Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life

2015/16 seasonal vaccine effectiveness against hospitalisation with influenza a(H1N1)pdm09 and B among elderly people in Europe: Results from the I-MOVE+ project

We conducted a multicentre test-negative caseâ\u80\u93control study in 27 hospitals of 11 European countries to measure 2015/16 influenza vaccine effectiveness (IVE) against hospitalised influenza A(H1N1)pdm09 and B among people aged â\u89¥ 65 years. Patients swabbed within 7 days after onset of symptoms compatible with severe acute respiratory infection were included. Information on demographics, vaccination and underlying conditions was collected. Using logistic regression, we measured IVE adjusted for potential confounders. We included 355 influenza A(H1N1)pdm09 cases, 110 influenza B cases, and 1,274 controls. Adjusted IVE against influenza A(H1N1)pdm09 was 42% (95% confidence interval (CI): 22 to 57). It was 59% (95% CI: 23 to 78), 48% (95% CI: 5 to 71), 43% (95% CI: 8 to 65) and 39% (95% CI: 7 to 60) in patients with diabetes mellitus, cancer, lung and heart disease, respectively. Adjusted IVE against influenza B was 52% (95% CI: 24 to 70). It was 62% (95% CI: 5 to 85), 60% (95% CI: 18 to 80) and 36% (95% CI: -23 to 67) in patients with diabetes mellitus, lung and heart disease, respectively. 2015/16 IVE estimates against hospitalised influenza in elderly people was moderate against influenza A(H1N1)pdm09 and B, including among those with diabetes mellitus, cancer, lung or heart diseases

Ground level photosynthetically active radiation dynamics in stands of Acacia mearnsii De Wild

ABSTRACTThe objective is to study the dynamics of photosynthetic radiation reaching the soil surface in stands of Acacia mearnsii De Wild and its influence on height growth in stands. This fact gives rise to the formulation of the following hypothesis for this study: "The reduction of the incidence of light inside the stand of black wattle will cause the inflection point in its height growth when this reaches 4 to 5 m in height, i.e. when the stand is between 2 and 3 years of age". The study was conducted in stands in the state of Rio Grande do Sul, Brazil, where diameters at breast height, total height and photosynthetically active radiation available at ground level were measured. The frequency tended to be more intense when the age of the stands increases. It was evident that a reduction of light incidence inside the forest occurred, caused by canopy closure. Consequently, closed canopy propitiated the competition of plants. This has affected the conditions for growth in diameter and height of this species, reason why it becomes possible to conceive the occurrence of an inflection point in the growth of these two variables, confirming the formulated hypothesis

Critical analyses when modeling tree biomass to ensure additivity of its components

ABSTRACT It is presented the theme additivity of biomass of tree components. To evaluate and discuss this context, experimental information collected in forests of Acacia mearnsii De Wild. was used. Equations for components (stem and crown) and total biomass were fitted by means of two procedures: 1) generalized nonlinear least squares and 2) weighted-nonlinear seemingly unrelated regressions. Analyzing the performance of the estimators, it can be concluded that the two tested procedures are equivalent. On the other hand, this conclusion differs when evaluated the consistency and efficiency of the estimators. Fitting equations for the components and for the total biomass by an independent way is not realistic, because from a biological point of view the estimates of biomass are inconsistent, i.e., are not additive. The biomass estimates of the components and of the total, resulting from equations adjusted by means of systems of equations, provided narrower confidence intervals in relation to the equations adjusted independently, and is therefore more efficient. The second procedure presents better biological properties and statistics to estimate allometric equations for biomass of the components and for the total when compared with the independent estimation, thus it should be the method to be used

Carbon production from seasonal litterfall in the Brazilian Atlantic Forest

Forests play an important role in climate change, acting as a source or sink of carbon. There is, however, a lack of data regarding the carbon production from litterfall in tropical forests. The Atlantic Forest is one of the most distinguished forest types in Brazil, encompassing the Araucaria Forest. In this study, we assessed the seasonal carbon production from litterfall. Data were collected every season from 27 litter traps. Dry matter and carbon fraction were investigated and confronted with meteorological variables. Litterfall components were stratified into Brazilian pine leaves and twigs: broadleaved leaves, twigs, bark, reproductive material, and other material (miscellaneous).The Tukey test indicated significant differences among the carbon fractions for litter components. Seven key species were determinant in litterfall production. Brazilian pine leaves and twigs were the primary carbon source to the forest, followed by leaves and twigs from broadleaved species. Most carbon input from litterfall comes during spring and summer. We concluded that litterfall is a source of carbon and nutrient to the ecosystem. This study contributes to improving the Brazilian national greenhouse inventory and related reports addressed to climate change mitigation