Adjunctive treatments for the management of septic shock - a narrative review of the current evidence.

Septic shock is a leading cause of death and morbidity worldwide. The cornerstones of management include prompt identification of sepsis, early initiation of antibiotic therapy, adequate fluid resuscitation and organ support. Over the past two decades, there have been considerable improvements in our understanding of the pathophysiology of sepsis and the host response, including regulation of inflammation, endothelial disruption and impaired immunity. This has offered opportunities for innovative adjunctive treatments such as vitamin C, corticosteroids and beta-blockers. Some of these approaches have shown promising results in early phase trials in humans, while others, such as corticosteroids, have been tested in large, international, multicentre randomised controlled trials. Contemporary guidelines make a weak recommendation for the use of corticosteroids to reduce mortality in sepsis and septic shock. Vitamin C, despite showing initial promise in observational studies, has so far not been shown to be clinically effective in randomised trials. Beta-blocker therapy may have beneficial cardiac and non-cardiac effects in septic shock, but there is currently insufficient evidence to recommend their use for this condition. The results of ongoing randomised trials are awaited. Crucial to reducing heterogeneity in the trials of new sepsis treatments will be the concept of enrichment, which refers to the purposive selection of patients with clinical and biological characteristics that are likely to be responsive to the intervention being tested.

Recurrent massive pulmonary emboli in a critically ill patient with COVID-19.

We report the haematological management of a critically ill patient with coronavirus disease 2019 (COVID-19), with recurrent massive pulmonary emboli. A previous healthy 56-year-old man presented to the emergency department with severe hypoxaemic respiratory failure due to suspected COVID-19. He required invasive mechanical ventilation and transfer to the intensive care unit for increasing ventilatory requirements and cardiovascular instability. A computed tomography (CT) pulmonary angiogram demonstrated large bilateral pulmonary emboli with right heart strain, for which he received intravenous systemic thrombolysis followed by therapeutic weight-adjusted anticoagulation with low molecular weight heparin (dalteparin). Two weeks later, following an acute respiratory deterioration, a repeat CT pulmonary angiogram demonstrated a new saddle embolus with right heart strain requiring another regime of intravenous systemic thrombolysis. This occurred despite anti-Xa-guided therapeutic anticoagulation. The dose of therapeutic dalteparin was increased incrementally to an eventual dose of 12,500 units twice daily. A low threshold for radiological imaging should be considered in all COVID-19 patients with acute cardiorespiratory deterioration. Multidisciplinary team discussions highlighted aspects of balancing the risks of bleeding from anticoagulation vs. risk of death from pulmonary embolism. This report highlights the need for further research into the underlying mechanisms and optimal management of thrombotic complications in COVID-19.

Variation in timing of decisions to withdraw life-sustaining treatment in adult ICU patients from three centres in different geographies: Do clinical factors explain the difference?

Background: Decisions to withdraw life-sustaining treatment (WLST) are common in intensive care units (ICUs). Clinical and non-clinical factors are important, although the extent to which each plays a part is uncertain. Objectives: To determine whether the timing of decisions to WLST varies between ICUs in a single centre in three countries and whether differences in timing are explained by differences in clinical decision-making. Methods: The study involved a convenience sample of three adult ICUs - one in each of the UK, USA and South Africa (SA). Data were prospectively collected on patients whose life-sustaining treatment was withdrawn over three months. The timing of decisions was collected, as were patients' premorbid functional status and illness severity 24 hours prior to decision to WLST. Multivariate analysis was used to identify factors associated with decisions to WLST. Clinicians participated in interviews involving hypothetical case studies devoid of non-clinical factors. Results: Deaths following WLST accounted for 23% of all deaths during the study period at the USA site v. 37% (UK site) and 70% (SA site) (p<0.0010 across the three sites). Length of stay (LOS) prior to WLST decision varied between sites. Controlling for performance status, age, and illness severity, study site predicted LOS prior to decision (p<0.0010). In the hypothetical cases, LOS prior to WLST was higher for USA clinicians (p<0.017). Conclusion: There is variation in the proportion of ICU patients in whom WLST occurs and the timing of these decisions between sites; differences in clinical decision-making may explain the variation observed, although clinical and non-clinical factors are inextricably linked. Contributions of the study: This study has identified variation in the timing of decisions to withdraw life-sustaining treatment in adult ICUs in three centres in three different healthcare systems. Although differences in clinical decision-making likely explain some of the variation, non-clinical factors (relating to the society in which the clinicians live and work) may also play a part.

Prolonged Wait Time Prior to Entry to Home Care Packages Increases the Risk of Mortality and Transition to Permanent Residential Aged Care Services: Findings from the Registry of Older South Australians (ROSA).

BACKGROUND: Older Australians prefer to live in their own homes for longer and reforms have attempted to increase the volume of home care packages (HCPs) accordingly but there remains a queue with the longer-term consequences unclear. OBJECTIVES: This study aims to characterise older Australians according to their wait times for a home care package (HCP), evaluate the association between wait time and mortality and evaluate the association between wait time and transition to permanent residential aged care services after HCP. DESIGN: A retrospective cohort study using data from the National Historical cohort (2003-2014) of the Registry of Older South Australians (ROSA) was conducted. SETTING: Home based aged care services, national cohort. METHODS: Wait time was estimated from approval date to date of receiving a HCP. Descriptive, survival estimates (95% confidence intervals (CIs)), and multivariable survival analyses (Cox-regression) were conducted to evaluate the risk of mortality and transition to permanent residential aged care services by quartiles of wait time for HCP. RESULTS: The cohort was followed for 4.0 years (interquartile range IQR (1.8-7.2)) and 38% were alive at the end of the study period with a median wait time for HCP of 62 (21-187) days. From 178,924 older people who received a HCP during the study period (2003-2013), 33.2% people received HCP within 30 days, 74.3% within 6 months and 25.7% after 6 months. The effect of wait time on risk of mortality was time-dependent, with longer wait times associated with higher mortality in the longer term. Compared to people who waited ≤30 days for a HCP, individuals who waited more than 6 months had an almost 20% excess risk of death (adjusted hazard ratio (aHR), 95%CI = (1.18, 1.16-1.21)) 2 years after entry into a HCP. Those who waited more than 6 months also had a 10% (1.10, 1.06-1.13) higher risk of transition to permanent residential aged care services after two years. CONCLUSION: Prolonged wait times for HCP is associated with a higher risk of long-term mortality as well as transition to permanent residential aged care. It remains to be seen if a shortening of this wait time translates into better health outcomes.

Antioxidative and antibacterial peptides derived from bovine milk proteins.

The search for alternative preservatives is on the rise due to safety issues linked with the application of synthetic antioxidants and the extensive increase in bacterial resistance to several conventional antibiotics. Therefore, the quest for finding suitable alternatives including bioactive peptides has received attention. This article reports a comprehensive insight concerning antioxidative and antibacterial peptides derived from milk proteins, a prolific source of peptides having various bioactivities. Caseins and whey proteins have also been evaluated for antioxidative and antibacterial potential using the BIOPEP database. A notable number of potentially active peptides are present in milk proteins. Technological approaches are here reported for the production of these peptides. The findings of this review show potentiality of utilizing dairy derived antioxidative and antibacterial peptides in the development of a superior alternative to the current generation of preservatives and therapeutic agents, as well as a functional ingredient in dietetic or pharmaceutical applications.

Effect of pineapple waste powder on probiotic growth, antioxidant and antimutagenic activities of yogurt.

Although many fruit by-products are good sources of nutrients, little is known about their prebiotic potential. This research was aimed at establishing the prebiotic effect of pineapple wastes on probiotics including Lactobacillus (L.) acidophilus (ATCC® 4356™), L. casei (ATCC® 393™) and L. paracasei spp. paracasei (ATCC® BAA52™) and the subsequent release of antioxidant and antimutagenic peptides in yogurt during their growth. Oven- and freeze- dried peel and pomace were milled separately into powders and tested for prebiotic activities. The net probiotic growth (1.28-2.14 log cfu/g) in customized MRS broth containing the pineapple powders as a direct carbohydrate source was comparable to MRS broth containing glucose. The powders were also separately added to milk during the manufacturing of yogurt with or without probiotics. An increase (by 0.3-1.4 log cycle) in probiotic populations was observed in the yogurts as a consequence of pineapple powder supplementation. Crude water-soluble peptide extracts, prepared by high-speed centrifugation of the yogurts, displayed remarkable antioxidant activities assessed through in vitro assays, namely scavenging activity of 1,1-diphenyl-2-picrylhydrazyl radicals (IC50 = 0.37-0.19 mg/ml) and hydroxyl radicals (58.52-73.55 %). The peptide extracts also exhibited antimutagenic activities (18.60-32.72 %) as sodium azide inhibitor in the Salmonella mutagenicity test. Together, these results suggest that pineapple by-products exhibited prebiotic properties and could possibly be commercially applied in new functional food formulations.

Antibacterial and antiproliferative peptides in synbiotic yogurt-Release and stability during refrigerated storage.

The search for alternative therapeutics is on the rise due to the extensive increase in bacterial resistance to various conventional antibiotics and side effects of conventional cancer therapies. Bioactive peptides released from natural sources such as dairy foods by lactic acid bacteria have received attention as a potential source of biotherapeutic peptides. However, liberation of peptides in yogurt depends on proteolytic activities of the cultures used. Thus, this research was conducted to establish generation of inhibitory peptides in yogurt against pathogenic bacteria and cancer cells during storage at 4°C for 28d. Water-soluble crude peptide extracts were prepared by high-speed centrifugation of plain and probiotic yogurts supplemented with or without pineapple peel powder (PPP). The inhibition zones against Escherichia coli and Staphylococcus aureus by PPP-fortified probiotic yogurt at 28d of storage were, respectively, 25.89 and 11.72mm in diameter, significantly higher than that of nonsupplemented control yogurts. Antiproliferative activity against HT29 colon cancer cells was also significantly higher in probiotic yogurt with PPP than in nonsupplemented probiotic yogurt. Overall, crude water-soluble peptide extracts of the probiotic yogurt with PPP possessed stronger inhibitory activities against bacteria and cancer cells than controls, and these activities were maintained during storage. However, activities were lowered substantially during in vitro gastrointestinal digestion. These findings support the possibility of utilizing dairy-derived bioactive peptides in the development of a superior alternative to the current generation of antibacterial and anticancer agents, as well as a functional ingredient in foods, nutraceuticals, and pharmaceuticals.

Effect of refrigerated storage on probiotic viability and the production and stability of antimutagenic and antioxidant peptides in yogurt supplemented with pineapple peel.

Fruit by-products are good resources of carbohydrates, proteins, vitamins, and minerals, which may function as growth nutrients for probiotic bacteria. This research aimed at evaluating effects of pineapple peel powder addition on the viability and activity of Lactobacillus acidophilus (ATCC 4356), Lactobacillus casei (ATCC393), and Lactobacillus paracasei ssp. paracasei (ATCC BAA52) in yogurts throughout storage at 4°C for 28d. Plain and probiotic yogurts supplemented with or without pineapple peel powder or inulin were prepared. The probiotic counts in supplemented yogurts at 28d of storage ranged from 7.68 and 8.03 log cfu/g, one log cycle higher compared with nonsupplemented control yogurt. Degree of proteolysis in synbiotic yogurts was significantly higher than plain yogurts and increased substantially during storage. Crude water-soluble peptide extract of the probiotic yogurt with peel possessed stronger antimutagenic and antioxidant activities [evaluated measuring reducing power and scavenging capacity of 1,1-diphenyl-2-picrylhydrazyl; 2,2'-azino-bis(3-ethyl benzothiazoline-6-sulfonic acid), and hydroxyl radicals] than control and maintained during storage. Pineapple peel, a by-product of juice production, could be proposed as a prebiotic ingredient in the manufacture of yogurts with enhanced nutrition, and functionality.

Identification of Anticancer Peptides from Bovine Milk Proteins and Their Potential Roles in Management of Cancer: A Critical Review.

Cancer is the most widely recognized reason for human deaths globally. Conventional anticancer therapies, including chemotherapy and radiation, are very costly and induce severe side effects on the individual. The discovery of natural anticancer compounds like peptides may thus be a better alternative for cancer prevention and management. The anticancer peptides also exist in the amino acid chain of milk proteins and can be generated during proteolytic activities such as gastrointestinal digestion or food processing including fermentation. This paper presents an exhaustive overview of the contemporary literature on antitumor activities of peptides released from milk proteins. In addition, caseins and whey proteins have been evaluated for anticancer potential using the AntiCP database, a web-based prediction server. Proline and lysine, respectively, dominate at various positions in anticancer peptides obtained from caseins and whey proteins. The remarkable number of potential anticancer peptides revealed milk proteins as favorable candidates for the development of anticancer agents or milk and milk products for reduction of cancer risks. Moreover, anticancer peptides liberated from milk proteins can be identified from fermented dairy products. Although current findings of correlation between dairy food intakes and cancer risks lack consistency, dairy-derived peptides show promise as candidates for cancer therapy. This critical review supports the notion that milk proteins are not only a nutritious part of a normal daily diet but also have potential for prevention and/or management of cancer.

Evidence and triggers for the transfusion of blood and blood products.

Allogeneic red cell transfusion is a commonly used treatment to improve the oxygen carrying capacity of blood during the peri-operative period. Increasing arterial oxygen content by increasing haemoglobin does not necessarily increase tissue oxygen delivery or uptake. Although the evidence-base for red cell transfusion practice is incomplete, randomised studies across a range of clinical settings, including surgery, consistently support the restrictive use of red cells, with no evidence of benefit for maintaining patients at higher haemoglobin thresholds (liberal strategy). A recent meta-analysis of 7593 patients concluded that a restrictive transfusion strategy was associated with a reduced risk of healthcare-associated infections (pneumonia, mediastinitis, wound infection, sepsis) when compared with a liberal transfusion strategy. The degree to which the optimal haemoglobin concentration or transfusion trigger should be modified for patients with additional specific risk factors (e.g. ischaemic heart disease), remains less clear and requires further research. Although most clinical practice guidelines recommend restrictive use of red cells, and many blood transfusion services have seen marked falls in overall usage of red cells, the use of other blood components such as fresh frozen plasma, platelets, and cryoprecipitate has risen. In clinical practice, administration of fresh frozen plasma is usually guided by laboratory tests of coagulation, mainly prothrombin time, international normalised ratio and activated partial thromboplastin time, but the predictive value of these tests to predict bleeding is poor.

A one-step-ahead pseudo-DIC for comparison of Bayesian state-space models.

In the context of state-space modeling, conventional usage of the deviance information criterion (DIC) evaluates the ability of the model to predict an observation at time t given the underlying state at time t. Motivated by the failure of conventional DIC to clearly choose between competing multivariate nonlinear Bayesian state-space models for coho salmon population dynamics, and the computational challenge of alternatives, this work proposes a one-step-ahead DIC, DICp, where prediction is conditional on the state at the previous time point. Simulations revealed that DICp worked well for choosing between state-space models with different process or observation equations. In contrast, conventional DIC could be grossly misleading, with a strong preference for the wrong model. This can be explained by its failure to account for inflated estimates of process error arising from the model mis-specification. DICp is not based on a true conditional likelihood, but is shown to have interpretation as a pseudo-DIC in which the compensatory behavior of the inflated process errors is eliminated. It can be easily calculated using the DIC monitors within popular BUGS software when the process and observation equations are conjugate. The improved performance of DICp is demonstrated by application to the multi-stage modeling of coho salmon abundance in Lobster Creek, Oregon.

Effect of probiotics on antioxidant and antimutagenic activities of crude peptide extract from yogurt.

Search for bioactive peptides is intensifying because of the risks associated with the use of synthetic therapeutics, thus peptide liberation by lactic acid bacteria and probiotics has received a great focus. However, proteolytic capacity of these bacteria is strain specific. The study was conducted to establish proteolytic activity of Lactobacillus acidophilus (ATCC® 4356™), Lactobacillus casei (ATCC® 393™) and Lactobacillus paracasei subsp. paracasei (ATCC® BAA52™) in yogurt. Crude peptides were separated by high-speed centrifugation and tested for antioxidant and antimutagenic activities. The degree of proteolysis highly correlated with these bioactivities, and its value (11.91%) for samples containing all the cultures was double that of the control. Liberated peptides showed high radical scavenging activities with 1,1-diphenyl-2-picrylhydrazyl and 2,2'-azino-bis(3-ethylbenzothiazoline-6-sulphonic acid), IC50 1.51 and 1.63mg/ml, respectively and strong antimutagenicity (26.35%). These probiotics enhanced the generation of bioactive peptides and could possibly be commercially applied in new products, or production of novel anticancer peptides.

A prospective multicentre observational study of adverse iatrogenic events and substandard care preceding intensive care unit admission (PREVENT).

We examined the current incidence, type, severity and preventability of iatrogenic events associated with intensive care unit admission in five hospitals in England. All unplanned adult admissions to intensive care units were prospectively reviewed over a continuous six-week period. In the week before admission, 76/280 patients (27%) experienced 104 iatrogenic events. The majority of iatrogenic events were categorised as medical (37%), drug (17%) or nursing events (17%). Seventy-seven per cent of the events were considered preventable and 80% caused or contributed to admission. Eleven events were thought to have contributed to a patient's death. The mean (SD) age of patients who had an event was greater (63 (21) years) than those who had not (57 (19) years, p = 0.023), and they had a longer median (IQR [range]) intensive care stay, 4 (1-8 [0-29]) days vs 3 (1-5 [0-20]) days, respectively, p = 0.043.

Patients with faecal peritonitis admitted to European intensive care units: an epidemiological survey of the GenOSept cohort.

INTRODUCTION: Faecal peritonitis (FP) is a common cause of sepsis and admission to the intensive care unit (ICU). The Genetics of Sepsis and Septic Shock in Europe (GenOSept) project is investigating the influence of genetic variation on the host response and outcomes in a large cohort of patients with sepsis admitted to ICUs across Europe. Here we report an epidemiological survey of the subset of patients with FP. OBJECTIVES: To define the clinical characteristics, outcomes and risk factors for mortality in patients with FP admitted to ICUs across Europe. METHODS: Data was extracted from electronic case report forms. Phenotypic data was recorded using a detailed, quality-assured clinical database. The primary outcome measure was 6-month mortality. Patients were followed for 6 months. Kaplan-Meier analysis was used to determine mortality rates. Cox proportional hazards regression analysis was employed to identify independent risk factors for mortality. RESULTS: Data for 977 FP patients admitted to 102 centres across 16 countries between 29 September 2005 and 5 January 2011 was extracted. The median age was 69.2 years (IQR 58.3-77.1), with a male preponderance (54.3%). The most common causes of FP were perforated diverticular disease (32.1%) and surgical anastomotic breakdown (31.1%). The ICU mortality rate at 28 days was 19.1%, increasing to 31.6% at 6 months. The cause of FP, pre-existing co-morbidities and time from estimated onset of symptoms to surgery did not impact on survival. The strongest independent risk factors associated with an increased rate of death at 6 months included age, higher APACHE II score, acute renal and cardiovascular dysfunction within 1 week of admission to ICU, hypothermia, lower haematocrit and bradycardia on day 1 of ICU stay. CONCLUSIONS: In this large cohort of patients admitted to European ICUs with FP the 6 month mortality was 31.6%. The most consistent predictors of mortality across all time points were increased age, development of acute renal dysfunction during the first week of admission, lower haematocrit and hypothermia on day 1 of ICU admission.

A proline repeat polymorphism of the Frost gene of Drosophila melanogaster showing clinal variation but not associated with cold resistance.

Genetic polymorphisms underlying adaptive shifts in thermal responses are poorly known even though studies are providing a detailed understanding of these responses at the cellular and physiological levels. The Frost gene of Drosophila melanogaster is a prime candidate for thermal adaptation; it is up-regulated under cold stress and knockdown of this gene influences cold resistance. Here we describe an amino-acid INDEL polymorphism in proline repeat number in the structural component of this gene. The two main repeats, accounting for more than 90% of alleles in eastern Australia, show a strong clinal pattern; the 6P allele was at a high frequency in tropical locations, and the 10P allele was common in temperate populations. However, the frequency of these alleles was not associated with three different assays of cold resistance. Adult transcription level of Frost was also unrelated to cold resistance as measured through post chill coma mobility. The functional significance of the proline repeat polymorphism therefore remains unclear despite its clinal pattern. The data also demonstrate the feasibility of using Roche/454 sequencing for establishing clinal patterns.

Widespread pyrethroid resistance in Australian diamondback moth, Plutella xylostella (L.), is related to multiple mutations in the para sodium channel gene.

Populations of Plutella xylostella, extending over 3800 km in southern Australia, show no genetic structure as assessed by microsatellite markers; yet outbreaks of pyrethroid resistance occur sporadically in cropping areas. Since mutations in the para voltage-gated sodium channel gene have been implicated in pyrethroid resistance, we looked for DNA sequence variation at this target among Australian moths. We found two resistance mutations previously reported for this species (L1014F and T929I), as well as a novel substitution (F1020S). Of the eight possible haplotypes formed by combinations of these three biallelic polymorphisms, only four were found in Australian populations: the wild-type allele (w), the kdr mutation allele (kdr) with only L1014F, the super-kdr-like combination of L1014F and T929I (skdrl), and the crashdown allele with only F1020S (cdr). Comparison of genotype frequencies among survivors of permethrin assays with those from untreated controls identified three resistant genotypes: skdrl homozygotes, cdr homozygotes and the corresponding heterozygote, cdr/skrdl - the heterozygote being at least as resistant as either homozygote. Spatial heterogeneity of allele frequencies was conspicuous, both across the continent and among local collections, consistent with reported spatial heterogeneity of pyrethroid resistance. Further, high resistance samples were sometimes associated with high frequency of cdr, sometimes high frequency of skdrl, or sometimes with a high combined cdr+skdrl frequency. The skdrl and cdr alleles explain a high proportion of the Australia-wide resistance variation. These data add to evidence that nerve insensitivity by mutations in the para-sodium channel gene is a common pyrethroid resistance mechanism in P. xylostella.

A clinally varying promoter polymorphism associated with adaptive variation in wing size in Drosophila.

Body size often shows adaptive clines in many ectotherms across altitude and latitude, but little is known about the genetic basis of these adaptive clines. Here we identify a polymorphism in the Dca (Drosophila cold acclimation) gene in Drosophila melanogaster that influences wing size, affects wing:thorax allometry and also controls a substantial proportion of the clinal wing-size variation. A polymorphism in the promoter region of Dca had two common alleles showing strong reciprocal clinal variation in frequency with latitude along the east coast of Australia. The Dca-237 allele increased towards the tropics where wing size is smaller. A within-population association study highlighted that an increase in the frequency of this allele decreased wing size but did not influence thorax size. A manipulated increase in the level of expression of Dca achieved through UAS-GAL4 was associated with a decrease in wing size but had no effect on thorax size. This was consistent with higher Dca expression levels in family lines with higher frequency of the Dca-237 allele. Genetic variation in the promoter region of the Dca gene appears to influence adaptive size variation in the eastern Australian cline of Drosophila melanogaster and accounts for more than 10% of the genetic variation in size within and between populations.

Selection for cold resistance alters gene transcript levels in Drosophila melanogaster.

Microarrays have been used to examine changes in gene expression underlying responses to selection for increased stress resistance in Drosophila melanogaster, but changes in expression patterns associated with increased resistance to cold stress have not been previously reported. Here we describe such changes in basal expression levels in replicate lines following selection for increased resistance to chill coma stress. We found significant up- or down-regulation of expression in 94 genes on the Affymetrix Genome 2.0 array. Quantitative RT-PCR was used to confirm changes in expression of six genes. Some of the identified genes had previously been associated with stress resistance but no previously identified candidate genes for cold resistance showed altered patterns of expression. Seven differentially expressed genes that form a tight chromosomal cluster and an unlinked gene AnnX may be potentially important for cold adaptation in natural populations. Artificial selection for chill coma resistance therefore altered basal patterns of gene expression, but we failed to link these changes to plastic changes in expression under cold stress or to previously identified candidate genes for components of cold resistance.