Probability of pregnancy before ninety days postpartum in water buffaloes

This study aimed to determine the effect of parity and season of calving on the probability of water buffalo cows becoming pregnant before 90 days postpartum. A retrospective analysis of reproductive records of 1,465 water buffaloes with 3,181 pregnancies was carried out. Buffaloes were grouped according to parity in one, two, or three and more calvings. Season of calving was created with the following values: long photoperiod (March-August) and short photoperiod (September-February) and predicted probabilities from the mixed-effects logistic regression model were calculated, and a generalized linear mixed model was fitted with random intercepts to calculate the log odds of becoming pregnant ≤90 days postpartum. The probability of pregnancy ≤90 days postpartum was 0.3645, and this was lower in primiparous (0.2717) in comparison with two-calved (0.3863) and three or more calving buffaloes (0.5166). Probability of pregnancy ≤90 days postpartum increased 1.77 odds by each increase in parity. The probability of becoming pregnant ≤90 days postpartum was higher in water buffaloes calving during the short photoperiod season (0.4239 vs. 0.2474, P>0.000), and water buffaloes calving during the long photoperiod season only had 0.2645 odds to become pregnant than those calving during the short photoperiod season. The negative effect of long photoperiod was observed indifferently of parity. In conclusion, primiparity and the long photoperiod affect water buffalo cow's reproductive performance, decreasing pregnancy probability during the first 90 days postpartum.

Driving Restrictions and Early Arrhythmias in Patients Receiving a Secondary Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD-II study)

Background: Regulatory authorities of most industrialized countries recommend 6-months of private driving restriction after implantation of a secondary prevention ICD. These driving restrictions result in significant inconvenience and social implications. The purpose of this study was to assess the incidence rate of appropriate device therapies in contemporary recipients of a secondary prevention ICD. Methods: A retrospective study at three Canadian tertiary care centers enrolling consecutive patients with new secondary prevention ICD implants between 2016-2020. Results: 721 patients were followed for a median of 760 days (324, 1190). The risk of recurrent ventricular arrhythmia was highest during the first three months after device insertion (34.4%), and decreased over time (10.6% between 3−6 months, 11.7% between 6-12 months). The corresponding incidence rate per 100 patient-days was 0.48 (95% CI 0.35-0.64) at 90 days, 0.28 (95% CI 0.18−0.48) at 180 days and 0.20 (95% CI 0.13−0.31) between 181-365 days after ICD insertion (p<0.001). The cumulative incidence of arrhythmic syncope resulting in sudden cardiac incapacitation was 1.8% within the first 90 days and subsequently dropped to 0.4% between 91-180 days (p<0.001) after ICD insertion. Conclusions: The incidence rate of appropriate therapies resulting in sudden cardiac incapacitation in contemporary recipients of a secondary prevention ICD is much lower than previously reported, and significantly declines after the first three months. Lowering driving restrictions to three months after the index cardiac event seems safe and revision of existing guidelines recommending should be considered in countries still adhering to a 6-months period. Existing restrictions for private driving after implantation of a secondary prevention ICD should be reconsidered.

Pulmonary Embolism in Patients with COVID-19: Comparison between Different Care Settings

The clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) who develop pulmonary embolism (PE) in the full spectrum of patient care settings need to be elucidated. The aim of this study was to compare the clinical characteristics, treatment, and 90-day outcomes in patients diagnosed with PE while recovering from COVID-19 in the outpatient setting versus those who were diagnosed with PE while being hospitalized with COVID-19. Data from the international Registro Informatizado de Enfermedad TromboEmbólica (RIETE) registry were used. The major study outcomes were all-cause death, major bleeding, and venous thromboembolism (VTE) recurrences during the first 90 days after PE. From March 2020 to March 2021, 737 patients with COVID-19 experienced acute PE. Of these, 340 (46%) were recovering from COVID-19 as outpatients (267 patients who had been treated at home for COVID-19 and 73 discharged after being hospitalized with COVID-19). Compared with inpatients with COVID-19, those recovering in the outpatient setting upon PE were less likely to be men (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.40–0.72) and less likely to have hypertension (OR: 0.55; 95% CI: 0.41–0.74) or diabetes (OR: 0.51; 95% CI: 0.33–0.76). At 90-day follow-up, eight patients (none recovering from COVID-19 as outpatient vs. 2.4% of inpatients with COVID-19) developed recurrent VTE, 34 (1.9 vs. 7.9%) had major bleeding, and 128 (10 vs. 24%) died. On multivariable analysis, inpatients with COVID-19 were at a higher risk of major bleeding (adjusted hazard ratio [HR]: 6.80; 95% CI: 1.52–30.4) or death (adjusted HR: 2.24; 95% CI: 1.40–3.58). In conclusion, using a large multinational registry of patients with COVID-19 who experienced PE, thromboembolic episodes occurring in those recovering from COVID-19 as outpatients were associated with less ominous outcomes than inpatients with COVID-19.

Impact of Prenatal SARS-CoV-2 Infection on Infant Emergency Department Visits and Hospitalization

To better understand the impact of prenatal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on infants, this study sought to compare the risk of hospital visits and of postnatal SARS-CoV-2 infection between infants born to mothers with and without prenatal SARS-CoV-2 infection. In this retrospective observational cohort study of 6871 mothers and their infants, overall rates of emergency department (ED) visits and hospital admissions in the first 90 days of life were similar for infants born to mothers with and without prenatal SARS-CoV-2 infection. Infants born to negative mothers were more likely than infants of positive mothers to be hospitalized after ED visit (relative risk: 3.76; 95% confidence interval: 1.27-11.13, P = .003). Five infants tested positive; all were born to negative mothers, suggesting that maternal prenatal SARS-CoV-2 infection may protect infants from postnatal infection. The lower acuity ED visits for infants born to mothers with prenatal SARS-CoV-2 infection may reflect a heightened level of concern among these mothers.

Epidural analgesia is associated with earlier gastrointestinal transit after radical cystectomy but does not reduce the incidence of postoperative ileus: A retrospective cohort study

Objective: To compare the effect of combined epidural thoracic analgesia and general anaesthesia (CEGA) in radical cystectomy (RC) with respect to the return of gastrointestinal passage, the incidence of paralytic postoperative ileus (POI) compared to general anaesthesia (GA) only. Patients and methods: We conducted a retrospective review using the electronic medical records of 236 patients who underwent RCs between July 2011 and September 2018 at the Medical Center – University of Freiburg. Results: A CEGA was administered to 202 patients, while 34 patients received only GA. The baseline characteristics of patients with and without CEGA showed no significant differences. CEGA will decrease the time required for return of gastrointestinal transit as measured by time to first defecation by about 13 hours. In the first 90 days after surgery, 82 (34.7%) patients had a POI. There was no significant difference between complications in the CEGA and GA groups. Conclusion: A CEGA accelerates the return of the gastrointestinal transit but does not reduce the incidence of postoperative ileus. Level of evidence: 2b

Clinical and Economic Burden of Tumor Lysis Syndrome Among Patients with Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Introduction: Tumor lysis syndrome (TLS) can be a life-threatening complication in patients with hematologic malignancies. In chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL), treatment guidelines identify a high risk of TLS for regimens containing anti-CD20-based chemoimmunotherapy (CIT), lenalidomide, obinutuzumab, or venetoclax. Patients who develop TLS require intensive care, adding to the overall clinical and economic burden of CLL/SLL. This study aimed to evaluate the clinical and economic burden of treatment-emergent TLS among patients with CLL/SLL treated with regimens with high risk of TLS. Methods: The IBM MarketScan Research Databases (01/01/2006-04/30/2020) were used to identify adults with CLL/SLL who initiated a CIT-, lenalidomide-, obinutuzumab-, or venetoclax-based regimen on or after 01/01/2007 or upon treatment approval date if post-2007 (index date) and had ≥12 months and ≥30 days of continuous eligibility pre- and post-index date, respectively. Treatment-emergent TLS was defined as developing TLS in the first 90 days of active treatment (based on claims with a TLS diagnosis or laboratory test results). The post-index period was divided into 30-day intervals until the end of the index regimen (earliest of start of next regimen or end of eligibility). Intervals pre-TLS were non-TLS intervals and all intervals starting from the TLS diagnosis were TLS intervals. If TLS occurred after the first 90 days of active treatment (non-treatment-emergent TLS), all intervals were non-TLS intervals and the post-index period was censored at TLS diagnosis. Per-patient-per-month (PPPM) healthcare resource utilization (HRU) and payer paid costs during TLS and non-TLS intervals were compared using rate ratios (RRs) and mean monthly cost differences (MMCDs), respectively, obtained from generalized linear models adjusted for baseline and time-varying confounders. The proportion of patients switching to a next therapy in the first 90 days post-index was compared between patients developing versus not developing TLS using Kaplan-Meier rates with log-rank P-value. Results: Among 6,343 patients with CLL/SLL, 71 (1.1%, mean age: 66.4 years, 26.8% females; 22 treated with venetoclax; mean [median] duration of the entire index regimen: 16.0 [10.0] months) developed TLS during the first 90 days of active treatment and 6,272 (98.9%, mean age: 65.9 years, 34.1% female; 170 treated with venetoclax; mean [median] duration of the entire index regimen: 22.0 [14.5] months) did not. Among all 6,343 patients, there were 1,129 TLS intervals and 138,429 non-TLS intervals observed post-index. All patients incurred considerable cumulative costs over the entire index regimen duration (TLS cohort: $201,200; non-TLS cohort: $158,590). Developing TLS was associated with 1.7 times more inpatient (IP) admissions (P&lt;0.001; Fig. 1a), 2.0 times more days of IP stay (P=0.012), 22% fewer days of antineoplastic drug administration (P=0.020; Fig. 1a), and $3,062 PPPM higher healthcare costs (P=0.016), driven by significantly higher IP costs PPPM (MMCD=$1,688; P=0.044; Fig. 1b) vs. not developing TLS. Higher costs during TLS intervals were observed for patients initiated on a venetoclax-based regimen (TLS intervals: $24,170 PPPM; non-TLS intervals: $20,091 PPPM) and patients initiated on a non-venetoclax-based regimen (TLS intervals: $8,746 PPPM; non-TLS intervals: $6,915 PPPM). In the first 90 days post-index, HRU and costs were higher than when averaged over the entire duration of the index regimen, regardless of developing TLS or not (Table 1). Among patients not developing TLS, those treated with a venetoclax-based regimen had numerically higher cumulative TLS prevention costs during the first 90 days post-index ($4,398) than those treated with a non-venetoclax-based regimen ($2,879). Patients developing TLS switched more quickly to a next line of therapy in the first 90 days of treatment compared to those not developing TLS (12.6% vs. 5.1%, P=0.006; Table 2). Conclusions: In this study of CLL/SLL patients treated with CIT-, lenalidomide-, obinutuzumab-, or venetoclax-based regimens, TLS led to a significant HRU and cost burden (mostly driven by IP admissions) and a higher rate of treatment switching. Consideration of available treatment options based on patient goals and treatment expectations is warranted before selecting a treatment with a high risk of developing TLS. Figure 1 Figure 1. Disclosures Rogers: AstraZeneca: Consultancy; Genentech: Consultancy, Research Funding; Innate Pharma: Consultancy; Pharmacyclics LLC: Consultancy; Janssen Pharmaceuticals, Inc: Research Funding; Acerta Pharma: Consultancy; AbbVie Inc.: Consultancy, Research Funding; ovartis Pharmaceuticals Corporation: Research Funding. Emond: GlaxoSmithKline: Consultancy; Janssen: Consultancy; Novartis: Consultancy; Pfizer: Consultancy; Pharmacyclics LLC, an AbbVie Company: Consultancy. Côté-Sergent: GlaxoSmithKline: Consultancy; Janssen: Consultancy. Kinkead: Janssen: Consultancy; Otsuka: Consultancy. Lafeuille: Pharmacyclics: Consultancy; Janssen Scientific Affairs, LLC: Consultancy; Pfizer: Consultancy; GlaxoSmithKline: Consultancy. Lefebvre: Pfizer: Consultancy; Pharmacyclics: Consultancy; Otsuka: Consultancy; Janssen Scientific Affairs, LLC: Consultancy; GlaxoSmithKline: Consultancy; Novartis: Consultancy; Regeneron: Consultancy. Huang: Johnson & Johnson: Current equity holder in publicly-traded company; Janssen Scientific Affairs, LLC: Current Employment.

8. Sepsis-Associated Acute Kidney Injury and Acute Kidney Disease: A 15-Year Cohort Study of 4,226 Adult Sepsis Inpatient Survivors at a Tertiary Medical Center in Taiwan

Background Sepsis is the most common cause of acute kidney injury (AKI) and about one-third of patients with sepsis-associated AKI (SA-AKI) develop acute kidney diseases (SA-AKD) and may progress to unfavorable outcomes. We aimed to study the characteristics and outcomes associated with SA-AKI and SA-AKD. Methods This cohort study included adult inpatients with first-time sepsis who were admitted during 2003-2017, had qualifying serum creatinine (SCr) measurements at baseline (-365 to -3 days), -2 to +7 days, and +8 to +90 days of sepsis index day, and survived the first 90 days (Figure 1). Sepsis was identified using an electronic medical records-based Sepsis-3 criteria. We classified sepsis inpatients into SA-AKI(-), SA-AKD(-), SA-relapsed-AKD, and SA-nonrecovery-AKD (Figure 2). ESRD and mortality were ascertained by linking to the Catastrophic Illness records and to National Death Registry, respectively. Multivariable Cox proportional hazard model was used to evaluate the risk of mortality and end-stage renal disease (ESRD) associated with SA-AKI/AKD subtypes. Figure 1. Flowchart of the selection process of adult sepsis survivors (N = 4226 patients). Figure 2. Definitions of sepsis associated-acute kidney injury (SA-AKI) and sepsis associated-acute kidney disease (SA-AKD). Results Of 4,226 eligible sepsis inpatient survivors, 47.1% developed SA-AKI and 10.1% progressed to SA-AKD (5.4% relapsed and 4.7% nonrecovery). Patient with AKI and non-recovered AKD had the worst baseline renal function (SCr, 1.3 mg/dL) (Table 1). The multivariable analyses revealed that SA-relapsed AKD was significantly associated with increased risk of all-cause mortality for 1-year (aHR 1.67; 95% CI 1.25, 2.24), 3-year (aHR 1.38; 95% CI 1.11, 1.71), and overall (aHR 1.35; 95% CI 1.12, 1.61), compared with SA-AKI(-). SA-relapsed AKD and SA-nonrecovery AKD were both significantly associated with 1-year, 3-year, and overall ESRD, with the risk of about 4-fold or higher than SA-AKI(-) (Table 2). Table 1. Baseline characteristics and outcomes among adult sepsis survivors, by different SA-AKI/AKD subtypes. Table 2. Risk of all-cause mortality and end stage renal disease (ESRD) among adult sepsis survivors. Conclusion Sepsis survivors who initially had AKI and developed relapsed or nonrecovery AKD tended to have worse outcomes of all-cause and ESRD, compared with those without AKI. Unexpectedly, patients with non-recovered AKD did not have a higher mortality risk, possibly because we have selected those who survived the first 90 days of sepsis. We will develop two-stage prediction models to identify sepsis patients at risk of developing AKI and SA-AKI patients at risk of developing different types of AKD. Disclosures All Authors: No reported disclosures

The impact of war on the health system of the Tigray region in Ethiopia: an assessment

The war in Tigray region of Ethiopia that started in November 2020 and is still ongoing has brought enormous damage to the health system. This analysis provides an assessment of the health system before and during the war. Evidence of damage was compiled from November 2020 to June 2021 from various reports by the interim government of Tigray, and also by international non-governmental organisations. Comparison was made with data from the prewar calendar year. Six months into the war, only 30% of hospitals, 17% of health centres, 11.5% of ambulances and none of the 712 health posts were functional. As of June 2021, the population in need of emergency food assistance in Tigray increased from less than one million to over 5.2 million. While the prewar performance of antenatal care, supervised delivery, postnatal care and children vaccination was 64%, 73%, 63% and 73%, respectively, but none of the services were likely to be delivered in the first 90 days of the war. A conservative estimate places the number of girls and women raped in the first 5 months of the war to be 10 000. These data indicate a widespread destruction of livelihoods and a collapse of the healthcare system. The use of hunger and rape as a weapon of war and the targeting of healthcare facilities are key components of the war. To avert worsening conditions, an immediate intervention is needed to deliver food and supplies and rehabilitate the healthcare delivery system and infrastructure.