Aphid infestations reduce monarch butterfly colonization, herbivory, and growth on ornamental milkweed

Anthropogenic disturbance is driving global biodiversity loss, including the monarch butterfly (Danaus plexippus), a dietary specialist of milkweed. In response, ornamental milkweed plantings are increasingly common in urbanized landscapes, and recent evidence indicates they have conservation value for monarch butterflies. Unfortunately, sap-feeding insect herbivores, including the oleander aphid (Aphis nerii), frequently reach high densities on plants in nursery settings and urbanized landscapes. Aphid-infested milkweed may inhibit monarch conservation efforts by reducing host plant quality and inducing plant defenses. To test this, we evaluated the effects of oleander aphid infestation on monarch oviposition, larval performance, and plant traits using tropical milkweed (Asclepias curassavica), the most common commercially available milkweed species in the southern U.S. We quantified monarch oviposition preference, larval herbivory, larval weight, and plant characteristics on aphid-free and aphid-infested milkweed. Monarch butterflies deposited three times more eggs on aphid-free versus aphid-infested milkweed. Similarly, larvae fed aphid-free milkweed consumed and weighed twice as much as larvae fed aphid-infested milkweed. Aphid-free milkweed had higher total dry leaf biomass and nitrogen content than aphid-infested milkweed. Our results indicate that oleander aphid infestations can have indirect negative impacts on urban monarch conservation efforts and highlight the need for effective Lepidoptera-friendly integrated pest management tactics for ornamental plants.

Practice Facilitation Improves Adolescent Reproductive Health Preventive Services in Primary Care

OBJECTIVES

Provision of reproductive health preventive services to adolescents is critical given their high rates of sexually transmitted infections and unintended pregnancies. Pediatricians are well positioned to provide these services but often face barriers. With this project, we aimed to build quality improvement (QI) capacity within pediatric practices to improve adherence to national guidelines for adolescent reproductive health preventive services.

METHODS

In 2016, an accountable care organization overseeing health care delivery for low-income children in the Midwestern United States used practice facilitation, a proven approach to improve health care quality, to support pediatric practices in implementing reproductive health QI projects. Interested practices pursued projects aimed at providing (1) sexual risk reduction and contraceptive counseling (reproductive health assessments [RHAs]) or (2) etonogestrel implants. QI specialists helped practices build key driver diagrams and implement interventions. Outcome measures included the proportion of well-care visits with RHAs completed and number of etonogestrel insertions performed monthly.

RESULTS

Between November 1, 2016, and December 31, 2019, 6 practices serving >7000 adolescents pursued QI projects. Among practices focused on RHAs, the proportion of well-care visits with completed RHAs per month increased from 0% to 65.8% (P < .001) within 18 months. Among practices focused on etonogestrel implant insertions, overall insertions per month increased from 0 to 8.5 (P < .001).

CONCLUSIONS

Practice facilitation is an effective way to increase adherence to national guidelines for adolescent reproductive health preventive services within primary care practices. Success was driven by practice-specific customization of interventions and ongoing, hands-on support.

[Survey on tobacco use and associated factors in population in Shandong province, 2016-2017]

Objective: To understand the status of tobacco use and related influencing factors in population in Shandong province. Methods: Stratified multi-stage cluster sampling was used to select respondents from 216 villages (communities) of 36 districts (counties) in Shandong province. Influencing factors on smoking were analyzed by logistic regression model. Results: The adequate sample size was 6 271 participants. After complex weighted, the current smoking prevalence was 23.93%,45.58% in males and 1.18% in females. The Public's smoking rates varied widely among different groups in the population. 45-64 age group had the highest smoking rate (25.07%). Smoking rates were substantially different in education levels, with the highest in junior high school (28.94%). The rate was higher in the rural area (24.98%) than that in the urban areas (23.08%). The average daily smoking rate was 20.23%. The average age of initiating smoking was 21.21 years. The average daily cigarette intake was 16.31 cigarettes. Among all the former and current smokers, the quitting rate was 20.79%. Multiple logistic regression model analysis showed that gender, age, occupation, region, and health knowledge score were correlated with smoking behavior. The current smoking rate of men was much higher than that of women (OR=49.625, 95%CI: 37.832-65.093). The current smoking rate in 45-64 age group was higher than that in the 15-24 age group (OR=1.830, 95%CI: 1.048-3.194). The current smoking rate of medical (OR=0.403, 95%CI: 0.187-0.866) and retired personnel (OR=0.648, 95%CI: 0.481-0.873) were lower than those engaging in agriculture, forestry, animal husbandry and the fishery ,respectively. The prevalence of residents living in the central part showed lower rate on current smoking than that in the eastern region (OR=0.724, 95%CI: 0.606-0.865). The current smoking prevalence of smoke hazard in 1-3 score group was higher than that in the group with 4-6 score (OR=1.432, 95%CI: 1.240-1.654). Conclusions: Smoking rate in adults in Shandong remained stable and at a high level. Comprehensive intervention measures such as tobacco control and health education should be carried out to reduce the smoking rate.

Is there a role for REBOA? A system assessment

INTRODUCTION

To analyze our experience to quantify potential need for resuscitative endovascular balloon occlusion of the aorta (REBOA).

METHODS

Retrospective review of patients over a three-year period who presented as a trauma with hemorrhagic shock. Patients were divided into two groups: REBOA Candidate vs. Non-candidates. Injuries, outcomes, and interventions were compared.

RESULTS

Of 7643 trauma activations, only 37 (0.44%) fit inclusion criteria, of which 16 met criteria for candidacy for potential REBOA placement. The groups did not differ in terms of injury severity, physiology, age, timing of intervention, nor massive transfusion. Survival was linked to TRISS (p = 0.01) and Emergency Room Thoracotomy (p = 0.002). Of Candidates, 8 (50%) had injuries that could have benefited from REBOA, while 7 (44%) had injuries that could be associated with potential harm.

DISCUSSION

The volume of patients who would potentially benefit from REBOA appears to be small and does not appear to support system wide adoption in the studied region.

LEVEL OF EVIDENCE

IV.

Del Nido cardioplegia in coronary surgery: a propensity-matched analysis

OBJECTIVES

Del Nido cardioplegia (DNC) has been shown to be safe in adults with normal coronary arteries who are undergoing valve surgery. This study compared the effects of DNC versus traditional blood-based cardioplegia on postoperative complications in patients who underwent coronary artery bypass grafting (CABG).

METHODS

A retrospective analysis was performed on 863 patients who underwent CABG with DNC (n = 420) or control cardioplegia (CC) (n = 443) between 2014 and 2017. The full cohort of DNC and CC recipients, as well as propensity score-matched pairs, was compared regarding preoperative risk variables and outcomes.

RESULTS

The DNC and CC groups showed no significant differences in mean cardiopulmonary bypass time (53.09 vs 52.10 min, P = 0.206) or aortic cross-clamp time (32.82 vs 33.28 min, P = 0.967). The groups also showed no difference in operative mortality (2.1% vs 2.5%, P = 0.734); however, DNC use resulted in lower rates of overall infections (1.7% vs 4.3%, P = 0.024), total sternal infections (0.9% vs 3.2%, P = 0.023), postoperative atrial fibrillation (23.8% vs 30.7%, P = 0.023) and postoperative ventricular tachycardia (0.5% vs 3.4%, P = 0.002). A propensity-matching analysis (n = 335 pairs) showed similar statistically significant decreases with DNC.

CONCLUSIONS

In this large cohort of CABG patients, DNC was shown as a safe alternative to CC and was associated with lower postoperative dysrhythmia and infection rates. These findings show that DNC is safe and effective in patients whose operative interventions may require only single-dosing cardioplegia; its use in longer cases should be further explored given its low complication rate.

THU0596 ABNORMAL RIGHT VENTRICLE RESERVE ON EXERCISE PREDICTS PULMONARY HYPERTENSION IN MIXED CONNECTIVE TISSUE DISEASE: A CASE REPORT

Background:

Pulmonary hypertension is one of the most common complications in patients with mixed connective tissue disease (MCTD). Patients are usually at the late stage and have irreversible right heart dysfunction when diagnosed as pulmonary hypertension with the rest echocardiography. Early detection of right heart dysfunction before pulmonary hypertension is essential to ensure that patients receive timely and appropriate treatment for this progressive disease. We aimed to use exercise stress echocardiography to detect early right heart dysfunction in patients with CTD and without pulmonary hypertension.

Objectives:

To present a clinical case of MCTD with normal right ventricular (RV) function at resting but presenting RV dysfunction on exercise, who developed pulmonary hypertension after one-year follow-up.

Methods:

Case report. The patient was subject to the treadmill exercise stress echocardiography. The autoantibodies including anti-nRNP/Sm, anti-Ro-52, and antinuclear antibody (ANA) were detected. The patient was followed-up to one year.

Results:

A 31-year-old female patient was admitted to our department in 2018, with a history of MCTD for five years. Autoantibodies testing revealed that the patient was positive for anti-nRNP/Sm (+++), anti-Ro-52 (+++), and ANA (1:3200). Echocardiography revealed no obvious cardiac dysfunction. However, the velocity of tricuspid valve regurgitation was 3.0m/s following treadmill exercise stress. The patient was followed-up to one year. Then, she developed occult pulmonary hypertension with the velocity of tricuspid valve regurgitation of 3.3m/s following treadmill exercise stress. Accordingly, MTX and prednisone were switched to MTX, prednisone, hydroxychloroquine (HCQ) and beraprost.

Conclusion:

This study showed that treadmill exercise echocardiography could detect right heart dysfunction early before diagnosed as pulmonary hypertension with rest echocardiography in patients with MCTD in its early stage.

References:

[1]Aithala R, Alex AG, Danda D. Pulmonary hypertension in connective tissue diseases: an update. Int J Rheum Dis. 2017;20(1):5–24.

Disclosure of Interests:

None declared

Estrogen-related receptor participates in regulating glycolysis and influences embryonic development in silkworm Bombyx mori

Estrogen-related receptors (ERRs) play indispensable roles in development, energy metabolism, and cancers and are metabolic switches in Drosophila. However, the mechanism underlying their metabolic role is unknown in insects. This study analysed the expression profiles of Bombyx mori ERR (BmERR), hexokinase (BmHK), pyruvate kinase (BmPK) and phosphofructokinase (BmPFK) during embryonic development. The expression of BmERR tended to be similar to that of the other genes. We observed a regulatory association between BmERR and glycolytic rate-limiting enzymes by BmERR overexpression, RNA interference (RNAi), and ERR inhibitors in B. mori embryo cells. Subsequently, ERR cis-regulation elements (ERREs) were predicted and identified in the BmPFK promoter. Transfection assays, electrophoretic mobility shift assays and chromatin immunoprecipitation showed that BmERR can bind to one of these elements to regulate the expression of BmPFK. ERREs were also predicted in the BmHK and BmPK promoters. In the eggs, the expression of glycolytic rate-limiting enzyme genes was suppressed when the expression of BmERR was interference by double-stranded BmERR, the glucose levels also was increased. Meanwhile, the development of silkworm embryos was delayed by about 1 day. These results indicate that BmERR can bind to the ERREs of glycolytic gene promoters and regulate the expression of glycolytic genes, ultimately affecting embryonic development in silkworms.

Analysis of Characteristics and Relevant Factors of 1 340 Cases of Intentional Injury Cases in Southwest China

Abstract

Objective To investigate the characteristics and patterns of factors such as victims' information, injury tools and time of occurrence of intentional injury cases in southwest China. Methods One thousand three hundred and forty intentional injury cases from several places in southwest China from 2014 to 2016 assessed as minor injury level Ⅱ and above had been randomly selected. Data on victims' information, motives, injury tools, sites of occurrence, time of occurrence, injured parts and degrees of injury were classified and gathered, and then association analyses of motives and types of injury tools as well as degrees of injury and injury tools were made. Results Most of the victims were young adults between 20-50 years （65.2%）, male （82.3%）, rural household registration （62.8%）; the motives were mainly dispute （45.8%）. Injury tools were mostly blunt （54.6%） or sharp （36.0%）. Specifically, injuries were mostly made bare-handed （36.9%） and by cutting tools （33.2%）; the cases mainly occurred in public areas （59.0%）. Cases occurred more frequently in January （11.3%）, February （13.1%）, March （11.6%） and from 22：00 to 01：00 every night. Injuries mainly involved the craniofacial region. The wounds were mainly assessed as minor injury level Ⅱ （61.6%）. There was statistical significance in the difference of types of injury tools among cases with different motives （P<0.05）. There was statistical significance in the difference of the distribution of injury tools among cases with different degrees of injury （P<0.05）. Conclusion The occurrence of intentional injury cases in southwest China has potential patterns and relevant influencing factors. Prevention and analysis of such cases need to be comprehensively considered from the aspects such as victims' information, injury tools and time of occurrence.

An Interobserver Agreement Study with a New Classification for Rib Fractures

Background: No consensus exists about the indication for surgical rib fixation in patients with rib fractures. Comparison between studies is difficult since a classification system is lacking for rib fractures. We introduced the first classification system for rib fractures, analogue to the Muller AO classification system and tested the classification with an interobserver agreement study. Methods: The classification is build up by four characters: the first one describes the rib number, the second character describes the location of the fracture in cranial-caudal fashion, the third character describes the fracture type and the fourth character described the subtype of the fracture. An interobserver agreement study was performed with the new classification. Results: Twenty CT scans of patients with rib fractures were analyzed. A total of 197 unilateral and bilateral rib fractures were scored by four reviewers. The interobserver agreement was substantial [Fleiss of 0.62 (95% CI 0.59 0.65)]. Conclusion: This is the first classification for rib fractures worldwide. The interobserver agreement of the classification was substantial. This classification is the first step in identifying patients who would benefit from surgical rib fixation.

See one, do one, but never teach one? An analysis of resident teaching assist cases under various levels of attending supervision

BACKGROUND

Surgical training has traditionally relied on increasing levels of resident autonomy. We sought to analyze the outcomes of senior resident teaching assist (TA) cases performed with a structured policy including varying levels of staff supervision.

METHODS

Retrospective review at a military medical center of TA cases from 2009 to 2014. The level of staff supervision included staff scrubbed (SS), staff present and not scrubbed (SP), or staff not present but available (NP). Operative variables were analyzed. An anonymous survey of residents and attendings at 6 military programs regarding experience and opinions on TA cases was distributed.

RESULTS

389 TA cases were identified. The majority (52%) were performed as NP. Operative times were shorter for NP cases (p < 0.05). Overall complication rate and length of stay were not different between groups (p > 0.05). Survey results demonstrated agreement amongst staff and residents that allowing selective NP was critical for achieving resident competence.

CONCLUSION

There were no identified adverse effects on intraoperative or postoperative complications. This practice is a critical component of training senior residents to transition to independent practice.

Traumatic thoracic rib cage hernias: Operative management and proposal for a new anatomic-based grading system

BACKGROUND

Traumatic Rib Cage Hernias (TRCH) requiring operative repair are rare and there is currently no literature to guiding surgical management.

METHODS

Perioperative review of TRCH over 32 years. Five operative grades were developed based on extent of tissue/bone damage, size, and location.

RESULTS

Twenty-four patients (20 blunt, 4 penetrating) underwent operative repair. Lung was the herniated organ in 88% with a median of 4 rib fractures and average size of 60.25 cm. Types of operation were well clustered by assigned TRCH grade. The majority required mesh (75%) and/or rib plating (79%). Complex tissue flap reconstruction was required in 10%. Full range-of-motion was maintained in 88% with79% returning to pre-injury activity levels. Five patients had continued pain at final follow up (mean = 7months).

CONCLUSION

The size and degree of injury has important implications in the optimal surgical management of TRCHs. These operative grades effectively direct surgical care for these rare and complex injuries.

Digital Diabetes Congress 2017

The purpose of developing mobile applications for diabetes is generally to: (1) provide enhanced access to timely information for patients, health care professionals, and researchers; (2) facilitate remote monitoring and diagnosis of patients, often based on information delivered by wearable devices; (3) provide decision support to assist patients in selecting treatment; or (4) deliver timely recommendations for treatment to increase adherence to prescribed therapy. There is a perception that mobile applications can provide meaningful clinical benefits, however, there is only sparse convincing evidence to support this belief at the present time. Compounding this problem is the short life span of digital software, such that if a traditional type of randomized controlled trial is conducted on a product, by the time the study has been designed, approved by an IRB, conducted, and analyzed, the product might have significantly changed to a next generation system. Because of great interest in establishing what are the potential benefits, metrics of success, and appropriate components of mobile applications for diabetes, Diabetes Technology Society and William Sansum Diabetes Center launched the Digital Diabetes Congress, March 7-8, 2017, in San Francisco. This report contains summaries of the meeting's 12 sessions. Each summary was written by the session's moderator who helped develop the session prior to the event and keep it on track during the event. This meeting report presents a summary of how 57 panelists, speakers, and moderators, who are leaders in digital health, see the current and future landscape of digital health tools applied to diabetes.

Estimating Patient's Health State Using Latent Structure Inferred from Clinical Time Series and Text

Modern intensive care units (ICUs) collect large volumes of data in monitoring critically ill patients. Clinicians in the ICUs face the challenge of interpreting large volumes of high-dimensional data to diagnose and treat patients. In this work, we explore the use of Hierarchical Dirichlet Processes (HDP) as a Bayesian nonparametric framework to infer patients' states of health by combining multiple sources of data. In particular, we employ HDP to combine clinical time series and text from the nursing progress notes in a probabilistic topic modeling framework for patient risk stratification. Given a patient cohort, we use HDP to infer latent "topics" shared across multimodal patient data from the entire cohort. Each topic is modeled as a multinomial distribution over a vocabulary of codewords, defined over heterogeneous data sources. We evaluate the clinical utility of the learned topic structure using the first 24-hour ICU data from over 17,000 adult patients in the MIMIC-II database to estimate patients' risks of in-hospital mortality. Our results demonstrate that our approach provides a viable framework for combining different data modalities to model patient's states of health, and can potentially be used to generate alerts to identify patients at high risk of hospital mortality.

Phenotyping Hypotensive Patients in Critical Care Using Hospital Discharge Summaries

Among critically-ill patients, hypotension represents a failure in compensatory mechanisms and may lead to organ hypoperfusion and failure. In this work, we adopt a data-driven approach for phenotype discovery and visualization of patient similarity and cohort structure in the intensive care unit (ICU). We used Hierarchical Dirichlet Process (HDP) as a nonparametric topic modeling technique to automatically learn a d-dimensional feature representation of patients that captures the latent "topic" structure of diseases, symptoms, medications, and findings documented in hospital discharge summaries. We then used the t-Distributed Stochastic Neighbor Embedding (t-SNE) algorithm to convert the d-dimensional latent structure learned from HDP into a matrix of pairwise similarities for visualizing patient similarity and cohort structure. Using discharge summaries of a large patient cohort from the MIMIC II database, we evaluated the clinical utility of the discovered topic structure in phenotyping critically-ill patients who experienced hypotensive episodes. Our results indicate that the approach is able to reveal clinically interpretable clustering structure within our cohort and may potentially provide valuable insights to better understand the association between disease phenotypes and outcomes.

Latent topic discovery of clinical concepts from hospital discharge summaries of a heterogeneous patient cohort

Patients in critical care often exhibit complex disease patterns. A fundamental challenge in clinical research is to identify clinical features that may be characteristic of adverse patient outcomes. In this work, we propose a data-driven approach for phenotype discovery of patients in critical care. We used Hierarchical Dirichlet Process (HDP) as a non-parametric topic modeling technique to automatically discover the latent "topic" structure of diseases, symptoms, and findings documented in hospital discharge summaries. We show that the latent topic structure can be used to reveal phenotypic patterns of diseases and symptoms shared across subgroups of a patient cohort, and may contain prognostic value in stratifying patients' post hospital discharge mortality risks. Using discharge summaries of a large patient cohort from the MIMIC II database, we evaluate the clinical utility of the discovered topic structure in identifying patients who are at high risk of mortality within one year post hospital discharge. We demonstrate that the learned topic structure has statistically significant associations with mortality post hospital discharge, and may provide valuable insights in defining new feature sets for predicting patient outcomes.

Genome-Wide Profiles of Extra-cranial Malignant Rhabdoid Tumors Reveal Heterogeneity and Dysregulated Developmental Pathways

Malignant rhabdoid tumors (MRTs) are rare lethal tumors of childhood that most commonly occur in the kidney and brain. MRTs are driven by SMARCB1 loss, but the molecular consequences of SMARCB1 loss in extra-cranial tumors have not been comprehensively described and genomic resources for analyses of extra-cranial MRT are limited. To provide such data, we used whole-genome sequencing, whole-genome bisulfite sequencing, whole transcriptome (RNA-seq) and microRNA sequencing (miRNA-seq), and histone modification profiling to characterize extra-cranial MRTs. Our analyses revealed gene expression and methylation subgroups and focused on dysregulated pathways, including those involved in neural crest development.

Full Endoscopic Spinal Surgery Techniques: Advancements, Indications, and Outcomes

Advancements in both surgical instrumentation and full endoscopic spine techniques have resulted in positive clinical outcomes in the treatment of cervical, thoracic, and lumbar spine pathologies. Endoscopic techniques impart minimal approach related disruption of non-pathologic spinal anatomy and function while concurrently maximizing functional visualization and correction of pathological tissues. An advanced understanding of the applicable functional neuroanatomy, in particular the neuroforamen, is essential for successful outcomes. Additionally, an understanding of the varying types of disc prolapse pathology in relation to the neuroforamen will result in more optimal surgical outcomes. Indications for lumbar endoscopic spine surgery include disc herniations, spinal stenosis, infections, medial branch rhizotomy, and interbody fusion. Limitations are based on both non spine and spine related findings. A high riding iliac wing, a more posteriorly located retroperitoneal cavity, an overly distal or proximally migrated herniated disc are all relative contra-indications to lumbar endoscopic spinal surgery techniques. Modifications in scope size and visual field of view angulation have enabled both anterior and posterior cervical decompression. Endoscopic burrs, electrocautery, and focused laser technology allow for the least invasive spinal surgical techniques in all age groups and across varying body habitus. Complications include among others, dural tears, dysesthsia, nerve injury, and infection.

Association of maternal KIR and fetal HLA-C genes with the risk of preeclampsia in the Chinese Han population

INTRODUCTION

This study is to investigate the distribution of inhibitory and activating killer-cell immunoglobulin-like receptors (KIRs) and the combination of KIR/human leukocyte antigen (HLA)-C in women with preeclampsia in the Chinese Han population.

METHODS

A total of 271 patients and 295 controls were enrolled in our study. The inhibitory/activating KIR and HLA-C genes were detected using the PCR-SSP (polymerase chain reaction with sequence-specific primers) method.

RESULTS

Our result showed that decreased numbers of individual activating KIR genes (2DS2, 2DS3, and 2DS5) were observed in women with preeclampsia. Furthermore, the gene frequency of total activating KIRs was significantly lower in patients compared with that of the controls (P = 0.03). The frequency of the KIR2DL1 gene was increased in women with preeclampsia when a homozygous HLA-C2 allele appeared in the fetus.

CONCLUSION

The results suggest that a KIR genetic variation might influence the risk of preeclampsia. The lack of activating KIRs could possibly lower uterine natural killer (uNK) cell activation, thereby contributing to the pathogenesis of preeclampsia. Moreover, the imbalance of the inhibitory or activating signals at the maternal-fetal interface seems to play a regulatory role in the occurrence of preeclampsia.

Acute coagulopathy in a porcine venous hemorrhage and ischemia reperfusion model

BACKGROUND

Injury-related coagulopathy is a complex process. We analyzed coagulation in a swine model of shock using rotational thromboelastometry (ROTEM).

METHODS

Forty-eight swine underwent laparotomy, 35% hemorrhage, supraceliac aortic cross-clamp, then reperfusion and resuscitation. ROTEM measurements and standard labs were taken at baseline and 6 hours into resuscitation.

RESULTS

Clot formation time (98 vs 53 seconds, P = .001) and international normalized ratio (1.67 vs 1.01, P < .001) were prolonged after resuscitation. Maximum clot firmness (61 vs 72 mm, P < .001) and fibrinogen levels (94 vs 165, P < .001) declined significantly during resuscitation. Despite decreased fibrinogen levels, there was no significant increase in fibrinolysis as measured by maximum lysis (3.9% vs 3.8%, P = .99).

CONCLUSIONS

ROTEM demonstrated the development of an acute coagulopathy. The most significant impacts on coagulopathy were seen with clot initiation and fibrin polymerization. Clot strength decreased over time, although there was little impact on clot breakdown because of fibrinolysis.

Thorium(IV) removal from aqueous medium by citric acid treated mangrove endophytic fungus Fusarium sp. #ZZF51

Thorium(IV) biosorption is investigated by citric acid treated mangrove endophytic fungus Fussarium sp. #ZZF51 (CA-ZZF51) from South China Sea. The biosorption process was optimized at pH 4.5, equilibrium time 90 min, initial thorium(IV) concentration 50 mg L(-1) and adsorbent dose 0.6 g L(-1) with 90.87% of removal efficiency and 75.47 mg g(-1) of adsorption capacity, which is obviously greater than that (11.35 mg g(-1)) of the untreated fungus Fussarium sp. #ZZF51 for thorium(IV) biosorption under the condition of optimization. The experimental data are analyzed by using isotherm and kinetic models. Kinetic data follow the pseudo-second-order model and equilibrium data agree very well with the Langmuir model. In addition, FTIR analysis indicates that hydroxyl, amino, and carbonyl groups act as the important roles in the adsorption process.

Epidermal panfolliculoma: an adnexal proliferation with advanced follicular differentiation confined to the epidermis

Follicular differentiation can be exhibited by a variety of epidermal lesions. We report an example of panfolliculoma purely confined to the epidermis. The lesion presented as a verrucous plaque on the leg of a 55-year-old man. Histopathologic sections showed an acanthoma with follicular differentiation including areas mimicking the follicular germ, matrix, root sheath and infundibular components.

Risk stratification of ICU patients using topic models inferred from unstructured progress notes

We propose a novel approach for ICU patient risk stratification by combining the learned "topic" structure of clinical concepts (represented by UMLS codes) extracted from the unstructured nursing notes with physiologic data (from SAPS-I) for hospital mortality prediction. We used Hierarchical Dirichlet Processes (HDP), a non-parametric topic modeling technique, to automatically discover "topics" as shared groups of co-occurring UMLS clinical concepts. We evaluated the potential utility of the inferred topic structure in predicting hospital mortality using the nursing notes of 14,739 adult ICU patients (mortality 14.6%) from the MIMIC II database. Our results indicate that learned topic structure from the first 24-hour ICU nursing notes significantly improved the performance of the SAPS-I algorithm for hospital mortality prediction. The AUC for predicting hospital mortality from the first 24 hours of physiologic data and nursing text notes was 0.82. Using the physiologic data alone with the SAPS-I algorithm, an AUC of 0.72 was achieved. Thus, the clinical topics that were extracted and used to augment the SAPS-I algorithm significantly improved the performance of the baseline algorithm.

A decade of experience with a selective policy for direct to operating room trauma resuscitations

BACKGROUND

The standard paradigm for acutely injured patients involves evaluation in an emergency department (ED). Our center has employed a policy for bypassing the ED and proceeding directly to the operating room (OR) based on prehospital criteria.

METHODS

This is a retrospective analysis of all trauma patients admitted "direct to OR" (DOR) over 10 years. Demographics, injury patterns, prehospital, and in-hospital data were analyzed.

RESULTS

There were 1,407 patients admitted as DOR resuscitations. Almost half (47%) had a penetrating mechanism, and 54% had chest or abdominal injury. The mean Injury Severity Score was 19, with altered mentation (Glasgow coma score [GCS] <9) in 20% and hypotension in 16%. Most patients (68%) required surgical intervention, and 33% required emergency surgery operations (abdominal [70%] followed by thoracic [22%] and vascular [4%]). The median time to intervention was 13 minutes. Mortality was significantly lower than predicted (5% vs 10%). Independent predictors of emergent surgical intervention were a penetrating truncal injury (odds ratio = 9.9), GCS <9 (odds ratio = 1.9), and hypotension (odds ratio = 1.8).

DISCUSSION

Our DOR protocol identified a severely injured cohort at high risk for requiring surgery with improved observed survival. High-yield triage criteria for DOR admission include a penetrating truncal injury, hypotension, and a severely altered mental status.

Evaluation of intramedullary rib splints for less-invasive stabilisation of rib fractures

BACKGROUND

Intramedullary fixation of rib fractures with generic Kirschner wires has been practiced for over 50 years. However, this technique has not been advanced to address reported complications of wire migration and cut-out. This biomechanical study evaluated a novel rib splint designed to replicate the less-invasive fixation approach of Kirschner wires while mitigating their associated complications.

METHODS

The durability, strength, and failure mode of rib fracture fixation with intramedullary rib splints were evaluated in 27 cadaveric ribs. First, intact ribs were loaded to failure to determine their strength and to induce realistic rib fractures. Subsequently, fractures were stabilised with a novel rib splint made of titanium alloy with a rectangular cross-section that was secured with a locking screw. All fixation constructs were dynamically loaded to 360,000 cycles at five times the respiratory load magnitude to determine their durability. Finally, constructs were loaded to failure to determine their residual strength and failure modes.

RESULTS

Native ribs had a strength of 9.7+/-5.0 N m, with a range of 3.5-19.6 N m. Fracture fixation with rib splints was uneventful. All 27 splint constructs sustained dynamic loading without fixation failure, implant migration or implant cut-out. Dynamic loading caused no significant decrease in construct stiffness (p=0.85) and construct subsidence remained on average below 0.5 mm. The residual strength of splint constructs after dynamic loading was 1.1+/-0.24 N m. Constructs failed by splint bending in 44% of specimens and by developing fracture lines along the superior and inferior cortices in 56% of specimens. Regardless of the failure mode, all rib splint constructs recoiled elastically after failure and retained functional reduction and fixation. No construct exhibited implant cut-out or migration through the lateral cortex.

CONCLUSIONS

Rib splints can provide sufficient stability to support respiratory loading throughout the healing phase, but they cannot restore the full strength of native ribs. Most importantly, rib splints mitigated the complications reported for rib fracture fixation with generic Kirschner wires, namely implant cut-out and migration through the lateral cortex. Therefore, rib splints may provide an advanced alternative to the original Kirschner wire technique for less-invasive fixation of rib fractures.

Current management of traumatic rupture of the descending thoracic aorta

Traumatic rupture of the descending thoracic aorta remains a leading cause of death following major blunt trauma. Management has evolved from uniformly performing emergent open repair with clamp and sew technique to include open repair with mechanical circulatory support, medical management and most recently, endovascular repair. This latter approach appears, in the short term, to be associated with perhaps better outcome, but long term data is still accruing. While an attractive option, there are specific anatomic and physiologic factors to be considered in each individual case.

Metastatic melanoma causing jejunal intussusception

The gastrointestinal (GI) tract is a common site of melanoma metastases although reports of small bowel intussusception are relatively rare. Most patients with intussusception will be symptomatic and resection will provide significant palliation. In rare instances, patients will have solitary metastases to the small intestine, and resection can provide long-term palliation and chance for cure. We describe a case of a patient with a widely metastatic melanoma who presented with crampy abdominal pain and CT findings of small bowel metastases. Exploration revealed jejunojejunal intussusception and resection provided excellent palliation.

Lessons extracting diseases from discharge summaries

We developed a program to extract diseases and procedures from discharge summaries and have applied this program to 96 cases annotated by physicians. We compared the concepts extracted by the program to those extracted by the annotators. The program extracts 93% of the desired concepts including some more specific than the annotators. Concepts were missed because phrases were ambiguous, phrases were missing words or were separated, or deduction was needed, among other reasons. The false positives were either insignificant findings, ambiguous phrases, or did not apply to the patient now. The analysis shows that extraction of medical concepts from discharge summaries with limited natural language processing and no domain inference is effective with still more potential.

The safety and efficacy of infliximab in moderate to severe chronic obstructive pulmonary disease

RATIONALE

Chronic obstructive pulmonary disease (COPD) is a progressive, smoking-related, inflammatory lung disease in which tumor necrosis factor-alpha is overexpressed and has been suggested to play a pathogenic role.

OBJECTIVES

To determine if infliximab, an anti-TNF-alpha antibody, results in clinical benefit and has an acceptable safety profile in patients with moderate to severe COPD.

METHODS

In a multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-finding study, subjects with moderate to severe COPD received infliximab (3 mg/kg [n = 78] or 5 mg/kg [n = 79]) or placebo (n = 77) at Weeks 0, 2, 6, 12, 18, and 24. Efficacy, health status, and safety were assessed through Week 44.

MEASUREMENTS AND MAIN RESULTS

Infliximab was generally well tolerated, but showed no treatment benefit as measured by the primary endpoint, Chronic Respiratory Questionnaire total score. Similarly, there was no change in secondary measures, including prebronchodilator FEV(1), 6-min walk distance, SF-36 physical score, transition dyspnea index, or moderate-to-severe COPD exacerbations. Post hoc analysis revealed that subjects who were younger or cachectic showed improvement in the 6-min walk distance. Malignancies were diagnosed during the study in 9 of 157 infliximab-treated subjects versus 1 of 77 placebo-treated subjects. No opportunistic infections were observed, and there were no differences in the occurrence of antibiotic-requiring infections, although the incidence of pneumonia was higher in infliximab-treated subjects. No infection-related mortality was observed. Higher proportions of infliximab-treated subjects discontinued the study agent due to adverse events (20-27%) than did placebo-treated subjects (9%).

CONCLUSIONS

Subjects with moderate to severe COPD did not benefit from treatment with infliximab. Although not statistically significant, more cases of cancer and pneumonia were observed in the infliximab-treated subjects. The impact of infliximab on malignancy risk in patients with COPD needs to be further elucidated.

Determining the microbiological criteria for lot rejection from the performance objective or food safety objective

The Microbiological Criteria (MC) is a set of parameters used to determine whether a specific lot of food is acceptable or not. These parameters are the microbial test protocol and its sensitivity, the confidence level that an unacceptable lot will be detected, the number of samples to be taken and the number of positive samples that are allowed before rejecting the lot. Determining the microbiological criteria begins with knowledge of the distribution of contamination from samples within a lot, particularly within a lot that is just at the unacceptable level of the microbial hazard. The just unacceptable lot can be defined by the Food Safety Objective (FSO) or Performance Objectives (PO), the small fraction of samples that can exceed these values and the standard deviation of the samples from the lot. With this information, a microbial test protocol is chosen to have a sensitivity level that would detect between approximately 15% and 45% of the samples. A confidence level for the MC and the number of positive samples that would be acceptable (c value which is usually zero) are also chosen. With this information the number of samples (n) required can be calculated. A critical factor in setting the microbiological criteria is the sensitivity of the microbiological test (m value). The sample size (weight) and sampling procedure can affect the standard deviation of the samples, particularly foods with non-homogeneous distribution and low numbers of microorganisms. Sampling, sample preparation and analytical procedures that reduce the variation between the samples will affect the choice of m value and maximum lot mean that meets the MC.

Discordance between lactate and base deficit in the surgical intensive care unit: which one do you trust?

PURPOSE

Both lactate and base deficit (BD) are used as predictors of injury severity and mortality. We examined the significance of these measures when used in combination, and particularly when they provide conflicting data.

METHODS

We reviewed all intensive care unit patients with simultaneously obtained lactate and BD measurements. The ability to predict mortality and hospital stay was compared alone, in combination, and when there was disagreement between the measures. Receiver operating characteristic curves were generated to compare predictive abilities.

RESULTS

There were 1,298 patients with 12,197 sets of paired laboratory data; 1,026 trauma patients and 272 surgical patients. Lactic acidosis was present in 41% and a significant BD level (> 2) was found in 52%. Nonsurvivors had higher admission lactate (6.2 vs. 3.3) and base deficit (6.1 vs. 3.2) levels than survivors (both P < .01), with a modest correlation (r = .52) between the measures. The admission lactate and BD levels had similar predictive ability for mortality, with areas under the receiver operating characteristic curve of .7 and .66, respectively (both P < .01). However, the predictive ability of the BD level decreased significantly during the intensive care unit stay (area, .5) compared with lactate level (area, .68). Lactate and BD levels disagreed in 44% of all laboratory sets. In patients with a normal lactate level (< 2.2), the BD level had no predictive ability for mortality (area, .48; P = .26). However, in patients with a normal BD level (< 2.0), the lactate level retained its predictive ability for mortality (area, .67; P < .01). Lengths of stay were longer among patients with an increased lactate level, even when the BD level was normal. There was no improvement in predictive ability using a combination of the 2 measures.

CONCLUSIONS

Both lactate and BD levels may be used to identify lactic acidosis and predict mortality at admission. Increased lactate levels predict mortality and a prolonged course regardless of the associated BD level, whereas an increased BD level has no predictive value if the lactate level is normal.