Fluid balance, intradialytic hypotension, and outcomes in critically ill patients undergoing renal replacement therapy: a cohort study

<p>Introduction: In this cohort study, we explored the relationship between fluid balance, intradialytic hypotension and outcomes in critically ill patients with acute kidney injury (AKI) who received renal replacement therapy (RRT).</p><p>Methods: We analysed prospectively collected registry data on patients older than 16 years who received RRT for at least two days in an intensive care unit at two university-affiliated hospitals. We used multivariable logistic regression to determine the relationship between mean daily fluid balance and intradialytic hypotension, both over seven days following RRT initiation, and the outcomes of hospital mortality and RRT dependence in survivors.</p><p>Results: In total, 492 patients were included (299 male (60.8%), mean (standard deviation (SD)) age 62.9 (16.3) years); 251 (51.0%) died in hospital. Independent risk factors for mortality were mean daily fluid balance (odds ratio (OR) 1.36 per 1000 mL positive (95% confidence interval (CI) 1.18 to 1.57), intradialytic hypotension (OR 1.14 per 10% increase in days with intradialytic hypotension (95% CI 1.06 to 1.23)), age (OR 1.15 per five-year increase (95% CI 1.07 to 1.25)), maximum sequential organ failure assessment score on days 1 to 7 (OR 1.21 (95% CI 1.13 to 1.29)), and Charlson comorbidity index (OR 1.28 (95% CI 1.14 to 1.44)); higher baseline creatinine (OR 0.98 per 10 mu mol/L (95% CI 0.97 to 0.996)) was associated with lower risk of death. Of 241 hospital survivors, 61 (25.3%) were RRT dependent at discharge. The only independent risk factor for RRT dependence was pre-existing heart failure (OR 3.13 (95% CI 1.46 to 6.74)). Neither mean daily fluid balance nor intradialytic hypotension was associated with RRT dependence in survivors. Associations between these exposures and mortality were similar in sensitivity analyses accounting for immortal time bias and dichotomising mean daily fluid balance as positive or negative. In the subgroup of patients with data on pre-RRT fluid balance, fluid overload at RRT initiation did not modify the association of mean daily fluid balance with mortality.</p><p>Conclusions: In this cohort of patients with AKI requiring RRT, a more positive mean daily fluid balance and intradialytic hypotension were associated with hospital mortality but not with RRT dependence at hospital discharge in survivors.</p>

A systematic review of population based epidemiological studies in Myasthenia Gravis

<p>Background: The aim was to collate all myasthenia gravis (MG) epidemiological studies including AChR MG and MuSK MG specific studies. To synthesize data on incidence rate (IR), prevalence rate (PR) and mortality rate (MR) of the condition and investigate the influence of environmental and technical factors on any trends or variation observed.</p><p>Methods: Studies were identified using multiple sources and meta-analysis performed to calculate pooled estimates for IR, PR and MR.</p><p>Results: 55 studies performed between 1950 and 2007 were included, representing 1.7 billion population-years. For All MG estimated pooled IR (eIR): 5.3 per million person-years (C.I.: 4.4, 6.1), range: 1.7 to 21.3; estimated pooled PR: 77.7 per illion persons (C.I.: 64.0, 94.3), range 15 to 179; MR range 0.1 to 0.9 per millions person-years. AChR MG eIR: 7.3 (C.I.: 5.5, 7.8), range: 4.3 to 18.0; MuSK MG IR range: 0.1 to 0.32. However marked variation persisted between populations studied with similar methodology and in similar areas.</p><p>Conclusions: We report marked variation in observed frequencies of MG. We show evidence of increasing frequency of MG with year of study and improved study quality. This probably reflects improved case ascertainment. But other factors must also influence disease onset resulting in the observed variation in IR across geographically and genetically similar populations.</p>

Energy levels, radiative rates and electron impact excitation rates for transitions in AlX

<p>Energy levels, radiative rates and lifetimes are calculated among the lowest 98 levels of the n ≤4 configurations of Be-like Al X. The GRASP (General-purpose Relativistic Atomic Structure Package) is adopted and data are provided for all E1, E2, M1 and M2 transitions. Similar data are also obtained with the FAC (Flexible Atomic Code) to assess the accuracy of the calculations. Based on comparisons between calculations with the two codes as well as with available measurements, our listed energy levels are assessed to be accurate to better than 0.3 per cent. However, the accuracy for radiative rates and lifetimes is estimated to be about 20 per cent. Collision strengths are also calculated for which the DARC (Dirac Atomic R-matrix Code) is used. A wide energy range (up to 380 Ryd) is considered and resonances resolved in a fine energy mesh in the thresholds region. The collision strengths are subsequently averaged over a Maxwellian velocity distribution to determine effective collision strengths up to a temperature of 1.6 × 10⁷ K. Our results are compared with the previous (limited) atomic data and significant differences (up to a factor of 4) are noted for several transitions, particularly those which are not allowed in jj coupling. </p>

Superluminous Supernovae as Standardizable Candles and High-Redshift Distance Probes

<p>We investigate the use of type Ic superluminous supernovae (SLSN Ic) as standardizable candles and distance indicators. Their appeal as cosmological probes stems from their remarkable peak luminosities, hot blackbody temperatures, and bright rest-frame ultraviolet emission. We present a sample of 16 published SLSN, from redshifts 0.1 to 1.2, and calculate accurate K corrections to determine uniform magnitudes in 2 synthetic rest-frame filter bandpasses with central wavelengths at 400 nm and 520 nm. At 400 nm, we find an encouragingly low scatter in their uncorrected, raw mean magnitudes with M(400) = -21.86 ± 0.35 mag for the full sample of 16 objects. We investigate the correlation between their decline rates and peak magnitude and find that the brighter events appear to decline more slowly. In a manner similar to the Phillips relation for type Ia SNe (SNe Ia), we define a ΔM 20 decline relation. This correlates peak magnitude and decline over 20 days and can reduce the scatter in standardized peak magnitudes to ±0.22 mag. We further show that M(400) appears to have a strong color dependence. Redder objects are fainter and also become redder faster. Using this peak magnitudecolor evolution relation, a surprisingly low scatter of between ±0.08 mag and ±0.13 mag can be found in peak magnitudes, depending on sample selection. However, we caution that only 8 to 10 objects currently have enough data to test this peak magnitudecolor evolution relation. We conclude that SLSN Ic are promising distance indicators in the high-redshift universe in regimes beyond those possible with SNe Ia. Although the empirical relationships are encouraging, the unknown progenitor systems, how they may evolve with redshift, and the uncertain explosion physics are of some concern. The two major measurement uncertainties are the limited numbers of low-redshift, well-studied objects available to test these relationships and internal dust extinction in the host galaxies.</p>

Learning from the QUEST multicentre feasibility randomization trials in breast reconstruction after mastectomy

<p>BACKGROUND: Breast reconstruction aims to improve health-related quality of life after mastectomy. However, evidence guiding patients and surgeons in shared decision-making concerning the optimal type or timing of surgery is lacking.</p><p>METHODS: QUEST comprised two parallel feasibility phase III randomized multicentre trials to assess the impact of the type and timing of latissimus dorsi breast reconstruction on health-related quality of life when postmastectomy radiotherapy is unlikely (QUEST A) or highly probable (QUEST B). The primary endpoint for the feasibility phase was the proportion of women who accepted randomization, and it would be considered feasible if patient acceptability rates exceeded 25 per cent of women approached. A companion QUEST Perspectives Study (QPS) of patients (both accepting and declining trial participation) and healthcare professionals assessed trial acceptability.</p><p>RESULTS: The QUEST trials opened in 15 UK centres. After 18 months of recruitment, 17 patients were randomized to QUEST A and eight to QUEST B, with overall acceptance rates of 19 per cent (17 of 88) and 22 per cent (8 of 36) respectively. The QPS recruited 56 patients and 51 healthcare professionals. Patient preference was the predominant reason for declining trial entry, given by 47 (53 per cent) of the 88 patients approached for QUEST A and 22 (61 per cent) of the 36 approached for QUEST B. Both trials closed to recruitment in December 2012, acknowledging the challenges of achieving satisfactory patient accrual.</p><p>CONCLUSION: Despite extensive efforts to overcome recruitment barriers, it was not feasible to reach timely recruitment targets within a feasibility study. Patient preferences for breast reconstruction types and timings were common, rendering patients unwilling to enter the trial.</p>

Two-year changes in refractive error and related biometric factors in an adult Chinese population

Importance: This article provides, to our knowledge, the first longitudinal population-based data on refractive error (RE) in Chinese persons.<br/><br/>Objective: To study cohort effects and changes associated with aging in REs among Chinese adults.<br/><br/>Design, Setting, and Participants: A 2-year, longitudinal population-based cohort study was conducted in southern China. Participants, identified using cluster random sampling, included residents of Yuexiu District, Guangzhou, China, aged 35 years or older who had undergone no previous eye surgery.<br/><br/>Methods: Participants underwent noncycloplegic automated refraction and keratometry in December 2008 and December 2010; in a random 50% sample of the participants, anterior segment ocular coherence tomography measurement of lens thickness, as well as measurement of axial length and anterior chamber depth by partial coherence laser interferometry, were performed.<br/><br/>Main Outcomes and Measures: Two-year change in spherical equivalent refraction (RE), lens thickness, axial length, and anterior chamber depth in the right eye.<br/><br/>Results: A total of 745 individuals underwent biometric testing in both 2008 and 2010 (2008 mean [SD] age, 52.2 [11.5] years; 53.7% women). Mean RE showed a 2-year hyperopic shift from −0.44 (2.21) to −0.31 (2.26) diopters (D) (difference, +0.13; 95% CI, 0.11 to 0.16). A consistent 2-year hyperopic shift of 0.09 to 0.22 D was observed among participants aged 35 to 64 years when stratifying by decade, suggesting that a substantial change in RE with aging may occur during this 30-year period. Cross-sectionally, RE increased only in the cohort younger than 50 years (0.11 D/y; 95% CI, 0.06 to 0.16). In the cross-sectional data, axial length decreased at −0.06 mm/y (95% CI, −0.09 to −0.04), although the 2-year change in axial length was positive and thus could not explain the cross-sectional difference. These latter results suggest a cohort effect, with greater myopia developing among younger persons.<br/><br/>Conclusions and Relevance: This first Chinese population-based longitudinal study of RE provides evidence for both important longitudinal aging changes and cohort effects, most notably greater myopia prevalence among younger persons.

Impact of age, various forms of cataract, and visual acuity on whole-field scotopic sensitivity screening for glaucoma in rural Taiwan.

OBJECTIVE: To evaluate the impact of age, various forms of cataract, and visual acuity on whole-field scotopic sensitivity screening for glaucoma in a rural population. DESIGN: Clinic-based study with population-based recruitment. SETTING: Jin Shan Township near Taipei, Taiwan. SUBJECTS: Three hundred forty-six residents (ages, &gt; or = 40 years) of Jin Shan Township. INTERVENTIONS: Whole-field scotopic testing, ophthalmoscopy with dilation of the pupils, cataract grading against photographic standards, and screening visual field testing in a random one-third subsample. MAIN OUTCOME MEASURES: Whole-field scotopic sensitivity (in decibels) and diagnostic status as a case of glaucoma, glaucoma suspect, or normal. RESULTS: Participants in Jin Shan Township did not differ significantly in the rate of blindness, low visual acuity, or family history of glaucoma from a random sample of nonrespondents. Scotopic sensitivity testing detected 100% (6/6) of subjects with open-angle glaucoma at a specificity of 80.2%. The mean +/- SE scotopic sensitivity for six subjects with open-angle glaucoma (32.78 +/- 1.51 dB) differed significantly from that of 315 normal individuals (38.51 +/- 0.22 dB), when adjusted for age and visual acuity (P = .05, t test). With linear regression modeling, factors that correlated significantly with scotopic sensitivity were intraocular pressure, screening visual field, best corrected visual acuity, presence of cortical cataract, and increasing age. CONCLUSIONS: Although cataract affects the whole-field scotopic threshold, it appears that scotopic testing may be of value in field-based screening for glaucoma.

Psychosocial interventions to improve quality of life and emotional wellbeing for recently diagnosed cancer patients

BACKGROUND:<br/>A cancer diagnosis may lead to significant psychological distress in up to 75% of cases. There is a lack of clarity about the most effective ways to address this psychological distress.<br/>OBJECTIVES:<br/>To assess the effects of psychosocial interventions to improve quality of life (QoL) and general psychological distress in the 12-month phase following an initial cancer diagnosis.<br/>SEARCH METHODS:<br/>We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE, EMBASE, and PsycINFO up to January 2011. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. Electronic searches were carried out across all primary sources of peer-reviewed publications using detailed criteria. No language restrictions were imposed.<br/>SELECTION CRITERIA:<br/>Randomised controlled trials of psychosocial interventions involving interpersonal dialogue between a 'trained helper' and individual newly diagnosed cancer patients were selected. Only trials measuring QoL and general psychological distress were included. Trials involving a combination of pharmacological therapy and interpersonal dialogue were excluded, as were trials involving couples, family members or group formats.<br/>DATA COLLECTION AND ANALYSIS:<br/>Trial data were examined and selected by two authors in pairs with mediation from a third author where required. Where possible, outcome data were extracted for combining in a meta-analyses. Continuous outcomes were compared using standardised mean differences and 95% confidence intervals, using a random-effects model. The primary outcome, QoL, was examined in subgroups by outcome measurement, cancer site, theoretical basis for intervention, mode of delivery and discipline of trained helper. The secondary outcome, general psychological distress (including anxiety and depression), was examined according to specified outcome measures.<br/>MAIN RESULTS:<br/>A total of 3309 records were identified, examined and the trials subjected to selection criteria; 30 trials were included in the review. No significant effects were observed for QoL at 6-month follow up (in 9 studies, SMD 0.11; 95% CI -0.00 to 0.22); however, a small improvement in QoL was observed when QoL was measured using cancer-specific measures (in 6 studies, SMD 0.16; 95% CI 0.02 to 0.30). General psychological distress as assessed by 'mood measures' improved also (in 8 studies, SMD - 0.81; 95% CI -1.44 to - 0.18), but no significant effect was observed when measures of depression or anxiety were used to assess distress (in 6 studies, depression SMD 0.12; 95% CI -0.07 to 0.31; in 4 studies, anxiety SMD 0.05; 95% CI -0.13 to 0.22). Psychoeducational and nurse-delivered interventions that were administered face to face and by telephone with breast cancer patients produced small positive significant effects on QoL (in 2 studies, SMD 0.23; 95% CI 0.04 to 0.43).<br/>AUTHORS' CONCLUSIONS:<br/>The significant variation that was observed across participants, mode of delivery, discipline of 'trained helper' and intervention content makes it difficult to arrive at a firm conclusion regarding the effectiveness of psychosocial interventions for cancer patients. It can be tentatively concluded that nurse-delivered interventions comprising information combined with supportive attention may have a beneficial impact on mood in an undifferentiated population of newly diagnosed cancer patients.

Preoperative characteristics and compliance with follow-up after trabeculectomy surgery in rural southern China

Purpose: To evaluate preoperative characteristics and follow-up in rural China after trabeculectomy, the primary treatment for glaucoma there. Methods: Patients undergoing trabeculectomy at 14 rural hospitals in Guangdong and Guangxi Provinces and their doctors completed questionnaires concerning clinical and sociodemographic information, transportation, and knowledge and attitudes about glaucoma. Follow-up after surgery was assessed as cumulative score (1 week: 10 points, 2 weeks: 7 points, 1 month: 5 points). Results Among 212 eligible patients, mean preoperative presenting acuity in the operative eye was 6/120, with 61.3% (n=130) blind (≤6/60). Follow-up rates were 60.8% (129/212), 75.9% (161/212) and 26.9% (57/212) at 1 week, 2 weeks and 1 month, respectively. Patient predictors of poor follow-up included elementary education or less (OR=0.37, 95% CI 0.20 to 0.70, p=0.002), believing follow-up was not important (OR=0.62, 95% CI 0.41 to 0.94, p=0.02), lack of an accompanying person (OR=0.14, 95% CI 0.07 to 0.29, p&lt;0.001), family annual income &lt;US$800 (OR=0.28, 95% CI 0.11 to 0.72, p=0.008) and not requiring removal of scleral flap sutures postoperatively (OR=0.11, 95% CI 0.06 to 0.22, p&lt;0.001). Age, sex, employment, travel distance/time/costs, patient preoperative clinical factors and physician factors were unassociated with follow-up. Conclusions: Follow-up after 2 weeks was inadequate to provide optimal clinical care, and surgery is being applied too late to avoid blindness in the majority of patients. Earlier surgery, support for return visits and better explanations of the importance of follow-up are needed. Directing all patients to return for possible scleral flap suture removal may be a valid strategy to improve follow-up.

Origin, seasonality and chemical characteristics of rainwater in Aveiro

Este trabalho teve como objectivo caracterizar quimicamente a água da chuva recolhida na cidade de Aveiro, localizada a sudoeste da Europa, no período de Setembro de 2008 a Setembro de 2009. Para matrizes diluídas como a da água da chuva, as metodologias analíticas a utilizar para se conseguir uma rigorosa caracterização química são de grande importância e ainda não estão uniformizadas. Assim, para caracterizar a fracção orgânica, primeiramente foram comparadas duas metodologias de filtração (0.22 e 0.45 μm) e foram estudados dois procedimentos de preservação da água da chuva (refrigeração e congelação), utilizando a espectroscopia de fluorescência molecular. Além disso, foram comparados dois procedimentos de isolamento e extracção da matéria orgânica dissolvida (DOM) da água da chuva, baseados na sorção nos sorbentes DAX-8 e C-18, utilizando as espectroscopias de ultravioleta-visível e fluorescência molecular. Relativamente aos resultados das metodologias de filtração e preservação, é recomendada a filtração por 0.45 μm, assim como, as amostras de água da chuva deverão ser mantidas no escuro a 4ºC, no máximo até 4 dias, até às análises espectroscópicas. Relativamente à metodologia de isolamento e extracção da DOM, os resultados mostraram que o procedimento de isolamento baseado na C-18 extraiu a DOM que é representativa da matriz global, enquanto que o procedimento da DAX-8 extraiu preferencialmente a fracção do tipo húmico. Como no presente trabalho pretendíamos caracterizar a fracção do tipo húmico da DOM da água da chuva, foi escolhida a metodologia de isolamento e extracção baseada na sorção no sorvente DAX-8. Previamente ao isolamento e extracção da DOM da água da chuva, toda a fracção orgânica das amostras de água da chuva foi caracterizada pelas técnicas de ultravioleta-visível e de fluorescência molecular. As amostras mostraram características semelhantes às de outras águas naturais, e a água da chuva do Verão e Outono apresentou maior conteúdo da matéria orgânica dissolvida cromofórica que a do Inverno e Primavera. Posteriormente, a fracção do tipo húmico de algumas amostras de água da chuva, isolada e extraída pelo procedimento baseado na DAX-8, foi caracterizada utilizando as técnicas espectroscópicas de ultravioleta-visível, fluorescência molecular e ressonância magnética nuclear de protão. Todos os extractos continham uma mistura complexa de compostos hidroxilados e ácidos carboxílicos, com uma predominância da componente alifática e um baixo conteúdo da componente aromática. A fracção inorgânica da água da chuva foi caracterizada determinando a concentração das seguintes espécies iónicas: H+, NH4 +, Cl-, NO3 -, SO4 2-. Os resultados foram comparados com os obtidos na chuva colectada no mesmo local entre 1986-1989 e mostraram que de todos os iões determinados a concentração de NO3 - foi a única que aumentou (cerca do dobro) em 20 anos, tendo sido atribuído ao aumento de veículos e emissões industriais na área de amostragem. Durante o período de amostragem cerca de 80% da precipitação esteve associada a massas de ar oceânicas, enquanto a restante esteve relacionada com massas que tiveram uma influência antropogénica e terrestre. De um modo geral, para as fracções orgânica e inorgânica da água da chuva analisadas, o conteúdo químico foi menor para as amostras que estiveram associadas a massas de ar marítimas do que para as amostras que tiveram contribuições terrestres e antropogénicas.

Identification of descendants of an extinct bovine population from the Algarve region of Portugal using numerical taxonomy analysis of morphological traits

The morphology of a sample of four bulls and 43 cows, presumed to be descendants of the extinct cattle breed ‘Algarvia’ (AG), was used to assign their relationship with animals from other Portuguese autochthonous breeds – Arouquesa (AR), Barrosa˜ (BA), Cachena (CA), Marinhoa (MA), Maronesa (MO), Minhota (MN), Mirandesa (MI), (only bulls), Alentejana (AL), Garvonesa (GA), Mertolenga (ME) and Preta (PR). Standard numerical taxonomic methods were applied to a set of 183 (cows) and 170 (bulls) traits, to derive average pairwise taxonomic distances among the sample of 257 cows and 76 bulls. Distance coefficients (morphological index of distance) ranged from 0.22 to 2.62 (cows) and from 0.49 to 2.13 (bulls). Unweighted pair group method using arithmetic averages (UPGMA)-based phenograms and a principal coordinate analysis showed that bulls were highly clustered and cows showed a tendency to cluster according to their geographical and breed origin. The AG population grouped together with GA, AL, ME and MN breeds in the Red Convex group. The average taxonomic distance among breeds was 1.02, the highest being 1.39 (ME versus BA) and the lowest being 0.64 (MA versus AR). The approach allowed for the identification of a phenotypically differentiated set of animals, comprising 19 cows and four bulls representative of the AG breed, and which can be targeted in further studies aiming at the recovery of this extinct breed.

Mögliche neue Strukturen im Ortsnetz und ihre minimale Länge

Auch für das Teilnehmeranschlußnetz werden neben dem heute üblichen „Sternnetz" neuerdings „Ring-" und „Verzweigungsnetze" genannt, und es wird die Frage diskutiert, ob damit geringere Kosten zu erwarten sind. Mit Begriffen der Graphentheorie werden hier z.B. die Strukturen Stern, Ring, Baum definiert. Ein gedachtes Ortsnetz wird dann in quadratische Bereiche mit der Seitenlänge l und mit M Teilnehmern aufgeteilt. Für verschiedene Strukturen des Leiternetzes in der Teilnehmerebene werden die Mindestlängen der Leiter und der Kabelkanäle berechnet. Unter anderem zeigt sich, daß unabhängig von der Struktur des Leiternetzes die Kabelkanäle, ein dominierender Kostenanteil in der Teilnehmerebene, praktisch gleich lang sind, nämlich l/M^0,5 je Teilnehmer.

The Impact of R10-Hydroxywarfarin on CYP2C9-Mediated S-Warfarin Metabolism

Thesis (Master's)--University of Washington, 2014

The influence of multimorbidity on hospital, intensive care, and emergency department use at the end of life for patients with chronic conditions

Thesis (Master's)--University of Washington, 2016-03

Liver fat in adults with GH deficiency: comparison to matched controls and the effect of GH replacement

CONTEXT: Existing data regarding the association between growth hormone deficiency (GHD) and liver fat content are conflicting. OBJECTIVE: We aimed i) to assess intrahepatocellular lipid (IHCL) content in hypopituitary adults with GHD compared to matched controls and ii) to evaluate the effect of growth hormone (GH) replacement on IHCL content. DESIGN: Cross-sectional comparison and controlled intervention study. PATIENTS, PARTICIPANTS: Cross-sectional comparison: 22 hypopituitary adults with GHD and 44 healthy controls matched for age, BMI, gender and ethnicity. Intervention study: 9 GHD patients starting GH replacement (GH Rx group), 9 GHD patients not starting replacement therapy (non-GH Rx group). INTERVENTION: Intervention study:GH replacement for 6 months in the GH Rx group, dosage was titrated to achieve normal IGF-1 levels. MAIN OUTCOME MEASURES: IHCL content determined by proton magnetic resonance spectroscopy (1 H MRS). RESULTS: Cross-sectional comparison: There was no difference in IHCL content between GHD patients and healthy controls (1.89% (0.30, 4.03) vs. 1.14% (0.22, 2.32); p=0.2), the prevalence of patients with hepatic steatosis (IHCL of ≥ 5.56%) was similar in the two groups (22.7% vs. 15.9%; chi square probability = 0.4). Intervention study: The change in IHCL content over 6 months did not differ between the GH Rx group and the non-GH Rx group (-0.63 ± 4.53% vs. +0.11 ± 1.46%; p=0.6). CONCLUSIONS: In our study liver fat content and the prevalence of hepatic steatosis did not differ between hypopituitary adults with GHD and matched controls. In GHD patients GH replacement had no effect on liver fat content.