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Abstract: The Polycystic Ovary Syndrome (PCOS) is a complex endocrine disorder characterised both by reproductive and metabolic disturbance, and is the most common cause globally of ovarian infertility. It is also a familial polygenic condition, linked genetically to both Type 2 diabetes and the metabolic syndrome. The striking evolutionary paradox of this prominent genetically-based condition, which impairs fertility, is that not only should it have diminished in prevalence, but it should have done so rapidly – unless there has been some form of balancing selection. The emerging discipline of evolutionary medicine can provide important insights into the causes and patterns of occurrence of common diseases such as PCOS. In this paper we review the impacts of PCOS on infertility, fecundability and lifetime reproductive success and then critically appraise published hypotheses about the evolutionary origins of PCOS and related conditions. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of the study was to examine the performance of the Predisposition, Insult/Infection, Response, and Organ dysfunction (PIRO) model compared with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Mortality in Emergency Department Sepsis (MEDS) scoring systems in predicting in-hospital mortality for patients presenting to the emergency department (ED) with severe sepsis or septic shock. Materials and Methods: This study was an analysis of a prospectively maintained registry including adult patients with severe sepsis or septic shock meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle over a 6-year period. The registry contains data on patient demographics, sepsis category, vital signs, laboratory values, ED length of stay, hospital length of stay, physiologic scores, and outcome status. The discrimination and calibration characteristics of PIRO, APACHE II, and MEDS were analyzed. Results: Five-hundred forty-one patients with age 63.5 ± 18.5 years were enrolled, 61.9% in septic shock, 46.9% blood-culture positive, and 31.8% in-hospital mortality. Median (25th and 75th percentile) PIRO, APACHE II, and MEDS scores were 6 (5 and 8), 28 (22 and 34), and 12 (9 and 15), with predicted mortalities of 48.5% (40.1 and 63.9), 66.0% (42.0 and 83.0), and 16.0% (9.0 and 39.0), respectively. The area under the receiver operating characteristic curves for PIRO was 0.71 (95% confidence interval, 0.66-0.75); APACHE II, 0.71 (0.66-0.76); and MEDS, 0.63 (0.60-0.70). The standardized mortality ratio was 0.70 (0.08-1.41), 0.70 (−0.46 to 1.80), and 4.00 (−8.53 to 16.62), respectively. Actual mortality significantly increased with increasing PIRO score in patients with APACHE II 25 or more (P < .01). Conclusions: The PIRO, APACHE II, and MEDS have variable abilities to early discriminate and estimate in-hospital mortality of patients presenting to the ED meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The PIRO may provide additional risk stratification in patients with APACHE II 25 or more. More studies are required to evaluate the clinical applicability of PIRO in high-risk patients with severe sepsis and septic shock. [Copyright &y& Elsevier]

Abstract: Introduction: Hemodynamic monitoring is an important aspect of caring for the critically ill patients boarding in the emergency department (ED). The purpose of this study is to investigate the interrater agreement of noninvasive cardiac output measurements using transcutaneous Doppler ultrasound technique. Methods: This is a prospective observational cohort study performed in a 32-bed adult ED of an academic tertiary center with approximately 65000 annual patient visits. Patients were enrolled after verbal consent over a 7-month period. The raters were ED personnel involved in patient care. Paired measurements of cardiac index (CI) and stroke volume index (SVI) were obtained from a transcutaneous Doppler ultrasound cardiac output monitor. Results: A convenience sample of 107 (50 women and 57 men) patients with a median age of 49 (32, 62) years was enrolled. One hundred two paired measurements were performed in 91 patients in whom adequate Doppler ultrasound signals were obtainable. The raters included 35 emergency medicine attending physicians, 31 emergency medicine residents, 80 medical students, 47 nurses, and 11 emergency medical technicians. Cardiac index range was 0.6 to 5.3 L/min per square meter, and SVI range was 7.7 to 63.0 mL/m2. The correlation of CI measurements between 2 raters was good (r 2 = 0.87; 95% confidence interval, 0.86-1.00; P < .001). Likewise, SVI measurements between 2 raters also showed acceptable correlation (r 2 = 0.84; 95% confidence interval, 0.81-0.96; P < .001). Interrater reliability was strong for CI (κ = 0.83 with 92.2% agreement) and SVI measurements (κ = 0.72 with 88.2% agreement). Most patients had an interrater difference below 10% in CI and SVI measurements. Conclusions: Emergency department personnel, regardless of their role in patient care, are able to obtain reliable cardiac output measurements in ED patients over a wide range of CI and SVI. Transcutaneous Doppler ultrasound technique may be an alternative to traditional invasive hemodynamic monitoring of critically ill patients presenting to the ED. [Copyright &y& Elsevier]

Abstract: We attempted to determine how accurately members of the public can identify venomous snakes. Six different snakes indigenous to southern California were displayed in cages for 265 people to view at a street fair. These included 4 nonvenomous snakes and 2 venomous snakes. People were asked whether the snake was venomous and the name of the snake, if they knew it. Overall, people recognized whether a snake was venomous or nonvenomous 81% of the time. They were most accurate at identifying rattlesnakes as being venomous (95%) but incorrectly identified nonvenomous snakes as being venomous 25% of the time. Men were more accurate than women, and adults were more accurate than children. Subjects were less well able to identify the exact species of snakes. The results suggest that there may be no need to capture, kill, or bring a snake to the hospital for identification, at least in this geographic area. [Copyright &y& Elsevier]

Effects of a diet high in fat on body weight, adiposity, and energy expenditure were investigated. Male rats were fed 8% (control) or 50% fat (by weight) for 6 mo. The high-fat group increased body weight (+26%), adipocyte size (+61%), and adipocyte number (+48%). However, food intake and resting oxygen consumption, although higher in absolute amount, were normal in that both were commensurate with the greater body mass the rats maintained. When body weight and adipocyte size were reduced by caloric restriction, the high-fat group displayed the same adaptive adjustments in resting oxygen consumption as controls. We conclude that rats fed high-fat diets for prolonged periods 1) have energy intakes and expenditures appropriate for the greater tissue mass and adipocyte number they maintain, and 2) show adaptive reductions in energy expenditure when food is restricted, which provide further evidence that the regulated level of body weight can be altered by such diets. [ABSTRACT FROM AUTHOR]

Abstract: Background: Evidence-based therapies for severe sepsis include early antibiotics, early goal-directed therapy, corticosteroids, recombinant human activated protein C, glucose control, and lung protective strategies. Objective: The objective of this study was to analyze methods, challenges, and outcomes observed by hospitals that implemented a hospital-wide sepsis management protocol incorporating evidence-based therapies. Methods: In a cross-sectional multi-center telephone survey over a 4-month period, clinicians (participants) responsible for developing a hospital sepsis protocol were questioned regarding its development and outcomes. Results: Participants completing surveys represented 40 hospitals (20 academic and 20 community). Twenty-seven percent of protocol champions were Emergency physicians or nurses. Sixty-three percent reported protocol development time of 6–12 months. Eighty-eight percent of participants reported protocol initiation in the Emergency Department. Three participants reported hiring a nurse educator to implement the protocol. Ninety-five percent of participants measure lactate as part of patient screening. Protocol therapies reported included early antibiotics (98%), early goal directed-therapy (EGDT) (98%), corticosteroids (80%), and activated protein C (73%). Contributions to success included having a protocol champion (85%) and sepsis education program (65%). Twenty-one participants had recorded patient-level data, totaling 2319 protocol patients, compared to 1719 non-protocol patients, with in-hospital mortality of 23% and 44%, respectively. Conclusions: Implementation of a sepsis management protocol incorporating evidence-based therapies can be accomplished in both academic and community hospitals, with minimal additional staffing. The presence of a protocol champion and education program is crucial to success, and may result in improved patient outcome. [Copyright &y& Elsevier]