Nationwide pediatric mortality: drug toxicology, unknown causes of death, and autopsy rates

Deaths among the pediatric population encompass a small percentage of the total number of fatalities across the United States. Since the deaths of infants, children, and adolescents are rare, there is little forensic literature concerning this age group. Autopsies, if performed completely, can reveal additional information surrounding circumstances of a case and leads to a determination of a cause of death or a diagnosis of exclusion. Yet studies report that nationwide autopsy rates are low, despite an increase of drugs in the environment and the prevalence of ill-defined causes of death. With the use of the Centers of Disease Control and Prevention (CDC) internet database Wide-ranging Online Data for Epidemiologic Research (WONDER), all deaths of individuals 19 years old and under were analyzed for years 2000, 2005, and 2010. The three main areas that were examined through the WONDER database were poisoning deaths for all ages, ill-defined causes of death for the infant age group, and overall autopsy rates for the three age groups with the highest crude rate of death. The crude death rate for all pediatric age groups have decreased within the examined decade. The infant age group comprised the majority of all pediatric fatalities and had the highest crude death rate. Individuals in the 15 to 19 year age group had the second highest crude death rate of the pediatric population. With a low number of total pediatric poisoning deaths, there has been a steady increase in crude death rate over the decade. The 15-19 age group encompassed the majority of these types of fatalities, with a total of 942 in 2010. It was also discovered that not every pediatric victim was autopsied when a death was diagnosed as a poisoning death when examined by a forensic pathologist. Infant ill-defined causes of death consisted of just over 12% nationwide for all years studied. However approximately 70% of all infant ill-defined causes of death were diagnosed as Sudden Infant Death Syndrome (SIDS) in 2000 and 2010. When examining autopsy rates for the year 2010, autopsies were performed for 32.9% of infant deaths, 55.1% of child deaths between 1-4 years of age, and 59.8% of teenage deaths between 15-19 years of age. In 2010, implementation of autopsies is uncertain for 2,454 deaths under 1 year, 255 deaths between 1 and 4 years, and 666 between 15 and 19 years. Measures need to be put in place nationwide to increase the rate of autopsies for the pediatric population and there needs to be strict accountability when it is not reported on a death certificate whether or not an autopsy was performed. Standard operating procedures should be applied for all autopsies of pediatric victims, with a toxicology examination always being included in an investigation

Telemedicine coverage for post-operative ICU patients.

Introduction There is an increased demand for intensive care unit (ICU) beds. We sought to determine if we could create a safe surge capacity model to increase ICU capacity by treating ICU patients in the post-anaesthesia care unit (PACU) utilizing a collaborative model between an ICU service and a telemedicine service during peak ICU bed demand. Methods We evaluated patients managed by the surgical critical care service in the surgical intensive care unit (SICU) compared to patients managed in the virtual intensive care unit (VICU) located within the PACU. A retrospective review of all patients seen by the surgical critical care service from January 1st 2008 to July 31st 2011 was conducted at an urban, academic, tertiary centre and level 1 trauma centre. Results Compared to the SICU group ( n = 6652), patients in the VICU group ( n = 1037) were slightly older (median age 60 (IQR 47-69) versus 58 (IQR 44-70) years, p = 0.002) and had lower acute physiology and chronic health evaluation (APACHE) II scores (median 10 (IQR 7-14) versus 15 (IQR 11-21), p \u3c 0.001). The average amount of time patients spent in the VICU was 13.7 + /-9.6 hours. In the VICU group, 750 (72%) of patients were able to be transferred directly to the floor; 287 (28%) required subsequent admission to the surgical intensive care unit. All patients in the VICU group were alive upon transfer out of the PACU while mortality in the surgical intensive unit cohort was 5.5%. Discussion A collaborative care model between a surgical critical care service and a telemedicine ICU service may safely provide surge capacity during peak periods of ICU bed demand. The specific patient populations for which this approach is most appropriate merits further investigation

Selected Hydrogeologic and Water-quality Data from Jones Beach Island, Long Island, New York

A data-collection site was instrumented on Jones Beach Island, a barrier island south of Long Island, N.Y., to study local freshwater/ saltwater relations in the shallow ground-water system. A geologic test boring revealed about 88 feet of well-sorted glacial outwash sand above about 15 feet of Gardiners Clay, which directly overlies silty sand of the Magothy Formation. Tidal effects on water levels in Great South Bay, the upper glacial aquifer, and the Magothy aquifer were observed and quantified with a tidal gage in the bay and analog water-level recorders in the wells.Chloride concentrations in the upper Magothy aquifer were higher than expected--about 270 mg/L (milligrams per liter), and those in the upper glacial aquifer were 17,000 to 19,000 mg/L, about the same as in Great South Bay. Estimates of pressure and freshwater equivalent heads indicate that, at the data-collection site, freshwater is discharging upward from the Magothy aquifer into the salty upper glacial aquifer, but dilution by this freshwater is undetectable. The reason for the elevated chloride concentration in the Magothy aquifer cannot be determined from available hydrogeologic information

Preliminary study on the use of near infrared hyperspectral imaging for quantitation and localisation of total glucosinolates in freeze-dried broccoli

peer-reviewedThe use of hyperspectral imaging to (a) quantify and (b) localise total glucosinolates in florets of a single broccoli species has been examined. Two different spectral regions (vis–NIR and NIR), a number of spectral pre-treatments and different mask development strategies were studied to develop the quantitative models. These models were then applied to freeze-dried slices of broccoli to identify regions within individual florets which were rich in glucosinolates. The procedure demonstrates potential for the quantitative screening and localisation of total glucosinolates in broccoli using the 950–1650 nm wavelength range. These compounds were mainly located in the external part of florets.Universidad de SevillaJ.M. Hernández-Hierro thanks the Spanish MICINN for the Juan de la Cierva contract (JCI-2011-09201) and Universidad de Sevilla for the mobility Grant (Universidad de Sevilla Research Plan). Spanish MICINN Project AGL2011-30254-C02 and Junta de Andalucia PGC Project AGR 6331

Higher Antioxidant Activity, Total Flavonols, and Specific Quercetin Glucosides in Two Different Onion (Allium cepa L.) Varieties Grown under Organic Production: Results from a 6‑Year Field Study

We carried out a 6-year study to assess the effect of conventional, organic, and mixed cultivation practices on bioactive compounds (flavonoids, anthocyanins) and antioxidant capacity in onion. Total flavonoids, total anthocyanins, individual flavonols, individual anthocyanins, and antioxidant activity were measured in two varieties (‘Hyskin’ and ‘Red Baron’) grown in a long-term split-plot factorial systems comparison trial. This is the first report of repeated measurements of bioactive content over an extensive time period in a single crop type within the same trial. Antioxidant activity (DPPH and FRAP), total flavonol content, and levels of Q 3,4′ D and Q 3 G were higher in both varieties under fully organic compared to fully conventional management. Total flavonoids were higher in ‘Red Baron’ and when onions were grown under organic soil treatment. Differences were primarily due to different soil management practices used in organic agriculture rather than pesticide/ herbicide application

Autofluorescence in eleocytes of some earthworm species.

Immunocompetent cells of earthworms, coelomocytes, comprise adherent amoebocytes and granular eleocytes (chloragocytes). Both cell populations can be expelled via dorsal pores of adult earthworms by exposure to an electric current (4.5 V) for 1 min. Analysis by phase contrast/fluorescence microscopy and flow cytometry demonstrated that eleocyte population of several species exhibits a strong autofluorescence. A high percentage (11-35%) of autofluorescent eleocytes was recorded in Allolobophora chlorotica, Dendrodrilus rubidus, Eisenia fetida, and Octolasion sp. (O. cyaneum, O. tyrtaeum tyrtaeum and O. tyrtaeum lacteum). In contrast, autofluorescent coelomocytes were exceptionally scarce (less than 1%) in representative Aporrectodea sp. (A. caliginosa and A. longa) and Lumbricus sp. (L. castaneus, L. festivus, L. rubellus, L. terrestris). Thus, this paper for the first time describes profound intrinsic fluorescence of eleocytes in some--but not all--earthworm species. The function (if any) and inter-species differences of the autofluorescent coelomocytes still remain elusive

CalDAG-GEFI deficiency protects mice in a novel model of FcγRIIA-mediated thrombosis and thrombocytopenia

Platelet activation via Fcγ receptor IIA (FcγRIIA) is a critical event in immune-mediated thrombocytopenia and thrombosis syndromes (ITT). We recently identified signaling by the guanine nucleotide exchange factor CalDAG-GEFI and the adenosine diphosphate receptor P2Y12 as independent pathways leading to Rap1 small GTPase activation and platelet aggregation. Here, we evaluated the contribution of CalDAG-GEFI and P2Y12 signaling to platelet activation in ITT. Mice transgenic for the human FcγRIIA (hFcR) and deficient in CalDAG-GEFI(−/−) (hFcR/CDGI(−/−)) were generated. Compared with controls, aggregation of hFcR/CDGI(−/−) platelets or P2Y12 inhibitor-treated hFcR platelets required more than 5-fold and approximately 2-fold higher concentrations of a FcγRIIA stimulating antibody against CD9, respectively. Aggregation and Rap1 activation were abolished in P2Y12 inhibitor-treated hFcR/CDGI(−/−) platelets. For in vivo studies, a novel model for antibody-induced thrombocytopenia and thrombosis was established. FcγRIIA-dependent platelet thrombosis was induced by infusion of Alexa750-labeled antibodies to glycoprotein IX (CD42a), and pulmonary thrombi were detected by near-infrared imaging technology. Anti-GPIX antibodies dose-dependently caused thrombocytopenia and pulmonary thrombosis in hFcR-transgenic but not wild-type mice. CalDAG-GEFI-deficient but not clopidogrel-treated hFcR-transgenic mice were completely protected from ITT. In summary, we established a novel mouse model for ITT, which was used to identify CalDAG-GEFI as a potential new target in the treatment of ITT

Associations among Race/Ethnicity, ApoC-III Genotypes, and Lipids in HIV-1-Infected Individuals on Antiretroviral Therapy

BACKGROUND: Protease inhibitors (PIs) are associated with hypertriglyceridemia and atherogenic dyslipidemia. Identifying HIV-1-infected individuals who are at increased risk of PI-related dyslipidemia will facilitate therapeutic choices that maintain viral suppression while reducing risk of atherosclerotic diseases. Apolipoprotein C-III (apoC-III) gene variants, which vary by race/ethnicity, have been associated with a lipid profile that resembles PI-induced dyslipidemia. However, the association of race/ethnicity, or candidate gene effects across race/ethnicity, with plasma lipid levels in HIV-1-infected individuals, has not been reported. METHODS AND FINDINGS: A cross-sectional analysis of race/ethnicity, apoC-III/apoA-I genotypes, and PI exposure on plasma lipids was performed in AIDS Clinical Trial Group studies (n = 626). Race/ethnicity was a highly significant predictor of plasma lipids in fully adjusted models. Furthermore, in stratified analyses, the effect of PI exposure appeared to differ across race/ethnicity. Black/non-Hispanic, compared with White/non-Hispanics and Hispanics, had lower plasma triglyceride (TG) levels overall, but the greatest increase in TG levels when exposed to PIs. In Hispanics, current PI antiretroviral therapy (ART) exposure was associated with a significantly smaller increase in TGs among patients with variant alleles at apoC-III-482, −455, and Intron 1, or at a composite apoC-III genotype, compared with patients with the wild-type genotypes. CONCLUSIONS: In the first pharmacogenetic study of its kind in HIV-1 disease, we found race/ethnic-specific differences in plasma lipid levels on ART, as well as differences in the influence of the apoC-III gene on the development of PI-related hypertriglyceridemia. Given the multi-ethnic distribution of HIV-1 infection, our findings underscore the need for future studies of metabolic and cardiovascular complications of ART that specifically account for racial/ethnic heterogeneity, particularly when assessing candidate gene effects

Plasma sTNFR1 and IL8 for prognostic enrichment in sepsis trials: a prospective cohort study.

BackgroundEnrichment strategies improve therapeutic targeting and trial efficiency, but enrichment factors for sepsis trials are lacking. We determined whether concentrations of soluble tumor necrosis factor receptor-1 (sTNFR1), interleukin-8 (IL8), and angiopoietin-2 (Ang2) could identify sepsis patients at higher mortality risk and serve as prognostic enrichment factors.MethodsIn a multicenter prospective cohort study of 400 critically ill septic patients, we derived and validated thresholds for each marker and expressed prognostic enrichment using risk differences (RD) of 30-day mortality as predictive values. We then used decision curve analysis to simulate the prognostic enrichment of each marker and compare different prognostic enrichment strategies.Measurements and main resultsAn admission sTNFR1 concentration > 8861 pg/ml identified patients with increased mortality in both the derivation (RD 21.6%) and validation (RD 17.8%) populations. Among immunocompetent patients, an IL8 concentration > 94 pg/ml identified patients with increased mortality in both the derivation (RD 17.7%) and validation (RD 27.0%) populations. An Ang2 level > 9761 pg/ml identified patients at 21.3% and 12.3% increased risk of mortality in the derivation and validation populations, respectively. Using sTNFR1 or IL8 to select high-risk patients improved clinical trial power and efficiency compared to selecting patients with septic shock. Ang2 did not outperform septic shock as an enrichment factor.ConclusionsThresholds for sTNFR1 and IL8 consistently identified sepsis patients with higher mortality risk and may have utility for prognostic enrichment in sepsis trials