Personalized approach using wearable technology for early detection of atrial fibrillation in high-risk primary care patients (PATCH-AF): Study protocol for a cluster randomized controlled trial.

BACKGROUND: Atrial fibrillation (AF) is a common cardiac arrhythmia with a lifetime risk of one in 4. Unfortunately, AF often remains undetected, particularly when it is paroxysmal, for which single time-point evaluation is less effective. Recently, unobtrusive cardiac arrhythmia monitoring devices have become available, providing the opportunity to conduct prolonged electrocardiographic (ECG) monitoring in a patient-friendly manner. We hypothesize that applying these devices in at risk patients may improve AF detection, particularly when used during repeated episodes. We therefore aim to evaluate the diagnostic yield of yearly screening for atrial fibrillation when using a wearable device for continuous ECG monitoring for 7 days in primary care patients ≥ 65 years deemed at high-risk of AF (CHA2DS2VASc score ≥3 for men or ≥4 for women) compared with usual care over a study period of 3 years. METHODS: Primary care based, cluster-randomized controlled trial with 10 general practices randomized to the intervention group and 10 general practices randomized to control group. In each group, we aim to enroll 930 patients, ≥65 years and a CHA2DS2VASc score ≥3 for men or ≥ 4 for women. The intervention consists of continuous ECG monitoring for 7 days at start of the study (t = 0), after one (t = 1) and 2 years (t = 2). The control practices will follow usual diagnostic care procedures. RESULTS: Results are expected in 2025. CONCLUSIONS: This study differs from previous randomized controlled trials, as it involves longitudinal screening of a risk-stratified population. In case of a beneficial diagnostic yield, the PATCH-AF study will add to the evidence for AF screening. TRIAL REGISTRATION: The PATCH-AF study is registered at The Netherlands Trial Register (NTR number NL9656).

Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria.

Gonadotropin-releasing hormone analogues (GnRHa) are recommended as initial treatment for adolescents diagnosed with gender dysphoria, providing time to follow gender identity development and consider further treatment wishes without distress caused by unwanted pubertal changes. This has been described as an extended diagnostic phase. However, there are also concerns about the physical, neurocognitive, and psychosocial effects of this treatment. In this retrospective study, we document trajectories after the initiation of GnRHa and explore reasons for extended use and discontinuation of GnRHa. Treatment was considered appropriate in 143 (67%) of the 214 adolescents eligible for GnRHa treatment by virtue of their age/pubertal status, and all started GnRHa (38 transgirls, 105 transboys; median age, 15.0 years [range, 11.1-18.6] and 16.1 years [range, 10.1-17.9]). After a median duration of 0.8 years (0.3-3.8) on GnRHa, 125 (87%) started gender-affirming hormones (GAH). Nine (6%) discontinued GnRHa, five of whom no longer wished gender-affirming treatment. Thirteen had used GnRHa for longer than required by protocol for reasons other than logistics and regularly met with a mental health professional during this time, supporting the use of GnRHa treatment as an extended diagnostic phase. In conclusion, the vast majority who started GnRHa proceeded to GAH, possibly due to eligibility criteria that select those highly likely to pursue further gender-affirming treatment. Due to the observational character of the study, it is not possible to say if GnRHa treatment itself influenced the outcome. Few individuals discontinued GnRHa, and only 3.5% no longer wished gender-affirming treatment.

Use of Fertility Preservation Among a Cohort of Transgirls in the Netherlands.

PURPOSE: The primary aims of the study are to examine the rate of attempted fertility preservation (FP) among a Dutch cohort of transgirls who started gonadotropin-releasing hormone analog treatment and the reasons why adolescents did or did not choose to attempt FP. METHODS: The study was a single-center retrospective review of medical records of 35 transgirls who started gonadotropin-releasing hormone analog treatment between 2011 and 2017. RESULTS: Ninety-one percent of adolescents were counseled on the option of FP. Thirty-eight percent of counseled adolescents attempted FP, and 75% of them were able to cryopreserve sperm suitable for intrauterine insemination or intracytoplasmic sperm injection. Younger and Caucasian transgirls were less likely to attempt FP. No specific reason for declining FP was known in 33% adolescents, 32% of adolescents were not able to produce a semen sample because of early puberty, 17% felt uncomfortable with masturbation, 17% did not want to have children, and 13% wanted to adopt. CONCLUSIONS: One third of adolescents attempted FP, which is much more than the percentage reported in previous studies from the United States. One third of the transgirls could not make use of FP because they were unable to produce a semen sample because of early pubertal stage. For these adolescents, alternatives need to be explored.

A case of fulminant Epstein-Barr virus encephalitis in an immune-competent adult.

A 21-year-old female presented with headache, nausea and vomiting, dysarthria, difficulty finding words, vertigo, episodical diplopia and an abnormal gait since 2 days. Additionally, we found marked ataxia and disturbed liver chemistry whilst her infection parameters were low. Her head CT scan was unremarkable, but her MRI scan showed leptomeningeal enhancement along the cerebellar folia. A lumbar punction revealed mononuclear leucocytosis and increased protein in her cerebrospinal fluid. She was admitted on a working diagnosis of herpes simplex encephalitis. Shortly after admission, she had a generalised seizure. She was tested for a wide range of viruses, bacteria and auto-immune antibodies and treated empirically with aciclovir, ceftriaxone, doxycycline and intravenous immunoglobulins. All tests continued to come back negative until the fifth day of admission, when repeat Epstein-Barr virus (EBV) serology showed evidence of an acute EBV infection, even though negative tests were acquired at admission. EBV encephalitis is a rare complication of EBV infection that is usually restricted to children and immune-compromised individuals. This is only the fifth case describing EBV encephalitis in an immune-competent adult, presenting with unique clinical features including a lack of fever and leptomeningeal enhancement on MRI investigation. Most interestingly, she tested negative for EBV until a few days after admission, underlining the need for repeated investigations in suspected virological encepahlitis. Even though our patient did not receive the often recommended glucocorticosteroids, she made a good neurological recovery.