Publications by authors named "M Boller"

107 Publications

Fetomaternal hemorrhage: evaluation of recurrence within a large integrated healthcare system.

Am J Obstet Gynecol 2021 May 4. Epub 2021 May 4.

Department of Pathology, Kaiser Permanente Oakland Medical Center, Oakland, CA.

Background: Fetomaternal hemorrhage is associated with severe fetal morbidity and mortality. The recurrence risk of fetomaternal hemorrhage is unknown.

Objective: We sought to establish the recurrence rate of fetomaternal hemorrhage in a large integrated healthcare system over a 10-year period.

Study Design: In this retrospective study within the Kaiser Permanente Northern California medical system, cases of fetomaternal hemorrhage were defined by either an elevated fetal hemoglobin level as determined by flow cytometry for a concerning pregnancy outcome (preterm delivery, perinatal demise, neonatal anemia, or transfusion within the first 2 days of life) or by perinatal demise with autopsy findings suggestive of fetomaternal hemorrhage. The outcomes of subsequent pregnancies were reviewed for features of recurrence.

Results: Within the 2008 to 2018 birth cohort of 375,864 pregnancies, flow cytometry testing for fetal hemoglobin levels was performed in 20,582 pregnancies. We identified 340 cases of fetomaternal hemorrhage (approximately 1 in 1100 births). Within the cohort of 340 affected pregnancies, perinatal loss was recorded for 80 (23.5%) pregnancies and 50 (14.7%) pregnancies delivered neonates who required transfusion. The affected patients had 225 subsequent pregnancies of which 210 were included in the analysis. Of these, 174 (82.9%) advanced beyond the threshold of viability and were delivered within our healthcare system. There was 1 case of recurrent fetomaternal hemorrhage identified. The recurrent case involved a spontaneous preterm delivery of an infant who was noted to have an elevated reticulocyte count but was clinically well.

Conclusion: Within our large integrated healthcare system, approximately 1 in 1100 pregnancies was affected by fetomaternal hemorrhage within a 10-year period, which is comparable with previous studies. We identified 1 case of recurrence, yielding a recurrence rate of 0.5%. This infant did not have features of clinically important fetomaternal hemorrhage. This information can inform counseling of patients with affected pregnancies.
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http://dx.doi.org/10.1016/j.ajog.2021.04.257DOI Listing
May 2021

Pet health insurance reduces the likelihood of pre-surgical euthanasia of dogs with gastric dilatation-volvulus in the emergency room of an Australian referral hospital.

N Z Vet J 2021 May 25:1-7. Epub 2021 May 25.

Department of Veterinary Clinical Sciences, Melbourne Veterinary School, University of Melbourne, Werribee, Australia.

Aims: To determine the association between the presence of pet health insurance and the risk of euthanasia at the time of diagnosis for dogs with gastric dilatation-volvulus (GDV).

Methods: Insurance status at the time of GDV diagnosis was sought for a cohort of 147 non-referred, confirmed cases of GDV that presented to the emergency department of a university-based veterinary hospital in Australia between 2008 and 2017. Insurance status was obtained from the medical record (n=18) or after contacting the owners by phone using a standardised questionnaire (n=129). Animal, clinical and outcome data was retrospectively compiled in a research database. The primary outcome measure was whether or not the dog was euthanised before surgery. The Mantel-Haenszel procedure was used to quantify the association between the presence of pet health insurance and the risk of euthanasia at the time of diagnosis for dogs with GDV, adjusting for the confounding effect of age at the time of presentation using Bayesian methods.

Results: Of the 69 dogs for which insurance information could be obtained, 10 (14%) cases were insured at the time of the GDV event and 59 (86%) cases were not. The majority of non-insured dogs (37/59; 63 (95% CI=50-74)%) were euthanised before surgery, while none (0 (95% CI=0-28)%) of the insured dogs were euthanised at that time (p<0.001). Of the 32 insured and non-insured dogs that underwent surgery, four dogs (13 (95% CI=5-28)%) did not survive to hospital discharge. Three dogs (9%) were euthanised during or after surgery and one dog (3%) experienced cardiopulmonary arrest during treatment. The majority of dogs for which insurance status was known did not survive to hospital discharge (41/69; 59%), and 90 (95% CI=7-96)% of deaths were caused by euthanasia prior to surgery. Uninsured dogs were 5.0 (95% credible interval=1.8-26) times more likely to undergo presurgical euthanasia compared with insured dogs.

Conclusions: Euthanasia prior to treatment was most common cause of death in non-referred dogs with GDV; such euthanasia was entirely absent in the cohort of dogs that were insured.

Clinical Relevance: Financial considerations significantly contribute to mortality of dogs with GDV presented to an emergency room. Financial instruments to reduce the out-of-pocket expense for pet owners confronted with unexpected veterinary expenses have potential to reduce pet mortality.
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http://dx.doi.org/10.1080/00480169.2021.1920512DOI Listing
May 2021

Fluid Therapy During Cardiopulmonary Resuscitation.

Front Vet Sci 2020 28;7:625361. Epub 2021 Jan 28.

Faculty of Veterinary and Agricultural Sciences, Melbourne Veterinary School, University of Melbourne, Werribee, VIC, Australia.

Cardiopulmonary arrest (CPA), the acute cessation of blood flow and ventilation, is fatal if left untreated. Cardiopulmonary resuscitation (CPR) is targeted at restoring oxygen delivery to tissues to mitigate ischemic injury and to provide energy substrate to the tissues in order to achieve return of spontaneous circulation (ROSC). In addition to basic life support (BLS), targeted at replacing the mechanical aspects of circulation and ventilation, adjunctive advanced life support (ALS) interventions, such as intravenous fluid therapy, can improve the likelihood of ROSC depending on the specific characteristics of the patient. In hypovolemic patients with CPA, intravenous fluid boluses to improve preload and cardiac output are likely beneficial, and the use of hypertonic saline may confer additional neuroprotective effects. However, in euvolemic patients, isotonic or hypertonic crystalloid boluses may be detrimental due to decreased tissue blood flow caused by compromised tissue perfusion pressures. Synthetic colloids have not been shown to be beneficial in patients in CPA, and given their documented potential for harm, they are not recommended. Patients with documented electrolyte abnormalities such as hypokalemia or hyperkalemia benefit from therapy targeted at those disturbances, and patients with CPA induced by lipid soluble toxins may benefit from intravenous lipid emulsion therapy. Patients with prolonged CPA that have developed significant acidemia may benefit from intravenous buffer therapy, but patients with acute CPA may be harmed by buffers. In general, ALS fluid therapies should be used only if specific indications are present in the individual patient.
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http://dx.doi.org/10.3389/fvets.2020.625361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876065PMC
January 2021

The Effect of Pet Insurance on Presurgical Euthanasia of Dogs With Gastric Dilatation-Volvulus: A Novel Approach to Quantifying Economic Euthanasia in Veterinary Emergency Medicine.

Front Vet Sci 2020 8;7:590615. Epub 2020 Dec 8.

Faculty of Veterinary and Agricultural Sciences, Melbourne Veterinary School, University of Melbourne, Werribee, VIC, Australia.

Euthanasia of companion animals in veterinary emergency medicine is a common cause of death. Euthanasia is economic when it is the consequence of the pet owner's inability to afford essential treatment while a viable medical alternative to euthanasia exists. Gastric dilatation-volvulus (GDV) is an acute life-threatening emergency condition of dogs; if left untreated, rapid death is highly likely. Surgical treatment leads to survival of around 80-90% of dogs; however, such treatment is costly. Therefore, pre-surgical euthanasia may be largely economically motivated. Having pet insurance, a financial instrument to reduce the burden of unforeseen veterinary medical costs on pet owners, would be expected to abolish the risk for pre-surgical economic euthanasia. We therefore aimed to determine whether pet insurance attenuates the risk of pre-surgical economic euthanasia in dogs with GDV. Non-referred dogs ( = 260) with GDV and known insurance status seen at 24 emergency clinics over a 2-year period were included. Relevant data (e.g., insurance status, age, comorbidities, outcome) were retrospectively extracted from a pet insurer's claim records (insured animals) or from electronic medical records of participating hospitals (non-insured animals). Forty-one percent of dogs (106 of 260 dogs) did not survive to hospital discharge; 82 (77%) of non-survivors died before surgery, all through euthanasia. The pre-surgical euthanasia rate was 10% in insured and 37% in non-insured dogs ( < 0.001). When adjusted for the effect of age, deposit size, comorbidities, and blood lactate concentration, the absence of insurance increased the odds of pre-surgical euthanasia by a factor of 7.4 (95% CI 2.0 to 37; = 0.002). Of dogs undergoing surgery, 86% survived to hospital discharge. Overall, 80% of insured animals and 53% of non-insured animals survived to hospital discharge ( < 0.001). Thus, insurance was associated with a marked decrease in risk of pre-surgical euthanasia indicating that the cause of pre-surgical euthanasia of dogs with GDV is predominantly economic in nature. The rate of pre-surgical euthanasia in dogs with GDV may emerge as a suitable marker to quantify economic decision making of pet owners and to measure the impact of financial interventions aimed at mitigating economic duress associated with cost of veterinary emergency care.
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http://dx.doi.org/10.3389/fvets.2020.590615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752994PMC
December 2020

[Small animal cardiopulmonary -resuscitation (CPR) in general practice].

Schweiz Arch Tierheilkd 2020 12;162(12):735-753

Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, Victoria 3030, Australia.

Introduction: Cardiopulmonary arrest (CPA) is the acute cessation of systemic perfusion and ventilation. It leads to a lack of tissue oxygen delivery and, if not addressed quickly, will inevitably cause death. Cardiopulmonary resuscitation (CPR) is the only available treatment for CPA and several opportunities exist to improve the veterinary team's resuscitation approach and optimize small animal CPR patient outcomes. In 2012, the Reassessment Campaign on Veterinary Resuscitation (RECOVER) initiative generated evidence-based clinical guidelines to form the basis for training and practice of CPR in dogs and cats. When employing an evidence-based, standardized approach to small animal CPR, return of spontaneous circulation can be achieved in up to 58% of patients and up to 7% of dogs and 19% of cats can be discharged from the veterinary hospital alive. Survival for dogs and cats that suffer CPA is best in patients that suffer a peri-anesthetic arrest, so high quality CPR in the anesthesia patient population is of utmost importance and expected to be the most rewarding. To ensure the best possible outcomes for any patient suffering from CPA and undergoing CPR, a comprehensive resuscitation strategy is necessary, that includes preventive and preparedness measures, basic life support (chest compressions and ventilation), advanced life support (optimization of the patient status by targeted drug therapy, cardiac rhythm monitoring, and defibrillation), and post-cardiac arrest critical care. This article summarizes the most important RECOVER CPR guidelines for the small animal practitioner.
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http://dx.doi.org/10.17236/sat00280DOI Listing
December 2020