Preventive and therapeutic strategies in critically ill patients with highly resistant bacteria.

The antibiotic pipeline continues to diminish and the majority of the public remains unaware of this critical situation. The cause of the decline of antibiotic development is multifactorial and currently most ICUs are confronted with the challenge of multidrug-resistant organisms. Antimicrobial multidrug resistance is expanding all over the world, with extreme and pandrug resistance being increasingly encountered, especially in healthcare-associated infections in large highly specialized hospitals. Antibiotic stewardship for critically ill patients translated into the implementation of specific guidelines, largely promoted by the Surviving Sepsis Campaign, targeted at education to optimize choice, dosage, and duration of antibiotics in order to improve outcomes and reduce the development of resistance. Inappropriate antimicrobial therapy, meaning the selection of an antibiotic to which the causative pathogen is resistant, is a consistent predictor of poor outcomes in septic patients. Therefore, pharmacokinetically/pharmacodynamically optimized dosing regimens should be given to all patients empirically and, once the pathogen and susceptibility are known, local stewardship practices may be employed on the basis of clinical response to redefine an appropriate regimen for the patient. This review will focus on the most severely ill patients, for whom substantial progress in organ support along with diagnostic and therapeutic strategies markedly increased the risk of nosocomial infections.

Glutamine and antioxidants in the critically ill patient: a post hoc analysis of a large-scale randomized trial.

BACKGROUND: The recent large randomized controlled trial of glutamine and antioxidant supplementation suggested that high-dose glutamine is associated with increased mortality in critically ill patients with multiorgan failure. The objectives of the present analyses were to reevaluate the effect of supplementation after controlling for baseline covariates and to identify potentially important subgroup effects. MATERIALS AND METHODS: This study was a post hoc analysis of a prospective factorial 2 × 2 randomized trial conducted in 40 intensive care units in North America and Europe. In total, 1223 mechanically ventilated adult patients with multiorgan failure were randomized to receive glutamine, antioxidants, both glutamine and antioxidants, or placebo administered separate from artificial nutrition. We compared each of the 3 active treatment arms (glutamine alone, antioxidants alone, and glutamine + antioxidants) with placebo on 28-day mortality. Post hoc, treatment effects were examined within subgroups defined by baseline patient characteristics. Logistic regression was used to estimate treatment effects within subgroups after adjustment for baseline covariates and to identify treatment-by-subgroup interactions (effect modification). RESULTS: The 28-day mortality rates in the placebo, glutamine, antioxidant, and combination arms were 25%, 32%, 29%, and 33%, respectively. After adjusting for prespecified baseline covariates, the adjusted odds ratio of 28-day mortality vs placebo was 1.5 (95% confidence interval, 1.0-2.1, P = .05), 1.2 (0.8-1.8, P = .40), and 1.4 (0.9-2.0, P = .09) for glutamine, antioxidant, and glutamine plus antioxidant arms, respectively. In the post hoc subgroup analysis, both glutamine and antioxidants appeared most harmful in patients with baseline renal dysfunction. No subgroups suggested reduced mortality with supplements. CONCLUSIONS: After adjustment for baseline covariates, early provision of high-dose glutamine administered separately from artificial nutrition was not beneficial and may be associated with increased mortality in critically ill patients with multiorgan failure. For both glutamine and antioxidants, the greatest potential for harm was observed in patients with multiorgan failure that included renal dysfunction upon study enrollment.

How patient-centered do female physicians need to be? Analogue patients' satisfaction with male and female physicians' identical behaviors (Published online: 30 Aug 2014)

Previous research suggests that female physicians may not receive appropriate credit in patients' eyes for their patient-centered skills compared to their male counterparts. An experiment was conducted to determine whether a performance of higher (versus lower) verbal patient-centeredness would result in a greater difference in analogue patient satisfaction for male than female physicians. Two male and two female actors portrayed physicians speaking to a patient using high or low patient-centered scripts while not varying their nonverbal cues. One hundred ninety-two students served as analogue patients by assuming the patient role while watching one of the videos and rating their satisfaction and other evaluative responses to the physician. Greater verbal patient-centeredness had a stronger positive effect on satisfaction and evaluations for male than for female physicians. This pattern is consistent with the hypothesis that the different associations between patient-centeredness and patients' satisfaction for male versus female physicians occur because of the overlap between stereotypical female behavior and behaviors that comprise patient-centered medical care. If this is the case, high verbal patient-centered behavior by female physicians is not recognized as a marker of clinical competence, as it is for male physicians, but is rather seen as expected female behavior.

Creating customer relationship management concept for engineering and service business

Customer relationship management has been one essential part of marketing for over 20 years. Today’s business environment is fast changing, international and highly competitive, and that is why the most important factor for long-term profitability is one-to-one customer relationships. However, managing relationships and serving customers that are profitable has been always challenging. In this thesis the objective was to define the main obstacles that the case company must overcome to succeed in CRM. Possible solutions have also been defined. The main elements of the implementation i.e. people, processes and technologies, can clearly be found behind these matters and solutions. This thesis also presents theoretical information about CRM and it is meant to act as a guide book inside the organisation to spread information about CRM for those who are not so familiar with the topic.

Metabolic and nutritional support of critically ill patients: consensus and controversies.

The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.

Change of Electricity Distribution Industry: Drivers and Opening Business Opportunities

As a result of the recent regulatory amendments and other development trends in the electricity distribution business, the sector is currently witnessing radical restructuring that will eventually impact the business logics of the sector. This report represents upcoming changes in the electricity distribution industry and concentrates on the factors that are expected to be the most fundamental ones. Electricity network companies nowadays struggle with legislative and regulatory requirements that focus on both the operational efficiency and the reliability of electricity distribution networks. The forces that have an impact on the distribution network companies can be put into three main categories that define the transformation at a general level. Those are: (1) a requirement for a more functional marketplace for energy, (2) environmental aspects (combating climate change etc.), and (3) a strongly emphasized requirement for the security of energy supply. The first point arises from the legislators’ attempt to increase competition in electricity retail markets, the second one concerns both environmental protection and human safety issues, and the third one indicates societies’ reduced willingness to accept interruptions in electricity supply. In the future, regulation of electricity distribution business may lower the threshold for building more weather-resistant networks, which in turn means increased underground cabling. This development pattern is reinforced by tightening safety and environmental regulations that ultimately make the overhead lines expensive to build and maintain. The changes will require new approaches particularly in network planning, construction, and maintenance. The concept for planning, constructing, and maintaining cable networks is necessary because the interdependencies between network operations are strong, in other words, the nature of the operation requires a linkage to other operations.

Chemical composition of volatiles from male and female specimens of Baccharis trimera collected in two distant regions of southern brazil: a comparative study using chemometrics

GC/MS/FID analyses of volatile compounds from cladodes and inflorescences from male and female specimens of Baccharis trimera (Less.) DC. collected in the states of Paraná and Santa Catarina, Brazil, showed that carquejyl acetate was the primary volatile component (38% to 73%), while carquejol and ledol were identified in lower concentrations. Data were subjected to hierarchical cluster analysis and principal component analysis, which confirmed that the chemical compositions of all samples were similar. The results presented here highlight the occurrence of the same chemotype of B. trimera in three southern states of Brazil.

Application of social media and ICT-tools in new and small business ventures.

The current research emphasizes on various questions raised and deliberated upon by different entrepreneurs. It provides a valuable contribution to comprehend the importance of social media and ICT-applications. Furthermore, it demonstrates how to support and implement the management consulting and business coaching start-ups with the help of social media and ICT-tools. The thesis presents a literary review from different information systems science, SME and e-business journals, web articles, as well as, survey analysis reports on social media applications. The methodology incorporated into a qualitative research method in which social anthropological approaches were used to oversee the case study activities in order to collect data. The collaborative social research approach was used to shelter the action research method. The research discovered that new business start-ups, as well as small businesses do not use social media and ICT-tools, unlike most of the large corporations use. At present, the current open-source ICT-technologies and social media applications are equally available for new and small businesses as they are available for larger companies. Successful implementation of social media and ICT-applications can easily enhance start-up performance and overcome business hassles. The thesis sheds some light on effective and innovative implementation of social media and ICT-applications for new business risk takers and small business birds. Key words

Improving customer service by identifying critical success factors and utilizing business process outsourcing

Consumers increasingly demand convenience when dealing with companies and therefore it is important to provide professional, diverse and speedy service via customer’s preferred communication channel. These interactions between the customer service and customer have a critical role in customer’s future purchasing decisions. Those customers who don't receive satisfactory customer service are willing to do business with another company that charges more but offers better customer service. This study identifies the critical success factors for the customer service in order to improve the customer service according to the company’s mission and meet customer expectations. Case study is used as a research method and data is collected via observation, archival records and interviews during a time span of fourteen months. The analysis suggests three critical success factors: voice support, scalable and flexible customer service and customer service champions. The study further analyzes the improvement measures according to the critical success factors concluding the Business Process Outsourcing to be the most proper to proceed with. As a conclusion of the study, critical success factors enable achieving the goals of the customer service and align operations according to the company’s mission. Business Process Outsourcing plays important role in improving the customer service by allowing fast expansion of new service offering and obtaining specialized workforce.

Finnish SMEs and Russian Business Environment: Challenges and Support Activities

The purpose of this study is based on the need of finding what kind of problems Finnish SMEs face in Russian market and how they could be supported. Used support activities in certain levels of internationalization and internationalization patterns are evaluated, international experience of entrepreneur is compared to used support activities and the most challenging pillars in Russia from the Institutional Theory are defined. The empirical part of the study is a semi structured qualitative analysis of ten case companies that represent different industry fields. All of them are SMEs and they represent different levels of internationalization and internationalization patterns. The results of this study indicated that usefulness of support activities have to be evaluated case by case. All the companies are individual organizations and usefulness of support activities have to be evaluated according to the actual situation of the company. International experience of manager has effect on the use of support activities. SMEs identified many problems related to pillars of Institutional theory and regulative environment seems to be the most challenging one.

Regulation of antioxidant enzyme activities in male and female rat macrophages by sex steroids

Human and animal immune functions present sex dimorphism that seems to be mainly regulated by sex hormones. In the present study, the activities of the antioxidant enzymes total superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GSH-Px) were measured in intraperitoneal resident macrophages from adult male and female rats. In addition to comparing males and females, we also examined the regulation of these enzyme activities in macrophages by sex steroids. GSH-Px activity did not differ between male and female macrophages. However, both total SOD and CAT activities were markedly higher in females than in males (83 and 180%). Removal of the gonads in both males and females (comparison between castrated groups) increased the difference in SOD activity from 83 to 138% and reduced the difference in CAT activity from 180 to 86%. Castration and testosterone administration did not significantly modify the activities of the antioxidant enzymes in male macrophages. Ovariectomy did not affect SOD or GSH-Px activity but markedly reduced (48%) CAT activity. This latter change was fully reversed by estrogen administration, whereas progesterone had a smaller effect. These results led us to conclude that differences in the SOD and CAT activities may partially explain some of the differences in immune function reported for males and females. Also, estrogen is a potent regulator of CAT in macrophages and therefore this enzyme activity in macrophages may vary considerably during the menstrual cycle.

Reproductive ability of pubertal male and female rats

Ten Fisher rats 50 to 55 days of age made up the pubertal group, and ten rats 90 to 95 days of age served as the controls. The testicular and epididymal weights and volumes of the pubertal males were lower than those of the controls (P<0.001). There was also a difference in relative epididymal weight (P<0.001). The sperm of pubertal males was morphologically abnormal in 58.2% of cases, as opposed to only 3.8% in the controls (P<0.001). The mean number of spermatozoa in the control group was 11.9 × 10(6)/ml and their viability was 99.6%, while these values could not be determined for pubertal rats. Serum testosterone was higher in the pubertal animals than in the controls (2.52 ± 1.46 vs 0.92 ± 0.34 nM, P<0.01). The ovaries of control females were heavier than those of pubertal females (P<0.001) but there was no difference in their relative weights. Serum estradiol was similar in both groups (75.5 ± 12.8 vs 81.8 ± 14.7 nM, P>0.05). At the beginning of gestation, the pubertal dams weighed less than the controls (P<0.001) but following uterectomy the body weights were equal. Pubertal dams delivered fewer pups than the controls (8.1 ± 2.5 vs 10.4 ± 1.3, P<0.05). There was no difference in the body weights of their offspring or in the weights of their placentas. The results suggest that, in contrast to their female counterparts, pubertal male rats are not fully mature and have not reached complete reproductive capacity at 50-55 days of age.

Preliminary data on the prevalence of psychiatric disorders in Brazilian male and female juvenile delinquents

The aim of the present investigation was to study the prevalence of psychiatric disorders in a sample of delinquent adolescents of both genders and to compare the prevalence between genders. A total of 116 adolescents (99 males and 17 females) aged 12 to 19 on parole in the State of Rio de Janeiro were interviewed using the screening interview based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime (KSADS-PL). Data were collected between May 2002 and January 2003. Of 373 male and 58 female adolescents present in May 2002 in the largest institution that gives assistance to adolescents on parole in the city of Rio de Janeiro, 119 subjects were assessed (three of them refused to participate). Their average age was 16.5 years with no difference between genders. The screening interview was positive for psychopathology for most of the sample, with the frequencies of the suggested more prevalent psychiatric disorders being 54% for attention-deficit/hyperactivity disorder, 77% for conduct disorder, 41% for oppositional defiant disorder, 57% for anxiety disorder 57, 60% for depressive disorder 60, 63% for illicit drug abuse, and 58% for regular alcohol use. Internalizing disorders (depressive disorders, anxiety disorders and phobias) were more prevalent in the female subsample. There was no significant difference in the prevalence of illicit drug abuse between genders. There were more male than female adolescents on parole and failure to comply with the sentence was significantly more frequent in females. The high prevalence of psychopathology suggested by this study indicates the need for psychiatric treatment as part of the prevention of juvenile delinquency or as part of the sentence. However, treatment had never been available for 93% of the sample in this study.

Morphometric analysis of the phrenic nerve in male and female Wistar-Kyoto (WKY) and spontaneously hypertensive rats (SHR)

Ventilatory differences between rat strains and genders have been described but the morphology of the phrenic nerve has not been investigated in spontaneously hypertensive (SHR) and normotensive Wistar-Kyoto (WKY) rats. A descriptive and morphometric study of the phrenic nerves of male (N = 8) and female (N = 9) SHR, and male (N = 5) and female (N = 6) WKY is presented. After arterial pressure and heart rate recordings, the phrenic nerves of 20-week-old animals were prepared for epoxy resin embedding and light microscopy. Morphometric analysis performed with the aid of computer software that took into consideration the fascicle area and diameter, as well as myelinated fiber profile and Schwann cell nucleus number per area. Phrenic nerves were generally larger in males than in females on both strains but larger in WKY compared to SHR for both genders. Myelinated fiber numbers (male SHR = 228 ± 13; female SHR = 258 ± 4; male WKY = 382 ± 23; female WKY = 442 ± 11 for proximal right segments) and density (N/mm²; male SHR = 7048 ± 537; female SHR = 10355 ± 359; male WKY = 9457 ± 1437; female WKY = 14351 ± 1448) for proximal right segments) were significantly larger in females of both groups and remarkably larger in WKY than SHR for both genders. Strain and gender differences in phrenic nerve myelinated fiber number are described for the first time in this experimental model of hypertension, indicating the need for thorough functional studies of this nerve in male and female SHR.

Outcomes and organ dysfunctions of critically ill patients with systemic lupus erythematosus and other systemic rheumatic diseases

Our objective was to compare the pattern of organ dysfunctions and outcomes of critically ill patients with systemic lupus erythematosus (SLE) with patients with other systemic rheumatic diseases (SRD). We studied 116 critically ill SRD patients, 59 SLE and 57 other-SRD patients. The SLE group was younger and included more women. Respiratory failure (61%) and shock (39%) were the most common causes of ICU admission for other-SRD and SLE groups, respectively. ICU length-of-stay was similar for the two groups. The 60-day survival adjusted for the groups’ baseline imbalances was not different (P = 0.792). Total SOFA scores were equal for the two groups at admission and during ICU stay, although respiratory function was worse in the other-SRD group at admission and renal and hematological functions were worse in the SLE group at admission. The incidence of severe respiratory dysfunction (respiratory SOFA >2) at admission was higher in the other-SRD group, whereas severe hematological dysfunction (hematological SOFA >2) during ICU stay was higher in the SLE group. SLE patients were younger and displayed a decreased incidence of respiratory failure compared to patients with other-SRDs. However, the incidences of renal and hematological failure and the presence of shock at admission were higher in the SLE group. The 60-day survival rates were similar.