Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

OBJECTIVE: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock," published in 2004. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the GRADE system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost), or clearly do not. Weak recommendations indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include: early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures prior to antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for post-operative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B) targeting a blood glucose < 150 mg/dL after initial stabilization ( 2C ); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper GI bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include: greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSION: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Endoscopic Approach and Management of Parasellar Lesions

The parasellar region is the location of a wide variety of inflammatory and benign or malignant lesions. A pathological diagnostic strategy may be difficult to establish relying solely on imaging data. Percutaneous biopsy through the foramen ovale using the Hartel technique has been developed for decision-making process. It is an accurate diagnostic tool allowing pathological diagnosis to determine the best treatment strategy. However, in some cases, this procedure may fail or may be inappropriate particularly for anterior parasellar lesions. Over these past decades, endoscopy has been widely developed and promoted in many indications. It represents an interesting alternative approach to parasellar lesions with low morbidity when compared to the classic microscopic sub-temporal extradural approach with or without orbito-zygomatic removal. In this chapter, we describe our experience with the endoscopic approach to parasellar lesions. We propose a complete overview of surgical anatomy and describe methods and results of the technique. We also suggest a model of a decision-making tree for the diagnosis and treatment of parasellar lesions.

Impact of bedside open lung biopsies on the management of mechanically ventilated immunocompromised patients with acute respiratory distress syndrome of unknown etiology.

BACKGROUND: Open lung biopsy (OLB) is helpful in the management of patients with acute respiratory distress syndrome (ARDS) of unknown etiology. We determine the impact of surgical lung biopsies performed at the bedside on the management of patients with ARDS. METHODS: We reviewed all consecutive cases of patients with ARDS who underwent a surgical OLB at the bedside in a medical intensive care unit between 1993 and 2005. RESULTS: Biopsies were performed in 19 patients mechanically ventilated for ARDS of unknown etiology despite extensive diagnostic process and empirical therapeutic trials. Among them, 17 (89%) were immunocompromised and 10 patients experienced hematological malignancies. Surgical biopsies were obtained after a median (25%-75%) mechanical ventilation of 5 (2-11) days; mean (+/-SD) Pao(2)/Fio(2) ratio was 119.3 (+/-34.2) mm Hg. Histologic diagnoses were obtained in all cases and were specific in 13 patients (68%), including 9 (47%) not previously suspected. Immediate complications (26%) were local (pneumothorax, minimal bleeding) without general or respiratory consequences. The biopsy resulted in major changes in management in 17 patients (89%). It contributed to a decision to limit care in 12 of 17 patients who died. CONCLUSION: Our data confirm that surgical OLB may have an important impact on the management of patients with ARDS of unknown etiology after extensive diagnostic process. The procedure can be performed at the bedside, is safe, and has a high diagnostic yield leading to major changes in management, including withdrawal of vital support, in the majority of patients.

Risks and benefits of percutaneous vertebroplasty or kyphoplasty in the management of osteoporotic vertebral fractures.

Vertebral fracture (VF) is the most common osteoporotic fracture and is associated with high morbidity and mortality. Conservative treatment combining antalgic agents and rest is usually recommended for symptomatic VFs. The aim of this paper is to review the randomized controlled trials comparing the efficacy and safety of percutaneous vertebroplasty (VP) and percutaneous balloon kyphoplasty (KP) versus conservative treatment. VP and KP procedures are associated with an acceptable general safety. Although the case series investigating VP/KP have all shown an outstanding analgesic benefit, randomized controlled studies are rare and have yielded contradictory results. In several of these studies, a short-term analgesic benefit was observed, except in the prospective randomized sham-controlled studies. A long-term analgesic and functional benefit has rarely been noted. Several recent studies have shown that both VP and KP are associated with an increased risk of new VFs. These fractures are mostly VFs adjacent to the procedure, and they occur within a shorter time period than VFs in other locations. The main risk factors include the number of preexisting VFs, the number of VPs/KPs performed, age, decreased bone mineral density, and intradiscal cement leakage. It is therefore important to involve the patients to whom VP/KP is being proposed in the decision-making process. It is also essential to rapidly initiate a specific osteoporosis therapy when a VF occurs (ideally a bone anabolic treatment) so as to reduce the risk of fracture. Randomized controlled studies are necessary in order to better define the profile of patients who likely benefit the most from VP/KP.

Management of nanomaterials safety in research environment

Despite numerous discussions, workshops, reviews and reports about responsible development of nanotechnology, information describing health and environmental risk of engineered nanoparticles or nanomaterials is severely lacking and thus insufficient for completing rigorous risk assessment on their use. However, since preliminary scientific evaluations indicate that there are reasonable suspicions that activities involving nanomaterials might have damaging effects on human health; the precautionary principle must be applied. Public and private institutions as well as industries have the duty to adopt preventive and protective measures proportionate to the risk intensity and the desired level of protection. In this work, we present a practical, 'user-friendly' procedure for a university-wide safety and health management of nanomaterials, developed as a multi-stakeholder effort (government, accident insurance, researchers and experts for occupational safety and health). The process starts using a schematic decision tree that allows classifying the nano laboratory into three hazard classes similar to a control banding approach (from Nano 3 - highest hazard to Nano1 - lowest hazard). Classifying laboratories into risk classes would require considering actual or potential exposure to the nanomaterial as well as statistical data on health effects of exposure. Due to the fact that these data (as well as exposure limits for each individual material) are not available, risk classes could not be determined. For each hazard level we then provide a list of required risk mitigation measures (technical, organizational and personal). The target 'users' of this safety and health methodology are researchers and safety officers. They can rapidly access the precautionary hazard class of their activities and the corresponding adequate safety and health measures. We succeed in convincing scientist dealing with nano-activities that adequate safety measures and management are promoting innovation and discoveries by ensuring them a safe environment even in the case of very novel products. The proposed measures are not considered as constraints but as a support to their research. This methodology is being implemented at the Ecole Polytechnique de Lausanne in over 100 research labs dealing with nanomaterials. It is our opinion that it would be useful to other research and academia institutions as well. [Authors]

Thermal modeling and management in ultrathin chip stack technology

This paper presents a thermal modeling for power management of a new three-dimensional (3-D) thinned dies stacking process. Besides the high concentration of power dissipating sources, which is the direct consequence of the very interesting integration efficiency increase, this new ultra-compact packaging technology can suffer of the poor thermal conductivity (about 700 times smaller than silicon one) of the benzocyclobutene (BCB) used as both adhesive and planarization layers in each level of the stack. Thermal simulation was conducted using three-dimensional (3-D) FEM tool to analyze the specific behaviors in such stacked structure and to optimize the design rules. This study first describes the heat transfer limitation through the vertical path by examining particularly the case of the high dissipating sources under small area. First results of characterization in transient regime by means of dedicated test device mounted in single level structure are presented. For the design optimization, the thermal draining capabilities of a copper grid or full copper plate embedded in the intermediate layer of stacked structure are evaluated as a function of the technological parameters and the physical properties. It is shown an interest for the transverse heat extraction under the buffer devices dissipating most the power and generally localized in the peripheral zone, and for the temperature uniformization, by heat spreading mechanism, in the localized regions where the attachment of the thin die is altered. Finally, all conclusions of this analysis are used for the quantitative projections of the thermal performance of a first demonstrator based on a three-levels stacking structure for space application.

Nitrate and ammonium in soil solution in tobacco management systems

Tobacco farmers of southern Brazil use high levels of fertilizers, without considering soil and environmental attributes, posing great risk to water resources degradation. The objective of this study was to monitor nitrate and ammonium concentrations in the soil solution of an Entisol in and below the root zone of tobacco under conventional tillage (CT), minimum tillage (MT) and no-tillage (NT). The study was conducted in the small-watershed Arroio Lino, in Agudo, State of Rio Grande do Sul, Brazil. A base fertilization of 850 kg ha-1 of 10-18-24 and topdressing of 400 kg ha-1 of 14-0-14 NPK fertilizer were applied. The soil solution was sampled during the crop cycle with a tension lysimeter equipped with a porous ceramic cup. Ammonium and nitrate concentrations were analyzed by the distillation and titration method. Nitrate concentrations, ranging from 8 to 226 mg L-1, were highest after initial fertilization and decreased during the crop cycle. The average nitrate (N-NO3-) concentration in the root zone was 75 in NT, 95 in MT, and 49 mg L-1 in CT. Below the root zone, the average nitrate concentration was 58 under NT, 108 under MT and 36 mg L-1 under CT. The nitrate and ammonium concentrations did not differ significantly in the management systems. However, the nitrate concentrations measured represent a contamination risk to groundwater of the watershed. The ammonium concentration (N-NH4+) decreased over time in all management systems, possibly as a result of the nitrification process and root uptake of part of the ammonium by the growing plants.

A Research Report on Roadside Vegetation Management, December 1975

According to prevailing ecological theory one would expect the most stable vegetation on sites which are least disturbed (Odum 1971). According to theory one would also expect the most diversity of species on undisturbed sites (Odum 1971). This stable and diverse community would be produced over a period of many years through a process of plant succession where annual herbs are replaced by perennial herbs and finally woody plants would come to dominate and perpetuate the community. Another ecological theory holds that the complexity (structure and species diversity) of a plant community is dependent upon the amount of disturbance to which it is subjected (Woodwell, 1970). According to this theory the normal succession of a plant community through its various stages may be arrested at some point depending upon the nature and severity of the disturbance. In applying these theories to roadside vegetation it becomes apparent that mass herbicide spraying and extensive mowing of roadsides has produced a relatively simple and unstable vegetation. It follows that if disturbances were reduced not only would the roadside plant community increase in stability but maintenance costs and energy usage would be reduced. In this study we have investigated several aspects of reduced disturbances on roadside vegetation. Research has centered on the effectiveness of spot spraying techniques on noxious weed control, establishment of native grass cover where ditch cleaning and other disturbance has left the bare soil exposed and the response of roadside vegetation when released from annual mass spraying.

Spatial planning to the test of property rights in Switzerland : an innovative land management approach to coordinate spatial planning goals with property rights interests

In Switzerland, the land management regime is characterized by a liberal attitude towards the institution of property rights, which is guaranteed by the Constitution. Under the present Swiss constitutional arrangement, authorities (municipalities) are required to take into account landowners' interests when implementing their spatial planning policy. In other words, the institution of property rights cannot be restricted easily in order to implement zoning plans and planning projects. This situation causes many problems. One of them is the gap between the way land is really used by the landowners and the way land should be used based on zoning plans. In fact, zoning plans only describe how landowners should use their property. There is no sufficient provision for handling cases where the use is not in accordance with zoning plans. In particular, landowners may not be expropriated for a non-conforming use of the land. This situation often leads to the opening of new building areas in greenfields and urban sprawl, which is in contradiction with the goals set into the Federal Law on Spatial Planning. In order to identify legal strategies of intervention to solve the problem, our paper is structured into three main parts. Firstly, we make a short description of the Swiss land management regime. Then, we focus on an innovative land management approach designed to implement zoning plans in accordance with property rights. Finally, we present a case study that shows the usefulness of the presented land management approach in practice. We develop three main results. Firstly, the land management approach brings a mechanism to involve landowners in planning projects. Coordination principle between spatial planning goals and landowners' interests is the cornerstone of all the process. Secondly, the land use is improved both in terms of space and time. Finally, the institution of property rights is not challenged, since there is no expropriation and the market stays free.

SOIL FUNGISTASIS AGAINST FUSARIUM GRAMINEARUM UNDER DIFFERENT CROP MANAGEMENT SYSTEMS

Soil management, in terms of tillage and cropping systems, strongly influences the biological properties of soil involved in the suppression of plant diseases. Fungistasis mediated by soil microbiota is an important component of disease-suppressive soils. We evaluated the influence of different management systems on fungistasis against Fusarium graminearum, the relationship of fungistasis to the bacterial profile of the soil, and the possible mechanisms involved in this process. Samples were taken from a long-term experiment set up in a Paleudult soil under conventional tillage or no-tillage management and three cropping systems: black oat (Avena strigose L.) + vetch (Vicia sativa L.)/maize (Zea mays L.) + cowpea (Vigna sinensis L.), black oat/maize, and vetch/maize. Soil fungistasis was evaluated in terms of reduction of radial growth of F. graminearum, and bacterial diversity was assessed using ribosomal intergenic spacer analysis (RISA). A total of 120 bacterial isolates were obtained and evaluated for antibiosis, and production of volatile compounds and siderophores. No-tillage soil samples showed the highest level of F. graminearum fungistasis by sharply reducing the development of this pathogen. Of the cropping systems tested, the vetch + black oat/maize + cowpea system showed the highest fungistasis and the oat/maize system showed the lowest. The management system also affected the genetic profile of the bacteria isolated, with the systems from fungistatic soils showing greater similarity. Although there was no clear relationship between soil management and the characteristics of the bacterial isolates, we may conclude that antibiosis and the production of siderophores were the main mechanisms accounting for fungistasis.

Organic Matter Fractions and Quality of the Surface Layer of a Constructed and Vegetated Soil After Coal Mining. II - Physical Compartments and Carbon Management Index

Soils constructed after mining often have low carbon (C) stocks and low quality of organic matter (OM). Cover crops are decisive for the recovery process of these stocks, improving the quality of constructed soils. Therefore, the goal of this study was to evaluate the effect of cover crops on total organic C (TOC) stocks, C distribution in physical fractions of OM and the C management index (CMI) of a soil constructed after coal mining. The experiment was initiated in 2003 with six treatments: Hemarthria altissima (T1), Paspalum notatum (T2), Cynodon dactylon (T3), Urochloa brizantha (T4), bare constructed soil (T5), and natural soil (T6). Soil samples were collected in 2009 from the 0.00-0.03 m layer, and the TOC and C stocks in the physical particle size fractions (carbon in the coarse fraction - CCF, and mineral-associated carbon - MAC) and density fractions (free light fraction - FLF; occluded light fraction - OLF, and heavy fraction - HF) of OM were determined. The CMI components: carbon pool index (CPI), lability (L) and lability index (LI) were estimated by both fractionation methods. No differences were observed between TOC, CCF and MAC stocks. The lowest C stocks in FLF and OLF fractions were presented by T2, 0.86 and 0.61 Mg ha-1, respectively. The values of TOC stock, C stock in physical fractions and CMI were intermediate, greater than T5 and lower than T6 in all treatments, indicating the partial recovery of soil quality. As a result of the better adaptation of the species Hemarthria and Brizantha, resulting in greater accumulation of labile organic material, the CPI, L, LI and CMI values were higher in these treatments, suggesting a greater potential of these species for recovery of constructed soils.

Medicaid Value Management Program SFY 2008 Report Executive Summary, 2007

In June, 2007, the Commonwealth Fund released a report entitled, “Aiming Higher: Results from a State Scorecard on Health System Performance.” The report ranked states’ health care performance based upon four areas: access, quality, potentially avoidable use of hospitals and costs of care, and healthy lives. Iowa was ranked second overall and was the only state to rank in the top 25 percent on each of the four measures.1 Coupling the HEDIS measures and CAHPS survey results with the Commonwealth report outcomes provides additional information for determining how the state performs with regard to the health care system, in general, and the Medicaid program specifically. For the past five years the results of eight outcome measures encompassing children and adults, and preventive, chronic and acute care have been reported by the University of Iowa Public Policy Center (PPC). The PPC is the independent evaluator for the Medicaid managed care programs and assists the state in an effort to understand the process of care within the Medicaid program. Seven of the eight measures are recommended by the Centers for Medicare and Medicaid, while the eighth, annual dental visit, is used in recognition of the challenges found in providing dental care to Medicaid‐enrolled children and adults.

Auditing the management of vaccine-preventable disease outbreaks: the need for a tool

Public health activities, especially infectious disease control, depend on effective teamwork. We present the results of a pilot audit questionnaire aimed at assessing the quality of public health services in the management of VPD outbreaks. Audit questionnaire with three main areas indicators (structure, process and results) was developed. Guidelines were set and each indicator was assessed by three auditors. Differences in indicator scores according to median size of outbreaks were determined by ANOVA (significance at p (greater than or equal to) 0.05). Of 154 outbreaks; eighteen indicators had a satisfactory mean score, indicator "updated guidelines" and "timely reporting" had a poor mean score (2.84±106 and 2.44±1.67, respectively). Statistically significant differences were found according to outbreak size, in the indicators "availability of guidelines/protocol updated less than 3 years ago" (p = 0.03) and "days needed for outbreak control" (p = 0.04). Improving availability of updated guidelines, enhancing timely reporting and adequate recording of control procedures taken is needed to allow for management assessment and improvement.

Iowa Wetland Management District: Environmental Assessment and Draft Comprehensive Conservation Plan

This Environmental Assessment documents the National Environmental Policy Act (NEPA) process for developing a Comprehensive Conservation Plan (CCP) for the Iowa Wetland Management District (WMD, district). In general, scoping reveals issues that drive alternative ways of managing the district. Implementation of each of those alternative management styles (including the No Action Alternative) may have different effects on the physical, biological, and socio-economic environment. Analysis of these effects reveals the “preferred” alternative, which constitutes the CCP. The CCP includes goals, objectives, and strategies for the district to guide overall management for the next 15 years. The Iowa WMD consists of scattered tracts of habitat (both wetland and upland grassland) known as Waterfowl Production Areas (WPAs). As of 2011, there are 75 WPAs in 18 counties in north-central Iowa totaling 24,712 acres in fee title primarily managed by the Iowa Department of Natural Resources (DNR). Even though district acquisition has only occurred in 18 counties to date, a larger 35-county boundary is approved. This boundary follows the historic range of the poorly drained Prairie Pothole Region (PPR) in Iowa, an area known for its waterfowl production. The district also includes 575 WPA acres and approximately 434 Farm Service Agency acres in conservation easements on private land. This plan was prepared with the intent that the strong partnership with the Iowa DNR will continue over the next 15 years.

Maintenance Asset Management Project -- Phase II, July 31, 2013

Expanded abstract: Iowa Department of Transportation (IA DOT) is finalizing research to streamline field inventory/inspection of culverts by Maintenance and Construction staff while maximizing the use of tablet technologies. The project began in 2011 to develop some new best practices for field staff to assist in the inventory, inspection and maintenance of assets along the roadway. The team has spent the past year working through the complexities of identifying the most appropriate tablet hardware for field data collection. A small scale deployment of tablets occurred in spring of 2013 to collect several safety related assets (culverts, signs, guardrail, and incidents). Data can be collected in disconnected or connected modes and there is an associated desktop environment where data can be viewed and queried after being synced into the master database. The development of a deployment plan and related workflow processes are underway; which will eventually feed information into IA DOTs larger asset management system and make the information available for decision making. The team is also working with the IA DOT Design Office on Computer Aided Drafting (CAD) data processing and the IA DOT Construction office with a new digital As-Built plan process to leverage the complete data life-cycle so information can be developed once and leveraged by the Maintenance staff farther along in the process.