Wan-Yi Lo, collaborative piano

Maurice RavelGustav MahlerGiacomo Puccin

Hyperglycaemic index as a tool to assess glucose control: a retrospective study

INTRODUCTION: Critically ill patients may benefit from strict glucose control. An objective measure of hyperglycaemia for assessing glucose control in acutely ill patients should reflect the magnitude and duration of hyperglycaemia, should be independent of the number of measurements, and should not be falsely lowered by hypoglycaemic values. The time average of glucose values above the normal range meets these requirements. METHODS: A retrospective, single-centre study was performed at a 12-bed surgical intensive care unit. From 1990 through 2001 all patients over 15 years, staying at least 4 days, were included. Admission type, sex, age, Acute Physiology and Chronic Health Evaluation II score and outcome were recorded. The hyperglycaemic index (HGI) was defined as the area under the curve above the upper limit of normal (glucose level 6.0 mmol/l) divided by the total length of stay. HGI, admission glucose, mean morning glucose, mean glucose and maximal glucose were calculated for each patient. The relations between these measures and 30-day mortality were determined. RESULTS: In 1779 patients with a median stay in the intensive care unit of 10 days, the 30-day mortality was 17%. A total of 65,528 glucose values were analyzed. Median HGI was 0.9 mmol/l (interquartile range 0.3–2.1 mmol/l) in survivors versus 1.8 mmol/l (interquartile range 0.7–3.4 mmol/l) in nonsurvivors (P < 0.001). The area under the receiver operator characteristic curve was 0.64 for HGI, as compared with 0.61 and 0.62 for mean morning glucose and mean glucose. HGI was the only significant glucose measure in binary logistic regression. CONCLUSION: HGI exhibited a better relation with outcome than other glucose indices. HGI is a useful measure of glucose control in critically ill patients

Persistent hyperglycemia is an independent predictor of outcome in acute myocardial infarction

BACKGROUND: Elevated blood glucose values are a prognostic factor in myocardial infarction (MI) patients. The unfavourable relation between hyperglycemia and outcome is known for admission glucose and fasting glucose after admission. These predictors are single measurements and thus not indicative of overall hyperglycemia. Increased persistent hyperglycemia may better predict adverse events in MI patients. METHODS: In a prospective study of MI patients treated with primary percutaneous coronary intervention (PCI) frequent blood glucose measurements were obtained to investigate the relation between glucose and the occurrence of major adverse cardiac events (MACE) at 30 days follow-up. MACE was defined as death, recurrent infarction, repeat primary coronary intervention, and left ventricular ejection fraction equal to or smaller than 30%. RESULTS: MACE occurred in 89 (21.3%) out 417 patients. In 17 patients (4.1%) it was a fatal event. A mean of 7.4 glucose determinations were available per patient. Mean +/- SD admission glucose was 10.1 +/- 3.7 mmol/L in patients with a MACE versus 9.1 +/- 2.7 mmol/L in event-free patients (P = 0.0024). Mean glucose during the first two days after admission was 9.0 +/- 2.8 mmol/L in patients with MACE compared to 8.1 +/- 2.0 mmol/L in event free patients (P < 0.0001). The area under the receiver operator characteristic curve was 0.64 for persistent hyperglycemia and 0.59 for admission glucose. Persistent hyperglycemia emerged as a significant independent predictor (P < 0.001). CONCLUSION: Persistent hyperglycemia in MI has a stronger relation with 30-day MACE than elevated glucose at admission

Zoning of mucosal phenotype, dysplasia, and telomerase activity measured by telomerase repeat assay protocol in Barrett's esophagus

Glandular dysplasia in Barrett's esophagus may regress spontaneously but can also progress to cancer. The human telomerase RNA template and the human telomerase reverse transcriptase enzyme which do not, of themselves, correlate strongly with telomerase activity, are too often overexpressed in Barrett's dysplasia to predict individual cancer risk. This study relates telomerase activity, mucosal phenotype, and dysplasia in Barrett's esophagus. Biopsies (n = 256) from squamous esophagus, columnar-lined esophagus every 2 cm, esophago-gastric junction, gastric body, and antrum from 32 patients with long-segment Barrett's esophagus were evaluated by telomerase repeat assay protocol (TRAP). Three biopsies for histology (n = 794) were simultaneously taken at each anatomical level. These and all prior and subsequent biopsies (n = 1917) were reviewed for mucosal phenotypes and dysplasia severity. Intestinal-type Barrett's mucosa was present at all levels in Barrett's esophagus. At least one Barrett's biopsy was TRAP(+) in 22 of 32 patients. TRAP positivity of intestinal-type Barrett's mucosa increased distally, possibly as a consequence of mucosal exposure to acid or bile reflux. Native gastric mucosa was rarely TRAP(+) (1/31 corpus, 2/32 antrum), whereas native squamous mucosa usually was TRAP(+) (31/32). Dysplasia almost always involved intestinal-type Barrett's mucosa (85/87; P</p

HLA-DR expression on monocytes and systemic inflammation in patients with ruptured abdominal aortic aneurysms

INTRODUCTION: Mortality from ruptured abdominal aortic aneurysms (RAAA) remains high. Severe systemic inflammation, leading to multi-organ failure, often occurs in these patients. In this study we describe the level of HLA-DR expression in a consecutive group of patients following surgery for RAAA and compare results between survivors and non-survivors. A similar comparison is made for IL-6 and IL-10 levels and Sequential Organ Failure Assessment (SOFA) scores. METHODS: This is a prospective observational study. Patients with RAAA were prospectively analysed. Blood samples were collected on days 1, 3, 5, 7, 10 and 14. The fraction of CD-14 positive monocytes expressing HLA-DR was measured by flow-cytometry. IL-6 and IL-10 levels were measured by ELISA. RESULTS: The study included 30 patients with a median age of 70 years, of which 27 (90%) were men. Six patients died from multiple organ failure, all other patients survived. The SOFA scores were significantly higher in non-survivors on days 1 through 14. HLA-DR expression on monocytes was significantly lower on days 3, 5, 7, 10 and 14 in non-survivors. IL-6 and IL-10 levels were significantly higher in non-survivors on day 1 and days 1 and 3, respectively. CONCLUSION: HLA-DR expression on monocytes was decreased, especially in non-survivors. All patients with RAAA displayed a severe inflammatory and anti-inflammatory response with an increased production of IL-6 and IL-10. Poor outcome is associated with high levels of IL-6 and IL-10 and a high SOFA score in the first three days after surgery, while low levels of HLA-DR expression are observed from day three after RAAA repair

Clinical correlates of arterial lactate levels in patients with ST-segment elevation myocardial infarction at admission: a descriptive study

Introduction: Blood lactate measurements can be used as an indicator of hemodynamic impairment and relate to mortality in various forms of shock. Little is known at the moment concerning the clinical correlates of systemic lactate in patients with ST-segment elevation myocardial infarction (STEMI).Methods: To assess the relation of systemic arterial lactate levels in STEMI patients with clinical correlates at presentation in the catheterization laboratory, we measured arterial lactate levels with a rapid point-of-care technique, immediately following femoral sheath insertion. The study population (n = 1,176) was divided into tertiles with lactate levels ≤1.1 (n = 410), 1.2 to 1.7 (n = 398) and ≥1.8 mmol/l (n = 368). We compared both baseline characteristics and outcome measures of the three lactate groups.Results: Factors independently associated with higher lactate levels were hypotension, heart rate, thrombolysis in myocardial infarction (TIMI) flow 0 to 1, diabetes and non-smoking. Mortality at 30 days in the three groups was 2.0%, 1.5% and 6.5%. The latter group also showed lower blush grades and greater enzymatic infarct sizes. An intra aortic balloon pump (IABP) was used more frequently in patients with higher lactate levels (4.2%, 7.6% and 14.7%).Conclusions: In STEMI patients, impaired hemodynamics, worse TIMI flow and non-smoking were related to increased arterial lactate levels. Higher lactate levels were independently related with 30-day mortality and an overall worse response to percutaneous coronary intervention (PCI). In particular, acute mortality was related to admission lactates ≥1.8 mmol/L. Point-of-care measurement of arterial lactate at admission in patients with STEMI has the potential to improve acute risk stratification

New distance measures for classifying X-ray astronomy data into stellar classes

The classification of the X-ray sources into classes (such as extragalactic sources, background stars, ...) is an essential task in astronomy. Typically, one of the classes corresponds to extragalactic radiation, whose photon emission behaviour is well characterized by a homogeneous Poisson process. We propose to use normalized versions of the Wasserstein and Zolotarev distances to quantify the deviation of the distribution of photon interarrival times from the exponential class. Our main motivation is the analysis of a massive dataset from X-ray astronomy obtained by the Chandra Orion Ultradeep Project (COUP). This project yielded a large catalog of 1616 X-ray cosmic sources in the Orion Nebula region, with their series of photon arrival times and associated energies. We consider the plug-in estimators of these metrics, determine their asymptotic distributions, and illustrate their finite-sample performance with a Monte Carlo study. We estimate these metrics for each COUP source from three different classes. We conclude that our proposal provides a striking amount of information on the nature of the photon emitting sources. Further, these variables have the ability to identify X-ray sources wrongly catalogued before. As an appealing conclusion, we show that some sources, previously classified as extragalactic emissions, have a much higher probability of being young stars in Orion Nebula.Comment: 29 page

Challenges to adaptation: a fundamental concept for the shared socio-economic pathways and beyond

The framework for the new scenarios being developed for climate research calls for the development of a set of Shared Socioeconomic Pathways (SSPs), which are meant to differ in terms of their challenges to mitigation and challenges to adaptation. In order for the scenario process to fulfill its goals, the research and policy communities need to develop a shared understanding of these concepts. This paper focuses on challenges to adaptation. We begin by situating this new concept in the context of the rich literatures related to inter alia adaptation, vulnerability, and resilience. We argue that a proper characterization of challenges to adaptation requires a rich, exploration of the concept, which goes beyond mere description. This has a number of implications for the operationalization of the concept in the basic and extended versions of the SSPs. First, the elements comprising challenges to adaptation must include a wide range of socioeconomic and even some (non-climatic) biophysical factors. Second, careful consideration must be given to differences in these factors across scales, as well as cross-scale interactions. Third, any representation of the concept will require both quantitative and qualitative elements. The scenario framework offers the opportunity for the SSPs and full scenarios to be of greater value than has been the case in past exercises to both Integrated Assessment Modeling (IAM) and Impacts,Adaptation, and Vulnerability (IAV) researchers, but this will require a renegotiation of the traditional, primarily unidirectional relationship between the two communities