An emergency department intervention to improve earlier detection of community-onset bloodstream infection among hospitalized patients.

BACKGROUND: Blood cultures (BCs) are essential microbiologic tests, but blood culturing diagnostic stewardship is frequently poor. We aimed to study the process-related failures and to evaluate the effect of an emergency department (ED) intervention on BCs collection practices and yield. METHODS: We implemented an ED-quality improvement intervention including educational sessions, phlebotomists addition, promoting single-site strategy for BC-collection and preanalytical data feedback. BC-bottles collected, positive BCs, blood volumes and documentation of collection times were measured, before (December 2021-August 2022) and after (September 2022-July 2023) intervention. Results were corrected to hospitalizations admissions or days. We used interrupted-time series analyses for comparisons. RESULTS: A total of 64,295 BC bottles were evaluated, 26,261 before and 38,034 postintervention. The median ED-BCs collected per week increased from 88 to 105 BCs (P < .0001), resulting from increased early sampling (P = .0001). Solitary BCs decreased (95%-28%), documented times increased (2.8%-25%), and average blood volume increased (3 mL to 4.5 mL) postintervention. Community-onset Bloodstream infections (BSIs) increased (39.6-52 bottles/1,000 admissions, P = .0001), while Health care-associated BSIs decreased (39-27 bottles/10,000 days, P = .0042). Contamination rates did not change. CONCLUSIONS: An ED-focused intervention based on the education sessions and single-site strategy improved culturing stewardship and facilitated the early identification of BSI without an increase in contamination.

Associations of High-Sensitive Cardiac Troponin T in Healthy Newborns and Prolonged Second Stage of Labor, Neonatal and Maternal Factors: A Prospective Study.

INTRODUCTION: High-sensitivity cardiac troponin T (hs-cTnT) is not used routinely as a diagnostic biomarker in newborns. The high precision of hs-cTnT assays increases the ability to determine small differences in cTnT over time and to detect troponin T elevation; thus, we believe that hs-cTnT assays might improve clinical care. We explored the plausible association between hs-cTnT levels (ng/L) in healthy newborns and prolonged second stage of labor, neonatal, and maternal factors. METHODS: A prospective study was performed among healthy newborns in the Obstetrics and Gynecology Department at Hillel Yaffe Medical Center in Israel in January-June 2021. The sociodemographic characteristics of the participants, maternal age, gravidity, parity, Pitocin use, epidural analgesia, and neonatal anemia were obtained from the electronic medical records. Gestational age was determined by ultrasound biometric measurements. We classified second-stage labor as normal or prolonged using the WHO guidelines. Samples from umbilical cord blood were drawn using syringes rinsed with anticoagulant by a specialist in pediatrics. The remaining blood was used to determine hs-cTnT levels (ng/L), which was defined as a continuous quantitative variable with the median value and the 25th-75th percentiles. RESULTS: Overall, 184 cord blood samples were performed from healthy newborns (60.6% males) with a median hs-cTnT of 39.03 (25th-75th percentiles = 30.53-54.09) ng/L. A multivariable linear regression model showed no significant association between neonatal anemia and hs-cTnT levels (ng/L) (p = 0.8). Gestational age (B coefficient -4.24, p < 0.001) and gravidity (B coefficient -2.41, p = 0.03) were negatively associated with hs-cTnT levels (ng/L), while Pitocin use (B coefficient 6.91, p = 0.04) and prolonged second stage of labor (B coefficient 18.07, p = 0.02) were positively associated with hs-cTnT levels (ng/L). CONCLUSIONS: High hs-cTnT levels (ng/L) were documented in the cord blood of healthy newborns. Hs-cTnT levels were positively correlated with a prolonged second stage of labor and Pitocin use and negatively correlated with longer gestational age and higher gravidity. Hs-cTnT may signify labor-related fetal distress. A larger surveillance study is mandatory to establish this correlation and assess for possible prognostic significance of elevated hs-cTnT in this context.

Incidence and risk factors of hospitalisations for respiratory syncytial virus among children aged less than 2 years.

The study aim was to examine the incidence and risk factors of respiratory syncytial virus (RSV) bronchiolitis hospitalisations and disease severity among infants. We compared demographic and health characteristics of children aged 0-23 hospitalised for RSV bronchiolitis (cases, n = 1227) during 2008-2018 and control children (n = 554) of the same age admitted for non-respiratory disease. RSV antigen was detected in nasal swabs by immunochromatography. Multiple logistic regression models were applied. The average annual incidence of hospitalisation for RSV bronchiolitis was 12.6 per 1000 and 1.7 per 1000 (P < 0.001) among infants and toddlers, respectively, with winter seasonality (November-March). The risk of hospitalisation for RSV bronchiolitis increased among children aged 0-5 months (OR 7.66; 95% CI 5.61-10.45) and 6-11 months (OR 12.88, 95% CI 8.48-19.55), compared to those aged 12-23 months. Additional risk factors were living in low vs. higher socio-economic status towns (OR 1.49; 95% CI 1.14-1.95), having chronic medical conditions (OR 2.75; 95% CI 1.61-4.70), birth month (October-January vs. June-September) (OR 2.19; 95% CI 1.60-2.99) and history of stay in neonatal intensive care unit at birth (OR 2.37; 95% CI 1.27-4.41). Male children and those who had pneumonia were more likely to have severe RSV bronchiolitis. In conclusion, the burden of hospitalisations for RSV bronchiolitis is high, especially in young infants. Effective preventive measures such as RSV active vaccines can reduce the risk of hospitalisations for RSV bronchiolitis among these vulnerable groups.

Does mRNA SARS-CoV-2 vaccine in the follicular fluid impact follicle and oocyte performance in IVF treatments?

PROBLEM: The COVID-19 pandemic has many clinical manifestations. Rapid vaccine development raised concerns and speculations about future fertility outcomes and vaccine safety. We evaluated the effect of Pfizer-BioNTech mRNA SARS-CoV-2 vaccine on IVF treatment, oocyte and embryo quality, and pregnancy outcomes. METHOD OF STUDY: This prospective, observational cohort study was conducted in a referral IVF Unit, 3/2021-5/2021. We aimed to recruit all women undergoing IVF/ICSI cycles from 3/1-4/30/2021, 2-8 weeks after the second vaccination, and to analyze 50-60 samples in the 2-month period. Patients were categorized according to serum antibody levels: positive for spike (S), positive for nucleotide (N), or negative for both. On the day of ovum pick-up, follicular fluid and blood samples were analyzed for anti-nucleotide (anti-N) antibodies, and anti-spike (anti-S) antibodies, hormonal profile, C-reactive protein (CRP) and other metabolic parameters. RESULTS: Of 59 women enrolled, 37 reported being vaccinated and 22 were not. We found 97% correlation between anti-S and anti-N in the blood and the follicular fluid. Follicular fluid was analyzed based on antibody categorization. All IVF treatment parameters in the follicular fluids and serum were comparable, except CRP was significantly elevated among patients with anti-N antibodies (2.29 [1.42-6.08] vs. 4.11 [1.62-5.75] vs. 1.44 [.36-8.33]; p < .001). Pregnancy outcomes were comparable (44% vs. 33% vs. 50%; p = .97). CONCLUSION: mRNA SARS-CoV-2 vaccine did not appear to affect treatment outcomes or ovarian reserves in the subsequent IVF cycle.

In-vitro model for bacterial growth inhibition of compartmentalized infection treated by an ultra-high concentration of antibiotics.

BACKGROUND: Pseudomonas aeruginosa (P. aeruginosa), Escherichia coli (E. coli), and Staphylococcus aureus (S. aureus) are common pathogens encountered in infected cardiovascular-implantable electronic device (CIED). Continuous, in-situ targeted, ultra-high concentration antibiotic (CITA) treatment is a novel antibiotic treatment approach for localized infections. CITA provides sufficient local antibiotic concentrations to heavily infected cavities while avoiding systemic toxicity. AIM: In-vitro confirmation of the efficacy of the CITA treatment approach in simulated compartmentalized infections. MATERIALS AND METHODS: A rapid automated bacterial culture analyzing system) Uro4 HB&L™ (was applied to compare the efficacy of selected antibiotics at a standard minimal inhibitory concentration (1MIC), 4MIC, and CITA at 103MIC, for growth inhibition of high bacterial loads (106 colony-forming-units/ml) of ATCC strains of P. aeruginosa, E. coli, and S. aureus. RESULTS: The addition of gentamicin and amikacin at 1MIC concentrations only temporarily inhibited the exponential growth of E. coli and P. aeruginosa. 4MIC level extended the delay of exponential bacterial growth. Increasing concentrations of vancomycin similarly temporarily delayed S. aureus growth. All tested antibiotics at CITA of 103MIC totally inhibited the exponential growth of the tested bacteria through 72 hours of exposure. (P<0.001). CONCLUSION: In this in-vitro model, CITA at 103MIC effectively inhibited exponential bacterial growth of high loads of P. aeruginosa, E. coli, and S. aureus. This model offers preliminary laboratory support for the benefit of the in-situ antibiotic treatment, providing ultra-high concentrations directly at the compartmentalized infection site, not achievable by the conventional intravenous and oral routes.

Rapid identification of uropathogens by combining Alfred 60 system with matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry technology.

Rapid identification of uropathogens is needed to determine appropriate antimicrobial therapy. This study evaluated performance of the Alfred 60 system combined with matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF MS) technology for rapid identification of uropathogens. The Alfred 60 system was used to screen urine cultures, followed by identifying the microbial pathogen in positive cultures using MALDI-TOF MS. The Alfred 60 detected positive cultures by measuring the turbidity of urine samples, which were transferred automatically to vials containing liquid medium and incubated for 3.5 h at 35 °C in the Alfred 60 system. Vials that showed growth were removed and centrifuged. The pellet was subjected to MALDI-TOF MS identification. In parallel, positive urine samples were inoculated onto agar plates for identification by conventional culture. The time required to detect positive urine cultures with Alfred 60 and identify the uropathogens with MALDI-TOF MS ranged from 15 min to 3.5 h. Among 146 positive urine samples tested, conventional cultures showed three culture groups: group 1 included 101 samples with growth of a single type of microorganism; group 2 included 34 samples with 2 types of microorganisms; and group 3 included 11 samples with ≥ 3 types of microorganisms. Direct identification by MALDI-TOF MS was concordant with 95% of the samples in group 1, 100% of the principal microorganism in group 2, but could not identify microorganisms in group 3. This combination of methods provides rapid, reliable microbial identification for most positive urine cultures.

A new rapid method for detecting extended-spectrum beta-lactamase/AmpC-producing Enterobacteriaceae directly from positive blood cultures using the Uro4 HB&L™ system.

PURPOSE: To evaluate the performance of the Uro4 HB&L™ system in screening ESBL/AmpC-producing Enterobacteriaceae as compared with the resistant test by VITEK 2. The resistance profile of the ESBL-producing bacteria was also evaluated. METHODOLOGY: Blood culture samples were collected at bedside, inoculated directly into BD BACTEC™ culture bottles, and incubated. When microbial growth was found, samples were prepared for identification using MALDI-ToF. The Uro4 HB&L™ system was used for direct detection of ESBL/AmpC-producing bacteria compared with conventional methods. RESULTS: A total of 103 positive blood cultures containing Gram-negative bacteria were tested. Uro4™ HB&L screening results were obtained in up to 6.5 h, with 91.3% concordance with the VITEK2 system, with 85% sensitivity, 95.2% specificity, and 91.1% positive and 90.9% negative predictive values. The resistance profile of ESBL-producing bacteria tested in the present study showed increased resistance ratio to ciprofloxacin, gentamicin, and trimethoprim/sulfamethoxazole. In parallel, susceptibility to amikacin and meropenem was not affected. CONCLUSIONS: The performance of the Uro4 HB&L™ system is acceptable for rapid screening ESBL/AmpC-producing Enterobacteriaceae. The data related to detecting ESBL-producing bacteria are crucial for managing antimicrobial therapy.

Serum separator tube method for matrix-assisted laser desorption/ionization time-of-flight analysis.

BACKGROUND: Without appropriate treatment, bloodstream infections have a high mortality rate. Quicker identification of the microbial pathogen allows the clinician to develop an initial strategy of antimicrobial therapy. Sample preparation protocols for matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-ToF MS; Bruker Daltonics for Microflex LT spectrometer) technology were evaluated in an attempt to identify pathogens directly from positive blood culture bottles and thus shorten the time to identify them. This application requires preparatory processing because blood culture bottles contain undesirable proteins. This study aimed to evaluate two methods for microbial preparation for identification by MALDI-ToF MS. METHODS: This study evaluated two methods for microbial preparation from 200 positive blood culture samples, half prepared by the differential centrifugation method and half with the serum separator tube method for identification by MALDI-ToF MS. Both methods were compared to conventional methods such as VITEK II and ChromAgar culture plates. RESULTS: All Gram-negative bacteria tested were identified correctly by MALDI-ToF MS compared to conventional methods, regardless of the preparation method. However, more Gram-positive bacteria were identified when the serum separator tube method was used (83.3%) compared with the differential centrifugation method (65.3  %). Moreover, the serum separator tube protocol requires 12-15 min, while the differential centrifugation protocol requires 30-45 min. CONCLUSIONS: Sample preparation using the serum separator tube method is easy to perform, fast and reliable for accurate microbial identification by MALDI-ToF MS technology.

Decrease in anaerobe-related bacteraemias and increase in Bacteroides species isolation rate from 1998 to 2007: a retrospective study.

Conflicting data have accumulated in recent years regarding the incidence of anaerobic bacteraemias. The aim of this study was to determine the prevalence of bacteraemias due to anaerobic bacteria and evaluate the importance of anaerobic blood cultures in a university hospital in Israel. A retrospective survey which focused on anaerobic blood culture bottles was performed on blood cultures received in our laboratory during the decade from January 1998 to December 2007. Anaerobic-related bacteraemias decreased during that period, whereas a significant increase was observed in Bacteroides species isolated from the blood cultures (from 18% during 1998-2002 to 43% during 2003-2007). Comparison of the medical records of 54 patients with Bacteroides-related bacteraemia during the two end periods (1998-1999 and 2006-2007) revealed a marked increase in complex underlying diseases. Hypertension and diabetes mellitus type II were found in 29% of the patients in 1998-1999 and increased to 43-45% of the patients in 2006-2007. Ischemic heart disease also increased from 14% of the patients in 1998-1999 to 43% in 2006-2007. We conclude that although positive anaerobic blood cultures account for a small percentage of positive blood samples, the growing involvement of Bacteroides species-related bacteraemias together with an increase in complex underlying diseases in these patients emphasize the importance of anaerobic blood cultures, particularly in patients with co-morbidities.

Exercise training alters the molecular response to myocardial infarction.

PURPOSE: We and others have shown that swimming exercise training performed before irreversible coronary occlusion improves the outcome of the heart injury and alters gene expression at the remodeling phase. The purpose of the current study was to identify temporal changes in the molecular response to myocardial infraction of prior exercise trained rats during the acute, the subacute, and the chronic phases postinfarction. METHODS: Rats underwent a 7-wk swimming or sedentary protocol and were subjected to surgical induction of acute myocardial infarction (MI). Hearts were removed before and at 4 h, 2 d, and 4 wk after surgery. RNA extracted from the surviving myocardium of the MI hearts or from corresponding tissues in the non-MI hearts was subjected to multitranscript profiling. Results for representative transcripts were validated by reverse transcription and quantitative polymerase chain reaction amplification. RESULTS: Global analysis of the 3686 detected transcripts generated a two-branch dendrogram that distinguished the pre-MI and the 4-h groups from the 2-d and the 4-wk groups and indicated that early after MI, the impact of infarction on the genes expressed overrides the training effect, whereas at 4 wk, the exercised hearts differ markedly from the nonexercised. Clustering the 1500 genes that showed the highest variance over time indicated differential expression of transcription regulators and proapoptotic genes 4 h and 2 d after MI and of stress-related and profibrotic genes 4 wk later in the exercised compared with sedentary hearts. CONCLUSION: Swimming exercise training conducted before acute MI reprograms the surviving myocardium for altered molecular response to MI that explains, in part, the protected cardiac phenotype of the exercised animals.

Novel function of ovarian growth factors: combined studies by DNA microarray, biochemical and physiological approaches.

Owing to the development of the DNA microarray technique, modulation of gene function can be studied systematically. Considerable attention has been focused on members of the growth factor family to elucidate the main regulators of oocyte maturation and ovarian follicle rupture. Among these growth factors, it was found both in rodents and in humans that amphiregulin (Ar) and epiregulin (Ep) of the epidermal growth factor (EGF) family were dramatically up-regulated by gonadotrophins in the intact ovary and in primary granulosa cells, respectively. Their role in cumulus expansion and oocyte maturation was established in rodents, and their formation under LH stimulation in granulosa cells was demonstrated in humans. To be activated, Ar and Ep must be cleaved by A Disintegrin And Metalloproteinases (ADAMs) family. However, the precise processing of Ar and Ep by the cumulus cells is still obscure. Future investigations using DNA microarray technique may reveal the repertoire of genes activated in Ar- and Ep-stimulated cumulus cells and may help elucidate the molecular basis of ovulation.

Expression of procollagen C-proteinase enhancer-1 in the remodeling rat heart is stimulated by aldosterone.

Excessive collagen deposition is a common complication of myocardial infarction that causes progressive heart disease. Several pro-fibrotic cytokines and hormones, including aldosterone, control this process. Procollagen processing by procollagen C-proteinase(s) is critical for collagen deposition and is potentiated by procollagen C-proteinase enhancer proteins (PCPEs). We have shown previously that, in addition to stimulation of collagen I expression, aldosterone increases PCPE-1 expression in cultured heart fibroblasts. The present study was designed to examine whether aldosterone acts similarly in vivo. Rats underwent coronary artery ligation to induce myocardial infarction. They were then left either untreated (control) or treated with spironolactone (an aldosterone receptor antagonist) for 5 weeks when they were sacrificed and their hearts removed for analysis. In situ hybridization co-localized PCPE-1 and collagen I mRNAs to fibroblasts surrounding the scar region and adjacent blood vessels. The levels of both transcripts in the remodeling myocardium of untreated rats increased twofold as compared to sham-operated controls, an increase greatly reduced by spironolactone. Correspondingly, a 2-5 fold increase in PCPE-1 and collagen I was observed in the hearts of untreated rats as compared to both the spironolactone-treated and sham-operated controls. The results establish aldosterone as a physiological stimulator of PCPE-1 expression in the remodeling myocardium after infarction. Since PCPE-1 itself is a positive regulator of collagen deposition, this finding suggests PCPE-1 as a new potential target for intervention with cardiac fibrosis.

Differential expression of genes coding for EGF-like factors and ADAMTS1 following gonadotropin stimulation in normal and transformed human granulosa cells.

We have demonstrated previously that the synthesis of epiregulin and amphiregulin, of the EGF-like growth factor family, is stimulated by luteinizing hormone in human follicular (granulosa) cells obtained from in vitro fertilization program. In the present work, we demonstrate that H89, a PKA inhibitor, attenuated the expression of these growth factors both in the mRNA and the protein levels, suggesting PKA involvement in this signaling pathway. SV40-transformed human granulosa cells showed higher basal levels of epiregulin and amphiregulin than normal cells, which were still elevated following cAMP stimulation by Forskolin. Cleavage by a disintegrin and metalloproteinases (ADAMs) is essential for activation of these growth factors, allowing their interaction with EGF receptor. Expression of ADAMTS1 and ADAM12 was downregulated by cAMP in normal, but not in SV40-transformed cells, suggesting that in normal cells epiregulin and amphiregulin activity is downregulated by a feedback mechanism that may be lost in SV40-transformed cells and their loss of downregulation may be involved in the development of ovarian tumors.

Immunocytochemical detection and reverse transcription polymerase chain reaction expression of oncostatin M (OSM) and its receptor (OSM-Rbeta) in human fetal and adult ovaries.

OBJECTIVE: To investigate the immunocytochemical expression and presence of mRNA transcripts of oncostatin M (OSM) and its exclusive receptor (OSM-Rbeta) in ovaries from human adults and fetuses. DESIGN: Immunocytochemical and reverse transcription polymerase chain reaction (RT-PCR) study. SETTING: Major tertiary care and referral academic centers. PATIENT(S): Ten women and girls undergoing laparoscopic ovarian biopsy and 30 women undergoing second-trimester and third-trimester pregnancy terminations. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Microscopic morphometric analysis, immunocytochemistry for OSM and OSM-Rbeta, and RT-PCR analyses. RESULT(S): There was strong to moderate immunocytochemical staining for OSM in both oocytes and granulosa cells of follicles from primordial stages onwards in ovaries from both fetuses and adults/adolescents. OSM-Rbeta was detected mainly in the oocytes. Transcripts of OSM and OSM-Rbeta RNA were detected by RT-PCR analyses. CONCLUSION(S): The expression of OSM and its receptor in ovarian tissue from fetuses and women suggests a possible role of OSM in growth initiation of human primordial follicles.

Prior exercise training improves the outcome of acute myocardial infarction in the rat. Heart structure, function, and gene expression.

OBJECTIVES: The aim of this research was to investigate the structural, functional, and molecular features of the remodeling heart in prior swim-trained infarcted rats. BACKGROUND: Physical exercise training is a known protective factor against cardiovascular morbidity and mortality. The structural and molecular aspects underlying this protection in the remodeling heart have not been investigated. METHODS: After seven weeks of swimming exercise training, rats underwent surgical ligation of the left coronary artery followed by a four-week sedentary period. Untrained control rats underwent the same surgical protocol. Left ventricular function was assessed by echocardiography four weeks after infarction, and hearts were sampled for histological and molecular analysis. Ribonucleic acid from the surviving left ventricle was analyzed by complementary deoxyribonucleic acid arrays followed by Northern blotting or quantitative reverse transcription polymerase chain reaction of selected messenger ribonucleic acids (mRNAs). RESULTS: Scar area was 1.6-fold smaller (p = 0.0002), arteriolar density was 1.7-fold higher (p = 0.0002), and left ventricular shortening fraction was 1.9-fold higher (p = 0.003) in the exercise-trained compared with sedentary hearts. Eleven genes whose expression level varied by at least +/-1.5-fold distinguished the prior exercised rats from their sedentary counterparts. Compared with sedentary, the exercised hearts displayed 9- and 2.4-times lower levels of atrial natriuretic peptide and aldolase mRNA (p = 0.03 and 0.04, respectively), and a 2.7- and 1.9-fold higher abundance of cytochrome c-oxidase and fatty acid binding protein, respectively (p < 0.03, each). CONCLUSIONS: Swimming exercise training before acute myocardial infarction reduces scar size, increases arteriole density, and manifests adaptation of stress- and energy-metabolism-related genes that may contribute to the improved heart function observed during remodeling.

Desensitization to gonadotropic hormones: a model system for the regulation of a G-protein-coupled receptor with 7-transmembrane spanning regions.

Gonadotropic hormone, luteinizing hormone, and follicle-stimulating hormone exert their effect via activation of G-coupled receptors, which activate the hormone sensitive adenylyl cyclase, protein kinase A, and cyclic AMP responsive elements. This activation leads to specific de novo synthesis of steroidogenic factors and steroidogenic enzymes. In normal cells and following activation of this signaling pathway, desensitization period will be followed. This down-regulation, which was studied in detail for the last three decays, was found to take place at various steps of these signal transduction pathways as well as at different kinetics. A common and diverse feature of the mechanism of desensitization in other G-coupled-7-transmembrane receptor system is also discussed.