Citations

Ultrasound-guided peripheral vascular access was rarely used by Certified Registered Nurse Anesthetists (CRNA) within a large academic hospital since the use of ultrasound had not been common practice among CRNAs. The purpose of this quality improvement project was to develop an educational intervention to increase the use of ultrasound for peripheral vascular access among CRNAs by 20% while also improving their knowledge, comfort, and confidence in using the technology. A pre-intervention survey revealed limited use of ultrasound for peripheral vascular access by practicing CRNAs, despite benefits of enhanced patient care demonstrated in the literature. The educational intervention included a virtual learning module, hands-on simulated training, and pre- and post-intervention knowledge assessments to measure CRNAs’ skills in ultrasound-guided techniques. Post-intervention results demonstrated a 64% increase in ultrasound use, with the average monthly rate of individual usage rising from 2.1 to 3.4 times. Additionally, participants’ knowledge scores improved from 52% to 82%, and they reported increased confidence with performing ultrasound-guided vascular access procedures. While certain barriers, like lack of access to ultrasound machines and time constraints persisted after the intervention, this education effectively addressed individual knowledge and skill gaps. This quality improvement project underscores the value of structured educational programs in advancing the use of ultrasound technology in healthcare. This highlights the importance of ongoing training and education to sustain and improve CRNAs’ knowledge and skills.

AbstractChronic pelvic pain (CPP), a debilitating condition affecting an estimated 25% of women worldwide, represents a significant yet understudied global health crisis. Existing research is limited and likely fails to capture the true impact of CPP on global health. What is known is that CPP results in a profound health, societal, and economic burden on women. Our inability to fully understand this burden is a critical gap in women's healthcare. To address this urgent need, the International Federation of Gynecology and Obstetrics (FIGO) and the International Pelvic Pain Society (IPPS) have partnered to develop this consensus statement where we examine the key challenges to accessing CPP care and propose a framework for overcoming these barriers. We emphasize that effective global strategies for addressing the negative health consequences of living with CPP must prioritize the lived experiences of patients, empower healthcare professionals with the necessary tools and training, and drive meaningful policy change. This call to action is grounded in a comprehensive vision of women's health and rights to address the full spectrum of conditions women experience throughout their lives. Given its high prevalence, CPP must be a central focus of this expanded vision.

Abstract Aims To investigate the cost‐effectiveness of early initiation of metformin and usual care for gestational diabetes mellitus (GDM). Methods Economic evaluation from a healthcare perspective, based on the EMERGE randomised controlled trial. In total, 535 women with GDM were randomised to placebo in addition to usual care or metformin in addition to usual care. Economic outcomes included incremental healthcare costs and quality adjusted life years ( QALYs ) and expected cost‐effectiveness at cost‐effectiveness threshold values of €20,000, €45,000 and €100,000 per QALY gained. Uncertainty was explored using parametric, non‐parametric, deterministic and probabilistic methods and heterogeneity using subgroup analysis. Results On average, relative to the placebo arm, the early metformin arm was associated with non‐statistically significant mean increases of €193.07 (95% CI : −€789.88, €1176.01; p = 0.700) and 0.002 QALYs (95% CI : −0.009, 0.013; p = 0.771). In terms of expected cost‐effectiveness at threshold values of €20,000, €45,000 and €100,000 per QALY gained, the probability of the early metformin arm being more cost‐effective was estimated at 0.423, 0.452 and 0.524. Exploratory subgroup analyses provided more favourable but not definitive evidence in favour of the early metformin arm for cohorts with previous GDM and previous caesarean section. Conclusions We do not find definitive evidence that early initiation of metformin in addition to usual care for GDM was more cost‐effective than usual care alone. The clinical and economic evidence may be considered equivocal, but worthy of further examination.

Despite ongoing efforts to employ structure-based methods to discover targeted protein degraders (TPD), the prevailing strategy remains synthesizing a focused set of heterobifunctional compounds and screening them for target protein degradation.

Abstract Background: There is a need for effective and affordable nondrug therapies for the acute treatment of migraine. Transnasal neuromodulation via evaporative cooling may modulate the sphenopalatine ganglion, which is implicated in migraine. The study aimed to evaluate the safety, tolerability, and optimal dose of this method for acute migraine treatment. Methods: A prospective, randomized, double-blind, multicenter study was conducted at 3 US sites. Subjects received 15 minutes of in-clinic treatment during a migraine attack. Twenty-four subjects were randomized into three groups: 24 liters per minute (LPM), 18 LPM, and 6 LPM. Pain and Most Bothersome Symptom (MBS) were recorded at baseline 2 and 24 hours post treatment. The primary endpoint was pain relief (PR) at 2 hours. Secondaryendpoints included tolerability, MBS relief and pain freedom (PF) at 2 hours and 24 hours Results: Eighty-seven adults with episodic migraine with or without aura were enrolled. PR at 2 hours without rescue medication (woRM) was reported by 89% (8/9) of the participants who received 6LPM. PR at 2 hwoRM was reported to be 56% (5/9) and 50% (3/6) in the 18LPM and 24LPM groups, respectively. PF at 2 hours woRM was reported by 44% (4/9) of participants in the 6LPM group, and no participants in the 18LPM or 24LPM group reported PF at 2 hours. MBS relief at 2 hwas 78% (7/9), 67% (6/9) and 50% (3/6) in the 16, 18 & 24LPM groups, respectively. No adverse events occurred in the 6LPM group,and none were serious or severe in any group. Moderate discomfort was reported by 11% (1/9) of the participants in the 6LPM group. In contrast, 33% (3/9) and 83% ofthe 18LPM and 24LPM groups reported moderate or severe discomfort, respectively. Zero, one, and two subjects discontinued the 15-minute session in the 6LPM, 18LPM, and 24LPM groups, respectively. The study was terminated early because of slow subject accrual. Conclusions: Lower flow rates during transnasal cooling were both effective and tolerable for acute migraine treatment. The study became a dose-ranging trial, with lower flow rates,showing greater efficacy. A future at-home study is planned. Trial Registration: ClinicalTrials.gov Identifier: NCT04936061; Registration date: June 15, 2021. The full study protocol can be accessed at https://clinicaltrials.gov/study/NCT04936061.

Background: Facial aberrant reinnervation syndrome (FARS) is a common sequelae of facial nerve injury followed by aberrant reinnervation and recovery. Patients with FARS can present with different patterns of facial synkinesis, facial muscle hypertonicity, and facial spasm/twitching. 1 Synkinesis associated with FARS is described as undesired muscle contraction when a voluntary movement is triggered. One of the most common and bothersome types of facial synkinesis is oral-ocular synkinesis, where patients experience unwanted eyelid closure with movement of the mouth such as smiling or pursing the lips. First-line treatment options for FARS include facial physical therapy and botulinum toxin selective chemodenervation. For patients with persistent or more significant symptoms, there are surgical options, including selective neurectomy and selective myectomy of the involved facial nerve branches and muscles. 2 , 3 Selective myectomy of the orbicularis oculi muscle has been shown to be an effective surgical treatment option for oral-ocular synkinesis. 3 – 4 There is nuance to this procedure, including deciding whether to target the upper eyelid, lower eyelid, or both, as well as which segments and how much of the orbicularis oculi muscle to remove, balancing the goals of improving synkinesis and hypertonicity while avoiding the creation of lagophthalmos. The novel implementation of autologous microfat grafting to the procedure can help improve postoperative eyelid volume and contour and may help prevent the cut edges of the muscle from fusing, thus reducing the likelihood of persistent or recurrent ocular synkinesis. Objective: To describe a selective myectomy of the orbicularis oculi with the novel addition of autologous microfat grafting for the treatment of oral-ocular synkinesis. Methods: This video demonstrates the procedural steps for a selective myectomy of the orbicularis oculi with autologous microfat grafting for a patient with oral-ocular synkinesis due to FARS. In addition, it demonstrates the preparation of harvested abdominal fat that is utilized for the autologous microfat grafting. Results: Selective myectomy of the orbicularis oculi with autologous microfat grafting has been routinely performed safely and effectively by the senior author for treatment of oral-ocular synkinesis. Postoperative aesthetic eyelid shape and functional results have been reassuring with improvements up to 1 year postoperative and a need for additional long-term follow-up. Conclusion: To the authors’ knowledge, a selective myectomy of the orbicularis oculi with autologous microfat grafting has not been demonstrated in video documentation. Autologous microfat grafting may be a helpful addition to selective myectomy of the orbicularis oculi to enhance both eyelid aesthetics and function. Patient Consent Statement: All patients included in the video have consented to the use of videos and photographs of their faces for research and educational purposes. Funding and Conflicts of Interest: The authors have no funding, financial relationships, or conflicts of interest to disclose. Runtime of video: 7 mins 11 secs.

Abstract Metformin is well‐established as a treatment for type 2 diabetes in non‐pregnant individuals. The low cost, acceptability and broad tolerability of metformin have also made it an attractive option for research into the treatment of other conditions associated with insulin resistance. Despite almost 50 years of clinical experience with the use of metformin to treat diabetes in pregnancy, many questions remain regarding its precise effectiveness in different maternal subgroups, as well as potential short‐term and long‐term effects on the offspring. In this narrative review, we present the current evidence for the use of metformin during pregnancy in various maternal subgroups, including women living with overweight and obesity, women at risk of gestational diabetes, women diagnosed with gestational diabetes and women with pregestational diabetes, including type 2 diabetes. Our specific focus is on the impact of metformin on short‐term maternal, fetal and neonatal outcomes. We also consider the evidence for other emerging indications for metformin in pregnancy, such as the prevention and management of pre‐eclampsia. Plain Language Summary This article looks at research on how metformin use in pregnancy affects mothers and newborns in the short term. Doctors have prescribed metformin since the 1970s for the treatment of diabetes in pregnancy. Despite years of use, there are still questions about how safe and effective metformin is for mothers and their children. Metformin taken during pregnancy moves through the placenta into the foetus's bloodstream. The short‐term and long‐term effects of metformin on offspring need careful attention. The studies that have looked at the link between metformin use and birth defects have not found any strong link between taking metformin in pregnancy and birth defects, however close attention will continue to be paid in this area. Some large studies have examined the use of metformin in pregnant women who do not have diabetes, but who do live with overweight or obesity. The studies are difficult to compare. Some, but not all, of these studies have shown less weight gain for the mother if metformin is taken by these women during pregnancy. Other large studies have looked at whether metformin can prevent gestational diabetes. The results are mostly disappointing. They suggest that metformin does not stop gestational diabetes from developing. However, the participants in these studies were mostly from white backgrounds and metformin may help prevent gestational diabetes in women of different ethnic backgrounds. However, more research is needed. Metformin has been widely studied as an alternative to insulin for the treatment of gestational diabetes. Because different countries diagnose and treat GDM differently, this makes comparing study results difficult. Women with gestational diabetes seem to gain less weight during pregnancy if they use metformin rather than insulin. Using metformin instead of insulin may result in lower average birth weights for babies from these pregnancies. Also, the use of metformin may lead to fewer babies being born abnormally large. Similarly, large trials have examined the use of metformin in pregnant women who are living with type 2 diabetes. These studies show that metformin can lower a mother's insulin needs. It can also help control weight gain and reduce the risk of having a large baby. One study found that metformin use in women living with Type 2 diabetes might increase the risk of having smaller babies. This was especially true if the mother had high blood pressure or kidney disease. This finding requires further investigation. Metformin might help prevent pre‐eclampsia, but this is still unclear. Research is ongoing into a potential role for metformin in the treatment of pre‐eclampsia. In conclusion, metformin has been studied in many groups of pregnant women. Women with gestational diabetes or type 2 diabetes may see benefits like less weight gain and better blood sugar/glucose control. Current evidence suggests that metformin shouldn't be used if there are foetal growth issues. It is also not recommended for mothers with high blood pressure or kidney disease. Future studies might find specific groups of pregnant women who would benefit the most from metformin.

Background/Purpose APS ACTION Registry was created to study the natural course of antiphospholipid syndrome (APS) over 10 years in persistently antiphospholipid antibody (aPL) positive patients with or without systemic autoimmune rheumatic diseases (SARDs). Our primary objective was to compare the characteristics of aPL-positive patients with or without thrombocytopenia (TP) and/or autoimmune hemolytic anemia (AIHA). Methods The registry inclusion criteria are positive aPL based on the Revised Sapporo APS Classification Criteria, tested at least twice within 1 year prior to enrollment. For the primary comparison of demographic, clinical, and serologic characteristics in this retrospective study, we divided patients into two groups: TP/AIHA ever and never. Thrombocytopenia was defined as a platelet count of <100,000 x 10 9 /L tested twice at least 12 weeks apart, and AIHA was defined as anemia with hemolysis and a positive direct antiglobulin test (DAT). For the secondary analysis, we compared patients with TP versus AIHA, and the immunosuppressive use stratified by systemic lupus erythematosus (SLE) classification. Results As of April 2022, of 1,039 patients (primary aPL/APS: 618 [59%]; SLE classification: 334 [31%]) included in the registry, 228 (22%) had baseline (historical or current) TP and/or AIHA (TP only: 176 [17%]; AIHA only: 35 [3%], and both: 17 [2%]). Thrombocytopenia and/or AIHA was significantly associated with Asian race, SLE classification, cardiac valve disease, catastrophic/microvascular APS, triple aPL (lupus anticoagulant, anticardiolipin antibody, and anti-β 2 -glycoprotein-I antibody) positivity, and SLE-related serologic and inflammatory markers. When 101/618 (16%) primary aPL/APS patients and 101/334 (34%) SLE patients with TP and/or AIHA were compared, azathioprine and mycophenolate mofetil were more commonly reported in lupus patients, however corticosteroid, intravenous immunoglobulin, and rituximab use were similar between groups. Conclusion In our large multi-center international cohort of persistently aPL-positive patients, approximately one-fifth had active or historical TP and/or AIHA at registry entry; half of these patients had additional SLE. Cardiac valve disease, catastrophic/microvascular APS, and triple aPL-positivity were aPL-related clinical and laboratory manifestations associated with TP and/or AIHA, suggesting a more severe APS clinical phenotype in aPL-patients with TP and/or AIHA.

Background: Various medial patellofemoral ligament (MPFL) reconstruction techniques have been developed to minimize risks to the physis in skeletally immature patients. Purpose: To examine outcomes of MPFL reconstruction (MPFLR) based on fixation technique in skeletally immature patients. Study Design: Systematic review; Level of evidence, 4. Methods: PubMed, Scopus, Ovid, Cochrane Library, and CINAHL databases were searched for the literature on outcomes of MPFLR in the pediatric population, utilizing various anatomic and nonanatomic techniques. Primary outcomes were postoperative redislocation rates, return-to-sports (RTS) rates, and patient-reported outcomes (PROs). Moreover, outcomes involving sequela of growth plate disturbance were collected. Results: The final analysis included 17 studies—2 using sling-based techniques, 3 using surface-based techniques, 5 using soft tissue realignments, and 7 utilizing transosseous femoral fixations. Higher rates of postoperative redislocation were found in the sling-based (14.8%) and distal soft tissue realignment using semitendinosus tenodesis (38%) techniques, while lower rates were noted with surface-based (1.3%) and transosseous (3.4%) techniques. For PROs, there were large amounts of heterogeneity among studies, but all reported postoperative improvements, with more positive PROs generally seen in anatomic reconstructions. The RTS rate was 100% for surface-based techniques, 79.4% for distal soft tissue realignments, 79.5% for soft tissue realignment techniques, and 83.2% for transosseous techniques. No negative outcomes as a sequela of growth plate disturbance were reported. Conclusion: Nonanatomic techniques—such as sling-based and distal soft tissue realignment techniques—have higher rates of redislocation and lower RTS rates in skeletally immature patients undergoing MPFLR. Surface-based and transosseous tunnel-based techniques were shown to have lower redislocation and higher RTS rates. Clinical Relevance: This review provides insight into the most appropriate surgical management of patellar instability in patients with open growth plates.