Mirtazapine-induced neutropenic sepsis in an older person: a case report.

BACKGROUND: Mirtazapine is a frequently prescribed psychotropic drug for depression in older age. It is considered safe and has a side-effect profile uniquely favorable to an older person affected by reduced appetite, difficulty maintaining body weight, or insomnia. However, it is largely unknown that mirtazapine can cause a dangerous decline in neutrophil count. CASE PRESENTATION: We present a case of mirtazapine-induced severe neutropenia in a 91-year-old white British woman requiring drug withdrawal and granulocyte-colony stimulating factor administration. CONCLUSION: This case is of significance because mirtazapine is regarded as a safe, and often preferable, antidepressant in older age. However, this case demonstrates a rare, life-threatening side effect of mirtazapine and calls for greater pharmacovigilance when prescribing it. There is no previous report of mirtazapine-induced neutropenia requiring drug withdrawal and granulocyte-colony stimulating factor administration in an older person.

Obstetrical Trauma: Reducing the Burden of Trauma Transfer to Tertiary Care Centers.

BACKGROUND: In rural state trauma systems, management of the obstetrical trauma patient often defaults to transfer to level I trauma centers. We evaluate the necessity of transferring obstetrical trauma patients without severe maternal injury. MATERIALS AND METHODS: A retrospective 5-year review of obstetrical trauma patients admitted to a rural state-level I trauma center was conducted. Injury severity measures such as abdominal AIS, ISS, and GCS were correlated with outcomes. Furthermore, the impact of maternal and gestational age on uterine compromise, uterine irritability, and the need for cesarean section intervention are presented. RESULTS: Twenty-one percent of patients were transferred from outside facilities with a median age of 29 years, average ISS of 3.9 ± 5.6, GCS of 13.8 ± 3.6, and abdominal AIS of 1.6 ± .8. Outcomes included maternal fatality of 2%, fetal demise of 4%, 6% experienced premature rupture of membranes, 9% experienced fetal placental compromise, 15% had uterine contractions, 15% of cesarean deliveries, and fetal decelerations occurred in 4%. Predictors of fetal compromise are strongly associated with high maternal ISS and low GCS. DISCUSSION: The frequency of traumatic injury in this unique population of patients is fortunately limited. The best predictor for fetal demise and uterine irritability is maternal injury severity, measured by ISS and GCS. Therefore, without severe maternal trauma, obstetrical trauma patients with minor injuries can safely be managed at non-tertiary care facilities with obstetrical capabilities.

Data resource profile: the Edinburgh Child Protection Dataset - a new linked administrative data source of children referred to Child Protection paediatric services in Edinburgh, Scotland.

Introduction: Child maltreatment affects a substantial number of children. However current evidence relies on either longitudinal studies, which are complex and resource-intensive, or linked data studies based on social services data, which is arguably the tip of the iceberg in terms of children who are maltreated. Reliable, linked, population-level data on children referred to services due to suspected abuse or neglect will increase our ability to examine risk factors for, and outcomes following, abuse and neglect. Objective: The objective of this project was to create a linkable population level dataset, The Edinburgh Child Protection Dataset (ECPD), comprising all children referred to the Edinburgh Child Protection Paediatric healthcare team due to a concern about their welfare between 1995 and 2015. Methods: The paper presents the process for creating the dataset. The analyses provide examples of available data from the main referrals dataset between 1995 and 2011 (where data quality was highest). Results: 19,969 referrals were captured, relating to 11,653 children. Of the 19,969 referrals, a higher proportion were girls (54%), although boys were referred for physical abuse more often than girls (41% versus 30%). Younger children were more likely to be referred for physical abuse (35% of 0-4 year olds vs. 27% 15+): older children were more likely to be referred for sexual abuse (48% of 15+ years vs. 18% of 0-4 years). Most referrals came from social workers (46%) or police (31%). Conclusions: The ECPD offers a unique insight into the characteristics of referrals to child protection paediatric services over a key period in the history of child protection in Scotland. It is hoped that by making these data available to researchers, and able to be easily linked with both mother and child current and future health records, evidence will be created to better support maltreated children and monitor changes over time.

Diet and Hydrogen Sulfide Production in Mammals.

Significance: In recent times, it has emerged that some dietary sulfur compounds can act on mammalian cell signaling systems via their propensity to release hydrogen sulfide (H2S). H2S plays important biochemical and physiological roles in the heart, gastrointestinal tract, brain, kidney, and immune systems of mammals. Reduced levels of H2S in cells and tissues correlate with a spectrum of pathophysiological conditions, including heart disease, diabetes, obesity, and altered immune function. Recent Advances: In the last decade, researchers have now begun to explore the mechanisms by which dietary-derived sulfur compounds, in addition to cysteine, can act as sources of H2S. This research has led to the identified several compounds, organic sulfides, isothiocyanates, and inorganic sulfur species including sulfate that can act as potential sources of H2S in mammalian cells and tissues. Critical Issues: We have summarised progress made in the identification of dietary factors that can impact on endogenous H2S levels in mammals. We also describe current research focused on how some sulfur molecules present in dietary plants, and associated chemical analogues, act as sources of H2S, and discuss the biological properties of these molecules as studied in a range of in vitro and in vivo systems. Future Directions: The identification of sulfur compounds in edible plants that can act as novel H2S releasing molecules is intriguing. Research in this area could inform future studies exploring the impact of diet on H2S levels in mammalian systems. Despite recent progress, additional work is needed to determine the mechanisms by which H2S is released from these molecules following ingestions of dietary plants in humans, whether the amounts of H2S produced is of physiological significance following the metabolism of these compounds in vivo, and if diet could be used to manipulated H2S levels in humans. Importantly, this will lead to a better understanding of the biological significance of H2S generated from dietary sources, and this information could be used in the development of plant breeding initiatives to increase the levels of H2S releasing sulfur compounds in crops, or inform dietary intervention strategies that could be used to alter the levels of H2S in humans.

Multiplexed Plasma Immune Mediator Signatures Can Differentiate Sepsis From NonInfective SIRS: American Surgical Association 2020 Annual Meeting Paper.

OBJECTIVES: Sepsis and sterile both release "danger signals' that induce the systemic inflammatory response syndrome (SIRS). So differentiating infection from SIRS can be challenging. Precision diagnostic assays could limit unnecessary antibiotic use, improving outcomes. METHODS: After surveying human leukocyte cytokine production responses to sterile damage-associated molecular patterns (DAMPs), bacterial pathogen-associated molecular patterns, and bacteria we created a multiplex assay for 31 cytokines. We then studied plasma from patients with bacteremia, septic shock, "severe sepsis," or trauma (ISS ≥15 with circulating DAMPs) as well as controls. Infections were adjudicated based on post-hospitalization review. Plasma was studied in infection and injury using univariate and multivariate means to determine how such multiplex assays could best distinguish infective from noninfective SIRS. RESULTS: Infected patients had high plasma interleukin (IL)-6, IL-1α, and triggering receptor expressed on myeloid cells-1 (TREM-1) compared to controls [false discovery rates (FDR) <0.01, <0.01, <0.0001]. Conversely, injury suppressed many mediators including MDC (FDR <0.0001), TREM-1 (FDR <0.001), IP-10 (FDR <0.01), MCP-3 (FDR <0.05), FLT3L (FDR <0.05), Tweak, (FDR <0.05), GRO-α (FDR <0.05), and ENA-78 (FDR <0.05). In univariate studies, analyte overlap between clinical groups prevented clinical relevance. Multivariate models discriminated injury and infection much better, with the 2-group random-forest model classifying 11/11 injury and 28/29 infection patients correctly in out-of-bag validation. CONCLUSIONS: Circulating cytokines in traumatic SIRS differ markedly from those in health or sepsis. Variability limits the accuracy of single-mediator assays but machine learning based on multiplexed plasma assays revealed distinct patterns in sepsis- and injury-related SIRS. Defining biomarker release patterns that distinguish specific SIRS populations might allow decreased antibiotic use in those clinical situations. Large prospective studies are needed to validate and operationalize this approach.

Heteroatom substitution effects in spin crossover dinuclear complexes.

We probe the effect of heteroatom substitution on the spin crossover (SCO) properties of dinuclear materials of the type [Fe2(NCX)4(R-trz)5]·S (X = S, Se; S = solvent; R-trz = (E)-N-(furan-2-ylmethylene)-4H-1,2,4-triazol-4-amine (furtrz); (E)-N-(thiophen-2-ylmethylene)-4H-1,2,4-triazole-4-amine (thtrz)). For the furtrz family ([Fe2(NCX)4(furtrz)5]·furtrz·MeOH; X = S (furtrz-S) and X = Se (furtrz-Se)) gradual and incomplete one-step SCO transitions are observed (furtrz-S (T1/2 = 172 K) and furtrz-Se (T1/2 = 205 K)) and a structural evolution from [HS-HS] to [HS-LS] per dinuclear species. Contrasting this, within the thtrz family ([Fe2(NCX)4(thtrz)5]·4MeOH; X = S (thtrz-S) and X = Se (thtrz-Se)) more varied SCO transitions are observed, with thtrz-S being SCO-inactive (high spin) and thtrz-Se showing a rare complete two-step SCO transition (T1/2(1,2) = 170, 200 K) in which the FeII sites transition from [HS-HS] to [HS-LS] to [LS-LS] per dinuclear unit with no long range ordering of spin-states at the intermediate plateau. Detailed structure-function analyses have been conducted within this growing dinuclear family to rationalise these diverse spin-switching properties.

A novel broad specificity fucosidase capable of core α1-6 fucose release from N-glycans labeled with urea-linked fluorescent dyes.

Exoglycosidases are often used for detailed characterization of glycan structures. Bovine kidney α-fucosidase is commonly used to determine the presence of core α1-6 fucose on N-glycans, an important modification of glycoproteins. Recently, several studies have reported that removal of core α1-6-linked fucose from N-glycans labeled with the reactive N-hydroxysuccinimide carbamate fluorescent labels 6-aminoquinolyl-N-hydroxysuccinimidylcarbamate (AQC) and RapiFluor-MS is severely impeded. We report here the cloning, expression and biochemical characterization of an α-fucosidase from Omnitrophica bacterium (termed fucosidase O). We show that fucosidase O can efficiently remove α1-6- and α1-3-linked core fucose from N-glycans. Additionally, we demonstrate that fucosidase O is able to efficiently hydrolyze core α1-6-linked fucose from N-glycans labeled with any of the existing NHS-carbamate activated fluorescent dyes.

Theoretical Investigations of the Electrochemical Reduction of CO on Single Metal Atoms Embedded in Graphene.

Single transition metal atoms embedded at single vacancies of graphene provide a unique paradigm for catalytic reactions. We present a density functional theory study of such systems for the electrochemical reduction of CO. Theoretical investigations of CO electrochemical reduction are particularly challenging in that electrochemical activation energies are a necessary descriptor of activity. We determined the electrochemical barriers for key proton-electron transfer steps using a state-of-the-art, fully explicit solvent model of the electrochemical interface. The accuracy of GGA-level functionals in describing these systems was also benchmarked against hybrid methods. We find the first proton transfer to form CHO from CO to be a critical step in C1 product formation. On these single atom sites, the corresponding barrier scales more favorably with the CO binding energy than for 211 and 111 transition metal surfaces, in the direction of improved activity. Intermediates and transition states for the hydrogen evolution reaction were found to be less stable than those on transition metals, suggesting a higher selectivity for CO reduction. We present a rate volcano for the production of methane from CO. We identify promising candidates with high activity, stability, and selectivity for the reduction of CO. This work highlights the potential of these systems as improved electrocatalysts over pure transition metals for CO reduction.

A highly active and stable IrOx/SrIrO3 catalyst for the oxygen evolution reaction.

Oxygen electrochemistry plays a key role in renewable energy technologies such as fuel cells and electrolyzers, but the slow kinetics of the oxygen evolution reaction (OER) limit the performance and commercialization of such devices. Here we report an iridium oxide/strontium iridium oxide (IrOx/SrIrO3) catalyst formed during electrochemical testing by strontium leaching from surface layers of thin films of SrIrO3 This catalyst has demonstrated specific activity at 10 milliamps per square centimeter of oxide catalyst (OER current normalized to catalyst surface area), with only 270 to 290 millivolts of overpotential for 30 hours of continuous testing in acidic electrolyte. Density functional theory calculations suggest the formation of highly active surface layers during strontium leaching with IrO3 or anatase IrO2 motifs. The IrOx/SrIrO3 catalyst outperforms known IrOx and ruthenium oxide (RuOx) systems, the only other OER catalysts that have reasonable activity in acidic electrolyte.

Telephone follow-up of older people after hospital admissions.

BACKGROUND: Older people are frequent users of hospital care and are at high risk of adverse outcomes such as unplanned hospital readmission after discharge. Various transitional care programmes targeting post-discharge outcomes have been studied, utilising telephone follow-up (TFU) both as a sole intervention and as part of multi-component interventions. LITERATURE REVIEW FINDINGS: The effects of TFU of older people after hospital discharge as a sole intervention upon healthcare utilisation outcomes such as readmissions have not been reported to date. The individual impact of TFU in multicomponent interventions that have reported reduced readmissions is hard to assess. There is considerable heterogeneity in terms of outcomes studied and how TFU was instituted. Outstanding questions remain about which health-care professional should perform TFU, when and how often it should be done after discharge, and what questions should be asked. CONCLUSIONS: TFU of older people after hospital discharge has been reported as a feasible, low cost, minimal harm intervention which patients appreciate, so assessing its effectiveness in more diverse settings and randomised trials is important.

Child protection medical assessments: why do we do them?

INTRODUCTION: Child protection guidelines highlight the importance of medical assessments for children suspected of having been abused. AIM: To identify how medical assessments might contribute to a diagnosis of child abuse and to the immediate outcome for the child. METHOD: Review of all notes pertaining to medical assessments between January 2002 and March 2006. RESULTS: There were 4549 child protection referrals during this period, of which 848 (19%) proceeded to a medical examination. 742 (88%) case notes were reviewed. Of the medical examinations, 383 (52%) were for alleged physical abuse, 267 (36%) for sexual abuse and 20 (3%) for neglect. 258 (67%) of the physical abuse cases were considered to have diagnostic or supportive findings as compared to 61 (23%) of the sexual abuse cases (chi2=146.31, p<0.001). In diagnostic or supportive examinations or where other potentially abusive concerns were identified, 366 (73%) proceeded to further multi-agency investigation and 190 (41%) to case conference. 131 (69%) of these resulted in the registration of the child on the child protection register. Other health concerns were identified in 121 (31%) of physical and 168 (63%) of sexual abuse cases. CONCLUSION: In this case series, 465 (63%) out of 742 examinations showed signs diagnostic or supportive of alleged abuse or highlighted other abusive concerns. This endorses the view that medical examination is an important component in the assessment of child abuse as it provides information to support or refute an allegation and helps to identify the health and welfare needs of vulnerable children.

Chronic post-traumatic headache after head injury in children and adolescents.

This was a prospective, observational study of children aged 3 to 15 years admitted to hospital with head injury (HI). Demographic data and information on the nature of the HI, and history of premorbid headache were collected. A structured telephone questionnaire was used to interview parents and children 2 months after injury and at 4-monthly intervals for up to 3 years, if headache was reported. One hundred and ninety children were admitted with HI. Data were available on 117 children (81 males, 36 females; mean age 8y 5mo [SD 3y 1mo]). HI was minor in 93 patients and significant in the rest. Minor HI was defined as a closed injury, no loss of consciousness, and a Glasgow Coma Score (GCS) of 13 to 15. Significant HI was associated with loss of consciousness for >30 minutes, GCS of <13, and post-traumatic amnesia for >48 hours. Eight children (five males, three females; mean age 10y 7mo [SD 2y]) reported chronic post-traumatic headache (CPTH). Five children had episodic tension-type headache and three had migraine with or without aura. Headache resolved over 3 to 27 months in all except one child who was lost to follow-up. Premorbid headache in three children transformed in frequency and type following HI. These patients were excluded from the study. CPTH is common after minor and significant HI. It has the clinical features of tension-type headache and migraine and has a good prognosis.