Usefulness of point of care ultrasound in older adults: a multicentre study across different geriatric care settings in Spain and the United Kingdom.

BACKGROUND: Point of care ultrasound (POCUS) is an imaging technique performed bedside. To date, few published studies have reported the usefulness of multiorgan POCUS in Geriatrics. The objective of this study was to describe the utility of multiorgan POCUS in the care of older adults admitted to geriatric care settings. METHODOLOGY: Observational retrospective study of patients admitted to geriatric settings in Spain and UK. Multiorgan POCUS was performed when there was a specific clinical suspicion or unexplained torpid clinical course despite physical examination and complementary tests. A geriatrician with a certificate degree in comprehensive ultrasound and long-standing experience in POCUS carried out POCUS. All patients underwent multiorgan POCUS in a cephalo-caudal manner. RESULTS: Out of 368 patients admitted to geriatric units, 29% met the inclusion criteria. Average age was 85.9 years (SD ± 6.1). POCUS identified 235 clinically significant findings (2.2 per patient). Findings were classified as 37.9% confirmed diagnosis, 16.6% ruled out diagnosis, 14.9% unsuspected relevant diagnoses and 30.6% clinical follow-ups. POCUS findings led to changes in pharmacological and non-pharmacological treatment in 66.3 and 69.2% respectively, resulted in completion or avoidance of invasive procedures in 17.8 and 15.9%, respectively, facilitating early referrals to other specialities in 14.9% and avoiding transfers in 25.2% of patients. CONCLUSION: Multiorgan POCUS is a tool that aids in the assessment and treatment of patients receiving care in geriatrics units. These results show the usefulness of POCUS in the management of older adults and suggest its inclusion in any curriculum of Geriatric Medicine speciality training.

Point of care HIV testing in dental settings in high-income countries: A mixed-methods systematic review.

OBJECTIVES: Expanding HIV testing beyond specialized services has been a key strategic approach to eliminating the transmission of HIV. In recent years, dental settings have been identified as offering an opportunity for delivering point of care HIV testing (POCT) interventions. Intervention components and implementation strategies have varied across studies and there is uncertainty about the prevalence of undiagnosed HIV in the dental patient population. Therefore, this systematic review aimed to synthesize the HIV testing outcomes of intervention studies, identify the core components of POCT interventions implemented in dental settings; and understand the barriers and facilitators to intervention implementation. METHODS: A mixed-methods systematic review was undertaken. Two authors reviewed abstracts and full papers for inclusion and appraised the studies using the Mixed Methods Appraisal Tool. A convergent integrated mixed methods study design underpinned the synthesis. Outcomes were presented using descriptive statistics. Intervention components were mapped to the Template for Intervention Description and Replication (TIDieR) checklist. Barriers and facilitators were described using a narrative thematic analysis. RESULTS: POCT was offered to 22 146 dental patients, 62.5% accepted POCT. Intervention studies that reported higher uptake of testing utilized a dedicated dental or researcher staff member to provide testing, integrated testing and provided results within the routine dental appointment and adopted a provider-initiated universal approach to offering testing. Six themes emerged that were pertinent to the barriers and facilitators to HIV testing in dental setting. CONCLUSIONS: POCT uptake in dental settings was comparable with other non-specialized health settings. Key to the operationalization of the intervention were perceptions about its value and relevance to the dental patient population, attitudes toward the intervention, logistical barriers to its implementation, the risk of HIV testing stigma to the patient-practitioner relationship and maximising the fit of the intervention within the constraints of the dental setting.

Prehospital use of point-of-care tests by community health workers: a scoping review.

Introduction: Point-of-Care Tests (POCTs) are utilized daily in resource abundant regions, however, are limited in the global south, particularly in the prehospital setting. Few studies exist on the use of non-malarial POCTs by Community Health Workers (CHWs). The purpose of this scoping review is to delineate the current diversity in and breadth of POCTs evaluated in the prehospital setting. Methods: A medical subject heading (MeSH) analysis of known key articles was done by an experienced medical librarian and scoping searches were performed in each database to capture "point of care testing" and "community health workers." This review was guided by the PRISMA Extension for scoping reviews. Results: 2735 publications were returned, 185 were nominated for full-text review, and 110 studies were confirmed to meet study criteria. Majority focused on malaria (74/110; 67%) or HIV (25/110; 23%); 9/110 (8%) described other tests administered. Results from this review demonstrate a broad geographic range with significant heterogeneity in terminology for local CHWs. Conclusion: The use of new POCTs is on the rise and may improve early risk stratification in limited resource settings. Current evidence from decades of malaria POCTs can guide future implementation strategies.

The Value of Pulmonary Bedside Ultrasound System in the Evaluation of Severity and Prognosis of Acute Lung Injury.

OBJECTIVE: To evaluate the value of pulmonary bedside ultrasound system in the assessment of severity and prognosis of acute lung injury (ALI). METHOD: Seventy-two ALI patients in the intensive care unit (ICU) of our hospital from April 2019 to April 2021 were selected as subjects. The changes of lung ultrasound score (LUS) and parameters at D1, D2, and D3 after admission were analyzed (LUS, oxygenation index (PaO2/FiO2), Acute Physiology and Chronic Health Evaluation II (APACHE-II), and Sequential Organ Failure Assessment (SOFA) score). Pearson correlation analysis was used to assess the relationship between LUS and PaO2/FiO2, APACHE-II score, and SOFA score at D1, D2, and D3. Logistic regression analysis was used for influencing factors for the prognosis of ALI patients. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of baseline LUS, PaO2/FiO2, APACHE-II score, and SOFA score for the prognosis of ALI patients. RESULT: LUSs at D1, D2 and D3 showed an increasing trend with the increase of disease severity (P < 0.05). From D1 to D3, LUS, PaO2/FiO2, APACHE-II score, and SOFA score showed a downward trend (P < 0.05). LUS was negatively correlated with PaO2/FiO2 at D1, D2, and D3 but positively correlated with APACHE-II score and SOFA score (P < 0.05). Logistic regression analysis showed that after controlling for age, PaO2 and PaCO2, an increase in baseline LUS, APACHE-II score, SOFA score, and a decrease in PaO2/FiO2 were independent risk factors for death at 28 d in ALI patients (P < 0.05). ROC curve showed that LUS, PaO2/FiO2, APACHE-II score, and SOFA score were combined to predict the prognosis of ALI patients with the highest AUC value of 0.920, corresponding sensitivity of 88.89%, and specificity of 95.56%. CONCLUSION: LUS can evaluate the change of pulmonary ventilation area in ALI patients, further evaluate the severity of the disease, and effectively predict the prognosis of patients.

Polymethyl Methacrylate-Based Smart Microfluidic Point-of-Care Testing of Prothrombin Time and International Normalized Ratio through Optical Detection.

The mechanical heart valve is a crucial solution for many patients. However, it cannot function on the state of blood as human tissue valves. Thus, people with mechanical valves are put under anticoagulant therapy. A good measurement of the state of blood and how long it takes blood to form clots is the prothrombin time (PT); moreover, it is an indicator of how well the anticoagulant therapy is, and of whether the response of the patient to the drug is as needed. For a more specific standardized measurement of coagulation time, an international normalized ratio (INR) is established. Clinical testing of INR and PT is relatively easy. However, it requires the patient to visit the clinic for evaluation purposes. Many techniques are therefore being developed to provide PT and INR self-testing devices. Unfortunately, those solutions are either inaccurate, complex, or expensive. The present work approaches the design of an anticoagulation self-monitoring device that is easy to use, accurate, and relatively inexpensive. Hence, a two-channel polymethyl methacrylate-based microfluidic point-of-care (POC) smart device has been developed. The Arduino based lab-on-a-chip device applies optical properties to a small amount of blood. The achieved accuracy is 96.7%.

Testing the Accuracy of a Bedside Screening Tool Framework to Clinical Records for Identification of Patients at Risk of Malnutrition in a Rural Setting: An Exploratory Study.

This study aimed to explore the diagnostic accuracy of the Patient-Generated Subjective Global Assessment (PG-SGA) malnutrition risk screening tool when used to score patients based on their electronic medical records (EMR), compared to bedside screening interviews. In-patients at a rural health service were screened at the bedside (n = 50) using the PG-SGA, generating a bedside score. Clinical notes within EMRs were then independently screened by blinded researchers. The accuracy of the EMR score was assessed against the bedside score using area under the receiver operating curve (AUC), sensitivity, and specificity. Participants were 62% female and 32% had conditions associated with malnutrition, with a mean age of 70.6 years (SD 14.9). The EMR score had moderate diagnostic accuracy relative to PG-SGA bedside screen, AUC 0.74 (95% CI: 0.59-0.89). The accuracy, specificity and sensitivity of the EMR score was highest for patients with a score of 7, indicating EMR screen is more likely to detect patients at risk of malnutrition. This exploratory study showed that applying the PG-SGA screening tool to EMRs had enough sensitivity and specificity for identifying patients at risk of malnutrition to warrant further exploration in low-resource settings.

Pathophysiologic Signature of Impending ICU Hypoglycemia in Bedside Monitoring and Electronic Health Record Data: Model Development and External Validation.

OBJECTIVES: We tested the hypothesis that routine monitoring data could describe a detailed and distinct pathophysiologic phenotype of impending hypoglycemia in adult ICU patients. DESIGN: Retrospective analysis leading to model development and validation. SETTING: All ICU admissions wherein patients received insulin therapy during a 4-year period at the University of Virginia Medical Center. Each ICU was equipped with continuous physiologic monitoring systems whose signals were archived in an electronic data warehouse along with the entire medical record. PATIENTS: Eleven thousand eight hundred forty-seven ICU patient admissions. INTERVENTIONS: The primary outcome was hypoglycemia, defined as any episode of blood glucose less than 70 mg/dL where 50% dextrose injection was administered within 1 hour. We used 61 physiologic markers (including vital signs, laboratory values, demographics, and continuous cardiorespiratory monitoring variables) to inform the model. MEASUREMENTS AND MAIN RESULTS: Our dataset consisted of 11,847 ICU patient admissions, 721 (6.1%) of which had one or more hypoglycemic episodes. Multivariable logistic regression analysis revealed a pathophysiologic signature of 41 independent variables that best characterized ICU hypoglycemia. The final model had a cross-validated area under the receiver operating characteristic curve of 0.83 (95% CI, 0.78-0.87) for prediction of impending ICU hypoglycemia. We externally validated the model in the Medical Information Mart for Intensive Care III critical care dataset, where it also demonstrated good performance with an area under the receiver operating characteristic curve of 0.79 (95% CI, 0.77-0.81). CONCLUSIONS: We used data from a large number of critically ill inpatients to develop and externally validate a predictive model of impending ICU hypoglycemia. Future steps include incorporating this model into a clinical decision support system and testing its effects in a multicenter randomized controlled clinical trial.

Influenza and RSV incidence during COVID-19 pandemic-an observational study from in-hospital point-of-care testing.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has forced the implementation of unprecedented public health measures strategies which might also have a significant impact on the spreading of other viral pathogens such as influenza and Respiratory Syncytial Virus (RSV) . The present study compares the incidences of the most relevant respiratory viruses before and during the SARS-CoV-2 pandemic in emergency room patients. We analyzed the results of in total 14,946 polymerase chain reaction point-of-care tests (POCT-PCR) for Influenza A, Influenza B, RSV and SARS-CoV-2 in an adult and a pediatric emergency room between December 1, 2018 and March 31, 2021. Despite a fivefold increase in the number of tests performed, the positivity rate for Influenza A dropped from 19.32% (165 positives of 854 tests in 2018/19), 14.57% (149 positives of 1023 in 2019-20) to 0% (0 positives of 4915 tests) in 2020/21. In analogy, the positivity rate for Influenza B and RSV dropped from 0.35 to 1.47%, respectively, 10.65-21.08% to 0% for both in 2020/21. The positivity rate for SARS-CoV2 reached 9.74% (110 of 1129 tests performed) during the so-called second wave in December 2020. Compared to the two previous years, seasonal influenza and RSV incidence was eliminated during the COVID-19 pandemic. Corona-related measures and human behavior patterns could lead to a significant decline or even complete suppression of other respiratory viruses such as influenza and RSV.

Placental growth factor in assessment of women with suspected pre-eclampsia to reduce maternal morbidity: a stepped wedge cluster randomised control trial (PARROT Ireland).

OBJECTIVE: To determine whether the addition of placental growth factor (PlGF) measurement to current clinical assessment of women with suspected pre-eclampsia before 37 weeks' gestation would reduce maternal morbidity without increasing neonatal morbidity. DESIGN: Stepped wedge cluster randomised control trial from 29 June 2017 to 26 April 2019. SETTING: National multisite trial in seven maternity hospitals throughout the island of Ireland PARTICIPANTS: Women with a singleton pregnancy between 20+0 to 36+6 weeks' gestation, with signs or symptoms suggestive of evolving pre-eclampsia. Of the 5718 women screened, 2583 were eligible and 2313 elected to participate. INTERVENTION: Participants were assigned randomly to either usual care or to usual care plus the addition of point-of-care PlGF testing based on the randomisation status of their maternity hospital at the time point of enrolment. MAIN OUTCOMES MEASURES: Co-primary outcomes of composite maternal morbidity and composite neonatal morbidity. Analysis was on an individual participant level using mixed-effects Poisson regression adjusted for time effects (with robust standard errors) by intention-to-treat. RESULTS: Of the 4000 anticipated recruitment target, 2313 eligible participants (57%) were enrolled, of whom 2219 (96%) were included in the primary analysis. Of these, 1202 (54%) participants were assigned to the usual care group, and 1017 (46%) were assigned the intervention of additional point-of-care PlGF testing. The results demonstrate that the integration of point-of-care PlGF testing resulted in no evidence of a difference in maternal morbidity-457/1202 (38%) of women in the control group versus 330/1017 (32%) of women in the intervention group (adjusted risk ratio (RR) 1.01 (95% CI 0.76 to 1.36), P=0.92)-or in neonatal morbidity-527/1202 (43%) of neonates in the control group versus 484/1017 (47%) in the intervention group (adjusted RR 1.03 (0.89 to 1.21), P=0.67). CONCLUSIONS: This was a pragmatic evaluation of an interventional diagnostic test, conducted nationally across multiple sites. These results do not support the incorporation of PlGF testing into routine clinical investigations for women presenting with suspected preterm pre-eclampsia, but nor do they exclude its potential benefit. TRIAL REGISTRATION: ClinicalTrials.gov NCT02881073.

Operational characteristics of 30 lateral flow immunoassays used to identify COVID-19 immune response.

Serology or antibody tests for COVID-19 are designed to detect antibodies (mainly Immunoglobulin M (IgM) and Immunoglobulin G (IgG) produced in response to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV-2) infection. In this study, 30 lateral flow immunoassays were tested using serum or plasma from patients with confirmed SARS CoV-2 infection. Negative serological controls were accessed from a well-characterised bank of sera which were stored prior to February 2020. Operational characteristics and ease of use of the assays are reported. 4/30 (13%) of kits (Zheihang Orient Gene COVID-19 IgG/IgM, Genrui Novel Coronavirus (2019-nCoV) IgG/IgM, Biosynex COVID-19 BSS IgG/IgM, Boson Biotech 2019-nCoV IgG/IgM) were recommended for SAHPRA approval based on kit sensitivity. Of these, only the Orientgene was recommended by SAHPRA in August 2020 for use within the approved national testing algorithm while the remaining three received limited authorization for evaluation. All kits evaluated work on the same basic principle of immunochromatography with minor differences noted in the shape and colour of cartridges, the amount of specimen volume required and the test duration. Performance of the lateral flow tests were similar to sensitivities and specificities reported in other studies. The cassettes of the majority of kits evaluated (90%) detected both IgG and IgM. Only 23% of kits evaluated contained all consumables required for point-of-care testing. The study highlights the need for thorough investigation of kits prior to implementation.

Accurate influenza forecasts using type-specific incidence data for small geographic units.

Influenza incidence forecasting is used to facilitate better health system planning and could potentially be used to allow at-risk individuals to modify their behavior during a severe seasonal influenza epidemic or a novel respiratory pandemic. For example, the US Centers for Disease Control and Prevention (CDC) runs an annual competition to forecast influenza-like illness (ILI) at the regional and national levels in the US, based on a standard discretized incidence scale. Here, we use a suite of forecasting models to analyze type-specific incidence at the smaller spatial scale of clusters of nearby counties. We used data from point-of-care (POC) diagnostic machines over three seasons, in 10 clusters, capturing: 57 counties; 1,061,891 total specimens; and 173,909 specimens positive for Influenza A. Total specimens were closely correlated with comparable CDC ILI data. Mechanistic models were substantially more accurate when forecasting influenza A positive POC data than total specimen POC data, especially at longer lead times. Also, models that fit subpopulations of the cluster (individual counties) separately were better able to forecast clusters than were models that directly fit to aggregated cluster data. Public health authorities may wish to consider developing forecasting pipelines for type-specific POC data in addition to ILI data. Simple mechanistic models will likely improve forecast accuracy when applied at small spatial scales to pathogen-specific data before being scaled to larger geographical units and broader syndromic data. Highly local forecasts may enable new public health messaging to encourage at-risk individuals to temporarily reduce their social mixing during seasonal peaks and guide public health intervention policy during potentially severe novel influenza pandemics.

SARS-CoV-2 screening among people living in homeless shelters in Brussels, Belgium.

BACKGROUND: Subgroups of precarious populations such as homeless people are more exposed to infection and at higher risk of developing severe forms of COVID-19 compared to the general population. Many of the recommended prevention measures, such as social distancing and self-isolation, are not feasible for a population living in shelters characterised by physical proximity and a high population density. The objective of the study was to describe SARS-CoV-2 infection prevalence in homeless shelters in Brussels (Belgium), and to identify risk factors and infection control practices associated with SARS-CoV-2 positivity rates. METHODS: A total of 1994 adults were tested by quantitative PCR tests in 52 shelters in Brussels (Belgium) between April and June, 2020, in collaboration with Doctors of the World. SARS-CoV-2 prevalence is here described site by site, and we identify risk factors associated with SARS-CoV-2 positivity rates. We also investigate associations between seropositivity and reported symptoms. RESULTS: We found an overall prevalence of 4.6% for the period, and a cluster of high rates of SARS-CoV-2 positivity (20-30% in two shelters). Among homeless people, being under 40 years of age (OR (CI95%) 2.3 (1.2-4.4), p = 0.02), having access to urgent medical care (AMU) (OR(CI95%): 2.4 (1.4-4.4)], p = 0.02), and sharing a room with someone who tested positive (OR(CI95%): 5.3 (2.9-9.9), p<0.0001) were factors associated with SARS-CoV-2 positivity rates. 93% of those who tested positive were asymptomatic. CONCLUSION: This study shows high rates of SARS-COV-2 infection positive tests in some shelters, with a high proportion of asymptomatic cases. The survey reveals how important testing and isolation measures are, together with actions taken by medical and social workers during the outbreak.

Test it earlier, result it faster, makes us stronger: how rapid viral diagnostics enable therapeutic success.

The COVID-19 pandemic has entailed simultaneous revolutions in virology diagnostics, clinical trials management, and antiviral therapy and vaccinology. Over the past year, SARS-CoV-2 diagnostic testing has moved from highly centralized laboratories to at-home and even over the-counter. This transition has been lionized for its potential public health impact via isolation, but has been less examined for its effect on individual health and therapeutics. Since early initiation of antiviral therapy routinely has been associated with greater treatment efficacy for viral infections, these diagnostic testing innovations offer new opportunities for both clinical testing as well as clinical trials for antiviral therapy. Given a rapidly growing antiviral therapeutic pipeline and the profound impact of individual beneficiary outcomes on sculpting reimbursement policy, the therapeutic benefits associated with rapid viral testing may lead to significant adoption beyond potential public health impacts.

Prognosis of hospitalized children under 2 years of age with co-detection of influenza A and respiratory syncytial virus at the healthcare facility / Prognóstico de crianças hospitalizadas menores de 2 anos com codetecção de influenza A e vírus sincicial respiratório no local de atendimento

Abstract Objectives: the aim of this study is to evaluate the impact of co-detection of Flu A and RSV using rapid immunochromatographic tests at the point of care, in pediatric patients under 2 years of age in a general hospital. Methods: a retrospective cohort study was conducted to analyze clinical outcomes in hospitalized infants with viral respiratory disease with positive results of rapid immunochromatographic test for RSV and/or Flu-A, from 2013 to 2018. A logistic regression model was adjusted to analyze predictors of orotracheal intubation during hospitalization. Results: we analyzed 220 cases: RSV (192), Flu-A (9), co-detection (19). Lethality rate was 1.8% (2 cases), and 88% (194) were under 1 year of age. Mean time of hospitalizations was higher in patients with co-detection. Variables significantly associated with orotracheal intubation were: younger age in months, comorbidities, RSV and Flu-A co-detection, and bacterial pneumonia during hospitalization. Conclusions: RSV and Flu-Aco-detection was associated with the least favorable clinical prognoses in this study. Rapid test diagnosis may provide important information at the point of care, because molecular panels are not widely accessible in general hospitals. Rapid diagnosis allows timely evaluation and treatment.

Resumo Objetivos: avaliar o impacto da codetecção de Influenza A (FluA) e Vírus Sincicial Respiratório (VSR) por meio de testes imunocromatográficos rápidos em tempo real, em pacientes menores de 2 anos em hospital público e universitário. Métodos: estudo de coorte retrospectivo foi conduzido para analisar os desfechos clínicos de crianças hospitalizadas com doença respiratória viral com resultados positivos do teste rápido imunocromatográfico para VSR e/ou FluA, de 2013 a 2018. Um modelo de regressão logística foi ajustado para analisar preditores de intubação orotraqueal durante a internação. Resultados: foram analisados 220 casos: RSV (192), FluA (9) eco-detecção (19). A letalidade foi de 1,8% (2 casos) e 88% (194) casos em menores de 1 ano. O tempo médio de internação foi maior nos pacientes com codetecção. As variáveis significativamente associadas à intubação orotraqueal foram: menor idade em meses, comorbidades, codetecção de VSR e Flu-A e pneumonia bacteriana durante a internação. Conclusões: codetecção VSR e FluA foi associada a prognósticos clínicos desfavoráveis. O teste rápido fornece informações importantes a beira-leito, pois os painéis moleculares não são amplamente acessíveis em hospitais públicos. O diagnóstico rápido permite a avaliação e tratamento oportunos.

The Queensland Inpatient Diabetes Survey (QuIDS) 2019: the bedside audit of practice.

OBJECTIVES: To assess the quality of care for patients with diabetes in Queensland hospitals, including blood glucose control, rates of hospital-acquired harm, the incidence of insulin prescription and management errors, and appropriate foot and peri-operative care. DESIGN, SETTING: Cross-sectional audit of 27 public hospitals in Queensland: four of five tertiary/quaternary referral centres, four of seven large regional or outer metropolitan hospitals, seven of 13 smaller outer metropolitan or small regional hospitals, and 12 of 88 hospitals in rural or remote locations. PARTICIPANTS: 850 adult inpatients with diabetes mellitus in medical, surgical, mental health, high dependency, or intensive care wards. RESULTS: Twenty-seven of 115 public hospitals that admit acute inpatients participated in the audit, including 4175 of 6652 eligible acute hospital beds in Queensland. A total of 1003 patients had diabetes (24%), and data were collected for 850 (85%). Their mean age was 65.9 years (SD, 15.1 years), 357 were women (42%), and their mean HbA1c level was 66 mmol/mol (SD, 26 mmol/mol). Rates of good diabetes days (appropriate monitoring, no more than one blood glucose measurement greater than 10 mmol/L, and none below 5 mmol/L) were low in patients with type 1 diabetes (22.1 per 100 patient-days) or type 2 diabetes treated with insulin (40.1 per 100 patient-days); hypoglycaemia rates were high for patients with type 1 diabetes mellitus (24.1 episodes per 100 patient-days). One or more medication errors were identified for 201 patients (32%), including insulin prescribing errors for 127 patients (39%). Four patients with type 1 diabetes experienced diabetic ketoacidosis in hospital (8%); 121 patients (14%) met the criteria for review by a specialist diabetes team but were not reviewed by any diabetes specialist (medical, nursing, allied health). CONCLUSIONS: We identified several deficits in inpatient diabetes management in Queensland, including high rates of medication error and hospital-acquired harm and low rates of appropriate glycaemic control, particularly for patients treated with insulin. These deficits require attention, and ongoing evaluation of outcomes is necessary.

Assessment of the Implementation of Pharmacogenomic Testing in a Pediatric Tertiary Care Setting.

Importance: Pharmacogenomic (PGx) testing provides preemptive pharmacotherapeutic guidance regarding the lack of therapeutic benefit or adverse drug reactions of PGx targeted drugs. Pharmacogenomic information is of particular value among children with complex medical conditions who receive multiple medications and are at higher risk of developing adverse drug reactions. Objectives: To assess the implementation outcomes of a PGx testing program comprising both a point-of-care model that examined targeted drugs and a preemptive model informed by whole-genome sequencing that evaluated a broad range of drugs for potential therapy among children in a pediatric tertiary care setting. Design, Setting, and Participants: This cohort study was conducted at The Hospital for Sick Children in Toronto, Ontario, from January 2017 to September 2020. Pharmacogenomic analyses were performed among 172 children who were categorized into 2 groups: a point-of-care cohort and a preemptive cohort. The point-of-care cohort comprised 57 patients referred to the consultation clinic for planned therapy with PGx targeted drugs and/or for adverse drug reactions, including lack of therapeutic benefit, after the receipt of current or past medications. The preemptive cohort comprised 115 patients who received exploratory whole-genome sequencing-guided PGx testing for their heart conditions from the cardiac genome clinic at the Ted Rogers Centre for Heart Research. Exposures: Patients received PGx analysis of whole-genome sequencing data and/or multiplex genotyping of 6 pharmacogenes (CYP2C19, CYP2C9, CYP2D6, CYP3A5, VKORC1, and TPMT) that have established PGx clinical guidelines. Main Outcomes and Measures: The number of patients for whom PGx test results warranted deviation from standard dosing regimens. Results: A total of 172 children (mean [SD] age, 8.5 [5.6] years; 108 boys [62.8%]) were enrolled in the study. In the point-of-care cohort, a median of 2 target genes (range, 1-5 genes) were investigated per individual, with CYP2C19 being the most frequently examined; genotypes in 21 of 57 children (36.8%) were incompatible with standard treatment regimens. As expected from population allelic frequencies, among the 115 children in the whole-genome sequencing-guided preemptive cohort, 92 children (80.0%) were recommended to receive nonstandard treatment regimens for potential drug therapies based on their 6-gene pharmacogenetic profile. Conclusions and Relevance: In this cohort study, among both the point-of-care and preemptive cohorts, the multiplex PGx testing program provided dosing recommendations that deviated from standard regimens at an overall rate that was similar to the population frequencies of relevant variants.

Point-of-care Ultrasound to Evaluate Breast Pathology in the Emergency Department.

INTRODUCTION: As physician-performed point-of-care ultrasound (POCUS) becomes more prevalent in the evaluation of patients presenting with various complaints in the emergency department (ED), one application that is significantly less used is breast ultrasound. This study evaluates the utility of POCUS for the assessment of patients with breast complaints who present to the ED and the impact of POCUS on medical decision-making and patient management in the ED. METHODS: This was a retrospective review of ED patients presenting with breast symptoms who received a POCUS examination. An ED POCUS database was reviewed for breast POCUS examinations. We then reviewed electronic health records for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of the POCUS study on patient care and disposition. RESULTS: We included a total of 40 subjects (36 females, 4 males) in the final analysis. Most common presenting symptoms were breast pain (57.5%) and a palpable mass (37.5%). "Cobblestoning," ie, dense bumpy appearance, was the most common finding on breast POCUS, seen in 50% of the patients. Simple fluid collections were found in 37.5% of patients. CONCLUSION: Our study findings illustrate the utility of POCUS in the evaluation of a variety of breast complaints in the ED.

Performance of a sensitive haemozoin-based malaria diagnostic test validated for vivax malaria diagnosis in Brazilian Amazon.

BACKGROUND: Vivax malaria diagnosis remains a challenge in malaria elimination, with current point of care rapid diagnostic tests (RDT) missing many clinically significant infections because of usually lower peripheral parasitaemia. Haemozoin-detecting assays have been suggested as an alternative to immunoassay platforms but to date have not reached successful field deployment. Haemozoin is a paramagnetic crystal by-product of haemoglobin digestion by malaria parasites and is present in the food vacuole of malaria parasite-infected erythrocytes. This study aimed to compare the diagnostic capability of a new haemozoin-detecting platform, the Gazelle™ device with optical microscopy, RDT and PCR in a vivax malaria-endemic region. METHODS: A comparative, double-blind study evaluating symptomatic malaria patients seeking medical care was conducted at an infectious diseases reference hospital in the western Brazilian Amazon. Optical microscopy, PCR, RDT, and Gazelle™ were used to analyse blood samples. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Kappa values were calculated. RESULTS: Out of 300 patients, 24 test results were excluded from the final analysis due to protocol violation (6) and inconclusive and/or irretrievable results (18). Gazelle™ sensitivity was 96.1 % (91.3-98.3) and 72.1 % (65.0-78.3) when compared to optical microscopy and PCR, respectively whereas it was 83.9 % and 62.8 % for RDTs. The platform presented specificity of 100 % (97.4-100), and 99.0 % (94.8-99.9) when compared to optical microscopy, and PCR, respectively, which  was the same for RDTs. Its correct classification rate was 98.2 % when compared to optical microscopy and 82.3 % for PCR; the test's accuracy when compared to optical microscopy was 98.1 % (96.4-99.7), when compared to RDT was 95.2 % (93.0-97.5), and when compared to PCR was 85.6 % (82.1-89.1). Kappa (95 % CI) values for Gazelle™ were 96.4 (93.2-99.5), 88.2 (82.6-93.8) and 65.3 (57.0-73.6) for optical microscopy, RDT and PCR, respectively. CONCLUSIONS: The Gazelle™ device was shown to have faster, easier, good sensitivity, specificity, and accuracy when compared to microscopy and was superior to RDT, demonstrating to be an alternative for vivax malaria screening particularly in areas where malaria is concomitant with other febrile infections (including dengue fever, zika, chikungunya, Chagas, yellow fever, babesiosis).