Rapid Infusion Research Articles

Faster Refill in an Urban EMS System Saves Lives: A Prospective Preliminary Evaluation of a Prehospital Advanced Resuscitative Care Bundle.

Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian EMS systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid (TXA), and PRBCs via a rapid infuser. ARC patients were compared to trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and SBP < 90 mmHg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. A total of 210 patients (ARC = 61, controls = 149) met criteria. Median age was 32 years, with no difference in demographics, initial SBP or heart rate recorded by EMS, or new injury severity score (NISS) between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls (p < 0.03). Fewer patients in the ARC group required prehospital advanced airway placement (p < 0.001). 24-hour and total in-hospital mortality were lower in the ARC group (p < 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (OR 0.19, 95%CI 0.05-0.68, p = 0.01). Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. ARC closer to the point of injury warrants consideration. Level IV, Prospective.

Initial experience of ureteric visualization using methylene blue during laparoscopy for gynecological surgery.

Iatrogenic ureteral injury is a severe surgical complication, with a highest incidence of 1.5% in gynecological surgeries. The purpose of this report is to document our initial experience with using methylene blue (MB) to label the ureter in gynecological laparoscopic surgeries and to explore its effectiveness and safety. This is also a novel description of simultaneously visualizing ureteral MB fluorescence and sentinel lymph nodes (SLN's) Indocyanine Green (ICG) fluorescence using the same camera. This study included patients undergoing gynecological laparoscopic surgeries, with the same surgeon performing all cases. During the early stages of each surgery, rapid intravenous infusion of MB was administered. For cases requiring SLN imaging, we also injected ICG solution into the cervix. Assessment of the included cases was conducted both intraoperatively and postoperatively. The group that had MB fluorescence (Group A) was compared to a control group that did not have it (Group B). A total of 25 patients (Group A) received MB during surgery, demonstrating 45 ureters clearly, with an imaging success rate of 90%. Continuous and clearer fluorescence imaging was achieved in cases with ureteral hydronephrosis. In most patients, ureteral fluorescence was visible 15-20 min after intravenous infusion of MB, and 64% still exhibited fluorescence at the end of the surgery. In patients who had both ICG and MB, dual fluorescence imaging was achieved clearly. Among the included cases, there were no iatrogenic ureteral injuries (0%), which we observed to be lower than in patients who did not receive MB (1.3%). The rate of adverse events was similar in both groups. Using MB fluorescence is an effective and safe method of visualizing the ureters during gynecological surgeries, and can diminish iatrogenic ureteral injury without increased associated adverse events. It therefore may offer promising prospects for clinical application.

Effectiveness of a Novel Rapid Infusion Device and Clinician Education for Early Fluid Therapy by Emergency Medical Services in Sepsis Patients: A Pre-Post Observational Study

Objective Emergency medical services (EMS) clinicians are tasked with early fluid resuscitation for patients with sepsis. Traditional methods for prehospital fluid delivery are limited in speed and ease-of-use. We conducted a comparative effectiveness study of a novel rapid infusion device for prehospital fluid delivery in suspected sepsis patients. Methods This pre-post observational study evaluated a hand-operated, rapid infusion device in a single large EMS system from July 2021-July 2022. Prior to device deployment, EMS clinicians completed didactic and simulation-based device training. Data were extracted from the EMS electronic health record. Eligible patients included adults with suspected sepsis treated by EMS with intravenous fluids. The primary outcome was the proportion of patients receiving goal fluid volume (at least 500 mL) prior to hospital arrival. Secondary outcomes included in-hospital mortality, disposition, and length of stay. Multivariable logistic regression was used to compare outcomes between 6-month pre- and post-implementation periods (July-December 2021 and February-July 2022, respectively), adjusting for patient demographics, abnormal prehospital vital signs, and EMS transport interval. Results Of 1,180 eligible patients (552 in the pre-implementation period; 628 in the post-implementation period), the mean age was 72 years old, 45% were female, and 25% were minority race-ethnicity. Median (interquartile range) fluid volume (in mL) increased between the pre- and post-implementation periods (600 [400,1,000] and 850 [500–1,000], respectively). Goal fluid volume was achieved in 70% of pre-implementation patients and 82% of post-implementation patients. In adjusted analysis, post-implementation patients were significantly more likely to receive goal fluid volume than pre-implementation patients (adjusted odds ratio (aOR) 2.00, 95% confidence interval (CI) 1.51–2.66). Pre-post in-hospital mortality was not significantly different (aOR 0.91, 95% CI 0.59–1.39). Conclusion In a single EMS system, sepsis education and introduction of a rapid infusion device was associated with achieving goal fluid volume for suspected sepsis. Further research is needed to assess the clinical effectiveness of infusion device implementation to improve sepsis patient outcomes.

EE425 Estimating HCP Labor Time and Cost Saving with the Use of Rapid Rituximab Infusions Versus Standard Rituximab Infusions for the Treatment of Adults with Follicular Lymphoma and Diffuse Large B-Cell Lymphoma in Induction Phase

EE425 Estimating HCP Labor Time and Cost Saving with the Use of Rapid Rituximab Infusions Versus Standard Rituximab Infusions for the Treatment of Adults with Follicular Lymphoma and Diffuse Large B-Cell Lymphoma in Induction Phase

Iatrogenic Hyperhydration in Sickle Cell Disease Patients Admitted for Acute Pain Crisis Management: A Retrospective Analysis from a Single Institution

Background: Parenteral fluids are an important component of acute pain crisis management in sickle cell disease patients. However, lack of uniform guidelines for fluid replacement coupled with underlying host comorbidities result in risk to patients from complications associated with hyperhydration. Contributing factors include inappropriate choice of fluid, rapid fluid infusion rates with prolonged time periods and inadequate monitoring of signs of hyperhydration. Complications of fluid replacement include excessive weight gain, extremity swelling, pulmonary edema and heart failure. In our study we examined the prevalence of hyperhydration in sickle cell anemia patients admitted for acute pain crisis management at our hospital. Methods: We conducted a retrospective chart review on EPIC of sickle cell anemia patients treated for acute pain crisis in the inpatient unit of John Dempsey Hospital, University of Connecticut between January 2022-December 2022, following IRB approval. To capture patients with signs and symptoms of hyperhydration and its clinical consequences, we looked at surrogate markers such as excessive weight gain during admission, signs of fluid retention, charting of patient fluid intake and output, increased oxygen use, diuretic (Lasix) administration, bronchodilator use, abnormal chest x ray findings indicative of fluid overload pattern, activation of rapid response team for patients developing acute symptoms of fluid overload, and urgent patient transfer to a higher level of care including intensive care unit. Results: 256 admitted patient charts were analyzed representing a total of 95 unique sickle cell disease patients. The median length of hospital stay (LOS) was 3 days. 168 patients had LOS from 3 to 10 days. We observed that 10.7% of the patients experienced an increase in oxygen requirements during their hospital stay. Daily weight was collected in only 27 patients (10.5%) for 3 or more days limiting its usefulness to detect subclinical hyperhydration( figure 1). 69 patients (27%) received parenteral Lasix injection for acute symptoms whose chest x rays also showed pulmonary edema or pleural effusions. 13 patients (18%) were transferred to a higher level of care that included 9 patients to step-down unit and 4 to intensive care for endotracheal intubations and ventilatory support. The median hospital stay was 4 days in patients requiring Lasix compared to 3 days in those who did not. Conclusion : Hyperhydration is undesirable complication associated with fluid administration of sickle cell anemia patients admitted with acute vaso-occlusive pain crisis. It occurs in a significant proportion of affected patients that can result in life threatening complications and prolonged hospitalization. Hyperhydration were missed in this retrospective analysis since daily weight measurements were not available in the majority of patients. Strict charting of fluid intake and output, choice of half normal saline for hydration, as well as clinical monitoring of signs and symptoms of subclinical hyperhydration will help reduce this complication and improve patient outcomes. Improving awareness of this complication among health care providers is important towards achieving this goals. Findings from this study are used to design a prospective quality improvement project in our hospital to improve outcomes and reduce hospitalization in sickle cell anemia patients admitted for acute vaso-occlusive pain crisis.

INNV-14. INTERIM REPORT OF A PHASE 1/2 STUDY OF SONODYNAMIC THERAPY (SDT) USING AMINOLEVULINIC ACID (ALA) AND LOW-INTENSITY FOCUSED ULTRASOUND IN PEDIATRIC PATIENTS WITH DIFFUSE INTRINSIC PONTINE GLIOMA (DIPG)

Abstract BACKGROUND DIPGs are devastating pediatric brain tumors with limited treatment options, poor prognosis, and survival of 9-11 months. Preclinical studies demonstrate that performing SDT through MR-guided focused ultrasound (MRgFUS) activates ALA metabolite, protoporphyrin IX (PpIX), leading to tumor cell death and prolonging survival in rodent glioma models through generation of reactive oxygen species and lipoperoxidation, without affecting normal tissue. MEDTHODS: Herein we report preliminary data from an ongoing first-in-child dose-escalation trial of ALA-SDT post-radiation therapy in children ≥ 5 years with DIPG. The trial aims to evaluate the safety and tolerability of ALA-SDT, determine the recommended-phase-2-dose and assess preliminary efficacy and pharmacokinetics (PK) of ALA administered intravenously. RESULTS The first study cohort completed enrollment of 3 subjects. Six hours prior to SDT, patients received an infusion of ALA (SONALA-001) at a dose of 5 mg/kg, followed by sonication with 200J. The first subject was treated in 2 sessions: each to half of the pons 30 days apart. Two subsequent subjects had the entire pons treated in a single session. No dose-limiting toxicity (DLT) or related adverse event grade ≥ 3 were observed. For SONALA-001, the Cmax occurred at the end of infusion, followed by rapid clearance (15.7 mL/min/kg), with a plasma half-life of &amp;lt; 1 hour, indicating rapid distribution (5530 ml/kg). For PpIX, the Cmax occurred 6 hours post-dose and declined with a longer mean half-life of 3.8 hours. Both Cmax and AUCall demonstrate circulating PpIX and systemic exposure were significantly lower than for ALA. CONCLUSION SDT signals an innovative and well-tolerated approach for patients with DIPG in our first study cohort. As expected, the PK for SONALA-001 demonstrate rapid infusion and clearance, whereas for PpIX, the PK are consistent with formation of a metabolite. Clinical trial enrollment is ongoing and dose-escalation cohorts will provide additional PK and safety data.

Lung ultrasound, echocardiography and fluid loading for the differential diagnosis of pulmonary hypertension

Abstract Background There may be interest in combining echocardiography and lung ultrasound for the differential diagnosis between pulmonary arterial hypertension (PAH) and post-capillary pulmonary hypertension on heart failure with preserved ejection fraction (PH-HFpEF). Methods Patients referred for PH underwent a right heart catheterization, echocardiography and lung ultrasound before and after rapid infusion of 7 ml/kg of saline. A 7-points echocardiographic score based on cardiac chamber dimensions and estimates of filling pressures was implemented for the prediction of pre-capillary PH. Pulmonary congestion was identified by lung ultrasound B-lines. Results The study enrolled 70 patients with PAH and 77 patients with HFpEF. The PAH patients had a higher echocardiographic score (3.5±1.8 v 1.6±1.5, p &amp;lt;0.001). Figure 1 represents the typical baseline echocardiographic components of pre-capillary pulmonary hypertension prediction score and pre- and post-fluid loading lung ultrasound imaging from patients with PAH and HFpEF respectively. The HFpEF patients had more B-lines both before (8.1±4.2 vs 5.1±3.0; p &amp;lt;0.001) and after fluid loading (14.6±5.4 vs 7.6±3.5; p &amp;lt;0.001), and a more important increase (Δ) of B-lines after fluid loading (6.5±2.9 vs 2.5±1.6; p &amp;lt;0.001). The sensitivity and specificity of the echocardiographic score alone for PAH were 0.91 and 0.49 respectively [area under the curve (AUC) 0.78]. The AUC for PAH was improved by addition of smaller ΔB-lines to the echocardiography prediction score after fluid loading, with significant increase in sensitivity [0.94 (95% CI 0.89;1.00)] and specificity [0.91 (95% CI 0.84;0.97)] and a positive predictive value of 0.90 (CI 0.84;0.97) and a negative predictive value of 0.95 (CI 0.89;1.00). Figure 2 represents the bar plot of AUC for echocardiographic score, pre- fluid loading B-lines, delta E/e', delta B-lines, post- fluid loading E/e', post- fluid loading B-lines, in ascending order. Conclusion Lung ultrasound combined with echocardiography at baseline and after fluid loading has an incremental value for the differential diagnosis between PAH and PH-HFpEF.Figure 1Figure 2

Rehydration Rates and Outcomes in Overweight Children With Diabetic Ketoacidosis.

The Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in Diabetic Ketoacidosis (DKA) (FLUID) Trial found that rapid fluid infusion does not increase the risk of cerebral injury. Concern persists, however, whether fluid rates should be adjusted for overweight or obese patients. We used the FLUID Trial database to evaluate associations between fluid infusion rate and outcomes in these patients. We compared children and youth who were overweight, obese, or normal weight, in regard to protocol adherence, mental status changes, time to DKA resolution, and electrolyte abnormalities. We investigated associations between outcomes and the amount of fluid received in these groups. Obese children and youth were more likely to receive fluids at rates slower than dictated by protocol. Overweight and obese children and youth in the fast fluid arms, who received fluids per the study protocol based on their measured weight, had similar rates of mental status changes or clinically apparent cerebral injury as those with normal weights. Risk of hypophosphatemia was increased in those receiving larger initial bolus volumes and reduced in those receiving higher rehydration rates. No other metabolic outcomes were associated with rehydration. Protocol adherence data in the FLUID Trial suggest that physicians are uncomfortable using weight-based fluid calculations for overweight or obese children. However, higher rates of fluid infusion were not associated with increased risk of mental status changes or cerebral injury, suggesting that physicians should not limit fluid resuscitation in obese children and youth with DKA.

Comparative effectiveness of two intravenous immunoglobulin products in children with Kawasaki disease, a nationwide cohort study

Kawasaki Disease (KD) is the most common acquired pediatric heart disease in the developed world. Rapid infusion of high-dose intravenous immunoglobulin is the standard therapy. Different manufacturing processes of IVIG may influence their efficacy. This study aims to conduct a head to head comparison of two IVIGs, TBSF and Privigen, from a nationwide perspective. The main data source was the National Health Insurance Research Database (NHIRD) of Taiwan. A total of 3368 KD cases involving children under 2 years of age were enrolled from January 2015 to November 2020. The primary endpoint was IVIG resistance, which we defined as the total amount exceeding 26 g in one admission. The secondary endpoints encompassed two distinct criteria: coronary involvement, which was defined as the prolonged use of aspirin or anti-coagulation agents between 180 and 360 days after the index date, and recurrence, which was defined as readmission for IVIG therapy occurring more than 30 days after previous KD index day and continuing until the end of the follow-up period. Privigen demonstrated a lower IVIG resistance rate at 9.4% in comparison to TBSF, which exhibited a rate of 9.7% (odds ratio 0.72, 95% CI 0.52–0.99). Privigen had a lower odds of coronary involvement (odds ratio 0.38, 95% CI 0.18–0.82). There is no difference in recurrence rate (odds ratio 0.60, 95% CI 0.22–1.68). Privigen might have a lower rate of IVIG resistance and reduced coronary artery involvement. The discrepancy may be due to the concentration, the stabilizers, or the source of plasma. Further investigation is needed to compare the effectiveness of different IVIGs in the large randomized controlled clinical trial.

Application Times, Placement Accuracy, andUser Ratings ofCommercially Available Manual andBattery-Powered Intraosseous Catheters ina High Bone Density Cadaveric Swine Model.

Intraosseous (IO) infusion, the pressurized injection of fluids into bone through a catheter, is a life-preserving resuscitative technique for treating trauma patients with severe hemorrhage. However, little is known regarding the application times, placement accuracy, and end-user ratings of battery-powered and manual IO access devices. This study was specifically designed to fill these knowledge gaps on six FDA-approved IO access devices. Three experienced U.S. Navy Emergency Medicine residents each placed commercially available 15-gauge IO catheters in cadaveric swine (Sus scrofa) proximal humeri and sternums in a randomized prospective experimental design. Devices included the battery-powered EZ-IO Rapid Infuser and the manual Jamshidi IO, PerSys NIO, SAM Manual IO, Tactical Advanced Lifesaving IO Needle (TALON), and PYNG First Access for Shock and Trauma 1 (30 trials per device, 10 per user, 210 total trials). Application times, placement accuracy in medullary (zone 1) and trabecular (zone 2) bone while avoiding cortical (zone 3) bone, and eight subjective user ratings were analyzed using ANOVA and nonparametric statistics at P < .05. The EZ-IO demonstrated the fastest application times, high rates in avoiding zone 3, and the highest user ratings (P < .0001). The TALON conferred intermediate placement times, highest rates of avoiding zone 3, and second-highest user ratings. The SAM Manual IO and Jamshidi performed poorly, with mixed results for the PerSys NIO and PYNG First Access for Shock and Trauma 1. The battery-powered EZ-IO performed best and remains the IO access device of choice. The present findings suggest that the TALON should be considered as a manual backup to the EZ-IO.

Comparison of the Analgesic Effects of Low-Dose Ketamine Versus Fentanyl in Patients With Long Bone Fractures in the Emergency Department: A Prospective Observational Study.

Aim and background In most emergency departments (ED), opioids are the primary analgesic agents for trauma patients. However, safe alternative drugs are required because of possible adverse effects. Ketamine, an anesthetic agent, provides satisfactory analgesia at low doses and is an alternative drug that has begun to be used in numerous areas with fewer side effects. This study aimed to compare low-dose ketamine and fentanyl infusions in terms of their pain-relieving effects and observed adverse effects in patients presenting to the ED with isolated long bone fractures. Materials and methods This single-center observational study was conducted in the ED of the Marmara University Pendik Training and Research Hospital between August 2018 and December 2019. Patients diagnosed with isolated long bone fractures who were administered low-dose ketamine or fentanyl rapid infusions for pain relief were included in the study. Patient pain scores were evaluated using the visual analog scale (VAS) with a standard horizontal 10-centimeter line. The primary outcome of the study was to compare the changes in pain at 30 and 60 min after medication administration for each group. Results A total of 100 patients were included in the study. Ketamineinfusion was administered to 48% (n=48) of the patients as a pain reliever. After 60 min of observation, pain was significantly reduced in both study groups. However, the pain scores at baseline (p=0.319), 30 min (p=0.631), and 60 min (p=0.347) after treatment were similar in both groups. In terms of the observed adverse effects, dizziness was more common in the ketamine group (p=0.010). Conclusion The results of this study showed that low-dose ketamine infusion (0.3 mg/kg/h) had a similar effect to fentanyl infusion (1 mcg/kg/h) as a pain reliever in patients with isolated long bone fractures in the ED.

Fluid Resuscitation in Patients With Traumatic Brain Injury: A Comprehensive Review.

Patients with traumatic brain injury (TBI) or head trauma present challenges for emergency physicians and neurosurgeons. Traumatic brain injury is currently a community health issue. For the best possible care, it is crucial to understand the various helpful therapy techniques in the pre-operative and pre-hospital phases. The initial rapid infusion of large volumes of mannitol and a hypertonic crystalloid solution to restore blood pressure and blood volume is the current standard of care for people with combined hemorrhagic shock (HS) and traumatic brain injury. The selection and administration of fluids to trauma and traumatic brain injury patients may be especially helpful in preventing subsequent ischemic brain damage because of the hemodynamic stabilizing effects of these fluids in hypovolemic shock. Traumatic brain injury is an essential factor that may lead to disability and death in a patient. Traumatic brain damage can develop either as a direct result of the trauma or as a result of the initial harm. Significant neurologic problems, such as cranial nerve damage, dementia, seizures, and Alzheimer's disease, can develop after a traumatic brain injury. The comorbidity of the victims may also be significantly increased by additional psychiatric problems such as psychological diseases and other behavioral and cognitive sequels. We review the history of modern fluid therapy, complications after traumatic brain injury, and the use of fluid treatment for decompressive craniectomy and traumatic brain injury.

Safety and feasibility of 120 min rapid infusion regimen of daratumumab in patients with multiple myeloma

Safety and feasibility of 120 min rapid infusion regimen of daratumumab in patients with multiple myeloma

Lung Ultrasound, Echocardiography, and Fluid Challenge for the Differential Diagnosis of Pulmonary Hypertension

The differential diagnosis between pulmonary arterial hypertension (PAH) and post-capillary pulmonary hypertension (PH) on heart failure with preserved ejection fraction (HFpEF) is sometimes difficult in spite of guidelines-derived standardized step-by-step diagnostic algorithms. We therefore explored the added value of lung ultrasound to previously validated echocardiographic score to right heart catheterization measurements. Patients referred for PH underwent a right heart catheterization, echocardiography and lung ultrasound before and after rapid infusion of 7 ml/kg of saline. A 7-point echocardiographic score based on cardiac chamber dimensions and estimates of filling pressures was implemented for the prediction of pre-capillary PH. Pulmonary congestion was identified by lung ultrasound B-lines. The study enrolled 70 patients with PAH and 77 patients with HFpEF. The PAH patients had a higher echocardiographic score (3.5±1.8 vs 1.6±1.5, p <0.001). The HFpEF patients had more B-lines both before (8.1±4.2 vs 5.1±3.0; p <0.001) and after fluid challenge (14.6±5.4 vs 7.6±3.5; p <0.001), and a more important increase (Δ) of B-lines after fluid challenge (6.5±2.9 vs 2.5±1.6; p <0.001). The sensitivity and specificity of the echocardiographic score (cut off ≥2) alone for PAH were 0.91 and 0.49 respectively [area under the curve (AUC) 0.78]. The best diagnostic improvement was observed with addition of ΔB lines + E/e' post fluid challenge to the echocardiographic score, with a significant increase of the AUC (0.98), and (with a cut-off given by the presence of: Echo score ≥ 2 and ΔB lines <4 or E/e' post < 11) a sensitivity of 0.90 (95% CI 0.83;0.97) and specificity 0.84 (95% CI 0.76;0.93)] CONCLUSION: Lung ultrasound combined with echocardiography at baseline and after fluid challenge has an incremental value for the differential diagnosis between PAH and PH-HFpEF.

Rapid home therapy infusion of velaglucerase alfa in naïve patients with Gaucher disease.

Enzyme replacement therapy (ERT) has revolutionised the management of patients with Gaucher disease (GD). In 2018, we published the safety and efficacy of rapid 10-min infusion of velaglucerase alfa in previously treated patients, mostly on low-dose therapy. To improve quality of life (QoL) for patients needing lifelong bi-weekly infusions by introducing a 10-min infusion instead of 1 h per label in patients naive to ERT and on high-dose therapy. Fifteen naive patients were enrolled; all received bi-weekly infusions of 60 units/kgBW velaglucerase alfa; the infusion rate was gradually reduced in the hospital, followed by home infusions. Each infusion was followed for safety. Efficacy parameters were assessed every 3 months. Patient-reported outcome questionnaires were collected at baseline and follow-up. Ten-minute rapid infusions were well tolerated without related severe adverse events (SAEs). Two patients experienced a non-related SAE and another a possibly related AE. In three patients, the infusion rate was increased to 30 or 60 min (two because of suboptimal response and one because of AE). Two patients dropped out because of an unwillingness to attend follow-up visits during the COVID-19 pandemic. All 13 remaining patients reached the 24-month end-point. The platelet counts increased by a median (range) of 68.38% (12.5-300%) and the lyso-Gb1 levels decreased by 62.6% (32.9-89.9%). Home therapy with rapid infusion of high-dose velaglucerase alfa was a safe, effective and preferable alternative for patients with GD naïve to treatment. We believe that shortening the infusion time improves the QoL of patients with GD who have a lifelong commitment to intravenous therapy.

Vaginal Drain to Prevent Ascending Infection in Preterm Premature Rupture of Membranes: A Novel Method.

Not to delay delivery for more than 24 hours after rupture of the membrane is the thumb rule in obstetrics. Ascending infection from the vagina results in dangerous chorioamnionitis, which threatens the lives of the baby and mother. We developed a novel method to prevent ascending infection by using a vaginal drain, which helps to continue pregnancies if the leak stops and buys some time for antenatal steroids to act if the leak doesn't stop. In this study, 20 uncomplicated singleton pregnant women with spontaneous preterm premature rupture of membranes at gestational ages <35 weeks were recruited. Under the speculum, vaginal epithelial debris and secretions were cleared by a saline wash. The tip of the Nelaton Catheter was kept in the posterior fornix and then strapped to the thigh. The outer end was connected to the collection bag system and allowed to hang down to the ground. The foot end of the cot was raised. Leaked amniotic fluid and amniotic fluid index (AFI) were measured daily. A daily AFOD estimation was done for leaked AF. Uterine activity was controlled with low-dose Isoxsuprine Hydrochloride rapid infusion tocolysis. Antenatal steroids (ANS) were given. The spread of infection was monitored by maternal pulse rate, fetal heart rate, TC, and CRP. Pregnancies were terminated when leaks didn't stop, AFI didn't raise, or mature AFOD was observed. The number of women in whom leaks stopped, the number of dayspregnancies continued, neonatal respiratory distress (NRD), birth weights, and perinatal deaths were recorded. Results: Leaks stopped in eight (40%) women. Pregnancy continuation ranged from 7 to 74 days. In 12 women, the leak did not stop, but we could buy 2-5 days' time for ANS to act. All parameters of the infection were within normal limits. Thirteen babies developed mild NRD, and we lost one baby. By using a vaginal drain for P(P)ROM, ascending infection can be prevented, leaks can be stopped in 40% of women, and can buy time for ANS to act.

A Phase II, Open-Label Study of an Accelerated Infusion Rate of Daratumumab in Patients With Relapsed and Refractory Multiple Myeloma.

Daratumumab is an anti-CD38 monoclonal antibody initially approved as a single agent for the treatment of relapsed and refractory multiple myeloma. The infusion-related reactions (IRRs) commonly seen with intravenous daratumumab have been managed by prolonging the first infusion, temporarily stopping/slowing the rate if reactions occur and using adequate pre- and post-infusion medications. Several retrospective studies have evaluated shorter infusions after ≥ 2 prior doses administered at the standard rates. Although the shorter infusions were well-tolerated, patients in these reports were given heterogeneous daratumumab regimens and had often already received multiple doses at the longer standard rates. CMRG-009 is a prospective study designed to demonstrate the safety of accelerated daratumumab infusions commencing with the second dose. After an initial dose on Cycle 1 Day consisting of 8 mg/kg over 4 hours, all subsequent doses were given over 90 minutes. No grade 3 IRRs were observed with the 90-minutes infusions. Both the safety profile and anti-myeloma effects were otherwise similar to those observed with other single agent daratumumab studies using longer infusion times. This is the first formal prospective trial using infusion times shorter than the standard schedule directly after an initial 4-hours dose. This rapid infusion protocol has resulted in more efficient resource utilization and has become the standard protocol for the use in all intravenous daratumumab regimens in Canada. This approach has been particularly helpful in shortening chair time during the COVID-19 pandemic and providing a useful alternative in jurisdictions without access to subcutaneous daratumumab.

Space-Confined Guest Synthesis to Fabricate Sn-Monodispersed N-Doped Mesoporous Host toward Anode-Free Na Batteries.

Severe issues including volume change and dendrite growth on sodium metal anodes hinder the pursuit of applicable high-energy-density sodium metal batteries. Herein, an in situ reaction approach is developed that takes metal-organic frameworks as nano-reactor and pore-former to produce a mesoporous host comprised of nitrogen-doped carbon fibers embedded with monodispersed Sn clusters (SnNCNFs). The hybrid host shows outstanding sodiophilicity that enables rapid Na infusion and ultralow Na nucleation overpotential of 2mV. Its porous structure holds a high Na content and guides uniform Na deposition. Such host provides favorable Na plating/stripping with an average Coulombic efficiency of 99.96% over 2000 cycles (at 3mA cm-2 and 3mA h cm-2 ). The Na-infused SnNCNF anode delivers extreme Na utilization of 86% in symmetric cells (at 10mA cm-2 and 10mA h cm-2 ), outstanding rate capability and cycle life in Na-SnNCNF||Na3 V2 (PO4 )3 full cells (at 1 A g-1 for over 1000 cycles with capacity retention of 92.1%). Furthermore, high-energy/power-density anode-less and anode-free Na cells are achieved. This work presents an effective heteroatom-doping approach for fabricating multifunctional porous carbon materials and developing high-performance metal batteries.

Experience with the use of Hizentra, an immunoglobulin preparation for subcutaneous administration, in patients with primary immunodeficiency diseases

Immunoglobulin replacement therapy is the gold standard of treatment for patients with antibody deficiencies. We aimed to investigate the efficacy and safety of replacement therapy with subcutaneous immunoglobulin (SCIG) Hizentra in patients with primary immunodeficiencies. This study was approved by the Independent Ethics Committee and the Academic Council of the Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology. All patients and / or their legal representatives gave informed consent for this treatment. In our study, 12 patients under 18 years of age with various forms of primary immunodeficiencies who had previously received intravenous immunoglobulin were switched to SCIG treatment to receive weekly infusions of Hizentra. Therapy SCIG was administered weekly at a dose of 0.1–0.15 g/kg by rapid push infusion. All patients received Hizentra for at least 3 months. None of the patients included in the study developed severe infections. Immunoglobulin G levels in blood after 3 months of SCIG therapy were significantly higher compared to those achieved on previous intravenous immunoglobulin therapy. There were no severe adverse events associated with Hizentra administration. Our study demonstrated Hizentra to be effective and safe for the treatment of children with various forms of primary immunodeficiencies.

Trauma Skill Stations to Improve ED Staff Confidence and Engagement

Introduction:Particular skills are critical when participating in trauma response. Engagement and practice with these skills can help build staff confidence, however, ensuring competency across all staff can prove challenging. Establishing a training utilizing skill stations can positively affect staff experience and confidence measures on predetermined dates to capture all team members is a way to ensure confidence in skills vital for patient care in ED settings. Execution of the “skill station” exercises at measured intervals demonstrated improved confidence in trauma skills by ED staff. Exercises with specific skill-oriented practicum offer low-cost, dynamic training opportunities. Improving confidence and competence in critical trauma-related clinical skills directly improves patient outcomes.Method:Six trauma skill stations were created, aimed at specific skill-based practices. These measured skill competencies include arterial line setup, rapid blood infuser use, defibrillator use, chest tube management, pelvic binder application, and tourniquet application. Competency was reached when participants could effectively perform the skills through teach-back technique.Results:Qualitative feedback demonstrated that nurses felt more confident responding to a patient needing trauma interventions in an ED setting. Nursing staff were more engaged with trauma skills in their scope. All participants were able to appropriately and adequately teach-back the skill with 100% accuracy. Improved knowledge retention will be measured in future training sessions.Pre and post-tests could be utilized to demonstrate more dynamic results. This measurement tool will be utilized in the formal training process moving forward to capture baseline and improvement data more objectively.Conclusion:This low-cost and highly efficient method of strengthening novice nurses’ trauma skills competency and confidence can be utilized across various skills and departments. More confident nurses show improved readiness to respond to a patient in need of trauma interventions.