Atypical eclampsia in a normotensive patient with altered mental status and severely elevated transaminases: Case report and review

Classically, pre-eclampsia and eclampsia are considered hypertensive disorders of pregnancy, and current diagnostic criteria include hypertension with proteinuria or other laboratory abnormalities or symptoms suggestive of end-organ damage. However, atypical presentations can occur in the absence of elevated blood pressures. We present the case of a pregnant patient who developed status epilepticus at 24 weeks and 4 days of gestation, followed by altered mental status and severely elevated transaminases. She had no elevated blood pressures during her prenatal care or hospital course. Following delivery, she experienced normalization of transaminase levels and a return to her baseline mental status. Pre-eclampsia and eclampsia can occur in the absence of elevated blood pressures, which highlights the limitations of using standard diagnostic criteria in normotensive patients with end-organ damage. In such cases, it is important to include pre-eclampsia and eclampsia in the differential diagnosis, as the diagnosis usually warrants preterm delivery to minimize maternal morbidity and mortality.

Association of prior treatment with nitrogen-containing bisphosphonates on outcomes of COVID-19 positive patients

COVID-19 infection has resulted in significant morbidity and mortality globally, especially among older adults. Repurposed drugs have demonstrated activity in respiratory illnesses, including nitrogen-containing bisphosphonates. In this retrospective longitudinal study at 4 academic medical centers, we show no benefit of nitrogen-containing bisphosphonates regarding ICU admission, ventilator use, and mortality among older adults with COVID-19 infection. We specifically evaluated the intravenous bisphosphonate zoledronic acid and found no difference compared to oral bisphosphonates.

BACKGROUND

Widely used in osteoporosis treatment, nitrogen-containing bisphosphonates (N-BP) have been associated with reduced mortality and morbidity among older adults. Based on prior studies, we hypothesized that prior treatment with N-BP might reduce intensive care unit (ICU) admission, ventilator use, and death among older adults diagnosed with COVID-19.

METHODS

This retrospective analysis of the PCORnet Common Data Model across 4 academic medical centers through 1 September 2021 identified individuals age >50 years with a diagnosis of COVID-19. The composite outcome included ICU admission, ventilator use, or death within 15, 30, and 180 days of COVID-19 diagnosis. Use of N-BP was defined as a prescription within 3 years prior. ICU admission and ventilator use were determined using administrative codes. Death included both in-hospital and out-of-hospital events. Patients treated with N-BP were matched 1:1 by propensity score to patients without prior N-BP use. Secondary analysis compared outcomes among those prescribed zoledronic acid (ZOL) to those prescribed oral N-BPs.

RESULTS

Of 76,223 COVID-19 patients identified, 1,853 were previously prescribed N-BP, among whom 559 were prescribed ZOL. After propensity score matching, there were no significant differences in the composite outcome at 15 days (HR 1.22, 95% CI: 0.89-1.67), 30 days (HR 1.24, 95% CI: 0.93-1.66), or 180 days (HR 1.17, 95% CI: 0.93-1.48), comparing those prescribed and not prescribed N-BP. Compared to those prescribed oral N-BP, there were no significant differences in outcomes among those prescribed ZOL.

CONCLUSION

Among older COVID-19 patients, prior exposure to N-BP including ZOL was not associated with a reduction in ICU admission, ventilator use, or death.

"The price is right" for diabetes management of older adults - Evidence for the closest glycemic target without going over

This editorial comments on the article by Lipska et al. in this issue.

Hypertensive disorders of pregnancy and occurrence of ADHD, ASD, and epilepsy in the child: A meta-analysis

AIM

To synthesize epidemiologic literature pertaining to the association between preeclampsia (PE), attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and epilepsy.

METHOD

A systematic search of PubMed and Embase was performed supplemented by hand-searching of reference lists of eligible studies. Two independent reviewers screened abstracts following a prepared protocol. Data extraction and quality appraisal using the Newcastle Ottawa Scale were performed by an independent reviewer. PRISMA guidelines were followed throughout. Random-effects meta-analyses were performed. Adjusted pooled Odds Ratios and their 95% confidence intervals were reported.

RESULTS

Fifteen out of 121 identified studies were eligible for inclusion. Six reported adjusted estimates for ADHD, resulting in a pooled odds ratio of 1.29 (95% CI: 1.20, 1.38). Eight reported adjusted estimates for ASD, resulting in a pooled odds ratio of 1.27 (95% CI:1.22, 1.32). Three reported adjusted estimates for epilepsy, resulting in a pooled odds ratio of 1.35 (95% CI: 1.12, 1.63).

INTERPRETATION

Intrauterine exposure to PE increased the risk of ADHD, ASD, and epilepsy, though it is unclear whether the true association is with pre-term birth. To our knowledge, this is the first meta-analysis to quantify the association between PE and epilepsy. The results of this meta-analysis can inform screening strategies among children born to preeclamptic mothers for early identification and treatment.

Metabolic factors associated with incident fracture among older adults with type 2 diabetes mellitus: a nested case-control study

Older adults with type 2 diabetes mellitus have an increased risk of fracture despite a paradoxically higher average bone mineral density. This study identified additional markers of fracture risk in this at-risk population. Non-esterified fatty acids and the amino acids glutamine/glutamate and asparagine/aspartate were associated with incident fractures.

PURPOSE

Type 2 diabetes mellitus (T2D) is associated with an increased risk of fracture despite a paradoxically higher bone mineral density. Additional markers of fracture risk are needed to identify at-risk individuals.

METHOD

The MURDOCK study is an ongoing study, initiated in 2007, of residents in central North Carolina. At enrollment, participants completed health questionnaires and provided biospecimen samples. In this nested case-control analysis, incident fractures among adults with T2D, age ≥ 50 years, were identified by self-report and electronic medical record query. Fracture cases were matched 1:2 by age, gender, race/ethnicity, and BMI to those without incident fracture. Stored sera were analyzed for conventional metabolites and targeted metabolomics (amino acids and acylcarnitines). The association between incident fracture and metabolic profile was assessed using conditional logistic regression, controlled for multiple confounders including tobacco and alcohol use, medical comorbidities, and medications.

RESULTS

107 incident fractures were identified with 210 matched controls. Targeted metabolomics analysis included 2 amino acid factors, consisting of: 1) the branched chain amino acids, phenylalanine and tyrosine; and 2) glutamine/glutamate, asparagine/aspartate, arginine, and serine [E/QD/NRS]. After controlling for multiple risk factors, E/QD/NRS was significantly associated with incident fracture (OR 2.50, 95% CI: 1.36-4.63). Non-esterified fatty acids were associated with lower odds of fracture (OR 0.17, 95% CI: 0.03-0.87). There were no associations with fracture among other conventional metabolites, acylcarnitine factors, nor the other amino acid factors.

CONCLUSION

Our results indicate novel biomarkers, and suggest potential mechanisms, of fracture risk among older adults with T2D.

A case of preeclampsia with severe features following septic shock and drug-induced acute kidney injury

Objectives

This article outlines a process for differentiating preeclampsia from other potential causes of end-organ damage in a critically ill patient.

Case Presentation

A patient in her early 30s, G2P1001 with intrauterine pregnancy at 12 weeks’ gestation was admitted seven months after delivering her first child due to new-onset psychosis and starvation ketosis. She was started on lithium for postpartum psychosis at 20 weeks’ gestation. She subsequently developed respiratory failure at 26 weeks’ gestation due to aspiration pneumonia in the setting of lithium toxicity, requiring admission to the intensive care unit (ICU) and intubation. She received antibiotics and vasopressors for suspected septic shock in addition to dialysis for lithium-induced acute kidney injury. One week after ICU admission, her sepsis resolved, her serum creatinine levels returned to normal, and her respiratory status improved. However, after vasopressors were discontinued, she suddenly developed persistently elevated blood pressures with proteinuria and elevated liver function tests (LFT’s). Due to concern for preeclampsia with severe features and rapidly increasing LFT’s, the patient underwent cesarean delivery at 27 weeks’ gestation.

Conclusions

In a critically ill patient with multiple comorbidities, it can be difficult to diagnose preeclampsia using the standard criteria. It is important to exclude other potential etiologies, as a misdiagnosis can have potentially devastating consequences.

Postpartum Glucose Tolerance Testing Among Patients With Gestational Diabetes During the Coronavirus Disease 2019 Pandemic

Introduction The impact of the coronavirus disease (COVID-19) COVID-19 pandemic on the care of pregnant patients with gestational diabetes (GDM) is largely unreported. The objective of this study was to compare the completion of postpartum oral glucose tolerance testing (GTT) prior to and during the COVID-19 pandemic among patients with GDM. Methods This was a retrospective review of patients diagnosed with GDM between April 2019 and March 2021. Medical records of patients diagnosed with GDM prior to and during the pandemic were compared. The primary outcome was the difference in the completion of postpartum GTT prior to and during the COVID-19 pandemic. Completion was defined as testing between four weeks to six months postpartum. Secondary objectives were: 1) to compare maternal and neonatal outcomes prior to and during the pandemic among patients with GDM, and 2) to compare pregnancy characteristics and outcomes by compliance with postpartum GTT. Results There were 185 patients included in the study, of whom 83 (44.9%) delivered prior to the pandemic and 102 (55.1%) delivered during the pandemic. There was no difference in completion of postpartum diabetes testing prior, compared to during the pandemic (27.7% vs 33.3%, p=0.47). Postpartum diagnosis of pre-diabetes and type two diabetes mellitus (T2DM) did not differ between groups (p=0.36 and p=1.00, respectively). Patients who completed postpartum testing were less likely to have preeclampsia with severe features compared to patients who did not (OR 0.08, 95% CI 0.01-0.96, p=0.02). Conclusion Completion of postpartum testing for T2DM remained poor prior to and during the COVID-19 pandemic. These findings underscore the need for the adoption of more accessible methods of postpartum testing for T2DM among patients with GDM.

Diabetes is associated with a lower minimum moment of inertia among older women: An analysis of 3D reconstructions of clinical CT scans

Hip fractures are a significant burden on the aging population, often resulting in reduced mobility, loss of independence, and elevated risk of mortality. While fracture risk is generally inversely related to bone mineral density (BMD), people with diabetes suffer a higher fracture rate despite having a higher BMD. To better understand the connection between diabetes and fracture risk, we developed a method to measure the minimum moment of inertia (mMOI; a geometric factor associated with fracture risk) from clinical CT scans of the pelvis. Since hip fractures are more prevalent in women, we focused on females in this study. We hypothesized that females with diabetes would have a lower mMOI along the femoral neck than those without diabetes, indicative of a higher fracture risk. Three-dimensional models of each hip were created from clinical CT scans of 40 older women (27 with diabetes: 10 fracture/17 non-fractured; 13 without diabetes: non-fractured controls). The mMOI of each hip (n = 80) was reported as the average from three trials. People with diabetes had an 18% lower mMOI as compared to those without diabetes after adjusting for age and BMI (p = 0.02). No differences in the mMOIs between the fractured and contralateral hips in the diabetic group were observed (p = 0.78). Similarly, no differences were observed between the fractured and non-fractured hips of people with diabetes (p = 0.29) when accounting for age and BMI. This suggests structural differences in the hips of individuals with diabetes (measured by the mMOI) may be associated with their elevated fracture risk.

Racial and ethnic disparity in characteristics and outcomes of women with placenta accreta spectrum: a comparative study

Placenta accreta spectrum (PAS) refers to the spectrum of diagnoses involving abnormally and morbidly adherent trophoblastic tissue to the gravid uterus. These disorders are associated with significant maternal morbidity and mortality. While race/ethnicity is known to impact pregnancy outcomes, racial disparities have not been previously examined in women with PAS. The objective of current study was to compare patient characteristics and perioperative outcomes of women with PAS who underwent cesarean delivery across race/ethnicity. This is a comparative study that retrospectively queried the National Inpatient Sample, a hospital-based inpatient database in the USA. The study cohort was women diagnosed with PAS who underwent cesarean delivery from 10/2015 to 12/2018. The exposure group was race/ethnicity. Main outcomes were (i) patient/pregnancy characteristics and (ii) surgical morbidity for cesarean delivery, assessed in multivariable analysis. A total of 10,535 women comprised the study cohort (White n = 5,230 [49.6%], Black n = 2,045 [19.4%], Hispanic n = 2,540 [24.1%], and Asian n = 720 [6.8%]). Patient demographics, pregnancy characteristics, and hospital factors for the non-White groups significantly differed compared to the White group. Older age, obesity, diabetes, placenta previa, percreta, non-elective surgery, lower median household income, and Medicaid particularly represented the non-White groups. When perioperative outcomes were compared, non-White women were more likely to have any measured complications, hemorrhage/transfusion, and shock/coagulopathy compared to White women. Various sensitivity analyses redemonstrated the main cohort results. In conclusion, this study suggests that there were significant disparities in patient characteristics and outcomes of women with PAS across race/ethnicity.

Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis

BACKGROUND

Ursodeoxycholic acid is commonly used to treat intrahepatic cholestasis of pregnancy, yet its largest trial detected minimal benefit for a composite outcome (stillbirth, preterm birth, and neonatal unit admission). We aimed to examine whether ursodeoxycholic acid affects specific adverse perinatal outcomes.

METHODS

In this systematic review and individual participant data meta-analysis, we searched PubMed, Web of Science, Embase, MEDLINE, CINAHL, Global Health, MIDIRS, and Cochrane without language restrictions for relevant articles published between database inception, and Jan 1, 2020, using search terms referencing intrahepatic cholestasis of pregnancy, ursodeoxycholic acid, and perinatal outcomes. Eligible studies had 30 or more study participants and reported on at least one individual with intrahepatic cholestasis of pregnancy and bile acid concentrations of 40 μmol/L or more. We also included two unpublished cohort studies. Individual participant data were collected from the authors of selected studies. The primary outcome was the prevalence of stillbirth, for which we anticipated there would be insufficient data to achieve statistical power. Therefore, we included a composite of stillbirth and preterm birth as a main secondary outcome. A mixed-effects meta-analysis was done using multi-level modelling and adjusting for bile acid concentration, parity, and multifetal pregnancy. Individual participant data analyses were done for all studies and in different subgroups, which were produced by limiting analyses to randomised controlled trials only, singleton pregnancies only, or two-arm studies only. This study is registered with PROSPERO, CRD42019131495.

FINDINGS

The authors of the 85 studies fulfilling our inclusion criteria were contacted. Individual participant data from 6974 women in 34 studies were included in the meta-analysis, of whom 4726 (67·8%) took ursodeoxycholic acid. Stillbirth occurred in 35 (0·7%) of 5097 fetuses among women with intrahepatic cholestasis of pregnancy treated with ursodeoxycholic acid and in 12 (0·6%) of 2038 fetuses among women with intrahepatic cholestasis of pregnancy not treated with ursodeoxycholic acid (adjusted odds ratio [aOR] 1·04, 95% CI 0·35-3·07; p=0·95). Ursodeoxycholic acid treatment also had no effect on the prevalence of stillbirth when considering only randomised controlled trials (aOR 0·29, 95% CI 0·04-2·42; p=0·25). Ursodeoxycholic acid treatment had no effect on the prevalence of the composite outcome in all studies (aOR 1·28, 95% CI 0·86-1·91; p=0·22), but was associated with a reduced composite outcome when considering only randomised controlled trials (0·60, 0·39-0·91; p=0·016).

INTERPRETATION

Ursodeoxycholic acid treatment had no significant effect on the prevalence of stillbirth in women with intrahepatic cholestasis of pregnancy, but our analysis was probably limited by the low overall event rate. However, when considering only randomised controlled trials, ursodeoxycholic acid was associated with a reduction in stillbirth in combination with preterm birth, providing evidence for the clinical benefit of antenatal ursodeoxycholic acid treatment.

FUNDING

Tommy's, the Wellcome Trust, ICP Support, and the National Institute for Health Research.

Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy: Replaces Consult #13, April 2011

Intrahepatic cholestasis of pregnancy is a hepatic disorder characterized by pruritus and an elevation in serum bile acid levels. Although intrahepatic cholestasis of pregnancy poses little risk for women, this condition carries a significant risk for the fetus, including complications such as preterm delivery, meconium-stained amniotic fluid, and stillbirth. The purpose of this Consult is to review the current literature on intrahepatic cholestasis of pregnancy and provide recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend measurement of serum bile acid and liver transaminase levels in patients with suspected intrahepatic cholestasis of pregnancy (GRADE 1B); (2) we recommend that ursodeoxycholic acid be used as the first-line agent for the treatment of maternal symptoms of intrahepatic cholestasis of pregnancy (GRADE 1A); (3) we suggest that patients with a diagnosis of intrahepatic cholestasis of pregnancy begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal fetal testing results or at the time of diagnosis if the diagnosis is made later in gestation (GRADE 2C); (4) we recommend that patients with total bile acid levels of ≥100 μmol/L be offered delivery at 36 0/7 weeks of gestation, given that the risk of stillbirth increases substantially around this gestational age (GRADE 1B); (5) we recommend delivery between 36 0/7 and 39 0/7 weeks of gestation for patients with intrahepatic cholestasis of pregnancy and total bile acid levels of <100 μmol/L (GRADE 1C); (6) we recommend administration of antenatal corticosteroids for fetal lung maturity for patients delivering before 37 0/7 weeks of gestation if not previously administered (GRADE 1A); (7) we recommend against preterm delivery at <37 weeks of gestation in patients with a clinical diagnosis of intrahepatic cholestasis of pregnancy without laboratory confirmation of elevated bile acid levels (GRADE 1B).

Neonatal hypoglycemia after initiation of late preterm antenatal corticosteroids

OBJECTIVE

To compare the frequency and severity of neonatal hypoglycemia in pregnancies treated with and without late preterm antenatal corticosteroids.

STUDY DESIGN

We conducted a retrospective cohort study of late preterm deliveries at LAC + USC (2015-2018). Neonatal outcomes were compared between pregnancies treated with and without corticosteroids.

RESULTS

93 pregnancies (39.9%) received corticosteroids and 140 (60.1%) did not. Neonates born to women given corticosteroids were more likely to be hypoglycemic (47.3 vs. 29.3%, OR_adj 2.25, p_adj = 0.01). The mean initial glucose (45.6 mg/dL vs. 51.9 mg/dL, p = 0.01) and glucose nadir (39.1 mg/dL vs. 45.4 mg/dL, p < 0.001) were significantly lower if the neonates received corticosteroids. Neonates admitted to the NICU solely for hypoglycemia were more likely to be born to women treated with corticosteroids (OR_adj 4.71, p_adj = 0.01).

CONCLUSION

Administration of late preterm corticosteroids was associated with an increased incidence and severity of neonatal hypoglycemia.

Acetylcholinesterase Inhibitors Are Associated with Reduced Fracture Risk among Older Veterans with Dementia

Acetylcholinesterase inhibitors (AChEIs) have been noted to increase bone density and quality in mice. Human studies are limited but suggest an association with improved bone healing after hip fracture. We examined the relationship between AChEI use and fracture risk in a national cohort of 360,015 male veterans aged 65 to 99 years with dementia but without prior fracture using Veterans Affairs (VA) hospital, Medicare, and pharmacy records from 2000 to 2010. Diagnosis of dementia, any clinical fracture (excluding facial and digital), comorbidities, and medications were identified using ICD-9 and drug class codes. Cox proportional hazard models considering AChEI use as a time-varying covariate and adjusting for fall and fracture risk factors compared the time-to-fracture in AChEI users versus non-AChEI users. Potential confounders included demographics (age, race, body mass index), comorbidities associated with fracture or falls (diabetes, lung disease, stroke, Parkinson's, seizures, etc.) and medications associated with fracture or falls (bisphosphonates, glucocorticoids, androgen deprivation therapy [ADT], proton pump inhibitors [PPIs], selective serotonin receptor inhibitors [SSRIs], etc.). Competing mortality risk was considered using the methods of Fine and Gray. To account for persistent effects on bone density or quality that might confer protection after stopping the medication, we completed a secondary analysis using the medication possession ratio (MPR) as a continuous variable in logistic regression models and also compared MPR increments of 10% to minimal/no use (MPR 0 to <0.10). Among older veterans with diagnosis of dementia, 20.1% suffered a fracture over an average of 4.6 years of follow-up. Overall, 42.3% of the cohort were prescribed AChEIs during the study period. The hazard of any fracture among AChEI users compared with those on other/no dementia medications was significantly lower in fully adjusted models (hazard ratio [HR] = 0.81; 95% confidence interval [CI] 0.75-0.88). After considering competing mortality risk, fracture risk remained 18% lower in veterans using AChEIs (HR = 0.82; 95% CI 0.76-0.89). © 2019 American Society for Bone and Mineral Research. Published 2019. This article is a U.S. Government work and is in the public domain in the USA.

Perinatal death by bile acid levels in intrahepatic cholestasis of pregnancy: a systematic review

Background: Intrahepatic cholestasis of pregnancy (ICP) is characterized by the elevation of total bile acids (TBAs). The primary concern in women with ICP is the increased risk of stillbirth. ICP is generally considered as "mild" when TBA levels range from 10 to 39 µmol/L and "severe" with levels greater than 40 µmol/L, although levels of TBA ≥100 µmol/L have been also considered as a further threshold of severity.Objective: To quantify the association between different severities of ICP (TBA 10-39, 40-99, and ≥100 µmol/L) and perinatal death.Data sources: Medline, Embase, Scopus, Web of Sciences, and ClinicalTrial.gov were searched from the inception of each database to February 2019.Methods of study selection: Randomized, cohort, case-control, or case series studies reporting maternal and perinatal outcomes on women with ICP by the three prespecified TBA levels (10-39, 40-99, and ≥100 µmol/L) were included. We excluded multiple gestations and trials which included an intervention. The analysis was performed with Pearson chi-square and Fisher's exact test as appropriate. Continuous outcomes were compared using metaregression with inverse variance weighting using reported sample sizes and standard deviations. Pairwise comparisons used a Bonferroni correction to control for multiple testing.Tabulation, integration, and results: Six articles including 1280 singleton pregnancies affected by ICP were included in the systematic review. Out of the 1280 singleton pregnancies affected by ICP included, 118 had ICP with TBA ≥100 µmol/L. Perinatal death was more common in women with TBA ≥100 µmol/L (0.4% for TBA 10-39 μmol/L versus 0.3% for TBA 40-99 μmol/L versus 6.8% for TBA ≥ 100 μmol/L, p < .0001). Of the 8 perinatal deaths in the TBA ≥100 µmol/L group, 3 occurred ≥34 weeks. TBA ≥100 µmol/L increased the risk of spontaneous preterm birth (PTB) (5.4% versus 8.6% versus 18.2% respectively, p < .0001) and iatrogenic PTB (10.8% versus 21.6% versus 35.8% respectively, p<.0001) as well as meconium-stained amniotic fluid (9.0% versus 18.4% versus 31.6% respectively, p < .0001).Conclusions: Maternal TBA ≥100 µmol/L is associated with a 6.8% incidence of perinatal death, most of which (5.9% overall) are stillbirths, while TBA <100 µmol/L are associated with an incidence of perinatal death of 0.3%. It may be reasonable to consider late preterm delivery (at about 35-36 weeks) in women with TBA ≥100 µmol/L.

Glycemic Control and Insulin Treatment Alter Fracture Risk in Older Men With Type 2 Diabetes Mellitus

Diabetes mellitus among older men has been associated with increased bone mineral density but paradoxically increased fracture risk. Given the interactions among medication treatment, glycemic control, and diabetes-associated comorbidities, the relative effects of each factor remains unclear. This retrospective study includes 652,901 male veterans aged ≥65 years with diabetes and baseline hemoglobin A1c (HbA1c) value. All subjects received primary care in the Veterans Health Administration (VHA) from 2000 to 2010. Administrative data included ICD9 diagnoses and pharmacy records and was linked to Medicare fee-for-service data. Hazard ratios (HR) for any clinical fracture and hip fracture were calculated using competing risk hazards models, adjusted for fracture risk factors including age, race/ethnicity, body mass index (BMI), alcohol and tobacco use, rheumatoid arthritis, corticosteroid use, as well as diabetes-related comorbidities including cardiovascular disease, chronic kidney disease, and peripheral neuropathy. HbA1c <6.5% was associated with a higher risk of any clinical fracture (HR = 1.08, 95% confidence interval [CI] 1.06-1.11) compared with the reference HbA1c of 7.5% to 8.5%. Fracture risk was not increased among those with A1c ≥8.5%, nor among those with A1c 6.5% to 7.5%. Use of insulin was independently associated with greater risk of fracture (HR = 1.10, 95% CI 1.07-1.12). There was a significant interaction between insulin use and HbA1c level, (p < 0.001), such that those using insulin with HbA1c <6.5% had HR = 1.23 and those with HbA1c 6.5% to 7.5% had HR = 1.15. Metformin use was associated with decreased fracture risk (HR = 0.88, 95% CI 0.87-0.90). We conclude that among older men with diabetes, those with HbA1c lower than 6.5% are at increased risk for any clinical and hip fracture. Insulin use is associated with higher fracture risk, especially among those with tight glycemic control. Our findings demonstrate the importance of the treatment regimen and avoiding hypoglycemia for fracture prevention in older men with diabetes. © 2019 American Society for Bone and Mineral Research.

Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses

BACKGROUND

Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcomes, but the association with the concentration of specific biochemical markers is unclear. We aimed to quantify the adverse perinatal effects of intrahepatic cholestasis of pregnancy in women with increased serum bile acid concentrations and determine whether elevated bile acid concentrations were associated with the risk of stillbirth and preterm birth.

METHODS

We did a systematic review by searching PubMed, Web of Science, and Embase databases for studies published from database inception to June 1, 2018, reporting perinatal outcomes for women with intrahepatic cholestasis of pregnancy when serum bile acid concentrations were available. Inclusion criteria were studies defining intrahepatic cholestasis of pregnancy based upon pruritus and elevated serum bile acid concentrations, with or without raised liver aminotransferase concentrations. Eligible studies were case-control, cohort, and population-based studies, and randomised controlled trials, with at least 30 participants, and that reported bile acid concentrations and perinatal outcomes. Studies at potential higher risk of reporter bias were excluded, including case reports, studies not comprising cohorts, or successive cases seen in a unit; we also excluded studies with high risk of bias from groups selected (eg, a subgroup of babies with poor outcomes were explicitly excluded), conference abstracts, and Letters to the Editor without clear peer review. We also included unpublished data from two UK hospitals. We did a random effects meta-analysis to determine risk of adverse perinatal outcomes. Aggregate data for maternal and perinatal outcomes were extracted from case-control studies, and individual patient data (IPD) were requested from study authors for all types of study (as no control group was required for the IPD analysis) to assess associations between biochemical markers and adverse outcomes using logistic and stepwise logistic regression. This study is registered with PROSPERO, number CRD42017069134.

FINDINGS

We assessed 109 full-text articles, of which 23 studies were eligible for the aggregate data meta-analysis (5557 intrahepatic cholestasis of pregnancy cases and 165 136 controls), and 27 provided IPD (5269 intrahepatic cholestasis of pregnancy cases). Stillbirth occurred in 45 (0·83%) of 4936 intrahepatic cholestasis of pregnancy cases and 519 (0·32%) of 163 947 control pregnancies (odds ratio [OR] 1·46 [95% CI 0·73-2·89]; I2=59·8%). In singleton pregnancies, stillbirth was associated with maximum total bile acid concentration (area under the receiver operating characteristic curve [ROC AUC]) 0·83 [95% CI 0·74-0·92]), but not alanine aminotransferase (ROC AUC 0·46 [0·35-0·57]). For singleton pregnancies, the prevalence of stillbirth was three (0·13%; 95% CI 0·02-0·38) of 2310 intrahepatic cholestasis of pregnancy cases in women with serum total bile acids of less than 40 μmol/L versus four (0·28%; 0·08-0·72) of 1412 cases with total bile acids of 40-99 μmol/L (hazard ratio [HR] 2·35 [95% CI 0·52-10·50]; p=0·26), and versus 18 (3·44%; 2·05-5·37) of 524 cases for bile acids of 100 μmol/L or more (HR 30·50 [8·83-105·30]; p<0·0001).

INTERPRETATION

The risk of stillbirth is increased in women with intrahepatic cholestasis of pregnancy and singleton pregnancies when serum bile acids concentrations are of 100 μmol/L or more. Because most women with intrahepatic cholestasis of pregnancy have bile acids below this concentration, they can probably be reassured that the risk of stillbirth is similar to that of pregnant women in the general population, provided repeat bile acid testing is done until delivery.

FUNDING

Tommy's, ICP Support, UK National Institute of Health Research, Wellcome Trust, and Genesis Research Trust.

Clinical Fractures Among Older Men With Diabetes Are Mediated by Diabetic Complications

INTRODUCTION

Type 2 diabetes mellitus among older women has been associated with increased bone mineral density, but paradoxically with increased fracture risk. Findings among older men have varied, and potential mechanisms have not been fully elucidated.

METHODS

A retrospective study of male veterans 65 to 99 years of age who received primary care in the Veterans Health Administration from 2000 to 2010, using administrative data from all 146 Veterans Health Administration medical centers linked to Centers for Medicare and Medicaid Services Medicare fee-for-service data. Potential mediating factors of the diabetes-associated risk were evaluated using negative binomial regression models with the outcomes of any clinical fracture and hip fracture.

RESULTS

Of 2,798,309 Veterans included in the cohort, 900,402 (32.3%) had a diagnosis of diabetes. After adjusting for age, race, ethnicity, body mass index, alcohol and tobacco use, rheumatoid arthritis, and corticosteroid use, the risk of any clinical fracture associated with diabetes was 1.22 (95% confidence interval, 1.21 to 1.23) and that of hip fracture was 1.21 (95% confidence interval, 1.19 to 1.23). Significant mediating factors included peripheral neuropathy, cardiovascular disease, and congestive heart failure, with 45.5% of the diabetes-associated fracture risk explained by these diagnoses.

CONCLUSIONS

Older male Veterans with diabetes have a 22% increased risk of incident clinical fracture compared with those without. A significant portion of this risk is explained by diabetes-related comorbidities, specifically peripheral neuropathy and congestive heart failure. Identification of these mediating factors suggests possible mechanisms, as well as potential interventions.

Maternal Serum B-Cell Activating Factor Levels

Hypertensive disorders of pregnancy are a leading cause of maternal and perinatal morbidity and mortality. Early suppression of B-cell lymphopoiesis is necessary for a normal pregnancy. Dysregulation of factors critical to B-cell survival may result in pregnancy complications, including hypertension. In this prospective observational study at a single medical center, serum levels of BAFF (B-cell activating factor) were measured in pregnant participants at each trimester, at delivery, and postpartum and in nonpregnant controls at a single time point. Comparisons were made between nonpregnant and pregnant subjects and between time periods of pregnancy. First-trimester serum BAFF levels were further tested for association with hypertensive disorders of pregnancy. The study included 149 healthy pregnant women, 25 pregnant women with chronic hypertension, and 48 nonpregnant controls. Median first-trimester serum BAFF level (ng/mL) for healthy women (0.90) was lower than median serum BAFF levels for women with chronic hypertension (0.96; P =0.013) and controls (1.00; P =0.002). Serum BAFF levels steadily declined throughout pregnancy, with the median second-trimester level lower than the corresponding first-trimester level (0.77; P =0.003) and the median third-trimester level lower than the corresponding second-trimester level (0.72; P =0.025). The median first-trimester serum BAFF level was elevated in women who subsequently developed hypertension compared with women who remained normotensive (1.02 versus 0.85; P =0.012), with the area under the receiver operating characteristic curve being 0.709. First-trimester serum BAFF level may be an early and clinically useful predictor of hypertensive disorders of pregnancy.

Erratum: iPS-derived MSCs from an expandable bank to deliver a prodrug-converting enzyme that limits growth and metastases of human breast cancers

[This corrects the article DOI: 10.1038/cddiscovery.2016.64.].

Weight management for adolescents with intellectual and developmental disabilities: Rationale and design for an 18month randomized trial

Adolescents with intellectual and developmental disabilities (IDD) are an underserved group in need of weight management. However, information regarding effective weight management for this group is limited, and is based primarily on results from small, non-powered, non-randomized trials that were not conducted in accordance with current weight management guidelines. Additionally, the comparative effectiveness of emerging dietary approaches, such as portion-controlled meals (PCMs) or program delivery strategies such as video chat using tablet computers have not been evaluated. Therefore, we will conduct an 18month trial to compare weight loss (6months) and maintenance (7-18months) in 123 overweight/obese adolescents with mild to moderate IDD, and a parent, randomized to a weight management intervention delivered remotely using FaceTime™ on an iPad using either a conventional meal plan diet (RD/CD) or a Stop Light diet enhanced with PCMs (RD/eSLD), or conventional diet delivered during face-to-face home visits (FTF/CD). This design will provide an adequately powered comparison of both diet (CD vs. eSLD) and delivery strategy (FTF vs. RD). Exploratory analyses will examine the influence of behavioral session attendance, compliance with recommendations for diet (energy intake), physical activity (min/day), self-monitoring of diet and physical activity, medications, and parental variables including diet quality, physical activity, baseline weight, weight change, and beliefs and attitudes regarding diet and physical activity on both weight loss and maintenance. We will also complete a cost and contingent valuation analysis to compare costs between RD and FTF delivery.

Awaiting blood pressure stabilization in ambulatory pregnant women: is 5 minutes sufficient?

OBJECTIVE

Current recommendations for timing of blood pressure measurement in ambulatory pregnant women vary and are based on studies in the nonpregnant population. The objective of this study was to determine if there is a difference in systolic blood pressure (SBP) and diastolic blood pressure (DBP) between minute-5 and minute-10.

METHODS

A prospective study was conducted at our prenatal care clinics. Participants had their blood pressure measured upon sitting and every 5 minutes for 15 minutes. Initial SBP and DBP were compared to measurements at each time point. Additionally, the SBP and DBP at minute-5 were compared to minute-10. All statistical tests were two-sided.

RESULTS

Data from 400 patients were analyzed. Of these, 34.0% were in the first, 30.7% were in the second trimester, and 35.2% were in the third trimester. In each trimester, there was a significant difference in the SBP and DBP at minute-5 compared to minute-0. At minute-10 compared to minute-5, there was no further drop for all trimesters, except for a small drop in DBP in the second trimester (-1.3 ± 6.0, p = 0.012).

CONCLUSION

In an ambulatory setting, 5 minutes after sitting appears to be an appropriate time point to measure blood pressure in pregnancy.

Platelet immunoreceptor tyrosine-based activation motif (ITAM) and hemITAM signaling and vascular integrity in inflammation and development

Platelets are essential for maintaining hemostasis following mechanical injury to the vasculature. Besides this established function, novel roles of platelets are becoming increasingly recognized, which are critical in non-injury settings to maintain vascular barrier integrity. For example, during embryogenesis platelets act to support the proper separation of blood and lymphatic vessels. This role continues beyond birth, where platelets prevent leakage of blood into the lymphatic vessel network. During the course of inflammation, platelets are necessary to prevent local hemorrhage due to neutrophil diapedesis and disruption of endothelial cell-cell junctions. Surprisingly, platelets also work to secure tumor-associated blood vessels, inhibiting excessive vessel permeability and intra-tumor hemorrhaging. Interestingly, many of these novel platelet functions depend on immunoreceptor tyrosine-based activation motif (ITAM) signaling but not on signaling via G protein-coupled receptors, which plays a crucial role in platelet plug formation at sites of mechanical injury. Murine platelets express two ITAM-containing receptors: the Fc receptor γ-chain (FcRγ), which functionally associates with the collagen receptor GPVI, and the C-type lectin-like 2 (CLEC-2) receptor, a hemITAM receptor for the mucin-type glycoprotein podoplanin. Human platelets express an additional ITAM receptor, FcγRIIA. These receptors share common downstream effectors, including Syk, SLP-76 and PLCγ2. Here we will review the recent literature that highlights a critical role for platelet GPVI/FcRγ and CLEC-2 in vascular integrity during development and inflammation in mice and discuss the relevance to human disease.

Evaluation of risk-factor-based screening for thyroid peroxidase antibody positivity in pregnancy

OBJECTIVE

To determine whether risk-factor-based screening for thyroid dysfunction in pregnancy performs well for detecting thyroid peroxidase antibodies (TPOAb), a marker for autoimmune thyroid disease.

STUDY DESIGN

We prospectively evaluated pregnant women for thyroid dysfunction using The Endocrine Society's eleven screening questions. Serum was analysed for TPOAb.

RESULT

We enrolled 546 women. TPOAb positivity was higher in women with a personal (odds ratio (OR) = 8·0; 95% confidence interval (CI) = 1·7-37·4; P = 0·02) or family history of thyroid disease (OR = 2·7; 95% CI = 1·3-5·7; P = 0·02). There was no association between the number of positive responses and TPOAb positivity (P = 0·41). Risk-factor-based screening missed 18 women (33%) with TPOAb.

CONCLUSION

One-third of women with TPOAb were missed by the case-finding method. A personal or family history of thyroid disease was most strongly associated with TPOAb positivity.

Geographic scope and accessibility of a centralized, electronic consult program for patients with recent fracture

INTRODUCTON

Low-trauma, osteoporotic fractures among older men are associated with a significant increase in morbidity and mortality. Despite effective therapies for osteoporosis, several studies have demonstrated that management and treatment after a low trauma fracture remains inadequate, especially among men. Fracture liaison services have been shown to significantly improve osteoporosis evaluation and treatment. However, such programs may be less feasible and accessible in rural areas, with limited availability of specialty services. The study objective was to evaluate a centralized, electronic consult (e-consult) program serving multiple veterans administration medical centers, including the geographic scope, accessibility to rural patients, and impact on osteoporosis evaluation and treatment.

METHODS

The e-consult program identified veterans with potential osteoporotic fractures from inpatient and outpatient encounter data, based on ICD9 diagnosis codes (800-829) from the central data warehouse. The medical record of an eligible patient was reviewed by a bone health specialist, and an e-consult note was sent to the patient's primary care provider that specified guideline-based recommendations for further evaluation and management. A bone health nurse liaison then coordinated the ordering and follow-up of laboratory and bone density assessment, osteoporosis education (eg medication administration and side effects, calcium and vitamin D supplementation, falls prevention, and exercise), and adherence follow-up via telephone. Patients were identified as living in a rural area if their ZIP code was not in a US Census Bureau-defined urban area (ie population density greater than approximately 386 persons per square kilometer/1000 persons per square mile).

RESULTS

From October 2013 to September 2014, 2775 fractures were identified by a fracture-related ICD9 code. After exclusion of those aged less than 50 years and high-trauma fractures, 321 e-consults were completed. Of those, 171 (53.3%) were for patients residing in a rural or highly rural area. The e-consult program saved a total of 19 187 km (11 917 miles) of travel. For rural patients, bisphosphonates were recommended 51 times, with 33 (64.7%) ordered, and bone density assessments were recommended 109 times with 79 (72.5%) ordered. A nurse liaison significantly improved bisphosphonate ordering (from 39.7% to 75.8%) and bone mineral density testing completion rates (from 37.1% to 63.0%), for both rural and urban patients (p<0.01).

CONCLUSIONS

A centralized e-consult program can effectively and efficiently provide specialty bone health services to patients residing in rural areas. The program was able to save substantial travel time and increase the rates of evaluation and treatment for osteoporosis.

Neonatal Outcomes by Mode of Delivery in Preterm Birth

OBJECTIVE

We set out to test the hypothesis that infants born vaginally at ≤ 30 weeks gestation have less respiratory distress syndrome (RDS) than those born by cesarean delivery.

STUDY DESIGN

We conducted a retrospective cohort study of 652 infants born between 24 and 30 (6/7) weeks gestation from March 31, 1996 to May 31, 2014. Comparisons of neonatal outcomes by intended and actual mode of delivery were made using chi-square and t-tests (α = 0.05). Multiple logistic regression was performed to control for confounding variables.

RESULTS

Neonates born by cesarean delivery were more likely to have RDS (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.10-2.90), require intubation (OR, 1.80; 95% CI, 1.12-2.88), and have longer neonatal intensive care unit stay (70.0 ± 37.1 vs. 57.3 ± 40.1 days, p = 0.02).

CONCLUSION

Compared with cesarean delivery, vaginal delivery is associated with a significant reduction in RDS among infants born at ≤ 30 weeks gestation.

Non-specific red cell reactivity in an obstetric population

OBJECTIVE

To examine non-specific red cell reactivity (NSR) on antibody (Ab) screening of obstetric inpatients.

METHODS

Observational study of 5438 obstetric inpatients (2009-2013). Ab-positive patients were identified and their records reviewed for NSR, other antibodies, transfusion reactions or hemolytic disease of the fetus/newborn (HDFN). Evaluation of NSR frequency by test era assessed the impact of an institutional change to solid-phase screening in 2011.

RESULTS

Of obstetric inpatients, 5.3% had at least one positive Ab screen; 1.6% had NSR. Of NSR-positive patients, 16.7% had identifiable Abs that pre-dated NSR; 25% had concurrent Abs and 8.5% had subsequent Ab identification. In 49.1%, NSR resolved during follow-up. The frequency of NSR was higher after the change to solid-phase Ab screening, but specific Ab frequency was similar in both testing periods. No transfusion reactions or cases of HDFN were noted in this cohort.

CONCLUSIONS

NSR is found in 1-2% of obstetrical inpatients at our institution, and has more than doubled since the initiation of solid-phase screening. Although likely clinically insignificant by itself, NSR is commonly found in relation to other red cell Abs and may precede their development.

Fetal-Maternal Hemorrhage Detected by Sudden Disappearance of Rh Immune Globulin-Related Anti-D

BACKGROUND

Fetal-maternal hemorrhage is usually spontaneous and goes undetected but can be associated with adverse perinatal outcomes.

CASE

We describe the detection of a fetal-maternal hemorrhage by abrupt disappearance of prophylactic anti-D on antibody screen in an Rh-negative mother with dichorionic twins admitted for atrial flutter of one twin. Both rosette and Kleihauer-Betke tests were positive. The diagnosis was confirmed by anemia in one twin at birth.

CONCLUSION

Fetal-maternal hemorrhage requires a high index of suspicion for diagnosis. An unexpected sudden decline in Rh immune globulin-related anti-D may be an indication of fetal-maternal hemorrhage.

Functional Impairments Mediate Association Between Clinical Fracture Risk and Type 2 Diabetes Mellitus in Older Women

OBJECTIVES

To examine the effect of functional impairments in older women with diabetes mellitus (DM) on incident clinical fractures.

DESIGN

Secondary analysis of two large prospective cohort studies.

SETTING

North Carolina Established Populations for Epidemiologic Studies of the Elderly (EPESE) and Women's Health Initiative (WHI) clinical trials.

PARTICIPANTS

EPESE included 2,704 community-dwelling women aged 65 and older; WHI clinical trials included 68,125 postmenopausal women.

MEASUREMENTS

Women with DM at baseline were compared with women without in successive Cox proportional hazards models. Functional limitations were determined according to self-reported difficulties with activities of daily living (ADLs) and physical activities.

RESULTS

The risk of any clinical fracture during the study period was greater in women with DM, after controlling for age, race and ethnicity, and body mass index, in the EPESE (hazard ratio (HR) = 1.36, 95% confidence interval (CI) = 1.08-1.72) and WHI (HR = 1.29, 95% CI = 1.19-1.39) cohorts. After inclusion of functional limitations, the greater risk of fracture associated with DM decreased in the EPESE (HR = 1.25, 95% CI = 0.98-1.59) and WHI (HR = 1.21, 95% CI = 1.12-1.31) cohorts. In participants with DM, difficulties with moderate physical activities, such as bending or stooping, walking several blocks, and heavy housework, were significantly associated with incident fracture (P < .05).

CONCLUSION

Older women with DM are at greater risk of clinical fractures than those without, independent of bone mineral density. Greater functional impairment in moderate physical activities mediates this greater fracture risk in part, although there remains an unexplained residual DM-associated risk for fracture.

Intrahepatic Cholestasis of Pregnancy (ICP) in U.S. Latinas and Chileans: Clinical features, Ancestry Analysis, and Admixture Mapping

In the Americas, women with Indigenous American ancestry are at increased risk of intrahepatic cholestasis of pregnancy (ICP), relative to women of other ethnicities. We hypothesized that ancestry-related genetic factors contribute to this increased risk. We collected clinical and laboratory data, and performed biochemical assays on samples from U.S. Latinas and Chilean women, with and without ICP. The study sample included 198 women with ICP (90 from California, U.S., and 108 from Chile) and 174 pregnant control women (69 from California, U.S., and 105 from Chile). SNP genotyping was performed using Affymetrix arrays. We compared overall genetic ancestry between cases and controls, and used a genome-wide admixture mapping approach to screen for ICP susceptibility loci. We identified commonalities and differences in features of ICP between the 2 countries and determined that cases had a greater proportion of Indigenous American ancestry than did controls (p = 0.034). We performed admixture mapping, taking country of origin into account, and identified one locus for which Native American ancestry was associated with increased risk of ICP at a genome-wide level of significance (P = 3.1 x 10(-5), Pcorrected = 0.035). This locus has an odds ratio of 4.48 (95% CI: 2.21-9.06) for 2 versus zero Indigenous American chromosomes. This locus lies on chromosome 2, with a 10 Mb 95% confidence interval which does not contain any previously identified hereditary 'cholestasis genes.' Our results indicate that genetic factors contribute to the risk of developing ICP in the Americas, and support the utility of clinical and genetic studies of ethnically mixed populations for increasing our understanding of ICP.

A case-control review of placentas from patients with intrahepatic cholestasis of pregnancy

OBJECTIVE

To compare the incidence of histopathological features in placentas from women with cholestasis of pregnancy to healthy individuals without ICP.

METHODS

Placentas from mothers with and without cholestasis of pregnancy were reviewed by a pathologist masked to the study group. Subjects were excluded if they had medical problems already associated with placental histopathology.

RESULTS

Twenty-four cases and 30 controls placentas were reviewed. Seventeen placental histopathological features were found. There was no statistically significant difference between the groups. Amongst patients with cholestasis, there was a decrease in villitis of unknown etiology in those treated with ursodeoxycholic acid.

CONCLUSION

There is no difference in the placental histopathology in cholestasis of pregnancy compared to normal pregnancies, but treatment of patients with cholestasis of pregnancy with ursodeoxycholic acid may decrease findings of villitis of unknown etiology.

Chorioamniotic membrane separation over the cervical os ("moon sign") in twin-twin transfusion syndrome

OBJECTIVES

To determine whether chorioamniotic membrane separation from the internal cervical os, the "moon sign," is associated with preterm premature rupture of membranes (PPROM) in twin-twin transfusion syndrome (TTTS).

METHODS

A retrospective study of patients with TTTS treated with laser surgery was performed. Membrane separation before and after surgery was tested against any PPROM, PPROM within 7 days, and PPROM within 21 days. Because intrauterine fetal demise (IUFD) was weakly associated with PPROM, these cases were studied separately.

RESULTS

Among 304 consecutive patients, 247 patients (81.3%) had no IUFD, and preoperative and postoperative membrane separation rates were 13.4% and 13.0%, respectively. In 7 cases (2.8%), preoperative membrane separation disappeared postoperatively, and in 6 cases (2.4%), membrane separation appeared postoperatively; 26 cases (10.5%) had membrane separation at both times. Rates of PPROM did not differ between those who did and did not have preoperative membrane separation (30.3% versus 28.0%; P= .9511). Among those with and without postoperative membrane separation, the rates of any PPROM were 34.4% and 27.4%, respectively (P = .5473), and the rates of PPROM within 21 days were 15.6% and 5.6% (P = .0524). Those with postoperative membrane separation were 3 times more likely to have PPROM within 21 days (odds ratio, 3.13; 95% confidence interval, 1.02-9.58; P= .0453). Preterm premature rupture of membranes was not associated with preoperative or postoperative membrane separation in patients with IUFD.

CONCLUSIONS

The preoperative moon sign does not appear to be associated with PPROM in TTTS. Postoperatively, membrane separation may be weakly associated with PPROM at 21 days, but further research is required to confirm this association.

Osteoporosis screening and treatment among veterans with recent fracture after implementation of an electronic consult service

Fewer than 24% of Veterans received appropriate evaluation and/or treatment for osteoporosis within 6 months of an index fracture. An electronic consult (E-consult) service was implemented at three Veterans Affairs Medical Centers to facilitate the identification of and recommend management for patients with recent fracture. The E-consult service used clinical encounter data based on ICD9 diagnosis codes to prospectively identify patients with potential osteoporotic fractures. Eligible patients' medical records were reviewed by a metabolic bone specialist, and an E-consult note was sent to the patient's primary provider with specific recommendations for further management. Recommendations were initiated at the provider's discretion. Between 2011 and 2013, the E-consult service identified 444 eligible patients with a low-trauma fracture who were not already on treatment. One hundred twenty-nine (29.1%) consults recommended immediate bisphosphonate treatment, and 258 (58.1%) recommended bone density assessments. Primary providers responded by prescribing bisphosphonates in 74 patients (57.4%) and by ordering bone density testing in 183 (70.9%) patients. At the facility level, prior to implementation of the E-consult service, the rate of osteoporosis treatment following a fracture was 4.8% for bisphosphonates and 21.3% for calcium/vitamin D. After implementation, the treatment rate increased to 7.3% for bisphosphonates (p = 0.02) and 35.2% for calcium/vitamin D (p < 0.01). While feasible and relatively low-cost, an E-consult service modestly improved the rate of osteoporosis treatment among patients with a recent fracture. These results suggest that a program with direct patient interaction is probably required to substantially improve treatment rates.

Placental abruption in an adolescent with liver cirrhosis and severe thrombocytopenia

Pregnancy in patients with cirrhosis of the liver poses significant risks to both the mother and her fetus. Little is known about the occurrence of thrombocytopenia or placental abruption in pregnant women with cirrhosis. We present an 18-year-old primigravida who was diagnosed with cirrhosis of the liver during evaluation of severe thrombocytopenia at 20 weeks’ gestation. Esophagogastroduodenoscopy confirmed large esophageal varices, and β-blocker therapy was initiated for primary prophylaxis of esophageal bleeding. She delivered via emergent cesarean section at 24 and 6/7 weeks for fetal heart rate decelerations and placental abruption. This case demonstrates how cirrhosis of the liver, especially in association with thrombocytopenia, may be associated with an increased risk for placental abruption. Hypersplenism should be considered in a pregnant woman with thrombocytopenia and leukopenia.

Interobserver reliability of fetal heart rate pattern interpretation using NICHD definitions

OBJECTIVE

To evaluate the interobserver reliability of fetal heart rate (FHR) pattern definition and interpretation assessed by physicians at various levels of training using standard Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) definitions and standard principles of interpretation.

STUDY DESIGN

We conducted an interrater reliability study of the intrapartum FHR tracings of 32 singleton term pregnancies at Los Angeles County-University of Southern California (LAC + USC) Medical Center. Analysis included the 5 hours immediately preceding delivery, divided into 10- minute segments. A medical student, resident, and three attending physicians evaluated the same set of FHR tracings. Interobserver agreement was assessed using the free-marginal kappa coefficient.

RESULTS

Reviewers demonstrated substantial to excellent agreement on baseline rate (κ = 0.97), moderate variability (κ = 0.80), accelerations (κ = 0.62), decelerations (κ = 0.63), category (κ = 0.68), and the ability to identify the presence of either moderate variability or accelerations (κ = 0.82).

CONCLUSIONS

Interobserver agreement was significantly higher on all components of FHR definition and interpretation than previously expected. Standardization of FHR definitions and interpretation may improve interobserver reliability and patient safety.

Comparison of cost-effectiveness of vitamin D screening with that of universal supplementation in preventing falls in community-dwelling older adults

OBJECTIVES

To compare the cost-effectiveness of population screening for vitamin D insufficiency with that of universal vitamin D supplementation in community-dwelling older adults.

DESIGN

A Markov decision model simulating follow-up over a 36-month period. Published data were used to estimate values for the model, including costs (measured in 2011 U.S. dollars), utilities (measured in quality-adjusted life years (QALYs)), and probabilities.

SETTING

Decision analysis simulation from a societal perspective.

PARTICIPANTS

Hypothetical cohort of community-dwelling women and men aged 65 to 80.

MEASUREMENTS

Net monetary benefit (NMB) was calculated by subtracting the incremental cost of the strategy from the product of incremental QALYs and willingness-to-pay threshold. A higher NMB indicates greater cost-effectiveness.

RESULTS

In women aged 65 to 80, population screening was slightly more cost-effective than universal supplementation, with an incremental NMB of $224 compared with $189 (P < .001). Population screening in men was also more cost-effective than universal supplementation (incremental NMB $298 vs $260, P < .001). Results differed according to age group. In those aged 65, population screening had cost-effectiveness similar to that of universal supplementation in women ($59 vs $71) and men ($114 vs $120), whereas in those aged 80, population screening was substantially more cost-effective than universal supplementation in women ($563 vs $428) and men ($703 vs $571).

CONCLUSION

Population screening and universal supplementation for vitamin D insufficiency are cost-effective strategies in community-dwelling older women and men. In the oldest old, population screening may be more cost-effective than universal supplementation.

Bile acid concentration reference ranges in a pregnant Latina population

OBJECTIVE

The total bile acid (TBA) concentration criterion for diagnosing intrahepatic cholestasis of pregnancy varies in the published literature. The purpose of this study was to establish pregnancy-specific reference ranges for the TBA concentration among Latina women.

STUDY DESIGN

Self-identified Latina women (n = 211) over 18 years of age with a singleton pregnancy were recruited and had random serum samples drawn during the second and third trimesters. The total and fractionated bile acid concentrations were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and reference ranges were calculated. Laboratory-provided general reference ranges from a general population of adult men and nonpregnant women were used for comparison.

RESULTS

The TBA reference range for our Latina pregnant population (<8.5 µmol/L) was markedly lower than the laboratory-provided reference range (4.5 to 19.2 µmol/L).

CONCLUSION

These data suggest that the upper TBA concentration reference range in our Latina pregnant population is 8.5 µmol/L, based on LC-MS/MS measurements.

Brachial plexus palsy and shoulder dystocia: obstetric risk factors remain elusive

OBJECTIVE

Shoulder dystocia (SD) and brachial plexus palsy (BPP) are complications of childbirth that can result in significant long-term sequelae. The purpose of the present study was to analyze risk factors in cases of SD and BPP.

METHODS

We performed a retrospective study of laboring women who delivered a singleton, term, live-born infant at the Los Angeles County + University of Southern California Medical Center from 1995 to 2004. Multivariable logistic regression models were used to analyze risk factors among SD cases with and without BPP.

RESULTS

Of the 13,998 deliveries that met inclusion criteria, 221 (1.6%) had SD. Of these, 42 (19.0%) had BPP. After testing for association with multiple potential risk factors, including maternal demographic variables, diabetes, hypertension, prior cesarean delivery, uterine abnormalities, induction of labor, prolonged second stage (adjusted by parity and epidural use), assisted vaginal delivery, and neonatal birth weight, no statistical association of BPP with any specific risk factor was identified.

CONCLUSION

In the present study, we were unable to identify any reliable risk factors for BPP among deliveries with or without SD. SD and BPP remain unpredictable complications of childbirth.

Concerning the time dependence of the decay rate of 137Cs

The decay rates of eight nuclides ((85)Kr, (90)Sr, (108)Ag, (133)Ba, (137)Cs, (152)Eu, (154)Eu, and (226)Ra) were monitored by the standards group at the Physikalisch-Technische Bundesanstalt (PTB), Braunschweig, Germany, over the time frame June 1999 to November 2008. We find that the PTB measurements of the decay rate of (137)Cs show no evidence of an annual oscillation, in agreement with the recent report by Bellotti et al. However, power spectrum analysis of PTB measurements of a (133)Ba standard, measured in the same detector system, does show such evidence. This result is consistent with our finding that different nuclides have different sensitivities to whatever external influences are responsible for the observed periodic variations.

Botulinum toxin for the treatment of achalasia in pregnancy

There is a paucity of data on the perinatal management of achalasia, an esophageal dysmotility disorder involving an abnormal relaxation of the lower esophageal sphincter. Botulinum toxin A is a well-described treatment for achalasia in the non-pregnant state but has been infrequently used for treatment of this condition in pregnancy. We describe a case of a successful treatment of achalasia in the first trimester of pregnancy with botulinum toxin A, and a subsequently uncomplicated pregnancy course and pregnancy outcome.

Recurrent shoulder dystocia: analysis of incidence and risk factors

OBJECTIVES

To determine the rate and associated risk factors for recurrent shoulder dystocia (SD).

STUDY DESIGN

A retrospective analysis was performed of patients delivered from January 1991 to June 2001. Patients with and without recurrent SD were identified and compared.

RESULTS

Among the 267,228 vaginal births during the study period, there were 1904 cases of SD (0.7%) and 270 patients with one additional vaginal birth. The recurrent SD rate was higher than the general population (3.7% versus 0.7%, odds ratio 7.36, 95% confidence interval 3.68 to 14.23, p < 0.001). Patients with recurrent SD had a slightly higher mean birth weight with the second delivery, but this difference was not statistically significant (4173 ± 544 g versus 4017 ± 577 g, p = 0.39).

CONCLUSION

Prior SD is a risk factor for recurrence in a subsequent delivery, but our results demonstrate that the rate appears to be lower than previously estimated. Most variables, including birth weight, do not appear to be useful parameters in predicting recurrence.

Adenosine trisphosphate appears to act via different receptors in terminals versus somata of the hypothalamic neurohypophysial system

ATP-induced ionic currents were investigated in isolated terminals and somata of the hypothalamic neurohypophysial system (HNS). Both terminals and somata showed inward rectification of the ATP-induced currents and reversal near 0 mV. In terminals, ATP dose-dependently evoked an inactivating, inward current. However, in hypothalamic somata, ATP evoked a very slowly inactivating, inward current with a higher density, and different dose dependence (EC(50) of 50 μm in somata versus 9.6 μm in terminals). The ATP-induced currents, in both the HNS terminals and somata, were highly and reversibly inhibited by suramin, suggesting the involvement of a purinergic receptor (P2XR). However, the suramin inhibition was significantly different in the two HNS compartments (IC(50) of 3.6 μm in somata versus 11.6 μm in terminals). Also, both HNS compartments show significantly different responses to the purinergic receptor agonists: ATP-γ-S and benzoyl-benzoyl-ATP. Finally, there was an initial desensitisation to ATP upon successive stimulations in the terminals, which was not observed in the somata. These differences in EC(50) , inactivation, desensitisation and agonist sensitivity in terminals versus somata indicate that different P2X receptors mediate the responses in these two compartments of HNS neurones. Previous work has revealed mRNA transcripts for multiple purinergic receptors in micropunches of the hypothalamus. In the HNS terminals, the P2X purinergic receptor types P2X2, 3, 4 and 7 (but not 6) have been shown to exist in AVP terminals. Immonohistochemistry now indicates that P2X4R is only present in AVP terminals and that the P2X7R is found in both AVP and oxytocin terminals and somata. We speculate that these differences in receptor types reflects the specific function of endogenous ATP in the terminals versus somata of these central nervous system neurones.

Antipsychotics leading to neuroleptic malignant syndrome in pregnancy

BACKGROUND

Neuroleptic malignant syndrome (NMS) is characterized by a tetrad of mental status changes, extrapyramidal symptoms, hyperpyrexia, and autonomic instability and can develop after the use of antipsychotics.

CASE

A young, multiparous woman presented at 26 weeks of gestation with acute psychosis and was treated with haloperidol until she developed rigidity of her extremities and then was switched to risperidone. She subsequently developed mental status changes, rigidity, hyperthermia, and autonomic instability, leading to a diagnosis of NMS. Risperidone was discontinued and, owing to ongoing psychosis, olanzapine was initiated. Subsequently, her symptoms resolved.

CONCLUSION

Neuroleptic malignant syndrome may complicate the treatment of pregnant women using antipsychotics. Clinicians should take into account the risks of untreated psychosis when discontinuing the offending agent and consider initiating alternative pharmacotherapy.