Co-Infection by Lf-89-like and Em-90-like Genogroups of Pis-Cirickettsia Salmonis in Farmed Atlantic Salmon in Chile: Implications for Surveillance and Control of Piscirickettsiosis

Piscirickettsiosis (SRS), caused by Piscirickettsia salmonis, is the main infectious disease that affects farmed Atlantic salmon in Chile. Currently, the official surveillance and control plan for SRS in Chile is based only on the detection of P. salmonis, but neither of its genogroups (LF-89-like and EM-90-like) are included. Surveillance at the genogroup level is essential not only for defining and evaluating the vaccination strategy against SRS, but it is also of utmost importance for early diagnosis, clinical prognosis in the field, treatment, and control of the disease. The objectives of this study were to characterize the spatio-temporal distribution of P. salmonis genogroups using genogroup-specific real-time probe-based polymerase chain reaction (qPCR) to discriminate between LF-89-like and EM-90-like within and between seawater farms, individual fish, and tissues/organs during early infection in Atlantic salmon under field conditions. The spatio-temporal distribution of LF-89-like and EM-90-like was shown to be highly variable within and between seawater farms. P. salmonis infection was also proven to be caused by both genogroups at farm, fish, and tissue levels. Our study demonstrated for the first time a complex co-infection by P. salmonis LF-89-like and EM-90-like in Atlantic salmon. Liver nodules (moderate and severe) were strongly associated with EM-90-like infection, but this phenotype was not detected by infection with LF-89-like or co-infection of both genogroups. The detection rate of P. salmonis LF-89-like increased significantly between 2017 and 2021 and was the most prevalent genogroup in Chilean salmon aquaculture during this period. Lastly, a novel strategy to identify P. salmonis genogroups based on novel genogroup-specific qPCR for LF-89-like and EM-90-like genogroups is suggested.

Combination anti-coronavirus therapies based on nonlinear mathematical models

Using nonlinear mathematical models and experimental data from laboratory and clinical studies, we have designed new combination therapies against COVID-19.

Atlantic Salmon Pre-smolt Survivors of Renibacterium salmoninarum Infection Show Inhibited Cell-Mediated Adaptive Immune Response and a Higher Risk of Death During the Late Stage of Infection at Lower Water Temperatures

Bacterial kidney disease (BKD) is widespread in many areas of the world and can cause substantial economic losses for the salmon aquaculture industry. The objective of this study was to investigate the pathophysiological response and gene expression profiles related to the immune response at different water temperatures and to identify the best immunopathological biomarkers to define a phenotype of resistance to BKD. The abundance of msa transcripts of R. salmoninarum in the head kidney was significantly higher in infected fish at 11°C. R. salmoninarum induced significantly more severe kidney lesions, anemia and impaired renal function at 11°C. In addition, the expression pattern of the genes related to humoral and cell-mediated immune responses in infected fish at 11 and 15°C was very similar, although R. salmoninarum induced a significantly greater downregulation of the adaptive immune response genes at the lower water temperature. These results could be due to a suppressed host response directly related to the lowest water temperature and/or associated with a delayed host response related to the lowest water temperature. Although no significant differences in survival rate were observed, fish infected at the lowest temperature showed a higher probability of death and delayed the mortality curve during the late stage of infection (35 days after infection). Thirty-three immunopathological biomarkers were identified for potential use in the search for a resistance phenotype for BKD, and eight were genes related specifically to the adaptive cell-mediated immune response.

Hydrogeological features affecting spatial distribution of glyphosate and AMPA in groundwater and surface water in an agroecosystem. Córdoba, Argentina

The study area is located in the eastern slope of Las Peñas Mountain and its adjacent oriental fluvio-aeolian-plain. Agriculture is the main activity (soybean, maize, wheat, peanuts and alfalfa) with no-tillage farming and intensive use of agrochemicals (pesticides-fertilizers). Glyphosate (N-phosphono-methylglycine) is the most common used herbicide which suffers microbial biodegradation giving aminomethylphosphonic acid (AMPA), its main metabolite. The objective of this work is to evaluate hydrogeological features which influence the presence of glyphosate and AMPA in waters. In the study area, the main flow direction of surface and groundwater is NW-SE. The unsaturated zone thickness decreases in the same direction from 60 to 0 m, so groundwater surges in low areas in the eastern sector. From the total water samples collected, glyphosate was detected in 66% of surface water samples (0.2 to 167.4 μg/L), in 15.8% of the groundwater samples (1.3 to 2 μg/L) and in the harvested precipitation sample (0.2 μg/L). AMPA was found in 33% of surface water and 15.8% of groundwater. The herbicide detection was related to areas with the shallowest water table (< 4 m), low hydraulic conductivity in the aquifer (K = 1.5 m/d), low hydraulic gradient (i = 0.16%) and very low flow velocity (0.02 m/d). The most outstanding result is that the groundwater presents higher values in comparison with the surface water samples, which can be explained by the greater dilution capacity of streams. The detection of glyphosate and AMPA in the unconfined aquifer shows that the application for decades under the prevailing agricultural model exceeds the degradation potential of the soil and the unsaturated zone, causing groundwater contamination.

Gene expression associated with immune response in Atlantic salmon head-kidney vaccinated with inactivated whole-cell bacterin of Piscirickettsia salmonis and pathogenic isolates

Piscirickettsiosis is the most challenging disease present in the Chilean salmon industry. The aim of this study was to describe the expression of genes associated with immune response of Atlantic salmon intraperitoneally infected with LF-89 and EM-90 Piscirickettsia salmonis and vaccinated with inactivated whole-cell bacterin of P. salmonis. The fish infected with PS-LF-89 showed an anti-inflammatory response, whereas this finding was not observed in the PS-EM-90-infected fish and vaccinated fish. Fish infected with both P. salmonis isolates showed mhc1-mhc2, cd4-cd8b and igm overexpression, suggesting that P. salmonis promotes a T CD4⁺ and T CD8⁺ cell response and a humoral immune response. The vaccinated-fish exhibited mhc1, mhc2 and cd4 overexpression but a significant downregulation of cd8b and igm, suggesting that the vaccine supported the CD4⁺ T-cell response but did not induce an immune response mediated by CD8⁺ T cells or a humoral response. In conclusion, the expression pattern of genes related to the humoral and cell-mediated adaptive immune response showed upregulation in fish infected with P. salmonis and down-regulation in vaccinated fish. The results of this study contribute to our understanding of the immune response against P. salmonis and can be used in the optimization of SRS prevention and control measures.

Transcriptomic profile of two developmental stages of the cestode parasite Mesocestoides corti

Cestode development involves complex morphological and physiological changes. Here, we performed a differential expression analysis of gene transcripts between two developmental stages of the model cestode Mesocestoides corti. A RNA-seq-based approach was used to compare the transcriptomes of the tetrathyridium (larval, TT) and strobilated worm (ST) stages of the parasite. We found 19,053 transcripts, from which ∼45% were complete matches to genes previously annotated in the available M. corti draft genome sequence, ∼24% were considered novel isoforms, and ∼24% were considered potential novel transcripts. Stage-specific transcripts were found for both TTs (66) and STs (136), along with shared transcripts significantly overrepresented in one stage (342 in TTs, and 559 in STs). Differential expression and Gene Ontology term enrichment analyzes provided evidence of upregulation of different sets of transcripts associated with 'cytoskeleton', 'metabolism' and 'oxidation-reduction' processes in each stage, suggesting functional involvement of the corresponding genes with stage-specific features. Transcripts and processes enriched in the TT reflect typical larval processes that occur with the parasite in the intermediate host, such as asexual reproduction and budding, as well as active migration from the peritoneum to the liver and vice versa. In STs, transcripts associated with 'development', 'cell growth', and 'morphogenesis' were enriched, along with processes related to sexual reproduction, represented by the upregulation of numerous transcription factors, protein kinases, and histones. Overall, our results contributed to significantly increase the knowledge on the M. corti gene repertoire and expression profile in two developmental stages. Functional implications for the biology of larval and adult cestode parasites and for host-parasite interactions are discussed.

Transcriptomic profiles of post-smolt Atlantic salmon challenged with Piscirickettsia salmonis reveal a strategy to evade the adaptive immune response and modify cell-autonomous immunity

Piscirickettsiosis is the main bacterial disease affecting the Chilean salmon farming industry and is responsible for high economic losses. The development of effective strategies to control piscirickettsiosis has been limited in part by insufficient knowledge of the host response. The aim of this study was to use RNA sequencing to describe the transcriptional profiles of the responses of post-smolt Atlantic salmon infected with LF-89-like or EM-90-like Piscirickettsia salmonis. Enrichment and pathway analyses of the differentially expressed genes revealed several central signatures following infection, including positive regulation of DC-SIGN and TLR5 signalling, which converged at the NF-κB level to modulate the pro-inflammatory cytokine response, particularly in the PS-EM-90-infected fish. P. salmonis induced an IFN-inducible response (e.g., IRF-1 and GBP-1) but inhibited the humoral and cell-mediated immune responses. P. salmonis induced significant cytoskeletal reorganization but decreased lysosomal protease activity and caused the degradation of proteins associated with cellular stress. Infection with these isolates also delayed protein transport, antigen processing, vesicle trafficking and autophagy. Both P. salmonis isolates promoted cell survival and proliferation and inhibited apoptosis. Both groups of Trojan fish used similar pathways to modulate the immune response at 5 dpi, but the transcriptomic profiles in the head kidneys of the cohabitant fish infected with PS-LF-89 and PS-MS-90 were relatively different at day 35 post-infection of the Trojan fish, probably due to the different degree of pathogenicity of each isolate. Our study showed the most important biological mechanisms used by P. salmonis, regardless of the isolate, to evade the immune response, maintain the viability of host cells and increase intracellular replication and persistence at the infection site. These results improve the understanding of the mechanisms by which P. salmonis interacts with its host and may serve as a basis for the development of effective strategies for the control of piscirickettsiosis.

Comparison of gene expression in post-smolt Atlantic salmon challenged by LF-89-like and EM-90-like Piscirickettsia salmonis isolates reveals differences in the immune response associated with pathogenicity

Piscirickettsiosis is the main bacterial disease affecting the Chilean salmon farming industry and is responsible for high economic losses. The aim of this study was to describe and comparatively quantify the immune response of post-smolt Atlantic salmon infected by cohabitation with fish bearing LF-89-like and EM-90-like Piscirickettsia salmonis. The expression of 17 genes related to the immune response was studied in head kidney from cohabitant fish by RT-qPCR. Our results at the transcriptomic level suggest that P. salmonis is able to manipulate the kinetics of cytokine production in a way that might constitute a virulence mechanism that promotes intracellular bacterial replication in cells of Atlantic salmon. This strategy involves the creation of an ideal environment for the microorganism based on induction of the inflammatory and IFN-mediated response, modulation of Th1 polarization, reduced antigen processing and presentation, modulation of the evasion of the immune response mediated by CD8⁺ T cells and promotion of the CD4⁺ T-cell response during the late stage of infection as a mechanism to escape host defences. This response was significantly exacerbated in fish infected by PS-EM-90 compared with fish infected by PS-LF-89, a finding that is probably associated with the higher pathogenicity of PS-EM-90.

Comparative pathogenesis of piscirickettsiosis in Atlantic salmon (Salmo salar L.) post-smolt experimentally challenged with LF-89-like and EM-90-like Piscirickettsia salmonis isolates

Piscirickettsiosis (SRS) is the most prevalent bacterial disease in Chilean salmon aquaculture and is responsible for high economic losses. The aim of this study was to comparatively characterize the pathogenesis of SRS in post-smolt Atlantic salmon during the early and late stages of infection with Piscirickettsia salmonis LF-89-like (PS-LF-89) and EM-90-like (PS-EM-90) using a cohabitation challenge. The pathogenesis of cohabitant fish infected with the two isolates was relatively different due to cohabitant fish infected with PS-EM-90 showing higher cumulative mortality and shorter time until death compared with PS-LF-89 fish. PS-LF-89 caused an SRS infection characterized by kidney and liver lesions, whereas PS-EM-90 caused systemic and haemorrhagic disease characterized by kidney, liver, heart, brain, skeletal muscle and intestine lesions. Decreased serum concentration of total proteins and albumin as well as increased serum ALT, AST and creatinine levels in fish infected with both isolates confirmed that changes in liver and kidney function occurred during infection. Tissue damage, expressed as an SRS histoscore, showed a strong positive correlation with the bacterial load expressed as abundance of P. salmonis 16S rRNA transcripts in the livers and kidneys of fish affected with either isolate, but the correlation was significantly higher in fish infected with PS-EM-90. The results contribute to improving the understanding of the bacteria-host interaction.

The effect of different propolis harvest methods on its lead contents determined by ET AAS and UV-visS

Argentinean propolis is exported to different countries, specially Japan. The market demands propolis quality control according to international standards. The analytical determination of some metals, as lead in food, is very important for their high toxicity even in low concentrations and because of their harmful effects on health. Flavonoids, the main bioactive compounds of propolis, tend to chelate metals as lead, which becomes one of the main polluting agents of propolis. The lead found in propolis may come from the atmosphere or it may be incorporated in the harvest, extraction and processing methods. The aim of this work is to evaluate lead level on Argentinean propolis determined by electrothermal atomic absorption spectrometry (ET AAS) and UV-vis spectrophotometry (UV-visS) methods, as well as the effect of harvest methods on those contents. A randomized test with three different treatments of collection was made to evaluate the effect of harvest methods. These procedures were: separating wedges (traditional), netting plastic meshes and stamping out plastic meshes. By means of the analysis of variance technique for multiple comparisons (ANOVA) it was possible to conclude that there are significant differences between scraped and mesh methods (stamped out and mosquito netting meshes). The results obtained in the present test would allow us to conclude that mesh methods are more advisable than scraped ones in order to obtain innocuous and safe propolis with minor lead contents. A statistical comparison of lead determination by both, ET AAS and UV-visS methods, demonstrated that there is not a significant difference in the results achieved with the two analytical techniques employed.

Improved detection of liver metastases with contrast-enhanced wideband harmonic imaging: comparison with CT findings

OBJECTIVE

To evaluate the capability of contrast-enhanced wideband harmonic imaging (WHI) to detect liver metastases in comparison with fundamental B-mode US and postcontrast CT.

METHODS

We studied 27 patients with hepatic metastases from different malignancies with conventional B-mode sonography, WHI 3 min after injection of contrast agent (Levovist(R) 2.5 g, 300 mg/ml) and postcontrast helical CT (HCT). The number and location of the lesions and the smallest lesion for each patient were noted by two different observers and compared.

RESULTS

Both readers recorded an increase in the number of lesions in harmonic mode compared with conventional B-mode in all 27 patients with hepatic metastases with a mean increase in both observers from 9.3 lesions with B-mode to 18.8 lesions with WHI. The smallest lesions were detected with WHI when compared with conventional US and HCT (2 mm with WHI, 5 mm with B-mode and 5 mm with CT). WHI detected more lesions than conventional US or HCT.

CONCLUSIONS

Contrast-enhanced WHI seems superior to conventional US and HCT for the detection of hepatic metastases, specially for those nodules under 1 cm of diameter.

[Value of power Doppler ultrasonography with intravenous contrast medium (Levograf) in the diagnosis of acute cholecystitis]

The aim of this study was to evaluate the potential capacity of color and power Doppler sonography with intravenous contrast medium in the diagnosis of acute cholecystitis. We examined 18 patients with acute cholecystitis, 5 patients with chronic cholecystitis and a control group of 11 patients without gallbladder disease. In these patients, vascularization of the gallbladder wall was evaluated by color and power Doppler sonography before and after intravenous administration of contrast medium (Levograf). Vascularization was evaluated with a 3-point scale (grades 0, 1 and 3) according to the intensity and localization of signs of color. In the diagnosis of acute cholecystitis, basal examination with power Doppler had a sensitivity of 38.8%. After administration of intravenous contrast medium, sensitivity was 100%. In conclusion, the use of sonographic contrast media in the diagnosis of acute cholecystitis showed a sensitivity and specificity of 100%. This technique represents a viable diagnostic alternative to other complementary or imaging studies.

Activity of Crohn's disease assessed by colour Doppler ultrasound analysis of the affected loops

The aim of this study was to evaluate with colour Doppler ultrasound the vascular changes in the wall of the loops affected by Crohn's disease, and to establish whether these changes reflects clinical or biochemical activity of Crohn's disease. Seventy-nine patients with Crohn's disease (44 with active disease and 35 inactive patients) were studied with frequency- and amplitude-encoded duplex Doppler sonography. A group of 35 healthy volunteers were also included. The exam consisted of the search for colour signals in the walls of the loops affected by Crohn's disease, classifying the degree of vascularity with a simple scoring system into three groups: absence of colour signal (score of 0); weak or scattered colour signals (score of 1); and multiple colour signals or clear identification of vessels in the loops walls (score of 2). Doppler curves were obtained of the detected vessels with measurement of the resistive index (RI). There was a visible increase in the gut walls' vascularity in the active patients compared with those with inactive disease. The mean RI was statistically significantly lower in the gut wall vessels of the patients with active illness than that obtained in the inactive patients. Colour Doppler ultrasound is a useful tool in the assessment of activity in Crohn's disease.

Nocardia beijingensis sp. nov., a novel isolate from soil

The taxonomic status of a soil isolate, provisionally assigned to the genus Nocardia, was established following a polyphasic study. An almost complete sequence of the 16S rDNA of the strain was determined and aligned with available sequences for nocardiae and phylogenetic trees were inferred using four tree-making algorithms. The organism was associated consistently with the type strains of Nocardia brasiliensis and Nocardia farcinica in the neighbour-joining analysis, albeit with low bootstrap values. It was also found to have chemotaxonomic and morphological properties consistent with its assignment to the genus Nocardia. The organism was readily separated from representatives of other Nocardia species by a broad range of phenotypic properties. The name proposed for the novel species is Nocardia beijingensis sp. nov. The type strain is AS4.1521T (= IFO 16342T = JCM 10666T).

Hyperechoic focal bacterial nephritis: findings on contrast-enhanced Colour Doppler ultrasound

We report a case of atypical focal bacterial nephritis (lobar nephronia) simulating a renal mass on gray-scale ultrasound, describing the findings on Colour Doppler ultrasound before and after administration of a galactose-based ultrasound contrast agent.

Nocardia africana sp. nov., a new pathogen isolated from patients with pulmonary infections

Eight actinomycete strains, isolated from 8 out of 400 sputum samples examined, taken from patients with pulmonary diseases at the Chest Unit of Khartoum Teaching Hospital in the Sudan, were provisionally assigned to the genus Nocardia according to morphological criteria. These isolates were studied further in order to establish their taxonomic status. They were found to have morphological and chemical properties typical of nocardiae and formed a monophyletic clade in the 16S ribosomal DNA tree together with Nocardia vaccinii. The strains showed a unique pattern of phenotypic properties that distinguished them from representatives of recognized Nocardia species, including Nocardia vaccinii. The strains were considered to merit species status and were designated Nocardia africana sp. nov. The findings of the present study are consistent with the view that pulmonary nocardiosis may occur in a substantial proportion of patients who exhibit chronic lung diseases in African countries. It is important, therefore, that clinicians in such countries consider this condition, especially when patients with respiratory infections fail to respond to antitubercular therapy.

The Nocardia salmonicida clade, including descriptions of Nocardia cummidelens sp. nov., Nocardia fluminea sp. nov. and Nocardia soli sp. nov

Large numbers of strains selectively isolated from soil, water and deteriorating vulcanised natural rubber pipe rings were provisionally assigned to the genus Nocardia. Twenty-eight representative isolates were found to have chemical and morphological properties typical of nocardiae. These organisms formed a monophyletic clade in the 16S rDNA tree together with Nocardia salmonicida. Three of the strains, isolates S1, W30 and R89, were distinguished from one another and from representatives of the validly described species of Nocardia using genotypic and phenotypic data. These organisms were considered to merit species status and were named Nocardia cummidelens sp. nov., Nocardia fluminea sp. nov. and Nocardia soli sp. nov. respectively. Additional comparative studies are needed to resolve the finer taxonomic relationships of the remaining isolates assigned to the Nocardia salmonicida clade and to further unravel the extent of nocardial diversity in artificial and natural ecosystems.

Prospective evaluation of a clinical guideline recommending hospital length of stay in upper gastrointestinal tract hemorrhage

CONTEXT

Upper gastrointestinal tract hemorrhage (UGIH) is a common and potentially life-threatening disorder. Resource utilization can vary without adverse effect on patient outcome. Clinical practice guidelines are a potential solution to reduce variation in practice while improving patient outcomes.

OBJECTIVE

To validate prospectively the safety, acceptability, and impact of a clinical practice guideline defining the medically appropriate length of stay (LOS) for patients hospitalized with UGIH.

DESIGN

Prospective, controlled time-series study with an alternate-month design. Outcome surveyors and patients were blinded to study group allocation. GUIDELINE: A retrospectively validated scoring system using 4 independent variables: hemodynamics, time from bleeding, comorbidity, and esophagogastroduodenoscopy (EGD) findings to predict risk of adverse events. The quantitative risk for the low-risk subset was 0.6% (95% confidence interval [CI], 0.0%-2.0%) for subsequent complications and 0% (95% CI, 0.0%-0.9%) for life-threatening complications from this retrospective evaluation.

SETTING

A 1000-bed, not-for-profit, university-affiliated teaching hospital.

PATIENTS

Consecutive adult patients hospitalized for acute UGIH.

INTERVENTION

Concurrent feedback of guideline recommendation (same-day hospital discharge) to physicians caring for patients at low risk for complication. No risk information was provided during control months.

RESULTS

Seventy percent (209/299) of UGIH patients achieved low-risk status according to the guideline and were therefore potentially suitable for early discharge from the hospital. Providing real-time quantitative risk information (intervention group only) was associated with an increase in guideline compliance from 30% to 70% (P<.001) and a decrease in mean (SD) LOS from 4.6 (3.5) days to 2.9 (1.3) days (mean reduction of 1.7 days per patient; P<.001). No differences in complications, patient health status, or patient satisfaction were found when measured 1 month after discharge. An independent variable predicting decreased hospital LOS for low-risk UGIH patients was early EGD.

CONCLUSIONS

Implementation of the clinical practice guideline safely reduced hospital LOS for selected low-risk patients with acute UGIH. Further prospective validation in other settings is warranted.

Prevalence and incidence of gallstones in liver cirrhosis

BACKGROUND

Our aim was to assess the prevalence and incidence of gallstone disease in patients with liver cirrhosis and to identify risk factors for cholecystolithiasis.

METHODS

We studied a cohort of 313 patients with liver cirrhosis confirmed by histology and/or laparoscopy and 357 patients free of liver disease, who had been referred for ultrasonographic examination of the upper abdomen. Hepatobiliary ultrasonography was performed when liver cirrhosis was diagnosed and every 6 months thereafter. Risk factors for cholelithiasis (age, gender, diet, pregnancy, diabetes, family history of cholelithiasis, etiology of cirrhosis, decompensated disease) were assessed.

RESULTS

The overall prevalence of gallstones in cirrhotic patients was 23.3%. In controls, the overall prevalence of cholecystolithiasis was 16.8%. After a median follow-up period of 65 months, 30 patients developed gallstones. The calculated annual incidence was 3.4%.

CONCLUSIONS

Given that the prevalence of gallstone disease is higher in cirrhotics than in noncirrhotic patients, cirrhosis of the liver may be considered a risk factor for cholecystolithiasis.

Peripherally inserted central catheters in general medicine

OBJECTIVE

To report the success rate and complications associated with peripherally inserted central venous catheters (PICCs) and to compare costs between PICCs and centrally inserted central catheters.

MATERIAL AND METHODS

We undertook a cohort study of the first 1,000 patients referred to the PICC service of a large tertiary-care, university-affiliated, community hospital. The data were analyzed for insertion success rate, insertion mode, complication rate, successful completion, insertion costs, and applicability of PICCs in "high-risk" groups (transplant, human immunodeficiency virus-infected, intensive-care unit, and pediatric populations).

RESULTS

Of 1,000 consecutive PICC attempts, 963 (96.3%) were successful. Cutdown procedures were necessary in 141 insertions (14.6%). Complications of PICC placement occurred in 170 cases (17.7%). Among the major complications were a need for multiple attempts at insertion in 92 cases, malpositioning in 56, mechanical phlebitis in 37, clotting in 37, and bleeding in 5. The rate for completion of therapy was 68.9%. Frequent reasons for early termination were dislodgment (in 85 cases) and infection (in 72-37 confirmed and 35 potential cases). The rate of confirmed infection was 11 per 10,000 catheter days. The costs of PICC insertion were less than those associated with centrally inserted central catheters.

CONCLUSIONS

PICCs can satisfy long-term vascular needs and are safe in many patient populations. The infection rate did not depend on insertion mode, lumen number, or patient's immune status. Use of total parenteral nutrition was the most important risk factor in all patient subsets. Cost and safety considerations strongly favor PICCs as alternatives to other vascular access devices.

Upper gastrointestinal hemorrhage clinical--guideline determining the optimal hospital length of stay

PURPOSE

Physicians lack objective outcome data to define the medically appropriate length of stay (LOS) for patients hospitalized with acute upper gastrointestinal hemorrhage (UGIH), resulting in wide variations in resource utilization and quality of care. A clinical practice guideline with the ability to assign relative risk for adverse events is proposed.

METHODS

A comprehensive scoring system was derived from the literature by using four variables; hemodynamics, time from bleeding, comorbidity, and esophagoduodenoscopy findings. The discriminatory ability, potential safety, and impact on resource utilization of the clinical practice guideline was measured in a retrospective, observational study.

RESULTS

Seventy percent of UGIH patients (349 of 500) achieved low-risk status according to the guideline, and, were therefore potentially suitable for early discharge from the hospital. If low-risk patients were discharged based upon the guideline, mean (+/- SD) hospital LOS would have been decreased from 4.8 +/- 2.4 days to 2.7 +/- 1.4 days; mean reduction was 2.1 bed-days per patient (95% CI 1.8 to 2.3, P <0.001). LOS would have increased in 4% of cases. Adopting the guideline's recommendation of early discharge would have resulted in a 0.6% (95% CI 0.07 to 2.1) complication rate, with no worsening of quality of care, as judged by implicit review.

CONCLUSIONS

The proposed clinical practice guideline may safely reduce hospital LOS for selected low-risk patients with acute UGIH. Moreover, it also may reduce premature discharge of high-risk patients prone to life-threatening events.

Obstructive uropathy following aortofemoral graft surgery

Fifty patients who had undergone aorto-bifemoral bypass with a bifurcated Dacron graft for aortoiliac arteriosclerotic obliteration were examined with real-time sectorial ultrasound to screen for the presence of hydronephrosis. Hydronephrosis was detected in only 1 case. The low incidence of this complication in our cases may be due to the fact that all our patients were explored at least 1 year after surgery. Some may have developed hydronephrosis early, but this may have resolved spontaneously during the first year after the operation, thus remaining undiagnosed. Pathogenic mechanisms suggested for the development of hydronephrosis and therapeutic approaches are discussed. We conclude that pre- and postoperative ultrasound examination and follow-up beyond 1 year postoperatively seem to be fully justified in all patients who undergo aortoiliac or aortofemoral reconstructive surgery.

Transitional cell carcinomatous meningitis after M-VAC (methotrexate, vinblastine, doxorubicin, and cisplatin) chemotherapy

The M-VAC (methotrexate, vinblastine, doxorubicin, and cisplatin) regimen has been utilized at our two institutions to treat 17 patients with advanced stage transitional cell carcinoma of the bladder. We report 2 cases of carcinomatous meningitis resulting from metastatic transitional cell carcinoma which occurred in patients treated with M-VAC. Review of the literature suggests that our experience with central nervous system metastases is not unique, and that treatment of advanced stage transitional cell carcinoma of the bladder with M-VAC may enhance the incidence of meningeal metastases. Carcinomatous meningitis, although rare, is a rapidly fatal manifestation of metastatic transitional cell carcinoma if left untreated. However, prompt diagnosis and early aggressive therapy may result in palliation and stabilization of neurologic status. We review the pathophysiology, diagnosis, and treatment of transitional cell carcinomatous meningitis.

The principle of parsimony: Glasgow Coma Scale score predicts mortality as well as the APACHE II score for stroke patients

Although the development and use of severity-of-illness measures has gained widespread enthusiasm, uncertainty remains as to the optimal measure for stroke patients. The Health Care Financing Administration recently derived a severity-of-illness measure based on the APACHE II system to explain differences in Medicare mortality rates among hospitals treating stroke patients. We hypothesized that the Glasgow Coma Scale score provides prognostic information of accuracy comparable to that of the APACHE II score for stroke patients, yet is simpler and cheaper to abstract from the medical record. We therefore studied 246 patients hospitalized with stroke, including 49 oversampled mortalities. The Glasgow Coma Scale score was as accurate as the APACHE II score in predicting stroke mortality both before (r = -0.50 and r = 0.50, respectively) and after (r = -0.40 and r = 0.38, respectively) the oversampled mortalities were excluded. The APACHE II score required abstraction of 16 variables from the medical record compared with three for the Glasgow Coma Scale score and required more than three times the time to abstract from the medical record. Therefore, in the interest of parsimonious data collection, the Glasgow Coma Scale may be a preferable severity-of-illness measure for patients with stroke.

Isoprenoid fatty acids from marine sponges. Are sponges selective?

The burrowing sponges Anthosigmella varians and Spheciospongia vesparium were found to be rich in the isoprenoid phospholipid fatty acid 4,8,12-trimethyltridecanoic (5.2% and 23%, respectively, of the total fatty acid composition), while the burrowing sponge Chondrilla nucula and the demosponge Agelas dispar contained the acid 3,7,11,15-tetramethylhexadecanoic (13.8% and 8.6%, respectively, of the total phospholipid fatty acid composition). No other isoprenoid fatty acid was found, and the two acids described in this work did not occur concomitantly in the same sponge.

Identification of 5,9-hexadecadienoic acid in the marine sponge Chondrilla nucula

The fatty acid 5,9-hexadecadienoic was identified in the sponge Chondrilla nucula. This is the shortest fatty acid with the delta 5,9 unsaturation yet isolated from a marine sponge.