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BackgroundSleep-disordered breathing (SDB) in pregnancy is associated with adverse maternal outcomes. The relationship between SDB and infant birthweight is unclear. This study's primary aim is to determine if objectively measured SDB in pregnancy is associated with infant birthweight.MethodsWe measured SDB objectively in early (6-15 weeks' gestation) and mid (22-31 weeks' gestation) pregnancy in a large cohort of nulliparous women. SDB was defined as an Apnea-Hypopnea Index ≥5 and in secondary analyses we also examined measures of nocturnal hypoxemia. We used a modified Poisson regression approach to estimate relative risks (RR) of large-for-gestational-age (LGA: >90th percentile for gestational age) and small-for-gestational-age (SGA

Objective To characterize the clinicopathologic findings, comorbidities, and treatment outcomes of women with lichen planopilaris (LPP). Method In this retrospective review of women with LPP at Mayo Clinic from 1992 to 2016, we searched for scarring alopecia in all female patients aged 1 to 100 years from January 1, 1992, through December 31, 2016. Men were excluded from this study to more accurately determine the association of hormonal factors in LPP pathogenesis. Two hundred thirty-two patients were included as they met diagnostic criteria for LPP based on clinicopathologic correlation, with 217 having confirmatory biopsies. Results We identified 232 women with LPP (mean age, 59.8 years). Of those, 92.7% (215) presented with hair loss; 23.7% (55) had preceding inflammation; 30.6% (71) had thyroid disease, including hypothyroidism (23.2%; 54); and 9.4% (22) had vitamin D deficiency. Incidence of depression and anxiety was 45.7% (106) and 41.8% (97), respectively. History of total abdominal hysterectomy/bilateral salpingo-oophorectomies and hormone replacement therapy was found in 16.8% (39) and 16.4% (38), respectively. Lichen planus at other body sites occurred in 16.4% (38) of patients; and 53.2% (123) had slowing of disease progression or disease stabilization, often requiring combination therapies. In those who achieved slowing or stabilization of disease, mean time to recurrence was 1.8 year. The mean time to remission was 1.1 year. Conclusion The typical LPP patient is a 60-year-old female with vertex scarring alopecia who presents with burning, erythema, inflammation, and scale. Almost half of patients will have comorbid autoimmunity. As previously reported, LPP is associated with thyroid disease. We also found higher rates of depression, anxiety, nutritional deficiencies, and skin cancer than reported in the general population.

The objective of the study was to evaluate the morbidity, mortality, and postoperative outcomes associated with simple or subcutaneous mastectomy in the management of prophylactic versus therapeutic resection. In this study we aimed to assess if simple or subcutaneous mastectomy for prophylaxis affects perioperative outcomes compared with resection performed for biopsy proven malignancy.The American College of Surgeons National Surgical Quality Improvement Program database was queried for subjects who underwent simple or subcutaneous mastectomy between 2007 and 2012. Patient demographic characteristics, comorbid conditions, and postoperative complications were analyzed.Of the 30,803 patients, 30,644 (99.5%) underwent therapeutic mastectomy and 159 (0.5%) underwent prophylactic mastectomy. Subjects who underwent prophylactic surgery were more likely to be younger (45 vs. 58 years; P .01) and white (134 [84%] vs. 20,647 [67%]; P .01). Surgery time was significantly greater in the prophylactic group (265 vs. 166 minutes; P .01). There was no significant difference in mortality between groups. There was a trend toward greater 30-day morbidity (15 [9%] vs. 1835 [6%]; P = .09) and occurrence of deep venous thrombosis (DVT; 2 [1%] vs. 74 [0.2%]; P = .06) in those who underwent prophylactic mastectomy. After age adjustment, the prophylactic group showed a nearly sixfold increase in DVT (odds ratio [OR], 5.77; 95% confidence interval [CI], 1.37-24.22), which persisted when controlling for surgery time (OR, 4.95; 95% CI, 1.18-20.86).Prophylactic simple or subcutaneous mastectomy incurs significant additional 30-day postoperative morbidity related to perioperative DVT. Risk-mitigating strategies should be considered in the perioperative care of this patient population.

Key Points Question Does postpartum blood pressure trajectory after a hypertensive disorder of pregnancy differ by race? Findings In this prospective cohort study that included 1077 women after a hypertensive disorder of pregnancy, blood pressure trajectories evaluated using mixed-effects linear regression models differed significantly by self-reported race. At the conclusion of the study, 68% of Black women and 51% of White women met the criteria for stage 1 or stage 2 hypertension. Meaning This study suggests that postpartum blood pressure trajectories indicate persistence of higher blood pressures among Black women in this cohort, which may have important implications for postpartum morbidity and mortality associated with hypertensive and cardiovascular conditions in this population., Importance Maternal morbidity and mortality are increasing in the United States, most of which occur post partum, with significant racial disparities, particularly associated with hypertensive disorders of pregnancy. Blood pressure trajectory after a hypertensive disorder of pregnancy has not been previously described. Objectives To describe the blood pressure trajectory in the first 6 weeks post partum after a hypertensive disorder of pregnancy and to evaluate whether blood pressure trajectories differ by self-reported race. Design, Setting, and Participants This prospective cohort study included deliveries between January 1, 2018, and December 31, 2019. Women with a clinical diagnosis of a hypertensive disorder of pregnancy were enrolled in a postpartum remote blood pressure monitoring program at the time of delivery and were followed up for 6 weeks. Statistical analysis was performed from April 6 to 17, 2020. Main Outcomes and Measures Mixed-effects regression models were used to display blood pressure trajectories in the first 6 weeks post partum. Results A total of 1077 women were included (mean [SD] age, 30.2 [5.6] years; 804 of 1017 White [79.1%] and 213 of 1017 Black [20.9%]). Systolic and diastolic blood pressures were found to decrease rapidly in the first 3 weeks post partum, with subsequent stabilization (at 6 days post partum: mean [SD] peak systolic blood pressure, 146 [13] mm Hg; mean [SD] peak diastolic blood pressure, 95 [10] mm Hg; and at 3 weeks post partum: mean [SD] peak systolic blood pressure, 130 [12] mm Hg; mean [SD] peak diastolic blood pressure, 85 [9] mm Hg). A significant difference was seen in blood pressure trajectory by race, with both systolic and diastolic blood pressure decreasing more slowly among Black women compared with White women (mean [SD] peak systolic blood pressure at 1 week post partum: White women, 143 [14] mm Hg vs Black women, 146 [13] mm Hg; P = .01; mean [SD] peak diastolic blood pressure at 1 week post partum: White women, 92 [9] mm Hg vs Black women, 94 [9] mm Hg; P = .02; and mean [SD] peak systolic blood pressure at 3 weeks post partum: White women, 129 [11] mm Hg vs Black women, 136 [15] mm Hg; P, This cohort study describes the blood pressure trajectory in the first 6 weeks post partum after a hypertensive disorder of pregnancy and evaluates whether blood pressure trajectories differ by self-reported race.

Objective The aim of study is to compare the performance of ultrasonographic customized and population fetal growth standards for prediction adverse perinatal outcomes. Study Design This was a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be, in which l data were collected at visits throughout pregnancy and after delivery. Percentiles were assigned to estimated fetal weights (EFWs) measured at 22 to 29 weeks using the Hadlock population standard and a customized standard (www.gestation.net). Areas under the curve were compared for the prediction of composite and severe composite perinatal morbidity using EFW percentile. Results Among 8,701 eligible study participants, the population standard diagnosed more fetuses with fetal growth restriction (FGR) than the customized standard (5.5 vs. 3.5%, p The population standard diagnosed FGR among black women and Hispanic women at nearly double the rate it did among white women (p Conclusion At 22 to 29 weeks' gestation, EFW percentile alone poorly predicts perinatal morbidity whether using customized or population fetal growth standards. The population standard diagnoses FGR at increased rates in subgroups not at increased risk of morbidity and at lower rates in subgroups at increased risk of morbidity, whereas the customized standard does not.

Birthweight is often used as a proxy for fetal weight. Problems with this practice have recently been brought to light. We explore whether data available at birth can be used to predict estimated fetal weight using linear and quantile regression, random forests, Bayesian additive regression trees, and generalized boosted models. We train and validate each approach using 18,517 pregnancies (31,948 ultrasound visits) from the Magee-Womens Obstetric Maternal and Infant data and 240 pregnancies in a separate dataset of high-risk pregnancies. We also quantify the relation between smoking and small-for-gestational-age birth, defined as a birthweight in the lower 10th percentile of a population birthweight standard and estimated and predicted fetal weight standard. Using mean squared error and median absolute deviation criteria, quantile regression performed best among the regression-based approaches, but generalized boosted models performed best overall. Using the birthweight standard, smoking during pregnancy increased the risk of small-for-gestational-age 3.84-fold (95% CI: 2.70, 5.47). This ratio dropped to 1.65 (95% CI: 1.50, 1.81) when using the correct fetal weight standard, which was no different from the machine learning-based predicted standards, but higher than the regression-based predicted standards. Machine learning algorithms show promise in recovering missing fetal weight information. See video abstract at, http://links.lww.com/EDE/B314.

OBJECTIVE: To evaluate the feasibility, acceptability, and compliance of a remote blood pressure monitoring protocol implemented as a quality improvement measure at the hospital level for management of hypertension in postpartum women after hospital discharge. METHODS: This is an ongoing quality improvement project that included women admitted to the postpartum unit of a single tertiary care hospital. We designed nursing call center-driven blood pressure management and treatment algorithms which were initiated after hospital discharge until 6 weeks postpartum. Women are eligible to participate if they have a diagnosis of chronic hypertension, superimposed preeclampsia, gestational hypertension, preeclampsia, or postpartum hypertension and have access to a text messaging-enabled smartphone device. After identification by an obstetric care provider, women are enrolled into the program, which is automatically indicated in the electronic medical record. Maternal, obstetric, and sociodemographic data were obtained from the electronic medical record. RESULTS: Between February 2018 and January 2019, we enrolled 499 patients. Here we report on the first 409 enrolled patients. Participants include 168 (41%) with gestational hypertension, 179 (44%) with preeclampsia with no history of chronic hypertension, 49 (12%) with chronic hypertension with superimposed preeclampsia, and 13 (3%) with postpartum preeclampsia. One hundred seventy-one (42%) participants had antihypertensives initiated or titrated through the program. Three hundred forty women (83%) continued the program beyond 3 weeks postpartum, and 360 (88%) attended an in-person 6-week postpartum visit. Two hundred thirty-five out of 250 women who completed a postprogram survey (94%) reported satisfaction with the program. CONCLUSION: In this study, we detail results from an ongoing remote blood pressure monitoring program. We demonstrate high compliance, retention, and patient satisfaction with the program. This is a feasible, scalable remote monitoring program connected to the electronic medical record.

Background: Cicatricial alopecia is a type of permanent hair loss in which the hair follicle is replaced by scar tissue. Given its relatively low incidence, limited information is available regarding baseline hair characteristics, onset, and other disease-associated factors. Objective: We sought to further elucidate this information in our lichen planopilaris (LPP) patients. Methods: Between 1993 and 2016, 505 patients were diagnosed with biopsy-proven LPP. Of these patients, we mailed a 20-question survey to 420 patients with updated mailing address and contact information. Responses were received from 129 of 420 patients for a response rate of 30.7%. A total of 108 patients completed the survey and 21 patients declined participation. Descriptive analysis was performed using JMP software. Results: Median age at time of pathologic diagnosis was 58 years, with self-reported average age of onset accordingly from 50 to 60 years. Approximately 15% of patients were diagnosed with frontal fibrosing alopecia (FFA), a subtype of LPP. Median follow-up from date of pathologic diagnosis was 72 months. At baseline, 46 out of 108 patients (42.6%) endorsed having thicker hair than peers in childhood. No trend was identified in the rate of traction hairstyle use in childhood, current use of cosmetics, sunscreen, or facial cleanser. Conclusions: Within our LPP cohort, FFA subtype pathology comprised approximately 15% of cases. There was no trend toward sunscreen use and FFA subtype. Our findings support previously published studies in terms of average age at disease onset, location of hair loss, and median follow-up at 72 months (range: 29–273) from date of pathologic diagnosis. Keywords: Lichen planopilaris, Frontal fibrosing alopecia, Natural history, Survey, Sunscreen, Facial cosmetics

Background Antenatal detection of fetal growth restriction (FGR) prompts antepartum surveillance to reduce perinatal mortality, yet most cases of FGR are undetected. Objective This study aims to compare rates of adverse neonatal outcomes when FGR is detected versus undetected. Study Design Small-for-gestational-age (SGA) newborns (birth weight Results Out of 29,885 neonates, 2,475 (8.3%) were SGA. Out of the 826 (33%) SGA neonates who underwent growth ultrasound, 185 (22%) were considered FGR. In the SGA-no US group, the adjusted odds ratio (aOR) for Apgar Conclusion Fetal growth ultrasound effectively stratifies risk amongst SGA neonates.

Acquired progressive lymphangioma (benign lymphangioendothelioma) is a rare lymphatic anomaly of unclear pathogenesis. Excision is generally advised for local disease, although other therapies have been tried. This report describes a unique case of extensive acquired progressive lymphangioma involving the abdomen, genitalia, and lower extremity of a 1-year-old boy. Rapid progression and multisite involvement required exploration of nonsurgical options for management.

Objective To characterize the clinicopathologic findings, comorbidities, and treatment outcomes of women with frontal fibrosing alopecia. Patients and Methods Retrospective review of women with frontal fibrosing alopecia at Mayo Clinic from January 1, 1992, to February 22, 2016. The terms "scarring alopecia," "lichen," "planopilaris," "fibrosing," and "alopecia" were used for the search of female patients aged 1 to 100 years. A total of 686 patients were reviewed to confirm the diagnosis of frontal fibrosing alopecia. Patients were included if they met diagnostic criteria. Results A total of 148 women with frontal fibrosing alopecia were identified, with a mean age of 62 years; 60.1% presented with eyebrow loss; 67.6% and 27.7% described preceding or concurrent pruritus and trichodynia, respectively; 44.6% had a history of hypothyroidism; 13% had a history of surgical menopause; and 63.3% had a history of hormone replacement therapy. A total of 18.2% had lichen planus at other body sites, and 26.3% achieved disease stabilization, often requiring combination therapies. The mean time to remission was 1.8 years. Conclusion Patients with frontal fibrosing alopecia typically present with frontotemporal and eyebrow alopecia with preceding symptoms. Hypothyroidism and a history of hysterectomy may be more common than previously reported. Time to presentation, diagnosis, and stabilization is often months to years. Patients who lack treatment response may present with eyebrow loss, eyelash loss, and facial papules. Combination therapy is helpful in achieving slowing of disease progression or disease stabilization, although recurrence is common. Additional studies on treatment and efficacy are needed. Limitations to this study include the retrospective design and varied follow-up.

We attempted to determine the feasibility of studying prehabilitation exercises to improve shoulder pain and abduction range of motion (ROM) after breast cancer surgery. We evaluated methods of exercise teaching and assessed effect on postsurgical seroma formation. This was a feasibility study with two non-blinded groups of subjects randomized by timing of appointment. This single-site study was performed at an academic tertiary medical center. Sixty cancer patients were randomly assigned to either group 1, in-person teaching arm, n = 36, or group 2, video-only teaching arm, n = 24. Forty-five patients completed the study. Shoulder exercises were assigned to both groups 1 month prior to surgery during evaluation. Group 1 received in-person instruction on exercises, plus an information sheet with exercises and a link to an online video. Group 2 received only the information sheet with exercises and a link to the online video. The primary outcomes considered are as follows: exercise compliance, shoulder pain (via visual analog scale), shoulder abduction ROM (via goniometer), and presence or absence of seroma. Seventy-six percent of study patients chose to exercise. There was no difference in exercise compliance between in-person teaching versus video teaching (75 %, 24/32 vs. 77 %, 10/13, OR = 1.03). Sixty-six of patients (20/30) lost greater than 10° shoulder abduction ROM at 1 month post surgery. Twenty-nine of patients (9/31) had worse shoulder pain than baseline at 1 month post surgery (24 %, 6/25 exercisers, and 50 %, 3/6 non-exercisers). Fifteen percent of patients (4/27) had worse shoulder pain than baseline at 3 months post surgery (8 %, 2/23 exercisers, and 100 %, 2/2 non-exercisers). Prehabilitation exercise program inferred no additional risk of seroma formation (Exercisers 21 %, 7/33 vs. non-exercisers 22 %, 2/9, OR = 0.94). Our subjects were able to perform three exercises independently in the preoperative period. A high-quality randomized controlled trial is necessary to assess the appropriate timing and efficacy of this intervention.

Objective This study aims to determine the risk of adverse outcomes associated with the current diagnostic criteria for fetal macrosomia. Study Design We evaluated three techniques for characterizing birth weight as a predictor of shoulder dystocia or third- or fourth-degree laceration in 79,879 vaginal deliveries. First, we compared deliveries with birth weights above or below 4,500 g. We then performed logistic regression using birth weight as a continuous predictor, both with and without fractional polynomial transformation. Finally, we calculated the number of cesarean sections required to prevent one incident of the interrogated outcomes (number needed to treat [NNT]). Results Rates of adverse intrapartum outcomes increase incrementally with increasing birth weight and are predicted most accurately with logistic regression following fractional polynomial transformation. The NNT for third- or fourth-degree laceration dropped from 14.3 (95% confidence interval [CI], 13.9–14.7) at a birth weight of 3,500 g to 6.4 (95% CI, 6.1–6.8) at 4,500 g and, for shoulder dystocia, from 54.9 (95% CI, 51.5–58.6) at 3,500 g to 5.6 (95% CI, 5.2–6.0) at 4,500 g. Conclusion The conventional distinction between “normal” and “macrosomic” does not reflect the incremental effect of increasing birth weight on the risk of obstetric morbidity. Outcomes analysis can inform fetal growth standards to better reflect relevant thresholds of risk.

Rosai-Dorfman disease (also known as sinus histiocytosis with massive lymphadenopathy) is a rare benign proliferative disorder of histiocytes that typically involves the lymph nodes and can also involve extranodal sites. Rosai-Dorfman disease confined to the breast is extremely rare, but important to recognize as it can mimic malignancy. We present the case of a 63-year-old woman who presented with a palpable breast lump that was highly suspicious for malignancy based on mammogram and ultrasound appearance. Biopsy revealed inflammatory tissue with lymphoplasmacytic and histiocytic predominance. The diagnosis of Rosai-Dorfman was made based on characteristic staining of histiocytes with S-100 and the presence of emperipolesis. Early recognition of this benign disease entity spared the patient further investigation and surgical intervention.

Preterm birth has staggering health implications, and yet the causes of most cases are still unknown. Placental features have been understudied as an etiology for preterm birth, and the association between placental pathologic lesions and neonatal outcomes are incompletely understood.We sought to characterize births according to placental pathology and relate these to adverse neonatal outcomes.We studied 20,091 births (15,710 term and 4381 preterm) with placental evaluations. Births were classified according to the presence or absence of placental lesions consistent with malperfusion (vasculopathy, infarct, advanced villous maturation, perivillous fibrin, fibrin deposition) and intrauterine inflammation/infection (chorioamnionitis, funisitis, vasculitis). Outcomes were gestational week of delivery, birthweight z-score, neonatal respiratory distress syndrome, and intraventricular hemorrhage.Among all preterm births, evidence of placental malperfusion was identified more often than inflammation/infection (50.6% vs 27.3%, P .0001). Placental malperfusion was associated with reduced fetal growth (adjusted birthweight z-score, -0.83, P.0001) and lesions of inflammation/infection were associated with earlier delivery (adjusted difference -2.08 weeks, P.0001) than those with no lesions. When both placental lesions were present, earlier delivery (adjusted difference -2.28 weeks, P.0001) and reduced fetal growth (adjusted birthweight z-score difference, -0.24, P = .001) were observed more often than when neither lesion was present. Findings were similar when restricted to cases of spontaneous preterm birth. Intraventricular hemorrhage was higher in preterm births with malperfusion lesions than cases with no lesions (7.6% vs 3.4%; odds ratio, 1.98; confidence interval, 1.18-3.32), accounting for gestational age and other covariates.Placental pathology provides important insight into subtypes of preterm birth with adverse neonatal outcomes. Co-occurrence of malperfusion and inflammation/infection, especially among spontaneous preterm births, may be a novel pattern of placental injury linked to severe adverse outcomes.

Objective We assessed the effect of an open vascular simulation course on the surgical skill of junior surgical residents in performing a vascular end-to-side anastomosis and determined the course length required for effectiveness. We hypothesized that a 6-week course would significantly increase the surgical skill of junior residents in performing an end-to-side anastomosis, while a 3-week course would not. Methods We randomized 37 junior residents (postgraduate year 1 to 3) to a course consisting of three (short course, n=18) or six (long course, n=19) consecutive weekly 1-hour teaching sessions. Content focused on instrument recognition and performance of an end-to-side vascular anastomosis using a simulation model. A standardized 50-point vascular skills assessment (SVSA) measured knowledge and technical proficiency. Senior residents (postgraduate year 4 to 5) were tested at baseline. Junior residents were tested at baseline and at 1 and 16 weeks after course completion, and their scores were compared with baseline and senior resident scores. Residents and faculty completed a standardized anonymous evaluation of the course. Results Baseline scores between short-course and long-course participants were not different. At baseline, junior residents had significantly lower SVSA scores than senior residents (36 ± 7 vs 41.4 ± 2.5; P = .002). One week after course completion, SVSA scores for short-course (43.5 ± 2.9 vs 34.2 ± 7.5; P = .008) and long-course (43.9 ± 5.6 vs 38.3 ± 5.9; P = .006) participants were significantly improved from baseline. SVSA scores decreased slightly at 16 weeks but remained above baseline in short-course (39 ± 6.2 vs 34.2 ± 7.5; P = .03) and long-course (40 ± 4.5 vs 38.3 ± 5.9; P = .08) participants. Long vs short course length didnot affect improvement in SVSA scores at 1 or 16 weeks. In short-course and long-course participants, SVSA scores at 1 and 16 weeks were not significantly different from senior resident scores. Course ratings were high, and 95% of residents indicated the course "made them a better surgeon." Residents and faculty felt the educational benefit of the course merited the investment of resources. Conclusions An open vascular simulation course consisting of three weekly 1-hour sessions increased the surgical skill of junior residents in performing a vascular end-to-side anastomosis to that of senior residents on a standardized assessment. A 6-week course provided no additional benefit. This study supports the use of an open vascular simulation course to teach vascular surgical skills to junior residents. A course consisting of three 1-hour sessions is an effective and efficient component of a simulation program for junior surgical residents in a busy surgical center.

Adrenalectomy remains the definitive therapy for most adrenal neoplasms. Introduced in the 1990s, laparoscopic adrenalectomy is reported to have lower associated morbidity and mortality. This study aimed to evaluate national adrenalectomy trends, including major postoperative complications and perioperative mortality. The Nationwide Inpatient Sample was queried to identify all adrenalectomies performed during 1998–2006. Univariate and multivariate logistic regression were performed, with adjustments for patient age, sex, comorbidities, indication, year of surgery, laparoscopy, hospital teaching status, and hospital volume. Annual incidence, major in-hospital postoperative complications, and in-hospital mortality were evaluated. Using weighted national estimate, 40,363 patients with a mean age of 54 years were identified. Men made up 40% of these patients, and 77% of the patients were white. The majority of adrenalectomies (83%) were performed for benign disease. The annual volume of adrenalectomies increased from 3,241 in 1998 to 5,323 in 2006 (p

Unconventional gas drilling (UGD) has enabled extraordinarily rapid growth in the extraction of natural gas. Despite frequently expressed public concern, human health studies have not kept pace. We investigated the association of proximity to UGD in the Marcellus Shale formation and perinatal outcomes in a retrospective cohort study of 15,451 live births in Southwest Pennsylvania from 2007–2010. Mothers were categorized into exposure quartiles based on inverse distance weighted (IDW) well count; least exposed mothers (first quartile) had an IDW well count less than 0.87 wells per mile, while the most exposed (fourth quartile) had 6.00 wells or greater per mile. Multivariate linear (birth weight) or logistical (small for gestational age (SGA) and prematurity) regression analyses, accounting for differences in maternal and child risk factors, were performed. There was no significant association of proximity and density of UGD with prematurity. Comparison of the most to least exposed, however, revealed lower birth weight (3323 ± 558 vs 3344 ± 544 g) and a higher incidence of SGA (6.5 vs 4.8%, respectively; odds ratio: 1.34; 95% confidence interval: 1.10–1.63). While the clinical significance of the differences in birth weight among the exposure groups is unclear, the present findings further emphasize the need for larger studies, in regio-specific fashion, with more precise characterization of exposure over an extended period of time to evaluate the potential public health significance of UGD.

ResumenEl propósito de este estudio era identificar los rasgos de la esquizofrenia de primer episodio que predicen el cumplimiento de la medicación antipsicótica en el seguimiento a los 6 meses. Utilizamos instrumentos validados para evaluar las variables clínicas y sociodemográficas en todos los pacientes con esquizofrenia de primer episodio de un área geográfica definida ingresados en un hospital psiquiátrico de Dublín durante un periodo de cuatro años (n = 100). En el seguimiento a los 6 meses (n = 60) evaluamos el cumplimiento de la medicación utilizando la Entrevista de Cumplimiento. Un tercio de los pacientes con esquizofrenia no tomaba la medicación a los seis meses de su primer episodio de enfermedad. Los niveles elevados de síntomas positivos en la linea de base, la falta de conciencia de la enfermedad en la línea de base, el uso inadecuado de alcohol en la línea de base y el uso inadecuado anterior de drogas predicen el incumplimiento. Estos resultados indican que un subgrupo identificable de pacientes con esquizofrenia de primer episodio tiene un riesgo alto de incumplimiento temprano de la medicación. Aunque las puntuaciones altas de síntomas positivos preceden y predicen el incumplimiento en la mayoría de los pacientes, la reducción de la conciencia de la enfermedad es el mejor predictor del incumplimiento en los pacientes que no utilizan inadecuadamente el alcohol u otras drogas.

ResumenLa esquizofrenia se asocia con desarrolló neural alterado. Evaluamos los signos neurológicos menores (SNM) y las anomalías dermatoglíficas (recuento total de crestas a-b [RTCAB] y recuento total crestas digitales [RTCD]) en 15 pares de gemelos concordantes y dis-cordantes para esquizofrenia. Las diferencias intrapar en las puntuaciones tanto de SNL como de RTCAB fueron significativamente mayo-res en los pares discordantes comparado con los pares monocigóticos concordantes. No hubo diferencias significativas en las puntuaciones de SNM y RTCAB entre los sujetos con esquizofrenia y los co-gemelos sin la enfermedad. Sin embargo, los gemelos discordantes monocigóticos con esquizofrenia tenían recuentos de crestas a-b (RCAB) mayores en su mano derecha comparado con sus co-gemelos sin la enfermedad. Estos hallazgos indican que un acontecimiento ambiental no identificado que actúa entre las semanas 6 y 15 de la gestación afecta al desarrollo de los gemelos monocigóticos que continúan hasta desarrollar esquizofrenia, pero no tiene un efecto correspondiente en sus co-gemelos que no desarrollan la enfermedad. El efecto de este acontecimiento sobre los perfiles dermatoglíficos parece laterali-zado a la mano derecha en los gemelos afectados.

BACKGROUND: Patients with heparin-induced thrombocytopenia and thrombosis may be acutely anticoagulated with direct thrombin inhibitors (DTIs). The anticoagulation is typically monitored using the activated partial thromboplastin time (aPTT) or ecarin clotting time (ECT). OBJECTIVE: To compare 14 methods for measuring aPTT, as well as ECT and thrombin inhibitor management test (TIM), in samples containing DTIs. METHODS: DTIs were added to pooled normal plasma to achieve low (0.1–1.2 μg/mL) and high (1.5–8.0 μg/mL) drug concentrations. Each low-concentration DTI sample was tested using all aPTT reagents, while each low- and high-concentration DTI was tested using the ECT and TIM. RESULTS: All aPTT reagents had a significant dose-dependent correlation with drug concentration. Only Actin FSL and APTT-S demonstrated equivalent aPTT ratios obtained from any DTI. The TAS-aPTT was the most sensitive aPTT reagent to argatroban, with the aPTT ranging from 52.7 to 121.2 seconds corresponding to 0.1 to 1.2 μg/mL of drug concentration. The TAS-aPTT and Pathromtin were the most sensitive aPTT reagents to bivalirudin, with aPTTs of 87.4 seconds and 101.5 seconds, respectively, at 1.2 μg/mL of drug. Pathromtin was the most sensitive aPTT reagent to lepirudin, with a maximum aPTT of 108.9 seconds at 1.2 μg/mL of drug. There was no statistically significant difference between the TIM and ECT clotting times for each DTI. Lepirudin and bivalirudin ECT and TIM clotting times were equivalent. CONCLUSIONS: There are unique differences between reagent manufacturers in the monitoring of DTIs. Acceptable alternatives to aPTT monitoring of DTI anticoagulation include the ECT and TIM.

ResumenTener un diagnóstico de esquizofrenia es un factor de riesgo para el ingreso no voluntario en la asistencia hospitalaria psiquiátrica, pero tenemos una comprensión limitada de por qué algunos pacientes precisan un ingreso no voluntario y otros no. Intentamos identificar los predictores del ingreso no voluntario en el primer episodio de esquizofrenia. Utilizamos instrumentos validados para evaluar las variables clínicas y sociodemográficas en todos los pacientes (n = 78) con primer episodio de esquizofrenia de un área geográfica definida ingresados en un hospital psiquiátrico de Dublín durante un periodo de 4 años. No se pudo distinguir a los pacientes no voluntarios (n = 17) de los voluntarios (n = 61) de acuerdo con la edad, el género, la situación de convivencia, el estado civil, el abuso de drogas o la duración de la psicosis no tratada. Ni los síntomas positivos ni los negativos fueron predictores útiles del tipo de ingreso. La falta de insight fue un fuerte predictor del ingreso de tipo no voluntario.

We evaluated six D-dimer methods to determine their sensitivity, specificity, and negative predictive values (NPV) in symptomatic patients suspected of deep vein thrombosis (DVT). In patients suspected of DVT a whole blood D-dimer test (SimpliRED, Agen) was performed, and then tested using enzyme-linked immunosorbent assay (VIDAS D-Dimer, BioMerieux; Asserachrome D-Di, Stago International; Dimertest Gold, Agen) and automated immunoturbidometric methods (Advanced D-Dimer, Dade Behring; MiniQuant, Biopool). Each D-dimer method was independently compared with radiographic results to determine sensitivity and NPV. There were 151 patients enrolled in the study. Thirty-five (23.2%) patients had a positive Doppler ultrasound, with 26 proximal, eight distal, and one patient with both proximal and distal thrombus. Two patients (1.3%) had inconclusive studies and were excluded from the analyses. For all patients, the sensitivities for the rapid D-dimer methods were: SimpliRED, 82.3% [95% confidence interval (CI), 80.3-84.3%]; VIDAS D-Dimer, 91.4% (95% CI, 89.9-92.9%); MiniQuant D-Dimer, 96.3% (95% CI, 95.1-97.5%); and Advanced D-Dimer, 97.1% (95% CI, 96.3-97.9%). The sensitivity improved for SimpliRED (86.4%; 95% CI, 83.3-89.4%), VIDAS D-Dimer (95.5%; 95% CI, 85.0-100%), MiniQuant D-Dimer (100%; 95% CI, 96.9-100%) and Advanced D-Dimer (100%; 95% CI, 98.9-100%) in the inpatient population. The automated immunoturbidometric methods, the MiniQuant D-Dimer and Advanced D-Dimer, demonstrated comparable sensitivities and NPV with the VIDAS D-Dimer method in symptomatic patients suspected of DVT, which would suggest that these newer D-dimer methods could be used as part of the diagnostic algorithm for patients suspected of DVT.

The conjunctival microcirculation of 18 homozygous sickle cell disease (SCD) patients during steady-state, painful crisis, and postcrisis conditions was recorded on high-resolution videotapes using intravital microscopy. Selected videotape sequences were subsequently coded, frame-captured, studied, and blindly analyzed using computer-assisted image analysis protocols. At steady-state (baseline), all SCD patients exhibited some of the following morphometric abnormalities: abnormal vessel diameter, comma signs, blood sludging, boxcar blood flow phenomenon, distended vessels, damaged vessels, hemosiderin deposits, vessel tortuosity, and microaneurysms. There was a decrease in vascularity (diminished presence of conjunctival vessels) in SCD patients compared with non-SCD controls, giving the bulbar conjunctiva a “blanched” avascular appearance in most but not all SCD patients during steady-state. Averaged steady-state red cell velocity in SCD patients was slower than in non-SCD controls. During painful crisis, a further decrease in vascularity (caused by flow stoppage in small vessels) and a 36.7% ± 5.2% decrease in large vessel (mostly venular) diameter resulted. In addition, the conjunctival red cell velocities either slowed significantly (6.6% ± 13.1%; P

Hypothesis: Children who undergo cardiopulmonary bypass (CPB) are proportionally more hemodiluted than adults who undergo CPB. Current methods of monitoring high-dose heparin sulfate anticoagulation are dependent on fibrinogen level. Because of the decreased fibrinogen levels in children, current methods of monitoring heparin anticoagulation overestimate their level of anticoagulation. Design: Prospective controlled trial. Main Outcome Measure: Production of thrombin (adequacy of anticoagulation). Methods: Children and adults undergoing cardiac surgery who received CPB were anticoagulated in the standard fashion as directed by activated clotting time (ACT) results. Each subject had blood sampled at baseline; heparinization; start of the CPB; CPB at 30, 60, and 90 minutes; and at termination of CPB. Samples were used to assess anticoagulation with the Heparin Management Test (less dependent on fibrinogen level than ACT). We also assessed 2 subclinical markers of thrombosis, thrombin-antithrombin complexes and prothrombin fragment F1.2; a marker of procoagulant reserve, fibrinogen; the natural antithrombotic, anti-thrombin; and heparin concentration. Results: Ten children and 10 adults completed the study. Children had lower fibrinogen levels than adults throughout CPB (P

Background The whole blood D-dimer assay has gained recognition as a noninvasive test to rule out pulmonary embolism (PE) in medical patients. Methods We performed a whole blood D-dimer assay in medical and surgical patients undergoing either pulmonary angiogram or pulmonary ventilation perfusion scan for suspected PE or duplex Doppler or venogram for suspected deep venous thrombosis (DVT). Results A total of 483 patients were enrolled; 16 were excluded because of an equivocal pulmonary ventilation perfusion scan. The 467 remaining patients had a mean age of 56 +/- 27 years. There were 258 women and 209 men. A total of 353 patients were admitted to a medical service and 114 to surgery/ trauma. A total of 82 patients (18%) developed thromboembolism: 20 had PE, and 62 had DVT. Conclusion No surgical patient with PE or DVT (n = 27) had a negative D-dimer. A negative D-dimer result in a stable surgical patient should be considered conclusive evidence to rule out thromboembolism and, thus, negate the need for further diagnostic studies. In our surgical patients suspected of DVT or PE, had D-dimer been used, one third of the patients would have avoided an expensive or invasive diagnostic test.

ResumenObjetivo:Los informes subjetivos de respuestas disfóricas a la medicación neuroléptica son comunes en la práctica clínica. Sin embargo, los efectos secundarios cognitivos y afectivos de las medicaciones neurolépticas son difíciles de diferenciar de los síntomas de esquizofrenia. Tratamos de dilucidar la contribución relativa de los efectos secundarios extrapiramidales y los síntomas a la respuesta disfórica.Método:Se evaluó a 50 pacientes ambulatorios estables clínicamente con esquizofrenia que asistían a un centro de rehabilitación en cuanto a los efectos secundarios extrapiramidales y los síntomas antes de completar el inventario de actitud hacia los medicamentos (DAI).Resultados:La presencia de efectos secundarios extrapiramidales, encontrados en 28 pacientes (Z = -1,99, p = 0,05), y la gravedad de los síntomas negativos (r = -0,47, p = 0,001) se asociaban independientemente con la respuesta disfórica, explicando una proporción significativa de la varianza (R = 0,53, R2 = 25,2%, F = 9,27, gl = 2, p = 0,0004).Conclusiones:Los pacientes que comunican una respuesta disfórica que ellos asocian con las medicaciones neurolépticas tienen más efectos secundarios extrapiramidales y síntomas negativos más graves. Aunque estas respuestas pueden ser parte de los síntomas negativos de la enfermedad o deberse a otros factores como la depresión, planteamos la posibilidad de que puedan ser clínicamente indistinguibles del llamado "síndrome de déficit inducido por neurolépticos" y una medida subjetiva de él.

SummaryOur study compared point-of-care (POC) device monitoring with traditional clinical laboratory methods device of patients on oral anticoagulant therapy. The POC devices used in the study were Coumatrak, CoaguChek, CoaguChek Plus, Thrombolytic Assessment System (TAS) PT-One, TAS PTNC, TAS PT, Hemachron Jr. Signature, Protime Microcoagulation System, and Medtronics ACT II. The clinical laboratory method used thromboplastins with different ISI values: Innovin and Thromboplastin C Plus (TPC). All POC INRs showed strong correlation with both laboratory methods, with correlation coefficients of >0.900. All POC methods demonstrated a significant (p 0.93), but there were still significant (p

ResumenLos individuos con esquizofrenia que participaron en un programa de rehabilitación psicosocial y educativa mostraron una mejoría del 46% en calidad de vida en ausencia de cambios significativos en la gravedad de los síntomas. Por contraste, no hubo cambios significativos en calidad de vida para los individuos que continuaron con rehabilitación de apoyo. Nuestros resultados preliminares destacan los beneficios en la “calidad de vida” de la rehabilitación psicosocial y educativa para los individuos con esquizofrenia que son clínicamente estables y viven en la comunidad.

To estimate and compare the risk of morbid perinatal outcomes in pregnancies identified as small for gestational age (SGA) with customized compared with conventional standards of fetal growth.Ultrasound-derived estimates of fetal weight were used to generate a fetal growth trajectory (N=7,510). The gestational age at delivery and pathologic and physiologic variables from 5,072 pregnancies were used to calculate a customized threshold for SGA. In a separate analysis of 32,070 pregnancies, rates of morbid outcomes were compared in participants classified as SGA according to a population-based birth weight standard only (SGApop only), a customized standard only (SGAcust only), and both methods (SGAboth).Eight-hundred seventy-five (2.7%) participants were SGApop only, 1,970 (6.1%) participants were SGAboth, and 609 (1.9%) participants were SGAcust only. The odds ratios of neonatal death in SGApop only and SGAcust only pregnancies were 1.78 (95% confidence interval [CI] 0.2-13.1) and 54.6 (95% CI 29.0-102.8), respectively. Rates of prematurity in the SGApop only and SGAcust only cohorts were 4.8% and 64.5%, respectively. After adjustment for the effect of prematurity, odds ratios of neonatal death in the SGApop only and SGAcust only cohorts were 4.8 (95% CI 0.6-37.0) and 2.9 (95% CI 1.4-6.1), respectively.After adjustment for confounding stemming from premature delivery, there is little difference in the risk of adverse outcomes between SGAcust only and SGApop only participants. Adoption of customized fetal growth standards into clinical practice may not improve the ability to identify pregnancies with increased risk of perinatal morbidity.

To explore whether Paget's disease (PD) has an effect on outcome in patients with breast cancer.Retrospective analysis of comprehensive pathology database, medical records, and slides of samples showing pathologic features.UMass Memorial Health Care.All patients with breast cancer and PD with records in a prospectively maintained database between January 1, 1990, and December 31, 2008, were identified. Each participant was matched (criteria: age within 5 years, year of treatment, and stage of breast cancer) with 2 controls (1:2 ratio).Overall and disease-free survival were analyzed using Kaplan-Meier statistics and Cox proportional hazards modeling, accounting for matching in the latter analyses by using robust standard error estimates.Mean (SD) follow-up was 47 (33) months. Treatment involved mastectomy in 29 (91%) PD vs 16 (25%) non-PD patients (P.001), radiotherapy in 14 (44%) PD vs 53 (83%) non-PD patients (P.001), and hormonal therapy in 14 (44%) PD vs 33 (52%) non-PD patients (P = .004). Biological markers were not significantly different except for ERBB2 (formerly HER2 or HER2/neu) overexpression in 14 (44%) PD vs 16 (25%) non-PD patients (P = .008). The PD group had an overall 5-year survival of 81.2% vs 93.8% of the non-PD group (Kaplan-Meier log-rank, P = .03). The unadjusted hazard ratio for the PD vs non-PD group was 5.31 (95% CI, 1.74-16.27; P = .003). The corresponding hazard ratio after adjusting for local and systemic treatment was 2.26 (95% CI, 0.46-11.06; P = .32).These exploratory data show that PD may have a negative effect on breast cancer survival. This finding needs to be substantiated in larger data sets.

Promoting a culture of teaching may encourage students to choose a surgical career. Teaching in a human factors (HF) curriculum, the nontechnical skills of surgery, is associated with surgeons' stronger identity as teachers and with clinical students' improved perception of surgery and satisfaction with the clerkship experience.To describe the effects of an HF curriculum on teaching culture in surgery.Surgeons and educators developed an HF curriculum including communication, teamwork, and work-life balance.Teacher identity, student interest in a surgical career, student perception of the HF curriculum, and teaching awards.Ninety-two of 123 faculty and residents in a single program (75% of total) completed a survey on teacher identity. Fifteen of the participants were teachers of HF. Teachers of HF scored higher than control participants on the total score for teacher identity (P.001) and for subcategories of global teacher identity (P = .001), intrinsic satisfaction (P = .001), skills and knowledge (P = .006), belonging to a group of teachers (P.001), feeling a responsibility to teach (P = .008), receiving rewards (P =.01), and HF (P = .02). Third-year clerks indicated that they were more likely to select surgery as their career after the clerkship and rated the curriculum higher when it was taught by surgeons than when taught by educators. Of the teaching awards presented to surgeons during HF years, 100% of those awarded to attending physicians and 80% of those awarded to residents went to teachers of HF.Curricular focus on HF can strengthen teacher identity, improve teacher evaluations, and promote surgery as a career choice.

Background This study examines the development and implementation of a pilot human factors curriculum during a 2-year period. It is one component of a comprehensive 5-year human factors curriculum spanning core competencies of interpersonal and communication skills, systems-based practice, and professionalism and using low-and high-fidelity simulation techniques. Study Design Members of the Department of Surgery and the Center for Clinical Communication and Performance Outcomes jointly constructed a curriculum for PGY1 and PGY2 residents on topics ranging from challenging communication to time and stress management. Video demonstrations, triggers, and simulated scenarios involving acting patients were created by surgeons and medical educators. Pre- and postintervention measures were obtained for communication skills, perceived stress level, and teamwork. Communication skills were evaluated using a series of video vignettes. The validated Perceived Stress Scale and Teamwork and Patient Safety Attitudes survey were used. Residents' perceptions of the program were also measured. Results Twenty-seven PGY1 residents and 15 PGY2 residents participated during 2 years. Analyses of video vignette tests indicated significant improvement in empathic communication for PGY1 ( t = 3.62, p=0.001) and PGY2 ( t = 5.00, p=0.004). There were no significant changes to teamwork attitudes. Perceived levels of stress became considerably higher. PGY1 residents reported trying 1 to 3 strategies taught in the time management session, with 60% to 75% reporting improvement post-training. Conclusions This unique and comprehensive human factors curriculum is shown to be effective in building communication competency for junior-level residents in the human and emotional aspects of surgical training and practice. Continued refinement and ongoing data acquisition and analyses are underway.

Objective To evaluate the effect of the 80-hour workweek restrictions on resident education within surgical programs in the New England area. Design Web-based survey. Setting All Accreditation Council for Graduate Medical Education (ACGME) accredited surgical residency programs in New England (n = 20). Participants Program directors/coordinators in each surgical residency program in New England. Main Outcome Measures First, American Board of Surgery In-Training Examination (ABSITE) scores and the passing rate of the ABS certifying examination were recorded for the years 2001, 2002, 2005, and 2006. Second, the changes in the curriculum of surgical education were documented as perceived by program coordinators and directors. Results In all, 85% (17/20) of surgical programs in New England responded to the survey. The programs began to implement the 80-hour workweek from 2002 to 2004. An equal distribution of community (n = 8) and university programs (n = 9) was sampled. Prior to the initiation of the 80-hour workweek, residency programs emphasized weekly didactic sessions given by attending physicians (88%), mock orals (88%), and conventional journal club (76%). After the 80-hour workweek was implemented, the education curriculum most often consisted of didactic sessions by attending (100%), mock orals (88%), and simulation laboratories (75%). No difference was observed in ABSITE scores and first-time pass rates of the ABS examination before or after the introduction of the 80-hour workweek (20% response). Only 25% of programs felt that surgical education was improved after the implementation of the 80-hour workweek, whereas 31% felt education was worse. Overall, 44% of respondents believed that there was no difference in surgical education. Conclusions Despite the positive effects the 80-hour workweek has had on resident quality of life and patient care, it does not seem that either significant improvements or detrimental effects have occurred on surgical education within residency programs in New England.

Advances in high-performance computing and optical networking are making it feasible to handle complex analysis of the multiple phases of cell division. While it is now possible to build and explore simulation and modeling of the cell cycle [1], the complexity of their user interfaces can be intimidating and undesirable to researchers and teachers of such biological phenomena. While supercomputers have already been used for simulation of cell division [2], research in this area has been limited.