The decarbonization of the electricity sector is leading to a substantial increase in the demand for wind energy. Will tribal nations, which account for 7.8% of utility-scale wind capacity, benefit ...from this policy shift? To examine why tribal nations vary in translating wind energy potential into wind installed capacity, we have constructed an original dataset of the potential as well as the location of wind turbines across tribal nations. Our statistical analysis of 286 tribal nations suggests that wind energy potential is not associated with wind installed capacity. Instead, casino square footage, a proxy for tribal nation's administrative capacity and business acumen, is associated with wind installed capacity. Political orientation plays a role as well: tribal nations are more likely to have wind installed capacity when they value tribal sovereignty. While tribes suffering from natural disasters do not install more wind turbines, those receiving federal grants for wind energy projects, and located in states that already have a substantial number of wind turbines, are more apt to have wind turbines. Surprisingly, tribes located in states with renewable portfolio standards do not show an association with installed wind turbines capacity.
Objective
To identify research priorities in the management, epidemiology, outcome and underlying causes of sepsis and septic shock.
Design
A consensus committee of 16 international experts ...representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine was convened at the annual meetings of both societies. Subgroups had teleconference and electronic-based discussion. The entire committee iteratively developed the entire document and recommendations.
Methods
Each committee member independently gave their top five priorities for sepsis research. A total of 88 suggestions (ESM 1 - supplemental table 1) were grouped into categories by the committee co-chairs, leading to the formation of seven subgroups: infection, fluids and vasoactive agents, adjunctive therapy, administration/epidemiology, scoring/identification, post-intensive care unit, and basic/translational science. Each subgroup had teleconferences to go over each priority followed by formal voting within each subgroup. The entire committee also voted on top priorities across all subgroups except for basic/translational science.
Results
The Surviving Sepsis Research Committee provides 26 priorities for sepsis and septic shock. Of these, the top six clinical priorities were identified and include the following questions: (1) can targeted/personalized/precision medicine approaches determine which therapies will work for which patients at which times?; (2) what are ideal endpoints for volume resuscitation and how should volume resuscitation be titrated?; (3) should rapid diagnostic tests be implemented in clinical practice?; (4) should empiric antibiotic combination therapy be used in sepsis or septic shock?; (5) what are the predictors of sepsis long-term morbidity and mortality?; and (6) what information identifies organ dysfunction?
Conclusions
While the Surviving Sepsis Campaign guidelines give multiple recommendations on the treatment of sepsis, significant knowledge gaps remain, both in bedside issues directly applicable to clinicians, as well as understanding the fundamental mechanisms underlying the development and progression of sepsis. The priorities identified represent a roadmap for research in sepsis and septic shock.
Community transmission of coronavirus 2019 (Covid-19) was detected in the state of Washington in February 2020.
We identified patients from nine Seattle-area hospitals who were admitted to the ...intensive care unit (ICU) with confirmed infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Clinical data were obtained through review of medical records. The data reported here are those available through March 23, 2020. Each patient had at least 14 days of follow-up.
We identified 24 patients with confirmed Covid-19. The mean (±SD) age of the patients was 64±18 years, 63% were men, and symptoms began 7±4 days before admission. The most common symptoms were cough and shortness of breath; 50% of patients had fever on admission, and 58% had diabetes mellitus. All the patients were admitted for hypoxemic respiratory failure; 75% (18 patients) needed mechanical ventilation. Most of the patients (17) also had hypotension and needed vasopressors. No patient tested positive for influenza A, influenza B, or other respiratory viruses. Half the patients (12) died between ICU day 1 and day 18, including 4 patients who had a do-not-resuscitate order on admission. Of the 12 surviving patients, 5 were discharged home, 4 were discharged from the ICU but remained in the hospital, and 3 continued to receive mechanical ventilation in the ICU.
During the first 3 weeks of the Covid-19 outbreak in the Seattle area, the most common reasons for admission to the ICU were hypoxemic respiratory failure leading to mechanical ventilation, hypotension requiring vasopressor treatment, or both. Mortality among these critically ill patients was high. (Funded by the National Institutes of Health.).
The opportunistic pathogen Acinetobacter baumannii is able to persist in the environment and is often multidrug resistant (MDR), causing difficulties in the treatment of infections. Here, we show ...that the two-component system AdeRS, which regulates the production of the AdeABC multidrug resistance efflux pump, is required for the formation of a protective biofilm in an ex vivo porcine mucosal model, which mimics a natural infection of the human epithelium. Interestingly, deletion of adeB impacted only on the ability of strain AYE to form a biofilm on plastic and only on the virulence of strain Singapore 1 for Galleria mellonella RNA-Seq revealed that loss of AdeRS or AdeB significantly altered the transcriptional landscape, resulting in the changed expression of many genes, notably those associated with antimicrobial resistance and virulence interactions. For example, A. baumannii lacking AdeRS displayed decreased expression of adeABC, pil genes, com genes, and a pgaC-like gene, whereas loss of AdeB resulted in increased expression of pil and com genes and decreased expression of ferric acinetobactin transport system genes. These data define the scope of AdeRS-mediated regulation, show that changes in the production of AdeABC mediate important phenotypes controlled by AdeRS, and suggest that AdeABC is a viable target for antimicrobial drug and antibiofilm discovery corrected.
Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to ...expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.
Early identification and appropriate management of sepsis improves outcomes. Despite convincing data showing the benefits of early recognition and treatment of sepsis and septic shock, implementation ...of such evidence-based therapy is suboptimal. This review describes methods that have been shown to improve bedside application of the evidence-based guidelines.
The Surviving Sepsis Campaign (SSC) has developed guidelines for the management of severe sepsis and septic shock. The initial SSC guidelines were published in 2004; as evidence continued to evolve, the guidelines were updated, with the most recent iteration published in 2016. Guidelines by themselves can take years to change clinical practice. To affect more rapid change, the SSC guidelines are filtered into bundles to impact behavior change in a simple and uniform way.
Implementation of the SSC bundles revolves around practice improvement measures. Hospitals that have successfully implemented these bundles have consistently shown improved outcomes and reductions in healthcare spending. Finally, the Centers for Medicare and Medicaid Services has approved SSC bundle compliance as a core measure, and hospitals in the United States are mandated to collect and report their data regularly to Centers for Medicare and Medicaid Services.
Introduction
Despite evidence demonstrating the value of performance initiatives, marked differences remain between hospitals in the delivery of care for patients with sepsis. The aims of this study ...were to improve our understanding of how compliance with the 3-h and 6-h Surviving Sepsis Campaign (SSC) bundles are used in different geographic areas, and how this relates to outcome.
Methods
This was a global, prospective, observational, quality improvement study of compliance with the SSC bundles in patients with either severe sepsis or septic shock.
Results
A total of 1794 patients from 62 countries were enrolled in the study with either severe sepsis or septic shock. Overall compliance with all the 3-h bundle metrics was 19 %. This was associated with lower hospital mortality than non-compliance (20 vs. 31 %,
p
< 0.001). Overall compliance with all the 6-h bundle metrics was 36 %. This was associated with lower hospital mortality than non-compliance (22 vs. 32 %,
p
< 0.001). After adjusting the crude mortality differences for ICU admission, sepsis status (severe sepsis or septic shock), location of diagnosis, APACHE II score and country, compliance remained independently associated with improvements in hospital mortality for both the 3-h bundle (OR = 0.64 (95 % CI 0.47−0.87),
p
= 0.004)) and 6-h bundle (OR = 0.71 (95 % CI 0.56−0.90),
p
= 0.005)).
Discussion
Compliance with all of the evidence-based bundle metrics was not high. Patients whose care included compliance with all of these metrics had a 40 % reduction in the odds of dying in hospital with the 3-h bundle and 36 % for the 6-h bundle.
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