Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016

OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy wasdeveloped at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroupsand among the entire committee served as an integral part of the development. METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.(AU)

Nicotiana occidentalis: A New Herbaceous Host for Blueberry scorch virus.

Blueberry scorch virus(BlScV) is a carlavirus that causes a serious disease of blueberries (Vaccinium corymbosum L.) in North America (2). In aphid-transmission studies of BlScV using blueberry as host and test species, we found the rate of transmission to be low, and a lengthy incubation period was required before BlScV could be detected. For sequencing studies, RNA extraction from blueberry using standard methods was unreliable and inefficient. These problems prompted a search for alternate hosts. Of 12 herbaceous hosts screened for BlScV transmission using the blueberry aphid, Ericaphis fimbriata Richards, with mechanical transmission, only Nicotiana occidentalis (Wheeler) became infected. After 3 to 4 weeks, infection of N. occidentalis with BlScV resulted in mild symptoms that included pronounced leaf twisting and swollen leaf veins. Infection with BlScV was confirmed using a double-antibody sandwich enzyme-linked immunosorbent assay (DAS-ELISA) kit (Agdia Inc., Elkhart, IN), polyclonal antibodies to BlScV from the antiserum collection at the Pacific Agri-Food Research Center, Summerland, British Columbia, Canada, and reverse transcription-polymerase chain reaction (RT-PCR). Forward (5'-NTAAACACTCCCGAATATAC-3') and reverse (5'-CAGATTGCTTATCCGGCTTC-3') primers were designed with the published sequence of BlScV isolate NJ-02 (GenBank Accession No. NC003499). An amplicon of the expected size was generated and sequenced. BLAST analysis indicated that the nucleotide sequence of the amplified fragment was 87% identical to the corresponding sequence in NJ-02 (1). N. occidentalis was readily infected with BlScV following aphid or mechanical inoculations from blueberry. With E. fimbriata as the aphid vector, the transmission rate from blueberry to N. occidentalis was approximately 26%, compared with 70% for mechanical inoculations. Mechanical transfer of BlScV between infected N. occidentalisplants resulted in a 100% transmission rate. Recently, with N. occidentalis, we have completely sequenced two strains of BlScV from British Columbia, Canada and identified several aphid vector species. The identification of N. occidentalis as an herbaceous host of BlScV greatly facilitates future studies on the virus. References: (1) T. D. Cavileer et al. J. Gen. Virol. 75: 711, 1994. (2) R. R. Martin and P. R. Bristow. Phytopathology 78:1636, 1988.

Cryoprecipitate for the correction of coagulopathy associated with liver disease.

In patients with liver disease at risk of pulmonary oedema, cryoprecipitate (small volume) might be a viable alternative to fresh frozen plasma (FFP, large volume) in the correction of coagulopathy. However, the efficacy of cryoprecipitate in these patients has not been tested. We evaluated the role of cryoprecipitate in the correction of the coagulopathy of liver disease. To establish initial evidence of efficacy, six consecutive patients with hepatic failure and coagulopathy received five units of cryoprecipitate. Then, using a crossover design, 11 consecutive patients were randomized to receive either four units of FFP or five units of cryoprecipitate. Pre and post infusion International Normalized Ratio (INR), activated Partial Thromboplastin Time (aPTT), fibrinogen D-dimers, Factors V and IX, and reptilase time were measured. In the first six patients, cryoprecipitate improved the INR, aPTT and fibrinogen concentration (P = 0.03). In the crossover study, FFP administration produced a greater improvement in INR (P = 0.007) and aPTT (P = 0.005) than cryoprecipitate. However, there were no differences in any of the other measured variables. One patient developed acute pulmonary oedema while receiving FFP. Cryoprecipitate improves the coagulopathy of liver disease. Four units of FFP are more efficacious than five units of cryoprecipitate. Cryoprecipitate may have a role in correction of the coagulopathy associated with liver disease where concerns about pulmonary oedema exist.

New Variant of Little cherry virus Associated with Little Cherry Disease of Sweet Cherry in British Columbia, Canada.

Little cherry disease (LChD) occurs in most cherry growing areas in the world. Infection of sensitive cultivars results in small fruit with poor color, angular shape, and insipid flavor. Three viruses associated with LCD have been described: (i) Little cherry virus-1 (LChV-1) first found and described in Germany (4); (ii) LChV-2 an isolate obtained from the United States (2); and (iii) LChV-3 first found and described in British Columbia (1). Despite similarities in symptom development in orchard trees and woody indexing, the three viruses have distinct molecular sequences (3). LChV-2 and -3 share greater homology with each other than either does with LChV-1. For many years, the British Columbia Ministry of Agriculture, Fisheries and Food (BCMAFF) in conjunction with Agriculture and Agri-Food Canada, Pacific Agri-Food Research Centre (AAFC-PARC) has conducted a survey to monitor the incidence and spread of LChD in the Okanagan and Kootenay valleys of British Columbia, Canada. Until recently, testing for LChD used woody indexing on indicator trees, Prunus avium cv. Lambert (fruit symptoms) and cvs. Canindex1 and Sam (foliar symptoms). Recently, incidence of LChD has been evaluated using double-antibody sandwich enzyme-linked immunosorbent assay (DAS-ELISA) developed at AAFC-PARC (3), and reverse transcription-polymerase chain reaction (RT-PCR) tests based on sequence data from LChV-3 (1). During the 1999 survey, orchard trees displaying symptoms typical of LChD tested negative for LChV-3 using ELISA and RT-PCR. Also, trees that formerly tested positive for LChD by woody indexing also tested negative for LChV-3 using RT-PCR and ELISA. Two hundred ninety-three trees were subsequently tested for LChV-1 by RT-PCR using the primer set LCV3EC/LCV16659 (4). A 276-bp fragment corresponding to the extreme 3' untranslated region (3' UTR) of the LChV-1 genome was amplified by RT-PCR from 140 of the trees. The RT-PCR amplicon from one sample (#99-68B from Peachland) was sequenced and using a BLASTn search, LChV-1 was identified as the most probable match (E value 4e-59). Sequence alignment using ClustalX identified two regions of high sequence homology; bases 2 to 70 (92%) and bases 99 to 239 (95%). The intervening region displayed much lower homology (61%). The overall homology of the amplicon was 88% compared to the corresponding region in LChV-1. Divergence between the published sequence of LChV-1 and the sequence of the new LChV isolate (tentatively named LChV-4) was investigated. Seven sets of primers constructed on the basis of sequence data from various regions of the LChV-1 genome (two sets from each of the RNA-dependent RNA polymerase, heat shock 70 protein homologue, and coat protein) failed to yield RT-PCR products when tested with the LChV-4 isolate. LChV-4 is clearly related to LChV-1 within the 3'-UTR but complete sequencing is required to determine the overall relationship with other viruses causing LChD. The discovery of a new isolate of LChV in British Columbia may require a reevaluation of the epidemiology of LChD and disease management strategy. References: (1) K. C. Eastwell and M. G. Bernardy. Phytopathology 91:268, 2001. (2) M. E. Rott, and W. Jelkmann. Phytopathology 91:261, 2001. (3) J. Theilmann et al. Phytopathology 92:87, 2002. (4) M. Vitushkina et al. Eur. J. Plant Pathol. 103;803, 1997.

Genetic diversity and phylogenetic relatedness among six endemic Pterostylis species (Orchidaceae; series Grandiflorae) of Western Australia, as revealed by allozyme polymorphisms.

Starch gel electrophoresis was employed to survey the allozyme polymorphism and phylogenetic relationships among 35 populations covering six closely related Western Australian endemic Pterostylis species (series Grandiflorae); viz P. rogersii, P. aspera, P. angusta, P. hamiltonii, P. scabra and P. aff. alata. The aim of this study was to determine intraspecific and interspecific genetic diversity and species relationships based on allozyme analysis. The frequencies of 56 alleles at 12 enzyme systems coded by 15 loci were determined along with a mean intraspecific genetic identity value. Allozyme markers clearly discriminated populations belonging to different species. Nei's genetic distance/identity co-efficient was used to measure the level of genetic differentiation among populations and species. Based on these values, a dendrogram was constructed which revealed that all the populations clustered into groups corresponding to the respective species. Gene diversity analysis among all the species revealed total genetic diversity H(t) of 0.23 with co-efficient of gene differentiation 10% (G(st)=0.10). Mean genetic variability (H(e)=0.136, P=40%) was also higher than for other outbreeding plant species. Mean genetic identity coefficient of populations of all species was 0.859 which increased to 0.877 upon exclusion of P. aff. alata, indicating a high degree of similarity among all species except P. aff. alata which segregated distinctively from the rest. Overall, the investigation provided independent support for the morphological segregation of these taxa.

Effect of ventilation equipment on imposed work of breathing.

OBJECTIVE: To determine the imposed work of different ventilation systems at 3 levels of pressure support. DESIGN: Laboratory study. SETTING: Teaching hospital respiratory laboratory. PARTICIPANTS: Healthy, human volunteers. INTERVENTIONS: Measurement of imposed work of breathing (WOB(i)) in six ventilators with alteration of ventilatory settings, humidification device, and triggering mechanisms. RESULTS: At 0 cmH2O CPAP and 0 cmH2O PSV, clinically significant (> 0.1 joules per litre or J/L) WOB(i )occurred in all systems. At 5 cmH2O pressure support ventilation (PSV) median WOB(i) ranged from 0.01 to 0.11 J/L. Removal of the pleated membrane heat and moisture exchanger (HME) significantly reduced WOB(i) (0.38 vs. 0.11 J/L, p < 0. 0001). Drawover humidification marginally increased WOB(i) (0.16 vs. 0.11 J/L, p = 0. 0001). Flow triggering reduced WOB(i) with the Servo (p < 0.0001) and Bennett ventilators (p = 0.001) but not with the Bear 1000 ventilator. CONCLUSIONS: Up to 7 cmH2O of PSV may be required to reduce WOB(i) related to the ventilator, circuit and humdification devices. This pressure support does not address the additional resistive effect of the endotracheal or tracheotomy tube. Higher levels of PSV may therefore be required to offset WOB(i).

First Report of Pepino mosaic virus in Canada and the United States.

During the winter of 2000, tomatoes (Lycopersicon esculentum) with a bright yellow leaf mosaic were observed in a commercial greenhouse in southern Ontario, Canada. Examination of leaf extracts, using leaf dips and immunosorbent absorption electron microscopy (ISEM), showed flexuous rods consistent with the potexvirus group. Polyclonal antibodies raised against the original Peruvian Pepino mosaic virus (PepMV) isolate (1) and commercial antibodies obtained from Deutsche Sammlung von Mikro-organismen und Zellkulturen (DSMZ), GmbH, Braunsweig, Germany, and Plant Research International (PRI), Wageningen, the Netherlands, were used in ISEM. Leaves tested positive in double-antibody sandwich-enzyme-linked immunosorbent assay (ELISA) with antibodies from DSMZ and PRI. A triple-antibody sandwich-ELISA obtained from Adgen Ltd. (Nellies Gate, UK) gave similar results. Potato virus X did not react with PepMV antiserum in ELISA. Positive PepMV ELISA controls were a U.K. and a Dutch isolate supplied by R. Mumford and R. A. A. van Vlugt, respectively, and DSMZ. Using primers generated from a sequence of the RNA polymerase region of a U.K. PepMV isolate (R. Mumford, unpublished data), a reverse transcription-polymerase chain reaction test showed the expected 312-bp amplicon for the Canadian, Dutch, and U.K. isolates. The primer sequences used were forward 5' CTA TTA CAA CTC CGG AAG CCA 3' and reverse 5' TGG TCT GGC CAG GCT TTG AC 3'. The three isolates were maintained in tomato cv. Bush Beefsteak. When mechanically inoculated on L. esculentum cv. Rapsodie, the Canadian isolate caused a bright yellow mosaic in 1 to 2 weeks, while the two European isolates caused a faint yellow mosaic and mild puckering of the leaves. When mechanically inoculated on 17 indicator plants, the Canadian isolate had a host range similar to the U.K. isolate. The most striking difference in symptoms occurred in L. pimpinellifolium, in which the Canadian isolate caused a yellow mosaic, the Dutch isolate caused no symptoms, and the U.K. isolate caused a marked puckering of the leaves, suggesting virus strain differences among the isolates. Tomato fruits originating from the United States were collected during border inspections by the Canadian Food Inspection Agency and tested for PepMV by ELISA with antisera from DSMZ. PepMV was not detected in 7 samples from California, but was detected in 6 of 12 samples from Colorado, 6 of 7 samples from Arizona, and 1 of 5 samples from Texas. PepMV was originally isolated from pepino (Solanum muricatum) in Peru in 1980 (1) and subsequently from tomato in the Netherlands in 1999 (2). To our knowledge, this is the first report of PepMV in North America. References: (1) R. Jones et al. Ann. Appl. Biol. 94:61, 1980. (2) R. A. A. van Vlugt et al. Plant Dis. 84:103, 2000.

Work of breathing measurement in the critically ill patient.

Weaning patients from mechanical ventilation in the intensive care unit can be difficult. In patients requiring prolonged ventilatory support it has been demonstrated that conventional weaning criteria are frequently incorrect. In this group measurement of respiratory work may be of benefit. Until recently, estimation of the work of breathing in patients receiving mechanical ventilation was logistically difficult. The availability of a computerized bedside monitoring device potentially allows easier estimation of the work of breathing at the bedside. The results of preliminary studies utilizing such monitoring are provocative: they highlight the phenomenon of nosocomial respiratory failure and challenge our clinical ability to determine patient workloads and timing of extubation. The potential benefits of work of breathing measurement, in particular the avoidance of respiratory muscle fatigue, earlier extubation, reduced duration of mechanical ventilation, reduction in ICU and hospital length of stay, and most importantly, a reduction in patient morbidity are yet to be demonstrated and concerns still exist about the monitor's accuracy.

Metabolic organization of liver during spawning migration of sockeye salmon.

Although earlier studies have established broad outlines of biochemical changes during salmon spawning migration, the metabolic organization of specific organs has hitherto remained unknown. In this study, we assessed the performance of isolated liver cells from anorexic female sockeye salmon (Oncorhynchus nerka) at four sampling sites along their 1,150-km spawning migration. Isolated hepatocytes maintain high rates of gluconeogenesis and CO2 release from amino acids and lactate throughout the migration. Alanine, derived from proteolysis of white muscle, constitutes the single most important source for de novo synthesis of glucose. Just before spawning, when glycogen reserves reach a maximum, gluconeogenesis from alanine is specifically inhibited, whereas its conversion to CO2 and the utilization of other substrates are relatively unchanged. Spawning, apparently supported by carbohydrate catabolism, is accompanied by depletion of glycogen reserves from muscle as well as liver and a stimulation of gluconeogenesis from amino acids. At the onset of migration, palmitate oxidation accounts for about half the CO2 released by liver cells; its contribution decreases during the migration and is negligible after spawning.

Amino acid utilisation in isolated hepatocytes from rainbow trout.

The utilisation (conversion to CO2 and/or glucose) of a series of amino acids by isolated trout hepatocytes was investigated and compared to the utilisation of lactate and palmitate. In fed fish, several amino acids (alanine, serine, asparagine and glycine) and lactate produced CO2 at considerably higher rates than palmitate. During starvation plus exercise, the rate of CO2 production from palmitate increased while that from lactate and most of the amino acids decreased. Gluconeogenesis from amino acids in fed fish was lower than from lactate. Serine and asparagine were the most effective substrates; alanine gave lower rates of incorporation. During prolonged starvation plus exercise, the rates of gluconeogenesis from amino acids increased twofold and, simultaneously, there was a corresponding increase in phosphoenolpyruvate carboxykinase activity in liver. It is concluded that several amino acids (dietary or released from muscle protein) are potentially major oxidative substrates in trout. In addition, amino acids appear to have the capability to maintain supplies of glucose during a period of prolonged starvation and exercise. No evidence could be found to support the contention that alanine is the most important glucogenic amino acid.

Hydrogen shuttles in air versus water breathing fishes.

1. The malate-aspartate cycle was demonstrable in subcellular preparations of hearts from Arapaima, Lepidosiren, and Synbranchus (obligate air breathers), Hoplerythriunus (facultative air breather), and Osteoglossum and Hoplias (obligate water breathers). 2. Although no respiratory evidence for significant alpha-glycerophosphate cycle participation could be shown in the air breathers, this cycle was demonstrable in hearts of water breathers. 3. In agreement with the O2 uptake studies, it was possible to reconstruct the malate-aspartate, but not the alpha-glycerophosphate cycle, in isolated mitochondria from air breathers, while both shuttles could be reconstructed with heart mitochondria in the case of water breathing fishes.

Pressure effects on water-swollen elastin. A model for hydrophobic interactions in proteins.

The effect of pressure on the swelling of elastin in pure water was investigated. Because elastin is a very non-polar protein, and because the swelling of elastin can be directly related to changes in the strength of hydrophobic interactions, we have used elastin as a model to study the effect of pressure on hydrophobic interactions in proteins. The elastin swelling model is particularly useful because it is based on a macromolecular system very similar to a globular protein and not on dilute aqueous solutions of small non-polar compounds. Increased pressure causes elastin to increase its swollen volume, and the observed swelling changes were analyzed in terms of the Flory-Rehner theory (Flory, P.J. and Rehner, Jr., J (1943) J. Chem. Phys. 11, 521--526) for the swelling of kinetically free, random polymer networks. Our calculations provide a measure of the volume change for the process of transferring 1 mol of an average non-polar amino acid side chain from a region where the side chains are surrounded by other non-polar groups and have no contact with water (i.e. a hydrophobic region) into contact with water. The results indicate that there is a small, negative volume change associated with this process, and quantitative estimates indicate that the volume change is of the order of --6 ml/mol side chain. The results support the hypothesis that the free energy required to transfer a non-polar side chain from a hydrophobic region into water becomes less positive (i.e. the hydrophobic interaction becomes weaker) as hydrostatic pressure is increased.