Torrance Memorial Medical Center

Previous single-center studies conducted in the United States in women with suspected preeclampsia indicated that serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio values of >38 measured on a widely available Elecsys immunoassay platform during the third trimester of pregnancy predicted the development of preeclampsia with severe features and adverse outcomes within 2 weeks of testing. This study aimed to validate the Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test for the prediction of preeclampsia with severe features in a United States population using the prospective Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification cohort that recruited women with a hypertensive disorder of pregnancy (gestational hypertension, chronic hypertension, de novo and superimposed preeclampsia) across 18 tertiary and community hospitals throughout the United States. We measured soluble fms-like tyrosine kinase 1-to-placental growth factor ratios using the Elecsys platform in archived serum samples from the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study that recruited hospitalized women with a hypertensive disorder of pregnancy between 23 0/7 and 34 6/7 weeks of gestation. The primary study outcome was prediction of preeclampsia with severe features within 2 weeks after testing. The secondary outcomes included a composite of adverse maternal and fetal/neonatal outcomes and prediction of delivery within 2 weeks. In the validation cohort of the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study (556 enrollments), the serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 67% positive predictive value (95% confidence interval, 61-73) and a 95% negative predictive value (95% confidence interval, 92-97) for the progression to preeclampsia with severe features within 2 weeks. Among women at <30 weeks of gestation (n=188), serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 78% positive predictive value (95% confidence interval, 68-86) and a 100% negative predictive value (95% confidence interval, 96-100) for the progression to preeclampsia with severe features within 2 weeks. The Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test performed better than standard-of-care clinical measures, with an area under the receiver operating characteristic curve of 0.92 (95% confidence interval, 0.89-0.90) for soluble fms-like tyrosine kinase 1-to-placental growth factor ratio vs <0.70 for standard-of-care tests, such as liver enzymes, platelet count, and serum creatinine (P<.001). Compared with women with a ratio of ≤38, those with a ratio of >38 had a higher risk of developing adverse maternal (relative risk, 4.9 [95% confidence interval, 2.6-9.9]; P<.001) and fetal/neonatal (relative risk, 3.2 [95% confidence interval, 2.6-4.0]; P<.001) outcomes and were more likely to deliver within 2 weeks (adjusted hazard ratio, 3.3 [95% confidence interval, 2.7-4.0]; P<.001). The soluble fms-like tyrosine kinase 1-to-placental growth factor ratio of >38 measured on the Elecsys platform predicted the development of preeclampsia with severe features, delivery, and adverse maternal and fetal/neonatal outcomes within 2 weeks of testing among preterm pregnant women hospitalized with a hypertensive disorder of pregnancy.

Reduced POUR: Chloroprocaine in TJA Chloroprocaine is emerging as a short-acting alternative to bupivacaine for spinal anesthesia in joint arthroplasty. In this retrospective matched cohort study, 50 patients undergoing primary total hip or knee arthroplasty with chloroprocaine were matched to 50 patients receiving bupivacaine. Outcomes included postoperative day 0 ambulation, postoperative urinary retention, and 90-day readmission. Chi-square tests and multivariable logistic regression were used for analysis. Urinary retention was significantly lower with chloroprocaine compared to bupivacaine (4% vs. 22%; p = 0.007). No significant differences were observed in postoperative day 0 ambulation or 90-day readmission rates. Secondary analysis identified younger age as a predictor of early ambulation, while procedure type was associated with reduced urinary retention. Spinal anesthesia with chloroprocaine was associated with a significantly lower incidence of postoperative urinary retention compared with bupivacaine and may be advantageous for patients at risk of this complication.

<title>Abstract</title> Background Emergency department (ED) misuse remains a persistent problem for healthcare organizations. How leaders perceive the causes and solutions to this issue strongly shapes their strategic responses. This study explores the alignment between senior leadership's perceptions and evidence about ED misuse reduction at a community health system serving a diverse, safety-net population. Methods A cross-sectional exploratory survey of senior managers (N = 47) at a mid-sized community health system in Southern California, was conducted between June 13–27, 2025. This exploratory analysis identified potential areas of perception-data divergence that warrant further investigation in larger samples with sufficient statistical power. Results Three areas of difference emerged between leadership perspectives and operational data. First, leaders identified mental health and substance abuse as primary drivers of ED misuse; however, institutional data show these issues accounted for only 8.3% of all ED visits between 2022 and 2024. Second, while 73.2% of survey respondents reported Human Resources (human factor) influence priority-setting, 55% of leaders cited an insufficient workforce as a barrier to establishing effective priorities. Third, although 55.2% of leaders reported confidence in their ability to discontinue ineffective programs, only one-third reported frequent success with de-implementation. These differences were accompanied by modest ratings in organizational data use capabilities. Conclusions While leadership perceptions diverged from institutional data, these differences may reflect resource intensity considerations not captured in utilization statistics alone. A mid-sized community health system could benefit from enhanced data analytics and formal processes to routinely check leadership perceptions before committing resources to priority initiatives.

The gut microbiome has been the subject of increasing interest as integral to our health. Few realize that the enormous benefits of vitamin D (VD) and magnesium (Mg) are highly dependent on a healthy gut microbiome. Short chain fatty acids, especially butyrate, reflect not only a healthy gut microbiome but also VD status. Suboptimal VD, Mg, or butyrate translates to some degree of gut dysbiosis and vice versa. Mg dependent secondary bile acids, indoles, and tryptophan, all microbial metabolites and longevity agents, are also discussed. Mg is indispensable to not only the synthesis of the active form of VD but also that of 7-dehydrocholesterol (7-DHC) from acetate. 7-DHC is the substrate for solar conversion to D3. The steadily increasing Ca:Mg in the Western diet and its troubling impact on parathormone (PTH) is discussed. Gut dysbiosis further complicates this. A model addressing the seemingly contradictory reports regarding calcium, magnesium, and VD efficacy among disparate groups is presented. Biochemical and physiologic interlinkages are legion and most remain hidden. This limited mini review exposes insight into the tight linkage between 25(OH) D3 and Ca:Mg, facilitated by the gut microbiome. A model incorporating the physiologically discordant but reinforcing effects on this linkage based on genes, culture, socioeconomic status, and diet is proposed.

Magnesium (Mg) is not prominent among the list of well known anti-aging agents. Yet the signs and symptoms of aging mimic those of Mg deficiency. Mg is required for nearly a thousand enzymatic reactions. This narrative review does not correlate Mg status with clinical data on agents linked to longevity. The approach is more novel and highlights specific Mg dependent physiologic reactions required by these longevity linked biomarkers. Many of these share common pathways to extend healthspan. Mg is a required cofactor in the synthesis of vitamin D and melatonin and activation of six of the eight B vitamins. It is a required cofactor for all CYP450 enzymes. It is directly responsible for the appropriate methylation of proteins and DNA, which control the epigenome. The MTHFR (methylenetetrahydrofolate reductase) 677T allele that compromises methylation is present in a majority of Americans. Aberrant methylation predicts the severity of Covid-19 and its persistence into long Covid. Mg is a silent benefactor that may indirectly link these longevity agents, but only if viewed in context with calcium (Ca), i.e., Ca:Mg. Both compete for the same receptor. To fully exploit these longevity agents sufficient Mg is required. The pertinent physiology is presented, although cause and effect awaits publication of supporting clinical data.

Abstract BackgroundExisting enhanced recovery after cesarean delivery (ERAC) professional society recommendations lack intersociety collaboration, multidisciplinary expert input and involvement of patient stakeholders. This initiative aimed to develop a multidisciplinary set of ERAC interventions endorsed by relevant US professional societies and patient representatives.MethodsThis American Society of Anesthesiologists (ASA) and American College of Obstetricians and Gynecologists (ACOG) led initiative received IRB approval from Stanford University. In total 19 stakeholders were invited to participate in this Delphi study, including 13 representatives from 8 US professional societies (American Society of Anesthesiologists (ASA - 1 representative), Society for Obstetric Anesthesia and Perinatology (SOAP - 2), American College of Obstetricians and Gynecologists (ACOG - 4), Society for Maternal Fetal Medicine (SMFM - 1), Society of OBGYN Hospitalists (SOGH - 1), Enhanced Recovery After Surgery Society (ERAS Society - 1), Association of Women’s Health Obstetric and Neonatal Nurses ((AWHONN -2), American Association of Nurse Anesthesiology (AANA - 1), a physical therapist, a lactation expert and 4 patient representatives from diverse backgrounds. A three-round modified Delphi approach was conducted (2 rounds of electronic questionnaires and a 3rdround of e-discussion), to produce the final set of ERAC recommendations. An initial list of 70 interventions was compiled based on a previously published systematic review of ERAC studies and professional society guidelines/recommendations (ERAS Society, SOAP, and Healthcare Canada). Consensus was obtained for the final list of interventions, with strong consensus defined as ≥70% agreement and weak consensus as 50–69% agreement.ResultsAll professional societies that were approached provided content-expert stakeholders to participate, and all stakeholders completed all rounds of the Delphi process. A final set of 32 interventions (6 preoperative, 13 intraoperative and 13 postoperative) achieved strong consensus.ConclusionsThis US intersociety and multidisciplinary Delphi study resulted in a list of ERAC interventions, which should be considered when implementing ERAC within US labor and delivery units.

Pulmonary thrombectomy for acute pulmonary arterial embolism has emerged as an effective endovascular therapy for high-risk patients. While the procedure is typically performed safely and efficaciously, given the nature of the treatment, complications may rarely occur. Pulmonary pseudoaneurysm is a rare condition occurring in a variety of settings, including pulmonary thrombectomy. To our knowledge, we present the first published case of pulmonary artery pseudoaneurysm following percutaneous thrombectomy, along with its successful endovascular management.