IMPORTANCE: Many patients with coronavirus disease 2019 (COVID-19) are critically ill and require care in the intensive care unit (ICU). OBJECTIVE: To evaluate the independent risk factors associated ...with mortality of patients with COVID-19 requiring treatment in ICUs in the Lombardy region of Italy. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, observational cohort study included 3988 consecutive critically ill patients with laboratory-confirmed COVID-19 referred for ICU admission to the coordinating center (Fondazione IRCCS Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy) of the COVID-19 Lombardy ICU Network from February 20 to April 22, 2020. Infection with severe acute respiratory syndrome coronavirus 2 was confirmed by real-time reverse transcriptase–polymerase chain reaction assay of nasopharyngeal swabs. Follow-up was completed on May 30, 2020. EXPOSURES: Baseline characteristics, comorbidities, long-term medications, and ventilatory support at ICU admission. MAIN OUTCOMES AND MEASURES: Time to death in days from ICU admission to hospital discharge. The independent risk factors associated with mortality were evaluated with a multivariable Cox proportional hazards regression. RESULTS: Of the 3988 patients included in this cohort study, the median age was 63 (interquartile range IQR 56-69) years; 3188 (79.9%; 95% CI, 78.7%-81.1%) were men, and 1998 of 3300 (60.5%; 95% CI, 58.9%-62.2%) had at least 1 comorbidity. At ICU admission, 2929 patients (87.3%; 95% CI, 86.1%-88.4%) required invasive mechanical ventilation (IMV). The median follow-up was 44 (95% CI, 40-47; IQR, 11-69; range, 0-100) days; median time from symptoms onset to ICU admission was 10 (95% CI, 9-10; IQR, 6-14) days; median length of ICU stay was 12 (95% CI, 12-13; IQR, 6-21) days; and median length of IMV was 10 (95% CI, 10-11; IQR, 6-17) days. Cumulative observation time was 164 305 patient-days. Hospital and ICU mortality rates were 12 (95% CI, 11-12) and 27 (95% CI, 26-29) per 1000 patients-days, respectively. In the subgroup of the first 1715 patients, as of May 30, 2020, 865 (50.4%) had been discharged from the ICU, 836 (48.7%) had died in the ICU, and 14 (0.8%) were still in the ICU; overall, 915 patients (53.4%) died in the hospital. Independent risk factors associated with mortality included older age (hazard ratio HR, 1.75; 95% CI, 1.60-1.92), male sex (HR, 1.57; 95% CI, 1.31-1.88), high fraction of inspired oxygen (Fio2) (HR, 1.14; 95% CI, 1.10-1.19), high positive end-expiratory pressure (HR, 1.04; 95% CI, 1.01-1.06) or low Pao2:Fio2 ratio (HR, 0.80; 95% CI, 0.74-0.87) on ICU admission, and history of chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.28-2.19), hypercholesterolemia (HR, 1.25; 95% CI, 1.02-1.52), and type 2 diabetes (HR, 1.18; 95% CI, 1.01-1.39). No medication was independently associated with mortality (angiotensin-converting enzyme inhibitors HR, 1.17; 95% CI, 0.97-1.42; angiotensin receptor blockers HR, 1.05; 95% CI, 0.85-1.29). CONCLUSIONS AND RELEVANCE: In this retrospective cohort study of critically ill patients admitted to ICUs in Lombardy, Italy, with laboratory-confirmed COVID-19, most patients required IMV. The mortality rate and absolute mortality were high.
International trade is one of the classic areas of study in economics. Its empirical analysis is a complex problem, given the amount of products, countries and years. Nowadays, given the availability ...of data, the tools used for the analysis can be complemented and enriched with new methodologies and techniques that go beyond the traditional approach. This new possibility opens a research gap, as new, data-driven, ways of understanding international trade, can help our understanding of the underlying phenomena. The present paper shows the application of the Latent Dirichlet allocation model, a well known technique in the area of Natural Language Processing, to search for latent dimensions in the product space of international trade, and their distribution across countries over time. We apply this technique to a dataset of countries' exports of goods from 1962 to 2016. The results show that this technique can encode the main specialisation patterns of international trade. On the country-level analysis, the findings show the changes in the specialisation patterns of countries over time. As traditional international trade analysis demands expert knowledge on a multiplicity of indicators, the possibility of encoding multiple known phenomena under a unique indicator is a powerful complement for traditional tools, as it allows top-down data-driven studies.
Resumen La formación inicial de profesorado constituye una de las áreas más relevantes de investigación educativa dado su impacto sobre los procesos de diseño e implementación de políticas públicas ...referidas a la educación en su conjunto. En términos metodológicos, el diseño de esta investigación incluye técnicas cualitativas, entre las que se destacan el análisis jurídico normativo y la generación de tipificaciones comparativas de las fuentes consideradas. La recolección de datos se realizó a través de diversas estrategias, que incluyeron un relevamiento de documentos normativos (legislación educativa, resoluciones, reglamentos y diseños curriculares) de los niveles nacional y subnacional y también del sector universitario referidos a la formación docente o a las dimensiones consideradas. Se plantean definiciones relativas a la formación docente inicial para el nivel primario (desde una perspectiva internacional comparativa), al federalismo y sus implicancias en términos curriculares, a la luz de los procesos de reformas. Se advierte que, si bien la Argentina ha tenido una profusa regulación normativa en esta materia, los resultados de las reformas no han dado lugar a una política integral de formación docente. Ello se debe tanto por la forma federal del Estado argentino (y la autonomía de las provincias) como por el carácter binario de la educación superior (con la particularidad de la autonomía de las universidades nacionales).
Regional Payment Agreements (RPAs) replicate, on a regional scale, John M. Keynes’s proposal at the Bretton Woods Conference, based on the recording and subsequent clearing of transactions. The ...analysis of the three “founding” RPAs from the Golden Age (Finland-USSR, European Payments Union and the LAFTA-LAIA Agreement on Reciprocal Payments and Credits) suggests that, in general, these agreements fulfiled their objectives: saving foreign currency and promoting trade. Hence, RPAs would present an alternative to currency convertibility for current account transactions.
The performance of viscoelastic coagulation monitor (VCM) compared with TEG 5000 (TEG) is unknown. In this multicenter study, the authors evaluated the agreement among VCM/TEG parameters and their ...relationship with standard coagulation tests in critically ill patients. Viscoelastic coagulation monitor, TEG, and laboratory samples were analyzed simultaneously. Viscoelastic coagulation monitor/TEG agreement was computed by Bland and Altman's plots, association with laboratory parameters was studied with Spearman's correlation coefficient and random-intercept linear models. One-hundred and twenty-seven patients enrolled, 320 paired observations: 210 (65.6%) under unfractioned heparin (UFH), 94 (29.4%) under low molecular weight heparin (LMWH), 16 (5.0%) no heparin. Under UFH prolonged clot formation times and reduced the amplitude of viscoelastic tracings on both devices, especially on TEG. The type of heparin affected the agreement between VCM/TEG homolog parameters. Reaction time (TEG-R) resulted 23.1 min longer than the homolog clotting time (VCM-CT) under UFH; maximum amplitude (TEG-MA) resulted 29.5 mm higher than maximum clot firmness (VCM-MCF) under LMWH. Weak correlation was observed between VCM-CT/TEG-R and activated partial thromboplastin time (aPTT)/anti-Xa; no correlation was found between VCM-alpha/TEG-angle and fibrinogen concentration. Viscoelastic coagulation monitor-MCF showed strong (LWMH) to moderate (UFH) correlation with platelet count, while TEG-MA only showed lower correlation. Viscoelastic coagulation monitor and TEG are differently affected by heparin. The platelet count is well represented by VCM-MCF even during UFH administration.
OBJECTIVE:Isoflurane is a volatile anesthetic that has a vasodilating effect on cerebral vessels producing a cerebral blood flow increase. Furthermore, it has been shown in animal studies that ...isoflurane, when used as a preconditioning agent, has neuroprotective properties, inducing tolerance to ischemia. However, it is not routinely used in neurointensive care because of the potential increase in intracranial pressure caused by the rise in cerebral blood flow. Nevertheless, subarachnoid hemorrhage patients who are at risk for vasospasm may benefit from an increase in cerebral blood flow. We measured regional cerebral blood flow during intravenous sedation with propofol and during sedation with isoflurane in patients with severe subarachnoid hemorrhage not having intracranial hypertension.
DESIGN:The study is a crossover, open clinical trial (NCT00830843).
SETTING:Neurointensive care unit of an academic hospital.
PATIENTS:Thirteen patients with severe subarachnoid hemorrhage, (median Fisher scale 4), monitored on clinical indication with intracranial pressure device and a thermal diffusion probe for the assessment of regional cerebral blood flow. An intracranial pressure >18 mm Hg was an exclusion criterion.
INTERVENTIONS:Cerebral and hemodynamic variables were assessed at three steps. Step 1sedation with propofol 3–4 mg/kg/hr; step 2after 1hr of propofol discontinuation and isoflurane 0.8%; step 3after 1hr of propofol at the same previous infusion rate. Cerebral perfusion pressure and arterial PCO2 were maintained constant. Mean cerebral artery flow velocity and jugular vein oxygen saturation were measured at the end of each step.
MEASUREMENTS AND MAIN RESULTS:Regional cerebral blood flow increased significantly during step 2 (39.3±29mL/100 hg/min) compared to step 1 (20.8±10.7) and step 3 (24.7±8). There was no difference in regional cerebral blood flow comparing step 1 vs. step 3. No significant difference in intracranial pressure, mean cerebral artery transcranial Doppler velocity, PaCO2, cerebral perfusion pressure between the different steps.
CONCLUSIONS:Isoflurane increases regional cerebral blood flow in comparison to propofol. Intracranial pressure did not change significantly in the population not affected by intracranial hypertension.
Background
The Pringle maneuver, which is performed during liver surgery to reduce blood loss, may result in liver ischemia/reperfusion injury resulting in metabolic, immunological, and microvascular ...changes, which may lead to hepatocellular damage. The aim of this study was the investigation of the effects of
N
-acetylcysteine (NAC) and methylprednisolone (MET) in the modulation of liver warm ischemia during hepatic resection.
Methods
Forty-eight patients were enrolled in a pilot double-blind, randomized clinical trial. The patients received either NAC, MET, or placebo. The primary endpoint was the reduction in postoperative alanine aminotransferase and bilirubin. The secondary endpoint was the difference in morbidity and mortality.
Results
All the 48 patients had liver resection with no mortality. Morbidity was observed in 8 (16 %) patients equally distributed among the groups. There was a significant favorable recovery of liver function tests in patients treated with NAC or MET compared with the placebo when the Pringle maneuver exceeded 70 min.
Conclusions
The administration of NAC or MET prior to the Pringle maneuver during hepatic resection is associated with lower postoperative aberration in liver function tests compared with placebo when the Pringle maneuver exceeded 70 min. Larger studies are required to validate our findings and to investigate the specific role of NAC and MET in liver surgery.
El diseño institucional del Banco del Sur Molinari, Andrea; Patrucchi, Leticia
H-industri@ (Ciudad Autónoma Buenos Aires),
12/2020, Letnik:
14, Številka:
27
Journal Article
Recenzirano
Odprti dostop
Los primeros años del siglo XXI mostraron un gran dinamismo en el mapa de actores financieros multilaterales, especialmente de iniciativas sureñas frente al debilitamiento de los actores financieros ...tradicionales. América del Sur formó parte de una vanguardia en esa agenda promoviendo, entre otras iniciativas, la creación de un nuevo banco regional de desarrollo: el Banco del Sur. Nuestro análisis caracteriza esa iniciativa describiendo y entendiendo sus limitaciones endógenas y exógenas que frenaron su puesta en marcha y poniendo énfasis en las características de su diseño, comparándolo luego tanto con los bancos consolidados que financian la región suramericana (BID y CAF) como con experiencias simultáneas que sí avanzaron (AIIB y NDB). Encontramos en su diseño una estructura de gobernanza más innovadora -sustentada en una legitimidad política que se fue debilitando en la región- pero que además convive con restricciones tradicionales del modelo financiero de este tipo de instituciones.
Over the first years of the 21st century, the map of multilateral financial actors has shown great dynamism, especially with southern initiatives in the face of the weakening of traditional financial actors. South America was part of a vanguard in the agenda promoting, among other initiatives, the creation of a new regional development bank: the Banco del Sur. Our analysis characterizes this initiative by describing and recognizing its current endogenous and exogenous limitations that stopped its implementation and emphasizing its design features. We compare it with both the consolidated banks that finance the South American region (IDB and CAF) and with simultaneous prospering experiences (AIIB and NDB). We find in the Banco del Sur’s design a more innovative, based upon a weakening regional political legitimacy, governance structure that, however, coexists with traditional restrictions of the financial model of this type of institutions.
Abstract Given their attractiveness as a source of financing for the least developed countries, multilateral development banks (MDBs) have grown in quantity and size supported by their sources of ...financing. We believe that this ‘resource dependency’ has not been sufficiently questioned in the literature, especially regarding the credit exposure these organizations have with their largest borrowing members. This article characterizes and identifies the differential effects of the three sources that make up the dependence on resources in the MDBs: capital contributions, leverage in the markets and their credit function. We analysed these sources particularly at the International Development Bank (IBRD), the Inter-American Development Bank (IDB) and the African Development Bank (AfDB) and in two recent events: the risk exchange implemented by the referred MDBs in 2015 and the effect of the Argentina’s selective default on the IDB’s capital adequacy (2014). We find an increasing relevance of leverage and the size of loans, which models a dependence on resources that weakens the development mandate of these organizations.
Resumo Dada sua atratividade como fonte de financiamento para os países menos desenvolvidos, os bancos multilaterais de desenvolvimento (BMDs) cresceram em quantidade e tamanho apoiados por suas fontes peculiares de financiamento. Acreditamos que essa ‘dependência de recursos’ não tenha sido suficientemente questionada na literatura dos BMDs, especialmente no que diz respeito à exposição de crédito que essas organizações têm com seus maiores membros tomadores de empréstimos. Este trabalho caracteriza e identifica os efeitos diferenciais das três fontes que compõem a dependência de recursos nos BMDs: aportes de capital, alavancagem nos mercados e sua função de crédito. Analisamos essas fontes particularmente no Banco Internacional para Reconstrução e Desenvolvimento (BIRD), no Banco Interamericano de Desenvolvimento (BID) e no Banco Africano de Desenvolvimento (BAD) e em dois eventos recentes: a troca de riscos implementada pelos referidos BMDs em 2015 e o efeito da inadimplência seletiva da Argentina na adequação de capital do BID (2014). Encontramos uma crescente relevância da alavancagem e do tamanho dos empréstimos, que modela a dependência de recursos que enfraquece o mandato de desenvolvimento dessas organizações.
In the Mediterranean Sea, the bivalve genus Pinna is represented by two species: the endemic Pinna nobilis and the (sub)tropical Atlantic Pinna rudis. P. rudis is generally less common and mostly ...restricted to the warmer regions of the western Mediterranean. However, since a mass mortality event, caused by a pathogen infection, has brought P. nobilis to the brink of extinction, records of P. rudis have increased in several Mediterranean regions, where it had not been previously observed. This paper reports on the presence of several P. rudis individuals in the Ligurian Sea, the northernmost reach of this species in the western Mediterranean. P. rudis has become increasingly common between 2021 and 2023, with a total of 28 new records from seven localities along the Ligurian coast. The size of the individuals and their estimated growth rate (3.6 cm·a−1) indicated that a recruitment event most likely took place in summer 2020, when P. nobilis was no longer present in the area. Our observations suggest that the recruitment success of P. rudis increased following the decline of P. nobilis. However, considering the thermophilic nature of P. rudis, in all likelihood, the ongoing water warming is playing a crucial role in the successful establishment of this species in the Ligurian Sea. A full understanding of the recent range expansion of P. rudis in the Mediterranean is far from being achieved, and whether P. rudis will be able to fulfil the ecological role of P. nobilis is difficult to predict. Large scale monitoring remains the only effective way to know about the future of Pinnids in the Mediterranean Sea.
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