Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study

Abstract Introduction The outcomes of patients ventilated for longer than average are unclear, in part because of the lack of an accepted definition of prolonged mechanical ventilation (PMV). To better understand the implications of PMV provision, we compared one-year health outcomes between two common definitions of PMV as well as between PMV patients and those ventilated for shorter periods of time. Methods We conducted a secondary analysis of prospectively collected data from medical and surgical intensive care units at an academic tertiary care medical center. The study included 817 critically ill patients ventilated for ≥ 48 hours, 267 (33%) of whom received PMV based on receipt of a tracheostomy and ventilation for ≥ 96 hours. A total of 114 (14%) patients met the alternate definition of PMV by being ventilated for ≥ 21 days. Survival, functional status, and costs were measured at baseline and at 2, 6, and 12 months after discharge. Of one-year survivors, 71 (17%) were lost to follow up. Results PMV patients ventilated for ≥ 21 days had greater costs ($140,409 versus$143,389) and higher one-year mortality (58% versus 48%) than did PMV patients with tracheostomies who were ventilated for ≥ 96 hours. The majority of PMV deaths (58%) occurred after hospital discharge whereas 67% of PMV patients aged 65 years or older had died by one year. At one year PMV patients on average had limitations in two basic and five instrumental elements of functional status that exceeded both their pre-admission status and the one-year disability of those ventilated for < 96 hours. Costs per one-year survivor were $423,596,$266,105, and $165,075 for patients ventilated ≥ 21 days, ≥ 96 hours with a tracheostomy, and < 96 hours, respectively. Conclusion Contrasting definitions of PMV capture significantly different patient populations, with ≥ 21 days of ventilation specifying the most resource-intensive recipients of critical care. PMV patients, particularly the elderly, suffer from a significant burden of costly, chronic critical illness and are at high risk for death throughout the first year after intensive care

LPS Responsiveness and Neutrophil Chemotaxis In Vivo Require PMN MMP-8 Activity

We identify matrix metalloproteinase (MMP)-8, the polymorphonuclear (PMN) leukocyte collagenase, as a critical mediator initiating lipopolysaccharide (LPS)-responsiveness in vivo. PMN infiltration towards LPS is abrogated in Mmp8-null mice. MMP-8 cleaves LPS-induced CXC chemokine (LIX) at Ser(4)∼Val(5) and Lys(79)∼Arg(80). LIX bioactivity is increased upon N-terminal cleavage, enhancing intracellular calcium mobilization and chemotaxis upon binding its cognate receptor, CXCR2. As there is no difference in PMN chemotaxis in Mmp8-null mice compared with wild-type mice towards synthetic analogues of MMP-8-cleaved LIX, MMP-8 is not essential for extravasation or cell migration in collagenous matrices in vivo. However, with biochemical redundancy between MMPs 1, 2, 9, and 13, which also cleave LIX at position 4∼5, it was surprising to observe such a markedly reduced PMN infiltration towards LPS and LIX in Mmp8-/- mice. This lack of physiological redundancy in vivo identifies MMP-8 as a key mediator in the regulation of innate immunity. Comparable results were found with CXCL8/IL-8 and CXCL5/ENA-78, the human orthologues of LIX. MMP-8 cleaves CXCL8 at Arg(5)-Ser(6) and at Val(7)-Leu(8) in CXCL5 to activate respective chemokines. Hence, rather than collagen, these PMN chemoattractants are important MMP-8 substrates in vivo; PMN-derived MMP-8 cleaves and activates LIX to execute an in cis PMN-controlled feed-forward mechanism to orchestrate the initial inflammatory response and promote LPS responsiveness in tissue

Rapid, energy-efficient synthesis of the layered carbide, Al₄C₃

The phase-pure binary aluminium carbide, Al4C3 can be synthesised in vacuo from the elements in 30 minutes via microwave heating in a multimode cavity reactor. The success of the reaction is dependent on the use of finely divided aluminium and graphite starting materials, both of which couple effectively to the microwave field. The yellow-brown powder product was characterised by powder X-ray diffraction, scanning electron microscopy/energy dispersive X-ray spectroscopy thermogravimetric-differential thermal analysis and Raman spectroscopy. Powders were composed of hexagonal single crystallites tens of microns in diameter (rhombohedral space group R[3 with combining macron]m; Z = 3; a = 3.33813(5) Å, c = 25.0021(4) Å) and were stable to 1000 °C in air, argon and nitrogen. Equivalent microwave reactions of the elements in air led to the formation of the oxycarbide phases Al2OC and Al4O4C

Effects of administration of a growth promoting implant during the suckling phase or at weaning on growth, reproduction, and ovarian development in replacement heifers grazing native range

Management strategies utilized during pre-breeding development of replacement heifers can impact fertility and the ovarian reserve. Angus- Hereford crossbred heifers (n = 233) were utilized over a 3-yr period to determine the effects of administration of a growth promoting implant at either branding or weaning on growth, reproduction, and ovarian development. Heifer calves were randomly assigned to one of three treatments: 1) nonimplanted controls (CON; n = 79), 2) implanted at approximately 2 mo of age (average calf age = 58 d) with Synovex-C (BIMP, n = 82), or 3) implanted at approximately 7 mo of age (average calf age = 210 d) with Synovex-C (WIMP; n = 72). In years 2 and 3, a subset of heifers (year 2 n = 16; year 3 n = 14) were unilaterally ovariectomized. Heifers implanted at 2 mo of age were heavier at weaning, yearling (mid-February; average calf age = 332 d), and at the beginning of the breeding season (P \u3c 0.01) compared to CON and WIMP heifers. Average daily gain (ADG) was similar among treatments from weaning to yearling and weaning to the start of the breeding season (P ≥ 0.61); however, WIMP heifers had increased (P = 0.05) ADG from yearling to the start of the breeding season compared to BIMP heifers. Antral follicle count and reproductive tract scores were not influenced by implant treatment (P ≥ 0.18). Response to synchronization of estrus was increased (P = 0.02) in WIMP compared to CON heifers, with BIMP heifers similar to all other treatments. First service conception rates tended to be increased (P = 0.09) in CON heifers compared to WIMP heifers, with BIMP heifers similar to CON and WIMP. Final pregnancy rates were similar (P = 0.54) among treatments. A treatment × yr interaction was detected (P = 0.01) for the number of primordial follicles/section with increased primordial follicles in WIMP heifers in year 3 compared to BIMP and WIMP heifers in year 2 and CON heifers in year 3, as well as in BIMP compared to WIMP heifers in year 2. Utilization of growth promoting implants did not negatively impact postweaning reproductive development or compromise pregnancy rates in beef heifers. Based on these results, administration of a growth promoting Synovex-C implant at 2 mo of age may allow for increased body weight at weaning, without hindering reproductive performance

A He3 driven instability near the fully convective boundary

We report on the discovery of an instability in low mass stars just above the threshold ($\sim 0.35 \textrm{M}_{\odot}$) where they are expected to be fully convective on the main sequence. Non-equilibrium He3 burning creates a convective core, which is separated from a deep convective envelope by a small radiative zone. The steady increase in central He3 causes the core to grow until it touches the surface convection zone, which triggers fully convective episodes in what we call the "convective kissing instability". These episodes lower the central abundance and cause the star to return to a state in which is has a separate convective core and envelope. These periodic events eventually cease when the He3 abundance throughout the star is sufficiently high that the star is fully convective, and remains so for the rest of its main sequence lifetime. The episodes correspond to few percent changes in radius and luminosity, over Myr to Gyr timescales. We discuss the physics of the instability, as well as prospects for detecting its signatures in open clusters and wide binaries. Secondary stars in cataclysmic variables (CVs) will pass through this mass range, and this instability could be related to the observed paucity of such systems for periods between two and three hours. We demonstrate that the instability can be generated for CV secondaries with mass-loss rates of interest for such systems, and discuss potential implications.Comment: 6 pages, 3 figures. Submitted to ApJ. For a brief video explaining the key result of this paper, see http://www.youtube.com/user/OSUAstronom

Molecular Characterization Reveals Diverse and Unknown Malaria Vectors in the Western Kenyan Highlands.

The success of mosquito-based malaria control is dependent upon susceptible bionomic traits in local malaria vectors. It is crucial to have accurate and reliable methods to determine mosquito species composition in areas subject to malaria. An unexpectedly diverse set of Anopheles species was collected in the western Kenyan highlands, including unidentified and potentially new species carrying the malaria parasite Plasmodium falciparum. This study identified 2,340 anopheline specimens using both ribosomal DNA internal transcribed spacer region 2 and mitochondrial DNA cytochrome oxidase subunit 1 loci. Seventeen distinct sequence groups were identified. Of these, only eight could be molecularly identified through comparison to published and voucher sequences. Of the unidentified species, four were found to carry P. falciparum by circumsporozoite enzyme-linked immunosorbent assay and polymerase chain reaction, the most abundant of which had infection rates comparable to a primary vector in the area, Anopheles funestus. High-quality adult specimens of these unidentified species could not be matched to museum voucher specimens or conclusively identified using multiple keys, suggesting that they may have not been previously described. These unidentified vectors were captured outdoors. Diverse and unknown species have been incriminated in malaria transmission in the western Kenya highlands using molecular identification of unusual morphological variants of field specimens. This study demonstrates the value of using molecular methods to compliment vector identifications and highlights the need for accurate characterization of mosquito species and their associated behaviors for effective malaria control

A previously undescribed Helotialean fungus that is superabundant in soil under maritime Antarctic higher plants

We report a previously undescribed member of the Helotiales that is superabundant in soils at two maritime Antarctic islands under Antarctic Hairgrass (Deschampsia antarctica Desv.). High throughput sequencing showed that up to 92% of DNA reads, and 68% of RNA reads, in soils from the islands were accounted for by the fungus. Sequencing of the large subunit region of ribosomal (r)DNA places the fungus close to the Pezizellaceae, Porodiplodiaceae, and Sclerotiniaceae, with analyses of internal transcribed spacer regions of rDNA indicating that it has affinities to previously unnamed soil and root fungi from alpine, cool temperate and Low Arctic regions. The fungus was found to be most frequent in soils containing C aged to 1,000–1,200 years before present. The relative abundances of its DNA and RNA reads were positively associated with soil carbon and nitrogen concentrations and δ13C values, with the relative abundance of its DNA being negatively associated with soil pH value. An isolate of the fungus produces flask-shaped phialides with a pronounced venter bearing masses of conidia measuring 4.5–6(7) × 1.8–2.5 μm, suggestive of anamorphic Chalara. Enzymatic studies indicate that the isolate strongly synthesizes the extracellular enzyme acid phosphatase, and also exhibits alkaline phosphatase and naphthol-AS-BI-phosphohydrolase activities. Ecophysiological measurements indicate optimal hyphal growth of the isolate at a pH of 4.2–4.5 and a water potential of −0.66 MPa. The isolate is a psychrotroph, exhibiting measureable hyphal growth at −2°C, optimal hyphal extension rate at 15°C and negligible growth at 25°C. It is proposed that the rising temperatures that are predicted to occur in maritime Antarctica later this century will increase the growth rate of the fungus, with the potential loss of ancient C from soils. Analyses using the GlobalFungi Database indicate that the fungus is present in cold, acidic soils on all continents. We advocate further studies to identify whether it is superabundant in soils under D. antarctica elsewhere in maritime Antarctica, and for further isolates to be obtained so that the species can be formally describe

The reductive activation of CO2 across a Ti═Ti double bond: synthetic, structural, and mechanistic studies

[Image: see text] The reactivity of the bis(pentalene)dititanium double-sandwich compound Ti(2)Pn(†)(2) (1) (Pn(†) = 1,4-{Si(i)Pr(3)}(2)C(8)H(4)) with CO(2) is investigated in detail using spectroscopic, X-ray crystallographic, and computational studies. When the CO(2) reaction is performed at −78 °C, the 1:1 adduct 4 is formed, and low-temperature spectroscopic measurements are consistent with a CO(2) molecule bound symmetrically to the two Ti centers in a μ:η(2),η(2) binding mode, a structure also indicated by theory. Upon warming to room temperature the coordinated CO(2) is quantitatively reduced over a period of minutes to give the bis(oxo)-bridged dimer 2 and the dicarbonyl complex 3. In situ NMR studies indicated that this decomposition proceeds in a stepwise process via monooxo (5) and monocarbonyl (7) double-sandwich complexes, which have been independently synthesized and structurally characterized. 5 is thermally unstable with respect to a μ-O dimer in which the Ti–Ti bond has been cleaved and one pentalene ligand binds in an η(8) fashion to each of the formally Ti(III) centers. The molecular structure of 7 shows a “side-on” bound carbonyl ligand. Bonding of the double-sandwich species Ti(2)Pn(2) (Pn = C(8)H(6)) to other fragments has been investigated by density functional theory calculations and fragment analysis, providing insight into the CO(2) reaction pathway consistent with the experimentally observed intermediates. A key step in the proposed mechanism is disproportionation of a mono(oxo) di-Ti(III) species to yield di-Ti(II) and di-Ti(IV) products. 1 forms a structurally characterized, thermally stable CS(2) adduct 8 that shows symmetrical binding to the Ti(2) unit and supports the formulation of 4. The reaction of 1 with COS forms a thermally unstable complex 9 that undergoes scission to give mono(μ-S) mono(CO) species 10. Ph(3)PS is an effective sulfur transfer agent for 1, enabling the synthesis of mono(μ-S) complex 11 with a double-sandwich structure and bis(μ-S) dimer 12 in which the Ti–Ti bond has been cleaved