Citations

INTRODUCTION: Emergencies during gynecologic office procedures are uncommon. However, knowledge in management of these complications is essential as more gynecologic procedures move from the operating room to the office. Our goal was to develop an interactive curriculum to address a gap in residency training in the management of office-based procedural emergencies. METHODS: A curriculum including management of unanticipated bleeding, anaphylaxis, vasovagal response, and local anesthetic systemic toxicity (LAST) was developed and implemented using a combination of simulated patient sessions, a “choose-your-own-adventure” PowerPoint, and a mock oral board session. Pre and post intervention surveys queried participants’ confidence in recognition and management. The curriculum was delivered as in-person simulation sessions or virtual sessions due to COVID restrictions. Institutional review board (IRB) approval was obtained. Mean pre and post intervention scores were compared using paired t-test. RESULTS: Four accredited obstetrics and gynecology residency programs participated. Twenty-nine trainees completed the curriculum, and 24 submitted pre and post surveys (82.8% response rate). There was significant improvement in confidence scores for management of unanticipated bleeding (mean difference 0.96, P<.001), anaphylaxis (mean difference 1.7, P<.001), vasovagal response (mean difference 1.0, P<.001), and LAST (mean difference 2.5, P<.001). Additionally, significant improvement in confidence scores for identification of risk factors and signs/symptoms of vasovagal response (mean difference 0.96, P<.001, and 0.46, P=.005) and LAST (mean difference 2.3, P<.001, and 2.2, P<.001) was noted. CONCLUSION: Implementation of an office emergencies curriculum significantly increased confidence in identification and management of unanticipated bleeding, anaphylaxis, vasovagal response, and LAST. Future studies evaluating knowledge-based assessments of learners are needed.

INTRODUCTION: While rare, emergencies encountered during office procedures have the potential for significant morbidity if the team is caught unprepared. The aim of this study was to evaluate current availability of and needs for training in office emergencies in residency programs in the United States. METHODS: This was a cross-sectional survey of residents from accredited obstetrics and gynecology residency programs. Identified programs were those with representation in the American College of Obstetricians and Gynecologists Simulation Working Group (ACOG SWG). A multi-item instrument was developed, designed, and edited by representatives of the ACOG SWG for accuracy and content validity. Participants were asked to rate their level of agreement with statements on importance of training in the recognition and management of obstetrics and gynecology emergencies and their confidence in management of those emergencies. Specific emergencies encountered in the office, gynecologic surgery, and obstetrics were queried. RESULTS: Six programs participated for a total of 116 residents and a response rate of 62% (116/188). Most residents agreed office emergency (97.5%) and obstetric emergency training (94.8%) were important in residency training. While 65.5% were confident in managing a vasovagal episode in the office, 0.9% were confident in managing lidocaine toxicity. In contrast, the majority of residents felt confident in obstetric emergency management across all listed emergencies (hemorrhage, cord prolapse, shoulder dystocia, eclampsia). CONCLUSION: While rated as important to residency training, significant gaps exist within resident preparation for identification and management of office-based emergencies, providing an opportunity for curriculum development and education.

Abstract Improving the chances of curing patients with cancer who have had surgery to remove metastatic sites of disease is a priority area for cancer research. Pexa-Vec (Pexastimogene Devacirepvec; JX-594, TG6006) is a principally immunotherapeutic oncolytic virus that has reached late-phase clinical trials. We report the results of a single-center, nonrandomized biological end point study (trial registration: EudraCT number 2012-000704-15), which builds on the success of the presurgical intravenous delivery of oncolytic viruses to tumors. Nine patients with either colorectal cancer liver metastases or metastatic melanoma were treated with a single intravenous infusion of Pexa-Vec ahead of planned surgical resection of the metastases. Grade 3 and 4 Pexa-Vec–associated side effects were lymphopaenia and neutropaenia. Pexa-Vec was peripherally carried in plasma and was not associated with peripheral blood mononuclear cells. Upon surgical resection, Pexa-Vec was found in the majority of analyzed tumors. Pexa-Vec therapy associated with IFNα secretion, chemokine induction, and resulted in transient innate and long-lived adaptive anticancer immunity. In the 2 patients with significant and complete tumor necrosis, a reduction in the peripheral T-cell receptor diversity was observed at the time of surgery. These results support the development of presurgical oncolytic vaccinia virus-based therapies to stimulate anticancer immunity and increase the chances to cure patients with cancer.

Context.— Organ weights are an essential part of autopsy analysis. Deviations from normal organ weights provide important clues to disease processes. The assessment of normal organ weights depends on reliable reference tables, but most widely available reference tables are based on data that are either decades old or derived from relatively small sample sizes. Objective.— To provide an updated reference table of organ weights based on contemporary sources and a large sample size. Design.— Organ weights from 4197 carefully screened autopsies performed on adults at the Palm Beach County Medical Examiner's Office in West Palm Beach, Florida, and the Mayo Clinic Hospital in Rochester, Minnesota. Results.— Height and body weight data in this study reflect the well-recognized increases in both variables, but most particularly in body weight, seen during the last decades. The study data show a strong positive association between organ weight and body weight for the heart, liver, and spleen. There is a similar but weaker association between body weight and the weight of the lungs and kidneys. Brain weight is independent of body weight but shows a strong negative association with age. Even when controlling for body weight, men's organs are heavier, except for the weight of the liver, which is comparable in men and women. These associations are in agreement with the findings of previous studies. The current study suggests that, for some of the commonly weighed organs, there has been an increase in median organ weight when compared with existing references. Conclusions.— The tables presented here provide an updated reference that should prove useful to autopsy pathologists in the forensic and hospital settings.

Background The COVID-19 pandemic increased the number of patients requiring intensive care nation-wide, leading to nurse staffing shortages in many units. Local Problem At the beginning of the statewide COVID-19 surge, a tertiary teaching hospital in the upper Midwest experienced a sharp increase in patients needing intensive care. To relieve the resulting staffing shortage, it implemented a pilot program to bring general care nurses into its 21-bed mixed specialty intensive care unit to free intensive care unit nurses to help staff the hospital’s COVID-designated units. Methods Using a team nursing model, the intensive care unit recruited, oriented, and incorporated 13 general care nurses within 4 days. Education and resources were developed to distinguish team nurses from intensive care unit nurses, introduce them to the intensive care unit environment, outline expectations, communicate between team nursing pairs, and guide charge nurses in making staffing decisions and assignments. Staff feedback identified additional resources, barriers, and successes. An adaptive process was used to improve and update tools and resources on the basis of staff needs. Results The pilot program ran for 6 weeks. Positive outcomes included a reduced need for float nurses and self-perceived reduction in nursing workload. The principal barrier was charge nurses’ challenges involving staffing-to-workload balance based on the existing staffing model. This model identified productivity of a general care nurse and an intensive care unit nurse as equivalent, despite differences in their skill sets. Conclusion Team nursing in the intensive care unit is an agile tactic easily replicated in dire staffing situations.

Background: It is known that hypokalemia, hypocalcemia and hypomagnesemia cause a prolonged QTc interval and are associated with an increased risk of ventricular arrhythmias. However, there are limited data on optimal serum electrolytes for patients admitted to the coronary care unit (CCU). Objective: Here, we aimed to evaluate the relationship between serum potassium, ionized calcium and magnesium levels and in-hospital mortality in the CCU setting. Methods: This retrospective cohort study included 8,498 consecutive patients admitted to the CCU at an academic tertiary medical center from 2004 through 2013. The mean of serum electrolytes was categorized as <3.5, 3.5-<4.0, 4.0-<4.5 (reference), 4.5-<5.0, and ≥5.0 mEq/L for potassium; <4.4, 4.4-<4.6, 4.6-<4.8, 4.8-<5.0 (reference), and ≥5.0 mg/dL for ionized calcium; and <1.8, 1.8-<2.0, 2.0-<2.2 (reference), 2.2-<2.4, and ≥2.4 mg/dL for magnesium. Multivariate logistic regression analysis was used to determine the association between the mean of serum electrolytes and in-hospital mortality. Results: Of the 8,498 patients, 599 (7%) died during hospitalization. Relationship between mean serum potassium (U-shaped), ionized calcium (inverted J-shape) and magnesium (J-shaped) and in-hospital mortality was present in Figure. Serum potassium levels <3.5, 4.5-<5.0 and ≥5.0 mEq/L were independently associated with an increased risk of in-hospital mortality (adjusted OR 1.7 95% CI 1.1-2.5, OR 1.7 95% CI 1.3-2.2, and OR 3.4 95% CI 2.4-4.8, respectively), compared to the reference group. As for serum ionized calcium, the levels of <4.4, 4.4-<4.6, and 4.6-<4.8 mg/dL independently increased risk of mortality (adjusted OR 3.0 95% CI 2.3-4.0, OR 2.0 95% CI 1.5-2.6, and OR 1.4 95% CI, 1.1-1.8, respectively). As for serum magnesium, an only level above 2.4 mg/dL was associated with an increased mortality risk (OR 1.6 95% CI, 1.1-2.2). Conclusions: In the CCU setting, serum potassium 3.5-<4.5 mEq/L, ionized calcium ≥5.0 mg/dL and magnesium <2.4 mg/dL are associated with the lowest in-hospital mortality. These findings do not support supratherapeutic repletion of potassium and magnesium.

Background: Health insurance coverage has been recently expanded to millions of Americans with the goal of improving access and quality of care. We evaluated long-term outcomes for patients with ST-elevation myocardial infarction (STEMI) with different insurance types. Methods: From 2004 to 2010, 970 consecutive STEMI patients who presented to 29 hospitals in Minnesota, Iowa or Wisconsin were treated according to the Mayo STEMI protocol. Demographic, clinical, procedural, and long-term follow up data were prospectively collected. 953 patients were categorized into groups by insurance type - private insurance (PI, n=430), Medicare (MC, n=420), Medicaid (MD, n=68), and uninsured (UN, n=35). Results: Median duration of follow-up was 32 months, and mean ages (years) were 55±8 for PI, 75±10 for MC, 49±10 for MD, and 52±9 for UN (p<0.001). Compared to PI patients, MC and MD patients were more likely to have diabetes (both 21% vs 10%, p<0.001); MC patients had more renal failure (4% vs <1%, p=0.012) but UN patients did not differ significantly (DM 12% and CRF 0%). All groups had similar frequency of cardiogenic shock (PI 9%, MC 14%, MD 9%, UN 6%, p=0.08) and comparable door-to-balloon (in minutes(Q1,Q3): PI 69(54,107), MC 79(61,114), MD 83(55,124), UN 76(58,94), p=0.09) and door-to-needle times (in minutes(Q1,Q3): PI 26(19,34), MC 29 (21,39), MD 27(22,34), UN 17(13,21), p=0.06). MC patients had the highest incidence of in-hospital death (7.6%; p=0.003 vs PI 3.0%). Significant differences in all cause mortality between insurance groups were present on 5-year follow-up (Figure). After risk factor adjustment for age (HR 1.89 per decade, p<0.001), female sex (HR 1.16, p=0.40), diabetes (HR 1.89, p<0.001), peripheral artery disease (HR 2.06, p=0.004), heart failure (HR 1.40, p=0.14), cardiogenic shock (4.22, p<0.001) and renal failure (HR 1.62, p=0.20); insurance type was not an independent risk factor for death (p=0.26). When compared to PI, the hazard ratio for UN was associated with a trend for worse survival (HR 2.69, 95%CI 0.94, 7.67, p=0.06) while MC (HR 0.94, 95%CI 0.55, 1.61, p=0.83) and MD patients (HR 1.37, 95%CI 0.52, 3.59, p=0.53) had similar survival after adjustment for covariates. Conclusion: Timeliness of reperfusion was similar across all insurance groups. After adjustment for baseline clinical variables, there was no significant difference in long-term survival according to insurance type.

Troponin is the biomarker of choice for the diagnosis of myocardial infarction (MI) in clinical practice. Data on its value to predict death, while documented in clinical trials, are lacking from community studies. There is little information from population studies of MI on short and long term predictive value of Troponin on death and nonfatal endpoints such as recurrent ischemic events and heart failure. Methods: We evaluated the prognostic value of Troponin T (TnT) among consecutive persons with incident MI in Olmsted County, MN. Results: 1220 persons (mean age 69±15 years, 45% women) experienced an incident MI (20% ST elevation MI) in Olmsted County, MN between 2002 and 2008. Peak TnT value measured at a median of 1 day post-MI was 1.88±4.19 ng/mL (median 0.52 (25%: 0.16, 75%: 1.75)). After 1.27 years of follow-up, 294 deaths occurred, 360 recurrent ischemic events (recurrent MI or hospitalized unstable angina) and 345 episodes of heart failure. Associations between clinical events and TnT tertiles are shown in the table . Conclusions: In the community, the magnitude of TnT elevation is predictive of recurrent ischemic events, heart failure and early death. It is not associated with long-term mortality. Hazard ratio compared to lowest TnT tertile, 95%CI and p value Adjusted for age, sex and comorbidity Outcome All events Events within 30 days Events among 30 day survivors Death TnT tertile 2 TnT tertile 3 p-value 1.02 (0.78-1.33) 1.15 (0.85-1.57) 0.64 0.64 (0.38-1.06) 1.59 (0.98-2.57) 0.004 1.24 (0.90-1.69) 0.93 (0.62-1.38) 0.26 Recurrent ischemic events TnT tertile 2 TnT tertile 3 p-value 1.45 (1.12-1.88) 1.70 (1.29-2.24) <0.001 1.45 (0.96-2.19) 2.07 (1.37-3.12) 0.002 1.46 (1.05-2.04) 1.45 (1.00-2.10) 0.049 Heart failure TnT tertile 2 TnT tertile 3 p-value 1.03 (0.78-1.36) 2.10 (1.58-2.78) <0.001 0.94 (0.68-1.29) 2.10 1.54-2.87) <0.001 1.38 (0.79-2.41) 2.19 (1.14-4.21) 0.067

Introduction: Hepatocyte growth factor (HGF) is released in response to endothelial injury, and higher levels of circulating HGF are associated with atherosclerosis. However, the association of HGF with atherosclerosis progression is unknown. Hypothesis: Circulating HGF is positively associated with atherosclerosis progression, measured as progression of 1) carotid artery plaque and 2) coronary artery calcium (CAC). Methods: The Multi-Ethnic Study of Atherosclerosis is a large, population-based cohort study of adults aged 45-84 and free of clinical cardiovascular disease. Participants had HGF measured in serum at baseline (2000-02), and were followed for progression of carotid plaque and CAC through 2012. We defined CAC and carotid plaque progression as dichotomous variables (progression, no progression). Carotid plaque progression is an increase in the number of carotid plaques. We used the Hokanson method to define CAC progression as an increase of ≥ 2.5 mm 3 in the square root-transformed calcium volume score. Relative risk regression quantified the association between HGF and carotid plaque progression. Cox regression models using inverse-probability-of-attrition weights estimated the association of HGF with progression of CAC. All effect estimates are adjusted for potential confounding variables. Results: The cohort included 6714 Americans with HGF measurements: 2593 non-Hispanic white, 797 Chinese, 1848 black, and 1476 Hispanic Americans. In 3363 participants with measurements for both carotid plaque and HGF, each standard deviation (259 pg/ml) increase in HGF was associated with a 4% greater risk (95% CI: 1.01-1.07) of carotid plaque progression (n=1875), which did not differ by race/ethnicity (interaction p = 0.3). Out of 6714 participants with measurements for both CAC and HGF, 2994 had CAC progression during follow-up. The association of HGF with CAC progression differed by race/ethnicity (interaction p = 0.01). Each standard deviation increase of HGF was associated with a 10% greater risk of CAC progression in non-Hispanic white (95% CI: 1.05-1.16) and black Americans (95% CI: 1.03-1.17), while HGF was not associated with CAC progression in Chinese (p = 0.5) nor Hispanic (p = 0.7) American participants. Conclusions: Circulating HGF was associated with a modestly increased risk of atherosclerosis progression in this large and diverse population, with the strongest associations between HGF and CAC progression in non-Hispanic white and black Americans. Our results suggest that HGF may have utility as a marker of atherosclerosis progression in some populations.

Background: There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. Methods: Using the National Inpatient Sample (2000–2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer—self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. Results: Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P <0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13–1.17]; P <0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83–0.87]; P <0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P <0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55–1.68]; P <0.001) and resource utilization. Conclusions: Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.