Using Methicillin-Resistant Staphylococcus aureus Nasal Screens to Rule Out Methicillin-Resistant S aureus Pneumonia in Surgical Intensive Care Units.

INTRODUCTION: The methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) has a high negative predictive value (NPV). We aimed to understand if there was a difference in the NPV of the MRSA screen in surgical intensive care units (ICUs) and to determine its role in antibiotic de-escalation. METHODS: We performed a single-center, retrospective cohort study of adults with a positive respiratory culture and MRSA nasal PCR admitted to a surgical ICU from 2016 to 2019. Patients were stratified by surgical ICU: cardiothoracic/cardiovascular intensive care unit (CVICU) or transplant/acute care surgery intensive care unit (ACS-ICU). Our primary outcome was the NPV of MRSA screen. Secondary outcome was the duration of empiric MRSA-targeted therapy. RESULTS: We analyzed 61 patients: 42.6% (n = 26) ACS-ICU and 57.4% (n = 35) CVICU. There were no differences in age, comorbidities, prior MRSA infection, recent antibiotic use, immunocompromised status, or renal replacement therapy. At pneumonia diagnosis, more patients in the ACS-ICU were hospitalized ≥5 d (65.4% versus 8.6%, P < 0.0001) and more patients in the CVICU were in septic shock (88.6% versus 34.5%, P < 0.0001) and thrombocytopenic (40% versus 11.5%, P = 0.02). NPV of the PCR was similar (ACS-ICU: 0.92 [0.75-0.98], CV-ICU 0.89 [0.73-0.96]). On multivariable linear regression, the CVICU was associated with longer empiric therapy (ß 1.5, 95% CI 0.8-2.3, P < 0.0001), as was hospitalization for ≥5 d (ß 0.73, 95% CI 0.06-1.39, P = 0.03). CONCLUSIONS: The MRSA nasal PCR screen has a high NPV for ruling out MRSA pneumonia in critically ill surgical patients. However, patients in the CVICU and patients hospitalized ≥5 d had a longer time to de-escalation of MRSA-targeted therapy, potentially due to higher clinical risk profile.

Psychosocial telephone interventions for patients with cancer and survivors: a systematic review.

OBJECTIVE: Over one third of patients with cancer experience elevated psychosocial distress. As screening for distress becomes more common, the number of patients referred for psychosocial care will increase. Psychosocial telephone interventions are recommended as a convenient and exportable alternative to in-person interventions addressing psychosocial distress. This study reviews the efficacy of randomized controlled trials (RCTs) of psychosocial telephone interventions for patients with cancer. METHODS: We conducted a systematic review of peer-reviewed RCTs evaluating telephone interventions in adult patients with cancer across the survivorship continuum. RESULTS: Through a database search, 480 articles were identified. After manual review, 13 were included, with 7 additional studies identified by back citation, totaling 20 studies. Participants were largely Caucasian, highly educated, with mean age ranging from 49 to 75 years. Most participants were patients with breast cancer (n = 13 studies). Sample sizes were generally small, with most patients recruited from large medical centers. Only one screened for psychosocial need. Interventions varied greatly in length and intensity. Eight studies reported significant effects post-intervention in the hypothesized direction on at least one psychosocial outcome measure. Of these eight studies, four included more than one follow-up assessment; of these, only one reported significant effects at last follow-up. No clear commonalities were found among studies reporting significant effects. CONCLUSIONS: Methodological concerns and lack of consistency in adherence to CONSORT reporting guidelines were identified. This body of research would benefit from well-designed, theory-based RCTs adequately powered to provide more definitive evidence for intervention efficacy. This will probably require multi-institutional collaborations, guided by intervention and research methodology best practices.

Understanding distress in posttreatment adult leukemia and lymphoma survivors: a lifespan perspective.

Using in-depth interviews, this paper explores the nature and sources of cancer-specific distress among 51 posttreatment adult leukemia and lymphoma survivors (LLS), focusing on the role of lifespan stage in shaping reported stressors. LLS (all ages) reported physical aftereffects of cancer treatment, with reported sources of emotional and financial distress varying by lifespan stage. Young adult survivors (18-39) reported a greater number of distress sources. Distress may persist up to 4 years posttreatment, particularly among younger LLS, who appear to be at greater risk of distress in multiple domains.

Prevalence and predictors of distress in posttreatment adult leukemia and lymphoma survivors.

This paper examines predictors of cancer-specific distress among posttreatment adult leukemia and lymphoma survivors (LLS). Using a survey mailed to LLS in the Colorado Central Cancer Registry (N = 477), the authors developed a multivariable risk profile for distress. Thirty one percent of LLS reported indicators of distress. Significantly higher distress was associated with younger age (p < 0.001) in bivariate analyses. The risk profile included fear of recurrence, financial burden, and younger age. Distress did not attenuate based on time since treatment completion and may persist up to 4 years posttreatment, suggesting a need for intervention, particularly among high-risk LLS.

Defining conditions for effective interdisciplinary care team communication in an open surgical intensive care unit: a qualitative study.

OBJECTIVE: Poor interdisciplinary care team communication has been associated with increased mortality. The study aimed to define conditions for effective interdisciplinary care team communication. DESIGN: An observational cross-sectional qualitative study. SETTING: A surgical intensive care unit in a large, urban, academic referral medical centre. PARTICIPANTS: A total 6 interviews and 10 focus groups from February to June 2021 (N=33) were performed. Interdisciplinary clinicians who cared for critically ill patients were interviewed. Participants included intensivist, transplant, colorectal, vascular, surgical oncology, trauma faculty surgeons (n=10); emergency medicine, surgery, gynaecology, radiology physicians-in-training (n=6), advanced practice providers (n=5), nurses (n=7), fellows (n=1) and subspecialist clinicians such as respiratory therapists, pharmacists and dieticians (n=4). Audiorecorded content of interviews and focus groups were deidentified and transcribed verbatim. The study team iteratively generated the codebook. All transcripts were independently coded by two team members. PRIMARY OUTCOME: Conditions for effective interdisciplinary care team communication. RESULTS: We identified five themes relating to conditions for effective interdisciplinary care team communication in our surgical intensive care unit setting: role definition, formal processes, informal communication pathways, hierarchical influences and psychological safety. Participants reported that clear role definition and standardised formal communication processes empowered clinicians to engage in discussions that mitigated hierarchy and facilitated psychological safety. CONCLUSIONS: Standardising communication and creating defined roles in formal processes can promote effective interdisciplinary care team communication by fostering psychological safety.

Slow Release of GA3 Hormone from Polymer Coating Overcomes Seed Dormancy and Improves Germination.

Seed dormancy often hinders direct seeding efforts that are attempting to restore degraded landscapes. Gibberellic acid (GA3) can be applied to physiologically dormant seeds to induce germination, but this hormone is rarely effective, as it can degrade or be leached from the seed. We tested different polymer matrixes (polylactic acid, polyvinylpyrrolidone, and ethylcellulose) to apply and slowly release GA3 to the seed. These polymers were tested as seed coatings in either a powder, liquid, or a combination of powder and liquid forms. We found that a liquid ethylcellulose/GA3 coating generally outperformed the other polymers and applications methods using our test species Penstemon palmeri. With this top-performing treatment, seed germination was 3.0- and 3.9-fold higher at 15 °C and 25 °C, respectively. We also evaluated the liquid ethylcellulose/GA3 coating on P. comharrenus, P. strictus, P. pachyphyllus, and P. eatonii. Again, the coating had a strong treatment response, with the degree of difference related to the relative level of dormancy of the species. Growth studies were also performed in pots to ensure that the side effects of GA3 overdosing were not present. Here, we found minimal differences in root length, shoot length, or biomass between plants grown from untreated and GA3-coated seeds.

Cytokinesis proteins Tum and Pav have a nuclear role in Wnt regulation.

Wg/Wnt signals specify cell fates in both invertebrate and vertebrate embryos and maintain stem-cell populations in many adult tissues. Deregulation of the Wnt pathway can transform cells to a proliferative fate, leading to cancer. We have discovered that two Drosophila proteins that are crucial for cytokinesis have a second, largely independent, role in restricting activity of the Wnt pathway. The fly homolog of RacGAP1, Tumbleweed (Tum)/RacGAP50C, and its binding partner, the kinesin-like protein Pavarotti (Pav), negatively regulate Wnt activity in fly embryos and in cultured mammalian cells. Unlike many known regulators of the Wnt pathway, these molecules do not affect stabilization of Arm/beta-catenin (betacat), the principal effector molecule in Wnt signal transduction. Rather, they appear to act downstream of betacat stabilization to control target-gene transcription. Both Tum and Pav accumulate in the nuclei of interphase cells, a location that is spatially distinct from their cleavage-furrow localization during cytokinesis. We show that this nuclear localization is essential for their role in Wnt regulation. Thus, we have identified two modulators of the Wnt pathway that have shared functions in cell division, which hints at a possible link between cytokinesis and Wnt activity during tumorigenesis.

Bacterial production of organic acids enhances H2O2-dependent iodide oxidation.

To develop an understanding of the role that microorganisms play in the transport of (129)I in soil-water systems, bacteria isolated from subsurface sediments were assessed for iodide oxidizing activity. Spent liquid medium from 27/84 bacterial cultures enhanced iodide oxidation 2-10 fold in the presence of H(2)O(2). Organic acids secreted by the bacteria were found to enhance iodide oxidation by (1) lowering the pH of the spent medium, and (2) reacting with H(2)O(2) to form peroxy carboxylic acids, which are extremely strong oxidizing agents. H(2)O(2)-dependent iodide oxidation increased exponentially from 8.4 to 825.9 µM with decreasing pH from 9 to 4. Organic acids with ≥2 carboxy groups enhanced H(2)O(2)-dependent iodide oxidation (1.5-15-fold) as a function of increasing pH above pH 6.0, but had no effect at pH ≤ 5.0. The results indicate that as pH decreases (≤5.0), increasing H(2)O(2) hydrolysis is the driving force behind iodide oxidation. However, at pH ≥ 6.0, spontaneous decomposition of peroxy carboxylic acids, generated from H(2)O(2) and organic acids, contributes significantly to iodide oxidation. The results reveal an indirect microbial mechanism, organic acid secretion coupled to H(2)O(2) production, that could enhance iodide oxidation and organo-iodine formation in soils and sediments.

Cell division requires a direct link between microtubule-bound RacGAP and Anillin in the contractile ring.

The mitotic microtubule array plays two primary roles in cell division. It acts as a scaffold for the congression and separation of chromosomes, and it specifies and maintains the contractile-ring position. The current model for initiation of Drosophila and mammalian cytokinesis [1-5] postulates that equatorial localization of a RhoGEF (Pbl/Ect2) by a microtubule-associated motor protein complex creates a band of activated RhoA [6], which subsequently recruits contractile-ring components such as actin, myosin, and Anillin [1-3]. Equatorial microtubules are essential for continued constriction, but how they interact with the contractile apparatus is unknown. Here, we report the first direct molecular link between the microtubule spindle and the actomyosin contractile ring. We find that the spindle-associated component, RacGAP50C, which specifies the site of cleavage [1-5], interacts directly with Anillin, an actin and myosin binding protein found in the contractile ring [7-10]. Both proteins depend on this interaction for their localization. In the absence of Anillin, the spindle-associated RacGAP loses its association with the equatorial cortex, and cytokinesis fails. These results account for the long-observed dependence of cytokinesis on the continual presence of microtubules at the cortex.

Iodide accumulation by aerobic bacteria isolated from subsurface sediments of a 129I-contaminated aquifer at the Savannah River site, South Carolina.

(129)I is of major concern because of its mobility in the environment, excessive inventory, toxicity (it accumulates in the thyroid), and long half-life (∼16 million years). The aim of this study was to determine if bacteria from a (129)I-contaminated oxic aquifer at the F area of the U.S. Department of Energy's Savannah River Site, SC, could accumulate iodide at environmentally relevant concentrations (0.1 µM I(-)). Iodide accumulation capability was found in 3 out of 136 aerobic bacterial strains isolated from the F area that were closely related to Streptomyces/Kitasatospora spp., Bacillus mycoides, and Ralstonia/Cupriavidus spp. Two previously described iodide-accumulating marine strains, a Flexibacter aggregans strain and an Arenibacter troitsensis strain, accumulated 2 to 50% total iodide (0.1 µM), whereas the F-area strains accumulated just 0.2 to 2.0%. Iodide accumulation by FA-30 was stimulated by the addition of H(2)O(2), was not inhibited by chloride ions (27 mM), did not exhibit substrate saturation kinetics with regard to I(-) concentration (up to 10 µM I(-)), and increased at pH values of <6. Overall, the data indicate that I(-) accumulation likely results from electrophilic substitution of cellular organic molecules. This study demonstrates that readily culturable, aerobic bacteria of the F-area aquifer do not accumulate significant amounts of iodide; however, this mechanism may contribute to the long-term fate and transport of (129)I and to the biogeochemical cycling of iodine over geologic time.

Nutritional support with endoluminal stenting during neoadjuvant therapy for esophageal malignancy.

BACKGROUND: Perioperative nutrition remains a significant problem in patients undergoing neoadjuvant treatment for esophageal cancer. The aim of this study was to evaluate the effectiveness of esophageal stenting, feeding tube placement, or observation among esophageal cancer patients receiving neoadjuvant therapy. METHODS AND MATERIALS: A review of our prospectively maintained database of esophageal cancer patients identified 58 patients who underwent neoadjuvant chemoradiotherapy. Operative complications, tolerance of neoadjuvant therapy, and nutritional outcomes were evaluated according to the type of nutritional adjunct used. RESULTS: A total of 25 patients received esophageal stenting with self-expanding silicone stents. Of these, 19 patients had feeding tubes placed (without stenting), and 14 nonstented patients were maintained on oral diets alone. Stent patients showed a lower rate of interruption of chemoradiotherapy (8% vs. 29% vs. 47%, P=.011). The stent group also demonstrated greater mean improvement in albumin levels (0.14 g/dL vs. -0.39 g/dL vs. -0.45 g/dL, P<.001) and less percentage body weight loss (1.5% vs. 4.2% vs. 5.5%, P<.001). Nasogastric tubes were used for additional nutritional supplementation during the last week of therapy for two stent patients. The rate of stent migration was 24%. Overall, 31% of patients did not go on to resection because of progression to metastatic disease. The rate of major operative complication was 20% vs. 47% vs. 43% among stent, feeding tube, and oral nutrition patients respectively (P=.130). CONCLUSIONS: Esophageal stenting in the neoadjuvant setting offers improved results compared with feeding tubes both in maintaining preoperative nutrition and in tolerance of neoadjuvant chemoradiotherapy. Future protocols of patients treated with multimodal therapy for cancer of the esophagus should investigate the potential therapeutic benefit of using removable silicone esophageal stents as an alternative to feeding tubes.

Does obesity confer an increased risk and/or more severe course of post-ERCP pancreatitis?: a retrospective, multicenter study.

BACKGROUND: Pancreatitis is the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP). Recent studies have suggested that obesity may serve as a prognostic indicator of poor outcome in non-ERCP-induced acute pancreatitis. However, to our knowledge, no one has ever investigated the potential association of obesity and ERCP-induced pancreatitis. Thus, the purpose of our study was to determine whether obesity conferred an increased risk and/or more severe course of post-ERCP pancreatitis. METHODS: A 160 variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study, evaluating whether prophylactic corticosteroids reduces the incidence of post-ERCP pancreatitis. Body mass indices (BMIs) were available on 964 of the 1115 patients from the original study. A BMI > or = 30 kg/m2 was defined as obese (World Health Organization) and used as a cutoff point in this study. BMIs were analyzed in a retrospective fashion to determine whether obesity confers an increased risk and/or more severe course of post-ERCP pancreatitis. Data were collected before the ERCP, at the time of procedure, and 24 to 72 hours after discharge. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis. RESULTS: Nine hundred sixty four patients were enrolled in the study. Pancreatitis occurred in 149 patients (15.5%) and was graded as mild in 101 (67.8%), moderate in 42 (28.2%), and severe in 6 (4.0%). The patients were categorized by BMI (kg/m2) using the following breakdowns: BMI < 20, 20 to < 25, 25 to < 30, and > or = 30, as well as BMI < 30 or > or = 30. The groups were similar with respect to the patient and procedure risk factors for post-ERCP pancreatitis except the group with BMI > or = 30 had a higher frequency of females, were younger, had less frequent chronic pancreatitis, a lower number of pancreatic duct injections, and fewer patients received more than 2 pancreatic duct injections. Of the patients with a BMI < 30, 119 (16.4%) developed post-ERCP pancreatitis compared with 30 (12.5%) of those with a BMI > or = 30 (P=0.14). There was no association between the presence of obesity and the severity of pancreatitis (P=0.74). Patients with a BMI < 20, 20 to < 25, 25 to < 30, and > or = 30 had a similar incidence of post-ERCP pancreatitis. CONCLUSIONS: Obesity did not seem to confer an increased risk for ERCP-induced pancreatitis. A statistically significant association between obesity and the severity of ERCP-induced pancreatitis was not apparent.

Reducing Inappropriate Testing for the Evaluation of Diarrhea Among Hospitalized Patients.

BACKGROUND: Diarrhea is one of the most common illnesses in the United States. Evaluation frequently does not follow established guidelines. The objective of this study was to evaluate the effectiveness of a computerized physician order entry-based test guidance algorithm with regard to the clinical, financial, and operational impacts. METHODS: Our population was patients with diarrheal illness at a tertiary academic medical center. The intervention was a computerized physician order entry-based test guidance algorithm that restricted the use of stool cultures and ova and parasites testing of diarrhea in the adult inpatient location vs nonintervention sites, which were the emergency department, pediatric inpatient and adult and pediatric outpatient locations. We measured stool culture, ova and parasites, and Clostridium difficile testing rates from July 1, 2012 to January 31, 2016. Additionally, we calculated advisor usage, consults generated, accuracy of information, and cost savings. RESULTS: There was a significant decrease in stool culture and ova and parasites testing rates at the adult inpatient (P = .001 for both), pediatric (P < .001 for both), and adult emergency department (P < .001; P = .009) locations. The decrease at the intervention site was immediate, whereas the other locations showed a delayed but sustained decrease that suggests a collateral impact. A significant increase in the rate of stool culture and ova and parasites testing was observed in the outpatient setting (P = .02 and P = .001). We estimate that $21,931 was saved annually. CONCLUSIONS: A point-of-order test restriction algorithm for hospitalized adults with diarrhea reduced stool testing. Similar programs should be considered at other institutions and for the evaluation of other conditions.

Wingless signaling: an axin to grind.

Negative regulation of Wingless/Wnt signaling plays an important role in embryonic patterning and is also needed for tumor suppression in adult tissues. New findings in Drosophila reveal a novel mechanism for down-regulating the activity of the Wingless/Wnt pathway.

Does Intrawound Vancomycin Application During Spine Surgery Create Vancomycin-Resistant Organism?

BACKGROUND: Surgical site infection (SSI) following spine surgery is a morbid and expensive complication. The use of intrawound vancomycin is emerging as a solution to reduce SSI. The development of vancomycin-resistant pathogens is an understandable concern. OBJECTIVE: To determine the occurrence of vancomycin-resistant SSI in patients with and without use of intrawound vancomycin. METHODS: Patients undergoing elective spine surgery were dichotomized based on whether intrawound vancomycin was applied. Outcome was occurrence of SSI requiring return to the operating room within postoperative 90 days. The intrawound culture and vancomycin minimal inhibitory concentrations (MIC) were reviewed. Analyses were conducted to compare the pathogen profile and MIC for vancomycin in patients who received vancomycin and those who did not. RESULTS: Of the total 2802 patients, 43% (n = 1215) had intrawound vancomycin application during the index surgery. The use of vancomycin was associated with significantly lower deep SSI rates (1.6% [n = 20] vs 2.5% [n = 40], P = .02). The occurrence of Staphylococcus aureus SSI was significantly lower in the patients who had application of intrawound vancomycin (32% vs 65%, P = .003). None of the patients who had application of intrawound vancomycin powder, and subsequently developed an S aureus SSI, demonstrated pathogens with resistance to vancomycin. All patients had MIC < 2 µg/mL, the vancomycin susceptibility threshold. The occurrence of gram-negative SSI (28% vs 7%) and culture negative fluid collection (16% vs 5%) was higher in the vancomycin cohort. CONCLUSIONS: The use of intrawound vancomycin during the index spine surgery was protective against SSI following spine surgery. The application of intrawound vancomycin during index surgery does not appear to create vancomycin-resistant organisms in the event of an SSI.

Morphological transformation in esophageal submucosa by bone marrow cells: esophageal implantation under external esophageal perfusion.

Accumulating clinical and experimental studies indicate that Barrett's esophagus might arise through multipotential stem cells under the stress of gastroesophageal reflux. Previously, we have presented a novel external pump perfusion rat model and demonstrated that perfusion with both acid and bile can induce severe esophagitis in 1 week with a similarly pathological change seen in humans. The aim of this study was to investigate the histological changes of esophagus after bone marrow cell engraftment with bile and acid perfusion. The external pump perfusion procedure involved implantation of a microosmotic pump for esophageal perfusion. Bone marrow cells were obtained by flushing of the femur marrow, and the cell suspension was injected between the esophageal muscular and inner mucosa layer. Histological changes were determined after 4 weeks of perfusion. Proliferating cell nuclear antigen, 8-hydroxy-deoxyguanosine, manganese superoxide dismutase, and apoptosis were measured by immunohistochemical staining and TUNEL assay, respectively. Severe esophagitis was seen in both acid and bile perfusion. Bone marrow engraftment and potentiation was seen in both the acid and bile perfusion, when compared to saline controls. Glandular-like cells in submucosa, consistent with intestinal metaplasia, confirmed by Alcin Blue-PAS staining were observed after bone marrow esophageal implantation along with bile perfusion, but not with acid perfusion and controls. Bone marrow implantation in conjunction with esophageal reflux injury contributes to abnormal histological changes consistent with early Barrett's esophageal changes. Engrafted bone marrow cells proliferate under oxidative stress conditions with bile perfusion.

RacGap50C negatively regulates wingless pathway activity during Drosophila embryonic development.

The Wingless (Wg)/Wnt signal transduction pathway directs a variety of cell fate decisions in developing animal embryos. Despite the identification of many Wg pathway components to date, it is still not clear how these elements work together to generate cellular identities. In the ventral epidermis of Drosophila embryos, Wg specifies cells to secrete a characteristic pattern of denticles and naked cuticle that decorate the larval cuticle at the end of embryonic development. We have used the Drosophila ventral epidermis as our assay system in a series of genetic screens to identify new components involved in Wg signaling. Two mutant lines that modify wg-mediated epidermal patterning represent the first loss-of-function mutations in the RacGap50C gene. These mutations on their own cause increased stabilization of Armadillo and cuticle pattern disruptions that include replacement of ventral denticles with naked cuticle, which suggests that the mutant embryos suffer from ectopic Wg pathway activation. In addition, RacGap50C mutations interact genetically with naked cuticle and Axin, known negative regulators of the Wg pathway. These phenotypes suggest that the RacGap50C gene product participates in the negative regulation of Wg pathway activity.

Cyclooxygenase-2 and epithelial growth factor receptor up-regulation during progression of Barrett's esophagus to adenocarcinoma.

AIM: To investigate the expression of cyclooxygenase-2 (COX-2) and epithelial growth factor receptor (EGFR) throughout the progression of Barretts esophagus (BE). METHODS: COX-2 and EGFR protein expressions were detected by using immunohistochemical method. A detailed cytomorphological changes were determined. Areas of COX-2 and EGFR expression were quantified by using computer Imaging System. RESULTS: The expressions of both COX-2 and EGFR increased along with the progression from BE to esophagus adenocarcinoma (EAC). A positive correlation was found between COX-2 expression and EGFR expression. CONCLUSION: COX-2 and EGFR may be cooperative in the stepwise progression from BE to EAC, thereby leading to carcinogenesis.