Impact of staffing a surgical intermediate care unit with a critical care specialist.

AIM: To assess the impact of reorganising an 11-bed surgical intermediate care unit (IMCU) from an open to a semi-closed system in a Swiss University Hospital by adding a critical care specialist (CCS). METHODS: This was a cohort study including adult IMCU patients enrolled in an Enhanced Recovery After Surgery protocol in the Department of Visceral Surgery, Lausanne University Hospital, from 1 February 2014 to 31 January 2016. Medical supervision by a CCS was implemented on 1 February 2015. RESULTS: Introduction of a CCS in a surgical IMCU significantly reduced intensive care unit length of stay (p = 0.005) and potentially preventable operation (p = 0.04) for patients undergoing oesophageal surgery. A CCS in IMCU also proved to significantly reduce readmission in IMCU for hepatic surgery patients (p = 0.04). For other sub-specialties (colorectal, pancreatic and gastric bypass surgery) no significant difference could be found. CONCLUSIONS: Reorganisation of a surgical IMCU from an open to a semi-closed system by implementing supervision by a CCS decreased length of stay and complications for the most fragile surgical patients (oesophageal and hepatic patients) after 12 months of implementation.

A walk in the maze: variation in Late Jurassic tridactyl dinosaur tracks from the Swiss Jura Mountains (NW Switzerland).

BACKGROUND: Minute to medium-sized (footprint length (FL) less than 30 cm) tridactyl dinosaur tracks are the most abundant in the Late Jurassic tracksites of Highway A16 (Reuchenette Formation, Kimmeridgian) in the Jura Mountains (NW Switzerland). During excavations, two morphotypes, one gracile and one robust, were identified in the field. Furthermore, two large-sized theropod ichnospecies (Megalosauripus transjuranicus and Jurabrontes curtedulensis) and an ornithopod-like morphotype (Morphotype II) have recently been described at these sites. METHODS: The quality of morphological preservation (preservation grade), the depth of the footprint, the shape variation, and the footprint proportions (FL/footprint width (FW) ratio and mesaxony) along the trackways have been analyzed using 3D models and false-color depth maps in order to determine the exact number of small to medium-sized morphotypes present in the tracksites. RESULTS: The study of footprints (n = 93) recovered during the excavations has made it possible to identify and characterize the two morphotypes distinguished in the field. The gracile morphotype is mainly characterized by a high FL/FW ratio, high mesaxony, low divarication angles and clear, sharp claw marks, and phalangeal pads (2-3-4). By contrast, the robust morphotype is characterized by a lower FL/FW ratio, weaker mesaxony, slightly higher divarication angles and clear, sharp claw marks (when preserved), whereas the phalangeal pads are not clearly preserved although they might be present. DISCUSSION: The analysis does not allow the two morphotypes to be associated within the same morphological continuum. Thus, they cannot be extramorphological variations of similar tracks produced by a single trackmaker. Comparison of the two morphotypes with the larger morphotypes described in the formation (M. transjuranicus, J. curtedulensis, and Morphotype II) and the spatio-temporal relationships of the trackways suggest that the smaller morphotypes cannot reliably be considered as small individuals of any of the larger morphotypes. The morphometric data of some specimens of the robust morphotype (even lower values for the length/width ratio and mesaxony) suggest that more than one ichnotaxon might be represented within the robust morphotype. The features of the gracile morphotype (cf. Kalohipus isp.) are typical of "grallatorid" ichnotaxa with low mesaxony whereas those of the robust morphotype (cf. Therangospodus isp. and Therangospodus? isp.) are reminiscent of Therangospodus pandemicus. This work sheds new light on combining an analysis of variations in footprint morphology through 3D models and false-color depth maps, with the study of possible ontogenetic variations and the identification of small-sized tridactyl ichnotaxa for the description of new dinosaur tracks.

Megalosauripus transjuranicus ichnosp. nov. A new Late Jurassic theropod ichnotaxon from NW Switzerland and implications for tridactyl dinosaur ichnology and ichnotaxomy.

A new ichnospecies of a large theropod dinosaur, Megalosauripus transjuranicus, is described from the Reuchenette Formation (Early-Late Kimmeridgian, Late Jurassic) of NW Switzerland. It is based on very well-preserved and morphologically-distinct tracks (impressions) and several trackways, including different preservational types from different tracksites and horizons. All trackways were excavated along federal Highway A16 near Courtedoux (Canton Jura) and systematically documented in the field including orthophotos and laserscans. The best-preserved tracks were recovered and additional tracks were casted. Megalosauripus transjuranicus is characterized by tridactyl tracks with clear claw and digital pad impressions, and notably an exceptionally large and round first phalangeal pad on the fourth digit (PIV1) that is connected to digit IV and forms the round heel area. Due to this combination of features, M. transjuranicus clearly is of theropod (and not ornithopod) origin. M. transjuranicus is compared to other Megalosauripus tracks and similar ichnotaxa and other unassigned tracks from the Early Jurassic to Early Cretaceous. It is clearly different from other ichnogenera assigned to large theropods such as Eubrontes-Grallator from the Late Triassic and Early Jurassic or Megalosauripus-Megalosauropus-Bueckeburgichnus and Therangospodus tracks from the Late Jurassic and Early Cretaceous. A second tridactyl morphotype (called Morphotype II) is different from Megalosauripus transjuranicus in being subsymmetric, longer than wide (sometimes almost as wide as long), with blunt toe impressions and no evidence for discrete phalangeal pad and claw marks. Some Morphotype II tracks are found in trackways that are assigned to M. transjuranicus, to M.? transjuranicus or M. cf. transjuranicus indicating that some Morphotype II tracks are intra-trackway preservational variants of a morphological continuum of Megalosauripus transjuranicus. On the other hand, several up to 40 steps long trackways very consistently present Morphotype II features (notably blunt digits) and do not exhibit any of the features that are typical for Megalosauripus (notably phalangeal pads). Therefore, it is not very likely that these tracks are preservational variants of Megalosauripus transjuranicus or Megalosauripus isp. These trackways are interpreted to have been left by an ornithopod dinosaur. The high frequency of large theropod tracks in tidal-flat deposits of the Jura carbonate platform, associated on single ichnoassemblages with minute to medium-sized tridactyl and tiny to large sauropod tracks has important implications for the dinosaur community and for paleoenvironmental and paleogeographical reconstructions. As with most other known occurrences of Megalosauripus tracks, M. transjuranicus is found in coastal settings, which may reflect the preference of their theropod trackmakers for expanded carbonate flats where food was abundant.

Low C-reactive protein values at admission predict mortality in patients with severe community-acquired pneumonia caused by Streptococcus pneumoniae that require intensive care management.

PURPOSE: To identify risk factors associated with mortality in patients with severe community-acquired pneumonia (CAP) caused by S. pneumoniae who require intensive care unit (ICU) management, and to assess the prognostic values of these risk factors at the time of admission. METHODS: Retrospective analysis of all consecutive patients with CAP caused by S. pneumoniae who were admitted to the 32-bed medico-surgical ICU of a community and referral university hospital between 2002 and 2011. Univariate and multivariate analyses were performed on variables available at admission. RESULTS: Among the 77 adult patients with severe CAP caused by S. pneumoniae who required ICU management, 12 patients died (observed mortality rate 15.6%). Univariate analysis indicated that septic shock and low C-reactive protein (CRP) values at admission were associated with an increased risk of death. In a multivariate model, after adjustment for age and gender, septic shock [odds ratio (OR), confidence interval 95%; 4.96, 1.11-22.25; p = 0.036], and CRP (OR 0.99, 0.98-0.99 p = 0.034) remained significantly associated with death. Finally, we assessed the discriminative ability of CRP to predict mortality by computing its receiver operating characteristic curve. The CRP value cut-off for the best sensitivity and specificity was 169.5 mg/L to predict hospital mortality with an area under the curve of 0.72 (0.55-0.89). CONCLUSIONS: The mortality of patients with S. pneumoniae CAP requiring ICU management was much lower than predicted by severity scores. The presence of septic shock and a CRP value at admission <169.5 mg/L predicted a fatal outcome.