Search

Objective: Confirmatory factor analysis (CFA) was used to test the hypothesis that the components of the metabolic syndrome are manifestations of a single common factor.Research Design and Methods: Three different datasets were used to test and validate the model. The Spanish and Mauritian studies included 207 men and 203 women and 1,411 men and 1,650 women, respectively. A third analytical dataset including 847 men was obtained from a previously published CFA of a U.S. population. The one-factor model included the metabolic syndrome core components (central obesity, insulin resistance, blood pressure, and lipid measurements). We also tested an expanded one-factor model that included uric acid and leptin levels. Finally, we used CFA to compare the goodness of fit of one-factor models with the fit of two previously published four-factor models.Results: The simplest one-factor model showed the best goodness-of-fit indexes (comparative fit index 1, root mean-square error of approximation 0.00). Comparisons of one-factor with four-factor models in the three datasets favored the one-factor model structure. The selection of variables to represent the different metabolic syndrome components and model specification explained why previous exploratory and confirmatory factor analysis, respectively, failed to identify a single factor for the metabolic syndrome.Conclusions: These analyses support the current clinical definition of the metabolic syndrome, as well as the existence of a single factor that links all of the core components. [ABSTRACT FROM AUTHOR]

Richard E Hughes,1,2 Brian R Hallstrom,1,2 Mark E Cowen,1,3 Rochelle M Igrisan,1,2 Bonita M Singal,1,3 David A Share,2,4 1Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), Ann Arbor, MI, USA; 2Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA; 3Quality Institute, St Joseph Mercy Hospital, Ann Arbor, MI, USA; 4Blue Cross and Blue Shield of Michigan, Detroit, MI, USA Background: The United States has been a difficult environment in which to develop arthroplasty registries, largely because of the absence of a national health system. The purpose of this paper is to describe the development of a statewide registry-based quality improvement collaborative in Michigan. Methods: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) was started in 2011 to improve the quality of care for total hip and knee replacement patients in Michigan. It is funded by Blue Cross and Blue Shield of Michigan/Blue Care Network as part of their Collaborative Quality Initiative (CQI) program. The CQI concept depends on capturing high-quality data (clinical status, process, and outcome), rigorously developing risk-adjustment models, and presenting risk-adjusted data to collaborative members at four face-to-face meetings a year. Results: MARCQI has grown to include 44 hospitals and 377 orthopedic surgeons. The registry contains 54,848 cases (18,421 hips and 36,427 knees). Four collaborative-wide quality improvement activities have been initiated: 1) transfusion reduction, 2) deep vein thrombosis and pulmonary emboli prevention, 3) infection prevention, and 4) readmission prevention. Conclusion: The CQI model developed by Blue Cross and Blue Shield of Michigan/Blue Care Network can be adapted to hip and knee arthroplasty, which demonstrates that private payers can play a role in the development and promotion of arthroplasty registries in the United States. Keywords: registry, arthroplasty, hip, knee, quality, collaboration

SNARE proteins drive membrane fusion as their core domains zipper into a parallel four-helix bundle 1,2 . After fusion, these bundles are disassembled by the AAA+ protein Sec18/NSF and its adaptor Sec17/ α-SNAP 3,4 to make them available for subsequent rounds of membrane fusion. SNARE domains are often flanked by C-terminal transmembrane or N-terminal domains 5 . Previous structures of the NSF-α-SNAP-SNARE complex revealed SNARE domain threaded through the D1 ATPase ring 6 , posing a topological constraint as SNARE transmembrane domains would prevent complete substrate threading as suggested for other AAA+ systems 7 . Here, in vivo mass-spectrometry reveals N-terminal SNARE domain interactions with Sec18, exacerbating this topological issue. Cryo-EM structures of a yeast SNARE complex, Sec18, and Sec17 in a non-hydrolyzing condition shows SNARE Sso1 threaded through the D1 and D2 ATPase rings of Sec18, with its folded, N-terminal Habc domain interacting with the D2 ring. This domain does not unfold during Sec18/NSF activity. Cryo-EM structures under hydrolyzing conditions revealed substrate-released and substrate-free states of Sec18 with a coordinated opening in the side of the ATPase rings. Thus, Sec18/NSF operates by substrate side-loading and unloading topologically constrained SNARE substrates.

Biotechnological processes hold tremendous potential for the efficient and sustainable conversion of one-carbon (C1) substrates into complex multi-carbon products. However, the development of robust and versatile biocatalytic systems for this purpose remains a significant challenge. In this study, we report a hybrid electrochemical-biochemical cell-free system for the conversion of C1 substrates into the universal biological building block acetyl-CoA. The synthetic reductive formate pathway (ReForm) consists of five core enzymes catalyzing non-natural reactions that were established through a cell-free enzyme engineering platform. We demonstrate that ReForm works in a plug-and-play manner to accept diverse C1 substrates including CO 2 equivalents. We anticipate that ReForm will facilitate efforts to build and improve synthetic C1 utilization pathways for a formate-based bioeconomy., Competing Interests: Competing interests: GML, BV, ASK, and MCJ have filed an invention disclosure based on the work presented. M.C.J. has a financial interest in National Resilience, Gauntlet Bio, Pearl Bio, Inc., and Stemloop Inc. M.C.J.’s interests are reviewed and managed by Northwestern University and Stanford University in accordance with their competing interest policies. All other authors declare no competing interests.

The stringent response is critical for the survival of Mycobacterium tuberculosis (Mtb) under nutrient starvation. The mechanism is mediated by a GTP pyrophosphokinase known as Rel, containing N-terminal synthetase and hydrolase domains and C-terminal regulatory domains, which include the TGS domain (ThrRS, GTPase, and SpoT proteins) that has been proposed to activate the synthetase domain via interaction with deacylated tRNA. Here, we present the NMR solution structure of the Mtb Rel TGS domain (MtRel TGS), consisting of five antiparallel β-strands and one helix-loop-helix motif. The interaction of MtRel TGS with deacylated tRNA is shown, indicating the critical amino acids of MtRel TGS in tRNA binding, and presenting the first structural evidence of MtRel TGS binding to deacylated tRNA in solution in the absence of the translational machinery., (© 2021 Federation of European Biochemical Societies.)

Coronavirus disease (COVID-19) is caused by a novel severe acute respiratory syndrome coronavirus (SARS-CoV-2), which is a positive single-stranded RNA virus having a large genome ~30 kb. SARSCoV- 2 is zoonotic and highly contagious, causing severe pneumonia-like symptoms. The efficacy of the different potential drug and drug candidates against COVID-19 has been investigated, which are under various stages of clinical trials. The drugs effective against SARS, and Middle east respiratory syndrome (MERS), have been proposed to have a high potential for the treatment of COVID-19. Here, we selected plant-based materials implicated in the prevention and therapy of COVID-19. The plant produces secondary metabolites in response to viral infection. Different classes of secondary metabolites have different mechanisms to counter virus attacks. Many nanomaterials produced by carbohydrates and lipids have been exploited for their in-vitro and in-vivo delivery of antiviral therapeutics. The vaccine has shown impressive results in producing antibodies against SARS-CoV2 and has been evaluated for safety, tolerance, and preliminary immunogenicity. Similarly, DNA/RNA-based therapy has shown high clinical significance. Various forms of vitamins, minerals, herbs, and phytonutrients help to enhance immunity and be implicated in the control of COVID-19. However, such measures should not replace social distancing, quarantine and special care., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

The stringent response, regulated by the bifunctional (p)ppGpp synthetase/hydrolase Rel in mycobacteria, is critical for long-term survival of the drug-tolerant dormant state of Mycobacterium tuberculosis. During amino acid starvation, MtRel senses a drop in amino acid concentration and synthesizes the messengers pppGpp and ppGpp, collectively called (p)ppGpp. Here, we investigate the role of the regulatory 'Aspartokinase, Chorismate mutase and TyrA' (ACT) domain in MtRel. Using NMR spectroscopy approaches, we report the high-resolution structure of dimeric MtRel ACT which selectively binds to valine out of all other branched-chain amino acids tested. A set of MtRel ACT mutants were generated to identify the residues required for maintaining the head-to-tail dimer. Through NMR titrations, we determined the crucial residues for binding of valine and show structural rearrangement of the MtRel ACT dimer in the presence of valine. This study suggests the direct involvement of amino acids in (p)ppGpp accumulation mediated by MtRel independent to interactions with stalled ribosomes. Database Structural data are available in the PDB database under the accession number 6LXG., (© 2020 Federation of European Biochemical Societies.)

Importance: There has been significant debate in the surgical and medical communities regarding the appropriateness of using aspirin alone for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA)., Objective: To determine the acceptability of aspirin alone vs anticoagulant prophylaxis for reducing the risk of postoperative VTE in patients undergoing TKA., Design, Setting, and Participants: Noninferiority study of a retrospective cohort of TKA cases submitted to the Michigan Arthroplasty Registry Collaborative Quality Initiative at 29 member hospitals, ranging from small community hospitals to large academic and nonacademic medical centers in Michigan. The study included 41 537 patients who underwent primary TKA between April 1, 2013, and October 31, 2015. Clinical events were monitored for 90 days after surgery. Data were analyzed between September and October 2016., Exposures: The method of pharmacologic prophylaxis: neither aspirin nor anticoagulants for 668 patients (1.6%), aspirin only for 12 831 patients (30.9%), anticoagulant only (eg, low-molecular-weight heparin, warfarin, and Xa inhibitors) for 22 620 patients (54.5%), and both aspirin/anticoagulant for 5418 patients (13.0%). Most patients were also using intermittent pneumatic compression stockings., Main Outcome and Measures: The primary composite outcome was the first occurrence of VTE or death. The noninferiority margin was specified as 0.3. The secondary outcome was bleeding events., Results: Of the 41 537 patients, 14 966 were men (36%), and the mean age was 65.8 years. A VTE event occurred in 573 of 41 537 patients (1.38%); 32 of 668 (4.79%) who received no pharmacologic prophylaxis, 149 of 12 831 (1.16%) treated with aspirin alone, 321 of 22 620 (1.42%) with anticoagulation alone, and 71 of 5418 (1.31%) prescribed both aspirin and anticoagulation. Aspirin only was noninferior for the composite VTE outcome compared with those receiving other chemoprophylaxis (adjusted odds ratio, 0.85; 95% CI, 0.68-1.07, P for inferiority = .007). Bleeding occurred in 457 of 41 537 patients (1.10%), 10 of 668 (1.50%) without prophylaxis, 116 of 12 831 (0.90%) in the aspirin group, 258 of 22 620 (1.14%) with anticoagulation, and 73 of 5418 (1.35%) of those receiving both. Aspirin alone was also noninferior for bleeding complications (adjusted odds ratio, 0.80; 95% CI, 0.63-1.00, P for inferiority <.001)., Conclusions and Relevance: In this study of patients undergoing TKA, aspirin was not inferior to other anticoagulants in the postoperative rate of VTE or death. Aspirin alone may provide similar protection from postoperative VTE compared with other anticoagulation treatments.

Background: The efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion requirements in total hip and knee arthroplasty has been well established in small controlled clinical trials and meta-analyses. The purpose of the current study was to determine the risks and benefits of TXA use in routine orthopaedic surgical practice on the basis of data from a large, statewide arthroplasty registry., Methods: From April 18, 2013, to September 30, 2014, there were 23,236 primary total knee arthroplasty cases and 11,489 primary total hip arthroplasty cases completed and registered in the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI). We evaluated the association between TXA use and hemoglobin drop, transfusion, length of stay (LOS), venous thromboembolism (VTE), readmission, and cardiovascular events by fitting mixed-effects generalized linear and mixed-effects Cox models. We used inverse probability of treatment weighting to enhance causal inference., Results: For total hip arthroplasty, TXA use was associated with a smaller drop in hemoglobin (mean difference = -0.65 g/dL; 95% confidence interval [CI] = -0.60 to -0.71 g/dL), decreased odds of blood transfusion (odds ratio [OR] = 0.72; 95% CI = 0.60 to 0.86), and decreased readmissions (OR = 0.77; 95% CI = 0.64 to 0.93) compared with no TXA use. There was no effect on VTE (hazard ratio [HR] = 0.91; 95% CI = 0.62 to 1.33), LOS (incident rate ratio [IRR] = 1.00; 95% CI = 0.97 to 1.03), or cardiovascular events (OR = 0.85; 95% CI = 0.47 to 1.52). For total knee arthroplasty, TXA was associated with a smaller drop in hemoglobin (mean difference = -0.68 g/dL; 95% CI = -0.64 to -0.71 g/dL) and one-fourth the odds of blood transfusion (OR = 0.26; 95% CI = 0.21 to 0.31). There was an association with decreased risk of VTE within 90 days after surgery (HR = 0.56; 95% CI = 0.42 to 0.73), slightly decreased LOS (IRR = 0.93; 95% CI = 0.92 to 0.95), and no association with readmissions (OR = 0.90; 95% CI = 0.79 to 1.04) or cardiovascular events (OR = 1.12; 95% CI = 0.74 to 1.71)., Conclusions: In routine orthopaedic surgery practice, TXA use was associated with decreased blood loss and transfusion risk for both total knee and total hip arthroplasty, without evidence of increased risk of complications. TXA use was also associated with reduced risk of readmission among total hip arthroplasty patients and reduced risk of VTE among total knee arthroplasty patients, and did not have an adverse effect on cardiovascular complications in either group., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Feedback on patient satisfaction (PS) as a means to monitor and improve performance in patient communication is lacking in residency training. A physician's promotion, compensation and job satisfaction may be impacted by his individual PS scores, once he is in practice. Many communication and satisfaction surveys exist but none focus on the emergency department setting for educational purposes. The goal of this project was to create an emergency medicine-based educational PS survey with strong evidence for content validity., Methods: We used the Delphi Method (DM) to obtain expert opinion via an iterative process of surveying. Questions were mined from four PS surveys as well as from group suggestion. The DM analysis determined the structure, content and appropriate use of the tool. The group used four-point Likert-type scales and Lynn's criteria for content validity to determine relevant questions from the stated goals., Results: Twelve recruited experts participated in a series of seven surveys to achieve consensus. A 10-question, single-page survey with an additional page of qualitative questions and demographic questions was selected. Thirty one questions were judged to be relevant from an original 48-question list. Of these, the final 10 questions were chosen. Response rates for individual survey items was 99.5%., Conclusion: The DM produced a consensus survey with content validity evidence. Future work will be needed to obtain evidence for response process, internal structure and construct validity.

Objective: To estimate the reference range of tissue oxygen saturation (StO2) values in pregnancy. Near-infrared spectroscopy-derived StO2 is a noninvasive continuous measure used to predict hypoperfusion. Normal StO2 values have not been established in pregnant women., Study Design: We enrolled 154 healthy pregnant women from an obstetric and gynecology resident clinic. Three sequential measurements were taken after securing the StO2 probe to the thenar eminence of one hand. One-way ANOVA was used to test for differences between trimesters and non-parametric methods to establish a reference range with 95% CI on the limits., Results: The reference interval for the entire cohort of pregnant women is 73% (95% CI 72-75) to 92% (95% CI 89-93), similar to the normal range in the general population. We found no statistically significant difference in StO2 measurements between trimesters. Due to inadequate sample sizes we could not estimate a valid reference range for each trimester., Conclusion: We estimated a reference range for StO2 values in normal pregnant women. This information may contribute to the study of StO2 monitoring to predict impending shock in the obstetric patient.

Prompt diagnosis and treatment of fungal meningitis are critical, but culture is insensitive. (1,3)-β-d-Glucan (BDG) testing is FDA approved for serological diagnosis of invasive fungal disease; however, BDG testing is not approved for cerebrospinal fluid (CSF), and the appropriate cutoff value is unknown. We aimed to validate the diagnostic accuracy of CSF BDG measurements for fungal meningitis among patients exposed to contaminated methylprednisolone acetate (MPA). A retrospective observational study was conducted at St. Joseph Mercy Hospital and Vanderbilt University from November 2013 to February 2014. Patients were included if they had received a contaminated MPA injection. Cases were classified as probable or proven meningitis according to Centers for Disease Control and Prevention guidelines. CSF BDG testing was performed according to the package insert instructions for serum samples, and results were validated using Clinical and Laboratory Standards Institute procedures (MiraVista Diagnostics). Of 233 patients, 45 had meningitis (28 proven cases), 53 had spinal/paraspinal infections (19 proven cases), and 135 did not develop disease. Using the manufacturer's cutoff value (≥80 pg/ml), the sensitivity and specificity were 96% and 95%, respectively, for proven meningitis and 84% and 95% for probable or proven meningitis. Receiver operating characteristic analysis identified the optimal cutoff value for proven meningitis to be 66 pg/ml (sensitivity, 100%; specificity, 94%) and that for probable or proven meningitis to be 66 pg/ml (sensitivity, 91%; specificity, 92%). Our results suggest that CSF BDG measurements are highly sensitive and specific for the diagnosis of fungal meningitis associated with contaminated MPA injections. Further study on the utility of CSF BDG testing for other types of fungal meningitis is needed., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Objectives: We developed a communication instrument to be used in the Emergency Department (ED) and hypothesized that use of this guide would increase patient comprehension of and satisfaction with care., Methods: This multi-site trial enrolled 643 patients in treatment and control groups. Comprehension of care was assessed by chart review and satisfaction measured via validated survey., Results: Use of the instrument was not associated with improvements in patient knowledge about their care, with a mean of 4.6 (95% CI: 4.8-5.8) comprehension defects in the control group and 4.4 (95% CI: 3.9-4.9) in the treatment group. There was no significant effect on patient satisfaction 76.4% versus 76.9%, p=0.34. Elderly patients in both groups were found to have 1.1 (p<0.01) more knowledge gaps than younger patients., Conclusion: Patients frequently misunderstand medical care in the ED. Comprehension decreases with increasing age. An isolated communication instrument does not improve satisfaction with or understanding of the care received., Practice Implications: Providing a structured place for providers and patients to record details of care does not seem to improve satisfaction with or comprehension of care. Interventions that focus on communication skills and face time with patients may prove more effective., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The hypothesis was that a reminder about recommended primary care physician (PCP) follow-up, sent via e-mail to patients discharged from the emergency department (ED), would increase the proportion of patients who followed up with their PCPs within the recommended time frame. Patient receptiveness to e-mail follow-up reminders was also assessed., Methods: This was a mixed methods clinical intervention study with subjects randomized either to receive the usual care discharge instructions only or to also receive a reminder e-mail message the day after the ED visit. The reminder e-mail contained the subject's PCP's name and address and the recommended PCP follow-up time interval. A blinded review of outpatient PCP medical records was conducted to determine whether and when follow-up occurred. Researchers attempted to contact patients with a telephone survey 2 weeks after their ED visits. The primary outcomes between groups were compared using chi-square tests and relative risks (RRs) with 95% confidence intervals (CIs)., Results: Thirty-three percent of the intervention group and 32% of the control group followed-up as recommended (RR = 1.04, 95% CI = 0.81 to 1.33); 52% of the intervention group and 48% of the control group followed-up within 10 days of the recommended time (RR = 1.08, 95% CI = 0.91 to 1.29). The 334 patients (57%) successfully contacted via telephone demonstrated a high interest in receiving future e-mail reminders (75%), with the group that received e-mail reminders more likely to want one in the future than those who did not receive e-mail reminders (82.5% vs. 69.76%; p = 0.04)., Conclusions: E-mail reminders sent after ED visits did not improve patients' adherence to the recommended timing of primary care follow-up contained in discharge instructions. Subjects in both the control and the intervention groups favorably viewed the concept of e-mail reminders, suggesting that the value of e-mail reminders after ED discharge may be in areas such as patient satisfaction that were not specifically targeted for measurement in this study., (© 2014 by the Society for Academic Emergency Medicine.)

Objective: To determine whether an educational intervention combined with a voluntary decision support system improves inpatient pain control., Design: Retrospective serial cross-sectional study., Setting: Community teaching hospital., Patients: Patients admitted to internal medicine teaching service from October to December 2011 and 2012. The study cohorts consisted of a random sample of 75 patients each from both time periods., Interventions: Beginning in August 2012, internal medicine residents participated in an interactive training session on the use of opioids for hospitalized patients and concurrently, a user initiated voluntary computerized decision support system (CDSS), in the form of computer order entry (COE) and pocket cards were introduced. The COE options correspond to the standardized opioid dosing regimen on the pocket card. Pain scores and opioid doses and demographic information were obtained from administrative databases. Additional covariates were abstracted via programmed electronic medical record (EMR) review., Main Outcome Measures: Pre- and postintervention, maximum reported pain score in every 8-hour period from first analgesic dose, to 72 hours after the first analgesic dose, were compared by fitting a multivariable linear mixed model. Naloxone use was a surrogate measure for secondary outcome of opioid overdose., Results: The intervention had no effect on maximum pain score (MPS) over time, p = 0.0930. The estimated mean MPS (95% confidence interval) was 4.7 (3.9, 5.5) preintervention and 5.2 (4.4, 6.0) postintervention., Conclusions: A combination of a resident educational intervention, CDSS, and pocket cards did not improve MPSs over time for patients on an internal medicine teaching service.

Background: A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone., Methods: Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports., Results: Of 544 patients who received an epidural injection from a contaminated lot of methylprednisolone at a pain clinic in southeastern Michigan, 153 (28%) were diagnosed at our institution with probable or confirmed spinal or paraspinal fungal infection at the injection site. Forty-one patients had both meningitis and spinal or paraspinal infection, and 112 had only spinal or paraspinal infection. Magnetic resonance imaging abnormalities included abscess, phlegmon, arachnoiditis, and osteomyelitis. Surgical debridement in 116 patients revealed epidural phlegmon and epidural abscess most often. Among 26 patients with an abnormal MRI but with no increase or change in chronic pain, 19 (73%) had infection identified at surgery. Fungal infection was confirmed in 78 patients (51%) by finding hyphae in tissues, positive polymerase chain reaction, or culture. Initial therapy was voriconazole plus liposomal amphotericin B in 115 patients (75%) and voriconazole alone in 38 patients (25%). As of January 31, 2014, 20 patients remained on an azole agent. Five patients died of infection., Conclusions: We report on 153 patients who had spinal or paraspinal fungal infection at the site of epidural injection of contaminated methylprednisolone. One hundred sixteen (76%) underwent operative debridement in addition to treatment with antifungal agents.

Study Objective: Senior (geriatric) emergency departments (EDs) are an emerging phenomenon across the United States, designed to provide greater comfort for elders, screening for common morbidities, and selective contact with social workers. We hypothesize that the senior ED will reduce recidivism, rate of admission, and hospital length of stay., Methods: This was a pre/postintervention observational study of seniors (≥65 years) before and after opening of a new senior ED in a large community hospital. Older nonseniors treated during the same periods were included to detect temporal trend bias. Outcomes included admission to the hospital, hospital length of stay, and ED return visits. Cox proportional hazards models, controlling for patient age, sex, triage level, insurance type, admission on the index visit, and hospital length of stay, were used to test association with time to return within 30 and 180 days. Multivariable regression modeling was used to determine whether the intervention was associated with admission on the index visit, and hospital length of stay., Results: There was no significant difference in time to return within 30 days (HR=1.09; 95% confidence interval [CI] 0.95 to 1.23), 180 days (HR=0.99; 95% CI 0.91 to 1.08), or average hospital length of stay. Risk of being admitted on the index visit was lower for seniors treated in the senior ED compared with the regular ED (Relative Risk=0.93; 95% CI 0.89 to 0.98)., Conclusion: A new senior ED was not associated with reduced ED recidivism or hospital length of stay, but was associated with decreased rate of admission., (Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Objectives: There is no perfectly sensitive or specific test for identifying young, febrile infants and children with occult serious bacterial infections (SBIs). Studies of procalcitonin (PCT), a 116-amino-acid precursor of the hormone calcitonin, have demonstrated its potential as an acute-phase biomarker for SBI. The objective of this study was to compare performance of serum PCT with traditional screening tests for detecting SBIs in young febrile infants and children., Methods: This was a prospective, multicenter study on a convenience sample from May 2004 to December 2005. The study was conducted in four emergency departments (EDs): one pediatric ED and three EDs with pediatric units, all with academic faculty on staff. A total of 226 febrile children 36 months old or younger who presented to the four participating EDs and were evaluated for SBI by blood, urine, and/or cerebral spinal fluid (CSF) cultures were included., Results: The test characteristics (with 95% confidence intervals [CIs]) of the white blood cell (WBC) counts including neutrophil and band counts were compared with PCT for identifying SBI. Thirty children had SBIs (13.3%, 95% CI = 8.85 to 17.70). Four (13.3%) had bacteremia (including one with meningitis), 18 (60.0%) had urinary tract infections (UTIs), and eight (26.6%) had pneumonia. Children with SBIs had higher WBC counts (18.6 × 10(9)  ± 8.6 × 10(9) cells/L vs. 11.5 × 10(9)  ± 5.3 × 10(9) cells/L, p < 0.001), higher absolute neutrophil counts (ANCs; 10.6 × 10(9)  ± 6.7 × 10(9) cells/L vs. 5.6 × 10(9)  ± 3.8 × 10(9) cells/L, p = 0.009), higher absolute band counts (0.90 × 10(9)  ± 1.1 × 10(9) cells/L vs. 0.35 × 10(9)  ± 0.6 × 10(9) cells/L, p = 0.009), and higher PCT levels (2.9 ± 5.6 ng/mL vs. 0.4 ± 0.8 ng/mL, p = 0.021) than those without SBIs. In a multivariable logistic regression analysis, the absolute band count and PCT were the two screening tests independently associated with SBI, although the area under the receiver operating characteristic (ROC) curve for PCT was the largest (0.80, 95% CI = 0.71 to 0.89)., Conclusions: Procalcitonin is a more accurate biomarker than traditional screening tests for identifying young febrile infants and children with serious SBIs. Further study on a larger cohort of young febrile children is required to definitively determine the benefit of PCT over traditional laboratory screening tests for SBIs., (© 2014 by the Society for Academic Emergency Medicine.)

Importance: Injection of contaminated methylprednisolone has resulted in an unprecedented nationwide outbreak of Exserohilum rostratum fungal infections, manifested initially as meningitis and/or basilar stroke. Insidious onset of spinal or paraspinal infection at the injection site has been increasingly reported and is occurring months after receipt of injection with the contaminated drug. The clinical findings are often subtle and similar to those that led the patient to undergo the methylprednisolone injection., Objective: To determine if patients who had not presented for medical care but who had received contaminated methylprednisolone developed spinal or paraspinal infection at the injection site using contrast-enhanced magnetic resonance imaging (MRI) screening., Design, Setting, and Participants: There were 172 patients who had received an injection of contaminated methylprednisolone from a highly contaminated lot (No. 06292012@26) at a pain facility but had not presented for medical care related to adverse effects after the injection. Screening MRI was performed between November 9, 2012, and April 30, 2013., Main Outcomes and Measures: Number of persons identified with previously undiagnosed spinal or paraspinal infection., Results: Of the 172 patients screened, MRI was abnormal in 36 (21%), showing epidural or paraspinal abscess or phlegmon, arachnoiditis, spinal osteomyelitis or diskitis, or moderate to severe epidural, paraspinal, or intradural enhancement. Of the 115 patients asked about new or worsening back or neck pain, lower extremity weakness, or radiculopathy symptoms, 35 (30%) had at least 1 symptom. Thirty-five of the 36 patients with abnormal MRIs met the Centers for Disease Control and Prevention (CDC) case definition for probable (17 patients) or confirmed (18 patients) fungal spinal or paraspinal infection. All 35 patients were treated with antifungal agents (voriconazole, with or without liposomal amphotericin B), and 24 required surgical debridement. At the time of surgery, 17 of 24 patients (71%), including 5 patients who denied having symptoms, had laboratory evidence of fungal infection., Conclusions and Relevance: Among patients who underwent screening MRI to look for infection at the site of injection of contaminated methylprednisolone, 21% had an abnormal MRI, and all but one met CDC criteria for probable or confirmed fungal spinal or paraspinal infection. Screening MRI led to identification of patients who had minimal or no symptoms of spinal or paraspinal infection and allowed early initiation of medical and surgical treatment.

Background: Emergency department (ED) communication has been demonstrated as requiring improvement and ED patients have repeatedly demonstrated poor comprehension of the care they receive. Through patient focus groups, the authors developed a novel tool designed to improve communication and patient comprehension., Study Design: This is a prospective, randomised controlled clinical trial to test the efficacy of a novel, patient-centred communication tool. Patients in a small community hospital ED were randomised to receive the instrument, which was utilised by the entire ED care team and served as a checklist or guide to the patients' ED stay. At the end of the ED stay, patients completed a survey of their comprehension of the care and a communication assessment tool-team survey (a validated instrument to assess satisfaction with communication). Three blinded chart reviewers scored patients' comprehension of their ED care as concordant, partially concordant or discordant with charted care. The authors tested whether there was a difference in satisfaction using a two-sample t test and a difference in comprehension using ordinal logistic regression analysis., Results: 146 patients were enrolled in the study with 72 randomised to receive the communication instrument. There was no significant difference between groups in comprehension (OR=0.65, 95% CI 0.34 to 1.23, p=0.18) or communication assessment tool-team scores (difference=0.2, 95% CI: -3.4 to 3.8, p=0.91)., Conclusions: Using their novel communication tool, the authors were not able to show a statistically significant improvement in either comprehension or satisfaction, though a tendency towards improved comprehension was seen.

Background: Data from community antimicrobial stewardship programs (ASPs) are limited. We describe clinical and economic outcomes from the first year of our hospital's ASP., Methods: The ASP team comprised 2 infectious disease physicians and 3 intensive care unit pharmacists. The team prospectively audited the new starts and weekly use of 8 target antimicrobials: aztreonam, caspofungin, daptomycin, ertapenem, linezolid, meropenem, tigecycline, and voriconazole. Using administrative data, outcomes from the first year of the program, including death within 30 days of hospitalization, readmission within 30 days of discharge, and development of Clostridium difficile infection (CDI), were compared with outcomes from a similar period before institution of the program., Results: A total of 510 antimicrobial orders were reviewed, of which 323 (63%) were appropriate, 94 (18%) prompted deescalation, 61 (12%) were denied, and 27 (5%) led to formal consultation with an infectious disease physician. On multivariate analysis, implementation of the ASP was associated with an approximate 50% reduction in the odds of developing CDI (odds ratio, 0.46; 95% confidence interval, 0.25-0.82). The ASP was not associated with decreased mortality at 30 days after discharge or readmission rate. The antimicrobial cost per patient-day decreased by 13.3%, from $10.16 to $8.81. The antimicrobial budget decreased by 15.2%, resulting in a total savings of $228,911. There was a 25.4% decrease in defined daily doses of the target antimicrobials., Conclusions: Implementation of the ASP was associated with significant reductions in CDI rate, antimicrobial use, and pharmacy costs., (Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: The purpose of this study was to compare the microleakage of traditional composite (Charisma/Gluma Comfort Bond) and self-priming resin (Embrace Wetbond)., Materials and Methods: Standardized Class V cavities partly in enamel and cementum were prepared in 20 extracted human premolars. Teeth were divided into two groups. Group 1 was restored with Charisma/Gluma Comfort Bond and Group 2 with Embrace Wetbond. The specimens were stored in distilled water at room temperature for 24 h and then subjected to 200 thermocycles at 5°C and 55°C with a 1 min dwell time. After thermocycling teeth were immersed in a 0.2% solution of methylene blue dye for 24 h. Teeth were sectioned vertically approximately midway through the facial and lingual surfaces using a diamond saw blade. Microleakage was evaluated at enamel and cementum surfaces using 10 × stereomicroscope. The statistical analysis was performed using Wilcoxon signed-rank test., Results: Wetbond showed less microleakage at occlusal and gingival margins as compared with Charisma/Gluma Comfort Bond and the results were statistically significant (P < 0.05)., Conclusion: Class V cavities restored with Embrace Wetbond with fewer steps and fewer materials offers greater protection against microleakage at the tooth restorative interface.

Background: Complications associated with blood transfusions have resulted in widespread acceptance of low hematocrit levels in surgical patients. However, preoperative anemia seems to be a risk factor for adverse postoperative outcomes in certain surgical patients. This study investigated the National Surgical Quality Improvement Program (NSQIP) database to determine if preoperative anemia in patients undergoing open and laparoscopic colectomies is an independent predictor for an adverse composite outcome (CO) consisting of myocardial infarction, stroke, progressive renal insufficiency or death within 30 days of operation, or for an increased hospital length of stay (LOS)., Study Design: Hematocrit levels were categorized into 4 classes: severe, moderate, mild, and no anemia. From 2005 to 2008, the NSQIP database recorded 23,348 elective open and laparoscopic colectomies that met inclusion criteria. Analyses using multivariable models, controlling for potential confounders and stratifying on propensity score, were performed., Results: Compared with nonanemic patients, those with severe, moderate, and mild anemia were more likely to have the adverse CO with odds ratios of 1.83 (95% CI 1.05 to 3.19), 2.19 (95 % CI 1.63 to 2.94), and 1.49 (95% CI 1.20 to 1.86), respectively. Patients with a normal hematocrit had a reduced hospital LOS, compared with those with severe, moderate, and mild anemia (p < 0.01). A history of cardiovascular disease did not significantly influence these findings., Conclusions: This large multicenter database analysis suggests that the presence of severe and moderate and even mild preoperative anemia is an independent risk factor for complications and a longer hospital stay after colon surgery., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Study Objective: We want to know whether a low B-type natriuretic peptide (BNP) level, obtained shortly after presentation and independent of information provided by other clinical findings and laboratory tests, would affect management decisions for emergency department (ED) patients with nondiagnostic troponin levels. Previous studies have generally been retrospective or inclusive of patients with heart failure., Methods: We prospectively studied patients evaluated for possible acute coronary syndromes who had nondiagnostic levels of serum troponin, nondiagnostic ECGs, and no clinical heart failure within 4 hours of presentation. BNP levels were obtained but results not provided to clinical staff. The primary outcome was the composite of acute myocardial infarction or death within 30 days. The secondary outcome was the composite of the primary outcome, percutaneous coronary intervention, or coronary artery bypass grafting., Results: Almost half of the patients screened for but excluded from the study had known heart failure or a history of heart failure. The resulting cohort was composed of 348 patients, with a median age of 64 years and 51% women. The primary outcome occurred in 16.1% of patients; the secondary outcome, in 27.6%. At a standard cutoff of BNP greater than or equal to 80 pg/mL, the negative predictive value for the primary outcome was 80% (95% confidence interval 73% to 86%). The negative predictive value for the secondary outcome was 69% (95% confidence interval 61% to 75%). Multivariable analyses supported these findings., Conclusion: A single, low BNP level obtained shortly after presentation to the ED could not identify patients at low risk for 30-day acute myocardial infarction or death., (Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Current American College of Cardiology/American Heart Association guidelines recommend loading clopidogrel >or=6 hours before percutaneous coronary intervention. Other American College of Cardiology guidelines advise withholding clopidogrel for 5 days before coronary artery bypass grafting (CABG) to avoid excessive bleeding. Previously published rules for predicting early CABG after coronary angiography (CA) were developed in selected patients with non-ST-segment elevation-acute coronary syndrome and not tested in community practice settings. Using logistic regression analysis we sought to develop an accurate decision rule to identify patients at higher risk for early CABG, in unselected community hospital patients undergoing diagnostic CA, who were candidates for percutaneous coronary intervention. The study was conducted at a community hospital in Ann Arbor, Michigan. A total of 986 randomly selected records from 2004 were reviewed. Sixty-two percent were men and mean age was 64 years. Twelve percent underwent CABG within 5 days of CA. Of those with previous CABG, only 2% underwent early CABG. From several potential predictor variables examined, age, male gender, previous CABG, history of typical angina pectoris, previous CA, and hypertension were identified through multivariate logistic regression and incorporated in a simple risk score. Sensitivity and specificity of a risk score >12 were 66% (95% confidence interval 56 to 74) and 66% (95% confidence interval 62 to 69), respectively, with an area under the receiver operating characteristics curve of 0.72. In conclusion, early CABG in those undergoing CA can be predicted with only modest accuracy from preprocedure clinical variables.

Although experimental evidence suggests that the preliminary surgical delay procedure physiologically improves the circulation of the TRAM flap, there are no published controlled studies evaluating the clinical outcomes associated with this procedure. The purpose of this study was to evaluate the efficacy of the surgical flap delay versus no delay in consecutive patients having pedicle TRAM breast reconstruction. This was a retrospective cohort study of breast cancer patients at the University of Michigan who had pedicle TRAM reconstruction between January 2004 and March 2008. Prior to September 2005, all patients had pedicle TRAM reconstruction without the delay procedure. Starting in September 2005, all patients had the delay procedure prior to TRAM flap reconstruction. Descriptive statistics were used to compare demographic data, comorbidities, and complication rates between the 2 cohorts. Regression analysis was used to determine the effects of the surgical delay procedure on the incidence of flap ischemia and major and minor complications while controlling for patient and treatment level factors. Eighty-seven postmastectomy breast cancer patients had unipedicle TRAM flap reconstruction, in which 112 flaps were used to reconstruct breasts. The nondelay cohort consisted of 42 consecutive patients (51 flaps) and the delay cohort consisted of 45 consecutive patients (61 flaps). Of the patients without the surgical delay procedure 17.6% experienced at least one ischemic complication of the flap compared with 6.6% of those who were surgically delayed (P = 0.082). When controlling for patient and treatment level factors, the delay procedure was found to significantly decrease the incidence of flap ischemia (OR = 0.21, P = 0.018). In addition, there were no significant differences in the incidence of major or minor complication rates in the surgically delayed versus nondelayed groups (P = 0.247, P = 0.486, respectively). When patient and treatment level factors were taken into consideration, undergoing the delay procedure also did not increase the incidence of having a major or minor complication. These data support the use of the preliminary surgical delay procedure to decrease ischemic complications of the flap in pedicle TRAM postmastectomy breast reconstruction.

Objective: An operative note is indispensable to physician documentation and decision-making; however, there are no accepted standards for operative note content. Our aim was to use a modified Delphi consensus-building method to construct a uniform operative note template for laparotomy., Study Design: Using Joint Commission on Accreditation of Healthcare Organizations requirements, literature review, and feedback from 15 medical malpractice defense attorneys, we compiled a draft operative note template of 31 elements. We surveyed 37 Association of Professor of Gynecology and Obstetrics/Solvay scholars asking for their input on inclusion of each item as essential content of the operative note., Results: Two iterations of the survey were required to reach a predetermined 75% level of consensus. Nine elements were eliminated from the template: 6 original and 3 expert-suggested elements., Conclusion: We provide an operative note template that was compiled through a Delphi process.