Involvement of veterinary students in the placement of intravenous catheters in adult horses in a teaching hospital does not significantly increase the rate of catheter complications

OBJECTIVE

To determine whether student involvement in intravenous catheter (IVC) placement increases the risk for complications and to report the rate and types of complications associated with IVCs in adult horses in a university teaching hospital.

ANIMALS

455 IVCs placed in 394 horses.

METHODS

Data relevant to IVC placement and removal were retrieved from an electronic medical record search including records of adult horses from January 1 to December 31, 2022. Data retrieved from records included the role of the individual who prepared the site and placed the IVC, site of IVC placement, and type of IVC. The reason for removal of the IVC and presence or absence of detectable changes within the vein at the time of removal were documented in addition to clinical data, allowing for classification of each case. Data were reviewed retrospectively, and statistical analyses were performed using mixed-effects logistic regression models. Significance was set at P ≤ .05.

RESULTS

The overall rate of complications was 15.6%, and the most common type of complication was swelling of the vein. Students were involved in 87 of 455 IVC site preparations and placements, and there were no statistically significant differences in complication rates between IVC sites prepared or placed by veterinary students versus nonstudent personnel.

CLINICAL RELEVANCE

Veterinary personnel and clients may be hesitant to allow student involvement in IVC placement in horses, but these data suggest that student involvement does not increase the risk of IVC complications.

Persistent long-term habitat use by Florida manatees at Fort Pierce, Florida from 1997 to 2020

To survive cold winters, Florida manatees (Trichechus manatus latirostris) depend on artificial (i.e., power plants) and natural warm water sources such as springs and passive thermal basins. Passive thermal basins can provide critical habitat for manatees for short or extended periods of time. The Henry D. King Powerplant in Fort Pierce, Florida discharged warm water into Moore's Creek until it went offline in 1995. However, it is unknown to what degree manatees continue to occupy this area and how environmental factors influence their occurrence in the creek. To explore this, we examined the habitat use of Florida manatees in Moore's Creek after the shutdown from November 1997 to March 2020 from daily counts of manatees. In addition, we correlated local environmental data (ambient air, temperature, salinity) to assess if Moore's Creek had properties indicative of a passive thermal basin. Results indicated there was not an increase or decrease in habitat use over twenty years in the Creek. The consistent use of Moore's Creek over the study period suggests that this habitat possesses thermal and freshwater resources to support manatee occurrence long-term. These findings provide robust support for the importance of this habitat and passive thermal basins for Florida manatees.

Identifying delay in glymphatic clearance of labeled protons post-acute head trauma utilizing 3D ASL MRI (arterial spin labeling): a pilot study

This study correlated mild traumatic brain injury (mTBI) cognitive changes with ASL-MRI glymphatic clearance rates (GCRs) and recovery with GCR improvement. mTBI disrupts the blood brain barrier (BBB), reducing capillary mean transit time and GCRs. mTBI is clinically diagnosed utilizing history/examination findings with no physiologic biomarkers. 3D TGSE (turbo-gradient spin-echo) pulsed arterial spin-labeling 3T MRI with 7 long inversion times (TIs) assessed the signal clearance of labeled protons 2800-4000 ms postlabeling in bifrontal, bitemporal, and biparietal regions within 7 days of mTBI and once clinically cleared to resume activities. The Sport Concussion Assessment Tool Version 5 (SKAT5) and Brief Oculomotor/Vestibular Assessment evaluated injured athletes' cognitive function prior to MRIs. The pilot study demonstrated significant GCRs improvement (95% CI - 0.06 to - 0.03 acute phase; to CI-recovery CI 0.0772 to - 0.0497; P < 0.001 in frontal lobes; and parietal lobes (95% CI - 0.0584 to - 0.0251 acute; CI - 0.0727 to - 0.0392 recovery; P = 0.024) in 9 mTBI athletes (8 female, 1 male). Six age/activity-matched controls (4 females, 2 males) were also compared. mTBI disrupts the BBB, reducing GCR measured using the 3D ASL MRI technique. ASL MRI is a potential noninvasive biomarker of mTBI and subsequent recovery.

Error reporting in a large animal veterinary teaching hospital identifies medication errors occur most often in the prescribing phase of therapy

OBJECTIVE

To identify the rate at which medication errors occurred over a 2-year period in a large animal veterinary teaching hospital and describe the types of errors that occurred.

SAMPLE

226 medication errors over 6,155 large animal visits occurred during the study period. Multiple errors may have affected the same patient.

METHODS

Medication error reports from March 1, 2021, to March 31, 2023, were reviewed retrospectively and classified by species, type of drug, and month and day of the week the error occurred. Errors were categorized according to multiple previously developed systems to allow for comparison to other studies.

RESULTS

226 medication errors occurred over 6,155 patient visits in a 2-year period: 57.5% (130/226) were identified by a dedicated large animal pharmacist, and 64.2% (145/226) of errors were identified and corrected before reaching the patient. Prescription/medication order errors (58.4% [132/226]) occurred significantly more often than errors in medication preparation (21.7% [49/226]; P < .001) and administration (19.6%; P < .001). Antibiotics (48.7% [110/226]) and NSAIDs (17.7% [40/226]) were the drug classes most involved in errors.

CLINICAL RELEVANCE

Most medication errors in this study occurred in the ordering/prescribing phase. This is similar to reports in human medicine, where standardized medication error reporting strategies exist. Developing and applying similar strategies in veterinary medicine may improve patient safety and outcome.

Fecal Lactoferrin Predicts Primary Nonresponse to Biologic Agents in Inflammatory Bowel Disease

INTRODUCTION

Fecal lactoferrin (FL) is a timely and accurate marker of inflammation in ulcerative colitis (UC) and Crohn's disease (CD). The aim of this study was to verify whether FL can predict primary nonresponse (PNR) to biologic agents during induction.

METHODS

Retrospective outcome review in 27 patients (13 with CD and 14 with UC) tested for baseline FL and retested within a week after the first and second induction doses. Clinical/biochemical outcomes were evaluated at end of induction and at follow-up (3-24 months).

RESULTS

Compared to baseline, changes of the Harvey-Bradshaw (CD) and Partial Mayo Scoring (UC) indices at end of induction separated responders (18/27 or 67%) from nonresponders (9/17 or 33%). In all patients, the initial FL value at induction decreased compared to baseline, continuing to decrease after the following dose in clinical responders while bouncing back in the others. Models targeting the 2 consecutively decreased FL values or the second FL value compared to baseline or the second FL value compared to the first were able to accurately predict response at end of induction. Follow-up assessment confirmed clinical remission in initial responders (with FL values reduced on the average by 94 ± 10% compared to baseline).

CONCLUSIONS

In CD and UC patients during induction with biologic agents, early FL measurements accurately separate clinical responders from those experiencing PNR. The method described here offers several potential advantages over other strategies to assess and manage these patients.

A systems approach using Diversity Outbred mice distinguishes the cardiovascular effects and genetics of circulating GDF11 from those of its homolog, myostatin

Growth differentiation factor 11 (GDF11) is a member of the TGF-β protein family that has been implicated in the development of cardiac hypertrophy. While some studies have suggested that systemic GDF11 protects against cardiomyocyte enlargement and left ventricular wall thickening, there remains uncertainty about the true impact of GDF11 and whether its purported effects are actually attributable to its homolog myostatin. This study was conducted to resolve the statistical and genetic relationships among GDF11, myostatin, and cardiac hypertrophy in a mouse model of human genetics, the Diversity Outbred (DO) stock. In the DO population, serum GDF11 concentrations positively correlated with cardiomyocyte cross-sectional area, while circulating myostatin levels were negatively correlated with body weight, heart weight, and left ventricular wall thickness and mass. Genetic analyses revealed that serum GDF11 concentrations are modestly heritable (0.23) and identified a suggestive peak on murine chromosome 3 in close proximity to the gene Hey1, a transcriptional repressor. Bioinformatic analyses located putative binding sites for the HEY1 protein upstream of the Gdf11 gene in the mouse and human genomes. In contrast, serum myostatin concentrations were more heritable (0.57) than GDF11 concentrations, and mapping identified a significant locus near the gene FoxO1, which has binding motifs within the promoter regions of human and mouse myostatin genes. Together, these findings more precisely define the independent cardiovascular effects of GDF11 and myostatin, as well as their distinct regulatory pathways. Hey1 is a compelling candidate for the regulation of GDF11 and will be further evaluated in future studies.

Assessing health disparities in foods and beverages served in early care and education programs across Georgia

BACKGROUND

Obesity disproportionately impacts children who are Black and Hispanic, those who live in rural communities and those who have low income. Predisposition to obesity early in life is profoundly impacted by feeding habits during the preschool years. The early care and education (ECE) setting impacts children's health by providing daily meals.

OBJECTIVE

The goal of this study was to identify whether or not health disparities in foods and beverages served in ECE programs in Georgia exist based on socioeconomic, demographic and geographic variables.

METHODS

A random sample was drawn from 3054 ECE programs across the state of Georgia. The likelihood of serving specific foods and beverages in ECE programs in the previous day was measured. Percentages and frequencies, logistic regressions, Spearman's rho and Odds ratio tests determined outcomes.

RESULTS

A total of 974 surveys were returned. Data were stratified based on the income level of the participant families, race of enrolled children and geographic location of the ECE program. Disparities existed between programs based on race of enrolled children and geographic location. For example, although the odds of providing sweets increased by 0.6% as the percentage of Black children enrolled increased, the provision of healthier foods, such as the odds of providing fruits (P = .001), vegetables (P = .001) and protein (P = .001) also increased. However, after results were adjusted for covariates findings did not remain significant.

CONCLUSIONS

Future research focused on evaluating the foods and beverages provided in ECE programs and the relationship of how income, race and location are related may provide further understanding about the disproportionate childhood obesity rates in America.

Fecal lactoferrin accurately reflects mucosal inflammation in inflammatory bowel disease

BACKGROUND

Studies have demonstrated a potential role for fecal biomarkers such as fecal calprotectin (FC) and fecal lactoferrin (FL) in monitoring inflammatory bowel diseases (IBD) - Crohn’s disease (CD) and ulcerative colitis (UC). However, their correlation to endoscopic scores, disease severity and affected intestinal surface has not been extensively investigated.

AIM

To correlate FL, and for comparison white blood cell (WBC) and C-reactive protein (CRP), with endoscopic scores, disease extent and location in CD and UC.

METHODS

Retrospective analysis in 188 patients who had FL, CRP and WBC determined within 30 d of endoscopy. Disease location, disease extent (number of intestinal segments involved), disease severity (determined by endoscopic scores), timing of FL testing in relation to colonoscopy, as well as the use of effective fast acting medications (steroids and biologics) between colonoscopy and FL measurement, were recorded.

RESULTS

In 131 CD and 57 UC patients, both CRP and FL - but not WBC - distinguished disease severity (inactive, mild, moderate, severe). In patients receiving fast-acting (steroids or biologics) treatment in between FL and colonoscopy, FL showed a higher correlation to endoscopic scores when tested before vs after the procedure (r = 0.596, P < 0.001, vs r = 0.285, P = 0.15 for the Simple Endoscopic Score for CD; and r = 0.402, P = 0.01 vs r = 0.054 P = 0.84 for Disease Activity Index). Finally, FL was significantly correlated with the diseased mucosal surface (colon-ileocolon > small bowel) and the number of inflamed colon segments.

CONCLUSION

FL and CRP separated disease severity categories with FL showing lower discriminating P-values. FL showed a close correlation with the involved mucosal surface and with disease extent and was more closely correlated to endoscopy when determined before the procedure – this indicating that inflammatory activity changes associated with therapy might be rapidly reflected by FL levels. FL can accurately and timely characterize intestinal inflammation in IBD.

Beverage Policy Implementation by Child and Adult Care Food Program Participation and Program Type: A Statewide Examination in Georgia

BACKGROUND

The child care setting is a promising venue to establish healthy habits and promote obesity prevention. One major contributor to weight gain among young children is high intake of sugar-sweetened beverages (SSBs). Increasing access to water and other healthy beverages is a viable strategy to reduce childhood obesity. The goal of our study was to investigate implementation of the beverage policies in child care programs in Georgia (GA) by Child and Adult Care Food Program (CACFP) participation and program type.

METHODS

The study employed a cross-sectional design. A statewide survey was conducted using the GA Child Care Wellness Survey. A random sample of 3054 child care programs was obtained. Programs were stratified by six state regions to acquire a representative sample.

RESULTS

A total of 974 surveys were returned. Sixty-seven percent of the respondents were enrolled in CACFP. Programs participating in CACFP (96%) were less likely to serve SSBs (x²(2) = 15.309, p < 0.001), than non-CACFP programs (90%). CACFP programs were more likely to serve low-fat or fat-free milk to 2-5-year olds than non-CACFP programs (87% vs. 35%, p < 0.001). Family child care homes were significantly more likely to comply with serving only whole milk to 1 year olds (66%; p < 0.001) than other program types. All program types had low compliance with implementing water policies.

CONCLUSIONS

Study outcomes provide vital information on the implementation of beverage policies that can inform beverage policy training, with the ultimate goal of reducing obesity risk and promoting healthier diets among preschool children in GA.

Therapeutic efficacy in a hemophilia B model using a biosynthetic mRNA liver depot system

DNA-based gene therapy has considerable therapeutic potential, but the challenges associated with delivery continue to limit progress. Messenger RNA (mRNA) has the potential to provide for transient production of therapeutic proteins, without the need for nuclear delivery and without the risk of insertional mutagenesis. Here we describe the sustained delivery of therapeutic proteins in vivo in both rodents and non-human primates via nanoparticle-formulated mRNA. Nanoparticles formulated with lipids and lipid-like materials were developed for delivery of two separate mRNA transcripts encoding either human erythropoietin (hEPO) or factor IX (hFIX) protein. Dose-dependent protein production was observed for each mRNA construct. Upon delivery of hEPO mRNA in mice, serum EPO protein levels reached several orders of magnitude (>125 000-fold) over normal physiological values. Further, an increase in hematocrit (Hct) was established, demonstrating that the exogenous mRNA-derived protein maintained normal activity. The capacity of producing EPO in non-human primates via delivery of formulated mRNA was also demonstrated as elevated EPO protein levels were observed over a 72-h time course. Exemplifying the possible broad utility of mRNA drugs, therapeutically relevant amounts of human FIX (hFIX) protein were achieved upon a single intravenous dose of hFIX mRNA-loaded lipid nanoparticles in mice. In addition, therapeutic value was established within a hemophilia B (FIX knockout (KO)) mouse model by demonstrating a marked reduction in Hct loss following injury (incision) to FIX KO mice.

Comparing ascitic aspirate and tissue biopsy in the diagnosis of ovarian malignancy

The objective of this retrospective study was to assess the role of tissue biopsy in ovarian cancer where a diagnosis had been made from cytological assessment of ascites. A total of 63 women had been coded for ovarian carcinoma during the period; 48 had undergone cytological or histological investigation, of which six had undergone tissue biopsy, despite having had a cytological diagnosis. In all six cases (100%), the tissue biopsy concurred with the original diagnosis. We conclude that, where a clinically- and radiologically-correlated cytological diagnosis is made, the benefits of an invasive procedure to obtain tissue samples do not outweigh the risks to the patient.

Contrast radiography of the lower urinary tract in the management of obstructive urolithiasis in small ruminants and swine

Contrast radiographic visualization of the small ruminant and porcine lower urinary tract is an infrequently used modality for the evaluation and management of obstructive urolithiasis. The administration of contrast medium through a tube cystostomy catheter used to divert urine flow until the resolution of the obstruction may provide an easy method to evaluate the status of the urethral obstruction. Contrast fluoroscopy is utilized to monitor and visualize therapeutic flushing of the urethra. A review of 26 patients seen at the Veterinary Medical Teaching Hospital suggested that among the radiographic techniques used, positive contrast normograde cystourethrography through the tube cystostomy catheter allowed the best visualization of the lower urinary tract structures and enabled assessment of the resolution of the obstructive lesion.

Analysis of 1.9 Mb of contiguous sequence from chromosome 4 of Arabidopsis thaliana

The plant Arabidopsis thaliana (Arabidopsis) has become an important model species for the study of many aspects of plant biology. The relatively small size of the nuclear genome and the availability of extensive physical maps of the five chromosomes provide a feasible basis for initiating sequencing of the five chromosomes. The YAC (yeast artificial chromosome)-based physical map of chromosome 4 was used to construct a sequence-ready map of cosmid and BAC (bacterial artificial chromosome) clones covering a 1.9-megabase (Mb) contiguous region, and the sequence of this region is reported here. Analysis of the sequence revealed an average gene density of one gene every 4.8 kilobases (kb), and 54% of the predicted genes had significant similarity to known genes. Other interesting features were found, such as the sequence of a disease-resistance gene locus, the distribution of retroelements, the frequent occurrence of clustered gene families, and the sequence of several classes of genes not previously encountered in plants.

FCA, a gene controlling flowering time in Arabidopsis, encodes a protein containing RNA-binding domains

A strong promoter of the transition to flowering in Arabidopsis is encoded by FCA. FCA has been cloned and shown to encode a protein containing two RNA-binding domains and a WW protein interaction domain. This suggests that FCA functions in the posttranscriptional regulation of transcripts involved in the flowering process. The FCA transcript is alternatively spliced with only one form encoding the entire FCA protein. Plants carrying the FCA gene fused to the strong constitutive 35S promoter flowered earlier, and the ratio and abundance of the different FCA transcripts were altered. Thus, FCA appears to be a component of a posttranscriptional cascade involved in the control of flowering time.

Emergence of further serotypes of multiple drug-resistant Streptococcus pneumoniae in Queensland

We describe 27 cases of multiple drug-resistant pneumococcal infection in Queensland children (7 cases) and adults (20 cases), between February 1995 and October 1996. Seven patients had invasive disease. Serotypes were those commonly associated with paediatric infections and included types 19F (15 strains), 14 (6), 23F (4), 6A (1) and 19A (1). No rifampicin or vancomycin resistance was encountered. However, pneumococci fully resistant to cotrimoxazole, erythromycin and tetracycline were isolated from 25 of 27 cases (93%). Strains with high level resistance to penicillin and chloramphenicol were also recovered from 16 (59%) and 19 (70%) patients respectively. Twelve of 16 penicillin-resistant isolates showed intermediate resistance to ceftriaxone and two strains were fully resistant to this antibiotic. Clones of types 19F and 14 pneumococci, each with two distinctive resistance patterns, appear to be established in south-east Queensland.

Description of 31 YAC contigs spanning the majority of Arabidopsis thaliana chromosome 5

In order to generate a physical map of Arabidopsis thaliana chromosome 5, 142 molecular markers mapping chromosome 5 have been used in colony hybridization experiments with four Arabidopsis, ecotype Columbia, yeast artificial chromosome (YAC) libraries. This resulted in 634 YAC clones being anchored on chromosome 5. Southern blot analysis confirmed their positioning and provided data, which along with knowledge of the sizes of all the YAC clones, enabled the clones to be arranged into 31 contigs. Genetic mapping of markers located within 29 of these contigs on the Landsberg erecta/Columbia recombinant inbred lines allowed positioning of the contigs along the chromosome. A high proportion of the YAC clones were found to contain chimaeric inserts. The availability of this YAC contig map will accelerate chromosome-walking experiments, provide substrates for large-scale genomic sequencing projects and facilitate the mapping of new probes to this chromosome.

Blood from a turnip. Financial models in case management

The Baptist Health System has saved more than $5.4 million in a 3-year period as a result of its comprehensive case management program. The key to its success has been the pairing of financial cost data with key clinical information. Sharing this information with physicians and employing clinical experts as case managers has dramatically affected patient care across the continuum at the Baptist Health System. With more than 8 years of case management experience, the Baptist Health System's financial model has evolved into a concise method of measuring cost at the patient/day level. This cost information is analyzed by team members and used to improve patient care. At the core of this process is the case manager. By providing the case manager with the resources necessary, any healthcare institution can achieve significant financial savings and clinical process improvement.

Detailed description of four YAC contigs representing 17 Mb of chromosome 4 of Arabidopsis thaliana ecotype Columbia

The detailed arrangement of 563 YAC clones comprising four contigs covering approximately 17 Mbp of chromosome 4 is presented. YAC clones were positioned relative to each other and to markers by taking into account marker and end fragment hybridization data and the sizes of all YAC clones. This analysis made it possible to estimate physical distances between the majority of chromosome 4 markers. It also identified a relatively large number of YAC clones containing chimaeric inserts. The YAC contig map of the Columbia ecotype presents an important resource for map-based cloning experiments, rapid mapping of DNA sequences and large-scale genomic sequencing programs.

Physical map and organization of Arabidopsis thaliana chromosome 4

A physical map of Arabidopsis thaliana chromosome 4 was constructed in yeast artificial chromosome clones and used to analyze the organization of the chromosome. Mapping of the nucleolar organizing region and the centromere integrated the physical and cytogenetic maps. Detailed comparison of physical with genetic distances showed that the frequency of recombination varied substantially, with relative hot and cold spots occurring along the whole chromosome. Eight repeated DNA sequence families were found in a complex arrangement across the centromeric region and nowhere else on the chromosome.

Effect of ethanol on Kupffer cell function

Kupffer cells are resident macrophages in the liver and are important in both local and systemic immune responses. We evaluated the ability of Kupffer cells in vitro to respond to immune stimulation after both acute exposure to ethanol and after long-term ethanol consumption of ethanol. Triplets of female Wistar rats were fed a liquid diet containing 0, 12, or 36% ethanol isocalorically for 112 days. When killed, the Kupffer cells were isolated by collagenase perfusion and adhered to plastic 24-well plates. They were then stimulated with 10 micrograms/ml lipopolysaccharide for 4.5 hr. Synthesis of procoagulant activity (PCA) and tumor necrosis factor (TNF), expressions of macrophage response to immune stimuli, were measured by a one-step clotting assay and L929 cytotoxicity assay, respectively. Within each of the 10 triplets, PCA and TNF levels were normalized and expressed as a percentage of the zero ethanol isocaloric control rat. The high ethanol group had significantly lower baseline and stimulated PCA and TNF levels than the low ethanol group. For evaluation of the effect of acute exposure to ethanol, Kupffer cells were stimulated with lipopolysaccharide and varying concentrations (0-400 mg/dl) of ethanol. Cells were incubated for 4.5 hr and assayed for PCA and TNF activity. There was dose-dependent inhibition of PCA and TNF, with increasing concentrations of ethanol. These results indicate that whereas exposure to high levels of ethanol depresses Kupffer cell function, lower levels may be immunostimulatory.

Response to hepatitis B vaccination by liver transplant candidates

Liver transplantation (OLTx) is a procedure offered to individuals with advanced liver disease who are expected to live less than a year. Despite improvement in the care of transplant recipients, these patients are exposed to large volumes of blood and, as a result, are at risk to acquire hepatitis. Currently, the only vaccines available for the prevention of hepatitis are those that induce a response to HBsAg. In this study, 144 patients awaiting OLTx and 15 controls were vaccinated three times, once a month, intramuscularly in the deltoid using the Merck Hepatovax plasma-derived vaccine. This schedule was continued regardless of whether or not OLTx occurred before the series was completed. For the 15 controls, the response rate was 93% and for individuals with end-stage liver disease, it ranged from 44 to 54% (P less than 0.004). No difference in the percentage of those developing antibody was detected between groups based upon disease indication or whether the vaccination series was completed before or after OLTx. Of the following: WBC, lymphocytes (percent and number), CD3+ cells (percent and number), CD4+ cells (percent and number), CD8+ cells (percent and number), CD4+/CD8+ ratio, and B cells (percent and number), only the absolute WBC (P less than 0.05) distinguished between those who did and did not develop antibody.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of the relationship between moderate alcoholic beverage consumption and serum levels of estradiol in normal postmenopausal women: effects of alcohol consumption quantitation methods and sample size adequacy

The purpose of this study was to evaluate the detectability of an effect of moderate alcoholic beverage consumption on the biologic correlate of postmenopausal estradiol levels. Total weekly consumption and beverage-specific intake were assessed using both self-reported usual consumption information and prospective food record data. In terms of total weekly drinks, discrepancies were observed in 35 of the 101 women who reported alcohol use; no consistent pattern of overreporting/underreporting was seen. Although the two alcohol estimates were highly correlated, the relationship between estradiol levels and total weekly alcohol intake was found to be detectable when alcohol consumption based on the food record data was analyzed, but not when the self-report data were examined in a two-tailed hypothesis-testing situation. Evaluating the association between postmenopausal estradiol levels and the two estimates of alcohol intake in random samples of varying sample sizes generated from the mother population of 128 normal postmenopausal women confirmed the finding that the prospectively obtained alcohol data better predict the relationship. Based on the results of this study, it must be concluded that self-reported usual alcohol consumption data must be used with caution when examining an association between alcohol intake and a biologic effect.

Treatment of end-stage chronic obstructive pulmonary disease with double lung transplantation

Six patients with end-stage emphysema (age 44 +/- 2 years) underwent double lung transplantation (Tx) from June 1988 through May 1990. All suffered from severe inanition and required oxygen therapy. The ischemic time was 193 +/- 28 minutes. Post-Tx immune suppression was OKT3 (14 days), cyclosporine (trough levels of 150 +/- 25 ng/ml), azathioprine to keep WBC at 3,000 to 5,000/cu mm (1 to 3.0 mg/kg/day) and following OKT3, a tapering prednisone regimen. Two rejection episodes that occurred in two patients on post-Tx day 5 and 10 were treated with bolus doses of methylprednisolone. The mean hospital stay was 32 +/- 7 days (range, 20 to 69 days). Four patients required treatment of cytomegalovirus (CMV) infection: gastritis (+donor, +recipient) in one and CMV pneumonia in two (+donor, -recipient). A fourth (+donor, -recipient) had right-sided Candida empyema six weeks post-Tx, developed CMV and staphylococcal sepsis, and died 64 days post-Tx. One patient required pyloroplasty eight weeks post-Tx and one patient underwent tracheal suture line repair at eight weeks. During a follow-up of 81 patients months (range, 8 to 24 months), one patient had developed Epstein-Barr viral (EBV) induced lymphoproliferative disease in the lung and one patient had developed EBV lymphoma. Three patients are at work, one is continuing rehabilitation, and one is at home. Double lung Tx offers a definitive benefit to patients with emphysema; however, a prolonged postoperative course can be expected. Viral infections remain serious but treatable problems.

Infectious complications in four long-term recipients of the Jarvik-7 artificial heart

This article describes the infectious complications that occurred among four of the longest-term recipients of the Jarvik-7 artificial heart. Infection arising from the drive lines, with spread to the mediastinal periprosthetic space, was the major limiting factor in long-term use of the device in these patients. Periprosthetic infections were due to coagulase-negative staphylococci, Staphylococcus aureus, Pseudomonas aeruginosa, and other Pseudomonas species. Other infectious complications incurred by some of the patients included pneumonia, empyema, urinary tract infection, and intravascular line sepsis with Candida. Intensive antimicrobial therapy for prolonged periods seemed to suppress but not to eradicate infection and was accompanied by the appearance of multiresistant bacterial strains. Complications of antimicrobial therapy included diarrhea secondary to overgrowth with Clostridium difficile in two patients. Use of the current device for more than 30 days should be considered extraordinary and should be reserved for patients for whom no other form of life support is available.

Diarrhea associated with clindamycin and ampicillin therapy: preliminary results of a cooperative study

Patients treated with clindamycin were monitored for development of diarrhea and colitis in a cooperative study at three hospitals in Edmonton, Toronto, and Winnipeg, Canada. Ampicillin-treated patients were matched with clindamycin-treated patients. Diarrhea occurred in 62 (18%) of 343 clindamycin-treated patients compared with 16 (5%) of 315 ampicillin-treated patients (P less than 0.001). Among the three hospitals, the rate of diarrhea associated with clindamycin therapy ranged from 10% to 23% compared with 0 to 10% for ampicillin therapy. The only identified risk factor in the development of diarrhea was increased age; clindamycin-associated diarrhea occurred in 18 (46%) of 39 patients greater than or equal to 60 years old. No correlation was observed between the risk of diarrhea and the duration of treatment, total dosage of drug, route of administration, or type of underlying disease. Pseudomembranous colitis was diagnosed in seven (2%) of 343 patients treated with clindamycin and in one (0.3%) of 315 patients treated with ampicillin.