Identification of hemostatic markers that define the pre-DIC state: A multi-center observational study.

BACKGROUND: A limitation of diagnostic scoring systems for disseminated intravascular coagulation (DIC) is that once DIC is identified, it may be in a state of irreversible deterioration. OBJECTIVES: To identify hemostatic markers that can identify the pre-DIC state. METHODS: This was a multi-center observational study of 357 septic patients. The incidence of DIC was determined using the International Society on Thrombosis and Haemostasis (ISTH) DIC Score. Markers of interest include components of the DIC score: protein C (PC), antithrombin (AT), and citrullinated histones (H3Cit), which is a marker of NETosis. RESULTS: Out of 357 sepsis patients, 236 patients did not develop DIC (without-DIC), 79 patients had DIC on Day 1 (overt-DIC), and 42 patients developed DIC after Day 1 (pre-DIC). Compared to without-DIC patients, pre-DIC patients had decreased platelet count, increased international normalized ratio (INR), decreased PC and AT, and increased H3Cit. In contrast, D-dimer and fibrinogen levels did not differ between pre-DIC and without-DIC patients. Using receiver operating characteristics (ROC) analysis, we found that platelet count and INR in combination with PC and AT could discriminate pre-DIC from without-DIC. The area under the curve in the ROC analysis was 0.83 (95% confidence interval, 0.76 to 0.89). CONCLUSION: Our study suggests that platelets and INR in combination with PC and AT can identify the pre-DIC state in septic patients. In contrast, D-dimer increased and fibrinogen decreased in the late (ie, overt) stages of DIC. Our data also suggest that NETosis contributes to the onset of DIC in sepsis.

Blood loss from laboratory testing, anemia, and red blood cell transfusion in the intensive care unit: a retrospective study.

BACKGROUND: Anemia is common in critically ill patients and associated with adverse outcomes. Phlebotomy associated with laboratory testing is a potentially modifiable contributor. This study aims to 1) characterize the blood volume taken for laboratory testing, and 2) explore the effect of blood loss on red blood cell (RBC) transfusion and anemia in adult intensive care unit (ICU) patients. METHODS: Using a transfusion research database, we retrospectively reviewed consecutively admitted patients to four medical-surgical ICUs in Hamilton, Ontario, Canada. The primary outcome was estimated blood loss for laboratory testing during ICU admission. Secondary outcomes were hemoglobin (Hb) of 90 g/L or less and RBC transfusion. RESULTS: Among the 7273 patients included, the median blood volume per patient taken for laboratory testing during their ICU stay was 213 mL (interquartile range [IQR], 133-382 mL). On ICU admission, median Hb was 97 g/L (IQR, 82-116 g/L). An Hb of 90 g/L or less occurred in 67.0% of patients during their ICU stay. Median Hb on ICU discharge adjusted for RBC transfusion was 84 g/L (IQR, 58-105 g/L). RBC transfusion was administered to 47.5% of patients, who received a median of 3 units (IQR, 2-7 units). Cumulative blood loss due to laboratory testing from Day 2 to Day 7 of ICU admission was independently associated with RBC transfusion (hazard ratio, 2.28 for each 150-mL increment; 95% confidence interval, 2.02-2.59). CONCLUSIONS: Blood loss for laboratory testing is substantial in ICU patients and significantly associated with RBC transfusion. Strategies to reduce blood loss from laboratory testing represents an area for further investigation.

Devices to Reduce the Volume of Blood Taken for Laboratory Testing in ICU Patients: A Systematic Review.

BACKGROUND: Intensive care unit (ICU) patients are at high risk of anemia, which is associated with adverse clinical outcomes and death. Blood sampling for diagnostic testing is a potentially modifiable contributor to anemia. METHODS: We conducted a systematic review by searching MEDLINE and EMBASE from inception to October 5, 2017, for studies reporting the volume of blood taken for laboratory testing using blood sampling conservation devices compared to standard care or another intervention in adult ICU patients. RESULTS: We identified 8 eligible studies (n = 1204 patients) that used 2 types of devices: arterial access devices (n = 5) and reduced-volume blood collection tubes (n = 3). All studies reported a reduction in the volume of blood taken for laboratory testing with devices compared to standard practice (range 19%-80%). The studies were judged to have serious risk of bias, and due to heterogeneity, pooling for meta-analysis was not considered appropriate. CONCLUSIONS: Devices used to reduce the volume of blood taken for laboratory testing in ICU patients appear to be effective, although study heterogeneity limited our ability to calculate pooled estimates of efficacy for each device. Further assessment of clinical outcomes may establish clinical benefit with minimal negative consequences for hospitals and laboratories to facilitate the use of small-volume tubes.

Comparison of the source and prognostic utility of cfDNA in trauma and sepsis.

BACKGROUND: Circulating cell-free DNA (cfDNA) may contribute to the pathophysiology of post-injury inflammation and coagulation in trauma. However, the source and mechanism of release of cfDNA in trauma is not well understood. One potential source of cfDNA is from Neutrophil Extracellular Traps (NETs), released by activated neutrophils during the process of NETosis. The primary objective of our study was to determine if cfDNA has prognostic utility in trauma. The secondary objective of this study was to determine the source of cfDNA in trauma compared to sepsis. METHODS: We studied trauma patients from two prospective observational cohort studies: the DNA as a Prognostic Marker in ICU Patients (DYNAMICS) study and the Endotoxin in Polytrauma (ENPOLY) study. We also studied septic patients from the DYNAMICS study. Citrated plasma samples were collected longitudinally from the patients (days 1 to 7). The following molecules were measured in the plasma samples: cfDNA, protein C (PC), myeloperoxidase (MPO) (a marker of neutrophil activation), citrullinated Histone H3 (H3Cit, a marker of NETosis), cyclophilin A (a marker of necrosis), and caspase-cleaved K18 (a marker of apoptosis). RESULTS: A total of 77 trauma patients were included (n = 38 from DYNAMICS and n = 39 from ENPOLY). The median age was 49 years; 27.3% were female, and mortality was 16.9% at 28 days. Levels of cfDNA were elevated compared to healthy values but not significantly different between survivors and non-survivors. There was a positive correlation between MPO and cfDNA in septic patients (r = 0.424, p < 0.001). In contrast, there was no correlation between MPO and cfDNA in trauma patients (r = - 0.192, p = 0.115). Levels of H3Cit, a marker of NETosis, were significantly elevated in septic patients compared to trauma patients (p < 0.01) while apoptosis and necrosis markers did not differ between the two groups. CONCLUSION: Our studies suggest that the source and mechanism of release of cfDNA differ between trauma and sepsis patients. In sepsis, cfDNA is likely primarily released by activated neutrophils via the process of NETosis. In contrast, cfDNA in trauma appears to originate mainly from injured or necrotic cells. Although cfDNA is elevated in trauma and sepsis patients compared to healthy controls, cfDNA does not appear to have prognostic utility in trauma patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01355042 . Registered May 17, 2011.

Assessing the Quality of Evidence Presented at Annual General Meetings: A 5-Year Retrospective Study.

INTRODUCTION: Health care professionals rely on annual general meetings (AGMs) to obtain up-to-date information and practice guidelines relevant to their specialty. The majority of such information at meetings is presented through abstract sessions. However, the quality of the evidence presented during such abstract sessions is unclear. Standardized measures were applied to assess the quality of evidence of abstracts presented at the Canadian Society of Nephrology AGM over a 5-year period. METHODS: Two authors independently reviewed all CSN AGM abstracts presented from 2012 to 2016. Using a schema published in 2011 by the Oxford Centre for Evidence-Based Medicine (OCEBM), each abstract was subsequently ranked based on the quality of evidence. Schema categories ranged from level I, representing the highest evidence quality, to level V, representing the lowest. The number of authors and the authors' institution affiliations were also collected from the abstracts, where available, or if affiliations were unclear, an internet search of the author was performed. RESULTS: Six hundred forty-two articles were screened. In total, 70% (n = 450) met the inclusion criteria. When assessed, 15% of articles were level I (highest quality), 17% level II, 53% level III, 12% level IV, and 3% level V (lowest quality). A Jonckheere-Terpstra test demonstrated a significant trend of increasing quality of evidence (P < .05) and collaboration (P < .005) over the 5-year study period. There was a significant correlation between level of evidence and collaboration across years reviewed in the study, rs(98) = -0.226, P < .001. DISCUSSION: The results indicate a consistent increase in quality of evidence and collaborative submissions over time. To the authors' knowledge, this is the first assessment and analysis of AGM presentation quality within internal medicine and its subspecialties. Documenting and monitoring changes in the quality of evidence with a standardized framework may offer valuable insight pertaining to the medical field and the research community.

The real-world outcomes of treating Polycythemia Vera: Physician adherence to treatment guidelines.

Therapy in Polycythemia Vera (PV), a myeloproliferative neoplasm, focuses on reducing cardiovascular (CV) risk without increasing bleeding or hematological progression. However, the real-world practice of treating PV in North America is understudied. We performed a retrospective cohort study of newly diagnosed PV (JAK2V617F mutation positive) patients in Hamilton, Canada to fill this knowledge gap. Out of 108 patients included, (n = 45, 41.7%) patients did not receive therapy consistent with contemporary treatment guidelines. Multivariable analysis showed increased white blood cell count at diagnosis (HR, 1.09; 95% CI, 1.04-1.14; p < 0.001), older age (HR, 1.15; 95% CI, 1.07-1.23; p < 0.001) and diabetic history (HR, 3.71; 95% CI, 1.27-10.78; p = 0.012) associated with greater mortality. Not receiving pharmacological treatment according to guidelines was also independently associated with increased mortality (HR, 3.12; 95% CI, 1.13-8.65; p = 0.029).

The adult foraging assay (AFA) detects strain and food-deprivation effects in feeding-related traits of Drosophila melanogaster.

We introduce a high-resolution adult foraging assay (AFA) that relates pre- and post-ingestive walking behavior to individual instances of food consumption. We explore the utility of the AFA by taking advantage of established rover and sitter strains known to differ in a number of feeding-related traits. The AFA allows us to effectively distinguish locomotor behavior in Fed and Food-Deprived (FD) rover and sitter foragers. We found that rovers exhibit more exploratory behavior into the center of an arena containing sucrose drops compared to sitters who hug the edges of the arena and exhibit thigmotaxic behavior. Rovers also discover and ingest more sucrose drops than sitters. Sitters become more exploratory with increasing durations of food deprivation and the number of ingestion events also increases progressively with prolonged fasting for both strains. AFA results are matched by strain differences in sucrose responsiveness, starvation resistance, and lipid levels, suggesting that under the same feeding condition, rovers are more motivated to forage than sitters. These findings demonstrate the AFA's ability to effectively discriminate movement and food ingestion patterns of different strains and feeding treatments.

Coordination of Myeloid Differentiation with Reduced Cell Cycle Progression by PU.1 Induction of MicroRNAs Targeting Cell Cycle Regulators and Lipid Anabolism.

During macrophage development, myeloid progenitor cells undergo terminal differentiation coordinated with reduced cell cycle progression. Differentiation of macrophages from myeloid progenitors is accompanied by increased expression of the E26 transformation-specific transcription factor PU.1. Reduced PU.1 expression leads to increased proliferation and impaired differentiation of myeloid progenitor cells. It is not understood how PU.1 coordinates macrophage differentiation with reduced cell cycle progression. In this study, we utilized cultured PU.1-inducible myeloid cells to perform genome-wide chromatin immunoprecipitation sequencing (ChIP-seq) analysis coupled with gene expression analysis to determine targets of PU.1 that may be involved in regulating cell cycle progression. We found that genes encoding cell cycle regulators and enzymes involved in lipid anabolism were directly and inducibly bound by PU.1 although their steady-state mRNA transcript levels were reduced. Inhibition of lipid anabolism was sufficient to reduce cell cycle progression in these cells. Induction of PU.1 reduced expression of E2f1, an important activator of genes involved in cell cycle and lipid anabolism, indirectly through microRNA 223. Next-generation sequencing identified microRNAs validated as targeting cell cycle and lipid anabolism for downregulation. These results suggest that PU.1 coordinates cell cycle progression with differentiation through induction of microRNAs targeting cell cycle regulators and lipid anabolism.