Identifying factors associated with intravenous fluid administration in patients with sepsis presenting to the emergency department: a retrospective cohort study.

BACKGROUND: Appropriate and timely administration of intravenous fluids to patients with sepsis-induced hypotension is one of the mainstays of sepsis management in the emergency department (ED), however, fluid resuscitation remains an ongoing challenge in ED. Our study has been undertaken with two specific aims: firstly, for patients with sepsis, to identify factors associated with receiving intravenous fluids while in the ED; and, secondly to identify determinants associated with the actual time to fluid administration. METHODS: We conducted a retrospective multicentre cohort study of adult ED presentations between October 2018 and May 2019 in four metropolitan hospitals in Western Sydney, Australia. Patients meeting pre-specified criteria for sepsis and septic shock and treated with antibiotics within the first 24 h of presentation were included. Multivariable models were used to identify factors associated with fluid administration in sepsis. RESULTS: Four thousand one hundred forty-six patients met the inclusion criteria, among these 2,300 (55.5%) patients with sepsis received intravenous fluids in ED. The median time to fluid administration from the time of diagnosis of sepsis was 1.6 h (Interquartile Range (IQR) 0.5 to 3.8), and the median volume of fluids administered was 1,100 mL (IQR 750 to 2058). Factors associated with patients receiving fluids were younger age (Odds Ratio (OR) 1.05, 95% Confidence Interval (CI (1.03 to 1.07), p < 0.001); lower systolic blood pressure (OR 1.11, 95% CI (1.08 to 1.13), p < 0.001); presenting to smaller hospital (OR 1.48, 95% CI (1.25 to 1.75, p < 0.001) and a Clinical Rapid Response alert activated (OR 1.64, 95% CI (1.28 to 2.11), p < 0.001). Patients with Triage Category 1 received fluids 101.22 min earlier (95% CI (59.3 to131.2), p < 0.001) and those with Category 2 received fluids 43.58 min earlier (95% CI (9.6 to 63.1), p < 0.001) compared to patients with Triage Category 3-5. Other factors associated with receiving fluids earlier included septic shock (-49.37 min (95% CI (-86.4 to -12.4), p < 0.001)); each mmol/L increase in serum lactate levels (-9.0 min, 95% CI (-15.7 to -2.3), p < 0.001) and presenting to smaller hospitals (-74.61 min, 95% CI (-94.0 to -55.3), p < 0.001). CONCLUSIONS: Younger age, greater severity of sepsis, and presenting to a smaller hospital increased the probability of receiving fluids and receiving it earlier. Recognition of these factors may assist in effective implementation of sepsis management guidelines which should translate into better patient outcomes. Future studies are needed to identify other associated factors that we have not explored.

Combining structured and unstructured data in EMRs to create clinically-defined EMR-derived cohorts.

BACKGROUND: There have been few studies describing how production EMR systems can be systematically queried to identify clinically-defined populations and limited studies utilising free-text in this process. The aim of this study is to provide a generalisable methodology for constructing clinically-defined EMR-derived patient cohorts using structured and unstructured data in EMRs. METHODS: Patients with possible acute coronary syndrome (ACS) were used as an exemplar. Cardiologists defined clinical criteria for patients presenting with possible ACS. These were mapped to data tables within the production EMR system creating seven inclusion criteria comprised of structured data fields (orders and investigations, procedures, scanned electrocardiogram (ECG) images, and diagnostic codes) and unstructured clinical documentation. Data were extracted from two local health districts (LHD) in Sydney, Australia. Outcome measures included examination of the relative contribution of individual inclusion criteria to the identification of eligible encounters, comparisons between inclusion criterion and evaluation of consistency of data extracts across years and LHDs. RESULTS: Among 802,742 encounters in a 5 year dataset (1/1/13-30/12/17), the presence of an ECG image (54.8% of encounters) and symptoms and keywords in clinical documentation (41.4-64.0%) were used most often to identify presentations of possible ACS. Orders and investigations (27.3%) and procedures (1.4%), were less often present for identified presentations. Relevant ICD-10/SNOMED CT codes were present for 3.7% of identified encounters. Similar trends were seen when the two LHDs were examined separately, and across years. CONCLUSIONS: Clinically-defined EMR-derived cohorts combining structured and unstructured data during cohort identification is a necessary prerequisite for critical validation work required for development of real-time clinical decision support and learning health systems.

Continental synchronicity of human influenza virus epidemics despite climatic variation.

The factors that determine the pattern and rate of spread of influenza virus at a continental-scale are uncertain. Although recent work suggests that influenza epidemics in the United States exhibit a strong geographical correlation, the spatiotemporal dynamics of influenza in Australia, a country and continent of approximately similar size and climate complexity but with a far smaller population, are not known. Using a unique combination of large-scale laboratory-confirmed influenza surveillance comprising >450,000 entries and genomic sequence data we determined the local-level spatial diffusion of this important human pathogen nationwide in Australia. We used laboratory-confirmed influenza data to characterize the spread of influenza virus across Australia during 2007-2016. The onset of established epidemics varied across seasons, with highly synchronized epidemics coinciding with the emergence of antigenically distinct viruses, particularly during the 2009 A/H1N1 pandemic. The onset of epidemics was largely synchronized between the most populous cities, even those separated by distances of >3000 km and those that experience vastly diverse climates. In addition, by analyzing global phylogeographic patterns we show that the synchronized dissemination of influenza across Australian cities involved multiple introductions from the global influenza population, coupled with strong domestic connectivity, rather than through the distinct radial patterns of geographic dispersal that are driven by work-flow transmission as observed in the United States. In addition, by comparing the spatial structure of influenza A and B, we found that these viruses tended to occupy different geographic regions, and peak in different seasons, perhaps indicative of moderate cross-protective immunity or viral interference effects. The highly synchronized outbreaks of influenza virus at a continental-scale revealed here highlight the importance of coordinated public health responses in the event of the emergence of a novel, human-to-human transmissible, virus.

Correction: Continental synchronicity of human influenza virus epidemics despite climactic variation.

[This corrects the article DOI: 10.1371/journal.ppat.1006780.].

Developing an Intranet-Based Lymphedema Dashboard for Breast Cancer Multidisciplinary Teams: Design Research Study.

BACKGROUND: A large quantity of data is collected during the delivery of cancer care. However, once collected, these data are difficult for health professionals to access to support clinical decision making and performance review. There is a need for innovative tools that make clinical data more accessible to support health professionals in these activities. One approach for providing health professionals with access to clinical data is to create the infrastructure and interface for a clinical dashboard to make data accessible in a timely and relevant manner. OBJECTIVE: This study aimed to develop and evaluate 2 prototype dashboards for displaying data on the identification and management of lymphedema. METHODS: The study used a co-design framework to develop 2 prototype dashboards for use by health professionals delivering breast cancer care. The key feature of these dashboards was an approach for visualizing lymphedema patient cohort and individual patient data. This project began with 2 focus group sessions conducted with members of a breast cancer multidisciplinary team (n=33) and a breast cancer consumer (n=1) to establish clinically relevant and appropriate data for presentation and the visualization requirements for a dashboard. A series of fortnightly meetings over 6 months with an Advisory Committee (n=10) occurred to inform and refine the development of a static mock-up dashboard. This mock-up was then presented to representatives of the multidisciplinary team (n=3) to get preliminary feedback about the design and use of such dashboards. Feedback from these presentations was reviewed and used to inform the development of the interactive prototypes. A structured evaluation was conducted on the prototypes, using Think Aloud Protocol and semistructured interviews with representatives of the multidisciplinary team (n=5). RESULTS: Lymphedema was selected as a clinically relevant area for the prototype dashboards. A qualitative evaluation is reported for 5 health professionals. These participants were selected from 3 specialties: surgery (n=1), radiation oncology (n=2), and occupational therapy (n=2). Participants were able to complete the majority of tasks on the dashboard. Semistructured interview themes were categorized into engagement or enthusiasm for the dashboard, user experience, and data quality and completeness. CONCLUSIONS: Findings from this study constitute the first report of a co-design process for creating a lymphedema dashboard for breast cancer health professionals. Health professionals are interested in the use of data visualization tools to make routinely collected clinical data more accessible. To be used effectively, dashboards need to be reliable and sourced from accurate and comprehensive data sets. While the co-design process used to develop the visualization tool proved effective for designing an individual patient dashboard, the complexity and accessibility of the data required for a cohort dashboard remained a challenge.

Kinetic study of sulforaphane stability in blanched and un-blanched broccoli (Brassica oleracea var. italica) florets during storage at low temperatures.

Sulforaphane is a health-promoting compound found in broccoli. Given its high thermo-lability, its preservation through high-temperature processes seems inconvenient. Accordingly, storage at low temperature is an alternative. There are no studies about the evolution of sulforaphane content during storage at low temperatures. The change of sulforaphane content in blanched and un-blanched broccoli florets during storage at 10, - 1, - 21 and - 45 °C for 83 days was studied. In blanched broccoli, sulforaphane content followed a first-order degradation kinetics (R2 ≥ 0.95). A two-consecutive irreversible reactions model described adequately the evolution of sulforaphane content in un-blanched broccoli (R2 ≥ 0.94). Activation energies from Arrhenius equation resulted in 19.4 kJ/mol for blanched and 30 kJ/mol (formation) and 58 kJ/mol (degradation) for un-blanched broccoli. Storage of un-blanched broccoli at - 45 °C for 40 days maximized sulforaphane content. These results could be useful to propose broccoli storage conditions that preserve or maximize sulforaphane content.

Comparison of clinical characteristics and outcomes of patients with sepsis identified by the Sepsis-3 criteria by blood and urine culture results: A multicentre retrospective cohort study.

Background and Aims: Blood and urine are the most common culture testing for sepsis patients. This study aimed to compare clinical characteristics and outcomes of sepsis patients by blood and urine culture positivity and to identify factors associated with positive cultures. Methods: This retrospective study included patients aged ≥16 years with sepsis identified by the Sepsis-3 criteria presenting to the emergency department at four hospitals between 2017 and 2019 in Australia. Patient clinical outcomes were in-hospital mortality, intensive care unit (ICU) admission, hospital length of stay, and representation following discharge. Four culture groups were defined based on the positivity of blood cultures (BC) and urine cultures (UC) ordered within 24 h of triage. Results: Of 4109 patient encounters with sepsis, 2730 (66%) were nonbacteremic, urine culture-negative (BC-UC-); 767 (19%) nonbacteremic, urine culture-positive (BC-UC+); 359 (9%) bacteremic, urine culture-negative (BC+UC-); and 253 (6%) bacteremic, urine culture-positive (BC+UC+). Compared with BC-UC- patients, BC+UC- patients had the highest risk of ICU admission (adjusted odds ratio [AOR] 95% CI: 1.60 [1.18-2.18]) while BC-UC+ patients had lowest risk (adjusted odds ratio [AOR]: 0.56 [0.41-0.76]). BC+UC- patients had the highest risk of 3-day representation (AOR: 1.51 [1.02-2.25]) and second longest hospital stay (adjusted relative risk 1.17 [1.03-1.34]). Antibiotic administration before sample collection for culture was associated with lower odds of positive blood or urine culture results (AOR: 0.38, p < 0.0001). Conclusions: Enhanced clinical care should be beneficial for nongenitourinary sepsis patients (BC+UC-) who had the highest comparative risk of adverse clinical outcomes. Every effort needs to be made to collect relevant culture samples before antibiotic administration, to follow up on culture results, and tailor treatment accordingly.

Association between timing and adequacy of antibiotics and adverse outcomes in patients with sepsis and septic shock: A multicentre retrospective cohort study.

OBJECTIVES: To investigate the association between the timing and adequacy of antibiotics administered to patients presenting with culture-positive sepsis and septic shock to the ED and in-hospital mortality and/or intensive care unit (ICU) admission. METHODS: Multicentre retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia between January 2017 and November 2019. Encounters for patients aged ≥16 years meeting specified criteria for sepsis or septic shock with antibiotic administration within the first 6 h of presentation were included. RESULTS: Of 7611 encounters included in the study, 2328 (31%) were culture positive, and 2228 (29%) met the criteria for septic shock. In culture-positive sepsis encounters, partial or inadequate antibiotic coverage was associated with higher risk of death or ICU admission (adjusted odds ratio [AOR] 1.50, 95% confidence interval [CI] 1.04-2.06 and 1.95, 95% CI 1.28-2.99, respectively). This effect was not significant in septic shock encounters (AOR 1.10, 95% CI 0.64-1.88) with partial coverage and (AOR 1.63, 95% CI 0.81-3.3) inadequate coverage. Time to antibiotics was not significantly associated with the risk of mortality/ICU admission. This inference remained the same when analysis was restricted to cases with adequate antibiotic coverage. CONCLUSIONS: In a large multicentre sample of patients with culture-positive sepsis, inadequacy of antibiotics was associated with higher risk of in-hospital mortality or ICU admission.

Association between intravenous fluid resuscitation and outcome among patients with suspected infection and sepsis: A retrospective cohort study.

OBJECTIVE: To investigate the association between timing and volume of intravenous fluids administered to ED patients with suspected infection and all-cause in-hospital mortality. METHODS: Retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia, between October 2018 and May 2019. Patients over 16 years of age with suspected infection who received intravenous fluids within 24 h of presentation were included. RESULTS: During the study period, 7533 patients with suspected infection received intravenous fluids. Of these, 1996 (26.5%) and 231 (3.1%) had suspected sepsis and septic shock, respectively. Each 1000 mL increase in intravenous fluids administered was associated with a reduction in risk of in-hospital mortality (adjusted odds ratio [AOR] 0.87, 95% confidence interval [CI] 0.76-0.99). This association was stronger in patients with septic shock (AOR 0.66, 95% CI 0.49-0.89), and those admitted to intensive care unit (ICU) (AOR 0.74, 95% CI 0.56-0.96). Patients with suspected sepsis and septic shock who received a total volume of >3600 mL had lower in-hospital mortality (AOR 0.44, 95% CI 0.22-0.91; AOR 0.16, 95% CI 0.05-0.57) compared to those administered <3600 mL within the first 24 h of presenting to the ED. There was no association between the time of initiation of fluids and in-hospital mortality among survivors and non-survivors (2.3 vs 2.5 h, P = 0.50). CONCLUSION: We observed a reduction in risk of in-hospital mortality for each 1000 mL increase in intravenous fluids administered in patients with septic shock or admitted to ICU suggesting illness severity to be a likely effect modifier.

Comparative Analysis of Conventional and Emerging Technologies for Seawater Desalination: Northern Chile as A Case Study.

The aim of this work was to study different desalination technologies as alternatives to conventional reverse osmosis (RO) through a systematic literature review. An expert panel evaluated thermal and membrane processes considering their possible implementation at a pilot plant scale (100 m3/d of purified water) starting from seawater at 20 °C with an average salinity of 34,000 ppm. The desalination plant would be located in the Atacama Region (Chile), where the high solar radiation level justifies an off-grid installation using photovoltaic panels. We classified the collected information about conventional and emerging technologies for seawater desalination, and then an expert panel evaluated these technologies considering five categories: (1) technical characteristics, (2) scale-up potential, (3) temperature effect, (4) electrical supply options, and (5) economic viability. Further, the potential inclusion of graphene oxide and aquaporin-based biomimetic membranes in the desalinization processes was analyzed. The comparative analysis lets us conclude that nanomembranes represent a technically and economically competitive alternative versus RO membranes. Therefore, a profitable desalination process should consider nanomembranes, use of an energy recovery system, and mixed energy supply (non-conventional renewable energy + electrical network). This document presents an up-to-date overview of the impact of emerging technologies on desalinated quality water, process costs, productivity, renewable energy use, and separation efficiency.

Reverse Osmosis Concentrate: Physicochemical Characteristics, Environmental Impact, and Technologies.

This study's aim is to generate a complete profile of reverse osmosis concentrate (ROC), including physicochemical characteristics, environmental impact, and technologies for ROC treatment, alongside element recovery with potential valorization. A systematic literature review was used to compile and analyze scientific information about ROC, and systematic identification and evaluation of the data/evidence in the articles were conducted using the methodological principles of grounded data theory. The literature analysis revealed that two actions are imperative: (1) countries should impose strict regulations to avoid the contamination of receiving water bodies and (2) desalination plants should apply circular economies. Currently, synergizing conventional and emerging technologies is the most efficient method to mitigate the environmental impact of desalination processes. However, constructed wetlands are an emerging technology that promise to be a viable multi-benefit solution, as they can provide simultaneous treatment of nutrients, metals, and trace organic contaminants at a relatively low cost, and are socially accepted; therefore, they are a sustainable solution.

Predictors of Discharge Against Medical Advice in a Tertiary Paediatric Hospital.

BACKGROUND: Patients who discharge against medical advice (DAMA) from hospital carry a significant risk of readmission and have increased rates of morbidity and mortality. We sought to identify the demographic and clinical characteristics of DAMA patients from a tertiary paediatric hospital. METHODS: Data were extracted retrospectively from electronic medical records for all inpatient admissions over a 5-year period. Demographic characteristics (age, sex, Aboriginality, socioeconomic status and remoteness of residence) and clinical characteristics (admitting hospital site, level of urgency on admission, diagnosis and previous DAMA) were extracted and logistic regression models were used to identify predictors of DAMA with 95% confidence intervals. RESULTS: There were 246,359 admissions for 124,757 patients, of which 1871 (0.8%) admissions and 1730 patients (1.4%) DAMA. Predictors of DAMA in a given admission were hospital site (OR 4.8, CI 4.2-5.7, p < 0.01), a mental health/behavioural diagnosis (OR 3.3, CI 2.2-4.8, p < 0.01), Aboriginality (OR 1.6, CI 1.3-2.1, p < 0.01), emergency rather than elective admissions (OR 0.7ha, CI 0.6-0.8, p < 0.01), a gastrointestinal diagnosis (OR 1.5, CI 1.1-2.0, p = 0.04) and a history of previous DAMA (OR 2.0, CI 1.2-3.2, p = 0.05). CONCLUSIONS: There are clear predictors of DAMA in this tertiary hospital admission cohort and identification of these provides opportunities for intervention at a practice and policy level in order to prevent adverse outcomes.

Discharge against medical advice in culturally and linguistically diverse Australian children.

OBJECTIVES: This study quantifies the prevalence and rates of discharge against medical advice (DAMA) in culturally and linguistically diverse (CALD) children and assesses the independent association between CALD status and DAMA accounting for key demographic confounders in a large tertiary Australian hospital network. METHODS: Prospectively collected data between 2010 and 2018 were extracted from the hospital network electronic medical records system for admitted patients (n=192 037), outpatients (n=268 904) and between 2015 and 2018 for emergency department (ED) patients (n=158 903). CALD status was defined as 'preferred language being not English' and DAMA was measured as 'discharge at own risk' in admissions, 'no show' in outpatients, 'left without being seen' and 'did not wait' in ED. Data were analysed using χ² test, bivariate analysis and multivariate logistic regression. RESULTS: The prevalence of DAMA was 1.34% in admitted patients, 19.31% in outpatients and 12.64% in ED patients. Rates of DAMA were higher among CALD children compared to non-CALD children (1.75% vs 1.29% in admitted patients, 26.53% vs 17.92% in outpatients and 18.74% vs 11.61% in ED patients). CALD status was independently associated with DAMA in admitted children (OR=1.30, 95% CI 1.15 to 1.44), outpatients (OR=1.55; 95% CI 1.51 to 1.58) and ED patients (OR=1.60; 95% CI 1.53 to 1.66). CONCLUSION: Being from a CALD background places children at increased risks to DAMA. Implementing appropriate health service responses may ensure equitable access and quality care for children from CALD backgrounds to reduce the rates of DAMA and its associated ramifications.

Combination treatment of autologous bone marrow stem cell transplantation and hyperbaric oxygen therapy for type 2 diabetes mellitus: A randomized controlled trial.

The objective of this study was to compare standard treatment versus the combination of intrapancreatic autologous stem cell (ASC) infusion and hyperbaric oxygen treatment (HBOT) before and after ASC in the metabolic control of patients with type 2 diabetes mellitus (T2DM). This study was a prospective, randomized controlled trial. The combined intervention consisted of 10 sessions of HBOT before the intrapancreatic infusion of ASC and 10 sessions afterwards. ASCs were infused into the main arterial supply of the pancreas to maximize the presence of the stem cells where the therapeutic effect is most desired. A total of 23 patients were included (control group = 10, intervention group = 13). Age, gender, diabetes duration, number of medications taken, body weight and height, and insulin requirements were recorded at baseline and every three months. Also, body mass index, fasting plasma glucose, C-peptide, and HbA1c, C-peptide/glucose ratio (CPGR) were measured every three months for one year. HbA1c was significantly lower in the intervention group compared with control throughout follow-up. Overall, 77% of patients in the intervention group and 30% of patients in the control group demonstrated a decrease of HbA1c at 180 days (compared with baseline) of at least 1 unit. Glucose levels were significantly lower in the intervention group at all timepoints during follow-up. C-peptide levels were significantly higher in the intervention group during follow-up and at one year: 1.9 ± 1.0 ng/mL versus 0.7 ± 0.4 ng/mL in intervention versus control groups, respectively, p = 0.0021. CPGR was higher in the intervention group at all controls during follow-up. The requirement for insulin was significantly lower in the intervention group at 90, 180, 270, and 365 days. Combined therapy of intrapancreatic ASC infusion and HBOT showed increased metabolic control and reduced insulin requirements in patients with T2DM compared with standard treatment.

Status of the scalar singlet dark matter model.

One of the simplest viable models for dark matter is an additional neutral scalar, stabilised by a Z 2 symmetry. Using the GAMBIT package and combining results from four independent samplers, we present Bayesian and frequentist global fits of this model. We vary the singlet mass and coupling along with 13 nuisance parameters, including nuclear uncertainties relevant for direct detection, the local dark matter density, and selected quark masses and couplings. We include the dark matter relic density measured by Planck, direct searches with LUX, PandaX, SuperCDMS and XENON100, limits on invisible Higgs decays from the Large Hadron Collider, searches for high-energy neutrinos from dark matter annihilation in the Sun with IceCube, and searches for gamma rays from annihilation in dwarf galaxies with the Fermi-LAT. Viable solutions remain at couplings of order unity, for singlet masses between the Higgs mass and about 300 GeV, and at masses above ∼ 1 TeV. Only in the latter case can the scalar singlet constitute all of dark matter. Frequentist analysis shows that the low-mass resonance region, where the singlet is about half the mass of the Higgs, can also account for all of dark matter, and remains viable. However, Bayesian considerations show this region to be rather fine-tuned.

Tratamiento de reestenosis carotidea intrastent con el uso de stent Graft Jostent recubierto con PTFE: a propósito de un caso clínico / Treatment of carotid intra stent stenosis with stent graft ( Jostent graft) balloon recovered with PTFE: a case report

Se presenta el caso de un paciente de 82 años, de alto riesgo quirúrgico que fue tratado exitosamente en forma endoluminal con un nuevo stent recubierto con PTFE (Jostent graft) para la exclusión de la hiperplasia difusa fibrointimal intrastent carotideo

Tratamiento de reestenosis carotidea intrastent con el uso de stent Graft Jostent recubierto con PTFE: a propósito de un caso clínico / Treatment of carotid intra stent stenosis with stent graft ( Jostent graft) balloon recovered with PTFE: a case report

Se presenta el caso de un paciente de 82 años, de alto riesgo quirúrgico que fue tratado exitosamente en forma endoluminal con un nuevo stent recubierto con PTFE (Jostent graft) para la exclusión de la hiperplasia difusa fibrointimal intrastent carotideo (AU)