Rapid administration of Kcentra® during cardiopulmonary arrest.

We present a case of cardiopulmonary arrest secondary to rivaroxaban related oropharyngeal hemorrhage, which required rapid intravenous (IV) push administration of 4-factor prothrombin complex concentrate (4F-PCC). Manufacturers recommend administering 4F-PCC IV at a rate of 0.12 mL/kg/min (approximately 3 units/kg/min) up to a maximum rate of 8.4 mL/min (approximately 210 units/min) [1]. The concern with rapid administration is increased potential for thromboembolic complications. There have been small studies assessing infusion rates greater than the manufacturer's recommendation with few reported thromboembolic events [2-5]. Our patient was an 81-year-old female presenting to the emergency department (ED) with sudden onset oropharyngeal hemorrhage. The patient had a pertinent history of oral and esophageal cancer and was prescribed rivaroxaban 20 mg once daily for treatment of deep vein thrombosis. Within moments of the patient arriving, she produced a large volume of blood from her nose and mouth. The source of the bleeding could not be determined, and as suctioning was attempted to clear her airway, the patient became unresponsive and pulseless. Advanced Cardiac Life Support (ACLS) procedures were initiated and 1000 mg of tranexamic acid were administered. Once the patient's active medication list was discovered, 2000 units of 4F-PCC was given as an IV push over roughly 20 s. Bleeding was controlled enough to secure the patient's airway within 5 min after 4F-PCC administration and subsequently return of spontaneous circulation was achieved. Unfortunately, the patient suffered a poor neurologic outcome and the family withdrew care after discussion with the treatment team and the patient's oncologist. This case report demonstrates rapid administration of 4F-PCC may be an effective intervention to treat immediately life threatening rivaroxaban related bleeding.

Incisionless fluorescent cholangiography (IFC): a pilot survey of surgeons on procedural familiarity, practices, and perceptions.

BACKGROUND: Incisionless fluorescent cholangiography (IFC) has recently been proven feasible, safe, and efficacious as an intraoperative procedure to help identify extrahepatic bile ducts during laparoscopic cholecystectomies (LC). We conducted a pilot survey of 51 surgeons attending an international conference who perform endoscopic cholecystectomies to identify their typical LC practices, and perceptions of IFC. METHODS: An international panel of ten IFC experts, all with > 500 prior IFC procedures and related research publications, convened during the 4th International Congress of Fluorescence-Guided Surgery in Boca Raton, Florida in February 2017. The panel was charged with developing questions about LC practices and experience with IFC, and perceptions regarding its advantages, barriers to use, and indications. These questions then were asked to other congress attendees during one of the didactic sessions using an online polling application. Attendees, who ranged from zero to considerable experience performing IFC, accessed the survey via their portable devices. RESULTS: Of the 51 survey participants, 51% were from North America; 77% identified themselves as general/minimally invasive surgeons, and roughly 60% performed under 50 cholecystectomies/year. Only 12% performed routine intraoperative cholangiography (IOC), while 72.3% routinely performed critical safety reviews. Thirty-five percent estimated that their institution's laparoscopic-to-open surgery conversion rate was > 1% during LC. Roughly 95% of respondents felt that surgeons should have access to a noninvasive method for evaluating extrahepatic biliary structures; 84% felt that the most advantageous characteristic of IFC is the lack of any biliary-tree incision; and 93.3% felt that IFC would have considerable educational value in surgical training programs; and 78% felt that any surgeon who performs LC could benefit. CONCLUSIONS: Surgeons who participated in our survey overwhelmingly recommended the routine use of IFC during laparoscopic cholecystectomy as a complimentary imaging technique. Prospective randomized clinical trials remain necessary to determine whether IFC reduces the incidence of bile duct injuries and other LC complications.

Retrospective Review of Oral Probiotic Therapy.

Purpose: There have been many in vitro studies reporting on the efficacy of probiotic bacteria in inhibiting pathogens, and there have been published studies reporting on the inhibitor effects of probiotic bacteria on the salivary levels of bacterial pathogens. However, there have not been but a few studies on the clinical benefits of oral probiotic therapy. Study design: Dental records of 60 patients that were enrolled in an Institutional Review Board approved study were reviewed as to current caries activity status with measurement of the Decayed Missing Filled Teeth index and by Caries Management By Risk Assessment (CAMBRA) determination. The current oral health status was compared to the prior-to-study enrollment status and then analyzed in respect to published national norms. The data (without any identifiers) had a statistical analysis by a blinded biostatistician. The data was subjected to statistical analysis (Statsgraphic) before and after the probiotic therapy. Results: Of the 53 subjects available for follow up, only 4 had remained caries active with a grand total of 27 carious lesions being detected and subsequently restored in this group. Of the original total of 60 patients with 292 initial carious lesions, after probiotic therapy and dental restoration, 78 total restorations were placed in the subject group over the following three years. Approximately half of these restorations were required in teeth that had initially presented with smaller lesions and had been placed in a "watch" category. Two of the patients that developed further carious lesions had been randomly assigned to the probiotic PerioBalance, while the other two caries active patients were assigned EvoraKids probiotic. Of the original group of caries active patients, 24 did not present with any further carious involvement. Another 25 could be categorized as caries static, as the restorations required were substantially less than before probiotic therapy had been begun. The F-ratio, which in this case equals 51.3313, is a ratio of the between-group estimate to the within-group estimate. Since the P-value of the F-test is less than 0.05, there is a statistically significant difference between the means of the 4 variables at the 95.0% confidence level. Conclusion: The tested probiotic supplements had a statistically significant effect on the caries experience of the enrolled subjects.

Residential tap water contamination following the Freedom Industries chemical spill: perceptions, water quality, and health impacts.

During January 2014, an industrial solvent contaminated West Virginia's Elk River and 15% of the state population's tap water. A rapid in-home survey and water testing was conducted 2 weeks following the spill to understand resident perceptions, tap water chemical levels, and premise plumbing flushing effectiveness. Water odors were detected in all 10 homes sampled before and after premise plumbing flushing. Survey and medical data indicated flushing caused adverse health impacts. Bench-scale experiments and physiochemical property predictions showed flushing promoted chemical volatilization, and contaminants did not appreciably sorb into cross-linked polyethylene (PEX) pipe. Flushing reduced tap water 4-methylcyclohexanemethanol (4-MCHM) concentrations within some but not all homes. 4-MCHM was detected at unflushed (<10 to 420 µg/L) and flushed plumbing systems (<10 to 96 µg/L) and sometimes concentrations differed among faucets within each home. All waters contained less 4-MCHM than the 1000 µg/L Centers for Disease Control drinking water limit, but one home exceeded the 120 µg/L drinking water limit established by independent toxicologists. Nearly all households refused to resume water use activities after flushing because of water safety concerns. Science based flushing protocols should be developed to expedite recovery, minimize health impacts, and reduce concentrations in homes when future events occur.

Sarcocystis oreamni, n. sp. (Apicomplexa: Sarcocystidae) from the mountain goat (Oreamnos americanus).

Numerous species of Sarcocystis have been reported from wild ruminants, but none has been named from the Rocky Mountain goat (Oreamnos americanus). Mature sarcocysts were found in frozen muscle samples of three of seven mountain goats from Alaska, USA. Two morphological types of sarcocysts were found; one had Sarcocystis cornagliai-like sarcocysts, previously named from the Alpine ibex (Capra ibex) from Europe. Two other goats were infected with a new species, Sarcocystis oreamni. Sarcocystis oreamni sarcocysts were microscopic with 2 µm-thick sarcocyst wall. By transmission electron microscopy, the sarcocyst wall had 1.7 µm-thick with unusual molar tooth-like villar protrusions (vp), type 29. The vp had an electron dense core and two disc-shaped plaques at the tip with fine microtubules. Bradyzoites were 8.6-9.1 µm long. Single nucleotide polymorphism (SNP) identified in 18S rRNA, and 28S rRNA loci of rDNA regions that suggested S. oreamni molecularly apart from related species. The phylogenetic analysis based on 18S rRNA and 28S rRNA sequences suggested S. oreamni is related with Sarcocystis species that employ members of the Canidae family as their definitive host.

First-in-Human Phase 1b Trial of Quinacrine Plus Capecitabine in Patients With Refractory Metastatic Colorectal Cancer.

BACKGROUND: Quinacrine plus a fluoropyrimidine has in vivo efficacy against metastatic colorectal cancer (mCRC). This phase 1b trial evaluated the combination of quinacrine plus capecitabine in patients with treatment-refractory mCRC. PATIENTS AND METHODS: Using a modified Simon accelerated titration design, adults with treatment-refractory mCRC were treated with capecitabine 1000 mg/m2 twice daily for 14/21-day cycle, and escalating doses of quinacrine 100 mg daily, 100 mg twice daily, and 200 mg twice daily for 21 days. The primary endpoint was identifying the maximum tolerated dose, determining tolerability and safety. In an expansion cohort, it was overall response rate and time to tumor progression (TTP). RESULTS: Ten patients (median age of 60 years) were treated in phase 1b. The first 2 quinacrine dosing levels were well tolerated. Dose-limiting toxicities were seen in 3 patients treated with quinacrine 200 mg twice daily. Five additional patients tolerated quinacrine 100 mg twice daily without further dose-limiting toxicities, thus establishing the maximum tolerated dose. Seven additional expansion-cohort patients enrolled onto the study before quinacrine manufacturing ceased within the United States. Five patients experienced stable disease, 1 partial response, and 10 disease progression. Median TTP overall was 2.12 months and median overall survival 5.22 months for the 17 patients. CONCLUSION: Capecitabine and quinacrine can be safely administered at the maximum tolerated dose of capecitabine 1000 mg/m2 by mouth twice daily on days 1-14 and quinacrine 100 mg by mouth twice daily on days 1-21 of a 21-day cycle in mCRC patients. Although the expansion study was halted early, TTP was in line with other studies of refractory mCRC, suggesting activity of this regimen in heavily pretreated patients.