Publisher Correction: A protein assembly mediates Xist localization and gene silencing.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

A protein assembly mediates Xist localization and gene silencing.

Nuclear compartments have diverse roles in regulating gene expression, yet the molecular forces and components that drive compartment formation remain largely unclear1. The long non-coding RNA Xist establishes an intra-chromosomal compartment by localizing at a high concentration in a territory spatially close to its transcription locus2 and binding diverse proteins3-5 to achieve X-chromosome inactivation (XCI)6,7. The XCI process therefore serves as a paradigm for understanding how RNA-mediated recruitment of various proteins induces a functional compartment. The properties of the inactive X (Xi)-compartment are known to change over time, because after initial Xist spreading and transcriptional shutoff a state is reached in which gene silencing remains stable even if Xist is turned off8. Here we show that the Xist RNA-binding proteins PTBP19, MATR310, TDP-4311 and CELF112 assemble on the multivalent E-repeat element of Xist7 and, via self-aggregation and heterotypic protein-protein interactions, form a condensate1 in the Xi. This condensate is required for gene silencing and for the anchoring of Xist to the Xi territory, and can be sustained in the absence of Xist. Notably, these E-repeat-binding proteins become essential coincident with transition to the Xist-independent XCI phase8, indicating that the condensate seeded by the E-repeat underlies the developmental switch from Xist-dependence to Xist-independence. Taken together, our data show that Xist forms the Xi compartment by seeding a heteromeric condensate that consists of ubiquitous RNA-binding proteins, revealing an unanticipated mechanism for heritable gene silencing.

Readability and quality assessment of online patient education materials for spinal and epidural anesthesia.

PURPOSE: Guidelines recommend that health-related information for patients should be written at or below the sixth-grade level. We sought to evaluate the readability level and quality of online patient education materials regarding epidural and spinal anesthesia. METHODS: We evaluated webpages with content written specifically regarding either spinal or epidural anesthesia, identified using 11 relevant search terms, with seven commonly used readability formulas: Flesh-Kincaid Grade Level (FKGL), Gunning Fox Index (GFI), Coleman-Liau Index (CLI), Automated Readability Index (ARI), Simple Measure of Gobbledygook (SMOG), Flesch Reading Ease (FRE), and New Dale-Chall (NDC). Two evaluators assessed the quality of the reading materials using the Brief DISCERN tool. RESULTS: We analyzed 261 webpages. The mean (standard deviation) readability scores were: FKGL = 8.8 (1.9), GFI = 11.2 (2.2), CLI = 10.3 (1.9), ARI = 8.1 (2.2), SMOG = 11.6 (1.6), FRE = 55.7 (10.8), and NDC = 5.4 (1.0). The mean grade level was higher than the recommended sixth-grade level when calculated with six of the seven readability formulas. The average Brief DISCERN score was 16.0. CONCLUSION: Readability levels of online patient education materials pertaining to epidural and spinal anesthesia are higher than recommended. When we evaluated the quality of the information using a validated tool, the materials were found to be just below the threshold of what is considered good quality. Authors of educational materials should provide not only readable but also good-quality information to enhance patient understanding.

RéSUMé: OBJECTIF: Les lignes directrices recommandent que les informations relatives à la santé destinées aux patient·es soient rédigées pour un niveau de sixième année ou en dessous. Nous avons cherché à évaluer le niveau de lisibilité et la qualité des matériels d'éducation disponibles en ligne pour les patient·es concernant l'anesthésie péridurale et la rachianesthésie. MéTHODE: Nous avons évalué les pages web dont le contenu était spécifiquement rédigé à propos de l'anesthésie rachidienne ou péridurale, identifiées à l'aide de 11 termes de recherche pertinents, avec sept formules de lisibilité couramment utilisées : Niveau scolaire Flesh-Kincaid (FKGL), Indice Gunning Fox (GFI), Indice Coleman-Liau (CLI), Indice de lisibilité automatisé (ARI), Mesure simple du charabia (SMOG), Facilité de lecture de Flesch (FRE) et New Dale-Chall (NDC). Deux personnes ont évalué la qualité du matériel de lecture à l'aide de l'outil Brief DISCERN. RéSULTATS: Nous avons analysé 261 pages web. Les scores de lisibilité moyens (écart type) étaient les suivants : FKGL = 8,8 (1,9), GFI = 11,2 (2,2), CLI = 10,3 (1,9), ARI = 8,1 (2,2), SMOG = 11,6 (1,6), FRE = 55,7 (10,8) et NDC = 5,4 (1,0). Le niveau de lecture moyen était plus élevé que le niveau recommandé de sixième année lorsqu'il a été calculé à l'aide de six des sept formules de lisibilité. Le score moyen de Brief DISCERN était de 16,0. CONCLUSION: Les niveaux de lisibilité des documents d'éducation en ligne relatifs à l'anesthésie péridurale et à la rachianesthésie destinés aux patient·es sont plus élevés que ceux recommandés. Lorsque nous avons évalué la qualité de l'information à l'aide d'un outil validé, nous avons constaté que les documents se situaient juste en dessous du seuil de ce qui est considéré comme de bonne qualité. Les personnes rédigeant du matériel éducatif doivent fournir des informations non seulement lisibles, mais aussi de bonne qualité afin d'améliorer la compréhension des patient·es.

Guidelines to the Practice of Anesthesia-Revised Edition 2024.

OVERVIEW: The Guidelines to the Practice of Anesthesia-Revised Edition 2024 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia-Revised Edition 2024 supersede all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

RéSUMé: Le Guide d'exercice de l'anesthésie, version révisée 2024 (le Guide), a été préparé par la Société canadienne des anesthésiologistes (SCA), qui se réserve le droit de décider des termes de sa publication et de sa diffusion. Le Guide est soumis à révision et des versions mises à jour sont publiées chaque année. Le Guide d'exercice de l'anesthésie, version révisée 2024, remplace toutes les versions précédemment publiées de ce document. Bien que la SCA incite les anesthésiologistes du Canada à se conformer à son guide d'exercice pour assurer une grande qualité des soins dispensés aux patient·es, elle ne peut garantir les résultats d'une intervention spécifique. Les anesthésiologistes doivent exercer leur jugement professionnel pour déterminer la méthode d'intervention la mieux adaptée à l'état de leur patient·e. La SCA n'accepte aucune responsabilité ou imputabilité de quelque nature que ce soit découlant d'erreurs ou d'omissions ou de l'utilisation des renseignements contenus dans son Guide d'exercice de l'anesthésie.

Minimally invasive far lateral tubular microdiscectomy: surgical technique and case series of 176 patients.

BACKGROUND: Far lateral (extraforaminal) disc herniations comprise approximately 10% of symptomatic lumbar disc herniations. They represent operative challenges due to accessibility and surgical unfamiliarity. Surgical strategies in the past have included open discectomy and posterior lumbar interbody fusion. Tubular microdiscectomies have gained traction due to their minimally invasive advantages, including reduced morbidity, pain and length of hospital stay. METHODS: We report our retrospective single institution consecutive case series of tubular far lateral microdiscectomies. One hundred and seventy-six patients were operated on over an eight-year period. Clinical outcomes were assessed after institutional ethics approval. We additionally describe our surgical technique with an illustrative video case. RESULTS: Over a mean follow-up of 21 weeks, 77% of patients had good or excellent clinical outcomes according to the MacNab criteria. 12% of patients underwent reoperation at the index level for symptom recurrence or persistence. Mean length of hospital stay was 1.3 days. There was a 1% rate of both postoperative haematoma and infection. Mean operation duration was 86 minutes. CONCLUSION: This case series represents the largest currently reported in the literature. Minimally invasive microdiscectomies performed through tubes allow for precise localisation, reduced tissue disruption and favourable clinical outcomes. Our results appear consistent with a review of the literature, demonstrating the safety and efficacy of this approach.

The efficacy of post-operative drains for anterior cervical discectomy and fusion: a systematic review and meta-analysis.

BACKGROUND: Controversy remains with the use of post-operative subfascial drains for anterior cervical discectomy and fusion, with limited guidelines and a paucity of conclusive evidence. Thus, the aim of this meta-analysis was to analyse and collate an evidence summary to determine the efficacy of such drains. METHODS: A systematic search of Medline (2002-2022.11), PubMed (2003-2022.11), Scopus (2002-2022.11), Cochrane Library (2015-2022.11) databases and reference lists of articles was conducted as per Cochrane systematic reviews standards. All relevant RCTs and NRCTs were included in this study. Data was extracted in a standardised form and analysed with RevMan version 5.4.1. Bias was assessed with RoB2 tool for RCTs and ROBINS-E tool for NRCTs. RESULTS: Two RCTs (136 patients) and five NRCTs (7563 patients) were included. These had a moderate to high risk of bias, except for one very high-risk article. Meta-analysis results showed no significant differences for post-operative haematoma (P = 0.31), surgical site infection (P = 0.84), take back to theatre (P = 0.27), length of stay (P = 0.34), and estimated blood loss (P = 0.09). Dysphagia (P = 0.002) and median operative time (P = 0.02) were significantly increased in the drain cohort. CONCLUSION: The low quality of available data in the included studies is insufficient to estimate the effect of post-operative drains for elective spondylotic ACDF. The findings suggest that if the decision to leave a drain in is left to the surgeon, then there is no difference in the rates of POH, SSI, LOS, or take back to the theatre. The significant association of dysphagia and increased operative time with drains, and the non-significant trend towards increased EBL with drains, must be considered in the context in which procedures may influence the decision to place drains. The results could not be stratified by various confounders that affect the decision-making process, including the number of levels operated. Due to the decreased quality and amount of evidence available, large-scale RCTs that adequately account for confounders should be performed.

Theoretical Schemas to Guide Back Pain Consortium (BACPAC) Chronic Low Back Pain Clinical Research.

BACKGROUND: Chronic low back pain (cLBP) is a complex with a heterogenous clinical presentation. A better understanding of the factors that contribute to cLBP is needed for accurate diagnosis, optimal treatment, and identification of mechanistic targets for new therapies. The Back Pain Consortium (BACPAC) Research Program provides a unique opportunity in this regard, as it will generate large clinical datasets, including a diverse set of harmonized measurements. The Theoretical Model Working Group was established to guide BACPAC research and to organize new knowledge within a mechanistic framework. This article summarizes the initial work of the Theoretical Model Working Group. It includes a three-stage integration of expert opinion and an umbrella literature review of factors that affect cLBP severity and chronicity. METHODS: During Stage 1, experts from across BACPAC established a taxonomy for risk and prognostic factors (RPFs) and preliminary graphical depictions. During Stage 2, a separate team conducted a literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to establish working definitions, associated data elements, and overall strength of evidence for identified RPFs. These were subsequently integrated with expert opinion during Stage 3. RESULTS: The majority (∼80%) of RPFs had little strength-of-evidence confidence, whereas seven factors had substantial confidence for either a positive association with cLBP (pain-related anxiety, serum C-reactive protein, diabetes, and anticipatory/compensatory postural adjustments) or no association with cLBP (serum interleukin 1-beta / interleukin 6, transversus muscle morphology/activity, and quantitative sensory testing). CONCLUSION: This theoretical perspective will evolve over time as BACPAC investigators link empirical results to theory, challenge current ideas of the biopsychosocial model, and use a systems approach to develop tools and algorithms that disentangle the dynamic interactions among cLBP factors.

Guidelines to the Practice of Anesthesia: Revised Edition 2023.

OVERVIEW: The Guidelines to the Practice of Anesthesia Revised Edition 2023 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2023 supersede all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgment in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

RéSUMé: Le Guide d'exercice de l'anesthésie, version révisée 2023 (le Guide), a été préparé par la Société canadienne des anesthésiologistes (SCA), qui se réserve le droit de décider des termes de sa publication et de sa diffusion. Le Guide est soumis à révision et des versions mises à jour sont publiées chaque année. Le Guide d'exercice de l'anesthésie, version révisée 2023, remplace toutes les versions précédemment publiées de ce document. Bien que la SCA incite les anesthésiologistes du Canada à se conformer à son guide d'exercice pour assurer une grande qualité des soins dispensés aux patients, elle ne peut garantir les résultats d'une intervention spécifique. Les anesthésiologistes doivent exercer leur jugement professionnel pour déterminer la méthode d'intervention la mieux adaptée à l'état de leur patient. La SCA n'accepte aucune responsabilité ou imputabilité de quelque nature que ce soit découlant d'erreurs ou d'omissions ou de l'utilisation des renseignements contenus dans son Guide d'exercice de l'anesthésie.

Rotational Thromboelastometry-Guided Use of Synthetic Blood Products in Cardiac Transplant Patients: A Retrospective Before-After Study.

OBJECTIVES: Viscoelastic hemostatic assays, such as rotational thromboelastometry (ROTEM), are used increasingly in cardiac surgery to guide transfusion decisions. After separation from cardiopulmonary bypass (CPB), achieving hemostasis rapidly is the main goal before chest closure. The authors hypothesized that introducing a ROTEM-guided factor- concentrate transfusion algorithm would reduce the duration from CPB separation to chest closure during cardiac transplantation. DESIGN: A retrospective cohort study of 21 patients before and 28 patients after implementation of the ROTEM-guided transfusion algorithm who underwent cardiac transplantation. SETTING: This single-center study was conducted at Saint Paul's Hospital, Vancouver, British Columbia, Canada. INTERVENTIONS: Using a ROTEM-guided factor-concentrate transfusion algorithm for cardiac transplant recipients. MEASUREMENT AND MAIN RESULTS: The primary outcome was the duration from CPB separation to chest closure analyzed using Mann-Whitney U tests. The secondary outcomes included the volume of postoperative chest tube drainage, packed red blood cell (pRBC) transfusion requirements within 24 hours of surgery, the incidence of adverse events, and the length of stay before and after introducing a ROTEM-guided factor-concentrate transfusion algorithm. After adjusting for confounders using multivariate linear regression analysis, using a ROTEM-guided factor-concentrate transfusion algorithm resulted in a significant decrease in time from CPB separation to skin closure of 39.4 minutes (-73.1 to 123.5 min, p = 0.016). For the secondary outcomes, the use of ROTEM-guided transfusion showed reductions in pRBC transfusion within 24 hours of surgery (-1.3 units, -2.7 to 0.1 units; p = 0.077) and chest tube bleeding (-0.44 mL, -0.96 to +0.083 mL; p = 0.097); however, neither was statistically significant after adjustment. The median hospital length of stay in the study group was lower by 3 days (13 days v 16) days; p = 0.048). CONCLUSION: The introduction of a ROTEM-guided factor-concentrate transfusion algorithm was associated with a significant reduction in time to chest closure after separation from CPB. Although it reduced the total hospital length of stay, there were no differences in mortality, major complications, or intensive care unit length of stay.

Intentional Bilateral Renal Artery Coverage During Ruptured Endovascular Paraanastomotic Pseudoaneurysm Repair.

The development of a paraanastomotic pseudoaneurysm is a serious complication after open prosthetic reconstruction of the aorta for occlusive or aneurysmal disease. Open repair of these lesions has previously been associated with high rates of morbidity and mortality. Endovascular repair may provide suitable treatment for proximal paraanastomotic aortic bypass graft pseudoaneurysms in patients who are poor candidates for open surgery. Bilateral renal artery coverage may be necessary to achieve adequate fixation and seal during life-threatening emergency cases of pseudoaneurysm rupture. Due to the infrequency of reported cases, the consequences of bilateral renal artery occlusion during these complex procedures are poorly understood. We present a case of a proximal paraanastomotic aortobifemoral bypass pseudoaneurysm rupture that was managed using endovascular repair with intentional coverage of both renal arteries. We also review the contemporary literature on endovascular management of paraanastomotic aneurysms and discuss the role of bilateral renal artery coverage in treating select patients with complex ruptured aortic pathology.

The safety of high-dose dexmedetomidine after cardiac surgery: a historical cohort study.

PURPOSE: The off-label use of dexmedetomidine beyond the monograph-recommended maximum dose of 0.7 µg·kg-1·hr-1 is common in postoperative cardiac surgical units; however, limited data exist on the association of higher doses and adverse hemodynamic effects. We sought to compare the rate of hypotension or bradycardia in cardiac surgery patients receiving peak infusion doses below and above 0.7 µg·kg-1·hr-1 for any indication or duration. METHODS: In this historical cohort study, we reviewed all patients who received dexmedetomidine infusion after cardiac surgery between June 2013 and July 2017 at a single centre. Regardless of the duration of exposure at the peak infusion dose, patients were categorized into high- or standard-dose groups using 0.7 µg·kg-1·hr-1 as the cutoff value. We compared rates of the primary composite outcome of hypotension or bradycardia, and secondary outcomes (i.e., arrhythmia and hyperglycemia) between groups using the two-proportion z test. Exploratory regression models were fitted to adjust for potential confounders. RESULTS: The median [interquartile range (IQR)] peak infusion dose was 1.0 [1.0-1.4] µg·kg-1·hr-1 in the high-dose group (N = 121) and 0.5 [0.4-0.7] µg·kg-1·hr-1 in the standard-dose group (N = 124). The rates of the primary composite outcome were 73% and 65%, respectively (absolute risk difference, 8%; 95% confidence interval, -3 to 20; P = 0.17). There was no significant difference in primary or secondary outcomes between groups. CONCLUSION: There was a high overall rate of hypotension or bradycardia in patients receiving dexmedetomidine after cardiac surgery; infusion rates below or above 0.7 µg·kg-1·hr-1 had similar rates of adverse hemodynamic events.

RéSUMé: OBJECTIF: L'utilisation non conforme (off-label) de la dexmédétomidine au-delà de la dose maximale recommandée dans la monographie de 0,7 µg·kg−1·h−1 est fréquente dans les unités de chirurgie cardiaque postopératoire; cependant, il n'existe que peu de données sur l'association entre des doses plus élevées et des effets hémodynamiques indésirables. Nous avons cherché à comparer le taux d'hypotension ou de bradycardie chez les patients de chirurgie cardiaque recevant des doses de perfusion maximales inférieures ou supérieures à 0,7 µg·kg−1·h−1 pour toute indication ou durée. MéTHODE: Dans cette étude de cohorte historique, nous avons passé en revue tous les patients qui ont reçu une perfusion de dexmédétomidine après une chirurgie cardiaque entre juin 2013 et juillet 2017 dans un seul centre. Quelle que soit la durée de l'exposition à la dose de perfusion maximale, les patients ont été classés en groupes à dose élevée ou standard selon une valeur seuil de 0,7 µg·kg−1·h−1. Nous avons comparé les taux d'hypotension ou de bradycardie, notre critère d'évaluation principal composite, et les taux des critères d'évaluation secondaires (soit l'arythmie et l'hyperglycémie) entre les groupes à l'aide du test z à deux proportions. Des modèles de régression exploratoire ont été ajustés pour tenir compte des facteurs de confusion potentiels. RéSULTATS: La dose de perfusion maximale médiane [écart interquartile (ÉIQ)] était de 1,0 [1,0­1,4] µg·kg−1·h−1 dans le groupe à forte dose (n = 121) et de 0,5 [0,4­0,7] µg·kg−1·h−1 dans le groupe à dose standard (n = 124). Les taux pour le critère d'évaluation principal composite étaient de 73% et 65%, respectivement (différence de risque absolue, 8%; intervalle de confiance à 95%, -3 à 20; P = 0,17). Aucune différence intergroupe significative n'a été observée dans les critères d'évaluation primaires ou secondaires. CONCLUSION: Nous avons observé un taux global élevé d'hypotension ou de bradycardie chez les patients recevant de la dexmédétomidine après une chirurgie cardiaque; les taux de perfusion inférieurs ou supérieurs à 0,7 µg·kg−1·h−1 ont entraîné des taux similaires d'événements hémodynamiques indésirables.

A novel ultrasound software system for lumbar level identification in obstetric patients.

PURPOSE: Using machine learning, we developed a proprietary ultrasound software called the Spine Level Identification (SLIDE) system, which automatically identifies lumbar landmarks in real time as the operator slides the transducer over the lumber spine. Here, we assessed the agreement between SLIDE and manual palpation and traditional lumbar ultrasound (LUS) for determining the primary target L3-4 interspace. METHODS: Upon institutional ethics approval and informed consent, 76 healthy term parturients scheduled for elective Caesarean delivery were recruited. The L3-4 interspace was identified by manual palpation and then by the SLIDE method. The reference standard was located using traditional LUS by an experienced operator. The primary outcome was the L3-4 interspace identification agreement of manual palpation and SLIDE with the reference standard, as percentage agreement and Gwet's agreement coefficient (AC1). RESULTS: The raw agreement was 70% with Gwet's agreement coefficient (AC1) = 0.59 (95% confidence interval [CI], 0.41 to 0.77) for manual palpation and 84% with Gwet's AC1 = 0.82 (95% CI, 0.70 to 0.93) for SLIDE. When the levels differ from the reference, the manual palpation method identified L2-3 more often than L4-5 while the SLIDE method identified equally above or below L3-4. The SLIDE system had greater agreement than palpation in locating L3-4 and all other lumber interspaces after controlling for body mass index (adjusted odds ratio, 2.99; 95% CI, 1.21 to 8.7; P = 0.02). CONCLUSION: The SLIDE system had higher agreement with traditional ultrasound than manual palpation did in identifying L3-4 and all other lumber interspaces after adjusting for BMI in healthy term obstetric patients. Future studies should examine factors that affect agreement and ways to improve SLIDE for clinical integration. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT02982317); registered 5 December 2016.

RéSUMé: OBJECTIF: À l'aide de l'apprentissage automatique, nous avons développé un logiciel d'échographie propriétaire appelé SLIDE (pour Spine Level Identification, c.-à-d. système d'identification du niveau vertébral), qui identifie automatiquement les points de repère lombaires en temps réel lorsque l'opérateur fait passer le transducteur sur la colonne lombaire. Ici, nous avons évalué l'agrément entre le SLIDE et la palpation manuelle et l'échographie lombaire traditionnelle pour déterminer l'espace intervertébral cible principal L3­L4. MéTHODE: Après avoir obtenu l'approbation du comité d'éthique de l'établissement et le consentement éclairé, 76 parturientes en bonne santé et à terme devant bénéficier d'un accouchement par césarienne programmée ont été recrutées. L'espace intervertébral L3­L4 a été identifié par palpation manuelle puis avec le logiciel SLIDE. L'étalon de référence a été localisé à l'aide d'une échographie lombaire traditionnelle par un opérateur expérimenté. Le critère d'évaluation principal était l'agrément entre l'identification de l'espace intervertébral L3­L4 par palpation manuelle et par logiciel SLIDE avec l'étalon de référence, en pourcentage d'agrément et coefficient d'agrément de Gwet (CA1). RéSULTATS: L'agrément brut était de 70 % avec le coefficient d'agrément de Gwet (CA1) = 0,59 (intervalle de confiance [IC] à 95 %, 0,41 à 0,77) pour la palpation manuelle et de 84 % avec le CA1 de Gwet = 0,82 (IC 95 %, 0,70 à 0,93) pour le logiciel SLIDE. Lorsque les niveaux lombaires différaient de la référence, la méthode de palpation manuelle a identifié L2­L3 plus souvent que L4­L5, tandis que la méthode SLIDE a identifié les vertèbres supérieures ou inférieures à L3­L4 de manière égale. Le système SLIDE a affiché un agrément plus important que la palpation pour localiser L3­L4 et tous les autres espaces intervertébraux lombaires après ajustement pour tenir compte de l'indice de masse corporelle (rapport de cotes ajusté, 2,99; IC 95 %, 1,21 à 8,7; P = 0,02). CONCLUSION: Le système SLIDE avait affiché un agrément plus élevé avec l'échographie traditionnelle que la palpation manuelle pour identifier le niveau L3­L4 et tous les autres espaces intervertébraux lombaires après ajustement pour tenir compte de l'IMC chez les patientes obstétricales à terme en bonne santé. Une étude future devrait examiner les facteurs qui affectent l'agrément et les moyens d'améliorer le logiciel SLIDE pour une intégration clinique. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT02982317); enregistrée le 5 décembre 2016.

Enhancing knowledge, skills, and comfort in providing anesthesia assistance during obstetric general anesthesia for operating room nurses: a prospective observational study.

BACKGROUND: Due to a nationwide shortage of anesthesia assistants, operating room nurses are often recruited to assist with the induction of obstetric general anesthesia (GA). We developed and administered a training program and hypothesized there would be significant improvements in knowledge and skills in anesthesia assistance during obstetric GA by operating room nurses following training with adequate retention at six months. METHODS: Following informed consent, all operating room nurses at our institution were invited to participate in the study. Baseline knowledge of participants was assessed using a 14-item multiple choice questionnaire (MCQ), and skills were assessed using a 12-item checklist scored by direct observation during simulated induction of GA. Next, a 20-min didactic lecture followed by a ten-minute hands-on skills station were delivered. Knowledge and skills were immediately reassessed after training, and again at six weeks and six months. The primary outcomes of this study were adequate knowledge and skills retention at six months, defined as achieving ≥ 80% in MCQ and ≥ 80% in skills checklist scores and analyzed using longitudinal mixed-effects linear regression. RESULTS: A total of 34 nurses completed the study at six months. The mean MCQ score at baseline was 8.9 (95% confidence interval [CI], 8.5 to 9.4) out of 14. The mean skills checklist score was 5.5 (95% CI, 4.9 to 6.1) out of 12. The mean comfort scores for assisting elective and emergency Cesarean deliveries were 3.6 (95% CI, 3.2 to 3.9) and 3.1 (95% CI, 2.7 to 3.5) out of 5, respectively. There was a significant difference in the mean MCQ and skills checklist scores across the different study periods (overall P value < 0.001). Post hoc pairwise tests suggested that, compared with baseline, there were significantly higher mean MCQ scores at all time points after the training program at six weeks (11.9; 95% CI, 11.4 to 12.4; P < 0.001) and at six months (12.0; 95% CI, 11.5 to 12.4; P < 0.001). DISCUSSION: The knowledge and skills of operating room nurses in providing anesthesia assistance during obstetric GA at our institution were low at baseline. Following a single 30-min in-house, anesthesiologist-led, structured training program, scores in both dimensions significantly improved. Although knowledge improvements were adequately retained for up to six months, skills improvements decayed rapidly, suggesting that sessions should be repeated at six-week intervals, at least initially.

RéSUMé: CONTEXTE: En raison d'une pénurie nationale d'assistants en anesthésie, le personnel infirmier de la salle d'opération est souvent sollicité pour aider à l'induction de l'anesthésie générale (AG) obstétricale. Nous avons élaboré et administré un programme de formation et émis l'hypothèse qu'il y aurait des améliorations significatives dans les connaissances et les compétences en matière d'assistance en anesthésie pendant l'anesthésie générale obstétricale par les infirmières de salle d'opération après avoir suivi une formation, avec une rétention adéquate à six mois. MéTHODE: Après avoir obtenu le consentement éclairé, tout le personnel infirmier de salle d'opération de notre établissement a été invité à participer à l'étude. Les connaissances de base des participants ont été évaluées à l'aide d'un questionnaire à choix multiples (QCM) à 14 éléments, et les compétences ont été évaluées à l'aide d'une liste de contrôle de 12 éléments notée par observation directe lors d'une simulation d'induction d'anesthésie générale. Par la suite, un cours didactique de 20 minutes suivi d'une station de compétences pratiques de dix minutes a été donné. Les connaissances et les compétences ont été réévaluées immédiatement après la formation, puis de nouveau à six semaines et six mois. Les critères d'évaluation principaux de cette étude étaient la rétention adéquate des connaissances et des compétences à six mois, définie comme l'atteinte de ≥ 80 % dans les scores du QCM et ≥ 80 % dans les scores de la liste de contrôle des compétences et analysée à l'aide d'une régression linéaire longitudinale à effets mixtes. RéSULTATS: Au total, 34 infirmières ont terminé l'étude à six mois. Au début de l'étude, le score moyen au QCM était de 8,9 (intervalle de confiance [IC] à 95 %, 8,5 à 9,4) sur 14. Le score moyen sur la liste de contrôle des compétences était de 5,5 (IC 95 %, 4,9 à 6,1) sur 12. Les scores moyens d'aisance dans l'assistance pour un accouchement par césarienne programmé et d'urgence étaient de 3,6 (IC 95 %, 3,2 à 3,9) et 3,1 (IC 95 %, 2,7 à 3,5) sur 5, respectivement. Une différence significative a été observée dans les scores moyens au QCM et sur la liste de contrôle des compétences entre les différentes périodes d'étude (valeur globale P < 0,001). Les tests appariés post-hoc ont suggéré que, par rapport aux connaissances évaluées au début de l'étude, les scores moyens au QCM étaient significativement plus élevés à tous les moments après le programme de formation, à six semaines (11,9; IC 95 %, 11,4 à 12,4; P < 0,001) et à six mois (12,0; IC 95 %, 11,5 à 12,4; P < 0,001). DISCUSSION: Les connaissances et les compétences du personnel infirmier de salle d'opération dans la prestation d'une assistance en anesthésie pendant l'AG obstétricale dans notre établissement étaient faibles au commencement de notre étude. Après un seul programme de formation structuré de 30 minutes à l'interne, dirigé par un anesthésiologiste, les scores dans les deux dimensions se sont considérablement améliorés. Bien que les améliorations des connaissances aient été retenues de manière adéquate jusqu'à six mois, les améliorations des compétences se sont rapidement détériorées, ce qui suggère que les séances devraient être répétées à des intervalles de six semaines, au moins au début.

Opioid dispensing after Cesarean delivery in British Columbia: a historical cohort analysis from 2004 to 2019.

PURPOSE: To describe postdischarge opioid dispensing after Cesarean delivery (CD) in 49 hospitals in British Columbia (BC) and assess opportunities for opioid stewardship. METHODS: Using the BC Ministry of Health's Hospital Discharge Abstract Database, we linked 135,725 CDs performed in 2004-2016 and 30,919 CDs performed in 2017-2019 (length of stay ≤ four days) by deidentified Personal Health Numbers to data on medications dispensed from all BC community pharmacies (PharmaNet). We excluded patients with cancer and those to whom opioids have been dispensed in the year before. We measured trends in annual percentages of patients dispensed opioids within seven days (opioid rate), with 95% confidence intervals (CIs), stratified by hospital and opioid type, adjusted for length of stay, and for autocorrelation within hospital using generalized linear modeling. RESULTS: The opioid dispensation rate dropped from 31% (95% CI, 30 to 33) in 2004 to 16% (95% CI, 15 to 17) in 2016, where it remained through 2019. Five hospitals showed steep reductions from over 40% to under 10% within two to three years, but in most hospitals the opioid dispensation rate decreased slowly-11 had little reduction and three showed increases. Codeine dispensing dropped from 31% in 2004-2008 by 4% per year, while tramadol and hydromorphone dispensing rose. After 2015, rates were stable (hydromorphone, 8%; tramadol, 6%; codeine, 3%; and oxycodone, 0.5%). CONCLUSION: After Health Canada's 2008 warning against codeine use by breastfeeding mothers, post-CD opioid dispensing declined disjointedly across BC hospitals. Rates did not decrease further after the opioid overdose epidemic was declared a public health emergency in BC in 2016. The present study highlights opportunities for quality improvement and opioid stewardship through monitoring using administrative databases.

RéSUMé: OBJECTIF: Décrire la délivrance d'opioïdes après le congé après un accouchement par césarienne dans 49 hôpitaux de la Colombie-Britannique (C.-B.) et évaluer les occasions de régulation des opioïdes. MéTHODE: À l'aide de la base de données sur les congés des patients du ministère de la Santé de la Colombie-Britannique, nous avons relié 135 725 accouchements par césarienne réalisés en 2004-2016 et 30 919 accouchements par césarienne réalisés en 2017-2019 (durée de séjour ≤ quatre jours) en utilisant les numéros de carte santé personnels dépersonnalisés aux données sur les médicaments délivrés par toutes les pharmacies communautaires de la Colombie-Britannique (PharmaNet). Nous avons exclu les patientes atteintes de cancer et celles à qui des opioïdes avaient été délivrés l'année précédente. À l'aide d'une modélisation linéaire généralisée, nous avons mesuré les tendances en pourcentages annuels de patientes ayant reçu des opioïdes dans les sept jours (taux d'opioïdes), avec des intervalles de confiance (IC) à 95 %, stratifiés par hôpital et par type d'opioïdes, ajustés en fonction de la durée de séjour et des autocorrélations entre des taux de chaque hôpital. RéSULTATS: Le taux de délivrance d'opioïdes est passé de 31 % (IC 95 %, 30 à 33) en 2004 à 16 % (IC 95 %, 15 à 17) en 2016, où il est resté jusqu'en 2019. Cinq hôpitaux ont montré des réductions importantes, passant de plus de 40 % à moins de 10 % en deux à trois ans, mais dans la plupart des hôpitaux, le taux de délivrance d'opioïdes a diminué lentement ­ 11 ont affiché une faible réduction et trois ont montré des augmentations. La délivrance de codéine a diminué de 4 % par année, à partir de 31 % en 2004-2008, tandis que la délivrance de tramadol et d'hydromorphone a augmenté. Après 2015, les taux étaient stables (hydromorphone, 8 %; tramadol, 6 %; codéine, 3 %; et oxycodone, 0,5 %). CONCLUSION: Suite à la mise en garde de Santé Canada en 2008 contre la consommation de codéine par les mères qui allaitent, la délivrance d'opioïdes post-césarienne a diminué de façon inconstante dans les hôpitaux de Colombie-Britannique. Les taux n'ont pas diminué davantage après que l'épidémie de surdose d'opioïdes a été déclarée urgence de santé publique en Colombie-Britannique en 2016. La présente étude met en évidence les possibilités d'amélioration de la qualité et de régulation des opioïdes en procédant à une surveillance via les bases de données administratives.

Trends in opioid dispensing after common abdominal and orthopedic surgery procedures in British Columbia: a retrospective cohort analysis.

PURPOSE: Postdischarge opioid prescriptions are reportedly much higher in Canada than in other countries. To assess potentially contributing factors, we examined trends after abdominal and orthopedic surgeries in British Columbia (BC). METHODS: Using the BC Ministry of Health's databases on physician billings, hospital discharge abstracts, and medication dispensations in community pharmacies for the period 2003-2016, we assembled a cohort of 263,056 patients who received laparoscopic appendectomy (LA, 11%), laparoscopic cholecystectomy (LC, 30%), open inguinal or femoral hernia repair (IHR, 20%), total hip arthroplasty (THA, 18%), or total knee arthroplasty (TKA, 22%). Adjusting for covariates using generalized linear modeling, we measured trends in percentages of patients dispensed opioids postdischarge (opioid rate) within 30 days after surgery, by surgery type, opioid type, prior use, surgeon, and trends in morphine milligram equivalents of first dispensations (MME) with 95% confidence intervals (CI). RESULTS: Opioid dispensation rates rose steadily. Mean annual increases were 1.7% in LA; 1.3% in LC; 0.8% in IHR; 0.9% in THA; and 0.8% in TKA. By 2016, rates were 69% in LA; 76% in LC; 81% in IHR; 88% in THA; and 94% in TKA. Codeine dispensations fell 2.4% (abdominal) and 3.1% (orthopedic) per year while tramadol dispensations increased 3.6% (abdominal) and 1.7% (orthopedic). Hydromorphone dispensations increased 2.9% per year (orthopedic); oxycodone was level at 22% between 2007 and 2014, but then fell. The mean MME rose 8 mg⋅yr-1 (95% CI, 7 to 9) (abdominal) and 61 mg⋅yr-1 (95% CI, 58 to 64) (orthopedic). Variation in rates was greater among abdominal than orthopedic surgeons. CONCLUSION: Rising opioid dispensation rates, together with shifts to prescribing higher MME opioids, doubled MME per patient in first dispensations postdischarge after abdominal or orthopedic surgery from 2003 to 2016 in BC.

RéSUMé: OBJECTIF: Les ordonnances d'opioïdes après le congé seraient beaucoup plus élevées au Canada que dans d'autres pays. Afin d'évaluer les facteurs contributifs potentiels, nous avons examiné les tendances après les chirurgies abdominales et orthopédiques en Colombie-Britannique (C.-B.). MéTHODE: En utilisant les bases de données du ministère de la Santé de la Colombie-Britannique de facturation des médecins, les résumés des congés d'hôpital et les délivrances de médicaments dans les pharmacies communautaires pour la période 2003-2016, nous avons regroupé une cohorte de 263 056 patients ayant bénéficié d'une appendicectomie par laparoscopie (AL, 11 %), d'une cholécystectomie par laparoscopie (CL, 30 %), d'une réparation ouverte de hernie inguinale ou fémorale (RHI, 20 %), d'une arthroplastie totale de la hanche (ATH, 18 %) ou d'une arthroplastie totale du genou (ATG, 22 %). En tenant compte des covariables à l'aide d'une modélisation linéaire généralisée, nous avons mesuré les tendances dans les pourcentages de patients ayant reçu des opioïdes après leur congé (taux de délivrance d'opioïdes) dans les 30 jours suivant leur chirurgie, par type de chirurgie, type d'opioïde, utilisation antérieure, chirurgien et tendances des équivalents de morphine en milligrammes (EMM) des premières délivrances avec des intervalles de confiance (IC) à 95 %. RéSULTATS: Les taux de délivrance d'opioïdes ont augmenté de manière constante. Les augmentations annuelles moyennes étaient de 1,7 % pour les AL, 1,3 % pour les CL, 0,8 % pour les RHI, 0,9 % pour les ATH, et 0,8 % pour les ATG. En 2016, les taux étaient de 69 % pour les AL, 76 % pour les CL, 81 % pour les RHI, 88 % pour les ATH, et 94 % pour les ATG. Les dispenses de codéine ont chuté de 2,4 % (chirurgie abdominale) et de 3,1 % (chirurgie orthopédique) par année, tandis que les délivrances de tramadol ont augmenté de 3,6 % (chirurgie abdominale) et de 1,7 % (chirurgie orthopédique). Les délivrances d'hydromorphone ont augmenté de 2,9 % par année (orthopédie); l'oxycodone était à 22 % entre 2007 et 2014, mais a ensuite diminué. Les EMM moyens ont augmenté de 8 mg·an-1 (IC 95 %, 7 à 9) (chirurgie abdominale) et de 61 mg·an-1 (IC 95 %, 58 à 64) (chirurgie orthopédique). La variation des taux était plus importante parmi les chirurgiens abdominaux que chez les chirurgiens orthopédistes. CONCLUSION: L'augmentation des taux de délivrance d'opioïdes, ainsi que le passage à une prescription d'opioïdes plus élevés en EMM, ont doublé les EMM par patient dans les premières délivrances après leur congé après une chirurgie abdominale ou orthopédique de 2003 à 2016 en Colombie-Britannique.

The Effect of Carbetocin Dose on Transmural Dispersion of Myocardial Repolarization in Healthy Parturients Scheduled for Elective Cesarean Delivery Under Spinal Anesthesia: A Prospective, Randomized Clinical Trial.

BACKGROUND: QT interval prolongation is associated with torsade de pointes but remains a poor predictor of drug torsadogenicity. Increased transmural dispersion of myocardial repolarization (TDR), measured as the time interval between the peak and end of the T wave (Tp-e), is a more reliable predictor. Carbetocin is recommended as an uterotonic in patients undergoing cesarean delivery (CD), but its effect on Tp-e is unknown. We evaluated the effect of carbetocin dose on Tp-e and Bazett-corrected QT intervals (QTc) during elective CD under spinal anesthesia. METHODS: On patient consent, 50 healthy parturients undergoing elective CD with a standardized spinal anesthetic and phenylephrine infusion were randomized to receive an intravenous (IV) bolus of carbetocin 50 µg (C50) or 100 µg (C100) via an infusion pump over 1 minute. A 12-lead electrocardiogram (ECG) was obtained at baseline, 5 minutes after spinal anesthesia, then 5 and 10 minutes after carbetocin administration. A cardiologist blinded to group and timing of ECGs measured QTc and Tp-e using Emori's criteria. Primary outcome was the change in Tp-e at 5 minutes after carbetocin administration between the C50 and C100 groups and within each group compared to baseline values. Secondary outcomes included occurrence of arrhythmias, changes in QTc at 5 and 10 minutes after carbetocin, changes in both QTc and Tp-e after spinal anesthesia compared to baseline between and within groups. RESULTS: Data from 41 parturients with a mean (standard deviation [SD]) age of 39.0 (0.7) years and weight of 75.0 (12.0) kg were analyzed. Between groups, at 5 minutes after carbetocin administration, Tp-e in C100 was 4.1 milliseconds longer compared to C50 (95% confidence interval [CI], 0.8-7.5; P = .01). Within groups, at 5 minutes after carbetocin administration, C50 did not significantly increase Tp-e compared to baseline (mean difference [MD] 1.9 milliseconds; 95% CI, -0.95 to 4.81 milliseconds; P = .42) but C100 did (MD 5.1 milliseconds; 95% CI, 2.1-8.1; P = .003). QTc increased significantly within C50 and C100 groups at 5 and 10 minutes after carbetocin administration (all P < .001), with no between-group differences. There were no arrhythmias. CONCLUSIONS: Tp-e was unaffected by C50 IV given after CD in healthy parturients under spinal anesthesia, but minimally prolonged by C100. The increase in QTc after carbetocin administration was statistically significant, but with no apparent dose-dependent effect. The minimal Tp-e prolongation at the higher dose is unlikely to have any clinically significant impact on TDR and therefore the risk of inducing torsade de pointes is low.

The impact of a barrier enclosure on time to tracheal intubation: a randomized controlled trial.

PURPOSE: Novel devices such as the barrier enclosure were developed in hopes of improving provider safety by limiting SARS-CoV-2 transmission during tracheal intubation. Nevertheless, concerns arose regarding a lack of rigorous efficacy and safety data for these devices. We conducted a randomized controlled trial to evaluate the impact of the barrier enclosure on time to tracheal intubation. METHOD: After Research Ethics Board approval, elective surgical patients with normal airway predictors were randomly allocated 1:1 to tracheal intubation with or without a barrier enclosure. The primary outcome was time to tracheal intubation. Secondary outcomes included first-pass success rate, total time of airway manipulation, anesthesiologists' perception of intubation difficulty, likelihood of use in SARS-CoV-2-positive patients, and patients' perception of comfort and acceptability. RESULTS: There were 48 participants in the barrier enclosure group and 46 participants in the control group. The mean (standard deviation [SD]) time to tracheal intubation was 62 (29) sec with barrier closure and 53 (27) sec without barrier enclosure (mean difference, 9 sec; 95% confidence interval, - 3 to 20; P = 0.14). Anesthesiologists rated the difficulty of intubation higher with barrier enclosure (mean [SD] visual analogue scale score, 27 [26] mm vs 9 [17] mm; P < 0.001). There were no significant differences in other secondary outcomes. CONCLUSION: In healthy surgical patients with normal airway predictors, the use of a barrier enclosure during tracheal intubation did not significantly prolong time to intubation or decrease first-pass intubation success. Nevertheless, there was an increase in difficulty of intubation perceived by the anesthesiologists with use of a barrier enclosure. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT04366141); registered 28 April 2020.

RéSUMé: OBJECTIF: De nouveaux dispositifs tels que des boîtes de protection ont été mis au point dans l'espoir d'améliorer la sécurité des fournisseurs de soins en limitant la transmission du SRAS-CoV-2 pendant l'intubation endotrachéale. Néanmoins, des inquiétudes ont été soulevées au sujet d'un manque de données rigoureuses sur l'efficacité et l'innocuité de ces dispositifs. Nous avons réalisé une étude randomisée contrôlée afin d'évaluer l'impact d'une boîte de protection sur le temps de l'intubation endotrachéale. MéTHODE: Après avoir reçu l'approbation du Comité d'éthique de la recherche, des patients de chirurgie élective présentant des prédicteurs des voies aériennes normales ont été aléatoirement répartis à un ratio de 1:1 pour une intubation endotrachéale avec ou sans boîte de protection. Le critère d'évaluation principal était le temps nécessaire à l'intubation endotrachéale. Les critères d'évaluation secondaires comprenaient le taux de réussite à la première tentative, le temps total de manipulation des voies aériennes, la perception par les anesthésiologistes de la difficulté d'intubation, la probabilité d'utilisation chez les patients atteints du SRAS-CoV-2, et la perception de confort et d'acceptabilité des patients. RéSULTATS: Il y avait 48 participants dans le groupe avec boîte et 46 participants dans le groupe témoin. Le temps moyen (écart type [ÉT]) pour l'intubation endotrachéale était de 62 (29) sec avec la boîte et de 53 (27) sec sans la boîte (différence moyenne, 9 sec; intervalle de confiance de 95 %, − 3 à 20; P = 0,14). Les anesthésiologistes ont estimé que la difficulté d'intubation était plus élevée avec une boîte de protection (score moyen sur l'échelle visuelle analogique [ÉT], 27 [26] mm vs 9 [17] mm; P < 0,001). Il n'y avait pas de différences pour les autres critères d'évaluation secondaires. CONCLUSION: Chez les patients chirurgicaux en bonne santé avec des prédicteurs de voies aériennes normales, l'utilisation d'une boîte de protection pendant l'intubation endotrachéale n'a pas prolongé de manière significative le temps d'intubation ni réduit le taux de réussite de l'intubation à la première tentative. Néanmoins, il y avait une augmentation de la difficulté d'intubation perçue par les anesthésiologistes avec l'utilisation d'une boîte de protection. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT04366141); enregistrée le 28 avril 2020.

Identifying Barriers to Implementation of the National Partnership for Maternal Safety Obstetric Hemorrhage Bundle at a Tertiary Center: Utilization of the Delphi Method.

BACKGROUND: In 2015, the National Partnership for Maternal Safety (NPMS) developed an obstetric hemorrhage consensus bundle to provide birthing facilities in the United States with consistent, validated practice guidelines for postpartum hemorrhage management. The process of implementing each bundle element at a large tertiary labor and delivery unit has not been described; we sought to identify practice deficiencies and perceived barriers to bundle implementation among multidisciplinary providers. METHODS: We conducted a prospective, cross-sectional, consensus-building study based on the Delphi method. A multidisciplinary expert panel comprised of anesthesiologists, obstetricians, nurses, and surgical technicians was assembled and participated in 4 sequential questionnaires. The first round identified bundle elements that experts determined as not currently adequate and perceived barriers to implementation. The second round established prioritization of elements within each professional group; and the third round ranked the elements with at least 60% agreement on feasibility of implementation and positive impact on patient care. The last round revealed responses across all 4 professional groups to derive a final consensus. Descriptive statistics were performed. RESULTS: A total of 38 experts completed the study (11 anesthesiologists, 11 obstetricians, 10 nurses, and 6 surgical technicians). While all 13 (100%) NPMS obstetric bundle elements were described as deficient in our labor and delivery unit by a provider in at least 1 discipline, consensus among at least 3 of the 4 disciplines was achieved for 6 element deficiencies. Barriers to implementation were determined. The initiatives that achieved consensus as possessing high patient impact and implementation feasibility were protocol-driven management, unit-based simulation drills, blood loss quantification, and team huddles and debriefings. CONCLUSIONS: The NPMS obstetric hemorrhage bundle was created to help guide practice and systems improvement for US birthing facilities. The Delphi method enabled identification of deficient elements and perceived barriers to element implementation, as well as group consensus on elements with highest patient impact and feasibility. Multidisciplinary group consensus can identify deficiencies and promote tangible, quality improvements in a large, tertiary-care labor and delivery unit. Institutions may utilize our described technique to guide implementation of future care bundles.

Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case-Control Study.

BACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis. METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls. RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour. CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy.