Each year, there are an estimated 11 million visits to ambulatory care centers for pharyngitis in children between the ages of 3 and 18 years. While there are many causes of pediatric pharyngitis, group A streptococcal pharyngitis represents 15 to 30% of infections and is the only cause for which treatment is recommended. Unfortunately, clinical suspicion is insufficient for the accurate diagnosis of group A streptococcal pharyngitis, and laboratory testing for confirmation of Streptococcus pyogenes infection is required to prevent complications of infection. Traditionally, throat swabs are inoculated onto agar plates for isolation of the large-zone beta-hemolytic streptococcus. However, traditional culture methods present a potential delay in treatment due to turnaround times of 18 to 48 h. In order to improve turnaround times and enhance antimicrobial stewardship, multiple point-of-care assays have been developed. This review describes current point-of-care testing for group A streptococcal pharyngitis, including rapid antigen detection tests and more recent molecular methods. Additional attention is given to the diagnostic considerations when choosing a method for group A streptococcal point-of-care testing, implementation of molecular group A streptococcal testing, and the institutional cost of immunoassays compared to those of newer molecular methods.

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Characterizing hyolaryngeal movement is important to dysphagia research. Prior methods require multiple measurements to obtain one kinematic measurement whereas coordinate mapping of hyolaryngeal mechanics using Modified Barium Swallow (MBS) uses one set of coordinates to calculate multiple variables of interest. For demonstration purposes, ten kinematic measurements were generated from one set of coordinates to determine differences in swallowing two different bolus types. Calculations of hyoid excursion against the vertebrae and mandible are correlated to determine the importance of axes of reference.To demonstrate coordinate mapping methodology, 40 MBS studies were randomly selected from a dataset of healthy normal subjects with no known swallowing impairment. A 5 ml thin-liquid bolus and a 5 ml pudding swallows were measured from each subject. Nine coordinates, mapping the cranial base, mandible, vertebrae and elements of the hyolaryngeal complex, were recorded at the frames of minimum and maximum hyolaryngeal excursion. Coordinates were mathematically converted into ten variables of hyolaryngeal mechanics.Inter-rater reliability was evaluated by Intraclass correlation coefficients (ICC). Two-tailed t-tests were used to evaluate differences in kinematics by bolus viscosity. Hyoid excursion measurements against different axes of reference were correlated. Inter-rater reliability among six raters for the 18 coordinates ranged from ICC = 0.90 -0.97. A slate of ten kinematic measurements was compared by subject between the six raters. One outlier was rejected, and the mean of the remaining reliability scores was ICC = 0.91, 0.84 -0.96, 95% CI. Two-tailed t-tests with Bonferroni corrections comparing ten kinematic variables (5 ml thin-liquid vs. 5 ml pudding swallows) showed statistically significant differences in hyoid excursion, superior laryngeal movement, and pharyngeal shortening (p < 0.005). Pearson correlations of hyoid excursion measurements from two different axes of reference were: r = 0.62, r 2 = 0.38, (thin-liquid); r = 0.52, r 2 = 0.27, (pudding).Obtaining landmark coordinates is a reliable method to generate multiple kinematic variables from video fluoroscopic images useful in dysphagia research. Video LinkThe video component of this article can be found at

In kidney transplantation acute allograft rejection is the most common cause of late allograft loss. Changes in indoleamine 2,3 dioxygenase (IDO) activity, which catabolizes the degradation of tryptophan to kynurenine, may predict rejection. However, exogenous IDO is immunosuppressive in rodent kidney transplantation. Thus, the increase in IDO activity observed in acute allograft rejection is insufficient to prevent rejection. To address this question, we assessed the regulation of IDO and its role in acute rejection in a porcine model of kidney transplant. In tissue samples from rejecting kidney allografts, we showed a 13-fold increase in IDO gene transcription and 20-fold increase in IDO enzyme activity when compared with autotransplanted kidneys. Allografts also demonstrated an over fourfold increase in tissue interferon (IFN)-γ, with marked increases in tumor necrosis factor (TNF)-α, TNF-β and interleukin 1β. Gene transcription and protein levels of kynurenine 3-monooxygenase (KMO) were decreased. KMO generates the immunosuppressive kynurenine, 3-hydroxykynurenine. The results of these studies demonstrate a clear association between rejection and increased allograft IDO expression, likely driven in part by IFN-γ and facilitated by other cytokines of the allogeneic response. Moreover, the loss of downstream enzymatic activity in the IDO metabolic pathway may suggest novel mechanisms for the perpetuation of rejection.

Background Cardiac surgical interventions, extracorporeal membrane oxygenation, transcutaneous coronary-artery angioplasty, and stenting are carried out while patients are being treated with the anticoagulation drug heparin. Monitoring the level and reversal of heparinization during and at the conclusion of medical and surgical procedures is a critical issue in patient care. Methods We performed parallel testing of the ACCRIVA Hemochron Signature Elite ACT+ and Hemochron Response analyzer, iSTAT platform, and 2 Hepcon Hemostasis Management System (HMS) Plus analyzers for monitoring intraoperative heparin treatment. Laboratory anti-Xa assay was used as the criterion standard for heparin measurement. Results Poor correlation between the 2 Hemochron analyzers was identified at 0.78. Correlation between the analyzers on the i-STAT platform was 0.97. Regression analysis revealed that i-STAT values were generally lower, by 43 seconds, than Hemochron values. The correlation between Hepcon and i-STAT activated clotting time (ACT) results was 0.94. The i-STAT ACT results were generally 23 seconds lower than the Hepcon ACT values. Correlation coefficients on comparing Hepcon ACT and i-STAT ACT using laboratory anti-Xa assay were 0.83 and 0.87, respectively. The correlation between Hepcon heparin concentration and anti-Xa results was 0.85. Conclusions ACT monitoring with iSTAT offers good correlation between instruments and with the Hepcon ACT. Hepcon occupies a specific niche in cardiac operating departments because of its ability to provide additional information regarding heparin concentration; however, lack of suitable proficiency testing may impair its use. The iSTAT is a more reliable platform for broader, hospital-wide application.

The hybrid off-pump CABG and transaortic TAVI procedure allows for more complete coronary revascularization, negates the need for DAPT, and minimizes treatment delay of a TAVI procedure, particularly in patients unsuitable for transfemoral access. We propose this as an important treatment option for the heart team to consider. © 2016 Wiley Periodicals, Inc.

Thirty male patients undergoing coronary artery bypass grafting were divided into two groups, group I receiving pulsatile perfusion, group II nonpulsatile perfusion. A double roller pump system for extracorporeal circulation was employed. Intra- and postoperative fluid balances and bodyweight gains were controlled under clinical conditions. There were no significant differences between the groups with regard to clinical data, operative procedure, perfusion parameters, drug treatment or intensive care treatment. The intra-operative mean fluid balance of group I was 794.0ml (66%) lower than that of group II, while the balance 24 hours postoperatively was 136.7ml (37%) lower in group I. Thus, the total mean fluid balance for the pulsatile group was 931.0ml (59%) lower than the nonpulsatile group, in accordance with the bodyweights, which showed a 954.0g (63%) lower outcome in the pulsatile group. Less supplementary volume and higher urine production were the main factors. It appears that volume saved during pulsatile ECC need not be replaced postoperatively. These findings indicate that pulsatile perfusion leads to diminished fluid overloading, which could be an important advantage, especially for high-risk patients.

Background Idiopathic inflammatory myopathies (IIMs) encompass many rheumatologic diseases characterized by inflammatory muscle disease, typically unified by proximal muscle weakness. A subset of patients with IIM present with interstitial lung disease (ILD) with identifiable antibodies such as in anti‐synthetase syndrome (AS) with antibodies to aminoacyl‐tRNA synthetases, and clinically amyopathic dermatomyositis (CADM) with anti‐melanoma differentiation‐associated protein 5 (MDA5). Recent case reports demonstrate response to therapeutic plasma exchange (TPE) or column filtration plasmapheresis in IIM with ILD resistant to medical management. We present our experience with eight patients with IIM with ILD undergoing TPE at a large US‐based hospital system. Patient characteristics Eight patients with IIM with ILD were treated with TPE over the last 10 years. The therapy consisted of 5‐7 one plasma volume exchanges every other day to daily. Seven of eight patients had identifiable antibodies. Results Following completion of TPE, seven of eight demonstrated improvement in pulmonary function despite lack of improvement of pulmonary function with standard therapy. Conclusion In antibody‐mediated, treatment refractory IIM with ILD, TPE may be a viable intervention. This is a disease for which the role of apheresis is evolving. Clinical trial registration Not application.