Patterns and Drivers of Antifungal Prescribing in Acute Leukemia: A Retrospective Cohort Study.

Background: Patients with hematological malignancy are at high risk of invasive fungal infections (IFIs). Diagnosis is challenging, which can lead to overtreatment. Reducing exposure to inappropriate antifungal prescribing is likely to improve patient safety, but modifying prescribing behavior is difficult. We aimed to describe patterns and drivers of therapeutic antifungal prescribing in a large tertiary hemato-oncology center in the United Kingdom. Methods: We studied adults receiving treatment for acute leukemia at our center between 1 April 2019 and 14 October 2022. We developed a reproducible method to analyze routinely collected data on antifungal therapy episodes in a widely used electronic health record system. We report antifungal use in days of therapy stratified by level of diagnostic confidence, as defined by consensus diagnostic guidelines (European Organisation for Research and Treatment of Cancer/Mycoses Study Group). Results: Two hundred ninety-eight patients were included in the analysis; 21.7% of inpatient antifungal use occurred in cases of proven/probable IFI. Substantial antifungal use occurred in the absence of strong evidence of infection in patients receiving high-intensity first-line chemotherapy or approaching death (81.0% and 77.9%, respectively). Approximately 33% of high-resolution computed tomography (HRCT) reports were indeterminate for IFI. Indeterminate reports were around 8 times more likely to be followed by a new antifungal therapy episode than a negative report. Conclusions: Antifungal stewardship remains challenging in the absence of reliable diagnostics, particularly in more unwell patients. The proportion of antifungal therapy given for proven/probable infection is a new metric that will likely be useful to target antifungal stewardship programs. The thoracic HRCT report is an important contributor to diagnostic uncertainty.

A large-scale and PCR-referenced vocal audio dataset for COVID-19.

The UK COVID-19 Vocal Audio Dataset is designed for the training and evaluation of machine learning models that classify SARS-CoV-2 infection status or associated respiratory symptoms using vocal audio. The UK Health Security Agency recruited voluntary participants through the national Test and Trace programme and the REACT-1 survey in England from March 2021 to March 2022, during dominant transmission of the Alpha and Delta SARS-CoV-2 variants and some Omicron variant sublineages. Audio recordings of volitional coughs, exhalations, and speech were collected in the 'Speak up and help beat coronavirus' digital survey alongside demographic, symptom and self-reported respiratory condition data. Digital survey submissions were linked to SARS-CoV-2 test results. The UK COVID-19 Vocal Audio Dataset represents the largest collection of SARS-CoV-2 PCR-referenced audio recordings to date. PCR results were linked to 70,565 of 72,999 participants and 24,105 of 25,706 positive cases. Respiratory symptoms were reported by 45.6% of participants. This dataset has additional potential uses for bioacoustics research, with 11.3% participants self-reporting asthma, and 27.2% with linked influenza PCR test results.

Comparing indicators of disease severity among patients presenting to hospital for urinary tract infections before and during the COVID-19 pandemic.

Background: During the COVID-19 pandemic, patients may have delayed seeking healthcare for urinary tract infections (UTIs). This could have resulted in more severe presentation to hospital and different antibiotic usage. Objectives: We explored evidence for such changes through existing national indicators of prescribing, and routine clinical data collected in the electronic health record (EHR). Methods: We carried out a retrospective cohort study of patients presenting to two UK hospitals for UTIs, comparing two indicators of disease severity on admission before and during the pandemic: intravenous (IV) antibiotic use, and National Early Warning Score 2 (NEWS2). We developed regression models to estimate the effect of the pandemic on each outcome, adjusting for age, sex, ethnicity and index of multiple deprivation. Results: During the pandemic, patients were less likely to present to hospital for UTI with NEWS2 of 0 or 1 [adjusted odds ratio (aOR): 0.66; 95% confidence interval (CI): 0.52-0.85] compared with before, more likely to present with score 2 (aOR: 1.52; 95% CI: 1.18-1.94), whereas the likelihood of presenting with a NEWS2 of >2 remained the same (aOR: 1.06; 95% CI: 0.87-1.29). We did not find evidence that this limited increase in disease severity resulted in changes to IV antibiotic use on admission (adjusted risk ratio: 1.02; 95% CI: 0.91-1.15). Conclusions: There may have been a small increase in disease severity at hospital presentation for UTI during the pandemic, which can be detected using routine data and not through national indicators of prescribing. Further research is required to validate these findings and understand whether routine data could support a more nuanced understanding of local antimicrobial prescribing practices.

Anesthetic Management for Cesarean Delivery in a Patient With a Difficult Airway and Risks for Postpartum Hemorrhage: A Case Report.

Neuraxial anesthesia is the preferred anesthesia technique for cesarean delivery, however, conversion to general anesthesia may be required for a variety of clinical scenarios, including massive post-partum hemorrhage. Obstetric patients are known to have otherwise more difficult airways and emergent situations can increase the likelihood of failed intubation with potentially disastrous consequences. We describe a novel anesthesia technique for cesarean delivery using neuraxial anesthesia as the primary anesthetic technique and electively securing the airway for a patient with multiple risk factors for post-partum hemorrhage and features concerning difficult intubation.

Simulation Study of Surveillance Strategies for Faster Detection of Novel SARS-CoV-2 Variants.

Earlier global detection of novel SARS-CoV-2 variants gives governments more time to respond. However, few countries can implement timely national surveillance, resulting in gaps in monitoring. The United Kingdom implemented large-scale community and hospital surveillance, but experience suggests it might be faster to detect new variants through testing England arrivals for surveillance. We developed simulations of emergence and importation of novel variants with a range of infection hospitalization rates to the United Kingdom. We compared time taken to detect the variant though testing arrivals at England borders, hospital admissions, and the general community. We found that sampling 10%-50% of arrivals at England borders could confer a speed advantage of 3.5-6 weeks over existing community surveillance and 1.5-5 weeks (depending on infection hospitalization rates) over hospital testing. Directing limited global capacity for surveillance to highly connected ports could speed up global detection of novel SARS-CoV-2 variants.

Epidural-related maternal fever: incidence, pathophysiology, outcomes, and management.

Epidural-related maternal fever affects 15% to 25% of patients who receive a labor epidural. Two meta-analyses demonstrated that epidural-related maternal fever is a clinical phenomenon, which is unlikely to be caused by selection bias. All commonly used neuraxial techniques, local anesthetics with or without opioids, and maintenance regimens are associated with epidural-related maternal fever, however, the impact of each component is unknown. Two major theories surrounding epidural-related maternal fever development have been proposed. First, labor epidural analgesia may lead to the development of hyperthermia through a sterile (noninfectious) inflammatory process. This process may involve reduced activation of caspase-1 (a protease involved in cell apoptosis and activation of proinflammatory pathways) secondary to bupivacaine, which impairs the release of the antipyrogenic cytokine, interleukin-1-receptor antagonist, from circulating leucocytes. Detailed mechanistic processes of epidural-related maternal fever remain to be determined. Second, thermoregulatory mechanisms secondary to neuraxial blockade have been proposed, which may also contribute to epidural-related maternal fever development. Currently, there is no prophylactic strategy that can safely prevent epidural-related maternal fever from occurring nor can it easily be distinguished clinically from other causes of intrapartum fever, such as chorioamnionitis. Because intrapartum fever (of any etiology) is associated with adverse outcomes for both the mother and baby, it is important that all parturients who develop intrapartum fever are investigated and treated appropriately, irrespective of labor epidural utilization. Institution of treatment with appropriate antimicrobial therapy is recommended if an infectious cause of fever is suspected. There is currently insufficient evidence to warrant a change in recommendations regarding provision of labor epidural analgesia and the benefits of good quality labor analgesia must continue to be reiterated to expectant mothers.

Enhancing antimicrobial surveillance in hospitals in England: a RAND-modified Delphi.

Background: Optimizing antimicrobial use (AMU) is key to reducing antimicrobial-resistant infections, but current AMU monitoring in hospital provides limited insights for quality improvement. Objectives: To understand stakeholders' priorities for developing national AMU surveillance in English hospitals to serve the needs of national policy makers and front-line practitioners. Methods: Characteristics of existing AMU surveillance systems were identified from a previous systematic review and categorized by the Acceptability, Practicability, Effectiveness, Affordability, Side-effects and Equity (APEASE) criteria. Stakeholders prioritized characteristics using a two-round RAND-modified Delphi (rating round 1, telephone panel discussion, rating round 2). Findings informed the design of a framework used to assess the extent to which existing surveillance approaches meet stakeholders' needs. Results: Between 17/09/19 and 01/11/19, 24 stakeholders with national and local roles related to AMU prioritized 23 characteristics of AMU surveillance describing: resource for surveillance, data collection, data availability and pathways to translate information from surveillance into practice. No existing surveillance approaches demonstrated all prioritized characteristics. The most common limitation was failure to facilitate clinician engagement with AMU through delays in data access and/or limited availability of disaggregated metrics of prescribing. Conclusions: Current surveillance delivers national public health priorities but improving stewardship demands patient-level data linked to clinical outcomes. This study offers a framework to develop current surveillance to meet the needs of local stakeholders in England. Increased investment in data infrastructure and training is essential to make information held within electronic systems available to front-line clinicians to facilitate quality improvement.

A Unique Mitochondrial Gene Block Inversion in Antarctic Trematomin Fishes: A Cautionary Tale.

Many Antarctic notothenioid fishes have major rearrangements in their mitochondrial (mt) genomes. Here, we report the complete mt genomes of 3 trematomin notothenioids: the bald notothen (Trematomus (Pagothenia) borchgrevinki), the spotted notothen (T. nicolai), and the emerald notothen (T. bernacchii). The 3 mt genomes were sequenced using next-generation Illumina technology, and the assemblies verified by Sanger sequencing. When compared with the canonical mt gene order of the Antarctic silverfish (Pleuragramma antarctica), we found a large gene inversion in the 3 trematomin mt genomes that included tRNAIle, ND1, tRNALeu2, 16S, tRNAVal, 12S, tRNAPhe, and the control region. The trematomin mt genomes contained 3 intergenic spacers, which are thought to be the remnants of previous gene and control region duplications. All control regions included the characteristic conserved regulatory sequence motifs. Although short-read next-generation DNA sequencing technology has allowed the rapid and cost-effective sequencing of a large number of complete mt genomes, it is essential in all cases to verify the assembly in order to prevent the publication and use of erroneous data.

Variation in approaches to antimicrobial use surveillance in high-income secondary care settings: a systematic review.

INTRODUCTION: In secondary care, antimicrobial use (AMU) must be monitored to reduce the risk of antimicrobial resistance and infection-related complications. However, there is variation in how hospitals address this challenge, partly driven by each site's level of digital maturity, expertise and resources available. This systematic review investigated approaches to measuring AMU to explore how these structural differences may present barriers to engagement with AMU surveillance. METHODS: We searched four digital databases and the websites of relevant organizations for studies in high-income, inpatient hospital settings that estimated AMU in adults. Excluded studies focused exclusively on antiviral or antifungal therapies. Data were extracted data on 12 fields (study description, data sources, data extraction methods and professionals involved in surveillance). Proportions were estimated with 95% CIs. RESULTS: We identified 145 reports of antimicrobial surveillance from Europe (63), North America (53), Oceania (14), Asia (13) and across more than continent (2) between 1977 and 2018. Of 145 studies, 47 carried out surveillance based on digital data sources. In regions with access to electronic patient records, 26/47 studies employed manual methods to extract the data. The majority of identified professionals involved in these studies were clinically trained (87/93). CONCLUSIONS: Even in regions with access to electronic datasets, hospitals rely on manual data extraction for this work. Data extraction is undertaken by healthcare professionals, who may have conflicting priorities. Reducing barriers to engagement in AMU surveillance requires investment in methods, resources and training so that hospitals can extract and analyse data already contained within electronic patient records.

Effects of State Law Limiting Postoperative Opioid Prescription in Patients After Cesarean Delivery.

BACKGROUND: The impact of the Florida State law House Bill 21 (HB 21) restricting the duration of opioid prescriptions for acute pain in patients after cesarean delivery is unknown. Our objective was to assess the association of the passage of Florida State law HB 21 with trends in discharge opioid prescription practices following cesarean delivery, necessity for additional opioid prescriptions, and emergency department visits at a large tertiary care center. METHODS: This was a retrospective cohort study conducted at a large, public hospital. The 2 cohorts represented the period before and after implementation of the law. Using a confounder-adjusted segmented regression analysis of an interrupted time series, we evaluated the association between HB 21 and trends in the proportions of patients receiving opioids on discharge, duration of opioid prescriptions, total opioid dose prescribed, and daily opioid dose prescribed. We also compared the need for additional opioid prescriptions within 30 days of discharge and the prevalence of emergency department visits within 7 days after discharge. RESULTS: Eight months after implementation of HB 21, the mean duration of opioid prescriptions decreased by 2.9 days (95% confidence interval [CI], 5.2-0.5) and the mean total opioid dose decreased by 20.1 morphine milligram equivalents (MME; 95% CI, 4-36.3). However, there was no change in the proportion of patients receiving discharge opioids (95% CI of difference, -0.1 to 0.16) or in the mean daily opioid dose (mean difference, 5.3 MME; 95% CI, -13 to 2.4). After implementation of the law, there were no changes in the proportion of patients who required additional opioid prescriptions (2.1% vs 2.3%; 95% CI of difference, -1.2 to 1.5) or in the prevalence of emergency department visits (2.4% vs 2.2%; 95% CI of difference, -1.6 to 1.1). CONCLUSIONS: Implementation of Florida Law HB 21 was associated with a lower total prescribed opioid dose and a shorter duration of therapy at the time of hospital discharge following cesarean delivery. These reductions were not associated with the need for additional opioid prescriptions or emergency department visits.

Transversus abdominis plane block compared with wound infiltration for postoperative analgesia following Cesarean delivery: a systematic review and network meta-analysis.

PURPOSE: This systematic review and network meta-analysis (NMA) compared postoperative analgesic efficacy of transversus abdominis plane (TAP) blocks with that of wound infiltration for Cesarean delivery (CD) without long-acting neuraxial opioid administration. METHODS: We sought randomized-controlled trials comparing TAP vs wound infiltration, and inactive control vs either TAP or wound infiltration. Wound infiltration included single-dose infiltration (WI), or continuous infusion via a catheter (WC). The primary outcome was 24 hr opioid consumption. Secondary outcomes included 12 and 24 hr pain scores (resting and movement), time to first analgesia request, incidence of postoperative nausea and vomiting (PONV), maternal sedation, and pruritus. We performed a NMA incorporating both direct and indirect comparisons and reported standardized mean differences and odds ratios with 95% confidence intervals for continuous and dichotomous outcomes. RESULTS: Forty-two studies were included, comprising 2,906 participants. Transversus abdominis plane blocks and WC were associated with significantly lower 24 hr opioid consumption than inactive controls, but there were no significant differences between WI and inactive controls. There was no statistically significant difference in 24 hr opioid consumption between TAP blocks and WC or WI techniques. The network ranking of treatments was TAP block, followed by WC or WI. No significant differences were shown between TAP, WC, and WI groups for 24 hr pain scores, time to first analgesia, PONV, sedation, and pruritus. Quality of evidence was moderate for most of the outcomes assessed. CONCLUSION: In the absence of long-acting neuraxial opioid after CD, single-dose TAP blocks and WC are effective opioid-sparing strategies.

RéSUMé: OBJECTIF: Cette revue systématique et méta-analyse en réseau (MAR) ont comparé l'efficacité analgésique postopératoire de blocs du plan du muscle transverse de l'abdomen (bloc TAP, Transversus Abdominis Plane) à celle d'infiltrations de l'incision chirurgicale après un accouchement par césarienne et en l'absence d'administration d'opioïdes neuraxiaux à action prolongée. MéTHODE: Nous avons examiné les études randomisées contrôlées comparant un bloc TAP à une infiltration de l'incision, et les comparateurs inactifs vs soit un bloc TAP ou une infiltration de l'incision. Les infiltrations de l'incision comprenaient des infiltrations à dose unique ou des perfusions continues via un cathéter. Le critère d'évaluation principal était la consommation d'opioïdes en 24 heures. Les critères d'évaluation secondaires comprenaient les scores de douleur à 12 et 24 h (au repos et avec mouvement), le délai jusqu'à la première demande d'analgésie, l'incidence de nausées et vomissements postopératoires (NVPO), la sédation maternelle et le prurit. Nous avons réalisé une MAR intégrant des comparaisons directes et indirectes et rapportons les différences moyennes standardisées et les rapports de cotes avec des intervalles de confiance de 95 % pour les critères d'évaluation continus et dichotomiques. RéSULTATS: Quarante-deux études ont été incluses, comprenant 2906 participantes. Les blocs TAP et les infiltrations par cathéter étaient associés à une consommation d'opioïdes en 24 heures significativement plus faible que les comparateurs inactifs, mais aucune différence significative n'a été observée entre infiltrations uniques et comparateurs inactifs. Aucune différence statistiquement significative dans la consommation d'opioïdes en 24 heures n'a été observée entre les blocs TAP et les techniques d'infiltration par perfusion continue ou unique. Le classement en réseau des traitements est : les blocs TAP, suivi par les infiltrations par perfusion continue ou unique. Aucune différence significative n'a été démontrée dans les scores de douleur à 24 h, le délai jusqu'à la première analgésie, les NVPO, la sédation et le prurit entre les groupes TAP, infiltration par perfusion continue et infiltration unique. La qualité des données probantes était modérée pour la plupart des critères évalués. CONCLUSION: En l'absence d'un opioïde neuraxial à action prolongée après un accouchement par césarienne, les blocs TAP en dose unique et les infiltrations par perfusion continue sont des stratégies efficaces pour réduire la consommation d'opioïdes.

Antibiotic prescribing in UK care homes 2016-2017: retrospective cohort study of linked data.

BACKGROUND: Older people living in care homes are particularly susceptible to infections and antibiotics are therefore used frequently for this population. However, there is limited information on antibiotic prescribing in this setting. This study aimed to investigate the frequency, patterns and risk factors for antibiotic prescribing in a large chain of UK care homes. METHODS: Retrospective cohort study of administrative data from a large chain of UK care homes (resident and care home-level) linked to individual-level pharmacy data. Residents aged 65 years or older between 1 January 2016 and 31 December 2017 were included. Antibiotics were classified by type and as new or repeated prescriptions. Rates of antibiotic prescribing were calculated and modelled using multilevel negative binomial regression. RESULTS: 13,487 residents of 135 homes were included. The median age was 85; 63% residents were female. 28,689 antibiotic prescriptions were dispensed, the majority were penicillins (11,327, 39%), sulfonamides and trimethoprim (5818, 20%), or other antibacterials (4665, 16%). 8433 (30%) were repeat prescriptions. The crude rate of antibiotic prescriptions was 2.68 per resident year (95% confidence interval (CI) 2.64-2.71). Increased antibiotic prescribing was associated with residents requiring more medical assistance (adjusted incidence rate ratio for nursing opposed to residential care 1.21, 95% CI 1.13-1.30). Prescribing rates varied widely by care home but there were no significant associations with the care home-level characteristics available in routine data. CONCLUSIONS: Rates of antibiotic prescribing in care homes are high and there is substantial variation between homes. Further research is needed to understand the drivers of this variation to enable development of effective stewardship approaches that target the influences of prescribing.

Preemptive ECMO Cannulation in a Patient with Severe Left Ventricular Systolic Dysfunction Undergoing Cesarean Delivery.

Obstetric patients with heart failure undergoing cesarean delivery are high risk and the perioperative care of these patients poses significant multidisciplinary challenges. In contrast to the nonobstetric patient population the potential role of mechanical circulatory support in parturients with heart failure is not well established and the use of extracorporeal membrane oxygenation (ECMO) has rarely been reported. We report the case of a super morbidly obese patient with decompensated heart failure, pulmonary hypertension, and superimposed preeclampsia undergoing preemptive ECMO cannulation for urgent cesarean delivery.

Informing the development of a standardised approach to measure antibiotic use in secondary care: a systematic review protocol.

INTRODUCTION: Ecological and individual-level evidence indicates that there is an association between level of antibiotic exposure and the emergence and spread of antibiotic resistance. The Global Point Prevalence Survey in 2015 estimated that 34.4% of hospital inpatients globally received at least one antimicrobial. Antimicrobial stewardship to optimise antibiotic use in secondary care can reduce the high risk of patients acquiring and transmitting drug-resistant infections in this setting. However, differences in the availability of data on antibiotic use in this context make it difficult to develop a consensus of how to comparably monitor antibiotic prescribing patterns across secondary care. This review will aim to document and critically evaluate methods and measures to monitor antibiotic use in secondary care. METHODS AND ANALYSIS: We will search Medline (Ovid), Embase (Ovid), Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials and websites of key organisations for published reports where an attempt to measure antibiotic usage among adult inpatients in high-income hospital settings has been made. Two independent reviewers will screen the studies for eligibility, extract data and assess the study quality using the Newcastle-Ottawa scale. A description of the methods and measures used in antibiotic consumption surveillance will be presented. An adaptation of the Affordability, Practicability, Effectiveness, Acceptability, Side-effects Equity framework will be used to consider the practicality of implementing different approaches to measuring antibiotic usage in secondary care settings. A descriptive comparison of definitions and estimates of (in)appropriate antibiotic usage will also be carried out. ETHICS AND DISSEMINATION: Ethical approval is not required for this study as no primary data will be collected. The results will be published in relevant peer-reviewed journals and presented at relevant conferences or meetings where possible. This review will inform future approaches to scale up antibiotic consumption surveillance strategies to attempt to maximise impact through standardisation. PROSPERO REGISTRATION NUMBER: CRD42018103375.

DNA barcoding a unique avifauna: an important tool for evolution, systematics and conservation.

BACKGROUND: DNA barcoding utilises a standardised region of the cytochrome c oxidase I (COI) gene to identify specimens to the species level. It has proven to be an effective tool for identification of avian samples. The unique island avifauna of New Zealand is taxonomically and evolutionarily distinct. We analysed COI sequence data in order to determine if DNA barcoding could accurately identify New Zealand birds. RESULTS: We sequenced 928 specimens from 180 species. Additional Genbank sequences expanded the dataset to 1416 sequences from 211 of the estimated 236 New Zealand species. Furthermore, to improve the assessment of genetic variation in non-endemic species, and to assess the overall accuracy of our approach, sequences from 404 specimens collected outside of New Zealand were also included in our analyses. Of the 191 species represented by multiple sequences, 88.5% could be successfully identified by their DNA barcodes. This is likely a conservative estimate of the power of DNA barcoding in New Zealand, given our extensive geographic sampling. The majority of the 13 groups that could not be distinguished contain recently diverged taxa, indicating incomplete lineage sorting and in some cases hybridisation. In contrast, 16 species showed evidence of distinct intra-species lineages, some of these corresponding to recognised subspecies. For species identification purposes a character-based method was more successful than distance and phylogenetic tree-based methods. CONCLUSIONS: DNA barcodes accurately identify most New Zealand bird species. However, low levels of COI sequence divergence in some recently diverged taxa limit the identification power of DNA barcoding. A small number of currently recognised species would benefit from further systematic investigations. The reference database and analysis presented will provide valuable insights into the evolution, systematics and conservation of New Zealand birds.

Genetic structure of the grey side-gilled sea slug (Pleurobranchaea maculata) in coastal waters of New Zealand.

Pleurobranchaea maculata is a rarely studied species of the Heterobranchia found throughout the south and western Pacific-and recently recorded in Argentina-whose population genetic structure is unknown. Interest in the species was sparked in New Zealand following a series of dog deaths caused by ingestions of slugs containing high levels of the neurotoxin tetrodotoxin. Here we describe the genetic structure and demographic history of P. maculata populations from five principle locations in New Zealand based on extensive analyses of 12 microsatellite loci and the COI and CytB regions of mitochondrial DNA (mtDNA). Microsatellite data showed significant differentiation between northern and southern populations with population structure being associated with previously described regional variations in tetrodotoxin concentrations. However, mtDNA sequence data did not support such structure, revealing a star-shaped haplotype network with estimates of expansion time suggesting a population expansion in the Pleistocene era. Inclusion of publicly available mtDNA sequence sea slugs from Argentina did not alter the star-shaped network. We interpret our data as indicative of a single founding population that fragmented following geographical changes that brought about the present day north-south divide in New Zealand waters. Lack of evidence of cryptic species supports data indicating that differences in toxicity of individuals among regions are a consequence of differences in diet.

Complete mitochondrial genome of the green-lipped mussel, Perna canaliculus (Mollusca: Mytiloidea), from long nanopore sequencing reads.

We describe here the first complete genome assembly of the New Zealand green-lipped mussel, Perna canaliculus, mitochondrion. The assembly was performed de novo from a mix of long nanopore sequencing reads and short sequencing reads. The genome is 16,005 bp long. Comparison to other Mytiloidea mitochondrial genomes indicates important gene rearrangements in this family.

The Effect of Glycopyrrolate on the Incidence of Hypotension and Vasopressor Requirement During Spinal Anesthesia for Cesarean Delivery: A Meta-analysis.

BACKGROUND: The objective of this meta-analysis was to determine the efficacy of glycopyrrolate at reducing spinal hypotension during cesarean delivery. METHODS: A literature search was performed to identify randomized controlled trials investigating the effect of glycopyrrolate on spinal-induced hypotension during cesarean delivery. Primary outcomes were intraoperative hypotension and vasopressor requirement (phenylephrine equivalents). Secondary outcomes included heart rate (HR), nausea and vomiting, dry mouth, and Apgar scores. Risk ratios (RRs), and mean differences (MDs) were calculated using random-effects modeling with 95% confidence intervals for primary outcomes and 99% confidence intervals for secondary outcomes. RESULTS: Five randomized controlled trials met our inclusion criteria. A total of 311 patients were included: 153 received glycopyrrolate and 158 placebo. The incidence of spinal-induced hypotension was no different with prophylactic glycopyrrolate compared to control (RR, 0.93 [0.71-1.21]; P = .59), but the total phenylephrine dose required was significantly reduced with glycopyrrolate (MD, -62.64 µg [-107.61 to -17.66 µg]; P = .006). The maximal HR achieved in the glycopyrrolate group was significantly higher compared to controls (MD, 15.85 bpm [5.40-26.31]; P < .0001); however, the incidence of bradycardia was not statistically different. The incidence of intraoperative nausea and vomiting was not different between groups; however, glycopyrrolate increased the risk of dry mouth (RR, 5.15 [1.82-14.57]; P < .0001). Apgar scores at 1 and 5 minutes did not differ between groups. CONCLUSIONS: Prophylactic glycopyrrolate does not reduce the incidence of spinal-induced hypotension but results in a modest reduction in vasopressor requirements while increasing maternal HR.

Genetic Kinship Analyses Reveal That Gray's Beaked Whales Strand in Unrelated Groups.

Some marine mammals are so rarely seen that their life history and social structure remain a mystery. Around New Zealand, Gray's beaked whales (Mesoplodon grayi) are almost never seen alive, yet they are a commonly stranded species. Gray's are unique among the beaked whales in that they frequently strand in groups, providing an opportunity to investigate their social organization. We examined group composition and genetic kinship in 113 Gray's beaked whales with samples collected over a 20-year period. Fifty-six individuals stranded in 19 groups (2 or more individuals), and 57 whales stranded individually. Mitochondrial control region haplotypes and microsatellite genotypes (16 loci) were obtained for 103 whales. We estimated pairwise relatedness between all pairs of individuals and average relatedness within, and between, groups. We identified 6 mother-calf pairs and 2 half-siblings, including 2 whales in different strandings 17 years and 1500 km apart. Surprisingly, none of the adults stranding together were related suggesting that groups are not formed through the retention of kin. These data suggest that both sexes may disperse from their mothers, and groups consisting of unrelated subadults are common. We also found no instances of paternity within the groups. Our results provide the first insights into dispersal, social organization, and the mating system in this rarely sighted species. Why whales strand is still unknown but, in Gray's beaked whales, the dead can tell us much about the living.