Monocyte anisocytosis increases during multisystem inflammatory syndrome in children with cardiovascular complications.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) is a life-threatening complication that can develop weeks to months after an initial SARS-CoV-2 infection. A complex, time-consuming laboratory evaluation is currently required to distinguish MIS-C from other illnesses. New assays are urgently needed early in the evaluation process to expedite MIS-C workup and initiate treatment when appropriate. This study aimed to measure the performance of a monocyte anisocytosis index, obtained on routine complete blood count (CBC), to rapidly identify subjects with MIS-C at risk for cardiac complications. METHODS: We measured monocyte anisocytosis, quantified by monocyte distribution width (MDW), in blood samples collected from children who sought medical care in a single medical center from April 2020 to October 2020 (discovery cohort). After identifying an effective MDW threshold associated with MIS-C, we tested the utility of MDW as a tier 1 assay for MIS-C at multiple institutions from October 2020 to October 2021 (validation cohort). The main outcome was the early screening of MIS-C, with a focus on children with MIS-C who displayed cardiac complications. The screening accuracy of MDW was compared to tier 1 routine laboratory tests recommended for evaluating a child for MIS-C. RESULTS: We enrolled 765 children and collected 846 blood samples for analysis. In the discovery cohort, monocyte anisocytosis, quantified as an MDW threshold of 24.0, had 100% sensitivity (95% CI 78-100%) and 80% specificity (95% CI 69-88%) for identifying MIS-C. In the validation cohort, an initial MDW greater than 24.0 maintained a 100% sensitivity (95% CI 80-100%) and monocyte anisocytosis displayed a diagnostic accuracy greater that other clinically available hematologic parameters. Monocyte anisocytosis decreased with disease resolution to values equivalent to those of healthy controls. CONCLUSIONS: Monocyte anisocytosis detected by CBC early in the clinical workup improves the identification of children with MIS-C with cardiac complications, thereby creating opportunities for improving current practice guidelines.

Scalp Staples Placed in a Pediatric Emergency Department: Feasibility and Benefits of Home Removal.

OBJECTIVES: Scalp lacerations are a common occurrence in the pediatric population. A preferred method of closure in a busy pediatric emergency department (PED) is skin staples, because of their ease of use and rapid application. However, using skin staples also demands that the child have a follow-up visit for their removal. This study examines whether caregivers can be taught how to safely remove their child's skin staples at home, obviating the need for a return clinic visit and its associated costs. METHODS: This is a prospective, convenience study of 30 children older than 4 years presenting with a scalp laceration that the attending physician chose to close with skin staples. Caregivers of enrolled children completed an initial survey and received training in skin staple removal in the PED. Upon discharge, caregivers were given the staple removal device and specific instructions indicating the date for staple removal and how to access an online video reviewing proper staple removal technique. Caregivers were contacted after anticipated staple removal for completion of a follow-up survey. We recorded caregiver success rate at staple removal and measured potential benefits with regard to lost wages, transportation costs, and missed school time. Data were analyzed using descriptive statistics. RESULTS: Twenty-eight (93%) of 30 enrolled caregivers were successful in completely removing their child's staples; one caregiver did not attempt removal and another was lost to follow-up. Twenty-five caregivers (83%) completed follow-up surveys. All caregivers reported that if given a future choice, they would prefer to remove their child's staples at home rather than return to a clinic and all said that they would be "very comfortable" if they needed to remove staples again in the future. Sixty-four percent of caregivers estimated that it would have taken greater than 2 hours to attend a clinic for staple removal. Thirty-two percent of caregivers would have lost greater than US $100 in wages. Eighty-eight percent of children would have missed school time, with 46% having to miss an entire school day. CONCLUSIONS: Caregivers who were taught how to remove their child's scalp staples in the PED before discharge were highly successful at home. Ninety-three percent of enrolled patients had their staples completely removed and no complications were reported. Benefits included avoiding lost wages, lost time attending a follow-up clinic, and lost time from school. Staple removal is a simple technique that can easily be taught to caregivers in a matter of minutes and lead to greater patient and parent satisfaction.

Dosimetric characterization of a novel 90Y source for use in the conformal superficial brachytherapy device.

PURPOSE: To characterize the dose distribution in water of a novel beta-emitting brachytherapy source for use in a Conformal Superficial Brachytherapy (CSBT) device. METHODS AND MATERIALS: Yttrium-90 (90Y) sources were designed for use with a uniquely designed CSBT device. Depth dose and planar dose measurements were performed for bare sources and sources housed within a 3D printed source holder. Monte Carlo simulated dose rate distributions were compared to film-based measurements. Gamma analysis was performed to compare simulated and measured dose rates from seven 90Y sources placed simultaneously using the CSBT device. RESULTS: The film-based maximum measured surface dose rate for a bare source in contact with the surface was 3.35 × 10-7 cGy s-1 Bq-1. When placed in the source holder, the maximum measured dose rate was 1.41 × 10-7 cGy s-1 Bq-1. The Monte Carlo simulated depth dose rates were within 10% or 0.02 cm of the measured dose rates for each depth of measurement. The maximum film surface dose rate measured using a seven-source configuration within the CSBT device was 1.78 × 10-7 cGy s-1 Bq-1. Measured and simulated dose rate distribution of the seven-source configuration were compared by gamma analysis and yielded a passing rate of 94.08%. The gamma criteria were 3% for dose-difference and 0.07056 cm for distance-to-agreement. The estimated measured dose rate uncertainty was 5.34%. CONCLUSIONS: 90Y is a unique source that can be optimally designed for a customized CSBT device. The rapid dose falloff provided a high dose gradient, ideal for treatment of superficial lesions. The dose rate uncertainty of the 90Y-based CSBT device was within acceptable brachytherapy standards and warrants further investigation.

Novel design and development of a 3D-printed conformal superficial brachytherapy device for the treatment of non-melanoma skin cancer and keloids.

BACKGROUND: Skin tumors are the most predominant form of cancer in the United States. Radiation therapy, particularly high dose-rate (HDR) brachytherapy, provides an effective form of cancer control when surgery is not possible or when surgical margins are incomplete. The treatment of superficial skin cancers on irregular surfaces, such as the nose, lips or ears, present challenges for treatment. To address this issue, we designed and constructed a novel conformal superficial brachytherapy (CSBT) device prototype to improve patient-specific treatment for complex sites. The device is mounted on an automated remote after-loader, providing limited radiation exposure to operating personnel, is inexpensive to construct, and offers a unique method of conformal surface radiation therapy. RESULTS: A prototype of the CSBT device was successfully manufactured. A computed tomography (CT) scan of a Rando phantom was used to plan the target treatment area. The CSBT device has a hexagonal lattice array of retractable rods with radioactive seeds placed at the tip of each rod. A 3D-printed conformal shape insert with a hexagonal array of cylindrical projections of varying length is driven into the rods by a single linear actuator. The rods are displaced to conform to the patient's skin. This elegant device design permits the delivery of radiation to complex targets using readily available beta-emitting radionuclides, such as Yttrium-90 (Y-90) or Strontium-90 (Sr-90). CONCLUSION: A working prototype of a novel CSBT device was built using 3D-printing technology that provides a safe and economically attractive means of improving radiation delivery to complex treatment sites.

Comparison of Primary Care Provider Office Hours and Pediatric Emergency Department Return Visits.

OBJECTIVE: The aim of this study was to evaluate the influence of primary care office hours of operation on 48-hour return visits (RVs) to a pediatric emergency department (ED). We compared characteristics of patients who return with those who follow up outpatient to determine the feasibility of opening off-hour clinics to decrease the RV rate. METHODS: The study was a retrospective chart review of patients presenting to a pediatric ED for a 3-year period. A subset of patients with a hospital-affiliated primary care provider was evaluated to compare those with 48-hour ED RVs with those with office follow-up. RESULTS: Patients with a hospital-affiliated primary care provider had 30,231 visits, of whom 842 had a 48-hour return (2.79%). A significant number (48.5%) of those who returned had seen their primary care doctor between emergency visits. The percentage of RVs occurring at night (55.7%) was slightly lower than the percentage of all visits occurring off hours (58.1%). Patients with more acute presentation at initial visit (emergency severity index level acuity 2, >20 orders placed) were more likely to follow up with their provider than return to the ED. CONCLUSIONS: The findings from this study show no significant increase in RVs during the evening and overnight hours and many patients with outpatient follow-up before returning to the ED. Opening a clinic at our hospital during nontraditional hours would not likely significantly decrease RV rate.