The Combined SIRS + qSOFA (qSIRS) Score is More Accurate Than qSOFA Alone in Predicting Mortality in Patients with Surgical Sepsis in an LMIC Emergency Department.

BACKGROUND: qSOFA has been proposed as a prognostic tool in patients with sepsis. This study set out to assess the sensitivity of several scores, namely: the pre-ICU qSOFA, the qSOFA with lactate (qSOFA L), SIRS score, qSOFA + SIRS score (qSIRS) and qSIRS with lactate (qSIRS L) in predicting in-hospital mortality in patients with surgical sepsis as well as the sensitivity of these scores in predicting high-grade sepsis. The secondary aim was to determine which of these scores is best suited to predict high-grade surgical sepsis. METHODS: This was a retrospective cohort study that was conducted between December 2012 and August 2017 in a public metropolitan surgical service. Data from patients aged > 13 years, who were admitted to the hospital and who had an emergency surgical procedure for source control were retrieved from a prospectively maintained hybrid electronic database. The qSOFA, qSOFA plus lactate (qSOFA L), SIRS and qSOFA + SIRS (qSIRS), as well as the qSIRS plus lactate (qSIRS L), were calculated for each patient. A lactate level that was greater than 2mmol/L was deemed to be a positive finding. Any score ≥2 was deemed to be a positive score. The outcome measure was in-hospital mortality. The prognostic value of qSOFA, qSOFA L, SIRS, qSIRS and qSIRS L was studied. Receiver operating characteristic analyses were performed to determine the area under the curve (AUC), sensitivity, specificity and positive and negative likelihood ratios for positive qSOFA, qSOFA L, SIRS, qSIRS, and qSIRS L. Contingency tables were used to calculate the sensitivity, specificity, PPV and NPV for predicting severe or high-grade surgical sepsis. RESULTS: There were a total number of 1884 patients in the sample group of whom 855 were female (45.4%). The median patient age was 36 years (IQR 23-56). A total of 1489 patients (79%) were deemed to have high-grade sepsis based on an advanced EGS AAST grading, whilst 395 patients (21%) had low-grade sepsis. A total of 71 patients died (3.8%). Of these patients who died, 67 (94.4%) had high-grade sepsis and 4 (5.6%) had low-grade sepsis. The mortality rate in the high-grade sepsis group was 4.5%, whilst the mortality rate in the low-grade sepsis group was 1%. The scores with the greatest accuracy in predicting mortality were qSIRS (AUROC 0.731, 95% CI 0.68-0.78), followed by SIRS (AUROC 0.70, 95% CI 0.65-0.75). The qSOFA and qSOFA L were the least accurate in predicting mortality (AUROC 0.684, 95% CI 0.63-0.74 for both). The addition of lactate had no significant effect on the accuracy of the five scores in predicting mortality. Patients with a qSOFA ≥ 2 have an increased risk of dying (OR 5.8), as do patients with a SIRS score ≥2 (OR 2.7). qSIRS L had the highest sensitivity (69%) in predicting the presence of high-grade surgical sepsis, followed by qSIRS (65.5% sensitivity). qSOFA showed a very low sensitivity of only 4.5% and a high specificity of 99.2%. The addition of lactate to the score marginally improved the sensitivity. Lactate of 2mmol/L or more was also an independent predictor of high-grade sepsis. CONCLUSION: The qSIRS score is most accurate in predicting mortality in surgical sepsis. The qSOFA score is inferior to both the SIRS and the qSIRS scores in predicting mortality. The qSIRS score with the addition of lactate to the qSIRS score made it the most sensitive score in predicting high-grade surgical sepsis.

Absence of mutations in the survival motor neuron cDNA from labrador retrievers with an inherited myopathy.

The clinical phenotype of hereditary myopathy of labrador retrievers is consistent, but the pathological changes within muscle biopsy specimens can vary from type 1 fibre predominance (type 2 fibre deficiency) to dystrophic changes or overt neurogenic atrophy. The condition shares many clinical and pathological features with the mildest form of human childhood spinal muscular atrophy, and the survival motor neuron gene was therefore evaluated in dogs with the disease. Direct sequencing and comparisons of cdna from the gene in seven labrador retrievers homozygous for the disease and four control dogs revealed no nucleotide mutations leading to changes in the deduced amino acid sequences. A single polymorphism was detected in two of the seven affected dogs, which was characterised by a nucleotide substitution at amino acid position 1155 within the non-coding 3' untranslated region of exon 8. Northern blot analysis indicated that there were no differences in the steady state levels of mrna from the gene of the affected labrador retrievers and control dogs.

Suspected hypovitaminosis A in a colony of captive green anoles (Anolis carolinensis).

In a colony of 18 green anoles (Anolis carolinensis), 3 animals experienced focally thickened lips, ulcerative cheilitis, lethargy, depression, and weight loss over a 5-month period. In addition to crickets fed fresh fruit and leafy green vegetables, the diet of the green anoles consisted of a supply of mealworms that had been dusted with a commercial liquid vitamin supplement. The history, clinical findings, and histopathologic lesions were suggestive of hypovitaminosis A, which is known to cause squamous metaplasia of the mucus secreting glands and epithelial surfaces in many species.

p21(Cip1) and p27(Kip1) regulate cell cycle reentry after hypoxic stress but are not necessary for hypoxia-induced arrest.

We investigated the role of the cyclin-dependent kinase inhibitors p21(Cip1) and p27(Kip1) in cell cycle regulation during hypoxia and reoxygenation. While moderate hypoxia (1 or 0.1% oxygen) does not significantly impair bromodeoxyuridine incorporation, at very low oxygen tensions (0.01% oxygen) DNA replication is rapidly shut down in immortalized mouse embryo fibroblasts. This S-phase arrest is intact in fibroblasts lacking the cyclin kinase inhibitors p21(Cip1) and p27(Kip1), indicating that these molecules are not essential elements of the arrest pathway. Hypoxia-induced arrest is accompanied by dephosphorylation of pRb and inhibition of cyclin-dependent kinase 2, which results in part from inhibitory phosphorylation. Interestingly, cells lacking the retinoblastoma tumor suppressor protein also display arrest under hypoxia, suggesting that pRb is not an essential mediator of this response. Upon reoxygenation, DNA synthesis resumes by 3.5 h and reaches aerobic levels by 6 h. Cells lacking p21, however, resume DNA synthesis more rapidly upon reoxygenation than wild-type cells, suggesting that this inhibitor may play a role in preventing premature reentry into the cell cycle upon cessation of the hypoxic stress. While p27 null cells did not exhibit rapid reentry into the cell cycle, cells lacking both p21 and p27 entered S phase even more aggressively than those lacking p21 alone, revealing a possible secondary role for p27 in this response. Cdk2 activity is also restored more rapidly in the double-knockout cells when returned to normoxia. These studies reveal that restoration of DNA synthesis after hypoxic stress, but not the S phase arrest itself, is regulated by p21 and p27.

p53 checkpoint-defective cells are sensitive to X rays, but not hypoxia.

X-ray-induced damage leads to cell-cycle "checkpoint" arrest by p53-dependent induction of the cyclin-dependent kinase inhibitor p21 (Waf1/Cip1/Sdi1). Human tumor cells that lack this response fail to arrest after exposure to DNA-damaging agents, undergo multiple rounds of endoreduplicative DNA synthesis, and eventually commit to an apoptotic cell death. Since low oxygen tension can also induce p53 protein accumulation, and can lead to cell-cycle arrest or apoptosis, we examined the expression of p21 in tumor cells under normoxic and hypoxic conditions. In a survey of cells, mRNA for the p21 gene was induced two- to threefold in response to hypoxia in a seemingly p53-independent manner. We therefore examined genetically matched cells that differ in their p21 and p53 status for response to ionizing radiation and hypoxia. We found that both p21-deficient and p53-deficient cells exhibit an increase in chromosome instability, an increased level of apoptosis, and a failure to arrest after exposure to ionizing radiation. However, cells that lack either p21 or p53 exhibit no increase in chromosome instability or elevated apoptosis and still arrest in response to hypoxia. Thus, the mechanism responsible for the differential response to either hypoxia or X rays presumably lies in the control of cell-cycle progression in response to stress and its dependence on p21. Since the loss of a DNA-damage-dependent checkpoint does not sensitize cells to killing by stresses that elicit a DNA-damage-independent checkpoint, targeting the function of p21 pharmacologically will not kill tumor cells in situ in the absence of a DNA damage signal.

Endometriosis and a paraovarian cyst in a rhesus macaque.

We describe endometriosis in an aged rhesus macaque. There was a large mass and a related paraovarian cyst, typical of the disease. Endometriosis is a common finding in nonhuman primate. In this report, we also review the pathophysiology of the disease and summarize the historical and more recent relevant literature. Given the frequency of endometriosis in the rhesus monkey and the long-life spans (15-30 years) of nonhuman primates in captivity, endometriosis should be suspected in animals displaying the earliest signs of the disease: anorexia, dysmenorrhea, menorrhagia, irregular menstrual cycles, or infertility. Despite recent advances in the diagnosis and therapeutic strategies for endometriosis in women, the disease remains a significant cause of morbidity and ultimately, a cause of mortality, in the older nonhuman primate.

Iron deprivation inhibits cyclin-dependent kinase activity and decreases cyclin D/CDK4 protein levels in asynchronous MDA-MB-453 human breast cancer cells.

Iron chelation, known to block progression through the cell cycle, was examined for effects on the activity and subunit levels of the cyclin-dependent protein kinases (cdk). Treatment of asynchronous MDA-MB-453 cells with the iron chelators mimosine or desferrioxamine (DFO) for 24 h stopped cell division, but did not produce a single, synchronous block. DNA content analysis demonstrated that although a majority of the cells were blocked in G1 (87.3%), an unexpectedly large fraction of the cells were blocked in S phase (11.5%). Western blot analysis of the treated lysates demonstrated the presence of cyclin B, confirming that part of the cell population was blocked in S phase. After release from mimosine treatment, 84% of the cell population remained in G1 up to 8 h. Treating breast cancer cells with 400 microM mimosine for 24 h inhibited cyclin E- and cyclin A-associated kinase activity by 85% or more, although immunoblots using anti-cyclin A, cyclin E, cdc2, and cdk2 antibodies showed that these key subunits were still present in the cells at pretreatment levels. Interestingly, Western blot analysis also demonstrated that iron chelation decreased the protein levels of the cyclin D and cdk4 subunits as compared to control and produced a change in retinoblastoma protein phosphorylation. These results indicate that iron deprivation effects the activity and protein levels of the cyclin-dependent kinases, and ultimately, the pathways that control cell division.

The DNA damage response in DNA-dependent protein kinase-deficient SCID mouse cells: replication protein A hyperphosphorylation and p53 induction.

Severe combined immunodeficient (SCID) mice display an increased sensitivity to ionizing radiation compared with the parental, C.B-17, strain due to a deficiency in DNA double-strand break repair. The catalytic subunit of DNA-dependent protein kinase (DNA-PKCS) has previously been identified as a strong candidate for the SCID gene. DNA-PK phosphorylates many proteins in vitro, including p53 and replication protein A (RPA), two proteins involved in the response of cells of DNA damage. To determine whether p53 and RPA are also substrates of DNA-PK in vivo following DNA damage, we compared the response of SCID and MO59J (human DNA-PKcs-deficient glioblastoma) cells with their respective wild-type parents following ionizing radiation. Our findings indicate that (i) p53 levels are increased in SCID cells following ionizing radiation, and (ii) RPA p34 is hyperphosphorylated in both SCID cells and MO59J cells following ionizing radiation. The hyperphosphorylation of RPA p34 in vivo is concordant with a decrease in the binding of RPA to single-stranded DNA in crude extracts derived from both C.B-17 and SCID cells. These results suggest that DNA-PK is not the only kinase capable of phosphorylating RPA. We conclude that the DNA damage response involving p53 and RPA is not associated with the defect in DNA repair in SCID cells and that the physiological substrate(s) for DNA-PK essential for DNA repair has not yet been identified.

Vesicular stomatitis in the horse.

Vesicular stomatitis (VS) is a viral disease of livestock that results in vesicles and ulcerations on the teats, oral mucosa, tongue, and coronary bands. All three main serotypes of the VS virus can infect the horse. Although VS does not have a major impact on the equine industry, it is clinically identical to the other more economically devastating vesicular diseases of cattle and swine and can produce influenza-like symptoms in humans. VS in horses is reportable, as are all vesicular diseases of livestock.

Adult respiratory distress syndrome with or without systemic disease associated with infections due to Mycoplasma fermentans.

An unusual but typical clinicopathological presentation was noted among several groups of previously healthy, human immunodeficiency virus-negative patients who had an apparent fulminant infectious disease but had no etiologic agent identified. The clinical courses were characterized by rapid progression and development of adult respiratory distress syndrome with or without systemic disease. Histopathological changes in the diseases tissues (other than lung) obtained by biopsy or at autopsy ranged from extensive necrosis with only minimal inflammatory reaction to prominent lymphohistiocytic infiltrate with focal areas of acute inflammation. This report focuses on pulmonary changes in three patients. The alveolar epithelial (type I) cells and type II pneumocytes are diffusely damaged. There is interstitial edema and thickened septa. An eosinophilic alveolar membrane may form, and the alveolar space may fill with foamy macrophages. Immunohistochemical studies identified Mycoplasma fermentans infection in the patients' lungs and liver. Mycoplasma-like particles could also be identified by electron microscopy. There is a previously unrecognized form of fulminant disease in humans that is associated with M. fermentans infections.

Postanesthetic recumbency associated with hyperkalemic periodic paralysis in a quarter horse.

Anesthesia and surgery in a Quarter Horse affected with hyperkalemic periodic paralysis resulted in euthanasia after 7 days of postoperative recumbency. Initial recovery was uneventful after extensive sinus surgery, but within 2 hours, the horse had severe muscle weakness. Plasma electrolyte concentrations were within the normal range during the period of recumbency. There was no clinical or laboratory evidence of severe muscle damage. Despite treatment with acetazolamide, isoproterenol, and intensive nursing, the horse was unable to stand for more than a few seconds and developed severe decubital ulcers. Ultrastructural examination revealed nemaline rods and swollen mitochondria in disrupted myofibers.

Neumonitis por radiación en pacientes con cáncer de mama tratados con radioterapia / Radiation neumonitis in patients with breast cancer treated with radiotherapy

La neumonitis por radiación es un síndrome acompañado de cambios radiológicos bien definidos a nivel pulmonar. Su presentación e intensidad están ralacionadas con diferentes factores. La frecuencia con que se presenta por irradiación a la mama y sus zonas linfoportadoras es variable. Para conocer la frecuencia y relación que guarda con el antecedente de patología pulmonar previa y asociación a tratamiento secuencial de radioterapia y quimioterapia se estudiaron 62 pacientes con cáncer de mama que recibieron radioterapia al tórax, con seguimiento radiológico mínimo de 52 semanas. En el 29 por ciento de las pacientes (18/62) se presentó el síndrome de neumonitis por radiacipon y el 45 por ciento (28/62) evolucionó a fibrosis pulmonar, con todas las pacientes asintomáticas al cierre del estudio. La patología pulmonar previa fue un factor de riesgo estadísticamente significativo (p=0.04) para el desarrollo de neumonitis y fibrosis pulmonar. Esto no se demostró con la asociación de radioterapia y quimioterapia.

A mouse endothelial cell-specific monoclonal antibody: its reactivity with LTMC endothelium.

The binding of a marrow cell-related monoclonal antibody (H513E3 MAb) has been investigated in long-term marrow cultures (LTMC) and in vivo. Immunogold labeling and electron microscopy revealed that this antibody labeled an endothelial-like cell. Cross-reaction of anti-human Factor VIII confirmed endothelial specificity of the H513E3 MAb. In addition, vessel endothelium (vena cava, aorta, and marrow) exhibited binding of the antibody. This antibody provides a unique tool to study the cellular architecture of LTMC and implicates endothelium as an important component of LTMC. The function of the endothelial cell-specific surface antigen is unknown, although preferential labeling of the upper surface of endothelial cells suggests that it may play a role in cell communication, particularly with the floating population. The H513E3 MAb reacts with an external membrane antigen, a property that makes this antibody particularly useful for fluorescences-activated sorting of endothelial cells.

Use of bone marrow somatic cell hybrid lines to generate monoclonal antibodies specifically reactive with rare marrow cells.

The technique of somatic cell hybridization has been applied to obtain new sources of immunogen for monoclonal antibody production. A marrow population enriched for rare and undifferentiated cells was hybridized with A9 cells. Mature cells were depleted by using mice at 8 days following 5-fluorouracil treatment and by using a sorting procedure. Selection of hybrids was in medium containing hypoxanthine, aminopterin, and thymidine (HAT). Chromosome analysis was used to verify that clones contained hybrid cells. An example of an antibody (H513E3) obtained by immunizing with a hybrid cell line (H5Scl1.4.4) is presented. The H513E3 antibody showed low reactivity with normal marrow (0%-3%), and hemopoietic cell lines of various types exhibited no cross-reaction. However, about 10% of cells from the adherent stromal layer of long-term marrow cultures reacted with the H513E3 antibody. A specific cell type was labeled that appeared to have endothelial-like morphology when observed with immunogold labeling and electron microscopy. The hybridization technique allows a cell of a particular differentiation lineage to be conserved, wholly or partially, in a cloned form, thus overcoming the heterogeneity of a normal marrow population.

Hemoperitoneum caused by rupture of a juvenile granulosa cell tumor in an equine neonate.

A neonatal foal was examined because of apparent abdominal pain and distention, anemia, and hemoperitoneum. Exploratory laparotomy was performed, and a large spherical mass, which had ruptured, was found in the area of the left ovary. Left salpingo-oophorectomy was performed. The mass was determined to be a juvenile granulosa cell tumor.

Avian mycobacteriosis in three horses.

The clinical, bacteriologic and pathologic findings of three adult horses suffering from avian tuberculosis are presented. Chronic weight loss and hypoproteinemia were pertinent clinical abnormalities in all three horses. Gross pathologic lesions were characterized by chronic enterocolitis with mesenteric lymphadenopathy in two horses and hepatic granulomas in the third horse. The microscopic diagnoses were chronic, non-caseating granulomatous enterocolitis, and necrotizing, non-mineralizing granulomatous hepatitis, respectively. All three horses had granulomatous lymphadenitis of mesenteric lymph nodes with varying degrees of non-mineralizing, coagulation necrosis. Various serotypes of the Mycobacterium avium-intracellulare complex were isolated from selected tissues and feces.