Transfusion-Transmitted Cache Valley Virus Infection in a Kidney Transplant Recipient With Meningoencephalitis.

BACKGROUND: Cache Valley virus (CVV) is a mosquito-borne virus that is a rare cause of disease in humans. In the fall of 2020, a patient developed encephalitis 6 weeks following kidney transplantation and receipt of multiple blood transfusions. METHODS: After ruling out more common etiologies, metagenomic next-generation sequencing (mNGS) of cerebrospinal fluid (CSF) was performed. We reviewed the medical histories of the index kidney recipient, organ donor, and recipients of other organs from the same donor and conducted a blood traceback investigation to evaluate blood transfusion as a possible source of infection in the kidney recipient. We tested patient specimens using reverse-transcription polymerase chain reaction (RT-PCR), the plaque reduction neutralization test, cell culture, and whole-genome sequencing. RESULTS: CVV was detected in CSF from the index patient by mNGS, and this result was confirmed by RT-PCR, viral culture, and additional whole-genome sequencing. The organ donor and other organ recipients had no evidence of infection with CVV by molecular or serologic testing. Neutralizing antibodies against CVV were detected in serum from a donor of red blood cells received by the index patient immediately prior to transplant. CVV neutralizing antibodies were also detected in serum from a patient who received the co-component plasma from the same blood donation. CONCLUSIONS: Our investigation demonstrates probable CVV transmission through blood transfusion. Clinicians should consider arboviral infections in unexplained meningoencephalitis after blood transfusion or organ transplantation. The use of mNGS might facilitate detection of rare, unexpected infections, particularly in immunocompromised patients.

Impact of Unexplored Data Sources on the Historical Distribution of Three Vector Tick Species in Illinois.

We updated the Illinois historical (1905-December 2017) distribution and status (not reported, reported or established) maps for Amblyomma americanum (L.) (Acari: Ixodidae), Dermacentor variabilis (Say) (Acari: Ixodidae), and Ixodes scapularis (Say) (Acari: Ixodidae) by compiling publicly available, previously unexplored or newly identified published and unpublished data (untapped data). Primary data sources offered specific tick-level information, followed by secondary and tertiary data sources. For A. americanum, D. variabilis, and I. scapularis, primary data contributed to 90% (4,045/4,482), 80% (2,124/2,640), and 32% (3,490/10,898) tick records vs 10%, 20%, and 68%, respectively from secondary data; primary data updated status in 95% (62/65), 94% (51/54) and in 90% (9/10) of the updated counties for each of these tick species; by 1985 there were tick records in 6%, 68%, and 0% of the counties, compared to 20%, 72%, and 58% by 2004, and 77%, 96%, and 75% of the counties by 2017, respectively for A. americanum, D. variabilis, and I. scapularis. We document the loss of tick records due to unidentified, not cataloged tick collections, unidentified ticks in tick collections, unpublished data or manuscripts without specific county location, and tick-level information, to determine distribution and status. In light of the increase in tick-borne illnesses, updates in historical distributions and status maps help researchers and health officials to identify risk areas for a tick encounter and suggest targeted areas for public outreach and surveillance efforts for ticks and tick-borne diseases. There is a need for a systematic, national vector surveillance program to support research and public health responses to tick expansions and tick-borne diseases.

Consistent multi-level trophic effects of marine reserve protection across northern New Zealand.

Through systematic Reef Life Survey censuses of rocky reef fishes, invertebrates and macroalgae at eight marine reserves across northern New Zealand and the Kermadec Islands, we investigated whether a system of no-take marine reserves generates consistent biodiversity outcomes. Ecological responses of reef assemblages to protection from fishing, including potential trophic cascades, were assessed using a control-impact design for the six marine reserves studied with associated reference sites, and also by comparing observations at reserve sites with predictions from random forest models that assume reserve locations are fished. Reserve sites were characterised by higher abundance and biomass of large fishes than fished sites, most notably for snapper Chrysophrys auratus, with forty-fold higher observed biomass inside relative to out. In agreement with conceptual models, significant reserve effects not only reflected direct interactions between fishing and targeted species (higher large fish biomass; higher snapper and lobster abundance), but also second order interactions (lower urchin abundance), third order interactions (higher kelp cover), and fourth order interactions (lower understory algal cover). Unexpectedly, we also found: (i) a consistent trend for higher (~20%) Ecklonia cover across reserves relative to nearby fished sites regardless of lobster and urchin density, (ii) an inconsistent response of crustose coralline algae to urchin density, (iii) low cover of other understory algae in marine reserves with few urchins, and (iv) more variable fish and benthic invertebrate communities at reserve relative to fished locations. Overall, reef food webs showed complex but consistent responses to protection from fishing in well-enforced temperate New Zealand marine reserves. The small proportion of the northeastern New Zealand coastal zone located within marine reserves (~0.2%) encompassed a disproportionately large representation of the full range of fish and benthic invertebrate biodiversity within this region.

Utility of observation units for young emergency department chest pain patients.

BACKGROUND: Determining which patients presenting to the Emergency Department (ED) require further work-up for acute coronary syndrome (ACS) can be difficult. The utility of routine observation for cardiac testing in low-risk young adult patients has been questioned. STUDY OBJECTIVES: We investigated the rate of positive findings yielded by routine cardiac observation unit work-up in patients aged 40 years or younger. METHODS: This was a retrospective observational cohort study of patients aged 18-40 years who were evaluated for ACS in an ED-based observation unit. Data were collected by trained abstractors from electronic medical records. RESULTS: A total of 362 patients met inclusion criteria. Of those, 239 received stress testing, yielding five positive and nine indeterminate results. One other patient had acute troponin elevation while under observation. The positive stress test patients and troponin-elevated patient underwent cardiac angiography. Only one positive stress test patient showed significant coronary stenosis and received coronary interventions. In follow-up data, one patient had an adverse cardiac outcome within 1 year of index visit, but no coronary interventions. Thus, only 3 patients had adverse cardiac events, with only one patient warranting intervention discovered by observation unit stress testing and a second via serial cardiac markers. CONCLUSION: Routine observation of symptomatic young adults for ACS had low yield. Observation identified one patient with acute cardiac marker elevation and further stress testing identified only one patient with intervenable ACS, despite a high false-positive rate. This suggests that observation and stress testing should not be routinely performed in this demographic absent other high-risk features.

Are patients with longer emergency department wait times less likely to consent to research?

OBJECTIVES: There are unique challenges to enrolling patients in emergency department (ED) clinical research studies, including the time-sensitive nature of emergency conditions, the acute care environment, and the lack of an established relationship with patients. Prolonged ED wait times have been associated with a variety of adverse effects on patient care. The objective of this study was to assess the effect of ED wait times on patient participation in ED clinical research. The hypothesis was that increased ED wait times would be associated with reduced ED clinical research consent rates. METHODS: This was a retrospective cohort study of all patients eligible for two diagnostic clinical research studies from January 1, 2008, through December 31, 2008, in an urban academic ED. Sex, age, race, study eligibility, and research consent decisions were recorded by trained study personnel. The wait times to registration and to be seen by a physician were obtained from administrative databases and compared between consenters and nonconsenters. An analysis of association between patient wait times for the outcome of consent to participate was performed using a multivariate logistic regression model. RESULTS: A total of 903 patients were eligible for enrollment and were asked for consent. Overall, 589 eligible patients (65%) gave consent to research participation. The consent rates did not change when patients were stratified by the highest and lowest quartile wait times for both time from arrival to registration (68% vs. 65%, p = 0.35) and time to be seen by a physician (65% vs. 66%, p = 0.58). After adjusting for patient demographics (age, race, and sex) and study, there was still no relationship between wait times and consent (p > 0.4 for both wait times). Furthermore, median time from arrival to registration did not differ between those who consented to participate (15 minutes; interquartile range [IQR] = 9 to 36 minutes) versus those who did not (15.5 minutes; IQR = 10 to 39 minutes; p = 0.80; odds ratio [OR] = 1.00, 95% confidence interval [CI] = 0.99 to 1.01). Similarly, there was no difference in the median time to be seen by a physician between those who consented (25 minutes; IQR = 15 to 55 minutes) versus those who did not (25 minutes; IQR = 15 to 56 minutes; p = 0.70; OR = 1.00, 95% CI = 0.99 to 1.01). CONCLUSIONS: Regardless of wait times, nearly two-thirds of eligible patients were willing to consent to diagnostic research studies in the ED. These findings suggest that effective enrollment in clinical research is possible in the ED, despite challenges with prolonged wait times.

Left ventricular dysfunction screening in hypertensive patients with N-terminal pro-B-type natriuretic peptide and electrocardiogram.

OBJECTIVE: Early recognition of left ventricular hypertrophy is important because antihypertensive treatment decreases morbidity and mortality. The ideal screening method for left ventricular hypertrophy in hypertensive emergency department (ED) patients has not been identified. Our objective was to determine the diagnostic accuracies of electrocardiogram (ECG) and N-terminal Pro-B-type natriuretic peptide (pro-BNP) for left ventricular hypertrophy individually and in combination in hypertensive ED patients. METHODS: Prospective diagnostic study in an academic urban tertiary care hospital ED with annual census of 65,000 visits. Inclusion criteria are as follows: adult ED patients with systolic blood pressure greater than or equal to 160 mm Hg or diastolic blood pressure greater than or equal to 100 mm Hg on 2 or more measurements taken 60 minutes apart. Exclusion criteria are as follows: patients with heart failure, renal insufficiency/failure, acute myocardial infarction, or without recent or scheduled echocardiograms. All patients received echocardiograms and had pro-BNP levels measured using a RAMP point-of-care device (Response Biomedical, Vancouver, BC, Canada). We calculated diagnostic test characteristics with 95% confidence intervals (CIs). RESULTS: A total of 49 patients were enrolled. The average age was 57.9 years, 26.5% were male, and 63.3% were African American. Thirty-two patients (65%) had left ventricular hypertrophy by echocardiogram. Twenty-one (43%) had ECG evidence of left ventricular hypertrophy. Median pro-BNP level was 268 pg/mL. The combination of the 2 tests provided the greatest specificity (94%; 95% CI, 69%-99.7%) and positive predictive value (94%; 95% CI, (68%-99.7%). CONCLUSIONS: The combination of ECG and pro-BNP is a promising screening algorithm for identification of hypertensive ED patients with left ventricular hypertrophy.