Impact of bedside open lung biopsies on the management of mechanically ventilated immunocompromised patients with acute respiratory distress syndrome of unknown etiology.

BACKGROUND: Open lung biopsy (OLB) is helpful in the management of patients with acute respiratory distress syndrome (ARDS) of unknown etiology. We determine the impact of surgical lung biopsies performed at the bedside on the management of patients with ARDS. METHODS: We reviewed all consecutive cases of patients with ARDS who underwent a surgical OLB at the bedside in a medical intensive care unit between 1993 and 2005. RESULTS: Biopsies were performed in 19 patients mechanically ventilated for ARDS of unknown etiology despite extensive diagnostic process and empirical therapeutic trials. Among them, 17 (89%) were immunocompromised and 10 patients experienced hematological malignancies. Surgical biopsies were obtained after a median (25%-75%) mechanical ventilation of 5 (2-11) days; mean (+/-SD) Pao(2)/Fio(2) ratio was 119.3 (+/-34.2) mm Hg. Histologic diagnoses were obtained in all cases and were specific in 13 patients (68%), including 9 (47%) not previously suspected. Immediate complications (26%) were local (pneumothorax, minimal bleeding) without general or respiratory consequences. The biopsy resulted in major changes in management in 17 patients (89%). It contributed to a decision to limit care in 12 of 17 patients who died. CONCLUSION: Our data confirm that surgical OLB may have an important impact on the management of patients with ARDS of unknown etiology after extensive diagnostic process. The procedure can be performed at the bedside, is safe, and has a high diagnostic yield leading to major changes in management, including withdrawal of vital support, in the majority of patients

Timing, diagnosis, and treatment of surgical site infections after colonic surgery: prospective surveillance of 1263 patients

Surgical site infections (SSIs) are the most frequent complication after colorectal surgery and have a major impact on length of stay and costs. To analyse the incidence, timing, and treatment of SSIs within 30 days after colonic surgery. This was a quality improvement project through retrospective analysis of consecutive colonic surgeries between February 2012 and October 2017 at Lausanne University Hospital (CHUV). SSIs were prospectively assessed by an independent national surveillance programme (www.swissnoso.ch) up to 30 postoperative days. Treatment strategies including drainage of infection (direct wound opening or percutaneous) and surgical management were reviewed. The study cohort included 1263 patients with 532 procedures (42%) performed as emergencies. SSIs were observed in 271 patients (21%), occurring at median postoperative day (POD) 9 (interquartile range (IQR): 4-16). Specifically, 53 (4%) were superficial incisional, 65 (5%) deep incisional, and 153 (12%) organ space infections (anastomotic insufficiency included). Superficial incisional SSI occurred at a median of POD 10.5 (IQR: 7-15), deep incisional at a median of POD 10 (8-15) and organ space at a median of POD 8 (5-11). Diagnosis was performed post discharge in 64 cases (24%). Whereas 47% of organ space infections were detected by POD 7, this rate was only 26% for superficial and deep incisional infections (P = 0.003). Surgical management was necessary in 133 cases (49%), and the remaining cases were managed by drainage without general anaesthesia (138 cases, 51%). Organ space infections occurred early in the postoperative course, whereas incisional infections were mostly detected post discharge over the entire 30-day observation period, emphasizing the importance of proper follow-up using a systematic, complete and independent surveillance programme

Risk prediction of developing venous thrombosis in combined oral contraceptive users.

Venous thromboembolism (VTE) is a complex multifactorial disease influenced by genetic and environmental risk factors. An example for the latter is the regular use of combined oral contraceptives (CC), which increases the risk to develop VTE by 3 to 7 fold, depending on estrogen dosage and the type of progestin present in the pill. One out of 1'000 women using CC develops thrombosis, often with life-long consequences; a risk assessment is therefore necessary prior to such treatment. Currently known clinical risk factors associated with VTE development in general are routinely checked by medical doctors, however they are far from being sufficient for risk prediction, even when combined with genetic tests for Factor V Leiden and Factor II G20210A variants. Thus, clinical and notably genetic risk factors specific to the development of thrombosis associated with the use of CC in particular should be identified. Step-wise (logistic) model selection was applied to a population of 1622 women using CC, half of whom (794) had developed a thromboembolic event while using contraceptives. 46 polymorphisms and clinical parameters were tested in the model selection and a specific combination of 4 clinical risk factors and 9 polymorphisms were identified. Among the 9 polymorphisms, there are two novel genetic polymorphisms (rs1799853 and rs4379368) that had not been previously associated with the development of thromboembolic event. This new prediction model outperforms (AUC 0.71, 95% CI 0.69-0.74) previously published models for general thromboembolic events in a cross-validation setting. Further validation in independent populations should be envisaged. We identified two new genetic variants associated to VTE development, as well as a robust prediction model to assess the risk of thrombosis for women using combined oral contraceptives. This model outperforms current medical practice as well as previously published models and is the first model specific to CC use

Stereoselective chromium- and molybdenum-mediated transformations of arenes

Tricarbonylchromium-mediated dearomatization provides a rapid access to substituted cyclohexadienes. Efficient asymmetric routes to planar chiral arene complexes and to substituted cyclohexadienes have been developed. The article sums up the main features of this chemistry. Highly enantiomerically enriched ortho-substituted benzaldehyde complexes are accessible via asymmetric lithiation followed by trapping with electrophiles. In different solvents, the trimethylsilyl complex exhibits [alpha] values ranging from −174 to +108 for the same enantiomer. Details of two asymmetric syntheses of natural products are given: the alkaloid lasubine I starting from a highly enantiomerically enriched planar chiral arene complex and the marine furanosesquiterpene acetoxytubipofuran. The latter is assembled via asymmetric dearomatization of a benzaldehyde imine complex. Other key steps include an Eschenmoser-Claisen rearrangement and a regio- and diastereoselective Pd-catalyzed allylic substitution. The final section deals with labile arene metal complexes. For the first time, dearomatization reactions mediated by the Mo(CO)3 group have been realized. The reactions show strong analogies to the Cr(CO)3-mediated reactions, but exhibit also marked differences: the arene-Mo bond is stronger, but more labile, and the sequential double additions show different selectivities compared to the chromium analog

On the Second Law of thermodynamics and the piston problem

The piston problem is investigated in the case where the length of the cylinder is infinite (on both sides) and the ratio $m/M$ is a very small parameter, where $m$ is the mass of one particle of the gaz and $M$ is the mass of the piston. Introducing initial conditions such that the stochastic motion of the piston remains in the average at the origin (no drift), it is shown that the time evolution of the fluids, analytically derived from Liouville equation, agrees with the Second Law of thermodynamics. We thus have a non equilibrium microscopical model whose evolution can be explicitly shown to obey the two laws of thermodynamics.Comment: 29 pages, 9 figures submitted to Journal of Statistical Physics (2003

GPS-Prot: A web-based visualization platform for integrating host-pathogen interaction data

<p>Abstract</p> <p>Background</p> <p>The increasing availability of HIV-host interaction datasets, including both physical and genetic interactions, has created a need for software tools to integrate and visualize the data. Because these host-pathogen interactions are extensive and interactions between human proteins are found within many different databases, it is difficult to generate integrated HIV-human interaction networks.</p> <p>Results</p> <p>We have developed a web-based platform, termed GPS-Prot <url>http://www.gpsprot.org</url>, that allows for facile integration of different HIV interaction data types as well as inclusion of interactions between human proteins derived from publicly-available databases, including MINT, BioGRID and HPRD. The software has the ability to group proteins into functional modules or protein complexes, generating more intuitive network representations and also allows for the uploading of user-generated data.</p> <p>Conclusions</p> <p>GPS-Prot is a software tool that allows users to easily create comprehensive and integrated HIV-host networks. A major advantage of this platform compared to other visualization tools is its web-based format, which requires no software installation or data downloads. GPS-Prot allows novice users to quickly generate networks that combine both genetic and protein-protein interactions between HIV and its human host into a single representation. Ultimately, the platform is extendable to other host-pathogen systems.</p

Reconstructing institutional complexity in practice: A relational model of institutional work and complexity

This article develops a relational model of institutional work and complexity. This model advances current institutional debates on institutional complexity and institutional work in three ways. First, it provides a relational and dynamic perspective on institutional complexity by explaining how constellations of logics - and their degree of internal contradiction - are constructed rather than given. Second, it refines our current understanding of agency, intentionality and effort in institutional work by demonstrating how different dimensions of agency interact dynamically in the institutional work of reconstructing institutional complexity. Third, it situates institutional work in the everyday practice of individuals coping with the institutional complexities of their work. In doing so, it reconnects the construction of institutionally complex settings to the actions and interactions of the individuals who inhabit them