The Potential Influence of Common Viral Infections Diagnosed during Hospitalization among Critically Ill Patients in the United States

Viruses are the most common source of infection among immunocompetent individuals, yet they are not considered a clinically meaningful risk factor among the critically ill. This work examines the association of viral infections diagnosed during the hospital stay or not documented as present on admission to the outcomes of ICU patients with no evidence of immunosuppression on admission. This is a population-based retrospective cohort study of University HealthSystem Consortium (UHC) academic centers in the U.S. from the years 2006 to 2009. The UHC is an alliance of over 90% of the non-profit academic medical centers in the U.S. A total of 209,695 critically ill patients were used in this analysis. Eight hospital complications were examined. Patients were grouped into four cohorts: absence of infection, bacterial infection only, viral infection only, and bacterial and viral infection during same hospital admission. Viral infections diagnosed during hospitalization significantly increased the risk of all complications. There was also a seasonal pattern for viral infections. Specific viruses associated with poor outcomes included influenza, RSV, CMV, and HSV. Patients who had both viral and bacterial infections during the same hospitalization had the greatest risk of mortality RR 6.58, 95% CI (5.47, 7.91); multi-organ failure RR 8.25, 95% CI (7.50, 9.07); and septic shock RR 271.2, 95% CI (188.0, 391.3). Viral infections may play a significant yet unrecognized role in the outcomes of ICU patients. They may serve as biological markers or play an active role in the development of certain adverse complications by interacting with coincident bacterial infection

Development and optimization of quantitative PCR for the diagnosis of invasive aspergillosis with bronchoalveolar lavage fluid

Background: The diagnosis of invasive pulmonary aspergillosis (IPA) remains challenging. Culture and histopathological examination of bronchoalveolar lavage (BAL) fluid are useful but have suboptimal sensitivity and in the case of culture may require several days for fungal growth to be evident. Detection of Aspergillus DNA in BAL fluid by quantitative PCR (qPCR) offers the potential for earlier diagnosis and higher sensitivity. It is important to adopt quality control measures in PCR assays to address false positives and negatives which can hinder accurate evaluation of diagnostic performance. Methods: BAL fluid from 94 episodes of pneumonia in 81 patients was analyzed. Thirteen episodes were categorized as proven or probable IPA using Mycoses Study Group criteria. The pellet and the supernatant fractions of the BAL were separately assayed. A successful extraction was confirmed with a human 18S rRNA gene qPCR. Inhibition in each qPCR was measured using an exogenous DNA based internal amplification control (IAC). The presence of DNA from pathogens in the Aspergillus genus was detected using qPCR targeting fungal 18S rRNA gene. Results: Human 18S rRNA gene qPCR confirmed successful DNA extraction of all samples. IAC detected some degree of initial inhibition in 11 samples. When culture was used to diagnose IPA, the sensitivity and specificity were 84.5% and 100% respectively. Receiver-operating characteristic analysis of qPCR showed that a cutoff of 13 fg of Aspergillus genomic DNA generated a sensitivity, specificity, positive and negative predictive value of 77%, 88%, 50%, 96% respectively. BAL pellet and supernatant analyzed together resulted in sensitivity and specificity similar to BAL pellet alone. Some patients did not meet standard criteria for IPA, but had consistently high levels of Aspergillus DNA in BAL fluid by qPCR. Conclusion: The Aspergillus qPCR assay detected Aspergillus DNA in 76.9% of subjects with proven or probable IPA when the concentrated BAL fluid pellet fraction was used for diagnosis. There was no benefit from analyzing the BAL supernatant fraction. Use of both extraction and amplification controls provided optimal quality control for interpreting qPCR results and therefore may increase our understanding of the true potential of qPCR for the diagnosis of IPA.Supported by NIH grant R01 AI054703 from the National Institute of Allergy and Infectious Diseases

Combined Micro and Macro Additive Manufacturing of a Swirling Flow Coaxial Phacoemulsifier Sleeve with Internal Micro-Vanes

Microstereolithography (µSL) technology can fabricate complex, three-dimensional (3D) microstructures, although µSL has difficulty producing macrostructures with micro-scale features. There are potentially many applications where 3D micro-features can benefit the overall function of the macrostructure. One such application involves a medical device called a coaxial phacoemulsifier where the tip of the phacoemulsifier is inserted into the eye through a relatively small incision and used to break the lens apart while removing the lens pieces and associated fluid from the eye through a small tube. In order to maintain the eye at a constant pressure, the phacoemulsifier also includes an irrigation solution that is injected into the eye during the procedure through a coaxial sleeve. It has been reported, however, that the impinging flow from the irrigation solution on the corneal endothelial cells in the inner eye can damage these cells during the procedure. As a result, a method for reducing the impinging flow velocities and the resulting shear stresses on the endothelial cells during this procedure was explored, including the design and development of a complex, 3D micro-vane within the sleeve. The micro-vane introduces swirl into the irrigation solution, producing a flow with rapidly dissipating flow velocities. Fabrication of the sleeve and fitting could not be accomplished using µSL alone, and thus, a two-part design was accomplished where a sleeve with the micro-vane was fabricated with µSL and a threaded fitting used to attach the sleeve to the phacoemulsifier was fabricated using an Objet Eden 333 rapid prototyping machine. The new combined device was tested within a water container using particle image velocimetry, and the results showed successful swirling flow with an ejection of the irrigation fluid through the micro-vane in three different radial directions corresponding to the three micro-vanes. As expected, the sleeve produced a swirling flow with rapidly dissipating streamwise flow velocities where the maximum measured streamwise flow velocities using the micro-vane were lower than those without the micro-vane by 2 mm from the tip where they remained at ∼70% of those produced by the conventional sleeve as the flow continued to develop. It is believed that this new device will reduce damage to endothelial cells during cataract surgery and significantly improve patient outcomes from this procedure. This unique application demonstrates the utility of combining µSL with a macro rapid prototyping technology for fabricating a real macro-scale device with functional, 3D micro-scale features that would be difficult and costly to fabricate using alternative manufacturing methods