One important concern during high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemic respiratory failure is to not delay intubation.
To validate the diagnostic accuracy of an index ...(termed ROX and defined as the ratio of oxygen saturation as measured by pulse oximetry/Fi
to respiratory rate) for determining HFNC outcome (need or not for intubation).
This was a 2-year multicenter prospective observational cohort study including patients with pneumonia treated with HFNC. Identification was through Cox proportional hazards modeling of ROX association with HFNC outcome. The most specific cutoff of the ROX index to predict HFNC failure and success was assessed.
Among the 191 patients treated with HFNC in the validation cohort, 68 (35.6%) required intubation. The prediction accuracy of the ROX index increased over time (area under the receiver operating characteristic curve: 2 h, 0.679; 6 h, 0.703; 12 h, 0.759). ROX greater than or equal to 4.88 measured at 2 (hazard ratio, 0.434; 95% confidence interval, 0.264-0.715;
= 0.001), 6 (hazard ratio, 0.304; 95% confidence interval, 0.182-0.509;
< 0.001), or 12 hours (hazard ratio, 0.291; 95% confidence interval, 0.161-0.524;
< 0.001) after HFNC initiation was consistently associated with a lower risk for intubation. A ROX less than 2.85, less than 3.47, and less than 3.85 at 2, 6, and 12 hours of HFNC initiation, respectively, were predictors of HFNC failure. Patients who failed presented a lower increase in the values of the ROX index over the 12 hours. Among components of the index, oxygen saturation as measured by pulse oximetry/Fi
had a greater weight than respiratory rate.
In patients with pneumonia with acute respiratory failure treated with HFNC, ROX is an index that can help identify those patients with low and those with high risk for intubation. Clinical trial registered with www.clinicaltrials.gov (NCT02845128).
•Real-time random safety audits are associated with a reduction in the risk of death.•Clinical information systems provide us with valuable real-world data.•Real-world data available is useful in ...assessing the impact of safety actions.•Real-time random safety audits improve care, especially in the most severe patients.
Evidence-based care processes are not always applied at the bedside in critically ill patients. Numerous studies have assessed the impact of checklists and related strategies on the process of care and patient outcomes. We aimed to evaluate the effects of real-time random safety audits on process-of-care and outcome variables in critical care patients.
This prospective study used data from the clinical information system to evaluate the impact of real-time random safety audits targeting 32 safety measures in two intensive care units during a 9-month period. We compared endpoints between patients attended with safety audits and those not attended with safety audits. The primary endpoint was mortality, measured by Cox hazard regression after full propensity-score matching. Secondary endpoints were the impact on adherence to process-of-care measures and on quality indicators.
We included 871 patients; 228 of these were attended in ≥ 1 real-time random safety audits. Safety audits were carried out on 390 patient-days; most improvements in the process of care were observed in safety measures related to mechanical ventilation, renal function and therapies, nutrition, and clinical information system. Although the group of patients attended in safety audits had more severe disease at ICU admission APACHE II score 21 (16−27) vs. 20 (15−25), p = 0.023; included a higher proportion of surgical patients 37.3 % vs. 26.4 %, p = 0.003 and a higher proportion of mechanically ventilated patients 72.8 % vs. 40.3 %, p < 0.001; averaged more days on mechanical ventilation, central venous catheter, and urinary catheter; and had a longer ICU stay 12.5 (5.5−23.3) vs. 2.9 (1.7−5.9), p < 0.001, ICU mortality did not differ significantly between groups (19.3 % vs. 18.8 % in the group without safety rounds). After full propensity-score matching, Cox hazard regression analysis showed real-time random safety audits were associated with a lower risk of mortality throughout the ICU stay (HR 0.31; 95 %CI 0.20−0.47).
Real-time random safety audits are associated with a reduction in the risk of ICU mortality. Exploiting data from the clinical information system is useful in assessing the impact of them on the care process, quality indicators, and mortality.
Muscle involvement is found in most critical patients admitted to the intensive care unit (ICU). Diaphragmatic muscle alteration, initially included in this category, has been differentiated in ...recent years, and a specific type of muscular dysfunction has been shown to occur in patients undergoing mechanical ventilation. We found this muscle dysfunction to appear in this subgroup of patients shortly after the start of mechanical ventilation, observing it to be mainly associated with certain control modes, and also with sepsis and/or multi-organ failure. Although the specific etiology of process is unknown, the muscle presents oxidative stress and mitochondrial changes. These cause changes in protein turnover, resulting in atrophy and impaired contractility, and leading to impaired functionality. The term 'ventilator-induced diaphragm dysfunction' was first coined by Vassilakopoulos et al. in 2004, and this phenomenon, along with injury cause by over-distention of the lung and barotrauma, represents a challenge in the daily life of ventilated patients. Diaphragmatic dysfunction affects prognosis by delaying extubation, prolonging hospital stay, and impairing the quality of life of these patients in the years following hospital discharge. Ultrasound, a non-invasive technique that is readily available in most ICUs, could be used to diagnose this condition promptly, thus preventing delays in starting rehabilitation and positively influencing prognosis in these patients.
Abstract Muscle involvement is found in most critical patients admitted to the intensive care unit (ICU). Diaphragmatic muscle alteration, initially included in this category, has been differentiated ...in recent years, and a specific type of muscular dysfunction has been shown to occur in patients undergoing mechanical ventilation. We found this muscle dysfunction to appear in this subgroup of patients shortly after the start of mechanical ventilation, observing it to be mainly associated with certain control modes, and also with sepsis and/or multi-organ failure. Although the specific etiology of process is unknown, the muscle presents oxidative stress and mitochondrial changes. These cause changes in protein turnover, resulting in atrophy and impaired contractility, and leading to impaired functionality. The term ‘ventilator-induced diaphragm dysfunction’ was first coined by Vassilakopoulos et al. in 2004, and this phenomenon, along with injury cause by over-distention of the lung and barotrauma, represents a challenge in the daily life of ventilated patients. Diaphragmatic dysfunction affects prognosis by delaying extubation, prolonging hospital stay, and impairing the quality of life of these patients in the years following hospital discharge. Ultrasound, a non-invasive technique that is readily available in most ICUs, could be used to diagnose this condition promptly, thus preventing delays in starting rehabilitation and positively influencing prognosis in these patients.
Background
Urinary tract infection (UTI) is one of the most common bacterial infections in childhood and is associated with long-term complications. We aimed to assess the effect of adjuvant ...dexamethasone treatment on reducing kidney scarring after acute pyelonephritis (APN) in children.
Methods
Multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial (RCT) where children from 1 month to 14 years of age with proven APN were randomly assigned to receive a 3-day course of either an intravenous corticosteroid (dexamethasone 0.30 mg per kg/day) twice daily or placebo. The late technetium 99 m-dimercaptosuric acid scintigraphy (> 6 months after acute episode) was performed to assess kidney scar persistence. Kidney scarring risk factors (vesicoureteral reflux, kidney congenital anomalies, or urinary tract dilatation) were also assessed.
Results
Ninety-one participants completed the follow-up and were finally included (dexamethasone
n
= 49 and placebo
n
= 42). Both groups had similar baseline characteristics. Twenty participants showed persistent kidney scarring after > 6 months of follow-up without differences in incidence between groups (22% and 21% in the dexamethasone and placebo groups,
p
= 0.907). Renal damage severity in the early DMSA (β = 0.648,
p
= 0.023) and procalcitonin values (β = 0.065
p
= 0.027) significantly modulated scar development. Vesicoureteral reflux grade showed a trend towards significance (β = 0.545,
p
= 0.054), but dexamethasone treatment showed no effect.
Conclusion
Dexamethasone showed no effect on reducing the risk of scar formation in children with APN. Hence, there is no evidence for an adjuvant corticosteroid treatment recommendation in children with APN. However, the study was limited by not achieving the predicted sample size and the expected scar formation.
Trial registration
Clinicaltrials.gov, NCT02034851. Registered in January 14, 2014.
Graphical abstract
“A higher resolution version of the Graphical abstract is available as Supplementary information.”
I HAVE ∥GUBBO DE PRADA-SAMPER, JOSÉ MANUEL
South African archaeological bulletin,
12/2017, Letnik:
72, Številka:
206
Journal Article
Recenzirano
This article presents for the first time an almost unknown map drawn by ∥kabbo, a |xam Bushman (San) around 1872–1873. Some additional information is given in connection with the context in which the ...maps in the Bleek-Lloyd Collection were drawn. Since the map shows what appears to be the core of ∥kabbo’s !xoe (‘place’), this crucial concept is discussed in detail.
Highlights • Over half the patients showed inadequate glycemic control. • Glycemic control worsens as treatment becomes more complex. • There is no association between A1c levels and diabetes ...mellitus duration. • The study shows the underuse of A1c.
Sin embargo, quienes hayan vivido en una gran ciudad la mayor parte de su vida, tenderán a considerar de entrada estas tradiciones como relatos ficticios, aunque por otro lado den crédito a los ...rumores sobre cocodrilos en las alcantarillas o platillos volantes. Sin embargo, supe poco después por Antonio Ortí, que es un experto en la materia, que hacía por lo menos un año que circulaba la historia de una señora que recibe una advertencia similar de un joven al que ha prestado un euro para poder sacar un carrito de la compra en una sucursal de Eroski, situada en las afueras de Bilbao. No sólo porque, por usar las palabras de Hitler en el Mein Kampf, traer al mundo a un ser «enfermizo y débil» era una «lamentable desgracia» y una «deshonra» (Hitler, s.a), sino porque para el oficial era casi una obligación sacrificar personalmente a su hijo en virtud del epígrafe llamado Acción 14, nombre encubierto de las tareas de eugenesia que el régimen practicó de forma bastante abierta hasta 1941. En la mayor parte de las sociedades, la narración de los mitos y los cuentos suele ser el dominio de personas especialmente dotadas para contarlos, en ocasiones de verdaderos profesionales.
This article explores the unique perspectives and uses of a traditional Upper Karoo Bushman tale retold in a cultural setting by a traditional teller. The role of the folklorist is dedicated to ...preserving and studying Bushman oral tradition (past and present) and the use of story for a violence prevention project by a contemporary nontraditional storyteller.
PDF
