Heterogeneity exists in sepsis-associated acute kidney injury (SA-AKI). This study aimed to perform unsupervised consensus clustering in critically ill patients with dialysis-requiring SA-AKI.
This ...prospective observational cohort study included all septic patients, defined by the Sepsis-3 criteria, with dialysis-requiring SA-AKI in surgical intensive care units in Taiwan between 2009 and 2018. We employed unsupervised consensus clustering based on 23 clinical variables upon initializing renal replacement therapy. Multivariate-adjusted Cox regression models and Fine-Gray sub-distribution hazard models were built to test associations between cluster memberships with mortality and being free of dialysis at 90 days after hospital discharge, respectively.
Consensus clustering among 999 enrolled patients identified three sub-phenotypes characterized with distinct clinical manifestations upon renal replacement therapy initiation (n = 352, 396 and 251 in cluster 1, 2 and 3, respectively). They were followed for a median of 48 (interquartile range 9.5-128.5) days. Phenotypic cluster 1, featured by younger age, lower Charlson Comorbidity Index, higher baseline estimated glomerular filtration rate but with higher severity of acute illness was associated with an increased risk of death (adjusted hazard ratio of 3.05 95% CI, 2.35-3.97) and less probability to become free of dialysis (adjusted sub-distribution hazard ratio of 0.55 95% CI, 0.38-0.8) than cluster 3. By examining distinct features of the sub-phenotypes, we discovered that pre-dialysis hyperlactatemia ≥3.3 mmol/L was an independent outcome predictor. A clinical model developed to determine high-risk sub-phenotype 1 in this cohort (C-static 0.99) can identify a sub-phenotype with high in-hospital mortality risk (adjusted hazard ratio of 1.48 95% CI, 1.25-1.74) in another independent multi-centre SA-AKI cohort.
Our data-driven approach suggests sub-phenotypes with clinical relevance in dialysis-requiring SA-AKI and serves an outcome predictor. This strategy represents further development toward precision medicine in the definition of high-risk sub-phenotype in patients with SA-AKI.
Key messages
Unsupervised consensus clustering can identify sub-phenotypes of patients with SA-AKI and provide a risk prediction.
Examining the features of patient heterogeneity contributes to the discovery of serum lactate levels ≥ 3.3 mmol/L upon initializing RRT as an independent outcome predictor.
This data-driven approach can be useful for prognostication and lead to a better understanding of therapeutic strategies in heterogeneous clinical syndromes.
Abstract
Introduction
Various approaches have been suggested to identify acute kidney injury (AKI) early and to initiate kidney-protective measures in patients at risk or with AKI. The objective of ...this study was to evaluate whether care bundles improve kidney outcomes in these patients.
Methods
We conducted a systematic review of the literature to evaluate the clinical effectiveness of AKI care bundles with or without urinary biomarkers in the recognition and management of AKI. The main outcomes were major adverse kidney events (MAKEs) consisting of moderate-severe AKI, receipt of renal replacement therapy (RRT), and mortality.
Results
Out of 7434 abstracts screened, 946 published studies were identified. Thirteen studies five randomized controlled trials (RCTs) and eight non-RCTs including 16,540 patients were eligible for inclusion in the meta-analysis. Meta-analysis showed a lower incidence of MAKE in the AKI care bundle group odds ratio (OR) 0.73, 95% confidence interval (CI) 0.66–0.81 with differences in all 3 individual outcomes moderate–severe AKI (OR 0.65, 95% CI 0.51–0.82), RRT (OR 0.63, 95% CI = 0.46–0.88) and mortality. Subgroup analysis of the RCTs, all adopted biomarker-based approach, decreased the risk of MAKE (OR 0.55, 95% CI 0.41–0.74). Network meta-analysis could reveal that the incorporation of biomarkers in care bundles carried a significantly lower risk of MAKE when compared to care bundles without biomarkers (OR = 0.693, 95% CI = 0.50–0.96), while the usual care subgroup had a significantly higher risk (OR = 1.29, 95% CI = 1.09–1.52).
Conclusion
Our meta-analysis demonstrated that care bundles decreased the risk of MAKE, moderate–severe AKI and need for RRT in AKI patients. Moreover, the inclusion of biomarkers in care bundles had a greater impact than care bundles without biomarkers.
Proenkephalin A 119-159 (PENK) is freely filtered in the glomerulus with plasma levels correlating with glomerular filtration rate. Therefore, PENK has been proposed as an early indicator of acute ...kidney injury (AKI) although its performance is dependent on the clinical setting. This meta-analysis aimed to investigate the correlation between PENK levels and the development of AKI.
We conducted a comprehensive search on the PubMed, Embase, Cochrane databases, the website ClinicalTrials.gov and Cnki.net until June 26, 2023. Summary receiver operating characteristic (SROC) curves were used to amalgamate the overall test performance. Diagnostic odds ratio (DOR) was employed to compare the diagnostic accuracy of PENK with other biomarkers. Quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria.
We incorporated 11 observational studies with 3969 patients with an incidence of AKI of 23.4% (929 out of 3969 patients) with the best optimal cutoff value of PENK for early detection of AKI being 57.3 pmol/L. The overall sensitivity and specificity of PENK in identifying AKI were 0.69 (95% CI 0.62-0.75) and 0.76 (95% CI 0.68-0.82), respectively. The combined positive likelihood ratio (LR) stood at 2.83 (95% CI 2.06-3.88), and the negative LR was 0.41 (95% CI 0.33-0.52). The SROC curve showcased pooled diagnostic accuracy of 0.77 (95% CI 0.73-0.81). Interestingly, patients with a history of hypertension or heart failure demonstrated a lower specificity of PENK in correlating the development of AKI.
Our results indicate that PENK possesses significant potential as a biomarker for the early detection of the development of AKI, using a cutoff point of 57.3 pmol/L for PENK.
In response to the irreversible aging trend, the Taiwan government has promoted the Long-Term Care (LTC) policy 1.0 launched in 2007 and the LTC policy 2.0 reform since 2016. This study aimed to ...explore the utilization of formal home and community-based care under LTC policy 1.0 to add scientific support for the on-going LTC policy 2.0 reform.
By using Andersen and Aday's behavioral model of healthcare utilization, the long-term care dataset was analyzed from 2013 to 2016. A total of 101,457 care recipients were identified after data cleaning.
The results revealed that about 40.7% of the care recipients stayed in the care system for more than two years. A common factor influencing the length of home and community-based services (HCBS) utilization period included need factors, where more dependent recipients leave the LTC system regardless of their socio-economic status. However, the utilization period of non-low-income households is significantly affected by the level of service resources.
For long-term care needs, the phenomenon of a short utilization period was concerning. This study adds information which suggests policy should reconsider care capacity and quality, especially for moderate to severely dependent recipients. This will allow for better understanding to help maintain care recipients in their own communities to achieve the goal of having an aging in place policy.
To test the Clustered Cardiometabolic Risk (CCMR) factor explaining the relationship between physical activity and physical quality of life (QOL).
Using the U.S. National Health and Nutrition ...Examination Survey 2003–2006, 2,445 adults completed the CDC Healthy Days Questionnaire for measuring QOL, wore the accelerometer for assessing physical activity pattern (PAP), and completed triglyceride, glucose, serum insulin, waist circumference, blood pressure, and HDL-cholesterol tests from which the CCMR factor was created. Physical QOL was classified as poor (≥14 days with poor physical health within past 30 days) vs. good (<14 days). We classified PAP by moderate-to-vigorous physical activity (MVPA), light-intensity physical activity (LIPA), and sedentary behavior (SB). We defined MVPA, LIPA, and SB as ≥2020 counts/minute, 100–2019 counts/minute, and ≤99 counts/minute, respectively. We further classified PAP status as unhealthy (MVPA <150 min/week & SB>LIPA) or healthy (MVPA <150 min/week & SB<LIPA, or MVPA ≥150 min/week regardless of SB>LIPA or SB<LIPA). Logistic regressions analyzed the association between unhealthy PAP and poor physical QOL, adjusting for the CCMR factor, age, sex, education, and smoking behavior.
Compared with having healthy PAP, individuals having unhealthy PAP had an elevated risk of poor physical QOL (OR = 1.96; 95% CI = 1.42–2.72). However, this association was explained by higher levels of the CCMR factor (OR = 1.46; 95% CI = 1.07–1.99) through poorer serum insulin (OR = 1.35; 95% CI = 1.04–1.75) and waist circumference (OR = 1.23; 95% CI = 1.02–1.50).
The CCMR factor (typically insulin and waist circumference) explained the association between unhealthy physical activity and poor physical QOL.
As the climate seriously changes, ecofriendly nanomaterials have attracted tremendous interest in renewable energy as photocatalysis. Herein, we designed a new green bismuth-based Z-scheme Bi2O22+ ...slabs coordinate with 2-aminoterephthalic acid (N-BOB)/BiOIO3 through a simple anion exchange and postsynthetic hydrothermal reaction. FTIR, XRD, FESEM and TEM were employed to characterize the functional groups, structure, and morphologies. UV-DRS revealed the difference in band energy of the N-BOB and N-BOB/BiOIO3. Toward Rh B, TC and CIP degradation tests, 1-N-BOB/BiOIO3 manifests the best photocatalytic degradation (52.3%, 63.6% and 30.2%) efficiency. Also, 1-N-BOB/BiOIO3 possesses high durability in photocatalytic reactions and can inhibit 32.3% of bacterial growth. The results indicate that the synergistic effect between surface amine groups and Z-scheme heterojunction harvests light absorption to increase solar-to-energy (STE) efficiency, accelerate the charge separation, and increases the active sites with high photoredox potential, thus improving the photocatalytic performance. ROS scavenging tests further elucidated that photogenerated holes and hydroxyl radicals play a critical role. In addition, the surface amine groups and benzene rings can be utilized for supercapacitors and other multidisciplinary applications. 0.5 N-BOB/BiOIO3/GO impressively showed 5 times higher specific capacitance than pure GO electrode. We hope this work provides new sight into designing green nanomaterials to relieve environmental pollution and leave behind a clean future for the next generation.
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•A new green bismuth-based Z-scheme Bi2O22+ slabs coordinate with 2-aminoterephthalic acid (N-BOB)/BiOIO3 performed.•1-N-BOB/BiOIO3 manifests the great photocatalytic degradation for Rh B, TC and CIP tests.•1-N-BOB/BiOIO3 possesses high durability in photocatalytic reactions and can inhibit 32.3% of bacterial behavior.•The surface amine groups and benzene rings of N-BOB/BiOIO3 can be utilized for multidisciplinary applications.
The energy-intensive pulp and paper industry is a major contributor to carbon dioxide emissions. The potential to reduce energy consumption and carbon dioxide emissions is generally assessed using ...energy conservation supply curves and marginal abatement cost curves; however, both of these methods have inherent faults. For a given negative cost, conventional marginal abatement cost curves tend to favor options that lead to small reductions in carbon dioxide emissions over options that produce larger reductions. In the current study, we employed extended versions of energy conservation supply curves and marginal abatement cost curves to analyze the various options to reduce energy consumption and carbon dioxide emissions. The technical potential energy savings and carbon dioxide abatement were respectively estimated at 5.05% of the final energy use in the sector and 6.32% of carbon dioxide emissions in 2019. We determined that 52.3% of the electricity savings and 82.8% of fuel savings could be achieved in a cost-effective manner. Additionally, the utilization of solid recovered fuels remains a largely untapped opportunity to reduce carbon dioxide emissions for the Taiwanese pulp and paper industry. Thus, efforts should be made to establish a comprehensive database pertaining to the direction and volume of waste flows and improve waste collection networks with corresponding standards pertaining to solid recovered fuels quality and air pollution.
•Ranking of negative cost options is unreliable in marginal abatement cost curves.•This study employed extended versions of marginal abatement cost curves.•We empirically demonstrate the bias in marginal abatement cost curves.•Our method explicitly addresses the problem of ranking negative cost options.
This research focuses on developing a reliable methodology for predicting the performance of buoyancy-driven ventilation in atrium buildings during the design stage using both computational fluid ...dynamics (CFD) and scale model tests. The results show several features. First, the agreement between CFD simulation and measurement results in the heated zone is better with rng
k–
ɛ and zero-equation turbulent schemes; whereas, in the atrium space, the laminar and zero-equation CFD models provide better results. Second, the external ambient temperature has a larger effect on the temperature distribution in the atrium space than the thermal load inside the building. Third, the position of the stack openings that create a direct ventilation path can improve the internal thermal environment. The size of the stack openings also affects the temperature distribution in the atrium space. Lastly, due to the small temperature difference in hot and humid climates, a buoyancy-only ventilation strategy is not very effective in such a situation. That is, when a low-rise atrium building is situated in a hot and humid environment, additional efforts such as wind-driven ventilation, wind-buoyancy ventilation or mechanically driven ventilation will be necessary to achieve the thermal comfort desired.
Rapid advances in mobile technology have given rise to a proliferation of mobile apps. LINE, an instant messaging app popular around the world, combines text-based communications with cute emoji-like ...images called “e-stickers.” This study extended the stimulus-organism-response (SO-R) model to investigate how sticker features and user characteristics influence branding effect (brand awareness, brand attitude, and brand attachment), download willingness, and product purchase intention.
A 2 (brand image: with vs. without) × 2 (product image percentage: high vs. low) × 2 (usage period: short vs. long) × 2 (sticker-use frequency: high vs. low) between-subjects design was employed. Structural equation modeling (SEM) of data collected from 361 participants in 2016 found that brand image, product image percentage, usage period, and sticker-use frequency had different impacts on branding effect. Moreover, brand attitude significantly influenced download willingness of LINE stickers, and both brand attitude and brand attachment influenced product purchase intentions.
Finally, this study further examined the moderating effect of sticker-use frequency and 24 indirect effects of three mediators to detail how sticker features and user characteristics influence download willingness and product purchase intention. Important managerial implications for online marketing managers are discussed.
In this study we focused on how Facebook games affect players' behaviors and influence their purchase intention. Participants (N = 194) completed questionnaires relating to their game playing ...behaviors on Facebook. We found that 3 factors - interactivity, challenge, and
novelty - had a positive influence on players' flow experience, a concept introduced by Csikszentmihalyi (1975); while a fourth factor - sociality - was found not to affect flow. Furthermore, price perception, i.e., players' views of value as measured against cost, also influenced
their purchase intention. Therefore, we determined that flow and price perception significantly enhance purchase intention. Future game developers could focus on the game attributes that increase players' flow experience, thereby attracting more players, especially those willing to purchase
a game.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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