Anemia and red blood cell transfusion in neurocritical care

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a randomized controlled trial

Diurnal carbohydrate and fat distribution modulates glycaemic control in rodents. In humans, the optimal timing of both macronutrients and its effects on glycaemic control after prolonged consumption are not studied in detail. In this cross-over trial, 29 non-obese men were randomized to two four-week diets: (1) carbohydrate-rich meals until 13.30 and fat-rich meals between 16.30 and 22.00 (HC/HF) versus (2) inverse sequence of meals (HF/HC). After each trial period two meal tolerance tests were performed, at 09.00 and 15.40, respectively, according to the previous intervention. On the HF/HC diet, whole-day glucose level was increased by 7.9% (p = 0.026) in subjects with impaired fasting glucose and/or impaired glucose tolerance (IFG/IGT, n = 11), and GLP-1 by 10.2% (p = 0.041) in normal glucose-tolerant subjects (NGT, n = 18). Diet effects on fasting GLP-1 (p = 0.009) and PYY (p = 0.034) levels were observed in IFG/IGT, but not in NGT. Afternoon decline of glucose tolerance was more pronounced in IFG/IGT and associated with a stronger decrease of postprandial GLP-1 and PYY levels, but not with changes of cortisol rhythm. In conclusion, the HF/HC diet shows an unfavourable effect on glycaemic control in IFG/IGT, but not in NGT subjects. Consequently, large, carbohydrate-rich dinners should be avoided, primarily by subjects with impaired glucose metabolism

Red blood cell transfusion in patients with subarachnoid hemorrhage: a multidisciplinary North American survey

Abstract Introduction Anemia is associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). It remains unclear whether this association can be modified with more aggressive use of red blood cell (RBC) transfusions. The degree to which restrictive thresholds have been adopted in neurocritical care patients remains unknown. Methods We performed a survey of North American academic neurointensivists, vascular neurosurgeons and multidisciplinary intensivists who regularly care for patients with SAH to determine hemoglobin (Hb) concentrations which commonly trigger a decision to initiate transfusion. We also assessed minimum and maximum acceptable Hb goals in the context of a clinical trial and how decision-making is influenced by advanced neurological monitoring, clinician characteristics and patient-specific factors. Results The survey was sent to 531 clinicians, of whom 282 (53%) responded. In a hypothetical patient with high-grade SAH (WFNS 4), the mean Hb concentration at which clinicians administered RBCs was 8.19 g/dL (95% CI, 8.07 to 8.30 g/dL). Transfusion practices were comparatively more restrictive in patients with low-grade SAH (mean Hb 7.85 g/dL (95% CI, 7.73 to 7.97 g/dL)) (P < 0.0001) and more liberal in patients with delayed cerebral ischemia (DCI) (mean Hb 8.58 g/dL (95% CI, 8.45 to 8.72 g/dL)) (P < 0.0001). In each setting, there was a broad range of opinions. The majority of respondents expressed a willingness to study a restrictive threshold of ≤8 g/dL (92%) and a liberal goal of ≥10 g/dl (75%); in both cases, the preferred transfusion thresholds were significantly higher for patients with DCI (P < 0.0001). Neurosurgeons expressed higher minimum Hb goals than intensivists, especially for patients with high-grade SAH (β = 0.46, P = 0.003), and were more likely to administer two rather than one unit of RBCs (56% vs. 19%; P < 0.0001). Institutional use of transfusion protocols was associated with more restrictive practices. More senior clinicians preferred higher Hb goals in the context of a clinical trial. Respondents were more likely to transfuse patients with brain tissue oxygen tension values <15 mmHg and lactate-to-pyruvate ratios >40. Conclusions There is widespread variation in the use of RBC transfusions in SAH patients. Practices are heavily influenced by the specific dynamic clinical characteristics of patients and may be further modified by clinician specialty and seniority, the use of protocols and advanced neurological monitoring

The RCSB Protein Data Bank: views of structural biology for basic and applied research and education.

The RCSB Protein Data Bank (RCSB PDB, http://www.rcsb.org) provides access to 3D structures of biological macromolecules and is one of the leading resources in biology and biomedicine worldwide. Our efforts over the past 2 years focused on enabling a deeper understanding of structural biology and providing new structural views of biology that support both basic and applied research and education. Herein, we describe recently introduced data annotations including integration with external biological resources, such as gene and drug databases, new visualization tools and improved support for the mobile web. We also describe access to data files, web services and open access software components to enable software developers to more effectively mine the PDB archive and related annotations. Our efforts are aimed at expanding the role of 3D structure in understanding biology and medicine

Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury : a CAnadian High Resolution-TBI (CAHR-TBI) cohort study

Background: Brain tissue oxygen tension (PbtO2) and cerebrovascular pressure reac-tivity monitoring have emerged as potential modalities to individualize care in moder-ate and severe traumatic brain injury (TBI). The relationship between these modalities has had limited exploration. The aim of this study was to examine the relationship between PbtO(2) and cerebral perfusion pressure (CPP) and how this relationship is modified by the state of cerebrovascular pressure reactivity.Methods: A retrospective multi-institution cohort study utilizing prospectively collected high-resolution physiologic data from the CAnadian High Resolution-TBI (CAHR-TBI) Research Collaborative database collected between 2011 and 2021 was performed. Included in the study were critically ill TBI patients with intracranial pres-sure (ICP), arterial blood pressure (ABP), and PbtO(2) monitoring treated in any one of three CAHR-TBI affiliated adult intensive care units (ICU). The outcome of interest was how PbtO2 and CPP are related over a cohort of TBI patients and how this relationship is modified by the state of cerebrovascular reactivity, as determined using the pressure reactivity index (PRx).Results: A total of 77 patients met the study inclusion criteria with a total of 377,744 min of physiologic data available for the analysis. PbtO2 produced a triphasic curve when plotted against CPP like previous population-based plots of cerebral blood flow (CBF) versus CPP. The triphasic curve included a plateau region flanked by regions of relative ischemia (hypoxia) and hyperemia (hyperoxia). The plateau region shortened when cerebrovascular pressure reactivity was disrupted compared to when it was intact.Conclusions: In this exploratory analysis of a multi-institution high-resolution physiology TBI database, PbtO(2) seems to have a triphasic relationship with CPP, over the entire cohort. The CPP range over which the plateau exists is modified by the state of cerebrovascular reactivity. This indicates that in critically ill TBI patients admitted to ICU, PbtO2 may be reflective of CBF.Peer reviewe

Stabilization of an ambient-pressure collapsed tetragonal phase in CaFe2As2 and tuning of the orthorhombic-antiferromagnetic transition temperature by over 70 K via control of nanoscale precipitates

We have found a remarkably large response of the transition temperature of CaFe2As2 single crystals grown from excess FeAs to annealing and quenching temperature. Whereas crystals that are annealed at 400ˆC exhibit a first-order phase transition from a high-temperature tetragonal to a low-temperature orthorhombic and antiferromagnetic state near 170 K, crystals that have been quenched from 960ˆC exhibit a transition from a high-temperature tetragonal phase to a low-temperature, nonmagnetic, collapsed tetragonal phase below 100 K. By use of temperature-dependent electrical resistivity, magnetic susceptibility, x-ray diffraction, Mössbauer spectroscopy, and nuclear magnetic resonance measurements we have been able to demonstrate that the transition temperature can be reduced in a monotonic fashion by varying the annealing or quenching temperature from 400ˆ to 850ˆC with the low-temperature state remaining antiferromagnetic for transition temperatures larger than 100 K and becoming collapsed tetragonal, nonmagnetic for transition temperatures below 90 K. This suppression of the orthorhombic-antiferromagnetic phase transition and its ultimate replacement with the collapsed tetragonal, nonmagnetic phase is similar to what has been observed for CaFe2As2 under hydrostatic pressure. Transmission electron microscopy studies indicate that there is a temperature-dependent width of formation of CaFe2As2 with a decreasing amount of excess Fe and As being soluble in the single crystal at lower annealing temperatures. For samples quenched from 960ˆC there is a fine (of order 10 nm) semiuniform distribution of precipitate that can be associated with an average strain field, whereas for samples annealed at 400ˆC the excess Fe and As form mesoscopic grains that induce little strain throughout the CaFe2As2 lattice

Spatial and temporal patterns of surface-atmosphere energy exchange in a dense urban environment using scintillometry

Spatially-integrated measurements of the surface energy balance (SEB) are needed in urban areas to evaluate urban climate models and satellite observations. Scintillometers allow observations of sensible heat flux (QH) over much larger areas than techniques such as eddy covariance (EC), however methods are needed to partition between remaining unmeasured SEB terms. This is the first study to use observed spatial and temporal patterns of QH from a scintillometer network to constrain estimates of remaining SEB terms in a dense, heterogeneous urban environment. Results show that QH dominates the surface energy balance in central London throughout the year, with expected diurnal courses and seasonal trends in QH magnitude related to solar radiation input. Measurements also reveal a clear anthropogenic component of QH with winter (summer) weekday QH values 11.7% (5.1%) higher than weekends. Spatially, QH magnitude is correlated with vegetation and building land cover fraction in the measurement source areas. Spatial analysis provides additional evidence of anthropogenic influence with highest weekday/weekend ratios (1.55) from the City of London. Spatial differences are used to estimate horizontal advection and a novel method to estimate monthly latent heat flux is developed based on observed land cover and wet-dry surface variations in normalized QH. Annual anthropogenic heat emissions are estimated to be 46.3 W m−2 using an energy balance residual approach. The methods presented here have potential to significantly enhance understanding of urban areas, particularly in areas with tall buildings where there is little observational data

A cytomorphological and immunohistochemical profile of aggressive B-cell lymphoma: high clinical impact of a cumulative immunohistochemical outcome predictor score

We analyzed morphological and immunohistochemical features in 174 aggressive B-cell lymphomas of nodal and extranodal origin. Morphological features included presence or absence of a follicular component and cytologic criteria according to the Kiel classification, whereas immunohistochemical studies included expression of CD10, BCL-2, BCL-6, IRF4/MUM1, HLA-DR, p53, Ki-67 and the assessment of plasmacytoid differentiation. Patients were treated with a CHOP-like regimen. While the presence or absence of either CD10, BCL-6 and IRF4/MUM1 reactivity or plasmacytoid differentiation did not identify particular cytomorphologic or site-specific subtypes, we found that expression of CD10 and BCL-6, and a low reactivity for IRF4/MUM1 were favourable prognostic indicators. In contrast, BCL-2 expression and presence of a monotypic cytoplasmic immunoglobulin expression was associated with an unfavourable prognosis in univariate analyses. Meta-analysis of these data resulted in the development of a cumulative immunohistochemical outcome predictor score (CIOPS) enabling the recognition of four distinct prognostic groups. Multivariate analysis proved this score to be independent of the international prognostic index. Such a cumulative immunohistochemical scoring approach might provide a valuable alternative in the recognition of defined risk types of aggressive B-cell lymphomas