Australian and New Zealand practice in intensive care (ANZPIC II): Predictors of physician confidence to diagnose pneumonia and determine illness severity in ventilated patients

The manner in which elements of clinical history, physical examination and investigations influence subjectively assessed illness severity and outcome prediction is poorly understood. This study investigates the relationship between clinician and objectively assessed illness severity and the factors influencing clinician's diagnostic confidence and illness severity rating for ventilated patients with suspected pneumonia in the intensive care unit (ICU). A prospective study of fourteen ICUs included all ventilated admissions with a clinical diagnosis of pneumonia. Data collection included pneumonia type - community-acquired (CAP), hospital-acquired (HAP) and ventilator-associated (VAP), clinician determined illness severity (CDIS), diagnostic methods, clinical diagnostic confidence (CDC), microbiological isolates and antibiotic use. For 476 episodes of pneumonia (48% CAP, 24% HAP, 28% VAP), CDC was greatest for CAP (64% CAP, 50% HAP and 49% VAP, P < 0.01) or when pneumonia was considered life-threatening (84% high CDC, 13% medium CDC and 3% low CDC, P < 0.001). Life-threatening pneumonia was predicted by worsening gas exchange (OR 4.8, CI 95% 2.3-10.2, P < 0.001), clinical signs of consolidation (OR 2.0, CI 95% 1.2-3.2, P < 0.01) and the Sepsis-Related Organ Failure Assessment (SOFA) Score (OR 1.1, CI 95% 1.1-1.2, P < 0.001). Diagnostic confidence increased with CDIS (OR 163, CI 95% 8.4-31.4, P < 0.001), definite pathogen isolation (OR 3.3, CI 95% 2.0-5.6) and clinical signs of consolidation (OR 2.1, CI 95% 1.3-3.3, P = 0.001). Although the CDIS, SOFA Score and the Simplified Acute Physiologic Score (SAPS II) were all associated with mortality, the SAPS II Score was the best predictor of mortality (P = 0.02). Diagnostic confidence for pneumonia is moderate but increases with more classical presentations. A small set of clinical parameters influence subjective assessment. Objective assessment using SAPS II Scoring is a better predictor of mortality.

Structure and thermal stability of Langmuir-Blodgett films of barium arachidate

The structures of multilayer Langmuir-Blodgett films of barium arachidate before and after heat treatment have been investigated using both atomic force microscopy (AFM) and grazing incidence synchrotron X-ray diffraction (GIXD). AFM gave information on surface morphology at molecular resolution while GIXD provided quantitative details of the lattice structures of the films with their crystal symmetries and lattice constants. As-prepared films contained three coexisting structures: two triclinic structures with the molecularchains tilted by about 20degrees from the film normal and with 3 x 1 or 2 x 2 super-lattice features arising from height modulation of the molecules in the films; a rectangular structure with molecules perpendicular to the film surface. Of these, the 3 x 1 structure is dominant with a loose correlation between the bilayers. In the film plane both superstructures are commensurate with the local structures, having different oblique symmetries. The lattice constants for the 3 x 1 structure are a(s) = 3a = 13.86 Angstrom, b(s) = b = 4.31 Angstrom and gamma(s) = gamma = 82.7degrees; for the 2 x 2 structure a(s) = 2a = 16.54 Angstrom, b(s) = 2b = 9.67 Angstrom, gamma(s) = gamma = 88degrees. For the rectangular structure the lattice constants are a = 7.39 Angstrom, b = 4.96 Angstrom and gamma = 90degrees. After annealing, the 2 x 2 and rectangular structures were not observed, while the 3 x 1 structure had developed over the entire film. For the annealed films the correlation length in the film plane is about twice that in the unheated films, and in the out-of-plane direction covers two bilayers. The above lattice parameters, determined by GIXD, differed significantly from the values obtained by AFM, due possibly to distortion of the films by the scanning action of the AFM tip. (C) 2004 Published by Elsevier B.V.

The pearl oysters, Pinctada maxima and P margaritifera, respond in different ways to culture in dissimilar environments

Growth, Condition Index (CI) and survival of the pearl oysters, Pinctada maxima and R margaritifera, were measured in three size groups of oysters over 14 months at two dissimilar environments in the Great Barrier Reef lagoon. These were the Australian Institute of Marine Science (AIMS) in a mainland bay and Orpheus Island Research Station (OIRS) in coral reef waters. Temperature, suspended particulate matter (SPM) and particulate organic matter (POM) were monitored during the study. Temperature at AIMS fluctuated more widely than at OIRS both daily and seasonally, with annual ranges 20-31 degrees C and 22-30 degrees C, respectively. Mean SPM concentration at AIMS (11.1 mg l(-1)) was much higher than at OIRS (1.4 mg l(-1)) and fluctuated widely (2-60 mg l(-1)). Mean POM level was also substantially higher at AIMS, being 2.1 mg l(-1) compared with 0.56 mg l(-1) at OIRS. Von Bertalatiffy growth curve analyses showed that P. maxima grew more rapidly and to larger sizes than P. margaritifera at both sites. For the shell height (SH) of R maxima, growth index phi'=4.31 and 4.24, asymptotic size SHinfinity = 229 and 205 mm, and time to reach 120 mm SH (T-(120))= 1.9 and 2.1 years at AIMS and OIRS, respectively. While for P margaritifera, phi'=4.00 and 4.15, SHinfinity = 136 and 157 mm, and T-(120) = 2.5 and 3.9 years at AIMS and OIRS, respectively. R maxima had significantly lower growth rates and lower survival of small oysters during winter compared with summer. There were, however, no significant differences between the two sites in growth rates of P. maxima and final Cl values. In contrast, P. margaritifiera showed significant differences between sites and not seasons, with lower growth rates, survival of small oysters, final Cl values and asymptotic sizes at AIMS. The winter low temperatures, but not high SPM at AIMS, adversely affected P. maxima. Conversely, the high SPM levels at AIMS, but not temperature, adversely affected P. margaritifera. This was in accordance with earlier laboratory-based energetics studies of the effects of temperature and SPM on these two species. P maxima has potential to be commercially cultured in ca. > 25 degrees C waters with a wide range of SPM levels, including oligotrophic coral reef waters with appropriate particle sizes. It is possible to culture R margaritifera in turbid conditions, but its poor performance in these conditions makes commercial culture unlikely. (c) 2005 Elsevier B.V. All rights reserved.

Drug utilization evaluation of parenteral proton pump inhibitors

Current evidence supports parenteral infusion of proton pump inhibitors (PPI) after endoscopic treatment of bleeding peptic ulcers and such treatment seems reasonable where there is active bleeding or visible vessel on endoscopy. Parenteral boluses of PPI can be used in patients nil by mouth who cannot tolerate oral therapy. We sought to examine the appropriateness of parenteral PPI use. Drug utilisation evaluation was performed on 94 patients admitted to a 500 bed metropolitan hospital. 39 patients received continuous parenteral infusion of omeprazole (8 mg/ h) over a mean of 60 ± 29 h. 55 patients had parenteral boluses (40 mg bd) of omeprazole over a mean of 5 ± 4 days. Indications for PPI infusion (n = 39) were: major haemorrhage requiring transfusion (23), minor haemorrhage (8), dyspepsia (4) and others (4). 31 of the 39 patients on PPI infusion had upper gastrointestinal (GI) endoscopy. PPI infusion was commenced prior to endoscopy in 26 (84%) patients. 13 patients (33%) had active bleeding or visible non bleeding vessels at endoscopy. Only 11 patients (28%) had endoscopically treated peptic ulcers. Indications for parenteral PPI boluses (n = 55) included patients nil by mouth unable to take maintenance PPI orally (21), minor haemorrhage (8), peptic ulcer prophylaxis in seriously unwell (6), major haemorrhage (4), dyspepsia (2), postoprative period following peptic ulcer surgery (2) and others (12). Endoscopy was performed in 10 patients (18%) with only 1 endoscopically treated peptic ulcer. Our data suggest significant inappropriate use of parenteral PPI, which may be used for minor GI bleeding and dyspepsia and are typically commenced prior to endoscopy. These findings can explain the costly hospital expenditure on PPI.