Reflect urine culture cancellation in the emergency department.

BACKGROUND: The yield of urine culture testing in the emergency department (ED) is often low, resulting in wasted laboratory and ED resources. Use of a reflex culture cancellation protocol, in which urine cultures are canceled when automated urinalysis results predict that culture yield will be low, may help to conserve these resources. STUDY OBJECTIVES: To identify a reflex culture cancellation protocol consisting of urinalysis-based criteria to limit urine culture over-utilization. METHODS: We studied patients aged 5 years and older whose ED evaluation included both an automated urinalysis and urine culture. Logistic regression models incorporating individual urinalysis components were used to predict culture growth. Receiver operating characteristic curves corresponding to each model were constructed, and the area under the curve was used to identify the model that best predicted positive urine culture growth. RESULTS: There were 1546 ED patients who met study inclusion criteria. Of these, 314 (20%) had positive urine cultures. Restriction of culture testing to samples with white blood cells > 10 per high-power field, positive nitrites, positive leukocyte esterase, or positive bacteria provided a sensitivity of 96.5% (95% confidence interval [CI] 93.6-98.1%) and specificity of 48.1% (95% CI 45.3-51.0%) for positive urine culture. Implementation of a reflex culture cancellation protocol based on these criteria would have eliminated 604 of 1546 cultures (39%); 11 of 314 positive cultures (3.5%) would have been missed. CONCLUSION: These results suggest that a substantial reduction in urine culture testing might be achievable by implementing this protocol. Confirmation of these findings in a validation cohort is necessary.

Selective, α2ß1 integrin-dependent secretion of il-6 by connective tissue mast cells.

Mast cells, critical mediators of inflammation and anaphylaxis, are poised as one of the first lines of defense against external assault. Mast cells release several classes of preformed and de novo synthesized mediators. Cross-linking of the high-affinity FcεRI results in degranulation and the release of preformed, proinflammatory mediators including histamine and serotonin. We previously demonstrated that mast cell activation by Listeria monocytogenes requires the α2ß1 integrin for rapid IL-6 secretion both in vivo and in vitro. However, the mechanism of IL-6 release is unknown. Here, we demonstrate the Listeria- and α2ß1 integrin-mediated mast cell release of preformed IL-6 without the concomitant release of histamine or ß-hexosaminidase. α2ß1 integrin-dependent mast cell activation and IL-6 release is calcium independent. In contrast, IgE cross-linking-mediated degranulation is calcium dependent and does not result in IL-6 release, demonstrating that distinct stimuli result in the release of specific mediator pools. These studies demonstrate that IL-6 is presynthesized and stored in connective tissue mast cells and can be released from mast cells in response to distinct, α2ß1 integrin-dependent stimulation, providing the host with a specific innate immune response without stimulating an allergic reaction.

Crosstalk between the alpha2beta1 integrin and c-met/HGF-R regulates innate immunity.

Data from several investigators suggest that the alpha2beta1 integrin, a receptor for collagens, laminins, decorin, E-cadherin, matrix metalloproteinase-1, endorepellin, and several viruses, is required for innate immunity and regulation of autoimmune/allergic disorders. We demonstrated that the innate immune response to Listeria monocytogenes required alpha2beta1 integrin expression by peritoneal mast cells (PMCs). Ligation of the alpha2beta1 integrin by C1q contained in immune complexes comprised of Listeria and antibody was required for PMC activation in vitro and in vivo. However, ligation of the alpha2beta1 integrin alone was insufficient to activate cytokine secretion, suggesting that one or more additional signals emanating from a coreceptor were required for PMC activation. Here, we demonstrate that C1q, but neither other complement proteins nor FcRgamma, is required for early innate immune response to Listeria. The binding of Listeria's Internalin B (InlB) to hepatocyte growth factor receptor (HGF-R)/c-met provides the costimulatory function required for PMC activation. Either HGF or Listeria InlB bound to c-met and either C1q or type I collagen bound to alpha2beta1 integrin stimulates PMC activation. These findings suggest that crosstalk between c-met and the alpha2beta1 integrin may contribute to mast-cell activation in autoimmune and inflammatory disorders.