Staphylococcus aureus bacteremia in immunosuppressed patients: a multicenter, retrospective cohort study.

Staphylococcus aureus bacteremia (SAB) causes significant morbidity and mortality. We assessed the disease severity and clinical outcomes of SAB in patients with pre-existing immunosuppression, compared with immunocompetent patients. A retrospective cohort investigation studied consecutive patients with SAB hospitalized across six hospitals in Toronto, Canada from 2007 to 2010. Patients were divided into immunosuppressed (IS) and immunocompetent (IC) cohorts; the IS cohort was subdivided into presence of one and two or more immunosuppressive conditions. Clinical parameters were compared between cohorts and between IS subgroups. A competing risk model compared in-hospital mortality and time to discharge. A total of 907 patients were included, 716 (79%) were IC and 191 (21%) were IS. Within the IS cohort, 111 (58%) had one immunosuppressive condition and 80 (42%) had two or more conditions. The overall in-hospital mortality was 29%, with no differences between groups (IS 32%, IC 28%, p = 0.4211). There were no differences in in-hospital mortality (sub-distribution hazard ratio [sHR] 1.17, 95% confidence interval [CI] 0.88-1.56, p = 0.2827) or time to discharge (sHR 0.94, 95% CI 0.78-1.15, p = 0.5570). Independent mortality predictors for both cohorts included hypotension at 72 h (IS: p < 0.0001, IC: p < 0.0001) and early embolic stroke (IS: p < 0.0001, IC: p = 0.0272). Congestive heart failure was a mortality predictor in the IS cohort (p = 0.0089). Fever within 24 h (p = 0.0092) and early skin and soft tissue infections (p < 0.0001) were survival predictors in the IS cohort. SAB causes significant mortality regardless of pre-existing immune status, but immunosuppressed patients do not have an elevated risk of mortality relative to immunocompetent patients.

Comparison of pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a protocol for a systematic review incorporating network meta-analyses.

BACKGROUND: Delirium is characterized by acute changes in mental status including inattention, disorganized thinking, and altered level of consciousness, and is highly prevalent in critically ill adults. Delirium has adverse consequences for both patients and the healthcare system; however, at this time, no effective treatment exists. The identification of effective prevention strategies is therefore a clinical and research imperative. An important limitation of previous reviews of delirium prevention is that interventions were considered in isolation and only direct evidence was used. Our systematic review will synthesize all existing data using network meta-analysis, a powerful statistical approach that enables synthesis of both direct and indirect evidence. METHODS: We will search Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science from 1980 to March 2016. We will search the PROSPERO registry for protocols and the Cochrane Library for published systematic reviews. We will examine reference lists of pertinent reviews and search grey literature and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We will include randomized and quasi-randomized trials of critically ill adults evaluating any pharmacological, non-pharmacological, or multi-component intervention for delirium prevention, administered in or prior to (i.e., peri-operatively) transfer to the ICU. Two authors will independently screen search results and extract data from eligible studies. Risk of bias assessments will be completed on all included studies. To inform our network meta-analysis, we will first conduct conventional pair-wise meta-analyses for primary and secondary outcomes using random-effects models. We will generate our network meta-analysis using a Bayesian framework, assuming a common heterogeneity parameter across all comparisons, and accounting for correlations in multi-arm studies. We will perform analyses using WinBUGS software. DISCUSSION: This systematic review will address the existing knowledge gap regarding best practices for delirium prevention in critically ill adults by synthesizing evidence from trials of pharmacological, non-pharmacological, and multi-component interventions administered in or prior to transfer to the ICU. Use of network meta-analysis will clarify which delirium prevention strategies are most effective in improving clinical outcomes while causing least harm. The network meta-analysis is a novel approach and will provide knowledge users and decision makers with comparisons of multiple interventions of delirium prevention strategies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016036313.

Clinical prediction rules in Staphylococcus aureus bacteremia demonstrate the usefulness of reporting likelihood ratios in infectious diseases.

Infectious diseases specialists often use diagnostic tests to assess the probability of a disease based on knowledge of the diagnostic properties. It has become standard for published studies on diagnostic tests to report sensitivity, specificity and predictive values. Likelihood ratios are often omitted. We compared published clinical prediction rules in Staphylococcus aureus bacteremia to illustrate the importance of likelihood ratios. We performed a narrative review comparing published clinical prediction rules used for excluding endocarditis in S. aureus bacteremia. Of nine published clinical prediction rules, only three studies reported likelihood ratios. Many studies concluded that the clinical prediction rule could safely exclude endocarditis based on high sensitivity and high negative predictive value. Of the studies with similar high sensitivity and high negative predictive value, calculated negative likelihood ratios were able to differentiate and identify the best clinical prediction rule for excluding endocarditis. Compared to sensitivity, specificity and predictive values, likelihood ratios can be more directly used to interpret diagnostic test results to assist in ruling in or ruling out a disease. Therefore, a new standard should be set to include likelihood ratios in reporting of diagnostic tests in infectious diseases research.

A review of neuromuscular blockade in the critically ill patient.

The continuous administration of neuromuscular blocking agents is thought to be associated with a number of adverse effects and complications, including post-paralytic syndrome (characterized by persistent paralysis), muscle weakness, and the inability to wean from the ventilator despite discontinuation of the therapy. Consequently, clinical objectives emphasize administering only the dose necessary to optimize the effect of the drug and for the shortest possible time. This article provides an overview of the administration of neuromuscular blocking agents, from the perspective of a critical care pharmacist and critical care nurses. The complexities associated with pharmacological paralysis in critically ill patients warrants the comprehensive approach to care that multidisciplinary team members can provide.

Anticoagulation in continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) is a specialized intervention that is managed largely by critical care nurses who are educated in the theoretical and practical aspects of the therapy. CRRT is most commonly indicated for hemodynamically unstable patients who have acute renal failure and a narrow margin of tolerance for the rapid fluid shifts associated with traditional dialysis. Although the utilization of CRRT in the critical care setting is becoming more widespread, numerous factors need to be considered before therapy is initiated. The use of anticoagulation is a concern because of the associated risk of bleeding and thrombocytopenia. Nurses at the bedside must be expert in both managing CRRT and assisting in identifying patients who may be at potential risk when this form of treatment is in place. An overview of possible anticoagulants for use in CRRT is outlined in this article.

Evaluation of warm-up for improvement in flexibility.

The purpose of this investigation was to evaluate the effects of warming the joints by jogging and then stretching on increases in joint flexibility. Subjects were 51 students enrolled in a physical conditioning class assigned to a jog and then stretch (JS), stretch and no jog (S), or a control group (C). Both the JS and S groups performed a series of stretching exercises 2 days a week for 9 weeks, with the JS group jogging for 5 minutes prior to stretching. Subjects were pretested and posttested for shoulder, hamstrings, trunk, and ankle flexibility with a Leighton flexometer. Results of t-tests indicated that significant increases in flexibility occurred for all of the joint angles evaluated for both the JS and S groups with the exception of trunk flexibility for the JS group. An analysis of variance (ANOVA) of gain scores indicated a significant gain in ankle flexibility for the JS group compared to S and C groups. The S group produced a significant gain in trunk flexibility compared to the JS group. Both JS and S groups were effective in improving flexibility, but when the gain scores were compared the results were variable. The data from this study again demonstrate that increases in flexibility can occur as a result of a static stretching training program. However, the results do not support the claim that warming the muscles prior to stretching by jogging will result in significant increases for all of the joint angles evaluated. Both methods offer possible advantages associated with improving joint flexibility.

Uso de líquenes como indicadores biológicos de contaminación atmosférica; aplicación al Gran La Plata

Se contempla el uso de líquenes como indicadores biológicos de contaminación atmosférica en el área del Gran La Plata. Se han relevado ya las especies arboreas existentes en plazas y espacios abiertos y calles de la ciudad de La Plata y se han elegido cinco hospedantes (forofitos): tipa, paraíso, fresno, sófora y arce. Sobre ellos se han identificado 23 géneros de líquenes y, dentro de ellos 24 especies. Se proyecta aplicar una técnica de muestreo normalizada (perímetro y edad de los individuos hospedantes, altura desde el suelo, orientación) a tres áreas de características ecológicas naturalmente comparables pero potencialmente expuestas a diferentes grados de contaminación. Se aplicará, en principio, la metodología de Hoffman, para el establecimiento del "índice de pureza atmosférica", sobre la base de vigor, vitalidad y sociabilidad (grado de cobertura) de los líquenes, así como de índice ecológico (número promedio de otras epifitas asociadas a cada liquen sobre los mismos forofitos)

Uso de líquenes como indicadores biológicos de contaminación atmosférica; aplicación al Gran La Plata

Se contempla el uso de líquenes como indicadores biológicos de contaminación atmosférica en el área del Gran La Plata. Se han relevado ya las especies arboreas existentes en plazas y espacios abiertos y calles de la ciudad de La Plata y se han elegido cinco hospedantes (forofitos): tipa, paraíso, fresno, sófora y arce. Sobre ellos se han identificado 23 géneros de líquenes y, dentro de ellos 24 especies. Se proyecta aplicar una técnica de muestreo normalizada (perímetro y edad de los individuos hospedantes, altura desde el suelo, orientación) a tres áreas de características ecológicas naturalmente comparables pero potencialmente expuestas a diferentes grados de contaminación. Se aplicará, en principio, la metodología de Hoffman, para el establecimiento del "índice de pureza atmosférica", sobre la base de vigor, vitalidad y sociabilidad (grado de cobertura) de los líquenes, así como de índice ecológico (número promedio de otras epifitas asociadas a cada liquen sobre los mismos forofitos)