Jewish Hospital

Phenylephrine infusion is widely endorsed by guidelines as the preferred prophylactic drug for spinal hypotension in patients undergoing caesarean delivery; however, clinical practice continues to show marked variability in the selection of vasopressor drugs. To address this, we aimed to synthesise current evidence from randomised controlled trials comparing vasopressor infusions for various feto-maternal outcomes in normotensive adult patients undergoing caesarean delivery. Randomised controlled trials evaluating maternal and fetal outcomes associated with prophylactic vasopressor infusion were identified through comprehensive database searches. Primary outcomes were the incidence of maternal hypotension and umbilical artery base excess. Secondary outcomes comprised maternal and fetal parameters including: umbilical artery and vein pH; umbilical vein base excess; Apgar scores at 1 min and 5 min; and incidence of maternal intra-operative nausea and vomiting, bradycardia, tachycardia and hypertension. Fifty-five trials involving 5487 patients undergoing caesarean delivery under spinal or combined spinal and epidural anaesthesia using a variety of vasopressor infusions were included in the final analysis. Four drugs-metaraminol, noradrenaline, phenylephrine and adrenaline-were judged to be 'definitely superior' to control (no active vasopressor infusion) for the prevention of hypotension. Umbilical vessel analyses indicated that mephentermine and metaraminol provided superior preservation of both umbilical arterial and venous acid-base balance. Current evidence suggests that continuous infusions of α-agonists with mild β-activity (e.g. noradrenaline, metaraminol) are preferable to mixed adrenergic agonists such as ephedrine for preventing maternal hypotension. While these findings reinforce existing recommendations for maternal haemodynamic management, the evidence base for fetal outcomes remains limited.

Evidence supporting prehabilitation before cardiac procedures is growing, but the efficacy of different components remains unclear. The primary aim was to assess the efficacy of prehabilitation on clinical outcomes based on recent randomized controlled trials (RCTs). The secondary aim was to identify effective intervention and which patient subgroups benefit most. We searched Medline, Web of Science, PsycINFO, Embase, Scopus, and Cochrane Central Register of Controlled Trials Library for RCTs comparing prehabilitation with standard care in cardiac patients up to August 2024. Trials were screened by 2 reviewers and meta-analyses were performed using random-effects models. Forty-four RCTs including 3,925 patients were identified. Prehabilitation improved preprocedural functional capacity (6-minute walk distance) and recovery (in-hospital length of stay, intensive care unit stay, and occurrence of postprocedural pneumonia). Six trials (n = 600) showed improved 6-minute walk distance (mean difference [MD] 68.87 m; 95% CI: 12.76-124.98 m; P = 0.020). In 18 studies (n = 1,568), length of stay was shorter (MD -0.95 days; 95% CI: -1.77 to -0.13 days; P = 0.026) and meta-regression showed greater effect in studies including more women (P = 0.015). In 16 trials (n = 1,149), intensive care unit stay was reduced (MD -6.03 hours; 95% CI: -12.01 to -0.06 hours; P = 0.048). In 5 studies (n = 729), postprocedural pneumonia occurred less frequently (OR: 0.33; 95% CI: 0.15-0.72; P = 0.017). The analysis revealed substantial heterogeneity and risk of bias. Analysis of specific components showed no consistent effects. Prehabilitation before cardiac procedures may enhance preprocedural functional capacity and postprocedural recovery, particularly in women. Further multicenter studies are needed.

High-grade astrocytoma with piloid features (HGAP) is a recently defined central nervous system (CNS) tumor, first introduced into the 2021 World Health Organization (WHO) classification. While predominantly observed in adults, pediatric cases remain rare and poorly characterized. This study aimed to review the epidemiology, clinical features, and molecular profile of pediatric HGAP. A comprehensive review of studies published from 2018 to 2025 was performed to identify methylation-confirmed HGAP cases in patients aged 18years or younger. Data extracted from studies included subject demographics, tumor location, histological features, molecular alterations, and the implemented treatment sequence. The search identified 17 pediatric cases meeting the inclusion criteria. The median age at diagnosis was 15years (range: 4-18years), and a male predilection of approximately twofold was observed. Tumors most commonly arose in the posterior fossa (56.3%). Recurrent molecular alterations included CDKN2A/B loss (75%), FGFR1 mutations or fusions (55.6%), and ATRX loss (45.5%). This review did not identify definitive clinical or histomolecular differences between pediatric and adult HGAP, underscoring the need for further comparative studies. Pediatric HGAP may represent an underrecognized diagnostic entity within the glioma spectrum, emphasizing the critical role of methylation profiling for accurate diagnosis and classification. Retrospective reclassification of histologically and molecularly ambiguous gliomas is warranted and may reveal additional cases. Larger pediatric cohorts are urgently needed to inform clinical management and refine prognostic stratification.

Abstract Background ­The use of labile, weak AmpC-inducing β-lactams (e.g., ceftriaxone (CRO), ceftazidime (CAZ), piperacillin-tazobactam (TZP)) for organisms with moderate risk of inducible AmpC production may lead to treatment failure due to AmpC overproduction. Recent guidance from the Infectious Disease Society of America and Clinical Laboratory Standards Institute state Serratia marcescens is at low risk of significant AmpC production and suggests it is reasonable to treat low-risk organisms with a labile, weak AmpC-inducing β-lactam. Prior to October 2023, S. marcescens isolates were reported as resistant to CRO, CAZ and TZP at our institution; these susceptibilities are now reported as tested.Figure 1.Inclusion-Exclusion FlowchartTable 1.Baseline Characteristics Methods This study evaluated safety, effectiveness, and antibiotic utilization before and after this change in susceptibility reporting. The primary outcome was AmpC stable β-lactam (cefepime or carbapenem) inpatient days of therapy (DOT). This pre-test (October 2022–September 2023), post-test (October 2023–September 2024) quasi-experiment included inpatients at Barnes-Jewish and St. Louis Children’s Hospitals with first-positive S. marcescens culture and at least 48 hours of antibiotic therapy. Exclusions included concomitant Gram-negative infections resistant to CRO, CAZ, or TZP, ocular cultures, and death prior to susceptibility results.Table 2.Days of Gram-Negative Antimicrobial TherapyTable 3.Clinical and Microbiological Outcomes Results A total of 268 patients were screened and 166 patients were included (Figure 1). Baseline characteristics including age, ICU status, immunocompromised status, and no or incomplete source control were well balanced between groups (Table 1). The most common infection source was pneumonia (30%). The median total DOT for AmpC stable β-lactams was 8 in the pre-group vs 5 in the post-group (P < 0.001) (Table 2). In patients treated with ≥ 3 days of AmpC labile β-lactams who had repeat cultures, there was no emergence of resistance (0/26). No statistically significant differences in clinical outcomes were observed (Table 3). Conclusion In conclusion, a change in susceptibility reporting for S. marcescens was associated with a decrease in AmpC stable β-lactam use, with no significant changes in microbiological or clinical outcomes. Disclosures Christine R. Lockowitz, PharmD, BCIDP, AbbVie: Grant/Research Support|Premier Inc.: Honoraria Tamara Krekel, PharmD, BCPS, BCIDP, AbbVie: Advisor/Consultant|AbbVie: Honoraria|Shionogi: Advisor/Consultant|Shionogi: Honoraria David J. Ritchie, PharmD, BCPS (AQ-ID), Shionogi: Honoraria Rebekah Dumm, PhD D(ABMM), BD: Advisor/Consultant|BD: Grant/Research Support|Biomerieux: Advisor/Consultant|Biomerieux: Grant/Research Support|Diasorin: Grant/Research Support|Pattern Biosciences: Grant/Research Support|Qiagen: Grant/Research Support|Roche Diagnostics: Advisor/Consultant|Shionogi: Advisor/Consultant

Introduction: Post-traumatic and post-surgical ulnar nerve neuropathies at the elbow and wrist remain challenging conditions often associated with significant sensory and motor impairment. Traditional approaches such as neurolysis alone may be insufficient, especially in complex or recurrent cases. Adipofascial flaps have shown promising outcomes in peripheral nerve surgery. The aim of this study was to evaluate the outcomes of 13 patients with severe ulnar neuropathies who were treated with a size- and shape-personalized adipofascial flap for nerve coverage. Materials and Methods: We retrospectively analyzed 13 patients treated between May 2020 and May 2024 for severe post-traumatic or post-surgical ulnar neuropathies. All underwent surgical decompression, external neurolysis, and adipofascial flap coverage. Pre- and postoperative outcomes were assessed with clinical and neurological evaluations and using the QuickDASH and NRS pain scores. Discussion: All patients showed improvement in pain and sensory-motor function, including those with complications, supporting the role of flap coverage in neuroprotection. This is the first study to describe the use of adipofascial flaps for pseudo-palsy and painful neuroma-in-continuity of the ulnar nerve at the elbow and wrist level. Conclusions: Adipofascial flaps represent a safe, technically feasible, and effective option in complex ulnar nerve injuries, providing both mechanical and biological support. Despite the small cohort, the results suggest strong clinical potential across varied injury patterns.