119 research outputs found
Progression of renal insufficiency: Role of blood pressure
Progression of renal insufficiency: Role of blood pressure. The effect of blood pressure on progression of renal insufficiency was examined in a large group of patients who eventually required dialysis. Out of 198 consecutive new chronic dialysis patients, 86 had sufficient data predi alysis to determine rates of progression of renal insufficiency by reciprocal creatinine versus time plots. Average plasma creatinine at first contact was 3.8 ± 0.2 mg/dl and at the time of dialysis was 11.4 ± 0.4 mg/dl. Mean duration of follow-up was 33.4 ± 2.5 months and the average rate of decline in reciprocal creatinine was -0.009 ± 0.001 di! mg month. Patients were stratified by average value of diastolic blood pressure measured in clinic. Patients in the lowest quartile had a rate of decline in reciprocal creatinine of -0.007 ± 0.001 dl/mg month, which was slower than that of patients in the third and fourth quartiles, -0.010 ± 0.001 and -0.011 ± -0.002 dl/mg month, respectively (P < 0.05). In individual patients, a mean diastolic BP of <90mm Hg was associated with a rate of decline in reciprocal creatinine of -0.006 ± 0.001 dl/mg month which was significantly less than the rate of -0.009 ± 0.001 when the diastolic BP was >90mm Hg. Thus, in a large group of patients who have progressed to ESRD, there is an associatiOn between control of diastolic blood pressure and a slower rate of decline in renal function
Effect of CPOE User Interface Design on User-Initiated Access to Educational and Patient Information during Clinical Care
Objective: Authors evaluated whether displaying context sensitive links to infrequently accessed educational materials and patient information via the user interface of an inpatient computerized care provider order entry (CPOE) system would affect access rates to the materials. Design: The CPOE of Vanderbilt University Hospital (VUH) included "baselineâ clinical decision support advice for safety and quality. Authors augmented this with seven new primarily educational decision support features. A prospective, randomized, controlled trial compared clinicians' utilization rates for the new materials via two interfaces. Control subjects could access study-related decision support from a menu in the standard CPOE interface. Intervention subjects received active notification when study-related decision support was available through context sensitive, visibly highlighted, selectable hyperlinks. Measurements: Rates of opportunities to access and utilization of study-related decision support materials from April 1999 through March 2000 on seven VUH Internal Medicine wards. Results: During 4,466 intervention subject-days, there were 240,504 (53.9/subject-day) opportunities for study-related decision support, while during 3,397 control subject-days, there were 178,235 (52.5/subject-day) opportunities for such decision support, respectively (p = 0.11). Individual intervention subjects accessed the decision support features at least once on 3.8% of subject-days logged on (278 responses); controls accessed it at least once on 0.6% of subject-days (18 responses), with a response rate ratio adjusted for decision support frequency of 9.17 (95% confidence interval 4.6-18, p < 0.0005). On average, intervention subjects accessed study-related decision support materials once every 16 days individually and once every 1.26 days in aggregate. Conclusion: Highlighting availability of context-sensitive educational materials and patient information through visible hyperlinks significantly increased utilization rates for study-related decision support when compared to "standardâ VUH CPOE methods, although absolute response rates were lo
Soft Phenotyping for Sepsis via EHR Time-aware Soft Clustering
Sepsis is one of the most serious hospital conditions associated with high
mortality. Sepsis is the result of a dysregulated immune response to infection
that can lead to multiple organ dysfunction and death. Due to the wide
variability in the causes of sepsis, clinical presentation, and the recovery
trajectories identifying sepsis sub-phenotypes is crucial to advance our
understanding of sepsis characterization, identifying targeted treatments and
optimal timing of interventions, and improving prognostication. Prior studies
have described different sub-phenotypes of sepsis with organ-specific
characteristics. These studies applied clustering algorithms to electronic
health records (EHRs) to identify disease sub-phenotypes. However, prior
approaches did not capture temporal information and made uncertain assumptions
about the relationships between the sub-phenotypes for clustering procedures.
We develop a time-aware soft clustering algorithm guided by clinical context to
identify sepsis sub-phenotypes using data from the EHR. We identified six novel
sepsis hybrid sub-phenotypes and evaluated them for medical plausibility. In
addition, we built an early-warning sepsis prediction model using logistic
regression. Our results suggest that these novel sepsis hybrid sub-phenotypes
are promising to provide more precise information on the recovery trajectory
which can be important to inform management decisions and sepsis prognosis
Transmission of Mycobacterium tuberculosis in a Rural Community, Arkansas, 1945â2000
A cluster of tuberculosis cases in a rural community in Arkansas persisted from 1991 to 1999. The cluster had 13 members, 11 linked epidemiologically. Old records identified 24 additional patients for 40 linked case-patients during a 54-year period. Residents of this neighborhood represent a population at high risk who should be considered for tuberculin testing and treatment for latent tuberculosis infection
The 28 November 2020 landslide, tsunami, and outburst flood â a hazard cascade associated with rapid deglaciation at Elliot Creek, British Columbia, Canada
We describe and model the evolution of a recent landslide, tsunami, outburst flood, and sediment plume in the southern Coast Mountains, British Columbia, Canada. On November 28, 2020, about 18 million m3 of rock descended 1,000 m from a steep valley wall and traveled across the toe of a glacier before entering a 0.6 km2 glacier lake and producing >100-m high run-up. Water overtopped the lake outlet and scoured a 10-km long channel before depositing debris on a 2-km2 fan below the lake outlet. Floodwater, organic debris, and fine sediment entered a fjord where it produced a 60+km long sediment plume and altered turbidity, water temperature, and water chemistry for weeks. The outburst flood destroyed forest and salmon spawning habitat. Physically based models of the landslide, tsunami, and flood provide real-time simulations of the event and can improve understanding of similar hazard cascades and the risk they pose
Genetic mechanisms of critical illness in COVID-19.
Host-mediated lung inflammation is present1, and drives mortality2, in the critical illness caused by coronavirus disease 2019 (COVID-19). Host genetic variants associated with critical illness may identify mechanistic targets for therapeutic development3. Here we report the results of the GenOMICC (Genetics Of Mortality In Critical Care) genome-wide association study in 2,244 critically ill patients with COVID-19 from 208 UK intensive care units. We have identified and replicated the following new genome-wide significant associations: on chromosome 12q24.13 (rs10735079, PÂ =Â 1.65Â ĂÂ 10-8) in a gene cluster that encodes antiviral restriction enzyme activators (OAS1, OAS2 and OAS3); on chromosome 19p13.2 (rs74956615, PÂ =Â 2.3Â ĂÂ 10-8) near the gene that encodes tyrosine kinase 2 (TYK2); on chromosome 19p13.3 (rs2109069, PÂ =Â 3.98Â ĂÂ Â 10-12) within the gene that encodes dipeptidyl peptidase 9 (DPP9); and on chromosome 21q22.1 (rs2236757, PÂ =Â 4.99Â ĂÂ 10-8) in the interferon receptor gene IFNAR2. We identified potential targets for repurposing of licensed medications: using Mendelian randomization, we found evidence that low expression of IFNAR2, or high expression of TYK2, are associated with life-threatening disease; and transcriptome-wide association in lung tissue revealed that high expression of the monocyte-macrophage chemotactic receptor CCR2 is associated with severe COVID-19. Our results identify robust genetic signals relating to key host antiviral defence mechanisms and mediators of inflammatory organ damage in COVID-19. Both mechanisms may be amenable to targeted treatment with existing drugs. However, large-scale randomized clinical trials will be essential before any change to clinical practice
Between Convergence and Exceptionalism: Americans and the British Model of Labor Relations, c. 1867â1920
A História da Alimentação: balizas historiogråficas
Os M. pretenderam traçar um quadro da HistĂłria da Alimentação, nĂŁo como um novo ramo epistemolĂłgico da disciplina, mas como um campo em desenvolvimento de prĂĄticas e atividades especializadas, incluindo pesquisa, formação, publicaçÔes, associaçÔes, encontros acadĂȘmicos, etc. Um breve relato das condiçÔes em que tal campo se assentou faz-se preceder de um panorama dos estudos de alimentação e temas correia tos, em geral, segundo cinco abardagens Ia biolĂłgica, a econĂŽmica, a social, a cultural e a filosĂłfica!, assim como da identificação das contribuiçÔes mais relevantes da Antropologia, Arqueologia, Sociologia e Geografia. A fim de comentar a multiforme e volumosa bibliografia histĂłrica, foi ela organizada segundo critĂ©rios morfolĂłgicos. A seguir, alguns tĂłpicos importantes mereceram tratamento Ă parte: a fome, o alimento e o domĂnio religioso, as descobertas europĂ©ias e a difusĂŁo mundial de alimentos, gosto e gastronomia. O artigo se encerra com um rĂĄpido balanço crĂtico da historiografia brasileira sobre o tema
General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multi-centre observational study
There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent changes to patient baseline characteristics and airway management guidelines. This analysis of data from the direct reporting of awareness in maternity patients' (DREAMY) study of accidental awareness during obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare with earlier surveys and best-practice recommendations. Consenting patients who received general anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline characteristics, airway management, anaesthetic techniques and major complications were collected. Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted. Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367 (11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16-22) and failed intubation in 1 in 312 (95%CI 1 in 169-667). Obese patients were over-represented compared with national baselines and associated with difficult, but not failed intubation. There was more evidence of change in practice for induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the most popular). There was evidence of improvement in practice, with increased monitoring and reversal of neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this population, videolaryngoscopy was rarely used (1.9%)
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