United States

Background Patient-proxies often provide informed consent for neurocritical care research. Informed consent success depends on research staff availability, rapport-building time between patients-proxy, language barriers, health literacy, cultural biases that affect patient comprehension, proxy&#39;s distress with acute brain injury news, and perceived patient choices. Pandemic-related visitor restrictions made proxy consents harder to obtain. Two clinical trials highlight the importance of remote e-consent and proposed solutions.
Methods Consent workflow description for Study A utilizing multiple modality e-consent with remote investigators compared to Study B using in-person dedicated staff when remote e-consent was not allowed.
Results 
Study A contacted 51 of 70 eligible patients. Only one consent was obtained in-person during the 3-month recruitment period when IRB only allowed in-person consents. After remote e-consent approval, 50 patient proxies were mailed consent to sign after patient discharge, taking 6 hours of remote-investigator time. Only one returned signed form after 21 days. 49 proxies were phoned by Doximity over 6 months, taking 3.5 min/eligible subject with one redial every month (average 4 calls/subject), with 17 rejected, 11 unreachable. 8/21 phone proxies received DocuSign®-based consent emails and returned signed forms in average 36 days (4 hrs-144 days). Mail yielded 2% and email-based DocuSign consent 38%, compared to 1% in-person. 
Study B: Of 81 eligible over 6 months, 50 consented in-person or by-mail through 3 in-house investigators with a 62% success rate, with average of 48 minutes/consent (15–50 minutes), and 2 consents received by-mail. Getting consent in-person while patient was hospitalized, meeting proxies in parking lots when visiting premises for unrelated purposes, and dedicated unit staff increased success rate.
Conclusion 
Email-based DocuSign® e-consent through remote investigators can overcome pandemic-induced visitor limitations. Our institutional Digital Communications Governance Committee is exploring HIPAA-compliant text-based messaging solutions using cloud-based communication platform (Twilio®) to facilitate remote consenting access.


AMA Research Challenge 2023

Pandemic-Induced Challenges in Consenting Patients andProposed Solutions for Neurocritical Care Trials

Background Patient-proxies often provide informed consent for neurocritical care research. Informed consent success depends on research staff availability, rapport-building time between patients-proxy, language barriers, health literacy, cultural biases that affect patient comprehension, proxy's distress with acute brain injury news, and perceived patient choices. Pandemic-related visitor restrictions made proxy consents harder to obtain. Two clinical trials highlight the importance of remote e-consent and proposed solutions.
Methods Consent workflow description for Study A utilizing multiple modality e-consent with remote investigators compared to Study B using in-person dedicated staff when remote e-consent was not allowed.
Results 
Study A contacted 51 of 70 eligible patients. Only one consent was obtained in-person during the 3-month recruitment period when IRB only allowed in-person consents. After remote e-consent approval, 50 patient proxies were mailed consent to sign after patient discharge, taking 6 hours of remote-investigator time. Only one returned signed form after 21 days. 49 proxies were phoned by Doximity over 6 months, taking 3.5 min/eligible subject with one redial every month (average 4 calls/subject), with 17 rejected, 11 unreachable. 8/21 phone proxies received DocuSign®-based consent emails and returned signed forms in average 36 days (4 hrs-144 days). Mail yielded 2% and email-based DocuSign consent 38%, compared to 1% in-person. 
Study B: Of 81 eligible over 6 months, 50 consented in-person or by-mail through 3 in-house investigators with a 62% success rate, with average of 48 minutes/consent (15–50 minutes), and 2 consents received by-mail. Getting consent in-person while patient was hospitalized, meeting proxies in parking lots when visiting premises for unrelated purposes, and dedicated unit staff increased success rate.
Conclusion 
Email-based DocuSign® e-consent through remote investigators can overcome pandemic-induced visitor limitations. Our institutional Digital Communications Governance Committee is exploring HIPAA-compliant text-based messaging solutions using cloud-based communication platform (Twilio®) to facilitate remote consenting access.


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Background
Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide. Pupillometry is a noninvasive method to assess for preserved midbrain function. Specifically, poor pupil reactivity has been shown to be an early predictor of neurological deterioration and can signify impending herniation hours before clinical symptoms arise. In patients with TBI, absent pupil reactivity can stratify severity and prognosticate outcome. However, abnormal pupil phenotypes over the first 72 hours in mild, moderate, and severe TBI patients is poorly characterized. We calculated the incidence and burden of abnormal pupil phenotypes and investigated their relationship to unfavorable patient outcome at discharge (death or disposition to hospice or long-term care).
Methods
We performed a single-center retrospective observational study of 137 TBI patients with quantitative pupil measurements using the Neuroptics pupillometer. We calculated the median Neurologic Pupil Index (a metric of pupil reactivity ranging from 0-5) over 72 hours and compared cumulative burdens of abnormal pupil phenotypes (unilateral poor pupil reactivity and bilateral poor pupil reactivity) for mild, moderate, and severe TBI patients using ANOVA tests. We then used logistic regression to test the association of median average NPi and bilateral poor pupil reactivity burden with death or disposition to hospice or long-term care adjusting for age, sex, black race, TBI severity, and penetrating v. blunt injury. 
Results
Of 137 patients, 97 were male and median age was 59 [25th percentile 38, 75th percentile 72], of whom 49 (36%) had unfavorable outcomes. Fifty patients had mild TBI, 21 had moderate and 66 had severe TBI. Unilateral poor pupil reactivity occurred in 12 (24%), 6 (29%) and 32 (48%) patients with mild, moderate, and severe TBI. Bilateral poor pupil reactivity occurred in 3 (6%), 2 (10%), and 19 (29%) patients with mild, moderate, and severe TBI. After adjusting for confounders, median NPi over 72 hours was inversely associated with unfavorable outcome (0.22 [0.07-0.51]; p=0.004), while burden of bilateral poor pupil reactivity was associated with unfavorable outcomes (1.23 [1.08-1.45]; p=0.004).
Conclusion
Lower median NPi and higher burden of bilateral poor pupil reactivity over 72 hours in TBI patients is associated with unfavorable outcomes in TBI patients.

Prognostic Pupil Reactivity Markers within the first 72 hours of Traumatic Brain Injury

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a fatal neurodegenerative disease affecting motor neurons in the brain and spinal cord. Progressive muscle weakness, atrophy, and spasticity characterize the condition, which eventually leads to paralysis and respiratory failure. There is currently no cure for ALS, and the standard of care is supportive, with riluzole being one of the few FDA approved medications that has been shown to slightly slow disease progression along with Radicava (edaravone) and RELYVRIO (AMX0035) approved in 2022 with Qalsody (tofersen) being approved in 2023. With limited options for medications, the use of mesenchymal stem cells (MSCs) in the treatment of ALS is a new area of research in regenerative medicine. MSCs are multipotent stem cells that can differentiate into a variety of cell types, including neurons, and have immunomodulatory and anti-inflammatory properties, making them an appealing therapy for neurodegenerative diseases such as ALS. This review examines the safety and efficacy of MSC therapy for ALS in three Phase II randomized controlled trials. The trials involved administering MSCs via various routes, including intrathecal and intravenous, and assessing outcomes such as survival, disease progression, and quality of life. 


Mesenchymal Stem Cell Therapy for Amyotrophic Lateral Sclerosis: A Narrative Review


Background 
Benefits of early skin-to-skin contact (SSC) are widely documented, including improved breastfeeding outcomes. While promoting immediate SSC is standard practice for vaginal birth, it happens less often after cesarean birth.  It is not known how changes in hospital practices and staff shortages during the COVID-19 pandemic have influenced the practice of SSC in the operating room.  This study aims to identify the relationship between SSC after cesarean birth and breastfeeding and compare SSC rates before and during the COVID-19 pandemic. 
Methods 
This was a retrospective, cohort chart review. Sample was 244 subjects who had scheduled cesarean deliveries at term during April-October 2019 and April-October 2020. Primary outcome was exclusive breastfeeding on discharge. Secondary outcomes were time to initiate breastfeeding, exclusive breastfeeding at postpartum visit and rate of SSC in the OR in 2019 compared to 2020. 
Results 
SSC in the first 3 days after birth was associated with feeding type on discharge (p<0.001) and/or at the postpartum visit (p=0.04). The study did not identify a statistically significant association between location of SSC and feeding type either on discharge (p=0.55) or at the postpartum visit (p=0.55). Infants who had SSC in the OR had significantly earlier initiation of breastfeeding (p<0.001). There was an increase in SSC in the OR between 2019 and 2020 (27% and 39%, respectively).  
Conclusion 
SSC practices after cesarean birth are associated with breastfeeding outcomes. Knowledge of this relationship will be important for optimizing surrounding SSC practices and breastfeeding support in the future.

Skin-to-skin contact and breastfeeding after cesarean birth at UIHC, before and during the COVID-19 pandemic

Background: Sonographic measurement of foetal biparietal diameter is a
well-accepted predictor of gestational age. However, there is a high variability
in the calculated gestational age which increases as pregnancy progresses with a
maximum difference approximating 3.6 weeks in the third trimester. Conditions
like oligohydramnios can alter the shape of the foetal skull, affect the BPD and
increase variability. The present study is being undertaken to measure the
transverse cerebellar diameter (TCD) to validate it as an additional
morphological measurement of foetal growth with less variability.
The cerebellum and posterior fossa are aligned perpendicular to the plane of
maximum extrinsic compression. Hence they can withstand deformation by
extrinsic pressure than the parietal bones and can be a more accurate parameter
for determining gestational age.
Methods: A cross-sectional study was done in 100 healthy women with
uncomplicated pregnancy between the 28th week of gestation and 40th week of
gestation over three years in outpatient and in-patient sections of Obstetrics and
Gynaecology Department of SRM Hospital and Research Institute,
Kattankulathur, Chennai. This study was undertaken to determine a correlation
between the transverse cerebellar diameter and the gestational age as
determined by the last menstrual period and other sonographic parameters like
biparietal diameter and femur length. After satisfying the inclusion and
exclusion criteria, Transabdominal ultrasonography was performed with the
patient in a supine position. The Pearson Correlation technique was used to test
the direction and strength of the relationship between gestational age obtained
using transverse cerebellar diameter vs individual parameters such as biparietal
diameter and femoral length.
Results: A scatter diagram showing the correlation and regression analysis of
the Gestational age with BPD in the third trimester. Here TCD is correlated with
BPDby87.1 %. A scatter diagram showing the correlation and regression
analysis of the TCD with FL in the third trimester. Here TCD is correlated with
FL by 93.0 %
Conclusion: Obstetric sonography was performed in 100 pregnant women with
uncomplicated pregnancy with known LMP, previous history of normal
menstrual cycle, and no exclusion criteria were included in the study. Foetal
biometry evaluated includes BPD, FL, and TCD. The nomogram of the TCD
shows that there is a linear relationship between cerebellar growth and
gestational age. So TCD can be used as a reliable parameter for determining
gestational age

 Accuracy of transcerebellar diameter in estimation of gestational age in third trimester and its comparison with conventional parameters such as biparietal diameter and femur length

Introduction
Trauma complicates 1 in 12 pregnancies and is the leading cause of mortality outside of obstetric-related complications. Guidelines for trauma activation in pregnancy differ from non-pregnant populations but are not universally established. This study aims to investigate under or overtriage of our pregnant patient population according to our established trauma triage criteria.
Methods
A retrospective study including all patients with pregnancy and trauma ICD-10 codes between January 2017-December 2020 at a level 1 trauma center was included. Patient demographics, vitals, injuries, service involvement during admission, gestational age, and obstetric and medical history were collected and compared to our hospital’s trauma triage criteria to evaluate undertriage in this patient population.
Results
330 patients were identified based on inclusion criteria. Trauma evaluation only occurred in 13.0% of patients and 30.9% of patients received obstetric (OB) evaluation. According to our institutional criteria, 55.8% of all pregnant patients had a missed trauma evaluation. 87.2% (n=130/149) of patients ≥20 weeks had a missed trauma evaluation (Fig. 1). For patients presenting directly to the trauma bay, patients ≥20 weeks received OB evaluation 100% (n=11) of the time, and patients <20 weeks received OB evaluation only 53.9% (n=7/13) of the time.
Conclusion
Pregnant patients are a vulnerable population, and thus, it is essential to triage these patients based on OB-specific criteria. This study has revealed that most OB patients are undertriaged according to our institution's criteria, prompting further investigation to understand barriers to appropriate triage.

Trauma Trends and Outcomes in Obstetrical Patients at a Level 1 Trauma Center

Background
Pregnant women were one of the most vulnerable populations during the Coronavirus Disease 2019 (COVID-19) pandemic. Understanding how the pandemic influenced prenatal care utilization and birth outcomes of pregnant populations is essential to guiding disaster preparedness in the face of future global threats. We sought to evaluate the COVID-19 pandemic’s influence on the adequacy of prenatal care and birth outcomes.

Methods
Retrospective cohort study compared prenatal care adequacy, diagnostic testing, and gestational age of 481 patients seen at an urban medical center in New York City during the pandemic (October 1, 2020 and October 14, 2020), and in the corresponding pre-pandemic period (October 1, 2019 and October 14, 2019) using student t-test, Mann-Whitney, and chi-squared tests.

Results
Patients seen during the pandemic were more likely to receive Adequate Prenatal Care (OR 2.634 95%CI 1.672-4.184 p < 0.001) than pre-pandemic patients (OR 0.385 95% CI 0.244-0.606 p < 0.001). Adequate Prenatal Care (OR 0.102 95%CI 0.014-0.763 p = 0.005) was negatively associated with early preterm pregnancy (32-36 weeks). There were no statistically significant differences in gestational age between the pre-pandemic and pandemic cohorts (Moderate Preterm 32-36 weeks OR 1.145 95%CI 0.532-2.465 p=0.845, Early Term 37-38 weeks OR 1.049 95%CI 0.658-1.671 p=0.905, Full Term OR 1.044 95% CI 0.689-1.581 p=0.916). 

Conclusion
Though the pandemic imposed unprecedented stresses upon expectant mothers, patients had significantly greater likelihoods of receiving adequate prenatal care during the pandemic, which may be attributed to the expansion of telehealth services and increased health awareness. Despite this increase in prenatal care adequacy, the pandemic had no statistically significant influence on preterm birth rates.

Improving Prenatal Care Adequacy in Urban Settings: Lessons from the COVID 2019 Pandemic

Background: Prior studies demonstrate that chronic prenatal opioid exposure leads to an increased risk for preterm labor and fetal growth restriction, both conditions associated with placenta insufficiency. Current literature also suggests that chronic prenatal opioid exposure negatively impacts the placenta (and fetus) during a critical developmental period where unyielding foundational processes for organ growth are initiated. Not only is there evidence of abnormal biochemical signaling between the placenta and fetus, but there is also histological evidence of chronic hypoxia in placentas chronically exposed to opioids. In a worsening opioid epidemic where identifying avenues for future therapeutics has become critical, the placenta may be an ideal therapeutic target for improving fetal health outcomes related to exposure. The goal of this study was to investigate histological differences in human placental tissue following chronic prenatal opioid exposure.

Methods: Placental tissue was collected from 7 opioid-exposed and 17 unexposed placentas from full-term pregnancies. Analyses were completed for 7 unexposed, control placentas by matching age and smoking history to exposed placentas. All participants in the opioid-exposed group were exclusively taking buprenorphine at some point during their third trimesters. Placental tissue samples were fixed in neutral buffered, 10% formalin, embedded in paraffin wax, and stained with hematoxylin and eosin prior to blinded histopathological analysis by an experienced pathologist. A generalized linear mixed model with a binomial outcome, paired t-tests, and linear mixed effects models were utilized to measure the frequency of a grade 2 or higher score (grade 3 or higher, villous morphology), total grade, or average grade.

Results: No statistically significant differences were observed in vascular pathology and inflammation between the opioid-exposed group and their respective matched controls. The control group placentas were found to exhibit significantly higher frequencies of grade 3, 4 or 5 villous morphology compared to the opioid-exposed placental tissue. When villous morphology was measured by total and average grade, no statistically significant differences were appreciated. 

Conclusion: The findings from this study may suggest that chronic opioid exposure, specifically chronic exposure to the partial opioid agonist buprenorphine, may not have unfavorable histopathological consequences as compared to unexposed placentas. The findings of this study may be limited by small sample size and an inability to control for other substances being used (including tobacco and illicit drugs) in the exposed group throughout pregnancy. Further investigation of microvascular changes as well as signaling changes in the placenta following chronic prenatal opioid exposure is warranted.

Histopathology of placental tissue after chronic opioid exposure

Background
Vaginal agenesis (VA) refers to the congenital absence of a vaginal canal often linked with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Current VA treatments include mechanical dilation and surgical vaginoplasty. Our vaginal expansion sleeve (VES) is a novel, transiently implanted device which lengthens the vaginal canal over time and is less complex and invasive than surgery or conventional dilation therapy which may improve patient compliance. Our study evaluated histologic effects of VES on rat vaginal tissue following VA.

Methods
Novel VES were made using a proprietary woven cylindrical material with helicoid trusses and flat resin caps. VES were used at 25-30mm in length depending on initial vaginal canal lengths and all VES pre-contracted to 50% of their original length. VES were then inserted and sutured into the vaginal canals of Sprague-Dawley rats (n=6) and allowed to spontaneously re-expand post-deployment. After one week, VES were removed and new vaginal lengths were measured. Rat vaginas were harvested en-bloc for histologic analysis. Test (n=6) and control (n=4) formalin-fixed paraffin-embedded tissues were stained with hematoxylin and eosin (H&E), Masson’s trichrome, and anti-Desmin immunochemical stain and evaluated.

Results
In 7days, mean vaginal canal lengths increased from 20.0 ± 2.4 mm to 23.8 ± 1.2 mm post-VES (n=6, p <.001), a 19% increase. H&E staining revealed increased submucosal eosinophilic inflammation in 5:6 of samples compared to 1:4 control tissues with an average 30.2 eosinophils per HPF (range: 16 - 38; median: 35). The test tissues also showed increased scattered neutrophils and lymphocytes in the mucosa and submucosa, with one test tissue having the longest VES (30mm) containing lymphocytic and neutrophilic inflammation. Desmin immunostaining and Masson’s trichrome staining both revealed a thinner muscularis with more infiltrative fibrous tissue between muscle fibers in the test tissues compared to control tissues.

Conclusion
VESs achieved significant vaginal lengthening. A positive correlation was observed between the VES length (and therefore tension generated in the vagina) and the degree of inflammation. The eosinophilia observed in the test tissues may indicate a localized, specific immune reaction to the VES device. The Desmin immunostain and Masson’s trichrome stain is consistent with muscularis remodeling. Future studies with longer durations of VES placement as well as serial implants with VESs of increasing lengths can inform longer-term remodeling of test tissues and help further characterize immune response associated with VES.

Histologic Changes in Rat Vaginal Tissue Following Vaginal Expansion Sleeve (VES) Implantation: Implications for Vaginal Agenesis Treatment

Background
Premature ovarian failure, whether occurring spontaneously or iatrogenically, especially as a result from chemotherapy, is a challenging clinical problem in Reproductive Endocrinology and Infertility and Oncology. These patients have no autologous fertility-restoration options available if preemptive egg or embryo freezing was not successfully completed. Lack of endogenous hormone production has sequelae beyond reproduction, including accelerated bone loss, increased risk of cardiovascular disease, and sexual dysfunction. While hormone replacement therapies exist, long-term outcomes from such treatments, especially when initiated at a young age, remain unclear. These issues are heightened in cancer survivors, who have lower baseline fertility rates and success with assisted reproduction.
Methods
A methodology for the creation of oocytes via reprogrammed granulosa cells was first performed in mouse and, to the greatest extent possible, recapitulated in human cells. Granulosa cells (GCs) were reprogrammed to generate induced pluripotent stem cells (IPSCs) as previously described in our lab. Human GCs and follicular fluid were obtained from the IVF lab after oocyte removal during egg retrieval procedures. Cells were labeled with GFP and differentiated into ovarian lineages using an oocyte derivation media containing follicular fluid. Stem cell and differentiated cell status was verified via RT-PCR, immunocytochemistry, alkaline-phosphatase reaction, steroidogenic activity, and the formation of embryoid bodies and teratomas. Mouse GFP-labeled differentiated IPSCs were orthotopically implanted into one ovary of subfertile immunocompromised mice which also had chemotherapeutically-induced ovarian failure to assess for the restoration of hormone production and fertility.
Results
Differentiated IPSCs expressed ovarian markers (i.e. AMHR2, ZP1) and were able to produce physiologically relevant concentrations of the reproductive steroid hormones (i.e. estradiol/progesterone) in vitro. Interestingly, the addition of follicular fluid increased the steroidogenic potential of the cells in mice. Mice treated with alkylating chemotherapy to induce ovarian failure had ovarian follicular atresia and breast atrophy, which was reversed within 72 hours of transplanting terminally differentiated GFP-IPSCs into the thighs or ovaries of these mice. In subfertile nude mice, the orthotopic implantation of terminally differentiated IPSCs enhanced fertility, resulting stem cell-derived neogametogenesis and delivery of F1 and F2 litters with GFP expression.
Conclusion
New autologous methods of restoring fertility and ovarian function would be indispensable for patients with prematurity ovarian insufficiency or failure. Our work demonstrates that other populations of cells within the body may be reprogrammed for the purpose of endocrine health and fertility restoration in such patients.

The Generation of Stem Cell-Derived Functional Oocytes from Reprogrammed Granulosa Cells

Background: Cardiovascular disease (CVD) affects 1-4% of pregnancies in the U.S. and is the primary contributor to morbidity and mortality in pregnancy and post-partum. While it has been established that adverse pregnancy outcomes (APOs) increase future maternal CVD risk, the factors predicting these pregnancy complications are less studied. Our primary objective is to report preliminary data from our cardio-obstetrics registry on the association between pre-conception cardiovascular risk factor burden and APO development. Given the relative sparsity of cardio-obstetrics patient data, we also aim to contribute patient demographics.

Methods: Utilizing retrospective chart review, we created a registry of patients evaluated at USF’s cardio-obstetrics program October 7, 2021-November 1, 2022. Charts were queried for demographics, pre-conception risk factors, and maternal-fetal outcomes. Risk factors included BMI>25 kg/m2, chronic hypertension, hyperlipidemia, pre-existing diabetes, tobacco use, sleep apnea, chronic kidney disease, autoimmune disease, advanced maternal age, and history of a prior APO. APOs were defined as intrauterine growth restriction (IUGR), hypertensive disorder of pregnancy (HDP), and pre-term birth (delivery <37 weeks). Statistical analysis included chi-square test and Fisher’s exact test for categorical variables and Mann-Whitney U test for continuous variables.

Results: Our analysis included 63 women, most commonly presenting with valvular or structural heart disease (33.3%), cardiomyopathy (28.6%), and arrythmias (15.9%). Throughout pregnancy and post-partum, 42 (66.7%) women did not experience any APO, while 21 (33.3%) did; 19 (30.2%) developed an HDP, 3 (4.8%) experienced IUGR, and 12 (19.0%) delivered pre-term. Race, ethnicity, age, gravidity, parity, gestational age at first cardio-obstetrics visit, and individual risk factors were not significantly associated with APO development. Analysis of risk factor burden showed the number of risk factors a woman had pre-conception was not a statistically significant predictor APO development (p=0.139). While the risk factor burden did not affect the overall incidence of APOs, patients who gave birth pre-term did have a significantly higher number of risk factors (p<0.001; 3.08 ± 1.00 pre-term, 1.69 ± 1.19 not pre-term), as did patients with chronic hypertension with superimposed HDP (p<0.001; 3.43 ± 0.79 with, 1.77 ± 1.21 without). 

Conclusion: Cardiovascular risk factor burden was not associated with APO development in pregnant women with CVD. Women who deliver pre-term may have a higher risk factor burden than those who deliver at term. Since pre-term birth is associated with future CVD in women independent of its cause, optimization of preconception cardiovascular health could help mitigate these risks in an already vulnerable high-risk population.

Next from AMA Research Challenge 2023

Prognostic Pupil Reactivity Markers within the first 72 hours of Traumatic Brain Injury

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