Fluid resuscitation practice patterns in intensive care units of the USA: a cross-sectional survey of critical care physicians.

BACKGROUND: Fluid resuscitation is a cornerstone of intensive care treatment, yet there is a lack of agreement on how various types of fluids should be used in critically ill patients with different disease states. Therefore, our goal was to investigate the practice patterns of fluid utilization for resuscitation of adult patients in intensive care units (ICUs) within the USA. METHODS: We conducted a cross-sectional online survey of 502 physicians practicing in medical and surgical ICUs. Survey questions were designed to assess clinical decision-making processes for 3 types of patients who need volume expansion: (1) not bleeding and not septic, (2) bleeding but not septic, (3) requiring resuscitation for sepsis. First-choice fluid used in fluid boluses for these 3 patient types was requested from the respondents. Descriptive statistics were performed using a Kruskal-Wallis test to evaluate differences among the physician groups. Follow-up tests, including t tests, were conducted to evaluate differences between ICU types, hospital settings, and bolus volume. RESULTS: Fluid resuscitation varied with respect to preferences for the factors to determine volume status and preferences for fluid types. The 3 most frequently preferred volume indicators were blood pressure, urine output, and central venous pressure. Regardless of the patient type, the most preferred fluid type was crystalloid, followed by 5 % albumin and then 6 % hydroxyethyl starches (HES) 450/0.70 and 6 % HES 600/0.75. Surprisingly, up to 10 % of physicians still chose HES as the first choice of fluid for resuscitation in sepsis. The clinical specialty and the practice setting of the treating physicians also influenced fluid choices. CONCLUSIONS: Practice patterns of fluid resuscitation varied in the USA, depending on patient characteristics, clinical specialties, and practice settings of the treating physicians.

Morphological and Phylogenetic Characterization of New Gephyrocapsa Isolates Suggests Introgressive Hybridization in the Emiliania/Gephyrocapsa Complex (Haptophyta)

The coccolithophore genus Gephyrocapsa contains a cosmopolitan assemblage of pelagic species, including the bloom-forming Gephyrocapsa oceanica, and is closely related to the emblematic coccolithophore Emiliania huxleyi within the Noëlaerhabdaceae. These two species have been extensively studied and are well represented in culture collections, whereas cultures of other species of this family are lacking. We report on three new strains of Gephyrocapsa isolated into culture from samples from the Chilean coastal upwelling zone using a novel flow cytometric single-cell sorting technique. The strains were characterized by morphological analysis using scanning electron microscopy and phylogenetic analysis of 6 genes (nuclear 18S and 28S rDNA, plastidial 16S and tufA, and mitochondrial cox1 and cox3 genes). Morphometric features of the coccoliths indicate that these isolates are distinct from G. oceanica and best correspond to G. muellerae. Surprisingly, both plastidial and mitochondrial gene phylogenies placed these strains within the E. huxleyi clade and well separated from G. oceanica isolates, making Emiliania appear polyphyletic. The only nuclear sequence difference, 1 bp in the 28S rDNA region, also grouped E. huxleyi with the new Gephyrocapsa isolates and apart from G. oceanica. Specifically, the G. muellerae morphotype strains clustered with the mitochondrial β clade of E. huxleyi, which, like G. muellerae, has been associated with cold (temperate and sub-polar) waters. Among putative evolutionary scenarios that could explain these results we discuss the possibility that E. huxleyi is not a valid taxonomic unit, or, alternatively the possibility of past hybridization and introgression between each E. huxleyi clade and older Gephyrocapsa clades. In either case, the results support the transfer of Emiliania to Gephyrocapsa. These results have important implications for relating morphological species concepts to ecological and evolutionary units of diversity.

Morphological and Phylogenetic Characterization of New Gephyrocapsa Isolates Suggests Introgressive Hybridization in the Emiliania/Gephyrocapsa Complex (Haptophyta)

The coccolithophore genus Gephyrocapsa contains a cosmopolitan assemblage of pelagic species, including the bloom-forming Gephyrocapsa oceanica, and is closely related to the emblematic coccolithophore Emiliania huxleyi within the Noëlaerhabdaceae. These two species have been extensively studied and are well represented in culture collections, whereas cultures of other species of this family are lacking. We report on three new strains of Gephyrocapsa isolated into culture from samples from the Chilean coastal upwelling zone using a novel flow cytometric single-cell sorting technique. The strains were characterized by morphological analysis using scanning electron microscopy and phylogenetic analysis of 6 genes (nuclear 18S and 28S rDNA, plastidial 16S and tufA, and mitochondrial cox1 and cox3 genes). Morphometric features of the coccoliths indicate that these isolates are distinct from G. oceanica and best correspond to G. muellerae. Surprisingly, both plastidial and mitochondrial gene phylogenies placed these strains within the E. huxleyi clade and well separated from G. oceanica isolates, making Emiliania appear polyphyletic. The only nuclear sequence difference, 1 bp in the 28S rDNA region, also grouped E. huxleyi with the new Gephyrocapsa isolates and apart from G. oceanica. Specifically, the G. muellerae morphotype strains clustered with the mitochondrial β clade of E. huxleyi, which, like G. muellerae, has been associated with cold (temperate and sub-polar) waters. Among putative evolutionary scenarios that could explain these results we discuss the possibility that E. huxleyi is not a valid taxonomic unit, or, alternatively the possibility of past hybridization and introgression between each E. huxleyi clade and older Gephyrocapsa clades. In either case, the results support the transfer of Emiliania to Gephyrocapsa. These results have important implications for relating morphological species concepts to ecological and evolutionary units of diversity.

Energy efficient measures to reduce electrical energy use in commercial buildings in New York City

GEA Consulting Engineers, acting as the design engineers, was hired by the owner, East Village 207 Residential LLC2 for energy modeling for compliance with LEED NC V3 -- This report details the results of the energy simulation done with the 100% construction documents -- This report only refers to entities within the LEED3 project boundary -- The project consists of a new eight-story high-end residential condominium building with 81 units, as shown in illustration 1, and approximately 117,905 GSF, equivalent to 10,953.73 m2, is located at 211 E 13th Street in New York, NY -- The residential portion of the building will function 24-7 -- The design goal is to utilize energy efficient measures to reduce electrical energy use and aims to achieve LEED certification -- LEED EA Credit 14 requires a building to demonstrate a percentage improvement in the proposed building performance compared with the baseline building -- The Credit rewards 1 point for achieving 12% reduction in energy costs -- Additionally, the Credit rewards another point for each subsequent reduction of 2% in the building’s energy cost

National parks in greater New York City /

Covers Manhattan and adjacent districts.

National parks in greater New York City /

"*GPO: 1994--301-085/00060. Reprint 1993."

National parks in greater New York City /

"*GPO: 1997--417-648/60121. Reprint 1997."

National parks in greater New York City /

"*GPO:2000--460-976/00285. Reprint 1997."

National parks in greater New York City /

"*GPO:2005--310-394/00396. Reprint 2005."

Experiences of health professionals with nutritional support of critically ill patients in tertiary hospitals in Malawi

Background Nutritional support is a recognized determinant of outcome in critically ill patients. Development of critical care services in low-income countries has not been accompanied by certain appropriate ancillary services and interventions, such as adequate nutritional support. This study was designed to investigate the experiences of health professionals who have provided nutritional supportive care to critically ill patients admitted to two major central hospitals in Malawi, with the aim of identifying the common practices in nutritional support in these settings. Materials and Methods A cross-sectional study in which 50 health professionals working in intensive care and high dependency units, admitting both adult and pediatric patients, were interviewed using a semi-structured questionnaire. Data were coded and then analyzed using SPSS version 16.0. Responses between the two hospitals were compared using Fisher’s exact test. Results There was no difference in the composition of respondents from the two hospitals. About 60% of respondents had had experience with nutritional supplementation in their patients—mainly enteral. The most commonly used formulations were the “ready-to-use therapeutic feeds,” followed by modified milk. A high percentage of respondents (40%) reported having used dextrose solution as the sole nutritional supplement. Lack of in-service training, nonexistent nutrition protocols pertaining to acutely and critically ill patients, and a lack of clinical nutritionists were the major challenges identified. Conclusion Knowledge of nutrient supplementation was poor among the respondents. The use of ready-to-use therapeutic feeds was quite common, although there is no evidence of its effectiveness in care of acutely critically ill patients. There is a need to establish nutritional support teams in these tertiary hospitals. Clinical nutritionists would ideally help train and play leadership roles in such teams, who would be responsible for assessing patients for their nutritional needs, and ensuring that the feeds provided to patients are appropriate and adequate for their needs.

Is cost-related non-collection of prescriptions associated with a reduction in health? Findings from a large-scale longitudinal study of New Zealand adults

OBJECTIVE: To investigate whether cost-related non-collection of prescription medication is associated with a decline in health. SETTINGS: New Zealand Survey of Family, Income and Employment (SoFIE)-Health. PARTICIPANTS: Data from 17 363 participants with at least two observations in three waves (2004-2005, 2006-2007, 2008-2009) of a panel study were analysed using fixed effects regression modelling. PRIMARY OUTCOME MEASURES: Self-rated health (SRH), physical health (PCS) and mental health scores (MCS) were the health measures used in this study. RESULTS: After adjusting for time-varying confounders, non-collection of prescription items was associated with a 0.11 (95% CI 0.07 to 0.15) unit worsening in SRH, a 1.00 (95% CI 0.61 to 1.40) unit decline in PCS and a 1.69 (95% CI 1.19 to 2.18) unit decline in MCS. The interaction of the main exposure with gender was significant for SRH and MCS. Non-collection of prescription items was associated with a decline in SRH of 0.18 (95% CI 0.11 to 0.25) units for males and 0.08 (95% CI 0.03 to 0.13) units for females, and a decrease in MCS of 2.55 (95% CI 1.67 to 3.42) and 1.29 (95% CI 0.70 to 1.89) units for males and females, respectively. The interaction of the main exposure with age was significant for SRH. For respondents aged 15-24 and 25-64 years, non-collection of prescription items was associated with a decline in SRH of 0.12 (95% CI 0.03 to 0.21) and 0.12 (95% CI 0.07 to 0.17) units, respectively, but for respondents aged 65 years and over, non-collection of prescription items had no significant effect on SRH. CONCLUSION: Our results show that those who do not collect prescription medications because of cost have an increased risk of a subsequent decline in health.

Engineering fundamentals in a new undergraduate curriculum

CONTEXTIn recent years there has been a push in Engineering education to change the basic model fromstudents learning discrete subjects, followed by design projects in third and fourth year, to learningand practicing the design process from the first year. At the same time, there has also been a pushtowards “active learning” (Prince, 2004) as opposed to the more traditional lecture/tutorial/practicalapproach. This year, Deakin University has launched a new design-centred curriculum inundergraduate engineering. Named “Project-Oriented Design-Based Learning” (PODBL), the newcourse structure is running in first and second years. In semester one of first year in the new course,students enrol in one double-unit of design, one unit of maths, and one unit of fundamental science.PURPOSEThis work seeks to determine whether a new fundamental-science unit called “EngineeringFundamentals” fulfils the educational needs of first-year students in the PODBL curriculum. It alsoseeks to determine student perceptions of the new unit.APPROACHThe unit was first offered in semester-one, 2016 to two separate on-campus cohorts and an offcampuscohort. Innovations in this unit include using the CADET model for teaching combinedpractical-tutorial seminars, a shift in lectures from delivering conceptual content to teaching problemsolving and applications (flipping the classroom), and extensive use of online videos and study guidesfor delivering primary content (Cloud Learning). Student learning was assessed by means of problembasedonline quizzes, practical reports, and a final exam. Student perceptions were queried by astandard unit-evaluation system and by a more focussed set of surveys given to students in threeseparate cohorts.RESULTSThe academic results in this unit were compared with those in the previous unit. No substantialdifferences were observed in the marks of this unit in 2016 compared with the 2015 marks of thecorresponding previous physics unit. On-campus students showed more general satisfaction with theunit than did off-campus students. However, not all on-campus students were happy with the flippedclassroommodel.CONCLUSIONSAs the course changes from a traditional approach to a design and project-based approach, it is best ifall units in the course adapt in some way to the new teaching style. Not all units need be completelyproject or design based. In the case of “Engineering Fundamentals,” we believe that due to the widevariety of topics covered, making the entire unit design-based is inappropriate. However, some designand project components can be built into the unit via the practicals. Semester one 2016 was asuccessful first offering of the unit. We recommend that in future years a design/project component beconsidered for the unit’s practicals.

Length of Stay in Intensive Care Units - A Case Base Evaluation

As a matter of fact, an Intensive Care Unit (ICU) stands for a hospital facility where patients require close observation and monitoring. Indeed, predicting Length-of-Stay (LoS) at ICUs is essential not only to provide them with improved Quality-of-Care, but also to help the hospital management to cope with hospital resources. Therefore, in this work one`s aim is to present an Artificial Intelligence based Decision Support System to assist on the prediction of LoS at ICUs, which will be centered on a formal framework based on a Logic Programming acquaintance for knowledge representation and reasoning, complemented with a Case Based approach to computing, and able to handle unknown, incomplete, or even contradictory data, information or knowledge.

NEW DATA ON THE CHRONOLOGY OF THE VALE DO FORNO SEDIMENTARY SEQUENCE (LOWER TAGUS RIVER TERRACE STAIRCASE) AND ITS RELEVANCE AS FLUVIAL ARCHIVE OF THE MIDDLE PLEISTOCENE IN WESTERN IBERIA

NEW DATA ON THE CHRONOLOGY OF THE VALE DO FORNO SEDIMENTARY SEQUENCE (LOWER TAGUS RIVER TERRACE STAIRCASE) AND ITS RELEVANCE AS FLUVIAL ARCHIVE OF THE MIDDLE PLEISTOCENE IN WESTERN IBERIA Pedro P. Cunha 1, António A. Martins 2, Jan-Pieter Buylaert 3,4, Andrew S. Murray 4, Luis Raposo 5, Paolo Mozzi 6, Martin Stokes 7 1 MARE - Marine and Environmental Sciences Centre, Department of Earth Sciences, University of Coimbra, Portugal: pcunha@dct.uc.pt 2 MARE - Marine and Environmental Sciences Centre, Dep. Geociências, University of Évora, Portugal; aam@uevora.pt 3 Centre for Nuclear Technologies, Technical University of Denmark, Risø Campus, Denmark; jabu@dtu.dk 4 Nordic Laboratory for Luminescence Dating, Aarhus University, Risø DTU, Denmark; anmu@dtu.dk 5 Museu Nacional de Arqueologia, Lisboa, Portugal; 3raposos@sapo.pt 6 Department of Geosciences, University of Padova, Italy; paolo.mozzi@unipd.it 7 School of Geography, Earth and Environmental Sciences, University of Plymouth, UK; m.stokes@plymouth.ac.uk The stratigraphic units that record the evolution of the Tagus River in Portugal (study area between Vila Velha de Ródão and Porto Alto villages; Fig. 1) have different sedimentary characteristics and lithic industries (Cunha et al., 2012): - a culminant sedimentary unit (the ancestral Tagus, before the drainage network entrenchment) – SLD13 (+142 to 262 m above river bed – a.r.b.; with probable age ca. 3,6 to 1,8 Ma), without artefacts; - T1 terrace (+84 to 180 m; ca. 1000? to 900 ka), without artefacts; - T2 terrace (+57 to 150 m; top deposits with a probable age ca. 600 ka), without artefacts; - T3 terrace (+43 to 113 m; ca. 460 to 360? ka), without artefacts; - T4 terrace (+26 to 55 m; ca. 335 a 155 ka), Lower Paleolithic (Acheulian) at basal and middle levels but early Middle Paleolithic at top levels; - T5 terrace (+5 to 34 m; 135 to 73 ka), Middle Paleolithic (Mousterian; Levallois technique); - T6 terrace (+3 to 14 m; 62 to 32 ka), late Middle Paleolithic (late Mousterian); - Carregueira Sands (aeolian sands) and colluvium (+3 a ca. 100 m; 32 to 12 ka), Upper Paleolithic to Epipaleolithic; - alluvial plain (+0 to 8 m; ca. 12 ka to present), Mesolithic and more recent industries. The differences in elevation (a.r.b.) of the several terrace staircases results from differential uplift due to active faults. Longitudinal correlation with the terrace levels indicates that a graded profile ca. 200 km long was achieved during terrace formation periods and a strong control by sea base level was determinant for terrace formation. The Neogene sedimentary units constituted the main source of sediments for the fluvial terraces (Fig. 2). Geomorphological mapping, coupled with lithostratigraphy, sedimentology and luminescence dating (quartz-OSL and K-feldspar post-IRIR290) were used in this study focused on the T4 terrace, which comprises a Lower Gravels (LG) unit and an Upper Sand (US) unit. The thick, coarse and dominantly massive gravels of the LG unit indicate deposition by a coarse bed-load braided river, with strong sediment supply, high gradient and fluvial competence, during conditions of rapidly rising sea level. Luminescence dating only provided minimum ages but it is probable that the LG unit corresponds to the earlier part of the MIS9 (ca. 335 to 325 ka), immediately postdating the incision promoted by the very low sea level (reaching ca. -140 m) during MIS10 (362 to 337 ka), a period of relatively cold climate conditions with weak vegetation cover on slopes and low sea level. Fig. 1. Main Portuguese reaches in which the Tagus River can be divided (Lower Tagus Basin): I – from the Spanish border to Arneiro (a general E–W trend, mainly consisting of polygonal segments); II – from Arneiro to Gavião (NE–SW); III – from Gavião to Arripiado (E–W); IV – from Arripiado to Vila Franca de Xira (NNE-SSW); V – from Vila Franca de Xira to the Atlantic shoreline. The faults considered to be the limit of the referred fluvial sectors are: F1 – Ponsul-Arneiro fault (WSW-ENE); F2 – Gavião fault (NW-SE); F3 – Ortiga fault (NW-SE); F4 – Vila Nova da Barquinha fault (W-E); F5 – Arripiado-Chamusca fault (NNE-SSW). 1 – estuary; 2 – terraces; 3 – faults; 4 – Tagus main channel. The main Iberian drainage basins are also represented (inset). The lower and middle parts of the US unit, comprising an alternation of clayish silts with paleosols and minor sands to the east (flood-plain deposits) and sand deposits to the west (channel belt), have a probable age of ca. 325 to 200 ka. This points to formation during MIS9 to MIS7, under conditions of high to medium sea levels and warm to mild conditions. The upper part of the US unit, dominated by sand facies and with OSL ages of ca. 200 to 154 ka, correlates with the early part of the MIS6. During this period, progradation resulted from climate deterioration and relative depletion of vegetation that promoted enhanced sediment production in the catchment, coupled with initiation of sea-level lowering that increased the longitudinal slope. The Vale do Forno and Vale da Atela archaeological sites (Alpiarça, central Portugal) document the earliest human occupation in the Lower Tagus River, well established in geomorphological and environmental terms, within the Middle Pleistocene. The Lower Palaeolithic sites were found on the T4 terrace (+26 m, a.r.b.). The oldest artefacts previously found in the LG unit, display crude bifacial forms that can be attributed to the Acheulian, with a probable age of ca. 335 to 325 ka. The T4 US unit has archaeological sites stratigraphically documenting successive phases of an evolved Acheulian, that probably date ca. 325 to 300 ka. Notably, these Lower Palaeolithic artisans were able to produce tools with different sophistication levels, simply by applying different strategies: more elaborated reduction sequences in case of bifaces and simple reduction sequences to obtain cleavers. Fig. 2. . Simplified geologic map of the Lower Tagus Cenozoic basin, adapted from the Carta Geológica de Portugal, 1/500000, 1992). The study area (comprising the Vale do Forno and Vale de Atela sites) is located on the more upstream sector of the Lower Tagus River reach IV, between Arripiado and Chamusca villages. 1 – alluvium (Holocene); 2 – terraces (Pleistocene); 3 – sands, silts and gravels (Paleogene to Pliocene); 4 – Sintra Massif (Cretaceous); 5 – limestones, marls, silts and sandstones (Mesozoic); 6 – quartzites (Ordovician); 7 – basement (Proterozoic to Palaeozoic); 8 – main fault. The main Portuguese reaches of the Tagus River are identified (I to V). The VF3 site (Milharós), containing a Final Acheulian industry, with fine and elaborated bifaces) found in a stratigraphic level located between the T4 terrace deposits and a colluvium associated with Late Pleistocene aeolian sands (32 to 12 ka), has an age younger than ca. 154 ka but much older than 32 ka. In the study area, the sedimentary units of the T4 terrace seem to record the river response to sea-level changes and climatically-driven fluctuations in sediment supply. REFERENCES Cunha P. P., Almeida N. A. C., Aubry T., Martins A. A., Murray A. S., Buylaert J.-P., Sohbati R., Raposo L., Rocha L., 2012, Records of human occupation from Pleistocene river terrace and aeolian sediments in the Arneiro depression (Lower Tejo River, central eastern Portugal). Geomorphology, vol. 165-166, pp. 78-90.