Frailty Syndrome and Risk of Sepsis in the REasons for Geographic And Racial Differences in Stroke (REGARDS) Cohort.

BACKGROUND:: Frailty is associated with increased morbidity and mortality in older persons. We sought to characterize the associations between the frailty syndrome and long-term risk of sepsis in a large cohort of community-dwelling adults. METHODS:: We analyzed data on 30 239 community-dwelling adult participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. We defined frailty as the presence of at least 2 frailty indicators (weakness, exhaustion, and low physical activity). We defined sepsis as hospitalization for a serious infection with ≥2 system inflammatory response syndrome criteria, identified for the period 2003-2012. We determined the associations between frailty and risk of first sepsis and sepsis 30-day case fatality. RESULTS:: Among REGARDS participants, frailty was present in 6018 (19.9%). Over the 10-year observation period, there were 1529 first-sepsis hospitalizations. Frailty was associated with increased risk of sepsis (adjusted hazard ratio [HR] 1.44; 95% CI: 1.26 to 1.64). The total number of frailty indicators was associated with increased risk of sepsis ( P trend <.001). Among first-sepsis hospitalizations, frailty was associated with increased sepsis 30-day case fatality (adjusted OR 1.62; 95% CI: 1.06 to 2.50). CONCLUSIONS:: In the REGARDS cohort, frailty was associated with increased long-term risk of sepsis and sepsis 30-day case fatality.

Uterine myomas: effect of prior myomectomy on pregnancy outcomes.

OBJECTIVE: Reproductive aged women with fibroids must weigh the risks and benefits of preconception myomectomy. Women with fibroids may have higher rates of fetal growth restriction (FGR) and stillbirth; however, there is a paucity of data on the impact of myomectomy on pregnancy outcomes. We compared perinatal outcomes in women with prior myomectomy versus those with no prior myomectomy and at least one fibroid ≥ 5 cm. METHODS: Retrospective cohort study of women at a single center who delivered between 2008 and 2017 with a viable intrauterine pregnancy at initial ultrasound scan and either prior myomectomy, or, in the no-myomectomy cohort, at least one fibroid ≥ 5 cm on a prenatal scan performed at < 21 weeks' gestation (wga). Pregnancies complicated by major congenital anomalies were excluded. Primary outcome was preterm birth (PTB) < 37wga. Secondary outcomes included rates of spontaneous loss, cesarean delivery (CD), abnormal placentation, malpresentation, FGR, birthweight, birthweight percentile, estimated blood loss (EBL), blood transfusion, and neonatal survival to discharge. RESULTS: A total of 290 women met inclusion criteria: 70 had a prior myomectomy, 220 women had ≥1 fibroid ≥5cm. Women with prior myomectomy were older, more likely to have private insurance, and more likely used artificial reproductive technology to conceive; 20% with prior myomectomy still had at least one ≥ 5 cm myoma on their obstetric scan. Rates of spontaneous loss were lower in the prior myomectomy group (1.4% vs 7.3%; p = .08). Of the 273 pregnancies continuing beyond 20 weeks, women with prior myomectomy had significantly more PTBs (35% vs. 21%, p = .02) and significantly different primary birth indications (p < .0001). However, after controlling for late preterm, prelabor cesareans recommended by providers in the myomectomy cohort, the difference in PTB rates was not significant (p = .13). The myomectomy group had more CDs (88% vs. 53%, p < .0001), higher EBL (1250 mL vs. 811 mL, p = .04), and a trend toward more blood transfusions (16% vs 8%, p = .05). Other selected outcomes were similar, including rates of FGR. CONCLUSIONS: Women with prior myomectomy had significantly more PTBs, due in part to more preterm, prelabor cesareans in the late preterm period. Otherwise, prior myomectomy did not confer appreciable obstetric or perinatal benefits, as patients had more CDs, and higher EBL. Recommendations to perform preterm prelabor cesareans in this population may explain some of the PTB disparity. The effect of prior myomectomy on early pregnancy loss and infertility requires further study.

Evaluation of a Risk-Stratified, Heparin-Based, Obstetric Thromboprophylaxis Protocol.

OBJECTIVE: To evaluate outcomes before and after implementation of a risk-stratified heparin-based obstetric thromboprophylaxis protocol. METHODS: We performed a retrospective cohort study of all patients who delivered at our tertiary care center from 2013 to 2018. Deliveries were categorized as preprotocol (2013-2015; no standardized heparin-based thromboprophylaxis) and postprotocol (2016-2018). Patients receiving outpatient anticoagulation for active venous thromboembolism (VTE) or high VTE risk were excluded. Coprimary effectiveness and safety outcomes were postpartum VTEs and wound hematomas, respectively, newly diagnosed after delivery and up to 6 weeks postpartum. Secondary outcomes were other wound or bleeding complications, including unplanned surgical procedures (eg, hysterectomies, wound explorations) and blood transfusions. Outcomes were compared between groups, and adjusted odds ratios (aORs) and 95% CIs were calculated using the preprotocol group as reference. RESULTS: Of 24,229 deliveries, 11,799 (49%) occurred preprotocol. Although patients were more likely to receive heparin-based prophylaxis postprotocol (15.6% vs 1.2%, P<.001), there was no difference in VTE frequency between groups (0.1% vs 0.1%, odds ratio 1.0, 95% CI 0.5-2.1). However, patients postprotocol experienced significantly more wound hematomas (0.7% vs 0.4%, aOR 2.34, 95% CI 1.54-3.57), unplanned surgical procedures (aOR 1.29, 95% CI 1.06-1.57), and blood transfusions (aOR 1.34, 95% CI 1.16-1.55). CONCLUSION: Risk-stratified heparin-based thromboprophylaxis in a general obstetric population was associated with increased wound and bleeding complications without a complementary decrease in postpartum VTE. Guidelines recommending this strategy should be reconsidered.