Safety and Outcomes in 100 Consecutive Donation After Circulatory Death Liver Transplants Using a Protocol That Includes Thrombolytic Therapy.

Donation after circulatory death (DCD) liver transplantation (LT) reportedly yields inferior survival and increased complication rates compared with donation after brain death (DBD). We compare 100 consecutive DCD LT using a protocol that includes thrombolytic therapy (late DCD group) to an historical DCD group (early DCD group n = 38) and a cohort of DBD LT recipients (DBD group n = 435). Late DCD LT recipients had better 1- and 3-year graft survival rates than early DCD LT recipients (92% vs. 76.3%, p = 0.03 and 91.4% vs. 73.7%, p = 0.01). Late DCD graft survival rates were comparable to those of the DBD group (92% vs. 93.3%, p = 0.24 and 91.4% vs. 88.2%, p = 0.62). Re-transplantation occurred in 18.4% versus 1% for the early and late DCD groups, respectively (p = 0.001). Patient survival was similar in all three groups. Ischemic-type biliary lesions (ITBL) occurred in 5%, 3%, and 0.2% for early DCD, late DCD, and DBD groups, respectively, but unlike in the early DCD group, in the late DCD group ITBL was endoscopically managed and resolved in each case. Using a protocol that includes a thrombolytic therapy, DCD LT yielded patient and graft survival rates comparable to DBD LT.

Effect of contact precautions for MRSA on patient satisfaction scores.

Contact precautions may have an adverse effect on a patient's hospital experience and the delivery of care. This case-control study compared patient satisfaction scores between 70 patients isolated for MRSA and 139 non-isolated patients. Based on an adjusted analysis, there was no difference in patient satisfaction between the two groups. Age and educational status were found to affect patient satisfaction.

Excellent liver retransplantation outcomes in hepatitis C-infected recipients.

UNLABELLED: Survival outcomes for liver retransplantation (LRTx) after graft loss in HCV patients (HCV-LRTx) are generally considered inferior to those after non-HCV-LRTx. Between January 1, 2005 and June 30, 2011, our center performed 663 LTx, including 116 (17.5%) LRTx, 41 (35.3%) of which were more than 90 d after the LTx. Twenty-nine (70.7%) LRTx were performed in HCV antibody-positive individuals. We compared patient demographics, baseline characteristics and outcomes of our HCV-LRTx group with the HCV-LRTx patients from the most recent OPTN database covering the same time period. Our Kaplan-Meier HCV-LRTx one-, three-, and five-yr HCV-LRTx patient survival rates were 86.2%, 79.0%, and 72.4%, respectively compared with the OPTN one-, three-, and five-yr HCV-LRTx survival rates of 73.3%, 59.0%, and 51.3% respectively. Likewise, our graft survival rates were higher than OPTN rates at all time points studied. We performed a higher percentage of HCV-LRTx as simultaneous liver/kidney transplants (SLK) (37.9% vs. 21.8%) and recorded shorter warm (30 ± 4 vs. 45 ± 23 min) and cold ischemic times (5:44 ± 1:53 vs. 7:36 ± 3:12 h:min). CONCLUSION: In our experience, HCV-LRTx patient and graft survival rates are comparable to LTx survival rates and are higher than the rates described by OPTN.

False-positive Aspergillus galactomannan assay in solid organ transplant recipients with histoplasmosis.

Post-transplantation histoplasmosis may be acquired via inhalation, may result from endogenous reactivation, or may be derived from the allograft. The Histoplasma and Aspergillus enzyme-linked immunoassays are increasingly being relied upon for rapid diagnosis of fungal infections, especially in immunocompromised patients. We describe 4 cases of solid organ transplant recipients who had histoplasmosis and a falsely positive Aspergillus galactomannan (GM) obtained from the serum or bronchoalveolar lavage (BAL) fluid. We also report our experience, testing for Histoplasma antigen (Ag) in specimens positive for Aspergillus GM. From January 2007 through December 2010, of 2432 unique patients who had positive Aspergillus GM tests, 514 (21%) were tested for Histoplasma Ag, and 27 were found to be positive. Most specimens that tested positive for both Aspergillus and Histoplasma were obtained by BAL. False-positive tests for Aspergillus GM can occur in immunosuppressed patients who have histoplasmosis, and may obscure the correct diagnosis.

Pseudo-outbreak of Mycobacterium chelonae and Methylobacterium mesophilicum caused by contamination of an automated endoscopy washer.

OBJECTIVE: To evaluate an unusual number of rapidly growing acid-fast bacilli, later identified as Mycobacterium chelonae, and pink bacteria, later identified as Methylobacterium mesophilicum, from fungal cultures obtained by bronchoscopy. DESIGN: Outbreak investigation. SETTING: An academic medical center performing approximately 500 bronchoscopies and 4,000 gastrointestinal endoscopies in 1998. PATIENTS: Patients undergoing bronchoscopy July 21 to October 2, 1998. METHODS: The infection control department reviewed patient charts and bronchoscopy logs; obtained cultures of source water, faucets, washers, unopened glutaraldehyde, glutaraldehyde from the washers, and endoscopes; observed endoscope and bronchoscope cleaning and disinfecting procedures; reviewed glutaraldehyde monitoring records; and sent M. chelonae isolates for DNA fingerprinting. RESULTS: M. chelonae, M. mesophilicum, gram-negative bacteria, and various molds grew from endoscopes, automated washers, and glutaraldehyde from the washers but not from unopened glutaraldehyde. The endoscopy unit regularly monitored the pH of glutaraldehyde, and the logs contained no deficiencies. The above sources remained positive for the same organisms after a glutaraldehyde cleaning cycle of the automated washers. DNA finger-printing of the M. chelonae revealed that they were clonally related. CONCLUSIONS: The automated washers were contaminated with a biofilm that rendered them resistant to decontamination. The washers then contaminated the endoscopes and bronchoscopes they were used to disinfect. Our institution purchased new endoscopes and a new paracetic acid sterilization system.

Cryptococcosis in children with AIDS.

We compiled the clinical and immunologic features of Cryptococcus neoformans infections in human immunodeficiency virus (HIV)-infected children from 1985 to 1996 in a retrospective case series. Thirty cases of cryptococcosis were identified. These children had a median age of 9.8 years, a median CD4+ cell count of 54/microL at the time of diagnosis, and either a culture positive for C. neoformans or cryptococcal antigen in serum or cerebrospinal fluid. Sixty-three percent of the cases occurred in children vertically infected with HIV and in children between 6 and 12 years of age. The clinical and laboratory characteristics of this pediatric cohort were similar to those of adults with AIDS and cryptococcosis. On the basis of a subset of the cases, a 10-year point prevalence of cryptococcosis among children with AIDS of approximately 1% was estimated.

A comprehensive educational approach to improving patient isolation practice.

OBJECTIVE: To describe a workable plan for the successful education of a large, diverse group of healthcare workers in a university hospital setting. DESIGN: A prospective, nonrandomized study of compliance with infection control isolation practice following various educational interventions. SETTING: 300-bed tertiary-care, academic medical center with out-patient clinics. PARTICIPANTS: Hospital employees and contract workers. INTERVENTIONS: The infection control department introduced a plan to implement the Centers for Disease Control and Prevention's new isolation guidelines. A comprehensive proposal was presented to administration. It included a time line for institution and a comprehensive educational and performance-improvement plan, including standard lectures and a video that explained Standard and Transmission-Based Precautions. Follow-up consisted of customized in-services and one-on-one continued education tailored to the individual units. RESULTS: Compliance with isolation procedure after standardized lectures and video alone was poor. Compliance improved after institution of smaller, more intensive in-services tailored to individual departments and given during all shifts. CONCLUSIONS: Intensive, individualized education is the key to compliance. This requires sufficient infection control staffing and administrative support.

Analysis of human monoclonal antibodies elicited by vaccination with a Cryptococcus neoformans glucuronoxylomannan capsular polysaccharide vaccine.

The Cryptococcus neoformans capsular polysaccharide glucuronoxylomannan (GXM) has been conjugated to tetanus toxoid (GXM-TT) as an investigational vaccine. GXM-TT elicits antibodies that are protective in C. neoformans-infected mice. In an effort to characterize the fine specificity and molecular structure of human GXM-TT-elicited antibodies, we generated two GXM monoclonal antibodies (MAbs) from peripheral blood lymphocytes of a volunteer GXM-TT recipient and studied serum GXM antibody idiotype expression in 10 additional vaccinees. The MAbs, 2E9 and 3B6, are the immunoglobulin M(lambda) isotype and bind capsular polysaccharides of C. neoformans serotypes other than the serotype A that was used for immunization. Neither antibody competes with murine GXM MAbs for antigen binding, suggesting that the human MAbs recognize a different epitope. The B-cell superantigen staphylococcal protein A binds both MAbs, and human immunodeficiency virus gp120 binds 2E9. MAb nucleic acid sequence analysis revealed that both antibodies use an identical V lambda 1a-J lambda genetic element with different, somatically mutated, members of the VH3 gene family and different DH and JH gene elements. The gene elements used by both MAbs occur in fetal B-lymphocyte repertoires, autoantibodies, and other polysaccharide antibodies. Post-GXM-TT vaccination GXM antibodies from 10 additional vaccinees expressed a shared idiotype defined by rabbit antiserum raised against MAb 2E9. Our data suggest that the human GXM antibody response is restricted and raise questions regarding the importance of specific variable-region elements and superantigens in the generation of human antibody responses to encapsulated pathogens.

Systemic inflammatory disorder related to fibrous breast capsules after silicone implant removal.

Silicone breast implants have been associated with connective-tissue inflammatory syndromes such as systemic sclerosis, and as with other artificial breast prostheses, fibrous capsules tend to form around the implants. The capsular tissue is generally considered inert and typically is left in situ when the prostheses are explanted. We report a patient who formed symptomatic bilateral submammary cysts associated with pain, swelling, arthralgia, fever, axillary lymphadenopathy, accelerated erythrocyte sedimentation rate, and antinuclear antibody following removal of intact silicone breast implants without capsulectomy. Clinical improvement followed removal of the capsules, which histologically displayed fragments of silicone, fibrous tissue, and inflammatory cells. Our experience suggests that when silicone breast implants are thought to be the cause of a clinical inflammatory syndrome characterized by mammary pain, swelling, arthralgia, or serologic abnormalities, consideration should be given to removing the capsules entirely so that the chance of a perpetuating reaction will be reduced.

Albino spatial vision as an instance of arrested visual development.

Adult albinos and human infants share a number of common visual characteristics: both have low grating acuity, both lack a foveal pit (foveal hypoplasia), and both have much lower central cone densities than in the normal adult. We have explored the consequences of these characteristics by measuring both spatial and temporal contrast sensitivity in the central retina and by comparing central and peripheral grating and vernier acuities in two young adult albino subjects. To compensate for nystagmus, horizontally oriented patterns were employed. Both subjects had normal flicker sensitivities, but their central grating and vernier acuities were approximately five times worse than normal. At 10.0 degrees in the inferior visual field, however, vernier and grating acuities were normal for both subjects. Finally, the ratio of grating to vernier acuity in albino central vision fell within the normal foveal range, suggesting that albino central vision does not resemble the adult periphery. These results are consistent with the hypothesis that spatial processing deficiencies in albino central vision are a direct consequence of the increased spacing of their central cones. Our data are comparable to available psychophysical results obtained from infants of approx. 10 months of age, thus suggesting that the albino visual system may represent a case of arrested development.