Evidence Based Management of Labor

Importance

Induction of labor (IOL) is a common obstetric intervention. Augmentation of labor and active management of the second stage is frequently required in obstetric practice. However, techniques around labor and induction management vary widely. Evidence-based practice regarding induction and labor management can reduce birth complications such as infection and hemorrhage and decrease rates of cesarean delivery.

Objective

To review existing evidence on IOL and labor management strategies with respect to preparing for induction, cervical ripening, induction and augmentation, and second stage of labor techniques.

Evidence acquisition

Review of recent original research, review articles, and guidelines on IOL using PubMed (2000-2022).

Results

Preinduction, pelvic floor training and perineal massage reduce postpartum urinary incontinence and perineal trauma, respectively. Timely membrane sweeping (38 weeks) can promote spontaneous labor and prevent postterm inductions. Outpatient Foley bulb placement in low-risk nulliparous patients with planned IOL reduces time to delivery. Inpatient Foley bulb use beyond 6 to 12 hours shows no benefit. When synthetic prostaglandins are indicated, vaginal misoprostol should be preferred. For nulliparous patients and those with obesity, oxytocin should be titrated using a high-dose protocol. Once cervical dilation is complete, pushing should begin immediately. Warm compresses and perineal massage decrease risk of perineal trauma.

Conclusion and relevance

Several strategies exist to assist in successful IOL and promote vaginal delivery. Evidence-based strategies should be used to improve outcomes and decrease risk of complications and cesarean delivery. Recommendations should be shared across interdisciplinary team members, creating a model that promotes safe patient care.

Best Practices for Writing Letters of Recommendation for Maternal-Fetal Medicine Fellowship: An Empty Scoping Review

OBJECTIVES

 Though letters of recommendation (LOR) for Maternal-Fetal Medicine (MFM) fellowship are a critical part of application process, little is known regarding best practices for writing them. This scoping review sought to identify published data outlining best practices in writing MFM fellowship LOR.

STUDY DESIGN

 Scoping review conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and JBI guidelines. MEDLINE, Embase, Web of Science, and ERIC were searched, by professional medical librarian using database-specific controlled vocabulary and keywords representing MFM, fellowship, as well as personnel selection, academic performance, examinations, or clinical competence in 4/22. Prior to execution, the search was peer reviewed by another professional medical librarian using the Peer Review Electronic Search Strategies (PRESS) checklist. Citations imported to Covidence, dual screened by authors with disagreements resolved by discussion, and extraction performed by one author and checked by the second.

RESULTS

 A total of 1,154 studies were identified, with 162 removed as duplicates. Of the 992 screened, 10 imported for full-text review. None of these met inclusion criteria; four were not about fellows and six did not report on best practices for writing LOR for MFM.

CONCLUSION

 No articles were identified that outlined best practices for writing LOR for MFM fellowship. The lack of guidance and published data guiding those writing LOR for MFM fellowship applicants is concerning given the importance of these as a tool used by fellowship directors in selecting applicants for interviews and ranking.

KEY POINTS

· No published articles were identified addressing best practices for writing LOR for MFM fellowship.. · Fellowship directors rely on LOR for offering interviews and rank list.. · Future research is urgently needed to identify best practices..

Pregnant individuals' information needs and intention to vaccinate their children with routine and COVID-19 vaccines: Findings from a cross-sectional survey

OBJECTIVE

The current study assessed pregnant individuals' intention to accept routine and COVID-19 vaccines for their baby after birth, and to identify key demographic (e.g., age) and nondemographic characteristics (e.g., prior birth) associated with vaccination intention.

METHODS

The authors conducted a cross-sectional survey with pregnant individuals attending prenatal practices affiliated with a large academic medical center and two rural county health departments in the southeastern United States. The survey included 11 questions and was self-administered by pregnant individuals in clinic settings. The final analysis included responses from 443 pregnant individuals.

RESULTS

Only 67% of pregnant individuals planned to vaccinate their baby with all recommended routine vaccines; an additional 22% reported having questions about recommendations. Only 35% of pregnant individuals said they would vaccinate their baby as soon as possible with a COVID-19 vaccine. Younger pregnant individuals and those identifying as Black or African American had lower routine and COVID-19 vaccination intention. Routine vaccination, but not COVID-19 vaccination intention, was associated with familiarity with routine vaccination schedule, trimester of pregnancy, Hispanic ethnicity, history of prior birth, and having access to a computer.

CONCLUSION

Study findings support differential tailoring of future interventions targeting pregnant individuals to promote routine and COVID-19 vaccines for children.

Reproductive Considerations for the LGBTQ+ Community

When working with LGBTQ+ patients who want to build families, primary care providers play a key role in increasing access to reproductive health care. There is growing demand for assisted reproductive services among LGBTQ+ individuals who do not already have their own children or do not wish to adopt. Fertility-preservation options are available for transgender patients; however, many of these treatments are inaccessible to patients because of lack of insurance coverage and high cost. Legal options for LGBTQ+ patients' reproduction vary by state. Knowledge of the laws and regulations in your own state of practice is necessary to manage expectations.

Resident Education in Complex Obstetric Procedures: Are We Adequately Preparing Tomorrow's Obstetricians?

OBJECTIVES

The Accreditation Council for Graduate Medical Education (ACGME) milestones for obstetrics and gynecology (OB/GYN) residents include obstetrical technical skills. We sought to describe resident experience with surgical obstetrics and comfort performing procedures independently postgraduation.

STUDY DESIGN

An anonymous 27-question e-survey was sent to OB/GYN residents in United States in March 2018, using the Council of Resident Education in Obstetrics and Gynecology coordinator listserv. Complex obstetric procedures included: forceps-assisted vaginal delivery (FAVD) and vacuum-assisted vaginal delivery (VAVD), cerclage, breech second twin, breech delivery, perineal repairs, and cesarean hysterectomy. Technical skill questions included experience as primary surgeon, comfort performing procedures independently, and for 4th year residents-comfort performing procedures postresidency. Demographic information was queried. Descriptive statistics was used to analyze responses.

RESULTS

A total of 417 residents completed the survey. Respondents were 88% female, 75% from academic programs, and 48% postgraduate year 3 and 4. Among all residents, many had been primary surgeon in operative vaginal deliveries (51% FAVD, 72% VAVD), fewer for breech vaginal delivery (21%), breech second twin (34%), cesarean hysterectomy (21%), and 4th degree repairs (37%). All 4th-year respondents stated that they would feel comfortable performing either VAVD or FAVD postresidency. Note that 17, 33, 28, and 74% would not feel comfortable performing a 4th degree repair, cesarean hysterectomy, breech second twin, and breech vaginal delivery, respectively, postresidency.

CONCLUSION

Despite ACGME recommendations, data suggest that many graduating residents may not be comfortable with these complex procedures.

Pain perception with cervical tenaculum placement during intrauterine device insertion: a randomised controlled trial

INTRODUCTION

'Slow' and 'cough' techniques for tenaculum placement are commonly used. This trial sought to determine if one method of placement resulted in less pain for patients.

METHODS

This study was a randomised controlled trial of patients presenting for intrauterine device placement. Sixty-six participants were randomised to tenaculum placement via the 'slow' method (closure of tenaculum over a 5-s period) versus the 'cough' method (closure of tenaculum at the time of patient's cough). The primary outcome was pain at time of tenaculum placement measured on a 100 mm visual analogue scale. The study was powered to detect a 16 mm difference in pain. Secondary outcomes included pain with insertion and provider satisfaction with tenaculum grasp. Pain scores were analysed with Wilcoxon rank-sum test.

RESULTS

Sixty-six women were enrolled, 33 randomised to each group. Demographics were similar in each group. The primary outcome of pain with tenaculum placement showed a median pain score of 44 (IQR=21, 63) with slow placement and 32 (IQR=19, 54) with cough placement. There was no significant difference in pain scores between methods of tenaculum placement (p=0.16). There was no significant difference in overall pain scores (p=0.12). Provider satisfaction was not associated with one method of placement (p=1). Pre-procedure anxiety was significantly associated with pain at the time of tenaculum placement (p=0.01).

CONCLUSIONS

Neither the slow method nor cough method is superior for pain reduction or provider satisfaction. Pain with tenaculum use is significantly associated with anxiety.

CLINICAL TRIAL REGISTRATION

NCT02969421.

Abstract P1-17-05: The impact of clinical risk assessment versus PAM-50 ROR score on prognosis and therapeutic decision making in patients with hormone-receptor positive early stage breast cancer

Background: Therapeutic recommendations for adjuvant treatment of hormone-receptor positive breast cancer patients depend on the individual recurrence risk. A number of genomic assays introduced to achieve this goal, but it's still questioned if they actually offer superior risk assessment compared to traditional risk evaluation by experienced clinicians. This study was designed to compare the prognostic accuracy of PAM-50 to clinical judgment.

Methods: Based on the real data of a large adjuvant trial cohort (ABCSG-8, postmenopausal HR positive breast cancer patients), we created online-questionnaires including demographic, histological, and local-therapy details, with and without results of PAM50 ROR score. Out of 14 international breast cancer experts asked for individual patient's risk evaluation (low, intermediate, high) and therapy recommendations, 9 completed the questionnaire.

Patient data were described by Kaplan-Meier estimates of distant disease free survival (DDFS) stratified by risk group. Cox regression models were compared using the Akaike Information Criterion (AIC).

Results: 10 years DDFS and hazard ratios for distant recurrences stratified by risk-group as estimated giving in Table 1:

10 years DDFS and hazard ratios for distant recurrences stratified by risk-group as estimated Low riskIntermediate riskHigh risk n (%)10y DDFS,%(95%CI)n (%)10y DDFS,%(95%CI)n (%)10y DDFS, %(95%CI)  HR(95% CI) HR(95% CI) HR(95% CI)Clinical only: AIC 817.6269 (43)93.0(89.8-96.2)289 (46)89.7(85.9-93.5)73 (11)76.6(66.1-87.1)  0.68(0.39,1.20) 1 2.57(1.41,4.65)PAM50 ROR: AIC 804.8241 (34)96.5(93.1-99.1)210 (33)89.2(84.7-93.7)207 (33)82.5(76.9-88.2)  0.27(0.11,0.62) 1 1.66(0.99,2.78)Combined: AIC 813.4232 (37)95.7(93.0-98.5)282 (45)87.8(83.7-92.0)117 (18)81.7(74.2-89.2)  0.42(0.22,0.84) 1 1.90(1.11,3.24)

Adding genomic information to clinical risk factors leads to escalation of therapeutic recommendations (i.e. additional chemotherapy, extended adjuvant endocrine) in 20% of patients, and de-escalation in 13% of patients.

Conclusions: Clinical judgment accurately identified the patients at high risk of relapse, but was clearly inferior to multi-genomic testing using the PAM-50 ROR score in differentiating low from intermediate risk. Particularly when avoiding unnecessary escalated therapy is the strategic goal, the addition of PAM-50 testing to clinical judgment offers improved accuracy in predicting low vs. intermediate risk of breast cancer recurrence.

Citation Format: Devyatko Y, Filipits M, Greil R, Balic M, Bago-Horvath Z, Singer C, Fitzal F, Steger G, Gray B, Ferree S, Fesl C, Soelkner L, von Minckwitz G, Gnant M. The impact of clinical risk assessment versus PAM-50 ROR score on prognosis and therapeutic decision making in patients with hormone-receptor positive early stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-17-05.

Detection of prohibited substances in equine hair by ultra-high performance liquid chromatography-triple quadrupole mass spectrometry - application to doping control samples

The detection of drugs in human hair samples has been performed by laboratories around the world for many years and the matrix is popular in disciplines, such as workplace drug testing. To date, however, hair has not become a routinely utilised matrix in sports drug detection. The analysis of hair samples offers several potential advantages to doping control laboratories, not least of which are the greatly extended detection window and the ease of sample collection and storage. This article describes the development, validation, and utilisation of a sensitive ultra-high performance liquid chromatography-triple quadrupole mass spectrometry (UHPLC-MS/MS) method for the detection of 50 compounds. This provides significantly improved coverage for those analytes which would be of particular interest if detected in hair, such as anabolic steroid esters and selective androgen receptor modulators (SARMs). Qualitative validation of the method resulted in estimated limits of detection as low as 0.1 pg/mg for the majority of compounds, with all being detected at 2 pg/mg or below. The suitability of the method for the detection of prohibited substances in incurred material was demonstrated by the successful detection of several compounds, such as stanozolol, boldenone undecylenate, clenbuterol, and GW-501516, in genuine equine hair samples. Estimated concentrations of the detected substances ranged from 0.27 to 8.6 pg/mg. The method has been shown to be fit-for-purpose for routine screening of equine hair samples by the analysis of over 400 genuine hair samples.

The in vitro detection of botulinum neurotoxin-cleaved endogenous VAMP is epitope-dependent

The in vitro potency of botulinum neurotoxin (BoNT) serotypes is often measured by monitoring cleavage of their soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) protein substrates. A frequently used method is Western blot, whereby the full-length protein and cleaved form migrate at different molecular weights. Until now, it has been extremely difficult to detect the cleaved cellular form of the SNARE protein vesicle associated membrane protein 1, 2 or 3 (VAMP1, 2 or 3) by Western blot. These VAMP isoforms are the substrates of BoNT serotypes BoNT/B, D, F and G as well as tetanus neurotoxin. Using custom made anti-VAMP antibodies against epitopes either side of the cleavage sites for BoNT/B, BoNT/D and BoNT/F, we have successfully detected the cleaved C-terminal VAMP fragment in cortical neurons. These new antibodies enable quantitative assessment of the potency of VAMP-cleaving neurotoxins by a gain of signal Western blot assay.

Site-selective spectroscopy with depth resolution using resonant x-ray reflectometry

Combining dissimilar transition metal oxides (TMOs) into artificial heterostructures enables to create electronic interface systems with new electronic properties that do not exist in bulk. A detailed understanding of how such interfaces can be used to tailor physical properties requires characterization techniques capable to yield interface sensitive spectroscopic information with monolayer resolution. In this regard resonant x-ray reflectivity (RXR) provides a unique experimental tool to achieve exactly this. It yields the element specific electronic depth profiles in a non-destructive manner. Here, using a YBa₂Cu₃O_7−δ (YBCO) thin film, we demonstrate that RXR is further capable to deliver site selectivity. By applying a new analysis scheme to RXR, which takes the atomic structure of the material into account, together with information of the local charge anisotropy of the resonant ions, we obtained spectroscopic information from the different Cu sites (e.g., chain and plane) throughout the film profile. While most of the film behaves bulk-like, we observe that the Cu-chains at the surface show characteristics of electron doping, whereas the Cu-planes closest to the surface exhibit an orbital reconstruction similar to that observed at La_1−xCa_xMnO₃/YBCO interfaces.

Endovascular Management of Unusual Aneurysms of the Axillary and Subclavian Arteries

Purpose:

Aneurysms of the upper extremity arteries are uncommon and may be difficult to manage with standard surgical techniques. We report the exclusion of three axillary-subclavian aneurysms with covered stents.

Methods and Results:

Palmaz stents were covered with either polytetrafluoroethylene (2 cases) or brachial vein and deployed to exclude pseudoaneurysms in 1 axillary (ruptured) and 2 left subclavian arteries. Two of the patients had advanced cancer and died within 52 days and 3 months of treatment, but their aneurysms were occluded at the time of their death. The repair in the third patient is patent at 9 months.

Conclusions:

Endovascular exclusion of axillary and subclavian aneurysms with covered stents may offer a useful alternative to operative repair, particularly in patients with significant comorbidities.

Simulated games activity vs continuous running exercise: a novel comparison of the glycemic and metabolic responses in T1DM patients

To compare the glycemic and metabolic responses to simulated intermittent games activity and continuous running exercise in type 1 diabetes. Nine patients (seven male, two female; 35 ± 4 years; HbA1c 8.1 ± 0.2%/65 ± 2 mmol/mol) treated on a basal-bolus regimen completed two main trials, a continuous treadmill run (CON) or an intermittent running protocol (INT). Patients arrived to the laboratory fasted at ∼ 08:00 h, replicating their usual pre-exercise meal and administering a 50% reduced dose of rapid-acting insulin before exercising. Blood glucose (BG), K(+) , Na(++) , pH, triglycerides, serum cortisol and NEFA were measured at baseline and for 60 min post-exercise. Interstitial glucose was measured for a further 23 h under free-living conditions. Following exercise, BG declined under both conditions but was less under INT (INT -1.1 ± 1.4 vs CON -5.3 ± 0.4 mmol/L, P = 0.037), meaning more patients experienced hypoglycemia (BG ≤ 3.5 mmol/L; CON n = 3 vs INT n = 2) but less hyperglycemia (BG ≥ 10.9 mmol/L; CON n = 0 vs INT n = 6) under CON. Blood lactate was significantly greater, and pH lower, with a temporal delay in K(+) under INT (P < 0.05). No conditional differences were observed in other measures during this time, or in interstitial glucose concentrations during the remaining 23 h after exercise. Simulated games activity carries a lower risk of early, but not late-onset hypoglycemia than continuous running exercise in type 1 diabetes.

The treatment of stable paediatric forearm fractures using a cast that may be removed at home

We investigated whether, in the management of stable paediatric fractures of the forearm, flexible casts that can be removed at home are as clinically effective, cost-effective and acceptable to both patient and parent as management using a cast conventionally removed in hospital. A single-centre randomised controlled trial was performed on 317 children with a mean age of 9.3 years (2 to 16). No significant differences were seen in the change in Childhood Health Assessment Questionnaire index score (p = 0.10) or EuroQol 5-Dimensions domain scores between the two groups one week after removal of the cast or the absolute scores at six months. There was a significantly lower overall median treatment cost in the group whose casts were removed at home (£150.88 (sem 1.90) vs £251.62 (sem 2.68); p <  0.001). No difference was seen in satisfaction between the two groups (p = 0.48).

Cite this article: Bone Joint J 2013;95-B:1714–20.

Rehabilitation after anterior cruciate ligament reconstruction: a systematic review

BACKGROUND

Rigorous rehabilitation after anterior cruciate ligament (ACL) reconstruction is necessary for a successful surgical outcome. A large number of clinical trials continue to assess aspects of this rehabilitation process. Prior systematic reviews evaluated fifty-four Level-I and II clinical trials published through 2005.

METHODS

Eighty-five articles from 2006 to 2010 were identified utilizing multiple search engines. Twenty-nine Level-I or II studies met inclusion criteria and were evaluated with use of the CONSORT (Consolidated Standards of Reporting Trials) criteria. Topics included in this review are postoperative bracing, accelerated strengthening, home-based rehabilitation, proprioception and neuromuscular training, and six miscellaneous topics investigated in single trials.

RESULTS

Bracing following ACL reconstruction remains neither necessary nor beneficial and adds to the cost of the procedure. Early return to sports needs further research. Home-based rehabilitation can be successful. Although neuromuscular interventions are not likely to be harmful to patients, they are also not likely to yield large improvements in outcomes or help patients return to sports faster. Thus, they should not be performed to the exclusion of strengthening and range-of-motion exercises. Vibration training may lead to faster and more complete proprioceptive recovery but further evidence is needed.

CONCLUSIONS

Several new modalities for rehabilitation after ACL reconstruction may be helpful but should not be performed to the exclusion of range-of-motion, strengthening, and functional exercises. Accelerated rehabilitation does not appear to be harmful but further investigation of rehabilitation timing is warranted.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Metal-insulator transition and orbital reconstruction in Mott-type quantum wells made of NdNiO3

The metal-insulator transition and the underlying electronic and orbital structure in e(g)(1) quantum wells based on NdNiO3 were investigated by dc transport and resonant soft x-ray absorption spectroscopy. By comparing quantum wells of the same dimension but with two different confinement structures, we explicitly demonstrate that the quantum well boundary condition of correlated electrons is critical to selecting the many-body ground state. In particular, the long-range orderings and the metal-insulator transition are found to be strongly enhanced under quantum confinement by sandwiching NdNiO(3) with the wide-gap dielectric LaAlO(3), while they are suppressed when one of the interfaces is replaced by a surface (interface with vacuum). Resonant spectroscopy reveals that the reduced charge fluctuations in the sandwich structure are supported by the enhanced propensity to charge ordering due to the suppressed e(g) orbital splitting when interfaced with the confining LaAlO3 layer.

Use of variability in national and regional data to estimate the prevalence of lymphangioleiomyomatosis

BACKGROUND

Understanding the true prevalence of lymphangioleiomyomatosis (LAM) is important in estimating disease burden and targeting specific interventions. As with all rare diseases, obtaining reliable epidemiological data is difficult and requires innovative approaches.

AIM

To determine the prevalence and incidence of LAM using data from patient organizations in seven countries, and to use the extent to which the prevalence of LAM varies regionally and nationally to determine whether prevalence estimates are related to health-care provision.

METHODS

Numbers of women with LAM were obtained from patient groups and national databases from seven countries (n = 1001). Prevalence was calculated for regions within countries using female population figures from census data. Incidence estimates were calculated for the USA, UK and Switzerland. Regional variation in prevalence and changes in incidence over time were analysed using Poisson regression and linear regression.

RESULTS

Prevalence of LAM in the seven countries ranged from 3.4 to 7.8/million women with significant variation, both between countries and between states in the USA. This variation did not relate to the number of pulmonary specialists in the region nor the percentage of population with health insurance, but suggests a large number of patients remain undiagnosed. The incidence of LAM from 2004 to 2008 ranged from 0.23 to 0.31/million women/per year in the USA, UK and Switzerland.

CONCLUSION

Using this method, we have found that the prevalence of LAM is higher than that previously recorded and that many patients with LAM are undiagnosed.