Utility of Office Hysteroscopy in Diagnosing Retained Products of Conception Following Early Pregnancy Loss After In Vitro Fertilization.

OBJECTIVE: To evaluate the utility of office hysteroscopy in diagnosing and treating retained products of conception in patients with infertility who experience early pregnancy loss (EPL) after in vitro fertilization (IVF). METHODS: We evaluated a retrospective cohort of 597 pregnancies that ended in EPL in patients aged 18-45 years who conceived through fresh or frozen embryo transfer at an academic fertility practice between January 2016 and December 2021. All patients underwent office hysteroscopy after expectant, medical, or surgical management of the EPL. The primary outcome was presence of retained products of conception at the time of office hysteroscopy. Secondary outcomes included incidence of vaginal bleeding, presence of intrauterine adhesions, treatment for retained products of conception, and duration of time from EPL diagnosis to resolution. Log-binomial regression and Poisson regression were performed, adjusting for potential confounders including oocyte age, patient age, body mass index, prior EPL count, number of prior dilation and curettage procedures, leiomyomas, uterine anomalies, and vaginal bleeding. RESULTS: Of the 597 EPLs included, 129 patients (21.6%) had retained products of conception diagnosed at the time of office hysteroscopy. The majority of individuals with EPL were managed surgically (n=427, 71.5%), in lieu of expectant management (n=140, 23.5%) or medical management (n=30, 5.0%). The presence of retained products of conception was significantly associated with vaginal bleeding (relative risk [RR] 1.72, 95% CI 1.34-2.21). Of the 41 patients with normal pelvic ultrasonogram results before office hysteroscopy, 10 (24.4%) had retained products of conception detected at the time of office hysteroscopy. When stratified by EPL management method, retained products of conception were significantly more likely to be present in individuals with EPL who were managed medically (adjusted RR 2.66, 95% CI 1.90-3.73) when compared with those managed surgically. Intrauterine adhesions were significantly less likely to be detected in individuals with EPL who underwent expectant management when compared with those managed surgically (RR 0.14, 95% CI 0.04-0.44). Of the 127 individuals with EPL who were diagnosed with retained products of conception at the time of office hysteroscopy, 30 (23.6%) had retained products of conception dislodged during the office hysteroscopy, 34 (26.8%) chose expectant or medical management, and 63 (49.6%) chose surgical management. The mean number of days from EPL diagnosis to resolution of pregnancy was significantly higher in patients who elected for expectant management (31 days; RR 1.18, 95% CI 1.02-1.37) or medical management (41 days; RR 1.54, 95% CI 1.25-1.90) when compared with surgical management (27 days). CONCLUSION: In patients with EPL after IVF, office hysteroscopy detected retained products of conception in 24.4% of those with normal pelvic ultrasonogram results. Due to the efficacy of office hysteroscopy in diagnosing and treating retained products of conception, these data support considering office hysteroscopy as an adjunct to ultrasonography in patients with infertility who experience EPL after IVF.

Tibial Spine Avulsion Repair With FiberRing Suture and Anterior Cruciate Ligament Repair TightRope.

Tibial spine avulsion fractures occur predominantly in children and young adults and are an uncommon type of knee injury. To ensure knee stability and preserve range of motion with minimal knee laxity, it is essential to restore anterior cruciate ligament length through surgical reduction and fixation of the fracture. Achieving anatomic reduction of tibial spine avulsion fractures with an arthroscopic approach is a technically complex procedure. In this Technical Note and accompanying video, we describe a unique fixation repair of tibial spine avulsion fractures using Arthrex FiberRing sutures and an Arthrex ACL Repair TightRope. The technique presented is an effective method to reduce tibial spine avulsion fractures to anatomic position with a variable tensioning system that allows for a strong and secure fixation method.

Reproductive Justice: A Case-Based, Interactive Curriculum.

Introduction: Reproductive injustices such as forced sterilization, preventable maternal morbidity and mortality, restricted access to family planning services, and policy-driven environmental violence undermine reproductive autonomy and health outcomes, with disproportionate impact on historically marginalized communities. However, curricula focused on reproductive justice (RJ) are lacking in medical education. Methods: We designed a novel, interactive, case-based RJ curriculum for postclerkship medical students. This curriculum was created using published guidelines on best practices for incorporating RJ in medical education. The session included a prerecorded video on the history of RJ, an article, and four interactive cases. Students engaged in a 2-hour small-group session, discussing key learning points of each case. We evaluated the curriculum's impact with a pre- and postsurvey and focus group. Results: Sixty-eight students participated in this RJ curriculum in October 2020 and March 2021. Forty-one percent of them completed the presurvey, and 46% completed the postsurvey. Twenty-two percent completed both surveys. Ninety percent of respondents agreed that RJ was relevant to their future practice, and 87% agreed that participating in this session would impact their clinical practice. Most respondents (81%) agreed that more RJ content is needed. Focus group participants appreciated the case-based, interactive format and the intersectionality within the cases. Discussion: This interactive curriculum is an innovative and effective way to teach medical students about RJ and its relevance to clinical practice. Walking alongside patients as they accessed reproductive health care in a case-based curriculum improved students' comfort and self-reported knowledge on several RJ topics.

Intraoperative cholangiography: a stepping stone to streamlining the treatment of choledocholithiasis.

BACKGROUND: An estimated 8-15% of patients undergoing cholecystectomy have concomitant common bile duct stones. In this 14-year study, we utilize data of patients at a high-volume tertiary care academic center and compare the clinical outcomes of patients undergoing intraoperative cholangiography (IOC) and endoscopic retrograde pancreatography (ERCP). METHODS: The charts of 1715 patients in the institutional NSQIP database who underwent cholecystectomy between October 1st, 2005 and September 30th, 2019 were retrospectively reviewed. Patients who underwent cholecystectomy in relation to a malignancy diagnosis or who underwent an ERCP in a different index hospitalization were excluded. Main outcomes included hospital length of stay (LOS), post-operative morbidity, and rate of readmissions. RESULTS: Of the 1409 patients included in the final analysis, 185 patients underwent ERCP, while 95 patients underwent IOC. Use of IOC compared to preoperative ERCP resulted in a shorter LOS (2.6 vs. 5.3 days, p < 0.001), lower rate of readmission (1.1% vs. 6.5%, p = 0.040), and similar rates of post-operative complications. Mean operative time increased by only 15 min in the IOC compared to the ERCP group (129 vs.114 min, p = 0.047). Additional variables that increased LOS on multivariable logistic regression included age, ASA classification, post-operative complications, and increased number of preoperative tests. CONCLUSIONS: This study demonstrates that use of IOC during cholecystectomy results in shorter LOS and fewer readmissions compared to ERCP. Future studies comparing these two approaches should focus on patient randomization, a cost-effectiveness analysis, and identifying barriers to implementation of a one-stage approach in the management of suspected choledocholithiasis.

Providing social support for inpatients: Insights from a virtual medical student initiative.

BACKGROUND: Although the COVID-19 pandemic increased social isolation among hospitalised patients given isolation precautions, visitor restrictions and curtailed interactions with healthcare teams, medical students had limited opportunities for involvement in the care of inpatients. APPROACH: We designed a humanistic and narrative medicine intervention to engage medical students in combating social isolation in hospitalised patients during the COVID-19 pandemic at a tertiary care teaching hospital. In our programme, medical students provided virtual social support to hospitalised patients via phone by providing assistance connecting with family members, having informal conversations and check-ins and writing up patient life narratives. EVALUATION: From April 2020 to March 2021, we received 126 referrals of potentially isolated patients from inpatient medical teams. Fifty patients accepted and received our intervention, including 26 who completed life narratives. Feedback was positive, demonstrating benefit to medical students in learning about humanism and connecting with patients through their life stories. In addition, patients and medical teams felt more supported. We share key operational lessons and resources to facilitate the implementation of this intervention elsewhere. IMPLICATIONS: Our intervention allows medical students to meaningfully contribute to the care of inpatients, support beleaguered inpatient teams and learn important lessons about humanism in medicine. This educational and patient care intervention holds promise in other settings, including beyond the COVID-19 pandemic.

Single-Portal, Single-Anchor Repair of a Superior Third Subscapularis Tear Using a Self-Punching Knotless Soft Suture Anchor.

Numerous techniques exist for arthroscopic subscapularis repair with varying degrees of complexity based on tear morphology, all of which have established satisfactory outcomes in function and patient satisfaction. Arthroscopic subscapularis repair can require several working portals and suture anchors, increasing both technical complexity and operative time. This Technical Note describes an arthroscopic repair of a superior one-third subscapularis tear using a self-punching knotless soft suture anchor through a single anterior working portal. Thus, we offer a unique approach to arthroscopic repair of superior one-third subscapularis tears that is time-saving, reproducible, and highly efficient while minimizing iatrogenic damage and postoperative complications.

MiR155 modulates vascular calcification by regulating Akt-FOXO3a signalling and apoptosis in vascular smooth muscle cells.

microRNA-155 (miR155) is pro-atherogenic; however, its role in vascular calcification is unknown. In this study, we aim to examine whether miR155 regulates vascular calcification and to understand the underlying mechanism. Quantitative real-time PCR showed that miR155 is highly expressed in human calcific carotid tissue and positively correlated with the expression of osteogenic genes. Wound-healing assay and TUNEL staining showed deletion of miR155 inhibited vascular smooth muscle cell (VSMC) migration and apoptosis. miR155 deficiency attenuated calcification of cultured mouse VSMCs and aortic rings induced by calcification medium, whereas miR155 overexpression promoted VSMC calcification. Compared with wild-type mice, miR155-/- mice showed significant resistance to vitamin D3 induced vascular calcification. Protein analysis showed that miR155 deficiency alleviated the reduction of Rictor, increased phosphorylation of Akt at S473 and accelerated phosphorylation and degradation of FOXO3a in cultured VSMCs and in the aortas of vitamin D3-treated mice. A PI3K inhibitor that suppresses Akt phosphorylation increased, whereas a pan-caspase inhibitor that suppresses apoptosis reduced VSMC calcification; and both inhibitors diminished the protective effects of miR155 deficiency on VSMC calcification. In conclusion, miR155 deficiency attenuates vascular calcification by increasing Akt phosphorylation and FOXO3a degradation, and thus reducing VSMC apoptosis induced by calcification medium.

Perceived Access to Abortion Among Women in the United States in 2018: Variation by State Abortion Policy Context.

Objectives. To describe perceptions of access to abortion among women of reproductive age and their associations with state abortion policy contexts.Methods. We used data from the 2018 Survey of Family Planning and Women's Lives, a probability-based sample of 2115 adult women aged 18 to 44 years in US households.Results. We found that 27.6% of women (95% confidence interval [CI] = 23.3%, 32.7%) believed that access to medical abortion was difficult and 30.1% of women (95% CI = 25.6%, 35.1%) believed that access to surgical abortion was difficult. Adjusted for covariates, women were significantly more likely to perceive access to both surgical and medical abortions as difficult when they lived in states with 4 or more restrictive abortion policies compared with states with fewer restrictions (surgical adjusted odds ratio [AORsurgical] = 1.60, 95% CI = 1.15, 2.21; AORmedical = 1.65, 95% CI = 1.04, 1.95). Specific restrictive abortion policies (e.g., public funding restrictions, mandatory counseling or waiting periods, and targeted regulation of abortion providers) were also associated with greater perceived difficulty accessing both surgical and medical abortions.Conclusions. State policies restricting abortion access are associated with perceptions of reduced access to both medical and surgical abortions among women of reproductive age.

Tibial Plateau With Arthroscopic Reduction-Internal Fixation.

Arthroscopic-assisted internal fixation is an ideal technique for visualizing chondral reduction during tibial open reduction-internal fixation. Typically, open reduction-internal fixation is performed using radiographic and Fluoroscan imaging (Hologic, Bedford, MA) for reduction of subchondral bone. However, reduction without visualization does not ensure chondral surface reduction. This Technical Note and supplemental video describe an arthroscopic-assisted technique involving the tibial plateau that gives complete visualization as tamping occurs to restore the cartilage surface of the subchondral bone and elevate the fracture.

Arthroscopic Harvesting of Autologous Bone Graft for Use as a Mesenchymal Stem Cell Carrier in Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) tears are detrimental to knee stability and normal function. Although the standard of treatment is an ACL reconstruction, technical improvements are sought to enhance clinical outcomes due to the appreciable failure rate. The use of autologous biologic substances as carriers of stem cells are desirable because of their multipotent properties. Traditionally, the collection of autologous bone grafts is through an open incision of the iliac crest, which causes substantial morbidity to the patient. This Technical Note describes an arthroscopic, minimally invasive collection method of autologous tibial and femoral bone graft to use in backfilling the tunnels during an ACL reconstruction to improve graft incorporation and clinical outcomes.

Transtibial Pull-Out Repair of Converted Radial Tear Adjacent to Medial Meniscus Root.

Radial tears increase tibiofemoral contact pressure and disrupt the ability of the meniscus to withstand hoop stress, leading to earlier-onset osteoarthritis. Repair of radial tears is problematic because they have a lower healing rate and lack a single gold standard technique. However, when a radial tear is proximal to the root, there is an opportunity to convert it into a root tear. This is ideal because root tears fixed through a transtibial tunnel technique have improved clinical outcomes and reduced rates of osteoarthritis. This Technical Note and accompanying video describe a method for repairing a radial tear near the meniscus root by converting a radial tear to a root tear followed by a pull-out root repair through a transtibial tunnel. This method restores the meniscus root, allowing it to withstand hoop stress. Our technique uses a disposable root repair kit that includes a FlipCutter, a Knee Scorpion Suture Passer, a 4.75-mm SwiveLock anchor tap, a SutureLasso, a PassPort Cannula, 0 FiberLink sutures, and TigerLink sutures.

Anticancer activity of emodin is associated with downregulation of CD155.

Emodin is a Chinese herb-derived compound that exhibits a variety of pharmacological benefits. Although emodin has been shown to inhibit growth of cancer cells, its antineoplastic function is incompletely understood. CD155 is a member of poliovirus receptor-related (PRR) family of adhesion molecules; it is constitutively expressed on many tumor cell lines and tissues and has diverse functions. CD155 has been reported to mediate activation of T cells via CD226 or inhibition of T cells via T-cell immunoreceptor with Ig and ITIM domains (TIGIT). In addition, CD155 may play a critical role through non-immunological mechanisms in cancer. In this study, we tested the ability of emodin to modulate CD155 expression in cancer cells. We found that emodin significantly decreased the expression of CD155 in tumor cells and inhibited tumor cell proliferation and migration, and induced cell-cycle arrest at G2/M phase. The tumor inhibitory effects of emodin were lost with CD155 knockdown. Furthermore, emodin was used to treat mice bearing B16 melanoma. It was shown that emodin attenuated tumor growth accompanied by suppressing CD155 expression. Therefore, we propose that emodin could inhibit tumor growth, and the antineoplastic properties of emodin are at least partially CD155 dependent. Our study provides new insights into the mechanisms by which emodin inhibits tumor growth.

Stem Cell-Infused Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) tears are unfortunate but common injuries in the athletic population. The standard of care for ACL tears is a surgical intervention to reconstruct the ACL to restore knee functionality as well as quality of life. In recent years, bone marrow aspirate concentrate (BMAC) has seen increasing use in various orthopaedic settings. This increase can be attributed to the potential beneficial qualities that mesenchymal stem cells, progenitor cells, and growth factors, all of which are present in BMAC, can provide. In this technical note and accompanying video, we describe an anatomic allograft ACL reconstruction infused with BMAC to utilize BMAC's potential benefits.

2015 AAHA Canine and Feline Behavior Management Guidelines.

The 2015 AAHA Canine and Feline Behavior Management Guidelines were developed to provide practitioners and staff with concise, evidence-based information to ensure that the basic behavioral needs of feline and canine patients are understood and met in every practice. Some facility in veterinary behavioral and veterinary behavioral medicine is essential in modern veterinary practice. More cats and dogs are affected by behavioral problems than any other condition. Behavioral problems result in patient suffering and relinquishment and adversely affect staff morale. These guidelines use a fully inclusive team approach to integrate basic behavioral management into everyday patient care using standardized behavioral assessments; create a low-fear and low-stress environment for patients, staff and owners; and create a cooperative relationship with owners and patients so that the best care can be delivered. The guidelines' practical, systematic approach allows veterinary staff to understand normal behavior and recognize and intervene in common behavioral problems early in development. The guidelines emphasize that behavioral management is a core competency of any modern practice.

AAFP and ISFM feline-friendly handling guidelines.

BACKGROUND: The number of pet cats is increasing in most countries, often outnumbering pet dogs, yet cats receive less veterinary care than their canine counterparts.(1) Clients state the difficulty of getting the cat into a carrier at home, driving to the clinic, and dealing with the fearful cat at the veterinary clinic as reasons for fewer visits.(2) Educating and preparing the client and the veterinary team with regard to respectful feline handling is necessary in order to avoid stress and accomplish the goal of good health care. Without such preparation, feline stress may escalate into fear or fear-associated aggression. The resulting stress may alter results of the physical examination and laboratory tests, leading to incorrect diagnoses (eg, diabetes mellitus) and unnecessary treatments.(3-5) Without compassionate and respectful handling by the veterinary team, clients may feel the team lacks skills and compassion, or does not understand cats. Injury may occur to the cat, client and/or veterinary team.(6) Clients who want to avoid stress for their cat may avoid veterinary visits or choose another practice instead. GOALS: The use of feline-friendly handling techniques should reduce these problems. Handling is most successful when the veterinary team adapts the approach to each individual cat and situation. The goal of these guidelines is to provide useful information for handling cats that can lead to: ✜ Reduced fear and pain for the cat. ✜ Reinforced veterinarian-client-cat bond, trust and confidence, and thus better lifelong medical care for the cat. ✜ Improved efficiency, productivity and job satisfaction for the veterinary team. ✜ Increased client compliance. ✜ Timely reporting and early detection of medical and behavioral concerns. ✜ Fewer injuries to clients and the veterinary team. ✜ Reduced anxiety for the client.