Protocol-Driven Intensive Outpatient Management of Pregnant Patients With Symptomatic Coronavirus Disease 2019.

BACKGROUND: Reports of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have focused on pregnant women hospitalized due to moderate to severe coronavirus disease 2019 (COVID-19) or asymptomatic women diagnosed through universal screening at the time of obstetric admission. Many pregnant women who have symptomatic SARS-CoV-2 infection may not meet criteria for hospitalization; however, whether and how these women can be managed safely in outpatient setting is not well described. METHODS: We sought to describe the time to symptom and viral clearance and to identify predictors of hospitalization to better understand the safety of monitoring pregnant patients with symptomatic COVID-19 in the outpatient setting. We performed a retrospective cohort study of pregnant patients with symptomatic, confirmed COVID-19 illness at a large, academic medical center. Patients had systematic telehealth follow up by a clinician team to assess for symptoms, provide virtual prenatal care, and arrange in-person visits when appropriate in a dedicated outpatient center. Data were collected via chart abstraction. RESULTS: Of 180 pregnant patients presenting with symptoms and undergoing reverse-transcription polymerase chain reaction (RT-PCR) testing, 67 patients with confirmed COVID-19 infection were identified during the study period. Nineteen (28%) required acute care given worsening of COVID-19 symptoms, and 95% of these were directed to this acute care setting due to symptom severity telehealth evaluation. Nine women (13%) were admitted to the hospital given worsening symptoms, 3 required intensive care unit care, 2 required ventilatory support, and 2 required delivery. Women with the presenting symptoms of fever, cough, shortness of breath, chest pain, or nausea and vomiting were more likely to require admission. The median duration from initial positive test to RT-PCR viral clearance was 26 days. Disease progression, time to viral clearance, and duration of symptoms did not vary significantly by trimester of infection. CONCLUSIONS: Management of the majority of pregnant women with symptomatic COVID-19 illness can be accomplished in the outpatient setting with intensive and protocol-driven monitoring for symptom progression.

Nutritional outcomes with implementation of probiotics in preterm infants.

OBJECTIVE: To assess nutritional outcomes in preterm infants after the implementation of probiotics. STUDY DESIGN: Retrospective chart review of infants with birth weight⩽1250 grams and/or⩽28 weeks of gestational age admitted to the KCH-Neonatal Intensive Care Unit was done. Data were collected over two periods, period 1 (before probiotics) and period 2 (after probiotics) and included demographic data, daily weight gain, feeding strategies (type, amount, caloric content and frequency of feeds) and comorbidities affecting feedings (Patent ductus arteriosus, Sepsis). Primary outcomes-extra uterine growth restriction (EUGR) status and incidence of necrotizing enterocolitis (NEC) as well as secondary outcomes-time to reach full feeds, feeding intolerance episodes and weight gain were compared between the two groups. RESULTS: A total of 113 infants (period 1) were compared with 108 infants (period 2). The odds of EUGR was significantly lower with probiotics (odds ratio: 0.3, 95% confidence interval 0.138 to 0.611). Time to reach full feeds was significantly reduced and weight gain was significantly better in period 2. Significant reduction was also noted in number of total parental nutrition days, central line days, nil per os days and number of feeding intolerance episodes in period 2. There was no significant difference in the incidence of NEC. CONCLUSION: Probiotics improve feeding tolerance leading to better overall growth and decreases the incidence of EUGR in preterm infants.

An embolic complication in a donor twin with severe twin-twin transfusion syndrome after fetoscopic intervention.

Necrotic injury of an extremity in a donor twin is a rare complication of twin-twin transfusion syndrome after selective fetoscopic laser photocoagulation. We present the case of a 20-year-old gravida 2, para 1 with a twin gestation with severe twin-twin transfusion syndrome (Quintero Stage 3B) who had treatment with selective fetoscopic laser photocoagulation. Selective fetoscopic laser photocoagulation may be associated with extremity necrosis in a donor twin.

Solitary hepatic abscess with associated glomerulonephritis in a neonate.

A full-term neonate with a history of umbilical venous catheterization followed by coagulase-negative staphylococcal sepsis is presented. The infant developed a solitary hepatic abscess with saprophytic organisms. Her liver abscess resulted in acute glomerulonephritis characterized by hypertension, proteinuria, oliguria, and azotemia. Surgical drainage and antibiotic treatment of the abscess was associated with resolution of the glomerulonephritis. Glomerulonephritis due to solitary liver abscess in a neonate has not been reported previously. Acute onset of glomerulonephritis should prompt a search for occult sources of infection.

Screening for major deep vein thrombosis in seriously injured patients: a prospective study.

The purpose of the study is to determine the prevalence of acute deep venous thrombosis (DVT) in severely injured trauma patients, to investigate the cost effectiveness of a noninvasive surveillance program, and to assess the merit of current methods of prophylaxis against DVT. One hundred and forty-eight patients (295 limbs) with a mean age of 36.5 years, mean trauma score of 13.3, mean injury severity score of 22.4 with predominantly blunt injuries (88.5%), were part of the study. The mean length of stay was 17.6 days. Venous duplex scans (VDS) were performed on inpatients on days 2-5, day 11, and day 30 following admission. Sequential compression device and/or subcutaneous heparin was used in 99% of patients with compliance being monitored by trauma nurse clinicians. A total of 272 VDS were performed with total charges of $111,520. DVT was found by VDS or venography in eight limbs (2.7%) of six patients (4%), our of the limbs being symptomatic. Two additional patients had pulmonary embolism, both with normal VDS. Routine serial VDS in severely injured patients who undergo aggressive prophylaxis against DVT is not cost effective and therefore not justified.

Effect of disinfectants on the bond strength of composite to dentin.

PURPOSE: To investigate the effect of two cavity disinfectants, a 2% chlorhexidine (Bisco) and a 0.11% iodine/potassium-iodide/copper sulfate solution (ORA-5), on the shear bond strength of composite to dentin mediated by the dentin bonding agents (DBA), Syntac and Tenure. MATERIALS AND METHODS: The occlusal surfaces of 72 noncarious extracted human molar teeth were flattened to dentin using 500 grit sandpaper. They were randomly assigned (n = 12) to three groups within each DBA system: Bisco/Tenure, ORA-5/Tenure, Tenure, Bisco/Syntac, ORA-5/Syntac and Syntac. Dentin disinfectants were applied for 20 seconds and dried. DBA was applied following manufacturer's instructions. A hybrid resin composite (Tetric) was then bonded to all treated samples. The samples were thermocycled and tested in shear until failure. Fracture analysis was performed on dentin surfaces with both light and scanning electron microscopy. Shear bond strength data was analyzed using ANOVA, Student-Neuman-Keuls and Dunnett tests at P < 0.05. RESULTS: Shear bond values (Mean +/- SD, MPa) were: Syntac control 14.3 +/- 2.0, Bisco/Syntac 8.1 +/- 4.9 and ORA-5/Syntac 5.7 +/- 5.1; Tenure control 15.0 +/- 1.9, Bisco/Tenure 14.2 +/- 3.0 and ORA-5/Tenure 13.9 +/- 3.7. The only significant difference found between disinfectant treatment groups and the control groups was with Syntac. Fracture surface analysis revealed that with Tenure most failures were cohesive in resin but with Syntac, the disinfected samples displayed adhesive failures.

Contralateral disease progression after carotid endarterectomy.

BACKGROUND: We report the natural history of the carotid artery contralateral to the ipsilateral endarterectomized carotid artery. METHODS: The incidence of new symptoms and disease progression of the patient contralateral side after unilateral carotid endarterectomy (CE) was studied by clinical follow-up and serial duplex scanning in 127 patients. RESULTS: During a mean follow-up of 44 months, new hemispheric events occurred in nine (7%) and significant progression was recorded in 27 (21%) patients. In 97 patients with initial stenosis of less than 50% (group I), contralateral progression to greater than 50% was noted in 22% and new symptoms (one transient ischemic attack and one cerebrovascular accident) in 2% of patients; three patients underwent CE. In 30 patients with initial stenosis between 50% and 99% (group II), new symptoms (all transient ischemic attacks) occurred in seven (23%) (group II vs group I; p < 0.003) and nine underwent CE (group II vs group I; p < 0.001). Progression in 26 patients with 50% to 79% stenosis within group II to greater than 80% was noted in 19% of patients (difference not significant compared with group I). CONCLUSIONS: Overall, new symptoms occurred in 7% and significant contralateral disease progression in 21% of patients; subsequent CE was performed in 9.4% of patients. Initial presence of greater than 50% contralateral stenosis is a predictor of future hemispheric symptoms, which are likely to be transient ischemic attacks. New symptoms did not necessarily correlate with disease progression. Because disease progression was observed in patients with varying degrees of initial contralateral stenosis, serial clinical and duplex scanning in all patients undergoing unilateral CE is recommended.

Dimethylthiourea reverses sepsis-induced pulmonary hypertension in piglets.

Dimethylthiourea (DMTU), a putative hydroxyl radical scavenger, attenuates thromboxane generation and pulmonary hypertension in the piglet model of group B streptococcal (GBS) sepsis. This study tested the hypothesis that DMTU reverses ongoing GBS-induced pulmonary hypertension coincident with decreased thromboxane production. Piglets (n = 15) received a 60 min infusion of GBS (10(-8) cfu/kg/min). Mean pulmonary artery pressure (Ppa), arterial blood gases (ABGs), and thromboxane B2 (TXB) levels were measured at 10 min intervals throughout the study. GBS infusion resulted in a marked increase in pulmonary artery pressure (mean delta Ppa = 31 mm Hg) and a significant decline in PaO2 (mean = -80 torr) within 10 min of beginning the infusion. pH decreased from a mean of 7.47 to 7.37. DMTU, 750 mg/kg, or normal saline vehicle was infused over 10-15 min beginning 10 min after initiating GBS. Ppa decreased significantly within 10 min of DMTU infusion. Piglets receiving vehicle had a slow decline in Ppa. Piglets receiving DMTU also had an improvement in PaO2 and showed no further drop in pH. Piglets receiving vehicle had no improvement in PaO2 and demonstrated a continued decline in pH. TXB levels did not differ between the groups at any time interval. We conclude that DMTU can partially reverse GBS-induced pulmonary hypertension, but may function through mechanisms independent of thromboxane generation.

Group B streptococcus promotes oxygen radical-dependent thromboxane accumulation in young piglets.

Both thromboxane A2 and oxygen-derived free radicals appear to play central roles in group B streptococcus (GBS)-induced pulmonary hypertension in piglets. This study tested the hypothesis that GBS promotes oxygen radical-dependent thromboxane accumulation and pulmonary hypertension in infant piglets. Piglets 4-12 d old were anesthetized and prepared for assessment of pulmonary arterial pressure and arterial blood gases. In control animals, GBS (10(8) organisms/kg/min for 15 min) increased mean pulmonary artery pressure by 30 +/- 1.5 torr and reduced arterial PO2 by 100 +/- 20 torr. Thromboxane A2, radioimmunoassayed in venous blood as thromboxane B2, increased by 2452 +/- 800 pg/mL. A second group of piglets was treated with dimethylthiourea (DMTU: 750 mg/kg), a putative oxygen radical scavenger. In these animals, GBS increased pulmonary arterial pressure by only 7 +/- 1 torr and reduced arterial PO2 by a modest 10 +/- 8 torr. Importantly, thromboxane B2 content in venous blood failed to increase above control levels in DMTU-treated animals. The protective effects of DMTU in GBS-treated piglets could not be ascribed to inhibition of cyclooxygenase or thromboxane synthase because the oxygen radical scavenger failed to attenuate increases in pulmonary arterial pressure and venous thromboxane B2 content or reductions in arterial PO2 caused by i.v. infusions of arachidonic acid. DMTU also did not ameliorate pulmonary hypertension evoked by the thromboxane mimetic U44069, thereby suggesting that the scavenger did not act as an end-organ antagonist of thromboxane receptors. These observations suggest that GBS promotes accumulation of thromboxane A2 and attendant pulmonary hypertension through an oxygen radical-dependent mechanism.

Rectal fist insertion. An unusual form of sexual behavior.

Rectal fist insertion (fist fucking) is an uncommon and potentially dangerous sexual practice. This is usually a homosexual activity, but can also be a heterosexual or an autoerotic practice. One known death has been reported associated with rectal fist insertion, in which the complications of anal and colonic tears and bleeding had occurred (see Editor's note). The possibility of drug overdose is also probable, as drugs and alcohol are commonly introduced into the rectum to promote sphincter relaxation and to ease the discomfort of anal dilatation.