History, ECG, Risk Factors (HER) Scoring for Cardiac Risk Stratification in Patients <45 Years of Age Presenting With Chest Pain.

Background Chest pain is a common chief complaint of patients presenting to the emergency department. Acute coronary syndrome (ACS) is found to be the etiology of this symptom in a minority of these patient encounters. This study aimed to determine the utility of using the History, ECG, Risk Factors (HER) components of the History, ECG, Age, Risk Factors, Troponin (HEART) score in ruling out 30-day Major Adverse Cardiac Event (MACE), ACS, ventricular tachycardia, and ventricular fibrillation in patients aged less than 45. Additionally, the utility of this score in ruling out a positive troponin was investigated as well. Methodology This is a retrospective chart review study that examined a consecutive cohort of 7,724 patients presenting with chest pain to the 11 emergency departments of a single healthcare system over a two-year period (January 2019 to December 2020). HER scores of 0 to 1 were categorized as negative (-) and scores of two or greater were categorized as positive (+). Sensitivity, specificity, and predictive values were calculated for the relationship between HER score positivity and primary cardiac disease and troponin results. Results Test characteristics of HER scoring for significant primary cardiac disease in patients between 18 and 45 years of age presenting with undifferentiated chest pain were sensitivity of 88.0 (CI = 80.0-94.0), specificity of 72.6 (CI = 71.8-73.8), positive predictive value of 3.1 (CI = 2.4-3.9), and negative predictive value of 99.8 (CI = 99.7-99.9). Furthermore, an HER score >1 was neither sensitive nor specific in predicting a positive troponin (sensitivity = 80, CI = 71.9-86; specificity = 71.3, CI = 70.3-72.3). However, the negative predictive value of an HER score of 0-1 was 99.5 (CI = 99.3-99.7) and the positive predictive value was 4.7 (CI = 3.9-5.7). Conclusions According to this study, when evaluating young patients who are deemed to have a subjectively non-highly suspicious history, who have minimal risk factors, and who have an ECG without significant ST deviation, troponin testing is low yield in the risk stratification of patients under the age of 45 for serious primary cardiac disease.

Patients' sex and race are independent predictors of HEART score documentation by emergency medicine providers.

INTRODUCTION: The HEART score is a widely used clinical decision tool that provides emergency providers with objective risk stratification for patients presenting to the emergency department (ED) with undifferentiated chest pain (CP). There is no data as to which patients undergo formal risk stratification with a HEART score, and whether patient demographics influence decisions to apply the HEART score. Our objective was to determine if sex or race independently predict documentation of patients' HEART scores in CP patients. METHODS: This is a retrospective cohort study of all patients with a chief complaint of CP who presented to EDs within a single health care system (11 EDs) from September 2018-January 2021. Charts were identified via query of the electronic medical record, and patient age, race, and sex were extracted. The presence or absence of documentation of a HEART score was also recorded. Patient race was categorized as white/non-white. Sex was categorized as male/female. Age was inputted as a continuous variable. We performed logistic regression to determine which variables were associated with documentation of a HEART score. RESULTS: 38,277 patients were included in the study. The median patient age was 51 with IQR 36-64, and 18,927 (47.5%) were male. HEART scores were documented in 24,181. Younger age, female sex, and non-white race were all independent predictors of not having HEART score risk stratification documented in the medical record. CONCLUSIONS: Women and non-white patients are less likely to receive HEART score risk stratification when presenting with undifferentiated CP, even when controlling for patient age. Further studies should address whether this influences patient centered outcomes.

Predictors of Humoral Response to SARS-CoV-2 Vaccination after Hematopoietic Cell Transplantation and CAR T-cell Therapy.

Cellular therapies including allogeneic hematopoietic cell transplant (allo-HCT) and autologous hematopoietic cell transplant (auto-HCT) and chimeric antigen receptor (CAR) T-cell therapy render patients severely immunocompromised for extended periods after therapy, and data on responses to COVID-19 vaccines are limited. We analyzed anti-SARS-CoV-2 spike IgG Ab (spike Ab) titers and neutralizing Ab among 217 recipients of cellular treatments (allo-HCT, n = 149; auto-HCT, n = 61; CAR T-cell therapy, n = 7). At 3 months after vaccination, 188 patients (87%) had positive spike Ab levels and 139 (77%) had positive neutralization activity compared with 100% for both in 54 concurrent healthy controls. Time from cellular therapy to vaccination and immune recovery post-cellular therapy were associated with response. Vaccination against COVID-19 is an important component of post-cellular therapy care, and predictors of quantitative and qualitative response are critical in informing clinical decisions about optimal timing of vaccines and the requirement for booster doses. Significance: Identifying predictors of response to vaccination against SARS-CoV-2 in patients following cellular therapy is critical to managing this highly vulnerable patient population. To date, this is the most comprehensive study evaluating quantitative and qualitative responses to vaccination, providing parameters most predictive of response and potentially informing booster vaccination strategies.See related article by Chung et al., p. 568. This article is highlighted in the In This Issue feature, p. 549.

Using stable-hydrogen isotopes to reveal immigration in an Arctic-breeding songbird population.

BACKGROUND: Knowledge of immigration and emigration rates is crucial for understanding of population dynamics, yet little is known about these vital rates, especially for arctic songbirds. We estimated immigration in an Arctic population of northern wheatears on Baffin Island, Canada, by the use of stable hydrogen isotopes in tail feathers (δ(2)HK). We assumed that δ(2)HK values of juvenile (hatch-year) feathers grown at the breeding grounds were representative of the local population, while those of breeding adults were indicative of where they grew their feathers during their post-breeding molt the previous year. The extent to which adult isotope values differ from those of juveniles provides an estimate of the minimum level of immigration into the breeding population. RESULTS: Mean δ(2)HK values did not differ in juvenile birds between years. Breeding adult birds did not differ significantly in mean δ(2)HK values compared to juveniles but did differ in their respective standard deviations, reflecting a significantly wider range of isotopic signatures in adults than in juveniles. Thirty-eight percent of the δ(2)HK values in adults were greater ± 2 SD of the mean δ(2)HK values of juveniles, suggesting that at least 38 % of the breeding adults were of non-local origin, thus immigrants from elsewhere. CONCLUSIONS: Although the use of stable isotopes has limitations, the use of stable-hydrogen isotopic markers has the potential to contribute valuable information towards understanding immigration rates in bird populations. In our study, hydrogen isotope measurements of the feathers of northern wheatears indicated a high rate of immigration into the breeding population, which is consistent with low return rates of banded breeding adults as well as implying high emigration rates of local breeders.