Non-acute Cases Research Articles

Nationwide Effect of COVID-19 on Cases Performed During Pediatric Orthopaedic Surgery Fellowship Training in the United States.

The COVID-19 pandemic negatively affected surgical training in the United States. We hypothesized that reported case volume during pediatric orthopaedic surgery fellowship training would decrease markedly during the 2019 to 2020 academic year, which corresponded with the COVID-19 outbreak. The Accreditation Council for Graduate Medical Education provided nationwide case logs for accredited pediatric orthopaedic surgery fellows (2017 to 2021). Annual reported case volumes were extracted and summarized as means ± SD. Parametric tests were used to compare annual case volumes. A total of 149 pediatric orthopaedic fellows from 23 accredited fellowships were included. A 16% year-over-year (YoY) decrease was noted in the reported case volume during the 2019 to 2020 academic year (238 ± 80 vs. 255 ± 60, P < 0.001). Nonacute case categories had the most notable YoY percentage decreases: Soft Tissue: Transfer, Lengthen, Release (-42%); Clubfoot (-34%); and Foot and Ankle Deformity (-31%). Acute case categories had the most notable YoY percentage increases: Trauma Lower Limb (12%) and Trauma Upper Limb (10%). A subsequent 42% YoY increase was noted in the reported case volume during the 2020 to 2021 academic year. A 16% YoY decrease was noted in the reported case volume during the 2019 to 2020 academic year, which corresponded to widespread economic shutdowns during the initial COVID-19 outbreak. Nonacute cases experienced the greatest negative effect. The results from this study may inform the orthopaedic surgery community on the effect of future national emergencies, such as viral outbreaks.

SARS-CoV-2 and Placental Pathology: Malperfusion Patterns Are Dependent on Timing of Infection During Pregnancy.

The extent to which severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at different points in the pregnancy timeline may affect maternal and fetal outcomes remains unknown. We sought to characterize the impact of SARS-CoV-2 infection proximate and remote from delivery on placental pathology. We performed a secondary analysis of placental pathology from a prospective cohort of universally tested SARS-CoV-2 positive women >20 weeks gestation at 1 institution. Subjects were categorized as having acute or nonacute SARS-CoV-2 based on infection <14 or ≥14 days from delivery admission, respectively, determined by nasopharyngeal swab, symptom history, and serologies, when available. A subset of SARS-CoV-2 negative women represented negative controls. Placental pathology was available for 90/97 (92.8%) of SARS-CoV-2 positive women, of which 26 were from women with acute SARS-CoV-2 infection and 64 were from women with nonacute SARS-CoV-2. Fetal vascular malperfusion lesions were significantly more frequent among the acute SARS-CoV-2 group compared with the nonacute SARS-CoV-2 group (53.8% vs. 18.8%; P=0.002), while frequency of maternal vascular malperfusion lesions did not differ by timing of infection (30.8% vs. 29.7%; P>0.99). When including 188 SARS-CoV-2 negative placentas, significant differences in frequency of fetal vascular malperfusion lesions remained between acute, nonacute and control cases (53.8% vs. 18.8% vs. 13.2%, respectively; P<0.001). No differences were noted in obstetric or neonatal outcomes between acutely and nonacutely infected women. Our findings indicate timing of infection in relation to delivery may alter placental pathology, with potential clinical implications for risk of thromboembolic events and impact on fetal health.

Applicability and comparison of the sub-Saharan Africa and original WHO maternal near-miss criteria in a rural hospital in Western Tanzania

# Background After the introduction of the maternal near-miss (MNM) criteria by the World Health Organization (WHO), an adapted version for low-income countries was defined but has never been validated in a rural hospital in this setting. Aim of this study was to identify the occurrence of MNM by both the use of the WHO and the adapted sub-Saharan Africa (SSA) MNM tool and to compare the applicability of both versions. # Methods This cross-sectional study was done between November 2019 and July 2020 in Ndala Hospital, Tanzania. All pregnant women and women within 42 days after giving birth or termination of pregnancy were included when fulfilling at least one criterion according to either the WHO or the SSA MNM tool. # Results The SSA MNM criteria identified 47 near-miss cases and all seven maternal deaths. The WHO criteria identified ten near-miss cases and five maternal deaths. There were 948 livebirths, consequently leading to maternal near-miss ratio (MNMR) of 50 (95% CI 34-60) and 11 (95% CI 4 – 16) per 1,000 livebirths for the SSA criteria and respectively the WHO MNM criteria. The difference in these numbers seems to be primarily attributed to the addition of defined severe complications in the clinical criteria and the adapted threshold for blood transfusions. Eclampsia and severe malaria form roughly half of these complications. # Conclusions SSA MNM criteria are more suitable than the WHO criteria to identify patients with potentially life-threatening conditions (PLTC) in this rural hospital. The addition of clinical criteria and rejection of several unapplicable laboratory and management-based parameters in the SSA MNM tool seem appropriate adaptations for low-resource settings. However, some non-acute cases are discussable near-misses and the criterion “severe pre-eclampsia with ICU admission” seems not feasible in similar settings. Implementation of the SSA MNM criteria forms a strong basis for auditing. Better monitoring and documentation of patients will improve the use of the criteria and potentially the quality of audit sessions.

Hymenal morphology in children and adolescents following penile-vaginal penetration

The hymenal injuries in adolescents due to penile penetration is more common and more severe than in adults because of the lack of sexual and child birth experience. In a case of rape which has occurred within few days, the medical professional can identify the injuries on genitalia which are supportive of vaginal penetration. But if the child presents at a later stage there may not be any injury or scar to prove sexual abuse. The paper reviews the contribution of the different examination techniques in identifying the hymenal injuries, different features of an intact hymen, injuries and healing process, which can be expected if the hymen has been penetrated on adolescent children. The appearance of the normal hymen, hymenal injuries healing process of adolescents are not well documented except deep lacerations and transection through the posterior hymen which leaves evidence of previous injury. Most of the publications conclude with stressing the importance of recording the detailed statement given by the child as medico legal diagnosis of alleged non-acute cases of sexual abuse. Therefore obtaining a detailed history of the incident which is the standard duty of care in managing a victim of sexual abuse is as important as recording and interpretation of the hymenal injuries to help the law to make a judicial judgment. The words like no evidence of penetration, normal hymen and intact hymen should be used with caution.

La malrotazione intestinale: cosa deve sapere il pediatra

Intestinal malrotation includes anomalies of intestinal rotation and fixation occurred during embryogenesis. It may present with acute or chronic-intermittent symptoms or remain asymptomatic. There are several methods to identify a defect of intestinal rotation, however an upper gastrointestinal series remains the method of choice in non-acute cases. Surgical correction is performed by open laparotomy, while the laparoscopic approach is reserved only to selected cases. This article suggests an evaluation of children with suspected intestinal malrotation and gives information about its management and complications to paediatricians.

Long-term survival after descending thoracic and thoracoabdominal aortic aneurysm repair

ObjectivePatients with descending thoracic aortic aneurysms (dTAA) or thoracoabdominal aortic aneurysms (TAAA) often have a variety of medical comorbidities. Those that are deemed acceptable for intervention undergo complicated repairs with good early outcomes. The purpose of this study was to identify variables that were associated with mortality over time. MethodsThis was a retrospective review of a prospectively maintained database at our institution from 1983 to 2015. Patients were included if they underwent open or endovascular repair for dTAA or TAAA. Patients were excluded if they were intervened on for traumatic transections. The primary outcome for the study was long-term survival. Secondary outcomes included aortic-related mortality. We had mortality and survival data on all patients. ResultsA total of 946 patients met our study criteria with a median follow-up of 102.8 months (interquartile range [IQR], 58.9-148.2 months). The median age of the cohort was 71 years (IQR, 63-77 years) with the majority of patients being male (58.1%). The extent of TAAA pathology was as follows: type I (14.2%), type II (21.2%), type III (17.1%), type IV (26.2%), and dTAA (21.2%). A total of 147 patients (15.5%) had a prior dissection. The median diameter of aneurysm was 6.4 cm (IQR, 6.0-7.0 cm). A total of 158 patients (16.7%) underwent endovascular repair over the study period. Variables associated with mortality over time were age, surgical era, acute pathology, dissection, preoperative creatinine, and type IV TAAAs. In addition, experiencing the following complications in the postoperative period was associated with mortality over time: neurological, cardiac, and pulmonary. Aortic-related mortality was 2.1% (n = 20) over the study period. Patients who underwent endovascular repair for acute conditions had better long-term survival when compared with open repair. However, there were no differences in long-term survival between open and endovascular repair for nonacute cases. In addition, repair in the more modern era was associated with improved survival. ConclusionsTAAAs can be repaired with reasonable perioperative mortality rates. Once patients undergo repair of their aneurysm, aortic-related mortality remains low. The addition of endovascular options has dramatically changed management of patients with dTAA and TAAA. Further, endovascular repair was associated with decreased perioperative mortality and significantly increased long-term survival in acute patients. Patients undergoing TAAA repair are generally considered high risk and therefore require extensive long-term follow-up for management of their comorbidities and complications, because these are the main contributors to mortality over time.

MicroRNA-423-5p as a biomarker for early diagnosis and outcome prediction of acute kidney injury in patients with acute decompensated heart failure.

To evaluate the clinical significance of serum and urinary microRNA-423-5p in the prediction of acute kidney injury onset and survival in patients with acute decompensated heart failure. A total of 180 acute decompensated heart failure patients, including 57 acute kidney injury cases and 123 non-acute kidney injury cases, were included in this study. Serum and urinary neutrophil gelatinase-associated lipocalin, a biomarker of renal injury of acute kidney injury, was detected using an enzyme-linked immunosorbent assay. Expression of microRNA-423-5p in serum and urine samples was examined using quantitative real-time polymerase chain reaction. The clinical significance of microRNA-423-5p was evaluated using receiver operating characteristic curve and Kaplan-Meier survival analysis. The levels of neutrophil gelatinase-associated lipocalin and microRNA-423-5p in serum and urine samples were elevated in patients with acute kidney injury compared with the non-acute kidney injury cases (all P<0.05). Serum and urinary microRNA-423-5p had relatively high predictive performance for acute kidney injury onset in acute decompensated heart failure patients, and this predictive value was more significant when combined with urinary neutrophil gelatinase-associated lipocalin. In addition, serum and urinary elevated levels of microRNA-423-5p predicted a poor 180-day survival in the acute kidney injury group. Increased serum and urinary microRNA-423-5p can predict the occurrence of acute kidney injury in acute decompensated heart failure patients, and is associated with poor survival of acute kidney injury patients. In addition, the diagnostic value of urine neutrophil gelatinase-associated lipocalin for the early screening of acute kidney injury from acute decompensated heart failure patients might be improved by considering the changes in urinary microRNA-423-5p.

Impact of Medicaid Expansion of the Affordable Care on the Outcomes of Lower Extremity Bypass for Patients With Peripheral Artery Disease in the Vascular Quality Initiative Database.

The aim of this study was to evaluate changes in the utilization and outcomes of surgery after Medicaid Expansion (ME) for patients with peripheral artery disease (PAD). Recent studies have demonstrated increased insurance coverage and improved care with the Affordable Care Act's (ACA) state expansion of Medicaid. Infrainguinal bypass procedures performed due to occlusive pathology in the Vascular Quality Initiative database between 2010 and 2017 were included. Primary outcomes including postoperative mortality and major adverse limb events (MALE) at 1-year of follow-up were analyzed using interrupted time-series analysis (ITS). Out of 26,446 infrainguinal bypass procedures, 13,955 (52.8%) were included in this analysis. ME states witnessed an annual decrease in infrainguinal surgery for acute ischemia [annual change in post vs pre-ME period (95% confidence interval): -4.3% (-7.5% to -1.0%), P = 0.02] and an increase in revascularization for claudication [3.7% (1.7%-5.6%), P = 0.01]. Among nonacute cases, elective procedures increased in ME states [3.9% (0.1%-7.7%), P = 0.05] along with a significant annual decrease in in-hospital mortality [-0.4% (-0.8 to -0.02), P = 0.04) and MALE at 1 year of follow up [-9.0% (-20.3 to 2.3), P = 0.09]. These results were statistically significant after comparing them with the annual trend changes in states which did not adopt ME. The adoption of ME in 2014 was associated with significant increase in the use of infrainguinal bypass for nonsevere and elective cases, along with improved in-hospital mortality and MALE at 1 year. Longer follow-up is needed to evaluate the impact of ME on other aspects of care and longer term outcomes of PAD patients.

Immunohistochemical Evaluation of Aquaporin-4 and its Correlation with CD68, IBA-1, HIF-1α, GFAP, and CD15 Expressions in Fatal Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide. Our understanding of its pathobiology has substantially increased. Following TBI, the following occur, edema formation, brain swelling, increased intracranial pressure, changes in cerebral blood flow, hypoxia, neuroinflammation, oxidative stress, excitotoxicity, and apoptosis. Experimental animal models have been developed. However, the difficulty in mimicking human TBI explains why few neuroprotective strategies, drawn up on the basis of experimental studies, have translated into improved therapeutic strategies for TBI patients. In this study, we retrospectively examined brain samples in 145 cases of death after different survival times following TBI, to investigate aquaporin-4 (AQP4) expression and correlation with hypoxia, and neuroinflammation in human TBI. Antibodies anti-glial fibrillary acid protein (GFAP), aquaporin-4 (AQP4), hypoxia induced factor-1α (HIF-1α), macrophage/phagocytic activation (CD68), ionized calcium-binding adapter molecule-1 (IBA-1), and neutrophils (CD15) were used. AQP4 showed a significant, progressive increase between the control group and groups 2 (one-day survival) and 3 (three-day survival). There were further increases in AQP4 immunopositivity in groups 4 (seven-day survival), 5 (14-dayssurvival), and 6 (30-day survival), suggesting an upregulation of AQP4 at 7 to 30 days compared to group 1. GFAP showed its highest expression in non-acute cases at the astrocytic level compared with the acute TBI group. Data emerging from the HIF-1α reaction showed a progressive, significant increase. Immunohistochemistry with IBA-1 revealed activated microglia starting three days after trauma and progressively increasing in the next 15 to 20 days after the initial trauma. CD68 expression demonstrated basal macrophage and phagocytic activation mostly around blood vessels. Starting from one to three days of survival after TBI, an increase in the number of CD68 cells was progressively observed; at 15 and 30 days of survival, CD68 showed the most abundant immunopositivity inside or around the areas of necrosis. These findings need to be developed further to gain insight into the mechanisms through which brain AQP4 is upregulated. This could be of the utmost clinicopathological importance.

NPM1, FLT3 and CEBPA mutations in pediatric patients with AML from Argentina: incidence and prognostic value.

Mutations in NPM1, FLT3 and CEBPA genes are found in 25-35% of adult acute myeloblastic leukemia (AML) cases and correlate with prognosis. To date, there have been no reports about these mutations in pediatric AML from Argentina. The aims of the present study were to describe the incidence of NPM1, FLT3 and CEBPA mutations and to analyze their prognostic impact in this population. The incidences of these mutations within a population of 216 pediatric AML cases were: NPM1-mutated 4.2%, CEBPA-mutated 1.9%, FLT3-ITD 10.2% and FLT3-TKD 7.9%. Among 33 patients with normal karyotype, we found significantly higher frequencies for NPM1-mutated 24.2% and CEBPA-mutated 12.1%. Overall survival (pOS) for the 163 eligible non-acute promyelocytic leukemia cases was 46.2±4.3%, while leukemia-free survival probability was 51.0±4.4% (n=135). The NPM1-mutated/FLT3-ITD-negative genotype showed better outcome than any other combined NPM1/FLT3 genotype; this difference was statistically significant within the group of high-risk patients (pOS±SE 83.3±15.2% versus 33.1±4.7%; p=0.0251). This is the first report of the frequencies of these mutations in Argentina. Despite the limited number of patients, a favorable prognosis of AML with genotype NPM1-mutated/FLT3-ITD-negative was confirmed. This is especially relevant within the high-risk group of patients, as it may contribute to the detection of patients with better prognosis, and thus avoid unnecessary treatment intensification.

Stranded: causes and effects of discharge delays involving non-acute in-patients requiring maintenance care in a tertiary hospital general medicine service.

Objectives The aims of the present study were to identify causes of prolonged discharge delays among non-acute in-patients admitted to a tertiary general medicine service, quantify occupied bed days (OBDs) and propose strategies for eliminating avoidable delays. Methods A retrospective study was performed of patients admitted between 1 January 2012 and 31 May 2015 and discharged as non-acute cases requiring maintenance care and who incurred a total non-acute length of stay (LOS) >7 days and total hospital LOS >14 days. Long-stay patients with non-acute LOS ≥28 days were subject to chart review in ascertaining serial causes of discharge delay and their attributable OBDs. Literature reviews and staff feedback identified potential strategies for minimising delays. Results Of the 406 patients included in the present study, 131 incurred long-stays; for these 131 patients, delays were identified that accounted for 5420 of 6033 (90%) non-acute OBDs. Lack of available residential care beds was most frequent, accounting for 44% of OBDs. Waits for outcomes of guardianship applications accounted for 13%, whereas guardian appointments, Public Trustee applications and funding decisions for equipment or care packages each consumed between 4% and 5% of OBDs. Family and/or carer refusal of care accounted for 7%. Waits for aged care assessment team (ACAT) assessments, social worker reports, geriatrician or psychiatrist reviews and confirmation of enduring power of attorney each accounted for between 1% and 3% of OBDs. Of 30 proposed remedial strategies, those rated as high priority were: greater access to interim care or respite care beds or supported accommodation, especially for patients with special needs; dedicated agency officers for hospital guardianship applications and greater interagency collaboration and harmonisation of assessment and decision processes; and formal requests from hospital administrators to patients and family to accept care options and attend mediation meetings. Conclusions Delayed discharge of non-acute maintenance care patients results principally from impaired access to residential care, administrative delays involving external agencies and patient or family refusal of care. Proposed remedial actions require concerted interjurisdictional advocacy. What is known about this topic? Delays in discharge of non-acute patients requiring maintenance care can occur for many reasons and incur inordinately long hospital stays. What does this paper add? The present detailed chart review of 131 long-stay non-acute patients identified causes of serial discharge delays and quantified their prevalence and attributable bed days. Waits for residential care accounted for less than half the bed days, administrative delays involving decisions by agencies external to the hospital accounted for one-quarter and patient or family refusal of care options accounted for one-tenth. Strategies are proposed that may minimise these delays. What are the implications for practitioners? Delayed discharge of non-acute patients requiring maintenance care threatens to consume an ever-increasing proportion of acute hospital bed days. Remedial action is required from stakeholders both within and outside hospitals to reverse this trend.

Use of high-resolution 3.0-T magnetic resonance imaging to characterize atherosclerotic plaques in patients with cerebral infarction.

The present study aimed to evaluate the utility of high-resolution magnetic resonance imaging (MRI) in the characterization of atherosclerotic plaques in patients with acute and non-acute cerebral infarction. High-resolution MRI of unilateral stenotic middle cerebral arteries was performed to evaluate the degree of stenosis, the wall and plaque areas, plaque enhancement patterns and lumen remodeling features in 15 and 17 patients with acute and non-acute cerebral infarction, respectively. No significant difference was identified in the vascular stenosis rate between acute and non-acute patients. Overall, plaque eccentricity was observed in 29 patients, including 13 acute and 16 non-acute cases, with no significant difference identified between these groups. The wall area of stenotic arteries and the number of cases with plaque enhancement were significantly greater in the acute patients, but no significant difference in plaque or lumen area was identified between the 2 patient groups. Lumen remodeling patterns of stenotic arteries significantly differed between the acute and non-acute patients; the former predominantly demonstrated positive remodeling, and the latter group demonstrated evidence of negative remodeling. In conclusion, patients with acute and non-acute cerebral infarction exhibit specific characteristics in stenotic arteries and plaques, which can be effectively evaluated by high-resolution MRI.

Comparison of utilization rate of CT scans of the abdomen and pelvis in patients with elevated BMI compared to patients with normal BMI presenting to the ER with gastrointestinal symptoms

PurposeThe purpose of this study was to determine if patients with elevated BMI were more likely to get Abdominopelvic CT imaging compared to patients with normal BMI presenting with similar Gastrointestinal (GI) symptoms to the Emergency Room (ER). MethodsThe study included 611 adults presenting to the ER with GI symptoms during the study period, of which 291 patients underwent CT imaging. ER triage notes and electronic records were used to identify patients' demographic data, symptoms, body weight and height. BMI was used as a measure of obesity. Reports of the CT scans were reviewed and categorized into normal cases, cases with non-acute incidental findings and cases with acute significant findings by the reviewers. A chi-square test was used to compare the two groups. ResultsOf the 611 patients, 231 (37.8%) had a normal BMI (<25 kg/m2), and 380 (62.2%) had an elevated BMI (>25 kg/m2). Of the 231 patients with normal BMI, 98 (42.4%) received CT imaging. Of the 380 patients with elevated BMI, 193 (50.8%) underwent CT imaging, (p = 0.045). The percentage of acute significant CT findings was similar in both groups (45.9% vs. 45.6%), (p > 0.05). The elevated BMI group had a higher percentage of normal exams compared to the normal BMI group (44.0% vs. 10.2%), (p < 0.0001). The percentage of non-acute incidental findings was higher in the normal BMI group compared to the elevated BMI group (43.8% vs. 10.3%), (p < 0.0001). ConclusionAccording to our study results, there is a positive correlation between increased BMI and a higher utilization rate of abdominal CT imaging, (p = 0.045).

Use of Department of Veterans Affairs administrative data to identify veterans with acute low back pain: a pilot study.

This work compared administrative data obtained from the Department of Veterans Affairs (VA) databases with structured chart review. We set out to determine whether a decision tool using administrative data could discriminate acute from nonacute cases among the many patients seen for a low back pain (LBP)-related diagnosis. Large health care systems' databases present an opportunity for conducting research and planning operations related to the management of highly burdensome conditions. An efficient method of identifying cases of acute LBP in these databases may be useful. This was a retrospective review of all consecutive Iraq and/or Afghanistan Veterans seen in a VA primary care service during a 6-month period. Administrative data were extracted from VA databases. Patients with at least 1 encounter that was coded with at least 1 LBP-related ICD-9 code were included. Structured chart review of electronic medical record free text was the "gold standard" to determine acute LBP cases. Logistic regression models were used to assess the association of administrative data variables with chart review findings. We obtained complete data on 354 patient encounters, of which 83 (23.4%) were designated acute upon chart review. No diagnostic code was more likely to be used in acute cases than nonacute. We identified an administrative data model of 18 variables that were significant and positively associated with an acute case (C-statistic = 0.819). A reduced model of 5 variables including a lumbar magnetic resonance imaging order, tramadol prescription, skeletal muscle relaxant prescription, physical therapy order, and addition of a new LBP-related ICD-9 code to the electronic medical record remained reasonable (C-statistic = 0.784). Our results suggest that a decision model can identify acute from nonacute LBP cases in Veterans using readily available VA administrative data. N/A.

Operator learning curve for transradial percutaneous coronary interventions: implications for the initiation of a transradial access program in contemporary US practice

Our study aimed to assess the characteristics and outcomes of transfemoral approach (TFA) versus the initial steps of a transradial approach (TRA) program and to assess the learning curve of TRA in contemporary, US practice. When compared to TFA, TRA has been shown to lower bleeding and vascular complications during percutaneous coronary intervention (PCI). However, use of TRA is still low. There are limited data regarding the characteristics of TRA learning curve, especially in an era with designated TRA equipment. Consecutive patients undergoing PCI in a single US center were divided into two cohorts according to vascular access approach: the last 250 TFA patients prior to the establishment of a TRA program and the initial 239 TRA patients following the establishment of a TRA program. Subgroup analysis of the TRA group, which was divided into five sequential case groups of 50 cases per group, was performed in order to assess TRA learning curve. Overall, the baseline characteristics of TFA vs. TRA groups were comparable. Fluoroscopy time was significantly longer during TRA procedures (18±11 vs. 15±8min, respectively, p=0.002); however, contrast use was lower during TRA procedures (161±72 vs. 180±63ml, respectively, p=0.002). In-hospital outcomes were similar between the two groups, with low frequencies of mortality, myocardial infarction, and stent thrombosis. Subanalysis of TRA group for learning curve assessment showed no major differences in patient demographics among the five subgroups. In the initial cases, more PCI was performed among non-acute cases (62% in patients 1-50 vs. 8-27% in patients 51-239, p<0.001). Despite these differences, characteristics of the treated vessels were similar between groups. There was no significant change in fluoroscopy time or in the amount of iodinated contrast volume delivered. Similarly, no differences in procedural, in-hospital, and long-term outcomes were documented. Adopting TRA as a default is feasible for high-volume operators without significant learning curve effects.

Accuracy of Physician Reporting in Routine Public Health Surveillance for Hepatitis C Virus Infection

From January 2007 to December 2008, the Montréal Public Health Department sent postal questionnaires to physicians and conducted patient interviews for all those newly diagnosed with hepatitis C virus (HCV) infection. We evaluated physician responses to risk factor questions for non-acute HCV cases. We compared physician and patient responses with each of nine risk factor questions, determined the sensitivity and specificity of physician responses compared with patient responses, and evaluated agreement using Gwet's agreement coefficient (AC1). We ranked risk factors and compared the distributions by principal exposure category according to physician reporting vs. patient interview using the Chi-square test. The completeness of physicians' responses (yes, no, or unknown) varied by risk factor question from 90.8% to 96.7%. For risk factors present among more than 5% of cases, sensitivity of physician responses ranged from 26.9% to 87.7% and specificity ranged from 93.0% to 98.6%. The AC1 coefficients for agreement between physician and patient responses to lifetime risk factors considered most important in HCV acquisition were 0.80 for injection drug use, 0.95 for blood transfusion before 1990, and 0.86 for birth in a country with high HCV prevalence. Risk distributions by principal exposure category according to physician reporting vs. patient interview were not statistically different (χ(2)[4] = 2.17, p=0.704). Postal questionnaires completed by physicians appear valid for determining the principal exposure category among non-acute HCV cases. Physician reporting can be a useful and low-cost component of routine HCV surveillance.

Incidence of Treatment-Related, Laboratory and Clinical Tumor Lysis Syndrome

AbstractAbstract 238 Background:Tumor lysis syndrome (TLS) is a potentially life-threatening metabolic disorder that most often develops after cytotoxic therapy for hematologic malignancies and rapidly proliferating or large tumors. Rapid lysis of tumor cells may result in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia, leading to renal dysfunction, cardiac arrhythmia, seizures, and potentially death (Cairo et al Br J Haematol 2004). Acute TLS requires rapid and aggressive intervention focused on hydration and reducing uric acid levels. Despite optimal care, severe acute kidney injury may occur, requiring renal supportive therapy and delay of subsequent chemotherapy cycles (Cairo et al Br J Haematol 2011, Cairo et al Br J Haematol 2012). Prevention of TLS may be more cost-effective than treatment if accurate prediction of patients at risk is possible. Objective:In an effort to assess the risk of treatment-related TLS in large metropolitan hospitals, incidence data from the Henry Ford Health System, obtained between October 31, 2000 and June 30, 2011, were analyzed retrospectively. Methods:Patients included in the analysis were those newly diagnosed with cancer, were chemotherapy naïve at baseline, had their initial chemotherapy administration within 7 days of their cancer diagnosis, and had no prior history of TLS (N=951; Figure 1). The majority of patients were Caucasian (60%); slightly more than half were female (52%), and the median age at cancer diagnosis was 67 years.Laboratory TLS (LTLS) and clinical TLS (CTLS) were defined by using a modified Cairo-Bishop classification (Cairo et al Br J Haematol 2004). Patients who had 2 or more abnormal laboratory values (serum uric acid, potassium, phosphorous, or calcium) reported on the same day within 3 days before to 7 days after anticancer therapy were identified as having LTLS. Patients with LTLS who had ≥1 clinical complication (renal insufficiency, cardiac arrhythmia, seizure, or sudden death) within 5 days of an abnormal laboratory value were identified as having CTLS. Results:Preliminary descriptive results indicated that the overall incidence was 9.3% for LTLS and 6.7% for CTLS (Fig 2). TLS rates were highest for hematologic cancers (21.1% for LTLS, 15.1% for CTLS) followed by gastrointestinal (8.4% for LTLS, 5.0% for CTLS), epithelial (4.9% for LTLS, 4.0% for CTLS), and genitourinary cancers (3.8% for LTLS, 3.3% for CTLS). Among hematologic cancers, rates were highest for acute leukemia (26.0% for LTLS, 16.4% for CTLS) and multiple myeloma (21.7% for LTLS, 20.3% for CTLS). Among solid tumors, rates of TLS were highest for esophageal (23.5% for LTLS, 5.9% for CTLS), liver (14.3% for LTLS and CTLS), and endocrine tumors (11.8% for LTLS and CTLS).Across hematologic cancer types, approximately two-thirds of patients with LTLS developed CTLS. The rate of LTLS was highest in acute leukemia patients (26%) followed by multiple myeloma (21.7%), whereas multiple myeloma patients had the highest proportion of CTLS (20.3% for multiple myeloma vs 16.4% for leukemia). In examining the abnormal laboratory values used to determine LTLS, 52% of patients had hyperuricemia (Fig 3). Rates of hyperuricemia by cancer type were approximately 63% for hematologic, 56% for epithelial, 38% for genitourinary, and 20% for gastrointestinal cancers. For CTLS, the majority of patients had renal insufficiency or creatinine elevations (62.5%), followed by arrhythmia (35.9%), and seizure (1.6%).Findings suggest that hyperuricemia is not the sole contributor to treatment-related LTLS—hyperkalemia, hyperphosphatemia, and hypocalcemia were also evident in a substantial proportion of patients with LTLS. Limitations of the study include a restrictive exclusion of patients who do not initiate chemotherapy within 1 week of diagnosis, thereby eliminating non-acute TLS cases and possibly patients at low- to intermediate risk for developing TLS. Conclusion:This preliminary analysis will be the basis for refining the methodology for examining LTLS and CTLS incidence across a broad array of cancer types in a large population database. Such information may be used by health care providers to more accurately predict the risk of patients developing TLS. [Display omitted] [Display omitted] [Display omitted] Disclosures:Thompson:Sanofi-Aventis: Employment. Stern:Sanofi: Consultancy. Sherman:Sanofi: Consultancy.

Hospital discharge database optimization in guillain‐barré syndrome surveillance

Precise causes and risk factors for Guillain-Barré syndrome (GBS) remain incompletely understood, and monitoring its incidence remains important in public health. Active surveillance is not sustainable, but hospital discharge databases (HDDs) may be suitable for passive surveillance. We optimized Tennessee's HDD of all ICD-9 codes of 357.0, from 2000 to 2010. Discharges for persons with a GBS diagnosis in a previous hospitalization in the database were excluded. HDD results were compared with the CDC's active surveillance program during the H1N1 vaccination program of 2009-2010. Of 2,659 records of Tennessee residents initially identified, 1077 (40%) had prior diagnoses of GBS. Adjusted annual rates ranged from 1.24 to 1.57 per 100,000 population. The sensitivity of the optimized HDD was 0.81 with a positive predictive value of 0.45. Optimization of a HDD through exclusion of nonacute cases results in an acceptable and practical database for passive surveillance of GBS.

Mastoiditis diagnosed by clinical symptoms and imaging studies in children: Disease spectrum and evolving diagnostic challenges

Acute mastoiditis has been increasingly reported. We reviewed our experience of mastoiditis in children in the era of expanding application of imaging tools and endless emerging antimicrobial resistance. We reviewed all medical records of children (< 18 years of age) hospitalized with mastoiditis between January 2001and December 2010. Diagnosis of mastoiditis was based on clinical features and confirmed by imaging studies. Patients were classified as having acute or nonacute mastoiditis according to the duration of the disease. Acute mastoiditis was defined as illness of less than 3 weeks prior to hospitalization. Cases of longer than 3 weeks' duration were defined as nonacute mastoiditis. We compared the clinical, laboratory and microbiological features of acute and nonacute mastoiditis. A total of 104 children were enrolled in this study, comprising 56 acute cases and 48 nonacute cases. Fever and coryza were significantly more common in acute cases. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were both initially higher in acute mastoiditis. CRP, rather than ESR, declined faster in acute than in nonacute mastoiditis. Computerized tomography (CT) scans, but not plain films, were highly sensitive. Streptococcus pneumoniae and Haemophilus influenzae accounted for 52% of all isolates. Staphylococci, Pseudomonas spp. and polymicrobials were predominantly seen in non-acute mastoiditis. With the application of imaging studies, many cases of mastoiditis were identified. The classical postauricular signs were present in only 10% of patients. The presenting symptoms, inflammatory markers, pathogens, management and outcome were greatly influenced by the duration of the illness prior to admission.

A comparative laboratory diagnosis of malaria: microscopy versus rapid diagnostic test kits

ObjectiveTo compare the two methods of rapid diagnostic tests (RDTs) and microscopy in the diagnosis of malaria. MethodsRDTs and microscopy were carried out to diagnose malaria. Percentage malaria parasitaemia was calculated on thin films and all non-acute cases of plasmodiasis with less than 0.001% malaria parasitaemia were regarded as negative. Results were simply presented as percentage positive of the total number of patients under study. The results of RDTs were compared to those of microscopy while those of RDTs based on antigen were compared to those of RDTs based on antibody. Patients' follow-up was made for all cases. ResultsAll the 200 patients under present study tested positive to RDTs based on malaria antibodies (serum) method (100%). 128 out of 200 tested positive to RDTs based on malaria antigen (whole blood) method (64%), while 118 out of 200 patients under present study tested positive to visual microscopy of Lieshman and diluted Giemsa (59%). All patients that tested positive to microscopy also tested positive to RDTs based on antigen. All patients on the second day of follow-up were non-febrile and had antimalaria drugs. ConclusionsWe conclude based on the present study that the RDTs based on malaria antigen (whole blood) method is as specific as the traditional microscopy and even appears more sensitive than microscopy. The RDTs based on antibody (serum) method is unspecific thus it should not be encouraged. It is most likely that Africa being an endemic region, formation of certain levels of malaria antibody may not be uncommon. The present study also supports the opinion that a good number of febrile cases is not due to malaria. We support WHO's report on cost effectiveness of RDTs but, recommend that only the antigen based method should possibly, be adopted in Africa and other malaria endemic regions of the world.