A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs

BACKGROUND: Traditional vital signs (TVS), including systolic blood pressure (SBP), heart rate (HR) and their composite, the shock index, may be poor prognostic indicators in geriatric trauma patients. The purpose of this study is to determine whether lactate predicts mortality better than TVS. METHODS: We studied a large cohort of trauma patients age ≥ 65 years admitted to a level 1 trauma center from 2009-01-01 - 2011-12-31. We defined abnormal TVS as hypotension (SBP < 90 mm Hg) and/or tachycardia (HR > 120 beats/min), an elevated shock index as HR/SBP ≥ 1, an elevated venous lactate as ≥ 2.5 mM, and occult hypoperfusion as elevated lactate with normal TVS. The association between these variables and in-hospital mortality was compared using Chi-square tests and multivariate logistic regression. RESULTS: There were 1987 geriatric trauma patients included, with an overall mortality of 4.23% and an incidence of occult hypoperfusion of 20.03%. After adjustment for GCS, ISS, and advanced age, venous lactate significantly predicted mortality (OR: 2.62, p < 0.001), whereas abnormal TVS (OR: 1.71, p = 0.21) and SI ≥ 1 (OR: 1.18, p = 0.78) did not. Mortality was significantly greater in patients with occult hypoperfusion compared to patients with no sign of circulatory hemodynamic instability (10.67% versus 3.67%, p < 0.001), which continued after adjustment (OR: 2.12, p = 0.01). CONCLUSIONS: Our findings demonstrate that occult hypoperfusion was exceedingly common in geriatric trauma patients, and was associated with a two-fold increased odds of mortality. Venous lactate should be measured for all geriatric trauma patients to improve the identification of hemodynamic instability and optimize resuscitative efforts

Modelling circumstellar discs with 3D radiation hydrodynamics

We present results from combining a grid-based radiative transfer code with a Smoothed Particle Hydrodynamics code to produce a flexible system for modelling radiation hydrodynamics. We use a benchmark model of a circumstellar disc to determine a robust method for constructing a gridded density distribution from SPH particles. The benchmark disc is then used to determine the accuracy of the radiative transfer results. We find that the SED and the temperature distribution within the disc are sensitive to the representation of the disc inner edge, which depends critically on both the grid and SPH resolution. The code is then used to model a circumstellar disc around a T-Tauri star. As the disc adjusts towards equilibrium vertical motions in the disc are induced resulting in scale height enhancements which intercept radiation from the central star. Vertical transport of radiation enables these perturbations to influence the mid-plane temperature of the disc. The vertical motions decay over time and the disc ultimately reaches a state of simultaneous hydrostatic and radiative equilibrium.Comment: MNRAS accepted; 15 pages; 17 figures, 4 in colou

Protostellar accretion traced with chemistry. High resolution C18O and continuum observations towards deeply embedded protostars in Perseus

Context: Understanding how accretion proceeds is a key question of star formation, with important implications for both the physical and chemical evolution of young stellar objects. In particular, very little is known about the accretion variability in the earliest stages of star formation. Aims: To characterise protostellar accretion histories towards individual sources by utilising sublimation and freeze-out chemistry of CO. Methods: A sample of 24 embedded protostars are observed with the Submillimeter Array (SMA) in context of the large program "Mass Assembly of Stellar Systems and their Evolution with the SMA" (MASSES). The size of the C$^{18}$O emitting region, where CO has sublimated into the gas-phase, is measured towards each source and compared to the expected size of the region given the current luminosity. The SMA observations also include 1.3 mm continuum data, which are used to investigate whether a link can be established between accretion bursts and massive circumstellar disks. Results: Depending on the adopted sublimation temperature of the CO ice, between 20% and 50% of the sources in the sample show extended C$^{18}$O emission indicating that the gas was warm enough in the past that CO sublimated and is currently in the process of refreezing; something which we attribute to a recent accretion burst. Given the fraction of sources with extended C$^{18}$O emission, we estimate an average interval between bursts of 20000-50000 yr, which is consistent with previous estimates. No clear link can be established between the presence of circumstellar disks and accretion bursts, however the three closest known binaries in the sample (projected separations <20 AU) all show evidence of a past accretion burst, indicating that close binary interactions may also play a role in inducing accretion variability.Comment: Accepted for publication in A&A, 21 pages, 13 figure

Long-term efficacy and safety of first-line ibrutinib treatment for patients with CLL/SLL: 5 years of follow-up from the phase 3 RESONATE-2 study.

RESONATE-2 is a phase 3 study of first-line ibrutinib versus chlorambucil in chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Patients aged ≥65 years (n = 269) were randomized 1:1 to once-daily ibrutinib 420 mg continuously or chlorambucil 0.5-0.8 mg/kg for ≤12 cycles. With a median (range) follow-up of 60 months (0.1-66), progression-free survival (PFS) and overall survival (OS) benefits for ibrutinib versus chlorambucil were sustained (PFS estimates at 5 years: 70% vs 12%; HR [95% CI]: 0.146 [0.098-0.218]; OS estimates at 5 years: 83% vs 68%; HR [95% CI]: 0.450 [0.266-0.761]). Ibrutinib benefit was also consistent in patients with high prognostic risk (TP53 mutation, 11q deletion, and/or unmutated IGHV) (PFS: HR [95% CI]: 0.083 [0.047-0.145]; OS: HR [95% CI]: 0.366 [0.181-0.736]). Investigator-assessed overall response rate was 92% with ibrutinib (complete response, 30%; 11% at primary analysis). Common grade ≥3 adverse events (AEs) included neutropenia (13%), pneumonia (12%), hypertension (8%), anemia (7%), and hyponatremia (6%); occurrence of most events as well as discontinuations due to AEs decreased over time. Fifty-eight percent of patients continue to receive ibrutinib. Single-agent ibrutinib demonstrated sustained PFS and OS benefit versus chlorambucil and increased depth of response over time

The Green Bank Ammonia Survey: Unveiling the Dynamics of the Barnard 59 star-forming Clump

Understanding the early stages of star formation is a research field of ongoing development, both theoretically and observationally. In this context, molecular data have been continuously providing observational constraints on the gas dynamics at different excitation conditions and depths in the sources. We have investigated the Barnard 59 core, the only active site of star formation in the Pipe Nebula, to achieve a comprehensive view of the kinematic properties of the source. These information were derived by simultaneously fitting ammonia inversion transition lines (1,1) and (2,2). Our analysis unveils the imprint of protostellar feedback, such as increasing line widths, temperature and turbulent motions in our molecular data. Combined with complementary observations of dust thermal emission, we estimate that the core is gravitationally bound following a virial analysis. If the core is not contracting, another source of internal pressure, most likely the magnetic field, is supporting it against gravitational collapse and limits its star formation efficiency.Comment: 18 pages, 18 figure

CO2 Ice toward Low-luminosity, Embedded Protostars: Evidence for Episodic Mass Accretion via Chemical History

We present Spitzer IRS spectroscopy of CO2 ice bending mode spectra at 15.2 micrometer toward 19 young stellar objects with luminosity lower than 1 Lsun (3 with luminosity lower than 0.1 Lsun). Ice on dust grain surfaces can encode the history of heating because pure CO2 ice forms only at elevated temperature, T > 20 K, and thus around protostars of higher luminosity. Current internal luminosities of YSOs with L < 1 Lsun do not provide the conditions needed to produce pure CO2 ice at radii where typical envelopes begin. The presence of detectable amounts of pure CO2 ice would signify a higher past luminosity. Many of the spectra require a contribution from a pure, crystalline CO2 component, traced by the presence of a characteristic band splitting in the 15.2 micrometer bending mode. About half of the sources (9 out of 19) in the low luminosity sample have evidence for pure CO2 ice, and six of these have significant double-peaked features, which are very strong evidence of pure CO2 ice. The presence of the pure CO2 ice component indicates that the dust temperature, and hence luminosity of the central star/accretion disk system, must have been higher in the past. An episodic accretion scenario, in which mixed CO-CO2 ice is converted to pure CO2 ice during each high luminosity phase, explains the presence of pure CO2 ice, the total amount of CO2 ice, and the observed residual C18O gas.Comment: Accepted for publication in ApJ, total 24 pages, 14 figure

Interactions between brown-dwarf binaries and Sun-like stars

Several mechanisms have been proposed for the formation of brown dwarfs, but there is as yet no consensus as to which -- if any -- are operative in nature. Any theory of brown dwarf formation must explain the observed statistics of brown dwarfs. These statistics are limited by selection effects, but they are becoming increasingly discriminating. In particular, it appears (a) that brown dwarfs that are secondaries to Sun-like stars tend to be on wide orbits, a\ga 100\,{\rm AU} (the Brown Dwarf Desert), and (b) that these brown dwarfs have a significantly higher chance of being in a close (a\la 10\,{\rm AU}) binary system with another brown dwarf than do brown dwarfs in the field. This then raises the issue of whether these brown dwarfs have formed {\it in situ}, i.e. by fragmentation of a circumstellar disc; or have formed elsewhere and subsequently been captured. We present numerical simulations of the purely gravitational interaction between a close brown-dwarf binary and a Sun-like star. These simulations demonstrate that such interactions have a negligible chance ($<0.001$) of leading to the close brown-dwarf binary being captured by the Sun-like star. Making the interactions dissipative by invoking the hydrodynamic effects of attendant discs might alter this conclusion. However, in order to explain the above statistics, this dissipation would have to favour the capture of brown-dwarf binaries over single brown-dwarfs, and we present arguments why this is unlikely. The simplest inference is that most brown-dwarf binaries -- and therefore possibly also most single brown dwarfs -- form by fragmentation of circumstellar discs around Sun-like protostars, with some of them subsequently being ejected into the field.Comment: 10 pages, 8 figures, Accepted for publication in Astrophysics and Space Scienc