Citations

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 Anti‐Spike monoclonal antibodies (mAbs) progressively lost efficacy during the COVID‐19 pandemic due to the emergence and predominance of resistant SARS‐CoV‐2 variants. By contrast, high‐titre COVID‐19 convalescent plasma (CCP) collected from vaccinated donors recently recovered from infection provides a polyclonal source of antibodies that remains effective in clearing SARS‐CoV‐2 in immunosuppressed patients, unable to mount an adequate immune response against the virus. We conducted a systematic review and individual participant data meta‐analysis to examine the effect of CCP in immunocompromised patients persistently positive for SARS‐CoV‐2 viraemia following mAb therapy, and to evaluate possible biological factors associated with a favourable outcome. Electronic databases were searched for studies published from January 2020 to January 2026. All studies including eligible cases were considered in the systematic review. Unpublished cases were also collected from investigators of the selected studies. The protocol was registered at PROSPERO (CRD420251142891). Forty‐seven cases (30 cases from 12 published studies and 17 unpublished cases) were included. In 33 out of 47 patients (70.2%) with a mAb‐resistant infection, SARS‐CoV‐2 clearance occurred following CCP transfusion, with a mean of 2.7 CCP units administered. In logistic regression, total CCP volume transfused was positively associated with SARS‐CoV‐2 clearance. In conclusion, CCP transfusion was associated with SARS‐CoV‐2 clearance in persistently positive immunocompromised patients following failure of anti‐Spike mAb therapy.

OBJECTIVE Severe (level 3) hypoglycemia is a life-threatening complication of diabetes associated with substantial risk of recurrence and long-term morbidity. This study examined how adults with diabetes interpreted severe hypoglycemic events and why they declined participation in a community paramedicine program (Diabetes Rescue, Engagement, and Management [Diabetes-REM]) designed to prevent recurrence. RESEARCH DESIGN AND METHODS We conducted semistructured qualitative interviews with adults with type 1 or type 2 diabetes who experienced severe hypoglycemia requiring emergency medical services and declined enrollment in Diabetes-REM. Interviews explored hypoglycemia management experiences and reasons for nonparticipation and were explored using thematic analysis. RESULTS Sixteen adults (44% female; mean age 60 years, range 25–83) participated. Four interrelated themes emerged. First, participants normalized glucose variability as a baseline condition of diabetes and interpreted severe events as situational and correctable when a cause was identifiable, or as inevitable when it was not, rather than as evidence of increased risk. Second, participants relied on prevention systems encompassing habitual routines, caregiver involvement, and glucose-monitoring technologies. Third, severe episodes were frightening and disruptive but typically prompted adjustments to personal management over pursuit of additional clinical support. Finally, reasons for declining Diabetes-REM included time constraints (56%), perceived lack of benefit (25%), and privacy concerns or discomfort with home visits (25%). CONCLUSIONS Among adults who declined a community paramedicine hypoglycemia prevention intervention, severe events were absorbed into existing self-management frameworks rather than viewed as signals of increased risk. Programs targeting hypoglycemia recurrence should account for patients’ risk perceptions and existing management systems, positioning support as complementary rather than corrective.

Abstract Normal scapulothoracic function relies on a delicate balance among several periscapular muscles and is essential for shoulder motion. Disturbance in this balance can lead to abnormal motion, which can impair shoulder function, leading to pain and discomfort. A thorough scapular examination requires an accurate physical assessment and the ability to identify pathologies, such as muscle paralysis (e.g., trapezius or serratus anterior) and hyperactivity (e.g., pectoralis minor). Overall, a comprehensive approach to the physical examination is critical in accurately diagnosing and effectively treating shoulder and scapular pathologies. The purpose of this technical note is to provide a concise, standardized methodology for performing a comprehensive scapular examination, focusing on key clinical tests, anatomical landmarks, and motion patterns.

Background: The study aims to evaluate the postoperative outcomes of hiatal hernia repair with cruroplasty alone compared to the addition of fundoplication. We theorize that previously reported inferiority with crural-only repairs resulted from a lack of real-time feedback regarding the effectiveness of the repair. EndoFLIP TM allows for intraoperative assessment of the gastroesophageal junction. We predict equivalent postoperative outcomes will be achieved between hiatal hernia repairs performed by cruroplasty alone and with fundoplication when the final distensibility index (DI) is similar. Methods: This retrospective cohort review includes patients who underwent hiatal hernia repair with intraoperative EndoFLIP TM between 2020 and 2022. Propensity score-matching was utilized to identify cruroplasty alone and fundoplication patients with a final DI within 0.5 mm 2 /mmHg of one another. Postoperative development of dysphagia, reflux, or hernia recurrence were primary outcomes of interest. Results: Forty-two patients were included in the analysis. While the cruroplasty-alone cohort had an increased age at the time of surgery, 50% more redo repairs, and a slightly higher BMI, there were no significant preoperative or intraoperative differences between groups. Overall, the median duration of follow-up was 111 (IQR 213) days. During that time, there were no differences in the development of postoperative reflux or dysphagia between cohorts ( P = .228 and P = .451, respectively). Kaplan-Meier curve analysis did not demonstrate a significant difference in time-to-event for either outcome. There were 3 radiographic recurrences, with 2 occurring after fundoplication ( P = .000). Conclusions: This is the first study to utilize intraoperative EndoFLIP TM to determine the need for fundoplication during hiatal hernia repair. The results demonstrate no additional short-term benefit from fundoplication performance. These findings argue against routine fundoplication when an acceptable DI can be achieved after cruroplasty. Further research is needed to validate these results.

Immune checkpoint inhibitors (ICIs) have transformed cancer therapy but are associated with immune-related adverse events, including ICI–associated acute kidney injury (ICI-AKI). ICI-AKI presents diagnostic and management challenges and can influence decisions regarding immunosuppression and ICI rechallenge, with important implications for both kidney and cancer outcomes. An international, multidisciplinary panel convened at the 34th Acute Disease Quality Initiative (ADQI) consensus conference in September 2024. Systematic literature searches of PubMed were conducted to identify studies on the epidemiology, mechanisms, diagnosis, management, rechallenge, and outcomes of ICI-AKI. The meeting followed the established ADQI process and used a modified Delphi method to achieve consensus. Evidence was reviewed and appraised by workgroups, and consensus statements were developed through structured discussion and voting. Observational data suggest that AKI occurs in up to 20% of patients receiving ICIs, with ICI-AKI accounting for approximately 2%–5% of cases. Acute tubulointerstitial nephritis is the most common lesion, observed in 80%–90% of biopsies, although glomerular diseases are increasingly recognized. No clinical features reliably distinguish ICI-AKI from other causes of AKI, and kidney biopsy remains the diagnostic gold standard. Emerging urinary, circulating, and imaging biomarkers show promise but are not yet ready for routine clinical use. Early glucocorticoid initiation (within 3 days of ICI-AKI diagnosis versus >3 days after diagnosis) is associated with higher rates of kidney recovery, although optimal dosing and duration remain uncertain. Recurrent ICI-AKI occurs in fewer than 20% of patients undergoing ICI rechallenge. Management of high-risk populations, including kidney transplant recipients and patients with autoimmune disease or advanced CKD, requires individualized, multidisciplinary decision-making. ICI-AKI is an important and potentially reversible complication of cancer immunotherapy; these consensus statements provide a framework for diagnosis and management, support cautious ICI rechallenge in selected patients, and identify priorities for future research.

The total number of total hip arthroplasties performed each year is expected to increase significantly over the coming decades. As a result, an increasing number of young patients are undergoing total hip arthroplasty while similarly, a growing subset of active elderly patients desire to return to sports or high-impact activity after surgery. Patients are typically provided restrictions and activities to avoid following surgery. For these patients, there is no clear consensus or guidelines regarding whether they should limit their activity level postoperatively and in particular, if returning to high-impact exercise increases their risk of complications and subsequent revision surgery. This article will discuss the most common complications after total hip arthroplasty and whether patients who return to sports or a high-impact activity after surgery may be more predisposed to these complications in comparison to their more sedentary peers.

Abstract Background Existing formal feedback systems in graduate medical education often rely heavily on intangible Likert Scales linked to ACGME milestones as an end-of-rotation summative assessment. However, more frequent, actionable, formative feedback based on observations is essential to personal growth. Objective To evaluate the impact of changing from a milestone-based evaluation form to a brief narrative-based feedback form in a Pulmonary Disease and Critical Care Medicine (PCCM) fellowship as an exploratory pilot project. Our aim was to describe change in perception of feedback quality and the impact on Clinical Competency Committee (CCC) decisions. Methods We compared the quality of written rotation feedback before and after implementing a shorter feedback form on January 1, 2024 for 15 PCCM fellows at a single large academic institution using the Quality of Assessment for Learning (QuAL) score, (July 2023-December 2023 compared to January 2024-July 2024), fellow pre- and post-surveys (December 2023 and June 2024) and a CCC focus group (June 2024). Results Overall QuAL score improved significantly after narrative-based feedback form implementation (2.71 pre [n = 75] vs 3.70 post [n = 85], p &lt; 0.001). Surveys had 13/14 (92.8%) fellows respond pre-intervention and 8/14 (57.1%) post-intervention. There was significant improvement in the number of fellows indicating they could identify new learning goals based on written feedback after implementation of the new form (23.1% pre vs 75.0% post, p = 0.03). The CCC focus group with 5 of 8 eligible faculty participating described milestone decisions were better supported by more detailed narratives. Conclusions Implementing a brief narrative-based form improved feedback quality and the number of trainees able to create learning goals. The CCC identified that the new form provided better details to support milestone recommendations.

Urinary urea is a key biomarker for tracking protein oxidation and nitrogen balance. A persistent analytical limitation is that conventional total-nitrogen assays do not deconvolute urinary urea from urinary ammonia, and direct measurement still requires capital-intensive clinical analyzers. Here, we implement and independently validate two cost-effective methods that resolve urinary urea by pairing the presence and absence of urease: Method 1 is a urease-coupled potentiometric assay using an ammonium ion-selective electrode (ISE method); Method 2 is a microplate Berthelot–salicylate colorimetric assay employing a repurposed consumer-grade aquarium ammonia test kit (API®) (API method). Each method was validated against the Roche Cobas C311 clinical analyzer (ISE for urinary ammonia and API for urinary urea) in healthy adult volunteers (n = 10 each), and API–ISE were then compared head-to-head for urinary urea. ISE vs. Cobas yielded R2 = 0.967, slope 95% CI [0.867, 1.173], and Bland–Altman bias of −1.02 mM (95% LoA [−7.40, +5.36] mM). API vs. Cobas yielded R2 = 0.973, slope 95% CI [0.790, 1.039], and bias of −1.55 mM (95% LoA [−11.56, +8.46] mM). API–ISE urinary urea comparison confirmed mutual agreement (R2 = 0.9976, slope 95% CI [0.946, 1.024]; bias of +3.47 mM; 95% LoA [−14.60, +21.53] mM), with mean recoveries near 100% (API: 100.7 ± 2.9%; ISE: 100.6 ± 5.4%; 20–350 mM). Both methods agreed with the clinical analyzer, supporting their potential for decentralized, resource-limited testing; clinical and point-of-care validations are needed.

Abstract Background: Glioma diagnosed during pregnancy and pregnancy following glioma treatment present complex management challenges. The safety of glioma treatment during pregnancy is not well established. The ability to counsel patients on timing of conception after treatment remains limited. The aim of this study was to review our institution’s experience with glioma during and before pregnancy. Methods: In this single-institution study, we retrospectively identified patients diagnosed with glioma during or prior to pregnancy and reviewed treatment course and maternal and neonatal outcomes. Results: Twenty-one female patients were included in our study. Glioma diagnoses included 12 high-grade tumors and 9 low-grade tumors. Cohort A consisted of 8 patients who presented with glioma during pregnancy, of which, 7 underwent glioma treatment during pregnancy. All pregnancies in cohort A were without significant maternal complications and resulted in delivery of a healthy neonate. Cohort B consisted of 13 patients who experienced pregnancy after a prior diagnosis of glioma, totaling 23 pregnancies. Antepartum course was complicated by seizure in three pregnancies. Functionally inconsequential anatomic abnormalities in childhood offspring of cohort B occurred in 5 (27.8%) of the pregnancies. Four of the offspring with anatomic abnormalities had exposure to TMZ prior to conception. Conclusions: In this retrospective series, diagnosis of glioma before or during pregnancy was associated with generally favorable maternal, fetal and childhood outcomes. We observed a higher-than-expected rate of anatomic abnormalities in the post-diagnosis cohort, though none carried meaningful functional consequences. These findings add to the limited literature exploring maternal and fetal outcomes in patients with glioma.