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Objective-We sought to determine predictors of adverse neonatal outcomes in women with intrahepatic cholestasis of pregnancy (ICP).Study Design-This study was a multicenter retrospective cohort study of all women diagnosed with ICP across 5 hospital facilities from January 2009 through December 2014. Obstetric and neonatal complications were evaluated according to total bile acid (TBA) level. Multivariable logistic regression models were developed to evaluate predictors of composite neonatal outcome (neonatal intensive care unit admission, hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, transient tachypnea of the newborn, mechanical ventilation use, oxygen by nasal cannula, pneumonia, and stillbirth). Predictors including TBA level, hepatic transaminase level, gestational age at diagnosis, underlying liver disease, and use of ursodeoxycholic acid were evaluated.Results-Of 233 women with ICP, 152 women had TBA levels 10-39.9 μmol/L, 55 had TBA 40-99.9 μmol/L, and 26 had TBA ≥100 μmol/L. There was no difference in maternal age, ethnicity, or prepregnancy body mass index according to TBA level. Increasing TBA level was associated with higher hepatic transaminase and total bilirubin level (P < .05). TBA levels ≥100 μmol/L were associated with increased risk of stillbirth (P< .01). Increasing TBA level was also associated with earlier gestational age at diagnosis (P< .01) and ursodeoxycholic acid use (P = . 02). After adjusting for confounders, no predictors were associated with composite neonatal morbidity. TBA 40-99.9 μmol/L and TBA ≥100 μmol/L were associated with increased risk of meconium-stained amniotic fluid (adjusted odds ratio, 3.55; 95% confidence interval, 1. 45-8.68 and adjusted odds ratio, 4.55; 95% confidence interval, 1.47-14.08, respectively).Corresponding author: Tetsuya Kawakita, MD. tetsuya.x.kawakita@gunet.georgetown.edu. The authors report no conflict of interest.Presented at the 35th annual meeting of the Society for Maternal-Fetal Medicine, San Diego, CA, Feb. 2-7, 2015. Conclusion-In women with ICP, TBA level ≥100 μmol/L was associated with increased risk of stillbirth. TBA ≥40 μmol/L was associated with increased risk of meconium-stained amniotic fluid. HHS Public AccessKeywords bile acid; intrahepatic cholestasis of pregnancy; neonatal outcome; ursodeoxycholic acid Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease in pregnancy characterized by pruritus, elevated total serum bile acids, and elevated liver enzymes. ICP is associated with increased risk of preterm birth (19-60%), meconium passage <37 weeks (17.9%), intrapartum nonreassuring fetal heart tracing (22-41%), respiratory distress syndrome (RDS) (29%), and stillbirth (0.75-7%). 1-4 Based on high rates of stillbirth and neonatal morbidity, early delivery is often advocated to reduce the risk of term stillbirth. In the absence of evidence-based guidelines for optimal timing of delivery, induction of labor at 36-37 weeks of gestation or after documenting fetal lung maturity is freque...

Objective We seek to characterize the prescribing patterns of opioids, opioid consumption, and pain severity after thyroid and parathyroid surgery. We also aim to determine if a relationship exists between preoperative medication use and postoperative pain or opioid consumption. Study Design Case series with chart review. Setting Academic university hospital. Subjects and Methods Medical records of 237 adult patients undergoing thyroid and parathyroid surgery were included. Clinicopathologic data were collected, including pain scores, preoperative medications, and inpatient pain medications. Results The mean maximum pain score was 5.74 and varied by surgery type (range, 0-10). Mean pain score decreased to 2.61 upon discharge (0-8) and to 0.51 at the first postoperative visit. Patients with a length of stay exceeding 1 day had significantly higher maximum pain scores than those with a length of stay of 0 or 1 day (8 vs 5.58, P < .001). Morphine milligram equivalents while in the hospital averaged 25.4 per day and were significantly influenced by preoperative opioid use (0-202). Acetaminophen/oxycodone was the most commonly prescribed opioid. The mean number of pills prescribed postoperatively was 43.1 (0-120). Conclusion In our population, patients are discharged with opioid prescriptions that may be in excess of their requirements following thyroid and parathyroid surgery. Preoperative opioid use was associated with higher postoperative pain score and, on multivariate analysis, greater inpatient opioid consumption. Further investigation is warranted to ensure that we are prescribing opioids appropriately following thyroid and parathyroid surgery.

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Vulvar lichen sclerosus (LS) is a dermatologic condition characterized by labial atrophy, hypopigmentation, and synechiae leading to pruritis and vulvar pain. Lichen sclerosus also is associated with a 3% to 9% incidence of vulvar squamous cell carcinoma that may be mitigated by adequate treatment. Inconsistent prescribing and patient intolerance have reduced the proportion of LS patients receiving criterion standard treatment with clobetasol propionate, a potent topical steroid with a reported range of efficacy between 66% and 96% and rate of complete remission between 23% and 54%. In case series, additional treatment with vulvovaginal fractionated carbon dioxide (CO 2 ) laser has improved 80% to 88% of refractory LS patients.This single-center randomized controlled trial aimed to compare fractionated CO 2 laser treatment with clobetasol propionate in terms of safety and efficacy for the treatment of vulvar LS. Postmenopausal, English-speaking women with pathologically confirmed LS were recruited from urogynecologic and gynecology academic medical center office visits. Eligible participants had LS symptoms corresponding to a score of 21 or higher on the Skindex-29 dermatologic symptom scoring system, indicating at least mild bother. Patients who had received prior LS treatments were not excluded. Participants underwent block randomization in a 1:1 ratio to either the topical clobetasol ointment arm or the laser arm. Participants in the clobetasol arm applied 0.05% ointment to the affected area nightly for 1 month, 3 times weekly for 2 months, then as needed. Participants in the laser arm underwent 3 office laser treatments 4 to 6 weeks apart. Data collection occurred at baseline, 6 months, and 12 months with multiple validated scales, surveys, and photo documentation. The primary outcome was change in mean Skindex-29 score at 6 months.Between October 2015 and July 2018, a total of 52 participants were enrolled in this study. A total of 27 women completed laser treatment and 6-month follow-up, whereas 24 completed clobetasol treatment and 6-month follow-up, with 1 dropout. No significant differences in socioeconomic factors, length of diagnosis, Skindex-29 scores, or treatment history existed between the 2 groups. Intention-to-treat analysis found greater improvement in Skindex-29 score among the laser group compared with the steroid group (laser −16.83 ± 18.09 vs steroid −5.92 ± 5.81; P = 0.007). Secondary outcomes including Skindex-29 subscale scores for emotion (laser −19.63 ± 21.92 vs steroid −6.77 ± 9.99; P = 0.011) and symptoms (laser −21.93 ± 22.18 vs steroid −4.91 ± 11.19; P = 0.002) showed a similar trend. When stratifying for previous clobetasol propionate treatment, the improvement in Skindex-29 overall score was only seen in the previously exposed group. The clobetasol propionate-naive group in general had less improvement than the previous use group. Secondary outcomes of physician assessment scores found a significant improvement in mean change of Vaginal Health Index scores between baseline and 6 m...

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Background and ObjectiveThe brain is an unusual site for distant metastases of differentiated thyroid carcinoma (DTC). The aim of this study was to document the prevalence of brain metastases from DTC at our institutions and to analyze the current therapies and the outcomes of these patients.MethodsWe performed a retrospective chart review of patients with DTC and secondary neoplasia of the brain.ResultsFrom 2002 to 2016, 9514 cases of thyroid cancer were evaluated across our institutions and 24 patients met our inclusion criteria, corresponding to a prevalence of 0.3% of patients with DTC. Fourteen (58.3%) were female and 10 (41.7%) were male. Fifteen patients had papillary thyroid cancer (PTC) (62.5%). Brain metastases were diagnosed 0 to 37 years (mean ± SD, 10.6 ± 10.4 years) after the initial diagnosis of thyroid cancer. Patients undergoing surgery had a median survival time longer than those that did not undergo surgery (27.3 months vs 6.8 months; P = 0.15). Patients who underwent stereotactic radiosurgery (SRS) had a median survival time longer than those that did not receive SRS (52.5 months vs 6.7 months; P = 0.11). Twelve patients (50%) were treated with tyrosine kinase inhibitors (TKIs), and they had a better survival than those who have not used a TKI (median survival time, 27.2 months vs 4.7 months; P < 0.05).ConclusionThe prevalence of brain metastases of DTC in our institutions was 0.3% over 15 years. The median survival time after diagnosis of brain metastases was 19 months. In our study population, the use of TKI improved the survival rates.