Avaliação do prognóstico com a utilização de dois escores de mortalidade em terapia intensiva pediátrica de nível de atendimento terciário

A redução da mortalidade é um objetivo fundamental das unidades de terapia intensiva pediátrica (UTIP). O estágio de gravidade da doença reflete a magnitude das comorbidades e distúrbios fisiológicos no momento da internação e pode ser avaliada pelos escores prognósticos de mortalidade. Os dois principais escores utilizados na UTIP são o Pediatric Risk of Mortality (PRISM) e o Pediatric Index of Mortality (PIM). O PRISM utiliza os piores valores de variáveis fisiológicas e laboratoriais nas primeiras 24 horas de internação enquanto o PIM2 utiliza dados da primeira hora de internação na UTIP e apenas uma gasometria arterial. Não há consenso na literatura, entre PRISM e PIM2, quanto à utilidade e padronização na admissão na terapia intensiva para as crianças e adolescentes, principalmente em uma UTI de nível de atendimento terciário. O objetivo do estudo foi estabelecer o escore de melhor performance na avaliação do prognóstico de mortalidade que seja facilmente aplicável na rotina da UTIP, para ser utilizado de forma padronizada e contínua. Foi realizado um estudo retrospectivo onde foram revisados os escores PRISM e PIM2 de 359 pacientes internados na unidade de terapia intensiva pediátrica do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, considerada uma unidade de atendimento de nível terciário. A mortalidade foi de 15%, o principal tipo de admissão foi clinico (78%) sendo a principal causa de internação a disfunção respiratória (37,3%). Os escores dos pacientes que foram a óbito mostraram-se maiores do que o dos sobreviventes. Para o PRISM foi 15 versus 7 (p = 0,0001) e para o PIM2, 11 versus 5 (p = 0,0002), respectivamente. Para a amostra geral, o Standardized Mortality Ratio (SMR) subestimou a mortalidade tanto para o PIM2 quanto para o PRISM [1,15 (0,84 - 1,46) e 1,67 (1,23 - 2,11), respectivamente]. O teste de Hosmer-Lemeshow mostrou calibração adequada para ambos os escores [x2 = 12,96 (p = 0,11) para o PRISM e x2 = 13,7 (p = 0,09) para o PIM2]. A discriminação, realizada por meio da área sob a curva ROC, foi mais adequada para o PRISM do que para o PIM2 [0,76 (IC 95% 0,69 - 0,83) e 0,65 (IC 95% 0,57 - 0,72), respectivamente, p= 0,002]. No presente estudo, a melhor sensibilidade e especificidade para o risco de óbito do PRISM foi um escore entre 13 e 14, mostrando que, com o avanço tecnológico, o paciente precisa ter um escore mais elevado, ou seja, maior gravidade clínica do que a população original, para um maior risco de mortalidade. Os escores de gravidade podem ter seus resultados modificados em consequência: do sistema de saúde (público ou privado), da infraestrutura da UTIP (número de leitos, recursos humanos, parque tecnológico) e indicação da internação. A escolha de um escore de gravidade depende das características individuais da UTIP, como o tempo de espera na emergência, presença de doença crônica complexa (por exemplo, pacientes oncológicos) e como é realizado o transporte para a UTIP. Idealmente, estudos multicêntricos têm maior significância estatística. No entanto, estudos com populações maiores e mais homogêneas, especialmente nos países em desenvolvimento, são difíceis de serem realizados

Severe Cutaneous Leishmaniasis in a Human Immunodeficiency Virus Patient Coinfected with Leishmania braziliensis and Its Endosymbiotic Virus.

Leishmaniaparasites cause a broad range of disease, with cutaneous afflictions being, by far, the most prevalent. Variations in disease severity and symptomatic spectrum are mostly associated to parasite species. One risk factor for the severity and emergence of leishmaniasis is immunosuppression, usually arising by coinfection of the patient with human immunodeficiency virus (HIV). Interestingly, several species ofLeishmaniahave been shown to bear an endogenous cytoplasmic dsRNA virus (LRV) of theTotiviridaefamily, and recently we correlated the presence of LRV1 withinLeishmaniaparasites to an exacerbation murine leishmaniasis and with an elevated frequency of drug treatment failures in humans. This raises the possibility of further exacerbation of leishmaniasis in the presence of both viruses, and here we report a case of cutaneous leishmaniasis caused byLeishmania braziliensisbearing LRV1 with aggressive pathogenesis in an HIV patient. LRV1 was isolated and partially sequenced from skin and nasal lesions. Genetic identity of both sequences reinforced the assumption that nasal parasites originate from primary skin lesions. Surprisingly, combined antiretroviral therapy did not impact the devolution ofLeishmaniainfection. TheLeishmaniainfection was successfully treated through administration of liposomal amphotericin B.

Modeling Depression Progression Dynamics from Electronic Health Record

Thesis (Master's)--University of Washington, 2016-06

A survey of possible associations between preharvest environment conditions and postharvest rejections of cut freesia flowers

Botrytis cinerea is the major pathogen infecting cut freesia flowers. Flecking symptoms on petals caused by this fungus result in postharvest rejections and substantial economic loss to both growers and sellers. In a limited survey for industry, numbers of freesia stems sent from a specialist grower in The Netherlands and rejected at a cut flower wholesaler in the United Kingdom were documented. Relationships between preharvest environment conditions in Holland that may predispose flowers to infection and postharvest freesia rejection levels in the United Kingdom due to B. cinerea flecking symptom expression are reported. Freesia rejections peaked during spring and, to a lesser degree, autumn periods. However, no clear correlations between preharvest growing environment conditions (e.g. 3-day means for temperature preceding harvest) and postharvest rejection frequency (%) could be discerned. Thus, sporadic freesia rejections in the United Kingdom were probably attributable either to other unresolved variables during the pre- (e.g. infection pressure) and/or postharvest (e.g. condensation events) phases or to interactions among predisposing variables.

Sensitivity of Geraldton waxflower to ethylene-induced flower abscission is reduced at low temperature

Exposure to ethylene gas elicits flower abscission from cut stems of Geraldton waxflower (Chamelaucium uncinatum Schauer). Ethylene response rates in plants are mediated by temperature. At 20degreesC, flower abscission from waxflower 'Purple Pride' occurred upon 12 h exposure to I mu11(-1) ethylene. This ethylene treatment did not cause flower abscission at either 10 or 2degreesC. Moreover, flowers held at 2degreesC were insensitive to 48 h exposure to 1, 10 and 100 mu11(-1) ethylene. However, increasing the duration of treatment with I mu11(-1) ethylene at 10 and 2degreesC to 48 and 144 h, respectively, induced flower abscission. When flowers were held at 20degreesC in air without exogenous ethylene following continuous exposure to I mu11(-1) ethylene at 2degreesC, the duration required to elicit flower abscission was reduced from 144 to 72 It. Collectively, these responses show that maintaining harvested waxflower at low temperature (e.g. 2degreesC) is an effective means to minimise ethylene-mediated flower abscission.

Steatosis and liver cell apoptosis in chronic hepatitis C: A mechanism for increased liver injury

Steatosis is increasingly recognized as a cofactor influencing the progression of fibrosis in chronic hepatitis Q however, the mechanisms by which it contributes to liver injury remain uncertain. We studied 125 patients with chronic hepatitis C to assess the effect of steatosis on liver cell apoptosis and the expression of Bcl-2, Bd-x(L), Bax, and tumor necrosis factor alpha (TNF-alpha) and the relationship between liver cell apoptosis and disease severity. A significant increase in liver cell apoptosis was seen in liver sections with increasing grade of steatosis (r = 0.42; P < .0001). Hepatic steatosis and previous heavy alcohol consumption were the only two variables independently associated with the apoptotic index. Increasing steatosis was associated with decreased Bcl-2 mRNA levels and an increase in the proapoptotic Bax/Bcl-2 ratio (r = -0.32, P = .007; and r = 0.27, P = .02, respectively). In the absence of steatosis, increased liver cell apoptosis was not associated with stellate cell activation or fibrosis (r = 0.26, P = .11; r = 0.06, P = .71, respectively). In contrast, in the presence of steatosis, increasing apoptosis was associated with activation of stellate cells and increased stage of fibrosis (r = 0.35, P = .047; r = 0.33, P = .03, respectively), supporting the premise that the steatotic liver is more vulnerable to liver injury. In patients with hepatitis C virus genotype 3, there was a significant correlation between TNF-α mRNA levels and active caspase-3 (r = 0.54, P = .007). In conclusion, these observations suggest a mechanism whereby steatosis contributes to the progression of liver injury in chronic hepatitis C. Further investigation will be required to determine the molecular pathways responsible for the proapoptotic effect of steatosis and whether this increase in apoptosis contributes directly to fibrogenesis.

Nutrient partitioning during treatment of tuberculosis: gain in body fat mass but not in protein mass

Background: Tuberculosis is an important cause of wasting. The functional consequences of wasting and recovery may depend on the distribution of lost and gained nutrient stores between protein and fat masses. Objective: The goal was to study nutrient partitioning, ie, the proportion of weight change attributable to changes in fat mass (FM) versus protein mass (PM), during anti mycobacterial treatment. Design: Body-composition measures were made of 21 men and 9 women with pulmonary tuberculosis at baseline and after 1 and 6 mo of treatment. All subjects underwent dual-energy X-ray absorptiometry and deuterium bromide dilution tests, and a four-compartment model of FM, total body water (TBW), bone minerals (BM), and PM was derived. The ratio of PM to FM at any time was expressed as the energy content (p-ratio). Changes in the p-ratio were related to disease severity as measured by radiologic criteria. Results: Patients gained 10% in body weight (P < 0.001) from baseline to month 6. This was mainly due to a 44% gain in FM (P < 0.001); PM, BM, and TBW did not change significantly. Results were similar in men and women. The p-ratio decreased from baseline to month 1 and then fell further by month 6. Radiologic disease severity was not correlated with changes in the p-ratio. Conclusions: Microbiological cure of tuberculosis does not restore PM within 6 mo, despite a strong anabolic response. Change in the p-ratio is a suitable parameter for use in studying the effect of disease on body composition because it allows transformation of such effects into a normal distribution across a wide range of baseline proportion between fat and protein mass.

Assessment of volume depletion in children with malaria

Background The degree of volume depletion in severe malaria is currently unknown, although knowledge of fluid compartment volumes can guide therapy. To assist management of severely ill children, and to test the hypothesis that volume changes in fluid compartments reflect disease severity, we measured body compartment volumes in Gabonese children with malaria. Methods and Findings Total body water volume (TBW) and extracellular water volume (ECW) were estimated in children with severe or moderate malaria and in convalescence by tracer dilution with heavy water and bromide, respectively. Intracellular water volume (ICW) was derived from these parameters. Bioelectrical impedance analysis estimates of TBW and ECW were calibrated and bioelectrical impedance analysis measurements were taken daily against dilution methods, until discharge. Sixteen children had severe and 19 moderate malaria. Severe childhood malaria was associated with depletion of TBW (mean [SD] of 37 [33] ml/kg, or 6.7% [6.0%]) relative to measurement at discharge. This is defined as mild dehydration in other conditions. ECW measurements were normal on admission in children with severe malaria and did not rise in the first few days of admission. Volumes in different compartments (TBW, ECW, and ICW) were not related to hyperlactataemia or other clinical and laboratory markers of disease severity. Moderate malaria was not associated with a depletion of TBW. Conclusions Significant hypovolaemia does not exacerbate complications of severe or moderate malaria. As rapid rehydration of children with malaria may have risks, we suggest that fluid replacement regimens should aim to correct fluid losses over 12-24 h.

The distribution of Tannerella forsythia in an adolescent and adult population

Background: The fact that Tannerella forsythia, an important periopathogen, is difficult to cultivate from mixed infections has impeded precise estimates of its distribution within a given population. In order to discern T. forsythia alone from the mixed infection of plaque, the use of sensitive 16S ribosomal RNA based polymerase chain reaction (PCR) detection is necessary. Objectives: The aim of the present study was to determine the distribution of T. forsythia in an adult and in an adolescent population. Materials and methods: Subgingival plaque samples were obtained from 498 Australian adults and from 228 adolescent subjects from Manchester, UK. Tannerella forsythia was detected using PCR and confirmed by restriction analysis. Semi-quantitation of the organisms was carried out using two specific primers of differing sensitivities. Results: In the adolescent population, 25% were found to carry T. forsythia, albeit in relatively low numbers. In the adult population, a total of 37.8% and 11% were found to carry the organism with primer 2 and primer 1, respectively, suggesting that around 27% had between 10(3) and 10(7) organisms. Although there was an apparent increased proportion of T. forsythia positive subjects in those aged >= 50 years, this was not statistical significant. However, T. forsythia positive male smokers showed increased disease severity compared with T. forsythia negative subjects. Conclusion: This study has shown that at least 25% of the adolescent population carry low numbers of T. forsythia, whereas at least 37% of adults carry the organism, with some 11% having relatively high numbers. The relationship between T. forsythia and disease progression in these populations, however, remains to be determined.

Manipulating avocado fruit ripening with 1-methylcyclopropene

Previous investigations with 1-methylcyclopropene (1-MCP) on avocado (Persea americana Mill.) fruit have focussed mainly on improving storage life by reducing the severity of disorders causing discolouration of the flesh. Development of 1-MCP and ethylene treatments, which also help control the time to reach the eating ripe stage, may confer additional practical benefits. In this context, the current study investigated the potential of 1-MCP to accurately manipulate ripening of non-stored 'Hass' avocado fruit by treatment before or after ethylene and at different times during ripening. To investigate this, 500 nL L-1 1-MCP was applied within 1 day after harvest, followed by ethylene 0-14 days after 1-MCP. In addition, fruit were treated with ethylene, then 1-MCP 0-8 days after ethylene. Treatment of fruit with 500 nL L-1 1-MCP for 18 h at 20 degreesC provided the maximum effect by increasing the days from harvest to ripe (DTR) from 8 (with no 1-MCP) to 20. Fruit treated with 500 nL L-1 1-MCP for 18 h at 20 degreesC remained insensitive to 100 muL L-1 ethylene applied between 0 and 14 days after 1-MCP for 24 h at 20 degreesC. Ripening of fruit exposed to 100 muL L-1 ethylene for 24 h at 20 degreesC could be delayed by up to 3.3 days by applying 500 nL L-1 1-MCP for 18 h at 20 degreesC up to 2 days after ethylene treatment. However, once the fruit started to soften (sprung) there was little effect of 1-MCP on DTR, compared with no 1-MCP. 1-MCP treatment was associated with increased severity of body rots (caused mainly by Colletotrichum spp.) and stem-end rots (caused mainly by Dothiorella spp.), which was likely due to the increased DTR in these treatments. Significant differences in disease severity were found between orchards (replications), with replicates with low disease severity being less affected by 1-MCP treatment. These results indicate that 1-MCP can delay ripening, but careful sourcing of fruit is required to reduce the risk of diseases in ripe fruit. There is some capacity to delay ripening using 1-MCP after ethylene. There is little potential to control ripening using ethylene after treatment with 500 nL L-1 1-1-MCP, but lower concentrations may be more effective. (C) 2004 Elsevier B.V. All rights reserved.

Methyl jasmonate vapour treatment suppresses specking caused by Botrytis cinerea on cut Freesia hybrida L. flowers

Treatment of cut freesia var. Cote d'Azur flowers with methyl jasmonate (MeJA, 0.1 mu l MeJA l(-1)) vapour suppressed petal specking caused by Botrytis cinerea infection. MeJA efficacy was concentration and incubation temperature dependent. Disease severity, lesion numbers and lesion diameters decreased with increasing MeJA concentration from 0.025 to 0.1 mu l MeJA l(-1). However, there were no significant (P > 0.05) differences among MeJA concentrations examined. MeJA was more effective in reducing B. cinerea flower specking at 20 degrees C than at 12 degrees C. MeJA treatment was ineffective at 5 degrees C. At 20 degrees C, MeJA treatment at 0.1 mu l MeJA l(-1) reduced disease severity, lesion numbers and lesion diameters by 58, 50 and 48%, respectively, as compared to untreated controls. In a repeat experiment, disease severity, lesion numbers and lesion diameters on MeJA vapour treated flowers after 12 h of incubation were reduced by 68, 56 and 50%, respectively. MeJA did not exert direct antifungal activity in-vitro, suggesting that treatment in-vivo reduced B. cinerea-induced flower specking by induction of host defence responses. MeJA at 0.1 mu l MeJA l(-1) significantly (P < 0.05) increased vase life of cut freesia flowers and delayed senescence judged by lower wilt scores and higher fresh weights as compared to untreated controls. (c) 2005 Elsevier B.V. All rights reserved.

Characterization of two polymorphisms in the leukotriene C4 synthase gene in an Australian population of subjects with mild, moderate, and severe asthma

Background: The cysteinyl-leukotrienes (cys-LTs) are proinflammatory mediators that are important in the pathophysiology of asthma. LTC4 synthase is a key enzyme in the cys-LT biosynthetic pathway, and studies in small populations have suggested that a promoter polymorphism (A(-444)C) in the gene might be associated with asthma severity and aspirin intolerance. Objective: We sought to screen the LTC4 synthase gene for polymorphisms and to determine whether there is an association between these polymorphisms and asthma severity or aspirin sensitivity in a large, well-phenotyped population and to determine whether this polymorphism is functionally relevant. Methods: The coding regions of the LTC4 synthase gene were screened for polymorphisms and the A(-444)C polymorphism was analyzed in a large Australian white adult population of mild (n = 282), moderate (n = 236), and severe asthmatic subjects (n = 86) and nonasthmatic subjects (n = 458), as well as in aspirin-intolerant asthmatic subjects (n = 67). The functional activity of the promoter polymorphism was investigated by transient transfection of HL-60 cells with a promoter construct. Results: A new polymorphism was identified in intron 1 of the gene (IVS1-10c>a) but was not associated with asthma. Association studies showed that the A(-444)C polymorphism was weakly associated with asthma per se, but there was no association between the C-444 allele and chronic asthma severity or aspirin intolerance. A meta-analysis of all the genetic studies conducted to date found significant between-study heterogeneity in C-444 allele frequencies within different clinical subgroups. In vitro functional studies showed no significant differences in transcription efficiency between constructs containing the A(-444) allele or the C-444 allele. Conclusions: Our data confirm that, independent of transcriptional activity, the C-444 allele in the LTC4 synthase gene is weakly associated with the asthma phenotype, but it is not related to disease severity or aspirin intolerance.

Australian and New Zealand practice in intensive care (ANZPIC II: The spectrum of practice in the diagnosis and management of pneumonia in patients requiring mechanical ventilation

This study of ventilated patients investigated current clinical practice in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units (ICUs) within Australia and New Zealand. Diagnostic methods and confidence, disease severity, microbiology and antibiotic use were assessed. All pneumonia types had similar mortality (community-acquired pneumonia 33%, hospital-acquired pneumonia 37% and ventilator-associated pneumonia 24%, P = 0.15) with no inter-hospital differences (P = 0.08-0.91). Bronchoscopy was performed in 26%, its use predicted by admission hospital (one tertiary: OR 9.98, CI 95% 5.11-19.49, P < 0.001; one regional: OR 629, CI 95% 3.24-12.20, P < 0.001), clinical signs of consolidation (OR 3.72, CI 95% 2.09-662, P < 0.001) and diagnostic confidence (OR 2.19, CI 95% 1.29-3.72, P = 0.004). Bronchoscopy did not predict outcome (P = 0.11) or appropriate antibiotic selection (P = 0.69). Inappropriate antibiotic prescription was similar for all pneumonia types (11-13%, P = 0.12) and hospitals (0-16%, P = 0.25). Blood cultures were taken in 51% of cases. For community-acquired pneumonia, 70% received a third generation cephalosporin and 65% a macrolide. Third generation cephalosporins were less frequently used for mild infections (OR 0.38, CI 95% 0.16-0.90, P = 0.03), hospital-acquired pneumonia (OR 0.40, CI 95% 0.23-0.72, P < 0.01), ventilator-associated pneumonia (OR 0.04, CI 95% 0.02-0.13, P < 0.001), suspected aspiration (OR 0.20, CI 95% 0.04-0.92, P = 0.04), in one regional (OR 0.26, CI 95% 0.07-0.97, P = 0.05) and one tertiary hospital (OR 0.14, CI 95% 0.03-0.73, P = 0.02) but were more commonly used in older patients (OR 1.02, CI 95% 1.01-1.03, P = 0.01). There is practice variability in bronchoscopy and antibiotic use for pneumonia in Australian and New Zealand ICUs without significant impact on patient outcome, as the prevalence of inappropriate antibiotic prescription is low. There are opportunities for improving microbiological diagnostic work-up for isolation of aetiological pathogens.

Effects of postharvest methyl jasmonate treatments against Botrytis cinerea on Geraldton waxflower (Chamelaucium uncinatum)

Cut Geraldton waxflower (Chamelaucium uncinatum Schauer) flowers are often infected with Botrytis cinerea. Release of infection from quiescence can cause ethylene production by invaded host tissues and result in flower abscission. Postharvest floral organ abscission is a major problem for the commercial waxflower industry. Methyl jasmonate (MeJA) occurs naturally in plant tissue and has a signalling role in eliciting induced systemic resistance against disease. MeJA treatments have been shown to suppress B. cinerea infecting cut rose flowers. The present experiments investigated the potential of exogenous MeJA treatments for B. cinerea management on harvested waxflower. MeJA treatments of 10 and 100 L liquid MeJA/L of air applied to cv. Purple Pride and 1 L MeJA/L to cv. Mullering Brook gave reductions in disease severity for uninoculated stems. However, concentrations of 100 L MeJA/L applied to Purple Pride in addition to 1 and 10 L MeJA/L applied to Mullering Brook increased the incidence of floral organ fall. Flower abscission upon treatment with MeJA may be due to induced systemic resistance-associated upregulation of ethylene biosynthesis. MeJA treatments had no direct effect on B. cinerea hyphal elongation in vitro. Collectively, these results show that while MeJA treatment may elicit defence in waxflower against Botrytis, the chemical also causes floral organ fall. Thus, exogenous MeJA treatments do not have potential for B. cinerea management on harvested waxflower.

Survival strategy of Echinococcus multilocularis in the human host

As exemplified by aborted calcified liver lesions commonly found in patients from endemic areas, Echinococcus multilocularis metacestodes develop only in a minority of individuals exposed to infection with the papasite. Clinical research has disclosed some aspects of the survival strategy of E. multilocularis in human hosts. Clinical observations in liver transplantation and AIDS suggest that suppression of cellular/Th1related immunity increases disease severity. Most of the studies have stressed a role for CD8+ T cells and for Interleukin-10 in the development of tolerance. A spontaneous secretion of IL-10 by the PBMC seems to be the immunological hallmark of patients with progressive forms of alveolar echinococcosis (AE). IL-10-induced inhibition of effector macrophages, but also of antigen-presenting dendritic cells, may be operating and allowing parasite growth and survival. The genetic correlates of susceptibility to infection with E. multilocularis are clearer in humans than in the mouse model. A significant link between MHC polymorphism and clinical presentation of AE has been shown, and the spontaneous secretion of IL-10 in patients with a progressive AE is higher in patients with the HLA DR3+, DQ2+ haplotype. Clustering of cases in certain families, in communities otherwise exposed to similar risk factors, also points to immuno-genetic predisposition factors that may allow the larva to escape host immunity more easily. The first stage of larval development may be crucial in producing danger signals stimulating the initial production of cytokines. Therapeutic use of Interferon alpha is an attempt to foil the survival strategy of E. multilocularis. (C) 2005 Elsevier Ireland Ltd. All rights reserved.