Accuracy of sonographic lower segment thickness and prediction of vaginal birth after caesarean in a resourced-limited setting; Prospective study.

OBJECTIVES: To assess the accuracy of ultrasound measurement of the lower uterine segment (LUS) thickness against findings at laparotomy, and to investigate its correlation with the success rate of vaginal birth after one previous caesarean delivery (CD) in a resource-limited setting. DESIGN: Prospective study. SETTING: Obstetrics and Gynaecology department in a tertiary hospital in Ghana. POPULATION: Women with one previous CD undergoing either a trial of labour (TOLAC) or elective CD. METHODS: Myometrial lower uterine segment thickness (mLUS) and full lower uterine segment thickness (fLUS) were measured with transvaginal ultrasound (TVUS). The women were managed according to local protocols with the clinicians blinded to the ultrasound measurements. The LUS was measured intraoperatively for comparison with ultrasound measurements. MAIN OUTCOME MEASURES: Lower uterine segment findings at laparotomy, successful vaginal birth. RESULTS: A total of 311 pregnant women with one previous CD were enrolled; 147 women underwent elective CD and 164 women underwent a TOLAC. Of the women that underwent TOLAC, 96 (58.5%) women had a successful vaginal birth. The mLUS was comparable to the intraoperative measurement in the elective CD group with LUS thickness <5 mm (bias of 0.01, 95% CI -0.10 to 0.12 mm) whereas fLUS overestimated LUS <5 mm (bias of 0.93, 95% CI 0.80-1.06 mm). Successful vaginal birth rate correlated with increasing mLUS values (odds ratio 1.30, 95% CI 1.03-1.64). Twelve cases of uterine defect were recorded. LUS measurement ≤2.0 mm was associated with an increased risk of uterine defects with a sensitivity of 91.7% (95% CI 61.5-99.8%) and specificity of 81.8% (95% CI 75.8-86.8%). CONCLUSION: Accurate TVUS measurement of the LUS is technically feasible in a resource-limited setting. This approach could help in making safer decisions on mode of birth in limited-resource settings.

Patient and Public Involvement and Engagement in the Development of a Platform Clinical Trial for Parkinson's Disease: An Evaluation Protocol.

Background: Patient and public involvement and engagement (PPIE) in the design of trials is important, as participant experience critically impacts delivery. The Edmond J Safra Accelerating Clinical Trials in PD (EJS ACT-PD) initiative is a UK consortium designing a platform trial for disease modifying therapies in PD. Objective: The integration of PPIE in all aspects of trial design and its evaluation throughout the project. Methods: PwP and care partners were recruited to a PPIE working group (WG) via UK Parkinson's charities, investigator patient groups and participants of a Delphi study on trial design. They are supported by charity representatives, trial delivery experts, researchers and core project team members. PPIE is fully embedded within the consortium's five other WGs and steering group. The group's terms of reference, processes for effective working and PPIE evaluation were co-developed with PPIE contributors. Results: 11 PwP and 4 care partners have supported the PPIE WG and contributed to the development of processes for effective working. A mixed methods research-in-action study is ongoing to evaluate PPIE within the consortium. This includes the Patient Engagement in Research Scale -a quantitative PPIE quality measure; semi-structured interviews -identifying areas for improvement and overall impressions of involvement; process fidelity- recording adherence; project documentation review - identifying impact of PPIE on project outputs. Conclusions: We provide a practical example of PPIE in complex projects. Evaluating feasibility, experiences and impact of PPIE involvement in EJS ACT-PD will inform similar programs on effective strategies. This will help enable future patient-centered research.

Differentiating placenta accreta spectrum from scar dehiscence with underlying, non-adherent placenta: A systematic review of scoring systems and primary data analysis.

INTRODUCTION: Accurate discrimination between placenta accreta spectrum (PAS) and scar dehiscence with underlying non-adherent placenta is challenging both on prenatal ultrasound and intraoperatively. This can lead to overdiagnosis of PAS and unnecessarily aggressive management of scar dehiscence which increases the risk of morbidity. Several scoring systems have been published which combine clinical and ultrasound information to help diagnose PAS in women at high risk. This research aims to provide insights into the reliability and utility of existing accreta scoring systems in differentiating these two closely related but different conditions to contribute to improved clinical decision making and patient outcomes. MATERIAL AND METHODS: A literature search was performed in four electronic databases. The references of relevant articles were also assessed. The articles were then evaluated according to the predefined inclusion criteria. Primary data for testing each scoring system were obtained retrospectively from two hospitals with specialized PAS services. Each scoring system was used to evaluate the predicted outcome of each case. RESULTS: The literature review yielded 15 articles. Of these, eight did not have a clearly described diagnostic criteria for accreta, hence were excluded. Of the remaining seven studies, one was excluded due to unorthodox diagnostic criteria and two were excluded as they differed from the other systems hindering comparison. Four scoring systems were therefore tested with the primary data. All the scoring systems demonstrated higher scores for high-grade PAS compared to scar dehiscence (p < 0.001) with an excellent Area Under the receiver operator characteristic Curve ranging from 0.82 (95% CI 0.71-0.92) to 0.87 (95% CI 0.79-0.96) in differentiating between these two conditions. However, no statistically significant differences were noted between the low-grade PAS and scar dehiscence on all scoring systems. CONCLUSIONS: Most published scoring systems have no clearly defined diagnostic criteria. Scoring systems can differentiate between scar dehiscence with underlying non-adherent placenta from high-grade PAS with excellent diagnostic accuracy, but not for low-grade PAS. Hence, relying solely on these scoring systems may lead to errors in estimating the risk or extent of the condition which hinders preoperative planning.

'We're like Spider-Man; with great power comes great responsibility': Coaches' experiences supporting struggling medical students.

BACKGROUND: Medical students can experience a range of academic and non-academic struggles. Coaching is a valuable strategy to support learners, but coaches describe working with struggling learners as taxing. Transformative learning theory (TLT) provides insights into how educators grow from challenging experiences to build resilience. This study explores how coaches evolve as educators through supporting struggling students. METHODS: This qualitative study grounded in an interpretivist paradigm used interviews of longitudinal medical student coaches at two academic institutions. Interviews, using TLT as a sensitizing concept, explored coaches' experience coaching struggling learners. We performed thematic analysis. RESULTS: We interviewed 15 coaches. Coaches described supporting students through multi-faceted struggles which often surprised the coach. Three themes characterized coaches' experiences: personal responsibility, emotional response, and personal learning. Coaches shouldered high personal responsibility for learners' success. For some, this burden felt emotional, raised parental instincts and questions about maintaining boundaries with learners. Coaches evolved their coaching approach, challenged biases, and built skills. Coaches learned to better appreciate the learner point of view and employ resources to support students. DISCUSSION: Through navigating learner struggles, educators can gain self-efficacy, learn to understand learners' perspectives, and evolve their coaching approach to lessen their personal emotional burden through time.

Are international guideline recommendations for the management of placenta accreta spectrum applicable in low- and middle-income countries?

OBJECTIVE: The aim of this study was to explore how obstetricians-gynecologists in low- and middle-income countries (LMICs) can apply current international clinical practice guidelines (CPGs) for the management of placenta accreta spectrum (PAS) in limited resource settings. METHODS: This was an observational, survey-based study. Clinicians with expertise in managing patients with PAS in LMICs were contacted for their evaluation of the recommendations included in four PAS clinical practice guidelines. RESULTS: Out of the 158 clinicians contacted, we obtained responses from 65 (41.1%), representing 27 middle income countries (MICs). The results of this survey suggest that the care of PAS patients in middle income countries is very different from what is recommended by international CPGs. Participants in the survey identified that their practice was limited by insufficient availability of hospital infrastructure, low resources of local health systems and lack of trained multidisciplinary teams (MDTs) and this did not enable them to follow CPG recommendations. Two-thirds of the participants surveyed describe the absence of centers of excellence in their country. In over half of the referral hospitals with expertise in managing PAS, there are no MDTs. One-third of patients with intraoperative findings of PAS are managed by the team initially performing the surgery (without additional assistance). CONCLUSION: The care of patients with PAS in middle income countries frequently deviates from established CPG recommendations largely due to limitations in local resources and infrastructure. New practical guidelines and training programs designed for low resource settings are needed.

3D Single Vessel Fractional Moving Blood Volume (3D-svFMBV): Fully Automated Tissue Perfusion Estimation Using Ultrasound.

Power Doppler ultrasound (PD-US) is the ideal modality to assess tissue perfusion as it is cheap, patient-friendly and does not require ionizing radiation. However, meaningful inter-patient comparison only occurs if differences in tissue-attenuation are corrected for. This can be done by standardizing the PD-US signal to a blood vessel assumed to have 100% vascularity. The original method to do this is called fractional moving blood volume (FMBV). We describe a novel, fully-automated method combining image processing, numerical modelling, and deep learning to estimate three-dimensional single vessel fractional moving blood volume (3D-svFMBV). We map the PD signals to a characteristic intensity profile within a single large vessel to define the standardization value at the high shear vessel margins. This removes the need for mathematical correction for background signal which can introduce error. The 3D-svFMBV was first tested on synthetic images generated using the characteristics of uterine artery and physiological ultrasound noise levels, demonstrating prediction of standardization value close to the theoretical ideal. Clinical utility was explored using 143 first-trimester placental ultrasound volumes. More biologically plausible perfusion estimates were obtained, showing improved prediction of pre-eclampsia compared with those generated with the semi-automated original 3D-FMBV technique. The proposed 3D-svFMBV method overcomes the limitations of the original technique to provide accurate and robust placental perfusion estimation. This not only has the potential to provide an early pregnancy screening tool but may also be used to assess perfusion of different organs and tumors.

Is telehealth useful in the management of placenta accreta spectrum in low-resource settings? Results of an exploratory survey.

OBJECTIVE: The optimal management of placenta accreta spectrum (PAS) requires the participation of multidisciplinary teams that are often not locally available in low-resource settings. Telehealth has been increasingly used to manage complex obstetric conditions. Few studies have explored the use of telehealth for PAS management, and we aimed evaluate the usage of telehealth in the management of PAS patients in low-resource settings. METHODS: Between March and April 2023, an observational, survey-based study was conducted, and obstetricians-gynecologists with expertise in PAS management in low- and middle-income countries were contacted to share their opinion on the potential use of telehealth for the diagnosis and management of patients at high-risk of PAS at birth. Participants were identified based on their authorship of at least one published clinical study on PAS in the last 5 years and contacted by email. This is a secondary analysis of the results of that survey. RESULTS: From 158 authors contacted we obtained 65 responses from participants in 27 middle-income countries. A third of the participants reported the use of telehealth during the management obstetric emergencies (38.5%, n = 25) and PAS (36.9%, n = 24). Over 70% of those surveyed indicated that they had used "informal" telemedicine (phone call, email, or text message) during PAS management. Fifty-nine participants (90.8%) reported that recommendations given remotely by expert colleagues were useful for management of patients with PAS in their setting. CONCLUSION: Telehealth has been successfully used for the management of PAS in middle-income countries, and our survey indicates that it could support the development of specialist care in other low resource settings.

Three-dimensional volume rendering ultrasound for assessing placenta accreta spectrum severity and discriminating it from simple scar dehiscence.

BACKGROUND: Prenatal ultrasound discrimination between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta is challenging both prenatally and intraoperatively, which often leads to overtreatment. In addition, accurate prenatal prediction of surgical difficulty and morbidity in placenta accreta spectrum is difficult, which precludes appropriate multidisciplinary planning. The advent of advanced 3-dimensional volume rendering and contrast enhancement techniques in modern ultrasound systems provides a comprehensive prenatal assessment, revealing details that are not discernible in traditional 2-dimensional imaging. OBJECTIVE: This study aimed to evaluate the use of 3-dimensional volume rendering ultrasound techniques in determining the severity of placenta accreta spectrum and distinguishing between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta. STUDY DESIGN: A prospective, cohort study was conducted between July 2022 and July 2023 in the fetal medicine unit of Dr Soetomo Academic General Hospital, Surabaya, Indonesia. All pregnant individuals with anterior low-lying placenta or placenta previa with a previous caesarean section who were referred with suspicion of placenta accreta spectrum were consented and screened using the standardised 2-dimensional and Doppler ultrasound imaging. Additional 3-dimensional volumes were obtained from the sagittal section of the uterus with a filled urinary bladder. These were analyzed by rotating the region of interest to be perpendicular to the uterovesical interface. The primary outcomes were the clinical and histologic severity in the cases of placenta accreta spectrum and correct diagnosis of dehiscence with nonadherent placenta underneath. The strength of association between ultrasound and clinical outcomes was determined. Multivariate logistic regression analyses and diagnostic testing of accuracy were used to analyze the data. RESULTS: A total of 70 patients (56 with placenta accreta spectrum and 14 with scar dehiscence) were included in the analysis. Multivariate logistic regression of all 2-dimensional and 3-dimensional signs revealed the 3-dimensional loss of clear zone (P<.001) and the presence of bridging vessels on 2-dimensional Doppler ultrasound (P=.027) as excellent predictors in differentiating scar dehiscence and placenta accreta spectrum. The 3-dimensional loss of clear zone demonstrated a high diagnostic accuracy with an area under the curve of 0.911 (95% confidence interval, 0.819-1.002), with a sensitivity of 89.3% (95% confidence interval, 78.1-95.97%) and specificity of 92.9% (95% confidence interval, 66.1-99.8%). The presence of bridging vessels on 2-dimensional Doppler demonstrated an area under the curve of 0.848 (95% confidence interval, 0.714-0.982) with a sensitivity of 91.1% (95% confidence interval, 80.4-97.0%) and specificity of 78.6% (95% confidence interval, 49.2-95.3%). A subgroup analysis among the placenta accreta spectrum group revealed that the presence of a 3-dimensional disrupted bladder serosa with obliteration of the vesicouterine space was associated with vesicouterine adherence (P<.001). CONCLUSION: Three-dimensional volume rendering ultrasound is a promising tool for effective discrimination between scar dehiscence with underlying nonadherent placenta and placenta accreta spectrum. It also shows potential in predicting the clinical severity with urinary bladder involvement in cases of placenta accreta spectrum.

Absence of abnormal vascular changes on prenatal imaging aids in differentiating simple uterine scar dehiscence from placenta accreta spectrum: a case series.

Accurate prenatal discrimination between a simple, non-adherent uterine scar dehiscence with an underlying placenta and the severe end of the placenta accreta spectrum is problematic as the two can appear similar on prenatal imaging. This may lead to the false diagnosis of placenta accreta spectrum resulting obstetric anxiety, overtreatment and potential iatrogenic morbidity. Despite potential similarities in the etiology, the manifestation and management of these two conditions is very different. The prenatal sonographic features of seven confirmed cases of simple uterine scar dehiscence with an underlying placenta previa were examined. The common sonographic features found for scar dehiscence was a thinned myometrium (<1 mm) overlying a generally homogenous placenta and a placental bulge. There was absence of lacunae and features of hypervascularity including bridging vessels. Our findings suggest accurate discrimination between a simple scar dehiscence with the placenta underlying it and placenta accreta spectrum can be made on prenatal ultrasound if the placenta is carefully examined for the vascular features unique to PAS.

Ultrasound discrimination between placenta accreta spectrum and urinary bladder varices.

Distinguishing between urinary bladder varices and retroplacental neovascularization in placenta accreta spectrum in high-risk patients with placental previa is a diagnostic challenge since they have similar appearances on prenatal ultrasound. Placenta accreta spectrum is associated with massive obstetric haemorrhage while the presence of urinary bladder varices in pregnancy poses a lower surgical risk. Since the clinical implications and management approach for both conditions are entirely different, false positive diagnoses have iatrogenic consequences. In this article, we share our experiences in differentiating these two phenomena on prenatal ultrasound supported by ultrasound and intraoperative images.

Academic Leadership Academy Summer Program: Clerkship Transition Preparation for Underrepresented in Medicine Medical Students.

PROBLEM: Enhancing workforce diversity by increasing the recruitment of students who have been historically excluded/underrepresented in medicine (UIM) is critical to addressing healthcare inequities. However, these efforts are inadequate when undertaken without also supporting students' success. The transition to clerkships is an important and often difficult to navigate inflection point in medical training where attention to the specific needs of UIM students is critical. INTERVENTION: We describe the design, delivery, and three-year evaluation outcomes of a strengths-based program for UIM second year medical students. The program emphasizes three content areas: clinical presentations/clinical reasoning, community building, and surfacing the hidden curriculum. Students are taught and mentored by faculty, residents, and senior students from UIM backgrounds, creating a supportive space for learning. CONTEXT: The program is offered to all UIM medical students; the centerpiece of the program is an intensive four-day curriculum just before the start of students' second year. Program evaluation with participant focus groups utilized an anti-deficit approach by looking to students as experts in their own learning. During focus groups mid-way through clerkships, students reflected on the program and identified which elements were most helpful to their clerkship transition as well as areas for programmatic improvement. IMPACT: Students valued key clinical skills learning prior to clerkships, anticipatory guidance on the professional landscape, solidarity and learning with other UIM students and faculty, and the creation of a community of peers. Students noted increased confidence, self-efficacy and comfort when starting clerkships. LESSONS LEARNED: There is power in learning in a community connected by shared identities and grounded in the strengths of UIM learners, particularly when discussing aspects of the hidden curriculum in clerkships and sharing specific challenges and strategies for success relevant to UIM learners. We learned that while students found unique benefits to preparing for clerkships in a community of UIM students, near peers, and faculty, future programs could be enhanced by pairing this formal intensive curriculum with more longitudinal opportunities for community building, mentoring, and career guidance.

Validation of a sonographic checklist for the detection of histologic placenta accreta spectrum.

BACKGROUND: To standardize research terminology and to reduce unanticipated placenta accreta spectrum, the European Working Group for Abnormally Invasive Placenta developed a consensus checklist for reporting suspected placenta accreta spectrum observed during an antenatal ultrasound. The diagnostic accuracy of the European Working Group for Abnormally Invasive Placenta checklist has not been assessed. OBJECTIVE: This study aimed to test the performance of the European Working Group for Abnormally Invasive Placenta sonographic checklist in predicting histologic placenta accreta spectrum. STUDY DESIGN: This was a multisite, blinded, retrospective review of transabdominal ultrasound studies performed between 26 to 32 weeks' gestation for subjects with histologic placenta accreta spectrum between 2016 and 2020. We matched a control cohort of subjects without histologic placenta accreta spectrum in a 1:1 ratio. To reduce reader bias, we matched the control cohort for known risk factors including previa, number of previous cesarean deliveries, previous dilation and curettage, in vitro fertilization, and clinical factors affecting image quality including multiple gestation, body mass index, and gestational age at the ultrasound. Nine sonologists from 5 referral centers, blinded to the histologic outcomes, interpreted the randomized ultrasound studies using the European Working Group for Abnormally Invasive Placenta checklist. The primary outcome was the sensitivity and specificity of the checklist to predict placenta accreta spectrum. Two separate sensitivity analyses were performed. First, we excluded subjects with mild disease (ie, only assessed subjects with histologic increta and percreta). Second, we excluded interpretations from the 2 most junior sonologists. RESULTS: A total of 78 subjects were included (39 placenta accreta spectrum, 39 matched control). Clinical risk factors and image quality markers were statistically similar between the cohorts. The checklist sensitivity (95% confidence interval) was 76.6% (63.4-90.6) and the specificity (95% confidence interval) was 92.0% (63.4-99.9) with a positive and negative likelihood ratio of 9.6 and 0.3, respectively. When we excluded subjects with mild placenta accreta spectrum disease, the sensitivity (95% confidence interval) increased to 84.7% (73.6-96.4) and the specificity was unchanged at 92.0% (83.2-99.9). Sensitivity and specificity were unchanged when the interpretations from the 2 most junior sonologists were excluded. CONCLUSION: The 2016 European Working Group for Abnormally Invasive Placenta checklist for interpreting placenta accreta spectrum has a reasonable performance in detecting histologic placenta accreta spectrum and excluding cases without placenta accreta spectum.

Kasr Alainy simplified uterine preserving surgery for conservative management of placenta accreta spectrum (PAS): A modified surgical approach.

OBJECTIVE: The incidence of placenta accreta spectrum (PAS) is rising rapidly due to the global surge in Caesarean delivery. It is associated with significant maternal morbidity and mortality. It is usually managed with Caesarean hysterectomy. However, uterine preserving surgeries can have advantages over Caesarean hysterectomy and intentional placental retention techniques. STUDY DESIGN: We present a modified technique of uterine preserving surgery that uses a safe approach for placental bed surgical devascularization. This is followed by resection of the invaded uterine segment and uterine wall reconstruction. RESULTS: The technique was used in the management of 20 patients with antenatally suspected PAS that were confirmed at laparotomy. It was successful in preserving the uterus in 18/20 (90 %) women. The mean intraoperative blood loss in was 1305 CC (SD: +361.6) with a mean operative time of 123 min (SD: ±38.7). There was only one urinary bladder injury and no other maternal morbidity. CONCLUSION: Our surgical technique is safe and may be useful for conservative surgical management of PAS, particularly in low- and middle-income countries, where access to complex resources, such as interventional radiology, is limited.

Identifying Value Factors in Institutional Leaders' Perspectives on Investing in Health Professions Educators.

Importance: Investing in educators, educational innovation, and scholarship is essential for excellence in health professions education and health care. Funds for education innovations and educator development remain at significant risk because they virtually never generate offsetting revenue. A broader shared framework is needed to determine the value of such investments. Objective: To explore the value factors using the value measurement methodology domains (individual, financial, operational, social or societal, strategic or political) that health professions leaders placed on educator investment programs, including intramural grants and endowed chairs. Design, Setting, and Participants: This qualitative study used semi-structured interviews with participants from an urban academic health professions institution and its affiliated systems that were conducted between June and September 2019 and were audio recorded and transcribed. Thematic analysis was used to identify themes with a constructivist orientation. Participants included 31 leaders at multiple levels of the organization (eg, deans, department chairs, and health system leaders) and with a range of experience. Individuals who did not respond initially were followed up with until a sufficient representation of leader roles was achieved. Main Outcomes and Measures: Outcomes include value factors defined by the leaders for educator investment programs across the 5 value measurement methodology domains: individual, financial, operational, social or societal, and strategic or political. Results: This study included 29 leaders (5 [17%] campus or university leaders; 3 [10%] health systems leaders; 6 [21%] health professions school leaders; 15 [52%] department leaders). They identified value factors across the 5 value measurement methods domains. Individual factors emphasized the impact on faculty career, stature, and personal and professional development. Financial factors included tangible support, the ability to attract additional resources, and the importance of these investments as a monetary input rather than output. Operational factors identified educational programs and faculty recruitment or retention. Social and societal factors showcased scholarship and dissemination benefits to the external community beyond the organization and to the internal community of faculty, learners, and patients. Strategic and political factors highlighted impact on culture and symbolism, innovation, and organizational success. Conclusions and Relevance: These findings suggest that health sciences and health system leaders find value in funding educator investment programs in multiple domains beyond direct financial return on investment. These value factors can inform program design and evaluation, effective feedback to leaders, and advocacy for future investments. This approach can be used by other institutions to identify context-specific value factors.

Faculty Development for Education for Sustainable Health Care: A University System-Wide Initiative to Transform Health Professional Education.

Health professionals (HPs) are increasingly called upon to care for patients experiencing the health impacts of climate change, while working in the high eco-footprint health care system, which is starting to embrace a culture of sustainability. HPs are uniquely positioned to drive health care culture toward ecological responsibility and, consequently, improve patient care, health equity, and public health. Education for sustainable health care (ESHC or ESH) is the first step in developing health care practitioners able to think critically about and act upon the health impacts of the climate crisis. University of California Education for Sustainable Healthcare (UC-ESH) Faculty Development Initiative was developed to address the following goals: educate faculty on eco-medical literacy, empower faculty to build community and lead ESH at their institutions, and expand coverage of ESH to reach students beyond those for whom sustainability is already a focus. The initiative provided training to faculty across health professions and 6 health science campuses to integrate ESH into their courses using the train-the-trainer model, key knowledge and pedagogical skills, and longitudinal guidance and networking opportunities. Using a survey, questionnaire, and interviews, the initiative was evaluated using the process/elements and product/outcomes steps of the Context, Input, Process, and Product evaluation model. The UC-ESH educated over 100 faculty members and led to ESH integration into 99 existing and new courses that subsequently reached over 7,000 learners. The UC-ESH increased empowerment, awareness, and knowledge about the climate crisis, and built an ESH community of practice. Initiative elements that contributed to these outcomes included engaging training; creation of supportive group dynamics; helpful resources and activities; ongoing support; and integration approaches to ESH. This university-system-wide initiative provides a transferable model to institutions, schools, and departments seeking to develop eco-medical literate faculty who educate their students about the climate, ecosystem, and health crisis.

A Risk-Prediction Model for Placenta Accreta Spectrum Severity From Standardized Ultrasound Markers.

We aimed to generate a model to predict the risk of a woman having normal, abnormally adherent (AAP) or abnormally invasive placentation (AIP) based on the presence of recently codified ultrasound (US) markers and disease definitions of placenta accreta spectrum (PAS). We recruited women with anterior low-lying placenta or placenta previa and a history of previous caesarean delivery to a prospective cohort study. US markers of abnormal placentation were recorded on a standardized pro forma. The presence and International Federation of Gynecology and Obstetrics grade of PAS was evaluated clinically and histologically at delivery. Markers demonstrating a predictive relationship to PAS were incorporated into a logistic regression model. A total of 106 women were included, of whom 42 (40%) were normal, 24 (23%) had AAP and 40 (38%) had AIP. A model including just four key variables (loss of clear zone, abnormal placental lacunae, placental bulge and bladder wall interruption) was shown to reliably predict presence and severity of PAS, with an optimism-corrected C-index of 0.901. A simple model incorporating four US markers can predict likelihood and severity of PAS with high accuracy. This is the first time this has been demonstrated using the recently codified definitions of the US signs and disease definitions. Further work will see our model applied prospectively to a large patient cohort, ideally through a smartphone-based application, for external validation.

Connecting Biochemistry Knowledge to Patient Care in the Clinical Workplace: Senior Medical Students' Perceptions about Facilitators and Barriers.

Phenomenon: Medical students have difficulties applying knowledge about biomedical mechanisms learned before clerkships to patient care activities. Many studies frame this challenge as a problem of basic science knowledge transfer predominantly influenced by students' individual cognitive processes. Social cognitive theory would support extending this framing to the interplay between the individual's cognition, the environment, and their behaviors. This study investigates senior medical students' experiences of biochemistry knowledge use during workplace learning and examines how their experiences were influenced by interactions with people and other elements of the clinical learning environment. Approach: The authors used a qualitative approach with a constructivist orientation. From September to November 2020 they conducted semi-structured interviews with 11 fourth-year medical students at one institution who had completed the pre-clerkship curriculum, core clinical clerkships, and the United States Medical Licensing Exam Step 1. The authors identified themes using thematic analysis. Findings: Participants reported that they infrequently used or connected to biochemistry knowledge in workplace patient care activities, yet all had examples of such connections that they found valuable to learning. Most participants felt the responsibility for making connections between biochemistry knowledge and activities in the clinical workplace should be shared between themselves and supervisors, but connections were often recognized and acted on only by the student. Connections that participants described prompted their effort to retrieve knowledge or fill a perceived learning gap. Participants identified multiple barriers and facilitators to connecting, including supervisors' behaviors and perceived knowledge, and "patients seen" in clerkships. Participants also reported learning biochemistry during USMLE Step 1 study that did not connect to patient care activities, underscoring a perception of disconnect. Insights: This study identifies specific personal, social, and physical environmental elements that influence students' perceived use of biochemistry during patient care activities. Though these findings may be most significant for biochemistry, they likely extend to other basic science disciplines. Students' self-directed efforts to connect to their biochemistry knowledge could be augmented by increased social support from clinical supervisors, which in turn likely requires faculty development. Opportunities for connection could be enhanced by embedding into the environment instructional strategies or technologies that build on known authentic connections between biochemistry and "patients seen" in clerkships. These efforts could strengthen student learning, improve clinical supervisors' self-efficacy, and better inform curriculum design.

A simple guide to ultrasound screening for placenta accreta spectrum for improving detection and optimizing management in resource limited settings.

Placenta accreta spectrum is a pregnancy complication associated with severe morbidity and maternal mortality especially when not suspected antenatally and appropriate management instigated. Women in resource-limited settings are more likely to face adverse outcomes due to logistic, technical, and resource inadequacies. Accurate prenatal imaging is an important step in ensuring good outcomes because it allows adequate preparation and an appropriate management approach. This article provides a simple three-step approach aimed at guiding clinicians and sonographers with minimal experience in placental accreta spectrum through risk stratification and basic prenatal screening for this condition both with and without Doppler ultrasound.

Placenta accreta spectrum - variations in clinical practice and maternal morbidity between the UK and France: a population-based comparative study.

OBJECTIVE: To compare the management and outcomes of women with placenta accreta spectrum (PAS) in France and the UK. DESIGN: Two population-based cohorts. SETTING: All obstetrician-led hospitals in the UK and maternity hospitals in eight French regions. POPULATION: A cohort of 219 women with PAS in France and a cohort of 154 women with PAS in the UK. METHODS: The management and outcomes of women with PAS were compared between the UK and France. MAIN OUTCOME MEASURES: Median blood loss, severe postpartum haemorrhage (≥3 l), postpartum infection and damage to surrounding organs. RESULTS: The management of PAS differed between the two countries: a larger proportion of women with PAS in the UK had a caesarean hysterectomy compared with France (43% vs 26%, p < 0.001), whereas in France a larger proportion of women with PAS received a uterus-preserving approach compared with the UK (36% vs 19%, p < 0.001). The total median blood loss in the UK was 3 l (IQR 1.7-6.5 l), compared with 1 l (IQR 0.5-2.5 l) in France; more women with PAS had a severe postpartum haemorrhage (PPH) in the UK compared with women with PAS in France (58% vs 21%, p < 0.001) [Correction added on 06 May 2022, after first online publication: '24 hour' has been changed to 'total' in the preceding sentence]. There was no difference between the UK and French populations for postpartum infection or organ damage. CONCLUSIONS: The UK and France have very different approaches to managing PAS, with more women in France receiving a uterine-conserving approach and more women in the UK undergoing caesarean hysterectomy. A life-threatening haemorrhage was more common in the UK than in France, which may be the result of differential management and/or the organisation of the healthcare systems. In women with placenta accreta spectrum, severe haemorrhage was more common in the UK than in France. TWEETABLE ABSTRACT: In women with placenta accreta spectrum, severe haemorrhage was more common in the UK than in France.