Placental site nodules and reproductive outcomes: a clinicopathologic case series.

BACKGROUND: Placental site nodules (PSNs) are benign tumor-like growths that develop from chorionic-type intermediate trophoblastic cells. Their clinical significance is unknown. This study aims to determine the risk factors associated with PSNs, with focus on possible reproductive impact. METHODS: We performed a retrospective case series of all patients with a pathology diagnosis of PSN in a large urban hospital system from 2018 to 2022. We collected clinical variables such as pathology diagnosis/description, presenting symptoms, method of prior delivery, and prior history of infertility, pregnancy loss, and uterine instrumentation. RESULTS: A total of 32 patients were included in this case series. The most common presenting symptom was abnormal uterine bleeding (40.6%, 13/32). Recurrent pregnancy loss (RPL) (15.6%, 5/32) and infertility (15.6%, 5/32) were common presenting symptoms as well. 62.5% (20/32) patients had a history of prior uterine instrumentation. Coexisting chronic endometritis was identified in 9.4% (3/32) of cases. Of the 5 RPL/infertility patients who underwent hysteroscopic resection of a PSN, 1 achieved a live birth. CONCLUSION: PSNs may be associated with abnormal uterine bleeding, recurrent pregnancy loss, infertility, history of prior uterine instrumentation, and chronic endometritis. Although a rare diagnosis, the presence of a PSN should be considered in patients presenting for infertility or recurrent pregnancy loss workup.

Higher live birth rates are associated with a normal body mass index in preimplantation genetic testing for aneuploidy frozen embryo transfer cycles: a Society for Assisted Reproductive Technology Clinic Outcome Reporting System study.

OBJECTIVE: To determine whether body mass index (BMI) was associated with live birth in patients undergoing transfer of frozen-thawed preimplantation genetic testing for aneuploidy (PGT-A) embryos. DESIGN: Retrospective cohort study of cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System. SUBJECTS: All autologous and donor recipient PGT-A-tested cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System from 2014 to 2017. INTERVENTION(S): Body mass index. MAIN OUTCOME MEASURE(S): The primary outcome measure was the live birth rate, and the secondary outcome measures were the clinical pregnancy and biochemical pregnancy rates. Multivariable generalized additive mixed models and log-binomial models were used to model the relationship between BMI and outcome measures. RESULT(S): A total of 77,018 PGT-A cycles from 55,888 patients were analyzed. Of these cycles, 70,752 were autologous, and 6,266 were donor recipient. In autologous cycles, a statistically significant and clear nonlinear relationship was observed between the BMI and live birth rates, with the highest birth rates observed for the BMI range of 23-24.99 kg/m2. When using 23-24.99 kg/m2 as the referent, other BMI ranges demonstrated a lower probability of live birth and clinical pregnancy that continued to decrease as the BMI moved further from the reference value. Patients with a BMI of <18.5 kg/m2 had a 11% lower probability of live birth, whereas those with a BMI of ≥40 kg/m2 had a 27% lower probability than the referent. CONCLUSION(S): A normal-weight BMI range of 23-24.99 kg/m2 was associated with the highest probability of clinical pregnancy and live birth after a frozen-thawed PGT-A-tested blastocyst transfer in both autologous and donor recipient cycles. A BMI outside the range of 23-24.99 kg/m2 is likely associated with a malfunction in the implantation process, which is presumed to be related to a uterine factor and not an oocyte factor, as both autologous and donor recipient cycle outcomes were associated similarly with the BMI of the intended parent.

Relationship Between In-Hospital Adverse Events and Hospital Performance on 30-Day All-cause Mortality and Readmission for Patients With Heart Failure.

BACKGROUND: Hospitals with high mortality and readmission rates for patients with heart failure (HF) might also perform poorly in other quality concepts. We sought to evaluate the association between hospital performance on mortality and readmission with hospital performance rates of safety adverse events. METHODS: This cross-sectional study linked the 2009 to 2019 patient-level adverse events data from the Medicare Patient Safety Monitoring System, a randomly selected medical records-abstracted patient safety database, to the 2005 to 2016 hospital-level HF-specific 30-day all-cause mortality and readmissions data from the United States Centers for Medicare & Medicaid Services. Hospitals were classified to one of 3 performance categories based on their risk-standardized 30-day all-cause mortality and readmission rates: better (both in <25th percentile), worse (both >75th percentile), and average (otherwise). Our main outcome was the occurrence (yes/no) of one or more adverse events during hospitalization. A mixed-effect model was fit to assess the relationship between a patient's risk of having adverse events and hospital performance categories, adjusted for patient and hospital characteristics. RESULTS: The study included 39 597 patients with HF from 3108 hospitals, of which 252 hospitals (8.1%) and 215 (6.9%) were in the better and worse categories, respectively. The rate of patients with one or more adverse events during a hospitalization was 12.5% (95% CI, 12.1-12.8). Compared with patients admitted to better hospitals, patients admitted to worse hospitals had a higher risk of one or more hospital-acquired adverse events (adjusted risk ratio, 1.24 [95% CI, 1.06-1.44]). CONCLUSIONS: Patients admitted with HF to hospitals with high 30-day all-cause mortality and readmission rates had a higher risk of in-hospital adverse events. There may be common quality issues among these 3 measure concepts in these hospitals that produce poor performance for patients with HF.

Reproductive inequity and inferior intrauterine insemination outcomes in patients with limited English proficiency: a retrospective cohort study.

OBJECTIVE: To evaluate if language preference influences intrauterine insemination outcomes. DESIGN: Retrospective cohort. SETTING: The study was conducted at an urban medical center in New York from January 2016 to August 2021. PATIENT(S): All women older than 18 years undergoing their first IUI cycle with an infertility diagnosis were included. INTERVENTION(S): Intrauterine insemination after ovarian stimulation. MAIN OUTCOME MEASURE(S): Primary outcomes were intrauterine insemination success rate and duration of infertility before seeking infertility care. The primary outcomes used the Kaplan-Meier estimator to investigate the difference in duration of infertility before specialty consultation and logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) of clinical pregnancy among English speakers vs. those with limited English proficiency (LEP) undergoing initial IUI. Secondary outcomes included final IUI outcomes compared by language preference. Adjusted analyses controlled for race/ethnicity. RESULTS: A total of 406 patients were included in this study, of which 86% preferred English, 7.6% preferred Spanish, and 5.2% preferred other. Patients with LEP have longer duration of infertility before seeking infertility care than English-proficient women (mean 4.53 ± 3.65 years vs. 2.01 ± 1.58 years). Although clinical pregnancy rate of initial IUI did not significantly vary (OR, 2.92; 95% CI, 0.68-12.47 unadjusted and OR, 2.88; 95% CI, 0.67-12.35 adjusted), the cumulative pregnancy rate was significantly higher in English-proficient patients than in LEP patients at the time of final IUI (22.32% vs. 15.38%). This is despite a similar number of total IUIs (2.40 English vs. 2.70 LEP). Additionally, LEP patients were significantly more likely to discontinue care after unsuccessful IUI, instead of proceeding to further fertility treatments such as in vitro fertilization. CONCLUSIONS: Limited English proficiency is associated with longer duration of infertility before initiating care as well as poorer IUI outcomes, including lower cumulative pregnancy rate. Further research is needed to assess what clinical and socioeconomic factors are contributing to lower IUI success rates and lower continuation in infertility care in LEP patients.

Analysis of Hospital-Level Readmission Rates and Variation in Adverse Events Among Patients With Pneumonia in the United States.

Importance: It is known that hospitalized patients who experience adverse events are at greater risk of readmission; however, it is unknown whether patients admitted to hospitals with higher risk-standardized readmission rates had a higher risk of in-hospital adverse events. Objective: To evaluate whether patients with pneumonia admitted to hospitals with higher risk-standardized readmission rates had a higher risk of adverse events. Design, Setting, and Participants: This cross-sectional study linked patient-level adverse events data from the Medicare Patient Safety Monitoring System (MPSMS), a randomly selected medical record abstracted database, to the hospital-level pneumonia-specific all-cause readmissions data from the Centers for Medicare & Medicaid Services. Patients with pneumonia discharged from July 1, 2010, through December 31, 2019, in the MPSMS data were included. Hospital performance on readmissions was determined by the risk-standardized 30-day all-cause readmission rate. Mixed-effects models were used to examine the association between adverse events and hospital performance on readmissions, adjusted for patient and hospital characteristics. Analysis was completed from October 2019 through July 2020 for data from 2010 to 2017 and from March through April 2022 for data from 2018 to 2019. Exposures: Patients hospitalized for pneumonia. Main Outcomes and Measures: Adverse events were measured by the rate of occurrence of hospital-acquired events and the number of events per 1000 discharges. Results: The sample included 46 047 patients with pneumonia, with a median (IQR) age of 71 (58-82) years, with 23 943 (52.0%) women, 5305 (11.5%) Black individuals, 37 763 (82.0%) White individuals, and 2979 (6.5%) individuals identifying as another race, across 2590 hospitals. The median hospital-specific risk-standardized readmission rate was 17.0% (95% CI, 16.3%-17.7%), the occurrence rate of adverse events was 2.6% (95% CI, 2.54%-2.65%), and the number of adverse events per 1000 discharges was 157.3 (95% CI, 152.3-162.5). An increase by 1 IQR in the readmission rate was associated with a relative 13% higher patient risk of adverse events (adjusted odds ratio, 1.13; 95% CI, 1.08-1.17) and 5.0 (95% CI, 2.8-7.2) more adverse events per 1000 discharges at the patient and hospital levels, respectively. Conclusions and Relevance: Patients with pneumonia admitted to hospitals with high all-cause readmission rates were more likely to develop adverse events during the index hospitalization. This finding strengthens the evidence that readmission rates reflect the quality of hospital care for pneumonia.

Prevalence of early discontinuation and associated factors among a retrospective cohort of etonogestrel contraceptive implant users.

Purpose: To characterise the frequency of and predictors of contraceptive implant discontinuation within 12 months of insertion in our clinical setting.Materials and methods: This retrospective cohort study included women receiving the etonogestrel contraceptive implant at our hospital between May 2007 and May 2012. We abstracted data from charts including implant removal date, bleeding complaints, reproductive and demographic characteristics, prior contraceptive use, tobacco use and implant insertion timing. Our primary outcome was implant discontinuation within 12 months following insertion. SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used to generate frequencies, bivariate analyses and multivariate logistic regression models.Results: Implant discontinuation was documented in 16% of implant users prior to 12 months (89/544). Women with documented bleeding complaints in the medical record were more likely to discontinue within 12 months (OR: 4.36, CI: 2.71, 7.00). No other demographic or clinical characteristics were associated with premature discontinuation. Having less than two prior pregnancies and tobacco use were associated with documented bleeding complaints.Conclusions: Discontinuation of the implant is associated with bleeding complaints. Women with lower parity and tobacco users may be more likely to experience bleeding or to find it intolerable.

The Effect of HIV-Centered Obstetric Care on Perinatal Outcomes Among a Cohort of Women Living With HIV.

BACKGROUND: Elimination of perinatal transmission is possible but limited by missed care opportunities. Our objective was to investigate the effects of HIV-centered obstetric care (HCC) on missed care opportunities and perinatal HIV transmission in 2 obstetric cohorts at our institution from 2000 to 2014. METHODS: This was a retrospective cohort study of HIV-exposed mother-infant pairs delivering from 2000 to 2014, analyzed according to SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guidelines. Before 2009, women received care in high-risk obstetric care (HRC); subsequently, an HCC service was established. Women who received HRC vs HCC obstetric care were compared to determine differences in maternal and neonatal outcomes. Continuous variables were compared with Student t test and Wilcoxon rank sum tests. Categorical variables were compared using χ test and Fisher exact test. Logistic regression analyses were performed to determine factors associated with outcomes of interest. RESULTS: Over 14 years, 161 women delivered 217 HIV-exposed infants; 78 (36%) women received HCC. Two perinatal HIV transmissions (1.5%) occurred in HRC group compared with none in the HCC group (P = 0.3). Women in HCC were more likely to have HIV RNA viral load <1000 copies per milliliter at delivery (12% vs 26%, P = 0.02), have a contraception plan before delivery (93% vs 60%, P < 0.001), return for postpartum evaluation (80% vs 63%, P = 0.01), and have undetectable HIV viral load postpartum (50 copies per milliliter vs 2067, P < 0.0001). CONCLUSIONS: HCC can potentially reduce the risk of perinatal HIV transmission by improving maternal virologic control during pregnancy and postpartum and increasing postpartum contraceptive use.

New physics in resonant production of Higgs boson pairs.

We advocate a search for an extended scalar sector at the LHC via hh production, where h is the 125 GeV Higgs boson. A resonance feature in the hh invariant mass is a smoking gun of an s-channel heavy Higgs resonance, H. With one h decaying to two photons and the other decaying to b quarks, the resonant signal may be discoverable above the hh continuum background for M(H)<1 TeV. The product of the scalar and top Yukawa couplings can be measured to better than 10%-20% accuracy, and its sign can be inferred from the hh line shape via interference effects.

Factors associated with systemic hypertension in asthma.

PURPOSE: Asthmatics have unique characteristics that may influence cardiovascular morbidity. We tested the association of lower airway caliber, obstructive sleep apnea (OSA), and other asthma-related factors, with systemic hypertension (HTN). METHODS: Asthma individuals at specialty clinics completed the Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ). Medical records were reviewed for diagnosed HTN, OSA and comorbidities, spirometry, and current medications. FEV1% predicted was categorized as ≥ 80 (reference), 70-79, 60-69, and < 60. SA-SDQ ≥ 36 for men and ≥ 32 for women defined high OSA risk. RESULTS: Among 812 asthmatics (mean age ± standard deviation: 46 ± 14 years), HTN was diagnosed in 191 (24%), OSA in 65 (8%), and OSA or high OSA risk (combined OSA variable) in 239 (29%). HTN was more prevalent in lower FEV1% categories (p < 0.0001), in subjects with OSA, and those with combined OSA variable (55 vs. 21% and 46 vs. 14%, respectively, both p < 0.0001). With adjustment for covariates, associations with HTN remained significant for some FEV1% categories (70-79% odds ratio = 1.60 [95% CI 0.90-2.87]; 60-69% 2.73 [1.28-5.79]; < 60% 0.96 [0.43-2.14]), and for OSA (2.20 [1.16-4.19]). The combined OSA variable in comparison with OSA alone demonstrated a stronger association with HTN (3.17 [1.99-5.04]) in a reiteration of this model. Inhaled corticosteroids (ICS) at lowest doses, in comparison to no ICS use had an independent "protective" association with HTN (0.44 [0.22-0.90]). CONCLUSIONS: In this young population, worse lower airways obstruction and OSA were associated with HTN. In contrast, lower ICS doses attenuated likelihood for HTN. Adequate control of airway inflammation at appropriate ICS doses, and screening for OSA may reduce the burden of HTN in asthma.

Association of obstructive sleep apnea risk or diagnosis with daytime asthma in adults.

OBJECTIVE: Obstructive sleep apnea (OSA) worsens nocturnal asthma, but its potential impact on daytime asthma remains largely unassessed. We investigated whether the sleep disorder is associated with daytime, in addition to nighttime, asthma symptoms. METHODS: Asthma patients at tertiary-care centers completed the Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ), and an asthma control questionnaire. SA-SDQ scores ≥36 for males and ≥32 for females defined high OSA risk. Medical records were reviewed for established diagnosis of OSA and continuous positive airway pressure (CPAP) use. RESULTS: Among 752 asthma patients, high OSA risk was associated similarly with persistent daytime and nighttime asthma symptoms (p < .0001 for each). A diagnosis of OSA was robustly associated with persistent daytime (p < .0001) in addition to nighttime (p = .0008) asthma symptoms. In regression models that included obesity and other known asthma aggravators, high OSA risk retained associations with persistent daytime (odds ratio [OR] = 1.96 [95% confidence interval [CI] = 1.31-2.94]) and nighttime (1.97 [1.32-2.94]) asthma symptoms. Diagnosed OSA retained an association with persistent daytime (2.08 [1.13-3.82]) but not with nighttime (1.48 [0.82-2.69]) asthma symptoms. CPAP use was associated with lower likelihood of persistent daytime symptoms (0.46 [0.23-0.94]). CONCLUSIONS: Questionnaire-defined OSA risk and historical diagnosis were each associated with persistent daytime asthma symptoms, to an extent that matched or exceeded associations with nighttime asthma symptoms. Unrecognized OSA may be a reason for persistent asthma symptoms during the day as well as the night.

Frequency of urinary tract infection in dogs with inflammatory skin disorders treated with ciclosporin alone or in combination with glucocorticoid therapy: a retrospective study.

BACKGROUND: Few studies have investigated the frequency of urinary tract infection (UTI) in dogs receiving long-term ciclosporin therapy. HYPOTHESIS/OBJECTIVES: The goal of the study was to investigate the frequency of UTI in dogs receiving ciclosporin with or without glucocorticoids. A secondary goal was to determine whether bacteriuria, pyuria and urine specific gravity were good predictors of UTI, and if ciclosporin dose, concurrent ketoconazole therapy, sex or duration of therapy affected the frequency of UTI. Animals - Eighty-seven dogs with various inflammatory skin disorders and 59 control dogs with inflammatory skin conditions that had not received glucocorticoids or ciclosporin for 6 months were enrolled. METHODS: This study was retrospective. The first urine culture from dogs receiving ciclosporin was compared with control dogs using Fisher's exact test. A logistic mixed model was used to test for association between a positive bacterial culture and duration of treatment, dose of ciclosporin, concurrent ketoconazole therapy and sex. The sensitivities and specificities for bacteriuria, pyuria and urine specific gravity were determined. RESULTS: Twenty-six of 87 (30%) ciclosporin-treated dogs had at least one positive culture. Compared with 3% positive control samples, 15% were positive in treated dogs (P=0.027). The sensitivity and specificity were, respectively, 64.1 and 98.1% for bacteriuria, 74.4 and 70.9% for pyuria, and 56.4 and 65.3% for urine specific gravity. All other analysed parameters were not significantly different. CONCLUSIONS AND CLINICAL IMPORTANCE: The results suggest that routine urine cultures and assessment of bacteriuria by cystocentesis should be part of the monitoring for dogs on long-term ciclosporin with and without glucocorticoids.

Crusty cats: feline pemphigus foliaceus.

Pemphigus foliaceus (PF) is an immune-mediated disease that causes pustules and crusted lesions, most commonly on the pinnae, nasal planum, periocular area, chin, and feet of affected cats. Acantholytic cells caused by degradation of intercellular adhesions are often seen on cytology but are not pathognomonic for PF. A definitive diagnosis is made based on histopathology showing subcorneal pustules with nondegenerate neutrophils and acantholytic cells. PF is treated with immunosuppressive doses of corticosteroids alone or in combination with other immunosuppressive medications, such as chlorambucil or cyclosporine. Most patients require lifelong treatment with these medications to keep the disease in remission.

Association of obstructive sleep apnea risk with asthma control in adults.

BACKGROUND: Unrecognized obstructive sleep apnea (OSA) may lead to poor asthma control despite optimal therapy. Our objective was to evaluate the relationship between OSA risk and asthma control in adults. METHODS: Patients with asthma seen routinely at tertiary-care clinic visits completed the validated Sleep Apnea Scale of the Sleep Disorders Questionnaire (SA-SDQ) and Asthma Control Questionnaire (ACQ). An ACQ score of >or= 1.5 defined not-well-controlled asthma, and an SA-SDQ score of >or= 36 for men and >or= 32 for women defined high OSA risk. Logistic regression was used to model associations of high OSA risk with not-well-controlled asthma (ACQ full version and short versions). RESULTS: Among 472 subjects with asthma, the mean +/- SD ACQ (full version) score was 0.87 +/- 0.90, and 80 (17%) subjects were not well controlled. Mean SA-SDQ score was 27 +/- 7, and 109 (23%) subjects met the definition of high OSA risk. High OSA risk was associated, on average, with 2.87-times higher odds for not-well-controlled asthma (ACQ full version) (95% CI, 1.54-5.32; P = .0009) after adjusting for obesity and other factors known to worsen asthma control. Similar independent associations were seen when using the short ACQ versions. CONCLUSIONS: High OSA risk is significantly associated with not-well-controlled asthma independent of known asthma aggravators and regardless of the ACQ version used. Patients who have difficulty achieving adequate asthma control should be screened for OSA.

Peripheral nerve stimulation in treatment of intractable postherpetic neuralgia.

Objective. This case report presents an application of peripheral nerve stimulation to a patient with intractable postherpetic neuralgia that conventional treatment failed to ameliorate. Methods. The patient underwent an uneventful peripheral nerve stimulator trial with placement of two temporal eight-electrode percutaneous leads (Octrode leads, Advanced Neuromodulation Systems, Plano, TX, USA) into the right subscapular and right paraspinal area of the upper thoracic region. Results. Upon experiencing excellent pain relief over the next two weeks, the patient underwent implantation of permanent leads two weeks later and reported sustained pain relief. Conclusion. Peripheral nerve stimulation offers an alternative treatment option for intractable pain associated with postherpetic neuralgia, especially for elderly patients where treatment options are limited due to existing comorbidities. Further studies are warranted.

Hypothyroidism alters striatal dopamine release mediated by 3,4-methylenedioxymethamphetamine (MDMA, ecstasy).

Microdialysis cannulas were surgically implanted into the striatum of thyroparathyroidectomized (TX) and sham rats in order to determine differences in dopamine release and core body temperature following MDMA administration. Rats were subsequently treated with MDMA (10 mg/kg, s.c.), and striatal DA levels were monitored at 20 min intervals, as well as core temperature every 30 min. Sham rats responded to MDMA with a characteristic hyperthermic response and significant increases in extracellular dopamine. Conversely, TX rats responded to MDMA with a hypothermic response and failed to demonstrate a similar increase from basal dopamine levels. On the basis of these data, thyroid hormones are not only important in the thermogenic effects of MDMA but also appear to have an auxiliary role in MDMA-induced striatal dopamine release.

Menopausal status and sleep-disordered breathing in the Wisconsin Sleep Cohort Study.

Menopause is considered to be a risk factor for sleep-disordered breathing, but this hypothesis has not been adequately tested. The association of premenopause, perimenopause, and postmenopause with sleep-disordered breathing was investigated with a population-based sample of 589 women enrolled in the Wisconsin Sleep Cohort Study. Menopausal status was determined from menstrual history, gynecologic surgery, hormone replacement therapy, follicle-stimulating hormone, and vasomotor symptoms. Sleep-disordered breathing was indicated by the frequency of apnea and hypopnea events per hour of sleep, measured by in-laboratory polysomnography. Multivariable logistic regression was used to estimate odds ratios for having 5 or more and 15 or more apnea and hypopnea events per hour. Odds ratios (95% confidence interval), adjusted for age, body habitus, smoking, and other potential confounding factors, for 5 or more apnea and hypopnea events per hour were 1.2 (0.7, 2.2) with perimenopause and 2.6 (1.4, 4.8) with postmenopause; odds ratios for 15 or more apnea and hypopnea events per hour were 1.1 (0.5, 2.2) with perimenopause and 3.5 (1.4, 8.8) with postmenopause. The menopausal transition is significantly associated with an increased likelihood of having sleep-disordered breathing, independent of known confounding factors. Evaluation for sleep-disordered breathing should be a priority for menopausal women with complaints of snoring, daytime sleepiness, or unsatisfactory sleep.