Placental Cortisol Dysregulation in Mothers with Experiences of Childhood Adversity: Potential Mechanisms and Clinical Implications.

Adverse childhood experiences (ACEs) are extremely prevalent in the United States population. Although ACEs occurs in childhood, exposure to them has been associated with adverse future pregnancy outcomes and an increased risk of poorer social determinants of health, which further drive the risk of negative pregnancy outcomes. In addition, maternal ACE exposure has been linked to poor infant and child outcomes, highlighting the intergenerational transmission of risk from mother to child. While alterations along the Maternal-Placental-Fetal Hypothalamic-pituitary-adrenal (HPA) axis is hypothesized to be involved, the exact biological pathway underlying this intergenerational passage of risk is mostly unknown. This present work will highlight what is known about pregnancy-related stress hormone physiology, discuss the potential mechanisms of action of ACEs on cortisol regulation, and suggest opportunities for further clinical and translational studies.

Substance Use in Pregnancy and Its Impact on Communities of Color.

Stigma toward pregnant and postpartum people who use drugs is common and seeks to define addiction as a moral weakness rather than a chronic medical illness that requires resources and treatment. More concerning is the additive impact of substance use and racial discrimination, whose intersections present particularly challenging circumstances. In this article, the authors review the history of substance use in the United States and focus on 3 substances of abuse that illustrate the inequity faced by pregnant person of color who use drugs.

Teen pregnancy in the setting of familial dilated cardiomyopathy: a case report.

BACKGROUND: Women with pre-existing forms of familial cardiomyopathy are at increased risk for morbidity and mortality due to hemodynamic changes of pregnancy. There is a lack of consensus about the management and care for these patients given the rarity of this condition. This case represents possibly the youngest pregnant familial dilated cardiomyopathy patient to deliver and the youngest patient to be fitted for a wearable cardiac defibrillator in the postpartum period. CASE PRESENTATION: A 14-year-old gravida 1 with familial dilated cardiomyopathy presented late for prenatal care at 38 weeks, which precluded typical care plans including baseline and serial echocardiograms, medication management, and routine prenatal care. An echocardiogram showed severely decreased left ventricular systolic function compared to studies from one year prior. Three days later the patient presented in labor and had a spontaneous vaginal delivery complicated by postpartum hemorrhage. Her postpartum course was notable for persistence of decreased cardiac function testing and placement of a wearable cardiac defibrillator for prevention against life threatening arrhythmias. CONCLUSION: This case report adds to the literature on pregnancy complicated by familial dilated cardiomyopathy and describes management best practices and considerations during the antepartum, intrapartum, and postpartum periods.

Potential Impact of Pass/Fail Scores on USMLE Step 1: Predictors of Excellence in Obstetrics and Gynecology Residency Training.

AIM: The study aims to determine resident applicant metrics most predictive of academic and clinical performance as measured by the Council of Resident Education in Obstetrics and Gynecology (CREOG) examination scores and Accreditation Council for Graduate Medical Education (ACGME) clinical performance (Milestones) in the aftermath of United States Medical Licensing Examination Scores (USMLE) Step 1 becoming a pass/fail examination. METHODS: In this retrospective study, electronic and paper documents for Wayne State University Obstetrics and Gynecology residents matriculated over a 5-year period ending July 2018 were collected. USMLE scores, clerkship grade, and wording on the letters of recommendation as well as Medical Student Performance Evaluation (MSPE) were extracted from the Electronic Residency Application Service (ERAS) and scored numerically. Semiannual Milestone evaluations and yearly CREOG scores were used as a marker of resident performance. Statistical analysis on residents (n = 75) was performed using R and SPSS and significance was set at P < .05. RESULTS: Mean USMLE score correlated with CREOG performance and, of all 3 Steps, Step 1 had the tightest association. MSPE and class percentile also correlated with CREOGs. Clerkship grade and recommendation letters had no correlation with resident performance. Of all metrics provided by ERAS, none taken alone, were as useful as Step 1 scores at predicting performance in residency. Regression modeling demonstrated that the combination of Step 2 scores with MSPE wording restored the predictive ability lost by Step 1. CONCLUSIONS: The change of USMLE Step 1 to pass/fail may alter resident selection strategies. Other objective markers are needed in order to evaluate an applicant's future performance in residency.

Standard 6-mm Compared with Widefield 16.5-mm OCT for Staging of Posterior Vitreous Detachment.

PURPOSE: To assess whether 6-mm OCT scans, which image the macula, can distinguish complete from partial posterior vitreous detachment (PVD) in comparison with 16.5-mm OCT scans, which image the macula, optic nerve, and mid periphery. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: We compared 6-mm and 16.5-mm scans in 157 eyes of 157 retina clinic patients (mean age, 50 years; range, 10-64 years) with diabetic retinopathy (36%), no retinal disease (19%), and various retinal conditions (45%). We also analyzed 16.5-mm scans in 35 healthy eyes (asymptomatic fellow eyes of patients with unilateral retinal conditions; mean age, 46 years; range, 9-63 years). METHODS: Each participant underwent Heidelberg Spectralis imaging with the standard lens (6-mm scan) and/or the 55° lens (16.5-mm scan). On 6-mm scans, we classified eyes as stage 3 partial PVD when the posterior vitreous cortex was visualized without visible attachment. On 16.5-mm scans, we classified eyes as stage 3 when the vitreous was attached at the optic nerve and separated from the macula. On both scan types, we classified eyes as stage 4 when neither the premacular bursa nor the posterior vitreous cortex were visualized. We assessed the accuracy of this system for detecting complete PVD on 6-mm scans by calculating test characteristics using 16.5-mm scans as a reference standard. MAIN OUTCOME MEASURE: Posterior vitreous detachment stage (0-4). RESULTS: Posterior vitreous detachment stage was identical in 6-mm and 16.5-mm scans in 88% of eyes. Compared with 16.5-mm scans, 6-mm scans detected complete PVD (vs. earlier stages 0-3) with 91% sensitivity and 99% specificity. Seven eyes were classified as no PVD on 6-mm scans and were classified as partial PVD on 16.5-mm scans because vitreoretinal separation was localized to the mid periphery. All 16.5-mm scans showed some degree of PVD, including scans from 9 participants between 9 and 20 years of age. CONCLUSIONS: Six-millimeter scans distinguished complete from partial PVD with good sensitivity and specificity but missed the earliest stages of PVD, which occur in the mid periphery. Posterior vitreous detachment may begin as early as the second decade of life.

Avoiding the fatal misdiagnosis of pregnancy in a noncommunicating rudimentary horn using 3D transvaginal ultrasound.

Rudimentary horn pregnancies are an increasingly recognized complication of Mullerian duct anomalies. They can lead to uterine rupture with severe maternal morbidity and mortality. We present the case of a 28-year-old woman with a prior surgical diagnosis of bicornuate uterus who was diagnosed with a 7-week pregnancy in the left horn of a bicornuate uterus by 2D ultrasound. Further investigation with 3D ultrasound revealed that the pregnancy was within a noncommunicating rudimentary horn of a unicornuate uterus. These findings were confirmed at laparotomy. This case illustrates the importance and benefits of utilizing 3D ultrasound in diagnosing suspected Mullerian anomalies.

Effects of lipoic acid on migration of human B cells and monocyte-enriched peripheral blood mononuclear cells in relapsing remitting multiple sclerosis.

Multiple sclerosis (MS) is a disease of the central nervous system characterized by inflammation and demyelination resulting in clinical disability. The rodent MS model suggests that infiltration of monocytes and B cells contributes to disease pathogenesis. Here, we compared the migratory capacity of human monocytes and B cells from healthy control (HC) and relapsing-remitting MS (RRMS) subjects, with or without lipoic acid (LA) treatment. Basal migration of monocyte-enriched PBMCs from RRMS subjects is significantly higher than HC PBMCs. LA treatment significantly inhibits monocyte and B cell migration in both cohorts, and may thus be therapeutically effective for treatment of MS.

Analysis of IL-6, IL-1ß and TNF-α production in monocytes isolated from multiple sclerosis patients treated with disease modifying drugs.

OBJECTIVE AND DESIGN: The etiology of multiple sclerosis (MS) is unknown, but blood derived monocytes/macrophages are believed to be involved in the pathogenesis through phagocytosis of myelin and production of inflammatory mediators. The objective of this study is to examine inflammatory cytokines that are present at elevated levels in active MS lesions to determine whether there are differences between classically stimulated monocytes isolated from healthy control (HC) and relapsing-remitting MS (RRMS) subjects taking disease modifying drugs (DMDs), including dimethyl fumarate (DMF). SUBJECTS: Thirty-nine veterans of the US Armed Forces were enrolled, 21 health controls (HC), and 18 with relapsing-remitting MS (RRMS), all taking DMDs. METHODS: Use ELISAs to measure production of IL-6, IL-1ß and TNF-α by LPS-stimulated peripheral monocytes. RESULTS: Activation of monocytes from MS subjects produced significantly more IL-6 than healthy controls (49531 ± 20795 vs 10526 ± 4845), and IL-6 production trended higher in MS subjects taking DMF than those taking other DMDs (72186.9 ± 35156.2 vs 32585.8 ± 17135.4). There were no significant differences in IL-1ß or TNF-α secretion. CONCLUSIONS: Our data suggest that not all DMDs may provide disease modification by suppressing monocyte/macrophage production of pro-inflammatory mediators.

Student Performance in a Pharmacotherapy Oncology Module Before and After Flipping the Classroom.

Objective. To determine if a flipped classroom improved student examination performance in a pharmacotherapy oncology module. Design. Third-year pharmacy students in 2012 experienced the oncology module as interactive lectures with optional case studies as supplemental homework. In 2013, students experienced the same content in a primarily flipped classroom. Students were instructed to watch vodcasts (video podcasts) before in-class case studies but were not held accountable (ie, quizzed) for preclass preparation. Examination questions were identical in both cohorts. Performance on examination questions was compared between the two cohorts using analysis of covariance (ANCOVA), with prior academic performance variables (grade point average [GPA]) as covariates. Assessment. The students who experienced the flipped classroom approach performed poorer on examination questions than the cohort who experienced interactive lecture, with previous GPA used as a covariate. Conclusion. A flipped classroom does not necessarily improve student performance. Further research is needed to determine optimal classroom flipping techniques.

Educational Value of a Medical Student-Led Head and Neck Cancer Screening Event.

OBJECTIVE: To evaluate improvement of medical student knowledge of head and neck cancer (HNC) through participation in HNC screening fairs run by medical students. STUDY DESIGN: Prospective cohort study of surveys assessing medical students' knowledge of HNC before and after volunteering at screening fairs. SETTING: Four screening fairs held at the University of Miami Miller School of Medicine during Oral, Head and Neck Cancer Awareness Week. SUBJECTS: Medical student screening fair volunteers. METHODS: Four HNC screening fairs were organized by medical student volunteers. All students completed a preevent survey assessing baseline knowledge and participated in an otolaryngologist-led training session about HNC and the screening examination. During the screening events, students educated guests about HNC and performed physician-guided history and physical examinations. Finally, students completed identical surveys 1 week and 3 months after the event. RESULTS: Thirty-four (n = 34) students completed the preevent surveys. At baseline, 59%, 44%, and 24% named tobacco, alcohol, and human papilloma virus as risk factors, compared with 84%, 81%, and 69% on 3 month follow-up, respectively. Out of 6 analyzed questions, the median total number of correctly answered questions improved from 2 on pretest to 5 at 3 months (P < .0001). CONCLUSION: Volunteer participation in a HNC screening program improves medical students' knowledge of HNC risk factors and symptoms. This innovative approach to students' education via participation and organization of screening events is a useful method of improving their HNC knowledge.

Prevalence of retinopathy of prematurity in Brunei Darussalam.

AIM: To identify the prevalence of retinopathy of prematurity (ROP) among preterm neonates admitted to Department of Neonatology, RIPAS hospital, Brunei Darussalam. METHODS: We studied 67 preterm infants fulfilling the eligibility criteria for ROP screening. All infants studied were admitted to the Department of Neonatology, RIPAS Hospital, within a period of one year. Birth weight (BW), gestational age (GA), corrected age at each review, initial and final diagnoses and number of reviews required was recorded for each infant. Infants were followed up two weekly until they reach a corrected age of 40 weeks or complete vascularization was noted. Prevalence of ROP was identified. Descriptive analysis, regression analysis and independent-sample t-test were used to statistically check for differences between ROP and non-ROP groups. RESULTS: A total number of 201 ROP screenings were carried out for 67 preterm infants. Males outnumbered females (56.7%). The mean number of reviews per child was (3.19±1.1) times (range: 1-6 times), the mean GA among the preterm babies examined was (29.5±2.6) weeks (range: 23-36 weeks), and the mean BW was 1300±500g (range: 660-3600g). The prevalence of ROP among the examined infants was 34.8%. Prevalence of threshold disease that required laser treatment was 25.4%. Prevalence of ROP among those with extremely low BW was 86.7% compared to 27.8% in those with very low BW. Respiratory distress and congenital heart diseases were significantly associated with higher incidence of ROP. CONCLUSION: Lower BW, lower GA and female gender are associated with higher risk of developing ROP among preterm infants in Brunei Darussalam.

Spectrum of intra-ocular foreign bodies and the outcome of their management in Brunei Darussalam.

To review the etiologies, prognostic factors and treatment outcomes of intraocular foreign bodies (IOFBs) occurring in the population of Brunei Darussalam, and provide guidelines to prevent and manage such injuries. A retrospective review was performed for all cases of traumatic IOFBs managed in our centre during a 3-year period between May 2008 and April 2011. The mechanism of injury, management, complications and visual outcomes were analyzed. Majority of the patients were males (93 %) and the mean age was 36 years. The main causes of trauma were metal hammering and grass cutting (43 % each). Other causes include road traffic accidents and firecracker explosion (7 % each). The visual outcome was ≥6/18 in 50 % and 'No perception of light' in 29 %. Causes of poor visual outcome were retinal detachment with proliferative vitreoretinopathy (21 %), endophthalmitis (21 %) and globe maceration (7 %). Prognostic factors associated with significantly worse final visual outcome included posterior location of the IOFB (p = 0.05) and larger IOFB size (p < 0.001). The time from injury to surgery did not correlate with a worse visual prognosis. In Brunei Darussalam, the commonest causes of IOFBs are hammering metal and cutting grass using power tools. The visual outcome varies between 6/6 and NPL. Poor visual outcome is related to the severity of the initial ocular injury, posterior segment IOFB and endophthalmitis.

Comparison of pH-adjusted bupivacaine with a mixture of non-pH-adjusted bupivacaine and lignocaine in primary vitreoretinal surgery.

PURPOSE: To compare the efficacy of alkalinized bupivacaine with that of a mixture of nonalkalinized bupivacaine and lignocaine for local anesthesia in primary vitreoretinal surgery. METHODS: Through a prospective, double-blind, randomized, controlled clinical trial, 540 consecutive patients undergoing primary vitreoretinal surgery received either alkalinized 0.5% bupivacaine (group B) or a mixture of nonalkalinized 0.5% bupivacaine and 2% lignocaine (group BL), both of which were administered with hyaluronidase, for periocular anesthetic block. The periocular block involved two injections in the extraconal space-one in the lower temporal quadrant and the other in the medial periconal space. The efficacy of the block was graded from 0 to 5 depending on the adequacy of anesthesia and akinesia and the need for local supplementation. RESULTS: Adequate anesthesia and akinesia (grade 5) were achieved in 72.2% of the patients in group B compared with 57.4% in group BL (P = 0.0003). Intraoperative supplementation was needed in 9.6% and 20.7% of the patients in groups B and BL, respectively (P = 0.0003). Postoperative analgesics were required in 7.4% of the patients in group B and in 15.2% of those in group BL (P = 0.004). CONCLUSION: Alkalinized 0.5% bupivacaine provides better quality of anesthesia than does the mixture of nonalkalinized 0.5% bupivacaine and 2% lignocaine for patients undergoing primary vitreoretinal surgery.