Risk of Postpartum Hemorrhage in Hypertensive Disorders of Pregnancy: Stratified by Severity.

OBJECTIVE: We aimed to determine the composite maternal hemorrhagic outcome (CMHO) among individuals with and without hypertensive disorders of pregnancy (HDP), stratified by disease severity. Additionally, we investigated the composite neonatal adverse outcome (CNAO) among individuals with HDP who had postpartum hemorrhage (PPH) versus did not have PPH. STUDY DESIGN: Our retrospective cohort study included all singletons who delivered at a Level IV center over two consecutive years. The primary outcome was the rate of CMHO, defined as blood loss ≥1,000 mL, use of uterotonics, mechanical tamponade, surgical techniques for atony, transfusion, venous thromboembolism, intensive care unit admission, hysterectomy, or maternal death. A subgroup analysis was performed to investigate the primary outcome stratified by (1) chronic hypertension, (2) gestational hypertension and preeclampsia without severe features, and (3) preeclampsia with severe features. A multivariable regression analysis was performed to investigate the association of HDP with and without PPH on a CNAO which included APGAR <7 at 5 minutes, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, seizures, neonatal sepsis, meconium aspiration syndrome, ventilation >6 hours, hypoxic-ischemic encephalopathy, or neonatal death. RESULTS: Of 8,357 singletons, 2,827 (34%) had HDP. Preterm delivery <37 weeks, induction of labor, prolonged oxytocin use, and magnesium sulfate usage were more common in those with versus without HDP (p < 0.001). CMHO was higher among individuals with HDP than those without HDP (26 vs. 19%; adjusted relative risk [aRR] 1.11, 95% CI 1.01-1.22). In the subgroup analysis, only individuals with preeclampsia with severe features were associated with higher CMHO (n = 802; aRR 1.52, 95% CI 1.32-1.75). There was a higher likelihood of CNAO in individuals with both HDP and PPH compared to those with HDP without PPH (aRR 1.49, 95% CI 1.06-2.09). CONCLUSION: CMHO was higher among those with HDP. After stratification, only those with preeclampsia with severe features had an increased risk of CMHO. Among individuals with HDP, those who also had a PPH had worse neonatal outcomes than those without hemorrhage. KEY POINTS: · Individuals with HDP had an 11% higher likelihood of CMHO.. · After stratification, increased CMHO was limited to those with preeclampsia with severe features.. · There was a higher likelihood of CNAO in those with both HDP and PPH compared to HDP without PPH..

Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum.

Magnesium sulfate reduces the risk for eclamptic seizures antepartum, intrapartum, and in the immediate postpartum period, however, there are no studies that have evaluated the benefits and risks of magnesium sulfate among women with late postpartum severe hypertension only. Juxtaposed on this clinical uncertainty is the increased incidence of severe hypertension owing to a rise in pregnancies complicated by advanced maternal age, obesity, chronic hypertension, diabetes, and recent protocols for intensive monitoring of blood pressure in the postpartum period. These factors have led to a significant increase in postpartum presentations for the evaluation and management of severe hypertension, in some cases leading to postpartum readmissions for administration of antihypertensive therapy and magnesium sulfate without data demonstrating clear clinical benefit. Postpartum readmissions can have several negative consequences, including interfering with early bonding with a newborn, breastfeeding, and use of scarce healthcare resources. In addition, magnesium sulfate is associated with risks for serious cardiorespiratory depression and bothersome side effects and can delay determining the optimal antihypertensive regimen, which is typically the most pressing clinical need during postpartum presentations of late-postpartum severe hypertension. Eclampsia that occurs more than 48 hours after delivery is rare (constitutes 16% of all cases of eclampsia) and is most commonly preceded by headaches or other cerebral symptoms. In this commentary, we propose an approach to evaluating and managing patients with late postpartum severe hypertension aimed at identifying those women at highest risk for end-organ injury. We recommend that the short- and long-term focus for all patients with severe hypertension should be the optimal management of blood pressures with a goal of close outpatient monitoring when logistically feasible and clinically appropriate. We suggest reserving magnesium sulfate therapy for the subset of patients with neurologic symptoms who may be at highest risk for an eclamptic seizure.

Cytokine response over the course of COVID-19 infection in pregnant women.

OBJECTIVE: To study how severity and progression of coronavirus disease (COVID-19) affect cytokine profiles in pregnant women. MATERIALS AND METHODS: 69 third-trimester, pregnant women were tested for COVID-19 infection and SARS-CoV-2 specific IgM and IgG antibodies. Patients were stratified according to SARS-CoV-2 Reverse Transcriptase-PCR (RT-PCR) status and serology (IgM and IgG) status. Cytokines G-CSF, HGF, IL-18, IL-1Ra, IL-2Ra, IL-8, and IP-10 were measured via ELISA. Retrospective chart review for COVID-19 symptoms and patient vitals was conducted, and cytokine levels were compared between SARS-CoV-2 positive and negative cohorts, by seronegative and seropositive infection, by time course since onset of infection, and according to NIH defined clinical severity. RESULTS: IL-18, IL-1Ra, and IP-10 increased in the 44 RT-PCR positive pregnant women compared to the 25 RT-PCR negative pregnant controls. Elevated cytokine levels were found in early infections, defined by positive RT-PCR and seronegative status, and higher cytokine levels were also associated with more severe disease. By IgM seroconversion, IL-8 and IP-10 returned to levels seen in uninfected patients, while IL-18 levels remained significantly elevated. CONCLUSION: Cytokine profiles of third-trimester pregnant women vary with the time course of infection and are correlated with clinical severity.

Is Amniocentesis after CVS Risky?

OBJECTIVE: Approximately, 2% of women who undergo chorionic villi sampling (CVS) will subsequently undergo amniocentesis due to placental mosaicism or sampling/laboratory issues. Our objective was to compare obstetric outcomes in women who underwent both procedures with those who had CVS alone. STUDY DESIGN: Retrospective case-control study of patients with singleton pregnancies undergoing invasive testing from 2010 to 2020 was performed. All women who underwent CVS followed by amniocentesis were compared with a control group who underwent CVS alone matched (2:1) for age and year of pregnancy. Women with pregnancy loss at <16 weeks were excluded from the control group. Pregnancies terminated for genetic abnormalities were excluded. Obstetric outcomes were compared between cases and controls. Student t-test and Fisher's exact test were used for statistical comparison. RESULTS: During the study period 2,539 women underwent CVS, and 66 (2.6%) subsequently underwent amniocentesis. The 66 cases were compared with 132 age-matched controls who underwent CVS alone. Mean maternal age was 36.8 ± 3.4 years, and 43% of women were nulliparous. Amniocentesis was performed due to sampling or laboratory issues in 33% of cases, placental mosaicism in 44%, and further diagnostic testing in 23%. There were no pregnancy losses or stillbirths in either group. Those who had two invasive procedures delivered at similar gestational ages and birthweights and did not have higher rates of adverse outcomes compared with those who underwent CVS alone. CONCLUSION: Patients considering CVS who are concerned about the possibility that a second invasive procedure could be required should be reassured that this does not appear to be associated with higher rates of adverse outcomes. Due to study size, we cannot exclude the possibility of small differences in uncommon outcomes, such as pregnancy loss or stillbirth. KEY POINTS: · Amniocentesis may be recommended after CVS due to mosaicism, sampling issues, or further testing.. · Amniocentesis after CVS is not associated with pregnancy loss or other adverse outcomes compared.. · Patients who have both CVS and amniocentesis deliver at similar gestational ages and birthweights..

SARS-CoV-2 and Placental Pathology: Malperfusion Patterns Are Dependent on Timing of Infection During Pregnancy.

The extent to which severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at different points in the pregnancy timeline may affect maternal and fetal outcomes remains unknown. We sought to characterize the impact of SARS-CoV-2 infection proximate and remote from delivery on placental pathology. We performed a secondary analysis of placental pathology from a prospective cohort of universally tested SARS-CoV-2 positive women >20 weeks gestation at 1 institution. Subjects were categorized as having acute or nonacute SARS-CoV-2 based on infection <14 or ≥14 days from delivery admission, respectively, determined by nasopharyngeal swab, symptom history, and serologies, when available. A subset of SARS-CoV-2 negative women represented negative controls. Placental pathology was available for 90/97 (92.8%) of SARS-CoV-2 positive women, of which 26 were from women with acute SARS-CoV-2 infection and 64 were from women with nonacute SARS-CoV-2. Fetal vascular malperfusion lesions were significantly more frequent among the acute SARS-CoV-2 group compared with the nonacute SARS-CoV-2 group (53.8% vs. 18.8%; P=0.002), while frequency of maternal vascular malperfusion lesions did not differ by timing of infection (30.8% vs. 29.7%; P>0.99). When including 188 SARS-CoV-2 negative placentas, significant differences in frequency of fetal vascular malperfusion lesions remained between acute, nonacute and control cases (53.8% vs. 18.8% vs. 13.2%, respectively; P<0.001). No differences were noted in obstetric or neonatal outcomes between acutely and nonacutely infected women. Our findings indicate timing of infection in relation to delivery may alter placental pathology, with potential clinical implications for risk of thromboembolic events and impact on fetal health.

Association between low fetal fraction and hypertensive disorders of pregnancy in in vitro fertilization-conceived pregnancies.

BACKGROUND: Fetal fraction from noninvasive prenatal screening has been used as a predictive marker for hypertensive disorders of pregnancy in spontaneous pregnancies. OBJECTIVE: We aimed to determine whether fetal fraction from noninvasive prenatal screening predicts hypertensive disorders of pregnancy in pregnancies conceived by assisted reproductive technology, stratified by fresh and frozen embryo transfer. STUDY DESIGN: Retrospective cohort study of women with singleton pregnancies who underwent fresh or frozen embryo transfer, had noninvasive prenatal screening, and had a live birth >20 weeks at a single institution from 2013 to 2019. Women with major anomalies, nonreportable noninvasive prenatal screening, or chronic hypertension were excluded. Fetal fraction was corrected for gestational age, noninvasive prenatal screening platform, and defined as low if it is less than fifth percentile for the study population. The primary outcome was hypertensive disorders of pregnancy during delivery hospitalization, stratified by fresh vs frozen embryo transfer. We performed multivariable logistic regression analyses to determine whether low fetal fraction predicts hypertensive disorders of pregnancy for fresh and frozen embryo transfer, controlling for age, prepregnancy body mass index, heparin use, low-dose aspirin use, estradiol level if fresh embryo transfer, and trophectoderm biopsy and cycle type if frozen embryo transfer. RESULTS: We included 81 women with low fetal fraction and 847 women with normal fetal fraction. The adjusted prevalence of hypertensive disorders of pregnancy in women with low fetal fraction was 24.9% in fresh embryo transfer and 34.5% in frozen embryo transfer. In fresh embryo transfer pregnancies, the odds of hypertensive disorders of pregnancy were higher among women with low fetal fraction (adjusted odds ratio, 2.46; 95% confidence interval, 1.07-5.30; P=.026). In frozen embryo transfer pregnancies, there was no association between low fetal fraction and hypertensive disorders of pregnancy (adjusted odds ratio, 1.43; 95% confidence interval, 0.69-2.88; P=.321). CONCLUSION: Low fetal fraction is associated with hypertensive disorders of pregnancy in women who conceive by fresh embryo transfer. Fetal fraction may represent a clinically useful marker for screening for hypertension and allow clinicians to target risk reduction strategies, such as low-dose aspirin, in pregnancies conceived by fresh embryo transfer.

Laparoscopic management of a primary posterior cul-de-sac abdominal ectopic pregnancy.

OBJECTIVE: To report a case of laparoscopic management of a primary posterior cul-de-sac abdominal ectopic pregnancy (AEP). DESIGN: Video article. SETTING: Academic medical center. PATIENT(S): A 40-year-old G5P3013 woman at approximately 7 weeks of pregnancy was referred to our emergency department because of abnormally rising ß-human chorionic gonadotropin levels. Transvaginal ultrasonography revealed a cystic structure measuring 2.8 × 1.6 ×1.9 cm in the posterior cul-de-sac distinct from the cervix. The mass was noted to have peripheral hypervascularity and a thickened wall. A moderate amount of complex free fluid was noted adjacent to the mass. The patient's baseline ß-human chorionic gonadotropin level and hematocrit were 6,810.7 mIU/mL and 42.4%, respectively. INTERVENTION(S): Laparoscopy for suspected AEP. MAIN OUTCOME MEASURE(S): Laparoscopic excision of a primary AEP. RESULT(S): Diagnostic laparoscopy revealed a normal uterus, normal right ovary, normal left ovary with a corpus luteal cyst, and normal bilateral fallopian tubes without dilatation or hemorrhage. The AEP was noted in the right posterior cul-de-sac and was excised from the underlying peritoneum. The left lateral aspect of the AEP extended into the posterior vaginal wall. The patient was admitted for overnight observation, and her postoperative hematocrit was 35.1%. CONCLUSION(S): AEPs are extremely rare and account for 1% of all ectopic pregnancies. Approximately 90% of AEPs require surgical management. Historically, AEPs were treated with laparotomy because of the high risk of hemorrhage and hemodynamic instability. However, as exemplified by the current case, laparoscopy is a safe and feasible option for surgical management of AEPs.

Severe acute respiratory syndrome coronavirus 2 serology levels in pregnant women and their neonates.

BACKGROUND: Pregnant women and their neonates represent 2 vulnerable populations with an interdependent immune system that are highly susceptible to viral infections. The immune response of pregnant women to severe acute respiratory syndrome coronavirus 2 and the interplay of how the maternal immune response affects the neonatal passive immunity have not been studied systematically. OBJECTIVE: We characterized the serologic response in pregnant women and studied how this serologic response correlates with the maternal clinical presentation and with the rate and level of passive immunity that the neonate received from the mother. STUDY DESIGN: Women who gave birth and who tested positive for immunoglobulin M or immunoglobulin G against severe acute respiratory syndrome coronavirus 2 using semiquantitative detection in a New York City hospital between March 22, 2020, and May 31, 2020, were included in this study. A retrospective chart review of the cases that met the inclusion criteria was conducted to determine the presence of coronavirus disease 2019 symptoms and the use of oxygen support. Serology levels were compared between the symptomatic and asymptomatic patients using a Welch 2 sample t test. Further chart review of the same patient cohort was conducted to identify the dates of self-reported onset of coronavirus disease 2019 symptoms and the timing of the peak immunoglobulin M and immunoglobulin G antibody levels after symptom onset was visualized using local polynomial regression smoothing on log2-scaled serologic values. To study the neonatal serology response, umbilical cord blood samples of the neonates born to the subset of serology positive pregnant women were tested for serologic antibody responses. The maternal antibody levels of serology positive vs the maternal antibody levels of serology negative neonates were compared using the Welch 2 sample t test. The relationship between the quantitative maternal and quantitative neonatal serologic data was studied using a Pearson correlation and linear regression. A multiple linear regression analysis was conducted using maternal symptoms, maternal serology levels, and maternal use of oxygen support to determine the predictors of neonatal immunoglobulin G levels. RESULTS: A total of 88 serology positive pregnant women were included in this study. The antibody levels were higher in symptomatic pregnant women than in asymptomatic pregnant women. Serology studies in 34 women with symptom onset data revealed that the maternal immunoglobulin M and immunoglobulin G levels peak around 15 and 30 days after the onset of coronavirus disease 2019 symptoms, respectively. Furthermore, studies of 50 neonates born to this subset of serology positive women showed that passive immunity in the form of immunoglobulin G is conferred in 78% of all neonates. The presence of passive immunity is dependent on the maternal antibody levels, and the levels of neonatal immunoglobulin G correlate with maternal immunoglobulin G levels. The maternal immunoglobulin G levels and maternal use of oxygen support were predictive of the neonatal immunoglobulin G levels. CONCLUSION: We demonstrated that maternal serologies correlate with symptomatic maternal infection, and higher levels of maternal antibodies are associated with passive neonatal immunity. The maternal immunoglobulin G levels and maternal use of oxygen support, a marker of disease severity, predicted the neonatal immunoglobulin G levels. These data will further guide the screening for this uniquely linked population of mothers and their neonates and can aid in developing maternal vaccination strategies.

Surgical Management of Adnexal Masses in Pregnancy: A Systematic Review and Meta-analysis.

OBJECTIVE: The incidence of adnexal masses in pregnancy is 1% to 6%. Although surgery is often indicated, there are no definitive management guidelines. We aimed to investigate the optimal approach to surgical management of adnexal masses in pregnancy on the basis of a meta-analysis of previous studies. DATA SOURCES: We performed a systematic review using MEDLINE, Embase, Cochrane Library, and Clinicaltrials.gov from inception to July 17, 2020. METHODS OF STUDY SELECTION: There were no restrictions on study type, language, or publication date. Comparative and noncomparative retrospective studies that reviewed operative techniques used in surgery of adnexal masses in pregnancy were included. Meta-analyses were performed to assess outcomes. This study was registered in the International Prospective Register of Systematic Reviews (CRD42019129709). TABULATION, INTEGRATION, AND RESULTS: Comparative studies were identified for laparoscopy vs laparotomy and elective vs emergent surgery (11 and 4, respectively). Elective surgery is defined as a scheduled antepartum procedure. For laparoscopy vs laparotomy, the mean maternal ages and gestational ages at time of surgery were similar (27.8 years vs 27.7 years, p = .85; 16.2 weeks in laparoscopy vs 15.4 weeks in laparotomy, p = .59). Mass size was larger in those undergoing laparotomy (mean 8.8 cm vs 7.8 cm, p = .03). The most common pathologic condition was dermoid cyst (36%), and the risk of discovering a malignant tumor was 1%. Laparoscopy was not associated with a statistically increased risk of spontaneous abortion (SAB) or preterm delivery (PTD) (odds ratio [OR] 1.53; 95% confidence interval [CI], 0.67-3.52; p = .31 and OR 0.95; 95% CI, 0.47-1.89; p = .88, respectively). The mean length of hospital stay was 2.5 days after laparoscopy vs 5.3 days after laparotomy (p <.001). The decrease in estimated blood loss in laparoscopy was not statistically significant (94.0 mL in laparotomy vs 54.0 mL in laparoscopy, p = .06). Operative times were similar in laparoscopy and laparotomy (80.0 minutes vs 72.5 minutes, p = .09). Elective surgery was associated with a decreased risk of PTD (OR 0.13; 95% CI, 0.04-0.48; p = .05). Noncomparative studies were identified for laparoscopy and laparotomy. Laparotomy had more SABs and PTDs than laparoscopy (pooled proportion = 0.02 vs 0.07 and pooled proportion = 0.02 vs 0.14, respectively). CONCLUSION: Laparoscopy for the surgical management of adnexal masses in pregnancy is associated with shorter length of hospital stay and similar risk of SAB or PTD. Elective surgery is associated with a decreased risk of PTD.

Treatment patterns and outcomes among women with brain metastases from gynecologic malignancies.

BACKGROUND: Brain metastasis secondary to gynecologic malignancy is rare and has no definitive management guidelines. In this descriptive study, we aimed to identify prognostic factors and treatments that may be associated with longer overall survival. METHODS: Patients with brain metastases from gynecologic malignancies were identified between 2004 and 2019 at two institutions. Descriptive statistics were performed using N (%) and median (interquartile range). Univariate cox proportional hazards regression was performed to evaluate the effect of different factors on overall survival. RESULTS: 32 patients presented with brain metastasis from gynecologic primaries (ovarian/fallopian tube/primary peritoneal n = 14, uterine n = 11, cervical n = 7). Median age of initial cancer diagnosis was 61 (34-79). At initial cancer diagnosis 83% of patients were Stage III/IV and underwent surgery (66%), chemotherapy (100%), and/or pelvic radiation (33%). Median time from initial cancer diagnosis to brain metastasis was 18 months. Treatment of brain metastasis with surgery and radiation compared to stereotactic radiosurgery or whole brain radiation therapy alone revealed a trend toward longer overall survival (p = 0.07). Time from initial cancer diagnosis to brain metastasis was associated with longer overall survival with each one-month increase from initial cancer diagnosis associated with a 7% reduction in risk of death (HR 0.93, 95% CI = 0.89-0.97, p = 0.01). Initial cancer treatment, stage, histology, and number of brain lesions did not affect overall survival. CONCLUSIONS: Patients with brain metastasis secondary to gynecologic malignancies with the longest overall survival had the greatest lag time between initial cancer diagnosis and brain metastasis. Brain metastasis treated with surgery and radiation was associated with longer overall survival.

Multiple malignant transformations of an ovarian mature cystic teratoma.

BACKGROUND: Malignant transformation of mature cystic teratomas (MCTs) is a rare phenomenon. The most common histology of a malignant transformation is squamous cell carcinoma, and there are limited reports of multiple malignancies arising in a single MCT. Further data are necessary to guide management of these atypical cases. CASE: We present the case of a 48-year-old with MCT containing a malignant papillary thyroid carcinoma (PTC) arising in the context of struma ovarii and a carcinoid tumour. CONCLUSION: Malignant transformations of MCTs are exceedingly rare with no guidelines on management. We use this case to demonstrate an approach for the workup and management of malignantly transformed MCTs.

Inverse relationship between the evans index and cognitive performance in non-disabled, stroke-free, community-dwelling older adults. A population-based study.

OBJECTIVE: The Evans Index (EI) is used for recognition of individuals with normal pressure hydrocephalus. However, recent studies suggest that the EI is not a reliable marker of this condition. Rather, the EI may be inversely correlated with cognitive performance, but information on this correlation is lacking. We aimed to assess the relationship between the EI and cognitive performance in community-dwelling older adults. PATIENTS AND METHODS: The study included 314 non-disabled, stroke-free, individuals aged ≥60 years enrolled in the Atahualpa Project undergoing brain MRI and MoCA testing. Using generalized linear models, adjusted for demographics, cardiovascular risk factors edentulism, depression, global cortical atrophy and white matter hyperintensities of vascular origin, we assessed the relationship between the EI and cognitive performance. Predictive margins of the MoCA score according to percentiles of the EI were also evaluated, after adjusting for variables reaching significance in univariate models. RESULTS: The mean EI was 0.248 ±â€¯0.022 and the mean MoCA score was 19.7 ±â€¯4.8 points. A fully-adjusted generalized linear model showed a significant inverse relationship between the EI and the MoCA score. Predictive models showed a decrease in the MoCA score according to increased levels of the EI (ß: -3.28; 95% C.I.: -6.09 to -0.47; p = 0.022). CONCLUSION: The independent effect of the EI on the MoCA score provides evidence of the utility of the EI to evaluate cognitive performance.

Effect of academic status on outcomes of surgery for rectal cancer.

BACKGROUND: The purpose of our study was to investigate surgical outcomes following advanced colorectal procedures at academic versus community institutions. METHODS: The SPARCS database was used to identify patients undergoing Abdominoperineal resection (APR) and Low Anterior Resection between 2009 and 2014. Linear mixed models and generalized linear mixed models were used to compare outcomes. Laparoscopic versus open procedures, surgery type, volume status, and stoma formation between academic and community facilities were compared. RESULTS: Higher percentages of laparoscopic surgeries (58.68 vs. 41.32%, p value < 0.0001), more APR surgeries (64.60 vs. 35.40%, p value < 0.0001), more high volume hospitals (69.46 vs. 30.54%, p value < 0.0001), and less stoma formation (48.00 vs. 52.00%, p value < 0.0001) were associated with academic centers. After adjusting for confounding factors, academic facilities were more likely to perform APR surgeries (OR 1.35, 95% CI 1.04-1.74, p value = 0.0235). Minorities and Medicaid patients were more likely to receive care at an academic facility. Stoma formation, open surgery, and APR were associated with longer LOS and higher rate of ED visit and 30-day readmission. CONCLUSION: Laparoscopy and APR are more commonly performed at academic than community facilities. Age, sex, race, and socioeconomic status affect the facility at which and the type of surgery patients receive, thereby influencing surgical outcomes.

Academic status does not affect outcome following complex hepato-pancreato-biliary procedures.

INTRODUCTION: There is a growing debate regarding outcomes following complex hepato-pancreato-biliary (HPB) procedures. The purpose of our study is to examine if facility type has any impact on complications, readmission rates, emergency department (ED) visit rates, and length of stay (LOS) for patients undergoing HPB surgery. METHODS: The SPARCS administrative database was used to identify patients undergoing complex HPB procedures between 2012 and 2014 in New York. Univariate generalized linear mixed models were fit to estimate the marginal association between outcomes such as overall/severe complication rates, 30-day and 1-year readmission rates, 30-day and 1-year ED-visit rates, and potential risk factors. Univariate linear mixed models were used to estimate the marginal association between possible risk factors and LOS. Facility type, as well as any variables found to be significant in our univariate analysis (p = 0.05), was further included in the multivariable regression models. RESULTS: There were 4122 complex HPB procedures performed. Academic facilities were more likely to have a higher hospital volume (p < 0001). Surgery at academic facilities were less likely to have coexisting comorbidities; however, they were more likely to have metastatic cancer and/or liver disease (p = 0.0114, < 0. 0001, and = 0.0299, respectively). Postoperatively, patients at non-academic facilities experienced higher overall complication rates, and higher severe complication rates, when compared to those at academic facilities (p < 0.0001 and = 0.0018, respectively). Further analysis via adjustment for possible confounding factors, however, revealed no significant difference in the risk of severe complications between the two facility types. Such adjustment also demonstrated higher 30-day readmission risk in patients who underwent their surgery at an academic facility. CONCLUSION: No significant difference was found when comparing the outcomes of academic and non-academic facilities, after adjusting for age, gender, race, region, insurance, and hospital volume. Patients from academic facilities were more likely to be readmitted within the first 30-days after surgery.

Neuroimaging signatures of frailty: A population-based study in community-dwelling older adults (the Atahualpa Project).

AIMS: Frailty is a geriatric state of physical vulnerability that might be associated with cognitive decline in the absence of a concurrent neurodegenerative disorder. This assumes that neuroimaging studies are normal, but such examinations have rarely been considered for a frailty work-up. The present study identifies neuroimaging signatures in older adults interviewed with the Edmonton Frail Scale (EFS). METHODS: Community-dwellers aged ≥60 years enrolled in the Atahualpa Project were invited to undergo brain magnetic resonance imaging. Using generalized regression models, we evaluated the association between frailty and diffuse cortical and subcortical brain damage, after adjusting for relevant confounders. Multivariate models estimated the interaction of age in the association between frailty and these neuroimaging signatures. RESULTS: Out of 298 participants (mean age 70 ± 8 years, 57% women), 151 (51%) had moderate-to-severe cortical atrophy and 74 (25%) had moderate-to-severe white matter hyperintensities of presumed vascular origin. Mean EFS scores were 5 ± 3 points, with 140 (47%) individuals classified as robust, 65 (22%) as pre-frail and 93 (31%) as frail. Multivariate models showed a significant association between cortical atrophy with the continuous (P = 0.002) and the categorized (P = 0.008) EFS score. The relationship between white matter hyperintensities and the EFS was marginal. According to interaction models, prefrail or frail individuals aged ≥67 years presented more prominent neuroimaging signatures of diffuse cortical or subcortical damage than their robust counterparts. CONCLUSIONS: Neuroimaging signatures of frailty are mainly related to age. This reinforces the importance of early frailty detection to reduce its catastrophic consequences. Geriatr Gerontol Int 2017; 17: 270-276.

The Effect of Age in the Association between Frailty and Poor Sleep Quality: A Population-Based Study in Community-Dwellers (The Atahualpa Project).

PURPOSE: To assess the effect of age in the association between poor sleep quality and frailty status. DESIGN AND SETTING: Population-based, cross-sectional study conducted in Atahualpa, a rural village located in coastal Ecuador. METHODS: Out of 351 Atahualpa residents aged ≥ 60 years, 311 (89%) were interviewed with the Pittsburgh Sleep Quality Index (PSQI) and the Edmonton Frail Scale (EFS). The independent association between PSQI and EFS scores was evaluated by the use of a generalized linear model adjusted for relevant confounders. A contour plot with Shepard interpolation was constructed to assess the effect of age in this association. RESULTS: Mean score in the PSQI was 5 ± 2 points, with 34% individuals classified as poor sleepers. Mean score in the EFS was 5 ± 3 points, with 46% individuals classified as robust, 23% as prefrail, and 31% as frail. In the fully adjusted model, higher scores in the PSQI were significantly associated with higher scores in the EFS (ß 0.23; 95% CI 0.11-0.35; P < .0001). Several clusters depicted the strong effect of age in the association between PSQI and EFS scores. Older individuals were more likely to have high scores in the EFS and the PSQI, and younger individuals had low EFS scores and were good sleepers. Clusters of younger individuals who were poor sleepers and had high EFS scores accounted for the independent association between PSQI and EFS scores. CONCLUSIONS: This study shows the strong effect of age in the association between poor sleep quality and frailty status.