Do established prognostic factors explain the different mortality rates in ICU septic patients around the world?

BACKGROUND

The aim of this paper was to clarify if previously established prognostic factors explain the different mortality rates observed in ICU septic patients around the world.

METHODS

This is a sub-study from the PROGRESS study, which was an international, prospective, observational registry of ICU patients with severe sepsis. For this study we included 10930 patients from 24 countries that enrolled more than 100 patients in the PROGRESS. The effect of potential prognostic factors on in-hospital mortality was examined using univariate and multivariate logistic regression. The complete set of data was available for 7022 patients, who were considered in the multivariate analysis. Countries were classified according to country income, development status, and in-hospital mortality terciles. The relationship between countries' characteristics and in-hospital mortality was evaluated using linear regression.

RESULTS

Mean in-hospital mortality was 49.2%. Severe sepsis in-hospital mortality varied widely in different countries, ranging from 30.6% in New Zealand to 80.4% in Algeria. Classification as developed or developing country was not associated with in-hospital mortality (P=0.16), nor were levels of gross national product per capita (P=0.15). Patients in the group of countries with higher in-hospital mortality had a crude OR for in-hospital death of 2.8 (95% CI 2.5-3.1) in comparison to those in the lower risk group. After adjustments were made for all other independent variables, the OR changed to 2.9 (95% CI 2.5-3.3).

CONCLUSION

Severe sepsis mortality varies widely in different countries. All known markers of disease severity and prognosis do not fully explain the international differences in mortality. Country income does not explain this disparity either. Further studies should be developed to verify if other organizational or structural factors account for disparities in patient care and outcomes.

Juvenile granulosa-cell tumor of the ovary - interphase cytogenetics for chromosome-12 and chromosome-x and flow cytometric DNA-ploidy study

We performed interphase in situ hybridization (ISH) for chromosomes 12 and X and now cytometric DNA analysis on seven juvenile granulosa cell tumors to verify this observation and correlate the results with clinicopathologic factors. Five cases were primary ovarian tumors and two were metastatic lesions. Our results show that four tumors exhibited polysomy 12 and four had monosomy X; only two tumors displayed concurrent aberrations of both chromosomes. Of the six tumors with interpretable flow cytometric histograms three showed DNA aneuploidy and three were DNA diploid. All three aneuploid tumors manifested polysomy 12. Of the three diploid DNA neoplasms two showed monosomy X and one displayed disomy for chromosomes 12 and X. No apparent correlation between numerical chromosomal abnormalities and the biological course was observed in this small cohort. Our results indicate that chromosomes 12 and X are frequently altered in these neoplasms and thus could be targeted for further molecular studies in order to identify genetic aberrations which might be associated with JGCT tumorigenesis.

Linear and nonlinear analysis of heart rate variability in healthy subjects and after acute myocardial infarction in patients

The objectives of this study were to evaluate and compare the use of linear and nonlinear methods for analysis of heart rate variability (HRV) in healthy subjects and in patients after acute myocardial infarction (AMI). Heart rate (HR) was recorded for 15 min in the supine position in 10 patients with AMI taking β-blockers (aged 57 ± 9 years) and in 11 healthy subjects (aged 53 ± 4 years). HRV was analyzed in the time domain (RMSSD and RMSM), the frequency domain using low- and high-frequency bands in normalized units (nu; LFnu and HFnu) and the LF/HF ratio and approximate entropy (ApEn) were determined. There was a correlation (P < 0.05) of RMSSD, RMSM, LFnu, HFnu, and the LF/HF ratio index with the ApEn of the AMI group on the 2nd (r = 0.87, 0.65, 0.72, 0.72, and 0.64) and 7th day (r = 0.88, 0.70, 0.69, 0.69, and 0.87) and of the healthy group (r = 0.63, 0.71, 0.63, 0.63, and 0.74), respectively. The median HRV indexes of the AMI group on the 2nd and 7th day differed from the healthy group (P < 0.05): RMSSD = 10.37, 19.95, 24.81; RMSM = 23.47, 31.96, 43.79; LFnu = 0.79, 0.79, 0.62; HFnu = 0.20, 0.20, 0.37; LF/HF ratio = 3.87, 3.94, 1.65; ApEn = 1.01, 1.24, 1.31, respectively. There was agreement between the methods, suggesting that these have the same power to evaluate autonomic modulation of HR in both AMI patients and healthy subjects. AMI contributed to a reduction in cardiac signal irregularity, higher sympathetic modulation and lower vagal modulation.

Long-term regulation of Na+,K+-ATPase in opossum kidney cells by ouabain

Na(+),K(+)-ATPase, a basolateral transporter responsible for tubular reabsorption of Na(+) and for providing the driving force for vectorial transport of various solutes and ions, can also act as a signal transducer in response to the interaction with steroid hormones. At nanomolar concentrations ouabain binding to Na(+),K(+)-ATPase activates a signaling cascade that ultimately regulates several membrane transporters including Na(+),K(+)-ATPase. The present study evaluated the long-term effect of ouabain on Na(+),K(+)-ATPase activity (Na(+) transepithelial flux) and expression in opossum kidney (OK) cells with low (40) and high (80) number of passages in culture, which are known to overexpress Na(+),K(+)-ATPase (Silva et al., 2006, J Membr Biol 212, 163-175). Activation of a signal cascade was evaluated by quantification of ERK1/2 phosphorylation by Western blot. Na(+),K(+)-ATPase activity was determined by electrophysiological techniques and expression by Western blot. Incubation of cells with ouabain induced activation of ERK1/2. Long-term incubation with ouabain induced an increase in Na(+) transepithelial flux and Na(+),K(+)-ATPase expression only in OK cells with 80 passages in culture. This increase was prevented by incubation with inhibitors of MEK1/2 and PI-3K. In conclusion, ouabain-activated signaling cascade mediated by both MEK1/2 and PI-3K is responsible for long-term regulation of Na(+) transepithelial flux in epithelial renal cells. OK cell line with high number of passages is suggested to constitute a particular useful model for the understanding of ouabain-mediated regulation of Na(+) transport.

Antigens from Leishmania amastigotes inducing clinical remission of psoriatic arthritis

A first generation vaccine (AS100-1) was manufactured with protein from four cultured Leishmania species, which proved to be effective in the treatment of psoriasis. A single blind trial on 3,132 psoriasis patients revealed 508 (16.2%) subjects with psoriatic arthritis (PsA) that received AS100-1 antigens. The study group was distributed according to percent psoriasis area and severity index (PASI) reduction from PASI 10 to PASI 100. All groups decreased in arthritis score (AS), tender joints counts and nail changes after treatment; the highest decreased in the PASI 100 group. Relapses of psoriasis and PsA had PASI and AS lower than initial values before treatment. Clinical remissions were at lower doses and less time, after the second course of treatment. Peripheral blood mononuclear cells (PBMC) lymphocyte subsets (LS) varied with PASI range (1-10, 11-20 and 21-72). Pre-treatment, absolute values of gated LS: CD4+, CD8+HLA-, CD8+HLA+, CD8+CD3-, CD8+CD3+ decreased in PBMC as PASI increased, suggesting migration from the blood to the skin. In contrary to the previous finding, the following LS: CD8+CD4-, CD3+CD8-, HLA+CD8-, CD19, CD8+CD4+ and membrane surface immunoglobulin IgA+, IgD+, IgM+, IgE+, and IgG+ increased in PBMC as PASI increased suggesting activation and proliferation by unknown antigens creating a homeostatic cycle between skin/joints and peripheral blood. After nine doses of AS100-1, the following LS: CD8+CD3+, CD8+HLA+, CD3+CD8-, CD4+CD8-, CD8+HLA-, HLA+CD8-, CD8+CD3-, CD19+, CD8+CD4-, CD8+CD4+, IgA+, IgD+, IgM+, IgE+, and IgG+ decreased significantly as compared with values before treatment. The LS decreased stops the vicious cycle between skin/joints and blood explaining clinical remission of lesions.

Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection

INTRODUCTION

Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection, although relatively common, remains controversial.

METHODS

Prospective, observational, multicenter study from 23 June 2009 through 11 February 2010, reported in the European Society of Intensive Care Medicine (ESICM) H1N1 registry.

RESULTS

Two hundred twenty patients admitted to an intensive care unit (ICU) with completed outcome data were analyzed. Invasive mechanical ventilation was used in 155 (70.5%). Sixty-seven (30.5%) of the patients died in ICU and 75 (34.1%) whilst in hospital. One hundred twenty-six (57.3%) patients received corticosteroid therapy on admission to ICU. Patients who received corticosteroids were significantly older and were more likely to have coexisting asthma, chronic obstructive pulmonary disease (COPD), and chronic steroid use. These patients receiving corticosteroids had increased likelihood of developing hospital-acquired pneumonia (HAP) [26.2% versus 13.8%, p < 0.05; odds ratio (OR) 2.2, confidence interval (CI) 1.1-4.5]. Patients who received corticosteroids had significantly higher ICU mortality than patients who did not (46.0% versus 18.1%, p < 0.01; OR 3.8, CI 2.1-7.2). Cox regression analysis adjusted for severity and potential confounding factors identified that early use of corticosteroids was not significantly associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p < 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed.

CONCLUSIONS

Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections.

Feeding associations between Guiana dolphins, Sotalia guianensis (Van Bénèden, 1864) and seabirds in the Lagamar estuary, Brazil

The main objective of the present study was to describe the characteristics regarding interactions between Guiana dolphins, Sotalia guianensis and seabirds in feeding associations in two distinct areas of the Lagamar estuary, Brazil. Boat-based surveys directed towards photo-identification studies of S. guianensis were conducted in the Cananéia Estuary (CE) (25 degrees 01' S and 47 degrees 55' W) from July 2004 to March 2008, as well as in the Paranaguá Estuarine Complex (PEC) (25 degrees 24' S and 48 degrees 24' W) from April 2006 to February 2008. On all occasions when seabirds were observed engaging in multi-species feeding associations with S. guianensis, data on species involved and their numbers were gathered. From 435 observed groups of S. guianensis in the CE, 38 (8.7%) involved interactions with seabirds. In the PEC, from the 286 observed groups, 32 (11.2%) involved the mentioned interactions. The following seabirds were observed in feeding associations with S. guianensis: Fregata magnificens, Sula leucogaster, Phalacrocorax brasilianus, and Sterna sp. In the CE, S. leucogaster was more commonly observed in feeding associations with Guiana dolphins (chi2 = 22.84; d.f. = 3, p < 0.05), while in the PEC no differences were reported when comparing seabird species (chi2 = 5.78; d.f.=3, p = 0.1223). In the CE, feeding associations were significantly more frequent in inner waters (subset A0; chi2 = 9.52; d.f. = 2, p < 0.05), and in winter (chi2 = 12.46; d.f. = 1, p < 0.05). Within these events, 44.7% of the association groups were composed by more than one seabird species. Seasonality in feeding associations was also observed in the PEC (chi2 = 4.76; d.f. = 1, p < 0.05), with same patterns observed in the CE. Interactions were more frequent in inner waters of the Laranjeiras bay, PEC (chi2 = 11.65; d.f. = 2, p < 0.05). Within these events, 74.2% of the association groups were composed by more than one seabird species. Water transparency, prey and seabird abundance and distribution, cetacean group size, and the life cycle of prey and seabirds are listed as the main factors addressing multi-species feeding associations in the Lagamar estuary.

Prostaglandin synthesis genes are differentially transcripted in normal and pyometra endometria of bitches

Pro-inflammatory stimuli, such as endotoxins released by Gram-negative bacteria, are potent stimulators of prostaglandin (PG) synthesis. The aim of this study was to evaluate the gene transcription pattern of PG synthesis enzymes in normal (anestrous, n = 6 and diestrous, n = 8) and pyometra (n = 7) endometria of bitches. Uteri were collected during routine ovariohysterectomy, processed for histopathological evaluation and uterine contents cultured. Gene transcription of COX-1, COX-2, mPGES-1 and PGF-synthase (PGFS) were evaluated by relative real-time PCR and normalized with the ribosomal protein L27 (RPL27) housekeeping gene. Normal uteri had no histological abnormalities and were negative for bacteriology. All pyometra uteri were hyperplasic and Escherichia coli was the only isolated bacterium. Except for COX-1, gene transcription was significantly higher in pyometra than in normal endometria. No significant differences in gene transcription were observed between normal diestrous and anestrous endometria. COX-2 gene transcription was 19 and 69 times higher in pyometra than in diestrous and anestrous endometria (p < 0.001), while PGFS gene transcription had a 3- and 600-fold increase in pyometra endometria compared to normal diestrous and anestrous endometria (p < 0.001). Gene transcription of mPGES-1 was 9 times higher in pyometra than in normal uteri (p < 0.01). Based on these results, we suggest that pyometra-associated E. coli endotoxin release stimulates the up-regulation of COX-2 PGFS and mPGES-1 gene transcription in the endometrium.

Group size and composition of Guiana dolphins (Sotalia guianensis) (Van Bénèden, 1864) in the Paranaguá Estuarine Complex, Brazil

The aim of the present study was to describe the characteristics of Guiana dolphins (S. guianensis) group size and composition in the Paranaguá Estuarine Complex (25° 15' -25° 36' S and 48° 02'-48° 45' W), Paraná State, as well as to verify the existence of relationships between a given environmental variable (water depth, salinity, transparency and temperature) and group size. An area of around 124 km² was surveyed by boat from April 2006 to February 2008 in the following subsets of the estuary: Canal do Superagui (~28 km²), Pinheiros bay (~34 km²), part of Laranjeiras bay, which included the Guaraqueçaba sub-estuary (~38 km²), and part of the Mixture Section of the Paranaguá Estuarine Complex (~24 km²). In 45 survey days, a total of 147 hours were spent observing 286 groups of S. guianensis. Groups varied from two individuals to aggregations of up to 90 individuals (mean ± SD: 11.5 ± 14.4 individuals). Solitary individuals were seen only on five occasions (1.7% of all observations). Groups with calves (n = 247) represented 86.4% overall and were more common in all sub-areas when compared to groups without calves. Groups without calves were found in all sub-areas and were usually smaller and composed of up to 12 individuals. A usual group composition of 70% of adults and 30% of calves was observed considering all sub-areas and seasons. No correlations were found between group size and water temperature (Spearman's rank test, r = 0.0059, p = 0.9338), transparency (Spearman's rank test, r = 0.0597, p = 0.9333), depth (Spearman's rank test, r = 0.1421, p = 0.4698), and salinity (Spearman's rank test, r = -0.1938, p = 0.0665). While Guiana dolphin groups were seen in the entire surveyed area, group size varied significantly among the three main surveyed sub-areas (Kruskal Wallis, H2,196 = 29.85, p = 0.0000). Groups were larger in Laranjeiras bay and smaller in Canal do Superagui. The physical environment, risk of predation, seasonal distribution and abundance of prey are the main possible factors driving larger groups in inner and protected waters.