Unfractionated heparin versus enoxaparin for venous thromboembolism prophylaxis in intensive care units: a propensity score adjusted analysis

Venous thromboembolism (VTE) is a common complication in hospitalized patients. Pharmacologic prophylaxis is used in order to reduce the risk of VTE events. The main purpose of this study is to compare the prevalence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients admitted to the intensive care unit (ICU) who received unfractionated heparin (UFH) versus enoxaparin as VTE prophylaxis. Mortality was evaluated as a secondary outcome. This was a Propensity Score Adjusted Analysis. Patients admitted to neurology, surgical, or medical ICUs and screened with venous doppler ultrasonography or computed tomography angiography for detection of VTE were included in the analysis. We identified 2228 patients in the cohort, 1836 (82.4%) patients received UFH and 392 (17.6%) patients received enoxaparin. Propensity score matching yielded a well-balanced cohort of 950 (74% UFH, 26% enoxaparin) patients. After matching, there was no difference in prevalence of DVT (RR 1.05; 95% CI 0.67-1.64, p = 0.85) and PE (RR 0.76; 95% CI, 0.44-1.30, p = 0.31). No significant differences in location and severity of DVT and PE between the two groups were detected. Hospital and intensive care unit stay was similar between the two groups. Unfractionated heparin was associated with a higher rate of mortality, (HR 2.04; 95% CI, 1.13-3.70; p = 0.019). The use of UFH as VTE prophylaxis in ICU patients was associated with a similar prevalence of DVT and PE compared with enoxaparin, and the site and degree of occlusion were similar. However, a higher mortality rate was seen in the UFH group.

Beneficial effects of the 30-minute door-to-needle time standard for alteplase administration

OBJECTIVE

The American Heart Association recently raised the bar on the timely treatment of acute ischemic stroke (AIS) with intravenous alteplase. Our study looks at the effectiveness of this new standard, by examining the effect of varying door-to-needle times of alteplase initiation on the clinical, quality of care, and efficiency of care outcomes.

METHODS

This retrospective case-control study examined 752 AIS patients treated with intravenous alteplase in a large academic health system during 2015-2018, and compared their outcomes after treatment within 30, 45, and 60 min of arrival. The outcomes compared were: (1) clinical - discharge and 90-day modified Rankin Scale (mRS), and post-intravenous alteplase (24-h) NIH Stroke Scale (NIHSS); (2) quality of care - inpatient mortality, 30-day readmission, discharge to home, and disability at discharge; (3) efficiency of care - length of stay (LOS) and index stroke hospitalization costs. Adjusted logistic and linear regression analyses were used to estimate the effects, after controlling for baseline characteristics.

RESULTS

Based on the adjusted regression analyses, treatment within 30 min of arrival was associated with better post-treatment mRS and NIHSS scores, and the clinical benefits were reduced when the windows were expanded to within 45 or 60 min. An important finding of the study was that treatment within 30 min of arrival significantly reduced the average LOS.

INTERPRETATION

Early intravenous alteplase treatment significantly improved clinical and efficiency of care outcomes. This study provides evidence that meeting the new AHA Target Stroke recommendations will help hospitals improve patient clinical outcomes and reduce LOS, thereby improving the efficiency of care standards.

Abstract P265: Identifying Factors Associated With Early Transfer Death of Stroke Patients Can Improve Transfer Criteria

Introduction: Mortality is an important performance metric monitored by CMS, US News and World Report, and Vizient UHC. Large academic medical centers have high mortality given higher severity of disease and volume. We analyzed mortality of stroke patients transferred to our university hospital from community EDs. Transferring patients who die within 48 hours raises questions about resources, financial burden, and unrealistic expectations from families. We analyzed our transfer early death (TED) population to improve identification of patients who likely do not benefit from transfer out of a community hospital.

Methods: Patients with DRG codes for ischemic and hemorrhagic strokes admitted from July 2018-June 2020 were identified. Transfer patients were isolated and grouped as outside hospital (OSH) or intra-system transfers. Data were analyzed for overall hospital mortality and TED mortalities and characteristics. Demographic and clinic variables were compared between intra-system and outside transfers by chi-square test, Fisher’s exact test, t test or Wilcoxon rank sum test.

Results: The total stroke mortality rate was 13% with 276 deaths out of 2,145 patients. There were 171 early deaths out of 276 deaths (62%). There were a total of 923 transfer patients in the 2-year period; 76 were TED (8%) and TED accounted for 27% of all in-hospital mortality at our center. Median age of TED was 67, median NIHSS was 27, 39% were >70, and 80% were ICH with a median ICH score 4. The mean volume of ICH was 68mL (SD=55.2). There were no significant associations between age, sex and ethnicity with TED compared with patients who survived beyond 48 hrs. Among TED, 31 (41%) were from within our health system and 45 (59%) were OHS transfers. There were no significant differences among stroke type, severity (GCS, NIHSS, ICH score, MRS), or demographics between intra-system and OSH transfers.

Conclusions: TED patients are more likely to have severe ICH where medical care may be futile. Strategies are needed to work with community hospitals to establish goals of care and implement approaches to provide end-of-life services at these facilities. Identification and implementation of such strategies may also reduce intra-system transfers of patients with high mortality.

Abstract WMP88: Shorter Door-to-Needle Times of Intravenous Alteplase Improve “Efficiency” of Care and Moderately Affect “Quality” of Care: Study Based on a Large Comprehensive Stroke Center

Introduction: The American Heart Association (AHA) recently raised the bar on timely treatment of acute ischemic stroke (AIS) with intravenous (IV) alteplase, by recommending door-to-needle times of 30 minutes or less for 50% or more of the AIS patients. Our study looks at the effectiveness of this new standard, by examining the effect of varying door-to-needle times on efficiency and quality of care, and clinical outcomes.

Methods: Our study examined 762 AIS patients treated with IV alteplase in a large academic health system from 2015-2018, and compared their outcomes after treatment within 30, 45 and 60 minutes of arrival. The outcomes compared were: 1) Efficiency of care outcome - Length of stay (LOS); 2) Quality of care outcomes - Inpatient mortality and Disability at discharge; 3) Clinical outcomes - Discharge and 90-day modified Rankin Scale (mRS), and Post-alteplase (24 hr) NIH Stroke Scale (NIHSS). Adjusted logistic and linear regression analyses were used, after controlling for baseline patient socio-demographic and clinical characteristics.

Results: Based on the adjusted regression analyses (Table 1), being treated within 30 minutes of arrival reduced the average LOS by 1.3 days (p-value: 0.02), but did not affect the quality of care outcomes. Similarly, being treated within 45 minutes of arrival reduced LOS by 0.9 days (p-value: 0.04). Being treated within 60 minutes of arrival did not affect LOS, but reduced the odds of inpatient mortality by 68% (p-value: 0.00), and disability at discharge by 29% (p-value: 0.08). Being treated within 30 minutes of arrival was associated with better mRS and NIHSS scores as compared with being treated within 45 or 60 minutes.

Conclusion: Quicker IV alteplase treatment significantly improved efficiency of care and clinical outcomes. Quality of care outcomes did not improve beyond the 60 minute door-to-needle threshold. This study provides evidence supporting AHA’s new recommendation of 30 minutes or less door-to-needle time.

Abstract WP364: Utilization of End-of-Life Care Services in Stroke Patients Across a Large Health System

Background: Patients presenting to hospitals with devastating strokes have high mortality rates (a national quality metric) and significant needs for end-of-life (EOL) care including palliative care (PC) and hospice services. Appropriate utilization of PC/hospice services across a health system can improve timeliness of care delivery and inpatient mortality rates. Our hospital system consists of 11 hospitals; 1 tertiary academic center (TAC)/comprehensive stroke center (CSC) and 10 community hospitals of which 3 are CSCs and 5 are primary stroke centers. In-house hospice is based in a community CSC and not the TAC. We investigated mortality, early death, and PC/hospice utilization to understand whether EOL services are effectively used across our system.

Methods: Stroke patients (by DRG) and EOL utilization (defined by PC/hospice ICD 10 codes or MD specialty) were identified from January-December 2018. The TAC data were compared to the combined data of the other 10 system hospitals. Outcomes include EOL utilization, PC/Hospice utilization rates, and early deaths (deaths within 48 hours of admission). Chi-square was used to analyze categorical variables. Significance level was set at p<0.05. Analyses were performed using SAS 9.4

Results: Total stroke volume was 4,062: 1228 presented to the TAC and 2,834 to the 10 other system hospitals. The TAC and system mortality is 12% and 6% respectively. The EOL utilization rate at the TAC (19%) is significantly higher (p<0.0001) than across the system (8%). PC utilization (TAC 18% vs system 6%, p<0.0001) and hospice utilization (TAC 7% vs system 4%, p=0.0009) are significantly higher at the TAC. At the EOL, the TAC (37%) had significantly fewer (p=0.0004) patients with hospice involvement compared to the system (53%). Early deaths occurred significantly more (p<0.0001) at the TAC (7%) than across the system (2%).

Conclusions: Stroke mortality and EOL needs are concentrated at our TAC while hospice care is based at and more utilized in the community hospitals. Our data supports implementing a hospice service at the TAC to enhance PC delivery for high mortality stroke volume and developing an EOL Stroke Pathway to standardize care delivery.

Abstract WP357: Implementation of Stroke Templates and Enhanced Trainee Education in an Academic Hospital Improved Data Capture of Risk Variables and Reduced Hospital Costs

Background: Effective medical record documentation is required to support accurate capture of diagnoses and reflect true patient acuity (case mix index [CMI]) related to resource utilization for healthcare reimbursement. Increasing complexity and expansion in billing codes combined with the lack of a documentation education component in provider training programs has created a need for academic medical centers to incorporate training for new residents and nurse practitioners. We hypothesized that standardized stroke templates combined with formal education of trainees and feedback from chart audits would improve costs and documentation accuracy (increase expected length of stay (LOS), CMI).

Purpose: To design and implement ischemic and hemorrhagic stroke templates with high frequency complication and comorbidity diagnoses that have the greatest impact on stroke populations, combined with trainee education and real-time chart audits, to improve the capture and accuracy of Vizient risk variables (LOS, CMI).

Methods: Descriptive statistics were used to analyze outcomes before and after implementation of the templates. The outcomes include expected (E) LOS and observed (O) LOS. The O/E ratio and variance days (O-E) were calculated. Cost avoidance was calculated by multiplying the terminal day total cost by the variance days. The Wilcoxon rank sum test was used to compare groups with significance set at p<0.05. Analyses were performed using SAS 9.4.

Results: The post-template group demonstrated significant improvement in all outcomes. The ELOS showed the most improvement contributing to the reduction in the O/E LOS. Cost avoidance increased from $24.49 to $1,897.01 per patient, yielding a net cost avoidance of $1,252,373.02.

Conclusions: Stroke-specific templates, combined with trainee education and chart audits, significantly improves the accuracy of documentation and addresses the importance of quality and efficiency in healthcare reform.

Abstract P3-05-01: Immune and transcriptional signatures of dendritic dell (DC) vaccination combined with chemotherapy in locally advanced, triple-negative breast cancer (TNBC) patients

BACKGROUND: Women with TNBC who do not achieve a pathologic complete response (pCR) with preoperative (preop) chemotherapy have a high risk of recurrence and death from BC. Immunotherapy is an attractive strategy as human BCs can be immunogenic, and enhancing the immune effector function may augment the cytotoxic effects of standard therapies.

CLINICAL TRIAL: Following IRB-approved informed consent, 10 pts with locally advanced TNBC received preop dose-dense doxorubicin/cyclophosphamide (AC) followed by paclitaxel and carboplatin (TCb) chemotherapy, combined with antigen-loaded (TNBC antigens: Cyclin B1, WT1, and control viral antigens: CEF) autologous monocyte-derived DC vaccinations administered intratumorally and subcutaneously. DCs were generated with GM-CSF and type I interferon, loaded with antigen in the form of long peptides and activated with innate ligands (LPS and Clo75) and CD40 ligand. Vaccines were given at 4 time points prior to definitive surgery, and 3 times post-surgery, pre- and post-radiation therapy (RT). Safety was the primary study endpoint, and pCR rate in breast and axilla was a secondary endpoint. Correlative studies included assessment of immune response via ELISpot and transcriptional profiling of blood samples collected over time.

RESULTS: All pts received the 4 vaccines during preop chemotherapy, and 7/10 received all 7 vaccines. At the time of definitive surgery, 4 pts achieved a pCR, 3 pts had macroscopic residual disease in the breast and axillary lymph nodes, and 3 pts had residual cancer burden scores of 1. As of June 1, 2017, all pts have been in follow-up for at least 1 year s/p completion of all vaccines, and 7/10 patients have no evidence of disease.

To assess immune signatures with IFN-γ-ELISpot, PBMCs from baseline (BL) and several time points during vaccine treatment were cultured with control peptides or with peptide libraries covering vaccine antigens. Using a linear mixed model to account for repeated and missing observations we found statistically significant (α = 0.05) increases in Cyclin B1, WT1, and CEF ELISpots in at least 1 time point post-DC vaccination and in follow-up. Compared to BL, Cyclin B1 and WT1 increased at 3 day pre-RT in 8/10 and 7/10 pts, respectively. To assess transcriptional signatures, a linear mixed model was utilized to determine statistically significant differences in fold-change over time compared to the BL and healthy controls. Modular analysis of differentially expressed transcripts at BL revealed downregulation of transcripts related to the monocyte lineage in 7/10 pts. Longitudinal analysis revealed profound transcriptional changes during AC with downregulation of lymphocyte modules and upregulation of innate and inflammation modules. While the latter ones have normalized during TCb and follow-up, T cell module remained substantially downregulated throughout treatment and follow-up.

CONCLUSIONS: Combination of preop chemotherapy and intratumoral and subcutaneous autologous DC vaccination is safe in locally advanced TNBC pts and is linked with profound changes in immune transcription signatures and with expansion of antigen-specific immune responses that can be detected in IFN-γ ELISpot.

Citation Format: Palucka AK, Roberts LK, Zurawski SM, Tarnowski J, Turner J, Wang X, Blankenship D, Smith JL, Levin MK, Finholt JP, Burkeholder SB, Timis R, Muniz LS, Dao T, Grant M, Banchereau J, Zurawski G, Pascual V, O'Shaughnessy JA. Immune and transcriptional signatures of dendritic dell (DC) vaccination combined with chemotherapy in locally advanced, triple-negative breast cancer (TNBC) patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-01.

Infectious Diseases: Tolerance of Vancomycin for Surgical Prophylaxis in Patients Undergoing Cardiac Surgery and Incidence of Vancomycin-Resistant Enterococcus Colonization

Background:

In 2001, vancomycin replaced cefuroxime for antibiotic prophylaxis in patients undergoing cardiac surgery at our institution due to high rates of surgical site infections caused by methicillin-resistant Staphylococcus spp. However, few data supported the use of vancomycin for surgical prophylaxis.

Objective:

To determine the tolerance of vancomycin for antibiotic prophylaxis and incidence of vancomycin-resistant Enterococcus (VRE) in cardiac surgery patients.

Methods:

In 2 separate studies, we assessed the adverse effects in patients given perioperative vancomycin (study 1) and the incidence of VRE in patients given perioperative vancomycin (study 2). Study 1 was a prospective cohort study of patients undergoing coronary artery bypass graft (CABG) or valve replacement surgery given vancomycin (1 dose preoperatively/2 doses postoperatively) for antibiotic prophylaxis between October 2003 and December 2004. Patients were assessed for tolerance to the antibiotic regimen. In study 2, cardiac surgery patients receiving perioperative vancomycin were screened for VRE before therapy and at day 7 of hospitalization. VRE was detected using standard microbiologic procedures.

Results:

In study 1, 1161 patients (CABG = 75%; valve = 19%; both = 6%) were evaluated. All patients but one (99.9%) were prescribed preoperative vancomycin. Therapy was changed for 34 (2.9%) patients, of which 20 changes were due to physician preference for another antibiotic. The only toxicity that required a change in the vancomycin regimen was red man's syndrome, which was experienced by 9 (0.8%) patients. Four patients did not receive a second postoperative dose due to prior renal insufficiency. Patients were most commonly switched to cefuroxime (n = 26), linezolid (n = 2), cefepime (n = 2), gatifloxacin, cefazolin, levofloxacin, or ceftriaxone (n = 1, each). In study 2, 100 patients were screened for the emergence of VRE colonization. No patient was VRE positive at baseline and 4 (4%) were positive at day 7.

Conclusions:

Surgical antibiotic prophylaxis with vancomycin was reasonably well tolerated in CABG and valve replacement surgery, with a 4% incidence of VRE colonization.

Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society

BACKGROUND

Neuropathic pain (NeP), redefined as pain caused by a lesion or a disease of the somatosensory system, is a disabling condition that affects approximately two million Canadians.

OBJECTIVE

To review the randomized controlled trials (RCTs) and systematic reviews related to the pharmacological management of NeP to develop a revised evidence-based consensus statement on its management.

METHODS

RCTs, systematic reviews and existing guidelines on the pharmacological management of NeP were evaluated at a consensus meeting in May 2012 and updated until September 2013. Medications were recommended in the consensus statement if their analgesic efficacy was supported by at least one methodologically sound RCT (class I or class II) showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment were based on the degree of evidence of analgesic efficacy, safety and ease of use.

RESULTS

Analgesic agents recommended for first-line treatments are gabapentinoids (gabapentin and pregabalin), tricyclic antidepressants and serotonin noradrenaline reuptake inhibitors. Tramadol and controlled-release opioid analgesics are recommended as second-line treatments for moderate to severe pain. Cannabinoids are now recommended as third-line treatments. Recommended fourth-line treatments include methadone, anticonvulsants with lesser evidence of efficacy (eg, lamotrigine, lacosamide), tapentadol and botulinum toxin. There is support for some analgesic combinations in selected NeP conditions.

CONCLUSIONS

These guidelines provide an updated, stepwise approach to the pharmacological management of NeP. Treatment should be individualized for each patient based on efficacy, side-effect profile and drug accessibility, including cost. Additional studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics, long-term outcomes and treatment of pediatric, geriatric and central NeP.

A facile and versatile methodology for cysteine specific labeling of proteins with octahedral polypyridyl d⁶ metal complexes

We have synthesized and characterized four octahedral polypyridyl d(6) metal complexes bearing the 5,6-epoxy-5,6-dihydro-[1,10]phenanthroline ligand (L1) as cysteine specific labeling reagents. The proposed synthetic pathways allow the preparation of the metal complexes containing Re(I), Ru(II), Os(II) and Ir(III) while preserving the epoxide functionality. The complexes were characterized by (1)H and (13)C NMR, mass spectrometry, UV-visible and luminescence spectroscopies as well as cyclic voltammetry. As proof of concept, a set of non-native single cysteine P450 BM3 heme domain mutants previously developed in our laboratory was used to study the labeling reaction. We demonstrate that the proposed labels can selectively react, often in high yield, with cysteine residues of the protein via the nucleophilic thiol ring opening of the epoxide moiety. In addition, under basic conditions, subsequent loss of a water molecule led to the aromatization of the phenanthroline ring on the protein-bound label compounds, as observed by mass spectrometry and luminescence measurements.

Hydroxymethylation as a Novel Environmental Biosensor

Beyond the genome, epigenetics has become a promising approach in understanding the interactions between the gene and the environment. Epigenetic regulation includes DNA methylation, histone modifications, and non-coding RNAs. Among these, DNA methylation, which is the addition of a methyl group to the fifth base of cytosine to produce 5-methylcytosine (5-mC), is most commonly studied. Epigenetic regulation has changed given the discovery of 5-hydroxymethylcytosine (5-hmC), considered the "sixth base", and the nature of TET proteins to catalyze 5-mC oxidation to 5-hmC. 5-hydroxymethylation has been proposed to be a stable intermediate between methylation and demethylation and has raised questions about the functions of 5-hmC in gene regulation in cells, tissues, and organs in response to environmental exposure. Herein, we have provided an introduction to the chemistry of 5-hydroxymethylation, and the techniques for detection of 5-hydroxymethylation. In addition, we have reviewed current reports describing how 5-hmC responds to environmental factors, leading to the development of disease. And finally, we have discussed the potential use of 5-hmC in the study of disease development. All in all, it is our goal to provide innovative and convincing epigenetic studies for understanding the etiology of environmentally-related human disease, and translate these epigenetic findings into lifestyle recommendations and clinical practices to prevent and cure disease.

An efficient light-driven P450 BM3 biocatalyst

P450s are heme thiolate enzymes that catalyze the regio- and stereoselective functionalization of unactivated C-H bonds using molecular dioxygen and two electrons delivered by the reductase. We have developed hybrid P450 BM3 heme domains containing a covalently attached Ru(II) photosensitizer in order to circumvent the dependency on the reductase and perform P450 reactions upon visible light irradiation. A highly active hybrid enzyme with improved stability and a modified Ru(II) photosensitizer is able to catalyze the light-driven hydroxylation of lauric acid with total turnover numbers of 935 and initial reaction rate of 125 mol product/(mol enzyme/min).

Risk Factors for Postoperative Chest Wound Infections Due to Gram-negative Bacteria in Cardiac Surgery Patients

Gram-negative bacteria account for up to 35% of postoperative sternal wound infections (SWI) in patients undergoing cardiac surgery. Despite this, risk factors for Gram-negative SWI have not been investigated. The objective of this study was to define risk factors associated with Gram-negative SWI in patients undergoing cardiac surgery. 2590 patients undergoing cardiac surgery between 2002-2005 were prospectively monitored for development of SWI. Patient, operative, and post-operative risk factors were compared among patients that developed Gram-negative SWI and Gram-positive SWI to uninfected controls using univariate and multivariate analysis. A p < 0.05 was considered significant. Surgical site infections developed in 152 (5.9%) patients. Isolates were recovered from the sternum for 128 (5.0%) patients, from the leg donor site for 19 (0.73%) patients, and from the sternum and donor site for 5 (0.19%) patients. Gram-positive pathogens were isolated from 83 (3.3%) patients, Gram-negative pathogens from 42 (1.6%) patients, and mixed pathogens from 27 (1.0%) patients. Hospital admission greater than 48 hours before surgery (OR: 2.25; 95% CI: 1.11 - 4.58), ventilator-dependency preoperatively (OR: 5.32 95% CI: 2.22 - 12.75), and thoracentesis procedure postoperatively (OR: 3.71; 95% CI: 1.45 - 9.49) and diabetes (OR: 2.04; 95% CI: 1.17 - 3.55) were identified as significant risk factors for SWI due to Gram-negative bacteria using multivariate logistic regression. Diabetes, increased age, and peripheral vascular disease were identified as significant risk factors for SWI due to Gram-positive bacteria (p < 0.05, each). The risk factors associated with Gram-negative SWI differed significantly from those associated with Gram-positive SWI. Risk factors associated with Gram-negative SWI were identified. Unique interventions may be necessary to prevent Gram-negative SWI in cardiac surgery patients.

Constitutive expression of immunosuppression-associated cytokine genes in a panel of human T-leukemia-cell lines - high-incidence of transforming growth-factor-Beta gene-expression

The expression of RNA for interleukin (IL) -9, -10 and -12, interferon gamma (IFN-gamma), transforming growth factor beta one (TGF-beta1), macrophage inflammatory protein one alpha (MIP-1alpha) and granulocyte-macrophage colony-stimulating factor (GM-CSF) in a panel of human T leukemia cell lines at various stages of differentiation, and normal thymocytes was examined using reverse transcriptase-polymerase chain reaction (RT-PCR). Fourteen of 16 T cell lines expressed the gene for TGF-beta1 and 12 of the cell lines also expressed the gene for GM-CSF. None of the 5 normal thymocyte samples constitutively expressed RNA for TGF-beta1 or GM-CSF. One cell line established from a patient with adult T cell leukemia (ATL), ED-S-, expressed the genes for TGF-beta1, GM-CSF, IL-10, IL-12, IFN-gamma and MIP-1alpha. IL-9 was not expressed by any cell line, IL-10 was expressed by only three cell lines and IL-12 was expressed by only two cell lines. The production of immunosuppressive factors such as TGF-beta1 by T leukemic cells is a possible mechanism for the clinical progression of this disease.

Randomised clinical trial: enteral nutrition does not improve the long-term outcome of alcoholic cirrhotic patients with jaundice

BACKGROUND

Malnutrition and jaundice are independent prognostic factors in cirrhosis.

AIM

To assess the impact of enteral nutrition on the survival of alcoholic cirrhotic patients with jaundice but without acute alcoholic hepatitis.

METHODS

The study was a multicentre prospective randomised controlled trial comparing effects of enteral nutrition vs. a symptomatic support in patients with alcoholic cirrhosis and jaundice (bilirubin ≥51 µmol/L) but without severe acute alcoholic hepatitis. A total of 99 patients were randomised to receive either the conventional symptomatic treatment (55 patients) or the symptomatic support associated with 35 kcal/Kg/day of enteral nutrition during 4 weeks followed by an oral nutritional support during 2 months (44 patients). Randomisation was stratified on nutritional status. One-year survival curves were compared using the Kaplan-Meier method and Logrank test.

RESULTS

Populations in both arms were similar. One-year survival was similar in the overall population (27/44 patients (61.4%) in the enteral nutrition arm vs. 36/55 (65.5%) in the control arm; Logrank P = 0.60) and in the subgroup suffering from malnutrition [18/29 patients (62.1%) in the enteral nutrition arm vs. 20/32 (62.5%) in the control arm; Logrank P = 0.99]. There was no statistical difference for bilirubin, prothrombin rate, Child-Pugh score, albumin or nutritional assessment. Complications during treatment (bleeding, encephalopathy, infection) occurred in 23% of patients in the enteral nutrition group (10/44) vs. 16% (9/55) of the control patients (P = 0.59).

CONCLUSION

Enteral nutrition does not improve the survival and hepatic or nutritional parameters of cirrhotic patients with jaundice.

Use of the Weibull model to describe inactivation of dry-harvested conidia of different Penicillium species by ethanol vapours

AIMS

This study aimed at modelling the effect of ethanol vapours, in the range 0.7-7.5 kPa, on the inactivation of dry-harvested conidia of Penicillium chrysogenum, Penicillium digitatum and Penicillium italicum.

METHODS AND RESULTS

Survival curves were modelled by a Weibull model: log (N/N(0)) = -1/2.303 (t/alpha)(beta). The shape parameter beta was different from one in all cases, indicating that the classical first-order kinetics approach is the exception rather than the rule. Survival curves exhibited upward concavity (beta < 1) with the notable exception of P. chrysogenum at ethanol vapour pressures 0.7 and 1.5 kPa. The scale parameter alpha (h) varied greatly depending on the ethanol vapour pressure and on the species.

CONCLUSIONS

For safety reasons, it is recommended not to exceed an ethanol vapour pressure of 3.3 kPa. At 2.8 kPa, more than 4 log(10) reductions in viable conidia were achieved for all the species after 24-h exposure.

SIGNIFICANCE AND IMPACT OF THE STUDY

Ethanol has GRAS status in the USA and represents an interesting alternative to fungicides. The effectiveness of ethanol vapours to inactivate dry-harvested conidia of some Penicillium was demonstrated in this study.

Irritable bowel syndrome is more frequent in patients hospitalized for ischaemic colitis: results of a case-control study

It has been suspected that there is an epidemiological link between irritable bowel syndrome (IBS) and ischaemic colitis (IC). We performed a retrospective case-control study to compare the frequency of IBS in patients hospitalized for IC compared with that of patients with peptic ulcer bleeding. Cases were patients with a first episode of IC and controls were patients with a first episode of peptic ulcer bleeding, matched to cases for sex and 10-year age-class. Diagnosis of IBS was based on medical information extracted from hospital medical files and a standard self-questionnaire. The association between IBS and IC was tested using Mc Nemar's paired odds ratio (OR); confidence interval at 95% (CI 95%) was calculated; Mantel-Haenzel's Chi(2) was applied. A total of 113 cases and 113 matched controls were studied. There were 37 males and 76 females and the mean age was 69 +/- 15 years in each group. The prevalence of IBS in cases was 16.9%vs 1.8% in controls. The risk of IBS was 11.05 times higher among cases than in controls (P < 0.001); CI 95%: (2.45-49.74). A total of 87 pairs with complete data were used for OR calculation. The risk of IBS was 7.5 times higher in cases than in controls (P = 0.002); CI 95%: (1.72-32.80). This case-control study shows that IBS is more frequent in IC patients than in controls.

Timing of vancomycin prophylaxis for cardiac surgery patients and the risk of surgical site infections

BACKGROUND

Increased incidence of methicillin-resistant Staphylococcus species has required some hospitals to choose vancomycin for surgical prophylaxis. Guidelines for appropriate timing of vancomycin prophylaxis state that the infusion should begin within 120 min before the first surgical incision. However, no studies have investigated the proper timing of vancomycin prophylaxis in relationship to surgical site infections (SSI). The objective of the present study was to assess the effect of vancomycin prophylaxis timing in relation to the first surgical incision on the incidence of SSI.

METHODS

We prospectively monitored vancomycin prophylaxis timing and incidence of SSI in 2048 patients undergoing coronary bypass graft or valve replacement surgery. The timing of vancomycin was categorized into five groups based on the relation between the start of the infusion and the surgical cut time. Study hypotheses were tested using logistic analysis and further validated using a Heckman two-stage model.

RESULTS

The incidence of SSI were lowest in the 176 patients given vancomycin between 16 and 60 min before the surgical incision (3.4%) compared with 15 patients given vancomycin between 0 and 15 min [26.7%; relative risk (RR): 7.8; 95% CI: 2.5-24.7], 888 patients given vancomycin between 61 and 120 min (7.7%; RR: 2.2; 95% CI: 0.99-5.09), 700 patients given vancomycin between 121 and 180 min (6.9%; RR: 2.0; 95% CI: 0.87-4.62) or 269 patients given vancomycin >180 min (7.8%; RR: 2.3; 95% CI: 0.94-5.56) (P = 0.0119 by chi(2) analysis). Stepwise logistic regression analysis and a Heckman two-stage model confirmed that vancomycin administration between 16 and 60 min before the first surgical incision was associated with the lowest incidence of SSI.

CONCLUSIONS

Vancomycin administration within 16-60 min before the first surgical incision reduced the risk of SSI in cardiac surgery patients.

Pilot trial of a synthetic breakpoint peptide vaccine in patients with chronic myeloid leukemia (CML) and minimal disease

6514

Background: CML is characterized by a tumor-specific fusion oncoprotein, BCR-ABL. Peptides spanning the B3A2 breakpoint of BCR-ABL can elicit MHC restricted T cell responses and clinical responses. No such data have previously been reported for vaccines targeting B2A2. Methods: We initiated a clinical trial administering synthetic analog breakpoint specific peptide vaccines for either B3A2 or B2A2 breakpoints to CML patients with major or complete cytogenetic remission. Measurable minimal disease was determined by either quantitative polymerase chain reaction (RQ-PCR) or nested PCR for BCR-ABL. Vaccine was administered with GM-CSF and Montanide ISA 51 subcutaneously. Eleven vaccinations were planned over the course of 1 year with the first 5 doses administered bi-weekly. Results: Eleven of 20 planned patients have been accrued to the study. Eight had documented cytogenetic remission and 3 were BCR-ABL positive via FISH analysis. Seven of the 11 patients had measurable BCR-ABL transcript levels as determined by RQ-PCR and all 11 were positive using the nested technique. Of the 5 patients positive for BCR-ABL (by RQ-PCR) before vaccination, 3 converted from RQ-PCR positive to negative while the transcript levels in the other patients decreased by approximately 1 log after 5 doses. All 5 of these patients remained positive using the nested PCR technique. Vaccination was well tolerated with local skin reactions at the injection sites. Immunologic reactivity was assessed ex vivo by CD4 autologous proliferation assay and T cell interferon (IFN) secretion (ELISPOT) assay. Ten of 11 patients were immunologically unreactive to the peptides prior to the vaccinations. Following the 5th dose of vaccine, 8/8 patients (including 2 with B2A2) tested showed significant immunologic responses by one of the above assays. Conclusions: These preliminary results suggest vaccination with synthetic analog peptides derived from CML proteins results in immunologic responses and may be associated with molecular improvement. Clinical efficacy of these vaccines in reducing/ eliminating minimal disease has yet to be established.

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Prevalence of diarrhea at a university hospital and association with modifiable risk factors

OBJECTIVE

To assess the prevalence of diarrhea at a university-affiliated medical center and the presence of modifiable risk factors.

METHODS

A point prevalence survey was conducted. All patients hospitalized for more than 24 hours were asked if they were experiencing diarrhea. Stools of patients not previously tested were assessed for Clostridium difficile (CD) toxins A and B. Univariate analysis and multivariate logistic regression analyses were used to identify modifiable variables associated with diarrhea (significance defined as p < 0.05).

RESULTS

Four hundred eighty-five hospitalized patients were interviewed, of whom 60 (12.4%) reported 2 or more loose, unformed stools in the last 24 hours. Six of 81 (7.4%) patients tested positive for CD toxin. Three (50%) of the CD toxin-positive patients had not previously been tested during the current admission. Patients with diarrhea were more likely to have tested CD toxin-positive (OR 10.6; p = 0.01), received antibiotics (OR 1.79; p = 0.04), or been hospitalized for a longer period of time (p = 0.04).

CONCLUSIONS

Diarrhea was prevalent in 12.4% of hospitalized patients at a large university hospital at one point in time. Patients with diarrhea were more likely to have CD infection, receive antibiotics, or experience a longer hospitalization. Half of the CD diarrhea cases occurring in the hospital had been previously unidentified. Hospitalized patients should be evaluated for diarrhea on an ongoing basis with appropriate interventions instituted.

The transition from open to endoscopic saphenous vein harvesting and its clinical impact: The Texas Heart Institute experience

Open saphenous vein harvesting can be associated with wound complications, incision pain, prolonged convalescence, and poor cosmetic results. Endoscopic vein harvesting has been widely used for prevention of these problems. We compared outcomes of open and endoscopic vein harvesting for coronary artery bypass grafting at the Texas Heart Institute. We retrospectively analyzed data from 1,573 consecutive coronary artery bypass procedures performed at our institution during a 20-month period. Each procedure included saphenectomy by endoscopic vein harvesting (n = 588) performed by physician assistants, or by traditional open vein harvesting (n = 985) performed by physicians or physician assistants. The primary outcome variable was the incidence of postoperative leg infections. Both groups were similar in terms of preoperative risk factors. After surgery, leg wound infections were significantly less frequent in the endoscopic vein harvesting group (3/588, 0.5%) than in the open vein harvesting group (27/985, 2.7%; P < 0.002). The most common organism involved in leg infections was Staphylococcus (20/30, 66%): S. aureus was present in 14 of 30 infections (47%). Open vein harvesting was the only significant independent risk factor for leg infection. We conclude that endoscopic vein harvesting reduces leg wound infections, is safe and reliable, and should be the standard of care when venous conduits are required for coronary artery bypass grafting and vascular procedures. Although the transition from open to endoscopic vein harvesting can be challenging in institutions, it can be successful if operators receive adequate training in endoscopic technique and are supported by surgeons and staff.

Reducing the incidence of nosocomial pneumonia in cardiovascular surgery patients

Outcomes management provides a mechanism to foster development of patient-driven services through revision of practice and measurement of outcomes. Because nosocomial pneumonia is the most common hospital-acquired infection in intensive care units, reducing the rate of nosocomial pneumonia became on area of intense scrutiny at our institution. This article shares an outcome initiative that focused on reducing the incidence of nosocomial pneumonia in a hospital setting. Strategies used such as multidisciplinary team formation, case/control study, quality improvement activities, risk tool development, and protocol implementation, are discussed. Process and outcome data are provided to demonstrate the initiative's positive impact. The benefits of this outcome effort are easily identified and well-illustrated. The backbone of the initiative--proactive identification of problems and the methodical, reasoned search for answers--is universally applicable.

Methohexital Dosage in Electroconvulsive Therapy

A comparison of methohexital at 0.5 mg/kg versus 1 mg/kg iv as anesthesia for unilateral brief pulse electroconvulsive therapy showed no difference in systolic or diastolic blood pressure before, immediately after, or 5 or 10 min after the seizure. Mean seizure duration was not significantly shorter using the higher methohexital dosage. These results show that methohexital can be safely used in a broad dosage range without undue effects on blood pressure or seizure duration.

Involvement of CD1 in peripheral deletion of T lymphocytes is independent of NK T cells

During peripheral T cell deletion, lymphocytes accumulate in nonlymphoid organs including the liver, a tissue that expresses the nonclassical, MHC-like molecule, CD1. Injection of anti-CD3 Ab results in T cell activation, which in normal mice is followed by peripheral T cell deletion. However, in CD1-deficient mice, the deletion of the activated T cells from the lymph nodes was impaired. This defect in peripheral T cell deletion was accompanied by attenuated accumulation of CD8(+) T cells in the liver. In tetra-parental bone marrow chimeras, expression of CD1 on the T cells themselves was not required for T cell deletion, suggesting a role for CD1 on other cells with which the T cells interact. We tested whether this role was dependent on the Ag receptor-invariant, CD1-reactive subset of NK T cells using two other mutant mouse lines that lack most NK T cells, due to deletion of the genes encoding either beta(2)-microglobulin or the TCR element J alpha 281. However, these mice had no abnormality of peripheral T cell deletion. These findings indicate a novel role for CD1 in T cell deletion, and show that CD1 functions in this process through mechanisms that does not involve the major, TCR-invariant set of NK T cells.

[Patients with alcoholic liver disease hospitalized in gastroenterology. A national multicenter study]

OBJECTIVES

To describe the characteristics of in-patients with alcoholic liver disease in Hepatogastroenterology and to evaluate whether geographic location was a risk factor for cirrhosis.

METHODS

A French, national, multicenter, prospective investigation was performed in the last quarter of 1997. To be included in the study, patients had to have drunk at least 50 g of alcohol per day for the past year or to have cirrhosis.

RESULTS

Seventeen centers included 802 patients, 20% had histologically proven cirrhosis or probable cirrhosis. Thirty-five percent had undergone liver biopsy. Twenty five percent of these patients had cirrhosis without acute alcoholic hepatitis and 37% had cirrhosis with acute alcoholic hepatitis. After dividing France along a Bordeaux-Strasbourg axis, there was more histologically proven or probable cirrhosis in the North (46%) than in the South (36%) (P<0.005) while daily alcohol intake was greater the South (150 +/- 6 g) than in the North (129 +/- 4 g) (P<0.0001). When the six variables (age, sex, daily consumption of alcohol over the past 5 years, presence of hepatitis B surface antigen and antibodies to hepatitis C virus, total duration of alcohol abuse) were considered together in stepwise logistic regression analysis, geographic location changed the prediction of cirrhosis. The odds ratio for cirrhosis in patients living to the North of the Bordeaux-Strasbourg axis was 1.9 (95% confidence interval range 1.1-3.2) (P<0.02), suggesting the role of nutritional factors.

Induction of murine hepatocyte death by membrane-bound CD95 (Fas/APO-1)-ligand: characterization of an in vitro system

Hepatocytes constitutively express CD95 (also called Fas/APO-1) and are therefore potential targets for CD95-ligand (CD95L)-mediated injury. To study this mechanism of cell death in hepatocytes we developed an in vitro model of liver cell apoptosis using membrane-bound CD95L as the inducing agent. Primary mouse hepatocytes were cocultured with NIH 3T3 fibroblasts, stably transfected with mouse CD95L (F(CD95L+)). Fibroblasts stably transfected with vector only (F(CD95L-)) served as controls. Hepatocytes from mice expressing low levels of CD95 (Fas(lpr) mice) served as controls for effects unrelated to CD95. Morphologic and biochemical studies indicate that CD95 is expressed in cultured mouse hepatocytes. Membrane-bound CD95 from transfected fibroblasts destroyed all cocultured hepatocytes within 24 hours in the absence of protein synthesis inhibitors. Characteristic features of apoptosis were observed in dying hepatocytes and occurred in the following sequence: formation of cytoplasmic blebs and nuclear condensation after 3 hours; nuclear fragmentation and DNA strand breaks after 4 hours. These changes were observed only when normal hepatocytes were cocultured with F(CD95L+) and were not observed with F(CD95L-) or in hepatocytes from Fas(lpr) mice. Anti-CD95 antibody (Jo2) evoked similar changes in hepatocytes, although to a much lesser extent. We conclude that coculture of mouse hepatocytes with F(CD95L+) is a useful in vitro model for CD95-mediated apoptosis induced by CD95L. The high incidence of apoptosis caused by membrane-bound CD95L differs from the much smaller effects induced by the Jo2 antibody. In view of the high sensitivity of hepatocytes towards CD95L we speculate that CD95L-induced liver damage in vivo may be minimized by restricting exposure of hepatocytes to CD95L.

CD95/Fas signaling in T lymphocytes induces the cell cycle control protein p21cip-1/WAF-1, which promotes apoptosis

Ligation of CD95 on T lymphocytes resulted in the up-regulation of a cell cycle control protein, p21cip-1/WAF-1, an inhibitor of cyclin-dependent kinases. This up-regulation was completely blocked by the cysteine protease inhibitor Z-VAD-fmk (benzyloxycarbonyl-Val-Ala-Asp-fluoromethylketone), whereas DEVD-CHO (succinyl-Asp-Glu-Val-Asp-aldehyde), a caspase 3 inhibitor, had no effect. In Faslpr-cg mice, a point mutation in the death domain of CD95 results in failure to recruit FADD (Fas-associated death domain), and in the present study this mutation prevented both CD95-mediated apoptosis and p21cip-1/WAF-1 induction. During apoptotic cell death due to irradiation, p21cip-1/WAF-1 is up-regulated by a p53-dependent pathway that responds to DNA damage. However, CD95-induced up-regulation of p21cip-1/WAF-1 in T cells was p53-independent. T cells deficient in p21cip-1/WAF-1 were less susceptible to CD95-induced apoptosis. We conclude that in T cells, ligation of CD95 and activation of caspases cause the induction of p21cip-1/WAF-1, which acts to promote cell death.

The liver as a site of T-cell apoptosis: graveyard, or killing field?

The liver is a site at which apoptotic CD8+ cells accumulate during the clearance phase of peripheral immune responses. Normal mouse liver contains an unusual mixture of lymphocytes in which natural killer (NK) and NK-T cells are abundant and apoptotic T cells are present, and we interpret these cell populations as, respectively, agents and targets of an intrahepatic T-cell trapping and killing mechanism. In support of this idea, direct perfusion of activated lymphocyte populations through the normal liver results in the selective retention of activated CD8+ T cells. T cells trapped in this manner undergo apoptosis in the liver. This mechanism could explain the importance of the liver in oral tolerance, the phenomenon of tolerance induced by portal vein infusion of antigenic cells, the tolerance to allogeneic liver allografts, and the persistence of some liver pathogens including hepatitis C.

Liver adenomatosis: reappraisal, diagnosis, and surgical management: eight new cases and review of the literature

OBJECTIVE

Liver adenomatosis (LA) is a rare disease originally defined by Flejou et al in 1985 from a series of 13 cases. In 1998, 38 cases were available for analysis, including eight personal cases. The aim of this study was to review and reappraise the characteristics of this rare liver disease and to discuss diagnosis and therapeutic options.

BACKGROUND

LA was defined as the presence of >10 adenomas in an otherwise normal parenchyma. Neither female predominance nor a relation with estrogen/progesterone intake has been noted. Natural progression is poorly known.

METHODS

The clinical presentation, evolution, histologic characteristics, and therapeutic options and results were analyzed based on a personal series of eight new cases and an updated review of the literature.

RESULTS

From a diagnostic standpoint, two forms of liver adenomatosis with different presentations and evolution can be defined: a massive form and a multifocal form. The role of estrogen and progesterone is reevaluated. The risks of hemorrhage and malignant transformation are of major concern. In the authors' series, liver transplantation was indicated in two young women with the massive, aggressive form, and good results were obtained.

CONCLUSION

Liver adenomatosis is a rare disease, more common in women, where outcome and evolution vary and are exacerbated by estrogen intake. Most often, conservative surgery is indicated. Liver transplantation is indicated only in highly symptomatic and aggressive forms of the disease.

Prevalence of electrocardiographic and echocardiographic abnormalities in ambulatory ischemic colitis

The aim of this study was to evaluate the prevalence of cardiac arrhythmia and intracardiac embolic process in ambulatory ischemic colitis. From November 1994 to November 1997, 33 consecutive cases of ambulatory ischemic colitis were detected. This study included 21 women and 12 men with a mean age of 71 years. All patients underwent a cardiovascular investigation including questioning, electrocardiogram, 24-hr ambulatory electrocardiography and transthoracic echocardiography. A prior history of ischemic colitis was found in four cases (12%). Cardiac arrhythmia was detected in eight cases. Transthoracic echocardiography showed an intracardiac process, potentially responsible for a peripheral embolism, in four cases. In conclusion, the aggregate, in 33% of the patients, there was potential cardiac etiology. This suggests that when ambulatory ischemic colitis occurs, it is necessary to perform an exhaustive cardiovascular evaluation similar to those performed in other ischemic diseases.

Interferon and ursodeoxycholic acid combined therapy in chronic viral C hepatitis: controlled randomized trial in 203 patients

AIMS

This prospective randomized trial was carried out in order to determine whether the long-term administration of ursodeoxycholic acid after discontinuation of interferon had any beneficial effect on the clinical course of hepatitis C virus infection.

METHODS

Enrolled in the study were 203 patients with chronic active hepatitis C. They were all given: interferon alpha-2a (3 MU subcutaneously thrice a week) and ursodeoxycholic acid (10 mg/kg/day) for 9 months. At month 9, biochemical responders only were randomized into ursodeoxycholic acid treatment or placebo for 12 additional months (double blind study).

RESULTS

At the end of interferon therapy, 71 patients (37%) were virological responders and 107 (56%) patients were biochemical responders and were randomized: 54 into the ursodeoxycholic acid group and 53 into the placebo group. Sustained response was evaluated 12 months after withdrawal of interferon. Sustained biochemical and virological responses were, respectively, 30% and 22% in the ursodeoxycholic acid group and 46% and 32% in the placebo group, which did not significantly differ. Histological evolution of fibrosis and necrotic inflammatory activity were similar in the two groups.

CONCLUSION

Continuation of ursodeoxycholic acid therapy after withdrawal of interferon in patients with end-of-treatment response did not result in any significant improvement either in the maintenance of response to interferon or in liver histology.

Comparative spectra analysis (CoSA): spectra as three-dimensional molecular descriptors for the prediction of biological activities

A novel 3D QSAR approach, comparative spectra analysis (CoSA), in which molecular spectra are used as three-dimensional molecular descriptors for the prediction of biological activities, is presented and discussed. To this purpose, experimentally determined 1H NMR, mass, and IR spectra, as well as simulated IR and 13C NMR spectra, for a set of 45 diverse progestagens are converted by a program, SpecMat, into matrixes, which are subsequently employed in a multivariate regression analysis (PLS). The results are compared with those resulting from a comparative molecular field analysis (CoMFA). When used individually, spectral descriptors yield better correlations and predictions than molecular field descriptors. A combination of spectral descriptors with other descriptors, either spectral or molecular field in nature, leads in most cases to models that are statistically superior to the ones obtained by their corresponding individual spectral or molecular field descriptors.