Tranexamic acid for the treatment of postpartum hemorrhage: a cost-effectiveness analysis.

BACKGROUND: Postpartum hemorrhage is a leading cause of pregnancy-related morbidity and mortality. Recent data have demonstrated that tranexamic acid reduces death because of bleeding when used as a treatment for postpartum hemorrhage. The World Health Organization now recommends tranexamic acid as a first-line treatment for postpartum hemorrhage; however, data are not yet available on the frequency of use in the United States, where tranexamic acid is currently recognized as an adjunct treatment for postpartum hemorrhage. OBJECTIVE: We aimed to strengthen the current evidence that tranexamic acid should be recognized as a first-line treatment for postpartum hemorrhage, even in high-resource countries. Furthermore, we aimed to determine whether early administration of tranexamic acid (within 3 hours of diagnosis) is a cost-effective strategy for reducing maternal morbidity and mortality from postpartum hemorrhage in the United States. STUDY DESIGN: A decision-analytical model was designed to compare the outcomes and costs of the administration of tranexamic acid in the treatment of postpartum hemorrhage. Moreover, this model was used to compare outcomes for early administration with those of routine use. The interventions compared were 1 g of intravenous tranexamic acid or matching placebo. The risks analyzed in the model were death because of hemorrhage and laparotomy to control bleeding. Probabilities, utilities, and costs were derived from literature. Quality-adjusted life-years were calculated using a discounted life expectancy rate of 3%. Cost-effectiveness was determined on the basis of a willingness-to-pay threshold of $100,000 per quality-adjusted life year. RESULTS: The administration of tranexamic acid to a theoretical cohort of 100,000 women would prevent 11 maternal deaths, 6 postpartum laparotomies after vaginal delivery, and 112 reoperations after cesarean delivery. This would lead to an increase in 329 quality-adjusted life years and a total cost savings of $15.39 million. Furthermore, if tranexamic acid were administered early (within 3 hours of postpartum hemorrhage diagnosis) to the same theoretical cohort, 16 maternal deaths owing to hemorrhage, 9 laparotomies, and 155 reoperations would be prevented. This amounts to an increase in 438 quality-adjusted life years and an annual cost savings of $23.15 million. A sensitivity analysis showed that the administration of tranexamic acid was the dominant strategy at all probabilities of maternal death owing to hemorrhage >0.00002. When the cost of tranexamic acid was varied, the administration of tranexamic acid remained dominant up to a cost of $267 per administration in the United States if given within the first 3 hours. Furthermore, in a Monte Carlo probabilistic sensitivity analysis, the early administration of tranexamic acid remained the dominant strategy (both lowered costs and improved outcomes) in 99.8% of models. CONCLUSION: Early administration of tranexamic acid was a cost-effective strategy for reducing maternal morbidity and mortality owing to postpartum hemorrhage in the United States.

Surgical Outcomes After Esophagectomy in Patients with Achalasia: a NSQIP Matched Analysis With Non-Achalasia Esophagectomy Patients.

PURPOSE: The data on surgical outcomes of esophagectomy in patients with achalasia is limited. We sought to evaluate surgical outcomes in achalasia patients after an esophagectomy versus non-achalasia patients to elucidate if the outcomes are affected by the diagnosis. METHODS: We conducted a retrospective review of the National Surgical Quality Improvement Program database (2010-2018). Patients who underwent an esophagectomy (open or laparoscopic approach) were included. Patients were divided into two groups, achalasia vs non-achalasia patients, and matched using propensity match analysis. RESULTS: Of the 10,997 esophagectomy patients who met inclusion criteria, 213 (1.9%) patients had a diagnosis of achalasia. A total of 418 patients were included for the final analysis, with 209 patients in each group (achalasia vs non-achalasia). The overall median age was 57 years (IQR 47-65 years), and 48.6% were female. Most underwent an open (93.1%) vs laparoscopic (6.9%) esophagectomy. Overall complication rate was 40%. No difference was identified on overall complications, readmission, reoperation, or mortality between both groups. Postoperative sepsis was significantly higher in the achalasia group, and organ space SSI was higher in the non-achalasia group. Multivariable analysis showed that a diagnosis (achalasia or non-achalasia) was not predictive of reoperation or overall complications. CONCLUSION: Esophagectomy outcomes are similar in patients with achalasia vs non-achalasia, and the diagnosis of achalasia does not independently increase the risk of reoperation and overall complications. Finally, regardless of diagnosis, the potential for morbidity following esophagectomy, should to be discussed with patients in the preoperative setting.

Facial protection for healthcare workers during pandemics: a scoping review.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to personal protective equipment (PPE) shortages, requiring mask reuse or improvisation. We provide a review of medical-grade facial protection (surgical masks, N95 respirators and face shields) for healthcare workers, the safety and efficacy of decontamination methods, and the utility of alternative strategies in emergency shortages or resource-scarce settings. METHODS: We conducted a scoping review of PubMed and grey literature related to facial protection and potential adaptation strategies in the setting of PPE shortages (January 2000 to March 2020). Limitations included few COVID-19-specific studies and exclusion of non-English language articles. We conducted a narrative synthesis of the evidence based on relevant healthcare settings to increase practical utility in decision-making. RESULTS: We retrieved 5462 peer-reviewed articles and 41 grey literature records. In total, we included 67 records which met inclusion criteria. Compared with surgical masks, N95 respirators perform better in laboratory testing, may provide superior protection in inpatient settings and perform equivalently in outpatient settings. Surgical mask and N95 respirator conservation strategies include extended use, reuse or decontamination, but these strategies may result in inferior protection. Limited evidence suggests that reused and improvised masks should be used when medical-grade protection is unavailable. CONCLUSION: The COVID-19 pandemic has led to critical shortages of medical-grade PPE. Alternative forms of facial protection offer inferior protection. More robust evidence is required on different types of medical-grade facial protection. As research on COVID-19 advances, investigators should continue to examine the impact on alternatives of medical-grade facial protection.

Dynamic sound localization in cats.

Sound localization in cats and humans relies on head-centered acoustic cues. Studies have shown that humans are able to localize sounds during rapid head movements that are directed toward the target or other objects of interest. We studied whether cats are able to utilize similar dynamic acoustic cues to localize acoustic targets delivered during rapid eye-head gaze shifts. We trained cats with visual-auditory two-step tasks in which we presented a brief sound burst during saccadic eye-head gaze shifts toward a prior visual target. No consistent or significant differences in accuracy or precision were found between this dynamic task (2-step saccade) and the comparable static task (single saccade when the head is stable) in either horizontal or vertical direction. Cats appear to be able to process dynamic auditory cues and execute complex motor adjustments to accurately localize auditory targets during rapid eye-head gaze shifts.

Simultaneous comparison of two sound localization measures.

Almost all behavioral studies of sound localization have used either an approach-to-target or pointing/orienting task to assess absolute sound localization performance, yet there are very few direct comparisons of these measures. In an approach-to-target task, the subject is trained to walk to a sound source from a fixed location. In an orienting task, finger, head and/or eye movements are monitored while the subject's body is typically constrained. The fact that subjects may also initiate head and eye movements toward the target during the approach-to-target task allows us to measure the accuracy of the initial orienting response and compare it with subsequent target selection. To perform this comparison, we trained cats to localize a broadband noise presented randomly from one of four speakers located ± 30° and ± 60° in azimuth. The cat responded to each sound presentation by walking to and pressing a lever at the perceived location, and a food reward was delivered if the first attempt was correct. In tandem, we recorded initial head and eye orienting movements, via magnetic search coils, immediately following target onset and prior to the walking response. Reducing either stimulus duration or level resulted in a systematic decline in both measurements of localization performance. When the task was easy, localization performance was accurate for both measures. When the task was more difficult, the number of incorrect (i.e., wrong selection) and no-go (i.e., no selection) responses increased. Interestingly, for many of the incorrect trials, there was a dissociation between the orienting response and the target selected, and for many of the no-go trials, the gaze oriented towards the correct target even though the cat did not move to it. This suggests different neural systems governing walking to a target as compared to unconditioned gaze orienting.

Comparison of laser-assisted hatching and acidified Tyrode's hatching by evaluation of blastocyst development rates in sibling embryos: a prospective randomized trial.

OBJECTIVE: To assess two zona drilling methods in terms of blastocyst development rates using sister embryos. DESIGN: Prospective, randomized study. Sister embryos of 14 patients were randomly assigned on day 3 to acidified Tyrode's zona drilling or to laser zona drilling. After biopsy, subsequent embryo culture until the blastocyst stage (day 5) was performed. SETTING: Private fertility center. PATIENT(S): Patients undergoing IVF-preimplantation genetic diagnosis. INTERVENTION(S): Embryo biopsy using either laser-assisted hatching or acidified Tyrode's hatching on sibling embryos and subsequent blastocyst development evaluation. MAIN OUTCOME MEASURE(S): Evaluation of blastocyst development in terms of degree of expansion and cell number in the inner cell mass and trophectoderm. RESULT(S): Blastocyst development rates (and blastocyst quality) were similarly high in both the acidified Tyrode's hatching group and the laser-assisted hatching group. CONCLUSION(S): Laser hatching does not impair embryonic development to the blastocyst stage, demonstrating that laser-assisted hatching is a suitable alternative to the use of acidified Tyrode's solution for zona drilling.