Journal articles: 'Range Site (Ill.)'

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Evans, A., and EH Winslow. "Oxygen saturation and hemodynamic response in critically ill, mechanically ventilated adults during intrahospital transport." American Journal of Critical Care 4, no. 2 (March 1, 1995): 106–11. http://dx.doi.org/10.4037/ajcc1995.4.2.106.

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BACKGROUND: Despite the frequency of intrahospital transport of critically ill patients, little research has been done on this topic and the findings are contradictory. OBJECTIVES: To describe arterial oxygen saturation by pulse oximetry, heart rate, heart rhythm, and systolic blood pressure and equipment problems in critically ill, mechanically ventilated adults during intrahospital transport. METHODS: The sample consisted of 36 critically ill, mechanically ventilated adults who required transport out of the intensive care unit for diagnostic testing or procedures within the hospital. Arterial oxygen saturation, heart rate, heart rhythm, and systolic blood pressure were measured at baseline, at least every 5 minutes during transport to and from the test site and at the test site, and every 5 minutes for 15 minutes after return to the unit. Descriptive statistics were used to analyze the data. RESULTS: Nineteen patients (53%) had clinically important changes in arterial oxygen saturation, heart rate, and/or systolic blood pressure. New cardiac arrhythmias developed in two patients. The clinically important changes occurred most frequently at the test/procedure site. Equipment problems such as monitor power failure and ventilator disconnection occurred during transport of 4 patients (11%). Total time out of ICU averaged 62 +/- 30 (range = 26 to 166) minutes. CONCLUSIONS: Transport outside the intensive care unit places the critically ill patient at additional risk. Although transport is often unavoidable, its risks versus benefits should be carefully and collaboratively evaluated for every patient prior to making the decision for transport.

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Woods-Hill, Charlotte Z., Danielle W. Koontz, Annie Voskertchian MPH, Anping Xie PhD, Marlene R. Miller, James C. Fackler MD, Elizabeth A. Colantuoni PhD, Aaron Milstone, and Aaron Milstone. "1350. Optimizing Blood Culture Use in Critically Ill Children: Year One of a Multi-Center Diagnostic Stewardship Collaborative." Open Forum Infectious Diseases 7, Supplement_1 (October 1, 2020): S685—S686. http://dx.doi.org/10.1093/ofid/ofaa439.1532.

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Abstract Background Overuse of blood cultures can lead to false positives and unnecessary antibiotics. Our objective was to describe the implementation and 12-month impact of a multi-site quality improvement collaborative to reduce unnecessary blood cultures in pediatric intensive care unit (PICU) patients. Methods In 2018, 14 PICUs joined the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR) Collaborative, designed to understand and improve blood culture practices in PICUs. Guided by a multidisciplinary study team, sites 1) reviewed existing evidence for safe blood culture reduction, 2) assessed local practices and barriers to change, and 3) developed and implemented new blood culture practices informed by local context. We facilitated and monitored project progress through phone calls, site visits, and collaborative-wide teleconferences. We collected monthly blood culture rates and monitored for delays in culture collection as a safety balancing metric. We compared 24 months of baseline data to post-implementation data (2-14 months) using a Poisson regression model accounting for the site-specific patient days and correlation of culture use within a site over time. Results Across 14 sites, there were 41,986 pre-implementation blood cultures collected over 238,182 PICU patient days. The mean pre-implementation site-specific blood culture rate was 19.42 cultures/100 patient days (range 9.59 to 48.18 cultures/100 patient days). Post-implementation, there were 12,909 blood cultures collected over 118,600 PICU patient days. The mean post-implementation rate was 14.02 cultures/100 patient days (range 5.40 to 37.57 cultures/100 patient days), a 23% decrease (relative rate 0.77, 95% CI: 0.60, 0.99, p = 0.04). In 12 months post-implementation, sites reviewed 463 positive blood cultures, and identified only one suspected delay in culture collection possibly attributable to the site’s culture reduction program. Bright STAR Collaborative Site Blood Culture Rate 100 Patient Days Conclusion Multidisciplinary teams facilitated a 23% average reduction in blood culture use in 14 PICUs. Future work will determine the impact of blood culture diagnostic stewardship on antibiotic use and other important patient safety outcomes. Disclosures James C. Fackler MD, MD, Rubicon Health LLC (Other Financial or Material Support, Founder)

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Eschenfelder, Kristin R., Tien-I. Tsai, Xiaohua Zhu, and Brenton Stewart. "How Institutionalized Are Model License Use Terms? An Analysis of E-Journal License Use Rights Clauses from 2000 to 2009." College & Research Libraries 74, no. 4 (July 1, 2013): 326–55. http://dx.doi.org/10.5860/crl-289.

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This paper explored the degree to which use terms proposed by model licenses have become institutionalized across different publishers’ licenses. It examined model license use terms in four areas: downloading, scholarly sharing, interlibrary loan, and electronic reserves. Data collection and analysis involved content analysis of 224 electronic journal licenses spanning 2000–2009. Analysis examined how use terms changed over time, differences between consortia and site license use terms and differences between commercial and noncommercial publisher license use terms. Results suggest that some model license use terms have become institutionalized while others have not. Use terms with higher institutionalization included: allowing ILL, permitting secure e-transmission for ILL, allowing e-reserves with no special permissions, and not requiring deletion of e-reserves files. Scholarly sharing showed lower institutionalization with most publishers not including scholarly sharing allowances. Other use terms showing low institutionalization included: recommendations to avoid printing requirements related to ILL and recommendations to allow hyperlinks for e-reserves. The results provide insight into the range of use terms commonly employed in e-journal licenses.

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Umadat, Deviani, Dharscika Arudkumaran, and Deirdre Cocks Eschler. "Intravenous Insulin Resistance in a Critically Ill Patient Secondary to Decreased Peripheral Perfusion." Journal of the Endocrine Society 5, Supplement_1 (May 1, 2021): A388. http://dx.doi.org/10.1210/jendso/bvab048.791.

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Abstract Introduction: Intravenous (IV) insulin infusion is the preferred treatment modality for hyperglycemia in the intensive care unit (ICU) due to its short duration of action and easy titratability. However, administration of IV insulin has challenges. These include frequent monitoring, site infiltration, and high insulin dose requirements with other ICU medications such as epinephrine. There are, however, limited reports demonstrating an elevated insulin requirement due to poor peripheral perfusion. Below illustrates such a case, necessitating a change from peripheral to central IV insulin administration. Case Presentation: A 50 year old male with well controlled type 2 diabetes and previous aortic valve replacement presented to our facility for prosthetic valve endocarditis complicated by aortic root abscess. He was admitted to the ICU, treated with IV antibiotics, abscess washout and aortic valve replacement. Preoperatively, he was started on IV regular insulin via continuous infusion through a central line. During the pre and intraoperative periods, his hourly IV insulin requirement ranged from 2.4 to 5 units/ hour (hr). His blood glucose (BG) ranged from 107-251mg/dL (n 70-99mg/dL). The patient became hypotensive intraoperatively requiring vasopressor support. Dobutamine and norepinephrine infusions were started via central access and were continued postoperatively at steady rates. Vasopressin was added through central access as the patient failed to meet hemodynamic targets. Postoperatively, the propofol infusion was discontinued and the IV regular insulin infusion was moved to the peripheral line where the propofol had previously been administered. BG increased steadily to a maximum of 402 mg/dL despite an increase in the peripheral IV insulin rate to 152.4 units/hr. The site of the IV insulin drip was changed to another solitary peripheral access without success in decreasing the IV insulin infusion rate. The elevated requirements were deemed secondary to the patient’s lack of peripheral perfusion and should decrease with transition to a central line. A preemptive decrease in insulin drip rate to 10% of the peripheral dose was used to avoid hypoglycemia. The insulin drip was changed to a central access with a rate of 15units/ hr. BG values declined to a range of 140 -180 mg/dL. The patient remained on the multiple vasopressors for hemodynamic support, however, the insulin drip was able to be decreased and ultimately, discontinued. Conclusion: This case illustrates a unique challenge in the treatment of hyperglycemia with multifactorial shock and our approach to management. Elevated IV insulin requirements persisted despite stability in vasopressor dose, change to a solitary peripheral IV site, and lack of interfering medications in the treatment regimen. This is the first case to demonstrate a relationship between high IV insulin requirements and poor peripheral perfusion.

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Kindler, Christoph H., Davide Verotta, Andrew T. Gray, Michael A. Gropper, and C. Spencer Yost. "Additive Inhibition of Nicotinic Acetylcholine Receptors by Corticosteroids and the Neuromuscular Blocking Drug Vecuronium." Anesthesiology 92, no. 3 (March 1, 2000): 821–32. http://dx.doi.org/10.1097/00000542-200003000-00026.

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Background Neuromuscular disorders associated with muscular weakness and prolonged paralysis are common in critically ill patients. Acute myopathy has been described in patients receiving a combination therapy of corticosteroids and nondepolarizing neuromuscular blocking drugs for treatment of acute bronchospasm. The cause of this myopathy is not fully established and may involve drug interactions that perturb neuromuscular transmission. To investigate the interaction of corticosteroids with neuromuscular blocking drugs, the authors determined the effects of methylprednisolone and hydrocortisone alone and in combination with vecuronium on fetal (gamma-subunit containing) and adult (epsilon-subunit containing) subtypes of the muscle-type nicotinic acetylcholine receptor. Methods Functional channels were expressed in Xenopus laevis oocytes and activated with 1 microM acetylcholine. The resulting currents were recorded using a whole cell two-electrode voltage clamp technique. Results Both forms of the muscle-type acetylcholine receptor were potently inhibited by methylprednisolone and hydrocortisone, with concentrations producing 50% inhibition in the range of 400-600 microM and 1-2 mM, respectively. The corticosteroids produced noncompetitive antagonism of the muscle-type nicotinic acetylcholine receptor at clinical concentrations. Both receptor forms were also inhibited, even more potently, by vecuronium, with a concentration producing 50% inhibition in the range of 1-2 nM. Combined application of vecuronium and methylprednisolone showed additive effects on both receptor forms, which were best described by a two-site model, with each site independent. Conclusions The enhanced neuromuscular blockade produced when corticosteroids are combined with vecuronium may augment pharmacologic denervation and contribute to the pathophysiology of prolonged weakness observed in some critically ill patients.

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Zardo, Karen Maciel, Lucas Petri Damiani, Julia Maria Matera, and Ana Carolina B. C. Fonseca-Pinto. "Feline injection site sarcoma: computed-tomographic density and assessment of tumor dimensions by different methods." Pesquisa Veterinária Brasileira 37, no. 10 (October 2017): 1113–18. http://dx.doi.org/10.1590/s0100-736x2017001000012.

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ABSTRACT: Feline injection site sarcoma is a malignant neoplasm with digitiform projections into muscular planes that are ill recognized during physical examination and may compromise tumor margin demarcation. This study compared tumoral size of 32 cats measured by different methods, and evaluated the CT density of 10 tumoral tissues (Hounsfield unit) based on histograms. Tumor axes were measured by physical examination and CT images. Larger craniocaudal axis measurements were obtained following multiplanar reconstruction of pre- and post-contrast CT images (p=0.049 and p=0.041 respectively); dorsoventral axis measurements taken from post-contrast CT images were also larger (p=0.010). Tumor volume estimates increased following contrast-enhancement. Histograms tended to produce two peaks: one in the fat and another in the soft tissue attenuation range. Multiplanar reconstructed post-contrast CT images provided clearer definition of tumor margins and more judicious determination of tumor size. A tendency of common FISS attenuation profile could be described.

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Byrne, Mary W., Elana Evan, Lorie S. Goshin, Matthew D. Erlich, Jackie H. J. Kim, John M. Saroyan, and Lonnie K. Zeltzer. "Parent self-efficacy for managing pain in seriously ill children and adolescents nearing end of life." Palliative and Supportive Care 9, no. 2 (May 4, 2011): 137–47. http://dx.doi.org/10.1017/s1478951511000010.

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AbstractObjective:Using data from a multi-site study of parent–child symptom reporting concordance, this secondary analysis explored the role of parent self-efficacy related to pain management for seriously ill school-age children and adolescents.Method:In the initial study, 50 children and adolescents who were expected to survive 3 years or less were recruited along with their parent/primary caregiver. Parent self-report data were used in this secondary analysis to describe parent self-efficacy for managing their child's pain, caregiver strain, mood states, and perception of the child's pain; to explore relationships among these variables; and to determine predictors of greater self-efficacy.Results:Parents expressed a wide range of self-efficacy levels (Chronic Pain Self-Efficacy Scale; possible range 10–100, mean 76.2, SD 14.7) and higher levels on average than reported previously by family caregivers of adult patients. Caregiver Strain Index scores were markedly high (possible range 0–13, mean 8.1, SD 3.8) and inversely correlated with self-efficacy (r = −0.44, p = 0.001). On the Profile of Mood States parents reported more negative moods (t = 4.0, p < 0.001) and less vigor (t = −5.0, p < 0.001) than adults in a normative sample, yet vigor rather than mood disturbance predicted self-efficacy. With the exception of child age, self-efficacy was not associated with demographics (child gender, ethnicity, household income, parent age, education, family size) or with the diagnostic groups (primarily cardiac and oncologic) comprising the sample. Younger child age, less caregiver strain, more parent vigor, and parent perception that child is without pain predicted more than half of the variance in parent self-efficacy (R2 = 0.51).Significance of results:Findings advance knowledge of parent self-efficacy in managing the pain of a child with life-threatening illness. Results can be used to design supportive interventions enhancing parents’ caregiving roles during their child's last stages of life.

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Finn, Stephen P., Eamon Leen, Liam English, and D. Sean O'Briain. "Autopsy Findings in an Outbreak of Severe Systemic Illness in Heroin Users Following Injection Site Inflammation: An Effect of Clostridium novyi Exotoxin?" Archives of Pathology & Laboratory Medicine 127, no. 11 (November 1, 2003): 1465–70. http://dx.doi.org/10.5858/2003-127-1465-afiaoo.

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Abstract Context.—An epidemic of unexplained illness among injecting drug users characterized by injection site inflammation and severe systemic toxicity occurred in Ireland and the United Kingdom from April to August 2000. One hundred eight persons became ill, and 43 persons died. In Dublin, 8 of 22 patients died. Six of the 8 fatal cases were epidemiologically linked to a source of heroin. Most had experienced local injection site lesions for 7 to 14 days before developing a rapidly fatal systemic illness characterized by hypotension, thirst, pulmonary edema, pericardial and pleural effusions, and leukocytosis. Objective.—To document the clinical course and autopsy findings of the fatal cases in Dublin. Design.—To study the clinical, autopsy, microbiologic, and toxicologic findings from the 8 fatal cases in Dublin. Results.—In Dublin, there were 6 men and 2 women who were fatally involved in the epidemic, with the mean age being 34 years (range, 22–51 years). The injection site inflammations involved the buttock (n = 4), leg, iliac region, arm, and a Portacath site. At autopsy, the local lesions were ulcerated, swollen, and indurated but were inconspicuous in 2 patients. All the deceased had pulmonary edema. There were pleural effusions in 7, 2 of whom had pericardial effusions. Five had prominent left ventricular subendocardial hemorrhages. Five had splenomegaly. Microscopy showed pulmonary edema and a granulocytic reaction mainly in the spleen, marrow, and myocardium. Toxicology showed a range of narcotic drugs in the toxic or fatal range. Clostridium novyi type A, a fastidious toxin-producing anaerobe, was identified in 2 cases. Conclusion.—The clinicopathologic findings of a local inflammatory lesion followed 7 to 14 days later by a rapidly fatal systemic illness are consistent with the effect of exotoxin produced by organisms growing in the local inflammatory site. Clostridium novyi–derived exotoxin is the likely cause of such a syndrome, although the fastidious organism was isolated from only 2 of 8 cases (from none of the 14 surviving patients and from only 13 of 60 cases in Scotland). In the setting of an epidemic, the toxic and fatal range blood levels of narcotics are unlikely to explain these events, and no other candidate organism could be isolated. The heroin is likely to have come from Afghanistan, but local contamination at a putative distribution site in the United Kingdom is more likely than international terrorism to be the initiating factor.

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Cesca, Eleonora, Giacomo Garetto, Emanuela Frascella, Simone Cesaro, Patrizia Dall'Igna, and Giovanni Cecchetto. "Hyperbaric oxygen treatment of superficial soft tissue lesions in children with oncologic disease." Pediatric Reports 4, no. 1 (December 27, 2011): 1. http://dx.doi.org/10.4081/pr.2012.e1.

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This study aimed to assess the feasibility and results of hyperbaric oxygen therapy (HOT) as supportive treatment of lesions of superficial soft tissues in children with oncological diseases. This was a retrospective analysis and review of all records of children observed at the Pediatric Hematology-Oncology Department of the University of Padova and treated adjuvantly with HOT. Between 1996 and 2010, 12 patients (5 males and 7 females, median age 7 years, range 0.5-16) underwent HOT. The effectiveness of HOT varied according to the lesion treated. Ten out of 12 patients were cured. Efficacy was most questionable in 2 patients with skin graft and flaps at risk. Compliance to therapy was close to 100%. In just one case, HOT was interrupted for the appearance of local skin metastases close to the site of primary tumor. HOT showed itself to be safe and effective in most patients even those immunocompromised or critically ill.

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Dr.Chandrasinh Rajput, Dr.Hitendra Shah, Dr.Shruti Mehta, Dr.Tanvi Goyal, Dr.Vinita Karia, and Dr.Viraj Shah. "Etiology and Management of Inflammatory Papillary Hyperplasia in Completely Edentulous Patients - A Review." Journal of Current Medical Research and Opinion 3, no. 09 (September 9, 2020): 614–18. http://dx.doi.org/10.15520/jcmro.v3i09.334.

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Oral mucosa of complete denture wearing patients is subjected to varying amount of stresses as compared to patient having natural teeth. This can leads to different type of oral mucosal lesions like denture stomatitis, epulis fissuratum, angular cheilitis, traumatic ulcers, inflammatory papillary hyperplasia (IPH) etc. IPH is a type of chronic inflammatory proliferative lesion characterized by numerous small, wart like edematous red papillary growth most commonly seen in deepest part of the palate. Review of literature suggest denture associated widely distributed etiology for IPH like over accentuation of palatal relief and vacuum chamber in upper denture, old ill fitting dentures, poor denture hygiene, continuous denture wearing habit, faulty occlusion, skidding of instable denture etc. Treatment for IPH varies with the severity of the condition and may range from conservative to surgical depending on clinical presentation. Conservative approach include discontinuing use of ill fitting denture, correction of faulty prostheses, improving the oral and denture hygiene and antifungal drugs. However, the surgical approach is used when the lesion is more aggressive and this include supraperiosteal excision, resesctive surgery, cryotherapy, and electrosurgery, blade-loop surgery, fulguration, and mucoabrasion or laser surgery. As a method of prevention patient should be advised to avoid continuous day and night wearing of denture. Additionally, avoid providing excessive relief in the palatal region, as these areas become site for bacterial and fungal colonization. Patients should be well motivated for proper care and maintenance of denture hygiene and also for the importance of periodic dental visits and follow-ups.

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Nesseler, Nicolas, Marie-Clémence Verdier, Yoann Launey, Alexandre Malherbe, Marine Dermu, Caroline Piau, Erwan Flécher, Olivier Tribut, Yannick Mallédant, and Philippe Seguin. "High-Dose Continuous Oxacillin Infusion Results in Achievement of Pharmacokinetics Targets in Critically Ill Patients with Deep Sternal Wound Infections following Cardiac Surgery." Antimicrobial Agents and Chemotherapy 58, no. 9 (June 30, 2014): 5448–55. http://dx.doi.org/10.1128/aac.02624-14.

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ABSTRACTKnowledge regarding antimicrobial therapy strategies in deep sternal wound infections (DSWI) following cardiac surgery is limited. Therefore, we aimed to determine the steady-state plasma and mediastinal concentrations of oxacillin administered by continuous infusion in critically ill patients with DSWI and to compare these concentrations with the susceptibility of staphylococci recovered. A continuous infusion of oxacillin (150 to 200 mg/kg of body weight/24 h) was administered after a loading dose (50 mg/kg). Plasma and mediastinal concentrations of total and unbound oxacillin were determined 4 h after the loading dose (H4) and then at day 1 (H24) and day 2 (H48). Twelve patients were included. Nine patients exhibited bacteremia, 5 were in septic shock, 8 were positive forStaphylococcus aureus, and 4 were positive for coagulase-negative staphylococci. The median MIC (first to third interquartile range) was 0.25 (0.24 to 0.41) mg/liter. Median plasma concentrations of total and unbound oxacillin at H4, H24, and H48 were, respectively, 64.4 (41.4 to 78.5) and 20.4 (12.4 to 30.4) mg/liter, 56.9 (31.4 to 80.6) and 21.7 (6.5 to 27.3) mg/liter, and 57.5 (32.2 to 85.1) and 20 (14.3 to 35.7) mg/liter. The median mediastinal concentrations of total and unbound oxacillin at H4, H24, and H48 were, respectively, 2.3 (0.7 to 25.9) and 0.9 (<0.5 to 15) mg/liter, 29.1 (19.7 to 38.2) and 12.6 (5.9 to 19.8) mg/liter, and 31.6 (14.9 to 42.9) and 17.1 (6.7 to 26.7) mg/liter. High-dose oxacillin delivered by continuous infusion is a valuable strategy to achieve our pharmacokinetic target (4× MIC) at the site of action at H24. But concerns remain in cases of higher MICs, emphasizing the need for clinicians to obtain the MICs for the bacteria and to monitor oxacillin concentrations, especially the unbound forms, at the target site.

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Shamji, Mohammed F., Mohammed Bafaquh, and Eve Tsai. "The pathogenesis of ankylosing spondylitis." Neurosurgical Focus 24, no. 1 (January 2008): E3. http://dx.doi.org/10.3171/foc/2008/24/1/e3.

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✓ Ankylosing spondylitis (AS) is a chronic inflammatory disease that can cause significant functional complications by affecting the sacroiliac joints and axial skeleton. Despite a longstanding knowledge about the familial associations of this disease, particularly among patients positive for human leukocyte antigen (HLA)–B27, the fundamental pathogenetic mechanism by which this disease arises in genetically susceptible individuals remains ill defined. Furthermore, the molecular predilection for characteristic articular site involvement remains under ongoing investigation. Current theories about the HLA-B27 association range from the presentation of novel arthritogenic peptides, to abnormal autoimmune stimulation, to anomalous microbial tolerance. The immune effectors of this damage include CD4+, CD8+, and natural killer cells, with marked heterogeneity at different sites. Biomechanical stresses may trigger this disease by exposing the body to previously immune-sequestered autoantigens or by providing a route for bacterial seeding. Environmental triggers such as infection have not been definitively established but may represent a primary pathogenic step in a molecular-mimicry process. In this article, the authors review the current literature on the origin and pathophysiology of AS, focusing on genetic and molecular associations, consequent pathomechanisms, and associated triggers. An improved understanding of the sequence of molecular events that predispose and initiate the onset of this disease will allow for more specific and targeted therapy and better avoidance of the significant side effects of systemic immunomodulation.

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Heyland, Daren, Luis A. Ortiz, Warren L. Garner, Samuel P. Mandell, Kirsten Colpaert, Christian Stoppe, and Andrew G. Day. "15 Nutrition Therapy in the Burn Care Setting: What Is Best Achievable Practice?" Journal of Burn Care & Research 41, Supplement_1 (March 2020): S12—S13. http://dx.doi.org/10.1093/jbcr/iraa024.019.

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Abstract Introduction The fourth most common injury worldwide are burn injuries. The uncontrolled inflammation, hyper-catabolism, and nutrient deficiencies associated with burn injuries can translate into worse clinical outcomes. Accordingly, CPGs recommends increasing energy requirements from 25–35 kcal/kg/day and provide 1.5–2 grams of protein/kg/day. Thus, the aim of this research is to evaluate the adherence level to CPGs recommendations in adult burn patients and describe the nutritional variability intake across Burn Units (BU) in North America (NA), Latin America (LATAM), and Europe (EU). Methods In a multi-national, multi-centre (n=43), double-blinded, controlled RCT of adult burn patients randomly allocated to receive either L-glutamine (0.5g/kg/day) or placebo via enteral nutrition (EN), we explored the nutritional adequacy. Patients with a deep 2nd-3rd degree burns were enrolled. Patients with renal failure, electrical injuries, BMI < 18 or > 50, liver cirrhosis, contraindication for EN, pregnancy, or moribund were excluded. BUs with >5 burn patients with completed data were included in this analysis. Patient demographics, nutritional intake and clinical outcomes were collected. Nutritional adequacy was calculated from all sources (glucose and oral intake no collected). Descriptive analyses for quantitative data were performed. The data is presented as mean and standard deviation (±) or median with interquartile range [25th to 75th percentile] Results Six hundred and eight burn patients from 32 BUs were included. Overall, 75% (n=455) of the patients were male and Caucasians (78% [n=477]) with a median age of 51 [34–64] years, moderately ill (12 [8–19] APACHE II score), and the most common type of burn was fire (87% [n=530]) with a %TBSA of 27 [20–40], Table 1. Overall, 242 (40%) patients received artificial nutrition. The proportion of patients receiving EN alone at each BU averaged 84% [worst: 7% to best site:88%]. Overall, time from admission to start of EN was an average of 0.7 [0.4 – 0.9] days across all BUs [best:0.2 to worst site: 1.7 day]. PN+EN was used on 13% (n=31) of the patients [site range, 5–89%]. Average adequacy of calories at all sites was 71 % (site average range, 22–82 %) and 72 % (29%– 97%) for protein with greater adequacy observed in LATAM BUs and worst adequacy observed in NA BUs, Figure 1. At the site level, a total of 7 (21%) and 9 (28%) BU successfully achieved >80% of calories and protein via artificial nutrition, respectively, Figure 2. The average use of motility agents in patients receiving >80% at site level was 72 [60–85 %]. Conclusions The actual energy and protein intake remains suboptimal in burn patients worldwide but tremendous variability exists across BU worldwide. Efforts to standardize and enhance EN delivery are warranted. Applicability of Research to Practice Compliance with clinical guidelines recommendations might improve clinical outcomes in burn victims.

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Miller, Joshua, Sera Young, Elizabeth Bryan, and Claudia Ringler. "Household Water Insecurity Is Common and Associated With Higher Odds of Hunger and Lower Dietary Diversity Across Sub-Saharan Africa and Asia." Current Developments in Nutrition 5, Supplement_2 (June 2021): 668. http://dx.doi.org/10.1093/cdn/nzab045_050.

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Abstract Objectives Household water insecurity may exacerbate poor nutrition (e.g., via limited water to produce or prepare preferred foods) and health, but comparable quantification of water access and use has only recently become possible. We therefore aimed to assess the prevalence of household water insecurity and estimate its association with dietary diversity, hunger, and illness. Methods The International Food Policy Research Institute is conducting panel phone surveys among a random subsample of men and women in ongoing studies to understand the impacts of the COVID-19 pandemic. Surveys last 20–30 minutes and include information about respondent and household characteristics; experiences with household water insecurity [using the Household Water Insecurity Experiences Scale-4 (HWISE-4), range: 0–12], hunger, and illness in the prior 2 weeks; and 24-hour dietary recall (range: 0–10 food groups). We assessed the relationship between water insecurity and dietary diversity, hunger, and illness using random coefficient models (which account for variation by site and adjust for measured confounders) among sites with available baseline data: Senegal (interviews conducted June 2020, n = 501), Nepal (July 2020, n = 759), Ghana (September 2020, n = 543), Nigeria (September 2020, n = 501), Kenya (October 2020, n = 547), and Niger (October 2020, n = 364). Additional data from other sites and timepoints are forthcoming. Results The prevalence of water insecurity (HWISE-4 scores > 3) ranged from 8.9% of sampled households in Nepal to 47.4% in Ghana. In bivariate analyses for each site, household water insecurity did not differ by respondent sex but was consistently lower among households that had an on-premises compared to off-premises water source [e.g., mean, 2.3 vs. 3.7, p < 0.001 in Senegal]. In adjusted models across all sites, greater water insecurity was associated with lower dietary diversity (B: –0.08; 95% CI: –0.10, –0.05), and higher odds of experiencing hunger (OR: 1.10; 95% CI: 1.08, 1.14) and having an ill household member (OR: 1.04; 95% CI: 1.01, 1.07). Conclusions Water insecurity is experienced by many households and may be an important determinant of nutritional and physical well-being. Funding Sources The Bureau for Resilience and Food Security at the United States Agency for International Development.

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Bellomo, Rinaldo, Michael Farmer, and Neil Boyce. "A Prospective Study of Continuous Venovenous Hemodiafiltration in Critically Ill Patients with Acute Renal Failure." Journal of Intensive Care Medicine 10, no. 4 (July 1995): 187–92. http://dx.doi.org/10.1177/088506669501000405.

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We studied the biochemical and the clinical consequences of the application of continuous venovenous hemodiafiltration to the management of acute renal failure in critically ill patients. One hundred consecutive surgical and medical ICU patients with acute renal failure were entered into a prospective clinical study at an intensive care unit of tertiary institution. Intervention included assessment of illness severity by APACHE II score on admission and by organ failure score prior to initiation of renal replacement therapy; treatment of patients with continuous venovenous hemodiafiltration; and measurement of biochemical variables prior to and after therapy. Outcome assessment included incidence of complications, duration of oliguria, duration of intensive care and hospital stays, and survival to hospital discharge. Measurements and main results included the following: mean patient age was 60.9 years (range 21–81 yr); mean APACHE II score, 28.6 (95% confidence interval; 27.4-29.8); and number of failing organs, mean, 4.1 (95% confidence interval; 3.8-4.4). At commencement of continuous venovenous hemofiltration with dialysis, 79% of patients were receiving inotropic drugs and 72% were septic, and, in 35%, bacteremia or fungemia was demonstrated. Renal replacement therapy was applied for a mean duration of 186.2 hours (95% confidence interval; 149.2-223.7), with a mean hourly net ultrafiltrate production of 621 mL (95% confidence interval; 594–648) and a mean urea clearance of 28.1 mL/min (95% confidence interval; 26.7-29.5). Azotemia was controlled in all patients (plasma urea < 30 mmol/L). During the more than 18,000 hours of treatment, there was no therapy-associated hemodynamic instability. Complications were rare. They included two cases of hemofilter rupture with minor blood loss and a single case of bleeding at the site of the vascular-access catheter. Forty-three patients survived to ICU discharge, and 40 survived to hospital discharge. Continuous venovenous hemodiafiltration is a safe and an effective form of renal replacement therapy in critically ill patients. In such patients, who have a high predicted mortality rate, it was associated with a 40% survival rate. These findings suggests that continuous venovenous hemodiafiltration may be ideally suited to patients with multisystem organ failure with acute renal failure.

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Tajkia, Gule, Mahfuza Shirin, M. Monir Hossain, and Mohammad Abdullah Al Mamun. "Accuracy of SpO2 measurements by placing probes on newborns' wrist and ankle." Bangladesh Medical Research Council Bulletin 45, no. 3 (December 30, 2019): 191–96. http://dx.doi.org/10.3329/bmrcb.v45i3.44651.

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Background: Pulse oximetry is a noninvasive technique of measuring oxygenation of the blood that is used worldwide to assess critically ill patients. The accuracy of pulse oximetry reading may be related to the site of pulse oximeter probe placement; but this may be difficult in sick neonates. In neonates, palm and sole are commonly used site for probe placement. Objective: This study was conducted to assess the accuracy of pulse oximeter oxygen saturation (SpO2) from probe placement at wrist and ankle as an alternative to palm and sole in neonates. Methods: This cross sectional study was carried out in SCABU of Dhaka Shishu (Children) Hospital from December 2012 to March 2013. A total of 169 neonates were enrolled in this study. Two pulse oximeters were used for simultaneous paired SpO2 measurements. The SpO2 was measured at 0 sec, then at 30 sec and at 1 min over the palm and ipsilateral wrist, both side and repeated the same procedure over the sole and ipsilateral ankle, both side and were recorded in the case record form. Two tailed, Student’s t-test was performed for analysis of continuous, normally distributed variables. Regression analysis was performed to determine the relationship between paired SpO2 measurements. Results: A total of 169 patients (birth weight 2530.8±772.2 g, gestational age 36.7±3.9 weeks, mean age 7.7 days and age range 1-27 days) were enrolled. There was a good correlation between SpO2 measured at the palm versus the wrist (r= 0.92, p<0.0001 (right); r= 0.88, p< 0.0001 (left)) and between SpO2 measured at the sole versus the ankle (r=0.90, p<0.0001 (right); r= 0.98, p<0.0001 (left)). There was also a good agreement between paired SpO2 measurements from these sites. The bias and precision for SpO2 at the right palm and right wrist was 0.08 ± 0.65% and for the left palm and left wrist 0.05 ± 0.79%. Similarly, the bias and precision for SpO2 at the right sole and right ankle was -0.11 ± 0.63% and for the left sole and left ankle was 0.56 ± 0.32%. Conclusion: The wrist and ankle can be used as alternative sites, to measure SpO2 in newborn infants in place of the routinely used palm or sole.

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Lau, Anna F., Masrura Kabir, Sharon C. A. Chen, E. Geoffrey Playford, Deborah J. Marriott, Michael Jones, Jeffrey Lipman, et al. "Candida Colonization as a Risk Marker for Invasive Candidiasis in Mixed Medical-Surgical Intensive Care Units: Development and Evaluation of a Simple, Standard Protocol." Journal of Clinical Microbiology 53, no. 4 (February 11, 2015): 1324–30. http://dx.doi.org/10.1128/jcm.03239-14.

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Colonization withCandidaspecies is an independent risk factor for invasive candidiasis (IC), but the minimum and most practicable parameters for prediction of IC have not been optimized. We evaluatedCandidacolonization in a prospective cohort of 6,015 nonneutropenic, critically ill patients. Throat, perineum, and urine were sampled 72 h post-intensive care unit (ICU) admission and twice weekly until discharge or death. Specimens were cultured onto chromogenic agar, and a subset underwent molecular characterization. Sixty-three (86%) patients who developed IC were colonized prior to infection; 61 (97%) tested positive within the first two time points. The median time from colonization to IC was 7 days (range, 0 to 35). Colonization at any site was predictive of IC, with the risk of infection highest for urine colonization (relative risk [RR] = 2.25) but with the sensitivity highest (98%) for throat and/or perineum colonization. Colonization of ≥2 sites and heavy colonization of ≥1 site were significant independent risk factors for IC (RR = 2.25 and RR = 3.7, respectively), increasing specificity to 71% to 74% but decreasing sensitivity to 48% to 58%. Molecular testing would have prompted a resistance-driven decision to switch from fluconazole treatment in only 11% of patients infected withC. glabrata, based upon species-level identification alone. Positive predictive values (PPVs) were low (2% to 4%) and negative predictive values (NPVs) high (99% to 100%) regardless of which parameters were applied. In the Australian ICU setting, culture of throat and perineum within the first two time points after ICU admission captures 84% (61/73 patients) of subsequent IC cases. These optimized parameters, in combination with clinical risk factors, should strengthen development of a setting-specific risk-predictive model for IC.

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Cristina, Maria, Marina Sartini, and Anna Spagnolo. "Serratia marcescens Infections in Neonatal Intensive Care Units (NICUs)." International Journal of Environmental Research and Public Health 16, no. 4 (February 20, 2019): 610. http://dx.doi.org/10.3390/ijerph16040610.

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Serratia marcescens belongs to the family Enterobacteriaceae, which is commonly found in water, soil, animals, insects, plants. Although S. marcescens displays relatively low virulence, it causes nosocomial infections and outbreaks in severely immunocompromised or critically ill patients, particularly in settings such as intensive care units (ICUs), especially neonatal units (NICUs). This microorganism gives rise to a wide range of clinical manifestations in newborns: from asymptomatic colonization to keratitis, conjunctivitis, urinary tract infections, pneumonia, surgical wound infections, sepsis, bloodstream infection and meningitis. The most frequent site of infection is the bloodstream, followed by the respiratory apparatus and the gastrointestinal tract. Strains of S. marcescens involved in epidemic events have frequently proved to be multi-resistant. Indeed, this species displays intrinsic resistance to several classes of antibiotics. Often, the specific source of the infection cannot be identified. However, the contaminated hands of healthcare workers are believed to be a major vehicle of its transmission. In neonatal intensive care units, colonized or infected newborns are the main potential source of S. marcescens, particularly in the respiratory apparatus, but also in the gastrointestinal tract. The early identification of colonized or infected patients and the prompt implementation of infection control measures, particularly rigorous hand hygiene and contact precautions, are essential in order to curb the spread of infection.

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Peón, Alberto N., Yadira Ledesma-Soto, Jonadab E. Olguín, Marcel Bautista-Donis, Edda Sciutto, and Luis I. Terrazas. "Helminth Products Potently Modulate Experimental Autoimmune Encephalomyelitis by Downregulating Neuroinflammation and Promoting a Suppressive Microenvironment." Mediators of Inflammation 2017 (2017): 1–16. http://dx.doi.org/10.1155/2017/8494572.

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A negative correlation between the geographical distribution of autoimmune diseases and helminth infections has been largely associated in the last few years with a possible role for such type of parasites in the regulation of inflammatory diseases, suggesting new pathways for drug development. However, few helminth-derived immunomodulators have been tested in experimental autoimmune encephalomyelitis (EAE), an animal model of the human disease multiple sclerosis (MS). The immunomodulatory activities of Taenia crassiceps excreted/secreted products (TcES) that may suppress EAE development were sought for. Interestingly, it was discovered that TcES was able to suppress EAE development with more potency than dexamethasone; moreover, TcES treatment was still effective even when inoculated at later stages after the onset of EAE. Importantly, the TcES treatment was able to induce a range of Th2-type cytokines, while suppressing Th1 and Th17 responses. Both the polyclonal and the antigen-specific proliferative responses of lymphocytes were also inhibited in EAE-ill mice receiving TcES in association with a potent recruitment of suppressor cell populations. Peritoneal inoculation of TcES was able to direct the normal inflammatory cell traffic to the site of injection, thus modulating CNS infiltration, which may work along with Th2 immune polarization and lymphocyte activation impairment to downregulate EAE development.

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Huang, Maoyi, Zhangshuan Hou, L. Ruby Leung, Yinghai Ke, Ying Liu, Zhufeng Fang, and Yu Sun. "Uncertainty Analysis of Runoff Simulations and Parameter Identifiability in the Community Land Model: Evidence from MOPEX Basins." Journal of Hydrometeorology 14, no. 6 (November 22, 2013): 1754–72. http://dx.doi.org/10.1175/jhm-d-12-0138.1.

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Abstract In this study, the authors applied version 4 of the Community Land Model (CLM4) integrated with an uncertainty quantification (UQ) framework to 20 selected watersheds from the Model Parameter Estimation Experiment (MOPEX) spanning a wide range of climate and site conditions to investigate the sensitivity of runoff simulations to major hydrologic parameters and to assess the fidelity of CLM4, as the land component of the Community Earth System Model (CESM), in capturing realistic hydrological responses. They found that for runoff simulations, the most significant parameters are those related to the subsurface runoff parameterizations. Soil texture–related parameters and surface runoff parameters are of secondary significance. Moreover, climate and soil conditions play important roles in the parameter sensitivity. In general, water-limited hydrologic regime and finer soil texture result in stronger sensitivity of output variables, such as runoff and its surface and subsurface components, to the input parameters in CLM4. This study evaluated the parameter identifiability of hydrological parameters from streamflow observations at selected MOPEX basins and demonstrated the feasibility of parameter inversion/calibration for CLM4 to improve runoff simulations. The results suggest that in order to calibrate CLM4 hydrologic parameters, model reduction is needed to include only the identifiable parameters in the unknowns. With the reduced parameter set dimensionality, the inverse problem is less ill posed.

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Braverman, Eric R., and Kenneth Blum. "Substance Use Disorder Exacerbates Brain Electrophysiological Abnormalities in a Psychiatrically-III Population." Clinical Electroencephalography 27, no. 4_suppl (October 1996): 5–28. http://dx.doi.org/10.1177/1550059496027s0402.

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Objective: To assess by brain electrical activity mapping whether cocaine and alcohol abuse and dependence would exacerbate electrophysiological abnormalities in a psychiatrically-ill population. Design, Setting, and Participants: Utilizing a brain mapping system, we assessed EEG, Spectral Analysis (Quantitative EEG[QEEG]), Evoked Potentials (Auditory and Visual), and P300 (cognitive evoked potential), in a total of 111 probands divided into three groups: controls (N = 16), psychiatrically-ill without comorbid substance use disorder (N = 34), and psychiatrically-ill with comorbid substance use disorder (cocaine and alcohol abuse and dependence) (N = 61), at an outpatient neuropsychiatric clinic. With regard to demographic data, the group participating in this study did not differ significantly. A comparison was made among the groups to assist in differentiating the effects of substance use disorder compared to psychiatric disease on brain electrical activity. Main Outcome Measures: An assessment of electrophysiological abnormalities and their brain location in psychiatric and substance use disorder patients was done with a brain electrical activity mapping test. Main Results: Among the non-substance use disorder, psychiatrically-ill (PI) and substance use disorder, psychiatrically-ill (PI/SD) groups, significantly different brain map abnormalities were observed relative to an assessed normal population MANOVA (P = .017). Moreover, with regard to Spectral Analysis, ANOVA was significant at a P = .038, and we found a weighted linear trend of increased abnormal total spectral analysis (P = .0113), whereby substance use was significantly worse than controls. Moreover among the PI and PI/SD groups, significantly greater total evoked potential (EP) brain map abnormalities were observed when compared with a characterized normal population (P = .0023) with increasing abnormalities as a function of substance use disorder as measured by a weighted linear trend (P = .0022). In order to determine the site of the EPS abnormalities, we evaluated these abnormalities by location. In this regard, we found all temporal abnormalities (AVBITA, see Table 2 ) among the PI and PI/SD groups to be significantly greater relative to an assessed normal population (P = .0026). Furthermore, we observed a linear trend of increased temporal abnormalities with increasing substance use disorder (P < .0008). In terms of bitemporal abnormalities (AVBIT) among the PI and PI/SD groups, we also found significantly more bitemporal lobe abnormalities in the PI/SD group compared to our control population (P = .009). Additionally, a weighted linear trend of increased abnormal bitemporal lobe abnormalities was observed with increasing substance use disorder (P = .0022). In the frontal lobe similar findings were observed. With AVBIFA the ANOVA was P < .011, with a weighted linear trend of P < .005 and the PI/SD group were significantly more abnormal than PI or CS on a Duncan Range test. It is noteworthy that in a selected group of depressed (Major Depressive Disorder Recurrent, 296.3) patients, we found profound abnormalities in the various brain map parameters tested. MANOVA and Univariate ANOVA's revealed significantly greater abnormalities in the PI and PI/SD groups compared to assessed controls. A MANOVA for total brain abnormalities was significant at P = .043 and univariate ANOVA's for composite measurements of TSA (P = .017), EPS (P = .0002), AVBITA (P = .000015), and AVBIT (P < .00002) are also significant. With regard to EPS and AVBITA a weighted linear trend was observed where there were increasing abnormalities with increasing substance use disorder, P = .0001 and P = .000003, respectively. Most importantly we found that in addition to increased abnormalities with increasing substance use disorder the PI/SD group had significantly more abnormalities compared to the PI group with regard to both the TSA (P < .05) and AVBIT (P < .05) composite parameters as measured by a Duncan Range test. Additionally, we found increased abnormalities in EPS in the frontal (but not occipital and parietal) lobes, AVBIF (P = .0116) and AVBIFA (P = .0116), of both the PI and PI/SD groups, where PI/SD groups had more abnormalities relative to PI and CS in our total population as well as the select depressed group, with a weighted linear trend of P = .0054 and P = .0065 respectively. Conclusion: Comorbid substance use disorder in psychiatric probands (especially in depressed patients) significantly exacerbates a potential premorbid vulnerability, and suggests a gene-environment interaction which leads psychiatrically-disturbed individuals with substance use disorder to worsen their brain dysfunction, particularly in the bitemporal regions of the brain.

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Patel, Anjan J., Marc Zumberg, Jessica Cope, Jennifer Bushwitz, and Abigail D. Antigua. "Use Of Fondaparinux For Venous Thromboembolism Prophylaxis In Critically Ill Adult Patients With Moderate Renal Insufficiency." Blood 122, no. 21 (November 15, 2013): 4806. http://dx.doi.org/10.1182/blood.v122.21.4806.4806.

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Introduction Fondaparinux, a selective activated Factor Xa inhibitor, is a parenteral anticoagulant primarily excreted by the kidneys. Renal insufficiency (RI), commonly encountered in the critically ill, has been shown to portend an increased risk of bleeding than in normal healthy adults. In comparison to the low molecular weight heparin dalteparin, fondaparinux has been shown to be superior for the prevention of post-surgical venous thromboembolism (VTE), however an increased rate of nonfatal bleeding has been observed. Recently, data has emerged supporting empiric dose reductions in patients with moderate RI, defined as a creatinine clearance (CrCl) between 30 and 50 mL/min. Overall, the data supporting appropriate use of fondaparinux in patients with RI is lacking. This retrospective, single center study describes our experience using prophylactic fondaparinux in critically ill patients with moderate RI. Methods We report our experience utilizing fondaparinux in a mixed medical and surgical, critically ill adult population with moderate RI. The site examined was UF Health; an 852-bed sized tertiary care hospital in Gainesville, Florida between 2006 and 2012. Moderate RI was defined as a CrCl between 30 and 50 mL/min calculated by the Cockcroft/Gault equation. Only patients treated with fondaparinux for prophylaxis of VTE were included, patients treated for other indications were excluded. Doses, dose frequency and dose adjustments were documented. If patients had anti-Xa level monitoring these values were recorded. Timing of anti-Xa levels drawn with respect to fondaparinux dosing was also noted. The primary end point of the study was the rate of clinically significant bleeding events in patients receiving at least 72 hours of fondaparinux. Clinically significant bleeding was defined as transfusion of at least two units of packed red blood cells within 48 hours of a documented bleeding event or the workup of bleeding with endoscopy or imaging. Bleeding events were screened by ICD-9 codes and validated via chart review, incidence of VTE was also noted. Results Sixty-fourpatients met inclusion criteria between October 2006 and November 2012. Two patients (3.1%) experienced clinically significant bleeding events as per our definition, both in the form of gastrointestinal bleeding. Empiric dose reductions occurred in 8 (12.5%) patients, this occurred in the form of every other day administration or dose reduction using fondaparinux 1.25mg daily. Nine (14%) patients were monitored with anti-Xa levels, none of these patients encountered bleeding events. The median anti-Xa level was 0.5 mcg/mL, which is in the target prophylactic range for in our lab. The median time interval after last dose of fondaparinux to anti-Xa level measurement was 4 hours. Seven (10.9%) patients had VTE diagnoses prior to the initiation of prophylactic fondaparinux. No patients suffered a VTE event after treatment with prophylactic fondaparinux in our data set. Conclusion We report a cohort of patients with moderate RI receiving fondaparinux for the prevention of VTE. The incidence of clinically significant bleeding was 3.1%. The risk of VTE was low, no patients suffered from a VTE after treatment with fondaparinux in our data set. The rate of bleeding is slightly higher compared to patients with normal renal function. Our experience over this 6 year period supports the notion that RI portends an increased risk of bleeding with the use of fondaparinux. Further prospective studies are needed to determine the safety and efficacy of empiric fondaparinux dose reductions in patients with RI and end stage renal disease. Anti-Xa monitoring may help reduce the risk of bleeding in this patient population by identifying those patients in whom a dose reduction may be beneficial. Disclosures: No relevant conflicts of interest to declare.

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Pauling, John D., Elizabeth Reilly, Theresa Smith, and Tracy M. Frech. "Factors Influencing Raynaud Condition Score Diary Outcomes in Systemic Sclerosis." Journal of Rheumatology 46, no. 10 (March 1, 2019): 1326–34. http://dx.doi.org/10.3899/jrheum.180818.

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Objective.Raynaud phenomenon (RP) in systemic sclerosis (SSc) could be influenced by clinical phenotype, environmental factors (e.g., season), and personal factors (e.g., coping strategies and ill-health perceptions). We studied the relative influence of a range of putative factors affecting patient-reported assessment of SSc-RP severity.Methods.SSc patients were enrolled at UK and US sites. Participants completed the 2-week Raynaud Condition Score (RCS) diary alongside collection of patient demographics, clinical phenotype, the Coping Strategies Questionnaire, Pain Catastrophizing Scale, Scleroderma Health Assessment Questionnaire (SHAQ), and both patient/physician visual analog scale (VAS) assessments for RP, digital ulcer disease, and global disease. Environmental temperature data were obtained at each site. A second RCS diary was completed 6 months after enrollment.Results.We enrolled 107 patients (baseline questionnaires returned by 94). There were significant associations between RCS diary variables and both catastrophizing and coping strategies. There were significant associations between RCS diary outcomes and both environmental temperature and season of enrollment. Age, disease duration, sex, disease subtype, smoking, and vasodilator use were not associated with RCS diary outcomes. The best-fitting multivariate model identified the patient RP VAS, SHAQ pain VAS, and SHAQ gastrointestinal VAS subscales as the strongest independent predictors of the RCS.Conclusion.Patient-reported assessment of SSc-RP severity is associated with a number of factors including pain, catastrophizing, and coping strategies. The effects of seasonal variation in environmental temperature on SSc-RP burden has implications for clinical trial design. Treatments targeting SSc-RP pain and the development of behavioral interventions enhancing coping strategies may reduce the burden of SSc-RP.

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Strandås, Maria, and Sven-Tore D. Fredriksen. "Ethical challenges in neonatal intensive care nursing." Nursing Ethics 22, no. 8 (November 3, 2014): 901–12. http://dx.doi.org/10.1177/0969733014551596.

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Background: Neonatal nurses report a great deal of ethical challenges in their everyday work. Seemingly trivial everyday choices nurses make are no more value-neutral than life-and-death choices. Everyday ethical challenges should also be recognized as ethical dilemmas in clinical practice. Research objective: The purpose of this study is to investigate which types of ethical challenges neonatal nurses experience in their day-to-day care for critically ill newborns. Research design: Data were collected through semi-structured qualitative in-depth interviews. Phenomenological-hermeneutic analysis was applied to interpret the data. Participants and research context: Six nurses from neonatal intensive care units at two Norwegian hospitals were interviewed on-site. Ethical considerations: The study is designed to comply with Ethical Guidelines for Nursing Research in the Nordic Countries and the Helsinki declaration. Findings: Findings suggest that nurses experience a diverse range of everyday ethical challenges related to challenging interactions with parents and colleagues, emotional strain, protecting the vulnerable infant, finding the balance between sensitivity and authority, ensuring continuity of treatment, and miscommunication and professional disagreement. Discussion: A major finding in this study is how different agents involved in caring for the newborn experience their realities differently. When these realities collide, ethical challenges arise. Findings suggest that acting in the best interests of the child becomes more difficult in situations involving many agents with different perceptions of reality. Conclusion: The study presents new aspects which increases knowledge and understanding of the reality of nursing in a neonatal intensive care unit, while also demanding increased research in this field of care.

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Vignoli, Giulio, Julien Guillemoteau, Jeniffer Barreto, and Matteo Rossi. "Reconstruction, with tunable sparsity levels, of shear wave velocity profiles from surface wave data." Geophysical Journal International 225, no. 3 (February 19, 2021): 1935–51. http://dx.doi.org/10.1093/gji/ggab068.

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SUMMARY The analysis of surface wave dispersion curves is a way to infer the vertical distribution of shear wave velocity. The range of applicability is extremely wide: going, for example, from seismological studies to geotechnical characterizations and exploration geophysics. However, the inversion of the dispersion curves is severely ill-posed and only limited efforts have been put in the development of effective regularization strategies. In particular, relatively simple smoothing regularization terms are commonly used, even when this is in contrast with the expected features of the investigated targets. To tackle this problem, stochastic approaches can be utilized, but they are too computationally expensive to be practical, at least, in case of large surveys. Instead, within a deterministic framework, we evaluate the applicability of a regularizer capable of providing reconstructions characterized by tunable levels of sparsity. This adjustable stabilizer is based on the minimum support regularization, applied before on other kinds of geophysical measurements, but never on surface wave data. We demonstrate the effectiveness of this stabilizer on (i) two benchmark—publicly available—data sets at crustal and near-surface scales and (ii) an experimental data set collected on a well-characterized site. In addition, we discuss a possible strategy for the estimation of the depth of investigation. This strategy relies on the integrated sensitivity kernel used for the inversion and calculated for each individual propagation mode. Moreover, we discuss the reliability, and possible caveats, of the direct interpretation of this particular estimation of the depth of investigation, especially in the presence of sharp boundary reconstructions.

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Zakarija, Anaadriana, Nicholas Bandarenko, Dilip K. Pandey, Hau Kwaan, Kathryn McCaffrey, Denise Finley, Ken Carson, Paul Yarnold, and Charles L. Bennett. "Preliminary Findings from the Prospective Multicenter Surveillance, Epidemiology and Risk Factors for Thrombotic Thrombocytopenic Purpura (SERF-TTP) Study." Blood 104, no. 11 (November 16, 2004): 855. http://dx.doi.org/10.1182/blood.v104.11.855.855.

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Abstract Background: Due to the rarity of TTP (approximately 4 cases per million), epidemiologic data and correlative laboratory samples from a prospectively identified incident cohort of TTP patients are needed. Methods: SERF TTP is a NHLBI-funded 15-site study targeted to identify 300 incident TTP patients and 600 age-/gender-matched community controls. Results: From nine IRB-approved collaborating sites, 22 incident TTP cases and 17 controls have been interviewed. Data and plasma (acute and convalescent samples) are available for 19 TTP patients (Table 1). Their mean age is 42.5 years (range, 20 – 80 years), and 90% are female. Using the Rose-Eldor TTP Scoring system based on platelets, creatinine, hemoglobin, and neurologic function, 37% would be classified as severely ill (score > 4 of a maximum 8 points). Mean time from symptom onset to diagnosis was 9.2 days, median 5.5 days (range, 0 to 33 days). Severity of TTP was poorer for the 5 patients whose treatment did not begin for at least 16 days (16–33 days) versus the other 14 patients (mean Rose-Eldor score of 4.6 versus 4). Medications which had been prescribed to the patients prior to TTP onset included herbal supplements (n= 5) and hormone replacement therapy or oral contraceptives (n= 6). All patients received at least daily therapeutic plasma exchange (TPE). A platelet count >150,000 was reached at a mean of 9.4 days following TPE initiation. At 30-days follow-up, all patients were alive, although 3 had an exacerbation requiring daily TPE reinstitution. Fourteen patients (78%) experienced an adverse event, including allergic reactions to plasma (n=9), citrate-related toxicity (n=9) and venous access complications (n=2) including one with major hemorrhage requiring transfer to the intensive care unit. Conclusion: The clinical characteristics of the SERF-TTP cohort are similar to those reported from large single-site studies, although the survival rate (100% versus 71% and 83%) is higher. Only a minority of incident TTP cases in the modern era present with renal insufficiency or neurologic findings - highlighting the importance of developing reliable diagnostic laboratory testing. Clinical Characteristics at Presentation Study Platelets <100,000 Hgb <10 or Hct <.3 Cr > 2mg/dl Fever Neurologic symptoms Mortality (1) Zheng XL, Kaufman RM et al. Blood.2004; 103: 4043; (2)Vesely SK, George JN et al. Blood.2003; 102: 60. HSCT: Hematopoetic stem cell transplantation, FK-506: Tacrolimus. SERF-TTP n=19 95% 79% 32% 11% 47% 0% Washington University (1) (excluding HSCT/FK506 cases) n= 28 96% 82% 29% 32% 50% 29% Oklahoma TTP-HUS Registry (2) (ADAMTS13 < 5%) n=18 100% 100% 22% NA (Not Available) 56% 17%

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Bose, Mallika, Eliza Pennypacker, and Thomas Yahner. "Enhancing Critical Thinking Through “Independent Design Decision Making” in the Studio." Open House International 31, no. 3 (September 1, 2006): 33–42. http://dx.doi.org/10.1108/ohi-03-2006-b0005.

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A group of faculty at Penn State's Department of Landscape Architecture observed that the traditional master/apprentice model of studio instruction fosters greater student dependence on faculty for decision-making guidance than the faculty considers desirable. They contend that this traditional model promotes a studio dynamic that encourages students to look to the professor for design ideas and wait for faculty approval before making design decisions. The faculty considered this decision-making dependency to be in conflict with the need for students to develop the critical-thinking skills required to address the complex and ill-structured problems that are common in architecture and landscape architecture. In response to their concern this faculty team developed a studio teaching method they termed “independent design decision-making.” They speculated that by transferring the responsibility for design decisions from professor to the student, students could improve their critical thinking and gain confidence in design decision-making. The faculty conceived a set of strategies to implement in a 3rd year team-taught site planning and design studio that presents a range of complex design issues and scales. In collaboration with Penn State's Schreyer Institute for Teaching Excellence, the faculty researchers developed a 2-year comparative study to test this new teaching method in the same design studio with two consecutive student groups-evaluating the strategies implemented in the first year, refining methods, then applying and re-evaluating the results in the next year's class. These new strategies included ways students receive information to inspire their designs (“input strategies”) and ways to receive critique on their design ideas (“feedback strategies”). Two evaluation instruments were chosen to assess this method of studio teaching: 1) the Group Embedded Figures Test (GEFT), and 2) Student Assessment of Learning Gains (SALG). This paper presents this teaching/learning method and reports on the results of the comparative study.

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Bedikian, A. Y., T. Sato, K. B. Kim, N. E. Papadopoulos, W. Hwu, J. Homsi, M. Davies, et al. "Phase II study of vincristine sulfate liposomes injection in patients with metastatic uveal melanoma." Journal of Clinical Oncology 27, no. 15_suppl (May 20, 2009): 9067. http://dx.doi.org/10.1200/jco.2009.27.15_suppl.9067.

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9067 Background: Preclinical and clinical studies showed that liposomal encapsulation of vincristine sulfate (VCR) results in increased drug circulation time and accumulation of VCR at the tumor site. Marqibo has been administered safely at 2.25 mg/m2, a dose exceeding that typically employed for VCR ( dose capped at 2 mg), with tolerable clinical toxicities consistent with VCR. Of the 27 previously treated patients with metastatic melanoma in the Marqibo pharmacokinetic studies, 3 patients had a tumor response, including one patient with uveal melanoma metastatic to the lung that experienced a complete response. Methods: Patients with metastatic uveal melanoma with no more than one prior systemic therapy were enrolled. Patients with controlled brain metastases were allowed. Marqibo (2.25 mg/m2 by 1-hour intravenous infusion, no dose capping) was administered every 14 days until tumor progression. Responses were assessed every 6 weeks using the Response Evaluation Criteria in Solid Tumors (RECIST). Toxicity was assessed at least as frequently as before each dose. Results: Preliminary data is available for 22 enrolled patients (73% female). Median age was 65 years (range 38–79), 23% were previously treated with systemic chemotherapy, 86% had liver metastasis and 96% had M1c disease. Baseline serum LDH levels were elevated in 73% and were more than 2 × ULN in 37% of the patients. Twenty-one patients were evaluable for response; one patient discontinued the treatment after a single dose of therapy for toxicity without tumor progression. No patients died of drug toxicity while on the study. Twelve patients (57%) had stable disease. Estimated median survival is 6.4 months. Fourteen patients are alive, 2 for more than 12 months. Treatment related side effects were mostly grade 1 or 2; peripheral neuropathy was the only grade 3 toxicity, seen in 18% of the patients. The hematologic toxicities were minor; no neutropenia or thrombocytopenia was seen. Conclusions: Marqibo is well tolerated as single agent therapy in patients with advanced stage IV uveal melanoma. Its impact on the progression-free and overall survival of these critically ill patients will be presented. No significant financial relationships to disclose.

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Kogan, Jane N., James Schuster, Cara Nikolajski, Patricia Schake, Tracy Carney, Sally C. Morton, Chaeryon Kang, and Charles F. Reynolds. "Challenges encountered in the conduct of Optimal Health: A patient-centered comparative effectiveness study of interventions for adults with serious mental illness." Clinical Trials 14, no. 1 (September 28, 2016): 5–16. http://dx.doi.org/10.1177/1740774516670895.

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Background: The aim of patient-centered comparative effectiveness research is to conduct stakeholder-driven investigations that identify which interventions are most effective for which patients under specific circumstances. Conducting this research in real-world settings comes with unique experiences and challenges. We provide the study design, challenges confronted, and the solutions we devised for Optimal Health, a stakeholder-informed patient-centered comparative effectiveness study focused on the needs of seriously mentally ill individuals receiving case management services in community mental health centers across Pennsylvania. Methods: Optimal Health, supported by the Patient-Centered Outcomes Research Institute, is a cluster-randomized trial of two evidence-based interventions for improving health and wellness across 11 provider sites. Participants were followed for 18–24 months, with repeated measurements of self-reported health status and activation in care and administrative measurements of primary and specialty health service utilization. Health-related quality of life, engagement in care, and service utilization are to be compared via random effects mixed models. Stakeholders were, and continue to be, engaged via focus groups, interviews, and stakeholder advisory board meetings. A learning collaborative model was used to support shared learning and implementation fidelity across provider sites. Results: From 1 November 2013 through 15 July 2014, we recruited 1229 adults with serious mental illness, representing 85.1% of those eligible for study participation. Of these, 713 are in the Provider-Supported arm of the study and 516 in Patient Self-Directed Care. Across five data collection time points, we retained 86% and 83% of the participants in the Provider-Supported and Self-Directed arms, respectively. Lessons learned: Lessons learned relate to estimation of the size of our study population, the value of multiple data sources, and intervention training and implementation. The use of historical claims data can lead to an overestimation of eligible participants and, subsequently, a reduced study sample and an imbalance between intervention arms. Disruptions in continuity of care in real-world settings can pose challenges to on-site self-report data collection, although the inclusion of multiple data sources in study design can improve data completeness. Geographic dispersion of rural provider sites and staff turnover can lead to training and intervention fidelity challenges that can be overcome with the use of a “train-the-trainer” model, “wellness champions,” and the use of a Learning Collaborative approach. Stakeholder engagement in mitigating these challenges proved to be critical to study progress. Conclusion: Conducting real-world patient-centered comparative effectiveness research in healthcare systems that care for seriously mentally ill persons is an important yet challenging undertaking, one which requires flexibility in identifying potential adaptations within all major study phases. Advice from a wide range of stakeholders is critical in development of successful strategies.

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Uchida, Shumpei, Osamu Imataki, Mami Shimatani, Shigeyuki Yokokura, Makiko Uemura, and Norimitsu Kadowaki. "Ultrasound-Guided Catheter Insertion Did Not Decrease Catheter-Related Blood Stream Infection in Hematological Oncology Care Unit." Blood 128, no. 22 (December 2, 2016): 2394. http://dx.doi.org/10.1182/blood.v128.22.2394.2394.

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Abstract Background: Central venous catheters (CVCs) are necessary for critically ill patients requiring intravenous pharmacological intervention and subsequent parenteral nutritional support. Although CVCs allow delivery of medications and nutritional support that cannot be administered safely through central venous, their use is inevitably associated with adverse events, mechanical complication and catheter-related infection. While ultrasound guide has already been proven to decrease mechanical complications, it is not fully elucidated whether ultrasound guide decrease the risk of catheter-related infection. Methods: We observed consecutive CVC insertions between April 2009 and January 2013. In total, 395 insertion cases were surveyed in the hematological oncology unit. We divided the research period into two terms: before December 2011 (early term) and after January 2012 (latter term). Between the early and latter terms, there were substantial differences regarding the use of ultrasound guides. Because insertion maneuvers changed from blind to ultrasound-guided approach after 2012. SMAC Plus MicroNeedle (15G, 13 cm or 12G, 20 cm; Covidien Tokyo, Japan) was used. Practitioners determined which CVC device and which insertion site was preferred for each patient. To determine the clinical efficacy of chlorhexidine gluconate dressing (CHGD) at catheter insertion site, we performed matched cohort analysis among the patients who underwent stem cell transplantation. Total 44 cases were included in the cohort from the total study population. Results: Underlying diseases included hematological malignancies and immunological disorders such as auto-immune diseases and solid organ malignancies. A total of 235 and 160 cases were included in early and latter terms, respectively. Insertion duration was a median 26 days (range, 2-126 days) in the early term and 18 days (range, 2-104) in the latter term. During the early term, the insertion sites were 22.6%, 40.2%, and 25.7% at the cervical, subclavian, and femoral veins, respectively, and 32.3%, 16.9%, and 25.4% in the latter term, respectively. The ultrasound-guided insertion method became a routine practice in the latter term. The frequency of catheter-related blood stream infection (CRBSI) was 8.46/person-days and 13.62/person-days in the early and latter terms, respectively. Mechanical comorbidities decreased from 0.39 (13/33) incidences/month to 0.00 (0/13) after the introduction of the ultrasound-guided insertion method. Using subgroup analysis, detected causative pathogens of CRBSI did not differ between the two terms: gram-positive coccus, gram-positive bacillus, and gram-negative bacillus were 68.9%, 11.5%, and 14.8% in the early term and 68.2%, 11.4%, and 18.2% in the latter term, respectively. Controlled-cohort study revealed CHGD decreased CRBSI caused by Staphylococcus spp. significantly, but not overall other organisms. Conclusion: Ultrasound-guided insertion did not decrease the incidence of CRBSI. However, in our survey, insertion through the cervical vein approach clearly increased after the introduction of the ultrasound-guided method, and mechanical complications decreased significantly. Ultrasound guide and cervical vein approach trended for patients with hematological diseases who required CVC and those who concurrently harbored multiple risks, including thrombocytopenia. The prevalence of CRBSI slightly increased with this trend. With respect to CRBSI, the preventative effect of CHGD in patients undergoing allogeneic stem cell transplantation was promising. We advocate trending of ultrasound-guided, cervical approach CVC with CHGD can provide the safest parental alimentation for the patients with hematological malignancies. Disclosures No relevant conflicts of interest to declare.

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Tickell, Kirkby, Donna Denno, Ali Saleem, Zaubina Kazi, Barbra Richardson, Catherine Achieng, Charles Mutinda, et al. "Enteric Function as a Determinant of Nutritional and Clinical Recovery from Acute Illness Among Children in Kenya and Pakistan." Current Developments in Nutrition 4, Supplement_2 (May 29, 2020): 916. http://dx.doi.org/10.1093/cdn/nzaa053_121.

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Abstract Objectives In low- and middle-income countries (LMICs), acutely ill undernourished children remain at high risk of mortality for months following discharge from hospital. Community-based studies suggest that enteric dysfunction (ED), including permeability and impaired absorption, is associated with poor outcomes. We used the lactulose rhamnose ratio (L: R) test, which provides a functional assessment of gut integrity, to determine if ED influences clinical and nutritional recovery in the post-discharge period. Methods Children aged 2–24 months without diarrhea were recruited from Civil Hospital Karachi, Pakistan and Migori County Referral Hospital, Kenya. L: R tests were administered after children were clinically stable (oral feeds, not dehydrated, no oxygen needs) and pre-discharge. Similarly aged children were pseudo-randomly selected from homes near those of children being discharged and were also tested. Prior to administration of sugars, urine was collected to detect background levels, followed by a two-hour collection. Samples were analyzed by high-performance chromatography mass spectroscopy. Crude L: R distributions were compared using the Mann-Whitney test. A priori determined confounders (age, mid-upper arm circumference [MUAC], HIV status, site) were adjusted for in linear regression of log-transformed L: R. Results 156 hospitalized and 91 community children were recruited. Median age was nine months in each group. Hospitalized children had lower median MUAC (12.4 vs 13.5 cm) and higher HIV infection prevalence (5% vs 1%). Both sugars were largely undetectable in pre-dose samples. Urinary median L: R among children being discharged (0.36 (interquartile range [IQR] 0.20–0.87)) was significantly higher compared to community peers (0.30 (IQR: 0.17–0.48, P = 0.038)). This difference remained significant in the adjusted model (p: 0.008). Conclusions Children at discharge from hospital in LMICs appear to have worse enteric function than community peers, and this difference does not appear to be attributable to young age or nutritional or HIV status. This analysis will be expanded to include L: R association with mortality, morbidity and growth outcomes prior to the conference. Funding Sources Thrasher Research Foundation 14,466, the Bill & Melinda Gates Foundation OPP 1,131,320.

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Neese, Jeremy, and Nada Harik. "1525. Epidemiology, Management, and Outcomes of Skin and Soft-Tissue Infections in Well-Appearing Infants Less Than 60 Days of Age." Open Forum Infectious Diseases 6, Supplement_2 (October 2019): S555—S556. http://dx.doi.org/10.1093/ofid/ofz360.1389.

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Abstract Background Skin and soft-tissue infections (SSTIs) in children are increasingly common. The IDSA has published guidelines for SSTI treatment in children, adolescents, and adults but data in infants less than 2 months is sparse despite their higher risk of concomitant serious bacterial infection (SBI). Clinical work-up and management of these patients varies widely with little evidence to guide providers. Methods We retrospectively identified 536 patients, from 2007 to 2017, seen at our EDs or hospital-associated clinic and diagnosed with SSTI by ICD9/10 code. We excluded those with ill-appearance, prematurity, known immunodeficiency, skin disorder, previous SSTI, or previous procedure at infection site. Remaining patient’s medical records were reviewed to confirm a SSTI. The total included study population was 182 (Figure 1). Data collected included demographics, type/location of infection, laboratory/imaging studies obtained, procedures performed, disposition, treatment, and treatment failure. Results Demographics are reported in Table 1. Mean age was 24.2 days (range 2–57 days). Of 182 patients, 13% had fever. 34% had a superficial infection (impetigo or pustulosis), 24% had cellulitis/scalded skin, 35% had an abscess/paronychia, and 7% had periorbital cellulitis. The most common SSTI locations were perineal/genital (30%) and head/scalp/face (23%). 63% of infants had a blood culture obtained and 4/114 grew a pathogenic bacteria. 52% had a wound culture and 72/95 grew a pathogenic bacteria. No infants had bacterial meningitis or a UTI (Table 2). 25% underwent incision/drainage and 93% received any antibiotic. The most commonly prescribed antibiotics were clindamycin and mupirocin. Of 80 non-admitted infants, 21% had an unscheduled return visit within 2 weeks (Table 3): 9% for treatment failure, 6% unrelated to SSTI, and 1% for missed SBI (1 patient with GAS bacteremia). Conclusion Most well-appearing infants with SSTI were afebrile. The majority of studied infants had blood cultures obtained but rates of clinically significant bacteremia were low. Management varied considerably and antibiotics were commonly administered. However, overall rates of SBI were low and there was only 1 case of missed SBI. Extensive evaluation of well-appearing infants with SSTI may be unnecessary. Disclosures All authors: No reported disclosures.

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Gabrellas, Alithea D., John J. Veillette, Brandon J. Webb, Edward A. Stenehjem, Nancy A. Grisel, and Todd J. Vento. "889. Impact of an Infectious Disease Telehealth (IDt) Service on S. aureus Bacteremia (SAB) Outcomes in 15 Small Community Hospitals." Open Forum Infectious Diseases 6, Supplement_2 (October 2019): S22. http://dx.doi.org/10.1093/ofid/ofz359.048.

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Abstract Background Infectious diseases (ID) consultation improves SAB readmission rates, compliance with care bundles and mortality. Small community hospitals (SCHs) (which comprise 70% of US hospitals) often lack access to on-site ID physicians. IDt is one way to overcome this barrier, but it is unknown if IDt provides similar clinical benefits to traditional ID consultation. Our study aims to evaluate the impact of IDt on patient outcomes at 15 SCHs (bed range: 16–146) within the Intermountain Healthcare system in Utah. Methods Baseline demographics, Charlson Comorbidity Index (CCI), hospital length of stay (LOS), and mortality (in-hospital, 30- and 90-day) were collected using an electronic health record database and health department vital records on all patients with a positive S. aureus blood culture from January 1, 2009 through December 31, 2018. Data from January 2014 through Sep 2016 were excluded to avoid potential influence of a concurrent antimicrobial stewardship study. Starting in October 2016 an IDt program (staffed by an ID physician and pharmacist) provided consultation for SCH providers and patients using electronic consultation and encrypted two-way audiovisual communication.Statistical analyses were performed using Fisher’s exact test or χ 2 test for categorical variables and Mann–Whitney U test for nonparametric continuous data. Results In total, 625 patients with SAB were identified: 127 (20%) received IDt and 498 (80%) did not (non-IDt). The two groups (IDt vs. non-IDt) were similar in median age (66 vs. 62 years; P = 0.76), percent male (62% vs. 58%; P = 0.35), and median baseline CCI (4 vs. 4; P = 0.54). There were no statistically significant differences in median LOS (5 vs. 5 days; P = 0.93) or in-hospital mortality (2% in both groups). The IDt group had a lower 30-day (9% vs. 15%; P = 0.049) and 90-day mortality (13% vs. 21%; P = 0.034). Conclusion IDt consultation was associated with a decrease in 30- and 90-day mortality for SCH SAB cases. Early transfer of critically ill patients might have affected LOS and in-hospital mortality. Post-discharge care factors might also contribute to 30- and 90-day mortality. While more work is needed to identify other factors associated with the effect of IDt on SAB, these data support the use of IDt to increase access to care and improve SAB outcomes in SCHs. Disclosures All Authors: No reported Disclosures.

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Niaz, Furquana, Nadia Shams, Irfan Sheikh, Naresh Kumar, Najia ahmed, Mahrukh Kamran, Nayyerul Islam, and Waqar Ahmed. "ACANTHOSIS NIGRICANS IN OBESE VERSUS NON-OBESE IN A TERTIARY CARE HOSPITAL ASSOCIATION WITH BMI AND CENTRAL OBESITY." International Journal of Advanced Research 9, no. 06 (June 30, 2021): 589–98. http://dx.doi.org/10.21474/ijar01/13050.

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Background and objectives:Acanthosis nigricans (AN) is a major cosmetic and pathological condition associated with obesity,hirsutism, polycystic ovary, DM, metabolic syndrome and insulin resistance. This study was conducted to determine frequency of obesity in acanthosis nigricans and the association of BMI and central obesity with gender, age andtype of AN. Methodology: This hospital based observational study was conducted from1st March to 31st May 2021 at department of Medicine RIHS Islamabad after ethical approval. Sample size was calculated to be 221.Inclusion criteria: Adult cases of both the genders presenting with AN in medical OPD. Exclusion criteria:Diagnosed cases of malignancy, critically ill cases, endocrine disorders and pregnant women were excluded.After detailed history and examination, clinical diagnosis of Acanthosis nigricanswasmade. The weight in kg and height in meters measured and BMI calculatedby formula weigh in Kg/height (m2).Waist circumference measured in cm by flexible measuring tape from narrowest part of torso,midway between the lowest rib and iliac crest for central obesity and relevant investigations suggested. Data analyzed by SPSS version 21.Chi-square test was used to compare various variables between obese and non-obese AN cases with significant p<0.05. Results: Among 221 cases with acanthosis nigricans, there were152(68.8%)females and 69(31.2%) males . The mean age was 27 + 13.56 years with a range of 18-64 years. The mean BMI was 31.63 + 6.92 kg/m2.Obesity was observed in 144(65%).Mean waist circumference was 37.75 + 13.73 inches. Most frequent site involved was neck (98.6%), followed by groin (80.5%), knuckles (59.7%),sub-mammary (49%) and axilla (47%).The benign acanthosis nigricans was most frequent(98.6%) followed by HAIR AN Syndrome 46% cases, acral AN14%, Syndromic AN 1.7% and mixed 1.4%. No case had unilateral AN.The types of AN had no association with obesity (p>0.05).Diabetes mellitus observed in 47 (21%) AN cases.Polycystic ovaries (PCOs) in 111 out of 152 females with AN. Autoimmune conditions seen in 53(24%) AN cases. Conclusion: Benign and HAIR-AN were most frequent type in our study that was associated with raised BMI, waist circumference, PCOS and diabetes. It is recommended to screen acanthosis nigricans cases regardless of age or gender for obesity, PCOS, DM, hypertension and autoimmune conditions. Hence,early diagnosis may improve quality of life, prevent complications of systemic disease and improve outcome of diseases and quality of life of patients.

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Rambourg, Dimitri, Philippe Ackerer, and Olivier Bildstein. "Groundwater Parameter Inversion Using Topographic Constraints and a Zonal Adaptive Multiscale Procedure: A Case Study of an Alluvial Aquifer." Water 12, no. 7 (July 3, 2020): 1899. http://dx.doi.org/10.3390/w12071899.

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The identification of aquifer parameters (i.e., specific yield and hydraulic conductivity) and forcing terms (recharge) is crucial for the process of modeling groundwater flow and contamination. Inversion techniques allow the unravelling of complex systems’ heterogeneity with more ease than manual calibration by computing parameter fields through an automated minimization between simulated and measured data (i.e., water head or measured aquifer parameters). It also allows the iterative search of multiple, equally plausible solutions, depending on system complexity (e.g., aquifer heterogeneity and variability of the forcing terms such as recharge). A Zoned Adaptive Multiscale Triangulation (ZAMT) is used for parameter estimation. ZAMT is the extension of an adaptive multiscale parameter estimation procedure already applied on different field cases. This extension consists of adding constraints varying over the domain. The ZAMT dissociates the parameter grid from the calculation mesh and allows local parameter grid refinement depending on local criteria, addressing the ill-posedness of inversion problems, decreasing computation time by reducing the amount of possible solutions and local minima, and ensuring flexibility in the parameter’s distribution. Each parameter is defined per vertex of the parameter grid; it can be set with a different range of values in order to integrate more pedo-geological information and help the optimization process by reducing the number of local minima. For the same purpose, a plausibility term based on topological characteristics of the aquifer or minimal and maximal water levels is added to the objective function. Groundwater flow is described by a classical nonlinear diffusion-type equation (unconfined aquifer), which is discretized with a two-dimensional nonconforming finite element method because water head data is unsuitable to invert three-dimensional parameter fields. Therefore, flow is considered mainly horizontal, and the parameters are obtained as average values on the saturated thickness. The study area is an alluvial (unconfined) aquifer of 6.64 km², situated in the southern, Mediterranean part of France. The simulation runs with a chronicle of 191 piezometers over 7 years (2012–2019), using a calibration period of 5 years (2012–2016). The optimization threshold is set to ensure a mean absolute error below 40 cm. The ZAMT and the additional plausibility criterion were found to produce an ensemble of realistic parameter sets with low parameter standard deviation. The model is considered robust as the water head error remains at the same level during the verification period, which includes an exceptionally dry year (2017). Overall, the calibration is best near the rivers (Dirichlet boundaries), while the terraced portion of the site challenges the limits of the 2D approach and the inversion procedure.

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Burska, Agata N., Peter V. Giannoudis, Boon Hiang Tan, Dragos Ilas, Elena Jones, and Frederique Ponchel. "Dynamics of Early Signalling Events during Fracture Healing and Potential Serum Biomarkers of Fracture Non-Union in Humans." Journal of Clinical Medicine 9, no. 2 (February 11, 2020): 492. http://dx.doi.org/10.3390/jcm9020492.

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To characterise the dynamic of events during the early phases of fracture repair in humans, we investigated molecular events using gene expression profiling of bone fragments from the fracture site at different time points after trauma and immune/stromal cells recruitment at the fracture site using flow cytometry. Bone and inflammatory markers were expressed at low levels at homeostasis, while transcripts for bone constituent proteins were consistently detected at higher levels. Early after fracture (range 2–4 days), increased expression of CXCL12, suggested recruitment of immune cells associated with a change in the balance of degradation enzymes and their inhibitors. At intermediate time after fracture (4–8 days), we observed high expression of inflammatory cytokines (IL1-beta, IL6), CCL2, the T-cell activation marker CD69. Late after fracture (8–14 days), high expression of factors co-operating towards the regulation of bone turnover was detected. We identified potential soluble factors and explored circulating levels in patients for whom a union/non-union (U/NU) outcome was known. This showed a clear difference for PlGF (p = 0.003) at day 1. These findings can inform future studies further investigating the cascade of molecular events following fractures and for the prediction of fracture non-union.

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Gomez-Roca, C. A., R. Ruiz-Soto, M. Castaing, V. Marty, S. Bonvalot, P. Terrier, C. Le Pechoux, J. Domont, A. Cioffi, and A. Le Cesne. "Localized myxoid/round cell liposarcoma in adult patients. IL6 protein expression analysis." Journal of Clinical Oncology 25, no. 18_suppl (June 20, 2007): 10075. http://dx.doi.org/10.1200/jco.2007.25.18_suppl.10075.

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10075 Background: Myxoid/round cell liposarcoma (MLPS) is an uncommon soft tissue sarcoma with a relatively favorable prognosis and is considered a low grade malignancy. Methods: Retrospective analysis of 123 localized MLPS adult patients (pts) treated at our institution from 1987 to 2005 was performed. Paraffin embedded tissue was analyzed for IL6, IL6 receptor, NFkB and bcl-2 protein expression (positive (+) or negative) by tissue microarray immunostaining. Results: The median age of the 77 males and 46 females was 42 years (yr) (range 15–70). Lower extremity (LE) was the site more affected (77 pts). Median tumor size was 11 cm (range 2.5–40 cm), 87 were deep tumors and 63 were grade 1 tumors. Preoperative biopsy was carried on 38 pts. All but 2 pts underwent surgery (R0 24%, R1/R2 76%); 44 pts had a second surgery. Chemotherapy (CT) and radiation therapy were given to 30% and 52% of pts respectively. Complete remission was achieved in 98% of pts. After a median follow up of 6 yr (range 0.1–19 yr) 53 pts relapsed (43%); 37 locally, 11 distant and 5 both. Metastases occurred in 26 pts, 17 solitary and 9 multiple. The 5-yr, 10-yr and 15-yr DFS were 56%, 48% and 44% respectively. Median time to first relapse was 6.5 yr (range 0.1–16 yr). The 5-yr, 10-yr and 15-yr OS are 90%, 79% and 64% respectively. Tumor site, pre-surgical biopsy, R0 surgery and second surgery correlates with a better DFS in the multivariate analysis. So far 19 tumors have been studied for, NFkB (+) 57%, IL6 (+) 47% and Bcl2 (+) 30%, positivity. All tumors (+) for IL6 were also (+) for IL6 receptor. None of the proteins correlated to DFS and/or OS. Conclusions: Pts with localized resected MLPS require a prolonged follow-up since relapses occur after 10 yrs. PFS and OS correlate with an optimal loco-regional treatment. Half of MLPS expressed IL6, probably involving an autocrine phenomenon; whether this cytokine is involved in tumor aggressiveness, remains to be established. No significant financial relationships to disclose.

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Nahar, Kuldeep, and Nikita Nahar. "Management of unusual metallosis and failed elbow replacement in rheumatoid female: a case report." International Journal of Research in Orthopaedics 6, no. 2 (February 25, 2020): 413. http://dx.doi.org/10.18203/issn.2455-4510.intjresorthop20200746.

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<p class="abstract">42 years old female who was operated for rheumatoid arthritis elbow right side with revision of total replacement. Her elbow was primarily replaced 10 years before this surgery. She had severe metallosis and breakage of ulnar stem, loosening of cement (ulnar). Humerus stem was well fixed. Massive metal debris in soft tissue was removed. humerus side cement and stem were removed by splitting the bone. Revision stem was fixed with cement and circumferential wiring. On 6 yrs following surgery, patient is doing well in terms of pain relief and range of motion around elbow. She is doing almost all activities of daily life. Early detection and removal primary implant are the need of hour to save the ill effects of metallosis and bone resorption.</p>

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Sık, Guntulu, Asuman Demirbuga, Agageldi Annayev, and Agop Citak. "Regional citrate versus systemic heparin anticoagulation for continuous renal replacement therapy in critically ill children." International Journal of Artificial Organs 43, no. 4 (December 19, 2019): 234–41. http://dx.doi.org/10.1177/0391398819893382.

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Objectives: Anticoagulation is used to prevent filter clotting in patients undergoing continuous renal replacement therapy. Regional citrate anticoagulation is associated with lower rates of bleeding complications and prolongs the filter life span; however, a number of metabolic side effects had been associated with this therapy. The aim of this study was to evaluate the effect and safety of citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill children. Methods: A retrospective comparative cohort study. Department of Pediatric Intensive Care, Acibadem Mehmet Ali Aydınlar University School of Medicine. Results: From August 2016 to August 2018, 45 patients (19 in the citrate group and 26 in the heparin group) were included. A total of 101 hemofilters were used in all therapies: 44 in the citrate group (total continuous renal replacement therapy time: 2699 h) and 57 in the heparin group (total continuous renal replacement therapy time: 2383 h). The median circuit lifetime was significantly longer for regional citrate anticoagulation (53.0; interquartile range, 40–70 h) than for heparin anticoagulation (40.25; interquartile range, 22.75–53.5 h; p = 0.025). Mortality rates were similar in both groups (31.58% vs 30.77%). The most common indication for dialysis was hypervolemia in both groups. Transfusion rates were 1.65 units (interquartile range, 0.5–2.38) with heparin and 0.8 units (interquartile range, 0.3–2.0) with citrate (p = 0.32). Clotting-related hemofilter failure occurred in 11.36% of filters in the citrate group compared with 26.31% of filters in the heparin group. Conclusion: Our study showed that citrate is superior in terms of safety and efficacy, with longer filter life span. Regional citrate should be considered as a better anticoagulation method than heparin for continuous renal replacement therapy in critically ill children.

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Mogdans, J., and E. I. Knudsen. "Site of auditory plasticity in the brain stem (VLVp) of the owl revealed by early monaural occlusion." Journal of Neurophysiology 72, no. 6 (December 1, 1994): 2875–91. http://dx.doi.org/10.1152/jn.1994.72.6.2875.

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1. The optic tectum of the barn owl contains a physiological map of interaural level difference (ILD) that underlies, in part, its map of auditory space. Monaural occlusion shifts the range of ILDs experienced by an animal and alters the correspondence of ILDs with source locations. Chronic monaural occlusion during development induces an adaptive shift in the tectal ILD map that compensates for the effects of the earplug. The data presented in this study indicate that one site of plasticity underlying this adaptive adjustment is in the posterior division of the ventral nucleus of the lateral lemniscus (VLVp), the first site of ILD comparison in the auditory pathway. 2. Single and multiple unit sites were recorded in the optic tecta and VLVps of ketamine-anesthetized owls. The owls were raised from 4 wk of age with one ear occluded with an earplug. Auditory testing, using digitally synthesized dichotic stimuli, was carried out 8-16 wk later with the earplug removed. The adaptive adjustment in ILD coding in each bird was quantified as the shift from normal ILD tuning measured in the optic tectum. Evidence of adaptive adjustment in the VLVp was based on statistical differences between the VLVp's ipsilateral and contralateral to the occluded ear in the sensitivity of units to excitatory-ear and inhibitory-ear stimulation. 3. The balance of excitatory to inhibitory influences on VLVp units was shifted in the adaptive direction in six out of eight owls. In three of these owls, adaptive differences in inhibition, but not in excitation, were found. For this group of owls, the patterns of response properties across the two VLVps can only be accounted for by plasticity in the VLVp. For the other three owls, the possibility that the difference between the two VLVps resulted from damage to one of the VLVps could not be eliminated, and for one of these, plasticity at a more peripheral site (in the cochlea or cochlear nucleus) could also explain the data. In the remaining two owls, there was no evidence of adaptive adjustment in the VLVp despite large adaptive adjustments in the optic tectum. 4. The adjustment of ILD coding in the VLVp was always substantially smaller than expected based on the adjustment of ILD tuning in the optic tectum measured in the same animals. This indicates the involvement of at least one additional site of adaptive plasticity in the auditory pathway above the level of the VLVp.(ABSTRACT TRUNCATED AT 400 WORDS)

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Lewis, P., E. Nichols, G. Mackey, A. Fadol, L. Sloane, E. Villagomez, and P. Liehr. "The effect of turning and backrub on mixed venous oxygen saturation in critically ill patients." American Journal of Critical Care 6, no. 2 (March 1, 1997): 132–40. http://dx.doi.org/10.4037/ajcc1997.6.2.132.

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OBJECTIVE: To examine the effect of a change in body position (right or left lateral) and timing of backrub (immediate or delayed) on mixed venous oxygen saturation in surgical ICU patients. METHODS: A repeated-measures design was used to study 57 critically ill men. Mixed venous oxygen saturation was recorded at 1-minute intervals for 5 minutes in each of three periods: baseline, after turning, and after backrub. Subjects were randomly assigned to body position and timing of backrub. Subjects in the immediate-backrub group were turned and given a 1-minute backrub. Mixed venous oxygen saturation was measured at 1-minute intervals for 5 minutes at two points: after the backrub and then with the patient lying on his side. For subjects in the delayed-backrub group, saturation was measured at 1-minute intervals for 5 minutes at two different points: after the subject was turned to his side and after the backrub. RESULTS: Both position and timing of backrub had significant effects on mixed venous oxygen saturation across conditions over time. Subjects positioned on their left side had a significantly greater decrease in saturation when the backrub was started. At the end of the backrub, saturation was significantly lower in subjects lying on their left side than in subjects lying on their right side. The pattern of change differed according to the timing of the backrub, and return to baseline levels of saturation after intervention differed according to body position. CONCLUSIONS: Two consecutive interventions (change in body position and backrub) cause a greater decrease in mixed venous oxygen saturation than the two interventions separated by a 5-minute equilibration period. Turning to the left side decreases oxygen saturation more than turning to the ride side does. Oxygen saturation returns to clinically acceptable ranges within 5 minutes of an intervention. In patients with stable hemodynamic conditions, the standard practice of turning the patient and immediately giving a backrub is recommended. However, it is prudent to closely monitor individual patterns of mixed venous oxygen saturation, particularly in patients with unstable hemodynamic conditions.

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Tabarroki, Ali, Daniel Lindner, Valeria Visconte, Heesun J. Rogers, John Desamito, Hien K. Duong, Alan E. Lichtin, et al. "Modified Dose Escalation Of Ruxolitinib: A Feasible Therapeutic Approach In The Management Of Myelofibrosis." Blood 122, no. 21 (November 15, 2013): 1586. http://dx.doi.org/10.1182/blood.v122.21.1586.1586.

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Abstract Ruxolitinib, is a JAK1/2 inhibitor approved for the treatment of intermediate and high risk myelofibrosis (MF). The recommended starting doses for ruxolitinib, are 20 mg PO BID or 15 mg PO BID if platelet (PLT) counts are ≥200 x109/L or 100 to 200 x109/L, respectively. However, drug related side effects which includes grade 3/4 anemia (45.2%), thrombocytopenia (12.9%), fatigue (25.2%) and diarrhea (23.2%) are common using standard dosing. Moreover 70% of patients (pts) started on the standard regimen require dose reduction because of drug related toxicities. Although hematologic side effects are generally expected during early phases of ruxolitinib therapy and reversible in most cases, a therapeutic approach that can avoid myelosuppression while still providing adequate clinical responses is warranted. Therefore, to obviate toxicities and achieve symptom improvement in pts with MF, we employed a dose escalation (DE, starting at 5 mg QOD) approach for ruxolitinib and compared outcomes with another group that previously received standard regimens (SR, 15 or 20 mg BID). In addition to baseline characteristics, clinical data including hematologic parameters, bone marrow (BM) results, Dynamic International Prognostic Scoring System-Plus (DIPSS-plus) risk, and transfusion (TF) requirement were collected. Hematologic and non-hematologic side effects based on CTCAEv.4 and evidence of clinical response (reduction of splenomegaly by palpation) were assessed at 8, 12 and 16 weeks after starting treatment (post-Tx). Descriptive data were summarized as frequency of counts and percentages and continuous data were presented as mean and ranges and the comparison between two groups was performed. Survival outcomes were analyzed using the Kaplan-Meier method. Plasma concentrations for interleukins (IL) including IL1A, IL1B, IL2, IL4, IL6, IL8, IL10, IL12, IL17A, INFg, TNFa and GM-CSF were also measured pre and post- ruxolitinib treatment using a Multi-Analyte ELISArray Kits (SABiosciences) A total of 42 pts seen in our MPN clinic were studied, including 23 females (54%) and 19 males (46%). The median age of the cohort was 69 (43-83 years). Disease subtypes include 23 PMF, 10 post-PV MF, 6 post-ET MF and, 1 CMML-1. Based on the DIPSS-plus risk score, there were 17 high, 16 intermediate-2, and 8 intermediate-1 risk pts. Thirty-two pts (76%) were JAK2V617F mutant and 10 were wild type. The mean duration of treatment was 8 mos (range, 3-17) and follow up was 11 mos (4-36). Twenty-six pts started on DE and 16 received SR. The mean ruxolitinib dose in the whole cohort was 10 mg BID (range; 5mg QOD-25mg BID). The mean maintenance dose in the DE cohort was 5mg BID while in the SR cohort was 15mg BID. In terms of clinical response, the mean pre and post-Tx spleen size was 13.69 cm and 6.8 cm in the DE cohort compared to 17.68 cm and 13.07 cm in SR cohort (p = .03). In terms of hematological side effects, the DE approach resulted in less frequent grade 3-4 or any grade anemia compared to SR (G3-4: 3% vs. 18%, p =.02; overall anemia: 14% vs. 50%, p =.04). In pts treated with DE and SR, 57% and 75% were TF dependent pre-Tx. Post-Tx, 35% of pts treated with DE became transfusion independent vs 0% in the SR group. The DE approach also resulted in less frequent grade 3-4 or any grade thrombocytopenia compared to SR (G3-4: 11% vs. 31%, p= .04; overall thrombocytopenia: 23% vs. 43%, p=.06). There was no difference in the frequency or degree of neutropenia between the DE and SR treated pts. Non-hematologic side effects were also less frequent in the DE group compared to the SR group (bruising: 36 vs 75%, diarrhea: 28 vs 56%, lower extremity edema: 21% vs 50%, and dizziness: 15 vs 31%). In 3 pts treated with DE, the degree of reticulin fibrosis reduced from MF3 to MF2 confirmed with bone marrow biopsy performed 6-12 months post-Tx. We also compared the differences in cytokine profile between the patients treated with DE (n=2) and SR (N=2). No difference in the degree of reduction of MF relevant cytokines including IL-1A, IL-1B, IL-2, IL-4, IL-6, IL-12, TNF-α and GM-CSF were observed between both groups (p=0.2). At the time of analysis, 38 pts are still alive and no difference in survival were observed between DE and SR treated patients (log rank p=0.69). In conclusion, a dose escalation approach for ruxolitinib therapy is better tolerated and with preserved clinical responses compared to the standard dosing regimen in MF patients. Disclosures: No relevant conflicts of interest to declare.

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Hutschala, Doris, Christian Kinstner, Keso Skhirdladze, Florian Thalhammer, Markus Müller, and Edda Tschernko. "Influence of Vancomycin on Renal Function in Critically Ill Patients after Cardiac Surgery." Anesthesiology 111, no. 2 (August 1, 2009): 356–65. http://dx.doi.org/10.1097/aln.0b013e3181a97272.

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Background Vancomycin is frequently used in clinical practice to treat severe wound and systemic infections caused by Gram-positive bacteria after cardiac surgery. The drug is excreted almost entirely by glomerular filtration and might exhibit nephrotoxic side effects. This study compared the nephrotoxic impact of vancomycin during continuous versus intermittent administration. Methods The authors analyzed 149 patients admitted to the intensive care unit during a 5-yr period. All patients were treated at the intensive care unit after elective open heart surgery. Thirty patients received a dosage of 1325 +/- 603 mg/d vancomycin (range 300-3400 mg/d) by intermittent infusion, and 119 patients received a mean dosage of 1935 +/- 688 mg/d (range 352-3411 mg/d) by continuous infusion. Results Nephrotoxicity occurred in 11 patients (36.7%) in the intermittent treatment group and in 33 patients (27.7%) in the continuous treatment group (P = 0.3; 95% CI = 0.283). Continuous veno-venous hemofiltration after vancomycin administration was required for 9 patients (9 of 30; 30%) in the intermittent treatment group and for 28 (28 of 119; 23.5%) in the continuous treatment group (P = 0.053; 95% CI = 0.256). A change of one unit (1 mg/l) in vancomycin serum concentration (DeltaVancoC) induced an average change of 0.04 mg/dl in creatinine (DeltaCrea) in the intermittent treatment group versus 0.006 mg/dl in the continuous treatment group (P < 0.001). Conclusions The data show that both the intermittent and also the continuous application modality of vancomycin are associated with deterioration of renal function in critically ill patients after cardiac surgery. However, continuous infusion showed the tendency to be less nephrotoxic than the intermittent infusion of vancomycin.

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Verderber, A., and KJ Gallagher. "Effects of bathing, passive range-of-motion exercises, and turning on oxygen consumption in healthy men and women." American Journal of Critical Care 3, no. 5 (September 1, 1994): 374–81. http://dx.doi.org/10.4037/ajcc1994.3.5.374.

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BACKGROUND: Baseline data are needed to provide a foundation for future studies investigating the effects of various nursing interventions on the oxygen requirements of critically ill patients. OBJECTIVES: To establish reference values for the oxygen requirements of adults in response to three common patient events: a nurse-administered bed bath, passive range-of-motion exercises, and turning from side to side; and to determine whether the order in which the interventions were administered had an effect on oxygen consumption. METHODS: A convenience sample of 30 healthy men and women were randomly assigned to one of three treatment groups, for which the order in which interventions were to be administered had previously been designated. Data were analyzed using analysis of variance with repeated measures. RESULTS: There was a significant difference in the mean oxygen consumption among activities, as well as between men and women, with men having a significantly higher mean oxygen consumption than that of the women. For both men and women, the mean oxygen consumption during unassisted turning and back care was significantly higher than at baseline. The oxygen consumption for men averaged 4.25 mL/kg per minute, SD = .71 at baseline, 5.08 mL/kg per minute, SD = .98 for turning, and 4.72 mL/kg per minute, SD = .90 during back care. Women averaged 3.74 mL/kg per minute, SD = .49 at baseline, 4.48 mL/kg per minute, SD = .85 for turning, and 3.89 mL/kg per minute, SD = 1.15 during back care. Changes in oxygen consumption for other interventions were nonsignificant and negligible. Oxygen consumption returned to near baseline within 15 minutes of cessation of activity. The order in which interventions were administered did not have a significant effect on oxygen consumption. CONCLUSIONS: The anterior bath and passive range of motion exercises have minimal effect on oxygen consumption. Turning and back care significantly increase oxygen consumption from the baseline value. The order in which interventions are administered does not have any appreciable effect on oxygen consumption.

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Mai, Hanh P., Peter Vu, Arjune Patel, Joseph Clark, and Elizabeth Henry. "Experience with IL-2 in metastatic renal cell carcinoma after treatment with one or more targeted therapies." Journal of Clinical Oncology 34, no. 2_suppl (January 10, 2016): 622. http://dx.doi.org/10.1200/jco.2016.34.2_suppl.622.

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622 Background: Over half of patients (pts) diagnosed with Renal Cell Carcinoma require systemic therapy for metastatic disease (mRCC). Approved first line treatment includes immunotherapy and targeted therapy (TT). TT is commonly used given its efficacy, favorable side effect profile, and convenience of oral administration. High dose IL-2 (HD-IL2) can induce durable long term remissions in a subset of pts. There is limited data on the efficacy of HD-IL2 after disease progression on TT. Methods: All pts treated with HD-IL2 for mRCC from 2008-2014 were reviewed. A focused analysis was performed on pts who received HD-IL2 after first-line TT. Three pts were excluded from analysis. Data regarding pt demographics, health status, disease related characteristics, prognostic factors, treatment history and toxicity were captured. Response to HD-IL2 was also classified using RECIST definition. Utilizing descriptive statistics, we examined response rates, toxicities, and outcomes in this subset of pts. Results: Eighteen pts received HD-IL2 after TT. Median age was 60 (range 48-72). Six pts had primary mRCC and 12 had recurrent mRCC. Twelve pts received HD-IL2 as a 2nd line of treatment. Six pts received HD-IL2 as a 3rd or higher line of treatment. Among pts treated with HD-IL2 as 2nd line, 8 pts (67%) had partial response and 1 (8%) had complete response; duration of response ranged from 5-20+ months and 3 pts remain in remission. All 6 pts treated as 3rd line or higher did not show objective response to HD-IL2. The 2nd line group received significantly more doses than pts treated as 3rd line or higher (mean doses, 37 vs. 18, p=0.01). Overall, adverse events were expected, with the exception of grade 4 cardiac toxicity in 2 pts who received HD-IL2 as 3rd line. Conclusions: The administration of HD-IL2 as 2nd line is tolerated without excess toxicity and can induce clinical response. In our sample, there was no response to HD-IL2 among pts who received two or more prior TT. More investigation is warranted to determine if 3rd line HD-IL2 is safe and retains clinical benefit.

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Ao, Xiang, Yong Zhong, Xiao-he Yu, Mark R. Marshall, Tao Feng, Jian-ping Ning, and Qiao-ling Zhou. "Acute Peritoneal Dialysis System for Neonates with Acute Kidney Injury Requiring Renal Replacement Therapy: A Case Series." Peritoneal Dialysis International: Journal of the International Society for Peritoneal Dialysis 38, no. 2_suppl (December 2018): 45–52. http://dx.doi.org/10.3747/pdi.2018.00109.

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Background Acute kidney injury (AKI) is common in critically ill neonates, and peritoneal dialysis (PD) can be a lifesaving option. In China, however, much of the equipment for PD in neonates is not available. We describe results with a novel system for PD, which has been developed locally to improve access to therapy and care for critically ill neonates requiring PD in China. Methods The system comprises a 14-gauge single-lumen central venous catheter serving as a PD catheter, inserted by Seldinger technique, with an adapted twin bag PD system. Ten neonates with AKI were treated using the novel PD system. Results The 10 patients ranged in age from 1 day to 22 days, with bodyweights between 700 g and 3,300 g. Average time to renal function recovery was between 14 and 96 hours. Complications related to the novel PD system included leak ( n = 1), catheter displacement ( n = 1), and catheter obstruction ( n = 1). There were no complications related to insertion, no cases of peritonitis or exit-site infection, and no subsequent hernias. A comparison of costs indicated that the novel PD system is less expensive than conventional systems involving open insertion of Tenckhoff catheters. Conclusions Peritoneal dialysis using the novel PD system is simple, safe, and effective for suitable neonates with AKI in China.

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Hutton, Brian, Dean Fergusson, Paul C. Hebert, Alan Tinmouth, Lauralyn McIntyre, and Andrew Kmetic. "Variation in Transfusion Rates amongst Canadian Academic and Community Medical Centers." Blood 104, no. 11 (November 16, 2004): 2709. http://dx.doi.org/10.1182/blood.v104.11.2709.2709.

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Abstract Purpose: Few recent studies have examined approaches to transfusion practice in high-risk patients. We therefore documented practice variation following repair of hip fracture or cardiac surgery, as well as those requiring intensive care following a surgical intervention or multiple trauma. Methods: We documented rates of red cell transfusion in 41,568 patients admitted to 11 hospitals across Canada between August 1998 and August 2000 as part of a retrospective observational cohort study. Adjusted odds of transfusion, median number of transfusions per patient and median number of transfusions per patient day were compared across sites. We also compared mean nadir hemoglobin concentrations from center to center in the subgroup of 7,552 patients that received red cells. Results: The overall rate of red cell transfusion was 38.7 %, and ranged from 23.8% to 51.9% across centers among the 41,568 peri-operative and critically ill patients. Women were more likely to be transfused (43.7% versus 35.3%, p<0.0001), with higher rates of transfusion in 8 of 11 centers. Following adjustment for the effects of age, gender, severity of illness and the presence of twelve different comorbidities, the odds of transfusion ranged from 0.44 to 1.53 overall, from 0.42 to 1.22 in patients undergoing a hip fracture repair, from 0.72 to 3.17 in cardiac surgical patients undergoing cardiac surgery, and from 0.27 to 1.11 in critically ill and trauma patients (figure 1). Examination of both median number of units transfused and median number of units transfused per patient day also revealed between-site variation (figure 2). In the 7,552 transfused patients, the mean adjusted nadir hemoglobin was 74.0±4.83g/L overall, and ranged from 66.9±1.7g/L to 84.5±1.6g/L across centers. Similar differences among centers were observed amongst hip fracture patients (71.2±2.9g/L to 82.8±1.7g/L), cardiac surgical patients (65.7±1.1g/L to 77.3±1.0g/L) and critically ill and trauma patients (66.1±3.04g/L to 87.5±2.5g/L). Conclusions: We noted significant differences in the rates of red cell transfusion and nadir hemoglobin concentrations in various surgical and critical care settings. Such variation provides the impetus for investigators to explore its potential causes, and furthermore to attempt to define optimal transfusion practice in a variety of clinical settings by conducting randomized controlled trials.

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Yaguchi, Arino, Ryuichi Moroi, Tomoyuki Harada, Munekazu Takeda, Masaru Abe, Mizuho Namiki, Keiko Natori, et al. "Diagnosis of Deep Vein Thrombosis (DVT) In Critically Ill Patients." Blood 116, no. 21 (November 19, 2010): 5123. http://dx.doi.org/10.1182/blood.v116.21.5123.5123.

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Abstract Abstract 5123 Introduction: The assessment of existences of DVT is important to prevent pulmonary embolism for hospitalized patients. Especially, there is a high incidence of DVT in critically ill patients in the intensive care unit (ICU). Because almost all the patients in the ICU have limitations of their activities of daily living due to unstable vital status, controlled under the analgesia, or multiple injuries. The aim of the present study is to evaluate D-dimer levels as a diagnostic marker of DVT in critically ill patients. Methods: One-hundred ten adult patients (66 men, 44 women; age range 20–94 [median 64.5]) who admitted in our medico-surgical ICU in a university hospital were enrolled in this study. Serum D-dimer test and ultrasonic duplex scanning (ALOKA, Co., Ltd, Tokyo) were performed within one week after admission to the ICU. Serum D-dimer levels (μ g/mL) were measured by latex agglutination test (Sekisui Medical®, Tokyo) (normal <1.0μ g/mL). PT-INR (Quick one method) and APTT ratio (Langdell method) were also measured (Sysmex®, Kobe, Japan). DVT was diagnosed by ultrasonic duplex scanning. Value was expressed by median. Data were analyzed by Fisher's exact probability test and Mann-Whitney U test. A p < .05 was considered as statistically significant. Results: There were 32 patients (29.0 %) with DVT and 78 without DVT (71%) in the ICU. Primary diagnoses on admission were 31 cerebrovascular disease, 30 trauma patients, 16 sepsis, 9 acute respiratory failure, 8 hemorrhagic shock, 8 cardiogenic failure and 8 others. Between patients with DVT and without DVT, there were no significant differences in age (67.5 vs. 64.0, p=0.71), sex (19 men and 13 women vs. 47 men and 31 women, p=0.93), primary diagnosis (p=0.13), PT-INR (1.06 vs. 1.07, p=0.97) or APTT ratio (1.02 vs. 1.04, p=0.81), respectively. D-dimer level was also no statistically significant difference (10.4 vs. 7.3μ g/mL, p=0.21) between patients with DVT and without DVT. D-dimer level was higher in all DVT patients with DVT and in 95 per cent of non-DVT patients than normal range. Moreover, thromobosis tended to exist in soleal vein and femoral vein (Table) Conclusion: The present study suggests that D-dimer level could not be a useful marker for assessment of existence of DVT in critically ill patients. And DVT almost existed in soleal and femoral veins. D-dimer level elevates because of the primary disease and/or complications of patients in the ICU. The ultrasonic duplex scanning is an easy and non-invasive examination at the bed side, while there is a limitation to perform it for ICU patients due to their unstable vital status, difficulty of appropriate posture, such as prone positioning, or injured lower limbs. But at least the examination by duplex scan of soleal and femoral veins, which have more possibility to develop to pulmonary embolism, could be significance in the ICU patients. Disclosures: No relevant conflicts of interest to declare.

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Treichl, Benjamin, Mirjam Bachler, Ingo Lorenz, Barbara Friesenecker, Elgar Oswald, Christoph Schlimp, Florian Pedross, and Dietmar Fries. "Efficacy of Argatroban in Critically Ill Patients with Heparin Resistance: A Retrospective Analysis." Seminars in Thrombosis and Hemostasis 41, no. 01 (January 16, 2015): 061–67. http://dx.doi.org/10.1055/s-0034-1398382.

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The patients who do not respond even to very high dosages of heparin are assumed to suffer from heparin resistance. The aim of this study was to investigate whether critically ill patients suffering from heparin resistance generally have low antithrombin III (AT) levels, and if the direct thrombin inhibitor argatroban in that case can be an effective option to achieve prophylactic anticoagulation. The study was conducted at the Department for General and Surgical Intensive Care Medicine at the University Hospital Innsbruck. We retrospectively included all patients between 2008 and 2012, who received argatroban because of poor response to high-dosage heparin prophylaxis. The period under observation lasted in total for 9 days, 2 days of anticoagulation with unfractionated heparin (UFH) and 7 days with argatroban. The primary objective was to investigate if after 7 (± 1) hours of switching to argatroban the activated partial thromboplastin time (aPTT) levels were in a prophylactic range of 45 to 55 seconds. Further objectives were to assess the AT level, side effects such as bleeding or thromboembolism, platelet count, correlation between organ function and argatroban dose as well as any need for allogeneic blood products. The study population, consisting of 5 women and 15 men with a mean (± standard deviation, SD) age of 54.6 ± 16.3 years, differed in many clinical aspects. A median (interquartile range) heparin dose of 1,000, 819 to 1,125 IU/h was administered for 2 days and failed in providing a prophylactic anticoagulation measured by the aPTT. The mean aPTT level with heparin treatment was 38.5 seconds (± 4.7) its change within that period was not significant. After switching to argatroban, the mean increase of the aPTT levels in all study patients amounted from 38.5 to 48.3 seconds (p < 0.001). The rise in aPTT clearly reaches sufficient prophylactic anticoagulant levels. The maintenance of prophylactic aPTT levels was achieved over the period of 1 week. There was neither a correlation found between low-AT levels and occurrence of heparin resistance, nor between the simplified acute physiology score II and the administered argatroban dose (r = −0.224, p = 0.342). The results of the present study indicate that argatroban is an effective alternative therapy, especially in critically ill patients, to achieve prophylactic anticoagulation when heparin resistance occurs.

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OGBOGU, SYLVESTER, and WILLIAMS ADU. "Life history and larval density of Cheumatopsyche digitata Mosely (Trichoptera: Hydropsychidae) in Opa Reservoir spillway, Ile-Ife, southwestern Nigeria." Zoosymposia 5, no. 1 (June 10, 2011): 401–7. http://dx.doi.org/10.11646/zoosymposia.5.1.32.

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The life history and density of Cheumatopsyche digitata Mosely (Trichoptera: Hydropsychidae) were examined below Opa Reservoir in Ile-Ife, southwestern Nigeria. This caddisfly is the only species that occurs immediately below the impoundment auxiliary spillway where it closely associates with an aquatic bryophyte, Fontinalis sp. We collected larvae every month between July 2004 and June 2005 as long as larvae were available in the study site. The instar growth ratio was fairly constant and ranged from 1.198 to 1.402 (mean ± standard error = 1.285 ± 0.073) but mean head capsule width increased with larval development. The frequency distribution of head capsule width of larvae clustered into 5 size classes, suggesting 5 larval instars for C. digitata in the study site. Density of larvae ranged from 1,100 to 11,150 inds.m-2 (mean ± SE = 6739 inds.m-2 ± 3904.70), the highest densities occurring in October 2004 during the bloom of Fontinalis. The first larval instar appeared in July 2004. Adult emergence occurred mainly in December 2004 through January 2005 at the onset of reservoir draw-down and death of Fontinalis. These patterns indicate that C. digitata tended to show a univoltine life cycle in the study site.

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Journal articles on the topic 'Range Site (Ill.)'

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