Probiotic-Associated Central Venous Catheter Bloodstream Infections Lead to Increased Mortality in the ICU.

OBJECTIVES: To determine the occurrence rate and impact on patient outcomes of probiotic-associated central venous catheter bloodstream infections in the ICU. DESIGN: Retrospective observational cohort study. SETTING: The cohort was gathered using HCA Healthcare's data warehouse. PATIENTS: Adult patients with central venous catheters in the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Blood culture data were used to determine whether an infection had occurred with an organism contained in an administered probiotic. Eighty-six probiotic-associated central venous catheter bloodstream infections were identified among the 23,015 patient cohort who received probiotics (0.37%). The number needed to harm was 270. Zero infections were found in the cohort that did not receive probiotics. Patients who contracted a probiotic infection had increased mortality (odds ratio, 2.23; 1.30-3.71; p < 0.01). Powder formulations had an increased rate of infection compared with nonpowder formulations (0.76% vs 0.33%; odds ratio, 2.03; 1.05-3.95; p = 0.04). CONCLUSIONS: Probiotic administration is associated with a substantial rate of probiotic-associated bloodstream infection in ICU patients with central venous catheters in place. Probiotic-associated bloodstream infections result in significantly increased mortality. Powder formulations cause bloodstream infections more frequently than nonpowder formulations. In ICU patients with central venous catheters, the risks of probiotic-associated central venous catheter bloodstream infection and death outweigh any potential benefits of probiotic administration.

A retrospective analysis of bleeding risk with rivaroxaban, enoxaparin, and aspirin following total joint arthroplasty or revision.

STUDY OBJECTIVE: Rivaroxaban, enoxaparin, and aspirin are commonly used medications for thromboprophylaxis following lower extremity joint arthroplasty or revision. Previous research has demonstrated efficacy in preventing venous thromboembolism with each medication, however, the comparative risk of bleeding between them remains poorly understood. The aim of this study was to compare the odds of bleeding between rivaroxaban, enoxaparin, and aspirin following lower extremity joint arthroplasty or revision. DESIGN: This is a 3-year retrospective cohort study. SETTING: Data were obtained from 148 facilities across 55 states and territories of the United States. PATIENTS: This study included 85,938 patients who underwent hip or knee arthroplasty or revision. INTERVENTION: Patients received enoxaparin, rivaroxaban, or aspirin as monotherapy for thromboprophylaxis. MEASUREMENTS: The primary outcome was all bleeding, classified as major or minor bleeding, occurring in the 40 days following surgery. The secondary outcome was venous thromboembolism. MAIN RESULTS: Among 85,938 patients, 10,465 received rivaroxaban, 14,047 received enoxaparin, and 61,426 received aspirin. Bleeding occurred in 126 (1.20%) patients with rivaroxaban, 253 (1.80%) with enoxaparin, and 611 (0.99%) with aspirin. There was a significant increase in odds of bleeding in the enoxaparin compared to aspirin group odds ratio (OR) 1.18, 95% confidence interval (CI) 1.01-1.38, p = 0.042), and a trend toward increased odds of bleeding in rivaroxaban compared to aspirin group (OR 1.21, 95% CI 0.99-1.47, p = 0.058) and rivaroxaban compared to enoxaparin (OR 1.03, 95% CI 0.82-1.28, p = 0.827). Odds of venous thromboembolism were not statistically significant between all three study medications. CONCLUSIONS: Among rivaroxaban, enoxaparin, and aspirin used for thromboprophylaxis in knee and hip arthroplasty or revision, aspirin had significantly decreased odds of bleeding complications compared to enoxaparin. Although not statistically significant, aspirin also had a trend toward decreased odds of bleeding complications compared to rivaroxaban. Our study results suggest that aspirin is a safer alternative for use in postoperative thromboprophylaxis following lower extremity joint arthroplasty or revision.

A Retrospective Analysis Comparing Post-Operative Bleeding with Various Doses of Aspirin after Lower Extremity Joint Arthroplasty or Revision.

STUDY OBJECTIVE: Previous studies have shown that aspirin is noninferior to other anticoagulation therapies in preventing postoperative venous thromboembolism following lower extremity arthroplasty or revision; however, its optimal dosing for this indication is less clear. This study aims to compare the odds of bleeding between different aspirin dosages following lower extremity joint arthroplasty or revision. DESIGN: This is a 3-year retrospective multi-center cohort study across the United States and its territories. SETTING: This study included patients admitted for total hip or knee arthroplasty or revision and were treated with prophylactic aspirin. PATIENTS, INTERVENTION, MEASUREMENTS: Patients were assigned to groups based on a total daily aspirin dose of 81, 162, 325, or 650 mg. Data were analyzed for postsurgical bleeding and thromboembolism events occurring during the initial admission and up to 40 days following surgery. Other exploratory variables included type of surgery, hip or knee arthroplasty, length of stay, and patient demographic data. MAIN RESULTS: Among 53,848 patients receiving aspirin, 3922 received a total daily dose of 81 mg, 19,341 received a total daily dose of 162 mg, 5256 received a total daily dose of 325 mg, and 25,329 received a total daily dose of 650 mg. Bleeding occurred in 466 (0.87%) patients and venous thromboembolism (VTE) in 209 patients (0.39%). The odds of bleeding were compared using logistic regression, with the 650-mg dose as the reference group. None were statistically significant for bleeding between all studied aspirin doses: 81 mg (OR 1.12, 95% CI 0.83-1.51, p = 0.451), 162 mg (OR 0.83, 95% CI 0.67-1.03, p = 0.097), and 325 mg (OR 0.83, 95% CI 0.59-1.13, p = 0.245). The odds of VTE were also not statistically significant: 81 mg (OR 0.71, 95% CI 0.40-1.17, p = 0.181), 162 mg (OR 0.75 95% CI 0.54-1.03, p = 0.072), and 325 mg (OR 1.00, 95% CI 0.64-1.53, p = 0.989). CONCLUSIONS: There were no significant differences in the odds of bleeding or venous thromboembolism among all studied aspirin dosages in patients receiving aspirin for thromboprophylaxis following lower extremity joint arthroplasty or revision.

How Do COVID-19 Inpatients in the Denver Metropolitan Area Measure Up?

BACKGROUND: Inpatient data for COVID-19 (SARS-CoV-2) afflicted inpatients remain sparse. Data are needed to create accurate projections for resource consumption as the pandemic continues. Published reports of inpatient data have come from China, Italy, Singapore, and both the East and West coasts of the United States. OBJECTIVE: The objective is to present our inpatient experience with COVID-19. Design, Setting, and Participants. This is a retrospective study of 681 patients with laboratory-confirmed COVID-19 from six hospitals in the Denver metropolitan area admitted between February 18 and April 30, 2020. Clinical outcomes of patients discharged or expired by April 30, 2020, were analyzed. Main Outcomes. We compiled patient demographics, length of stay, number of patients transferred to or admitted to the ICU, ICU length of stay, mechanical ventilation requirements, and mortality rates. RESULTS: Of the 890 patients with laboratory-confirmed COVID-19, 681 had discharged and were included in this analysis. We observed 100% survival of the 0-18 age group (n = 2), 97% survival of the 19-30 age group, 95% survival of the 31-64 age group, 79% survival of the 65-84 age group, and 75% survival of the 85 and older age group. Our total inpatient mortality was 13% (91 patients), rising to 29% (59 patients) for those requiring ICU care. CONCLUSIONS: Compared to similar reports from other metropolitan areas, our analysis of discharged or expired COVID-19 patients from six major hospitals in the Denver metropolitan area revealed a lower mortality. This includes the subset of patients admitted to the ICU regardless of the need for intubation. A lower ICU length of stay was also observed.

Flash Pulmonary Edema: A Case and Review of Left Ventricular Non-Compaction Cardiomyopathy.

Description Left ventricular non-compaction cardiomyopathy is an uncommon type of cardiomyopathy caused by malformation of the myocardium during embryogenesis. This results in trabeculations within the ventricular wall that can affect the left and, less commonly, right ventricles. Presentation ranges from clinically asymptomatic to life-threatening arrhythmias. It is a rare and relatively unknown form of cardiomyopathy, though thought to be underdiagnosed. Prevalence is increasing due to improvements in imaging and awareness. Management is similar to that of other cardiomyopathies including angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers, beta-blockers, diuretics, automatic implantable cardioverter defibrillator placement and cardiac transplantation. We present a case of a 38-year-old, otherwise healthy, Indian male who presented with flash pulmonary edema and was found to have left ventricular non-compaction cardiomyopathy. This report includes a review of left ventricular non-compaction cardiomyopathy.

Correcting Hypokalemia in Hospitalized Patients Does Not Decrease Risk of Cardiac Arrhythmias.

BACKGROUND: It is currently standard practice to correct hypokalemia for the purpose of preventing cardiac arrhythmias in all hospitalized patients. However, the efficacy of this intervention has never been previously studied. OBJECTIVE: The objective of our study was to evaluate whether patients without acute coronary syndrome or history of arrhythmias were at increased risk of clinically significant cardiac arrhythmias if their potassium level was not corrected to ≥3.5 mEq/L. DESIGN: A retrospective case control study. SETTING: A community hospital. PARTICIPANTS: We enrolled selected patients who had episodes of hypokalemia during their hospital stay and were monitored on telemetry. Patients were split into groups based on success of replacing serum potassium to ≥3.5 mEq/L after 24 hours. MEASUREMENTS: The primary outcome was the development of an arrhythmia. Arrhythmias included supraventricular tachycardia, atrial fibrillation, atrial flutter, Mobitz type II second-degree or third-degree AV block, ventricular tachycardia, or ventricular fibrillation. A one-tailed Fisher's exact test and logistic regression were used for analysis. RESULTS: A total of 1338 hypokalemic patient days were recorded. Out of these days, 22 arrhythmia events (1.6% of patient days) were observed, 8 in the uncorrected group (1% patient days) and 14 in the corrected group (2.6% patient days). We found no statistically significant relationship between successfully correcting potassium to ≥3.5 mEq/L and number of arrhythmic events (p=0.037, OR = 2.38 (95% CI: 0.99, 6.03)). Logistic regression revealed that correction of potassium does not seem to be significantly related to arrhythmias (ß = 0.869, p=0.0517). CONCLUSIONS: In the acute care setting, we found that patients with hypokalemia whose potassium level did not correct to ≥3.5 mEq/L were not at increased odds of having an arrhythmia. This study suggests that the common practice of checking and replacing potassium is likely inconsequential.

Meningococcemia Masquerading as a Nonspecific Flu-Like Syndrome.

Neisseria meningitidis is a cause of bacterial meningitis and meningococcemia worldwide. Rarely, it causes invasive disease with significant lifelong sequela if survived. Early clinical recognition is key as meningococcemia is an easily treatable disease, yet mortality is 50% if it is left untreated. In this case review, we present a classic case of meningococcemia, with an atypical presentation.

Transdifferentiation of Human Circulating Monocytes Into Neuronal-Like Cells in 20 Days and Without Reprograming.

Despite progress, our understanding of psychiatric and neurological illnesses remains poor, at least in part due to the inability to access neurons directly from patients. Currently, there are in vitro models available but significant work remains, including the search for a less invasive, inexpensive and rapid method to obtain neuronal-like cells with the capacity to deliver reproducible results. Here, we present a new protocol to transdifferentiate human circulating monocytes into neuronal-like cells in 20 days and without the need for viral insertion or reprograming. We have thoroughly characterized these monocyte-derived-neuronal-like cells (MDNCs) through various approaches including immunofluorescence (IF), flow cytometry, qRT-PCR, single cell mRNA sequencing, electrophysiology and pharmacological techniques. These MDNCs resembled human neurons early in development, expressed a variety of neuroprogenitor and neuronal genes as well as several neuroprogenitor and neuronal proteins and also presented electrical activity. In addition, when these neuronal-like cells were exposed to either dopamine or colchicine, they responded similarly to neurons by retracting their neuronal arborizations. More importantly, MDNCs exhibited reproducible differentiation rates, arborizations and expression of dopamine 1 receptors (DR1) on separate sequential samples from the same individual. Differentiation efficiency measured by cell morphology was on average 11.9 ± 1.4% (mean, SEM, n = 38,819 cells from 15 donors). To provide context and help researchers decide which in vitro model of neuronal development is best suited to address their scientific question,we compared our results with those of other in vitro models currently available and exposed advantages and disadvantages of each paradigm.

Subcorneal Pustular Dermatosis: A Review of 30 Years of Progress.

Subcorneal pustular dermatosis (SPD), also known as Sneddon-Wilkinson disease, is a rare, benign yet relapsing pustular dermatosis. Its incidence and prevalence have not been well studied. It characteristically presents as hypopyon pustules on the trunk and intertriginous areas of the body. SPD is similar to two other disease entities. Both SPD-type immunoglobulin (Ig)-A pemphigus and annular pustular psoriasis clinically and histologically present similarly to SPD. Immunologic studies separate SPD-type IgA pemphigus from SPD and pustular psoriasis. However, there is still an unclear designation as to whether SPD is its own entity distinct from pustular psoriasis, as the once thought characteristic histologic picture of psoriasis does not hold true for pustular psoriasis. SPD has been reported to occur in association with several neoplastic, immunologic, and inflammatory conditions. Dapsone remains the first-line treatment for SPD, although dapsone-resistant cases have been increasingly reported. Other therapies have been used singly or as adjunctive therapy with success, such as corticosteroids, immunosuppressive agents, tumor necrosis factor inhibitors, and ultraviolet light therapy. This article provides a review of the last 30 years of available literature, with a focus on successful treatment options and a suggestion for reappraisal of the classification of SPD.

Unusual primary syphilis: Presentation of a likely case with a review of the stages of acquired syphilis, its differential diagnoses, management, and current recommendations.

Syphilis is an ancient disease that has re-emerged in the last decade. It is prevalent among men who have sex with men and has increased in incidence with certain ethnic groups. It usually presents as primary or secondary syphilis and can progress to tertiary syphilis if not treated. Primary syphilis will classically manifest as a single, painless ulcer with smooth, clean, and raised borders on the genitals or less often on the oral mucosa. Unusual primary syphilis cases have been reported and can be easily misdiagnosed with a resulting delay of treatment. Secondary syphilis is a systemic disease, wherein the treponemes have disseminated to various organ systems, typically presenting with characteristic mucocutaneous lesions. Tertiary syphilis has a higher rate of morbidity and mortality; as such, the aim of this article is to provide the readers with tools to recognize early syphilis and prevent its progression to late stages. In this review, we present a likely case of unusual primary syphilis mimicking herpes progenitalis as well as a compilation of all atypical cases of primary syphilis from 1973 to 2015. We will also review the differential diagnosis, management, and recommendations for each stage of syphilis.

Minimotif Miner 3.0: database expansion and significantly improved reduction of false-positive predictions from consensus sequences.

Minimotif Miner (MnM available at http://minimotifminer.org or http://mnm.engr.uconn.edu) is an online database for identifying new minimotifs in protein queries. Minimotifs are short contiguous peptide sequences that have a known function in at least one protein. Here we report the third release of the MnM database which has now grown 60-fold to approximately 300,000 minimotifs. Since short minimotifs are by their nature not very complex we also summarize a new set of false-positive filters and linear regression scoring that vastly enhance minimotif prediction accuracy on a test data set. This online database can be used to predict new functions in proteins and causes of disease.

A computational tool for identifying minimotifs in protein-protein interactions and improving the accuracy of minimotif predictions.

Protein-protein interactions are important to understanding cell functions; however, our theoretical understanding is limited. There is a general discontinuity between the well-accepted physical and chemical forces that drive protein-protein interactions and the large collections of identified protein-protein interactions in various databases. Minimotifs are short functional peptide sequences that provide a basis to bridge this gap in knowledge. However, there is no systematic way to study minimotifs in the context of protein-protein interactions or vice versa. Here we have engineered a set of algorithms that can be used to identify minimotifs in known protein-protein interactions and implemented this for use by scientists in Minimotif Miner. By globally testing these algorithms on verified data and on 100 individual proteins as test cases, we demonstrate the utility of these new computation tools. This tool also can be used to reduce false-positive predictions in the discovery of novel minimotifs. The statistical significance of these algorithms is demonstrated by an ROC analysis (P = 0.001).