Nosocomial infections and their relationship to non-traditional risk factors in a medical intensive care unit

Background. Nosocomial infections are a source of concern for many hospitals in the United States and worldwide. These infections are associated with increased morbidity, mortality and hospital costs. Nosocomial infections occur in ICUs at a rate which is five times greater than those in general wards. Understanding the reasons for the higher rates can ultimately help reduce these infections. The literature has been weak in documenting a direct relationship between nosocomial infections and non-traditional risk factors, such as unit staffing or patient acuity.^ Objective. To examine the relationship, if any, between nosocomial infections and non-traditional risk factors. The potential non-traditional risk factors we studied were the patient acuity (which comprised of the mortality and illness rating of the patient), patient days for patients hospitalized in the ICU, and the patient to nurse ratio.^ Method. We conducted a secondary data analysis on patients hospitalized in the Medical Intensive Care Unit (MICU) of the Memorial Hermann- Texas Medical Center in Houston during the months of March 2008- May 2009. The average monthly values for the patient acuity (mortality and illness Diagnostic Related Group (DRG) scores), patient days for patients hospitalized in the ICU and average patient to nurse ratio were calculated during this time period. Active surveillance of Bloodstream Infections (BSIs), Urinary Tract Infections (UTIs) and Ventilator Associated Pneumonias (VAPs) was performed by Infection Control practitioners, who visited the MICU and performed a personal infection record for each patient. Spearman's rank correlation was performed to determine the relationship between these nosocomial infections and the non-traditional risk factors.^ Results. We found weak negative correlations between BSIs and two measures (illness and mortality DRG). We also found a weak negative correlation between UTI and unit staffing (patient to nurse ratio). The strongest positive correlation was found between illness DRG and mortality DRG, validating our methodology.^ Conclusion. From this analysis, we were able to infer that non-traditional risk factors do not appear to play a significant role in transmission of infection in the units we evaluated.^

Posttraumatic stress disorder among veterans of the Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) wars: Psychological comorbidities, postdeployment social support and unit support

Much attention has been given to treating Operation Iraqi Freedom/Operation Enduring (OIF/OEF) Veterans with posttraumatic stress disorder (PTSD). However, little attention is given to those Veterans who do not meet diagnostic criteria for PTSD but who may still benefit from intervention. Research is needed to investigate the impact of how different racial/ethnic backgrounds, different levels of social support and comorbid mental health disorders impact OIF/OEF Veterans with varying levels of PTSD. The purpose of this dissertation is to examine the association of comorbid Axis I disorders, race/ethnicity, different levels of postdeployment social support and unit support on OIF/OEF Veterans with varying levels of PTSD. Data for this dissertation were from postdeployment screenings of OIF/OEF Veterans from a large Veterans Affairs hospital in southeast Texas. To examine the study hypotheses, we conducted multinomial logistic regressions of the clinician reported data. ^ The first article examined the prevalence of subthreshold and full levels of PTSD and compared Axis I and alcohol use comorbidity rates among 1,362 OIF/OEF Veterans with varying levels of PTSD. Results suggest that OIF/OEF Veterans with subthreshold PTSD experience similar levels of psychological distress as those with full PTSD and highlight the need to provide timely and appropriate mental health services to individuals who may not meet the diagnostic criteria for full PTSD. ^ These results suggest that OIF/OEF Veterans of all race/ethnicities can benefit from strong social support systems. Postdeployment social support was found to be a protective factor against the development of PTSD among White, Black and Hispanic veterans while deployment unit support was a protective factor only among Black Veterans. The second article investigated the association between postdeployment social support and unit support with varying levels of PTSD by race/ethnicity among 1,115 OIF/OEF Veterans. ^ The results of this study can help to formulate treatment and interventions for OIF/OEF Veterans with varying levels of PTSD and social support systems.^

TIME SERIES ANALYSIS AS INPUT FOR PREDICTIVE MODELING: PREDICTING CARDIAC ARREST IN A PEDIATRIC INTENSIVE CARE UNIT

The first manuscript, entitled "Time-Series Analysis as Input for Clinical Predictive Modeling: Modeling Cardiac Arrest in a Pediatric ICU" lays out the theoretical background for the project. There are several core concepts presented in this paper. First, traditional multivariate models (where each variable is represented by only one value) provide single point-in-time snapshots of patient status: they are incapable of characterizing deterioration. Since deterioration is consistently identified as a precursor to cardiac arrests, we maintain that the traditional multivariate paradigm is insufficient for predicting arrests. We identify time series analysis as a method capable of characterizing deterioration in an objective, mathematical fashion, and describe how to build a general foundation for predictive modeling using time series analysis results as latent variables. Building a solid foundation for any given modeling task involves addressing a number of issues during the design phase. These include selecting the proper candidate features on which to base the model, and selecting the most appropriate tool to measure them. We also identified several unique design issues that are introduced when time series data elements are added to the set of candidate features. One such issue is in defining the duration and resolution of time series elements required to sufficiently characterize the time series phenomena being considered as candidate features for the predictive model. Once the duration and resolution are established, there must also be explicit mathematical or statistical operations that produce the time series analysis result to be used as a latent candidate feature. In synthesizing the comprehensive framework for building a predictive model based on time series data elements, we identified at least four classes of data that can be used in the model design. The first two classes are shared with traditional multivariate models: multivariate data and clinical latent features. Multivariate data is represented by the standard one value per variable paradigm and is widely employed in a host of clinical models and tools. These are often represented by a number present in a given cell of a table. Clinical latent features derived, rather than directly measured, data elements that more accurately represent a particular clinical phenomenon than any of the directly measured data elements in isolation. The second two classes are unique to the time series data elements. The first of these is the raw data elements. These are represented by multiple values per variable, and constitute the measured observations that are typically available to end users when they review time series data. These are often represented as dots on a graph. The final class of data results from performing time series analysis. This class of data represents the fundamental concept on which our hypothesis is based. The specific statistical or mathematical operations are up to the modeler to determine, but we generally recommend that a variety of analyses be performed in order to maximize the likelihood that a representation of the time series data elements is produced that is able to distinguish between two or more classes of outcomes. The second manuscript, entitled "Building Clinical Prediction Models Using Time Series Data: Modeling Cardiac Arrest in a Pediatric ICU" provides a detailed description, start to finish, of the methods required to prepare the data, build, and validate a predictive model that uses the time series data elements determined in the first paper. One of the fundamental tenets of the second paper is that manual implementations of time series based models are unfeasible due to the relatively large number of data elements and the complexity of preprocessing that must occur before data can be presented to the model. Each of the seventeen steps is analyzed from the perspective of how it may be automated, when necessary. We identify the general objectives and available strategies of each of the steps, and we present our rationale for choosing a specific strategy for each step in the case of predicting cardiac arrest in a pediatric intensive care unit. Another issue brought to light by the second paper is that the individual steps required to use time series data for predictive modeling are more numerous and more complex than those used for modeling with traditional multivariate data. Even after complexities attributable to the design phase (addressed in our first paper) have been accounted for, the management and manipulation of the time series elements (the preprocessing steps in particular) are issues that are not present in a traditional multivariate modeling paradigm. In our methods, we present the issues that arise from the time series data elements: defining a reference time; imputing and reducing time series data in order to conform to a predefined structure that was specified during the design phase; and normalizing variable families rather than individual variable instances. The final manuscript, entitled: "Using Time-Series Analysis to Predict Cardiac Arrest in a Pediatric Intensive Care Unit" presents the results that were obtained by applying the theoretical construct and its associated methods (detailed in the first two papers) to the case of cardiac arrest prediction in a pediatric intensive care unit. Our results showed that utilizing the trend analysis from the time series data elements reduced the number of classification errors by 73%. The area under the Receiver Operating Characteristic curve increased from a baseline of 87% to 98% by including the trend analysis. In addition to the performance measures, we were also able to demonstrate that adding raw time series data elements without their associated trend analyses improved classification accuracy as compared to the baseline multivariate model, but diminished classification accuracy as compared to when just the trend analysis features were added (ie, without adding the raw time series data elements). We believe this phenomenon was largely attributable to overfitting, which is known to increase as the ratio of candidate features to class examples rises. Furthermore, although we employed several feature reduction strategies to counteract the overfitting problem, they failed to improve the performance beyond that which was achieved by exclusion of the raw time series elements. Finally, our data demonstrated that pulse oximetry and systolic blood pressure readings tend to start diminishing about 10-20 minutes before an arrest, whereas heart rates tend to diminish rapidly less than 5 minutes before an arrest.

Petrology and geochemistry of sedimentary Unit III of ODP Hole 135-840B

The sedimentary sequence recovered at Site 840, on the Tonga frontal-arc platform, is 597.3 m thick and is subdivided into three lithostratigraphic units. The lowermost, late Miocene Unit III is 336.8 m thick and consists of a sequence of volcaniclastic mass-flow deposits (predominantly turbidites) interbedded with pelagic/hemipelagic deposits. Unit III was deposited in the forearc basin of the Lau volcanic arc, probably on a slope dominated by mass flows that built eastward from the ridge front and across the forearc. Upward through the unit a thinning and fining of individual turbidites takes place, interpreted to reflect a reduced sediment supply and a change from large to smaller flows. Decreasing volcanic activity with time is inferred from a decrease in coarse-grained volcaniclastic content in the upper part of the unit. The majority of the turbidites show the typical Bouma-type divisions, although both high- and low-density turbidity currents are inferred. High-density turbidity currents were especially common in the lower part of the unit. Geochemical analyses of detrital glass lie mainly in the low-K tholeiite field with a compositional range from basalt to rhyolite. A coherent igneous trend indicates derivation from a single volcanic source. This source was probably situated on the rifted part of the Lau-Tonga Ridge, within the present Lau backarc basin. The initial opening of the Lau Basin may have been around 6.0 m.y. ago. The onset of more extensive rifting, approximately 5.6 m.y. ago, is reflected in an increase in the silica content of volcanic glass. At the boundary toward Unit II, at approximately 5.25 Ma, an influx of thicker bedded and coarser grained volcaniclastic material is interpreted to reflect increasing volcanism and tectonism during the final breakup of the Lau-Tonga Ridge.

Major oxides, trace elements and rare earth elements of selected basalt samples at DSDP Hole 83-504B

DSDP Hole 504B is the deepest section drilled into oceanic basement, penetrating through a 571.5-m lava pile and a 209-m transition zone of lavas and dikes into 295 m of a sheeted dike complex. To define the basement composition 194 samples of least altered basalts, representing all lithologic units, were analyzed for their major and 26 trace elements. As is evident from the alteration-sensitive indicators H2O+, CO2, S, K, Mn, Zn, Cu, and the iron oxidation ratio, all rocks recovered are chemically altered to some extent. Downhole variation in these parameters enables us to distinguish five depth-related alteration zones that closely correlate with changes in alteration mineralogy. Alteration in the uppermost basement portion is characterized by pronounced K-uptake, sulfur loss, and iron oxidation and clearly demonstrates low-temperature seawater interaction. A very spectacular type of alteration is confined to the depth range from 910 to 1059 m below seafloor (BSF). Rocks from this basement portion exhibit the lowest iron oxidation, the highest H2O+ contents, and a considerable enrichment in Mn, S, Zn, and Cu. At the top of this zone a stockwork-like sulfide mineralization occurs. The chemical data suggest that this basement portion was at one time within a hydrothermal upflow zone. The steep gradient in alteration chemistry above this zone and the ore precipitation are interpreted as the result of mixing of the upflowing hydrothermal fluids with lower-temperature solutions circulating in the lava pile. Despite the chemical alteration the primary composition and variation of the rocks can be reliably established. All data demonstrate that the pillow lavas and the dikes are remarkably uniform and display almost the same range of variation. A general characteristic of the rocks that classify as olivine tholeiites is their high MgO contents (up to 10.5 wt.%) and their low K abundances (-200 ppm). According to their mg-values, which range from 0.60 to 0.74, most basalts appear to have undergone some high-level crystal fractionation. Despite the overall similarity in composition, there are two major basalt groups that have significantly different abundances and ratios of incompatible elements at similar mg-values. The majority of the basalts from the pillow lava and dike sections are chemically closely related, and most probably represent differentiation products of a common parental magma. They are low in Na2O, TiO2, and P2O5, and very low in the more hygromagmaphile elements. Interdigitated with this basalt group is a very rarely occurring basalt that is higher in Na2O, TiO2, P2O5, much less depleted in hygromagmaphile elements, and similar to normal mid-ocean ridge basalt (MORB). The latter is restricted to Lithologic Units 5 and 36 of the pillow lava section and Lithologic Unit 83 of the dike section. The two basalt groups cannot be related by differentiation processes but have to be regarded as products of two different parental magmas. The compositional uniformity of the majority of the basalts suggests that the magma chamber beneath the Costa Rica Rift reached nearly steady-state conditions. However, the presence of lavas and dikes that crystallized from a different parental magma requires the existence of a separate conduit-magma chamber system for these melts. Occasionally mixing between the two magma types appears to have occurred. The chemical characteristics of the two magma types imply some heterogeneity in the mantle source underlying the Costa Rica Rift. The predominant magma type represents an extremely depleted source, whereas the rare magma type presumably originated from regions of less depleted mantle material (relict or affected by metasomatism).

Elements and isotopic measurements of magmatic rock samples from ODP Hole 104-642E

Trace element and isotopic signatures of magmatic rock samples from ODP Hole 642E at the Vøring Plateau provide insight into the interaction processes of mantle melt with crust during the initial magma extrusion phases at the onset of the continental breakup. The intermediate (basaltic-andesitic) to felsic (dacitic and rhyolitic) Lower Series magmas at ODP Hole 642E appear to be produced by large amounts of melting of upper crustal material. This study not only makes use of the traditional geochemical tools to investigate crust-mantle interaction, but also explores the value of Cs geochemistry as an additional tool. The element Cs forms the largest lithophile cation, and shows the largest contrast in concentration between (depleted) mantle and continental crust. As such it is a very sensitive indicator of involvement of crustal material. The Cs data reinforce the conclusion drawn from isotopic signatures that the felsic magmas are largely anatectic crustal melts. The down-hole geochemical variation within ODP Hole 642E defines a decreasing continental crustal influence from the Lower Series into the Upper Series. This is essential information to distinguish intrinsic geochemical properties of the mantle melts from signatures imposed by crustal contamination. A comparison with data from the SE Greenland margin highlights the compositional asymmetry of the crust-mantle interactions at both sides of the paleo-Iapetus suture. While Lower Series and Middle Series rocks from the SE Greenland margin have isotopic signatures reflecting interactions with lower and middle crust, such signatures have not been observed at the mid-Norwegian margin. The geochemical data either point to a dissimilar Caledonian crustal composition and/or to different geodynamic pre-breakup rifting history at the two NE Atlantic margin segments.

Ordinary and duplicate analysis from major and trace elements of ODP Holes 146-888B and 168-1027B

Oceanic sediments deposited at high rate close to continents are dominated by terrigenous material. Aside from dilution by biogenic components, their chemical compositions reflect those of nearby continental masses. This study focuses on oceanic sediments coming from the juvenile Canadian Cordillera and highlights systematic differences between detritus deriving from juvenile crust and detritus from old and mature crust. We report major and trace element concentrations for 68 sediments from the northernmost part of the Cascade forearc, drilled at ODP Sites 888 and 1027. The calculated weighted averages for each site can then be used in the future to quantify the contribution of subducted sediments to Cascades volcanism. The two sites have similar compositions but Site 888, located closer to the continent, has higher sandy turbidite contents and displays higher bulk SiO2/Al2O3 with lower bulk Nb/Zr, attributed to the presence of zircons in the coarse sands. Comparison with published data for other oceanic sedimentary piles demonstrates the existence of systematic differences between modern sediments deriving from juvenile terranes (juvenile sediments) and modern sediments derived from mature continental areas (cratonic sediments). The most striking systematic difference is for Th/Nb, Th/U, Nb/U and Th/Rb ratios: juvenile sediments have much lower ratios than cratonic sediments. The small enrichment of Th over Nb in cratonic sediments may be explained by intracrustal magmatic and metamorphic differentiation processes. In contrast, their elevated Th/U and Nb/U ratios (average values of 6.87 and 7.95, respectively) in comparison to juvenile sediments (Th/U ~ 3.09, Nb/U ~ 5.15) suggest extensive U and Rb losses on old cratons. Uranium and Rb losses are attributed to long-term leaching by rain and river water during exposure of the continental crust at the surface. Over geological times, the weathering effects create a slow but systematic increase of Th/U with exposure time.

Lignin, phenols, and some chemical elements in aerosols and bottom sediments from the Tropical North Atlantic

A study of composition of biomarkers (lignin and phenols) in aerosols and bottom sediments from the Tropical North Atlantic was carried out. It was shown that organic matter of aerosols was mostly composed of products of terrestrial plants (arboreal fibers, pollen, and spores). Biomarker composition in the aerosols and in the bottom sediments was practically similar, which proved delivery of terrigenous organic matter to the ocean via the atmosphere.

(Table 1) Major and trace elements of basalts at DSDP Hole 72-516F

The geochemistry of basalts recovered during Leg 72 is described with emphasis on trace elements. Only Hole 516F penetrated basement; the basalts recovered are plagioclase-phyric and olivine-phyric and pervasively altered. Chemically, the basalts from Hole 516F are rather uniform in composition. However, four distinct geochemical units can be recognized, although the chemistry of two of the units appears to be controlled by chemical mobility associated with alteration. The two less-altered units cannot be related by fractional crystallization processes. Hole 516F basalts have a trace element chemistry characteristic of T-type mid-ocean ridge basalt; rare-earth element patterns (as indicated by Ce/Y ratios) are mildly fractionated flight rare-earth element enriched), and a number of incompatible element ratios are close to chondritic.