Evaluation of the Use of Low-Dose 4-Factor Prothrombin Complex Concentrate in the Reversal of Direct Oral Anticoagulants in Bleeding Patients.

OBJECTIVE: This study investigated the percentage of patients who achieved hemostasis with 4-factor prothrombin complex concentrate (4-factor PCC) 35 U/kg. The primary end point was to determine the effect of 4-factor PCC 35 U/kg on bleeding progression, assessed using computed tomography. METHODS: This was a retrospective, observational, single-center study conducted in patients with a major bleed admitted to a level 1 trauma center from May 1, 2013, to June 15, 2015, who received 4-factor PCC 35 U/kg for reversal of a direct factor Xa inhibitor taken prior to admission. RESULTS: Thirty-three patients were included in the study, with 31 patients in the final analysis. The mean (standard deviation) age was 73 (14.8) years; 54.5% of patients were female. Of the 33 patients, 13 presented with a traumatic brain injury, 9 with an aneurysmal subarachnoid hemorrhage, 8 with an intracerebral hemorrhage, 1 with a gastrointestinal bleed, 1 with a hematoma with active extravasation, and 1 with an intra-abdominal bleed. The most frequently used direct factor Xa inhibitor was rivaroxaban (81.8%). Overall, 83.8% of patients achieved hemostasis with 4-factor PCC 35 U/kg. Progression of hemorrhage was observed in 4 patients on repeat computed tomography scan and 1 patient had continued surgical bleeding. No thromboembolic events were reported. CONCLUSIONS: Low-dose, 4-factor PCC 35 U/kg appeared to produce hemostasis in a majority of the patients. This may be an effective dosing regimen for anticoagulant reversal of factor Xa inhibitors in clinically bleeding patients.

Carbonate formation events in ALH 84001 trace the evolution of the Martian atmosphere.

Carbonate minerals provide critical information for defining atmosphere-hydrosphere interactions. Carbonate minerals in the Martian meteorite ALH 84001 have been dated to ∼ 3.9 Ga, and both C and O-triple isotopes can be used to decipher the planet's climate history. Here we report Δ(17)O, δ(18)O, and δ(13)C data of ALH 84001 of at least two varieties of carbonates, using a stepped acid dissolution technique paired with ion microprobe analyses to specifically target carbonates from distinct formation events and constrain the Martian atmosphere-hydrosphere-geosphere interactions and surficial aqueous alterations. These results indicate the presence of a Ca-rich carbonate phase enriched in (18)O that formed sometime after the primary aqueous event at 3.9 Ga. The phases showed excess (17)O (0.7‰) that captured the atmosphere-regolith chemical reservoir transfer, as well as CO2, O3, and H2O isotopic interactions at the time of formation of each specific carbonate. The carbon isotopes preserved in the Ca-rich carbonate phase indicate that the Noachian atmosphere of Mars was substantially depleted in (13)C compared with the modern atmosphere.

Adhesion of Yeast and Bacteria to Oral Surfaces.

Colonization of surfaces in the human body by microorganisms is an early, essential, step in the initiation of infectious disease. We have developed in vitro assays to investigate interactions between yeast or bacterial cells and human tissues, fluids, or prostheses. Such assays can be used to identify the adhesins, ligands, and receptors involved in these interactions, for example, by determining which components of the microbe or human tissue/fluid interfere with adherence in the assay. The assays can also be applied to find ways of preventing adhesion, and subsequent disease, by investigating the effects of different conditions and added compounds on adherence in the in vitro assays. Here we describe assays for measuring adhesion of the oral yeast Candida albicans, a common commensal and opportunistic pathogen, or the bacterium Staphylococcus epidermidis, which is not normally pathogenic but is known to form biofilms on medical prostheses. The assays described belong to two approaches to investigating adhesion and biofilm formation: (i) retention at a fixed time point following liquid washes, and (ii) retention against a continuous flow of medium.

Yeast colonization of voice prostheses: pilot study investigating effect of a bovine milk product containing anti-Candida albicans immunoglobulin A antibodies on yeast colonization and valve leakage.

OBJECTIVES: Our goals were to determine whether a bovine milk product containing anti-Candida albicans immunoglobulin A antibodies ("immune milk") could reduce the adherence of C albicans to voice prosthesis silicone in vitro, and whether administration of the milk could reduce C albicans colonization and voice prosthesis damage in vivo. METHODS: An in vitro assay of C albicans attachment to silicone was developed with radiolabeled C albicans. A pilot crossover in vivo trial, over 3 periods of 3 months, was also undertaken for 4 patients with voice prostheses, comparing daily administrations of immune milk and a control milk product. The prosthesis valves were replaced at each changeover and were assessed for wet weight of removable biofilm, yeast numbers in removable biofilm, valve leakage, and valve damage. RESULTS: Immune milk inhibited C albicans adherence to silicone in vitro. However, in a small clinical pilot study, this effect was not replicated. CONCLUSIONS: There is scope to further investigate the topical use of immune milk for management of voice prosthesis biofilms.

Adhesion of Yeast and Bacteria to Oral Surfaces.

Colonization of surfaces in the human body by microorganisms is an early, essential, step in the initiation of infectious disease. We have developed in vitro assays to investigate interactions between yeast or bacterial cells and human tissues, fluids, or prostheses. Such assays can be used to identify the adhesins, ligands, and receptors involved in these interactions, for example, by determining which components of the microbe or human tissue/fluid interfere with adherence in the assay. The assays can also be applied to finding ways of preventing adhesion, and subsequent disease, by investigating the effects of different conditions and added compounds on adherence in the in vitro assays.Here we describe assays for measuring adhesion of the oral yeast Candida albicans, a common commensal and opportunistic pathogen, or the bacterium Staphylococcus epidermidis, which is not normally pathogenic but is known to form biofilms on medical prostheses. The assays described belong to two approaches to investigating adhesion and biofilm formation: (1) retention at a fixed time point following liquid washes and (2) retention against a continuous flow of medium.

Acute renal failure secondary to angiotensin II receptor blockade in a patient with bilateral renal artery stenosis.

A 54-year-old man with diabetes mellitus, peripheral vascular disease, and hypertension was admitted to the hospital for an acute exacerbation of chronic heart failure. Therapy with intravenous furosemide and oral losartan 100 mg twice/day was begun. Ten days later, the patient's blood urea nitrogen and serum creatinine levels rose and peaked at 110 and 6.0 mg/dl, respectively. His serum potassium level increased to 5.7 mg/dl, urine output dropped to 400 ml over 24 hours, and mental status changes occurred. Magnetic resonance angiography revealed bilateral renal artery stenosis. After losartan was discontinued and hemodialysis was performed for 3 consecutive days, the patient's renal function returned to his baseline level. Reports in the medical literature reinforce the importance of recognizing that angiotensin-converting enzyme inhibitors should be used with caution in patients with bilateral renal artery stenosis. However, the literature is not as definitive about using of angiotensin II receptor blockers (ARBs) in these patients. Our patient's experience suggests that ARBs should be used with caution in patients with bilateral renal artery stenosis. Clinicians should be aware that renal failure might occur when using ARBs in these patients.

Types and rate of implementation of palliative care team recommendations for care of hospitalized veterans.

BACKGROUND: Hospital-based interdisciplinary palliative care teams (PCTs) are increasingly being established to meet the growing demand for high quality care for patients with life-limiting illnesses in which the goal is comfort rather than cure. Two recent studies suggest that PCTs teams are highly effective in influencing care of patients within large academic medical centers. The current study examines whether the previously demonstrated success of palliative care teams within subspecialty academic health centers could be replicated in an urban Veterans Affairs medical center (VAMC). OBJECTIVE: To describe the characteristics of patients referred to, recommendations made by, and implementation rate of an interdisciplinary PCT in an urban VAMC. DESIGN: Retrospective, observational study. SETTING/SUBJECTS: One hundred patients referred by inpatient doctor to the PCT between October 1999 and March 2002 in a 214-bed VA hospital in the New York City area. MEASUREMENTS: Patient demographics, prevalence of five types of recommendations by the PCT and implementation rate by primary physician: (1) advance directives; (2) discharge planning; (3) pain management; (4) symptom management of dyspnea, delirium, constipation, nausea, anxiety, and depression; and (5) consultation orders for other services. RESULTS: The average number of recommendations per patient was 2.84 and 84.2% were implemented. The most frequent recommendations concerned discharge plans. The reasons recommendations were not implemented included: (1) patient or family refusal noted in the medical record, (2) the patient's clinical status changed, including patient death, and (3) the attending physician chose a different dose, medication, or route of administration than was recommended. CONCLUSIONS: Overall, most recommendations were implemented by the referring physicians. This finding is consistent with several prior studies demonstrating that PCTs in acute care can and do influence processes of care for hospitalized patients. Well-designed observational studies and randomized controlled trials of specific palliative care interventions and their effect on patient, family, and health care system outcomes are needed.

Adhesion of yeast and bacteria to oral surfaces.

Colonization of surfaces in the human body by microorganisms is an early, essential, step in the initiation of infectious disease. We have developed in vitro assays to investigate interactions between yeast or bacterial cells and human tissues, fluids, or prostheses. Such assays can be used to identify the adhesins, ligands, and receptors involved in these interactions, for example by determining which components of the microbe or human tissue/fluid interfere with adherence in the assay. The assays can also be applied to finding ways of preventing adhesion, and subsequent disease, by investigating the effects of different conditions and added compounds on adherence in the in vitro assays. We describe six assays for measuring adhesion of the oral yeast Candida albicans, a common commensal and opportunistic pathogen, or the bacterium Staphylococcus epidermidis, which is not normally pathogenic but is known to form biofilms on medical prostheses. The assays described represent two approaches to investigating adhesion; retention at a fixed time point following liquid washes; and retention against a continuous flow of medium.

Thermal and photochemical transformation of conformational chirality into configurational chirality in the crystalline state.

Because they crystallize in chiral conformations in which abstraction of only one of two diastereotopic gamma-hydrogen atoms is possible, salts formed between achiral keto-acids possessing the tricyclo[4.4.1.0]undecane ring system and optically pure amines undergo Norrish type II cleavage in the solid state in enantiomeric excesses as high as 95% at 98% conversion, following removal of the ionic chiral auxiliaries. Thermal enolene rearrangement of the same salts results in optical yields approximately half those observed for the photochemical reaction.

Use of chirally modified zeolites and crystals in photochemical asymmetric synthesis.

Three different approaches to asymmetric induction in the cis-to-trans photoisomerization of a number of 1-benzoyl-2,3-diphenylcyclopropane derivatives are reported: the use of chiral inductors and covalent chiral auxiliaries in MY zeolites and the use of ionic chiral auxiliaries in crystals. High levels of asymmetric induction were achieved using the latter two methods-up to 71% through the use of covalent chiral auxiliaries in zeolites and a remarkable 99% via the solid state ionic chiral auxiliary approach. In the zeolite method, the diastereomeric excess was found to depend strongly on the nature of the zeolite cation, M(+), and in the ionic chiral auxiliary approach, evidence is presented that it is the fixed orientation of the benzoyl group with respect to the cyclopropane ring that controls enantioselectivity in the crystalline state-a finding that is directly relevant to theoretical work on this topic.

Asymmetric synthesis in a Norrish type II cleavage reaction induced by crystal chirality.

Moderate to high enantiomeric excesses for the cis and trans olefinic products of a Norrish type II cleavage reaction have been obtained for the first time through the use of the solid-state ionic chiral auxiliary approach.