Patient outcomes following transfer between intensive care units during the COVID-19 pandemic.

Transferring critically ill patients between intensive care units (ICU) is often required in the UK, particularly during the COVID-19 pandemic. However, there is a paucity of data examining clinical outcomes following transfer of patients with COVID-19 and whether this strategy affects their acute physiology or outcome. We investigated all transfers of critically ill patients with COVID-19 between three different hospital ICUs, between March 2020 and March 2021. We focused on inter-hospital ICU transfers (those patients transferred between ICUs from different hospitals) and compared this cohort with intra-hospital ICU transfers (patients moved between different ICUs within the same hospital). A total of 507 transfers were assessed, of which 137 met the inclusion criteria. Forty-five patients underwent inter-hospital transfers compared with 92 intra-hospital transfers. There was no significant change in median compliance 6 h pre-transfer, immediately post-transfer and 24 h post-transfer in patients who underwent either intra-hospital or inter-hospital transfers. For inter-hospital transfers, there was an initial drop in median PaO2 /FI O2 ratio: from median (IQR [range]) 25.1 (17.8-33.7 [12.1-78.0]) kPa 6 h pre-transfer to 19.5 (14.6-28.9 [9.8-52.0]) kPa immediately post-transfer (p < 0.05). However, this had resolved at 24 h post-transfer: 25.4 (16.2-32.9 [9.4-51.9]) kPa. For intra-hospital transfers, there was no significant change in PaO2 /FI O2 ratio. We also found no meaningful difference in pH; PaCO2 ;, base excess; bicarbonate; or norepinephrine requirements. Our data demonstrate that patients with COVID-19 undergoing mechanical ventilation of the lungs may have short-term physiological deterioration when transferred between nearby hospitals but this resolves within 24 h. This finding is relevant to the UK critical care strategy in the face of unprecedented demand during the COVID-19 pandemic.

Persisting Symptomatic Severe Secondary Mitral Regurgitation in Heart Failure Patients.

Aims We aimed to assess the rate of persisting severe symptomatic secondary mitral regurgitation (MR) in a newly diagnosed heart failure (HF) population following optimisation of guideline directed medical therapy (GDMT), cardiac resynchronisation therapy (CRT) and revascularisation. Methods We assessed all new patients referred to our hospital group's HF clinics. We retrospectively reviewed these patients at HF clinic enrolment, HF programme completion, as well as most recent follow up. Results Of the 242 new patients referred to our HF clinics, there were 10 patients (4.1%) who had either persisting symptomatic severe secondary MR at HF programme completion, or had undergone mitral valve surgery. There were no percutaneous mitral valve repairs at the time of these patients' referrals. The rates of ACE/ARB/ARNI, BB and MRA use were 87.8%, 94.1%, and 49.8% in those with mid ranged, or reduced ejection fraction. The rates of ICD and CRT therapy were 15.1% and 4.4% at follow up. Patients with severe MR had higher time adjusted rates of death or hospitalization for heart failure. Conclusion In a well-treated newly diagnosed HF population, repeat assessment at HF programme completion suggests 4.1% of patients have a persisting indication for percutaneous mitral valve repair based on persisting severe symptomatic secondary MR.

Brucella suis biovar 2 infection in humans in France: emerging infection or better recognition?

Brucellosis is usually acquired by humans through contact with infected animals or the consumption of raw milk from infected ruminants. Brucella suis biovar 2 (BSB2) is mainly encountered in hares and wild boars (Sus scrofa), and is known to have very low pathogenicity to humans with only two case reports published in the literature. Human cases of brucellosis caused by BSB2 were identified through the national mandatory notification of brucellosis. The identification of the bacterium species and biovar were confirmed by the national reference laboratory. Epidemiological data were obtained during medical follow-up visits. Seven human cases were identified between 2004 and 2016, all confirmed by the isolation of BSB2 in clinical specimens. All patients had direct contact with wild boars while hunting or preparing wild boar meat for consumption. Five patients had chronic medical conditions possibly responsible for an increased risk of infection. Our findings suggest that BSB2 might be an emerging pathogen in hunters with massive exposure through the dressing of wild boar carcasses. Hunters, especially those with chronic medical conditions, should be informed about the risk of BSB2 infection and should receive information on protective measures.

The Brucella suis IbpA heat-shock chaperone is not required for virulence or for expression of the VirB type IV secretion system VirB8 protein.

UNLABELLED: Brucella suis, facultative intracellular bacterial pathogen of mammals, and Agrobacterium tumefaciens, a plant pathogen, both use a VirB type IV secretion system (T4SS) to translocate effector molecules into host cells. HspL, an α-crystalline-type small heat-shock protein, acts as a chaperone for the Agrobacterium VirB8 protein, an essential component of the VirB system. An Agrobacterium mutant lacking hspL is attenuated due to a misfunctional T4SS. We have investigated whether IbpA (BRA0051), the Brucella HspL homologue, plays a similar role. Unlike HspL, IbpA does not interact with VirB8, and an IbpA mutant shows full virulence and no defect in VirB expression. These data show that the Brucella α-crystalline-type small heat-shock protein IbpA is not required for Brucella virulence. SIGNIFICANCE AND IMPACT OF STUDY: Many bacteria use type IV secretion systems (T4SS), multi-protein machines, to translocate DNA and protein substrates across their envelope. Understanding how T4SS function is important as they play major roles in the spread of plasmids carrying antibiotic resistance and in pathogenicity. In the plant pathogen Agrobacterium tumefaciens, HspL, an α-crystalline-type small heat-shock protein, acts as a chaperone for the essential type IV secretion system component VirB8. Here, we show that this is not the case for all T4SS; in the zoonotic pathogen Brucella suis, IbpA, the protein most related to HspL, does not play this role.

The quest for a true One Health perspective of brucellosis.

One Health is an interdisciplinary collaboration that aims at mitigating risks to human health arising from microorganisms present in non-human animal species, which have the potential to be transmitted and cause disease in humans. Different degrees of scientific collaboration and sectoral integration are needed for different types of zoonotic diseases, depending on the health and associated economic gains that can be expected from a One Health approach. Indeed, mitigating zoonotic risks related to emerging diseases with pandemic potential is different from mitigating risks related to endemic zoonotic diseases like brucellosis. Likewise, management of brucellosis at the wildlife-livestock interface in wildlife conservation areas is in essence different from mitigating transmission of a given Brucella species within its preferential host species, which in turn is different from mitigating the spillover of a given Brucella species to non-preferential host species, humans included. Brucellosis economic models often oversimplify and/or wrongly assess transmission between reservoir hosts and spillover hosts. Moreover,they may not properly value non-market outcomes, such as avoidance of human disease, consumer confidence and conservation biology issues. As a result, uncertainty is such that the economic predictions of these models can be questionable. Therefore, understanding the infection biology of Brucella species is a prerequisite. This paper reviews and highlights important features of the infection biology of Brucella species and the changing epidemiology of brucellosis that need to be integrated into a true One Health perspective of brucellosis.

Effect of increasing the protein-to-fat ratio and reducing fat content on the chemical and physical properties of processed cheese product.

Scientific studies indicate that the intake of dietary fat and saturated fats in the modern Western diet is excessive and contributes adversely to health, lifestyle, and longevity. In response, manufacturers of cheese and processed cheese products (PCP) are pursuing the development of products with reduced fat contents. The present study investigated the effect of altering the fat level (13.8, 18.2, 22.7, 27.9, and 32.5 g/100g) in PCP on their chemical and physical properties. The PCP were formulated in triplicate to different fat levels using Cheddar cheese, skim milk cheese, anhydrous milk fat, emulsifying salt (ES), NaCl, and water. The formulations were designed to give fixed moisture (~53 g/100g) and ES:protein ratio (0.105). The resultant PCP, and their water-soluble extracts (WSE), prepared from a macerated blend of PCP and water at a weight ratio of 1:2, were analyzed at 4d. Reducing the fat content significantly increased the firmness of the unheated PCP and reduced the flowability and maximum loss tangent (fluidity) of the melted PCP. These changes coincided with increases in the levels of total protein, water-soluble protein, water-insoluble protein, and water-soluble Ca, and a decrease in the molar ratio of water-soluble Ca to soluble P. However, both water-soluble Ca and water-soluble protein decreased when expressed as percentages of total protein and total Ca, respectively, in the PCP. The high level of protein was a major factor contributing to the deterioration in physical properties as the fat content of PCP was reduced. Diluting the protein content or reducing the potential of the protein to aggregate, and thereby form structures that contribute to rigidity, may provide a means for improving quality of reduced-fat PCP by using natural cheese with lower intact casein content and lower calcium:casein ratio, for example, or by decreasing the ratio of sodium phosphate to sodium citrate-based ES.

The association between resting and mild-to-moderate exercise pulmonary artery pressure.

The mean pulmonary artery pressure (P(pa)) achieved on mild-to-moderate exercise is age related and its haemodynamic correlates remain to be documented in patients free of pulmonary hypertension (PH). Our retrospective study involved patients free of PH investigated in our centre for possible pulmonary vascular disease between January 1, 2007 and October 31, 2009 who underwent right heart catheterisation at rest and during supine exercise up to 60 W. The 38 out of 99 patients aged <50 yrs were included and a P(pa) of 30 mmHg was considered the upper limit of normal on exercise. The 24 subjects who developed P(pa)>30 mmHg on exercise had higher resting P(pa) (19±3 versus 15±4 mmHg) and indexed pulmonary vascular resistance (PVRi; 3.4±1.5 versus 2.2±1.1 WU·m(2); p<0.05) than the remaining 14 subjects. Resting P(pa) >15 mmHg predicted exercise P(pa) >30 mmHg with 88% sensitivity and 57% specificity. The eight patients with resting P(pa) 22-24 mmHg all had exercise P(pa) >30 mmHg. In subjects aged <50 yrs investigated for possible pulmonary vascular disease and free of PH, patients with mild-to-moderate exercise P(pa) >30 mmHg had higher resting PVRi and higher resting P(pa), although there was no resting P(pa) threshold value that could predict normal response on mild-to-moderate exercise. The clinical relevance of such findings deserves further long-term follow-up studies.

Effects of hydrolysis on solid-state relaxation and stickiness behavior of sodium caseinate-lactose powders.

Hydrolyzed or nonhydrolyzed sodium caseinate-lactose dispersions were spray dried, at a protein: lactose ratio of 0.5, to examine the effects of protein hydrolysis on relaxation behavior and stickiness of model powders. Sodium caseinate (NC) used included a nonhydrolyzed control (DH 0) and 2 hydrolyzed variants (DH 8.3 and DH 15), where DH = degree of hydrolysis (%). Prior to spray drying, apparent viscosities of liquid feeds (at 70°C) at a shear rate of 20/s were 37.6, 3.14, and 3.19 mPa·s, respectively, for DH 0, DH 8, and DH 15 dispersions. Powders containing hydrolyzed casein were more susceptible to sticking than those containing intact NC. The former had also lower bulk densities and powder particle sizes. Scanning electron microscopy showed that hydrolyzed powders had thinner particle walls and were more friable than powders containing intact NC. Secondary structure of caseinates, determined by Fourier transform infrared spectroscopy, was affected by the relative humidity of storage and the presence of lactose as co-solvent rather than its physical state. Glass transition temperatures and lactose crystallization temperatures, determined by differential scanning calorimetry were not affected by caseinate hydrolysis, although the effects of protein hydrolysis on glass-rubber transitions (T(gr)) could be determined by thermo-mechanical analysis. Powders containing hydrolyzed NC had lower T(gr) values (~30°C) following storage at a higher subcrystallization relative humidity (33%) compared with powder with nonhydrolyzed NC (T(gr) value of ~40°C), an effect that reflects more extensive plasticization of powder matrices by moisture. Results support that sodium caseinate-lactose interactions were weak but that relaxation behavior, as determined by the susceptibility of powder to sticking, was affected by hydrolysis of sodium caseinate.

Preliminary evaluation of endogenous milk fluorophores as tracer molecules for curd syneresis.

A front-face fluorescence spectroscopy probe was installed in the wall of a laboratory-scale cheese vat. Excitation and emission filters were chosen for the selective detection of vitamin A, tryptophan, and riboflavin fluorescence. The evolution of the fluorescence of each fluorophore during milk coagulation and syneresis was monitored to determine if they had the potential to act as intrinsic tracers of syneresis and also coagulation. The fluorescence profiles for 2 of the fluorophores during coagulation could be divided into 3 sections relating to enzymatic hydrolysis of κ-casein, aggregation of casein micelles, and crosslinking. A parameter relating to coagulation kinetics was derived from the tryptophan and riboflavin profiles but this was not possible for the vitamin A response. The study also indicated that tryptophan and riboflavin may act as tracer molecules for syneresis, but this was not shown for vitamin A. The evolution of tryptophan and riboflavin fluorescence during syneresis followed a first-order reaction and had strong relationships with curd moisture and whey total solids content (r=0.86-0.96). Simple 1- and 2-parameter models were developed to predict curd moisture content, curd yield, and whey total solids using parameters derived from the sensor profiles (standard error of prediction=0.0005-0.394%; R(2)=0.963-0.999). The results of this study highlight the potential of tryptophan and riboflavin to act as intrinsic tracer molecules for noninvasive inline monitoring of milk coagulation and curd syneresis. Further work is required to validate these findings under a wider range of processing conditions.

Effects of milk composition, stir-out time, and pressing duration on curd moisture and yield.

A study was undertaken to investigate the effects of milk composition (i.e., protein level and protein:fat ratio), stir-out time, and pressing duration on curd moisture and yield. Milks of varying protein levels and protein:fat ratios were renneted under normal commercial conditions in a pilot-scale cheese vat. During the syneresis phase of cheese making, curd was removed at differing times, and curd moisture and yield were monitored over a 22-h pressing period. Curd moisture after pressing decreased with longer stir-out time and pressing duration, and an interactive effect was observed of stir-out time and pressing duration on curd moisture and yield. Milk total solids were shown to affect curd moisture after pressing, which has implications for milk standardization; that is, it indicates a need to standardize on a milk solids basis as well as on a protein:fat basis. In this study, a decreased protein:fat ratio was associated with increased total solids in milk and resulted in decreased curd moisture and increased curd yield after pressing. The variation in total solids of the milk explains the apparent contradiction between decreased curd moisture and increased curd yield. This study points to a role for process analytic technology in minimizing variation in cheese characteristics through better control of cheesemilk composition, in-vat process monitoring (coagulation and syneresis), and post-vat moisture reduction (curd pressing). Increased control of curd composition at draining would facilitate increased control of the final cheese grade and quality.

Current management approaches to portopulmonary hypertension.

Portopulmonary hypertension (PoPH) is a rare but life-threatening complication of portal hypertension that is characterised by proliferative changes in the pulmonary microvasculature indistinguishable from other forms of pulmonary arterial hypertension (PAH). Although PoPH is most commonly observed in the setting of cirrhosis, patients with non-cirrhotic portal hypertension are also at risk of developing the disorder. A definitive diagnosis requires invasive haemodynamic confirmation by right heart catheterisation and screening for PoPH should be routinely performed in all patients being considered for liver transplantation. Although severe PoPH is considered a contraindication to liver transplantation, there is now compelling data supporting the use of PAH-specific therapies with the aim of improving pulmonary haemodynamics to allow transplantation to be successfully performed. This review explores possible relevant aetiological factors and summarises current diagnostic and therapeutic approaches for PoPH patients.

Survival in incident and prevalent cohorts of patients with pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) is a progressive, fatal disease. We studied 674 consecutive adult patients who were prospectively enrolled in the French PAH registry (121 incident and 553 prevalent cases). Two survival analyses were performed. First, the cohort of 674 patients was followed for 3 yrs after study entry and survival rates described. Then, we focused on the subset with incident idiopathic, familial and anorexigen-associated PAH (n = 56) combined with prevalent patients who were diagnosed <3 yrs prior to study entry (n = 134). In the cohort of 674 patients, 1-, 2-, and 3-yr survival rates were 87% (95% CI 84-90), 76% (95% CI 73-80), and 67% (95% CI 63-71), respectively. In prevalent idiopathic, familial and anorexigen-associated PAH, 1-, 2-, and 3-yr survival rates were higher than in incident patients (p = 0.037). In the combined cohort of patients with idiopathic, familial and anorexigen-associated PAH, multivariable analysis showed that survival could be estimated by means of a novel risk-prediction equation using patient sex, 6-min walk distance, and cardiac output at diagnosis. This study highlights survivor bias in prevalent cohorts of PAH patients. Survival of idiopathic, familial and anorexigen-associated PAH can be characterised by means of a novel risk-prediction equation using patients' characteristics at diagnosis.

Comparison between red-green-blue imaging and visible-near infrared reflectance as potential process analytical tools for monitoring syneresis.

The current work focuses on the comparison of 2 on-line optical sensing systems; namely red-green-blue imaging and visible-near infrared reflectance, for monitoring syneresis during cheese manufacture. The experimental design consisted of 3 temperature treatments carried out in an 11-L cheese vat in triplicate. Both systems were shown to predict syneresis without significant differences in prediction accuracy. However, a single-wavelength near infrared model was the most parsimonious (standard error of prediction=4.35g/100g) for predicting syneresis. This technique was also the simplest in terms of parameters in the model (standard error of prediction=4.15g/100g with 2 parameters), when time after gel cutting and process parameters (temperature and cutting time) were included in the models. The study showed that either system could be employed to control syneresis in cheese manufacture and improve the control of moisture content in cheese.

Validation of a curd-syneresis sensor over a range of milk composition and process parameters.

An online visible-near-infrared sensor was used to monitor the course of syneresis during cheesemaking with the purpose of validating syneresis indices obtained using partial least squares, with cross-validation across a range of milk fat levels, gel firmness levels at cutting, curd cutting programs, stirring speeds, milk protein levels, and fat:protein ratio levels. Three series of trials were carried out in an 11-L cheese vat using recombined whole milk. Three factorial experimental designs were used, consisting of 1) 3 curd stirring speeds and 3 cutting programs; 2) 3 milk fat levels and 3 gel firmness levels at cutting; and 3) 2 milk protein levels and 3 fat:protein ratio levels, respectively. Milk was clotted under constant conditions in all experiments and the gel was cut according to the respective experimental design. Prediction models for production of whey and whey fat losses were developed in 2 of the experiments and validated in the other experiment. The best models gave standard error of prediction values of 6.6 g/100 g for yield of whey and 0.05 g/100 g for fat in whey, as compared with 4.4 and 0.013 g/100 g, respectively, for the calibration data sets. Robust models developed for predicting yield of whey and whey fat losses using a validation method have potential application in the cheese industry.

Effects of cutting intensity and stirring speed on syneresis and curd losses during cheese manufacture.

Recombined whole milk was renneted under constant conditions of pH, temperature, and added calcium, and the gel was cut at a constant firmness. The effects of cutting and stirring on syneresis and curd losses to whey were investigated during cheese making using a factorial design with 3 cutting modes designed to provide 3 different cutting intensity levels (i.e., total cutting revolutions), 3 levels of stirring speed, and 3 replications. These cutting intensities and stirring speeds were selected to give a wide range of curd grain sizes and curd shattering, respectively. Both factors affected curd losses, and correct selection of these factors is important in the cheesemaking industry. Decreased cutting intensity and increased stirring speed significantly increased the losses of fines and fat from the curd to the whey. Cutting intensities and stirring speeds in this study did not show significant effects on curd moisture content over the course of syneresis. Levels of total solids, fines, and fat in whey were shown to change significantly during syneresis. It is believed that larger curd particles resulting from low cutting intensities coupled with faster stirring speeds resulted in a higher degree of curd shattering during stirring, which caused significant curd losses.

Thermal stability of soy protein isolate and hydrolysate ingredients.

The objective of this study was to characterize the effects of pH, protein concentration and calcium supplementation on thermal stability, at 140°C, of soy protein isolate (SPI) and soy protein hydrolysate (SPH) ingredients. Increasing pH between 6.4 and 7.5 led to significantly (p<0.05) higher mean heat coagulation times (HCTs) at 140°C, for all soy protein ingredients at 1.8, and 3.6% (w/v) protein. Increasing protein concentration from 1.8 to 7.2% (w/v) led to shorter HCTs for protein dispersions. Calcium supplementation up to 850mg/L, except in the case of supplementation of SPI 1 with calcium citrate (CaCit), decreased HCT for soy protein ingredient dispersions, at pH 6.4 - 7.5. No significant differences (p<0.05) were found in mean HCT for dispersions supplemented with calcium chloride (CaCl2) and those supplemented with CaCit at 450, 650 and 850mg/L Ca(2+), in the pH range 6.4-7.5.

Pulmonary hypertension and left heart disease: emerging concepts and treatment strategies.

At least two thirds of patients with chronic severe left heart disease have associated pulmonary hypertension, and mortality associated with biventricular failure is >two-fold higher compared with isolated left ventricular failure. This review considers and discusses emerging concepts and strategies from recent studies of specific treatments in populations with pulmonary hypertension complicating overt left ventricular dysfunction. While the results reported in the studies considered are encouraging, to date there are no large randomised studies of specific treatments in populations with pulmonary hypertension complicating overt left ventricular dysfunction.

Effect of cutting time, temperature, and calcium on curd moisture, whey fat losses, and curd yield by response surface methodology.

Response surface methodology was used to study the effect of temperature, cutting time, and calcium chloride addition level on curd moisture content, whey fat losses, and curd yield. Coagulation and syneresis were continuously monitored using 2 optical sensors detecting light backscatter. The effect of the factors on the sensors' response was also examined. Retention of fat during cheese making was found to be a function of cutting time and temperature, whereas curd yield was found to be a function of those 2 factors and the level of calcium chloride addition. The main effect of temperature on curd moisture was to increase the rate at which whey was expelled. Temperature and calcium chloride addition level were also found to affect the light backscatter profile during coagulation whereas the light backscatter profile during syneresis was a function of temperature and cutting time. The results of this study suggest that there is an optimum firmness at which the gel should be cut to achieve maximum retention of fat and an optimum curd moisture content to maximize product yield and quality. It was determined that to maximize curd yield and quality, it is necessary to maximize firmness while avoiding rapid coarsening of the gel network and microsyneresis. These results could contribute to the optimization of the cheese-making process.

Computer vision and color measurement techniques for inline monitoring of cheese curd syneresis.

Optical characteristics of stirred curd were simultaneously monitored during syneresis in a 10-L cheese vat using computer vision and colorimetric measurements. Curd syneresis kinetic conditions were varied using 2 levels of milk pH (6.0 and 6.5) and 2 agitation speeds (12.1 and 27.2 rpm). Measured optical parameters were compared with gravimetric measurements of syneresis, taken simultaneously. The results showed that computer vision and colorimeter measurements have potential for monitoring syneresis. The 2 different phases, curd and whey, were distinguished by means of color differences. As syneresis progressed, the backscattered light became increasingly yellow in hue for circa 20 min for the higher stirring speed and circa 30 min for the lower stirring speed. Syneresis-related gravimetric measurements of importance to cheese making (e.g., curd moisture content, total solids in whey, and yield of whey) correlated significantly with computer vision and colorimetric measurements.