Optimal management of urinary tract infections in older people

Urinary tract infections (UTI) occur frequently in older people. Unfortunately, UTI is commonly overdiagnosed and overtreated on the basis of nonspecific clinical signs and symptoms. The diagnosis of a UTI in the older patient requires the presence of new urinary symptoms, with or without systemic symptoms. Urinalysis is commonly used to diagnose infection in this population, however, the evidence for its use is limited. There is overwhelming evidence that asymptomatic bacteriuria should not be treated. Catheter associated urinary tract infection accounts for a significant amount of hospital-associated infection. Indwelling urinary catheters should be avoided where possible and alternatives sought. The use of narrow spectrum antimicrobial agents for urinary tract infection is advocated. Local guidelines are now widely used to reflect local resistance patterns and available agents. Guidelines need to be updated to reflect changes in antimicrobial prescribing and a move from broad to narrow spectrum antimicrobials

Identifying which septic patients have increased mortality risk using severity scores:a cohort study

Background: Early aggressive therapy can reduce the mortality associated with severe sepsis but this relies on prompt recognition, which is hindered by variation among published severity criteria. Our aim was to test the performance of different severity scores in predicting mortality among a cohort of hospital inpatients with sepsis. Methods: We anonymously linked routine outcome data to a cohort of prospectively identified adult hospital inpatients with sepsis, and used logistic regression to identify associations between mortality and demographic variables, clinical factors including blood culture results, and six sets of severity criteria. We calculated performance characteristics, including area under receiver operating characteristic curves (AUROC), of each set of severity criteria in predicting mortality. Results: Overall mortality was 19.4% (124/640) at 30 days after sepsis onset. In adjusted analysis, older age (odds ratio 5.79 (95% CI 2.87-11.70) for ≥80y versus <60y), having been admitted as an emergency (OR 3.91 (1.31-11.70) versus electively), and longer inpatient stay prior to sepsis onset (OR 2.90 (1.41-5.94) for >21d versus <4d), were associated with increased 30 day mortality. Being in a surgical or orthopaedic, versus medical, ward was associated with lower mortality (OR 0.47 (0.27-0.81) and 0.26 (0.11-0.63), respectively). Blood culture results (positive vs. negative) were not significantly association with mortality. All severity scores predicted mortality but performance varied. The CURB65 community-acquired pneumonia severity score had the best performance characteristics (sensitivity 81%, specificity 52%, positive predictive value 29%, negative predictive value 92%, for 30 day mortality), including having the largest AUROC curve (0.72, 95% CI 0.67-0.77). Conclusions: The CURB65 pneumonia severity score outperformed five other severity scores in predicting risk of death among a cohort of hospital inpatients with sepsis. The utility of the CURB65 score for risk-stratifying patients with sepsis in clinical practice will depend on replicating these findings in a validation cohort including patients with sepsis on admission to hospital

Individual correlates of podoconiosis in areas of varying endemicity: a case-control study

BACKGROUND Podoconiosis is a non-filarial form of elephantiasis resulting in lymphedema of the lower legs. Previous studies have suggested that podoconiosis arises from the interplay of individual and environmental factors. Here, our aim was to understand the individual-level correlates of podoconiosis by comparing 460 podoconiosis-affected individuals and 707 unaffected controls. METHODS/PRINCIPAL FINDINGS This was a case-control study carried out in six kebeles (the lowest governmental administrative unit) in northern Ethiopia. Each kebele was classified into one of three endemicity levels: 'low' (prevalence 5%). A total of 142 (30.7%) households had two or more cases of podoconiosis. Compared to controls, the majority of the cases, especially women, were less educated (OR = 1.7, 95% CI = 1.3 to 2.2), were unmarried (OR = 3.4, 95% CI = 2.6-4.6) and had lower income (t = -4.4, p<0.0001). On average, cases started wearing shoes ten years later than controls. Among cases, age of first wearing shoes was positively correlated with age of onset of podoconiosis (r = 0.6, t = 12.5, p<0.0001). Among all study participants average duration of shoe wearing was less than 30 years. Between both cases and controls, people in 'high' and 'medium' endemicity kebeles were less likely than people in 'low' endemicity areas to 'ever' have owned shoes (OR = 0.5, 95% CI = 0.4-0.7). CONCLUSIONS Late use of shoes, usually after the onset of podoconiosis, and inequalities in education, income and marriage were found among cases, particularly among females. There were clustering of cases within households, thus interventions against podoconiosis will benefit from household-targeted case tracing. Most importantly, we identified a secular increase in shoe-wearing over recent years, which may give opportunities to promote shoe-wearing without increasing stigma among those at high risk of podoconiosis

Exposure to a maternal cafeteria diet changes open-field behaviour in the developing offspring

The early postnatal period is a sensitive period in rodents as behavioural systems are developing and maturing during this time. However, little is currently known about the behavioural effects of feeding a hyper-energetic cafeteria diet (CD) during the lactational period when offspring behaviour is tested during early adolescence. To this end, 23 days old offspring from dams (Wistar) fed on CD during lactation were tested in either the open-field or the elevated plus-maze for exploration and anxiety-related behaviour. On postnatal day 9, maternal behaviour and non-maternal behaviour of the dam was assessed. It was hypothesized that lactational CD feeding would reduce anxiety in the offspring. CD-fed dams had a higher energy intake, due to an overconsumption of sugars and fats. When offspring from these dams were exposed to the open field after weaning, their locomotor activity was increased. They entered the more aversive inner zone of the open-field after a shorter latency, made more entries into and spent more time in the inner zone. Anxiety-related behaviour was not affected upon exposure to the elevated plus maze, suggesting anxiolysis in the open-field only. Increased maternal licking/grooming behaviour could possibly contribute to the anxiolytic phenotype as observed in the offspring from the CD group. In conclusion, we demonstrate that lactational overfeeding impacts on the development of behaviour in the early adolescent rat

Variation in the SLC23A1 gene does not influence cardiometabolic outcomes to the extent expected given its association with L-ascorbic acid

Background: Observational studies showed that circulating l-ascorbic acid (vitamin C) is inversely associated with cardiometabolic traits. However, these studies were susceptible to confounding and reverse causation. Objectives:We assessed the relation between l-ascorbic acid and 10 cardiometabolic traits by using a single nucleotide polymorphism in the solute carrier family 23 member 1 (SLC23A1) gene (rs33972313) associated with circulating l-ascorbic acid concentrations. The observed association between rs33972313 and cardiometabolic outcomes was compared with that expected given the rs33972313-l-ascorbic acid and l-ascorbic acid–outcome associations. Design: A meta-analysis was performed in the following 5 independent studies: the British Women's Heart and Health Study (n = 1833), the MIDSPAN study (n = 1138), the Ten Towns study (n = 1324), the British Regional Heart Study (n = 2521), and the European Prospective Investigation into Cancer (n = 3737). Results: With the use of a meta-analysis of observational estimates, inverse associations were shown between l-ascorbic acid and systolic blood pressure, triglycerides, and the waist-hip ratio [the strongest of which was the waist-hip ratio (−0.13-SD change; 95% CI: −0.20-, −0.07-SD change; P = 0.0001) per SD increase in l-ascorbic acid], and a positive association was shown with high-density lipoprotein (HDL) cholesterol. The variation at rs33972313 was associated with a 0.18-SD (95% CI: 0.10-, 0.25-SD; P = 3.34 × 10−6) increase in l-ascorbic acid per effect allele. There was no evidence of a relation between the variation at rs33972313 and any cardiometabolic outcome. Although observed estimates were not statistically different from expected associations between rs33972313 and cardiometabolic outcomes, estimates for low-density lipoprotein cholesterol, HDL cholesterol, triglycerides, glucose, and body mass index were in the opposite direction to those expected. Conclusions: The nature of the genetic association exploited in this study led to limited statistical application, but despite this, when all cardiometabolic traits were assessed, there was no evidence of any trend supporting a protective role of l-ascorbic acid. In the context of existing work, these results add to the suggestion that observational relations between l-ascorbic acid and cardiometabolic health may be attributable to confounding and reverse causation

Unraveling the directional link between adiposity and inflammation: a bidirectional mendelian randomization approach

&lt;b&gt;Context&lt;/b&gt;: Associations between adiposity and circulating inflammation markers are assumed to be causal, although the direction of the relationship has not been proven. &lt;b&gt;Objective&lt;/b&gt;: The aim of the study was to explore the causal direction of the relationship between adiposity and inflammation using a bidirectional Mendelian randomization approach. &lt;b&gt;Methods&lt;/b&gt;: In the PROSPER study of 5804 elderly patients, we related C-reactive protein (CRP) single nucleotide polymorphisms (SNPs) (rs1800947 and rs1205) and adiposity SNPs (FTO and MC4R) to body mass index (BMI) as well as circulating levels of CRP and leptin. We gave each individual two allele scores ranging from zero to 4, counting each pair of alleles related to CRP levels or BMI. &lt;b&gt;Results&lt;/b&gt;: With increasing CRP allele score, there was a stepwise decrease in CRP levels (P for trend &#60; 0.0001) and a 1.98 mg/liter difference between extremes of the allele score distribution, but there was no associated change in BMI or leptin levels (P ≥ 0.89). By contrast, adiposity allele score was associated with 1) an increase in BMI (1.2 kg/m2 difference between extremes; P for trend 0.002); 2) an increase in circulating leptin (5.77 ng/ml difference between extremes; P for trend 0.0027); and 3) increased CRP levels (1.24 mg/liter difference between extremes; P for trend 0.002). &lt;b&gt;Conclusions&lt;/b&gt;: Greater adiposity conferred by FTO and MC4R SNPs led to higher CRP levels, with no evidence for any reverse pathway. Future studies should extend our findings to other circulating inflammatory parameters. This study illustrates the potential power of Mendelian randomization to dissect directions of causality between intercorrelated metabolic factors

Remote Sensing Phenology of Antarctic Green and Red Snow Algae Using WorldView Satellites

Snow algae are an important group of terrestrial photosynthetic organisms in Antarctica, where they mostly grow in low lying coastal snow fields. Reliable observations of Antarctic snow algae are difficult owing to the transient nature of their blooms and the logistics involved to travel and work there. Previous studies have used Sentinel 2 satellite imagery to detect and monitor snow algal blooms remotely, but were limited by the coarse spatial resolution and difficulties detecting red blooms. Here, for the first time, we use high-resolution WorldView multispectral satellite imagery to study Antarctic snow algal blooms in detail, tracking the growth of red and green blooms throughout the summer. Our remote sensing approach was developed alongside two Antarctic field seasons, where field spectroscopy was used to build a detection model capable of estimating cell density. Global Positioning System (GPS) tagging of blooms and in situ life cycle analysis was used to validate and verify our model output. WorldView imagery was then used successfully to identify red and green snow algae on Anchorage Island (Ryder Bay, 67°S), estimating peak coverage to be 9.48 × 104 and 6.26 × 104 m2, respectively. Combined, this was greater than terrestrial vegetation area coverage for the island, measured using a normalized difference vegetation index. Green snow algae had greater cell density and average layer thickness than red blooms (6.0 × 104 vs. 4.3 × 104 cells ml−1) and so for Anchorage Island we estimated that green algae dry biomass was over three times that of red algae (567 vs. 180 kg, respectively). Because the high spatial resolution of the WorldView imagery and its ability to detect red blooms, calculated snow algal area was 17.5 times greater than estimated with Sentinel 2 imagery. This highlights a scaling problem of using coarse resolution imagery and suggests snow algal contribution to net primary productivity on Antarctica may be far greater than previously recognized