Single Medical Center Research Articles

Apixaban versus enoxaparin to prevent venous thromboembolism in post-operative patients with gynecologic cancers at an urban academic medical center

ObjectiveA recent clinical trial demonstrated that the use of apixaban was safe and equal to enoxaparin (LMWH) in post-operative gynecologic oncology patients. This study aimed to determine if these findings are applicable in a diverse patient population at a single site urban academic medical center. MethodsThis was a retrospective cohort study of patients who underwent an exploratory laparotomy for confirmed or presumed gynecologic cancer from the years 2017–2023 at a single-site urban academic medical center. Venous thromboembolism (VTE) prophylaxis with LMWH was standard practice at our institution up until January 2021 after which apixaban became standard for post-operative prophylaxis in our division. Baseline demographic and clinical characteristics of patients receiving apixaban post-operatively were compared to the population previously receiving enoxaparin. The primary outcome was a VTE event within 90days of surgery. Secondary outcomes included major and minor bleeding events. ResultsTwo hundred fifteen patients met inclusion criteria, of which 65 were discharged on enoxaparin and 150 were discharged on apixaban. Baseline characteristics in terms of age, race/ethnicity and BMI found no significant difference between the two groups. Rates of any VTE event within 90 days of surgery were similar for apixaban and LMWH (3.33 % vs. 4.61 %, p = 0.6). Secondary outcomes demonstrated that the rate of a major bleeding event in apixaban group was 1.31 % and LMWH group was 3.08 %, (p = 0.38). Minor bleeding events in the apixaban group were comparable to the LMWH group (10.60 % vs 10.16 %, p = 0.5). ConclusionsIn this real world, urban setting, for women undergoing laparotomy for gynecologic cancer, apixaban as post-operative VTE prophylaxis showed no increase in VTE events and appeared safe with no increase in bleeding events compared to LMWH. This study adds to the literature demonstrating that apixaban is safe and effective for VTE prophylaxis in our gynecologic oncology patients.

Dual trigger versus human chorionic gonadotropin trigger for blastocyst quality and cumulative live birth.

To evaluate the difference in the number of euploid blastocysts and cumulative live birth rate (LBR) between dual and human chorionic gonadotropin (hCG) triggers in poor and normal ovarian responders undergoing preimplantation genetic testing (PGT) cycles. This retrospective cohort study was enrolled from July 2018 to December 2021 and followed up until June 2024 at a single reproductive medical center. Overall, 1040 in vitro fertilization (IVF)-PGT and 784 frozen-thawed embryo transfer (FET) cycles were assessed. Dual (triptorelin acetate 0.2 mg and recombinant hCG [rhCG] 250 µg) or hCG (rhCG 250 µg) trigger was used for oocyte maturation in the gonadotropin-releasing hormone antagonist protocol and PGT cycles. We assessed the embryo outcomes and FET cumulative pregnancy outcomes. The number of oocytes retrieved (10.17 ± 5.22 vs 10.27 ± 5.14, P = 0.789), MII oocytes (8.24 ± 4.26 vs 8.28 ± 4.05, P = 0.888), blastocysts (2.16 ± 1.50 vs 2.12 ± 1.49, P = 0.729), euploid blastocysts (1.06 ± 1.14 vs 1.09 ± 1.23, P = 0.726), and the rate of cumulative LBR (24.9% vs 24.9%, P = 1.000) in the dual trigger group were comparable with those in the hCG group. The trigger method was not correlated with higher LBR based on logistic regression analysis (odds ratio[OR] = 1.040 [0.778-1.392], P = 0.790). For poor and normal ovarian responders, the dual trigger, compared with the hCG trigger, did not improve the PGT embryo outcomes and FET cumulative pregnancy outcomes.

Expression of activin A in liver tissue and the outcome of patients with biliary atresia

Biliary atresia (BA) is a rare disease of unknown etiology which leads to cirrhosis and death if left untreated. The standard of care is an early hepatoportoenterostomy (HPE). Long-term follow-up is mandatory, during which most patients will require a liver transplant. Activin A belongs to the transforming growth factor-β (TGF-β) superfamily. TGF-β is a central regulator in chronic liver disease. We have studied the expression of activin A in liver tissue collected intraoperatively during the HPE. We included patients who underwent HPE in a single medical center. Clinical, ultrasonographic, and pathohistological data were collected. Activin A immunostaining was performed. Expression in the bile duct epithelium and hepatocytes was scored as either weakly positive, moderately positive, or strongly positive. Patients were then divided into three groups accordingly. We observed the outcome after the HPE at 3 months, 2 years, and at the end of follow-up. The study encompassed 37 patients. At 3 months after HPE, 92.3% of those with a weakly positive activin A reaction (group A) achieved good jaundice clearance, whereas only 44.4% of those with a moderately (group B) and 40% of those with a strongly positive reaction (group C) achieved good jaundice clearance (p = 0.008). Furthermore, 2 years after the HPE, 92.3% of those in group A survived with native liver (SNL), but only 33.3% of those in group B and 46.7% of those in group C had SNL (p = 0.007). At the end of follow-up, 83.3% of those in group A survived with native liver, as did 33.3% in group B and 40% in group C. Activin A is a valuable pathohistological predictor of the outcome of BA after an HPE.

Association of the Preoperative Controlling Nutritional Status (CONUT) Score with Clinicopathological Characteristics in Patients with Papillary Thyroid Carcinoma.

The Controlling Nutritional Status (CONUT) score is an immunonutritional test tool based on serum albumin, total cholesterol, and lymphocyte counts. It has been studied as a simple prognostic predictor for various carcinomas. This study aimed to investigate the association between preoperative CONUT scores and the clinicopathological characteristics in papillary thyroid carcinoma (PTC) patients. This study included 2,403 PTC patients who underwent total thyroidectomy between 2012 and 2016 at a single tertiary medical center. The CONUT scores were calculated based on preoperative blood tests. The clinicopathological characteristics were retrospectively reviewed. The patients were categorized by the CONUT score (relatively low, 0-2; relatively high, 3-5). Among the 2,997 PTC patients who underwent total thyroidectomy at Pusan National University Hospital between 2012 and 2016, those without preoperative blood test were excluded (n=149). Finally 2,403 patients were analyzed after excluding 439 patients taking lipid-lowering drugs and six patients without available T stage data after surgery. Based on the CONUT score, the relatively high score group had a lower body mass index (23.7±3.3 kg/m2 vs. 21.9±2.9 kg/m2, P<0.001), more advanced T stage (T stage 3/4, 5.9% vs. 11.4%, P=0.045), and higher extrathyroidal extension (2.1% vs. 7.6%, P=0.005). Patients included in this large, single-center study all had a preoperative CONUT score of 0-5, but this study demonstrated that higher preoperative CONUT scores were significantly associated with advanced T stage and extrathyroidal extension. The CONUT score, which can be easily used in clinical practice, is thought to be helpful in predicting the aggressiveness of PTC.

BS O03 - One-stage conversion of Adjustable Gastric band (AGB) to One-anastomosis Gastric Bypass (cOAGB) versus Sleeve Gastrectomy (cSG): A single-center experience with a short and mid-term Follow-up

Abstract Background Laparoscopic adjustable gastric band was a common bariatric procedure . However; due to its failure rate some patients sought another revisional surgery. In which, we compared two of the most common Bariatric metabolic surgery (BMS) performed nowadays: the laparoscopic sleeve gastrectomy and laparoscopic one- anastomosis gastric bypass. Method A prospective cohort study was conducted from June 2020 to June 2022 at a single medical center, which included 77 patients undergoing single-stage conversion to (cOAGB) vs (cSG). Patients were reassessed for weight loss, associated medical problems remission and post-operative complications at 6, 12, and 18 months. Results Group (I) was 43 patients who underwent cOAGB and Group (II) was 34 patients who underwent cSG. The BMI was calculated post-operative at three visits. Both groups had no statistically significant values at 6 and 12 months follow-up. However, patients who underwent cOAGB after 18 months of follow-up achieved lower BMI than those who underwent cSG . Regarding EBWL% there was a statistically significant difference between the two groups after 6, 12 and 18 months follow-up. Regarding associated medical problems remission with follow-up 18 months post-operative , there were no statistically significant differences between the two groups Conclusion This study suggests that the conversion of LAGB to either cOAGB or cSG could be feasibly performed in a single-stage operation. cOAGB had a significant difference as regards the weight loss results than cSG among the mid-term follow-up. However, there is no significant difference in the postoperative complications and the resolution of the co-morbidities. Therefore, cOAGB could provide a reliable alternative but needs to be substantiated in future long-term studies.

QOL-22. VACILLATING EMOTIONS AND SHIFTING INFORMATION PREFERENCES: A QUALITATIVE ANALYSIS OF CAREGIVER DISTRESS IN FACING A MALIGNANT GLIOMA DIAGNOSIS

Abstract BACKGROUND Caregivers of patients with malignant gliomas (MG) experience considerable psychological distress as they contend with the implications of their loved one’s terminal illness. However, caregivers’ specific reactions to the patient’s diagnosis/prognosis and optimal ways to support caregivers in the months following diagnosis remain poorly understood. METHODS At a single academic medical center, we enrolled English-speaking adults identified by patients with newly diagnosed MG as their primary caregiver. Using a semi-structured interview guide, we conducted in-depth interviews with caregivers at the conclusion of concurrent chemoradiation exploring their experiences learning about the patient’s diagnosis and their prognostic information preferences. We used rapid qualitative analysis to analyze interview data. RESULTS We interviewed 7 caregivers (female: 5/7; spouse/partner: 6/7, sibling: 1/7) of MG patients (glioblastoma: 5/7). Caregivers described the time following diagnosis as tumultuous and difficult as they struggled to cope with their distress related to navigating the practical burdens of cancer treatment while also managing the emotional burden (e.g. fear, sadness) of living amidst uncertainty. Caregivers vacillated between feeling devastated by the patient’s poor prognosis and wanting to remain hopeful (e.g., by seeking out inspiring survivorship stories). Caregivers also reported varying and often evolving preferences regarding the manner, timing, and context in which they received information about the patient’s MG. Many caregivers desired more prognostic information (e.g., to facilitate planning for their future and for the patient’s eventual demise) while some chose to focus on the present (e.g., to avoid “dwelling” on potential negative outcomes), in light of inherent uncertainty about the patient’s trajectory. CONCLUSIONS Caregivers experience significant distress in the context of vacillating emotions and shifting information needs as they adapt to life in the aftermath of a MG diagnosis. These results highlight the need for tailored prognostic information and support for caregivers during this stressful, emotionally fraught time.

QOL-09. “I’VE DEFINITELY CHANGED WHO I AM”: A THEMATIC ANALYSIS OF CHALLENGES FACED BY PATIENTS WITH IDH-MUTANT GLIOMAS

Abstract BACKGROUND Despite their more favorable prognosis, patients with isocitrate dehydrogenase (IDH)-mutant gliomas experience significant psychological distress across their disease trajectory. The specific drivers of distress in this population are poorly understood, and interventions to support these patients are lacking. We sought to better characterize drivers of distress and ways to enhance support for patients with IDH-mutant gliomas as they confront potentially prolonged but ultimately unpredictable survival with an incurable, progressive brain tumor. METHODS Eligible individuals were English-speaking adults ages 65 and younger diagnosed with an IDH-mutant glioma at a single academic medical center. We conducted semi-structured interviews (N=20) to better understand the distress patients experience as they progress along their illness trajectories. We audio-recorded and transcribed interviews and analyzed interview content using reflexive thematic analysis. RESULTS Distress among participating patients (female = 7/20; age &amp;lt;40 years = 10/20) was linked to their struggles to maintain a coherent sense of identity while adapting to 1) neurocognitive changes and 2) altered life plans amidst prognostic uncertainty. Patients described feeling self-conscious and distrustful of their cognitive capacities, frequently comparing their current performance to their premorbid functioning (e.g. by checking their symptoms and indexing perceived deficits against scan results). Patients felt overwhelmed by the need to make decisions and set priorities (e.g., regarding family planning, retirement) due to the uncertain timing of their tumor’s progression and its unclear impact on their future functioning. Patients identified the transition from treatment to surveillance as a time of heightened worry, as they shifted their focus from the logistics of cancer care to the task of planning – financially, occupationally, socially – for an uncertain future. CONCLUSION These findings highlight the need for tailored supportive care to help patients with IDH-mutant gliomas cope with the distress caused by significant changes to identity and ongoing uncertainties regarding their future.

Census growth and challenges of a novel Hospital at Home program: A retrospective cohort study.

Hospital at Home (HaH) is a growing care model requiring significant investments. Critical to starting a program is estimating census and enrollments. The objective of this study was to compare expected versus actual consults, enrollments, and barriers in a novel HaH program. This was an observational, retrospective cohort study at a single urban academic medical center. Adult inpatients considered for enrollment to HaH were included. Demographic data, diagnoses and outcomes data were extracted for HaH patients. Volume and outcomes of HaH consults were recorded, including reasons for ineligibility or a patient declining to enroll. Over the first year of implementation, 248 patients enrolled. The average daily census (ADC) grew over months 1-6, then plateaued at a mean of 4.4 patients during month 10, with an overall ADC range from 0 to 7 patients. From months 7 to 12, there were 724 consults for a home hospital assessment, of which 22.5% (163/724) of patients were enrolled, 21.8% (158/724) declined to enroll, 29.3% (212/724) were ineligible for the program, and 26.4% (191/724) had consults that were deferred until the time of discharge and never explicitly consented or refused. The most common reasons for program ineligibility were complex care needs, insurance status, and not meeting inpatient status. The most common reasons patients declined to enroll were a preference to remain in the brick-and-mortar hospital and home conditions not suitable for HaH. This retrospective, cohort study defines the challenges of enrolling patients in an HaH program and provides areas for other programs to examine as they start or grow a program.

EXPRESS: Normal Saline Versus Balanced Intravenous Fluids in Acute Ischemic Stroke: A Retrospective Study.

Background While some studies have suggested better outcomes for critically ill patients with balanced solutions over normal saline, the best type of intravenous fluid to use for stroke patients remains unknown.Objective To determine if balanced solutions or normal saline are associated with risk of hemorrhagic transformation or 90-day disability in patients with acute ischemic stroke treated with intravenous thrombolysis.Methods This was a retrospective review of the 2015-2019 Get with the Guidelines® data at a single academic medical center. Exposure was type of intravenous fluid and outcomes were modified Rankin scale (mRS) ≤2 at 90 days and hemorrhagic transformation. Multivariate analysis controlled for age, demographics, medical history, time to tPA, and admission stroke scale.Results We included 302 patients who received thrombolysis, of which 166 patients had mRS data at 90 days. In univariate analysis, exposure to any balanced solution was associated with increased 90-day disability (OR 4.3, 95% CI 3.8-4.9) and hemorrhagic transformation (OR 2.0, 95% CI 1.3-2.2). In multivariate analysis, exposure to a balanced solution at any time was associated with increased 90-day disability (OR 6.3, 95% CI 2.4-17.0, p<0.01), but not hemorrhagic transformation.Conclusion This observational trial demonstrated that exposure to balanced solutions is associated with increased risk of disability at 90 days and possibly hemorrhagic transformation in patients with acute ischemic stroke treated with intravenous thrombolysis. This data would suggest that normal saline is a preferred solution in these patients, though larger future trials are needed.

Airway Management With Congenital Tracheal Stenosis: Surgical and Anesthetic Consideration.

To investigate demographic data and airway management techniques for patients with congenital tracheal stenosis (CTS) during the preoperative, intraoperative, and postoperative periods. A retrospective chart review. This study was a retrospective case series at a single tertiary care pediatric medical center. It encompassed all children diagnosed with CTS who underwent slide tracheoplasty from January 2001 through December 2018. Exclusion criteria were acquired stenosis, tracheomalacia, patients without a confirmed diagnosis of CTS, and those with missing data. Patient demographics and details of airway management were collected and analyzed. A total of 148 patients met the inclusion criteria. The most common etiology of CTS was congenital tracheal rings (90.5%). The median age at surgery was 9 months (interquartile range [IQR] 3.3-35.4), and the median stenosis length was 4.0 cm (IQR 3.5-5.4). The most frequent comorbidities were genetic diseases, prematurity, and preoperative intubation. The most common related cardiac comorbidities were pulmonary artery sling, patent ductus arteriosus, atrial septal defect, ventricular septal defect, and tetralogy of Fallot. Most of the patients with CTS exhibited 50% to 80% stenosis. Most of the patients underwent thoracic approach slide tracheoplasty. Airway management was primarily accomplished using an oral or nasal endotracheal tube preoperatively, cardiopulmonary bypass during surgical repair, and an oral or nasal endotracheal tube during closure and the postoperative period. Slide tracheoplasty is an effective treatment for congenital tracheal stenosis. Coordinated airway management between the anesthesia and surgical teams is crucial. Appropriate planning yields the best patient outcomes. 4 Laryngoscope, 2024.

Prenatal diagnosis, ultrasound findings and pregnancy outcome of 7q11.23 deletion and duplication syndromes: what are the fetal features?

ObjectiveAnalyze the ultrasound findings, single nucleotide polymorphism array (SNP-array) results, and pregnancy outcomes of fetuses with 7q11.23 deletions and duplications in the second and third trimesters. Investigate the prenatal ultrasound characteristics and follow up information of these fetuses.MethodsSeven fetuses were diagnosed with 7q11.23 deletion and six with 7q11.23 duplication via SNP-array at the prenatal diagnosis center of a single Chinese tertiary medical center from January 2017 to May 2024. Maternal demographics, ultrasound findings, SNP-array results, pregnancy outcomes, and follow-up information were comprehensively reviewed and analyzed.ResultsThe copy number variations (CNVs) ranged from 1.43 Mb to 1.78 Mb in cases of 7q11.23 deletions and from 1.42 Mb to 1.68 Mb in cases of 7q11.23 duplications. These CNVs encompassed 29 OMIM-listed genes, including ELN, DNAJC30, GTF2IRD1, and GTF2I. Among the seven cases of 7q11.23 deletion syndrome, six exhibited ultrasound abnormalities. The main clinical phenotypes included three cases of intrauterine growth restriction and four cases of cardiovascular system abnormalities, specifically two cases with ventricular septal defects, one case with aortic narrowing, and one case with supravalvular pulmonary stenosis. One case was particularly notable, exhibiting complex multi-organ structural malformations. Out of six cases of 7q11.23 duplication syndrome, five exhibited ultrasound abnormalities. These included two cases of cardiovascular abnormalities: one case with a widened left ventricle and another case with a shortened fetal humerus length. One case revealed complex multi-organ structural malformations, including hydronephrosis, a microgallbladder, and a cleft lip and palate. All seven cases of 7q11.23 deletions and three cases of 7q11.23 duplications opted for termination of the pregnancy. The remaining three cases of 7q11.23 duplications chose to continue the pregnancy. One case underwent surgical treatment for a ventricular septal defect after birth, and the prognosis was favorable. Another case involved a full-term delivery, this child was followed up at the age of 4 and exhibited a phenotype of poor language expression ability.ConclusionOur study broadened the clinical phenotype spectrum of fetuses with 7q11.23 deletions and duplications. Additionally, it conducted a preliminary evaluation of prenatal ultrasound findings and postnatal clinical phenotypes in follow-up cases. The clinical phenotype of fetuses with 7q11.23 deletion and duplication syndromes involves multiple systems and is relatively complex. Cardiovascular abnormalities and intrauterine growth restriction are the most common clinical manifestations observed in prenatal 7q11.23 deletion syndrome. Fetuses with 7q11.23 duplications exhibit a wide range of clinical phenotypes that lack specificity.

Obstetric Life Support Education for Maternal Cardiac Arrest: A Randomized Clinical Trial.

Management of maternal cardiac arrest (MCA) requires understanding the unique physiology of pregnancy and modifications to life support. Health care professionals have historically demonstrated inadequate knowledge and skills necessary to treat MCA. To evaluate the effect of Obstetric Life Support (OBLS) education on health care professionals' cognitive performance, skills, and self-efficacy in managing MCA. In this single-masked randomized clinical trial, 46 health care professionals, including emergency medical service and hospital staff representing diverse specialties, were randomized to intervention or control groups at a single academic medical center in Farmington, Connecticut between May 1, 2022, and July 23, 2023. The intervention group received OBLS education, which included a blended learning curriculum with simulation-based training on common maternal medical emergencies that lead to MCA. Participants were assessed for knowledge, confidence, and skills (eg, megacode scores as team leaders during MCA simulations). Intervention participants were compared with control group participants who received no OBLS education. The primary outcome was cognitive scores. Secondary outcomes included megacode scores rated by experienced OBLS instructors masked to assignment groups, combined assessment pass rates, and cognitive and confidence scores at baseline and 6 and 12 months after education. Data were analyzed from January 2024 to May 2024. Forty-six participants (mean [SD] age, 41.1 [16.2] years; 24 [52%] women) were randomized. Despite most participants holding certification in basic and advanced cardiac life support, significant between-group differences were identified in knowledge, skills, and confidence. Mean (SD) cognitive scores were 79.5% (9.4%) in the intervention group vs 63.4% (12.3%) in the control group (P < .001). Mean (SD) megacode skills were higher in the intervention vs control group (91.0% [5.0%] vs 61.0% [12.0%], P < .001), as were confidence scores (72.7 [13.3] vs 56.2 [17.9] points, P = .002). Combined assessment pass rates were 90% in the intervention group compared with 10% in the control group (P < .001). In this randomized clinical trial, OBLS education significantly improved health care professionals' knowledge, skills, and confidence in managing MCA. These findings underscore the urgent need for implementation of a standardized MCA curriculum nationwide, especially as the US continues to face unacceptably high maternal mortality rates. ClinicalTrials.gov Identifier: NCT05355519.

Characteristics and Outcomes of ICU-admitted COVID-19 Patients in the Omicron and Alpha-dominated periods.

Comparing the outcomes of intensive care unit (ICU) admitted COVID-19 patients during the Alpha and Omicron-dominated periods. Patients with critical COVID-19 disease, requiring ICU admission from May to September 2021 and February to August 2022, were enrolled from a single medical center in Northern Taiwan. Clinical demographics, comorbidities, disease severity, and management strategies were recorded. The 28-day mortality from the two periods were compared both in the original and propensity score (PS)-matched cohort. Of 231 patients, 72 (31.2%) were from the Alpha period and 159 (68.8%) from the Omicron period. Patients in the Omicron period were older, had a lower body mass index, more comorbidities, higher disease severities, and increased 28-day mortality (26.4% vs. 13.9%, p=0.035). In multivariable analysis, the Omicron-dominated period was not identified as an independent factor associated with increased 28-day mortality. COVID-19 patients in Alpha- and Omicron-dominated periods had comparable 28-day mortality in PS-matched cohort (12.1% vs. 18.2%, p=0.733). Independent factors associated with 28-day mortality were a lower PF ratio (PF ratio <100, adjusted odds ratio [aOR] 2.68, 95% confidence interval, CI 1.21-5.94), septic shock ([aOR] 2.39, 95% CI 1.12-5.09) and absence of remdesivir ([aOR] 0.36, 95% CI 0.16-0.83). While patients in the Omicron period exhibited greater severity, the variant was not independently linked to higher 28-day mortality in ICU-admitted patients.

Sequence of events leading to medical abortion for fetal indications after 34 weeks' gestation: 23 years of experience in a single medical center.

Technical advances are rapidly improving the ability to detect anatomical malformations and genetic abnormalities during pregnancy. We aimed to identify the sequence of events leading to medical abortion ≥ 34 weeks' gestation, to determine whether the procedure could have been carried out earlier. Retrospective study of medical abortions in singleton pregnancies carried out in our department over a 23-year period from1998 to 2021. 36/4055 (0.88%) abortions were carried out ≥ 34 weeks' gestation. The indications were anatomical in 20 (55%), chromosomal or genetic in 14 (39%) and CMV infection In two. Evaluation of the sequence of events suggests that an earlier diagnosis would have been unfeasible before the third trimester in 18 cases (50%) because the disorder was developmental and ultrasound findings would not have presented earlier. By contrast, certain other cases might have been diagnosed earlier if the patient had not delayed routine screening or if screening had been administered on schedule. In this series, full adherence to local screening tests and protocols, and timely decision-making could have substantially reduced the late abortion rate by as much as half.

Medical Decision-Making and Bereavement Experiences After Cardiac Arrest: Qualitative Insights From Surrogates.

Surrogates of incapacitated patients in the intensive care unit (ICU) face decisions related to life-sustaining treatments. Decisional conflict is understudied. To compare experiences of ICU surrogates by reported level of decisional conflict related to treatment decisions after a patient's cardiac arrest preceding death. Convergent mixed methods were used. Bereaved surrogates recruited from a single northeastern US academic medical center completed surveys including the low-literacy Decisional Conflict Scale (moderate-to-high cut point >25) and individual interviews about 1 month after the patient's death. Interview data were analyzed by directed and conventional content analysis. Surrogates were stratified by median total survey score, and interview findings were compared by decisional conflict level. Of 16 surrogates, 7 reported some decisional conflict (median survey score, 0; range, 0-25). About two-thirds decided to withdraw treatments. Three themes emerged from interviews: 2 reflecting decision-making experiences ("the ultimate act"; "the legacy of clinician communication") and 1 reflecting bereavement experiences ("I wish there was a handbook"). Surrogates reporting decisional conflict included those who first pursued but later withdrew treatments after a patient's in-hospital cardiac arrest. Surrogates with decisional conflict described suboptimal support, poor medical understanding, and lack of clarity about patients' treatment preferences. These findings provide insight into bereaved ICU surrogates' experiences. The low overall survey scores may reflect retrospective measurement. Surrogates who pursued treatment were underrepresented. Novel approaches to support bereaved surrogates are warranted.

The impact of prior levonorgestrel intrauterine device use at the time of embryo transfer.

To investigate whether infertile women with a history of levonorgestrel intrauterine device (LNG IUD) use have impaired pre-transfer endometrial thickness and pregnancy rates after embryo transfer. Retrospective cohort study at a single academic medical center of infertile women ages 18-44 with a history of LNG IUD use undergoing their first embryo transfer cycle between January 2019 and January 2021 compared to controls with a history of no prior birth control use (NONE) or only prior oral contraceptive use (OCP). The primary outcome is endometrial thickness prior to embryo transfer. Secondary outcomes include embryo transfer results. We analyzed data from a total of 616 patients (197 NONE, 357 OCP, 62 LNG IUD). Women with a history of LNG IUD use had thinner endometrial stripes than women with a history of no prior birth control use (LNG IUD 8.93mm, NONE 10.32mm [aRR 0.88, 95% CI 0.80-0.97]), but not when compared to women with a history of OCP use (OCP 9.61mm [aRR 0.92, 95% CI 0.84-1.01]). Women with a history of LNG IUD use had slightly higher implantation rates than those with no birth control use history (LNG IUD 43.37%, NONE 24.17% [RR 1.79, 95% CI 1.21-2.45]), though not when compared to prior OCP users (OCP 38.72% [RR 1.12, 95% CI 0.86-1.47]). The remainder of the embryo transfer outcomes were similar between the three groups. Prior LNG IUD users have reduced endometrial thickness at the time of embryo transfer but do not have worse pregnancy outcomes.

Maternal body mass index, maneuvers, and neonatal morbidity associated with shoulder dystocia

BackgroundShoulder dystocia is associated with neonatal morbidity. Higher maternal prepregnancy body mass index is an established risk factor for shoulder dystocia, yet the relationship between maternal prepregnancy body mass index and resulting neonatal morbidity after shoulder dystocia is not well studied. ObjectivesWe assessed the association between body mass index and neonatal adverse outcomes following shoulder dystocia. The frequency and type of maneuvers used to resolve shoulder dystocia by maternal body mass index was compared. Study DesignWe conducted a retrospective cohort study of pregnant individuals who experienced a shoulder dystocia at delivery from June 2012-July 2021 at a tertiary care center. We included singleton non-anomalous livebirths ≥36 weeks’ gestation at a single academic medical center in the Midwestern US. The primary exposure was prepregnancy body mass index categorized as: <30 kg/m2 [referent], 30-34.9 kg/m2, and ≥35 kg/m2. The primary outcome was a composite neonatal morbidity including birth injury (brachial plexus injury or fracture), seizures, hypoxic ischemic encephalopathy, and 5-minute Apgar < 7. Secondary outcomes were neonatal intensive care unit admission and neonatal acidemia (cord arterial pH < 7.10). Shoulder dystocia duration and the number and types of maneuvers were compared by body mass index group. Multivariable logistic regression was used and adjusted for nulliparity, diabetes, operative vaginal delivery, and gestational age. ResultsAmong 872 individuals who experienced a shoulder dystocia at delivery, 602 (69.0%) had a body mass index <30 kg/m2, 160 (18.3%) had a body mass index between 30-34.9 kg/m2, and 110 (12.6%) had a body mass index ≥35 kg/m2. The median duration of shoulder dystocia was 40 seconds (interquartile range 30, 60 seconds) and did not vary by maternal body mass index. Deliveries complicated by body mass index ≥35 kg/m2 required a greater number of maneuvers compared to those with lower maternal body mass index (p<0.01). McRoberts (96.0%), suprapubic pressure (90.2%) and delivery of the posterior arm (41.1%) were the most frequent maneuvers in all body mass index groups. Rubin’s maneuver was more frequently used with body mass index ≥35 kg/m2 compared with body mass index <30 kg/m2 (34.6% versus 22.4%, p = 0.02, adjusted odds ratio 1.63, 95% CI 1.04-2.57). Composite neonatal morbidity did not differ by body mass index. Neonatal injury was more frequent with body mass index ≥35 kg/m2 compared with body mass index <30 kg/m2 (adjusted odds ratio 1.97, 95% CI 1.06-3.68). Interaction between body mass index and number of maneuvers was not statistically significant (p=0.94). ConclusionsAmong pregnant individuals who experienced a shoulder dystocia, increased prepregnancy body mass index was associated with an increased number of maneuvers performed during a shoulder dystocia, but not longer duration. Risk of neonatal injury following shoulder dystocia, but not the composite neonatal adverse outcome, was increased with body mass index ≥35 kg/m2.

ABLE-SCORE: a simplified risk score for major adverse cardiovascular outcomes in patients with left ventricular noncompaction

Abstract Background Left ventricular noncompaction (LVNC) is a heterogeneous entity with life-threatening complications and variable prognosis [1,2]. However, there are limited prediction models available to identify individuals at high risk of adverse outcomes, and the current risk score in LVNC is comparatively complex for clinical practice [3,4]. Purpose To develop and validate a simplified risk score to predict major adverse cardiovascular events (MACE) in LVNC. Methods This multicenter longitudinal cohort study consecutively enrolled morphologically diagnosed LVNC patients between January 2009 and December 2020 at a single national-level medical center (derivation cohort n=300; internal validation cohort n=129), and between January 2014 and December 2022 at two national-level medical centers (external validation cohort n=95). The derivation/internal validation cohorts and the multicenter external validation cohort were followed annually until December 2022 and December 2023, respectively. MACE was defined as a composite of all-cause mortality, heart transplantation/left ventricular assist device implantation, cardiac resynchronization therapy, malignant ventricular arrhythmia, and thromboembolism. A simplified risk score, the ABLE-SCORE, was developed based on independent risk factors for MACE in the multivariable Cox regression predictive model, and underwent both internal and external validation to confirm its discrimination (Harrell’s C-index), calibration (calibration plots), and clinical applicability (decision curve analysis). Results A total of 524 LVNC patients (43.5 ± 16.6 years, 65.8% male) were included in the study. At the end of the follow-up, 97 (32.3%), 38 (29.5%), and 20 (21.1%) individuals in the derivation, internal validation, and external validation cohort experienced at least one endpoint of MACE. The ABLE-SCORE was established using four easily accessible clinical variables: age at diagnosis, N-terminal pro-brain natriuretic peptide levels, left atrium enlargement and left ventricular ejection fraction≤40% measured by echocardiography. The risk score showed excellent performance in discrimination, with Harrell’s C-index of 0.821 (95%CI 0.772-0.869), 0.786 (95%CI 0.703-0.869), and 0.750 (95%CI 0.644-0.856) in the derivation, internal validation, and external validation cohort, respectively. Calibration plots of the three datasets suggested accurate agreement between the predicted and observed 5-year risk of MACE in LVNC. According to decision curve analysis, the ABLE-SCORE displayed greater net benefit than the currently existing risk score for MACE in LVNC [3], indicating its strength in clinical applicability. Conclusions Derived from readily available laboratory and echocardiographic variables, a simplified and efficient risk score for MACE was developed and validated using a large LVNC cohort, making it a reliable and convenient tool for the risk stratification and clinical management of patients with LVNC.Development of the ABLE-SCOREValidation of the ABLE-SCORE

Thirty-Day Postoperative Complications after Spinal Fusion in Patients with Spinal Metastasis

Objective: Decompression with instrumented fusion is a common approach for treating spinal metastatic disease. However, in many cases, poor bone quality and compromised general condition increase the likelihood of mechanical failure and other complications. This study investigated complications, including those related to surgery, following decompression and fusion in patients with spinal metastatic disease.Methods: A study at a single tertiary medical center focusing on surgical details and perioperative complications was performed on 35 patients who underwent spinal surgery due to metastatic spinal disease based on a review of a prospective database. Data on patients' underlying conditions and the status of the primary tumors were collected, and various complications that occurred within the first month after surgery were analyzed.Results: During the study, 35 patients (mean age, 66.5 years; 26 men) were enrolled. The most frequent primary cancers were lung (34%) and prostate cancer (17%), followed by liver and breast cancer and others. The overall complication rate was 37% (14% surgery-related complications, 23% general complications). In all cases, surgery was performed due to lower extremity weakness, and 59% of patients showed improvements in motor function after surgery. Furthermore, 23% of patients regained the ability to walk.Conclusion: Surgery for spinal metastasis is frequently performed as an emergency due to the severity of symptoms such as lower extremity weakness. Despite a high risk of acute complications, the procedure has significant benefits, including improvement in weakness and recovery of walking ability. Therefore, proactive treatment using appropriate surgical techniques is recommended.

Impact of burden and distribution of aortic valve calcification on the hemodynamic performance and procedural outcomes of a self-expanding, intra-annular transcatheter aortic valve system.

Aortic valve calcification (AVC) has been explored as a powerful predictor of procedural complications in patients undergoing transcatheter aortic valve implantation (TAVI). However, little evidence exists on its impact on intra-annular devices' performance. We aimed to investigate the impact of AVC burden and distribution pattern on the occurrence of paravalvular leak (PVL), conduction disturbances requiring permanent pacemaker implantation (PPI) and 30-day clinical outcomes in patients undergoing TAVI with a self-expanding, intra-annular device. According to AVC, 103 patients enrolled in a single medical centre from November 2019 to December 2022 were divided into tertiles. Valve Academic Research Consortium (VARC)-3 definitions were used to classify procedural complications and outcomes. Patients in the highest AVC tertile showed an increased occurrence of mild or more PVL and conduction disorders (p < 0.001 and p = 0.006). AVC tertiles (highest tertile) emerged as an independent predictor of PVL (OR 7.32, 95%CI 3.10-17.28, p < 0.001) and post-TAVI conduction disturbances (OR 3.73, 95%CI 1.31-10.60, p = 0.013) but not of PPI (OR 1.44, 95%CI 0.39-5.35, p = 0.579). Considering calcium distribution, ROC analyses revealed that annular AVC but not left ventricle outflow tract (LVOT) calcium burden significantly indicated the development of PVL (AUC 0.863, 0.77-0.93, p < 0.001) and conduction disorders/PPI (AUC 0.797, 0.70-0.89, p < 0.001 and 0.723, 0.58-0.86, p = 0.018, respectively). After adjustment for age and sex, the highest tertile remained an independent predictor of the 30-day composite outcome (death, myocardial infarction, stroke, major vascular complications, type 3/4 bleedings, acute kidney injury, PPI and ≥ moderate PVL) (OR 3.26; 95%CI 1.26-8.40, p = 0.014). A higher AVC is associated with an increased risk of PVL and conduction disturbances after TAVI with a self-expanding, intra-annular device. However, our findings suggest a minor role for LVOT calcification compared with annular AVC in the performance of this specific prosthesis.