EPIdemiology of Surgery-Associated Acute Kidney Injury (EPIS-AKI) : Study protocol for a multicentre, observational trial

More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI. EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI. EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials. Trial registration number NCT04165369

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p<0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p<0\ub70001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding: No funding

A warning threshold for monitoring tuberculosis surveillance data: An alternative to hidden Markov model

Objectives: Although hidden Markov model (HMM) is known as a powerful tool for the detection of epidemics based on the historical data, the frequent use of such a model poses some limitation especially when decision-making is required for new observations. This study was aimed to address a warning threshold for monitoring the weekly incidences of tuberculosis as an alternative to HMM. Methods: We extracted the weekly counts of newly diagnosed patients with sputum smear-positive pulmonary TB from 2005 to 2011 nationwide. To detect unexpected incidences of the disease, two approaches: Serfling and HMM, were applied in presence/absence of linear, seasonal and autoregressive components. Models were subsequently evaluated in terms of goodness of fit, and their results were compared in detection of the disease phases. Then, multiple hypothetical thresholds were constructed based on the estimate of models and the optimal one was revealed through ROC curve analysis. Results: Findings from both adjusted R-square (R~2) and Bayesian information criterion (BIC) presented a higher goodness of fit for periodic autoregressive HMM (BIC = -1323.6; R~2=0.74) than other models. According to ROC analysis, better values for both Youden's index and area under curve (0. 96 and 0. 98 respectively) were obtained by the threshold based on the estimate of periodic autoregressive model. Conclusions: As the optimal threshold presented in this study is simple in concept and has no limitation in practice, especially for monitoring new observations, we would recommend such a threshold to be used for monitoring of TB incidence data in the surveillance system. © 2015 John Wiley & Sons Ltd

Tuberculosis Surveillance Using a Hidden Markov Model

Background: Routinely collected data from tuberculosis surveillance system can be used to investigate and monitor the irregularities and abrupt changes of the disease incidence. We aimed at using a Hidden Markov Model in order to detect the abnormal states of pulmonary tuberculosis in Iran.Methods: Data for this study were the weekly number of newly diagnosed cases with sputum smear-positive pulmonarytuberculosis reported between April 2005 and March 2011 throughout Iran. In order to detect the unusual states of the disease, two Hidden Markov Models were applied to the data with and without seasonal trends as baselines.Consequently, the best model was selected and compared with the results of Serfling epidemic threshold which is typically used in the surveillance of infectious diseases.Results: Both adjusted R-squared and Bayesian Information Criterion (BIC) reflected better goodness-of-fit for the model with seasonal trends (0.72 and -1336.66, respectively) than the model without seasonality (0.56 and -1386.75).Moreover, according to the Serfling epidemic threshold, higher values of sensitivity and specificity suggest a higher validity for the seasonal model (0.87 and 0.94, respectively) than model without seasonality (0.73 and 0.68, respectively).Conclusion: A two-state Hidden Markov Model along with a seasonal trend as a function of the model parameters provides an effective warning system for the surveillance of tuberculosis

Comparison of the effects of intrathecal fentanyl and intrathecal morphine on pain in elective total knee replacement surgery

PubMedID: 28115877Objective. Total knee replacement is one of the most painful orthopedic surgical procedures. In this study, our goal was to compare the intraoperative and postoperative hemodynamic effects, the side effects, the effect on the duration of pain start, the 24-hour VAS, and the amount of additional analgesia used, of the fentanyl and morphine we added to the local anesthetic in the spinal anesthesia we administered in cases of elective knee replacement. Materials and Methods.After obtaining the approval of the ErciyesUniversity Medical Faculty Clinical Drug Trials Ethics Committee, as well as the verbal and written consent of the patients, we included 50 patients in our prospective, randomized study. Results. In our study, the morphine group (Group M) had lower pain scores in the 2nd, 6th, 12th, and 24th hours compared to the fentanyl group (Group F).When additional analgesic requirements were compared, it was found that in the 2nd, 6th, and 24th hours fewer Group M patients needed more analgesics than did Group F patients. Conclusion.The fentanyl group also had lower first analgesic requirement times than did the morphine group. In terms of nausea and vomiting, there was no statistically significant difference between the two groups. Copyright © 2016 Refika Kiliçkaya et al

Fluid resuscitation in the treatment of uncontrolled hemorrhagic shock

Background: We evaluated the effect of continuous fluid resuscitation on the hemodynamic response and survival following massive splenic injury (MSI) in rats

Yield potentials of narbonne vetch (Vicia narbonensis L.) genotypes in different environmental conditions

The purpose of the research was to determine the yield potentials of narbonne vetch (Vicia narbonnesis L.) genotypes in different environmental conditions. Narbonne vetch genotypes were grown in three different locations of Trakya region during 2002-2004. Eight Narbonne vetch genotypes (genotype numbered 236, 512, 524, 570, 908, 14, Ege and one population) were used as material in the research. The results showed that seed yield, herbage yield and hay yield were significantly affected (P <= 0.05) by genotypes, while branch number and pod number per plant were not significantly affected by genotypes. Therefore, plant height and thousand seed weight were significantly affected (P <= 0.01) by genotypes. Plant height, seed yield, herbage yield and hay yield were significantly affected (P <= 0.01) by locations and location x genotype interaction. Branch number per plant, pod number per plant and thousand seed weight were not affected significantly by locations. While the highest seed and forage yields were obtained in Hayrabolu location, seed and forage yields in Kirklareli were less than in the other locations. In the study; plant height, branch number, pod number, thousand seed weight, seed yield, herbage yield and hay yield were 43.02 - 78.85 cm, 1.40 - 3.17, 6.63 - 19.23, 173.83 - 239.09 g, 143.48 - 351.24 kg da(-1), 821.31 - 2710.79 kg da(-1) and 134.63 - 482.16 kg da(-1), respectively. It was concluded that genotype numbered 908 in Hayrabolu, genotype numbered 512 in Tekirdag and genotype numbered 524 in Kirklareli were suitable for forage production whereas genotype numbered 908 in Hayrabolu, genotype numbered 908 and 570 in Tekirdag and genotype numbered 512 in Kirklareli for seed production. Narbonne vetch genotypes had different yield potentials in three environmental conditions of Trakya region which is in the Marmara region of Turkey