BACKGROUND:
Annually, approximately 24,000 fetuses in the United States are stillborn, and parents often feel alone in their grief. Obstetric providers may not be adequately trained to manage the ...medical and emotional aspects of stillbirth; therefore, we implemented a didactic for OB/GYN residents to address this need.
METHODS:
A 2-hour resident didactic including an overview of medical management and a panel of patients and families who had experienced stillbirth was offered in 2013 and 2015. Prior to each session, OB/GYN residents received an electronic 26-question survey about previous training and comfort with caring for patients with stillbirth. Following the didactic, residents were sent a follow-up survey to evaluate and reflect on the content.
RESULTS:
Of 47 residents, 41 responded to the pre-didactic survey (85%). Residents disagreed that the management of stillbirth was adequately covered in medical school (100%) or residency (90%). Forty-one percent agreed that they were unsure of how much personal emotion to express to patients. In qualitative comments following the session, residents felt more comfortable and confident caring for these patients throughout their experience. Residents felt that the session was “incredibly important,” “powerful and memorable,” “hard to attend…so much emotion, so many memories of so many patients.”
DISCUSSION:
Our experience suggests that residents feel unprepared to medically and emotionally care for families with stillbirth. Incorporating a didactic on stillbirth that includes a patient panel can improve resident knowledge and comfort.
Heterogeneity among reported outcomes from enhanced recovery after cesarean delivery impact studies is high. This study aimed to develop a standardized enhanced recovery core outcome set for use in ...future enhanced recovery after cesarean delivery studies.
An international consensus study involving physicians, patients and a director of Midwifery and Nursing Services, was conducted using a three-round modified Delphi approach (2 rounds of electronic questionnaires and a 3rd round e-discussion), to produce the core outcome set. An initial list of outcomes was based on a previously published systematic review. Consensus was obtained for the final core outcome set, including definitions for key terms, and preferred units of measurement. Strong consensus was defined as ≥70% agreement and weak consensus as 50-69% agreement. Of the 64 stakeholders who were approached, 32 agreed to participate. All 32, 31 and 26 stakeholders completed Rounds 1, 2 and 3, respectively.
The number of outcomes in the final core outcome set was reduced from 98 to 15. Strong consensus (≥70% stakeholder agreement) was achieved for 15 outcomes. The core outcome set included: length of hospital stay; compliance with enhanced recovery protocol; maternal morbidity (hospital re-admissions or unplanned consultations); provision of optimal analgesia (maternal satisfaction, compliance with analgesia, opioid consumption / requirement and incidence of nausea or vomiting); fasting times; breastfeeding success; and times to mobilization and urinary catheter removal. The Obstetric Quality of Recovery-10 item composite measure was also included in the final core outcome set. Areas identified as requiring further research included readiness for discharge and analysis of cost savings.
Results from an international consensus to develop a core outcome set for enhanced recovery after cesarean delivery are presented. These are outcomes that could be considered when designing future enhanced recovery studies.
Background:
Glucocorticoid (GC) administration prior to exposure-based cognitive-behavioural therapy (CBT) has emerged as a promising approach to facilitate treatment outcome in anxiety disorders. ...Further components relevant for improved CBT efficacy include raised endogenous GCs and reductions in information-processing biases to threat.
Aims:
To investigate hydrocortisone as an adjunct to CBT for spider fear and the modulating role of threat bias change and endogenous short-term and long-term GCs for treatment response.
Methods:
Spider-fearful individuals were randomized to receiving either 20 mg of hydrocortisone (n = 17) or placebo (n = 16) one hour prior to single-session predominantly computerised exposure-based CBT. Spider fear was assessed using self-report and behavioural approach measures at baseline, 1-day and 1-month follow-up. Threat processing was assessed at baseline and 1-day follow-up. Cortisol and cortisone were analysed from hair and saliva samples at baseline.
Results/outcomes:
Self-report, behavioural and threat processing indices improved following CBT. Hydrocortisone augmentation resulted in greater improvement of self-report spider fear and stronger increase in speed when approaching a spider, but not on threat bias. Neither threat bias nor endogenous GCs predicted symptom change, and no interactive effects with hydrocortisone emerged. Preliminary evidence indicated higher hair cortisone as predictor of a stronger threat bias reduction.
Conclusions/interpretation:
Our data extend earlier findings by suggesting that GC administration boosts the success of exposure therapy for specific fear even with a low-level therapist involvement. Future studies corroborating our result of a predictive hair GC relationship with threat bias change in larger clinical samples are needed.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
The risk of infant exposure to dextromethorphan (DM) and its active metabolite, dextrorphan (DX), through breast milk has not been evaluated. In this study, bound and unbound DM and DX concentrations ...in breast milk and plasma at 2 hours post‐dose were measured in 20 lactating women (n = 20) following a single 30 mg oral dose of DM. The DM and DX concentrations in breast milk were positively correlated with their respective plasma concentrations. The breast milk‐to‐plasma (M/P) ratios of 1.0 and 1.6 and the unbound M/P ratios of 1.1 and 2.0 for DM and DX, respectively, suggested that DM and DX are extensively distributed into breast milk. The infant exposure following a single dose of 30 mg DM was estimated using breast milk concentrations of 0.33 ± 0.32 and 1.8 ± 1.0 μg/kg/day for DM and DX, respectively. The steady‐state infant exposure was estimated using the M/P ratios and previously reported area under the concentration‐time curve (AUC) of DM and DX following repeated dosing of DM 60 mg orally, twice daily, to be 0.64 ± 0.22 and 1.23 ± 0.38 μg/kg/day, respectively. Based on these estimated infant doses, the relative infant doses (RIDs) were estimated to be <1%, suggesting the infant is only exposed to a minor fraction of adult dose through breast milk; however, one nursing infant developed an erythematous rash during this study, which warrants additional research to fully elucidate the risks of infant exposure to DM and DX through breast milk.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
PURPOSE:
To develop and evaluate a comprehensive curriculum about stillbirth focused on both the patient and the provider experience with this difficult topic.
BACKGROUND:
Pilot data from our ...institution showed that OB/GYN residents felt ill prepared to care for patients with stillbirth, and that training about the patient experience of stillbirth was impactful but emotionally distressing. We sought to develop a comprehensive stillbirth curriculum that included knowledge, communication skills, and emotional domains.
METHODS:
A four-part curriculum was created including: 1. Medical management, 2. A stillbirth panel discussion with patients/families, 3. Simulation training in delivering serious news, and 4. Workshop on resiliency. OB/GYN residents completed pre- and post-testing for each session. Five-point Likert scales were compared using the Wilcoxon signed rank test (alpha = 0.05).
RESULTS:
All 28 residents participated in parts of the curriculum, with 85% attending two or more sessions. Following the curriculum, we found statistically significant self-reported improvements in multiple aspects of the stillbirth training: general knowledge (
P
<.01), appropriate tests to order (
P
<.05), interpretation of placental pathology (
P
<.01), genetic evaluation (
P
<.01), comfort conveying sympathy (
P
<.05), expressing emotion (
P
<.01), and confidence in delivering serious news (
P
<.001). In the resiliency workshop, residents shared ideas about how faculty can support them during difficult clinical situations.
DISCUSSION:
A comprehensive stillbirth curriculum which addressed the cognitive, emotional, and skills aspects of this topic was well received and effective. Long-term data is needed to evaluate whether these improvements persist and can enhance resident satisfaction with other challenging topics within OB/GYN.
Fetal growth restriction is associated with stillbirth and other adverse pregnancy outcomes, and the use of the correct weight standard is an essential proxy indicator of growth status and perinatal ...risk.
This study aimed to assess the performance of two international birthweight standards for their ability to identify perinatal morbidity and mortality indicators associated with small for gestational age infants at term.
This retrospective cohort study used data from a multicenter perinatal quality initiative, including a multiethnic dataset of 125,826 births from 2012 to 2017. Of the singleton term births, 92,622 had complete outcome data including stillbirth, neonatal death, 5-minute Apgar score <7, neonatal glucose instability and need for newborn transfer to a higher level of care or neonatal intensive care unit admission. The customized GROW and INTERGROWTH-21st birthweight standards were applied to determine small for gestational age (<10th percentile) according to their respective methods and formulae. The associations with adverse outcomes were expressed as relative risks with 95% confidence intervals and population attributable fractions.
GROW and INTERGROWTH-21st classified 9578 (10.3%) and 4079 (4.4%) pregnancies as small for gestational age, respectively. For all of the outcomes assessed, GROW identified more small for gestational age infants with adverse outcomes than INTERGROWTH-21st, including more stillbirths, perinatal deaths, low Apgar scores, glucose instability, newborn seizure, and transfers to a higher level of care. Moreover, 13 of 27 stillbirths (48%) that were small for gestational age by either method were identified as small for gestational age by GROW but not by INTERGROWTH-21st. Similarly, additional cases of all other adverse outcome indicators were identified by GROW as small for gestational age, whereas INTERGROWTH-21st identified in only 1 category (glucose instability) 9 of 295 cases (3.1%), which were not identified as small for gestational age by GROW.
Customized assessment using GROW resulted in increased identification of small for gestational age term infants that were at significantly increased risk of an array of adverse pregnancy outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
INTRODUCTION
Post-transplant lymphoproliferative disorder (PTLD) is a rare and potentially fatal complication of both solid organ and hematopoietic stem cell transplant. Incidence of PTLD varies ...based on extent of immunosuppression (IS). The long-term impact of IS reduction on graft function following a diagnosis of PTLD in renal transplant recipients is unclear.
METHODS
Data was collected via review of electronic medical records (EMR) for 1628 patients who underwent renal transplant at our institution from September 1, 1996- June 30, 2015. Twenty-seven patients (1.7%) developed PTLD defined as an early lesion, polymorphic PTLD, or monomorphic PTLD. 10 patients did not have clinical data available in the EMR and were excluded. Graft rejection and failure rates of 17 patients prior to diagnosis of PTLD were compared to the same group at most recent follow up using a two-sided binomial test.
RESULTS
Median age at PTLD diagnosis was 50 years (range 24-79 years). Kidney donor type included living related (8), deceased donor (6), and deceased donor followed by a living related donor (1). We were unable to identify donor type for 2 patients.
At time of PTLD diagnosis, 16 patients were on tacrolimus-based IS regimens combined with either mycophenolic acid (6), prednisone (1), mycophenolic acid with prednisone (7), or azathioprine (2). 1 patient was on a sirolimus-based regimen with mycophenolic acid. Four of 17 patients experienced an episode of acute (1) or chronic (3) renal graft rejection prior to PTLD diagnosis. Two of 3 patients with chronic rejection developed graft failure. Median time patients were on IS prior to a diagnosis of PTLD was 11 years (range 1-37 years).
PTLD histology included polymorphic PTLD (2) and monomorphic PTLD (14), 1 of which was a T-cell lymphoma. There was 1 early lesion thought secondary to Epstein Barr virus (EBV) viremia. Immunohistochemical staining for EBV was positive in 2 out of 14 available cases. There were no cases of classical Hodgkin lymphoma. Treatment included reduction of immunosuppression in all patients combined with either rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in 8 patients, single agent rituximab followed by R-CHOP (3), dose adjusted rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (daR-EPOCH) in 3 patients, bexarotene plus phototherapy (1), whole brain radiation (1), and reduction of IS only (1). Thirteen of 17 patients achieved complete remission (CR) following their initial treatment regimen. Median disease free survival or relapse free survival was 55 months (range 9-98 months). There were no cases with partial response or stable disease. Two patients developed relapsed disease. One relapsed 6 months after remission, the other 7 months. At time of analysis, 11 patients were alive, 2 died of refractory PTLD, 2 died of pneumonia while in CR, and 2 were lost to follow up.
IS regimens were held in all patients following a diagnosis of PTLD and subsequently resumed at an attenuated level if patient achieved CR. Three of 17 patients had an episode of renal graft rejection following reduction of IS after PTLD diagnosis, including acute T-cell-mediated (2) and chronic rejection (1). The patient with chronic rejection developed graft failure following IS reduction.
CONCLUSION
At median follow up of 24 months, there was no significant difference in the overall rate of renal graft rejection following PTLD development as compared to prior to diagnosis of PTLD (p= 0.78). There was no significant difference in rate of acute rejection after diagnosis of PTLD compared to prior to diagnosis (p= 0.26). Additionally, there was no significant difference in the rate of renal graft failure following PTLD development compared to prior to diagnosis (p= 0.71). Our rate of PTLD development in renal transplant recipients was comparable to previously reported data.
No relevant conflicts of interest to declare.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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