Evaluation of Administrative Data for Identifying Maternal Opioid Use at Delivery in Florida.

OBJECTIVES: Studies have shown significant increases in the prevalence of maternal opioid use. Most prevalence estimates are based on unverified ICD-10-CM diagnoses. This study determined the accuracy of ICD-10-CM opioid-related diagnosis codes documented during delivery and examined potential associations between maternal/hospital characteristics and diagnosis with an opioid-related code. METHODS: To identify people with prenatal opioid use, we identified a sample of infants born during 2017-2018 in Florida with a NAS related diagnosis code (P96.1) and confirmatory NAS characteristics (N = 460). Delivery records were scanned for opioid-related diagnoses and prenatal opioid use was confirmed through record review. The accuracy of each opioid-related code was measured using positive predictive value (PPV) and sensitivity. Modified Poisson regression was used to calculate adjusted relative risks (aRR) and 95% confidence intervals (CI). RESULTS: We found the PPV was nearly 100% for all ICD-10-CM opioid-related codes (98.5-100%) and the sensitivity was 65.9%. Non-Hispanic Black mothers were 1.8 times more likely than non-Hispanic white mothers to have a missed opioid-related diagnosis at delivery (aRR:1.80, CI 1.14-2.84). Mothers who delivered at a teaching status hospital were less likely to have a missed opioid-related diagnosis (p < 0.05). CONCLUSIONS FOR PRACTICE: We observed high accuracy of maternal opioid-related diagnosis codes at delivery. However, our findings suggest that over 30% of mothers with opioid use may not be diagnosed with an opioid-related code at delivery, although their infant had a confirmed NAS diagnosis. This study provides information on the utility and accuracy of ICD-10-CM opioid-related codes at delivery among mothers of infants with NAS.

From 2010 to 2017, maternal opioid-related diagnoses at delivery increased by 100% in the US. Most prevalence estimates are based on unverified ICD-10-CM diagnosis codes. Evaluations of maternal opioid-related diagnoses at delivery are extremely limited but essential for utilizing prevalence estimates generated from administrative data.

Occupational traumatic injuries rarely affect genitourinary organs: a retrospective, comparative study.

PURPOSE: To determine the mechanisms of injury associated with occupational injuries (OI) to genitourinary (GU) organs and compare GU OIs with GU non-OIs. METHODS: A single institution, retrospective study was conducted at a level 1 trauma center between 2010 and 2016 of all patients with GU injuries. OI was defined as any traumatic event that occurred in the workplace requiring hospital admission. Types of occupations were recorded in addition to the location of injury, mechanisms of injury, concomitant injuries, operative interventions, total cost, and mortality. GU OI patients were then compared to GU non-OI patients. RESULTS: 623 patients suffered a GU injury, of which 39 (6.3%) had a GU OI. Fall (43%) was the most common mechanism of injury; followed by motor vehicle collision/motorcycle crash (31%), crush injury (18%), and pedestrian struck (8%). The adrenal gland (38%) and kidney (38%) were the most commonly injured organs. There was no difference in mortality (13% GU OI vs. 15% GU non-OI, p = 0.70) or total direct cost ($21,192 ± 28,543 GU OI vs. $28,215 ± 32,332 GU non-OI, p = 0.45). Total costs were decreased with mortality from a GU injury (odds ratio (OR) 0.3, CI 0.26-0.59; p = < 0.001) and increased with higher injury severity scores (OR 1.1, CI 1.09-1.2; p = < 0.0001). Total costs were not affected by OI status. CONCLUSIONS: Occupational GU trauma presents with similar patterns of injury, hospital course, and direct cost as GU trauma that occurs in non-occupational settings.

Does tranexamic acid really work in an urban US level I trauma center? A single level 1 trauma center's experience.

BACKGROUND: The use of Tranexamic Acid (TXA) in trauma patients remains controversial. The CRASH II trial, while randomized and prospective, did not include patients suffering from major bleeding. We wanted to examine our population of patients who underwent a massive transfusion protocol (MTP) (greater than 10 Units of packed red blood cells in the first 24 h of admission) to see if those who were undergoing massive transfusion and received TXA had any benefit in mortality. Our hypothesis was that massively transfused patients who received TXA and those that did not had no difference in mortality. METHODS: We performed a single institution retrospective review of our Trauma Registry for all patients who received a massive transfusion between 2010 and 2017. Patients were separated into two cohorts, those who received TXA within the first 24 h of admission and those who did not. The primary outcome of the study was mortality. Secondary outcomes included total blood products transfused, Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), Myocardial Infarction (MI), and cardiac arrest. RESULTS: 283 patients received MTP between 2010 and 2017. 179 (63%) did not receive TXA and 104 (37%) were treated with TXA. The groups were then propensity matched and yielded 62 patients in each group (124 total) (ISS 36 ±â€¯12 no TXA vs. 37 ±â€¯13 TXA; p = 0.59). There was no significant difference observed in mortality (50% no TXA vs. 39% TXA; p = 0.21), total PRBC's transfused (20 ±â€¯11 no TXA vs. 23 ±â€¯18 TXA; p = 0.45), DVT (8% no TXA vs. 6% TXA; p = 0.99), PE (2% no TXA vs. 3% TXA; p = 0.99), MI (3% no TXA vs. 0% TXA; p = 0.50), or cardiac arrest (26% no TXA vs. 18% TXA; p = 0.28). CONCLUSION: There does not appear to be any benefit to TXA administration in Trauma Patients in our institution. This is a single-center retrospective review. More data from other similar centers in the region or the United States is warranted.

Female Medical Student Retention in Neurosurgery: A Multifaceted Approach.

BACKGROUND: Since 2011, more women than men have graduated from medical school, yet there remains a paucity of female physicians in surgical specialties. After the 2018 Neurosurgery Match, only 17.5% of neurosurgery residents are women. Previous literature documented gender inequality, poor medical school exposure, and lack of female mentorship as reasons for this disparity. We sought to further explore factors that deter female medical students from pursuing neurosurgery. METHODS: A comprehensive survey was created and distributed to the 2017-2018 Rutgers New Jersey Medical School student body, requesting anonymous input from female medical students. RESULTS: Of 104 female respondents, 26.9% had considered neurosurgery as a career and felt dissuaded because of their gender. Of respondents, 88% did not have a senior female medical student pursuing neurosurgery or a female neurosurgical resident as a mentor. More than half of respondents disagreed that they would be dissuaded from a field if they did not have a female mentor. The 88.46% of women who felt that there was a glass ceiling in medicine were also more likely to feel that they would face inequality and adversity that would inhibit training in a male-dominated field. Women who described themselves as seeking challenging and competitive careers strongly felt that they would benefit from exposure to surgical subspecialties during their preclinical years. CONCLUSIONS: Female medical students remain resilient, ambitious, interested in competitive specialties, and eager to explore surgical subspecialties during preclinical years. A multifaceted approach is imperative to recruit and retain qualified women interested in neurosurgery.

Current management of pelvic fracture urethral injuries: to realign or not?

The acute management of pelvic fracture urethral injuries (PFUIs) remains a controversial topic. Currently, suprapubic tube (SPT) placement with delayed repair or primary realignment (PR) represents the strategies used to treat patients. While many will advocate the use of one technique over the other, the 2014 American Urological Association (AUA) Guidelines give providers the option for the management PFUI. Current literature evaluates these two interventions, focusing on the incidence of re-stricture formation, erectile dysfunction, and urinary incontinence. Here we perform a comprehensive review of the current management for PFUI, as well as, discuss the limitations of the studies and need for more prospective studies on this debated topic.

Elucidation of Renal Scars in Children With Vesicoureteral Reflux Using Contrast-Enhanced Ultrasound: A Pilot Study.

INTRODUCTION: Vesicoureteral reflux is a common disorder in children but can result in kidney scarring following acute pyelonephritis. The gold standard diagnostic to detect renal scars in children is 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy. DMSA has a number of limitations including radiation exposure, need for sedation, and radiotracer supply shortages. Contrast-enhanced ultrasound (CEUS) is a technique whereby biocompatible microspheres of inert gas are administered i.v. that reflect ultrasonography sound waves and do not involve radiation. Because the contrast agent is rapidly cleared, contrast images must be obtained within minutes of administration. CEUS has been used in a variety of organ systems, but its use in pediatric kidney diseases is limited. METHODS: In this study, we performed CEUS in 7 children with documented renal scars by radiographic imaging consistent with reflux nephropathy. RESULTS: In all subjects, CEUS detected all previously known radiologic abnormalities as well as detecting new areas of hypoenhancing renal parenchyma. None of the patients experienced any serious adverse events. DISCUSSION: This study represents the first report of using CEUS to characterize renal scars in children with reflux nephropathy. We conclude that CEUS is a highly sensitive, rapid, and cost-effective diagnostic imaging modality for detecting and monitoring renal scars in children with vesicoureteral reflux.

Metastatic Renal Cell Carcinoma to the Contralateral Ureter: A Rare Phenomenon.

Metastatic renal cell carcinoma (RCC) to the contralateral ureter is a rare phenomenon. We report a metastatic RCC to the contralateral ureter 5 months after right radical nephrectomy for Fuhrman grade 3/4 clear cell adenocarcinoma with pathologic T3 staging. The distal ureter was excised followed by partial ileal ureteral substitution. Pathology confirmed metastatic clear cell RCC Fuhrman grade 2/4. Ileal ureteral substitution has been shown to provide good long-term functional outcomes and should be considered as a possible option for surgical treatment of ureteral metastasis.

The Still-Face Paradigm and bidirectionality: associations with maternal sensitivity, self-esteem and infant emotional reactivity.

The Still-Face Paradigm (SFP) is a structured stressful event within which researchers have investigated the influence of maternal psychological and behavioral characteristics on infant behavior. The present investigation contributes to this body of work by examining the joint contributions of maternal and child behavioral and affective characteristics on subsequent behaviors and affectations following the SFP. A sample of non-clinically depressed mothers and their infants (n=31) engaged in a modified Still-Face Paradigm (SFP), followed by a period of toy play. These interactions were videotaped and behaviorally coded along the following dimensions: maternal sensitivity prior to the SFP and during toy play, infant negative emotional reactivity during the still-face, and infant resistance during the reunion phase. Additionally, mothers reported global self-esteem and this was examined as a predictor of infant behavior. Results revealed significant bidirectional influences such that maternal self-esteem predicted infant emotional reactivity, maternal sensitivity pre-SFP predicted infant resistance during the reunion phase, and infant resistance predicted subsequent levels of maternal sensitivity. Indirect effects were also examined, and provided additional support for bidirectionality in mother-infant interactions. Implications for clinical practice are discussed in light of these findings.

Maternal effects on ethanol teratogenesis in a cross between A/J and C57BL/6J mice.

Genetic factors influence adverse pregnancy outcome in both humans and animal models. Animal research reveals that both the maternal and fetal genetic profiles are important for determining the risk of physical birth defects and prenatal mortality. Using a reciprocal-cross breeding design, we investigated whether the mother's genes may be more important than fetal genes in determining risk for ethanol teratogenesis. Examination of possible synergistic genetic effects on ethanol teratogenesis was made possible by using two mouse strains known to be susceptible to specific malformations. Inbred A/J (A) and C57BL/6J (B6) mice were mated to produce four fetal genotype groups: the true-bred AcA and B6cB6 genotypes and the genetically identical AcB6 and B6cA genotypes (the F(1) genotype). Dams were administered either 5.8 g/kg ethanol or an isocaloric amount of maltose-dextrin on day 9 of pregnancy. Fetuses were removed by laparotomy on gestation day 18, weighed, and assessed for digit, vertebral, and kidney malformations. Digit malformations in the genetically identical F(1) ethanol-exposed litters showed a pattern consistent with a maternal genetic effect (AcB6 [2%] and B6cA [30%]). In contrast, vertebral malformations were similar in all ethanol-exposed litters (AcA [26%], AcB6 [18%], B6cA [22%], and B6cB6 [33%]). The percentage of malformations did not differ between male and female fetuses, indicating sex-linked factors are not responsible for the maternal effect. Ethanol exposure decreased litter weights but did not affect litter mortality compared with maltose-exposed controls. This study supports the idea that genes influence malformation risk following in utero alcohol exposure. Specifically, maternal genes influence risk more than fetal genes for some teratogenic outcomes. No evidence supported synergistic genetic effects on ethanol teratogenesis. This research supports the conclusion that uterine environment contributes to determining risk of Fetal Alcohol Spectrum Disorder.