Mediators of gram-positive septic shock

Septic shock can occur as a result of Gram-negative or Gram-positive infection and involves a complex interaction between bacterial factors and the host immune system producing a systemic inflammatory state that may progress to multiple organ failure and death. Gram-positive bacteria are increasingly becoming more prevalent especially Staphylococcus epidermidis in association with indwelling devices. Lipopolysaccaride (LPS) is the key Gram-negative component involved in this process, but it is not clear which components of Gram-positive bacteria are responsible for progression of this often fatal disease. The aim of this thesis was to investigate the effect of bacterial components on the immune systems. Lipid S, a short chain form of lipoteichoic acid (LTA) found to be excreted from bacteria during growth in culture medium was examined along with other Gram-positive cell wall components: LTA, peptidoglycan (PG) and wall teichoic acids (WTA) and LPS from Gram-negative bacteria. Lipid S, LTA, PG and LPS but not WTA all stimulated murine macrophages and cell lines to produce significant amounts of NO, TNF-a, IL-6 and IL-1 and would induce fever and tissue damage seen in inflammatory diseases. Lipid S proved to be the most potent out of the Gram-positive samples tested. IgG antibodies in patients serum were found to bind to and cross react with lipid S and LTA. Anti-inflammatory antibiotics, platelet activating factor (PAF), PAF receptor antagonists and monoclonal antibodies (mAbs) directed to LTA, CD14 and toll-like receptors were utilised to modulate cytokine and NO production. In cell culture the anti-LTA and the anti-CD14 mAbs failed to markedly attenuate the production of NO, TNF-a, IL-6 or IL-1, the anti-TLR4 antibody did greatly inhibit the ability of LPS to stimulate cytokine production but not lipid S. The tetracyclines proved to be the most effective compounds, many were active at low concentrations and showed efficacy to inhibit both lipid S and LPS stimulated macrophages to produce NO.

A total quality management methodology for universities

This research document is motivated by the need for a systemic, efficient quality improvement methodology at universities. There exists no methodology designed for a total quality management (TQM) program in a university. The main objective of this study is to develop a TQM Methodology that enables a university to efficiently develop an integral total quality improvement (TQM) Plan. ^ Current research focuses on the need of improving the quality of universities, the study of the perceived best quality universities, and the measurement of the quality of universities through rankings. There is no evidence of research on how to plan for an integral quality improvement initiative for the university as a whole, which is the main contribution of this study. ^ This research is built on various reference TQM models and criteria provided by ISO 9000, Baldrige and Six Sigma; and educational accreditation criteria found in ABET and SACS. The TQM methodology is proposed by following a seven-step metamethodology. The proposed methodology guides the user to develop a TQM plan in five sequential phases: initiation, assessment, analysis, preparation and acceptance. Each phase defines for the user its purpose, key activities, input requirements, controls, deliverables, and tools to use. The application of quality concepts in education and higher education is particular; since there are unique factors in education which ought to be considered. These factors shape the quality dimensions in a university and are the main inputs to the methodology. ^ The proposed TQM Methodology is used to guide the user to collect and transform appropriate inputs to a holistic TQM Plan, ready to be implemented by the university. Different input data will lead to a unique TQM plan for the specific university at the time. It may not necessarily transform the university into a world-class institution, but aims to strive for stakeholder-oriented improvements, leading to a better alignment with its mission and total quality advancement. ^ The proposed TQM methodology is validated in three steps. First, it is verified by going through a test activity as part of the meta-methodology. Secondly, the methodology is applied to a case university to develop a TQM plan. Lastly, the methodology and the TQM plan both are verified by an expert group consisting of TQM specialists and university administrators. The proposed TQM methodology is applicable to any university at all levels of advancement, regardless of changes in its long-term vision and short-term needs. It helps to assure the quality of a TQM plan, while making the process more systemic, efficient, and cost effective. This research establishes a framework with a solid foundation for extending the proposed TQM methodology into other industries. ^

Availability estimation and management for complex processing systems

“Availability” is the terminology used in asset intensive industries such as petrochemical and hydrocarbons processing to describe the readiness of equipment, systems or plants to perform their designed functions. It is a measure to suggest a facility’s capability of meeting targeted production in a safe working environment. Availability is also vital as it encompasses reliability and maintainability, allowing engineers to manage and operate facilities by focusing on one performance indicator. These benefits make availability a very demanding and highly desired area of interest and research for both industry and academia. In this dissertation, new models, approaches and algorithms have been explored to estimate and manage the availability of complex hydrocarbon processing systems. The risk of equipment failure and its effect on availability is vital in the hydrocarbon industry, and is also explored in this research. The importance of availability encouraged companies to invest in this domain by putting efforts and resources to develop novel techniques for system availability enhancement. Most of the work in this area is focused on individual equipment compared to facility or system level availability assessment and management. This research is focused on developing an new systematic methods to estimate system availability. The main focus areas in this research are to address availability estimation and management through physical asset management, risk-based availability estimation strategies, availability and safety using a failure assessment framework, and availability enhancement using early equipment fault detection and maintenance scheduling optimization.

Evaluación de tenacidad a la fractura e integridad estructural de tubos de generadores de vapor nucleares.

Dado el impacto negativo asociado a la ocurrencia de fallas en tubos de generadores de vapor (TGVs) en centrales nucleares, el estudio de la integridad estructural de éstos ha comenzado a recibir mayor atención recientemente. Diversas metodologías basadas en análisis de carga límite han sido propuestas para asegurar la integridad estructural de los tubos, según los requerimientos establecidos por las autoridades regulatorias. Éstas han conducido, sin embargo, a la definición de criterios de reparación o taponado de TGVs excesivamente conservativos. Por lo tanto, con el objetivo de reducir la cantidad de tubos innecesariamente removidos de servicio, nuevos criterios de evaluación de integridad han sido propuestos recientemente en la literatura. En este contexto, la mecánica de fractura elastoplástica se presenta como una alternativa para la evaluación de la integridad de TGVs, requiriéndose dos elementos para su aplicación: la estimación de la fuerza impulsora en términos del parámetro elastoplástico (por ejemplo, la integral J) y la medición experimental de la tenacidad a la fractura del material de los tubos (por ejemplo, a través de la curva de resistencia J-R). Este trabajo presenta el desarrollo de técnicas experimentales no normalizadas para la determinación de curvas J-R para TGVs con fisuras pasantes circunferenciales y longitudinales. Debido a las dimensiones reducidas de los TGVs, diferentes probetas no normalizadas fueron propuestas. Además, en los ensayos se utilizaron condiciones de carga de tracción y flexión con el objetivo de modelar más adecuadamente los estados tensionales y las condiciones de constraint reales en TGVs. Los valores de la integral J fueron estimados utilizando el método del factor η. La aptitud del método fue evaluada a partir de simulaciones numéricas de los ensayos propuestos mediante análisis elastoplásticos con la técnica de elementos finitos. Se encontró que condiciones de mayor constraint asociadas con fisuras profundas y cargas de flexión favorecen la validez del método del factor η, mientras que configuraciones de menor constraint dan como resultado factores η que exhiben una mayor dependencia con el nivel de carga aplicada. También se observó que los factores η basados en la apertura de la boca de la fisura (Crack Mouth Opening Displacement o CMOD) presentan una dependencia mucho menor con el nivel de carga respecto a los factores η definidos a partir del desplazamiento del punto de aplicación de la carga (Load Line Displacement o LLD). Se presentan los valores del factor η para las probetas estudiadas con fisuras profundas (a/W ≥ 0,40). Se realizaron ensayos de fractura a temperatura ambiente y 300 °C con probetas obtenidas de TGVs nucleares fabricados a partir de las aleaciones 690 (Ni: 61; Cr: 29; Fe: 8,95, % en peso) y 800 (Ni: 33; Cr: 21,6; Fe: 42,2, % en peso). Durante los ensayos de fractura a temperatura ambiente, la extensión estable de fisura fue medida mediante una técnica óptica utilizando un microscopio digital. Para estos ensayos también se aplicó el método de normalización que propone la norma ASTM E1820-15 en el Anexo 15, encontrándose una buena coincidencia entre las longitudes estimadas por éste y las medidas ópticamente. De esta manera, el método de normalización fue utilizado para los ensayos a alta temperatura. Los resultados experimentales mostraron que ambos materiales tienen elevadas tenacidades a la fractura, siendo la aleación 800 la que presentó curvas J-R más elevadas que la aleación 690 tanto para fisuras circunferenciales como longitudinales. Las curvas J-R para ambas aleaciones mostraron un efecto marcado con la orientación de la fisura, es decir que existe una importante anisotropía en las propiedades de fractura: las fisuras circunferenciales presentaron curvas J-R más elevadas que las fisuras longitudinales. El nivel de constraint desarrollado en los ensayos, dado por las condiciones de carga de tracción y flexión, evidenció poco efecto sobre las curvas J-R para probetas con fisuras profundas (a/W ~ 0,50). A su vez, la temperatura de ensayo (temperatura ambiente y 300 °C) presentó un efecto prácticamente nulo para ambas aleaciones. Usando las propiedades de fractura obtenidas en este trabajo, la metodología FAD (Failure Assessment Diagram) fue propuesta y utilizada para la predicción de las condiciones de falla de TGVs fisurados para diferentes geometrías de fisura y condiciones de carga. La comparación entre análisis teóricos y datos experimentales muestra la potencialidad del FAD como una metodología capaz de predecir adecuadamente las fallas de estos componentes.

Evaluación de tenacidad a la fractura e integridad estructural de tubos de generadores de vapor nucleares.

Dado el impacto negativo asociado a la ocurrencia de fallas en tubos de generadores de vapor (TGVs) en centrales nucleares, el estudio de la integridad estructural de éstos ha comenzado a recibir mayor atención recientemente. Diversas metodologías basadas en análisis de carga límite han sido propuestas para asegurar la integridad estructural de los tubos, según los requerimientos establecidos por las autoridades regulatorias. Éstas han conducido, sin embargo, a la definición de criterios de reparación o taponado de TGVs excesivamente conservativos. Por lo tanto, con el objetivo de reducir la cantidad de tubos innecesariamente removidos de servicio, nuevos criterios de evaluación de integridad han sido propuestos recientemente en la literatura. En este contexto, la mecánica de fractura elastoplástica se presenta como una alternativa para la evaluación de la integridad de TGVs, requiriéndose dos elementos para su aplicación: la estimación de la fuerza impulsora en términos del parámetro elastoplástico (por ejemplo, la integral J) y la medición experimental de la tenacidad a la fractura del material de los tubos (por ejemplo, a través de la curva de resistencia J-R). Este trabajo presenta el desarrollo de técnicas experimentales no normalizadas para la determinación de curvas J-R para TGVs con fisuras pasantes circunferenciales y longitudinales. Debido a las dimensiones reducidas de los TGVs, diferentes probetas no normalizadas fueron propuestas. Además, en los ensayos se utilizaron condiciones de carga de tracción y flexión con el objetivo de modelar más adecuadamente los estados tensionales y las condiciones de constraint reales en TGVs. Los valores de la integral J fueron estimados utilizando el método del factor η. La aptitud del método fue evaluada a partir de simulaciones numéricas de los ensayos propuestos mediante análisis elastoplásticos con la técnica de elementos finitos. Se encontró que condiciones de mayor constraint asociadas con fisuras profundas y cargas de flexión favorecen la validez del método del factor η, mientras que configuraciones de menor constraint dan como resultado factores η que exhiben una mayor dependencia con el nivel de carga aplicada. También se observó que los factores η basados en la apertura de la boca de la fisura (Crack Mouth Opening Displacement o CMOD) presentan una dependencia mucho menor con el nivel de carga respecto a los factores η definidos a partir del desplazamiento del punto de aplicación de la carga (Load Line Displacement o LLD). Se presentan los valores del factor η para las probetas estudiadas con fisuras profundas (a/W ≥ 0,40). Se realizaron ensayos de fractura a temperatura ambiente y 300 °C con probetas obtenidas de TGVs nucleares fabricados a partir de las aleaciones 690 (Ni: 61; Cr: 29; Fe: 8,95, % en peso) y 800 (Ni: 33; Cr: 21,6; Fe: 42,2, % en peso). Durante los ensayos de fractura a temperatura ambiente, la extensión estable de fisura fue medida mediante una técnica óptica utilizando un microscopio digital. Para estos ensayos también se aplicó el método de normalización que propone la norma ASTM E1820-15 en el Anexo 15, encontrándose una buena coincidencia entre las longitudes estimadas por éste y las medidas ópticamente. De esta manera, el método de normalización fue utilizado para los ensayos a alta temperatura. Los resultados experimentales mostraron que ambos materiales tienen elevadas tenacidades a la fractura, siendo la aleación 800 la que presentó curvas J-R más elevadas que la aleación 690 tanto para fisuras circunferenciales como longitudinales. Las curvas J-R para ambas aleaciones mostraron un efecto marcado con la orientación de la fisura, es decir que existe una importante anisotropía en las propiedades de fractura: las fisuras circunferenciales presentaron curvas J-R más elevadas que las fisuras longitudinales. El nivel de constraint desarrollado en los ensayos, dado por las condiciones de carga de tracción y flexión, evidenció poco efecto sobre las curvas J-R para probetas con fisuras profundas (a/W ~ 0,50). A su vez, la temperatura de ensayo (temperatura ambiente y 300 °C) presentó un efecto prácticamente nulo para ambas aleaciones. Usando las propiedades de fractura obtenidas en este trabajo, la metodología FAD (Failure Assessment Diagram) fue propuesta y utilizada para la predicción de las condiciones de falla de TGVs fisurados para diferentes geometrías de fisura y condiciones de carga. La comparación entre análisis teóricos y datos experimentales muestra la potencialidad del FAD como una metodología capaz de predecir adecuadamente las fallas de estos componentes.

Do simple ventilation and gas exchange measurements predict early successful weaning from respiratory support in unselected general intensive care patients?

Background. The value of respiratory variables as weaning predictors in the intensive care unit (ICU) is controversial. We evaluated the ability of tidal volume (Vtexp), respiratory rate ( f ), minute volume (MVexp), rapid shallow breathing index ( f/Vt), inspired–expired oxygen concentration difference [(I–E)O2], and end-tidal carbon dioxide concentration (PE′CO2) at the end of a weaning trial to predict early weaning outcomes. Methods. Seventy-three patients who required .24 h of mechanical ventilation were studied. A controlled pressure support weaning trial was undertaken until 5 cm H2O continuous positive airway pressure or predefined criteria were reached. The ability of data from the last 5 min of the trial to predict whether a predefined endpoint indicating discontinuation of ventilator support within the next 24 h was evaluated. Results. Pre-test probability for achieving the outcome was 44% in the cohort (n¼32). Non-achievers were older, had higher APACHE II and organ failure scores before the trial, and higher baseline arterial H+ concentrations. The Vt, MV, f, and f/Vt had no predictive power using a range of cut-off values or from receiver operating characteristic (ROC) analysis. The [I–E]O2 and PE′CO2 had weak discriminatory power [areaunder the ROC curve: [I–E]O2 0.64 (P¼0.03); PE′CO2 0.63 (P¼0.05)]. Using best cut-off values for [I–E]O2 of 5.6% and PE′CO2 of 5.1 kPa, positive and negative likelihood ratios were 2 and 0.5, respectively, which only changed the pre- to post-test probability by about 20%. Conclusions. In unselected ICU patients, respiratory variables predict early weaning from mechanical ventilation poorly.

Red blood cell rheology in sepsis

Changes in red blood cell (RBC) function can contribute to alterations in microcirculatory blood flow and cellular dysoxia in sepsis. Decreases in RBC and neutrophil deformability impair the passage of these cells through the microcirculation. While the role of leukocytes has been the focus of many studies in sepsis, the role of erythrocyte rheological alterations in this syndrome has only recently been investigated. RBC rheology can be influenced by many factors, including alterations in intracellular calcium and adenosine triphosphate (ATP) concentrations, the effects of nitric oxide, a decrease in some RBC membrane components such as sialic acid, and an increase in others such as 2,3 diphosphoglycerate. Other factors include interactions with white blood cells and their products (reactive oxygen species), or the effects of temperature variations. Understanding the mechanisms of altered RBC rheology in sepsis, and the effects on blood flow and oxygen transport, may lead to improved patient management and reductions in morbidity and mortality.

Procalcitonin Biomarker Kinetics to Predict Multiorgan Dysfunction Syndrome in Children With Sepsis and Systemic Inflammatory Response Syndrome

Background: Procalcitonin (PCT) kinetics is a good prognosis marker in infectious diseases, but few studies of children sepsis have been performed. Objectives: The aim of our study was to examine kinetics of procalcitonin, to evaluate its relationship with severity and to analyze its usefulness in the prediction of multiorgan dysfunction syndrome (MODS). Patients and Methods: Prospective observational study in an 8-bed pediatric intensive care unit of a university hospital. Sixty-two children aged 0-19 years with systemic inflammatory response syndrome or septic states. The degree of severity was evaluated according pediatric logistic organ dysfunction (PELOD) score. Blood tests to determine levels of PCT were taken if the patients had the criteria of systemic inflammatory response syndrome or sepsis. The serum to determine levels of PCT in control group has been taken from patients undergoing elective surgery. Results: Higher values of PCT were identified in patients with PELOD score 12 and more compared to those with PELOD < 12 (P = 0.016). Similarly, higher PCT values were found in patients who developed MODS in contrast to those without MODS (P = 0.011). According to ROC analysis cut-off value of 4.05 ng/mL was found to best discriminate patients with PELOD < 12 and PELOD ≥ 12 with AUC = 0.675 (P = 0.035). Effect of procalcitonin levels on mortality was not demonstrated. Conclusions: Levels of procalcitonin from day 1 to day 5 are related to the severity and multiorgan dysfunction syndrome in children.

Effect of a sequential education and monitoring programme on quality-of-life components in heart failure

Aims Trials of disease management programmes (DMP) in heart failure (HF) have shown controversial results regarding quality of life. We hypothesized that a DMP applied over the long-term could produce different effects on each of the quality-of-life components. Methods and results We extended the prospective, randomized REMADHE Trial, which studied a DMP in HF patients. We analysed changes in Minnesota Living with Heart Failure Questionnaire components in 412 patients, 60.5% male, age 50.2 +/- 11.4 years, left ventricular ejection fraction 34.7 +/- 10.5%. During a mean follow-up of 3.6 +/- 2.2 years, 6.3% of patients underwent heart transplantation and 31.8% died. Global quality-of-life scores improved in the DMP intervention group, compared with controls, respectively: 57.5 +/- 3.1 vs. 52.6 +/- 4.3 at baseline, 32.7 +/- 3.9 vs. 40.2 +/- 6.3 at 6 months, 31.9 +/- 4.3 vs. 41.5 +/- 7.4 at 12 months, 26.8 +/- 3.1 vs. 47.0 +/- 5.3 at the final assessment; P<0.01. Similarly, the physical component (23.7 +/- 1.4 vs. 21.1 +/- 2.2 at baseline, 16.2 +/- 2.9 vs. 18.0 +/- 3.3 at 6 months, 17.3 +/- 2.9 vs. 23.1 +/- 5.7 at 12 months, 11.4 +/- 1.6 vs. 19.9 +/- 2.4 final; P<0.01), the emotional component (13.2 +/- 1.0 vs. 12.1 +/- 1.4 at baseline, 11.7 +/- 2.7 vs. 12.3 +/- 3.1 at 6 months, 12.4 +/- 2.9 vs. 16.8 +/- 5.9 at 12 months, 6.7 +/- 1.0 vs. 10.6 +/- 1.4 final; P<0.01) and the additional questions (20.8 +/- 1.2 vs. 19.3 +/- 1.8 at baseline, 14.3 +/- 2.7 vs. 17.3 +/- 3.1 at 6 months, 12.4 +/- 2.9 vs. 21.0 +/- 5.5 at 12 months, 6.7 +/- 1.4 vs. 17.3 +/- 2.2 final; P<0.01) were better (lower) in the intervention group. The emotional component improved earlier than the others. Post-randomization quality of life was not associated with events. Conclusion Components of the quality-of-life assessment responded differently to DMP. These results indicate the need for individualized DMP strategies in patients with HF. Trial registration information www.clincaltrials.gov NCT00505050-REMADHE.

IQRray, a new method for Affymetrix microarray quality control, and the homologous organ conservation score, a new benchmark method for quality control metrics.

MOTIVATION: Microarray results accumulated in public repositories are widely reused in meta-analytical studies and secondary databases. The quality of the data obtained with this technology varies from experiment to experiment, and an efficient method for quality assessment is necessary to ensure their reliability. RESULTS: The lack of a good benchmark has hampered evaluation of existing methods for quality control. In this study, we propose a new independent quality metric that is based on evolutionary conservation of expression profiles. We show, using 11 large organ-specific datasets, that IQRray, a new quality metrics developed by us, exhibits the highest correlation with this reference metric, among 14 metrics tested. IQRray outperforms other methods in identification of poor quality arrays in datasets composed of arrays from many independent experiments. In contrast, the performance of methods designed for detecting outliers in a single experiment like Normalized Unscaled Standard Error and Relative Log Expression was low because of the inability of these methods to detect datasets containing only low-quality arrays and because the scores cannot be directly compared between experiments. AVAILABILITY AND IMPLEMENTATION: The R implementation of IQRray is available at: ftp://lausanne.isb-sib.ch/pub/databases/Bgee/general/IQRray.R. CONTACT: Marta.Rosikiewicz@unil.ch SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

The CLIF Consortium Acute Decompensation score (CLIF-C ADs) for prognosis of hospitalised cirrhotic patients without acute-on-chronic liver failure

BACKGROUND & AIMS Cirrhotic patients with acute decompensation frequently develop acute-on-chronic liver failure (ACLF), which is associated with high mortality rates. Recently, a specific score for these patients has been developed using the CANONIC study database. The aims of this study were to develop and validate the CLIF-C AD score, a specific prognostic score for hospitalised cirrhotic patients with acute decompensation (AD), but without ACLF, and to compare this with the Child-Pugh, MELD, and MELD-Na scores. METHODS The derivation set included 1016 CANONIC study patients without ACLF. Proportional hazards models considering liver transplantation as a competing risk were used to identify score parameters. Estimated coefficients were used as relative weights to compute the CLIF-C ADs. External validation was performed in 225 cirrhotic AD patients. CLIF-C ADs was also tested for sequential use. RESULTS Age, serum sodium, white-cell count, creatinine and INR were selected as the best predictors of mortality. The C-index for prediction of mortality was better for CLIF-C ADs compared with Child-Pugh, MELD, and MELD-Nas at predicting 3- and 12-month mortality in the derivation, internal validation and the external dataset. CLIF-C ADs improved in its ability to predict 3-month mortality using data from days 2, 3-7, and 8-15 (C-index: 0.72, 0.75, and 0.77 respectively). CONCLUSIONS The new CLIF-C ADs is more accurate than other liver scores in predicting prognosis in hospitalised cirrhotic patients without ACLF. CLIF-C ADs therefore may be used to identify a high-risk cohort for intensive management and a low-risk group that may be discharged early.

[the Modified Us7 Score In The Assessment Of Synovitis In Early Rheumatoid Arthritis].

To evaluate the modified US7 score (MUS7 score SYN) in the assessment of patients with early rheumatoid arthritis (ERA). In addition, dorsal and palmar recesses of the wrists as well as of small joints of the hands and feet were examined for the presence of synovitis by means of a global assessment of joints. The study sample comprised 32 patients treated for arthritis, with an average disease duration of 13 months. An ultrasound machine with high frequency transducer was used. Hands were also X-rayed and analysed by Larsen score. Out of the 832 examined joints, synovitis was detected in 173 (20,79%), tenosynovitis in 22 (4,91%), and erosions in 3 (1,56%). Synovitis was predominantly detected in the dorsal recess (73,38%) of MCP and PIP joints, when compared with palmar recess (26%). The presence of synovitis in the joints evaluated correlated with clinical (HAQ-DI, DAS28), laboratory (ACPA, RF, CRP), and ultrasound results (r = 0,37 to r = 0,42; p = 0,04 to p = 0,003). We found correlation of the MUS7 score SYN of the gray scale US or of the power Doppler US with DAS28 (PCR) values (r = 0,38; p = 0,0332), and with CRP results (r = 0,39; p = 0,0280), respectively. The dorsal recess, the wrist, and small joints can be considered as important sites to detect synovitis by the MUS7 score SYN in patients with ERA.

Roles assessment in families of children with chronic renal failure on peritoneal dialysis

Families with a child on chronic peritoneal dialysis have to assume a significant burden of care, intensifying the demands and the reorganization of roles in the families of children. The purpose of this study is to describe the implications of role changes in families of children with chronic renal disease on peritoneal dialysis. This is a case study of four families of children with chronic renal disease on peritoneal dialysis. Fourteen family members participate in the study. After the child`s chronic kidney failure and the start of treatment, each relative`s ways, acts and functions are changed, maintained or adapted to the new family dynamics, imposed by the child`s treatment conditions. Appropriate role assessment provides the nurse and the families of children with chronic renal failure on peritoneal dialysis with insight regarding current and potential health problems and aids in identifying the needs of the families.

Computed tomographic assessment of lung weights in trauma patients with early posttraumatic lung dysfunction

Introduction: Quantitative computed tomography (qCT)-based assessment of total lung weight (M(lung)) has the potential to differentiate atelectasis from consolidation and could thus provide valuable information for managing trauma patients fulfilling commonly used criteria for acute lung injury (ALI). We hypothesized that qCT would identify atelectasis as a frequent mimic of early posttraumatic ALI. Methods: In this prospective observational study, M(lung) was calculated by qCT in 78 mechanically ventilated trauma patients fulfilling the ALI criteria at admission. A reference interval for M(lung) was derived from 74 trauma patients with morphologically and functionally normal lungs (reference). Results are given as medians with interquartile ranges. Results: The ratio of arterial partial pressure of oxygen to the fraction of inspired oxygen was 560 (506 to 616) mmHg in reference patients and 169 (95 to 240) mmHg in ALI patients. The median reference M(lung) value was 885 (771 to 973) g, and the reference interval for M(lung) was 584 to 1164 g, which matched that of previous reports. Despite the significantly greater median M(lung) value (1088 (862 to 1,342) g) in the ALI group, 46 (59%) ALI patients had M(lung) values within the reference interval and thus most likely had atelectasis. In only 17 patients (22%), Mlung was increased to the range previously reported for ALI patients and compatible with lung consolidation. Statistically significant differences between atelectasis and consolidation patients were found for age, Lung Injury Score, Glasgow Coma Scale score, total lung volume, mass of the nonaerated lung compartment, ventilator-free days and intensive care unit-free days. Conclusions: Atelectasis is a frequent cause of early posttraumatic lung dysfunction. Differentiation between atelectasis and consolidation from other causes of lung damage by using qCT may help to identify patients who could benefit from management strategies such as damage control surgery and lung-protective mechanical ventilation that focus on the prevention of pulmonary complications.