APACHE III outcome prediction in patients admitted to the intensive care unit after liver transplantation: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after orthotopic liver transplantation (OLT). We hypothesized that APACHE III would perform satisfactorily in patients after OLT</p> <p>Methods</p> <p>A retrospective cohort study was performed. Patients admitted to the ICU after OLT between July 1996 and May 2008 were identified. Data were abstracted from the institutional APACHE III and liver transplantation databases and individual patient medical records. Standardized mortality ratios (with 95% confidence intervals) were calculated by dividing the observed mortality rates by the rates predicted by APACHE III. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow C statistic were used to assess, respectively, discrimination and calibration of APACHE III.</p> <p>Results</p> <p>APACHE III data were available for 918 admissions after OLT. Mean (standard deviation [SD]) APACHE III (APIII) and Acute Physiology (APS) scores on the day of transplant were 60.5 (25.8) and 50.8 (23.6), respectively. Mean (SD) predicted ICU and hospital mortality rates were 7.3% (15.4) and 10.6% (18.9), respectively. The observed ICU and hospital mortality rates were 1.1% and 3.4%, respectively. The standardized ICU and hospital mortality ratios with their 95% C.I. were 0.15 (0.07 to 0.27) and 0.32 (0.22 to 0.45), respectively.</p> <p>There were statistically significant differences in APS, APIII, predicted ICU and predicted hospital mortality between survivors and non-survivors. In predicting mortality, the AUC of APACHE III prediction of hospital death was 0.65 (95% CI, 0.62 to 0.68). The Hosmer-Lemeshow C statistic was 5.288 with a p value of 0.871 (10 degrees of freedom).</p> <p>Conclusion</p> <p>APACHE III discriminates poorly between survivors and non-survivors of patients admitted to the ICU after OLT. Though APACHE III has been shown to be valid in heterogenous populations and in certain groups of patients with specific diagnoses, it should be used with caution – if used at all – in recipients of liver transplantation.</p

Glacial-Interglacial changes in moisture balance and the impact on vegetation in the southern hemisphere tropical Andes (Bolivia/Peru)

A palynological investigation of the last glacial-interglacial cycle in the southern hemisphere tropical Andes reveals changes in the moisture balance as the main driver in vegetation change. Thirty accelerated mass spectrometry radiocarbon dates, biostratigraphy and tephra correlation reveal that a 119 metre sediment core recovered from the Huiñaimarca sub-basin of Lake Titicaca (16.0° to 17.5° S, 68.5° to 70° W; 3810 masl) contains sediments covering >151,000 years. Correlation of aridity indicators with precessional variations in insolation is used to fine tune the structure of the age-depth curve within this period. Variations in Isoëtes concentration (above/below 10,000 grains/cm3) identify the extent of shallow water environments. Examination of other palaeolimnological indicators (Pediastrum) and consideration of the bathymetry of the Huiñaimarca sub-basin allow the reconstruction of lake level fluctuations. These data indicate five wet/dry cycles between c. 151,000 and 14,200 cal yr BP. High stands are suggested during the transition into (c. 134,000 cal yr BP), and out of (c. 114,000, 92,000 cal yr BP), the last interglacial,and during full glacial conditions (c. 70,000 and 45,000 cal yr BP). These cycles are superimposed on a general trend of deepening lake levels through the glacial period. This interpretation is supported by correlation with sediments from Salar de Uyuni (20oS, 68oW; 3653 masl). The youngest wet episode is concurrent with palaeolake Minchin (c. 45,000 cal yr BP), with further evidence for an additional wet period commencing c. 28,000 cal yr BP, concomitant with palaeolake Tauca. The timing of lake level fluctuations is also supported by palaeoshoreline reconstructions from the Uyuni-Poopó region. However, our data do not suggest a major peak in lake level in Huiñaimarca during the Ouki lake cycle (c. 120,000-98,000 cal yr BP) as inferred from U-Th ages obtained from palaeoshorelines around Lago Poopó. The most extreme dry event occurs during the last interglacial period and resulted in a sedimentary hiatus tentatively dated to c. 121,000-129,000 cal yr BP. The observed wet/dry cycles are shown to have a marked and rapid impact on the vegetation. The aridity of the last interglacial promoted a community dominated by Chenopodiaceae/Amaranthacae, with no modern Andean analogue. Polylepis/Acaena pollen is also shown to fluctuate markedly (0-20%), particularly during the transitions into, and out of, the last interglacial. It is probable that this pollen taxon is primarily representative of the high altitude arboreal genus Polylepis, which is a key component of highly biodiverse Andean woodlands today. Rapid fluctuations indicate the sensitivity of this ecosystem to natural environmental pressure and potential vulnerability to future human impact and climate change. The 100,000 year (eccentricity) solar cycle is shown to be the major controlling factor in moisture balance and vegetation over the last glacial-interglacial cycle. However, significant fluctuations in moisture balance are also evident on timescales considerably shorter than the full glacial-interglacial cycle. We have linked these to precessional (21,000 year) forcing. Nevertheless, precise independent dating during the full glacial cycle is required to confirm the importance of this forcing mechanism

Two-Photon Imaging of Cortical Surface Microvessels Reveals a Robust Redistribution in Blood Flow after Vascular Occlusion

A highly interconnected network of arterioles overlies mammalian cortex to route blood to the cortical mantle. Here we test if this angioarchitecture can ensure that the supply of blood is redistributed after vascular occlusion. We use rodent parietal cortex as a model system and image the flow of red blood cells in individual microvessels. Changes in flow are quantified in response to photothrombotic occlusions to individual pial arterioles as well as to physical occlusions of the middle cerebral artery (MCA), the primary source of blood to this network. We observe that perfusion is rapidly reestablished at the first branch downstream from a photothrombotic occlusion through a reversal in flow in one vessel. More distal downstream arterioles also show reversals in flow. Further, occlusion of the MCA leads to reversals in flow through approximately half of the downstream but distant arterioles. Thus the cortical arteriolar network supports collateral flow that may mitigate the effects of vessel obstruction, as may occur secondary to neurovascular pathology

Moderate Traumatic Brain Injury Causes Acute Dendritic and Synaptic Degeneration in the Hippocampal Dentate Gyrus

Hippocampal injury-associated learning and memory deficits are frequent hallmarks of brain trauma and are the most enduring and devastating consequences following traumatic brain injury (TBI). Several reports, including our recent paper, showed that TBI brought on by a moderate level of controlled cortical impact (CCI) induces immature newborn neuron death in the hippocampal dentate gyrus. In contrast, the majority of mature neurons are spared. Less research has been focused on these spared neurons, which may also be injured or compromised by TBI. Here we examined the dendrite morphologies, dendritic spines, and synaptic structures using a genetic approach in combination with immunohistochemistry and Golgi staining. We found that although most of the mature granular neurons were spared following TBI at a moderate level of impact, they exhibited dramatic dendritic beading and fragmentation, decreased number of dendritic branches, and a lower density of dendritic spines, particularly the mushroom-shaped mature spines. Further studies showed that the density of synapses in the molecular layer of the hippocampal dentate gyrus was significantly reduced. The electrophysiological activity of neurons was impaired as well. These results indicate that TBI not only induces cell death in immature granular neurons, it also causes significant dendritic and synaptic degeneration in pathohistology. TBI also impairs the function of the spared mature granular neurons in the hippocampal dentate gyrus. These observations point to a potential anatomic substrate to explain, in part, the development of posttraumatic memory deficits. They also indicate that dendritic damage in the hippocampal dentate gyrus may serve as a therapeutic target following TBI

Brazilian montane rainforest expansion induced by Heinrich Stadial 1 event

The origin of modern disjunct plant distributions in the Brazilian Highlands with strong floristic affinities to distant montane rainforests of isolated mountaintops in the northeast and northern Amazonia and the Guyana Shield remains unknown. We tested the hypothesis that these unexplained biogeographical patterns reflect former ecosystem rearrangements sustained by widespread plant migrations possibly due to climatic patterns that are very dissimilar from present-day conditions. To address this issue, we mapped the presence of the montane arboreal taxa Araucaria, Podocarpus, Drimys, Hedyosmum, Ilex, Myrsine, Symplocos, and Weinmannia, and cool-adapted plants in the families Myrtaceae, Ericaceae, and Arecaceae (palms) in 29 palynological records during Heinrich Stadial 1 Event, encompassing a latitudinal range of 30°S to 0°S. In addition, Principal Component Analysis and Species Distribution Modelling were used to represent past and modern habitat suitability for Podocarpus and Araucaria. The data reveals two long-distance patterns of plant migration connecting south/southeast to northeastern Brazil and Amazonia with a third short route extending from one of them. Their paleofloristic compositions suggest a climatic scenario of abundant rainfall and relative lower continental surface temperatures, possibly intensified by the effects of polar air incursions forming cold fronts into the Brazilian Highlands. Although these taxa are sensitive to changes in temperature, the combined pollen and speleothems proxy data indicate that this montane rainforest expansion during Heinrich Stadial 1 Event was triggered mainly by a less seasonal rainfall regime from the subtropics to the equatorial region.This work was funded by FAPESP research grant 2015/50683-2 to P.E. De Oliveira, VULPES Project, Belmount Forum