Hospital Medical Center Research Articles

Efficacy of combining aspirin with hydroxychloroquine in pregnancies at high risk for pre-eclampsia: a prospective, multicentre, open-label, single-arm clinical trial, investigator-initiated study (HUGS study)

IntroductionThe use of hydroxychloroquine (HCQ) during pregnancies complicated by systemic lupus erythematosus or refractory antiphospholipid antibody syndrome has demonstrated a significant ability to prevent pre-eclampsia (PE). As such, the potential...

Clinical, Immunologic, and Genetic Characteristics in Patients with Syndrome of Undifferentiated Recurrent Fevers (SURF).

Syndrome of Undifferentiated Recurrent Fevers (SURF) is characterized by recurrent fevers and autoinflammation without a confirmed molecular diagnosis of a Hereditary Recurrent Fever syndrome (HRF), and not fulfilling criteria for Periodic Fever, Adenitis, Pharyngitis, Aphthous stomatitis syndrome (PFAPA). The goal of this study was to characterize clinical features of SURF patients compared to PFAPA, and to analyze their cytokine signature, genetic variations, and responses to treatment. We enrolled 46 patients followed at Cincinnati Children's Hospital Medical Center. Baseline data and inflammatory cytokines were collected at enrollment, and their clinical course was followed. Cytokine analysis was performed using a cytokine multiplex assay. Many patients had specific or whole exome genetic testing. The prevalence of rash and arthralgias were higher in SURF compared to PFAPA. Pharyngitis and adenopathy were less frequent. A subset of SURF patients clustered together with elevated pro-inflammatory cytokines and more frequently required biologic therapy. Focused analysis of WES data revealed that variants of unknown clinical significance (VUCS) were frequently identified in genes implicated in B cell development, immunodeficiencies, and inflammatory bowel disease risk. Treatments for SURF patients commonly included on-demand steroids, colchicine, and anti-IL1 therapy. Our findings suggest SURF is a heterogeneous group but has distinct clinical and immunologic features from disorders like PFAPA. Patients have frequent VUCS, which may have relevance to disease pathogenesis. A subset of patients showed more inflammation and increased need for biologic use. Further research is necessary to define whether there exist distinct SURF endotypes and to better predict treatment outcomes.

Patients' perceptions of nocturnal erectile function assessment with the RigiScan®.

In recent decades, the assessment of male sexual function has been a subject of enduring interest. The use of the RigiScan®, a conventional diagnostic tool designed to differentiate between psychological and organic causes of erectile dysfunction (ED), has decreased due to several disadvantages. In this study, patient perspectives on the merits and drawbacks of the RigiScan®, as well as preferences for a future diagnostic device, were explored. Patients at St. Antonius Hospital and Leiden University Medical Center who underwent RigiScan® examinations were surveyed. A pretested questionnaire was used to gather data on their experiences, satisfaction levels, and suggestions for improvement. Among the 120 distributed questionnaires, a 39.2% response rate was achieved. The process of applying the RigiScan® around the penis was reported to have an average difficulty rating of 4.6 ± 2.5 (range: 1-9) points. While 74.5% of the participants were able to keep the device on all night, 25.5% of the participants experienced difficulties. Sleep quality was assessed at 5.5 ± 2.6 (range: 0-9) points. The participants reported an average pain rating of 4.7 ± 2.8 (range: 0-9) points. Despite these challenges, 69.6% of the participants reported that the device met their expectations, while 30.4% of the participants were dissatisfied. The key areas for improvement included device size (33.7%), user-friendliness (25.5%), sound (9.2%), hygiene (7.1%), and pain (6.1%). This study revealed that patients who underwent a nocturnal erectile function assessment with the RigiScan® device preferred a more patient-friendly and less intrusive diagnostic device. Further research is needed to determine whether a new sensor possessing these improved characteristics can increase patient satisfaction.

Moving Beyond Thoughts and Prayers: Creating a Firearm-Related Injury Task Force

Firearm injuries among children have increased dramatically, creating a public health crisis. Academic medical centers should address this critical public health need, but often struggle to apply their resources and methodological expertise to move beyond public statements to real action. Cincinnati Children’s Hospital Medical Center, a large quaternary care academic medical center, serves as the American College of Surgeons Level I pediatric trauma center for the region. Cincinnati Children’s Hospital has established a task force to reduce firearm-related injuries in the area. Key challenges have included staying within scope, building momentum, standardizing communication, and balancing aspirational change with practical progress. Such initiatives require buy-in from institutional leaders and building a team that is balanced between members with decision-making authority and members who execute the work.

Compatibility of hypokalaemia caused by low-dose prednisolone plus abiraterone acetate therapy for metastatic castration-resistant prostate cancer

BackgroundThis study aimed to investigate the relationship between low-dose prednisolone (PSL) and the incidence of hypokalaemia at abiraterone acetate (abiraterone) plus PSL combination therapy targeting Japanese patients with metastatic castration-resistant prostate cancer (mCRPC).MethodsThis retrospective observational study included 153 Japanese patients treated with abiraterone and PSL for mCRPC at Kariya Toyota General Hospital and Gifu General Medical Center between September 2014 and October 2022. The incidence of grade ≥ 2 hypokalaemia as well as serum potassium level variations and the continuous combination therapy duration were compared between the low-dose (5 mg/day of PSL) and the standard-dose (10 mg/day of PSL) groups.ResultsThis study included 153 patient of which 95 were matched to establish the analysis population. The low-dose and the standard-dose groups consisted of 13 and 82 patients, respectively. No significant difference in the incidence of grade ≥ 2 hypokalaemia was observed between the two groups [15.4% (2/13 patients) in the low-dose group and 12.2% (10/82 patients) in the standard-dose group, P = 0.667]. The low-dose group exhibited a decrease in serum potassium levels from 4.63 on day − 7 − 0 to 4.16 mmol/L on day 84 ± 10 (n = 7, P = 0.066), and serum potassium levels from day − 7 − 0 to 84 ± 10 in the low-dose group appeared to be great in the standard-dose group (n = 37, P = 0.475). The Kaplan–Meier curves for continuity of abiraterone and PSL therapy were not significantly different between the low-dose group (n = 13) and standard-dose group (n = 82, P = 0.427).ConclusionCombination therapy with abiraterone and 5 mg/day of PSL in Japanese patients with mCRPC did not change the incidence of grade ≥ 2 hypokalaemia. However, although not significant, 5 mg/day of PSL demonstrated a decreasing trend in serum potassium levels with a larger degree of change than that of 10 mg/day of PSL. Therefore, the combination of abiraterone and 5 mg/day PSL can be administered to Japanese patients with mCRPC. The patients must be monitored for hypokalaemia through measurement of serum potassium levels and observation of subjective symptoms such as muscle weakness, convulsion etc. In addition, the doctor or the pharmacist must explain these symptoms to the patient and instruct them to consult their medical staff immediately in the event of development of such symptoms.

Evaluating the need for magnesium administration following cardioplegic arrest with del Nido cardioplegia solution

Background: del Nido cardioplegia (dNC) solution is widely used in pediatric and congenital cardiac surgery. In 2014, Cincinnati Children’s Hospital Medical Center (CCHMC) changed from Mee cardioplegic solution to dNC. Since Mee solution does not contain magnesium, magnesium was administrated post cross-clamp removal, at a dose of 25mg/kg up to 1g, to abate hypomagnesemia. This practice remained in place with the use of dNC. We postulated that patients may experience hypermagnesemia under this protocol, possibly resulting in deleterious effects such as dysrhythmias and/or hypotension. Methods: To determine if exogenous magnesium is necessary post-clamp removal in our practice, a study examining magnesium levels during cardiopulmonary bypass (CPB) was completed from January 2022 through October 2023 (IRB #2021-0816). One hundred patients undergoing CPB with cross-clamp, ranging from infants to adults, were consented. Two magnesium samples were collected. Draw 1 (D1) was collected post cardioplegia administration and 30 minutes prior to cross-clamp removal. Draw 2 (D2) was collected post cross-clamp removal and 10 +/- 2 minutes following magnesium administration. Results: Both samples demonstrated magnesium levels >1.6mg/dl or higher (normal magnesium range at CCHMC, 1.6-2.6mg/dl). A Wilcoxon rank sum test demonstrated statistical significance for D1, comparing the number of samples which fell above 2.6 mg/dl vs. those that fell within the normal range (p<0.001). D2 demonstrated values above normal range for all but one sample, which does not satisfy the criteria of the Wilcoxon rank sum test for demonstrating significance (p=0.089); however, ninety-nine samples displayed hypermagnesemia. Conclusion: This study demonstrates that exogenous magnesium administration may not be necessary in the setting of our practice at CCHMC and dNC cardioplegic arrest.

Investigating the Prevalence of Hypercalciuria in Children Aged 2-16 Years With Asymptomatic Microscopic Hematuria in 2020 in Tehran Children's Medical Center.

The prevalence of hypercalciuria in children is 3%-10% globally and up to 35% in the United States. Hypercalciuria in children has many presentations; it causes different metabolic disorders and can negatively affect a child's growth. It also increases the risk of low bone mineral density and urinary tract infections. In addition, it is the most widespread cause of persistent microscopic hematuria. Changes in the diet and medications in cases of advanced stage can be useful to prevent further complications. This study aimed to determine the prevalence of hypercalciuria and to investigate its relationship with different factors in children aged 2-16 years with asymptomatic microscopic hematuria in 2020 in the Children's Medical Center hospital. This retrospective cross-sectional study was performed in a population of children aged 2-16 years old with asymptomatic microscopic hematuria who were referred to the Children's Medical Center clinic in 2020. Data such as age, sex, serum creatinine level, and proteinuria were extracted from the patient's medical records, and their relationship with hypercalciuria was analyzed using logistic regression analysis. According to the inclusion criteria, 166 children with asymptomatic microscopic hematuria (72 boys and 94 girls) were included in this study. The prevalence of hypercalciuria (ratio of random urine calcium to creatinine more than 0.2) in these patients was estimated at 25% with a confidence interval of 18%-32%. In order of prevalence, the most common conditions accompanying microscopic hematuria were kidney stones, urinary tract infections, and proteinuria. The age of patients with hypercalciuria was 2 years younger on average. Each year of age increase and every 5 years of age increase between the ages of 2 and 16 years reduced the chance of hypercalciuria in this category of patients by 12% and 45%, respectively. Our findings also showed that children with a positive history of kidney stones were about 2.2 times more likely to have hypercalciuria than their counterparts, which is considered a medium effect size. Our results showed that hypercalciuria in children with hematuria is significantly related to younger age and a positive history of kidney stones.

How Do Craniometric Measurements and Skull Morphology Influence Subthalamic Nucleus Target Coordinations in Deep Brain Stimulation Surgery for Parkinson Disease?

This study investigates the correlation among craniometric measurements, skull morphology,and subthalamic nucleus (STN) target coordinates in DBS surgery. We conducted a retrospective study of 77 Parkinson disease patients who underwent bilateral STN-DBS surgery at Nguyen Tri Phuong Hospital and University Medical Center in Ho Chi Minh City, Vietnam. Craniometric measurements and STN target coordinates were analyzed using Pearson correlation and multivariate linear regression. The coordinates of the STN were compared between 2 hemispheres in the same patient, based on skull morphology indices, including the Cephalic Index and the Cranial Vault Asymmetry Index. Significant gender-based differences were observed in craniometric measurements, with males exhibiting larger dimensions. STN coordinates demonstrated correlations with various cranial measurements,notablywith X-coordinates correlating most strongly with horizontal arc and third ventricle width(r= 0.4 and r= 0.42, respectively).Thelinear regression equation:X(mm)= 0.967+ 0.202∗ Third ventricle width (mm)+ 0.024∗Horizontal arc (mm)with R2= 0.32.Skull morphologyrevealed potential asymmetries affecting STN coordinates. Craniometric measurements and third ventricle width correlate significantly with STN coordinates, particularly the X-coordinates. Our study highlights the importance of individualized craniometric considerations in DBS surgery planning to optimize electrode placement and therapeutic outcomes.

First bipolar episode following booster dose of COVID-19 vaccination

Introduction and importance: The interactions between the susceptibility of the host and some of the COVID-19 vaccine components happened. Viral infections, including COVID-19, are related to the pathogenesis of bipolar disorder (BD). These findings could trigger an initial bipolar episode. Case presentation: A 48-year-old Syrian married female, presented to the out-clinic of Modern Medical Centre Hospital, in July 2022 for episodes of sub-maniac/mania episodes, which began within 15 days after the booster dose of COVID-19 vaccination, preceded by depressive mood. Both family and personal past psychiatric and/or trauma history were negatives. Initiation of carbamazepine 600 mg/day showed significant improvement within 3 days; 3 months later, carbamazepine dose was decreased to 200 mg/day, as there were no clinical symptoms. Clinical discussion: mRNA vaccines of COVID-19 increase the levels of type I interferon (INF), an inflammatory cytokine that creates a signal leading to the expression of interleukins, INF, and tumor necrosis factor-alpha. The pathology of BD is also unclear. Genetic predisposition, immunological effects, and the classification of BD, itself, as an autoimmune disease play a role. Although rapid improvement following treatment, prolonged and maintenance treatment by essentially mood stabilizer should be considered in bipolar episodes initiated by COVID-19 vaccination. Rare data are available about maniac episodes after COVID-19 infection, but to our knowledge, we reported the first case of bipolar onset after the booster vaccination of COVID-19. Conclusion: Bipolar disease can present following a booster dose of COVID-19 vaccination in previously healthy people.

Carbapenem resistance in gram-negative pathogens in an Iranian hospital: high prevalence of OXA-type carbapenemase genes.

The widespread dissemination of carbapenem-resistant Gram-negative bacteria poses a significant threat to global public health. This study aimed to investigate the prevalence of carbapenem resistance in Gram-negative bacteria isolated from patients at the Children's Medical Center Hospital, Tehran, Iran, to understand the molecular mechanisms underlying this resistance. During the period spanning from June 2019 to June 2020, 777 Gram-negative bacterial strains were isolated. Antibiotic susceptibility testing was performed according to Clinical and Laboratory Standards Institute. Polymerase chain reaction was used to detect carbapenem resistance genes including bla OXA23, bla OXA24, bla OXA48, bla OXA51, bla OXA58, bla OXA143, bla KPC, bla IMP, bla VIM, and bla NDM. Among the total bacterial isolates, 141 (18.1%) exhibited carbapenem resistance. Escherichia coli was the most prevalent (57.4%), followed by Klebsiella pneumoniae (11.3%) and Acinetobacter baumannii (10.6%). Other notable contributors included Enterobacter spp. (5.7%), Salmonella spp. (3.5%), and Stenotrophomonas maltophilia (2.8%). Citrobacter spp., Proteus mirabilis, and Pseudomonas aeruginosa contributed to the distributions of two, one, and three isolates, respectively. Notably, bla OXA48 showed the highest prevalence (33%), followed by bla OXA143 and bla OXA58 (27% and 24%, respectively). In addition, bla OXA24 was present in 11% of the total isolates, bla OXA23 in 10%, and bla NDM in 10%, whereas bla KPC, bla VIM, and bla IMP were not detected. Our study highlights the prevalence of carbapenemase-producing Gram-negative isolates among pediatric patients. Notable resistance patterns, especially in K. pneumoniae and E. coli, underline the urgent need for proactive interventions, including appropriate antibiotic prescription practices and strengthening of antibiotic stewardship programs.

Radical Prostatectomy Survivorship: What Are We Really Asking?

Introduction Urinary incontinence, sexual dysfunction, and bowel dysfunction are well-recognized cancer survivorship outcomes affected by radical prostatectomy (RP) in the treatment of prostate cancer (PCa).The aim of this study was to audit the thoroughness of outpatient discussions and documentation of survivorship outcomes for patients who have undergone RP. Methods This was a retrospective audit of all 253 radical prostatectomies conducted at two tertiary-level Australian institutions (Monash Medical Centre and Alfred Hospital), over a five-year period between 2014 and 2018. Electronic medical records were reviewed across five time points: preoperative and then six weeks, three months, six months, and 12 months post-RP.The main outcomes measured were rates of documented discussions of urinary incontinence, sexual dysfunction, and bowel dysfunction. Results At the initial six-week postoperative review, there was an 86%, 47%, and 27% probability that urinary, sexual, and bowel functions were discussed and documented. When averaging across the four postoperative time points, from six weeks to 12 months, there was a 73%, 45%, and 14% respective rate of documented discussion for each survivorship outcome. Sexual and bowel function discussions were less frequently documented in men over 65 years of age compared with those under 65 years of age by 16% (p < 0.001) and 8% (p = 0.003), respectively. Conclusion Sexual and bowel dysfunction were less frequently discussed and documented in the follow-up of our cohort of RP patients compared with urinary continence outcomes.

Platelet counts to spleen diameter ratio: A promising noninvasive tool for predicting esophageal varices in cirrhosis patients.

Liver cirrhosis is the end stage of progressive liver fibrosis as a consequence of chronic liver inflammation, wherein the standard hepatic architecture is replaced by regenerative hepatic nodules, which eventually lead to liver failure. Cirrhosis without any symptoms is referred to as compensated cirrhosis. Complications such as ascites, variceal bleeding, and hepatic encephalopathy indicate the onset of decompensated cirrhosis. Gastroesophageal varices are the hallmark of clinically significant portal hypertension. To determine the accuracy of the platelet count-to-spleen diameter (PC/SD) ratio to evaluate esophageal varices (EV) in patients with cirrhosis. This retrospective observational study was conducted at Tikur Anbessa Specialized Hospital and Adera Medical Center from January 1, 2019, to December 30, 2023. Data were collected via chart review and direct patient interviews using structured questionnaires. The data were exported to the SPSS software version 26 for analysis and clearance. A receiver operating characteristic curve was plotted for splenic diameter, platelet count, and PC/SD ratio to obtain sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. Of the 140 participants, 67% were men. Hepatitis B (38%) was the most common cause of cirrhosis, followed by cryptogenic cirrhosis (28%) and hepatitis C (16%). Approximately 83.6% of the participants had endoscopic evidence of EV, whereas 51.1% had gastric varices. Decompensated cirrhosis and PC were associated with the presence of EV with adjusted odds ratios of 12.63 (95%CI: 3.16-67.58, P = 0.001) and 0.14 (95%CI: 0.037-0.52, P = 0.004), respectively. A PC/SD ratio < 1119 had a sensitivity of 86.32% and specificity of 70% with area under the curve of 0.835 (95%CI: 0.736-0.934, P < 0.001). A PC/SD ratio < 1119 predicts EV in patients with cirrhosis. It is a valuable, noninvasive tool for EV risk assessment in resource-limited settings.

Exploring the long-term disability outcomes in Trauma patients: study protocol

ObjectivesTrauma registries are essential tools for improving trauma care quality and efficiency, but many fail to capture long-term patient-reported outcome measures (PROMs). Focusing on these outcomes is crucial for understanding the extent of disability patients experience and identifying potential post-discharge interventions to optimize recovery. Studies reflecting the experience from low- and middle-income countries in this area are limited. Therefore, we aim to develop a digital trauma registry in Pakistan to prospectively capture patient-reported outcome measures at one, three, six, and twelve months post-injury.MethodsWe will develop and implement a digital trauma registry at two tertiary care facilities in Karachi, Pakistan: Aga Khan University Hospital and Jinnah Postgraduate Medical Center. The registry will include all admitted adult trauma patients (≥ 18 years). Data collection will be conducted digitally using tablets, with mortality, level of disability, functional status, and quality of life as primary outcomes. Follow-up data will be collected through telephone interviews with patients and caregivers. We will employ descriptive statistics to summarize participant’s socio-demographic and clinical characteristics. Additionally, we will perform survival analysis using Kaplan-Meier curves and Cox proportional hazard models and utilize mixed-effects linear regression to adjust for potential confounders for primary outcomes.DiscussionThe trauma registry will fill the current gap in knowledge regarding long-term outcomes among trauma patients in low- and middle-income countries (LMICs). This study will delineate future direction for capturing post-discharge data, enhancing our understanding of recovery, and informing the design of interventions aimed at improving long-term outcomes.

Outcomes of Del Nido and hyperkalemic blood cardioplegia in adult cardiac surgery with prolonged aortic cross clamp times.

Background The utility and uptake of Del Nido cardioplegia in adult cardiac surgery is rapidly increasing. Cases with prolonged aortic cross clamp times necessitate multi dosing however an understanding of safe ischaemic times and definitive guidelines in this domain are lacking. Therefore, the aim of this study was to assess the safety and efficacy of our DNC strategy by comparing post-operative troponin profiles and clinical outcomes between del Nido and hyperkalaemic cardioplegia for cases with aortic cross clamp times of greater than 90 minutes. Methods A single centre, retrospective cohort study at Flinders Medical Centre and Flinders Private Hospital of patients undergoing composite cardiac surgery with a cross clamp time longer than 90 minutes. Data was prospectively collected from the Flinders Cardiac Surgery Registry from June 2014 to December 2022. A propensity matched (1:1) analysis was performed comparing patients receiving del Nido cardioplegia (n=194) to those receiving hyperkalemic blood cardioplegia (n=194). Primary outcome was the post-operative troponin release profile with clinical events reported as secondary outcomes . Results There was no difference in the peak or median troponin at 6, 12 and 72 hours nor number of patients with positive troponin profile post operatively between cohorts. There was no difference in clinical outcomes between groups with aortic cross clamp times of 90min which remained true in Sensitivity analysis extending out to 120min. The Del Nido cohort received less cardioplegia volume (p &lt;0.001) and were more likely to return to spontaneous rhythm (p &lt;0.002). Conclusion Del Nido cardioplegia for anticipated aortic cross clamp times of greater than 90min provided equivocal post operative troponin profiles and clinical outcomes compared to multidose hyperkalemic blood cardioplegia.

Utility of Clinical Features in Identifying Electrographic Seizures in Hospitalized Patients Admitted for Non-Neurological Diagnoses.

Electrographic seizures (ESz) are seizures without prominent motor activity diagnosed with electroencephalogram and are a common complication in critically ill patients with alterations of consciousness. Previous studies suggested clinical signs, including ocular movement abnormalities, facial/periorbital twitching, or remote seizure risk factors, are sensitive for presence of ESz. To assess the utility of clinical features in identifying ESz in critically ill patients with alterations of consciousness. This is a retrospective case-control study of 50 patients admitted to the University of North Carolina (UNC) Medical Center and UNC Rex Hospital. Inpatients older than 18 years old undergoing continuous video electroencephalogram (cEEG) were included. Patients admitted for neurologic diagnoses were excluded. A total of 25 patients with ESz (Sz-EEG) were matched with 25 controls by electroencephalogram duration ± 12 hours (No-Sz-EEG). Elements of patient's history and physical findings previously shown to be sensitive for presence of ESz were collected. Descriptive statistical analyses were used. Most patients were admitted to medical ICUs (72%; n = 36). There was no difference between groups in clinical findings previously shown to be sensitive for ESz. Positive and negative likelihood ratios for these findings generally fell between 1-2 and 0.5-1, respectively, indicating they are inaccurate predictors for ESz. Patients with ESz had significantly higher mortality (p = 0.012). Our matched case-control study showed that in the critically ill patient population hospitalized in tertiary care centers and admitted for non-neurologic primary diagnoses, incidence of ocular movement abnormalities, facial/periorbital twitching, and presence of remote risk factors for seizures had low predictive accuracy for ESz. However, these findings are not generalizable to patients with neurologic diseases or to other practice settings with different levels of access to cEEG. We concluded that in this exploratory analysis of hospitalized critically ill patients with non-neurologic diagnoses, these clinical signs did not reliably stratify risk for ESz on cEEG. However, further prospective studies are needed to better evaluate these conclusions.

Efficient Biomedical Waste Management: Optimizing Segmentation and Classification with EnU-Net-DNN-BMWC

&lt;p style="margin-bottom:8px;text-align:justify;"&gt;&lt;span style="font-family:&amp;quot;Times New Roman&amp;quot;,serif;font-size:12.0pt;line-height:200%;tab-stops:0in 21.3pt;"&gt;In India, biomedical waste (BMW) management is governed by strict regulations to mitigate health and environmental risks. It includes materials such as sharps, infectious wastes, pharmaceuticals, and non-hazardous items contaminated with potentially infectious substances. Proper management and disposal of BMW are critical to prevent environmental contamination and health risks.&amp;nbsp; This article introduces an Enhanced U-Network (EnU-Net) integrated with Deep Neural Network BMW Classification (EnU-Net-DNN-BMWC) to enhance accuracy in this critical task. Leveraging the U-Net framework with an Encoder-Decoder Network (EDN) and pixel-wise classification layer initially optimizes image segmentation. Bayesian functions mitigate segmentation uncertainties, while Content-Sensitive Sampling (CSS) refines pixel sampling to prioritize data-sparse regions. Data collected from G. Kuppuswamy Naidu Memorial Hospital and Kovai Medical Center and Hospital (KMCH) in Coimbatore over six months, categorizing sharps, infectious materials, pharmaceuticals, and non-hazardous waste, informs waste management strategies. Experimental validation using 100 biomedical waste images demonstrates EnU-Net-DNN-BMWC achieving good accuracy, surpassing standalone DNN-BMWC using Matlab 2022. The comparative analysis across different metrics such as accuracy, precision, F-measure, recall, error rate, and RMSE between DNN-BMWC and the proposed EnU-Net-DNN-BMWC framework were evaluated in this study, highlighting EnU-Net-DNN-BMWC's superior performance. Finally, this study underscores EnU-Net-DNN-BMWC’s efficacy in enhancing biomedical waste classification, crucial for sustainable waste management practices and regulatory compliance in healthcare settings.&lt;/span&gt;&lt;/p&gt;

Invasive Fungal Disease in Pediatric Heart Transplant Recipients

Abstract Background The epidemiology of IFD following pediatric heart transplantation (pHT) is poorly characterized. We sought to evaluate use of antifungal prophylaxis and describe the epidemiology of IFD in pHT at two large children’s hospitals. Methods We performed a retrospective cohort study of pediatric and young adult (≤21 years) patients undergoing heart transplantation at Cincinnati Children’s Hospital Medical Center (CCHMC) and Children’s Hospital of Philadelphia (CHOP) between 2012 and 2021. We recorded demographic, clinical, medication, and laboratory data for pHT patients through 12 months post-transplant. We identified use of topical (oral nystatin) and systemic antifungal prophylaxes in the peri-transplant period (7 days prior through 14 days following transplant) and analyzed if certain transplant variables were associated with the administration of systemic antifungals during this period using rank sum and chi squared tests. Applying published definitions, we quantified the incidence of proven and probable IFD and explored the characteristics of these cases. Results A total of 201 patients underwent heart transplant at CCHMC and CHOP. The majority were male (60.2%), White (66.7%), and not Hispanic or Latino (88.1%). Median age at time of transplant was 7.4 years (IQR 0.9-14.2). During the peri-transplant period, 143 (71.1%) patients received oral nystatin and 37 (18.4%) received systemic antifungal prophylaxis, not including PJP prophylaxis. 41 individuals (20.4%) were not on any antifungal prophylaxis throughout this period. Delayed chest closure was significantly associated with the administration of systemic antifungals (p&amp;lt;0.001) while several other variables (age, hospital, immunosuppression medication, ECMO/LVAD pre-transplant) were not. In total, 8 patients (4%) developed proven (n=5) or probable (n=3) IFD. In our cohort, the incidence rate of proven/probable IFD in the first year post-transplant was 44.8 per 1000 patient-years. The characteristics of these cases are shown in Table 1. Time from pHT to IFD ranged from 11 days to 196 days (median time = 25.5 days). All cases of proven IFD occurred within 28 days of transplant. In three cases of proven/probable IFD, patients were receiving a systemic antifungal or PJP prophylaxis in the seven days prior to IFD onset. Two cases met the definition of probable IFD but the infections resolved without directed therapies. Four patients with proven IFD died within 1 year following transplant, although in only 3 cases was IFD a contributing factor. The one-year all-cause mortality rate among pHT patients with proven/probable IFD (50%) was higher than that in pHT patients without IFD (10.3%; Fisher’s exact p=0.008). Conclusion Over a 10-year period at CCHMC and CHOP, 4% of pHT patients developed proven or probable IFD within one-year post-transplant. All proven IFD cases occurred within a month of transplant while probable cases occurred more than 100 days post-transplant. Delayed chest closure was significantly associated with the administration of systemic antifungal prophylaxis. Patients with proven IFD had poor outcomes despite receipt of appropriate antifungal treatment. Given the low incidence of IFD at these two centers, we were unable to evaluate risk factors for IFD in this population and so larger studies would be needed.

6663 Amputation Rate in Hospitalized Patients With Diabetic Foot Ulcer at Montefiore Medical Center, Bronx, NY

Abstract Disclosure: R. Lopez Fanas: None. A. Herrera Chancay: None. H. Tabassum: None. J. Milosavljevic: None. S. Xu: None. J. Daily: None. A.K. Myers: None. Introduction: Diabetic foot ulcers (DFU) are associated with poor outcomes including lower extremity amputations and death in individuals with diabetes. Our study aims to define health outcomes and explore the association of sociodemographic and clinical factors on amputation rates in patients hospitalized with DFU addressing an existing knowledge gap in our population. Methods: This was a retrospective review of the electronic health record of adult patients hospitalized with DFU at one of the three major Montefiore Medical Center hospitals in the Bronx, New York between 06/01/2016 and 05/30/2021. Patient data extracted from the index admission included demographics, comorbidities, and laboratory values. Survival and amputation rates were calculated for each patient over the five-year study period. Results: In our analysis of 650 patients, 88% self-identified as non-white, and only 23% had commercial insurance. The amputation rate during the initial DFU admission was 44%, with 76% experiencing at least one amputation over five years. Male sex, low BMI, and smoking were associated with amputation during the study period, with an OR of 0.62 (p=0.01), 0.98 (p=0.05), and 1.45 (p=0.05) respectively. Patients with history of osteomyelitis had a higher risk of any amputation during the index admission (OR 2.05, p&amp;lt;0.0001), and the 5-year study period (OR 3.03, p&amp;lt;0.0001). PAD or prior history of amputation increased the risk of any amputation during the study period, OR 2.11 (p=0.0002) and OR 7.92 (p&amp;lt;0.001) ESRD was associated with a higher risk of AKA and BKA during the index admission (OR 2.31, p=0.05). Elevated ESR, CRP, WBC, and low albumin were associated with amputation during admission, with ORs of 1.01 (p=0.0006), 1.05 (p&amp;lt;0.0001), 1.11 (p&amp;lt;0.0001), and 0.41 (p&amp;lt;0.0001), respectively. Discussion: This study revealed a 44% amputation rate during the initial DFU admission, with 76% experiencing at least one amputation within five years. Bivariate analyses identified male sex, lower BMI, and smoking as correlated with a heightened amputation risk, consistent with previous studies. Prior amputation, PAD, ESRD, and osteomyelitis were also associated with an increased risk. Multiple regression analysis found significant associations between elevated ESR, CRP, WBC, and low albumin with amputations. As a result, interventions need to be devised for patients with these characteristics to prevent this high rate of amputation. Presentation: 6/2/2024

Defining the Etiology of Renal Allograft Dysfunction Using Banff 2019 Classification: Correlation with Post-Transplant Duration and Creatinine Levels-A Comprehensive Analysis of 200 Renal Biopsies at a Tertiary Care Medical Center Hospital.

Chronic kidney disease is a growing global health issue, contributing significantly to morbidity and mortality. The incidence of end-stage renal disease (ESRD) is approximately 100 per million population. Renal transplantation remains the cornerstone treatment for ESRD, with a projected 20-year survival rate of 60%. We aim to define the etiology of renal allograft dysfunction using the Banff 2019 classification by analyzing 200 renal allograft biopsies in correlation with creatinine levels across post-transplant time frames. 200 renal allograft biopsies are analyzed using the recent Banff 2019 classification with creatinine levels and post-transplant duration correlation. The study included 150 (75%) male patients and 50 (25%) female patients, with the majority 78 (39%) representing the age group of 16-30 years. 36 (18%) biopsies were within 3-month post-transplant, while 92 (46%) were 2-year post-transplant. According to the Banff 2019 classification, 92 (46.0%) transplant rejection biopsies were identified, with most 54 (27%) exhibiting antibody-mediated rejection (Category 2), including 40 (20%) active acute antibody-mediated rejection (ABMR) and 14 (7.0%) chronic active ABMR. T-cell-mediated rejection (TCMR; Category 4) represented 12 (6%) biopsies, including 10 (5%) acute TCMR and 2 (1%) chronic active TCMR. Category 5, the miscellaneous group, represented 100 (50%) biopsies, out of which 32 (16%) exhibited calcineurin inhibitor (CNI) toxicity, 38 (19%) acute tubular necrosis, and 8 (4%) thrombotic microangiopathy. A notable variation in the dysfunction distribution across different post-transplant time frames indicated a temporal evolution in the underlying causes of allograft dysfunction. Specific Banff categories showed a robust association with renal dysfunction, potentially contributing to the elevation of creatinine levels and renal function deterioration. Our study highlights the intricate pathophysiology of renal allograft dysfunction. Most biopsies were attributed to ABMR whereas one-third of biopsies exhibited mixed lesions (ABMR and TCMR or ABMR and calcineurin inhibitor toxicity (CNIT)). Additionally, this study suggests that renal allograft rejection remains a significant contributor to graft dysfunction. A complex interplay between histological findings, Banff classification, and renal function is noted. A significant difference in the distribution of dysfunction across post-transplant time frames is noted suggesting a temporal evolution in the etiology of allograft dysfunction. Certain Banff categories demonstrate a stronger association with renal dysfunction that may influence creatinine level increase and renal function deterioration. In correspondence to the recent Banff 2019 guidelines for diagnosing ABMR, we emphasize the role of C4d staining on immunofluorescence or immunohistochemistry in allograft biopsies as imperative for timely diagnosis and immunosuppressant therapy adjustment, ultimately enhancing graft survival. Further research is needed to elucidate the underlying mechanisms driving renal dysfunction in different Banff categories, ultimately informing personalized management strategies for patients with renal allograft dysfunction. In line with the Banff 2019 guidelines for diagnosing ABMR, this study highlights the critical role of C4d staining through immunofluorescence or immunohistochemistry in allograft biopsies for early diagnosis and timely adjustment of immunosuppressive therapy, ultimately improving graft survival.

Lead poisoning as a differential diagnosis in pediatric patients with chronic abdominal pain: a case–control study in Tehran-Iran

BackgroundChronic abdominal pain is a potential symptom of lead poisoning, which is often challenging to diagnose. This case–control study aimed to evaluate blood lead levels in pediatric patients with chronic abdominal pain.MethodsThe case–control study was conducted on 190 pediatrics who presented to the Children's Medical Center Hospital clinics, Tehran between April 2021- 2023. The children were divided into two groups: the case group, consisting of 81 patients with chronic abdominal pain, and the matched control group; 109 children without any gastrointestinal symptoms. The statistical analysis of the data was performed using STATA 16. A multiple logistic regression model was used to assess the association of different independent variables with chronic abdominal pain.ResultsThere was no significant difference between mean (± standard deviation [SD]) of age (8.80(2.7) years vs. control group: 9.23(3.9) years), sex, and BMI (16.55(4.6) vs. 17.32(4.7)) of the patients with chronic abdominal pain (case group) and the control group, whereas the mean weight was remarkably low in patients with chronic abdominal pain: 27.25(± 12.1) kg vs. 31.70(± 14.7) kg (P value = 0.028). Fifty-nine percent of children with chronic abdominal pain had serum lead levels ≥ 10 µg/dL. The mean (SD) of blood lead levels was statistically high in the case group: 11.09 (± 5.35) µg/dL vs. control group: 8.26 (± 5.01) µg/dL) (P value ≤ 0.05). The appetite level was significantly low in the case group: 3.8 (± 2.5) vs. control group 5.4 (± 1.3).ConclusionsLead poisoning could be a possible cause of children's chronic abdominal pain. Regarding the high rate of lead poisoning in children exerting appropriate measures to reduce their exposure to lead is necessary.