The Impact of a Multidisciplinary Opioid Use Disorder Prenatal Clinic on Breastfeeding Rates and Postpartum Care

OBJECTIVE

 To evaluate the hypothesis that patients with opioid use disorder (OUD), who receive prenatal care in a multidisciplinary, prenatal OUD clinic, have comparable postpartum breastfeeding rates, prenatal and postpartum visit compliance, and postpartum contraceptive use when compared with matched controls without a diagnosis of OUD.

STUDY DESIGN

 This was a retrospective, matched, cohort study that included all patients who received prenatal care in a multidisciplinary, prenatal OUD clinic-Clinic for Acceptance Recovery and Empowerment (CARE)-between September 2018 and August 2020. These patients were maintained on opioid agonist therapy (OAT) throughout their pregnancy. CARE patients were matched to controls without OUD in a 1:4 ratio for mode of delivery, race, gestational age ± 1 week, and delivery date ± 6 months. The primary outcome was rate of exclusive breastfeeding at maternal discharge. Secondary outcomes included adherence with prenatal care (≥4 prenatal visits), adherence with postpartum care (≥1 postpartum visit), postpartum contraception plan prior to delivery, and type of postpartum contraceptive use. Conditional multivariate logistic regression was used to account for possible confounders in adjusted calculations.

RESULTS

 A total of 210 patients were included (42 CARE and 168 matched controls). Despite having lower rates of adequate prenatal care, 40 CARE patients (95%) were exclusively breastfeeding at discharge resulting in CARE patients being significantly more likely to be breastfeeding at discharge (adjusted relative risk (aRR): 1.28, 95% confidence interval [CI]: 1.05-1.55). CARE patients and controls demonstrated no difference in postpartum visit compliance (86 vs. 81%, aRR: 1.03, 95% CI: 0.76-1.40) or effective, long-term contraception use (48 vs. 48%; aRR: 0.81, 95% CI: 0.36-1.84).

CONCLUSION

 In the setting of multidisciplinary OUD prenatal care during pregnancy, patients with OUD were more likely to be breastfeeding at the time of discharge than matched controls, with no difference in postpartum visit compliance or effective, long-term contraception.

KEY POINTS

· Women with OUD are more likely to breastfeed when engaged in a multidisciplinary prenatal clinic.. · Women with OUD had no difference in LARC use when engaged in a multidisciplinary prenatal clinic.. · Women with OUD had no difference in postpartum visit rate in a multidisciplinary prenatal clinic..

WaveGate: a versatile tool for temporal shaping of synchrotron beams

We present a full performance characterization of a solid state pulse picker for hard x-ray pulses at synchrotrons. The device is called WaveGate. Specifically, we quantify its efficiency (>30 %), timing capabilities (switching times between 100 ns and ms), on-off contrast (>104) and influence on the coherence properties of the incident x-ray beam. In addition, we discuss the implementation of the WaveGate in an optical pump - x-ray probe setup. Even if single pulse selection is performed by external detector gating, the WaveGate drastically increases the efficiency of a measurement. Finally, we introduce advanced timing schemes that can be realized by modulating the time structure of the synchrotron beam.

The Risk of Neonatal Morbidity in Umbilical Artery Hypercarbia and Respiratory Acidosis

OBJECTIVE

 To test the hypothesis that elevated umbilical artery (UA) partial pressure of carbon dioxide (pCO2) is associated with neonatal morbidity and to compare the risk of neonatal morbidity with different patterns of UA acidosis.

STUDY DESIGN

 This was a secondary analysis of a prospective cohort of term, singleton, nonanomalous deliveries with universal cord gas collection. The primary outcome was composite neonatal morbidity. Multivariable logistic regression was used to determine the relative risk (RR) for neonatal morbidity in patients with and without UA hypercarbia. A receiver operating characteristic curve determined the predictive value of pCO2 for neonatal morbidity. An additional multivariable logistic regression was used to evaluate the risk of neonatal morbidity in different patterns of UA acidosis.

RESULTS

 UA hypercarbia was associated with an increased risk of neonatal morbidity (RR: 2.56, 95% confidence interval [CI]: [2.07, 3.17]). After adjusting for UA acidemia, this association remained significant (adjusted RR: 1.39, 95% CI: [1.05, 1.83]). UA pCO2 was less predictive of neonatal morbidity than UA pH (area under the curve [AUC]: 0.65, 95% CI: [0.62, 0.68] vs. AUC: 0.72, 95% CI: [0.69, 0.75], p < 0.01). The odds ratios for neonatal morbidity for respiratory, mixed, and metabolic acidosis compared with normal cord gases were 1.48 (95% CI: [0.88, 2.49]), 6.41 (95% CI: [3.68, 11.17]), and 7.49 (95% CI: [5.76, 9.72]), respectively, p-trend < 0.01.

CONCLUSION

 UA hypercarbia is an independent predictor of neonatal morbidity, even in the setting of concomitant UA acidemia. UA mixed and metabolic acidosis carry significantly greater risk of neonatal morbidity compared with respiratory acidosis.

KEY POINTS

· UA pCO2 is associated with neonatal morbidity.. · UA respiratory acidosis is the UA cord gas pattern least associated with neonatal morbidity.. · UA pH is a superior predictor of neonatal morbidity compared with UA pCO2..

Severity of intrapartum fever and neonatal outcomes

BACKGROUND

The few studies that have addressed the relationship between severity of intrapartum fever and neonatal and maternal morbidity have had mixed results. The impact of the duration between reaching maximum intrapartum temperature and delivery on neonatal outcomes remains unknown.

OBJECTIVE

To test the association of severity of intrapartum fever and duration from reaching maximum temperature to delivery with neonatal and maternal morbidity.

STUDY DESIGN

This was a secondary analysis of a prospective cohort of term, singleton patients admitted for induction of labor or spontaneous labor who had intrapartum fever (≥38°C). Patients were divided into 3 groups according to maximum temperature during labor: afebrile (<38°C), mild fever (38°C-39°C), and severe fever (>39°C). The primary outcome was composite neonatal morbidity (umbilical artery pH <7.1, mechanical ventilation, respiratory distress, meconium aspiration with pulmonary hypertension, hypoglycemia, neonatal intensive care unit admission, and Apgar <7 at 5 minutes). Secondary outcomes were composite neonatal neurologic morbidity (hypoxic-ischemic encephalopathy, hypothermia treatment, and seizures) and composite maternal morbidity (postpartum hemorrhage, endometritis, and maternal packed red blood cell transfusion). Outcomes were compared between the maximum temperature groups using multivariable logistic regression. Cox proportional-hazards regression modeling accounted for the duration between reaching maximum intrapartum temperature and delivery.

RESULTS

Of the 8132 patients included, 278 (3.4%) had a mild fever and 74 (0.9%) had a severe fever. The incidence of composite neonatal morbidity increased with intrapartum fever severity (afebrile 5.4% vs mild 18.0% vs severe 29.7%; P<.01). After adjusting for confounders, there were increased odds of composite neonatal morbidity with severe fever compared with mild fever (adjusted odds ratio, 1.93 [95% confidence interval, 1.07-3.48]). Severe fevers remained associated with composite neonatal morbidity compared with mild fevers after accounting for the duration between reaching maximum intrapartum temperature and delivery (adjusted hazard ratio, 2.05 [95% confidence interval, 1.23-3.43]). Composite neonatal neurologic morbidity and composite maternal morbidity were not different between patients with mild and patients with severe fevers.

CONCLUSION

Composite neonatal morbidity correlated with intrapartum fever severity in a potentially dose-dependent fashion. This correlation was independent of the duration from reaching maximum intrapartum temperature to delivery, suggesting that clinical management of intrapartum fever, in terms of timing or mode of delivery, should not be affected by this duration.

1582. Is Antibiotic Prophylaxis Needed for All Acute Variceal Bleeds in Decompensated Cirrhosis? A Retrospective Pilot Study

Background

Guidelines recommend empiric antibiotic prophylaxis for acute variceal bleeding, but no studies compare the outcomes between those treated with guideline recommended duration and those not treated (low suspicion) or treatment duration truncated (negative work up). We hypothesized that outcomes may not be different between the two groups.

Methods

Retrospective pilot study for the period 2013–2017. Cases were extracted using ICD 9(4,560) and ICD 10(I8501, I8511) codes and the following criteria were applied. Inclusion: Age >18 years and decompensated cirrhosis with acute variceal bleeding. Exclusion: Age <18 years, septic shock, receipt of antibiotics <14 days before admission, human immunodeficiency virus infection. Data gathered on demographics, APACHE II, Charlson score, modified Child-Turcotte-Pugh classification (CTP), mortality at 6 weeks, re-bleeding within 7 days, readmissions (30 and 90 days), incidence of infections at admission and follow-up. Using SPSS, we compared those who received antibiotics <3 days to ≥ 3 days.

Results

Eighty-three cases met criteria (M:F = 52:31, age = 54.5 ± 11.6 years), CTP: A = 20(24.1%), B = 34 (41.9%), C = 29(33.7%). Alcohol was etiology in 57(68.67%) [52(91.2%) alcohol only, 5(8.8%) with alcohol and viral hepatitis]; hepatitis C virus (HCV): 12/83 (14.6%)[6(50%) HCV only]; hepatitis B virus: 3(3.6%); NASH: 12(14.6%) [9(75%) NASH only, 2(16.7%) with HCV, 1 with autoimmune hepatitis)]; cryptogenic: 3(3.6%); autoimmune: 2(2.4%), others: 4(ischemic, metastases, biliary cirrhosis, transplant). Antibiotics were either not administered or truncated in 21(25.3%) patients. In comparing guideline concordant (≥3 days) and truncated (<3 days) groups, no statistically significant difference was present for APACHEII, Charlson score, mortality (10 vs. 3, P 0.928), re-bleeding (2 vs. 0, P 0.387) and readmission at 30 and 90 days (18 vs. 3, P 0.147; 11 vs. 3, P 0.715). Drug-resistant infections were seen in 4(4.8%) patients requiring readmissions within 90 days.

Conclusion

We found no differences in outcomes between guideline concordant and truncated duration of antimicrobial prophylaxis for acute variceal bleeding. Truncating the duration of empiric prophylactic antibiotics reduces unnecessary antibiotic use.

Disclosures

All authors: No reported disclosures.

Impact on blood pressure and intestinal perfusion of dobutamine or dopamine in hypotensive preterm infants

In a prospective study hemodynamic effects of dobutamine or dopamine (10 micrograms/kg/min) were investigated in 20 preterm infants who had protracted arterial hypotension refractory to volume therapy. Doppler ultrasonography of the superior mesenteric artery (SMA) was applied to verify intestinal perfusion and blood pressure was recorded in parallel. Mean arterial pressure (MAP) raised significantly in both groups (from 31.0 +/- 6.8 to 37.7 +/- 9.8 mm Hg during dobutamine and from 27.7 +/- 3.6 to 36.0 +/- 9.3 mm Hg during dopamine). Mean blood flow velocity increased from 25.8 +/- 13.5 to 31.5 +/- 16 cm/s with dobutamine and from 16.3 +/- 5.0 to 19.0 +/- 6.0 cm/s with dopamine (significant for dobutamine). Vascular resistance of SMA (indicated by resistance index; RI) decreased from 0.81 +/- 0.07 to 0.74 +/- 0.11 for dobutamine and from 0.89 +/- 0.06 to 0.79 +/- 0.07 for dopamine (significant for both groups). These data indicate that in the dose tested here both catecholamines are equally effective in raising MAP and lead to a significant increase of intestinal perfusion. Thus, a negative impact on mesenteric blood supply, predisposing to necrotizing enterocolitis, is not probable.

Comparative evaluation of selective and nonselective culture techniques for isolation of group A beta-hemolytic streptococci

A new selective blood agar medium, Strep A Isolation Agar (SI) from Remel (Lenexa, KS), was compared with Becton Dickinson's Streptococcus Selective Agar (SA) (Becton Dickinson Microbiology Systems, Cockeysville, MD) and with a nonselective Columbia Blood Agar (CB) (Difco, Detroit, MI). Throat swabs from patients with acute pharyngitis were cultured with the use of a single swab to inoculate each of the three plates in a specific order, rotating in three-week cycles. Plates were examined (each medium by a different technologist) after 24 and 48 hours of incubation at 35 degrees C in 5% carbon dioxide, and beta-hemolytic streptococci were serogrouped with the use of coagglutination. The positivity rate was significantly greater for SI (25%) and SA (26%) than for CB (18%) (P less than 0.001). The respective rates of Group A streptococcal detection by SI, SA, and CB were 91%, 95%, and 67%, respectively. However, a feature associated with the use of SI or SA, in contrast to CB, was delayed identification of isolates by 24-48 hours because of small colony size, slower growth rate, and inability to serogroup colonies taken directly from primary culture plates. Recovery of non-Group A beta-hemolytic streptococci occurred with CB (12%) greater than SI (8%) greater than SA (6%). SI is superior to a nonselective medium, such as CB, and is equal to SA for recovery of Group A streptococci from throat cultures.

A newly recognized fastidious gram-negative pathogen as a cause of fever and bacteremia

BACKGROUND

We identified a motile, curved, gram-negative bacillus as the cause of persistent fever and bacteremia in two patients with symptomatic human immunodeficiency virus infection. The same organism was subsequently recovered from a bone marrow-transplant recipient with septicemia and from two immunocompetent persons with week-long febrile illnesses. All the patients recovered after antimicrobial therapy.

METHODS AND RESULTS

Primary cultures of blood processed by centrifugation after blood-cell lysis yielded adherent, white, iridescent, morphologically heterogeneous colonies in 5 to 15 days. Subcultures grew in four days on chocolate, charcoal-yeast extract, or blood agar. The organisms stained weakly with safranin and were not acid-fast. Fluorescent-antibody tests for legionella and francisella were negative. Biochemical reactivity was minimal and difficult to ascertain. Agar-dilution testing revealed in vitro susceptibility to most antimicrobial agents tested. The cellular fatty acid composition of the isolates was similar, resembling that of Rochalimaea quintana or brucella species, but not Helicobacter pylori or species of campylobacter or legionella. As resolved by gel electrophoresis, cell-membrane preparations of all isolates contained similar proteins, with patterns that differed from that of R. quintana. Patterns of digestion of DNA from all isolates by EcoRV restriction endonuclease were virtually identical and also differed from that of R. quintana. On immunodiffusion, serum from one convalescent patient produced a line of identity with sonicates of all five isolates.

CONCLUSIONS

This pathogen may have been unidentified until now because of its slow growth, broad susceptibility to antimicrobial agents, and possible requirement of blood-cell lysis for recovery in culture. It should be sought as a cause of unexplained fever, especially in persons with defective cell-mediated immunity.

Evaluation of a lysis direct plating method for pediatric blood cultures

The Isolator 1.5 Microbial tube (E. I. du Pont de Nemours & Co., Inc., Wilmington, Del.) is a commercially available blood culture system for use in pediatrics. The methodology is based on blood lysis followed by direct plating of the sample on culture media to detect bacteria and fungi. Comparative recovery rates of pathogens from blood collected in this and a conventional broth system were similar. The Isolator detected 104 of 120 clinically significant isolates, whereas 106 of 120 isolates were detected by the broth system. The major advantage of the Isolator methodology was early detection of septicemia. Initial detection of gram-negative bacteria occurred an average of 14.2 h earlier by the Isolator system than by the conventional broth method. The Isolator also permitted quantitation of bacteremia and fungemia. Probable contaminants were recovered from 10.0% of the cultures processed by the Isolator, but steps which could be taken to minimize this problem were identified. The Isolator is a useful method for pediatric blood cultures.

Evaluation of the Phadebact CSF test for detection of the four most common causes of bacterial meningitis

A five-center collaborative study was undertaken to determine the suitability of the Phadebact CSF test kit and the Phadebact group B Streptococcus reagent for routine use by clinical laboratories to detect antigens of common organisms causing bacterial meningitis. The kits employ staphylococcal protein A coagglutination to detect the antigens of Haemophilus influenzae types a, b, c, d, e, and f, Neisseria meningitidis groups A, B, C, Y, and W135, Streptococcus pneumoniae (83 serotypes), and group B Streptococcus. A total of 2,817 individual tests were performed on 577 cerebrospinal fluid specimens. The percent positive specimens detected by coagglutination was as follows: overall, 84%; H. influenzae, 97%; group B Streptococcus, 75%; S. pneumoniae, 71%; and N. meningitidis, 58%. Eighty-five of the specimens were also tested by counterimmunoelectrophoresis. Coagglutination was more sensitive than counterimmunoelectrophoresis because it detected 74% of the positive specimens, whereas counterimmunoelectrophoresis detected only 65%. No false-positive results were obtained with coagglutination. The Phadebact CSF test kit is recommended for routine use in screening cerebrospinal fluid samples for antigens of the common organisms causing bacterial meningitis along with the Gram stain and culture for delayed confirmation of the rapid results.

Polarity in mechanoreceptor cells of trigger hairs of Dionaea muscipula Ellis

Both the apical and the basal cell poles of the sensory cells in trigger hairs of Dionaea muscipula are structured identically. A complex of concentrically arranged endoplasmic reticulum cisternae occupies each of the poles. One to four vacuoles are enclosed within the central cisterna and contain polyphenols (deposits of "tannin"). Structural polarity, whether symmetric or asymmetric, as well as the occurrence of abundant endoplasmic reticulum and numerous mitochondria are characteristics of the perception cells of most animals and plants.

Evaluation of Bactogen and Phadebact for detection of Haemophilus influenzae type b antigen in cerebrospinal fluid

Latex agglutination and coagglutination tests are commercially available as Bactogen and the Phadebact Haemophilus Test, respectively. We evaluated both for the detection of Haemophilus influenzae type b in cerebrospinal fluids. Both tests were positive in all of 51 culture-positive cases of meningitis caused by H. influenzae. Both were more sensitive than counterimmunoelectrophoresis. Antigen was also detected by Bactogen in seven of seven additional cerebrospinal fluid specimens (compared with four of seven by Phadebact) after 1 to 15 days of antimicrobial therapy. The cerebrospinal fluid of infants with meningitis owing to other common causative agents did not react with Bactogen or Phadebact. However, the cerebrospinal fluid of one patient with overwhelming infection owing to Proteus mirabilis reacted positively with Bactogen. Cost analysis revealed that Phadebact was less expensive to perform than Bactogen.