Context-Responsive Anticoagulation Reduces Complications in Pediatric Extracorporeal Membrane Oxygenation.

Purpose: We sought to determine the impact of a comprehensive, context-responsive anticoagulation and transfusion guideline on bleeding and thrombotic complication rates and blood product utilization during extracorporeal membrane oxygenation (ECMO). Design: Single-center, observational pre- and post-implementation cohort study. Setting: Academic pediatric hospital. Patients: Patients in the PICU, CICU, and NICU receiving ECMO support. Interventions: Program-wide implementation of a context-responsive anticoagulation and transfusion guideline. Measurements: Pre-implementation subjects consisted of all patients receiving ECMO between January 1 and December 31, 2012, and underwent retrospective chart review. Post-implementation subjects consisted of all ECMO patients between September 1, 2013, and December 31, 2014, and underwent prospective data collection. Data collection included standard demographic and admission data, ECMO technical specifications, non-ECMO therapies, coagulation parameters, and blood product administration. A novel grading scale was used to define hemorrhagic complications (major, intermediate, and minor) and major thromboembolic complications. Main Results: Seventy-six ECMO patients were identified: 31 during the pre-implementation period and 45 in the post-implementation period. The overall observed mortality was 33% with no difference between groups. Compared to pre-implementation, the post-implementation group experienced fewer major hemorrhagic and major thrombotic complications and less severe hemorrhagic complications and received less RBC transfusion volume per kg. Conclusions: Use of a context-responsive anticoagulation and transfusion guideline was associated with a reduction in hemorrhagic and thrombotic complications and reduced RBC transfusion requirements. Further evaluation of guideline content, compliance, performance, and sustainability is needed.

Commercial Motor Vehicle Driver Positive Airway Pressure Therapy Adherence in a Sleep Center.

STUDY OBJECTIVES: To assess positive airway pressure (PAP) therapy adherence in commercial motor vehicle (CMV) drivers presenting to a sleep center. METHODS: A retrospective chart review of 120 drivers evaluated for obstructive sleep apnea OSA and 53 initiated on PAP therapy in a single sleep center over a one-year period (2012); PAP therapy data were collected up to 1 year. RESULTS: Early PAP usage best predicted adherence up to 1 year (p < 0.0001) compared to patient factors, OSA disease characteristics, and treatment elements analyzed. The proportion of participants adherent to therapy was 68.0% at 1 week, decreasing to 39.6% at 1 year, with 31.1% lost to follow-up by 1 year. In the group categorized based on adherence at week 1, 80.6% were adherent at 1 month, decreasing to 52.8% at 1 year. For the group non-adherent at 1 week, 29.4% were adherent at 1 month, decreasing to 11.7% at 1 year. Participants were predominantly male (75.8%), middle-aged (median 50.5 years), and African American (71.7%). Of those referred to the sleep center, 86.7% had OSA (median apnea-hypopnea index [AHI] or respiratory event index [REI] 20.1), with 51.0% of the OSA group having an AHI or REI > 20 and initiating PAP therapy. CONCLUSIONS: Early PAP utilization patterns predicted one year adherence for our CMV driver population within a sleep clinic setting. OSA testing of these CMV drivers after occupational health referral identifies high proportions of undiagnosed OSA, with approximately half requiring PAP therapy based on current published treatment recommendations.

Choline intake in a large cohort of patients with nonalcoholic fatty liver disease.

BACKGROUND: There is significant histologic and biochemical overlap between nonalcoholic fatty liver disease (NAFLD) and steatohepatitis associated with choline deficiency. OBJECTIVE: We sought to determine whether subjects with biopsy-proven NAFLD and evidence of an inadequate intake of choline had more severe histologic features. DESIGN: We performed a cross-sectional analysis of 664 subjects enrolled in the multicenter, prospective Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN) with baseline data on diet composition (from a recall-based food-frequency questionnaire) within 6 mo of a liver biopsy. Food questionnaires were analyzed with proprietary software to estimate daily intakes of choline. Liver biopsies were centrally read, and consensus was scored with the NASH CRN-developed scoring system. Because choline needs vary by age, sex, and menopausal status, participants were segregated into corresponding categories (children 9-13 y old, males ≥14 y old, premenopausal women ≥19 y old, and postmenopausal women) on the basis of the Institute of Medicine's definition of adequate intake (AI) for choline. Deficient intake was defined as <50% AI. RESULTS: Postmenopausal women with deficient choline intake had worse fibrosis (P = 0.002) once factors associated with NAFLD (age, race-ethnicity, obesity, elevated triglycerides, diabetes, alcohol use, and steroid use) were considered in multiple ordinal logistic regression models. Choline intake was not identified as a contributor to disease severity in children, men, or premenopausal women. CONCLUSION: Decreased choline intake is significantly associated with increased fibrosis in postmenopausal women with NAFLD. The Pioglitazone vs Vitamin E vs Placebo for Treatment of Non-Diabetic Patients With Nonalcoholic Steatohepatitis trial was registered at clinicaltrials.gov as NCT00063622, and the Treatment of Nonalcoholic Fatty Liver Disease in Children trial was registered at clinicaltrials.gov as NCT00063635.