Implementing a Rapid Response System in a tertiary-care hospital. A cost-effectiveness study.

PURPOSE: The occurrence of adverse events (AE) in hospitalized patients substancially increases the risk of disability or death, having a major negative clinical and economic impact on public health. For early identification of patients at risk and to establish preventive measures, different healthcare systems have implemented rapid response systems (RRS). The aim of this study was to carry out a cost-effectiveness analysis of implementing a RRS in a tertiary-care hospital. METHODS: We included all the patients admitted to Hospital Clínic de Barcelona from 1 to 2016 to 31 December 2016. The cost-effectiveness analysis was summarized as the incremental cost-effectiveness ratio (incremental cost divided by the incremental effectiveness of the two alternatives, RRS versus non-RRS). The effectiveness of the RRS, defined as improvements in health outcomes (AE, cardiopulmonary arrest and mortality), was obtained from the literature and applied to the included patient cohort. A budget impact analysis on the implementation of the RRS from a hospital perspective was performed over a 5-year time horizon. RESULTS: 42,409 patients were included, and 448 (1.05%) had severe AE requiring ICU admission. The cost-effectiveness analysis showed an incremental cost (savings) of EUR - 1,471,101 of RRS versus the non-RRS. The budgetary impact showed a cost reduction of EUR 896,762.00 in the first year and EUR 1,588,579.00 from the second to the fifth year. CONCLUSIONS: The present analysis shows the RRS as a dominant, less costly and more effective structure compared to the non-RRS.

Characterization of the phone-calls made to a poison center related to household and cosmetics products exposition in pediatrics. / Caracterización de las consultas realizadas a un Centro de Información Toxicológica por productos de aseo y productos cosméticos en niños.

INTRODUCTION: Household cleaning products and cosmetics are necessary for daily life and widely used by the population. However, their use may not be risk-free, especially when they are not used or stored as recommended. It is important to characterize exposures, as this is useful for developing stra tegies to reduce morbidity, mortality, and health costs associated, especially in the child population. OBJECTIVE: To describe reports associated with household cleaning products and cosmetics exposure in patients under the age of 12, reported to the Poison Information Center of the Catholic University of Chile (CITUC). PATIENTS AND METHOD: Descriptive cross-sectional study of phone calls to CITUC during 2016. The analyzed variables were age, sex, product, caller, caller and incident location, ex posure circumstances, exposure route(s), symptoms, and severity from manual records and from the WHO's electronic record software 'INTOX Data Management System'. RESULTS: 3,415 cases met the inclusion criteria. Children under the age of five represented 91% of the exposures, and 58.5% were male. 99.4% were accidental exposures, and 98.6% occurred at home. Family members (57%) and health personnel (42%) made the calls. 68.3% of the patients had no symptoms after exposure. The four products with the highest incidence were household bleach (27.6%), floor cleaners and polishers (13.1%), dish soap (7.9%), and perfume/cologne (5.8%). The main exposure route was by ingestion (89.4%). CONCLUSIONS: Household cleaning products and cosmetics are common causes of exposures especially in children under the age of five. Although these products have a low morbidity and mortality rate, it is important to educate the population to prevent possible poisonings in the child population.

Relation between acute and long-term cognitive decline after surgery: Influence of metabolic syndrome.

INTRODUCTION: The relationship between persistent postoperative cognitive decline and the more common acute variety remains unknown; using data acquired in preclinical studies of postoperative cognitive decline we attempted to characterize this relationship. METHODS: Low capacity runner (LCR) rats, which have all the features of the metabolic syndrome, were compared postoperatively with high capacity runner (HCR) rats for memory, assessed by trace fear conditioning (TFC) on the 7th postoperative day, and learning and memory (probe trial [PT]) assessed by the Morris water-maze (MWM) at 3 months postoperatively. Rate of learning (AL) data from the MWM test, were estimated by non-linear mixed effects modeling. The individual rat's TFC result at postoperative day (POD) 7 was correlated with its AL and PT from the MWM data sets at postoperative day POD 90. RESULTS: A single exponential decay model best described AL in the MWM with LCR and surgery (LCR-SURG) being the only significant covariates; first order AL rate constant was 0.07 s(-1) in LCR-SURG and 0.16s(-1) in the remaining groups (p<0.05). TFC was significantly correlated with both AL (R=0.74; p<0.0001) and PT (R=0.49; p<0.01). CONCLUSION: Severity of memory decline at 1 week after surgery presaged long-lasting deteriorations in learning and memory.

Rationale and study design for an Individualized PeriopeRative Open lung VEntilatory approach in Emergency Abdominal Laparotomy/scopy: study protocol for a prospective international randomized controlled trial.

BACKGROUND: Postoperative pulmonary complications (PPC) are the most frequent postoperative complications, with an estimated prevalence in elective surgery ranging from 20% in observational cohort studies to 40% in randomized clinical trials. However, the prevalence of PPCs in patients undergoing emergency abdominal surgery is not well defined. Lung-protective ventilation aims to minimize ventilator-induced lung injury and reduce PPCs. The open lung approach (OLA), which combines recruitment manoeuvres (RM) and positive end-expiratory pressure (PEEP) titration, aims to minimize areas of atelectasis and the development of PPCs; however, there is no conclusive evidence in the literature that OLA can prevent PPCs. The purpose of this study is to compare an individualized perioperative OLA with conventional standardized lung-protective ventilation in patients undergoing emergency abdominal surgery with clinical signs of intraoperative lung collapse. METHODS: Randomized international clinical trial to compare an individualized perioperative OLA (RM plus individualized PEEP and individualized postoperative respiratory support) with conventional lung-protective ventilation (standard PEEP of 5 cmH2O and conventional postoperative oxygen therapy) in patients undergoing emergency abdominal surgery with clinical signs of lung collapse. Patients will be randomised to open-label parallel groups. The primary outcome is any severe PPC during the first 7 postoperative days, including: acute respiratory failure, pneumothorax, weaning failure, acute respiratory distress syndrome, and pulmonary infection. The estimated sample size is 732 patients (366 per group). The final sample size will be readjusted during the interim analysis. DISCUSSION: The Individualized Perioperative Open-lung Ventilatory Strategy in emergency abdominal laparotomy (iPROVE-EAL) is the first multicentre, randomized, controlled trial to investigate whether an individualized perioperative approach prevents PPCs in patients undergoing emergency surgery.

Functional identification of a Streptomyces lividans FKBP-like protein involved in the folding of overproduced secreted proteins.

Some bacterial peptidyl-prolyl cis/trans isomerases (PPIases) are involved in secretory protein folding after the translocation step. Streptomyces lividans has been used as a host for engineering extracellular overproduction of homologous and heterologous proteins in industrial applications. Although the mechanisms governing the major secretory pathway (Sec route) and the minor secretory pathway (Tat route) are reasonably well described, the function of proteins responsible for the extracellular secretory protein folding is not characterized as yet. We have characterized a Tat-dependent S. lividans FK506-binding protein-like lipoprotein (FKBP) that has PPIase activity. A mutant in the sli-fkbp gene induces a secretion stress response and affects secretion and activity of the Sec-dependent protein α-amylase. Additionally, propagation in high copy number of the sli-fkbp gene has a positive effect on the activity of both the overproduced α-amylase and the overproduced Tat-dependent agarase, both containing proline cis isomers. Targeted proteomic analyses showed that a relevant group of secreted proteins in S. lividans TK21 are affected by Sli-FKBP, revealing a wide substrate range. The results obtained indicate that, regardless of the secretory route used by proteins in S. lividans, adjusting the expression of sli-fkbp may facilitate folding of dependent proteins when engineering Streptomyces strains for the overproduction of homologous or heterologous secretory proteins.

Synthesis of yeast histone 3 in an Escherichia coli cell-free system.

The gene for histone H3 from the yeast Saccharomyces cerevisiae was placed under the control of the lac promoter of Escherichia coli by fusing the H3 coding sequence to that of beta-galactosidase. The gene was shown to be transcribed in vivo, but its product was not detected in cell extracts. However, synthesis of the fused polypeptide was detected in an in vitro transcription-translation system derived from E. coli. Proteolytic degradation of the newly synthesized polypeptides may be the cause of their apparent absence in the in vivo experiment.

In vivo transcription of bacteriophage phi 29 DNA early and late promoter sequences.

The in vivo transcription initiation sites of eight putative phi 29 promoters have been accurately determined: seven of them correspond to early promoters, including the four main ones, and the other corresponds to the only late promoter found in vivo. Comparison of the phi 29 promoter sequences with the consensus sequence for the Bacillus subtilis sigma 43 RNA polymerase suggests that the sigma 43 enzyme is involved in the recognition of the viral early promoters, whereas the late promoter sequences share homology with the consensus sequence only at its -10 region.

Ribosomal RNA synthesis in Streptomyces lividans under heat shock conditions.

Clones containing rRNA genes were isolated from a gene library of Streptomyces lividans when RNA produced under heat shock conditions was used as a probe. Two of the clones carried entire rRNA operons rrnA and rrnF, respectively, the expression of both operons being under the control of four different promoters. At least two of the promoters were fully functional when the temperature increased from 30 to 45 degrees C, ensuring transcription of the rRNA genes under the heat shock. A third clone carried a partial rRNA operon in which expression was controlled by a main promoter that was functional at both 30 and 45 degrees C.

Effect of glucose on agarase overproduction by Streptomyces.

The Streptomyces coelicolor dagA gene, coding for an extracellular agarase, has been propagated on a multicopy plasmid in S. coelicolor A3(2), the natural agarase producer strain and in S. lividans TK21, a closely related, nonproducer strain. The effect of the carbon source on the production of agarase by both strains, upon cultivation in liquid medium, revealed that the glucose repression affected the synthesis of agarase at the level of secretion, rather than at the level of transcription. In the presence of glucose, the pre-agarase was degraded intracellularly and the overall secretion of proteases decreased considerably in both strains, suggesting a negative regulatory role for glucose in the overall secretion in Streptomyces.

Initiation of phage phi 29 DNA replication by mutants with deletions at the carboxyl end of the terminal protein.

Series of deletions at the C end of p3, the phage phi 29 DNA terminal protein (TP), have been constructed and characterized. Measurements of the activity of those deletion mutants in the formation of the p3-dAMP initiation complex in vitro indicate the need of an intact C-end for the normal TP primer function in DNA replication. It appears that the region at the C-end between aa 240 and 262 of p3, or part of it, might be essential for the normal TP function.

Initiation of phage phi 29 DNA replication by mutants with deletions at the amino end of the terminal protein.

Series of deletions at the amino end of protein p3, the phage phi 29 DNA terminal protein (TP), have been constructed and characterized. Measurements of the activity of the deletion mutants in the formation of the protein p3-dAMP initiation complex in vitro indicate the dispensability of the first 13 amino acids (aa) of the protein. The activity of protein p3 decreased considerably when 17 or more aa were deleted. The results on the in vitro phi 29 DNA replication primed by the p3 deletion mutants correlated very well with those obtained in the formation of the TP-dAMP initiation complex.

A set of expression plasmids for the synthesis of fused and unfused polypeptides in Escherichia coli.

A set of plasmid expression vectors for cloning of DNA fragments containing open reading frames has been obtained. The plasmids carry the strong leftward promoter of bacteriophage lambda and the translation initiation signals from either the gene ner of bacteriophage Mu or the gene 4 of bacteriophage phi 29. The vectors could overexpress the cloned sequences as fusion peptides at the N terminus with the N-terminal segment of the phi 29 protein p4 or at the C terminus with the Escherichia coli beta-galactosidase from its 8th residue, or both. Alternatively, the cloned sequences could be directed to overproduce proteins in an unfused form. DNA fragments of the hemagglutinin gene from human influenza A virus, have been cloned in one of the plasmid vectors and some potential antigenic determinants have been characterized using monoclonal antibodies.

Bacillus subtilis phage phi 29 main promoters are efficiently recognized in vivo by the Streptomyces lividans RNA polymerase.

A DNA fragment from the Bacillus subtilis phage phi 29, containing the main early and late viral promoters, has been inserted upstream of the aminoglycoside phosphotransferase gene (neo) derived from the transposon Tn5 and present in a Streptomyces lividans promoter-probe plasmid. The phi 29 promoters are specifically recognized by the S. lividans RNA polymerase which initiates transcription in vivo at the same sites utilized in B. subtilis. Moreover, the viral promoters efficiently direct the synthesis of high levels of the APHII enzyme in S. lividans.

A Bacillus subtilis phage phi 29 transcription terminator is efficiently recognized in Streptomyces lividans.

A DNA fragment from the Bacillus subtilis phage phi 29, containing the bidirectional transcription terminator TD1, where the right early transcription and late viral transcription terminate, has been inserted in one orientation between the aminoglycoside phosphotransferase (APH) gene (neo) and the phi 29 main early and late promoters present in derivative constructs of the Streptomyces promoter-probe plasmid pIJ486. The TD1 terminator is efficiently recognized in S. lividans and ends the transcription, started in vivo at the phi 29 promoters, at the same point as the B. subtilis RNA polymerase, resulting in a considerable reduction of the level of the APHII enzyme synthesized under the control of the phage promoters.

Effects of internal deletions on the priming activity of the phage phi 29 terminal protein.

A series of internal deletions of gene 3, coding for the phage phi 29 DNA terminal protein, have been constructed and characterized. In addition, a substitution mutant in the sequence corresponding to amino acids (aa) 49-51 was obtained. The priming activity of the substitution mutant protein, in the formation of the protein p3-dAMP initiation complex, was drastically reduced suggesting that some of the aa present at position 49-51 are essential for p3 function. Deletions of 8 to 33 aa, from aa residue 48 towards the N terminus of the substitution mutant, further decreased the priming activity of the protein. The activity of deletion mutants lacking 15 or 21 aa from residue 57 towards the C terminus, and also containing a point mutation at position 56, was greatly reduced, and no activity was seen when 24 aa were lacking.

Symmetrical transcription in bacteriophage phi 29 DNA.

Transcription of some early genes occurring during phi 29 infection in the absence but not in the presence of chloramphenicol has been shown to depend upon the synthesis of the viral protein p4, the positive regulator of late transcription. In addition, the early promoter B1, responsible for early transcription on the late region of the phi 29 genome, has been accurately mapped by nuclease S1 protection experiments. The deduced promoter sequence shares homology with that of the other early phi 29 promoters previously described and with the consensus sequence of the promoters recognized by the Bacillus subtilis sigma 43-RNA polymerase.

Activation of the actinorhodin biosynthetic pathway in Streptomyces lividans.

Production of the antibiotic actinorhodin was activated in Streptomyces lividans under conditions in which it is not normally produced when transformed with an activator gene from S. lividans. The gene encodes a 86-nucleotide transcript, responsible for the actinorhodin production phenotype, which is homologous to the 132 nucleotide transcript from S. fradiae, thought to act as a putative antisense RNA.

Heterologous recognition in vivo of promoter sequences from the Streptomyces coelicolor dagA gene.

The Streptomyces coelicolor dagA gene that codes for an extracellular agarase was cloned in the closely related bacterium S. lividans and transferred to the distantly related low G+C Gram-positive bacterium Bacillus subtilis and to the far more distantly related Gram-negative bacterium Escherichia coli. S1 nuclease mapping experiments identified a putative fifth promoter from which transcription of the dagA gene can take place, and accurately mapped the transcription termination site. The transcription terminator was specific for the Streptomyces strains and could terminate transcription initiated by promoters other than those of dagA. The agarase gene is efficiently transcribed in B. subtilis and E. coli, although pulse-chase experiments failed to detect the synthesis of agarase in these two bacteria.

Expression of an heterologous gene activating actinorhodin biosynthesis in Streptomyces lividans and Streptomyces coelicolor.

Production of the blue-pigmented antibiotic actinorhodin resulted in activation in the non-producer strain Streptomyces lividans, but not in the natural producer strain Streptomyces coelicolor, when transformed with an heterologous activator gene from Streptomyces fradiae. The gene encodes a 132 nucleotide-long transcript, responsible for the actinorhodin production phenotype, and thought to act as a putative antisense RNA, which has been detected in the transformed S. lividans cultures by reverse transcription followed by cyclic amplification.

Streptomyces lividans possesses a GroEL-like chaperonin.

Streptomyces lividans grown at 45 degrees C produces a GroEL-like chaperonin. This protein is specifically synthesized in bacterial cell cultures upon heat shock induction. It has a similar size (62 kDa) to the GroEL-like proteins from Escherichia coli and Bacillus subtilus and shows immunological cross-reaction with serum raised against GroEL from E. coli. The S. lividans 62-kDa protein assembles into oligomers around 20S that show a morphology consistent with a barrel showing six-fold and seven-fold symmetries as previously described in E. coli and B. subtilis.