January June Research Articles

Procalcitonin Testing With Secondary Coinfection in Patients With COVID-19.

BackgroundThe coronavirus disease (COVID-19) virus has caused millions of deaths. It is difficult to differentiate between pure viral COVID-19 pneumonia and secondary infection. Clinicians often use procalcitonin (PCT) to decide on empiric antibiotic therapy.MethodologyWe performed a retrospective study of patients admitted with COVID-19 between January 1st, 2020, and June 30th, 2020. Patient demographics, clinical findings, and laboratory findings with a focus on PCT levels were recorded. Coinfection was considered if clinicians ordered a septic workup (urine, blood, and respiratory cultures) or if the physicians started or escalated antimicrobial therapy. PCT levels on the day of culture and daily for the next three days were recorded. Significant PCT change was defined as a decrease in PCT levels of >50% from the initial elevated PCT level.ResultsIn total, 143 (59.8%) patients had one secondary infection. These included pulmonary infections (118, 49.4%), blood infections (99, 41.4%), and urine infections (64, 26.8%). Many patients had more than one documented positive culture: respiratory system and blood together in 80 (33.4%) patients, sputum and urine in 55 (23.1%) patients, and urine and blood in 46 (19.2%) patients. Out of the 143 patients with a positive culture, PCT was abnormal on the day of positive culture in 93 (65.5%), while PCT was abnormal in 64 out of 96 on the day of negative culture (66.7%) (p = 0.89). Individual analysis for PCT levels of respiratory cultures showed out of 118 positive sputum cultures, 86 (72%) had abnormal PCT on the day of culture. PCT in positive versus negative cultures was not significantly different, with median PCT (interquartile range, IQR) of 1.66 (6.61) versus 1.03 (2.23) (p = 0.172). For blood cultures, out of 99 positive blood cultures, 73 (73%) had abnormal PCT levels on the day of the culture. PCT in positive versus negative cultures was significantly elevated, with a median of 1.61 (5.97) vs. 0.65 (1.77) (p < 0.001). For urine, out of 64 positive cultures, 41 (64.1%) had abnormal PCT levels on the day of the culture. PCT in positive versus negative cultures was not significantly different, with a median of 0.71 (2.92) vs. 0.93 (4.71) (p = 0.551). To observe the change in PCT after culture, PCT values for the next three days after culture were analyzed. We found that patients with positive cultures had higher PCT levels than those with negative cultures. There was no significant improvement over the following three days. Patients with abnormal PCT on the day of the suspected infection had a longer length of stay in the hospital, with a median (IQR) of 23.9 days (3.16) vs. 16.9 days (2.18) (p = 0.021).ConclusionsSecondary coinfections in patients with COVID-19 infections are not associated with PCT elevation on the day of suspected secondary infection. However, most patients with bacteremia had a significant elevation of PCT on the day of bacteremia before collection and reporting of positive culture. Patients with abnormal PCT levels on the day of suspected infection had a longer hospital stay than patients with normal PCT levels. Subsequent testing of PCT in patients showed no significant improvement in PCT.

Arrhythmia related to hypertensive left ventricular hypertrophy in Iraqi patients: frequency and outcome.

Left ventricular hypertrophy (LVH) caused by high blood pressure is linked to increased mortality and arrhythmia risk. This study aimed to evaluate arrhythmia in hypertensive patients due to left ventricular hypertrophy (LVH). A cross-sectional study was performed, assessing participants' blood pressure, echocardiography and electrocardiography, and Holter monitoring in certain cases. There were 300 hypertensive patients >18 years attending the cardiology unit of Baghdad medical city. The study was conducted between January-June 2022. The electrocardiograms at rest for 300 adults with hypertension were investigated. 130 (43.5%) were females, and 170 (56.5%) were males. The mean age of participants was 58 years. Forty-nine (16.3%) patients had arrhythmia. As compared to those without arrhythmia, participants with arrhythmia were older (62.3 vs. 56.1, p=0.03), had a greater prevalence of left ventricular hypertrophy (24.5% vs. 12.7%, p=0.026), and more prone to experience cardiac failure (32.7% vs. 8.5%, p<0.011). Atrial fibrillation was found in 6 (27.2%) female patients and 5 (18.5%) males. In addition, two (7.4%) male patients and one female patient (4.5%) had atrial flutter, and premature ventricular contractions (PVCs) were noted in 10 (37%) and 11 (50%) patients. Left ventricular mass index (LVMI) was 103 gm/m2 in female patients and 119.2 gm/m2 in males. Palpitation was present in 22 (44.9%) female patients and 27 (55.1%) males. The study revealed that hypertensives with LVH have an arrhythmia frequency of 16.3%. The most common arrhythmias were atrial fibrillation and premature ventricular complex.

Physical Environmental Conditions and Germ Number in Bedroom of Tuberculosis Patients in Kupang City, East Nusa Tenggara Province

The ability of Mycobacterium tuberculosis as the agent of tuberculosis (TB) to live in the air is generally very dependent on environmental factors, which can cause bacteria to last long in the air and increase the risk of transmission of TB. The research purpose was to analyze the relationship between the physical environment condition and the number of germs in the bedroom of TB patients. This cross-sectional research was conducted in Kupang city, East Nusa Tenggara province, in January–June 2022 with 77 TB patients as samples, whose TB patients' rooms would be observed based on research variables for physical environmental conditions. Data were collected directly by observing and measuring directly from the variables studied and then analyzed using a correlation test and linear regression test to see the relationship between variables and the effect of the physical environmental condition on germ number in the bedroom. The correlation test shows the variables related to the bedroom germ number (p&lt;0.25) were the number of people sleeping the TB patients, lighting, humidity, ventilation size, percentage of ventilation compared to room size, and room density. The model equation explains that 28.8% of the germ number variation in bedroom TB patients depends on the constant reduction (789,884) added to 19,217 times the bedroom humidity, then reduced by 9,518 times the percentage of room ventilation and also reduced by 31,185 times the density of the room occupancy. The most significant influence on the germ number in TB patients' bedrooms is the room humidity, which is 0.319.

Prevalence of chronic non-communicable diseases in Ethiopia: A systematic review and meta-analysis of evidence.

BackgroundNon-communicable diseases (NCDs) are a growing global health challenge disproportionately impacting low- and middle-income settings, including Ethiopia. Currently, the body of evidence describing the burden of NCDs is fragmented, inconsistent, health facility- or institution-based, and out-dated in Ethiopia. We conducted a systematic review of the literature and meta-analysis of the prevalence of NCDs in community settings in Ethiopia.Review methodologyCommunity-based quantitative studies published in English between January 1st, 2012, and June 30th, 2022, that reported on the prevalence of NCDs in Ethiopia were included. A systematic search of Medline, Embase, Scopus, CINAHL, and Global Health using pretested search terms related to NCDs was conducted, and data were extracted using a piloted data extraction proforma adapted from the Joanna Briggs Institute tool. Meta-analysis was performed using Stata 16. While the pooled prevalence of Diabetes Mellitus (DM) and undiagnosed (DM) was computed and presented using forest plots, then overall prevalence of NCDs and other various types of NCDs were narratively synthesized. I2 was used to assess heterogeneity. Studies that did not fulfill the criteria (used similar tool to measure the types of NCDs) for meta-analysis were narratively synthesized.ResultsTwenty-two studies met the inclusion criteria. Five studies measured the prevalence of NCDs (all NCDs together), ranging from 29 to 35% (prevalence estimates not pooled). The pooled prevalence of Diabetes Mellitus (DM) across ten studies was 5% (95% CI: 4–7%). Three studies each reported on the prevalence of undiagnosed DM (pooled prevalence 5%, 95% CI: 4–7%) and pre-DM (pooled prevalence 7%, 95% CI: 3–14%%). In a narrative analysis the prevalence of cardiovascular conditions ranged from 13.4 to 32.2% (n = 3 studies), cancer mortality ranged from 4 to 18% (n = 3 studies) and respiratory conditions ranged from 1 to 18% (n = 3 studies). Some studies have determined more than one NCDs and that is why the total number of studies are exceeding more than twenty studies.Conclusion and recommendationsOur analysis found that approximately one-third of Ethiopians have an NCD, with cardiovascular diseases the most common of all NCDs. The prevalence of respiratory conditions also appears high, but there are insufficient data for a pooled estimate. Whilst the prevalence of DM appears relatively low, there is evidence that the magnitude is increasing. Public health actions to address the high burden of cardiovascular and respiratory diseases, as well as the increasing magnitude of DM in Ethiopia, must be prioritized.Systematic review registrationPROSPERO [CRD42020196815].

Evaluating Post-Injury Functional Status among Patients Presenting for Emergency Care in Kigali, Rwanda

Despite high injury-related morbidity, approaches for evaluating post-injury functional status after emergency care are poorly characterized in resource-limited settings. This study evaluated the feasibility of standardized disability assessments among patients presenting with significant trauma to the Centre Hospitalier Universitaire de Kigali ED in Rwanda from January–June 2020. The functional status at 28-days post-injury was assessed using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS-2), the Katz Activities of Daily Living (ADL) Scale, and self-reported functional state. The primary outcome was a descriptive profile of the disability status at 28-days post-injury. The WHODAS 2.0, Katz ADL Scale and patients’ self-perceived functional status was compared using Kendall’s rank correlation coefficient. Twenty-four patients were included. The most common injury mechanism was road traffic accident (70.8%); 58.3% of patients had traumatic brain injury. The self-perception questionnaire and the Katz ADL scale were strongly correlated with the WHODAS 2.0 scale; however, self-perception was not well correlated with the ADL scale. Post-injury morbidity was high and morbidity assessment was feasible, with a strong correlation between patients’ self-perceived functional status and the WHODAS-2 scale. Structured post-injury assessments may serve to inform the development of rehabilitation services in Rwanda, although larger studies are needed to inform such initiatives.

Engagement in Protective Behaviors by Digital Exposure Notification Users During the COVID-19 Pandemic, Washington State, January-June 2021.

Smartphone-based digital exposure notification (EN) tools were introduced during the COVID-19 pandemic to supplement strained case investigation and contact tracing efforts. We examined the influence of an EN tool implemented in Washington State, WA Notify, on user engagement in behaviors that protect against COVID-19 transmission. From January 25 through June 30, 2021, we administered 2 surveys to WA Notify users who received notification of a possible COVID-19 exposure. The initial survey, sent when users received a notification, focused on intent to engage in protective behaviors. The follow-up survey captured data on self-reported actual engagement in protective behaviors and contact by a public health contact tracer. Of 1507 WA Notify users who completed the initial survey, 40.1% (n = 604) reported intending to seek COVID-19 testing and 67.1% (n = 1011) intended to watch for COVID-19 symptoms. Of 407 respondents to the follow-up survey, 57.5% (n = 234) reported getting tested and 84.3% (n = 343) reported watching for COVID-19 symptoms. Approximately 84% (n = 1266) of respondents to the initial survey received a notification from WA Notify before being reached by public health contact tracers; on follow-up, 42.5% (n = 173) of respondents reported never being contacted by public health. Our findings suggest that WA Notify users may initiate protective behaviors earlier than nonusers who will not know of an exposure until notified by public health or by a known contact. Digital EN tools may be a valuable addition to existing public health outbreak investigation and response activities.

Perspectives of Healthcare Professionals Towards Combination Use of Oral Paracetamol and Topical Non-Steroidal Inflammatory Drugs in Managing Mild-to-Moderate Pain for Osteoarthritis in a Clinical Setting: An Exploratory Study.

PurposeTo seek indicative evidence on clinical prescription practice and perspectives regarding combined oral paracetamol (APAP) and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) therapy for managing mild-to-moderate osteoarthritis (OA) pain.Participants and MethodsAn exploratory qualitative study to investigate the perspectives towards using APAP and/or topical NSAIDs for OA pain management and whether current clinical practices are aligned with OA guidelines was conducted using a two-round modified Delphi methodology among three general practitioners, three orthopedists, and two pharmacists from Australia, Malaysia, and Sweden during January–June 2021. In the first round, 60-minute virtual in-depth interviews were conducted individually; in the second round, summary of the key findings was shared with the panel to seek clarity on the level of consensus (≥70% unanimity) and disagreement.ResultsThe healthcare professionals (HCPs) agreed that APAP was considered as a universally accepted pharmacologic for most OA patients except those with contraindications or allergies. Consensus was achieved towards APAP combination with topical NSAIDs being a safer alternative than with oral NSAIDs. However, prescription uptake of combined therapy APAP with topical NSAIDs was low among the panel due to lack of strong scientific evidence on efficacy and awareness. Differences in clinical practice across and within countries could be due to different reference sources for OA pain – clinical practice experience or local/international guidelines/medical products handbooks.ConclusionThe study suggests an opportunity to raise awareness of the suitability and potential benefits for adjuvant topical NSAIDs to APAP for effective OA pain management as well as a need for universal OA guidelines.

Design of Buck DC-DC Converter Space Application

Abstract: The buck converter is a power electronic device which converts the higher level of input voltage to lower level of output voltage. For space applications, several tests were performed on direct current (DC) to (DC) converters to evaluate potential performance and reliability issues in space use of DC to DC converters and to determine if the use of electromagnetic interference (EMI) filters mitigates concerns observed during tests. Test findings reported here include those done up until January–June 2022. Tests performed include efficiency, regulation, load regulation, power consumption with inhibit on, load transient response, synchronization, and turn-on tests. Some of the test results presented here span the thermal range -20°C to 55°C. Lower range was extended to -40°C in some tested converters.

Evaluation of phytochemical profiles and relationships of compounds in Lippia citriodora during multiple growth-exploitation phases

In the present study the variations of biomass, essential oil content and composition of lemon verbena (Lippia citriodora) during different growth-exploitation phases from 27th May 2020 to 8th June 2021 were investigated. The uniform rooted cuttings were planted in the greenhouse under natural light. The aerial parts of lemon verbena at flowering stage were harvested at six times included 27th May (H1), 29th August (H2), 4th November (H3), 17th January (H4), 27th March (H5), and 8th June (H6). Hydro distillated essential oils were analyzed by using GC-FID and GC/MS techniques to determine the essential oil profile. Results showed a considerable variation in plant biomass, essential oil quantity and quality at different harvesting times. Plant biomass increased by 66.83% up to fourth harvesting time (H4) then decreased. During the studied harvesting frequencies the essential oil content of L. citriodora showed a sinusoidal trend. The highest essential oil content (0.858% v/w) and yield (17.95 L ha−1) were obtained at third harvesting time (H3) and in the followed harvesting times their contents were decreased. The observed changes in the essential oil composition of L. citriodora during different harvesting times were due to the relative proportions of constituents and the presence of new constituents. In the all essential oil samples, oxygenated monoterpenes represented by geranial (25.42–30.11%) and neral (19.81–24.19%) were the predominant compounds. The highest ratio of monoterpenes to sesquiterpenes compounds (≈5:1) was recorded in collected plants at third harvesting time.

“For the Defense of the Liberties and Independence of the United States”: Remembering a Forgotten Militia Post and Quasi-War Cantonment in Plainfield, New Jersey (Part 1 of 2)

The area around Green Brook Park in Plainfield, New Jersey, was the site of two significant military encampments during the American Revolution and the new nation’s first international conflict, the Quasi-War. This is part one of a two-part article arguing the significance of the site in both conflicts through an analysis of surviving primary source material. Part one concerns the Vermeule militia post during the American Revolution. In late December 1776, a militia post was established on the property of Cornelius Vermeule, a well-known Patriot and significant landholder. This militia post is examined in the context of the forage war, the petite-guerre that raged in the New Jersey countryside between January and late June 1777. Various aspects of the post are interpreted, including its role in defending the countryside from Crown depredation, what life may have been like at the post, and what impact the militia and the post at Vermeules had on the course of the forage war and raising American military skill and morale. Part two, which is forthcoming, concerns the reuse of the site as a winter cantonment by Alexander Hamilton, Aaron Ogden, William S. Smith, and three regiments of the “New Army” during the winter of 1799–1800.

Homelessness at the San Diego Central Library: Assessing the Potential Role of Social Workers.

Nationwide, public libraries are experiencing an increase in “on-premise” opioid overdoses and other issues (e.g., suicide attempts) affecting unstably housed library users. The public library presents a unique opportunity to access an otherwise hidden population. In partnership with the San Diego Central Library, researchers led focus groups, in-depth interviews, and surveys with 63 library patrons experiencing homelessness or housing instability (n = 49) and library staff (n = 14) (January–June 2019). Using a consensus organizing framework and mixed methods approach, the researchers conducted in-depth interviews exploring the library’s strengths and opportunities for patrons experiencing homelessness, the barriers to meeting their aspirations, and whether having a social worker at the library or other policy changes in government or the library could help. Specifically, participants answered inquiries about the opportunities for the library to address substance use and human trafficking. In brief surveys, library patrons and staff provided views on the patrons’ educational needs, library staff’s training needs, and changes needed in government or library policies. Results revealed the desire of the library patrons (69%) and staff (93%) to have a library social worker who could link patrons to housing services, substance use harm reduction or treatment, and address food-insecure youth/families and human trafficking/sexual exploitation. Participants also valued peer advocates with lived homelessness experiences. Over 70% of the unstably housed patrons said they would like library patrons to participate in peer leadership training. Other significant themes were the need for crisis prevention and intervention, connecting patrons to resources and each other, and creating consistent assistance. Libraries urgently need more on-premise support to address patrons’ pressing housing, health, and mental health needs.

The Impact of the COVID-19 Pandemic on Tobacco Treatment Program Implementation at National Cancer Institute-Designated Cancer Centers.

IntroductionThe COVID-19 pandemic disrupted cancer screening and treatment delivery, but COVID-19’s impact on tobacco cessation treatment for cancer patients who smoke has not been widely explored.Aims and MethodsWe conducted a sequential cross-sectional analysis of data collected from 34 National Cancer Institute (NCI)-designated cancer centers participating in NCI’s Cancer Center Cessation Initiative (C3I), across three reporting periods: one prior to COVID-19 (January–June 2019) and two during the pandemic (January–June 2020, January–June 2021). Using McNemar’s Test of Homogeneity, we assessed changes in services offered and implementation activities over time.ResultsThe proportion of centers offering remote treatment services increased each year for Quitline referrals (56%, 68%, and 91%; p = .000), telephone counseling (59%, 79%, and 94%; p = .002), and referrals to Smokefree TXT (27%, 47%, and 56%; p = .006). Centers offering video-based counseling increased from 2020 to 2021 (18% to 59%; p = .006), Fewer than 10% of centers reported laying off tobacco treatment staff. Compared to early 2020, in 2021 C3I centers reported improvements in their ability to maintain staff and clinician morale, refer to external treatment services, train providers to deliver tobacco treatment, and modify clinical workflows.ConclusionsThe COVID-19 pandemic necessitated a rapid transition to new telehealth program delivery of tobacco treatment for patients with cancer. C3I cancer centers adjusted rapidly to challenges presented by the pandemic, with improvements reported in staff morale and ability to train providers, refer patients to tobacco treatment, and modify clinical workflows. These factors enabled C3I centers to sustain evidence-based tobacco treatment implementation during and beyond the COVID-19 pandemic.ImplicationsThis work describes how NCI-designated cancer centers participating in the Cancer Center Cessation Initiative (C3I) adapted to challenges to sustain evidence-based tobacco use treatment programs during the COVID-19 pandemic. This work offers a model for resilience and rapid transition to remote tobacco treatment services delivery and proposes a policy and research agenda for telehealth services as an approach to sustaining evidence-based tobacco treatment programs.

Seasonal carryover of water and effects on carbon dynamics in a dryland ecosystem

AbstractNet primary productivity in arid and semiarid regions is controlled by water availability for which rainfall has been a commonly used proxy at annual scales. However, the hydrological partitioning occurring through the water balance can also shape both seasonal and annual net ecosystem productivity. In this study, we used 10 years of water and carbon flux measurements in a mixed shrubland watershed of the Chihuahuan Desert to investigate the seasonal variability and controls on net ecosystem production. Over this period, the site exhibited a bimodal rainfall regime with an average of 211 and 67 mm for the wet (July–December) and dry (January–June) periods of the year, respectively. During the wet season, soil infiltration and channel transmission losses led to an average of 35.8 mm of water stored in the subsurface for subsequent dry periods. By contrast, dry seasons consumed 30.3 mm of stored subsurface water to fulfill the ecosystem water demand, particularly during the springtime. In response, gross primary productivity occurred in equal amounts for both seasons, while ecosystem respiration was substantially higher during the wet season. This resulted in the mixed shrubland acting as an annual net sink of carbon (average of 153.2 g C m−2 year−1) of which 65% occurred during the dry season. We determined that the wet season provided water in excess of vegetation demands in that season, a portion of which was stored in the watershed subsurface for subsequent use, leading to a legacy effect. Gross primary productivity during the dry season was dependent on carryover soil moisture accessed by deep‐rooted shrubs. Our coordinated observations of water–carbon dynamics revealed that water availability during the wet season can sustain the annual ecosystem productivity by impacting the subsequent dry season carbon uptake.

Isoniazid preventive therapy among child contacts of TB patients, India.

BACKGROUND: Isoniazid preventive therapy (IPT) for child contacts of TB patients, a globally accepted intervention, needs to be evaluated in diverse geographical regions.OBJECTIVES: To assess the extent of IPT coverage and adherence, to ascertain its sociodemographic and programmatic correlates and to explore existing constraints from service providers and beneficiaries´ perspectives.METHODS: A mixed-method study was conducted in January-June 2021 in Paschim Bardhaman District, West Bengal, India. Quantitative assessment was done among 280 child contacts of TB cases registered between January and December 2020 in all TB units in the district. Primary caregivers were interviewed using a pre-designed questionnaire. Two focus group discussions with all senior treatment supervisors of the district and in-depth interviews with 12 purposively selected caregivers of the children were undertaken. Qualitative data were analysed thematically.RESULTS: Only 48.9% (137/280) of child contacts were screened; 58.9% (165/280) were initiated on IPT and 40% (66/165) adhered to a full course. Coverage of the full 6-month IPT among total study participants was 23.6% (66/280). Household visits by health personnel and initial screening significantly predicted increased coverage. Programmatic inadequacies, poor understanding, social stigma and COVID situation were major constraints.CONCLUSION: Coverage of IPT remains unacceptably low and requires health system strengthening for effectively implementing current recommendations of TB preventive treatment.

Using PCM for building energy management to postpone the electricity demand peak load and approving a new PID controller to activate alternative chiller

In this study, PCM was used to delay the maximum heat transfer and postpone it to a low load time in a building. Hence, a new proportional–integral–derivative (PID) controller system was introduced that could adjust the temperature using six setpoints. To evaluate PCM performance accurately, a 5 cm layer of PCM was added to the wall and instead, the thickness of Thermalite Turbo (which had the highest heat resistance) was reduced by 5 cm to keep the final wall thickness constant. The energy equation for indoor space was approved and by considering the PCM phase change along with radiation effects, the temperature distribution within the wall was obtained. The PCM inside the wall during January–June lessened electricity demand but raised it slightly in the remaining months. However, in the annual analysis, PCM managed to reduce electricity demand by 15.3%. To compensate for poor PCM performance during summer, a PID control system disconnects the main chiller and adds an alternative chiller to the circuit. Using new PID system led to an electricity demand reduction of 2.2%. According to the schedule, electricity consumption decreased by 2.3%.

Obat Off-label pada Pasien Pediatri Rawat Jalan: Penelitian Observasi Retrospektif di RSUD Dr. H. Abdul Moeloek Lampung

Several medications are prescribed for infants and children, but adequate information about these drugs are unavailable. Previous studies also revealed that the use of off-label drug is prevalent among pediatric outpatients. Therefore, this study aimed to determine the prevalence of off-label drug use in pediatric outpatients at Dr. H. Abdul Moeloek Lampung Hospital from January–June 2019. This observational descriptive was conducted using simple random and retrospective sampling methods. Drugs were identified using a brochure, British National Formulary for Children (BNF), and Specialist Health Science Formulary from the Indonesian Pediatrician Association (IDAI), followed by classification with the Anatomical Therapeutical Chemical (ATC). The results showed that there were 120 samples, of which 56% are males, while 42% are within the age range of 6–12 years. The most common diagnoses were SNRS, followed by epilepsy and anemia. A total of 393 drugs were used in this study and analgesic-antipyretic was the most prescribed. The prevalence of off-label drug usage in pediatric patients was 19.6%, where the off-label age was higher (16.29%) than indication (2,81%) and doses (0,5). Furthermore, most of these medications were for the cardiovascular, respiratory, digestive, and metabolic systems. There has been a 19,6% prevalence in the use of off-label drug among pediatric outpatients, where off-label age was the highest, and most of the medication are used for the treatment of the cardiovascular system.

Machine Learning Forecasts to Reduce Risk of Entrainment Loss of Endangered Salmonids at Large-Scale Water Diversions in the Sacramento–San Joaquin Delta, California

Incidental entrainment of fishes at large-scale state and federal water diversion facilities in the Sacramento-San Joaquin Delta, California, can trigger protective management actions when limits imposed by environmental regulations are approached or exceeded. These actions can result in substantial economic costs, and likewise they can affect the status of vulnerable species. Here, we examine data relevant to water management actions during January–June; the period when juvenile salmonids are present in the Delta. We use a quantile regression forest approach to create a risk forecasting tool, which can inform adjustments of diversions based on near real-time predictions. Models were trained using historical entrainment data (Water Years 1999–2019) for Sacramento River winter-run Chinook Salmon or Central Valley Steelhead and a suite of environmental and water operations metrics. A range of models was developed; their performance was evaluated by comparison of a quantile loss metric. The models were validated through examination of partial dependence plots, cross-validation procedures, and further evaluated through WY 2019 pilot testing, which integrated real-world uncertainty in environmental parameters into model predictions. For both species, the strongest predictor of loss was the previous week’s entrainment loss. In addition, risk increased with higher water exports and more negative Old and Middle Rivers (OMR) flows. Point estimates of loss were modestly correlated with observations (R2 0.4 to 0.6), but the use of a quantile regression approach provided reliable prediction intervals. For both species, the predicted 75th quantile appears to be a robust and conservative estimator of entrainment risk, with overprediction occurring in fewer than 20% of cases. This quantile balances the magnitude of over- and under-prediction and results in a low probability (&lt; 5% of predictions) of unexpected high-take events. These models, and the web-based application through which they are made accessible to non-technical users, can provide a useful and complementary approach to the current system of managing entrainment risk.

Expert clinical pharmacological advice may make an antimicrobial TDM program for emerging candidates more clinically useful in tailoring therapy of critically ill patients

BackgroundTherapeutic drug monitoring (TDM) may represent an invaluable tool for optimizing antimicrobial therapy in septic patients, but extensive use is burdened by barriers. The aim of this study was to assess the impact of a newly established expert clinical pharmacological advice (ECPA) program in improving the clinical usefulness of an already existing TDM program for emerging candidates in tailoring antimicrobial therapy among critically ill patients.MethodsThis retrospective observational study included an organizational phase (OP) and an assessment phase (AP). During the OP (January–June 2021), specific actions were organized by MD clinical pharmacologists together with bioanalytical experts, clinical engineers, and ICU clinicians. During the AP (July–December 2021), the impact of these actions in optimizing antimicrobial treatment of the critically ill patients was assessed. Four indicators of performance of the TDM-guided real-time ECPA program were identified [total TDM-guided ECPAs July–December 2021/total TDM results July–December 2020; total ECPA dosing adjustments/total delivered ECPAs both at first assessment and overall; and turnaround time (TAT) of ECPAs, defined as optimal (< 12 h), quasi-optimal (12–24 h), acceptable (24–48 h), suboptimal (> 48 h)].ResultsThe OP allowed to implement new organizational procedures, to create a dedicated pathway in the intranet system, to offer educational webinars on clinical pharmacology of antimicrobials, and to establish a multidisciplinary team at the morning bedside ICU meeting. In the AP, a total of 640 ECPAs were provided for optimizing 261 courses of antimicrobial therapy in 166 critically ill patients. ECPAs concerned mainly piperacillin–tazobactam (41.8%) and meropenem (24.9%), and also other antimicrobials had ≥ 10 ECPAs (ceftazidime, ciprofloxacin, fluconazole, ganciclovir, levofloxacin, and linezolid). Overall, the pre–post-increase in TDM activity was of 13.3-fold. TDM-guided dosing adjustments were recommended at first assessment in 61.7% of ECPAs (10.7% increases and 51.0% decreases), and overall in 45.0% of ECPAs (10.0% increases and 35.0% decreases). The overall median TAT was optimal (7.7 h) and that of each single agent was always optimal or quasi-optimal.ConclusionsMultidisciplinary approach and timely expert interpretation of TDM results by MD Clinical Pharmacologists could represent cornerstones in improving the cost-effectiveness of an antimicrobial TDM program for emerging TDM candidates.

The concentration and type of monoclonal protein and their impact on clinical severity in patients with symptomatic myeloma

Background and objectives: Multiple Myeloma is a clonal plasma cell proliferation in the bone marrow that produces abnormal monoclonal proteins in serum and /or urine that leads to end-organ damage. We aimed to evaluate concentration, type of monoclonal protein, and their impact on the severity of symptomatic multiple myeloma patients. Methods: The study was conducted on 124 patients with symptomatic myeloma who were registered in the three centers in Kurdistan-Iraq from January–June 2019. Out of the 74 were males, and 50 were females. Demographic details, laboratory investigations, imaging study were reviewed, and informed consent was obtained for all patients; smoldering myeloma was excluded. Results: The most prevalent subtypes were IgG followed by IgA (61.3%, 18.5% respectively), whereas free light chain and non-secretory myeloma forming the rest, 12.1% and 6.45% for each subtype. There is a statistically positive association found between the concentration of monoclonal protein and the level of hemoglobin, ß2-microglobulin, and lactic acid dehydrogenase. There is no association for the concentration of monoclonal protein with each of calcium, albumin, creatinine, and erythrocyte sedimentation rate. Conclusions: We found a higher percentage of IgG/Kappa, high rates of non-secretory myeloma, low rates of light chain myeloma and younger age at presentation in comparison to western reports. The association between monoclonal protein concentration and some parameter of prognostic value in patients studied underscores its relevance to severity of disease in our locality.

Independent risk factors of mortality in patients with sepsis receiving single-dose etomidate as an induction agent during rapid sequence intubation in a large tertiary emergency department in Thailand

BackgroundThere is limited evidence regarding factors associated with mortality in septic patients receiving etomidate. This study aimed to determine independent pre-intubation factors predicting 28-day mortality in septic patients receiving single-dose etomidate as an induction agent during rapid sequence intubation (RSI).MethodsThis single-center retrospective cohort study included intubated septic patients receiving etomidate as an induction agent during RSI in the emergency department of Siriraj hospital, Bangkok, Thailand, between January 1st, 2016 and June 30th, 2020. Pre-intubation characteristics were compared between survivors and non-survivors. Independent risk factors associated with 28-day mortality were identified using the Cox proportional hazards regression model. Association between etomidate dosage and mortality was also determined.ResultsA total of 344 patients, 238 (69%) survivors and 106 (31%) non-survivors, were included in the analyses. The initial Cox hazards model identified a pre-intubation lactate level ≥ 4 mmol/L as an independent factor associated with mortality (adjusted Hazards ratio [aHR] 2.66, 95% confidence interval [CI] 1.55–4.56). After removing lactate level from the model due to limited lactate values in the data, cancer was also predictive of 28-day mortality (aHR 1.83, 95%CI 1.10–3.04), while patients with respiratory infections and underlying chronic lung disease were associated with lower mortality (aHR 0.54, 95%CI 0.37–0.80 and aHR 0.57, 0.33–0.96, respectively). Etomidate dosage was not associated with mortality in our study.ConclusionIn septic patients who received a single dose of etomidate, a pre-intubation lactate level ≥ 4 mmol/L and cancer were associated with increased 28-day mortality, while respiratory infection and underlying chronic lung disease were associated with lower mortality. Physicians may take these factors into consideration when selecting induction agents for septic patients.