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Ultrasound in Obstetrics & Gynecology :... Nov 2023To assess whether coexisting fetal growth restriction (FGR) influences pregnancy latency among women with preterm pre-eclampsia undergoing expectant management....
OBJECTIVES
To assess whether coexisting fetal growth restriction (FGR) influences pregnancy latency among women with preterm pre-eclampsia undergoing expectant management. Secondary outcomes assessed were indication for delivery, mode of delivery and rate of serious adverse maternal and perinatal outcomes.
METHODS
We conducted a secondary analysis of the Pre-eclampsia Intervention (PIE) and the Pre-eclampsia Intervention 2 (PI2) trial data. These randomized controlled trials evaluated whether esomeprazole and metformin could prolong gestation of women diagnosed with pre-eclampsia between 26 and 32 weeks of gestation undergoing expectant management. Delivery indications were deteriorating maternal or fetal status, or reaching 34 weeks' gestation. FGR (defined by Delphi consensus) at the time of pre-eclampsia diagnosis was examined as a predictor of outcome. Only placebo data from PI2 were included, as the trial showed that metformin use was associated with prolonged gestation. All outcome data were collected prospectively from diagnosis of pre-eclampsia to 6 weeks after the expected due date.
RESULTS
Of the 202 women included, 92 (45.5%) had FGR at the time of pre-eclampsia diagnosis. Median pregnancy latency was 6.8 days in the FGR group and 15.3 days in the control group (difference 8.5 days; adjusted 0.49-fold change (95% CI, 0.33-0.74); P < 0.001). FGR pregnancies were less likely to reach 34 weeks' gestation (12.0% vs 30.9%; adjusted relative risk (aRR), 0.44 (95% CI, 0.23-0.83)) and more likely to be delivered for suspected fetal compromise (64.1% vs 36.4%; aRR, 1.84 (95% CI, 1.36-2.47)). More women with FGR underwent a prelabor emergency Cesarean section (66.3% vs 43.6%; aRR, 1.56 (95% CI, 1.20-2.03)) and were less likely to have a successful induction of labor (4.3% vs 14.5%; aRR, 0.32 (95% CI, 0.10-1.00)), compared to those without FGR. The rate of maternal complications did not differ significantly between the two groups. FGR was associated with a higher rate of infant death (14.1% vs 4.5%; aRR, 3.26 (95% CI, 1.08-9.81)) and need for intubation and mechanical ventilation (15.2% vs 5.5%; aRR, 2.97 (95% CI, 1.11-7.90)).
CONCLUSION
FGR is commonly present in women with early preterm pre-eclampsia and outcome is poorer. FGR is associated with shorter pregnancy latency, more emergency Cesarean deliveries, fewer successful inductions and increased rates of neonatal morbidity and mortality. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Infant, Newborn; Infant; Pregnancy; Female; Humans; Pregnancy Outcome; Cesarean Section; Pre-Eclampsia; Fetal Growth Retardation; Watchful Waiting; Metformin
PubMed: 37289938
DOI: 10.1002/uog.26282 -
Archives of Gynecology and Obstetrics Sep 2023Cesarean scar pregnancy (CSP) is a potentially life-threatening disease that has been steadily increasing in prevalence. Pregnancy termination is usually recommended... (Review)
Review
OBJECTIVE
Cesarean scar pregnancy (CSP) is a potentially life-threatening disease that has been steadily increasing in prevalence. Pregnancy termination is usually recommended given the risk of life-threatening complications. In some cases, patients refuse to terminate viable CSPs, even after counseling. Recent studies report that, even with a high burden of possible complications and maternal morbidity, many CSPs progress to live, close to term births. The aim of this study is to further demonstrate the natural history of viable cesarean scar pregnancies.
METHODS
We conducted a systematic review of original studies reporting cases of expectant management of CSPs with positive fetal heartbeats.
RESULTS
After selection, 28 studies were included in the review, with a total of 398 cases of CSP, 136 managed expectantly and 117 with positive fetal heartbeat managed expectantly. This study confirmed that the majority of patients experience live births, as 78% of patients selected for expectant management experienced live births at or close to term, with 79% developing morbidly adherent placenta, 55% requiring hysterectomy, and 40% having severe bleeding.
DISCUSSION
The optimal management protocol for CSP is still to be defined and more studies are needed to further elucidate this rare but rising disease. Our study provides information on the natural history of untreated CSPs and suggests that termination may not be the only option offered to the patient.
Topics: Pregnancy; Female; Humans; Cicatrix; Watchful Waiting; Cesarean Section; Pregnancy, Ectopic; Abortion, Induced
PubMed: 36394667
DOI: 10.1007/s00404-022-06835-3 -
The Journal of Chemical Physics Mar 2024The proper balancing of information from experiment and theory is a long-standing problem in the analysis of noisy and incomplete data. Viewed as a Pareto optimization...
The proper balancing of information from experiment and theory is a long-standing problem in the analysis of noisy and incomplete data. Viewed as a Pareto optimization problem, improved agreement with the experimental data comes at the expense of growing inconsistencies with the theoretical reference model. Here, we propose how to set the exchange rate a priori to properly balance this trade-off. We focus on gentle ensemble refinement, where the difference between the potential energy surfaces of the reference and refined models is small on a thermal scale. By relating the variance of this energy difference to the Kullback-Leibler divergence between the respective Boltzmann distributions, one can encode prior knowledge about energy uncertainties, i.e., force-field errors, in the exchange rate. The energy uncertainty is defined in the space of observables and depends on their type and number and on the thermodynamic state. We highlight the relation of gentle refinement to free energy perturbation theory. A balanced encoding of prior knowledge increases the quality and transparency of ensemble refinement. Our findings extend to non-Boltzmann distributions, where the uncertainty in energy becomes an uncertainty in information.
PubMed: 38511656
DOI: 10.1063/5.0189901 -
Kidney360 Aug 2023The Oxford classification of IgA nephropathy defined five features scored subjectively in renal biopsies, identified by the initials MESTC. Two large studies with...
KEY POINTS
The Oxford classification of IgA nephropathy defined five features scored subjectively in renal biopsies, identified by the initials MESTC. Two large studies with independent observers showed reproducibility was moderate for T, moderate or poor for M and S, and poor for E and C. In multivariate analyses including clinical features, T was related to 58% of outcomes, with no correlation of MESTC with 24% of outcomes.
BACKGROUND
The Oxford classification of IgA nephropathy defined five prognostic features scored subjectively in renal biopsies: mesangial cellularity (M), endocapillary hypercellularity (E), segmental sclerosis (S), interstitial fibrosis/tubular atrophy (T), and (fibro)cellular crescents (C). Pathological scoring systems should be reproducible and have prognostic value independently of clinical features. Reproducibility of the classification was not previously investigated in a systematic review, and the most recent systematic reviews of prognostic value were in 2017.
METHODS
This systematic review followed PRISMA 2020 guidelines. MEDLINE, PUBMED, and EMBASE databases were searched using the terms “IgA nephropathy” and “Oxford.” Eligible papers applied the classification and mentioned statistical analysis of interobserver reproducibility and/or included multivariate analysis of outcomes related to individual Oxford scores and clinical features, including treatment with corticosteroids or other immunosuppressive drugs.
RESULTS
There were 99 suitable papers before September 23, 2022. Of 12 papers that mentioned reproducibility, only six reported statistics for MEST/MESTC scoring. Four of these were small studies and/or had observers at the same institution. These were considered less representative of application of the classification than two large studies with independent observers, in which agreement was moderate for T, either moderate or poor for M and S, and poor for E and C. In 92 papers with 125 multivariate analyses of various outcomes, the commonest Oxford element associated with outcomes was T (73 of 125, 58%), with no correlation of any element with outcomes in 30 analyses (24%). Treatment with immunosuppression was often related to scores, particularly C and E, without consistent relations between Oxford scores and outcomes in immunosuppressed patients.
CONCLUSIONS
This systematic review showed limitations of the Oxford classification in practice, particularly the moderate or poor reproducibility of scores. T was the Oxford score most often related to clinical outcomes, but even this was not consistently reliable as a prognostic indicator.
Topics: Humans; Glomerulonephritis, IGA; Prognosis; Reproducibility of Results; Kidney; Glomerular Filtration Rate
PubMed: 37357346
DOI: 10.34067/KID.0000000000000195 -
Journal of Education & Teaching in... Apr 2024This simulation case was created for emergency medicine (EM) residents at all levels of training.
AUDIENCE
This simulation case was created for emergency medicine (EM) residents at all levels of training.
BACKGROUND
Cardiac electrical storm (ES) is commonly defined as three or more episodes of sustained ventricular tachycardia, ventricular fibrillation, or three shocks from an implantable defibrillator within a 24 hour period.1 This can occur in up to 30-40% of patients with implantable defibrillators; however, it may also present in a wide variety of patients, including those with structural heart disease, myocardial infarction, electrolyte disturbances, and channelopathies.2,3 With each subsequent episode of ventricular arrhythmia, the arrhythmogenic potential of the heart may increase secondary to increased intracellular calcium dysregulation, myocardial injury, and increased endogenous release of catecholamines. The increased pain and catecholamine release from cardioversion/defibrillation and exogenous epinephrine during cardiac arrest further exacerbates ES.2 This carries a significant mortality risk of up to 12% in the first 48 hours.3This case involves a basic knowledge of the Advanced Cardiac Life Support (ACLS) for ventricular tachycardia, both with and without a pulse, and the application of Sgarbossa criteria in a patient with an ST elevation myocardial infarction (STEMI) which makes it ideal for the PGY-1. However, the case quickly becomes refractory to the basic management prescribed in ACLS, requiring trouble shooting and quick thinking about deeper pathophysiology, a skill that is crucial for all emergency medicine physicians. There are multiple ways to troubleshoot this case, making for a good variety of discussion and recent literature review on the complexities of a relatively common arrhythmia, ventricular tachycardia.
EDUCATIONAL OBJECTIVES
By the end of this simulation, learners should be able to: 1) recognize unstable ventricular tachycardia and initiate ACLS protocol, 2) practice dynamic decision making by switching between various ACLS algorithms, 3) create a thoughtful approach for further management of refractory ventricular tachycardia, 4) interpret electrocardiogram (ECG) with ST-segment elevation (STE) and left bundle branch block (LBBB), 5) appropriately disposition the patient and provide care after return of spontaneous circulation (ROSC), 6) navigate a difficult conversation with the patient's husband when she reveals that the patient's wishes were to not be resuscitated.
EDUCATIONAL METHODS
This simulation was performed using high-fidelity simulation followed by an immediate debriefing with nine learners who directly participated in the SIM and twenty-three residents, who were online observers via Zoom. This case was done during our conference day, and there were a total of approximately forty total learners comprised of medical students, PGY-1, PGY-2 and PGY-3 residents. There were several medical students who also observed via Zoom but were not surveyed, and the survey was sent to 32 learners. The case was run three separate times with each session consisting of three-four learners at the same level of training, with other learners in the same level of training observing via Zoom™ video platform. Since we can only have a team of three-four learners participate per group during simulation, the rest of the learners were observing the case and the debrief. There was one simulation instructor and one technician.
RESEARCH METHODS
We sent an online survey to all the participants and the observers after the debrief via surveymonkey.com. The survey collected responses to the following statements: (1) the case was believable, (2) the case had right amount of complexity, (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. Likert scale was used to collect the responses.
RESULTS
A total of thirteen participants responded to the survey. One hundred percent of them either strongly agreed or agreed that the case was believable and that it helped in improving medical knowledge and patient care. Fifty-four percent strongly agreed, 38 percent agreed, and eight percent were neutral about the case having the right amount of complexity. Thirty one percent strongly agreed, 61 percent agreed, and eight percent were neutral about the case giving them real-life experience. All of them agreed that the debriefing session helped them improve their knowledge.
DISCUSSION
The high-fidelity simulation case was helpful with educating learners with ventricular tachycardia and fibrillation. Learners learned how to switch between various ACLS algorithms and how to manage a patient with refractory ventricular fibrillation. Learners enforced their knowledge in how to communicate with patient's family members when the patient does not want resuscitation.
TOPICS
Stable ventricular tachycardia, unstable ventricular tachycardia, refractory ventricular tachycardia, electrical storm, STEMI equivalents, medical simulation.
PubMed: 38707938
DOI: 10.21980/J8TS80 -
Sexual Medicine Reviews Sep 2023Synchronous behaviors between individuals are nonverbal signs of closeness and common purpose. In the flow from initial attraction to intimate sexual interaction,... (Review)
Review
From distal to proximal to interactive: behavioral and brain synchrony during attraction, courtship, and sexual interaction-implications for clinical assessments of relationship style and quality.
INTRODUCTION
Synchronous behaviors between individuals are nonverbal signs of closeness and common purpose. In the flow from initial attraction to intimate sexual interaction, attention and synchrony move from distal to proximal to interactive and are mediated by sensitized activation of neural systems for sexual motivation, arousal, and desire and those that recognize and mimic common facial and body movements between individuals. When reinforced by sexual pleasure and other relationship rewards, this results in the strengthening of attraction and bonding and the display of more common motor patterns. As relationships falter, nonverbal behaviors likely become asynchronous.
OBJECTIVES
To define behavioral, romantic, and sexual synchrony during phases of attraction and how their disruption can be observed and utilized by clinicians to assess individual relationship styles and quality.
METHODS
We review the literature on behavioral and attentional synchrony in humans and animals in an effort to understand experiential and innate mechanisms of synchrony and asynchrony and how they develop, as well as implications for attraction, relationship initiation, maintenance of romantic and sexual closeness, and relationship disintegration.
RESULTS
Evidence is presented that behavioral synchrony and the neural mechanisms that underlie it are vital to relationship formation and satisfaction.
CONCLUSION
Behavioral synchrony helps to create feelings of sexual and romantic synergy, cohesion, and arousal among individuals. Asynchrony is aversive and can spark feelings of discontent, aversion, and jealousy. Thus, observing patterns of nonverbal sexual and romantic synchrony between individuals offers insights into the potential quality of their relationships.
Topics: Animals; Humans; Courtship; Sexual Partners; Brain; Emotions; Motivation
PubMed: 37544764
DOI: 10.1093/sxmrev/qead034 -
Joint Commission Journal on Quality and... Aug 2023Improving the reliability of handoffs and care transitions is an important goal for many health care organizations. Increasing evidence shows that human-centered design...
BACKGROUND
Improving the reliability of handoffs and care transitions is an important goal for many health care organizations. Increasing evidence shows that human-centered design and improved teamwork can lead to sustainable care transition improvements and better patient outcomes. This study was conducted within a cardiovascular service line at an academic medical center that performs more than 600 surgical procedures annually. A handoff process previously implemented at the center was poorly adopted. This work aimed to improve cardiovascular handoffs by applying human factors and the science of teamwork.
METHODS
The study's quality improvement method used Plan-Do-Study-Act cycles and participatory design and ergonomics to develop, implement, and assess a new handoff process and bundle. Trained observers analyzed video-recorded and live handoffs to assess teamwork, leadership, communication, coordination, cooperation, and sustainability of unit-defined handoff best practices. The intervention included a teamwork-focused redesign process and handoff bundle with supporting cognitive aids and assessment metrics.
RESULTS
The study assessed 153 handoffs in multiple phases over 3 years (2016-2019). Quantitative and qualitative assessments of clinician (teamwork) and implementation outcomes were performed. Compared with the baseline, the observed handoffs demonstrated improved team leadership (p < 0.0001), communication (p < 0.0001), coordination (p = 0.0018), and cooperation (p = 0.007) following the deployment of the handoff bundle. Sustained improvements in fidelity to unit-defined handoff best practices continued 2.3 years post-deployment of the handoff bundle.
CONCLUSION
Participatory design and ergonomics, combined with implementation and safety science principles, can provide an evidence-based approach for sustaining complex sociotechnical change and making handoffs more reliable.
Topics: Humans; Patient Handoff; Reproducibility of Results; Patient Transfer; Quality Improvement; Communication
PubMed: 37357132
DOI: 10.1016/j.jcjq.2023.05.006 -
Journal of Physical Therapy Science Sep 2023[Purpose] This study aimed to develop a clinical observation method to evaluate the position of the mass center. From the human visual capability, we considered it would...
[Purpose] This study aimed to develop a clinical observation method to evaluate the position of the mass center. From the human visual capability, we considered it would be practical to divide the body into two parts: the upper and the lower body mass. If we could identify their optimal position, we could observe the middle point in between as the center of mass. [Participants and Methods] Twenty healthy males performed forward bending, backward bending, squatting, and walking. The three-dimensional coordinates were analyzed using a conventional model. In addition, five "virtual" markers were assigned as upper and lower mass, respectively. The midpoints of each five virtual marker combinations defined the mass centers, providing 25 coordinates. We calculated the difference in the coordinates between mass centers from virtual markers and mass centers using a conventional model. The combination with the slightest error was evaluated to determine the 95% confidence interval of the observed points and whether the value was clinically beneficial. [Results] The optimal combination of the upper and lower mass was Th8 and in the middle of both hip and knee centers. [Conclusion] The overall magnitude of error was about 30 mm and enough to evaluate the center of mass with macroscopy.
PubMed: 37670758
DOI: 10.1589/jpts.35.638 -
International Journal of Antimicrobial... Jan 2024The efficacy of BIC/FTC/TAF in HIV late presenters initiating antiretroviral therapy (ART) has not been sufficiently evaluated.
OBJECTIVES
The efficacy of BIC/FTC/TAF in HIV late presenters initiating antiretroviral therapy (ART) has not been sufficiently evaluated.
METHODS
The aim of this study was to assess the effectiveness and tolerability of BIC/FTC/TAF compared to other first-line antiretroviral regimens in treatment-naïve adult individuals from the CoRIS Cohort starting ART with CD4 counts <200 cells/mm and/or AIDS-defining conditions between January 1st 2019 and November 30th 2020. Logistic regression models were used to estimate odds ratios (ORs) of association between initial regimen and achievement of viral suppression (VS) (primary objective), defined as HIV RNA <50 cop/mL, and immunological recovery (IR) (secondary objective), defined as CD4 count >200 cells/mm, at weeks 24 and 48 after initiation of ART.
RESULTS
We evaluated 314 individuals (84.7% men, median age 40 years). Of them, 158 initiated with BIC/FTC/TAF. At inclusion, 117 had an AIDS-defining condition. In multivariable analyses, individuals with AIDS-defining conditions initiating ART with BIC/FTC/TAF achieved higher rates of VS at 24 weeks than other regimens (aOR: 0.2; 95% CI: 0.06-0.64) and, at 48 weeks, than DTG/ABC/3TC (aOR: 0.06; 95% CI: 0.01-0.76) and DTG + TDF/3TC (aOR: 0.2; 95% CI: 0.47-0.9). No other differences in VS or IR were observed. At 24 and 48 weeks after ART initiation, treatment discontinuations were lower with BIC/FTC/TAF than with other regimens (3.2% and 7.6% vs. 24.4% and 37.8%, respectively; P < 0.005).
CONCLUSION
Our results suggest that BIC/FTC/TAF could be a preferred regimen as initial therapy in HIV late presenters because of its high effectiveness and good tolerability.
Topics: Adult; Male; Humans; Female; Anti-HIV Agents; Acquired Immunodeficiency Syndrome; HIV Infections; Drug Combinations; Emtricitabine; Piperazines; Tenofovir; Pyridones; Alanine; Amides; Heterocyclic Compounds, 3-Ring
PubMed: 37890734
DOI: 10.1016/j.ijantimicag.2023.107016 -
BioRxiv : the Preprint Server For... Mar 2024In this report, we describe the architecture of Lipofectamine 2000 and 3000 transfection- reagents, as they appear inside of transfected cells, using classical...
In this report, we describe the architecture of Lipofectamine 2000 and 3000 transfection- reagents, as they appear inside of transfected cells, using classical transmission electron microscopy (EM). We also demonstrate that they provoke consistent structural changes after they have entered cells, changes that not only provide new insights into the mechanism of action of these particular transfection-reagents, but also provide a convenient and robust method for identifying by EM which cells in any culture have been successfully transfected. This also provides clues to the mechanism(s) of their toxic effects, when they are applied in excess. We demonstrate that after being bulk-endocytosed by cells, the cationic spheroids of Lipofectamine remain intact throughout the entire time of culturing, but escape from their endosomes and penetrate directly into the cytoplasm of the cell. In so doing, they provoke a stereotypical recruitment and rearrangement of endoplasmic reticulum (ER), and they ultimately end up escaping into the cytoplasm and forming unique 'inclusion-bodies.' Once free in the cytoplasm, they also invariably develop dense and uniform coatings of cytoplasmic ribosomes on their surfaces, and finally, they become surrounded by 'annulate' lamellae' of the ER. In the end, these annulate-lamellar enclosures become the ultrastructural 'signatures' of these inclusion-bodies, and serve to positively and definitively identify all cells that have been effectively transfected. Importantly, these new EM-observations define several new and unique properties of these classical Lipofectamines, and allow them to be discriminated from other lipoidal or particulate transfection-reagents, which we find do not physically break out of endosomes or end up in inclusion bodies, and in fact, provoke absolutely none of these 'signature' cytoplasmic reactions.
PubMed: 38496608
DOI: 10.1101/2024.03.07.583927