Quantitative blood loss: a validation study

Objective: To determine if quantitative blood loss would correlate to predicted blood loss based on change in blood concentration of hemoglobin. Conclusion: The correlation between calculated blood using modified Brecher’s formula showed poor overall correlation to quantitative blood loss. There was a higher correlation at blood loss greater than 1500 cc which is where estimated blood loss has been shown to be most poor. Possible reasons for this poor correlation include maternal factors influencing hemoglobin levels, gestational age, error in blood loss calculation, inaccuracy of Brecher’s formula in pregnancy

Quantitative Blood Loss (QBL) at every delivery: a quality improvement initiative utilizing Electronic Medical Record tools

Maternal hemorrhage is a major cause of maternal morbidity and mortality in the United States and efforts are in place to eliminate preventable harm. Accurate assessment of blood lost around the time of birth is essential for timely recognition and intervention. As part of the Alliance for Innovation on Maternal Health (AIM) Obstetrical Hemorrhage Patient Safety Bundle at our institution a quantitative blood loss (QBL) calculator was created within the electronic medical record. This process allows for real-time tracking of cumulative blood loss measurements and is built with triggers to alert the care team when criteria for various hemorrhage stages are achieved along with suggested interventions and assessments. The consistency of implementation and efficacy of the QBL calculator was evaluated by following both utilization of the calculator flowsheet as well as tracking of rates of erroneous QBL values, defined by negative values and cesarean deliveries with QBL2019, 14 months after implementation and post three system-based improvements. By the end of this implementation review the calculator was in use consistently at all cesarean deliveries with improved confidence in the process by providers

Management of vaginal wall perforation during a second trimester dilation and evacuation

Background: We report an unusual case involving vaginal perforation associated with second trimester dilation and evacuation. Review of the literature fails to identify additional reports. Case: A 22 year G3P1011 female at 16 weeks gestation referred for evaluation following incomplete dilation and evacuation was found to have vaginal perforation, and communication with the peritoneal cavity on pelvic examination. Examination under anesthesia and laparoscopy confirmed multiple vaginal perforations with intraperitoneal defects and hematomas but no viscus involvement. Cervical dilation was accomplished with osmotic dilators placed under ultrasound guidance during exam under anesthesia, with evacuation completed approximately 16 hours later without further complication. Conclusion: This is the first case of vaginal perforation at time of dilation and evacuation reported in the literature. Laparoscopy should be performed to evaluate for intraabdominal injury to bowel, bladder and/or blood vessels. Use of osmotic dilators during the second trimester could potentially decrease the risk of vaginal perforation during the dilation portion of the procedure

The genomic and transcriptional landscape of primary central nervous system lymphoma

Primary lymphomas of the central nervous system (PCNSL) are mainly diffuse large B-cell lymphomas (DLBCLs) confined to the central nervous system (CNS). Molecular drivers of PCNSL have not been fully elucidated. Here, we profile and compare the whole-genome and transcriptome landscape of 51 CNS lymphomas (CNSL) to 39 follicular lymphoma and 36 DLBCL cases outside the CNS. We find recurrent mutations in JAK-STAT, NFkB, and B-cell receptor signaling pathways, including hallmark mutations in MYD88 L265P (67%) and CD79B (63%), and CDKN2A deletions (83%). PCNSLs exhibit significantly more focal deletions of HLA-D (6p21) locus as a potential mechanism of immune evasion. Mutational signatures correlating with DNA replication and mitosis are significantly enriched in PCNSL. TERT gene expression is significantly higher in PCNSL compared to activated B-cell (ABC)-DLBCL. Transcriptome analysis clearly distinguishes PCNSL and systemic DLBCL into distinct molecular subtypes. Epstein-Barr virus (EBV)+ CNSL cases lack recurrent mutational hotspots apart from IG and HLA-DRB loci. We show that PCNSL can be clearly distinguished from DLBCL, having distinct expression profiles, IG expression and translocation patterns, as well as specific combinations of genetic alterations

Cesarean delivery availability in Iowa was not constrained by anesthesia workforce limitations: Retrospective cohort study of inpatient surgery case counts

Our goal was to assess whether anesthesia workforce limited surgical obstetrical care in the rural US state of Iowa. All Iowa hospitals with obstetrics have anesthesia practitioners (i.e., constraints would be functional, not related to having no anesthesia coverage). Our hypothesis #1 was that scheduling for cesarean delivery would functionally be separate from other inpatient operating room scheduling. Our hypothesis #2 was absence of systematic differences among hospitals in their distributions of cesarean deliveries between weekends and regular workdays. The retrospective cohort study included all inpatient surgical cases at hospitals with cesarean births in the state of Iowa October 2015 through June 2021. There were analyzed 112 hospitals ×  2100 days ×  2 numbers, counts of cesarean deliveries and counts of all other surgical cases. The incremental risk ratio between daily cesarean deliveries and other inpatient surgical cases was 1.00 per cesarean delivery (99% confidence interval 0.99 to 1.01). Thus, doing another cesarean delivery was not associated with either a proportional reduction (ratio 1) in other cases performed on the same day. Multiple sensitivity analyses showed the same results. In addition, there was no association in cesarean deliveries between hospitals’ percentages on weekends and overall weekly numbers (P = 0.08). Multiple sensitivity analyses showed the same results, no systematic differences between large versus small obstetrical programs in the distributions of cesareans between weekends versus workdays. Finally, among the 19/73 hospitals ending obstetrics during the study period, all continued to perform surgery. Limitations in the anesthesia workforce did not constrain surgical obstetrical care statewide. Similarly, cesarean births were at most negligibly causing other inpatient surgical cases to be postponed to later days

Patients in Iowa Counties Lacking Hospitals With Labor and Delivery Services Disproportionately Receive Care at Level III Maternal Care Hospitals When Undergoing Cesarean Delivery: A Retrospective Longitudinal Study

Introduction Many obstetrical patients from rural areas in the United States lack hospitals that provide labor and delivery care. Our objective was to examine the effects of such patients on caseloads of cesarean deliveries at Iowa hospitals with level III maternal care, as defined by the Iowa Department of Public Health (e.g., with obstetric anesthesiologists). Methods This retrospective longitudinal study included every discharge with cesarean delivery in the state of Iowa from October 2015 through June 2021. There were N=60,534 such deliveries from 76 hospitals, of which three were level III, and the rest were level I or II. Poisson regression models with robust variance estimation and controlling for geography, maternal risk factors, and insurance, were used to evaluate the binary outcome of whether patients received care at the university level III hospital in Eastern Iowa, or not. Similar models were also developed for care at the two private level III hospitals in Central Iowa, or not. Differences in the mean probabilities of receiving care at the level III hospitals were then estimated using logistic regression, with results reported in units of changes in cases per week at the hospitals. Results Statewide, the university level III hospital performed 7.4% of the cesarean deliveries, and the two private level III hospitals performed 23.4%. Patients from counties in which no cesarean deliveries were performed during the quarter of the year when they underwent a cesarean delivery disproportionately received care at level III hospitals versus levels I and II hospitals. Lower 99% confidence limits for incremental risk ratios were 1.46 and 4.20, respectively. Cesarean deliveries among patients residing in counties where no hospital had a labor and delivery ward were distributed unequally between the counties of the hospitals with level III maternal care. There were approximately 1.09 (standard error 0.10) extra cesarean deliveries per week at the university hospital versus 5.81 (standard error 0.11) at the private hospitals. The 1.09 vs 5.81 difference was caused, in part, by the effects of insurance and other hospitals with similar services. Conclusions Patients residing in counties without labor and delivery care disproportionately go to level III hospitals. These results can help anesthesiologists, obstetricians, and analysts at hospitals with large tertiary (level III) programs interpret their annual increases in total obstetric anesthesia activity

The CO2CRC Otway shallow CO2 controlled release experiment: Preparation or Phase 2

CO2CRC and its partners are undertaking a feasibility study for a planned CO2 controlled release and monitoring experiment on a shallow fault at the CO2CRC Otway Research Facility. In this project we plan to image, using a diverse range of geophysical and geochemical CO2 monitoring techniques, the migration of CO2 up a fault from a controlled release point at approximately 30 m depth. This paper describes the results of site characterisation and modelling work undertaken to date. It also includes a description of the activities planned that will enable for a more detailed characterization of the fault and proposed injection interval. Together these results will enable an assessment as to whether the planned injection experiment is feasible and how it can be optimally designed