The Effect of Umbilical Cord Milking on Hemodynamic Status of Preterm Infants: A Randomized Controlled Trial

BACKGROUND: Delayed cord clamping may be difficult to perform in extremely preterm infants. The effects of the alternative, cord milking, have not been fully evaluated.

OBJECTIVES: To determine whether cord milking (CM) at birth improves systemic blood flow and short term outcomes, as compared with immediate cord clamping (ICC).

DESIGN/METHODS: Babies born to eligible, consenting women presenting in preterm labor between 24 and 31 weeks' gestation were randomized to receive CM or ICC. Echocardiography was performed at 4-6 and 10-12 hours after birth. The primary outcome was systemic blood flow as represented by echo-derived superior vena cava (SVC) flow. Neonatal care staff, echogardiographer and interpreter were blind to the randomization. Analysis was by intention to treat.

RESULTS: A total of 73 eligible infants were randomized (37 to CM and 36 to ICC) during the study period (November 2011-2014). There were no statistically significant differences in maternal demographic and antenatal variables. Mean (SD) gestational age was 26.1 (11) weeks and mean (SD) birth weight was 1025 (308) g. 38% of infants were born by vaginal delivery. No significant differences were found between groups in SVC flow, cardiac outputs or neonatal morbidities [table1].

CONCLUSION: There were no statistically significant differences in functional cardiac outcomes, mortality or morbidity between preterm infants who received CM and those who received ICC. Larger trials are needed to establish the best practice in managing the umbilical cord at birth in extremely preterm infants.

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Venous thromboembolism rates in patients undergoing major hip and knee joint surgery at Waitemata District Health Board: a retrospective audit

BACKGROUND/AIM

Symptomatic venous thromboembolism (VTE) complicates approximately 4% of major orthopaedic surgical procedures performed without thromboprophylaxis. Randomised clinical trials demonstrate primary thromboprophylaxis reduces VTE rates to <1%, with low rates of clinically important bleeding, using low molecular weight heparin (LMWH), oral FXa inhibitors or thrombin inhibitors. We reviewed the rates of VTE in patients undergoing major hip/knee joint surgery at Waitemata District Health Board (WDHB).

METHODS

Cases of VTE within 90 days of orthopaedic surgery were identified by retrospective audit of data from the haematology VTE database. The number of major hip/knee joint surgeries at WDHB from January 2006 to December 2010 was obtained from clinical coding data.

RESULTS

The cumulative incidence of VTE within 90 days of surgery was 3.29%. The median time from surgery to diagnosis was 7 days. Deep vein thrombosis comprised 75% of cases, 77.6% distal and 23.2% proximal. Pulmonary embolism comprised 26.5% of VTE; 47.7% had right heart strain on computed tomography/echocardiography. Hip fracture surgery comprised one-third of patients. Of patients developing VTE, 85.5% had chemical thromboprophylaxis - aspirin 73%, LMWH 20 mg 16%, LMWH 40 mg 16%, therapeutic LMWH 3%, unfractionated heparin twice daily 1%, and warfarin 4%; 75.6% received mechanical prophylaxis, while 4% of patients received no prophylaxis.

CONCLUSION

VTE incidence after major hip/knee joint surgery at WDHB is high, with pulmonary embolism comprising almost one-third of all VTE in this study, indicating the prophylaxis given is suboptimal. Implementation of appropriate, extended duration prophylaxis as per evidence-based guidelines is required to reduce these rates.

Management and outcomes of single subsegmental pulmonary embolus: a retrospective audit at North Shore Hospital, New Zealand

BACKGROUND

It is unknown whether filling defects in subsegmental arteries on multidetector computed tomography pulmonary angiography correlate with clinically relevant subsegmental pulmonary embolism (PE) on pulmonary angiography. Current guidelines do not differentiate between PE in segmental and subsegmental vessels, and many patients receive at least 3 months anticoagulation. The strategy employed at North Shore Hospital in haemodynamically stable patients with single subsegmental PE is to perform bilateral lower leg compression ultrasound (CUS). Anticoagulation is withheld if CUS is negative; a bilateral CUS is repeated in 7-10 days.

AIM

The aim of this retrospective audit was to ensure our current management strategy is safe.

METHODS

All diagnoses of single subsegmental PE between June 2005 and June 2013 were included. The primary outcome was the rate of venous thromboembolism (VTE) recurrence within 3 months of single subsegmental PE diagnosis. Secondary outcomes were rates of major/minor bleeding and all-cause mortality.

RESULTS

Thirty-two patients were included - 20 were treated with anticoagulation; 12 were managed with observation/serial bilateral lower limb CUS. None of the patients in either group had VTE recurrence by 3 months. No bleeding episodes were observed in the observation group; there was a 10% major bleeding rate (n = 2) in the treatment group. One death occurred in each group, neither of which was attributed to VTE.

CONCLUSION

Withholding anticoagulation in patients with single subsegmental PE and negative serial bilateral CUS appears to be a safe and effective management strategy, with a low risk of VTE recurrence.

TEMPORARY REMOVAL: A "cough induced" pelvic fracture as the first sign of a malignant neoplasm

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Pharmacology and anti-addiction effects of the novel κ opioid receptor agonist Mesyl Sal B, a potent and long-acting analogue of salvinorin A

BACKGROUND AND PURPOSE

Acute activation of κ opioid (KOP) receptors results in anticocaine-like effects, but adverse effects, such as dysphoria, aversion, sedation and depression, limit their clinical development. Salvinorin A, isolated from the plant Salvia divinorum, and its semi-synthetic analogues have been shown to have potent KOP receptor agonist activity and may induce a unique response with similar anticocaine addiction effects as the classic KOP receptor agonists, but with a different side effect profile.

EXPERIMENTAL APPROACH

We evaluated the duration of effects of Mesyl Sal B in vivo utilizing antinociception assays and screened for cocaine-prime induced cocaine-seeking behaviour in self-administering rats to predict anti-addiction effects. Cellular transporter uptake assays and in vitro voltammetry were used to assess modulation of dopamine transporter (DAT) function and to investigate transporter trafficking and kinase signalling pathways modulated by KOP receptor agonists.

KEY RESULTS

Mesyl Sal B had a longer duration of action than SalA, had anti-addiction properties and increased DAT function in vitro in a KOP receptor-dependent and Pertussis toxin-sensitive manner. These effects on DAT function required ERK1/2 activation. We identified differences between Mesyl Sal B and SalA, with Mesyl Sal B increasing the Vmax of dopamine uptake without altering cell-surface expression of DAT.

CONCLUSIONS AND IMPLICATIONS

SalA analogues, such as Mesyl Sal B, have potential for development as anticocaine agents. Further tests are warranted to elucidate the mechanisms by which the novel salvinorin-based neoclerodane diterpene KOP receptor ligands produce both anti-addiction and adverse side effects.

LINKED ARTICLES

This article is part of a themed section on Opioids: New Pathways to Functional Selectivity. To view the other articles in this section visit http://dx.doi.org/10.1111/bph.2015.172.issue-2.

Incidence of venous thromboembolism in different ethnic groups: a regional direct comparison study

BACKGROUND

There are few studies that directly compare the variation in incidence of venous thromboembolism (VTE) according to ethnicity.

OBJECTIVE

The aim of this study was to compare the rates of VTE, deep venous thrombosis (DVT) and pulmonary embolism (PE) among different ethnic groups.

METHOD

The cases diagnosed with VTE, DVT and PE for a period between March 2004 and June 2009 were identified through the hospital-based database system. The 2006 New Zealand Census data were used to calculate the rate of diagnosis.

RESULTS

The observed annual incidence of VTE during this period was 81.6 per 100000 population. The relative risks of VTE when comparing European subjects with Maori, Pacific Island and Asian subjects after age standardization were 1.98 (95% confidence interval [CI], 1.63-2.41), 3.22 (95% CI, 2.60-3.99) and 4.02 (95% CI, 3.34-4.84), respectively. Relative risks of DVT after age standardization when comparing European subjects with Maori, Pacific Island and Asian subjects, were 2.14 (95% CI, 1.72-2.66), 3.20 (95% CI, 2.46-4.17) and 4.75 (95% CI, 3.80-5.94), respectively. Indirect age standardization was used for comparison of the diagnosis of PE. The ratio between the calculated expected number of cases and the actual number of cases was 1.32 (95% CI, 0.89-1.75) for Maori subjects, 2.96 (95% CI, 1.89-4.03) for Pacific Islanders and 3.89 (95% CI, 3.00-4.78) for Asians.

CONCLUSION

Europeans have a significantly higher incidence of VTE compared with Maori, Pacific Island and Asian populations.