Acute Coronary Syndrome Revascularization Strategies With Multivessel Coronary Artery Disease

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multivessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multicentered, retrospective observational study from a large hospital system in the United States. We abstracted data in patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG, or medical management (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and gender. There were 295 patients with CABG (median age 66 years [interquartile range 59.7 to 73.1]; 73% male), 1,559 patients with PCI (median age 68.3 years [interquartile range 60 to 76.6]; 69.1% male], and 307 patients with MM (median age 70 years [60.9 to 77.1] 74% male]. Patients revascularized with PCI had greater all-cause mortality at 1 year (14.1% vs 5.1%; hazard ratio 2.4, confidence interval [1.5 to 3.8], p <0.001) and similar mortality to MM (13.4%). CABG also showed a reduced 1-year MI rate compared with PCI (1.7% vs 3.9%; hazard ratio 0.36, confidence interval 0.21 to 0.61, p ≤0.001), with a similar 1-year rate of MI to MM (3.9%). In conclusion, CABG is associated with lower mortality than are PCI and MM, and repeat ACS events at 1 year in patients with ACS and MV-CAD.

The Association Among Clinical Profiles, Modifiers, and Prolonged Recovery in Adolescents With Sport-Related Concussion

OBJECTIVE

The purposes were to (1) describe the prevalence of clinical profiles and modifiers, (2) examine the association between clinical profiles and prolonged recovery, and (3) examine the interaction between clinical profiles and modifiers and prolonged recovery in adolescents with sport-related concussion (SRC).

DESIGN

Retrospective, cross-sectional.

SETTING

Interdisciplinary specialty sports concussion clinic.

PATIENTS

Patients (n = 299) aged 12 to 19 years who were diagnosed with SRC within 30 days of injury.

INDEPENDENT VARIABLES

Clinical profiles and modifiers were decided by the clinical judgment of the clinical neuropsychologist and sports medicine physician, using data from the Clinical Profile Screen and information gathered from the clinical interview, neurocognitive, and vestibular and ocular motor testing.

MAIN OUTCOME MEASURES

Prolonged recovery was defined as ≥28 days from the date of injury to the date of clearance.

RESULTS

The most common clinical profiles were migraine (34.8%) and cognitive-fatigue (23.4%). There were no significant relationships between clinical profiles and prolonged recovery (Wald = 5.89, df = 4, P = 0.21). The presence of a modifier did not significantly affect the relationship between clinical profiles and prolonged recovery ( = 6.5, df = 5, P = 0.26). The presence of any modifier yielded a 10-day increase in median recovery time within the cognitive/fatigue clinical profile (Wilcoxon rank-sum = 268.5, P = 0.01).

CONCLUSIONS

Although patients with a clinical profile and modifier may not experience prolonged recovery, they may experience longer recovery time than patients with a clinical profile and no modifier.

Salvage prostate bed plus elective pelvic node radiation without androgen deprivation therapy

BACKGROUND AND PURPOSE

In men with biochemical recurrence (BCR) of prostate cancer (PCA) after radical prostatectomy (RP), there is limited data on the effectiveness of adding elective pelvic nodal radiation (EPNI) to salvage prostate bed radiation (PBRT) without androgen deprivation therapy (ADT) to prevent progression.

MATERIALS AND METHODS

Retrospective chart review of 326 patients treated for BCR of PCA from a single institution was performed to capture baseline pre-operative PSA, pathologic details, post-operative PSA, treatment details (radiation and ADT), subsequent failure (rising PSA), response to radiation, and subsequent outcomes after radiation.

RESULTS

Between 2004 through 2017, 326 patients received PBRT. Majority (n = 253; 78%) did not receive ADT. Majority received EPNI (n = 227; 90%) with salvage PBRT (n = 213; 94%). The median pre-PBRT PSA was 0.50 ng/ml (0.10-75.60 ng/ml). Of the patients that did not receive ADT, 83% (210/253) achieved an undetectable (< 0.2 ng/ml) PSA after salvage PBRT. After a median follow-up of 87 months, 172 (53%) patients were without a rising PSA and 50 (15%) developed metastatic disease.

CONCLUSION

Outcomes with salvage PBRT plus EPNI without ADT appear comparable to salvage PBRT plus EPNI plus ADT. These results need confirmation in a randomized setting.

Outcomes for non-treatment-requiring infants evaluated for retinopathy of prematurity

PURPOSE

To evaluate the rates of visually significant disorders in patients without treatment-requiring retinopathy of prematurity (ROP) at initial follow-up after completion of ROP examinations.

METHODS

The medical records of all babies evaluated for retinopathy of prematurity between June 2015 and September 2020 were reviewed. Patients with documented gestational age, birth weight, and single versus multiple birth status who did not require ROP treatment and who followed-up with our institution's pediatric ophthalmologist were included.

RESULTS

A total of 304 patients were included. Of these, 15 (4.9%) had strabismus (12 [4.0%] with esotropia, 3 [0.9%] with exotropia), 30 (9.9%) had myopia, 174 (57.2%) had hyperopia, 54 (18%) had astigmatism, 4 (1.3%) had amblyopia, 5 (1.6%) were labeled amblyopia suspects, 1 (0.3%) had congenital glaucoma, and 1 (0.3%) had congenital cataract. Nineteen (6.3%) had a condition requiring intervention at the first evaluation following completion of ROP examinations, and in 5 (2%), this was a condition that would typically not have been identified without evaluation by a pediatric ophthalmologist.

CONCLUSIONS

In our population of infants evaluated for retinopathy of prematurity who did not require ROP treatment, the incidence of other ocular disorders requiring intervention at the first non-ROP evaluation was about 6%. This study highlights the need for further research that may aid in the creation of an evidence-based follow-up strategy for premature infants who never undergo ROP treatment.

Effect of the COVID-19 pandemic on racial disparities in postpartum visits at a Texas level IV maternal center

Background

The primary aim of our study was to determine the attendance of postpartum visits stratified by race and if the COVID-19 pandemic affected racial disparities in postpartum visit attendance.

Methods

We searched our labor and delivery records from July 1, 2019 to December 31, 2019 and from July 1, 2020 to December 31, 2020 and included patients who delivered liveborn infants. The final analysis was restricted to patients who identified as White or Caucasian only, Black or African American only, or Hispanic. We then performed joint tests on the logistic regression with an interaction term of race and year of delivery to determine the final model.

Results

The odds ratio of Black or African American and Hispanic patients attending a postpartum visit was 0.589 (95% CI 0.456, 0.760; P < .001) and 0.836 (95% CI 0.676, 1.034; P = 0.099), respectively, compared to White or Caucasian patients. The interaction term of race and year of delivery was not statistically significant.

Conclusion

Black or African American patients at our hospital had a clinically and statistically significant lower utilization of postpartum visits compared to White or Caucasian patients and this disparity was not exacerbated by the COVID-19 pandemic.

A comparison of anesthetic outcomes between activation and removal of epidural catheters for patients who underwent unscheduled intrapartum cesarean delivery

Background

We hypothesized that patients who underwent unscheduled intrapartum cesarean delivery and had removal of an indwelling epidural catheter followed by an attempt of a new regional anesthetic would be more likely to have regional anesthesia without conversion to general anesthesia or administration of additional anesthetic medication compared to patients who had activation of an epidural catheter.

Methods

Patients who had an unscheduled intrapartum cesarean delivery from July 1, 2019, through June 30, 2021, who had an indwelling labor epidural catheter were included. Patients were propensity matched based on obstetric indication for cesarean delivery and number of physician-administered rescue analgesia boluses administered during labor. A multivariate proportional odds regression was performed.

Results

After adjusting for parity, depression, last neuraxial labor analgesic technique, physician-administered rescue analgesia boluses, and duration from neuraxial placement to entering the operating room for cesarean delivery, patients who had removal of their epidural catheters were more likely to have regional anesthesia without conversion to general anesthesia or administration of additional anesthetic medication (odds ratio 4.298; 95% confidence interval 2.448, 7.548; P < 0.01).

Conclusion

Removal of epidural catheters was associated with a greater chance of avoiding conversion to general anesthesia or administration of additional anesthetic medication.

The role of the RAPID score in surgical planning for empyema

Background

The RAPID [Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)] score is a validated scoring system which allows risk stratification in patients with pleural infection at presentation. Surgical intervention plays a key role in managing pleural empyema.

Methods

A retrospective study of patients with complicated pleural effusions and/or empyema undergoing thoracoscopic or open decortication admitted to multiple affiliated Texas hospitals from September 1, 2014 to September 30, 2018. The primary outcome was all-cause 90-day mortality. The secondary outcomes were organ failure, length of stay and 30-day readmission rate. The outcomes were compared between early surgery (≤3 days from diagnosis) and late surgery (>3 days from diagnosis) and low [0-3] vs. high [4-7] RAPID scores.

Results

We enrolled 182 patients. Late surgery was associated with increased organ failure (64.0% vs. 45.6%, P=0.0197) and longer length of stay (16 vs. 10 days, P<0.0001). High RAPID scores were associated with a higher 90-day mortality (16.3% vs. 2.3%, P=0.0014), and organ failure (81.6% vs. 49.6%, P=0.0001). High RAPID scores with early surgery were associated with higher 90-day mortality (21.4% vs. 0%, P=0.0124), organ failure (78.6% vs. 34.9%, P=0.0044), 30-day readmission (50.0% vs. 16.3%, P=0.027) and length of stay (16 vs. 9 days, P=0.0064). High vs. low RAPID scores with late surgery was associated with a higher rate of organ failure (82.9% vs. 56.7%, P=0.0062), but there was not a significant association with mortality.

Conclusions

We found a significant association between RAPID scores and surgical timing with new organ failure. Patients with complicated pleural effusions who had early surgery and low RAPID scores experienced better outcomes including decreased length of stay and organ failure compared with those who had late surgery and low RAPID scores. This suggests that using the RAPID score may help identify those who would benefit from early surgery.

Airway management for 362 cesarean deliveries performed with general anesthesia at a Texas level IV maternal facility

At our hospital, direct and video laryngoscopy are used in airway management for cesarean deliveries performed with general anesthesia. We hypothesized that video laryngoscopy would have a higher success rate of endotracheal intubation on the first attempt compared to direct laryngoscopy. We used our electronic medical record system to search for patients who had cesarean deliveries with general anesthesia with endotracheal intubation performed in the operating room from July 1, 2017, through June 30, 2021. Totals of 186 and 176 patients had direct and video laryngoscopy for the first intubation attempts, respectively; 177 (95%) and 163 (93%) patients, respectively, had a successful intubation on the first attempt with each method. The odds ratio of successful intubation on the first attempt for video laryngoscopy was 0.64 (95% CI 0.27, 1.53; P = 0.31) compared to patients who had direct laryngoscopy. There was no statistically significant difference in Cormack-Lehane grade views of the glottis between direct and video laryngoscopy on the first attempt. In conclusion, there was no statistically significant improvement in the success rate of intubation on the first attempt when video laryngoscopy was used for patients undergoing general anesthesia for cesarean delivery.

Effect of the COVID-19 pandemic on racial disparities in neuraxial labor analgesia at a Texas level IV maternal care center

We hypothesized that racial disparities in labor epidural analgesia at our hospital that existed prior to the COVID-19 pandemic would be exacerbated during the COVID-19 pandemic. We examined patients who delivered vaginally at our hospital for the last 6 months of 2019 and the last 6 months of 2020. We performed joint testing of coefficient P values, and the interaction term between race and year of delivery was not significant (0.364). A multivariate logistic regression model found that Hispanic patients (odds ratio 0.555 [0.408, 0.756], P < 0.001) and Black or African American patients (odds ratio 0.613 [0.408, 0.921], P = 0.018) were less likely to receive labor epidural analgesia compared to White or Caucasian patients. Odds ratios of receiving labor epidural analgesia were higher with increasing gestational age (1.116 [1.067, 1.168], P < 0.001) and lower with increasing parity (0.789 [0.719, 0.867], P < 0.001). The year of birth that corresponded to before or during the COVID-19 pandemic did not predict whether a patient received labor epidural analgesia (1.247 [0.941, 1.652], P = 0.124). Because the interaction between race and year of birth was not statistically significant, we conclude that the COVID-19 pandemic did not exacerbate racial disparities in labor epidural analgesia at our hospital.

Long-Term Effects of Radiation on Lymphocytes and Risk of Opportunistic Infections

Objectives

Lymphocytes are very sensitive to ionizing radiation. The long-term effects and the risk of permanent immune compromise are not well defined in spite of more than a century of therapeutic radiation. The contemporary analysis is made more difficult in that most patients also receive immunosuppressive chemotherapy.

Methods

Cohort-all patients that underwent a prostate biopsy from 2002 to 2007. Those (n=1118) with at least two blood counts, with one at a minimum of 10 years after biopsy, were included. We identified three groups: those that received no treatment (due to benign biopsy findings or active surveillance), those undergoing prostate cancer surgery, and those undergoing radiation therapy. Blood counts were collected and analyzed for differences with a median follow-up of 178 months. Also evaluated was the risk of opportunistic infections.

Results

The median granulocyte count gradually increased with time, with no difference between the groups. Overall, the median lymphocyte count decreased from baseline over time (with a slight rise at 20 years). For the no treatment and surgery groups, the lymphocyte counts declined, but due to the initial decline after radiation therapy, that group saw a slow improvement. By 20 years, there was no difference between the groups. Most patients’ counts remained in the normal range throughout. The risk of defined opportunistic infections was low (12%) with no difference between the groups.

Conclusion

Pelvic radiation has minimal lasting effects on lymphocyte and granulocyte counts. In addition, patients receiving radiation do not appear to be significantly immunocompromised.

Infant nutrition (donor human milk vs. maternal milk) and long-term neurodevelopmental and growth outcomes in very low birth weight infants

BACKGROUND

Human milk, the ultimate source of nutrition for premature infants, enhances host defense mechanism, gastrointestinal maturation, lowers infection rate, improves neurodevelopmental outcomes, and reduces long-term cardiovascular and metabolic disease. Recently, there has been an increase in donor breast milk (DBM) use for premature infants; however, data are limited on the long-term effects of DBM on the infant's growth and neurodevelopmental outcomes.

OBJECTIVE

To determine if there is an association between type of infant nutrition (maternal breast milk (MBM) or DBM) and neurodevelopmental and growth outcomes in very low birth weight (VLBW) infants.

DESIGN/METHODS

Retrospective cohort study of VLBW (<1500 g) infants admitted to the Baylor Scott & White Memorial Hospital Neonatal Intensive Care Unit from January 2014 to December 2016. Infants with major congenital anomalies, born at an outside hospital, who were nil per os (NPO) for >15 days, or who died before NICU discharge were excluded. Infants were stratified into two groups (MBM or DBM) based on predominant nutrition (>50%) received in the first month of life. Primary outcomes of neurodevelopmental delay(s) between 2 and 4 years of age identified via ICD 9/10 codes. Growth data (weight, length, and head circumference) were obtained from well-check visits at 12-, 18-, 24-, 36-, and 48-months. Severity of illness was determined using the Clinical Risk Index in Babies-II (CRIB-II) score. Generalized linear models were used to assess the relationship between nutrition and neurodevelopmental delay and trends in growth over time.

RESULTS

Two hundred and nine infants were included: 146 MBM; 63 DBM. Median gestational age was 28 weeks (range, 23-35) and median birthweight was 1050 g (range, 410-1470). There were no significant differences in birthweight, gestational age, CRIB-II score, or length of stay between the groups. Infants fed DBM had a significantly larger weight z-score (p=.005), length z-score (p=.01), and head circumference z-score (p=.04), on average from birth to 48 months compared to MBM infants, while controlling for NICU length of stay and number of follow-up months; however, this only equated to DBM infants being 0.5 in taller and 0.9 lbs heavier at 48 months. There were no statistically significant differences among type of infant nutrition and long-term neurodevelopmental outcomes, while controlling for CRIB-II score.

CONCLUSIONS

Infants fed DBM have a slightly greater propensity for growth over time compared to infants fed MBM. Longer follow-up is needed to further determine the effect, infant nutrition has on neurodevelopmental outcomes.

Reference Results for Blood Parameter Changes and Recovery after Pelvic Radiation without Chemotherapy

Introduction: There are few reports on the effect of radiation alone on blood cells (without chemotherapy). We sought to develop a single source as a reference. Materials and Methods: For over 300 prostate cancer patients treated with radiation alone, we collected the baseline, end-of-treatment and three-month post-therapy complete blood counts (CBC). Results: The hemoglobin dropped by a mean of 1.00 g/dL (−7.1%), with an RBC count of 0.40 × 1012 (−8.6%) at the end of treatment and remained significantly (but <5%) below baseline at follow-up. Significant declines were seen in the levels of the granulocytes (−12.2%; −0.67 × 109), monocytes (−2.2%; −0.05 × 109) and platelets (−12.7%; −30.31 × 109) at the end of treatment, but all returned to baseline on follow-up. The neutrophils and basophils (the primary components of the granulocytes) suffered a significant decline but returned to baseline by the follow-up. The other granulocyte components, the eosinophils, did not decline significantly. The most dramatic decline was in the levels of lymphocytes −62.5% (−1.29 × 109), which were still significantly below baseline (−38%) after two years. Conclusion: The effect of radiation is mostly transitory, with some persistence in hemoglobin/erythrocyte levels (<5%). Lymphocytes are slower to recover, remaining significantly below baseline after two years. It is noteworthy that of the patients whose lymphocytes were in the normal range at the start of therapy, only 14% were below normal at follow-up. Radiation alone has negligible-to-modest long-term effects on blood counts.

The Effect of High-Dose Radiation Therapy on Healthy Vertebral Bone Density

Objective

Increased rates of insufficiency fractures are reported after radiation therapy without well-defined causality. Here, we conduct a cross-sectional study on the density change of a non-lesioned vertebral bone after irradiation relative to a control bone in patients with spinal metastases.

Methods

Patients were identified who received radiation therapy for spinal metastases to a region, including an adjacent vertebra without identifiable malignancy on pre-treatment CT. Every patient had an untreated vertebra of a similar type available as a control. A Hounsfield-density calibration curve was used to measure the vertebral body density before and after treatment. Analysis of covariance was used to model vertebral bone density changes with respect to treatment status. Significance was established as p < 0.05.

Results

We identified 36 patients who fit the study criteria. The irradiated healthy bone received a median dose of 30 Gy. The median biologically effective dose (BED) was 60 Gy (α/β = 3) and 39 Gy (α/β = 10). Median follow-up imaging intervals between pre-treatment and follow-up CT scans was 13.4 months. Levene’s test was used to confirm the equality of error variance assumption of ANCOVA (p = 0.093). The mean change in the density of the irradiated vertebral bone was -3.59% (95% CI = -8.51% - 1.32%, p = 0.149).

Conclusions

We found no significant change in vertebral bone density attributable to radiation treatment. Further work is needed to elucidate if increased fracture rates after radiation are due to factors other than bone density.

Improved local control in p16 negative oropharyngeal cancers with hypermethylated MGMT

INTRODUCTION

Patients with oropharyngeal cancers that are p16 negative (p16-) have worse outcomes than those who are p16 positive (p16+) and there is an unmet need for prognostic markers in this population. O6-Methylguanine (O6-MG)-DNA-methyltransferase (MGMT) gene methylation has been associated with response to chemoradiotherapy (CRT) in glioblastoma. We sought to find if MGMT promoter methylation was associated with outcomes of locally advanced oropharyngeal and oral cavity squamous cell carcinoma (OOSCC) in patients treated with definitive concurrent CRT.

METHODS

Patients were identified with primary OOSCC, known p16 status, retrievable pre-treatment biopsies, and at least 6 months of follow-up who received definitive concurrent CRT from 2004 to 2015. Biopsies were tested for MGMT hypermethylation (MGMT+) using a Qiagen pyrosequencing kit (Catalog number 970061). Outcomes were subsequently recorded and analyzed.

RESULTS

Fifty-eight patients were included with a median follow up of 78 (range 6-196) months. Fourteen patients (24.1%) had oral cavity cancer and 44 (75.9%) had oropharyngeal cancer. A significant difference was found for local recurrence free survival (LRFS) by combined MGMT and p16 status (p = 0.0004). Frequency of LR in MGMT+/p16+, MGMT+/p16-, MGMT-/p16+, and MGMT-p16- patients was 14.3%, 14.3%, 13.0%, and 69.2%, respectively (p = 0.0019). A significant difference was not found for distant recurrence free survival (p = 0.6165) or overall survival (p = 0.1615). LRFS remained significant on analysis restricted to oropharyngeal cancer patients (p-value = 0.0038).

CONCLUSION

Patients who are p16- and MGMT+ with oropharyngeal and oral cavity squamous cell carcinoma have significantly better LC with definitive CRT than those who are p16- and MGMT-. Prospective studies are needed to verify these findings.

Variations in umbilical cord clamping practices in the United States: a national survey of neonatologists

OBJECTIVE

Since the first publication of the American College of Obstetricians and Gynecologists committee opinion in 2012, and following the update in 2017, multiple institutions in the United States (US) adopted the practice of delayed cord clamping (DCC) and/or umbilical cord milking (UCM) in preterm and term infants. However, there have been variations reported in practices with regard to method of placental transfusion, timing of cord clamping and gestational age thresholds. Furthermore, the optimal cord clamping practice in situations of depressed infants needing resuscitation or in higher-risk delivery situations, such as placental abruption, intrauterine growth restriction, multiple gestation, chorioamnionitis, maternal human immunodeficiency virus syndrome/hepatitis or maternal general anesthesia is often debated. An evaluation of these variations and exploration of associated factors was needed to optimally target opportunities for improvement and streamline research activities. The objective of this survey, specifically aimed at neonatologists working in the US was to identify and describe current cord clamping practices and evaluate factors associated with variations.

STUDY DESIGN

The survey was distributed electronically to the US neonatologists in August 2019 with a reminder email sent in October 2019. Clinicians were primarily identified from Perinatal Section of AAP, with reminders also sent through various organizations including California Association of Neonatologists, Pediatrix and Envision national groups. Descriptive variables of interest included years of experience practicing neonatology, affiliation with a teaching institution, level of the neonatal intensive care unit (NICU) and practicing region of the US. Questions on variations in cord management practices included information about center specific guideline/protocol, cord clamping practices, gestational age threshold of placental transfusion, performance of UCM and practice in higher-risk delivery situations.

RESULTS

The response rate was 14.8%. Among 517 neonatologists whom responded, majority (85.5%) of the practices had a guideline and performed (81.7%) DCC in all gestational ages. The cord clamping practice was predominantly DCC and it was categorized as reporting clamping times <60 s in 46.6% and ≥60 s in 48.7% of responses. A significant association was detected between time of delay in cord clamping and region of practice. The Northeast region was more likely to clamp the cord in <60 s than other regions in the US. More than half of the providers responded not performing any UCM (57.3%) in their practice. Significant associations were detected between performance of UCM and all queried demographic variables independently. Clinicians with >20 years of experience were more likely from institutions performing UCM compared to the providers with fewer years of experience. However, teaching hospitals were less likely to perform UCM compared to non-teaching hospitals. Similarly, practices with level IV NICUs were less likely to perform UCM compared to practices with level III units. Hospitals in the Midwest region of US were less likely to perform UCM compared to hospitals in the Western region. Significant variations were also noticed for not providing placental transfusion in higher-risk deliveries. Demographic and professional factors were noted to be associated with these differences.

CONCLUSION

Although the majority of practices have a guideline/protocol and are performing DCC in all gestational ages, there are variations noted with regard to timing, method, and performance in higher-risk deliveries. Demographic and professional factors play an important role in these variations. Future research needs to focus on the modifiable factors to optimize the procedure and impact of DCC.

Relationship between splenomegaly and transfusion requirements in patients with cirrhosis

Patients with cirrhosis and splenomegaly commonly develop cytopenias and require the transfusion of blood products. In this study, we evaluated spleen size as a clinical indicator for red blood cell transfusion effectiveness and hypothesized that transfusion would be less effective in patients with splenomegaly. Our retrospective cohort study compared 215 cirrhotic patients with splenomegaly and 114 cirrhotic patients without splenomegaly and measured their respective change in hemoglobin concentration after a unit of transfused red blood cells. The primary endpoint was the percent difference between the measured rise in hemoglobin after transfusion in these cohorts. Patient sex (P < 0.0035), body mass index (P < 0.0001), and the change in hemoglobin concentration after a leukocyte-reduced red blood transfusion (P < 0.0001) were found to be significantly related to spleen size. When compared to the nonsplenomegaly cohort, it was found that the splenomegaly cohort experienced 79.70% (95% CI 71.26%-89.14%) of the change in hemoglobin concentration after red blood cell transfusion when adjusted for patient sex and body mass index. In conclusion, in patients with cirrhosis, increased spleen size was correlated with a decreased responsiveness to red blood cell transfusion when adjusted for patient sex and body mass index.

Characterizing the impact of magnesium and potassium-supplemented hydration with cisplatin and the subsequent electrolyte replacement requirements

BACKGROUND

Cisplatin-associated electrolyte dysregulation is a prevalent therapy-related adverse effect. There are numerous electrolyte-supplemented hydration regimens that have been evaluated, however these studies focused on the development of nephrotoxicity. The objective of this study was to characterize the impact of magnesium and potassium-supplemented hydration during cisplatin administration on subsequent magnesium and potassium imbalances.

METHODS

A single-region retrospective study from central Texas at Baylor Scott & White Cancer Clinics who were treated with two or more cycles of cisplatin were included. Standard hydration for this study was defined as normal saline before and after cisplatin along with potassium chloride 10 mEq and magnesium sulfate 1 g added to the cisplatin bag.

RESULTS

A total of 477 patients were included in the study with376 patients receiving the standard hydration. Overall, 17 percent of patients experienced a potassium level below 3.5 mEq/L, but no major depletion was observed. Thirty-three percent of the patients experienced a magnesium level below 1.8 mg/dL, and time to first rescue magnesium supplementation was 4 weeks.

CONCLUSION

Our study demonstrated despite routine magnesium and potassium supplementation in hydration, magnesium imbalances were observed. Potassium levels post cisplatin administration were maintained with minimal routine supplementation in hydration.

The use of adjunct anesthetic medication with regional anesthesia and rates of general anesthesia for 1867 cesarean deliveries from 2014 to 2018 in a community hospital

The number of cesarean deliveries performed with a general anesthetic decreased when regional anesthesia for cesarean delivery was reported to be associated with lower maternal mortality. Anesthetic adjunct administration for cesarean deliveries performed with regional anesthesia is typically not reported alongside general anesthesia rates for cesarean delivery. This retrospective study analyzed rates of general anesthesia and systemic anesthetic adjunct administration for cesarean deliveries performed under regional anesthesia at a community hospital from 2014 to 2018. We used the hospital electronic medical record system to collect data on cesarean deliveries during the study period. A total of 1867 cesarean deliveries were performed, corresponding to a cesarean delivery rate of 30.4%. Of the subjects, 104 (5.6%) received general anesthesia and 333 (17.8%) received regional anesthesia with at least one systemic anesthetic adjunct. These adjuncts included a variety of intravenous agents-midazolam (1.7%), fentanyl (5.2%), morphine (6.6%), propofol (7.9%), and ketamine (1.7%)-as well as inhaled nitrous oxide (1.4%) and sevoflurane (0.1%). These data on anesthetic adjunct administration with regional anesthesia provide clinical context for the rates of general anesthesia reported for cesarean delivery.

The effect of pelvic radiation alone on lymphocyte subgroups

•

Radiation therapy alone has dramatic effects on lymphocyte subgroups.

•

CD4+, CD8+ and CD56+ counts drop by >70%, CD 19+ by >90%.

•

Three months post exposure, no subgroup has returned to baseline levels.

•

All subgroups except CD 56+ (including CD19+) recovered modestly to about 40% of pre-treatment levels.

•

CD56+ were more resistant and recovered to 64% of pretreatment levels.

•

CD56+ cells recover more fully (to >60% of pretreatment levels).

There is a lack of information on the radiosensitivity of lymphocyte subgroups to radiation alone. CD4+ and CD8+ lymphocytes respond similarly. CD 19+ dropped most precipitously, but recovered to levels similar to the other subgroups by 3 months. NK cells decline more modestly and recover more fully by 3 months.

Parental perceptions of the impact of neonatal unit visitation policies during COVID-19 pandemic

OBJECTIVES

To ascertain parental perceptions of the impact of restricted visiting policies to neonatal intensive care units during the current COVID-19 pandemic.

DESIGN

Cross-sectional survey of parents impacted by visitation policies.

SETTING

Six tertiary level neonatal units, four from the UK and two from the USA, participated in the study.

PARTICIPANTS

Parents and families of infants hospitalised in the participating centres between 1 May 2020 and 21 August 2020.

METHODS

Online-based and/or paper-based survey, querying the visitation policies and their impact on parents' ability to visit, care for and bond with their infants.

RESULTS

A total of 231 responses were received. Visitation limited to a single visitor with no restrictions on duration was the most frequently reported policy; 140/217 (63%). Visitation policies were perceived as being restrictive by 62% (138/219) of the respondents with 37% (80/216) reporting being able to visit less often than desired, 41% (78/191) reporting being unable to bond enough and 27% (51/191) reporting not being able to participate in their baby's daily care. Mild to severe impact on breast feeding was reported by 36% (75/209) of respondents. Stricter policies had a higher impact on families and were significantly associated with a lack of bonding time, inability to participate in care and an adverse impact on breast feeding.

CONCLUSIONS

Visitation policies during the COVID-19 pandemic varied between centres and over time with stricter restrictions implemented earlier on in the pandemic. Parents reported significant impacts on their ability to visit, care for and bond with their infants with perceived severity of impact worse with stricter restrictions.