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Nashif SK, Mahr RM, Tessier KM, Hoover EA, Ajagbe-Akingbola O, Chiu E, Andrews JI, Sabol BA, Rogers WK, Wernimont SA. Neonatal outcomes and rationale for timing of birth in perinatal diabetes: a retrospective cohort study. Am J Obstet Gynecol MFM 2023; 5:101129. [PMID: 37567447 PMCID: PMC10592060 DOI: 10.1016/j.ajogmf.2023.101129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/02/2023] [Accepted: 08/05/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND The American College of Obstetricians and Gynecologists recommends delivery in the 39th week of pregnancy for patients with pregestational and medication-controlled gestational diabetes with consideration for earlier delivery among those with poor glucose control. OBJECTIVE We sought to evaluate the impact of birth before 39 weeks' gestation exclusively for diabetes-related indications on neonatal outcomes and clinician rationale for these recommendations. STUDY DESIGN This was a retrospective cohort study of all singleton, nonanomalous pregnancies complicated by diabetes. Patients were identified through an obstetrical database containing information of 90,185 births from 2011 to 2021. Patients who delivered in a given week of gestation exclusively for diabetes-related indications were compared with ongoing pregnancies. Recommended births for other obstetrical indications were excluded from the diabetes-related indications cohorts. The primary outcome was neonatal intensive care unit admission. Secondary outcomes included neonatal intensive care unit length of stay, stillbirth, neonatal death, hypoglycemia, respiratory distress syndrome, and shoulder dystocia. For all births before 39 weeks' gestation, the electronic medical records were reviewed to confirm the rationale for the intervention for a diabetes-indicated condition. RESULTS From the 90,185 recorded births that occurred in 2011 to 2021, 4750 patients with diabetes were identified. Of those, 30.5% (n=1449) had a recommended birth for a diabetes-related indications with 2.2% of those (n=32) occurring at 36 weeks' gestation, 7.9% (n=114) at 37 weeks' gestation, 9.7% (n=141) at 38 weeks' gestation, and 63.0% (n=913) at 39 weeks' gestation. Births that occurred at 36 and 37 weeks' gestation exclusively for diabetes-related indications had higher rates of neonatal intensive care unit admission than the respective ongoing pregnancies (62.5% vs 8.7%; P<.001 and 25.4% vs 7.2%; P<.001). There was no difference in neonatal intensive care unit admission for births at 38 or 39 weeks' gestation when compared with ongoing pregnancy. For neonates born at 36 and 37 weeks' gestation in comparison with ongoing pregnancies, the median neonatal intensive care unit length of stay was 11.0 vs 2.8 days, (P<.001) and 4.4 vs 2.6 days (P=.026), respectively. There were significantly increased rates of neonatal hypoglycemia and respiratory distress syndrome among births that occurred at 36, 37, and 38 weeks' gestation when compared with ongoing pregnancies. There were no differences in the rate of stillbirth in this cohort. Primary factors cited for early birth were poor glycemic control (71.4%), recommendation by a maternal-fetal medicine specialist (38.7%), and suspected fetal macrosomia (27.9%). Overall, 46.7%, 32.8%, and 20.6% of patients had 1, 2, or ≥3 indications, respectively, listed as rationale for early birth. Overall, few objective measures were used to recommend birth before 39 weeks' gestation owing to diabetes. CONCLUSION In pregnancies complicated by diabetes, early birth exclusively for diabetes-related indications was associated with increased neonatal intensive care unit admission and length of stay and with neonatal morbidity. Little objective data are documented by clinicians to support their recommendations for early birth associated with diabetes. Additional clinical guidelines are needed to define suboptimal glucose control necessitating birth before 39 weeks' gestation.
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Affiliation(s)
- Sereen K Nashif
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, MN (Dr Nashif, Ms Mahr, Drs Hoover, Ajagbe-Akingbola, Andrews, Sabol, and Wernimont)
| | - Renee M Mahr
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, MN (Dr Nashif, Ms Mahr, Drs Hoover, Ajagbe-Akingbola, Andrews, Sabol, and Wernimont); Division of Molecular Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN (Ms Mahr and Dr Wernimont)
| | - Katelyn M Tessier
- Masonic Cancer Center, Biostatistics Core, University of Minnesota, Minneapolis, MN (Ms Tessier)
| | - Elizabeth A Hoover
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, MN (Dr Nashif, Ms Mahr, Drs Hoover, Ajagbe-Akingbola, Andrews, Sabol, and Wernimont)
| | - Oluwabukola Ajagbe-Akingbola
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, MN (Dr Nashif, Ms Mahr, Drs Hoover, Ajagbe-Akingbola, Andrews, Sabol, and Wernimont)
| | - Emily Chiu
- University of Minnesota Medical School, University of Minnesota, Minneapolis, MN (Dr Chiu)
| | - Janet I Andrews
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, MN (Dr Nashif, Ms Mahr, Drs Hoover, Ajagbe-Akingbola, Andrews, Sabol, and Wernimont)
| | - Bethany A Sabol
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, MN (Dr Nashif, Ms Mahr, Drs Hoover, Ajagbe-Akingbola, Andrews, Sabol, and Wernimont)
| | - William K Rogers
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN (Dr Rogers)
| | - Sarah A Wernimont
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, MN (Dr Nashif, Ms Mahr, Drs Hoover, Ajagbe-Akingbola, Andrews, Sabol, and Wernimont); Division of Molecular Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN (Ms Mahr and Dr Wernimont).
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Reeder JA, O’Sullivan CT, Xu M, Wu N, Ince D, Rogers WK, An G. Model-Informed Clinical Practice - Determining an Appropriate Ampicillin-Sulbactam Redosing Regimen in Surgical Patients by Utilizing Population Pharmacokinetics and Target Attainment Analysis. Antimicrob Agents Chemother 2023; 67:e0124822. [PMID: 36920230 PMCID: PMC10112153 DOI: 10.1128/aac.01248-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 02/04/2023] [Indexed: 03/16/2023] Open
Abstract
In the current study, population pharmacokinetic (PK) of ampicillin-sulbactam was performed based on the clinical pharmacokinetics data collected from a prospective study conducted in 40 surgical patients undergoing prolonged surgery where antibiotic redosing was implemented. A population PK model was successfully developed to characterize the disposition of ampicillin and sulbactam. The final models were two-compartment models for both drugs, with creatinine clearance and heart failure affecting clearance and body surface area having an impact on the central volume of distribution of both ampicillin and sulbactam. Comprehensive Monte Carlo simulations were performed to evaluate the probability of target attainment (PTA) of 24 different redosing scenarios. Simulation results indicated that the ampicillin-sulbactam 2-h redosing scheme recommended by ASHP guidelines is likely too conservative given that 3-g dose (2-g ampicillin/1-g sulbactam) with 4-h redosing interval can reach the breakpoint of 2 mg/L for ampicillin in all populations even with the aggressive pharmacokinetic/pharmacodynamic (PK/PD) target of 100% fT > MIC. With the target 50% fT > MIC, all redosing schemes evaluated, including the 8-h redosing scenario, are predicted to be able to reach the breakpoint of 64 mg/L in all patients. According to our findings, redosing of ampicillin-sulbactam should be every 4 h instead of the currently recommended 2-h redosing schedule. Our PTA results should inform future updates to existing general antibiotic redosing guidelines; and, when used in combination with the availability of institution- and/or unit-specific ampicillin susceptibility patterns, our PTA results may be used to customize SSI prophylaxis redosing recommendations for ampicillin-sulbactam at individual hospitals.
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Affiliation(s)
- Joshua A. Reeder
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa City, Iowa, USA
| | - Cormac T. O’Sullivan
- College of Nursing, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Min Xu
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa City, Iowa, USA
| | - Nan Wu
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa City, Iowa, USA
| | - Dilek Ince
- Department of Internal Medicine, Division of Infectious Diseases, Carver College of Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - William K. Rogers
- Department of Anesthesia, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Guohua An
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa City, Iowa, USA
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Lin SH, Galet C, Zanaty M, Bayman E, Rogers WK, Hasan D, Allan LD. Melatonin and risk of mortality in subjects with aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2021; 210:106990. [PMID: 34739880 DOI: 10.1016/j.clineuro.2021.106990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/09/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is a cause of morbidity associated with aneurysmal subarachnoid hemorrhage (aSAH). Neuroinflammation contributes to the development of DCI. Melatonin is a sleep-promoting hormone known to have cerebral anti-inflammatory properties. We hypothesized that synthetic melatonin (or the selective melatonin receptor agonist ramelteon) incidentally prescribed to improve sleep may lower the incidence of DCI among hospitalized aSAH patients. METHODS Subjects with a Hunt and Hess Grade I-III were identified from a data registry involving all aSAH patients admitted to our hospital between January 2015 and September 1, 2018. A cohort of patients who received either melatonin or ramelteon during their hospitalization was compared to a matched cohort that did not receive these drugs. The primary endpoint was incidence of DCI. Secondary outcomes included modified Rankin score (mRS) at discharge, discharge destination, and mortality at 6 weeks from discharge. The two groups were compared using univariate analysis. P < 0.05 was considered significant. RESULTS There was no significant difference in the incidence of DCI (15.8% vs. 16.9%, p = 1), discharge mRS (mRS 0-3: 51.3% vs. 45.1%, p = 0.59), discharge disposition (Home: 43.6% vs. 44.4, p = 0.47), or mortality (0% vs. 9.2%; p = 0.074) between the melatonin/ramelteon and non-melatonin groups. CONCLUSION The use melatonin had no effect on DCI but may improve mortality in aSAH subjects. Prospective studies using a larger cohort are warranted to validate these findings.
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Affiliation(s)
- Suzy H Lin
- Department of Surgery, Division of Acute Care Surgery, University of Iowa, Iowa City, IA, United States
| | - Colette Galet
- Department of Surgery, Division of Acute Care Surgery, University of Iowa, Iowa City, IA, United States
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa, Iowa City, IA, United States
| | - Emine Bayman
- Department of Anesthesia, University of Iowa, Iowa City, IA, United States
| | - William K Rogers
- Department of Anesthesia, University of Iowa, Iowa City, IA, United States
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, IA, United States
| | - Lauren D Allan
- Department of Surgery, Division of Acute Care Surgery, University of Iowa, Iowa City, IA, United States.
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Nalbant D, Reeder JA, Li P, O'Sullivan CT, Rogers WK, An G. Development and validation of a simple and sensitive LC-MS/MS method for quantification of ampicillin and sulbactam in human plasma and its application to a clinical pharmacokinetic study. J Pharm Biomed Anal 2021; 196:113899. [PMID: 33508765 DOI: 10.1016/j.jpba.2021.113899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/15/2020] [Accepted: 01/11/2021] [Indexed: 12/27/2022]
Abstract
Ampicillin-sulbactam is a broad-spectrum combination antibiotic used for a variety of clinical applications, including as a prophylactic agent to reduce the risk of surgical site infection. The pharmacokinetics of ampicillin-sulbactam after redosing during prolonged surgeries remains incompletely understood. In anticipation of further studying the intra-operative pharmacokinetics of this drug, we have developed a novel liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the quantification of ampicillin and sulbactam. The plasma samples were prepared using a simple protein precipitation method. Gradient chromatographic elution was used to separate analytes, and MS/MS analysis was performed in negative ionization mode for both analytes via multiple reaction monitoring (MRM). All validation parameters were evaluated under a good laboratory practice (GLP) environment. For both ampicillin and sulbactam, the lower limit of quantitation (LLOQ) was established as 0.25 μg/mL. The calibration curve ranged from 0.25 to 200 μg/mL for ampicillin and 0.25-100 μg/mL for sulbactam. Inter- and intra-day precisions for both analytes were ≤11.5 % for quality controls and ≤17.4 % for LLOQ; accuracies ranged from -11.5 to 12.5% for 3 quality control levels and -18.1-18.7% for LLOQ. In addition to sensitivity, accuracy and precision, 13 other parameters were also validated for both analytes, and the results met the acceptance criteria. Our method was successfully applied to quantify ampicillin and sulbactam concentrations in patients undergoing surgery.
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Affiliation(s)
- Demet Nalbant
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, USA
| | - Joshua A Reeder
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, USA
| | - Peizhi Li
- College of Pharmacy, University of Iowa, USA
| | | | - William K Rogers
- Department of Anesthesia, University of Minnesota Medical School, M Health Fairview, USA
| | - Guohua An
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, USA.
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Abstract
By cooling the blood just before returning it to the body, marked reduction in the temperature of the heart, brain, liver, and kidney can be produced easily and with great economy in heat transfer, since the great bulk of the animal or patient, consisting of skin, muscle, and bone, is cooled much more slowly. This results in a marked oxygen saving, due to the direct antimetabolic effect of the cooling. Metabolic acidosis can be avoided and so far no irreversible effects of the cooling have been discoverable. Warming is so greatly facilitated by the heat stored in the nonvital areas that it is not necessary to warm the blood returning from the extracorporeal circuit. The use of safe, low, extracorporeal flows offers a number of possible advantages including great simplicity of cannulation and of the pump oxygenator design and operation.
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Affiliation(s)
- E C Peirce
- East Tennessee Tuberculosis Hospital, Knoxville, USA
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