Baylor University Medical Center Research Articles

Classification and treatment of vaginal strictures at the donor-recipient anastomosis after uterus transplant

To describe the incidence and management of vaginal stricture after uterus transplants (UTx) in the United States, to propose a grading system to classify stricture severity, and to identify risk factors for stricture formation. Prospective cohort study. Recipients undergoing UTx from 2016 to 2023 at Baylor University Medical Center at Dallas, Cleveland Clinic, University of Pennsylvania, and University of Alabama at Birmingham were monitored postoperatively with regular pelvic exams. Stricture was defined as vaginal narrowing less than 3 cm in patients with graft survival of at least 7 days. Demographic and surgery characteristics. Stricture development and severity (Grade 1 for diameter 2 to <3 cm, Grade 2 for 1 to <2 cm, or Grade 3 for <1 cm). Of the 45 UTx from 2016 to 2023 (16 deceased donor, 29 living donor), 3 were excluded from the analysis due to graft loss within 7 days. Of the 42 remaining recipients, 39 (92.9%) had Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and 3 (7.1%) had a prior hysterectomy. Twenty-eight UTx recipients (66.7%) developed postoperative vaginal strictures with median time to stricture of 33 days (interquartile range 19 to 53 days). Most strictures were of moderate severity, with 4 strictures (14.3%) categorized as Grade 1, 19 (67.9%) as Grade 2, and 5 (17.9%) as Grade 3. History of MRKH and preoperative recipient vaginal length were significant risk factors for stricture, after adjustment for donor and recipient age and BMI, anastomosis technique, total ischemia time, center, and year. Patients with longer preoperative vaginal length had a lower risk of stricture (HR 0.45, 0.29-0.70). Severity grading of the stricture was associated with effectiveness of a non-operative treatment approach (p=0.018, Grade 1 vs. Grade 3). No patients with Grade 3 strictures improved with self-dilation alone; all required surgical repair and/or dilation under anesthesia. Conversely, for Grade 1 or 2 strictures, self-dilation alone was successful in 47.8% (11/23), and no Grade 1 strictures required surgical repair. Vaginal stricture is a common postoperative complication after UTx, affecting over 65% of recipients. Short preoperative vaginal length and history of Müllerian agenesis in the recipient are significant risk factors. Vaginal self-dilation was effective for some mild to moderate strictures, though dilation under anesthesia or surgical repair was required in most cases.

Are Deep Odontogenic Infections Associated With an Increased Risk for Sepsis?

Quick Sequential Organ Failure Assessment (qSOFA) is recommended to identify sepsis. Odontogenic infection (OI) can progress to sepsis, causing systematic inflammatory complications or organ failure. The purpose of the study was to measure the association between OI location and risk for sepsis at admission. This retrospective cohort study included subjects treated for OI at Baylor University Medical Center in Dallas, TX, from January 9, 2019 to July 30, 2022. Subjects > 18years old who were treated under general anesthesia were included. OI limited to periapical, vestibular, buccal, and/or canine spaces were excluded from the sample. The primary predictor variable was OI anatomic location (superficial or deep). Superficial OI infection includes submental, submandibular, sublingual, submasseteric, and/or superficial temporal spaces. Deep OI includes pterygomandibular, deep temporal, lateral pharyngeal, retropharyngeal, pretracheal, and/or prevertebral. The primary outcome variable was risk for sepsis measured using a qSOFA score (0 to 3). A higher score (>0) indicates the patient has a high risk for sepsis. Covariates were demographics, clinical, laboratory, and radiological findings, antibiotic route, postoperative endotracheal intubation, tracheostomy, intensive care unit, admission, and length of stay. Descriptive and bivariate analyses were performed. A χ2 test was used for categorical variables. The Mann-Whitney U test was used for continuous variables. Statistical significance was P<.05. The sample was composed of 168 subjects with a mean age of 42.8±21.5 and 69 (48.6%) subjects were male. There were 11 (6.5%) subjects with a qSOFA score > 0. The relative risk of a qSOFA > 0 for a deep OI is 5.4 times greater than for a superficial OI (136 (95.8) versus 21 (80.8%): RR (95% confidence interval): 5.4 (1.51 to 19.27), P=.004). After adjusting for age, sex, American Society of Anesthesiologists score, and involved anatomical spaces, there was a significant correlation between laterality and the number of involved anatomical spaces and qSOFA score (odd ratio=9.13, 95% confidence interval: 2.48 to 33.55, adjusted P= <.001). The study findings suggest that the OI location is associated with the qSOFA score >0.

We are our history: Baylor University Medical Center and Black physicians in Dallas

The Texas Baptist Memorial Sanatorium, the hospital that later became known as Baylor University Medical Center, dates back to 1904. With this long-lived history comes the truths that affected all hospitals during the Jim Crow era: segregation and inequality. This paper attempts to place Baylor University Medical Center, which aimed (and continues to aim) to be a “great humanitarian hospital,” in its historical context. Understanding this history may help explain and combat the inequities we continue to see in health care today.

Real-World Validation of the European Leukemia Network 2022 Risk Stratification in Acute Myelogenous Leukemia

Background: The 2017 European LeukemiaNet (ELN 2017) guidelines have become foundational for the risk stratification, prognostication, and treatment of acute myelogenous leukemia (AML). The updated 2022 European LeukemiaNet (ELN 2022) guidelines include additional cytogenetic abnormalities and genetic mutations for risk group assignment. It remains unknown how these updated guidelines compare for risk stratification and prognosis. Methods: We studied (N=287) adults with newly diagnosed AML from MedStar Georgetown University, MedStar Washington Hospital Center, and Baylor University Medical Center from 2012 to June 2023. Patients were stratified as favorable (fav), intermediate (int), or adverse (adv) risk according to ELN 2017 and ELN 2022 criteria. Overall survival (OS) was compared by age, race, and sex. Statistical analysis performed with SAS. Results: Median age was 65+16 years with a predominance of males (N=168, 59%). African-Americans (AA) composed 15% (N=44) of the cohort. Myelodysplastic-related mutations were present in 33 patients (15%), whereas the prevalence of epigenetic mutations was 25% (N=55). By ELN 2017 criteria, 19 (7%) patients were characterized as fav, 64 (23%) as int, and 198 (70%) as adv risk. Using ELN 2022 criteria, 18 (6%) patients were categorized as fav, 52 (19%) as int, and 211 (75%) as adv risk. Kaplan-Meier (KM) curves revealed a median overall survival of 200 days (d), 400 d, and 1532 d in the adv, int, and fav risk groups, respectively (log-rank p&amp;lt;0.001) by ELN 2017 criteria. Median OS was 379 d, 527 d, and 1552 d for the adv, int, and fav groups, respectively (log-rank p&amp;lt;0.001) in the ELN 2022 cohort. Stratifying by age &amp;lt;60 years, median OS was 390 d in the adv group and 832 d in the int group (log-rank p=.021)by ELN 2017 criteria,as compared to 350 d in the adv group and 757 d in the int group (log-rank p=.0012) by ELN 2022 criteria.Among those &amp;gt;60 years of age, median OS was 244 d and 349 d in the adv and int groups, respectively by ELN 2017 criteria (Anova p&amp;lt;0.25). In the ELN 2022 cohort, median OS among those &amp;gt;60 years of age was 284 d for the adv group and 209 days in the int group (Anova p&amp;lt;0.62). Among females, median OS in the adv group was 224 d and 342 d in the int group by ELN 2017 criteria (Anova p=0.4). In the ELN 2022 cohort, median OS among females was 214 d in the adv group and 421 d in the int group (Anova p=.13). Median OS among male patients in the ELN 2017 cohort was 324 d for those of adv risk and 623 d for those of int risk (Anova p&amp;lt;0.004). In the ELN 2022 cohort, median OS in males was 352 d and 563 d in the adv and int groups, respectively (Anova p&amp;lt;0.07) . In the ELN 2017 cohort, median OS was 259 d in AA patients as compared to 719 d in non-AA patients; this was not statistically significant (Anova p=0.16). Comparatively, in the ELN 2022 cohort, median OS for the AA patients was 153 d as compared to 212 d for the non-AA patient population (Anova p=0.86) .Conclusions: In this real-world dataset, the updated ELN 2022 guidelines reproduce differential survival for proposed favorable, intermediate, and adverse risk categories. When considering time to endpoint survival [Kaplan Meier curves] in our study, ELN 2022 seems to lack the ability to clearly discriminate among the adverse and intermediate risk subgroups. It is possible that patients seen in academic institutions not participating in FLT3 directed therapy trials retained inferior survival whereas similar patients fared better through early enrollment in trials using molecular targeted therapy. Finally, neither ELN 2017 nor ELN 2022 discriminate survival in AA populations for either adverse or intermediate subgroups. Efforts should be directed to develop novel risk stratification schemas to better encapsulate this vulnerable population.

Comparison of hospitalist service staffing models at Baylor University Medical Center

Background Baylor University Medical Center benefits from being a quaternary care center with 900+ licensed beds and multiple different models to staff patients on the hospitalist service. These models include hospitalist only, resident teaching teams, and two different advanced practice practitioner teams. The primary goal of this study was to assess these different staffing models and to ascertain which model, if any, has better outcomes related to length of stay, total hospital charges, 30-day readmission rates, patient satisfaction, hospital-acquired infections, mortality, and early discharges. Methods The study was an observational retrospective chart review of all discharges from the hospitalist service at Baylor University Medical Center from October 1, 2021, to February 28, 2022. Patients were included if the hospitalist team was the primary team of record at the time of discharge. A total of 7803 patients were included. Results There was no difference in patient satisfaction, hospital-acquired infections, and mortality between the groups. The teaching teams had a shorter length of stay before the removal of outliers. Independent advanced practice practitioners reliably had more patients discharged before 11:30 am. Results support the concept of continuity of care, as well as lower patient-to-provider ratios. Conclusions These results have actionable implications that support the use of different advanced practice practitioner teams for the safe care of hospitalized patients as well as the safe integration of residents into patient care.

Adapting Compassionate Conversations for Virtual Mediated Communication

The Covid-19 pandemic resulted in a shift in communication of difficult, emotionally charged topics from almost entirely in-person to virtual mediated communication (VMC) methods due to restrictions on visitation for safety. The objective was to train residents in VMC and assess performance across multiple specialties and institutions. The authors designed a teaching program including asynchronous preparation with videos, case simulation experiences with standardized patients (SPs), and coaching from a trained faculty member. Three topics were included - breaking bad news (BBN), goals of care / health care decision making (GOC), and disclosure of medical error (DOME). A performance evaluation was created and used by the coaches and standardized patients to assess the learners. Trends in performance between simulations and sessions were assessed. Four academic university hospitals - Virginia Commonwealth University Medical Center in Richmond, Virginia, The Ohio State University Wexner Medical Center in Columbus, Ohio, Baylor University Medical Center in Dallas, Texas and The University of Cincinnati in Cincinnati, Ohio- participated. Learners totaled 34 including 21 emergency medicine interns, 9 general surgery interns and 4 medical students entering surgical training. Learner participation was voluntary. Recruitment was done via emails sent by program directors and study coordinators. A statistically significant improvement in mean performance on the second compared to the first simulation was observed for teaching communication skills for BBN using VMC. There was also a small but statistically significant mean improvement in performance from the first to the second simulation for the training overall. This work suggests that a deliberate practice model can be effective for teaching VMC and that a performance evaluation can be used to measure improvement. Further study is needed to optimize the teaching and evaluation of these skills as well as to define minimal acceptable levels of competency.

Editorial introductions.

Current Opinion in Gastroenterology was launched in 1985. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of gastroenterology is divided into 12 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Matthew A. CiorbaMatthew A. CiorbaDr Matthew Ciorba is a gastroenterologist and biomedical researcher dedicated to advancing care in the Inflammatory Bowel Diseases (IBD) and Colon Cancer. His clinical expertise is in caring for patients with Crohn's and ulcerative colitis and preventing colon cancer. He is Director of the IBD Center at Washington University, USA, and leads one of the largest clinical teams in the USA dedicated to providing comprehensive and cutting-edge clinical care to more than 8000 patients affected by IBD. His basic-translational research program is dedicated to defining pathways and mechanisms of intestinal inflammation and the transition to colon cancer. His lab has developed methods to study intestinal organoids and tumoroids to facilitate studies of the epithelial response to inflammation, injury and repair. His lab investigations have spawned four ground-breaking Bench-to-Bedside clinical trials addressing unmet patient needs in colitis, enteritis and rectal cancer using probiotics, novel immunotherapies and manipulating bile acids. In addition to his own lab, Dr Ciorba is also Director of IBD Research at Washington University and use this platform to foster collaborative discovery between the world-class scientific investigators and the robust IBD clinical program. Finally, he is deeply committed to training the next generation of medical investigators who will advance discovery and treatment of digestive diseases. Supporting this mission, he serves as Associate Director of the GI Fellowship's T32 Research Training grant and serves on several training grant review committees for several organizations including the CCF, AGA and NIH. Stuart J. SpechlerStuart J. SpechlerStuart Jon Spechler, MD is Chief of the Division of Gastroenterology and Co-Director of the Center for Esophageal Diseases at Baylor University Medical Center at Dallas, as well as the Co-Director of the Center for Esophageal Research at the Baylor Scott and White Research Institute. Prior to joining Baylor University Medical Center in January 2017, Dr Spechler was the Chief of the Division of Gastroenterology for the VA North Texas Healthcare System, Professor of Medicine, and holder of the Berta M. and Cecil O. Patterson Chair in Gastroenterology at the University of Texas Southwestern Medical Center, and he had been the Director of the Center for Swallowing Disorders at the Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts. Dr Spechler's research has focused primarily on disorders of the esophagus, especially GERD and its complications, and eosinophilic esophagitis. He has chaired three VA Cooperative Studies on medical and surgical treatments for gastroesophageal reflux disease. He described the condition known as “short-segment Barrett's esophagus” in 1994. Dr. Spechler has published more than 300 scientific reports, editorials, review articles, and book chapters on esophageal disorders. He is best known for his work in the areas of GERD, Barrett's esophagus, and eosinophilic esophagitis. Dr Spechler has served on the editorial boards of numerous journals including Gastroenterology, Gut, Alimentary Pharmacology and Therapeutics, Digestive Diseases and Sciences and Diseases of the Esophagus, and he has served as Chair of the Gastroenterology Teaching Project and the Esophago-Gastro-Duodenal Section of the American Gastroenterological Association.

PULM11: Regional Variation in Severe COVID-19 Therapeutics and Outcomes Within a Single Large Healthcare System: Insights from the ECMOCARD Study

Purpose: Despite extensive descriptions of patients and outcomes associated with critical illness due to COVID-19, there is paucity of data from individual large healthcare systems. Here we describe our experience at Baylor Scott & White Health in Texas. Methods: Patients, treatments, and outcomes were compared among our 4 ECMO centers in Central (Temple) and North Texas (Baylor All Saints (BAS), Baylor University Medical Center (BUMC), The Heart Hospital Baylor-Plano (THHBP)) via the ECMOCARD Registry (Covid-19 Critical Care Consortium) using Bonferroni-corrected multivariable statistics and post-hoc comparisons. Results: Of 228 patients (mean age 57.9 y; 56% men), 26% were treated at BAS, 27% at BUMC, 34% at Temple, and 13% at THBBP. All were admitted to the ICU or high dependency unit with a median length of stay of 17 days. The majority were on inotropes or vasopressors. Overall, 85% received some level of O2 support including 39% non-invasive, 67% high flow nasal cannula, and 34% ECMO, non-exclusive. The 28-day survival was 63% overall with some regional differences (BAS, 47%; BUMC, 72%; Temple, 64%; THHBP, 75%; P=0.02). Patient demographics differed by center with Temple having older patients and BUMC the largest proportion of Black patients (P<0.001). The most prevalent comorbidities were hypertension (59%), obesity (39%), Type 2 diabetes (36%), and chronic cardiac disease (29%). Temple patients had the highest prevalence of chronic neurological disorder, hypertension, and chronic kidney disease. The most frequent level of support at BAS, BUMC, and THHBP was invasive ventilation, whereas Temple patients most frequently were on high flow nasal O2. ECMO support was used most commonly at BUMC and least frequently at Temple. Summary: In this large hospital system there was significant variation among characteristics and treatments for patients with severe-COVID 19 illness despite system-wide protocolized care. Regional impact on patient characteristics and health outcomes warrants further study.

Every ED Visit is an Opportunity to Talk about Contraception

Figure: contraception, emergency medicine, ED, birth control, algorithm, EPs, reproductive health care, ectopic pregnancy, Supreme Court, miscarriage, pre-eclampsia, pregnancy, uterine bleeding, vaginitis, pelvic pain, family planning, gynecologists, Ella, Plan B, oral contraceptive, IUDFigureFigureFigureThese algorithms make providing birth control routine without significant cognitive burden for EPs Access to reproductive health care was seismically altered on June 24, 2022, with the Supreme Court's Dobbs v. Jackson decision. We may have viewed pregnancy prevention as another department's problem in years past, but ectopic pregnancy, miscarriage, pre-eclampsia, and pregnancy-related venous thromboembolic disease are squarely in our wheelhouse, and the prevention of undesired pregnancy should be a unifying cri de cœur for us all. The task of initiating contraception can be daunting, yet every visit for abnormal uterine bleeding, vaginitis, and female pelvic pain is an opportunity to talk about initiating contraception with our patients. Intent on using our place as the front door of the house of medicine, we enlisted a multidisciplinary group to develop a streamlined algorithm for initiating contraception in the ED. The algorithm incorporates months of discussions with family planning experts and gynecologists as well as a critical appraisal of the literature and the costs associated with each medication. We relied heavily on the existing quick start algorithm published by the Reproductive Health Access Project and adapted its recommendations to be slightly more conservative, given the risk of litigiousness in the emergency department and the challenges many of our patients have with knowing the exact timing of their recent cycle. (February 2021; https://bit.ly/3Ah122k.) We also approached our recommendations about emergency contraception slightly differently, prioritizing the efficacy of Ella over the ability to start an oral contraceptive on the same day as Plan B. The field of contraception can feel incredibly complicated with progestin-only, combined progestin-estrogen, long-acting reversible contraception, and other non-oral contraceptive options. Our simplified quick start algorithm for contraceptives from the ED can make this a routine part of any visit without significantly adding to a physician's cognitive burden. The first question is not which contraceptive to initiate, but understanding when to start birth control. Your patient's last menstrual period (LMP) and recent sexual activity will help guide you through the algorithm. Initiating birth control while continuing to use a backup method for one week is prudent for those who present with an LMP within the last week. No pregnancy testing is necessary in this clinical scenario. (Contraception. 2013;87[5]:524; https://bit.ly/40ksSoQ.) Start in the ED Excluding pregnancy is the first step for those presenting outside that seven-day window. We recommend the use of Ella for emergency contraception given the improved efficacy compared with Plan B if a patient had unprotected intercourse within the preceding five days, has a negative pregnancy test, and does not desire pregnancy. (Adv Therapy. 2011;28[2]:87; https://bit.ly/41r19UW.) Ella can interfere with the efficacy of oral contraceptives, so one must wait five days to initiate oral contraceptives after taking it. A backup method in this scenario is warranted for one week, with a repeat pregnancy test in two weeks. It is important to understand that Ella and Plan B are less effective in patients with a BMI over 30 and under 25, respectively. (EMN. 2022; https://bit.ly/3MYAhae.) Counsel your patients regarding the potential risk for failure. We recommend starting birth control on the same day as the index visit for patients who do not need emergency contraception and who test negative for pregnancy. Remind your patient that birth control will not harm an early pregnancy, and a repeat pregnancy test in two weeks is recommended. (Obstet Gynecol. 1990;76[3 Pt 2]:552.) Same-day initiation of birth control regardless of where patients are in their menstrual cycle is associated with improved adherence and does not increase the risk of irregular bleeding. (MMWR Recomm Rep. 2016;65[4]:1; https://bit.ly/3NehmIS.) A prescription can be provided with the plan to start the medication on the first day of the next menstrual period if a patient is not interested in starting contraceptives on the index visit. Explain that a barrier method is necessary to prevent pregnancy in the meantime. Choosing a Method We then discuss with patients which method to start. Hormonal contraceptives are inadvisable in patients with a history of breast cancer and uterine malignancy or in those with various forms of liver disease. (MMWR Recomm Rep. 2016;65[3]:1; https://bit.ly/41ZHvz2.) A copper IUD or barrier method is preferable for these patients. Combined progestin-estrogen oral contraceptive pills are preferable to progestin-only pills for patients without contraindications because of their effect in suppressing ovulation. (See contraindications for combined pills in our algorithm.) Progestin-estrogen combined pills also have the advantage of allowing patients to control the timing of their menstrual periods; a patient can skip the placebo doses and take the pills continuously to suppress menses. We make suggestions about which combined progestin-estrogen pill to prescribe to make the algorithm as user-friendly as possible. There are, of course, many combined oral contraceptive pills that you can choose. A physician may prescribe a progestin-only pill if combined progestin-estrogen medications are contraindicated. Progestin-only pills work by thickening the cervical mucus and thinning the uterine lining. (J Fam Plann Reprod Health Care. 2008;34[4]:237.) They need to be taken at the same time each day to be efficacious because of their pharmacokinetics. (MMWR Recomm Rep. 2016;65[4]:9; https://bit.ly/3N8MeKI.) Patients should also be counseled that irregular bleeding can be expected with progestin-only products. IUDs could, in theory, also be included in this algorithm, but most emergency departments are not placing IUDs, so we left this option out of our algorithm.FigureThe ability to provide care for any patient who comes through our doors is the hallmark of emergency medicine. You can use our algorithm to make providing birth control a routine part of your practice without significant cognitive burden. This is our chance to meet the needs of our most vulnerable patients by offering them control of their reproductive health, especially in today's drastically altered landscape of reproductive health care access. DR. MORRISSEY is an emergency physician, the chair of the Baylor University Medical Center safety in pain management committee, and core faculty for the Baylor University Medical Center emergency medicine residency. DR. GHELANI is an assistant professor of emergency medicine at Baylor University Medical Center. DR. FINE is an emergency physician, the medical director of forensic medicine, and a chair of the medical education diversity, equity, and inclusion committee at Baylor University Medical Center in Dallas. Follow her on Twitter @laurencfine. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].

Sack Sackler: the role of medical student activism in creating meaningful change at Tufts University

"Sack Sackler: the role of medical student activism in creating meaningful change at Tufts University." Baylor University Medical Center Proceedings, ahead-of-print(ahead-of-print), p. 1 Disclosure statementThe authors report no funding or conflicts of interests.

Make it quick and to the point: EHJ introduces new rapid communications category for faster delivery of translational data

As of February 2023, EHJ will be able to offer a new category suited to the concise reporting of focused clinical and translational data. The Rapid Communications category which has already received and reviewed around 50 papers, will publish articles of up to 1000 words online focusing on methods and results with minimal introduction and discussion. The new Deputy Editor is Milton Packer MD, Distinguished Scholar in Cardiovascular Science at Baylor University Medical Center in Dallas, TX, USA, who also holds an appointment at Imperial College, London, UK. Prof. Packer told CardioPulse what the new category will mean for authors and readers of the Journal. (Figure 1) Many excellent papers have a single core message. But all too often, the authors try to create a full-length paper even though there is only a single set of important data. When there is a single core message, much of the conventional elements of a full-length paper do not add very much. The Introduction often repeats what is already known. The Methods have often been published elsewhere. The Results may have 4–8 tables and figures, but only one has data of real interest or importance. The Discussion is often a repetition of the Results or reads like a review article. Therefore, the paper would have much greater impact if it presented only the elements that were novel or important. That is why the Rapid Communications format was created. In a Rapid Communications paper, the article typically has 1–2 sentences for the introduction and 2–3 sentences for the Discussion. The core of the paper is the Methods and the Results. If one thinks about it, those are the elements that really matter in every paper in medicine and science, regardless of its length.

Efficacy of nasal continuous positive airway pressure as a preferred airway management during intravenous sedation of patients undergoing transcatheter aortic valve replacement

Background As the incidence of aortic stenosis is increasing in correlation with the aging population, symptomatic patients commonly require valve replacement procedures. If left untreated, symptomatic aortic stenosis can lead to death in 2 to 3 years. Often, transcatheter aortic valve replacement (TAVR) procedures are performed with the assistance of oxygenation via nasal cannula. However, oxygenation achieved through a nasal continuous positive airway pressure (nCPAP) device could be a more optimized strategy for patients without any sacrifice in efficacy compared to nasal cannula. Methods A retrospective chart review was conducted on 28 patients at Baylor University Medical Center who presented to the operating room for a TAVR between January and October 2021. Fourteen patients received oxygenation via nasal cannula (control group) and 14 received oxygenation with nCPAP. Information gathered included method of oxygenation, length of stay, episodes of hypoxia (defined as sustained oxygen saturation <92% for at least 1 minute), paravalvular leak, pacemaker placement, and mean atrial valve (AV) gradient before and after the procedure. Results In the nCPAP group, the average length of stay was 2.79 days vs 2.71 days in the nasal cannula group. In the nCPAP group, no patient required a permanent pacemaker, while the nasal cannula group had a 40% rate of permanent pacemaker placement. The average preprocedure AV gradient was 51.14 in the nCPAP group and 42.57 in the nasal cannula group. The average postprocedure AV gradient was 8.5 in the nCPAP group and 5.36 in the nasal cannula group. Both groups had an intensive care unit admission rate of 0%. The rate of paravalvular leak was 35.7% in the nCPAP group and 28.6% in the nasal cannula group. The nCPAP group had an average of 0 episodes of hypoxia and the nasal cannula group had an average of 0.93 episodes of hypoxia. Conclusion The findings demonstrate the viability of nCPAP as an effective method of oxygenation during intravenous sedation of TAVR patients when compared to oxygenation achieved via nasal cannula during TAVRs.

The First 5 Years of Uterus Transplant in the US—A Report From the United States Uterus Transplant Consortium

ABSTRACT Women affected by absolute uterine-factor infertility (AUFI) were previously considered to have an untreatable condition, although uterus transplant has now changed this calculation. Although AUFI is a cause of female infertility (affecting 1 in 500 women), the counseling describing potential family-building options (gestational carrier or adoption) now includes a third choice of uterus transplant. This procedure is meant to restore reproductive ability and to allow gestation and childbirth. Further data regarding uterus transplant are essential to counsel appropriate individuals regarding this potential option. The US Uterus Transplant Consortium was formed in 2019 by centers performing uterus transplant in the United States: Baylor University Medical Center, Dallas, Tex; Cleveland Clinic, Cleveland, Ohio; and the University of Pennsylvania, PA. Accounting for approximately half of worldwide cases and of live births after uterus transplant, these centers have been instrumental in the evolution of the procedure, including the invention of novel surgical techniques for deceased donors, early embryo transfer, using the superior uterine veins for live birth and graft survival, and fully robotic living donor hysterectomies. This study examined data from all uterine transplants performed in the United States between 2016 and 2021, including donor, recipient, and offspring outcomes. Follow-up included the time from uterine transplant until the most recent visit. Evaluation of patients took place via a multidisciplinary transplant team and an independent living advocate. Primary outcomes of the study included patient survival (primary living donor outcome), allograft survival (30 days, 1 year, and 3 years), and live birth. Offspring primary outcomes included weight percentile and gestational age at delivery. During the study years (2016–2021), a total of 33 uterus transplants were performed, with 21 living and 12 deceased donors. No mortality of living donors or recipients was recorded. Overall, 25 of 33 uterus transplants had a viable graft at 30 days, and 19 of the 33 participants (58%) were able to achieve at least 1 live birth. A total of 8 recipients experienced graft loss (26%), and infection occurred in 10 participants (30%). Acute cellular rejection occurred for 10 participants within the 1-year graft survival group, but these patients were successfully treated. Time to the first menstrual cycle after transplant was a mean of 30 days (range, 10–59 days). Pregnancy following the transplant requires in vitro fertilization, as fallopian tubes are not transplanted with the uterus. For those participants who were able to conceive, the most common complications were gestational diabetes (12%), gestational hypertension (24%), and preeclampsia (12%). The mean gestational age at delivery was 36 weeks 6 days (range, 30 weeks 1 day to 38 weeks), with more than half (52%) being born after 36 weeks' gestation. After live birth, patients underwent a graft hysterectomy, the timing of which was determined by the patient (either during delivery or later in the recovery process). Medical indications for hysterectomy were conditions such as preeclampsia, acute kidney injury, abnormal placentation, and gestational diabetes. Overall, the first 5 years of US clinical experience of uterus transplant demonstrate technical feasibility and the ability of patients to have a live birth. High rates of technical success (76%) within US centers performing uterus transplants are promising. Despite the fact that the 1-year survival rate of the uterus transplant (76%) is lower than other organ transplant graft survival rates, the required longevity of the uterus differs from others. Nevertheless, a learning curve is expected to allow for improvements to this success rate over time. Based on the outcomes of uterine transplant described in this report, the authors conclude that the procedure is safe for both mother and child, as success is not limited to single centers, and is reproducible. They note that the success of the procedure is achieved both with living and deceased donors, and the rate of success is comparable to other infertility treatments. They conclude that the procedure ought to be recognized as an option for AUFI-diagnosed individuals desiring parenthood.

Medical Assistance in Dying and Organ Donation, the Ultimate Gift: Have We Got the Ethics Right?

*Chair Emeritus Department of Anesthesiology, Baylor University Medical Center, Dallas, Texas †Staff Surgeon Annette C and Harold C. Simmons Transplant Institute, Department of Surgery, Baylor University Medical Center, Dallas, Texas Sources of Funding/grants: None Informed Consent: Not indicated Ethical Committee Approval: Not indicated Running Head: MAiD Organ Donor Ethics Contributions: Michael Ramsay: Co-author Anji Wall: Co-author Conflict of interest: None [email protected]

Peer reviewer survey for Baylor University Medical Center Proceedings

Editors of medical journals have important responsibilities and depend on peer reviewers to evaluate the quality of submitted manuscripts. However, invitations to undertake peer review are often declined, and in some cases the reviewer fails to provide a review in a reasonable timeframe. Baylor University Medical Center Proceedings surveyed recent reviewers to determine their motivations for undertaking a review and possible benefits associated with reviewing. Sixty-seven reviewers (12.4%) out of 540 responded to the survey request. Reviewer characteristics included long-standing involvement in research (50 reviewers in research ≥11 years) and prior publication (50 reviewers ≥6 articles). Many reviewers thought that reviewing articles represented a responsibility and provided an opportunity for them to contribute to scientific efforts and medical publications and to learn new information. Survey respondents suggested that recognition by the journal was an adequate benefit. This survey, like others, indicates that editors will continue to depend on a core set of reviewers who consider this activity both an opportunity and a responsibility.

Use of synchronous kidney and lung extracorporeal support for severe COVID-19: A single-center retrospective study.

Infection with severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) has been associated with both kidney and respiratory failure. During the early phase of the coronavirus disease pandemic, patients often required the use of mechanical assistance to provide adequate kidney and lung function. In this paper we describe the clinical outcomes of patients who required synchronous kidney and lung extracorporeal support for COVID-19. All patients admitted to Baylor University Medical Center, Dallas, between February 1, 2020, to April 23, 2021, with COVID-19 who required both extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) were retrospectively analyzed. Patients who were on hemo- or peritoneal dialysis prior to admission or who required veno-arterial (VA) ECMO were excluded. 35 patients with COVID-19 required ECMO and CRRT support. Four patients (11%) were excluded, 2 due to being on dialysis prior to admission and 2 due to the requirement of VA-ECMO. The median time on CRRT was 33 days (IQR 13-51). The median time on ECMO was 28 days (IQR 10.5-59.5). At 90 days, 9 patients had died (29%), 4 patients remained hospitalized, and 18 patients had been discharged: 10 to long-term acute care, 2 to inpatient rehabilitation, and 6 to home. Patients with severe COVID-19 requiring concurrent ECMO and CRRT in this institution had a 29% mortality at 90 days.

Nonselective beta-blocker use is associated with increased hepatic encephalopathy-related readmissions in cirrhosis.

BACKGROUNDHepatic encephalopathy (HE) is a neurocognitive condition in cirrhosis leading to frequent hospitalizations. Nonselective beta-blockers (NSBBs) are the mainstay of pharmacologic treatment in cirrhotic patients. We hypothesized that since NSBBs decrease cardiac output and portal flow, the decreased metabolic filtering process of liver parenchyma may lead to increased HE-related hospitalizations.AIMTo evaluate the impact of NSBB administration on HE-related readmissions in cirrhotic patients.METHODSIn this retrospective cohort study, we included 393 patients admitted to Baylor University Medical Center for liver-related portal hypertension indications between January 2013 and July 2018. Independent predictors of the first HE-related readmissions were identified using Cox proportional hazards analysis. The cumulative incidence of the first HE-related readmissions between patients receiving NSBBs and not receiving NSBBs was examined using Fine-Gray modeling to account for the competing risk of death or liver transplantation.RESULTSThe mean age was 58.1 ± 10.2 years and most patients fell into Child class C (49.1%) or B (43.8%). The median Model for End-Stage Liver Disease-Sodium score was 22 (IQR: 11). The cumulative incidence of the first HE-related readmissions was significantly higher in patients taking NSBBs compared to patients not receiving NSBBs (71.8% vs 41.8%, P < 0.0001). In multivariate analysis, after adjusting for demographics, markers of liver disease severity, selective beta-blocker, lactulose and rifaximin use, NSBB use [Hazard ratio: 1.74 (95%CI: 1.29-2.34)] was independently associated with the first HE-related readmissions over a median follow-up of 3.8 years. CONCLUSIONNSBB use is independently associated with increased HE-related readmissions in patients with cirrhosis, regardless of liver disease severity.

Children after uterus transplantation: 2-year outcomes from the Dallas UtErus Transplant Study (DUETS).

To describe outcomes in the first 2 years of life for the children born in the Dallas UtErus Transplant Study. Cohort study comprising all live births from uterus transplantation at a single centre. Baylor University Medical Center, Dallas, Texas. A total of 14 children from 12 uterus transplantation recipients. Retrospective review of data through 2 years of life. Information on children's development was collected based on the Bright Futures Guideline and the Bright Futures Previsit Questionnaire. Primary outcomes were anthropometric measures (children's body length, weight, head circumference), neurological status, cognitive status and physical development at 6, 12, 18 and 24 months of age. The median gestational age at delivery was 36+6 weeks, with a median birthweight of 2940 g. Follow-up data were available for 13 offspring. Physical and neurological developmental milestones were met and were age appropriate in all children within the first 24 months. General health was good, and no abnormalities in immune development were found. Cognitive deviations were only mild and temporary and improved with interventions. The children's growth and physical, neurological and cognitive development were age appropriate within the first 2 years of life. To confirm these outcomes, further data should be collected in collaboration with other centres.

Looking back at the Baylor University Medical Center Proceedings (1988–2022)

Looking back at the Baylor University Medical Center Proceedings (1988–2022)

The First 5 Years of Uterus Transplant in the US

Uterus transplant is a viable surgical treatment for women affected by absolute uterine-factor infertility, which affects 1 in 500 women. To review transplant and birth outcomes of uterus transplant recipients in the US since the first case in 2016. In this cohort study, 5 years of uterus transplant outcome data were collected from the 3 centers performing uterus transplants in the US: Baylor University Medical Center, Dallas, Texas; Cleveland Clinic, Cleveland, Ohio; and University of Pennsylvania, Philadelphia. A total of 33 women with absolute uterine-factor infertility who underwent uterus transplant between February 2016 and September 2021 were included. Graft survival, live birth, and neonatal outcome. Of the 33 included uterus transplant recipients, 2 (6%) were Asian, 1 (3%) was Black, 1 (3%) was South Asian, and 29 (88%) were White; the mean (SD) age was 31 (4.7) years; and the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 24 (3.6). Most uterus transplant recipients (31 of 33 [94%]) had a congenitally absent uterus (Mayer-Rokitansky-Küster-Hauser syndrome), and 21 of 33 (64%) received organs from living donors. Mean (range) follow-up was 36 (1-67) months. There was no donor or recipient mortality. One-year graft survival was 74% (23 of 31 recipients). Through October 2021, 19 of 33 recipients (58%) had delivered 21 live-born children. Among recipients with a viable graft at 1 year, the proportion with a live-born child was 83% (19 of 23). The median (range) gestational age at birth of neonates was 36 weeks 6 days (30 weeks, 1 day to 38 weeks), and the median (range) birth weight was 2860 (1310-3940) g (median [range], 58th [6th-98th] percentile). No congenital malformations were detected. Uterus transplant is a surgical therapy that enables women with uterine-factor infertility to successfully gestate and deliver children. Aggregate data from US centers demonstrate safety for the recipient, living donor, and child. These data may be used to counsel women with uterine-factor infertility on treatment options.