Clinical associations with a polygenic predisposition to benign lower white blood cell counts

Polygenic variation unrelated to disease contributes to interindividual variation in baseline white blood cell (WBC) counts, but its clinical significance is uncharacterized. We investigated the clinical consequences of a genetic predisposition toward lower WBC counts among 89,559 biobank participants from tertiary care centers using a polygenic score for WBC count (PGSWBC) comprising single nucleotide polymorphisms not associated with disease. A predisposition to lower WBC counts was associated with a decreased risk of identifying pathology on a bone marrow biopsy performed for a low WBC count (odds-ratio = 0.55 per standard deviation increase in PGSWBC [95%CI, 0.30-0.94], p = 0.04), an increased risk of leukopenia (a low WBC count) when treated with a chemotherapeutic (n = 1724, hazard ratio [HR] = 0.78 [0.69-0.88], p = 4.0 × 10-5) or immunosuppressant (n = 354, HR = 0.61 [0.38-0.99], p = 0.04). A predisposition to benign lower WBC counts was associated with an increased risk of discontinuing azathioprine treatment (n = 1,466, HR = 0.62 [0.44-0.87], p = 0.006). Collectively, these findings suggest that there are genetically predisposed individuals who are susceptible to escalations or alterations in clinical care that may be harmful or of little benefit.

Comparative study of AR infographic posters vs. offline videos for micro-video delivery in cardiology education

Augmented reality has promised a new paradigm in medical education. Multimedia videos are the most preferred assent for augmentation. So, this study aimed to assess the effect of using an augmented reality infographic poster for delivering micro-videos on the knowledge and satisfaction of medical students in cardiology rotation. Sixty students participated in this quasi-experimental study and were allocated to three study groups; namely routine method, routine method plus offline micro-video delivery, and routine method plus micro-video delivery in an augmented reality infographic poster. The students' knowledge and satisfaction were evaluated through a multiple-choice question pre and post-test and a satisfaction questionnaire respectively. Within-group comparison of pre and post-test scores showed a significant increase in each study group (all p-values = 0.000). The highest post-test score was for the offline micro-video delivery group and pairwise comparisons of post-test scores showed a significant difference between this group and the control one (p-value = 0.013). Additionally, the augmented reality infographic poster group had the highest satisfaction score (p-value = 0.000). This experience showed the positive effect of micro-videos in clinical education. Although students were satisfied with accessing these videos through an augmented reality infographic poster, their knowledge acquisition was better when they received them offline.

Effect of clinical decision support for severe hypercholesterolemia on low-density lipoprotein cholesterol levels

Severe hypercholesterolemia/possible familial hypercholesterolemia (FH) is relatively common but underdiagnosed and undertreated. We investigated whether implementing clinical decision support (CDS) was associated with lower low-density lipoprotein cholesterol (LDL-C) in patients with severe hypercholesterolemia/possible FH (LDL-C ≥ 190 mg/dL). As part of a pre-post implementation study, a CDS alert was deployed in the electronic health record (EHR) in a large health system comprising 3 main sites, 16 hospitals and 53 clinics. Data were collected for 3 months before ('silent mode') and after ('active mode') its implementation. Clinicians were only able to view the alert in the EHR during active mode. We matched individuals 1:1 in both modes, based on age, sex, and baseline lipid lowering therapy (LLT). The primary outcome was difference in LDL-C between the two groups and the secondary outcome was initiation/intensification of LLT after alert trigger. We identified 800 matched patients in each mode (mean ± SD age 56.1 ± 11.8 y vs. 55.9 ± 11.8 y; 36.0% male in both groups; mean ± SD initial LDL-C 211.3 ± 27.4 mg/dL vs. 209.8 ± 23.9 mg/dL; 11.2% on LLT at baseline in each group). LDL-C levels were 6.6 mg/dL lower (95% CI, -10.7 to -2.5; P = 0.002) in active vs. silent mode. The odds of high-intensity statin use (OR, 1.78; 95% CI, 1.41-2.23; P < 0.001) and LLT initiation/intensification (OR, 1.30, 95% CI, 1.06-1.58, P = 0.01) were higher in active vs. silent mode. Implementation of a CDS was associated with lowering of LDL-C levels in patients with severe hypercholesterolemia/possible FH, likely due to higher rates of clinician led LLT initiation/intensification.

Education and electronic medical records and genomics network, challenges, and lessons learned from a large-scale clinical trial using polygenic risk scores

Polygenic risk scores (PRS) have potential to improve health care by identifying individuals that have elevated risk for common complex conditions. Use of PRS in clinical practice, however, requires careful assessment of the needs and capabilities of patients, providers, and health care systems. The electronic Medical Records and Genomics (eMERGE) network is conducting a collaborative study which will return PRS to 25,000 pediatric and adult participants. All participants will receive a risk report, potentially classifying them as high risk (∼2-10% per condition) for 1 or more of 10 conditions based on PRS. The study population is enriched by participants from racial and ethnic minority populations, underserved populations, and populations who experience poorer medical outcomes. All 10 eMERGE clinical sites conducted focus groups, interviews, and/or surveys to understand educational needs among key stakeholders-participants, providers, and/or study staff. Together, these studies highlighted the need for tools that address the perceived benefit/value of PRS, types of education/support needed, accessibility, and PRS-related knowledge and understanding. Based on findings from these preliminary studies, the network harmonized training initiatives and formal/informal educational resources. This paper summarizes eMERGE's collective approach to assessing educational needs and developing educational approaches for primary stakeholders. It discusses challenges encountered and solutions provided.

Clinical consequences of a polygenic predisposition to benign lower white blood cell counts: Consequences of benign WBC count genetics

Polygenic variation unrelated to disease contributes to interindividual variation in baseline white blood cell (WBC) counts, but its clinical significance is undefined. We investigated the clinical consequences of a genetic predisposition toward lower WBC counts among 89,559 biobank participants from tertiary care centers using a polygenic score for WBC count (PGSWBC) comprising single nucleotide polymorphisms not associated with disease. A predisposition to lower WBC counts was associated with a decreased risk of identifying pathology on a bone marrow biopsy performed for a low WBC count (odds-ratio=0.55 per standard deviation increase in PGSWBC [95%CI, 0.30 - 0.94], p=0.04), an increased risk of leukopenia (a low WBC count) when treated with a chemotherapeutic (n=1,724, hazard ratio [HR]=0.78 [0.69 - 0.88], p=4.0×10-5) or immunosuppressant (n=354, HR=0.61 [0.38 - 0.99], p=0.04). A predisposition to benign lower WBC counts was associated with an increased risk of discontinuing azathioprine treatment (n=1,466, HR=0.62 [0.44 - 0.87], p=0.006). Collectively, these findings suggest that a WBC count polygenic score identifies individuals who are susceptible to escalations or alterations in clinical care that may be harmful or of little benefit.

Hyepereosiniphilic syndrome and COVID-19: 2 case reports

BACKGROUND

Nearly half of the patients with hypereosinophilic syndrome (HES) have cardiovascular involvement, a major cause of mortality. COVID-19 infection can lead to cardiac involvement, negatively impacting the clinical course and prognosis. We reported two patients with HES complicated by COVID-19, with cardiac involvement and valve replacement.

CASE PRESENTATION

Our first patient was a 27-year-old woman admitted due to dyspnea and signs of heart failure. She had severe mitral stenosis and mitral regurgitation on the echocardiogram. Corticosteroid therapy improved her symptoms initially, but she deteriorated following a positive COVID-19 test. A repeated echocardiogram showed right ventricular failure, severe mitral regurgitation, and torrential tricuspid regurgitation and, she underwent mitral and tricuspid valve replacement. Our second patient was a 43-year-old man with HES resulted in severe tricuspid stenosis, which was improved with corticosteroid treatment. He underwent tricuspid valve replacement due to severe valvular regurgitation. He was admitted again following tricuspid prosthetic mechanical valve thrombosis. Initial workups revealed lung involvement in favor of COVID-19 infection, and his PCR test was positive.

CONCLUSION

COVID-19 infection can change the clinical course of HES. It may result in a heart failure exacerbation due to myocardial injury and an increased risk of thrombosis in prosthetic valves or native vessels due to hypercoagulability.

Familial Hypercholesterolemia in the Electronic Medical Records and Genomics Network: Prevalence, Penetrance, Cardiovascular Risk, and Outcomes After Return of Results

BACKGROUND

The implications of secondary findings detected in large-scale sequencing projects remain uncertain. We assessed prevalence and penetrance of pathogenic familial hypercholesterolemia (FH) variants, their association with coronary heart disease (CHD), and 1-year outcomes following return of results in phase III of the electronic medical records and genomics network.

METHODS

Adult participants (n=18 544) at 7 sites were enrolled in a prospective cohort study to assess the clinical impact of returning results from targeted sequencing of 68 actionable genes, including LDLR, APOB, and PCSK9. FH variant prevalence and penetrance (defined as low-density lipoprotein cholesterol >155 mg/dL) were estimated after excluding participants enrolled on the basis of hypercholesterolemia. Multivariable logistic regression was used to estimate the odds of CHD compared to age- and sex-matched controls without FH-associated variants. Process (eg, referral to a specialist or ordering new tests), intermediate (eg, new diagnosis of FH), and clinical (eg, treatment modification) outcomes within 1 year after return of results were ascertained by electronic health record review.

RESULTS

The prevalence of FH-associated pathogenic variants was 1 in 188 (69 of 13,019 unselected participants). Penetrance was 87.5%. The presence of an FH variant was associated with CHD (odds ratio, 3.02 [2.00-4.53]) and premature CHD (odds ratio, 3.68 [2.34-5.78]). At least 1 outcome occurred in 92% of participants; 44% received a new diagnosis of FH and 26% had treatment modified following return of results.

CONCLUSIONS

In a multisite cohort of electronic health record-linked biobanks, monogenic FH was prevalent, penetrant, and associated with presence of CHD. Nearly half of participants with an FH-associated variant received a new diagnosis of FH and a quarter had treatment modified after return of results. These results highlight the potential utility of sequencing electronic health record-linked biobanks to detect FH.

Transient disruption of functional connectivity and depression of neural fluctuations in a mouse model of acute septic encephalopathy

Septic encephalopathy leads to major and costly burdens for a large percentage of admitted hospital patients. Elderly patients are at an increased risk, especially those with dementia. Current treatments are aimed at sedation to combat mental status changes and are not aimed at the underlying cause of encephalopathy. Indeed, the underlying pathology linking together peripheral infection and altered neural function has not been established, largely because good, acutely accessible readouts of encephalopathy in animal models do not exist. Behavioral testing in animals lasts multiple days, outlasting the time frame of acute encephalopathy. Here, we propose optical fluorescent imaging of neural functional connectivity (FC) as a readout of encephalopathy in a mouse model of acute sepsis. Imaging and basic behavioral assessment were performed at baseline, Hr8, Hr24, and Hr72 following injection of either lipopolysaccharide or phosphate buffered saline. Neural FC strength decreased at Hr8 and returned to baseline by Hr72 in motor, somatosensory, parietal, and visual cortical regions. Additionally, neural fluctuations transiently declined at Hr8 and returned to baseline by Hr72. Both FC strength and fluctuation tone correlated with neuroscore indicating this imaging methodology is a sensitive and acute readout of encephalopathy.

Pathogenic variants in arteriopathy genes detected in a targeted sequencing study: Penetrance and 1-year outcomes after return of results

PURPOSE

We estimated the penetrance of pathogenic/likely pathogenic (P/LP) variants in arteriopathy-related genes and assessed near-term outcomes following return of results.

METHODS

Participants (N = 24,520) in phase III of the Electronic Medical Records and Genomics network underwent targeted sequencing of 68 actionable genes, including 9 genes associated with arterial aneurysmal diseases. Penetrance was estimated on the basis of the presence of relevant clinical traits. Outcomes occurring within 1 year of return of results included new diagnoses, referral to a specialist, new tests ordered, surveillance initiated, and new medications started.

RESULTS

P/LP variants were present in 34 participants. The average penetrance across genes was 59%, ranging from 86% for FBN1 variants to 25% for SMAD3. Of 16 participants in whom results were returned, 1-year outcomes occurred in 63%. A new diagnosis was made in 44% of the participants, 56% were referred to a specialist, a new test was ordered in 44%, surveillance was initiated in 31%, and a new medication was started in 31%.

CONCLUSION

Penetrance of P/LP variants in arteriopathy-related genes, identified in a large, targeted sequencing study, was variable and overall lower than that reported in clinical cohorts. Meaningful outcomes within the first year were noted in 63% of participants who received results.

Caspofungin-Induced Cardiotoxicity in Patients Treating for Candidemia

Echinocandins selectively inhibit fungal cell wall synthesis and, therefore, have few side effects. However, there are reports of hemodynamic and cardiac complications. We conducted this study to investigate the effects of caspofungin both on the noninvasive echocardiographic indices of myocardial function and myocardial injury based on serum high-sensitivity cardiac troponin I (hs-cTnI) levels. This study was conducted on patients treated for candidemia. The hs-cTnI level and echocardiographic parameters were measured before and 1 h after the infusion of the induction dose of caspofungin. Data were compared between central and peripheral venous drug administration routes. Fifteen patients were enrolled in the study. There were no significant differences in the echocardiographic parameters between the baseline and post-treatment period. The mean hs-cTnI level exhibited a significant rise following drug administration (0.24 ± 0.2 ng/mL vs 0.32 ± 0.3 ng/mL; p = 0.006). There was also a significant difference concerning the hs-cTnI level between central and peripheral venous drug administration routes (p = 0.034). Due to differences in the hs-cTnI level, it appears that the administration of caspofungin may be associated with myocardial injury. Our findings also showed a higher possibility of cardiotoxicity via the central venous administration route.

Abstract 431: MaxSpliZer: A Tool To Predict Effects Of LDLR Splice Variants Based On The Maximum Entropy Model

Background: The Clinical Genome Resource Consortium (ClinGen) recommends MaxEntScan (MES) model to predict the effects of LDLR splice variants. We developed “MaxSpliZer”, a software tool to automate the implementation of MES, and validated it using ClinVar and UK-Biobank (UKBB) data.

Method: We tested concordance of MaxSpliZer predictions with ClinVar classifications of benign/likely benign (B/LB) and pathogenic/likely pathogenic (P/LP) for LDLR variants with potential effect on splicing. We also annotated LDLR splice variants in 200,618 UKBB participants, categorizing them using MaxSpliZer as deleterious (n=90) and non-deleterious (n=7,404). Low-density lipoprotein cholesterol (LDL-C) levels were compared in these two groups after adjustment for lipid-lowering medication use.

Results: MaxSpliZer prediction was concordant with the ClinVar classification in 128 of 138 P/LP variants (sensitivity 93%) and 432 of 436 B/LB variants (specificity 99%). In the UKBB, splice variants predicted as deleterious by MaxSpliZer had higher LDL-C than non-deleterious splice variants (158.7±47.4 vs. 146.0±34.8mg/dL, p-value = 0.014). Compared to manual curation time of 12±7 min per variant, MaxSpliZer took 0.52±0.11 min for single entries and 1.5 s per variant for biobank-scale data.

Conclusion: MaxSpliZer, a software tool that implements MES based on the ClinGen guideline, can accurately classify LDLR splice variants in a rapid automated fashion.

Global and Regional Burden and Quality of Care of Non-Rheumatic Valvular Heart Diseases; A Systematic Analysis of Global Burden of Disease 1990-2017

Background

With increase in incidence and prevalence of non-rheumatic valvular heart diseases (NRVHDs), having a proper understanding of the disease current status in terms of quality of care and healthcare access can considerably affect further planning for the healthcare system. In this study we aimed to evaluate and compare the quality and equity of care concerning NRVHDs in terms of gender and sociodemographic index (SDI) using a newly proposed index.

Methods

We obtained the primary measures (e.g., incidence) from the Global Burden of Disease (GBD) data about NRVHD from 1990 to 2017 to calculate the subsequent secondary indices (e.g., mortality-to-incidence ratio) with close association to quality of care. Then, using principal component analysis (PCA), quality of care index (QCI) was calculated as a novel index from the secondary indices, rescaled to 0-100. QCI was calculated for all age-groups and both genders, globally, regionally, and nationally between 1990–2017.

Results

Globally, the QCI for NRVHDs in 2017 was 87.3, and it appears that gender inequity was unremarkable (gender disparity ratio=1.00, female QCI: 90.2, male QCI: 89.7) in 2017 similar to the past three decades. Among WHO world regions, the Western-Pacific Region and Eastern-Mediterranean Region showed the highest (90.1) and lowest (74.0) QCI scores. Regarding SDI, the high-middle-SDI quintile with a QCI of 89.4 and low-SDI quintile with a QCI of 77.8 were the two extremes of healthcare quality in 2017.

Conclusion

Although global status regarding the NRVHD’s quality of care is acceptable, higher attention is required for lower SDI countries.

J wave syndrome: Benign or malignant?

J wave syndrome is an electrical disease of the heart due to pathologic early repolarization. It encompasses a clinical spectrum from aborted sudden cardiac death due to ventricular arrhythmia (VA) usually in young affected patients to self-terminating ventricular ectopies, and finally, asymptomatic relatives of probands detected during electrocardiography acquisition (early repolarization pattern). This syndrome consists of 2 phenotypes, early repolarization and Brugada syndrome. Herein, we first describe 2 patients with early repolarization and Brugada syndrome, then, discuss their definition, epidemiology, genetics, cellular mechanism, diagnosis, risk stratification, and finally, therapeutic challenges and options one by one in detail.

Additive value of positron emission tomography/computed tomography scan for detection of aortic tube graft infection: a case report

Background

Diagnosis of aortic graft infection is challenging, and delayed diagnosis is associated with poor prognosis. Positron emission tomography/computed tomography (PET/CT) has improved diagnostic accuracy.

Case summary

A patient with a history of congenital heart disease was admitted due to fever. He had a history of four cardiac surgeries, including the Bentall procedure for endocarditis. Blood cultures were negative. A semi-mobile mass was detected in the distal portion of the aortic tube graft in echocardiography. PET/CT scan was used to confirm tube graft infection and to support proceeding to cardiac surgery.

Discussion

Using multimodality imaging, including PET/CT scan in combination with echocardiography, can improve diagnostic accuracy for the detection of aortic tube graft infection, infection of prosthetic valves, or intra-cardiac devices, especially in high-risk surgical cases.

Myocardial perfusion imaging and appropriateness of the test for preoperative cardiac risk evaluation in an Iranian population: clinical role of Duke Activity Status Index

OBJECTIVE

For preoperative radionuclide myocardial perfusion imaging, metabolic equivalent is one of the key factors to evaluate the appropriateness. Duke Activity Status Index is a practical method to calculate metabolic equivalents. We intended to validate Duke Activity Status Index in our population for the assessment of preoperative myocardial perfusion imaging appropriateness.

METHODS

A total of 542 patients referred for myocardial perfusion imaging were recruited. A questionary compiled from Duke Activity Status Index was filled out based on which metabolic equivalents were calculated. Demographic data and history of cardiac risk factors were also collected. Myocardial perfusion imaging was performed using a 2-day stress-rest protocol either by exercise tolerance test or by pharmacologic stress through injection of Tc-MIBI and imaging by a dual-head gamma camera.

RESULTS

Out of 542 patients, 369 (68.1%) were evaluated for preoperative risk assessment. Metabolic equivalents (oxygen consumption/min/kg) were calculated at 9.3 ± 5.1, 10.8 ± 4.8, and 8.7 ± 5.1 in total, preoperative patients and patients evaluated for ischemia due to nonsurgical purposes, respectively (p = 0.001). The myocardial perfusion imaging was rarely appropriate in 291 (79.5%), maybe appropriate in 67 (18.3%), and appropriate in 8 (2.2%) patients. The prevalence of abnormal myocardial perfusion imaging was 22.5%, 28.4%, and 12.5% in "rarely appropriate," "maybe appropriate," and "appropriate" scenarios, respectively. Metabolic equivalents were similar between patients with normal and abnormal myocardial perfusion imaging (8.7 ± 5.0 vs. 8.5 ± 5.4).

CONCLUSION

Either Duke Activity Status Index is not a proper tool for calculation of metabolic equivalents or the appropriate use criteria is not operational in the population of Iranian preoperative patients in which cultural factors may contribute.

Depression and Anxiety among Iranian Medical Students during COVID-19 Pandemic

Objective: COVID-19 has spread throughout the world and has become a global pandemic. This situation can cause psychological distress among people, especially health care workers.

This study aimed to determine depression and anxiety levels among Iranian medical students during the COVID-19 pandemic.

Method: In this cross sectional study, we designed an online survey of Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) questionnaires. The survey link was sent to 500 medical clerks and interns studying at Tehran University of Medical Sciences (TUMS).

Results: A total of 64.6% of the students completed the survey. The prevalence of mild to severe anxiety and depression among them was 38.1% and 27.6%, respectively. Anxiety and changes in sleep patterns were the most common symptoms. Higher levels of anxiety were related to female gender, lower grade point average (GPA), and experience of COVID-19 symptoms. Students with lower GPA and prior experience of COVID-19 symptoms were more likely to feel depressed.

Conclusion: Depression and anxiety did not significantly differ among Iranian medical students before and after the COVID-19 outbreak. Somatic symptoms of depression are more common during this pandemic and need particular attention in future similar situations. A higher GPA is related to lower anxiety and depression among medical students.

Usefulness of Biomarkers for Predicting Response to Cardiac Resynchronization Therapy

Cardiac Resynchronization Therapy (CRT) is an effective treatment strategy for heart failure. It significantly improves clinical symptoms and decreases mortality and long-term morbidity. However, some patients do not respond properly to this treatment. In this review, the role of different biomarkers in predicting response to CRT is discussed. Some biomarkers, including natriuretic peptides and inflammatory markers have promising results but further trials are needed for more evaluation.

Assessment of Carvedilol Therapy in Prevention of Heart Failure in HER2 Positive Breast Cancer Patients Receiving Trastuzumab

Abstract- Breast cancer is the most common cancer among the female population, and its prevalence is increasing worldwide. Trastuzumab (Herceptin) therapy improves prognosis in HER2 positive patients, but Heart Failure (HF) is one of its known complications. In this study, we aimed to assess the potential benefits of prophylactic carvedilol therapy in patients receiving Herceptin. Sixty five patients with HER2 positive breast cancer were enrolled in the study. All of the patients received Herceptin. Twenty seven patients also received carvedilol 6.25 mg twice daily, and 38 patients had usual care. Echocardiography was performed at baseline, and after three months in both groups and changes in cardiac function, parameters were compared between two groups. After 3 months, LA volume index (P=0.012), TAPSE (P=0.009), Tei index (P=0.015) and Lateral Longitudinal Strain (P=0.024) were significantly better in patients receiving carvedilol. Carvedilol can be effective in the prevention of systolic and diastolic dysfunction following Herceptin therapy.

A Rare Case of Cardiogenic Shock Following Severe Multivessel Coronary Vasospasm

Prinzmetal's angina occurs following spasms in a single or multiple vascular beds, resulting in a typical chest pain and an ST-segment elevation in electrocardiography (ECG). It can lead to life-threatening arrhythmias and sudden cardiac death. We describe a 37-year-old woman who was admitted with a typical chest pain and hypotension. Her initial ECG showed an ST-segment elevation in the inferior and precordial leads. She was transferred to the catheterization unit, where coronary angiography illustrated multivessel spasms. The spasms were relieved with a nitroglycerin injection. She was discharged with stable hemodynamics 7 days later, and at 1 month's follow-up, no recurrent attack was detected.