Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries

IMPORTANCE: Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS). OBJECTIVES: To evaluate intensive care unit (ICU) incidence and outcome of ARDS and to assess clinician recognition, ventilation management, and use of adjuncts-for example prone positioning-in routine clinical practice for patients fulfilling the ARDS Berlin Definition. DESIGN, SETTING, AND PARTICIPANTS:The Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) was an international, multicenter, prospective cohort study of patients undergoing invasive or noninvasive ventilation, conducted during 4 consecutive weeks in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across 5 continents. EXPOSURES:Acute respiratory distress syndrome. MAIN OUTCOMES AND MEASURES: The primary outcome was ICU incidence of ARDS. Secondary outcomes included assessment of clinician recognition of ARDS, the application of ventilatory management, the use of adjunctive interventions in routine clinical practice, and clinical outcomes from ARDS. RESULTS: Of 29,144 patients admitted to participating ICUs, 3022 (10.4%) fulfilled ARDS criteria. Of these, 2377 patients developed ARDS in the first 48 hours and whose respiratory failure was managed with invasive mechanical ventilation. The period prevalence of mild ARDS was 30.0% (95% CI, 28.2%-31.9%); of moderate ARDS, 46.6% (95% CI, 44.5%-48.6%); and of severe ARDS, 23.4% (95% CI, 21.7%-25.2%). ARDS represented 0.42 cases per ICU bed over 4 weeks and represented 10.4% (95% CI, 10.0%-10.7%) of ICU admissions and 23.4% of patients requiring mechanical ventilation. Clinical recognition of ARDS ranged from 51.3% (95% CI, 47.5%-55.0%) in mild to 78.5% (95% CI, 74.8%-81.8%) in severe ARDS. Less than two-thirds of patients with ARDS received a tidal volume 8 of mL/kg or less of predicted body weight. Plateau pressure was measured in 40.1% (95% CI, 38.2-42.1), whereas 82.6% (95% CI, 81.0%-84.1%) received a positive end-expository pressure (PEEP) of less than 12 cm H2O. Prone positioning was used in 16.3% (95% CI, 13.7%-19.2%) of patients with severe ARDS. Clinician recognition of ARDS was associated with higher PEEP, greater use of neuromuscular blockade, and prone positioning. Hospital mortality was 34.9% (95% CI, 31.4%-38.5%) for those with mild, 40.3% (95% CI, 37.4%-43.3%) for those with moderate, and 46.1% (95% CI, 41.9%-50.4%) for those with severe ARDS. CONCLUSIONS AND RELEVANCE: Among ICUs in 50 countries, the period prevalence of ARDS was 10.4% of ICU admissions. This syndrome appeared to be underrecognized and undertreated and associated with a high mortality rate. These findings indicate the potential for improvement in the management of patients with ARDS

Septic facet arthritis in young patient without risk factors

Se reporta el caso de un varón de 22 años que presentó lumbalgia aguda grave sin respuesta a los analgésicos comunes. El estudio por resonancia magnética mostró un proceso inflamatorio en la articulación facetaria T8-T9 y una pequeña colección epidural. Se realizó drenaje con aguja bajo control tomográfico y el cultivo de la muestra aisló Streptococcus agalactiae. El paciente evolucionó en forma favorable a la terapia antibiótica administrada, penicilina G sódica intravenosa durante tres semanas y otros betalactámicos oral por 4 semanas. La infección piógena de las articulaciones facetarias es rara.A 22-year-old male who had severe acute low back pain with no response to common analgesics is reported.The MRI study showed an inflammatory process in the T8-T9 facet joint and a small epidural collection. Needle drainage was performed under tomographic control and it was isolated Streptococcus agalactiae the culture of the sample. The patient evolved favorably to antibiotic therapy administered, intravenous sodium penicillin G for 3 weeks and other beta-lactam agents orally for 4 weeks. Pyogenic infection of the facet joints is rare

Optimal liability sharing and court errors: an exploratory analysis

We focus in this paper on the effects of court errors on the optimal sharing of liability between firms and financiers, as an environmental policy instrument. Using a structural model of the interactions between firms, financial institutions, governments and courts we show, through numerical simulations, the distortions in liability sharing between firms and financiers that the imperfect implementation of government policies implies. We consider in particular the role played by the efficiency of the courts in avoiding Type I (finding an innocent firm guilty of inappropriate care) and Type II (finding a guilty firm innocent of inappropriate care) errors. This role is considered in a context where liability sharing is already distorted (when compared with first best values) due not only to the courts' own imperfect assessment of safety care levels exerted by firm but also to the presence of moral hazard and adverse selection in financial contracting, as well as of noncongruence of objectives between firms and financiers on the one hand and social welfare maximization on the other. Our results indicate that an increase in the efficiency of the court system in avoiding errors raises safety care levels, thereby reducing the probability of accident, and allowing the social welfare maximizing government to impose a lower liability [higher] share for firms [financiers] as well as a lower standard level of care

Tensile Deformation of Oriented Poly(ε-caprolactone) and Its Miscible Blends with Poly(vinyl methyl ether)

The structural evolution of micromolded poly(ε-caprolactone) (PCL) and its miscible blends with noncrystallizable poly(vinyl methyl ether) (PVME) at the nanoscale was investigated as a function of deformation ratio and blend composition using in situ synchrotron smallangle X-ray scattering (SAXS) and scanning SAXS techniques. It was found that the deformation mechanism of the oriented samples shows a general scheme for the process of tensile deformation: crystal block slips within the lamellae occur at small deformations followed by a stressinduced fragmentation and recrystallization process along the drawing direction at a critical strain where the average thickness of the crystalline lamellae remains essentially constant during stretching. The value of the critical strain depends on the amount of the amorphous component incorporated in the blends, which could be traced back to the lower modulus of the entangled amorphous phase and, therefore, the reduced network stress acting on the crystallites upon addition of PVME. When stretching beyond the critical strain the slippage of the fibrils (stacks of newly formed lamellae) past each other takes place resulting in a relaxation of stretched interlamellar amorphous chains. Because of deformation-induced introduction of the amorphous PVME into the interfibrillar regions in the highly oriented blends, the interactions between fibrils becomes stronger upon further deformation and thus impeding sliding of the fibrils to some extent leading finally to less contraction of the interlamellar amorphous layers compared to the pure PCLNational Natural Science Foundation of China (21204088 and 21134006). This work is within the framework of the RCUK/EPSRC Science Bridges China project of UK−China Advanced Materials Research Institute (AMRI)

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

Meeting abstrac

Polycomb group ring finger protein 6 suppresses Myc-induced lymphomagenesis

Max is an obligate dimerization partner for the Myc transcription factors and for several repressors, such as Mnt, Mxd1-4, and Mga, collectively thought to antagonize Myc function in transcription and oncogenesis. Mga, in particular, is part of the variant Polycomb group repressive complex PRC1.6. Here, we show that ablation of the distinct PRC1.6 subunit Pcgf6-but not Mga- accelerates Myc-induced lymphomagenesis in Eμ-myc transgenic mice. Unexpectedly, however, Pcgf6 loss shows no significant impact on transcriptional profiles, in neither pre-tumoral B-cells, nor lymphomas. Altogether, these data unravel an unforeseen, Mga- and PRC1.6-independent tumor suppressor activity of Pcgf6

¿“Nos enfrentamos y nos abrazamos”? Un nuevo recorrido por los usos oficiales del pasado durante el bicentenario de la Revolución de Mayo

El presente trabajo analiza, en primer lugar, los modos en que la historia argentina se tradujo, durante los festejos oficiales del bicentenario de la Revolución de Mayo, en artefactos culturales y festivos dirigidos a atraer un público vasto, prestando especial atención a los usos del pasado allí exhibidos. En segundo lugar, pone en relación dichas operaciones con las variaciones ocurridas en el nivel de las prácticas políticas gubernamentales tras la crisis política de 2008. En última instancia, se plantea que el gobierno de Cristina Fernández de Kirchner se inclinó, al momento de proyectar el festejo patrio en cuestión, por una lógica discursiva liberal–centrada, especialmente, en el consenso inclusivo y la aceptación de las diferencias–con el fin de matizar la partición del espacio socio-político, exhibir una nación reconciliada, interpelar a la sociedad argentina en su conjunto y, de ese modo, contribuir a la reconstrucción de su hegemonía política.Firstly, this paper analyzes how Argentinian history was translated, during the national celebrations of the May Revolution bicentennial, into cultural and festive devices aimed at attracting a massive audience, paying special attention to the uses of the past displayed. Secondly, it illustrates the relations between these operations and the variations of government policy that occurred after the 2008 political crisis. Ultimately, it claims that the Cristina Fernández de Kirchner administration adopted, when it came to planning this national holiday, a liberal discursive logic – mainly characterized by inclusive consensus and pluralism – in order to ease the division of the social and political space, display a reconciled nation, address the entire Argentinean society and, thereby, contribute to the reconstruction of Kirchnerist hegemony.Fil: Amorebieta y Vera, María Laura. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - La Plata. Instituto de Investigaciones en Humanidades y Ciencias Sociales. Universidad Nacional de La Plata. Facultad de Humanidades y Ciencias de la Educación. Instituto de Investigaciones en Humanidades y Ciencias Sociales; Argentin

FENOLOGIA E PRODUÇÃO DE Eugenia candolleana D.C. EM ÁREA DE RESTINGA LITORÂNEA EM ARAQUARI-SC, BRASIL: RESULTADOS PARCIAIS

As espécies florestais nativas desempenharem um papel muito importante na dinâmica e estabilidade dos ecossistemas naturais, em muitos casos figuram como alternativa de cultivo e renda para o produtor rural. Apesar de pertencer à família Myrtaceae, que possui espécies de reconhecida importância ambiental e valor econômico, Eugenia candolleana D.C. ainda é muito pouco conhecida e estudada, principalmente no âmbito agronômico e nas condições da região do litoral nordeste catarinense.Este trabalho teve por objetivos verificar a fenologia e a produção de E. candolleana D.C. em área de restinga litorânea. em Araquari-SC, Brasil. O estudo foi realizado em uma população plantas existentes na área do IFC-Campus Araquari (26°22'12'' S e 48°43' 19'' O), durante o período 01/08/2019 a 31/07/2020. Foram analisados:a fenologia, por meio da observação de eventos relativos à floração, frutificação e mudanças foliares, a cada duas semanas; a estimativa de produção de frutos, determinada pelo acumulado de colheita de todos os frutos maduros por planta; a caracterização física dos frutos, em classes de matéria fresca (g); e o desenvolvimento vegetativo da planta(comprimento de número de brotos). Da população de plantas observadas, foi possível realizar a colheita em apenas uma, possivelmente devido à juvenilidade das demais. A planta é semi-decidual e a fase reprodutiva estendeu-se de janeiro à início de abril. A colheita iniciou no dia 28/02/2020 e estendeu-se por 29 dias. A produção total estimada foi 22,17 kg.planta-1 e o peso médio de matéria fresca dos frutos foi de 5,09g, com a seguinte composição média: casca, 8,4%; polpa, 74%; sementes, 16,8%; suco, 39%; e bagaço, 27,7%. O rendimento em matéria seca foi de 22,6% do fruto inteiro fresco, com 4,2% de cascas secas, 15,4% de polpa seca e 45,4% de sementes. Houveram danos decorrentes de pássaros, vespas e/ou queda natural em 21% dos frutos. Os frutos variaram entre 2,1 e 9 gramas de matéria fresca, sendo que as principais classes foram de 4,1 à 5,0 g de matéria fresca e de 5,1 à 6 g, que perfizeram respectivamente 34,7 e 35,4% do total de frutos. O número médio de brotos por ramo foi de 10, com um incremento médio anual de 57 cm no somatório do comprimento das ramificações ocorrentes no período de um ano. De acordo com as condições em que o trabalho foi desenvolvido pode-se concluir que: Os principais eventos fenológicos observados foram: senescência de folhas velhas e brotação de folhas novas, ocorridas simultaneamente de forma intensa entre os meses de outubro e novembro e em menor escala no final da frutificação; floração, do início de janeiro a fevereiro; e colheita, do final de fevereiro à março. E. candolleana apresenta potencial agronômico quanto à produtividade de frutos; o reduzido tempo de prateleira demanda cuidados na comercialização de frutos frescos in natura e a refrigeração é uma alternativa na conservação da qualidade dos frutos em póscolheita; Mosca das frutas é a principal praga encontrada, com potencial de dano econômico principalmente em pós-colheita

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p<0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p<0\ub70001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding: No funding