"In the wilderness dealing with difficult situations": Knowledge exchange with care home staff in England on managing seizures and epilepsy - An initial exploration.

PURPOSE: With epilepsy increasingly affecting older adults, seizure-related care needs arise in new settings. Persons in these settings must receive optimal support and challenges identified for remediation. This may entail the epilepsy community researching in unfamiliar environments. One setting is care homes. Seizure-related ambulance incidents in them are common. We conducted the first qualitative study with care home staff to explore their experiences and challenges in managing suspected seizures. METHODS: Three online focus groups were organised for January 2024 to explore ambulance calls, post-incident procedures, and challenges faced by care home staff when managing seizures. Persons were eligible to participate if they worked as a care assistant, nurse or manager in a care home in North-West England. Different recruitment pathways were employed including direct approach, a managers' network, social media and a register of research interested homes. Focus group audio recordings were transcribed and analysed using Hamilton's Rapid Analysis. RESULTS: Recruitment was difficult; 13 care home staff from 12 different homes were ultimately recruited. Despite data saturation not being achieved, insights were gained regarding ambulance call decisions, paperwork navigation, and follow-up care challenges. Patients not having meaningful seizure action plans in place and regulatory restrictions were identified as factors that contributed to potentially avoidable calls for ambulance help being made. CONCLUSION: This study highlights systemic issues in care homes' seizure care, emphasizing the need for further research. The epilepsy community may need to innovate to better research within this increasingly important setting. This study offers insights into the effectiveness of different recruitment strategies.

Sepsis-associated acute kidney injury in patients with chronic kidney disease: Patient characteristics, prevalence, timing, trajectory, treatment and associated outcomes.

AIM: The features and outcomes of sepsis-associated acute kidney injury (SA-AKI) may be affected by chronic kidney disease (CKD). Accordingly, we aimed to compare SA-AKI in patients with or without CKD. METHODS: Retrospective cohort study in 12 intensive care units (ICU). We studied the prevalence, patient characteristics, timing, trajectory, treatment and outcomes of SA-AKI with and without CKD. RESULTS: Of 84 240 admissions, 7255 (8.6%) involved patients with CKD. SA-AKI was more common in patients with CKD (21% vs 14%; p < .001). CKD patients were older (70 vs. 60 years; p < .001), had a higher median Charlson co-morbidity index (5 vs. 3; p < .001) and acute physiology and chronic health evaluation (APACHE) III score (78 vs. 60; p < .001) and were more likely to receive renal replacement therapy (RRT) (25% vs. 17%; p < .001). They had less complete return to baseline function at ICU discharge (48% vs. 60%; p < .001), higher major adverse kidney events at day 30 (MAKE-30) (38% vs. 27%; p < .001), and higher hospital and 90-day mortality (21% vs. 13%; p < .001, and 27% vs. 16%; p < .001, respectively). After adjustment for patient characteristics and severity of illness, however, CKD was not an independent risk factor for increased 90-day mortality (OR 0.88; 95% CI 0.76-1.02; p = .08) or MAKE-30 (OR 0.98; 95% CI 0.80-1.09; p = .4). CONCLUSION: SA-AKI is more common in patients with CKD. Such patients are older, more co-morbid, have higher disease severity, receive different ICU therapies and have different trajectories of renal recovery and greater unadjusted mortality. However, after adjustment day-90 mortality and MAKE-30 risk were not increased by CKD.

Increase in muscle power is associated with myofibrillar ATPase adaptations during resistance training.

NEW FINDINGS: What is the central question of this study? The aim of this study was to examine the effects of resistance training on gains in the external mechanical power output developed during climbing and myofibrillar ATPase activity in rats. What is the main finding and its importance? Using rapid flow quench experiments, we show that resistance training increases both the power output and the myofibrillar ATPase activity in the flexor digitorum profundus, biceps and deltoid muscles. Data fitting reveals that these functional ameliorations are explained by an increase in the rate constant of liberation of ATP hydrolysis products and contribute to performance gains. ABSTRACT: Skeletal muscle shows a remarkable plasticity that permits functional adaptations in response to different stimulations. To date, modifications of the proportions of myosin heavy chain (MHC) isoforms and increases in fibre size are considered to be the main factors providing sarcomeric plasticity in response to exercise training. In this study, we investigated the effects of a resistance training protocol on the myofibrillar ATPase (m-ATPase) cycle, muscle performance (power output) and MHC gene expression. For this purpose, 8-week-old Wistar Han rats were subjected to 4 weeks of resistance training, with five sessions per week. Muscle samples of flexor digitorum profundus (FDP), biceps and deltoid were collected and subjected to RT-qPCR analyses and assessment of m-ATPase activity with rapid flow quench apparatus. Training led to a significant increase in muscle mass, except for the biceps, and in total mechanical power output (+135.7%, P < 0.001). A shift towards an intermediate fibre type (i.e. MHC2x-to-MHC2a isoform transition) was also observed in biceps and FDP but not in the deltoid muscle. Importantly, rapid flow quench experiments revealed an enhancement of the m-ATPase activity during contraction at maximal velocity (kF ) in the three muscles, with a more marked effect in FDP (+242%, P < 0.001). Data fitting revealed that the rate constant of liberation of ATP hydrolysis products (k3 ) appears to be the main factor influencing the increase in m-ATPase activity. In conclusion, the data showed that, in addition to classically observed changes in MHC isoform content and fibre hypertrophy, m-ATPase activity is enhanced during resistance training and might contribute significantly to performance gains.

Modelling performance and skeletal muscle adaptations with exponential growth functions during resistance training.

System theory is classically applied to describe and to predict the effects of training load on performance. The classic models are structured by impulse-type transfer functions, nevertheless, most biological adaptations display exponential growth kinetics. The aim of this study was to propose an extension of the model structure taking into account the exponential nature of skeletal muscle adaptations by using a genetic algorithm. Thus, the conventional impulse-type model was applied in 15 resistance trained rodents and compared with exponential growth-type models. Even if we obtained a significant correlation between actual and modelled performances for all the models, our data indicated that an exponential model is associated with more suitable parameters values, especially the time constants that correspond to the positive response to training. Moreover, positive adaptations predicted with an exponential component showed a strong correlation with the main structural adaptations examined in skeletal muscles, i.e. hypertrophy (R2 = 0.87, 0.96 and 0.99, for type 1, 2A and 2X cross-sectional area fibers, respectively) and changes in fiber-type composition (R2 = 0.81 and 0.79, for type 1 and 2A fibers, respectively). Thus, an exponential model succeeds to describe both performance variations with relevant time constants and physiological adaptations that take place during resistance training.

The ethical experiences of trainees on short-term international trips: a systematic qualitative synthesis.

BACKGROUND: Medical student and resident participation in short-term international trips for trainees (STINTTs) has increased in the past few decades. However, there has been no systematic review of trainees' actual ethical experiences. The authors sought to identify what ethical issues medical trainees encounter during STINTTs, as elicited by and reported in peer-reviewed, quantitative and qualitative research papers. METHODS: The authors systematically searched five academic databases finding 659 unique titles and abstracts. The authors applied inclusion and exclusion criteria to these titles and abstracts resulting in fourteen papers, which were analyzed using qualitative thematic synthesis. RESULTS: The qualitative analysis of the papers generated four themes: (1) Trainees' Concerns Over Perpetuating Medical Tourism; (2) Struggling to Identify and Balance the Benefits and Harms of STINTTs; (3) The Complicated Trainee Mens (mind); and (4) Ethical Situations Encountered by Trainees. The fourth theme, which was the largest, was further divided into (a) Navigating social and cultural dynamics, (b) Trainees' experiences related to the learner role, and (c) Ethical situations not qualifying for other catagories. Some of these issues reported in the empirical research papers are well represented in the broader literature on STINTTs, while others were less so-such as mistreatment of trainees. All included papers were published after 2010, and comprised a total of less than 170 medical trainees. CONCLUSIONS: Medical trainees report experiencing a wide range of ethical challenges during short-term international trips in which they engage in clinical or research activities. The authors call educators' attention to specific challenges that trainees face. The relevant literature covering US and Canadian STINTTs is relatively young and largely qualitative. The authors briefly sketch a program for expanding the research on this increasingly common educational experience.

Surviving Triple Trouble: Synchronous Breast and Cervical Cancer, HIV Infection and Myocardial Infarction.

Breast and cervical cancer are the two most common cancers in female. However, owing to the contrasting risk factors, synchronous breast and cervical cancer has very rarely been reported. However, noncommunicable disease like cardiovascular disease and different infections has tended to make situations complicated because of complex interaction. In recent years, such cases are being seen frequently and their management is challenging. We report such a case of synchronous breast and cervical cancer complicated by HIV infection and myocardial infarction. This highlights the importance of a wide spectrum of clinical knowledge and skill and interdisciplinary coordination.

NK cells modulate the lung dendritic cell-mediated Th1/Th17 immunity during intracellular bacterial infection.

The impact of the interaction between NK cells and lung dendritic cells (LDCs) on the outcome of respiratory infections is poorly understood. In this study, we investigated the effect and mechanism of NK cells on the function of LDCs during intracellular bacterial lung infection of Chlamydia muridarum in mice. We found that the naive mice receiving LDCs from C. muridarum-infected NK-cell-depleted mice (NK-LDCs) showed more serious body weight loss, bacterial burden, and pathology upon chlamydial challenge when compared with the recipients of LDCs from infected sham-treated mice (NK+LDCs). Cytokine analysis of the local tissues of the former compared with the latter exhibited lower levels of Th1 (IFN-γ) and Th17 (IL-17), but higher levels of Th2 (IL-4), cytokines. Consistently, NK-LDCs were less efficient in directing C. muridarum-specific Th1 and Th17 responses than NK+LDCs when cocultured with CD4(+) T cells. In NK cell/LDC coculture experiments, the blockade of NKG2D receptor reduced the production of IL-12p70, IL-6, and IL-23 by LDCs. The neutralization of IFN-γ in the culture decreased the production of IL-12p70 by LDCs, whereas the blockade of TNF-α resulted in diminished IL-6 production. Our findings demonstrate that NK cells modulate LDC function to elicit Th1/Th17 immunity during intracellular bacterial infection.

Perceived training intensity and performance changes quantification in judo.

The objective of this study was to determine the methods of quantification for training and performance, which would be the most appropriate for modeling the responses to long-term training in cadet and junior judo athletes. For this, 10 young male judo athletes (15.9 ± 1.3 years, 64.9 ± 10.3 kg, and 170.8 ± 5.4 cm) competing at a regional/state level volunteered to take part in this study. Data were collected during a 2-year training period (i.e., 702 days) from January 2011 to December 2012. Their mean training volume was 6.52 ± 0.43 hours per week during the preparatory periods and 4.75 ± 0.49 hours per week during the competitive periods. They followed a training program prescribed by the same coach. The training load (TL) was quantified through the session rating of perceived exertion (RPE) and expressed in arbitrary unit (a.u.). Performance was quantified from 5 parameters and divided into 2 categories: performance in competition and performance in training. The evaluation of performance in competition was based on the number of points per level. Performance in training was assessed through 4 different tests. A physical test battery consisting of a standing long jump, 2 judo-specific tests that were the maximal number of dynamic chin-up holding the judogi, and the Special Judo Fitness Test was used. System modeling for describing training adaptations consisted of mathematically relating the TL of the training sessions (system input) to the change in performance (system output). The quality of the fit between TL and performance was similar, whether the TL was computed directly from RPE (R = 0.55 ± 0.18) or from the session RPE (R = 0.56 ± 0.18) and was significant in 8 athletes over 10, excluding the standing jump from the computation of the TL, leading to a simplest method. Thus, this study represents a first attempt to model TL effects on judo-specific performance and has shown that the best relationships between amounts of training and changes in performance were obtained when training amounts were quantified simply from RPE.

2-(10-Bromo-anthracen-9-yl)-N-phenyl-aniline.

In the title compound, C26H18BrN, the central benzene ring makes dihedral angles with its adjacent anthracene ring system and pendant benzene ring of 87.49 (13) and 62.01 (17)°, respectively. The N-H moiety is sterically blocked from forming a hydrogen bond, but weak C-H⋯π inter-actions occur in the extended structure.

10-Bromo-N,N-di-phenyl-anthracen-9-amine.

In the title compound, C26H18BrN, the dihedral angles between the anthracene ring system and the phenyl rings are 89.51 (14) and 74.03 (15)°. In the extended structure, a weak C-H⋯Br inter-action occurs, which generates [100] chains, but no significant π-π or C-H⋯π inter-actions are observed.

Nurse-led immunotreatment DEcision Coaching In people with Multiple Sclerosis (DECIMS) - A cluster- randomised controlled trial and mixed methods process evaluation.

OBJECTIVE: To evaluate a nurse-led decision coaching programme aiming to redistribute health professionals' tasks to support immunotherapy decision-making in people with multiple sclerosis (MS). METHODS: Cluster-randomised controlled trial with an accompanying mixed methods process evaluation (2014 - 2018). We planned to recruit 300 people with clinically isolated syndrome or relapsing-remitting MS facing immunotherapy decisions in 15 clusters across Germany. Participants in the intervention clusters received up to three decision coaching sessions by a trained nurse and access to an evidence-based online information platform. In the control clusters, participants also had access to the information platform. The primary outcome was informed choice after six months, defined as good risk knowledge and congruent attitude and uptake. RESULTS: Twelve nurses from eight clusters participated in the decision coaching training. Due to insufficient recruitment, the randomised controlled trial was terminated prematurely with 125 participants (n = 42 intervention clusters, n = 83 control clusters). We found a non-significant difference between groups for informed choice favouring decision coaching: odds ratio 1.64 (95% CI 0.49-5.53). CONCLUSIONS: Results indicate that decision coaching might facilitate informed decision-making in MS compared to providing patient information alone. PRACTICE IMPLICATIONS: Barriers have to be overcome to achieve structural change and successful implementation.

Exergaming in augmented reality is tailor-made for aerobic training and enjoyment among healthy young adults.

In recent years, the use of exergaming for physical activity practice has gain in popularity but few is known about the use of augmented reality for physical activity, particularly at moderate to vigorous intensities. The present study examined the use of an exergame in augmented reality for aerobic training in healthy young adults. In a within-subject design, 18 participants (19.8 ± 1.4 years of age) have performed two physical activity sessions playing dodgeball. Indeed, they realized a classical dodgeball session and an exergaming session with an augmented reality version of dodgeball game. Physical loads and intensities were measured with accelerometers, RPE and heart sensors. Enjoyment experienced during the sessions was measured with the short version of the physical activity enjoyment scale questionnaire. Results revealed that both physical load and intensity were appropriate for aerobic training in the two conditions (i.e., classical and exergame in augmented reality) although values were significantly higher in the classical condition. Enjoyment was high in the two conditions with a higher significant value in the classical condition compared to the exergame in augmented reality condition. Put together, these results indicate that an aerobic state can be attained through both physical gameplay and its augmented reality equivalent and was associated to a high level of enjoyment among healthy young adults.

Rapid uptake of adjunctive corticosteroids for critically ill adults with septic shock following publication of ADRENAL trial. A multicenter, retrospective analysis of prescribing practices in Queensland Intensive Care Units.

BACKGROUND: Septic shock is common and associated with significant morbidity and mortality. The ADRENAL trial examined the use of hydrocortisone in patients with septic shock, demonstrating no difference in patient-centred outcomes but a decrease in the time to shock resolution. The change in clinical practice related to the publication of the ADRENAL trial is currently unknown. METHODS: A retrospective cohort study examining the use of hydrocortisone in patients with septic shock was conducted in 12 intensive care units (ICUs). A segmented linear regression was performed to identify a stepwise change in hydrocortisone administration and 90-day mortality associated with the publication of the ADRENAL trial. RESULTS: We included 4,198 patients with a mean age of 58 years (standard deviation, SD17), and the median noradrenaline equivalent score (NEE) was 0.07 µg/kg/min (IQR 0.02 - 0.17). Segmented regression analysis for hydrocortisone administration identified two breakpoints, 3 months before and 6 months after publication, leading to three periods: Pre-publication, Transition and Post-publication. Compared to the pre-publication period, the Transition and Post-publication cohorts had a higher proportion of hydrocortisone administration (28% vs. 34% vs. 43%; p < 0.0001). Furthermore, after adjustment for temporal change, the transition period had a significant change in the slope of the proportion of patients receiving hydrocortisone (-0.1% per month vs. +1.4% per month; p = 0.026), whereas this was not statistically significant during the post-publication period (+0.1% per month, p = 0.66). After adjusting for confounders, the Transition and Post-publication periods were independently associated with an increase in hydrocortisone (OR 1.4, 95% CI 1.14 - 1.77; p = 0.0015 and OR 2.03; 95% CI 1.74 - 2.36; p < 0.001, respectively). Furthermore, after adjusting for confounders, when compared to the Pre-transition period, the use of hydrocortisone was associated with a statistically significant decrease in 90-day mortality (14% vs. 24% absolute difference, aHR for hydrocortisone effect -0.81; 95% CI 0.65 - 0.99; p = 0.044). CONCLUSION: Publication of the ADRENAL trial changed clinical practice in Queensland ICUs with increased prescription of hydrocortisone for patients with septic shock with an associated reduction in mortality.

Hypothermia and Influence of Rewarming Rates on Survival Among Patients Admitted to Intensive Care with Bloodstream Infection: A Multicenter Cohort Study.

Although critically ill patients with bloodstream infections (BSIs) who present with hypothermia are at the highest risk for death, it is not known how rewarming rates may influence the outcomes. The objective of this study was to identify the occurrence and determinants of hypothermia among patients admitted to intensive care units (ICUs) with BSI and assess how the rate of temperature correction may influence 90-day all-cause case-fatality. A cohort of 3951 ICU admissions associated with BSI was assembled. The lowest temperature measured within the first 24 hours of admission was identified, and among those who were hypothermic (<36°C), the rewarming rate [(time difference between lowest and subsequent first temperature ≥36°C) divided by hypothermia severity (difference between lowest measured and 36°C)] was determined. Within the first 24 hours of admission to the ICU, 329 (8.4%) and 897 (22.7%) subjects had the lowest temperature measurements ranging <34.9°C and 35-35.9°C, respectively. Patients with lower temperatures were more likely to be admitted to tertiary care ICUs, have more comorbid illnesses, have greater severity of illness, and have a higher need for organ-supportive therapies. The 90-day all-cause case-fatality rate was 22.9% overall and was 45.3%, 24.8%, and 19.6% for those with the lowest 24 hours temperatures of <35°C, 35-35.9°C, and ≥36°C, respectively (p < 0.001). Among 1133 hypothermic patients with documented temperatures corrected to the normal range while admitted to the ICU, the median rate of temperature increase was 0.24 (interquartile range, 0.13-0.45)oC/hour. After controlling for the severity of illness and comorbidity, a faster rewarming rate was associated with significantly lower 90-day case-fatality. Hypothermia is a significant risk factor associated with death among critically ill patients with BSI that faster rates of rewarming may modify.

Impact of mild hypercapnia in critically ill patients with metabolic acidosis.

PURPOSE: Clinical trials focusing on critically ill patients with metabolic acidosis, a common exclusion criterion is the presence of a PaCO2 > 45 mmHg. The aim of this study was to assess the impact of mild hypercapnia on patient characteristics, severity, and clinical outcomes in critically ill patients with metabolic acidosis. MATERIAL AND METHODS: Multicentre, retrospective, observational study conducted in 12 intensive care units (ICUs) in Queensland, Australia. Patients with metabolic acidosis and concurrent vasopressor requirement were included and the exposure of interest was the PaCO2 level at the time of meeting the eligibility criteria divided in two groups: PaCO2 ≤ 45 mmHg and PaCO2 46-50 mmHg. Primary clinical outcome was major adverse kidney events within 30 days (MAKE30). RESULTS: We studied 5601 patients, with 3605 (64.4 %) in the PaCO2 ≤ 45 mmHg group and 1996 (35.6 %) in the PaCO2 46-50 mmHg group. The incidence of MAKE30 was lower in the PaCO2 46-50 mmHg group (29 % vs. 34 %; OR, 0.79 [95 %CI, 0.69 to 0.90]; p < 0.001) as was the use of renal replacement therapy, and the incidence of acute kidney injury. After adjustment for confounders, no outcome was different between the groups. The maximum fall of pH associated with an increase of 1 mmHg of PaCO2 in the PaCO2 46-50 mmHg group was 0.006. CONCLUSION: In patients with metabolic acidosis, after adjustment for potential confounders, mild hypercapnia does not increase the MAKE-30 rate and does not have a major impact on pH.

Percutaneous coronary intervention versus optimal medical therapy for stable coronary artery disease: An umbrella review.

Background: Invasive management of stable coronary artery disease is still a controversial topic. The purpose of this umbrella review was to synthesize systematic reviews (SRs) that evaluate the benefits and harms of percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with stable coronary artery disease. Methods: We systematically searched PubMed/MEDLINE, Embase, and CENTRAL from 2018 to August 7, 2022. We included SRs with meta-analyses of randomized controlled trials (RCTs) that evaluated the question of interest. We assessed the methodological quality of the SRs with the AMSTAR-2 tool. We summarized the results of the outcomes for each SR. We calculated the degree of overlap of the RCTs included in the SRs using the corrected covered area (CCA). Results: We found 10 SRs with meta-analyses. The SRs included 3 to 15 RCTs. The degree of overlap among the SRs was very high (CCA > 15%). No SR evaluated the certainty of the evidence using the GRADE system and 9 out of 10 had critically low methodological quality. The SRs reported heterogeneous results for the outcomes of all-cause mortality, myocardial infarction, revascularization, and angina. On the other hand, for the outcomes of cardiovascular mortality and stroke, all SRs agreed that there were no differences between PCI and OMT alone. Conclusions: We found 10 SRs on the use of PCI compared to OMT alone for patients with stable coronary artery disease. However, none had high methodological quality, none evaluated the certainty of the evidence using the GRADE approach, and the results were inconsistent for several outcomes. This variability in evidence may result in divergent clinical decisions for the management of stable coronary artery disease among healthcare professionals. It is necessary to perform a high-quality SR using the GRADE approach to clarify the balance of benefits and harms of PCI.

The Effect of Intervention Approaches of Emotion Regulation and Learning Strategies on Students' Learning and Mental Health.

University students are a vulnerable population, and many recent studies show that anxiety, depressive symptoms, and academic burnout have been on the increase since the beginning of the COVID-19 pandemic. These findings point to a need for interventions to reduce these difficulties. The purpose of the present study was to assess the effects of 2 formats of an innovative program on students' mental health (anxiety, depressive symptoms, and academic burnout), intolerance of uncertainty, learned helplessness, and learning. Our sample was composed of 105 university students, recruited on a voluntary basis. They were divided into 3 groups: online intervention group (n = 36), face-to-face intervention group (n = 32), and control group (n = 37). The following variables were measured through online questionnaires: anxiety and depressive symptoms, academic burnout, intolerance of uncertainty, learned helplessness, perceived social support, learning strategies, and beliefs. There were 2 assessments 10 weeks apart (ie, before and after the program in the case of the 2 intervention groups). We performed nonparametric analyses to run comparisons between the 2 assessment timepoints in each group. Results showed that participants in the 2 intervention groups had lower levels of learned helplessness and intolerance of uncertainty at the end of the program. Furthermore, participants in the face-to-face group reported higher levels of perceived social support, academic self-efficacy, and help-seeking strategies. The present study highlighted the benefits of our innovative program, especially its face-to-face format.Clinical Trial - ID: NCT04978194.

Exploring the Health Effectiveness of a Physical Activity Program Co-Constructed with Students after the COVID-19 Pandemic.

BACKGROUND: University students have low levels of physical activity and high levels of sedentary behaviors that were exacerbated by the COVID-19 pandemic. Even before the pandemic, there was poor uptake of university sports activities. Therefore, it is essential to develop and test innovative programs to increase students' motivation to engage in physical activity in order to prevent any future deterioration in their general health. OBJECTIVE: This exploratory study was conducted to test the effectiveness of a physical activity program that was co-constructed with students. METHODS: First, a workshop drawing on social design methodologies and the fundamentals of physical activity programs was conducted to assess students' needs and desires in terms of physical activity. Second, the effectiveness of a program co-constructed with students on the basis of this workshop was assessed on physical and mental health parameters. The results showed that the workshop outcomes allowed the physical activity program to be tailored to meet students' expectations (e.g., session duration and type of activities). This innovative physical activity program was found to improve body image, autonomous motivation, and certain physical parameters. At the end of the 8-week program, the adherence rate was 89%, and 83% of the final respondents expressed a wish to re-enroll for the following semester. CONCLUSIONS: Involving students and considering their wishes, needs, and objectives could facilitate the development of attractive and innovative programs.

Sepsis-associated acute kidney injury in the intensive care unit: incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes. A multicenter, observational study.

PURPOSE: The Acute Disease Quality Initiative (ADQI) Workgroup recently released a consensus definition of sepsis-associated acute kidney injury (SA-AKI), combining Sepsis-3 and Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria. This study aims to describe the epidemiology of SA-AKI. METHODS: This is a retrospective cohort study carried out in 12 intensive care units (ICUs) from 2015 to 2021. We studied the incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes of SA-AKI based on the ADQI definition. RESULTS: Out of 84,528 admissions, 13,451 met the SA-AKI criteria with its incidence peaking at 18% in 2021. SA-AKI patients were typically admitted from home via the emergency department (ED) with a median time to SA-AKI diagnosis of 1 day (interquartile range (IQR) 1-1) from ICU admission. At diagnosis, most SA-AKI patients (54%) had a stage 1 AKI, mostly due to the low urinary output (UO) criterion only (65%). Compared to diagnosis by creatinine alone, or by both UO and creatinine criteria, patients diagnosed by UO alone had lower renal replacement therapy (RRT) requirements (2.8% vs 18% vs 50%; p < 0.001), which was consistent across all stages of AKI. SA-AKI hospital mortality was 18% and SA-AKI was independently associated with increased mortality. In SA-AKI, diagnosis by low UO only, compared to creatinine alone or to both UO and creatinine criteria, carried an odds ratio of 0.34 (95% confidence interval (CI) 0.32-0.36) for mortality. CONCLUSION: SA-AKI occurs in 1 in 6 ICU patients, is diagnosed on day 1 and carries significant morbidity and mortality risk with patients mostly admitted from home via the ED. However, most SA-AKI is stage 1 and mostly due to low UO, which carries much lower risk than diagnosis by other criteria.

Pancreatic cancer: surgical management and outcomes after 6 years of follow-up.

OBJECTIVE: To describe the management and outcomes of a population-based cohort of patients with pancreatic cancer in Victoria, Australia. DESIGN, SETTING AND PATIENTS: Retrospective study based on questionnaires completed from medical histories of patients diagnosed with pancreatic cancer during 2002-2003 in Victoria who were identified from the Victorian Cancer Registry and followed up for 6 years. MAIN OUTCOME MEASURES: Proportion of patients receiving each form of treatment, 30-day mortality, median survival, and 5-year and 6-year survival. RESULTS: Of 1044 patients with pancreatic cancer identified, 927 were eligible for the study, and questionnaires were completed for 830 (response rate, 89.5%); 67 patients with ampulla of Vater and neuroendocrine tumours were excluded. Of the 763 remaining patients (median age, 72 years), notification of death was available for 747 (97.9%). Most patients (n = 548) had tumours in the head and neck of the pancreas. Resection was performed in a total of 87 patients (11.4%). Patients managed with Whipple resection (n = 75) had a 30-day mortality rate of 5.3% and median survival of 16.3 months. A relatively large number of surgeons (n = 31) each performed a modest number of Whipple resections during the study period. Jaundice was palliated with biliary stents (n = 240) and bypass surgery (n = 99). Survival was shortest in those treated with best supportive care (median, 2.3 months for those with head and neck of pancreas tumours, and 3.4 months for body and tail of pancreas tumours). Of the 20 patients who survived to 5 years, 10 did not have histological confirmation of carcinoma and were presumably false-positive diagnoses, and three of the 10 patients who did have positive histological results had experienced recurrent disease by 6-year follow-up. CONCLUSIONS: Most outcomes in Victoria compared favourably with other studies. Prognosis for patients with carcinoma of the pancreas is grim, with few long-term survivors. Six-year survival appears to be a better proxy for cure than 5-year survival.