Enhancing discharge decision-making through continuous monitoring in an acute admission ward: a randomized controlled trial.

In Acute Admission Wards, vital signs are commonly measured only intermittently. This may result in failure to detect early signs of patient deterioration and impede timely identification of patient stability, ultimately leading to prolonged stays and avoidable hospital admissions. Therefore, continuous vital sign monitoring may improve hospital efficacy. The objective of this randomized controlled trial was to evaluate the effect of continuous monitoring on the proportion of patients safely discharged home directly from an Acute Admission Ward. Patients were randomized to either the control group, which received usual care, or the sensor group, which additionally received continuous monitoring using a wearable sensor. The continuous measurements could be considered in discharge decision-making by physicians during the daily bedside rounds. Safe discharge was defined as no unplanned readmissions, emergency department revisits or deaths, within 30 days after discharge. Additionally, length of stay, the number of Intensive Care Unit admissions and Rapid Response Team calls were assessed. In total, 400 patients were randomized, of which 394 completed follow-up, with 196 assigned to the sensor group and 198 to the control group. The proportion of patients safely discharged home was 33.2% in the sensor group and 30.8% in the control group (p = 0.62). No significant differences were observed in secondary outcomes. The trial was terminated prematurely due to futility. In conclusion, continuous monitoring did not have an effect on the proportion of patients safely discharged from an Acute Admission Ward. Implementation challenges of continuous monitoring may have contributed to the lack of effect observed. Trial registration: https://clinicaltrials.gov/ct2/show/NCT05181111 . Registered: January 6, 2022.

Do Growers Using Solo Fungicides Affect the Durability of Disease Control of Growers Using Mixtures and Alternations? The Case of Spot-Form Net Blotch in Western Australia.

Growers often use alternations or mixtures of fungicides to slow down the development of resistance to fungicides. However, within a landscape, some growers will implement such resistance management methods, whereas others do not, and may even apply solo components of the resistance management program. We investigated whether growers using solo components of resistant management programs affect the durability of disease control in fields of those who implement fungicide resistance management. We developed a spatially implicit semidiscrete epidemiological model for the development of fungicide resistance. The model simulates the development of epidemics of spot-form net blotch disease, caused by the pathogen Pyrenophora teres f. maculata. The landscape comprises three types of fields, grouped according to their treatment program, with spore dispersal between fields early in the cropping season. In one field type, a fungicide resistance management method is implemented, whereas in the two others, it is not, with one of these field types using a component of the fungicide resistance management program. The output of the model suggests that the use of component fungicides does affect the durability of disease control for growers using resistance management programs. The magnitude of the effect depends on the characteristics of the pathosystem, the degree of inoculum mixing between fields, and the resistance management program being used. Additionally, although increasing the amount of the solo component in the landscape generally decreases the lifespan within which the resistance management program provides effective control, situations exist where the lifespan may be minimized at intermediate levels of the solo component fungicide. [Formula: see text] Copyright © 2024 The Author(s). This is an open access article distributed under the CC BY 4.0 International license.

[The assessment of volume status]. / Het beoordelen van de vullingsstatus.

Accurately assessing volume status is crucial, as an incorrect evaluation can lead to inappropriate therapy. Evaluating volume status using medical history and physical examination can be challenging. Medical history and physical examination are readily available, cost-effective, and non-invasive, remaining the initial steps in assessing fluid status. Point-of-care ultrasound (POCUS) is a valuable adjunct to physical examination. The collapse point of the internal jugular vein, the diameter of the inferior vena cava, and the presence of pulmonary B-lines can be easily and rapidly assessed using POCUS. Combining medical history, physical examination, and POCUS enhances diagnostic certainty in evaluating volume status.

Continuous monitoring of patients in and after the acute admission ward to improve clinical pathways: study protocol for a randomized controlled trial (Optimal-AAW).

BACKGROUND: Because of high demand on hospital beds, hospitals seek to reduce patients' length of stay (LOS) while preserving the quality of care. In addition to usual intermittent vital sign monitoring, continuous monitoring might help to assess the patient's risk of deterioration, in order to improve the discharge process and reduce LOS. The primary aim of this monocenter randomized controlled trial is to assess the effect of continuous monitoring in an acute admission ward (AAW) on the percentage of patients who are discharged safely. METHODS: A total of 800 patients admitted to the AAW, for whom it is equivocal whether they can be discharged directly after their AAW stay, will be randomized to either receive usual care without (control group) or with additional continuous monitoring of heart rate, respiratory rate, posture, and activity, using a wearable sensor (sensor group). Continuous monitoring data are provided to healthcare professionals and used in the discharge decision. The wearable sensor keeps collecting data for 14 days. After 14 days, all patients fill in a questionnaire to assess healthcare use after discharge and, if applicable, their experience with the wearable sensor. The primary outcome is the difference in the percentage of patients who are safely discharged home directly from the AAW between the control and sensor group. Secondary outcomes include hospital LOS, AAW LOS, intensive care unit (ICU) admissions, Rapid Response Team calls, and unplanned readmissions within 30 days. Furthermore, facilitators and barriers for implementing continuous monitoring in the AAW and at home will be investigated. DISCUSSION: Clinical effects of continuous monitoring have already been investigated in specific patient populations for multiple purposes, e.g., in reducing the number of ICU admissions. However, to our knowledge, this is the first Randomized Controlled Trial to investigate effects of continuous monitoring in a broad patient population in the AAW. TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT05181111 . Registered on 6 January 2022. Start of recruitment: 7 December 2021.

Feasibility of a standardized family participation programme in the intensive care unit: A pilot survey study.

AIM: To assess the feasibility and applicability of a standardized programme to facilitate family participation in essential care activities in the intensive care unit. DESIGN: Pilot study with a cross-sectional survey design. METHODS: A standardized programme to facilitate family participation in essential nursing care activities was implemented in intensive care units of three hospitals in the Netherlands from November 2018 until March 2019. The feasibility and applicability of the programme were assessed with surveys of the patients, relatives and healthcare providers. RESULTS: Three intensive care units successfully implemented the standardized programme. Three patients, ten relatives and 37 healthcare providers responded to the surveys. Patients appreciated family participation and recognized that their relatives liked to participate. Relatives appreciated being able to do something for the patient (80%) and to participate in essential care activities (60%). The majority of relatives (60%) felt they had sufficient knowledge and skills to participate and did not feel obliged nor uncomfortable. Healthcare providers felt they were trained adequately and motivated to apply family participation; application was perceived as easy, clear and relatively effortless according to the majority. According to 68% of the healthcare providers, most relatives were perceived to be capable of learning to participate in essential care activities. Some healthcare providers felt uncertain about the patient's wishes regarding family participation, with some indicating the behaviours of relatives and patients discouraged them from offering family participation. Use of a standardized programme to facilitate family participation in essential care activities in the intensive care unit seems feasible and applicable as determined by relatives and healthcare providers.

The value of volunteer surveillance for the early detection of biological invaders.

Early detection of invaders requires finding small numbers of individuals across large landscapes. It has been argued that the only feasible way to achieve the sampling effort needed for early detection of an invader is to involve volunteer groups (citizen scientists, passive surveyors, etc.). A key concern is that volunteers may have a considerable false-positive and false-negative rate. The question then becomes whether verification of a report from a volunteer is worth the effort. This question is the topic of this paper. Since we are interested in early detection we calculate the Z% upper limit of the one sided confidence interval of the incidence (fraction infected) and use the term maximum expected plausible incidence for this. We compare the maximum plausible incidence when the expert samples on their own, qE∼, and the maximum plausible incidence when the expert only verifies cases reported by the volunteer surveyor to be infected, qV∼. The maximum plausible incidences qE∼ and qV∼. are related as, qV∼=θfp1-θfnqE∼ where θfp and θfn are the false positive and false negative rate of the volunteer surveyor, respectively. We also show that the optimal monitoring programme consists of verifying only the cases reported by the volunteer surveyor if, TXTN<θfp1-θfn, where TN is the time needed for a sample taken by the expert and TX is the time needed for an expert to verify a case reported by a volunteer surveyor. Our results can be used to calculate the maximum plausible incidence of a plant disease based on reports of passive surveyors that have been verified by experts and data from experts sampling on their own. The results can also be used in the development phase of a surveillance project to assess whether including passive surveyor reports is useful in the early detection of exotic invaders.

POCUS in dyspnea, nontraumatic hypotension, and shock; a systematic review of existing evidence.

BACKGROUND: Point-of-care ultrasound (POCUS) has been adopted as a powerful tool in acute medicine. This systematic review aims to critically appraise the existing literature on point-of-care ultrasound in respiratory or circulatory deterioration. METHODS: Original studies on POCUS and dyspnea, nontraumatic hypotension, and shock from March 2002 until March 2022 were assessed in the PubMed and Embase Databases. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. RESULTS: We included 89 articles in this review. Point-of-care ultrasound in the initial workup increases the diagnostic accuracy in patients with dyspnea, nontraumatic hypotension and shock in the ED, ICU and medical ward setting. No improvement is found in patients with severe sepsis in the ICU setting. POCUS is capable of narrowing the differential diagnoses and is faster, and more feasible in the acute setting than other diagnostics available. Results on outcome measures are heterogenous. The quality of the included studies is considered low most of the times, mainly because of performance and selection bias and absence of a gold standard as the reference test. CONCLUSION: We conclude that POCUS contributes to a higher diagnostic accuracy in dyspnea, nontraumatic hypotension, and shock. It aides in narrowing the differential diagnoses and shortening the time to correct diagnosis and effective treatment. TRIAL REGISTRY: INPLASY; Registration number: INPLASY202220020; URL: https://inplasy.com/.

Epidemiologically-based strategies for the detection of emerging plant pathogens.

Emerging pests and pathogens of plants are a major threat to natural and managed ecosystems worldwide. Whilst it is well accepted that surveillance activities are key to both the early detection of new incursions and the ability to identify pest-free areas, the performance of these activities must be evaluated to ensure they are fit for purpose. This requires consideration of the number of potential hosts inspected or tested as well as the epidemiology of the pathogen and the detection method used. In the case of plant pathogens, one particular concern is whether the visual inspection of plant hosts for signs of disease is able to detect the presence of these pathogens at low prevalences, given that it takes time for these symptoms to develop. One such pathogen is the ST53 strain of the vector-borne bacterial pathogen Xylella fastidiosa in olive hosts, which was first identified in southern Italy in 2013. Additionally, X. fastidiosa ST53 in olive has a rapid rate of spread, which could also have important implications for surveillance. In the current study, we evaluate how well visual surveillance would be expected to perform for this pathogen and investigate whether molecular testing of either tree hosts or insect vectors offer feasible alternatives. Our results identify the main constraints to each of these strategies and can be used to inform and improve both current and future surveillance activities.

Prognosis After Cardiac Arrest: The Additional Value of DWI and FLAIR to EEG.

BACKGROUND: Despite application of the multimodal European Resuscitation Council and European Society of Intensive Care Medicine algorithm, neurological prognosis of patients who remain comatose after cardiac arrest remains uncertain in a large group of patients. In this study, we investigate the additional predictive value of visual and quantitative brain magnetic resonance imaging (MRI) to electroencephalography (EEG) for outcome estimation of comatose patients after cardiac arrest. METHODS: We performed a prospective multicenter cohort study in patients after cardiac arrest submitted in a comatose state to the intensive care unit of two Dutch hospitals. Continuous EEG was recorded during the first 3 days and MRI was performed at 3 ± 1 days after cardiac arrest. EEG at 24 h and ischemic damage in 21 predefined brain regions on diffusion weighted imaging and fluid-attenuated inversion recovery on a scale from 0 to 4 were related to outcome. Quantitative MRI analyses included mean apparent diffusion coefficient (ADC) and percentage of brain volume with ADC < 450 × 10-6 mm2/s, < 550 × 10-6 mm2/s, and < 650 × 10-6 mm2/s. Poor outcome was defined as a Cerebral Performance Category score of 3-5 at 6 months. RESULTS: We included 50 patients, of whom 20 (40%) demonstrated poor outcome. Visual EEG assessment correctly identified 3 (15%) with poor outcome and 15 (50%) with good outcome. Visual grading of MRI identified 13 (65%) with poor outcome and 25 (89%) with good outcome. ADC analysis identified 11 (55%) with poor outcome and 3 (11%) with good outcome. EEG and MRI combined could predict poor outcome in 16 (80%) patients at 100% specificity, and good outcome in 24 (80%) at 63% specificity. Ischemic damage was most prominent in the cortical gray matter (75% vs. 7%) and deep gray nuclei (45% vs. 3%) in patients with poor versus good outcome. CONCLUSIONS: Magnetic resonance imaging is complementary with EEG for the prediction of poor and good outcome of patients after cardiac arrest who are comatose at admission.

Modelling cassava production and pest management under biotic and abiotic constraints.

KEY MESSAGE: We summarise modelling studies of the most economically important cassava diseases and arthropods, highlighting research gaps where modelling can contribute to the better management of these in the areas of surveillance, control, and host-pest dynamics understanding the effects of climate change and future challenges in modelling. For over 30 years, experimental and theoretical studies have sought to better understand the epidemiology of cassava diseases and arthropods that affect production and lead to considerable yield loss, to detect and control them more effectively. In this review, we consider the contribution of modelling studies to that understanding. We summarise studies of the most economically important cassava pests, including cassava mosaic disease, cassava brown streak disease, the cassava mealybug, and the cassava green mite. We focus on conceptual models of system dynamics rather than statistical methods. Through our analysis we identified areas where modelling has contributed and areas where modelling can improve and further contribute. Firstly, we identify research challenges in the modelling developed for the surveillance, detection and control of cassava pests, and propose approaches to overcome these. We then look at the contributions that modelling has accomplished in the understanding of the interaction and dynamics of cassava and its' pests, highlighting success stories and areas where improvement is needed. Thirdly, we look at the possibility that novel modelling applications can achieve to provide insights into the impacts and uncertainties of climate change. Finally, we identify research gaps, challenges, and opportunities where modelling can develop and contribute for the management of cassava pests, highlighting the recent advances in understanding molecular mechanisms of plant defence.

Comparing lung ultrasound: extensive versus short in COVID-19 (CLUES): a multicentre, observational study at the emergency department.

BACKGROUND: Bedside lung ultrasound (LUS) is an affordable diagnostic tool that could contribute to identifying COVID-19 pneumonia. Different LUS protocols are currently used at the emergency department (ED) and there is a need to know their diagnostic accuracy. DESIGN: A multicentre, prospective, observational study, to compare the diagnostic accuracy of three commonly used LUS protocols in identifying COVID-19 pneumonia at the ED. SETTING/PATIENTS: Adult patients with suspected COVID-19 at the ED, in whom we prospectively performed 12-zone LUS and SARS-CoV-2 reverse transcription PCR. MEASUREMENTS: We assessed diagnostic accuracy for three different ultrasound protocols using both PCR and final diagnosis as a reference standard. RESULTS: Between 19 March 2020 and 4 May 2020, 202 patients were included. Sensitivity, specificity and negative predictive value compared with PCR for 12-zone LUS were 91.4% (95% CI 84.4 to 96.0), 83.5% (95% CI 74.6 to 90.3) and 90.0% (95% CI 82.7 to 94.4). For 8-zone and 6-zone protocols, these results were 79.7 (95% CI 69.9 to 87.6), 69.0% (95% CI 59.6 to 77.4) and 81.3% (95% CI 73.8 to 87.0) versus 89.9% (95% CI 81.7 to 95.3), 57.5% (95% CI 47.9 to 66.8) and 87.8% (95% CI 79.2 to 93.2). Negative likelihood ratios for 12, 8 and 6 zones were 0.1, 0.3 and 0.2, respectively. Compared with the final diagnosis specificity increased to 83.5% (95% CI 74.6 to 90.3), 78.4% (95% CI 68.8 to 86.1) and 65.0% (95% CI 54.6 to 74.4), respectively, while the negative likelihood ratios were 0.1, 0.2 and 0.16. CONCLUSION: Identifying COVID-19 pneumonia at the ED can be aided by bedside LUS. The more efficient 6-zone protocol is an excellent screening tool, while the 12-zone protocol is more specific and gives a general impression on lung involvement. TRIAL REGISTRATION NUMBER: NL8497.

[Communication about in hospital resuscitation orders]. / Communicatie over reanimatiebeleid in het ziekenhuis.

BACKGROUND: The decision to attempt or refrain from resuscitation is preferably based on prognostic factors for outcome and subsequently communicated with patients. Both patients and physicians consider good communication important, however little is known about patient involvement in and understanding of cardiopulmonary resuscitation (CPR) directives. AIM: To determine the prevalence of Do Not Resuscitate (DNR)-orders, to describe recollection of CPR-directive conversations and factors associated with patient recollection and understanding. METHODS: This was a two-week nationwide multicentre cross-sectional observational study using a study-specific survey. The study population consisted of patients admitted to non-monitored wards in 13 hospitals. Data were collected from the electronic medical record (EMR) concerning CPR-directive, comorbidity and at-home medication. Patients reported their perception and expectations about CPR-counselling through a questionnaire. RESULTS: A total of 1136 patients completed the questionnaire. Patients' CPR-directives were documented in the EMR as follows: 63.7% full code, 27.5% DNR and in 8.8% no directive was documented. DNR was most often documented for patients >80 years (66.4%) and in patients using >10 medications (45.3%). Overall, 55.8% of patients recalled having had a conversation about their CPR-directive and 48.1% patients reported the same CPR-directive as the EMR. Most patients had a good experience with the CPR-directive conversation in general (66.1%), as well as its timing (84%) and location (94%) specifically. CONCLUSIONS: The average DNR-prevalence is 27.5%. Correct understanding of their CPR-directive is lowest in patients aged ≥80 years and multimorbid patients. CPR-directive counselling should focus more on patient involvement and their correct understanding.

Assessing COVID-19 pneumonia-Clinical extension and risk with point-of-care ultrasound: A multicenter, prospective, observational study.

BACKGROUND: Assessing the extent of lung involvement is important for the triage and care of COVID-19 pneumonia. We sought to determine the utility of point-of-care ultrasound (POCUS) for characterizing lung involvement and, thereby, clinical risk determination in COVID-19 pneumonia. METHODS: This multicenter, prospective, observational study included patients with COVID-19 who received 12-zone lung ultrasound and chest computed tomography (CT) scanning in the emergency department (ED). We defined lung disease severity using the lung ultrasound score (LUS) and chest CT severity score (CTSS). We assessed the association between the LUS and poor outcome (ICU admission or 30-day all-cause mortality). We also assessed the association between the LUS and hospital length of stay. We examined the ability of the LUS to differentiate between disease severity groups. Lastly, we estimated the correlation between the LUS and CTSS and the interrater agreement for the LUS. We handled missing data by multiple imputation with chained equations and predictive mean matching. RESULTS: We included 114 patients treated between March 19, 2020, and May 4, 2020. An LUS ≥12 was associated with a poor outcome within 30 days (hazard ratio [HR], 5.59; 95% confidence interval [CI], 1.26-24.80; P = 0.02). Admission duration was shorter in patients with an LUS <12 (adjusted HR, 2.24; 95% CI, 1.47-3.40; P < 0.001). Mean LUS differed between disease severity groups: no admission, 6.3 (standard deviation [SD], 4.4); hospital/ward, 13.1 (SD, 6.4); and ICU, 18.0 (SD, 5.0). The LUS was able to discriminate between ED discharge and hospital admission excellently, with an area under the curve of 0.83 (95% CI, 0.75-0.91). Interrater agreement for the LUS was strong: κ = 0.88 (95% CI, 0.77-0.95). Correlation between the LUS and CTSS was strong: κ = 0.60 (95% CI, 0.48-0.71). CONCLUSIONS: We showed that baseline lung ultrasound - is associated with poor outcomes, admission duration, and disease severity. The LUS also correlates well with CTSS. Point-of-care lung ultrasound may aid the risk stratification and triage of patients with COVID-19 at the ED.

Smallholder Cassava Planting Material Movement and Grower Behavior in Zambia: Implications for the Management of Cassava Virus Diseases.

Cassava (Manihot esculenta) is an important food crop across sub-Saharan Africa, where production is severely inhibited by two viral diseases, cassava mosaic disease (CMD) and cassava brown streak disease (CBSD), both propagated by a whitefly vector and via human-mediated movement of infected cassava stems. There is limited information on growers' behavior related to movement of planting material, as well as growers' perception and awareness of cassava diseases, despite the importance of these factors for disease control. This study surveyed a total of 96 cassava subsistence growers and their fields across five provinces in Zambia between 2015 and 2017 to address these knowledge gaps. CMD symptoms were observed in 81.6% of the fields, with an average incidence of 52% across the infected fields. No CBSD symptoms were observed. Most growers used planting materials from their own (94%) or nearby (<10 km) fields of family and friends, although several large transactions over longer distances (10 to 350 km) occurred with friends (15 transactions), markets (1), middlemen (5), and nongovernmental organizations (6). Information related to cassava diseases and certified clean (disease-free) seed reached only 48% of growers. The most frequent sources of information related to cassava diseases included nearby friends, family, and neighbors, while extension workers were the most highly preferred source of information. These data provide a benchmark on which to plan management approaches to controlling CMD and CBSD, which should include clean propagation material, increasing growers' awareness of the diseases, and increasing information provided to farmers (specifically disease symptom recognition and disease management options).[Formula: see text] Copyright © 2021 The Author(s). This is an open access article distributed under the CC BY 4.0 International license.

[Lung ultrasound in patients with symptoms of covid-19]. / Longechografie bij patiënten met symptomen van covid-19.

The SARS-CoV-2 pandemic presents a challenge for healthcare worldwide. In this context, rapid, correct diagnosis and early isolation of infected persons is of great importance. Pneumonia as an expression of COVID-19 is responsible for the most part of morbidity and mortality. Lung ultrasound can provide valuable information about the diagnosis of a COVID-19 pneumonia in daily practice. A normal ultrasound excludes COVID-19 pneumonia. Conversely, finding abnormalities matching with a COVID-19 pneumonia can be useful for isolation policy. Follow up lung ultrasound visualizes the development of the pneumonia and a possible alternative diagnosis can thereby be determined in the event of a deviating clinical course.

Life-sustaining treatment preferences in older patients when referred to the emergency department for acute geriatric assessment: a descriptive study in a Dutch hospital.

BACKGROUND: In many cases, life-sustaining treatment preferences are not timely discussed with older patients. Advance care planning (ACP) offers medical professionals an opportunity to discuss patients' preferences. We assessed how often these preferences were known when older patients were referred to the emergency department (ED) for an acute geriatric assessment. METHODS: We conducted a descriptive study on patients referred to the ED for an acute geriatric assessment in a Dutch hospital. Patients were referred by general practitioners (GPs), or in the case of nursing home residents, by elderly care physicians. The referring physician was asked if preferences regarding life-sustaining treatments were known. The primary outcome was the number of patients for whom preferences were known. Secondary outcomes included which preferences, and which variables predict known preferences. RESULTS: Between 2015 and 2017, 348 patients were included in our study. At least one preference regarding life-sustaining treatments was known at referral in 45.4% (158/348) cases. In these cases, cardiopulmonary resuscitation (CPR) policy was always included. Preferences regarding invasive ventilation policy and ICU admission were known in 17% (59/348) and 10.3% (36/348) of the cases respectively. Known preferences were more frequent in cases referred by the elderly care physician than the GP (P < 0.001). CONCLUSIONS: In less than half the patients, at least one preference regarding life-sustaining treatments was known at the time of referral to the ED for an acute geriatric assessment; in most cases it concerned CPR policy. We recommend optimizing ACP conversations in a non-acute setting to provide more appropriate, desired, and personalized care to older patients referred to the ED.

Effect of a Lower vs Higher Positive End-Expiratory Pressure Strategy on Ventilator-Free Days in ICU Patients Without ARDS: A Randomized Clinical Trial.

Importance: It is uncertain whether invasive ventilation can use lower positive end-expiratory pressure (PEEP) in critically ill patients without acute respiratory distress syndrome (ARDS). Objective: To determine whether a lower PEEP strategy is noninferior to a higher PEEP strategy regarding duration of mechanical ventilation at 28 days. Design, Setting, and Participants: Noninferiority randomized clinical trial conducted from October 26, 2017, through December 17, 2019, in 8 intensive care units (ICUs) in the Netherlands among 980 patients without ARDS expected not to be extubated within 24 hours after start of ventilation. Final follow-up was conducted in March 2020. Interventions: Participants were randomized to receive invasive ventilation using either lower PEEP, consisting of the lowest PEEP level between 0 and 5 cm H2O (n = 476), or higher PEEP, consisting of a PEEP level of 8 cm H2O (n = 493). Main Outcomes and Measures: The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for the difference in ventilator-free days at day 28 of -10%. Secondary outcomes included ICU and hospital lengths of stay; ICU, hospital, and 28- and 90-day mortality; development of ARDS, pneumonia, pneumothorax, severe atelectasis, severe hypoxemia, or need for rescue therapies for hypoxemia; and days with use of vasopressors or sedation. Results: Among 980 patients who were randomized, 969 (99%) completed the trial (median age, 66 [interquartile range {IQR}, 56-74] years; 246 [36%] women). At day 28, 476 patients in the lower PEEP group had a median of 18 ventilator-free days (IQR, 0-27 days) and 493 patients in the higher PEEP group had a median of 17 ventilator-free days (IQR, 0-27 days) (mean ratio, 1.04; 95% CI, 0.95-∞; P = .007 for noninferiority), and the lower boundary of the 95% CI was within the noninferiority margin. Occurrence of severe hypoxemia was 20.6% vs 17.6% (risk ratio, 1.17; 95% CI, 0.90-1.51; P = .99) and need for rescue strategy was 19.7% vs 14.6% (risk ratio, 1.35; 95% CI, 1.02-1.79; adjusted P = .54) in patients in the lower and higher PEEP groups, respectively. Mortality at 28 days was 38.4% vs 42.0% (hazard ratio, 0.89; 95% CI, 0.73-1.09; P = .99) in patients in the lower and higher PEEP groups, respectively. There were no statistically significant differences in other secondary outcomes. Conclusions and Relevance: Among patients in the ICU without ARDS who were expected not to be extubated within 24 hours, a lower PEEP strategy was noninferior to a higher PEEP strategy with regard to the number of ventilator-free days at day 28. These findings support the use of lower PEEP in patients without ARDS. Trial Registration: ClinicalTrials.gov Identifier: NCT03167580.

Optimising risk-based surveillance for early detection of invasive plant pathogens.

Emerging infectious diseases (EIDs) of plants continue to devastate ecosystems and livelihoods worldwide. Effective management requires surveillance to detect epidemics at an early stage. However, despite the increasing use of risk-based surveillance programs in plant health, it remains unclear how best to target surveillance resources to achieve this. We combine a spatially explicit model of pathogen entry and spread with a statistical model of detection and use a stochastic optimisation routine to identify which arrangement of surveillance sites maximises the probability of detecting an invading epidemic. Our approach reveals that it is not always optimal to target the highest-risk sites and that the optimal strategy differs depending on not only patterns of pathogen entry and spread but also the choice of detection method. That is, we find that spatial correlation in risk can make it suboptimal to focus solely on the highest-risk sites, meaning that it is best to avoid 'putting all your eggs in one basket'. However, this depends on an interplay with other factors, such as the sensitivity of available detection methods. Using the economically important arboreal disease huanglongbing (HLB), we demonstrate how our approach leads to a significant performance gain and cost saving in comparison with conventional methods to targeted surveillance.