Standardized Calcium Replacement in Massive Transfusion: A Quality Improvement Project

BACKGROUND

Hypocalcemia is common in trauma patients receiving massive transfusion protocol and often leads to worsening coagulopathies. Despite the identified problem and recommendations for replacement, few institutions have implemented a standardized calcium replacement protocol.

OBJECTIVE

This study aims to assess whether a revised massive transfusion protocol, including standardized calcium replacement, increases the incidence of calcium administration in trauma patients receiving massive transfusion protocol.

METHODS

This quality improvement project used a retrospective pre-/postdesign to study the revision of the current facility's massive transfusion protocol to include calcium replacement and ionized calcium monitoring at an urban Level I academic trauma center. Pre- and postintervention data were collected from January 2022 through October 2022 to determine the number of times massive transfusion protocol was ordered, ionized calcium monitoring, and calcium administration rates. Feedback regarding the protocol was collected throughout the monitoring period and was utilized in the final analysis.

RESULTS

A total of 40 patients received massive transfusion protocol, preintervention, 18 of 23 (78%) received calcium supplementation, postintervention, 15 of 16 (98%) were treated. The majority of protocol activations occurred in the trauma bay (79%) and postintervention; ionized calcium monitoring dropped by 14%.

CONCLUSION

This study found that the addition of standardized calcium replacement improved administration rates of calcium in this patient population. Ongoing research will ensure the recommended changes improve the identified shortcomings and that patients maintain adequate ionized calcium levels with the current dosing parameters.

The prehospital use of younger age whole blood is associated with an improved arrival coagulation profile

INTRODUCTION

Recent in vitro data have shown that the hemostatic profile of whole blood (WB) degrades significantly after 14 days, yet the optimal storage remains debated. We hypothesized that arrival coagulation studies would be improved in patients receiving younger WB in the prehospital setting.

METHODS

This study was approved by our institutional institutional review board. We evaluated all trauma patients who received prehospital blood products by our helicopter service between July 2017 and July 2019. "Young" WB was defined as 14 days or less. Patients who received at least 1 U of young WB were classified as YOUNG, while the remainder was classified as OLD. Continuous data are presented as medians (25th-75th interquartile range) with comparisons performed using Wilcoxon rank sum. Assessments of clinical hemostatic potential included arrival platelet cell count and rapid thrombelastography. Multivariate regression analysis was also performed (Stata 12.1; College Station, TX).

RESULTS

A total of 220 patients received prehospital WB during the study period. Of these, 153 patients received YOUNG WB, while 67 were transfused only OLD WB units. There were no differences in demographics, prehospital or arrival physiology, or Injury Severity Score among the two groups. The measures of clot initiation (activated clotting time) and kinetics (k time) were improved, as were the measures of clot acceleration/fibrinogen function (angle) and platelet function (maximum amplitude). As well, arrival platelet count was higher in the YOUNG cohort. No significant differences in postarrival transfusion were noted (p = 0.220). Multivariate analysis showed the greatest differences in maximum amplitude and α angle but failed to reach significance.

CONCLUSION

Previous in vitro data have suggested deterioration of platelet function in cold-stored WB after 14 days. The current study demonstrated decreased global hemostasis by clinically available laboratory tests, especially related to fibrinogen and platelet interactions on univariate, but not multivariate analysis. This did not translate into increased transfusion requirements. Further studies are needed to determine the optimal storage duration for cold-stored WB for transfusion in the bleeding trauma patient, as well as rule out the presence of confounding variables.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Flea blood feeding patterns in cats treated with oral nitenpyram and the topical insecticides imidacloprid, fipronil and selamectin

A series of studies was conducted to determine the effect of systemically and topically active insecticides on blood consumption by fleas (Ctenocephalides felis). Infestations were conducted by placing fleas into plexi-glass chambers attached to the lateral rib cage of domestic short-hair cats. After pre-defined periods, fleas and flea feces were extracted using vacuum aspiration and spectrophotometrically analyzed for hemoglobin using Drabkin's reagent. To determine how rapidly nitenpyram kills actively feeding fleas, a single oral treatment was administered 24h after infestation. To determine the effect of nitenpyram on blood consumption of newly acquired fleas, cats were infested with fleas 1h post-treatment and fleas and flea feces from both studies were extracted at 15, 30, 60, 120, 240 and 480min post-treatment or post-infestation. To compare the effects of topically versus systemically active insecticides, 20 cats each with 2 chambers attached, were randomly allocated among groups and were infested with fleas 1h after each of 4 nitenpyram treatments, or at 7, 14, 21 and 28 days after a single application of commercial spot-on formulations of fipronil, imidacloprid or selamectin. Infestations were also completed for untreated (control) cats. Twenty-four hours after infestation, fleas and flea feces were removed for host blood quantification. If at any time, flea blood consumption in a treated group did not significantly differ from that of fleas infesting controls, that treatment group was withdrawn from the study. Nitenpyram effects on actively feeding fleas were first observed at 60min post-dosing when 38% of fleas were dead or moribund, and at 240min 100% were dead or moribund. Nitenpyram produced a significant reduction in flea blood consumption (p<0.05), which appeared to cease 15min after infestation. For the treatment comparisons, significantly more (p<0.05) blood was consumed by fleas taken from imidacloprid and fipronil-treated cats than from the nitenpyram or selamectin groups. Only on nitenpyram- or selamectin-treated cats were there significant reductions (p<0.05) in flea blood consumption on days 21 and 28, with significant difference (p>0.05) between these two groups on day 28. In this study systemically acting insecticides such as nitenpyram, and the topically applied but systemically active insecticide selamectin, were more effective in interfering with flea blood feeding than were imidacloprid and fipronil.

Phase I dose-escalation study of novel oral multi-target tumor growth inhibitor (MTGI) ZK 304709 administered daily for 7 days of a 21-day cycle to patients with advanced solid tumors

2073

Background: ZK304709 is a novel MTGI that selectively inhibits activity of Cyclin Dependent Kinases (CDKs) 1, 2, 4, 7, 9, and the tyrosine kinase activity of VEGF-R 1, 2, 3 and PDGF-βR. Methods: Adult patients (pts) with a good performance status (WHO PS ≤2) and a histologically or cytologically confirmed relapsed/refractory solid tumor were eligible. ZK304709 is administered, as a monotherapy, orally on days 1–7 of a 21-day cycle to fasting patients at a starting dose of 15 mg qd. Dose escalation has ranged from 33% - 100% of prior dose, depending on occurrence of drug-related toxicity ≥ grade (gr) 2 (CTC v2.0). Between 3 and 7 patients are to be enrolled per dose level, depending on DLTs that are observed. The primary objective is determination of the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT) of ZK304709. Secondary objectives include tolerability, pharmacokinetic (PK) profile, and preliminary efficacy. Results: Interim results are available for 22 pts (15 M/7 F, median age 60.5 yrs; range 37–71) treated with ZK304709 at 6 dose levels (15 - 180 mg qd). Patients completed a median of 2 cycles (range 0–8). Common AEs were nausea, vomiting, diarrhea, and lethargy. Two DLT were observed: supraventricular tachycardia and vomiting, but the MTD was not reached. The PK profile shows rapid absorption, with a Tmax of 2–4 hrs, and a dose-dependent increase in systemic exposure over the 15–90 mg dose range. Disease stabilization for ≥4 cycles has been observed. Conclusions: ZK304709 is rapidly absorbed and has been tolerated on this schedule at doses up to 180 mg qd. The MTD has not been reached, and enrolment is ongoing. These preliminary data demonstrate that oral delivery on this schedule of an agent that inhibits both cell cycle and angiogenesis is feasible.

[Table: see text]

Phase I dose-escalation study of ZK 304709, an oral multi-target tumor growth inhibitor (MTGI), administered for 14 days of a 28-day cycle

2076

Background: ZK 304709 is a novel oral MTGI that induces cell cycle arrest and inhibits tumour angiogenesis by selectively inhibiting Cyclin Dependent Kinases (CDKs) 1, 2, 4, 7 and 9,VEGF-R 1, 2 and 3, and PDGF-Rβ tyrosine kinases. Methods: Adult patients (pts) (WHO PS ≤2) with a histologically or cytologically confirmed solid tumor, resistant or refractory to conventional therapy, were eligible. ZK304709 was administered orally, once daily, at a 15 mg starting dose, on days 1–14 of a 28-day cycle, then escalated by 33–100% depending on incidence of drug-related toxicity ≥ grade (gr) 2 (CTC v2.0). At least 3 pts were treated at each dose level. The primary objective was to identify the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT). Secondary objectives were to determine the tolerability, pharmacokinetic (PK) profile, and preliminary efficacy. Results: Interim results were available for 24 pts (19 M/5 F; median age 56.5) at 5 dose levels (15–120 mg qd). Pts received a median of 2 cycles (range 0–10). Common drug related toxicities were nausea, vomiting, and fatigue. Two DLT were observed: dizziness and hypertension. However, the MTD has yet to be established. The PK profile for dose levels up to 90 mg demonstrated rapid absorption and a dose-dependent increase of exposure and Cmax. Disease stabilization for ≥4 cycles has been observed. Conclusions: ZK 304709 was rapidly absorbed and has been tolerated on this schedule at up to 120 mg qd. The MTD has not been reached and enrolment is ongoing. These preliminary data demonstrate that oral delivery on this schedule of an agent that inhibits both cell cycle and angiogenesis is feasible.

[Table: see text]

Kentucky's graduated driver licensing program for young drivers: barriers to effective local implementation

OBJECTIVES

To examine the implementation of graduated driver licensing (GDL) in Kentucky and to use the data collected to recommend actions to enhance the effectiveness of the GDL program.

METHODS

Data were acquired from surveys of 700 law enforcement officers and more than 40 judges and from interviews with 100 persons who implement or are affected by Kentucky's GDL program-for example, traffic court judges, licensing clerks, law enforcement officers, insurance agents, driving instructors, parents, and employers of teens. Transcripts from interviews were analyzed using a qualitative data analysis computer program.

RESULTS AND CONCLUSIONS

Participants noted a widespread lack of awareness of the night-time driving restriction and a substantial number of young drivers receiving little driving time during the learner permit phase. It appeared that specific GDL provisions can be difficult for judges and law officers to enforce and the penalty of license suspension after several traffic violations may not be a sufficient deterrent. Efforts are needed to increase parental awareness of GDL provisions, GDL purpose, and their teen's traffic violations and to increase parental enforcement of restrictions that are difficult for law enforcement agencies to monitor, such as the night-time driving restriction and the adult supervision requirement.

Repetitive strain injuries in youth

PURPOSE

To review the anatomic and physiologic considerations in repetitive strain injuries (RSI) in youth in relation to normal growth and development.

DATA SOURCES

Extensive review of scientific literature, laws relating to youth labor, and the authors' experience.

CONCLUSIONS

Early detection of youth at risk for RSIs is crucial for prevention and treatment. Physical maturity and size are more important than chronological age in the safe performance of work tasks or sports.

IMPLICATIONS FOR PRACTICE

Interventions that reduce injury in youth include gradually increasing training load, improving flexibility, and strength, improving biomechanics, and correcting malalignment. Assessments should include tests of flexibility, laxity, and muscle symmetry.

The relative protective effects of moderate dietary restriction versus dietary modification on spontaneous cardiomyopathy in male Sprague-Dawley rats

The relative protective effects of modifying dietary protein, fat, fiber, and energy content vs moderate food or dietary restriction (DR) on spontaneous cardiomyopathy of Charles River male Sprague-Dawley (SD) rats was evaluated at 1 and 2 years. For 2 years, SD rats were fed Purina Rodent Chow 5002 (21.4% protein, 5.7% fat, 4.1% fiber, 3.1 kcal/g) or a modified rodent chow 5002-9 (13.6% protein, 4.6% fat, 15.7% crude fiber, 2.4 kcal/g) ad libitum (AL) or by moderate DR at approximately 65% of the caloric intake of the AL group fed the 5002 diet. Serum lipids, carcass composition, and organ weights were evaluated and hearts were qualitatively and quantitatively examined microscopically for male SD rats at 1 and 2 years. Cardiomyopathy was characterized by the colocalization of myocardial degeneration, the development of subepicardial, perivascular, subendocardial, and interstitial fibrosis, and mononuclear inflammatory cell infiltration that increased by incidence and severity in an age-dependent manner from 1 to 2 years. SD rats fed the 5002 diet AL had the greatest heart weights and the most severe cardiomyopathy, with the highest myocardial fibrotic index. These parameters were relatively decreased in the AL 5002-9 diet, the DR 5002 diet, and the DR 5002-9 diet rats at 1 and 2 years. Regardless of the type of diet fed, both AL groups had the most severe cardiomyopathy by 2 years. Moderate DR allowed isocaloric comparisons of the relative effects of modified diets on survival, obesity, and heart disease. Only slight improvements in the severity and progression of spontaneous cardiomyopathy were seen by modification of the protein, fiber, fat, and energy content of the diet if fed AL. However, moderate DR with either diet was more effective than changing the diet composition in preventing and controlling the progression of cardiomyopathy in male SD rats.

Measurement of the extracellular pH of solid tumours in mice by magnetic resonance spectroscopy: a comparison of exogenous (19)F and (31)P probes

Precise measurement of pH(e) in vivo may be of clinical value for both diagnosis and selection of therapy. pH(e) measurements made by the (31)P probe 3-aminopropylphosphonate (3-APP) were compared with those made by the (19)F probe, 3-[N-(4-fluor-2-trifluoromethylphenyl)-sulphamoyl]-propionic acid (ZK-150471) in three solid tumour types, human HT29 xenografts, murine RIF-1 fibrosarcomas and Lettre tumours grown subcutaneously in mice. No significant differences were observed when probe measurements of pH(e) were compared at 20-60 min post-administration, although very low pH(e) values (ca. 6.0) were recorded in two out of eight Lettre tumours by ZK-150471. The more rapid pH(e) measurements possible using ZK-150471 showed that during the first 20 min post-administration significant increases occurred in pH(e) which were greatest in the more necrotic tumours. Since isolated cell experiments showed that ZK-150471 was non-toxic and did not enter the cells, this early increase in pH(e) may reflect gradual penetration by ZK-150471 of the reportedly alkaline necrotic space in the tumours. The wide chemical shift range, improved signal-to-noise and absence of signal overlap allowed a more rapid and precise measurement of pH(e) by ZK-150471 compared to 3-APP. These characteristics suggest that ZK-150471 is currently the preferred pH(e) probe for non-invasive MRS.

The Wilms' tumor suppressor, WT1, inhibits 12-O-tetradecanoylphorbol-13-acetate activation of the multidrug resistance-1 promoter

Overexpression of P-glycoprotein, the product of the multidrug resistance-1 (MDR1) gene, is associated with treatment failure in some hematopoietic tumors. Although expression of P-glycoprotein in normal hematopoietic cells is tightly regulated during hematopoietic differentiation, its aberrant overexpression in hematopoietic malignancies occurs at the transcriptional level. We have demonstrated that 12-O-tetradecanoylphorbol-13-acetate (TPA) increases transcription of the MDR1 gene and activates the MDR1 promoter, and that promoter activation by TPA requires binding of the zinc finger transcription factor EGR1 to specific MDR1 promoter sequences (C. McCoy and M. M. Cornwell, Mol. Cell. Biol., 15: 6100-6108, 1995). We demonstrate here that the Wilms' tumor (WT) suppressor, WT1, a member of the EGR family, inhibits the response of the MDR1 promoter to TPA in K562 cells. Inhibition is likely a direct effect of WT1 binding to the MDR1 promoter because: (a) WT1 expression does not inhibit the increase in EGR1 after TPA treatment; (b) inhibition by WT1 requires the zinc finger domain; (c) WT1 binds to MDR1 promoter sequences that bind EGR1 and are responsive to TPA; and (d) there is an inverse correlation between WT1 protein expression and MDR1 expression and promoter activity. These results suggest that the MDR1 gene is a target for regulation by WT1 and suggest mechanisms by which MDR1 may be regulated by WT1 and EGR1 during normal and aberrant hematopoiesis.

Comparison of an asymmetric screen-film combination with a conventional screen-film combination for chest radiography in 51 patients

Comparison is made between a new asymmetric screen-film combination and a conventional screen-film combination for use in chest radiography. Seven anatomical features were assessed by three consultant radiologists in each of 51 film pairs. A preference was indicated if one system better demonstrated a particular feature. Alternatively, no preference was indicated if the feature was equally demonstrated by both systems or not demonstrated at all. Any pathology incidentally noted which remained unchanged between the two films was localized to lung, mediastinum or bone and marked in the same way. The asymmetric high contrast system scored higher than the conventional system for demonstration of anatomy in both mediastinum and lungs, but no difference emerged between the two systems in the demonstration of pathology. The asymmetric screen-film system showed improved mediastinal and, to a lesser degree, improved lung detail. Further assessment in necessary to define any associated improvement in diagnostic yield.

12-O-tetradecanoylphorbol-13-acetate activation of the MDR1 promoter is mediated by EGR1

P-glycoprotein, the product of the MDR1 gene (multidrug resistance gene 1), is an energy-dependent efflux pump associated with treatment failure in some hematopoietic malignancies. Its expression is regulated during normal hematopoietic differentiation, although its function in normal hematopoietic cells is unknown. To identify cellular factors that regulate the expression of MDR1 in hematopoietic cells, we characterized the cis- and trans-acting factors mediating 12-O-tetradecanoylphorbol-13-acetate (TPA) activation of the MDR1 promoter in K562 cells. Transient-transfection assays demonstrated that an MDR1 promoter construct containing nucleotides -69 to +20 conferred a TPA response equal to that of a construct containing nucleotides -434 to +105. TPA induced EGR1 binding to the -69/+20 promoter sequences over a time course which correlated with increased MDR1 promoter activity and increased steady-state MDR1 RNA levels. The -69/+20 promoter region contains an overlapping SP1/EGR site. The TPA-responsive element was localized to the overlapping SP1/EGR site by using a synthetic reporter construct. A mutation in this site that inhibited EGR protein binding blocked the -69/+20 MDR1 promoter response to TPA. The expression of a dominant negative EGR protein also blocked the TPA response of the -69/+20 promoter construct. Finally, the expression of EGR1 was sufficient to activate a construct containing tandem MDR1 promoter SP1/EGR sites. These data suggest a role for EGR1 in modulating MDR1 promoter activity in hematopoietic cells.

Normal bone density in Irish women: is American normative data suitable for use in Ireland?

The objective of the study was to determine whether or not U.S. normal data for female Vertebral Bone Mineral Density is suitable for use in an Irish population. One hundred and fifty-six healthy Caucasian women of permanent Irish domicile had bone densitometry performed using single energy quantitative computed tomography of L2, L3 and L4 vertebrae. We found that comparison of our results to normal American data shows a slight and progressive increase in bone mineral content of postmenopausal American women with age relative to the Irish population. This difference is small and not sufficient to justify development of separate normal values for Irish women. We conclude that this discrepancy may be due to a combination of environmental and racial factors or to the more rigorous exclusion criteria applied in our study.

Fetal umbilical artery Doppler response to graded maternal aerobic exercise and subsequent maternal mean arterial blood pressure: predictive value for pregnancy-induced hypertension

Predictive tests for the identification of women at high risk of the development of preeclampsia are critical to allow the most appropriate preventive measures. Preeclampsia is a vasospastic condition of pregnancy characterized by early and enhanced vascular reactivity to endogenous pressor agents. Exercise tolerance testing with cycle ergometry to induce hemodynamic response measured with duplex Doppler A/B ratio of the umbilical artery could unmask latent vascular pressor hypersensitivity. Our prospective cohort study was designed to test the efficacy of the American College of Obstetricians and Gynecologists exercise in pregnancy guidelines for the low-risk athletic, physically active, or sedentary patient. The pattern of fetal response to material exercise testing at 28 weeks' gestation was compared with subsequent maternal mean arterial blood pressure and the development of pregnancy-induced hypertension and preeclampsia. Doppler A/B ratio during the recovery period was assessed as below baseline (18) or elevated above resting baseline values (12). Third-trimester blood pressure pattern was assessed to be elevated in 11 patients, 10 of whom had elevated recovery A/B ratios. The Fisher exact test results were (p = 0.00002) positive predictive value, 83%; negative predictive value, 94%; sensitivity, 91%; and specificity, 89%. Preeclampsia developed in four patients; all had elevated recovery A/B ratios. Fisher exact test results were (p = 0.01806) positive predictive value, 33%; negative predictive value, 100%; sensitivity, 100%; and specificity, 69%.

A novel type of aberrant T cell receptor alpha-chain gene rearrangement. Implications for allelic exclusion and the V-J recombination process

In the process of analyzing the contribution of nonproductive alpha- and beta-chain gene rearrangements to the allelic exclusion of TCR gene expression, we have found a novel type of aberrant alpha-gene rearrangement. In one alpha-allele of the mouse KB5-C20 T cell clone, a J alpha gene segment has been abutted precisely to a sequence that does not display any homology to known V and D gene segment. The appended sequence originates from within the V alpha locus and is located, in the germ-line, 1 kb upstream of a member of the V alpha 2-gene segment subfamily. No recombination signal sequences have been found contiguous to the recombination point. These observations indicate that in normal T lymphocytes, TCR alpha-genes may be affected by aberrant rearrangements similar to those that predominate in human T cell tumors containing chromosome 14 inversion or translocation. Furthermore, compilation of published data and cloning and sequencing of three additional alpha-alleles has allowed us to examine the status of alpha-loci in nine mouse T cell clones expressing functional alpha beta-heterodimers. Interestingly, in contrast to the situation observed at the beta-locus, only 1 of 18 analyzed alpha-alleles has retained a germ-line unrearranged configuration. In addition, in each T cell clone, alpha-rearrangements on homologous chromosomes were unevenly distributed over the J alpha region and shown to generally involve neighboring J alpha gene segments.

A novel type of aberrant T cell receptor alpha-chain gene rearrangement. Implications for allelic exclusion and the V-J recombination process

In the process of analyzing the contribution of nonproductive alpha- and beta-chain gene rearrangements to the allelic exclusion of TCR gene expression, we have found a novel type of aberrant alpha-gene rearrangement. In one alpha-allele of the mouse KB5-C20 T cell clone, a J alpha gene segment has been abutted precisely to a sequence that does not display any homology to known V and D gene segment. The appended sequence originates from within the V alpha locus and is located, in the germ-line, 1 kb upstream of a member of the V alpha 2-gene segment subfamily. No recombination signal sequences have been found contiguous to the recombination point. These observations indicate that in normal T lymphocytes, TCR alpha-genes may be affected by aberrant rearrangements similar to those that predominate in human T cell tumors containing chromosome 14 inversion or translocation. Furthermore, compilation of published data and cloning and sequencing of three additional alpha-alleles has allowed us to examine the status of alpha-loci in nine mouse T cell clones expressing functional alpha beta-heterodimers. Interestingly, in contrast to the situation observed at the beta-locus, only 1 of 18 analyzed alpha-alleles has retained a germ-line unrearranged configuration. In addition, in each T cell clone, alpha-rearrangements on homologous chromosomes were unevenly distributed over the J alpha region and shown to generally involve neighboring J alpha gene segments.

Direct evidence for chromosomal inversion during T-cell receptor beta-gene rearrangements

A germline T-cell receptor variable region (V beta) gene segment (V beta 14) has been mapped 10 kilobases to the 3' side of the constant region (C beta 2) gene. The V beta 14 gene segment is in an inverted transcriptional polarity relative to the diversity-region (D beta) and joining-region (J beta) gene segments and the C beta genes. Analyses of a T-cell clone (J 6.19), which has productively rearranged the V beta 14 gene segment, indicate that the productive V beta-D beta-J beta rearrangement and its reciprocal flank recombination product are linked and located at either border of a chromosomal inversion. These data demonstrate for the first time a linkage between mammalian V and C genes and verify that a functional T-cell receptor V beta gene can be constructed through a chromosomal inversion.

Fetal health assessment in pregnancies complicated by sickle hemoglobinopathies

The contraction stress test (CST) and nonstress test (NST) are used as fetal health assessments. Severe sickle hemoglobinopathies in the parturient have been shown to place the fetus significantly at risk. This study correlates these fetal health assessment tests with outcome data in 58 pregnancies occurring in women with sickle cell disease. There were 30 patients with homozygous sickle cell anemia (HbS-S), 19 with hemoglobin S-C disease (HbS-C), and nine with hemoglobin S-thalassemia (HbS-Thal). All received prophylactic partial exchange transfusions as part of their antepartal care. At 34 weeks' gestation, NSTs followed by CSTs were begun in each patient. A total of 255 tests were performed. Of these, 19 NSTs and 24 CSTs were unsatisfactory or questionably abnormal and were repeated. There were no nonreactive NSTs, and no patient demonstrated a positive CST. The neonatal outcome revealed one infant who was small for gestational age and two infants who were of low birth weight but appropriate for gestational age. All infants survived and were normal. These data suggest that the fetal reactivity and placental reserve among these parturients with severe sickle hemoglobinopathies were uncompromised, as these tests have been shown to be relatively sensitive assessments of fetal well-being in other maternal disorders.