Fluid removal associates with better outcomes in critically ill patients receiving continuous renal replacement therapy: a cohort study

BACKGROUND: Fluid overload is associated with morbidity and mortality in patients receiving renal replacement therapy (RRT). We aimed to explore whether fluid overload at initiation of RRT was independently associated with mortality and whether changes in cumulative fluid balance during RRT were associated with outcome. METHODS: We retrospectively analysed the data of patients who were admitted to the multidisciplinary adult intensive care unit (ICU) in a tertiary care centre in the UK between 2012 and 2015 and received continuous RRT (CRRT) for acute kidney injury for at least 24 h. We collected baseline demographics, body mass index (BMI), comorbidities, severity of illness, laboratory parameters at CRRT initiation, daily cumulative fluid balance (FB), daily prescribed FB target, fluid bolus and diuretic administration and outcomes. The day of the lowest cumulative FB during CRRT was identified as nadir FB. RESULTS: Eight hundred twenty patients were analysed (median age 65 years; 49% female). At CRRT initiation, the median cumulative FB was + 1772 ml; 89 patients (10.9%) had a cumulative FB > 10% body weight (BW). Hospital survivors had a significantly lower cumulative FB at CRRT initiation compared to patients who died (1495 versus 2184 ml; p < 0.001). In the 7 days after CRRT initiation, hospital survivors had a significant decline in cumulative FB (mean decrease 473 ml per day, p < 0.001) whilst there was no significant change in cumulative FB in non-survivors (mean decrease 112 ml per day, p = 0.188). Higher severity of illness at CRRT initiation, shorter duration of CRRT, the number of days without a prescribed FB target and need for higher doses of noradrenaline were independent risk factors for not reaching a FB nadir during CRRT. Multivariable analysis showed that older age, lower BMI, higher severity of illness, need for higher doses of noradrenaline and smaller reductions in cumulative FB during CRRT were independent risk factors for ICU and hospital mortality. Cumulative FB at CRRT initiation was not independently associated with mortality. CONCLUSION: In adult patients receiving CRRT, a decrease in cumulative FB was independently associated with lower mortality. Fluid overload and need for vasopressor support at CRRT initiation were not independently associated with mortality after correction for severity of illness

Using semantically paired images to improve domain adaptation for the semantic segmentation of aerial images

Modern machine learning, especially deep learning, which is used in a variety of applications, requires a lot of labelled data for model training. Having an insufficient amount of training examples leads to models which do not generalize well to new input instances. This is a particular significant problem for tasks involving aerial images: Often training data is only available for a limited geographical area and a narrow time window, thus leading to models which perform poorly in different regions, at different times of day, or during different seasons. Domain adaptation can mitigate this issue by using labelled source domain training examples and unlabeled target domain images to train a model which performs well on both domains. Modern adversarial domain adaptation approaches use unpaired data. We propose using pairs of semantically similar images, i.e., whose segmentations are accurate predictions of each other, for improved model performance. In this paper we show that, as an upper limit based on ground truth, using semantically paired aerial images during training almost always increases model performance with an average improvement of 4.2% accuracy and .036 mean intersection-over-union (mIoU). Using a practical estimate of semantic similarity, we still achieve improvements in more than half of all cases, with average improvements of 2.5% accuracy and .017 mIoU in those cases. © 2020 Copernicus GmbH. All rights reserved

The new small-angle neutron scattering instrument SANS-1 at MLZ—characterization and first results

AbstractA thorough characterization of the key features of the new small-angle neutron scattering instrument SANS-1 at MLZ, a joint project of Technische Universität München and Helmholtz Zentrum Geesthacht, is presented. Measurements of the neutron beam profile, divergency and flux are given for various positions along the instrument including the sample position, and agree well with Monte Carlo simulations of SANS-1 using the program McStas. Secondly, the polarization option of SANS-1 is characterized for a broad wavelength band. A key feature of SANS-1 is the large accessible Q-range facilitated by the sideways movement of the detector. Particular attention is hence paid to the effects that arise due to large scattering angles on the detector where a standard cos3 solid angle correction is no longer applicable. Finally the performance of the instrument is characterized by a set of standard samples

Early Troponin I in critical illness and its association with hospital mortality: a cohort study:Early Troponin I in ICU and hospital mortality

Background: Troponin I (TnI) is frequently elevated in critical illness, but its interpretation is unclear. Our primary objectives in this study were to evaluate whether TnI is associated with hospital mortality and if this association persists after adjusting for potential confounders. We also aimed to ascertain whether addition of TnI to the Acute Physiological and Chronic Health Evaluation II (APACHE II) risk prediction model improves its performance in general intensive care unit (ICU) populations. Methods: We performed an observational cohort study with independent derivation and validation cohorts in two general level 3 ICU departments in the United Kingdom. The derivation cohort was a 4.5-year cohort (2010–2014) of general ICU index admissions (n = 1349). The validation cohort was used for secondary analysis of a prospective study dataset (2010) (n = 145). The primary exposure was plasma TnI concentration taken within 24 h of ICU admission. The primary outcome was hospital mortality. We performed multivariate regression, adjusting for components of the APACHE II model. We derived the risk prediction score from the multivariable model with TnI. Results: Hospital mortality was 37.3% (n = 242) for patients with detectable TnI, compared with 14.6% (n = 102) for patients without detectable TnI. There was a significant univariate association between TnI and hospital mortality (OR per doubling TnI 1.16, 95% CI 1.13–1.20, p &lt; 0.001). This persisted after adjustment for APACHE II model components (TnI OR 1.05, 95% CI 1.01–1.09, p = 0.003). TnI correlated most strongly with the acute physiology score (APS) component of APACHE II (r = 0.39). Addition of TnI to the APACHE II model did not improve discrimination (APACHE II concordance statistic [c-index] 0.835, 95% CI 0.811–0.858; APACHE II + TnI c-index 0.837, 95% CI 0.813–0.860; p = 0.330) or other measures of model performance. Conclusions: TnI is an independent predictor of hospital mortality and correlates most highly with the APS component of APACHE II. It does not improve risk prediction. We would not advocate the adoption of routine troponin analysis on admission to ICU, and we recommend that troponin be measured only if clinically indicate

Lagrangian theory of structure formation in relativistic cosmology I: Lagrangian framework and definition of a nonperturbative approximation

In this first paper we present a Lagrangian framework for the description of structure formation in general relativity, restricting attention to irrotational dust matter. As an application we present a self-contained derivation of a general-relativistic analogue of Zel'dovich's approximation for the description of structure formation in cosmology, and compare it with previous suggestions in the literature. This approximation is then investigated: paraphrasing the derivation in the Newtonian framework we provide general-relativistic analogues of the basic system of equations for a single dynamical field variable and recall the first-order perturbation solution of these equations. We then define a general-relativistic analogue of Zel'dovich's approximation and investigate its implications by functionally evaluating relevant variables, and we address the singularity problem. We so obtain a possibly powerful model that, although constructed through extrapolation of a perturbative solution, can be used to put into practice nonperturbatively, e.g. problems of structure formation, backreaction problems, nonlinear properties of gravitational radiation, and light-propagation in realistic inhomogeneous universe models. With this model we also provide the key-building blocks for initializing a fully relativistic numerical simulation.Comment: 21 pages, content matches published version in PRD, discussion on singularities added, some formulas added, some rewritten and some correcte

Report of the first AKI Round Table meeting: an initiative of the ESICM AKI Section.

Critical Care Nephrology is an emerging sub-specialty of Critical Care. Despite increasing awareness about the serious impact of acute kidney injury (AKI) and renal replacement therapy (RRT), important knowledge gaps persist. This report represents a summary of a 1-day meeting of the AKI section of the European Society of Intensive Care Medicine (ESICM) identifying priorities for future AKI research. International Members of the AKI section of the ESICM were selected and allocated to one of three subgroups: "AKI diagnosis and evaluation", "Medical management of AKI" and "Renal Replacement Therapy for AKI." Using a modified Delphi methodology, each group identified knowledge gaps and developed potential proposals for future collaborative research. The following key research projects were developed: Systematic reviews: (a) epidemiology of AKI with stratification by patient cohorts and diagnostic criteria; (b) role of higher blood pressure targets in patients with hypertension admitted to the Intensive Care Unit, and (c) specific clearance characteristics of different modalities of continuous renal replacement therapy (CRRT). Observational studies: (a) epidemiology of critically ill patients according to AKI duration, and (b) current clinical practice of CRRT. Intervention studies:( a) Comparison of different blood pressure targets in critically ill patients with hypertension, and (b) comparison of clearance of solutes with various molecular weights between different CRRT modalities. Consensus was reached on a future research agenda for the AKI section of the ESICM

A prospective study of the impact of serial troponin measurements on the diagnosis of myocardial infarction and hospital and six-month mortality in patients admitted to ICU with non-cardiac diagnoses.

INTRODUCTION: Troponin T (cTnT) elevation is common in patients in the Intensive Care Unit (ICU) and associated with morbidity and mortality. Our aim was to determine the epidemiology of raised cTnT levels and contemporaneous electrocardiogram (ECG) changes suggesting myocardial infarction (MI) in ICU patients admitted for non-cardiac reasons. METHODS: cTnT and ECGs were recorded daily during week 1 and on alternate days during week 2 until discharge from ICU or death. ECGs were interpreted independently for the presence of ischaemic changes. Patients were classified into four groups: (i) definite MI (cTnT ≥15 ng/L and contemporaneous changes of MI on ECG), (ii) possible MI (cTnT ≥15 ng/L and contemporaneous ischaemic changes on ECG), (iii) troponin rise alone (cTnT ≥15 ng/L), or (iv) normal. Medical notes were screened independently by two ICU clinicians for evidence that the clinical teams had considered a cardiac event. RESULTS: Data from 144 patients were analysed (42% female; mean age 61.9 (SD 16.9)). A total of 121 patients (84%) had at least one cTnT level ≥15 ng/L. A total of 20 patients (14%) had a definite MI, 27% had a possible MI, 43% had a cTNT rise without contemporaneous ECG changes, and 16% had no cTNT rise. ICU, hospital and 180-day mortality was significantly higher in patients with a definite or possible MI. CONCLUSIONS: The majority of critically ill patients (84%) had a cTnT rise and 41% met criteria for a possible or definite MI of whom only 20% were recognised clinically. Mortality up to 180 days was higher in patients with a cTnT rise