Iris Publishers- Open access Journal of Urology & Nephrology | Unexplained Recurrent Nocturnal Urethral Bleeding: An Unusual Presentation of Penile Fracture

 

Authored by Mukesh Chandra Arya*

Abstract

Introduction: Penile fracture is an emergency condition. Common presentation is classical history of trauma to erect penis followed by detumescence, penile swelling, ecchymosis and discoloration. Management is primarily surgical. We report our experience of such cases including a subgroup of patients with unexplained recurrent nocturnal urethral bleed without penile swelling and normal voiding.

Material and methods: This a retrospective study performed at our institution. Records of penile fracture cases managed over last 6 years were reviewed. Total of 63 patients were managed either by surgical (53 patients) or conservative (10 patients) approach. Sexual outcomes were measured with abbreviated International Index of Erectile Function (IIEF 5) questionnaire and compared with preoperative scores.

Results: Most common aetiology was coital trauma, seen in 88.9 % of patients. Mean age was 34.95 years. Urethral injury was present in 5 (9.4%) patients in the surgical group. Most common site of injury was ventrolateral {32 (60.4%)} over proximal shaft {49 (92.5%)}. Mean follow up was 19.27 months ranging from 6 to 41 months. Erectile function was preserved (no deterioration in IIEF 5 category) in 96.3 % and 100% of patients from surgical and conservative groups.

Conclusion: Unexplained recurrent nocturnal urethral bleed as a presentation of penile fracture, should be kept in mind. Such peculiar presentation, to our knowledge, has not been reported in literature. This subgroup of patients can be managed conservatively with good sexual and voiding functional outcome.

Keywords: Nocturnal urethral bleed; Penile fracture; Conservative management; Erectile dysfunction

Abbreviations: IIEF: International Index of Erectile Function; ED: Erectile Dysfunction

Introduction

Penile fracture is an emergency urological condition defined as rupture of tunica albuginea of corpora cavernosa because of trauma to erect penis as a result of sudden increase in intra-corporeal pressure. Typically it occurs during coitus when the phallus strikes against the pubis or perineum of partner producing a buckling injury [1]. It can also occur during self-manipulation, rolling over or falling onto erect penis or due to practice of “taqaandan” [2,3]. Patient usually describes a “cracking” or “popping” sound followed by detumescence, pain, swelling and discoloration of penile shaft. If the Buck’s fascia remains intact the hematoma is limited to shaft. If it is also disrupted the hematoma can reach to perineum and suprapubic area. Diagnosis is clinical and management is primarily surgical. We report our experience of managing penile fracture cases over last 6 years with especial impression upon a group of patients having an unusual clinical presentation with unexplained recurrent nocturnal urethral bleeding without penile swelling.

Materials and Methods

Introduction

This is a retrospective analytical study of cases of penile fracture treated at our institution from August 2014 to September 2019. Patients with penile fracture with diagnosis based on classical history of trauma on erect penis followed by sudden detumescence were included. They underwent routine hematology and biochemistry investigations. Pretrauma erectile function was documented using IIEF 5 questionnaire. They were managed either with surgery (N=53) or conservative treatment (N=10).Patients with minimum 6 months follow up were included. Patients with false penile fracture due to rupture of dorsal vein were excluded. Dorsal venous injury could be differentiated from penile fracture as the former does not lead to sudden detumescence, patient can cohabitate further and the site of hematoma being limited to dorsal surface of penis. Data was retrieved from institutional registry of penile fracture patients. Diagnosis of the condition was virtually clinical. Institutional protocol is of emergency repair of such cases without any delay. Conservative management was opted in a special subgroup of patients who presented with unexplained recurrent nocturnal urethral bleeding and either not diagnosed or misdiagnosed and treated for hematuria of unknown cause before being referred to us. This treatment plan was based on shared decision making. On enquiring further these patients had classical history of sexual trauma with “popping” sound and sudden detumescence but no penile swelling. The temporal association of proper history with their symptoms helped us to clinch the diagnosis. Classically all of them had no penile swelling and were voiding well. To document tunical rupture in this subgroup, imaging studies were performed. Ultrasound of penis in 8 /10 cases confirmed the diagnosis. MRI documented it in the remaining 2 cases. Conservative management included compressive dressing, Foley catheterization, antibiotics, anti-inflammatory and antierotic drugs (conjugated estrogen 0.625 mg PO twice daily for 1 week). Many of them refused admission and were managed on outpatient basis. The catheter was kept for 7 days. The surgical management included penile exploration under anaesthesia by a circumcoronal incision, penile degloving, inspection of corporeal tear, repair with delayed absorbable sutures (using PDS 3-0 with knots buried inside) followed by repair of Buck’s fascia over it and circumcision at conclusion of procedure. Circumcoronal incision allowed survey of whole penile shaft and also avoided overlying suture lines with sound healing. Delayed absorbable suture provides ample time for corporeal and tunical tissue to heal without abnormal feeling of knot post operatively. If Bucks fascia is intact and exploration is being performed, one can reach the site of tunic tear only after incising the fascia. Foley catheter was kept and compressive dressing applied. Concomitant urethral repair was undertaken if found injured except in one case in which the repair was staged. Apart from postoperative antibiotics (third generation Cephalosporin and aminoglycoside), anti-inflammatory drugs all patients were given conjugated estrogen 0.625 mg PO twice daily for 1week to prevent erections and advise was given to refrain from sexual activity for 6 weeks. Patients who had not undergone urethral repair were discharged on post-operative day 2nd after removal of dressing and Foley catheter. Catheter was kept for 2 weeks if urethral repair was contemplated. Follow up included history for any voiding or sexual symptoms and local physical examination. Erectile function was assessed at 6 months with IIEF 5 score [4].

Result

Total of 63 patients were included in the study. Mean age was 34.95 years ranging from 18 to 60 years. Most common mode of injury was coital trauma in 88.9 % of patients. Presentation was in different combinations of “popping” sound, sudden detumescence, penile swelling, ecchymosis, deviation and urethral bleed (Table 1).

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Iris Publishers- Open access Journal of Nutrition & Food Science | Contamination Status of Polycyclic Aromatic Hydrocarbons (PAH s) In Atmospheric Particulate Matter PM2.5 Samples of a Semi-Residential Area of Dhaka, Bangladesh

 

Authored by YN Jolly*

Abstract

This study deals with the determination of the polycyclic aromatic hydrocarbons (PAHs) in the atmospheric particulate matters (PM2.5) at a semi residential site of Gazipur, Dhaka, Bangladesh. Source identification and possible human health impact of polycyclic aromatic hydrocarbon was evaluated as well. A total of 20 samples were collected in six weeks period of time. Polycyclic Aromatic Hydrocarbons (PAH’s) were determined using gas chromatography-mass spectrometry. The average concentration of Anthracene, Phenanthrene, Pyrene, Chrysene, Benzo (a) anthracene, Benzo(a)pyrene, perylene were found to be 0.309, 0.159, 0.227, 2.120, 1.954, 2.269 and 3.373μgm-3 respectively. Two-way ANOVA test revealed that the concentration of different PAHs species (Fcal> Fcrit) are significantly different from each other at a 95% confidence level. The main contributory sources for PAHs were found gasoline exhaust, diesel exhaust, wood burning and brick kilns. The result revealed that these compounds are present in a higher level in the atmosphere when compared with the value of other countries in the world. Concentration of highly carcinogenic Benzo(a) pyrene was in a range where carcinogenic effect is an immediate threat in case of long-time exposure and hence regular monitoring is suggested.

Keyword: Polycyclic Aromatic Hydrocarbon; Air-Metrics Mini-Vol Samplers; Gas Chromatography-Mass Spectrometry; Quartz Filters

Introduction

Polycyclic aromatic hydrocarbons (PAHs) are organic compounds consist of two or more fused benzene rings in a linear or cluster arrangement, typically found as a complex mixtures [1]. They are very stable organic pollutants that are made up of only carbon and hydrogen and occur naturally but, they can be synthesized as individual compounds for research purposes. Furthermore, they have high boiling and melting points with high molec ular weights and are able to survive at high temperatures from the combustion of fuel from automobiles and airplanes engines and most of them have low water solubility [2]. Polycyclic aromatic hydrocarbons (PAHs) are considered ubiquitous in the environment and can be formed from either natural or manmade combustion sources [3]. The dominant sources of PAHs in the environment are thus from human activity: wood-burning and combustion of other bio-fuels etc., and wildfires are another notable source. Dungor crop residues contribute more than half of annual global PAHs emissions, particularly due to bio fuel use in India and China (Anita and Maharaj,2004), industrial processes and the extraction and use of fossil fuels made up slightly more than one quarter of global PAHs emissions, dominating outputs in industrial countries such as the United States. Lower-temperature combustion, such as tobacco smoking tends to generate low molecular weight PAHs, whereas high-temperature industrial processes typically generate PAHs with higher molecular weights [4].

Atmospheric PAHs are distributed (Figure 1) between the gas and particulate phases depending on their physicochemical properties. They can be transported through the atmosphere over long distances. Polycyclic Aromatic hydrocarbons are emitted into the atmosphere either as vapors or associated with primary aerosol particles. Once enters in the atmosphere, the residence times and ultimate fates of these semi volatile chemicals depend upon their distributions among vapor, particle, and droplet phases. The atmospheric chemical and photochemical reactions of PAHs are of great importance because the decomposition product of the PAHs may be more hazardous to human health than the PAHs from which they were derived [5]. A number of experimental studies have demonstrated that many PAHs are susceptible to photochemical and/or chemical oxidation under simulated atmospheric conditions [6]. Nitro PAHs are emitted as a result of incomplete combustion processes.

PAHs have been linked to different cancers in well-established animal model studies [7]. The structure of a PAH influences whether and how the individual compound is carcinogenic [8]. Some carcinogenic PAHs are genotoxic and induce mutations that initiate cancer; others are not genotoxic and instead affect cancer promotion or progression [9] and hence continued research regarding the mutagenic and carcinogenic effects from chronic exposure to PAHs and metabolites is needed. Other than carcinogenic, adult exposure to PAHs has been linked to cardiovascular disease as well [10]. PAHs are among the complex suite of contaminants in tobacco smoke and particulate air pollution and may contribute to cardiovascular disease resulting from such exposures [11]. laboratory experiments, animals exposed to certain PAHs have shown increased development of plaques (atherogenesis) within arteries [12]. Oxidative stress following PAH exposure could also result in cardiovascular disease by causing inflammation, which has been recognized as an important factor in the development of atherosclerosis and cardiovascular disease [13,14]. Biomarkers of exposure to PAHs in humans have been associated with inflammatory biomarkers that are recognized as important predictors of cardiovascular disease, suggesting that oxidative stress resulting from exposure to PAHs may be a mechanism of cardiovascular disease in humans [15]. Multiple epidemiological studies of people living in Europe, the United States, and China have linked in uterus exposure to PAHs, through air pollution or parental occupational exposure, with poor fetal growth, reduced immune function, and poorer neurological development, including lower IQ.

As PAHs are known to have carcinogenic, mutagenic and teratogenic properties, their persistence in the environment have been placed them on the list of priority pollutants by the United States Environmental Protection Agency (US-EPA) and also the European Environment Agency [16]. People from all over the world are concerned more about the air pollution aspects due to the increased rate of mortality and morbidity and also multifarious effects of particulate pollution and we are not out of it. In this regard it is imperative to have a systematic study ascertaining the facts concerning the nature, sources, and trends of the particulate pollution in our beloved city, Dhaka, Bangladesh.

Gazipur area of Dhaka, Bangladesh is known to have moderately dense in population with high traffic and other industrial establishments like garments factories etc. There are several brick kilns in and around the area; more over there is a very busy rail station. Different types of industrial and regular activities are there responsible to contribute a lot carcinogenic aromatic polycyclic hydro carbons in the air of that area that ultimately affects local habitants as well as the visitors. Present study therefore sketched to determine the polycyclic aromatic hydrocarbon concentration in the atmospheric particulate matters collected from Gazipur, Dhaka, Bangladesh, identification of possible sources and human health impact. The main objectives are therefore:

• Determination of the polycyclic aromatic hydro-carbons concentration in the atmospheric particulate matters of Gazipur air

• Identification of the source of the polycyclic aromatic hydrocarbon in the atmosphere.

• Understanding the possible human health impact of polycyclic aromatic hydrocarbon.

Materials and Methods

Sampling site

Air samples were collected from Gazipur area of Dhaka, Bangladesh, which is a residential area of moderate population density. The sampling location is within 20 m from a local road and about 200m from a secondary roadwith moderate traffic density. The highway of Joydeb puris a very busy traffic point, which is about 5 km west to the studied site. Joydebpur rail station, through which daily 60 trains pass away, is about 100m away from the sampling location. At “Konabari” and “Kodda” which are about 5 to 7 km to the north-west of the sampling site, more than 100 brick kilns are there in production using kindle wood. There are also many garments and other industrial units at 4 to 7 km distance from this site (Figure 2).

Samples collection and preparation

PM2.5 (particulate matter) sampling was started from 13 January 2014 by Air-Metrics Mini-Vol samplers at Joydebpur (Gazipur), Dhaka, Bangladesh. And the samplers were placed on the flat roof of the continuous air monitoring station (CAMS-4) site of Clean Air and Sustainable Environment (CASE) project, Gazipur city corporation central symmetry, at 20 feet height from the ground level. The amount of air passed was maintained at 7.2m3.PM2.5 was collected simultaneously for every 24 hours (from 10 a.m. to 10 a.m. of the next day) at the sampling site. The pre-weighted conditioned clean filters (quartz) were loaded to respective filter holder assembly at the conditioning room of CAMS. After sampling, filter holder assemblies (keeping the exposed filters inside) were brought to the conditioning room of the Atomic Energy Centre (AEC), Dhaka, directly from the sampling site for conditioning and PM filter retrieval. Special care was taken in transporting the exposed filter holder assemblies, so that there should be no PM loss.PM2.5 masses were measured in the Atmospheric and Environmental Chemistry Laboratory of Chemistry Division of the Atomic Energy Centre (AECD), Dhaka and preserved under 4°C temperatures. The aerosol sample having PM2.5 was determined by weighing filter before and after exposure using a micro balance. The difference in weights for each filter was calculated and the mass of each PM2.5 sample thus determined.

Extraction of Samples

The particulate PAHs containing sample was weighed and taken into the volumetric flask, then about 30 ml dichloromethane (DCM solvent solution) was added to dissolve the PAHs, kept for 24 hours then sonicated. After sanitations the extract was filtered through what man filter paper and collected in a clean volumetric flask. Special attention was given to avoid loss of extract. Silica clean up column was prepared and the samples were passed through the column and collected. The total solution was concentrated using liquid nitrogen gas to 1-2 ml and transferred into a GC vial for analysis.

Preparation of standard PAHs solution

A known amount of PAHs was dissolved in definite amount of solvent (dichloromethane) to prepare 5 ppm PAHs standard solution of Phenanthrene, Anthracene, Pyrene, Chrysene, 1.2-benzanthracene, Perylene, Benzo-a-pyrene, marked with individual identification number and was stored in the refrigerator. The quantitative determination of PAHs has been done by external calibration curve method. The calibration curve of each compound is prepared with known concentrations of the compound prepared and run through GC-MS. Standard curve for each compound is generated by plotting the area vs. the concentration range for corresponding samples. Over this concentration range, the linear regression analysis of peak areas (y) in function of concentration (x), calculated by least square method. Calibration curve for each compound is presented in (Figure 3).

Chromatogram of a standard PAHs solution

The GC column temperature program employed was 400C to 2800C, started from 400C with holding time 1 min and then raised to 1600C at 100C min-1 ramping and finally the temperature raised to 2800C at 150C min-1 ramping. The injector and detector temperature were 2500C and 2800C respectively. The difference in the chemical properties between different molecules in a mixture and their relative affinity for the stationary phase of the column will promote separation of the molecules as the sample travels the length of the column. The molecules are retained by the column and then elute come off from the column at different time (called the retention time), and this allows the mass spectrometer downstream to capture, ionize, accelerate, deflect, and detect the ionized molecules separately. The mass spectrometer does this by breaking each molecule into ionized fragments and detecting these fragments using their mass-to-charge ratio. So, the components have been separated and detected through their retention time and quantified the area through their charge to mass ratio. The retention time of standard solution is 21.59, 21.75, 25.79, 29.40, 29.51, 33.23 and 33.45 min for Phenanthrene, Anthracene, Pyrene, Chrysene, Benz[a]anthracene, Perylene, Benzo[a]pyrene respectively.

Result and Discussion

Analysis of different PAHs in PM2.5 samples

Distribution of different PAHs revealed that the concentrations vary from time to time depending on the trend of air flow. In general, concentration of total PAHs is easily affected by location and seasonal variation. Besides local sources of PAHs, in both urban and rural areas, transport of PAHs through atmosphere can play a large role. The highly carcinogenic benzo[a]pyrene was normally found in the range of 1-20 ng/m3 in Europe, and around 1 ng/m3 in the USA. For other PAHs, individual concentrations were generally in the range of 1-50 ng/m3 in Europe, 0.1-1 in North and South America and in Australia, 1-10 in Japan, and 10-100 in two towns in India and New Zealand [17]. The measured concentration of Phenanthrene, Anthracene, Pyrene, Chrysene, 1,2- Benzanthracene, Perylene, Benzo-a-Pyrene are presented in (Table 1).

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Iris Publishers- Open access Journal of Iris Journal of Nursing & Care | The Evolution of Nursing Faculty During Unprecedented Times

 

Authored by Tori Canillas-Dufau*

Abstract

With the arrival of the COVID-19 pandemic, nursing education has made unprecedented rapid changes in policy and procedure directly impacting faculty, students, and didactic, clinical, and skills laboratory instruction. There has been a constant ebb and flow in the development of government mandates, accrediting body guidelines, clinical partnering organizational protocol, and infection control procedures all aimed at reducing the spread of the Coronavirus. As a result, nursing faculty have had to evolve as well. In this rapid transition, nursing faculty have had to quickly learn and apply online course design, and have done so with unwavering student-centered dedication and astonishing speed. Even prior to the pandemic, nursing students had consistently reported high levels of anxiety, self-doubt, and stress during their nursing education programs. These feelings have only been magnified during these times of uncertainty and have also negatively impacted students’ sense of self-efficacy. However, nursing faculty have been instrumental in helping students to handle these recent losses and adapt to the new “normal.” Hence, nursing faculty interaction with students has “expanded” to include purposeful focused behaviors and strategies that not only encourage and support students, but also reduce their perceived stress and develop and sustain student self-efficacy through periods of great change and loss. The evolution of nursing faculty during this pandemic has been characterized by incredible resourcefulness, unrelenting dedication, and selfless compassion in how instruction is delivered, and in interactions with a diverse, multigenerational nursing student population at a deeper level of connectedness.

Introduction

Historically, nurses have served in a variety of different arenas from community-based and home care settings to acute and ambulatory care settings. To this end, within the highly specialized area of nursing education, and despite a shortage of qualified nurse educators, it has been the nursing faculty that have consistently prepared future nurses to continue the tradition of the provision of safe, quality nursing care and service.

Nursing education leadership and nursing faculty must respond to Boards of Nursing mandates, health care industry needs, and societal trends in shaping and revising curriculum and implementing teaching strategies to best meet the needs of an everchanging and diverse, multigenerational student population. However, with the arrival of the COVID-19 pandemic and its subsequent changes to daily life, nursing education leadership has had to make a number of unprecedented rapid changes in policy and procedure directly impacting faculty, students, and didactic, clinical, and skills laboratory instruction. Additionally, with COVID-19 as the impetus, there has been a constant ebb and flow in the development of government mandates, accrediting body guidelines, clinical partnering organizational protocol, and even infection control procedures all aimed at reducing the spread of the Coronavirus. As a result, nursing faculty have had to evolve as well.

Nursing Faculty Role Evolution

Traditionally, like most nurses, nursing faculty have worn many hats and have a number of very specific responsibilities unique to serving in an educational setting. It is important to note that according to the American Association of Colleges of Nursing (AACN) Fact Sheet: Nursing Faculty Shortage, the average age of nursing faculty ranges from 50.6-62.4 years dependent upon their level of academic preparation and rank held (AACN, 2019) [1]. Regardless of the type of academic program, or the level of educational destination (e.g., vocational, prelicensure, graduate, or doctoral), in addition to scholarly activity and service to the institution, one of the main responsibilities of nursing faculty to students is the facilitation and evaluation of learning and instructional delivery in the classroom, clinical, and/or online settings.

As a direct result of the current pandemic, the nursing faculty role has evolved and nursing faculty have had to make two very rapid changes in how students are served. These two obvious and immediate changes are: 1) how instruction is delivered; and, 2) how nursing faculty interact with students. These essential and necessary changes have re-emphasized the importance of the role of nursing faculty in nursing student success.

Instructional Delivery Transition

Although the use of technology has been quite commonplace in the nursing classroom, nursing skills laboratory, clinical site, and online learning environment, its frequency of use and how it is utilized have had to change. Prior to the pandemic, although not required, it was not unusual to find the use of technology and a variety of different software applications used to enhance learning in the nursing classroom setting. Software applications such as Kahoot! PowerPoint, Prezi, Socrative, and Whiteboards were widespread among nursing faculty.

In the clinical setting and in preparing nursing students for transition to the clinical setting, the use of mock electronic health records, interactive manikins, and low and high-fidelity simulation have become very popular in nursing education skills laboratories. In the online learning environment, seasoned online nursing faculty have been utilizing various learning management systems and e-learning platforms such as Blackboard, Canvas, and Moodle for years.

With social distancing requirements and in light of safety concerns for students and faculty, nursing programs around the country have opted to not only postpone most clinical rotations involving direct patient care assignments, but also on-campus classroom meetings. Creative options for both classroom instruction and clinical practice education that would be acceptable to Boards of Nursing, accrediting bodies, and industry were required almost overnight. Thereby, forcing the evolution of nursing faculty requiring no-choice in the use of technology and digital tools for both didactic and clinical instruction.

At the unified request of Deans of Nursing, Nursing Program Directors, and other nursing education program leadership, Boards of Nursing gave temporary approvals to methodically increase simulation instruction hours to meet on-site clinical practice hours. Yet, in spite of several researchers having documented nursing faculty resistance and barriers to the use of technology in the past [2-5], nursing faculty did not hesitate to rise to the occasion. Those nursing faculty that had not previously utilized simulation responded quickly by taking and completing courses on simulation in order to meet this need. Those nursing faculty that had previously utilized simulation volunteered to collaborate, mentor, and support their novice colleagues. For didactic instruction, experienced nursing faculty who had previously taught online would have little difficulty during the pandemic in meeting students’ learning needs in terms of the use of technology, setting up the online course, and facilitating the course. Conversely, nursing faculty that had either taught hybrid courses or nursing faculty that had taught only faceto- face courses who may have lacked digital literacy were instantly challenged with moving instruction to an online delivery model. In this rapid transition, these nursing faculty had to quickly learn and apply online course design, and have done so with unwavering student-centered dedication and astonishing speed. Subsequently, countless nursing faculty are now utilizing virtual classroom solutions like Adobe Connect, Google Classroom, Newrow Smart, WizIQ, and Zoom for the very first time.

Nursing Faculty and Student Interaction

Even prior to the pandemic, nursing students had already consistently reported experiencing high levels of anxiety, selfdoubt, and stress at different stages of various levels of nursing education programs [6-9]. These feelings plague nursing students whether they are new to an undergraduate prelicensure program, in the middle of their program, graduating seniors, or even studying at the graduate or doctoral levels. In spite of where the student is in their nursing education, these feelings have only been magnified during these times of uncertainty and have also negatively impacted students’ sense of self-efficacy. A positive, strong self-efficacy has been correlated to human accomplishment and maintenance of psychological well-being [10].

Adding to these feelings of anxiety and self-doubt, some nursing students may have never even taken an online course before this seemingly overnight mandatory transition to remote learning. However, one well documented constant significant to increasing nursing student self-efficacy and improving nursing student success is the positive and supportive relationship between nursing faculty and nursing students; and, this is especially critical in nursing students of color [11-12]. Therefore, how nursing faculty interact with students to manage such feelings and improve student’s selfefficacy has also had to evolve.

During this uncertain time, it clearly became the role of the nursing faculty to not only serve as the instructional guide and learning facilitator, but also to be a more obvious role model, mentor, and counselor for students both collectively and individually. Nursing students were now forced to deal with abrupt changes related to the added stress of classes moving online, alternate methods of clinical training, and in some cases delayed program completion. Yet, students have had very little time to grieve the loss of the way things were and adapt to these new stressful changes. There is a clear inverse relationship between nursing students’ perceived stress and self-efficacy, and these stressors compromise students’ self-efficacy and their ability to complete their educational program [13-14]. Thus, nursing faculty are instrumental in helping students to handle the losses and adapt to the “new normal.” Hence, nursing faculty interaction with students has expanded to include purposeful behaviors that not only encourage and support students, but also focused behaviors and strategies that reduce their perceived stress and develop and sustain student self-efficacy through periods of great change and loss.

These purposeful focused behaviors and strategies require more time and expediency than rendered under prior circumstances, and include providing exceptionally prompt feedback on course work, same day response times of less than 24 hours to email communications and discussion thread posts, using personal cell phones for text messaging, and offering expanded office hours several times per week at non-traditional times. Modeling behaviors such as empathy and flexibility as demonstrated by extending due dates for assignments, offering open-book quizzes, sharing extra resources at no cost to students, and providing opportunities for group projects and make-up exams help to show understanding and build trust with students. Additionally, appropriate self-disclosure and not being afraid to share vulnerability and humanness, especially during a crisis, promotes connectedness with students. Offering students authentic praise for their efforts, resiliency, perseverance, and steadfast determination positively reinforces the behavior expected of students, as well as decreases their stress while increasing their self-efficacy.

Conclusion

The evolution of nursing faculty during this pandemic has been characterized by incredible resourcefulness, unrelenting dedication, and selfless compassion in how instruction is delivered, and in interactions with a diverse, multigenerational nursing student population at a deeper level of connectedness. The outcomes have indeed re-emphasized the importance of the vital role nursing faculty play in ensuring nursing student success.

Although it may be too early to tell definitively, there appears to be an increase in student engagement, and an improvement in student learning and student satisfaction secondary to this evolution. Additionally, and, of clear equal importance, nursing faculty interactions with students have been more empathetic, genuine, and caring. Consequently, nursing student self-efficacy has been sustained as despite the unprecedented changes caused by this global health disaster, nursing students are staying the course and demonstrating that they indeed believe they can complete their education with the support of nursing faculty.

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Iris Publishers- Open access Journal of Gynecology & Womens Health | Updates in the Prevention of Preeclampsia, What’s Beyond Aspirin?

 

Authored by Abanoub Gabra*

Abstract

Hypertensive disorders of pregnancy are among the most common medical problems during pregnancy and they are associated with significant mortality and morbidity rate. Low dose Aspirin is already approved by many societies like ACOG and WHO to be used as prophylaxis for preeclampsia in high-risk patients. Recent studies showed a possible reduction in the incidence of preeclampsia and intrauterine growth restriction for high-risk mothers who taking LMWH during pregnancy. Although, the published evidence supporting LMWH is characterized by profound heterogeneity and inconsistency in terms of selection criteria and treatment regimens. Antepartum treatment with a combination of LMWH with low-dose ASA is endorsed by the American College of Chest Physicians and The American College of Obstetricians and Gynecologists for treatment of Antiphospholipid syndrome during pregnancy. WHO recommends Calcium as the first nutritional supplementation to prevent preeclampsia among population with low calcium in the diet. Folic acid and statins showed possible reduction in incidence of preeclampsia in high-risk patients but there is a need for further studies to confirm that. Dietary and lifestyle interventions have the potential to reduce the risk of preeclampsia. Both Metformin and vascular endothelial growth factors has promising preventive role that has been found through recent studies.

Keywords: Preeclampsia; Prevention; Hypertensive disorders of pregnancy

Introduction

Hypertensive disorders of pregnancy are among the most common medical problems during pregnancy and they are associated with significant mortality and morbidity rate [1]. They affect 4 % of pregnant women and may cause serious complications like stroke, heart failure, and renal failure [2]. Those diseases are among the top 6 causes of maternal mortality in the USA being responsible for 10% of maternal deaths [3]. They should be considered as a syndrome rather than a single disease entity [4]. Highest mortality rates were found to be related to eclampsia, HELLP syndrome, hemorrhage, delayed diagnosis [5]. The incidence may be affected by parity, socioeconomic level, race, and environmental factors [6]. African Americans have a high incidence of preeclampsia, eclampsia, related maternal mortality [5]. Their incidence has been dramatically increased recently with significant health burden in terms of affection of both mother and fetus health [3]. Having standardized health care for those patients is associated with a significant reduction in both mortality and morbidity [7,8].

Many societies contribute to Classifying hypertensive disorders of pregnancy in order to determine proper management lines and timelines for each category.

Chronic hypertension is defined as systolic BP of 140 or greater Or diastolic BP of 90 or greater Or both on 2 separate occasions at least 4 hours apart, This condition is diagnosed at or before 20 gestational weeks or already documented before pregnancy [9]. However, ACOG suggests that gestational hypertension or earlyonset preeclampsia should be considered if 1st trimester BP measures are within normal range [10]. Gestational hypertension is defined as elevated BP above 140/90 mmHg after 20 weeks at two separate occasions 6 hours apart in the absence of features of severe preeclampsia [11]. Severe gestational hypertension is defined by sustained elevated BP at more than or equal 160/110mmHg [12]. SOMANZ defines preeclampsia with severe features as a unique condition of pregnancy with multisystem effects involving liver, kidney and hematological parameters [13]. ACOG criteria for diagnosis include new-onset hypertension after 20 weeks associated with new-onset proteinuria (>300 mg/24 hours urine collection) [14]. In absence of proteinuria, diagnosis can be made upon presence of gestational hypertension plus any of the following: low platelet count less than 100.000/cc, creatinine level more than 1.1 (double the baseline creatinine level in absence of other renal problem), raised liver enzymes (double baseline), pulmonary edema, visual or cerebral symptoms [15].

Low dose Aspirin is already approved by many societies like ACOG and WHO to be used as prophylaxis for preeclampsia in high-risk patients. In this article, we are going beyond Aspirin to know more updates about other possible prophylactic measures of preeclampsia including Low molecular weight heparin, Calcium, vitamin D, Arginine, statins, and Folic acid.

Pathogenesis

The pathogenesis of preeclampsia is not completely understood despite extensive researches focused on it [16,17]. Placental ischemia remains the most accepted theory that was postulated to explain the pathogenesis of preeclampsia because delivery of the fetoplacental unit remains the main curative line of treatment [17,18]. In addition to that, placental ischemia also explains other complications e.g. IUGR and oligohydramnios. Also, it explains a higher incidence of disease in patients with chronic hypertension, DM and autoimmune diseases. Placental ischemia may explain the effectiveness of both low dose Aspirin and Low molecular weight heparin [19,20]. In normal pregnancy, invasion of uterine arteries to cytotrophoblast causes their transformation from epithelial to endothelial cells with low resistance pressure allowing enough blood supply to fetus through a process called ‘’pseudovasculogenesis’’ [18]. Cytotrophoblast cells initiate migration of extra villous trophoblast to decidua of uterus and invade partially myometrium inducing remodeling of spiral arteries [16]. 2-stage theory has been hypothesized recently to understand this pathology [17,21]. The first stage is abnormal events during embryogenesis of trophoblast which contribute to fetoplacental oxidative distress and abnormal release of antiangiogenetic factors in maternal circulation and subsequent multisystem endothelial dysfunction [17,22]. Abnormal remodeling of spiral arteries and early immunologically mediated events are considered major causes of those events [18]. Moreover, trophoblast fails to adequately invade uterine wall and spiral arteries so subsequently vascular resistance in this area could not be decreased to allow adequate placental transfusion [23]. Also, the failure of obliteration of tunica media of myometrium vessels contributes to inability of placenta to accommodate enough blood supply due to lack of thinning of those vessels [17]. This leads to excessive secretion of sFlt-1 (soluble-fms like tyrosine kinase-1) and soluble endoglin [24]. sFlt-1 binds in the blood to both the vascular endothelial growth factor (VEGF) and the placental growth factor (PLGF). Both sFlt-1 and low VEGF/PLGF play a major role in the development of systematic hypertension [21,24]. Later on, maternal syndrome may occur in terms of vascular endothelial dysfunction, intravascular hypercoagulability, and vasospasm leading to multiple systems dysfunctions [21]. Abnormal vascular changes in placenta are confirmed by histopathological examination of postpartum specimens of placenta which showed vascular infarcts and sclerosis of arterioles [17]. Immunological maternal reaction towards fetal and paternal derived Antigens may also contribute, which is considered a certain type of immunological intolerance [25]. Immunological theory is supported by high serum level of cell-free fetal DNA. This theory has been also postulated to understand pathogenesis of hyperemesis gravidarum [26,27]. Recently genetic factors were found to contribute to preeclampsia; Angiotensinogen gene T235 and Leiden factor deficiency were found to be associated with disease [28]. Also, the higher incidence of preeclampsia was found in trisomy 13 pregnancy than pregnancy with normal karyotyping [29,30]. Interestingly, the gene for sFlt-1 which is known for contributing to preeclampsia is also encoded in chromosome 13q [31].

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Iris Publishers- Open access Journal of Gynecology & Womens Health | Black Box Warning: Cardiovascular Complications Make Motherhood Unsafe for African American Women

 

Authored by Rolanda Lister*

Abstract

Background: In the United States, cardiovascular disease and its complications in pregnancy is the leading killer in mothers. The black maternal mortality rate is quadruple the rate among white women.

Main Body: The reasons for this staggering discrepancy hinge on two central issues: First, black women are more likely to have pre-existing cardiovascular morbidity that increase the risk of maternal mortality. Second, black women are more likely to experience adverse pregnancy outcomes including small for gestational age, gestational diabetes and preeclampsia. These perinatal complications put them at risk for developing long-term cardiovascular disease.

Conclusions: This article is a call to action to recognize that adverse pregnancy outcomes represent an opportunity to intervene in order to change the long-term cardiovascular health of black women.

Keywords: Maternal mortality; Cardiovascular; African American; Blacks; Whites

Abbreviations: APO (adverse pregnancy outcomes); GDM (Gestational Diabetes Mellitus); PTB (Preterm birth); PEC (Preeclampsia); FGR (Fetal growth restriction); IUFD (Intrauterine Fetal Demise).

Background

In the United States, maternal mortality is on the rise. In the United States, the causes of maternal death have shifted over time. While the mortality for haemorrhage, infection and hypertensive disorders of pregnancy have decreased from 1987 to 2005, the incidence of mortality due to cardiomyopathy and cardiovascular conditions has increased. Whereby, cardiovascular causes are now the leading cause of maternal mortality in the United States [1]. Adverse pregnancy outcomes, such as preterm birth, gestational diabetes, preeclampsia, placental abruption and fetal growth restriction, are independent risk factors for the development of long-term cardiovascular disease and are overrepresented in black women [2].

Cardiovascular deaths are the leading cause of maternal mortality and black women are disproportionately affected

Cardiovascular deaths are now the leading cause of maternal mortality in the United States [1]. Contrary to trends in other wealthy nations, maternal mortality is on the rise in the United States. Black pregnant women are four times as likely to die as white women.

Pre-existing medical complications such as chronic hypertension and Type 2 diabetes mellitus are more common in obese patients and increase the risk of death. Black women are disproportionately obese and are predisposed to these chronic conditions that often predate pregnancy.

Black women are at higher risk for perinatal complications which lead to the development of cardiovascular disease

Black women are at higher risk for adverse pregnancy outcomes (APO), which increase the risk of developing cardiovascular disease. APO such as preterm birth, gestational diabetes, preeclampsia, placental abruption, and fetal growth restriction are independent risk factors for the development of long-term cardiovascular disease and are essentially a “stress test”. Shown in Figure 1 is the common correlation of cardiac markers in cardiovascular disease sharing similar pathophysiology of perinatal complications.

Women who have delivered preterm have elevated total cholesterol, elevated systolic blood pressure and coronary intimal vessel thickness. Additionally, women who deliver prematurely are more likely to have inflammatory markers such as TNF-alpha and IL-6, both of which are markers for cardiovascular disease [3-5].

Both preeclampsia and coronary artery disease share common biologic markers, including excessive circulation maternal hypertriglyceridemia, free fatty acids, reduced high density lipoprotein, and increased concentration of small LDL and oxidized LDL. Common histopathological features such as foam cells or lipid laden macrophages exist in the spiral arteries of preeclampsia placentas and the vessels of individuals that had fatal coronary artery disease [6].

Gestational diabetes mellitus (GDM) has a higher incidence in minorities, including blacks and Hispanics, versus whites. Over half of women that are diagnosed with gestational diabetes will develop Type 2 diabetes (a cardiovascular risk equivalent) within 10 years of their GDM diagnosis.

Black women are also more likely to have a small for gestational age (SGA) infant, which correlates with an increased risk of both the child and the mother experiencing cardiovascular disease and an increased risk of premature death in the mother.

It’s time to act

Black mothers have an increased risk of dying in the peripartum period and are also at risk of dying in the long term should they develop cardiovascular disease. The United States’ disproportionately high black maternal mortality ratio reflects a lack of appreciation for the significance of the pregnancy co-morbidities of black women in this country. Implementing strategies to improve cardiovascular health before and after pregnancy will likely result in a significant reduction in mortality among black women.

Focusing on black maternal cardiac health may reduce perinatal complications

Cardio-obstetrics is a promising approach that is emerging in many tertiary institutions. This care model uses interdisciplinary teams (Cardiology, Maternal Fetal Medicine, Anaesthesia, Nursing) to care for pregnant patients with heart disease. It focuses on how the pregnancy-associated hemodynamic changes potentially exacerbate cardiac disease. At our institutions, the primary focus of our interdisciplinary team is to reduce cardiac death around the time of labour and delivery and the immediate post-partum period. At Vanderbilt, between October 2016 and August 2019, using a Redcap database, we have used a Cardio-obstetrics model to care for 37 women with significant cardiac disease of which 6/37 self-identified as black. The most common groups of cardiac lesions are valve disease (aortic stenosis, mitral stenosis and pulmonary stenosis) and corrected congenital heart disease (Fontan procedure, arterial switch procedures, and septal closure) accounting for 15/37 or 40% and 12/37 or 32% respectively. Other groups of cardiac lesions include coronary artery disease (5/37 or 13%), pulmonary hypertension/heart failure (3/37 or 8%) and arrhythmias (2/37 or 5%). Black women’s heart lesions (2/group) were distributed evenly amongst heart failure, repaired congenital heart defects, and valve disease. There was 1 maternal death and no black maternal deaths. Historically, high risk cardiac lesions such as aortic stenosis and mitral stenosis carried a maternal death rate of 10% and upwards of 25-50% for pulmonary hypertension. However, this model in our institution has been associated with a maternal mortality of <3%.

While cardio-obstetrics has shown promise for reducing maternal mortality in pregnant patients with known cardiac disease, it does not consider long-term follow-up care for patients who are at greatest risk of cardiovascular complications (i.e., APO) after their pregnancies is completed. We postulate that similar reductions will be observed with black females identified as being high risk for the development of cardiovascular disease if we use that critical period for prevention and intervention.

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