Iowa Department of Human Services - Case Management Unit, June 30, 2002

State Agency Audit Report

Added prognostic value of myocardial blood flow quantitation in rubidium-82 positron emission tomography imaging

Les maladies cardiovasculaires restent la cause de mortalité la plus élevée dans le monde occidental. Il s'agit d'un processus long et complexe, dont l'infarctus du myocarde et la mort cardiaque ne sont que la fin d'un spectrum. La perfusion myocardique joue un rôle central dans l'évolution de la maladie et survient chronologiquement en amont de la dysfonction diastolique et systolique, ainsi que de l'infarctus du myocarde. Une meilleure compréhension de la Physiopathologie sous-jacente est cruciale dans le diagnostique et la prise en charge du patient. Dans ce sens, ce travail tente d'évaluer l'apport de l'évaluation de la perfusion myocardique évaluée par la tomographic à émission de positron (PET/CT) quant à la prédiction d'événements cardiovasculaires. De plus, l'apport de l'évaluation quantitative par rapport à l'évaluation qualitative a été démontré dans ce travail. Nous avons utilisé un radiotraceur unique au regard de ses caractéristiques. En effet, Le Rubidium-82 est un traceur qui ne nécessite pas d'un cyclotron pour sa fabrication, dès lors qu'il est produit par un générateur, rendant ainsi sa disponibilité un atout et un avantage potentiel lors de futurs implémentations à plus grande échelle. Ce travail démontre la supériorité de l'analyse de perfusion myocardique quantitative par rapport à l'analyse traditionnelle qualitative, ce qui n'était pas encore confirmé avec le Rubidium-82. Les résultats montrent une démarcation significative entre les différentes valeurs de perfusion quantitative/absolue, permettant de distinguer différentes populations plus ou moins à risque en terme de prédiction d'événements cardiaques futurs. Il est intéressant de noter que dans un modèle combinant l'analyse qualitative et quantitative proposé dans ce travail, l'inclusion des résultats les plus ischémiques obtenus par l'analyse qualitative avec les résultats de perfusion les plus bas en terme de flux myocardique absolu (analyse quantitative) démarque une population à très bas risque d'événements cardiovasculaires majeurs, une prédiction pouvant être observée surplus de 1'000 jours. Ces résultats forment un ajout significatif quant à l'évaluation de la perfusion myocardique par la médecine nucléaire, notamment par ce model intégratif proposé, lequel permet une prédiction précise et contributive dans le cadre de futurs événements cardiovasculaires majeurs.

Pancreatic stone protein as an early biomarker predicting mortality in a prospective cohort of patients with sepsis requiring ICU management.

ABSTRACT: INTRODUCTION: Biomarkers, such as C-reactive protein [CRP] and procalcitonin [PCT], are insufficiently sensitive or specific to stratify patients with sepsis. We investigate the prognostic value of pancreatic stone protein/regenerating protein (PSP/reg) concentration in patients with severe infections. METHODS: PSP/reg, CRP, PCT, tumor necrosis factor-alpha (TNF-α), interleukin 1 beta (IL1-β), IL-6 and IL-8 were prospectively measured in cohort of patients ≥ 18 years of age with severe sepsis or septic shock within 24 hours of admission in a medico-surgical intensive care unit (ICU) of a community and referral university hospital, and the ability to predict in-hospital mortality was determined. RESULTS: We evaluated 107 patients, 33 with severe sepsis and 74 with septic shock, with in-hospital mortality rates of 6% (2/33) and 25% (17/74), respectively. Plasma concentrations of PSP/reg (343.5 vs. 73.5 ng/ml, P < 0.001), PCT (39.3 vs. 12.0 ng/ml, P < 0.001), IL-8 (682 vs. 184 ng/ml, P < 0.001) and IL-6 (1955 vs. 544 pg/ml, P < 0.01) were significantly higher in patients with septic shock than with severe sepsis. Of note, median PSP/reg was 13.0 ng/ml (IQR: 4.8) in 20 severely burned patients without infection. The area under the ROC curve for PSP/reg (0.65 [95% CI: 0.51 to 0.80]) was higher than for CRP (0.44 [0.29 to 0.60]), PCT 0.46 [0.29 to 0.61]), IL-8 (0.61 [0.43 to 0.77]) or IL-6 (0.59 [0.44 to 0.75]) in predicting in-hospital mortality. In patients with septic shock, PSP/reg was the only biomarker associated with in-hospital mortality (P = 0.049). Risk of mortality increased continuously for each ascending quartile of PSP/reg. CONCLUSIONS: Measurement of PSP/reg concentration within 24 hours of ICU admission may predict in-hospital mortality in patients with septic shock, identifying patients who may benefit most from tailored ICU management.

Pancreatic stone protein as a novel marker for neonatal sepsis.

PURPOSE: Early-onset sepsis (EOS) is one of the main causes for the admission of newborns to the neonatal intensive care unit. However, traditional infection markers are poor diagnostic markers of EOS. Pancreatic stone protein (PSP) is a promising sepsis marker in adults. The aim of this study was to investigate whether determining PSP improves the diagnosis of EOS in comparison with other infection markers. METHODS: This was a prospective multicentre study involving 137 infants with a gestational age of >34 weeks who were admitted with suspected EOS. PSP, procalcitonin (PCT), soluble human triggering receptor expressed on myeloid cells-1 (sTREM-1), macrophage migration inhibitory factor (MIF) and C-reactive protein (CRP) were measured at admission. Receiver-operating characteristic (ROC) curve analysis was performed. RESULTS: The level of PSP in infected infants was significantly higher than that in uninfected ones (median 11.3 vs. 7.5 ng/ml, respectively; p = 0.001). The ROC area under the curve was 0.69 [95 % confidence interval (CI) 0.59-0.80; p < 0.001] for PSP, 0.77 (95 % CI 0.66-0.87; p < 0.001) for PCT, 0.66 (95 % CI 0.55-0.77; p = 0.006) for CRP, 0.62 (0.51-0.73; p = 0.055) for sTREM-1 and 0.54 (0.41-0.67; p = 0.54) for MIF. PSP independently of PCT predicted EOS (p < 0.001), and the use of both markers concomitantly significantly increased the ability to diagnose EOS. A bioscore combining PSP (>9 ng/ml) and PCT (>2 ng/ml) was the best predictor of EOS (0.83; 95 % CI 0.74-0.93; p < 0.001) and resulted in a negative predictive value of 100 % and a positive predictive value of 71 %. CONCLUSIONS: In this prospective study, the diagnostic performance of PSP and PCT was superior to that of traditional markers and a combination bioscore improved the diagnosis of sepsis. Our findings suggest that PSP is a valuable biomarker in combination with PCT in EOS.

Natural genetic variation of root system architecture from Arabidopsis to Brachypodium: towards adaptive value.

Root system architecture is a trait that displays considerable plasticity because of its sensitivity to environmental stimuli. Nevertheless, to a significant degree it is genetically constrained as suggested by surveys of its natural genetic variation. A few regulators of root system architecture have been isolated as quantitative trait loci through the natural variation approach in the dicotyledon model, Arabidopsis. This provides proof of principle that allelic variation for root system architecture traits exists, is genetically tractable, and might be exploited for crop breeding. Beyond Arabidopsis, Brachypodium could serve as both a credible and experimentally accessible model for root system architecture variation in monocotyledons, as suggested by first glimpses of the different root morphologies of Brachypodium accessions. Whether a direct knowledge transfer gained from molecular model system studies will work in practice remains unclear however, because of a lack of comprehensive understanding of root system physiology in the native context. For instance, apart from a few notable exceptions, the adaptive value of genetic variation in root system modulators is unknown. Future studies should thus aim at comprehensive characterization of the role of genetic players in root system architecture variation by taking into account the native environmental conditions, in particular soil characteristics.

Delirium auf der Intensivstation [Delirium in the intensive care unit.]

The prevalence of delirium in the Intensive Care Unit (ICU) is reported to vary from 20 to 80 %. Delirium in the ICU is not only a frightening experience for the patient and his or her family, it is also a challenge for the nurses and physicians taking care of the patient. Furthermore, it is also associated with worse outcome, prolonged hospitalisation, increased costs, long-term cognitive impairment and higher mortality rates. Thus, strategies to prevent ICU-delirium in addition to the early diagnosis and treatment of delirium are important. The pathophysiology of delirium is still incompletely understood, but numerous risk factors for the development of delirium have been identified in ICU-patients, among which are potentially modifiable factors such as metabolic disturbances, hypotension, anaemia, fever and infection. Key factors are the prevention and management of common risk factors, including avoiding overzealous sedation and analgesia and creating an environment that enhances reintegration. Once delirium is diagnosed, treatment consists of the use of typical and atypical antipsychotics. Haloperidol is still the drug of choice for the treatment of delirium and can be given intravenously in incremental doses of 1 to 2 to 5 (to 10) mg every 15 - 20 minutes.

Iowa Department of Human Services - Case Management Unit, Independent Auditor's Reports Basic Financial Statements and Supplementary Information, June 30, 2003

State Agency Audit Report

Prognostic value of serial blood S100B determinations in stage IIB-III melanoma patients: a corollary study to EORTC trial 18952.

S100B is a prognostic factor for melanoma as elevated levels correlate with disease progression and poor outcome. We determined its prognostic value based on updated information using serial determinations in stage IIb/III melanoma patients. 211 Patients who participated in the EORTC 18952 trial, evaluating efficacy of adjuvant intermediate doses of interferon α2b (IFN) versus observation, entered a corollary study. Over a period of 36 months, 918 serum samples were collected. The Cox time-dependent model was used to assess prognostic value of the latest (most recent) S100B determination. At first measurement, 178 patients had S100B values <0.2 μg/l and 33 ≥ 0.2 μg/l. Within the first group, 61 patients had, later on, an increased value of S100B (≥ 0.2 μg/l). An initial increased value of S100B, or during follow-up, was associated with worse distant metastasis-free survival (DMFS); hazard ratio (HR) of S100B ≥ 0.2 versus S100B < 0.2 was 5.57 (95% confidence interval (CI) 3.81-8.16), P < 0.0001, after adjustment for stage, number of lymph nodes and sex. In stage IIb patients, the HR adjusted for sex was 2.14 (95% CI 0.71, 6.42), whereas in stage III, the HR adjusted for stage, number of lymph nodes and sex was 6.76 (95% CI 4.50-10.16). Similar results were observed regarding overall survival (OS). Serial determination of S100B in stage IIb-III melanoma is a strong independent prognostic marker, even stronger compared to stage and number of positive lymph nodes. The prognostic impact of S100B ≥ 0.2 μg/l is more pronounced in stage III disease compared with stage IIb.

Is it worth treating fever in intensive care unit patients? Preliminary results from a randomized trial of the effect of external cooling.

BACKGROUND: Antipyresis is a common clinical practice in intensive care, although it is unknown if fever is harmful, beneficial, or a negligible adverse effect of infection and inflammation. METHODS: In a randomized study, rectal temperature and discomfort were assessed in 38 surgical intensive care unit patients without neurotrauma or severe hypoxemia and with fever (temperature >/=38.5 degrees C) and systemic inflammatory response syndrome. Eighteen patients received external cooling while 20 received no antipyretic treatment. RESULTS: Temperature and discomfort decreased similarly in both groups after 24 hours. No significant differences in recurrence of fever, incidence of infection, antibiotic therapy, intensive care unit and hospital length of stay, or mortality were noted between the groups. CONCLUSIONS: These results suggest that the systematic suppression of fever may not be useful in patients without severe cranial trauma or significant hypoxemia. Letting fever take its natural course does not seem to harm patients with systemic inflammatory response syndrome or influence the discomfort level and may save costs.

La Suisse des mosquées. Derrière le voile de l'unité musulmane

En Suisse, un peu moins de 5 % de la population se déclarent musulmans. Originaires pour la majeure partie des grandes vagues migratoires de la fin du XXe siècle, les musulmans helvétiques sont le plus souvent identifiés individuellement. Ce livre présente la réalité institutionnelle et peu connue de l'islam en Suisse à partir de plusieurs enquêtes menées sur la manière dont il s'organise. Sa présence est très diversifiée selon les contextes cantonaux différents et les origines culturelles bien contrastées d'un musulman des Balkans, du Maghreb ou de la Turquie. Ces recherches menées par des sociologues et des politologues dessinent une mosaïque qui montre à partir de l'islam pratiquant et confessant qu'il ne peut être réduit aux formes conservatrices et violentes que certains considèrent comme la traduction obligée de toute posture musulmane. Cet ouvrage propose un portrait contrasté de l'islam en Suisse avec, d'une part, des ensembles qui tentent d'organiser légitimement leur culte et de maintenir leur héritage religieux et, d'autre part, des défis déterminants à relever pour l'intégration des fidèles, comme les liens avec le pays d'origine, l'indépendance financière des mosquées ou les questions relatives aux revendications religieuses ou culturelles de l'identité musulmane. A partir de la réalité musulmane, ce livre expose toute l'ambiguïté de nos sociétés « tolérantes » et « ouvertes », mais démunies et contradictoires face à l'émergence récente de la pluralité religieuse.

El fet migratori a Catalunya i els processos d'identificació nacional en la població nouvinguda

En el marc de la recerca sobre identitats i nova ciutadania, l’objecte d’aquest treball és reconèixer elements clau dels processos d’identificació nacional a Catalunya en la població nouvinguda, i identificar els factors que n'afavoreixen la seva vinculació comunitària. La recerca s'ha desenvolupat en un primer bloc analitzant la perspectiva sociològica entorn a la idea d’identitat, així com l’evolució del discurs identitari a Catalunya, a fi de continuar desenvolupant amb profunditat el debat sobre identitat i nació en relació al fet migratori i la diversitat social existent. En un segon bloc d’anàlisi, la recerca fixa la mirada a una dotzena de casos treballats a través d’històries de vida de diverses realitats migratòries del nostre país corresponents a les diverses onades del segle XX, tant d’immigració espanyola com d'immigració de fora de l'Estat espanyol. La voluntat d’aquest segon bloc és extreure experiències socials d’interpretacions individuals que assenyalin quins elements permeten o dificulten la mobilitat social, quines experiències tenen valor identitari i de quin tipus, i quins fenòmens esdevenen rellevants en la configuració d’espais de referència i identificació nacional a nivell individual. Finalment s’incorpora un apartat d’entrevistes en profunditat a diversos actors socials i polítics rellevants a fi de reconèixer aquells elements que centren el discurs de la “nova cultura pública comuna”. L’objectiu és interrelacionar el discurs polític i filosòfic actual amb l’experiència biogràfica de les persones, assenyalant aquells elements que han estat significatius per a la seva identitat com a catalans i catalanes o, ans al contrari, que no han afavorit una situació en aquests termes. En aquest sentit la pregunta que vincula aquest espai de reflexió és: Quins elements afavoreixen la identificació nacional englobant la diversitat social existent i quins mecanismes d'adhesió hi podrien funcionar?

On the foundations of well-being economics and policy

When one wishes to implement public policies, there is a previous need of comparing different actions and valuating and evaluating them to assess their social attractiveness. Recently the concept of well-being has been proposed as a multidimensional proxy for measuring societal prosperity and progress; a key research topic is then on how we can measure and evaluate this plurality of dimensions for policy decisions. This paper defends the thesis articulated in the following points: 1. Different metrics are linked to different objectives and values. To use only one measurement unit (on the grounds of the so-called commensurability principle) for incorporating a plurality of dimensions, objectives and values, implies reductionism necessarily. 2. Point 1) can be proven as a matter of formal logic by drawing on the work of Geach about moral philosophy. This theoretical demonstration is an original contribution of this article. Here the distinction between predicative and attributive adjectives is formalised and definitions are provided. Predicative adjectives are further distinguished into absolute and relative ones. The new concepts of set commensurability and rod commensurability are introduced too. 3. The existence of a plurality of social actors, with interest in the policy being assessed, causes that social decisions involve multiple types of values, of which economic efficiency is only one. Therefore it is misleading to make social decisions based only on that one value. 4. Weak comparability of values, which is grounded on incommensurability, is proved to be the main methodological foundation of policy evaluation in the framework of well-being economics. Incommensurability does not imply incomparability; on the contrary incommensurability is the only rational way to compare societal options under a plurality of policy objectives. 5. Weak comparability can be implemented by using multi-criteria evaluation, which is a formal framework for applied consequentialism under incommensurability. Social Multi-Criteria Evaluation, in particular, allows considering both technical and social incommensurabilities simultaneously.