Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals

Importance: Sepsis is present in many hospitalizations that culminate in death. The contribution of sepsis to these deaths, and the extent to which they are preventable, is unknown. Objective: To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals. Design, Setting, and Participants: Cohort study in which a retrospective medical record review was conducted of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015, who died in the hospital or were discharged to hospice and not readmitted. Medical records were reviewed from January 1, 2017, to March 31, 2018. Main Outcomes and Measures: Clinicians reviewed cases for sepsis during hospitalization using Sepsis-3 criteria, hospice-qualifying criteria on admission, immediate and underlying causes of death, and suboptimal sepsis-related care such as inappropriate or delayed antibiotics, inadequate source control, or other medical errors. The preventability of each sepsis-associated death was rated on a 6-point Likert scale. Results: The study cohort included 568 patients (289 [50.9%] men; mean [SD] age, 70.5 [16.1] years) who died in the hospital or were discharged to hospice. Sepsis was present in 300 hospitalizations (52.8%; 95% CI, 48.6%-57.0%) and was the immediate cause of death in 198 cases (34.9%; 95% CI, 30.9%-38.9%). The next most common immediate causes of death were progressive cancer (92 [16.2%]) and heart failure (39 [6.9%]). The most common underlying causes of death in patients with sepsis were solid cancer (63 of 300 [21.0%]), chronic heart disease (46 of 300 [15.3%]), hematologic cancer (31 of 300 [10.3%]), dementia (29 of 300 [9.7%]), and chronic lung disease (27 of 300 [9.0%]). Hospice-qualifying conditions were present on admission in 121 of 300 sepsis-associated deaths (40.3%; 95% CI 34.7%-46.1%), most commonly end-stage cancer. Suboptimal care, most commonly delays in antibiotics, was identified in 68 of 300 sepsis-associated deaths (22.7%). However, only 11 sepsis-associated deaths (3.7%) were judged definitely or moderately likely preventable; another 25 sepsis-associated deaths (8.3%) were considered possibly preventable. Conclusions and Relevance: In this cohort from 6 US hospitals, sepsis was the most common immediate cause of death. However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved

A Two Micron All-Sky Survey View of the Sagittarius Dwarf Galaxy: II. Swope Telescope Spectroscopy of M Giant Stars in the Dynamically Cold Sagittarius Tidal Stream

We present moderate resolution (~6 km/s) spectroscopy of 284 M giant candidates selected from the Two Micron All Sky Survey photometry. Radial velocities (RVs) are presented for stars mainly in the south, with a number having positions consistent with association to the trailing tidal tail of the Sagittarius (Sgr) dwarf galaxy. The latter show a clear RV trend with orbital longitude, as expected from models of the orbit and destruction of Sgr. A minimum 8 kpc width of the trailing stream about the Sgr orbital midplane is implied by verified RV members. The coldness of this stream (dispersion ~10 km/s) provides upper limits on the combined contributions of stream heating by a lumpy Galactic halo and the intrinsic dispersion of released stars, which is a function of the Sgr core mass. The Sgr trailing arm is consistent with a Galactic halo containing one dominant, LMC-like lump, however some lumpier halos are not ruled out. An upper limit to the total M/L of the Sgr core is 21 in solar units. A second structure that roughly mimics expectations for wrapped, leading Sgr arm debris crosses the trailing arm in the Southern Hemisphere; however, this may also be an unrelated tidal feature. Among the <13 kpc M giants toward the South Galactic Pole are some with large RVs that identify them as halo stars, perhaps part of the Sgr leading arm near the Sun. The positions and RVs of Southern Hemisphere M giants are compared with those of southern globular clusters potentially stripped from the Sgr system and support for association of Pal 2 and Pal 12 with Sgr debris is found. Our discussion includes description of a masked-filtered cross-correlation methodology that achieves better than 1/20 of a resolution element RVs in moderate resolution spectra.Comment: 41 pages, 6 figures, Astronomical Journal, in press (submitted Nov. 24, 2003; tentatively scheduled for July 2004 issue

Vlasov-Maxwell, self-consistent electromagnetic wave emission simulations in the solar corona

1.5D Vlasov-Maxwell simulations are employed to model electromagnetic emission generation in a fully self-consistent plasma kinetic model for the first time in the solar physics context. The simulations mimic the plasma emission mechanism and Larmor drift instability in a plasma thread that connects the Sun to Earth with the spatial scales compressed appropriately. The effects of spatial density gradients on the generation of electromagnetic radiation are investigated. It is shown that 1.5D inhomogeneous plasma with a uniform background magnetic field directed transverse to the density gradient is aperiodically unstable to Larmor-drift instability. The latter results in a novel effect of generation of electromagnetic emission at plasma frequency. When density gradient is removed (i.e. when plasma becomes stable to Larmor-drift instability) and a $low$ density, super-thermal, hot beam is injected along the domain, in the direction perpendicular to the magnetic field, plasma emission mechanism generates non-escaping Langmuir type oscillations which in turn generate escaping electromagnetic radiation. It is found that in the spatial location where the beam is injected, the standing waves, oscillating at the plasma frequency, are excited. These can be used to interpret the horizontal strips observed in some dynamical spectra. Quasilinear theory predictions: (i) the electron free streaming and (ii) the beam long relaxation time, in accord with the analytic expressions, are corroborated via direct, fully-kinetic simulation. Finally, the interplay of Larmor-drift instability and plasma emission mechanism is studied by considering $dense$ electron beam in the Larmor-drift unstable (inhomogeneous) plasma. http://www.maths.qmul.ac.uk/~tsiklauri/movie1.mpg * http://www.maths.qmul.ac.uk/~tsiklauri/movie2.mpg * http://www.maths.qmul.ac.uk/~tsiklauri/movie3.mpgComment: Solar Physics (in press, the final, accepted version

Adequacy of therapy for people with both COPD and heart failure in the UK : historical cohort study

Acknowledgments We thank Derek Skinner for his contributions to the data acquisition and handling and Carole Nicholls and Priyanka Raju Konduru for statistical support. Writing and editorial support was provided by Elizabeth V. Hillyer, DVM, supported by Novartis Pharma AG, Basel, Switzerland. Funding This work was supported by Novartis. Employees of the sponsor (listed as authors) participated in the study design, interpretation of the results, writing of the report, and the decision to submit the paper for publication.Peer reviewedPublisher PD

Nonspecific Protein-DNA Binding Is Widespread in the Yeast Genome

Recent genome-wide measurements of binding preferences of ~200 transcription regulators in the vicinity of transcription start sites in yeast, have provided a unique insight into the cis- regulatory code of a eukaryotic genome (Venters et al., Mol. Cell 41, 480 (2011)). Here, we show that nonspecific transcription factor (TF)-DNA binding significantly influences binding preferences of the majority of transcription regulators in promoter regions of the yeast genome. We show that promoters of SAGA-dominated and TFIID-dominated genes can be statistically distinguished based on the landscape of nonspecific protein-DNA binding free energy. In particular, we predict that promoters of SAGA-dominated genes possess wider regions of reduced free energy compared to promoters of TFIID-dominated genes. We also show that specific and nonspecific TF-DNA binding are functionally linked and cooperatively influence gene expression in yeast. Our results suggest that nonspecific TF-DNA binding is intrinsically encoded into the yeast genome, and it may play a more important role in transcriptional regulation than previously thought

X-ray Astronomy in the Laboratory with a Miniature Compact Object Produced by Laser-Driven Implosion

Laboratory spectroscopy of non-thermal equilibrium plasmas photoionized by intense radiation is a key to understanding compact objects, such as black holes, based on astronomical observations. This paper describes an experiment to study photoionizing plasmas in laboratory under well-defined and genuine conditions. Photoionized plasma is here generated using a 0.5-keV Planckian x-ray source created by means of a laser-driven implosion. The measured x-ray spectrum from the photoionized silicon plasma resembles those observed from the binary stars Cygnus X-3 and Vela X-1 with the Chandra x-ray satellite. This demonstrates that an extreme radiation field was produced in the laboratory, however, the theoretical interpretation of the laboratory spectrum significantly contradicts the generally accepted explanations in x-ray astronomy. This model experiment offers a novel test bed for validation and verification of computational codes used in x-ray astronomy.Comment: 5 pages, 4 figures are included. This is the original submitted version of the manuscript to be published in Nature Physic

Disruption of thalamic functional connectivity is a neural correlate of dexmedetomidine-induced unconsciousness

Understanding the neural basis of consciousness is fundamental to neuroscience research. Disruptions in cortico-cortical connectivity have been suggested as a primary mechanism of unconsciousness. By using a novel combination of positron emission tomography and functional magnetic resonance imaging, we studied anesthesia-induced unconsciousness and recovery using the α2-agonist dexmedetomidine. During unconsciousness, cerebral metabolic rate of glucose and cerebral blood flow were preferentially decreased in the thalamus, the Default Mode Network (DMN), and the bilateral Frontoparietal Networks (FPNs). Cortico-cortical functional connectivity within the DMN and FPNs was preserved. However, DMN thalamo-cortical functional connectivity was disrupted. Recovery from this state was associated with sustained reduction in cerebral blood flow and restored DMN thalamo-cortical functional connectivity. We report that loss of thalamo-cortical functional connectivity is sufficient to produce unconsciousness. DOI: http://dx.doi.org/10.7554/eLife.04499.00

Genotoxic agents promote the nuclear accumulation of annexin A2: role of annexin A2 in mitigating DNA damage

Annexin A2 is an abundant cellular protein that is mainly localized in the cytoplasm and plasma membrane, however a small population has been found in the nucleus, suggesting a nuclear function for the protein. Annexin A2 possesses a nuclear export sequence (NES) and inhibition of the NES is sufficient to cause nuclear accumulation. Here we show that annexin A2 accumulates in the nucleus in response to genotoxic agents including gamma-radiation, UV radiation, etoposide and chromium VI and that this event is mediated by the nuclear export sequence of annexin A2. Nuclear accumulation of annexin A2 is blocked by the antioxidant agent N-acetyl cysteine (NAC) and stimulated by hydrogen peroxide (H2O2), suggesting that this is a reactive oxygen species dependent event. In response to genotoxic agents, cells depleted of annexin A2 show enhanced phospho-histone H2AX and p53 levels, increased numbers of p53-binding protein 1 nuclear foci and increased levels of nuclear 8-oxo-2'-deoxyguanine, suggesting that annexin A2 plays a role in protecting DNA from damage. This is the first report showing the nuclear translocation of annexin A2 in response to genotoxic agents and its role in mitigating DNA damage.Natural Sciences and Engineering Research Council of Canada (NSERC); European Union [PCOFUND-GA-2009-246542]; Foundation for Science and Technology of Portugal; Beatrice Hunter Cancer Research Institute; Terry Fox Foundationinfo:eu-repo/semantics/publishedVersio

Evaluation of criteria for clinical control in a prospective, international, multicenter study of patients with COPD

BACKGROUND: The concept of clinical control in COPD has been developed to help in treatment decisions, but it requires validation in prospective studies. METHOD: This international, multicenter, prospective study aimed to validate the concept of control in COPD [control = stability (no exacerbations or impairment in CAT scores) + low impact (low level of symptoms)]. Data from the screening visit was used to: investigate the level of control, compare characteristics of patients according to the control status, and perform a sensitivity analysis of the levels of control using either clinical criteria or questionnaires (COPD Assessment Test -CAT- or Clinical COPD Questionnaire -CCQ-). RESULTS: A total of 314 patients were analysed, mean age was 68.5 years and mean FEV1 was 52.6% of predicted. According to the prespecified criteria 21% of patients were classified as controlled, all of them with mild/moderate COPD (Body mass index, Obstruction, Dyspnea and Exacerbations, -BODEx-index <5). A high level of dyspnea, a high CAT score or an exacerbation in the previous 3 months were found, using univariate analysis, to be the main reasons for patients not being classified as controlled. Multivariate analysis showed that female sex, chronic bronchitis and having exacerbations in the previous year were associated with uncontrolled COPD. Changing the severity cut off of BODEx from 5 to 3 did not change significantly the percentage of patients fulfilling the criteria of control. CONCLUSIONS: The proposed criteria of control were only fulfilled by 21% of patients. The suggested cut offs and their predictive value for poor outcomes need to be refined in prospective studies

Cluster analysis of inflammatory biomarker expression in the International Severe Asthma Registry (ISAR)

Funding: ISAR is conducted by Optimum Patient Care Global Ltd, and co-funded by OPC Global Ltd and AstraZeneca.Peer reviewedPublisher PD