Condensation pageTweetable statement: The prevalence of abnormal findings on postpartum echocardiogram in severe preeclampsia was 14%.Abnormal echocardiogram was associated with increased length of stay and diuretic use.Routine echocardiography may have a role in tailoring preeclampsia care.

ObjectiveTo determine if a single brain biopsy utilizing a freeze-core needle harvest system Cassi II under ultrasound guidance provides a diagnostic sample; to evaluate the technique's efficacy in procuring diagnostic samples in comparison with “open” surgical biopsies; and to describe intraoperative complications associated with the technique.Study designExperimental clinical study.AnimalsSeventeen dogs and four cats with magnetic resonance imaging (MRI) diagnoses of readily surgically accessible intracranial masses.MethodsImmediately prior to surgical biopsy (SB), freeze-core biopsy (FCB) sample was obtained from each patient under ultrasound guidance.ResultsHistopathology results from single FCB samples were found to be in 100% agreement with the SB samples. Freezing artifact was minimal and did not interfere with histopathologic interpretation. There were no intraoperative complications specifically attributable to the use of the FCB system.ConclusionBased on the results of this small experimental study, the FCB system is expected to safely yield diagnostic quality intracranial masses biopsy specimens.Clinical significanceThis system has the potential of obtaining diagnostic biopsies of more deeply seated brain lesions (i.e., intra-axial tumors considered inaccessible or with large risks/difficulties by standard surgical means) which would provide a definitive diagnosis to guide appropriate therapy.

Robotic abdominal wall reconstruction (RAWR) is one of the most significant advances in the management of complex abdominal wall hernias. The objective of this study was to evaluate long term outcomes in a cohort of patients that underwent complex RAWR in a single center. This was a longitudinal retrospective review of a cohort of 56 patients who underwent complex RAWR at least 24 months prior by a single surgeon at a tertiary care institution. All patients underwent bilateral retro-rectus release (rRRR) with or without robotic transversus abdominis release (rTAR). Data collected include demographics, hernia details, operative and technical details. The prospective analysis included a post-procedure visit of at least 24 months from the index procedure with a physical examination and quality of life survey using the Carolinas Comfort Scale (CCS). Patients with reported symptoms concerning for hernia recurrence underwent radiographic imaging. Descriptive statistics (mean ± standard deviation or median) were calculated for continuous variables. Chi-square or Fisher’s exact test as deemed appropriate for categorical variables, and analysis of variance or the Kruskal–Wallis test for continuous data, were performed among the separate operative groups. A total score for the CCS was calculated and analyzed in accordance with the user guidelines. One-hundred and-forty patients met the inclusion criteria. Fifty-six patients consented to participate in the study. Mean age was 60.2 years. Mean BMI was 34.0. Ninety percent of patients had at least one comorbidity and 52

BACKGROUND: Diabetes mellitus is a common medical complication of pregnancy, and its treatment is complex. Recent years have seen an increase in the application of mobile health tools and advanced technologies, such as remote patient monitoring, with the aim of improving care for diabetes mellitus in pregnancy. Previous studies of these technologies for the treatment of diabetes in pregnancy have been small and have not clearly shown clinical benefit with implementation. OBJECTIVE: Remote patient monitoring allows clinicians to monitor patients' health data (such as glucose values) in near real-time, between office visits, to make timely adjustments to care. Our objective was to determine if using remote patient monitoring for the management of diabetes in pregnancy leads to an improvement in maternal and neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study of pregnant patients with diabetes mellitus managed by the maternal-fetal medicine practice at one academic institution between October 2019 and April 2021. This practice transitioned from paper-based blood glucose logs to remote patient monitoring in February 2020. Remote patient monitoring options included (1) device integration with Bluetooth glucometers that automatically uploaded measured glucose values to the patient's Epic MyChart application or (2) manual entry in which patients manually logged their glucose readings into their MyChart application. Values in the MyChart application directly transferred to the patient's electronic health record for review and management by clinicians. In total, 533 patients were studied. We compared 173 patients managed with paper logs to 360 patients managed with remote patient monitoring (176 device integration and 184 manual entry). Our primary outcomes were composite maternal morbidity (which included third- and fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage requiring transfusion, postpartum hysterectomy, wound infection or separation, venous thromboembolism, and maternal admission to the intensive care unit) and composite neonatal morbidity (which included umbilical cord pH < 7.00, 5 minute Apgar score < 7, respiratory morbidity, hyperbilirubinemia, meconium aspiration, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumonia, seizures, hypoxic ischemic encephalopathy, shoulder dystocia, trauma, brain or body cooling, and neonatal intensive care unit admission). Secondary outcomes were measures of glycemic control and the individual components of the primary composite outcomes. We also performed a secondary analysis in which the patients who used the two different remote patient monitoring options (device integration vs manual entry) were compared. Chi-square, Fisher's exact, 2-sample t, and Mann-Whitney tests were used to compare the groups. A result was considered statistically significant at P <.05. RESULTS: Maternal baseline characteristics were not significantly different between the remote patient monitoring and paper groups aside from a slightly higher baseline rate of chronic hypertension in the remote patient monitoring group (6.1% vs 1.2%; P=.011). The primary outcomes of composite maternal and composite neonatal morbidity were not significantly different between the groups. However, remote patient monitoring patients submitted more glucose values (177 vs 146; P=.008), were more likely to achieve glycemic control in target range (79.2% vs 52.0%; P <.0001), and achieved the target range sooner (median, 3.3 vs 4.1 weeks; P=.025) than patients managed with paper logs. This was achieved without increasing in-person visits. Remote patient monitoring patients had lower rates of preeclampsia (5.8% vs 15.0%; P=.0006) and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (29.8% vs 51.7%; P <.0001). CONCLUSION: Remote patient monitoring for the management of diabetes mellitus in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and is associated with improved maternal and neonatal outcomes.

What was the research about?Heart failure occurs when the heart is unable to pump enough blood to the rest of the body.It can often cause admission to the hospital, especially for people 65 or older.Heart failure can lead to frequent hospital visits, poor quality of life, and death.In this study, the research team wanted to improve care for black and Hispanic adults with heart failure after they leave the hospital.The team compared two groups for three months.

Background:Although the American Heart Association promotes telehealth models to improve care access, there is limited literature on its use in underserved populations. This study is the first to compare utilization and quality of life (QoL) for underserved black and Hispanic heart failure (HF) patients assigned to telehealth self-monitoring (TSM) or comprehensive outpatient management (COM) over 90 days.Methods:This randomized controlled trial enrolled 104 patients. Outcomes included emergency department (ED) visits, hospitalizations, QoL, depression, and anxiety. Binary outcomes for utilization were analyzed using chi-square or Fisher's exact test. Poisson or negative binomial regression, repeated-measures analysis of variance, or generalized estimating equations were also used as appropriate.Results:Of 104 patients, 31% were Hispanic, 69% black, 41% women, and 72% reported incomes of <$10,000/year. Groups did not differ regarding binary ED visits (relative risk [RR]=1.37, confidence interval [CI]=0.83-2.27), hospitalization (RR=0.92, CI=0.57-1.48), or length of stay in days (TSM=0.54 vs. COM=0.91). Number of all-cause hospitalizations was significantly lower for COM (TSM=0.78 vs. COM=0.55; p=0.03). COM patients reported greater anxiety reduction from baseline to 90 days (TSM=50-28%; COM=57-13%; p=0.05).Conclusions:These findings suggest that TSM is not effective in reducing utilization or improving QoL for underserved patients with HF. Future studies are needed to determine whether TSM can be effective for populations facing health care access issues.

Objective: Pancreatectomies have been identified as procedures with an increased risk of readmission. In surgical patients, readmissions within 30 days of discharge are usually attributed to the index surgical procedure. We sought to determine predictors of 30-day readmission following pancreatic resections in a large healthcare system. Methods: We retrospectively collected information from the records of 383 patients who underwent pancreatic resections from 2004 to 2013. We performed a univariate screen of possible variables using the Fisher's exact test for categorical variables and the Mann–Whitney-U test for continuous variables. Multivariate analysis was used to determine the independent effects of each factor. Results: 58 (18.1%) patients were readmitted within 30 days of discharge. Of the patients readmitted, the most common reasons for readmission were sepsis (17.5%), and dehydration (8.8%). Multivariate logistic regression found that development of intra-abdominal fluid collections (OR=5.32, p<0.0001), new thromboembolic events (OR=4.08, p=0.016), and pre-operative BMI (OR=1.06, p=0.040) were associated with readmissions within 30 days of discharge. Conclusion: Our data demonstrates that factors predictive of 30-day readmission are a combination of patient factors and the development of post-operative complications. Rates of readmission can be reduced by taking measures to address these specific issues. Future research will focus on factors that predispose to the development of intra-abdominal collections.

Objectives: To determine mortality and costs associated with adherence to an aggressive, 3-hour sepsis bundle versus noncompliance with greater than or equal to one bundle element for severe sepsis and septic shock patients. Design: Prospective, multisite, observational study following three sequential, independent cohorts, from a single U.S. health system, through their hospitalization. Setting: Cohort 1: five tertiary and six community hospitals. Cohort 2: single tertiary, academic medical center. Cohort 3: five tertiary and four community hospitals. Patients: Consecutive sample of all severe sepsis and septic shock patients (defined: infection, ≥ 2 systemic inflammatory response syndrome, and hypoperfusive organ dysfunction) identified by a quality initiative. The exposure was full 3-hour bundle compliance. Bundle elements are as follows: 1) blood cultures before antibiotics; 2) parenteral antibiotics administered less than or equal to 180 minutes from greater than or equal to two systemic inflammatory response syndrome “and” lactate ordered, or less than or equal to 60 minutes from “time-zero,” whichever occurs earlier; 3) lactate result available less than or equal to 90 minutes postorder; and 4) 30 mL/kg IV crystalloid bolus initiated less than or equal to 30 minutes from “time-zero.” Main outcomes were in-hospital mortality (all cohorts) and total direct costs (cohorts 2 and 3). Measurements and Main Results: Cohort 1: 5,819 total patients; 1,050 (18.0%) bundle compliant. Mortality: 604 (22.6%) versus 834 (26.5%); CI, 0.9–7.1%; adjusted odds ratio, 0.72; CI, 0.61–0.86; p value is less than 0.001. Cohort 2: 1,697 total patients; 739 (43.5%) bundle compliant. Mortality: 99 (13.4%) versus 171 (17.8%), CI, 1.0–7.9%; adjusted odds ratio, 0.60; CI, 0.44–0.80; p value is equal to 0.001. Mean costs: $14,845 versus $20,056; CI, –$4,798 to –5,624; adjusted &bgr;, –$2,851; CI, –$4,880 to –822; p value is equal to 0.006. Cohort 3: 7,239 total patients; 2,115 (29.2%) bundle compliant. Mortality: 383 (18.1%) versus 1,078 (21.0%); CI, 0.9–4.9%; adjusted odds ratio, 0.84; CI, 0.73–0.96; p value is equal to 0.013. Mean costs: $17,885 versus $22,108; CI, –$2,783 to –5,663; adjusted &bgr;, –$1,423; CI, –$2,574 to –272; p value is equal to 0.015. Conclusions: In three independent cohorts, 3-hour bundle compliance was associated with improved survival and cost savings.

Background/ObjectivesWhereas opiate prescribing patterns have been well described in outpatient and emergency department settings, they have been less defined in hospitalized older adults. The objective was to describe patterns of opiate prescribing and associated outcomes in hospitalized older adults. DesignRetrospective cohort study. SettingTertiary care facility. ParticipantsHospitalized medical patients aged 65 and older (N = 9,245; mean age 80.3, 55.2% female, 72.3% white, 90.8% non-Hispanic). MeasurementsOpiate exposure and duration of action, concurrent use of potentially inappropriate medications (PIMs), adverse events, discharge disposition, length of stay (LOS), and 30-day readmissions. ResultsThere was no difference in sex, race, ethnicity, or Charlson Comorbidity Index between opiate exposure groups. Participants who had never received opiates had a significantly shorter mean LOS than prior and new opiate users (5.2, 6.8, 7.7 days; P < .001) and were more likely to be discharged home (88.6%, 82.8%, 82.5%; P < .001) and significantly less likely to be readmitted within 30-days (19.6%, 25.0%, 22.3%; P < .001). Participant who had never been exposed to opiates had a significantly shorter mean LOS than those receiving short- and long-acting opiates (5.2, 7.3, 8.6 days; P < .001) and were more likely to be discharged home (88.6%, 82.6%, 82.4%; P < .001) and significantly less likely to be readmitted within 30-days (19.6%, 27.7%, 28.9%; P < .001). ConclusionOpiate use is widespread during hospitalization and is associated with significant negative clinical outcomes and quality metrics. There is an urgent need to develop innovative pain management alternatives to opiate use.

For the interaction between the biostatistician and the clinician or research investigator to be successful, it is important not only for the investigator to be able to explain biological and medical principles in a way that can be understood by the biostatistician, so, too, the biostatistician needs tools to help the investigator understand both the practice of statistics and specific statistical methods. In our practice, we have found it useful to draw analogies between statistical concepts and familiar medical or everyday ideas. These analogies help to stress a point or provide an understanding on the part of the investigator. For example, explaining the reason for using a nonparametric procedure (a general procedure used when the underlying distribution of the data is not known or cannot be assumed) by comparing it to using broad spectrum antibiotics (a general antibiotic used when the specific bacteria causing infection is unknown or cannot be assumed) can be an effective teaching tool. We present a variety of useful (and hopefully amusing) analogies that can be adopted by statisticians to help investigators at all levels of experience better understand principles and practice of statistics.

On finding a significant association between rows and columns of an r x c contingency table, the next step is to study the nature of the association in more detail. The use of a scree plot to visualize the largest contributions to X-2 among all cells in the table in order to determine the nature of the association in more detail is proposed.

OBJECTIVE:To objectively describe morphometric features of the craniocervical junction region of Cavalier King Charles Spaniels (CKCSs) and non-CKCS dogs with suspected Chiari-like malformation (CLM) and identify associations between these features and the presence of other malformations in this region.ANIMALS:216 CKCSs and 58 non-CKCS dogs.PROCEDURES:Magnetic resonance and computed tomographic images of the head and craniocervical junction region of patients evaluated because of suspected CLM were assessed for cerebellar compression (CC), ventral spinal cord compression at the C1-C2 articulation (medullary kinking), and dorsal spinal cord compression at the C1-C2 articulation (dorsal compression). A compression index was calculated for each of these 3 locations in each dog. Multiple logistic regression analysis was performed to determine whether breed (CKCS vs non-CKCS) and compression index values were associated with the presence of other craniocervical junction abnormalities.RESULTS:All 274 dogs had CC; medullary kinking was identified in 187 (68.2%) and dorsal compression was identified in 104 (38.0%). Atlantooccipital overlapping (AOO) was identified in 76 (27.7%) dogs. Breed of dog (CKCS vs non-CKCS) and value of CC index were the only significant predictors of AOO. The CKCSs had an almost 5-fold decrease in risk of AOO, compared with the non-CKCS dogs, and the risk of AOO nearly doubled for every 10% increase in CC index.CONCLUSIONS AND CLINICAL RELEVANCE:The anatomic abnormality responsible for CC was AOO in a substantial percentage of dogs suspected to have CLM. The CC index value may be used to help differentiate subtypes of craniocervical junction abnormalities in dogs.