Sidebottom, Abbey

BACKGROUND AND OBJECTIVES Some Minnesota clinicians perceive that the incidence of prophylactic vitamin K refusal is increasing, yet the actual incidence and which populations are most likely to refuse is unknown. Our objective is to identify the incidence of vitamin K refusal and to characterize the maternal-newborn dyads with increased refusal rates. METHODS This retrospective multi-institution study analyzed vitamin K refusal in newborns born from 2015 to 2019. Maternal-newborn dyad delivery and community characteristics (language, religion, population size) were collected and analyzed by univariable and multivariable logistic regression. RESULTS Among 102 451 term infants, 1.3% did not receive intramuscular vitamin K. Refusal increased from 0.9% in 2015 to 1.6% by 2019 (P < .0001). In multivariable analysis, factors associated with increased likelihood of refusal included female sex (odds ratio [OR] 1.22, 95% CI 1.09–1.36), exclusive human milk feeding at hospital discharge (OR 3.46, 95% CI 2.87–4.17), parity greater than 0 (OR ranging from 1.32 [95% CI 1.13–1.54] for parity of 1, to 3.70 [95% CI 2.80–4.90] for parity of 4), having a midwife at delivery (OR 1.70, 95% CI 1.45–2.01), public insurance (OR 1.84, 95% CI 1.60–2.12), and Russian language (OR 4.92, 95% CI 2.90–8.35). Some religious identities had higher refusal rates (ie, Pentecostal 7.0%, Baptist 3.3%). CONCLUSION In a cohort of Minnesota hospital-born infants, the incidence of vitamin K refusal increased between 2015 and 2019. We identified large populations (eg, public insurance, exclusive human milk feeding) and smaller discrete communities (eg, Russian, Pentecostal) with opportunities for increasing prophylactic vitamin K acceptance through targeted community conversations.

OBJECTIVES: Systemic thrombolysis improves outcomes in patients with pulmonary embolism (PE) but is associated with the risk of hemorrhage. The data on efficacy and safety of reduced-dose alteplase are limited. The study objective was to compare the characteristics, outcomes, and complications of patients with PE treated with full- or reduced-dose alteplase regimens. DESIGN: Multicenter retrospective observational study. SETTING: Tertiary care hospital and 15 community and academic centers of a large healthcare system. PATIENTS: Hospitalized patients with PE treated with systemic alteplase. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pre- and post-alteplase hemodynamic and respiratory variables, patient outcomes, and complications were compared. Propensity score (PS) weighting was used to adjust for imbalances of baseline characteristics between reduced- and full-dose patients. Separate analyses were performed using the unweighted and weighted cohorts. Ninety-eight patients were treated with full-dose (100 mg) and 186 with reduced-dose (50 mg) regimens. Following alteplase, significant improvements in shock index, blood pressure, heart rate, respiratory rate, and supplemental oxygen requirements were observed in both groups. Hemorrhagic complications were lower with the reduced-dose compared with the full-dose regimen (13% vs. 24.5%, p = 0.014), and most were minor. Major extracranial hemorrhage occurred in 1.1% versus 6.1%, respectively (p = 0.022). Complications were associated with supratherapeutic levels of heparin anticoagulation in 37.5% of cases and invasive procedures in 31.3% of cases. The differences in complications persisted after PS weighting (15.4% vs. 24.7%, p = 0.12 and 1.3% vs. 7.1%, p = 0.067), but did not reach statistical significance. There were no significant differences in mortality, discharge destination, ICU or hospital length of stay, or readmission after PS weighting. CONCLUSIONS: In a retrospective, PS-weighted observational study, when compared with the full-dose, reduced-dose alteplase results in similar outcomes but fewer hemorrhagic complications. Avoidance of excessive levels of anticoagulation or invasive procedures should be considered to further reduce complications.