Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study

Abstract: To determine the validity of the Australian clinical prediction tool Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL) based on objective clinical criteria to accurately identify risk of death within 3 months of admission among older patients. Methods: Prospective study of ≥ 65 year-olds presenting at emergency departments in five Australian (Aus) and four Danish (DK) hospitals. Logistic regression analysis was used to model factors for death prediction; Sensitivity, specificity, area under the ROC curve and calibration with bootstrapping techniques were used to describe predictive accuracy. Results: 2493 patients, with median age 78–80 years (DK–Aus). The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% CI 7.7–8.6 vs. 5.8 95% CI 5.6–5.9) and Danish mean 7.1 (95% CI 6.6–7.5 vs. 5.5 95% CI 5.4–5.6). The model with Fried Frailty score was optimal for the Australian cohort but prediction with the Clinical Frailty Scale (CFS) was also good (AUROC 0.825 and 0.81, respectively). Values for the Danish cohort were AUROC 0.764 with Fried and 0.794 using CFS. The most significant independent predictors of short-term death in both cohorts were advanced malignancy, frailty, male gender and advanced age. CriSTAL’s accuracy was only modest for in-hospital death prediction in either setting. Conclusions: The modified CriSTAL tool (with CFS instead of Fried’s frailty instrument) has good discriminant power to improve prognostic certainty of short-term mortality for ED physicians in both health systems. This shows promise in enhancing clinician’s confidence in initiating earlier end-of-life discussions.</p

Epidemiology, prehospital care and outcomes of patients arriving by ambulance with dyspnoea: An observational study

Background: This study aimed to determine epidemiology and outcome for patients presenting to emergency departments (ED) with shortness of breath who were transported by ambulance. Methods: This was a planned sub-study of a prospective, interrupted time series cohort study conducted at three time points in 2014 and which included consecutive adult patients presenting to the ED with dyspnoea as a main symptom. For this sub-study, additional inclusion criteria were presentation to an ED in Australia or New Zealand and transport by ambulance. The primary outcomes of interest are the epidemiology and outcome of these patients. Analysis was by descriptive statistics and comparisons of proportions. Results: One thousand seven patients met inclusion criteria. Median age was 74 years (IQR 61-68) and 46.1 % were male. There was a high rate of co-morbidity and chronic medication use. The most common ED diagnoses were lower respiratory tract infection (including pneumonia, 22.7 %), cardiac failure (20.5%) and exacerbation of chronic obstructive pulmonary disease (19.7 %). ED disposition was hospital admission (including ICU) for 76.4 %, ICU admission for 5.6 % and death in ED in 0.9 %. Overall in-hospital mortality among admitted patients was 6.5 %. Discussion: Patients transported by ambulance with shortness of breath make up a significant proportion of ambulance caseload and have high comorbidity and high hospital admission rate. In this study, >60 % were accounted for by patients with heart failure, lower respiratory tract infection or COPD, but there were a wide range of diagnoses. This has implications for service planning, models of care and paramedic training. Conclusion: This study shows that patients transported to hospital by ambulance with shortness of breath are a complex and seriously ill group with a broad range of diagnoses. Understanding the characteristics of these patients, the range of diagnoses and their outcome can help inform training and planning of services

Evaluación del riesgo de inundación a múltiples componentes en la costa del Maresme

The coast is one of the areas most affected by natural hazards, with floods being the most frequent and significant of these in terms of their induced impacts, so any management scheme requires their evaluation. In coastal areas, flooding is a hazard associated with different processes acting at different scales: coastal storms, flash floods and sea level rise (SLR). To address the problem as a whole, this study presents a methodology to undertake a preliminary integrated risk assessment of the magnitude of each flood component, taking into account their scope (extension of the affected area) and their temporal scale. The risk is quantified using specific indicators to assess the hazard magnitude (for each component) and the consequences. This allows for a robust comparison of the spatial risk distribution along the coast in order to identify both the most at-risk areas and the most influential risk components. This methodology is applied to a stretch of coastline (Maresme, Catalonia) representative of the Spanish Mediterranean coast. The results obtained characterise this coastline as an area with a relatively low overall risk, although some hotspots are identified as having high-risk values. Resumen: La costa es una de las zonas más sometidas a riesgos naturales, siendo la inundación uno de los más frecuentes e importantes en términos de daños inducidos, por lo que cualquier esquema de gestión requiere evaluación. La inundación en zonas costeras es una amenaza natural asociada a diferentes procesos que actúan a distintas escalas: tormentas costeras, riadas y subida del nivel del mar (SNM). Para abarcar la totalidad del problema, este trabajo propone una metodología para la evaluación preliminar del riesgo integrado de inundación costera a una escala regional que permite evaluar la magnitud de cada componente teniendo en cuenta su alcance (extensión de la zona afectada) y su escala temporal. El riesgo se cuantifica en función de unos indicadores específicos que valoran la magnitud de la amenaza para cada componente y las consecuencias. Esto permite comparar robustamente la distribución espacial del riesgo a lo largo de la costa, para identificar tanto zonas de mayor riesgo como las componentes que más contribuyen al mismo. Aplicamos esta metodología a un tramo de costa característica del Mediterráneo español (Maresme, Cataluña). Los resultados permiten caracterizar esta costa como un área con un riesgo global relativamente bajo, pero algunos puntos singulares con riesgo alto

The comparative osmoregulatory ability of two water beetle genera whose species span the fresh-hypersaline gradient in inland waters (Coleoptera: Dytiscidae, Hydrophilidae).

A better knowledge of the physiological basis of salinity tolerance is essential to understanding the ecology and evolutionary history of organisms that have colonized inland saline waters. Coleoptera are amongst the most diverse macroinvertebrates in inland waters, including saline habitats; however, the osmoregulatory strategies they employ to deal with osmotic stress remain unexplored. Survival and haemolymph osmotic concentration at different salinities were examined in adults of eight aquatic beetle species which inhabit different parts of the fresh-hypersaline gradient. Studied species belong to two unrelated genera which have invaded saline waters independently from freshwater ancestors; Nebrioporus (Dytiscidae) and Enochrus (Hydrophilidae). Their osmoregulatory strategy (osmoconformity or osmoregulation) was identified and osmotic capacity (the osmotic gradient between the animal's haemolymph and the external medium) was compared between species pairs co-habiting similar salinities in nature. We show that osmoregulatory capacity, rather than osmoconformity, has evolved independently in these different lineages. All species hyperegulated their haemolymph osmotic concentration in diluted waters; those living in fresh or low-salinity waters were unable to hyporegulate and survive in hyperosmotic media (> 340 mosmol kg(-1)). In contrast, the species which inhabit the hypo-hypersaline habitats were effective hyporegulators, maintaining their haemolymph osmolality within narrow limits (ca. 300 mosmol kg(-1)) across a wide range of external concentrations. The hypersaline species N. ceresyi and E. jesusarribasi tolerated conductivities up to 140 and 180 mS cm(-1), respectively, and maintained osmotic gradients over 3500 mosmol kg(-1), comparable to those of the most effective insect osmoregulators known to date. Syntopic species of both genera showed similar osmotic capacities and in general, osmotic responses correlated well with upper salinity levels occupied by individual species in nature. Therefore, osmoregulatory capacity may mediate habitat segregation amongst congeners across the salinity gradient

A multi-component flood risk assessment in the Maresme coast (NW Mediterranean)

Coastal regions are the areas most threatened by natural hazards, with floods being the most frequent and significant threat in terms of their induced impacts, and therefore, any management scheme requires their evaluation. In coastal areas, flooding is a hazard associated with various processes acting at different scales: coastal storms, flash floods, and sea level rise (SLR). In order to address the problem as a whole, this study presents a methodology to undertake a preliminary integrated risk assessment that determines the magnitude of the different flood processes (flash flood, marine storm, SLR) and their associated consequences, taking into account their temporal and spatial scales. The risk is quantified using specific indicators to assess the magnitude of the hazard (for each component) and the consequences in a common scale. This allows for a robust comparison of the spatial risk distribution along the coast in order to identify both the areas at greatest risk and the risk components that have the greatest impact. This methodology is applied on the Maresme coast (NW Mediterranean, Spain), which can be considered representative of developed areas of the Spanish Mediterranean coast. The results obtained characterise this coastline as an area of relatively low overall risk, although some hot spots have been identified with high-risk values, with flash flooding being the principal risk process

Exploring the Trypanosoma brucei Hsp83 Potential as a Target for Structure Guided Drug Design

Human African trypanosomiasis is a neglected parasitic disease that is fatal if untreated. The current drugs available to eliminate the causative agent Trypanosoma brucei have multiple liabilities, including toxicity, increasing problems due to treatment failure and limited efficacy. There are two approaches to discover novel antimicrobial drugs--whole-cell screening and target-based discovery. In the latter case, there is a need to identify and validate novel drug targets in Trypanosoma parasites. The heat shock proteins (Hsp), while best known as cancer targets with a number of drug candidates in clinical development, are a family of emerging targets for infectious diseases. In this paper, we report the exploration of T. brucei Hsp83--a homolog of human Hsp90--as a drug target using multiple biophysical and biochemical techniques. Our approach included the characterization of the chemical sensitivity of the parasitic chaperone against a library of known Hsp90 inhibitors by means of differential scanning fluorimetry (DSF). Several compounds identified by this screening procedure were further studied using isothermal titration calorimetry (ITC) and X-ray crystallography, as well as tested in parasite growth inhibitions assays. These experiments led us to the identification of a benzamide derivative compound capable of interacting with TbHsp83 more strongly than with its human homologs and structural rationalization of this selectivity. The results highlight the opportunities created by subtle structural differences to develop new series of compounds to selectively target the Trypanosoma brucei chaperone and effectively kill the sleeping sickness parasite

Asthma among adult patients presenting with dyspnea to the emergency department: An observational study

Introduction: Shortness of breath is a common presenting symptom to the emergency department (ED) that can arise from a myriad of possible diagnoses. Asthma is one of the major causes. Objective: The aim of this study was to describe the demographic features, clinical characteristics, management and outcomes of adults with an ED diagnosis of asthma who presented to an ED in the Asia Pacific region with a principal symptom of dyspnea. Methods: Planned sub‐study of patients with an ED diagnosis of asthma identified in the Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study. AANZDEM was a prospective cohort study conducted in 46 EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia over three 72 hour periods in May, August and October 2014. Primary outcomes were patient epidemiology, clinical features, treatment and outcomes (hospital length of stay (LOS) and mortality). Results: Of the 3044 patients with dyspnea, 387 (12.7%) patients had an ED diagnosis of asthma. The median age was 45 years, 60.1% were female, 16.1% were active or recent smokers and 30.4% arrived by ambulance. Inhaled bronchodilator therapy was initiated in 88.1% of patients, and 66.9% received both inhaled bronchodilators and systemic corticosteroids. After treatment in the ED, 65.4% were discharged. No death was reported. Conclusion: Asthma is common among patients presenting with a principal symptom of dyspnea in the ED of the Asia Pacific region. There was a suboptimal adherence to international guidelines on investigations and treatments of acute asthma exacerbations presenting an opportunity to improve the efficiency of care.Full Tex

Evidence of strong small-scale population structure in the Antarctic freshwater copepod Boeckella poppei in lakes on Signy Island, South Orkney Islands

Environmental conditions were particularly severe during the Last Glacial Maximum, altering the distribution of the Southern Hemisphere biota, particularly at higher latitudes. The copepod Boeckella poppei is the only macroscopic continental invertebrate species known to be distributed today across the three main biogeographic regions in Antarctica as well as in southern South America. Signy Island (South Orkney Islands) is a unique location for the study of Antarctic freshwater ecosystems due to its location and geographic isolation; it contains 17 lakes in several low altitude catchments. We conducted phylogeographic and demographic analyses using the cox1 gene on 84 individuals of B. poppei from seven lakes across Signy Island. We recorded low levels of genetic diversity and a strong genetic differentiation signal between the eastern and western valleys within the island. Phylogeographic structure and demographic inference analyses suggested at least one asymmetrical dispersal event from west to east. Demographic inference detected a strong signal of population growth during the deglaciation process, which may have followed either (1) a strong genetic bottleneck due to a reduction in population size during the last glacial period, or (2) a founder effect associated with postglacial recolonization of Signy Island from elsewhere. The genetic architecture of this island's populations of B. poppei shows that historical events, rather than continuous dispersal events, likely played a major role in the species' current distribution. Finally, our study considers possible mechanisms for dispersal and colonization success of the most dominant species in the Antarctic freshwater community