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Context: Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress., Objectives: The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates., Methods: Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER's acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments., Results: Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen's d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER., Conclusions: EMPOWER appeared feasible and acceptable, increased surrogates' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later., (Copyright © 2024 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Acute respiratory failure and a systemic coagulopathy are critical aspects of the morbidity and mortality characterizing infection with severe acute respiratory distress syndrome-associated coronavirus-2, the etiologic agent of Coronavirus disease 2019 (COVID-19). We examined skin and lung tissues from 5 patients with severe COVID-19 characterized by respiratory failure (n= 5) and purpuric skin rash (n = 3). COVID-19 pneumonitis was predominantly a pauci-inflammatory septal capillary injury with significant septal capillary mural and luminal fibrin deposition and permeation of the interalveolar septa by neutrophils. No viral cytopathic changes were observed and the diffuse alveolar damage (DAD) with hyaline membranes, inflammation, and type II pneumocyte hyperplasia, hallmarks of classic acute respiratory distress syndrome, were not prominent. These pulmonary findings were accompanied by significant deposits of terminal complement components C5b-9 (membrane attack complex), C4d, and mannose binding lectin (MBL)-associated serine protease (MASP)2, in the microvasculature, consistent with sustained, systemic activation of the complement pathways. The purpuric skin lesions similarly showed a pauci-inflammatory thrombogenic vasculopathy, with deposition of C5b-9 and C4d in both grossly involved and normally-appearing skin. In addition, there was co-localization of COVID-19 spike glycoproteins with C4d and C5b-9 in the interalveolar septa and the cutaneous microvasculature of 2 cases examined. In conclusion, at least a subset of sustained, severe COVID-19 may define a type of catastrophic microvascular injury syndrome mediated by activation of complement pathways and an associated procoagulant state. It provides a foundation for further exploration of the pathophysiologic importance of complement in COVID-19, and could suggest targets for specific intervention., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Context: Deaths in the intensive care unit (ICU) are increasingly common in the U.S., yet little is known about patients' experiences at the end of life in the ICU., Objectives: The objective of this study was to determine nurse assessment of symptoms experienced, and care received by ICU patients in their final week, and their associations with nurse-perceived suffering and dignity., Methods: From September 2015 to March 2017, nurses who cared for 200 ICU patients who died were interviewed about physical and psychosocial dimensions of patients' experiences. Medical chart abstraction was used to document baseline patient characteristics and care., Results: The patient sample was 61% males, 70.2% whites, and on average 66.9 (SD 15.1) years old. Nurses reported that 40.9% of patients suffered severely and 33.1% experienced severe loss of dignity. The most common symptoms perceived to contribute to suffering and loss of dignity included trouble breathing (44.0%), edema (41.9%), and loss of control of limbs (36.1%). Most (n = 9) remained significantly (P < 0.05) associated with suffering, after adjusting for physical pain, including fever/chills, fatigue, and edema. Most patients received vasopressors and mechanical ventilation. Renal replacement therapy was significantly (<0.05) associated with severe suffering (adjusted odds ratio [AOR] 2.53) and loss of dignity (AOR 3.15). Use of feeding tube was associated with severe loss of dignity (AOR 3.12)., Conclusion: Dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. Attention to symptoms such as dyspnea and edema may improve the quality of death in the ICU., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

The objectives of this study were to determine the force of infection (FOI) for Theileria equi in horses in Israel and to evaluate risk factors associated with seroprevalence a decade after it was last determined by PCR, in 2002. Using a commercial cELISA kit, we demonstrated a widespread and constant exposure to T. equi in Israel (110/216; 50.9%) and the Palestinian Authority (32/108; 29.6%). Owing to the paired samples collected from the same horses approximately one year apart, we were able to determine the FOI rate with which susceptible individuals become infected. Out of the 75 naïve horses in the first collection, four seroconverted during 10-16 months, demonstrating an FOI of 5% for that period. Similar results were obtained by calculating FOI using age-specific seroprevalence (4.2% per year). Housing management type was significantly associated with T. equi seroprevalence with 87.9% seropositivity in horses on pasture and 32.6% seropositivity in horses in stalls/yards. This strong association and the very high seroprevalence found in horses held on pasture, prompted stratification of data accordingly. Geographical location of horses in Israel showed a strong association with seroprevalence to T. equi ranging from 34.5% in central Israel to 80.8% in the northern part of the country. However, when analyzing this association only in horses held in stalls/yards, the lower seroprevalence was noted in the north. In addition, age was significantly associated with seroprevalence for T. equi only in horses held in stalls/yards (R(2)=0.94). Environmental variables were not found to be associated with seroprevalence for T. equi. Here, we report for the first time the FOI for T. equi in horses and highlight the influence housing management type has on the evaluation of risk factors associated with a vector-borne disease, perhaps leading to the discrepancies observed between studies throughout the world., (Copyright © 2014 Elsevier GmbH. All rights reserved.)

The prevalence of Theileria equi infection as well as the environmental and demographic risk factors for infection was studied in 590 healthy horses from 46 farms in Israel. The prevalence of T. equi DNA was assessed using a polymerase chain reaction for a segment of the Theileria 18S rRNA gene. The overall prevalence was 26.4% (156/590). There was a significant geographical variation in the prevalence of T. equi infection, ranging from 9.3% (25/270) in the central lowlands to 81.7% (49/60) in the Golan Heights. The prevalence of T. equi infection was found to be significantly associated with management types with more horses with access to pasture being positive. Breed was identified as a risk factor for T. equi infection in a univariate analysis with relatively high infection rates in the Quarter horse and local breeds (41.1% and 36.3% respectively), while ponies and Arabian horses had a relatively low prevalence (10% and 9.1%, respectively). However, since a correlation between geographic location and breed was found, it is difficult to draw definite conclusions regarding this risk factor. Age and gender were not found as risk factors for T. equi infection in this study. The environmental variables that were significantly associated with positivity were relative humidity and minimum land surface temperature at day which both showed negative correlation with T. equi prevalence. In conclusion, Israel was found to be enzootic for T. equi infection, as indicated by the high sub-clinical infection rate, which differed between geographical areas., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Tube and line interpretation in portable chest radiographs was assessed using a new visualization method. When using the new method, radiologists' interpretation time was reduced by 30% vs. standard modality processing and window and level (23 vs. 33 s). For pulmonary ICU physicians, reading time was essentially unchanged. There was more than a 50% reduction in the use of inferential language in the dictation for both reader groups when using the new method, suggesting greater interpretation confidence., (Copyright © 2011 Elsevier Inc. All rights reserved.)

An outbreak of trypanosomoasis caused by Trypanosoma evansi involving horses, camels and donkeys occurred in a farm in Israel. A longitudinal study of two outbreak phases was conducted which included clinical monitoring, blood smears, packed cell volume (PCV), serology and polymerase chain reaction (PCR) followed by reverse dot blot (RDB) for the molecular detection of infection. This was the first reported T. evansi outbreak in domestic animals in Israel. Most of the camels on the farm (8/10; 80%) were diagnosed with T. evansi infection whereas infection was less prevalent in the horses (3/7; 43%) and donkeys (6/13; 46%). Clinical disease was evident in 4 camels and 1 horse exhibiting characteristic clinical signs, anemia and parasitemia detected on blood smears and by positive RDB. Six other animals were diagnosed as asymptomatic latent carriers by positive RDB and 6 additional animals were only seropositive and were considered suspected carriers. A significant difference was found in the mean PCV between symptomatic and latent carriers with severe anemia observed only in the symptomatic animals. An anaphylactic-like reaction, fatal in one case, was observed in 2 camels diagnosed with severe trypanosome parasitemia immediately following treatment with melarsenoxide cysteamine. Furthermore, recurrence of infection was documented in one camel 4 months post treatment., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Trypanosomiasis caused by Trypanosoma evansi ("Surra") is mainly a wasting disease affecting equids, camels and cattle as well as other domestic and wild animal species. In horses, infection may cause severe neurological abnormalities; however, the clinical progression, pathogenesis and molecular ante-mortem detection of this form of the disease have not been described in detail. A mare with progressive ataxia, head tilt, nystagmus and cranial nerve deficits submitted to treatment was diagnosed with central nervous system trypanosomiasis following the detection of a Trypanosoma tryposmastigote in cerebrospinal fluid cytology. Histopathology following necropsy showed that the brain, spinal cord and kidneys were the main affected tissues with disseminated multifocal non-suppurative meningoencephalitis of the central nervous system and membranoproliferative glomerulonephritis. Serology for T. evansi was positive and PCR indicated the presence of parasite DNA in the cerebellum, brain stem, spinal cord and bone marrow but not in other organs and confirmed the identity of causative agent as T. evansi. This is the first report of ante-mortem detection of T. evansi in the cerebrospinal fluid of a horse and the first description of post-mortem PCR identification of the parasite DNA in the nervous system.

Background & Aims: Malnutrition is frequently observed in chronic and severe diseases and associated with impaired outcome. In Germany general data on prevalence and impact of hospital malnutrition are missing., Methods: Nutritional state was assessed by subjective global assessment (SGA) and by anthropometric measurements in 1,886 consecutively admitted patients in 13 hospitals (n=1,073, university hospitals; n=813, community or teaching hospitals). Risk factors for malnutrition and the impact of nutritional status on length of hospital stay were analyzed., Results: Malnutrition was diagnosed in 27.4% of patients according to SGA. A low arm muscle area and arm fat area were observed in 11.3% and 17.1%, respectively. Forty-three % of patients 70 years old were malnourished compared to only 7.8% of patients <30 years. The highest prevalence of malnutrition was observed in geriatric (56.2%), oncology (37.6%), and gastroenterology (32.6%) departments. Multivariate analysis revealed three independent risk factors: higher age, polypharmacy, and malignant disease (all P<0.01). Malnutrition was associated with an 43% increase of hospital stay (P<0.001)., Conclusions: In German hospitals every fourth patient is malnourished. Malnutrition is associated with increased length of hospital stay. Higher age, malignant disease and major comorbidity were found to be the main contributors to malnutrition. Adequate nutritional support should be initiated in order to optimize the clinical outcome of these patients.

Background: Pathological brain iron deposition has been implicated as a source of neurotoxic reactive oxygen species in Alzheimer disease (AD). Recent reports suggest that heterozygosity for the two common hfe mutations responsible for hereditary hemochromatosis (HH) may be a risk factor for AD, possibly by accelerating brain iron accumulation., Methods: To test this hypothesis, we genotyped 213 sporadic AD, 106 MCI, and 63 normal elderly control (NEC) individuals for the H63D and C282Y hfe mutations by polymerase chain reaction (PCR)/restriction fragment length polymorphism (RFLP) analysis. We determined the relationship of these mutations to the demographic, clinical, and neuropsychological features of AD and MCI, and evaluated whether an interaction existed between hfe and apolipoprotein E (apoE) status in these patients., Results: We observed no significant impact of H63D or C282Y heterozygosity on age at AD symptoms onset or diagnosis, age at onset of cognitive symptoms (AD and MCI combined), rates of MCI-to-AD conversion or specific neuropsychological deficits. No interactions between hfe zygosity and apoE status were discerned. Patients homozygous for H63D exhibited trends towards accelerated MCI-to-AD conversion rates and a subset of younger individuals (aged 55-75) exhibited earlier onset of cognitive symptoms relative to wild-type hfe and H63D heterozygotes., Conclusions: Contrary to earlier reports, the results of the present study do not implicate the common hfe mutations as genetic modifiers of sporadic AD and MCI. Trends towards accelerated cognitive dysfunction in H63D homozygotes warrant further study.

The occurrence of pneumothorax after an invasive transthoracic procedure is a well-known complication. Less well-recognized is the occurrence of bilateral pneumothoraces after a unilateral intervention with a potential for life-threatening consequences in patients who have undergone median sternotomies. We present a patient who had undergone a thymoma resection in the remote past and developed bilateral pneumothoraces after undergoing transthoracic needle biopsy of a right lung nodule.

Hitherto the mechanisms controlling the selective cleavage of peptide bonds by the 20 S proteasome have been poorly understood. The observation that peptide bond cleavage may eventually occur at the carboxyl site of either amino acid residue rules out a simple control of cleavage preferences by the P1 residue alone. Here, we follow the rationale that the presence of specific cleavage-determining amino acids motifs (CDAAMs) around the scissile peptide bond are required for the attainment of substrate conformations susceptible to cleavage. We present an exploratory search for these putative motifs based on empirical regression functions relating the cleavage probability for a given peptide bond to some selected side-chain properties of the flanking amino acid residues. Identification of the sequence locations of cleavage-determining residues relative to the scissile bond and of their optimal side-chain properties was carried out by fitting the cleavage probability to (binary) experimental observations on peptide bond cleavage gathered among a set of seven different peptide substrates with known patterns of proteolytic degradation products. In this analysis, all peptide bonds containing the same residue in the P1 position were assumed to be cleaved by the same active sites of the proteasome, and thus to be under control of the same CDAAMs. We arrived at a final set of ten different CDAAMs, accounting for the cleavage of one to five different groups of peptide bonds with an overall predictive correctness of 93 %. The CDAAM is composed of two to four "anchor" positions preferentially located between P5 and P5' around the scissile bond. This implies a length constraint for the usage of cleavage sites, which could considerably suppress the excision of shorter fragments and thus partially explain for the observed preponderance of medium-size cleavage products., (Copyright 1999 Academic Press.)

The purposes of the research reported here were first to explore a murine model for human placental and umbilical cord blood transplantation and second to evaluate the engraftment ability of ex vivo cultured hematopoietic cells. Murine near-term fetal and neonatal peripheral blood (FNPB) cells, genetically marked with the human multiple drug resistance transgene (MDR1) were used for syngeneic transplants into sublethally irradiated adult mice. Donor cells were transplanted either fresh and untreated, or after ex vivo culture in the presence of the hematopoietic growth factors recombinant murine stem cell factor, recombinant human interleukin-3 (rHu IL-3), and rHu IL-6, in a liquid culture system. To evaluate, count, and characterize FNPB progenitor cell-derived colonies, neonatal mouse mononuclear cells were cultured directly in methylcellulose with growth factors. To assess their ex vivo expansion ability, FNPB mononuclear cells were first cultured in liquid medium for 3 to 8 days and then transferred to semisolid assay plates. Evaluation of the cell counts after liquid culture showed a 1.4- to 11.6-fold increase, and the numbers of colonies observed in methylcellulose were similar to those produced by fresh FNPB cells. Donor-type engraftment was demonstrated by polymerase chain reaction (PCR) amplification of the human MDR1 transgene in the peripheral blood of all surviving animals (5 of 7 recipients of the fresh, and 3 of 8 recipients of the ex vivo-cultured cells) 2 to 4 months after transplantation. The proportion of donor leukocytes in the peripheral blood of the recipients (chimerism) was evaluated using fluorescence in situ hybridization (FISH) analysis 4 to 6 months after transplantation and ranged from 2% to 26%. In addition, bone marrow cultures were obtained from two recipient animals: one had received fresh-untreated cells and was evaluated 8 months after transplant, the other had received ex vivo cultured cells and was tested 14 months after grafting. The derived hematopoietic colonies were tested by PCR and the transgene was detected, conclusively proving long-term engraftment of donor cells. These results indicate that FNPB transplants can be successfully performed in sublethally irradiated mice with and without ex vivo culture. Long-term donor-type engraftment with sustained chimerism has been demonstrated. Thus, murine neonatal blood grafts can be used as an animal model for cord blood transplantation for gene therapy studies where complete myeloablation is not desirable and partial replacement of defective marrow may be sufficient. Furthermore, the possibility of numerically expanding hematopoietic progenitor cells contained in neonatal blood without affecting their engraftment ability could facilitate use of cord blood grafts in adult recipients.

A high-performance liquid chromatographic method with solid-phase extraction was developed for the assay of the enantiomers of a novel 20,21-dinoreburnamenine derivative (RU 49041) in rat plasma and brain using a chiral stationary phase (Nucleosil Chiral 2) and ultraviolet detection. The limit of detection was 10 ng/ml (or ng/g) in both tissues and the intra-assay precision was satisfactory (plasma, ca. 5%; brain, ca. 1%). The pharmacokinetic profiles of the two enantiomers were determined following oral administration of the racemate (10 mg/kg). The results show that their pharmacokinetics are very different: whereas both enantiomers appear in the brain, only the 3 alpha,16 beta-enantiomer is detected in plasma.