Health disparities in hymenoptera venom allergy management.

Background: Hymenoptera venom anaphylaxis (HVA) is reported in up to 3% of stings and accounts for approximately 40 US deaths annually. HVA patients require immediate availability of epinephrine and Allergist referrals for consideration of venom immunotherapy. Data regarding epinephrine autoinjector prescriptions, Allergist referral rates, and potential racial disparities are limited. Objective: The primary objective was to determine if there were statistically significant differences in epinephrine autoinjector prescriptions and Allergist referrals between white and African American patients. The secondary objectives were to determine if there were statistically significant differences between adult and pediatric patients and to determine if there were significant differences between epinephrine prescriptions between patients with and without Allergist referrals. Method: This study is a retrospective, descriptive chart review analyzing patients seen between January 01, 2019 and December 31, 2021. Data were obtained utilizing the Epic Systems (Verona, WI) application Slicer Dicer. Individual chart review was performed for age, race, epinephrine autoinjector prescription, and Allergist referral. Results: 342 patients were identified as having HVA. White patients (60 out of 219; 27.4%) were more likely to get epinephrine autoinjector prescriptions than African American patients (17 out of 109; 15.6%) (p = 0.018). Adult patients (25 out of 314; 8.0%) were less likely than pediatric patients (8 out of 28; 28.6%) to have Allergist referrals (p = 0.004). Patients with Allergist referrals (25 out of 32; 78.1%) were more likely to be prescribed an epinephrine autoinjector than patient without Allergist referrals (54 out of 310; 17.4%) (p < 0.00001). Conclusion: Epinephrine autoinjector prescriptions and Allergist referrals are low overall in HVA. Racial disparities were identified with African American patients being significantly less likely to receive epinephrine autoinjector prescriptions. Additionally, adult patients, who may be at increased risk, were less likely to receive Allergist referrals.

Autologous pericardial aortic valve reconstruction: early results and comparison with mechanical valve replacement.

INTRODUCTION: Autologous pericardial aortic valve reconstruction is an attractive option compared with prosthetic valve replacement due to the absence of anticoagulation, lower pressure gradient across the valve and excellent valve haemodynamics. OBJECTIVE: We wanted to share the early results of autologous pericardial aortic valve reconstruction from our centre. The outcomes were compared with that of mechanical valve replacement. MATERIALS AND METHODS: Between August 2016 to July 2018, 20 patients underwent autologous aortic valve reconstruction as per the techniques described by Ozaki et al. The surgery was done for aortic stenosis or regurgitation or a combination of both. All the surgeries were done by a single experienced surgeon. The results were compared to that of mechanical valve replacement. A comprehensive echocardiographic evaluation was done pre-discharge and at 6 months after surgery. The postoperative echocardiographic parameters that were evaluated include aortic valve pressure gradient, aortic valve orifice area, ejection fraction, left ventricular diameters etc. All the parameters were measured by a single expert. Other perioperative parameters were also evaluated like cardiopulmonary bypass and cross-clamp time, need for anticoagulation etc. Statistical analysis was done using chi-square test/Mann-Whitney U test/independent sample t test. RESULTS: Autologous pericardial aortic valve reconstruction had several favourable results including lower aortic valve pressure gradient, bigger aortic valve orifice area etc. None of the patients required anticoagulation. There were no conversions to prosthetic valve replacement or reinterventions in the follow-up period. CONCLUSION: Autologous pericardial aortic valve reconstruction is a feasible alternative to prosthetic valve replacement with several advantages.

Drowsy Driving Considerations in Non-Commercial Drivers for the Sleep Physician.

ABSTRACT: The sleep physician faces many challenges in the assessment of drowsy driving. The following article reviews current clinical evaluation methods and legal considerations at the state level in the United States.

Variability of cytokine gene expression in intestinal tissue and the impact of normalization with the use of reference genes.

OBJECTIVE: To determine the intra- and inter-subject variability of mucosal cytokine gene expression in rectal biopsies from healthy volunteers and to screen cytokine and chemokine mRNA as potential biomarkers of mucosal inflammation. DESIGN AND METHODS: Rectal biopsies were collected from 8 participants (3 biopsies per participant) and 1 additional participant (10 biopsies). Quantitative reverse transcription polymerase chain reaction (RT-qPCR) was used to quantify IL-1ß, IL-6, IL-12p40, IL-8, IFN-γ, MIP-1α, MIP-1ß, RANTES, and TNF-α gene expression in the rectal tissue. The intra-assay, inter-biopsy and inter-subject variance was measured in the eight participants. Bootstrap re-sampling of the biopsy measurements was performed to determine the accuracy of gene expression data obtained for 10 biopsies obtained from one participant. Cytokines were both non-normalized and normalized using four reference genes (GAPDH, ß-actin, ß2 microglobulin, and CD45). RESULTS: Cytokine measurement accuracy was increased with the number of biopsy samples, per person; four biopsies were typically needed to produce a mean result within a 95% confidence interval of the subject's cytokine level approximately 80% of the time. Intra-assay precision (% geometric standard deviation) ranged between 8.2 and 96.9 with high variance between patients and even between different biopsies from the same patient. Variability was not greatly reduced with the use of reference genes to normalize data. CONCLUSIONS: The number of biopsy samples required to provide an accurate result varied by target although 4 biopsy samples per subject and timepoint, provided for >77% accuracy across all targets tested. Biopsies within the same subjects and between subjects had similar levels of variance while variance within a biopsy (intra-assay) was generally lower. Normalization of inflammatory cytokines against reference genes failed to consistently reduce variance. The accuracy and reliability of mRNA expression of inflammatory cytokines will set a ceiling on the ability of these measures to predict mucosal inflammation. Techniques to reduce variability should be developed within a larger cohort of individuals before normative reference values can be validated.