Bleeding Risk With Combination Intrapleural Fibrinolytic and Enzyme Therapy in Pleural Infection: An International, Multicenter, Retrospective Cohort Study

BACKGROUND

Combination intrapleural fibrinolytic and enzyme therapy (IET) has been established as a therapeutic option in pleural infection. Despite demonstrated efficacy, studies specifically designed and adequately powered to address complications are sparse. The safety profile, the effects of concurrent therapeutic anticoagulation, and the nature and extent of nonbleeding complications remain poorly defined.

RESEARCH QUESTION

What is the bleeding complication risk associated with IET use in pleural infection?

STUDY DESIGN AND METHODS

This was a multicenter, retrospective observational study conducted in 24 centers across the United States and the United Kingdom. Protocolized data collection for 1,851 patients treated with at least one dose of combination IET for pleural infection between January 2012 and May 2019 was undertaken. The primary outcome was the overall incidence of pleural bleeding defined using pre hoc criteria.

RESULTS

Overall, pleural bleeding occurred in 76 of 1,833 patients (4.1%; 95% CI, 3.0%-5.0%). Using a half-dose regimen (tissue plasminogen activator, 5 mg) did not change this risk significantly (6/172 [3.5%]; P = .68). Therapeutic anticoagulation alongside IET was associated with increased bleeding rates (19/197 [9.6%]) compared with temporarily withholding anticoagulation before administration of IET (3/118 [2.6%]; P = .017). As well as systemic anticoagulation, increasing RAPID score, elevated serum urea, and platelets of < 100 × 10⁹/L were associated with a significant increase in bleeding risk. However, only RAPID score and use of systemic anticoagulation were independently predictive. Apart from pain, non-bleeding complications were rare.

INTERPRETATION

IET use in pleural infection confers a low overall bleeding risk. Increased rates of pleural bleeding are associated with concurrent use of anticoagulation but can be mitigated by withholding anticoagulation before IET. Concomitant administration of IET and therapeutic anticoagulation should be avoided. Parameters related to higher IET-related bleeding have been identified that may lead to altered risk thresholds for treatment.

Reducing Unnecessary Laboratory Utilization in the Medical ICU: A Fellow-Driven Quality Improvement Initiative

OBJECTIVES:

Overutilization of laboratory services is now recognized as harmful to patients and wasteful. In fact, the American Board of Internal Medicine’s Choosing Wisely campaign recommends against ordering routine testing that does not answer a clinical question. Per peer benchmarking, our institution as a whole occupied an extreme outlier position at the 100th percentile for laboratory utilization. We sought to address this problem starting in our medical ICUs with a quality improvement project.

DESIGN:

Quality improvement project using the design, measure, analyze, improve, and control process. The primary endpoint was a sustained reduction in laboratory utilization. Counterbalance metrics were also followed, and these included mortality, renal replacement therapy initiation rates, stat laboratory orders, and central catheter–associated blood stream infections.

SETTING:

The medical ICU at the Ohio State University Medical Center.

PATIENTS:

All patients admitted to the medical ICU from March 2019 to March 2020.

INTERVENTIONS:

Root causes were identified and addressed with the implementation of a wide range of interventions involving a multidisciplinary team led by trainee physicians.

MEASUREMENTS AND MAIN RESULTS:

There was a sustained 20% reduction in the number of tests performed per patient day, with no change in the counterbalance metrics.

CONCLUSIONS:

Trainees can affect positive change in the culture and processes at their institutions to safely reduce laboratory utilization.

Dry Rehydratable Film Method for Enumerating Confirmed Escherichia coli in Poultry, Meats, and Seafood: Collaborative Study

A rehydratable dry-film plating method for Escherichia coli, the Petrifilm E. coli/Coliform (EC) Count Plate in foods, has been compared with the AOAC INTERNATIONAL most probable number (MPN) method. Eleven laboratories participated in the collaborative study. Three E. coli levels in 8 samples each of frozen raw ground turkey, frozen raw ground beef, and frozen cooked fish were tested in duplicate. Mean log counts for the Petri film plate procedure were not significantly different from those for the MPN procedure for cooked fish samples inoculated with low or high inocula levels, for samples of raw turkey inoculated at medium level, and for beef inoculated at low, medium, and high levels. Repeatability and reproducibility vari ances of the Petrifilm EC Plate method recorded at 24 h were as good as or better than those of the MPN method. The dry rehydratable film method for enumerating confirmed E. coli in poultry, meats, and seafood has been adopted first action by AOAC INTERNATIONAL.

Leishmania donovani infection induces anemia in hamsters by differentially altering erythropoiesis in bone marrow and spleen

Leishmania donovani is a parasite that causes visceral leishmaniasis by infecting and replicating in macrophages of the bone marrow, spleen, and liver. Severe anemia and leucopenia is associated with the disease. Although immune defense mechanisms against the parasite have been studied, we have a limited understanding of how L. donovani alters hematopoiesis. In this study, we used Syrian golden hamsters to investigate effects of L. donovani infection on erythropoiesis. Infection resulted in severe anemia and leucopenia by 8 weeks post-infection. Anemia was associated with increased levels of serum erythropoietin, which indicates the hamsters respond to the anemia by producing erythropoietin. We found that infection also increased numbers of BFU-E and CFU-E progenitor populations in the spleen and bone marrow and differentially altered erythroid gene expression in these organs. In the bone marrow, the mRNA expression of erythroid differentiation genes (α-globin, β-globin, ALAS2) were inhibited by 50%, but mRNA levels of erythroid receptor (c-kit, EpoR) and transcription factors (GATA1, GATA2, FOG1) were not affected by the infection. This suggests that infection has a negative effect on differentiation of erythroblasts. In the spleen, erythroid gene expression was enhanced by infection, indicating that the anemia activates a stress erythropoiesis response in the spleen. Analysis of cytokine mRNA levels in spleen and bone marrow found that IFN-γ mRNA is highly increased by L. donovani infection. Expression of the IFN-γ inducible cytokine, TNF-related apoptosis-inducing ligand (TRAIL), was also up-regulated. Since TRAIL induces erythroblasts apoptosis, apoptosis of bone marrow erythroblasts from infected hamsters was examined by flow cytometry. Percentage of erythroblasts that were apoptotic was significantly increased by L. donovani infection. Together, our results suggest that L. donovani infection inhibits erythropoiesis in the bone marrow by cytokine-mediated apoptosis of erythroblasts.

Ciprofloxacin-sensitive and ciprofloxacin-resistant Campylobacter jejuni are equally susceptible to natural orange oil-based antimicrobials

A total of 10 ciprofloxacin-sensitive (ciprofloxacin minimum inhibitory concentration, MIC < 0.5 micro g/ml) and 10 ciprofloxacin-resistant (MIC 16 to 32 micro g/ml) presumptive C. jejuni were further characterized and evaluated for their inhibition by natural orange oil fractions. Partial species identification was performed by using a hippuricase gene-based polymerase chain reaction (PCR) assay. One of the isolates appeared to be atypical and failed to hydrolyze hippurate. Of the ciprofloxacin-resistant C. jejuni isolates tested, six were found to have their quinolone resistance determined by a C --> T mutation in codon 86 of gyrA. Both groups of ciprofloxacin-sensitive and -resistant C. jejuni isolates were most susceptible to cold-pressed terpeneless Valencia orange oil (C4) which yielded inhibition zones from 44.0 +/- 1.4 to 80 +/- 0.0 mm. Less inhibitory responses were recorded for 5-fold concentrated Valencia orange oil (C3) and distilled d-limonene (C7) which exerted similar effects on both ciprofloxacin-sensitive and -resistant C. jejuni isolates. In general, ciprofloxacin-resistant and -sensitive C. jejuni isolates were equally susceptible to the respective orange oil fractions.

Familial aggregation of food allergy and sensitization to food allergens: a family-based study

BACKGROUND

The increasing prevalence of food allergy (FA) is a growing clinical and public health problem. The contribution of genetic factors to FA remains largely unknown.

OBJECTIVE

This study examined the pattern of familial aggregation and the degree to which genetic factors contribute to FA and sensitization to food allergens.

METHODS

This study included 581 nuclear families (2,004 subjects) as part of an ongoing FA study in Chicago, IL, USA. FA was defined by a set of criteria including timing, clinical symptoms obtained via standardized questionnaire interview and corroborative specific IgE cut-offs for > or =95% positive predictive value (PPV) for food allergens measured by Phadia ImmunoCAP. Familial aggregation of FA as well as sensitization to food allergens was examined using generalized estimating equation (GEE) models, with adjustment for important covariates including age, gender, ethnicity and birth order. Heritability was estimated for food-specific IgE measurements.

RESULTS

FA in the index child was a significant and independent predictor of FA in other siblings (OR=2.6, 95% CI: 1.2-5.6, P=0.01). There were significant and positive associations among family members (father-offspring, mother-offspring, index-other siblings) for total IgE and specific IgE to all the nine major food allergens tested in this sample (sesame, peanut, wheat, milk, egg white, soy, walnut, shrimp and cod fish). The estimated heritability of food-specific IgE ranged from 0.15 to 0.35 and was statistically significant for all the nine tested food allergens.

CONCLUSION

This family-based study demonstrates strong familial aggregation of FA and sensitization to food allergens, especially, among siblings. The heritability estimates indicate that food-specific IgE is likely influenced by both genetic and environmental factors. Together, this study provides strong evidence that both host genetic susceptibility and environmental factors determine the complex trait of IgE-mediated FA.

Moderate exercise training slows mammary tumour growth in adolescent rats

Adolescence and young adulthood may be critical windows in establishing risk for breast cancer development in humans. Epidemiological data suggest that exercise during this life stage is associated with decreased breast cancer risk yet few experimental studies to elucidate the mechanism have been performed. The purpose of these studies was to evaluate the effects of moderate exercise training on mammary tumour development in adolescent rats using the 1-methyl 1-nitrosourea (MNU) chemical carcinogen model. Exercise (EX) consisted of moderate-intensity treadmill running 30 min/day, 5 days a week. A total of 274 animals were used: 94 in study 1 and 180 in study 2. Animals were injected with MNU (50 and 25 mg/kg body weight in studies 1 and 2, respectively) at 21 days of age and began training at 28 days of age. Groups of animals (n=10-30 depending on the study and time point) were sacrificed every 2 weeks for 8 weeks to evaluate tumour development. No difference in median tumour-free survival time was observed in the EX versus sham-exercise (SHAM), nor were there any differences in multiplicity at either a high or moderate dose of MNU. Latency to first tumour palpated was increased in both studies by 3-4 days. Consistent across both studies, tumour weights were less and the growth rates of the tumours, defined as tumour weight divided by the number of days elapsed since the tumour was first palpated, were reduced in the EX group. The data suggest that latency is increased and tumour growth is retarded in response to moderate exercise training.

Reactivities of genus-specific monoclonal antibody EM-6E11 against Listeria species and serotypes of Listeria monocytogenes grown in nonselective and selective enrichment broth media

Depending on the growth medium used for enrichment of bacterial cells prior to assay, the monoclonal antibody (MAb) EM-6E11 recognizing Listeria genus-specific epitope on 43 and 94 to 97 kDa cell-surface antigens (A. K. Bhunia and M. G. Johnson, Appl. Environ. Microbiol. 58:1924-1929, 1992) exhibited extensive variability in the detection of Listeria species. MAb EM-6E11 strongly detected live cells of all Listeria species and all serotypes of L. monocytogenes by ELISA when cells were grown in nonselective brain heart infusion (BHI) broth, in selective Listeria enrichment broth (LEB), or in Listeria repair broth (LRB). In contrast, EM-6E11 detected only four of the thirteen serotypes of L. monocytogenes (serotypes 1/2c, 3b, 4ab, and 7) when cells were grown in the UVM1 formulation of Listeria enrichment broth (UVM1) or Fraser broth (FRB). This MAb failed to react with live cells of four other Listeria species, including L. ivanovii, L. welshimeri, L. grayi, and L. murrayi cells grown in UVM1 or FRB. Heating of Listeria cells at 100 degrees C for 20 min, irrespective of the enrichment media used, led to large losses of MAb EM-6E11 reactivity in ELISA, suggesting that the specific cell-surface epitopes involved may not be heat stable. Our results confirm that MAb EM-6E11 is suitable for detection of live cells but not heat-killed cells of Listeria spp. and can be used in conjunction with an enrichment step in BHI, LEB, or LRB but not in UVM1 or FRB.

Unstable expression and thermal instability of a species-specific cell surface epitope associated with a 66-kilodalton antigen recognized by monoclonal antibody EM-7G1 within serotypes of Listeria monocytogenes grown in nonselective and selective broths

Conditions that resulted in unstable expression and heat instability of a cell surface epitope associated with a 66-kDa antigen in Listeria monocytogenes serotypes were identified with the probe monoclonal antibody (MAb) EM-7G1 in an enzyme-linked immunosorbent assay. This epitope appeared to be absent in three serotypes (serotypes 3b, 4a, and 4c), which did not react with MAb EM-7G1 irrespective of the enrichment broth tested. The remaining 10 serotypes were detected by MAb EM-7G1 only when cells were grown in nonselective brain heart infusion broth (BHI) or selective Listeria enrichment broth (LEB). When cells were grown in Listeria repair broth (LRB), only 6 of the 13 serotypes were detected by MAb EM-7G1, and recognition of serogroup 4 was completely lost. None of the 13 serotypes was detected by MAb EM-7G1 when cells were grown in two other commonly used Listeria-selective media, UVM1 broth and Fraser broth (FRB), indicating that possible loss of epitope expression occurred under these conditions. MAb EM-7G1 maintained species specificity without cross-reacting with live or heat-killed cells of six other Listeria spp. (Listeria ivanovii, Listeria innocua, Listeria seeligeri, Listeria welshimeri, Listeria grayi, and Listeria murrayi) irrespective of the enrichment conditions tested. Due to heat instability of the cell surface epitope when it was exposed to 80 or 100 degrees C for 20 min, MAb EM-7G1 is suitable for detection of live cells of L. monocytogenes in BHI or LEB but not in LRB, UVM1, or FRB enrichment medium.

Control of Yellowmargined Leaf Beetle on Turnip, 1995

Insecticide treatments were applied at labeled rates on 11 May and 18 May at the Burden Research Plantation, Baton Rouge, LA, 1995 on turnip. A CO2 powered backpack sprayer calibrated to deliver 40 gallons per acre at 30 psi through a spray boom with three nozzles was used. Experimental plots consisted of single rows (30 ft long, 4 ft wide) arranged in a RCB design with 4 replications. Insect counts were made with beat sheets (3 X 2) on 10 and 17 May (pre-treatment counts) and 12 and 19 May (post-treatment counts). Three samples were taken from each plot and the number of insects present of each species was recorded.

Frozen stored murine hybridoma cells can be used to determine the virulence of Listeria monocytogenes

Murine hybridoma cells, designated Ped-2E9, when stored up to 60 days at -196 degrees C or up to 48 days at -80 degrees C, gave results equivalent to those for freshly grown murine hybridoma cells in an in vitro pathogenicity assay of Listeria species. Thus, laboratories do not need to have their own tissue culture facilities to maintain the hybridoma cells for the assay described.

Children's beliefs about listening: is it enough to be still and quiet?

This study examined children's conception of listening and their performance as listeners, 7-, 9-, and 11-year-old children were interviewed for their conceptions of good listening, their beliefs about appropriate actions for confused listeners to take, their attributions of responsibility for a listener's confusion, their reports of how speakers and listeners feel during communication breakdown, and their ability to detect inconsistencies during a comprehension-monitoring task. Results indicated that older children relied less on behavioral orientation and more on attempts to comprehend and other criteria in their definitions of good listening. Children believed that appropriate listening responses depend on the situation, and there was a developmental increase in asking the speaker a question and listening more carefully. With age, children also tended to report more complex negative emotions for listeners and speakers experiencing a breakdown in understanding. Children recalled incongruent material more than congruent material on the comprehension-monitoring task.