Effects of a Video on Organ Donation Consent Among Primary Care Patients: A Randomized Controlled Trial

BACKGROUND

Low organ donation rates remain a major barrier to organ transplantation.

OBJECTIVE

We aimed to determine the effect of a video and patient cueing on organ donation consent among patients meeting with their primary care provider.

DESIGN

This was a randomized controlled trial between February 2013 and May 2014.

SETTING

The waiting rooms of 18 primary care clinics of a medical system in Cuyahoga County, Ohio.

PATIENTS

The study included 915 patients over 15.5 years of age who had not previously consented to organ donation.

INTERVENTIONS

Just prior to their clinical encounter, intervention patients (n?=?456) watched a 5-minute organ donation video on iPads and then choose a question regarding organ donation to ask their provider. Control patients (n?=?459) visited their provider per usual routine.

MAIN MEASURES

The primary outcome was the proportion of patients who consented for organ donation. Secondary outcomes included the proportion of patients who discussed organ donation with their provider and the proportion who were satisfied with the time spent with their provider during the clinical encounter.

KEY RESULTS

Intervention patients were more likely than control patients to consent to donate organs (22 % vs. 15 %, OR 1.50, 95%CI 1.10–2.13). Intervention patients were also more likely to have donation discussions with their provider (77 % vs. 18 %, OR 15.1, 95%CI 11.1–20.6). Intervention and control patients were similarly satisfied with the time they spent with their provider (83 % vs. 86 %, OR 0.87, 95%CI 0.61–1.25).

LIMITATION

How the observed increases in organ donation consent might translate into a greater organ supply is unclear.

CONCLUSION

Watching a brief video regarding organ donation and being cued to ask a primary care provider a question about donation resulted in more organ donation discussions and an increase in organ donation consent. Satisfaction with the time spent during the clinical encounter was not affected.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01697137

     

Colonic tuberculosis mimicking Crohn's disease: case report

Background

Intestinal tuberculosis is a rare disease in western countries, affecting mainly immigrants and immunocompromised patients. Intestinal tuberculosis is a diagnostic challenge, especially when active pulmonary infection is absent. It may mimic many other abdominal diseases.

Case presentation

Here, we report a case of isolated colonic tuberculosis where the initial diagnostic workup was suggestive of Crohn's disease. Computed tomography findings however, raised the possibility of colonic tuberculosis and the detection of acid-fast bacilli in biopsy specimens confirmed the diagnosis.

Conclusions

In conclusion, this case highlights the need for awareness of intestinal tuberculosis in the differential diagnosis of chronic intestinal disease

     

Role of neutrophil to lymphocyte and monocyte to lymphocyte ratios in the diagnosis of bacterial infection in patients with fever

Purpose

To study the role of the neutrophil:lymphocyte ratio (NLR) and monocyte:lymphocyte ratio (MLR) in discriminating between different patient groups hospitalized for fever due to infection and those without infection.

Methods

For 299 patients admitted to hospital for fever with unknown cause, a number of characteristics including NLR and MLR were recorded. These characteristics were used in a multiple multinomial regression analysis to estimate the probability of a final diagnostic group of bacterial, viral, clinically confirmed, or no infection.

Results

Both NLR and MLR significantly predicted final diagnostic group. Being highly correlated, however, both variables could not be retained in the same model. Both variables also interacted significantly with duration of fever. Generally, higher values of NLR and MLR indicated larger probabilities for bacterial infection and low probabilities for viral infection. Patients with septicemia had significantly higher NLR compared to patients with other bacterial infections with fever for less than one week. White blood cell counts, neutrophil counts, and C-reactive proteins did not differ significantly between septicemia and the other bacterial infection groups.

Conclusions

NLR is a more useful diagnostic tool to identify patients with septicemia than other more commonly used diagnostic blood tests. NLR and MLR may be useful in the diagnosis of bacterial infection among patients hospitalized for fever.

     

Detection of viable but non-culturable <Emphasis Type="Italic">Pseudomonas aeruginosa</Emphasis> in cystic fibrosis by qPCR: a validation study

Background

Routine culture-based diagnosis of Pseudomonas aeruginosa lung infection in Cystic Fibrosis (CF) patients can be hampered by the phenotypic variability of the microorganism, including its transition to a Viable But Non-Culturable (VBNC) state. The aim of this study was to validate an ecfX-targeting qPCR protocol developed to detect all viable P. aeruginosa bacteria and to identify VBNC forms in CF sputum samples.

Methods

The study involved 115 P. aeruginosa strains of different origins and 10 non-P. aeruginosa strains and 88 CF sputum samples, 41 Culture-Positive (CP) and 47 Culture-Negative (CN). Spiking assays were performed using scalar dilutions of a mixture of live and dead P. aeruginosa ATCC 9027 and a pooled P. aeruginosa-free sputum batch. Total DNA from sputum samples was extracted by a commercial kit, whereas a crude extract was obtained from the broth cultures. Extracellular DNA (eDNA) interference was evaluated by comparing the qPCR counts obtained from DNase-treated and untreated aliquots of the same samples. The statistical significance of the results was assessed by the Wilcoxon test and Student’s t test.

Results

The newly-developed qPCR protocol identified 96.6% of the P. aeruginosa isolates; no amplification was obtained with strains belonging to different species. Spiking assays supported protocol reliability, since counts always matched the amount of live bacteria, thus excluding the interference of dead cells and eDNA. The protocol sensitivity threshold was 70 cells/ml of the original sample. Moreover, qPCR detected P. aeruginosa in 9/47 CN samples and showed higher bacterial counts compared with the culture method in 10/41 CP samples.

Conclusions

Our findings demonstrate the reliability of the newly-developed qPCR protocol and further highlight the need for harnessing a non-culture approach to achieve an accurate microbiological diagnosis of P. aeruginosa CF lung infection and a greater understanding of its evolution.

     

Serotype-specific mortality from invasive <Emphasis Type="Italic">Streptococcus pneumoniae</Emphasis>disease revisited

Background

Invasive infection with Streptococcus pneumoniae (pneumococci) causes significant morbidity and mortality. Case series and experimental data have shown that the capsular serotype is involved in the pathogenesis and a determinant of disease outcome.

Methods

Retrospective review of 464 cases of invasive disease among adults diagnosed between 1990 and 2001. Multivariate Cox proportional hazard analysis.

Results

After adjustment for other markers of disease severity, we found that infection with serotype 3 was associated with an increased relative risk (RR) of death of 2.54 (95% confidence interval (CI): 1.22–5.27), whereas infection with serotype 1 was associated with a decreased risk of death (RR 0.23 (95% CI, 0.06–0.97)). Additionally, older age, relative leucopenia and relative hypothermia were independent predictors of mortality.

Conclusion

Our study shows that capsular serotypes independently influenced the outcome from invasive pneumococcal disease. The limitations of the current polysaccharide pneumococcal vaccine warrant the development of alternative vaccines. We suggest that the virulence of pneumococcal serotypes should be considered in the design of novel vaccines.

     

Hepatitis C Virus Treatment in Non-Liver Organ Transplantation Programs

Purpose of Review

Solid organ transplantation is the treatment of choice for many patients with end organ damage. Hepatitis C (HCV) infection is prevalent among solid organ candidates and recipients and remains to be a significant source of morbidity and mortality for this population. New therapies are currently available for this population. In the following review, we will outline HCV treatment strategies in non-liver transplantation candidates and recipients.

Recent Findings

Direct-acting antivirals (DAAs) have drastically modified the treatment landscape of HCV. New DAA agents have been studied in patients with chronic diseases, transplantation candidates, and transplantation recipients.

Summary

The safety and efficacy of DAAs in patients awaiting liver transplantation and liver transplantation recipients has provided us with guidance on how to use them effectively for patients who received or are awaiting non-liver solid organ transplantations.

     

Hepatitis C: Current Controversies and Future Potential in Solid Organ Transplantation

Purpose of Review

To highlight the changing landscape of hepatitis C virus (HCV) infection in the context of organ transplantation. This focuses on areas of controversy and future potential in the era of highly effective direct-acting antiviral (DAA) agents.

Recent Findings

Since the advent of safe and highly effective DAA therapy, HCV infection is now curable in virtually all cases, including organ transplant recipients. Excellent drug tolerability and safety combined with high cure rates across all organ groups means that HCV is no longer a barrier to transplantation or its outcomes. Mounting data demonstrate the safety of using organs from HCV-infected donors with subsequent treatment of HCV in the recipient and a potential to expand the donor pool.

Summary

Historical data demonstrating inferior survival in transplant recipients with HCV is of limited relevance in the DAA era. Virtually all transplant recipients with HCV infection can be cured, while early data also suggest excellent outcomes in recipients of organs from HCV viremic donors. The optimal timing of HCV therapy in relation to transplantation and the optimal use of organs from HCV viremic donors remain areas of controversy and ongoing research efforts.

     

Essentials in the management of <Emphasis Type="Italic">S. aureus</Emphasis> bloodstream infection

Aims

Staphylococcus aureus bloodstream infection is one of the most common serious bacterial infections worldwide. It represents a heterogenous clinical entity with a high risk of metastatic complications and a high in-hospital mortality ranging between 20 and 30%. The outcome can be improved by optimised diagnostic and therapeutic management. Thus, our minireview should provide important and often missed pieces of information in the management of S. aureus bloodstream infection.

Methods

We describe the essentials in the management of S. aureus bloodstream infection.

Results

Five essentials were identified: 1) S. aureus bacteremia should always be considered clinically significant. 2) Length of bacteremia and fever is relevant for diagnostic workup, duration of therapy and prognosis. 3) Prompt identification and eradication of portal of entry and infective/metastatic foci are essential. 4) Infective endocarditis should be excluded. 5) Intravenous treatment for at least two weeks up to 4–6 weeks with antistaphylococcal penicillins for MSSA and vancomycin or daptomycin for MRSA bloodstream infection is indicated.

Conclusion

Further efforts should be undertaken to increase the adherence to the essentials in the management of S. aureus bloodstream infection.

     

A case of acute hepatitis A infection in an HIV-positive patient despite complete hepatitis A vaccination

Background

Vaccination against hepatitis A virus infection is recommended for men who have sex with men and other risk groups. The protection offered by the combined hepatitis A and B vaccine is comparable to that offered by the monovalent hepatitis A vaccine.

Case

A 38-year-old HIV-positive patient presented with right upper abdominal pain, fever and jaundice. Serological work-up and detection of hepatitis A RNA in stool sample revealed an acute hepatitis A infection despite a previous complete vaccination with the combined hepatitis A and B vaccine.

Conclusion

Although the combined hepatitis A and B vaccine is associated with very good seroconversion rates, the effectiveness in HIV-positive patients is not ensured, even in cases with CD4 cell counts of > 500/μl. Therefore, regular post-vaccine testing should be encouraged to assess seroconversion in immunocompromised subjects.

     

Application of the qSOFA score to predict mortality in patients with suspected infection in a resource-limited setting in Malawi

Purpose

To determine the predictive value of qSOFA (quick Sequential Organ Failure Assessment) in Malawian patients with suspected infection.

Methods

Prospective observational study in a tertiary referral hospital in Malawi.

Results

Predictive ability of qSOFA was reasonable [AUROC 0.73 (95% CI 0.68–0.78)], increasing to 0.77 (95% CI 0.72–0.82) when classifying all patients with altered mental status as high risk. Adding HIV status as a variable to the qSOFA score did not improve predictive value.

Conclusion

qSOFA is a simple tool that can aid risk stratification in resource-limited settings.

     

Trimethoprim–sulfamethoxazole therapy for patients with carbapenemase-producing <Emphasis Type="Italic">Klebsiella pneumoniae</Emphasis> infections: retrospective single-center case series

Objective

The objective of the study was to evaluate the efficacy and tolerability of trimethoprim–sulfamethoxazole (also known as co-trimoxazole, TMPS) to treat Klebsiella pneumoniae (Kp)-K. pneumoniae carbapenemase (KPC) infections.

Methods

Clinical data of patients with a TMPS-susceptible Kp-KPC infection were collected as a case series.

Results

We report clinical outcomes and tolerability for 14 patients infected by Kp-KPC strains susceptible to TMPS, including three bloodstream infections. In ten cases (71.4%), TMPS was administered as monotherapy. In all but one case, Kp-KPC infection was cured. In the remaining patient, therapy was discontinued because of an adverse event.

Conclusions

The use of TMPS to treat TMPS-susceptible Kp-KPC infections seems promising.

     

TIMP-1 Promotes the Immune Response in Influenza-Induced Acute Lung Injury

Introduction

Influenza infects millions of people each year causing respiratory distress and death in severe cases. On average, 200,000 people annually are hospitalized in the United States for influenza related complications. Tissue inhibitor of metalloproteinase-1 (TIMP-1), a secreted protein that inhibits MMPs, has been found to be involved in lung inflammation. Here, we evaluated the role of TIMP-1 in the host response to influenza-induced lung injury.

Methods

Wild-type (WT) and Timp1-deficient (Timp1^?/?) mice that were 8–12 weeks old were administered A/PR/8/34 (PR8), a murine adapted H1N1 influenza virus, and euthanized 6 days after influenza installation. Bronchoalveolar lavage fluid and lungs were harvested from each mouse for ELISA, protein assay, PCR, and histological analysis. Cytospins were executed on bronchoalveolar lavage fluid to identify immune cells based on morphology and cell count.

Results

WT mice experienced significantly more weight loss compared to Timp1^?/? mice after influenza infection. WT mice demonstrated more immune cell infiltrate and airway inflammation. Interestingly, PR8 levels were identical between the WT and Timp1^?/? mice 6 days post-influenza infection.

Conclusion

The data suggest that Timp1 promotes the immune response in the lungs after influenza infection facilitating an injurious phenotype as a result of influenza infection.

     

Disseminated nocardiosis caused by <Emphasis Type="Italic">Nocardia elegans</Emphasis>: a case report and review of the literature

Background

Disseminated nocardiosis is a rare disease mostly occurring in immunocompromised patients.

Methods

We report a case of disseminated nocardiosis in a diabetic patient with both pulmonary and cutaneous involvement. Nocardia elegans was isolated and identified using the 16s ribosomal RNA gene sequence data.

Results

Clinical improvement was observed within 3 months after initiation of antimicrobial treatment with oral doxycycline, trimethoprim-sulfamethoxazole and intravenous penicillin, but the patient died 5 months later after arbitrary discontinuation of the treatment.

Conclusions

This is the first case report of disseminated nocardiosis caused by Nocardia elegans in China.

     

A human stool-derived <Emphasis Type="Italic">Bilophila wadsworthia</Emphasis> strain caused systemic inflammation in specific-pathogen-free mice

Background

Bilophila wadsworthia is a major member of sulfidogenic bacteria in human gut, it was originally recovered from different clinical specimens of intra-abdominal infections and recently was reported potentially linked to different chronic metabolic disorders. However, there is still insufficient understanding on its detailed function and mechanism to date.

Methods

A B. wadsworthia strain was isolated from fresh feces of a latent autoimmune diabetes in adults patient and we investigated its pathogenicity by oral administration to specific-pathogen-free mice. Tissue samples and serum were collected after sacrifice. Stool samples were collected at different time points to profile the gut microbiota.

Results

Bilophila wadsworthia infection resulted in the reduction of body weight and fat mass, apparent hepatosplenomegaly and elevated serum inflammatory factors, including serum amyloid A and interleukin-6, while without significant change of the overall gut microbiota structure.

Conclusions

These results demonstrated that higher amount of B. wadsworthia caused systemic inflammatory response in SPF mice, which adds new evidence to the pathogenicity of this bacterium and implied its potential role to the chronic inflammation related metabolic diseases like diabetes.

     

Cost of Transformation among Primary Care Practices Participating in a Medical Home Pilot

Background

Medical home initiatives encourage primary care practices to invest in new structural capabilities such as patient registries and information technology, but little is known about the costs of these investments.

Objectives

To estimate costs of transformation incurred by primary care practices participating in a medical home pilot.

Design

We interviewed practice leaders in order to identify changes practices had undertaken due to medical home transformation. Based on the principles of activity-based costing, we estimated the costs of additional personnel and other investments associated with these changes.

Setting

The Pennsylvania Chronic Care Initiative (PACCI), a statewide multi-payer medical home pilot.

Participants

Twelve practices that participated in the PACCI.

Measurements

One-time and ongoing yearly costs attributed to medical home transformation.

Results

Practices incurred median one-time transformation-associated costs of $30,991 per practice (range, $7694 to $117,810), equivalent to $9814 per clinician ($1497 to $57,476) and $8 per patient ($1 to $30). Median ongoing yearly costs associated with transformation were $147,573 per practice (range, $83,829 to $346,603), equivalent to $64,768 per clinician ($18,585 to $93,856) and $30 per patient ($8 to $136). Care management activities accounted for over 60% of practices’ transformation-associated costs. Per-clinician and per-patient transformation costs were greater for small and independent practices than for large and system-affiliated practices.

Limitations

Error in interviewee recall could affect estimates. Transformation costs in other medical home interventions may be different.

Conclusions

The costs of medical home transformation vary widely, creating potential financial challenges for primary care practices—especially those that are small and independent. Tailored subsidies from payers may help practices make these investments.

Primary Funding Source

Agency for Healthcare Research and Quality

     

First case of <Emphasis Type="Italic">E. meningoseptica</Emphasis> in Italy in a patient with necrotic hemorrhagic pancreatitis

Introduction

Elizabethkingia meningoseptica can frequently colonizes the respiratory tract, but its pathogenetic role and its clinical significance are frequently questioned. However, recent data reported E. meningoseptica outbreaks in particular settings, as hospitalized patients.

Case Report

We report here the first case of Elizabethkingia meningoseptica infection in Italy in a patient with necrotic-hemorrhagic pancreatitis. E. meningoseptica was isolated from respiratory tract and treated with combination antibiotic therapy.

Conclusion

We discuss here the role of isolation of E. meningoseptica in hospitalized patients as a sign of patient’s frailty.

     

Evaluation and management of <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> bacteriuria: an updated review

Background and aims

There is little guidance regarding the evaluation and management of patients with Staphylococcus aureus bacteriuria (SABU). Here, we aimed to provide an up-to-date review of the literature.

Methods

We searched PubMed, Scopus, and clinical trial registries for articles evaluating the epidemiology of SABU, risk factors of SABU, the association of SABU with urinary tract infection, bacteremia and invasive S. aureus infections, and the management of patients with SABU.

Results

S. aureus is an uncommon isolate in urine cultures. It is more common among certain patients, e.g., patients with indwelling urinary tract devices or prior urinary tract instrumentation. SABU may represent asymptomatic bacteriuria, primary urinary tract infection, or hematogenous seeding of the urinary tract associated with other foci of infection. SABU may also serve as the focus for subsequent bacteremia and invasive infections. We did not find any clinical trials regarding the management of patients with SABU.

Conclusions

Based on our review, we suggest an algorithmic approach for the evaluation and management of patients with SABU. However, evidence from clinical trials is lacking and there are severalgaps in the current literature. These are discussed in this review.

     

Hepatitis delta infection in Italian patients: towards the end of the story?

Background

The endemicity of hepatitis delta virus infection in Italy has decreased in the last decades.

Aim

To evaluate the current epidemiology of chronic delta infection in Italy and to compare the present findings with the corresponding figures from the previous studies.

Methods

A cross-sectional study involving 16 referral centres scattered all over the country in 2014.

Results

Out of the 513 hepatitis B surface antigen-positive subjects enrolled, 61 (11.9%) were anti-delta positive, with a sex ratio (M/F) of 2.05. The majority (80.3%) of them was 50 years or older, while the proportion of subjects younger than 30 years of age was as low as 3.3%. No difference was detected by geographical area of residence. The presence of liver cirrhosis was diagnosed in 52.4% of cases. In comparison to previous studies, a further shift towards the oldest age groups and an increasing proportion of subjects having liver cirrhosis among all anti-delta-positive subjects are observed.

Conclusions

Currently, hepatitis delta infection mostly affects old people who have an advanced but indolent liver disease, reflecting a survival effect. The defective hepatitis delta virus is near to disappear in the country, where it has been discovered in the second half of 70s.

     

Neue β‑Laktam-Antibiotika und β‑Laktamase-Inhibitoren gegen multiresistente Gram-negative Erreger

Background

The worldwide spread of multidrug-resistant Gram-negative bacteria (MDR-GN) continues. Treatment options for infections caused by MDR-GN remain scarce and only few new substances are currently in clinical phase II/III studies or have already been granted market approval.

Objectives

To provide an overview about current data on new β?lactam antibiotics and β?lactamase inhibitor combinations, respectively. New macrolides, ketolides and aminoglycosides are not addressed.

Materials and methods

Selective literature research regarding published data on ceftazidim/avibactam, ceftolozan/tazobactam, imipenem/cilastatin?+?relebactam, meropenem/vaborbactam, aztreonam/avibactam and cefiderocol, as well as registered trials.

Results

The development of new antimicrobials for the treatment of MDR-GN infections offers new options for attending physicians. β?Lactamase producers are inhibited by these new substances, though with varying efficacy; however, there are still no adequate treatment options for metallo-β-lactamase (MBL) producers.

Conclusions

Clinical data are still indifferent and come from heterogeneous patient collectives. Direct comparisons with established treatment strategies, such as the “last-resort use” of polymyxins are hardly possible. Cases of early development of resistance have already been described. Finally, the importance of toxicity and optimal dosing—in organ failure or organ replacement procedures such as dialysis—remain unclear.