Routine Repeat Research Articles

Epicardial adipose tissue volume and density are associated with heart failure with improved ejection fraction

Abstract Background Heart failure (HF) with improved ejection fraction (EF, HFimpEF) gains increasing attention as a distinct HF subtype, characterized by left ventricular reverse remodeling and myocardial recovery. Multiple cardiometabolic factors are implicated in this process. Epicardial adipose tissue (EAT), emerging as an endocrine and paracrine organ, contributes to the onset and progression of HF. However, the relation between EAT and the incidence of HFimpEF is still unclear. Methods A total of 203 hospitalized HF patients with reduced EF (HFrEF, EF≤ 40%) who underwent coronary CT angiography (CCTA) during index hospitalization were consecutively enrolled between November 2011 and December 2022. Routine follow-up and repeat echocardiograms were performed. The incidence of HFimpEF was defined as (1) an absolute EF improvement ≥10% and (2) a second EF > 40% (at least 3 months apart). EAT volume and density were semiautomatically quantified on non-enhanced series of CCTA scans. Results During a median follow-up of 8.6 (4.9~13.3) months, 104 (51.2%) patients developed HFimpEF. Compared with HFrEF patients, HFimpEF patients had lower EAT volume (126.03 ± 57.71 cm3 vs 182.74 ± 82.99 cm3 , P< 0.001) and higher EAT density (-74.92 ± 6.84 HU vs -78.76 ± 6.28 HU, P< 0.001) both in ischemic and non-ischemic HF patients. EAT density was inversely correlated with EAT volume (r= -0.33, P< 0.001). Multivariate analysis showed lower EAT volume (OR: 0.881 [95% CI 0.821~0.939]) and higher density (OR: 2.354 [95% CI 1.314~4.415]) were both independently associated with the incidence of HFimpEF, after adjusting for conventional risk factors, pharmacological therapies and baseline anthropometric parameters including body mass index. Subgroup analysis revealed that the association between EAT properties and HFimpEF was not modified by HF etiology. Conclusions This study reveals that lower EAT volume and higher EAT density are associated with development of HFimpEF. Therapies targeted at reducing EAT quantity and improving its quality might provide favorable effects on myocardial recovery in HF patients.

8586 A Case Of Vitamin D Toxicity: From Michigan To Hawaii, Vitamin D Is Very High

Abstract Disclosure: A. Abu Limon: None. S.A. Aldasouqi: None. K. Patel: None. F. Akanbi: None. S. Khan: None. P. Kachhadia: None. We report a patient case who is a 46-year-old male, managed for Type 2 diabetes and Vitamin D deficiency (Defined by 25-hydroxy vitamin D levels less than 20ng/ml) at Michigan State University Endocrinology specialty clinic.He started taking 5000 IU daily Vitamin D supplements and on subsequent follow up his levels corrected to 88 ng/ml. His supplements were held.On a routine repeat lab check, his 25-hydroxy vitamin D level is reported to be higher than 200 ng/ml. Which meets the biochemical diagnosis of Vitamin D toxicity. His Calcium level was 9.7 mg/dL (N 8.7-10.3 mg/dL) and PTH-intact level was 38.3 pg/mL (N 14.0-72.0 pg/mL).On questioning the patient, he assured us he is still not on any Vitamin D supplements and that he just got back from a two-weeks long trip from Hawaii and spent hours daily on the beach without using sunblock.He is sure he didn't get tanning, sunburns, or any burns during that period.He was feeling fine without any symptoms or complications.While in Michigan during the winter, with limited number of sunny days, His 25-hydroxy vitamin D levels trended down slowly over the following few months, while Vitamin D supplements kept on hold.The most common cause of Vitamin D toxicity is excessive supplemental Vitamin D use. Other reasons can be related to excessive tanning or burns, that our patient didn't have. Excessive sun exposure or dietary intake is not a known reason to raise Vitamin D levels to a toxic range.Our patient lives in Mid-Michigan, an area known for low number of sunny days (150-180 sunny/ partly sunny days per year ), Which is a reason for high prevalence of vitamin D deficiency in the population. This is Compared to mostly sunny days on the Hawaiian Islands.Coming Back home for the winter season did help his Vitamin D levels to continue trending down back to a safe, non-toxic range. Presentation: 6/2/2024

Follow-Up Imaging in Angiography-Negative Spontaneous Subarachnoid Hemorrhage

BackgroundThe aim of this study was to assess the diagnostic yield of follow-up investigations in aneurysm negative SAH patients. Material and MethodsIn 109 (25%) of 435 patients with SAH and initial negative DSA, the diagnostic yield of repeat DSA and MRI of the brain and craniocervical junction was reviewed. ResultsOf the 109 patients with an initial negative DSA, 51 (47%) had perimesencephalic (PM), 54 (50%) had non-perimesencephalic (NPM) blood distribution, and 4 (3.7%) had CT-negative SAH. A delayed bleeding source was determined in 3 of 82 (3.7%) patients who underwent repeat DSA, and in 1/5 patients who underwent a third DSA. The bleeding patterns of these patients were all NPM (n=4). Repeat DSA did not identify a bleeding source in patients with PM-SAH. MRI of the brain and craniocervical junction after 2 days revealed a bleeding source in 1/105 patients (1%) in a CT-negative SAH. When all diagnostic modalities, including exploratory craniotomy and MRI of the spinal axis were considered, the rate of delayed diagnosis of the bleeding source was 6.4% (7/109). In addition to the bleeding pattern, patients with delayed diagnosis of the bleeding source were characterized by worse disease severity parameters, worse radiological grading scales, and more in-hospital complications than patients without delayed diagnosis of a bleeding source. ConclusionThe results of this study support the use of repeat DSA in patients with NPM-SAH, however, routine repeat DSA may not be indicated in PM-SAH patients. The routine use of MRI remains controversial.

Epicardial adipose tissue volume and density are associated with heart failure with improved ejection fraction

BackgroundHeart failure (HF) with improved ejection fraction (EF, HFimpEF) is a distinct HF subtype, characterized by left ventricular (LV) reverse remodeling and myocardial functional recovery. Multiple cardiometabolic factors are implicated in this process. Epicardial adipose tissue (EAT), emerging as an endocrine and paracrine organ, contributes to the onset and progression of HF. However, the relation between EAT and the incidence of HFimpEF is still unclear.MethodsA total of 203 hospitalized HF patients with reduced EF (HFrEF, LVEF ≤ 40%) who underwent coronary CT angiography (CCTA) during index hospitalization were consecutively enrolled between November 2011 and December 2022. Routine follow-up and repeat echocardiograms were performed. The incidence of HFimpEF was defined as (1) an absolute LVEF improvement ≥ 10% and (2) a second LVEF > 40% (at least 3 months apart). EAT volume and density were semiautomatically quantified on non-enhanced series of CCTA scans.ResultsDuring a median follow-up of 8.6 (4.9 ~ 13.3) months, 104 (51.2%) patients developed HFimpEF. Compared with HFrEF patients, HFimpEF patients had lower EAT volume (115.36 [IQR 87.08 ~ 154.78] mL vs. 169.67 [IQR 137.22 ~ 218.89] mL, P < 0.001) and higher EAT density (-74.92 ± 6.84 HU vs. -78.76 ± 6.28 HU, P < 0.001). Multivariate analysis showed lower EAT volume (OR: 0.885 [95%CI 0.822 ~ 0.947]) and higher density (OR: 1.845 [95%CI 1.023 ~ 3.437]) were both independently associated with the incidence of HFimpEF. Subgroup analysis revealed that the association between EAT properties and HFimpEF was not modified by HF etiology.ConclusionsThis study reveals that lower EAT volume and higher EAT density are associated with development of HFimpEF. Therapies targeted at reducing EAT quantity and improving its quality might provide favorable effects on myocardial recovery in HF patients.Graphical abstract

A challenging decision for emergency physicians: Routine repeat computed brain tomography of the brain in head trauma in infants and neonates.

Head trauma is a leading cause of death and disability. While standard treatment protocols exist for severe head trauma, no clear follow-up standards are available for mild head trauma with positive imaging findings in infants and newborns. Although routine follow-up brain computed tomography (CT) imaging is not recommended for children with moderate and mild head trauma, the necessity for follow-up imaging in infants and newborns remains uncertain. Our study is a retrospective, observational, and descriptive study. Infants under 1 year old presenting to the emergency department with isolated head trauma were reviewed with the approval of the Ethics Committee of Ankara Etlik City Hospital. Inclusion criteria included presentation to the emergency department, undergoing more than one brain CT scan, and sustaining mild head trauma (Glasgow Coma Scale [GCS] >13). Patients with incomplete follow-up data or multiple traumas were excluded. Age, gender, mechanism of trauma, initial and follow-up brain CT findings, hospital admission, and surgical procedures were recorded and analyzed using the SPSS statistical package. Out of 238 screened patients, 154 were included in the study. Of these, 66.9% were male and the average age was 5.99 months. The most common presenting symptom was swelling at the trauma site, observed in 79.2% of cases. The most common mechanism of injury was falling from a height of less than 90 cm, accounting for 85.1% of cases. Pathological progression on follow-up CT was observed in 5.2% of the patients, and only 1.9% required surgical treatment. A total of 34.4% of the patients required hospitalization. Patients with parenchymal brain pathology had a higher rate of pathological progression on follow-up CT and a longer hospital stay. Follow-up CT scans in infants with mild head trauma do not alter patient outcomes except in cases with brain parenchymal pathology. Study data indicated that repeat imaging is not beneficial for isolated skull fractures. Imaging artifacts often necessitated repeated scans, contributing to increased radiation exposure. Unnecessary repeat imaging escalates radiation exposure and healthcare costs. Only a small percentage of patients exhibited progression of intracranial pathology, justifying follow-up imaging solely in the presence of brain parenchymal injury. Larger prospective studies are necessary to confirm these findings.

Impact of early follow-up CT in the conservative management of traumatic brain injury on surgical decision making: A retrospective, single-center analysis with special respect to coagulopathy.

Initial management of traumatic brain injury (TBI) without immediate need for surgical therapy varies across centers. The additional value of routine repeat cranial computerized tomography (CT) to neurological monitoring is controversial. This retrospective study investigates the impact of routine follow-up CT after 6h (CT6h) in initially conservatively managed TBI on surgical decision making. Furthermore, the impact of coagulopathy on lesion size and progression was examined. We reviewed charts of patients admitted to our clinic in the time between 1st January 2020 and 30th June 2022 for the ICD10 diagnosis S06.3 (traumatic brain contusion), S06.4 (epidural hematoma), S06.5 (subdural hematoma), and S06.6 (traumatic subarachnoid hemorrhage). Baseline characteristics as well as timing, reason, and consequences of first and second cranial CT, clinical course, lesion size at first and second CT as well as presence and type of coagulopathy (standard laboratory testing and prior medical history) were noted among others. Significance testing was carried out using Student's t-test. The significance level was set to p < 0.005. A total of 213 patients were included, 78 were operated after first CT, 123 underwent clinical and imaging surveillance, and 12 patients were not treated. CT6h did not anticipate imminent neurological deterioration. Early secondary deteriorating patients (9/123, 7.3%) did so before 6h after admission clustering between 3 and 4h (6/9, 66.7%). CT6h changed surgical decision making in one case (1/114, < 1%). Nine out of 106 (8.5%) patients managed conservatively after CT6h showed a late secondary clinical deterioration or failure of conservative treatment, eight out of which had stable size of hemorrhage in CT6h. There was no significant difference in lesion size at first CT related to the presence of coagulopathy, antiplatelet agents, or anticoagulant drugs for SDH or contusions. In patients with radiological progression of SDH in combined brain injury (CBI), coagulopathy was associated with a higher increase of lesion size (diameter increase > 6mm: 11.1% with vs. 2.8% without coagulopathy). This effect was not observed for contusions in CBI (volume increase > 6ml: 17.4% with vs. 22.7% without coagulopathy). Early routine follow-up CT does neither anticipate imminent neurological deterioration nor impact surgical decision making. A substantial number of patients with initially stable follow-up imaging need delayed surgery due to conservative treatment failure. If patients can be monitored clinically, surgical decision making depends on clinical status. Patients with coagulopathy do not present with larger lesions, but show a higher ratio of drastic increase in SDH in contrast to contusions.

Normalised repeat serum prostate-specific antigen: associations with age and magnetic resonance imaging results.

To assess the value of a repeat prostate-specific antigen measurement (PSA2) before magnetic resonance imaging (MRI) in men with a raised PSA (PSA1) <10 µg/L. Medical records of men aged < 75 years referred in 2021 for PSA1 3.0-9.9 µg/L (< 70 years) or 5.0-9.9 µg/L (70-74 years) were reviewed. PSA2 was sampled before MRI within 60 days from PSA1. Odds ratios (ORs) were calculated with logistic regression. Chi-square and trend-test were used for categorical variables. A total of 341 men were included. Median time between PSA1 and PSA2 was 28 days (interquartile range 20-35 days). PSA normalised in 16% (95% confidence interval [CI]: 13-21). Younger men were more likely to have a normal PSA2 (OR: 0.95 per year older, 95% CI: 0.92-0.99). Among men aged < 70 years, those with PSA1 < 5 µg/L were more likely to have normalised PSA2 than those with PSA1 ≥ 5 µg/L (21% vs. 10%, p = 0.01). A greater proportion of men with normalised PSA2 had a Prostate Imaging Data and Reporting System MRI score of 1-3 than men with non-normalised PSA2 (93% vs. 77%, p = 0.01). A clinically significant proportion of men with a moderately raised PSA value have a normal PSA2. Younger men and men with lower PSA1 were more likely to have a normal PSA2. Few men with normalised PSA2 had suspicious MRI findings. Routine repeat PSA-testing may be motivated in men with a moderately raised PSA value to save MRI resources, particularly in younger men.

Repeat placental growth factor-based testing in women with suspected preterm pre-eclampsia (PARROT-2): a multicentre, parallel-group, superiority, randomised controlled trial

Placental growth factor (PlGF)-based testing has high diagnostic accuracy for predicting pre-eclampsia needing delivery, significantly reducing time to diagnosis and severe maternal adverse outcomes. The clinical benefit of repeat PlGF-based testing is unclear. We aimed to determine whether repeat PlGF-based testing (using a clinical management algorithm and nationally recommended thresholds) reduces adverse perinatal outcomes in pregnant individuals with suspected preterm pre-eclampsia. In this multicentre, parallel-group, superiority, randomised controlled trial, done in 22 maternity units across England, Scotland, and Wales, we recruited women aged 18 years or older with suspected pre-eclampsia between 22 weeks and 0 days of gestation and 35 weeks and 6 days of gestation. Women were randomly assigned (1:1) to revealed repeat PlGF-based testing or concealed repeat testing with usual care. The intervention was not masked to women or partners, or clinicians or data collectors, due to the nature of the trial. The trial statistician was masked to intervention allocation. The primary outcome was a perinatal composite of stillbirth, early neonatal death, or neonatal unit admission. The primary analysis was by the intention-to-treat principle, with a per-protocol analysis restricted to women managed according to their allocation group. The trial was prospectively registered with the ISRCTN registry, ISRCTN 85912420. Between Dec 17, 2019, and Sept 30, 2022, 1253 pregnant women were recruited and randomly assigned treatment; one patient was excluded due to randomisation error. 625 women were allocated to revealed repeat PlGF-based testing and 627 women were allocated to usual care with concealed repeat PlGF-based testing (mean age 32·3 [SD 5·7] years; 879 [70%] white). One woman in the concealed repeat PlGF-based testing group was lost to follow-up. There was no significant difference in the primary perinatal composite outcome between the revealed repeat PlGF-based testing group (195 [31·2%]) of 625 women) compared with the concealed repeat PlGF-based testing group (174 [27·8%] of 626 women; relative risk 1·21 [95% CI 0·95-1·33]; p=0·18). The results from the per-protocol analysis were similar. There were four serious adverse events in the revealed repeat PlGF-based testing group and six in the concealed repeat PlGF-based testing group; all serious adverse events were deemed unrelated to the intervention by the site principal investigators and chief investigator. Repeat PlGF-based testing in pregnant women with suspected pre-eclampsia was not associated with improved perinatal outcomes. In a high-income setting with a low prevalence of adverse outcomes, universal, routine repeat PlGF-based testing of all individuals with suspected pre-eclampsia is not recommended. Tommy's Charity, Jon Moulton Charitable Trust, and National Institute for Health and Care Research Guy's and St Thomas' Biomedical Research Centre.

Reconsidering Routine Repeat Group and Screens During Pregnancy-Personalizing Pregnancy Care

The group and screen (G&S) are performed in early pregnancy to identify clinically significant antibodies (CSA) that may necessitate fetal monitoring for hemolysis/anemia or affect RhIg eligibility. Guidelines vary, including differences between RhD-positive and negative patients, but typically, the G&S is repeated at 28 weeks, and sometimes pre-delivery. We reviewed data showing a low risk (0.01%–0.43%) of detecting a new CSA in late gestation (late alloimmunization) and the risk of late alloimmunization causing severe hemolysis/anemia is even lower at <0.01%. Routinely repeating a G&S at 28 weeks and delivery may not be necessary for healthy, low-risk pregnancies.

Role of scheduled repeat CT scan in traumatic brain injuries: A prospective observational study.

Scheduled CT scan is a routine practice at many centers after traumatic brain injury (TBI), but it has been questioned by few authors. The majority of the studies are reported in mild TBI; however, no specific data exist for the same in moderate and severe TBI. This was a single-center and 1-year prospective study. All cases with TBI who underwent scheduled repeat scans were included in the study. Patients who underwent emergency surgery after first computed tomography (CT) and those who expired before repeat CT were excluded from the study. Data included demographics, Glasgow coma scale (GCS) score, initial head CT findings, findings of repeat CT, and the need for any intervention (medical/surgical). A total of 231 cases were analyzed. The mean time interval for the repeat CT was 7.8 h. One hundred and seventy-one patients underwent scheduled repeat CT (Group 1), 53 patients with GCS >13 were discharged from emergency before the repeat scan (Group 2), and seven cases underwent repeat CT before the scheduled time in view of clinical deterioration (Group 3). The mean age and gender did not vary significantly between the three groups. Mixed lesions predominated in all; however, the proportion significantly differed between groups. In Group 1, two patients required surgery; in Group 3, all patients required a significant change in treatment, whereas none deteriorated or required a repeat scan in Group 2. In our study, the yield of routine repeat CT scans requiring surgery was 3.5%. Based on the results of our study and the observations from previous studies, we have proposed a few general working statements regarding indications for repeat CT scans in TBI.

Tri-Allelic Autosomal STR Patterns Observed in Pakistani Population during Forensic Case Work

The tri-allelic pattern is a genotyping abnormality that can be observed during routine short tandem repeat (STR) profiling in the field of forensic science. Fourteen tri-allelic patterns have been observed in nine different loci during routine forensic casework consisting of 20,000 STR profiles. All these 20,000 STR unrelated profiles were profiled using AmpFlSTR Identifiler Plus® and Global Filer® kits. Tri-allelic patterns can be divided into two types based on RFUs (relative fluorescent units) in peaks of three component alleles. Unequal RFUs of all three peaks are observed in the Type-I pattern, whereas in the Type-II pattern, RFUs of all three peaks are nearly equal. A total of nine novel tri-allelic genotypes were observed out of 20,000 unrelated individuals in the Pakistani population. All of these forensic cases belonged to the Type-I pattern which means that the sum of the height of two smaller peaks is nearly equal to the height of the third larger peak. The frequency of occurrence for all these patterns was compared with already reported data. In this study, eight novel tri-allelic patterns have been reported which are not listed in the National Institute of Standards and Technology (NIST) database as well as in any published article.

Utility of Repeat Uterine Cavity Evaluation in the Infertility Workup.

Background: Uterine cavity abnormalities contribute to infertility. The purpose of this study was to evaluate the incidence, recurrence rates, and risk factors for uterine cavity abnormalities in women undergoing infertility workup and treatment, focusing on the utility of routinely repeated imaging. Methods: Retrospective cohort study at single academic medical center of 833 infertile women who had uterine cavity evaluations performed at least 9 months apart. Results: Of 833 eligible patients, 664 (79.7%) had normal initial imaging and 169 (20.3%) had abnormal initial imaging. Among the former, 10% had abnormal uterine cavity on repeat saline infusion sonohysterography (SIS); among the latter, 32% had abnormal repeat SIS [Chi-square p < 0.0001, risk ratio 2.30 (95% confidence interval 1.85-2.86)]. On average, 23.1 ± 13.6 months passed between studies. Regardless of initial imaging findings, women with abnormal repeat SIS were older than those with normal repeat SIS, with no difference in time elapsed between studies. There were no associations between repeat imaging outcomes and body mass index, uterine instrumentation, number of treatment cycles, or maximum peak estradiol levels in a single cycle between studies. There was no difference in live birth rate among cycles started within 1 year after repeat SIS across groups. Conclusions: Uterine cavity abnormalities were found in 10% of patients on repeat imaging despite initially normal testing. No risk factors for cavity abnormality on repeat imaging were identified besides age and prior abnormality. It would be prudent to continue performing routine repeat uterine cavity evaluation for women undergoing fertility treatment, particularly if corrective measures had been taken in the past.

Prevalence and Predictors of Barrett’s Esophagus After Negative Initial Endoscopy: Analysis From Two National Databases

Guidelines suggest a single screening esophagogastroduodenoscopy (EGD) in patients with multiple risk factors for Barrett's esophagus (BE). We aimed to determine BE prevalence and predictors on repeat EGD after a negative initial EGD, using 2 large national databases (GI Quality Improvement Consortium [GIQuIC] and TriNetX). Patients who underwent at least 2 EGDs were included and those with BE or esophageal adenocarcinoma detected at initial EGD were excluded. Patient demographics and prevalence of BE on repeat EGD were collected. Multivariate logistic regression was performed to assess for independent risk factors for BE detected on the repeat EGD. In 214,318 and 153,445 patients undergoing at least 2 EGDs over a median follow-up of 28-35 months, the prevalence of BE on repeat EGD was 1.7% in GIQuIC and 3.4% in TriNetX, respectively (26%-45% of baseline BE prevalence). Most (89%) patients had nondysplastic BE. The prevalence of BE remained stable over time (from 1 to >5 years from negative initial EGD) but increased with increasing number of risk factors. BE prevalence in a high-risk population (gastroesophageal reflux disease plus ≥1 risk factor for BE) was 3%-4%. In this study of >350,000 patients, rates of BE on repeat EGD ranged from 1.7%-3.4%, and were higher in those with multiple risk factors. Most were likely missed at initial evaluation, underscoring the importance of a high-quality initial endoscopic examination. Although routine repeat endoscopic BE screening after a negative initial examination is not recommended, repeat screening may be considered in carefully selected patients with gastroesophageal reflux disease and ≥2 risk factors for BE, potentially using nonendoscopic tools.

Should Infants with Blunt Traumatic Brain Injuries and Intracranial Hemorrhage Have Routine Repeat Imaging?

The practice of repeat head CT imaging in infants as a distinct population is poorly studied. The purpose of this study was to evaluate the incidence and utility of repeat head CT in the infant population. A 10-year retrospective review was conducted of infants with blunt traumatic head injuries (N = 50) that presented to a trauma center. Information from the hospital trauma registry and patient medical records were extracted regarding the size and type of injury, number and results of computed tomography (CT) imaging, changes in neurological exams, and any interventions that were required. Most patients (68%) had at least one repeat CT, with 26% showing progression of hemorrhage. Decreased Glasgow Coma Scale was associated with having repeat CT scans. Nearly one in four infants had a change in management associated with repeat imaging. Repeat CT scans resulted in operative interventions in 11.8% of cases and longer intensive care unit (ICU) stays in 8.8% of cases. Repeat CT scans were associated with increased hospital length of stay, but not with increased ventilator days, ICU length of stay, or mortality. Worsening bleeds were associated with mortality, but not with other hospital outcomes. Changes in management following repeat CT appeared to be more common in this population than in older children or adults. Findings from this study supported repeat CT imaging in infants, however, further research is needed to validate results of this study.

Approach to Intrapartum Fever During the COVID-19 Pandemic: A New York City Hospital Experience [ID: 1377237

INTRODUCTION: At the start of the COVID-19 pandemic, repeat testing for SARS-CoV-2 was added to the management of intrapartum fever. Mother–newborn isolation and separation were implemented until repeat results were available and negative. As few data exist to support or refute repeat testing in this setting, we assessed the yield of repeat testing for intrapartum fever. METHODS: We performed a retrospective, IRB-exempt, study from October 2020 to June 2022 of patients who had a negative SARS-CoV-2 test at admission and developed intrapartum fever without an alternative explanation for the fever. Maternal and newborn demographic and clinical variables were extracted from electronic medical records. RESULTS: During the study period, among 3,236 deliveries, 151 (4.7%) patients (median age, 34 years) had intrapartum fever; 43%, 11%, and 37% were Asian, Black, and White: 17% were Hispanic. All delivered live newborns (median gestational age, 39 weeks). The median time to fever after admission was 19 hours (range, 0.17–46.17 hours), the median fever was 38.3°C, and median time to repeat test result was 2.07 hours (range, 0.42–12.70 hours). On repeat testing, one (0.7%) patient was positive for SARS-CoV-2 and two had other respiratory viruses detected. Less than 1% had COVID symptoms other than fever. Nine percent of newborns needed transient respiratory support. Two newborns were tested for SARS-CoV-2; both were negative. CONCLUSION: Repeat SARS-CoV-2 testing for intrapartum fever management resulted in one additional case, suggesting that routine repeat testing in patients with intrapartum fever and no other symptoms is generally not needed. Additionally, in this setting, mother–newborn isolation and separation are not warranted.

HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings.

HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative. It is implemented in 24 countries and over 2,000 primary healthcare facilities. This paper describes the results of a multicomponent, stepwise, quality improvement intervention designed by the HEARTS in the Americas to support advances in hypertension treatment protocols and evolution towards the Clinical Pathway. The quality improvement intervention comprised: 1) the use of the appraisal checklist to evaluate the current hypertension treatment protocols, 2) a peer-to-peer review and consensus process to resolve discrepancies, 3) a proposal of a clinical pathway to be considered by the countries, and 4) a process of review, adopt/adapt, consensus and approval of the clinical pathway by the national HEARTS protocol committee. A year later, 16 participants countries (10 and 6 from each cohort, respectively) were included in a second evaluation using the HEARTS appraisal checklist. We used the median and interquartile scores range and the percentages of the maximum possible total score for each domain as a performance measure to compare the results pre and post-intervention. Among the eleven protocols from the ten countries in the first cohort, the baseline assessment achieved a median overall score of 22 points (ICR 18 -23.5; 65% yield). After the intervention, the overall score reached a median of 31.5 (ICR 28.5 -31.5; 93% yield). The second cohort of countries developed seven new clinical pathways with a median score of 31.5 (ICR 31.5 -32.5; 93% yield). The intervention was effective in three domains: 1. implementation (clinical follow-up intervals, frequency of drug refills, routine repeat blood pressure measurement when the first reading is off-target, and a straightforward course of action). 2. treatment (grouping all medications in a single daily intake and using a combination of two antihypertensive medications for all patients in the first treatment step upon the initial diagnosis of hypertension) and 3. management of cardiovascular risk (lower BP thresholds and targets based on CVD risk level, and the use of aspirin and statins in high-risk patients). This study confirms that this intervention was feasible, acceptable, and instrumental in achieving progress in all countries and all three domains of improvement: implementation, blood pressure treatment, and cardiovascular risk management. It also highlights the challenges that prevent a more rapid expansion of HEARTS in the Americas and confirms that the main barriers are in the organization of health services: drug titration by non-physician health workers, the lack of long-acting antihypertensive medications, lack of availability of fixed-doses combination in a single pill and cannot use high-intensity statins in patients with established cardiovascular diseases. Adopting and implementing the HEARTS Clinical Pathway can improve the efficiency and effectiveness of hypertension and cardiovascular disease risk management programs.

Donor Derived Myelodysplastic Syndrome after Sex Matched Haploidentical Allograft for AML with Monosomy 7 in Both Diseases: Importance of Donor Chimerism Assessment By Two Independent Techniques

Donor-derived leukaemia is a rare outcome in patients following allogeneic hematopoietic cell transplant (HCT) accounting for ~ 0.1-5% of relapsed cases although the true incidence is likely underestimated. A 39-year-old male patient with a history of ulcerative colitis treated with mercaptopurine was subsequently diagnosed with therapy related acute myeloid leukaemia (AML) and karyotype showed 45,XY,-7. The patient achieved remission after two cycles of treatment and proceeded to a paternal haploidentical HCT. Complete remission with no detectable disease by flow cytometry and fluorescent in-situ hybridisation (FISH) was achieved by day 40 of transplantation with whole blood and T-cell chimerism of 97% as assessed by routine short tandem repeat (STR) chimerism analysis. With withdrawal of immunosuppression this increased to 100% in both fractions. At 11 months post-transplant evidence of low-level cytogenetic relapse emerged with monosomy 7 seen by FISH in 15/200 interphase cells. Chimerism remained stable at 99% with aspirate findings indicating 2-3% blasts and some trilineage dysplasia. Two subsequent marrows showed persistence of monosomy 7 by FISH with full donor STR chimerism. Although a possibility of donor derived myelodysplastic syndrome (DD-MDS) was considered, due to the monosomy 7, donor lymphocyte infusion (DLI) therapy was administered at 16 and 19 months post-transplant. Monosomy 7 persisted on FISH and standard cytogenetic analysis. To confirm validity of STR chimerism and to distinguish between DD-MDS and relapse of original disease, HLA typing by next generation sequencing (NGS) to exclude HLA loss related relapse and potentially guide rescue decisions was performed alongside NGS chimerism assessment. NGS chimerism utilises genetic markers with population independent discriminative power distributed across 17 chromosomes and further selected to allow sensitive detection combined with accurate and precise quantification of mixed chimerism. NGS chimerism is demonstrated to be sensitive enough to detect a minor DNA contributor comprising down to 0.5% of the sample, detection of low level mixed chimerism and therefore clinical utility in better predicting relapse compared to conventional techniques. Original stored donor cells were tested and showed no evidence of monosomy 7 by FISH. After confirming DD-MDS a second HCT was considered. Originally unsuccessful unrelated donor search was re-opened and wide family donor search initiated. With azacytidine therapy the patient achieved a short lived cytogenetic remission, but subsequently relapsed and progressed to AML with karyotype of 45,XY,-7,der(16)t(11;16)(q13;p13.1)[9]/46,XY[1] and died 33 months after HCT prior to initiation of a second HCT. This case was complicated by the presence of monosomy 7 detected by karyotyping in both the initial diagnostic t-AML and in the DD MDS. Monosomy 7 is the most common abnormality found in DD-MDS but a review of the literature available does not seem to indicate any cases where it was also present in the patient's initial diagnostic sample as a separate disease entity. The pathogenesis of DD-MDS remains unclear. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Things We Do for No Reason™: Routine repeat electrocardiogram for low-to-intermediate risk chest pain.

Things We Do for No Reason™: Routine repeat electrocardiogram for low-to-intermediate risk chest pain.

Assessing the use of environmental DNA (eDNA) as a tool in the detection of human DNA in water.

Environmental DNA (eDNA) is a highly sensitive and cost-effective tool that is increasingly being applied to studies of biodiversity and species detection. This non-invasive method relies on the collection of environmental samples that contain genetic material being shed into surrounding environment by the target organism/s. While forensic science has a long history of using molecular tools for collecting DNA from the environment, the detection of human DNA from environmental water samples has been limited. This study investigated the detection and degradation rates of human eDNA in water samples under controlled laboratory conditions. Using a human-specific qPCR assay targeting the ND1 region of human mitochondrial DNA, eDNA degradation over time in water spiked with human blood was assessed. Recovery of nuclear DNA was investigated by determining if routine DNA short tandem repeat (STR) profiles of the blood source could be generated. Results demonstrated that human eDNA remains detectable for up to 11 days under laboratory conditions in environmental water and up to 35 days in distilled water. Partial STR profiles could be recovered from environmental water only up to 24 h, while, in distilled water, partial profiles continued to be recovered up to 840 h. These findings demonstrate that sampling human eDNA from aquatic samples can provide reliable human DNA detection within relatively short time windows, assisting law enforcement agencies by providing information about the potential time an individual may have been present in an area or assisting in the detection and location of a body or remains in aquatic environments.

BIG Kids: Application of a modified brain injury guideline in a pediatric trauma center

BackgroundBrain Injury Guidelines (BIG) were developed to stratify traumatic brain injuries (TBIs) by severity to decrease unnecessary CT imaging and neurosurgical consultation in low-risk cases. This study evaluated the potential effect of a modified pediatric BIG (pBIG) algorithm would have on resource utilization. MethodsIsolated TBIs (<18 years) were queried from our Pediatric Trauma Registry from 2017 to 2020. Injuries were classified as mild (pBIG 1), moderate (pBIG 2), or severe (pBIG 3) based on neurologic status, skull fractures, size, and the number of bleeds. Modifications from the institutional adult algorithm were upgrading <4 mm epidural hematomas to pBIG 2 and eliminating interfacility transfer as a pBIG 2 criteria. The proposed pBIG 1 and 2 care plans do not include routine repeat CTs or neurosurgical consultation. ResultsA total of 314 children with a mean age of 4.9 years were included. Skull fractures (213, 68%) and subdural hematomas (162, 52%) were the most common injuries. 89 (28%) children had repeat head CTs (2 (7%) pBIG 1, 26 (25%) pBIG 2, 61 (34%) pBIG 3). Neurosurgical consultation was obtained in 306 (98%), with 50 (16%) requiring intervention (1 (1%) pBIG 2 and 49 (27%) pBIG 3). Following the proposed pBIG would decrease neurosurgical consults to 181 (58%) and repeat CTs to 63 (20%). Following the algorithm, 91 (29%) kids would have been admitted to a higher level of care and 45 (14.3%) to a lower level. ConclusionsImplementation of our pBIG algorithm would decrease neurosurgery consults (40% reduction) and repeat head CTs (29% reduction).