Purpose
To quantify the numbers of critical care beds in Europe and to understand the differences in these numbers between countries when corrected for population size and gross domestic product.
...Methods
Prospective data collection of critical care bed numbers for each country in Europe from July 2010 to July 2011. Sources were identified in each country that could provide data on numbers of critical care beds (intensive care and intermediate care). These data were then cross-referenced with data from international databases describing population size and age, gross domestic product (GDP), expenditure on healthcare and numbers of acute care beds.
Results
We identified 2,068,892 acute care beds and 73,585 (2.8 %) critical care beds. Due to the heterogeneous descriptions of these beds in the individual countries it was not possible to discriminate between intensive care and intermediate care in most cases. On average there were 11.5 critical care beds per 100,000 head of population, with marked differences between countries (Germany 29.2, Portugal 4.2). The numbers of critical care beds per country corrected for population size were positively correlated with GDP (
r
2
= 0.16,
p
= 0.05), numbers of acute care beds corrected for population (
r
2
= 0.12,
p
= 0.05) and the percentage of acute care beds designated as critical care (
r
2
= 0.59,
p
< 0.0001). They were not correlated with the proportion of GDP expended on healthcare.
Conclusions
Critical care bed numbers vary considerably between countries in Europe. Better understanding of these numbers should facilitate improved planning for critical care capacity and utilization in the future.
Coronal jets represent important manifestations of ubiquitous solar transients, which may be the source of significant mass and energy input to the upper solar atmosphere and the solar wind. While ...the energy involved in a jet-like event is smaller than that of "nominal" solar flares and coronal mass ejections (CMEs), jets share many common properties with these phenomena, in particular, the explosive magnetically driven dynamics. Studies of jets could, therefore, provide critical insight for understanding the larger, more complex drivers of the solar activity. On the other side of the size-spectrum, the study of jets could also supply important clues on the physics of transients close or at the limit of the current spatial resolution such as spicules. Furthermore, jet phenomena may hint to basic process for heating the corona and accelerating the solar wind; consequently their study gives us the opportunity to attack a broad range of solar-heliospheric problems.
Objectives
To define a set of indicators that could be used to improve quality in intensive care medicine.
Methodology
An European Society of Intensive Care Medicine Task Force on Quality and Safety ...identified all commonly used key quality indicators. This international Task Force consisted of 18 experts, all with a self-proclaimed interest in the area. Through a modified Delphi process seeking greater than 90% consensual agreement from this nominal group, the indicators were then refined through a series of iterative processes.
Results
A total of 111 indicators of quality were initially found, and these were consolidated into 102 separate items. After five discrete rounds of debate, these indicators were reduced to a subset of nine that all had greater than 90% agreement from the nominal group. These indicators can be used to describe the structures (3), processes (2) and outcomes (4) of intensive care. Across this international group, it was much more difficult to obtain consensual agreement on the indicators describing processes of care than on the structures and outcomes.
Conclusion
This document contains nine indicators, all of which have a high level of consensual agreement from an international Task Force, which could be used to improve quality in routine intensive care practice.
Retrospective studies suggest that preoperative anaemia is associated with poor outcomes after surgery. The objective of this study was to describe mortality rates and patterns of intensive care ...resource use for patients with anaemia undergoing non-cardiac and non-neurological in-patient surgery.
We performed a secondary analysis of a large prospective study describing perioperative care and survival in 28 European nations. Patients at least 16 yr old undergoing in-patient surgery during a 7 day period were included in the study. Data were collected for in-hospital mortality, duration of hospital stay, admission to intensive care, and intensive care resource use. Multivariable logistic regression analysis was performed to understand the effects of preoperative haemoglobin (Hb) levels on in-hospital mortality.
We included 39 309 patients in the analysis. Preoperative anaemia had a high prevalence in both men and women (31.1% and 26.5%, respectively). Multivariate analysis showed that patients with severe odds ratio 2.82 (95% confidence interval 2.06–3.85) or moderate 1.99 (1.67–2.37) anaemia had higher in-hospital mortality than those with normal preoperative Hb concentrations. Furthermore, hospital length of stay (P<0.001) and postoperative admission to intensive care (P<0.001) were greater in patients with anaemia than in those with normal Hb concentrations.
Anaemia is common among non-cardiac and non-neurological surgical patients, and is associated with poor clinical outcome and increased healthcare resource use.
NCT01203605 (ClinicalTrials.gov).
Objective
To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.
Design
A consensus committee of 68 international ...experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.
Methods
The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations.
Results
Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pa
o
2
/Fi
o
2
ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient
without
ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients
with
early ARDS and a Pa
o
2
/F
i
o
2
<150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C).
Conclusions
Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
Atmospheric pollution in Mexico City Metropolitan Area (MCMA) represents a serious social and economic concern due to the very high population density. The most important industrial activities are ...the main responsible of the production of particulate matter PM10 that can damage seriously the human respiratory system. In the present study we investigate the dynamical properties of the time series of PM10 emissions recorded from 2005 to 2016 by the Automatic Atmospheric Monitoring Network (RAMA) in five zones of MCMA (NW, NE, CE, SW and SE). Several methods (periodogram, multifractal detrended fluctuation analysis and the Fisher–Shannon method) were applied to get the most exhaustive description of the dynamical characteristics of the series. Our findings point out to: (1) the existence of a twofold power law behavior in the power spectrum of all the series, indicating the co-existence of two different mechanisms underlying the time dynamics of PM10; (2) the emergence of the 7-day periodicity of anthropogenic nature; (3) the multifractal behavior of all the series, dominated by small fluctuations; (4) the identification of NE zone, which is also the most polluted one as characterized by the larger disorder.
•PM10 time series in five zones of Mexico City Metropolitan Area were investigated.•A twofold power law behavior in the power spectrum was detected.•The 7-day periodicity in PM10 series suggest the anthropogenic nature of the pollution source.•The PM10 of the more polluted zone is less multifractal.•The PM10 of the more polluted zone shows higher level of disorder.
Background
The emotional state of parents of babies with Down syndrome affects their babies' development and their parent–child bonding. The aim for this study was to conduct a pilot randomised ...controlled evaluation of the effect of infant massage on parents of babies with Down syndrome.
Methods
This pilot study compared two groups (intervention and control), each with 16 parents of babies with Down syndrome. Indices of acceptance, engagement and awareness of influence were measured at two different time points (pre‐test and after 5 weeks) using the ‘This Is My Baby’ Interview. The allocation of families to each group was randomised. The experimental group performed infant massage, applied by the parents, for 5 weeks, every day for at least 10 min. The massage protocol was based on the methodology created by Vimala McClure. Parents in the control group received the intervention after completion of the study.
Results
The indices of acceptance, commitment and awareness of influence improved in the experimental group and in the control group. The 2 × 2 mixed‐model analysis of variance indicates a statistically significant group‐by‐time interaction for all indices (P < 0.001), which was significantly higher in the experimental group than in the control group.
Conclusions
The application of infant massage, by parents to their babies, improves the rates of acceptance, commitment and awareness of influence of parents of babies with Down syndrome in the short term.
Aromatherapy uses essential oils (EOs) for several medical purposes, including relaxation. The association between the use of aromas and a decrease in anxiety could be a valuable instrument in ...managing anxiety in an ever increasing anxiogenic daily life style. Linalool is a monoterpene commonly found as the major volatile component of EOs in several aromatic plant species. Adding to previously reported sedative effects of inhaled linalool, the aim of this study was to investigate the effects of inhaled linalool on anxiety, aggressiveness and social interaction in mice. Additionally, we investigated the effects of inhaled linalool on the acquisition phase of a step-down memory task in mice. Inhaled linalool showed anxiolytic properties in the light/dark test, increased social interaction and decreased aggressive behavior; impaired memory was only seen the higher dose of linalool. These results strengthen the suggestion that inhaling linalool rich essential oils can be useful as a mean to attain relaxation and counteract anxiety.
The history and dynamics of deciduous Nothofagus forests along the eastern slopes of the central Patagonian Andes (44°-49°S) remain insufficiently studied and understood, particularly at timescales ...ranging from centuries to millennia. Available fossil pollen records point to time-transgressive responses of the arboreal vegetation to climatic changes during the Last Glacial Termination (T1) and early Holocene, and spatial heterogeneity since then along north-south, east-west, and elevation transects. The degree to which these results represent biogeographic and climatic trends, varying environmental gradients, or site-specific phenomena has not been assessed in detail. Here we present a fossil pollen and macroscopic charcoal record from Lago Churrasco (45°41′S, 71°49′W), a small closed-basin lake located in the deciduous Nothofagus forest zone of the central-east Andes of Chilean Patagonia. Our results suggest that Nothofagus trees colonized newly deglaciated terrains at ∼16,000 cal yr BP and formed scrublands/woodlands several millennia earlier than reported by previous studies east of the Andes. This suggests expansion and local densification of tree populations sourced from the eastern margin of the Patagonian Ice Sheet during the Last Glacial Maximum, with the additional implication that temperature and precipitation conditions favorable for tree survival and reproduction developed early during T1. We posit that the amount of moisture delivered by the Southern Westerly Winds was not a limiting factor for arboreal expansion during T1 in this sector of the central Patagonian Andes. Closed-canopy Nothofagus forests established at ∼10,000 cal yr BP and have remained essentially invariant despite climate change and natural disturbance regimes. This resilience was challenged and exceeded by human disturbance during the 20th century through the use of fire, leading to deforestation and spread of invasive exotic species in an extraordinarily rapid event. Our record suggests a permanent influence of the Southern Westerly Winds over the last 10,000 years, with relatively modest variations at centennial and millennial timescales.
•We studied lake-sediment records from the eastern slopes of central Andean Patagonia.•Deglaciation started at 17,800 cal yr BP and led to the formation of a glacial lake.•Colonization and densification of Nothofagus trees started at ∼16,000 cal yr BP.•Closed-canopy forests have persisted essentially unaltered since ∼10,000 cal yr BP.•Chilean/European disturbance drove the largest-magnitude vegetation changes on record.
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