Comparison of the quick Sepsis-related Organ Failure Assessment and adult sepsis pathway in predicting adverse outcomes among adult patients in general wards: a retrospective observational cohort study

BACKGROUND

Quick Sepsis-related Organ Failure Assessment (qSOFA) is recommended for use by the most recent international sepsis definition taskforce to identify suspected sepsis in patients outside the intensive care unit (ICU) at risk of adverse outcomes. Evidence of its comparative effectiveness with existing sepsis recognition tools is important to guide decisions about its widespread implementation.

AIM

To compare the performance of qSOFA with the adult sepsis pathway (ASP), a current sepsis recognition tool widely used in NSW hospitals and systemic inflammatory response syndrome criteria in predicting adverse outcomes in adult patients on general wards.

METHODS

A retrospective observational cohort study was conducted which included all adults with suspected infections admitted to a Sydney teaching hospital between December 2014 and June 2016. The primary outcome was in-hospital mortality with two secondary composite outcomes.

RESULTS

Among 2940 patients with suspected infection, 217 (7.38%) died in-hospital and 702 (23.88%) were subsequently admitted to ICU. The ASP showed the greatest ability to correctly discriminate in-hospital mortality and secondary outcomes. The area under the receiver-operating characteristic curve for mortality was 0.76 (95% confidence interval (CI): 0.74-0.78), compared to 0.64 for the qSOFA tool (95% CI: 0.61-0.67, P < 0.0001). Median time from the first ASP sepsis warning to death was 8.21 days (interquartile range (IQR): 2.29-16.75) while it was 0 days for qSOFA (IQR: 0-2.58).

CONCLUSIONS

The ASP demonstrated both greater prognostic accuracy and earlier warning for in-hospital mortality for adults on hospital wards compared to qSOFA. Hospitals already using ASP may not benefit from switching to the qSOFA tool.

Trajectories of attention-deficit/hyperactivity disorder dimensions in adults

OBJECTIVE

There is a lack of available information on the trajectories of attention-deficit/hyperactivity disorder (ADHD) dimensions during adulthood. This study investigates the course and the predictors of change for each ADHD domain in a clinical sample of adults with ADHD.

METHOD

Adults with ADHD (n = 344) were followed up for 7 years, with a final retention rate of 66.0%. Trajectories of inattention, hyperactivity, and impulsivity and their potential predictors were examined.

RESULTS

On average, symptoms declined in all ADHD domains during follow-up. Despite this, rises in inattentive, hyperactive, and impulsive symptoms were observed in approximately 13%, 25%, and 17% of patients respectively. Different predictors influenced the trajectory of each ADHD dimension. Oppositional defiant disorder and social phobia were associated with the maintenance of symptoms, while alcohol use disorder was associated with both maintenance and rise of symptoms.

CONCLUSION

Unexpectedly, a rise in the symptoms after 7 years was not uncommon in adults with ADHD. Prevalent comorbidities have the potential to influence the neurodevelopment and the trajectory of ADHD. Therefore, such predictors should be investigated in population cohorts to better characterize the course of ADHD. Additionally, these findings may be relevant in prevention studies and in strategies for ADHD treatment.

Improving actuation efficiency through variable recruitment hydraulic McKibben muscles: modeling, orderly recruitment control, and experiments

Hydraulic control systems have become increasingly popular as the means of actuation for human-scale legged robots and assistive devices. One of the biggest limitations to these systems is their run time untethered from a power source. One way to increase endurance is by improving actuation efficiency. We investigate reducing servovalve throttling losses by using a selective recruitment artificial muscle bundle comprised of three motor units. Each motor unit is made up of a pair of hydraulic McKibben muscles connected to one servovalve. The pressure and recruitment state of the artificial muscle bundle can be adjusted to match the load in an efficient manner, much like the firing rate and total number of recruited motor units is adjusted in skeletal muscle. A volume-based effective initial braid angle is used in the model of each recruitment level. This semi-empirical model is utilized to predict the efficiency gains of the proposed variable recruitment actuation scheme versus a throttling-only approach. A real-time orderly recruitment controller with pressure-based thresholds is developed. This controller is used to experimentally validate the model-predicted efficiency gains of recruitment on a robot arm. The results show that utilizing variable recruitment allows for much higher efficiencies over a broader operating envelope.

Mixing Homologous High Viscosity Ratio Polymer Blends in Converging Flow

Several studies have shown that deformation and breakup of dispersed droplets is easier in extensional than in shear flow field and this is particularly true for systems with high viscosity ratios. The simplest way to generate a significant extensional flow field in compounding equipment is to use converging flow conditions. In this work, the mixing efficiency of converging flow has been investigated as a function of the entry profile and the flow rate by using a capillary rheometer equipped with dies of different geometries. The material used for this study was a bimodal polyethylene presenting inhomo-geneities due to the high viscosity ratio between the low and high molecular weight fractions. The results indicated that the mixing performance depended strongly on the die geometry and flow rate. A critical flow rate was observed for each particular entry profile at which the highest efficiency was observed. This critical flow rate was found to correspond to the onset of melt flow instabilities.

Sediment contact tests as a tool for the assessment of sediment quality in German waters

A sediment contact test (SCT) battery consisting of five ecotoxicological test systems was applied to 21 native freshwater sediments characterized by a broad variety of geochemical properties and anthropogenic contamination. Higher plants (Myriophyllum aquaticum), nematodes (Caenorhabditis elegans), oligochaetes (Lumbriculus variegatus), zebrafish embryos (Danio rerio), and bacteria (Arthrobacter globiformis), representing various trophic levels and exposure pathways, were used as test organisms. The test battery detected sediment toxicity caused by anthropogenic pollution, whereas the various tests provided site-specific, nonredundant information to the overall toxicity assessment. Based on the toxicity pattern derived from the test battery, the sediments were classified according to a newly proposed classification system for sediment toxicity assessment. The SCT-derived classification generally agreed well with the application of consensus-based sediment quality guidelines (SQGs), especially with regard to sediments with high toxic potential. For sediments with low to medium toxic potential, the SQGs often underestimated the toxicity that was detected by the SCTs, underpinning the need for toxicity tests in sediment quality assessment.

Variability of sediment-contact tests in freshwater sediments with low-level anthropogenic contamination--determination of toxicity thresholds

Freshwater sediments with low levels of anthropogenic contamination and a broad range of geochemical properties were investigated using various sediment-contact tests in order to study the natural variability and to define toxicity thresholds for the various toxicity endpoints. Tests were performed with bacteria (Arthrobacter globiformis), yeast (Saccharomyces cerevisiae), nematodes (Caenorhabditis elegans), oligochaetes (Lumbriculus variegatus), higher plants (Myriophyllum aquaticum), and the eggs of zebrafish (Danio rerio). The variability in the response of some of the contact tests could be explained by particle size distribution and organic content. Only for two native sediments could a pollution effect not be excluded. Based on the minimal detectable difference (MDD) and the maximal tolerable inhibition (MTI), toxicity thresholds (% inhibition compared to the control) were derived for each toxicity parameter: >20% for plant growth and fish-egg survival, >25% for nematode growth and oligochaete reproduction, >50% for nematode reproduction and >60% for bacterial enzyme activity.

Changes in placental adipocytokine gene expression associated with gestational diabetes mellitus

Leptin and adiponectin, two adipocytokines, may work together in regulating energy homeostasis and insulin action. Leptin gene expression has been investigated in term placental tissue complicated by gestational diabetes mellitus (GDM), but never in conjunction with all isoforms of the leptin receptor (LEPR A-D), or with adiponectin receptors (ADIPOR1 and 2). In this study we examined the association between changes in expression of these genes in placental tissue and GDM risk. We assessed placental gene expression of leptin, LEPR A-D and ADIPOR1 and 2 by real time PCR using mRNA from maternal and fetal biopsies. Tissues were collected from uncomplicated pregnancies (n=28) and those complicated by GDM (n=19). Gene expression was normalized to three endogenous housekeeping genes. Relative gene expression values were reported as fold change between groups. Adiponectin gene expression was out of the sensitive range of our assay. There were increases in leptin mRNA expression in GDM cases compared with controls for maternal-side (p=0.06), and fetal-side (p=0.09) placental biopsies. No significant changes were seen in GDM cases compared with controls in LEPR A-D or ADIPOR1 and 2. mRNA derived from maternal-side tissue was positively correlated with tissue from the fetal side for all genes studied (all p<0.01). Finally, we noted that absence or presence of GDM was a major factor in leptin mRNA expression after adjusting for maternal age, mode of delivery, parity and smoking status. In conclusion, increases in leptin mRNA expression in term placenta, but not that of its receptors, are associated with the diagnosis of GDM. Changes seen in the ligand, but not the receptor, of the leptin pathway in GDM-complicated pregnancies may also apply to the adiponectin pathway, as the ADIPOR1 and 2 mRNAs do not change with GDM diagnosis.

Evaluation of housekeeping genes in placental comparative expression studies

Preeclampsia and diabetes are complications of pregnancy that contribute to maternal and perinatal mortality worldwide. Results emerging from molecular studies of placentae may elucidate etiologically important genomic alterations. Appropriate application of real time reverse transcription (RT) PCR in comparative gene expression studies requires endogenous housekeeping genes to normalize between sample variations. Ideal housekeeping genes must have stable tissue expression, but few have been specifically studied in the placenta. We sought to identify candidate control genes by analyzing seven functionally distinct housekeeping genes (B2M, GAPDH, HMBS, HPRT, SDHA, TBP, YWHAZ) for their expression stability and level in the placenta. mRNA isolated from 20 placentae was analyzed for gene expression using RT-PCR. Expression stability (M) was assessed using normalization strategies previously used for other tissues. TBP and SDHA were the most stable, with an average expression stability of M = 0.43, followed by YWHAZ (M = 0.44) > HPRT (M = 0.53) > HMBS (M = 0.57) > GAPDH (M = 0.61) > B2M (M = 0.69). The genes tested ranged in abundance, with an approximately 300-fold increase from the lowest (HMBS) to the highest (B2M). By using TBP, SDHA and YWHAZ, with greater expression stability than those housekeeping genes commonly used in placenta studies, gene expression profile comparisons will have more sensitivity and specificity.

Environmental fate of pharmaceuticals in water/sediment systems

In recent years there has been growing interest on the occurrence and the fate of pharmaceuticals in the aquatic environment. Nevertheless, few data are available covering the fate of the pharmaceuticals in the water/sediment compartment. In this study, the environmental fate of 10 selected pharmaceuticals and pharmaceutical metabolites was investigated in water/sediment systems including both the analysis of water and sediment. The experiments covered the application of four 14C-labeled pharmaceuticals (diazepam, ibuprofen, iopromide, and paracetamol) for which radio-TLC analysis was used as well as six nonlabeled compounds (carbamazepine, clofibric acid, 10,11-dihydro-10,11-dihydroxycarbamazepine, 2-hydroxyibuprofen, ivermectin, and oxazepam), which were analyzed via LC-tandem MS. Ibuprofen, 2-hydroxyibuprofen, and paracetamol displayed a low persistence with DT50 values in the water/sediment system < or =20 d. The sediment played a key role in the elimination of paracetamol due to the rapid and extensive formation of bound residues. A moderate persistence was found for ivermectin and oxazepam with DT50 values of 15 and 54 d, respectively. Lopromide, for which no corresponding DT50 values could be calculated, also exhibited a moderate persistence and was transformed into at least four transformation products. For diazepam, carbamazepine, 10,11-dihydro-10,11-dihydroxycarbamazepine, and clofibric acid, system DT90 values of >365 d were found, which exhibit their high persistence in the water/sediment system. An elevated level of sorption onto the sediment was observed for ivermectin, diazepam, oxazepam, and carbamazepine. Respective Koc values calculated from the experimental data ranged from 1172 L x kg(-1) for ivermectin down to 83 L x kg(-1) for carbamazepine.

Leaching behaviour of pharmaceuticals in soil-testing-systems: a part of an environmental risk assessment for groundwater protection

The leaching behaviour of six selected pharmaceuticals was tested in different soils. Leaching experiments are a part of environmental risk assessment to estimate the distribution and fate of these pharmaceuticals in the environment. Based on the results of this assessment their mobility in soil and their potential to contaminate groundwater was evaluated. When assessing the leaching behaviour of these compounds, the influence of the properties (e.g. grain size distribution, pH, Corg) of different soils has to be taken into account. The test results indicated that the leaching potential found could be rated as low for diazepam, ibuprofen, ivermectin and carbamazepine. Therefore, contamination of the groundwater with these substances seems to be unlikely if the groundwater level is covered with sufficient layers of the soils investigated. Clofibric acid and iopromide were very mobile under the experimental conditions and thus, groundwater contamination would be possible if the soil is exposed to these pharmaceuticals, i.e. wastewater irrigation. These results are more or less in agreement with groundwater monitoring data found in the literature for ibuprofen and diazepam which were in general not present in groundwater, while clofibric acid and iopromide were frequently detected. However, a discrepancy was found for carbamazepine, since it occurs very often in groundwater. This discrepancy might be explained by the fact that the leaching tests were performed with soil, whereas in reality the groundwater contamination occurs mainly over river sediments and sub soil from receiving waters.

[Diagnosis and surgical treatment of idiopathic macular holes]

AIM

Evaluation of diagnostical methods and pars plana vitrectomy (ppv) in surgical treatment of idiopathic macular holes.

MATERIAL AND METHODS

Group of 16 patients, 15 women and 1 man, aged between 48 and 78 years, mean age 63 years. The surgical treatment--ppv were performed in all patients with macular holes stage II-IV. In all patients the following examinations were performed: distant and near visual acuity, ophthalmoscopy in Volk 60 lens, Amsler test, colour vision test with anomaloscope IF2, ultrasonic evaluation of vitreous chamber and particularly of premacular region, and electrophysiological tests-visual evoked potentials (VEP) and electroretinography (ERG). 12 patients were treated by ppv with exchange fluid-gas SF6, and in 4 patients extra adjuvant--own patient's serum was injected after earlier exchange fluid-air-gas SF6.

RESULTS

In 80% of cases there was an improvement of vision observed by patients, improvement of near visual acuity and reduction of metamorphopsia in Amsler test. In USG examination the reduction of macular thickening, lack of operculum and presence of complete posterior vitreous detachment in the region of macula were observed after surgery. In electrophysiological investigations there was the improvement of VEP parameters using 1/4 visual field as a stimulus. In 1 case treated with adjuvants, there was endophtalmitis with secondary retinal detachment after ppv.

CONCLUSIONS

Ppv in nearly all cases gave good results for patients--improvement of visual comfort and reduction of central defect of vision. It also gave good surgical--anatomical results. Using of adjuvant--own patient's serum, did not improve in particular way the functional and anatomical results of surgery.

Analysis of melanocyte precursors in Nf1 mutants reveals that MGF/KIT signaling promotes directed cell migration independent of its function in cell survival

Neural crest-derived melanocyte precursors (MPs) in avian and murine embryos emerge from the dorsal neural tube into a migration staging area (MSA). MPs subsequently migrate from the MSA on a dorsolateral pathway between the dermamyotome and the overlying epithelium. In mouse embryos, MPs express the receptor tyrosine kinase, KIT, and require its cognate ligand, Mast cell growth factor (MGF), for survival and differentiation. Prior to the onset of MP migration, MGF is expressed on the dorsolateral pathway at some distance from cells in the MSA and appears to be required for normal MP development. To learn if MGF is required solely for MP survival on this pathway, or if it also provides directional cues for migration, we uncoupled survival from chemoattractive or motogenic functions of this ligand using mice that carry a targeted mutation at the Neurofibromin (Nf1) locus and consequently lack RAS-GAP function. We show that Nf1-mutant MPs survive in the absence of MGF in vitro and in vivo and that Nf1-mutant MPs disperse normally on the lateral migration pathway in the presence of MGF. In contrast, Nf1-mutant MPs persist in the location of the MSA but are not observed on the lateral migration pathway in double-mutant mice that also lack MGF. We conclude that MGF/KIT function provides a signal required for directed migration of the MPs on the lateral pathway in vivo, independent of its function in survival. We further suggest that the MGF mediates MP migration through a signaling pathway that does not involve RAS.

[Diagnostic studies of optic neuritis in children and adolescents]

PURPOSE

To evaluate the sensitivity of various diagnostic methods in the optic neuritis.

MATERIAL AND METHODS

15 patients, 10 boys and 5 girls, aged 6-18 years, with optic neuritis have been examined. Multiple sclerosis was diagnosed in 12 cases, the etiology of 3 was unknown. The full ophthalmological examination, including static perimetry and visual evoked potentials (VEP) as well as brain computed tomography (CT) and magnetic resonance imaging (MRI) were performed.

RESULTS

MRI revealed plaques of demyelination in 11 patients; no pathological changes were observed in cases of idiopathic neuritis. In CT plaques of demyelination were found in 2 patients only. In most cases VEPs were abnormal, mainly there was prolonged latency of deflection, decreased amplitude and more rarely changes of the shape of the record. Static perimetry, with white and blue target, revealed multiple scattered absolute and relative scotoma in the 30 degrees central area.

CONCLUSIONS

MRI and static perimetry were the most sensitive methods for detection of the changes in optic neuritis and these methods are also useful in cases with asymptomatic involvement of visual pathway, especially in multiple sclerosis.

Short-term toxicity of lindane, hexachlorobenzene, and copper sulfate to tubificid sludgeworms (Oligochaeta) in artificial media

The toxicity of lindane, hexachlorobenzene, and copper sulfate to Tubifex tubifex and Limnodrilus hoffmeisteri was determined using an easily applicable and standardizable 72-h short-term test system. It was designed for the quick assessment of sublethal and lethal effects of sediment-associated chemicals on the worms. An artificial sediment based on the Artificial Soil according to OECD Guideline No. 207 was used as test medium. The data confirm the common view that oligochaetes are highly tolerant of lethal effects. However, sublethal effects were detected at considerably lower concentrations than found for lethal effects. The EC50 values for autotomy (172 mg/kg dry wt sediment) and sediment avoidance (217 mg/kg) for T. tubifex exposed to lindane-contaminated sediment were, for example, more than five times lower than the LC50 value (> 1000 mg/kg). The no-observed-effect concentration for reworking activity (8 mg/kg) was more than 125 times lower than the LC50. Tubificids thus turned out to represent useful test organisms for the assessment of the ecotoxicological hazard potential of chemicals in the sediment compartment, because the sublethal effects not only affect the individual, but can influence the population levels and, consequently, the composition of the benthic community.

[A case of recurrent total ophthalmoplegia]

The author presented a case of a girl, aged 10, with total ophthalmoplegia of the right eye, recurring 4 times. The onset of the disease was preceded by nausea, vomits and headache. The symptoms of the palsy released spontaneously after 2-3 weeks.

[A case of Recklinghausen's disease with glioma of the optic nerve]

A case of Recklinghausen's disease in a 2.5-year-old girl, with typical skin changes and tumor of the optic nerve is presented. The tumor was excised, preserving the eyeball, and diagnosed histopathologically as glioma. The child remained under control.

[Possible advantages of visual evoked potentials and computerized static perimetry in early diagnosis of glaucoma]

Aim of the studies was to evaluate usefulness of the visual evoked potentials and static perimetry in diagnosis of an early glaucoma. There were 12 examined cases, divided into 3 equal groups: 1) patients suspected for glaucoma basing on the characteristic picture of the optic disc, 2) patients after acute glaucoma in one eye with no history of the disease in the fellow eye, 3) patients with open angle glaucoma diagnosed in one eye. Abnormal results of the examinations were found only in the second group. The authors concluded that visual evoked potentials and static perimetry could be helpful in proper diagnosis of many difficult cases suspected for glaucoma.

High-dose intravenous immunoglobulins in HIV-1-infected adults with AIDS-related complex and Walter-Reed 5

The influence of high-dose intravenous immunoglobulins (HD-IVIG) on the clinical status and T4 cell count of adults with AIDS-related complex (ARC) and Walter-Reed 5 (WR5) was evaluated in a randomized double-blind longitudinal study. Inclusion criteria were: (1) T4 cells less than 400/microliters and (2a) oral thrush or cutaneous anergy or (2b) two clinical ARC criteria (fever, diarrhea, weight loss, fatigue, night sweats). Thirty patients [28 males, 2 females, median age 41 (24-64) years] with ARC (n = 8), WR5 (n = 12) and both (n = 10) were stratified according to their T4 cell count (greater than or equal to vs. less than 300/microliters). Fifteen patients received 0.4 g/kg body weight IVIG and 15 placebo (albumin 0.03%) every other week for 26 weeks with follow-up for another 26 weeks. The clinical status was defined as a score consisting of fever, diarrhea, night sweats, fatigue, weight loss, oral candidiasis and mucosal or cutaneous herpes simplex. Clinical examination and routine laboratory assessments were performed before initiation of the study and before each administration, lymphocyte phenotyping every 4 weeks and cutaneous reaction, serology and lymphocyte stimulation every 12 weeks. Both groups were comparable in initial clinical symptoms and laboratory values. Seven patients developed AIDS (treatment group: 3, placebo group: 4), 1 patient died by homicide. After 26 weeks, the clinical score (particularly fatigue and fever) was significantly improved in the treatment group, while the T4 cell count and other clinical and immunological parameters remained unaltered. This limited effect was still evident at termination of the study after 52 weeks. In conclusion, HD-IVIG can improve the clinical status of patients with advanced HIV-1 infection without obviously correcting the underlying impaired cellular immunity. The substitution of intact antibodies in the state of functional hypogammaglobulinemia is suggested as possible therapeutic mechanism.

[Malignant melanoma and HIV infection]

Among 1000 patients with HIV infection consecutively examined at our dermatological department during the last 3 years, we diagnosed 4 cases of malignant melanoma. This figure is clearly higher than the statistical incidence of 4-13 cases per 100.000 people a year observed in West Germany. The mean age of our 4 patients and 3 additional cases reported in the literature is 10 years less than the average age found in melanoma patients without HIV infection. These findings indicate an increased risk of malignant melanoma in patients with HIV infection. In most of our patients, the cellular immunity was only marginally impaired, corresponding to the stages WR1 and WR2 (Walter Reed classification). Tumor formation, therefore, does apparently not depend on the severity of decompensation of the immunity.