The Impact of Transit Times on the Detection of Bacterial Pathogens in Blood Cultures: A College of American Pathologists Q-Probes Study of 36 Institutions.

CONTEXT.­: Consolidation of clinical microbiology laboratory services has resulted in extended transit time for blood cultures from service points distant from the laboratory. Sepsis is critical; delays in identification of etiologic agents of diseases could adversely impact patient care. OBJECTIVE.­: To examine the effect of total preanalytic time and blood culture volume on the instrument time-to-detection for bacterial pathogens in blood cultures. A secondary objective was to obtain relevant blood culture information by questionnaire. DESIGN.­: Participants in this Q-Probes study recorded date, time, and volume information for the first 50 positive blood cultures collected during the 12-week study period. Additional information regarding blood culture collection practices was obtained through questionnaire. RESULTS.­: Prolonged overall time-to-detection was secondary to prolonged preanalytic time, particularly prolonged transit time, rather than slower organism growth once bottles were placed on the instrument. Among 1578 blood cultures, the overall time from collection to positive result was significantly less for blood cultures collected on-site than for off-site locations. Most institutions lack sufficient training programs and do not monitor preanalytic time metrics associated with blood cultures. Four hundred fifty-six of the 1580 blood cultures with blood volume adequacy reported (28.9%) were inadequately filled. CONCLUSIONS.­: Overall process time (specimen collection to positive blood culture detection) is predicted to be higher for blood cultures collected off-site. Transit time is a variable that can be reduced to decrease overall time to detection. Thus, improved training and closer attention to preanalytic metrics associated with blood cultures could decrease hospital stays and mortality rates.

Glomerulonephritis causing acute renal failure during the course of bacterial infections. Histological varieties, potential pathogenetic pathways and treatment.

To illustrate diagnostic approaches, potential pathogenetic differences, epidemiological implications and therapeutic dilemmas posed by glomerulonephritis (GN) with acute renal failure (ARF) complicating bacterial infections, we analyzed the course of four male patients, aged 53-71 years, who developed GN and ARF following bacterial infections. The first two patients developed GN with immunoglobulin A (IgA) deposits after infections with hospital-acquired methicillin resistant Staphylococcus aureus (MRSA). Clinical, serologic and histological features, classification of GN and treatment differed between the two patients. In the first patient, serological features (transient hypocomplementemia, normal serum protein electrophoresis) and histological findings were consistent with typical post-infectious GN. Treatment with antibiotics alone resulted in normalization of the renal function despite the severity of ARF, which required temporary hemodialysis. In the second patient, serological features (normal serum complement, polyclonal elevation of gamma globulins) and histological picture of the kidneys were characteristic of IgA nephropathy with fibrocellular crescents, and skin histology was consistent with vasculitis. Cyclophosphamide and corticosteroids were added to the antibiotics, with partial improvement of the renal failure. The third patient developed simultaneous acute rheumatic fever and post-streptococcal GN causing severe ARF requiring hemodialysis. Complete recovery of ARF and migratory polyarthritis followed initiation of corticosteroids. The fourth patient developed ARF and cerebral vasculitis following a prolonged course of Streptococcus mutans endocarditis with delayed diagnosis. He also developed multiple serological abnormalities including elevated titers of antineutrophil cytoplasmic antibodies (ANCA), antinuclear antibodies (ANA), anti-phospholipid antibodies, rheumatoid factor, and modest hypocomplementemia. Kidney biopsy revealed ANCA-mediated focal GN with 10% crescents and acute interstitial nephritis. Treatment with cyclophosphamide plus corticosteroids, but not with antibiotics alone, resulted in resolution of both the ARF and the features of cerebral vasculitis. GN following bacterial infections may have various pathogenetic mechanisms, presents complex diagnostic challenges, may be preventable in the case of hospital-acquired MRSA, and, in addition to antibiotics, may require immunosuppressive therapy in carefully selected and monitored cases.

Immunoglobulin A nephropathy complicating ulcerative colitis.

Ulcerative colitis is rarely associated with immunoglobulin A nephropathy (IgAN). The development of IgA nephropathy complicates further the clinical course of patients with ulcerative colitis. A 72-year old man with a 30-year history of ulcerative colitis requiring colectomy and modest renal insufficiency secondary to complications of nephrolithiasis and renal artery stenosis developed glomerular hematuria, proteinuria and progressive renal failure. Percutaneous kidney biopsy revealed IgAN with extensive glomerular and interstitial sclerotic changes. After resection of a chronically infected ileo-rectal pouch, renal function improved, while hematuria and proteinuria gradually disappeared without specific treatment of the IgAN. The manifestations of IgAN complicating ulcerative colitis can be improved with effective treatment of the bowel disease even when there are extensive sclerotic changes in the kidneys.

Twenty-five years of accomplishments of the College of American Pathologists Q-probes program for clinical pathology.

CONTEXT: During the past 25 years, the College of American Pathologists' (CAP) Q-Probes program has been available as a subscription program to teach laboratorians how to improve the quality of clinical laboratory services. OBJECTIVE: To determine the accomplishments of the CAP Q-Probes program. DESIGN: We reviewed Q-Probes participant information, study data and conclusions, author information, and program accomplishments. RESULTS: During this time 117 Q-Probes clinical pathology studies were conducted by 54 authors and coauthors, 42,899 laboratories enrolled from 24 countries, 98 peer-reviewed publications occurred and were cited more than 1600 times, and the studies were featured 59 times in CAP Today. The most frequent studies (19) focused on turnaround times for results or products at specific locations (emergency department, operating room, inpatients, outpatients), specific diseases (acute myocardial infarction, urinary tract), availability for specific events such as morning rounds or surgery, a specific result (positive blood cultures), and a method on how to use data for improvement (stat test outliers). Percentile ranking of study participants with better performance provided benchmarks for each study with attributes statistically defined that influenced improved performance. Other programs, such as an ongoing quality improvement program (Q-Tracks), a laboratory competency assessment program, a pathologist certification program, and an ongoing physician practice evaluation program (Evalumetrics), have been developed from Q-Probes studies. CONCLUSIONS: The CAP's Q-Probes program has made significant contributions to the medical literature and has developed a worldwide reputation for improving the quality of clinical pathology services worldwide.

Telomere DNA content in prostate biopsies predicts early rise in prostate-specific antigen after radical prostatectomy for prostate cancer.

OBJECTIVE: To determine whether measurement of telomere DNA content (TC) in prostate biopsy tissue predicts prostate-specific antigen (PSA) recurrence in men after undergoing radical prostatectomy for prostate cancer. METHODS: Slot blot titration assay was used to quantitate TC in archived diagnostic prostate needle biopsy specimens for subjects (n = 103) diagnosed with prostate cancer and who subsequently underwent radical prostatectomy between 1993 and 1997. TC was compared to the clinical outcome measure; PSA recurrence, defined as an increase in PSA > or = 0.2 ng/mL on 2 or more consecutive measurements post-prostatectomy, was observed retrospectively, for a mean follow-up period of 114 months (range, 1-165). RESULTS: In the cohort, 46 subjects had a PSA recurrence. In a univariate Cox proportional hazards model, low TC (< 0.3 of standard) demonstrated a significant risk for PSA recurrence (HR = 1.94; 95% CI: 1.02-3.69, P = .04). In a subset analysis of men with biopsy Gleason sum < or = 6 (n = 63; 25 recurrences), a univariate Cox proportional hazards model demonstrated that low TC had a greater risk of PSA recurrence (HR = 4.53; 95% CI: 2.00-10.2, P < .01). In a multivariate Cox proportional hazards model, low TC was also significantly associated with PSA recurrence in this subset after controlling for preoperative PSA levels (HR = 6.62; 95% CI: 2.69-16.3, P < .01). CONCLUSIONS: Low TC measured in prostate biopsy tissue predicts early likelihood of post-prostatectomy PSA recurrence in a retrospective analysis, and in men with biopsy Gleason sum < or = 6 disease it is also independent of preoperative PSA level.