The obstetrical emergency department: need, rationale, and guide to implementation.

The past 2 decades have seen dramatic growth in the number of obstetrics and gynecology hospitalists, and many hospitals have created obstetrical-specific emergency departments. The goals of an obstetrics emergency department are to provide safe and efficient care to the pregnant dyad and postpartum patient, while generating revenue for emergency services provided. In an obstetrics emergency department, all patients must be evaluated in person by a licensed practitioner, whereas historically they may have been evaluated in person by nursing staff or a trainee. We make the argument that formation of an obstetrics emergency department has the potential to improve the safety and quality of patient care. In addition, the financial benefits to institutions are substantial and can subsidize the cost of maintaining obstetrician presence all the time in the hospital. There are various regulatory requirements to become certified, accredited, and licensed as an emergency department. In addition, there are many operational and systems issues that institutions should consider before implementation. We provide a guide for healthcare systems considering creating an obstetrics emergency department.

Real-World Utilization of an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device.

OBJECTIVE: To assess the real-world effectiveness and safety of a U.S. Food and Drug Administration (FDA)-cleared intrauterine vacuum-induced-hemorrhage control device for postpartum hemorrhage (PPH) management. METHODS: Sixteen centers in the United States participated in this observational, postmarket registry medical record review (October 2020 through March 2022). The primary effectiveness outcome was treatment success , defined as bleeding control after insertion with no treatment escalation or bleeding recurrence. Additional outcomes included blood loss, time to device insertion, indwelling time, bleeding recurrence, and time to bleeding control. Treatment success and severe maternal morbidity measures (transfusion of 4 or more units of red blood cell, intensive care unit admission, and hysterectomy) were evaluated by blood loss before insertion. To assess safety, serious adverse events (SAEs) and adverse device effects were collected. All outcomes were summarized by mode of delivery; treatment success was summarized by bleeding cause (all causes, any atony, isolated atony, nonatony). RESULTS: In total, 800 individuals (530 vaginal births, 270 cesarean births) were treated with the device; 94.3% had uterine atony (alone or in combination with other causes). Median total blood loss at device insertion was 1,050 mL in vaginal births and 1,600 mL in cesarean births. Across all bleeding causes, the treatment success rate was 92.5% for vaginal births and was 83.7% for cesarean births (95.8% [n=307] and 88.2% [n=220], respectively, in isolated atony). Median indwelling time was 3.1 hours and 4.6 hours, respectively. In vaginal births, 14 SAEs were reported among 13 individuals (2.5%). In cesarean births, 22 SAEs were reported among 21 individuals (7.8%). Three (0.4%) SAEs were deemed possibly related to the device or procedure. No uterine perforations or deaths were reported. CONCLUSION: For both vaginal and cesarean births in real-world settings, rapid and effective bleeding control was achieved with an FDA-cleared intrauterine vacuum-induced hemorrhage-control device. The safety profile was consistent with that observed in the registrational trial (NCT02883673), and SAEs or adverse device effects were of the nature and severity expected in the setting of PPH. This device is an important new tool for managing a life-threatening condition, and timely utilization may help to improve obstetric hemorrhage outcomes. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT04995887.

PDZ Proteins SCRIB and DLG1 Regulate Myeloma Cell Surface CD86 Expression, Growth, and Survival.

Despite advances in the treatment of multiple myeloma in the past decades, the disease remains incurable, and understanding signals and molecules that can control myeloma growth and survival are important for the development of novel therapeutic strategies. One such molecule, CD86, regulates multiple myeloma cell survival via its interaction with CD28 and signaling through its cytoplasmic tail. Although the CD86 cytoplasmic tail has been shown to be involved in drug resistance and can induce molecular changes in multiple myeloma cells, its function has been largely unexplored. Here, we show that CD86 cytoplasmic tail has a role in trafficking CD86 to the cell surface. This is due in part to a PDZ-binding motif at its C-terminus which is important for proper trafficking from the Golgi apparatus. BioID analysis revealed 10 PDZ domain-containing proteins proximal to CD86 cytoplasmic tail in myeloma cells. Among them, we found the planar cell polarity proteins, SCRIB and DLG1, are important for proper CD86 surface expression and the growth and survival of myeloma cells. These findings indicate a mechanism by which myeloma cells confer cellular survival and drug resistance and indicate a possible motif to target for therapeutic gain. IMPLICATIONS: These findings demonstrate the importance of proper trafficking of CD86 to the cell surface in myeloma cell survival and may provide a new therapeutic target in this disease.

Best practices for the pregnant neurosurgical resident: balancing safety and education.

Establishment of a diverse neurosurgical workforce includes increasing the recruitment of women in neurosurgery. The impact of pregnancy on the training and career trajectory of female neurosurgeons poses a barrier to recruitment and retention of women in neurosurgery. A recent Women in Neurosurgery survey evaluated female neurosurgeons' perception and experience regarding childbearing of female neurosurgeons and identified several recommendations regarding family leave policies. Additionally, pregnancy may carry higher risk in surgical fields, yet little guidance exists to aid both the pregnant resident and her training program in optimizing the safety of the training environment with specific considerations to risks inherent in neurosurgical training. This review of current literature aims to address best practices that can be adopted by pregnant neurosurgery residents and their training programs to improve the well-being of these residents while considering the impact on their education and the educational environment for their colleagues.

Game of Bones: How Myeloma Manipulates Its Microenvironment.

Multiple myeloma is a clonal disease of long-lived plasma cells and is the second most common hematological cancer behind Non-Hodgkin's Lymphoma. Malignant transformation of plasma cells imparts the ability to proliferate, causing harmful lesions in patients. In advanced stages myeloma cells become independent of their bone marrow microenvironment and form extramedullary disease. Plasma cells depend on a rich array of signals from neighboring cells within the bone marrow for survival which myeloma cells exploit for growth and proliferation. Recent evidence suggests, however, that both the myeloma cells and the microenvironment have undergone alterations as early as during precursor stages of the disease. There are no current therapies routinely used for treating myeloma in early stages, and while recent therapeutic efforts have improved patients' median survival, most will eventually relapse. This is due to mutations in myeloma cells that not only allow them to utilize its bone marrow niche but also facilitate autocrine pro-survival signaling loops for further progression. This review will discuss the stages of myeloma cell progression and how myeloma cells progress within and outside of the bone marrow microenvironment.

Natural aminoacyl tRNA synthetase fragment enhances cardiac function after myocardial infarction.

A naturally-occurring fragment of tyrosyl-tRNA synthetase (TyrRS) has been shown in higher eukaryotes to 'moonlight' as a pro-angiogenic cytokine in addition to its primary role in protein translation. Pro-angiogenic cytokines have previously been proposed to be promising therapeutic mechanisms for the treatment of myocardial infarction. Here, we show that systemic delivery of the natural fragment of TyRS, mini-TyrRS, improves heart function in mice after myocardial infarction. This improvement is associated with reduced formation of scar tissue, increased angiogenesis of cardiac capillaries, recruitment of c-kitpos cells and proliferation of myocardial fibroblasts. This work demonstrates that mini-TyrRS has beneficial effects on cardiac repair and regeneration and offers support for the notion that elucidation of the ever expanding repertoire of noncanonical functions of aminoacyl tRNA synthetases offers unique opportunities for development of novel therapeutics.

Initiation and continuation rates seen in 2-year experience with Same Day injections of DMPA.

BACKGROUND: Women often need prompt initiation of effective contraception. Quick Start/Same Day Start protocols for combined hormonal contraceptive methods have been extensively studied. Experience with Same Day injections of longer-acting progestins is less well reported. The Same Day injection protocol is comprehensive and includes emergency contraception, backup methods for 7 days and repeat pregnancy testing within 2-3 weeks. STUDY DESIGN: This is a historical cohort study based on review of the charts of all women who received injections of depot medroxyprogesterone acetate (DMPA) at the Women's Health Care Clinic at the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center between January 1, 2003, and December 31, 2004. RESULTS: The study population included 1056 women who had a total of 3185 DMPA injections. More than 81% of the initial injections were given Same Day--outside the first 5 days of menses. At each reinjection, 14-27% of women were late and also benefited from rapid access to DMPA. Continuation rates were low in both groups but were not lower among those who utilized Same Day injections compared with On Time starters. Six pregnancies were diagnosed, all in the Same Day Start group. CONCLUSIONS: The introduction of DMPA as a Same Day injection policy is a safe and efficient way of providing women needed effective contraception within 7 days of the office visit.