Prediction of mortality in adult emergency department patients with sepsis

OBJECTIVES

To determine the efficacy of the abbreviated Mortality in Emergency Department Sepsis (MEDS) score, the Modified Early Warning (MEW) score and near-patient-test (NPT) lactate levels in predicting 28-day mortality in adult emergency department (ED) patients with sepsis.

METHODS

A retrospective cohort study of adult ED patients with sepsis admitted to hospital was conducted in a large urban teaching and a district general hospital. Data were collected during four time periods between 1 January 2006 and 31 January 2007. Inclusion criteria were age > or =16 years and an ED diagnosis of sepsis. Primary outcome for all patients was 28-day mortality. Patients were preassigned to risk groups according to their abbreviated MEDS score, MEW score and NPT lactate.

RESULTS

307 ED patients with sepsis were included in the study. Among these there were 72 deaths (23%). Mortality rates for the low-, moderate- and high-risk groups of the abbreviated MEDS score were 1/63 (1.6%), 48/205 (23.4%) and 23/39 (59.0%) patients. The MEDS score for low-risk patients was 98.6% (95% CI 92.5% to 99.9%) sensitive and 26.5% (95% CI 21.0% to 32.6%) specific and for high-risk patients it was 31.9% (95% CI 21.4% to 44.0%) sensitive and 93.2% (95% CI 89.2% to 96.1%) specific for death within 28 days. Mortality rates for the low- and high-risk MEW score were 20/159 (12.6%) and 52/148 (35.1%) patients. The MEW score for high-risk patients was 72.2% (95% CI 60.4% to 82.1%) sensitive and 59.2% (95% CI 52.6% to 65.5%) specific for mortality. An NPT lactate level of > or =4 mmol/l was 49.1% (95% CI 35.1% to 63.2%) sensitive and 74.3% (95% CI 64.8% to 82.3%) specific for 28-day mortality.

CONCLUSION

These results demonstrate the efficacy of the abbreviated MEDS score, the MEW score and NPT venous lactate levels in predicting 28-day mortality in ED patients with sepsis. The abbreviated MEDS score was found to be the best performing risk assessment model which, with prospective validation, may aid early clinical decision-making in ED patients with sepsis and might affect the outcome from sepsis.

Water-mediated interactions between hydrophobic and ionic species in cylindrical nanopores

We use Metropolis Monte Carlo and umbrella sampling to calculate the free energies of interaction of two methane molecules and their charged derivatives in cylindrical water-filled pores. Confinement strongly alters the interactions between the nonpolar solutes and completely eliminates the solvent separated minimum (SSM) that is seen in bulk water. The free energy profiles show that the methane molecules are either in contact or at separations corresponding to the diameter and the length of the cylindrical pore. Analytic calculations that estimate the entropy of the solutes, which are solvated at the pore surface, qualitatively explain the shape of the free energy profiles. Adding charges of opposite sign and magnitude 0.4e or e (where e is the electronic charge) to the methane molecules decreases their tendency for surface solvation and restores the SSM. We show that confinement induced ion-pair formation occurs whenever l(B)/D approximately O(1), where l(B) is the Bjerrum length and D is the pore diameter. The extent of stabilization of the SSM increases with ion charge density as long as l(B)/D<1. In pores with D<or=1.2 nm, in which the water is strongly layered, increasing the charge magnitude from 0.4e to e reduces the stability of the SSM. As a result, ion-pair formation that occurs with negligible probability in the bulk is promoted. In larger diameter pores that can accommodate a complete hydration layer around the solutes, the stability of the SSM is enhanced.

An economic approach for l-(+) lactic acid fermentation by Lactobacillus amylophilus GV6 using inexpensive carbon and nitrogen sources

AIMS

Development of cost-effective production medium by applying statistical designs for single-step fermentation of starch (corn flour - CF) to L-(+) lactic acid, using inexpensive nitrogen sources as substitutes for peptone and yeast extract in MRS medium by amylolytic Lactobacillus amylophilus GV6.

METHODS AND RESULTS

A two-level Plackett-Burman design was employed for screening various available crude starches (flours) for L-(+) lactic acid production by Lact. amylophilus GV6 using red lentil flour (RL) and bakers yeast cells (YC) as substitutes for commercial peptone and yeast extract in MRS medium in anaerobic submerged fermentation. Of all the tested flours, CF was found to be the most significant. Central composite rotatable design was employed to determine maximum production of L-(+) lactic acid at optimum values of process variables, CF, RL, YC, CaCO(3) and incubation period (IP). minitab analyses showed that lactic acid production was significantly affected by the linear terms CF, RL, CaCO(3) and IP. The interactions of CF-RL, CF-YC, CF-CaCO(3), RL-YC and RL-CaCO(3) and the square terms CF and IP were significant. The maximum lactic acid production of 29 g/37 g of starch present in 50 g of CF was obtained at optimized concentrations of CF 5%, RL 0.7%, YC 0.8%, CaCO(3) 0.8% and IP 2.9 days.

CONCLUSIONS

Successful application of Plackett-Burman design helped in identifying CF as the best carbon source among the tested flours for L-(+) lactic acid production using inexpensive nitrogen sources. Further optimization of the process variables by response surface methods (RSMs) led to maximum production of lactic acid (29 g lactic acid from 37 g of starch present in 50 g of flour).

SIGNIFICANCE AND IMPACT OF THE STUDY

Lactobacillus amylophilus GV6 showed 78.4% lactic acid production efficiency (g lactic acid produced/g starch taken) and 96% lactic acid yield efficiency (g lactic acid produced/g starch utilized). Information from the present studies provides a better understanding on production of L-(+) lactic acid on fermentation of CF using inexpensive nitrogen sources and on changes in the production as a response from interaction of factors. Use of inexpensive nitrogen sources and starch as substrate in MRS medium for single-step fermentation of lactic acid can become an efficient, economic and viable process. This report is on optimization of inexpensive nitrogen sources completely replacing peptone and yeast extract in single-step submerged fermentation of starch (present in CF) to lactic acid with high production efficiency.

Selection of medium components by Plackett-Burman design for production of L(+) lactic acid by Lactobacillus amylophilus GV6 in SSF using wheat bran

Plackett-Burman design was employed for screening 15 parameters for production of L(+) lactic acid from wheat bran, an inexpensive substrate and solid support, by Lactobacillus amylophilus GV6 in solid state fermentation (SSF). Eleven nutrients belonging to two categories viz.; nitrogen sources and salt sources along with three physical parameters and a buffer were screened. This design screens n variables in n + 1 number of experiments. Coefficients and sum of squares ratio in percentage (SS%) of these variables were calculated by subjecting the experimental data to statistical analysis. The nitrogen sources peptone, yeast extract and tri-ammonium citrate, along with NaH2PO4.2H2O and Tween 80, were found to influence productivity, which can be further optimized for increased lactic acid production. Use of this design is scarce in solid state fermentation and has not been attempted previously for single step conversion of starch to L(+) lactic acid using a bacterial system.

Production of Ethanol From Cellulosic Biomass by Clostridium thermocellum SS19 in Submerged Fermentation: Screening of Nutrients Using Plackett-Burman Design

Plackett-Burman design, a statistical methodology, was used to screen 23 nutrients belonging to three categories--carbon, nitrogen, and salt/mineral sources--for the production of ethanol from cellulosic biomass by Clostridium thermocellum SS19 in anaerobic submerged fermentation. In this design, just n number of experiments is required for screening n-1 variables. The experimental data were subjected to statistical analysis for calculating the regression coefficients and t-values. Filter paper, Solka Floc, corn steep liquor (CSL), cysteine HCl, magnesium chloride, and ferrous sulfate showed relatively higher regression coefficients on ethanol production and growth. Among the 23 nutrients screened, based on their performance in terms of product-promoting ability, availability, and cost, filter paper, CSL, cysteine HCl, magnesium chloride, and ferrous sulfate were identified as the most effective and, therefore, selected for inclusion in further optimization studies.

Fermentation of cellulose to acetic acid by Clostridium lentocellum SG6: induction of sporulation and effect of buffering agent on acetic acid production

AIMS

To determine the growth, correlation between sporulation and acetic acid production and effect of buffering agent at high substrate cellulose concentrations of the strain Clostiridium lentocellum SG6.

METHODS AND RESULTS

The strain SG6 was grown in cellulose mineral salt medium containing cellulose (Whatman No. 1 filter paper, Whatmore International Ltd., Maidstone, UK) or cellobiose. The strain fermented cellulose even after several transfers on cellobiose medium. The formation of endospores on third day onwards indicated the lowering of pH in the medium because of the formation of acetic acid. Maintaining the pH 7.2 at higher substrate concentrations resulted in increase of biomass, cellulose fermentation, acetic acid production, etc.

CONCLUSIONS

The strain SG6, with its high fermentation yields and sporulating character can become a potential strain for acetic acid production and also as a probiotic strain in animal nutrition.

SIGNIFICANCE AND IMPACT OF THE STUDY

The direct conversion of cellulosic biomass to acetic acid can eliminate expensive three-step saccharification, fermentation processes. The strain SG6 can ferment cellulose at high substrate concentrations.

Clostridium lentocellum SG6--a potential organism for fermentation of cellulose to acetic acid

A cellulolytic, acetic acid producing anaerobic bacterial isolate, Gram negative, rod-shaped, motile, terminal oval shaped endospore forming bacterium identified as Clostridium lentocellum SG6 based on physiological and biochemical characteristics. It produced acetic acid as a major end product from cellulose fermentation at 37 degrees C and pH 7.2. Acetic acid production was 0.67 g/g cellulose substrate utilized in cellulose mineral salt (CMS) medium. Yeast extract (0.4%) was the best nitrogen source among the various nitrogenous nutrients tested in production medium containing 0.8% cellulose as substrate. No additional vitamins or trace elemental solution were required for acetic acid fermentation. This is the highest acetic acid fermentation yield in monoculture fermentation for direct conversion of cellulose to acetic acid.

Sequential magnetic resonance monitoring of pulmonary flow with endovascular stents placed across the pulmonary valve in growing Swine

BACKGROUND

Patients with endovascular stent implantation for the treatment of right ventricular outflow tract obstruction are often left with incomplete relief of the obstruction and significant pulmonary regurgitation. A noninvasive and reproducible method for monitoring such patients is desirable. MRI in the presence of a stent, however, has to overcome the problem of potential metallic artifacts.

METHODS AND RESULTS

Under x-ray fluoroscopic guidance, endovascular nitinol stents were placed across the pulmonary valve in 6 young pigs to induce pulmonary regurgitation. Five additional pigs served as controls. Initial MRI was performed after 2 days (13.5+/-1.8 kg) and follow-up after 3 months (32+/-2.9 kg). Pulmonary flow volumes and regurgitant fraction were quantified by velocity-encoded cine (VEC) MRI through (VEC-TS) and distal to (VEC-DS) the stent. VEC-TS was compared with VEC-DS and volumetric measurements of left and right ventricular stroke volumes provided by cine MRI ("gold standard"). Antegrade and retrograde pulmonary flow volumes by VEC-TS were slightly but significantly less than those with VEC-DS and cine MRI. Excellent correlations (r>0.97) for phasic pulmonary flow volumes as measured by VEC-TS and VEC-DS were shown. Pulmonary regurgitant fraction increased from 32.8+/-15% to 49.6+/-17% (P<0.05) over the course of 3 months with VEC-TS.

CONCLUSIONS

MRI demonstrates the progression of pulmonary regurgitation in growing swine. VEC MRI has the ability to quantify pulmonary blood flow inside the lumen of nitinol stents. MRI appears to be ideally suited for monitoring patients with endovascular nitinol stents in the pulmonary artery or pulmonary valve position.

Design and synthesis of a series of (2R)-N(4)-hydroxy-2-(3-hydroxybenzyl)-N(1)- [(1S,2R)-2-hydroxy-2,3-dihydro-1H-inden-1-yl]butanediamide derivatives as potent, selective, and orally bioavailable aggrecanase inhibitors

A pharmacophore model of the P1' site, specific for aggrecanase, was defined using the specificity studies of the matrix metalloproteinases and the similar biological activity of aggrecanase and MMP-8. Incorporation of the side chain of a tyrosine residue into compound 1 as the P1' group provided modest selectivity for aggrecanase over MMP-1, -2, and -9. A cis-(1S)(2R)-amino-2-indanol scaffold was incorporated as a tyrosine mimic (P2') to conformationally constrain 2. Further optimization resulted in compound 11, a potent, selective, and orally bioavailable inhibitor of aggrecanase.

Occurrence of ochratoxin A in black pepper, coriander, ginger and turmeric in India

Ochratoxin A (OA) contamination of black pepper, coriander seeds, powdered ginger and turmeric powder was estimated using indirect competitive ELISA. Samples (1 g) were extracted with 0.5% potassium chloride (KCl) in 70% methanol (5 ml) and diluted subsequently to give two-fold to ten-fold step-wise dilutions in phosphate-buffered saline containing 0.05% Tween 20 and 0.2% bovine serum albumin (PBS-T BSA). For extracts from the spices analysed, ELISA estimates of OA concentrations were compared with those made by HPLC. All estimates were within 1-2 standard deviation of the ELISA values. More than 90% of OA added to spice samples was recovered from samples containing between 5 and 100 microg/kg OA. Extracts of OA-free spice samples contained substances that interfered with ELISA, presumably because of non-specific reactions. This effect was avoided by preparing all the test solutions in extracts of OA-free spice samples. In 126 samples obtained from retail shops, OA was found to exceed 10 microg/kg in 14 (in the range of 15-69 microg/kg) of 26 black pepper samples, 20 (in the range of 10-51 microg/kg) of 50 coriander samples, two (23 microg/kg and 80 microg/kg) of 25 ginger samples and nine (in the range of 11-102 microg/kg) of 25 turmeric samples. This is the first record in India of the occurrence of OA in what are some of the most widely used spices in Indian cooking.