Right to Left Cardiac Power Output- New Prognosticator in STEMI Patients With Cardiogenic Shock (R-Shock).

ST elevation myocardial infarction (STEMI) is a leading cause of cardiogenic shock (CS) and carries substantial mortality. Cardiac power output (CPO) is the strongest predictor of clinical outcome in CS, and worse outcomes result from concomitant right and left ventricular failure. Right ventricular performance is calculated using right sided CPO. Our aim was to measure the right sided CPO and compute their ratio to predict in-hospital mortality in STEMI patients with cardiogenic shock. This was a retrospective observational study of consecutive STEMI patients with CS that developed within the first 24hours of admission requiring left and right cardiac catheterization at a large tertiary care center from January 2014-December 2018. One hundred sixty-four patients identified with STEMI; 46% (75) excluded due to incomplete data. 88 remaining patients, 52.8% (47) developed CS. 98.9% within 24 hours. Mean left & right CPO 0.62 (SD 0.3) and 0.22 (SD 0.13), PAPi score 1.81. Logistic regression analysis indicated odds ratio of in-hospital mortality lower for low left CPO, high right CPO and low ratio of left to right CPO (95% CI; 0.69, 0.34, 1.20; 1.38, 0.87, 2.20; 0.52, 0.28, 1.00 respectively). This is the first study to assess right sided CPO and ratio of right and left side CPO and mortality. Our study indicates that there is trend towards higher in-hospital mortality in patients with high right sided CPO and lower ratio of left to right CPO. The exploratory results of this study need to be confirmed in a larger population.

Rethinking hiker preparedness: Association of carrying "10 essentials" with adverse events and satisfaction among day-hikers.

INTRODUCTION: Many trusted organizations recommend a particular set of gear for hikers. Termed the "10 essentials," the importance of these items to wilderness preparedness has not been critically evaluated. We sought to better understand the value of these items in day hiker preparedness by assessing the association between carried items, the occurrence of adverse events, and satisfaction. METHODS: A cross-sectional survey study was conducted at Mount Monadnock (NH) over 4 non-consecutive days. Adults finishing a day hike were invited to participate. The survey assessed items carried, adverse events, satisfaction, and whether hikers felt prepared for the adverse events that occurred. The primary outcome was the occurrence of an adverse event. RESULTS: A total sample of 961 hikers reported 1686 adverse events. Hikers felt prepared for 89% of the events experienced. The most common adverse events reported were thirst (62%), hunger (50%), feeling cold (18%), and needing rain gear (11%). Medical events such as sprains and lacerations made up 18% of all adverse events. Carrying more items was associated with an increased likelihood of reporting an adverse event and a decreased likelihood of adverse events that the hiker was not prepared for, without a change in satisfaction rates. CONCLUSIONS: Carrying more items did not translate into improved satisfaction for day hikers, but was associated with fewer events for which the hiker was unprepared. Other than adverse events related to hunger, thirst, weather, and minor medical events, adverse events were unlikely during this day hike. Nutrition, hydration, and insulation were the items reported as most often needed, followed by a kit to treat minor medical events, while the remaining 6 items were infrequently used.

Anterior Bilateral Sacrospinous Ligament Fixation: A Safe Route for Apical Repair.

OBJECTIVES: Traditionally, sacrospinous ligament fixation is performed unilaterally with a posterior dissection for correction of apical vaginal prolapse. There is limited information on alternative techniques including bilateral application and use of anterior vaginal dissection for this procedure. The objective of this study is to evaluate the anatomic and perioperative outcomes in women who have undergone bilateral sacrospinous ligament fixation through an anterior approach. METHODS: This cohort represents women in our prospective repository who underwent anterior approach bilateral sacrospinous ligament fixation between September 2011 and June 2014. Concomitant procedures were performed as indicated. Pelvic organ prolapse quantification points were measured preoperatively and at 6 weeks and 6 months postoperatively and were compared. Perioperative outcome measures and adverse events were also analyzed. RESULTS: In this cohort, 144 women underwent anterior approach to bilateral sacrospinous ligament fixation. The patients' mean age was 57.8 ± 10.9 years, and the average body mass index was 29.6 ± 5.8 kg/m. In patients who underwent anterior approach bilateral sacrospinous ligament fixation, points Aa, Ba, C, Gh, Ap, and Bp remained at stage I or less when compared with pelvic organ prolapse quantification measurements at the baseline. Perioperative and postoperative complications were minimal, with 1 (0.7%) patient requiring a blood transfusion and 3 (2%) patients suffered from intraoperative lower urinary tract injuries, none of which were attributable to the sacrospinous fixation part of the procedure. CONCLUSIONS: Anterior approach bilateral sacrospinous ligament fixation is a safe and effective procedure for reestablishing apical support in a patient with apical vaginal prolapse.

Does Shared Decision Making Actually Occur in the Emergency Department? Looking at It from the Patients' Perspective.

OBJECTIVE: We sought to assess the frequency, content, and quality of shared decision making (SDM) in the emergency department (ED), from patients' perspectives. METHODS: Utilizing a cross-sectional, multisite approach, we administered an instrument, consisting of two validated SDM assessment tools-the CollaboRATE and the SDM-Q-9-and one newly developed tool to a sample of ED patients. Our primary outcome was the occurrence of SDM in the clinical encounter, as defined by participants giving "top-box" scores on the CollaboRATE measure, and the ability of patients to identify the topic of their SDM conversation. Secondary outcomes included the content of the SDM conversations, as judged by patients, and whether patients were able to complete each of the two validated scales included in the instrument. RESULTS: After exclusions, 285 participants from two sites completed the composite instrument. Just under half identified as female (47%) or as white (47%). Roughly half gave top-box scores (i.e., indicating optimal SDM) on the CollaboRATE scale (49%). Less than half of the participants were able to indicate a decision they were involved in (44%), although those who did gave high scores for such conversations (73/100 via the SDM-Q-9 tool). The most frequently identified decisions discussed were admission versus discharge (19%), medication options (17%), and options for follow-up care (15%). CONCLUSIONS: Fewer than half of ED patients surveyed reported they were involved in SDM. The most common decision for which SDM was used was around ED disposition (admission vs. discharge). When SDM was employed, patients generally rated the discussion highly.

Colpocleisis: A Survey of Current Practice Patterns.

BACKGROUND: Currently, there are no standard treatment guidelines for colpocleisis. Clinical practice varies widely for this safe and effective procedure. OBJECTIVE: The aim of this study was to evaluate the current practice patterns in the United States among surgeons who perform colpocleisis. METHODS: A 27-item anonymous Web-based survey was sent to all practicing physicians affiliated with the American Urogynecologic Society. It consisted of questions regarding the demographic background of the physicians and their current practice as it relates to colpocleisis. RESULTS: Of the 1422 physicians contacted, 322 responded (23%) to the questionnaire. Slightly more than half were female with an average time of 15 years in practice. The majority of respondents (79%) were urogynecologists. Most surgeons chose colpocleisis for its high success rate, short operating time, and low risk of complications. Approximately half of the providers performed both LeFort and total colpocleisis. Only 18% performed a routine hysterectomy at the time of surgery. Routine preoperative endometrial evaluation was preferred by 68% of the respondents, with 81% utilizing a transvaginal ultrasound first. Almost all providers would perform concomitant incontinence procedures, with 54% requiring a positive cough stress test and normal postvoid residual. CONCLUSIONS: There is variation in the current practice of colpocleisis in the United States. LeFort colpocleisis is most commonly performed, and routine hysterectomy is uncommon. Two thirds of surgeons evaluate the endometrium prior to surgery. Concomitant anti-incontinence procedures appear to be standard.

The impact of Bakri balloon tamponade on the rate of postpartum hysterectomy for uterine atony.

OBJECTIVE: Our objective was to evaluate the impact of uterine tamponade with a Bakri balloon on the rate of postpartum hysterectomy due to uterine atony. METHODS: We performed a retrospective cohort study of all deliveries >20 weeks gestation from January 2002 to March 2013 at Baystate Medical Center. Charts were reviewed to determine incidence of postpartum hysterectomy, Bakri balloon placement, uterine artery embolization (UAE) and the B-Lynch procedure. Patients with evidence of placenta accreta were excluded. The primary outcome was the change in rates of postpartum hysterectomy for uterine atony before and after the introduction of Bakri balloon tamponade, using chi-square testing. RESULTS: There were 48 767 deliveries during the study period, with 17 950 before and 30 817 after the introduction of the Bakri balloon. A total of 43 Bakri balloons were placed during the study period and 21 hysterectomies were performed for postpartum hemorrhage secondary to uterine atony, 14 before and 7 after the introduction of the Bakri balloon. This was consistent with a decrease in the rate of postpartum hysterectomy from 7.8/10 000 deliveries to 2.3/10 000 deliveries (p = 0.01). CONCLUSION: Our findings show that utilization of the Bakri balloon is associated with a decreased rate of postpartum hysterectomy.

Are perinatal outcomes affected by blastocyst vitrification and warming?

BACKGROUND: Transfer of cryopreserved-warmed embryos into an appropriately prepared uterus unaffected by controlled ovarian hyperstimulation is common in the practice of in vitro fertilization. There is limited information on the effect of blastocyst vitrification and warming on perinatal outcomes. OBJECTIVE: We sought to determine if perinatal outcomes are affected after the transfer of vitrified-warmed blastocysts compared to the transfer of fresh blastocysts, by comparing preeclampsia rate, birthweight, percentage of low birthweight, and preterm delivery rate between embryo transfer types. STUDY DESIGN: We performed a retrospective database cohort study of 289 fresh and 109 vitrified-warmed blastocyst transfer cycles at an academic medical center. Cycles were performed from July 2, 2009, through Dec. 8, 2014, and included infants born at ≥20 weeks gestational age, excluding donor egg cycles. We examined the association between transfer type (fresh or vitrified-warmed) and proportion of deliveries complicated by preeclampsia, preterm delivery (gestational age <37 weeks), and low birthweight (<2500 g). We assessed associations using generalized linear models, both unadjusted and adjusted, for maternal age, newborn sex, diabetes status, and parity. RESULTS: We observed more pregnancies complicated by preeclampsia following vitrified-warmed transfers (7.6%) compared to fresh embryo transfers (2.6%) (P = .023) (adjusted odds ratio, 3.1; 95% confidence interval, 1.2-8.4). Newborns resulting from vitrified-warmed embryo transfer cycles were similar to those resulting from fresh embryo transfer cycles with regard to low birthweight (7.4% vs 5.3%, P = .421), mean birthweight (3443 vs 3431 g, P = .865), and preterm delivery rate (9.2% vs 8.7%, P = .869). CONCLUSION: We conclude that embryo vitrification with warming may affect some perinatal outcomes since preeclampsia is increased compared to fresh blastocyst transfer. However, other perinatal outcomes such as low birthweight and preterm delivery rate are not affected. Fresh blastocyst transfers should be considered when possible as they may reduce the incidence of preeclampsia.

Implantation of fresh and thawed-warmed embryos in single embryo transfer cycles: interpreting the initial beta-HCG.

Little is known about the effects of human embryo cryopreservation on developmental potential. Initial beta-HCG, indicating embryo implantation, was measured in 322 single embryo transfer cycles (246 fresh and 76 thawed-warmed). Median initial beta-HCG was higher for fresh compared with thawed-warmed transfers (126 versus 100 mIU/ml; P = 0.04). Blastocyst slow cooling resulted in a lower initial beta-HCG compared with vitrification (P = 0.01). Live birth rates were lower for blastocyst slow cooling (25%) compared with vitrification (71%) and fresh transfer (70%). We conclude that cryopreservation may impair an embryo's ability to produce beta-HCG, but that vitrification does not impair developmental potential.

Obstetrician-gynecologists' opinions on elective bilateral oophorectomy at the time of hysterectomy in the United States: a nationwide survey.

OBJECTIVE: This study aims to assess obstetrician-gynecologists' opinions on elective bilateral oophorectomy (BO) at the time of hysterectomy in the United States and to describe factors that influence their views. METHODS: In April 2012, an anonymous survey was mailed twice to practicing obstetrician-gynecologists, randomly selected from a list produced by the American Medical Association, in an effort to assess their opinions regarding elective BO at the time of hysterectomy. The effects of gynecologists' various characteristics on their opinions were also evaluated. RESULTS: Of 1,002 mailed surveys, 443 (44%) were returned completed. Of the respondents, 59% were male and 79% were white. The largest age group was 51 to 55 years (20%), and the mean time since completion of residency was 23 years. In women with an average risk of ovarian cancer, the proportions of physicians who favored elective BO were as follows: women younger than 51 years, 32%; women aged 51 to 65 years, 62%; women older than 65 years, 6%. These recommendations were not influenced by the physicians' age, sex, training, or geographic region. If a hysterectomy candidate was younger than 51 years and had a personal history of breast or ovarian cancer and a family history of ovarian cancer, these proportions were increased to 77% and 64%, respectively. Other factors that influenced the respondents' recommendations were the women's personal history of cardiovascular disease (21%), osteoporosis (23%), and sexual dysfunction (23%). CONCLUSIONS: One third of obstetrician-gynecologists continue to recommend elective BO for hysterectomy candidates younger than 51 years. The majority recommend elective BO for women aged 51 to 65 years. Their demographic characteristics do not influence their opinions.

Phantom vibration syndrome among medical staff: a cross sectional survey.

OBJECTIVE: To describe the prevalence of and risk factors for experiencing "phantom vibrations," the sensory hallucination sometimes experienced by people carrying pagers or cell phones when the device is not vibrating. DESIGN: Cross sectional survey. SETTING: Academic medical centre. PARTICIPANTS: 176 medical staff who responded to questionnaire (76% of the 232 people invited). Measurements Electronic survey consisting of 17 questions about demographics, device use, phantom vibrations experienced, and attempts to stop them. RESULTS: Of the 169 participants who answered the question, 115 (68%, 95% confidence interval 61% to 75%) reported having experienced phantom vibrations. Most (68/112) who experienced phantom vibrations did so after carrying the device between 1 month and 1 year, and 13% experienced them daily. Four factors were independently associated with phantom vibrations: occupation (resident v attending physician, prevalence ratio 1.47, 95% confidence interval 1.10 to 1.97), device location (breast pocket v belt, prevalence ratio 1.66, 1.29 to 2.14), hours carried (per 6 hour increment, prevalence ratio 1.30, 1.07 to 1.58), and more frequent use in vibrate mode (per frequency category, prevalence ratio 1.18, 1.03 to 1.34). Of those who experienced phantom vibrations, 43 (39%, 30% to 48%) were able to stop them. Strategies for stopping phantom vibrations included taking the device off vibrate mode, changing the location of the device, and using a different device (success rates 75% v 63% v 50%, respectively, P=0.217). However, 39% (30% to 49%) of respondents did not attempt any strategies. CONCLUSIONS: Phantom vibration syndrome is common among those who use electronic devices.