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Carlos E KummerfeldtDivision of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USAAbstract: Anthrax is a highly contagious and potentially fatal human disease caused by Bacillus anthracis, an aerobic, Gram-positive, spore-forming rod-shaped bacterium with worldwide distribution as a zoonotic infection in herbivore animals. Bioterrorist attacks with inhalational anthrax have prompted the development of more effective treatments. Antibodies against anthrax toxin have been shown to decrease mortality in animal studies. Raxibacumab is a recombinant human monoclonal antibody developed against inhalational anthrax. The drug received approval after human studies showed its safety and animal studies demonstrated its efficacy for treatment as well as prophylaxis against inhalational anthrax. It works by preventing binding of the protective antigen component of the anthrax toxin to its receptors in host cells, thereby blocking the toxin's deleterious effects. Recently updated therapy guidelines for Bacillus anthracis recommend the use of antitoxin treatment. Raxibacumab is the first monoclonal antitoxin antibody made available that can be used with the antibiotics recommended for treatment of the disease. When exposure is suspected, raxibacumab should be given with anthrax vaccination to augment immunity. Raxibacumab provides additional protection against inhalational anthrax via a mechanism different from that of either antibiotics or active immunization. In combination with currently available and recommended therapies, raxibacumab should reduce the morbidity and mortality of inhalational anthrax.Keywords: anthrax, monoclonal antibody, protective antigen, raxibacumab

BackgroundThe tobacco industry has organised research institutions to generate misleading data on indoor air quality, including second-hand smoke exposure and health effects.ObjectivesTo describe tobacco industry involvement in the organisation and financial support of an air quality research laboratory in El Salvador.MethodsTobacco industry documents on the internet were systematically searched from August 2007 to February 2008 for air quality studies undertaken in El Salvador, and laboratory personnel were interviewed.ResultsPhilip Morris sought to establish a network of air quality laboratories throughout Latin America. In El Salvador, in 1997, through Tabacalera de El Salvador (a subsidiary of Philip Morris) and the Salvadoran Foundation for Economic Development (FUSADES), the industry organised an air quality research laboratory. FUSADES was part of the industry's Latin American Scientific Network, which consisted of doctors hired as consultants who would send air samples from their research to FUSADES. Philip Morris Scientific Affairs personnel hired LabStat, a Canadian-based laboratory, to provide technical assistance to FUSADES (train and assist the laboratory in air quality measurements). In addition, the Washington-based HMS Group successfully implemented a plan to upgrade the laboratory and obtain international certifications. HMS Group also assisted in searching for sustainable funding for FUSADES, including seeking funds from international aid for Hurricane Mitch.ConclusionAir quality studies that have used the FUSADES laboratory should be carefully interpreted, given the support that this laboratory received from Philip Morris.

Introduction: To describe the incidence of discordant exudate (DE) effusions, their underlying etiologies and their effect on the accuracy of the Light's criteria to diagnose exudate effusions., Methods: A retrospective review of pleural fluid analysis (PFA) from a cohort of patients with pleural effusion (PE) who underwent thoracentesis. PEs were defined as exudative based on the Light's criteria. The effusions were further classified in concordant or DE., Results: From 847 PE samples, 611 (72.1%) were diagnosed as an exudate and 236 (27.9%) as a transudate. In 10.3% of cases (n = 87), there was discordancy between the final pleural fluid diagnosis and the PFA defined by Light's criteria. 281 (33.2%) of the 632 effusions classified as an exudate by Light's criteria were DE (52 transudates and 229 exudates). 182 (65%) of the 281 DE were found to be protein discordant (37 transudates and 145 exudates), and 99 (35.2%) were lactate dehydrogenase discordant (15 transudates and 84 exudates). The positive predictive value and positive likelihood ratio of Light's criteria for the diagnosis of an exudate effusion decreased from 99.4% and 67.4%, respectively, when the exudates were concordant to 81.5% and 1.7, respectively, if they were discordant., Conclusions: In a significant percentage of patients, there is discordancy between the results of the PFA and the final clinical diagnosis. DE decreased the accuracy of Light's criteria to identify exudate PE, increasing the risk of misclassifying a transudate as an exudate. Concordant exudates almost universally established the presence of an exudative PE., (Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: Application of Light's criteria results in misclassification of some transudative effusions as exudative, particularly because of congestive heart failure (CHF). We sought to determine if the serum to pleural fluid albumin (SF-A) and serum to pleural fluid protein (SF-P) gradients increased the predictive accuracy to correctly identify exudative effusions., Methods: We retrospectively analyzed 1,153 consecutive patients who underwent a diagnostic thoracentesis at the Medical University South Carolina. Univariable logistic regression analyses were used to determine the statistical significance of pleural fluid tests that correctly identified exudative effusions. Tests with significant diagnostic accuracy were combined in multivariable logistic regression models, with calculation of areas under the curve (AUCs) to determine their predictive accuracy. The predictive capability of the best model was compared with Light's criteria and other test combinations., Results: Pleural fluid lactate dehydrogenase (LDH), SF-A gradient, and SF-P gradient had a significant effect on the probability of identifying exudative pleural effusions. When combined together in a multivariable logistic regression, LDH (OR, 14.09 [95% CI, 2.25-85.50]), SF-A gradient (OR, 7.16 [95% CI, 1.24-41.43]), and SF-P gradient (OR, 6.83 [95% CI, 1.56-27.88]) had an AUC of 0.92 (95% CI, 0.85-0.98)., Conclusions: Application of Light's criteria, not uncommonly, misclassifies CHF transudative effusions as exudates. In cases where no cause for an exudative effusion can be identified or CHF is suspected, the sequential application of the fluid LDH, followed by the SF-P and then the SF-A gradients, may assist in reclassifying pleural effusions as transudates.

Rickettsiosis, Q fever, tularemia, and anthrax are all bacterial diseases that can affect the pleura. Rocky Mountain Spotted Fever (RMSF) and Mediterranean Spotted Fever (MSF) are caused by Rickettsia rickettsii and Rickettsia conorii, respectively. Pleural fluid from a patient with MSF had a neutrophil-predominant exudate. Coxiellaburnetii is the causative agent of Q fever. Of the two cases described in the literature, one was an exudate with a marked eosinophilia while the other case was a transudate due to a constrictive pericarditis. Francisella tularensis is the causative agent of tularemia. Pleural fluid from three tularemia patients showed a lymphocyte predominant exudate. Bacillusanthracis is the causative agent of anthrax. Cases of inhalational anthrax from a recent bioterrorist attack evidenced the presence of a serosanguineous exudative pleural effusion. These four bacterial microorganisms should be suspected in patients presenting with a clinical history, exposure to known risk factors and an unexplained pleural effusion.

Objectives: To determine tobacco point of sale advertising prevalence in Guatemala City, Guatemala and Buenos Aires, Argentina., Methods: Convenience stores (120 per city) were chosen from randomly selected blocks in low, middle and high socioeconomic neighbourhoods. To assess tobacco point of sale advertising we used a checklist developed in Canada that was translated into Spanish and validated in both countries studied. Analysis was conducted by neighbourhood and store type., Results: All stores sold cigarettes and most had tobacco products in close proximity to confectionery. In Guatemala, 60% of stores had cigarette ads. High and middle socioeconomic status neighbourhood stores had more indoor cigarette ads, but these differences were determined by store type: gas stations and supermarkets were more prevalent in high socioeconomic status neighbourhoods and had more indoor cigarette ads. In poorer areas, however, more ads could be seen from outside the stores, more stores were located within 100 metres of schools and fewer stores had 'No smoking' or 'No sales to minors' signs. In Argentina, 80% of stores had cigarette ads and few differences were observed by neighbourhood socioeconomic status. Compared to Guatemala, 'No sales to minors' signs were more prevalent in Argentina., Conclusions: Tobacco point of sale advertising is highly prevalent in these two cities of Guatemala and Argentina. An advertising ban should also include this type of advertising.