Prior sepsis studies evaluating antibiotic timing have shown mixed results.
To evaluate the association between antibiotic timing and mortality among patients with sepsis receiving antibiotics within ...6 hours of emergency department registration.
Retrospective study of 35,000 randomly selected inpatients with sepsis treated at 21 emergency departments between 2010 and 2013 in Northern California. The primary exposure was antibiotics given within 6 hours of emergency department registration. The primary outcome was adjusted in-hospital mortality. We used detailed physiologic data to quantify severity of illness within 1 hour of registration and logistic regression to estimate the odds of hospital mortality based on antibiotic timing and patient factors.
The median time to antibiotic administration was 2.1 hours (interquartile range, 1.4-3.1 h). The adjusted odds ratio for hospital mortality based on each hour of delay in antibiotics after registration was 1.09 (95% confidence interval CI, 1.05-1.13) for each elapsed hour between registration and antibiotic administration. The increase in absolute mortality associated with an hour's delay in antibiotic administration was 0.3% (95% CI, 0.01-0.6%; P = 0.04) for sepsis, 0.4% (95% CI, 0.1-0.8%; P = 0.02) for severe sepsis, and 1.8% (95% CI, 0.8-3.0%; P = 0.001) for shock.
In a large, contemporary, and multicenter sample of patients with sepsis in the emergency department, hourly delays in antibiotic administration were associated with increased odds of hospital mortality even among patients who received antibiotics within 6 hours. The odds increased within each sepsis severity strata, and the increased odds of mortality were greatest in septic shock.
The authors used a validated model with electronic-medical-record data to identify hospitalized patients at high risk for clinical deterioration. The intervention, which involved remote monitoring by ...nurses who reviewed records of high-risk patients and communicated with in-hospital rapid-response teams, was associated with decreased 30-day mortality.
Abstract
We present ALMA C ii line and far-infrared (FIR) continuum observations of three $z \gt 6$ low-luminosity quasars ($M_{\rm 1450} \gt -25$ mag) discovered by our Subaru Hyper Suprime-Cam ...(HSC) survey. The C ii line was detected in all three targets with luminosities of $(2.4\mbox{--}9.5) \times 10^8\, L_{\odot }$, about one order of magnitude smaller than optically luminous ($M_{\rm 1450} \lesssim -25$ mag) quasars. The FIR continuum luminosities range from $\lt 9 \times 10^{10}\, L_{\odot }$ (3 $\sigma$ limit) to ${\sim } 2 \times 10^{12}\, L_{\odot }$, indicating a wide range in star formation rates in these galaxies. Most of the HSC quasars studied thus far show C ii/ FIR luminosity ratios similar to local star-forming galaxies. Using the C ii-based dynamical mass ($M_{\rm dyn}$) as a surrogate for bulge stellar mass ($M_{\rm\, bulge}$), we find that a significant fraction of low-luminosity quasars are located on or even below the local $M_{\rm\, BH}$–$M_{\rm\, bulge}$ relation, particularly at the massive end of the galaxy mass distribution. In contrast, previous studies of optically luminous quasars have found that black holes are overmassive relative to the local relation. Given the low luminosities of our targets, we are exploring the nature of the early co-evolution of supermassive black holes and their hosts in a less biased way. Almost all of the quasars presented in this work are growing their black hole mass at a much higher pace at $z \sim 6$ than the parallel growth model, in which supermassive black holes and their hosts grow simultaneously to match the local $M_{\rm\, BH}$–$M_{\rm\, bulge}$ relation at all redshifts. As the low-luminosity quasars appear to realize the local co-evolutionary relation even at $z \sim 6$, they should have experienced vigorous starbursts prior to the currently observed quasar phase to catch up with the relation.
Objective
To describe the character and composition of the 2015 US adult rheumatology workforce, evaluate workforce trends, and project supply and demand for clinical rheumatology care for 2015–2030.
...Methods
The 2015 Workforce Study of Rheumatology Specialists in the US used primary and secondary data sources to estimate the baseline adult rheumatology workforce and determine demographic and geographic factors relevant to workforce modeling. Supply and demand was projected through 2030, utilizing data‐driven estimations regarding the proportion and clinical full‐time equivalent (FTE) of academic versus nonacademic practitioners.
Results
The 2015 adult workforce (physicians, nurse practitioners, and physician assistants) was estimated to be 6,013 providers (5,415 clinical FTE). At baseline, the estimated demand exceeded the supply of clinical FTE by 700 (12.9%). By 2030, the supply of rheumatology clinical providers is projected to fall to 4,882 providers, or 4,051 clinical FTE (a 25.2% decrease in supply from 2015 baseline levels). Demand in 2030 is projected to exceed supply by 4,133 clinical FTE (102%).
Conclusion
The adult rheumatology workforce projections reflect a major demographic and geographic shift that will significantly impact the supply of the future workforce by 2030. These shifts include baby‐boomer retirements, a millennial predominance, and an increase of female and part‐time providers, in parallel with an increased demand for adult rheumatology care due to the growing and aging US population. Regional and innovative strategies will be necessary to manage access to care and reduce barriers to care for rheumatology patients.
Objective: Using a comprehensive inpatient electronic medical record, we sought to develop a risk-adjustment methodology applicable to all hospitalized patients. Further, we assessed the impact of ...specific data elements on model discrimination, explanatory power, calibration, integrated discrimination improvement, net reclassification improvement, performance across different hospital units, and hospital rankings. Design: Retrospective cohort study using logistic regression with split validation. Participants: A total of 248,383 patients who experienced 391,584 hospitalizations between January 1, 2008 and August 31, 2011. Setting: Twenty-one hospitals in an integrated health care delivery system in Northern California. Results: Inpatient and 30-day mortality rates were 3.02% and 5.09%, respectively. In the validation dataset, the greatest improvement in discrimination (increase in c statistic) occurred with the introduction of laboratory data; however, subsequent addition of vital signs and end-of-life care directive data had significant effects on integrated discrimination improvement, net reclassification improvement, and hospital rankings. Use of longitudinally captured comorbidities did not improve model performance when compared with present-on-admission coding. Our final model for inpatient mortality, which included laboratory test results, vital signs, and care directives, had a c statistic of 0.883 and a pseudo-R 2 of 0.295. Results for inpatient and 30-day mortality were virtually identical. Conclusions: Risk-adjustment of hospital mortality using comprehensive electronic medical records is feasible and permits one to develop statistical models that better reflect actual clinician experience. In addition, such models can be used to assess hospital performance across specific subpopulations, including patients admitted to intensive care.
The gene encoding IgH δ has been found in all species of teleosts studied to date. However, catfish (Ictalurus punctatus) is the only species of fish in which a secretory form of IgD has been ...characterized, and it occurs through the use of a dedicated δ-secretory exon, which is absent from all other species examined. Our studies have revealed that rainbow trout (Oncorhynchus mykiss) use a novel strategy for the generation of secreted IgD. The trout secretory δ transcript is produced via a run-on event in which the splice donor site at the end of the last constant domain exon (D7) is ignored and transcription continues until a stop codon is reached 33 nt downstream of the splice site, resulting in the production of an in-frame, 11-aa secretory tail at the end of the D7 domain. In silico analysis of several published IgD genes suggested that this unique splicing mechanism may also be used in other species of fish, reptiles, and amphibians. Alternative splicing of the secretory δ transcript resulted in two δ-H chains, which incorporated Cμ1 and variable domains. Secreted IgD was found in two heavily glycosylated isoforms, which are assembled as monomeric polypeptides associated with L chains. Secretory δ mRNA and IgD(+) plasma cells were detected in all immune tissues at a lower frequency than secretory IgM. Our data demonstrate that secretory IgD is more prevalent and widespread across taxa than previously thought, and thus illustrate the potential that IgD may have a conserved role in immunity.
The Subaru Prime Focus Spectrograph (PFS) is a massively multiplexed fiber-fed optical and near-infrared three-arm spectrograph (N
fiber = 2400, 380 ≤ λ ≤ 1260 nm, 1
$_{.}^{\circ}$
3 diameter field ...of view). Here, we summarize the science cases in terms of provisional plans for a 300-night Subaru survey. We describe plans to constrain the nature of dark energy via a survey of emission line galaxies spanning a comoving volume of 9.3 h
−3 Gpc3 in the redshift range 0.8 < z < 2.4. In each of six redshift bins, the cosmological distances will be measured to 3% precision via the baryonic acoustic oscillation scale, and redshift-space distortion measures will constrain structure growth to 6% precision. In the near-field cosmology program, radial velocities and chemical abundances of stars in the Milky Way and M 31 will be used to infer the past assembly histories of spiral galaxies and the structure of their dark matter halos. Data will be secured for 106 stars in the Galactic thick-disk, halo, and tidal streams as faint as V ∼ 22, including stars with V < 20 to complement the goals of the Gaia mission. A medium-resolution mode with R = 5000 to be implemented in the red arm will allow the measurement of multiple α-element abundances and more precise velocities for Galactic stars. For the galaxy evolution program, our simulations suggest the wide wavelength range of PFS will be powerful in probing the galaxy population and its clustering over a wide redshift range. We plan to conduct a color-selected survey of 1 < z < 2 galaxies and AGN over 16 deg2 to J ≃ 23.4, yielding a fair sample of galaxies with stellar masses above ∼1010 M
⊙ at z ≃ 2. A two-tiered survey of higher redshift Lyman break galaxies and Lyman alpha emitters will quantify the properties of early systems close to the reionization epoch.
ABSTRACT
At fixed galaxy stellar mass, there is a clear observational connection between structural asymmetry and offset from the star-forming main sequence, ΔSFMS. Herein, we use the TNG50 ...simulation to investigate the relative roles of major mergers (stellar mass ratios μ ≥ 0.25), minor (0.1 ≤ μ < 0.25), and mini mergers (0.01 ≤ μ < 0.1) in driving this connection amongst star-forming galaxies (SFGs). We use dust radiative transfer post-processing with SKIRT to make a large, public collection of synthetic Hyper Suprime-Cam Subaru Strategic Program (HSC-SSP) images of simulated IllustrisTNG (TNG) galaxies over 0.1 ≤ z ≤ 0.7 with log (M⋆/M⊙) ≥ 9 (∼750 k images). Using their instantaneous star formation rates (SFRs), known merger histories/forecasts, and HSC-SSP asymmetries, we show (1) that TNG50 SFGs qualitatively reproduce the observed trend between ΔSFMS and asymmetry and (2) a strikingly similar trend emerges between ΔSFMS and the time-to-coalescence for mini mergers. Controlling for redshift, stellar mass, environment, and gas fraction, we show that individual mini merger events yield small enhancements in SFRs and asymmetries that are sustained on long time-scales (at least ∼3 Gyr after coalescence, on average) – in contrast to major/minor merger remnants which peak at much greater amplitudes but are consistent with controls only ∼1 Gyr after coalescence. Integrating the boosts in SFRs and asymmetries driven by μ ≥ 0.01 mergers since z = 0.7 in TNG50 SFGs, we show that mini mergers are responsible for (i) 55 per cent of all merger-driven star formation and (ii) 70 per cent of merger-driven asymmetric structure. Due to their relative frequency and prolonged boost time-scales, mini mergers dominate over their minor and major counterparts in driving star formation and asymmetry in SFGs.
To use unsupervised topic modeling to evaluate heterogeneity in sepsis treatment patterns contained within granular data of electronic health records.
A multicenter, retrospective cohort study of 29 ...253 hospitalized adult sepsis patients between 2010 and 2013 in Northern California. We applied an unsupervised machine learning method, Latent Dirichlet Allocation, to the orders, medications, and procedures recorded in the electronic health record within the first 24 hours of each patient's hospitalization to uncover empiric treatment topics across the cohort and to develop computable clinical signatures for each patient based on proportions of these topics. We evaluated how these topics correlated with common sepsis treatment and outcome metrics including inpatient mortality, time to first antibiotic, and fluids given within 24 hours.
Mean age was 70 ± 17 years with hospital mortality of 9.6%. We empirically identified 42 clinically recognizable treatment topics (eg, pneumonia, cellulitis, wound care, shock). Only 43.1% of hospitalizations had a single dominant topic, and a small minority (7.3%) had a single topic comprising at least 80% of their overall clinical signature. Across the entire sepsis cohort, clinical signatures were highly variable.
Heterogeneity in sepsis is a major barrier to improving targeted treatments, yet existing approaches to characterizing clinical heterogeneity are narrowly defined. A machine learning approach captured substantial patient- and population-level heterogeneity in treatment during early sepsis hospitalization.
Using topic modeling based on treatment patterns may enable more precise clinical characterization in sepsis and better understanding of variability in sepsis presentation and outcomes.
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