Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report.

Importance: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking. Objective: To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH. Evidence Review: With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach. Findings: After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified. Conclusions and Relevance: Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group.

INTRODUCTION: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS: Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS: Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS: These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Obstetric anaesthetic practice in the UK: a descriptive analysis of the National Obstetric Anaesthetic Database 2009-14.

BACKGROUND: Data on UK obstetric anaesthetic practice between 2009 and 2014 were collected by the Obstetric Anaesthetists' Association's National Obstetric Anaesthetic Database. This database provides information on workload, variation in practice, and complication rates. METHODS: During 2009-14, data were submitted by 190 UK hospitals. The number of hospitals that submitted data each year ranged between 114 and 145. During this 6 yr period, between 27 and 35 data items were requested, although not all hospitals submitted information on all data items. The dataset was assessed for quality and only those data items with acceptable quality were analysed. RESULTS: The dataset contains information on 3 030 493 deliveries, 770 545 Caesarean sections, 623 050 women with labour neuraxial analgesia, and 61 121 general anaesthetics for Caesarean section. There was increased use of patient-controlled regimens for labour neuraxial analgesia over the 6 yr period. The mean rate of general anaesthesia used for Caesarean section was 8.75% (95% confidence interval, 8.26-9.24%). The rate of failed intubation for general anaesthesia for Caesarean section was one in 379. Inadvertent dural puncture rates varied between hospitals with a mean of 1.2% (95% confidence interval, 1.02-1.37%). The rate of a high neuraxial block causing unconsciousness was one in 6667 for all blocks. CONCLUSIONS: This unique large dataset provides a valuable insight of obstetric anaesthetic activity in the UK. Although missing data may place limitations on interpretation, it provides comparative estimates for the rates of rare complications and highlights variations in practice in time and place.

Preeclampsia and the anaesthesiologist: current management.

PURPOSE OF REVIEW: Preeclampsia remains an important cause of maternal and neonatal morbidity and mortality. Recent interest in angiogenic biomarkers as a prognostic indicator is reviewed, together with analgesic, anaesthetic and critical-care management of the preeclamptic patient. RECENT FINDINGS: There has been recent interest in the angiogenic biomarkers placental growth factor and soluble fms-like tyrosine kinase-1 in establishing the diagnosis of preeclampsia and guiding its management. Neuraxial blocks are recommended for both labour and operative delivery if not contraindicated by thrombocytopenia or coagulopathy, although a safe lower limit for platelet numbers has not been established. For spinal hypotension phenylephrine is noninferior to ephedrine in preeclamptic parturients and may offer some benefits. When general anaesthesia is required, efforts must be made to blunt the hypertensive response to laryngoscopy and intubation. Transthoracic echocardiography has emerged as useful technique to monitor maternal haemodynamics in preeclampsia. SUMMARY: Improvements in the diagnosis of preeclampsia may lead to better outcomes for mothers and babies. Peripartum care requires a multidisciplinary team approach with many preeclamptic women receiving neuraxial analgesia or anaesthesia. Women with severe preeclampsia may require critical-care support and this should meet the same standards afforded to other acutely unwell patients.

Deprescribing as a Clinical Improvement Focus.

OBJECTIVES: Polypharmacy is a concern in the practice of geriatrics because of consequences such as adverse drug events and poorer quality of life. Deprescribing, a response to polypharmacy, refers to the systematic, programmed, and appropriate reduction in drug number and dose. Although now broadly recognized, challenges exist in practice for effective implementation. This study was conducted to determine the deprescribing success rate and relate it to drug classes and clinical settings, and to identify factors that influence the deprescribing process. DESIGN: As a performance improvement (PI) project, fellows in geriatric medicine, under supervision of faculty geriatricians, attempted deprescribing during at least 1 encounter daily at 2 long-term care (LTC) facilities and an outpatient geriatrics clinic (C) in Bronx, New York, from August 2018 to January 2019. Deprescribing was initiated following discussion and consent from patient or caregiver. Following the data collection, involved fellows and faculty physicians participated in a survey to identify factors that influenced the process. RESULTS: Out of 449 encounters, 383 encounters were included for analysis. Average patient age was 78.2 years (LTC: 77.9, C: 79.1). Average patient comorbidities was 6.5 (LTC: 6.7, C: 5.8). Deprescribing was successful in 90.1% of encounters (LTC: 96.9%, C: 67.4%). On average, 1.3 medications were deprescribed per encounter (LTC: 1.4, C: 1.0). Analgesics (32.2%), multivitamin-minerals supplements (29.7%), lipid-lowering agents (22.9%), antihistamines (46.7%), and acid blockers (26.2%) had highest success. CONCLUSIONS AND IMPLICATIONS: Deprescribing is possible in practice in both LTC and community settings at each encounter, until it is no longer applicable. Factors that contribute to successful deprescribing primarily include meaningful and earnest provider effort, ideally in collaboration with interdisciplinary team members (nurses, pharmacists, social worker, and others), besides interactions with consultants for the patient. Certain medication classes such as vitamins, minerals, analgesics, and proton pump inhibitors can be deprescribed with high success, as noted in our study, whereas antipsychotic agents, antidepressants, and ophthalmic preparations, prescribed by specialists, proved harder to deprescribe. An understanding of barriers to deprescribing (outlined in the article) and addressing them are crucial in enabling success. The study demonstrates that as a performance improvement project in collaborative effort with multiple disciplines, deprescribing is possible in health care. Factors promoting success and barriers to deprescribing are detailed. Appropriate deprescribing has the potential to help lower adverse drug events, costs of care, and possibly improve quality of life.

Differential plague susceptibility in species and populations of prairie dogs.

Laboratory trials conducted over the past decade at U.S. Geological Survey National Wildlife Health Center indicate that wild populations of prairie dogs (Cynomys spp.) display different degrees of susceptibility to experimental challenge with fully virulent Yersinia pestis, the causative agent of plague. We evaluated patterns in prairie dog susceptibility to plague to determine whether the historical occurrence of plague at location of capture was related to survival times of prairie dogs challenged with Y. pestis. We found that black-tailed prairie dogs (Cynomys ludovicianus) from South Dakota (captured prior to the detection of plague in the state), Gunnison's prairie dogs (Cynomys gunnisoni) from Colorado, and Utah prairie dogs (Cynomys parvidens) from Utah were most susceptible to plague. Though the susceptibility of black-tailed prairie dogs in South Dakota compared with western locations supports our hypothesis regarding historical exposure, both Colorado and Utah prairie dogs have a long history of exposure to plague. It is possible that for these populations, genetic isolation/bottle necks have made them more susceptible to plague outbreaks.

Challenges and Opportunities Developing Mathematical Models of Shared Pathogens of Domestic and Wild Animals.

Diseases that affect both wild and domestic animals can be particularly difficult to prevent, predict, mitigate, and control. Such multi-host diseases can have devastating economic impacts on domestic animal producers and can present significant challenges to wildlife populations, particularly for populations of conservation concern. Few mathematical models exist that capture the complexities of these multi-host pathogens, yet the development of such models would allow us to estimate and compare the potential effectiveness of management actions for mitigating or suppressing disease in wildlife and/or livestock host populations. We conducted a workshop in March 2014 to identify the challenges associated with developing models of pathogen transmission across the wildlife-livestock interface. The development of mathematical models of pathogen transmission at this interface is hampered by the difficulties associated with describing the host-pathogen systems, including: (1) the identity of wildlife hosts, their distributions, and movement patterns; (2) the pathogen transmission pathways between wildlife and domestic animals; (3) the effects of the disease and concomitant mitigation efforts on wild and domestic animal populations; and (4) barriers to communication between sectors. To promote the development of mathematical models of transmission at this interface, we recommend further integration of modern quantitative techniques and improvement of communication among wildlife biologists, mathematical modelers, veterinary medicine professionals, producers, and other stakeholders concerned with the consequences of pathogen transmission at this important, yet poorly understood, interface.

Local factors associated with on-host flea distributions on prairie dog colonies.

Outbreaks of plague, a flea-vectored bacterial disease, occur periodically in prairie dog populations in the western United States. In order to understand the conditions that are conducive to plague outbreaks and potentially predict spatial and temporal variations in risk, it is important to understand the factors associated with flea abundance and distribution that may lead to plague outbreaks. We collected and identified 20,041 fleas from 6,542 individual prairie dogs of four different species over a 4-year period along a latitudinal gradient from Texas to Montana. We assessed local climate and other factors associated with flea prevalence and abundance, as well as the incidence of plague outbreaks. Oropsylla hirsuta, a prairie dog specialist flea, and Pulex simulans, a generalist flea species, were the most common fleas found on our pairs. High elevation pairs in Wyoming and Utah had distinct flea communities compared with the rest of the study pairs. The incidence of prairie dogs with Yersinia pestis detections in fleas was low (n = 64 prairie dogs with positive fleas out of 5,024 samples from 4,218 individual prairie dogs). The results of our regression models indicate that many factors are associated with the presence of fleas. In general, flea abundance (number of fleas on hosts) is higher during plague outbreaks, lower when prairie dogs are more abundant, and reaches peak levels when climate and weather variables are at intermediate levels. Changing climate conditions will likely affect aspects of both flea and host communities, including population densities and species composition, which may lead to changes in plague dynamics. Our results support the hypothesis that local conditions, including host, vector, and environmental factors, influence the likelihood of plague outbreaks, and that predicting changes to plague dynamics under climate change scenarios will have to consider both host and vector responses to local factors.

Factors Influencing Uptake of Sylvatic Plague Vaccine Baits by Prairie Dogs.

Sylvatic plague vaccine (SPV) is a virally vectored bait-delivered vaccine expressing Yersinia pestis antigens that can protect prairie dogs (Cynomys spp.) from plague and has potential utility as a management tool. In a large-scale 3-year field trial, SPV-laden baits containing the biomarker rhodamine B (used to determine bait consumption) were distributed annually at a rate of approximately 100-125 baits/hectare along transects at 58 plots encompassing the geographic ranges of four species of prairie dogs. We assessed site- and individual-level factors related to bait uptake in prairie dogs to determine which were associated with bait uptake rates. Overall bait uptake for 7820 prairie dogs sampled was 70% (95% C.I. 69.9-72.0). Factors influencing bait uptake rates by prairie dogs varied by species, however, in general, heavier animals had greater bait uptake rates. Vegetation quality and day of baiting influenced this relationship for black-tailed, Gunnison's, and Utah prairie dogs. For these species, baiting later in the season, when normalized difference vegetation indices (a measure of green vegetation density) are lower, improves bait uptake by smaller animals. Consideration of these factors can aid in the development of species-specific SPV baiting strategies that maximize bait uptake and subsequent immunization of prairie dogs against plague.

Sylvatic Plague Vaccine Partially Protects Prairie Dogs (Cynomys spp.) in Field Trials.

Sylvatic plague, caused by Yersinia pestis, frequently afflicts prairie dogs (Cynomys spp.), causing population declines and local extirpations. We tested the effectiveness of bait-delivered sylvatic plague vaccine (SPV) in prairie dog colonies on 29 paired placebo and treatment plots (1-59 ha in size; average 16.9 ha) in 7 western states from 2013 to 2015. We compared relative abundance (using catch per unit effort (CPUE) as an index) and apparent survival of prairie dogs on 26 of the 29 paired plots, 12 with confirmed or suspected plague (Y. pestis positive carcasses or fleas). Even though plague mortality occurred in prairie dogs on vaccine plots, SPV treatment had an overall positive effect on CPUE in all three years, regardless of plague status. Odds of capturing a unique animal were 1.10 (95% confidence interval [C.I.] 1.02-1.19) times higher per trap day on vaccine-treated plots than placebo plots in 2013, 1.47 (95% C.I. 1.41-1.52) times higher in 2014 and 1.19 (95% C.I. 1.13-1.25) times higher in 2015. On pairs where plague occurred, odds of apparent survival were 1.76 (95% Bayesian credible interval [B.C.I.] 1.28-2.43) times higher on vaccine plots than placebo plots for adults and 2.41 (95% B.C.I. 1.72-3.38) times higher for juveniles. Our results provide evidence that consumption of vaccine-laden baits can protect prairie dogs against plague; however, further evaluation and refinement are needed to optimize SPV use as a management tool.

DISPERSAL HAZARDS OF PSEUDOGYMNOASCUS DESTRUCTANS BY BATS AND HUMAN ACTIVITY AT HIBERNACULA IN SUMMER.

Bats occupying hibernacula during summer are exposed to Pseudogymnoascus destructans (Pd), the causative agent of white-nose syndrome (WNS), and may contribute to its dispersal. Furthermore, equipment and clothing exposed to cave environments are a potential source for human-assisted spread of Pd. To explore dispersal hazards for Pd during the nonhibernal season, we tested samples that were collected from bats, the environment, and equipment at hibernacula in the eastern US between 18 July-22 August 2012. Study sites included six hibernacula known to harbor bats with Pd with varying winter-count impacts from WNS and two hibernacula (control sites) without prior history of WNS. Nucleic acid from Pd was detected from wing-skin swabs or guano from 40 of 617 bats (7% prevalence), including males and females of five species at five sites where WNS had previously been confirmed as well as from one control site. Analysis of guano collected during summer demonstrated a higher apparent prevalence of Pd among bats (17%, 37/223) than did analysis of wing-skin swabs (1%, 4/617). Viable Pd cultured from wing skin (2%, 1/56) and low recapture rates at all sites suggested bats harboring Pd during summer could contribute to pathogen dispersal. Additionally, Pd DNA was detected on clothing and trapping equipment used inside and near hibernacula, and Pd was detected in sediment more readily than in swabs of hibernaculum walls. Statistically significant differences in environmental abundance of Pd were not detected among sites, but prevalence of Pd differed between sites and among bat species. Overall, bats using hibernacula in summer can harbor Pd on their skin and in their guano, and demonstration of Pd on clothing, traps, and other equipment used at hibernacula during summertime within the WNS-affected region indicates risk for pathogen dispersal during the nonhibernal season.

When mechanism matters: Bayesian forecasting using models of ecological diffusion.

Ecological diffusion is a theory that can be used to understand and forecast spatio-temporal processes such as dispersal, invasion, and the spread of disease. Hierarchical Bayesian modelling provides a framework to make statistical inference and probabilistic forecasts, using mechanistic ecological models. To illustrate, we show how hierarchical Bayesian models of ecological diffusion can be implemented for large data sets that are distributed densely across space and time. The hierarchical Bayesian approach is used to understand and forecast the growth and geographic spread in the prevalence of chronic wasting disease in white-tailed deer (Odocoileus virginianus). We compare statistical inference and forecasts from our hierarchical Bayesian model to phenomenological regression-based methods that are commonly used to analyse spatial occurrence data. The mechanistic statistical model based on ecological diffusion led to important ecological insights, obviated a commonly ignored type of collinearity, and was the most accurate method for forecasting.

A Framework for Modeling Emerging Diseases to Inform Management.

The rapid emergence and reemergence of zoonotic diseases requires the ability to rapidly evaluate and implement optimal management decisions. Actions to control or mitigate the effects of emerging pathogens are commonly delayed because of uncertainty in the estimates and the predicted outcomes of the control tactics. The development of models that describe the best-known information regarding the disease system at the early stages of disease emergence is an essential step for optimal decision-making. Models can predict the potential effects of the pathogen, provide guidance for assessing the likelihood of success of different proposed management actions, quantify the uncertainty surrounding the choice of the optimal decision, and highlight critical areas for immediate research. We demonstrate how to develop models that can be used as a part of a decision-making framework to determine the likelihood of success of different management actions given current knowledge.

Effects of wind energy generation and white-nose syndrome on the viability of the Indiana bat.

Wind energy generation holds the potential to adversely affect wildlife populations. Species-wide effects are difficult to study and few, if any, studies examine effects of wind energy generation on any species across its entire range. One species that may be affected by wind energy generation is the endangered Indiana bat (Myotis sodalis), which is found in the eastern and midwestern United States. In addition to mortality from wind energy generation, the species also faces range-wide threats from the emerging infectious fungal disease, white-nose syndrome (WNS). White-nose syndrome, caused by Pseudogymnoascus destructans, disturbs hibernating bats leading to high levels of mortality. We used a spatially explicit full-annual-cycle model to investigate how wind turbine mortality and WNS may singly and then together affect population dynamics of this species. In the simulation, wind turbine mortality impacted the metapopulation dynamics of the species by causing extirpation of some of the smaller winter colonies. In general, effects of wind turbines were localized and focused on specific spatial subpopulations. Conversely, WNS had a depressive effect on the species across its range. Wind turbine mortality interacted with WNS and together these stressors had a larger impact than would be expected from either alone, principally because these stressors together act to reduce species abundance across the spectrum of population sizes. Our findings illustrate the importance of not only prioritizing the protection of large winter colonies as is currently done, but also of protecting metapopulation dynamics and migratory connectivity.

When can the cause of a population decline be determined?

Inferring the factors responsible for declines in abundance is a prerequisite to preventing the extinction of wild populations. Many of the policies and programmes intended to prevent extinctions operate on the assumption that the factors driving the decline of a population can be determined. Exogenous factors that cause declines in abundance can be statistically confounded with endogenous factors such as density dependence. To demonstrate the potential for confounding, we used an experiment where replicated populations were driven to extinction by gradually manipulating habitat quality. In many of the replicated populations, habitat quality and density dependence were confounded, which obscured causal inference. Our results show that confounding is likely to occur when the exogenous factors that are driving the decline change gradually over time. Our study has direct implications for wild populations, because many factors that could drive a population to extinction change gradually through time.