Integrating technologies to provide comprehensive remote fetal surveillance: A prospective pilot study

OBJECTIVE

To determine the feasibility of extending remote maternal-fetal care to include fetus well-being.

METHODS

The authors performed a prospective pilot study investigating low-risk pregnant participants who were recruited at the time of their first full-term in-person visit and scheduled for a follow-up telemedicine visit. Using novel self-operated fetal monitoring and ultrasound devices, fetal heart monitoring and amniotic fluid volume measurements were obtained to complete a modified biophysical profile (mBPP). Total visit length was measured for both the in-person first visit and the subsequent telemedicine encounter. A patient satisfaction survey form was obtained.

RESULTS

Ten women between 40 + 1 and 40 + 6 weeks of gestation participated in telemedicine encounters. Nine women (90%) were able to complete remote mBPP assessment. For one participant, fetal assessment was not completed due to technically inconclusive fetal monitoring. Another participant was referred for additional assessment in the delivery room. Satisfactory amniotic fluid volume measurements were achieved in 100% of participants. The telemedicine encounter was significantly shorter (93.1 ± 33.1 min) than the in-person visit (247.2 ± 104.7 min; P < 0.001). We observed high patient satisfaction.

CONCLUSION

Remote fetal well-being assessment is feasible and time-saving and results in high patient satisfaction. This novel paradigm of comprehensive remote maternal and fetal assessment is associated with important clinical, socioeconomic, and logistics advantages.

Transient osteoporosis of the hip in pregnancy - a case series

OBJECTIVE

Transient Osteoporosis of the Hip is a self-limiting disorder of severe hip joint pain presenting in pregnancy or postpartum, of which magnetic resonance imaging (MRI) is the modality of choice for diagnosis. Clinical data regarding transient osteoporosis of the hip is limited, precluding evidence-based decision-making such as recommended mode of delivery. In this case-series retrospective study, we aim to describe the natural course of transient osteoporosis of the hip during pregnancy and the postpartum period including implications of the mode of delivery.

METHODS

All women diagnosed with unilateral/bilateral transient osteoporosis of the hip by MRI during pregnancy or postpartum between 2010 and 2019 at a single tertiary medical center were retrospectively studied. All MRI scans were reviewed by an experienced radiologist at the same single tertiary medical center. Data obtained from patients' electronic medical records and telephone questionnaires included maternal baseline characteristics, obstetric history, and current pregnancy obstetric and clinical outcome characteristics. Outcomes of normal vaginal delivery (NVD) and cesarean delivery (CD) were compared and analyzed.

RESULTS

Thirty-four women were diagnosed with unilateral or bilateral transient osteoporosis of the hip during pregnancy (17 women) and postpartum (17 women). The mean maternal age was 34.18 ± 4.75 years. A family history of osteoporosis was reported in a rate of 29.4%. The rate of smokers was 47.1%, 32.4% of pregnancies were conceived by in-vitro fertilization (IVF), pre-pregnancy and term body mass index (BMI) were 22.03 and 27.6, respectively. No significant differences were found between NVD and CD in all parameters evaluated. Of 15 women with a sequential pregnancy, two were diagnosed with transient osteoporosis of the hip (13.3%).

CONCLUSION

Women diagnosed with transient osteoporosis of the hip had advanced maternal age, low BMI, family history of osteoporosis, prevalent smoking and IVF pregnancies. Transient osteoporosis of the hip was bilateral in 25% and presented postpartum in 50% of cases. There was no significant difference in maternal outcomes between NVD and CD. Higher awareness of this potential diagnosis during pregnancy and postpartum may improve patient management and outcomes.

A multicenter interdisciplinary survey of practices and opinions regarding oral intake during labor

INTRODUCTION

Different society guidelines diverge regarding oral intake in labor. Our goal was to assess practices and opinions in Israeli labor and delivery units, comparing different disciplines.

METHODS

An anonymous Google Forms survey was sent to anesthesiologists, obstetricians and midwives in all Israeli labor and delivery units.

RESULTS

Responses were collected from all 27 labor and delivery units contacted, with a total of 501 respondents comprising 161 anesthesiologists, 102 obstetricians and 238 midwives. Forty-eight per cent stated there were no institutional guidelines for oral intake. The most common oral intake permitted was light food (60%). Midwives were significantly more likely than anesthesiologists and obstetricians to consider that women who are both low risk for cesarean delivery (P <0.00001) and high risk for cesarean delivery (P=0.001) should eat. Epidural analgesia did not impact recommendations regarding oral intake. The most common reasons for restricting oral intake were obstetric. Sixty-two per cent identified aspiration as the main risk associated with eating during labor, but 19% of midwives compared with 4% of anesthesiologists and obstetricians stated there were no risks (P <0.00001). The annual delivery volume of the unit did not impact staff practices.

CONCLUSIONS

There was a discrepancy between opinions and practices across all disciplines. Permissive practices identified in this survey should be addressed to find the safe middle ground between restrictive and permissive policies for low- and high-risk women.

Ritodrine versus salbutamol for external cephalic version

INTRODUCTION

Treatment with beta-agonist tocolytics preceding external cephalic version (ECV) attempt increases success rates. Most studies have focused on intravenously and orally administered beta-agonists, while other administration routes including intramuscularly (IM) and subcutaneously (SC) are understudied. We aimed to compare the efficacy of IM ritodrine to SC salbutamol given prior to ECV.

METHODS

A retrospective study of patients who underwent ECV between 1/2012 and 12/2019 at two medical centers. We compared patients undergoing ECV following IM ritodrine versus SC salbutamol. We matched the two groups by parity and placental location. Maternal, pregnancy, ECV procedure and neonatal characteristics were compared.

RESULTS

Overall, 601 women were included in each group. Median maternal age and amniotic fluid index (AFI) were lower in the Ritodrine group (27 vs. 32 years, p<0.001, 11 vs. 15 AFI cm, p<0.001, respectively). The median gestational age at ECV was higher in the Ritodrine group (380/7 vs. 370/7 weeks gestation). Success rate was higher in the Ritodrine group (71.7% vs. 63.8%, p=0.003). Vaginal delivery rate was higher in the Ritodrine group (70.7% vs. 60.1%, p<0.001). The number needed to treat to benefit was 10. In a multivariate analysis, Ritodrine was independently associated with higher ECV success rates as compared with Salbutamol (aOR 2.1, 95%CI 1.52-2.89).

CONCLUSIONS

Intramuscular ritodrine significantly improved the success rate of ECV compared to SC salbutamol, and both drugs were safe and acceptable before ECV.

Early Atrial Fibrillation During Acute Myocardial Infarction May Not Be an Indication for Long-Term Anticoagulation

Patients with new-onset of atrial fibrillation (NOAF) during acute myocardial infarction (AMI) currently receive long-term oral anticoagulation. The risk for stroke of “early” versus “late” onset of atrial fibrillation (AF) has not been elucidated. Consecutively, AMI patients admitted to a tertiary medical center were analyzed. We excluded patients with preexisting AF, AMI onset ≥24 hours prior to admission, significant valvular disease, fever >38.5°C, in-hospital death, or coronary artery bypass graft. Atrial fibrillation was verified by electrocardiography and medical records. Overall 7061 patients were included, 1.4% developed “early-paroxysmal AF (PAF)” that resolved within 24 hours of admission and 2.5% had “late-AF” beyond the first 24 hours. Median follow-up was ≈6 years. Primary end points included ischemic stroke and all-cause mortality. Stroke rates were higher only in patients with late-AF versus no-AF but not in the early-PAF: 10.6% versus 4.2%, 5.3%, respectively ( P < .001). Death rates were higher in patients with late-AF and early-PAF versus no-AF: 55.3%, 43.2%, and 29.2%, respectively ( P < .001). Congestive heart failure, hypertension, age ≥75, diabetes mellitus, a stroke or transient ischemic attack, vascular disease, age 65-74, female (CHA2DS2-VASc) score underestimated stroke risk in the late-AF group. In conclusion, the study generates the hypothesis that patients with early-PAF may not have a high stroke risk questioning the indication for long-term anticoagulation.

Early Versus Late New-Onset Atrial Fibrillation in Acute Myocardial Infarction: Differences in Clinical Characteristics and Predictors

New-onset atrial fibrillation (NOAF) during acute myocardial infarction (AMI) has significant consequences but is often misdiagnosed. The aim of the study was to evaluate predictors of NOAF throughout different phases of AMI. Patients with AMI admitted to a tertiary medical center were analyzed. Exclusion criteria were preexisting AF, AMI onset ≥24 hours prior to admission, in-hospital death, significant valvular disease, and in-hospital coronary artery bypass graft. Study population were AMI without-NOAF, early-AF (AF terminated within 24 hours of admission), and late-AF (beyond the first 24 hours). Overall 5946 patients were included, age: 64.8 ±14.8 years; 30% women. The incidence of NOAF was 4.6%: 1.6% early-AF, and 3% late-AF. Patients with NOAF comprised greater rate of women, cardiovascular risk-factors burden, severe left ventricular-dysfunction, pulmonary hypertension, valvular disorders, and left atrial enlargement compared with patients without-NOAF. Non-ST-elevation myocardial infarction and inferior-ST-elevation myocardial infarction (STEMI) were significantly more prevalent among early-AF group, while anterior-STEMI, in late-AF. The final multivariate models showed c-statistics of 0.73 and 0.76 for the prediction of new-onset early-AF and late-AF, respectively. In conclusion, there are different clinical predictors of early- versus late-NOAF. The study points out “high risk” AMI population for more meticulous heart rate monitoring for NOAF.

Modulation of ultraviolet light-induced epidermal damage: beneficial effects of tocopherol

Oxygen free radicals have been shown to result from and mediate deleterious effects of ultraviolet radiation on the skin. The purpose of this study was to determine if topical DL-alpha-tocopherol (vitamin E) could reduce ultraviolet-induced damage to the epidermis. Twenty mice were treated with either ethanol or a 1:1 mixture of tocopherol and ethanol. Treatments consisted of once-daily 0.1-ml topical applications for 1 week, followed by irradiation with 0.30 mW/cm2 of ultraviolet B irradiation. A statistically significant decrease in Schiff base formation was noted between tocopherol-treated animals and their controls. Histologic study revealed a statistically significant increase in epidermal thickness in tocopherol-treated skin versus controls or vehicle alone. The thicker epidermis was accompanied by the presence of parakeratosis, implicating increased proliferation as the cause of the increasing thickness. The number of sunburn cells was decreased by tocopherol treatment. Tocopherol protection from ultraviolet irradiation may have been due to both direct protection from free radicals and indirect protection by means of increased epidermal thickness. The demonstration of beneficial effects of tocopherol administration suggests that further studies in clinically relevant models to define optimal dosage, frequency of administration, vehicle, and quantitation of the possible protective effects afforded to Langerhans cells may be useful.

Effects of dietary fish oil on renal insufficiency in rats with subtotal nephrectomy

We studied the effects of fish oil on the progression of renal insufficiency in rats with subtotal nephrectomy. Five weeks after a 1-2/3 nephrectomy, sixteen rats were fed two different diets which differed only in fat composition. Lipid in the control diet was primarily beef tallow; that of the experimental diet, menhaden oil. Fish oil-fed rats had significant increases in plasma creatinines, decreases in urinary PGE2 and accelerated death rates. An additional twelve rats underwent 1-1/3 nephrectomies, and the same dietary manipulations, followed by renal clearance, histologic and biochemical studies after 12 weeks on the diets. Fish oil-fed rats again did worse, with decreased glomerular filtration rates and filtration fractions, more proteinuria and more glomerular sclerosis. Glomeruli and slices of cortex, medulla and papillae from rats fed fish oil produced much less PGE2 and TXB2 than dietary controls. Fish oil-induced suppression of renal PGE2 may be deleterious in this model and may outweigh the beneficial effect derived from TXA2 suppression. In contrast to fish oil's potentially therapeutic role in cardiovascular and immune-mediated renal disease, this diet is detrimental in rat renoprival nephropathy. This illustrates the importance of examining the effects of fatty acid manipulation individually for each disease entity.

Measurement of effective renal plasma flow: a comparison of methods

We have compared two in vitro methods and three variations of kidney background (BG) subtraction within a gamma camera method (41 examinations, 31 patients) for determination of effective renal plasma flow (ERPF) using 131I orthoiodohippurate (OIH). Method I: plasma samples at 20 and 45 min after OIH injection, ERPF = dose X slope/intercept; Method II: 45-min plasma sample, ERPF = -51.1 + 8.21x + 0.019x2, x = dose/45-min plasma activity/I. Individual kidney and total ERPF were determined from gamma camera (GC) methods using renal uptake 1-2 min after injection. All methods were compared against Method I (previously validated against paraaminohippurate (PAH) clearances). Method II, which requires one blood sample is more accurate than GC methods. GC methods are insensitive to operator variability in placement of renal and BG regions of interest. They may be useful to follow changes in relative or total ERPF, but accurate depth correction of renal data is suggested. In vitro, blood sample-based methods are more accurate.

Attitudes toward women physicians in medical academia

To determine attitudes toward women physicians within medical academia, we administered a survey to a probability sample of male and female senior medical students, faculty, and top-level administrators in a randomized, stratified subset of ten medical schools. Of the 984 respondents (65% response rate), men were much less supportive overall than women of female leaders. While women strongly disagreed with the idea that women physicians who spend long hours at work neglect home and family, men were almost equally divided on this issue. Each group rated the "typical" faculty member as "strong, fair, and progressive," but male faculty also were characterized as "egotistical" while female faculty were rated more "sensitive and altruistic." Male students were least likely to support a search for a female dean, hiring more female faculty members, or accepting an incoming class in which the majority were women.

Indicine-N-oxide: the antitumor principle of Heliotropium indicum

Extracts of Heliotropium indicum Linn. (Boraginaceae) showed significant activity in several experimental tumor systems. The active principle is isolated and shown to be the N-oxide of the alkaloid, indicine, previously isolated from this plant. Supporting structural data and anti-tumor data are provided.