Septoplasty versus expectant management in women with septate uterus and a previous history of a live birth

Study question: Does hysteroscopic septoplasty improve reproductive outcome in patients who were diagnosed to have a septate uterus (SU) after a previous live birth? Summary answer: This study suggests that hysteroscopic septoplasty improves the chance of a live birth in patients with both SU and a history of previous live birth. What is known already: SU accounts for 50% of uterine anomalies and can be associated with adverse pregnancy outcomes. Many observational studies reported significant improvement in pregnancy outcomes following hysteroscopic septoplasty. However, some investigators have reported good reproductive outcome among women with SU without surgical interventions. A recent randomized controlled trial, albeit with a small sample size, reported no difference in reproductive outcomes between patients who underwent hysteroscopic septoplasty and those who had no surgery (Rikken 2021). Therefore, more studies are needed to be able to counsel patients with SU presenting with reproductive failure, especially those with a history of a previous live birth. Study design, size, duration: This retrospective study included 114 patients who had a previous live birth and subsequently complained of reproductive failure. A SU was diagnosed during their work up between 2005- 2022. Patients presented with secondary infertility (98.3%) or with recurrent pregnancy loss (RPL) [1.7%]. Forty-two patients presented with both secondary infertility and RPL (36.8%). Participants/materials, setting, methods: Diagnosis of SU was suspected on transvaginal 3D ultrasound scan and was confirmed on a diagnostic hysteroscopy at an infertility clinic affiliated with an academic hospital. Patients were offered the option of hysteroscopic septoplasty or expectant management. Infertility treatment options depended on the underlying etiology and included spontaneous conception, oral fertility medications, intrauterine insemination, and in-vitro fertilization/embryo transfer. Eighty-two patients underwent hysteroscopic septoplasty (Group 1), while 32 patients declined surgery (Group 2). Main results and the role of chance: There were no significant differences in mean age (years), BMI (Kg/m2), infertility duration, baseline FSH levels (mIU/mL), number of miscarriages, and gestational age at delivery before treatment between the two groups. There were no significant differences in incidence of≤3 or≥3 pregnancies, nor incidence of one live birth or\u3e1 live birth between the two groups. There were no significant differences in the underlying etiology, except for a significantly higher incidence of endometriosis (P=0.004) and diminished ovarian reserve (P=0.04) in Group 1 compared to Group 2. There were no significant differences in the incidence of partial septate uterus (PSU) [angle of indentation \u3c90 degrees] and complete septate uterus between the two groups. However, there was significantly lower incidence of PSU with angle of indentation \u3e 90 degrees (P=0.028) and higher mean septum length in mm (18.9 ± 1.0 vs 13.8 ± 1.1, P=0.024) on hysteroscopy in Group 1 compared to Group 2. After treatment, there were significantly higher pregnancy (68.3% vs 37.5%, p=0.003) and live birth (61.7% vs 25%, P=0.000) rates, but no significant difference in miscarriages (4.9% vs 6.3%), preterm birth (14% vs 25%) rates, or method of pregnancy in Group 1 compared to Group 2. Limitations, reasons for caution: Our study has limitations being retrospective in nature with a small sample size. Therefore, more studies are required to support our findings. However, our pilot study explored management options in a particular group of patients with SU who initially proved their fertility and subsequently presented with reproductive failure. Wider implications of the findings: Our data support the notion that patients with SU can have a normal reproductive outcome, although those who undergo septoplasty are expected to have a better chance of conception and live birth. During counselling of patients with SU, both surgical and expectant management can be offered

RECOGNITION OF DISEASE ACTIVITY AND TREATMENT MONITORING IN CARDIAC SARCOIDOSIS: INTEGRAL ROLE OF CARDIAC POSITRON EMISSION TOMOGRAPHY (PET)

Background 18F-Flourodeoxyglucose (FDG) PET imaging is crucial for diagnosing and monitoring disease activity in cardiac sarcoidosis (CS). However, little is known regarding the utility of follow-up PET scans in managing immunosuppression. Case 49 year old male with history of heart failure with reduced EF, complete heart block s/p CRT-D, atrial fibrillation, underwent a cardiac 82Rubidium 18F FDG PET scan for suspected CS. In the top figure, multifocal FDG uptake was observed, indicating active inflammation in the septum, right ventricle (RV), and right atrium despite normal perfusion. Treatment began with methotrexate and prednisone. After 3 months, follow-up PET scan revealed no inflammation (middle figure), resulting in reduction of prednisone dose with symptomatic improvement. 6 months later, another PET scan revealed recurrent inflammatory pattern of uptake in the septum, anterior wall, and RV prompting initiation of infliximab alongside methotrexate and a gradual prednisone taper until discontinuation. Decision-making Our case highlights the importance of serial 18F-FDG PET imaging in monitoring CS, emphasizing the challenges of immunosuppressive therapy, the recurrence of inflammation, and the value of follow-up cardiac PET scans. Increased RV FDG uptake is linked to higher long term event rates. Conclusion In the absence of specific guidelines, FDG PET may serve as a valuable tool for monitoring inflammation progression and assessing the response to immunosuppressive therapy. [Formula presented

Project #09: Potential Cost Savings in the Reversal of DOAC Associated Bleeding

Background: Direct oral anticoagulants (DOACs) are a cornerstone of therapy in treatment and prevention of deep vein thrombosis, pulmonary embolism and other thromboembolic disorders. Despite their favorable safety profile, patients are still at an increased risk of intracranial hemorrhages (ICH), gastrointestinal (GI) and/or fatal bleeding. Two agents commonly used in DOAC associated bleeding include andexanet-alfa and four factor prothrombin concentrate complex (4F-PCC). Reversal agent selection is determined by clinical presentation, cost, and institutional preference. 4F-PCC costs $9,099 per patient compared to$12,310 and $22,158 for low dose and high dose of andexanet-alfa respectively. Objectives: To evaluate adherence to Henry Ford Health System (HFHS) 2023 “Tier 1: Anticoagulation Reversal Guidelines” and determine cost efficiency in the management of DOAC-associated bleeding with andexanet-alfa.https://scholarlycommons.henryford.com/qualityexpo2024/1021/thumbnail.jp

Urinary catheter alleviation navigator protocol (UCANP): Update to the hospital-wide implementation at a single tertiary health care center

BACKGROUND: Catheter-associated urinary tract infections are commonly reported health care-associated infections. It was demonstrated that the urinary catheter alleviation navigator protocol (UCANP) pilot resulted in a reduction of catheter utilization and catheter days. METHODS: Quality improvement initiative that was implemented at a single urban, tertiary health care center, focusing on early discontinuation of indwelling urinary catheters (IUCs) and avoidance of reinsertion. The protocol was expanded hospital-wide from September 2020 to April 2022. We compared IUC utilization, IUC standardized utilization ratio (SUR), and catheter-associated urinary tract infection standardized infection ratio in the preintervention period (March 2020 to August 2020) to the postintervention period (May 2022 to October 2022). RESULTS: Preimplementation, 2 patients with IUC removal were placed on UCANP. Postimplementation, 835 (45%) patients with IUC removal participated in the protocol. The number of patients requiring IUC reinsertion did not differ among the 2 groups. IUC utilization was significantly decreased from 0.28 to 0.24 with a 14% reduction (P = .025). SUR decreased by 11% from 0.778 to 0.693 (P = .007) and standardized infection ratio by 84% from 0.311 to 0.049 (P = .009). CONCLUSIONS: Our protocol significantly reduced IUC utilization and SUR after hospital-wide implementation. UCANP is a safe and effective strategy that can potentially decrease unnecessary IUCs in patients with transient urinary retention

Association of early dexmedetomidine exposure with brain injury biomarker levels following moderate - Severe traumatic brain injury: A TRACK-TBI study

BACKGROUND: Traumatic brain injury (TBI) triggers autonomic dysfunction and inflammatory response that can result in secondary brain injuries. Dexmedetomidine is an alpha-2 agonist that may modulate autonomic function and inflammation and has been increasingly used as a sedative agent for critically ill TBI patients. We aimed to investigate the association between early dexmedetomidine exposure and blood-based biomarker levels in moderate-to-severe TBI (msTBI). METHODS: We conducted a retrospective cohort study using data from the Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study (TRACK-TBI), which enrolled acute TBI patients prospectively across 18 United States Level 1 trauma centers between 2014-2018. Our study population focused on adults with msTBI defined by Glasgow Coma Scale score 3-12 after resuscitation, who required mechanical ventilation and sedation within the first 48 h of ICU admission. The study\u27s exposure was early dexmedetomidine utilization (within the first 48 h of admission). Primary outcome included brain injury biomarker levels measured from circulating blood on day 3 following injury, including glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase-L1 (UCH-L1), neuron-specific enolase (NSE), S100 calcium-binding protein B (S100B) and the inflammatory biomarker C-reactive protein (CRP). Secondary outcomes assessed biomarker levels on days 5 and 14. Linear mixed-effects regression modelling of the log-transformed response variable was used to analyze the association of early dexmedetomidine exposure with brain injury biomarker levels. RESULTS: Among the 352 TRACK-TBI subjects that met inclusion criteria, 50 (14.2 %) were exposed to early dexmedetomidine, predominantly male (78 %), white (81 %), and non-Hispanic (81 %), with mean age of 39.8 years. Motor vehicle collisions (27 %) and falls (22 %) were common causes of injury. No significant associations were found between early dexmedetomidine exposure with day 3 brain injury biomarker levels (GFAP, ratio = 1.46, 95 % confidence interval [0.90, 2.34], P = 0.12; UCH-L1; ratio = 1.17 [0.89, 1.53], P = 0.26; NSE, ratio = 1.19 [0.92, 1.53], P = 0.19; S100B, ratio = 1.01 [0.95, 1.06], P = 0.82; hs-CRP, ratio = 1.29 [0.91, 1.83], P = 0.15). The hs-CRP level at day 14 in the dexmedetomidine group was higher than that of the non-exposure group (ratio = 1.62 [1.12, 2.35], P = 0.012). CONCLUSIONS: There were no significant associations between early dexmedetomidine exposure and day 3 brain injury biomarkers in msTBI. Our findings suggest that early dexmedetomidine use is not correlated with either decrease or increase in brain injury biomarkers following msTBI. Further research is necessary to confirm these findings

Real-world approaches to outpatient treatment of status migrainosus: A survey study

OBJECTIVES: Identify how the American Headache Society (AHS) membership manages status migrainosus (SM) among outpatients. BACKGROUND: SM is defined as a debilitating migraine attack lasting more than 72 h. There is no standard of care for SM, including whether a 72-h duration is required before the attack can be treated as SM. METHODS: The Refractory Headache Special Interest Group from AHS developed a four-question survey distributed to AHS members enquiring (1) whether they treat severe refractory migraine attacks the same as SM regardless of duration, (2) what their first step in SM management is, (3) what the top three medications they use for SM are, and (4) whether they are United Council for Neurologic Subspecialties (UCNS) certified. The survey was conducted in January 2022. Descriptive statistical analyses were performed. RESULTS: Responses were received from 196 of 1859 (10.5%) AHS members; 64.3% were UCNS certified in headache management. Respondents treated 69.4% (136/196) of patients with a severe refractory migraine attack as SM before the 72-h period had elapsed. Most (76.0%, 149/196) chose treat remotely using outpatient medications at home as the first step, 11.2% (22/196) preferred procedures, 6.1% (12/196) favored an infusion center, 6.1% (12/196) sent patients to the emergency department (ED) or urgent care, and 0.5% (1/196) preferred direct hospital admission. The top five preferred medications were as follows: (1) corticosteroids (71.4%, 140/196), (2) nonsteroidal anti-inflammatory drugs (NSAIDs) (50.1%, 99/196), (3) neuroleptics (46.9%, 92/196), (4) triptans (30.6%, 60/196), and (5) dihydroergotamine (DHE) (21.4%, 42/196). CONCLUSIONS: Healthcare professionals with expertise in headache medicine typically treated severe migraine attacks early and did not wait 72 h to fulfill the diagnostic criteria for SM. Outpatient management with one or more medications for home use was preferred by most respondents; few opted for ED referrals. Finally, corticosteroids, NSAIDs, neuroleptics, triptans, and DHE were the top five preferred treatments for home SM management

Treatment of vascular dementia in female rats with AV-001, an Angiopoietin-1 mimetic peptide, improves cognitive function

BACKGROUND: Vascular dementia (VaD) is a complex neurodegenerative disorder. We previously found that treatment of VaD in middle-aged male rats subjected to multiple microinfarction (MMI) with AV-001, a Tie2 receptor agonist, significantly improves cognitive function. Age and sex affect the development and response of VaD to therapeutic intervention. Thus, the present study investigated the therapeutic effect of AV-001 on VaD in aged female rats subjected to MMI. METHODS: Female 18-month-old Wistar rats were subjected to MMI by injecting either 1,000 (low dose, LD-MMI) or 6,000 (high dose, HD-MMI) cholesterol crystals of size 70-100 μm into the right internal carotid artery. AV-001 (1 μg/Kg, i.p.) was administered once daily after MMI for 1 month, with treatment initiated 1 day after MMI. A battery of behavioral tests to examine sensorimotor and cognitive functions was performed at 21-28 days after MMI. All rats were sacrificed at 1 month after MMI. RESULTS: Aged female rats subjected to LD-MMI exhibit severe neurological deficits, memory impairment, and significant white matter (WM) and oligodendrogenesis injury in the corpus callosum compared with control rats. HD-MMI in aged female rats induces significant anxiety- and depression-like behaviors, which were not detected in LD-MMI aged female rats. Also, HD-MMI induces significantly increased WM injury compared to LD-MMI. AV-001 treatment of LD-MMI and HD-MMI increases oligodendrogenesis, myelin and axon density in the corpus callosum and striatal WM bundles, promotes WM integrity and attenuates neurological and cognitive deficits. Additionally, both LD-MMI and HD-MMI rats exhibit a significant increase, while AV-001 significantly decreases the levels of inflammatory factors in the cerebrospinal fluid (CSF). CONCLUSION: MMI reduces oligodendrogenesis, and induces demyelination, axonal injury and WM injury, and causes memory impairment, while HD-MMI induces increased WM injury and further depression-like behaviors compared to LD-MMI rats. AV-001 has a therapeutic effect on aged female rats with MMI by reducing WM damage and improving neuro-cognitive outcomes

Ciprofloxacin versus levofloxacin prophylaxis in hematopoietic stem cell transplantation: A randomized trial

OBJECTIVES: We aimed to assess whether there is a difference between ciprofloxacin and levofloxacin as prophylaxis in hematopoietic stem cell transplant (SCT) recipients. METHODS: This is a prospective, randomized trial in patients receiving SCT at Henry Ford Health in the United States of America. We randomly assigned patients (1:1) to receive ciprofloxacin or levofloxacin. The primary outcome was incidence of bloodstream bacterial infections (BSI) up to day 60 after SCT. RESULTS: Between June 4, 2018, and May 23, 2022, we randomly assigned 308 consecutive patients to receive ciprofloxacin (154 patients) or levofloxacin (154 patients). BSI was similar in both the ciprofloxacin and levofloxacin groups (18 [11.7%] vs 18 [11.7%]). Pneumonia was more frequent in the ciprofloxacin group compared to the levofloxacin group (18 [18%] vs 7 [23%]; relative risk 2.57, 95% CI 1.11-5.98; p = 0.028). There were no differences in neutrophil engraftment, fever, Clostridium difficile infection, relapse incidence, overall survival, nonrelapse mortality, length of stay post-SCT, or intensive care unit admission. CONCLUSION: Although both prophylaxis regimens demonstrated the same efficacy in SCT recipients, levofloxacin prophylaxis led to less pneumonia in the first 60 days post-SCT. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov, NCT03850379

Photobiomodulation CME part II: Clinical applications in dermatology

Photobiomodulation (PBM) is an emerging treatment modality in dermatology with increasing office and home-based use. PBM is the use of various light sources in the red light (620-700 nm) and near-infrared (700-1440 nm) spectrum as a form of light therapy. PBM is often administered through low-level lasers or light-emitting diodes. Studies show that PBM can be used effectively to treat conditions secondary to cancer therapies, alopecia, ulcers, herpes simplex virus, acne, skin rejuvenation, wounds, and scars. PBM offers patients many benefits compared to other treatments. It is noninvasive, cost-effective, convenient for patients, and offers a favorable safety profile. PBM can be used as an alternative or adjuvant to other treatment modalities including pharmacotherapy. It is important for dermatologists to gain a better clinical understanding of PBM for in-office administration and to counsel patients on proper application for home-use devices to best manage safety and expectations as this technology develops. PBM wavelengths can induce varied biological effects in diverse skin types, races, and ethnicities; therefore, it is also important for dermatologists to properly counsel their skin of color patients who undergo PBM treatments. Future clinical trials are necessary to produce standardized recommendations across conditions and skin types