DESIGN: Blood glucose levels in 22 gravidae without diabetes and 11 gravidae with diabetes were recorded for 48h following betamethasone administration for threatened preterm delivery. Maximum blood glucose value and time to maximum value were compared. Area under the curve calculations were used to express the duration and degree of significant hyperglycemia for individual subjects. These summary measures were then correlated to subject characteristics and laboratory values to determine a risk profile of those subjects without diabetes at risk for significant hyperglycemia. RESULTS: All subjects with diabetes and the majority of those without diabetes had significant hyperglycemia during the study period. Mean maximum blood glucose was higher for those with diabetes (205mg/dL vs. 173mg/dL, p⩽0.01). Mean time to reach the maximum glucose level was similar for both groups. Result of a glucose tolerance test given immediately prior to betamethasone correlated strongly with amount of time spent with hyperglycemia for subjects without diabetes (rho=0.59, p⩽0.01). Morbidly obese subjects spent less time with hyperglycemia than those with lower body mass indices (p=0.03). CONCLUSION: Both subjects with and without diabetes demonstrate significant hyperglycemia after receipt of antenatal betamethasone.