Resolution of Clinical Signs of Ventilator-Associated Pneumonia in Trauma Patients

Objectives: The ATS/IDSA Ventilator-Associated Pneumonia (VAP) guidelines suggest that clinical improvement of VAP should be apparent within 3–6 days. This study evaluated resolution of clinical signs of VAP in trauma patients after diagnosis. Methods: Critically injured adults admitted to the trauma intensive care unit (ICU) from June 1, 2006, to December 31, 2007, and subsequently given a diagnosis of VAP were retrospectively assessed. Clinical signs, including derangements of maximum temperature (Tmax), white blood cell (WBC) count, and PaO2/FiO2, were evaluated on days 1–16 after VAP diagnosis. Data are presented as mean ± SD unless otherwise stated. Clinical parameters after VAP were compared using repeated-measures ANOVA with the Tukey test for multiple comparisons. Results: A total of 82 patients were identified. Data for the 34 patients without concurrent infections are presented. Demographic data include: Age 46 ± 17 years; 71% men; 94% blunt trauma; median (IQR) Injury Severity Score 29.5 (24–38); duration of mechanical ventilation 33 ± 27 days; ICU length of stay (LOS) 39 ± 25 days; hospital LOS 53 ± 33 days. Clinical signs following VAP diagnosis: Tmax (°F): Day 1=101.8 ± 1.3, Day 3=101.1 ± 1.1, Day 6=101.1 ± 1.4, Day 16=100.1 ± 3. Compared to Day 1, there was a significant reduction in Tmax at days 10, 11, 12, 13, 14, and 16 (p\u3c0.05 for all). WBC count (cells per microliter): day 1 = 12.9 ± 5, day 3 = 13.7 ± 5, day 6 = 14.4 ± 5, and day 16 = 13.8 ± 6. There was no significant difference in WBC on days 1–16 (p=0.42). PaO2/FiO2: day 1 = 232 ± 108, day 3 = 200 ± 87, day 6 = 218 ± 104, day 16 = 246 ± 126. Differences in PaO2/FiO2 on days 1–16 did not reach statistical significance (p=0.06). Conclusion: Improvement of clinical parameters after a VAP diagnosis is delayed in trauma patients. Alternative methods for determining resolution should be investigated. Published in To be published in Critical Care Medicine’s December 2009 supplement

Comparison of National Policy Frameworks for Marine Renewable Energy within the United Kingdom and France

A report prepared as part of the MERiFIC Project “Marine Energy in FAR Peripheral and Island Communities”The MERiFIC Project: MERiFIC is an EU project linking Cornwall and Finistère through the ERDF INTERREG IVa France (Manche) England programme. The project seeks to advance the adoption of marine energy in Cornwall and Finistère, with particular focus on the island communities of the Parc naturel marin d’Iroise and the Isles of Scilly. Project partners include Cornwall Council, University of Exeter, University of Plymouth and Cornwall Marine Network from the UK, and Conseil général du Finistère, Pôle Mer Bretagne, Technôpole Brest-Iroise, Parc naturel marin d’Iroise, IFREMER and Bretagne Développement Innovation from France. MERiFIC was launched on 13th September at the National Maritime Museum Cornwall and runs until June 2014. During this time, the partners aim to Develop and share a common understanding of existing marine energy resource assessment techniques and terminology; Identify significant marine energy resource ‘hot spots’ across the common area, focussing on the island communities of the Isles of Scilly and Parc Naturel Marin d’Iroise; Define infrastructure issues and requirements for the deployment of marine energy technologies between island and mainland communities; Identify, share and implement best practice policies to encourage and support the deployment of marine renewables; Identify best practice case studies and opportunities for businesses across the two regions to participate in supply chains for the marine energy sector; Share best practices and trial new methods of stakeholder engagement, in order to secure wider understanding and acceptance of the marine renewables agenda; Develop and deliver a range of case studies, tool kits and resources that will assist other regions. To facilitate this, the project is broken down into a series of work packages: WP1: Project Preparation; WP2: Project Management; WP3: Technology Support; WP4: Policy Issues; WP5: Sustainable Economic Development; WP6: Stakeholder Engagement; WP7: Communication and DisseminationThis report provides a comparative assessment of the wider planning, innovation and energy policy instruments relevant to marine renewable energy and applicable to the regions of Brittany in France and South West England. In addition to this, aspects of the wider institutional and political contexts in each country that have an adverse or positive effect upon policies for marine renewable energy (such as regionalisation, devolution or European legislation) are covered when considered appropriate and of value. The intention of this document is to highlight best-practice policies and highlight opportunities and examples of where these have been put into place both nationally and regionally within the two study areas. This work will then feed on to later MERiFIC documents, (specifically within work packages 5 and 6, concerning Sustainable Economic Development and Stakeholder Engagement respectively). The primary reference sources for this document are the two earlier MERiFIC report: National Policy Framework for Marine Renewable Energy within the United Kingdom and National Policy Framework for Marine Renewable Energy within France (Vantoch-Wood et al., 2012, Kablan et al., 2012)

National Policy Framework for Marine Renewable Energy within the United Kingdom

A report prepared as part of the MERiFIC Project "Marine Energy in Far Peripheral and Island Communities"The MERiFIC Project: MERiFIC is an EU project linking Cornwall and Finistère through the ERDF INTERREG IVa France (Manche) England programme. The project seeks to advance the adoption of marine energy in Cornwall and Finistère, with particular focus on the island communities of the Parc naturel marin d’Iroise and the Isles of Scilly. Project partners include Cornwall Council, University of Exeter, University of Plymouth and Cornwall Marine Network from the UK, and Conseil général du Finistère, Pôle Mer Bretagne, Technôpole Brest-Iroise, Parc naturel marin d’Iroise, IFREMER and Bretagne Développement Innovation from France. MERiFIC was launched on 13th September at the National Maritime Museum Cornwall and runs until June 2014. During this time, the partners aim to Develop and share a common understanding of existing marine energy resource assessment techniques and terminology; Identify significant marine energy resource ‘hot spots’ across the common area, focussing on the island communities of the Isles of Scilly and Parc Naturel Marin d’Iroise; Define infrastructure issues and requirements for the deployment of marine energy technologies between island and mainland communities; Identify, share and implement best practice policies to encourage and support the deployment of marine renewables; Identify best practice case studies and opportunities for businesses across the two regions to participate in supply chains for the marine energy sector; Share best practices and trial new methods of stakeholder engagement, in order to secure wider understanding and acceptance of the marine renewables agenda; Develop and deliver a range of case studies, tool kits and resources that will assist other regions. To facilitate this, the project is broken down into a series of work packages: WP1: Project Preparation; WP2: Project Management; WP3: Technology Support; WP4: Policy Issues; WP5: Sustainable Economic Development; WP6: Stakeholder Engagement; WP7: Communication and DisseminationThis document is intended to provide an introduction into the international, national and regional policy and legislation framework relevant to the deployment of marine renewable energy technologies within the UK, and specifically with a focus upon the South West and the county of Cornwall and its neighbouring Isles of Scilly. Within the context and scope of this document, devices that utilize wave, tidal stream, and floating wind within the marine environment are included within the definition of ‘marine renewable energy devices’ however limited focus is also given to offshore fixed wind turbines as it is recognised that, (although outside of the scope and context of this document and at a much further stage of technology maturity) there are many complimentarities between these technology groupings

Resolution of Clinical Signs in Trauma Intensive Care Unit Patients Following Diagnosis of Ventilator-Associated Pneumonia

PURPOSE: The ATS/IDSA Ventilator-Associated Pneumonia (VAP) guidelines suggest that clinical improvement of VAP should be apparent within 3-6 days. Anecdotally, such improvement has not been noted in trauma patients at our institution. The current study was conducted to evaluate resolution of clinical signs of VAP following diagnosis. METHODS: Critically injured adults admitted to the trauma intensive care unit (TICU) from 6/1/06-12/31/07 and subsequently diagnosed with VAP were retrospectively reviewed. Clinical signs, including derangements of maximum temperature (Tmax), white blood cell (WBC) count and Pa02/FiO2, were evaluated on days 1-16 following VAP diagnosis. Data are presented as mean ± SD unless otherwise stated. Clinical parameters following VAP were compared using repeated measures ANOVA with the Tukey test for multiple comparisons. RESULTS: A total of 82 patients were identified. Data for the 34 patients without concurrent infections are presented. Demographic data include: Age 46 ± 17 years; 71% males; 94% blunt trauma; median (IQR) Injury Severity Score 29.5 (24 to 38); duration of mechanical ventilation 33 ± 27 days; ICU length of stay (LOS) 39 ± 25 days; hospital LOS 53 ± 33 days. Clinical signs following VAP diagnosis (Figure): Tmax (°F): Day 1=101.8 ± 1.3, Day 3=101.1 ± 1.1, Day 6=101.1 ± 1.4, Day 16=100.1 ± 3. Compared to Day 1, there was a significant reduction in Tmax at Days 10, 11, 12, 13, 14 and 16 (p \u3c 0.05 for all). WBC count (cells/μL): Day 1=12.9 ± 5, Day 3=13.7 ± 5, Day 6=14.4 ± 5, Day 16=13.8 ± 6. There was no significant difference in WBC count on Days 1-16 (p=0.42). PaO2/FiO2: Day 1=232 ± 108, Day 3=200 ± 87, Day 6=218 ± 104, Day 16=246 ± 126. Differences in PaO2/FiO2 on Days 1-16 did not reach statistical significance (p=0.06). CONCLUSIONS: In trauma patients, improvement of clinical parameters following diagnosis of VAP is delayed beyond the 3-6 day timeframe suggested in the ATS/IDSA guidelines. Alternative methods for determining resolution of VAP in trauma patients should be investigated. METHODS INTRODUCTIO

Application of Policy Instruments for Regional Support of Marine Renewable Energy

EWTEC 2013, 10th European Wave and Tidal Energy Conference, Aalborg, Denmark, 2-5 September 2013Copyright © 2013 European Wave and Tidal Energy ConferenceThe potential future benefits of having a strong marine renewable energy (MRE) sector within a country or region are both well recognised and well documented (Kablan et al., 2012; Vantoch-Wood et al., 2012; PMSS, 2010). Several basic requirements are needed to commercialise MRE in coastal regions: • adequate primary resource within an economic distance from the shore; • accessible and available harbour facilities; • a practicable onshore high voltage connection (with available capacity); • an absence of any strongly prohibitive environmental sensitivity There are also many legal, economic and other social considerations, such as predominant marine spatial designations, public acceptability and regional political agendas, that need to be both understood and aligned correctly before project development justifies commercial pursuit. The many risks associated with these non-technical factors are multiplied when considering less mature MRE technologies such as wave, tidal and floating wind, and their higher associated costs (e.g. design liability, insurance, deployment). Additionally, remote and peripheral regions see complicating factors arise from a range of geographical limitations on accessibility, communications, skills/employment difficulties and other potentially problematic logistics (Trama TecnoAmbiental et al., 2012). Cumulatively, the hurdles associated with MRE commercialisation in remote and peripheral regions can be substantial. Opportunities for cost and risk reduction within the development and market growth stage can enable or block successful deployment. This paper identifies some of the opportunities for collaborative learning and cost reduction emerging from a two stage stakeholder consultation process carried out in Cornwall, UK and Finistère, France. This covers opportunities within the application of legal and regulatory compliance, innovation and business support policy, social and educational policy opportunities and the identification of specific technology areas that (from a non-technical perspective) present opportunities for collaboration and exploitation for mutual benefit, such as complementary assets or relative levels of technology maturity. It should be noted that the opportunities identified are not certainties. They have ‘potential’ in that if adopted they may reduce the overall non-technical hurdles (and therefore risk and cost as mentioned earlier) to commercialisation of MRE within both regions, and relative to being overcome separately. This is likely only if adequate funding, time and commitment is provided, and most likely with the leadership and support of key public sector bodies

Application of Policy Instruments for Regional Support of Marine Renewable Energy

EWTEC 2013, 10th European Wave and Tidal Energy Conference, Aalborg, Denmark, 2-5 September 2013Copyright © 2013 European Wave and Tidal Energy ConferenceThe potential future benefits of having a strong marine renewable energy (MRE) sector within a country or region are both well recognised and well documented (Kablan et al., 2012; Vantoch-Wood et al., 2012; PMSS, 2010). Several basic requirements are needed to commercialise MRE in coastal regions: • adequate primary resource within an economic distance from the shore; • accessible and available harbour facilities; • a practicable onshore high voltage connection (with available capacity); • an absence of any strongly prohibitive environmental sensitivity There are also many legal, economic and other social considerations, such as predominant marine spatial designations, public acceptability and regional political agendas, that need to be both understood and aligned correctly before project development justifies commercial pursuit. The many risks associated with these non-technical factors are multiplied when considering less mature MRE technologies such as wave, tidal and floating wind, and their higher associated costs (e.g. design liability, insurance, deployment). Additionally, remote and peripheral regions see complicating factors arise from a range of geographical limitations on accessibility, communications, skills/employment difficulties and other potentially problematic logistics (Trama TecnoAmbiental et al., 2012). Cumulatively, the hurdles associated with MRE commercialisation in remote and peripheral regions can be substantial. Opportunities for cost and risk reduction within the development and market growth stage can enable or block successful deployment. This paper identifies some of the opportunities for collaborative learning and cost reduction emerging from a two stage stakeholder consultation process carried out in Cornwall, UK and Finistère, France. This covers opportunities within the application of legal and regulatory compliance, innovation and business support policy, social and educational policy opportunities and the identification of specific technology areas that (from a non-technical perspective) present opportunities for collaboration and exploitation for mutual benefit, such as complementary assets or relative levels of technology maturity. It should be noted that the opportunities identified are not certainties. They have ‘potential’ in that if adopted they may reduce the overall non-technical hurdles (and therefore risk and cost as mentioned earlier) to commercialisation of MRE within both regions, and relative to being overcome separately. This is likely only if adequate funding, time and commitment is provided, and most likely with the leadership and support of key public sector bodies

Resolution of Clinical and Laboratory Abnormalities after Diagnosis of Ventilator-Associated Pneumonia in Trauma Patients

Background: Guidelines advise that patients with ventilator-associated pneumonia (VAP) should respond clinically by Day 3 of antibiotics. White blood cell (WBC) count, maximum temperature (Tmax), and PaO2:FIO2 ratio are all said to respond significantly by Day 6. Resolution of abnormalities has not been evaluated in trauma patients. Methods: Retrospective review of trauma patients with VAP. The WBC count, Tmax, and PaO2:FIO2 were evaluated for 16 days after diagnosis. Patients were grouped into uncomplicated VAP, complicated VAP (those with inadequate empirical therapy [IEAT], VAP relapse/superinfection, or acute respiratory distress syndrome), and concurrent infection +VAP (those also infected at another site). Results: There were 126 patients (uncomplicated VAP= 29, complicated VAP = 69, and concurrent infection + VAP = 28). The mean Tmax in patients with uncomplicated VAP decreased significantly from diagnosis to Day 4 (Day 1: 39 – 0.5°C vs. Day 4: 38.6 – 0.7°C; p = 0.028) but never normalized. Their WBC counts and PaO2:FIO2 did not change significantly over the 16-day follow-up and never normalized.When comparing the three groups, the probability of resolving all three abnormalities was not different (p = 0.5). Conclusions: Clinical and laboratory abnormalities in critically injured patients with VAP do not resolve as quickly as suggested in the guidelines. Future studies should evaluate new methods to determine the response to antibiotic therapy in critically injured patients with VAP

Race, Socioeconomic Status, and Treatment Center Are Associated with Insulin Pump Therapy in Youth in the First Year Following Diagnosis of Type 1 Diabetes

Background: Increasing numbers of children and adolescents with type 1 diabetes (T1D) have been placed on insulin pump therapy. Nevertheless, data are limited regarding patterns of pump use during the first year of treatment and the clinical and socioeconomic factors associated with early use of pump therapy. Therefore, we sought to determine factors associated with pump therapy within the first year of diagnosis in youth enrolled in the Pediatric Diabetes Consortium (PDC) T1D New-Onset (NeOn) Study. Subjects and Methods: The NeOn Study includes youth <19 years old at T1D diagnosis who have been followed from the time of diagnosis at seven U.S. pediatric diabetes centers. Cox regression was used to determine factors associated with transition from injection to pump therapy during the first year of T1D in 1,012 participants. Results: Twenty-seven percent (n=254) of participants began pump therapy within the first year of diagnosis, ranging from 18% to 59% among the seven centers. After adjusting for center effect, factors associated with pump use in multivariate analysis included private health insurance (37% vs. 7%; P<0.001), having annual household income over $100,000 (50% vs. 15%; P<0.001), and non-Hispanic white race (36% vs. 11%; P<0.001). The hemoglobin A1c level did not appear to influence the decision to initiate pump use. Conclusions: Participants of non-Hispanic white race and higher socioeconomic status were more likely to be placed on pumps during the first year. Further investigations are needed to gain a better understanding of barriers to use of pumps in youth with T1D, especially in disadvantaged and minority families.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140353/1/dia.2013.0132.pd

Cetaceans have complex brains for complex cognition

MEDLINE® is the source for the citation and abstract of this record.Peer reviewedPublisher PD