Patients with chronic kidney disease (CKD) have altered physiologic processes, which result in different treatment outcomes compared with the general population. We aimed to systematically evaluate the efficacy of clinical interventions in reducing mortality of patients with CKD. We searched PubMed, MEDLINE, Embase, and Cochrane Database of Systematic Reviews for meta-analyses of randomized controlled trials (RCT) or observational studies (OS) studying the effect of treatment on all-cause mortality of patients with CKD. The credibility assessment was based on the random-effects summary estimate, heterogeneity, 95% prediction intervals, small study effects, excess significance, and credibility ceilings. Ninety-two articles yielded 130 unique meta-analyses. Convincing evidence from OSs supported mortality reduction with three treatments: angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers for patients not undergoing dialysis, warfarin for patients with atrial fibrillation not undergoing dialysis, and (at short-term) percutaneous coronary intervention compared to coronary artery bypass grafting for dialysis patients. Two treatment comparisons were supported by highly credible evidence from RCTs in terms of all-cause mortality. These were high-flux hemodialysis (HD) versus low-flux HD as a maintenance HD method and statin versus less statin or placebo for patients not undergoing dialysis. Most significant associations identified in OSs failed to be replicated in RCTs. Associations of high credibility from RCTs were in line with current guidelines. Given the heterogeneity of CKD, it seems hard to assume mortality reductions based on findings from OSs. Chronic kidney disease (CKD) is a progressive condition arising from various heterogeneous disease pathways, which results in irreversible changes of kidney function and structure . The KidIt may be difficult to generalize findings from other populations to patients with CKD because kidney disease impacts multiple organ systems and physiologic processes in addition to altering absorption, metabolism, and excretion capabilities, which leads to a higher chance of toxin accumulation and medication interactions ,6. DespiTo synthesize the available evidence of the efficacy of interventions in CKD patients, we performed an umbrella review of the literature. We identified meta-analyses of randomized controlled trials (RCTs) or OSs reporting the efficacy of clinical interventions on patients with CKD in terms of all-cause mortality. In addition, to assess potential biases such as reporting biases and confounding biases in statistically significant findings that might lead to false positives or inflated estimate of the association ,14, we pThis systematic review was performed according to a pre-specified protocol registered at the International Prospective Register of Systematic Reviews (PROSPERO registration: CRD42018103559). The reporting was done according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  15]..15].We searched PubMed, MEDLINE, Embase, and Cochrane Database of Systematic Reviews from inception to 19 February 2019. The search was limited to articles in English. We adopted search strategies using keywords such as chronic kidney disease, end-stage renal disease, dialysis, mortality, and meta-analysis (full search strategy in PubMed and MEDLINE presented in the Two investigators (J.Y.K. and J.S.) independently screened for eligible articles by screening the title, then the abstract, and then the full text. Meta-analyses of RCTs or OSs  that investigated the associations between certain clinical interventions and all-cause mortality of patients with CKD were thought eligible. CKD definition and staging followed those of the KDIGO 2012 Clinical Practice Guideline [Data extraction was performed independently by two investigators (J.Y.K. and J.S.). From eligible meta-analyses, we extracted the name of the first author, year of publication, intervention therapy, control therapy, population characteristics such as CKD stages, outcome metrics such as risk ratio (RR), odds ratio (OR), and hazard ratio (HR), summary estimate, 95% confidence interval (CI), follow-up duration, study design (RCT or OS), the number of observed deaths, and the number of total participants. From meta-analyses of OSs, we extracted the maximally adjusted summary estimate. When available, we extracted the effect estimate and its 95% CI of all component studies in the meta-analysis to perform tests for various biases and grade their level of evidence based on criteria developed over previous reviews. The eligible meta-analyses that provided these data were regarded as meta-analyses eligible for re-analysis. p-value < 0.05. We also assessed p-value below thresholds of 10−3 and 10−6 [Q test and calculated the I2 statistic for evaluation of heterogeneity [p-value < 0.05) is greater compared to their expected number [For meta-analyses eligible for re-analysis, we re-performed meta-analysis under random and a fixed effects model. Statistical significance was claimed at and 10−6 ,17. In sogeneity ,19. We eogeneity ,21. We aogeneity ,23. We pd number ,25. We ad number ,27. All d number ,29,30,31p-value under random effects, the number of deaths, statistical significance of the largest component study, heterogeneity, 95% prediction interval, estimate under credibility ceiling, and presence of biases. From meta-analyses of RCTs, we identified associations of high credibility by assessing the p-value under random effects, the number of deaths, the statistical significance of the largest component study, heterogeneity, a 95% prediction interval, and presence of biases. Details of criteria are provided in In accordance with previous umbrella reviews ,34,35,36Q test for heterogeneity. In addition, for overlapping meta-analyses that investigated the similar comparison groups in a similar study design but studied patient groups of different CKD levels or dialysis statuses, we compared the direction and the statistical significance of the associations and assessed the difference of effect using Cochran’s Q test. A difference beyond chance between the summary estimates of the two meta-analyses was claimed at a p-value for Cochran’s Q test < 0.1. For evidence from observational studies graded as convincing or highly suggestive evidence, we performed sensitivity subset analyses by including only prospective studies, and recorded the change of the evidence level.We attempted to identify the impact of different CKD stages and potential biases arising from study designs. For overlapping meta-analyses of either OSs or RCTs that investigated the similar comparison in similar patient groups, we compared the direction and the statistical significance of the associations and assessed the difference of effect in terms of Cochran’s The search initially identified 3219 potentially eligible articles. After the screening process, we identified 92 articles including 130 unique meta-analyses that examined the association between a clinical intervention and all-cause mortality among patients with CKD . Out of p-value < 10−3, which were warfarin for atrial fibrillation in non-hemodialysis (HD) patients, beta blockers for heart failure, and high-flux HD versus low-flux HD. Seven (13%) associations were based on 1000 or more deaths. Out of 10 statistically significant associations, seven were also supported by the statistically significant result of the largest component study, and 95% prediction intervals excluded the null in six associations. Out of statistically significant associations, only one had small study effects, and an excess significance bias was not claimed in any of the associations. Out of 56 eligible meta-analyses of RCTs, a total of 10 (18%) associations showed statistical significance under the random effects model, and only three (5%) had p-value < 10−3, and 15 (30%) had a p-value < 10−6. Thirty (60%) associations were based on 1000 or more deaths, of which 22 (44%) were also supported by a p-value < 10−3. Out of 33 statistically significant associations, 29 were also supported by the statistically significant result of the largest component study. Nine associations had small study effects, and two associations were claimed to have an excess of a significant bias. Heterogeneity between the studies was generally high with 34 (68%) associations having I2 greater than 50%. Furthermore, a 95% prediction interval excluded the null in only seven (14%) associations. While 33 (66%) associations were statistically significant under the random effects model, 28 (56%), 20 (40%), 12 (24%), and 7 (14%) retained statistical significance under 5%, 10%, 15%, and 20% credibility ceilings.Out of 50 eligible meta-analyses of OSs, a total of 33 (66%) associations showed statistical significance under the random effects model, 22 (44%) had a Associations between clinical interventions and all-cause mortality were graded to adhere to the pre-determined criteria . Out of p-values were larger than the high credibility threshold of 10−3, so these associations did not meet criteria for high credibility. One exception was statin versus no statin or placebo for patients with CKD stage 1–2, but another eligible meta-analysis of RCTs of similar intervention, including statin versus no statin or placebo for patients not on dialysis, were already graded as having high credibility.We identified 24 meta-analyses reporting all-cause mortality, which were unique in design but not eligible for re-analysis . All theMeta-analyses of similar design were conducted with both RCTs and OSs in 10 comparisons . The totWe identified and comprehensively analyzed 130 meta-analyses from 92 articles. While 43 associations were statistically significant, only three were supported by convincing evidence from OSs, and only two were supported by robust evidence from RCTs. Some fields of treatment studied by multiple meta-analyses were sparsely supported by statistically significant mortality benefit. Nine meta-analyses studied interventions for anemia in CKD, of which only meta-regression analyses of RCTs achieved statistical significance, which shows that a higher dose of erythropoietin stimulating agents was associated with higher mortality . Out of More advanced CKD is associated with a higher risk of cardiovascular mortality . In patip-values were close to the significance threshold. Convincing evidence from OSs also suggested that ACEI or ARB were associated with lower mortality in CKD patients not on dialysis. Meta-analyses of RCTs also suggested that, compared to placebo, ACEI was associated with lower mortality, while ARB was not. However, whether these findings lead to superiority of ACEI over ARB is uncertain because trials of ACEIs tended to be outdated than trials of ARBs, and head-to-head trials failed to show a statistically significant difference on mortality . In CKD Warfarin was associated with lower mortality in non-HD patients with atrial fibrillation, which is supported by convincing evidence from OSs. Meta-analysis of RCTs was not available. A post-hoc analysis of RCT reported reduced ischemic stroke/systemic embolism events in patients with CKD stage 3 using adjusted-dose warfarin compared to aspirin/low-dose warfarin . Based oHighly credible evidence from RCTs showed that high-flux HD was associated with lower mortality compared with low-flux HD. Guidelines recommended both high-flux HD and low-flux HD as maintenance dialysis methods, while acknowledging a moderate benefit of high-flux HD on several secondary outcomes with no increase in harm but also high cost and low availability . Highly When meta-analyses of RCTs and OSs with a similar design  were compared, only one out of nine statistically significant associations from OSs were replicated in RCTs, while the heterogeneity of effects between study designs was statistically significant in eight out of ten associations. Compared with eligible meta-analyses of RCTs, a higher percentage of meta-analyses of OSs reported significant associations but had large heterogeneity or signs of small study effects. These differences could have been caused by patient group heterogeneity among the individual studies, and a relatively low number of patients or a selection bias in RCTs. Residual confounding among observational studies is also likely. When estimating a treatment effect using observational data, it is very difficult to fully adjust for all potential biases including confounding by indication . The higNumerous guidelines highlighted the importance of specific treatment recommendations for patients with CKD due to their high rate of morbidities and high mortality ,47,48,57One notable limitation of our study is that we only searched for meta-analyses in our study, and large individual trials might have been missed. We could not identify new, large trials comparing statin use versus non-statin use, but concurrent meta-analyses all showed a consensus in that statin therapy lowered mortality in non-dialysis patients ,60. We iSome other limitations also exist. We did not assess the individual quality of the included meta-analyses, as this was the responsibility of the original authors. Although we adopted evidence grading criteria applied and developed for numerous previous studies, the criteria are mainly based on arbitrary thresholds. Although we applied the most rigorous criteria to control the potential biases in literature, we cannot be fully sure that results thought as credible in our review are indeed genuine. Fourth, we assessed only all-cause mortality of the reported associations. While doing so allowed us to objectively assess the comparative efficacy of various treatments and avoid reporting a large number of nominally significant associations, other treatments shown to improve secondary outcomes such as progression of CKD and cardiovascular events could have been missed. Non-significant mortality associations may not necessarily imply that treatment is not beneficial, and further well-designed studies are warranted. This relates particularly to associations supported by studies with a short follow-up period reporting a benefit in secondary outcomes.Despite the limitations, we have identified the available evidence regarding the efficacy of a vast range of treatments for patients with CKD. While the associations from RCTs graded as having high credibility were in line with recommendations from current guidelines, treatment efficacy supported by OSs was not consistent with results from RCTs. It may be hard to assume the benefit of treatment on mortality based on findings from OSs. Future trials focusing on CKD patients are warranted to provide optimized treatment strategies to this cohort with a high unmet need.


The other six patients had coexisting neurological diseases with SARS-CoV-2. One patient with a large artery stroke succumbed to the illness due to respiratory complication. Memory impairment as a sequela is present during follow up of one encephalitis patient. Presently the early recognition and diagnosis of neurological manifestations remains a challenge for clinicians as the SARS-CoV-2 related neurological manifestations are in evolution. A long-term correlation study of clinical profile, radiological and laboratory investigations, along with neuropathological studies is needed to further understand the pathophysiology behind the SARS-CoV-2 neurological manifestations. Further understanding will facilitate timely recognition, therapeutic intervention, and possible prevention of long-term sequalae.The neurotrophic potential of SARS-CoV-2 virus is manifesting as various neurological disorders in the present pandemic. Nervous system involvement can be due to the direct action of the virus on the brain tissue or due to an indirect action through the activation of immune-mediated mechanisms. This study will discuss the detailed systematically evaluated clinical profile and relevant investigations and outcome of 14 laboratory confirmed SARS-CoV-2 positive patients presenting with neurological signs and symptoms. The patients were further categorized into confirmed, probable, and possible neurological associations. The probable association was found in meningoencephalitis ( The pandemic due to COVID-19 is growing exponentially worldwide after first being notified from Wuhan, China, in December 2019. The virus that causes COVID-19 is designated as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Primarily this virus affects the respiratory system and thereby initiates the cascade of sequences that involves multiple organs. There are evidences of involvement of other systems like nervous system, cardiovascular system, and gastrointestinal system, which are a matter of scientific study and research. Six months into this pandemic, the understanding and recognition of neurological manifestations and complications has increased as evident from the cases series and reports in literature  considering the current pandemic.Routine hematological , biochemical parameters  were done. X ray chest, ultrasound abdomen, and neuroimaging–brain MRI and CT head was done in all patients.Autoimmune Profile  was done in selected patients.CSF examination was selectively done for cytology and biochemistry.Neuroviral panel  was done in all CSF samples of patients suspected of having meningoencephalitis. CSF PCR for SARS-CoV-2 was done in all patients of meningoencephalitis.The neurological diagnosis was made after evaluating the clinical history, examination, and relevant investigations. The patients were critically evaluated and investigated for atypical neurological presentation.Patients with atypical neurological presentation and with influenza like illness (ILI) in the recent past or during hospitalization were categorized into suspected COVID-19.The real-time reverse-transcription polymerase chain reaction assay using a SARS-CoV-2 nucleic acid was done from oral and nasopharyngeal sample in all patients, from CSF in selected patients by the below mentioned method.Nucleic acid extraction was done using chemagic Viral DNA/RNA 300 Kit H96 in Chemagic 360 instrument from Perkin Elmer as per the manufacturer's instruction. The sample processing was carried out in BSL-2 following standard precautions. An amount of 315 μl of lysis buffer was added to 300 μl of sample volume for extraction. Internal reference of 5 μl as provided by the FOSUN COVID-19 PCR kit was added to each sample to monitor the efficiency of sample preparation and to differentiate between true negative and false negative. A qualitative PCR test was done subsequently with the FOSUN COVID-19 PCR detection kit using primer-probe mixture for detection of N gene, E gene, and ORF1ab gene. The results were interpreted as per the kit insert.The laboratory confirmed cases of COVID-19 with neurological manifestations are included in study. The demographic, clinical, laboratory investigations, follow up, and outcome of the patients is presented.We obtained written consent from patients or their relatives for publication of the data including images and any identifiable data that might reveal a patient's identity.A total of 358 patients with neurological diagnosis were admitted in the hospital during the study period. Out of these, 69 cases were suspected of having COVID-19 disease and there were 14 laboratory confirmed cases.The detailed demographic, clinical profile, investigations, and outcome has been summarized in n = 6), headache (n = 4), seizures (n = 5), limb weakness (n = 3), anosmia (n = 2), while ophthalmoplegia and memory impairment occurred in one patient, respectively.Among 14 positive SARS-CoV-2 infection patients, there were seven male and female patients, respectively. Median age at onset of symptoms was 41.5 years (range 15–70). The presenting neurological symptoms were altered sensorium (Influenza like illness (ILI) was present in 10 patients. Nine had fever; sore throat and shortness of breath were present in two patients, diarrhea and myalgia were seen in one patient, respectively. The ILI symptoms were present in seven patients on an average of 1 week prior to admission. One patient developed ILI on admission while other two developed these symptoms after 7–14 days of hospitalization. Four patients were asymptomatic.n = 6), hyperglycemia (n = 1), deranged INR (n = 1), and hyponatremia (n=3). Complete blood counts were normal in eight patients. CRP was raised in two patients. D dimer was raised in one patient. Serum ferritin was found to be normal in all patients.Abnormal laboratory parameters included leucocytosis . Contrary to our study, eight adults patients aged 24–78 years (median 62 IQR 40–70), four women and men each, have been described with encephalitis associated with COVID-19 . The braCSF pleocytosis was a predominant finding indicating brain inflammation in patients with meningoencephalitis. The neuroviral panel was negative for all patients. CSF PCR for SARS-CoV-2 done in four patients was found to be negative. Recently the presence of SARS-CoV-2 RNA in the cerebrospinal fluid has been detected by genome sequencing in a patient with clinically proved meningoencephalitis in Japan .In one study of 183 hospitalized children with clinically suspected acute encephalitis, 22 (12%) had coronavirus infection, the type was not specified by detection of anti-CoVIgM . NeuroimPoyiadji et al. described a report where haemorrhagic ring enhancing lesions consistent with acute necrotizing encephalitis were seen in the bilateral thalami, medial temporal lobes, and sub-insular regions on brain MRI . They haAccording to the provisional case definition for the association of COVID-19 with neurological disease, the probable case is defined as SARS-CoV-2 detected in respiratory or other non-CNS sample, or evidence of SARS-CoV-2 specific antibody in serum indicating acute infection and no other explanatory pathogen or cause found . AccordiThe possibility of stroke associated with COVID-19 has increased as reported from publications from around the world. In the pooled analysis of four studies on cerebrovascular disease (CVD) with COVID-19, it is concluded that there is 2.5-fold increase in odds of severe COVID-19 illness with a history of stroke and trend toward increased mortality rate .SARS-CoV-2 infection is associated with hypercoagulable state and the depletion of angiotensin-converting enzyme 2 (ACE2) that results in tissue damage, including stroke. The binding of SARS-CoV-2 with ACE2 (a cardio-cerebro vascular factor) damages ACE2 and can lead to strokes. The cytokinin related injury also plays a role in causing stroke , 21.There is a predilection for large vessel involvement and male preponderance. Avula et al. reported four patients who initially presented with computed tomography (CT) proven stroke and later tested positive for COVID-19 . PatientIn the case series from Turkey, four patients with COVID-19 were reported to be simultaneously accompanied by acute ischemic stroke. The average time from COVID-19 symptom onset to the diagnosis of stroke was 2 days in this series .Patient 2 presented in a late window period with NIHSS score of 6. CT head scan was normal. She was thrombolyzed with alteplase. She had a developed fever the next day. Her nasopharyngeal swab PCR was positive for SARS-CoV-2. Her NIHSS improved to 4 in 2 days. Her post-thrombolysis CT scan showed hypodensity in right centrum semiovale. She was managed with antiplatelets and neurorehabilitation.Intravenous thrombolysis in acute stroke during this pandemic is a bigger challenge. The patients are reaching emergency care late due to several reasons. At large patients with minor strokes are also avoiding attending hospitals for the fear of infection. There is possibility of neurological symptoms being masked by the infection itself, or a delay in access to neuroimaging or revascularization techniques could be responsible as reported by Oxley et al. .The single center retrospective study describes 13 of 221 patients diagnosed with SARS-CoV-2 virus to have ischemic stroke . ThromboHyposmia, anosmia, and dysgeusia are commonly reported symptoms seen in COVID-19 pausisymptomatic or asymptomatic patients. In a retrospective study by Klopfenstein et al. on analysis of patients with anosmia, he concluded that 47% (54 out of 114) of COVID-19 patients reported anosmia . AnosmiaPatient 14 had only subacute onset of anosmia and ageusia for around 2 weeks. He was followed up in isolation for development of any other symptoms. No further symptoms developed and he was SARS-CoV-2 negative after 15 days. This is contrary to a patient reported by Eliezer et al. who reported a woman in her 40s presented with hyposmia with a history of dry cough along with headache and generalized fatigue a few days before presentation .The pathophysiologic mechanism underlying the smell and taste impairment needs to be understood; the neurotrophic potential of the SARS-CoV-2 virus is known and it is hypothesized that the virus spread through olfactory bulbs into the central nervous system . ScreeniNeuromuscular disorder has been reported with SARS-CoV-2 by Tsai et al. . GuillaiThe common antecedent infections related with GBS are Campylobacter jejuni, Zika virus, and influenza virus –35.The SIn our clinical practice we have seen the concomitant infection of tubercular meningitis and SARS-CoV-2 in Patients 7 and 8. The tubercular meningitis is diagnosed at the presentation and simultaneously she was positive for SARS-Co-V-2. Another 6 months follow up stable case of tubercular meningitis with tuberculoma presented in status epilepticus. She was asymptomatic and found to be SARS-CoV-2 positive on day 2 of hospitalization. There are reports wherein the new onset of seizure or status epilepticus can be a presenting symptom of COVID-19 . To explPatient 6 presented with acute onset encephalopathy. The CSF showed mild pleocytosis with normal sugar and protein, TB PCR and neuroviral panel were negative. Contrast brain MRI was normal. His chest radiograph showed opacities . TubercuAn observational study has explored the relationship between MTB infection and COVID-19 pneumonia, suggesting that individuals with latent or active TB may be more susceptible to SARS-CoV-2 infection, and that COVID-19 disease progression may be more rapid and severe . A chronThere is evidence that SARS-CoV-2 virus may penetrate the brainstem, aggravating respiratory impairment . SeizureThere is limited information in literature that suggests that individuals with epilepsy are more likely to be infected by the virus. Giovanni et al. reported worsening of seizures in 18% of people with epilepsy (PwE) during the COVID-19 period, mostly seen in patients who were having poor sleep quality and on multiple antiepileptics. PwE were not found to be at increased risk of acquiring SARS-CoV-2 infection . New onsIn our study, five patients presented with seizures and were concomitantly diagnosed with SARS-CoV-2. Patient 9 with history of 1 week duration of myoclonic jerks and generalized seizures was diagnosed with subacute sclerosing panencephalitis (SSPE). Her CSF examination showed 2 cells with normal sugar and protein. CSF IgG measles for antibody was positive. EEG showed slow periodic 2–3 Hz discharges. Patient 10 with post-traumatic seizure disorder, who was well-controlled for 2 years, presented in status epilepticus.Diabetic patients are considered to be at risk for SARS-CoV-2 infection. Patient 12, a middle aged female with uncontrolled diabetes mellitus, presented in non-convulsive status epilepticus. She was asymptomatic for COVID-19 symptoms and was in non-ketotic hyperosmolar state. Patient 11 presented with right eye ptosis, complete ophthalmoplegia, anosmia, and ageusia with headache. His neuroimaging revealed cavernous sinus thrombosis. In diabetes, due to hyperglycaemic state there is high risk of acquiring infection and progression to severe-stage of COVID-19 leading to immune dysfunction . The patThe presentation of patients with seizures raises the question of whether epilepsy patients are more prone to SARS-CoV-2 infection. COVID-19 may exacerbate epileptic seizures from associated systemic effects not directly related to SARS-CoV-2 CNS infection. The reasonable current understanding remains that in some patients with COVID-19, seizures develop as a consequence of hypoxia, metabolic derangements, organ failure, or even cerebral damage. The association of COVID-19 with the patients of epilepsy needs to be explored further in well-planned studies.This study gives an insight into the neurological associations of SARS-CoV-2, the new emergent virus in the current pandemic. The infection itself might be a source of neurological manifestations, and patients with neurological disorders might be at risk of the most severe complications of this infection. The effect of SARS-CoV-2 on pulmonary tuberculosis and tubercular meningitis in endemic areas needs to be closely monitored for increased risk of occurrence and its appropriate management.Our limitations include the spectrum of neurological manifestations from a single center study may not be complete. The long term follow up for possible sequalae is essential to elucidate the pathophysiological mechanism.Absent of the dedicated CT facility for COVID-19 patients, the respiratory involvement at the early stage may have been missed.As we are still evolving with our knowledge in the pandemic, identification and reporting of neurological manifestations of SARS-CoV-2 will help in formulating the guidelines and protocol for early diagnosis and management.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.VS, PB, and KR were involved in patient management and care. SK, VS, PB, and KR summarized and conceptualized the data and drafted the initial manuscript. SK, VS, SM, and AA revised the final manuscript. RG and SB collected the laboratory data including RT PCR for COVID-19. Radiological images have been described by MC. All authors agreed upon the final form of the manuscript before submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Objectives: 1 Measure serial serum intestinal fatty acid binding protein levels in infants undergoing cardiac surgery with cardiopulmonary bypass to evaluate for evidence of early post-operative enterocyte injury. 2 Determine the association between immediate post-operative circulating intestinal fatty acid binding protein levels and subsequent development of necrotizing enterocolitis.Design: Observational cohort study. Intestinal fatty acid binding protein was measured pre-operatively, at rewarming, and at 6 and 24 h post-operatively. Percent of goal enteral kilocalories on post-operative day 5 and episodes of necrotizing enterocolitis were determined. Multivariable analysis assessed for factors independently associated with clinical feeding outcomes and suspected/definite necrotizing enterocolitis.Setting: Quaternary free-standing children's hospital pediatric cardiac intensive care unit.Patients: 103 infants <120 days of age undergoing cardiothoracic surgery with cardiopulmonary bypass.Interventions: None.Results: Median pre-operative intestinal fatty acid binding protein level was 3.93 ng/ml (range 0.24–51.32). Intestinal fatty acid binding protein levels rose significantly at rewarming , continued to rise slightly by 6 h , then decreased by 24 h . Sixteen subjects (15.7%) developed modified Bell criteria Stage 1 necrotizing enterocolitis and 9 subjects (8.8%) developed Stage 2 necrotizing enterocolitis. Infants who developed necrotizing enterocolitis demonstrated a significantly higher distribution of intestinal fatty acid binding protein levels at both 6 h (p = 0.005) and 24 h (p = 0.005) post-operatively. On multivariable analysis, intestinal fatty acid binding protein was not associated with percentage of goal enteral kilocalories delivered on post-operative day 5. Higher intestinal fatty acid binding protein was independently associated with subsequent development of suspected/definite necrotizing enterocolitis .Conclusions: Intestinal fatty acid binding protein levels rise following infant cardiopulmonary bypass, indicating early post-operative enterocyte injury. Intestinal fatty acid binding protein was not associated with percent of goal enteral nutrition achieved on post-operative day 5, likely due to protocolized feeding advancement based on clinically observable factors. Higher intestinal fatty acid binding protein at 6 h post-operatively was independently associated with subsequent development of necrotizing enterocolitis and may help identify patients at risk for this important complication. Infants undergoing surgery for congenital heart disease (CHD) with cardiopulmonary bypass (CPB) are at high risk for intestinal injury, both during the surgery itself and subsequently from ongoing post-operative low cardiac output , 2. Thisinfant CHD population, which is a unique and important age group given the complexity of the surgeries performed at this age and the risk for diffuse organ injury. Additionally, associations between IFABP levels and feeding tolerance or clinical suspicion of NEC have not been assessed in this high-risk population.Intestinal epithelial injury can be assessed by minimally invasive testing of intestinal fatty acid-binding protein (IFABP). IFABP is a 15-kD cytosolic protein localized mainly to mature enterocytes of the small intestinal villi with normally low circulating levels –20. IFABIn this study, we sought to describe the pattern of serum IFABP in infants undergoing CPB. In addition, we aimed to determine the clinical risk factors associated with elevated preoperative and postoperative IFABP levels, hypothesizing that higher IFABP levels would be associated with worse clinical severity of disease. Finally, we investigated whether there was an association between IFABP and early enteral feeding outcomes/development of NEC, hypothesizing that greater elevation of IFABP levels in the immediate post-operative period would predict worse enteral feeding outcomes and greater odds of developing NEC.post-hoc analysis of infant feeding outcomes. Over a period of two-and-a-half years from September 2013 to February 2016, infants ≤ 120 days at time of cardiothoracic surgery with use of CPB were enrolled. Exclusion criteria were weight <2 kg (as limited blood volume could increase risk of anemia with research blood draws), adjusted gestation age <34 weeks , and prior participation in this protocol. The protocol was approved by the Colorado Multiple Institution Review Board, and informed consent was obtained from the subjects' parents prior to enrollment. The primary aims of the current study were to measure pre- and post-op IFABP levels in an infant cohort undergoing CPB and determine the association between IFABP levels and early enteral feeding outcomes and development of NEC.This study was a pre-specified secondary aim of a prospective cohort study evaluating alkaline phosphatase activity after infant CPB , with prAs previously published , CPB wasIFABP levels were obtained pre-operation, immediately prior to withdrawal of CPB, and 6 and 24-h post-operation. Serum concentration of IFABP was analyzed at the University of Colorado, Denver using Meso Scale Discovery (MSD) multiplex immunoassay system, Meso Scale Diagnostics, LLC, Gaithersburg, MD.Pre-operative, intraoperative, and post-operative variables were collected to evaluate for potential risk factors for pre- and post-operative intestinal damage. Pre-operative variables included age, weight, sex, Aristotle score (comprehensive and basic) , pre-opeDiagnosis and staging of NEC was made based on the modified Bell's Staging Criteria via retrospective chart review . Althougpost-hoc data collection from the electronic medical record was utilized to gather nutrition and feeding data. We examined the primary feeding outcome of percent of goal feeds achieved enterally on post-op day 5. Additionally, we examined secondary outcomes of percent of goal feeds achieved on post-op day 3. To calculate the percent of goal feeds achieved enterally, we took the patient's achieved enteral feeds  as recorded in the patient's electronic medical record flowsheet and divided this by the goal kcals as documented daily by the cardiac intensive care unit dieticians. The feeding protocol utilized in our CICU is included as A P-values were used to evaluate the most harmonious model. Multivariable logistic regression model was performed to assess the association between NEC and IFABP, demographic and clinical covariates were selected through univariate logistic regression with area under curve (AUC) >0.6, then added to the multivariable model. Akaike information criterion (AIC) was used to evaluate the best fitting model. P-values < 0.05 were considered as statistically significant. All statistical analysis was performed using SAS version 9.4  and all plots were produced with GraphPad Prism version 8.Patients' demographics and clinical characteristics are summarized using descriptive statistics. The comparison groups were divided by IFABP level below and equal or above 50th percentile at the given time point. The distributions of continuous variables were inspected before data analysis, all the continuous variables were summarized with median and range (min and max). Wilcoxon rank sum test was conducted to determine the significant difference in distributions between the comparison groups. The categorical data was summarized as count and percentage for the “Yes” category for a giving measurement. To model the association between percentage of goal enteral kilocalories achieved and IFABP, multivariable general linear model was used with pre-selected clinical variables as covariates. Backwards model selection strategy was used, and R-square and type III The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.The study consecutively enrolled 100 and two subjects, plus one screen failure (converted to non-bypass surgery after enrollment). Of these subjects, one patient did not have a preoperative IFABP level, one patient did not have an IFABP level at rewarming, three patients did not have a 6 h IFABP level, and two patients did not have a 24 h IFABP level due to insufficient sample volume, leaving a total of 101 preoperative and rewarming samples, 99 six hour samples, and 100 twenty-four hour samples . The distribution of IFABP levels initially rose at rewarming, increased slightly at 6 h, and by 24 h had trended down to near preoperative levels as shown in The median number of days from surgery to NEC onset was 10 days . The association between clinical characteristics and post-operative NEC are shown in Infants steadily progressed in terms of amount of enteral feeds achieved over time, with mean percent of goals kcals achieved by enteral nutrition advancing from 26% on post-op day 1, to 48% on post op day 3, to 71% on post-op day 5, to 82% on post-op day 7. On multivariable analysis, IFABP was not associated with percentage of goal enteral kcal achieved. Rather, selective cerebral perfusion time, higher Aristotle score, longer intubation time, and the need for pre-operative intubation were all independently associated with lower percentage of goal Kcals given enterally on post-op day 5, as shown in n = 77) were categorized as Stage 0, 15.7% (n = 16) were categorized as Stage 1 (suspected NEC), and 8.8% (n = 9) were categorized as Stage 2 (definite NEC). We did not have any patients categorized as Stage 3 (advanced NEC). None of the patients in our study had previous clinical NEC, though prior subclinical intestinal stress cannot be completely ruled out by this study design. A comparison of the distribution of IFABP levels at 6 and 24 h demonstrates a significantly higher distribution of IFABP levels at both time points in patients who subsequently developed suspected or definite NEC vs. patients who did not develop post-operative NEC (Of our patients, by modified Bell Staging Criteria, 75.5% (tive NEC . On multIn this study, we present the first evaluation of IFABP levels following cardiothoracic surgery with CPB in a specifically infant population. Additionally, we present the associations between clinical factors and pre-operative and post-operative IFABP levels. Counter to our initial hypothesis, immediate post-operative IFABP levels were not found to be associated with the percentage of goal kcals achieved enterally on post-operative day 3 or 5; rather, clinician-observable factors indicating illness severity were associated with achieved enteral kcals. We present the novel finding of an independent association in infants undergoing CPB between early enterocyte injury, as identified by circulating IFABP levels, and subsequent post-operative NEC.We show that IFABP levels rise immediately after CPB, continue to rise at 6 h, and then return back to pre-operative levels by 24 h after surgery. A physiologic understanding of IFABP offers an explanation for this pattern of early rise and rapid fall. IFABP is located predominantly in the mature enterocytes in the villi as opposed to younger enterocytes in the crypts . These mHigher pre-operative IFABP levels were associated with increased patient age, increased patient weight, prior initiation of pre-operative nutrition, and no prior prostaglandin use. The association of IFABP with age is both a pronounced and an interesting finding, as previously Pathan et al.  found noHigher post-operative IFABP levels were associated with longer CPB time, higher VIS, higher peak creatinine, single ventricle physiology, and duration of mechanical ventilation. Increased VIS has been prospectively shown to be associated with longer length of intubation, ICU stay, and hospital stay , and itsWe did not find a significant association between IFABP levels and early enteral feeding initiation/advancement, as measured by percentage of goal enteral kcal achieved by post-operative days 3 or 5. Our lack of a significant association is in contrast to the study by Typpo et al.  which doWe did show that higher Aristotle score, longer selective cerebral perfusion time, the need for pre-operative intubation, longer post-operative intubation time, and higher VIS were all associated with slower enteral feeding advances. A prior study by Alten et al., using the Pediatric Cardiac Critical Care Consortium registry to examine perioperative feeding management showed a wide variety of clinical practice surrounding feeding advancements , highligIn both our study and the study by Alten et al., the variables found to be associated with enteral feeding initiation/advancement were known to the clinicians making the decisions regarding the speed of enteral feed advances. This finding is not surprising, as decisions to initiate and advance enteral nutrition in the early post-operative period generally hinge on observable physiologic markers and clinically visible risk factors. Whether an infant will tolerate advancing nutrition is more difficult to assess, as evidenced by the findings of Lannucci et al., who elegantly demonstrated similar clinical characteristics among infants who were initiated on post-operative enteral nutrition and did or did not subsequently proceed to develop NEC . TherefoIn this study, we demonstrate for the first time in CHD patients an independent association between early IFABP levels and subsequent development of suspected or definite post-operative NEC. This association is consistent with prior studies in the premature neonate population –25, 56. Our study has several limitations. The subjects were recruited from a single institution, limiting generalizability to other centers. Additionally, while limited to infants, this study incorporated a range of congenital defects and subsequently a range of clinical severity. A large multi-institutional study would better be able to account for variances in disease process and clinical severity. The study was designed to only look at pre- and immediate post-operative IFABP, and did not look at ongoing IFABP levels, which would help better establish the temporal relationship between serum IFABP and NEC, as well as its potential utility as a point-of-care biomarker. Finally, the modified Bell Staging Criteria for NEC is imperfect in its application in the cardiac population, as it was designed primarily for the neonatal population. In particular, it is very challenging to differentiate post-operative ileus from NEC, as there is significant overlap between the radiographic and gastrointestinal findings in these two disease processes.IFABP levels rise initially following surgery with CPB in infants with CHD, then begin to fall by 24 h. IFABP levels were not associated with the clinical feeding outcome of percent of goal kcals achieved enterally on post-operative day 5. Instead, the primary predictors of clinical feeding outcomes were clinically observable factors. IFABP at 6 h was independently associated with subsequent development of suspected or definite NEC and may be useful for identifying patients at risk for development of post-operative NEC.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Colorado Multiple Institution Review Board. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.JW, PW, and JD conceived the design of the study. TU and JD performed patient recruitment. JW and TU performed data extraction. LK and JD performed IFABP analysis. JW, ST, JZ, and JD performed the data analysis and interpretation. JW and JD wrote the primary manuscript. All authors were responsible for reviewing and approving the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Since the beginning of the coronavirus disease (COVID-19) pandemic, several frontline workers have expressed their concerns about reduced emergency department (ED) utilization. We aimed to examine the changes in ED utilization during the early phase of the COVID-19 pandemic, in a country with a well-developed primary care system.COVID-related (defined as COVID-19 suspected) or non-COVID-related. Admission rates were compared using chi-square tests, and the reduction in ED visits was assessed descriptively.A retrospective analysis of ED utilization was performed in 3 Dutch hospitals during a 60-day period, starting on February 15, 2020. The identical period in 2019 was used as a reference. ED visits were labeled as P < 0.001), and they were higher for COVID-19 versus non-COVID-19 ED visits (P < 0.001).During the study period, daily ED volume was 18% lower compared to that of 2019. ED utilization further declined (-29%) during lockdown. Combined admission rates were higher in 2020 compared to those in 2019 (ED utilization was markedly reduced during the local rise of COVID-19 in a region with a well-developed primary care system and relatively low ED self-referral rates. Although it cannot directly be concluded from the findings of our study, this observation likely reflects a complex interaction between pure lockdown effects and viral fear, which warrants further research. Although it was a challenge for many EDs to simultaneously preserve sufficient capacity for “regular” emergencies, frontline workers in several disciplines and from different countries have expressed their concerns about reduced ED utilization since the beginning of the pandemic.4In the Netherlands, the first case of COVID-19 was identified on February 27, 2020. On March 12, the Dutch Government issued social-distancing rules, including a ban on events and encouraging people to work from home. These measures were further expanded on March 23, when the government declared a modified lockdown, including school closures and stay-at-home orders for those with fever or respiratory complaints. As of June 15, there have been 48 948 confirmed cases of infection  and 6065 confirmed COVID-19 deaths.In this retrospective observational study, we aimed to examine the changes in ED volume during the early phase of the COVID-19 pandemic.4 Before and immediately upon arrival, patients were screened for possible COVID-19 in all 3 EDs, based on their symptoms, known COVID-19 contacts, and travel history. ED visits were subsequently labeled as COVID (defined as possible or suspected COVID-19) or non-COVID-related. We retrieved these data, as well as whether or not patients were admitted to the hospital. ARs were compared using chi-square tests, and the percentage of reduction in ED visits was assessed descriptively. The study was approved by the medical ethical committee of Zuyderland Medical Center, Heerlen, the Netherlands (METCZ20200081).We retrospectively investigated the utilization of 3 hospital-based EDs in the southeast of the Netherlands, during a 60-day period starting on February 15, 2020. This study period corresponds with the local rise of the COVID-19 pandemic. An identical period in 2019 was used as a reference. ED 1 is a level 2 trauma center with an annual census of 25 000 patients, ED 2 is a level 2 trauma center with an annual census of 35 000 patients, and ED 3 is a level 3 trauma center with an annual census of 25 000 patients. The combined adherence area of the 3 hospitals comprises 760 000 individuals. The hospitals are situated in regions with the highest prevalence of COVID-19 in the Netherlands, with COVID-19 admission rates (ARs) ranging from 90 to 330 per 100 000 inhabitants.From February 15 to April 16, 2020, 10 347 people visited 1 of the 3 EDs. The combined AR was 52%. Of all ED visits, 2497 (AR 67%) were COVID-related and 7814 (AR 48%) non-COVID-related . During P < 0.001 for all comparisons). Only in ED 2 the AR slightly declined. Furthermore, the ARs in 2020 for COVID-related visits were significantly higher than for non-COVID ED visits .Combined ARs were significantly higher in 2020 compared to 2019 . If the COVID-related visits in 2020 are not included in the analysis, this difference rises to 66%.When comparing a 30-day period around the modified lockdown (March 16 to April 15) with the corresponding period in 2019, the decline in ED utilization is even more pronounced. ED visits were 29% lower in 2020 compared to 2019  media coverage.5 However, there probably is more than fear that keeps patients away. The (indirect) effects of lockdowns, social distancing, and improved personal hygiene have likely played a substantial role.The reduced ED volumes during the pandemic cannot be attributed to a single cause. Several papers have raised concerns about the impact of the fear of contracting COVID-19 in the hospital, and it has indeed been reported that patients have delayed seeking emergency care because of COVID-19 fears.8 Similarly, due to the restrictions in the catering industry, we expect that nightlife-related ED attendances, such as injuries and intoxications, have declined, too. Some reports also argue that reduced access may be explained by reduced ED utilization for low-urgency complaints.3 However, this may be less evident in our EDs because of the strong gatekeeper role of primary care in the Netherlands. Self-referral rates in Dutch EDs are exceptionally low compared to other countries.7 Second, hospitals canceled elective surgeries and chemotherapies, which may have caused fewer ED visits for iatrogenic complications. In addition, there may have been a tendency to postpone consultations with specialists.2 It is likely that this tendency affected ED utilization as well. Third, there are theories that a decrease in physical exertion by patients as well as improved air quality may be associated with reduced access for pulmonary and cardiovascular emergencies.9 Finally, the lockdown and school closures were associated with a significant decrease in pediatric infectious diseases disseminated through airborne or fecal-oral transmission.10 Improved hand hygiene in the community may have had similar effects.First, the lockdown has been associated with a vast reduction in workplace and traffic accidents.The strengths of this study are its multicenter design and the discrimination between COVID- and non-COVID-related ED visits. Similar utilization patterns were observed in all 3 EDs, underscoring the relevance of this phenomenon. Furthermore, this is the first study to determine changes in ED utilization in a country where primary care is well developed and largely responsible for relatively low self-referral rates to EDs. Its limitations are the retrospective nature of the study and the lack of adjustment for multiple potentially confounding factors. Also, the discrimination between COVID- and non-COVID-related ED visits could be debated, because triage criteria continued to evolve. However, this was probably the case in EDs all around the world. Furthermore, our observational findings do not allow for firm conclusions about the causes of reduced access for emergency conditions. In order to quantify the impact of fear and other potential variables on ED utilization, prospective, population-based research is warranted during future waves of this and other pandemics. This should include a qualitative analysis of the risk perception of patients who visited the ED and those who did not. A better understanding of underlying mechanisms may help reduce preventable injury resulting from delayed emergency care.In our cohort compromising 3 hospitals in the Netherlands, ED utilization was markedly reduced during the local rise of the COVID-19 pandemic. Although it cannot directly be concluded from the findings of our study, this observation probably reflects a complex interaction between pure lockdown effects and viral fear. To limit the potential collateral damage of fear on emergencies, emergency physicians and public health authorities should advocate the safety of hospital environments for patients with urgent medical problems.


Adoption of High-sensitivity troponin (hs-cTn) assays by hospitals worldwide is increasing. We sought to determine the effects of a simultaneous state-wide hs-cTn assay introduction on the implementing health service. A quasi-experimental pre–post design was used. Participants included all adult patients presenting to 21 Australian hospitals who had troponin testing commenced within the Emergency Department (ED). Data were collected for 124,357 episodes of care between 30 April 2018 and 23 April 2019; six months pre- and six months post-implementation of the assay. The primary outcome was hospital length of stay (LOS). Secondary outcomes included ED LOS, 90-day cardiovascular mortality, elevated troponin, diagnosis of acute myocardial infarction (AMI), admission to a cardiology ward, invasive cardiac procedures, and total hospital costs. Following hs-cTn implementation, there was a 1.9-h (95% CI: −2.9 to −1.0 h) reduction in overall LOS. This equated to a cost saving of over 9 million Australian dollars per year. There was no increase in diagnosis of AMI, invasive cardiac procedures or ward admissions. The use of hs-cTn assays facilitates important benefits for health services by enabling more rapid evaluation protocols within the ED. This benefit may be considerable given the large cohort of emergency patients with possible ACS. Symptoms of chest pain, indicative of possible acute myocardial infarction (AMI), are one of the most common causes for emergency department (ED) admissions worldwide ,2. PatieOver the past two decades, assays for the detection of troponin have advanced dramatically, now enabling the detection of low concentrations with high precision . High-seHowever, the potential benefits of hs-cTn assay introduction must be balanced with possible unintended harms. The use of hs-cTn assays have been linked to increased proportions of emergency patients with elevated troponin concentrations ,10 and cThe objective of this study was to describe impacts on patient care and healthcare utilisation following the introduction of a hs-cTn assay (Beckman Coulter Access hsTnI) across a large health care service. Firstly, we examined ED and hospital length of stay (LOS) in the six months pre- and post-implementation of the hs-cTnI assay. Secondly, we reported the proportions of patients with elevated troponin values, admission to cardiology wards, invasive cardiac procedures, discharge diagnoses, 90-day mortality and costs in these two periods.This is a pre–post comparison of consecutive patients who presented to EDs and underwent hs-cTn testing in 21 Queensland Health (QH) hospitals. QH provides public health care for 5 million people  with appPatients were included if they were 18 years or older and had one or more troponin tests ordered within four hours of ED presentation. Patients were excluded if they (1) discharged against medical advice, or (2) died during their admission. Such patients were excluded as the intended assessment or healthcare utilisation for such patients is unknown.The pre-intervention period was defined by the use of the Beckman Coulter AccuTnI+3 assay; an assay with the 99th percentile being 40 ng/L with the 10% coefficient of variation (CV) at 40 ng/L . The posFor both the pre- and post-intervention periods, patient management was at the discretion of the treating physician, but all sites had a recommended pathway based upon the Australian Heart Foundation and Cardiac Society of Australia and New Zealand guidelines . In the In the post-implementation period following introduction of the new assay, a reduced sampling interval of two to three hours was adopted for all patients, regardless of risk. Existing pathways were modified to incorporate shorter testing intervals but all other elements of assessment  were unchanged. Online and in-house education and training for clinicians was supported by a designated project team.Data were obtained from several QH state-wide databases. Data on ED arrival and discharge time, demographics, discharge disposition and ED diagnosis were collated from the QH Emergency Data Collection (EDC). Troponin results were obtained from Auslab laboratory information system. Data on hospital discharge time, hospital admission, procedures, and hospital diagnosis were obtained from the Queensland Hospital Admitted Patient Data Collection (QHAPDC). Death data were obtained from the Queensland Death Registry. Deterministic linkage was used to link these three databases. This linkage method involves linking records based on exact agreement of selected match variables and is recommended where direct identifiers are available and are of good quality. Each database contains a unique patient record number (URN) that was used in combination with date and time data to link the patient records.The primary outcome was hospital LOS, calculated as the difference between date and time of arrival and date and time of discharge as an acute care patient. Time spent in a healthcare facility as a nonacute patient was not incorporated in overall LOS . Secondary outcomes included ED LOS; 90-day cardiovascular mortality, defined as death resulting from an AMI, sudden cardiac death, heart failure, cardiovascular (CV) procedures, CV hemorrhage, or other CV causes; elevated troponin, defined as a troponin value > 99th percentile ; ED and hospital diagnosis of AMI, defined using ICD-10 codes assigned on ED or hospital discharge see ; admissiA total of 1.6 million patients present to a Queensland ED each year  and apprData were analysed using Stata 14 . The cohort comprised episodes of care six months pre- and post- implementation of hs-cTn assay. Data for the two weeks after implementation of the hs-cTnI assay were not included as a mix of hs-cTnI and c-TnI were used during this time in some hospitals.Descriptive statistics were calculated for the pre- and post-implementation periods. For all endpoints, data were presented for the overall cohort and by sex. For LOS, the median was reported for the pre- and post-implementation periods. The difference between the two medians and 95% confidence interval (CI) of that difference was calculated using quantile regression. Quantile regression was also conducted to adjust for a number of factors, including time (weeks after study commencement), triage category and arrival mode. Time was incorporated to ensure that the results were not confounded by changes in LOS that can occur across time due to nonintervention factors . The median difference calculated after adjusting for time reflects the immediate change in LOS that occurred after implementation of the assay. Triage category and arrival mode were incorporated to adjust for the minor baseline differences in these variables across the two study periods.The proportion of patients meeting the secondary endpoints of admission to a cardiac ward, invasive cardiac procedures, or elevated troponins were reported for the pre- and post- implementation periods. The difference in proportions and 95% CI of the difference were calculated using generalised linear models with a binomial distribution. As with the primary endpoint, all differences were then adjusted for time, triage category and arrival mode. For both the primary and secondary endpoints, CIs were adjusted for clustering of patients within hospitals.For mortality, patients were followed up for 90 days after presentation to the ED. In cases where the patient re-presented within 90 days, a single representative admission was selected at random from within that period for inclusion in the study dataset. Kaplan-Meier survival functions were calculated for cardiovascular mortality.To describe the potential savings associated with ward time, the difference in mean LOS between pre- and post-implementation was calculated. The average number of hours saved was multiplied by the hourly ward cost. We used previously published estimates for ward costs ($67 per hour) , but indData were available from 63,335 episodes in the pre- and 61,022 in the post-implementation periods. While the baseline data were similar across study periods, there were minor differences in triage category and arrival mode .Median hospital LOS was 11.1 h (IQR 5.0–45.4) in the pre-intervention and 9.1 h (IQR = 5.1 to 43.7 h) in the post-intervention period; a reduction of 1.9 h  . There wDeath from a CV cause (up to 90 days after presentation) occurred in 513/54,600 (0.9%) pre-implementation patients and 333/52,310 (0.6%) post-implementation patients; a reduction of 0.3% (95% CI: −0.4 to −0.2). After adjustment for baseline characteristics, there was no difference in CV mortality in the two periods . Death from a CV cause occurred in 219 (0.8%) females pre- and 140 (0.5%) post-implementation. For males, CV deaths occurred in 294 (1.1%) patients pre- and 193 (0.7%) patient’s post-implementation.There was no extra cost associated with using the new assay; the cost per test was the same for pre- and post-implementation periods, and the average number of troponin tests ordered per patient did not differ. Using unadjusted data, there was a 1.6-h difference in the mean length of stay between groups; a reduction in hospital costs of approximately $119.20 per person. Presuming 124,357 patients per year (as seen in this study), this would mean a saving of $14,823,354 per annum. Using adjusted data, there was a 1.0-h difference, making this saving $9,264,597. Adoption of the new assay would save the system 198,971 h of ward-bed time—approximately 8290 days—per annum, across the Queensland hospitals included.This is the first large study examining the implications of introducing the Beckman Coulter hs-cTnI assay into clinical practice. In this emergency population, implementing a hs-cTnI assay was associated with a moderate reduction in hospital LOS. There was an increased proportion of patients with troponin values above the 99th percentile but no increase in cardiac admissions, invasive coronary procedures or diagnosis of AMI.The rate of detection of myocardial injury (with or without AMI) increased by 12% for females and 5% for males  with the introduction of the hs-cTnI assay. The increase in females is higher than males as sites transitioned from using the overall 99th percentile cut point for the sensitive assay, to the new sex-specific 99th percentile cut points for the hs-cTn assay. The overall increase is slightly higher than that reported in previous research; there was an absolute increase of 4% using the Roche Elecsys hs-cTnT assay  and an iDespite the increased identification of myocardial injury, diagnostic rates for AMI were unchanged. This finding is counter to previous research that has reported increases in diagnostic rates for AMI of between 4% and 5% after the introduction of the hs-cTnT assay ,21. PrevThe proportion of patients undergoing single troponin testing decreased markedly following implementation of the hs-cTnI assay. This finding was not anticipated as there are some indications for single troponin testing when using a hs-cTnI assay but not a contemporary cTn assay . During Hospital LOS was reduced by 1−2 h in the current study. This is likely a conservative estimate of the LOS reductions that can be gained using a hs-cTn assay as around half of the sites had previously converted to the IMPACT pathway. This pathway incorporates two- to three- hour serial sampling using a sensitive troponin assay for patients with low- to intermediate-risk clinical features . As showThe ED LOS was unchanged in our study. This may be due to the Australian focus on a 4-h disposition metric . To meetOur study showed no change in the proportions of patients undergoing invasive cardiac procedures with the introduction of the new assay. Prior reports of the impact of hs-cTn assays on cardiac procedures is mixed. Some studies have shown no impact ,24. One This was based on administrative data. The accuracy of such data are not known, potentially influencing study estimates. In accordance with the universal definition of myocardial infarction, sex specific cut-points were reported for hs-cTn assay . The speThe transition to a more precise troponin assay for patients with suspected ACS was associated with reduced hospital LOS, without an increase in cardiac admissions, invasive coronary procedures or diagnosis of AMI. The current study supports the increasing adoption of hs-cTn assays around the world. High sensitivity cTn assays enable more rapid evaluation protocols within the ED; a considerable benefit given the large cohort of emergency patients with possible ACS.


To determine whether individuals with proposed gadolinium deposition disease (GDD) have elevated serum levels of pro-inflammatory and pro-fibrotic cytokines, and whether specific cytokines are correlated with certain symptoms.Twenty-four participants recruited between May 2016 and June 2017 met GDD diagnostic criteria. The 64 control subjects provided serum samples before prophylactic flu vaccination. Serum cytokine levels were obtained with Luminex serum cytokine assay using eBiosciences/Affymetrix human 62-plex kits. Wilcoxon rank-sum tests were performed to assess the difference between the median fluorescence intensity values for the participants and the control group. Generalized linear models were built to evaluate the association between each cytokine of interest and selected participant symptoms.p ≤ 0.05). Hypotheses regarding pro-fibrotic cytokines and cytokine links to specific symptoms' intensity were not confirmed.Serum levels of 14 cytokines, including nine pro-inflammatory cytokines, were statistically significantly elevated compared to controls (The statistically significantly elevated cytokines may be markers of susceptibility to GDD or agents of symptom induction. These findings suggest that individuals developing symptoms characteristic of GDD after a contrast-assisted magnetic resonance imaging should be studied to investigate whether gadolinium retention and elevated cytokines may be related to their symptoms. The symptoms begin unexpectedly within minutes (pain) to two months (skin thickening). The symptomatic patients exhibit gadolinium (Gd) retention a month or more post MRI, which is unexpected because contrast media half-lives are about 1.5 hours. Gd retention in patients with normal renal function has been reported, albeit without concomitant investigation for retention-associated symptoms, in bone, skin , cerebral spinal fluid , and brain ,7.A recently described disease termed gadolinium deposition disease (GDD) has been reported in patients with normal kidney function after magnetic resonance imaging (MRI) enhanced by gadolinium-based contrast agents (GBCAs)in vivo cytokine serum levels in individuals meeting the proposed diagnostic criteria for GDD. The study's case-control design compared the serum cytokine levels of the study's volunteer sample to those of age and sex-matched controls. Based on in vitro and animal studies of Gd effects on cytokine expression, we hypothesized that serum levels of pro-inflammatory and pro-fibrotic cytokines would be abnormally elevated and associated with specific GDD symptoms, as detailed below.We report the first study of . Some characteristic NSF symptoms are common and chronic in GDD, including skin pain in a glove-and-stocking distribution with a burning or pins-and-needles quality, bone pain, distal leg and arm pain, spongy or rubbery subcutaneous skin thickening and tightness, and hyperpigmentation,8. Many GDD patients, however, experience symptoms not reported in NSF, including frequent, persistent headaches, clouded mentation, and changes in vision or hearing.In patients with markedly reduced renal function, exposure to GBCAs has caused a devastating illness, nephrogenic systemic fibrosis (NSF). The effect under study here is increased cytokine expression. Other disruptive effects include calcium channel blockade; inhibition of mitochondrial function; inhibition of Ca2+-activated enzymes; and, induction of oxidative stress.Many biological effects of Gd disrupt normal physiology and could lead to symptoms of toxicityIn vitro studies report that both linear and macrocyclic GBCAs, as well as GdCl3, induce pro-inflammatory and profibrotic cytokine production by human monocytes,12. The induced cytokines include the pro-inflammatory cytokines interleukin-6 (IL-6) and interferon-γ (IFN-γ) and the pro-fibrotic cytokines IL-4 and transforming growth factor-β (TGF-β), along with cytokine IL-13 (both fibrogenic and with mixed pro- and anti-inflammatory actions), and growth factor vascular endothelial growth factor (VEGF). The monocyte response variability across individuals suggests variability in individual sensitivity to GdCl3 and to the contrast agent studied, Gd-DTPA..Rats injected with the GBCA gadodiamide, again reaching higher than clinical serum concentrations, exhibit significantly elevated serum levels of VEGF and the pro-inflammatory cytokines tumor necrosis factor-α (TNF-α), and monocyte chemotactic proteins 1 and 3 (MCP-1 and MCP-3)-16. DRG inflammation up-regulates several pro-inflammatory cytokines including IL-6 and induces hyperalgesia/allodynia.Animal studies indicate that TNF-α can enhance pain sensation by increasing the sensitivity of peripheral nociceptive and dorsal root ganglion (DRG) neuronsallodynia.in vitro and animal study results and the symptoms of GDD, we hypothesized that serum levels of the pro-inflammatory cytokines IL-6 and TNF-α, of VEGF, and of the pro-fibrotic cytokines IL-4 and TGF-β will be higher in GDD patients than in age- and sex-matched controls. Secondarily, we hypothesized that serum levels of cytokines heretofore unstudied in relationship to Gd, both pro-inflammatory cytokines related to pain symptoms and pro-fibrotic cytokines related to skin thickening and other symptoms, will be higher in GDD patients than in controls.Given these https://gadoliniumtoxicity.com. One investigator (LMK) carefully interviewed all respondents by telephone to determine their study participation interest and their inclusion/exclusion criteria status.This case-control study enrolling a volunteer sample was approved by the Stanford Institutional Review Board. All participants signed written informed consent. GDD participants were recruited between May 2016, when the first participant was seen clinically, and June 2017. The subsequent participants were recruited via a study notice posted on the website Study inclusion criteria were: i) meets provisional diagnostic criteria for GDD, as specified in an FDA-approved protocol for treating GDD with DTPA chelation . These criteria are: presence of ≥ 3 of 8 symptoms-cognitive disturbance, extremity pain, arthralgia, chest wall pain, skin pain, headache, skin induration, and skin hyperpigmentation. Although the latter two symptoms were reported in investigator's interview and were not investigator-observed, excluding these symptoms did not affect participant eligibility. All study participants reported presence of at least three of the remaining six GDD symptom criteria; ii) had an unprovoked 24-hour Gd urine excretion level exceeding the laboratory norm ≥ 28 days after the symptom-inducing MRI.Study exclusion criteria were: i) GDD present for > 2 years before the interview date ; ii) original GDD symptoms no longer causing substantial distress or impaired functioning in activities of daily living; iii) presence of an illness or medication known to markedly elevate serum cytokine levels, e.g., rheumatoid arthritis, systemic lupus, or cancer. Presence/absence was determined in the detailed clinical interview.Of the 48 respondents, 24 (50%) met the inclusion criteria and agreed to participate; 7 (15%) did not meet diagnostic criteria; 6 (13%) had been ill for more than two years; 4 (8%) had a confounding illness ; 3 (6%) were no longer suffering substantial distress or impaired functioning; 3 (6%) declined to participate after the study was explained; and 1 (2%) was too ill with GDD symptoms to participate. One participant (number 2) had been ill for 2.9 years, but was included before the 2-year cutoff criterion was decided upon. (None of the cytokine results for this subject were at the extremes for the participant group.)The 24 participants, 20 women and 4 men, had a median age of 46 years . Their GDD symptoms are shown in  and unpublished studies in which one author [HTM] collaborated) to provide a large enough, age- and sex-matched group whose cytokine results should adequately represent the cytokine range for healthy subjects. We cannot guarantee that there are no confounding factors in any of these individuals, but this control group is relatively large. Potential control subjects were excluded for a history of autoimmune disease, cancer (other than non-melanoma skin cancer), or other major chronic illness, but not for history of cardiovascular disease. Further description of the inclusion/exclusion criteria, the serum sampling schedule, and the assays utilized for all members of the control group is provided elsewhere.The 64 control subjects were 45 women and 19 men with a median age of 41.5 years . The control group was drawn to closely match the GDD participants' demographic characteristics. None were acutely ill; their serum samples were obtained prior to a prophylactic flu vaccination. The control group was selected from several influenza vaccine studies , 11 months and 21 months after the symptom-inducing MRIs.. Each sample was measured in duplicate.Luminex serum cytokine assay was performed by the Human Immune Monitoring Center. Human 62-plex kits purchased from eBiosciences/Affymetrix were used according to the manufacturer's recommendations with modifications as described elsewhereThe cytokine median fluorescence intensity (MFI) values were normalized before being entered into the analysis. The samples were contained in four plates, so normalization to a shared control serum was used to minimize plate-to-plate differences. Control serum values  in one plate were taken as the reference objects, and the other plates were normalized according to their control serum value ratios  to remove the batch effects across plates.Blank ratings in the symptom questionnaire  were trea priori knowledge; therefore there was no adjustment for multiplicity testing. Analyses were conducted first without and then with adjustment for participant age, gender and body mass index. The tests were performed in JMP® Pro 13.1.0 (SAS Institute Inc.) and R (version 3.4.3). All p values reported are two-sided; and a p value ≤ 0.05 was considered statistically significant.Generalized linear models were built using stats package in R to evaluate the association between each cytokine of interest and selected participant symptoms, according to our None of the indications for contrast-enhanced MRIs involved conditions with major effects on cytokines . Some paMacrocyclic GBCAs were associated with symptom onset in 14 participants and linear GBCAs in 10 . The parSerum levels of 14 of 62 tested cytokines were significantly elevated compared with those of the controls . Only onin vitro monocyte exposure to Gd, only one, IL-6, was significantly elevated in the participants compared with the controls. One participant had a comorbid condition that tends to increase IL-6 serum levels and eight were taking medications/supplements that tend to lower these levels. Serum levels of the other cytokines-VEGF, IL-4, IFN-γ and TGF-β, which are involved in angiogenesis, fibrosis, wound repair, cell growth, cell proliferation and stimulating macrophage phagocytosis-were not significantly elevated in the participants' serum.Of the five cytokines found elevated after Serum level of the pro-inflammatory cytokine TNF-α was also significantly elevated. Four participants had conditions that tend to increase TNF-α serum levels and seven were taking medications/supplements that tend to lower these levels.As hypothesized, pro-inflammatory and inflammation-related cytokines previously unstudied in relationship to Gd exhibited significantly increased serum levels: IL-8, IL-18, IL-23, IL-31, TGF-α, growth related oncogene alpha (GRO-α), and leukemia inhibitory factor (LIF). Though not specified in our hypothesis, serum MCP-3 levels were also elevated. The elevations of vascular cell adhesion molecule (VCAM), stem cell factor (SCF) and IL-15, which stimulates natural killer cells to kill viruses, were unexpected.p value of < 0.05. However, higher serum levels of IL-10 were significantly associated with reduced muscle pain ratings (p = 0.005).The hypotheses regarding associations of specific individual cytokines with the pain symptom cluster or with individual symptoms were not confirmed. No symptom or symptom cluster yielded a For the serum samples from the five participants providing samples before and after one or more chelation treatments with DTPA, we focused on the six cytokines most significantly elevated in the whole groups' samples compared to the controls: TNF-α, GRO-α, TGF-α, IL-15, IL-6, and MCP-3. Of these cytokines, five participate in inflammatory response, and one, IL-15, activates cell proliferation and natural killer cells. In general, post-chelation increases in these cytokine levels were more frequent and larger in participants whose serum was drawn sooner after their last MRI. More specifically, cytokine level increases for IL-6 were larger for all three participants drawn sooner than for those drawn at 11 and 21 months post-MRI. One participant demonstrated an increase in all six cytokines post-chelation, one in five of the six, one in four, and two in two. Looked at together, the patterns of cytokine changes post-chelation were patient-specific, but with many cytokines following a similar pattern in a given patient, often increasing immediately after chelation .in vitro and animal studies,13,19.This first study of cytokine serum levels in individuals meeting proposed diagnostic criteria for GDD after exposure to linear or macrocyclic GBCAs found significantly elevated serum levels of multiple pro-inflammatory cytokines, but not of pro-fibrotic cytokines, as compared to the levels in normal controls. These cytokine findings are the first biological abnormalities reported in this disorder. We intentionally used a multiplex assay to assess a large battery of cytokines in order to discover possible changes beyond those we hypothesized, which hypothesized changes were based on reported GDD symptoms and on the findings from the Given that the elevated cytokine levels were observed in subjects exposed to six different GBCAs, it is uncertain whether all GBCA agents had sufficiently similar immunologic effects or if some consistent de-chelated species of Gd was responsible . No significant difference in cytokine levels was seen between participants receiving the most commonly represented GBCA (gadobutrol) and those receiving other GBCAs..Because no serum samples were available from before exposure to the symptom-associated GBCAs, we cannot be certain that the elevations are related to Gd retention. However, the cytokine increases frequently seen after induction of Gd into the circulatory system via chelation, lend weight to the possible association. Perhaps the elevations signal patients who are more sensitive to cytokine stimulation effects of Gd, as proposed by the group that first described GDD, and the findings in other disease settings such as chronic fatigue syndrome, dilated cardiomyopathy, and hepatitis C infection in abstinent alcoholics.Second, the participant and control group cytokine distributions overlap. This is not unexpected, given the broad range of normal human variation. However, the four other pro-inflammatory cytokines elevated in chronic stress studies were not elevated in our participant sample, nor were five of the nine such cytokines observed in the sample. Thus, while chronic stress may have played a role in the observed pattern of elevated pro-inflammatory cytokines, the pattern is unlikely to be due solely to chronic stress.Many factors, including obesity, presence of infectious disease, chronic stress, menstrual cycle day, diet, and time of day a serum sample is obtained, can influence the levels of pro-inflammatory cytokines. As noted, however, adjusting the analyses for body mass index did not change the results. Further, one study author (LMK) confirmed that no study participant had a cold, flu or other infectious disease when the serum sample was drawn. With regard to chronic stress, four of the nine abnormally elevated, pro-inflammatory cytokines, TNF-α, TGF-β, IL-2, and IL-6, observed in the participants have been reported elevated in chronic stressThe distributions of the other factors, menstrual cycle day, diet, and time of day of serum sample draw, would be expected to be similar within the participant group and the age- and sex-matched control group. The consistent pattern of elevated inflammatory cytokines in the participant group is unlikely to have occurred by chance affecting all these potential influences in one direction in the participant group and in the other direction in the control group.; and, the pain of GDD sufferers is frequently of neuropathic quality. The elevation of TNF-α is of interest in that it both plays a role in inflammation and increases the excitability of nociceptive neurons in the DRG. The abnormal elevation of SCF, which stimulates melanocytes, is of interest given that half the participants complained of increased skin pigmentation. The possible roles of all of these abnormally elevated cytokines in producing GDD symptoms deserve exploration in future research. The degree of participants' cytokine level elevation did not diminish with length of illness, which finding is consistent with the persistence of their GDD symptoms. Moreover, the adverse drug reaction probability scale indicates that Gd retention is at least a "probable" cause, i.e., the participants' symptom picture scores 7 of 13 points; "probable" is a score of 5 to 8 points. In addition, Gd chelation with DTPA can provoke transient symptom worsening, likely due to temporary exposure to increased circulating Gd.The elevated cytokines we found have plausible mechanistic connections to the GDD symptoms of chronic pain and new, frequent headaches. IL-6 promotes increased levels of MCP-3, which in turn appears to play a role in neuropathic pain statesThe non-confirmation of our hypotheses relating specific cytokines to a pain symptom cluster and other symptoms may reflect a true absence of relationships, the small sample size, clustering pain symptoms inappropriately, the use of an unvalidated questionnaire, or collecting serum samples at different times of day. The absence of an elevated serum level of IL-10, except in relationship to muscle pain, suggests this compensatory mechanism plays only a limited role in the body's chronic response to Gd physiological actions.. The differences in the participants' cytokine responses to chelation also echo the variable responses seen in the in vitro study of monocyte preparations from healthy individuals.The reason for the cytokine level changes immediately after DTPA chelation is not clear. Suggested explanations include that the transmetallation process converting Ca-DTPA to Gd-DTPA during chelation creates Gd exposure; reintroduction into the vascular system of Gd as Gd-DTPA or other Gd species that stimulates immune cells to produce cytokines; or cytokine response simply to Gd-DTPA itself. Third, the participants' cytokine levels were studied at varying times after symptom onset. As noted, however, serum cytokine levels were not significantly related to the time between symptom onset and serum draw. Fourth, the participants' pre-MRI cytokine levels were not ascertainable. Although participants' blood samples were not all drawn at the same time of day, this was equally true for the control subjects. And, while, some participants' comorbid condition, medications or supplements could affect certain cytokine levels, these effects were more often to lower than to raise these levels. Future studies utilizing larger patient samples, designs able to test for causality, and more closely matched control groups, are needed.This study has several limitations. First, the sample size is small. Second, although patients receiving a GBCA injection but not reporting post-MRI symptoms would be an ideal control group, our approach, employing a control group of random, healthy subjects is a standard one in medical research, including prior research on Gd toxicityin vitro and in animal studies deserve further investigation.In summary, GDD appears to be associated with elevations of cytokines that are pro-inflammatory or involved in inflammation; some of these cytokines can also enhance pain sensation, a common symptom in the disorder. These biological findings suggest that individuals with normal renal function who complain of symptoms characteristic of GDD after a contrast-assisted MRI should be tested to determine whether their symptoms may be associated with Gd retention. In such cases, preliminary evidence suggests chelation with DTPA may be beneficial. Whether and how symptoms of GDD are related to cytokine changes and the other biological effects of Gd observed