The incidence of severe sepsis increases dramatically with advanced age, with a mortality rate that approaches 50%. The main purpose of this investigation was to determine both short- and long-term ...survival outcomes among 386 patients aged ⩾75 years who were enrolled in the Protein C Worldwide Evaluation of Severe Sepsis (PROWESS) trial. Subjects who were treated with drotrecogin alfa (activated; DAA) had absolute risk reductions in 28-day and in-hospital mortality of 15.5% and 15.6%, respectively (P = .002 for both), compared with placebo recipients. The relative risk (RR) for 28-day mortality was 0.68 (95% confidence interval CI, 0.54–0.87), and the in-hospital RR was 0.70 (95% CI, 0.56–0.88). Resource use and patient disposition for DAA-treated patients compared favorably with those for placebo recipients. In addition, long-term follow-up data were available for 375 subjects (97.2%), and survival rates for DAA recipients were significantly higher over a 2-year period (P = .02). The incidences of serious adverse bleeding during the 28-day study period in the DAA and placebo groups were 3.9% and 2.2%, respectively (P = .34). There was no interaction between age and bleeding rates (P = .97). In conclusion, older patients with severe sepsis have higher short- and long-term survival rates when treated with DAA than when treated with placebo but an increased risk of serious bleeding that is not aged related.
Background
Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect ...patient outcome.
Aim
To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU.
Findings
Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources.
Conclusions
Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.
Here, we report, for what we believe to be the first time, on the modification of a low cost sensor, designed for the smartphone camera market, to develop an ultraviolet (UV) camera system. This was ...achieved via adaptation of Raspberry Pi cameras, which are based on back-illuminated complementary metal-oxide semiconductor (CMOS) sensors, and we demonstrated the utility of these devices for applications at wavelengths as low as 310 nm, by remotely sensing power station smokestack emissions in this spectral region. Given the very low cost of these units, ≈ USD 25, they are suitable for widespread proliferation in a variety of UV imaging applications, e.g., in atmospheric science, volcanology, forensics and surface smoothness measurements.
OBJECTIVEDespite concern over the appropriateness and quality of care provided in an intensive care unit (ICU) at the end of life, the number of Americans who receive ICU care at the end of life is ...unknown. We sought to describe the use of ICU care at the end of life in the United States using hospital discharge data from 1999 for six states and the National Death Index.
DESIGNRetrospective analysis of administrative data to calculate age-specific rates of hospitalization with and without ICU use at the end of life, to generate national estimates of end-of-life hospital and ICU use, and to characterize age-specific case mix of ICU decedents.
SETTINGAll nonfederal hospitals in the states of Florida, Massachusetts, New Jersey, New York, Virginia, and Washington.
PATIENTSAll inpatients in nonfederal hospitals in the six states in 1999.
INTERVENTIONNone.
MEASUREMENTS AND MAIN RESULTSWe found that there were 552,157 deaths in the six states in 1999, of which 38.3% occurred in hospital and 22.4% occurred after ICU admission. Using these data to project nationwide estimates, 540,000 people die after ICU admission each year. The age-specific rate of ICU use at the end of life was highest for infants (43%), ranged from 18% to 26% among older children and adults, and fell to 14% for those >85 yrs. Average length of stay and costs were 12.9 days and $24,541 for terminal ICU hospitalizations and 8.9 days and $8,548 for non-ICU terminal hospitalizations.
CONCLUSIONSOne in five Americans die using ICU services. The doubling of persons over the age of 65 yrs by 2030 will require a system-wide expansion in ICU care for dying patients unless the healthcare system pursues rationing, more effective advanced care planning, and augmented capacity to care for dying patients in other settings.
The traditional goal of intensive care has been to decrease short-term mortality. While worthy, this goal fails to address the issue of what it means to survive intensive care. Key questions include ...whether intensive care survivors have optimal long-term outcomes and whether ICU care decisions would change if we knew more about these outcomes. The 2002 Brussels Roundtable, "Surviving Intensive care", highlighted these issues, summarizing the available evidence on natural history and risk factors for critical illness and outlining future directions for care and research. Critical illness is associated with a wide array of serious and concerning long-term sequelae that interfere with optimal patient-centered outcomes. Although traditional short-term outcomes, such as hospital mortality, remain extremely important, they are not likely to be adequate surrogates for subsequent patient-centered outcomes. As such, it is important to focus specifically on how critical illness and intensive care affects a patient's and relatives' long-term health and well-being. There are a large number of potential pre-, intra-, and post-ICU factors that may improve or worsen these outcomes, and these factors are subjects for future research. In addition, future clinical trials of ICU therapies should include long-term follow-up of survival, quality of life, morbidity, functional status, and costs of care. Follow-up ought to be for at least six months. The SF-36 and EuroQOL EQ-5D are the best-suited instruments for measuring quality of life in multicenter critical care trials though further methodologic research and instrument design is encouraged. There are also opportunities today to improve care. Key to taking advantage of such opportunities is the need for a global awareness of critical illness as an entity that begins and ends outside the ICU 'box'. Specific interventions that show promise for improving care include ICU discharge screening tools and ICU follow-up clinics.
We wanted to determine the incidence, cost, outcome, and patterns of care for neonates requiring mechanical ventilation (MV) in the United States. Using 1994 state hospital discharge data from ...California and New York, we conducted an observational study of all neonatal hospitalizations (n = 16,405) with MV, comparing outcomes at centers of different technological capability, and generating national projections using census and natality reports. The MV rate was 18 per 1,000 live births. Although the incidence was much higher in lower birth weight (BW) babies, one-third had normal BW. The incidence was higher in boys (20 versus 15.6 per 1,000) and in blacks (29 per 1,000). Hospital mortality was 11.1%, higher in minority groups, and associated with low BW, congenital anomalies, and major hemorrhage. Mean hospital length of stay and costs were 31.1 d and $51,700. Half of all deaths occurred at lower level centers. There are 80,000 cases per year in the United States with 8,500 deaths and total hospital costs of $4.4 billion. We conclude neonatal respiratory failure is common, expensive, and frequently fatal. There are a surprisingly large number of normal BW cases and there are large racial differences.
Microcirculatory dysfunction is a pivotal element of the pathogenesis of severe sepsis and septic shock. Technological development, including sidestream darkfield videomicroscopy, now allows for ...bedside assessment of the microcirculation. A number of clinical studies have established the importance of the microcirculation in sepsis. The objective of this review is to discuss human trials that have assessed interventions aimed at improving microcirculatory flow in patients with sepsis.
ABC (ATP-binding cassette) proteins constitute a large family of membrane proteins that actively transport a broad range of substrates. Cystic fibrosis transmembrane conductance regulator (CFTR), the ...protein dysfunctional in cystic fibrosis, is unique among ABC proteins in that its transmembrane domains comprise an ion channel. Opening and closing of the pore have been linked to ATP binding and hydrolysis at CFTR's two nucleotide-binding domains, NBD1 and NBD2 (see, for example, refs 1, 2). Isolated NBDs of prokaryotic ABC proteins dimerize upon binding ATP, and hydrolysis of the ATP causes dimer dissociation. Here, using single-channel recording methods on intact CFTR molecules, we directly follow opening and closing of the channel gates, and relate these occurrences to ATP-mediated events in the NBDs. We find that energetic coupling between two CFTR residues, expected to lie on opposite sides of its predicted NBD1-NBD2 dimer interface, changes in concert with channel gating status. The two monitored side chains are independent of each other in closed channels but become coupled as the channels open. The results directly link ATP-driven tight dimerization of CFTR's cytoplasmic nucleotide-binding domains to opening of the ion channel in the transmembrane domains. This establishes a molecular mechanism, involving dynamic restructuring of the NBD dimer interface, that is probably common to all members of the ABC protein superfamily.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
An expert consultation was conducted to provide quantitative parameters required to inform risk-based surveillance of aquaculture holdings for selected infectious hazards. The hazards were four fish ...diseases endemic in some or several European countries: infectious salmon anaemia (ISA), viral haemorrhagic septicaemia (VHS), infectious haematopoietic necrosis (IHN), and koi herpes virus disease (KHD). Experts were asked to provide estimates for the relative importance of 5 risk themes for the hazard to be introduced into and infect susceptible fish at the destination. The 5 risk themes were: (1) live fish and egg movements; (2) exposure via water; (3) on-site processing; (4) short distance mechanical transmission and (5) distance independent mechanical transmission. The experts also provided parameter estimates for hazard transmission pathways within the themes. The expert consultation was undertaken in a 2 step approach: an online survey followed by an expert consultation meeting. The expert opinion indicated that live fish movements and exposure via water were the major relevant risk themes. Experts were recruited from several European countries and thus covered a range of farming systems. Therefore, the outputs from the expert consultation have relevance for the European context.
Objective Safety culture may influence patient outcomes, but evidence is limited. We sought to determine if intensive care unit (ICU) safety culture is independently associated with outcomes. Design ...Cohort study combining safety culture survey data with the Project IMPACT Critical Care Medicine (PICCM) clinical database. Setting Thirty ICUs participating in the PICCM database. Participants A total of 65 978 patients admitted January 2001–March 2005. Interventions None. Main outcome measures Hospital mortality and length of stay (LOS). Methods From December 2003 to April 2004, we surveyed study ICUs using the Safety Attitudes Questionnaire-ICU version, a validated instrument that assesses safety culture across six factors. We calculated factor mean and percent-positive scores (% respondents with mean score ≥75 on a 0–100 scale) for each ICU, and generated case-mix adjusted, patient-level, ICU-clustered regression analyses to determine the independent association of safety culture and outcome. Results We achieved a 47.9% response (2103 of 4373 ICU personnel). Culture scores were mostly low to moderate and varied across ICUs (range: 13–88, percent-positive scores). After adjustment for patient, hospital and ICU characteristics, for every 10% decrease in ICU perceptions of management percent-positive score, the odds ratio for hospital mortality was 1.24 (95% CI: 1.07–1.44; P = 0.005). For every 10% decrease in ICU safety climate percent-positive score, LOS increased 15% (95% CI: 1−30%; P = 0.03). Sensitivity analyses for non-response bias consistently associated safety climate with outcome, but also yielded some counterintuitive results. Conclusion In a multicenter study conducted in the USA, perceptions of management and safety climate were moderately associated with outcomes. Future work should further develop methods of assessing safety culture and association with outcomes.
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