The Impact of New Commercial Tests Evaluating Cell-free Fetal DNA in Maternal Circulation for Aneuploidy Detection in High-risk Patients

ABSTRACT The purpose of this study is to assess how the introduction of cell-free fetal DNA (cffDNA) tests on a population of patients with high-risk for aneuploidy from Maternal Fetal Medicine of Lehigh Valley Health Network has affected the use of invasive procedure in the practice over a period of time. This study included all women determined by specific indicators to be at a high-risk for aneuploidy seen in Maternal Fetal Medicine at Lehigh Valley Health Network (LVHN) from 01/01/2012 to 12/31/13 who underwent cell-free fetal DNA testing. The cffDNA tests performed during the study period included MaterniT21 Plus, Verifi Prenatal Test, and Harmony Prenatal Test. A total of 958 patients underwent cffDNA testing during this time period. The results were, 922 negative, 28 positive, 5 non-reportable, 1 unclassified, and two cancelled tests. There was one false positive and two false negatives. The use of non-invasive cffDNA testing increased over the two-year period while the use of invasive procedures decreased. BACKGROUND Fetal aneuploidy is an abnormal number of chromosomes in a fetus’s DNA caused by missing or extra chromosomes that originate during cell division. An abnormal number of chromosomes can result in genetic disorders and birth defects. The three most common types of aneuploidy are Trisomy 21 (Down syndrome), Trisomy 18 (Edwards syndrome) and Trisomy 13 (Patau syndrome). Each of these forms of aneuploidy result in mental retardation, growth abnormalities, heart abnormalities and significantly increased death rate, as well as other distinctive features and abnormalities. Screening for fetal aneuploidy is important in both low-risk and high-risk pregnant patients. While the risk of aneuploidy does increase with different factors such as advanced maternal age (≥35 years old), all patients have some degree of risk. Acknowledging the importance of these tests, starting in 2007 the American College of Obstetricians and Gynecologists (ACOG) has recommended that all pregnant women be offered aneuploidy screening and testing, regardless of risk factors (1). Both invasive and non-invasive tests are available. Invasive tests, such as amniocentesis and chorionic villus sampling (CVS), provide the most accurate information but, because they are invasive, are associated with a small risk of miscarriage. Non-invasive tests are performed on maternal serum (blood), and are therefore not associated with a risk of miscarriage. However, these tests are not precise and produce some false positive and false negative results. Previously, the only commercially available noninvasive screening tests were maternal blood tests that identified levels of maternal serum biochemical markers, such as hCG, PAPP-A, Estriol, Inhibin-A, and AFP, and also used a number of factors including age and ethnicity to determine a ratio estimating a patient’s chance of fetal aneuploidy (2). Studies show the maternal serum tests have an accuracy of 80-92% for trisomy 21 and 70-85% for trisomy 18, dependent on the type of test. These screening tests can only be performed during the first trimester of pregnancy and require specific patient demographics to produce an accurate result (2). Although the sensitivity and specificity of screening protocols have improved, until recently, definitive diagnosis was possible only through the use of invasive procedures. In the fall of 2011, a new form of non-invasive aneuploidy tests for the diagnosis of fetal trisomy 13, 18, and 21, and sex chromosome abnormalities first became commercially available. These tests are referred to as cell-free fetal DNA (cffDNA) or non-invasive prenatal testing (NIPT). These tests evaluate fetal genetic material in the maternal circulation and can be offered as early as 10 weeks of pregnancy and can be performed at any point during pregnancy (3). Several studies have reported sensitivities and specificities for the three different aneuploidies approaching 100% (4,5). The commercial use of the tests is less than five years in practice and while supported with many studies, it is in need of large-scale clinical trials to confirm results and provide more information for both provider and patient. With higher accuracy than previous screening tests, and less risk and discomfort than invasive testing, the cffDNA tests have the potential to replace invasive testing over time. The purpose of this study is to assess how the introduction of cell-free fetal DNA tests on a population of patients with high-risk for aneuploidy from Maternal Fetal Medicine of Lehigh Valley Health Network has affected the use of invasive procedure in the practice over a period of time. METHODS This is a retrospective cohort study. The inclusion criteria for this study were all women determined by specific indicators to be at a high-risk for aneuploidy seen in Maternal Fetal Medicine at Lehigh Valley Health Network (LVHN) from 01/01/2012 to 12/31/13 who underwent cell-free fetal DNA testing. Indicators of “high-risk” included advanced maternal age (AMA-maternal age ≥35), abnormal maternal serum screen, abnormal ultrasound findings, and/or family/personal history of aneuploidy. The exclusion criteria were women at low risk for aneuploidy. Women meeting inclusion criteria were identified in a preexisting Maternal Fetal Medicine clinical database used to track these women. Tests performed during the study period included MaterniT21 Plus (Sequenom CMM), Verifi Prenatal Test (Verinata), and Harmony Prenatal Test (Integrated Genetics). Tests were chosen based on insurance coverage/cost to patient, availability of kits to perform a given test, perceptions regarding turn-around time and specific characteristics of the test. During the study period all three tests began to offer testing for sex chromosome abnormalities; additionally MaterniT21 Plus added information on chromosomes 16 and 22. Results for MaterniT21 Plus were reported as “positive”, “negative”, and “non-reportable” for each trisomy. Non-reportable results were due to insufficient fetal DNA from maternal serum. Women with non-reportable results were offered a redraw or an invasive test. Results for Verifi were reported as “aneuploidy detected”, “aneuploidy not detected”, “aneuploidy suspected” or “unclassifiable”. Aneuploidy suspected referred to results that could not be accurately interpreted. Unclassifiable are those found to be in the gray zone or in the overlap between what is considered positive and negative for a specific aneuploidy, and a redraw is not recommended in this case. Invasive testing was recommended for both “aneuploidy suspected” and “unclassifiable” cases. Results for Harmony were reported as “high risk” or “low risk” for each trisomy. Medical records were reviewed and data was collected on demographics, indication for test, results, whether they had any invasive testing performed, and pregnancy outcomes. Neonatal records and maternal postpartum visit records were reviewed whenever possible to confirm neonatal outcome and identify false positive and/or false negative results. Descriptive statistics were generated using Excel 2010. Utilization of cffNDNA as compared to invasive testing over time was determined. RESULTS A total of 958 patients seen underwent cell-free fetal DNA testing during the study period. Two patients cancelled the test prior to results returning (one miscarried and one terminated the pregnancy for abnormal ultrasound findings – both opted to have full karyotype done on the fetal tissue instead), for a final test cohort of 956. Indications for testing included advanced maternal age (40%), abnormal ultrasound (30%), abnormal serum screen (27%), and personal/family history (3%) (Figure 1). On initial testing, 13 were non-reportable (1.4%). Twelve of the thirteen repeated the test – of those, 4 were again non-reportable and the other 8 were all negative. No patients were tested a third time, per lab policy. For the 951 patients with results, there were 28 (2.9%) positive and 1 (0.1%) unclassifiable results (Table 1). Most of the positive results were trisomy 21 (21); the remainder were trisomy 18 (4), trisomy 16 (1), triple X (1) and monosomy X (1). Of the women that were positive, only 9 had invasive testing to confirm the results. All women with confirmed aneuploidy on invasive testing opted to terminate the pregnancy (Figure 2). Table 2 shows the pregnancy outcome of women with a positive result: 19 continued the pregnancy and 9 terminated the pregnancy. There was one false positive (monosomy X). There were 2 false negatives (trisomy 13 and trisomy 21). Both of the false negatives had ultrasound abnormalities. The combined sensitivity and specificity of all three tests were calculated for trisomy 21 (Table 3). Only women for whom pregnancy outcomes were confirmed by karyotype were included in the calculation. There was not enough data to calculate sensitivity and specificity for trisomy 18 (only two confirmed outcomes) and trisomy 13 (zero outcomes). Sensitivity, specificity, positive predictive value, and negative predictive value were 94.7%, 100%, 100% and 99.9%. Cell-free fetal DNA test utilization increased significantly over time (Figure 3) and was associated with a concomitant decrease in the number of invasive tests being performed. Table 1. Results of cell-free fetal DNA testing Negative 922/956 (96.4%) Positive 28/956 (2.9%) Non-reportable 5/956 (0.5%) Unclassifiable 1/956 (0.1%) Figure 2. Use of confirmatory invasive tests for women with positive cell-free fetal DNA Table 2. Pregnancy continuation after positive results Continuation of pregnancy 19/28 (67.9%) Live birth Miscarriage 16/19 3/19 Termination 9/29 (32.1%) *The invasive test had results of a normal karyotype, identifying a false positive cell free fetal DNA test result. Table 3. Test performance for detection of Trisomy 21* Sensitivity Specificity Positive Predictive Value Negative Predictive Value Trisomy 21 94.7% 100% 100% 99.9% *For the results that were confirmed by karyotype Figure 3. Cell-free fetal DNA test utilization over the first two years offered as compared to the utilization of invasive procedures DISCUSSION The American College of Obstetricians and Gynecologists recommends that all pregnant women be offered aneuploidy screening and testing. Cell-free fetal DNA is the newest option for women who opt to undergo screening. First used in our practice in January of 2012, this paper serves to describe our experience over the first two years with these tests. The commercial use of cell-free fetal DNA tests has demonstrated both its advantages and disadvantages compared to previous methods of aneuploidy detection, invasive and non-invasive. Compared to other non-invasive fetal aneuploidy screening tests like the maternal serum screen cffDNA has much higher detection rates of 97% to 100%, supported by many studies validating these high values (5-7). Although cffDNA tests do have very high detection rates for aneuploidy, they are not a diagnostic test. The cffDNA tests do not produce a full karyotype of the fetus, but instead use comprehensive comparisons of fetus DNA fragments against controls to determine aneuploidy. Although rare, this method allows for the possibility of false positive and false negative results. Therefore, the only method available for diagnostic results of fetal aneuploidy is with invasive testing. Invasive testing remains the gold standard for determining any fetal aneuploidy. Cell-free fetal DNA tests also detect sex chromosome aneuploidies. However, the detection rates for these aneuploidies ( X, XXX, XXY, and XYY) are lower than those for trisomy 13, 18, with a detection rate of 95% (8). Fewer studies of cffDNA detection of sex chromosome aneuploidies have been conducted to verify the lab reported detection rates. This increases the uncertainty with the sex chromosome aneuploidy results and allows the possibility of accuracy sex chromosome detection accuracy to be much lower for cffDNA, as compared to the other aneuploidies it detects until more studies are reviewed. The study was consistent with one false positive and two false negatives demonstrating the highly accurate but not diagnostic nature of the test. The false positive detected a sex chromosome aneuploidy, monosomy X, for a woman whose only high-risk indication was advanced maternal age at 38 years old. After receiving a positive result from cffDNA, she opted to have invasive testing for conformation. Amniocentesis presented a normal male karyotype, and she delivered a healthy baby. The detection rate for sex aneuploidy in cffDNA is the least accurate of all the aneuploidy detection rates and the results found in our study support the need to further study the detection rates of sex chromosome aneuploidy. The first false negative found in the study did not detect trisomy 21. The patient opted to have cffDNA testing due to AMA (37) and an abnormal maternal serum screen. The test came back negative and the patient did not follow up with any invasive procedures for diagnosis. She gave birth to a baby boy diagnosed with trisomy 21 after delivery and confirmed with chromosome analysis of the baby’s blood. The second false negative did not detect Trisomy 13. The patient opted to have cffDNA due to AMA. The results were negative however, on a regular twenty week growth scan, numerous ultrasound abnormalities surfaced. The patient opted to proceed with amniocentesis which diagnosed trisomy 13 in the fetus. After definitive results the patient decided to terminate the pregnancy. Although false positive and false negative results are rare with cffDNA testing, they are still very real limitations of this test as seen within our own study. Invasive testing should strongly be considered as the next step after receiving positive aneuploidy results. From the twenty-eight positive cffDNA test results, only nine patients decided to proceed with invasive testing. Most patients opted to continue the pregnancy without any further knowledge of the baby’s karyotype and possible birth defects. Many patients seen in Maternal Fetal Medicine of LVHN do not want to alter their pregnancy in any way, even when faced with a positive test result. The number of patients who opted to have invasive testing is surprisingly low, especially since both the physician and the genetic counselor recommend invasive testing to the patient. Of the patients who did have invasive testing to confirm, eight terminated and one identified a false negative. The other positive patients continued their pregnancy to birth or miscarried. Although a patient may refuse invasive testing because they are unwilling to alter pregnancy no matter what, there may still be advantages to knowing whether a result is a true positive. It is important to identify all false positive tests which is done through invasive testing and also it is important to prepare for a pregnancy when a fetus is affect with aneuploidy. Since the introduction of the cffDNA tests, the amount of invasive procedures has decreased, as the use of the cffDNA tests has increased rapidly. The use of cffDNA tests is increasing each year because although not diagnostic, they provide patients with a highly accurate detection of aneuploidy in pregnancy without the chance of miscarriage or added stress of invasive testing. CffDNA testing is becoming the primary indication of aneuploidy with invasive testing secondary as a conformation. CONCLUSION Cell-free fetal DNA is a new prenatal aneuploidy screening test being used with increasing frequency in high risk obstetrical patients. As utilization of cffDNA is increasing, the performance of invasive (diagnostic) procedures is decreasing due to the high detection rates reported for cffDNA. Although detection rates are much better than older aneuploidy screening tests, cffDNA should be considered a screen, not a diagnostic test, as it does have rare false positive and false negative results. It is therefore important to confirm positive cffDNA results with an invasive test. The limitations of this study were found to be the ability to confirm aneuploidy in baby after patient delivered. Some patients do not proceed with genetic testing for children or if they miscarry and therefore pregnancy outcomes cannot be truly confirmed for those patients. CffDNA testing is still a new form of screening patients and needs large clinical trials to further understand the limitation of this test. Future studies should look at test performance in low-risk populations. REFERENCES 1. American College of Obsterticians Gynecologists: Screening for Fetal Chromosomal Abnormalities. Practice Bulletin No. 77, January 2007. 2. Chiu RWK, Chiu RW, Chan KC, Gao Y, Lau VY, Zheng W, Leung TY, Foo CH, Xie B, Tsui NB, Lun FM, Zee BC, Lau TK, Cantor CR, Lo YM. Noninvasive prenatal diagnosis of fetal chromosomal aneuploidy by massively parallel genomic sequencing of DNA in maternal plasma. Proc Natl Acad Sci U S A. 2008;14:20 458–20 463. 3. Noninvasive Prenatal Diagnosis of Fetal Aneuploidy Using Cell-Free Fetal Nucleic Acids in Maternal Blood: Clinical Policy (Effective 05/01/2014) 4. BlueCross BlueShield Technology Evaluation Center (TEC). Sequencing-based tests to determine fetal Down syndrome (trisomy 21) from maternal plasma DNA. Technol Eval Cent Assess Program Exec Summ. 2013 Apr;27(10):1-6. 5. Bianchi DW, Platt LD, Goldberg JD, Abuhamad AZ, Sehnert AJ, et al. (2012) Genome-wide fetal aneuploidy detection by maternal plasma DNA sequencing. Obstet Gynecol 119: 890–901 6. Chiu RW, Akolekar R, Zheng YW, Leung TY, Sun H, Chan KC, et al. Non-invasive prenatal assessment of trisomy 21by multiplexed maternal plasma DNA sequencing: large scale validity study. BMJ 2011 7. Palomaki GE, Deciu C, Kloza EM, Lambert-Messerlian GM, Haddow JE, Neveux LM, et al. DNA sequening of maternal plasma reliably identifies trisomy 18 and trisomy 13 as well as Down syndrome; an international collaborative study. Genet Med 2012; 14:296-305. 8. Ehrich M, Deciu C, Zwiefelhofer T, Tynan JA, Cagasan L, Tim R, et al. Noninvasive detection of fetal trisomy 21 by sequencing of DNA in maternal blood: a study in a clinical setting. AM J Obstet Gynecol 2011;204:205. El-11

Management of Upper Aerodigestive Tract Bleeding in Patients on ECMO.

Introduction: Bleeding complications on Extracorporeal Membrane Oxygenation (ECMO) are often encountered. In a review of our own series, it was found that upper aero digestive tract bleeding was common and management was often difficult. We propose an algorithm to help manage upper aero digestive tract bleeding in the anticoagulated, ECMO patient. Hypothesis: Once an ECMO patient fails conservative management for upper aero digestive bleeding, more aggressive measures will prove successful, which will provide benefit to the patient. Methods: A retrospective chart review was performed of the patients who underwent venovenous or veno-arterial ECMO at our institution between July 2010 and July 2012. The patients that had upper aero digestive tract bleeding that required an Otolaryngology consultation were identified. They were further investigated to determine location of bleed and procedures performed to control the bleeding. Results: Among the 37 consecutive patients on ECMO, 11 (30%) had upper aero digestive tract bleeding events. Of these 11, 6 (55%) were secondary to an iatrogenic incident, such as placing a nasogastric tube or transesophageal echo probe. All 11 patients were treated at bedside with conservative management and 2 were treated in the operating room. 72.7 % of patients treated with conservative management required repeated procedures due to incomplete hemostasis, compared to 0% of patients once surgical intervention was complete. Conclusions: Approximately one third of the ECMO patients developed upper aero digestive tract bleeding. This bleeding should be controlled in a timely manner otherwise it may result in massive transfusions. Delaying intervention or conservative management may not be effective. We recommend surgical intervention if the initial conservative management failed and continued to bleed for more than 24-36 hours

Trauma: An Interim Analysis of Trial Efficacy in a Pilot Study Investigating the Effects of Music Therapy in Ventilated ICU Patients

Trauma: An Interim Analysis of Trial Efficacy in a Pilot Study Investigating the Effects of Music Therapy in Ventilated ICU Patients Katherine Kapelshon¹, Meredith Johnson² Affiliations: ¹Muhlenberg College ²Dickinson College Corresponding authors: Heather A. LaBarre, PhD, LCSW, Lehigh Valley Health Network John Hong, MD, Lehigh Valley Health Network Abstract Music Therapy (MT) is quickly becoming a standard of care to reduce patient distress and promote emotional, psychological, and psycho-social well-being in the medical field. The available alternatives to achieving these patient results often have serious side effects. MT is frequently used bedside on hospital floors, but its effects on critically ill patients requiring sedation in an ICU has not been previously studied. The recovery of patients suffering from traumatic injuries in an ICU setting is often complicated or lengthened by adverse effects of the ventilators and other noxious stimuli. MT holds the potential to reduce ventilator time, reduce hospital stay, and decrease the possibility of potential mortality. In this study, we set out to investigate differences in pharmacological sedation requirements for patients exposed to MT as compared to when they are at rest with no MT. We collected data, including total sedation medication required as well as changes in sedatives and pain medications, for 27 patients over a 2.5-year period (March 2013 to May 2015). A regression model analysis showed that sedation requirement rose by an average of 62.34% across the total patient population on non-MT days. A chi-square test demonstrated a statistically significant reduction of pharmacological sedation requirements for trauma patients in a hospital ICU setting. Background According to the American Music Therapy Association, Music Therapy (MT) is the clinical and evidence-based use of music interventions by a licensed individual to accomplish customized goals within a therapeutic relationship. MT has been seen to promote emotional, psychological, and psycho-social well-being in humans, accomplished by diverting patients’ attention from the disconcerting environment surrounding them in most critical care settings, such as the ICU. MT has been shown to reduce anxiety, fear, and the effects of noxious stimuli while promoting relaxation, rest, and sleep without pharmacological use (Chlan, 2000). Many patients in the ICU experience feelings of exhaustion, fear, anxiety, and pain due to the invasive nature of the procedures/conditions (Ho, et al., 2012; Henry, 1995; Cardozo, 2004; Pattison, 2005; Friese, 2008). They often become combative or lose necessary sleep, which prevents the health care providers from adequately caring for the patient. Sedation is often initiated in such cases, and then maintained throughout the patient’s length of stay. Although this allows the patient to calm down and relax, pharmacologic intervention to this degree has shown potentially serious side effects, some of which include respiratory depression, unwanted gastrointestinal effects (e.g., decreased gastric motility), muscle atrophy, hypotension, venous stasis, pressure damage to soft tissue, respiratory muscle weakness, increased infection risk, mental status changes (e.g., psychosis, delirium), and extended days on the ventilator, as well as consequently increased ICU and hospital length of stay, and even potentially increased mortality (Chlan, 2000; Hogarth & Hall, 2004; Cardozo, 2004; Tracy & Chlan, 2011). Since the 1990s, numerous studies have investigated music therapy in the critical care setting (Almerud & Petersson, 2003; Chlan, 1998; Ho et al., 2012; Lee, Chung, Chan, & Chan, 2005). In 1998, Chlan investigated MT’s relaxation and anxiety reduction effects in intubated patients. In the study, 54 non-sedated ICU patients received 30 minutes of MT or 30 minutes of rest each day. The analysis of the data looked at longitudinal changes in the patients’ heart rates, respiratory rates, and other significant vital signs (Chlan, 1998). Wong, Lopez-Nahas, and Molassiotis (2001) also conducted a similar study with ventilated ICU patients, again looking at their vital signs for improvements when receiving MT. Although considerable research has investigated the effects of music therapy on patients in a critical care setting, most of the studies had limitations, including homogenous study population, solely looking at physiological changes, short MT/RP lengths, and limited music selection. In this study, we aimed to revise the limitations of previous studies through strict procedural outlining and participant selection criteria. We hypothesized that music therapy would lessen the pharmacological sedation requirements in trauma ICU patients. Methods Setting and Participants The study\u27s primary objective was to show a change in pharmacological sedation requirements when patients are exposed to MT as compared to when they are not exposed to MT. The study was conducted at the Lehigh Valley Health Network Cedar Crest, Allentown, PA, USA. The study was directed at patients admitted to the Trauma/Neuro ICU (TNICU) due to the homogeneous nature of the population. For example, those admitted are usually younger, accustomed to listening to music, and often require sedatives due to injury. A total of 27 participants were enrolled in a 2.5 year period. All participants received standard care, regardless of which therapy was being administered. Inclusion criteria included that the patient was 18 years of age or older, admitted to the TNICU, sustained trauma-related injuries, required the assistance of mechanical ventilation including full-vent support, tracheotomy, C-Pap, and Bi-Pap. Criteria also included that the patient fell at a Glasgow Come Scale (GCS) of 9 or above for 24 hours prior to enrollment, required intermittent sedation, was able to understand and sign the informed consent form (ICF) or have a legally authorized representative (LAR) who can provide the ICF, and the music preference was known by family at the time of consent. Exclusion criteria included a presentation of a neurological deficit with a GCS less than or equal to eight, radiologic evidence of severe head injury with a GCS less than or equal to eight, and continuous sedation that required propofol, pentabarbital, or paralysis. Criteria also included a diagnosis of dementia, known hearing impairment or use of a hearing aid, unknown music preference, and required support of mechanical ventilation indefinitely. Procedures Prior to Day 1 of therapy, informed consent, music selection, and coordination of bedside healthcare activities were completed. MT and undisturbed rest periods (RPs) were given on alternating days until the end of therapy. Each session of MT and RP lasted one hour and was administered twice per day at a minimum of five hours apart. On Day 1, two sessions of MT were delivered. On Day 2, two sessions of RP were delivered. From Day 3 forward, the study intervention alternated daily between MT and RP until the end of therapy. To ensure that the patient was undisturbed, health care providers with direct access to the patient were educated and a do-not-disturb sign was posted outside the patient\u27s door. However, quiet visitation during research sessions was allowed. Music was delivered by the bedside nursing staff via Mp3 player devices with headphones. Music selection was determined by patient preference or the LAR from a researcher-provided music library. Approximately 10-15 songs were downloaded and placed onto the Mp3 player. The songs were played in a random order during the therapy sessions through headphones. Headphones were also worn during the rest sessions. Bedside nurses recorded any interruptions during treatment sessions. Participants were permitted to keep the music devices at the end of the study. Data Collection Data were collected from enrollment through the end of therapy for each participant on a 24-hour basis. The start and end time of each therapy session was recorded. Changes in pain and sedative medications and/or their dosages were recorded. The total amount of sedation medication given in a 24-hour period was collected. Additional data collected during the study were: gender, date of intubation and extubation, indication for intubation, ICU length of stay, hospital length of stay, type of injury, injury severity score, number of MT sessions provided, number of RP sessions provided, and any interruptions during research intervention periods. All collected data were de-identified and kept in a secure office. Subjects were identified by a unique number, consisting of initials and age. Data were analyzed to compare sedation requirement differences between MT days and non-MT days; P-value of \u3e0.05 was considered significant. Results From 27 total patients with collected data, 23 patients were included in the analysis. The four participants not included were not enrolled long enough to collect a satisfactory amount of data. Of the 23 patients in the analysis, 75% of the participants were male and 25% were female. The summation of sedation for all patients (in mcg/ml) was divided by the total number of days of MT, resulting in an average amount of sedation per day of 223 886.5 mcg/ml. Using the same formula for all patients on RP, the average amount of sedation per day was determined to be 359 157.1 mcg/ml. Therefore, 62.34% more sedation was used during the rest period than during the MT period. Table 1 lists the distribution of days enrolled in the study, and total pharmacological sedation administered on MT days versus RP days per subject. Table 2 shows changes in sedation requirement from the first day of study enrollment to the last day of study enrollment. The chi-square test for independence generated P Discussion Previous studies on the effects of MT noted considerable improvements in patient heart rate, respiratory rate, and other physiologic responses (Almerud et al., 2003; Chlan, Engeland, Anthony & Guttormson, 2007; Lee, et al., 2005; Tracy et al., 2011; Wong et al., 2001). Therefore, we hypothesized that the amount of sedation required by the patients would decrease on the days that they received the MT treatment, and would increase on days when they were receiving the RP. The results showed that, across the study population, patients required 62.34% more sedation on RP days than on MT days. The patients were used as their own controls to determine differences in sedation requirements. Historical controls were not used for comparison because of difficulties in accounting for all the variables, even if we performed a 1:1 match—by age, gender, ISS, GCS score—of each study participant with a patient in the LVHN Trauma Registry. The summation of sedation, in mcg/ml, for the days a patient received MT was divided by the number of days on the study. Consequently, the summation of sedation, in mcg/ml, for the days a patient received RP was divided by the number of days on the study. This process was conducted for 23 of the 27 patients enrolled in the study. The four patients remaining could not be analyzed because they were not enrolled long enough to obtain a suitable amount of data. Previously published studies limited the amount of time that patients received MT to 30 minutes per day (Almerud et al., 2003; Chlan, 1998; Lee et al., 2005; Wong et al., 2005). The patients enrolled in this study received two 60-minute sessions of MT on each alternate day, which is more therapy than previous studies, which is something that aided in determining the efficacy of MT. Sample size was a noticeable limitation in this study. Originally, the study team planned to enroll 100 patients; however, this projected number was realized by less than half of the expected number of participants. The lack of participants can be attributed to the fact that the study was limited to the TNICU. The data collection was also fraught with complications and subsequent missing data. Speculations as to the cause led researchers to informally survey nurses on the TNICU floor. Anecdotal responses among the nursing staff were similar. They felt that one-hour sessions were too lengthy for patients and often interrupted by either familial distractions (e.g., family pulling out the headphones to listen to the music at MT times, or family trying to talk loudly to patients and startling them awake during RP days) or medical interventions (e.g., suctioning the ventilator tube, or patient coughing and dislodging the headphones). However, when the data were able to be collected, the one-hour sessions allowed for a more definitive correlation between the sedation requirements and the MT. Although a goal of the study was to achieve more heterogeneity in the sample population when compared with previous studies, limiting the patient pool to TNICU patients was a possible cause for difficulties with patient accrual. In future studies, all patients in critical care settings—TNICU, medical ICU (MICU), and surgical ICU (SICU)—should be included in MT studies. This would create an ideal population, as the majority of TNICU patients are of a younger age, and MICU/SICU patients trend toward more advanced ages, on average. Conclusion Although limitations affected the data collection stage of this study, the results clearly showed that MT plays a key role in reducing sedation requirements for patients on days when they received the MT sessions. Reduction of sedation has the potential to lessen ventilator time and expedite discharge from the TNICU/ICU. Until this study, no one had looked at the effects of MT on patient sedation requirements. Further research with a larger sample size should be conducted to confirm the results of this study. Additionally, the study could be expanded to investigate the effect of music characteristics (e.g., with or without lyrics, slow vs. fast tempo) on patients’ sedation requirements. References Almerud, S., & Petersson, K. (2003). Music therapy -- a complementary treatment for mechanically ventilated intensive care patients. Intensive & Critical Care Nursing, 19(1), 21-30. Cardozo, M. (2004). Harmonic sounds: complementary medicine for the critically ill. British Journal of Nursing, 13(22), 1321-1324. Chlan, L. (1998). Effectiveness of a music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance. Heart and Lung: The Journal of Acute and Critical Care, 27(3), 169-176. Chlan,L.L. (2000). Music therapy as a nursing intervention for patients supported by mechanical ventilation. Chlan, L. L., Engeland, W. C., Anthony, A. & Guttormson, J. (2007). Influence of music on the stress response in patients receiving mechanical ventilatory support: A pilot study. American journal of Critical Care, 16(2), 141-145. Friese, R. S. (2008). Sleep and recovery from critical illness and injury: A review of theory, current practice, and future direction. Critical Care Medicine, 36(3), 697-705. Henry, L.L. (1995). Music Therapy: A Nursing Intervention for the Control of Pain and Anxiety in the ICU: A Review of the Research Literature. Dimensions of Critical Care Nursing, 14(6), 295-304. Hogarth, D. K. & Hall, J. (2004). Management of sedation in mechanically vented patients. Current Opinion in Critical Care, 10(1), 40-46. Ho, V., Chang, S., Olivas, R., Almacen, C., Dimanlig, M., & Rodriguez, H. (2012). A Student Paper: Music in Critical Care Setting for Clients on Mechanical Ventilators: A Student Perspective. Dimensions of Critical Care Nursing, 31(6), 318-321. Lee, O. K. A., Chung, Y. F. L., Chan, M. F., & Chan, W. M. (2005). Music and its effect on the physiological responses and anxiety levels of patients receiving mechanical ventilation: a pilot study. Journal of Clinical Nursing, 14, 609-620. American Music Therapy Association, Inc. Music Therapy and Medicine. Retrieved from http://www.musictherapy.org/assets/1/7/MT_Medicine_2006.pdf. (No authors listed). (2013). Music to calm patients who are ventilated and awake. BMJ Clinical Research Ed., 346, f3278. Pattison, N. (2005). Psychological implications of admission to critical care. British Journal of nursing, 14(13), 708-714. Tracy M, Chlan L. (2011). Nonpharmacological Interventions to Manage Common Symptoms in Patients Receiving Mechanical Ventilation. Critical Care Nurse. June 2011;31(3):19-29. What Is Music Therapy? Retrieved on November 5, 2008 from http://www.music-therapy. org/faqs.html#WHAT_IS_MUSIC_THERAPY Wong, H. L. C., Lopez-Nahas,V. & Molassiotis, A. (2001). Effects of music therapy on anxiety in ventilator-dependent patients. Heart and Lung: The Journal of Acute and Critical Care, 30(5), 376-387. Table 1. Pharmacological sedation administered on MT days versus RP days Subject ID Total Days on MT Total Sedation in mcg/mL Total Days on Non MT Total Sedation in mcg/mL DSP18 1 50 1 M-M19 5 14,000,200 9 30,002,000 EWB33 6 500 11 200 M-R25 4 1300 11 12,002,000 DAS69 8 1000 9 1200 LMK69 1 300 2 800 A-Z28 4 2000 4 2000 CLS48 6 1700 12 2400 T-H64 1 700 2 700 RAM23 4 1000 5 1200 G-K51 1 800 2 400 GTM75 7 3,001,100 6 1400 V-S27 3 1700 3 1950 D-B51 2 400 2 300 RHD51 2 3 ASF46 2 100 6 1700 E-G33 3 500 3 750 SLM19 2 1500 8 1500 J-L40 5 11 50 B-W45 3 125 3 CPM40 2 3 BDS61 3 6 R-C65 1 400 4 325 Total 76 17,015,375 117 42,021,375 MT, music therapy; RP, rest period Average amount of sedation per day on MT = 223886.5132 mcg/mL Average amount of sedation per day on RP = 359157.0513 mcg/mL Table 2. Change in sedation requirements from first to last days of study enrollment Identification Sedation initial (mcg) Sedation final (mcg) Sedation change (mcg) DSP18 50 200 150 BDS61 M-M19 3,000,325 -3,000,325 EWB33 500 -500 M-R25 600 -600 DAS69 R-C65 300 25 -275 D-B51 200 200 RHD51 ASF46 100 100 LMK78 A-Z28 400 100 -300 CLS48 700 -700 T-H64 200 200 RAM23 200 -200 E-G33 100 450 350 SLM19 1500 -1,500 G-K51 2450 500 -1,950 J-L40 GTM75 CPM40 B-W45 100 -100 V-S27 600 60

Pericardial Effusion Worm-Like Strands on Transthoracic Echocardiogram

Background: Fibrinous Pericardial Effusion is the accumulation of excess fluid in the pericardial fibroelastic sac. It can be a symptom of any pathological process that affects the pericardium from acute pericarditis to systemic disorders. This broad differential poses a diagnostic challenge in the setting of acute fluid accumulation. Case Presentation: A 50-year-old male with a past medical history of extensive intravenous drug use complicated by bacteremia and left ankle abscess formation presented to the Emergency Department complaining of mild-moderate chest pain for four days. Within the last month, he presented to the Emergency Department three times for similar symptoms; however, he eloped each time before receiving proper medical treatment. Chest x-ray revealed an enlarged cardiac silhouette, and follow-up computed tomography (CT) scan demonstrated a large transudative pericardial effusion, bilateral lower lobe consolidation, and retroperitoneal lymphadenopathy. Prior to pericardiocentesis, a transthoracic echocardiogram was performed that revealed intrapericardial adhesions with a larva-like appearance. His clinical course was complicated by a concurrent left ankle abscess managed by podiatry. He received a pericardial window procedure one week later. Blood cultures from both procedures were negative, and the etiology was determined to be idiopathic. Subsequently, the cardiothoracic surgery team signed the patient off to the primary medical team for further medical management. Discussion/Conclusions: This case illustrates that imaging results can create a disproportionately severe clinical picture. Additionally, even in the case of explained systemic disease, the idiopathic nature of this patient presentation complicates the post-pericardiocentesis management of this patient. The extent of intrapericardial adhesion density and clinically severe appearance is not indicative of a pericardial effusion’s etiology. Transthoracic echocardiogram alone does not have a significant role in the formulation of a differential diagnosis for the treatment of fibrinous pericardial effusion

Globulin expression in grain of Australian hard wheat cultivars is affected by growth environment

Our aim was to study changes in wheat proteomes across different growth locations as the first step in linking protein composition with functional changes in grains produced using commercial production systems. Soluble and insoluble proteins were extracted sequentially from grain of three commercial wheat cultivars grown at four locations in New South Wales, Australia during a single season. Bands were separated using SDS-PAGE and identified by peptide mass fingerprinting. Quantitative changes in the electrophoretic patterns were observed mainly in the insoluble polypeptides of molecular mass between 40 – 70 kDa for all three cultivars grown at two of the four locations. These proteins were identified as mainly globulin and serpin isoforms, and triticin. Other proteins with changed expression included disease-resistance proteins, class III peroxidase, starch branching enzyme I, β-amylase, and storage proteins. Two-dimensional electrophoretic analysis was performed on two of the same wheat cultivars grown at one of the locations during two consecutive seasons. Protein spots that varied between seasons consisted of globulin and serpin isoforms, triticin, HMW-glutenin, gamma-gliadin, starch branching enzyme IIb and alpha amylase. The implications of the upregulation of globulin and triticin on whole meal flour quality, through their participation in polymerization of the gluten network, are considered