The Impact of a High Sensitivity Troponin HEART Pathway Based Clinical Decision Protocol on Observation Visits.

BACKGROUND: Use of high-sensitivity troponin (hs-cTn) might lead to an increase in hospital observation visits due to higher number of abnormal troponin levels. STUDY OBJECTIVES: To determine the impact of incorporating hs-cTn into a chest pain clinical decision protocol (CDP) on observation visits in a large academic health system. METHODS: This is a retrospective observational cohort study of all chest pain observation patients in four hospitals in an academic health system over 24 months. All hospitals used the Beckman Coulter Unicel Dxi instrument, and all shared the same emergency department (ED) chest pain protocol, which used the HEART pathway and serial troponins and directed ED dispositions to either an observation stay, ED discharge, or inpatient admission. Outcomes studied before and after introduction of a hs-cTn protocol included daily chest pain observation census, cost, observation hours, and inpatient admit rate. Census was reported as the daily chest pain observation census and as a proportion of all observation visits. Data was retrieved from a health system data warehouse and a cost accounting program. RESULTS: There were 6,712 chest pain observation visits over 24-months, with 4,087 visits before and 2,634 visits after the hs-cTn protocol implementation. Comparison groups were similar in terms of age, gender, and type of insurance. There were 10.59 (95% CI: 10.24 - 10.95) daily chest pain observation visits before and 7.66 (95% CI: 7.34 - 7.97) visits after implementation, with a 28% (95% CI: 35% - 20%) decrease in the total daily census. As a portion of all observation visits, there was a 22% drop in the proportion that were observed for chest pain. The daily number of chest pain patients requiring inpatient admission was unchanged. The daily total direct cost for chest pain observation decreased with an effective daily cost savings of $4,313 USD (95% CI: $1,534 - $6,998). The total daily number of chest pain observation bed hours also decreased by 41.5 hours (95% CI 13.4 - 96.4 hr). CONCLUSION: Implementation of a hs-cTn chest pain protocol was associated with a significant decrease in the number and proportion of observation visits, a decrease in total daily cost and bed hours used, and no increase in inpatient admissions.

Opt-Out Syphilis Screening at an Urgent Care Center in Atlanta: Evaluation of a Pilot Program.

BACKGROUND: Human immunodeficiency virus (HIV) and syphilis disproportionately impact communities with low access to primary care, who often utilize urgent care centers (UCCs) for sexual health care. UCC visits represent an opportunity for identification and treatment of syphilis and linkage to HIV testing and prevention services. We describe a universal, opt-out syphilis screening program pilot at an Atlanta UCC. METHODS: A chart review was performed on patients 18 years and older who were offered opt-out syphilis screening and had a rapid plasma reagin (RPR) test collected from September 1, 2021 to December 31, 2021. Demographic data, syphilis stage and treatment, and HIV testing and serostatus were abstracted from the electronic health record. Patients with reactive RPRs were contacted by a study physician for syphilis staging and treatment, counseling, and referral for HIV preexposure prophylaxis (PrEP) or treatment. RESULTS: From September 1, 2021 to December 31, 2021, 5794 patients were triaged and 1381 underwent RPR screening (23.8%). Eighty (5.8%) had reactive RPRs, and 42 (52.5%) had active syphilis. Of those with active syphilis, 39 (92.9%) received any treatment, and 35 (83.3%) completed treatment. Patients with late syphilis were less likely to complete syphilis treatment (adjusted odds ratio, 0.03; P = 0.009; 95% confidence interval, 0.002-0.42). Among 955 offered PrEP, 41 (4.3%) expressed interest in PrEP, and 7 (0.7%) completed PrEP clinic intake. Univariate analysis did not identify any factors associated with interest in PrEP. CONCLUSIONS: In a UCC setting, routine, opt-out syphilis testing resulted in increased syphilis identification and treatment. It also provided an opportunity for PrEP counseling and referral, although few patients completed PrEP clinic intake.

Editing VvDXS1 for the creation of muscat flavour in Vitis vinifera cv. Scarlet Royal.

Muscat flavour represents a group of unique aromatic attributes in some grape varieties. Biochemically, grape berries with muscat flavour produce high levels of monoterpenes. Monoterpene biosynthesis is mainly through the DOXP/MEP pathway, and VvDXS1 encodes the first enzyme in this plastidial pathway of terpene biosynthesis in grapevine. A single-point mutation resulting in the substitution of a lysine with an asparagine at position 284 in the VvDXS1 protein has previously been identified as the major cause for producing muscat flavour in grapes. In this study, the same substitution in the VvDXS1 protein was successfully created through prime editing in the table grape Vitis vinifera cv. 'Scarlet Royal'. The targeted point mutation was detected in most of the transgenic vines, with varying editing efficiencies. No unintended mutations were detected in the edited alleles, either by PCR Sanger sequencing or by amplicon sequencing. More than a dozen edited vines were identified with an editing efficiency of more than 50%, indicating that these vines were likely derived from single cells in which one allele was edited. These vines had much higher levels of monoterpenes in their leaves than the control, similar to what was found in leaf samples between field-grown muscat and non-muscat grapes.

Inferior intravitreal injection site associated with a higher incidence of post-injection endophthalmitis / 国际眼科杂志(Guoji Yanke Zazhi)

?AlM:To determine whether inferior injections had a higher incidence of post-injection endophthalmitis than superior injections. The incidence of endophthalmitis is higher for inferior than superior trabeculectomy filtering blebs, possibly due to bacteria pooling in the inferior tear lake. ? METHODS: A practice - wide database of endophthalmitis cases identified 5 occurring during the two-year study period. A retrospective review of 8 672 injections in 1 121 eyes of 909 patients treated during the same two-year study period was performed in order to assess the injection site location. ?RESULTS: Five eyes developed presumed infectious endophthalmitis. Eighty percent of endophthalmitis cases were injected inferiorly, even though 84. 6% of the total cohort was injected superiorly. The odds ratio of infection associated with inferior injection location is 22. 1 (P=0. 006). ? CONCLUSlON: Endophthalmitis after intravitreal injection is rare, occurring in only 0. 025% of injections overall. Avoiding intravitreal injections in the inferior quadrants may further reduce the rate of endophthalmitis.