Failure to reduce C-reactive protein levels more than 25% in the last 24 hours before intensive care unit discharge predicts higher in-hospital mortality: A cohort study

Purpose: To discharge a patient from the intensive care unit (ICU) is a complex decision-making process because in-hospital mortality after critical illness may be as high as up to 27%. Static C-reactive protein (CRP) values have been previously evaluated as a predictor of post-ICU mortality with conflicting results. Therefore, we evaluated the CRP ratio in the last 24 hours before ICU discharge as a predictor of in-hospital outcomes. Methods: A retrospective cohort study was performed in 409 patients from a 6-bed ICU of a university hospital. Data were prospectively collected during a 4-year period. Only patients discharged alive from the ICU with at least 72 hours of ICU length of stay were evaluated. Results: In-hospital mortality was 18.3% (75/409). Patients with reduction less than 25% in CRP concentrations at 24 hours as compared with 48 hours before ICU discharge had a worse prognosis, with increased mortality (23% vs 11%, P = .002) and post-ICU length of stay (26 [7-43] vs 11 [5-27] days, P = .036). Moreover, among hospital survivors (n = 334), patients with CRP reduction less than 25% were discharged later (hazard ratio, 0.750; 95% confidence interval, 0.602-0.935; P = .011). Conclusions: In this large cohort of critically ill patients, failure to reduce CRP values more than 25% in the last 24 hours of ICU stay is a strong predictor of worse in-hospital outcomes. (C) 2012 Elsevier Inc. All rights reserved.

Effect of heat and moisture exchangers on the prevention of ventilator-associated pneumonia in critically ill patients

Ventilator-associated pneumonia (VAP) remains one of the major causes of infection in the intensive care unit (ICU) and is associated with the length of hospital stay, duration of mechanical ventilation, and use of broad-spectrum antibiotics. We compared the frequency of VAP 10 months prior to (pre-intervention group) and 13 months after (post-intervention group) initiation of the use of a heat and moisture exchanger (HME) filter. This is a study with prospective before-and-after design performed in the ICU in a tertiary university hospital. Three hundred and fourteen patients were admitted to the ICU under mechanical ventilation, 168 of whom were included in group HH (heated humidifier) and 146 in group HME. The frequency of VAP per 1000 ventilator-days was similar for both the HH and HME groups (18.7 vs 17.4, respectively; P = 0.97). Duration of mechanical ventilation (11 vs 12 days, respectively; P = 0.48) and length of ICU stay (11 vs 12 days, respectively; P = 0.39) did not differ between the HH and HME groups. The chance of developing VAP was higher in patients with a longer ICU stay and longer duration of mechanical ventilation. This finding was similar when adjusted for the use of HME. The use of HME in intensive care did not reduce the incidence of VAP, the duration of mechanical ventilation, or the length of stay in the ICU in the study population.

Monitorização de eletrólitos urinários em pacientes críticos: estudo preliminar observacional

OBJETIVO: Sobreviventes e não sobreviventes da unidade de terapia intensiva apresentam perfis ácido-básicos distintos. A regulação renal de eletrólitos urinários e a diferença de íons fortes urinários têm papéis principais na homeostase ácido- básica. O objetivo deste estudo foi avaliar a potencial utilidade da mensuração diária dos eletrólitos urinários na monitorização ácido-básica e da função renal. MÉTODOS: Foram registrados, prospectivamente e diariamente, parâmetros ácido-básicos plasmáticos e marcadores tradicionais da função renal, em paralelo à medição dos eletrólitos urinários em pacientes com sonda vesical internados na unidade de terapia intensiva. Os pacientes que permaneceram na unidade de terapia intensiva com sonda vesical por pelo menos 4 dias foram incluídos neste estudo. RESULTADOS: Dos 50 pacientes incluídos neste estudo, 22% vieram a óbito durante a internação na unidade de terapia intensiva. A incidência de lesão renal aguda foi significativamente maior nos não sobreviventes, durante os 4 dias de observação (64% versus 18% em sobreviventes). O cloreto e o sódio urinário foram mais baixos, e a diferença de íons fortes urinários mais alta, no 1º dia, em pacientes que desenvolveram lesão renal aguda tanto nos sobreviventes como nos não sobreviventes. Ambos os grupos tiveram débito urinário semelhante, embora os não sobreviventes tenham apresentado diferença de íons fortes urinários persistentemente mais alta durante o período de observação. Os sobreviventes apresentaram melhoria progressiva no perfil metabólico ácido-básico devido ao aumento, no plasma, da diferença de íons fortes e à diminuição dos ácidos fracos. Essas mudanças foram concomitantes à diminuição da diferença de íons fortes urinários. Com relação aos não sobreviventes, os parâmetros ácido-básicos não tiveram alteração significativa durante o seguimento. CONCLUSÃO: A avaliação diária dos eletrólitos urinários e da diferença de íons fortes urinários é útil para a monitorização ácido-básica e da função renal em pacientes críticos, tendo perfis distintos entre sobreviventes e não sobreviventes na unidade de terapia intensiva.

Endotracheal suction in intubated critically ill adult patients undergoing mechanical ventilation: a systematic review

AIM: identify and analyze in the literature the evidence of randomized controlled trials on care related to the suctioning of endotracheal secretions in intubated, critically ill adult patients undergoing mechanical ventilation. METHOD: the search was conducted in the PubMed, EMBASE, CENTRAL, CINAHL and LILACS databases. From the 631 citations found, 17 studies were selected. RESULTS: Evidence was identified for six categories of intervention related to endotracheal suctioning, which were analyzed according to outcomes related to hemodynamic and blood gas alterations, microbial colonization, nosocomial infection, and others. CONCLUSIONS: although the evidence obtained is relevant to the practice of endotracheal aspiration, the risks of bias found in the studies selected compromise the evidence's reliability.

Macroalgal composition and its association with local hydrodynamics in the Laje de Santos Marine State Park, southwestern Atlantic, São Paulo, Brazil

The Laje de Santos Marine State Park (LSMSP), located in southeastern Brazil, is the only marine park in São Paulo State. This conservation unit has been established as a protected area of high biological diversity. Despite its importance for the conservation of the marine biota, little is known about the park's seaweed flora. The objectives of this study were as follows: to furnish increased knowledge of the composition of the macroalgae in the Park area; to relate the area's macroalgal composition to the presence of an important water mass in the region, the South Atlantic Central Water (SACW); and to investigate the possible influence of the Port of Santos on the composition of the macroalgae of the LSMSP. This study registered 31 new records for the LSMSP, 11 for São Paulo State, four for Brazil, one for the western Atlantic and one for the South Atlantic Ocean, in addition to the possible occurrence of one new species of Osmundea (Rhodomelaceae) and one new genus belonging to Ceramiaceae. The taxonomic composition of the macroalgae had a direct correlation with the arrival of the SACW in the summer-fall season. The SACW generated a strong thermocline and increased the supply of nutrients in the water column. Hydrodynamic and dispersion modeling analyses suggested that the Port of Santos influenced the composition of the LSMSP phycoflora.

Petrography and sedimentology of aeolian sands: a tool for diagnose the sedimentary deficit in La Graciosa island (Natural Park of Archipielago Chinijo, Canary Islands, Spain).

[EN] Petrography and sedimentology of aeolian sands: a tool for diagnose the sedimentary deficit in La Graciosa island (Natural Park of Archipielago Chinijo, Canary Islands, Spain).

Assessment of candidemia-attributable mortality in critically ill patients using propensity score matching analysis

[EN] Introduction: Candidemia in critically ill patients is usually a severe and life-threatening condition with a high crude mortality. Very few studies have focused on the impact of candidemia on ICU patient outcome and attributable mortality still remains controversial. This study was carried out to determine the attributable mortality of ICU-acquired candidemia in critically ill patients using propensity score matching analysis. Methods: A prospective observational study was conducted of all consecutive non-neutropenic adult patients admitted for at least seven days to 36 ICUs in Spain, France, and Argentina between April 2006 and June 2007. The probability of developing candidemia was estimated using a multivariate logistic regression model. Each patient with ICU-acquired candidemia was matched with two control patients with the nearest available Mahalanobis metric matching within the calipers defined by the propensity score. Standardized differences tests (SDT) for each variable before and after matching were calculated. Attributable mortality was determined by a modified Poisson regression model adjusted by those variables that still presented certain misalignments defined as a SDT > 10%. Results: Thirty-eight candidemias were diagnosed in 1,107 patients (34.3 episodes/1,000 ICU patients). Patients with and without candidemia had an ICU crude mortality of 52.6% versus 20.6% (P < 0.001) and a crude hospital mortality of 55.3% versus 29.6% (P = 0.01), respectively. In the propensity matched analysis, the corresponding figures were 51.4% versus 37.1% (P = 0.222) and 54.3% versus 50% (P = 0.680). After controlling residual confusion by the Poisson regression model, the relative risk (RR) of ICU- and hospital-attributable mortality from candidemia was RR 1.298 (95% confidence interval (CI) 0.88 to 1.98) and RR 1.096 (95% CI 0.68 to 1.69), respectively. Conclusions: ICU-acquired candidemia in critically ill patients is not associated with an increase in either ICU or hospital mortality.

Ecological tools for assessing rock-art conservation in the Côa Valley Archaeological Park (V.N. Foz Côa, Northeast Portugal)

Centro de Investigação em Biodiversidade e Recursos Genéticos da Universidade do Porto. Departamento de Biologia, Faculdade de Ciências da Universidade do Porto. EscolaUniversitaria de Enxeñeria Forestal, Universidade de Vigo

Marine Park Espacio de Innovación Marina

[ES] Marinepark es un espacio de co-working para empresas del sector marino; un lugar en el que tratar de concentrar empresas que trabajen en tópicos relacionados con el medio marino y afines, tratando de contribuir de esa manera a la creación de colaboraciones directas, a incrementar la visibilidad de las empresas del sector, etc.

Ectomycorrhizae of sessile oak (Quercus petraea (Matt.) Liebl.)

Investigations were performed during the years 1999 to 2001 on a limed and unlimed plot within a high-elevated sessile oak forest. The oak forest (with 90 years old European beech at the understorey) was 170 to 197 years old. It is located at forest district Merzalben, location 04/0705, which is situated in the Palatinate Forest in south-west Germany. Liming was performed in December 1988 when 6 tons/ha of powdered Dolomite were brought up by the forestry department. Liming was performed to counteract the effects of soil acidification (pH(H2O) at Horizon A (0-10 cm): 3.9), which is induced by long-term (anthropogenic) acidic cloud cover and precipitation. Potentially toxic Al3+ ions, which become solubilized below pH 5, were suspected to be responsible for forest dieback and sudden death of the mature oaks. The most logical entry point for these toxic ions was suspected to occur in the highly absorptive region of the ectomycorrhizae (fungal covered root tips). However, the diversity and abundance of oak-ectomycorrhizal species and their actual roles in aluminum translocation (or blockage) were unknown. It was hypothesized that the ectomycorrhizae of sessile oaks in a limed forest would exhibit greater seasonal diversity and abundance with less evidence of incorporated aluminum than similar oak ectomycorrhizae from unlimed soils. To test this hypothesis, 12 oaks in the limed plot and 12 in an adjacent unlimed plot were selected. Each spring and fall for 2 years (1999 & 2000), 2 sets of soil cylinders (9.9 cm dia.) were extracted from Horizon A (0-10 cm), Horizon B (30-40 cm) and Horizon C (50-60 cm depth) at a distance of 1 meter from each tree base. Roots were extracted from each probe by gentle sieving and rinsing. Soil samples were retained for pH (H2O, CaCl2, and KCl) and moisture analysis. One set of roots was sorted by size and air-dried for biomass analysis. The finest mycorrhizal roots of this set were used for bound and unbound (cytosolic) mineral [Al, Ca, Mg, K, Na, Mn, S, Zn, Fe, Cd and Pb] analysis (by Landwirtschaftliche Untersuchungs- und Forschungsanstalt Rheinland Palatinate (LUFA)). Within 7 days of collection, the mycorrhizal tips from the second set of probes were excised, sorted, identified (using Agerer’s Color Atlas), counted and weighed. Seasonal diversity and abundance was characterized for 50 of the 93 isolates. The location and relative abundance of Al within the fungal and root cell walls was characterized for 68 species using 0.01% Morin dye and fluorescence microscopy. Morin complexes with Al to produce an intense yellow fluorescence. The 4 most common species (Cenococcum geophilum, Quercirhiza fibulocsytidiata, Lactarius subdulcis, Piceirhiza chordata) were prepared for bound Al, Ca, Fe and K mineral analysis by LUFA. The unlimed and limed plots were then compared. Only 46 of the 93 isolated ectomycorrhizal species had been previously associated with oaks in the literature. Mycorrhizal biomass was most abundant in Horizon A, declining with depth, drought and progressive soil acidification. Mycorrhizae were most diverse (32 species) in the limed plot, but individual species abundance was low (R Selection) in comparison to the unlimed plot, where there were fewer species (24) but each species present was abundant (K Selection). Liming increased diversity and altered dominance hierarchy, seasonal distributions and succession trends of ectomycorrhizae at all depths. Despite an expected reduction in Al content, the limed ectomycorrhizae both qualitatively (fluorescence analysis) and quantitatively (mineral analysis) contained more bound Al, especially so in Horizon A. The Al content qualitatively and quantitatively increased with depth in the unlimed and limed plots. The bound Al content fluctuated between 4000-and 20000 ppm while the unbound component was consistently lower (4 -14 ppm). The relative amount of unbound Al declined upon liming implying less availability for translocation to the crown area of the trees. This correspouds with the findings of good crown appearance and lower tree mortality in the limed zone. Each ectomycorrhizal species was unique in its ability to block, sequester (hold) or translocate Aluminum. In several species, Al uptake varied with changes in moisture, pH, depth and liming. According to the fluorescence study, about 48% of the isolated ectomycorrhizal species blocked and/or sequestered (held) Al in their mantle and/or Hartig net walls, qualitatively lowering bound Al in the adjacent root cell walls. Generally, if Al was more concentrated in the fungal walls, it was less evident in the cortex and xylem and conversely, if Al was low or absent from the fungal walls it was frequently more evident in the cortex and xylem.

Osmosis Theme Park: piano per la rigenerazione urbana della ex discarica di Küçükçekmece ad Istanbul

Questa tesi di laurea nasce dall’approfondimento del progetto che abbiamo sviluppato nel laboratorio di progettazione architettonica frequentato presso la Middle East Technical University, METU, di Ankara, Turchia, durante l’anno accademico 2011-12. La prima parte del corso, tenuto dai professori S. Özkan e Z. Mennan, consisteva nello studio e analisi critica dei progetti in concorso per il bando “Istanbul Theme Park” e nella riproposizione, da presentare a gruppi, di uno dei masterplan studiati, con le modifiche ritenute necessarie a fronte delle considerazioni fatte e di nuove idee progettuali. Lo step successivo è stato quello di approfondire individualmente la progettazione architettonica di un area di almeno 100.000 mq in scala 1:500 e di un edificio in dettaglio 1:200. Date le tempistiche molto ridotte del corso, che si completava in tredici settimane, abbiamo scelto di continuare il lavoro e approfondire, con l’aiuto della prof.ssa V. Orioli e dell’arch. E. Brighi, l’elaborazione del masterplan arrivando ad una definizione maggiore di tutta l’area e non solamente delle aree di interesse approfondite durante la permanenza in Turchia. Il progetto presentato è quindi il frutto di un anno di lavoro sulla riqualificazione di un area di 150 ettari precedentemente adibita a discarica, situata nella parte occidentale di Istanbul. L’obiettivo che abbiamo perseguito è stato quello di ricreare nella periferia della metropoli turca uno stralcio di città con caratteri più “europei”, comprendendo in un solo grande ambito di progetto tutte le funzioni necessarie alla vita di un quartiere cittadino ma anche le grandi strutture attrattive richieste dal concorso. Durante il nostro percorso abbiamo cercato anche di non perdere di vista il contesto in cui lavoravamo e le abitudini della società turca con cui ci andavamo a confrontare. Nonostante la forte occidentalizzazione delle zone ricche delle grandi città come Istanbul, Ankara e Izmir, gli stili di vita europeo e turco sono fondamentalmente differenti e progettare una città, o uno stralcio di essa, per un popolo diverso necessita la conoscenza dei suoi valori fondamentali e delle abitudini che ne scandiscono le giornate.

Iterative regularization methods for ill-posed problems

This Ph.D thesis focuses on iterative regularization methods for regularizing linear and nonlinear ill-posed problems. Regarding linear problems, three new stopping rules for the Conjugate Gradient method applied to the normal equations are proposed and tested in many numerical simulations, including some tomographic images reconstruction problems. Regarding nonlinear problems, convergence and convergence rate results are provided for a Newton-type method with a modified version of Landweber iteration as an inner iteration in a Banach space setting.