Derivation and External Validation of the Ottawa Bloodstream Infection Model for Acutely Ill Adults.

BACKGROUND: Knowing the probability that patients have a bloodstream infection (BSI) could influence the ordering of blood cultures and interpretation of their preliminary results. Many previous BSI probability models have limited applicability and accuracy. This study used currently recommended modeling techniques and a large sample to derive and validate the Ottawa BSI Model. METHODS: At a tertiary care teaching hospital, we retrieved a random sample of 4180 adults having blood cultures in our emergency department or during the initial 48 h of the encounter. Variable selection was based on clinical experience and a systematic review of previous model performance. Model performance was measured in a temporal external validation group of 4680 patients. RESULTS: A total of 327 derivation patients had a BSI (8.0%). BSI risk increased with increased number of culture sets (2 sets: adjusted odds ratio [aOR] 1.52 [1.10-2.11]; 3 sets: 1.99 [0.86-4.58]); with indwelling catheter (aOR 2.07 [1.34-3.20); with increasing temperature, heart rate, and neutrophil-lymphocyte ratio; and with decreasing systolic blood pressure, platelet count, urea-creatinine ratio, and estimated glomerular filtration rate. In the temporal external validation group, model discrimination was good (c-statistic 0.71 [0.69-0.74]) and calibration was very good (integrated calibration index .016 [.010-.024]). Exclusion of validation patients with acute SARS-CoV-2 infection improved discrimination slightly (c-statistic 0.73 [0.69-0.76]). CONCLUSIONS: The Ottawa BSI Model uses commonly available data to return an expected BSI probability for acutely ill patients. However, it cannot exclude BSI and its complexity requires computational assistance to use.

Concurrent external validation of bloodstream infection probability models.

OBJECTIVE: Accurately estimating the likelihood of bloodstream infection (BSI) can help clinicians make diagnostic and therapeutic decisions. Many multivariate models predicting BSI probability have been published. This study measured the performance of BSI probability models within the same patient sample. METHODS: We retrieved validated BSI probability models included in a recently published systematic review that returned a patient-level BSI probability for adults. Model applicability, discrimination, and accuracy was measured in a simple random sample of 4485 admitted adults having blood cultures ordered in the emergency department or the initial 48 hours of hospitalization. RESULTS: Ten models were included (publication years 1991-2015). Common methodological threats to model performance included overfitting and continuous variable categorization. Restrictive inclusion criteria caused seven models to apply to <15% of validation patients. Model discrimination was less than originally reported in derivation groups (median c-statistic 60%, range 48-69). The observed BSI risk frequently deviated from expected (median integrated calibration index 4.0%, range 0.8-12.4). Notable disagreement in expected BSI probabilities was seen between models (median (25th-75th percentile) relative difference between expected risks 68.0% (28.6-113.6%)). DISCUSSION: In a large randomly selected external validation population, many published BSI probability models had restricted applicability, limited discrimination and calibration, and extensive inter-model disagreement. Direct comparison of model performance is hampered by dissimilarities between model-specific validation groups.

Epidemiology and reporting characteristics of preclinical systematic reviews.

In an effort to better utilize published evidence obtained from animal experiments, systematic reviews of preclinical studies are increasingly more common-along with the methods and tools to appraise them (e.g., SYstematic Review Center for Laboratory animal Experimentation [SYRCLE's] risk of bias tool). We performed a cross-sectional study of a sample of recent preclinical systematic reviews (2015-2018) and examined a range of epidemiological characteristics and used a 46-item checklist to assess reporting details. We identified 442 reviews published across 43 countries in 23 different disease domains that used 26 animal species. Reporting of key details to ensure transparency and reproducibility was inconsistent across reviews and within article sections. Items were most completely reported in the title, introduction, and results sections of the reviews, while least reported in the methods and discussion sections. Less than half of reviews reported that a risk of bias assessment for internal and external validity was undertaken, and none reported methods for evaluating construct validity. Our results demonstrate that a considerable number of preclinical systematic reviews investigating diverse topics have been conducted; however, their quality of reporting is inconsistent. Our study provides the justification and evidence to inform the development of guidelines for conducting and reporting preclinical systematic reviews.

A systematic review of interventions aiming to improve communication of prognosis to adult patients.

OBJECTIVE: Our objective was to describe interventions that aim to improve communication of prognosis to adult patients and to summarize the effect of interventions. METHODS: We included randomized controlled trials of interventions that included prognosis delivery. We excluded studies of decision aids. Our analysis was a narrative synthesis of interventions and outcomes. RESULTS: Our search identified 1151 unique records. After screening, and full text review we included 21 reports from 17 RCTs. Only 2 studies used a prediction model to generate prognostic estimates. Four studies used education, ten used patient mediated interventions, and 2 used coordination of care. In some studies education that includes prognosis improves patient reported outcomes, communication and treatment decisions, patient mediated interventions can increase the number of questions patients ask about prognosis. Coordination of care may improve satisfaction. CONCLUSIONS: Education for clinicians that includes teaching about how to communicate prognosis may improve patient reported outcomes. Patient mediated interventions can increase the number of prognosis related questions asked by patients. PRACTICE IMPLICATIONS: Communication skills training that includes training on delivering prognosis may improve communication and patient reported outcomes, but the evidence is uncertain. Giving patients question prompt lists can help them ask more prognosis related questions.

Resveratrol integrates metabolic and growth effects in PC3 prostate cancer cells-involvement of prolyl hydroxylase and hypoxia inducible factor-1.

Resveratrol (RES) is a polyphenol produced by certain plant species that has been well studied due to its ability to slow the growth of cancer cells. In numerous cell types and tissues, RES has been demonstrated to promote mitochondrial biogenesis, fusion, and oxidative phosphorylation. The present study investigated the interaction between RES's effects on growth and metabolism in PC3 prostate cancer cells, and demonstrated that RES-mediated growth inhibition is only observed under conditions in which a metabolic shift from glucose fermentation to mitochondrial respiration can occur. When this shift was prevented by growing cells in galactose medium or by pharmacologically inhibiting prolyl hydroxylase (PHD) in order to stabilize hypoxia inducible factor-1α, RES did not effect mitochondrial fusion, biogenesis, respiration or cell growth. Similar results were observed in PC3 cells expressing a mutant HIF-1α lacking the prolines that are hydroxylated by PHD to promote its degradation. Thus, RES appears to slow PC3 cell growth by interfering with glucose fermentation and promoting respiration. Consistent with this, RES was observed to be particularly effective at inhibiting PC3 cell growth under hypoxic conditions that precluded increased reliance on oxidative phosphorylation. These observations are important in understanding how RES may affect cancer cell growth in vivo where hypoxia is common in growing tumours.

Hydrogen peroxide production is affected by oxygen levels in mammalian cell culture.

Although oxygen levels in the extracellular space of most mammalian tissues are just a few percent, under standard cell culture conditions they are not regulated and are often substantially higher. Some cellular sources of reactive oxygen species, like NADPH oxidase 4, are sensitive to oxygen levels in the range between 'normal' physiological (typically 1-5%) and standard cell culture (up to 18%). Hydrogen peroxide in particular participates in signal transduction pathways via protein redox modifications, so the potential increase in its production under standard cell culture conditions is important to understand. We measured the rates of cellular hydrogen peroxide production in some common cell lines, including C2C12, PC-3, HeLa, SH-SY5Y, MCF-7, and mouse embryonic fibroblasts (MEFs) maintained at 18% or 5% oxygen. In all instances the rate of hydrogen peroxide production by these cells was significantly greater at 18% oxygen than at 5%. The increase in hydrogen peroxide production at higher oxygen levels was either abolished or substantially reduced by treatment with GKT 137831, a selective inhibitor of NADPH oxidase subunits 1 and 4. These data indicate that oxygen levels experienced by cells in culture influence hydrogen peroxide production via NADPH oxidase 1/4, highlighting the importance of regulating oxygen levels in culture near physiological values. However, we measured pericellular oxygen levels adjacent to cell monolayers under a variety of conditions and with different cell lines and found that, particularly when growing at 5% incubator oxygen levels, pericellular oxygen was often lower and variable. Together, these observations indicate the importance, and difficulty, of regulating oxygen levels experienced by cells in culture.