Effect of transitioning from conventional cardiac troponin to high-sensitivity cardiac troponin on resource utilization- a single center experience.

BACKGROUND: Compared to conventional cardiac troponin (cTn), the high-sensitivity cardiac troponin (hs-cTn) assay is associated with improved detection of myocardial infarction (MI). METHODS: We performed a descriptive retrospective analysis of resource utilization at Rush University Medical Center over the transition period (July 1, 2021) from a cTn to a hs-cTn assay. Inclusion criteria included emergency department (ED) encounters between January 1 to December 31, 2021, with chief complaints of "chest pain" or "dyspnea" with associated troponin orders. The primary endpoint was the percentage of ED discharges. Secondary endpoints included the number of cardiac studies ordered. Univariable comparisons of these endpoints were performed using Student's t-test for continuous variables and Chi-square tests for binary/categorical variables. RESULTS: A total of 5113 encounters were analyzed. Hs-cTn was associated with an overall increase in ED patient discharges with negative troponin tests (44.1% vs. 29.9%, P < 0.01). In terms of cardiac testing per encounter, hs-cTn was associated with significant increases in the number of troponin tests (1.9 vs. 1.6, P < 0.01), electrocardiograms (3.0 vs. 2.9, P = 0.01), and echocardiograms (0.5 vs. 0.4, P < 0.01). There was a significant decrease in the utilization of stress testing (0.21 vs. 0.26, P < 0.01). There was a significant increase in total coronary angiography use during the hs-cTn period compared to cTn (227/2471 (9.2%) vs. 195/2642 (7.4%), P = 0.02). CONCLUSION: Transitioning from cTn to hs-cTn was associated with significantly increased ED discharges and an increase in troponin tests, ECG, echocardiograms, and coronary angiograms. There was a decrease in the number of stress tests.

Functional and Quality of Life Outcomes After TAVR in Patients With Low Gradient Aortic Stenosis.

Severe aortic stenosis is a common valvular heart disease associated with significant mortality and morbidity. Transcatheter aortic valve replacement (TAVR) is an effective treatment for this condition. Less data is available regarding functional and quality-of-life outcomes in patients with severe, low-gradient aortic stenosis following TAVR. This single-center, retrospective study compared changes in New York Heart Association (NYHA) class and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores at 30 days and 1 year in patients with 3 variants of severe, low-gradient aortic stenosis following TAVR. Secondary outcomes included 1-year major adverse cardiovascular event. A total of 170 patients were included. All 3 low-gradient variants had significant improvement in NYHA class and KCCQ overall scores at 30 days and 1 year. There were no significant differences in KCCQ overall scores between the 3 groups and no significant differences in secondary outcomes. Patients with low-gradient aortic stenosis experienced significant improvements in functional and quality-of-life outcomes following TAVR.

Unusual vasovagal-type autonomic dysfunction secondary to immune checkpoint inhibitor therapy.

We present the case of a patient with oral squamous cell carcinoma treated with the programmed death ligand inhibitor, pembrolizumab, an immune checkpoint inhibitor. She subsequently developed vasovagal-type autonomic dysfunction thought to be secondary to the pembrolizumab. The patient's vasovagal symptoms resolved with the initiation of oral glucocorticoids.

The association of phosphodiesterase-5 inhibitors with the biochemical recurrence-free and overall survival of patients with prostate cancer following radical prostatectomy.

PURPOSE: To determine whether phosphodiesterase-5 inhibitor documentation is associated with biochemical relapse-free and overall survival of patients with prostate cancer treated with radical prostatectomy. MATERIALS AND METHODS: We undertook a retrospective cohort analysis of 3,100 patients with prostate cancer treated with radical prostatectomy between 2003 and 2015. The patients were categorized as a phosphodiesterase- 5- inhibitor user or non-user. The biochemical relapse-free and overall survival at 5-years and 10-years were determined. RESULTS: Of the patients, 1,372 reported phosphodiesterase-5 inhibitor documentation, and 1,728 did not. The biochemical recurrence-free survival for non-users at 5- and 10-years follow-up was 87.6% and 85.3%, respectively, and the overall survival at these time intervals was 97.9% and 94.5%. The biochemical recurrence-free survival for phosphodiesterase-5 inhibitor users was 94.3% and 93.2% at 5- and 10-years follow-up, respectively, and overall survival was 99.2% and 95.8% at these intervals. The hazard ratio for biochemical recurrence-free survival was 0.44 (CI 0.34-0.56) and for overall survival was 0.65 (CI 0.45-0.94). On the multivariate analysis, phosphodiesterase-5 inhibitor documentation was associated with a lower risk of biochemical recurrence and death when corrected for the other variables. Age at surgery and Gleason scores >8 was associated with a higher risk of death. Higher pathological stage, higher Gleason score, presence of lymph node metastases, and nonwhite race were associated with a higher risk of recurrence. CONCLUSION: This retrospective analysis revealed a significant association of postoperative phosphodiesterase-5 inhibitor documentation with biochemical recurrence-free- and overall survival in patients with localized prostate cancer treated with radical prostatectomy. Larger scale studies are warranted to investigate the clinical significance of this association.

A Durable Response to Pembrolizumab in a Patient with Uterine Serous Carcinoma and Lynch Syndrome due to the MSH6 Germline Mutation.

Pembrolizumab, a programmed death 1 ligand (PD-1) checkpoint inhibitor, has elicited responses in mismatch repair (MMR)-deficient advanced solid tumors, leading to its agnostic approval by the US Food and Drug Administration in 2017 when no other therapeutic options are available. However, there are still insufficient data on the response to checkpoint inhibitors in advanced endometrial cancer related to Lynch syndrome (LS) and, specifically, in uterine serous carcinoma, which is uncommon in LS. Here we report a case of metastatic uterine serous carcinoma due to a germline MSH6 mutation (Lynch syndrome) that was discovered because of a patient's tumor MMR deficiency. The patient was started on first-line pembrolizumab in 2018 and sustained a partial response. She remains asymptomatic and progression free for more than 2 years. Tumor sequencing showed a high mutational burden and an upstream somatic mutation in the same gene, p.F1088fs. Immunohistochemical staining was negative for PD-L1 expression. We discuss clinical characteristics of the patient, molecular features of her tumor, and the mechanism of her tumor response. We also discuss the duration of immunotherapy in her case. Our case demonstrated a partial response and a long-term remission from the frontline single-agent pembrolizumab in a woman with metastatic uterine serous carcinoma and Lynch syndrome due to a germline MSH6 gene mutation. Our experience suggests a potential significant clinical benefit of checkpoint inhibitors used as single agents early on in the treatment of MMR-deficient/high microsatellite instability/hypermutated uterine cancers in women with Lynch syndrome. KEY POINTS: Even though checkpoint inhibitors are effective in mismatch repair-deficient endometrial cancer, it is unknown whether the response to them differs between women with endometrial cancer due to germline mutations in a mismatch repair gene (Lynch syndrome) and women with sporadic endometrial cancer. In our case, a patient with Lynch syndrome and recurrent mismatch repair-deficient serous endometrial cancer achieved a durable remission on the first-line therapy with the checkpoint inhibitor pembrolizumab and remains progression free after more than 2 years. Based on our observation and the data, suggesting the stronger immune activation in women with Lynch syndrome-associated endometrial cancer, we propose to use checkpoint inhibitor monotherapy early in the course of their treatment and stratify patients for the presence of Lynch syndrome in clinical trials.

4-month-old boy coinfected with COVID-19 and adenovirus.

A 4-month-old boy with a history of muscular ventricular septal defect and atopic dermatitis presented with decreased oral intake, loose stools, stuffy nose, mild cough and diaphoresis. The patient had an in-home exposure to COVID-19. The initial respiratory pathogen panel was positive for adenovirus, consistent with his symptoms. The following day, the COVID-19 PCR was also positive. The patient was treated with supportive care, isolation precautions were implemented and the patient was discharged on day 4. This case demonstrates the importance of testing for COVID-19 even if a patient tests positive for another virus due to the possibility of coinfection, especially in children, in order to limit spread of COVID-19 to others.

Radiation Exposure in Pediatric Sarcoma Patients Receiving Initial Curative Chemotherapy.

The objective of our study is to estimate the radiation exposure to pediatric patients with sarcoma getting required (or highly recommended) ionizing radiation scans during initial chemotherapy and to determine how often distant progressive disease was discovered. Data from the last 25 years from the Children's Oncology Group open phase III protocols were reviewed for the most common pediatric sarcomas: osteosarcoma, Ewing's sarcoma, and rhabdomyosarcoma. The number of required/recommended ionizing radiation scans, including chest radiographs, chest computed tomography, positron emission tomography scans, and bone scans during induction, consolidation, and maintenance chemotherapy, were recorded and the total radiation dose per patient was calculated. In addition, the number of patients who were removed from protocol during chemotherapy because of new or distant progressive disease was documented. In our analysis of 5845 patients, the average pediatric patient with sarcoma on protocol was exposed to an ionizing radiation dose of 37.1 mGy, equivalent to the lifetime dose of nuclear power plant workers, whereas the progression of disease was detected at most in 5.4% of the patients. Our study is meant to inform pediatric oncologists more precisely of the actual risks and benefits of mandated surveillance scans during chemotherapy in patients with sarcoma.