Timing and Clinical Significance of Fluid Overload in Pediatric Acute Respiratory Distress Syndrome.

OBJECTIVES: Fluid overload is associated with worse outcomes in adult and pediatric acute respiratory distress syndrome. However, the time-course of fluid overload and its relationship to outcome has not been described. We aimed to determine the relationship between the timing of fluid overload and outcomes over the first 7 days after acute respiratory distress syndrome onset in children. DESIGN: Retrospective cohort study. SETTING: Single tertiary care PICU. PATIENTS: Intubated children with acute respiratory distress syndrome between 2011 and 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Daily and cumulative total fluid intake, total output, urine output, and fluid balance were collected for each 24-hour period from days 1 to 7 after acute respiratory distress syndrome onset. We tested the association between daily cumulative fluid metrics with PICU mortality and probability of extubation by 28 days using multivariable logistic and competing risk regression, respectively. In a subset of children, plasma was collected on day 1 and day 3 of acute respiratory distress syndrome and angiopoietin-2 quantified. Of 723 children with acute respiratory distress syndrome, 132 died (18%). In unadjusted analysis, nonsurvivors had higher cumulative fluid balance starting on day 3. In multivariable analysis, a positive cumulative fluid balance on days 5 through 7 was associated with increased mortality. Higher cumulative fluid balance on days 4 to 7 was associated with lower probability of extubation. Elevated angiopoietin-2 on day 1 predicted early (within 3 d) fluid overload greater than or equal to 10%, and elevated angiopoietin-2 on day 3 predicted late (between days 4 and 7) fluid overload. CONCLUSIONS: Fluid overload after day 4 of acute respiratory distress syndrome, but not before, was associated with worse outcomes. Higher angiopoietin-2 predicted subsequent fluid overload. Our results suggest that future interventions aimed at managing fluid overload may have differential efficacy depending on when in the time-course of acute respiratory distress syndrome they are initiated.

Distribution of Late-Onset Neonatal Sepsis Pathogens Differs in Inpatient and Outpatient Settings.

OBJECTIVE: We sought to examine pathogen distribution and clinical presentation of late-onset sepsis (LOS) at an urban tertiary care center. STUDY DESIGN: We performed a retrospective review of all culture-confirmed cases of LOS presenting to our institution from 2013 to 2017. Medical records were evaluated for demographic information, sepsis risk factors, encounter location, and clinical outcome. RESULTS: We identified 97 cases of LOS, with a median age at diagnosis of 25 days. The most common pathogens were Escherichia coli (22.7%), Staphylococcus aureus (17.5%), coagulase-negative staphylococci (12.4%), and Enterococcus faecalis (12.4%). Infections due to E. coli predominated in the outpatient setting (44%), whereas S. aureus and Gram-negative organisms other than E. coli were more frequently isolated from inpatients (21 and 24%, respectively). Gram-positive organisms were more common in infants delivered through cesarean section (p = 0.002) and were associated with more complications (p = 0.03). Escherichia coli LOS presented at an earlier age than S. aureus (15 vs. 32 days; p = 0.04). Of the 15 cases of meningitis, 40% did not have a positive blood culture. CONCLUSION: Pathogen distribution in our population was different from those previously reported, with a higher prevalence of S. aureus. Encounter location and age at presentation varied significantly by pathogen.

Microbial diversity and the presence of algae in halite endolithic communities are correlated to atmospheric moisture in the hyper-arid zone of the Atacama Desert.

The Atacama Desert is one of the oldest and driest deserts in the world, and its hyper-arid core is described as 'the most barren region imaginable'. We used a combination of high-throughput sequencing and microscopy methods to characterize the endolithic microbial assemblages of halite pinnacles (salt rocks) collected in several hyper-arid areas of the desert. We found communities dominated by archaea that relied on a single phylotype of Halothece cyanobacteria for primary production. A few other phylotypes of salt-adapted bacteria and archaea, including Salinibacter, Halorhabdus, and Halococcus were major components of the halite communities, indicating specific adaptations to the unique halite environments. Multivariate statistical analyses of diversity metrics clearly separated the halite communities from that of the surrounding soil in the Yungay area. These analyses also revealed distribution patterns of halite communities correlated with atmospheric moisture. Microbial endolithic communities from halites exposed to coastal fogs and high relative humidity were more diverse; their archaeal and bacterial assemblages were accompanied by a novel algae related to oceanic picoplankton of the Mamiellales. In contrast, we did not find any algae in the Yungay pinnacles, suggesting that the environmental conditions in this habitat might be too extreme for eukaryotic photosynthetic life.

Whip use by jockeys in a sample of Australian Thoroughbred races--an observational study.

The use of whips by jockeys is an issue. The current study viewed opportunistic high-speed footage of 15 race finishes frame-by-frame to examine the outcomes of arm and wrist actions (n = 350) on 40 horses viewed from the left of the field. Any actions fully or partially obscured by infrastructure or other horses were removed from the database, leaving a total of 104 non-contact sweeps and 134 strikes. For all instances of arm actions that resulted in fully visible whip strikes behind the saddle (n = 109), the outcomes noted were area struck, percentage of unpadded section making contact, whether the seam made contact and whether a visible indentation was evident on impact. We also recorded use of clockwise or counter-clockwise arm action from each jockey's whip, whether the whip was held like a tennis racquet or a ski pole, whether the hind leg on the side of the impact was in stance or swing phase and whether the jockey's arm was seen traveling above shoulder height. The goal of the study was to characterize the area struck and the visual impact of whip use at the level of the horse. We measured the ways in which both padded and unpadded sections of the whip made impact. There was evidence of at least 28 examples, in 9 horses, of breaches of the whip rules (one seam contact, 13 contacts with the head, and 14 arm actions that rose above the height of the shoulder). The whip caused a visible indentation on 83% of impacts. The unpadded section of the whip made contact on 64% of impacts. The results call into question the ability of Stewards to effectively police the rules concerning whip use and, more importantly, challenge the notion that padding the distal section of whips completely safeguards horses from any possible whip-related pain.