Glucose in the ICU - Evidence, Guidelines, and Outcomes

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Reciprocal Interactions between Cadmium-Induced Cell Wall Responses and Oxidative Stress in Plants

Cadmium (Cd) pollution renders many soils across the world unsuited or unsafe for food- or feed-orientated agriculture. The main mechanism of Cd phytotoxicity is the induction of oxidative stress, amongst others through the depletion of glutathione. Oxidative stress can damage lipids, proteins, and nucleic acids, leading to growth inhibition or even cell death. The plant cell has a variety of tools to defend itself against Cd stress. First and foremost, cell walls might prevent Cd from entering and damaging the protoplast. Both the primary and secondary cell wall have an array of defensive mechanisms that can be adapted to cope with Cd. Pectin, which contains most of the negative charges within the primary cell wall, can sequester Cd very effectively. In the secondary cell wall, lignification can serve to immobilize Cd and create a tougher barrier for entry. Changes in cell wall composition are, however, dependent on nutrients and conversely might affect their uptake. Additionally, the role of ascorbate (AsA) as most important apoplastic antioxidant is of considerable interest, due to the fact that oxidative stress is a major mechanism underlying Cd toxicity, and that AsA biosynthesis shares several links with cell wall construction. In this review, modifications of the plant cell wall in response to Cd exposure are discussed. Focus lies on pectin in the primary cell wall, lignification in the secondary cell wall and the importance of AsA in the apoplast. Regarding lignification, we attempt to answer the question whether increased lignification is merely a consequence of Cd toxicity, or rather an elicited defense response. We propose a model for lignification as defense response, with a central role for hydrogen peroxide as substrate and signaling molecule

The efficacy of physiotherapy for prevention and treatment of prenatal symptoms: a systematic review

Introduction and hypothesis: Several studies described the evidence of prenatal physiotherapy for one symptom, but none made an overview. We provided a systematic review on the effectiveness of prenatal physiotherapy. Methods: A full search was conducted in three electronic databases (Embase, PubMed/MEDLINE and PEDro), selecting randomized controlled trials concerning prenatal physiotherapy. Methodological quality was assessed using the PEDro scale. Results: We identified 1249 studies and after exclusions 54 studies were included concerning the evidence of prenatal physiotherapy. The majority of studies indicated a preventative effect for low back pain/pelvic girdle pain, weight gain, incontinence and perineal massage. For leg edema, fear and prenatal depression, the efficacy was only based on one study per symptom. No preventative effect was found for gestational diabetes, while literature concerning gestational hypertensive disorders was inconclusive. Regarding the treatment of low back pain/pelvic girdle pain and weight gain, most therapies reduced respectively pain and weight. Evidence regarding exercises for diabetes was contradictory and for incontinence only minimally researched. Foot massage and stockings reduced respectively leg edema and leg symptoms. Concerning gestational hypertensive disorders, perineal pain, fear and prenatal depression no treatment studies were performed. Conclusions: The majority of studies indicated that prenatal physiotherapy had a preventative role for low back pain/ pelvic girdle pain, weight gain, incontinence and pelvic pain. Evidence for the remaining symptoms was inclusive or only minimally investigated. Regarding treatment, most studies indicated a reduction of low back pain/pelvic girdle pain , weight gain, incontinence and the symptoms of leg edema.status: publishe

Evaluation of the Initial General Ward Early Warning Score and ICU Admission, Hospital Length of Stay and Mortality

Introduction: Despite widespread implementation of the Early Warning Score (EWS) in hospitals, its effect on patient outcomes remains mostly unknown. We aimed to evaluate associations between the initial EWS and in-hospital mortality, intensive care unit (ICU) admission, and hospital length of stay (LOS).  Methods: We performed a retrospective cohort study of adult patients admitted to a general hospital ward between July 1, 2014–December 31, 2017. Data were obtained from electronic health records (EHR). The primary outcome was in-hospital mortality. Secondary outcomes were ICU admission and hospital LOS. We categorized patients into three risk groups (low, medium or high risk of clinical deterioration) based on EWS. Descriptive analyses were used. Results: After applying inclusion and exclusion criteria, we included 53,180 patients for analysis. We found that the initial (low- vs high-risk) EWS was associated with an increased in-hospital mortality (1.5% vs 25.3%, P <0.001), an increased ICU admission rate (3.1% vs 17.6%, P <0.001), and an extended hospital LOS (4.0 days vs 8.0 days, P <0.001). Conclusion: Our findings suggest that an initial high-risk EWS in patients admitted to a general hospital ward was associated with an increased risk of in-hospital mortality, ICU admission, and prolonged hospital LOS. Close monitoring and precise documentation of the EWS in the EHR may facilitate predicting poor outcomes in individual hospitalized patients and help to identify patients for whom timely and adequate management may improve outcomes

Evaluation of the Initial General Ward Early Warning Score and ICU Admission, Hospital Length of Stay and Mortality

Introduction: Despite widespread implementation of the Early Warning Score (EWS) in hospitals, its effect on patient outcomes remains mostly unknown. We aimed to evaluate associations between the initial EWS and in-hospital mortality, intensive care unit (ICU) admission, and hospital length of stay (LOS).  Methods: We performed a retrospective cohort study of adult patients admitted to a general hospital ward between July 1, 2014–December 31, 2017. Data were obtained from electronic health records (EHR). The primary outcome was in-hospital mortality. Secondary outcomes were ICU admission and hospital LOS. We categorized patients into three risk groups (low, medium or high risk of clinical deterioration) based on EWS. Descriptive analyses were used. Results: After applying inclusion and exclusion criteria, we included 53,180 patients for analysis. We found that the initial (low- vs high-risk) EWS was associated with an increased in-hospital mortality (1.5% vs 25.3%, P <0.001), an increased ICU admission rate (3.1% vs 17.6%, P <0.001), and an extended hospital LOS (4.0 days vs 8.0 days, P <0.001). Conclusion: Our findings suggest that an initial high-risk EWS in patients admitted to a general hospital ward was associated with an increased risk of in-hospital mortality, ICU admission, and prolonged hospital LOS. Close monitoring and precise documentation of the EWS in the EHR may facilitate predicting poor outcomes in individual hospitalized patients and help to identify patients for whom timely and adequate management may improve outcomes

Peiling wiskunde in het basisonderwijs - Eindrapport

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Effect of intensive insulin therapy on the somatotropic axis in critically ill children

INTRODUCTION Critical illness evokes a ‘catabolic’ response within the growth hormone (GH)/insulin-like growth factor-I (IGF-I) axis. Despite improving patient outcome, intensive insulin therapy (IIT) in critically ill adults unexpectedly lowered IGF-I and increased GH, possibly explained by concomitant malnutrition. In the pediatric intensive care unit (PICU), targeting blood glucose levels to age-adjusted normal fasting values also reduced morbidity and mortality, despite increased incidence of (brief) hypoglycemia. Hormonal responses in children may differ from adults and higher amounts of feeding are administered in critically ill children. We therefore hypothesized that IIT in PICU patients could reactivate the somatotropic axis. METHODS This was a pre-planned subanalysis of all 700 pediatric critically ill patients included in a prospective, randomized study on IIT. Patients were randomly assigned to target blood glucose levels of 50-80 mg/dL in infants (age <1 year, n=317) and 70-100 mg/dL in children (age ≥1 year, n=383) with insulin infusion throughout ICU stay (IIT), or to insulin infusion only to prevent blood glucose from exceeding 215 mg/dL (conventional insulin therapy, CIT). We analyzed blood samples taken upon PICU admission, day 3 and day 7 from patients who were still in PICU on these days. In addition, using a nested case-control design, samples taken before and after hypoglycemia were analyzed in 63 patients experiencing hypoglycemia and in 63 matched patients without hypoglycemia. Circulating insulin, C-peptide, GH, IGF-I, IGF-binding protein (IGFBP)-1, IGFBP-3 and acid labile subunit (ALS) were determined by radio-immunoassays (RIA). Bio-available IGF-I was quantified using a kinase receptor activation assay. In the nested case-control study, we also quantified circulating cortisol and glucagon. RESULTS On day 3 and day 7, circulating insulin was somewhat higher (p=0.026 and p=0.004) whereas C-peptide was >10-fold lower (all p<0.001) in the IIT group than in the CIT group. On day 3, IIT increased circulating GH (p=0.041), while there was no difference on day 7. Total IGF-I was unaltered. In contrast, bio-available IGF-I was lower on day 3 (p=0.002), but not on day 7, in the IIT group. IIT also decreased IGFBP-3 and ALS levels on day 3 (p=0.001 and p=0.007) and day 7 (p=0.003 and p=0.038) as compared with CIT. In contrast, IGFBP-1 levels were increased by IIT on day 3 only (p=0.044). Multivariate logistic regression analysis suggested that only the lowering of portal insulin, as reflected by C-peptide, may have mediated an important part of the mortality benefit. In the nested case-control study, after “hypoglycemia”, only IGFBP-1 remained high in the cases whereas it decreased in controls (p=0.055). No changes in cortisol or glucagon occurred with hypoglycemia. CONCLUSION While improving outcome of PICU patients, IIT further accentuated the illness-associated ‘catabolic’ response within the somatotropic axis, despite feeding. Too low blood glucose targets may have played a role. However, the elimination of the portal insulin effect by exogenous insulin, as reflected by C-peptide, may also explain the changes within the GH axis. This C-peptide effect appeared to statistically explain at least part of the survival benefit with IIT.status: publishe