Background: Diagnosis is the traditional basis for decision-making in clinical practice. Evidence is often lacking about future benefits and harms of these decisions for patients diagnosed with and without disease. We propose that a model of clinical practice focused on patient prognosis and predicting the likelihood of future outcomes may be more useful.DiscussionDisease diagnosis can provide crucial information for clinical decisions that influence outcome in serious acute illness. However, the central role of diagnosis in clinical practice is challenged by evidence that it does not always benefit patients and that factors other than disease are important in determining patient outcome. The concept of disease as a dichotomous ‘yes’ or ‘no’ is challenged by the frequent use of diagnostic indicators with continuous distributions, such as blood sugar, which are better understood as contributing information about the probability of a patient’s future outcome. Moreover, many illnesses, such as chronic fatigue, cannot usefully be labelled from a disease-diagnosis perspective. In such cases, a prognostic model provides an alternative framework for clinical practice that extends beyond disease and diagnosis and incorporates a wide range of information to predict future patient outcomes and to guide decisions to improve them. Such information embraces non-disease factors and genetic and other biomarkers which influence outcome.SummaryPatient prognosis can provide the framework for modern clinical practice to integrate information from the expanding biological, social, and clinical database for more effective and efficient care.
Background: Extension of a single incision for the purpose of specimen extraction in single-port laparoscopic surgery (SPLS) can undermine the merits of SPLS, either by hurting cosmesis or by increasing wound morbidity. Methods: We retrospectively analyzed the clinical outcomes of patients undergoing SPLS sigmoidectomy, either with transanal specimen extraction (TASE, n = 15) or transumbilical specimen extraction (TUSE, n = 68), for colorectal cancer between March 2009 and March 2013. The inclusion criterion was a tumor diameter of <= 5 cm. The median follow-up was 93 months (range 13 - 149). Results: Most of intraoperative and postoperative variables were comparable between the two groups, except for lengthening of operation time in TASE (287 +/- 87 min vs. 226 +/- 78 min, P = 0.011). TUSE did not lengthen the duration of postoperative recovery, hospital stay, or pain, or increase the incidence of postoperative complications. Whereas TUSE showed 8.8% (6/68) of wound-related complications, TASE did not show wound-related complications during follow-up period (P = 0.586). Conclusion: With the exception of a prolonged operation time, TASE showed equivalent surgical outcomes as TUSE in SPLS sigmoidectomy. Thus, the implement of TASE is expected to provide one way of reducing wound-related complications in SPLS in patients with a tumor diameter of <=5 cm.
Background: In an attempt to reduce environmental loading during ethanol production from cellulosic plant biomass, we have previously proposed an on-site solid state fermentation (SSF) method for producing ethanol from whole crops, which at the same time provides cattle feed without producing wastes. During the ensiling of freshly harvested plant biomass with cellulase and glucoamylase, the added yeast and lactic acid bacteria induced simultaneous saccharification and production of ethanol and lactic acid in hermetically sealed containers on-farm. In a previous study, laboratory-scale SSF (using 250 g of fresh rice crop biomass) yielded 16.9 weight % ethanol in dry matter (DM) after 20 days of incubation. In this study, the fermentation volume was scaled up to a normal-sized round bale and the fermentation process (ethanol concentrations of the products) was monitored. The ethanol produced was recovered and the recovery efficiency was evaluated. Results: SSF tests with forage rice round bales using polyethylene-wrapped whole plant materials (cultivar Leaf Star, average of 125.2 kg dry weight) were monitored in the field without temperature control. They yielded 14.0 weight % ethanol and 2.9 weight % lactic acid in DM after six months of incubation, and the ethanol ratio in the bale remained stable for 14 months after processing. SSF tests with three different rice cultivars were conducted for three years. Ethanol recovery from a fermented whole bale (244 kg fresh matter (FM) containing about 12.4 kg ethanol) by one-step distillation using vacuum distillation equipment yielded 86.3% ethanol collected from distilled solution (107 kg of 10.0 weight % ethanol). In addition, an average of 1.65 kg ethanol in 40.8 kg effluent per bale was recovered. Relative nitrogen content was higher in SSF products than in silage made from the same plant material, indicating that fermentation residue, whose quality is stabilized by the lactic acid produced, can be used as cattle feed. Conclusions: We have successfully demonstrated an efficient on-site ethanol production system with non-sterilized whole rice crop round bale. However, issues concerning the establishment of the ethanol recovery procedure on-site and evaluation of the fermentation residue as cattle feed have to be addressed.
Background: Symbiotic nitrogen fixation in plants occurs in roots with the help of some bacteria which help in soil nitrogen fertility management. Isolation of significant environment friendly bacteria for nitrogen fixation is very important to enhance yield in plants. Results: In this study effect of different magnetic field intensity and treatment time was studied on the morphology, physiology and nitrogen fixing capacity of newly isolated Paenibaccilus sp. from brown soil. The bacterium was identified by 16S rDNA sequence having highest similarity (99%) with Paenibacillus sp as revealed by BLAST. Different magnetic intensities such as 100mT, 300mT and 500mT were applied with processing time of 0, 5, 10, 20 and 30?minutes. Of all these treatment 300mT with processing time of 10?minutes was found to be most suitable treatment. Results revealed that magnetic treatment improve the growth rate with shorter generation time leading to increased enzyme activities (catalase, peroxidase and superoxide dismutase) and nitrogen fixing efficiencies. High magnetic field intensity (500mT) caused ruptured cell morphology and decreased enzyme activities which lead to less nitrogen fixation. Conclusion: It is concluded that appropriate magnetic field intensity and treatment time play a vital role in the growth of soil bacteria which increases the nitrogen fixing ability which affects the yield of plant. These results were very helpful in future breading programs to enhance the yield of soybean.
Background: Edoxaban is an oral, direct, factor Xa inhibitor approved in Japan for thromboembolic prophylaxis after lower-limb orthopedic surgery (LLOS), but contraindicated in patients with severe renal impairment (SRI; creatinine clearance [CLCR] ?15 to <30?mL/min). Methods: This open-label study compared the safety of edoxaban 15?mg once daily in Japanese patients with SRI to that of edoxaban 30?mg in patients with mild renal impairment (MiRI; CLCR ?50 to ?80?mL/min; N?=?30) undergoing LLOS. Patients with CLCR ?20 to <30?mL/min were randomized to receive edoxaban 15?mg (N?=?22) or subcutaneous fondaparinux 1.5?mg once daily (N?=?21). All patients with CLCR ?15 to <20?mL/min received edoxaban 15?mg (N?=?7). Treatment was administered for 11 to 14?days. Results: Major or clinically relevant non-major bleeding occurred in 6.7%, 3.4%, and 5.0% of patients in the MiRI edoxaban 30-mg, SRI edoxaban 15-mg, and SRI fondaparinux groups, respectively; there were no major bleeding events. No thromboembolic events occurred. At all time points assessed, edoxaban plasma concentrations and changes in coagulation biomarkers were similar between the SRI and MiRI groups. Conclusions: These results suggest edoxaban 15?mg once daily is well tolerated in Japanese patients with SRI undergoing LLOS.Trial registrationClinicaltrials.gov Identifier: NCT01857583 https://clinicaltrials.gov/ct2/show/NCT01857583?term=01857583&rank;=1.
Background: The purpose of this paper is to present the finding of Suaeda foliosa in El Yali National Reserve, Chile. With this finding, the southern limit of the distribution is displaced from the current position at 31° S, 300 km southward.FindingsIn this work, we found this species on the banks of the Colejuda lagoon, 33° 45′ S, which belongs to a body of hypersaline seasonal water found inside the protected area distinguished as a Ramsar site (No. 878). The determination of the genus and species was achieved by comparing with herbarium material deposited in the National Herbarium SGO Natural History Museum in Santiago de Chile. Once we identified the species, the collected material was deposited in the referred Herbarium (SGO 163975). pH, salinity, and conductivity of the water column and soil adjacent the three protected lagoons are compared, discussing the unique conditions of the lagoon Colejuda that may explain the presence of S. foliosa only in their environment and not in other water bodies. Conclusions: It can be concluded that El Yali wetland system harbors the S. foliosa southernmost population of the Americas.
Background: The identification of protective immune responses to P. falciparum infection is an important goal for the development of a vaccine for malaria. This requires the identification of susceptible and resistant individuals, so that their immune responses may be studied. Time-to-infection studies are one method for identifying putative susceptible individuals (infected early) versus resistant individuals (infected late). However, the timing of infection is dependent on random factors, such as whether the subject was bitten by an infected mosquito, as well as individual factors, such as their level of immunity. It is important to understand how much of the observed variation in infection is simply due to chance. Methods: We analyse previously published data from a treatment-time-to-infection study of 201 individuals aged 0.5 to 78 years living in Western Kenya. We use a mathematical modelling approach to investigate the role of immunity versus random factors in determining time-to-infection in this cohort. We extend this analysis using a modelling approach to understand what factors might increase or decrease the utility of these studies for identifying susceptible and resistant individuals. Results: We find that, under most circumstances, the observed distribution of time-to-infection is consistent with this simply being a random process. We find that age, method for detection of infection (PCR versus microscopy), and underlying force of infection are all factors in determining whether time-to-infection is a useful correlate of immunity. Conclusions: Many epidemiological studies of P. falciparum infection assume that the observed variation in infection outcomes, such as time-to-infection or presence or absence of infection, is determined by host resistance or susceptibility. However, under most circumstances, this distribution appears largely due to the random timing of infection, particularly in children. More direct measurements, such as parasite growth rate, may be more useful than time-to-infection in segregating patients based on their level of immunity.
IntroductionThe aim of this study was to explore the impact of augmented creatinine clearance, and differing minimum inhibitory concentrations (MIC), on piperacillin pharmacokinetic/pharmacodynamic (PK/PD) target attainment (time above MIC - fT>MIC), in critically ill septic patients receiving intermittent dosing. Methods: Critically ill patients with sepsis receiving piperacillin-tazobactam 4.5?g intravenously (IV) by intermittent infusion every 6-hours for presumed or confirmed nosocomial infection, without significant renal impairment (defined by a plasma creatinine concentration >171??mol/L or the need for renal replacement therapy), were eligible for enrolment. Over a single dosing interval, blood samples were drawn to determine unbound plasma piperacillin concentrations. Renal function was assessed by a measured creatinine clearance (CLCR, mL/min). A population PK model was constructed, and the probability of target attainment (PTA) for 50% and 100% fT>MIC calculated for varying MIC and CLCR values. Results: In total, 48 patients provided data. Increasing CLCR was associated with lower trough plasma piperacillin concentrations (P MIC would only be achieved in one-third (n?=?16) of patients. Mean piperacillin clearance was approximately 1.5 fold higher than in healthy volunteers, and correlated with CLCR (r?=?0.58, P MIC, was noted with increasing CLCR measures. Conclusions: Standard intermittent piperacillin-tazobactam dosing is unlikely to achieve optimal piperacillin exposures in a significant proportion of critically ill patients with sepsis, due to elevated drug clearance. These data suggest CLCR can be employed as a useful tool to determine whether piperacillin PK/PD target attainment is likely with a range of MIC values.
Background: Inflammatory cell infiltration and residual areas of fibrosis in kidneys after renal transplantation can lead to functional abnormalities with long-term implications.ObjectivesThe aim of this study was to determine urinary monocyte chemoattractant protein-1 (uMCP-1) levels, relative cortical interstitial area (RCIA), and cortical tubulointerstitial macrophage infiltration in renal transplant patients with delayed graft function (DGF) and their possible correlation with graft outcome.DesignPatients were followed after biopsies for one year, and their renal function and structure were evaluated, as well as parameters of inflammatory process.SettingClinical Hospital of the School of Medicine of Ribeir?o Preto.PatientsTwenty-two cadaveric kidney transplant recipients with DGF were followed for one year.MeasurementsRenal function, RCIA, macrophages infiltration and uMCP-1 levels were evaluated. Methods: Renal function was evaluated by plasma creatinine levels. RCIA was determined by morphometry. Immunohistochemical staining of macrophages was performed using an anti-CD68 monoclonal antibody. uMCP-1 levels were determined using a human MCP-1/CCL2 immunoassay kit. Results: There was a significant increase in uMCP-1 levels in transplant patients compared with controls (p?