Aerosol therapy in intensive and intermediate care units: prospective observation of 2808 critically ill patients.

PURPOSE: Unlike in the outpatient setting, delivery of aerosols to critically ill patients may be considered complex, particularly in ventilated patients, and benefits remain to be proven. Many factors influence aerosol delivery and recommendations exist, but little is known about knowledge translation into clinical practice. METHODS: Two-week cross-sectional study to assess the prevalence of aerosol therapy in 81 intensive and intermediate care units in 22 countries. All aerosols delivered to patients breathing spontaneously, ventilated invasively or noninvasively (NIV) were recorded, and drugs, devices, ventilator settings, circuit set-up, humidification and side effects were noted. RESULTS: A total of 9714 aerosols were administered to 678 of the 2808 admitted patients (24 %, CI95 22-26 %), whereas only 271 patients (10 %) were taking inhaled medication before admission. There were large variations among centers, from 0 to 57 %. Among intubated patients 22 % (n = 262) received aerosols, and 50 % (n = 149) of patients undergoing NIV, predominantly (75 %) inbetween NIV sessions. Bronchodilators (n = 7960) and corticosteroids (n = 1233) were the most frequently delivered drugs (88 % overall), predominantly but not exclusively (49 %) administered to patients with chronic airway disease. An anti-infectious drug was aerosolized 509 times (5 % of all aerosols) for nosocomial infections. Jet-nebulizers were the most frequently used device (56 %), followed by metered dose inhalers (23 %). Only 106 (<1 %) mild side effects were observed, despite frequent suboptimal set-ups such as an external gas supply of jet nebulizers for intubated patients. CONCLUSIONS: Aerosol therapy concerns every fourth critically ill patient and one-fifth of ventilated patients.

Competence in intensive and critical care nursing - development of a basic assessment scale for graduating nursing students

Intensive and critical care nursing is a speciality in its own right and with its own nature within the nursing profession. This speciality poses its own demands for nursing competencies. Intensive and critical care nursing is focused on severely ill patients and their significant others. The patients are comprehensively cared for, constantly monitored and their vital functions are sustained artificially. The main goal is to win time to cure the cause of the patient’s situation or illness. The purpose of this empirical study was i) to describe and define competence and competence requirements in intensive and critical care nursing, ii) to develop a basic measurement scale for competence assessment in intensive and critical care nursing for graduating nursing students, and iii) to describe and evaluate graduating nursing students’ basic competence in intensive and critical care nursing by seeking the reference basis of self-evaluated basic competence in intensive and critical care nursing from ICU nurses. However, the main focus of this study was on the outcomes of nursing education in this nursing speciality. The study was carried out in different phases: basic exploration of competence (phase 1 and 2), instrumentation of competence (phase 3) and evaluation of competence (phase 4). Phase 1 (n=130) evaluated graduating nursing students’ basic biological and physiological knowledge and skills for working in intensive and critical care with Basic Knowledge Assessment Tool version 5 (BKAT-5, Toth 2012). Phase 2 focused on defining competence in intensive and critical care nursing with the help of literature review (n=45 empirical studies) as well as competence requirements in intensive and critical care nursing with the help of experts (n=45 experts) in a Delphi study. In phase 3 the scale Intensive and Critical Care Nursing Competence Scale (ICCN-CS) was developed and tested twice (pilot test 1: n=18 students and n=12 nurses; pilot test 2: n=56 students and n=54 nurses). Finally, in phase 4, graduating nursing students’ competence was evaluated with ICCN-CS and BKAT version 7 (Toth 2012). In order to develop a valid assessment scale of competence for graduating nursing students and to evaluate and establish the competence of graduating nursing students, empirical data were retrieved at the same time from both graduating nursing students (n=139) and ICU nurses (n=431). Competence can be divided into clinical and general professional competence. It can be defined as a specific knowledge base, skill base, attitude and value base and experience base of nursing and the personal base of an intensive and critical care nurse. Personal base was excluded in this self-evaluation based scale. The ICCN-CS-1 consists of 144 items (6 sum variables). Finally, it became evident that the experience base of competence is not a suitable sum variable in holistic intensive and critical care competence scale for graduating nursing students because of their minor experience in this special nursing area. ICCN-CS-1 is a reliable and tolerably valid scale for use among graduating nursing students and ICU nurses Among students, basic competence of intensive and critical care nursing was self-rated as good by 69%, as excellent by 25% and as moderate by 6%. However, graduating nursing students’ basic biological and physiological knowledge and skills for working in intensive and critical care were poor. The students rated their clinical and professional competence as good, and their knowledge base and skill base as moderate. They gave slightly higher ratings for their knowledge base than skill base. Differences in basic competence emerged between graduating nursing students and ICU nurses. The students’ self-ratings of both their basic competence and clinical and professional competence were significantly lower than the nurses’ ratings. The students’ self-ratings of their knowledge and skill base were also statistically significantly lower than nurses’ ratings. However, both groups reported the same attitude and value base, which was excellent. The strongest factor explaining students’ conception of their competence was their experience of autonomy in nursing. Conclusions: Competence in intensive and critical care nursing is a multidimensional concept. Basic competence in intensive and critical care nursing can be measured with self-evaluation based scale but alongside should be used an objective evaluation method. Graduating nursing students’ basic competence in intensive and critical care nursing is good but their knowledge and skill base are moderate. Especially the biological and physiological knowledge base is poor. Therefore in future in intensive and critical care nursing education should be focused on both strengthening students’ biological and physiological knowledge base and on strengthening their overall skill base. Practical implications are presented for nursing education, practice and administration. In future, research should focus on education methods and contents, mentoring of clinical practice and orientation programmes as well as further development of the scale.

Profundización, apertura y cierre de mercados de exportación a nivel sectorial en Colombia : una estimación de los márgenes del comercio y su relación con el ciclo económico

En este trabajo se explora, desde el punto de vista empírico, el comportamiento de la profundización, apertura y cierre de mercados de exportación a nivel sectorial para Colombia durante el periodo 1997- 2010, con énfasis en los dos periodos de recesión que presenta la economía durante el mismo. Para ello se emplea una metodología de descomposición de los cambios registrados por el comercio, en sus márgenes intensivo y extensivo, que permite la identificación de estos fenómenos y su observación tanto a lo largo del tiempo como a nivel transversal. Los resultados indican que, en el corto plazo, el margen intensivo del comercio explica la mayor parte de las variaciones en las exportaciones, en tanto que en el mediano plazo se encuentra una importante contribución del margen extensivo a éstas. Adicionalmente, desde el punto de vista sectorial, la crisis de 1997-1999 no presenta un patrón homogéneo en términos del comportamiento de los márgenes del comercio, en tanto que la de 2008- 2009 se caracteriza por presentar un patrón más homogéneo a través de los distintos sectores de la actividad económica.

Bode's maximum available feedback and phase margin

'Maximum Available Feedback' is Bode's term for the highest possible loop gain over a given bandwidth, with specified stability margins, in a single loop feedback system. His work using asymptotic analysis allowed Bode to develop a methodology for achieving this. However, the actual system performance differs from that specified, due to the use of asymptotic approximations, and the author[2] has described how, for instance, the actual phase margin is often much lower than required when the bandwidth is high, and proposed novel modifications to the asymptotes to address the issue. This paper gives some new analysis of such systems, showing that the method also contravenes Bode's definition of phase margin, and shows how the author's modifications can be used for different amounts of bandwidth.

Exploring the paradox of competence-creating subsidiaries: balancing bandwidth and dispersion in MNEs

This paper seeks to synthesise the various contributions to the special issue of Long Range Planning on competence-creating subsidiaries (CCS), and identifies avenues for future research. Effective competence-creation through a network of subsidiaries requires an appropriate balance between internal and external embeddedness. There are multiple types of firm-specific advantages (FSAs) essential to achieve this. In addition, wide-bandwidth pathways are needed with collaborators, suppliers, customers as well as internally within the MNE. Paradoxically, there is a natural tendency for bandwidth to shrink as dispersion increases. As distances (technological, organisational, and physical) become greater, there may be decreasing returns to R&D spread. Greater resources for knowledge integration and coordination are needed as intra-MNE and inter-firm R&D cooperation becomes more intensive and extensive. MNEs need to invest in mechanisms to promote wide-bandwidth knowledge flows, without which widely dispersed and networked MNEs can suffer from internal market failures.

Denudation history of the Bocaina Plateau, Serra do Mar, southeastern Brazil: Relationships to Gondwana breakup and passive margin development

The Bocaina Plateau, which is situated on the eastern flank of the continental rift of southeastern Brazil, is the highest part of the Serra do Mar. Topographic relief in this area is suggested to be closely related to its complex tectono-magmatic evolution since the breakup of Western Gondwana and opening of the South Atlantic Ocean. Apatite fission track ages and track length distributions from 27 basement outcrops were determined to assess these hypotheses and reconstruct the denudation history of the Bocaina Plateau. The ages range between 303 +/- 32 and 46 +/- 5 Ma, and are significantly younger than the stratigraphic ages. Mean track lengths vary from 13.44 +/- 1.51 to 11.1 +/- 1.48 mu m, with standard deviations between 1.16 and 1.83 mu m. Contrasting ages within a single plateau and similar ages at different altitudes indicate a complex regional tectonothermal evolution. The thermal histories inferred from these data imply three periods of accelerated cooling related to the Early Cretaceous continental breakup, Early Cretaceous alkaline magmatism, and the Paleogene evolution of the continental rift of southeastern Brazil. The oldest fission track ages (>200 Ma) were obtained in the Serra do Mar region, suggesting that these areas were a long-lived source of sediments for the Parana, Bauru, and Santos basins. (C) 2010 International Association for Gondwana Research. Published by Elsevier B.V. All rights reserved.

Real power losses reduction and loading margin improvement via continuation method

This letter presents an alternative approach for reducing the total real power losses by using a continuation method. Results for two simple test systems and for the IEEE 57-bus system show that this procedure results in larger voltage stability margin. Besides, the reduction of real power losses obtained with this procedure leads to significant money savings and, simultaneously, to voltage profile improvement. Comparison between the solution of an optimal power flow and the proposed method shows that the latter can provide near optimal results and so, it can be a reasonable alternative to power system voltage stability enhancement.

Phylogenetic relationships within the speciose family Characidae (Teleostei: Ostariophysi: Characiformes) based on multilocus analysis and extensive ingroup sampling

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Denudation history of the Bocaina Plateau, Serra do Mar, southeastern Brazil: Relationships to Gondwana breakup and passive margin development

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Lower intercanine width and gingival margin changes. A retrospective study.

OBJECTIVE: To determine if changes in the lower intercanine widths during orthodontic treatment with fixed appliances result in gingival margin changes around the lower canines and incisors. METHOD: Pre- and post-treatment intra-oral photographs and orthodontic study models of 178 Caucasian adolescents (101 female, 77 male) were used. All subjects were treated with fixed appliances. The subjects had mean ages of 11.41 (SD: 1.83) years and 14.91 (SD: 1.78) years on their initial and final records respectively. The latter were taken 28 days or more after the appliances had been removed. The inclusion criteria were: Angle Class I or Class II malocclusion (with or without transverse and/or vertical discrepancies); nonextraction treatment; less than 4 mm crowding or spacing; fully erupted lower incisors and good periodontal health. The intercanine widths and the positions of the gingival margins relative to the maximum curvatures of the labial surfaces of the lower canines and incisors were measured with digital calipers. RESULTS: A significant association was found between unaltered intercanine widths and coronal migration of the gingival margins (p = 0.045). There were no significant associations between either increased or reduced intercanine widths and changes in the gingival margins. CONCLUSIONS: Following orthodontic treatment coronal migration of the gingival margins around the lower incisors and canines is more likely to be associated with an unaltered intercanine width.

Eimeria species in young and adult sheep raised under intensive and/or semi-intensive systems of a herd from Umuarama city, Parana State, Brazil

The present study aimed to identify Eimeria species in young and adult sheep raised under intensive and / or semi-intensive systems of a herd from Umuarama city, Parana State, Brazil using the traditional diagnostic methods and to correlate the infection level/types of infection in the different age/system in this herd. Fecal samples were collected from the rectum of 210 sheep and were subjected to laboratory analysis to differentiate the species. Furthermore, animals were observed to determine the occurrences of the clinical or subclinical forms of eimeriosis. Out of the 210 collected fecal samples, 147 (70%) were positive for Eimeria oocysts, and 101 (47.86%) belonged to young animals that were raised under intensive and / or semi-intensive farming systems. Oocysts from 9 species of Eimeria parasites were identified in the sheep at the following prevalence rates: E. crandallis, 50.0%; E. parva, 21.6%; E. faurei, 8.1%; E. ahsata, 8.1%; E. intricata, 5.4%; E. granulosa, 2.7%; E. ovinoidalis, 2.0%; E. ovina, 1.3%; and E. bakuensis, 0.6%. There were no differences regarding the more frequent Eimeria species among the different ages of animals or between the different farming management systems. Based on these data, E. crandallis was the most prevalent, followed by E. parva and E. faurei species, regardless of the age. Higher parasitism was diagnosed in the young animals that were raised in a confinement regime, and the disease found in the herd was classified as subclinical. Further studies should be conducted in this herd, to verify if the eimeriosis subclinical can cause damage especially in young animals with a high level of infection.

Role of Urbanization, Land-Use Diversity, and Livestock Intensification in Zoonotic Emerging Infectious Diseases

Emerging infectious diseases (EIDs) continue to significantly threaten human and animal health. While there has been some progress in identifying underlying proximal driving forces and causal mechanisms of disease emergence, the role of distal factors is most poorly understood. This article focuses on analyzing the statistical association between highly pathogenic avian influenza (HPAI) H5N1 and urbanization, land-use diversity and poultry intensification. A special form of the urban transition—peri-urbanization—was hypothesized as being associated with ‘hot-spots’ of disease emergence. Novel metrics were used to characterize these distal risk factors. Our models, which combined these newly proposed risk factors with previously known natural and human risk factors, had a far higher predictive performance compared to published models for the first two epidemiological waves in Viet Nam. We found that when relevant risk factors are taken into account, urbanization is generally not a significant independent risk factor. However, urbanization spatially combines other risk factors leading to peri-urban places being the most likely ‘hot-spots’. The work highlights that peri-urban areas have highest levels of chicken density, duck and geese flock size diversity, fraction of land under rice, fraction of land under aquaculture compared to rural and urban areas. Land-use diversity, which has previously never been studied in the context of HPAI H5N1, was found to be a significant risk factor. Places where intensive and extensive forms of poultry production are collocated were found to be at greater risk.

Benthic respiration and physical oceanography on two contrasting continental margins in the western Indian Ocean: the Yemen-Somali upwelling region and the margin off Kenya

During the Netherlands Indian Ocean Project (NIOP, 1992-1993) sediment community oxygen consumption (SCOC) was measured on two continental margins in the Indian Ocean with different productivity: the productive upwelling region off Yemen-Somalia and the supposedly less productive Kenyan margin, which lacks upwelling. The two margins also differ in terms of river input (Kenya) and the more severe oxygen minimum in the Arabian Sea. Simultaneously with SCOC, distributions of benthic biomass and phytodetritus were studied. Our expectation was that benthic processes in the upwelling margin of the Arabian Sea would be relatively enhanced as a result of the higher productivity. On the Kenyan margin, SCOC (range 1-36 mmol/m**2/d) showed a clear decrease with increasing water depth, and little temporal variation was detected between June and December. Highest SCOC values of this study were recorded at 50 m depth off Kenya, with a maximum of 36 mmol/m**2/d in the northernmost part. On the margin off Yemen-Somalia, SCOC was on average lower and showed little downslope variation, 1.8-5.7 mmol/m**2/d, notably during upwelling, when the zone between 70 and 1700 m was covered with low O2 water (10-50 µM). After cessation of upwelling, SCOC at 60 m depth off Yemen increased from 5.7 to 17.6 mmol/m**2/d concurrently with an increase of the near-bottom O2 concentration (from 11 to 153 µM), suggesting a close coupling between SCOC and O2 concentration. This was demonstrated in shipboard cores in which the O2 concentration in the overlying water was raised after the cores were first incubated under in situ conditions (17 µM O2). This induced an immediate and pronounced increase of SCOC. Conversely, at deeper stations permanently within the oxygen minimum zone (OMZ), SCOC showed little variation between monsoon periods. Hence, organic carbon degradation in sediments on a large part of the Yemen slope appears hampered by the oxygen deficiency of the overlying water. Macrofauna biomass and the pooled biomass of smaller organisms, estimated by the nucleic acid content of the sediment, had comparable ranges in the two areas in spite of more severe suboxic conditions in the Arabian Sea. At the Kenyan shelf, benthic fauna (macro- and meiofauna) largely followed the spatial pattern of SCOC, i.e. high values on the northern shelf-upper slope and a downslope decrease. On the Yemen-Somali margin the macrofauna distribution was more erratic. Nucleic acids displayed no clear downslope trend on either margin owing to depressed values in the OMZ, perhaps because of adverse effects of low O2 on small organisms (meiofauna and microbes). Phytodetritus distributions were different on the two margins. Whereas pigment levels decreased downslope along the Kenya margin, the upper slope off Yemen (800 m) had a distinct accumulation of mainly refractory carotenoid pigments, suggesting preservation under low 02. Because the accumulations of Corg and pigments on the Yemen slope overlap only partly, we infer a selective deposition and preservation of labile particles on the upper slope, whereas refractory material undergoes further transport downslope.