Clinical factors associated with a Candida albicans Germ Tube Antibody positive test in Intensive Care Unit patients

Background: Poor outcomes of invasive candidiasis (IC) are associated with the difficulty in establishing the microbiological diagnosis at an early stage. New scores and laboratory tests have been developed in order to make an early therapeutic intervention in an attempt to reduce the high mortality associated with invasive fungal infections. Candida albicans IFA IgG has been recently commercialized for germ tube antibody detection (CAGTA). This test provides a rapid and simple diagnosis of IC (84.4% sensitivity and 94.7% specificity). The aim of this study is to identify the patients who could be benefited by the use of CAGTA test in critical care setting. Methods: A prospective, cohort, observational multicentre study was carried out in six medical/surgical Intensive care units (ICU) of tertiary-care Spanish hospitals. Candida albicans Germ Tube Antibody test was performed twice a week if predetermined risk factors were present, and serologically demonstrated candidiasis was considered if the testing serum dilution was >= 1: 160 in at least one sample and no other microbiological evidence of invasive candidiasis was found. Results: Fifty-three critically ill non-neutropenic patients (37.7% post surgery) were included. Twenty-two patients (41.5%) had CAGTA-positive results, none of them with positive blood culture for Candida. Neither corrected colonization index nor antifungal treatment had influence on CAGTA results. This finding could corroborate that the CAGTA may be an important biomarker to distinguish between colonization and infection in these patients. The presence of acute renal failure at the beginning of the study was more frequent in CAGTA-negative patients. Previous surgery was statistically more frequent in CAGTA-positive patients. Conclusions: This study identified previous surgery as the principal clinical factor associated with CAGTA-positive results and emphasises the utility of this promising technique, which was not influenced by high Candida colonization or antifungal treatment. Our results suggest that detection of CAGTA may be important for the diagnosis of invasive candidiasis in surgical patients admitted in ICU.

A direct D-bar reconstruction algorithm for recovering a complex conductivity in 2D

A direct reconstruction algorithm for complex conductivities in W-2,W-infinity(Omega), where Omega is a bounded, simply connected Lipschitz domain in R-2, is presented. The framework is based on the uniqueness proof by Francini (2000 Inverse Problems 6 107-19), but equations relating the Dirichlet-to-Neumann to the scattering transform and the exponentially growing solutions are not present in that work, and are derived here. The algorithm constitutes the first D-bar method for the reconstruction of conductivities and permittivities in two dimensions. Reconstructions of numerically simulated chest phantoms with discontinuities at the organ boundaries are included.

Die Faktorisierungsmethode für die elektrische Impedanztomographie im Halbraum

In der vorliegenden Arbeit wird die Faktorisierungsmethode zur Erkennung von Inhomogenitäten der Leitfähigkeit in der elektrischen Impedanztomographie auf unbeschränkten Gebieten - speziell der Halbebene bzw. dem Halbraum - untersucht. Als Lösungsräume für das direkte Problem, d.h. die Bestimmung des elektrischen Potentials zu vorgegebener Leitfähigkeit und zu vorgegebenem Randstrom, führen wir gewichtete Sobolev-Räume ein. In diesen wird die Existenz von schwachen Lösungen des direkten Problems gezeigt und die Gültigkeit einer Integraldarstellung für die Lösung der Laplace-Gleichung, die man bei homogener Leitfähigkeit erhält, bewiesen. Mittels der Faktorisierungsmethode geben wir eine explizite Charakterisierung von Einschlüssen an, die gegenüber dem Hintergrund eine sprunghaft erhöhte oder erniedrigte Leitfähigkeit haben. Damit ist zugleich für diese Klasse von Leitfähigkeiten die eindeutige Rekonstruierbarkeit der Einschlüsse bei Kenntnis der lokalen Neumann-Dirichlet-Abbildung gezeigt. Die mittels der Faktorisierungsmethode erhaltene Charakterisierung der Einschlüsse haben wir in ein numerisches Verfahren umgesetzt und sowohl im zwei- als auch im dreidimensionalen Fall mit simulierten, teilweise gestörten Daten getestet. Im Gegensatz zu anderen bekannten Rekonstruktionsverfahren benötigt das hier vorgestellte keine Vorabinformation über Anzahl und Form der Einschlüsse und hat als nicht-iteratives Verfahren einen vergleichsweise geringen Rechenaufwand.

Heterogeneous multicore systems for signal processing

This thesis explores the capabilities of heterogeneous multi-core systems, based on multiple Graphics Processing Units (GPUs) in a standard desktop framework. Multi-GPU accelerated desk side computers are an appealing alternative to other high performance computing (HPC) systems: being composed of commodity hardware components fabricated in large quantities, their price-performance ratio is unparalleled in the world of high performance computing. Essentially bringing “supercomputing to the masses”, this opens up new possibilities for application fields where investing in HPC resources had been considered unfeasible before. One of these is the field of bioelectrical imaging, a class of medical imaging technologies that occupy a low-cost niche next to million-dollar systems like functional Magnetic Resonance Imaging (fMRI). In the scope of this work, several computational challenges encountered in bioelectrical imaging are tackled with this new kind of computing resource, striving to help these methods approach their true potential. Specifically, the following main contributions were made: Firstly, a novel dual-GPU implementation of parallel triangular matrix inversion (TMI) is presented, addressing an crucial kernel in computation of multi-mesh head models of encephalographic (EEG) source localization. This includes not only a highly efficient implementation of the routine itself achieving excellent speedups versus an optimized CPU implementation, but also a novel GPU-friendly compressed storage scheme for triangular matrices. Secondly, a scalable multi-GPU solver for non-hermitian linear systems was implemented. It is integrated into a simulation environment for electrical impedance tomography (EIT) that requires frequent solution of complex systems with millions of unknowns, a task that this solution can perform within seconds. In terms of computational throughput, it outperforms not only an highly optimized multi-CPU reference, but related GPU-based work as well. Finally, a GPU-accelerated graphical EEG real-time source localization software was implemented. Thanks to acceleration, it can meet real-time requirements in unpreceeded anatomical detail running more complex localization algorithms. Additionally, a novel implementation to extract anatomical priors from static Magnetic Resonance (MR) scansions has been included.

Entwicklung und Tests von Algorithmen für die Impedanztomographie

Die Elektrische Impedanztomographie soll als kostengünstige und nebenwirkungsfreie Tomographiemethode in der medizinischen Diagnostik, z. B. in der Mammographie dienen. Mit der EIT läßt sich Krebsgewebe von gesundem Gewebe unterscheiden, da es eine signifikant erhöhte Leitfähigkeit aufweist. Damit kann die EIT als Ergänzung zu den klassischen Diagnoseverfahren dienen. So ist z.B. bei jungen Frauen mit einem dichteren Fettgewebe die Identifizierung eines Mammakarzinoms mit der Röntgentomographie nicht immer möglich. Ziel dieser Arbeit war es, einen Prototypen für die Impedanztomographie zu entwickeln und mögliche Anwendungen zu testen. Der Tomograph ist in Zusammenarbeit mit Dr. K.H.Georgi gebaut worden. Der Tomograph erlaubt es niederohmige, Wechselströme an Elektroden auf der Körperoberfläche einzuspeisen. Die Potentiale können an diesen Elektroden programmierbar vorgegeben werden. Weitere hochohmige Elektroden dienen zur Potentialmessung. Um den Hautwiderstand zu überbrücken, werden Wechselstromfrequenzen von 20-100 kHz eingesetzt. Mit der Möglichkeit der Messung von Strom und Potential auf unterschiedlichen Elektroden kann man das Problem des nur ungenau bekannten Hautwiderstandes umgehen. Prinzipiell ist es mit dem Mainzer EIT System möglich, 100 Messungen in der Sekunde durchzuführen. Auf der Basis von mit dem Mainzer EIT gewonnenen Daten sollten unterschiedliche Rekonstruktionsalgorithmen getestet und weiterentwickelt werden. In der Vergangenheit sind verschiedene Rekonstruktionsalgorithmen für das mathematisch schlecht gestellte EIT Problem betrachtet worden. Sie beruhen im Wesentlichen auf zwei Strategien: Die Linearisierung und iterative Lösung des Problems und Gebietserkennungsmethoden. Die iterativen Verfahren wurden von mir dahingehend modifiziert, dass Leitfähigkeitserhöhungen und Leitfähigkeitserniedrigungen gleichberechtigt behandelt werden können. Für den modifizierten Algorithmus wurden zwei verschiedene Rekonstruktionsalgorithmen programmiert und mit synthetischen Daten getestet. Zum einen die Rekonstruktion über die approximative Inverse, zum anderen eine Rekonstruktion mit einer Diskretisierung. Speziell für die Rekonstruktion mittels Diskretisierung wurde eine Methode entwickelt, mit der zusätzliche Informationen in der Rekonstruktion berücksichtigt werden können, was zu einer Verbesserung der Rekonstruktion beiträgt. Der Gebietserkennungsalgorithmus kann diese Zusatzinformationen liefern. In der Arbeit wurde ein neueres Verfahren für die Gebietserkennung derart modifiziert, dass eine Rekonstruktion auch für getrennte Strom- und Spannungselektroden möglich wurde. Mit Hilfe von Differenzdaten lassen sich ausgezeichnete Rekonstruktionen erzielen. Für die medizinischen Anwendungen sind aber Absolutmessungen nötig, d.h. ohne Leermessung. Der erwartende Effekt einer Inhomogenität in der Leitfähigkeit ist sehr klein und als Differenz zweier grosser Zahlen sehr schwierig zu bestimmen. Die entwickelten Algorithmen kommen auch gut mit Absolutdaten zurecht.

Analog Signal Acquisition and Conditioning for Near-Field Capacitive Communication and Active Combined EEG-EIT Monitoring

The work of the present thesis is focused on the implementation of microelectronic voltage sensing devices, with the purpose of transmitting and extracting analog information between devices of different nature at short distances or upon contact. Initally, chip-to-chip communication has been studied, and circuitry for 3D capacitive coupling has been implemented. Such circuits allow the communication between dies fabricated in different technologies. Due to their novelty, they are not standardized and currently not supported by standard CAD tools. In order to overcome such burden, a novel approach for the characterization of such communicating links has been proposed. This results in shorter design times and increased accuracy. Communication between an integrated circuit (IC) and a probe card has been extensively studied as well. Today wafer probing is a costly test procedure with many drawbacks, which could be overcome by a different communication approach such as capacitive coupling. For this reason wireless wafer probing has been investigated as an alternative approach to standard on-contact wafer probing. Interfaces between integrated circuits and biological systems have also been investigated. Active electrodes for simultaneous electroencephalography (EEG) and electrical impedance tomography (EIT) have been implemented for the first time in a 0.35 um process. Number of wires has been minimized by sharing the analog outputs and supply on a single wire, thus implementing electrodes that require only 4 wires for their operation. Minimization of wires reduces the cable weight and thus limits the patient's discomfort. The physical channel for communication between an IC and a biological medium is represented by the electrode itself. As this is a very crucial point for biopotential acquisitions, large efforts have been carried in order to investigate the different electrode technologies and geometries and an electromagnetic model is presented in order to characterize the properties of the electrode to skin interface.

Fluid shifts have no influence on ciprofloxacin pharmacokinetics in intensive care patients with intra-abdominal sepsis

This study aimed to investigate whether fluid shifts alter ciprofloxacin pharmacokinetics in critically ill patients over time. Patients >= 18 years, with normal renal function, requiring intensive care treatment and parenteral antibiotics were enrolled. Group A (22 patients) included patients with documented intra-abdominal infections. Group B (18 patients) included patients with severe sepsis from other causes. All patients received intravenous ciprofloxacin 400 mg every 8 h infused over 60 min. Eight timed blood specimens were taken on days 0, 2 and 7. Ciprofloxacin plasma concentrations were determined using high performance liquid chromatography. There were no significant differences between the pharmacokinetics of the two groups or over time. Ciprofloxacin pharmacokinetics in critically ill patients do not change over time, and intra-abdominal sepsis does not alter ciprofloxacin pharmacokinetic parameters to a greater degree than sepsis from other causes in critically ill patients. (c) 2005 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.

Antibacterial dosing in intensive care: Pharmacokinetics, degree of disease and pharmacodynamics of sepsis

Treatment of sepsis remains a significant challenge with persisting high mortality and morbidity. Early and appropriate antibacterial therapy remains an important intervention for such patients. To optimise antibacterial therapy, the clinician must possess knowledge of the pharmacokinetic and pharmacodynamic properties of commonly used antibacterials and how these parameters may be affected by the constellation of pathophysiological changes occurring during sepsis. Sepsis, and the treatment thereof, increases renal preload and, via capillary permeability, leads to 'third-spacing', both resulting in higher antibacterial clearances. Alternatively, sepsis can induce multiple organ dysfunction, including renal and/or hepatic dysfunction, causing a decrease in antibacterial clearance. Aminoglycosides are concentration-dependent antibacterials and they display an increased volume of distribution (V-d) in sepsis, resulting in decreased peak serum concentrations. Reduced clearance from renal dysfunction would increase the likelihood of toxicity. Individualised dosing using extended interval dosing, which maximises the peak serum drug concentration (C-max)/minimum inhibitory concentration ratio is recommended. beta-Lactams and carbapenems are time-dependent antibacterials. An increase in Vd and renal clearance will require increased dosing or administration by continuous infusion. If renal impairment occurs a corresponding dose reduction may be required. Vancomycin displays predominantly time-dependent pharmacodynamic properties and probably requires higher than conventionally recommended doses because of an increased V-d and clearance during sepsis without organ dysfunction. However, optimal dosing regimens remain unresolved. The poor penetration of vancomycin into solid organs may require alternative therapies when sepsis involves solid organs (e.g. lung). Ciprofloxacin displays largely concentration-dependent kill characteristics, but also exerts some time-dependent effects. The V-d of ciprofloxacin is not altered with fluid shifts or over time, and thus no alterations of standard doses are required unless renal dysfunction occurs. In order to optimise antibacterial regimens in patients with sepsis, the pathophysiological effects of systemic inflammatory response syndrome need consideration, in conjunction with knowledge of the different kill characteristics of the various antibacterial classes. In conclusion, certain antibacterials can have a very high V-d, therefore leading to a low C-max and if a high peak is needed, then this would lead to underdosing. The Vd of certain antibacterials, namely aminoglycosides and vancomycin, changes over time, which means dosing may need to be altered over time. Some patients with serum creatinine values within the normal range can have very high drug clearances, thereby producing low serum drug levels and again leading to underdosing. Copyright © 2010 Elsevier Inc. All rights reserved.

Estudo teórico da tomografia por impedância elétrica

O presente trabalho descreve um estudo sobre a metodologia matemática para a solução do problema direto e inverso na Tomografia por Impedância Elétrica. Este estudo foi motivado pela necessidade de compreender o problema inverso e sua utilidade na formação de imagens por Tomografia por Impedância Elétrica. O entendimento deste estudo possibilitou constatar, através de equações e programas, a identificação das estruturas internas que constituem um corpo. Para isto, primeiramente, é preciso conhecer os potencias elétricos adquiridos nas fronteiras do corpo. Estes potenciais são adquiridos pela aplicação de uma corrente elétrica e resolvidos matematicamente pelo problema direto através da equação de Laplace. O Método dos Elementos Finitos em conjunção com as equações oriundas do eletromagnetismo é utilizado para resolver o problema direto. O software EIDORS, contudo, através dos conceitos de problema direto e inverso, reconstrói imagens de Tomografia por Impedância Elétrica que possibilitam visualizar e comparar diferentes métodos de resolução do problema inverso para reconstrução de estruturas internas. Os métodos de Tikhonov, Noser, Laplace, Hiperparamétrico e Variação Total foram utilizados para obter uma solução aproximada (regularizada) para o problema de identificação. Na Tomografia por Impedância Elétrica, com as condições de contorno preestabelecidas de corrente elétricas e regiões definidas, o método hiperparamétrico apresentou uma solução aproximada mais adequada para reconstrução da imagem.

Desenlaces de la escala Omaha+ en los pacientes en cuidado intensivo en la fundación santa fe de Bogotá

Introducción La ventilación mecánica es fundamental en el manejo de la falla respiratoria aguda, actualmente no existe consenso sobre el momento exacto de extubación. Este estudio describe el comportamiento de la escala OMAHA+ en nuestra institución. Objetivo Principal Describir los desenlaces clínicos relacionados con la escala OMAHA+ durante la extubación de los pacientes de las unidades de cuidado intensivo del hospital universitario. Métodos Estudio descriptivo, retrospectivo, basado en el registro de la escala OMAHA+ de 68 pacientes durante el proceso de extubación en las Unidades de cuidado intensivo adulto de la Fundación Santa Fe de Bogotá durante Agosto de 2014 a Mayo de 2015. Resultados Se encontraron valores gasométricos cercanos a la normalidad, con una PaO2/FiO2 media de 261 (DS 60,6), SaO2 media de 96% (DS 2%), media de lactato sérico de 1.5 mmol/L (DS 1,2 mmol/L), con signos vitales normales. La causa más común de ingreso a UCI fue Neumonía, seguida por cirugía cardiaca y abdominal. Las medias de parámetros ventilatorios al momento de extubación fueron; PEEP de 6 (DS 0,8), volumen corriente de 8ml/Kg (DS 1,4 ml/Kg), índice de Tobín de 34 (DS 11,9), test de fuga positivo 94%, y sólo una extubación fallida. Conclusiones La escala OMAHA+ puede ser una herramienta útil, aplicable y fácilmente reproducible en los pacientes con soporte ventilatorio mecánico invasivo previo al proceso de extubación, con baja proporción de fallo. Estos resultados deben ser evaluados en estudios prospectivos.

Smoothing a Discrete Hazard Function for the Number of Patients Colonized with Methicillin-Resistance Staphylococcus Aureus in an Intensive Care Unit

A new method for estimating the time to colonization of Methicillin-resistant Staphylococcus Aureus (MRSA) patients is developed in this paper. The time to colonization of MRSA is modelled using a Bayesian smoothing approach for the hazard function. There are two prior models discussed in this paper: the first difference prior and the second difference prior. The second difference prior model gives smoother estimates of the hazard functions and, when applied to data from an intensive care unit (ICU), clearly shows increasing hazard up to day 13, then a decreasing hazard. The results clearly demonstrate that the hazard is not constant and provide a useful quantification of the effect of length of stay on the risk of MRSA colonization which provides useful insight.

Re-invent yourself: from London intensive care nursing and the Nigerian oil fields to an an academic library in Brisbane; a career change worth making.

A complete change of career forces a seismic shift in every aspect of your life. From day one, you have to face the loss of long held beliefs, behaviours, the known world of self, and security. We came from professions that themselves are poles apart, and many of the challenges we faced entering the profession were the same: juggling full-time work, part time study, and family commitmemts, taking a pay cut, and loss of social life. But over a short period of time we both transitioned to our new profession successfully. so what make our successful transition possible?

Using a longitudinal model to estimate the effect of methicillin-resistant staphylococcus aureus infection on length of stay in an intensive care unit

Healthcare-associated methicillin-resistant Staphylococcus aureus(MRSA) infection may cause increased hospital stay or, sometimes, death. Quantifying this effect is complicated because it is a time-dependent exposure: infection may prolong hospital stay, while longer stays increase the risk of infection. We overcome these problems by using a multinomial longitudinal model for estimating the daily probability of death and discharge. We then extend the basic model to estimate how the effect of MRSA infection varies over time, and to quantify the number of excess ICU days due to infection. We find that infection decreases the relative risk of discharge (relative risk ratio = 0.68, 95% credible interval: 0.54, 0.82), but is only indirectly associated with increased mortality. An infection on the first day of admission resulted in a mean extra stay of 0.3 days (95% CI: 0.1, 0.5) for a patient with an APACHE II score of 10, and 1.2 days (95% CI: 0.5, 2.0) for a patient with an APACHE II score of 30. The decrease in the relative risk of discharge remained fairly constant with day of MRSA infection, but was slightly stronger closer to the start of infection. These results confirm the importance of MRSA infection in increasing ICU stay, but suggest that previous work may have systematically overestimated the effect size.