University of Texas Medical School

Background Endoscopic submucosal dissection (ESD) is a potentially surgery-sparing technique for colorectal neoplasia resection. Outcomes of ESD for residual or recurrent colorectal neoplasia are not well described. This meta-analysis aimed to evaluate the effectiveness and safety of ESD in treating residual or recurrent colorectal neoplasia. Methods We searched MEDLINE and Embase up to July 24, 2023, for studies on ESD for residual or recurrent colorectal neoplasia at prior surgery or endoscopic resection sites. The primary outcome of the meta-analysis was R0 resection; secondary outcomes included recurrence, adverse events (AE), procedure time, and hospitalization length. Pooled effect sizes were obtained using inverse variance random effects models. Subgroup analyses were based on study location, lesion size, and endoscopist experience. Results From 1,133 abstracts, data from 25 observational studies were included, reporting on 863 residual or recurrent lesions treated with ESD. R0 resection was achieved in 80.7% (95% CI 72.7-86.7%, I2 81%) of patients, while recurrence occurred in 2.0% (0.7-5.1%, I2 0%). The incidence of delayed bleeding and delayed perforation were 1.8% (0.7-4.2%, I2 0%) and 1.9% (0.6-6.3%, I2 35%) respectively. The former was independent of country of study, recurrent lesion size, or endoscopist experience. Mean procedure duration was 80.4 (66.6-94.2, I2 96%) minutes and hospitalization length was 4.2 (2.0-6.4, I2 98%) days. Conclusions This meta-analysis suggests that ESD is effective and safe for treating residual or recurrent colorectal neoplasia after previous resection, with further prospective validation studies needed to compare ESD with other endoscopic resection methods and surgery in this context.

Acute suppurative thyroiditis is a rare but serious condition that can progress to a thyroid abscess, requiring emergency surgical intervention. It is typically caused by Gram-positive bacteria like Staphylococcus or Streptococcus , with mycobacteria or fungi seen in immunocompromised patients. We report a case of a 46-year-old female who presented with neck pain, swelling, palpitations, and malaise. Initial diagnosis was a viral infection, but imaging at our facility revealed a 6 × 5.5 cm abscess in the right thyroid lobe, causing tracheal compression. Labs showed thyrotoxicosis, leukocytosis, and anemia. She was started on β-blockers, PTU, IV steroids, antibiotics, and given a blood transfusion on admission. Her condition worsened, and she underwent neck exploration with drainage of the abscess, revealing E . coli . After treatment, she recovered and was discharged with antibiotics and antithyroid medications. This case emphasizes the importance of early detection and timely surgical intervention of acute suppurative thyroiditis.

Background: Research results are often not communicated to study participants or others with relevant lived experience. Effective communication of research results would help study participants understand their contribution to research and could improve trust in research and likelihood of research participation. Few randomized controlled trials (RCTs), however, have compared the effectiveness of research communication tools, and it is not known which tools work best for different people. We will conduct the Scleroderma Patient-centered Intervention Network-Communicating Latest Evidence and Results (SPIN-CLEAR) trial series via the multi-national SPIN Cohort to compare tool effectiveness. Primary objectives of each RCT will be to compare tools based on (1) information completeness, (2) understandability, and (3) ease of use. We will additionally evaluate comprehension of key aspects of disseminated research; likelihood that participants would enroll in a similar future study; and, for all primary and secondary outcomes, outcomes by participant characteristics (gender, age, race or ethnicity, country, language, education level, health literacy). Methods: An advisory team of people with systemic sclerosis (SSc, also known as scleroderma) participated in developing research questions, selecting outcomes, and designing the series of parallel-arm RCTs that will each compare two or more tools or tool variations to a plain-language summary comparator; the common comparator will facilitate across-trial comparisons. In each RCT, people with SSc and researchers will select a recent SSc research study to disseminate. Tools will be developed by experienced tool developers and people with SSc. SPIN Cohort participants (current N eligible = 1522 from 50 SPIN sites in Australia, Canada, France, UK, USA) and additional participants recruited via social media and patient organization partners who consent to participate will be randomized to a dissemination tool or plain-language summary comparator and complete outcomes. Analyses will be intent-to-treat and use linear regression models. Discussion: Each trial in the planned series of trials will build upon knowledge from previous trials. Results will contribute to the evidence base on how to best disseminate results to study participants and others with relevant lived experience. Trial registration: ClinicalTrials.gov NCT06373263. Registered on April 17, 2024 (first trial in series).

Green-top Guidelines (GTGs) by the Royal College of Obstetrics and Gynecology (RCOG) guide clinical practices similar to Practice Bulletins (PBs) by the American College of Obstetrics and Gynecology (ACOG). Previous analyses reveal that most recommendations lack Grade A evidence and are not based on randomized clinical trials (RCTs). This descriptive study evaluates the quality of evidence supporting RCOG Obstetrical recommendations. We reviewed obstetrical RCOG GTGs available as of September 2024, checking each citation in PubMed for RCT status. Quality assessments were not made independently. The senior author verified a random 10% of the data (B.J.F.H.). Data were recorded and summarized in Excel. RCOG lists 37 obstetrical GTGs with 1,861 recommendations. About 1,288 (69%) of recommendations are supported by 3,674 references. A total of 43% of GTGs rely on consensus and expert opinion. When omitting recommendations based on expert opinion, 98 (9%) of RCOG recommendations are Grade A (based on high-quality evidence), and of the cited references, 5% of GTGs are Evidence Level 1 + + (highest quality), while 7% are RCTs. Among the recommendations, 69% of GTGs have identifiable references. However, 43% of GTG references are nonanalytical studies or expert opinions. Our findings highlight the need for more high-quality evidence in guidelines and suggest further research in evidence-based obstetrical care.

OBJECTIVE: The primary objective was to ascertain if the proportion of time in category II fetal heart rate tracing (FHRT) prior to birth among term (> 37 weeks) singletons in labor was associated with composite adverse neonatal outcomes (CANO). STUDY DESIGN: The inclusion criteria for this retrospective cohort study were non-anomalous singletons at term, whose FHRT was reviewed by obstetricians blinded to the maternal characteristics and neonatal outcomes. According to ACOG’s criteria, the last 20 to 120 minutes of the tracing were reviewed in 20 min epochs. The cohorts were divided into 3 groups: Group A, category II for < 33% of the available tracing; group B, for > 33 and <66%; and, group C, for > 66% of the FHRT. CANO was any of the following: Apgar score < 7 at 5 min, mechanical ventilation, hypoxic-ischemic encephalopathy, neonatal seizure, confirmed sepsis, or neonatal death. Group A was compared to group B and C, using adjusted odds ratio (OR). RESULTS: FHRT for 5,160 consecutive deliveries was reviewed, and 2,780 (53.8%) met the inclusion criteria. Of the 321,980 min of FHRT reviewed, 223,000 min (69.2%) were category II. The overall CANO among the cohorts was 1.4% (38/ 2,780), and it did not vary significantly between group A versus B (aOR 1.11, 95% CI 0.35- 3.48), or between group A versus C (aOR 0.80; 95% CI 0.27-2.35). The overall rate of cesarean delivery for non-reassuring FHRT was 9.7% (270/2,780), and it did not differ between group A versus B (aOR 0.86, 95% CI 0.51-1.47) or group A versus C (aOR 1.18, 95% CI 0.73-1.91). CONCLUSION: Among term deliveries, in the last 20 to 120 min before birth, 70% of the time FHRT was category II, and the proportion of time in Category II did not significantly influence adverse neonatal outcomes.

Objective : The relationship between BMI > 30 in pregnancy and postpartum hemorrhage (PPH) has been unclear. While, some risk stratification protocols classify elevated BMI as a moderate risk factor while others do not. This study aimed to examine the effect of elevated BMI on PPH in a contemporary population. Material and Methods: This retrospective cohort study included all singletons ≥14 weeks with recorded BMI who delivered at a Level IV center for two consecutive years. The exposure group was sub-categorized into BMI 30-39.9 and BMI ≥ 40 kg/m2, with a planned subgroup by mode of delivery. Data was collected by clinicians, and the composite maternal hemorrhagic outcome (CMHO) was defined as: blood loss ≥ 1000 mL, interventions for atony including use of uterotonics (excluding prophylactic oxytocin), mechanical tamponade, surgical intervention, venous thromboembolism, admission to the intensive care unit, hysterectomy, or maternal death. Adjusted relative risks (aRR) with 95% confidence intervals (CI) were calculated using multivariate Poisson regression with robust error variance. Results: Of 8,623 deliveries in the study period, 8,340 (96.7%) met inclusion criteria, with 2943 (35%) with BMI <30.0, 3,900 (46%) with BMI of 30-39.9 kg/m2, and 1497 (17%) with BMI of ≥40 kg/m2. CHMO was increased for BMI 30-39.9 (aRR 1.16, 95% CI 1.04-1.29) and ≥40.0 (aRR 1.19, 95% CI 1.04-1.36), largely due to increased risk of blood loss ≥ 1,000 and uterotonic use. A subgroup analysis of by mode of delivery noted that increased risk for CHMO was only present in BMI ≥40 for vaginal deliveries (aRR 1.35, 95% CI 1.10-1.65) and only for BMI 30-39.9 in cesarean delivery (aRR 1.28, 95% CI 1.10-1.50). Conclusion: Parturients with BMI>30 had a higher risk of hemorrhage related morbidity compared to patients with BMI <30, however clinical management and impact needs further investigation.

This pilot study consists of a two‐phase intervention to examine the effectiveness of unilateral resistance training to mitigate the negative consequences of immobilization and expedite the restoration of muscle strength and size following a period of retraining. Ten females were randomized to a unilateral training (TRAIN, n = 6) or control (CON, n = 4) group. During Phase 1, all participants wore an arm sling for a total of 4 weeks on their non‐dominant arm. This phase required the TRAIN group to perform unilateral resistance training with the non‐immobilized arm while the CON group did not. Phase 2 commenced thereafter and consisted of 4 weeks of bilateral resistance training for both groups. Outcome measures of neuromuscular function and muscle size were assessed at baseline and after each phase, with neuromuscular function quantified by maximal dynamic and isometric strength alongside electromyographic responses and muscle size measured using ultrasonography and regional lean mass via DEXA. Unilateral training of the non‐immobilized arm during Phase 1 attenuated dynamic (p < 0.05; g > 1.2), but not isometric (p > 0.40; g < 0.095), strength loss following immobilization and showed large effects for improving the recovery of strength after retraining. Similarly, the imaging data show the relative changes in muscle size and regional lean mass of the non‐dominant arm favor TRAIN. Although the small sample prevents definitive conclusions, our study suggests resistance training of the non‐immobilized arm attenuates muscle weakness and atrophy for the contralateral, immobilized arm during immobilization and facilitates their recovery following retraining.

A growing specialty within veterinary medicine is end-of-life (EOL) care, including EOL mobile practice. EOL care is a broad term referring to euthanasia services, as well as hospice and palliative care for terminally-ill patients. This study was designed to better understand how EOL mobile veterinarians feel about their work, including the benefits and challenges, their reasons for choosing this career, and their levels of professional fulfillment and burnout compared to other veterinary professionals. To this end, an online, anonymous, cross-sectional survey was developed using Qualtrics, and adult EOL mobile practitioners were recruited for the study. A total of 162 veterinarians responded to the survey. Results suggest that the primary reasons why veterinarians are drawn to mobile EOL work include the ability to make a positive impact and provide personalized care to pets and families, and enjoy a better work environment. When participants were asked to indicate how challenging they found 16 EOL mobile practitioner work-related factors, the factors reported as “very challenging” by the largest number of participants included a lack of health benefits (24/99, 24%), followed by the hassle of the business side (e.g., taxes, recordkeeping, etc.) (21/122, 17.2%). When assessing burnout and professional fulfillment, a total of 21/142 (14.80%) indicated they felt burned out and 99/142 (69.72%) participants’ scores fell above the cutoff for professional fulfillment, suggesting that mobile EOL practitioners have higher job fulfillment and lower burnout than other veterinary professionals. These results suggest that engagement in euthanasia, per say, does not necessarily lead to a negative impact on mental health. While not for everyone, mobile EOL practice appears to be a viable career path for some veterinarians.

Most shoulder dystocia (SD) cases do not have associated adverse outcomes. The objective was to assess whether SD relieved with ≥3 maneuvers, compared with fewer, is associated with a higher likelihood of adverse outcomes. The secondary objective was to examine if postpartum hemorrhage is associated with SD managed with ≥3 maneuvers versus fewer. This was a secondary analysis of the assessment of perinatal excellence (APEX) study, an observational cohort of over 115,000 deliveries in 25 U.S. hospitals from 2008 to 2011. We included individuals with singleton, vertex, and nonanomalous fetuses at ≥34 weeks who had SD requiring at least one maneuver. We stratified participants according to if ≥3 maneuvers, versus fewer, were utilized to resolve the SD. The primary outcome was the incidence of a neonatal composite adverse outcome including APGAR <5 at 5 minutes, fetal fractures, intracranial hemorrhage, brachial plexus palsy, facial nerve palsy, hypotension treated, hypoxic-ischemic encephalopathy, or neonatal death. Using modified-Poisson-regression, we calculated adjusted incidence relative risk (aIRR) with 95% confidence intervals (CI). The rate of SD in APEX was 1.9% (2,138/118,422). Of 2,138 cases of SD, 96% met the inclusion criteria. ≥3 maneuvers were utilized in 18.9% (391/2,062) of SD cases. The composite neonatal adverse outcome occurred in 8.1% (168/2,062) of cases, and in adjusted models, the risk for the composite outcome was significantly higher with SD requiring ≥3 maneuvers (15.1%) versus <3 maneuvers (6.5%; aIRR: 2.08; 95% CI: 1.50–2.89). Additionally, APGAR <5 at 5 minutes (aIRR: 4.10; 95% CI: 1.18–14.25), neonatal brachial plexus palsy (aIRR: 2.58; 95% CI: 1.45–4.60), and hypoxic-ischemic encephalopathy (aIRR: 2.83; 95% CI: 1.36 and 5.89) were significantly more likely when ≥3 were used. No significant difference was noted for postpartum hemorrhage (PPH) by number of maneuvers (aIRR: 0.74; 95% CI: 0.44 and 1.21). SD relieved by ≥3 maneuvers, compared with <3, was associated with a 2-fold-increased risk for the composite neonatal adverse outcome, with no difference in risk for PPH.

Objective Compare the progression of systemic sclerosis-associated interstitial lung disease (SSc-ILD) based on serological status. Methods In a post-hoc analysis of the SENSCIS trial (nintedanib vs placebo in SSc-ILD; NCT02597933 ), we analyzed the rate of decline in forced vital capacity (FVC) over 52 weeks in 3 subsets: positive for anti-centromere antibody (ACA), positive for anti-RNA polymerase III antibody (ARA), negative for ACA, ARA and anti-topoisomerase I antibody (ATA). Results Among study participants who underwent baseline serological evaluation, 32/549 (5.8%) were ACA positive, 98/528 (18.6%) were ARA positive, and 127/526 (24.1%) were negative for ACA, ARA and ATA. Among the serological subsets of interest, in the placebo arm, the adjusted rate (SE) of decline in FVC (mL/year) was -31.2 (41.5) among participants who were positive for ACA and -64.7 (35.1) among participants who were positive for ARA, numerically lower than in the overall SENSCIS trial population (-93.3 [13.5]). However, participants who were negative for ACA, ARA and ATA experienced a numerically greater rate of decline in FVC (mL/year) than the overall trial population, both in those randomized to placebo (-115.6 [35.4] vs. -93.3 [13.5], respectively) and those randomized to nintedanib (-91.8 [34.3] vs. -52.4 [13.8]). Conclusion These analyses of data from the SENSCIS trial suggest that patients with SSc-ILD who are ACA positive or ARA positive can experience progression of SSc-ILD. Patients negative for ACA, ARA and ATA had a higher rate of progression than the overall trial population and should be monitored closely.

Background Neonatal trauma resuscitation is particularly challenging in cases of profound hemorrhagic shock. Low‐titer group O+ whole blood ( LTOWB +) has emerged as a potentially effective option in pediatric trauma, but its use in neonates is debated due to risks such as D‐alloimmunization. In life‐threatening emergencies, decisions must carefully balance immediate survival benefits against long‐term risks. Study Design and Methods We present a case report of a 4‐day‐old neonate transported as a Level 1 trauma following a dog attack to the head, resulting in hemorrhagic shock and cardiac arrest. Upon arrival to the trauma bay, the patient was pulseless, with unsuccessful intraosseous and intravenous vascular access attempts. Access was eventually achieved using an umbilical venous catheter, enabling administration of LTOWB+. Results Administration of LTOWB+ resulted in the return of spontaneous circulation, improved perfusion, and hemodynamic stabilization. The patient remained alive at the 6‐month follow‐up. LTOWB+ facilitated rapid correction of hemorrhagic shock with no immediate complications observed. Discussion This case underscores the challenges of neonatal trauma resuscitation, including vascular access and the use of LTOWB+. LTOWB+ proved lifesaving, enabling rapid correction of acidosis and an improved outcome. Although concerns persist regarding LTOWB+ administration, the immediate survival benefits outweigh the risks, supported by evidence demonstrating its efficacy and safety. This case highlights the need for adaptability and a systematic approach to managing complex neonatal trauma scenarios. We argue that LTOWB+ is poised to become a pillar of pediatric resuscitation, providing a lifesaving, efficient, and safe option even in the newborn.

Background New and minimally-invasive tools to aid the diagnosis of invasive fungal diseases (IFD) are urgently needed as the immunocompromised population at highest risk increases. Advancements in molecular technology have rendered new diagnostics more readily available for clinical use. Methods This case-control study utilized prospectively collected, archived plasma specimens and data from the Aspergillus Technology Consortium (AsTeC) Repository to investigate the diagnostic performance of microbial cell free DNA (mcfDNA) sequencing as a minimally-invasive diagnostic for IFDs in a population of high-risk immunocompromised hosts including hematologic malignancy, stem cell and solid organ transplants patients. The 2008 Mycoses Study Group/European Organization for the Research and Treatment of Cancer diagnostic criteria served as the gold standard for test performance. Results Sixty-five adult subjects with proven or probable IFD and 65 controls without IFD were included. Among IFD episodes Aspergillus was the most common pathogen (70.8%, 46/65), followed by Mucorales (10.8%, 7/65). Overall, sensitivity was 47.7% and specificity was 100%. Sensitivity varied based on disease certainty and pathogen; sensitivity was higher in proven versus probable IFD (60.0% vs 37.1%, respectively) and higher for subjects with invasive mucormycosis (100%) compared with aspergillosis (45.7%). Conclusions A positive result by mcfDNA sequencing may reduce the need for invasive sampling in patients with suspected IFD. In this exploratory analysis, its high sensitivity and specificity for invasive mucormycosis suggests it could be useful for early treatment and intervention of this IFD. Future studies should focus on understanding how specific factors impact the sensitivity of mcfDNA sequencing for invasive aspergillosis.

Alpha-synuclein seed amplification assays can improve neurodegenerative disease diagnosis and care, but widespread use depends on a framework that standardizes protocols and encourages data sharing.