Implementation of care bundles for prevention of ventilator-associated pneumonia (VAP) and its impact on patient outcomes requires validation with long-term follow-up. A collaborative multi-centre ...cohort study was conducted in five Spanish adult intensive-care units. A care bundle approach based on five measures was implemented after a 3-month baseline period, and compliance, VAP rates, intensive-care unit length of stay (ICU LOS) and duration of mechanical ventilation were prospectively recorded for 16 months. There were 149 patients in the baseline period and 885 after the intervention. Compliance with all measures after intervention was <30% (264/885). In spite of this, VAP incidence decreased from 15.5% (23/149) to 11.7% (104/885), after the intervention (p <0.05). This reduction was significantly associated with hand hygiene (OR = 0.35), intra-cuff pressure control (OR = 0.21), oral hygiene (OR = 0.23) and sedation control (OR = 0.51). Use of the care bundle was associated with an incidence risk ratio of VAP of 0.78 (95% CI 0.15–0.99). We documented a reduction of median ICU LOS (from 10 to 6 days) and duration of mechanical ventilation (from 8 to 4 days) for patients with full bundle compliance (intervention period). Efforts on VAP prevention and outcome improvement should focus on achieving higher compliance in hand and oral hygiene, sedation protocols and intracuff pressure control.
Objective
To assess the effect on survival of macrolides or fluoroquinolones in intubated patients admitted to the intensive care unit (ICU) with severe community-acquired pneumonia (severe CAP).
...Methods
Prospective, observational cohort, multicenter study conducted in 27 ICUs of 9 European countries. Two hundred eighteen consecutive patients requiring invasive mechanical ventilation for an admission diagnosis of CAP were recruited.
Results
Severe sepsis and septic shock were present in 165 (75.7%) patients. Microbiological documentation was obtained in 102 (46.8%) patients. ICU mortality was 37.6% (
n
= 82). Non-survivors were older (58.6 ± 16.1 vs. 63.4 ± 16.7 years,
P
< 0.05) and presented a higher score on the simplified Acute Physiology Score II at admission (45.6 ± 15.4 vs. 50.8 ± 17.5,
P
< 0.05). Monotherapy was given in 43 (19.7%) and combination therapy in 175 (80.3%) patients. Empirical antibiotic therapy was in accordance with the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines in 100 (45.9%) patients (macrolides in 46 patients and fluoroquinolones in 54). In this cohort, a Cox regression analysis adjusted by severity identified that macrolide use was associated with lower ICU mortality (hazard ratio, HR 0.48, confidence intervals, 95% CI 0.23–0.97,
P
= 0.04) when compared to the use of fluoroquinolones. When more severe patients presenting severe sepsis and septic shock were analyzed (
n
= 92), similar results were obtained (HR 0.44, 95% CI 0.20–0.95,
P
= 0.03).
Conclusions
Patients with severe community-acquired pneumonia had a low adherence with the 2007 IDSA/ATS guidelines. Combination therapy with macrolides should be preferred in intubated patients with severe CAP.
The objectives of this study were to assess the determinants of empirical antibiotic choice, prescription patterns and outcomes in patients with hospital-acquired pneumonia ...(HAP)/ventilator-associated pneumonia (VAP) in Europe. We performed a prospective, observational cohort study in 27 intensive care units (ICUs) from nine European countries. 100 consecutive patients on mechanical ventilation for HAP, on mechanical ventilation>48 h or with VAP were enrolled per ICU. Admission category, sickness severity and Acinetobacter spp. prevalence>10% in pneumonia episodes determined antibiotic empirical choice. Trauma patients were more often prescribed non-anti-Pseudomonas cephalosporins (OR 2.68, 95% CI 1.50-4.78). Surgical patients received less aminoglycosides (OR 0.26, 95% CI 0.14-0.49). A significant correlation (p<0.01) was found between Simplified Acute Physiology Score II score and carbapenem prescription. Basal Acinetobacter spp. prevalence>10% dramatically increased the prescription of carbapenems (OR 3.5, 95% CI 2.0-6.1) and colistin (OR 115.7, 95% CI 6.9-1,930.9). Appropriate empirical antibiotics decreased ICU length of stay by 6 days (26.3±19.8 days versus 32.8±29.4 days; p=0.04). The antibiotics that were prescribed most were carbapenems, piperacillin/tazobactam and quinolones. Median (interquartile range) duration of antibiotic therapy was 9 (6-12) days. Anti-methicillin-resistant Staphylococcus aureus agents were prescribed in 38.4% of VAP episodes. Admission category, sickness severity and basal Acinetobacter prevalence>10% in pneumonia episodes were the major determinants of antibiotic choice at the bedside. Across Europe, carbapenems were the antibiotic most prescribed for HAP/VAP.
A special feature of the Filament Winding (FW) process is known as
pattern
: diamond-shaped mosaic that results from the sequence of movements of the mandrel and tow delivery eye. One of the main ...factors to generate different patterns is the return path of the tow and, for a non-geodesic trajectory, the path depends on the friction between tow and mandrel. Aiming at a practical description of the FW process, a novel geometric approach on pattern construction is presented. Pattern generation, skip configurations and definitions of geodesic and non-geodesic trajectories in regular winding and return regions are described based on developed surfaces, residue classes and modular arithmetic. The influence of mandrel’s length, mandrel’s rotation angle and variation of the winding angle in the return region are presented, for they are important parameters of the process. Examples of winding angle, mandrel rotation and non-geodesic path in cylindrical and non-cylindrical surfaces of revolution are shown and discussed.
A modified version of Adomian decomposition method is presented and applied to solve linear elliptic differential equations in anisotropic domains in a recursive manner. A complementary constitutive ...decomposition, guided by a constitutive hierarchy, governs the superposition of the operator—a step of the Adomian’s method—and is defined as the original constitutive tensor being constructed by an isotropic tensor added to an anisotropic one. The recursive system obtained by the application of Adomian decomposition method is related to an enhancement of the problem’s isotropic solution by the domain’s anisotropy. Alternative solution procedures as Rayleigh–Ritz and and finite element methods are considered. Requirements for absolute convergence are presented and are related to the decomposition as well as to the material’s anisotropy. The rate of convergence is close related to the eigenvalues of the decomposed constitutive terms. The methodology is demonstrated for two- and three-dimensional of heat conduction, two- and three-dimensional elasticity problems and for homogeneous and heterogeneous thin and thick plates. Numeric and semi-analytic results are presented generalised plane stress elasticity as well as for anisotropic thin and laminated thick plates.
The influence of infecting serotype group on outcome in bacteraemic pneumococcal pneumonia remains unclear. We performed a prospective, 10-yr observational study in an 800-bed teaching hospital. 299 ...adults diagnosed with pneumonia whose blood cultures showed growth of Streptococcus pneumoniae were included in the study. High invasive disease potential (H) serotypes included serotypes 1, 5 and 7F, which served as a reference category, were compared with low invasive disease potential (L) serotypes (3, 6A, 6B, 8, 19F, and 23F) and other (O) serotypes (non-H, non-L). The influence on outcome was determined for each group of serotypes after adjusting for underlying conditions and severity of illness at admission. Overall, 30-day mortality was 11%. H serotypes (n = 93) infected primarily younger people and presented a higher risk of complicated parapneumonic effusion or empyema (17.2 versus 5.1%; p = 0.01), with lower mortality (3.2%). The isolation of L serotypes (n = 78) was an independent risk factor for 30-day mortality (OR 7.02, 95% CI 1.72-28.61), as were Charlson score (OR 1.30, 95% CI 1.08-1.58), alcohol abuse (OR 3.99, 95% CI 1.39-11.39) and severity of illness measured by American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) criteria (OR 4.80, 95% CI 1.89-12.13). A vaccination strategy including serotypes 3, 6A, 6B, 8, 19F and 23F may improve survival in adults.
The aim of this study was to determine if severity assessment tools (general severity of illness and community-acquired pneumonia specific scores) can be used to guide decisions for patients admitted ...to the intensive care unit (ICU) due to pandemic influenza A pneumonia. A prospective, observational, multicentre study included 265 patients with a mean age of 42 (±16.1) years and an ICU mortality of 31.7%. On admission to the ICU, the mean pneumonia severity index (PSI) score was 103.2 ± 43.2 points, the CURB-65 score was 1.7 ± 1.1 points and the PIRO-CAP score was 3.2 ± 1.5 points. None of the scores had a good predictive ability: area under the ROC for PSI, 0.72 (95% CI, 0.65-0.78); CURB-65, 0.67 (95% CI, 0.59-0.74); and PIRO-CAP, 0.64 (95% CI, 0.56-0.71). The PSI score (OR, 1.022 (1.009-1.034), p 0.001) was independently associated with ICU mortality; however, none of the three scores, when used at ICU admission, were able to reliably detect a low-risk group of patients. Low risk for mortality was identified in 27.5% of patients using PIRO-CAP, but above 40% when using PSI (I–III) or CURB65 (<2). Observed mortality was 13.7%, 13.5% and 19.4%, respectively. Pneumonia-specific scores undervalued severity and should not be used as instruments to guide decisions in the ICU.
This study aimed to verify preferences for microhabitat by the monogeneans on the gills of the south american catfish, Rhamdia quelen (Quoy & Gaimard, 1824), at different stocking densities under ...controlled laboratory conditions. Three stocking densities were used: 14, 28 and 42 fish per tank (50 L) and the fish were sampled initially, at day 5 and 10 of the experiment. Aphanoblastella mastigatus (Suriano, 1986) was noted as the most abundant species at all stocking densities, except for the initial collection day. The gill arches I and II were the most parasitized, showing the highest mean abundance in the dorsal region, at the highest density. The pattern of microhabitat preference of A. mastigatus for outer regions of the gills of the host was independent of the stocking density and collection day. Higher prevalence and abundance of Scleroductus sp. at the initial collection reflected the parasitic infection of the fish at the farm from where the fish were taken. The abundance of Scleroductus sp. decreased along the experiment, and no preference for gill arches was recorded for the species, probably due to the low abundance of this parasite on the gills.
Clinically relevant animal models capable of simulating traumatic hemorrhagic shock are needed. We developed a hemorrhagic shock model with male New Zealand rabbits (2200-2800 g, 60-70 days old) that ...simulates the pre-hospital and acute care of a penetrating trauma victim in an urban scenario using current resuscitation strategies. A laparotomy was performed to reproduce tissue trauma and an aortic injury was created using a standardized single puncture to the left side of the infrarenal aorta to induce hemorrhagic shock similar to a penetrating mechanism. A 15-min interval was used to simulate the arrival of pre-hospital care. Fluid resuscitation was then applied using two regimens: normotensive resuscitation to achieve baseline mean arterial blood pressure (MAP, 10 animals) and hypotensive resuscitation at 60% of baseline MAP (10 animals). Another 10 animals were sham operated. The total time of the experiment was 85 min, reproducing scene, transport and emergency room times. Intra-abdominal blood loss was significantly greater in animals that underwent normotensive resuscitation compared to hypotensive resuscitation (17.1 ± 2.0 vs 8.0 ± 1.5 mL/kg). Antithrombin levels decreased significantly in normotensive resuscitated animals compared to baseline (102 ± 2.0 vs 59 ± 4.1%), sham (95 ± 2.8 vs 59 ± 4.1%), and hypotensive resuscitated animals (98 ± 7.8 vs 59 ± 4.1%). Evidence of re-bleeding was also noted in the normotensive resuscitation group. A hypotensive resuscitation regimen resulted in decreased blood loss in a clinically relevant small animal model capable of reproducing hemorrhagic shock caused by a penetrating mechanism.
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