Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study.

BACKGROUND: Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches. METHODS: This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality. RESULTS: There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis. CONCLUSIONS: Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.

Experimental Validation and Computational Predictions Join Forces to Map Catalytic C-H Activation in Ferrocene Metalated Porous Organic Polymers.

In recent times, a self-complementary balanced characteristic feature with the combination of both covalent bonds (structural stability) and open metal sites (single-site catalysis) introduced an advanced emerging functional nanoarchitecture termed metalated porous organic polymers (M-POPs). However, the development of M-POPs in view of the current interest in catalysis has been realized still in its infancy and remains a challenge for the years to come. In this work, we built benzothiazole-linked Fe-metalated porous organic polymer (Fc-Bz-POP) using ferrocene dicarboxaldehyde (FDC), 1,3,5-tris(4-aminophenyl) benzene (APB), and elemental sulfur (S8) via a template-free, multicomponent, cost-effective one-pot synthetic approach. This Fc-Bz-POP is endowed with unique features including an extended network unit, isolated active sites, and catalytic pocket with a possible local structure, in which convergent binding sites are positioned in such a way that substrate molecules can be held in close proximity. Prospective catalytic application of this Fc-Bz-POP has been explored in executing catalytic allylic "C-H" bond functionalization of cyclohexene (CHX) in water at room temperature. Catalytic screening results identified that a superior performance with a CHX conversion of 95% and a 2-cyclohexene-1-ol selectivity (COL) of 80.8% at 4 h and 25 °C temperature has been achieved over Fc-Bz-POP, thereby addressing previous shortcomings of the other conventional catalytic systems. Comprehensive characterization understanding with the aid of synchrotron-based extended X-ray absorption fine structure (EXAFS) analysis manifested that the Fe atom with an oxidation state of +2 in our Fc-Bz-POP catalytic system encompasses a sandwich structural environment with the two symmetrical eclipsed cyclopentadienyl (Cp) rings, featuring nearest-neighbor (NN) Fe-C (≈2.05 Å) intramolecular bonds, as validated by the Fe L3-edge EXAFS fitting result. Furthermore, in situ attenuated total reflection-infrared spectroscopy (ATR-IR) analysis data for liquid-phase oxidation of cyclohexene allow for the formulation of a molecular-level reaction mechanistic pathway with the involvement of specific reaction intermediates, which is initiated by the radical functionalization of the allyl hydrogen. A deep insight investigation from density functional theory (DFT) calculations unambiguously revealed that the dominant pathway from cyclohexene to 2-cyclohexene-1-ol is initiated by an allyl-H functionalization step accompanied by the formation of 2-cyclohexene-1-hydroperoxide species as the key reaction intermediate. Electronic properties obtained from DFT simulations via the charge density difference plot, Bader charge, and density of state (DOS) demonstrate the importance of the organic polymer frame structure in altering the electronic properties of the Fe site in Fc-Bz-POP, resulting in its high activity. Our contribution has great implications for the precise design of metalated porous organic polymer-based robust catalysts, which will open a new avenue to get a clear image of surface catalysis.

Sensory, structural breakdown, microstructure, salt release properties, and shelf life of salt-coated air-dried yellow alkaline noodles.

Salt reduction in food has been employed to improve public health. The effects of salt coatings on sodium content, sensory properties, structural breakdown, microstructure, salt release properties, and shelf life of yellow alkaline noodles (YAN) were evaluated. 15 g/dL resistant starch HYLON™ VII (HC) or 5% (v/v) Semperfresh™ (SC) with 10, 20, and 30 g/dL sodium chloride (NaCl) were used. HC-Na30 and SC-Na30 had the highest sodium content and came closest to commercial YAN in taste and saltiness perception. Structural improvement was demonstrated with HC-Na10 and SC-Na10 as both noodles required maximum work to be broken down. Moreover, SEM micrographs of these noodles showed a more compact and dense appearance with increased continuity of the matrix and fewer voids and hollows. However, ruptured surfaces were observed in noodles coated with 20 and 30% salt. The enhanced salt release from the coatings was demonstrated in an in vivo analysis, with the released salt occurring rapidly from HC and SC coatings. HC-Na10 and SC-Na10 noodles had a shelf life of more than 8 days when stored at 4 °C, which is longer than HC-Na0 and SC-Na0 noodles. Storage at 4 °C decelerated the microbiological growth, changes in pH and CIE L* values in salt-coated noodles than storage at 25 °. Thus, HC-Na10 and SC-Na10 could be suitable formulations to replace commercial YAN.

Quality characteristics of green Tea's infusion as influenced by brands and types of brewing water.

The influences of four types of brewing waters including tap water (TAP), alkaline ionized water (ALK), magnetized water (MAG) and mineral water (MIN), and two brands of commercial green tea (L and T) on quality characteristics of tea infusions were studied. The Oxidation Reduction Potential (ORP) values of the brewing waters was TAP > MAG, MIN > ALK. After brewing, all infusions showed a significant drop (p < 0.05) in pH values. The pH of original brewing waters of ALK (8.64) was the highest as compared to other waters, whereas L-MIN (pH 6.63) and T-MIN (pH 5.82) showed the highest pH values after brewing. Overall, the quality characteristics of green tea infusions were influenced by the brands of tea and the types of brewing water used. MAG was the most superior brewing water in extracting the green tea. Evidenced by total phenolic and flavonoids contents, both L-MAG and T-MAG infusions were superior in extracting antioxidative compounds as compared to other tea infusions. In addition, T-MAG infusion was the least astringent (P < 0.05) and scored the highest (P < 0.05) overall acceptability ( 5.40 ) by sensory panelists.

Improvement of cooking and textural properties of rice flour-soy protein isolate noodles stabilised with microbial transglutaminase and glucono-δ-lactone and dried using superheated steam.

In a bid to produce rice flour noodles with improved texture and reduced cooking time, rice flour-soy protein isolate noodles (RNS) were structurally enhanced by a combined treatment (COM) of microbial transglutaminase (MTG) with glucono-δ-lactone (GDL). The RNS-COM was either dried using superheated steam (SHS) to yield RNS-COM-SHS or steamed for 10 min (S10) before air drying to produce RNS-COM-S10 noodles. Control samples were SHS-dried rice flour (RN-SHS) and air-dried RN-S10 noodles. In general, textural and microstructural properties indicated higher textural properties and a more robust network in RNS-COM-SHS and RNS-COM-S10 than in other noodles. However, optimum cooking time (P < 0.5) was in the order; RN-SHS, RNS-COM-SHS < RN-S10 < RNS-COM-S10. As a result of the COM treatment, structurally enhanced noodles were more resistant to cooking. As applied in RNS-COM-SHS noodles, SHS was able to improve cooking quality, probably through the formation of bigger and evenly spread pores that had promoted faster gelatinisation of starch, with a high order of relative starch crystallinity.

Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project.

OBJECTIVES: We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients. METHODS: The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients' care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions. RESULTS: Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05). CONCLUSIONS: Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.

Effective Antimicrobial StewaRdship StrategIES (ARIES): Cluster Randomized Trial of Computerized Decision Support System and Prospective Review and Feedback.

BACKGROUND: Prospective review and feedback (PRF) of antibiotic prescriptions and compulsory computerized decision support system (CDSS) are 2 strategies of antimicrobial stewardship. There are limited studies investigating their combined effects. We hypothesized that the use of on-demand (voluntary) CDSS would achieve similar patient outcomes compared with automatically triggered (compulsory) CDSS whenever broad-spectrum antibiotics are ordered. METHODS: A parallel-group, 1:1 block cluster randomized crossover study was conducted in 32 medical and surgical wards from March to August 2017. CDSS use for piperacillin-tazobactam or carbapenem in the intervention clusters was at the demand of the doctor, while in the control clusters CDSS use was compulsory. PRF was continued for both arms. The primary outcome was 30-day mortality. RESULTS: Six hundred forty-one and 616 patients were randomized to voluntary and compulsory CDSS, respectively. There were no differences in 30-day mortality (hazard ratio [HR], 0.87; 95% CI, 0.67-1.12), re-infection and re-admission rates, antibiotic duration, length of stay, or hospitalization cost. The proportion of patients receiving PRF recommendations was not significantly lower in the voluntary CDSS arm (62 [10%] vs 81 [13%]; P = .05). Appropriate indication of antibiotics was high in both arms (351/448 [78%] vs 330/433 [74%]; P = .18). However, in geriatric medicine patients where antibiotic appropriateness was <50%, prescription via compulsory CDSS resulted in a shorter length of stay and lower hospitalization cost. CONCLUSIONS: Voluntary broad-spectrum antibiotics with PRF via CDSS did not result in differing clinical outcomes, antibiotic duration, or length of stay. However, in the setting of low antibiotic appropriateness, compulsory CDSS may be beneficial.

Photocatalytic and Photoelectrochemical Systems: Similarities and Differences.

Photocatalytic and photoelectrochemical processes are two key systems in harvesting sunlight for energy and environmental applications. As both systems are employing photoactive semiconductors as the major active component, strategies have been formulated to improve the properties of the semiconductors for better performances. However, requirements to yield excellent performances are different in these two distinctive systems. Although there are universal strategies applicable to improve the performance of photoactive semiconductors, similarities and differences exist when the semiconductors are to be used differently. Here, considerations on selected typical factors governing the performances in photocatalytic and photoelectrochemical systems, even though the same type of semiconductor is used, are provided. Understanding of the underlying mechanisms in relation to their photoactivities is of fundamental importance for rational design of high-performing photoactive materials, which may serve as a general guideline for the fabrication of good photocatalysts or photoelectrodes toward sustainable solar fuel generation.

The Importance of the Interfacial Contact: Is Reduced Graphene Oxide Always an Enhancer in Photo(Electro)Catalytic Water Oxidation?

Optimizing interfacial contact between graphene and a semiconductor has often been proposed as essential for improving their charge interactions. Herein, we fabricated bismuth vanadate-reduced graphene oxide (BiVO4/rGO) composites with tailored interfacial contact extents and revealed their disparate behavior in photoelectrochemical (PEC) and powder suspension (PS) water oxidation systems. BiVO4/rGO with a high rGO coverage on the BiVO4 surface (BiVO4/rGO HC) exhibited an 8-fold enhancement in the PEC photocurrent density with respect to neat BiVO4 at 0 V versus Ag/AgCl, while BiVO4/rGO with a low rGO coverage (BiVO4/rGO LC) gave a lesser 3-fold enhancement. In contrast, BiVO4/rGO HC delivered a detrimental effect, while BiVO4/rGO LC exhibited an enhanced performance for oxygen evolution in the PS system. The phenomenon is attributed to changes in the hydrophobicity of the BiVO4/rGO composite in conjunction with the interfacial contact configuration. A better BiVO4/rGO interfacial contact was found to improve the charge separation efficiency and charge transfer ability of the composite material, explaining the superior PEC performance of BiVO4/rGO HC. Additionally, optimization of the interfacial contact extent was revealed to further improve the energetics of the composite material, as evidenced by a Fermi level shift to a more negative potential. However, the high hydrophobicity of BiVO4/rGO HC arising from the higher rGO reduction extent triggered poor water miscibility, reducing the surface wettability and therefore hampering the photocatalytic O2 evolution activity of the sample. The study underlines water miscibility as a governing issue in the PS system.

Heterogeneous photocatalysts: an overview of classic and modern approaches for optical, electronic, and charge dynamics evaluation.

The functionality of a photoactive semiconductor (i.e., photocatalysts, photoelectrodes, etc.) is largely dictated by three key aspects: (i) band gap; (ii) absolute potentials of the conduction band minimum and the valence band maximum; and (iii) bulk and surface charge carrier dynamics. Their relevance to governing the energetics and the photo(electro)chemical mechanisms of the semiconductor has prompted development of a multitude of characterization tools to probe the specific characteristic of the material. This review aims to summarize the current experimental techniques, including the conventional and the state-of-the-art tools, directed at examining the key aspects (i), (ii), and (iii) of semiconductors. Although not being exhaustive, this didactic review can be useful to apprise the research community of the sophisticated research tools currently available for characterization of photo(electro)catalyst semiconductors as well as to bridge the multidisciplinary knowledge.

Exploring the Different Roles of Particle Size in Photoelectrochemical and Photocatalytic Water Oxidation on BiVO4.

Water oxidation on visible-light-active bismuth vanadate (BiVO4) has commonly been demonstrated to be viable in powder suspension (PS) and particulate photoelectrochemical (PEC) systems. Here, we demonstrate that particle size reduction, which is known to be efficacious in promoting charge carrier extraction and boosting surface active sites, has an opposite effect on BiVO4's photoactivity in the two systems. With three BiVO4 samples of distinctive particle sizes, smaller BiVO4 particle size is shown to be beneficial for enhancing PEC photocurrent generation, but deleterious for photocatalytic O2 evolution on suspended BiVO4. Such contrary effect of particle size in the PEC and PS systems is revealed to be due to the different governing factors of the systems: charge transport in the former and charge separation in the latter. Smaller particle size was found to enrich the interparticle and the particle/FTO substrate contacts which improve charge transport and charge collection efficiency in BiVO4 particulate electrode. On the contrary, larger particle size is necessary for improved photocatalytic O2 evolution because of increased crystallinity and greater band bending, which are essential for charge separation.

Interfacing BiVO4 with Reduced Graphene Oxide for Enhanced Photoactivity: A Tale of Facet Dependence of Electron Shuttling.

Efficient interfacial charge transfer is essential in graphene-based semiconductors to realize their superior photoactivity. However, little is known about the factors (for example, semiconductor morphology) governing the charge interaction. Here, it is demonstrated that the electron transfer efficacy in reduced graphene oxide-bismuth oxide (RGO/BiVO4 ) composite is improved as the relative exposure extent of {010}/{110} facets on BiVO4 increases, indicated by the greater extent of photocurrent enhancement. The dependence of charge transfer ability on the exposure degree of {010} relative to {110} is revealed to arise due to the difference in electronic structures of the graphene/BiVO4 {010} and graphene/BiVO4 {110} interfaces, as evidenced by the density functional theory calculations. The former interface is found to be metallic with higher binding energy and smaller Schottky barrier than that of the latter semiconducting interface. The facet-dependent charge interaction elucidated in this study provides new aspect for design of graphene-based semiconductor photocatalyst useful in manifold applications.

BiVO4 {010} and {110} Relative Exposure Extent: Governing Factor of Surface Charge Population and Photocatalytic Activity.

The {010} and {110} crystal facets of monoclinic bismuth vanadate (m-BiVO4) has been demonstrated to be the active reduction and oxidation sites, respectively. Here, we show using dual-faceted m-BiVO4 with distinctly different dominant exposed facets, one which is {010}-dominant and the other {110}-dominant, contrary to prediction, the former m-BiVO4 exhibits superior photooxidation activities. The population of photogenerated electrons and holes on the surface are revealed to be proportional to the respective surface areas of {010} and {110} exposed on m-BiVO4, as evidenced by steady-state photoluminescence (PL) measurements in the presence of charge scavengers. The better photoactivity of {010}-dominant m-BiVO4 is attributed to prompt electron transfer facilitated by the presence of more photogenerated electrons on the larger {010} surface. Additionally, the greater extent of electron trapping in {110}-dominant m-BiVO4 also deteriorates its photoactivity by inducing electron-hole pair recombination.

Dual role of 3-methyladenine in modulation of autophagy via different temporal patterns of inhibition on class I and III phosphoinositide 3-kinase.

A group of phosphoinositide 3-kinase (PI3K) inhibitors, such as 3-methyladenine (3-MA) and wortmannin, have been widely used as autophagy inhibitors based on their inhibitory effect on class III PI3K activity, which is known to be essential for induction of autophagy. In this study, we systematically examined and compared the effects of these two inhibitors on autophagy under both nutrient-rich and deprivation conditions. To our surprise, 3-MA is found to promote autophagy flux when treated under nutrient-rich conditions with a prolonged period of treatment, whereas it is still capable of suppressing starvation-induced autophagy. We first observed that there are marked increases of the autophagic markers in cells treated with 3-MA in full medium for a prolonged period of time (up to 9 h). Second, we provide convincing evidence that the increase of autophagic markers is the result of enhanced autophagic flux, not due to suppression of maturation of autophagosomes or lysosomal function. More importantly, we found that the autophagy promotion activity of 3-MA is due to its differential temporal effects on class I and class III PI3K; 3-MA blocks class I PI3K persistently, whereas its suppressive effect on class III PI3K is transient. Because 3-MA has been widely used as an autophagy inhibitor in the literature, understanding the dual role of 3-MA in autophagy thus suggests that caution should be exercised in the application of 3-MA in autophagy study.

Activation of the PI3K-Akt-mTOR signaling pathway promotes necrotic cell death via suppression of autophagy.

Our previous work has shown that autophagy plays a pro-survival function in two necrotic cell death models: zVAD-treated L929 cells as well as H(2)O(2)-treated Bax(-/-)Bak(-/-) mouse embryonic fibroblasts (DKO MEF). This study aims to further explore the regulatory role of autophagy in necrosis by examining the functional role of the phosphoinositide-3 kinase (PI3K)-Akt-mammalian target of rapamycin (mTOR) signaling pathway. Our initial intriguing finding was that insulin is able to promote necrotic cell death induced by zVAD and MNNG in L929 cells or by H(2)O(2) in DKO MEF cells cultured in full-growth medium. The pro-necrosis function of insulin was further supported by the observations that insulin is capable of abolishing the protective effect of starvation on necrotic cell death induced by zVAD in L929 cells. Next, we demonstrated that insulin acts on the PI3K-Akt-mTOR pathway to promote necrosis as the suppression of the above pathway by either chemical inhibitors (LY294002 and rapamycin) or mTOR knockdown is able to mitigate the pro-death function of insulin. Finally, we provided evidence that the pro-death function of insulin is dependent on its inhibitory effect on autophagy, which serves as an important pro-survival function in necrosis. Taken together, here we provide compelling evidence to show that activation of the PI3K-Akt-mTOR signaling pathway can promote necrotic cell death via suppression of autophagy, at least in the necrosis models defined in our study in which autophagy serves as a pro-survival function. Data from this study not only further underscore the pro-survival function of autophagy in necrotic cell death, but also provide a novel insight into the intricate connections linking the PI3K-Akt-mTOR signaling pathway with cell death via modulation of autophagy.