Delivering bad or difficult news. An innovative simulation-based education approach to prepare interdisciplinary fellowships.

BACKGROUND: There is limited data on the effectiveness of training interventions to improve the delivery of bad news. METHODS: This preliminary research included pre-post assessments and an open-ended survey to evaluate the effectiveness and perceived value of training on delivering bad news for 26 first- and second-year fellows from five adult and pediatric fellowship programs. RESULTS: There was a significant increase in faculty assessment scores (34.5 vs. 41.0, respectively, Z = -3.661, p < 0.001) and Standardized Patient (SP) assessment scores (37.5 vs .44.5, respectively, Z = -2.244, p = 0.025). Fellows valued having a standard framework to aid in the delivery of bad news; receiving targeted feedback and having the opportunity to apply their skills in a subsequent case. CONCLUSIONS: A one-hour, four-phase lesson plan that includes an individualized training approach and simulation do-overs can be effective and valuable for preparing fellows to deliver bad news.

Tricuspid Stenosis in Pregnancy: A Valve-in-Valve Conundrum.

Redo tricuspid valve replacement has high surgical operative mortality. Transcatheter valve-in-valve provides a viable option for valve replacement. We discuss the decision-making process involved in performing transcatheter tricuspid valve-in-valve replacement in a 23-week pregnant woman with multiple comorbidities and symptomatic severe bioprosthetic stenosis. (Level of Difficulty: Intermediate.).

A comparison of Doppler waveform parameters versus flow-mediated vascular dilation of the brachial artery in pregnant women.

OBJECTIVE: Flow mediated dilation of the brachial artery is impaired with endothelial dysfunction. We previously identified that brachial artery waveforms were changed in preeclamptic women. We therefore sought to compare Doppler waveform analysis with flow mediated vascular dilation (FMVD) measurements in pregnant women. STUDY DESIGN: A cross sectional study of 71 pregnant women at >20weeks gestation comparing FMVD measurements with Doppler waveform parameters was performed. Research was conducted at three hospitals and two geographic settings; (1) Yale-New Haven Hospital in New Haven, CT, (2) Mount Hope Maternity and (3) Port of Spain General Hospital in Trinidad. Brachial artery Doppler waveform measurements were done at baseline and 90s post cuff-release. From the Doppler waveforms we assessed percent change in Peak Systolic Velocity (% ΔPSV), systolic acceleration, acceleration time and pulsatility index and compared them with the percent change in FMVD. Statistical analysis using Student's t tests and correlation coefficient was done as necessary. RESULTS: Correlation analysis between the % change in the Doppler waveform parameters and the % change in mean FMVD identified only the waveform parameter of % ΔPSV as significantly correlated (p=0.040). CONCLUSION: FMVD remains the gold standard for assessment of endothelial dysfunction. A correlation was observed between the Doppler measured % ΔPSV and FMVD, which may allow it to be used to assess endothelial dysfunction changes under different conditions was identified.

Improving antenatal prediction of small-for-gestational-age neonates by using customized versus population-based reference standards.

OBJECTIVES: The purpose of this study was to evaluate whether the use of customized fetal reference standards improves the prenatal detection of intrauterine growth restriction. METHODS: We conducted a retrospective cohort study. Singleton pregnancies with a diagnosis of a small-for-gestational-age (SGA) fetus based on the in utero reference standard of Hadlock et al (Am J Obstet Gynecol 1985; 151:333-337; Radiology 1991; 181:129-133) were identified from our ultrasound database, and customized percentiles were calculated by adjusting for maternal height, weight, ethnicity, parity, and sex. RESULTS: A total of 300 pregnancies were identified as SGA by both the Hadlock and customized standards, and 60 were identified as SGA by the Hadlock standard only. Small-for-gestational age pregnancies identified by the Hadlock standard only were significantly less likely to have any abnormal sonographic findings, including an elevated head to abdominal circumference ratio (8.3% versus 21.7%; P = .019), oligohydramnios (3.3% versus 13%; P = .027), abnormal umbilical artery Doppler findings (3.4% versus 14.7%; P = .017), maternal hypertensive disease (3.3% versus 12.7%; P = .041), and preterm delivery (6.7% versus 27.7%; P < .001). There was no difference in neonatal intensive care unit admission rates; however, neonates identified as SGA by the Hadlock standard only were less likely to have a postnatal diagnosis of SGA (9.1% versus 78.3%; P < .001) and had a shorter neonatal intensive care unit stay (median, 2 versus 8 days; P < .001). CONCLUSIONS: Using a customized standard, we have identified a population of pregnancies with low rates of antenatal complications and sonographic findings associated with pathologic growth. Adoption of customized standards to improve our antenatal detection rate of intrauterine growth restriction may decrease the need for intervention in healthy but constitutionally small fetuses.

Karyotype of miscarriages in relation to maternal weight.

BACKGROUND: Obesity has been identified as a risk factor for spontaneous miscarriage although the mechanism is unclear. The purpose of this study is to better understand the effect of obesity on early pregnancy success by examining the cytogenetic results of miscarriages in women with normal and elevated body mass index (BMI). METHODS: We conducted a retrospective case-control study in an academic infertility practice. Medical records of women ages <40 years with first trimester missed abortion (n = 204), who underwent dilatation and curettage between 1999 and 2008, were reviewed for demographics, BMI, diagnosis of polycystic ovary syndrome (PCOS) and karyotype analysis. chi(2) and Student's t-test analysis were used for statistical analysis, with P < 0.05 considered significant. RESULTS: A total of 204 miscarriages were included, from women with a mean age of 34.5 years. The overall rate of aneuploidy was 59%. Women with BMI > or = 25 kg/m(2) had a significant increase in euploid miscarriages compared with women with lower BMI (P = 0.04), despite a similar mean age (34.4 years for both). CONCLUSIONS: We found a significant increase in normal embryonic karyotypes in the miscarriages of overweight and obese women (BMI > or = 25). These results suggest that the excess risk of miscarriages in the overweight and obese population is independent of embryonic aneuploidy. Further studies are needed to assess the impact of lifestyle modification, insulin resistance and PCOS on pregnancy outcomes in the overweight and obese population.

Identification of a candidate regulatory region in the human CD8 gene complex by colocalization of DNase I hypersensitive sites and matrix attachment regions which bind SATB1 and GATA-3.

To locate elements regulating the human CD8 gene complex, we mapped nuclear matrix attachment regions (MARs) and DNase I hypersensitive (HS) sites over a 100-kb region that included the CD8B gene, the intergenic region, and the CD8A gene. MARs facilitate long-range chromatin remodeling required for enhancer activity and have been found closely linked to several lymphoid enhancers. Within the human CD8 gene complex, we identified six DNase HS clusters, four strong MARs, and several weaker MARs. Three of the strong MARs were closely linked to two tissue-specific DNase HS clusters (III and IV) at the 3' end of the CD8B gene. To further establish the importance of this region, we obtained 19 kb of sequence and screened for potential binding sites for the MAR-binding protein, SATB1, and for GATA-3, both of which are critical for T cell development. By gel shift analysis we identified two strong SATB1 binding sites, located 4.5 kb apart, in strong MARs. We also detected strong GATA-3 binding to an oligonucleotide containing two GATA-3 motifs located at an HS site in cluster IV. This clustering of DNase HS sites and MARs capable of binding SATB1 and GATA-3 at the 3' end of the CD8B gene suggests that this region is an epigenetic regulator of CD8 expression.