The safety and efficacy of transitioning from parenteral to oral antibiotics in patients aged less than 60 days with urinary tract infections were assessed. Patients who transitioned to oral therapy had a lower mean length of stay with no significant difference in medically attended urinary tract infection symptoms within 30 days of treatment.
Background: For young women who require cardiac valve replacement, the optimum prosthetic type for successful future pregnancy is not well established. Current data is limited to single-center studies and guidelines offer weak or no recommendations on valve selection. This study compares outcomes of pregnancy in women with mechanical valves (MHVs), bioprosthetic valves (BHVs), and valve repair. Methods: This was a retrospective analysis of 268 pregnancies in 222 women with a history of cardiac valve replacement or repair in California and New Jersey between 2005 and 2015. Each pregnancy was treated as a unique event. Patients were identified using state-run mandatory administrative databases which capture all inpatient, emergency department, and ambulatory surgery discharges. A multivariable logistic regression model with clustering by patient was used to identify factors associated with pregnancy loss, defined as spontaneous or induced abortion, fetal death, or maternal death prior to delivery. Covariates included maternal demographic characteristics and baseline comorbidities, time between most recent valve operation and pregnancy, year of pregnancy, and valve characteristics. Results: There were 64 pregnancies with MHVs present, 107 with BHVs, and 97 with repair only. Mean age at the time of first valve operation was 27.5 years (SD, 7.9 years; range, 11.2-53.7 years). Mean maternal age was 30.3 years (SD, 6.4 years; range, 15.6-54.9), with no significant difference between the three groups. Rates of spontaneous abortion for MHVs, BHVs, and repair were 32.8%, 8.4%, and 13.4%, respectively (p<0.0001), and rates of total pregnancy loss were 57.8%, 15.0%, and 22.7% (p<0.0001). After adjustment for covariates, the odds ratio for pregnancy loss with MHVs compared to BHVs was 5.3 (95% CI, 3.9-28.3) and 1.2 (95% CI, 0.9-6.2) with repair compared to BHVs. Other risk factors for pregnancy loss included maternal age ≥35 years and maternal hypertension. Conclusion: For women in the United States with mechanical heart valves, the risk of pregnancy loss is significant, with less than half of all pregnancies successfully progressing to delivery.
Introduction: In the US, ∼80,000 new cases of bladder cancer are diagnosed yearly, 4% of which present with metastatic disease (lymph nodes, liver, peritoneum, lung). Most bladder cancers are pure urothelial carcinoma (Uca). Metastatic spread to the biliary system and small bowel has been rarely described. We present a report of 3 patients with known urothelial carcinoma who presented with gastrointestinal (GI) metastasis. Case Description/Methods: Case 1: A 71-year-old male with Uca presented with cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) was done, subhilar biliary stricture found, brush cytology performed, biliary stent placed (Figure A). Endoscopic ultrasonography (EUS) revealed an ill-defined hypoechoic peribiliary mass. Fine-needle aspiration (FNA) cytology confirmed malignant cells from metastatic Uca. Case 2: A 63-year-old male with UCa presented with gastric outlet obstruction (GOO). Imaging revealed a possible pancreatic head mass. Biopsies of the duodenum were non-diagnostic initially. EUS-FNA of the pancreatic head mass revealed benign pancreatic cells. Endoscopy was repeated with extensive biopsies taken of a lumen obstructing externally infiltrating duodenal mass/stricture (Figure B) which confirmed poorly differentiated carcinoma consistent with metastatic Uca. A duodenal stent was placed. Case 3: A 68-year-old male with Uca with metastases to the liver and omentum presented with abdominal pain and biliary obstruction. ERCP was performed with biliary stent placement across the biliary stricture. Brush cytology revealed malignant cells of urothelial origin, representative of metastasis to the CBD (Figure C). Discussion: Metastatic Uca to the biliary tree and duodenum has been rarely reported. GOO from Uca is also unusual but may occur due to retroperitoneal, hepatic flexure or duodenal masses. Endoscopic evaluation can be challenging due to altered anatomy. This case series emphasizes several important points: i. In the appropriate clinical context, non-GI malignancies should be in the differential diagnosis when managing biliary obstruction and GOO. ii. Role of repeat endoluminal biopsy if initial effort is non-diagnostic. iii. Role of EUS-FNA for tissue sampling. iv. Role of ERCP and biliary stenting for palliation of biliary obstruction. v. Importance of an accurate pathologic diagnosis in a patient with suspected metastatic malignancy, given management and prognostic implications.Figure 1.: Figure A: Cholangiogram from ERCP for Case 1 demonstrating a high-grade subhilar biliary stricture Figure B: Infiltrating, obstructing duodenal mass with stricture secondary to urothelial carcinoma metastases in Case 2 Figure C: Cholangiogram from ERCP for Case 3 demonstrating a long stricture of the distal CBD and the mid CBD.
Objectives: Dandy-Walker malformation (DWM) is a common cerebellar malformation characterized by vermian hypoplasia with upward rotation, cystic dilatation of the fourth ventricle and elevated torcular.DWM can be diagnosed prenatally by fetal sonogram and/or magnetic resonance imaging (MRI).However, its associated neurodevelopmental abnormalities are variable and difficult to predict in prenatal counseling.We hypothesized that DWM have abnormalities beyond cerebellum and the posterior fossa, which may potentially impact neurodevelopmental variations.Methods: We retrospectively reviewed medical record and fetal MRIs of 15 fetuses with DWM.We performed post-acquisition regional volumetric fetal MRI analysis in 11 fetuses with DWM and 12 control fetuses to measure volumes of cortical plate, subcortical parenchyma, cerebellar hemispheres, and vermis.Growth trajectories between 18 and 33 weeks' gestation in each structure were modeled for each group.A logarithmic transform of the volume data was used before fitting the linear regression model.Intergroup measures were compared using ANCOVA. Results:The median (interquartile range) gestational ages of fetal MRI studies in 11 fetuses with DWM and 12 controls were 22.6 (4.3) weeks and 25.1 (9.2) weeks, respectively (p value = 0.31).
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