Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial

Context Goal-directed resuscitation for severe sepsis and septic shock has been reported to reduce mortality when applied in the emergency department. Objective To test the hypothesis of noninferiority between lactate clearance and central venous oxygen saturation (ScvO2) as goals of early sepsis resuscitation. Design, Setting, and Patients Multicenter randomized, noninferiority trial involving patients with severe sepsis and evidence of hypoperfusion or septic shock who were admitted to the emergency department from January 2007 to January 2009 at 1 of 3 participating US urban hospitals. Interventions We randomly assigned patients to 1 of 2 resuscitation protocols. The ScvO2 group was resuscitated to normalize central venous pressure, mean arterial pressure, and ScvO2 of at least 70%; and the lactate clearance group was resuscitated to normalize central venous pressure, mean arterial pressure, and lactate clearance of at least 10%. The study protocol was continued until all goals were achieved or for up to 6 hours. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. Main Outcome Measure The primary outcome was absolute in-hospital mortality rate; the noninferiority threshold was set at Δ equal to −10%. Results Of the 300 patients enrolled, 150 were assigned to each group and patients were well matched by demographic, comorbidities, and physiological features. There were no differences in treatments administered during the initial 72 hours of hospitalization. Thirty-four patients (23%) in the ScvO2 group died while in the hospital (95% confidence interval [CI], 17%-30%) compared with 25 (17%; 95% CI, 11%-24%) in the lactate clearance group. This observed difference between mortality rates did not reach the predefined −10% threshold (intent-to-treat analysis: 95% CI for the 6% difference, −3% to 15%). There were no differences in treatment-related adverse events between the groups. Conclusion Among patients with septic shock who were treated to normalize central venous and mean arterial pressure, additional management to normalize lactate clearance compared with management to normalize ScvO2 did not result in significantly different in-hospital mortality

Fantastically reasonable: ambivalence in the representation of science and technology in super-hero comics

A long-standing contrast in academic discussions of science concerns its perceived disenchanting or enchanting public impact. In one image, science displaces magical belief in unknowable entities with belief in knowable forces and processes and reduces all things to a single technical measure. In the other, science is itself magically transcendent, expressed in technological adulation and an image of scientists as wizards or priests. This paper shows that these contrasting images are also found in representations of science in super-hero comics, which, given their lowly status in Anglo-American culture, would seem an unlikely place to find such commonality with academic discourse. It is argued that this is evidence that the contrast constitutes an ambivalence arising from the dilemmas that science poses; they are shared rhetorics arising from and reflexively feeding a set of broad cultural concerns. This is explored through consideration of representations of science at a number of levels in the comics, with particular focus on the science-magic constellation, and enchanted and disenchanted imagery in representations of technology and scientists. It is concluded that super-hero comics are one cultural arena where the public meaning of science is actively worked out, an activity that unites “expert” and “non-expert” alike

A practical handbook on rat destruction, by C. Leopold Claremont ...

Pages 189-190 incorrectly numbered 179-180.Mode of access: Internet