Evaluating a decision tool for diagnosing diastolic dysfunction and estimation of left ventricular filling pressures in the presence of mitral annular calcium.

OBJECTIVES: This study sought to evaluate a decision algorithm for the estimation of left ventricular filling pressure (LVFP) in patients with mitral annular calcification (MAC). BACKGROUND: In a single center study, Abudiab et al evaluated echocardiographic parameters to estimate LVFP in patients with MAC against invasive hemodynamic measurements and developed a decision algorithm which demonstrated high predictive accuracy. METHODS: Retrospectively, 55 patients (mean age 68.5 ± 11.5) with MAC and a left heart catheterization within 24 hours of an echocardiogram were identified. The decision algorithm was applied using echo data to classify patients as having normal or elevated LVFP which was then compared with the invasively obtained LVFP. RESULTS: The algorithm performed poorly at predicting pre-A LVFP as normal or high (P = .182). Accuracy for the algorithm was 0.59 [0.46, 0.72] (mean [95% CI]), sensitivity was 0.45 [0.28, 0.62], specificity was 0.73 [0.54, 0.86], false positive rate was 0.27 [0.14, 0.46], and false negative rate was 0.55 [0.38, 0.72]. E/A ratio, IVRT, and E/e'ratio showed no significant relationship to actual patient LVFP. CONCLUSIONS: The Abudiab et al algorithm failed to demonstrate comparable sensitivity, specificity, and accuracy in our sample. Additional study is necessary to refine this tool prior to more widespread use in clinical practice.

Do Bacteremic patients with end-stage renal disease have a fever when presenting to the emergency department? A paired, retrospective cohort study.

BACKGROUND: Fever is a common symptom when patients present to Emergency Departments. It is unclear if the febrile response of bacteremic hemodialysis-dependent patients differs from bacteremic patients not receiving hemodialysis. The objective of this study was to compare Emergency Departments triage temperatures of patients with and without hemodialysis-dependent end-stage rental disease who have Staphylococcus aureus bacteremia and determine the incidence of afebrile S. aureus bacteremia. METHODS: Paired, retrospective cohort study of 37 patients with and 37 patients without hemodialysis hospitalized with Methicillin-resistant or Methicillin-susceptible S. aureus bacteremia. Emergency Department triage temperatures were reviewed for all patients, as were potential confounding variables. RESULTS: 54% (95% CI, 38-70%) and 82% (95% CI 65-91%) of hemodialysis and non-hemodialysis patients did not have a detectable fever (<100.4 °F) at triage. Triage temperatures were 100.5 °F (95% CI 99.9-101.2 °F) and 99.0 °F (95% CI 98.4-99.6 °F) in the hemodialysis and non-hemodialysis cohorts, respectively (p < 0.001). Triage temperature in patients with and without diabetes mellitus was 99.2 °F (95% CI 98.4-99.9 °F) and 100.4 °F (95% CI 99.7-101.0 °F), respectively (p = 0.03). We were unable to detect a significant effect of diabetes mellitus and other potential confounding variables on differences in temperature between the hemodialysis and non-hemodialysis cohorts (all interactions p > 0.19). CONCLUSIONS: Hemodialysis-dependent patients with S. aureus bacteremia had significantly higher temperatures than non- hemodialysis-dependent end stage renal disease patients but more than half of patients were without detectable fever at triage, possibly reflecting use of insensitive methods for measuring temperature. Absence of fever at presentation to the Emergency Department should not delay blood culture acquisition in patients who are at increased risk of S. aureus bacteremia.

Opportunities Revealed for Antimicrobial Stewardship and Clinical Practice with Implementation of a Rapid Respiratory Multiplex Assay.

Few studies assess the utility of rapid multiplex molecular respiratory panels in adult patients. Previous multiplex PCR assays took hours to days from order time to result. We analyze the clinical impact of switching to a molecular assay with a 3-h test-turnaround-time (TAT). We performed a retrospective review of adult patients who presented to our emergency departments with respiratory symptoms and had a respiratory viral panel (xTAG RVP; RVP) or respiratory pathogen panel (ePlex RP; RPP) within 48 h of presentation. The average TATs for the RVP and RPP were 27.9 and 3.0 h, respectively (P < 0.0001). In RVP-positive and RPP-positive patients, 68.9 and 44.5% of those with normal chest imaging received antibiotics (P = 0.013), while 95.4 and 89.6% of those with abnormal imaging received antibiotics, respectively (P = 0.187). There was no difference in antibiotic duration in RVP-positive and RPP-positive patients with abnormal chest imaging (6.2 and 6.0 days, respectively; P = 0.923) and normal chest imaging (4.5 and 4.3 days, respectively; P = 0.922). Fewer patients were admitted in the RPP-positive compared to the RVP-positive group (76.9 and 88.6%, respectively; P = 0.013), while the proportion of admissions were similar among RPP-negative and RVP-negative patients (85.3 and 87.1%, P = 0.726). Switching to a multiplex respiratory panel with a clinically actionable TAT is associated with reduced hospital admissions and, in admitted adults without focal radiographic findings, reduced antibiotic initiation. Opportunities to further mitigate inappropriate antibiotic use may be realized by combining rapid multiplex PCR with provider education, clinical decision-care algorithms, and active antibiotic stewardship.

The next generation of therapy for multiple myeloma: a review of ongoing clinical trials utilizing ClinicalTrials.gov.

The therapeutic armamentarium for multiple myeloma has grown significantly over the past decade. We characterized ongoing multiple myeloma clinical trials utilizing ClinicalTrials.gov . A search of ClinicalTrials.gov on 21 April 2017 returned 239 therapeutic interventional trials in multiple myeloma. A majority (84.1%) of trials are early-phase (I/II). Immunotherapies are significantly more likely to be studied in Phase I trials than Phase II trials (p = 0.0049). Primary sponsor (academic, cooperative group, industry) is significantly associated with phase of trial (p = 0.0334). Quality of life assessment is included as a secondary objective in only 10.1% of trials. Areas of need are continued advancement of immunotherapies, late-phase studies utilizing a triplet control group, and an objective focus on quality of life.

Surgeon Gender-Related Differences in Operative Coding in Plastic Surgery.

BACKGROUND: Numerous studies in the medical and surgical literature have discussed the income gap between male and female physicians, but none has adequately accounted for the disparity. METHODS: This study was performed to determine whether gender-related billing and coding differences may be related to the income gap. A 10 percent minimum difference was set a priori as statistically significant. A cohort of 1036 candidates' 9-month case lists for the American Board of Plastic Surgery over a 5-year span (2014 to 2018) was evaluated for relationships between surgeon gender and work relative value units, coding information, major and minor cases performed, and work setting. Data were deidentified by the American Board of Plastic Surgery before evaluation. The authors hypothesized that work relative value units, average codes per case, major cases, and minor cases would be at least 10 percent higher for male than for female physicians. RESULTS: Significant differences were found between male and female surgeons in work relative value units billed, work relative value units billed per case, and the numbers of major cases performed. The average total work relative value units for male surgeons was 19.34 percent higher than for female surgeons [3253.2 (95 percent CI, 3090.5 to 3425.8) versus 2624.1 (95 percent CI, 2435.2 to 2829.6)]. Male surgeons performed 14.28 percent more major cases than female surgeons [77.6 percent (95 percent CI, 72.7 to 82.7 percent) versus 90.5 percent (95 percent CI, 86.3 to 94.9 percent); p = 0.0002]. CONCLUSIONS: The authors' findings support the hypothesis that billing and coding practices can, in part, account for income differences between male and female plastic surgeons. Potential explanations include practices focusing on larger and more complex operative cases and differences in coding practices.

Peripheral Markers of Vascular Endothelial Dysfunction Show Independent but Additive Relationships with Brain-Based Biomarkers in Association with Functional Impairment in Alzheimer's Disease.

BACKGROUND: Cerebrovascular dysfunction confers risk for functional decline in Alzheimer's disease (AD), yet the clinical interplay of these two pathogenic processes is not well understood. OBJECTIVE: We utilized Alzheimer's Disease Neuroimaging Initiative (ADNI) data to examine associations between peripherally derived soluble cell adhesion molecules (CAMs) and clinical diagnostic indicators of AD. METHODS: Using generalized linear regression models, we examined cross-sectional relationships of soluble plasma vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and E-Selectin to baseline diagnosis and functional impairment (clinical dementia rating sum-of-boxes, CDR-SB) in the ADNI cohort (n = 112 AD, n = 396 mild cognitive impairment (MCI), n = 58 cognitively normal). We further analyzed associations of these biomarkers with brain-based AD biomarkers in a subset with available cerebrospinal fluid (CSF) data (n = 351). p-values derived from main effects and interaction terms from the linear regressions were used to assess the relationship between independent and dependent variables for significance (significance level was set at 0.05 a priori for all analysis). RESULTS: Higher mean VCAM-1 (p = 0.0026) and ICAM-1 (p = 0.0189) levels were found in AD versus MCI groups; however, not in MCI versus cognitively normal groups. Only VCAM-1 was linked with CDR-SB scores (p = 0.0157), and APOE ɛ4 genotype modified this effect. We observed independent, additive associations when VCAM-1 and CSF amyloid-ß (Aß42), total tau, phosphorylated tau (P-tau), or P-tau/Aß42 (all < p = 0.01) were combined in a CDR-SB model; ICAM-1 showed a similar pattern, but to a lesser extent. CONCLUSION: Our findings indicate independent associations of plasma-based vascular biomarkers and CSF biomarkers with AD-related clinical impairment.

Prediction of anemia and estimation of hemoglobin concentration using a smartphone camera.

Anemia, defined as a low hemoglobin concentration, has a large impact on the health of the world's population. We describe the use of a ubiquitous device, the smartphone, to predict hemoglobin concentration and screen for anemia. This was a prospective convenience sample study conducted in Emergency Department (ED) patients of an academic teaching hospital. In an algorithm derivation phase, images of both conjunctiva were obtained from 142 patients in Phase 1 using a smartphone. A region of interest targeting the palpebral conjunctiva was selected from each image. Image-based parameters were extracted and used in stepwise regression analyses to develop a prediction model of estimated hemoglobin (HBc). In Phase 2, a validation model was constructed using data from 202 new ED patients. The final model based on all 344 patients was tested for accuracy in anemia and transfusion thresholds. Hemoglobin concentration ranged from 4.7 to 19.6 g/dL (mean 12.5). In Phase 1, there was a significant association between HBc and laboratory-predicted hemoglobin (HBl) slope = 1.07 (CI = 0.98-1.15), p<0.001. Accuracy, sensitivity, and specificity of HBc for predicting anemia was 82.9 [79.3, 86.4], 90.7 [87.0, 94.4], and 73.3 [67.1, 79.5], respectively. In Phase 2, accuracy, sensitivity and specificity decreased to 72.6 [71.4, 73.8], 72.8 [71, 74.6], and 72.5 [70.8, 74.1]. Accuracy for low (<7 g/dL) and high (<9 g/dL) transfusion thresholds was 94.4 [93.7, 95] and 86 [85, 86.9] respectively. Error trended with increasing HBl values (slope 0.27 [0.19, 0.36] and intercept -3.14 [-4.21, -2.07] (p<0.001) such that HBc tended to underestimate hemoglobin in higher ranges and overestimate in lower ranges. Higher quality images had a smaller bias trend than lower quality images. When separated by skin tone results were unaffected. A smartphone can be used in screening for anemia and transfusion thresholds. Improvements in image quality and computational corrections can further enhance estimates of hemoglobin.

Three-Dimensional Characterization of Trabecular Bone Mineral Density of the Distal Radius Utilizing Quantitative Computed Tomography.

Background: Distal radius (DR) fractures demonstrate patterns of predictable fragments. Bone mineral density (BMD) measurements of these regions of interest (ROIs) may guide more precise treatment. Methods: Computed tomography (CT) scans of the DR of 42 healthy volunteers (23 female) were analyzed using quantitative CT software, measuring BMD within trabecular bone. Seven ROIs were described by alignment with the distal (volar ulnar distal [VUD], dorsal ulnar distal [DUD], volar radial distal [VRD], and dorsal radial distal [DRD]) or proximal (middle ulnar proximal [MUP], middle proximal [MP], and middle radial proximal [MRP]) sigmoid notch. Additional ROIs were the radial styloid (RS) and metadiaphysis (MD). A general estimation equation assessed subject's BMDs with predictive factors of gender, ROI, and age. The interaction between gender, ROI, and age was included in the model to allow for differences in ROI to vary with gender and/or age. Results: Comparing ROIs within the same gender and, separately, within the same age group revealed significantly higher BMD adjacent to the radioulnar and radiocarpal joints. Male and female individuals aged ≥50 years (mean: 172.7 mg/cm3 ± 6.1) had significantly lower BMD than those aged <50 years (mean: 202.7 mg/cm3 ± 5.8) when all ROIs were considered. Males had higher mean BMD at each ROI compared with females; these differences were significant in 5 of the 9 ROIs: VUD, DUD, DRD, RS, MUP. Conclusions: Trabecular BMD of the DR is highest adjacent to the radioulnar and radiocarpal joints. Female patients and those ≥50 years have lower trabecular BMD.

Orthopaedic Resident Preparation and Confidence in Treating On-Field Injuries.

BACKGROUND: Orthopaedic surgery residents may cover athletic events, although the training provided to prepare residents for this role and oversight from attending physicians during these activities is not well understood. PURPOSE: To survey orthopaedic residents about the training provided by their residency program for on-field athletic coverage and to understand their levels of preparation for this role and confidence in treating commonly encountered on-field conditions. STUDY DESIGN: Descriptive epidemiology study. METHODS: An anonymous survey was emailed to residents in all American College of Graduate Medical Education-accredited, allopathic, nonmilitary orthopaedic surgery residency programs. This survey queried residents about their demographics, the opportunities their residencies require or allow for athletic coverage, their level of preparation for serving an on-field physician, and their comfort level with treating a number of on-field conditions. Likert-type scales were used to assess resident comfort level for treating 13 orthopaedic and nonorthopaedic conditions as well as their perceived level of preparedness. RESULTS: Of 148 residency programs contacted, 57 programs responded (39%). Of the 57 programs responding, 51 (89.5%) allowed or required residents to cover athletic events, and 27 of 51 (52.9%) reported that training to prepare for this role was provided. Only 6 of 24 programs without training available (25%) had direct attending supervision of residents at all athletic events. Residents who answered that their residency programs mandate training prior to their participation in athletic coverage activities reported a higher level of preparation for this role than those with no training, optional training, or those who were unsure of their training requirement (P < .0001, P = .035, and P = .013, respectively). In addition, the more senior the resident was, the higher the level of confidence was in treating all orthopaedic and some nonorthopaedic conditions. Residents who had mandatory training displayed a higher comfort level in treating on-field orthopaedic and nonorthopaedic conditions than those without training. CONCLUSION: Formal training of orthopaedic residents prior to their covering athletic events can improve confidence in treating orthopaedic and nonorthopaedic conditions. Many programs do not ensure that residents are familiar with key and potentially life-saving equipment. An opportunity exists to improve resident education.

Vertically Oriented Femoral Neck Fractures: A Biomechanical Comparison of 3 Fixation Constructs.

OBJECTIVES: To compare the static and dynamic mechanical properties of a modified crossed cannulated screw (CS) configuration, the inverted triangle (IT) cannulated screw configuration, and a compression hip screw (CHS) with derotation screw in Pauwels type III femoral neck fractures. METHODS: Thirty synthetic femora were divided into 3 groups, and vertical femoral neck osteotomies were made. Ten osteotomized femora were fixed with a CS configuration, 10 were fixed with 3 parallel screws in an IT configuration, and the remaining 10 osteotomized femora were fixed with a CHS construct. All groups were tested using a cyclic (up to 15,000 load cycles) axial loading protocol, and survivors were statically loaded to failure. Cycles to failure, load to failure, and stiffness were calculated. The Kaplan-Meier method was used to estimate survival functions and were compared among fixation methods. The relationship between construct structural properties (maximum load and stiffness) and treatment were assessed using general linear modeling. RESULTS: All CHS fixation constructs survived the 15,000 cycle loading protocol. They endured longer (P = 0.034) than the CS fixation constructs (mean failure 13,332 cycles), but were not different from IT fixation constructs (mean failure 13,592 cycles). Maximum loads to failure for CS (3870 N) and IT (3756 N) fixation constructs were not different, but were less (P < 0.0001) than the maximum loads to failure for the CHS fixation constructs (5654 N). These findings parallel the results of the axial stiffness measurements: CS fixation constructs (663.01 N/mm) were not stiffer than IT fixation constructs (620.0 N/mm), but were less (P = 0.0005) than the axial stiffness of the CHS fixation constructs (1241.86 N/mm). CONCLUSIONS: The biomechanical performance of the CHS fixation method was superior to both the CS fixation method and the IT fixation method using a synthetic femoral model and this test protocol. Biomechanical performance of the latter 2 groups was indistinguishable. We recommend the use of CHS with the derotational screw construct for Pauwels III femoral neck fractures whenever possible.