Evaluation of Recombinant Factor VIIa Off-Label Use at an Acute Care Hospital with Established Guidelines for Use

Purpose

At present, there are a scarcity of data available evaluating off-label prescribing patterns of recombinant factor VIIa (rFVIIa), pharmacoeconomic impact, and patient outcomes in clinical practice in an acute care setting with guidelines in place to influence prescribing practices. The primary objective of this study was to retrospectively evaluate the off-label usage and prescribing patterns of rFVIIa at a large acute care hospital with established rFVIIa guidelines.

Results

During the study period, a total of 199 patients were ordered rFVIIa, of which 181 (91%) received at least one dose of rFVIIa for an off-label use (n=181). Refractory bleeding and intracerebral hemorrhage were the 2 leading uses for rFVIIa, accounting for 30% (n = 54) and 29% (n = 51) of all uses, respectively. Overall, the mean number of doses per patient for all uses was 1.79. The mean number of doses per patient by non–FDA-approved use was highest in patients with cardiac surgery and refractory bleeding. The total yearly acquisition of rFVIIa for the study institution has decreased from 5.25 mcg/patient-day in 2005 to 2.52 mcg/patient-day in 2009.

Conclusion

The findings are encouraging and support the impact that education of pharmacy, nursing, and physician staff along with guideline development may have on off-label rFVIIa usage. Further research evaluating the impact of rFVIIa guidelines and/or order sets is warranted.

Differential regulation of the proapoptotic multidomain protein Bak by p53 and p73 at the promoter level

During apoptosis Bcl-2 proteins control permeabilization of the mitochondrial outer membrane leading to the release of cytochrome c. Essential gatekeepers for cytochrome c release are the proapoptotic multidomain proteins, Bax, and Bak. The expression of Bax is upregulated upon cellular stress by the tumor suppressor p53. Despite the high functional homology of Bax and Bak, little is known about how the bak gene is regulated. To investigate its transcriptional regulation in further detail, we have analyzed a region spanning 8200 bp upstream of the bak start codon (within exon 2) for transcription factor-binding sites, and identified three p53 consensus sites (BS1-3). Reporter gene assays in combination with site-directed mutagenesis revealed that only one putative p53-binding site (BS3) is necessary and sufficient for induction of reporter gene expression by p53. Consistently, p53 induces expression of endogenous Bak. At the mRNA level, induction of Bak expression is weaker than induction of Puma and p21. Interestingly, Bak expression can also be induced by p73 that binds however to each of the three p53-binding sites within the bak promoter region. Our data suggest that expression of Bak can be induced by both, p53 and p73 utilizing different binding sites within the bak promoter.

Effects of organic matter on acidic electrolysed water for reduction of foodborne pathogens on lettuce and spinach

AIMS

To evaluate the efficacy of acidic electrolysed water (EW) in the presence of organic matter (bovine serum) on the inoculated surfaces of lettuce and spinach.

MATERIALS AND RESULTS

Lettuce and spinach leaves were inoculated with a cocktail of three strains each of Escherichia coli O157:H7, Salmonella Typhimurium and Listeria monocytogenes and treated with deionized water, acidic EW and acidic EW containing bovine serum (5, 10, 15 and 20 ml l(-1)) for 15 s, 30 s, 1 min, 3 min and 5 min at room temperature (22 +/- 2 degrees C). In the absence of bovine serum, acidic EW treatment reduced levels of cells below the detection limit (0.7 log) in 5 min. In the presence of bovine serum, bactericidal activity of acidic EW decreased with increasing serum concentration.

CONCLUSIONS

Organic matter reduces the effectiveness of acidic EW for reducing pathogens on the surfaces of lettuce and spinach.

SIGNIFICANCE AND IMPACT OF THE STUDY

From a practical standpoint, organic matter reduces the efficacy of acidic EW. This study was conducted to confirm the effect of organic matter on the properties of acidic EW in the inactivation of foodborne pathogens on the surface of vegetables.

Effect of electrolyzed water for reduction of foodborne pathogens on lettuce and spinach

The ability of electrolyzed water (EW) to inactivate foodborne pathogens on the surfaces of lettuce and spinach was investigated. Lettuce and spinach leaves were inoculated with a cocktail of 3 strains each of Escherichia col O157:H7, Salmnonella Typhimurium, and Listeria monocytogenes and treated with acidic electrolyzed water (AC-EW), alkaline electrolyzed water (AK-EW), alkaline electrolyzed water followed by acidic electrolyzed water (sequential treatment, AK-EW + AC-EW), deionized water followed by acidic electrolyzed water (sequential treatment, DW + AC-EW), and deionized water (control, DW) for 15, 30 s, and 1, 3, and 5 min at room temperature (22 +/- 2 degrees C). For all 3 pathogens, the same pattern of microbial reduction on lettuce and spinach were apparent. The relative efficacy of reduction was AC-EW > DW + AC-EW approximately = AK-EW + AC-EW > AK-EW > control. After a 3-min treatment of AC-EW, the 3 tested pathogens were reduced below the detection limit (0.7 log). DW + AC-EW and AK-EW + AC-EW produced the same levels of reduction after 5 min when compared to the control. AK-EW did not reduce levels of pathogens even after a 5-min treatment on lettuce and spinach. Results suggest that AC-EW treatment was able to significantly reduce populations of the 3 tested pathogens from the surfaces of lettuce and spinach with increasing time of exposure.

Fate of foodborne pathogens on green onions and tomatoes by electrolysed water

AIMS

To investigate the efficacy of electrolysed water (EW) in killing Escherichia coli O157:H7, Salmonella typhimurium and Listeria monocytogenes on the surfaces of spot-inoculated green onions and tomatoes.

METHODS AND RESULTS

Green onions and tomatoes were inoculated with a cocktail of three strains each of E. coli O157:H7, Salm. typhimurium and L. monocytogenes and treated with acidic electrolysed water (AC-EW), alkaline electrolysed water (AK-EW), alkaline electrolysed water followed by acidic electrolysed water (AK-EW + AC-EW), deionized water followed by acidic electrolysed water (DW + AC-EW) and deionized water (control, DW) for 15 s, 30 s, 1 min, 3 min and 5 min at room temperature (22 +/- 2 degrees C). The relative efficacy of reduction was AC-EW > DW + AC-EW approximately AK-EW + AC-EW > AK-EW > DW.

CONCLUSIONS

Acidic EW treatment was able to significantly reduce populations of the three tested pathogens from the surfaces of green onions and tomatoes with increasing exposure time.

SIGNIFICANCE AND IMPACT OF THE STUDY

Rinsing in acidic EW reveals an effective method to control the presence of E. coli O157:H7, Salm. typhimurium and L. monocytogenes on the surfaces of fresh green onions and tomatoes, without affecting their organoleptic characteristics. This indicates its potential application for the decontamination of fresh produce surfaces.

Retrospective Evaluation of Commonly Used Equations to Predict Energy Expenditure in Mechanically Ventilated, Critically Ill Patients

STUDY OBJECTIVE

To determine which of four commonly used equations to estimate energy expenditure is precise and unbiased compared with energy expenditure as measured by indirect calorimetry.

DESIGN

Retrospective, observational study.

SETTING

Adult medical intensive care unit in a research hospital of the National Institutes of Health Clinical Center.

PATIENTS

Seventy-six adult, mechanically ventilated, critically ill patients.

INTERVENTION

Indirect calorimetry reports generated by the National Institutes of Health Critical Care Medicine Department's Metabolic Cart Consult Service were reviewed. Bias and precision of resting energy expenditure (REE) estimated by equations were computed using mean prediction error (ME) and root mean squared prediction error (MSE). Equations were considered precise if the 95% confidence interval for MSE was within 15% of the measured energy expenditure (MEE) determined by indirect calorimetry. Equations were considered unbiased if the 95% confidence interval for ME included zero. Paired t tests were used to compare estimated REE values for each predictive equation with MEE values determined by indirect calorimetry. Data were stratified into regions of bias using classification and regression tree analysis, as well as visual inspection of estimated REE-versus-MEE curves for each equation.

MEASUREMENTS AND MAIN RESULTS

The Harris-Benedict equation multiplied by an activity factor of 1.2 was unbiased and precise. The Ireton-Jones equation was precise but biased. The American College of Chest Physicians' consensus recommendation was biased and imprecise. The Harris-Benedict equation without an activity factor also demonstrated bias and imprecision.

CONCLUSIONS

The Harris-Benedict equation multiplied by an activity factor of 1.2 is suitable for predicting REE and may be used in the absence of indirect calorimetry.

Procalcitonin and enteral nutrition tolerance in critically ill patients

BACKGROUND

Serum procalcitonin concentrations have been reported to be elevated in patients with bacterial infection. Early enteral nutrition (EN) has been shown to decrease infections in trauma patients. The purpose of this study was to characterize procalcitonin and other serum proteins during EN of trauma patients based on EN tolerance and presence of infection.

METHODS

Twenty traumatized patients received a high-protein enteral formulation within 5 days of injury. Serum for procalcitonin, C-reactive protein, and prealbumin was analyzed on days 1 and 7 of EN. The procalcitonin/prealbumin and C-reactive protein/prealbumin ratios were calculated the same days. Patients who were infected during the study were compared with those not infected, and enteral-tolerant patients were compared with enteral-intolerant patients using these measurements.

RESULTS

In the 20 trauma patients, procalcitonin (10.35 +/- 27.87 versus 1.03 +/- 1.24 ng/mL, p < .001) and procalcitonin/prealbumin ratio (1.70 +/- 4.20 versus 0.18 +/- 0.28, p < .01) decreased significantly over the 7-day period of EN. In the 12 patients who had infection, procalcitonin (16.33 +/- 35.31 versus 1.37 +/- 1.41 ng/mL, p < .004) and procal- citonin/prealbumin ratio (2.74 +/- 5.31 versus 0.26 +/- 0.33, p < .01) decreased significantly over the 7-day period of enteral nutrition. There were no significant changes in the measurements for 8 patients without infection. In the 15 patients who were enteral-tolerant, procalcitonin (12.56 +/- 32.84 versus 1.07 +/- 1.23 ng/mL, p < .004) and procalcitonin/prealbumin ratio (2.03 +/- 4.93 versus 0.20 +/- 0.29, p < .01) decreased significantly.

CONCLUSION

Procalcitonin serum concentrations decrease significantly during EN in enteral-tolerant, critically ill patients with infection.

Preparation and incorporation of probe-labeled apoA-I for fluorescence resonance energy transfer studies of rHDL

Apolipoprotein A-I (apoA-I), the major constituent of HDL, plays an essential role in regulating cholesterol metabolism, acting as the physiological activator of lecithin: cholesterol acyltransferase, which converts cholesterol to cholesterol ester. Thiol-reactive fluorescent probes attached to cysteine-containing apoA-I mutants are currently being used to investigate the "LCAT active" conformation of lipid-bound apoA-I. Herein, we report new methodologies allowing rapid expression, fluorescent labeling, and recombinant HDL (rHDL) preparation for use in apoA-I in fluorescence resonance energy transfer (FRET) studies. Cysteine-containing mutant forms of human apoA-I were cloned into the pTYB12 vector containing a T7 promoter, a modified self-splicing protein element (intein), and a small affinity tag [chitin binding domain (CBD)]. The fusion proteins were expressed in Escherichia coli, isolated from cell lysates, and bound to a chitin-affinity column. Release of mature human apoA-I was initiated by the addition of DTT, which induced self-cleavage at the COOH terminus of the intein - CBD fusion protein. ApoA-I was further purified by Q-sepharose and then used for fluorescent probe labeling. Discoidal rHDL were then prepared with donor and/or acceptor labeled apoA-I and characterized with respect to their size, composition and ability to activate LCAT.

Linac radiosurgery for skull base meningiomas

INTRODUCTION

Skull base meningiomas present a difficult surgical challenge because of the high potential morbidity of radical surgical extirpation and their low potential for incapacitating symptomatology. The focal character of meningiomas makes stereotactic radiosurgery an attractive adjuvant treatment modality to resection. The purpose of this study was to evaluate the local control rates and complications in 56 patients with base of skull meningiomas undergoing radiosurgery.

METHODS

Patients underwent radiosurgery using the dedicated stereotactic linear accelerator at the Brigham and Women's Hospital. Minimal peripheral doses of radiosurgery ranged from 12 to 18.5 Gy (mean 15 Gy). Doses were designed to conform to the frequently irregular tumor volumes using the X-Knife treatment planning system. Multiple isocenters were used when required to increase conformality of dose. For 36 patients (64%), radiosurgery was used as an adjunct to surgery; for 20 patients (36%) it was the primary treatment.

RESULTS

Median followup was five years. Nineteen patients (34%) were improved clinically at follow-up; 32 (57%) were unchanged; and 5 patients (9%) developed new or worsened neurologic deficits. Serial imaging studies after radiosurgery showed a reduction in tumor volume in 23 patients (41%); 30 (54%) showed stable disease; 3 patients (5%) had tumors which increased in size (2 being outside the radiosurgery treatment site). The actuarial freedom from progression rate (defined as further tumor growth) was thus 95%, with a median imaging follow-up of 26 months (range, 6-66 months). Although further follow-up is necessary, the results of this series clearly demonstrate that these lesions are feasible for treatment by modern radiosurgical techniques. Linac radiosurgery can stabilize skull base meningiomas, with decreased or unchanged tumor volumes on radiologic follow-up in approximately 95% of patients. Radiosurgery is a low-morbidity, effective technique as adjunct and sometimes primary treatment of small to moderate-sized meningiomas of the skull base.