Probing the envelopes of massive young stellar objects with diffraction limited mid-infrared imaging

Massive stars form whilst they are still embedded in dense envelopes. As a result, the roles of rotation, mass loss and accretion in massive star formation are not well understood. This study evaluates the source of the Q-band, lambda=19.5 microns, emission of massive young stellar objects (MYSOs). This allows us to determine the relative importance of rotation and outflow activity in shaping the circumstellar environments of MYSOs on 1000 AU scales. We obtained diffraction limited mid-infrared images of a sample of 20 MYSOs using the VLT/VISIR and Subaru/COMICS instruments. For these 8 m class telescopes and the sample selected, the diffraction limit, ~0.6", corresponds to approximately 1000 AU. We compare the images and the spectral energy distributions (SEDs) observed to a 2D, axis-symmetric dust radiative transfer model that reproduces VLTI/MIDI observations of the MYSO W33A. We vary the inclination, mass infall rate, and outflow opening angle to simultaneously recreate the behaviour of the sample of MYSOs in the spatial and spectral domains. The mid-IR emission of 70 percent of the MYSOs is spatially resolved. In the majority of cases, the spatial extent of their emission and their SEDs can be reproduced by the W33A model featuring an in-falling, rotating dusty envelope with outflow cavities. There is independent evidence that most of the sources which are not fit by the model are associated with ultracompact HII regions and are thus more evolved. We find that, in general, the diverse 20 micron morphology of MYSOs can be attributed to warm dust in the walls of outflow cavities seen at different inclinations. This implies that the warm dust in the outflow cavity walls dominates the Q-band emission of MYSOs. In turn, this emphasises that outflows are an ubiquitous feature of massive star formation.Comment: Accepted for publication in A&A. The images in this version have been compressed. A high resolution version is available on reques

The RMS Survey: Critical Tests of Accretion Models for the Formation of Massive Stars

There is currently no accepted theoretical framework for the formation of the most massive stars, and the manner in which protostars continue to accrete and grow in mass beyond \sim10Msun is still a controversial topic. In this study we use several prescriptions of stellar accretion and a description of the Galactic gas distribution to simulate the luminosities and spatial distribution of massive protostellar population of the Galaxy. We then compare the observables of each simulation to the results of the Red MSX Source (RMS) survey, a recently compiled database of massive young stellar objects. We find that the observations are best matched by accretion rates which increase as the protostar grows in mass, such as those predicted by the turbulent core and competitive accretion (i.e. Bondi-Hoyle) models. These 'accelerating accretion' models provide very good qualitative and quantitative fits to the data, though we are unable to distinguish between these two models on our simulations alone. We rule out models with accretion rates which are constant with time, and those which are initially very high and which fall away with time, as these produce results which are quantitatively and/or qualitatively incompatible with the observations. To simultaneously match the low- and high-luminosity YSO distribution we require the inclusion of a 'swollen-star' pre-main-sequence phase, the length of which is well-described by the Kelvin-Helmholz timescale. Our results suggest that the lifetime of the YSO phase is \sim 10^5yrs, whereas the compact Hii-region phase lasts between \sim 2 - 4 \times 10^5yrs depending on the final mass of the star. Finally, the absolute numbers of YSOs are best matched by a globally averaged star-formation rate for the Galaxy of 1.5-2Msun/yr.Comment: 22 pages, 24 figures. Accepted for publication in MNRA

CO bandhead emission of massive young stellar objects: determining disc properties

Massive stars play an important role in many areas of astrophysics, but numerous details regarding their formation remain unclear. In this paper we present and analyse high-resolution (R~30 000) near-infrared 2.3 μm spectra of 20 massive young stellar objects (MYSOs) from the Red MSX Source (RMS) data base, in the largest such study of CO first overtone bandhead emission to date. We fit the emission under the assumption it originates from a circumstellar disc in Keplerian rotation. We explore three approaches to modelling the physical conditions within the disc-a disc heated mainly via irradiation from the central star, a disc heated mainly via viscosity, and a disc in which the temperature and density are described analytically. We find that the models described by heating mechanisms are inappropriate because they do not provide good fits to the CO emission spectra. We therefore restrict our analysis to the analytic model, and obtain good fits to all objects that possess sufficiently strong CO emission, suggesting circumstellar discs are the source of this emission. On average, the temperature and density structure of the discs correspond to geometrically thin discs, spread across a wide range of inclinations. Essentially all the discs are located within the dust sublimation radius, providing strong evidence that the CO emission originates close to the central protostar, on astronomical unit scales. In addition, we show that the objects in our sample appear no different to the general population of MYSOs in the RMS data base, based on their near- and mid-infrared colours. The combination of observations of a large sample of MYSOs with CO bandhead emission and our detailed modelling provide compelling evidence of the presence of small-scale gaseous discs around such objects, supporting the scenario in which massive stars form via disc accretion. © 2013 The Authors. Published by Oxford University Press on behalf of the Royal Astronomical Society

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Circulating microRNAs in sera correlate with soluble biomarkers of immune activation but do not predict mortality in ART treated individuals with HIV-1 infection: A case control study

Introduction: The use of anti-retroviral therapy (ART) has dramatically reduced HIV-1 associated morbidity and mortality. However, HIV-1 infected individuals have increased rates of morbidity and mortality compared to the non-HIV-1 infected population and this appears to be related to end-organ diseases collectively referred to as Serious Non-AIDS Events (SNAEs). Circulating miRNAs are reported as promising biomarkers for a number of human disease conditions including those that constitute SNAEs. Our study sought to investigate the potential of selected miRNAs in predicting mortality in HIV-1 infected ART treated individuals. Materials and Methods: A set of miRNAs was chosen based on published associations with human disease conditions that constitute SNAEs. This case: control study compared 126 cases (individuals who died whilst on therapy), and 247 matched controls (individuals who remained alive). Cases and controls were ART treated participants of two pivotal HIV-1 trials. The relative abundance of each miRNA in serum was measured, by RTqPCR. Associations with mortality (all-cause, cardiovascular and malignancy) were assessed by logistic regression analysis. Correlations between miRNAs and CD4+ T cell count, hs-CRP, IL-6 and D-dimer were also assessed. Results: None of the selected miRNAs was associated with all-cause, cardiovascular or malignancy mortality. The levels of three miRNAs (miRs -21, -122 and -200a) correlated with IL-6 while miR-21 also correlated with D-dimer. Additionally, the abundance of miRs -31, -150 and -223, correlated with baseline CD4+ T cell count while the same three miRNAs plus miR- 145 correlated with nadir CD4+ T cell count. Discussion: No associations with mortality were found with any circulating miRNA studied. These results cast doubt onto the effectiveness of circulating miRNA as early predictors of mortality or the major underlying diseases that contribute to mortality in participants treated for HIV-1 infection

Development and Validation of a Risk Score for Chronic Kidney Disease in HIV Infection Using Prospective Cohort Data from the D:A:D Study

Ristola M. on työryhmien DAD Study Grp ; Royal Free Hosp Clin Cohort ; INSIGHT Study Grp ; SMART Study Grp ; ESPRIT Study Grp jäsen.Background Chronic kidney disease (CKD) is a major health issue for HIV-positive individuals, associated with increased morbidity and mortality. Development and implementation of a risk score model for CKD would allow comparison of the risks and benefits of adding potentially nephrotoxic antiretrovirals to a treatment regimen and would identify those at greatest risk of CKD. The aims of this study were to develop a simple, externally validated, and widely applicable long-term risk score model for CKD in HIV-positive individuals that can guide decision making in clinical practice. Methods and Findings A total of 17,954 HIV-positive individuals from the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study with >= 3 estimated glomerular filtration rate (eGFR) values after 1 January 2004 were included. Baseline was defined as the first eGFR > 60 ml/min/1.73 m2 after 1 January 2004; individuals with exposure to tenofovir, atazanavir, atazanavir/ritonavir, lopinavir/ritonavir, other boosted protease inhibitors before baseline were excluded. CKD was defined as confirmed (>3 mo apart) eGFR In the D:A:D study, 641 individuals developed CKD during 103,185 person-years of follow-up (PYFU; incidence 6.2/1,000 PYFU, 95% CI 5.7-6.7; median follow-up 6.1 y, range 0.3-9.1 y). Older age, intravenous drug use, hepatitis C coinfection, lower baseline eGFR, female gender, lower CD4 count nadir, hypertension, diabetes, and cardiovascular disease (CVD) predicted CKD. The adjusted incidence rate ratios of these nine categorical variables were scaled and summed to create the risk score. The median risk score at baseline was -2 (interquartile range -4 to 2). There was a 1: 393 chance of developing CKD in the next 5 y in the low risk group (risk score = 5, 505 events), respectively. Number needed to harm (NNTH) at 5 y when starting unboosted atazanavir or lopinavir/ritonavir among those with a low risk score was 1,702 (95% CI 1,166-3,367); NNTH was 202 (95% CI 159-278) and 21 (95% CI 19-23), respectively, for those with a medium and high risk score. NNTH was 739 (95% CI 506-1462), 88 (95% CI 69-121), and 9 (95% CI 8-10) for those with a low, medium, and high risk score, respectively, starting tenofovir, atazanavir/ritonavir, or another boosted protease inhibitor. The Royal Free Hospital Clinic Cohort included 2,548 individuals, of whom 94 individuals developed CKD (3.7%) during 18,376 PYFU (median follow-up 7.4 y, range 0.3-12.7 y). Of 2,013 individuals included from the SMART/ESPRIT control arms, 32 individuals developed CKD (1.6%) during 8,452 PYFU (median follow-up 4.1 y, range 0.6-8.1 y). External validation showed that the risk score predicted well in these cohorts. Limitations of this study included limited data on race and no information on proteinuria. Conclusions Both traditional and HIV-related risk factors were predictive of CKD. These factors were used to develop a risk score for CKD in HIV infection, externally validated, that has direct clinical relevance for patients and clinicians to weigh the benefits of certain antiretrovirals against the risk of CKD and to identify those at greatest risk of CKD.Peer reviewe

Effects of Anacetrapib in Patients with Atherosclerotic Vascular Disease

BACKGROUND: Patients with atherosclerotic vascular disease remain at high risk for cardiovascular events despite effective statin-based treatment of low-density lipoprotein (LDL) cholesterol levels. The inhibition of cholesteryl ester transfer protein (CETP) by anacetrapib reduces LDL cholesterol levels and increases high-density lipoprotein (HDL) cholesterol levels. However, trials of other CETP inhibitors have shown neutral or adverse effects on cardiovascular outcomes. METHODS: We conducted a randomized, double-blind, placebo-controlled trial involving 30,449 adults with atherosclerotic vascular disease who were receiving intensive atorvastatin therapy and who had a mean LDL cholesterol level of 61 mg per deciliter (1.58 mmol per liter), a mean non-HDL cholesterol level of 92 mg per deciliter (2.38 mmol per liter), and a mean HDL cholesterol level of 40 mg per deciliter (1.03 mmol per liter). The patients were assigned to receive either 100 mg of anacetrapib once daily (15,225 patients) or matching placebo (15,224 patients). The primary outcome was the first major coronary event, a composite of coronary death, myocardial infarction, or coronary revascularization. RESULTS: During the median follow-up period of 4.1 years, the primary outcome occurred in significantly fewer patients in the anacetrapib group than in the placebo group (1640 of 15,225 patients [10.8%] vs. 1803 of 15,224 patients [11.8%]; rate ratio, 0.91; 95% confidence interval, 0.85 to 0.97; P=0.004). The relative difference in risk was similar across multiple prespecified subgroups. At the trial midpoint, the mean level of HDL cholesterol was higher by 43 mg per deciliter (1.12 mmol per liter) in the anacetrapib group than in the placebo group (a relative difference of 104%), and the mean level of non-HDL cholesterol was lower by 17 mg per deciliter (0.44 mmol per liter), a relative difference of -18%. There were no significant between-group differences in the risk of death, cancer, or other serious adverse events. CONCLUSIONS: Among patients with atherosclerotic vascular disease who were receiving intensive statin therapy, the use of anacetrapib resulted in a lower incidence of major coronary events than the use of placebo. (Funded by Merck and others; Current Controlled Trials number, ISRCTN48678192 ; ClinicalTrials.gov number, NCT01252953 ; and EudraCT number, 2010-023467-18 .)