Prevenção de riscos de tromboembolismo venoso: estratégias para redução da morbimortalidade

Estudo prospectivo com abordagem quantitativa envolvendo 3 grupos distintos de sujeitos. Grupo 1 constituído por 56 pacientes avaliados para o risco de tromboembolismo venoso (TEV) em um acompanhamento de 30 meses para verificar os desfechos morte, reinternação e profilaxia de TEV. Grupo 2 constituído por 50 enfermeiros assistenciais que responderam questionários sobre TEV, com o propósito de avaliar seus conhecimentos sobre os riscos e profilaxia dessa doença em pacientes clínicos internados. Grupo 3 constituído por 100 enfermeiros assistenciais que responderam questionários similares aos respondidos pelo grupo 2, antes e após treinamento sobre profilaxia de TEV. O objetivo geral foi verificar o grau de conhecimento de enfermeiros sobre tromboembolismo venoso considerando sua inserção no processo de prevenção de riscos; Os objetivos específicos foram: propor e implantar uma estratégia de treinamento para capacitação de enfermeiros no rastreamento de riscos de TEV em pacientes internados; verificar o impacto do treinamento sobre TEV no conhecimento dos enfermeiros para identificação de fatores de risco dessa doença; descrever os desfechos relacionados à TEV em pacientes internados por mais de 24 horas em um hospital quaternário num seguimento de 30 meses. No grupo 1 identificou-se que o evento TEV apresenta alta mortalidade 63,6% para pacientes que não receberam profilaxia. Identificou-se também que a maioria 89,2% desses sujeitos é acompanhada de seus médicos, 53,6% passaram por reinternações e 28,6% continuam usando alguma profilaxia para TEV. No grupo 2 verificou-se que os profissionais não sabem identificar corretamente os fatores de risco para TEV, havendo grande déficit de conhecimento em relação aos fatores de risco e profilaxia da doença, pois 90% da amostra não consegue apontar mais que 5 fatores de risco para TEV considerando-se 24 fatores contemplados por consensos internacionais, demonstrando um grau de conhecimento insuficiente pela utilização de uma escala intervalar proposta nesse estudo. No grupo 3, assim como identificado no grupo 2, houve similaridade no déficit de conhecimento, pois 100% não conseguiram apontar mais que 4 fatores de risco para a doença. Identificou-se que a realização de um treinamento sobre profilaxia de TEV para esses enfermeiros apresenta alto impacto em relação ao grau de retenção de informações sobre TEV, sendo uma ação facilmente replicável para profissionais de instituições hospitalares. Concluiu-se que o uso de um algoritmo/protocolo de avaliação voltado para rastreamento de riscos de TEV por enfermeiros representa uma ferramenta importante no processo de rastreamento e prevenção dessa doença em pacientes clínicos, como proposto nesse estudo, pois nos resultados demonstrou-se que 97% dos enfermeiros do grupo 3 não conhecem qualquer tipo de protocolo relacionado a prevenção de riscos de TEV. Os sujeitos apresentaram excelente nível de conhecimento sobre meios de profilaxia mecânica, mas identificou-se que a maioria 63% nunca deu orientações sobre a profilaxia enquanto cuidam, reforçando o entendimento de que não estão inseridos no processo de prevenção de riscos de TEV para pacientes internados. A inserção dos enfermeiros nesse processo de identificação de riscos deve ser capaz de reduzir a alta taxa de morbimortalidade e reduzir a incidência dessa doença em unidades hospitalares.

Das práticas espontâneas à receita de humanização: um estudo sobre a implementação da política nacional de humanização em um hospital do Rio de Janeiro

Este estudo contempla a implementação da Política Nacional de Humanização no Hospital da Lagoa, unidade hospitalar sob gestão do Governo Federal, situada no Município do Rio de Janeiro. A escolha do Hospital da Lagoa baseou-se na tradição dessa unidade em implantar ações e atividades inovadoras com vistas à melhoria da qualidade da assistência e, também, pela proximidade que a pesquisadora desenvolveu com a instituição ao longo de sua vida profissional. Foi privilegiada a perspectiva dos gestores da instituição quanto à experiência de Humanização, iniciada em 2003 e ainda em curso. De acordo com a política, entende-se por humanização a valorização dos diferentes sujeitos implicados no processo de produção de saúde: usuários, trabalhadores e gestores. Como estratégia de mudanças, a humanização orienta-se por três princípios: a transversalidade; a estreita vinculação entre a atenção e a gestão em saúde; e a autonomia e protagonismo dos sujeitos nos processos de trabalho. Em se tratando de um estudo de caso, a metodologia do trabalho observou a triangulação, combinando análise documental, observação participante e realização de entrevistas semi-estruturadas com 17 gestores, de diversas categorias profissionais e diferentes níveis de chefia. A análise dos dados revelou a existência de muitos obstáculos a serem transpostos para a institucionalização da política. Entre estes, foram apontados pelos entrevistados: a fragilidade da política de humanização e a própria cultura organizacional instituída. Nesta, segundo os entrevistados, se localizam os entraves à gestão do trabalho: dificuldade na formação de equipes multiprofissionais, desconsideração com a saúde do trabalhador e inoperância do Colegiado de Gestão Participativa local. Embora tenham sido indicados aspectos favoráveis ao processo, ao final do trabalho de campo ainda não tinham sido implantados todos os dispositivos preconizados pela Política Nacional de Humanização. Ademais, os esforços para sua implementação passaram a concorrer com o a implantação de um programa de acreditação hospitalar, pactuado com o Ministério da Saúde.

Growth, mortality and yield-per-recruit of the poor cod, Trisopterus minutus capelanus, from the Strait of Sicily

Length-based methods (LBMs) were used to study the growth of Trisopterus minutus capelanus in the Strait of Sicily (Messina Strait). A total of 16,304 'merluzzetto' or poor cod collected by experimental trawling off the southern coast of Sicily during spring, summer, autumn 1986 and winter 1987 were measured in order to estimate the length structure of the population. Length-frequency distribution were analyzed and normal components were discriminated. Von Bertalanffy growth parameters were derived from the mean length of the normal components. The growth parameters obtained by weighted non-linear regression were: K=0.462 (yr super(1)), L sub( infinity )=222.3 (TL,mm) and t sub(o)=-0.679 yr. The resulting growth performance index ( Phi ') was 4.36, a value slightly lower than those derived for Western Mediterranean (mean Phi '=4.45) and Adriatic ( Phi '=4.58) populations and slightly higher than that derived for Hellenic waters ( Phi '=4.27). On the basis of the von Bertalanffy parameters estimated, an array of age-specific instantaneous natural mortality rate (M sub(t)=0.5-1.1) and an average value of total natural mortality rate (Z=2.1 yr super(1)) were estimated and used in the Thompson and Bell yield per recruit (Y/R) analysis in order to evaluate the status of the fishery and forecast the effects of changes in the fishing pattern. Results indicate that this resource is overexploited and that Y/R could be increased by postponing the age at first capture from 0.5 to 1.0 yr. Even a slight reduction in fishing mortality could improve the performance of the fishery. At the present level of exploitation, and assuming a constant recruitment, the spawning stock biomass per recruit (SPR) is well below the conservative threshold of 30% of the pristine or unexploited SPR.

Avaliação da disnatremia em pacientes com indicação de suporte renal em unidades de terapia intensiva

As disnatremias são os distúrbios hidroeletrolíticos mais comuns, sendo relatados em cerca de 30-40% dos pacientes hospitalizados. Quando presentes na admissão em Unidade de Tratamento Intensivo (UTI) são fatores de risco independentes de pior prognóstico, estando associadas à maior letalidade hospitalar. Mesmo disnatremias limítrofes (130 135 mEq/l na hiponatremia e 145 a 150 mEq/L na hipernatremia) têm sido associadas a um maior tempo de internação na UTI e a um aumento de letalidade hospitalar, independente da gravidade da doença de base. A concentração sérica do sódio é mantida por um fino controle, por meio da regulação renal do sal e da água. Pacientes com doença renal crônica (DRC) em tratamento conservador ou em terapia renal substitutiva, apresentam maior prevalência de disnatremia. Embora a hiponatremia seja mais frequente nessa população, o diagnóstico de hipo- ou hipernatremia tem sido associado a uma maior mortalidade. Não há relato claro na literatura da prevalência de disnatremias na injúria renal aguda (IRA), em especial nos casos mais graves, em que há indicação de suporte dialítico. O presente estudo teve como objetivos avaliar a prevalência da disnatremia e o seu impacto no prognóstico de pacientes gravemente enfermos com IRA e necessidade de suporte renal (SR) na UTI.Em um período de 44 meses (de dezembro de 2004 a julho 2008) foram incluídos de forma prospectiva todos os pacientes que iniciaram SR em 14 UTIs de 3 hospitais terciários do Rio de Janeiro. Dados clínicos e laboratoriais foram coletados prospectivamente e lançados em uma planilha eletrônica para posterior análise com o software R. Os desfechos de interesse foram letalidade na UTI e no hospital. As variáveis que, além do sódio, apresentavam associação com os desfechos de interesse na análise bivariada, foram selecionadas e incluídas no modelo de regressão logística múltipla.Um total de 772 pacientes foram incluídos no estudo. A mediana da idade foi de 75 [IIQ: 61-82 anos]; 81,5% (IC: 78,4%-84%) foram admitidos na UTI por complicações clínicas. A presença de pelo menos uma comorbidade (hipertensão, diabetes, doença coronariana, insuficiência cardíaca, doença pulmonar obstrutiva crônica ou cirrose) esteve presente em 84% dos pacientes. A maior parte dos pacientes (72,5%, IC: 69,2%-75,7%) apresentava o diagnóstico de sepse. Os principais fatores contribuinte para IRA foram sepse (72%) e isquemia/choque (66%). A mortalidade na UTI foi de 64,6% (IC: 61,1%-68%) e a hospitalar foi de 69,7% (IC: 66,3%-72,9%). O diagnóstico de disnatremia foi frequente, estando presente em 47,3% (IC: 43,7%-50,9%) dos pacientes. A hipernatremia foi significantemente mais frequente do que a hiponatremia (33,7% X 13,6%, p=0.001) na população estudada. Na análise multivariada, os pacientes mais idosos, a admissão clínica, o número de comorbidades e o número de disfunções orgânicas estiveram associados a uma maior letalidade hospitalar. Os paciente com hipernatremia grave (>155 mEq/l) apresentaram maior associação com o óbito na UTI e no hospital [odds ratio (OR) ajustado de 3.39 (1,48-7,8) e 2,87 (1,2-6,89), respectivamente], apesar de todos terem sido submetidos ao SR durante a internação na UTI. O estudo demonstrou que as disnatremias são altamente prevalentes em pacientes com IRA e necessidade de diálise na UTI. Diferente do que tem sido demonstrado na população de UTI e na com DRC, a hipernatremia é o distúrbio do sódio mais frequentemente observado na população estudada. A idade mais avançada, a admissão clínica, o número de comorbidades e o número de disfunções orgânicas e a hipernatremia grave estão associados a um pior desfecho na IRA com necessidade de SR na UTI.

Declining Rockfish Lengths in the Monterey Bay, California, Recreational Fishery, 1959–94

California’s Monterey Bay area is an important center of recreational fishing for rockfish of various Sebastes species. The species composition of commercial passenger fishing vessel catches from 1959 to 1994 varied with changes in fishing location and depth. The shift from shallow nearshore locations to deeper offshore locations in the late 1970’s and 1980’s changed the emphasis from the blue rockfish, S. mystinus, of shallow waters to the deeper, commercially fished chilipepper, S. goodei, and bocaccio, S. paucispinis. The mean size of rockfish in the catch increased as the latter species were targeted at greater depths but then declined as stocks of older fish disappeared by the mid 1980’s. During 1960–94 the mean size of all ten leading species in the recreational catch declined. The declines ranged from 1% for canary rockfish, S. pinniger, to 27% for chilipepper. The sizes of the deeper living species declined more than those of shallower species. The low frequency of strong recruitment events and increase in fishing mortality and natural mortality appear to have contributed to the declining mean size. The scarcity of older fish, observed as a drop in mean size to below the size of maturity for 50% of females, leads to concern for future recruitment of the larger species, especially bocaccio, chilipepper, yellowtail rockfish, S. flavidus, and canary rockfish.

Caracterização fenotípica e molecular de amostras de Enterococcus isoladas em um hospital universitário da cidade do Rio de Janeiro

Os enterococos estão amplamente distribuídos no ambiente. Nos seres humanos, compõem a microbiota do trato gastrintestinal, da cavidade oral e do trato geniturinário. Nas últimas décadas, esses microrganismos se tornaram importantes agentes etiológicos de infecções hospitalares. Uma característica marcante desses microrganismos é a resistência intrínseca a vários antimicrobianos utilizados habitualmente no tratamento de infecções, além de alguns fatores que tem sido relacionado à virulência de enterococos. Este estudo investigou a presença de enterococos em amostras de infecção e colonização de pacientes hospitalizados, profissionais de saúde, dietas hospitalares e manipuladores de alimentos. Foram analisadas 276 amostras de colonização, de quadros de infecção, dietas orais e manipuladores de alimento. Não foram recuperadas amostras dos profissionais de saúde. Todas as amostras foram submetidas a testes convencionais de caracterização do gênero e espécies. Testes de susceptibilidade aos antimicrobianos foram empregados pelo método de disco difusão, além da CIM para vancomicina e teicoplanina. A produção de biofilme e a expressão da gelatinase também foram avaliadas. Os genes de resistência a gentamicina, estreptomicina e vancomicina e os genes de virulência cylA, esp e fsr foram pesquisados pela técnica de PCR. O polimorfismo genético foi determinado por PFGE. A espécie E. faecalis foi a prevalente nas amostras isoladas de colonização e infecção (42,2% e 81,9%, respectivamente). E. casseliflavus (58,9%) foi a mais freqüente dentre as amostras das dietas hospitalares e E. faecium (46,7%) de manipuladores. Dentre as amostras de colonização as maiores taxas de resistência foram observadas para eritromicina (76,3%) e ciprofloxacina (53,9%). Dentre as amostras de infecção, >70% foram resistentes a eritromicina, ciprofloxacina e tetraciclina. Resistência a níveis elevados de gentamcina (HLR-GE) e estreptomicina (HLR-ST) foi detectada em 24,6% e 20,4% das amostras, respectivamente, e todas foram portadoras dos respectivos genes. A maioria das amostras de colonização (52,6%) e infecção (55,7%) foram multirresistentes. A taxa para resistência a níveis elevados de vancomicina foi de 5,2% e todas eram portadoras do gene vanA. Em relação a formação de biofilme, 70,2% foram produtoras, com uma maior freqüência dentre as de infecção. A expressão de gelatinase foi detectada em 28,9% e 44,3% das amostras de colonização e infecção, respectivamente. Nenhuma das amostras isoladas das dietas hospitalares e de manipuladores expressou gelatinase. Nas amostras pertencentes as espécies E. faecalis e E. faecium (n=109) 16,5%, 51,4% e 48,6% apresentaram produtos de amplificação referentes aos genes cylA, esp e fsr, respectivamente. A análise do polimorfismo genético revelou uma extensa diversidade dentre as amostras pertencentes as espécies E. faecalis e E. faecium, não acarretando um perfil eletroforético prevalente. Entretanto, foi observado um perfil único dentre as amostras de E. gallinarum resistentes a vancomicina (vanA). Este estudo mostrou que amostras de enterococos isoladas de diferentes fontes, não só de quadros infecciosos, podem representar um risco para a população, apontando para uma maior reflexão quanto ao papel desses microrganismos nas infecções humanas, particularmente no ambiente hospitalar.

Severe decline in abundance of the red porgy (Pagrus pagrus) population off the southeastern United States

Status of the southeastern U.S. stock of red porgy (Pagrus pagrus) was estimated from fishery-dependent and fishery-independent data, 1972–97. Annual population numbers and fishing mortality rates at age were estimated from virtual population analysis (VPA) calibrated with fishery-independent data. For the VPA, a primary matrix of catch at age was based on age-length keys from fishery-independent samples; an alternate matrix was based on fishery-dependent keys. Additional estimates of stock status were obtained from a surplus-production model, also calibrated with fishery-independent indices of abundance. Results describe a dramatic increase in exploitation of this stock and concomitant decline in abundance. Estimated fully recruited fishing mortality rate (F) from the primary catch matrix increased from 0.10/yr in 1975 to 0.88/yr in 1997, and estimated static spawning potential ratio (SPR) declined from about 67% to about 18%. Estimated recruitment to age 1 declined from a peak of 3.0 million fish in 1973–74 to 94,000 fish in 1997, a decline of 96.9%. Estimated spawning-stock biomass declined from a peak of 3530 t in 1979 to 397 t in 1997, a decline of 88.8%. Results from the alternate catch matrix were similar. Retrospective patterns in the VPA suggest that the future estimates of this population decline will be severe, but may be less than present estimates. Long-term and marked declines in recruitment, spawning stock, and catch per unit of effort (both fishery-derived and fishery-independent)are consistent with severe overexploitation during a period of reduced recruitment. Although F prior to 1995 has generally been estimated at or below the current management criterion for overfishing (F equivalent to SPR=35%), the recent spawning-stock biomass is well below the biomass that could support maximum sustainable yield. Significant reductions in fishing mortality will be needed for rebuilding the southeastern U.S. stock.

Physicians in leadership: the association between medical director involvement and staff-to-patient ratios

In a hospital environment that demands a careful balance between commercial and clinical interests, the extent to which physicians are involved in hospital leadership varies greatly. This paper assesses the influence of the extent of this involvement on staff-to-patient ratios. Using data gathered from 604 hospitals across Germany, this study evidences the positive relationship between a full-time medical director (MD) or heavily involved part-time MD and a higher staff-to-patient ratio. The data allows us to control for a range of confounding variables, such as size, rural/urban location, ownership structure, and case-mix. The results contribute to the sparse body of empirical research on the effect of clinical leadership on organizational outcomes.

Studies on nitric oxide synthase activity in haemocytes of shrimps Fenneropenaeus chinensis and Marsupenaeus japonicus after white spot syndrome virus infection

The nitric oxide synthase (NOS) activity in the haemocytes of shrimps Fenneropenaeus chinensis (Osbeck) and Marsupenaeus japonicus (Bate) was Studied after white spot syndrome virus (WSSV) infection to determine its characteristics in response to virus infection. First, the NOS activity in haemocytes of shrimps was determined by the means of NBT reduction and changes in cell conformation. And the variations of NOS activity in shrimps after challenge with WSSV intramuscularly were evaluated through the analysis Of L-citrulline and total nitrite/nitrate (both as NO derivates) concentrations. The result showed that NOS activity in the haemocytes of F chinensis increased slightly from 0 to 12 h postchallenge, indicated by the variations Of L-Citrulline (from 11.15 +/- 0.10 to 12.08 +/- 0.64 mu M) and total nitrite/nitrate concentrations (from 10.45 +/- 0.65 to 12.67 +/- 0.52 mu M). Then it decreased sharply till the end of the experiment (84 h postchallenge), the concentrations Of L-Citrulline and total nitrite/nitrate at 84 It were 1.58 +/- 0.24 and 2.69 +/- 0.70 mu M, respectively. The LPS-stimulated NOS activity kept constant during the experiment. However, in M. japonicus, the NOS activity kept increasing during the first 72 It postchallenge, the concentrations Of L-Citrulline and total nitrite/nitrate increased from 7.82 +/- 0.77 at 0 h to 10.79 +/- 0.50 mu M at 72 h, and from 8.98 +/- 0.43 at 0 h to 11.20 +/- 0.37 mu M at 72 h, respectively. Then it decreased till the end of the experiment (216 h postchallenge), and the concentrations of L-Citrulline and total nitrite/nitrate at 216 h were 5.66 +/- 0.27 and 4.68 +/- 0.16 mu M, respectively. More importantly, an apparent increase of I-PS-stimulated NOS activity was observed in M japonicus at 48 h postchallenge, which was about 4 times higher than that in the control group of health shrimps. In correspondence with the difference of NOS activity between the two species of shrimps, the Cumulative mortalities of the shrimps were also different. All shrimps of F. chinensis in the mortality experiment died in 66 h, much more quickly than M. japonicus, Whose accumulative mortality reached 100% after 240 h. Data here reported let us hypothesize that NOS activity in the haemocytes of shrimps F chinensis and M. japonicus responses to WSSV infection differently, and this might be one of the reasons for the different susceptibility of F chinensis and M. japonicus to WSSV infection. (c) 2005 Elsevier Inc. All rights reserved.

Mycobacteriosis in Chesapeake Bay Striped Bass (Morone saxatilis): The Interaction of Nutrition and Disease

Field and laboratory studies were conducted from 1998 - 2005 to examine the relationship between nutritional status and mycobacteriosis in Chesapeake Bay striped bass (Morone saxatilis). A review of DNA from archived tissue blocks indicated that the disease has been present since at least 1984. Field surveys and feeding trials were conducted from 1998-1999 to determine the nutritional condition of striped bass and the association with disease state. Proximate composition revealed elevated moisture (~ 80%) and low storage lipids (< 0.5% ww), characteristic of a poorly nourished population. These findings were not consistent with data collected in 1990-1991, or with experimentally fed fish. Mycobacteriosis explained little of the variance in chemical composition (p > 0.2); however elevated moisture and low lipid concentration were associated with fish with ulcerative lesions (p < 0.05). This suggests that age 3 and 4 striped bass were in poor nutritional health in 1998-1999, which may be independent from the disease process. Challenge studies were performed to address the hypothesis that disease progression and severity may be altered by nutritional status of the host. Intraperitoneal inoculation of 104 CFU M. marinum resulted in high mortality, elevated bacterial density, and poor granuloma formation in low ration (0.15% bw/d) groups while adequately fed fish (1% bw/d) followed a normal course of granulomatous inflammation with low mortality to a steady, equilibrium state. Further, we demonstrated that an active inflammatory state could be reactivated in fish through reductions in total diet. The energetic demand of mycobacteriosis, was insignificant in comparison to sham inoculated controls in adequately fed fish (p > 0.05). Declines in total body energy were only apparent during active, inflammatory stages of disease. Overall, these findings suggest that: 1) mycobacteriosis is not a new disease of Chesapeake Bay striped bass, 2) the disease has little energetic demand in the normal, chronic progression, and 3) poor nutritional health can greatly enhance the progression and severity, and reactivation of disease. The implications of this research are that management strategies focused on enhancing the nutritional state of striped bass could potentially alter the disease dynamics in Chesapeake Bay.

The Impact of Worsening Heart Failure in the United States.

In-hospital worsening heart failure represents a clinical scenario wherein a patient hospitalized for acute heart failure experiences a worsening of their condition, requiring escalation of therapy. Worsening heart failure is associated with worse in-hospital and postdischarge outcomes. Worsening heart failure is increasingly being used as an endpoint or combined endpoint in clinical trials, as it is unique to episodes of acute heart failure and captures an important event during the inpatient course. While prediction models have been developed to identify worsening heart failure, there are no known FDA-approved medications associated with decreased worsening heart failure. Continued study is warranted.

Modelling the flow of congestive heart failure patients through a hospital system

The number of hospital admissions in England due to heart failure is projected to increase by over 50% during the next 25 years. This will incur greater pressures on hospital managers to allocate resources in an effective manner. A reliable indicator for measuring the quantity of resources consumed by hospital patients is their length of stay (LOS) in care. This paper proposes modelling the length of time heart failure patients spend in hospital using a special type of Markov model, where the flow of patients through hospital can be thought of as consisting of three stages of care—short-, medium- and longer-term care. If it is assumed that new admissions into the ward are replacements for discharges, such a model may be used to investigate the case-mix of patients in hospital and the expected patient turnover during some specified period of time. An example is illustrated by considering hospital admissions to a Belfast hospital in Northern Ireland, between 2000 and 2004.

Impact of antibiotics on conjugational resistance gene transfer in Staphylococcus aureus in sewage.

Ohlsen K, Ternes T, Werner G, Wallner U, Löffler D, Ziebuhr W, Witte W, Hacker J. Institute for Molecular Biology of Infectious Diseases, The University of Würzburg, Röntgenring 11, D-97070 Würzburg, Germany. knut.ohlsen@mail.uni-wuerzburg.de The growing rate of microbial pathogens becoming resistant to standard antibiotics is an important threat to public health. In order to assess the role of antibiotics in the environment on the spread of resistance factors, the impact of subinhibitory concentrations of antibiotics in sewage on gene transfer was investigated using conjugative gentamicin resistance (aacA-aphD) plasmids of Staphylococcus aureus. Furthermore, the concentration of antibiotics in hospital sewage was measured by high-performance liquid chromatography (HPLC)-electrospray tandem mass spectrometry. Several antibiotics were found to be present in sewage, e.g. ciprofloxacin up to 0.051 mgl(-1) and erythromycin up to 0.027 mgl(-1). Resistance plasmid transfer occurred both on solidified (dewatered) sewage and in liquid sewage in a bioreactor with a frequency of 1.1x10(-5)-5.0x10(-8). However, low-level concentrations of antibiotics measured in sewage are below concentrations that can increase plasmid transfer frequencies of gentamicin resistance plasmids of staphylococci.

Cyclin G associated kinase interacts with interleukin 12 receptor beta2 and suppresses interleukin 12 induced IFN-gamma production.

BACKGROUND: Although severe encephalopathy has been proposed as a possible contraindication to the use of noninvasive positive-pressure ventilation (NPPV), increasing clinical reports showed it was effective in patients with impaired consciousness and even coma secondary to acute respiratory failure, especially hypercapnic acute respiratory failure (HARF). To further evaluate the effectiveness and safety of NPPV for severe hypercapnic encephalopathy, a prospective case-control study was conducted at a university respiratory intensive care unit (RICU) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) during the past 3 years. METHODS: Forty-three of 68 consecutive AECOPD patients requiring ventilatory support for HARF were divided into 2 groups, which were carefully matched for age, sex, COPD course, tobacco use and previous hospitalization history, according to the severity of encephalopathy, 22 patients with Glasgow coma scale (GCS) <10 served as group A and 21 with GCS = 10 as group B. RESULTS: Compared with group B, group A had a higher level of baseline arterial partial CO2 pressure ((102 +/- 27) mmHg vs (74 +/- 17) mmHg, P <0.01), lower levels of GCS (7.5 +/- 1.9 vs 12.2 +/- 1.8, P <0.01), arterial pH value (7.18 +/- 0.06 vs 7.28 +/- 0.07, P <0.01) and partial O(2) pressure/fraction of inspired O(2) ratio (168 +/- 39 vs 189 +/- 33, P <0.05). The NPPV success rate and hospital mortality were 73% (16/22) and 14% (3/22) respectively in group A, which were comparable to those in group B (68% (15/21) and 14% (3/21) respectively, all P > 0.05), but group A needed an average of 7 cm H2O higher of maximal pressure support during NPPV, and 4, 4 and 7 days longer of NPPV time, RICU stay and hospital stay respectively than group B (P <0.05 or P <0.01). NPPV therapy failed in 12 patients (6 in each group) because of excessive airway secretions (7 patients), hemodynamic instability (2), worsening of dyspnea and deterioration of gas exchange (2), and gastric content aspiration (1). CONCLUSIONS: Selected patients with severe hypercapnic encephalopathy secondary to HARF can be treated as effectively and safely with NPPV as awake patients with HARF due to AECOPD; a trial of NPPV should be instituted to reduce the need of endotracheal intubation in patients with severe hypercapnic encephalopathy who are otherwise good candidates for NPPV due to AECOPD.

Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials

Background: After breast-conserving surgery, radiotherapy reduces recurrence and breast cancer death, but it may do so more for some groups of women than for others. We describe the absolute magnitude of these reductions according to various prognostic and other patient characteristics, and relate the absolute reduction in 15-year risk of breast cancer death to the absolute reduction in 10-year recurrence risk.
Methods: We undertook a meta-analysis of individual patient data for 10?801 women in 17 randomised trials of radiotherapy versus no radiotherapy after breast-conserving surgery, 8337 of whom had pathologically confirmed node-negative (pN0) or node-positive (pN+) disease.
Findings: Overall, radiotherapy reduced the 10-year risk of any (ie, locoregional or distant) first recurrence from 35·0% to 19·3% (absolute reduction 15·7%, 95% CI 13·7–17·7, 2p<0·00001) and reduced the 15-year risk of breast cancer death from 25·2% to 21·4% (absolute reduction 3·8%, 1·6–6·0, 2p=0·00005). In women with pN0 disease (n=7287), radiotherapy reduced these risks from 31·0% to 15·6% (absolute recurrence reduction 15·4%, 13·2–17·6, 2p<0·00001) and from 20·5% to 17·2% (absolute mortality reduction 3·3%, 0·8–5·8, 2p=0·005), respectively. In these women with pN0 disease, the absolute recurrence reduction varied according to age, grade, oestrogen-receptor status, tamoxifen use, and extent of surgery, and these characteristics were used to predict large (=20%), intermediate (10–19%), or lower (<10%) absolute reductions in the 10-year recurrence risk. Absolute reductions in 15-year risk of breast cancer death in these three prediction categories were 7·8% (95% CI 3·1–12·5), 1·1% (–2·0 to 4·2), and 0·1% (–7·5 to 7·7) respectively (trend in absolute mortality reduction 2p=0·03). In the few women with pN+ disease (n=1050), radiotherapy reduced the 10-year recurrence risk from 63·7% to 42·5% (absolute reduction 21·2%, 95% CI 14·5–27·9, 2p<0·00001) and the 15-year risk of breast cancer death from 51·3% to 42·8% (absolute reduction 8·5%, 1·8–15·2, 2p=0·01). Overall, about one breast cancer death was avoided by year 15 for every four recurrences avoided by year 10, and the mortality reduction did not differ significantly from this overall relationship in any of the three prediction categories for pN0 disease or for pN+ disease.
Interpretation: After breast-conserving surgery, radiotherapy to the conserved breast halves the rate at which the disease recurs and reduces the breast cancer death rate by about a sixth. These proportional benefits vary little between different groups of women. By contrast, the absolute benefits from radiotherapy vary substantially according to the characteristics of the patient and they can be predicted at the time when treatment decisions need to be made.
Funding: Cancer Research UK, British Heart Foundation, and UK Medical Research Council.