Thread by @Ron_George

Good afternoon and good evening…thank you all for joining us for this portion of the 2020 @SOAPHQ virtual annual meeting

What's new in #OBAnes - A comprehensive review of the most relevant articles published in 2019

#MedThread #Tweetorial #Ostheimer #SOAPAM2020

#Halifax would have been amazing - @ruthi_landau and I worked incredibly hard with our amazing management team to bring you an innovative agenda and in many ways we reimagined the way @SOAPHQ delivers an annual meeting #MedThread #Tweetorial #OBAnes #Ostheimer

Most of us have never lived through something like #COVID19 - As we embrace the new normal, remind ourselves of strategies to address our own wellness as physician leaders on the frontline - let's continue to look out for one another! #MedThread #Tweetorial #OBAnes #Ostheimer

The #Ostheimer, What’s New in Obstetric Anesthesia Lecture is to celebrate the life and important contributions to regional and obstetric anesthesia of Dr. Gerald W. Ostheimer, former Professor of Anesthesiology @BrighamWomens #MedThread #Tweetorial #OBAnes #SOAPAM2020

And like his mentees, I to was blessed to receive guidance and inspiration from many people I have worked with during my career. Thank you, my mentors and friends from my time at @Dal_Anesthesia @DalhousieU and @Duke_Anesthesia #MedThread #Tweetorial #OBAnes #Ostheimer

Each article mentioned will have a complete reference listed, I’d encourage you to share your thoughts to the #OBAnes community and highlight this virtual rounds with the #Ostheimer and #SOAPAM2020 hashtags #MedThread #Tweetorial - QR code files !!!

Not all areas can be covered during my time - This is how I have organized by #ostheimer - #MedThread #Tweetorial #OBAnes #SOAPAM2020

We need facilities to manage the uncomplicated and unmedicated births to facilities to manage the sickest of mothers - the facility must match the needs of the patient #MedThread #Tweetorial #OBAnes #Ostheimer #SOAPAM2020

This report is the latest annual report of the Confidential Enquiry into Maternal Deaths and Morbidity in the UK and Ireland which includes data on women who died between 2015 and 2017 #MedThread #Tweetorial #OBAnes #Ostheimer #SOAPAM2020

There was a statistically non-significant increase in the overall, direct and indirect maternal death rates between 2012-14 and 2015-17 #MedThread #Tweetorial #OBAnes #Ostheimer #SOAPAM2020

Thrombosis & thromboembolism remain the leading cause of direct #maternalmortality - Maternal #suicide is the second largest cause of direct maternal deaths, which is unchanged from the previous triennium #MedThread #Tweetorial #OBAnes #Ostheimer #SOAPAM2020

#Anesthesia as a direct cause of maternal death was reduced to 0.04, although that reduction was not statistically significant #MedThread #Tweetorial #OBAnes #Ostheimer #SOAPAM2020

In the UK and Ireland, there was a five-fold difference in maternal mortality rates amongst Black women and a two-fold difference amongst women from Asian ethnic backgrounds compared to white women - #MedThread #Tweetorial #OBAnes #Ostheimer #SOAPAM2020

Facility factors contribute to 60-75% of preventable maternal deaths - There is significant heterogeneity in outcomes among hospitals providing care for pregnant women, partially due to hospital-level variables - #MedThread #Tweetorial #OBAnes #Ostheimer #SOAPAM2020

.@ACOG in their document on the levels of maternal care lays out a means to ensure that the highest-risk patients are delivered at institutions with comprehensive services, including high-quality and dedicated #OBAnes #MedThread #Tweetorial #OBAnes #Ostheimer #SOAPAM2020

Led by @CarvalB @SOAPHQ proposed Centers of Excellence for #OBAnes care - recognizing institutions that demonstrate excellence in #OBAnes care in various domains including personnel and staffing; equipment, protocols and policies #MedThread #Tweetorial #Ostheimer #SOAPAM2020

Easter et al. sought to estimate the degree to which women at high-risk for developing severe maternal morbidity are delivered at an appropriate level of maternal care center #MedThread #Tweetorial #OBAnes #Ostheimer #SOAPAM2020

Cross sectional study from 7 states and the 2014 State Inpatient Database & AHA Annual Survey - MLOC were assigned to each woman based on unique co-morbidities #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

70% of all facilities are classified as Level I and II, while most deliveries occur at Level 2 & 3 centre - Lower level centers are smaller, rural, have lower delivery volumes and have no NICU beds #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Majority had risk factors appropriate for delivery at level I hospitals with relatively few patients warranting delivery at level III or IV centers #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

But 2.4% of women overall delivered at hospitals without the appropriate level of maternal health resources

In fact, 43% of women who required a Level 3 or 4 center delivered at an inappropriate center

#MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Race is a major risk factor adverse OB outcomes - Black women are at significantly greater risk to be readmitted postpartum, suffer severe maternal morbidity and life-threatening complications, particularly acute heart failure #MedThread #Tweetorial #SOAPAM2020 #Ostheimer

There were significant improvements in relative disparities for Black infants compared with white infants in states that expanded Medicaid #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Kendle conducted a cross-sectional analysis of delivery hospitalizations in the United States among women from 2002 through 2015, using data the largest publicly available database in the US inclusive of 47 states #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

From the 55 million deliveries during the study period there were over 13,000 cases of sepsis, that is a rate of 2.4 cases per 10,000 deliveries. As displayed this was a 6.6% annual increase in the number of cases of sepsis #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

1 : 11 women with sepsis at delivery died prior to D/C, compared with 1 death in every 15,000 deliveries without sepsis - Was a pronounced decrease in the mortality rate, postulated to coincide with release of “Surviving Sepsis” bundled care #MedThread #Tweetorial #Ostheimer

Increasing maternal age was associated with a 3.5 greater likelihood of sepsis; Compared with whites, black and Asian women had increased odds of sepsis
#MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Hensley & Bauer analyzed data from 2013-2016 from National Readmissions Database - Maternal sepsis occurred in 0.04% of deliveries in the United States, and 23% of all maternal deaths were sepsis related #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Arnolds reviewed the first 400 deliveries at the University of Chicago - 281 of 400 patients triggered MEWC on L&D - As a screening tool, MEWC appropriately prioritized sensitivity & has an excellent NPV #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

.@MelissaEBauer1 took data from 7 academic centers (1995-2012) - Control patients matched by delivery date - calculated sensitivity & specificity of the SIRS, the qSOFA, and MEWC for identifying sepsis - No perfect answer #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Pulmonary embolism is one of the leading causes of maternal death in North America with an overall incidence of one death in every 100,000 deliveries.
#MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

PE could be ruled out without CT in only 16% of pregnant women on the basis of a decision rule, d-dimer, & compression US - Van der Pol in the @NEJM a prospective study to evaluate pregnancy-adapted YEARS algorithm #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

The pregnancy-adapted YEARS algorithm was able to safely rule out PE in pregnant women with suspected PE & provides solid evidence for the safe management of suspected PE in pregnant women #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Included just as a reference is this “state of the art” review of preeclampsia from Graham Burton at Cambridge, published in the @bmj_latest - this is one we should all read and be up to date with the science #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

- preeclampsia was associated with increased risks of CKD
- PlGF has emerged as one of the key biomarkers to predict preeclampsia
- PlGF reduced time to confirmation of preeclampsia & lower incidence of adverse outcomes
#MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

.@MySMFM states its reasonable to offer elective induction of labor to low-risk nulliparous women 39/0 weeks recommend against offering elective IOL to women under circumstances that are inconsistent with the #ARRIVE study #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Souter identified that @ 39 wks, the CD rate in electively induced nullip women was 14.7% vs 23.2%...after 40 wks or within their multiparous group there was no clinical benefit #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

IOL for a theoretical/simulated cohort resulted in 55,000 fewer CD & 80,000 less cases of HDP to manage but at a cost of 2 billion dollars - an increased QALY with an incremental cost-effectiveness ratio of $87K per QALY #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

#SystematicReview of observational studies compared eIOL @ 39 wks among nullip women with expectant mgmt - 1 CD would be avoided for every 37 women who underwent eIOL @ 39 weeks #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Evidence limited re: needing additional #anesthesia in the event an operative delivery after spinal labor analgesia - @emilysharpe @MayoClinic - 428 pts received spinal analgesia for labor - 14.0% additional analgesia #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

A randomized, crossover study - opting for unmedicated labor assigned to receive nothing or #VirtualReality...NRS scores of the primary outcome for worst pain intensity were significantly lower in VR #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

In Ireland, Remifentanil PCA was the most popular form of labour analgesia, selected by 32% of women, while only 25.0% received labour epidural analgesia #LaborDoesntHaveToHurt #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

#RemiPCAsafe develop standards & monitor maternal/neonatal outcomes for remifentanil labour analgesia - incidence of maternal hypoxia 25-30% #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

#PIEB - implies that the results from RCTs on PIEB regarding maternal motor function seem to be generalisable to parous women but does not excuse us from doing more rigorous generalizable RCT - #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

#DPE #SystematicReview - 5 RCTs - difficulty in interpreting from a high failure rate among these studies - 2.5 - 15% of the epidurals failed #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

0.5 - 1.0 % of women who received neuraxial develop #PDPH. The risk of PDPH is estimated at about 50% after accidental dural puncture with tuohy - PDPH constitutes a non-negligible amount of claims of medical wrong doing #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Over 1M deliveries with neuraxial in NY State during the study time period - 4,808 women with PDPH which 5.5% where identified on readmission - PDPH rate of 4.79 per 1,000 neuraxial procedures - 53% were treated with EBP #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

The incidence of the primary composite outcome of cerebral venous thrombosis & non-traumatic subdural hematoma was significantly higher in women with #PDPH #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

A cohort was constructed of women who had delivered and had a 2-month period of follow-up. The primary exposure was the presence of post–dural puncture headache within 2 months of birth #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

There were 68,374 deliveries identified with PDPHs from over 22 Million births, for an overall rate of 309 per 100 000 women and from that 22 million deliveries they identified 100 women with a PDPH and a SDH #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

The adjusted odds ratio for the association of post–dural puncture headache and subdural hematoma was 199 (95% CI, 126-317; P < .001) #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Addressing language barriers for women with limited English proficiency and using shared decision-making in all clinical encounters may improve access to labor analgesia #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

The educational program along with their routine counseling reduced misconceptions regarding epidural analgesia in both cohorts - presumably led to the Hispanic patients being more likely to choose epidural labor analgesia #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

.@ThorneloeBarry used targeted survey of obstetricians & directors of #OBAnes at all OB units of university-affiliated hospitals across Canada - KEY FINDING - 65% of clinicians were unaware of the rate of PPH in their institution #MedThread #Tweetorial #SOAPAM2020 #Ostheimer

.@josecarvalhoyyz and colleagues completed a non-inferiority study in women at low risk of PPH - carbetocin-20 vs. carbetocin-100 rather than oxytocin #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

The lower 95%CI for the difference in mean NRS score was -1.1 at the 2 minutes, which was outside the non-inferiority margin of -1; therefore, they could not reject inferiority of the carbetocin 20 vs. 100 #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Repeated stimulation with oxytocin results in temporary or permanent inactivity of its receptor - In labor, endogenous oxytocin is secreted in pulses

Myometrial samples from healthy non-laboring women having a schedule cesarean and not exposed to exogenous oxytocin were mounted in an organ bath with a physiological solution #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

3 pretreatment groups: (1) no pretreatment (control group); (2) a continuous oxytocin solution for 2 hours (continuous group); or (3) intermittent oxytocin for 2 hours #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Subsequent oxytocin-induced myometrial responsiveness was superior in myometrial samples that were exposed to intermittent oxytocin versus continuous infusions #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

International uterotonic consensus statement - Oxytocin or carbetocin for routine delivery - Dose requirements for intrapartum cesarean are greater -
Oxytocin should be small bolus followed by an infusion...#MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Large total oxytocin doses should be avoided to minimize the antidiuretic effect - A 2nd-line drug (ergot or prostaglandins) should be considered early #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

#Systematicreview & trial sequential analysis confirmed a statistically significant reduction in the use of additional uterotonics with carbetocin #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Even if TXA provides no benefit, its routine use in the treatment of PPH in the United States would only add an estimated $4.5 million in health care costs per year #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Patel & colleagues reviewed accidental spinal administration of tranexamic acid, identifying 21 cases of spinal tranexamic acid administration - life-threatening complications occurred in 20 patients - 10 DIED - #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

During the 2017 @SOAPHQ meeting Seattle we convened a working group to develop these guidelines in response to the recently published @ASALifeline guidelines #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

A more obstetric focused consensus statement was necessary - led by @jrbcpyw #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Neuraxial opioids have been safely administered to millions of women for cesarean - cases of respiratory depression are rare - Low-dose ( <= 150 mcg) of neuraxial morphine minimizes the risk of respiratory depression #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Terada recruited 100 elective cesarean patients who received 3 mg of epidural morphine & monitored them postoperatively with the Nellcor respiratory rate monitoring #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Seventy-six women or 85% developed at least one episode of bradypnea and 52% developed mild respiratory depression #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

.@CarolynWeiniger aimed to study an estimate of the number of apnea alert events in women who received 150 mcg of IT morphine for elective #cesarean - #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

39 of them had apneic events - NO relationship between nurse-reported RR and Spo2 and NO clinical consequences #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

In 2017, @CarvalB demonstrated a patients’ ability to anticipate their analgesic needs by choosing intrathecal morphine dose for cesarean delivery #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

In 2019 they follow up this interesting line of work to determine if providing women with a choice of post-cesarean delivery analgesic protocol would significantly reduce their postoperative oxycodone requirements #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Of those randomized to having choice the majority opted for the safe middle of the road regimen. But many women did opt for increased or decreased dosing #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Patients who chose the higher dose took significantly more oxycodone at 24 and 48 hours #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Simply being given a choice did not impact oxycodone use or opioid-related side effects and 2/3 of women chose the standard plan - this study highlights that our patients have significant insight into their analgesic needs #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Badreldin hypothesized disparities exist in pain management - Retrospective cohort of women hospitalized for delivery - 3 outcomes 1) postpartum pain score 2) opioid dosing 3) receipt of an opioid prescription at discharge #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Key differences - Non-Hispanic white women were significantly older, more likely to be married, nulliparous, have private insurance, smoke, and have a history of depression or anxiety #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

White women were significantly less likely to report a pain score at discharge of 5 or greater - received significantly greater opioids for pain - more likely to receive an opioid prescription at discharge :( #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Both non-Hispanic Black & Hispanic women were significantly more likely than non-Hispanic white women to report a pain yet white women received significantly more opioids and had lower odds of receiving an opioid prescription #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Similarly, Johnson et al. revealed severe pain was more common among Black and Hispanic women - Compared with non-Hispanic white women, Black, Asian, & Hispanic women all received less pain medication postpartum #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Action must be taken, prescribing more opioids is not the answer - multimodal non-opioid postop pain regimens need to be offered equitably, assessment needs to focus on function > systems that don’t cross cultural barriers #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Leaders in obstetric care, addiction medicine, mental health, and pediatrics gathered in conjunction with the @MySMFM Annual Meeting and @SOAPHQ #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

A panel of obstetric & gynecologic physician leaders were invited to participate in an e-Delphi panel - recommendations for opioid-prescribing guidelines for labor & delivery #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Clinicians asked not to order opioids, continue established acetaminophen & NSAID regimens, and counsel that opioids are available if needed #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

The percentage of women who were discharged with a prescription for opioids dropped significantly from 91% to 40% - #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Rogers et al. created a multimodal pain power plan - Overall reduction in opioid prescription from 92% to 79%, as well as a reduction in average opioid dose from 107 MME to 71 MME #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Smith et al. eliminated the combination of opioids with acetaminophen - 75% reduction in the MME - the number of patients using 100 or more MME postpartum was reduced from 69% to 15% - #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

.@jalalnanji from @UAlbertaAnesth allowed split doses of oral oxycodone - 56% reduction in the opioid consumption in the first 48 hours after #cesarean #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

TTN is 2- to 6-fold more common during elective cesarean delivery compared to vaginal birth - Singh et al. suggests the duration & degree of pre-delivery maternal SBP <90 mm Hg after neuraxial is associated with TTN #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Hirose from Japan and Kornilov from Israel both use NIRS to assess the impact of spinal anesthesia with phenylephrine support of blood pressure during cesarean anesthesia #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Despite preservation of blood pressure to within 20% of baseline measurements, the mean frontal lobe ScO2 significantly decreased after spinal anesthesia #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Decreases in MAP in the control group led to significant decreases in tissue oxygen index, suggesting hypotension secondary to spinal for #cesarean causes a decrease in maternal rCBV & rCBO - phenylephrine attenuates! #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Heesen, did focus a metaanalysis on spinal #anesthesia induced hypotension in high risk cases - 5 studies focused on pre-e as an indication for #cesarean, 2 studies focused on fetal compromise, and 1 focused on emerg cesarean #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Incidence of fetal acidosis -> no sig diff b/w ephedrine & phenylephrine - nor was there a difference in arterial pH or any maternal outcomes - the number of included patients was too small to allow a definitive conclusion #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Tan - Only 60% of term pregnant women achieved the recommended level of end-tidal oxygen

Shippam - HFNO had a significantly lower estimated mean EtO2 compared with the control group after 3 min of tidal volume breathing

#MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

General anesthesia for #cesarean is safe, necessary in many cases and sometimes unavoidable - This study examined risks of maternal adverse events, temporal trends, and patient risk factors for potentially avoidable GA #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

5 adverse events were analyzed: 1-composite out come of death or cardiac arrest, 2-anesthesia-related complications, 3-severe anesthesia-related complications, 4-surgical site infections, & 5-venous thromboembolic events #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

GA was associated with significant ⬆︎ risk of anesthesia-related complications, surgical site infection, and VTE events

Avoidable GA was not associated with increased risk of death or cardiac arrest

#MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

The odds of general anesthesia for your #cesarean were greater if you were younger, Black, Hispanic or a beneficiary of Medicaid

#MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer #inequities

#ThisIsOurLane support academia & efforts of our leaders to stay in that lane & improve conditions for our pts - We must better understand important, comprehensive and consistently use of patient centered outcomes #ResearchMatters #MedThread #Tweetorial #SOAPAM2020 #Ostheimer

Support QI endeavors, trust colleagues and own our mistakes - strive for the highest quality care #PatientSafety

Lastly, racism exists in our workplaces and in our science, we must call it by name & commit to #antiracism #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Our last #SOAPAM2020 virtual meeting event will take place Oct 29th at 6 pm EST with @aljabut @CarolynWeiniger & @FarberMichaela #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer

Thank you for listening / tweeting - all files and articles can be found by scanning the QR code #MedThread #Tweetorial #OBAnes #SOAPAM2020 #Ostheimer @threader_app compile

Updated QR Code from #OBAnes #SOAPAM2020 #Ostheimer