The hepatoadrenal syndrome: A common yet unrecognized clinical condition

Objective: Adrenal failure is common in critically ill patients, particularly those with sepsis. As liver failure and sepsis are both associated with increased circulating levels of endotoxin and proinflammatory mediators and reduced levels of apoprotein-1/ high-density lipoprotein, we postulated that adrenal failure may be common in patients with liver disease. Design: Clinical study. Setting: Liver transplant intensive care unit. Patients: The study cohort included 340 patients with liver disease. Interventions: Based on preliminary observational data, all patients admitted to our 28-bed liver transplant intensive care unit (LTICU) undergo adrenal function testing. An honest broker system was used to extract clinical, hemodynamic, medication, and laboratory data on patients admitted to the LTICU from March 2002 to March 2004. A random (stress) cortisol level <20 μg/dL in a highly stressed patient (respiratory failure, hypotension) was used to diagnose adrenal insufficiency. In all other patients, a random cortisol level <15 μg/dL or a 30-min level <20 μg/dL post-low-dose (1 μg) cosyntropin was considered diagnostic of adrenal insufficiency. Patients were grouped as follows: a) chronic liver failure; b) fulminant hepatic failure; c) patients immediately status post-orthotopic liver transplantation receiving a steroid-free protocol of immunosuppression; and d) patients status post-remote liver transplant (≥6 months). The decision to treat patients with stress doses of hydrocortisone was at the discretion of the treating intensivist and transplant surgeon. Measurements and Main Results: Two-hundred and forty-five (72%) patients met our criteria for adrenal insufficiency (the hepatoadrenal syndrome). Eight (33%) patients with fulminant hepatic failure, 97 (66%) patients with chronic liver disease, 31(61%) patients with a remote history of liver transplantation, and 109 (92%) patients who had undergone liver transplantation under steroid-free immunosuppression were diagnosed with adrenal insufficiency. The high-density lipoprotein level at the time of adrenal testing was the only variable predictive of adrenal insufficiency (p < .0001). In vasopressor-dependent patients with adrenal insufficiency, treatment with hydrocortisone was associated with a significant reduction (p = .02) in the dose of norepinephrine at 24 hrs, whereas the dose of norepinephrine was significantly higher (p = .04) in those patients with adrenal failure not treated with hydrocortisone. In vasopressor-dependent patients without adrenal insufficiency, treatment with hydrocortisone did not affect vasopressor dose at 24 hrs. One hundred and forty-one patients (26.4%) died during their hospitalization. The baseline serum cortisol was 18.8 ± 16.2 μg/dL in the nonsurvivors compared with 13.0 ± 11.8 μg/dL in the survivors (p < .001). Of those patients with adrenal failure who were treated with glucocorticoids, the mortality rate was 26% compared with 46% (p = .002) in those who were not treated. In those patients receiving vasopressor agents at the time of adrenal testing, the baseline cortisol was 10.0 ± 4.8 μg/dL in those with adrenal insufficiency compared with 35.6 ± 21.2 μg/dL in those with normal adrenal function. Vasopressor-dependent patients who did not have adrenal failure had a mortality rate of 75%. Conclusions: Patients with liver failure and patients post-liver transplantation have an exceedingly high incidence of adrenal failure, which may be pathophysiologically related to low levels of high-density lipoprotein. Treatment of patients with adrenal failure may improve outcome. High baseline serum cortisol levels may be a maker of disease severity and portend a poor prognosis. Copyright © 2005 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

FluoroType MTB system for the detection of pulmonary tuberculosis

Altres ajuts: The authors would like to acknowledge Hain Lifescience (Germany) for their provision of a FluoroCycler and sufficient FluoroType MTB assays to carry out the study. Hain Lifescience had no influence on the study design, data analysis or preparation of the manuscript. Funding information for this article has been deposited with the Crossref Funder RegistryDiagnosis continues to be a major barrier for the control of tuberculosis (TB), especially in low- and middle-income countries (LMIC) [1]. The number of platforms for the molecular diagnosis of TB have increased in recent years and they can provide test results more rapidly than culture. Molecular assays are increasingly being used as alternative or adjunct methods to culture and smear microscopy, and modern systems seek to partially or fully automate the DNA extraction and amplification steps, increasing their suitability for resource-limited laboratories. One of these platforms, the GeneXpert MTB/RIF (Cepheid, USA), has a sensitivity of roughly 85% compared to culture [2] and has seen significant uptake in developing countries [3]. However, as a fully closed system, the DNA extracted during the process cannot be used for further downstream drug susceptibility testing (DST), which is crucial for patients with suspected drug-resistant TB. FluoroType MTB is a sensitive test for TB but specificity is low compared with fully integrated molecular system

Understanding charge transport in lead iodide perovskite thin-film field-effect transistors

Fundamental understanding of the charge transport physics of hybrid lead halide perovskite semiconductors is important for advancing their use in high-performance optoelectronics. We use field-effect transistors (FETs) to probe the charge transport mechanism in thin films of methylammonium lead iodide (MAPbI$_{3}$). We show that through optimization of thin-film microstructure and source-drain contact modifications, it is possible to significantly minimize instability and hysteresis in FET characteristics and demonstrate an electron field-effect mobility (μ$_{FET}$) of 0.5 cm$^{2}$/Vs at room temperature. Temperature-dependent transport studies revealed a negative coefficient of mobility with three different temperature regimes. On the basis of electrical and spectroscopic studies, we attribute the three different regimes to transport limited by ion migration due to point defects associated with grain boundaries, polarization disorder of the MA$^{+}$ cations, and thermal vibrations of the lead halide inorganic cages.S.P.S. acknowledges funding from the Royal Society London for a Newton Fellowship. B.Y. acknowledges support from China Council Scholarship and Cambridge Overseas Trust. A.S. and R.H.F. acknowledge funding and support from the Engineering and Physical Sciences Research Council (EPSRC) through the India-U.K. APEX project. P.D. acknowledges support from the European Union through the award of a Marie Curie Intra-European Fellowship. X.M. is grateful for the support from the Royal Society. B.N. is grateful for the support from Gates Cambridge and the Winton Program for the Physics of Sustainability. We acknowledge funding from the EPSRC through a program grant (EP/M005143/1). We acknowledge funding from the German Federal Ministry of Education and Research under agreement number 01162525/1. This work was performed in part on the SAXS/WAXS beamline of the Australian Synchrotron, Victoria, Australia (55, 56). C.R.M. acknowledges support from the Australian Research Council (DP13012616)

Parietal white matter lesions in Alzheimer’s disease are associated with cortical neurodegenerative pathology, but not with small vessel disease

The research was supported by the Alzheimer’s Society (Grant Number: AS-PG-2013-011). Tissue for this study was provided by the Newcastle Brain Tissue Resource, which is funded in part by a grant from the UK Medical Research Council (G0400074) and by Brains for Dementia research, a joint venture between Alzheimer’s Society and Alzheimer’s Research UK.Cerebral white matter lesions (WML) encompass axonal loss and demyelination, and the pathogenesis is assumed to be small vessel disease (SVD)-related ischemia. However, WML may also result from the activation of Wallerian degeneration as a consequence of cortical Alzheimer’s disease (AD) pathology, i.e. hyperphosphorylated tau (HPτ) and amyloid-beta (Aβ) deposition. WML seen in AD have a posterior predominance compared to non-demented individuals but it is unclear whether the pathological and molecular signatures of WML differ between these two groups. We investigated differences in the composition and aetiology of parietal WML from AD and non-demented controls. Parietal WML tissue from 55 human post-mortem brains (AD, n = 27; non-demented controls, n = 28) were quantitatively assessed for axonal loss and demyelination, as well as for cortical HPτ and Aβ burden and SVD. Biochemical assessment included Wallerian degeneration protease calpain and the myelin-associated glycoprotein (MAG) to proteolipid protein (PLP) ratio (MAG:PLP) as a measure of hypoperfusion. WML severity was associated with both axonal loss and demyelination in AD, but only with demyelination in controls. Calpain was significantly increased in WML tissue in AD, whereas MAG:PLP was significantly reduced in controls. Calpain levels were associated with increasing amounts of cortical AD-pathology but not SVD. We conclude that parietal WML seen in AD differ in their pathological composition and aetiology compared to WML seen in aged controls: WML seen in AD may be associated with Wallerian degeneration that is triggered by cortical AD-pathology, whereas WML in aged controls are due to ischaemia. Hence, parietal WML as seen on MRI should not invariably be interpreted as a surrogate biomarker for SVD as they may be indicative of cortical AD-pathology, and therefore, AD should also be considered as the main underlying cause for cognitive impairment in cases with parietal WML.Publisher PDFPeer reviewe

Effective Lagrangian Approach to pion photoproduction from the nucleon

We present a pion photoproduction model on the free nucleon based on an Effective Lagrangian Approach (ELA) which includes the nucleon resonances ($\Delta(1232)$, N(1440), N(1520), N(1535), $\Delta (1620)$, N(1650), and $\Delta (1700)$), in addition to Born and vector meson exchange terms. The model incorporates a new theoretical treatment of spin-3/2 resonances, first introduced by Pascalutsa, avoiding pathologies present in previous models. Other main features of the model are chiral symmetry, gauge invariance, and crossing symmetry. We use the model combined with modern optimization techniques to assess the parameters of the nucleon resonances on the basis of world data on electromagnetic multipoles. We present results for electromagnetic multipoles, differential cross sections, asymmetries, and total cross sections for all one pion photoproduction processes on free nucleons. We find overall agreement with data from threshold up to 1 GeV in laboratory frame.Comment: Misprints corrected. 60 pages. 33 figures.5 tables. Accepted for publication in Annals of Physics (NY

The role of the reactor size for an investment in the nuclear sector: an evaluation of not-financial parameters

The literature presents many studies about the economics of new Nuclear Power Plants (NPPs). Such studies are based on Discounted Cash Flow (DCF) methods encompassing the accounts related to Construction, Operation & Maintenance, Fuel and Decommissioning. However the investment evaluation of a nuclear reactor should also include not-financial factors such as siting and grid constraints, impact on the national industrial system, etc. The Integrated model for the Competitiveness Assessment of SMRs (INCAS), developed by Politecnico di Milano cooperating with the IAEA, is designed to analyze the choice of the better Nuclear Power Plant size as a multidimensional problem. In particular the INCAS’s module “External Factors” evaluates the impact of the factors that are not considered in the traditional DCF methods. This paper presents a list of these factors, providing, for each one, the rationale and the quantification procedure; then each factor is quantified for the Italian case. The IRIS reactor has been chosen as SMR representative. The approach and the framework of the model can be applied to worldwide countries while the specific results apply to most of the European countries. The results show that SMRs have better performances than LRs with respect to the external factors, in general and in the Italian scenario in particular

Child feces disposal practices in rural Orissa: a cross sectional study.

BACKGROUND: An estimated 2.5 billion people worldwide lack access to improved sanitation facilities. While large-scale programs in some countries have increased latrine coverage, they sometimes fail to ensure optimal latrine use, including the safe disposal of child feces, a significant source of exposure to fecal pathogens. We undertook a cross-sectional study to explore fecal disposal practices among children in rural Orissa, India in villages where the Government of India's Total Sanitation Campaign had been implemented at least three years prior to the study. METHODS AND FINDINGS: We conducted surveys with heads of 136 households with 145 children under 5 years of age in 20 villages. We describe defecation and feces disposal practices and explore associations between safe disposal and risk factors. Respondents reported that children commonly defecated on the ground, either inside the household (57.5%) for pre-ambulatory children or around the compound (55.2%) for ambulatory children. Twenty percent of pre-ambulatory children used potties and nappies; the same percentage of ambulatory children defecated in a latrine. While 78.6% of study children came from 106 households with a latrine, less than a quarter (22.8%) reported using them for disposal of child feces. Most child feces were deposited with other household waste, both for pre-ambulatory (67.5%) and ambulatory (58.1%) children. After restricting the analysis to households owning a latrine, the use of a nappy or potty was associated with safe disposal of feces (OR 6.72, 95%CI 1.02-44.38) though due to small sample size the regression could not adjust for confounders. CONCLUSIONS: In the area surveyed, the Total Sanitation Campaign has not led to high levels of safe disposal of child feces. Further research is needed to identify the actual scope of this potential gap in programming, the health risk presented and interventions to minimize any adverse effect

Determinants of Organophosphorus Pesticide Urinary Metabolite Levels in Young Children Living in an Agricultural Community

Organophosphorus (OP) pesticides are used in agriculture and several are registered for home use. As young children age they may experience different pesticide exposures due to varying diet, behavior, and other factors. We measured six OP dialkylphosphate (DAP) metabolites (three dimethyl alkylphosphates (DMAP) and three diethyl alkylphosphates (DEAP)) in urine samples collected from ∼400 children living in an agricultural community when they were 6, 12, and 24 months old. We examined bivariate associations between DAP metabolite levels and determinants such as age, diet, season, and parent occupation. To evaluate independent impacts, we then used generalized linear mixed multivariable models including interaction terms with age. The final models indicated that DMAP metabolite levels increased with age. DMAP levels were also positively associated with daily servings of produce at 6- and 24-months. Among the 6-month olds, DMAP metabolite levels were higher when samples were collected during the summer/spring versus the winter/fall months. Among the 12-month olds, DMAP and DEAP metabolites were higher when children lived ≤60 meters from an agricultural field. Among the 24-month-olds, DEAP metabolite levels were higher during the summer/spring months. Our findings suggest that there are multiple determinants of OP pesticide exposures, notably dietary intake and temporal and spatial proximity to agricultural use. The impact of these determinants varied by age and class of DAP metabolite