A Retrospective Cohort Study of the Association of Inpatient Amlodipine Dose With Renal Complication Rates and Hospital Length of Stay.

Background Correct hospital medication reconciliation is important for continuity of care, but optimal home antihypertensive medication ordering has not been adequately studied. Since excessive hospital blood pressure control is associated with adverse renal and cardiovascular outcomes, we assessed the association of inpatient doses of amlodipine (10mg vs. 5mg) with length of stay and renal failure and fluid and electrolyte disorders (RF/FED). Methods In this retrospective cohort study, clinical and demographic data on patients not initially admitted to the ICU between 2008 and 2019 were extracted from the Medical Information Mart for Intensive Care (MIMIC-IV). Multivariable logistic regression was used to assess the association between amlodipine dose during the first 24 hours of admission and RF/FED. Multivariable linear regression was used to assess the association between amlodipine dose and length of stay when controlling for RF/FED or maximum blood urea nitrogen (BUN) concentration and other confounders. Results There were 5,932 patients included in this study, and 3,038 of whom received 10mg of amlodipine. A 10mg dose of amlodipine was associated with an increased likelihood of RF/FED (OR: 1.248, 95% CI (1.104, 1.412), p<0.001). It was also associated with a longer length of stay (coef.: 0.338, 95% CI (0.067, 0.609), p=0.015). This was not significant when controlling for RF/FED (dose coef.: 0.197, 95% CI (-0.070, 0.464), p=0.147) or maximum BUN (dose coef.: 0.082, 95% CI (-0.147, 0.312), p=0.482). Interpretation Higher amlodipine dose was associated with longer length of stay, and this is likely mediated by RF/FED. Randomized trials are needed to determine which home blood pressure medications should be ordered in the hospital.

Machine Learning for Acute Kidney Injury Prediction in the Intensive Care Unit.

Machine learning is the field of artificial intelligence in which computers are trained to make predictions or to identify patterns in data through complex mathematical algorithms. It has great potential in critical care to predict outcomes, such as acute kidney injury, and can be used for prognosis and to suggest management strategies. Machine learning can also be used as a research tool to advance our clinical and biochemical understanding of acute kidney injury. In this review, we introduce basic concepts in machine learning and review recent research in each of these domains.

Ambient-pressure lignin valorization to high-performance polymers by intensified reductive catalytic deconstruction.

Chemocatalytic lignin valorization strategies are critical for a sustainable bioeconomy, as lignin, especially technical lignin, is one of the most available and underutilized aromatic feedstocks. Here, we provide the first report of an intensified reactive distillation­reductive catalytic deconstruction (RD-RCD) process to concurrently deconstruct technical lignins from diverse sources and purify the aromatic products at ambient pressure. We demonstrate the utility of RD-RCD bio-oils in high-performance additive manufacturing via stereolithography 3D printing and highlight its economic advantages over a conventional reductive catalytic fractionation/RCD process. As an example, our RD-RCD reduces the cost of producing a biobased pressure-sensitive adhesive from softwood Kraft lignin by up to 60% in comparison to the high-pressure RCD approach. Last, a facile screening method was developed to predict deconstruction yields using easy-to-obtain thermal decomposition data. This work presents an integrated lignin valorization approach for upgrading existing lignin streams toward the realization of economically viable biorefineries.

High resolution data modifies intensive care unit dialysis outcome predictions as compared with low resolution administrative data set.

High resolution clinical databases from electronic health records are increasingly being used in the field of health data science. Compared to traditional administrative databases and disease registries, these newer highly granular clinical datasets offer several advantages, including availability of detailed clinical information for machine learning and the ability to adjust for potential confounders in statistical models. The purpose of this study is to compare the analysis of the same clinical research question using an administrative database and an electronic health record database. The Nationwide Inpatient Sample (NIS) was used for the low-resolution model, and the eICU Collaborative Research Database (eICU) was used for the high-resolution model. A parallel cohort of patients admitted to the intensive care unit (ICU) with sepsis and requiring mechanical ventilation was extracted from each database. The primary outcome was mortality and the exposure of interest was the use of dialysis. In the low resolution model, after controlling for the covariates that are available, dialysis use was associated with an increased mortality (eICU: OR 2.07, 95% CI 1.75-2.44, p<0.01; NIS: OR 1.40, 95% CI 1.36-1.45, p<0.01). In the high-resolution model, after the addition of the clinical covariates, the harmful effect of dialysis on mortality was no longer significant (OR 1.04, 95% 0.85-1.28, p = 0.64). The results of this experiment show that the addition of high resolution clinical variables to statistical models significantly improves the ability to control for important confounders that are not available in administrative datasets. This suggests that the results from prior studies using low resolution data may be inaccurate and may need to be repeated using detailed clinical data.

Heads up: don't forget the ordinary.

A 72-year-old woman presented to the emergency department with shortness of breath, diffuse swelling and a haemoglobin of 4.2 g/dl. Her history was notable for an unusual necrotic occipital neck mass that had begun to enlarge and intermittently bleed over the past year. The patient was initially unable to tolerate a CT scan because of the neck mass, and care was further complicated by extended boarding for more than 24 h in the emergency department. Initial fevers were attributed to blood transfusion, but she subsequently developed septic shock and disseminated intravascular coagulation from Escherichia coli bacteraemia, which led to anuric renal failure requiring haemodialysis. When the CT was performed, it revealed an obstructing ureteric stone which was the source of her infection, not the neck mass as had been assumed. This case underscores the importance of maintaining a broad and impartial differential diagnosis.

Immunoglobulin G subclass and antibody avidity responses in Malian children immunized with Plasmodium falciparum apical membrane antigen 1 vaccine candidate FMP2.1/AS02A.

BACKGROUND: A malaria vaccine based on Plasmodium falciparum apical membrane antigen 1 (AMA1) elicited strain specific efficacy in Malian children that waned in the second season after vaccination despite sustained AMA1 antibody titers. With the goal of identifying a humoral correlate of vaccine-induced protection, pre- and post-vaccination sera from children vaccinated with the AMA1 vaccine and from a control group that received a rabies vaccine were tested for AMA1-specific immunoglobulin G (IgG) subclasses (IgG1, IgG2, IgG3, and IgG4) and for antibody avidity. METHODS: Samples from a previously completed Phase 2 AMA1 vaccine trial in children residing in Mali, West Africa were used to determine AMA1-specific IgG subclass antibody titers and avidity by ELISA. Cox proportional hazards models were used to assess correlation between IgG subclass antibody titers and risk of time to first or only clinical malaria episode and risk of multiple episodes. Asexual P. falciparum parasite density measured for each child as area under the curve were used to assess correlation between IgG subclass antibody titers and parasite burden. RESULTS: AMA1 vaccination did not elicit a change in antibody avidity; however, AMA1 vaccinees had a robust IgG subclass response that persisted over the malaria transmission season. AMA1-specific IgG subclass responses were not associated with decreased risk of subsequent clinical malaria. For the AMA1 vaccine group, IgG3 levels at study day 90 correlated with high parasite burden during days 90-240. In the control group, AMA1-specific IgG subclass rise and persistence over the malaria season was modest and correlated with age. In the control group, titers of several IgG subclasses at days 90 and 240 correlated with parasite burden over the first 90 study days, and IgG3 at day 240 correlated with parasite burden during days 90-240. CONCLUSIONS: Neither IgG subclass nor avidity was associated with the modest, strain-specific efficacy elicited by this blood stage malaria vaccine. Although a correlate of protection was not identified, correlations between subclass titers and age, and correlations between IgG subclass titers and parasite burden, defined by area under the curve parasitaemia levels, were observed, which expand knowledge about IgG subclass responses. IgG3, known to have the shortest half-life of the IgG subclasses, might be the most temporally relevant indicator of ongoing malaria exposure when examining antibody responses to AMA1.

Comparison of analogue and electronic stethoscopes for pulmonary auscultation by internal medicine residents.

BACKGROUND: Electronic stethoscopes are becoming more common in clinical practice. They may improve the accuracy and efficiency of pulmonary auscultation, but the data to support their benefit are limited. OBJECTIVE: To determine how auscultation with an electronic stethoscope may affect clinical decision making. METHODS: An online module consisting of six fictional ambulatory cases was developed. Each case included a brief history and lung sounds recorded with an analogue and electronic stethoscope. Internal medicine resident participants were randomly selected to hear either the analogue or electronic lung sounds. Numbers of correct answers, time spent on each case and numbers of times the recordings were played were compared between the groups who heard each mode of auscultation, with a p value of less than 0.05 indicating statistical significance. RESULTS: 61 internal medicine residents completed at least one case, and 41 residents completed all six cases. There were no significant differences in overall scores between participants who heard analogue and electronic lung sounds (3.14±0.10 out of 6 correct for analogue, 3.20±0.10 out of 6 for electronic, p=0.74). There were no significant differences in performance for any of the six cases (p=0.78), time spent on the cases (p=0.67) or numbers of times the recordings were played (p=0.85). CONCLUSION: When lung sounds were amplified with an electronic stethoscope, we did not detect an effect on performance, time spent on the cases or numbers of times participants listened to the recordings.

Higher mobility scores in patients with cystic fibrosis are associated with better lung function.

OBJECTIVE: The purpose of this study was to determine whether mobility and physical activity were associated with lung function in adults with cystic fibrosis (CF). DESIGN: This was a prospective cohort observational study in an urban, academic, specialized care center. Participants were ambulatory, nonhospitalized adults with CF. MAIN OUTCOME MEASURES: Mobility was assessed monthly by the Life-Space Assessment (LSA) questionnaire and quarterly by pedometer. Lung function was assessed by spirometry. RESULTS: Twenty-seven subjects participated. Subjects recorded mean pedometer steps of 20,213 ± 11,331 over three days and FEV1% predicted of 77.48% ± 22.60% over one year. The LSA score at enrollment was correlated with initial pedometer steps (r = 0.42 and P = 0.03), and mean LSA score over one year was correlated with mean number of steps (r = 0.51 and P = 0.007). LSA mobility and pedometer scores were correlated with FEV1% predicted at enrollment and throughout the study. CONCLUSIONS: Mobility and physical activity measured by LSA questionnaire and pedometer are positively associated with lung function in adults with CF. This study confirms the importance of mobility and physical activity and supports the utility of a simple office-based questionnaire as a measure of mobility in adults with CF.