Alrahmani, Layan

Background: The comparative effectiveness of robotic-assisted versus conventional minimally invasive (“straight stick”) approaches across multiple solid organ malignancies remains incompletely defined, limiting evidence-based operative platform selection. Study Design: Patients undergoing minimally invasive primary tumor resection for 17 solid organ cancers were identified in the National Cancer Database (2010–2022) and stratified by robotic-assisted versus straight stick approach. The primary endpoint was conversion to open surgery. Secondary endpoints included short-term outcomes and oncologic/technical metrics. Multivariable logistic and negative binomial regression models were used to estimate adjusted associations. Results: Among 2,258,360 patients, 1,339,482 (59.3%) underwent robotic-assisted resection. Robotic surgery was associated with lower adjusted conversion rates compared with straight stick approaches (6.1% vs 13.6%, p<0.001), a finding consistent across all organ sites. Robotic approaches yielded approximately one additional lymph node on average after adjustment. Length of stay, 90-day mortality, and negative margin rates were overall similar between groups, with variation by disease site. Conclusions: In this large national cohort, robotic-assisted resection for solid organ malignancies was more frequently utilized and associated with lower conversion rates and modestly higher lymph node yield compared with straight stick approaches. These findings support consideration of robotic platforms to reduce conversion risk, although equivalence in other short-term outcomes and potential residual confounding warrant cautious interpretation.

Importance Monochorionic (MC) twins are hemodynamically connected by vascular anastomoses within the single shared placenta. The transfer of fluid or blood from one fetus to the other may result in development of pathologic complications, such as twin-twin transfusion syndrome, twin anemia polycythemia sequence, selective intrauterine growth restriction, and twin reversed arterial perfusion sequence. Monoamniotic gestations, which comprise a small fraction of MC pregnancies, can also present with unique challenges, particularly antepartum umbilical cord entanglement. All these complications carry a high risk of fetal morbidity and mortality if not recognized and managed in a timely fashion. Objective The purpose of this article is to review evidence-based management of complicated MC twin gestations and propose a standardized approach to surveillance. Evidence Acquisition Monochorionic gestations account for the majority of complications that occur in twin pregnancies; however, there is unclear evidence on the appropriate surveillance for and management of specific complications associated with these pregnancies. Results This article summarizes management for each specific type of MC complication in a structured and clear manner. Conclusions Early pregnancy ultrasound, ideally between 10 and 13 weeks' gestation, is critical for the diagnosis and characterization of twin pregnancies. To improve outcomes for MC twins, appropriate fetal surveillance should be initiated at 16 weeks' gestation and continued until delivery. Relevance Improve perinatal outcomes in MC twin pregnancies. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to describe the sonographic findings used to establish the diagnosis of MC twin pregnancies; identify complications unique to MC twins pregnancies, including twin-twin transfusion syndrome, twin reversed arterial perfusion sequence, twin anemia polycythemia syndrome, co-twin demise, cord entanglement, and conjoined twins; and explain the management of complications associated with MC twin pregnancies.

Key Points Women with severe preeclampsia demonstrate abnormal levels of the complement alternative pathway components. Genetic variants in the complement alternative pathway are more prevalent in those with severe phenotype preeclampsia compared with the general population. Future studies should explore the role of medications that block the complement alternative pathway in treatment of preeclampsia. Background Preeclampsia and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome share many clinical and biologic features with thrombotic microangiopathy syndromes caused by complement abnormalities. Our hypothesis was that similar functional and genetic alterations in the complement alternative pathway (CAP) are present in these disorders of pregnancy. Methods We conducted quantitative analysis of proteins involved in CAP using ELISA and nephelometry on prospectively collected blood samples from patients with severe phenotype preeclampsia (defined as delivery ≤34 weeks due to preeclampsia), HELLP syndrome, or eclampsia, and matched normotensive controls ( n =25 in each arm) between 2011 and 2016. Sequencing was performed to interrogate 14 genes encoding CAP components. Results Both groups were similar in age, gravidity, parity, marital status, and race. The study group had a higher BMI (mean±SD, 32±8 versus 25±4 kg/m 2 ; P =0.002) and earlier gestational age at delivery (32.5±3.6 versus 40.3±1 weeks; P <0.001). Serologic studies demonstrated elevated Bb subunit (median [range], 1.2 [0.5–4.3] versus 0.6 [0.5–1] μ g/ml; P<0.001), complement C5 concentration (28 [18–33] versus 24 [15–34] mg/dl; P =0.03), and sMAC (371 [167–761] versus 184 [112–249] ng/ml; P<0.001) concentrations in patients with preeclampsia. Two thirds of patients with preeclampsia had at least one nonsynonymous sequence variant in CAP genes. Conclusion Patients with severe phenotype preeclampsia manifest functional alterations in CAP activation. Genetic variants in the CAP genes were detected in several patients, but a larger population study is necessary to fully evaluate genetic risk. Genetic screening and complement-targeted treatment may be useful in risk stratification and novel therapeutic approaches.

Gestational diabetes mellitus (GDM) is a frequently observed complication of pregnancy and is associated with an elevated risk of adverse maternal and neonatal outcomes. Many women with GDM will go on to have future pregnancies, and these pregnancies may or may not be affected by GDM. We conducted a literature search, and based on data from key studies retrieved during the search, we describe the epidemiology of GDM recurrence. This includes a summary of the observed clinical risk factors of increasing maternal age, weight, ethnicity, and requirement for insulin in the index pregnancy. We then present our data from Mayo Clinic (January 2013–December 2017) which identifies a GDM recurrence rate of 47.6%, and illustrates the relevance of population-based studies to clinical practice. Lastly, we examine the available evidence on strategies to prevent GDM recurrence, and note that more research is needed to evaluate the effect of interventions before, during and after pregnancy.

AbstractBackgroundDescriptions of coronavirus disease 2019 (COVID-19) have focused on the nonpregnant adult population. This study aims to describe the clinical characteristics and perinatal outcomes of COVID-19 in pregnancy.MethodsWe searched databases from December 2019 to 30 April 2020. Eligible studies reported clinical characteristics, radiological findings, and/or laboratory testing of pregnant women during infection. Data were pooled across studies using a random-effects model.ResultsTwenty-four studies (136 women) were included. The most common symptoms were fever (62.9%) and cough (36.8%). Laboratory findings included elevated C-reactive protein (57%) and lymphocytopenia (50%). Ground-glass opacity was the most common radiological finding (81.7%). Preterm birth rate was 37.7% and cesarean delivery rate was 76%. There was 1 maternal death. There were 2 fetal COVID-19 cases.ConclusionsThe clinical picture in pregnant women with COVID-19 did not differ from the nonpregnant population; however, the rate of preterm birth and cesarean delivery are considerably higher than international averages.

The Center for Disease Control and Prevention ranks diabetes mellitus (DM) as the seventh leading cause of death in the USA. The most prevalent forms of DM include Type 2 DM, Type 1 DM, and gestational diabetes mellitus (GDM). While the acute problem of diabetic hyperglycemia can be clinically managed through dietary control and lifestyle changes or pharmacological intervention with oral medications or insulin, long-term complications of the disease are associated with significant morbidity and mortality. These long-term complications involve nearly all organ systems of the body and share common pathologies associated with endothelial cell abnormalities. To better understand the molecular mechanisms underlying DM as related to future long-term complications following hyperglycemia, we have undertaken a study to determine the frequency that GDM did or did not occur in the second pregnancy of women who experienced GDM in their first pregnancy between 2013 and 2018 at Mayo Clinic, Rochester, MN. Within the five-year period of the study, the results indicate that 7,330 women received obstetrical care for pregnancy during the study period. Of these, 150 developed GDM in their first pregnancy and of these, 42 (28%) had a second pregnancy. Of these 42 women, 20 again developed GDM and 22 did not develop GDM in their second pregnancy within the study period. Following the occurrence of GDM in the first pregnancy, the study (1) established the number of women with and without GDM in the second pregnancy and (2) confirmed the feasibility to study diabetic metabolic memory using maternal placental tissue from GDM women. These studies represent Phase I of a larger research project whose goal is to analyze epigenetic mechanisms underlying true diabetic metabolic memory using endothelial cells isolated from the maternal placenta of women with and without GDM as described in this article.

INTRODUCTION: The influence of concurrent hypertensive disorders of pregnancy (HDP) on clinical outcomes of patients with peripartum cardiomyopathy (PPCM) remains incompletely characterized, with authors describing harmful and beneficial relationships with regards to maternal mortality or requirement for cardiac transplantation. METHODS: Ovid Medline, EMBASE, CENTRAL and Scopus were searched for combinations of the following terminology: hypertension, preeclampsia, cardiomyopathy, peripartum, postpartum or puerperium. Eligibility criteria included all articles addressing mortality rates of PPCM with and without HDP using a combination of the European Society of Cardiology 2010 and the National Heart Lung Blood Institute 2000 diagnostic criteria. Two independent reviewers analyzed abstracts and article text to determine eligibility and risk of bias. Risk of bias was determined using the Newcastle-Ottawa scale and a Peto fixed effects model was used to combine odds ratios in a meta-analytic fashion due to the relatively rare frequency of these events. RESULTS: 1838 articles were identified using the search strategy; 148 full text articles were reviewed for eligibility, with 10 observational studies meeting criteria. There was substantial agreement between the two raters for selection (K: 0.799) and for risk of bias (K: 0.851). An overall protective effect was identified [0.565 (95% CI 0.327, 0.974)], with a low degree of heterogeneity (I2 17.66%). No significant differences were found between subgroups-chronic hypertension, access to social medicine, high-income countries and post-diagnosis duration of care greater than 12 months. CONCLUSION: Although the strength of association is weak, concurrent HDP appears to be protective against mortality and need for cardiac transplantation in PPCM.

INTRODUCTION: Peripartum cardiomyopathy (PPCM) and cardiomyopathy secondary to hypertensive disorders of pregnancy (HDP) are considered to represent distinct cardiac entities (i.e. dilated vs hypertrophic cardiomyopathy). The goal of this systematic review and meta-analysis was to determine if HDP alters the odds of recovery and if baseline left ventricle characteristics are significantly different. METHODS: Ovid Medline, EMBASE, CENTRAL and Scopus were searched for combinations of the following: hypertension, preeclampsia, cardiomyopathy, peripartum, postpartum or puerperium. Articles describing initial left ventricular ejection fraction (LVEF), odds of recovery (EF >50%) or end diastolic diameter (EDD) amongst those with PPCM were included. Two raters analyzed abstracts and full text to determine eligibility and risk of bias. Risk of bias was determined using the Newcastle-Ottawa scale and the DerSimonian-Laird method was used to combine odds ratios. RESULTS: 1838 articles were identified and 148 full text articles were reviewed for eligibility, with 11 observational studies meeting criteria. There was substantial agreement for selection (K: 0.817) and for risk of bias (K: 0.633) between raters. There was no significant difference (mean: 1.837%, 95% CI-4.882, 1.282) in baseline LVEF or EDD (1.837 cm, 95% CI-1.104, 4.778) between patients who developed PPCM +/- HDP. Further, recovery rates between groups were similar with OR of 1.870 (95% CI 0.854, 4.094) and a moderate degree of heterogeneity. CONCLUSION: Counseling regarding eventual recovery of LVEF after PPCM should not be altered due to the presence of HDP; it is unlikely that a phenotypic difference exists in the cardiomyopathy induced by HDP compared to idiopathic PPCM.

ObjectivesWe evaluated the current state of ultrasound training in obstetrics and gynecology (OB‐GYN) residency programs across the United States.MethodsAn electronic survey was sent to OB‐GYN residency program directors and OB‐GYN residents. Responses were obtained in September 2016. Program directors and residents were asked to reflect on their current ultrasound curriculum.ResultsA total of 93 program directors and 437 residents responded. Respondents were mostly from university programs located in tertiary centers. Ultrasound curricula varied: 11% of program directors and 23% of residents did not have any ultrasound‐related didactics; of those who did, 27% of program directors and 40% of residents had it yearly or less. Three‐quarters had mandatory ultrasound rotations, and few offered ultrasound electives (program directors, 52%; residents, 28%). Most residents were required to perform ultrasound examinations daily or weekly (98%). Most stated that the main focus of the rotation was OB only. Skill was evaluated mainly subjectively by direct observation. Although most program directors stated that residents were satisfactory/excellent in ultrasound, 22% would not treat patients on the basis of ultrasound examinations performed by their senior residents. Similarly, of all postgraduate year 4 respondents (n = 86), 76% stated that they will require additional training to be able to perform or read ultrasound examinations independently, and 43% would not treat a patient on the basis of their own ultrasound examinations without further confirmation. Residents believed that the biggest obstacle in ultrasound training is lack of dedicated faculty time (41%).ConclusionsRecognizing the lack of clearly defined milestones in ultrasound training in OB‐GYN residency, this study confirms the substantial heterogeneity in curricula between programs, highlighting a need for a standardized ultrasound curriculum.