Complementary value of the Shock Index v. the Modified Shock Index in the prediction of in-hospital intensive care unit admission and mortality: A single-centre experience

Background

Shock is a state of circulatory insufficiency that creates an imbalance between tissue oxygen supply and demand, resulting in end-organ dysfunction and hypodynamic circulatory failure. Most patients with infectious and trauma-related illnesses present to the emergency department (ED) in shock.

Objectives

To study the usefulness of the shock index (SI) and modified shock index (MSI) in identifying and triaging patients in shock presenting to the ED.

Methods

This was a year-long observational, cross-sectional study of 290 patients presenting to the ED of a tertiary hospital in compensated or overt shock. The SI and MSI were calculated at the time of first contact, and then hourly for the initial 3 hours. Relevant background investigations targeting the cause of shock and prognostic markers were done. The outcome measures of mortality and intensive care unit admission were documented for each participant.

Results

The mean age of the participants was 49 years, and 67% of them were men. In consensus with local and national data, the major medical comorbidities were hypertension (20%) and diabetes mellitus (16%). An SI ≥0.9 and an MSI ≥1.3 predicted in-hospital mortality (p<0.05) and ICU admission (p<0.05) with no significant superiority of the MSI over the SI in terms of mortality, although the MSI was a better surrogate marker for critical care admission.

Conclusion

The study showed the complementary value of the SI and MSI in triage in a busy tertiary hospital ED, surpassing their components such as blood pressure, heart rate and pulse pressure. We determined useful cut-offs for these tools for early risk assessment in the ED, and larger multicentre studies are needed to support our findings.

Study synopsis

What the study adds. The study highlights the usefulness of clinical bedside tools such as the shock index (SI) and modified shock index (MSI) in triaging patients in the emergency department, and their role in predicting morbidity and mortality.Implications of the findings. Compared with systolic blood pressure, diastolic blood pressure and mean arterial pressure, alone or in combination, the SI and MSI had higher sensitivity and specificity in terms of outcome prediction. While both an elevated SI and an elevated MSI predicted in-hospital mortality, the MSI was a better surrogate marker for ICU admission.

Docking Investigation on Bis (Nitro Indazolyl) Methanes; Synthesis and Antimicrobial Activity Towards Breast Cancer Applications

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Bismuth (III) nitrate pentahydrate (BN) was found to be a mild and efficient catalyst for the electrophilic condensation of 5-nitroindazole with a wide range of aldehydes to obtain Bis (5-nitro indazolyl) methanes 3 (a-h) at ambient temperature. This was structurally confirmed from FTIR, NMR, and HR-MS technique. Molecular docking studies of all compounds was carried out using breast cancer-causing human estrogen receptor (ER) from Molegro Virtual Docker software. Hydroxy Bis (nitro indazolyl) methanes (3b) were shown better binding affinities and the score obtained was -150.146 Kcal/mol compared with Tamoxifen drug. The major H-bond interactions were observed with the compound 3f and the value was -5.679. The antimicrobial activity results revealed that compounds 3b and 3d showed promising activity against bacteria Escherichia coli, Klebsiella pneumonia, Staphylococcus aureus, and Pseudomonas aeruginosa and maximum inhibition against Aspergillus niger and Aspergillus flavus. Methoxy derivatives of Bis (nitro indazolyl methanes) (3e) have shown better antioxidant activity and low MIC (6.25 µg/ml) observed for the compounds 3a and 3b. The synthesized compounds have a very promising starting point for the development and improvement of anti-breast cancer drugs.

Enteric fever presenting as catatonia syndrome - Case report

Enteric or typhoid fever is an emerging tropical infectious disease and a global public health problem with a documented spectrum of neuro-psychiatric manifestations especially from endemic countries. Although neuro-psychiatric manifestations are reported in nearly 50-75% of patients at any phase of enteric fever, the chance of their misdiagnosis and deferred diagnosis of the prime illness is quite common. Atypical symptoms are commonly attributed to be a part of 'typhoid toxaemia', the acute febrile phase of the illness. We report a case of young male presenting with catatonia in the aftermath of such.

Intestinal Epithelial Wnt Signaling Mediates Acetylcholine-Triggered Host Defense against Infection

Regulated antimicrobial peptide expression in the intestinal epithelium is key to defense against infection and to microbiota homeostasis. Understanding the mechanisms that regulate such expression is necessary for understanding immune homeostasis and inflammatory disease and for developing safe and effective therapies. We used Caenorhabditis elegans in a preclinical approach to discover mechanisms of antimicrobial gene expression control in the intestinal epithelium. We found an unexpected role for the cholinergic nervous system. Infection-induced acetylcholine release from neurons stimulated muscarinic signaling in the epithelium, driving downstream induction of Wnt expression in the same tissue. Wnt induction activated the epithelial canonical Wnt pathway, resulting in the expression of C-type lectin and lysozyme genes that enhanced host defense. Furthermore, the muscarinic and Wnt pathways are linked by conserved transcription factors. These results reveal a tight connection between the nervous system and the intestinal epithelium, with important implications for host defense, immune homeostasis, and cancer.

RNAi Screening: Automated High-Throughput Liquid RNAi Screening in Caenorhabditis elegans

RNAi is a powerful reverse genetics tool that has revolutionized genetic studies in model organisms. The bacteriovorous nematode Caenorhabditis elegans can be genetically manipulated by feeding it an Escherichia coli strain that expresses a double-stranded RNA (dsRNA) corresponding to a C. elegans gene, which leads to systemic silencing of the gene. This unit describes protocols for performing an automated high-throughput RNAi screen utilizing a full-genome C. elegans RNAi library. The protocols employ liquid-handling robotics and 96-well plates. © 2018 by John Wiley & Sons, Inc.

Plate Design for and Cherry Picking of Bacterial RNAi Clones for Systematic Error Detection in High-Throughput Caenorhabditis elegans RNAi Screens

Automated or semi-automated high-throughput RNAi screens are highly prone to systematic errors because of multistep repetitive protocols and extensive use of automated instruments. A well-designed RNAi library can help detect and minimize systematic human and robotic errors. In this unit, we describe how to design an RNAi bacterial library for use in conjunction with the well-studied nematode Caenorhabditis elegans for automated phenotypic screens. We provide strategies to design and assemble RNAi libraries to reduce or eliminate systematic errors. These strategies serve as a good quality-control check and facilitate obtaining high-quality data from a genome-wide and sub-library RNAi screen. © 2018 by John Wiley & Sons, Inc.

On the Mechanism of Berberine-INF55 (5-Nitro-2-phenylindole) Hybrid Antibacterials

Berberine-INF55 hybrids are a promising class of antibacterials that combine berberine and the NorA multidrug resistance pump inhibitor INF55 (5-nitro-2-phenylindole) together in one molecule via a chemically stable linkage. Previous studies demonstrated the potential of these compounds for countering efflux-mediated antibacterial drug resistance but they didn't establish whether the compounds function as originally intended, i.e. with the berberine moiety providing antibacterial activity and the attached INF55 component independently blocking multidrug resistance pumps, thereby enhancing the activity of berberine by reducing its efflux. We hypothesised that if the proposed mechanism is correct, then hybrids carrying more potent INF55 pump inhibitor structures should show enhanced antibacterial effects relative to those bearing weaker inhibitors. Two INF55 analogues showing graded reductions in NorA inhibitory activity compared with INF55 were identified and their corresponding berberine-INF55 hybrids carrying equivalent INF55 inhibitor structures synthesised. Multiple assays comparing the antibacterial effects of the hybrids and their corresponding berberine-INF55 analogue combinations showed that the three hybrids all show very similar activities, leading us to conclude that the antibacterial mechanism(s) of berberine-INF55 hybrids is different from berberine-INF55 combinations.

Retromolar foramen and canal: a comprehensive review on its anatomy and clinical applications

The retromolar foramen (RMF) and retromolar canal (RMC) are the anatomical structures of the mandible located in retromolar fossa behind the third molar tooth. This foramen and canal contain neurovascular structures which provide accessory/additional innervation to the mandibular molars and the buccal area. These neurovascular contents of the canal gain more importance in medical and dental practice, because these elements are vulnerable to damage during placement of osteointegrated implants, endodontic treatment and sagittal split osteotomy surgeries and a detailed knowledge of this anatomical variation would be vital in understanding failed inferior alveolar nerve blockage, spread of infection and also metastasis. Although few studies have been conducted in the past showing the incidence and types in different population groups, a lacunae in comprehensive review of this structure is lacking. Though this variation posed challenging situations for the practicing surgeons, it has been quite neglected and the incidence of it is not well presented in all the textbooks. Hence, we made an attempt to provide a consolidated review regarding variations and clinical applications of the RMF and RMC.

A novel "four-component" two-component signal transduction mechanism regulates developmental progression in Myxococcus xanthus

Histidine-aspartate phosphorelays are employed by two-component signal transduction family proteins to mediate responses to specific signals or stimuli in microorganisms and plants. The RedCDEF proteins constitute a novel signaling system in which four two-component proteins comprising a histidine kinase, a histidine-kinase like protein, and two response regulators function together to regulate progression through the elaborate developmental program of Myxococcus xanthus. A combination of in vivo phenotypic analyses of in-frame deletions and non-functional point mutations in each gene as well as in vitro autophosphorylation and phosphotransfer analyses of recombinant proteins indicate that the RedC histidine kinase protein autophosphorylates and donates a phosphoryl group to the single domain response regulator, RedF, to repress progression through the developmental program. To relieve this developmental repression, RedC instead phosphorylates RedD, a dual receiver response regulator protein. Surprisingly, RedD transfers the phosphoryl group to the histidine kinase-like protein RedE, which itself appears to be incapable of autophosphorylation. Phosphorylation of RedE may render RedE accessible to RedF, where it removes the phosphoryl group from RedF-P, which is otherwise an unusually stable phosphoprotein. These analyses reveal a novel "four-component" signaling mechanism that has probably arisen to temporally coordinate signals controlling the developmental program in M. xanthus. The RedCDEF signaling system provides an important example of how the inherent plasticity and modularity of the basic two-component signaling domains comprise a highly adaptable framework well suited to expansion into complex signaling mechanisms.

Acute adrenocortical crisis and an abnormal electrocardiogram

Acute adrenocortical crisis is often the first presentation of Addison's disease. The combination of pigmentation, peripheral circulatory failure and the electrolyte abnormality usually lead to suspicion and early treatment with corticosteroids is the key to the success in such cases. Failure of response to the standard treatment should highlight the possibility of a coexisting condition. We report a case where the patient did not respond to the treatment until such a condition was recognized.