Rapid Initiation Research Articles

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus

ObjectiveThere are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international...

Renal potassium regulation in a pig model of therapeutic hypothermia

Therapeutic hypothermia is increasingly utilized clinically to reduce tissue metabolism and protect against neurological damage in cases of cardiac arrest, traumatic brain injury or perinatal hypoxic ischemia. With even mild exposure to hypothermia, hypokalemia develops purportedly due to transcellular potassium shifts resulting in decreased circulating potassium levels. Renal dysfunction with body temperature cooling has also been postulated to potentially contribute to development of sustained hypokalemia. In this study, we used a pig model of controlled acute hypothermia without confounding hypotension and hypoxemia, to test the hypothesis that renal handling of potassium remains intact in hypothermia and is not the cause of decreased circulating plasma potassium seen with body cooling. Anesthetized, mechanically ventilated Duroc cross young pigs (n=25, body weight = 10.0 ± 0.4 kg, male or female) were catheterized for hemodynamic monitoring, regional blood flow assessment via colored microspheres, and urine collection. After baseline values were obtained, pigs were divided into a control normothermia group (n=12) with body temperature maintained at 38.4 ± 0.1 oC or a hypothermia group (n=13) with core body temperature cooled to 34.5 ± 0.1 oC and hypothermia sustained for 2 hours. Hypothermia reduced tissue metabolism as indicated by a decrease in oxygen consumption (VO2= 5.2 ± 0.2 ml/kg in normothermia vs 3.7 ± 0.3 ml/kg in hypothermia. Mean arterial pressure (68± 3 mm Hg) and cardiac output (199 ± 21 ml/min/kg) were not different between groups. Even with the short duration of cold exposure, plasma potassium was lower (p<0.05) within 2 hours of hypothermia (4.1 ± 0.1 mEq/L) vs control (4.8 ± 0.1 mEq/L). Cold exposure caused redistribution of blood flow to the small intestines from other internal organs. Renal blood flow tended to decrease with cold, but glomerular filtration rate was suffcient to maintain urine flow, sodium excretion and free water clearance. Potassium clearance, however, was lower (p<0.05) in hypothermia (0.70 ± 0.07 ml/min/kg) than in normothermia (1.04 ± 0.07 ml/min/kg), with lower potassium excretion (hypothermia = 2997 ± 331 mEq/min vs control = 4784 ± 393 mEq/min, p<0.05) and fractional excretion of potassium. Reduced renal potassium excretion is consistent with renal compensation for lower circulating potassium induced by hypothermia. Interestingly, with relatively higher blood flow to the small intestines compared to decreased blood flow of other internal organs, potassium secretion in the early colon may contribute to further potassium wasting in hypothermia. The rapid initiation of decreased potassium circulating levels with hypothermia supports the thesis of temperature sensitive cell membrane potassium channels affecting extracellular to intracellular shifts of potassium. Results of this study indicate that renal potassium regulation is maintained in hypothermia and functions to decrease urinary potassium loss in the face of hypokalemia. The views expressed are those of the authors and do not necessarily reflect the offcial policy or position of the Defense Health Agency, Department of the Army, Department of Defense, or the U.S. Government. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Pharmacist-Driven Rapid Initiation of Antiretroviral Therapy Decreases Time to Viral Suppression in People With HIV.

Rapid initiation of antiretroviral therapy (rapid ART) improves clinical outcomes in people with HIV and is endorsed by clinical guidelines. However, logistical challenges limit widespread implementation. We describe an innovative rapid ART model led by pharmacists and its impact on clinical outcomes, including time to viral suppression (TVS). On 1 January 2019, we implemented Pharmacist-Driven Rapid ART (PHARM-D RAPID ART), including rapid ART initiation by pharmacists. Our retrospective cohort study compared TVS, using a Cox proportional hazards model, and clinical outcomes among individuals with a new HIV diagnosis before (1 January 2017 to 31 December 2017) and after (1 January 2019 to 31 December 2019) implementation. A total of 108 individuals were included. TVS was significantly shorter (P < .001) for the PHARM-D RAPID ART group (n = 51) compared with the preimplementation group (n = 57) (median: 30 days and 66 days, respectively). Those in the PHARM-D RAPID ART group were significantly more likely to achieve VS at any given time during the study period (adjusted hazard ratio: 3.47 [95% confidence interval, 2.25-5.33]). A total of 94.1% (48/51) of patients in the PHARM-D RAPID ART group were retained in care at 1 year. With a median follow-up of 2.4 years in the PHARM-D RAPID ART group, 98% remained suppressed at last recorded viral load. A pharmacist-driven model for rapid ART delivery decreases TVS with high rates of retention in care and durable VS. This model could improve clinical outcomes and increase program feasibility and sustainability.

Higher cardiovascular disease risks in people living with HIV: A systematic review and meta-analysis.

The prognosis of AIDS after active antiretroviral therapy (ART) and the quality of life of people living with HIV (PLWH) are both affected by non-AIDS-related diseases such as cardiovascular disease (CVD). However, the specific risk ratios between PLWH and individuals negative for HIV are poorly understood. We aimed to systematically review and investigate the CVD risk factors associated with HIV. We searched PubMed, Embase, Web of Science, and Cochrane Library databases between 1 January 2015, and 12 May 2023 for articles reported the prevalence and risk factors of CVD such as hypertension, dyslipidaemia, coronary artery disease (CAD), and myocardial infarction (MI). Due to the high heterogeneity, we used a random-effects model to analyse the data. All statistical analyses were performed using Stata/MP 17.0 with 95% confidence intervals (CIs). We analysed 31 eligible studies including 312 913 PLWH. People living with HIV had higher risks of dyslipidaemia (hazard ratio (HR) = 1.53; 95% CI = 1.29, 1.82), CAD (HR = 1.37; 95% CI = 1.24, 1.51), and MI (HR = 1.47; 95% CI = 1.28, 1.68) compared to individuals without HIV. However, there were no significant differences in the prevalence of hypertension between groups (HR = 1.17; 95% CI = 0.97, 1.41). Subgroup analysis revealed that men with HIV, PLWH who smoked and the elderly PLWH had a high prevalence of CVD. Moreover, the disease prevalence patterns varied among regions. In the USA and Europe, for instance, some HRs for CVD were higher than in other regions. Active ART initiation after 2015 appears to have a lower risk of CVD (hypertension, hyperlipidaemia, CAD). All outcomes under analysis showed significant heterogeneity (I2>70%, P < 0.001), which the available study-level variables could only partially account for. People living with HIV had a higher CVD risk than the general population; thus, CVD prevention in PLWH requires further attention. Rapid initiation of ART may reduce the incidence of CVD in PLWH. For timely screening of CVD high-risk individuals and thorough disease management to prevent CVD, further studies are required to evaluate the risk factors for CVD among PLWH, such as age, region, etc. PROSPERO (CRD42021255508).

Experimental study on the cold-seep methane hydrate formation kinetics

Cold-seep methane hydrates are widespread in the natural environment. A comprehensive understanding of the cold-seep methane hydrate formation kinetics is crucial for the knowledge of formation mechanisms and the development and utilization of natural gas hydrate. This study monitored the kinetics of methane hydrate formation in cold-seep fluids using continuous time-series Raman spectroscopy. A novel spectroscopic method was proposed to accurately determine the nucleation time of gas hydrates with a ten-second accuracy. Experimental results showed a smooth transition from dissolved methane to hydrated methane. Rapid hydrate nucleation and growth initiation were observed at the gas–liquid interface, forming hydrate films wrapping gas bubbles and suspending hydrate microcrystals in cold-seep fluids. Furthermore, a model for cold-seep methane hydrate formation kinetics was proposed, which indicated three distinct stages including an induction period, a metastable nucleation period, and a stable growth period.

Rapid start-up and operational characteristics of partial denitrification coupled with anammox driven by innovative strategies

The Partial Denitrification-Anammox (PD/A) process established a low-consumption, efficient and sustainable pathway for complete nitrogen removal, which is of great interest to the industry. Rapid initiation and stable operation of the PD/A systems were the main issues limiting its engineering application in wastewater nitrogen removal. A PD/A system was initiated in a continuous stirred-tank reactors (CSTRs) in the presence of low concentration of organic matter, and the effects of organic matter types and COD/NO3−-N ratios on the performance of the PD/A system, and microbial community characteristics were explored. The results showed that low concentrations of organic matter could promote the rapid initiation of the Anammox process and then the strategy of gradually replacing NO2−-N with NO3−-N could successfully initiate the PD/A system at 70 days. The type of organic matter had a significant effect on the initiation of the Anammox and the establishment of the PD/A system. Compared to glucose, sodium acetate was more favorable for rapid start-up and the synergy among microorganisms, and organic matter was lower, with an optimal COD/NO3−-N ratio of 3.0. Microorganisms differed in their sensitivity to environmental factors. The relative abundance of Planctomycetota and Proteobacteria in R2 was 51 %, with the presence of three typical anammox bacteria, Candidatus_Brocadia, Candidatus_Kuenenia, and Candidatus_Jettenia in the system. This study provides a new strategy for the rapid initiation and stable operation of the PD/A process.

Protein disulfide isomerase cleaves allosteric disulfides in histidine-rich glycoprotein to regulate thrombosis

The essence of difference between hemostasis and thrombosis is that the clotting reaction is a highly fine-tuned process. Vascular protein disulfide isomerase (PDI) represents a critical mechanism regulating the functions of hemostatic proteins. Herein we show that histidine-rich glycoprotein (HRG) is a substrate of PDI. Reduction of HRG by PDI enhances the procoagulant and anticoagulant activities of HRG by neutralization of endothelial heparan sulfate (HS) and inhibition of factor XII (FXIIa) activity, respectively. Murine HRG deficiency (Hrg−/−) leads to delayed onset but enhanced formation of thrombus compared to WT. However, in the combined FXII deficiency (F12−/−) and HRG deficiency (by siRNA or Hrg−/−), there is further thrombosis reduction compared to F12−/− alone, confirming HRG’s procoagulant activity independent of FXIIa. Mutation of target disulfides of PDI leads to a gain-of-function mutant of HRG that promotes its activities during coagulation. Thus, PDI-HRG pathway fine-tunes thrombosis by promoting its rapid initiation via neutralization of HS and preventing excessive propagation via inhibition of FXIIa.

Initiation process of non-premixed continuous rotating detonation wave through Schlieren visualization

High-speed schlieren visualization on the initiation process of non-premixed air and hydrogen continuous rotating detonation (CRD) is carried out in a well-designed rounded-rectangle hollow combustor in this study. The CRD initiation processes of pre-detonator ignition and spark plug ignition are comprehensively revealed by synchronous high-speed schlieren images and high-frequency dynamic pressure results. The results show that the CRD undergoes three processes after ignition, including initiation process, adjustment process and stable propagation process. The CRD initiation process of pre-detonator ignition involves the upstream-propagation phase of leading shock wave and reaction zone and the coupling phase of circumferentially-propagating shock wave and reaction zone, while that of spark plug ignition includes the upstream-propagation phase of reaction zone, and the coupling phase of circumferentially-propagating pressure wave and reaction zone. The formation of deflagration combustion flowfield and re-establishment of combustible mixture layer after ignition are important prerequisites for CRD initiation. The strong interaction between circumferentially-propagating shock wave and post-shock wave reaction conduces to the rapid initiation of CRD by pre-detonator ignition, while the pressure wave gradually interacts with reaction leading to the detonation initiation by spark plug ignition. The CRD initiation time and adjustment time of pre-detonator ignition are shorter than those of spark plug ignition. This study provides detailed insight into the physics of CRD initiation process of pre-detonator and spark plug ignition, which can deepen the understanding of the initiation mechanism and provide practical guidance for the optimal design of CRDE ignitor.

Signs and symptoms in the diagnosis of type 1 diabetes mellitus and interventions for the management of diabetic ketoacidosis: scoping review

Objective: To identify the most prevalent signs and symptoms in the diagnosis of Type 1 Diabetes Mellitus (DM1) in children and adolescents, as well as the signs and symptoms of Diabetic Ketoacidosis (DKA), its complications, and the nursing and medical interventions indicated for its management. Method: This is a scoping review, carried out in the LILACS, PUBMED, SCOPUS, LIVIVO, and Embase databases, with additional search in gray literature. The data were analyzed qualitatively. Results: We found 840 studies in the search, but only 10 studies met the eligibility criteria. The most frequent signs and symptoms in the diagnosis of DM1 were polydipsia (83%), polyuria (78%), and weight loss (56%). DKA symptoms were variable. The main complications of DKA were cerebral edema and death and transfer to the pediatric intensive care unit and continuous infusion of intravenous insulin were the most recommended interventions. Conclusion: Early recognition of the signs and symptoms of DM1 plays an important role in patient management, leading to rapid initiation of treatment and relevant interventions, thus preventing the occurrence of complications.

Bictegravir/emtricitabine/tenofovir alafenamide as first-line treatment in naïve HIV patients in a rapid-initiation model of care: BIC-NOW clinical trial

ObjectiveMultiple strategies have been utilised to reduce the incidence of HIV, including PrEP and rapid antiretroviral therapy initiation. The study objectives were to evaluate the efficacy, safety, satisfaction, treatment adherence, and system retention obtained with rapid initiation of bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) in naïve patients. MethodsThis phase IV, multicenter, open-label, single-arm, 48-week clinical trial enrolled patients between January 2020 and June 2022. Adherence to treatment was evaluated with the SMAQ questionnaire and patient satisfaction with the EQ-5D. ResultsTwo hundred eight participants were enrolled with mean age of 35.6 years; 87.6% were males; mean CD4 count was 393.5 cells/uL (<200 cells/uL in 22.1%); viral load log was 5.6 (VL>100 000 cop/mL in 43.3%); 22.6% had AIDS, and 4.3% were coinfected with HBV. BIC/FTC/TAF was initiated on the day of their first visit to the HIV specialist in 98.6% of participants, and 9.6% were lost to follow-up. The efficacy at week 48 was 84.1 % by intention-to- treat (ITT), 94.6% by modified ITT, and 98.3% by per protocol analysis. The regimen was discontinued in two subjects (0.9%) during week 1 for grade 3 adverse events. Treatment adherence (weeks 4 [90%, IQR: 80–99%] vs. 48 [90%, IQR: 80–95%; P = 0.49]) and patient satisfaction (weeks 4 [90%, IQR: 80–99%] vs. 48 [90%, IQR: 80–95 P = 0.49]) rates were very high over the 48- week study period. ConclusionsBIC/FTC/TAF is an appropriate option for rapid ART initiation in naïve HIV patients, offering high efficacy, safety, durability, treatment adherence, retention in the healthcare system, and patient satisfaction. Number Clinical Trial registration: NCT06177574.

Rapid Initiation of Antiretroviral Therapy Under the Treat-All Policy Reduces Loss to Follow-Up and Virological Failure in Routine Human Immunodeficiency Virus Care Settings in China: A Retrospective Cohort Study (2016-2022).

Following the World Health Organization's guidelines for rapid antiretroviral therapy (ART) initiation [≤7 days after human immunodeficiency virus (HIV) diagnosis], China implemented Treat-All in 2016 and has made significant efforts to provide timely ART since 2017. This study included newly diagnosed HIV adults from Tianjin, China, between 2016 and 2022. Our primary outcome was loss to follow-up (LTFU) at 12 months after enrollment. The secondary outcome was 12-month virological failure. The association between rapid ART and LTFU, as well as virological failure, was assessed via Cox regression and logistic regression. A total of 896 (19.1%) of 4688 participants received ART ≤7 days postdiagnosis. The rate of rapid ART has increased from 7.5% in 2016 to 33.3% by 2022. The rapid ART group had an LTFU rate of 3.3%, as opposed to 5.0% in the delayed group. The rapid ART group had a much reduced virological failure rate (0.6% vs. 1.8%). Rapid ART individuals had a reduced likelihood of LTFU [adjusted hazard ratio: 0.65, 95% confidence intervals (CI): 0.44-0.96] and virological failure (adjusted odds ratio: 0.35, 95% CI: 0.12-0.80). The real-world data indicated that rapid ART is practicable and beneficial for Chinese people with HIV, providing evidence for its widespread implementation and scaling up.

Abdominal involvement as a primary manifestation of systemic or isolated gastrointestinal vasculitis

Systemic vasculitides can cause a wide variety of gastrointestinal manifestations (GI) ranging from mild and frequently nonspecific abdominal pains to potentially life-threatening bowel perforations. Vascular involvement in systemic vasculitides can affect any GI blood vessel, most commonly mesenteric, hepatic, or splenic arteries. Inflammatory changes affecting different layers of arterial vessel walls can lead to aneurysmatic dilatation or blood vessel occlusion with subsequent organ ischemia leading to mucosal ulcerations, GI bleeding, perforations, or bowel obstruction. While the presence of extraintestinal manifestations may aid in diagnosis, delays in making appropriate diagnoses and rapid initiation of glucocorticoid and immunosuppressive treatment can have detrimental consequences. Awareness of isolated gastrointestinal vasculitis is of particular importance as it frequently remains undiagnosed until end-stage organ damage becomes apparent. Vasculitis mimics such as vascular Ehlers-Danlos syndrome or fibromuscular dysplasia add another lay of complexity in approaching patients with suspected GI vasculitis and should always be carefully considered.

Eligibility and Projected Benefits of Rapid Initiation of Quadruple Therapy for Newly Diagnosed Heart Failure

BackgroundU.S. nationwide estimates of the proportion of patients newly diagnosed with heart failure with reduced ejection fraction (HFrEF) eligible for quadruple medical therapy, and the associated benefits of rapid implementation, are not well characterized. ObjectivesThis study sought to characterize the degree to which patients newly diagnosed with HFrEF are eligible for quadruple medical therapy, and the projected benefits of in-hospital initiation. MethodsAmong patients hospitalized for newly diagnosed HFrEF in the Get With The Guidelines–Heart Failure registry from 2016 to 2023, eligibility criteria based on regulatory labeling, guidelines, and expert consensus documents were applied for angiotensin receptor-neprilysin inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and sodium-glucose cotransporter 2 inhibitor therapies. Of those eligible, the projected effect of quadruple therapy on 12-month mortality was modeled using treatment effects from pivotal clinical trials utilized by the AHA/ACC/HFSA Guideline for the Management of Heart Failure, and compared with observed outcomes among patients treated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta-blockers. ResultsOf 33,036 patients newly diagnosed with HFrEF, 27,158 (82%) were eligible for quadruple therapy, and 30,613 (93%) were eligible for ≥3 components. From 2021 to 2023, of patients eligible for quadruple therapy, 15.3% were prescribed quadruple therapy and 41.5% were prescribed triple therapy. Among Medicare beneficiaries eligible for quadruple therapy, 12-month incidence of mortality was 24.7% and HF hospitalization was 22.2%. Applying the relative risk reductions in clinical trials, complete implementation of quadruple therapy by time of discharge was projected to yield absolute risk reductions in 12-month mortality of 10.4% (number needed to treat = 10) compared with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta-blocker, and 24.8% (number needed to treat = 4) compared with no GDMT. ConclusionsIn this nationwide U.S. cohort of patients hospitalized for newly diagnosed HFrEF, >4 of 5 patients were projected as eligible for quadruple therapy at discharge; yet, <1 in 6 were prescribed it. If clinical trial benefits can be fully realized, in-hospital initiation of quadruple medical therapy for newly diagnosed HFrEF would yield large absolute reductions in mortality.

Assessment of rapid initiators and long-lasting nutrients for developing biological permeable reactive barriers to treat mine-contaminated groundwater

ABSTRACT The formation of mine-contaminated groundwater as a result of acidic mine drainage from the oxidation of sulfur-containing minerals entering the groundwater. Biological permeable reactive barrier (Bio-PRB) technology is excellent for the remediation of mine-contaminated groundwater. Usually, the organic substrates utilized in Bio-PRB are a combination of rapid initiators, which are readily bioavailable, and long-lasting nutrients, which are more difficult to degrade. Herein, we investigated the effectiveness of three rapid initiators and three long-lasting nutrients to remove sulfate from simulated mine-contaminated groundwater via simulated column experiments. The rapid initiators comprised crude glycerol, sodium acetate, and industrial syrup (IS), and the long-lasting nutrients included biodiesel emulsified oil, soybean oil emulsified oil, and high-carbon alcohol emulsified oil (HO). Microorganisms were stimulated using IS to create a sulfate reduction system owing to its high total organic carbon content (24.30 g L−1), achieving optimal sulfate removal rate (1.69 mmol dm−3 d−1). The fastest (2.93 mmol dm−3 d−1) and highest (88%) sulfate removal rates were achieved using HO, which is probably associated with the ability of HO to provide the most suitable C/N ratio (111.75) and induce the growth of sulfate-reducing bacteria (SRB) for substrate degradation. Conversely, a high concentration of sulfate reduction products inhibited SRB growth in the HO column. The addition of organic materials promoted SRB growth and various organic substrate–degrading bacteria. Furthermore, the competitive growth of methanogens (86.6%) may be responsible for the decrease in the relative abundance of SRB during the later stages of the experiment in the HO column.

Factors influencing rapid antiretroviral therapy initiation in Jiulongpo, Chongqing, China: a retrospective cohort from 2018 to 2022

BackgroundAntiretroviral Therapy (ART) is pivotal in extending the lives of people living with HIV (PLWH) and minimizing transmission. Rapid ART initiation, defined as commencing ART within seven days of HIV diagnosis, is recommended for all PLWH.MethodA retrospective cohort study was conducted using data from the China Information System for Disease Control and Prevention. This study included PLWH diagnosed between January 2018 and December 2021 and treated by December 2022. Factors influencing rapid ART initiation were examined using univariate and multivariate Cox regression analyses.ResultsThe study analyzed 1310 cases. The majority were male (77.4%), over 50 years old (46.7%), and contracted HIV through heterosexual transmission (70.0%). Rapid ART initiation was observed in 36.6% (n = 479) of cases, with a cumulative treatment rate of 72.9% within 30 days post-diagnosis. Heterosexual contact was associated with longer intervals from diagnosis to treatment initiation compared to homosexual contact (Adjusted Hazard Ratio (HR) = 0.813, 95% Confidence Interval (CI): 0.668–0.988). Individuals older than 50 years (Adjusted HR = 1.852, 95%CI: 1.149–2.985) were more likely to initiate ART rapidly. Conversely, treatment at the Second Public Hospital (Adjusted HR = 0.483, 95% CI: 0.330–0.708) and a CD4 cell counts above 500 (Adjusted HR = 0.553, 95% CI: 0.332–0.921) were associated with a lower likelihood of initiating treatment within seven days.ConclusionsA higher CD4 cell counts and receiving care in local public hospitals may deter rapid ART initiation. Providing CD4 counts results at diagnosis and offering testing and treatment in the same facility could enhance the rate of rapid ART initiation.

Desirability of Outcome Ranking and Response Adjusted for Antibiotic Risk (DOOR/RADAR) Post Hoc Analysis Supports Equipoise for Antibiotic Initiation Strategies in Intensive Care Unit-Acquired Pneumonia.

Background: Pneumonia is the most common intensive care unit (ICU)-acquired infection and source of potential sepsis in ICU populations but can be difficult to diagnose in real-time. Despite limited data, rapid initiation of antibiotic agents is endorsed by society guidelines. We hypothesized that a post hoc analysis of a recent randomized pilot study would show no difference between two antibiotic initiation strategies. Patients and Methods: The recent Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP) was a pragmatic cluster-randomized pilot of antibiotic initiation strategies for patients with suspected ICU-acquired pneumonia. Participating ICUs were cluster-randomized to either an immediate initiation protocol or a specimen-initiated protocol where a gram stain was required for initiation of antibiotics. Patients in the study were divided into one of seven mutually exclusive outcome rankings (desirability of outcome ranking; DOOR): (1) Survival, No Pneumonia, No adverse events; (2) Survival, Pneumonia, No adverse events; (3) Survival, No Pneumonia, ventilator-free-alive days ≤14; (4) Survival, Pneumonia, ventilator-free-alive days ≤14; (5) Survival, No Pneumonia, Subsequent episode of suspected pneumonia; (6) Survival, Pneumonia, Subsequent episode of suspected pneumonia; and (7) Death. These rankings were further refined using the duration of antibiotics prescribed for pneumonia (response adjusted for antibiotic risk; RADAR). Results: There were 186 patients enrolled in the study. After applying the DOOR analysis, a randomly selected patient was equally likely to have a better outcome in specimen-initiated arm as in the immediate initiation arm (DOOR probability: 50.8%; 95% confidence interval [CI], 42.7%-58.9%). Outcome probabilities were similar after applying the RADAR analysis (52.5%; 95% CI, 44.2%-60.6%; p = 0.31). Conclusions: We found that patients for whom antibiotic agents were withheld until there was objective evidence (specimen-initiated group) had similar outcome rankings to patients for whom antibiotic agents were started immediately. This supports the findings of the TARPP pilot trial and provides further evidence for equipoise between these two treatment strategies.

Income Level and Impaired Kidney Function Among Working Adults in Japan

Chronic kidney disease (CKD) is a major public health issue, affecting 850 million people worldwide. Although previous studies have shown the association between socioeconomic status and CKD, little is known about whether this association exists in countries such as Japan where universal health coverage has been mostly achieved. To identify any association of income-based disparity with development of impaired kidney function among the working population of Japan. This was a nationwide retrospective cohort study of adults aged 34 to 74 years who were enrolled in the Japan Health Insurance Association insurance program, which covers approximately 40% of the working-age population (30 million enrollees) in Japan. Participants whose estimated glomerular filtration rate (eGFR) had been measured at least twice from 2015 to 2022 were included in the analysis, which was conducted from September 1, 2021, to March 31, 2023. Individual income levels (deciles) in the fiscal year 2015. Odds ratios were calculated for rapid CKD progression (defined as an annual eGFR decline of more than 5 mL/min/1.73 m2), and hazard ratios, for the initiation of kidney replacement therapy (dialysis or kidney transplant) by income level deciles in the fiscal year 2015. The study population totaled 5 591 060 individuals (mean [SD] age, 49.2 [9.3] years) of whom 33.4% were female. After adjusting for potential confounders, the lowest income decile (lowest 10th percentile) demonstrated a greater risk of rapid CKD progression (adjusted odds ratio, 1.70; 95% CI, 1.67-1.73) and a greater risk of kidney replacement therapy initiation (adjusted hazard ratio, 1.65; 95% CI, 1.47-1.86) compared with the highest income decile (top 10th percentile). A negative monotonic association was more pronounced among males and individuals without diabetes and was observed in individuals with early (CKD stage 1-2) and advanced (CKD stage 3-5) disease. The findings of this retrospective cohort study suggest that, even in countries with universal health coverage, there may be a large income-based disparity in the risk of rapid CKD progression and initiation of kidney replacement therapy. These findings highlight the importance of adapting CKD prevention and management strategies according to an individual's socioeconomic status, even when basic health care services are financially guaranteed.

Solar energy innovations in the USA: A comparative global review

This comparative global review delves into solar energy innovations in the United States, providing insights into the nation's advancements and positioning within the international landscape. The United States has emerged as a key player in the field of solar energy, characterized by rapid technological innovations, policy initiatives, and substantial investments. By comparing these developments with global trends, the study aims to shed light on the unique characteristics and impacts of solar energy innovations in the USA. The review begins by examining the historical evolution of solar energy technologies in the United States, highlighting key milestones and breakthroughs. Subsequently, it explores the policy frameworks and regulatory measures that have shaped the growth of the solar energy sector, drawing comparisons with strategies adopted by other leading nations. The study delves into financial incentives, government support, and the role of private-sector initiatives in fostering a conducive environment for solar innovation. A critical aspect of the review is the comparative analysis of solar energy adoption rates, capacity additions, and grid integration strategies across various countries. By benchmarking the USA's solar energy landscape against global benchmarks, the study aims to identify best practices, challenges, and opportunities for further advancements. The review also considers the socio-economic and environmental impacts of solar energy innovations in the USA, assessing job creation, economic growth, and carbon emissions reductions. Comparative case studies with other nations provide a comprehensive understanding of the broader implications of solar energy adoption on a global scale. As solar energy continues to gain prominence as a sustainable and scalable solution, this review contributes to the ongoing discourse by providing a nuanced perspective on the unique trajectory of solar innovations in the USA. The findings aim to inform policymakers, researchers, and industry stakeholders, offering valuable insights for the continued growth and optimization of solar energy technologies in both domestic and global contexts.

Renal outcome in multiple myeloma patients with cast nephropathy: a retrospective analysis of potential predictive values on clinical and renal outcome

ABSTRACT Objective Cast nephropathy (CN) is the leading cause of acute kidney injury (AKI) in multiple myeloma (MM). Since it is sparsely documented why some patients with CN do achieve a renal response while others do not, we describe a single-center cohort of patients with multiple myeloma and biopsy-confirmed CN to evaluate potential markers of renal response. Methods The data was collected as a retrospective, single-center analysis of CN-patients treated at the Medical University Vienna between 01/01/2004 and 01/01/2022. Baseline parameters and clinical outcome was compared between renal responders and non-responders. Results Among 28 patients with CN, n = 23 were assessed for renal response (14 responders; 9 non-responders). Renal responders were younger (median age: 61 years; 77 years, p = 0.039), showed higher overall survival (153months; 58months, p = 0.044) and achieved hematologic response (≥PR) to first-line therapy (p = 0.029), and complete hematologic response (CR) at any time (p = 0.025) significantly more often. Further, we could show that rapid initiation of anti-myeloma therapy after initial presentation correlated significantly with renal response (median 9 days; 27 days, p = 0.016). Analyses of kidney biopsy specimens revealed that patients with a high IF/TA score showed end stage renal disease (dialysis ≥ 3 months) significantly more often (p = <0.001). Discussion In summary, our data suggests, that a rapid start with systemic hematologic treatment in patients with MM and CN is crucial and achieving an early hematologic response is important for renal recovery. Moreover, achieving a deep hematologic response and subsequent renal recovery improves clinical outcome as reflected by an overall survival benefit.

Improving response time and survival in ward based in-hospital cardiac arrest: A quality improvement initiative

BackgroundSurvival in cardiac arrest is associated with rapid initiation of high-quality cardiopulmonary resuscitation (CPR) and advanced life support. To improve ROSC rates and survival, we identified the need to reduce response times and implement coordinated resuscitation by dedicated cardiac arrest teams (CATs). We aimed to improve ROSC rates by 10% within 6 months, and subsequent survival to hospital discharge. MethodsWe used the Model for Improvement to implement a ward-based cardiac arrest quality improvement (QI) initiative across 3 Plan-Do-Study-Act (PDSA) cycles. QI interventions focused on instituting dedicated CATs and resuscitation equipment, staff training, communications, audit framework, performance feedback, as well as a cardiac arrest documentation form. The primary outcome was the rate of ROSC, and the secondary outcome was survival to hospital discharge. Process measures were call center processing times, CAT response times and CAT nurses’ knowledge and confidence regarding CPR. Balancing measures were the number of non-cardiac arrest activations and the number of cardiac arrest activations in patients with existing do-not-resuscitate orders. ResultsAfter adjustments for possible confounders in the multivariate analysis, there was a significant improvement in ROSC rate post-intervention as compared to the pre-intervention period (OR 2.05 [1.04–4.05], p = 0.04). Median (IQR) call center processing times decreased from 1.8 (1.6–2.0) pre-intervention to 1.4 (1.4–1.6) minutes post-intervention (p = 0.03). Median (IQR) CAT response times decreased from 5.1 (4.5–7.0) pre-intervention to 3.6 (3.4–4.3) minutes post-intervention (p < 0.001). After adjustments for possible confounders in the multivariate analysis, there was no significant improvement in survival to hospital discharge post-intervention as compared to the pre-intervention period (OR 0.71 [0.25–2.06], p = 0.53). ConclusionImplementation of a ward-based cardiac arrest QI initiative resulted in an improvement in ROSC rates, median call center and CAT response times.