"Understanding why she had to leave me": The roles of religion and spirituality in narratives of parents grieving the loss of a child to cancer

Religion and spirituality often influence how people experience illness, death, and grief. The roles of religion and spirituality for parents who have lost a child to cancer remain underexplored. This study aimed to describe how cancer-bereaved parents talk about religion and spirituality when reflecting on their experiences. Participants whose children died of cancer one to six years prior to participation completed a one-on-one semi-structured interview. Interview transcripts underwent qualitative analysis. Content pertaining to religion and/or spirituality underwent subsequent in-depth analysis to identify themes. Of 30 interviews analyzed, 28 contained religion/spirituality content. Four themes arose: (1) life after death, (2) divine control, (3) evolution of faith after loss, and (4) religious and spiritual interactions within the medical community. The absence of supports for religious and spiritual needs represents a gap in bereavement care. Future work should clarify needs and explore potential interventions.

Development and validation of an LC-MSMS method to quantify creatinine from dried blood spots

Introduction

Screening for chronic kidney disease relies on accurate and precise creatinine measurements. Traditionally, creatinine is measured in serum or plasma using high-throughput chemistry analyzers. However, dried blood spots (DBS) can also be utilized to improve testing access.

Methods

Samples were obtained from a 6 mm DBS punch, which was reconstituted in water before undergoing an acetonitrile crash. The resulting supernatant was diluted using an 80:20 acetonitrile: water before injection. Creatinine was identified using an isocratic gradient, and detected using an API 4000 triple quadrupole mass analyzer. Quantification relied on matrix-matched calibrators, with values harmonized to the Roche Cobas enzymatic assay. Validation studies assessing method performance included precision, linearity, accuracy, method comparison, stability, interference, and matrix effects.

Results

The LC-MSMS assay was linear from 0.3 to 20 mg/dL (y = 1.02x-0.11; R2 = 0.996). Precision ranged from 5.2 to 8.1 % using matrix-matched controls (n = 4) that spanned the analytical measurement range. LC-MSMS results corresponded to the enzymatic assay (Roche) with a fitted line equation of y = 0.956x-0.07 (R2 = 0.995; n = 173). The Siemens and Roche enzymatic assays demonstrated higher accuracy in correlating to the DBS creatinine concentration (n = 40 paired venous/DBS collections) compared to the Beckman Jaffe assay (-2.5 % and -0.8 % versus -6.3 % and -4.1 %, respectively) or the iSTAT (-28.4 % and -27.1 %, respectively). Accuracy was unaffected by hematocrit, blood spot volume, excess IgG or IgA, or hypertriglyceridemia. No matrix effects were observed, and both extraction and processing efficiency were robust.Ambient stability extended to at least 10 days, and exposure to extreme temperature did not affect the creatinine results.

Conclusion

We successfully developed an accurate and precise LC-MSMS method for quantifying creatinine in DBS.

Understanding Visual Disorders through Correlation of Clinical and Radiologic Findings

Patients presenting with visual disturbances often require a neuroimaging approach. The spectrum of visual disturbances includes three main categories: vision impairment, ocular motility dysfunction, and abnormal pupillary response. Decreased vision is usually due to an eye abnormality. However, it can also be related to other disorders affecting the visual pathway, from the retina to the occipital lobe. Ocular motility dysfunction may follow disorders of the cranial nerves responsible for eye movements (ie, oculomotor, trochlear, and abducens nerves); may be due to any abnormality that directly affects the extraocular muscles, such as tumor or inflammation; or may result from any orbital disease that can alter the anatomy or function of these muscles, leading to diplopia and strabismus. Given that pupillary response depends on the normal function of the sympathetic and parasympathetic pathways, an abnormality affecting these neuronal systems manifests, respectively, as pupillary miosis or mydriasis, with other related symptoms. In some cases, neuroimaging studies must complement the clinical ophthalmologic examination to better assess the anatomic and pathologic conditions that could explain the symptoms. US has a major role in the assessment of diseases of the eye and anterior orbit. CT is usually the first-line imaging modality because of its attainability, especially in trauma settings. MRI offers further information for inflammatory and tumoral cases. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Imaging of Drug-Related Vasculopathy

Illicit and recreational drugs, such as cocaine, heroin, amphetamines, and marijuana, can result in drug-related vasculitis or vasculopathy. Similarly, the use of certain antithyroid, oncologic, and immunosuppressive medications for therapeutic purposes can lead to vasculopathy. This in turn may result in significant complications in the central nervous system, including intracranial hemorrhage and stroke. Cocaine abuse can also lead to midline destructive lesions of the sinonasal complex. MR imaging, Vessel Wall imaging, and CT/CTA are valuable imaging tools for the evaluation of patients with suspected drug-induced vasculopathy or vasculitis. This article reviews the pathomechanism, clinical presentation, and imaging findings of vasculopathy related to drug abuse and prescribed medications.

MRI Markers of Degenerative Disc Disease in Young Patients With Multiple Sclerosis

Background and Purpose: Evidence has emerged for an association between degenerative disc disease (DDD) and multiple sclerosis (MS). The purpose of the current study is to determine the presence and extent of cervical DDD in young patients (age <35) with MS, an age cohort that is less well studied for these changes. Methods: Retrospective chart review of consecutive patients aged <35 referred from the local MS clinic who were MRI scanned between May 2005 and November 2014. 80 patients (51 female and 29 male) with MS of any type ranging between 16 and 32 years of age (average 26) were included. Images were reviewed by 3 raters and assessed for presence and extent of DDD, as well as cord signal abnormalities. Interrater agreement was assessed using Kendall's W and Fleiss' Kappa statistics. Results: Substantial to very good interrater agreement was observed using our novel DDD grading scale. At least some degree of DDD was found in over 91% of patients. The majority scored mild (grade 1, 30-49%) to moderate (grade 2, 39-51%) degenerative changes. Cord signal abnormality was seen in 56-63%. Cord signal abnormality, when present, occurred exclusively at degenerative disc levels in only 10-15%, significantly lower than other distributions (P < .001 for all pairwise comparisons). Conclusions: MS patients demonstrate unexpected cervical DDD even at a young age. Future study is warranted to investigate the underlying etiology, such as altered biomechanics. Furthermore, cord lesions were found to occur independently of DDD.

Evaluating the Implementation of the Connect for Health Pediatric Weight Management Program

Importance

Adoption of primary care interventions to reduce childhood obesity is limited. Progress in reducing obesity prevalence and eliminating disparities can be achieved by implementing effective childhood obesity management interventions in primary care settings.

Objective

To examine the extent to which implementation strategies supported the uptake of research evidence and implementation of the Connect for Health pediatric weight management program.

Design, Setting, and Participants

This quality improvement study took place at 3 geographically and demographically diverse health care organizations with substantially high numbers of children living in low-income communities in Denver, Colorado; Boston, Massachusetts; and Greenville, South Carolina, from November 2019 to April 2022. Participants included pediatric primary care clinicians and staff and families with children aged 2 to 12 years with a body mass index (BMI) in the 85th percentile or higher.

Exposures

Pediatric weight management program with clinician-facing tools (ie, clinical decision support tools) and family-facing tools (ie, educational handouts, text messaging program, community resource guide) along with implementation strategies (ie, training and feedback, technical assistance, virtual learning community, aligning with hospital performance metrics) to support the uptake.

Main Outcomes and Measures

Primary outcomes were constructs from the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework examined through parent, clinician, and leadership surveys and electronic health record data to understand the number of children screened and identified, use of the clinical decision support tools, program acceptability, fidelity to the intervention and implementation strategies, and program sustainability.

Results

The program screened and identified 18 333 children across 3 organizations (Denver Health, 8480 children [46.3%]; mean [SD] age, 7.97 [3.31] years; 3863 [45.5%] female; Massachusetts General Hospital (MGH), 6190 children [33.8%]; mean [SD] age, 7.49 [3.19] years; 2920 [47.2%] female; Prisma Health, 3663 children [20.0%]; mean [SD] age, 7.33 [3.15] years; 1692 [46.2%] female) as having an elevated BMI. The actionable flagging system was used for 8718 children (48%). The reach was equitable, with 7843 children (92.4%) from Denver Health, 4071 children (65.8%) from MGH, and 1720 children (47%) from Prisma Health being from racially and ethnically minoritized groups. The sites had high fidelity to the program and 6 implementation strategies, with 4 strategies (67%) used consistently at Denver Health, 6 (100%) at MGH, and 5 (83%) at Prisma Health. A high program acceptability was found across the 3 health care organizations; for example, the mean (SD) Acceptability of Intervention Measure score was 3.72 (0.84) at Denver Health, 3.82 (0.86) at MGH, and 4.28 (0.68) at Prisma Health. The implementation strategies were associated with 7091 (39%) uses of the clinical decision support tool. The mean (SD) program sustainability scores were 4.46 (1.61) at Denver Health, 5.63 (1.28) at MGH, and 5.54 (0.92) at Prisma Health.

Conclusions and Relevance

These findings suggest that by understanding what strategies enable the adoption of scalable and implementation-ready programs by other health care organizations, it is feasible to improve the screening, identification, and management of children with overweight or obesity and mitigate existing disparities.

Epidemiological and clinical characteristics of adult acute lymphoblastic leukemia patients in Chile: A single-center analysis

Background

Acute lymphoblastic leukemia represents 20% of acute leukemias in adults. Currently, there is limited data in Chile regarding the clinical, cytogenetic, and prognostic characteristics of this condition.

Methods

This is a retrospective, observational, and descriptive study of 67 patients treated for acute lymphoblastic leukemia at the Arturo Lopez Perez Foundation between 2018 and 2021. The main objective is to evaluate epidemiological and clinical characteristics, as well as identifying factors associated with improved overall survival and/or progression-free survival.

Results

88% of the cases were B-lineage, mainly the common B phenotype. Cytogenetic analysis was performed in less than 50% of the patients, with lower yield than expected according to the literature. Molecular testing was performed in 86.5% of the patients, with the most frequent alteration being BCR-ABL. No study was performed to search for Ph-like abnormalities. The rate of complete response after induction was 83.3%, the majority of patients having negative minimal residual disease. Only 12% of the patients received consolidation with allogenic bone marrow transplant. At 2 years, the overall survival was 69% and the progression-free survival was 59%.

Conclusion

The results in terms of overall survival and progression-free survival are similar to those reported in the literature. Important diagnostic gaps prevent adequate prognostic characterization. Allogeneic consolidation transplantation was performed in a lower percentage than expected, highlighting the national deficit in access to this treatment.

Adapting Connect for Health pediatric weight management program for telehealth in response to the COVID-19 pandemic

BACKGROUND

To address the evolving needs and context changes due to the COVID-19 pandemic, we adapted Connect for Health, an evidence-based, primary care, pediatric weight management intervention. The objective of this study is to describe the planned adaptation process to ensure continued and equitable program uptake during the pandemic.

METHODS

Guided by adaptation frameworks, we identified the core functions and forms of Connect for Health and then adapted the intervention in response to a changing healthcare context. We engaged stakeholders and surveyed parents of children with a BMI ≥ 85th percentile and pediatric clinicians and examined their experiences using telehealth for pediatric weight management and needs and preferences. Using multivariable logistic regression, we examined the preferences of parents with limited English proficiency regarding key aspects of pediatric weight management.

RESULTS

We surveyed 200 parents and 43% had a primary language of Spanish. Parents wanted care to be a combination of in-person and virtual visits (80%). We found that parents with limited English proficiency had a higher odds ratio of affirming in-person visits are better than virtual visits for ensuring their child's health concern can be taken care of (OR: 2.91; 95% CI: 1.36, 6.21), feeling comfortable when discussing personal information (OR: 3.91; 95% CI: 1.82, 8.43), talking about healthy behaviors and setting goals (OR: 3.09; 95% CI: 1.39, 6.90), and talking about mental health and overall well-being (OR: 4.02; 95% CI: 1.83, 8.87) than parents without limited English proficiency. We surveyed 75 clinicians and 60% felt telehealth was a useful tool to provide care for pediatric weight management. Clinicians felt virtual visits did not pose barriers to all aspects of care. Informed by the surveys and stakeholder input, we made clinician- and family-level adaptations while retaining the program's function.

CONCLUSIONS

By engaging stakeholders and adapting the program for telehealth, we optimized the reach and fit of Connect for Health to ensure its continued uptake. We have provided a real-world example of how clinical innovations can evolve and how to systematically plan adaptations in response to changing healthcare contexts.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT04042493), Registered on August 2, 2019.

The Canadian Study of Arterial Inflammation in Patients with Diabetes and Recent Vascular Events, Evaluation of Colchicine Effectiveness (CADENCE): protocol for a randomised, double-blind, placebo-controlled trial

BACKGROUND

Inflammation is a key mediator in the development and progression of the atherosclerotic disease process as well as its resultant complications, like myocardial infarction (MI), stroke and cardiovascular (CV) death, and is emerging as a novel treatment target. Trials involving anti-inflammatory medications have demonstrated outcome benefit in patients with known CV disease. In this regard, colchicine appears to hold great promise. However, there are potential drawbacks to colchicine use, as some studies have identified an increased risk of infection, and a non-significant trend for increased all-cause mortality. Thus, a more thorough understanding of the underlying mechanism of action of colchicine is needed to enable a better patient selection for this novel CV therapy.

OBJECTIVE

The primary objective of the Canadian Study of Arterial Inflammation in Patients with Diabetes and Recent Vascular Events, Evaluation of Colchicine Effectiveness (CADENCE) trial is to assess the effect of colchicine on vascular inflammation in the carotid arteries and ascending aorta measured with 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT in patients with type 2 diabetes mellitus (T2DM) or pre-diabetes who have experienced a recent vascular event (acute coronary syndrome (ACS)/MI, transient ischaemic attack (TIA) or stroke). Secondary objectives include determining colchicine's effect on inflammatory biomarkers (high-sensitivity C reactive protein (hs-CRP) and interleukin-6 (IL-6)). Additionally, we will assess if baseline inflammation imaging or biomarkers are associated with a treatment response to colchicine determined by imaging. Exploratory objectives will look at: (1) the difference in the inflammatory response to colchicine in patients with coronary events compared with patients with cerebral events; (2) the difference in the inflammatory response to colchicine in different vascular beds; (3) the relationship of FDG-PET imaging markers with serum biomarkers and (4) assessment of quality-of-life changes.

METHODS AND DESIGN

CADENCE is a multicentre, prospective, randomised, double-blinded, placebo-controlled study to determine the effect of colchicine on arterial inflammation as assessed with imaging and circulatory biomarkers, specifically carotid arteries and aortic FDG uptake as well as hs-CRP and IL-6 among others. Patients with T2DM or pre-diabetes who have recently experienced a CV event (within 30-120 days after an ACS (ie, ST-elevation MI (STEMI) or non-STEMI)) or TIA/stroke with documented large vessel atherosclerotic disease will be randomised to treatment with either colchicine 0.6 mg oral daily or placebo. Participants will undergo baseline clinical evaluation including EQ5D assessment, blood work for inflammatory markers and FDG PET/CT scan of the ascending aorta and left and right carotid arteries. Patients will undergo treatment for 6 months and have repeat clinical evaluation including EQ5D assessment, blood work for inflammatory markers and FDG PET/CT scan at the conclusion of the study. The primary outcome will be the change in the maximum target to background ratio (TBRmax) in the ascending aorta (or carotid arteries) from baseline to follow-up on FDG PET/CT imaging.

DISCUSSION

Colchicine is an exciting potential new therapy for CV risk reduction. However, its use is associated with side effects and greater understanding of its underlying mechanism of action is needed. Importantly, the current study will determine whether its anti-inflammatory action is an indirect systemic effect, or a more local plaque action that decreases inflammation. The results will also help identify patients who will benefit most from such therapy.

TRIAL REGISTRATION NUMBER

NCT04181996.

Laryngeal Amyloidosis: What is the Role of Imaging?

OBJECTIVE/HYPOTHESIS

To review the imaging findings of laryngeal amyloidosis and to identify radiological findings suggestive of this disease.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective chart review of patients with pathologically confirmed laryngeal amyloidosis was performed from 2009 to 2022. Clinical and demographic factors were collected. A fellowship-trained head and neck radiologist reviewed all computed tomography (CT) scans and magnetic resonance imaging (MRI) findings within this cohort.

RESULTS

12 patients were identified and a total of 36 imaging studies analyzed. Localized amyloidosis was found in the supraglottic region (n = 6), glottic region (n = 7), and subglottic region (n = 5); six patients had disease spanning two subsites. The most common finding on the CT scan was a homogeneous and well-defined submucosal soft tissue mass. Punctate calcifications were present in three cases. The presence of contrast enhancement was identified in the majority of patients who underwent MRI (4/5). MRI showed consistent signal intensity, hypointense, or isointense on both T1-weighted and T2-weighted images. Diffusion-weighted sequences were obtained in every patient and did not demonstrate diffusion restriction.

CONCLUSION

This is the largest series searching for unifying imaging characteristics of laryngeal amyloidosis. This research suggests that characteristics from CT and MR provide both similar and unique features of laryngeal amyloidosis on imaging. Both modalities identify a submucosal mass. CT is the preferred modality to demonstrate punctate calcifications, while MRI identifies enhancement and altered signal characteristics. The main benefit of serial imaging is the correlation with patient symptoms, identification of the extent of disease, and assisting in delineating appropriate timing for surgery.

The impact of large-scale social media advertising campaigns on COVID-19 vaccination: Evidence from two randomized controlled trials

COVID-19 vaccines are widely available in wealthy countries, yet many remain unvaccinated. We report on two studies (United States and France) with millions of Facebook users that tested two strategies central to vaccination outreach: health professionals addressing common concerns and motivating “ambassadors” to encourage vaccination in their social networks. We can reject very small effects of any intervention on new first doses (0.16 pp, United States; 0.021 pp, France), with similar results for second doses and boosters (United States). During the Omicron wave, messaging aimed at the unvaccinated or those tasked with encouraging others did not change vaccination decisions.

[Update on the Diagnosis and Stratification of Patients with Acute Myeloid Leukemia: An Urgent National Need]

Acute myeloid leukemia is a neoplasm with a high lethality, with alarming results in our country, positioning it as a priority from the point of view of oncological public health. Cytology, immunophenotype, karyogram, and a few translocations/mutations by molecular biology are currently available for diagnosis and stratification. This diagnostic approach is insufficient since it allows classifying less than 50% of patients in a specific group. Therefore, consolidation therapy is selected with little biological information. The role of morphology and cytogenetics is progressively losing prognostic weight with respect to molecular biology, and next-generation sequencing has positioned itself as a key element for diagnosing our patients. In addition, the investigation of germline mutations is acquiring greater relevance, increasing its detection frequency and influencing decision-making regarding treatment and selecting a related donor for an allogeneic transplant. In this review, an update of the integrated diagnosis of patients with acute myeloid leukemia is carried out in light of the new diagnostic (WHO 2022 and ICC 2022), and prognostic classifications (ELN 2022). We propose an algorithm for integrated diagnosis to be considered for its implementation. It is imperative as a country to invest in new diagnostic technologies to improve the prognosis of our patients.

Impact of the 2021 La Palma volcanic eruption on air quality: Insights from a multidisciplinary approach

The La Palma 2021 volcanic eruption was the first subaerial eruption in a 50-year period in the Canary Islands (Spain), emitting ~1.8 Tg of sulphur dioxide (SO₂) into the troposphere over nearly 3 months (19 September-13 December 2021), exceeding the total anthropogenic SO₂ emitted from the 27 European Union countries in 2019. We conducted a comprehensive evaluation of the impact of the 2021 volcanic eruption on air quality (SO₂, PM₁₀ and PM_2.5 concentrations) utilising a multidisciplinary approach, combining ground and satellite-based measurements with height-resolved aerosol and meteorological information. High concentrations of SO₂, PM₁₀ and PM_2.5 were observed in La Palma (hourly mean SO₂ up to ~2600 μg m^-3 and also sporadically at ~140 km distance on the island of Tenerife (> 7700 μg m^-3) in the free troposphere. PM₁₀ and PM_2.5 daily mean concentrations in La Palma peaked at ~380 and 60 μg m^-3. Volcanic aerosols and desert dust both impacted the lower troposphere in a similar height range (~ 0-6 km) during the eruption, providing a unique opportunity to study the combined effect of both natural phenomena. The impact of the 2021 volcanic eruption on SO₂ and PM concentrations was strongly influenced by the magnitude of the volcanic emissions, the injection height, the vertical stratification of the atmosphere and its seasonal dynamics. Mean daily SO₂ concentrations increased during the eruption, from 38 μg m^-3 (Phase I) to 92 μg m^-3 (Phase II), showing an opposite temporal trend to mean daily SO₂ emissions, which decreased from 34 kt (Phase I) to 7 kt (Phase II). The results of this study are relevant for emergency preparedness in all international areas at risk of volcanic eruptions; a multidisciplinary approach is key to understand the processes by which volcanic eruptions affect air quality and to mitigate and minimise impacts on the population.

Case 309: Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy

HISTORY

A 64-year-old man presented with a 6-month history of lightheadedness and intermittent balance and coordination difficulties. Two months before admission, symptoms became more substantial and persistent, with a worsening sense of disequilibrium and unsteady gait. He reported difficulties pronouncing words and mild word-finding difficulties. His wife noted a change in his cognition and memory over the same time. His medical history included well-controlled chronic obstructive pulmonary disease (COPD) secondary to a long history of smoking with associated unintentional 30-lb (13.6-kg) weight loss over the previous 3 years, for which chest CT scanning was performed, revealing no abnormality. On clinical examination, the patient was alert and oriented but had slurred speech. A positive Romberg sign was noted, finger-to-nose and hand rapid alternating movement tests revealed impairment on the right side, and his gait was ataxic. The motor examination revealed normal muscle tone, bulk, and power in the upper and lower extremities. Sensory testing results were normal. Initial MRI of the brain at admission revealed abnormal findings in the left supratentorial brain. Of note, this patient's presentation predated the COVID-19 pandemic. Cerebrospinal fluid (CSF) analysis revealed predominant pleocytosis (23 × 106/L; normal range, [0-5] × 106/L) (78% lymphocytes, 22% monocytes), elevated protein level (1.23 g/L; normal range, 0.19-0.64 g/L), oligoclonal bands (faint one or two), and a high immunoglobulin G (IgG) index (0.130 g/L; normal reference, ≤0.059 g/L). Despite extensive initial work-up for inflammatory, infectious, autoimmune, or neoplastic causes, a definitive diagnosis was not reached. Thus, repeat MRI of the brain was performed 2 weeks after admission.

A 5-year clinical follow-up of the efficacy of proximal sealing in high caries risk children

OBJECTIVE

The aim of the present study was to evaluate, after 5 years, the efficacy of proximal microinvasive sealing of permanent teeth on the risk for caries lesion development.

METHODS

Children aged 8 to 10 y at baseline, at high caries risk, were studied. In the preventive (P) group the children had caries lesions on the distal surface of primary second molars (05d) but sound mesial surfaces of the approximating permanent first molars (6m). In the therapeutic (T) group the children had initial caries lesions on 6m that abutted lesions on 05d. Each child in the two groups had one 05d/6m pair. Using a split-mouth design, one 6m surface in each pair was randomly assigned to receive sealing while the other pair served as an unsealed control.

RESULTS

Of the 61 children at baseline 42 could be blindly examined clinically and radiographically both at baseline and after 5 years. In the P group, 8 of 28 (28.6%) sealed and 15 of 28 (53.6 %) unsealed sound 6m surfaces had developed caries lesions (p = 0.04). In the T group, the progression of the carious lesions on 6m was observed in 4 of 14 sealed (28.6%) and 8 of 14 (57.1%) unsealed caries control surfaces (p = 0.29). Pooling the data from the two groups, the difference between sealed and non-sealed surfaces was significant (p = 0.013).

CONCLUSION

Both preventive and therapeutic sealant to 6m adjacent to a lesion on 05d has effectiveness in caries reduction in high caries risk children CLINICAL SIGNIFICANCE: The beneficial effect of sealing is observed for at least 5 years after a single sealant treatment.

Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort

Background

Carotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture, dissection, coagulopathy, malignancy and cardioembolism. Our objectives were to classify the underlying aetiology of FFT and to estimate the proportion of patients with underlying stenosis requiring revascularisation.

Methods

We prospectively enrolled consecutive patients presenting to three comprehensive stroke centres with acute TIA/stroke and ipsilateral internal carotid artery FFT. The aetiology of FFT was classified as: carotid atherosclerotic disease, carotid dissection, cardioembolism, both carotid atherosclerosis and cardioembolism, or embolic stroke of uncertain source (ESUS). Patients with carotid atherosclerosis were further subclassified as having ≥50% or <50% stenosis.

Results

We enrolled 83 patients with confirmed FFT. Aetiological assessments revealed 66/83 (79.5%) had carotid atherosclerotic plaque, 4/83 (4.8%) had a carotid dissection, 10/83 (12%) had both atrial fibrillation and carotid atherosclerotic plaque and 3/83 (3.6%) were classified as ESUS. Of the 76 patients with atherosclerotic plaque (including those with atrial fibrillation), 40 (52.6%) had ≥50% ipsilateral stenosis.

Conclusions

The majority of symptomatic carotid artery FFT are likely caused by local plaque rupture, more than half of which are associated with moderate to severe carotid stenosis requiring revascularisation. However, a significant number of FFTs are caused by non-atherosclerotic mechanisms warranting additional investigations.

Smooth Muscle Proliferation in Hamartomatous Polyps Mimicking Prolapse in Pediatric Patients with PTEN Hamartoma Tumor Syndrome

Introduction/Objective

In the field of pediatric pathology, it is vital to find recognize cases that could be associated with cancer predisposition syndromes. PTEN hamartoma tumor syndrome (PHTS) is an inherited set of disorders caused by germline inactivating mutations of the PTEN tumor suppressor gene. In the GI tract, PHTS is associated with hamartomatous polyps that can display smooth muscle overgrowth. We therefore present a series of three cases of colonic polyps with smooth muscle overgrowth, mimicking prolapse, in pediatric patients with PTEN mutations.

Methods/Case Report

The first case is a 19-year-old male with PHTS who underwent colonoscopy due to hematochezia. Two pedunculated polyps were removed from the transverse and descending colon. Both polyps showed prominent smooth muscle and ganglion cells in the lamina propria. In the second case, a 9-year-old male with PHTS also underwent colonoscopy due to hematochezia. At least 20 sessile 2-4mm polyps were present in the colon. Histology showed smooth muscle proliferation and ganglion cells in the lamina propria. The third case is a 13-year-old male with undiagnosed PHTS, but a history of Chron’s disease, trichilemmoma, and plantar wart like lesions. He underwent upper and lower endoscopy for Chron’s disease assessment. Three polyps were removed from the descending colon. One was a juvenile polyp while the other two showed prominent smooth muscle proliferation and ganglion cells in the lamina propria.

Results (if a Case Study enter NA)

NA

Conclusion

Histologically, all hamartomatous polyps had smooth muscle overgrowth, confirmed by SMA immunostain, which could easily be confused with prolapse type changes such as in solitary rectal ulcer syndrome. The key in distinguishing between the two is by recognizing ganglion cells within the lamina propria, confirmed by S100 immunostain. Additional clues include identifying mucosal ganglion cells, disarray of crypt architecture, and fibromuscular proliferation as well as considering the location and number of polyps. It is vital for pathologists to recognize the differential diagnosis of polyps with smooth muscle proliferation, especially in pediatric populations where a diagnosis of cancer predisposition syndromes may not be established. Furthermore, is important to discuss pursuing PTEN genetic testing with clinical colleagues as it has immense medical implications and requires a thorough future medical following.

Skin Necrosis in a Patient with Protein S Deficiency, Warfarin Anticoagulation, and Acute COVID-19 Infection: A Case Report

Introduction/Objective

Although thrombotic complications from COVID are well documented, the pathophysiology remains poorly understood, especially in patients with comorbid hypercoagulable risk factors and anticoagulant medication use. COVID has several dermatologic manifestations that may occur due to alterations in hemostasis. We present a case of skin necrosis in a patient with protein S deficiency, warfarin anticoagulation, and acute COVID infection.

Methods/Case Report

A 48-year-old female, BMI &gt;50, heterozygous Protein S (PS) deficiency, Factor V Leiden, and history of recurrent venous thromboembolic events on warfarin, tested positive for COVID. Her only symptom was fatigue. Several days later, the patient developed painful ecchymoses and erythematous blisters on her breast, arm, and abdomen. Laboratory results showed INR 3.6, fibrinogen 675-1054 gm/dL, WBC 15k with absolute neutrophilia, and D-dimer 2274 ug/L DDU. The patient confirmed compliance with her maintenance warfarin dose. Biopsy showed thrombotic vasculopathy without leukocytoclastic vasculitis. Wound cultures were negative.

Results (if a Case Study enter NA)

NA.

Conclusion

The patient’s history and presentation were concerning for warfarin induced skin necrosis. However, the patient had taken warfarin for &gt; 20 years and had an INR of 3.6 which substantiated that warfarin was not discontinued or missed. A retrospective review of INR results during acute COVID infection showed a decrease in time in therapeutic range and an increase in supratherapeutic INRs, suggesting COIVD patients may require decreased warfarin doses. Additionally, PS levels decline in patients with COVID; a similar effect is seen with HIV and Varicella infections. It is theorized that this may be mediated by an increase in C4b binding protein, an acute phase reactant that regulates the complement cascade and binds PS. With an infectious source ruled out and the patients’ known comorbid conditions, an acute exacerbation of the patients underlying hypercoagulable state is the likely driver of the patient’s skin necrosis with COVID as the probable precipitator. In summary, inherited and acquired hypercoagulable risk factors should be included in the differential diagnosis as a cause of skin changes in patients with COVID infection. Although histology may be helpful in diagnosing the cause of skin changes with COVID, laboratory results and clinical correlation are key in identifying a etiology.

COST-EFFECTIVENESS OF BENRALIZUMAB VERSUS MEPOLIZUMAB AND DUPILUMAB IN PATIENTS WITH SEVERE UNCONTROLLED EOSINOPHILIC ASTHMA IN SPAIN

OBJECTIVE

To assess the cost-effectiveness of benralizumab (benra) vs. mepolizumab (mepo) and dupilumab (dupi) for the treatment of patients with severe uncontrolled asthma from the Spanish Health System perspective.

METHODS

Exacerbations avoided, quality-adjusted life years (QALYs) gained and costs in a 5-year period were estimated with a Markov model for a cohort of 1,000 patients in which, based on published evidence, 31% of the patients received biologics + oral corticosteroids (OCS) and 69% received only biologics. Efficacy data (exacerbation reduction and OCS elimination) were derived from a matching-adjusted indirect comparison. Published EQ-5D utilities per health state (biologic alone, biologic + OCS, standard of care + OCS, exacerbations, and post-exacerbations) were used for QALY estimation. Utility decrements associated with exacerbation management [-0.1 (OCS or emergency visits), -0.2 (hospitalization)] derived from the literature were applied. Costs (€, 2022) included drug acquisition (ex-factory price), administration and disease management. An expert panel (2 pneumologists and 1 pharmacist) validated all inputs.

RESULTS

Benra was more effective (52.21 QALYs) than mepo (51.39 QALYs) and dupi (51.30 QALYs). Benra avoided more exacerbations (2.87 exacerbations) compared to mepo (4.70 exacerbations) and dupi (5.11 exacerbations) for the 5-year horizon. Total costs/patient were €56,093.77 (benra), €59,280.45 (mepo) and €62,991.76 (dupi), resulting in benra dominating (more QALYs with lower costs) vs. mepo and dupi.

CONCLUSIONS

Benralizumab can be considered as a dominant treatment alternative vs. other biologic drugs for the treatment of uncontrolled severe eosinophilic asthma patients in Spain.

Case 309

HISTORY

A 64-year-old man presented with a 6-month history of lightheadedness, intermittent balance, and coordination difficulties. Two months before admission, symptoms became more substantial and persistent, with a worsening sense of disequilibrium and unsteady gait. He reported difficulties pronouncing words and mild word-finding difficulties. His wife noted a change in his cognition and memory over the same time. His medical history included well-controlled chronic obstructive pulmonary disease (COPD) secondary to a long history of smoking with associated unintentional 30-lb (13.6-kg) weight loss over the previous 3 years, for which chest CT scanning was performed, revealing no abnormality. On clinical examination, the patient was alert and oriented but had slurred speech. A positive Romberg sign was noted, finger-to-nose and hand rapid alternating movement tests revealed impairment on the right side, and his gait was ataxic. The motor examination revealed normal muscle tone, bulk, and power in the upper and lower extremities. Sensory testing results were normal. Initial MRI of the brain at admission revealed abnormal findings in the left supratentorial brain (Figs 1-3). Of note, this patient's presentation predated the COVID-19 pandemic. Cerebrospinal fluid analysis revealed predominant pleocytosis (23 × 10⁶/L; normal range, [0-5] × 10⁶/L) (78% lymphocytes, 22% monocytes), elevated protein level (1.23 g/L; normal range, 0.19-0.64 g/L), oligoclonal bands (faint one or two), and a high immunoglobulin G index (0.130 g/L; normal reference, ≤0.059 g/L). Despite extensive initial work-up for inflammatory, infectious, autoimmune, or neoplastic causes, a definitive diagnosis was not reached. Thus, repeat MRI of the brain was performed 2 weeks after admission (Fig 4).

Chemotherapy-Induced Toxicities: An Imaging Primer

The Coronavirus Disease of 2019 (COVID-19) pandemic has caused significant delays in the delivery of cancer treatments in Canada. As cancer treatment and imaging volumes return to normal, radiologists will encounter more cases of chemotherapy-induced toxicities. These toxicities have varied appearances on imaging, and can affect multiple organ systems. The purpose of this review is to offer a unified resource for general radiologists regarding the imaging appearances of chemotherapy-induced toxicities.

Cognitive Outcomes in Congenital Hypothyroidism: Impact of Socioeconomic Status - A Case-Control Study

OBJECTIVE

Chile is one of the few high-income countries in Latin America, being a pioneer in implementing a national newborn screening (NBS) program in 1992. Currently, it covers 98% of the population, but no long-term outcomes have been described so far. The aim of this study was to report the neurocognitive outcomes of children with congenital hypothyroidism (CH) diagnosed by the NBS program in Chile between 2005 and 2012 and to identify variables associated with the outcomes.

METHODS

We performed a case-control study in children with CH born in the two largest regions of the country. The Leiter-R and TEVI-R tests were administered at home to 69 children with CH and 68 matched control subjects. Other variables affecting cognition were obtained. Multivariate logistic regression analyses were performed for Leiter-R and TEVI-R tests, using a model for cases alone and another model for cases and controls.

RESULTS

No differences in Leiter-R and TEVI-R results were observed between children with CH and the control group. Children who performed better, regardless of whether they had CH, had a higher family income and more assets.

CONCLUSIONS

These results suggest that the Chilean NBS program strategy results in children with normal language, attention, and memory development. Socioeconomic disadvantage represents a significant detriment in cognitive function.

Performance of a Multianalyte 'Rule-Out' Assay in Pregnant Individuals With Suspected Preeclampsia

BACKGROUND

The ability to diagnose preeclampsia clinically is suboptimal. Our objective was to validate a novel multianalyte assay and characterize its performance, when intended for use as an aid to rule-out preeclampsia.

METHODS

Prospective, multicenter cohort study of pregnant individuals presenting between 280/7 and 366/7 weeks' with preeclampsia-associated signs and symptoms. Individuals not diagnosed with preeclampsia after baseline evaluation were enrolled in the study cohort, with those who later developed preeclampsia, classified as cases and compared with a negative control group who did not develop preeclampsia. Individuals with assay values at time of enrollment ≥0.0325, determined using a previously developed algorithm, considered at risk. The primary analysis was the time to develop preeclampsia assessed using a multivariate Cox regression model.

RESULTS

One thousand thirty-six pregnant individuals were enrolled in the study cohort with an incidence of preeclampsia of 30.3% (27.6%-33.2%). The time to develop preeclampsia was shorter for those with an at-risk compared with negative assay result (log-rank P<0.0001; adjusted hazard ratio of 4.81 [3.69-6.27, P<0.0001]). The performance metrics for the assay to rule-out preeclampsia within 7 days of enrollment showed a sensitivity 76.4% (67.5%-83.5%), negative predictive value 95.0% (92.8%-96.6%), and negative likelihood ratio 0.46 (0.32-0.65). Assay performance improved if delivery occurred <37 weeks and for individuals enrolled between 28 and 35 weeks.

CONCLUSIONS

We confirmed that a novel multianalyte assay was associated with the time to develop preeclampsia and has a moderate sensitivity and negative likelihood ratio but high negative predictive value when assessed as an aid to rule out preeclampsia within 7 days of enrollment.

REGISTRATION

The study was registered on Clinicaltrials.gov (Identifier NCT02780414).

Implementation Evaluation of HUGS/Abrazos During the COVID-19 Pandemic: A Program to Foster Resiliency in Pregnancy and Early Childhood

Early life adversity can significantly impact child development and health outcomes throughout the life course. With the COVID-19 pandemic exacerbating preexisting and introducing new sources of toxic stress, social programs that foster resilience are more necessary now than ever. The Helping Us Grow Stronger (HUGS/Abrazos) program fills a crucial need for protective buffers during the COVID-19 pandemic, which has escalated toxic stressors affecting pregnant women and families with young children. HUGS/Abrazos combines patient navigation, behavioral health support, and innovative tools to ameliorate these heightened toxic stressors. We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, to evaluate the implementation of the HUGS/Abrazos program at Massachusetts General Hospital from 6/30/2020-8/31/2021. Results of the quality improvement evaluation revealed that the program was widely adopted across the hospital and 392 unique families were referred to the program. The referred patients were representative of the communities in Massachusetts disproportionately affected by the COVID-19 pandemic. Furthermore, 79% of referred patients followed up with the initial referral, with sustained high participation rates throughout the program course; and they were provided with an average of four community resource referrals. Adoption and implementation of the key components in HUGS/Abrazos were found to be appropriate and acceptable. Furthermore, the implemented program remained consistent to the original design. Overall, HUGS/Abrazos was well adopted as an emergency relief program with strong post-COVID-19 applicability to ameliorate continuing toxic stressors while decreasing burden on the health system.

Raspberry Pi based photovoltaic I-V curve tracer

This paper details the design and implementation of a photovoltaic current - voltage (I-V) tracer. The I-V tracer employs a capacitive load controlled by a raspberry pi model 4B. The complete measurement system includes protections, capacitor charging/discharging power electronics and current, voltage, irradiance and temperature sensors. Results, which include maximum power point, open circuit voltage, short circuit current and module efficiency, are displayed on an LCD touch display. Detailed description of the required software and the graphical user interface is also presented. This measurement system is very useful for testing photovoltaic installations, allowing an immediate verification whether the panels fulfill with the specifications and detection of possible failures.

Impact of the COVID‐19 Economic Downturn on Tropospheric Ozone Trends: An Uncertainty Weighted Data Synthesis for Quantifying Regional Anomalies Above Western North America and Europe

This study quantifies the association between the COVID‐19 economic downturn and 2020 tropospheric ozone anomalies above Europe and western North America, and their impact on long‐term trends. Anomaly detection for an atmospheric time series is usually carried out by identifying potentially aberrant data points relative to climatological values. However, detecting ozone anomalies from sparsely sampled ozonesonde profiles (once per week at most sites) is challenging due to ozone's high temporal variability. We first demonstrate the challenges for summarizing regional trends based on independent time series from multiple nearby ozone profiling stations. We then propose a novel regional‐scale anomaly detection framework based on generalized additive mixed models, which accounts for the sampling frequency and inherent data uncertainty associated with each vertical profile data set, measured by ozonesondes, lidar or commercial aircraft. This method produces a long‐term monthly time series with high vertical resolution that reports ozone anomalies from the surface to the middle‐stratosphere under a unified framework, which can be used to quantify the regional‐scale ozone anomalies during the COVID‐19 economic downturn. By incorporating extensive commercial aircraft data and frequently sampled ozonesonde profiles above Europe, we show that the complex interannual variability of ozone can be adequately captured by our modeling approach. The results show that free tropospheric ozone negative anomalies in 2020 are the most profound since the benchmark year of 1994 for both Europe and western North America, and positive trends over 1994–2019 are diminished in both regions by the 2020 anomalies.

2020 is the only year that both Europe and western North America show strong negative tropospheric ozone anomalies since 1994

Positive free tropospheric ozone trends above Europe and western North America since 1994 are diminished by the 2020 anomalies

Data integration of multiple time series provides a better understanding of ozone variability compared to individual records

Papilledema: A Review of the Pathophysiology, Imaging Findings, and Mimics

Increased intracranial pressure is the most common cause of papilledema. Multiple etiologies such as cerebral edema, hydrocephalus, space occupying lesions, infection, and idiopathic intracranial hypertension among others should be considered. Imaging plays a critical role in the detection of pathologies that can cause papilledema. MRI with contrast and CE-MRV, in particular, are key for the diagnosis of idiopathic intracranial hypertension. This review will focus in common and infrequent causes of papilledema, the role of imaging in patients with papilledema as well as its potential mimickers.

Biopsia de próstata, acceso transperineal bajo anestesia local

Objetivo La biopsia de próstata es una ayuda esencial en el diagnóstico de cáncer, siendo el método más utilizado la biopsia transrectal guiada por ultrasonido (TRUS), con una tasa diagnóstica entre el 37% y el 45%, aunque no exenta de complicaciones como infecciones, dolor o sangrado.

El enfoque alternativo y seguro a las biopsias TRUS se encuentra en la biopsia transperineal (BTP), realizada comúnmente bajo anestesia regional o general.

El objetivo de este estudio fue determinar la efectividad de la BTP bajo anestesia local y guía ultrasonográfica transrectal, con el impacto sobre la sensibilidad del estudio y la tasa de readmisión hospitalaria por infección.

Métodos Estudio de cohorte retrospectiva en el que se evaluaron 83 pacientes sometidos a BTP con anestesia local y guía ultrasonográfica transrectal de enero de 2017 a agosto de 2018 en una ciudad intermedia de Colombia. La muestea incluyó todos los hombres mayores de 18 años con datos de historia clínica disponibles para su análisis, así como los reportes histopatológicos de las biopsias. Se excluyeron casos de rebiopsia o con datos insuficientes.

El análisis de datos nominales se realizó mediante la prueba de chi cuadrado, y el de los datos numéricos, con las prubas t de Student o de Mann-Whitney.

Resultados Un total de 83 pacientes, con media de edad de 65 ± 7.9 años fueron sometidos al análisis del estudio histopatológico. Se excluyeron nueve pacientes que no tenían información disponible en el registro clínico sistematizado, ni en historia clínica de formato físico. Se encontró una proporción de positividad y diagnóstico de cáncer de prostata en el 39.7% (33) de los pacientes, distribuidos así: grado de grupo 1 (69.7%; 23); grado de grupo 2 )15.2%; 5); grados de grupos 3 y 4 (3% cada uno de ellos; 2); y grado de grupo 5 (9%; 3). En total, 60% (50) fueron negativos para malignidad y, de estos el 54% (27) tuvo hiperplasia. El antibiótico profiláctico indicado en el 96.7% (80) de los casos fue una cefalosporina de primera generación, administrada en el 15% (12) por vía parenteral preoperatoria. En esta serie de casos, no se documentaron ingresos hospitalarios asociados a infección después del procedimiento.

Conclusiones La biopsia de próstata por vía transperineal es una técnica con rendimiento diagnostico similar al del abordaje transrectal: es segura, rápida, de fácil acceso, con bajo costo y, sobre todo, con un riesgo insignificante de infección y sepsis. Sus beneficios son altamente representativos en un sistema de salud como el de nuestro país, y la BTP facilita el acceso de la población vulnerable del área rural y de ciudades intermedias, en las que no se dispone de un urólogo experto.

Signal processing for slug flow analysis: MATLAB algorithm

This paper presents an easy-to-use MATLAB© program to characterize slug flow, one of the most observed gas-liquid flow patterns in pipes. “BSignalProcessing2020.m” based on the study reported in [1] is a flexible, expandable, and adaptable statistical algorithm used to calculate the film and slug cut threshold values, the disregard cut value to group slug pulses, and the disregard cut value to remove slug pulses, which are required to determine the slug characteristics. The code is provided for unlimited and unrestricted use.

• The statistical algorithm does not depend on any subjective criteria.

• The methodology is illustrated using voltage time-series, but it is applicable without changes to instantaneous liquid holdup time-series.

Characteristics and in-hospital outcomes among patients with type 2 myocardial infarction

Introduction

Type 2 myocardial infarction (T2MI) is one of the most common reasons for hospital admission in the United States (US). Despite its prevalence, it was only given its own ICD-10 code as recently as October 2017. Data are limited regarding the clinical characteristics and management of T2MI as compared with other types of myocardial infarction (MI). Epidemiological research involving large databases is crucial in laying the foundation for further investigation into disease characterization and management.

Purpose

To elucidate the clinical phenotype and prognostic implications of patients presenting with a T2MI by analyzing data from the largest inpatient database in the US.

Methods

The National Inpatient Sample Database was queried to identify patients admitted with T2MI using ICD-10 codes between October 2017 and December 2018. These were compared against control patients admitted for any other type of MI (ATMI) from January 2016 to December 2018. The chi-square test for univariate analysis and binary logistic regression were used to explore the association between T2MI, inpatient outcomes, and baseline characteristics when compared to the ATMI cohort.

Results

A total of 302,920 adults admitted with a diagnosis T2MI over a 15-month period were identified and compared against 3,243,669 admitted with ATMI over a 36-month period. Those admitted with T2MI tended to be older (mean ± SD, 71±14 vs. 69±14 years, p≤0.001) and had a relatively higher percentage of females (47.9% vs. 41.1%, p≤0.001). The African American cohort was the only racial group with a significantly higher percentage of T2MI (16% vs. 12.3%, p≤0.001).

Patients admitted with T2MI were more likely to have chronic comorbidities, especially heart failure (54.9% vs. 41.8%, p≤0.001), chronic kidney disease (CKD) (37.3% vs. 27.8%, p≤0.001), chronic lung disease (29.3% vs. 22.2%, p≤0.001), and atrial fibrillation/flutter (36.2% vs. 25.2%, p≤0.001). They were also more likely to be discharged to a skilled nursing or other facility (29.5% vs. 18.6%). Finally, they were less likely to receive a coronary stent (1.1% vs. 24.6%, p≤0.001) and more likely to undergo bypass grafting (37.3% vs. 27.6%, p≤0.001).

African Americans admitted with T2MI had the lowest risk of in-hospital mortality (adjusted odds ratio [aOR]: 0.606; 95% CI: 0.56–0.64, p≤0.001). Patients hospitalized with additional diagnoses of CKD (aOR: 2.59; 95% CI: 2.48–2.69, p≤0.001), right heart failure (aOR: 1.93; 95% CI: 1.68–2.19, p≤0.001), heart failure with bi-ventricular involvement (aOR: 1.82; 95% CI: 1.58–2.10), or atrial fibrillation or atrial flutter (aOR: 1.30; 95% CI: 1.26–1.33, p≤0.001) were at greatest risk for in-hospital mortality.

Conclusions

Patients admitted with T2MI represent a unique clinical phenotype compared with the broader ATMI population. They are more likely to be older, have more chronic comorbidities, and have a relatively higher percentage of females and African Americans.

Funding Acknowledgement

Type of funding sources: None.

Time-efficient three-dimensional transmural scar assessment provides relevant substrate characterization for ventricular tachycardia features and long-term recurrences in ischemic cardiomyopathy

Delayed gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) imaging requires novel and time-efficient approaches to characterize the myocardial substrate associated with ventricular arrhythmia in patients with ischemic cardiomyopathy. Using a translational approach in pigs and patients with established myocardial infarction, we tested and validated a novel 3D methodology to assess ventricular scar using custom transmural criteria and a semiautomatic approach to obtain transmural scar maps in ventricular models reconstructed from both 3D-acquired and 3D-upsampled-2D-acquired LGE-CMR images. The results showed that 3D-upsampled models from 2D LGE-CMR images provided a time-efficient alternative to 3D-acquired sequences to assess the myocardial substrate associated with ischemic cardiomyopathy. Scar assessment from 2D-LGE-CMR sequences using 3D-upsampled models was superior to conventional 2D assessment to identify scar sizes associated with the cycle length of spontaneous ventricular tachycardia episodes and long-term ventricular tachycardia recurrences after catheter ablation. This novel methodology may represent an efficient approach in clinical practice after manual or automatic segmentation of myocardial borders in a small number of conventional 2D LGE-CMR slices and automatic scar detection.

Incidence and Mortality Trends of Acute Gastroenteritis and Pneumococcal Disease in Children Following Universal Rotavirus and Pneumococcal Conjugate Vaccination in Ecuador

INTRODUCTION

Ecuador introduced routine infant rotavirus (RV) vaccination in 2008 and pneumococcal conjugate vaccination (PCV) in 2011 to manage disease and mortality in children caused by gastroenteritis (GE) and by pneumonia (PNE) and invasive pneumococcal disease (IPD), respectively.

METHODS

This retrospective ecological database study described vaccination coverage as well as the trends in incidence and mortality in the pre- versus post-vaccination periods and used time-trend analysis models to assess the impact of vaccination.

RESULTS

RV vaccination coverage of the second dose was between 79-97% from 2008 to 2016. GE incidence and mortality showed a declining trend before vaccination which continued in the post-vaccination period. The model estimated a statistically significant decrease of 72.4% for GE mortality and 51.2% for GE incidence in the post-vaccination period. PCV vaccination coverage remained above 80% (second dose) and 40% (third dose) after 2011. PNE mortality showed a declining trend before vaccination and a continued decline after vaccination, while PNE incidence was more variable (sharp increase from 2005-2009 then decrease and eventual stabilisation). The model estimated a statistically significant decline of 41.1% for PNE mortality and a stable PNE incidence in the post- versus pre-vaccination period. IPD incidence and mortality yearly data showed large variability by year and low numbers, making it difficult to discern a trend. The model estimated a statistically significant reduction of 51.1% for IPD mortality and 31.5% for IPD incidence in the post- versus pre-vaccination period.

CONCLUSION

After the first 9 years of routine RV vaccination and 6 years of routine PCV vaccination in Ecuador, significant decreases in incidence and mortality in children < 5 years of age due to GE and pneumococcal disease have been observed.

Differentiating Carotid Free-Floating Thrombus From Atheromatous Plaque Using Intraluminal Filling Defect Length on CTA: A Validation Study

OBJECTIVE

To validate a previously proposed filling defect length threshold of >3.8 mm on CT angiography (CTA) to discriminate between free-floating thrombus (FFT) and plaque of atheroma.

METHODS

This was a prospective multicenter observational study of 100 participants presenting with TIA/stroke symptoms and a carotid intraluminal filling defect on initial CTA. Follow-up CTA was obtained within 1 week and at weeks 2 and 4 if the intraluminal filling defect was unchanged in length. Resolution or decreased length was diagnostic of FFT, whereas its static appearance after 4 weeks was indicative of plaque. Diagnostic accuracy of FFT length was assessed by receiver operating characteristic analysis.

RESULTS

Ninety-five participants (mean [SD] age 68 [13] years, 61 men, 83 participants with FFT, 12 participants with a plaque) were evaluated. The >3.8-mm threshold had a sensitivity of 88% (73 of 83) (95% confidence interval [CI] 78%-94%) and specificity of 83% (10 of 12) (95% CI 51%-97%) (area under the curve 0.91, p < 0.001) for the diagnosis of FFT. The optimal length threshold was >3.64 mm with a sensitivity of 89% (74 of 83) (95% CI 80%-95%) and specificity of 83% (10 of 12) (95% CI 51%-97%). Adjusted logistic regression showed that every 1-mm increase in intraluminal filling defect length is associated with an increase in odds of FFT of 4.6 (95% CI 1.9-11.1, p = 0.01).

CONCLUSION

CTA enables accurate differentiation of FFT vs plaque using craniocaudal length thresholds.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifier: NCT02405845.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that in patients with TIA/stroke symptoms, the presence of CTA-identified filling defects of lengths >3.8 mm accurately discriminates FFT from atheromatous plaque.

Doctors' and Nurses' Social Media Ads Reduced Holiday Travel and COVID-19 infections: A cluster randomized controlled trial in 13 States

During the COVID-19 epidemic, many health professionals started using mass communication on social media to relay critical information and persuade individuals to adopt preventative health behaviors. Our group of clinicians and nurses developed and recorded short video messages to encourage viewers to stay home for the Thanksgiving and Christmas Holidays. We then conducted a two-stage clustered randomized controlled trial in 820 counties (covering 13 States) in the United States of a large-scale Facebook ad campaign disseminating these messages. In the first level of randomization, we randomly divided the counties into two groups: high intensity and low intensity. In the second level, we randomly assigned zip codes to either treatment or control such that 75% of zip codes in high intensity counties received the treatment, while 25% of zip codes in low intensity counties received the treatment. In each treated zip code, we sent the ad to as many Facebook subscribers as possible (11,954,109 users received at least one ad at Thanksgiving and 23,302,290 users received at least one ad at Christmas). The first primary outcome was aggregate holiday travel, measured using mobile phone location data, available at the county level: we find that average distance travelled in high-intensity counties decreased by -0.993 percentage points (95% CI -1.616, -0.371, p -value 0.002) the three days before each holiday. The second primary outcome was COVID-19 infection at the zip-code level: COVID-19 infections recorded in the two-week period starting five days post-holiday declined by 3.5 percent (adjusted 95% CI [-6.2 percent, -0.7 percent], p -value 0.013) in intervention zip codes compared to control zip codes.

One sentence summary

In a large scale clustered randomized controlled trial, short messages recorded by health professionals before the winter holidays in the United States and sent as ads to social media users led to a significant reduction in holiday travel, and to a decrease in subsequent COVID-19 infection at the population level.

Effect of Physician-Delivered COVID-19 Public Health Messages and Messages Acknowledging Racial Inequity on Black and White Adults' Knowledge, Beliefs, and Practices Related to COVID-19: A Randomized Clinical Trial

IMPORTANCE

Social distancing is critical to the control of COVID-19, which has disproportionately affected the Black community. Physician-delivered messages may increase adherence to these behaviors.

OBJECTIVES

To determine whether messages delivered by physicians improve COVID-19 knowledge and preventive behaviors and to assess the differential effectiveness of messages tailored to the Black community.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial of self-identified White and Black adults with less than a college education was conducted from August 7 to September 6, 2020. Of 44 743 volunteers screened, 30 174 were eligible, 5534 did not consent or failed attention checks, and 4163 left the survey before randomization. The final sample had 20 460 individuals (participation rate, 68%). Participants were randomly assigned to receive video messages on COVID-19 or other health topics.

INTERVENTIONS

Participants saw video messages delivered either by a Black or a White study physician. In the control groups, participants saw 3 placebo videos with generic health topics. In the treatment group, they saw 3 videos on COVID-19, recorded by several physicians of varied age, gender, and race. Video 1 discussed common symptoms. Video 2 highlighted case numbers; in one group, the unequal burden of the disease by race was discussed. Video 3 described US Centers for Disease Control and Prevention social distancing guidelines. Participants in both the control and intervention groups were also randomly assigned to see 1 of 2 American Medical Association statements, one on structural racism and the other on drug price transparency.

MAIN OUTCOMES AND MEASURES

Knowledge, beliefs, and practices related to COVID-19, demand for information, willingness to pay for masks, and self-reported behavior.

RESULTS

Overall, 18 223 participants (9168 Black; 9055 White) completed the survey (9980 [55.9%] women, mean [SD] age, 40.2 [17.8] years). Overall, 6303 Black participants (34.6%) and 7842 White participants (43.0%) were assigned to the intervention group, and 1576 Black participants (8.6%) and 1968 White participants (10.8%) were assigned to the control group. Compared with the control group, the intervention group had smaller gaps in COVID-19 knowledge (incidence rate ratio [IRR], 0.89 [95% CI, 0.87-0.91]) and greater demand for COVID-19 information (IRR, 1.05 [95% CI, 1.01-1.11]), willingness to pay for a mask (difference, $0.50 [95% CI, $0.15-$0.85]). Self-reported safety behavior improved, although the difference was not statistically significant (IRR, 0.96 [95% CI, 0.92-1.01]; P = .08). Effects did not differ by race (F = 0.0112; P > .99) or in different intervention groups (F = 0.324; P > .99).

CONCLUSIONS AND RELEVANCE

In this study, a physician messaging campaign was effective in increasing COVID-19 knowledge, information-seeking, and self-reported protective behaviors among diverse groups. Studies implemented at scale are needed to confirm clinical importance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04502056.