Expanding Access to Fetal Telecardiology During the COVID-19 Pandemic.

Background: This study aims to describe one center's experience in expanding a fetal telecardiology program through collaborative work with maternal fetal medicine (MFM) clinics with the goal of safely reaching mothers during the COVID-19 pandemic. We sought to define the extent of fetal telehealth conversion at a large fetal cardiac care center and evaluate the diagnostic accuracy for studies performed. Methods: At our center, fetal telemedicine expanded from one MFM site before the pandemic to four additional sites by May 2020. A retrospective review of fetal telecardiology visits between March 15 and July 15, 2020, was performed. The chart was reviewed for confirmation of diagnosis postnatally. Results: With pandemic onset, there was a large increase in the number of telemedicine visits with a total of 122 mothers seen between five MFM clinics. Fourteen mothers (11.5%) had abnormal fetal echocardiograms requiring additional follow-up, and seven mothers (5.8%) had a fetal echocardiogram suspicious for a critical congenital heart disease (CCHD). All the fetal echocardiograms suspicious for CCHD were confirmed on postnatal echocardiogram. To our knowledge, none of the normal fetal echocardiograms were found to have congenital heart disease postnatally. Conclusions: In response to the COVID-19 pandemic, we rapidly transitioned to fetal telecardiology using a variety of formats. This has reduced potential infectious exposure for pregnant mothers and minimized contact between physicians without compromising diagnostic accuracy. In our experience, the expansion of a telemedicine program requires strong initial infrastructure, prior relationships with MFM providers, and appropriate training among obstetric sonographers.

Creation and Evaluation of a Cesarean Section Simulator Training Program for Novice Obstetric Surgeons.

BACKGROUND: We evaluated a novel simulation-based cesarean section training program to teach critical techniques for cesarean section and hemorrhage management.  Methods: This was a prospective educational intervention. After Institutional Review Board approval, we recruited Obstetrics and Gynecology, Family Medicine, and General Surgery residents at three hospitals. All participants received didactic education. Participants were then randomized into two arms with one group to receive task-trainer based training and the other no training. Afterwards, all residents had their performance of a complete cesarean section and management of a post-partum hemorrhage evaluated on a high-fidelity simulator. Evaluators were blinded to randomization. EXPERIENCE: Thirty-three participants were recruited between July 2017 and January 2019. There were 19 trainees in the control group and 14 in the intervention group. The intervention group scored significantly higher on performance of the cesarean delivery (p-value 0.007), hemorrhage management (p-value 0.0002), and overall skill (p-value 0.008). There were no differences in the other categories. CONCLUSION: Participants trained with a combination of didactic education and task-trainers versus didactic education alone performed significantly better on all procedural aspects of a cesarean section and hemorrhage management on a high-fidelity simulator, demonstrating that simulation-based training allows trainees to gain procedural experience while decreasing patient risk.

Type I IFN ineffectively activates neonatal dendritic cells limiting respiratory antiviral T-cell responses.

Insufficient T-cell responses contribute to the increased burden of viral respiratory disease in infancy. Neonatal dendritic cells (DCs) often provide defective activation of pathogen-specific T cells through mechanisms that are incompletely understood, which hinders vaccine design for this vulnerable age group. Enhancing our characterization of neonatal DC sub-specialization and function is therefore critical to developing their potential for immunomodulation of T-cell responses. In this study, we engineered respiratory syncytial virus (RSV) to express a model protein, ovalbumin, to track antigen-presenting DCs in vivo. We found that murine neonatal conventional DC1s (cDC1s) efficiently migrated and presented RSV-derived antigen, challenging the paradigm that neonatal DCs are globally immature. In a key observation, however, we discovered that during infection neonatal cDC1s presenting viral antigen were unable to upregulate costimulatory molecules in response to type I interferons (IFN-I), contributing to poor antiviral T-cell responses. Importantly, we showed that the deficient response to IFN-I was also exhibited by human neonatal cDC1s, independent of infection. These findings reveal a functionally distinct response to IFN-I by neonatal cDC1s that may leave young infants susceptible to viral infections, and provide a new target for exploration, in light of failed efforts to design neonatal RSV vaccines.

Altered Sex Ratios in Offspring of U.S. Submariners Urban Legend or Fact - Do Submariners Have More Daughters?

INTRODUCTION: There is a widespread and long-held belief in the submarine community that submariners father more daughters than the general population. The U.S. Sex Ratio at birth (males/females) has remained around 1.05 since the early 2000s. Limited evidence exists that certain environmental exposures including chemicals, heavy metals, radiation and g-forces may influence sex ratio at birth. A reduction in male births in a population has been associated with lower male fertility. A 1970 single site study showed a higher ratio of female offspring in personnel serving aboard U.S. Navy nuclear submarines than the general population. A 2004 study concluded that this was probably not true. However, this study was small, and did not evaluate the difference between children conceived during sea duty versus shore duty. They did note a higher chance of female offspring correlated with a longer time in the community, as well as an increased ratio in sonar technicians. These findings warrant further investigation. METHODS: An electronic survey was e-mailed to submariners, after receiving required IRB and Navy approvals. Participants were asked birth year, year they entered submarine service, and how many children they had. For each child they were asked sex, child's birth year, mother's birth year, and whether they were on sea duty or shore duty at the time of conception. Those who were on sea duty at the time of conception were asked what their job was, where they were stationed and what type of submarine they were on. Those who were on shore duty at the time of conception were asked whether they were in contact with submarines on a regular basis, whether they were officer or enlisted, and what region they were stationed in for shore duty. RESULTS: Four thousand eight hundred responses were received with a total of 6,958 children included in the analysis. Respondents had a SR of 0.95 compared to 1.05 U.S. population in 2015 (p < 0.0001). Submariners on sea duty had a SR of 0.88 compared to 1.02 on shore duty (p = 0.007). Those who had regular submarine contact on shore duty had a SR of 0.72 compared to 1.17 in those who did not (p < 0.001). Geographical location during shore duty did show differences that were statistically significant (p = 0.018). Geographical location during sea duty did not show significant differences. No significant differences were seen for paternal age, maternal age, job during sea duty, type of submarine assigned to or time in community. CONCLUSION: The submariners surveyed reported greater numbers of daughters than the general population, especially when on sea duty or in regular contact with submarines during shore duty. Further study should be done to confirm results and explore possible etiologies of differences in sex ratio.

A Case of Intertwin Membrane Hemorrhage with Spontaneous Resolution.

Vaginal bleeding during pregnancy places women at increased risk of spontaneous abortion. Etiologies for threatened and spontaneous abortions have been well studied, but there is little information on intertwin membrane hemorrhage. We present a patient with a multiple gestation pregnancy who experienced first trimester vaginal bleeding with visualization and subsequent rapid resolution of an intertwin membrane hemorrhage. The patient had an otherwise normal pregnancy until the third trimester when she developed preeclampsia with severe features and elected for a primary cesarean section at 35 + 5 weeks. The implications of an intertwin membrane hemorrhage are not well understood, although there could be a possible correlation between the hemorrhage and the ultimate progression to preeclampsia with severe features. Despite the final diagnosis, the patient did not have any noticeable complications due to the hemorrhage both when it was discovered and in the weeks following its discovery.

Maternal coagulopathy after umbilical cord occlusion for twin reversed arterial perfusion sequence.

BACKGROUND: Twin reversed arterial perfusion sequence is a rare complication of monochorionic twin gestations for which therapy involves the disruption of vascular anastomoses between the pump twin and acardiac twin and death of the acardius. CASE: A 37-year-old woman, gravida 11 para 2, with a monochorionic twin pregnancy complicated by twin reversed arterial perfusion sequence who underwent umbilical cord occlusion at 24 weeks of gestation was admitted in preterm labor at 33 weeks of gestation. Maternal disseminated intravascular coagulation (DIC) was diagnosed and her labor was induced. She received multiple blood products to correct her coagulopathy and had an uncomplicated vaginal delivery of the viable pump twin. CONCLUSION: Maternal DIC may complicate fetal death after umbilical cord occlusion.

Spontaneous Resolution of Mirror Syndrome following Demise of Hydropic Twin.

Maternal mirror syndrome is a rare consequence of fetal hydrops. By convention, delivery is recommended in pregnancies complicated by mirror syndrome due to grave fetal prognosis. We describe a case of a dichorionic, diamniotic twin gestation complicated by hydrops fetalis of twin B. The patient declined selective feticide. Two weeks later, intrauterine fetal demise of fetus B was diagnosed and complete resolution of mirror syndrome followed. Unaddressed, mirror syndrome can lead to significant maternal and fetal complications. This case illustrates resolution of mirror syndrome following spontaneous intrauterine demise of the hydropic fetus.

Earlier gestational age at ultrasound evaluation predicts adverse neonatal outcomes in the preterm appropriate-for-gestational-age fetus with idiopathic oligohydramnios.

Oligohydramnios is related to adverse perinatal outcomes particularly when associated with fetal growth restriction. The purpose of this study was to delineate predictors of adverse perinatal outcomes in cases of preterm idiopathic oligohydramnios associated with appropriate-for-gestational-age (AGA) fetal biometry. A database of preterm AGA fetuses (< 37 weeks) presenting for evaluation of idiopathic oligohydramnios (defined as an amniotic fluid index [AFI] < 10th percentile) in the third trimester with delivery information and uterine artery Doppler indices (average resistance index [RI] and bilateral notching) available was prospectively collected ( N = 90). AFI and birth weight (BW) percentiles were calculated using standard tables. Chi-square and Student T test were used to evaluate for predictors of adverse perinatal outcomes including BW < or = 10th percentile, stillbirth, neonatal intensive care unit admission, 5-minute Apgar score < 7, preterm delivery < 35 weeks, and preeclampsia. Patients destined to experience poor perinatal outcomes (22%) were demographically similar to those experiencing normal outcomes in terms of maternal age ( P = 0.5), ethnicity ( P = 0.9), body mass index ( P = 0.3), and parity ( P = 0.9). However, at-risk patients were more likely to present with oligohydramnios at an earlier gestational age (GA) than those not at risk (33.0 +/- 3.0 versus 34.4 +/- 2.0 weeks; P = 0.02). There were no differences in perinatal outcomes associated with AFI percentile ( P = 0.9), increased average uterine artery RI ( P = 0.5), bilateral notching ( P = 0.4) or a combination of increased uterine artery RI and bilateral notching ( P = 0.2). Patients with preterm AGA fetuses who present with idiopathic oligohydramnios at an earlier GA are at risk for adverse perinatal outcomes compared with those presenting later in gestation. Sonographic indices, particularly uterine artery Doppler findings, were not found to be useful predictors of adverse outcomes.

Adenosquamous histology predicts a poor outcome for patients with advanced-stage, but not early-stage, cervical carcinoma.

BACKGROUND: The objective of this study was to compare survival between patients with adenocarcinoma and patients with adenosquamous carcinoma of the cervix. METHODS: Patients who were diagnosed with invasive cervical carcinoma from 1988 to 1999 were identified from the Automated Central Tumor Registry for the United States Military Health Care System. Clinical data, including race, age at diagnosis, histology, tumor grade, disease stage, lymph node status, treatment modality, and survival, were collected. Survival analysis was performed with Kaplan-Meier survival curves and compared using the log-rank test. RESULTS: A total of 273 women were identified, 185 women with a histologic diagnosis of adenocarcinoma (AC) and 88 women with a diagnosis of adenosquamous carcinoma (ASC). Among the women with ASC, only 5% had Grade 1 tumors, and 66% had Grade 3 tumors. By comparison, among the women with AC, 37% had Grade 1 tumors, and 26% had Grade 3 tumors (P < 0.001). There was no difference in the incidence of positive lymph nodes or in the number of patients who underwent radical hysterectomy as primary treatment between patients with ASC and patients with AC. More patients with ASC received radiation therapy (51% vs. 28%) or chemotherapy (29% vs. 12%) as treatment (P < 0.001). Patients who had tumors with ASC histology had a significantly decreased 5-year survival rate compared with patients who had tumors with AC histology (65% vs. 83%; P < 0.002). When patients with early-stage cervical carcinoma (International Federation of Gynecology and Obstetrics [FIGO] Stage I) were examined separately, there was no statistically significant difference in the 5-year survival rate (AC, 89%; ASC, 86%; P = 0.644). However, when patients with advanced-stage disease (FIGO Stages II-IV) were analyzed, ASC was associated with a significant decrease in median and overall survival (P = 0.01). When the results were analyzed by grade, patients who had tumors with ASC histology had a shorter survival compared with patients who had AC histology of any grade; however, this was a significant difference only for patients with Grade 1 tumors: The 5-year survival rate for patients with Grade 1 AC was 93%, compared with 50% for patients with Grade 1 ASC (P < 0.01). CONCLUSIONS: ASC histology appears to be an independent predictor of poor outcome in women with cervical carcinoma compared with their counterparts who have pure AC. The significant decrease in survival was observed only in patients with advanced-stage cervical carcinoma. This decreased survival may be related mainly to the grade of ASC.

Comparative antibiotic resistance of diarrheal pathogens from Vietnam and Thailand, 1996-1999.

Antimicrobial resistance rates for shigella, campylobacter, nontyphoidal salmonella, and enterotoxigenic Escherichia coli were compared for Vietnam and Thailand from 1996 to 1999. Resistance to trimethoprim-sulfamethoxazole, ampicillin, chloramphenicol, and tetracycline was common. Quinolone resistance remains low in both countries, except among campylobacter and salmonella organisms in Thailand. Nalidixic acid resistance among salmonellae has more than doubled since 1995 (to 21%) in Thailand but is not yet documented in Vietnam. Resistance to quinolones correlated with resistance to azithromycin in both campylobacter and salmonella in Thailand. This report describes the first identification of this correlation and its epidemiologic importance among clinical isolates. These data illustrate the growing magnitude of antibiotic resistance and important differences between countries in Southeast Asia.