False-positive Results In Patients Research Articles

Analysis of false-positive biopsy results of PIRADS 4 lesions in multiparametric magnetic resonance imaging of the prostate: Experience from a single nonacademic center using cognitive fusion.

321 Background: Multiparametric magnetic resonance imaging (mpMRI) of the prostate has been increasingly used in the algorithm of the initial diagnosis of patients suspected to harbor prostate cancer (PCa) with the aim of improving the selection of patients who really need a biopsy. Yet patients with PI-RADS 5 lesions almost always have cancer found in their prostates, the same is not true for patients with PI-RADS 4. In this study we sought to describe pathological findings in target biopsies of PI-RADS4, and to identify clinical data that could predict those patients with benign findings. Methods: A retrospective study was conducted in a data bank collected prospectively from December 2015 through April 2022 in a single nonacademic center. The whole series consist of 547 patients, all of whom had a mpMRI of the prostate (reports as per PI-RADS version 2) followed by cognitive fusion prostate biopsy performed by a single, experienced radiologist. All biopsy specimens were read by a specialist in urological pathology. Out of these, 259 had PI-RADS 4 lesion, and 83 had PI-RADS 5. Results: We found a false positive rate of 29% and 3.7% for any cancer in PI-RADS 4 and 5 lesions, respectively. Different histologic patterns were observed among target biopsies. At multivariate analysis, PIRADS lesion ≤ 6 mm and previous negative biopsy were independent predictors of false positive PI-RADS4 lesions. The 76 cases showed normal histology (n = 22), a combination of chronic inflammation, reactive epithelium, and glandular atrophy (n = 18), glandular atrophy (n = 9), stromal proliferation consistent with nodular hyperplasia (n =7), a combination of chronic inflammation, reactive epithelium and glandular atrophy (n = 6), chronic inflammation (n = 4) and HGPIN (n = 10). The small number (n=3) of false PI-RADS5 lesions precluded further analyses. Conclusions: Benign findings are common in PI-RADS4 lesions and most of them did not show obvious glandular or stromal hypercellularity as expected in hyperplastic nodules. Size ≤ 6 mm and previous negative biopsy predict higher probability of false positive results in patients with PI-RADS 4 lesions.[Table: see text]

Analysis of false positive PI-RADS 4 lesions: experience from a single nonacademic center using cognitive fusion.

We evaluated pathological findings in targeted biopsies of PI-RADS4 and PI-RADS5 lesions, and clinical data that could predict those patients with benign findings. A retrospective study was conducted to summarize the experience from a single nonacademic center using cognitive fusion and a 1.5 or 3.0 Tesla scanner. We found a false positive rate of 29 and 3.7% for any cancer in PI-RADS 4 and 5 lesions, respectively. Diverse histologic patterns were observed among target biopsies. At multivariate analysis, size ≤ 6mm and previous negative biopsy were independent predictors of false positive PI-RADS4 lesions. The small number of false PI-RADS5 lesions precluded further analyses. Benign findings are common in PI-RADS4 lesions and most of them do not show obvious glandular or stromal hypercellularity as expected in hyperplastic nodules. Size ≤ 6mm and previous negative biopsy predict a higher probability of false positive results in patients with PI-RADS 4 lesions.

Interim results of the PML-16, PML-19 protocols for primary mediastinal large B-cell lymphoma therapy

Introduction. Primary mediastinal lymphoma (PML) is an aggressive lymphoid tumor treatment success of which is determined by induction therapy. To date, none of the standard chemotherapy regimens (CT) have demonstrated an advantage in efficacy. Intensive therapy programs are associated with high toxicity.Aim — to evaluate the efficacy and toxicity of two pilot prospective treatment protocols PML-16 and PML-19 as well as the possibility of using the analysis of freely circulating tumor DNA (ctDNA) to assess MRD in patients with PML.Materials and methods. From January 2016 to January 2022, 34 previously untreated PML patients were included in the study; average age — 32; stage > I — in 60 %; extramediastinal lesions — in 14.7 %; bulky disease — in 73.5 % of patients. Positron emission tomography combined with computed tomography (PET-CT) was performed; ctDNA was determined to assess the completeness of remission.Results. Eighteen patients received treatment according to the PML-16 protocol (6 courses of chemotherapy; 2 blocks of RmNHL-BFM-90 + 4 courses of R-EPOCH). After the end of therapy, all 18 patients achieved PET-negative remission. The next 16 patients received treatment according to the PML-19 protocol (4 courses of chemotherapy; 2 blocks of R-mNHL-BFM-90 + 2 courses of R-EPOCH) in combination with lenalidomide. After the end of therapy, 9 (56 %) patients achieved PET-negative remission; 7 (44 %) retained pathological activity (D4–5 points). After 3 and 6 months 15 (94 %) patients achieved normalization of metabolic activity. Considering the high frequency of false-positive results in patients with PML, a ctDNA study was performed to determine the depth of remission in 15 patients. After the end of therapy, all 15 patients had complete elimination of ctDNA. Of these, 5 (33 %) remained PET-positive at the end of treatment. During further observation, after 3–6 months, in 4 patients the level of metabolic activity decreased to physiological without the use of consolidating therapy. After the end of therapy, one patient suffered the new coronavirus infection, COVID-19. A month later, residual formation of SUVmax 14.2 remained in the mediastinum. The patient is currently under observation. With a median follow-up of 36 months (9 to 76 months) all 34 patients are in remission.Conclusion. The effectiveness of PML-16 made it possible to abandon the consolidation therapy and refuted the idea of the need for 6 courses of CT. The combination of programs based on the application of the principle of high-dose shortpulse induction of remission (R-mNHL-BFM-90) in combination with the prolonged administration of medium doses (R-EPOCH) was crucial in achieving a successful result. The inclusion of lenalidomide in the “PML-19” program made it possible to achieve complete remission in 100 % of cases after 4 courses. The possibility of using DNA analysis to assess MRD in patients with PML was shown.

1117-P: High Rate of Histologically Proven NASH and Advanced Fibrosis in Outpatients with Type 2 Diabetes Screened for NAFLD

In patients with type 2 diabetes (T2D) , studies on nonalcoholic steatohepatitis (NASH) and hepatic fibrosis have been hindered by the constraints of histopathological diagnosis. We assessed the prevalence of, and features associated with, histologically proven NASH and fibrosis in a large group of T2D patients routinely screened for nonalcoholic fatty liver disease (NAFLD) .T2D outpatients with suspected NAFLD at their annual workup (based on ultrasound and liver function test results) were prospectively referred to an hepatologist. Patients with persistently elevated ALT (> 20 IU/L in females or > 30 IU/L in males) and no other causes for liver disease were proposed liver biopsy. Histological lesions were blindly analyzed by a single expert pathologist. Between October 2018 and March 2021, among 1,159 T2D patients screened, NASH and advanced fibrosis were found in 58% and 38% of 330 patients with adequate liver biopsy, respectively. Sequential use of FIB-4 and liver stiffness to rule in/out advanced fibrosis according to EASL algorithm, resulted in a 27% rate of false negative results in patients with FIB-4 <;1.3, and in 32% rate of false positive results in patients with FIB-4 >1.3 and liver stiffness >8 kPa. Hypertension, waist circumference, triglycerides, aspartate aminotransferase, serum albumin and creatinine, were independently associated with NASH (AUROC 0.81 (95% CI 0.76-0.86)) . Waist circumference, gamma-glutamyl transpeptidase, FIB-4 and HDL cholesterol were independently associated with advanced fibrosis (AUROC 0.77 (0.72-0.83)) . Vascular complications of T2D were not associated with liver lesions. In conclusion, more than half of T2D patients with NAFLD displayed severe hepatic injuries. Liver lesions were independently associated with metabolic syndrome, but not with complications of T2D. Screening for NASH and advanced fibrosis should be part of regular workup of T2D patients. Models based on easily available variables may be useful. Disclosure J.Gautier: Other Relationship; Novo Nordisk, Sanofi, Speaker's Bureau; Eli Lilly and Company. H.Bihan: Other Relationship; Vitalair. J.Julla: Consultant; Sanofi. E.Larger: None. S.Pol: Board Member; AbbVie Inc., Gilead Sciences, Inc., Novo Nordisk. P.Bedossa: None. C.Laouenan: None. D.C.Valla: Advisory Panel; Intercept Pharmaceuticals, Inc. L.Castera: Advisory Panel; Alexion Pharmaceuticals, Inc., Merck & Co., Inc., Pfizer Inc., Speaker's Bureau; Novo Nordisk. T.Vidal-trecan: None. V.Paradis: Consultant; Inventiva Pharma, Servier Laboratories. T.Poynard: Stock/Shareholder; Biopredictive. S.Czernichow: Consultant; Boehringer Ingelheim International GmbH, Janssen Pharmaceuticals, Inc., Lilly, Novo Nordisk. B.Terris: None. P.Manchon: None. D.Roulot: Consultant; AbbVie Inc., Gilead Sciences, Inc. Funding Agence Nationale pour la Recherche (ANR-17-T171105J)

False Positive Reaction to Vdrl Test with Prozone Phenomenon in a Case of Lepromatous Leprosy

Abstract The venereal disease research laboratory (VDRL) test, a nontreponemal test for syphilis, may under a certain set of conditions give false positive results in patients who are not infected with Treponema pallidum. A false positive reaction is defined as a positive reaction to nontreponemal tests, and a negative reaction to treponemal tests, in the serum of a patient who has no history or clinical evidence of syphilis or other treponematosis. A prozone phenomenon in nontreponemal tests is seen largely with secondary syphilis due to high-titer samples that show nonreactive results unless the specimens are diluted. We report here perhaps the first case of lepromatous leprosy, which had a false positive reaction to the VDRL test with the prozone phenomenon. The case initially presented to the outpatient clinic with complaints of epistaxis with nasal stuffiness. The finding of septal perforation on nasal endoscopy is what led to the initial suspicion of syphilis and the subsequent syphilis workup. It was only when the false positive reaction to VDRL test with the prozone phenomenon was noted that the search for other causes was made, which eventually lead to the diagnosis of lepromatous leprosy.

Late Night Salivary Cortisol in the diagnosis of neoplastic hypercortisolism (including cyclic Cushing's syndrome).

Late night salivary cortisol (LNSC) is a mainstay in the diagnosis of neoplastic hypercortisolism (Cushing's syndrome) with a sensitivity and specificity of > 90% in patients with syndromic signs and symptoms. Intermittent hormonogenesis (day to day variation) is common in milder Cushing's disease whereas true cyclic Cushing's syndrome (weeks to months of tumor quiescence) is unusual. In both cases, LNSC is useful as a sensitive evaluative diagnostic tool, although its lower specificity may lead to false positive results in patients without Cushing's disease. Furthermore, intermittent hormonogenesis may lead to false negative LNSC results in patients with mild Cushing's disease. Finally, LNSC is useful as an approach to follow patients after pituitary surgery to detect a recurrence even many years after a full remission.

Cross-Reactive Results in Serological Tests for Borreliosis in Patients with Active Viral Infections.

Currently, serological tests for Lyme disease (LD), routinely performed in laboratories following the European Concerted Action on Lyme Borreliosis recommendations as part of two-stage diagnostics, are often difficult to interpret. This concerns both the generation of false positive and negative results, which frequently delay the correct diagnosis and implementation of appropriate treatment. The above problems result from both morphological and antigenic variability characteristics for the life strategy of the spirochete Borrelia burgdorferi sensu lato, a complicated immune response, and imperfections in diagnostic methods. The study aimed to check the reactivity of sera from 69 patients with confirmed infection with Epstein–Barr virus (EBV), cytomegalovirus (CMV) and BK virus (BKV) with Borrelia antigens used in serological tests: indirect immunofluorescence (IIFT), enzyme-linked immunosorbent (ELISA) and immunoblot (IB). In the group of patients infected with EBV, the highest percentage of positive/borderline anti-Borrelia IgM and IgG results was obtained in the following tests: IIFT (51.9% for IgM, 63.0% for IgG), ELISA (22.2% for IgM, 29.6% for IgG) and IB (11.1% for IgM, 7.4% for IgG). In the group of CMV-infected patients, the highest percentage of positive/borderline anti-Borrelia IgM results were obtained in the following tests: IB (23.1%), IIFT (15.4%) and ELISA (7.7%), while in the IgG class in the IIFT (15.4%), IB (11.5%) and ELISA (3.9%) tests. In the group of patients infected with BKV, the highest percentage of positive/borderline anti-Borrelia IgM results was obtained in the following tests: IIFT (25.0%), IB (25.0%) and ELISA (3.9%), and in the IgG class in the tests: IB (50.0%), IIFT (6.2%) and ELISA (6.2%). The native flagellin (p41) and OspC proteins were the most frequently detected Borrelia antigens in all studied groups of patients in both classes of antibodies. Similar to other authors, the study confirmed the fact that serological tests used in the diagnosis of LD have a high potential to generate false positive results in patients with active viral infections, which may be related to cross-reacting antibodies appearing during the most common polyclonal activation of T/B lymphocytes, activated by viral superantigens.

Evaluation of standardized questionnaires for diagnosis and differentiation of obstructive and patulous Eustachian tube dysfunction

HintergrundEine klaffende Tube kann insbesondere durch Autophonie, Druckgefühl und gestörten Höreindruck zu einer Einschränkung der Lebensqualität führen. Bei fehlenden spezifischen Symptomen kann die Diagnose der klaffenden Tube schwierig sein. Insbesondere die Abgrenzung zur chronisch obstruktiven Tubenfunktionsstörung stellt eine Herausforderung dar. Da derzeit kaum standardisierte Diagnostik- und Therapieoptionen zur Verfügung stehen, ist eine strukturierte Untersuchung zur sicheren Diagnostik und wissenschaftlichen Aufarbeitung dieser Erkrankung erforderlich. Für die Diagnostik der chronisch obstruktiven Tubenfunktionsstörung wurde 2012 bereits der „Eustachian Tube Dysfunction Questionnaire“ (ETDQ-7-Fragebogen) nach McCoul entwickelt. Für die klaffende Tube existiert seit 2017 der PHI-10-Fragebogen („patulous Eustachian tube handicap inventory“) nach Kobayashi.Material und MethodenDer PHI-10-Fragebogen wurde ins Deutsche übersetzt und an 41 Gesunden, 13 Patienten mit Tinnitus auris, 11 Patienten mit klaffender Tube und 18 Patienten mit chronisch obstruktiver Tubenventilationsstörung getestet. Zusätzlich erfolgte im Vergleich die Auswertung des ETDQ‑7 nach McCoul.ErgebnisseEs erfolgt die Präsentation der deutschen Übersetzung des PHI-10 und der Ergebnisse von PHI-10 und ETDQ‑7 in allen Patientengruppen. Der ETDQ‑7 hat das Risiko falsch-positiver Ergebnisse bei Patienten mit klaffender Tube und der PHI-10 bei Patienten mit obstruktiver Tubenfunktionsstörung. Beide untersuchten Fragebögen sind falsch-positiv bei Tinnituspatienten.SchlussfolgerungDer PHI-10 (deutsch) und ETDQ‑7 (deutsch) sind eine nützliche Unterstützung der Anamnese bezüglich Tubenfunktionsstörungen. Sie unterscheiden jedoch nur unzureichend zwischen klaffenden und obstruktiven Tubenfunktionsstörungen und eignen sich nicht für Patienten mit Tinnitus. Die Stärke der Fragebögen ist in der Verlaufskontrolle und dem Monitoring von Therapieergebnissen zu sehen.

Antiphospholipid Syndrome Committee of the Brazilian Society of Rheumatology position statement on the use of direct oral anticoagulants (DOACs) in antiphospholipid syndrome (APS)

BackgroundThe term Direct Oral Anticoagulants (DOACs) refers to a group of drugs that inhibit factor Xa or thrombin. Even though their use for treating different thrombotic or prothrombotic conditions is increasing recently, there is no compelling evidence indicating that those medications are safe in all antiphospholipid syndrome (APS) patients.MethodologyTo address this issue, specialists from the Antiphospholipid Syndrome Committee of the Brazilian Society of Rheumatology performed a comprehensive review of the literature regarding DOACs use in APS to answer the three following questions: (1) potential mechanisms of action of these drugs that could be relevant to APS pathogenesis, (2) DOACs interference on lupus anticoagulant testing, and (3) the efficacy of DOACs in APS.Position statementAfter critically reviewing the relevant evidence, the authors formulated 8 Position Statements about DOACs use in APS.ConclusionDOACs should not be routinely used in APS patients, especially in those with a high-risk profile (triple positivity to aPL, arterial thrombosis, and recurrent thrombotic events). In addition, DOACs interferes with LA testing, leading to false-positive results in patients investigating APS.

The Clinical Pharmacology Sections in Drug Package Inserts: Do We Need to Reexamine the Basis?

The Clinical Pharmacology Sections in Drug Package Inserts: Do We Need to Reexamine the Basis?

Allergen-specific IgE to recombinant latex allergens in occupational allergy diagnostics.

ObjectivesSpecific challenge tests (SICs) are considered reference tests for allergic occupational diseases diagnosis. However, in numerous cases, SICs cannot be carried out in the diagnosis of allergy to latex due to the risk of generalized reactions. The aim of the study was to evaluate the usefulness of sIgE determination to recombinant latex allergens in diagnostics of occupational respiratory allergy.Materials and MethodsThe study group comprised 44 healthcare workers (HCW) suspected of suffering from occupational respiratory allergy to latex (they underwent a physical examination, skin‐prick tests (SPTs) to common and latex allergens, spirometry and SIC) and 17 controls not occupationally exposed to latex, with a positive sIgE against latex. Each serum was tested for allergen‐specific IgE to aeroallergens, latex, eight recombinant latex allergens and CCD‐markers.ResultsSpecific IgE against Hev b5, 6.01, and 6.02 were significantly more frequently detected in HCWs and their mean serum levels were higher compared with the control group. In 26 HCWs with occupational asthma (OA), sensitization to Hev b5, Hev b6.01, Hev b6.02 was significantly more frequent than in 18 HCWs with work‐exacerbated asthma (WEA); they had positive results SPT to latex significantly more frequently in comparison with subjects with WEA.ConclusionsTest for recombinant latex allergens is much more accurate in recognition of latex allergy than test for latex extract, which seems to produce false‐positive results in patients with pollen allergy. The measurements of sIgE against recombinant latex allergens Hev b 6.01, 6.02, 5, and 8 are useful in differentiating OA from WEA.

396. Clinical Features of Proven and Probable Cases of Histoplasmosis and the Role of Urinary Histoplasma Antigen Testing: A Case Series From India

BackgroundHistoplasmosis is considered uncommon in India, and the diagnosis usually depends on invasive tissue sampling. The histoplasma urinary antigen assay is a non-invasive test that has been recently introduced in India.MethodsThis was a single-centre retrospective study done from January 2013 till February 2018. Case records of patients with proven (confirmed by demonstrating intra-cellular yeast like organisms on histopathology or culture) and probable (presence of antigenuria—done by IMMY Alpha Histoplasma enzyme immunoassay) histoplasmosis were analysed.ResultsA total of 37 patients (18 proven and 19 probable) with mean age of 51.59 ± 11.17 years were studied. Diabetes was the most common co-morbidity (15 patients) followed by HIV (6), whereas no co-morbidity was found in 10 patients. Adrenals (29%), lungs (27%), lymph nodes (27%), and skin and oral mucosa (24.3%) were the most common organs involved (Figure 1). Anti-tubercular therapy based on granulomatous inflammation was given to 10 patients prior to the diagnosis. Raised GGTP and ALP (54%) and hyperglobulinemia (40%) were the common laboratory features. Most patients (83.7%) came from endemic areas (North-Eastern states, West Bengal, and Bangladesh) whereas all six cases from non-endemic areas were classified as probable (Figure 2). All-cause mortality rate was 10.8%, with 27 cases (72.9%) showing improvement at a median follow-up of 6 months. Comparison of proven and probable cases revealed that the following features were significantly higher in theprobable group: female sex (P = 0.001), coming from nonendemic areas (P = 0.009), requiring in-patient care (P = 0.001), leucocytosis (P = 0.043), absence of skin and oral mucosal findings (P = 0.002), simultaneous alternate diagnosis (P = 0.039), and death (P = 0.039).ConclusionThis study emphasises that histoplasmosis is an under recognised entity in India. Histoplasma antigenuria does help in making the diagnosis easily and needs to be more extensively utilized by clinicians. However, it can yield false-positive results in patients belonging to nonendemic areas and lacking typical clinical features of histoplasmosis. Further studies are needed to determine the utility of the antigen test in Indian settings.Figure 1.Distribution of involved organs.Figure 2.Distribution of cases in the study across Indian states.Disclosures All authors: No reported disclosures.

Factors accounting for HIV antibody test false positive results in patients with rheumatoid arthritis

Objective To investigate if immunological factors associated with the false HIV screening test results in RA. Methods Subjects who attended the Rheumatology Outpatient Clinic-Internal Medicine Unit of Guanghua Integrative Hospital, from October 2013 to October 2014, who met the American College of Rheumatology/European League Against Rheumatism Criteria for RA were recruited for the study. 100 subjects with RA were recruited. Each patient underwent clinical examination and blood sampling for assessment of serum HIV screening test and Rheumatoid factors (RF-IgA, -IgG, -IgM) and anti-cyclic citrullinated protein antibodies (anti-CCP) were purified from the plasma and detected by ELISA, Samples were collected and processed using standard protocols and were stored in the same freezer before analysis. RA patients were divided into two groups based on the titters of RF and anti-CCP: RF 300 U/ml / anti-CCP>500 U/ml group.HIV screening tests were determined by three methods: ELISA、Immuno-colloidal Golden Method and ECLIA.The positive results were confirmed by the Changning Centers for Disease Control, Shanghai through western-blotting test. Results 100 samples detected by ELISA and Immuno-colloidal Golden Method were given negative results, 16 positive results existed in ECLIA group. There were1, 12, 3 positive cases in RF-IgM 300 U/ml group(2.7%, 32.4%, 13.6%; P 500 RU/ml groups there were 2 and 4 positive results(4.7%, 24.6%; P<0.01). Conclusions Different HIV screening test methods would give different results, according to operation requirement using second method to determine the HIV screening result. HIV False-positivity was associated with the titers of anti-CCP and RF in RA.(Chin J Lab Med, 2016, 39: 522-525) Key words: Arthritis, rheumatoid; Human immunodeficiency virus; False positive reactions; Autoantibodies; Enzyme-linked immunosorbent assay

Leptospirosis Diagnostic Challenges, American Samoa

Leptospirosis Diagnostic Challenges, American Samoa

How likely is environmental or patient cross-contamination of Chlamydia trachomatis DNA to lead to false positive results in patients attending our clinic?

ObjectivesEnvironmental contamination with DNA from Chlamydia trachomatis (CT) has previously been found in Genitourinary Medicine (GUM) clinics. There are no known cases of cross-contamination of clinical samples and no known...

Technical Aids in the Diagnosis of Brain Death

The use of technical aids to confirm brain death is a controversial matter. Angiography with the intra-arterial administration of contrast medium is the international gold standard, but it is not allowed in Germany except in cases where it provides a potential mode of treatment. The currently approved tests in Germany are recordings of somatosensory evoked potentials (SSEP), brain perfusion scintigraphy, transcranial Doppler ultrasonography (TCD), and electroencephalography (EEG). CT angiography (CTA), a promising new alternative, is being increasingly used as well. In a prospective, single-center study that was carried out from 2008 to 2011, 71 consecutive patients in whom brain death was diagnosed on clinical grounds underwent recording of auditory evoked potentials (AEP) and SSEP as well as EEG, TCD and CTA. The validity of CTA for the confirmation of brain death was 94%; the validity of the other tests was: 94% for EEG, 92% for TCD, 82% for SSEP, and 2% for AEP. In 61 of the 71 patients (86%), the EEG, TCD and CTA findings all accorded with the clinical diagnosis. The diagnosis of brain death was established beyond doubt in all patients. In this study, the technical aids yielded discordant results in 14% of cases, necessitating interpretation by an expert examiner. The perfusion tests, in particular, can give false-positive results in patients with large cranial defects, skull fractures, or cerebrospinal fluid drainage. In such cases, electrophysiologic tests or a repeated clinical examination should be performed instead. CTA is a promising, highly reliable new method for demonstrating absent intracranial blood flow. In our view, it should be incorporated into the German guidelines for the diagnosis of brain death.

P183 How likely is environmental contamination of Chlamydia trachomatis DNA to lead to false positive results in patients attending our clinic?

BackgroundEnvironmental contamination with DNA from Chlamydia trachomatis (CT) has been reported from GUM clinics, suggesting the possibility of cross contamination of specimens during sample processing or the environment. If it...

Effect of Right Ventricular Dysfunction on Dynamic Preload Indices to Predict a Decrease in Cardiac Output After Inferior Vena Cava Clamping During Liver Transplantation

Background Dynamic preload indices such as stroke volume variation (SVV) and pulse pressure variation (PPV) have yielded false-positive results in patients with right ventricular (RV) dysfunction. We therefore assessed the effect of RV dysfunction on dynamic indices to predict the decrease in cardiac output (CO) during liver transplantation. Methods Hemodynamic parameters were measured before and after inferior vena cava (IVC) clamping in 52 recipients. The RV dysfunction was defined as an RV ejection fraction (RVEF) ≤ 30%. The area under the receiver operating characteristic curve (AUC) sufficient to detect changes in CO (ΔCO) ≥ 20% after IVC clamping in recipients was calculated. Results Recipients with RVEF ≤ 30% did not show significant increases in SVV or PPV despite having ΔCO ≥ 20%. In recipients with RVEF > 30%, the threshold value and AUC of SVV predicting a decrease in CO were 10% and 0.755 (compared with an AUC of 0.5, P = .011), respectively, whereas those for PPV were 10% and 0.767 ( P = .007), respectively. However, in recipients with RVEF ≤ 30%, the threshold value and AUC of SVV were 10% and 0.638 ( P = .305), respectively, whereas those for PPV were 12% and 0.684 ( P = .159), respectively. Conclusions These results suggest that dynamic preload indices may not be sufficiently sensitive to detect a CO decrease in liver transplant recipients with RV dysfunction, emphasizing the importance of evaluating RV function when determining the predictability of dynamic indices.

Interpretation of high sensitivity cardiac troponin I results: Reference to biological variability in patients who present to the emergency room with chest pain: Case report series

Background The development of highly sensitive cardiac troponin (cTnI) assays has increased the number of true and false positive results for patients suspected of acute myocardial infarction (AMI). Cases are reported whereby the use of serial testing, the 99th percentile cutoff, and the application of biological variation of cTnI were used to help determine ischemic vs. non-ischemic causes of myocardial injury. Methods cTnI was measured using the Siemens Ultra assay from 13 representative patients who presented to the emergency department with symptoms suggestive of acute cardiac disease. Based on a previous study, reference change values of a 46% increase and 32% decrease were used to interpret results. These differences were compared against the patient's discharge diagnosis. Results Two patients who subsequently ruled in for AMI had a negative cTnI (< 0.04 μg/l) and borderline positive cTnI (0.07 μg/l) at admission, respectively. While the 4–6 h results were also borderline, there was a significant increase from the baseline (+ 575% and + 50%, respectively) to suggest the presence of an acute cardiac event. Two other AMI cases document the significant cTnI decline in results after peak values. In 7 other non-AMI cases (heart and renal failure, gastrointestinal bleeding, stroke and venous thrombosis), while baseline concentrations were clearly positive (0.18–2.12 μg/l), subsequent serial samples were not significantly increased or decreased from baseline. These findings were not typical for AMI. There were 2 cases with acute blunt cardiac trauma and intracranial hemorrhage, respectively, that produced cTnI results that were initially low (< 0.04 and 0.05 μg/l, respectively), but significantly increased with serial testing thereby producing false positive Δ cTnI results for AMI. Conclusions Serial testing for troponin was useful in differentiating early AMI from non-ischemic causes of troponin increases. However, non-AMI patients with acute cardiac injury can produce troponin results that mimic AMI. Therefore serial troponin testing must be used in conjunction with clinical presentation and other laboratory findings.

Significance of Isolated Positive IgM Serologic Results by Enzyme Immunoassay for Coccidioidomycosis

Serologic testing is important for diagnosis of coccidioidomycosis. Many methods are available for diagnostic testing. Enzyme immunoassay (EIA) can be performed quickly and locally but has the potential for false-positive results in patients manifesting a positive EIA for immunoglobulin M (IgM) antibodies and a negative EIA for immunoglobulin G (IgG). We retrospectively reviewed the charts of 405 patients with coccidioidal serologic testing performed between 1999 and 2003. Of 706 EIAs, 37 (5%) produced test results for 28 patients that showed isolated IgM positivity. Among these 28 patients, 24 (86%) had positive serologic findings by other methods (complement fixation or immunodiffusion or both), and 7 (25%) had positive microbiologic or histopathologic findings. All 4 (14%) patients without other positive serologic results had diagnostic tests with positive microbiologic or histopathologic results. No false-positive IgM assays were observed. We conclude that the false-positive rate of the EIA IgM is low, and that an isolated positive EIA IgM should prompt further follow-up and diagnostic testing.