Pro-thrombotic autoantibodies targeting Platelet Factor 4/polyanion are associated with pediatric cerebral malaria

BACKGROUND

Features of consumptive coagulopathy and thromboinflammation are prominent in cerebral malaria (CM). We hypothesized that thrombogenic autoantibodies contribute to a procoagulant state in CM.

METHODS

Plasma from children with uncomplicated malaria (UM, n = 124) and CM (n = 136) was analyzed by ELISA for a panel of 8 autoantibodies including anti-Platelet Factor 4/polyanion (anti-PF4/P), anti-Phospholipid, anti-Phosphatidylserine, anti-Myeloperoxidase, anti-Proteinase 3, anti-dsDNA, anti-Beta-2-Glycoprotein I (β2GPI), and anti-Cardiolipin. Non-malaria coma (NMC, n = 49) and healthy controls (HC, n = 56) were assayed for comparison. Associations with clinical and immune biomarkers were determined using univariate and logistic regression analyses.

RESULTS

Median anti-PF4/P and anti-PS IgG levels were elevated with malaria infection relative to HC (P < 0.001) and NMC (PF4/P: P < 0.001). Anti-PF4/P IgG levels were elevated in CM (median = 0.27, IQR: 0.19-0.41) compared to UM (median = 0.19, IQR: 0.14-0.22, P ≤ 0.0001). Anti-PS IgG levels did not differ between UM and CM (P = 0.39). When CM cases were stratified by malaria retinopathy (Ret) status, levels of anti-PF4/P IgG correlated negatively with peripheral platelet count in Ret+ CM cases (Rs = 0.201, P = 0.04) and associated positively with mortality (OR = 15.2, 95% CI: 1.02-275, P = 0.048). Plasma from CM patients induced a greater platelet activation capacity in an ex-vivo assay relative to plasma from UM patients (P = 0.02). Platelet activation was associated with anti-PF4/P IgG levels (Rs = 0.293, P = 0.035).

CONCLUSIONS

Thrombosis mediated by elevated anti-PF4/P autoantibodies may be one mechanism contributing to the clinical complications of CM.

Identifying Neutrophil Extracellular Traps (NETs) in Blood Samples Using Peripheral Smear Autoanalyzers

Neutrophil Extracellular Traps (NETs) are large neutrophil-derived structures composed of decondensed chromatin, cytosolic, and granule proteins. NETs play an important role in fighting infection, inflammation, thrombosis, and tumor progression processes, yet their fast and reliable identification has been challenging. Smudge cells (SCs) are a subcategory of white cells identified by CellaVision^®, a hematology autoanalyzer routinely used in clinical practice that uses digital imaging to generate "manual" differentials of peripheral blood smears. We hypothesize that a proportion of cells identified in the SC category by CellaVision^® Hematology Autoanalyzers are actually NETs. We demonstrate that NET-like SCs are not present in normal blood samples, nor are they an artifact of smear preparation. NET-like SCs stain positive for neutrophil markers such as myeloperoxidase, leukocyte alkaline phosphatase, and neutrophil elastase. On flow cytometry, cells from samples with high percent NET-like SCs that are positive for surface DNA are also positive for CD45, myeloperoxidase and markers of neutrophil activation and CD66b. Samples with NET-like SCs have a strong side fluorescent (SFL) signal on the white count and nucleated red cells (WNR) scattergram, representing cells with high nucleic acid content. When compared to patients with low percent SCs, those with a high percentage of SCs have a significantly higher incidence of documented bacterial and viral infections. The current methodology of NET identification is time-consuming, complicated, and cumbersome. In this study, we present data supporting identification of NETs by CellaVision^®, allowing for easy, fast, cost-effective, and high throughput identification of NETs that is available in real time and may serve as a positive marker for a bacterial or viral infections.

Machine learning in the coagulation and hemostasis arena: an overview and evaluation of methods, review of literature, and future directions

Artificial Intelligence and machine-learning (ML) studies are increasingly populating the life science space and some have also started to integrate certain clinical decision support tasks. However, most of the activities within this space understandably remain within the investigational domain and are not yet ready for broad use in healthcare. In short, artificial intelligence/ML is still in an infancy stage within the healthcare arena, and we are nowhere near reaching its full potential. Various factors have contributed to this slow adoption rate within healthcare, which include but are not limited to data accessibility and integrity issues, paucity of specialized data science personnel, certain regulatory measures, and various voids within the ML operational platform domain. However, these obstacles and voids have also introduced us to certain opportunities to better understand this arena as we fully embark on this new journey, which undoubtedly will become a major part of our future patient care activities. Considering the aforementioned needs, this review will be concentrating on various ML studies within the coagulation and hemostasis space to better understand their shared study needs, findings, and limitations. However, the ML needs within this subspecialty of medicine are not unique and most of these needs, voids, and limitations also apply to the other medical disciplines. Therefore, this review will not only concentrate on introducing the audience to ML concepts and ML study design elements but also on where the future within this arena in medicine is leading us.

Indeterminate serotonin release assays are associated with a high mortality rate

Background

The serotonin release assay (SRA) is considered the gold standard for diagnosis of heparin-induced thrombocytopenia (HIT). Although the SRA holds high sensitivity and specificity when results are definitive, up to 10% of samples from patients with suspected HIT yield "indeterminate" results.

Objectives

We aimed to study the clinical course of patients with indeterminate results.

Methods

We conducted a cohort analysis of 2056 patients that underwent SRA testing.

Results

Of 2056 total patients, 152 (7.4%) had indeterminate assays. The prevalence of thrombocytopenia <50,000 × 10⁶ was higher in patients with an indeterminate or positive SRA, compared with a negative SRA (39.5% and 40.0% vs. 27.5%, p < 4.0 × 10^-4). Patients with an indeterminate SRA were more likely to have been treated in the intensive care unit than patients with a positive SRA (93.3% vs. 73.7%, p = 0.03). The mean thrombocytopenia, timing of platelet count fall, thrombosis or other sequelae, and other causes for thrombocytopenia score in patients with indeterminate SRA was 2.9, corresponding to a HIT probability of <5%. Of 152 patients, 128 (78.9%) had heparin-PF4 optical densities (ODs) below 0.60 OD, whereas four patients (2.6%) had ODs above 2.00 OD. Inpatient mortality was significant in patients with indeterminate SRAs compared with positive or negative SRA (49.3% vs. 21.1% and 27.2%, p < 2.4 × 10^-10).

Conclusions

Our data suggest that an indeterminate SRA may signal an in vivo platelet activation process that is not related to heparin but is associated with increased mortality.

HTLV-1 infection in acute t- lymphocytic leukemia/lymphoma

Adult T- lymphocyte leukemia/ lymphoma (ATLL), described by Uchiyama et al. in 1977, is a distinct neoplasia of peripheral T-lymphocytes caused by human T-cell lymphotropic virus type 1 (HTLV-1). The authors describe the case of a 75-year-old female patient who presented with fever, chills, and altered mental status. The peripheral blood morphology showed large atypical lymphocytes with multilobed nuclei and flow cytometry consistent with ATLL. The authors discuss the pathophysiology, differential diagnosis, and subtypes of ATLL in addition to the diagnostic approach using flow cytometry when bone marrow biopsy is not available and modalities of treatment.

Silencing VEGFR-2 Hampers Odontoblastic Differentiation of Dental Pulp Stem Cells

Dental pulp stem cells (DPSCs) are a source of postnatal stem cells essential for maintenance and regeneration of dentin and pulp tissues. Previous in vivo transplantation studies have shown that DPSCs are able to give rise to odontoblast-like cells, form dentin/pulp-like structures, and induce blood vessel formation. Importantly, dentin formation is closely associated to blood vessels. We have previously demonstrated that DPSC-induced angiogenesis is VEGFR-2-dependent. VEGFR-2 may play an important role in odontoblast differentiation of DPSCs, tooth formation and regeneration. Nevertheless, the role of VEGFR-2 signaling in odontoblast differentiation of DPSCs is still not well understood. Thus, in this study we aimed to determine the role of VEGFR-2 in odontoblast differentiation of DPSCs by knocking down the expression of VEGFR-2 in DPSCs and studying their odontoblast differentiation capacity in vitro and in vivo. Isolation and characterization of murine DPSCs was performed as previously described. DPSCs were induced by VEGFR-2 shRNA viral vectors transfection (MOI = 10:1) to silence the expression of VEGFR-2. The GFP+ expression in CopGFP DPSCs was used as a surrogate to measure the efficiency of transfection and verification that the viral vector does not affect the expression of VEGFR-2. The efficiency of viral transfection was shown by significant reduction in the levels of VEGFR-2 based on the Q-RT-PCR and immunofluorescence in VEGFR-2 knockdown DPSCs, compared to normal DPSCs. VEGFR-2 shRNA DPSCs expressed not only very low level of VEGFR-2, but also that of its ligand, VEGF-A, compared to CopGFP DPSCs in both transcriptional and translational levels. In vitro differentiation of DPSCs in osteo-odontogenic media supplemented with BMP-2 (100 ng/ml) for 21 days demonstrated that CopGFP DPSCs, but not VEGFR-2 shRNA DPSCs, were positive for alkaline phosphatase (ALP) staining and formed mineralized nodules demonstrated by positive Alizarin Red S staining. The expression levels of dentin matrix proteins, dentin matrix protein-1 (Dmp1), dentin sialoprotein (Dspp), and bone sialoprotein (Bsp), were also up-regulated in differentiated CopGFP DPSCs, compared to those in VEGFR-2 shRNA DPSCs, suggesting an impairment of odontoblast differentiation in VEGFR-2 shRNA DPSCs. In vivo subcutaneous transplantation of DPSCs with hydroxyapatite (HAp/TCP) for 5 weeks demonstrated that CopGFP DPSCs were able to differentiate into elongated and polarized odontoblast-like cells forming loose connective tissue resembling pulp-like structures with abundant blood vessels, as demonstrated by H&E, Alizarin Red S, and dentin matrix staining. On the other hand, in VEGFR-2 shRNA DPSC transplants, odontoblast-like cells were not observed. Collagen fibers were seen in replacement of dentin/pulp-like structures. These results indicate that VEGFR-2 may play an important role in dentin regeneration and highlight the potential of VEGFR-2 modulation to enhance dentin regeneration and tissue engineering as a promising clinical application.

First Report of Compound Heterozygosity for Hb S (HBB: c.20A>T) and Hb Haringey (HBB: c.131A>G)

Sickle cell disease variants include hemoglobinopathies that result from inheritance of the sickle cell globin mutation with another globin mutation. The most common variants include the homozygous disease state (Hb SS disease), Hb S (HBB: c.20A>T)/Hb C (HBB: c.19G>A) disease and Hb S/β-thalassemia (Hb S/β-thal). Other rare/less common variants such as Hb S/Hb E (HBB: c.79G>A) and Hb S/HPFH [hereditary persistence of fetal hemoglobin (Hb)] disease exist. We report the first case of compound heterozygosity for Hb S and Hb Haringey (HBB: c.131A>G) in a 35-year-old male following a positive sickle screen test on hospital admission for pancreatitis. Ion exchange high performance liquid chromatography (HPLC), Hb electrophoresis and genetic sequencing were utilized to identify a new sickle Hb variant: Hb S/Hb Haringey. Hb S/Hb Haringey is a newly discovered sickle cell variant which seems to portray a mild/benign clinical phenotype of sickle cell disease.

Low ADAMTS13 Activity Correlates with Increased Mortality in COVID-19 Patients

The causes of coagulopathy associated with coronavirus disease 2019 (COVID-19) are poorly understood. We aimed to investigate the relationship between von Willebrand factor (VWF) biomarkers, intravascular hemolysis, coagulation, and organ damage in COVID-19 patients and study their association with disease severity and mortality. We conducted a retrospective study of 181 hospitalized COVID-19 patients randomly selected with balanced distribution of survivors and nonsurvivors. Patients who died had significantly lower ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity, significantly elevated lactate dehydrogenase levels, significantly increased shistocyte/RBC fragment counts, and significantly elevated VWF antigen and activity levels compared with patients discharged alive. These biomarkers correlate with markedly elevated D-dimers. Additionally, only 30% of patients who had an ADAMTS13 activity level of less than 43% on admission survived, yet 60% of patients survived who had an ADAMTS13 activity level of greater than 43% on admission. In conclusion, COVID-19 may present with low ADAMTS13 activity in a subset of hospitalized patients. Presence of schistocytes/RBC fragment and elevated D-dimer on admission may warrant a work-up for ADAMTS13 activity and VWF antigen and activity levels. These findings indicate the need for future investigation to study the relationship between endothelial and coagulation activation and the efficacy of treatments aimed at prevention and/or amelioration of microangiopathy in COVID-19.

Using Automated Machine Learning to Predict the Mortality of Patients With COVID-19: Prediction Model Development Study

BACKGROUND

During a pandemic, it is important for clinicians to stratify patients and decide who receives limited medical resources. Machine learning models have been proposed to accurately predict COVID-19 disease severity. Previous studies have typically tested only one machine learning algorithm and limited performance evaluation to area under the curve analysis. To obtain the best results possible, it may be important to test different machine learning algorithms to find the best prediction model.

OBJECTIVE

In this study, we aimed to use automated machine learning (autoML) to train various machine learning algorithms. We selected the model that best predicted patients' chances of surviving a SARS-CoV-2 infection. In addition, we identified which variables (ie, vital signs, biomarkers, comorbidities, etc) were the most influential in generating an accurate model.

METHODS

Data were retrospectively collected from all patients who tested positive for COVID-19 at our institution between March 1 and July 3, 2020. We collected 48 variables from each patient within 36 hours before or after the index time (ie, real-time polymerase chain reaction positivity). Patients were followed for 30 days or until death. Patients' data were used to build 20 machine learning models with various algorithms via autoML. The performance of machine learning models was measured by analyzing the area under the precision-recall curve (AUPCR). Subsequently, we established model interpretability via Shapley additive explanation and partial dependence plots to identify and rank variables that drove model predictions. Afterward, we conducted dimensionality reduction to extract the 10 most influential variables. AutoML models were retrained by only using these 10 variables, and the output models were evaluated against the model that used 48 variables.

RESULTS

Data from 4313 patients were used to develop the models. The best model that was generated by using autoML and 48 variables was the stacked ensemble model (AUPRC=0.807). The two best independent models were the gradient boost machine and extreme gradient boost models, which had an AUPRC of 0.803 and 0.793, respectively. The deep learning model (AUPRC=0.73) was substantially inferior to the other models. The 10 most influential variables for generating high-performing models were systolic and diastolic blood pressure, age, pulse oximetry level, blood urea nitrogen level, lactate dehydrogenase level, D-dimer level, troponin level, respiratory rate, and Charlson comorbidity score. After the autoML models were retrained with these 10 variables, the stacked ensemble model still had the best performance (AUPRC=0.791).

CONCLUSIONS

We used autoML to develop high-performing models that predicted the survival of patients with COVID-19. In addition, we identified important variables that correlated with mortality. This is proof of concept that autoML is an efficient, effective, and informative method for generating machine learning-based clinical decision support tools.

Correlation of Coagulation Parameters With Clinical Outcomes During the Coronavirus-19 Surge in New York: Observational Cohort

Importance

COVID-19 has caused a worldwide illness and New York became the epicenter of COVID-19 in the United States from Mid-March to May 2020.

Objective

To investigate the coagulopathic presentation of COVID and its natural course during the early stages of the COVID-19 surge in New York. To investigate whether hematologic and coagulation parameters can be used to assess illness severity and death.

Design

Retrospective case study of positive COVID inpatients between March 20, 2020-March 31, 2020.

Setting

Montefiore Health System main hospital, Moses, a large tertiary care center in the Bronx.

Participants

Adult inpatients with positive COVID tests hospitalized at MHS.

Exposure (for observational studies)

Datasets of participants were queried for demographic (age, sex, socioeconomic status, and self-reported race and/or ethnicity), clinical and laboratory data.

Main Outcome and Measures

Relationship and predictive value of measured parameters to mortality and illness severity.

Results

Of the 225 in this case review, 75 died during hospitalization while 150 were discharged home. Only the admission PT, absolute neutrophil count (ANC) and first D-Dimer could significantly differentiate those who were discharged alive and those who died. Logistic regression analysis shows increased odds ratio for mortality by first D-Dimer within 48 hrs. of admission. The optimal cut-point for the initial D-Dimer to predict mortality was found to be 2.1 μg/mL. 15% of discharged patients required readmission and more than a third of readmitted patients died (5% of all initially discharged).

Conclusion

We describe here a comprehensive assessment of hematologic and coagulation parameters in COVID-19 and examine the relationship of these to mortality. We demonstrate that both initial and maximum D-Dimer values are biomarkers that can be used for survival assessments. Furthermore, D-Dimer may be useful to follow up discharged patients.

Treatment of severe COVID-19 with convalescent plasma in Bronx, NYC

Convalescent plasma with severe acute respiratory disease coronavirus 2 (SARS-CoV-2) antibodies (CCP) may hold promise as a treatment for coronavirus disease 2019 (COVID-19). We compared the mortality and clinical outcome of patients with COVID-19 who received 200 mL of CCP with a spike protein IgG titer ≥ 1:2430 (median 1:47,385) within 72 hours of admission with propensity score-matched controls cared for at a medical center in the Bronx, between April 13 and May 4, 2020. Matching criteria for controls were age, sex, body mass index, race, ethnicity, comorbidities, week of admission, oxygen requirement, D-dimer, lymphocyte counts, corticosteroid use, and anticoagulation use. There was no difference in mortality or oxygenation between CCP recipients and controls at day 28. When stratified by age, compared with matched controls, CCP recipients less than 65 years had 4-fold lower risk of mortality and 4-fold lower risk of deterioration in oxygenation or mortality at day 28. For CCP recipients, pretransfusion spike protein IgG, IgM, and IgA titers were associated with mortality at day 28 in univariate analyses. No adverse effects of CCP were observed. Our results suggest CCP may be beneficial for hospitalized patients less than 65 years, but data from controlled trials are needed to validate this finding and establish the effect of aging on CCP efficacy.

Mater Artium Necessitas: The Birth of a COVID-19 Command Center

In February of 2020, New York City was unprepared for the COVID-19 pandemic. Cases of SARS-CoV-2 infection appeared and spread rapidly. Hospitals had to repurpose staff and establish diagnostic testing for this new viral infection. In the background of the usual respiratory pathogen testing performed in the clinical laboratory, SARS-CoV-2 testing at the Montefiore Medical System grew exponentially, from none to hundreds per day within the first week of testing. The job of appropriately routing SARS-CoV-2 viral specimens became overwhelming. Additional staff was required to triage these specimens to multiple in-house testing platforms as well as external reference laboratories. Since medical school classes and many research laboratories shut down at the Albert Einstein College of Medicine and students were eager to help fight the pandemic, we seized the opportunity to engage and train senior MD-PhD students to assist in triaging specimens. This volunteer force enabled us to establish the "Pathology Command Center," staffed by these students as well as residents and furloughed dental associates. The Pathology Command Center staff were tasked with the accessioning and routing of specimens, answering questions from clinical teams, and updating ever evolving protocols developed in collaboration with a team of Infectious Disease clinicians. Many lessons were learned during this process, including how best to restructure an accessioning department and how to properly onboard students and repurpose staff while establishing safeguards for their well-being during these unprecedented times. In this article, we share some of our challenges, successes, and what we ultimately learned as an organization.

Treatment of Severe COVID-19 with Convalescent Plasma in the Bronx, NYC

Convalescent plasma with severe acute respiratory disease coronavirus 2 (SARS-CoV-2) antibodies (CCP) may hold promise as treatment for Coronavirus Disease 2019 (COVID-19). We compared the mortality and clinical outcome of patients with COVID-19 who received 200mL of CCP with a Spike protein IgG titer ≥1:2,430 (median 1:47,385) within 72 hours of admission to propensity score-matched controls cared for at a medical center in the Bronx, between April 13 to May 4, 2020. Matching criteria for controls were age, sex, body mass index, race, ethnicity, comorbidities, week of admission, oxygen requirement, D-dimer, lymphocyte counts, corticosteroids, and anticoagulation use. There was no difference in mortality or oxygenation between CCP recipients and controls at day 28. When stratified by age, compared to matched controls, CCP recipients <65 years had 4-fold lower mortality and 4-fold lower deterioration in oxygenation or mortality at day 28. For CCP recipients, pre-transfusion Spike protein IgG, IgM and IgA titers were associated with mortality at day 28 in univariate analyses. No adverse effects of CCP were observed. Our results suggest CCP may be beneficial for hospitalized patients <65 years, but data from controlled trials is needed to validate this finding and establish the effect of ageing on CCP efficacy.

Coagulation Testing Gone Awry; Effect of Direct Oral Anticoagulant (DOAC) Removal on Lupus Anticoagulant Assays

Background

Direct oral anticoagulants (DOACs) such as apixaban and rivaroxaban are widely used to treat those with or at risk for thromboembolic disease. However, DOACs have been shown to interfere with coagulation assays making their interpretations challenging. Importantly, lupus anticoagulant (LA) assays using the dilute Russell Viper Venom Time (dRVVT) to screen for patients at increased risk of thrombosis are particularly affected by DOACs leading to inaccurate results. DOAC removal agents are available to improve dRVVT specificity for LA and eliminate assay interferences.

Aims

To evaluate the performance of DOAC-Remove to accurately measure LA in patient plasma.

Methods

10 LA positive and 10 LA negative samples without DOAC as well as normal pool plasma (NPP) were used as controls. We assessed 64 patient plasma samples including 39 patients on apixaban and 25 patients on rivaroxaban (anticoagulation was confirmed by chart review). LA testing by dRVVT was performed using Staclot® DRVV Screen and Staclot® DRVV Confirm reagents on STA R Max analyzer. DRVVT testing was performed before and after DOAC removal (DOAC-Remove, Aniara). DOAC plasma concentrations were measured using STA Liquid Anti-Xa assay. Acceptable DOAC removal was defined as an anti Xa level &lt;0.03 IU/mL. Positive LA was defined as a screen ratio and mix ratio greater than 1.15.

Results

Positive and negative samples without DOAC remained the same after DOAC removal treatment. Factor levels in NPP were not affected by DOAC removal treatment. DOAC removal resulted in shortening of the dRVVT in 91% of the samples. Surprisingly, 6 cases showed prolongation in the dRVVT after DOAC removal. Before DOAC removal, 47 cases (24 apixaban and 23 rivaroxaban) tested positive and 17 tested negative (15 apixaban and 2 rivaroxaban). Following DOAC removal, 28 cases tested positive and 36 tested negative. As expected, many samples of patients on DOAC were found to be falsely positive (27/64; 15 on apixaban and 12 on rivaroxaban). Interestingly, 8 of 64 tests were found to be falsely negative. Of the 8 samples that were falsely negative, 7 were on apixaban and 1 on rivaroxaban. 9 samples that were negative before DOAC removal remained negative after DOAC removal, and 20 tests that were positive before DOAC removal remained positive after DOAC removal for a total of 29 results (45%) that remained unchanged. It was found that DOACs caused inaccurate results in 55% of cases.

Conclusions

Our study was able to demonstrate the effectiveness of DOAC-Remove to eliminate DOACs from patient plasma and provide accurate LA results. DOAC interference on LA assays predictably creates many false positive results, however, presence of DOACs can produce false negative results as well, underlying the importance of pretest screening for presence of anticoagulants in plasma samples.

Evidence for Age-Adjusted D-Dimer to Rule out Pulmonary Embolism: An Institutional Study

The diagnostic approach for ruling out suspected acute pulmonary embolism (PE) in the ED setting includes several tests: ultrasound, plasma d-dimer assays, ventilation-perfusion scans and computed tomography pulmonary angiography (CTPA). Importantly, a pretest probability scoring algorithm is highly recommended to triage high risk cases while also preventing unnecessary testing and harm to low/moderate risk patients. The d-dimer assay (both ELISA and immunoturbidometric) has been shown to be extremely sensitive to rule out PE in conjunction with clinical probability. In particularly, d-dimer testing is recommended for low/moderate risk patients, in whom a negative d-dimer essentially rules out PE sparing these patients from CTPA radiation exposure, longer hospital stay and anticoagulation. However, an unspecific increase in fibrin-degradation related products has been seen with increase in age, resulting in higher false positive rate in the older population. This study analyzed patient visits to the ED of a large academic institution for five years and looked at the relationship between d-dimer values, age and CTPA results to better understand the value of age-adjusted d-dimer cut-offs in ruling out PE in the older population. A total of 7660 ED visits had a CTPA done to rule out PE; out of which 1875 cases had a d-dimer done in conjunction with the CT and 5875 had only CTPA done. Out of the 1875 cases, 1591 had positive d-dimer results (&gt;0.50 µg/ml (FEU)), of which 910 (57%) were from patients older than or equal to fifty years of age. In these older patients, 779 (86%) had a negative CT result. The following were the statistical measures of the d-dimer test before adjusting for age: sensitivity (98%), specificity (12%); negative predictive value (98%) and false positive rate (88%). After adjusting for age in people older than 50 years (d-dimer cut off = age/100), 138 patients eventually turned out to be d-dimer negative and every case but four had a CT result that was also negative for a PE. The four cases included two non-diagnostic results and two with subacute/chronic/subsegmental PE on imaging. None of these four patients were prescribed anticoagulation. The statistical measures of the d-dimer test after adjusting for age showed: sensitivity (96%), specificity (20%); negative predictive value (98%) and a decrease in the false positive rate (80%). Therefore, imaging could have been potentially avoided in 138/779 (18%) of the patients who were part of this older population and had eventual negative or not clinically significant findings on CTPA if age-adjusted d-dimers were used. This data very strongly advocates for the clinical usefulness of an age-adjusted cut-off of d-dimer to rule out PE.

Pregnancy-Related RBC Alloimmunization in Sickle Cell Trait Patients; A Single-Center Experience

Background

Sickle Cell Disease (SCD) is an autosomal recessive disorder, which results from a point mutation in the β-globin gene. The production of mutant Hb S (V6E) leads to hemolytic anemia and numerous clinical complications. Patients homozygous for HbS gene (SS) typically rely on life-long transfusion therapy. Alloimmunization to foreign RBC antigens in multiply transfused patients is significantly more frequent in SS patients (observed in 7–47%) compared to patients with HbA (AA), and can pose a significant hurdle in finding compatible RBCs. However, the mechanism for enhanced alloimmunization in SS patients has not yet been elucidated. Patients heterozygous for HbS (SA) have a no distinct clinical phenotype and do not typically require transfusions. We investigated the rate of RBC antigen alloimmunization and specificity in SA patients.

Aim

The aim of this study was to determine and compare the rate and specificities of RBC antigen pregnancy-related alloimmunization in SA and AA patients.

Methods

In our retrospective study, we identified females who delivered a newborn between January 2014 to October 2019, for whom prenatal hemoglobin electrophoresis testing, and prenatal and perinatal antibody screening and identification was performed. R (V.3.6.2) statistical computing program was used for analysis.

Results

A total of 41735 subjects were identified: 40058 (AA) and 1677 (SA). African Americans were more prevalent in the SA compared to the AA group (55.8% vs 29.4%, P&lt;0.01)and were more likely to have received ≥ 1 transfusion during pregnancy (4.5% vs 3.3%, P&lt;0.01). A total number of 267 alloantibodies were detected in 246 patients (0.6% of the studied population) during pregnancy, 228 patients (0.6%) in the AA group and 18 patients (1.1%) in the SA group.229/246 (93%) of patients with antibodies did not receive transfusion during pregnancy, and thus antibodies were considered to represent pregnancy-related alloimmunization. In non-transfused subjects the SA group were more likely to have developed alloantibodies in pregnancy compared to the AA group [OR= 1.94, P=0.015]. The median age of patients with antibodies in the SA was older [33.5 vs 27 (p=0.008)] as compared to those in the AA group [29 vs 27 (p=0.002)].

The most common antibody identified was anti-E (SA 42% vs AA 28%), anti-Lea (SA 21% vs AA 13%) and anti-C (SA 5% vs AA 12%). Subjects with pre-existing alloantibodies had a 5.4x increased risk of forming a new allo-antibody. However only 0.1% of subjects had a history of prior allo-antibodies, with no significant difference identified between AA and SA.

Conclusions

SA patients were found to have an increased rate of pregnancy-related alloimmunization (OR 1.75, P=0.02) after adjusting for the effects of increasing age, RH type, ethnicity, number of previously existing antibodies and number of transfusions in pregnancy.

Neutrophilic Extracellular Traps (NETs); A Subset of Smudge Cells Identifiable by Peripheral Smear Autoanalyzers in the Rising Era of Artificial Intelligence

Background

Digitized microscopy such as CellaVision® technology has revolutionized the laboratory. Smudge cells, also called basket cells, are usually seen in lymphoproliferative disorders representing remnants from degenerated lymphocytes (DLs). CellaVision® classifies DLs and web-like remnants as smudge cells. The morphology of the web-like remnants is compatible with Neutrophil Extracellular Traps (NETs) where extracellular decondensed DNA chromatin network is formed as one of several neutrophilic reactions to stress. Currently, we lack clinical tests that reliably identify and quantify NETs.

Aims

To develop an in-vitro model for NETs formation in blood, create a library of their morphological changes at different maturation stages; correlate their presence to infections in absence of leukocytosis and develop an artificial intelligence platform (AI-Heme-1) for their detection.

Methods

A library was built to develop AI-Heme-1 where NETs were induced with classic triggers (phorbol-myristate-acetate, lipopolysaccharide and ionomycin) in EDTA whole blood from normal subjects. Smears were prepared at 30 minutes intervals for 24 hours to identify NETs by Immunofluorescence and immunohistochemistry. WBC differentials were performed by CellaVision® to capture different stages of NETs. AI-Heme-1 was modified from Python online convolutional neural network.

For the clinical correlation, smears with &gt;20% smudge cells were classified morphologically as NETs vs. DLs compared to a control group, &lt; 5% smudge cells. We used morphologic characteristics, immunohistochemistry, immunofluorescence and flow cytometry to differentiate NETs from DLs. Medical chart review performed by blinded investigators, included patient demographics, CBC and presence of microbial infection occurring &lt; 1 week of sample collection. Statistical analyses included two sided t-test and chi square.

Results

The classical triggers for Netosis showed consistent morphological changes following a canonical order: vacuolation, nuclear decondensation, degranulation and chromatin ejection. These cell remnants were positive for citrullinated histones, myeloperoxidase, leukocyte alkaline phosphatase and neutrophil elastase by immunofluorescence. On Wright Giemsa stain, web-like remnants resembling NETs stained for SytoxGreen. On flow cytometry, NETs were large with extracellular DNA and MPO.

For the clinical study group of &gt;20% smudge cells, 88 were morphologically designated as NETs, 8 as DL vs. 59 as control group. A random sampling from &gt;20% smudge cells showed cases with NET subclassification stained strongly with myeloperoxidase, neutrophil elastase and SytoxGreen while DLs were negative. Comparing patients with &gt;20% smudge and NET sub-classification to &lt;5% smudge cells, the formers had higher incidence of bacterial and viral infections (p=0.009/0.005 and p=0.008/0.007).

Conclusions

Our study was able to identify NETs on peripheral smears performed by a routine Hematology Autoanalyzer using a reliable set of morphologic characteristics, immunohistochemical stains and flow cytometry. It supports data that associate NETs with infections in the absence of leukocytosis. AI-Heme-1 was able to identify NETs on blood smears. This approach can provide a rapid, early and accurate tool to screen patients with infections.

Evidence for secondary thrombotic microangiopathy in COVID-19

The causes of coagulopathy associated with COVID-19 disease are poorly understood. We aimed to investigate the relationship between markers of endothelial activation, intravascular hemolysis, coagulation, and organ damage in COVID-19 patients and study their association with disease severity and mortality. We conducted a retrospective study of 181 hospitalized COVID-19 patients randomly selected with equal distribution of survivors and non-survivors. Patients who died had significantly lower ADAMTS13 activity, significantly higher LDH, schistocytes and von Willebrand Factor levels compared to patients discharged alive. Only 30% of patients with an initial ADAMTS13 activity <43% survived vs. 60% with ADAMTS13 ≥43% who survived. In conclusion, COVID-19 may manifest as a TMA-like illness in a subset of hospitalized patients. Presence of schistocytes on admission may warrant a work-up for TMA. These findings indicate the need for future investigation to study the relationship between endothelial and coagulation activation and the efficacy of TMA treatments in COVID-19.

The association of race and COVID-19 mortality

BACKGROUND

COVID-19 mortality disproportionately affects the Black population in the United States (US). To explore this association a cohort study was undertaken.

METHODS

We assembled a cohort of 505,992 patients receiving ambulatory care at Bronx Montefiore Health System (BMHS) between 1/1/18 and 1/1/20 to evaluate the relative risk of hospitalization and death in two time-periods, the pre-COVID time-period (1/1/20-2/15/20) and COVID time-period (3/1/20-4/15/20). COVID testing, hospitalization and mortality were determined with the Black and Hispanic patient population compared separately to the White population using logistic modeling. Evaluation of the interaction of pre-COVID and COVID time periods and race, with respect to mortality was completed.

FINDINGS

A total of 9,286/505,992 (1.8%) patients were hospitalized during either or both pre-COVID or COVID periods. Compared to Whites the relative risk of hospitalization of Black patients did not increase in the COVID period (p for interaction=0.12). In the pre- COVID period, compared to Whites, the odds of death for Blacks and Hispanics adjusted for comorbidity was statistically equivalent. In the COVID period compared to Whites the adjusted odds of death for Blacks was 1.6 (95% CI 1.2-2.0, p = 0.001). There was a significant increase in Black mortality risk from pre-COVID to COVID periods (p for interaction=0.02). Adjustment for relevant clinical and social indices attenuated but did not fully explain the observed difference in Black mortality.

INTERPRETATION

The BMHS COVID experience demonstrates that Blacks do have a higher mortality with COVID incompletely explained by age, multiple reported comorbidities and available metrics of sociodemographic disparity.

FUNDING

N/A.

Hemoglobin F or: How I Learned to Stop Wondering and Love the Flow Cytometer

Sickle cell disease (SCD) is the most common inherited blood disorder in the United States. It is a hemoglobinopathy that leads to red blood cell (RBC) sickling and a broad range of disease complications including vaso-occlusive crisis, acute chest syndrome, and retinopathy. Hydroxyurea, a drug used to treat SCD, is known to increase expression of hemoglobin F (HbF), a type of hemoglobin normally expressed in infancy; HbF levels between 10% and 20% are associated with decreased vaso-occlusive episodes and improved survival. Hereditary persistent hemoglobin F (HPHF), a typically asymptomatic hemoglobinopathy associated with sustained hemoglobin F (HbF) expression into adulthood (HbF >10%), in combination with SCD is associated with decreased complications. Laboratories typically determine the HbF level via high-performance liquid chromatography (HPLC). HbF levels approaching 30% on HPLC are thought to be protective against SCD complications. However, HbF may be found within a majority or minority of RBCs, pancellular (deletional HPHF) or heterocellular distribution (nondeletional HPHF), respectively. Additionally, the quantity of HbF within cells can range from low (<10 picograms/cell) to high (>35 picograms). We sought to determine the quantity and distribution of HbF required to protect against sickle cell disease symptoms both via traditional HPLC as well as flow cytometry. This retrospective study was conducted at a large academic medical center over a period of 2 months (January-February 2019). We collected blood from sickle cell patients that had a detectable HbF level on hemoglobin electrophoresis. We then stained RBCs from 16 of the patients for HbF and performed flow cytometry to examine the HbF distribution. We calculated the cellular concentration of HbF within each HbF+ cell using the formula (MHC × %HbF)/%F-cells. We performed a chart review to determine the native hemoglobin type, exposure to hydroxyurea, and clinical symptoms of sickle cell disease. We identified four patients over the age of 20 with HbS/HPHP and no exposure to hydroxyurea. Two of these patients experienced no sickle cell disease complications; the protected patients had heterocellular distribution of HbF, but had a high concentration of HbF per HbF+ cell (>35 picograms/cell). Notably, these asymptomatic patients both had HbF level by HPLC less than 30. One of the symptomatic HbS/HPHF patients had heterocellular expression of HbF with low cellular concentration (28 picograms/cell) while the other patient had pancellular HbF expression with very low cellular concentration (6.4 picograms/cell). Our study demonstrates that HPHF alone does not prevent sickle cell disease complications. Our study highlights the importance of quantifying the cellular concentration of HbF, which can provide useful information beyond that of HPLC. In addition, our study raises the potential of the clinical use of hydroxyurea in patients with sickle cell disease even in the presence of HPHF.

Anemia in Hidradenitis Suppurativa, Hepcidin as a Diagnostic Tool

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent nodules, abscesses, and dermal tracts. We recently reported a high prevalence of anemia in HS patients. These data led to the hypothesis that chronic inflammation in HS predominantly causes anemia of chronic disease (ACD) through upregulation of IL-6 and hepcidin, a key regulator of iron homeostasis. Hepcidin is widely accepted as a marker distinguishing ACD from iron deficiency anemia (IDA) in inflammatory conditions. The purpose of this study was to measure serum hepcidin in HS patients to classify the type of anemia observed in this cohort. We measured hematologic data, inflammatory markers, and serum hepcidin using an enzyme-linked immunosorbent assay (ELISA; R&D Systems) in 55 patients with varying degrees of HS severity. Independent Student t tests and one-way ANOVA were used to compare hepcidin levels in HS patients with anemic and nonanemic states. Of 55 HS patients evaluated in this study, 42 (76%) were female and the average age was 37.6 ± 13.2 years. The mean hemoglobin (Hb) was 12.2 ± 2.0 g/dL and mean hepcidin was 19.5 ± 12.9 ng/mL. Anemic patients (n = 26) with reduced iron stores (ferritin ≤30 ng/mL) had significantly lower hepcidin than anemic patients with adequate iron stores (9.7 ± 15.8 ng/mL vs 23.8 ± 11.1, P = .03). Elevated hepcidin in this subset suggests that ACD is the predominant cause of anemia. Analysis by ANOVA also found that hepcidin levels were significantly greater in patients with more severe HS, as measured by HS-Physician Global Assessment scores (P = .005). Hepcidin may serve as a surrogate biomarker for active disease and inflammation in HS. These findings affirm the utility of hepcidin as a promising tool for distinguishing IDA from ACD and, in turn, help identify HS patients in whom dietary iron supplementation is unlikely to be beneficial.

A Center-Wide Study of D-Dimer Testing for Pulmonary Embolism in the ED Setting

Pulmonary embolism (PE) is a life-threatening condition associated with a very high mortality. While its diagnosis remains challenging, the use of diagnostic tests has increased tremendously. There are many different guidelines used to work up suspected PE. The Wells and/or Geneva scores are used to estimate the pretest probability (PTP) of PE before any complementary testing is done. While a CT pulmonary angiography (CTPA) should not be performed in individuals with a low/intermediate PTP and a negative D-dimer (DD), some data suggest that up to 55% of patients with low PTP undergo a CTPA, even though they might not have had a DD or had a negative DD. As such, in this study, we wanted to evaluate the use of DD in our emergency department (ED). A pilot study was conducted using an interactive software developed in-house for the evaluation of health care quality, efficiency, and effectiveness. The EMR database (EPIC) we use consists of laboratory, clinical, pathological, and radiological reports, allowing us to use different search criteria and to outline cutoff values for continuous and categorical variables while permitting us to define a timeframe for the different observations. We looked at all ED visits in the period from 2014 to 2018 in which CTPAs were done for suspected PE. A total of 8,873 ED visits from 2014 to 2018 had a CTPA done for suspected PE. Of these, 6,117 cases had no DD done and 1,812 had a DD done along with CTPA. The high percent of visits with imaging done without a DD (69%) is justified if these are all cases with a high PTP (DD not indicated). If this assumption was true, then we expected a high percent of positive confirmation of PE by imaging. However, only 11% of these cases showed positive findings of PE. This rate is similar to published studies in many US hospitals that demonstrate overuse of CT owing to a lack of using the PTP-based approach. On the other hand, a vast majority of cases in our study with normal DD (<0.5 μg/L) had negative CT results (98%). Interestingly, all four cases that had positive PE findings by CT despite a negative DD (2%) were women (three below the age of 62 with chronic and/or subsegmental PE and one 47-year-old with a DD = 0.49 μg/L). This finding calls for consideration of age and possibly gender-based DD reference ranges. Lastly, while CTPA is considered the gold standard for PE diagnosis, it has limitations: cost, increased length of stay, unnecessary exposure of radiation, contrast, and unnecessary treatment of subsegmental PE. Therefore, an approach using PTP and using DD appropriately is warranted in order to prevent patients from being exposed to unnecessary risks and also to reduce costs.

The Magnificent VWF SNPs and Where to Find Them: A Journey in Exon 28 of the Hispanic Population

von Willebrand disease (VWD) is a common coagulation disorder with a prevalence of 0.1% to 1.0% manifesting as a wide spectrum of bleeding symptoms. Type 1 is diagnosed by confirming a quantitative decrease in VWF level, while type 3 has undetectable levels of VWF. Type 2 VWD variants are characterized by functional and binding defects. Initial diagnosis and follow-up depend mainly on measuring VWF protein and VWF activity and calculating the activity to protein ratio. Ristocetin cofactor activity (VWF:RCo) is the most widely used and gold standard activity assay. In our institute, we use a cutoff of VWF:RCo/VWF:Ag <0.7 to screen for possible type 2 VWD. However, the use of this ratio is flawed by the presence of specific SNPs (I1380V, N1435S, and D1472H) in the A1 domain, especially in African Americans. These SNPs lead to a decrease in ristocetin binding to VWF and hence decreased VWF:RCo/VWF:Ag ratio. In this retrospective study, we analyzed the levels of VWF:AG and VWF:RCo based on patients’ ethnicity using an in-house data mining software from 2011 to 2016. Then, we validated several exon 28 primers, kindly provided by Dr. Montgomery (Blood Center of Wisconsin), used to detect type 2 mutations and SNPs in African Americans. We excluded cases diagnosed as positive for VWD and included only cases rendered nondiagnostic of VWD following a comprehensive panel including multimers, collagen binding, and molecular studies when indicated. In our Hispanic population (n = 936), VWF:Ag was 138.9% and 117% (average and median) and VWF:RCo was 110.5% and 93.0% (average and median); 43.2% of Hispanics had VWF:RCo/VWF:Ag <0.7. In our African American population (n = 664), VWF:Ag was 163.0% and 138.5% (average and median) and VWF:RCo was 108.5% and 92.0% (average and median); 50.6% of the African American patients had VWF:RCo/VWF:Ag <0.7. Patients from Caucasian origins (n = 242) had VWF:Ag of 149.6% and 113.0% (average and median) and VWF:RCo of 137.6% and 116.0% (average and median), respectively; 30.9% of Caucasian patients had VWF:RCo/VWF:Ag of less than 0.7. We then selected four random Hispanic cases with VWF:RCo/VWF:Ag <0.5 as part of the validation study of exon 28 sequencing. Using a Sanger sequence assay, we found multiple benign/likely benign single-nucleotide polymorphisms (SNPs) at exon 28 that code for VWF antigen A1 domain. All four cases showed P.Thr1381Ala and P.Thr1547 = [OC1] polymorphism, three showed p.Val1565Leu polymorphism, and two showed p.Ala1555 = polymorphism. The statistical analysis of VWF:Ag/VWF:RCo levels from Hispanics shows a similar trend to African Americans with a high rate of cases with VWF:RCo/VWF:Ag <0.7 in comparison to Caucasians. However, the finding of SNPs and absence of known African American polymorphisms suggest that these SNPs may be the cause of decreased ristocetin binding in Hispanics. This study calls for ethnic-based considerations in VWD workflows.

Hemolysis and Nonhemorrhagic Stroke During Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Hemolysis, even at low levels, activates platelets to create a prothrombotic state and is common during mechanical circulatory support. We examined the association of low-level hemolysis (LLH) and nonhemorrhagic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support.

METHODS

A single-center retrospective review of all adult patients placed on VA ECMO from January 2012 to September 2017 was conducted. To determine the association between LLH and nonhemorrhagic stroke, patients were categorized as those with and without LLH. LLH was defined by 48-hour plasma free hemoglobin (PFHb) of 11 to 50 mg/dL after VA ECMO implantation.

RESULTS

Of 201 patients who underwent VA ECMO placement, 150 (75%) met inclusion criteria and comprised the study population. They were 55 ± 14 years of age and 50 (33%) were women. Sixty-two (41%) patients had LLH. Patients with LLH had a higher likelihood of incident nonhemorrhagic stroke during VA ECMO support (20 [32%] versus 4 [5%]; adjusted hazard ratio [HR], 7.6; 95% confidence interval [CI], 2.2 to 25.9; p = 0.001). The severity of LLH was associated with an incrementally higher likelihood of a nonhemorrhagic stroke (PFHb 26 to 50 mg/dL: HR, 11.3; 95% CI, 3.6 to 35.1; p = 0.001; PFHb 11 to 25 mg/dL: HR, 4.4; 95% CI, 1.36 to 14.85; p = 0.014) in comparison with no LLH. Those with LLH had a 2-fold greater increase in mean platelet volume after VA ECMO placement (0.98 ± 1.1 fL versus 0.49 ± 0.96 fL; p = 0.03). Patients with a nonhemorrhagic stroke had a higher operative mortality (20 [83%] versus 57 [45%]; adjusted HR, 3.1; 95% CI, 1.8 to 5.3; p < 0.001).

CONCLUSIONS

Hemolysis at low levels during VA ECMO support is associated with subsequent nonhemorrhagic stroke.

Sildenafil Is Associated With Reduced Device Thrombosis and Ischemic Stroke Despite Low-Level Hemolysis on Heart Mate II Support

Background:

Persistent low-level hemolysis (LLH) during continuous-flow mechanical circulatory support is associated with subsequent thrombosis. Free hemoglobin from ongoing hemolysis scavenges nitric oxide (NO) to create an NO deficiency which can augment platelet function leading to a prothrombotic state. The phosphodiesterase-5 inhibitor, sildenafil, potentiates NO signaling to inhibit platelet function. Accordingly, we investigated the association of sildenafil administration and thrombotic events in patients with LLH during Heart Mate II support.

Methods and Results:

A single-center review of all patients implanted with a Heart Mate II who survived to discharge (n=144). LLH was defined by a discharge lactate dehydrogenase level of 400 to 700 U/L. Patients were categorized as (1) LLH not on sildenafil, (2) LLH on sildenafil, (3) no LLH not on sildenafil, and (4) no LLH on sildenafil. Age, sex, platelet count, and mean platelet volume were similar between groups. Seventeen patients had either device thrombosis or ischemic stroke. Presence of LLH was associated with a greater risk of thrombosis (adjusted hazard ratio, 15; 95% confidence interval, 4.5–50; P <0.001 versus no LLH, not on sildenafil). This risk was reduced in patients with LLH on sildenafil (adjusted hazard ratio, 1.7; 95% confidence interval, 0.2–16.1; P =0.61). Device thrombosis and ischemic stroke were associated with an increase in mean platelet volume (9.6±0.5 to 10.9±0.8 fL, P <0.001). Patients with LLH not on sildenafil had a greater increase in mean platelet volume in comparison to those with LLH on sildenafil ( P <0.001).

Conclusions:

Sildenafil is associated with reduced device thrombosis and ischemic stroke during ongoing LLH on Heart Mate II support.

Using Artificial Intelligence to Reduce the Risk of Nonadherence in Patients on Anticoagulation Therapy

BACKGROUND AND PURPOSE

This study evaluated the use of an artificial intelligence platform on mobile devices in measuring and increasing medication adherence in stroke patients on anticoagulation therapy. The introduction of direct oral anticoagulants, while reducing the need for monitoring, have also placed pressure on patients to self-manage. Suboptimal adherence goes undetected as routine laboratory tests are not reliable indicators of adherence, placing patients at increased risk of stroke and bleeding.

METHODS

A randomized, parallel-group, 12-week study was conducted in adults (n=28) with recently diagnosed ischemic stroke receiving any anticoagulation. Patients were randomized to daily monitoring by the artificial intelligence platform (intervention) or to no daily monitoring (control). The artificial intelligence application visually identified the patient, the medication, and the confirmed ingestion. Adherence was measured by pill counts and plasma sampling in both groups.

RESULTS

For all patients (n=28), mean (SD) age was 57 years (13.2 years) and 53.6% were women. Mean (SD) cumulative adherence based on the artificial intelligence platform was 90.5% (7.5%). Plasma drug concentration levels indicated that adherence was 100% (15 of 15) and 50% (6 of 12) in the intervention and control groups, respectively.

CONCLUSIONS

Patients, some with little experience using a smartphone, successfully used the technology and demonstrated a 50% improvement in adherence based on plasma drug concentration levels. For patients receiving direct oral anticoagulants, absolute improvement increased to 67%. Real-time monitoring has the potential to increase adherence and change behavior, particularly in patients on direct oral anticoagulant therapy.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02599259.

[Strabismus and congenital cataracts]

PURPOSE

To study the prevalence, characteristics, indications for and results of strabismus treatment secondary to congenital cataracts.

MATERIALS AND METHODS

This was a retrospective study of 21 cases from 29 with congenital cataracts with strabismus (unilateral in 11 and bilateral in 10 cases). In 20 patients surgery on the cataracts was performed, with an intraocular lens inserted in 15 patients. Botulinum toxin and/or strabismus surgery were deemed to be indicated when the deviation was stable after rehabilitation therapy. A good motor end result was considered when the final deviation was < or =5 degrees, and a good sensorial result was when there was no suppression in the Worth test even without stereopsis in the TNO test.

RESULTS

The strabismus prevalence was 72.4%. Strabismus was present before cataract surgery was performed in 12 cases, 8 with esotropia (ET) and 4 with exotropia (XT). Strabismus which appeared after cataract surgery was classified as 13 ET, 5 XT, 1 ET with vertical anisotropia in <<V>>, and 2 XT with dissociated vertical deviation (DVD). The strabismus angle was variable in 6 patients and was not treated. The other 6 cases required strabismus treatment. Botulinum toxin was injected as the only treatment in 1 patient, strabismus surgery was performed in 4, and strabismus surgery and botulinum toxin were used in another case. The average age at the time of treatment was 5.2 years. The motor result was good in 5 cases (83.3%) and the sensorial result good in two (33.3%).

CONCLUSIONS

Strabismus secondary to congenital cataracts occurred in a significant number of patients and increased after cataract extraction. Esotropia occurred twice as often as exotropia. Strabismus surgery was not required in most of the cases. The motor results were better than sensorial results.

[Myocardial revascularization in patients with acute myocardial infarction complicated with shock]

In the last 20 years, the acute myocardial infarction 30 day mortality rate has been reduced significantly, following pharmacological and mechanical reperfusion therapies. Nevertheless, cardiogenic shock complicating acute myocardial infarction remains the leading cause of death because of the extensive ventricular function damage non. Randomized studies were over optimistic reporting markedly lower mortality rates among patients who had undergone revascularization for shock. Further randomised studies showed that the angiographic improvement is not always followed by a significant mortality reduction. However, angiographic study and revascularisation is the treatment of choice. In addition to an early reperfusion, new pharmacological and/or genetic ways to improve the ventricular function have to be found.

Transjugular liver biopsy in 52 patients with an automated Trucut-type needle

A three-year prospective study was conducted to assess the efficacy and safety of transjugular liver biopsy with a Trucut-type needle employing an automated device. Fifty-two consecutive patients (39 women and 13 men), ages 46.3+/-14.6 years, in whom percutaneous liver biopsy was contraindicated were included in the study. An 18-gauge transjugular hepatic needle with a 20-mm throw length, a cutting cannula at the distal end, and an automated trigger device on the proximal end was used. All procedures were performed under fluoroscopic control, and the following variables were assessed: (1) number of passes, (2) size and average number of the obtained fragments, (3) number of portal triads, and (4) adequacy of the specimen for histologic diagnosis. The procedure was successful in 49/52 patients, and all samples obtained were satisfactory for histologic analysis even when cirrhosis or bridging fibrosis were present. Mean biopsy specimen length was 1.7+/-0.88 cm; mean number of passes was 2.42+/-1.01, the mean number of biopsy fragments and portal triads per attempt were 2.5+/-1.01 and 6.24+/-3.18, respectively. No major complications were observed. Transjugular hepatic biopsy with this new cutting system is an effective and safe procedure in patients with contraindication for percutaneous liver biopsy.