Clinician preference instrumental variable analysis of the effectiveness of magnesium supplementation for atrial fibrillation prophylaxis in critical care

Atrial fibrillation is a frequently encountered condition in critical illness and causes adverse effects including haemodynamic decompensation, stroke and prolonged hospital stay. It is a common practice in critical care to supplement serum magnesium for the purpose of preventing episodes of atrial fibrillation. However, no randomised studies support this practice in the non-cardiac surgery critical care population, and the effectiveness of magnesium supplementation is unclear. We sought to investigate the effectiveness of magnesium supplementation in preventing the onset of atrial fibrillation in a mixed critical care population. We conducted a single centre retrospective observational study of adult critical care patients. We utilised a natural experiment design, using the supplementation preference of the bedside critical care nurse as an instrumental variable. Using routinely collected electronic patient data, magnesium supplementation opportunities were defined and linked to the bedside nurse. Nurse preference for administering magnesium was obtained using multilevel modelling. The results were used to define "liberal" and "restrictive" supplementation groups, which were inputted into an instrumental variable regression to obtain an estimate of the effect of magnesium supplementation. 9114 magnesium supplementation opportunities were analysed, representing 2137 critical care admissions for 1914 patients. There was significant variation in magnesium supplementation practices attributable to the individual nurse, after accounting for covariates. The instrumental variable analysis showed magnesium supplementation was associated with a 3% decreased relative risk of experiencing an atrial fibrillation event (95% CI − 0.06 to − 0.004, p = 0.03). This study supports the strategy of routine supplementation, but further work is required to identify optimal serum magnesium targets for atrial fibrillation prophylaxis

Zirconium oxide nanoparticles: Protocolicidal effect against hydatid cyst protoscoleces with interleukins evaluation in mice

The current study investigated the effect of zirconium oxide nanoparticles NPs on the levels of interleukins in mice inoculated with protoscoleces of Echinococcus granulosus, after exposure to ZrO2 NPs at the doses,5,10,50, and 100 µg /ml for 30 minutes, and different periods of infection, on the other hand, control groups inoculated with unexposed protoscoleces to the nanoparticles. Following the infection, blood serum was obtained from animals to determine interleukin levels using sandwich ELISA technique three, four, and five months following the infection. The outcome of the study demonstrated a significant decrease in IL-5, IL-12 levels, and a significant increase in IFN-γ- levels in treated mice compared with control groups. The lowest value of IL-5 was 11.164 ng /ml at the dose of 100 µg /ml compared to the control group 47.446 ng /ml, four months after infestation, while the lowest value for IL-12 was 12.824 ng/ml, at 100 µg /ml, compared to 112.485 ng/mL in the control group, five months to infection. IFN-γ was significantly increased in the treated mice, 207.39 ng/ml, at 100 µg /ml, compared to 110.07 ng/mL in the control group, five months after injury. Based on the research outcome, ZrO2 nanoparticles could be exploited as a consequential titer for assessing the immune situation and, consequently as a dynamic curative of hydatidosis

Larvicidal effect of zirconium oxide nanoparticles in protoscoleces of hydatid cysts in the laboratory and mice

The research focuses on the effect of zirconium oxide nanoparticles in the activity of protoscoleces of Echinococcus granulosus in the lab., seven strengths of the solution have been employed, 2.5, 5, 10, 15, 25, 50, and 100 µg/milliliter in distinct exposition durations, 10, 20, 30, 60, 90 minutes. Scottish mice have been inoculated with PSCs exposed to zirconium oxide nanoparticles of 5, 10, 50, and 100 ug/milliliter, for 30 minutes. Unimposing protoscoleces to ZrO2 nanoparticles were administered to another group of animals as a controlling series. The whole experimental series has been anatomized after 3, 4, and 5 months after infestation. The results illustrated the apparent impact of zirconium oxide on the liveliness of protoscoleces, by increasing exposure time and strength concentricity in the laboratory, predominantly 29 and 0% at a concentration of 100 ug/ml at 60, and 90 minutes, distinctly. Likewise considerable diminished numbering of rising cysts in treated mice, mainly, at a concentration of 50 and 100 ug/ml in the fourth and fifth months 89.53 and 90.21% of invasion, with a presumed decrease in the diameters and weights of cysts in treated mice, exceptionally in the fifth month, in comparison with the untreated group. These observations presumed ZrO2 nanoparticles, as a promising alternative agent against hydatid disease through future supplementary research

Protocol and statistical analysis plan for the mega randomised registry trial comparing conservative vs. liberal oxygenation targets in adults with nonhypoxic ischaemic acute brain injuries and conditions in the intensive care unit (Mega-ROX Brains)

Background: The effect of conservative vs. liberal oxygen therapy on 90-day in-hospital mortality in adults who have nonhypoxic ischaemic encephalopathy acute brain injuries and conditions and are receiving invasive mechanical ventilation in the intensive care unit (ICU) is uncertain. Objective: The objective of this study was to summarise the protocol and statistical analysis plan for the Mega-ROX Brains trial. Design, setting, and participants: Mega-ROX Brains is an international randomised clinical trial, which will be conducted within an overarching 40,000-participant, registry-embedded clinical trial comparing conservative and liberal ICU oxygen therapy regimens. We expect to enrol between 7500 and 9500 participants with nonhypoxic ischaemic encephalopathy acute brain injuries and conditions who are receiving unplanned invasive mechanical ventilation in the ICU. Main outcome measures: The primary outcome is in-hospital all-cause mortality up to 90 d from the date of randomisation. Secondary outcomes include duration of survival, duration of mechanical ventilation, ICU length of stay, hospital length of stay, and the proportion of participants discharged home. Results and conclusions: Mega-ROX Brains will compare the effect of conservative vs. liberal oxygen therapy regimens on 90-day in-hospital mortality in adults in the ICU with acute brain injuries and conditions. The protocol and planned analyses are reported here to mitigate analysis bias. Trial Registration: Australian and New Zealand Clinical Trials Registry (ACTRN 12620000391976)

Experiences of ICU survivors in a low middle income country - A multicenter study

Background Stressful patient experiences during the intensive care unit (ICU) stay is associated with reduced satisfaction in High Income Countries (HICs) but has not been explored in Lower and Middle Income Countries (LMICs). This study describes the recalled experiences, stress and satisfaction as perceived by survivors of ICUs in a LMIC. Methods This follow-up study was carried out in 32 state ICUs in Sri Lanka between July and December 2015.ICU survivors’ experiences, stress factors encountered and level of satisfaction were collected 30 days after ICU discharge by a telephone questionnaire adapted from Granja and Wright Results Of 1665 eligible ICU survivors, 23.3% died after ICU discharge, 49.1% were uncontactable and 438 (26.3%) patients were included in the study. Whilst 78.1% (n = 349) of patients remembered their admission to the hospital, only 42.3% (n = 189) could recall their admission to the ICU. The most frequently reported stressful experiences were: being bedridden (34.2%), pain (34.0%), general discomfort (31.7%), daily needle punctures (32.9%), family worries (33.6%), fear of dying and uncertainty in the future (25.8%). The majority of patients (376, 84.12%) found the atmosphere of the ICU to be friendly and calm. Overall, the patients found the level of health care received in the ICU to be “very satisfactory” (93.8%, n = 411) with none of the survivors stating they were either “dissatisfied” or “very dissatisfied”. Conclusions In common with HIC, survivors were very satisfied with their ICU care. In contrast to HIC settings, specific ICU experiences were frequently not recalled, but those remembered were reported as relatively stress-free. Stressful experiences, in common with HIC, were most frequently related to uncertainty about the future, dependency, family, and economic concerns

Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting

Objective This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented. Design Longitudinal observational cohort study. Setting District General Hospital Monaragala Participants All adult (age >17 years) admitted patients. Main outcome measures Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period. Statistical Analysis Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve. Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV). Results Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%). Conclusion There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients

The Association between Supraphysiologic Arterial Oxygen Levels and Mortality in Critically Ill Patients. A Multicenter Observational Cohort Study.

Rationale: There is conflicting evidence on harm related to exposure to supraphysiologic PaO2 (hyperoxemia) in critically ill patients.Objectives: To examine the association between longitudinal exposure to hyperoxemia and mortality in patients admitted to ICUs in five United Kingdom university hospitals.Methods: A retrospective cohort of ICU admissions between January 31, 2014, and December 31, 2018, from the National Institute of Health Research Critical Care Health Informatics Collaborative was studied. Multivariable logistic regression modeled death in ICU by exposure to hyperoxemia.Measurements and Main Results: Subsets with oxygen exposure windows of 0 to 1, 0 to 3, 0 to 5, and 0 to 7 days were evaluated, capturing 19,515, 10,525, 6,360, and 4,296 patients, respectively. Hyperoxemia dose was defined as the area between the PaO2 time curve and a boundary of 13.3 kPa (100 mm Hg) divided by the hours of potential exposure (24, 72, 120, or 168 h). An association was found between exposure to hyperoxemia and ICU mortality for exposure windows of 0 to 1 days (odds ratio [OR], 1.15; 95% compatibility interval [CI], 0.95-1.38; P = 0.15), 0 to 3 days (OR 1.35; 95% CI, 1.04-1.74; P = 0.02), 0 to 5 days (OR, 1.5; 95% CI, 1.07-2.13; P = 0.02), and 0 to 7 days (OR, 1.74; 95% CI, 1.11-2.72; P = 0.02). However, a dose-response relationship was not observed. There was no evidence to support a differential effect between hyperoxemia and either a respiratory diagnosis or mechanical ventilation.Conclusions: An association between hyperoxemia and mortality was observed in our large, unselected multicenter cohort. The absence of a dose-response relationship weakens causal interpretation. Further experimental research is warranted to elucidate this important question

Sample multiplexing-based targeted pathway proteomics with real-time analytics reveals the impact of genetic variation on protein expression.

Targeted proteomics enables hypothesis-driven research by measuring the cellular expression of protein cohorts related by function, disease, or class after perturbation. Here, we present a pathway-centric approach and an assay builder resource for targeting entire pathways of up to 200 proteins selected from \u3e10,000 expressed proteins to directly measure their abundances, exploiting sample multiplexing to increase throughput by 16-fold. The strategy, termed GoDig, requires only a single-shot LC-MS analysis, ~1 µg combined peptide material, a list of up to 200 proteins, and real-time analytics to trigger simultaneous quantification of up to 16 samples for hundreds of analytes. We apply GoDig to quantify the impact of genetic variation on protein expression in mice fed a high-fat diet. We create several GoDig assays to quantify the expression of multiple protein families (kinases, lipid metabolism- and lipid droplet-associated proteins) across 480 fully-genotyped Diversity Outbred mice, revealing protein quantitative trait loci and establishing potential linkages between specific proteins and lipid homeostasis