The impact of active cytomegalovirus infection on donor-derived cell-free DNA testing in heart transplant recipients

BACKGROUND

Little is known about the relationship between cytomegalovirus (CMV) infections and donor-derived cell-free DNA (dd-cfDNA) in heart transplant recipients.

METHODS

In our study, CMV and dd-cfDNA results were prospectively collected on single-organ heart transplant recipients. If the CMV study was positive, a CMV study with dd-cfDNA was repeated 1-3 months later. The primary aim was to compare dd-cfDNA between patients with positive and negative CMV results.

RESULTS

Of 44 patients enrolled between August 2022 and April 2023, 12 tested positive for CMV infections, 25 were included as controls, and seven patients with a viral infection without CMV were excluded. Baseline characteristics did not differ significantly between CMV-positive and CMV-negative patients with the exception of a later median time post-transplant in the CMV-positive group (253 days vs. 120 days, p = .03). Dd-cfDNA levels were significantly higher in patients with CMV infections compared to those without (p < .001) with more patients in the CMV positive group showing dd-cfDNA results ≥.12% (75% vs. 8%, p < .001) and ≥.20% (58% vs. 8%, p = .002). Each 1 log10 copy/ml reduction in CMV viral load from visit 1 to visit 2 was associated with a.23% reduction in log10 dd-cfDNA (p = .002).

CONCLUSION

Our findings suggest that active CMV infections may raise dd-cfDNA levels in patients following heart transplantation. Larger studies are needed to validate these preliminary findings.

Rejection! Or is it? Correlation among molecular microscope diagnostic system, histopathology and clinical judgement following heart transplantation

PURPOSE

Little is known about clinical decision making among discordant findings concerning for rejection with endomyocardial biopsy (EMBx) and Molecular Microscope Diagnostic System (MMDx) in patients following heart transplantation.

METHODS

Two hundred and twenty-eight corresponding EMBx and MMDx specimens from 135 adult heart transplant patients were retrospectively reviewed. Rejection was classified as t-cell mediated rejection ≥2R and/or antibody mediated rejection ≥1. Clinical decision making among concordant and discordant cases of EMBx and MMDx results were reviewed.

RESULTS

Patient characteristics were comparable between concordant and discordant patient groups (median age 60 yrs., 76% male, and 71% White). A total of 167/228 specimens (73%) were concordant for no rejection with 98% agreement in clinical decision making and 25/228 (11%) concordant for rejection with 64% agreement in clinical decision making. Among the 36/228 (16%) discordant samples, clinical decision-making agreed on treatment for rejection in five of the MMDx samples and three of the EMBx samples.

CONCLUSIONS

MMDx can be an additional tool to diagnose rejection not detected by the traditional EMBx and influence clinical decision making in guiding appropriate treatment. Ongoing investigation into the clinical utility of MMDx is warranted to determine the significance of discordant findings among diagnostic modalities when assessing for rejection.

Alert! Does Prolonged Temporary Support Induce an Immunological Response?

Little is known about the development of human leukocyte antigen antibodies with use of the temporary transvalvular pump 5.5 mechanical circulatory support device. This case reports a patient who developed de novo antibodies prior to his heart transplantation and remains free of any episodes of rejection post transplantation to date. (Level of Difficulty: Advanced.).

Induced Moderate Hypothermia After Cardiac Arrest

The use of induced hypothermia has been considered for treatment of head injuries since the 1900s. However, it was not until 2 landmark studies were published in 2002 that induced hypothermia was considered best practice for patients after cardiac arrest. In 2005, the American Heart Association included recommendations in the postresuscitation support guidelines recommending consideration of mild hypothermia for unconscious adult patients with return of spontaneous circulation following out-of-hospital cardiac arrest due to ventricular fibrillation. This article provides an overview on the history and supportive research for inducing mild hypothermia after cardiac arrest, the pathophysiology associated with cerebral ischemia occurring with hypothermia, nursing management for this patient population, and the development of a protocol for induced hypothermia after cardiac arrest.

Use of intravenous steroids at induction of anaesthesia for adult tonsillectomy to reduce post-operative nausea and vomiting and pain: a double-blind randomized controlled trial

OBJECTIVE

To assess the effectiveness of intravenous steroids at induction of anaesthetic to reduce post-operative nausea and vomiting and pain after adult tonsillectomy.

DESIGN

Prospective, double-blind, randomized, placebo controlled trial, with ethical approval, following Consolidated Standards of Reporting Trials guidelines.

SETTING

District General Hospital in Scotland, UK.

PARTICIPANTS

Seventy-two adults between 16 and 70 years, American Association of Anaethetists (ASA) 1, listed for elective tonsillectomy.

INTERVENTION

Single dose of either 10 mg of dexamethasone or 2 mL of saline after induction with a consistent anaesthetic technique.

MAIN OUTCOME MEASURES

Patients filled in a visual analogue scale relating to pain and post-operative nausea and vomiting for the day of operation and 7 days after operation. The time to first ingestion of food and drink after operation was also noted.

RESULTS

Data completion rate of 64% (46 of 72 patients enrolled). Statistically significant relative decrease (62%P = 0.001) in the incidence of post-operative nausea and vomiting was seen in those treated with dexamethasone. Statistically significant relative decrease (23%P = 0.016) in post-operative pain scores for the day of operation was seen in those treated with dexamethasone. Significant decrease (17.5%, P < 0.001) in mean pain score for seven post-operative days was seen in those treated with dexamethasone. No adverse effects were seen.

CONCLUSIONS

Dexamethasone given as a single dose of 10 mg at induction of anaesthesia for adult tonsillectomy is an effective, safe and inexpensive method for reducing morbidity in adult tonsillectomy.

Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan

PURPOSE

Unplanned hospital readmission within 30 days of discharge is considered a "sentinel event" for poor quality. Patients at high risk for this adverse event could be targeted for interventions designed to reduce their risk of readmission. The purpose of this study was to identify patient characteristics and risk factors at discharge associated with unplanned readmission within 30 days of hospital discharge.

SUBJECTS AND METHODS

We performed a matched case-control study among patients in a Medicare managed care plan who had been admitted to an academic hospital. The cases were patients aged 65 years or older who were urgently or emergently readmitted to the hospital within 30 days of discharge. One control patient who was not readmitted within 30 days was matched to each case by principal diagnosis. The medical records of the first admission of the cases and the admission of the controls underwent review (blinded to case-control status) to determine the patient's baseline demographic characteristics, comorbid conditions, previous health care utilization, and functional status. The records were also reviewed to assess risk factors on discharge, including clinical instability, inability to ambulate and feed, mental status changes, number of discharge medications, and discharge disposition.

RESULTS

Five factors were independently associated (P < 0.05) with unplanned readmission within 30 days. These included four baseline patient characteristics: age 80 years or older [odds ratio = 1.8; 95% confidence interval (CI), 1.02-3.2], previous admission within 30 days (odds ratio = 2.3; 95% CI, 1.2-4.6), five or more medical comorbidities (odds ratio = 2.6; 95% CI, 1.5-4.7), and history of depression (odds ratio = 3.2; 95% CI, 1.4-7.9); and one discharge factor: lack of documented patient or family education (odds ratio = 2.3; 95% CI, 1.2-4.5).

CONCLUSIONS

If validated, these factors may identify patients at high risk of readmission. They suggest that interventions, such as improved discharge education programs, may reduce unplanned readmission.