Unrecognized Cases Research Articles

Detection and quantification of human immunodeficiency virus-1 (HIV-1) total nucleic acids in wastewater settled solids from two California communities

ABSTRACT Wastewater surveillance for infectious agents has proved useful in identifying the circulation of viruses within populations. We investigated the presence and concentration of human immunodeficiency virus (HIV)-1 total nucleic acids (including both viral RNA and proviral DNA) in wastewater solids. We retrospectively measured HIV-1 nucleic acids in two samples per week for 26 months at two wastewater treatment plants serving populations with different prevalences of HIV infections in San Francisco and Santa Clara County, California, USA. We detected HIV nucleic acids in a majority of samples with concentrations ranging from non-detect to 3.9 × 10 5 cp/g ( N = 459 samples total). Concentrations of HIV-1 were significantly higher in samples from the wastewater treatment plant serving a population with a higher prevalence of people living with HIV than in the plant serving a population with a lower prevalence. The HIV-1 nucleic acids amplified were primarily DNA and thus represented proviral DNA shedding into wastewater. Additionally, we found that HIV-1 nucleic acid concentrations in wastewater solids were orders of magnitude higher than those in liquid wastewater indicating that the HIV-1 target preferentially sorbs to solids. Whether concentrations of HIV-1 in wastewater solids can be used to identify the number of incident cases remains unknown. Additional work on HIV-1 shedding from individuals with viremia and people living with HIV is needed to translate wastewater measurements into quantitative information on infections. Additional work may also be needed to document non-human sources of HIV-1 nucleic acids in wastewater. IMPORTANCE Human immunodeficiency virus (HIV)-1 has infected nearly 100 million people since it emerged in the 1980s. Antiretroviral therapy prevents transmission of HIV and also allows infected individuals to live healthy lives with normal life expectancy. Consequently, identifying unrecognized cases of HIV is of paramount importance. Since wastewater represents a composite biological sample from a community, it may provide valuable information on HIV-1 prevalence that can be used to inform HIV testing and outreach.

Detecting Unrecognized Dementia Using Deep Learning Methods with Korean National Claims Data

Abstract Background Dementia is one of the leading causes of death in elderly people. In Korea, the government supports dementia screening for people aged 60 and older, but it is not a population-based organized screening program. It is difficult to achieve early diagnosis and early treatment. The objective of this study is to detect unrecognized dementia using Korean National Claims Data for early diagnosis. Methods This study used the National Health Insurance Claims data in Korea. The case group is the new dementia visit as an unrecognized group, while the control group was randomly selected from the general population without dementia. The predictors included health utilization, socioeconomic and demographic, procedure codes, diagnostic codes and health screenings data. The health utilization variables included length of stay, the number of outpatient visits, health expenditures and other encounter information. All medical utilization data was aggregated monthly. In the case group, 12 months of data from 6-month or 2-years before the onset of dementia were used. In the control group, 12 months of data from randomly selected time point were included. Transformer, embedding methods, and Time2Vec were used as the deep learning methods. This study included 453,306 incidents of dementia, representing almost all cases reported from 2010 to 2019 in Korea. The control group consisted of 669,873. Results After training the deep learning prediction model, the AUC for 6-month dementia prediction on the test dataset was 0.87, and for 2-year dementia prediction, it was 0.76. The most important variables were health utilization variables, especially health expenditures. The health utilization trajectories of the case group were significantly different from those of the control group. Conclusions Based on the claims data, we could detect unrecognized dementia case. We can extend the model to other chronic disease such as cancer and stroke, which are significant burden of disease. Key messages • Screening in healthcare facilities or using lab test results would be more accurate, but it would be difficult to apply to a large population due to the cost-effectiveness and timeliness constraints. • On the other hand, the detection model using the existing claims data would be helpful to to develop cost-effective mass screening program. It can cover the weakness of current screening program.

Seroprevalence of B. pertussis infection and the changes of specific antibody levels in health care workers during the first two years of COVID-19 in Wuhu, China

BackgroundThe reported number of pertussis cases declined after the implementation of COVID-19 prevention and control measures, however, the burden of pertussis among adults in China remains largely unknown. Additionally, the waning of natural antibody level has also rarely been assessed. MethodsA total of 762 healthcare workers (HCWs) who had underwent the health examinations in 2021 and 2022 were included. Serum anti-PT IgG and IgA levels were determined by ELISA. Recent B. pertussis infection was defined as anti-PT IgG ≥100 IU/ml and/or anti-PT IgA ≥10 IU/ml. ResultsIn 2021, the seroprevalence of recent B. pertussis infection was 10.1 %, and those HCWs in outpatient department had a higher percentage (18.6 %), and geometric mean concentration (GMC) (6.3 IU/ml) than those in other departments. This seroprevalence decreased to 2.4 % in 2022, although the difference remained significant. In the 77 subjects with recent B. pertussis infection in 2021, anti-PT IgG was undetectable in 18 cases the following year. Majority (68/76) of the subjects with anti-PT IgA ≥10 IU/ml in 2021 no longer had detected this antibody in 2022. Among 95 pertussis cases, approximately 60.0 % of cases reported no history of cough. Among those with a documented cough history, 36 cases with suspected pertussis courses who had never been diagnosed. Prolonged cough with nocturnal exacerbation (29/38) was the most commonly reported clinical symptom, and whoop was confirmed in six cases. Uroclepsia and syncopes during the cough attacks were reported by three and one subjects, respectively. One case presented with subconjunctival hemorrhage and tensionic purpura during the course. ConclusionsThe results suggested a high prevalence of B. pertussis infection among HCWs. The presence of unrecognized adult pertussis cases and the rapid waning of antibody indicate the need to improve clinical management for suspected pertussis in adults, and to updated immunization schedule after childhood program.

Healthcare Workers' Perspectives on the Utilization of the International HIV Dementia Scale for the Screening HIV-Associated Neurocognitive Disorders: A Qualitative Study at TASO Centres in Central and Southwestern Uganda.

HIV-associated neurocognitive disorders (HAND) are becoming a significant public health concern in the continuum of human immune virus (HIV) treatment.These disorders range from subtle cognitive impairments to severe dementia. Despite many early-stage HAND cases being asymptomatic, healthcare workers (HCWs) rarely perform routine neurocognitive assessments. This leads to a high number of unrecognized cases and increases the risk of HAND among people living with HIV (PLWH). We aimed to explore HCWs' perspectives on integrating the International HIV Dementia Scale (IHDS) into routine care for screening HAND at The AIDS Support Organization (TASO) centres in central and southwestern Uganda. We conducted five focus group discussions with 37 HCWs from five TASO centres. Thematic analysis revealed eight key theme: 1) Impaired brain function, 2) Changes in activities of daily living, 3) Promotion of quality care perspectives, 4) Tool applicable and user-friendly, 5) Client increased self-awareness and self-confidence, 6) Integration of IHDS into routine HIV care, 7) Uncertainty about IHDS use, and 8) Continuous training for HCWs. As PLWH enjoy longer and healthier lives, their risk for HAND increases, potentially affecting their quality of life. The use of the IHDS has raised awareness among HCWs and improved decision-making through cognitive assessments, emphasizing it value in PLWH. We recommend a prospective study to assess the long-term outcomes and efficacy of increased HAND screening. Furthermore, integrating a HAND screening module into the consolidated HIV guidelines is recommended to enhance its relevance.

Epstein-Barr virus-positive inflammatory follicular dendritic cell sarcoma with significant granuloma: case report and literature review

BackgroundEpstein-Barr virus-positive inflammatory follicular dendritic cell sarcoma (EBV+IFDCS) is a rare disease characterized by mild clinical symptoms and non-specific imaging findings. The diagnosis of the disease depends on pathological diagnosis. However, EBV+IFDCS has a very broad spectrum of histological morphology and immune phenotypes, and its histopathological features have not been fully described by pathologists.Case presentationA 59-year-old female, with no significant discomfort, was found to have a splenic mass during a routine physical examination. Microscopic examination at low magnification revealed numerous epithelioid granulomas, amidst which a substantial inflammatory response was observed. Interspersed among the dense inflammatory cells were spindle or oval-shaped cells, distributed sporadically with indistinct boundaries. Under high magnification, these spindle cells had subtle features: smooth and clear nuclear membranes, inconspicuous small nucleoli, and infrequent mitotic figures. Immunophenotypically, the spindle cells expressed CD21 and CD23, and Epstein-Barr encoding region (EBER) in situ hybridization yielded positive results. The inflammatory milieu predominantly consisted of T cells, with a minority of plasma cells expressing IgG4. The confluence of morphological and immunohistochemical findings led to the final pathological diagnosis of EBV+IFDCS in this case.ConclusionsThe presentation of EBV+IFDCS with pronounced granulomatous changes is rare. This morphological variant poses a high risk of misdiagnosis, frequently leading to confusion with other granulomatous diseases. Accurate diagnosis necessitates a comprehensive analysis, integrating immunohistochemistry and in situ hybridization. The case presented here is instrumental in raising awareness and understanding of EBV+IFDCS, with the goal of reducing misdiagnoses and unrecognized cases.

Spontaneous Emphysema, Pneumomediastinum and Pneumopericardium Revealing Unrecognized Inhalation of a Foreign Body

Inhalation of a foreign body is a frequent problem in pediatrics with a very difficult diagnosis in the absence of penetration syndrome. It is a very rare cause of emphysema moreover the combination of emphysema, pneumomediastinum or pneumopericardium is an exceptional form. We report an unrecognized case of inhalation of a foreign body, a 5-year-old girl was admitted for respiratory distress with diffuse subcutaneous emphysema in the eyelids , face, neck and chest more marked on the left . A chest CT revealed emphysema with pneumomediastinum, pneumopericardium and a focus of LIG condensation. The diagnostic bronchoscopy was performed under general anesthesia. A sunflower seed, landlocked completely obstructing the bronchial lumen was detected and recovered in the left main bronchus. The removal of the foreign body resulted in improvement of the emphysema and the gradual disappearance of symptoms.

Self-sampling monkeypox virus testing in high-risk populations, asymptomatic or with unrecognized Mpox, in Spain

The recent monkeypox virus (MPXV) outbreak was of global concern and has mainly affected gay, bisexual and other men who have sex with men (GBMSM). Here we assess prevalence of MPXV in high-risk populations of GBMSM, trans women (TW) and non-binary people without symptoms or with unrecognized monkeypox (Mpox) symptoms, using a self-sampling strategy. Anal and pharyngeal swabs are tested by MPXV real-time PCR and positive samples are tested for cytopathic effect (CPE) in cell culture. 113 individuals participated in the study, 89 (78.76%) were cis men, 17 (15.04%) were TW. The median age was 35.0 years (IQR: 30.0–43.0), 96 (85.02%) individuals were gay or bisexual and 72 (63.72%) were migrants. Seven participants were MPXV positive (6.19% (95% CI: 1.75%–10.64%)). Five tested positive in pharyngeal swabs, one in anal swab and one in both. Six did not present symptoms recognized as MPXV infection. Three samples were positive for CPE, and showed anti-vaccinia pAb staining by FACS and confocal microscopy. This suggests that unrecognized Mpox cases can shed infectious virus. Restricting testing to individuals reporting Mpox symptoms may not be sufficient to contain outbreaks.

Clinical and molecular description of the first Italian cohort of 33 subjects with hypophosphatasia.

Hypophosphatasia (HPP) is a rare genetic disease caused by inactivating variants of the ALPL gene. Few data are available on the clinical presentation in Italy and/or on Italian HPP surveys. There were 30 suspected HPP patients recruited from different Italian tertiary cares. Biological samples and related clinical, biochemical, and anamnestic data were collected and the ALPL gene sequenced. Search for large genomic deletions at the ALPL locus (1p36) was done. Phylogenetic conservation and modeling were applied to infer the effect of the variants on the protein structure. There were 21 ALPL variants and one large genomic deletion found in 20 out of 30 patients. Unexpectedly, NGS-driven differential diagnosis allowed uncovering three hidden additional HPP cases, for a total of 33 HPP subjects. Eight out of 24 coding variants were novel and classified as "pathogenic", "likely pathogenic", and "variants of uncertain significance". Bioinformatic analysis confirmed that all the variants strongly destabilize the homodimer structure. There were 10 cases with low ALP and high VitB6 that resulted negative to genetic testing, whereas two positive cases have an unexpected normal ALP value. No association was evident with other biochemical/clinical parameters. We present the survey of HPP Italian patients with the highest ALPL mutation rate so far reported and confirm the complexity of a prompt recognition of the syndrome, mostly for HPP in adults. Low ALP and high VitB6 values are mandatory for the genetic screening, this latter remaining the gold standard not only to confirm the clinical diagnosis but also to make differential diagnosis, to identify carriers, to avoid likely dangerous therapy in unrecognized cases.

Total Knee Arthroplasty in Unrecognized Septic Arthritis-A Descriptive Case Series Study.

Synovitis, like that associated with chronic bacterial arthritis, is a very rare finding during the implantation of knee endoprostheses. In such cases, we fix the knee prostheses with cement containing two antibiotics and carry out a course of systemic antibiotic administration. The aim was to analyze these cases for incidence, detection of bacteria, risk factors, and outcome. Out of 7534 knee replacements between January 2013 and December 2020, 25 cases were suspected during the surgical procedure to have suffered from bacterial arthritis and were treated accordingly. Total synovectomy was carried out, whereby five intraoperative synovial samples were examined bacteriologically, and the complete synovitis was analyzed histologically. The mean follow-up was 65.3 ± 27.1 (24-85) months. In nine cases (0.12%), the diagnosis of bacterial arthritis was made histologically and by clinical chemistry (elevated CRP), and in two of these cases, pathogen verification was performed. Eight of these nine patients had previously had injections or surgery associated with the corresponding knee joint or had an underlying immunomodulatory disease. None of the patients developed a periprosthetic infection at a later stage. With an incidence of 0.12%, it is rare to unexpectedly detect bacterial synovitis during surgery. Total synovectomy, use of bone cement with two antibiotics, and immediate systemic antibiotic therapy seem to keep the risk of periprosthetic infection low.

Fully digital self-screening for atrial fibrillation with patch electrocardiogram.

Atrial fibrillation (AF) is the most common arrhythmia worldwide. The AF is associated with severe mortality, morbidity, and healthcare costs, and guidelines recommend screening people at risk. However, screening methods and organization still need to be clarified. The current study aimed to assess the feasibility of a fully digital self-screening procedure and to assess the prevalence of undetected AF using a continuous patch electrocardiogram (ECG) monitoring system. Individuals ≥65 years old with at least one additional risk factor for stroke from the general population of Norway were invited to a fully digital continuous self-screening for AF using a patch ECG device (ECG247 Smart Heart Sensor). Participants self-reported clinical characteristics and usability online, and all participants received digital feedback of their results. A total of 2118 individuals with a mean CHA2DS2-VASc risk score of 2.6 (0.9) were enrolled in the study [74% women; mean age 70.1 years (4.2)]. Of these, 1849 (87.3%) participants completed the ECG self-screening test, while 215 (10.2%) did not try to start the test and 54 (2.5%) failed to start the test. The system usability score was 84.5. The mean ECG monitoring time was 153 h (87). Atrial fibrillation was detected in 41 (2.2%) individuals. This fully digitalized self-screening procedure for AF demonstrated excellent feasibility. The number needed to screen was 45 to detect one unrecognized case of AF in subjects at risk for stroke. Randomized studies with long-term follow-up are needed to assess whether self-screening for AF can reduce the incidence of AF-related complications. NCT04700865.

Monkeypox Disease with Predominant Genital Symptoms: A Nigerian Case Report

Mpox presents typically with macular papular body rashes with similar-looking sores in genital or oral areas. It may be missed, or wrongly managed as sexually transmitted infections (STI), especially in settings where symptom-based treatment practices are sufficient for care.
 We describe a 40-year-old cisgender male, heterosexual Nigerian who developed some rash in the genital region associated with penile swelling. It was suspected to be syphilis and managed with presumptive antibiotics. Laboratory investigation (PCR) confirmed that it was a Mpox disease, and VDRLT was negative. Notably, in this case, the early symptoms were a paradigm case of Mpox disease presenting as an STI, which syndromically conformed more to an STI than the case definition for a suspected case of Mpox in our setting. Consequently, the expected early containment activities were delayed. This increased the potential of further disease spread. An Update of the standard case definition as well as a reclassification of the disease as a possible STI is recommended for enhanced surveillance, increased case detection, and reduction in the burden of unrecognized cases.

Improving Surveillance and Epidemic Response in Ohio Childcare Settings.

At the start of the Coronavirus Disease of 2019 (COVID-19) pandemic, the risk of cases in childcare programs was unknown. Thus, a rapid-response research approach was launched in Ohio childcare settings. Passive surveillance data from a state-operated incident reporting system were evaluated to estimate the number of COVID-19 cases from 15 August 2020 to 1 January 2021. Additionally, active surveillance with self-administered reverse transcriptase-polymerase chain reaction (RT-PCR) tests were conducted among staff at 46 childcare programs. Finally, six zoom-based focus groups with program administrators were used to gain feedback. Staff and children in childcare settings contributed 0.38% and 0.15% of the COVID-19 cases in Ohio during this timeframe, respectively. RT-PCR testing identified 3 unrecognized cases (0.88% of tests), and all occurred when the statewide positivity rate was >5%. Focus groups revealed that access to affordable cleaning supplies, masks, and reliable staffing were critical. Perhaps most importantly, we conclude that expanding the incident reporting system to include a childcare census would allow for the tracking of future health problems with highly valuable incidence rate estimations.

Renal Clear Cell Carcinoma with Unknown Primary: Is It Real Entity or Just Hypothesis?

Renal cell carcinoma (RCC) is a common type of cancer, and about 25% of patients are diagnosed at an advanced stage. Bone metastasis is common in RCC, but instances of bone metastases without a primary kidney tumour have rarely been reported. Here, we report a case of a 56-year male patient who presented with extensive bone metastases. The biopsy was reported as clear cell RCC and no primary renal tumour was detected by positron emission tomography and magnetic resonance imaging. Pazopanib was initiated and progression was detected in the 6th month of treatment. Nivolumab was initiated as second line therapy. In the literature, primary unrecognised RCC cases are found only as case reports. This case highlights the importance of clinicians' consideration of possible metastatic RCC in a patient with pathologically diagnosed clear cell carcinoma, even if no primary renal tumour is identified. Key Words: Renal cell carcinoma, İmmunohistochemistry, Diagnosis, Kidney, Cancer.

An Unrecognized Case of Subcutaneous Emphysema: Expanding the Frontiers of POCUS

An Unrecognized Case of Subcutaneous Emphysema: Expanding the Frontiers of POCUS

Prevalence of cardiac amyloidosis among cardiac- and non-cardiac patients undergoing echocardiography at a large university echo lab in Germany: a cohort study

Abstract Background Cardiac amyloidosis (CA) is a progressive infiltrative cardiomyopathy that leads to severe heart failure and, once clinically relevant, poses a high mortality risk. Epidemiological data for CA are still sparse and heterogeneous, but urgently needed since novel therapies against ATTR-CA are now available. Aim We aimed to assess minimum prevalence rates of CA among cardiac and non-cardiac patients undergoing routine echocardiography in an echo lab of a large university clinic serving all medical specialities in central Germany. Methods We established a retro- and prospective database based on suspicious findings in echocardiography for all echocardiographic exams over an 8.5 year period (03/2013 and 09/2021). During this time, 41,375 patients underwent at least one echo exam. Indication for echos were mixed, and consisted of non-cardiac and cardiac patients with acute and chronic illnesses as well as screening exams (e.g. before major surgery or chemotherapy). Suspicious echocardiography were retrospectively analysed whether they underwent further diagnostic or if it remained an unproven suspicion (figure). All echos of suspicious cases were comprehensively re-analysed regarding novel surrogate parameters and indices for CA. Various clinical and laboratory parameters were collected. Results The mean age of the cohort of 41,375 patients was 65.1±15.8 years for the first or only echo examination with a slightly unbalanced gender distribution (45% female). The age distribution is shown in the table. While 128 patients were suspected, the diagnosis was falsified in 16 patients and proven in 47 patients (light chain n=16, ATTR n=31; figure). A substantial proportion of patients with suspicious echo received no further diagnostic work-up (N=65). Over the given time frame of 101 months, the prevalence of suspicious echocardiograms was 1 per 323 patients (or 31 per 10,000). The proven cases had a prevalence of 1 per 880 patients (or 11.3 per 10,000). Since ATTR-CA is a disease of the elderly, we saw a vanishingly small number of cases in persons younger than 70 years (table), whereas 90% of all CA patients were older than 70 years. At timing of diagnosis, AL-CA patients were almost 10 years younger compared to diagnosis of ATTR-CA (69.1±8.4 years vs. 77.4±8.5 years). In patients older than 80 years, the prevalence rate of ATTR-CA peaked with 22.6 cases per 10.000 patients (0.23%). The prevalence rate of ATTR-CA was roughly twice as high compared to AL-CA. Conclusion For the first time, an estimation of minimum prevalence rates for CA for a defined volume of echocardiograms in an all-comers population is provided. In a mixed population of a hospital of maximum care CA prevalence rate is much higher than expected. Awareness for this “rare” disease is needed, since routine echo exams can prompt suspicion in clinically silent or so far unrecognized CA cases. Funding Acknowledgement Type of funding sources: None.

The Roles of Unrecognized Mpox Cases, Contact Isolation and Vaccination in Determining Epidemic Size in Belgium: A Modeling Study.

We used a network model to simulate a mpox epidemic among men who have sex with men. Our findings suggest that unrecognized infections have an important impact on the epidemic, and that vaccination of individuals at highest risk of infection reduces epidemic size more than post-exposure vaccination of sexual partners.

Retrospective Analysis Revealed an April Occurrence of Monkeypox in the Czech Republic.

Herein, we present our findings of an early appearance of the Monkeypox virus in Prague, Czech Republic. A retrospective analysis of biological samples, carried out on the 28th of April, revealed a previously unrecognized case of Monkeypox virus (MPxV) infection. Subsequent data analysis confirmed that the virus strain belongs to the ongoing outbreak. Combined with clinical and epidemiological investigations, we extended the roots of the current outbreak at least back to 16th of April, 2022.

Development and external validation of a diagnostic model for biopsy-proven acute interstitial nephritis using electronic health record data.

Patients with acute interstitial nephritis (AIN) can present without typical clinical features, leading to a delay in diagnosis and treatment. We therefore developed and validated a diagnostic model to identify patients at risk of AIN using variables from the electronic health record. In patients who underwent a kidney biopsy at Yale University between 2013 and 2018, we tested the association of >150 variables with AIN, including demographics, comorbidities, vital signs and laboratory tests (training set 70%). We used least absolute shrinkage and selection operator methodology to select prebiopsy features associated with AIN. We performed area under the receiver operating characteristics curve (AUC) analysis with internal (held-out test set 30%) and external validation (Biopsy Biobank Cohort of Indiana). We tested the change in model performance after the addition of urine biomarkers in the Yale AIN study. We included 393 patients (AIN 22%) in the training set, 158 patients (AIN 27%) in the test set, 1118 patients (AIN 11%) in the validation set and 265 patients (AIN 11%) in the Yale AIN study. Variables in the selected model included serum creatinine {adjusted odds ratio [aOR] 2.31 [95% confidence interval (CI) 1.42-3.76]}, blood urea nitrogen:creatinine ratio [aOR 0.40 (95% CI 0.20-0.78)] and urine dipstick specific gravity [aOR 0.95 (95% CI 0.91-0.99)] and protein [aOR 0.39 (95% CI 0.23-0.68)]. This model showed an AUC of 0.73 (95% CI 0.64-0.81) in the test set, which was similar to the AUC in the external validation cohort [0.74 (95% CI 0.69-0.79)]. The AUC improved to 0.84 (95% CI 0.76-0.91) upon the addition of urine interleukin-9 and tumor necrosis factor-α. We developed and validated a statistical model that showed a modest AUC for AIN diagnosis, which improved upon the addition of urine biomarkers. Future studies could evaluate this model and biomarkers to identify unrecognized cases of AIN.

Impact of a Severe Rocky Mountain Spotted Fever Case on Treatment Practices at an Academic Institution Within a Nonendemic Area.

Rocky Mountain spotted fever (RMSF) is a bacterial disease associated with morbidity and mortality when untreated. The primary study objectives are to describe clinician diagnostic and treatment practices in a nonendemic area after the occurrence of an unrecognized severe pediatric presumed RMSF case (index case). We hypothesized that inpatient diagnostic testing frequency and initiation of empiric treatment will increase after the index case. We performed a retrospective chart review of patients aged less than 18 y evaluated for RMSF at Penn State Hershey Children's Hospital between 2010 and 2019. We divided the study population into 2 groups (preindex and postindex) and evaluated patient characteristics, RMSF testing completion, and timing of doxycycline administration. Fifty-four patients (14 [26%] preindex and 40 [74%] postindex) were included. Age (median [25th percentile, 75th percentile]) decreased from 14.5 y (8.6, 16) preindex to 8.3 y (3.6, 14) postindex. Twelve (86%) preindex and 31 (78%) postindex patients received empiric doxycycline (P=0.70). Four years after the index case, a decrease in empiric and urgent initiation of doxycycline administration was noted. One case of severe RMSF was diagnosed 4 y after the index case. Our study found that inpatient RMSF testing increased after the index case, but not all patients received empiric treatment. This may represent an underappreciation of RMSF severity even after a recent devastating case. We suggest that when severe rare but possibly reversible diseases, such as RMSF occur, all clinicians are educated on the diagnostic and treatment approach to reduce the morbidity and mortality risk.

An Automated Electronic Screening Tool (DETECT) for the Detection of Potentially Irreversible Loss of Brain Function.

A major reason for the low number of organ donors in Germany is a deficit in the recognition of patients who may have impending irreversible loss of brain function (ILBF) in hospitals capable of organ retrieval. We used anonymized data from the German Organ Procurement Organization (Deutsche Stiftung Organtransplantation, DSO) to compare two 12-month periods (a reference period and an evaluation period) before and after the implementation of an electronic screening tool (DETECT) at the University Hospital Dresden (UKD) with four other university hospitals without tool implementation (comparative cohort). DETECT is intended to aid in the recognition of potentially impending ILBF. The study endpoints encompassed patients with potentially unrecognized ILBF, patients with recognized ILBF, organ donations performed, and reports to the DSO. Changes in absolute risk were compared with Breslow-Day tests. 309 patients who died with primary or secondary brain lesions were identified in the UKD in the reference and evaluation periods (164 and 145 patients, respectively), and 1060 (529, 531) in the comparative cohort. In the UKD, the number of unrecognized cases of possibly impending ILBF was 14/164 (8.54%) in the reference period and 1/145 (0.69%) in the evaluation period, yielding an absolute reduction of 7.85% (95% confidence interval [--3.36; --12.33]); by contrast, in the comparative cohort, there was a 0.55% absolute increase between the two periods ([--2.21; 3.30]; p = 0.002 for the comparison between the two cohorts). Only minor differences in absolute risk change were seen with regard to the probability of recognized ILBF (7.09% [0.29; 13.88] vs. 2.42% [1.18; 6.01]; p = 0.234), organ donation (4.70% [--0.89; 10.28] vs. 0.55% [--2.17; 3.26]; p = 0.214), or reporting to the DSO (4.17% [--1.77; 10.11] vs. 2.22% [--1.44; 5.89; p = 0.447); these changes may have arisen by chance. These findings suggest that the use of DETECT can help to reduce the deficit in the recognition of patients with impending or manifest ILBF.