First Report of Anthracnose on Dioscorea opposita Caused by Colletotrichum siamense in Guangdong province in China

Yam is the world's fourth most important tuber crop, after cassava, potato, and sweet potato in the world, the cultivation area of yam from the Food and Agriculture Organization of the United Nations Statistics Division database (FAOSTAT) is about 8,831,037 ha in 2020. Chinese yam (Dioscorea opposita Thunb.) is an economically important root crop throughout China due to its high economic and medicinal value. South China including Guangdong and Guangxi provinces is one of the important production districts of Chinese yam with economic value. A disease affecting the leaves was observed on yam leaves in August 2021 with an incidence of 20 to 90% in Guangdong and Guangxi provinces. Symptoms start as pinpoint lesions on yam leaves which enlarged to oval spots and large irregular spots. The spots were brown and surrounded by a chlorotic halo with sunken cavities, which are typical symptoms of anthracnose. To identify the causal agent, 9 symptomatic leaves from 3 different districts were collected in Guangdong and Guangxi provinces. Leaf samples were disinfested with 1% NaOCl for 3 min, and cultured on potato dextrose agar (PDA) at 28 °C for 3 days week. 9 single-spore isolates were recovered from each PDA medium. Colonies on PDA were grayish white with bright orange conidial spore masses. Fungal mycelia were hyaline, septate, and branched. Conidia were born on a long conidiogenous cell, straight, hyaline and cylindrical with rounded ends, 5.3 to 6.8×15.2 to 21.3μm (n = 50). Appressoria were dark, smooth-walled, oval in shape. The isolates were morphologically identified as Colletotrichum sp. (Weir et al. 2012). 3 strains were used for the pathogenicity test, 5 plants at creeping stage were inoculated with each isolate separately and 3-5 leaves of each plant were inoculated. Fresh wounds were made with a sterile needle on the healthy surface of yam leaves and each leaf was covered with a piece of cotton drenched with conidial suspension (106 conidia/mL) from each isolate. Control seedlings were inoculated identically except sterile water was used. Inoculated plants were placed in a moisturizing light incubator at 25℃ and 80% humidity under a 12-h light/dark cycle for 7 days and examined daily to monitor disease symptom development. Small round brown spots were observed at the inoculation sites 3 days after the inoculation and eventually became large brown lesions. No symptoms wre observed in the water-inoculated plants. A Colletotrichum sp. strain based on morphology was reisolated from inoculated leaves, fulfilling Koch's postulates. For molecular identification, the direct colony PCR method (Lu et al. 2012) was used to amplify the internal transcribed spacer (ITS) region of ribosomal DNA, calmodulin (Cal), tubulin (Tub) and Apmat loci of three isolates using primer pairs of ITS4/ITS5, CL1C/CL2C, T1/T2 and AM-F/AM-R (Sharma et al. 2015). A phylogenetic tree derived from a maximum likelihood analysis of a concatenated alignment of ITS, Cal, Tub and ApMAT sequences was created. The accession numbers of the three isolates YamZJCS, YamSXCS and YamYLCS used in this study were OP128056-OP128058 for ITS, OP128059-OP128061 for ApMAT，OP128062-OP128064 for Cal and OP128065-OP128067 for Tub. The sequences of the 3 isolates were aligned with related species of Colletotrichum (Sharma et al. 2015). Analyses based on concatenated data sets of 4 genes showed that the sequences had high levels of identity to that of the C. siamense strains. According to both morphological and sequence analyses, the pathogen was identified as C. siamense. There were reports of anthracnose on yam caused by Colletotrichum sp. in Guangxi (Zhu et al. 2007), Hainan (Lin et al. 2018) and Jiangsu (Han et al. 2020) provinces in China. To our knowledge, this is the first report of anthracnose on D. opposita caused by C. siamense in Guangdong province in China.

N6-methyladenosine methylation mediates non-coding RNAs modification in microplastic-induced cardiac injury

Owing to their potential adverse health effects, global contamination by microplastics (MPs) has attracted increased scientific and societal concerns. However, in vivo studies on MP toxicity, along with its effects and underlying mechanisms, remain limited. We recently found that non-coding RNA (ncRNAs) contribute to MP-mediated vascular toxicity. Moreover, previous studies have identified N6-methyladenosine (m6A) modifications in ncRNAs as influencing factors in cardiovascular disease. However, whether and how m6A modifications in ncRNAs are affected by MP-induced cardiotoxicity remain unknown. Herein, we profiled differentially expressed ncRNAs and their related m6A modification profiles in MP-exposed myocardial tissue using RNA sequencing (RNA-seq) and methylated RNA immunoprecipitation sequencing (MeRIP-seq). First, we observed that MPs accumulated in different organs and upregulated apoptosis in the heart, liver, spleen, and kidney cells. Furthermore, total m6A and METTL3 levels increased in the myocardium after exposure to MPs. RNA-seq results revealed that 392 lncRNAs and 302 circRNAs were differentially expressed in MP-treated mouse myocardium compared to the control group. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses showed that these altered lncRNAs and circRNAs were closely associated with endocytosis, cellular senescence, and cell cycle signaling pathways, which may cause cardiotoxicity. Furthermore, MeRIP-seq data showed different distributions and abundances of m6A modifications in lncRNAs and circRNAs. Additionally, we identified differentially m6A methylated lncRNAs and circRNAs through conjoint analysis of the two high-throughput sequencing datasets and found that both m6A modifications and the expression of circ-Arfgef2 and lncG3bp2 were upregulated after exposure to MPs. This suggests that MP-induced m6A modifications in ncRNAs are involved in cardiotoxicity. Our findings contribute to a better understanding of MP-induced cardiotoxicity and new molecular targets for treating cardiac injury.

Tissue oxygen saturation is predictive of lactate clearance in patients with circulatory shock

BACKGROUND

Tissue oxygen saturation (StO₂) decrease could appear earlier than lactate alteration. However, the correlation between StO₂ and lactate clearance was unknown.

METHODS

This was a prospective observational study. All consecutive patients with circulatory shock and lactate over 3 mmol/L were included. Based on the rule of nines, a BSA (body surface area) weighted StO₂ was calculated from four sites of StO₂ (masseter, deltoid, thenar and knee). The formulation was as follows: masseter StO₂ × 9% + (deltoid StO₂ + thenar StO₂) × (18% + 27%)/ 2 + knee StO₂ × 46%. Vital signs, blood lactate, arterial and central venous blood gas were measured simultaneously within 48 h of ICU admission. The predictive value of BSA-weighted StO₂ on 6-hour lactate clearance > 10% since StO₂ initially monitored was assessed.

RESULTS

A total of 34 patients were included, of whom 19 (55.9%) had a lactate clearance higher than 10%. The mean SOFA score was lower in cLac ≥ 10% group compared with cLac < 10% group (11 ± 3 vs. 15 ± 4, p = 0.007). Other baseline characteristics were comparable between groups. Compared to non-clearance group, StO₂ in deltoid, thenar and knee were significantly higher in clearance group. The area under the receiver operating curves (AUROC) of BSA-weighted StO₂ for prediction of lactate clearance (0.92, 95% CI [Confidence Interval] 0.82-1.00) was significantly higher than StO₂ of masseter (0.65, 95% CI 0.45-0.84; p < 0.01), deltoid (0.77, 95% CI 0.60-0.94; p = 0.04), thenar (0.72, 95% CI 0.55-0.90; p = 0.01), and similar to knee (0.87, 0.73-1.00; p = 0.40), mean StO₂ (0.85, 0.73-0.98; p = 0.09). Additionally, BSA-weighted StO₂ model had continuous net reclassification improvement (NRI) over the knee StO₂ and mean StO₂ model (continuous NRI 48.1% and 90.2%, respectively). The AUROC of BSA-weighted StO₂ was 0.91(95% CI 0.75-1.0) adjusted by mean arterial pressure and norepinephrine dose.

CONCLUSIONS

Our results suggested that BSA-weighted StO₂ was a strong predictor of 6-hour lactate clearance in patients with shock.

A Comparison of Diagnostic Criteria for Invasive Pulmonary Aspergillosis in Critically Ill Patients

INTRODUCTION

Invasive pulmonary aspergillosis (IPA) is a common infection in intensive care units (ICUs). There are no consensus criteria for defining IPA in the ICU. We aimed to compare the diagnosis and prognosis performances of three criteria (the 2020 EORTC/MSG criteria, the 2021 EORTC/MSG ICU criteria, the modified AspICU criteria (M-AspICU)) for IPA in the ICU.

METHODS

In this retrospective study from our single center, we applied the three different criteria for IPA in patients with suspected pneumonia and undergoing at least one mycological test between November 10, 2016 and November 10, 2021. We compared the diagnosis agreement and prognosis performances of these three criteria in the ICU.

RESULTS

Overall, 2403 patients were included. The rates of IPA according to the 2020 EORTC/MSG, 2021 EORTC/MSG ICU, and M-AspICU were 3.37%, 6.53%, and 23.10%, respectively. Diagnostic agreement among these criteria was poor (Cohen's kappa 0.208-0.666). IPA diagnosed by either the 2020 EORTC/MSG (odds ratio = 2.709, P < 0.001) or the 2021 EORTC/MSG ICU (odds ratio = 2.086, P = 0.001) criteria was independently associated with 28-day mortality. IPA diagnosed by M-AspICU is an independent risk factor of 28-day mortality (odds ratio = 1.431, P = 0.031) when excluding patients who fulfilled neither host criteria nor radiological factors of 2021 EORTC/MSG ICU.

CONCLUSIONS

Although M-AspICU criteria have the highest "sensitivity", IPA diagnosed by M-AspICU was not an independent risk factor of 28-day mortality. Caution is required when using the M-AspICU criteria in ICU, especially in patients with non-specific infiltration and non-classical host factors.

Prevalence and mortality risk of low skeletal muscle mass in critically ill patients: an updated systematic review and meta-analysis

Background

Patients with critical illness often develop low skeletal muscle mass (LSMM) for multiple reasons. Numerous studies have explored the association between LSMM and mortality. The prevalence of LSMM and its association with mortality are unclear. This systematic review and meta-analysis was performed to examine the prevalence and mortality risk of LSMM among critically ill patients.

Methods

Three internet databases (Embase, PubMed, and Web of Science) were searched by two independent investigators to identify relevant studies. A random-effects model was used to pool the prevalence of LSMM and its association with mortality. The GRADE assessment tool was used to assess the overall quality of evidence.

Results

In total, 1,582 records were initially identified in our search, and 38 studies involving 6,891 patients were included in the final quantitative analysis. The pooled prevalence of LSMM was 51.0% [95% confidence interval (CI), 44.5-57.5%]. The subgroup analysis showed that the prevalence of LSMM in patients with and without mechanical ventilation was 53.4% (95% CI, 43.2-63.6%) and 48.9% (95% CI, 39.7-58.1%), respectively (P-value for difference = 0.44). The pooled results showed that critically ill patients with LSMM had a higher risk of mortality than those without LSMM, with a pooled odds ratio of 2.35 (95% CI, 1.91-2.89). The subgroup analysis based on the muscle mass assessment tool showed that critically ill patients with LSMM had a higher risk of mortality than those with normal skeletal muscle mass regardless of the different assessment tools used. In addition, the association between LSMM and mortality was statistically significant, independent of the different types of mortality.

Conclusion

Our study revealed that critically ill patients had a high prevalence of LSMM and that critically ill patients with LSMM had a higher risk of mortality than those without LSMM. However, large-scale and high-quality prospective cohort studies, especially those based on muscle ultrasound, are required to validate these findings.

Systematic review registration

http://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022379200.

Mortality and prognostic factors in connective tissue disease-associated pulmonary arterial hypertension patients complicated with right heart failure

OBJECTIVE

To identify predictive factors associated with mortality in connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) patients who were complicated with right heart failure (RHF).

METHODS

In this single-center retrospective study, baseline demographics, clinical features, laboratory results, and hemodynamic assessments were collected. Kaplan-Meier analysis was applied to analyze all-cause mortality. Univariate and forward stepwise multivariate Cox proportional regression analyses were performed to identify independent predictors of mortality.

RESULTS

A total of 51 right heart catheterization-confirmed CTD-PAH patients complicated with RHF were consecutively enrolled in this study from 2012 to 2022. Forty-eight (94%) enrolled patients were female and the mean age was 36.0 ± 11.8 years. Thirty-two (61.5%) were systemic lupus erythematosus-PAH and 33%/67% showed World Health Organization functional class III/IV, respectively. Twenty-five (49%) of those patients died and Kaplan-Meier analysis showed the overall 1-, 3-, and 5-week survival rates from the time of hospitalization as 86.28%, 60.78%, and 56.86%, respectively. RHF in CTD-PAH patients mainly resulted from progression of PAH (n = 19) and infection (n = 5), which also contributed to the leading causes of death. Statistical analysis between survivors and non-survivors showed that death from RHF was associated with higher levels of urea (9.66 vs 6.34 mmol/L, P = 0.002), lactate (cLac: 2.65 vs 1.9 mmol/L, P = 0.006), total bilirubin (23.1 vs 16.9 μmol/L, P = 0.018) and direct bilirubin (10.5 vs 6.5 μmol/L, P = 0.004), but with lower levels of hematocrit (33.7 vs 39, P = 0.004), cNa+ (131 vs 136 mmol/L, P = 0.003). Univariate and forward stepwise multivariate Cox proportional regression analyses indicated that the level of cLac (hazards ratio:1.297; 95% CI: 1.076-1.564; P = 0.006) was an independent risk factor for mortality.

CONCLUSION

The short-term prognosis of CTD-PAH complicated with RHF was very poor, and hyperlactic acidemia (cLac > 2.85 mmoL/L) was an independent predicting factor for mortality of CTD-PAH patients complicated with RHF.

National incidence and mortality of hospitalized sepsis in China

BACKGROUND

Sepsis is a leading cause of preventable death around the world. Population-based estimation of sepsis incidence is lacking in China. In this study, we aimed to estimate the population-based incidence and geographic variation of hospitalized sepsis in China.

METHODS

We retrospectively identified hospitalized sepsis from the nationwide National Data Center for Medical Service (NDCMS) and the National Mortality Surveillance System (NMSS) by ICD-10 codes for the period from 2017 to 2019. In-hospital sepsis case fatality and mortality rate were calculated to extrapolate the national incidence of hospitalized sepsis. The geographic distribution of hospitalized sepsis incidence was examined using Global Moran's Index.

RESULTS

We identified 9,455,279 patients with 10,682,625 implicit-coded sepsis admissions in NDCMS and 806,728 sepsis-related deaths in NMSS. We estimated that the annual standardized incidence of hospitalized sepsis was 328.25 (95% CI 315.41-341.09), 359.26 (95% CI 345.4-373.12) and 421.85 (95% CI 406.65-437.05) cases per 100,000 in 2017, 2018 and 2019, respectively. We observed 8.7% of the incidences occurred among neonates less than 1 year old, 11.7% among children aged 1-9 years, and 57.5% among elderly older than 65 years. Significant spatial autocorrelation for incidence of hospitalized sepsis was observed across China (Moran's Index 0.42, p = 0.001; 0.45, p = 0.001; 0.26, p = 0.011 for 2017, 2018, 2019, respectively). Higher number of hospital bed supply and higher disposable income per capita were significantly associated with a higher incidence of hospitalized sepsis.

CONCLUSION

Our study showed a greater burden of sepsis hospitalizations than previous estimated. The geographical disparities suggested more efforts were needed in prevention of sepsis.

Identification, validation and biological characterisation of novel glioblastoma tumour microenvironment subtypes: implications for precision immunotherapy

BACKGROUND

New precision medicine therapies are urgently required for glioblastoma (GBM). However, to date, efforts to subtype patients based on molecular profiles have failed to direct treatment strategies. We hypothesised that interrogation of the GBM tumour microenvironment (TME) and identification of novel TME-specific subtypes could inform new precision immunotherapy treatment strategies.

MATERIALS AND METHODS

A refined and validated microenvironment cell population (MCP) counter method was applied to >800 GBM patient tumours (GBM-MCP-counter). Specifically, partition around medoids (PAM) clustering of GBM-MCP-counter scores in the GLIOTRAIN discovery cohort identified three novel patient clusters, uniquely characterised by TME composition, functional orientation markers and immune checkpoint proteins. Validation was carried out in three independent GBM-RNA-seq datasets. Neoantigen, mutational and gene ontology analysis identified mutations and uniquely altered pathways across subtypes. The longitudinal Glioma Longitudinal AnalySiS (GLASS) cohort and three immunotherapy clinical trial cohorts [treatment with neoadjuvant/adjuvant anti-programmed cell death protein 1 (PD-1) or PSVRIPO] were further interrogated to assess subtype alterations between primary and recurrent tumours and to assess the utility of TME classifiers as immunotherapy biomarkers.

RESULTS

TME^High tumours (30%) displayed elevated lymphocyte, myeloid cell immune checkpoint, programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein 4 transcripts. TME^High/mesenchymal+ patients featured tertiary lymphoid structures. TME^Med (46%) tumours were enriched for endothelial cell gene expression profiles and displayed heterogeneous immune populations. TME^Low (24%) tumours were manifest as an 'immune-desert' group. TME subtype transitions upon recurrence were identified in the longitudinal GLASS cohort. Assessment of GBM immunotherapy trial datasets revealed that TME^High patients receiving neoadjuvant anti-PD-1 had significantly increased overall survival (P = 0.04). Moreover, TME^High patients treated with adjuvant anti-PD-1 or oncolytic virus (PVSRIPO) showed a trend towards improved survival.

CONCLUSIONS

We have established a novel TME-based classification system for application in intracranial malignancies. TME subtypes represent canonical 'termini a quo' (starting points) to support an improved precision immunotherapy treatment approach.

Impact of intravenous immunoglobulins on serum (1-3)-β-D-Glucan

BACKGROUND

The purpose of this study was to evaluate the changes in serum (1-3)-β-D-glucan (BDG) in adults due to intravenous immunoglobulins (IVIG) infusion and the factors that affect these changes.

METHODS

Patients who had BDG tests both before and after IVIG infusion during hospitalization were retrospectively included, and trends in BDG values were analyzed before and after IVIG infusion. Factors associated with false-positive BDG were then explored using univariate analysis.

RESULTS

A total of 347 serum BDG tests from 131 patients were included in the analysis, and 71.8% (94/131) patients had false positive serum BDG after IVIG infusion. All BDG values on day 7 were negative. Univariate analysis showed that patients with false positive BDG tests had higher daily IVIG doses (P = 0.043) and higher levels of serum IgG increments (P = 0.001). The median peak blood BDG on day 1 after completion of IVIG infusion was 199.6 (154.5-277.7, inter-quartile ranges (IQR)) pg/mL, and both the peak BDG and incremental BDG values (ΔBDG, BDG at the first day after IVIG infusion minus BDG before infusion) were slightly and positively correlated with ΔIgG (BDG vs. ΔIgG, P = 0.0016; ΔBDG vs. ΔIgG, P = 0.0003).

CONCLUSION

Most adults showed false positive BDG tests after IVIG infusion and negative BDG tests within 1 week. Daily IVIG dosage may contribute to the evaluation of ΔBDG.

Blood gas analysis as a surrogate for microhemodynamic monitoring in sepsis

BACKGROUND

Emergency patients with sepsis or septic shock are at high risk of death. Despite increasing attention to microhemodynamics, the clinical use of advanced microcirculatory assessment is limited due to its shortcomings. Since blood gas analysis is a widely used technique reflecting global oxygen supply and consumption, it may serve as a surrogate for microcirculation monitoring in septic treatment.

METHODS

We performed a search using PubMed, Web of Science, and Google scholar. The studies and reviews that were most relevant to septic microcirculatory dysfunctions and blood gas parameters were identified and included.

RESULTS

Based on the pathophysiology of oxygen metabolism, the included articles provided a general overview of employing blood gas analysis and its derived set of indicators for microhemodynamic monitoring in septic care. Notwithstanding flaws, several parameters are linked to changes in the microcirculation. A comprehensive interpretation of blood gas parameters can be used in order to achieve hemodynamic optimization in septic patients.

CONCLUSION

Blood gas analysis in combination with clinical performance is a reliable alternative for microcirculatory assessments. A deep understanding of oxygen metabolism in septic settings may help emergency physicians to better use blood gas analysis in the evaluation and treatment of sepsis and septic shock.

Edge-Guided Recurrent Positioning Network for Salient Object Detection in Optical Remote Sensing Images

Optical remote sensing images (RSIs) have been widely used in many applications, and one of the interesting issues about optical RSIs is the salient object detection (SOD). However, due to diverse object types, various object scales, numerous object orientations, and cluttered backgrounds in optical RSIs, the performance of the existing SOD models often degrade largely. Meanwhile, cutting-edge SOD models targeting optical RSIs typically focus on suppressing cluttered backgrounds, while they neglect the importance of edge information which is crucial for obtaining precise saliency maps. To address this dilemma, this article proposes an edge-guided recurrent positioning network (ERPNet) to pop-out salient objects in optical RSIs, where the key point lies in the edge-aware position attention unit (EPAU). First, the encoder is used to give salient objects a good representation, that is, multilevel deep features, which are then delivered into two parallel decoders, including: 1) an edge extraction part and 2) a feature fusion part. The edge extraction module and the encoder form a U-shape architecture, which not only provides accurate salient edge clues but also ensures the integrality of edge information by extra deploying the intraconnection. That is to say, edge features can be generated and reinforced by incorporating object features from the encoder. Meanwhile, each decoding step of the feature fusion module provides the position attention about salient objects, where position cues are sharpened by the effective edge information and are used to recurrently calibrate the misaligned decoding process. After that, we can obtain the final saliency map by fusing all position attention cues. Extensive experiments are conducted on two public optical RSIs datasets, and the results show that the proposed ERPNet can accurately and completely pop-out salient objects, which consistently outperforms the state-of-the-art SOD models.

Sepsis-induced Coagulopathy: The Different Prognosis in Severe Pneumonia and Bacteremia Infection Patients

Sepsis-induced coagulopathy (SIC) is a critical condition in sepsis patients, with varying outcomes depending on the type of infection. This study aims to analyze the prognosis of different infections in SIC cohort. A retrospective cohort study was conducted on 525 patients diagnosed with SIC in the intensive care unit from December 2013 to December 2022. These patients were divided into four groups: a non-pneumonia or bacteremia group, a severe pneumonia group, a bacteremia group, and a severe pneumonia concomitant with bacteremia group. The 28-day mortality was 18% (49/271) in the other infections group, 31% (33/106) in the lung infections group, 23% (29/126) in the blood infections group and 36% (8/36) in the lung and blood co-infections group, respectively. Pearson correlation analysis showed that procalcitonin (PCT) correlated strongly with all detected hemostatic markers (p < 0.001). The 28-day mortality rate in Lung infections group was significantly higher (p = 0.019), while Blood infections group had a higher incidence of disseminated intravascular coagulation (p = 0.011). By multivariable model analyses, longer duration of ventilation (p = 0.039) and severe pneumonia (p = 0.040) are risk factors associated with mortality. Different infections, including Lung and Blood infections, indicated different conditions in vivo. Longer duration of ventilation is associated with mortality, while Lung infections indicated higher 28-day mortality rate.

Diversity of hemodynamic types in connective tissue disease associated pulmonary hypertension: more than a subgroup of pulmonary arterial hypertension

Objective

Connective tissue disease associated pulmonary hypertension (CTD-PH) is classified as a subgroup of WHO group 1 PH, also called pulmonary arterial hypertension (PAH). However, not all CTD-PH fit hemodynamic definition of PAH. This study investigates the diversity of hemodynamic types of CTD-PH, their differences in clinical characteristics and outcomes.

Method

We performed a retrospective cohort study. CTD-PH patients were enrolled and divided into WHO group1 PH, WHO group 2 PH and hyperdynamic PH (mPAP > 20 mmHg, PVR < 3WU, PAWP < 15 mmHg) according to hemodynamics obtained by right heart catheterization. Patients with severe lung diseases, heart failure with reduced ejection fraction, pulmonary embolism, and hepatic cirrhosis were excluded. Baseline characteristics, autoantibodies, cardiac function, echocardiogram parameters, hemodynamics and survival rates were compared.

Result

A total of 202 CTD-PH patients were included, 138 in WHO group 1 PH, 33 in WHO group 2 PH and 31 in hyperdynamic PH. We found hyperdynamic PH is less severe, presenting lower NT-proBNP level, better WHO function class, lower mPAP and PVR, higher cardiac output, and less cardiac remodeling. Incidence of anti-RNP was significantly lower in patients with elevated PAWP. Short-term survival was worse in WHO group 2 PH, yet 5-year survival rates didn’t differ between groups.

Conclusion

Considering diversity in hemodynamic types, CTD-PH is more than a subgroup of PAH. Different types of CTD-PH present different clinical phenotypes and outcome. Phenotyping PH in CTD-PH patients is important.

Dynamic prediction of life-threatening events for patients in intensive care unit

Background

Early prediction of patients’ deterioration is helpful in early intervention for patients at greater risk of deterioration in Intensive Care Unit (ICU). This study aims to apply machine learning approaches to heterogeneous clinical data for predicting life-threatening events of patients in ICU.

Methods

We collected clinical data from a total of 3151 patients admitted to the Medical Intensive Care Unit of Peking Union Medical College Hospital in China from January 1st, 2014, to October 1st, 2019. After excluding the patients who were under 18 years old or stayed less than 24 h at the ICU, a total of 2170 patients were enrolled in this study. Multiple machine learning approaches were utilized to predict life-threatening events (i.e., death) in seven 24-h windows (day 1 to day 7) and their performance was compared.

Results

Light Gradient Boosting Machine showed the best performance. We found that life-threatening events during the short-term windows can be better predicted than those in the medium-term windows. For example, death in 24 h can be predicted with an Area Under Curve of 0.905. Features like infusion pump related fluid input were highly related to life-threatening events. Furthermore, the prediction power of static features such as age and cardio-pulmonary function increased with the extended prediction window.

Conclusion

This study demonstrates that the integration of machine learning approaches and large-scale high-quality clinical data in ICU could accurately predict life-threatening events for ICU patients for early intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-02026-x.

A case of disseminated Legionnaires’ disease: The value of metagenome next-generation sequencing in the diagnosis of Legionnaires

Background

Legionella rarely causes hospital-acquired pneumonia (HAP), although it is one of the most common pathogens of community-acquired pneumonia. Hospital-acquired Legionnaires’ disease, mainly occurring in immunocompromised patients, is often delayed in diagnosis with high mortality. The use of the metagenome Next-Generation Sequencing (mNGS) method, which is fast and unbiased, allows for the early detection and identification of microorganisms using a culture-independent strategy.

Case report

A 52-year-old male, with a past medical history of Goods syndrome, was admitted due to nephrotic syndrome. The patient developed severe pneumonia, rhabdomyolysis, and soft tissue infection after receiving immunosuppressive therapy. He did not respond well to empiric antibiotics and was eventually transferred to the medical intensive care unit because of an acute respiratory failure and septic shock. The patient then underwent a comprehensive conventional microbiological screening in bronchoalveolar lavage fluid (BALF) and blood, and the results were all negative. As a last resort, mNGS of blood was performed. Extracellular cell-free and intracellular DNA fragments of Legionella were detected in plasma and blood cell layer by mNGS, respectively. Subsequent positive results of polymerase chain reaction for Legionella in BALF and soft tissue specimens confirmed the diagnosis of disseminated Legionnaires’ disease involving the lungs, soft tissue, and blood stream. The patient’s condition improved promptly after a combination therapy of azithromycin and moxifloxacin. He was soon extubated and discharged from ICU with good recovery.

Conclusion

Early recognition and diagnosis of disseminated Legionnaires’ disease is challenging. The emergence and innovation of mNGS of blood has the potential to address this difficult clinical issue.

Cross-cultural validation of the Chinese version of the EmPHasis-10 questionnaire in connective tissue disease patients with pulmonary arterial hypertension and its relationship with risk stratification

BACKGROUNDS

The EmPHasis-10 questionnaire is a disease-specific quality of life (QoL) measurement in patients with pulmonary hypertension. We report the results of cross-cultural validation of the Chinese version of the EmPHasis-10 and its relationship with risk stratification in patients with connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH).

METHODS

The Emphasis-10 was administered to 75 CTD-PAH patients along with the 36-item Medical Outcomes Study Short Form Survey (SF-36) and EuroQol five dimensions questionnaire (EQ-5D). The diagnosis of PAH was confirmed by right heart catheterization. Demographic and clinical data were obtained. Multivariable logistic regression was conducted based on the low risk profile assessed by a 4-strata risk assessment model (COMPERA 2.0) at follow-up.

RESULTS

Date from 75 patients with CTD-PAH were analysed. The EmPHasis-10 demonstrated satisfactory reliability (Cronbach α = 0.95) and convergent validity showed by the significant relationship with WHO Functional Class (P = 0.003), SF-36 (P < 0.001) and EQ-5D (P = 0.002). EmPHasis-10 was significantly associated with achieving the low risk profile at 12 months of follow-up (Odds ratio: 0.928, P = 0.029) after adjusting for WHO Functional Class.

CONCLUSION

EmPHasis-10 has acceptable reliability and validity in CTD-PAH patients and may serve as an additional parameter in risk stratification.

Association of annual hospital septic shock case volume and hospital mortality

BACKGROUND

The burden of sepsis remains high in China. The relationship between case volume and hospital mortality among patients with septic shock, the most severe complication of sepsis, is unknown in China.

METHODS

In this retrospective cohort study, we analyzed surveillance data from a national quality improvement program in intensive care units (ICUs) in China in 2020. Association between septic shock case volume and hospital mortality was analyzed using multivariate linear regression and restricted cubic splines.

RESULTS

We enrolled a total of 134,046 septic shock cases in ICUs from 1902 hospitals in China during 2020. In this septic shock cohort, the median septic shock volume per hospital was 33 cases (interquartile range 14-76 cases), 41.4% were female, and more than half of the patients were over 61 years old, with average hospital mortality of 21.2%. An increase in case volume was associated with improved survival among septic shock cases. In the linear regression model, the highest quartile of septic shock volume was associated with lower hospital mortality compared with the lowest quartile (β - 0.86; 95% CI - 0.98, - 0.74; p < 0.001). Similar differences were found in hospitals of respective geographic locations and hospital levels. With case volume modeled as a continuous variable in a restricted cubic spline, a lower volume threshold of 40 cases before which a substantial reduction of the hospital mortality rate was observed.

CONCLUSIONS

The findings suggest that hospitals with higher septic shock case volume have lower hospital mortality in China. Further research is needed to explain the mechanism of this volume-outcome relationship.

POS1368 DIVERSITY OF HEMODYNAMIC TYPES IN CONNECTIVE TISSUE DISEASE ASSOCIATED PULMONARY HYPERTENSION: MORE THAN A SUBGROUP OF PULMONARY ARTERIAL HYPERTENSION

Background

Connective tissue disease (CTD) associated pulmonary hypertension (PH) is classified as a subgroup of WHO group 1 PH, also called pulmonary arterial hypertension (PAH). However, not all CTD-PH fit the hemodynamic definition of PAH. This study investigates the diversity of hemodynamical types of CTD-PH, their different clinical characteristics and outcomes.

Objectives

This study investigates the diversity of hemodynamical types of CTD-PH, their different clinical characteristics and outcomes.

Methods

We performed a retrospective cohort study. CTD-PH patients underwent right heart catheterization (RHC) were enrolled and divided into WHO group1 PH, WHO group 2 PH and high output PH (PVR<3WU and PAWP<15mmHg) according to hemodynamic features. Patients with obvious lung diseases, left heart disease and pulmonary embolism were excluded. Baseline characteristics, inflammatory markers, autoantibodies, cardiac function status, echocardiogram parameters, hemodynamics and survival rates were compared.

Results

207 CTD-PH patients were included, including 139 in WHO group 1 PH, 36 in WHO group 2 PH and 32 in high output PH. Incidence of anti-ribonucleoprotein antibody was lower in WHO Group 2 PH. High output PH is less severe, presenting lower NT-proBNP level, better WHO functional class, lower mPAP and PVR, higher cardiac output, and less cardiac remodeling. Among patients with elevated PAWP, combine pre& post-capillary PH had higher mPAP and larger right ventricle diameter. Association of mild to moderate interstitial lung disease didn’t show significant difference in disease characteristics. Short-term survival was significantly worse in WHO group 2 PH, yet 5-year survival rates didn’t differ between groups.

Conclusion

Pre-capillary PH is not the only hemodynamic type of CTD-PH. Different types of CTD-PH present different clinical phenotypes and outcome. Carefully phenotyping PH in CTD-PH patients is important.

Disclosure of Interests

None declared

Establishment and Implementation of Potential Fluid Therapy Balance Strategies for ICU Sepsis Patients Based on Reinforcement Learning

Objective

Fluid therapy for sepsis patients has always been a problem that puzzles clinicians, that is, knowing when patients need fluid infusion and when they need negative fluid balance. Different clinicians may have different judgment criteria and make different decisions. Recently, studies have suggested that different fluid treatment strategies can cause different clinical outcomes. This study is intended to establish and verify a model for judging the direction of fluid therapy based on machine learning.

Method

This study included 2705 sepsis patients from the Peking Union Medical College Hospital Intensive Care Medical Information System and Database (PICMISD) from January 2016 to April 2020. The training set and test set (January 2016 to June 2019) were randomly divided. Twenty-seven features were extracted for modeling, including 25 state features (bloc, vital sign, laboratory examination, blood gas assay and demographics), 1 action feature (fluid balance) and 1 outcome feature (ICU survival or death). SARSA was used to learn the data rules of the training set. Deep Q-learning (DQN) was used to learn the relationship between states and actions of the training set and predict the next balance. A double-robust estimator was used to evaluate the average expected reward of the test set in the deep Q-learning model. Lastly, we verified the difference between the predicted fluid therapy model and the actual treatment for the patient's prognoses, with sepsis patient data from July 2019 to April 2020 as the validation set.

Results

The training set and test set were extracted from the same database, and the distribution of liquid balance was similar. Actions were divided into five intervals corresponding to 0–20, 20–40, 40–60, 60–80, and 80–100% percentiles of fluid balance. The higher the reward of Q(s, a) calculated by SARSA from the training set, the lower the mortality rate. Deep Q-learning indicates that both fluid balance differences that are too high and too low show an increase in mortality. The more consistent the fluid balance prediction with the real result, the lower the mortality rate. The smaller the difference between the prediction and the reality, the lower the mortality rate. The double-robust estimator shows that the model has satisfactory stability. The validation set indicates that the mortality rate of patients in the “predicted negative fluid balance and actual negative fluid balance” subgroup was the lowest, which was statistically significant, indicating that the model can be used for clinical verification.

Conclusion

We used reinforcement learning to propose a possible prediction model for guiding the direction of fluid therapy for sepsis patients in the ICU. This model may accurately predict the best direction for fluid therapy, thereby improving patient prognosis.

Intravenous Immunoglobulin Therapy for Critically Ill COVID-19 Patients With Different Inflammatory Phenotypes: A Multicenter, Retrospective Study

Background

The benefits of intravenous immunoglobulin administration are controversial for critically ill COVID-19 patients.

Methods

We analyzed retrospectively the effects of immunoglobulin administration for critically ill COVID-19 patients. The primary outcome was 28-day mortality. Inverse probability of treatment weighting (IPTW) with propensity score was used to account for baseline confounders. Cluster analysis was used to perform phenotype analysis.

Results

Between January 1 and February 29, 2020, 754 patients with complete data from 19 hospitals were enrolled. Death at 28 days occurred for 408 (54.1%) patients. There were 392 (52.0%) patients who received intravenous immunoglobulin, at 11 (interquartile range (IQR) 8, 16) days after illness onset; 30% of these patients received intravenous immunoglobulin prior to intensive care unit (ICU) admission. By unadjusted analysis, no difference was observed for 28-day mortality between the immunoglobulin and non-immunoglobulin groups. Similar results were found by propensity score matching (n = 506) and by IPTW analysis (n = 731). Also, IPTW analysis did not reveal any significant difference between hyperinflammation and hypoinflammation phenotypes.

Conclusion

No significant association was observed for use of intravenous immunoglobulin and decreased mortality of severe COVID-19 patients. Phenotype analysis did not show any survival benefit for patients who received immunoglobulin therapy.

Non-HIV-infected patients with Pneumocystis pneumonia in the intensive care unit: A bicentric, retrospective study focused on predictive factors of in-hospital mortality

BACKGROUND

The incidence of Pneumocystis pneumonia (PCP) among patients without human immunodeficiency virus (HIV) infection continues to increase. Here, we identified potential risk factors for in-hospital mortality among HIV-negative patients with PCP admitted to the intensive care unit (ICU).

METHODS

We retrospectively analyzed medical records of 154 non-HIV-infected PCP patients admitted to the ICU at Peking Union Medical College Hospital (PUMCH) and China-Japan Friendship Hospital (CJFH) from October 2012 to July 2020. Clinical characteristics were examined, and factors related to in-hospital mortality were analyzed.

RESULTS

A total of 154 patients were enrolled in our study. Overall, the in-hospital mortality rate was 65.6%. The univariate analysis indicated that nonsurvivors were older (58 vs. 52 years, P = 0.021), were more likely to use high-dose steroids (≥1 mg/kg/day prednisone equivalent, 39.62% vs. 55.34%, P = 0.047), receive caspofungin during hospitalization (44.6% vs. 28.3%, P = 0.049), require invasive ventilation (83.2% vs. 47.2%, P < 0.001), develop shock during hospitalization (61.4% vs. 20.8%, P < 0.001), and develop pneumomediastinum (21.8% vs. 47.2%, P = 0.001) and had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores on ICU admission (20.32 vs. 17.39, P = 0.003), lower lymphocyte counts (430 vs. 570 cells/μl, P = 0.014), and lower PaO2/FiO2 values (mmHg) on admission (108 vs. 147, P = 0.001). Multivariate analysis showed that age (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.00-1.06; P = 0.024), use of high-dose steroids (≥1 mg/kg/day prednisone equivalent) during hospitalization (OR 2.29; 95% CI 1.07-4.90; P = 0.034), and a low oxygenation index on admission (OR 0.99; 95% CI 0.99-1.00; P = 0.014) were associated with in-hospital mortality.

CONCLUSIONS

The mortality rate of non-HIV-infected patients with PCP was high, and predictive factors of a poor prognosis were advanced age, use of high-dose steroids (≥1 mg/kg/day prednisone equivalent) during hospitalization, and a low oxygenation index on admission. The use of caspofungin during hospitalization might have no contribution to the prognosis of non-HIV-infected patients with PCP in the ICU.

Place of death and phenomenon of going home to die in Chinese adults: A prospective cohort study

BACKGROUND

China is embracing an ageing population without sustainable end-of-life care services. However, changes in place of death and trends of going home to die (GHTD) from the hospital remains unknown.

METHODS

A total of 42,956 participants from the China Kadoorie Biobank, a large Chinese cohort, who died between 2009 and 2017 was included into analysis. GHTD was defined as death at home within 7 days after discharge from the hospital. A modified Poisson regression was used to investigate temporal trends of the place of death and GHTD, and estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the association of GHTD with health insurance (HI) schemes.

FINDINGS

From 2009 to 2017, home remained the most common place of death (71·5%), followed by the hospital (21·6%). The proportion of GHTD for Urban and Rural Residents' Basic Medical Insurance (URRBMI) beneficiaries was around six times higher than that for Urban Employee Basic Medical Insurance (UEBMI) beneficiaries (66·0% vs 11·6%). Besides, a substantial increase in the proportion of GHTD throughout the study period was observed regardless of HI schemes (4·4% annually for URRBMI, and 5·4% for UEBMI). Compared with UEBMI beneficiaries, URRBMI beneficiaries were more likely to experience GHTD, with an adjusted PR (95% CI) of 1·19 (95% CI: 1·12, 1·27) (P<0·001).

INTERPRETATION

In China, most of deaths occurred at home, with a large proportion of decedents GHTD from the hospital, especially for URRBMI beneficiaries. Substantial variation in the phenomenon of GHTD across HI schemes indicates inequalities in end-of-life care utilization.

FUNDING

The National Natural Science Foundation of China, the Kadoorie Charitable Foundation, the National Key R&D Program of China, the Chinese Ministry of Science and Technology.

Clinical Characteristics and Prognoses of Patients With Systemic Lupus Erythematosus Hospitalized for Pulmonary Infections

Objective: To identify factors associated with mortality in SLE patients who were hospitalized for pulmonary infections (PIs). Methods: This single-center retrospective study analyzed the characteristics and risk factors for mortality in 95 SLE patients hospitalized for PIs. Results: Ninety-five SLE patients had 97 episodes of hospitalization for PIs, and 33 of these episodes (34.02%) led to death. Death from PI was associated with a higher neutrophil count (6.30 vs. 4.201 × 10⁹/L, p < 0.01), immunoglobulin G (6.20 vs. 9.82 g/L, p = 0.01), serum creatinine (126.00 vs. 73.00 μmol/L, p = 0.01), proteinuria (2.99 vs. 0.54 g/day, p < 0.01), cardiopulmonary involvement (57.58 vs. 34.38%, p < 0.05), SLE disease activity index (SLEDAI; 11.00 vs. 6.00, p < 0.05), and opportunistic infections (78.79 vs. 45.31%, p < 0.05). Demographic characteristics, antibody/complements, bacterial infection, and primary treatment before infection (including corticosteroid and immunosuppressants) had no effect. Multivariate analysis indicated cardiopulmonary involvement (HR: 2.077; 95%CI: 1.022-4.220; p = 0.043) and opportunistic infection (HR: 2.572; 95%CI: 1.104-5.993; p = 0.029) were independent risk factors for mortality. High-dose steroid pulse therapy (HR: 0.982; 95%CI: 0.410-2.350; p = 0.982) and first-line immunosuppressant therapy (HR: 1.635; 95%CI: 0.755-3.542, p = 0.212) had no effect on mortality. Conclusion: Cardiopulmonary involvement and opportunistic infection were independent risk factors for mortality for SLE patients hospitalized for PIs. Use of high-dose pulse steroids and or immunosuppressants before hospitalization had no significant effects.

TRIM11 suppresses ferritinophagy and gemcitabine sensitivity through UBE2N/TAX1BP1 signaling in pancreatic ductal adenocarcinoma

Gemcitabine is first-line chemotherapy for pancreatic cancer, however, the development of resistance limits its effectiveness. The tripartite motif-containing 11 (TRIM11) protein plays crucial roles in tumor development and undergoes auto-polyubiquitination to promote interactions in selective autophagy. Therefore, Understanding whether TRIM11 is involved in ferritinophagy and gemcitabine resistance in pancreatic cancer is critical in developing pancreatic cancer therapeutics. TRIM11 expression was validated by Western blot analysis, real-time polymease chain reaction, and immunohistochemical staining. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and Colony formation assays were performed to investigate pancreatic ductal adenocarcinomas (PDAC) cell viability. Mouse xenograft model of PDAC cells was established to verify the role of TRIM11 in vivo. Coimmunoprecipitation was used to identify the reciprocal regulation between TRIM11 and UBE2N. In this study, we found that TRIM11 expression were higher in PDAC cells and tissues. TRIM11 overexpression promotes PDAC cell proliferation in vitro and tumor growth in vivo. Decreased expression of TRIM11 in PDAC patients is associated with decreased UBE2N and increased TAX1BP1 expression. Coimmunoprecipitation established that TRIM11 interacts and colocalizes with UBE2N. Mechanistically, TRIM11 promoted gemcitabine resistance and suppressed ferritinophagy through UBE2N-TAX1BP1 signaling. Our findings identify TRIM11 as a key regulator of TAX1BP1 signaling with a crucial role in ferritinophagy and gemcitabine resistance in PDAC.