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Receptores de Interleucina-6 , Humanos , Embarazo , Femenino , Receptores de Interleucina-6/antagonistas & inhibidores , Complicaciones del Embarazo/tratamiento farmacológico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Anticuerpos Monoclonales Humanizados/farmacología , Anticuerpos Monoclonales Humanizados/efectos adversos , Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Artritis Reumatoide/inmunologíaRESUMEN
BACKGROUND: Static cold storage (SCS) remains the gold standard for preserving donor hearts before transplantation but is associated with ischaemia, anaerobic metabolism, and organ injuries, leading to patient morbidity and mortality. We aimed to evaluate whether continuous, hypothermic oxygenated machine perfusion (HOPE) of the donor heart is safe and superior compared with SCS. METHODS: We performed a multinational, multicentre, randomised, controlled, open-label clinical trial with a superiority design at 15 transplant centres across eight European countries. Adult candidates for heart transplantation were eligible and randomly assigned in a 1:1 ratio. Donor inclusion criteria were age 18-70 years with no previous sternotomy and donation after brain death. In the treatment group, the preservation protocol involved the use of a portable machine perfusion system ensuring HOPE of the resting donor heart. The donor hearts in the control group underwent ischaemic SCS according to standard practices. The primary outcome was time to first event of a composite of either cardiac-related death, moderate or severe primary graft dysfunction (PGD) of the left ventricle, PGD of the right ventricle, acute cellular rejection at least grade 2R, or graft failure (with use of mechanical circulatory support or re-transplantation) within 30 days after transplantation. We included all patients who were randomly assigned, fulfilled inclusion and exclusion criteria, and received a transplant in the primary analysis and all patients who were randomly assigned and received a transplant in the safety analyses. This trial was registered with ClicalTrials.gov (NCT03991923) and is ongoing. FINDINGS: A total of 229 patients were enrolled between Nov 25, 2020, and May 19, 2023. The primary analysis population included 204 patients who received a transplant. There were no patients who received a transplant lost to follow-up. All 100 donor hearts preserved with HOPE were transplantable after perfusion. The primary endpoint was registered in 19 (19%) of 101 patients in the HOPE group and 31 (30%) of 103 patients in the SCS group, corresponding to a risk reduction of 44% (hazard ratio 0·56; 95% CI 0·32-0·99; log-rank test p=0·059). PGD was the primary outcome event in 11 (11%) patients in the HOPE group and 29 (28%) in the SCS group (risk ratio 0·39; 95% CI 0·20-0·73). In the HOPE group, 63 (65%) patients had a reported serious adverse event (158 events) versus 87 (70%; 222 events) in the SCS group. Major adverse cardiac transplant events were reported in 18 (18%) and 33 (32%) patients in the HOPE and SCS group (risk ratio 0·56; 95% CI 0·34-0·92). INTERPRETATION: Although there was not a significant difference in the primary endpoint, the 44% risk reduction associated with HOPE was suggested to be a clinically meaningful benefit. Post-transplant complications, measured as major adverse cardiac transplant events, were reduced. Analysis of secondary outcomes suggested that HOPE was beneficial in reducing primary graft dysfunction. HOPE in donor heart preservation addresses the existing challenges associated with graft preservation and the increasing complexity of donors and heart transplantation recipients. Future investigation will help to further elucidate the benefit of HOPE. FUNDING: XVIVO Perfusion.
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Trasplante de Corazón , Preservación de Órganos , Perfusión , Humanos , Persona de Mediana Edad , Masculino , Femenino , Preservación de Órganos/métodos , Adulto , Perfusión/métodos , Anciano , Disfunción Primaria del Injerto/prevención & control , Adulto Joven , Donantes de Tejidos , Adolescente , Resultado del Tratamiento , Rechazo de Injerto/prevención & controlRESUMEN
Herein, we aimed to investigate the antifungal susceptibility pattern of Candida auris clinical strains in our setting Bahrain Oncology Center-King Hamad University Hospital-Bahrain. C. auris strains isolated from different clinical specimens in the Microbiology Laboratory from October-2021 to November-2022 were evaluated. Species-level identification of fungi was performed by MALDI-TOF (Bruker, Germany). Minimum inhibitory concentration (MIC) was determined either by E-test strips or by MICRONAUT MIC system based on CDC guidelines for C. auris antifungal interpretation. Fluconazole, amphotericin-B, voriconazole, and caspofungin susceptibility data of the clinical strains were analyzed. A total of 40 clinical isolates were included: 25% were blood culture isolates, 65% were urinary, and 10% were soft tissue isolates. Only 29 strains could be tested for amphotericin-B and 32 for voriconazole. Overall resistance pattern was as follows: 100% resistance to fluconazole, 2.5% resistance to caspofungin, and 0% resistance to amphotericin b. Median voriconazole MIC was 0.015 ug/ml (min 0.08, max= 0.064 ug/ml). We had no fluconazole-sensitive strain and only one caspofungin-resistant strain. A single isolate (2.5%), which was associated with candidemia, demonstrated resistance to two antifungal agents: fluconazole and caspofungin. No triple or quadruple drug resistant strain existed.
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Antifúngicos , Candida auris , Candidiasis , Farmacorresistencia Fúngica , Hospitales Universitarios , Pruebas de Sensibilidad Microbiana , Antifúngicos/farmacología , Humanos , Candidiasis/microbiología , Candida auris/efectos de los fármacos , Femenino , Masculino , Adulto , Voriconazol/farmacología , Persona de Mediana Edad , Centros de Atención Terciaria , Atención Terciaria de Salud , Caspofungina/farmacología , Candida/efectos de los fármacos , Candida/aislamiento & purificaciónRESUMEN
BACKGROUND: Pregnant patients with preterm prelabor rupture of membranes (PPROM) may experience prolonged hospitalization, which is an indication for pharmacologic venous thromboembolism (VTE) prophylaxis according to certain international guidelines. The proportion of patients who deliver unexpectedly and within a period during which pharmacologic prophylaxis would be expected to impact coagulation is unknown. OBJECTIVE: To estimate the proportion of patients with PPROM who would deliver within 12 hours of typical dosing of pharmacologic VTE prophylaxis if administered routinely for antepartum admissions >72 hours. STUDY DESIGN: This is a retrospective cohort study from a database including patients admitted for expectant management of PPROM January 2011 to September 2020. The outcome of the study was the proportion of patients who remained undelivered 72 hours after admission and experienced an unplanned delivery potentially within 12 hours of enoxaparin administration. We evaluated patients undelivered after 72 hours due to international recommendations to initiate VTE prophylaxis in hospitalized patients after 72 hours. Unplanned delivery was defined as onset of spontaneous labor or other indication for immediate delivery. Timing of delivery was analyzed based on usual timing of enoxaparin administration daily at approximately 8 am and the recommendation to withhold regional anesthesia until 12 hours after a prophylactic dose. RESULTS: 1381 deliveries were identified as PPROM out of the 49,322 deliveries in our database. 139 cases were included after the following exclusions: delivery >35 weeks (N=641), rupture of membranes >34 weeks (N=145), delivery <72 hours after admission (N=409), insufficient data (N=35), and duplicates (N=12). Sixty of the 139 (43%) had an unplanned delivery, while 33 of these (24% of total) occurred within 12 hours of enoxaparin administration. CONCLUSION: A quarter of patients admitted for PPROM had an unplanned delivery within 12 hours of typical enoxaparin dosing. This cohort may experience harm (ineligibility for regional anesthesia, risks of general anesthesia, increased risk of bleeding) if given routine pharmacologic VTE prophylaxis. Risk/benefit considerations should be discussed with patients in considering pharmacologic versus mechanical prophylaxis during prolonged hospitalization for PPROM.
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Anticoagulantes , Enoxaparina , Rotura Prematura de Membranas Fetales , Tromboembolia Venosa , Humanos , Femenino , Rotura Prematura de Membranas Fetales/epidemiología , Rotura Prematura de Membranas Fetales/prevención & control , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/epidemiología , Tromboembolia Venosa/etiología , Embarazo , Estudios Retrospectivos , Adulto , Enoxaparina/administración & dosificación , Anticoagulantes/administración & dosificación , Parto Obstétrico/métodos , Parto Obstétrico/efectos adversos , Parto Obstétrico/estadística & datos numéricosRESUMEN
Intestinal health is one of the key factors required for the growth and production of turkeys. Histomoniasis (blackhead disease), caused by a protozoan parasite, Histomonas meleagridis, is a reemerging threat to the turkey industry. Increased incidences of histomoniasis have been reported in recent years due to withdrawal of antihistomonas treatments. H. meleagridis affects ceca and causes cecal inflammation and necrosis. H. meleagridis migrates from ceca to the liver and causes liver necrosis, resulting in high mortalities. Ironically, field outbreaks of histomoniasis are not always associated with high mortalities, while low mortalities have also been documented. There are several exacerbating factors associated with high mortality rates in histomoniasis outbreaks, with concurrent infection being one of them. Recurrent histomoniasis outbreaks in a newly constructed barn were documented, and concurrent infection of H. meleagridis and hemorrhagic enteritis virus was confirmed. Currently, neither commercial vaccines nor prophylactic or therapeutic solutions are available to combat histomoniasis. However, there are treatments, vaccines, and solutions to minimize or prevent concurrent infections in turkeys. In addition to implementing biosecurity measures, measures to prevent concurrent infections are critical steps that the turkey industry can follow to reduce mortality rates and minimize the production and economic losses associated with histomoniasis outbreaks.
Infección simultánea por Histomonas meleagridis y el virus de la enteritis hemorrágica en una parvada de pavos con antecedentes recurrentes de enfermedad de la cabeza negra. La salud intestinal es uno de los factores clave necesarios para el crecimiento y producción de los pavos. La histomoniasis (enfermedad de la cabeza negra), causada por un parásito protozoario, Histomonas meleagridis, es una amenaza reemergente para la industria del pavo. En los últimos años se ha informado de un aumento de la incidencia de histomoniasis debido al retiro de los tratamientos con antihistomonas. Histomonas meleagridis afecta los ciegos y causa inflamación y necrosis cecal. Histomonas meleagridis migra desde los ciegos al hígado y causa necrosis hepática, lo que resulta en una alta mortalidad. Irónicamente, los brotes de histomoniasis en el campo no siempre se asocian con una mortalidad elevada, aunque también se han documentado mortalidades bajas. Hay varios factores exacerbantes asociados con altas tasas de mortalidad en los brotes de histomoniasis, siendo la infección concurrente uno de ellos. Se documentaron brotes recurrentes de histomoniasis en un alojamiento avícola recién construido y se confirmó la infección concurrente de H. meleagridis y el virus de la enteritis hemorrágica. Actualmente no se dis-pone de vacunas comerciales ni soluciones profilácticas o terapéuticas para combatir la histomoniasis. Sin embargo, existen tratamientos, vacunas y soluciones para minimizar o prevenir infecciones concurrentes en los pavos. Además de implementar medidas de bioseguridad, las medidas para prevenir infecciones concurrentes son pasos críticos que la industria del pavo puede seguir para reducir las tasas de mortalidad y minimizar las pérdidas económicas y de producción asociadas con los brotes de histomoniasis.
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Enfermedades de las Aves de Corral , Trichomonadida , Pavos , Animales , Enfermedades de las Aves de Corral/virología , Enfermedades de las Aves de Corral/parasitología , Trichomonadida/aislamiento & purificación , Infecciones Protozoarias en Animales/parasitología , Infecciones Protozoarias en Animales/epidemiología , Coinfección/veterinaria , Coinfección/virología , Coinfección/parasitología , Brotes de Enfermedades/veterinaria , Infecciones por Adenoviridae/veterinaria , Infecciones por Adenoviridae/virologíaRESUMEN
Hypoxic-ischemic encephalopathy (HIE) occurs in up to 7 out of 1000 births and accounts for almost a quarter of neonatal deaths worldwide. Despite the name, many newborns with HIE have little evidence of perinatal hypoxia. We hypothesized that some infants with HIE have genetic disorders that resemble encephalopathy. We reviewed genetic results for newborns with HIE undergoing exome or genome sequencing at a clinical laboratory (2014-2022). Neonates were included if they had a diagnosis of HIE and were delivered ≥35 weeks. Neonates were excluded for cardiopulmonary pathology resulting in hypoxemia or if neuroimaging suggested postnatal hypoxic-ischemic injury. Of 24 patients meeting inclusion criteria, six (25%) were diagnosed with a genetic condition. Four neonates had variants at loci linked to conditions with phenotypic features resembling HIE, including KIF1A, GBE1, ACTA1, and a 15q13.3 deletion. Two additional neonates had variants in genes not previously associated with encephalopathy, including DUOX2 and PTPN11. Of the six neonates with a molecular diagnosis, two had isolated HIE without apparent comorbidities to suggest a genetic disorder. Genetic diagnoses were identified among neonates with and without sentinel labor events, abnormal umbilical cord gasses, and low Apgar scores. These results suggest that genetic evaluation is clinically relevant for patients with perinatal HIE.
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Secuenciación del Exoma , Hipoxia-Isquemia Encefálica , Humanos , Hipoxia-Isquemia Encefálica/genética , Hipoxia-Isquemia Encefálica/diagnóstico , Hipoxia-Isquemia Encefálica/diagnóstico por imagen , Recién Nacido , Femenino , Masculino , Estudios Retrospectivos , Predisposición Genética a la Enfermedad , Exoma/genética , Enfermedades Genéticas Congénitas/genética , Enfermedades Genéticas Congénitas/diagnósticoRESUMEN
Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition that causes pain and discomfort in various body regions. This review explores the comparative effectiveness of two surgical techniques, namely, surgical deroofing and carbon dioxide laser therapy, in managing symptomatic HS, particularly in patients with Hurley stage I-III disease. We conducted a systematic literature search on PubMed and ClinicalTrials.gov. The clinical evidence suggests that surgical deroofing and carbon dioxide laser treatment are effective strategies for managing symptomatic HS. However, a comprehensive analysis of 1,120 patients indicates a higher recurrence rate with surgical deroofing. Further investigation into short-term and long-term follow-up data revealed comparable recurrence-free rates within 12 months post-procedure. Beyond 12 months, carbon dioxide laser treatment exhibited slightly higher recurrence-free rates, which necessitate more extensive studies for validation due to the limited sample size. In addition, surgical deroofing demonstrated quicker healing times, while carbon dioxide laser therapy showcased varying timelines, with primary closure after laser excision presenting a two-week healing time. Both procedures reported high patient satisfaction, emphasizing the need for personalized treatment decisions. Therefore, further research is essential to evaluate the efficacy of each treatment modality considering individual patient profiles and disease severity. It will benefit individuals affected by HS, leading to better health outcomes.
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BACKGROUND: Herein, it is aimed to present the decolonizing rates of Candida auris colonized cases after daily bathing with 4% chlorhexidine plus daily cleaning with 4% chlorhexidine wipe for 1 week (will be mentioned as DCHX). METHODS: The study period was from October, 2021, to November, 2022. Inclusion criteria were (i) age > 18, (ii) receiving DCHX, (iii) proven C. auris carrier on auricular, or axillar or inguinal swab surveillance cultures up to 5-day period before DCHX. Cases with three consecutive negative surveillance cultures 3 days apart were considered to be decolonized. RESULTS: A total of 38 cases [14 female, aged 61.8 ± 15.5 years] fulfilled the inclusion criteria. Six (15.8%), 23 (60.1%), and 22 cases (57.8%) were postauricular, inguinal, and axillary culture positive, respectively. Only three cases (7.9%) were triple culture positive. Nine cases (23.7%) had three consequent negative surveillance cultures after DCHX and were considered to be decolonized. There was no significant difference in decolonization rates of concomitant only antibiotic receiving cohort vs. concomitant antifungal + antibiotic receiving cohort (5/16 vs. 2/8, p = 1) were decolonized similarly. Of the nine C. auris decolonized cases, two developed C. auris infection in 30 days follow-up after decolonization. However, 10 (34.5%) of 29 non-decolonized cases developed C. auris infection (p: 0.450) within 30 days after surveillance culture positivity. Over all cohorts, day 30 mortality was 23.7% (9/38). CONCLUSION: In conclusion, based on our observational and relatively small uncontrolled series, it appears that DCHX is not very effective in decolonizing C. auris carriers (especially in cases who are C. auris colonized in > 1 areas), although it is not completely ineffective.
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Candidiasis Invasiva , Clorhexidina , Adulto , Femenino , Humanos , Persona de Mediana Edad , Antibacterianos , Antifúngicos/uso terapéutico , Candida auris , Clorhexidina/uso terapéuticoRESUMEN
BACKGROUND: Umbilical cord gases are often used to assess the impact of labor and delivery on the fetus. However, no large series exists that reflects contemporary obstetrical practice or that analyzed blood gas ranges by route of delivery. Baseline, prelabor acid-base status in the human fetus is also poorly defined, rendering the assessment of blood gas changes during labor difficult. OBJECTIVE: This study aimed to define normal umbilical cord gas and lactate values, stratified by mode of delivery, in a large contemporary series in which universal umbilical cord gas evaluation was dictated by protocol. STUDY DESIGN: This was a retrospective cohort study. We analyzed the umbilical cord gas and lactate data of an unselected population of infants born between March 2012 and April 2022 at a large teaching hospital. These values were then analyzed by mode of delivery and, for cesarean deliveries, by indication for cesarean delivery and type of anesthesia. Umbilical cord gas values from infants delivered by elective cesarean delivey under general anesthesia without labor were considered representative of baseline, prelabor values. RESULTS: Data were available for 45,475 infants. The median arterial pH values and interquartile ranges for vaginal births, elective cesarean deliveries without labor, and cesarean deliveries performed for fetal heart rate concerns were 7.27 (0.09), 7.27 (0.06), and 7.25 (0.09), respectively. Arterial lactate values for these same 3 groups were 4.1 (2.5), 2.5 (1.2), and 4.0 (2.8) mmoles/L, respectively. Because of the very large sample size, most comparisons yielded differences that were statistically significant, but clinically irrelevant. Of all the infants, 14% had an arterial pH <7.20; a pH value of 7.1 represents 2 standard deviations from the mean. CONCLUSION: This large, population-based study of umbilical cord gas and lactate levels in an unselected population, stratified by delivery mode, represents a previously unavailable benchmark for the evaluation of umbilical cord gases. Arterial umbilical cord pH values for infants delivered by elective caesarean delivery without labor (median pH 7.28) reflect a lower prelabor fetal pH baseline than previously assumed. This finding, coupled with our determination that a 2 standard deviation below normal pH limit of 7.1, instead of the historic arbitrary pH of 7.2 threshold, helps to explain the poor positive predictive value of electronic fetal heart rate monitoring, a test designed to detect arterial pH levels that have fallen from an assumed baseline near pH 7.4 to an assumed potentially injurious pH level of <7.2. Uncomplicated labor, even when prolonged, does not generally lead to a clinically significant cumulative hypoxic stress to the human fetus. These findings, along with our determination that there is no difference in the acid-base status among infants delivered by cesarean delivery for fetal heart rate concerns, help to explain the failure of current approaches in labor and delivery management to reduce the rates of neonatal hypoxic-ischemic encephalopathy and cerebral palsy, conditions that almost always reflect developmental events rather than the effects of labor on the fetus.
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Our understanding and management of gestational hypertension and its variants are substantially hindered by a reliance on antiquated terminology and on practice recommendations based largely on tradition rather than outcomes-based evidence. Unsurprisingly, gestational hypertension remains a major contributor to maternal and neonatal morbidity and mortality rates, with little improvement seen over the past half century except as it relates to better newborn care. Reliance on a binary classification of vastly disparate types and degrees of organ dysfunction (severe or not severe) and the use of nonphysiological and largely arbitrary gestational age cutoffs are particularly problematic. If this situation is to improve, it will be necessary to abandon current misleading terminology and non-evidence-based traditional practice patterns and start again, building on management approaches validated by outcomes-based data.
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Hipertensión Inducida en el Embarazo , Hipertensión , Preeclampsia , Embarazo , Recién Nacido , Femenino , Humanos , Hipertensión Inducida en el Embarazo/terapia , Edad GestacionalRESUMEN
OBJECTIVE: The aim of the study is to evaluate whether pathologic severity of placenta accreta spectrum (PAS) is correlated with the incidence of small for gestational age (SGA) and neonatal birthweight. STUDY DESIGN: This was a multicenter cohort study of viable, non-anomalous, singleton gestations delivered with histology-proven PAS. Data including maternal history, neonatal birthweight, and placental pathology were collected and deidentified. Pathology was defined as accreta, increta, or percreta. The primary outcome was rate of SGA defined by birth weight less than the 10th percentile. The secondary outcomes included incidence of large for gestational age (LGA) babies as defined by birth weight greater than the 90th percentile as well as incidence of SGA and LGA in preterm and term gestations. Statistical analysis was performed using Chi-square, Kruskal-Wallis, and log-binomial regression. Increta and percreta patients were each compared with accreta patients. RESULTS: Among the cohort of 1,008 women from seven United States centers, 865 subjects were included in the analysis. The relative risk (RR) of SGA for increta and percreta did not differ from accreta after adjusting for confounders (adjusted RR = 0.63, 95% confidence interval [CI]: 0.36-1.10 for increta and aRR = 0.72, 95% CI: 0.45-1.16 for percreta). The results were stratified by placenta previa status, which did not affect results. There was no difference in incidence of LGA (p = 1.0) by PAS pathologic severity. The incidence of SGA for all PAS patients was 9.2% for those delivered preterm and 18.7% for those delivered at term (p = 0.004). The incidence of LGA for all PAS patients was 12.6% for those delivered preterm and 13.2% for those delivered at term (p = 0.8203). CONCLUSION: There was no difference in incidence of SGA or LGA when comparing accreta to increta or percreta patients regardless of previa status. Although we cannot suggest causation, our results suggest that PAS, regardless of pathologic severity, is not associated with pathologic fetal growth in the preterm period. KEY POINTS: · PAS severity is not associated with SGA in the preterm period.. · PAS severity is not associated with LGA.. · Placenta previa does not affect the incidence of SGA in women with PAS..
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Placenta Accreta , Placenta Previa , Recién Nacido , Embarazo , Femenino , Humanos , Placenta Accreta/epidemiología , Placenta/patología , Peso al Nacer , Placenta Previa/epidemiología , Incidencia , Estudios de Cohortes , Edad Gestacional , Estudios RetrospectivosRESUMEN
OBJECTIVE: Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the confirmatory gold standard, but is only obtained sometime after definitive treatment. The International Federation of Gynecology and Obstetrics (FIGO) has published a new clinical classification that can be assigned at delivery, and we aimed to investigate the association between this new FIGO classification and histopathology and also to assess its correlation with maternal outcomes. STUDY DESIGN: We studied a retrospective cohort of 185 patients with histopathologically proven PAS managed at our referral center between September 2012 and January 2019. Two experienced surgeons retrospectively reviewed charts and assigned the FIGO grading based on findings reported at delivery. A third experienced reviewer adjudicated to determine the classification used for final analysis. Categorical outcomes were compared with the use of chi-squared and the Fisher exact test, as appropriate. A multivariate model was designed to adjust outcomes in different FIGO groups for the involvement of a formal multidisciplinary management team. RESULTS: Among 185 patients, there were 41 (22%) placenta accreta, 44 (24%) placenta increta, and 100 (54%) placenta percreta on histopathology. The inter-rater reliability was found to be substantial with Kappa = 0.661 (p < 0.001), and 95% confidence interval (CI): 0.449-0.872. There was a significant association between all histopathology groupings and the FIGO clinical classification (p < 0.001). However, we found no association between FIGO classifications and maternal complications. CONCLUSION: The new FIGO clinical classification is strongly associated with histopathologic findings. A better understanding of the depth and extent of invasion as afforded by the clinical classification system will help standardize reporting and future research. KEY POINTS: · PAS includes a wide spectrum of placental invasion with varied clinical significance.. · Histopathological examination is considered the confirmatory gold standard.. · The new FIGO clinical classification is strongly associated with histopathologic findings..
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Placenta Accreta , Placenta Previa , Embarazo , Humanos , Femenino , Placenta Accreta/cirugía , Estudios Retrospectivos , Placenta , Reproducibilidad de los ResultadosRESUMEN
OBJECTIVE: Massive transfusion protocols are widely implemented in obstetrical practice in case of severe hemorrhage; however, different recommendations exist regarding the appropriate ratios of blood product components to be transfused. We report our extensive experience with massive component transfusion in a referral center in which the standard massive transfusion protocol is modified by ongoing clinical and laboratory evaluation. STUDY DESIGN: A retrospective chart review of all patients who had massive transfusion protocol activation in a level 4 referral center for obstetrical practice was performed from January 2014 to January 2020. Data collected included the etiology of obstetrical hemorrhage, number of blood products of each type transfused, crystalloid infusion, and several indices of maternal morbidity and mortality. Data are presented with descriptive statistics. RESULTS: A total of 62 patients had massive transfusion protocol activation, of which 97% received blood products. Uterine atony was found to be the most common etiology for massive hemorrhage (34%), followed by placenta accreta spectrum (32%). The mean estimated blood loss was 1,945 mL. A mean of 6.5 units of packed red blood cells, 14.8 units of fresh frozen plasma and cryoprecipitate, and 8.3 units of platelets were transfused per patient. No maternal deaths were seen. CONCLUSION: The ratios of transfused packed red blood cell to fresh frozen plasma/cryoprecipitate and of packed red blood cell to platelet units varied significantly from the fixed initial infusion ratio called for by our massive transfusion protocol resulting in universally favorable maternal outcomes. When rapid laboratory evaluation of hematologic and clotting parameters is available, careful use of this information may facilitate safe modification of an initial fixed transfusion ratio based on etiology of the hemorrhage and individual patient response. KEY POINTS: · Massive transfusion protocols in obstetrics follow fixed ratios of blood products.. · Actual usage of blood components is different than the standardized protocols.. · We recommend to modify the initial fixed transfusion ratio according to clinical response..
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Transfusión Sanguínea , Placenta Accreta , Embarazo , Femenino , Humanos , Estudios Retrospectivos , Transfusión Sanguínea/métodos , Hemorragia , Transfusión de Componentes Sanguíneos/métodosRESUMEN
The evolution of continuous electronic fetal heart rate (FHR) monitoring has presented the obstetrician with a critical clinical conundrum: basic science observations suggest that such monitoring might be associated with improved long-term neurologic outcomes, yet, after a half century of use and millions of cesarean deliveries based on FHR monitoring, evidence for such improvement remains absent. This dichotomy appears to be related to widespread misconceptions regarding the physiology underlying various FHR patterns and the developmental origins of cerebral palsy. These misconceptions are strengthened by a reliance on anecdotal experience and tradition in lieu of evidence-based medicine, the confusing "category II" FHR designation, medical-legal considerations, and our tendency to view fetal monitoring, as originally conceptualized, as a single, indivisible entity whose concepts must be accepted or rejected en bloc. Ill-defined and largely imaginary conditions such as "depletion of fetal reserve" are particularly harmful and their use in clinical medicine uniquely not evidence based. A solution to this self-inflicted injury to our specialty will require a concerted effort involving teachers, authors, and researchers.
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Frecuencia Cardíaca Fetal , Neoplasias del Timo , Cesárea , Medicina Basada en la Evidencia , Femenino , Monitoreo Fetal , Humanos , EmbarazoAsunto(s)
Enfermedades Placentarias , Placenta , Femenino , Humanos , Pelvis , Placenta/patología , Enfermedades Placentarias/patología , EmbarazoRESUMEN
Just like the scientific data they generate, simulation workflows for research should be findable, accessible, interoperable, and reusable (FAIR). However, while significant progress has been made towards FAIR data, the majority of science and engineering workflows used in research remain poorly documented and often unavailable, involving ad hoc scripts and manual steps, hindering reproducibility and stifling progress. We introduce Sim2Ls (pronounced simtools) and the Sim2L Python library that allow developers to create and share end-to-end computational workflows with well-defined and verified inputs and outputs. The Sim2L library makes Sim2Ls, their requirements, and their services discoverable, verifies inputs and outputs, and automatically stores results in a globally-accessible simulation cache and results database. This simulation ecosystem is available in nanoHUB, an open platform that also provides publication services for Sim2Ls, a computational environment for developers and users, and the hardware to execute runs and store results at no cost. We exemplify the use of Sim2Ls using two applications and discuss best practices towards FAIR simulation workflows and associated data.
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Manejo de Datos , Ecosistema , Simulación por Computador , Reproducibilidad de los Resultados , Programas Informáticos , Flujo de TrabajoRESUMEN
BACKGROUND: The terminology and diagnostic criteria presently used by pathologists to report placenta accreta spectrum is inconsistent and does not reflect current knowledge of the pathogenesis of this disease. OBJECTIVE: In 2020, the perinatal subcommittee of the Society for Pediatric Pathology Placenta Accreta Task Force proposed a new pathologic grading system for placenta accreta spectrum. We sought to correlate the clinical outcomes with the classification into each group in the new placenta accreta spectrum grading system. STUDY DESIGN: The pathology reports of patients with histopathologic confirmation of placenta accreta spectrum were reviewed in 2 academic referral centers by placental pathologists. Pathologic grading was assigned based on the new grading system according to which placenta accreta spectrum is categorized into 5 groups depending on the depth of invasion, from grade p1 with no invasion into the uterine wall to grade p3E with invasion beyond the uterine wall to the adjacent organs. Patient characteristics and clinical outcomes were compared among these groups. A univariate analysis was performed, and a multivariate linear or binomial regression was employed when needed. RESULTS: A total of 683 patients with placenta accreta spectrum were identified. Of those, 407 were included for histology review. There were 92 patients (23%) categorized into the grade p1 group, 74 (18%) in the grade p2 group, 84 (20%) in the grade p3A group, 121 (30%) in the grade p3D group, and 36 (9%) in the grade p3E group. There was a significant association between the pathology grading and the number of red blood cells transfused (ß=1.14; 95% confidence interval, 0.48-1.79) and the postoperative complications including the rate of readmission (risk ratio, 1.93; 95% confidence interval, 1.26-2.94) and bladder injury (risk ratio, 1.81; 95% confidence interval, 1.23-2.68) after adjustment for antenatal diagnosis and other variables. The pathology grading was not associated with the estimated blood loss (P=.072). CONCLUSION: The new pathology grading system accurately reflects maternal outcomes and complications of placenta accreta spectrum. We encourage the utilization of this new pathologic grading system because it is designed to omit discrepancies in placenta accreta spectrum reporting and to standardize communication.