Metagenomic Evaluation of Bacteria from Voles

Voles (Arvicolinae, Rodentia) are known carriers of zoonotic bacteria such as Bartonella spp. and Francisella tularensis. However, apart from F. tularensis, the bacterial microbiome of voles has not previously been determined in Finland and rarely elsewhere. Therefore, we studied liver samples from 61 voles using 16S ribosomal RNA gene PCR analysis, followed by Sanger sequencing. Twenty-three of these samples were also studied with tag-encoded pyrosequencing. The samples originated from 21 field voles (Microtus agrestis), 37 tundra voles (Microtus oeconomus), and 3 bank voles (Myodes glareolus). With the more conventional 16S rDNA PCR analysis, 90 (33%) of the recovered 269 sequence types could be identified to genus level, including Bartonella, Francisella, Mycoplasma, Anaplasma, and Acinetobacter in 31, 15, 9, 9, and 9 sequences, respectively. Seventy-five (28%) matched best with sequences of uncultured bacteria, of which 40/75 could be classified to the order Clostridiales and, more specifically, to families Lachnospiraceae and Ruminococcaceae. Pyrosequencing from 23 samples revealed comparable and similar results: clinically relevant bacterial families such as Mycoplasmataceae, Bartonellaceae, Anaplasmataceae, and Francisellaceae were recognized. These analyses revealed significant bacterial diversity in vole livers, consisting of distinct and constant sequence patterns reflecting bacteria found in the intestinal gut, but including some known zoonotic pathogens as well. The molecular bacterial sequence types determined with the two different techniques shared major similarities and verified remarkable congruency between the methods.Peer reviewe

The Long-Term Economic Implications of Burn Injury for Burn Survivors

Introduction: The long-term economic implications of burn injury on patients and payors has not been well described. Burn injury can be costly due to prolonged intensive care, wound care, rehabilitation, psychological care, and reconstructive surgery that may be required well after the initial injury. We investigated index and post-acute payor and out-of-pocket (OOP) costs related to burn injury for in-patient care at 30 days, and up to 36 months post-discharge to understand the long-term economic implications for burn survivors. Methods: An observational cohort study was conducted using a commercial claims database from IBM Watson Health® Marketscan. Patients age ≤ 65 years with an ICD9/10 diagnosis code of burn injury between 2011 and 2016 were identified and tracked for a three-year period following the injury. This was used to determine the payor and OOP costs for burn care during the initial treatment and the three-year period following discharge through 2019. Results: We identified 11,815 patients who were admitted for in-patient care for a burn injury between 2011 to 2016. The inflation-adjusted index out-patient evaluation or emergency room costs ranged from $400 to$942 during the study period. For the index admission, length of stay (LOS) ranged from 5.4 days to 6.2 days, 30-day complication rates ranged from 15.6% to 21.7%, and 30-day readmission rates ranged from 7.2% to 9.6% within this timeframe. The payor costs for burn care ranged from $2,057 to$3,944 at 30 days, and $2,615 to$5,166 at 36-months post discharge, for each year from 2011 to 2016. The OOP costs ranged from $105 to$217 at 30 days, and $149 to$263 at 36-months post discharge, respectively, for each year from 2011 to 2016 (Table 1). Conclusions: Burn injury creates significant financial burdens associated with care in the following years which are highly impactful to both patients and providers. Further investigation of the long-term economic implications related to burn injury is an area of interest in burn care

Racial Disparities at Mixed-Race and Minority Hospitals: Treatment of African American Males With High-Grade Splenic Injuries

INTRODUCTION: Racial and socioeconomic disparities in health access and outcomes for many conditions are well known. However, for time-sensitive high-acuity diseases such as traumatic injuries, disparities in access and outcomes should be significantly diminished. Our primary objective was to characterize racial disparities across majority, mixed-race, and minority hospitals for African American (AA) versus white males with high-grade splenic injuries. METHODS: Data from the National Trauma Data Bank was utilized from 2007 to 2015. A total of 24 855 AA or white males with high-grade splenic injuries were included. Multilevel mixed effects regression analysis was used to evaluate disparities in outcomes and resource allocation. RESULTS: Mortality was significantly higher for AA males at mixed-race (odds ratio [OR] 1.6; 95% CI 1.3-2.1; P < .001) and minority (OR 2.1; 95% CI 1.5-3.0; P < .001) hospitals, but not at majority hospitals. At minority hospitals, AA males were significantly less likely to be admitted to the intensive care unit (OR 0.7; 95% CI 0.49-0.97; P = .04) and experienced a significantly longer time to surgery (IRR 1.5; P = .02). Minority hospitals were significantly more likely to have failures from angiographic embolization requiring operative intervention (OR 2.2; P = .009). At both types of nonmajority hospitals, AA males with penetrating injuries were more likely to be managed with angiography (mixed-race hospitals: OR 1.7; P = .046 vs minority hospitals: OR 1.6; P = .08). DISCUSSION: While multiple studies have shown that minority hospitals have increased mortality compared to majority hospitals, this study found this disparity only existed for AAs

Experimental Infection of Voles with Francisella tularensis Indicates Their Amplification Role in Tularemia Outbreaks

Peer reviewe

Voriconazole more likely than posaconazole increases plasma exposure to sublingual buprenorphine causing a risk of a clinically important interaction

This study aimed to determine possible effects of voriconazole and posaconazole on the pharmacokinetics and pharmacological effects of sublingual buprenorphine.We used a randomized, placebo-controlled crossover study design with 12 healthy male volunteers. Subjects were given a dose of 0.4 mg (0.6 mg during placebo phase) sublingual buprenorphine after a 5-day oral pretreatment with either (i) placebo, (ii) voriconazole 400 mg twice daily on the first day and 200 mg twice daily thereafter or (iii) posaconazole 400 mg twice daily. Plasma and urine concentrations of buprenorphine and its primary active metabolite norbuprenorphine were monitored over 18 h and pharmacological effects were measured.Compared to placebo, voriconazole increased the mean area under the plasma concentration-time curve (AUC(0-a)) of buprenorphine 1.80-fold (90 % confidence interval 1.45-2.24; P < 0.001), its peak concentration (C-max) 1.37-fold (P < 0.013) and half-life (t (A1/2) ) 1.37-fold (P < 0.001). Posaconazole increased the AUC0(0-a) of buprenorphine 1.25-fold (P < 0.001). Most of the plasma norbuprenorphine concentrations were below the limit of quantification (0.05 ng/ml). Voriconazole, unlike posaconazole, increased the urinary excretion of norbuprenorphine 1.58-fold (90 % confidence interval 1.18-2.12; P < 0.001) but there was no quantifiable parent buprenorphine in urine. Plasma buprenorphine concentrations correlated with the pharmacological effects, but the effects did not differ significantly between the phases.Voriconazole, and to a minor extent posaconazole, increase plasma exposure to sublingual buprenorphine, probably via inhibition of cytochrome P450 3 A and/or P-glycoprotein. Care should be exercised in the combined use of buprenorphine with triazole antimycotics, particularly with voriconazole, because their interaction can be of clinical importance

An essential role for complement C5a in the pathogenesis of septic cardiac dysfunction

Defective cardiac function during sepsis has been referred to as “cardiomyopathy of sepsis.” It is known that sepsis leads to intensive activation of the complement system. In the current study, cardiac function and cardiomyocyte contractility have been evaluated in rats after cecal ligation and puncture (CLP). Significant reductions in left ventricular pressures occurred in vivo and in cardiomyocyte contractility in vitro. These defects were prevented in CLP rats given blocking antibody to C5a. Both mRNA and protein for the C5a receptor (C5aR) were constitutively expressed on cardiomyocytes; both increased as a function of time after CLP. In vitro addition of recombinant rat C5a induced dramatic contractile dysfunction in both sham and CLP cardiomyocytes, but to a consistently greater degree in cells from CLP animals. These data suggest that CLP induces C5aR on cardiomyocytes and that in vivo generation of C5a causes C5a–C5aR interaction, causing dysfunction of cardiomyocytes, resulting in compromise of cardiac performance

Impact of bleeding-related complications and/or blood product transfusions on hospital costs in inpatient surgical patients

<p>Abstract</p> <p>Background</p> <p>Inadequate surgical hemostasis may lead to transfusion and/or other bleeding-related complications. This study examines the incidence and costs of bleeding-related complications and/or blood product transfusions occurring as a consequence of surgery in various inpatient surgical cohorts.</p> <p>Methods</p> <p>A retrospective analysis was conducted using Premier's Perspective™ hospital database. Patients who had an inpatient procedure within a specialty of interest (cardiac, vascular, non-cardiac thoracic, solid organ, general, reproductive organ, knee/hip replacement, or spinal surgery) during 2006-2007 were identified. For each specialty, the rate of bleeding-related complications (including bleeding event, intervention to control for bleeding, and blood product transfusions) was examined, and hospital costs and length of stay (LOS) were compared between surgeries with and without bleeding-related complications. Incremental costs and ratios of average total hospital costs for patients with bleeding-related complications vs. those without complications were estimated using ordinary least squares (OLS) regression, adjusting for demographics, hospital characteristics, and other baseline characteristics. Models using generalized estimating equations (GEE) were also used to measure the impact of bleeding-related complications on costs while accounting for the effects related to the clustering of patients receiving care from the same hospitals.</p> <p>Results</p> <p>A total of 103,829 cardiac, 216,199 vascular, 142,562 non-cardiac thoracic, 45,687 solid organ, 362,512 general, 384,132 reproductive organ, 246,815 knee/hip replacement, and 107,187 spinal surgeries were identified. Overall, the rate of bleeding-related complications was 29.9% and ranged from 7.5% to 47.4% for reproductive organ and cardiac, respectively. Overall, incremental LOS associated with bleeding-related complications or transfusions (unadjusted for covariates) was 6.0 days and ranged from 1.3 to 9.6 days for knee/hip replacement and non-cardiac thoracic, respectively. The incremental cost per hospitalization associated with bleeding-related complications and adjusted for covariates was highest for spinal surgery ($17,279) followed by vascular ($15,123), solid organ ($13,210), non-cardiac thoracic ($13,473), cardiac ($10,279), general ($4,354), knee/hip replacement ($3,005), and reproductive organ ($2,805).</p> <p>Conclusions</p> <p>This study characterizes the increased hospital LOS and cost associated with bleeding-related complications and/or transfusions occurring as a consequence of surgery, and supports implementation of blood-conservation strategies.</p

Diagnostic Performance of a Saliva Urea Nitrogen Dipstick to Detect Kidney Disease in Malawi

Introduction: Kidney disease (KD), including acute kidney injury, is common, severe and leads to significant mortality in the developing world. However, simple tools to facilitate diagnosis and guide treatment are lacking. We studied the diagnostic performance of saliva urea nitrogen (SUN) measured by dipstick to diagnose KD in a low-resource setting. Methods: Medical admissions to a tertiary hospital in Malawi had serum creatinine tested at presentation; SUN was measured using a dipstick. Patients with serum creatinine above normal range underwent serial measurements of SUN and blood urea nitrogen for up to 7 days. Hospital outcome was recorded in all patients. Results: A total of 742 patients were included (age 41 ± 17·3 years, 56.1% male); 146 (19.7%) had KD, including 114 (15.4%) with acute kidney injury. SUN >14 mg/dl had a sensitivity of 0.72 and a specificity of 0.87 to diagnose KD; specificity increased to 0.97 when SUN levels were combined with self-reported urine output. The diagnostic performance of SUN was comparable with the one of blood urea nitrogen (SUN area under curve, 0.82; 95% confidence interval, 0.78–0.87; blood urea nitrogen area under curve, 0.82; 95% confidence interval, 0.59–1.0). SUN >14 mg/dl on admission was an independent predictor of all-cause mortality (hazard ratio = 2.43 [95% confidence interval, 1.63–3.62]). Discussion: SUN measured by dipstick can be used to identify patients with KD in a low-resource setting. SUN is an independent predictor of mortality in this population