The impact of cholecystectomy on the symptom relief and quality of life of patients with gallbladder dysmotility.

BACKGROUND: The aim of this study was to demonstrate the impact of laparoscopic cholecystectomy on the physical and mental health of patients with gallbladder dysmotility. METHODS: Retrospective data was collected from 314 patients who had undergone a hepatobiliary iminodiacetic acid (HIDA) scan between June 2012 and June 2022 in a District General Hospital in South East England. Sixty-three patients who were diagnosed with gallbladder dysmotility were then contacted and asked to participate in a telephone interview regarding their symptoms. We measured their health-related quality of life using the HRQoL SF-12 v2 (Health Related Quality of Life Short Form-12 version 2) questionnaire. Differences in the resolution of symptoms between those that had undergone a cholecystectomy and those who did not, were assessed using a chi square test. The two groups were then compared using the student t-test to assess statistically significant differences. RESULTS: 94% (n = 31/33) of the participants in the non-cholecystectomy group demonstrated persistent biliary pain symptoms as opposed to the 6% (n = 2/30) in the cholecystectomy group. A statistically significant improvement in five out of the eight domains of the HRQoL SF-12 questionnaire was demonstrated. These domains include PCS (physical component summary), MCS (mental component summary), mental health, general health and bodily pain. CONCLUSION: The results of our retrospective analysis demonstrate an improvement in both the physical and mental health-related quality of life symptoms in patients who underwent laparoscopic cholecystectomy. These findings support the use of laparoscopic cholecystectomy as an effective method for managing gallbladder dysmotility.

Evaluation of Early Screening for Diabetes Mellitus in Pregnancy with Hemoglobin A1c.

Early diabetes screening is recommended for high-risk pregnant women risk via a 1-hour glucose challenge test (1-hour GCT). Hemoglobin A1c (HbA1c) can be obtained with initial obstetric laboratories. We sought to examine the relationship between HbA1c and 1-hour GCT for early diabetes screening in pregnancy. This is a retrospective cohort study of 204 high-risk pregnant women who underwent early HbA1c and 1-hour GCT. Simple logistic regression analysis was performed to predict abnormal 1-hour GCT and diagnosis of diabetes using HbA1c. A total of 158 (77.5%), 44 (21.5%), and 2 (1%) women had HbA1c of less than 5.7, 5.7 to 6.4, and 6.5% or higher, respectively. Seven of 158 (4.4%) women with HbA1c less than 5.7% and 8 of 44 (18.2%) with HbA1c of 5.7 to 6.4% had a diagnosis of diabetes. A positive correlation between early HbA1c and 1-hour GCT was detected. Logistic regression showed HbA1c significantly predicted the risk of diabetes but was not a good predictor of abnormal 1-hour GCT. HbA1c of 5.5% or less had a 97% or higher negative predictive value for early diabetes in pregnancy. There is a positive correlation between HbA1c and 1-hour GCT for the early screening of diabetes in pregnancy. Women with early HbA1c ≤ 5.5% could forego further testing in early pregnancy.

Diabetes Group Prenatal Care: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the effect of diabetes group prenatal care on rates of preterm birth and large for gestational age (LGA) among patients with diabetes in pregnancy compared with individual diabetes prenatal care. DATA SOURCES: We searched Ovid Medline (1946-), Embase.com (1947-), Scopus (1823-), Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing diabetes group prenatal care with individual care among patients with type 2 diabetes mellitus or gestational diabetes mellitus (GDM). The primary outcomes were preterm birth before 37 weeks of gestation and LGA (birth weight at or above the 90th percentile). Secondary outcomes were small for gestational age, cesarean delivery, neonatal hypoglycemia, neonatal intensive care unit admission, breastfeeding at hospital discharge, long-acting reversible contraception (LARC) uptake, and 6-week postpartum visit attendance. Secondary outcomes, limited to the subgroup of patients with GDM, included rates of GDM requiring diabetes medication (A2GDM) and completion of postpartum oral glucose tolerance testing (OGTT). Heterogeneity was assessed with the Cochran Q test and I2 statistic. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean differences. TABULATION, INTEGRATION, AND RESULTS: Eight studies met study criteria and were included in the final analysis: three RCTs and five observational studies. A total of 1,701 patients were included in the pooled studies: 770 (45.3%) in diabetes group prenatal care and 931 (54.7%) in individual care. Patients in diabetes group prenatal care had similar rates of preterm birth compared with patients in individual care (seven studies: pooled rates 9.5% diabetes group prenatal care vs 11.5% individual care, pooled RR 0.77, 95% CI, 0.59-1.01), which held for RCTs and observational studies. There was no difference between diabetes group prenatal care and individual care in rates of LGA overall (four studies: pooled rate 16.7% diabetes group prenatal care vs 20.2% individual care, pooled RR 0.93, 95% CI, 0.59-1.45) or by study type. Rates of other secondary outcomes were similar between diabetes group prenatal care and individual care, except patients in diabetes group prenatal care were more likely to receive postpartum LARC (three studies: pooled rates 46.1% diabetes group prenatal care vs 34.1% individual care, pooled RR 1.44, 95% CI, 1.09-1.91). When analysis was limited to patients with GDM, there were no differences in rates of A2GDM or postpartum visit attendance, but patients in diabetes group prenatal care were significantly more likely to complete postpartum OGTT (five studies: pooled rate 74.0% diabetes group prenatal care vs 49.4% individual care, pooled RR 1.58, 95% CI, 1.19-2.09). CONCLUSION: Patients with type 2 diabetes and GDM who participate in diabetes group prenatal care have similar rates of preterm birth, LGA, and other pregnancy outcomes compared with those who participate in individual care; however, they are significantly more likely to receive postpartum LARC, and those with GDM are more likely to return for postpartum OGTT. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021279233.

Case report: Aorto-left atrial fistula-A rare complication of native aortic valve endocarditis.

BACKGROUND: Aorto-cavitary fistula is a rare complication of infective endocarditis. Multimodal imaging is commonly required to assess the severity and extent of infection because of the complex pathology of the valvular and paravalvular apparatus in endocarditis. CASE PRESENTATION: We present an unusual case of a middle-aged man with recent history of meningoencephalitis who developed infective endocarditis complicated by ruptured abscess in inter-valvular fibrosa between aortic and mitral valve resulting in free communication or fistula formation between aorta and left atrium. Patient underwent double valve replacement (aortic and mitral) along with repair of the aorta. CONCLUSIONS: Our case highlights recognition of this rare clinical presentation of aorto-left atrial fistula in infective endocarditis and the diagnostic role of transesophageal echocardiography in good clinical outcome with aggressive and timely management.

Mediastinal paraganglioma of the aortopulmonary subtype - A surgical challenge.

INTRODUCTION AND IMPORTANCE: This case report describes the successful surgical management of a 30-year-old male with a non-functional carotid body tumor and a mediastinal paraganglioma occupying the aortopulmonary space. The report highlights the rarity of mediastinal paragangliomas and the challenges in their surgical management. CASE PRESENTATION: The patient underwent pre-op angioembolisation of the carotid body tumor, followed by excision and left cervical lymph node dissection. A large mediastinal mass was identified and resected during surgery without needing a cardiopulmonary bypass. The patient recovered well from surgery. Histopathology confirmed the diagnosis of clinically recurrent paraganglioma. CLINICAL DISCUSSION: Mediastinal paragangliomas are rare and challenging to manage due to their proximity to major vascular structures. Surgical intervention is the preferred treatment, but the risk of complications is high. In this case, the surgical approach involved resection of the mediastinal mass without cardiopulmonary bypass. This approach reduced the risk of complications associated with bypass procedures. The procedure's success underscores the importance of early diagnosis and prompt surgical intervention. CONCLUSION: This case report highlights the successful surgical management of a rare and clinically challenging mediastinal paraganglioma without cardiopulmonary bypass. The report underscores the importance of prompt diagnosis and surgical intervention in mediastinal paragangliomas.

Hormonal Therapies in Cancers.

The hormonal therapy for cancer has become a household name and the series of experiments performed leading to the discovery of hormones use in the treatments of breast cancer. The hormones like antiestrogen, aromatase restrictors, antiandrogens, and use of extremely strong luteinizing hormone-releasing hormone agonists to perform a "medical hypophysectomy" because of their ability of causing desensitization in the pituitary gland have proven their value in the treatment of cancers over the last two decades. Millions of women still use hormonal therapy for menopause symptoms. Estrogen plus progestin or estrogen separately utilized as a menopause hormonal therapy throughout the world. Women receiving different premenopausal and postmenopausal hormonal therapies are on higher risk of having ovarian cancer. The risk of ovarian cancer did not increase with the increase of duration of hormonal therapy. Postmenopausal hormone use was found to be inversely related to major colorectal adenomas.

Outcomes after extended azithromycin administration in preterm premature rupture of membranes.

BACKGROUND: Preterm premature rupture of membranes accounts for approximately one-quarter of all preterm deliveries and occurs in 2% to 3% of all pregnancies. With subclinical infection being a suspected cause of preterm premature rupture of membranes, the administration of prophylactic antibiotics is an accepted standard of care to extend the latency period. Historically, erythromycin was used in the antibiotic regimen recommended for women with preterm premature rupture of membranes during expectant management; however, azithromycin has recently been shown to be a suitable alternative. OBJECTIVE: This study aimed to evaluate whether extended azithromycin administration affects the latency time in preterm premature rupture of membranes. STUDY DESIGN: This was a retrospective multi-institutional cohort study in Washington, District of Columbia, of patients admitted from January 2012 to December 2019 with preterm premature rupture of membranes of singleton pregnancies between 23 0/7 and 33 6/7 weeks of gestation. Patients were excluded if they had multiple pregnancies, had an allergy to penicillin or macrolides, were in labor, had suspected placental abruptions, had overt chorioamnionitis, or had nonreassuring fetal status on presentation indicating the need for prompt delivery. Patients that received limited azithromycin administration (<2 days) and patients that received extended azithromycin administration (7 days) were compared. All patients otherwise received the institutional standard of 2 days of intravenous ampicillin followed by 5 days of oral amoxicillin. The primary outcome was length of gestational latency, defined as the time from membrane rupture to delivery. The selective secondary outcomes that were evaluated were rates of chorioamnionitis and adverse neonatal outcomes, including sepsis, respiratory distress, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal death. RESULTS: During the study period, 416 cases of preterm premature rupture of membranes were identified. Of the 287 patients who met the inclusion criteria, 165 (57.5%) received limited azithromycin administration, and 122 (42.5%) received extended azithromycin administration. Adjusted median gestational latency was significantly longer for patients who received extended azithromycin administration, extended by >3 days (2.6 days [interquartile range, 2.2-3.1] for limited azithromycin administration vs 5.8 days [interquartile range, 4.8-6.9] for extended azithromycin administration; P<.001). Neonatal secondary outcome evaluation was performed on 216 cases (76%). There was no difference in chorioamnionitis or adverse neonatal outcomes between the 2 groups. CONCLUSION: Among patients with preterm premature rupture of membranes, extended azithromycin administration was associated with increased latency, without any effect on other maternal or neonatal outcomes.

Impact of the COVID-19 pandemic on the management and outcomes of emergency surgical patients: A retrospective cohort study.

INTRODUCTION: The COVID-19 pandemic has led to drastic measures being implemented for the management of surgical patients across all health services worldwide, including the National Health Service in the United Kingdom. It is suspected that the virus has had a detrimental effect on perioperative morbidity and mortality. Therefore, the aim of this study was to assess the impact of the COVID-19 pandemic on these outcomes in emergency general surgical patients. METHODS: Emergency general surgical admissions were included in this retrospective cohort study in one of the COVID-19 hotspots in the South East of England. The primary outcome was the 30-day mortality rate. Secondary outcomes included the length of stay in hospital, complication rate and severity grade and admission rates to the ITU. RESULTS: Of 123 patients, COVID-19 was detected in 12.2%. Testing was not carried out in 26%. When comparing COVID-positive to COVID-negative patients, the mean age was 71.8 + 8.8 vs. 50.7 + 5.7, respectively, and female patients accounted for 40.0 vs. 52.6%. The 30-day mortality rate was 26.7 vs. 3.9 (OR 6.49, p = 0.02), respectively. The length of stay in hospital was 20.5 + 22.2 vs. 7.7 + 9.8 (p < 0.01), the rate of complications was 80.0 vs. 23.7 (OR 12.9, p < 0.01), and the rate of admission to the ITU was 33.3 vs. 7.9% (OR 5.83, p = 0.01). CONCLUSION: This study demonstrates the detrimental effect of COVID-19 on emergency general surgery, with significantly worsened surgical outcomes.

MicroRNA analysis in maternal blood of pregnancies with preterm premature rupture of membranes reveals a distinct expression profile.

OBJECTIVE: To determine the expression profile of microRNAs in the peripheral blood of pregnant women with preterm premature rupture of membranes (PPROM) compared to that of healthy pregnant women. STUDY DESIGN: This was a pilot study with case-control design in pregnant patients enrolled between January 2017 and June 2019. Patients with healthy pregnancies and those affected by PPROM between 20- and 33+6 weeks of gestation were matched by gestational age and selected for inclusion to the study. Patients were excluded for multiple gestation and presence of a major obstetrical complication such as preeclampsia, diabetes, fetal growth restriction and stillbirth. A total of ten (n = 10) controls and ten (n = 10) patients with PPROM were enrolled in the study. Specimens were obtained before administration of betamethasone or intravenous antibiotics. MicroRNA expression was analyzed for 800 microRNAs in each sample using the NanoString nCounter Expression Assay. Differential expression was calculated after normalization and log2- transformation using the false discovery rate (FDR) method at an alpha level of 5%. RESULTS: Demographic characteristics were similar between the two groups. Of the 800 miRNAs analyzed, 116 were differentially expressed after normalization. However, only four reached FDR-adjusted statistical significance. Pregnancies affected by PPROM were characterized by upregulation of miR-199a-5p, miR-130a-3p and miR-26a-5p and downregulation of miR-513b-5p (FDR adjusted p-values <0.05). The differentially expressed microRNAs participate in pathways associated with altered collagen and matrix metalloprotease expression in the extracellular matrix. CONCLUSION: Patients with PPROM have a distinct peripheral blood microRNA profile compared to healthy pregnancies as measured by the NanoString Expression Assay.

Coronary artery to pulmonary artery fistula: Catheter or scalpel? A case report.

INTRODUCTION: Coronary artery fistula (CAF) is an abnormal connection between coronary artery and a major vessel or cardiac chamber with left to right shunt having an incidence of 0.002 % in recent literature. Fistulous communication of coronary artery with pulmonary artery (PA) is a rare subtype and comprises of about 17 % of all the CAF cases. CASE PRESENTATION: We report a case of a middle-aged gentleman, known case of asymptomatic CAF for the last 20 years. He presented to us with 6 months history of chest pain on exertion. On coronory angiogram he was diagnosed to have a preexisting CAF of proximal LAD to main PA and severe coronary artery disease in left anterior descending coronary artery (LAD). He was managed surgically and underwent ligation of the fistula along with coronary artery bypass grafting (CABG). CLINICAL DISCUSSION: Management of CAF is medical, percutaneous or open-heart surgery. Due to rarity of the disease no international guidelines exists and treatment is controversial. Complications of CAF include endocarditis, early atherosclerosis, rupture, hemopericardium, pulmonary hypertension and myocardial ischemia, hence early correction is warranted. Our case emphasizes on the natural course of this rare disease and how to change management plan accordingly in the better interest of patient. CONCLUSION: Our case presents the natural course and management of a rare congenital cardiac disease. Surgery was chosen as an appropriate option due to CAD involving proximal LAD and concomitant coronary artery to PA fistula.

A pilot study of vidofludimus calcium for treatment of primary sclerosing cholangitis.

The purpose of this pilot study was to explore the efficacy, safety, and tolerability of vidofludimus calcium (VC) in the treatment of primary sclerosing cholangitis (PSC). This was a single-arm open-label pilot study with a cohort of 18 patients with PSC. Study patients received VC for a period of 6 months. The study was undertaken at two sites, Mayo Clinic, Rochester, MN, and Mayo Clinic, Phoenix, AZ. The primary endpoint of the study was improvement of serum alkaline phosphatase (ALP) at the end of the study. Secondary endpoints included assessment of other liver biomarkers (bilirubin, alanine aminotransferase, and aspartate aminotransferase). Of 18 patients enrolled, 11 completed the 6 months of study treatment. Patients who completed treatment versus those who did not were similar other than a significantly higher direct bilirubin at baseline in the group that completed treatment (mean ± SD, 0.4 ± 0.3 versus 0.1 ± 0.1, p = 0.04). By intent to treat analysis, the primary outcome was met in 16.7% (3/18) of patients. By per-protocol analysis, including only patients who completed treatment, normalization of ALP occurred in 27.7% (3/11) at week 24 (95% confidence interval, 6.0% to 61.0%). VC was well tolerated with no drug-related serious adverse events. Conclusion: This proof of concept study provides support for further exploration of VC in patients with PSC.

Novel Reconstruction of Neosternum With Steel Wires for Recurrent Chondrosarcoma.

Chondrosarcoma is a primary chest wall tumor causing huge masses arising from rib, sternum, or costochondral junction. Successful treatment warrants complete surgical resection with wide, free margins followed by reconstruction of the bony chest wall and soft tissue coverage of the defect. We report the case of excision of giant recurrent sternal chondrosarcoma followed by reconstruction of neosternum using steel wires. This novel technique portrays steel wire-based reconstructions as a safe, reproducible, and readily available prosthetic material for complex chest wall surgeries.

'Hot gall bladder service' by emergency general surgeons: Is this safe and feasible?

BACKGROUND: Despite NICE/AUGIS recommendations, the practice of early laparoscopic cholecystectomy (ELC) has been particularly poor in the UK offered only by 11%-20% surgeons as compared to 33%-67% internationally, possibly due to financial constraints, logistical difficulties and shortage of expertise, thus, reflecting the varied provision of emergency general surgical care. To assess whether emergency general surgeons (EGS) could provide a 'Hot Gall Bladder Service' (HGS) with an acceptable outcome. PATIENTS AND METHODS: This was a prospective HGS observational study that was protocol driven with strict inclusion/exclusion criteria and secure online data collection in a district general hospital between July 2018 and June 2019. A weekly dedicated theatre slot was allocated for this list. RESULTS: Of the 143 referred for HGS, 86 (60%) underwent ELC which included 60 (70%) women. Age, ASA and body mass index was 54* (18-85) years, II* (I-III) and 27* (20-54), respectively. 86 included 46 (53%), 19 (22%), 19 (22%) and 2 (3%) patients presenting with acute calculus cholecystitis, gallstone pancreatitis, biliary colic, and acalculus cholecystitis, respectively. 85 (99%) underwent LC with a single conversion. Grade of surgical difficulty, duration of surgery and post-operative stay was 2* (1-4) 68* (30-240) min and 0* (0-13) day, respectively. Eight (9%) required senior surgical input with no intra-operative complications and 2 (2%) 30-day readmissions. One was post-operative subhepatic collection that recovered uneventfully and the second was pancreatitis, imaging was clear requiring no further intervention. CONCLUSION: In the current climate of NHS financial crunch, COVID pandemic and significant pressure on inpatient beds: Safe and cost-effective HGS can be provided by the EGS with input from upper GI/HPB surgeons (when required) with acceptable morbidity and a satisfactory outcome. *Median.

Comparative Trends in Ischemic Heart Disease Admissions, Presentation and Outcomes Due to the COVID-19 Pandemic: First Insights From a Tertiary Medical Center in Pakistan.

Introduction COVID-19 has manifested a striking disarray in healthcare access and provision, particularly amongst patients presenting with life-threatening ischemic heart disease (IHD). The paucity of data from low-middle income countries has limited our understanding of the consequential burden in the developing world. We aim to compare volumes, presentations, management strategies, and outcomes of IHD amongst patients presenting in the same calendar months before and during the COVID-19 pandemic. Methods We conducted a retrospective cross-sectional analysis at the Aga Khan University Hospital, one of the premier tertiary care centres in Pakistan. Data were collected on all adult patients (>18 years) who were admitted with IHD (acute coronary syndrome (ACS) and stable angina) from March 1 to June 30, 2019 (pre-COVID) and March 1 to June 30, 2020 (during-COVID), respectively. Group differences for continuous variables were evaluated using student t-test or Mann-Whitney U test. The chi-squared test or Fisher test was used for categorical variables. Values of p less than 0.05 were considered statistically significant. P-value trend calculation and graphical visualization were done using STATA (StataCorp, College Station, TX). Results Data were assimilated on 1019 patients, with 706 (69.3%) and 313 (30.7%) patients presenting in each respective group (pre-COVID and during-COVID). Current smoking status (p=0.019), admission source (p<0.001), month of admission (p<0.001), proportions ACS (p<0.001), non-ST-elevation-myocardial-infarction (NSTEMI; p<0.001), unstable angina (p=0.025) and medical management (p=0.002) showed significant differences between the two groups, with a sharp decline in the during-COVID group. Monthly trend analysis of ACS patients showed the most significant differences in admissions (p=0.001), geographic region (intra-district vs intracity vs outside city) (p<0.001), time of admission (p=0.038), NSTEMI (p=0.002) and medical management (p=0.001). Conclusion These data showcase stark declines in ACS admissions, diagnostic procedures (angiography) and revascularization interventions (angioplasty and coronary artery bypass graft surgery, CABG) in a developing country where resources and research are already inadequate. This study paves the way for further investigations downstream on the short- and long-term consequences of untreated IHD and reluctance in health-seeking behaviour.

Liver Transplant in a Polymerase Chain Reaction-Positive COVID-19 Recipient: A Case Report.

The severe acute respiratory syndrome coronavirus 2 coronavirus disease 2019 (COVID-19) global pandemic has ushered in an era of hesitation in performing transplants in affected patients. This stems from the paucity of data regarding the testing modalities, long-term implications, and uncertain prognosis in this group of patients. Current guidance from the Centers for Disease Control recommends assessing symptoms rather than polymerase chain reaction (PCR) positivity. In light of these recommendations, we describe a case of an orthotopic liver transplant in a patient infected with COVID-19 with persistent PCR positivity for 40 days before retransplant. The patient's perioperative and postoperative course was uncomplicated. Our experience leads us to advocate for liver transplants in patients who are PCR positive for COVID-19 after careful individualized and multidisciplinary evaluation regarding their liver disease and COVID-19 symptomatology.

Educational Video on Pain Management and Subsequent Opioid Use After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether viewing an educational video on pain management reduces opioid use after cesarean delivery. METHODS: We conducted a randomized, controlled trial of women aged 18 years or older who underwent cesarean delivery at a tertiary care center. Eligible women were randomized in a 1:1 ratio to usual discharge pain medication instructions plus an educational video on pain management or to usual discharge pain medication instructions alone. All women received the same opioid prescription at discharge: Twenty 5-mg oxycodone tablets. Participants were contacted at 7 days and at 14 days after delivery to assess the number of oxycodone tablets used, adjunct medication (acetaminophen and ibuprofen) use, pain scores, and overall satisfaction of pain control. The primary outcome was the number of oxycodone tablets used from discharge through postpartum day 14. A sample size of 23 per group (n=46) was planned to detect a 25% difference in mean number of oxycodone tablets used between groups, as from 20 to 15. RESULTS: From July 2019 through December 2019, 61 women were screened and 48 were enrolled-24 in each group. Women who viewed the educational video used significantly fewer opioid tablets from discharge through postpartum day 14 compared with women who received usual pain medication instructions (median 1.5, range 0-20 vs median 10, range 0-24, P<.001). Adjunct medication use, pain scores, and satisfaction with pain control did not differ significantly between groups. CONCLUSION: Among women who underwent cesarean delivery, viewing an educational video on pain management reduced postdischarge opioid use. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03959969.

Incidence of Hypertensive Disorders of Pregnancy in Women with COVID-19.

OBJECTIVE: The study aimed to examine the incidence of hypertensive disorders of pregnancy in women diagnosed with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2, also known as COVID-19). STUDY DESIGN: This was a retrospective cohort study of all women who delivered at MedStar Washington Hospital Center in Washington, DC from April 8, 2020 to July 31, 2020. Starting April 8, 2020, universal testing for COVID-19 infection was initiated for all women admitted to labor and delivery. Women who declined universal testing were excluded. Hypertensive disorders of pregnancy were diagnosed based on American College of Obstetricians and Gynecologists Task Force definitions.1 Maternal demographics, clinical characteristics, and labor and delivery outcomes were examined. Neonatal outcomes were also collected. Laboratory values from admission were evaluated. Our primary outcome was the incidence of hypertensive disorders of pregnancy among women who tested positive for COVID-19. The incidence of hypertensive disorders of pregnancy was compared between women who tested positive for COVID-19 and women who tested negative. RESULTS: Of the 1,008 women included in the analysis, 73 (7.2%) women tested positive for COVID-19, of which 12 (16.4%) were symptomatic at the time of admission. The incidence of hypertensive disorders of pregnancy was 34.2% among women who tested positive for COVID-19 and 22.9% women who tested negative for COVID-19 (p = 0.03). After adjusting for race, antenatal aspirin use, chronic hypertension, and body mass index >30, the risk of developing any hypertensive disorder of pregnancy was not statistically significant (odds ratio: 1.58 [0.91-2.76]). CONCLUSION: After adjusting for potential confounders, the risk of developing a hypertensive disorder of pregnancy in women who tested positive for COVID-19 compared with women who tested negative for COVID-19 was not significantly different. KEY POINTS: · There is an increased incidence of hypertensive disorders in women who test positive for COVID-19.. · Characteristics of pregnant women with COVID-19 are similar to those with hypertensive disorders.. · Liver function tests were similar between pregnant women with COVID-19 and women without COVID-19..

Refining the clinical definition of active phase arrest of dilation in nulliparous women to consider degree of cervical dilation as well as duration of arrest.

BACKGROUND: Maternal and neonatal outcomes associated with duration of arrest of dilation beyond 4 hours are not well known. In addition, the current definition of arrest does not consider the degree of cervical dilation (6 cm vs 7 cm vs 8 cm vs 9 cm) when arrest occurs. OBJECTIVE: We sought to examine maternal and neonatal outcomes in nulliparous women who achieved the active phase of labor according to the duration they required to achieve a cervical change of at least 1 cm (<4 hours vs 4-5.9 hours vs ≥6 hours) beginning at 6, 7, 8 and 9 cm. STUDY DESIGN: This was a retrospective cohort study of nulliparous women with term singleton cephalic pregnancies in spontaneous or induced active labor (≥6 cm). To evaluate the effect of labor duration on maternal and fetal outcomes at different degrees of cervical dilation, we categorized women based on time intervals they required to achieve a cervical change of at least 1 cm after membrane rupture ("<4 hours," "4-5.9 hours," and "≥6 hours"), and we correlated each time interval with referent cervical dilation status (6 cm, 7 cm, 8 cm, and 9 cm). Maternal and neonatal outcomes were analyzed according to the duration to progress at least 1 cm starting from each degree of cervical dilation. Our primary outcome was a composite of neonatal outcomes, including intensive care unit admission, neonatal death, seizure, ventilator use, birth injury, and neonatal asphyxia. In addition, we examined maternal outcomes. Adjusted odds ratios with 95% confidence intervals were calculated, controlling for predefined covariates. RESULTS: Of 31,505 nulliparous women included in this study, 13,142 (42%), 10,855 (34%), 11,761 (37%), and 17,049 (54%) reached documented cervical dilation of 6, 7, 8, and 9 cm, respectively. At cervical dilation of 6 or 7 cm, the arrest of dilation of <4 hours compared with arrest of dilation of 4 to 5.9 hours was associated with decreased risks of adverse maternal outcomes. When cervical dilation was 8 or 9 cm, arrest of dilation of <4 hours compared with arrest of dilation of 4 to 5.9 hours was associated with decreased risks of adverse maternal and neonatal outcomes. For example, women starting at a cervical dilation of 8 cm who required <4 hours to achieve a cervical change of 1 cm compared with those who required 4 to 5.9 hours had lower rates of cesarean delivery (adjusted odds ratio, 0.40; 95% confidence interval, 0.28-0.55), chorioamnionitis (adjusted odds ratio, 0.42; 95% confidence interval, 0.29-0.60), and the neonatal composite outcome (adjusted odds ratio, 0.51; 95% confidence interval, 0.36-0.72). CONCLUSION: When cervical dilation is 6 or 7 cm, allowing arrest of dilation of ≥4 hours is reasonable because it was not associated with increased risks of adverse neonatal outcomes. When cervical dilation is 8 or 9 cm, the benefit of allowing arrest of dilation of ≥4 hours should be balanced against the risk of adverse maternal and neonatal outcomes.

Evaluation of the Maternal-Fetal Triage Index in a tertiary care labor and delivery unit.

BACKGROUND: The Maternal-Fetal Triage Index is a 5-level system to facilitate the care of pregnant women seeking care in an obstetrical triage unit (priority 1 being the highest acuity and priority 5 being the lowest acuity). Although the American College of Obstetricians and Gynecologists recommends implementing labor and delivery triage tools, it remains unclear whether the Maternal-Fetal Triage Index facilitates the timely evaluation of high-acuity pregnant women. OBJECTIVE: We sought to examine the duration of a labor and delivery triage evaluation before and after the implementation of the Maternal-Fetal Triage Index. We also sought to examine the duration of a labor and delivery triage evaluation according to priority levels by the Maternal-Fetal Triage Index. STUDY DESIGN: This was a retrospective quality improvement study of all women presenting to an urban, tertiary labor and delivery triage unit at 16 weeks' gestation or later from December 2017 to February 2018 (historical cohort) and December 2018 to February 2019 (study cohort). As part of a quality improvement initiative, the Maternal-Fetal Triage Index was implemented in the labor and delivery unit in May 2018. All registered nurses who worked in the labor and delivery unit completed a formal education course and assigned the priority levels at the time of triage presentation. The primary outcome was the duration of a labor and delivery triage evaluation, which was defined as the time interval from triage presentation to the completion of history and physical examination in the electronic medical record. Secondary outcomes included the rates of labor and delivery unit admissions. RESULTS: There were 1305 and 1374 women in the historical cohort and study cohort, respectively. The duration of labor and delivery triage evaluation was longer for the study cohort than for the historical cohort (64 minutes vs 61 minutes; P=.02). Of the 1374 women in the study cohort, there were 28 (2%), 290 (21%), 459 (33%), 462 (34%), and 135 (10%) women with priority levels 1, 2, 3, 4, and 5 assigned, respectively. Women with a higher priority according to the Maternal-Fetal Triage Index had a shorter labor and delivery triage evaluation (priority 1, 57 minutes; priority 2, 66 minutes; priority 3, 63 minutes; priority 4, 62 minutes; and priority 5, 83 minutes; P<.001). The rates of admission were higher in the priority 1 and 5 groups (priority 1, 89.3%; priority 2, 41.4%; priority 3, 57.3%; priority 4, 53.3%; and priority 5, 92.6%; P<.001). CONCLUSION: Compared with the historical cohort, the duration of labor and delivery triage evaluation was longer in the study cohort. However, in the study cohort, women classified as higher priority according to the Maternal-Fetal Triage Index had a shorter labor and delivery triage evaluation. Our study supports the American College of Obstetricians and Gynecologists' recommendation on the implementation and utilization of labor and delivery triage tools such as the Maternal-Fetal Triage Index.

Innovation in surgical training: Simulating prosthetic heart valves and annuloplasty rings using pacifiers for cardiac surgery wet-labs in a resource limited setting.

Conducting a hands-on cardiac wet-lab on valvular surgeries in a resource-limited setting is restricted by the lack of prosthetic heart valves and annuloplasty rings for developing cognitive and technical skills required to understand and protect the three-dimensional cardiac anatomy. In recent times, simulation is regarded as an effective tool in surgical education and has proven to improve the technical skills of trainees. The current short report presents a novel simulator to mimic heart valve replacement surgeries by using a pacifier as a prosthetic valve and annuloplasty ring. Considering resource-constraints in the local context, pacifier-based valve simulators can be usedful as they are cost-effective, readily available, easy to assemble, sturdy to use and have been remarkably helpful in teaching heart valve surgeries to residents and junior surgeons.