Time Of Phlebotomy Research Articles

Characterization of COVID-19 Vaccine Hesitancy Among Essential Workforce Members of a Large Safety Net Urban Medical Center.

Vaccine hesitancy among essential workers remains a significant public health challenge. We examined psychological constructs of perceived susceptibility, threat, and self-efficacy and their associations with COVID-19 vaccine hesitancy among a racially and ethnically diverse essential workforce population. We performed a cross-sectional survey of essential workers from September-December 2020 at a large Los Angeles safety-net medical center as part of a program offering free COVID-19 serology testing. Program participants completed a standardized survey at the time of phlebotomy. Hierarchical logistic regression was utilized to determine factors independently associated with vaccine hesitancy. Among 1327 persons who had serology testing, 1235 (93%) completed the survey. Of these, 958 (78%) were healthcare workers. Based on expressed intent, 22% were vaccine-hesitant 78% were vaccine acceptors. In our multivariate model, vaccine hesitancy was associated with female gender [aOR = 2.09; 95% CI (1.44-3.05)], African American race [aOR = 4.32; (2.16-8.62)], LatinX ethnicity [aOR = 2.47; 95% CI (1.51-4.05)] and history of not/sometimes receiving influenza vaccination [aOR = 4.39; 95% CI (2.98-6.48)]. Compared to nurses, vaccine hesitancy was lower among physicians [aOR = 0.09; 95% CI (0.04-0.23)], non-nursing/non-physician healthcare workers [aOR = 0.55; 95% CI (0.33-0.92)], and non-healthcare care workers [aOR = 0.53; 95% CI (0.36-0.78)]. Among a racially/ethnically diverse group of safety net medical center essential workers, COVID-19 vaccine hesitancy was associated with racial/ethnic minority groups, employment type, and prior influenza vaccination hesitancy. Interestingly, we found no association with the Health Belief Model construct measures of perceived susceptibility, threat, and self-efficacy. Psychological constructs not assessed may be drivers of vaccine hesitancy in our population.

387. Predictors of Seropositivity to SARS-CoV-2 Among Workforce Members at a Large Urban Medical Center

BackgroundPrior to SARS-CoV-2 vaccination availability, medical centers workers were at significant COVID-19 (COVID) infection risk. As part of a program offering free SARS-CoV-2 serology tests to medical center employees, we examined risk factors for prior COVID infection.MethodsFrom Sept. to Dec. 2020, we advertised free IgG antibody testing to all Los Angeles County-Univ. of Southern California Medical Center (LAC+USC) workforce members (clinical and non-clinical) via repeated email blasts. Antibody was determined using the Abbott SARS-Cov-2 IgG test against SARS-CoV-2 nucleocapsid protein. Program participants were asked to fill out a detailed epidemiologic questionnaire about work and non-work COVID risks on their cell phone or on paper at the time of phlebotomy. All testing was done prior to COVID vaccine availability.ResultsAmong approximately 10,500 workforce members, 1327 had serologies done. Among those 1273 (96%) completed the questionnaire and were included in the analysis. SARS-CoV-2 IgG antibodies were found in 60 (4.7%). In bivariate analysis, we found associations between SARS-CoV-2 seropositivity and persons who previously tested positive for COVID (OR 175.8 [95% CI 77.6 – 398.6]), persons who thought they had prior COVID but tested negative (OR 3.9 [95% CI 1.3 – 11.4]), and persons who thought they had prior COVID but did not get a COVID test (OR 4.2 [95% CI 1.4 – 12.5]). In a multivariate model of SARS-CoV-2 seropositivity examining work- and non-work-related COVID exposures (Table), seropositivity was associated with work-related COVID exposure without adequate personal protective equipment (PPE) (OR 5.1 [95% CI 2.1 – 12.2]), work-related COVID exposure with adequate PPE (OR 3.5 [95% CI 1.5 – 8.0]), never wearing a mask outside of work (OR 7.1 [95% CI 1.3 – 38.4]), and Native Hawaiian/Pacific Islander race (OR 6.6 [95% CI 1.7 – 23.4]). Seropositivity was inversely associated with living at home with multiple age groups (OR 0.4 [95% CI 0.2 – 0.8]). Multivariate Model of Exposures Associated with Positive COVID Serology Among LAC+USC Workforce Members ConclusionAmong workers in a large urban medical center prior to COVID vaccine availability, SARS-CoV-2 seropositivity was associated with work-related COVID exposures and low mask use outside of work, suggesting that COVID transmission in workforce members occurs both via occupational and non-occupational routes.Disclosures Loren G. Miller, MD, MPH, Medline (Grant/Research Support, Other Financial or Material Support, Contributed product)Stryker (Other Financial or Material Support, Contributed product)Xttrium (Other Financial or Material Support, Contributed product)

Utility Of Non-Invasive Monitoring Of Circulating Tumor DNA At Diagnosis, Interim Therapy, and Relapse Of DLBCL Using High-Throughput Sequencing Of Immunoglobulin Genes

BackgroundRecent studies have shown limited utility of routine surveillance imaging for patients with diffuse large B-cell lymphoma achieving remission after R-CHOP (Thompson et al, ASCO 2013 #8503; Ghesquieres et al, ICML 2013 #226). Separately, response assessment using early interim PET-CT during R-CHOP has suboptimal accuracy. We hypothesized that non-invasive tumor burden monitoring using peripheral blood could have utility for diagnosis and monitoring of DLBCL. MethodsWe prospectively profiled two cohorts of patients with DLBCL at various stages in their disease, including at diagnosis, during various therapies, after achieving remission, and upon relapse or progression. Cohort1 patients were treated with curative intent at Stanford University with blood collected at multiple time points during follow-up. Cohort2 patients participated in a multi-center Austrialian Phase 2 study (ALLG NHL21), where patients with poor risk DLBCL as identified by residual disease on interim PET/CT after 4 R-CHOP cycles received early treatment intensification using R-ICE/ASCT; blood samples were collected before the 1st and after the 4thR-CHOP cycles. Tumor-derived clonotypic IgH and IgK sequences were defined in diagnostic tissues grossly involved with DLBCL, and then tracked using high-throughput sequencing of immunoglobulin genes (Faham et al 2012 Blood). ResultsWe successfully defined for 77% (30/39) of patients the tumor-specific immunoglobulin sequences required for non-invasive surveillance, with calibration success correlating with input tissue mass. Using 194 assays on 79 blood specimens from these patients, we detected disease in 75% of patients at diagnosis of DLBCL, in 18% at interim time-points during therapy, 0% during radiographic/clinical remissions, and 80% at relapse or disease progression. When considering radiographic/clinical follow-up, noninvasive monitoring had 0% false positive rate but 26% false negative rate, with the latter likely due to low tumor burden at time of phlebotomy. Disease burden detectable in the blood was significantly correlated between IgH and IgK assays, and between the cellular (leukocyte) and acellular (plasma) fractions (r=0.77, p=0.004). Strikingly, clonotypic IgH/IgK sequences were significantly more abundant in plasma than in circulating leukocytes, and identified exclusively in plasma in 5% of blood samples with available paired cellular/acellular fractions. This allowed more accurate disease detection and monitoring using plasma circulating tumor DNA than blood leukocytes, including in cases of radiographically defined isolated CNS involvement, and in histological transformation of FL. Within the limitations of this small study employing frequent surveillance imaging, we observed no significant lead time between detection of disease in the plasma and radiographic/clinical evidence of progression. ConclusionsNon-invasive surveillance of circulating tumor DNA has utility for tumor burden at diagnosis and relapse of DLBCL using high-throughput sequencing of immunoglobulin genes, with superior detection in blood plasma. The current assay has limited sensitivity at early interim time points during therapy. Disclosures:Kong:Sequenta Inc.: Employment. Faham:Sequenta, Inc.: Employment, Equity Ownership, Membership on an entity's Board of Directors or advisory committees.

Donation testing and transfusion transmissible infections

Donation testing and transfusion transmissible infections

Analysis of vasovagal syncope in the blood collection room in patients undergoing phlebotomy

Vasovagal syncope (VVS) is well-known to occur in patients undergoing phlebotomy, however, there have been no large-scale studies of the incidence of VVS in the blood collection room. The aim of our present retrospective study was to investigate the conditions of phlebotomy and determine the incidence/factors predisposing to the development of VVS. We investigated 677,956 phlebotomies performed in outpatients in the blood collection room, to explore factors predisposing to the development of VVS. Our analysis revealed an overall incidence of VVS of 0.004% and suggested that use of more than 5 blood collection tubes and a waiting time of more than 15 min were associated with a higher risk of VVS. The odds ratios of these factors were 8.10 (95% CI 3.76–17.50) and 3.69 (95% CI 0.87–15.60), respectively. This is the large-scale study to analyze factors of the development of VVS in the blood collection room, and according to our results, use of a large number of blood collection tubes and a prolonged waiting time for phlebotomy may be risk factors for the development of VVS.

Influence of Seasonality and Circulating Cytokines on Serial QuantiFERON Discordances.

Objectives. An 18-month prospective study serially tested healthcare workers (HCWs) for tuberculosis infection (TBI) and reported discordant QuantiFERON Gold In-Tube® (QFT) results in some participants. The purpose of the current study was to investigate whether the interferon-gamma (IFN-γ) measured by QFT in discordant individuals could be influenced by other circulating cytokines that vary seasonally at the time of phlebotomy. Methods. The CDC funded TBESC Task Order 18 (TO18) project to assess the use of Interferon Gamma Release Assays (IGRAs), T-SPOT.TB® and QFT, compared to the tuberculin skin test (TST) for the serial testing of TBI in HCW at 4 US sites. Unstimulated plasma from 9 discordant TO18 participants at 4 different time points from the Houston site was multiplexed to determine the association between circulating cytokines and antigen stimulated IFN-γ levels. Results. IL-12, IL-1β, IL-3, GCSF, and IL-7 were associated with the amount of IFN-γ measured in response to antigen stimulation. In addition to these cytokines, a significant relationship was found between a positive QFT result and the spring season. Conclusions. Allergens during the spring season can result in the upregulation of IL-1β and IL-3, and this upregulation was observed with the amount of IFN-γ measured in discordant results.

The administration of blood components: a British Society for Haematology Guideline.

The administration of blood components: a British Society for Haematology Guideline.

Delta check for blood groups: A step ahead in blood safety.

BACKGROUND:Blood grouping is the single most important test performed by each and every transfusion service. A blood group error has a potential for causing severe life-threatening complications. A number of process strategies have been adopted at various institutions to prevent the occurrence of errors at the time of phlebotomy, pretransfusion testing, and blood administration. A delta check is one such quality control tool that involves the comparison of laboratory test results with results obtained on previous samples from the same patient.MATERIALS AND METHODS:We retrieved the records of all transfusion-related incidents reported in our institute, between January 2008 and December 2014. Errors identified as “Failed Delta checks” and their root cause analyses (RCA) were reviewed.RESULTS:A total of 17,034 errors related to blood transfusion were reported. Of these, 38 were blood grouping errors. Seventeen blood group errors were identified due to failed delta checks, where the results of two individually drawn grouping samples yielded different blood group results. The RCA revealed that all of these errors occurred in the preanalytical phase of testing. Mislabeling resulting in wrong blood in tube was the most commonly identified cause, accounting for 11 of these errors, while problems with correct patient identification accounted for 5 failed delta checks.CONCLUSION:Delta checks proved to be an effective tool for detecting blood group errors and prevention of accidental mismatched blood transfusions. Preanalytical errors in patient identification or sample labeling were the most frequent.

Fasting time and lipid parameters: association with hepatic steatosis — data from a random population sample

BackgroundCurrent guidelines recommend measuring plasma lipids in fasting patients. Recent studies, however, suggest that variation in plasma lipid concentrations secondary to fasting time may be minimal. Objective of the present study was to investigate the impact of fasting time on plasma lipid concentrations (total cholesterol, HDL and LDL cholesterol, triglycerides). A second objective was to determine the effect of non-alcoholic fatty liver disease exerted on the above-mentioned lipid levels.MethodSubjects participating in a population-based cross-sectional study (2,445 subjects; 51.7% females) were questioned at time of phlebotomy regarding duration of pre-phlebotomy fasting. Total cholesterol, LDL and HDL cholesterol, and triglycerides were determined and correlated with length of fasting. An upper abdominal ultrasonographic examination was performed and body-mass index (BMI) and waist-to-hip ratio (WHR) were calculated. Subjects were divided into three groups based on their reported fasting periods of 1–4 h, 4–8 h and > 8 h. After application of the exclusion criteria, a total of 1,195 subjects (52.4% females) were included in the study collective. The Kruskal-Wallis test was used for continuous variables and the chi-square test for categorical variables. The effects of age, BMI, WHR, alcohol consumption, fasting time and hepatic steatosis on the respective lipid variables were analyzed using multivariate logistic regression.ResultsAt multivariate analysis, fasting time was associated with elevated triglycerides (p = 0.0047 for 1–4 h and p = 0.0147 for 4–8 h among females; p < 0.0001 for 1–4 h and p = 0.0002 for 4–8 h among males) and reduced LDL cholesterol levels (p = 0.0003 for 1–4 h and p = 0.0327 for 4–8 h among males). Among males, hepatic steatosis represents an independent factor affecting elevated total cholesterol (p = 0.0278) and triglyceride concentrations (p = 0.0002).ConclusionTotal and HDL cholesterol concentrations are subject to slight variations in relation to the duration of the pre-phlebotomy fasting period. LDL cholesterol and triglycerides exhibit highly significant variability; the greatest impact is seen with the triglycerides. Fasting time represents an independent factor for reduced LDL cholesterol and elevated triglyceride concentrations. There is a close association between elevated lipids and hepatic steatosis.

Noninvasive hemoglobin measurement in pregnancy

Hemoglobin measurement is one of the most frequently requested laboratory tests in amaternity setting. Traditional laboratory estimation assesses hemoglobin at a given time point. However, recent advances enable the continuous and noninvasive measurement of total hemoglobin [1,2]. The ability to assess hemoglobin continuously is of particular value in an emergency setting, in the early detection of hemorrhage, and in the identification of cases that warrant intervention, fluid replacement, and blood transfusion. Rapid access to measurements via devices such as the SpHb Pulse CO-Oximeter (Masimo, Irvine, CA, USA) in a clinical outpatient setting also facilitates the identification of the need for additional blood investigations and the instigation of supplemental iron therapy earlier in pregnancy. The aim of the present study was to validate continuous and noninvasive hemoglobin assessment in an outpatient obstetric setting using the SpHb Pulse CO-Oximeter and to compare the valueswith traditional laboratory measurements of hemoglobin. Between August 2 and 31, 2010, 125 women were recruited from the prenatal clinic of the National Maternity Hospital, Dublin, Ireland, at the time of phlebotomy for standard prenatal laboratory hemoglobin estimation. The SpHb Pulse CO-Oximeter was calibrated and 3 noninvasive estimations of hemoglobin were taken and recorded, with consent. Approval was obtained from the institutional ethics committee. The comparison ofmeans between laboratory hemoglobin and SpHb estimation was carried out via t test and f test, as appropriate. A Bland– Altman plot was used to determine the accuracy and precision of the noninvasive test as an alternative to invasive testing in an outpatient clinical setting (Fig. 1). The mean difference between the 2 methods was 0.47 g/dL. The upper limit of agreement was 3.46 and the lower limit was −2.50. Seven (5.6%) of the 125 samples were outside these limits but only 1 result was outside the 95th confidence interval of the limits. The limits of agreement were sufficient to be confident that noninvasive hemoglobin assessment is accurate in the prenatal setting. The present study showed that noninvasive hemoglobin measurement from Pulse COOximetry provides clinically acceptable accuracy comparable to that of traditional hemoglobin testing. Anemia in pregnancy has implications for maternal, fetal, and neonatal wellbeing. The goal of early identification of anemic patients is to facilitate earlier intervention and prevention of serious sequelae. Prenatally, the SpHb Pulse CO-Oximeter could facilitate the earlier identification andmanagement of anemic patients because, traditionally, women in Ireland who are identified as being anemic are contacted by post following receipt of the blood report—a process that involves a variable time delay between identification and treatment. Further advantages of noninvasive continuous hemoglobin measurement in an obstetric setting include the potential for a more efficient patient triage system and, in a cost-conscious era, the possibility of limiting costly “out-of-hours” laboratory investigations. The identification of a subset of patients in any hospital population who require increased monitoring and early transfusion to avoid decompensation is the ideal.

Effects of Adjuvant Chemoradiotherapy on the Frequency and Function of Regulatory T Cells in Patients with Head and Neck Cancer

Regulatory T cells (Treg) accumulate in tumor tissues and the peripheral blood of cancer patients and may persist after therapies. This cross-sectional study examines effects of adjuvant chemoradiotherapy (CRT) on Treg numbers and function in head and neck squamous cell carcinoma (HNSCC) patients. The frequency and absolute numbers of CD4(+), ATP-hydrolyzing CD4(+)CD39(+) and CD8(+) T cells, and expression levels of CD39, CD25, TGF-β-associated LAP and GARP on Treg were measured by flow cytometry in 40 healthy donors (NC) and 71 HNSCC patients [29 untreated with active disease (AD); 22 treated with surgery; 20 treated with CRT]. All treated subjects had no evident disease (NED) at the time of phlebotomy. In an additional cohort of 40 subjects with AD (n = 15), NED (n = 10), and NC (n = 15), in vitro sensitivity of CD4(+) T-cell subsets to cisplatin and activation-induced cell death (AICD) was tested in Annexin V-binding assays. CRT decreased the frequency of circulating CD4(+) T cells (P < 0.002) but increased that of CD4(+)CD39(+) Treg (P ≤ 0.001) compared with untreated or surgery-only patients. Treg frequency remained elevated for >3 years. CRT increased surface expression of LAP, GARP, and CD39 on Treg. In vitro Treg were resistant to AICD or cisplatin but conventional CD4(+) T cells (Tconv) were not. CRT-induced Treg from AD or NC subjects upregulated prosurvival proteins whereas Tconv upregulated proapoptotic Bax. Highly suppressive, cisplatin-resistant Treg increase in frequency and persist after CRT and could be responsible for suppression of antitumor immune responses and recurrence in HNSCC.

Is chronic nipple piercing associated with hyperprolactinemia?

Literature on hyperprolactinemia in the setting of a nipple piercing is limited to individuals with concomitant breast/chest wall infection. It is unclear if chronic nipple stimulation from a piercing alone can cause sustained elevations of serum prolactin. Nipple piercing is emerging as a more mainstream societal form of body art, and the answer to this clinical question would potentially alter patient management. Our aim was to assess serum prolactin levels in subjects with nipple piercing. Inclusion criteria were as follows: men and women ≥ 18 years old with nipple piercing(s) present > 6 months. Exclusion criteria included: women who are pregnant, lactating or < 6 months postpartum; subjects on medications known to increase prolactin levels; chest wall/breast infection at the time of phlebotomy or conditions known to be associated with hyperprolactinemia. Three men and eight women were enrolled. Median (range) ages for men and women were 33 (24-42) and 27 years (23-42), respectively. All except one subject had bilateral piercings. The median interval from nipple piercing to blood draw was 4.0 (2.0-12.0) years. None of the subjects had hyperprolactinemia. Median (range) prolactin levels for men and women were 5.6 ng/mL (3.8-7.4) and 8.0 ng/mL (2.8-10.9), respectively. Our results suggest that in the absence of any concomitant infection, chronic nipple piercing is not associated with hyperprolactinemia.

151: The accuracy of noninvasive hemoglobin assessment in an obstetric population

assessment in an obstetric population Sharon Cooley, Marie Bourke, Roger McMorrow, Fionnuala McAuliffe Rotunda Hospital, Obstetrics and Gynecology, Dublin, Ireland, National Maternity Hospital, UCD School of Medicine and Medical Sciences, Dublin 2, Ireland, National Maternity Hospital, Department of Anaesthesia, Dublin 2, Ireland, UCD Obstetrics and Gynaecology, School of Medicine and Medical Science, Dublin, Ireland OBJECTIVE: To validate continuous and non-invasive hemoglobin assessment in an obstetric setting, and to compare the values with traditional laboratory measurements of hemoglobin. STUDY DESIGN: Ethical approval was obtained and participants were recruited from the antenatal clinic of the National Maternity Hospital at the time of phlebotomy for their standard antenatal laboratory hemoglobin estimation. Hemoglobin was measured using the Sysmex XE-2100 automated haematology analyser (Sysmex Corporation, Sysmex Europe GmbH, Norderstedt, Germany). The SpHb Pulse CoOximeter was calibrated and the probe attached to the index finger of the patients hand. The mean of three non-invasive measurements of hemoglobin was recorded over 5 minutes. Maternal age, gestation, medical history, medications, body mass index and blood pressure were also recorded. Data analysis was undertaken using the Statistical Package for the Social Sciences (SPSS), Version 15.0. Bland Altman plots were used to determine acceptability of the new non-invasive test as a replacement for invasive testing in a clinical setting. RESULTS: In total 125 women were recruited and two women were excluded as their laboratory hemoglobin tests had to be repeated due to sampling error. The mean maternal age of the participants was 31.7 years. The mean gestation was 20.8 (8.6) weeks. Laboratory hemoglobin values ranged from 8.8 to 15.1 g/dL with a mean of 12.1 (1.0) g/dL. The range for the SpHb Pulse Co-Oximeter assessment was 9.1 to 15.8g/dL with a mean of 12.6 (1.3) g/dL. The Bland Altman plot for the two tests (Figure) illustrates the acceptable accuracy of haemoglobin assessment with the noninvasive method. CONCLUSION: Non-invasive hemoglobin measurement proved accurate compared to traditional hemoglobin testing and may offer a rapid cheap acceptable alternative to invasive testing in obstetric clinical scenarios. 152 Perinatal outcome of induction of labor compared with expectant management for term twin pregnancy Soo Hyeon Moon, Eun-Na Kim, Seung Chul Kim, Jong Kwan Jun Pusan National University School of Medicine, Department of Obstetrics and Gynecology, Busan, Korea, Seoul National University College of Medicine, Obstetrics and Gynecology, Seoul, Korea, Seoul National University College of Medicine, Department of Obstetrics and Gynecology, Seoul, Korea OBJECTIVE: It was reported that maternal complications such as cesarean section rate, chorioamnionitis, and uterine atony are increased in induction of labor in singleton pregnancies. The purpose of this study was to evaluate the risk of induction of labor in term twin pregnancy. STUDY DESIGN: We conducted a retrospective study of 479 term twin pregnancies between January 1999 and June 2011. Perinatal outcomes of induction of labor for term twin pregnancies (n 377) were compared with term twin pregnancies with spontaneous labor (n 102). Outcome criteria are cesarean section rate, chorioamnionitis, uterine atony, Apgar score at 5 minutes, umbilical artery pH 7.2, and the rate of NICU admission. RESULTS: The average gestational age at delivery in the induction group was significantly later than that in the expectant management group (38.25 0.69, 37.94 0.72 weeks, p 0,001). There were no significant differences in maternal and neonatal outcome between the two groups (Table). CONCLUSION: In the term twin pregnancy, induction of labor does not increase the maternal and neonatal complication. For the term twin pregnant women suffering from overdistended uterus, induction of labor is a reasonable approach without additional maternal and neonatal risk. www.AJOG.org Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology Poster Session I

High-Sensitivity Troponin T Concentrations in Acute Chest Pain Patients Evaluated With Cardiac Computed Tomography

For evaluation of patients with chest pain and suspected acute coronary syndrome (ACS), consensus guidelines recommend use of a cardiac troponin cut point that corresponds to the 99 th percentile of a healthy population. Most conventional troponin methods lack sufficient precision at this low level. In a cross-sectional study, 377 patients (mean age 53.7 years, 64.2% male) with chest pain and low to intermediate likelihood for ACS were enrolled in the emergency department. Blood was tested with a precommercial high-sensitivity troponin T assay (hsTnT) and compared with a conventional cardiac troponin T method. Patients underwent a 64-slice coronary computed tomography coronary angiogram at the time of phlebotomy, on average 4 hours from initial presentation. Among patients with acute chest pain, 37 (9.8%) had an ACS. Using the 99th percentile cut point for a healthy population (13 pg/mL), hsTnT had 62% sensitivity, 89% specificity, 38% positive predictive value, and 96% negative predictive value for ACS. Compared with the cardiac troponin T method, hsTnT detected 27% more ACS cases (P=.001), and an hsTnT above the 99 th percentile strongly predicted ACS (odds ratio 9.0, 95% confidence interval 3.9 to 20.9, P<0.001). Independent of ACS diagnosis, computed tomography angiography demonstrated that concentrations of hsTnT were determined by numerous factors, including the presence and severity of coronary artery disease, left ventricular mass, left ventricular ejection fraction, and regional left ventricular dysfunction. Among low- to intermediate-risk patients with chest pain, hsTnT provides good sensitivity and specificity for ACS. Elevation of hsTnT identifies patients with myocardial injury and significant structural heart disease, irrespective of the diagnosis of ACS.

Association of Epstein–Barr virus antibody levels with precancerous gastric lesions in a high‐risk cohort

We evaluated associations between Epstein-Barr virus (EBV) antibody levels and precancerous gastric lesions (chronic atrophic gastritis, intestinal metaplasia, and dysplasia) in 183 subjects from Linqu, China. Immunoglobulin G antibody titers to EBV nuclear antigen (EBNA) and viral capsid antigen (VCA) were determined by two-fold serial dilution using immunofluorescence assays. Histological progression and regression were assessed by gastroscopic examination at the time of phlebotomy and at follow up 2 years later. Antibody titers did not differ significantly among histological diagnoses determined at the time of phlebotomy. However, subjects with dysplasia at follow up had significantly higher geometric mean antibody titers for both anti-VCA and anti-EBNA. Subjects with greater than median antibody levels were more likely to progress between examinations, especially in the subgroup with intestinal metaplasia at the time of phlebotomy (odds ratios [95% confidence intervals]: 5.7 [1.6-20] for anti-EBNA >or=1:320; 3.8 [1.0-15] for anti-VCA >or=1:640). Our findings suggest a possible role for EBV reactivation at an early phase of gastric carcinogenesis.

The differential association of conjugated equine estrogen and esterified estrogen with activated protein C resistance in postmenopausal women.

Clinical trials have demonstrated that oral conjugated equine estrogen (CEE) therapy with or without medroxyprogesterone (MPA) increases venous thrombotic risk but this safety issue has not been investigated for other oral estrogens. Based on observational study findings that esterified estrogen (EE) was not associated with venous thrombotic risk whereas CEE was, we hypothesized that CEE users would be more resistant to activated protein C (APC), a prothrombotic phenotype, than EE users. We conducted an observational, cross-sectional study of postmenopausal women 30-89 years old who were controls in a case-control study of venous thrombosis. Use of CEE, EE, and MPA at the time of phlebotomy was determined using computerized pharmacy records. APC resistance was measured in plasma by the endogenous thrombin potential normalized APC sensitivity ratio. Adjusted mean APC resistance values were compared across estrogen type and CEE:EE ratios are presented. There were 119 CEE and 92 EE users at the time of phlebotomy. Compared with EE users, CEE users had APC resistance measures that were 52% higher (1.52; 95% confidence intervals: 1.07-2.17) in adjusted analyses. Restricting to modal dose users (0.625 mg) and stratifying by MPA use did not materially change associations. CEE use was associated with higher levels of APC resistance when compared with EE use in postmenopausal women. These findings might provide an explanation for the higher risk of venous thromboembolism previously observed with CEE compared with EE use and, if replicated, may have safety implications for women when choosing an estrogen for symptom relief.

The Thyrotropin Reference Range Should Remain Unchanged

Recent recommendations to decrease the upper limit of the TSH reference range from 4.5 to 2.5 mIU/liter, based on the high proportion of normal people whose serum TSH is less than 2.5 mIU/liter and the observation that those with TSH between 2.5 and 4.5 mIU/liter [upper reference range (URR)] have increased risk of progression to overt hypothyroidism (Whickham, 20-yr data), have not been subjected to critical analysis. The study subjects were from the Reference Group of NHANES III, 14,333 people more than 12 yr old, without known thyroid disease or antithyroid antibodies; 85% had TSH levels below 2.5 mIU/liter, and 2.3% had subclinical hypothyroidism (SCH). An additional 9.7% had URR TSH, representing 20.6 million Americans, who would also be identified as SCH if the upper TSH limit were decreased. Many with URR TSH do not have thyroid disease. The time of phlebotomy is important, because the TSH level varies throughout the day, with early morning values greater than later ones, and is accentuated by sleep deprivation, strenuous exercise, or working during the night or evening shifts. Repeated measurements in the same individual vary considerably over months. About half of those with URR TSH probably have thyroid disease, but most with thyroid disease, antithyroid peroxidase antibodies, have TSH below 2.5 mIU/liter. Those with URR TSH with thyroid disease probably have minimal thyroid deficiency, without any reported adverse health consequences or benefit of treatments with levothyroxine. Because routine levothyroxine treatment is not recommended for SCH, it is certainly not warranted in individuals with URR TSH. For all patients with URR TSH, it is reasonable to determine serum TSH every 1-2 yr.

Detection and treatment of bloodstream infection: laboratory reporting and antimicrobial management.

We analyzed antimicrobial use in 509 episodes of clinically significant bloodstream infection to assess the impact that microbiology laboratory reporting had on antimicrobial management. Most therapy interventions occurred at the time of phlebotomy and after notification of Gram stain results by telephone. Release of antimicrobial susceptibility data had the least impact on antimicrobial management.

PANCA antibodies in patients with anterior uveitis: identification of a marker antibody usually associated with ulcerative colitis.

A pANCA autoantibody (antineutrophil cytoplasmic antibody, perinuclear pattern) has been described in uveitis patients, but its correlation with systemic illnesses and the specific type of pANCA has not been defined. The goals of this study were to determine the (1) frequency of pANCA autoantibodies in uveitis, (2) systemic associations in the pANCA + uveitis patients, and (3) type of pANCA antigen recognized by the uveitis-associated autoantibody. Serum was obtained from 59 patients with anterior uveitis or panuveitis and from nonuveitis controls. A detailed medical and family history was obtained from each subject at the time of phlebotomy. Sera were screened by neutrophil ELISA to determine the frequency of ANCA positivity. Immunofluorescence assays were then used to differentiate cANCA from pANCA. The specificity of the pANCA + antibodies was further characterized by DNase 1 sensitivity and granule antigen ELISAs. ANCA antibodies were detected in 29% of all patients with panuveitis or anterior uveitis. In 41% of these ANCA + patients, serum antibody detected a perinuclear antigen that was sensitive in all cases to DNase 1. The majority of pANCA + uveitis patients were either HLA-B27 positive or had systemic evidence of immune-mediated diseases. Two pANCA + patients had no medical or family history of other immune-mediated diseases. This study identifies a subset of uveitis patients distinguished by expression of a specific pANCA marker antibody. The characteristics of this antibody are similar to the pANCA antibody present in most patients with ulcerative colitis. Expression of the pANCA autoantibody in uveitis patients is a susceptibility marker for other immune-mediated diseases.

Neutrophilia and lymphopenia in major mood disorders

Alterations in peripheral blood leukocyte distribution in major depression, including lymphopenia, neutrophilia, eosinopenia, and monocytopenia, have been described. The present study was designed to replicate these results, but with methodological improvements, including age-, sex-, and race-matched control subjects; DSM-III and Research Diagnostic Criteria diagnoses based on the Schedule for Affective Disorders and Schizophrenia interview; objective and subjective severity of depression measured quantitatively; and consideration of psychosocial stressors ( DSM-III, Axis IV). We found relative lymphopenia and absolute neutrophilia and leukocytosis in depression, but did not find decreased numbers of eosinophils or monocytes. The relative lymphopenia and absolute neutrophilia were present in the subgroup of only unipolar depressed patients, but not in the bipolar, currently depressed subgroup. However, these blood cell changes were not found in a subgroup of patients who had been medication free ⩾1 month but only in the subgroup of patients using medication at the time of phlebotomy. Groups formed on the basis of psychosocial stress levels were not found to have significant significant intergroup differences in white blood cell (WBC) counts. The clinical significance of these findings needs study. While leukovytosis and neutrophilia can be found in major depression, these changes are perhaps secondary to medication use.