The impact of changing reflexive to clinician-ordered Clostridioides difficile polymerase chain reaction (PCR) testing for indeterminate cases: Cost savings without associated adverse events.

OBJECTIVE: To evaluate changing Clostridioides difficile infection (CDI) testing among inpatients with indeterminate enzyme immunoassay (EIA) results (antigen+/toxin-) from reflexive polymerase chain reaction (PCR) testing to clinician-ordered PCR testing. DESIGN: Multicenter, before-and-after, quasi-experimental study. SETTING: Four large urban tertiary-care hospitals. METHODS: We evaluated two 6-month periods before and after an intervention. The primary study outcome was the change in the number of CDI diagnoses between periods. Secondary outcomes included the number of PCR tests performed, adverse events, and healthcare cost savings. RESULTS: In total, 500 EIA-indeterminate C. difficile test results were evaluated: 281 before the intervention and 219 thereafter. CDI was diagnosed by PCR among EIA-indeterminate cases in 182 in the preintervention period versus 94 patients in the postintervention period (48% reduction; P < .01). PCR testing was performed in 99.6% of indeterminate cases (280 of 281; 1 not performed due to an inhibitor) in the preintervention period versus 66% (144 of 219) in the postintervention period (34% reduction; P < .01). We observed no differences between study periods in 30-day all-cause (P = .96), GI-related (P = .93), or C. difficile (P = .47) readmissions, nor in 30-day C. difficile infections (P > .99). No patient without a PCR test in the postintervention period and not treated was later diagnosed with CDI. Each reflexive PCR test not performed led to a cost savings of $4,498 per patient. CONCLUSIONS: Applying diagnostic stewardship to C. difficile PCR testing in the inpatient setting led to significant reductions in both testing and cases. Changing the C. difficile PCR testing algorithm for EIA-indeterminate cases from reflexive to clinician-required ordering resulted in valuable cost savings without associated adverse events.

Necrotizing fasciitis due to Serratia marcescens: case report and review of the literature.

BACKGROUND: Necrotizing fasciitis is a severe, life-threatening infection.  Serratia marcescens, a Gram-negative bacterium, is an extremely rare cause of necrotizing fasciitis. METHODS: A case of S. marcescens necrotizing fasciitis is described, and a comprehensive review of the literature (1966-2015) of monomicrobial cases due to this organism performed. RESULTS: We report the first case of S. marcescens necrotizing fasciitis in the setting of calciphylaxis associated with end-stage renal disease.  A comprehensive review of the literature of S. marcescens necrotizing fasciitis is provided to enhance the awareness of this increasingly recognized infection, and to provide a concise summary of risk factors, treatment, and outcome. CONCLUSIONS: Our case and review highlight the potential risk factors for S. marcescens necrotizing fasciitis, including underlying renal disease and open wounds, and demonstrate the emergence of this organism as a cause of severe, life-threatening soft tissue infections.

Volume Delivered During Recruitment Maneuver Predicts Lung Stress in Acute Respiratory Distress Syndrome.

OBJECTIVE: Global lung stress varies considerably with low tidal volume ventilation for acute respiratory distress syndrome. High stress despite low tidal volumes may worsen lung injury and increase risk of death. No widely available parameter exists to assess global lung stress. We aimed to determine whether the volume delivered during a recruitment maneuver (V(RM)) is inversely associated with lung stress and mortality in acute respiratory distress syndrome. DESIGN: Substudy of an acute respiratory distress syndrome clinical trial on esophageal pressure-guided positive end-expiratory pressure titration. SETTING: U.S. academic medical center. PATIENTS: Forty-two patients with acute respiratory distress syndrome in whom airflow, airway pressure, and esophageal pressure were recorded during the recruitment maneuver. INTERVENTIONS: A single recruitment maneuver was performed before initiating protocol-directed ventilator management. Recruitment maneuvers consisted of a 30-second breath hold at 40 cm H2O airway pressure under heavy sedation or paralysis. V(RM) was calculated by integrating the flow-time waveform during the maneuver. End-inspiratory stress was defined as the transpulmonary (airway minus esophageal) pressure during end-inspiratory pause of a tidal breath and tidal stress as the transpulmonary pressure difference between end-inspiratory and end-expiratory pauses. MEASUREMENTS AND MAIN RESULTS: V(RM) ranged between 7.4 and 34.7 mL/kg predicted body weight. Lower V(RM) predicted high end-inspiratory and tidal lung stress (end-inspiratory: ß = -0.449; 95% CI, -0.664 to -0.234; p < 0.001; tidal: ß = -0.267; 95% CI, -0.423 to -0.111; p = 0.001). After adjusting for PaO2/FIO2 and either driving pressure, tidal volume, or plateau pressure and positive end-expiratory pressure, V(RM) remained independently associated with both end-inspiratory and tidal stress. In unadjusted analysis, low V(RM) predicted increased risk of death (odds ratio, 0.85; 95% CI, 0.72-1.00; p = 0.026). V(RM) remained significantly associated with mortality after adjusting for study arm (odds ratio, 0.84; 95% CI, 0.71-1.00; p = 0.022). CONCLUSIONS: Low V(RM) independently predicts high lung stress and may predict risk of death in patients with acute respiratory distress syndrome.

Prostate laser vaporization is safe and effective in elderly men.

INTRODUCTION: There are few data on the safety and efficacy of laser photoselective vaporization (LVP) in elderly men. We compared the safety and efficacy of LVP for the treatment of symptomatic benign prostatic hyperplasia (BPH) in men ≥75 years, who we defined as elderly, to those <75 years. MATERIALS AND METHODS: Safety and efficacy outcomes in elderly men undergoing LVP for lower urinary tract symptoms secondary to BPH from 2005 to 2012 were compared with men <75 years. Differences between-groups in demographics, perioperative outcomes, complications, and postoperative changes in International Prostate Symptom Score (I-PSS) were calculated. RESULTS: Of 202 patients, 49 (24%) were elderly (range: 75-95 years) and 153 (76%) were <75 years. Preoperatively, elderly men were more likely to have heart disease (35% vs. 20%, P = 0.03), gross hematuria (6.1% vs. 0.7%, P = 0.05), urinary retention (57% vs. 41%, P = 0.07), and take anti-coagulants (61% vs. 35%, P = 0.002). Elderly men had a longer median length of stay (1 day vs. 0 day, P = 0.001). There were no significant between-group differences in transfusion frequency (4.4% vs. 0.7%, P = 0.14) or Clavien III complications (2% vs. 2.6%, P = 1.0). One month postsurgery, elderly patients reported smaller median decreases in I-PSS (5.5 vs. 9, P = 0.02) and urinary bother (1 point vs. 2, P = 0.03) compared with preoperative values. At till 9 months follow-up, there were no significant between-group differences in median I-PSS or urinary bother scores. CONCLUSIONS: Despite a higher prevalence of preoperative comorbidity and urinary retention, elderly LVP patients experienced perioperative safety and shorter term efficacy outcomes comparable to younger men.

A dynamic model of calcific nodule destabilization in response to monocyte- and oxidized lipid-induced matrix metalloproteinases.

Vulnerable plaque remains clinically undetectable, and there is no accepted in vitro model. We characterize the calcific nodules produced by calcifying vascular cells (CVC) in ApoE-null mice, demonstrating increased destabilization of cultured nodules in the presence of oxidized low-density lipoprotein (oxLDL) and monocytes under pulsatile shear stress. CVC implanted in the subcutaneous space of hyperlipidemic mice produced nodules revealing features of calcific atherosclerotic plaque including a fibrous cap, cholesterol clefts, thin shoulder, lipids, and calcium mineral deposits. CVC nodules seeded in the pulsatile flow channel (τ(avg) = 23 dyn/cm(2), ∂τ/∂t = 71 dyn·cm(-2)·s(-1)) underwent deformation and destabilization. Computational fluid dynamics revealed distinct shear force profiles on the nodules. Presence of oxLDL or monocytic THP-1 cells significantly increased the numbers of nodules destabilized from the substrate. Both oxLDL and THP-1 increased matrix metalloproteinase (MMP) activity in CVC. The MMP inhibitor GM6001 significantly reversed oxLDL- and THP-1-induced nodule destabilization, whereas overexpression of MMP-9 increased destabilization. These findings demonstrate that CVC-derived nodules resembled calcific atherosclerotic plaque and were destabilized in the presence of active lipids and monocytes via induction of MMPs.

Ultrafine particles from diesel vehicle emissions at different driving cycles induce differential vascular pro-inflammatory responses: implication of chemical components and NF-kappaB signaling.

BACKGROUND: Epidemiological evidence supports the association between exposure to ambient particulate matter (PM) and cardiovascular diseases. Chronic exposure to ultrafine particles (UFP; Dp <100 nm) is reported to promote atherosclerosis in ApoE knockout mice. Atherogenesis-prone factors induce endothelial dysfunction that contributes to the initiation and progression of atherosclerosis. We previously demonstrated that UFP induced oxidative stress via c-Jun N-terminal Kinases (JNK) activation in endothelial cells. In this study, we investigated pro-inflammatory responses of human aortic endothelial cells (HAEC) exposed to UFP emitted from a diesel truck under an idling mode (UFP1) and an urban dynamometer driving schedule (UFP2), respectively. We hypothesize that UFP1 and UFP2 with distinct chemical compositions induce differential pro-inflammatory responses in endothelial cells. RESULTS: UFP2 contained a higher level of redox active organic compounds and metals on a per PM mass basis than UFP1. While both UFP1 and UFP2 induced superoxide production and up-regulated stress response genes such as heme oxygenease-1 (HO-1), OKL38, and tissue factor (TF), only UFP2 induced the expression of pro-inflammatory genes such as IL-8 (2.8 +/- 0.3-fold), MCP-1 (3.9 +/- 0.4-fold), and VCAM (6.5 +/- 1.1-fold) (n = 3, P < 0.05). UFP2-exposed HAEC also bound to a higher number of monocytes than UFP1-exposed HAEC (Control = 70 +/- 7.5, UFP1 = 106.7 +/- 12.5, UFP2 = 137.0 +/- 8.0, n = 3, P < 0.05). Adenovirus NF-kappaB Luciferase reporter assays revealed that UFP2, but not UFP1, significantly induced NF-kappaB activities. NF-kappaB inhibitor, CAY10512, significantly abrogated UFP2-induced pro-inflammatory gene expression and monocyte binding. CONCLUSION: While UFP1 induced higher level of oxidative stress and stress response gene expression, only UFP2, with higher levels of redox active organic compounds and metals, induced pro-inflammatory responses via NF-kappaB signaling. Thus, UFP with distinct chemical compositions caused differential response patterns in endothelial cells.

Ultrafine particles from diesel engines induce vascular oxidative stress via JNK activation.

Exposure to particulate air pollution is linked to increased incidences of cardiovascular diseases. Ambient ultrafine particles (UFP) from diesel vehicle engines have been shown to be proatherogenic in ApoE knockout mice and may constitute a major cardiovascular risk in humans. We posited that circulating nano-sized particles from traffic pollution sources induce vascular oxidative stress via JNK activation in endothelial cells. Diesel UFP were collected from a 1998 Kenworth truck. Intracellular superoxide assay revealed that these UFP dose-dependently induced superoxide (O(2)(-)) production in human aortic endothelial cells (HAEC). Flow cytometry showed that UFP increased MitoSOX red intensity specific for mitochondrial superoxide. Protein carbonyl content was increased by UFP as an indication of vascular oxidative stress. UFP also up-regulated heme oxygenase-1 (HO-1) and tissue factor (TF) mRNA expression, and pretreatment with the antioxidant N-acetylcysteine significantly decreased their expression. Furthermore, UFP transiently activated JNK in HAEC. Treatment with the JNK inhibitor SP600125 and silencing of both JNK1 and JNK2 with siRNA inhibited UFP-stimulated O(2)(-) production and mRNA expression of HO-1 and TF. Our findings suggest that JNK activation plays an important role in UFP-induced oxidative stress and stress response gene expression.