bluuebunny/crossref_metadata_2025 huggingface dataset:
O04 UKHSA Start Smart Then Focus antimicrobial stewardship: effective implementation during the COVID-19 pandemic at an NHS Foundation Trust in the UK
Authors: Elshenawy Rasha Abdelsalam , Umaru Nkiruka , Aslanpour Zoe
Published: August 2024

Background

Antimicrobial resistance (AMR), a major global public health threat that has caused 1.2 million deaths, calls for immediate action. Antimicrobial stewardship (AMS) promotes judicious antibiotic use, but the COVID-19 pandemic increased AMR by 15%.1

Objectives

To investigate the AMS implementation prior to and during the COVID-19 pandemic.

Methods

This cross-sectional retrospective study was undertaken to estimate the prevalence of inappropriate antibiotic prescribing, focusing on adult patients treated for respiratory tract infections (RTIs). It investigates antibiotic prescribing practices for RTI conditions such as pneumonia and COVID-19-related RTIs in 2020. A total of 640 patient records, 320 in each year, were retrospectively analysed using the UK Health Security Agency’s (UKHSA) ‘Start Smart, Then Focus’ (SSTF) AMS toolkit at one NHS Foundation Trust.2 Ethical approval was secured and public and patient involvement through the Citizens Senate was integral, with registration in ISRCTN related to WHO criteria and Octopus.

Results

During the pandemic, the ‘Start Smart’ antibiotic approach involved a retrospective analysis of 640 patient records from a Trust, showing stable prescription appropriateness with a marginal age increase from an average of 74.3 to 76.2 years (P=0.127). The predominant age group remained 66–85 years, with a slight decrease from 48.8% to 46.3%. The length of hospital stay decreased from 13.7% to 12.3% on average. Mortality rates were constant at 15%. Notably, ‘side effects’ as an antibiotic allergy classification changed significantly (P=0.023). Community-acquired pneumonia was the primary diagnosis, with uncertain admission diagnoses influencing antibiotic choice. Significant comorbidity shifts were noted; heart failure increased (P=0.007) while kidney diseases decreased (P=0.008). Antimicrobial stewardship interventions showed a notable rise in ‘De-escalation’ (P=0.005), with guideline adherence dropping from 64% to 36% during the pandemic (Figure 1).

Conclusions

The study highlights how AMS practices, such as ‘De-escalation’, have been pivotal in antimicrobial management during the pandemic. The resilience of AMS in this crisis indicates that sustainable, adaptable AMS measures are essential in the post-pandemic era to continue saving lives. The impact of this research study is significant, offering insights that enrich the global conversation on antimicrobial stewardship. It delves into the core aspects of AMS, emphasizing its vital role in everyday healthcare and its increased importance during public health crises, demonstrating the potential to save lives by reducing antimicrobial resistance.
P07 Study of Prescribing patterns and Effectiveness of Ceftolozane/Tazobactam Real-world Analysis (SPECTRA): results on critical care patients from a multinational, multicentre, observational analysis
Authors: Soriano Alejandro , Paterson David L , Thalhalmmer Florian , Kluge Stefan , Viale Pierluigi , Akrich Brune , Allen Mike , Wirbel Stephanie , Obi Engels N , Kaul Sunny
Published: August 2024

Background

Ceftolozane/tazobactam (C/T) is indicated for the treatment of complicated intra-abdominal infections (cIAI),1 complicated urinary tract infections (cUTI), including pyelonephritis,2 and hospital-acquired bacterial and ventilator-associated bacterial pneumonia.3 Information on real-world use and outcomes of patients treated with C/T in critical care settings is important to help inform disease management and clinical practice.

Objectives

This study presents findings on patient/treatment characteristics and outcomes associated with C/T use in patients managed in the critical care setting.

Methods

Data were collected from the SPECTRA study, a multinational, multicentre, retrospective, inpatient, observational study of patients treated with C/T across hospitals in seven countries (Spain, the UK, Germany, Italy, Austria, Australia and Mexico) from 2016–2020. All adult patients admitted to the ICU during the index hospitalization and treated with C/T for ≥48 h were included. Demographics, clinical characteristics, treatment management patterns and outcomes were assessed.

Results

The study sample included 298 critical care patients receiving C/T (mean age 57.0 years; 68.8% male), 41.9% of which had an infection-related ICU admission. Sites of infection were respiratory (50.0%), skin/wound/tissue (21.1%), blood (13.7%), urine (10.3%), pleural fluid/cerebrospinal fluid/other fluid (9.3%), line/device (2.9%), abdominal (1.0%), bone/joint (0.5%) and stool (0.5%). The most common pathogens were Pseudomonas aeruginosa (89.7%) and Escherichia coli (6.4%). Most patients (81.5%) had at least one comorbidity, with the most common being immunocompromised state (44.6%), sepsis (41.6%), heart disease (29.2%) and chronic pulmonary disease (27.2%). Renal replacement therapy was initiated in 21.5% of patients during index hospitalization, with 14.4% on continuous renal replacement therapy. The most common C/T regimen was 1.5 g every 8 h (36.9% of patients). About 51.6% of patients received C/T as third line or salvage (24.8% and 23.5% received C/T as first or second line, respectively). Median C/T treatment duration was 11.0 days (Q1, Q3: 7.0, 16.5 days). Clinical success was 53.4%. All-cause in-hospital mortality was 35.6% overall, and 13.8% infection related. Thirty-day all-cause readmission was 3.4% overall, and 1.7% infection related.

Conclusions

This multinational real-world study included a high number of critical care patients and reported outcomes associated with C/T use. In this very high-risk cohort presenting with severe Gram-negative infections, most C/T patients had beneficial outcomes despite their clinical complexity and late intervention with C/T.
P09 Genomic characterization of nasal Enterococcus faecalis carrying linezolid resistance in healthy hosts identifies zoonotic transmission
Authors: Abdullahi Idris Nasir , Lozano Carmen , Zarazaga Myriam , Latorre-Fernández Javier , Hallstrøm Søren , Rasmussen Astrid , Stegger Marc , Torres Carmen
Published: August 2024

Background

Linezolid resistance in Enterococcus faecalis (a normal gut bacterium) is increasingly considered a critical public health concern, hence the need to understand their genomic contents and dissemination patterns.

Methods

Illumina-based sequencing was used to characterize seven linezolid-resistant (LZDR) E. faecalis strains obtained from the nares of healthy humans and animals in Spain. Also, the relatedness of the strains with publicly available genomes of E. faecalis with similar lineages and AMR determinants was accessed by core-genome SNP analysis.

Results

E. faecalis was identified in 32.5% of 40 pigs, 30% of 10 pig farmers, 5.9% of 34 dogs and 4.9% of the 41 dog owners. Of the E. faecalis strains, only five, one and one strains from pigs, a pig farmer and a dog, respectively, were optrA-positive. All the optrA were chromosomally located and variants (types 5, 7 and 15) except one that was a WT strain (from a pig). All the strains carried between 16 and 35 virulence genes associated with ≥1 intact prophage. All the enterococci carried ≥1 plasmid replicon (1–5) carrying tetracycline and chloramphenicol resistance genes. SNP-based analyses identified closely related E. faecalis strains from a pig and pig farmer on the same farm (SNP=4). Moreover, E. faecalis ST32, ST59 and ST474 strains from pigs were related to those previously described from humans (sick and healthy) and cattle in Spain, Belgium, and Switzerland (SNP range 43–86).

Conclusions

These findings strongly suggest the zoonotic transmission of LZDRE. faecalis and potential international dissemination. These highlight the need to strengthen molecular surveillance of linezolid-resistant enterococci in all ecological niches and body parts to direct appropriate control strategies.
P14 Knowledge, attitude and practices on antibiotic usage and resistance among people attending primary healthcare in Rwanda
Authors: Ndayisenga Jerome , Tuyishimire Obed , Sibomana Olivier , Kwizera Philemon , Niyompano Hosee , Hakizayezu François , Fitch Margaret I
Published: August 2024

Background

Antimicrobial resistance (AMR) poses a global threat to public health, with Sub-Sahara African countries facing a substantial burden. Our study aimed to assess knowledge, attitude and awareness of antibiotic usage and resistance among people attending primary healthcare facilities in Rwanda.

Methods

The study was descriptive cross-sectional and proportionate stratified sampling was used to recruit 246 individuals who attended health centres in Kigali during October 2023. The study assessed the level of knowledge on antibiotic usage, knowledge on antimicrobial resistance, attitudes toward antibiotic accessibility and practices regarding the patient-prescriber relationship and infection prevention. The levels were calculated as proportions of correct answers and were grouped as poor (below 40%), moderate (from 40 and less than 70%) and high, good or positive (70% and higher). χ2 test was used find significance of associations between levels and age, gender and education.

Results

Most participants (87.40%) correctly identified Amoxicillin as an antibiotic while 57.72% wrongly identified Paracetamol as an antibiotic. Among participants, 3.2% had high knowledge on antibiotic usage, 20.7% had high knowledge on antimicrobial resistance, 32.9% had a positive attitude toward antibiotic accessibility and 39.4% had good practices regarding the patient-prescriber relationship and infection control. Male participants had significantly higher levels of positive attitude (P=0.003) and knowledge on antimicrobial resistance (P=0.047). Individuals with university education had significantly higher levels of positive attitude (P=0.007).

Conclusions

Limited levels of knowledge, attitude and practices on antibiotic usage and resistance were found, with women having lower levels in multiple aspects. Strategies to promote rational use of antibiotics ought to address social inequities.
P19 Impact of the introduction of the EUCAST 2020 susceptibility interpretation rules for Pseudomonas aeruginosa on selection of antibiotic therapy
Authors: Chan Chai Feng Benjamin , Sule Jumoke , Gouliouris Theodore
Published: August 2024

Background

In 2020, EUCAST changed the interpretation of WT Pseudomonas aeruginosa susceptibility to the first-line agents ciprofloxacin, piperacillin/tazobactam and ceftazidime from susceptible (S) to susceptible, increased exposure (I). The breakpoint changes were implemented at Cambridge University Hospitals (CUH) in March 2020, initially with no explanatory notes, and from June 2020 with the addition of an interpretative comment.

Objectives

To study the impact of implementing the EUCAST susceptibility interpretation of WT P. aeruginosa on carbapenem prescribing at CUH.

Methods

In this service evaluation, we analysed all clinical isolates of P. aeruginosa between 1 January 2020 and 30 September 2020. Only WT (fully susceptible isolates) were included. We retrospectively collected epidemiological data, clinical background, treatment information and Microbiology involvement and analysed this data to identify prescription rates and factors influencing meropenem prescription in P. aeruginosa infections, comparing three periods: Period 1 (pre-transition), Period 2 (transition) and Period 3 (post-transition).

Results

In total, 104 patients were included in the study. Meropenem use across all three periods was similar (17.6%, 18.4% and 12.5%, P=.799). Selective susceptibility reporting of meropenem susceptibility differed between periods, with a transient increase in reporting during period 2 (11.8%, 36.1% and 6.3%, respectively [P=.004]). Reporting of susceptibility to meropenem was associated with increased odds of meropenem prescribing (OR 4.3, 95% CI 1.40–13.7, P=.011).

Conclusions

The changes to the EUCAST breakpoints for P. aeruginosa did not have a significant impact on carbapenem prescription at CUH. This in part could be explained by selective susceptibility reporting of results.
P35 Impact of IV to oral antibiotic switch optimization on nurse time and plastic waste at the Royal Cornwall Hospital Trust
Authors: Tan Michelle , Powell Neil , Hearsey Daniel
Published: August 2024

Background

IV to oral switch (IVOS) is an important antimicrobial stewardship intervention with benefits that include a lower risk of bloodstream and catheter-related infections, reduced equipment costs, lower carbon footprint and reduced hospital length-of-stay as well as releasing nursing time to care for patients.1–3 We quantified the impact of more prompt IVOS on nurse drug administration time and unrecyclable waste generated from IV antibiotic administration.

Methods

Data were collected during three lunchtime drug administration rounds each week on the Acute Medical Unit (AMU) and the Emergency Surgical Unit (ESU) over a 4 week period in December 2023. A trainee pharmacist timed how long it took nurses to make up and administer both IV and oral antibiotic doses. Data collected included: antibiotic name, antibiotic route, IV antibiotic administration method (if applicable), time taken for drug preparation, time taken for preparation and to set up for administration. Photographs of the waste generated were obtained for each antibiotic. To estimate the potential for reducing excess IV doses, and to estimate potential nurse time savings, we used the Trust’s IVOS CQUIN data to estimate excess IV antibiotic use and EPMA IV administration data to quantify the number of IV antibiotic doses administered during the study period.

Results

The preparation and administration of 56 antibiotics (34 IVs and 22 orals) was observed for 53 patients. The mean time to prepare and administer IV infusions was 10:27 min and 5:53 min for IV bolus injections. Oral antibiotics took 2:42 min. During the audited month, a total of 24 248 doses of IV antibiotics were administered across all inpatient wards at RCHT, which equates to 782 doses per day. According to our data, 782 doses of IV antibiotics administration would require approximately 136 h of nursing time every single day. Based on our IVOS CQUIN data, approximately 11% (86 doses) of IV antibiotics could be switched to oral. This equates to 86 doses of IV antibiotics which could be saved and changed to oral which could save approximately 12 h of nursing time every day.

Conclusions

Optimizing IV to oral switching could save 12 h of nursing time every day. In addition, we could reduce our carbon footprint by reducing the generation of non-reusable plastic produced in the process of administering IV antibiotics compared with oral antibiotics.
Analysis of random induced dynamic response of rural roads considering friction effect and nonlocal effect under the load of construction vehicles
Authors: Wang Guobing , Yang Feiyue , Wu Wenli , Wang Hui
Published: August 2024

The objective of this paper is to propose a novel computational model for solving the problem of accurately evaluating the randomly induced road vibration response of engineering vehicles traveling on rural roads. The computational model, first, focuses on the unique pavement characteristics of rural roads, constructs a tire grounding function model and innovatively introduces a dynamic friction factor, and successfully develops a coupled stochastic excitation system model for the interaction between the dynamic loads of 1/4 vehicle tires and the pavement of rural roads by applying the power spectral density function of the rural roads and combining it with the elastic roller model of the vehicle tires. Second, considering the nonlocal superposition effect of the soil skeleton of the roadbed, a coupled vibration response model of a 1/4 automobile rural road is successfully developed, and a validation method is given. Finally, the coupled vibration response characteristics of engineering vehicles and rural roads under random excitation at different speeds are analyzed. The analysis results show that the model proposed in this paper can well predict the degree and influence the range of rural road vibration caused by random excitation of construction vehicles traveling at any speed.
Challenges faced by public sector community pharmacists in interior cities of Brazil during the early phase of COVID-19 pandemic: a qualitative study
Authors: Foggiatto Giovana , Garabeli Aline Ansbach , Possagno Gerusa Clazer Halila , Pontarolo Roberto , Benetoli Arcelio
Published: August 2024

Objectives

This study explored the experiences and perceptions of public sector pharmacists in primary healthcare during the early phase of the coronavirus disease 2019 (COVID-19) pandemic in nine small and medium-sized cities in the interior state of Paraná, Brazil.

Methods

Fourteen individual semi-structured online interviews were conducted using Google Meet®. Employing convenience sampling followed by “snowball” recruitment, audio-recorded interviews were transcribed verbatim and thematically analyzed through an inductive approach.

Key findings

Four major themes and two subthemes emerged: (i) workplace and service changes, (i.a) use of social media and remote communication; (ii) working conditions, (ii.b) supply and use of personal protective equipment; (iii) irrational use of medicines against COVID-19; and (iv) mental health.

Conclusion

Pharmacists reported a lack of preparation, centralization, and coordination, leading to overwhelming workloads and stress. However, they demonstrated resilience in delivering care and promoting rational medicine use. This study offers valuable insights into supporting stakeholders in managing abrupt changes in primary healthcare delivery.
A Physician Attack on the FDA—Will the Supreme Court Reduce Access to Mifepristone?
Authors: Watson K , Malina D
Published: August 2024

(N Engl J Med. 2024;390(6);563–567. doi: 10.1056/NEJMms2312012.)

In 1965, Ms R. traveled from Denver to have a legal abortion in Japan due to concerns about an illegal US abortion being unsafe. Today, more than 80% of women who get abortions are 11 weeks pregnant or less, and as such, may legally take abortion medication (mifepristone and misoprostol pills) at home. However, options will become much more limited if the Supreme Court decides in favor of antiabortion physicians who have sued the Food and Drug Administration (FDA) to revoke its approval and regulation of mifepristone.
Angiogenic Biomarkers in Preeclampsia
Authors: Burwick RM , Rodriguez MH
Published: August 2024

(Obstet Gynecol. 2024;143(4):515–523. doi:10.1097/AOG.0000000000005532)

Preeclampsia, a dangerous condition affecting 3% to 4% of pregnancies in the United States, causes significant maternal and neonatal complications worldwide. Monitoring for severe features is crucial for timely intervention. While it often develops from nonsevere hypertensive disorders, recent advancements include the use of 2 angiogenic biomarkers, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF), to predict its onset and severity. These biomarkers have been integrated into diagnostic assays in various regions, including Europe and parts of Asia and the Americas. The Food and Drug Administration (FDA) recently authorized the sFlt-1/PlGF test (KRYPTOR Test System) for use in the United States to aid in assessing the risk of progression to severe preeclampsia in hospitalized pregnant women. However, it is emphasized that these tests should complement, not replace, clinical judgment.
Neonatal Seizures
Authors: Yozawitz E
Published: August 2024

(N Engl J Med. 2023;388:1692–1700. doi: 10.1056/NEJMra2300188)

Seizures that occur within 4 weeks of the birth of a term infant or 44 weeks of corrected gestational age for preterm infants are defined as neonatal seizures, and the incidence is estimated at 2.29 per 1000 live births. Recent reports have described the incidence as higher among preterm infants. There are 2 classifications of neonatal seizures, epileptic, and provoked; provoked seizures are not considered epilepsy, do not require long-term treatment, and are usually attributable to hypoxic ischemic encephalopathy, stroke, or infection. This article is a review of the clinical presentation, evaluation, and treatment of neonatal seizures, along with a brief background of neonatal epilepsy syndromes and prognosis and complications of seizures in this population.
Evaluation of the “Sip Til Send” Regimen Before Elective Caesarean Delivery Using Bedside Gastric Ultrasound: A Paired Cohort Pragmatic Study
Authors: Harnett C , Connors J , Kelly S , Tan T , Howle R
Published: August 2024

(Eur J Anaesthesiol. 2024;41(2):129–135. doi: 10.1097/EJA.0000000000001926)

Preoperative fasting is commonly recommended to prevent the risk of pulmonary aspiration of gastric contents during anesthesia. The European Society of Anaesthesiology and Intensive Care (ESAIC) advises fasting for 6 hours for solids and 2 hours for liquids prior to surgery (eg, caesarean delivery, CD). However, a long fasting period can impart both maternal and neonatal risk. As such, the liberal drinking “Sip Til Send” protocol has been widely used in the United Kingdom and Ireland with no associated pulmonary aspiration cases reported. This study aimed to assess residual gastric volumes in nonlaboring parturients presenting for elective CD and compare volumes in fasted patients to volumes after the same patients were allowed liberal oral hydration. The authors hypothesized there would be no significant difference in gastric volumes.
A Study of the Pharmacokinetics and Pharmacodynamics of Oxytocin at Elective Cesarean Delivery
Authors: Monks DT , Singh PM , Kagan L , Palanisamy A
Published: August 2024

(Anaesthesia. 2023;78(11):1347–1353. doi: 10.1111/anae.16109)

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. The most common uterotonic agent used to prevent and treat PPH is oxytocin. In up to 38.8% of cases, oxytocin is unable to produce adequate uterine contractility and more uterotonic agents are required. Precise oxytocin dosing is ideal to balance PPH prevention/treatment and also avoid significant adverse side effects that can arise from high doses of oxytocin. While many factors contribute to the correct dosage for each individual, pharmacokinetic and pharmacodynamic data could assist in determining dosing for individual patients to both maximize desired effects and minimize adverse ones. This study was designed to obtain pharmacokinetic data to optimize the adjustment of oxytocin doses by patient weight, as well as to evaluate the relationship between serum oxytocin concentration and uterotonic and hemodynamic effects of the medication.
The Role of Transvaginal Ultrasound in the Third-Trimester Evaluation of Patients at High Risk of Placenta Accreta Spectrum at Birth
Authors: Jauniaux E , Hussein AM , Thabet MM , Elbarmelgy RM , Elbarmelgy RA , Jurkovic D
Published: August 2024

(Am J Obstet Gynecol. 2023;229(4):445.e1–445.e11. doi: 10.1016/j.ajog/2023.05.004)

Identifying high-risk placenta accreta spectrum (PAS) patients prenatally reduces maternal complications and hemorrhagic morbidity at birth. Expert multidisciplinary management decreases massive transfusion and reoperation. Ultrasound, utilized initially in 1982, screens high-risk PAS cases effectively and standardized prenatal scanning with enhances outcomes. Recent expert consensus via Delphi survey supports seven key transabdominal ultrasound (TAU) signs for PAS risk assessment. Transvaginal sonography (TVS) is a vital tool for the evaluation of cervical and lower uterine segment anatomy and expert opinion supports the use of TVS as a supplement to current prenatal assessment for PAS. This study evaluated the utility of third trimester TVS to predict surgical outcomes in patients with high suspicion for PAS.
Association Between Socioeconomic Status With Pregnancy and Neonatal Outcomes: An International Multicenter Cohort
Authors: Maher GM , Ward LJ , Hernandez L , Kublickas M , Duvekot JJ , McCarthy FP , Khashan AS , Kublickiene K
Published: August 2024

(Acta Obstet Gynecol Scand. 2023;102(11):1459–1468. doi: 10.1111/aogs.14659)

Many studies have shown that socioeconomic factors have large impacts on many areas of life including education, unemployment, housing security, nutrition, and reduced access to health care. In addition, low-socioeconomic indicators have been linked to pregnancy complications for both mother and neonate and have persisted even in areas with universal health care systems. However, other studies have shown an absence of association with socioeconomic status for outcomes such as low birthweight and preterm birth. Previous literature has suggested that assessing individual-level socioeconomic factors and their association with pregnancy outcomes may provide better understanding than area-based analysis. This study was designed to evaluate associations of individual-level socioeconomic factors (education, employment, relationship status, and income) with adverse pregnancy and neonatal outcomes (gestational hypertension, preeclampsia, gestational diabetes, emergency cesarean delivery, preterm birth, post-term delivery, small for gestational age, and Apgar score).
Neonatal Hypoxic-Ischemic Encephalopathy and Hypothermia Treatment
Authors: Arnautovic T , Sinha S , Laptook AR
Published: August 2024

(Obstet Gynecol. 2024;143(1):67–81. doi: 10.1097/AOG.0000000000005392)

Neonatal hypoxic-ischemic encephalopathy (HIE) is a significant condition linked to mortality and long-term disabilities such as cognitive impairment, cerebral palsy, seizures, and sensory deficits. It falls under neonatal encephalopathy, a broader syndrome characterized by various neurologic dysfunctions, including altered consciousness, respiratory difficulties, and impaired reflexes. This syndrome can arise from multiple causes, including HIE, brain malformations, strokes, genetic disorders, and infections. HIE alone accounts for approximately half of neonatal encephalopathy cases, highlighting its clinical importance due to its association with serious outcomes. HIE can occur suddenly, without warning, and its treatment historically relied on supportive care alone. However, recent research highlights a critical time window in the first hours to days posthypoxia-ischemia, during which hypothermia therapy can mitigate brain injury. This article aims to inform obstetricians about neonatal encephalopathy, particularly HIE, and the role of hypothermia treatment.
National, Regional, and Global Estimates of Preterm Birth in 2020, With Trends From 2010: A Systematic Analysis
Authors: Ohuma EO , Moller A-B , Bradley E , Chakwera S , Hussain-Alkhateeb L , Lewin A , Okwaraji YB , Mahanani WR , Johansson EW , Lavin T , Fernandez DE , Domínguez GG , de Costa A , Cresswell JA , Krasevec J , Lawn JE , Blencowe H , Requejo J , Moran AC
Published: August 2024

(Lancet. 2023;402(10409):1261–1271. doi:10.1016/S0140-6736(23)00878-4)

An analysis of global data from 2010 to 2020 found that there was not a measurable change in the rate of preterm births during that period. The analysis, led by the World Health Organization and UNICEF, is the first data published on preterm birth rates since 2015. The new estimates are crucial for understanding the burden of preterm births around the world and for determining where resources can best be targeted.
Risk Factors for Recurrence of Postdural Puncture Headache Following an Epidural Blood Patch: A Retrospective Cohort Study
Authors: Tomala S , Savoldelli GL , Pichon I , Haller G
Published: August 2024

(Int J Obstet Anesth. 2023;56:103925. doi: 10.1016/j.ijoa.2023.103925)

Neuraxial anesthesia is a commonly used technique during childbirth. Postdural puncture headache (PDPH) is a notable complication, occurring in a minority of patients but with the potential to lead to severe short and long-term adverse outcomes. Definitive treatment typically involves an epidural blood patch (EBP), although it may not always be successful, with some patients requiring multiple procedures. Risk factors for EBP failure remain uncertain, with conflicting findings regarding the timing and volume of blood injected. This study aimed to assess the incidence and risk factors for EBP failure in a substantial patient cohort, providing insights into improving outcomes for patients undergoing this procedure.
Role of Cosyntropin in the Prevention of Postdural Puncture Headache: A Propensity-matched Retrospective Analysis
Authors: Liu M , Mitchell A , Palanisamy A , Singh PM
Published: August 2024

(Int J Obstet Anesth. 2023;56:103922. doi: 10.1016/j.ijoa.2023.103922)

Postdural puncture headache (PDPH) frequently follows unintended dural puncture during epidural placement in obstetric patients, affecting up to 85% of cases and significantly impacting maternal well-being. PDPH can lead to prolonged hospital stays and even chronic headaches. Preventive measures like bed rest and hydration have shown limited efficacy, while medications like adrenocorticotropic hormone and cosyntropin offer potential relief, albeit with inconclusive evidence. Prophylactic use of cosyntropin has shown promise in reducing PDPH incidence and severity, possibly by enhancing analgesia and increasing cerebrospinal fluid production. However, this finding lacks replication in other trials, and widespread recommendation is lacking due to methodological limitations. Conducting randomized controlled trials in this context is challenging. This study retrospectively investigated the effectiveness of prophylactic cosyntropin in reducing PDPH incidence and severity in obstetric patients, aiming to address the gap in evidence regarding its use.
Embracing Labor Neuraxial Analgesia as a Tool to Reduce Health Inequities and Hemorrhage-related Maternal Morbidity
Authors: Bauer ME , Admon LK
Published: August 2024

(Anesthesiology. 2023;139(6):717–718. doi: 10.1097/ALN.0000000000004783)

The United States has higher rates of maternal morbidity and mortality in comparison to all other developed nations with health inequities affecting marginalized groups. Obstetric hemorrhage is one of the main factors that contribute to both maternal morbidity and mortality, and further interventions are needed to help minimize these events.
Brain and Heart Interactions Delineating Cardiac Dysfunction in Four Common Neurological Disorders: A Systematic Review and Meta-analysis
Authors: Rezk Amal , Liu Winnie , Nijs Kristof , Lee Jun Won , Rajaleelan Wesley , Nakatani Rodrigo , Al Azazi Emad , Englesakis Marina , Chowdhury Tumul
Published: August 2024

Neurological and cardiovascular disorders are the leading causes of morbidity and mortality worldwide. While the effects of cardiovascular disease (CD) on the nervous system are well understood, understanding of the reciprocal relationship has only recently become clearer. Based on disability-adjusted life years, this systematic review and meta-analysis present the pooled incidence and association of CD in 4 selected common, noncommunicable neurological disorders: (1) migraine, (2) Alzheimer disease and other dementias, (3) epilepsy, and (4) head injury. Sixty-five studies, including over 4 and a half million patients, were identified for inclusion in this review. Among the 4 neurological disorders, the majority of patients (89.4%) had epilepsy, 9.6% had migraine, and 0.97% had head injury. Alzheimer disease and other dementias were reported in only 0.02% of patients. The pooled effect estimates (incidence and association) of CD in the 4 neurological disorders was 10% (95% CI: 5.8%-16.9%; I
2 = 99.94%). When stratified by the neurological disorder, head injury was associated with the highest incidence of CD (28%). The 4 neurological disorders were associated with a 2-fold increased odds for developing CD in comparison to patients without neurological disorders. Epilepsy was associated with the greatest increased odds of developing CD (odds ratio: 2.25; 95% CI: 1.82-2.79; P = 0.04). In studies that reported this variable, the pooled hazard ratio was 1.64 (95% CI: 1.38-1.94), with head injury having the highest hazard ratio (2.17; 95% CI: 1.30-3.61). Large prospective database studies are required to understand the long-term consequences of CD in patients with neurological disorders.
Five-year Follow-up of a Prospective Food and Drug Administration Investigational Device Exemption Trial Evaluating a PEEK-on-Ceramic Cervical Disk Replacement
Authors: Guyer Richard D. , Bae Hyun , Coric Domagoj , Nunley Pierce D. , Musacchio Michael , Sasso Rick C. , Ohnmeiss Donna D.
Published: August 2024

Study Design.

Prospective trial comparing the investigation group to propensity-matched historic control group.

Objective.

To evaluate five-year results of single-level PEEK-on-ceramic cervical total disc replacement (TDR) compared with a propensity-matched anterior cervical discectomy and fusion (ACDF) control group.

Summary of Background Data.

Cervical TDR has gained acceptance as a treatment for symptomatic disk degeneration. The design and materials used in these devices continue to evolve.

Materials and Methods.

Data were collected in the Food and Drug Administration Investigational Device Exemption trial for the PEEK-on-ceramic Simplify Cervical Artificial Disc (n=150) with comparison to a propensity-matched ACDF control group (n=117). All patients were treated for single-level cervical disk degeneration with radiculopathy and/or myelopathy. Clinical outcome was based on composite clinical success (CCS), Neck Disability Index (NDI), visual analog scales (VAS) assessing pain, reoperations, and satisfaction. Radiographic measures included segmental range of motion (ROM), disk space height, and heterotopic ossification (HO). Evaluations were performed preoperatively and postoperatively within two and six weeks, and three, six, 12 months, and annually thereafter.

Results.

At five-year follow-up, CCS was significantly greater with TDR than ACDF (91.1% vs. 74.6%; P<0.01). In the TDR group, the mean NDI score was 63.3 preoperatively, reduced significantly to 23.1 at six weeks, and remained below 20 throughout the five-year follow-up. In the ACDF group, the mean preoperative NDI score was 62.4, decreasing to 33.7 at six weeks, and ranged from 25.9 to 21.5 throughout follow-up. Mean NDI scores were significantly lower in TDR group at all postoperative points (P<0.05). Mean TDR ROM was 7.3o preoperatively and 10.1o at five years. Bridging HO occurred in 9%. With TDR, there were six reoperations (4.0%) versus 11 (9.4%) with ACDF (P>0.40).

Conclusions.

PEEK-on-ceramic TDR produced significantly improved outcomes maintained throughout five-year follow-up that were similar or superior to ACDF, supporting TDR in appropriately selected patients.
Understanding Causes of Death in Patients With Acute Respiratory Distress Syndrome: A Narrative Review
Authors: Bromley Susan E. , Shakery Kaweh , Vora Pareen , Atabaki Artin , Reimer Thomas , McDermott Lawrence , Hajizadeh Negin
Published: August 2024

OBJECTIVES:

To provide a comprehensive summary of the published data on cause of death in patients with acute respiratory distress syndrome (ARDS).

DATA SOURCES:

PubMed (January 2015 to April 2024), bibliographies of relevant articles, and ARDS Network and Prevention & Early Treatment of Acute Lung Injury (PETAL) network websites.

STUDY SELECTION:

Observational studies and clinical trials that reported on cause of death in greater than or equal to 30 patients with ARDS, not obtained from death certificates. Animal studies, case reports, review articles, study protocols, and studies in pediatrics were excluded.

DATA EXTRACTION:

Causes of death among ARDS patients who died were extracted and tabulated along with other pertinent study characteristics.

DATA SYNTHESIS:

We identified 15 observational studies (nine non-COVID ARDS, five COVID-related ARDS; one both) and five clinical trials (all non-COVID ARDS). Mutually exclusive prespecified categories were used for recording the cause of death in only eight studies although studies differed in the categories included and their definitions. When multiple organ failure was a predetermined category, it was the most common cause of death recorded (~50% of deaths), followed by respiratory causes with proportions varying from 16% to 42% depending on nomenclature (e.g., refractory hypoxemia, pulmonary causes) and definitions. However, the largest observational study in non-COVID ARDS (964 deaths), did not include multiple organ failure as a predetermined category, and found that pulmonary failure (42%) and cardiac failure (37%) were the most common causes of death. In COVID-related ARDS observational studies, pulmonary reasons were the most reported cause of death (up to 88%).

CONCLUSIONS:

Few studies have reported cause of death in patients with ARDS. In those that do, cause of death categories and definitions used are heterogeneous. Further research is needed to see whether a more rigorous and unified approach to assigning and reporting cause of death in ARDS would help identify more relevant endpoints for the assessment of targeted treatments in clinical trials.
Detective flow imaging versus contrast-enhanced EUS in solid pancreatic lesions
Authors: Mulqui Maria Victoria , Caillol Fabrice , Ratone Jean Philippe , Hoibian Solène , Dahel Yanis , Meunier Élise , Archimbaud Clément , Giovannini Marc
Published: August 2024

Background and objectives

Detective flow imaging EUS (DFI-EUS) is a new technology that detects fine vessels and low-flow velocity without contrast agents, used in real time during EUS, with a better resolution compared to usual technologies such as color Doppler and eFLOW. The aim of this study was to compare DFI-EUS with contrast-enhanced EUS (CE-EUS) for the evaluation of vascularization in solid pancreatic lesions.

Methods

We included patients who had a pancreatic mass visualized by EUS, with recorded images of their assessment in DFI-EUS and CE-EUS techniques and a histological diagnosis confirmed malignant tumors or a minimum of 1-year follow-up for benign lesions.

Results

Of the 107 patients included in this retrospective single-center study, the histological diagnosis revealed 69 cases (64.5%) of pancreatic adenocarcinoma, 18 cases (16.8%) of neuroendocrine tumors (NETs), and 10 cases (9.3%) of metastases from nonpancreatic cancers. A smaller proportion (9.4%) exhibited other lesions. As a result, the incidence of intralesional microvascularization was 43.9% with DFI-EUS and 48.6% with CE-EUS, indicating a positive correlation between the 2 techniques (P = 0.0001). Compared to CE-EUS, DFI-EUS exhibited sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 88.5%, 98.2%, 97.9%, and 90%, respectively, for the detection of intralesional vessels.

Conclusions

The novel technique DFI-EUS demonstrates a remarkable correlation with CE-EUS, exhibiting high sensitivity and specificity for the assessment of microvascularization in solid pancreatic lesions. This method eliminates the need for a contrast agent, thus carrying no risk of adverse effects.
Current Concepts in Brachial Plexus Birth Injuries: A Comprehensive Narrative Review
Authors: Khabyeh-Hasbani Nathan , O’Brien Devon M. , Meisel Erin M. , Koehler Steven M.
Published: August 2024

Background:

Brachial plexus birth injury (BPBI) encompasses a spectrum of upper extremity paralysis cases following childbirth. The etiology of BPBI is multifactorial, involving maternal, obstetric, and neonatal associative factors. Despite opportunities for spontaneous recovery, recent literature demonstrates that a significant proportion of infants experience residual deficits and functional limitations as they age. Understanding the complex anatomy of the brachial plexus, clinical presentations of the pathology, diagnostic workup, current treatment options, and common secondary sequelae is instrumental for appropriate management of BPBI.

Methods:

Following a comprehensive search strategy used by the authors to identify relevant literature relating to the progression, patho-anatomy, clinical presentation, management, and treatment of BPBI, this comprehensive narrative review outlines current approaches to assess, manage, and advance BPBI care.

Results:

We advocate for prompt referral to specialized multicenter brachial plexus clinics for accurate diagnosis, timely intervention, and individualized patient-centered assessment. Further research is needed to elucidate mechanisms of injury, refine diagnostic protocols, and optimize long-term outcomes.

Conclusions:

Collaboration between healthcare providers and families is paramount in providing comprehensive care for infants with BPBI. This review offers insights into the current understanding and management of BPBI, highlighting the importance of tailored approaches and intraoperative decision-making algorithms to optimize functional outcomes.
Use of HEMHealing, an Oxygenating Dressing in the Treatment of a Full-thickness Burn on the Fingertips
Authors: Awan Tamer O. , Lhuaire Martin , Lantieri Laurent
Published: August 2024

The optimal treatment for full-thickness burn injuries involves surgical intervention, which may include skin grafting or reconstruction by flap. The complexity of treatment arises from the need for both effective temporary wound coverage and permanent skin restoration while also considering the potential risk of finger amputation in the case of hand burn. A 22-year-old woman sustained a thermal burn of three fingers while participating in an art activity involving wax hand molding. Initial treatment with a standard oily dressing did not yield satisfactory results, and the option to try HEMHealing was offered, a new oxygenating biological gel dressing, resulting in progressive debridement, granulation, and epithelialization of the wound. Complete healing was achieved within 10 and 15 days for the second and fourth fingers, respectively, and within 8 weeks for the third finger. The use of HEMHealing, in this case, most likely contributed to accelerating wound healing, promoting the growth of new tissues, improving local tissue oxygenation, and avoiding a disabling distal amputation.
Extracorporeal Membrane Oxygenation Pathway for Management of Refractory Cardiac Arrest: a Retrospective Study From a National Center of Extracorporeal Cardiopulmonary Resuscitation
Authors: Shehatta Ahmed Labib , Kaddoura Rasha , Orabi Bassant , Mohamed Ibrahim Mohamed Izham , El-Menyar Ayman , Alyafei Sumaya Alsaadi , Alkhulaifi Abdulaziz , Ibrahim Abdulsalam Saif , Hassan Ibrahim Fawzy , Omar Amr S.
Published: August 2024

Background:

Cardiac arrest remains a critical condition with high mortality and catastrophic neurological impact. Extracorporeal cardiopulmonary resuscitation (ECPR) has been introduced as an adjunct in cardiopulmonary resuscitation modalities. However, survival with good neurological outcomes remains a major concern. This study aims to explore our early experience with ECPR and identify the factors associated with survival in patients presenting with refractory cardiac arrest.

Methods:

This is a retrospective cohort study analyzing 6-year data from a tertiary center, the country reference for ECPR. This study was conducted at a national center of ECPR. Participants of this study were adult patients who experienced witnessed refractory cardiopulmonary arrest and were supported by ECPR. ECPR was performed for eligible patients as per the local service protocols.

Results:

Data from 87 patients were analyzed; of this cohort, 62/87 patients presented with in-hospital cardiac arrest (IHCA) and 25/87 presented with out-of-hospital cardiac arrest (OHCA). Overall survival to decannulation and hospital discharge rates were 26.4% and 25.3%, respectively. Among survivors (n = 22), 19 presented with IHCA (30.6%), while only 3 survivors presented with OHCA (12%). A total of 15/87 (17%) patients were alive at 6-month follow-up. All survivors had good neurological function assessed as Cerebral Performance Category 1 or 2. Multivariate logistic regression to predict survival to hospital discharge showed that IHCA was the only independent predictor (odds ratio: 5.8, P = 0.042); however, this positive association disappeared after adjusting for the first left ventricular ejection fraction after resuscitation.

Conclusions:

In this study, the use of ECPR for IHCA was associated with a higher survival to discharge compared to OHCA. This study demonstrated a comparable survival rate to other established centers, particularly for IHCA. Neurological outcomes were comparable in both IHCA and OHCA survivors. However, large multicenter studies are warranted for better understanding and improving the outcomes.
Trends in Transcatheter Aortic Valve Implantation Utilization, Outcomes, and Healthcare Resource Use in Patients With Liver Cirrhosis: A Decade of Insights (2011–2020)
Authors: Krittanawong Chayakrit , Wang Yichen , Qadeer Yusuf Kamran , Chen Bing , Wang Zhen , Al-Azzam Fu’ad , Alam Mahboob , Sharma Samin , Jneid Hani
Published: August 2024

It is well known that individuals with liver cirrhosis are considered at high risk for cardiac surgery, with an increased risk for morbidity and mortality as the liver disease progresses. In the last decade, there have been considerable advances in transcatheter aortic valve implantation (TAVI) as an alternative to surgical aortic valve replacement (SAVR) in individuals deemed to be at high risk for surgery. However, research surrounding TAVI in the setting of liver cirrhosis has not been as widely studied. In this national population-based cohort study, we evaluated the trends of mortality, complications, and healthcare utilization in liver cirrhotic patients undergoing TAVI, as well as analyzed the basic demographics of these individuals. We found that from 2011 to 2020, the amount of TAVI procedures conducted in cirrhotic patients was increasing annually, while mortality, procedural complications, and healthcare utilization trends in these cirrhotic patients undergoing TAVI decreased. Overall, TAVI does seem to be reasonable management for aortic stenosis patients with liver cirrhosis who need aortic valve replacement.
Plasma Clozapine and N-Desmethylclozapine (Norclozapine) Concentrations and the Clozapine/Norclozapine Ratio
Authors: Flanagan Robert James , Obee Stephen John , Kim Alice Hyun Min , Every-Palmer Susanna
Published: August 2024

Background

Smoking enhances plasma clozapine clearance, but the magnitude of the effect across the dose and age ranges is unclear.

Methods

We audited clozapine dose and predose plasma clozapine and N-desmethylclozapine (norclozapine) concentrations by sex and smoking habit in samples submitted for clozapine TDM, 1996–2017.

Results

There were 105,316/60,792 and 34,288/31,309 samples from male/female smokers/nonsmokers, respectively. There were distinct dose–median plasma concentration trajectories for male/female smokers/nonsmokers across the range <50 to >850 mg d−1. For both sexes, the percentage difference in median plasma clozapine in nonsmokers versus smokers averaged 50% but was greatest for men (76%) and women (59%) in the 151 to 250 mg d−1 dose band. In men, the percentage difference declined steadily to 34% at doses of ≥850 mg d−1. In women, the difference after falling initially remained relatively constant at 40% to 54%. The pattern in median plasma clozapine/norclozapine ratio by plasma clozapine concentration and dose groups was independent of sex and smoking habit, but increased with plasma clozapine concentration (higher ratio at higher concentrations) and also changed with dose. Median plasma clozapine concentration and median clozapine dose by sex and smoking habit were similar up to age 60 years. Proportional weight gain was similar over time in smokers and nonsmokers of either sex.

Implications

These data explain the variations in the effect size of starting or stopping smoking on plasma clozapine concentration at constant dose reported in different studies. Changes in smoking habit in patients prescribed clozapine require prompt dose adjustment.