Search

Elevated follicle-stimulating hormone (FSH) levels during the early follicular phase or in response to the clomiphene citrate challenge test indicate diminished ovarian reserve and poor reproductive potential. We performed a retrospective analysis of 413 infertile women, 23 to 40 years of age, who underwent 523 cycles of in vitro fertilization (IVF) to identify the critical FSH values that would predict a poor likelihood of success in our military IVF program. Each woman underwent a clomiphene citrate challenge test within 1 year of each IVF cycle. The overall live birth and implantation rates were 43% and 24%, respectively. The critical values for day 3 and day 10 FSH levels were 14.1 and 16.9 mIU/mL, respectively, with a 0% live birth rate and a 5% implantation rate above these levels. There were no differences in the live birth/implantation rates when stratified for FSH levels below the critical values. Medical centers offering IVF should determine their critical FSH values, to help identify patients unlikely to benefit from IVF and to ensure appropriate allocation of resources and realistic expectations for infertile couples. [ABSTRACT FROM AUTHOR]

We describe the obstetric management for a patient with Hermansky-Pudlak syndrome (HPS) and a previous cesarean delivery. The disease is characterized by oculocutaneous albinism, platelet storage dysfunction, and lipofuscin deposits in the reticuloendothelial system. Patients with the disorder are at high risk for major morbidity secondary to bleeding complications. The patient was a 22-year-old military spouse from Puerto Rico with HPS and a history of severe hemorrhage during cesarean delivery of her first child. In this report, we discuss the pathophysiologic features of HPS and the prophylactic administration of 1-deamino-8-arginine-vasopression during labor to minimize blood loss. [ABSTRACT FROM AUTHOR]

Black Americans in the US not only suffered from disproportionately high hospitalization and death rates throughout the pandemic but also from the consequences of low COVID-19 vaccination rates. This pattern of disparity is linked to distrust of public health systems that originates from a history of medical atrocities committed against Black people. For that reason, mitigation of race-based inequity in COVID-19 impacts might find more success in grassroots information contagion than official public health campaigns. While Black Twitter is well-positioned as a conduit for such information contagion, little is known about message characteristics that would afford it. Here, we tested the impact of four different message frames (personalization, interactive, fear appeal, neutral) on the social contagion potential of bi-modal social media messages promoting COVID-19 vaccinations and finding personalized messages to be the most shareable. Wary of recommending personalization as the blueprint for setting a social contagion health campaign in motion, we probed further to understand the influence of individual-level variables on the communicability of personalized messages. Subsequently, regression models and focus group data were consulted, revealing that thinking styles, vaccine confidence levels, and attitudes toward social media were significant factors of influence on the contagion potential of personalized messages. We discussed the implications of these results for health campaigns.

Objective: To assess whether infants born to women with a history of recurrent pregnancy loss (RPL) have an increased risk of adverse perinatal outcomes following frozen embryo transfer (FET) compared to women without a history of infertility or RPL., Design: Retrospective cohort study utilizing the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS) database between 2014 and 2020., Subjects: Patients in the SART CORS database who underwent their first FET resulting in live birth either with a diagnosis of RPL (cases n=3,299) or without a history of RPL or infertility, the comparison population being tubal ligation (TL) only (n=1408)., Exposure: Recurrent pregnancy loss MAIN OUTCOME: Low birthweight (<2500g), additional outcomes included gestational age (continuous), birthweight (continuous), preterm delivery (< 37 weeks), mode of delivery, and neonatal death, defined as death prior to the completion of the 28 th day of life., Results: We observed no statistically significant difference in low birthweight, birthweight overall, mode of delivery or risk of neonatal death between patients with RPL compared to women with tubal ligation who underwent their first FET resulting in live birth. Patients with history of RPL compared to TL utilizing FET were more likely to have a later gestational age at delivery (p<0.001). Patients with RPL were also less likely to have a preterm delivery (imputed AOR 0.75 [0.64, 0.89]) than the TL patients. Furthermore, performing preimplantation genetic testing for aneuploidy (PGTA) in both patients with recurrent pregnancy loss or tubal ligation did not impact perinatal outcomes compared to patients who did not undergo PGTA., Conclusions: Patients with history of recurrent pregnancy loss do not have an increased risk of adverse perinatal outcomes when they undergo FET compared to patients without infertility or recurrent pregnancy loss. In addition, performing IVF/PGTA in patients with RPL does not adversely impact birth outcomes of their infants., (Copyright © 2024. Published by Elsevier Inc.)

Isomerization, the process by which a molecule is coherently transformed into another molecule with the same molecular formula but a different atomic structure, is an important and well-known phenomenon of organic chemistry, but has only recently been observed for inorganic nanoclusters. Previously, CdS nanoclusters were found to isomerize between two end point structures rapidly and reversibly (the α-phase and β-phase), mediated by hydroxyl groups on the surface. This observation raised many significant structural and pathway questions. One critical question is why no intermediate states were observed during the isomerization; it is not obvious why an atomic cluster should only have two stable end points rather than multiple intermediate arrangements. In this study, we report that the use of amide functional groups can stabilize intermediate phases during the transformation of CdS magic-size clusters between the α-phase and the β-phase. When treated with amides in organic solvents, the amides not only facilitate the α-phase to β-phase isomerization but also exhibit three distinct excitonic features, which we call the β 340 -phase, β 350 -phase, and β 367 -phase. Based on pair distribution function analysis, these intermediates strongly resemble the β-phase structure but deviate greatly from the α-phase structure. All phases (β 340 -phase, β 350 -phase, and β 367 -phase) have nearly identical structures to the β-phase, with the β 340 -phase having the largest deviation. Despite these intermediates having similar atomic structures, they have up to a 583 meV difference in band gap compared to the β-phase. Kinetic studies show that the isomers and intermediates follow a traditional progression in the thermodynamic stability of β 340 -phase/β 350 -phase < α-phase < β 367 -phase < β-phase. The solvent identity and polarity play a crucial role in kinetically arresting these intermediates. Fourier transform infrared spectroscopy and X-ray photoelectron spectroscopy studies paired with simple density functional theory calculations reveal that the likely mechanism is due to the multifunctional nature of the amides that form an amphoteric surface binding bond motif, which promotes a change in the carboxylic acid binding mode. This change from chelating binding modes to bridging binding modes initiates the isomerization. We propose that the carbonyl group is responsible for the direct interaction with the surface, acting as an L-type ligand which then pulls electron density away from the electron-poor nitrogen site, enabling them to interact with the carboxylate ligands and initiate the change in the binding mode. The isomerization of CdS nanoclusters continues to be a topic of interest, giving insight into fundamental nanoscale chemistry and physics.

Objective: Non-Hispanic Black (NHB) and Hispanic/Latino (Hispanic) patients wait longer in the emergency department (ED) to see practitioners when compared with non-Hispanic White (NHW) patients. We investigate factors contributing to longer wait times for NHB and Hispanic patients using a linear decomposition approach., Methods: This retrospective observational study included patients presenting to one tertiary hospital ED from 2019 to 2021. Median wait times among NHW, NHB, and Hispanic were calculated with multivariable linear regressions. The extent to which demographic, clinical, and hospital factors explained the differences in average wait time among the three groups were analyzed with Blinder‒Oaxaca post-linear decomposition model., Results: There were 310,253 total patients including 34.7% of NHW, 34.7% of NHB, and 30.6% of Hispanic patients. The median wait time in NHW was 9 min (interquartile range [IQR] 4‒47 min), in NHB was 13 min (IQR 4‒59 min), and in Hispanic was 19 min (IQR 5‒78 min, p  < 0.001). The top two contributors of average wait time difference were mode of arrival and triage acuity level. Post-linear decomposition analysis showed that 72.96% of the NHB‒NHW and 87.77% of the Hispanic‒NHW average wait time difference were explained by variables analyzed., Conclusion: Compared to NHW patients, NHB and Hispanic patients typically experience longer ED wait times, primarily influenced by their mode of arrival and triaged acuity levels. Despite these recognized factors, there remains 12%‒27% unexplained factors at work, such as social determinants of health (including implicit bias and systemic racism) and many other unmeasured confounders, yet to be discovered., (© 2024 The Author(s). Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Objective: To study the role of the mesothelial cells in early endometriosis lesion formation by assessing in vitro cell to cell communication and invasion of endometrial cells across a mesothelial cell monolayer, with both cell types derived from both endometriosis and control patients., Design: Laboratory based experimental study SETTING: University hospital and laboratory PATIENT(S): Consenting reproductive aged women who underwent laparoscopy for gynecologic reasons and were confirmed to either have endometriosis with pathology tissue diagnosis (n=8) or no endometriosis (n=8) at the time of surgery INTERVENTION: Primary stromal cells cultured from endometrial pipelle biopsies and primary mesothelial cells cultured from peritoneal explants were utilized in trans-mesothelial invasion assays and gap junction coupling assays., Main Outcome: Comparison of potential for lesion formation, using in vitro models, of both primary endometrial and mesothelial cells from endometriosis and control patients, establishing the former as the primary disease driver., Results: When comparing mesothelial cells from control patients to mesothelial cells from endometriosis patients, there was no significant difference in the amount of stromal cell invasion across either barrier. In contrast, when comparing stromal cell origin, the amount of invasion by endometriosis stromal cells was greater than control stromal cells regardless of whether the mesothelial cell monolayer was derived from disease or control patients. Additionally, primary mesothelial cells induced more gap junction coupling, a requirement for invasion, in stromal cells from endometriosis than control patients, again independent of mesothelial origin. The notable exception was mesothelial cells derived from endometriotic lesion affected areas that showed depressed ability to support invasion., Conclusions: While both endometrial and mesothelial cells need to function for establishment of endometriosis lesions, the endometrium seems to be the key player, serving as an ideal target for diagnostic strategies and therapeutic intervention. This notion is consistent with prior studies, however we are the first to directly test both primary mesothelial and endometrial cells from endometriosis and control patients to compare propensities for mesothelial invasion., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: To investigate the role of formal reproductive endocrinology and infertility (REI) consultation in fertility preservation counseling in a pediatric/adolescent oncology patient population. Methods: Retrospective chart review was performed at an academic adult hospital from 2021 to 2022. Pre- and postpubertal patients admitted to the pediatric/adolescent oncology service with cancer diagnoses and imminent gonadotoxic chemotherapy plans were included. Baseline characteristics were collected, including patient age, sex, race, language, insurance, and cancer diagnosis. Primary outcomes were formal REI consultation and fertility preservation election. Results: Nineteen of 58 eligible patients received a formal REI consultation. Patients were more likely to elect fertility preservation if they received a consult. Females were more likely to receive a consult than males and more likely to elect fertility preservation. Patients of age ≥16 years were more likely to receive consultation than younger patients. However, all patients of age <16 years who received a consult elected fertility preservation. There was no difference in consultation based on race, language, or insurance. Thirteen of 19 patients who received an REI consultation elected fertility preservation. Ten of 11 female elections were ovarian suppression, an unproven method of fertility preservation. The two male elections were semen cryopreservation. Conclusion: Underutilization of formal REI consults and a relative lack of proven fertility preservation elections may shed light on a need for increased fertility preservation awareness among young oncology patients and the providers who care for them. A streamlined process that automates formal REI consultation for all eligible patients may maximize the potential for comprehensive counseling and improve patient participation in fertility preservation.

Synthesis of high-entropy oxide (HEO) nanocrystals has focused on increasing the temperature in the entropy term ( T (Δ S )) to overcome the enthalpy term. However, these high temperatures lead to large, polydisperse nanocrystals. In this work, we leverage the low solubility product ( K sp ) of metal oxides and optimize the Lewis-acid-catalyzed esterification reaction for equal rate production of the cation monomers to synthesize HEO nanocrystals at low temperatures, producing the smallest (<4 nm) and most monodisperse (<15% size dispersity) HEOs to date. We apply these HEO nanocrystals as electrocatalysts, exhibiting promising activity toward the oxygen evolution reaction in alkaline media, with an overpotential of 345 mV at 10 mA/cm 2 .

Experimental evolution studies that feature selection on life-history characters are a proven approach for studying the evolution of aging and variation in rates of senescence. Recently, the incorporation of genomic and transcriptomic approaches into this framework has led to the identification of hundreds of genes associated with different aging patterns. However, our understanding of the specific molecular mechanisms underlying these aging patterns remains limited. Here, we incorporated extensive metabolomic profiling into this framework to generate mechanistic insights into aging patterns in Drosophila melanogaster . Specifically, we characterized metabolomic change over time associated with accelerated aging in populations of D. melanogaster under selection for early reproduction compared to their controls. Using this data we: i) evaluated the evolutionary repeatability across the metabolome; ii) evaluated the value of the metabolome as a predictor of "biological age" in this system; and iii) identified specific metabolic pathways associated with accelerated aging. Generally, our findings suggest that the metabolome is a reliable predictor of age and senescence in populations that share a recent evolutionary history. Metabolomic analysis revealed that generations of selection for early reproduction resulted in highly repeatable alterations to the metabolome. Specifically, changes in carbohydrate, amino acid, and TCA cycle-related metabolite abundances over time point to metabolic remodeling that favors rapid early reproduction with long-term consequences for carbohydrate and protein utilization.

Measuring the three-dimensional (3D) distribution of chemistry in nanoscale matter is a longstanding challenge for metrological science. The inelastic scattering events required for 3D chemical imaging are too rare, requiring high beam exposure that destroys the specimen before an experiment is completed. Even larger doses are required to achieve high resolution. Thus, chemical mapping in 3D has been unachievable except at lower resolution with the most radiation-hard materials. Here, high-resolution 3D chemical imaging is achieved near or below one-nanometer resolution in an Au-Fe 3 O 4 metamaterial within an organic ligand matrix, Co 3 O 4 -Mn 3 O 4 core-shell nanocrystals, and ZnS-Cu 0.64 S 0.36 nanomaterial using fused multi-modal electron tomography. Multi-modal data fusion enables high-resolution chemical tomography often with 99% less dose by linking information encoded within both elastic (HAADF) and inelastic (EDX/EELS) signals. We thus demonstrate that sub-nanometer 3D resolution of chemistry is measurable for a broad class of geometrically and compositionally complex materials., (© 2024. The Author(s).)

Controllable synthesis of homochiral nano/micromaterials has been a constant challenge for fabricating various stimuli-responsive chiral sensors. To provide an avenue to this goal, we report electrospinning as a simple and economical strategy to form continuous homochiral microfibers with strain-sensitive chiroptical properties. First, electrospun homochiral microfibers from self-assembled cadmium sulfide (CdS) quantum dot magic-sized clusters (MSCs) are produced. Highly sensitive and reversible strain sensors are then fabricated by embedding these chiroptically active fibers into elastomeric films. The chiroptical response on stretching is indicated quantitatively as reversible changes in magnitude, spectral position (wavelength), and sign in circular dichroism (CD) and linear dichroism (LD) signals and qualitatively as a prominent change in the birefringence features under cross-polarizers. The observed periodic twisted helical fibrils at the surface of fibers provide insights into the origin of the fibers' chirality. The measurable shifts in CD and LD are caused by elastic deformations of these helical fibrillar structures of the fiber. To elucidate the origin of these chiroptical properties, we used field emission-electron microscopy (FE-SEM), atomic force microscopy (AFM), synchrotron X-ray analysis, polarized optical microscopy, as well as measurements to isolate the true CD, and contributions from photoelastic modulators (PEM) and LD. Our findings thus offer a promising strategy to fabricate chiroptical strain-sensing devices with multiple measurables/observables using electric-field-assisted spinning of homochiral nano/microfibers.

Chiral materials with strong linear anisotropies are difficult to accurately characterize with circular dichroism (CD) because of artifactual contributions to their spectra from linear dichroism (LD) and birefringence (LB). Historically, researchers have used a second-order Taylor series expansion on the Mueller matrix to model the LDLB interaction effects on the spectra in conventional materials, but this approach may no longer be sufficient to account for the artifactual CD signals in emergent materials. In this work, we present an expression to model the measured CD using a third-order expansion, which introduces "pairwise interference" terms that, unlike the LDLB terms, cannot be averaged out of the signal. We find that the third-order pairwise interference terms can make noticeable contributions to the simulated CD spectra. Using numerical simulations of the measured CD across a broad range of linear and chiral anisotropy parameters, the LDLB interactions are most prominent in samples that have strong linear anisotropies (LD, LB) but negligible chiral anisotropies, where the measured CD strays from the chirality-induced CD by factors greater than 10 3 . Additionally, the pairwise interactions are most significant in systems with moderate-to-strong chiral and linear anisotropies, where the measured CD is inflated twofold, a figure that grows as linear anisotropies approach their maximum. In summary, media with moderate-to-strong linear anisotropy are in great danger of having their CD altered by these effects in subtle manners. This work highlights the significance of considering distortions in CD measurements through higher-order pairwise interference effects in highly anisotropic nanomaterials., (© 2023 Wiley Periodicals LLC.)

While certain ternary spinel oxides have been well-explored with colloidal nanochemistry, notably the ferrite spinel family, ternary manganese (Mn)-based spinel oxides have not been tamed. A key composition is cobalt (Co)-Mn oxide (CMO) spinel, Co x Mn 3- x O 4 , that, despite exemplary performance in multiple electrochemical applications, has few reports in the colloidal literature. Of these reports, most show aggregated and polydisperse products. Here, we describe a synthetic method for small, colloidally stable CMO spinel nanocrystals with tunable composition and low dispersity. By reacting 2+ metal-acetylacetonate (M(acac) 2 ) precursors in an amine solvent under an oxidizing environment, we developed a pathway that avoids the highly reducing conditions of typical colloidal synthesis reactions; these reducing conditions typically push the system toward a monoxide impurity phase. Through surface chemistry studies, we identify organic byproducts and their formation mechanism, enabling us to engineer the surface and obtain colloidally stable nanocrystals with low organic loading. We report a CMO/carbon composite with low organic contents that performs the oxygen reduction reaction (ORR) with a half-wave potential ( E 1/2 ) of 0.87 V vs RHE in 1.0 M potassium hydroxide at 1600 rpm, rivaling previous reports for the highest activity of this material in ORR electrocatalysis. We extend the general applicability of this procedure to other Mn-based spinel nanocrystals such as Zn-Mn-O, Fe-Mn-O, Ni-Mn-O, and Cu-Mn-O. Finally, we show the scalability of this method by producing inorganic nanocrystals at the gram scale.

Purpose of Review: Nontubal ectopic pregnancies appear to be increasing in prevalence. Increasingly, minimally invasive methods for management are being utilized. A current literature review and recommendations for management of nontubal ectopic pregnancy is presented in this review., Recent Findings: Nontubal ectopic pregnancies are less common than tubal ectopic pregnancies but present a unique and significant threat to patient's health and are optimally managed by specialists familiar with the condition. Early diagnosis, prompt treatment and close follow-up to resolution are critical. Recent publications focus on fertility-sparing and conservative management through the use of medications both systemic and local; as well as minimally invasive surgical techniques. The Society of Maternal Fetal Medicine recommends against expectant management of cesarean scar pregnancies; however, optimal treatment is unknown and this holds true for management of other nontubal ectopic pregnancies., Summary: Minimally invasive and fertility sparing management should be the mainstay in treatment of stable patients with nontubal ectopic pregnancy., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The thiospinel group of nickel cobalt sulfides (Ni x Co 3- x S 4 ) are promising materials for energy applications such as supercapacitors, fuel cells, and solar cells. Solution-processible nanoparticles of Ni x Co 3- x S 4 have advantages of low cost and fabrication of high-performance energy devices due to their high surface-to-volume ratio, which increases the electrochemically active surface area and shortens the ionic diffusion path. The current approaches to synthesize Ni x Co 3- x S 4 nanoparticles are often based on hydrothermal or solvothermal methods that are difficult to scale up safely and efficiently and that preclude monitoring the reaction through aliquots, making optimization of size and dispersity challenging, typically resulting in aggregated nanoparticles with polydisperse sizes. In this work, we report a scalable "heat-up" method to colloidally synthesize Ni x Co 3- x S 4 nanoparticles that are smaller than 15 nm in diameter with less than 15% in size dispersion, using two inexpensive, earth-abundant sulfur sources. Our method provides a reliable synthetic pathway to produce phase-pure, low-dispersity, gram-scale nanoparticles of ternary metal sulfides. This method enhances the current capabilities of Ni x Co 3- x S 4 nanoparticles to meet the performance demands to improve renewable energy technologies., Competing Interests: The authors declare no competing financial interest., (© 2023 The Authors. Published by American Chemical Society.)

Cation exchange is a versatile post-synthetic method to explore a wide range of nanoparticle compositions, phases, and morphologies. Recently, several studies have expanded the scope of cation exchange to magic-size clusters (MSCs). Mechanistic studies indicated that MSC cation exchange undergoes a two-stage reaction pathway instead of the continuous diffusion-controlled mechanism found in nanoparticle cation exchange reactions. The cation exchange intermediate, however, has not been well-identified despite it being the key to understanding the reaction mechanism. Only indirect evidence, such as exciton peak shifts and powder x-ray diffraction, has been used to indicate the formation of the cation exchange intermediate. In this paper, we investigate the unusual nature of cation exchange in nanoclusters using our previously reported CdS MSC. High-resolution mass spectra reveal two cation exchanged reaction intermediates [Ag2Cd32S33(L) and AgCd33S33(L), L: oleic acid] as well as the fully exchanged Ag2S cluster. Crystal and electronic structure characterizations also confirm the two-stage reaction mechanism. Additionally, we investigate the Cu/CdS MSC cation exchange reaction and find a similar two-stage reaction mechanism. Our study shows that the formation of dilutely exchanged intermediate clusters can be generally found in the first stage of the MSC cation exchange reaction. By exchanging different cations, these intermediate clusters can access varying properties compared to their unexchanged counterparts., (© 2023 Author(s). Published under an exclusive license by AIP Publishing.)

Chiroptically active, hierarchically structured materials are difficult to accurately characterize due to linear anisotropic contributions (i.e., linear dichroism (LD) and linear birefringence (LB)) and parasitic ellipticities that produce artifactual circular dichroism (CD) signals, in addition to chiral analyte contributions ranging from molecular-scale clusters to micron-sized assemblies. Recently, we have shown that CdS magic-sized clusters (MSC) can self-assemble into ordered films that have a hierarchical structure spanning seven orders of length-scale. These films have a strong CD response, but the chiral origins are obfuscated by the hierarchical architecture and LDLB contributions. Here, we derive and demonstrate a method for extracting the "pure" CD signal (CD generated by structural dissymmetry) from hierarchical MSC films and identified the chiral origin. The theory behind the method is derived using Mueller matrix and Stokes vector conventions and verified experimentally before being applied to hierarchical MSC and nanoparticle films with varying macroscopic orderings. Each film's extracted "true CD" shares a bisignate profile aligned with the exciton peak, indicating the assemblies adopt a chiral arrangement and form an exciton coupled system. Interestingly, the linearly aligned MSC film possesses one of the highest g -factors (0.05) among semiconducting nanostructures reported. Additionally, we find that films with similar electronic transition dipole alignment can possess greatly different g -factors, indicating chirality change rather than anisotropy is the cause of the difference in the CD signal. The difference in g -factor is controllable via film evaporation geometry. This study provides a simple means to measure "true" CD and presents an example of experimentally understanding chiroptic interactions in hierarchical nanostructures.

Objective: To study whether application of the new 2018 guidelines for the diagnosis of polycystic ovary syndrome (PCOS) would decrease the diagnosis of PCOS. Second, to compare the metabolic profiles of women included and excluded in this new definition., Design: Retrospective cross-sectional chart review., Setting: University-affiliated hospital system., Patients: Women, ages 12-50, with the International Classification of Diseases code "Polycystic Ovary Syndrome" in 2017., Interventions: Application of the new 2018 guidelines for the diagnosis of PCOS., Main Outcome Measures: The primary outcome was the retention of PCOS diagnosis after applying the new 2018 guidelines. Secondary outcomes included the comparison of metabolic risk factors. Analysis was performed using chi-square tests for categorical variables and unpaired t tests for continuous variables, with a P value of <.05 determined to be significant., Results: Of 258 women with PCOS based on Rotterdam criteria, only 195 (76%) met the criteria based on the new 2018 guidelines. Those women who only met Rotterdam criteria (n = 63) had significantly lower body mass index (32.7 vs. 35.8), lower total cholesterol levels (151 vs. 176 mg/dL), lower triglyceride levels (96 vs. 124 mg/dL), lower total (33.2 vs. 52.3 ng/dL) and free testosterone levels (4.7 vs. 8.3), lower antimüllerian hormone levels (3.1 vs. 7.7 ng/mL), and were more likely to be multiparous (50% vs. 29%) than women who met 2018 criteria., Conclusions: Increasing the minimum antral follicle count to ≥20 antral follicles significantly decreases the number of women with the diagnosis of PCOS. Furthermore, the women that meet the new criteria have more health risks for metabolic syndrome than those who only meet the Rotterdam criteria., (© 2022 The Authors.)

Purpose: Successful identification of transcriptomic biomarkers within human IVF embryos may enhance implantation prediction and provide insights not available through conventional embryo biopsy genomic analysis. We demonstrate proof-of-concept for a methodology to assess overall embryo gene expression using qPCR with blastocoel fluid-conditioned media by examining the comparative presence of apoptotic genes., Methods: Blastocoel fluid-conditioned media were collected from 19 embryos (11 euploid) following trophectoderm biopsy of day-5 ICSI-IVF blastocysts. Media were assessed for apoptotic gene expression via qPCR. Statistical analysis of gene expression was conducted via Wilcoxon Signed-Ranks test (overall expression), multivariate ANOVA (functional gene groups), and chi-square test of independence (gene level)., Results: A significantly higher overall apoptotic gene expression within euploid versus aneuploid embryos (p = 0.001) was observed. There was significantly (p = 0.045) higher expression of pro-apoptotic genes between implanted and not implanted embryos. Pro- vs. anti-apoptotic gene expression from all euploid embryos approached significance (p = 0.053). The ploidy status-based claim is further substantiated at the gene level with significantly higher expression of BBC3 (p = 0.012) and BCL2L13 (p = 0.003) in euploid embryos compared to aneuploid embryos., Conclusions: In this preliminary study, we demonstrate that (1) qualitative analysis of blastocoel fluid-conditioned media gene expression is possible, (2) global trends of expression are potentially related to clinical outcomes, and (3) gene-level expression trends exist and may be another viable metric for comparative expression between samples. The presence of statistical significance within analyses conducted with this sample size warrants a larger investigation of blastocoel fluid-conditioned media as an additional beneficial predictive tool for future IVF cases., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Spontaneous hierarchical self-organization of nanometre-scale subunits into higher-level complex structures is ubiquitous in nature. The creation of synthetic nanomaterials that mimic the self-organization of complex superstructures commonly seen in biomolecules has proved challenging due to the lack of biomolecule-like building blocks that feature versatile, programmable interactions to render structural complexity. In this study, highly aligned structures are obtained from an organic-inorganic mesophase composed of monodisperse Cd 37 S 18 magic-size cluster building blocks. Impressively, structural alignment spans over six orders of magnitude in length scale: nanoscale magic-size clusters arrange into a hexagonal geometry organized inside micrometre-sized filaments; self-assembly of these filaments leads to fibres that then organize into uniform arrays of centimetre-scale bands with well-defined surface periodicity. Enhanced patterning can be achieved by controlling processing conditions, resulting in bullseye and 'zigzag' stacking patterns with periodicity in two directions. Overall, we demonstrate that colloidal nanomaterials can exhibit a high level of self-organization behaviour at macroscopic-length scales., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Objective: To evaluate similarities and differences in clinical and laboratory practices among high-performing fertility clinics., Design: Cross-sectional questionnaire study of selected programs., Setting: Academic and private fertility practices performing in vitro fertilization (IVF)., Patient(s): Not applicable., Intervention(s): A comprehensive survey was conducted of 13 IVF programs performing at least 100 cycles a year and having high cumulative singleton delivery rates for 2 years., Main Outcome Measure(s): Clinical and laboratory IVF practices., Result(s): Although many areas of clinical practice varied among top programs, some commonalities were observed. All programs used a combination of follicle-stimulating hormone and luteinizing hormone for IVF stimulation, intramuscular progesterone in frozen embryo transfer cycles, ultrasound-guided embryo transfers, and a required semen analysis before starting the IVF cycle. Common laboratory practices included vitrification of embryos at the blastocyst stage, air quality control with positive air pressure and high-efficiency particulate air filtration, use of incubator gas filters, working on heated microscope stages, and incubating embryos in a low-oxygen environment, most often in benchtop incubators., Conclusion(s): Some areas of consistency in clinical and laboratory practices were noted among high-performing IVF programs that are likely contributing to their success. High-performing programs focused on singleton deliveries. As the field of IVF is rapidly evolving, it is imperative that we share best practices in an effort to improve outcomes from all clinics for the good of our patients., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Efforts to improve energy storage depend greatly on the development of efficient electrode materials. Recently, strain has been employed as an alternate approach to improve ion mobility. While lattice strain has been well-researched in catalytic applications, its effects on electrochemical energy storage are largely limited to computational studies due to complexities associated with strain control in nanomaterials as well as loss of strain due to the phase change of the active material during charging-discharging. In this work, we overcome these challenges and investigate the effects of strain on supercapacitor performance in Li-ion-based energy devices. We synthesize epitaxial Fe 3 O 4 @MnFe 2 O 4 (core@shell) nanoparticles with varying shell thickness to control the lattice strain. A narrow voltage window for electrochemical testing is used to limit the storage mechanism to lithiation-delithiation, preventing a phase change and maintaining structural strain. Cyclic voltammetry reveals a pseudocapacitive behavior and similar levels of surface charge storage in both strained- and unstrained-MnFe 2 O 4 samples; however, diffusive charge storage in the strained sample is twice as high as the unstrained sample. The strained-MnFe 2 O 4 electrode exceeds the performance of the unstrained-MnFe 2 O 4 electrode in energy density by ∼33%, power density by ∼28%, and specific capacitance by ∼48%. Density functional theory shows lower formation energies for Li-intercalation and lower activation barrier for Li-diffusion in strained-MnFe 2 O 4 , corresponding to a threefold increase in the diffusion coefficient. The enhanced Li-ion diffusion rate in the strained-electrodes is further confirmed using the galvanostatic intermittent titration technique. This work provides a starting point to using strain engineering as a novel approach for designing high performance energy storage devices.

BiAgX ® , a mixed solder powder paste composed of a primary high-melting solder powder and an additive low-melting solder powder, exhibited a melting temperature above 260 °C and was comparable to, or even better than, the reliability of high-lead solders. The additive solder is designed to react preferentially with various surface metallizations and form a controllable intermetallic layer. Inside the joints, sub-micron AgSn particles are dispersed surrounding Bi colonies, which constrain the dislocation movement, thus enhancing strength, ductility, and associated joint reliability.

Chlamydia trachomatis (C. trachomatis) is a major pathogen implicated in the formation of hydrosalpinx in the female reproductive tract. In mice, a related strain of Chlamydia, Chlamydia trachomatis (C. trachomatis) can induce almost 100% bilateral hydrosalpinx. This model was used as a hydrosalpinx induction model to test whether oviduct delivery of platelet-rich plasma (PRP) can attenuate chlamydia induction of hydrosalpinx in a mouse model. Mice were infected intravaginally with Chlamydia muridarum organisms, and 21 days after the infection, PRP was instilled into the lumen of one oviduct, and a sham instillation with phosphate buffer solution was performed on the contralateral oviduct. Mice were then sacrificed at designated time points after infection for oviduct pathologic evaluation including incidence, severity, and histopathologic grade of chronic inflammation. Oviduct instillation of PRP was associated with a 36% reduction in the incidence of hydrosalpinx and a 33% reduction in severity compared with sham. The median grade of chronic inflammation on histopathology was significantly lower with PRP instillation compared with sham and control. No differences were observed in vaginal or rectal shedding of C. muridarum between the test group and the control group. In short, the results suggest that oviduct instillation of PRP can significantly reduce the incidence and severity of C. muridarum-induced hydrosalpinx without affecting chlamydial infection courses in CBA/J mice.

Objective: Burnout is a common occurrence among healthcare providers and has been associated with provider wellness culture. However, this association has not been extensively studied among emergency medicine (EM) providers. We aim to determine the association between EM provider burnout and their culture of wellness, and to elicit the independent wellness culture domains most predictive of burnout prevention., Methods: This was a multi-center observational study. We enrolled EM physicians and advanced practice providers from sixteen different emergency departments (EDs). Provider wellness culture and burnout surveys were performed. The wellness culture domains included in this study are personal/organizational value alignment, provider appreciation, leadership quality, self-controlled scheduling, peer support, and family support. Correlations between each wellness culture domain and burnout were analyzed by Pearson correlation co-efficiency, and their associations were measured by multivariate logistic regression with adjustments of other confounders., Results: A total of 242 ED provider surveys were entered for final analysis. The overall burnout rate was 54% (130/242). Moderate correlations were found between burnout and two wellness culture domains (value alignment: r=-0.43, P<0.001 and provider appreciation: r=-0.49, P<0.001). The adjusted odds ratio of provider appreciation associated with burnout was 0.44 (95% confidence interval, 0.25-0.77; P=0.004), adjusted odds ratio of family support was 0.67 (95% confidence interval, 0.48-0.95; P=0.025)., Conclusion: ED providers have a relatively high burnout rate. Provider burnout might have certain associations with wellness culture domains. Provider appreciation and family support seem to play important roles in burnout protection.

ConspectusChemically induced transformations are postsynthetic processing reactions applied to first generation (as-synthesized) nanomaterials to modify property-defining factors such as atomic structure, chemical composition, surface chemistry, and/or morphology. Compared with conditions for direct synthesis of colloidal nanocrystals, postsynthetic chemical transformations can be conducted in relatively mild conditions with a more controllable process, which makes them suitable for the precise manipulation of nanomaterials and for trapping metastable phases that are typically inaccessible from the conventional synthetic routes. Each of the chemically induced transformations methods can result in substantial restructuring of the atomic structure, but their transformation pathways can be very different. And the converse is also true: the atomic structure of the parent material plays a large role in the pathway toward and the resulting chemically transformed product. Additionally, the characteristic length of the parent material greatly affects the structure, which affects the outcome of the reaction.In this Account, we show how the atomic structure and nanoscale size directs the product formation into materials that are inaccessible from analogous chemically transformations in bulk materials. Through examples from the three chemical transformation processes (cation/anion exchange, redox reactions, and ligand exchange and ligand etching), the effect of the atomic structure on chemical transformations is made apparent, and vice versa. For cation exchange, an anisotropic atomic lattice results in a unidirectional exchange boundary. And because the interface can extend through the full crystal, a substantial strain field can form, influencing the phase of the material. In the redox reaction that leads to the nanoscale Kirkendall effect, the atomic structure is the key to inverting the diffusion rates in a diffusion couple to form the hollow cores. And for ligand etching, if one of the materials in a heterostructure has a defected and\or defect-tolerant atomic structure, it can be preferentially etched and its atomic structure can undergo phase transformations while the other composition remains intact. For length scales, we show how the chemically induced transformations greatly differ between bulk, nanocrystal, and nanocluster characteristic sizes. For instance, the structural transformation on relatively large nanocrystals (2-100 nm) can be a continuous process when the activation volume is smaller than the nanocrystal, while for smaller nanoclusters (<2 nm) the transformation kinetics could be swift resulting in only discrete thermodynamic states. Comparing the two nanosystems (nanocrystals to small nanoclusters), we address how their atomic structural differences can direct the divergent transformation phenomena and the corresponding mechanisms. Understanding the nanoscale mechanisms of chemically induced transformations and how they differ from bulk processes is key to unlocking new science and for implementing this processing for functional materials.

Objective: To study the association of endometrial thickness (EMT) with live birth rates (LBR) in ovarian stimulation with intrauterine insemination (OS-IUI) treatments for unexplained infertility., Design: Prospective cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial., Setting: Multicenter randomized controlled trial., Patients: A total of 868 couples with unexplained infertility (n=2,459 cycles)., Interventions: OS-IUI treatment cycles (n = 2,459) as part of the AMIGOS clinical trial., Main Outcome Measures: Live birth rates; unadjusted and adjusted risk ratios (RR) for live birth by EMT category, calculated using generalized estimating equations., Results: The overall mean EMT on day of human chorionic gonadotropin administration in cycles with a live birth was significantly greater than in those without. Compared to the referent EMT group of 9 to 12 mm, the unadjusted RR for live birth for the EMT groups of ≤5 and 6-8 were 0.48 and 0.92, respectively. The test for trend indicated evidence of decreasing LBR with decreasing EMT. After adjustment for ovarian stimulation medication, a linear trend was no longer supported. Stratified analyses revealed no differences in associations by treatment group., Conclusions: In OS-IUI for unexplained infertility, higher LBR are observed with increasing EMT; however, EMT is not significantly associated with LBR when adjusted for OS treatment type. Appreciable LBR are seen at all EMT, even those of ≤5 mm, suggesting that OS-IUI cycles should not be canceled for thin endometrium., Clinical Trial Registration Number: NCT01044862., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

The small-polaron hopping model has been used for six decades to rationalize electronic charge transport in oxides. The model was developed for binary oxides, and, despite its significance, its accuracy has not been rigorously tested for higher-order oxides. Here, the small-polaron transport model is tested by using a spinel system with mixed cation oxidation states (Mn x Fe 3- x O 4 ). Using molecular-beam epitaxy (MBE), a series of single crystal Mn x Fe 3- x O 4 thin films with controlled stoichiometry, 0 ≤ x ≤ 2.3, and lattice strain are grown, and the cation site-occupation is determined through X-ray emission spectroscopy (XES). Density functional theory + U analysis shows that charge transport occurs only between like-cations (Fe/Fe or Mn/Mn). The site-occupation data and percolation models show that there are limited stoichiometric ranges for transport along Fe and Mn pathways. Furthermore, due to asymmetric hopping barriers and formation energies, the Mn O h 2 + polaron is energetically preferred to the Fe O h 2 + polaron, resulting in an asymmetric contribution of Mn/Mn pathways. All of these findings are not contained in the conventional small-polaron hopping model, highlighting its inadequacy. To correct the model, new parameters in the nearest-neighbor hopping equation are introduced to account for percolation, cross-hopping, and polaron-distribution, and it is found that a near-perfect correlation can be made between experiment and theory for the electronic conductivity., (© 2020 Wiley-VCH GmbH.)

Self-assembly of three-dimensional structures with order across multiple length scales-hierarchical assembly-is of great importance for biomolecules for the functions of life. Creation of similar complex architectures from inorganic building blocks has been pursued toward artificial biomaterials and advanced functional materials. Current research, however, primarily employs only large, nonreactive building blocks such as Au colloids. By contrast, sulfur-bridged transition metal clusters (<2 nm) are able to offer more functionality in catalytic and biochemical reactions. Hierarchical assembly of these systems has not been well researched because of the difficulty in obtaining single-phase clusters and the lack of suitable ligands to direct structure construction. To overcome these challenges, we employ a rigid planar ligand with an aromatic ring and bifunctional bond sites. We demonstrate the synthesis and assembly of 1.2 nm sulfur-bridged copper (SB-Cu) clusters with tertiary hierarchical complexity. The primary structure is clockwise/counterclockwise chiral cap and core molecules. They combine to form clusters, and due to the cap-core interaction (C-H···π), only two enantiomeric isomers are formed (secondary structure). A tertiary hierarchical architecture is achieved through the self-assembly of alternating enantiomers with hydrogen bonds as the intermolecular driving force. The SB-Cu clusters are air stable and have a distribution of oxidation states ranging from Cu(0) to Cu(I), making them interesting for redox and catalytic activities. This study shows that structural complexity at different length scales, mimicking biomolecules, can occur in active-metal clusters and provides a new platform for investigation of those systems and for the design of advanced functional materials.

Background: An obesity survival paradox has been reported among obese patients with pneumonia., Aims: To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia., Methods: The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis., Results: A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07)., Conclusions: With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia., (Copyright © 2020. Published by Elsevier Ltd.)

Study Question: Are intrauterine insemination (IUI) performance characteristics and post-processing total motile sperm count (TMC) related to live birth rate in couples with unexplained infertility?, Summary Answer: Patient discomfort with IUI and lower inseminate TMC were associated with a reduced live birth rate, while time from hCG injection to IUI, sperm preparation method and ultrasound guidance for IUI were not associated with live birth success., What Is Already Known: We previously determined that some baseline characteristics of couples with unexplained infertility, including female age, duration of infertility, history of prior loss and income, were related to live birth rate across a course of ovarian stimulation and IUI treatment. However, the relationship between treatment outcomes and per-cycle characteristics, including ultrasound guidance for IUI, timing of IUI relative to hCG injection, difficult or painful IUI and inseminate TMC, are controversial, and most prior investigations have not evaluated live birth outcome., Study Design, Size, Duration: This was a secondary analyses of 2462 cycles from the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial. This prospective, randomised, multicentre clinical trial determined live birth rates following IUI after ovarian stimulation with clomiphene citrate, letrozole or gonadotropins in 854 couples with unexplained infertility. It was conducted between 2011 and 2014, and couples could undergo up to four consecutive treatment cycles., Participants/materials, Setting, Methods: AMIGOS was an NIH-sponsored Reproductive Medicine Network trial conducted at 12 clinical sites. Participants were women with unexplained infertility who were between 18 and 40 years of age. Cluster-weighted generalised estimating equations (GEE), which account for informative clustering of multiple IUI treatment cycles within the same patient, were used to determine associations between IUI performance characteristics, including inseminate TMC, and live birth rate. Efficiency curves were also generated to examine the relationship between inseminate TMC and live birth rate., Main Results and the Role of Chance: After adjustment for treatment group and baseline factors previously associated with live birth across a course of OS-IUI treatment, patient discomfort during the IUI procedure was associated with a reduction in live birth rate (aRR 0.40 (0.16-0.96)). Time from hCG trigger injection to IUI was not significantly associated with outcome. Higher TMC was associated with greater live birth rate (TMC 15.1-20.0 million (14.8%) compared to ≤5 million (5.5%)) (aRR 2.09 (1.31-3.33)). However, live births did occur with TMC ≤ 1 million (5.1%)., Limitations, Reasons for Caution: This investigation is a secondary analysis, and AMIGOS was not designed to address the present question. Since timed intercourse was allowed as part of the AMIGOS trial, we cannot rule out the possibility that any given pregnancy resulted from intercourse rather than IUI., Wider Implications of the Findings: Most factors associated with the performance of IUI were not significantly related to obtaining live birth. Our findings suggest that higher TMC inseminated leads to an increase in live birth rate up to TMC ~20 million. However, there may be no reasonable threshold below which live birth is not possible with IUI., Study Funding/competing Interest(s): Funding was received through grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): U10 HD077680, U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936 and U10 HD055925. This research was made possible by funding by the American Recovery and Reinvestment Act. Dr Hansen reports grants from NIH/NICHD and Yale University during the conduct of the study, grants from Roche Diagnostics and grants from Ferring International Pharmascience Center US outside the submitted work. Dr Peck reports support from Ferring Pharmaceuticals outside the submitted work. Dr Coward has nothing to disclose. Dr Wild reports grants from NICHD during the conduct of the study. Dr Trussell has nothing to disclose. Dr Krawetz reports grants from NICHD during the conduct of the study, grants from Merck and support from Taylor and Frances and from Springer, outside the submitted work. Dr Diamond reports grants from NIH/NICHD, Yale University, during the conduct of the study and support from Advanced Reproductive Care AbbVie, Bayer and ObsEva, outside the submitted work. Dr Legro reports support from Bayer, Kindex, Odega, Millendo and AbbVie and grants and support from Ferring, outside the submitted work. Dr Coutifaris reports grants from NICHD/NIH and personal fees from American Society for Reproductive Medicine, outside the submitted work. Dr Alvero has nothing to disclose. Dr Robinson reports grants from NIH during the conduct of the study. Dr Casson has nothing to disclose. Dr Christman reports grants from NICHD during the conduct of the study. Dr Santoro reports grants from NIH during the conduct of the study. Dr Zhang reports grants from NIH during the conduct of the study and support from Shangdong University outside the submitted work., Trial Registration Number: n/a., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To determine whether biochemical or clinical markers of androgenic activity predict live birth rate with ovarian stimulation in the unexplained infertility population., Design: Secondary analysis of the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial., Setting: Multicenter university-based clinical practices., Patient(s): Nine hundred couples with unexplained infertility were included. Women were 18-40 years old with regular menses, a normal uterine cavity, at least one patent fallopian tube, and a male partner with ≥5 million motile sperm. Women were randomized to receive gonadotropin, clomiphene, or letrozole with IUI for four or fewer four treatment cycles. Women were evaluated for biochemical (total testosterone, DHEAS, and free androgen index) and clinical markers of androgenic activity (sebum, acne, and hirsutism). Multivariable logistic regression models adjusting for treatment group, maternal age, and body mass index were performed., Intervention(s): None., Main Outcome Measure(s): The primary outcome was live birth. Secondary outcomes included conception, clinical pregnancy, and pregnancy loss., Result(s): When comparing 900 women in the AMIGOS trial based on quartiles of serum TT, women were of younger age, higher body mass index, and higher waist circumference with increasing TT. Increasing quartiles of TT also showed increasing DHEAS and free androgen index values. Serum androgens were not associated with outcomes of live birth, conception, clinical pregnancy, or pregnancy loss. Clinical androgen markers were not associated with pregnancy outcomes., Conclusion(s): In a randomized cohort of women with unexplained infertility, biochemical and clinical measures of androgens did not predict live birth rate after ovarian stimulation treatment., Clinical Trial Registration Number: NCT 01044862., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background and Objective: Attending physician productivity and efficiency can be affected when working simultaneously with Residents. To gain a better understanding of this effect, we aim to compare productivity, efficiency, and overall performance differences among Attendings working solo versus working with Residents in an Emergency Department (ED)., Methods: Data were extracted from the electronic medical records of all patients seen by ED Attendings and/or Residents during the period July 1, 2014 through June 30, 2017. Attending productivity was measured based on the number of new patients enrolled per hour per provider. Attending efficiency was measured based on the provider-to-disposition time (PDT). Attending overall performance was measured by Attending Performance Index (API). Furthermore, Attending productivity, efficiency, and overall performance metrics were compared between Attendings working solo and Attendings working with Residents. The comparisons were analyzed after adjusting for confounders via propensity score matching., Results: A total of 15 Attendings and 266 Residents managing 111,145 patient encounters over the study period were analyzed. The mean (standard deviation) of Attending productivity and efficiency were 2.9 (1.6) new patients per hour and 2.7 (1.8) hours per patient for Attendings working solo, in comparison to 3.3 (1.9) and 3.0 (2.0) for Attendings working with Residents. When paired with Residents, the API decreased for those Attendings who had a higher API when working solo (average API dropped from 0.21 to 0.19), whereas API increased for those who had a lower API when working solo (average API increased from 0.13 to 0.16)., Conclusion: In comparison to the Attending working solo staffing model, increased productivity with decreased efficiency occurred among Attendings when working with Residents. The overall performance of Attendings when working with Residents varied inversely against their performance when working solo., Competing Interests: The authors have declared that no competing interests exist.

Context: The relationship between reproductive and cardiometabolic aging is unclear. It is unknown if the relationship differs across different clinical populations., Objective: To determine whether markers of ovarian reserve are associated with cardiometabolic risk in reproductive aged women with unexplained infertility (UI), polycystic ovary syndrome (PCOS), and regularly cycling women (OVA)., Design and Setting: Cross-sectional data from 8 US-based academic centers., Participants: Women aged 25-40 from 3 clinical populations: 870 with UI, 640 with PCOS, and 921 community-based OVA., Main Outcome Measures: Multivariable linear regression models were used to relate anti-mullerian hormone (AMH) and antral follicle count with cardiometabolic parameters including body mass index (BMI), waist circumference (WC), fasting glucose and insulin, homeostasis model assessment-insulin resistance (HOMA-IR), lipids, and C-reactive protein., Results: In age and study site-adjusted models, AMH inversely related to BMI in the UI and OVA groups (P = 0.02 and P < 0.001). Among women with PCOS, AMH inversely related to BMI (P < 0.001), and also to WC (P < 0.001), fasting insulin (P < 0.01), HOMA-IR (P < 0.01), triglycerides (P = 0.04), and C-reactive protein (P < 0.001) and directly related to higher total (P = 0.02), low-density lipoprotein (P < 0.01), and high-density lipoprotein cholesterol (P < 0.01). In OVA, AMH also varied inversely with WC (P < 0.001), fasting insulin (P = 0.02), and HOMA-IR (P = 0.02). Adjustment for BMI eliminated associations in the OVA group but in PCOS, the relationship of AMH to total (P = 0.03) and low-density lipoprotein cholesterol (P = 0.003) remained., Conclusion: Associations observed between AMH and cardiometabolic indices are largely explained by BMI in women with and without PCOS. (J Clin Endocrinol Metab XX: 0-0, 2019)., (© Endocrine Society 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To assess the effect of assisted hatching (AH) on live birth rate (LBR) in first cycle, fresh in vitro fertilization (IVF) in good and poor prognosis patients., Methods: Retrospective cohort using cycles reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System. Live birth rate was compared in women who underwent first cycle, autologous, fresh IVF cycles with (n = 48,858) and without (n = 103,413) AH from 2007 to 2015., Results: The propensity-weighted LBR was 39.2% with AH versus 43.9% without AH in all patients. The rate difference (RD) with AH was - 4.7% ([CI - 0.053, - 0.040], P < 0.001) with the calculated number needed to harm being 22. AH affected live birth in both good prognosis and poor prognosis patients. The propensity-weighted monozygotic twinning (MZT) rate was 2.3% in patients treated with AH as compared to 1.2% patients that did not receive AH. The RD with AH on MZT in fresh, first IVF cycles was 1.1% ([0.008, 0.014], P < 0.001)., Conclusion: AH may affect LBR across all patients and in poor prognosis patients in fresh IVF cycles. Caution should be exercised when applying this technology. More prospective research is needed.

Background: An obesity survival paradox has been reported among obese patients with pneumonia., Aims: To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia., Methods: The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis., Results: A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07)., Conclusions: With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia., (Copyright © 2019 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.)

Study Objective: The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post-ED-discharge patient follow-up intervals., Methods: We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated., Results: There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non-low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%)., Conclusion: In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high., (Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Purpose: We sought to determine whether lower fertility related quality of life or depression in men of couples with unexplained infertility is associated with low total testosterone levels, abnormal semen quality or erectile dysfunction., Materials and Methods: This study is a secondary analysis of a large, multicenter, randomized controlled trial in couples with unexplained infertility. Male partners underwent baseline semen analysis with measurement of fasting total testosterone and gonadotropin. They also completed surveys, including the FertiQOL (Fertility Quality of Life), the PHQ-9 (Patient Health Questionnaire-9) and the IIEF (International Index of Erectile Function). The primary study outcomes were total testosterone with low total testosterone defined as less than 264 ng/dl, semen parameters and the IIEF score. We performed multivariable logistic regression analyses adjusted for patient age, race, body mass index, education, smoking, alcohol use, infertility duration and comorbidity., Results: A total of 708 men with a mean ± SD age of 34.2 ± 5.6 were included in study. Of the men 59 (8.3%) had a PHQ-9 score of 5 or greater, which was consistent with depression, 99 (14.0%) had low total testosterone and 63 (9.0%) had mild or worse erectile dysfunction. Neither the FertiQOL score nor depression was associated with total testosterone or any semen parameter. The FertiQOL score was inversely associated with erectile dysfunction (for every 5-point score decline AOR 1.30, 95% CI 1.16-1.46). Depressed men were significantly more likely to have erectile dysfunction than nondepressed men (AOR 6.31, 95% CI 3.12-12.77)., Conclusions: In men in couples with unexplained infertility lower fertility related quality of life and depression are strongly associated with erectile dysfunction. However, neither is associated with spermatogenesis or testosterone levels. Erectile dysfunction in infertile men merits longitudinal investigation in future studies.

Background: It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients., Methods: This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions., Result: A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001)., Conclusions: Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations.

Objectives: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models., Design, Setting and Participants: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days., Methods: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models., Results: A total of 227 627 patients were included. The S creening for H ealthcare f O llow- U p T ool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80)., Conclusion: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD., Methods: We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders., Results: A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits., Conclusion: Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.