Obesity and Penetrating Trauma: Outcomes from a Level 1 Trauma Center in New York City.

Background: Obesity is associated with increased morbidity and mortality in trauma scenarios; however, there has been conflicting evidence on outcomes of obesity and penetrating injuries, specifically gunshot wounds and stab wounds. We hypothesized that obesity may be protective due to a "cushioning effect" attributed to increased adiposity. Methods: This was a retrospective cohort study of patients presenting to a Level 1 Trauma Center with a penetrating trauma (gunshot/stab) injury during 2008-2021. Patients with a BMI ≥ 30 were compared to those with a BMI < 30. The primary outcome was Injury Severity Score (ISS). Secondary outcomes included intensive care unit (ICU) length of stay, days on ventilation, length of hospital stay, service of admission (trauma surgery, general surgery, discharged home, general medical floor), the body region of injury(s), Abbreviated Injury Scale (AIS), OR requirement, type of surgery, and discharge status. Statistical analysis was performed using χ2-test or Fisher's exact tests for categorical data, and Student's t-test or Mann-Whitney U-test for continuous variables with p < 0.05 as statistically significant. Subgroup analysis was performed based on the mechanism of injury. Results: There were 721 patients that met inclusion criteria, of which 540 were classified in the non-obese group and 181 (25.1%) in the obese group. The primary outcome, mean ISS score, in obese patients (9.0, SD = 13.0) and non-obese patients (9.4, SD = 13.8) was similar between groups respectively. Secondary outcomes, which included rates of severe abdominal injury (AIS ≥ 3), rates of intra-abdominal organ injury, and rates of gastro-intestinal resection, were also similar between non-obese and obese patients. Conclusion: This study did not demonstrate the existence of a "cushioning effect" in the setting of penetrating traumatic injury. Patients with increased BMI had similar a ISS score and patterns of injury as their non-obese counterparts.

Obesity as a Risk Factor for Adverse Outcomes After Pedestrian Trauma Accidents in the Pediatric Population.

OBJECTIVE: The aim of the study is to determine whether overweight or obese children are at an increased risk for injury and adverse outcomes following pedestrian motor vehicle accidents. METHODS: We performed a retrospective study of patients between the ages of 2 and 17 who were pedestrians injured in a collision with a motorized vehicle, presenting to a level 1 trauma center, between January 1, 2010, to December 31, 2021. Patients with admission weights falling above the 90th percentile of the Centers for Disease Control and Prevention's sex-specific growth charts were identified as overweight/obese, those below the cutoff were categorized as nonobese. Groups were compared regarding demographics, mechanism of injury, Injury Severity Score, and Abbreviated Injury Scale by body region of injury. Outcome measures included hospital admission, length of hospital stay, intensive care unit (ICU) admission, ICU length of stay, and mortality. RESULTS: Of the 306 patients included, 72 (23.5%) were overweight/obese and 234 (76.5%) were nonobese. The mean Injury Severity Score scores were higher among overweight/obese patients (5.37 vs 8.74, P = 0.008). Overweight/obese children were more likely to sustain severe abdominal injuries (Abbreviated Injury Scale ≥ 3) (12.2% vs 5.1%; odds ratio [OR], 2.64; 95% CI, 1.07-6.56; P = 0.030), be admitted to the hospital (94.5% vs 74.3%; OR, 12.07; 95% CI, 2.87-50.72; P < 0.001), require ICU admission (31.0% vs 20.0%, OR, 1.87; 95% CI, 1.03-3.36; P = 0.036), and require a longer ICU stay (0.9 vs 0.4 days, P = 0.014) compared with nonobese patients. CONCLUSIONS: Obese and overweight children are at increased risk for higher injury severity scores, severe abdominal injuries, and ICU admission after pedestrian motor vehicle accidents.

Predictive Factors for First-Pass Intubation Failure in Trauma Patients.

Objective: The primary objective of this study was to elucidate risk factors for multiple intubation attempts (MIA) in trauma patients requiring emergent tracheal intubation (ETI). Risk factors for mortality, intensive care unit (ICU) admission, and prolonged ventilation were assessed as secondary outcomes. The association between multiple intubation attempts and adverse outcomes has been well described in the literature. Though previous studies have identified anatomical risk factors for difficult airways, no study to date has investigated predictors for MIA in a trauma setting. Methods: The retrospective study involved 174 adult patients who required ETI and who presented to a Level 1 Trauma Center's emergency department between January 2019 and December 2022. Comorbidities, demographic information, triage vitals, intubation characteristics, and patient outcomes were identified to ascertain predictive risk factors for MIA. Variables were assessed for statistical significance on unadjusted analysis. Significant variables were entered into multivariate logistic regression models to test for adjusted associations, with p≤.0.05 as statistically significant, and presented as adjusted odds ratios with 95% confidence intervals. Results: Twenty-six (14.9%) of the 174 patients required multiple intubation attempts. There were no significant associations between MIA and patient gender, age, BMI, race, injury mechanism, or specific body region injuries. On univariate analysis, the MIA group had a statistically significant elevation in mean systolic blood pressure (151.71 ± 45.96 vs 133.55 ± 32.11, p = 0.019) and heart rate (106.30 ± 34.92 vs 93.35 ± 24.82, p < 0.032) compared to subjects with first-pass success. Elevation in systolic blood pressure (SBP) (151.71 ± 45.96 vs 133.55 ± 32.11, aOR 1.03 (1.01-1.06), p < 0.015) was an independent predictor of multiple intubation attempts. Conclusion: Elevation in SBP was a significant predictor of multiple intubation attempts. Critical appraisal of patients requiring ETI with elevated SBP may mitigate risk in trauma settings.

Evaluating Inpatient Hospital Charges Associated With Trauma Service Patients Participating in an Accountable Care Organization.

Background: The Medicare Accountable Care Organization (ACO) Program has created a vehicle for providers who practice cost containment and exceed quality for the Medicare population. The success of ACO's nationwide have been well documented. However, there is little research evaluating if there is a cost saving benefit in trauma care with respect to participating in an ACO. Thus, the primary objective of this study was to evaluate inpatient hospital charges associated with trauma service utilization of patients participating in the ACO compared to non-ACO patients. Methods: This case-control retrospective study includes a comparison of inpatients charges of ACO patients (cases) and general trauma patients (controls) presenting to our trauma center in Staten Island, New York from January 1st, 2019 to December 31st, 2021. A 1:1 matching of case to control was performed based on age, sex, race, and injury severity score. Statistical analysis was performed with IBM SPSS, with P < .05 as significant. Results: A total of 80 patients were included in the ACO cohort and 80 matched in the General Trauma cohort. Patient demographics were similar. Comorbidities were similar with the exception of a higher in incidence of hypertension (75.0% vs 47.5%, P < .001) and cardiac disease (35.0% vs 17.5%, P = .012) in the ACO cohort. Both the ACO and general trauma cohort had similar Injury Severity Scores, number of visits and lenght of stay. Both charge total ($76 148.93 vs $70 916.82, P = .630) receipt total ($15 080.26 vs $14 180, P = .662) charges were similar between ACO and General Trauma patients. Conclusion: In spite of increased incidence of hypertension and cardiac disease in ACO trauma patients, mean Injury Severity Score, number of visits, length of hospital stay, ICU admission rate and charge total was similar compared to general trauma patients presenting to our Level 1 Adult Trauma Center.

Trauma-related falls in an urban geriatric population: predictive risk factors for poorer clinical outcomes.

BACKGROUND: The aim of this study was to elucidate associations between polypharmacy, types of medications, and geriatric comorbidities to identify predictive risk factors for poorer clinical outcomes following trauma-related falls in the geriatric population. Nearly 80% of trauma-related hospital admissions in the older adult population are secondary to falls, accounting for 3 million emergency department visits annually. Numerous studies have demonstrated associations between falls, polypharmacy, and other geriatric comorbidities, but studies outlining predictive risk factors for poor clinical outcomes are lacking. METHODS: A retrospective cohort study of 1087 patients ≥ 65 years old who presented to Level 1 Trauma Center after a trauma-related fall. Comorbidities, current medication, demographic information, and clinical outcomes were identified to ascertain predictive risk factors for poorer clinical outcomes. Variables were assessed for statistical significance on unadjusted analysis. Variables found to be significant were entered into a multivariable logistic regression model to test for adjusted associations, with p < 0.05 as statistically significant, and presented as adjusted odds ratios with 95% confidence intervals. RESULTS: Polypharmacy ≥ 4 medications (aOR 2.38 (1.10-5.15), p < .028) was an independent predictor of hospital readmission within 30 days. Chronic kidney disease, male gender, and Asian race had an increased association with ICU admission. History of malignancy (aOR 3.65 (1.62-8.19), p < .002) and chronic kidney disease (aOR 2.56 (1.11-5.96), p < .027) were independent predictors of 30-day mortality. CONCLUSIONS: Polypharmacy, chronic renal disease, malignancy history, male gender, and Asian race had an increased association of adverse clinical outcomes after falls in the geriatric population. Critical evaluation of patients with these risk factors may be needed to mitigate risk in this population.

Robotic omentectomy in gynecologic oncology: surgical anatomy, indications, and a technical approach.

An omentectomy is a standard component care of gynecological cancers, particularly for surgical staging and treatment for malignant ovarian neoplasms, borderline tumors, fallopian tube cancers, primary peritoneal cancers as well as certain histological subtypes of endometrial cancer. Traditionally, an omentectomy is performed by an open laparotomy approach, however, use of a robotic approach has gained popularity and has been proven to be both safe and effective. In spite of the advantages of robotic surgery compared to laparotomy, the inherent technical challenges of a robotic omentectomy may limit its uptake. In this article, we review (1) the physiology and surgical anatomy of the omentum, (2) the role of the omentum in immune regulation and oncogenesis, (3) indications for an omentectomy in the setting of gynecological malignancy, and (4) describe a step-by-step 3-arm technique for performing both a infracolic and gastrocolic omentectomy procedure using a robotic approach.

Evaluation of the Virtual Interviews for Resident Recruitment Due to COVID-19 Travel Restrictions: A Nationwide Survey of US Senior Medical Students.

BACKGROUND AND OBJECTIVES: Due to COVID-19, residency programs could not conduct in-person interviews during the 2020-2021 match and were forced to implement a virtual format. We conducted a nationwide survey of US senior medical students to evaluate their perception of the virtual interview process and to solicit their recommendations for future virtual interview best practices. METHODS: This study was administered to US fourth-year medical students currently participating in the residency match using Survey Monkey during March 2021. Students were contacted through their respective student affairs deans. Surveys solicited demographic information, 26 4-point Likert-scale questions, and four free-response questions. RESULTS: A total of 357 surveys were completed. Most respondents stated that they could confidently represent themselves to the program (71.7%) using a virtual platform. However, only 11.6% stated that they could confidently assess a program's facility using a virtual platform. Although most respondents (58.26%) found that virtual meet and greets helped them better assess their fit for the program, less than half (46%) confidently believed they could assess their fit into the program after the conclusion of the virtual interview. Regarding potential disparities introduced by virtual interviews, 40.6% believed that the virtual interviews introduce greater inequalities into the match process. Two-thirds of respondents (239, 66.95%), believed that there should be a limit on the number of interview offers an applicant can accept, with the maximum number of interviews per specialty capped at 25.7 (10-150). Finally, just over two-thirds (69.47%), claimed they could confidently prepare their rank-order list at the conclusion of the interview. CONCLUSIONS: Most respondents found virtual interviews financially beneficial, however difficulty in assessing fit was a challenge. Best practice recommendations from the respondents include shorter interviews, more engaging resident-led social hours without faculty present, and preinterview packages to include video representations of the program facilities.

Impact of the COVID-19 Pandemic on Trauma Service Utilization at a New York City Level I Trauma Center.

Background: The COVID-19 pandemic globally impacted trauma facilities and overall healthcare utilization. This study was conducted to characterize the utilization of trauma services at our Level I Trauma Center in New York City during the COVID-19 pandemic compared to the preceding pre-pandemic year. Methods: A retrospective study of patient presenting to our Level 1 Trauma Center in Staten Island, New York. The pre-pandemic data was extracted from March 1st, 2019-February 29th, 2020. The pandemic year was divided into two phases: the initial wave (March 1st-Sept 1st, 2020) and the protracted phase (September 1st, 2020-March 1st, 2021). Patients were identified using ICD-10 coding and data regarding patient factors, mechanism of injury, and service utilization was extracted from the medical record. Statistical analysis was performed using IBM SPSS v.24. Results: A total of 1650 trauma activations registered during the pre-pandemic phase, 691 during the initial wave, and 826 during the protracted phase. Compared to pre-pandemic, the number of Level 1 trauma activations remained unchanged, however mechanisms of injury shifted. Gunshot wounds (2.6% vs 1.2%), motorcycle crash (4.2% vs 2.0%) and blunt force injury caused by an object (strike injuries) (2.7% vs 1.3%) significantly increased during the initial wave (p-value <0.05). There was a significant decrease in the percentage of both female (2.93% vs 2.33% vs 5.64%, p-value <0.01) and pediatric (3.30% vs 3.64% vs 12.9%, p-value <0.001) assault activations during the initial wave and protracted phase when compared to pre-pandemic levels, respectively. No significant changes were observed for self-harm, falls, accidents, burns, sports injuries, stab wounds, autobody collisions, or motor vehicle accident activations. Conclusion: Trauma centers should be prepared for increases in violent trauma. We also emphasize the need to implement strategies to raise public awareness of pediatric and female assault in the domestic setting, particularly during a mandatory stay-at-home policy where underreporting may occur.

The glitz and glamour randomized trial: the effect of fingernail polish on post-caesarean surgical site infection.

Current surgical scrub guidelines suggest that fingernail polish should not be worn by healthcare providers despite collective evidence not demonstrating a relationship between fingernail polish and surgical-site infection (SSI). The purpose of this study was to determine the effect of surgical staff wearing nail polish on the incidence of SSI after caesarean delivery. In this calendar block-randomised clinical trial, surgical staff were assigned to wear nail polish or to have unpainted nails for alternating two-week periods. The primary outcome was surgical site infection within 6 weeks of caesarean delivery. There were 372 patients in the nail polish arm and 465 in the polish-free arm. The rate of SSIs was not significantly different between the nail polish arm and the polish-free arm (1.3% vs 2.8% p = .155). We found the rate of SSI following caesarean delivery is not significantly affected by surgical staff wearing fingernail polish.Impact StatementWhat is already known on this subject? Current surgical scrub guidelines state that fingernail polish should not be worn by healthcare providers even though the collective evidence has not been able to show the relationship between fingernail polish and surgical site infection. Previous studies have only used bacterial colony count after handwashing as a primary endpoint. The evidence they provide for developing scrub guidelines have been contradictory and inconclusive.What do the results of this study add? To better inform surgical scrub guidelines, evidence is needed that evaluates the effect of fingernail polish on clinically significant endpoints. Our study, Glitz & Glamour, examined 885 non-emergent Caesarian sections using a calendar-block schedule to determine if wearing nail polish had an impact on rates of surgical site infection.What are the implications of these findings for clinical practice and/or further research? Results suggested that fingernail polish had no difference on frequency of surgical site infections, and neither condition of the polish (chipped vs. freshly applied) nor the type of polish (gel vs. regular) had any impact either.

Evaluation of the Virtual Interview Format for Resident Recruitment as a Result of COVID-19 Restrictions: Residency Program Directors' Perspectives.

PURPOSE: Due to the COVID-19 pandemic, residency programs could not conduct in-person interviews during the 2020-2021 Match cycle and were forced to implement a virtual format. The authors conducted a nationwide survey of residency program directors (PDs) to assess their confidence in using a virtual platform to holistically evaluate applicants during the 2020-2021 Match cycle and their desire to continue virtual recruitment during forthcoming interview seasons. METHOD: This prospective study was conducted by email questionnaire administered through the survey tool Survey Monkey to residency PDs from March 7, 2021-March 27, 2021. The residency PDs surveyed represented these subspecialties: internal medicine, general surgery, obstetrics and gynecology, pediatrics, psychiatry, and other. Email addresses of PDs were collected from a public list developed by the Accreditation Council for Graduate Medical Education. Surveys contained demographic questions, 4-point Likert scale questions evaluating several factors regarding the interview and matching process, and free-response questions. RESULTS: A total of 463 surveys were sent; response rate was 402 /463 (86.8%). Most PDs were less confident assessing an applicant's interpersonal skills (247, 61.4%) and professionalism (239, 59.5%) using a virtual platform. Assessment of an applicant's "fit" into the program was also challenging: 44.3% (178) of those surveyed disagreed with the statement that they could do so confidently. Additionally, 73.9% (297) of PDs found it challenging to gauge an applicant's genuine interest and only 41.3% (166) strongly agreed or agreed that they could accurately represent their own program using a virtual platform. More than half of PDs (220, 54. 7%) found it more difficult to rank interviewees compared with previous in-person Match cycles. CONCLUSIONS: Most residency PDs found virtual interviews convenient. However, difficulties in assessing fit virtually, gauging applicants' interest, and showcasing their respective programs were challenges that may persist should virtual interviews continue post-pandemic.

The virtual interview format for fellowship recruitment in obstetrics and gynecology: a nationwide survey of program directors.

Due to Covid-19, fellowship programs could not conduct in-person interviews during the 2020-2021 interview cycle and were forced to implement virtual interviews. We conducted two nationwide surveys of residency and fellowship Program Directors (PDs) involved in the Obstetrics and Gynecology (Ob/Gyn) Subspecialty Fellowship match cycle to gain a better understanding of virtual interviews from each of their perspectives. 1) Fellowship PDs' confidence in using a virtual platform to holistically evaluate applicants during the 2020-2021 match cycle, 2) Residency PD's perception of virtual interviews and impact on their program's operations, and 3) to assess the desire of fellowship and residency PDs to continue virtual recruitment during forthcoming interview seasons. Two separate nationwide web-based surveys were administered to 1) Ob/Gyn fellowship PDs and 2) residency PDs through SurveyMonkey from July-September 2020 to assess the impact of virtual interviews form each parties' perspective. Surveys solicited demographic information, four-point Likert scale questions, and free response questions Of programs meeting inclusion criteria, 75/111 (67.6%) fellowship PDs and 67/117 (57.3%) residency PDs responded to their respective surveys. Most fellowship PDs believed that they could confidently assess applicants' professionalism (88%) during a virtual interview and (90.7%) felt confident in making a rank-order list. However, only 73.3% were just as confident in preparing a rank list after a virtual interview as they have been with in-person interviews. Most residency PDs (69.9%) believed that virtual interviews made it easier for their program to comply with duty hours, and 76.8% agreed that virtual interviews allowed their residents to accept more interviews than an in-person format. Most fellowship PDs found virtual interviews convenient. However, difficulty in observing social interaction and gauging applicant interest may be the biggest challenge moving forward.

Sexual Health Screening for Gynecologic and Breast Cancer Survivors: A Review and Critical Analysis of Validated Screening Tools.

INTRODUCTION: Studies have shown that the sexual health concerns of gynecologic and breast cancer survivors are not adequately being addressed by clinicians. AIM: To provide a comprehensive narrative review of validated sexual health screening tools and aid clinicians in choosing a screening tool that will allow them to best address their patients' sexual health concerns METHODS: A review of PubMed and Google Scholar databases was conducted, using search terms "sexual health", "screening", "tools", "cancer", and "survivors" to identify sexual health screening tools meeting the following inclusion criteria: 1) published in a peer-reviewed journal, 2) were written in English, 3) included breast and/or gynecological cancer patient population, 4) included self-reported measure of sexual health and function, and 5) underwent psychometric validation. MAIN OUTCOME MEASURE: Criteria used to evaluate identified screening tools included ability to assess desire, arousal, satisfaction, orgasm, dyspareunia, solo sexual expression, relationship with partner, body image, distress over changes in sexual function, and support systems. Pre and post- treatment comparisons, differentiation between lack of sexual desire and inability, heterosexual bias, diversity in patient population, and ease of scoring were also evaluated. RESULTS: Based upon the inclusion criteria, the following 10 sexual health screening tools were identified and reviewed: Female Sexual Function Index, European Organization for Research and Treatment of Cancer Quality of Life Questionnaires for both Cervical and Endometrial Cancer, Sexual Adjustment and Body Image Scale, Sexual Adjustment and Body Image Scale- Gynecologic Cancer, Sexual Function and Vaginal Changes Questionnaire, Gynaecologic Leiden Questionnaire, Information on Sexual Health: Your Needs after Cancer, Sexual Satisfaction Questionnaire, and Sexual Activity Questionnaire. Most tools assessed satisfaction (n=10), desire (n=9), and dyspareunia (n=8). Fewer addressed objective arousal (n=7), body image/femininity (n=7), partner relationship (n=7), orgasm (n=5), pre/post treatment considerations (n=5), distress (n=4), and solo-sexual expression (n=2). Heterosexual bias (n=3) and failure to differentiate between lack of desire and inability (n=2) were encountered. CONCLUSION: Understanding the strengths and limitations of sexual health screening tools can help clinicians more effectively address cancer survivors' sexual health concerns, which is essential in providing comprehensive care and improving quality of life. Screening tools have room for improvement, such as eliminating heterosexual bias and including cancer and treatment-specific questions. Clinicians can use this guide to select the most appropriate screening tool for their patients and begin bridging the gap in sexual healthcare. Tounkel I, Nalubola S, Schulz A, et al. Sexual Health Screening for Gynecologic and Breast Cancer Survivors: A Review and Critical Analysis of Validated Screening Tools. Sex Med 2022;10:100498.

Maternal anthropometric measurements and correlation to maternal and fetal outcomes in late pregnancy.

BACKGROUND: Body mass index does not distinguish between lean and fat body mass; therefore, its utility defining body composition is limited in pregnancy. Anthropometric measurements may better represent variation in body composition among women who are overweight or obese. We sought to examine body fat composition using maternal anthropometric measurements in late pregnancy and correlate with mode of delivery. METHODS: A prospective study of pregnant patients who were overweight (body mass index: 25-29.9 kg/m2) or obese (body mass index ⩾ 30 kg/m2) with singleton pregnancies who underwent anthropometric measurements between 27 weeks, 0 days to 34 weeks, 6 days gestation. Maternal skinfold thicknesses from eight sites were used to estimate body fat mass. Correlation of skinfold thickness, anthroprometric measurements, and estimated body fat percentage on mode of delivery were analyzed with p < .05 as significant. RESULTS: A total of 41 women with overweight (34.1%) or obese (65.9%) body habitus were included. Mean age was 29.9 years, and the majority (43.9%) were Black and 31.7% identified Hispanic/Latinx. The average gestational age at recruitment was 30 weeks, 2 days and 38 weeks, 6 days at delivery. A greater weight at recruitment (94.2 vs 81.8 kg, p = .023), waist circumference (47.1 vs 43.5 inches, p = .010), Huston-Presley body fat percentage (36.4% vs 31.8%, p = .030), triceps skinfold thickness (20.1 vs 15.7 mm, p = .030), biceps skinfold thickness (18.6 vs 15.0 mm, p = .042), and skinfold thickness, as well as sum of skinfold sites (83.3 vs 68.8 mm, p = .049) were associated with cesarean delivery compared to vaginal delivery on univariate analysis. CONCLUSION: Third-trimester anthropometric measurements may help predict increased risk for c-section in women with obesity. Further research may elucidate utility in nutritional counseling and delivery planning.

Multidisciplinary Programed Learning Simulation to Improve Visual Blood Loss Estimation for Obstetric Trauma Scenarios.

INTRODUCTION: We designed and implemented a Programmed Learning Simulation (PLS) exercise depicting obstetric scenarios of hemorrhage to train anesthesiologists, ancillary staff, and surgeons to accurately estimate blood loss visually. We then measured the efficacy of this exercise in a clinical setting. METHODS: We conducted a prospective study to assess the effect of implementing a PLS exercise on quantification of blood loss in an operative setting. The PLS exercise consisted of 13 simulation stations of varying quantities of simulated blood loss paired with standardized objects of known volume. Eighty-eight individuals participated including attending physicians, residents, medical students, and ancillary staff participated in this study. The PLS was part of regularly scheduled continuing medical education activities; thus, the sampling used was non-randomized convenience method. The percent error was calculated for each of the 13 stations. A subgroup analysis was performed to assess the effect of the years of experience, size of hemorrhage, and occupation on accuracy. Univariate analyses for continuous variables were compared using a one-way ANOVA test. For the comparison of the three groups (years of experience and size of hemorrhage), a p-value of <0.02 was considered statistically significant and for 5-way comparison (professional grouping) a p <0.01 was considered significant after application of the Bonferroni correction (α=0.05). (Part A). To determine the effect of PLS in a clinical setting, the percent error of blood loss estimation for cesarean deliveries during the two-month period after the PLS exercise was compared to the two-month period immediately prior to using the student's t-test with p<0.05 as significant (Part B). Statistical analysis was performed using International Business Machine, Statistical Package for the Social Sciences, Version 26.0 (IBM SPSS). RESULTS: During Part A, the baseline performance of the participants was evaluated during the PLS activity. The PLS data showed no significant difference in absolute value of mean percent error estimation (standard deviation) across professions: student 63.61% (69.74), ob/gyn 56.91% (47.72), ancillary 62.15% (77.90), general/trauma surgeon 66.70% (65.06), anesthesia 61.51% (63.12). (p = 0.681), or levels of experience 0-5: 62.21% (60.06), 6-10 years: 56.22% (52.66), greater than 10 years: 61.89% (71.89) (p = 0.831). However, mean percent error of estimation was higher when participants estimated smaller samples 77.7% (104.73) compared to either medium 56.8% (49.06) or large 57.9% (46.19) samples (p<0.001). For Part B, 179 cesarean deliveries occurred during the pre-intervention period and 193 occurred during the post-intervention period. Mean error in provider estimation of blood loss significantly improved from 47% (68.51) pre-intervention to 31% (32.70) post-intervention (p=0.009). CONCLUSION: We believe our described PLS activity was effective in teaching techniques for visual blood loss estimation. This was reflected by improved competency in a clinical setting, demonstrated by more accurate visually estimated blood loss during the period immediately following simulation activity compared to a prior time frame. Further research is needed to assess the impact of simulation activities on patient outcomes, such as utilization of blood products and patient morbidity.

Fetal and maternal inflammatory response in the setting of maternal intrapartum fever with and without clinical and histologic chorioamnionitis.

BACKGROUND: Both infectious and noninfectious causes of maternal fever have been linked to adverse neonatal outcomes including low Apg0ar scores, respiratory distress, hypotonia, and neonatal seizures. Even in the absence of infection, the occurrence of intrapartum fever is a strong risk factor for poor long-term neonatal developmental outcomes, including encephalopathy, cerebral palsy, and neonatal death. OBJECTIVE: The primary objective of this study was to compare intrapartum and postpartum maternal and fetal umbilical cord serum levels of cytokines RANTES, interferon-É£, interleukin-1ß, interleukin-2, interleukin-4, interleukin-6, interleukin-8, interleukin-10, interleukin-13, and tumor necrosis factor-α among nonfebrile patients, febrile patients without clinical chorioamnionitis, and febrile patient with clinical chorioamnionitis. STUDY DESIGN: This study was conducted at the Richmond University Medical Center from May 15, 2020 to July 16, 2019. During this time, we recruited 30 nonfebrile patients at >36 gestational weeks who were in labor and collected umbilical cord and pre- and postdelivery maternal serum samples to evaluate the cytokine levels. Placentas were collected for pathologic review and to evaluate the histopathologic findings. These results were compared with 121 patients who developed a fever of >38°C during labor. The febrile patients were further divided based on the presence or absence of clinical chorioamnionitis. A secondary analysis was performed based on the presence of absence of histologic chorioamnionitis. Statistical analysis was performed using IBM Statistical Package for the Social Sciences version 25.0. For the 3 group comparisons, a P value of <.017 was considered statistically significant after application of a Bonferroni correction. RESULTS: A total of 151 patients were included in the study; 30 were nonfebrile patients, 46 were febrile patients with a diagnosis of clinical chorioamnionitis, and 75 were febrile patients without clinical chorioamnionitis. Compared with nonfebrile patients, umbilical cord serum interferon-É£, interleukin-1ß, interleukin-6, interleukin-8, RANTES, and tumor necrosis factor-α levels were elevated in the presence of maternal hyperthermia irrespective of the diagnosis of clinical chorioamnionitis. Interleukin-6 umbilical cord levels were more than doubled from 63.60 pg/mL (6.09-1769.03 pg/mL) in febrile patients with no clinical chorioamnionitis to 135.77 pg/mL (1.86-6004.78 pg/mL) in febrile patients with clinical chorioamnionitis, making it the only cytokine that was significantly different between these 2 groups. When comparing the intrapartum maternal serum, we found a significant elevation in the interleukin-10, RANTES, and tumor necrosis factor-α levels in the febrile group irrespective of the presence of clinical chorioamnionitis when compared with the nonfebrile group. In the postpartum maternal blood evaluations, tumor necrosis factor-α was the only cytokine that was significantly higher in febrile patients than in nonfebrile controls. CONCLUSION: In the setting of intrapartum fever, maternal cytokine profiles were similar irrespective of the diagnosis of clinical chorioamnionitis. Even in the absence of clinical or histologic chorioamnionitis, maternal hyperthermia induced elevations in fetal cytokines.

Predictive risk factors of adverse perinatal outcomes following blunt abdominal trauma in pregnancy.

BACKGROUND: The primary objective was to identify predictive risk factors of preterm delivery following blunt abdominal trauma. The secondary objective was to identify risk factors of other adverse outcomes, Neonatal Intensive Care Unit (NICU) admission, placental abruption, fetal demise, and Cesarean Delivery (CD). METHODS: This retrospective study included pregnant patients with gestational age (GA) ≥23 weeks who presented after blunt abdominal trauma to Richmond University Medical Center from October 2015 to January 2020. Patients were identified using the following diagnostic International diagnostic classification (ICD-10) codes: O9A.212, O9A.213, and 071.89, and excluded if trauma did not involve the abdomen, penetrating, <23 weeks, or incomplete records. Collected data points included maternal demographic factors, clinical laboratory values, maternal clinical findings at presentation, abdominal ultrasound, results of fetal monitoring, Abbreviated Injury Score (AIS) for abdomen, and Injury Severity Score (ISS). Univariate analyses were compared using the Student's t-test or Mann-Whitney U-test. Categorical data were compared using the chi-squared test or Fisher's exact test with P-value < .05 as significant. RESULTS: 154 patients were included in the final analysis. The incidence of the primary outcome, preterm delivery before 37 weeks, was 11.0% (17/154). The incidence of secondary outcomes following blunt abdominal trauma were abruption 0% (0/154), fetal demise 0.6% (1/154), CD 44% (68/154), NICU admission 24% (37/154). Maternal demographic factors, presence of uterine contractions, maternal clinical conditions (abdominal pain, abdominal tenderness, vaginal bleeding), hematologic and coagulation studies, ultrasound findings, fetal heart rate tracing category, AIS score for abdomen, and ISS score were not predictive of preterm delivery or other secondary outcomes. CONCLUSION: The incidence of adverse maternal and neonatal outcomes is low following blunt abdominal trauma. Extended monitoring of asymptomatic patients including laboratory tests and coagulation profiles were not predictive of preterm labor or secondary adverse perinatal outcomes. LEVEL OF EVIDENCE: Therapeutic/Care management, Level III.

The vertical dimension of obesity: adverse pregnancy outcomes in the short obese versus tall obese parturient.

The objective of this study was to examine the effect of maternal height on adverse perinatal outcomes in obese parturients. This retrospective study was conducted from January 2015 to December 2015. Patients with BMI ≥ 35.0 kg/m2 before delivery were included and divided into 2 groups based on height. Patients ≤63 inches were in the short stature group and those > 63 inches were in the tall stature group. One hundred and twenty-five patients were in the short stature cohort and 124 in the tall stature cohort. Patients in short cohort had a significantly higher risk of preterm delivery <37 weeks (RR = 4.21 [1.24, 12.88]), spontaneous rupture of membranes (RR 1.47 [1.01-2.16]), and second stage caesarean delivery (CD) (RR 2.64 [1.1-6.39]). After multiple regression analysis, Hispanic race and short stature were independent predictors of preterm birth for obese patients.IMPACT STATEMENTWhat is already known on this subject? Compared to normal weight individuals, those who are obese have at a higher risk of adverse obstetric and perinatal outcomes including gestational diabetes, hypertension, pre-eclampsia, thromboembolism, macrosomia, higher incidence of caesarean deliveries and perinatal mortality.What do the results of this study add? Our findings show that short stature is an independent predictor for adverse perinatal outcomes in obese women. Specifically, short obese patients had significantly higher risk of preterm delivery before 37 weeks and second stage CD.What are the implications of the findings for clinical practice and/or further research? Our findings highlight the need for formulating a tailored plan for preconception health including pregnancy weight goals in short obese women. Additionally, maternal fat distribution and its effect on pro-inflammatory cytokine profiles is a potential area for future research, as maternal body composition may be a better predictor of perinatal outcome than BMI.

Post-COVID Care Center to Address Rehabilitation Needs in COVID-19 Survivors: A Model of Care.

The severe acute respiratory syndrome coronavirus 2019 pandemic surge left a large cohort of patients vulnerable to cardiopulmonary, neurological, and psychiatric complications. This post-COVID Care center was established to identify patients with disease sequalae and deliver early multidisciplinary rehabilitation services. The evaluation included comprehensive history and physicals, screening tests, labs, and imaging to determine appropriate specialist referrals. After a 6-month period, 278 unique referrals were made to address symptoms reported by 114 patients in specialities including pulmonology, cardiology, and psychiatry. This framework allowed for individualized patient treatment and monitoring of disease after the acute phase of infection. This study highlights the substantial physical and psychosocial impact a coronavirus disease 2019 infection has on patients' long-term trajectory and emphasizes the need for early targeted rehabilitation Post-COVID Care centers. As the world transitions into the chronic phase of this pandemic, this model of care will provide a framework to improve the quality of health care delivery.

Initial surgical management of bulky malignant type II tumors of the endometrium by a robotic approach.

Type II uterine tumors often present with very large, necrotic tumor burden in the uterus that leads to dilation and effacement of the cervix. In patients with this presentation, conventional hysterectomy poses a much greater challenge as the ureters are composed of the mass of the tumor and are at an increased risk for injury. Given this surgical challenge, many of these patients may begin with neoadjuvant chemo-radiation. However, these treatment modalities are associated with significant toxicity and negatively impact patient quality of life. Therefore, we describe a minimally invasive robotic surgical approach that aims to optimize quality of life without sacrificing prognosis. Outcomes of 4 patients are presented.

Mechanistic Coupling of a Novel in silico Cotyledon Perfusion Model and a Physiologically Based Pharmacokinetic Model to Predict Fetal Acetaminophen Pharmacokinetics at Delivery.

Little is known about placental drug transfer and fetal pharmacokinetics despite increasing drug use in pregnant women. While physiologically based pharmacokinetic (PBPK) models can help in some cases to shed light on this knowledge gap, adequate parameterization of placental drug transfer remains challenging. A novel in silico model with seven compartments representing the ex vivo cotyledon perfusion assay was developed and used to describe placental transfer and fetal pharmacokinetics of acetaminophen. Unknown parameters were optimized using observed data. Thereafter, values of relevant model parameters were copied to a maternal-fetal PBPK model and acetaminophen pharmacokinetics were predicted at delivery after oral administration of 1,000 mg. Predictions in the umbilical vein were evaluated with data from two clinical studies. Simulations from the in silico cotyledon perfusion model indicated that acetaminophen accumulates in the trophoblasts; simulated steady state concentrations in the trophoblasts were 4.31-fold higher than those in the perfusate. The whole-body PBPK model predicted umbilical vein concentrations with a mean prediction error of 24.7%. Of the 62 concentration values reported in the clinical studies, 50 values (81%) were predicted within a 2-fold error range. In conclusion, this study presents a novel in silico cotyledon perfusion model that is structurally congruent with the placenta implemented in our maternal-fetal PBPK model. This allows transferring parameters from the former model into our PBPK model for mechanistically exploring whole-body pharmacokinetics and concentration-effect relationships in the placental tissue. Further studies should investigate acetaminophen accumulation and metabolism in the placenta as the former might potentially affect placental prostaglandin synthesis and subsequent fetal exposure.