Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial

Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.

International Society of Blood Transfusion survey of experiences of blood banks and transfusion services during the COVID-19 pandemic

BACKGROUND AND OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has impacted blood systems worldwide. Challenges included maintaining blood supplies and initiating the collection and use of COVID-19 convalescent plasma (CCP). Sharing information on the challenges can help improve blood collection and utilization.

MATERIALS AND METHODS

A survey questionnaire was distributed to International Society of Blood Transfusion members in 95 countries. We recorded respondents' demographic information, impacts on the blood supply, CCP collection and use, transfusion demands and operational challenges.

RESULTS

Eighty-two responses from 42 countries, including 24 low- and middle-income countries, were analysed. Participants worked in national (26.8%) and regional (26.8%) blood establishments and hospital-based (42.7%) institutions. CCP collection and transfusion were reported by 63% and 36.6% of respondents, respectively. Decreases in blood donations occurred in 70.6% of collecting facilities. Despite safety measures and recruitment strategies, donor fear and refusal of institutions to host blood drives were major contributing factors. Almost half of respondents working at transfusion medicine services were from large hospitals with over 10,000 red cell transfusions per year, and 76.8% of those hospitals experienced blood shortages. Practices varied in accepting donors for blood or CCP donations after a history of COVID-19 infection, CCP transfusion, or vaccination. Operational challenges included loss of staff, increased workloads and delays in reagent supplies. Almost half of the institutions modified their disaster plans during the pandemic.

CONCLUSION

The challenges faced by blood systems during the COVID-19 pandemic highlight the need for guidance, harmonization, and strengthening of the preparedness and the capacity of blood systems against future infectious threats.

Alimentación de ovinos con heno de avena cosechado en dos etapas de madurez en el noroeste de Chihuahua, México

Manipular la variedad y la etapa de madurez al corte del heno de avena (Avena sativa L.), puede mejorar el valor nutricional del forraje y por tanto la respuesta productiva de los animales. Se evaluó el efecto de la alimentación de corderas con heno de tres variedades de avena, cosechadas en dos etapas de madurez. El estudio se llevó a cabo en el noroeste del estado de Chihuahua, México. La hipótesis fue que la avena cosechada en madurez fisiológica presenta mayor proporción de grano lo que mejora el valor nutritivo del forraje y la ganancia de peso en las corderas. Las variedades de avena evaluadas fueron Cuauhtémoc, Menonita y Bachíniva. Las avenas fueron cosechadas para heno en las etapas de grano lechoso-masoso (L-Masoso) y madurez fiológica (M-Fisiológica). Se usaron 72 corderas (21,2 ± 3,7 kg), que fueron agrupadas por peso y alimentadas ad libitum durante 63 d, con una ración compuesta de 65 % heno de avena y 35 % concentrado. El diseño fue en bloques completos al azar con arreglo factorial 3 x 2 entre variedad y etapas de madurez. La composición química de los forrajes fue similar entre las variedades de avena. No se observó efecto de variedad ni etapa de madurez sobre el comportamiento productivo de las corderas. El consumo de materia seca, la ganancia diaria de peso y la conversión alimenticia en L-Masoso y M-Fisiologica fueron 1,03 y 1,01 kg, 119 y 130 g, y 9,6 y 8,9 kg a-1 d-1, respectivamente. La falta de respuesta en los animales se atribuyó a la composición química similar que presentaron los forrajes. Aunque la avena cosechada en L-Masoso mejoró (P

High prevalence of vitamin D insufficiency among elite Spanish athletes the importance of outdoor training adaptation

INTRODUCTION

The discovery of vitamin D muscle receptors in the last few years suggested a significant role in muscle tissue, pointing out athletes as a special group. Specific data are scarce.

AIM

The main aim of the current paper was to provide, for the first time, comparable data about vitamin D status in elite Spanish athletes by sport, age, season and training environment.

METHODS

Four hundred and eight elite athletes with a mean age of 22.8 ± 8.4 years were recruited from the High-performance sport centre in Barcelona for this cross-sectional study. Athletes from 34 different sports modalities were analysed. Data were available for vitamin D status, training environment, seasonality and number of medical visits. All data were analysed using SPSS version 18.0.

RESULTS

Mean 25(OH)D of all athletes was 56.7 ± 23.4 nmol/L. Approximately 82% of the athletes were below the optimal levels, (< 75nmol/l), 45% had moderate deficient levels (< 50 nmol/L) and 6% had severe deficiency (< 27.5 nmol/L). We have observed a steady increase in 25(OH)D concentrations with increasing age (p < 0.01) Highest levels were observed in those subjects training outdoors compared with those training indoor (p.

[Diabetic foot infection: a multidisciplinary approach]

Diabetic foot infection is a frequent, multifactorial and multifacettal disease. Its management requires an interdisciplinary collaboration. Multiple medical and surgical specialties are enrolled for its prevention and treatment, for good reasons. Concomitant management by various specialists shows a significant reduction in amputation rates. We review the issues of this interdisciplinary collaboration.

Information and topology in attractor neural networks

A wide range of networks, including those with small-world topology, can be modeled by the connectivity ratio and randomness of the links. Both learning and attractor abilities of a neural network can be measured by the mutual information (MI) as a function of the load and the overlap between patterns and retrieval states. In this letter, we use MI to search for the optimal topology with regard to the storage and attractor properties of the network in an Amari-Hopfield model. We find that while an optimal storage implies an extremely diluted topology, a large basin of attraction leads to moderate levels of connectivity. This optimal topology is related to the clustering and path length of the network. We also build a diagram for the dynamical phases with random or local initial overlap and show that very diluted networks lose their attractor ability.

Effect of proinflammatory cytokines (IL-6, TNF-alpha, IL-1beta) on hemodynamic performance during orthotopic liver transplantation

BACKGROUND

Proinflammatory cytokines (IL-6, IL-1beta, TNF-alpha) released during liver transplantation may affect hemodynamic stability. The aim of the present study was to analyze the association between IL-6, TNF-alpha, and IL-1beta and systemic vascular resistance during the phases of liver transplantation.

MATERIAL AND METHODS

The proinflammatory cytokines IL-6, IL-1beta, and TNF-alpha were analyzed in the blood of 20 consecutive patients who underwent transplantation. Blood samples were drawn from the pulmonary artery at serial times during surgery. Hemodynamic parameters were determined using a cardiac output monitor. Correlations between parameters were analyzed using the Spearman's rho and Kendall's tau-b methods.

RESULTS

Both in the vena cava and the pulmonary artery, significant association was observed between basal values of IL-6 during hepatectomy and systemic vascular resistance during the phases of liver transplantation: hepatectomy phase (r=.76, P=.02), anhepatic phase (r=.78, P=.03) and reperfusion phase (r=.87, P=.005).

CONCLUSIONS

Basal values of IL-6 may be considered a prognostic factor for hemodynamic performance during the phases of liver transplantation.

Structural and functional similarities between the central eukaryotic initiation factor (eIF)4A-binding domain of mammalian eIF4G and the eIF4A-binding domain of yeast eIF4G

The translation eukaryotic initiation factor (eIF)4G of the yeast Saccharomyces cerevisiae interacts with the RNA helicase eIF4A (a member of the DEAD-box protein family; where DEAD corresponds to Asp-Glu-Ala-Asp) through a C-terminal domain in eIF4G (amino acids 542-883). Mammalian eIF4G has two interaction domains for eIF4A, a central domain and a domain close to the C-terminus. This raises the question of whether eIF4A binding to eIF4G is conserved between yeast and mammalian cells or whether it is different. We isolated eIF4G1 mutants defective in eIF4A binding and showed that these mutants are strongly impaired in translation and growth. Extracts from mutants displaying a temperature-sensitive phenotype for growth have low in vitro translation activity, which can be restored by addition of the purified eIF4G1-eIF4E complex, but not by eIF4E alone. Analysis of mutant eIF4G(542-883) proteins defective in eIF4A binding shows that the interaction of yeast eIF4A with eIF4G1 depends on amino acid motifs that are conserved between the yeast eIF4A-binding site and the central eIF4A-binding domain of mammalian eIF4G. We show that mammalian eIF4A binds tightly to yeast eIF4G1 and, furthermore, that mutant yeast eIF4G(542-883) proteins, which do not bind yeast eIF4A, do not interact with mammalian eIF4A. Despite the conservation of the eIF4A-binding site in eIF4G and the strong sequence conservation between yeast and mammalian eIF4A (66% identity; 82% similarity at the amino acid level) mammalian eIF4A does not substitute for the yeast factor in vivo and is not functional in a yeast in vitro translation system.

Inhibition of integrin linked kinase (ILK) suppresses beta-catenin-Lef/Tcf-dependent transcription and expression of the E-cadherin repressor, snail, in APC-/- human colon carcinoma cells

Loss of functional adenomatous polyposis coli (APC) protein results in the stabilization of cytosolic beta-catenin and activation of genes that are responsive to Lef/Tcf family transcription factors. We have recently shown that an independent cell adhesion and integrin linked kinase (ILK)-dependent pathway can also activate beta-catenin/LEF mediated gene transcription and downregulate E-cadherin expression. In addition, ILK activity and expression are elevated in adenomatous polyposis and colon carcinomas. To examine the role of this pathway in the background of APC mutations we inhibited ILK activity in APC-/- human colon carcinoma cell lines. In all cases, inhibition of ILK resulted in substantial inhibition of TCF mediated gene transcription and inhibition of transcription and expression of the TCF regulated gene, cyclin D1. Inhibition of ILK resulted in decreased nuclear beta-catenin expression, and in the inhibition of phosphorylation of GSK-3 and stimulation of its activity, leading to accelerated degradation of beta-catenin. In addition, inhibition of ILK suppressed cell growth in culture as well as growth of human colon carcinoma cells in SCID mice. Strikingly, inhibition of ILK also resulted in the transcriptional stimulation of E-cadherin expression and correlated with the inhibition of gene transcription of snail, a repressor of E-cadherin gene expression. Overexpression of ILK caused a stimulation of expression of snail, but snail expression was found not to be regulated by beta-catenin/Tcf. These data demonstrate that ILK can regulate beta-catenin/TCF and snail transcription factors by distinct pathways. We propose that inhibition of ILK may be a useful strategy in the control of progression of colon as well as other carcinomas. Oncogene (2001) 20, 133 - 140.

Shunting is a translation strategy used by plant pararetroviruses (Caulimoviridae)

In eukaryotes standard initiation of translation involved 40S ribosome scanning to bridge the distance from the cap to the initiation codon. Recently deviations from that rule had been described, including "internal initiation", "poly-A dependent translation", and "ribosome shunting". In ribosome shunting, ribosomes start scanning at the cap but large portions of the leader are skipped. Thereby the secondary structure of the shunted region is preserved. Scanning in plant caulimoviruses involve a small open reading frame properly spaced in front of a strong stem structure, and, in order to function, the small open reading frome has to be translated and the peptide released. This arrangement can be mimicked by artificial small open reading frames and stem structures. Shunting with viral and synthetic leaders occurs not only in plant-, but also in mammalian and yeast systems. Thus it responds to an intrinsic property of the eukaryotic translational machinery and probably acts in many cases where coding regions are preceded by complex leaders.

Difference between observed and predicted length of stay as an indicator of inpatient care inefficiency

OBJECTIVES

To evaluate the performance of the difference between observed and predicted length of stay (OLOS-PLOS) as an inefficiency of care indicator for inpatients.

SETTING

The Internal Medicine and the General Surgery departments of Hermanos Ameijeiras Hospital in Havana.

DESIGN AND STUDY PARTICIPANTS

Two sets of clinical histories were needed for each department: one for deriving the predictive equation and another to validate it. The equation was a linear multiple regression model which included variables recognized as affecting length of stay. The validation group of histories was thoroughly examined and separated into two groups: (i) adequate efficiency or mild problems and (ii) inefficiencies considered to be moderate or severe. This classification was the gold standard to obtain a receiver operating characteristic (ROC) curve for the indicator.

RESULTS

The function explained 41% of the total variation for Internal Medicine and 70% for General Surgery. The indicator's mean difference between the two validation groups of histories was around 10 days for both departments. The areas under the ROC curve were 0.80 for Internal Medicine and 0.88 for General Surgery. Sensitivity and specificity > 0.7 for detecting inefficiencies of care are achieved with a cut off point of 2 days for Internal Medicine and 1 day for General Surgery.

CONCLUSIONS

The use of predictive equations might be quite useful for detecting efficiency problems in inpatient health care.

Interaction of translation initiation factor eIF4G with eIF4A in the yeast Saccharomyces cerevisiae

Eukaryotic initiation factor (eIF) 4A is an essential protein that, in conjunction with eIF4B, catalyzes the ATP-dependent melting of RNA secondary structure in the 5'-untranslated region of mRNA during translation initiation. In higher eukaryotes, eIF4A is assumed to be recruited to the mRNA through its interaction with eIF4G. However, the failure to detect this interaction in yeast brought into question the generality of this model. The work presented here demonstrates that yeast eIF4G interacts with eIF4A both in vivo and in vitro. The eIF4A-binding site was mapped to amino acids 542-883 of yeast eIF4G1. Expression in yeast cells of the eIF4G1 domain that binds eIF4A results in cell growth inhibition, and addition of this domain to an eIF4A-dependent in vitro system inhibits translation in a dose-dependent manner. Both in vitro translation and cell growth can be specifically restored by increasing the eIF4A concentration. These data demonstrate that yeast eIF4A and eIF4G interact and suggest that this interaction is required for translation and cell growth.

Plant ribosome shunting in vitro

It has been proposed that cauliflower mosaic virus 35S RNA with its 600 nt long leader uses an unusual translation process (the translational shunt). A wheat germ in vitro translation assay was used to improve the study of this mechanism. Deletions, the introduction of stable stem-loop structures, and the inhibitory effect of antisense oligonucleotides on gene expression were used to determine the roles of various parts of the leader. It was found that the 5'- and 3'-ends of the leader are absolutely required for translation whereas the middle part is apparently dispensable. These results confirm the data already reported from transient expression experiments with protoplasts. However, the in vitro data suggest in contrast to protoplast experiments that only two relatively short regions at both ends, approximately 100 nt each, are required. The in vitro system provides tools for further studying the shunt model at the molecular level and for examining the involvement of proteins in this mechanism. Shunting was also found to occur with the rice tungro bacilliform virus leader. As wheat is neither a host plant of cauliflower mosaic virus nor rice tungro bacilliform virus, the shunt seems to be host independent, a finding that deviates from earlier studies in protoplasts.

Assessing public health performance in Iowa's counties

Local health agencies in Iowa were surveyed to assess the performance of public health practices in their communities. Responses were received from 97 percent of counties. Less than 50 percent of counties were performing half of the indicators of the Assessment function. Policy Development functions also were frequently not performed. Performance was best in the Assurance function, with 86 percent of counties reporting that they inform and educate the public. However, the other three types of Assurance practices (Manage, Implement, and Evaluate) were performed less frequently. Comparison of the performance of Iowa's rural counties reveals a profile nearly identical to that reported elsewhere for a group of six other states.

Merging PICU and MICU: expanding nurse competencies

Unit mergers offer an opportunity for nurses to acquire additional skills. A model for unit mergers is presented. The authors describe how didactic and clinical competencies serve as a foundation upon which the nurse develops proficiency and expertise in a new subspecialty.

Progressive cardiomyopathic lentiginosis: report of six cases and one autopsy

Progressive cardiomyopathic lentiginosis (PCL) is a syndrome with progressive multisystem abnormalities. Lentigines, the cutaneous hallmark, are usually present from early age and are of utmost diagnostic value. Six children with PCL are reported. The most constant diagnostic features in this age group were multiple cutaneous lentigines, structural cardiac anomalies, and electrocardiographic alterations. Less constant findings were neurosensory deafness, short stature, and osseous, ocular, and genitourinary abnormalities.

Ring chromosome 6 in a child with minimal abnormalities

We describe a boy with a ring chromosome 6 and short stature, mild micrognathia, and bilateral transitional/simian creases. Five other patients with a ring 6 have been reported. The clinical and cytogenetic observations of all six patients are compared and discussed.