Branda, Megan

Background: Pregnancies complicated by fetal growth restriction are at increased risk of fetal demise and adverse neonatal outcomes. Distinguishing growth-restricted fetuses from constitutionally small ones remains challenging. Given the variability in current diagnostic criteria and the importance of identifying at-risk fetuses, fetal growth velocity has emerged as a predictor of adverse neonatal outcomes. Objective: To evaluate whether percentile-based fetal growth velocity, defined as change in estimated fetal weight percentile per week, predicts adverse neonatal outcomes in pregnancies affected by fetal growth restriction or small-for-gestational-age neonates. The primary aim was to determine the relationship between growth velocity and a composite of adverse neonatal outcomes. Study Design: This was a retrospective cohort study of pregnant patients 18 - 45 years old who delivered between August 2017 to December 2022 in a single healthcare system. Patients were excluded who had fewer than 2 ultrasounds after 16 weeks gestation, genetic or anatomic abnormalities, or a multiple gestation. Results: 300 patients met all inclusion criteria, and most patients (n=199) delivered at the tertiary care center. Three had an intrauterine fetal demise at a mean gestational age of 35w3d. 74 neonates were admitted to the NICU with a mean length of stay of 8.5 days; 29 required respiratory support. No neonatal deaths occurred. In fetuses with initial estimated fetal weight <3rd percentile (n=33), the probability of composite outcome was increased (50%, 95% CI 44.8-55.2) compared to those >50th percentile (5%, 95% CI 3.7-6.6). In the 3-10th and 10 - 50th percentile subgroups with decelerated growth, composite outcome rates were also increased (56.2% and 44.1%) compared to those with neutral or increased growth velocity. Conclusion: Percentile-based fetal growth velocity is a simple calculation that correlates with adverse neonatal outcomes regardless of initial estimated fetal weight. As fetal growth velocity decreased, our cohort saw increased rates of adverse outcomes. Change in EFW percentile normalizes for gestational age and allows ease of clinical interpretation. Decelerated growth identified fetuses at highest risk, suggesting growth velocity as a useful metric in routine surveillance.

ABSTRACT Advanced chronic diseases, or multicomplexity in older adults presents unique challenges. Transthyretin cardiac amyloidosis (ATTR‐CA) is one such scenario where heart failure is a common presentation, and management remains challenging. We describe the challenges involved in the diagnosis of ATTR‐CA in older adults, which has implications on treatment options. We discuss the application of comprehensive geriatric assessment (CGA) and shared decision making (SDM) in the context of these challenges. Based on geriatric medicine principles, an innovative framework for applying SDM in ATTR‐CA patients is proposed, including consideration of the patient priorities care approach. The proposed framework emphasizes assessing functionality, frailty, and life expectancy to help categorize risk. This framework can be applied in various advanced chronic diseases or multicomplexity. Based on risk categorization, treatment burden, and alignment with values and preferences, management pathways are suggested for each risk category. Incorporating CGA and SDM, the proposed framework supports patient‐centered care, ensuring that clinical recommendations are tailored to each older adult's unique needs and goals. In ATTR‐CA, a collaboration between cardiology and geriatric medicine provides significant value in managing older adults. The need to prevent age‐related bias in clinical decision‐making exists across all health conditions, and the proposed framework allows for a thorough evaluation of multimorbidity, frailty, disability, and patient preferences. While ATTR‐CA is used as a prototype, this integrated approach can be applied across all health conditions and is essential for delivering holistic care, improving communication, and aligning treatment plans with patient values.

Purpose To pilot test the impact of the ICAN Discussion Aid on clinical encounters. Methods A pre–post study involving 11 clinicians and 100 patients was conducted at two primary care clinics within a single health system in the Midwest. The study examined clinicians’ perceptions about ICAN feasibility, patients’ and clinicians’ perceptions about encounter success, videographic differences in encounter topics, and medication adherence 6 months after an ICAN encounter. Results 39/40 control encounters and 45/60 ICAN encounters yielded usable data. Clinicians reported ICAN use was feasible. In ICAN encounters, patients discussed diet, being active and taking medications more. Clinicians scored themselves poorer regarding visit success than their patients scored them; this effect was more pronounced in ICAN encounters. ICAN did not improve 6-month medication adherence or lengthen visits. Conclusion This pilot study suggests that using ICAN in primary care is feasible, efficient and capable of modifying conversations. With lessons learned in this pilot, we are conducting a randomised trial of ICAN versus usual care in diverse clinical settings. Trial registration number NCT02390570 .

Background— Decision aids (DAs) increase patient knowledge, reduce decisional conflict, and promote shared decision making (SDM). The extent to which they do so across diverse sociodemographic patient groups is unknown. Methods and Results— We conducted a patient-level meta-analysis of 7 randomized trials of DA versus usual care comprising 771 encounters between patients and clinicians discussing treatment options for chest pain, myocardial infarction, diabetes mellitus, and osteoporosis. Using a random effects model, we examined the impact of sociodemographic patient characteristics (age, sex, education, income, and insurance status) on the outcomes of knowledge transfer, decisional conflict, and patient involvement in SDM. Because of small numbers of people of color in the study population, we were not powered to investigate the role of race. Most patients were aged ≥65 years (61%), white (94%), and women (59%); two thirds had greater than a high school education. Compared with usual care, DA patients gained knowledge, were more likely to know their risk, and had less decisional conflict along with greater involvement in SDM. These gains were largely consistent across sociodemographic patient groups, with DAs demonstrating similar efficacy when used with vulnerable patients such as the elderly and those with less income and less formal education. Differences in efficacy were found only in knowledge of risk in 1 subgroup, with greater efficacy among those with higher education (35% versus 18%; P =0.02). Conclusions— In this patient-level meta-analysis of 7 randomized trials, DAs were efficacious across diverse sociodemographic groups as measured by knowledge transfer, decisional conflict, and patient involvement in SDM. To the extent that DAs increase patient knowledge and participation in SDM, they have potential to impact health disparities related to these factors.