Surviving sepsis: going beyond the guidelines

The Surviving Sepsis Campaign is a global effort to improve the care of patients with severe sepsis and septic shock. The first Surviving Sepsis Campaign Guidelines were published in 2004 with an updated version published in 2008. These guidelines have been endorsed by many professional organizations throughout the world and come regarded as the standard of care for the management of patients with severe sepsis. Unfortunately, most of the recommendations of these guidelines are not evidence-based. Furthermore, the major components of the 6-hour bundle are based on a single-center study whose validity has been recently under increasing scrutiny. This paper reviews the validity of the Surviving Sepsis Campaign 6-hour bundle and provides a more evidence-based approach to the initial resuscitation of patients with severe sepsis

Towards self-organized service-oriented multi-agent systems

The demand for large-scale systems running in complex and even chaotic environments requires the consideration of new paradigms and technologies that provide flexibility, robustness, agility and responsiveness. Multiagents systems is pointed out as a suitable approach to address this challenge by offering an alternative way to design control systems, based on the decentralization of control functions over distributed autonomous and cooperative entities. However, in spite of their enormous potential, they usually lack some aspects related to interoperability, optimization in decentralized structures and truly self-adaptation. This paper discusses a new perspective to engineer adaptive complex systems considering a 3-layer framework integrating several complementary paradigms and technologies. In a first step, it suggests the integration of multi-agent systems with service-oriented architectures to overcome the limitations of interoperability and smooth migration, followed by the use of technology enablers, such as cloud computing and wireless sensor networks, to provide a ubiquitous and reconfigurable environment. Finally, the resulted service-oriented multi-agent system should be enhanced with biologically inspired techniques, namely self-organization, to reach a truly robust, agile and adaptive system

Recent developments and future trends of industrial agents

The agent technology provides a new way to design and engineer control solutions based on the decentralization of control over distributed structures, addressing the current requirements for modern control systems in industrial domains. This paper presents the current situation of the development and deployment of agent technology, discussing the initiatives and the current trends faced for a wider dissemination and industrial adoption, based on the work that is being carried out by the IEEE IES Technical Committee on Industrial Agents

Hypertensive emergency and type 2 myocardial infarction resulting from pheochromocytoma and concurrent capnocytophaga canimorsus infection

A diagnosis of myocardial infarction is made using a combination of clinical presentation, electrocardiogram and cardiac biomarkers. However, myocardial infarction can be caused by factors other than coronary artery plaque rupture and thrombosis. We describe an interesting case presenting with hypertensive emergency and type 2 myocardial infarction resulting from Pheochromocytoma associated with Capnocytophaga canimorsus infection from a dog bite. We also review current literature on the management of hypertensive emergency and Pheochromocytoma

24 segment high field permanent sextupole magnets

We report on the design, construction, and magnetic field measurements of a system of high field sextupole magnets made from NdFeB compounds. The magnets are utilized as a focusing system for neutral hydrogen (or deuterium) atoms in a polarized atomic beam source based on Stern-Gerlach spin separation. Each magnet consists of 24 segments of permanently magnetized material differing in remanence and coercivity to reduce demagnetization. According to quadratic extrapolation to the pole tip the magnetic flux density reaches values of up to B-0=1.69 T. Three-dimensional field calculations using the MAFIA code were carried out to optimize the magnet performance and to avoid demagnetization by selecting appropriate materials for the individual segments. Measurements of the radial, azimuthal, and longitudinal magnetic flux density distributions were carried out by means of a small Hall probe (100x200x15 mu m(3)). The measurements with the small probe permitted to extract experimentally higher order multipole components very close (similar to 100 mu m) to the inner surface. Experimental values obtained are compared to predictions based on MAFIA calculations and on the Halbach formalism. (C) 2000 American Institute of Physics. [S0034-6748(00)05309-0]

Dynamic and volumetric variables reliably predict fluid responsiveness in a porcine model with pleural effusion

Background: The ability of stroke volume variation (SVV), pulse pressure variation (PPV) and global end-diastolic volume (GEDV) for prediction of fluid responsiveness in presence of pleural effusion is unknown. The aim of the present study was to challenge the ability of SVV, PPV and GEDV to predict fluid responsiveness in a porcine model with pleural effusions. Methods: Pigs were studied at baseline and after fluid loading with 8 ml kg−1 6% hydroxyethyl starch. After withdrawal of 8 ml kg−1 blood and induction of pleural effusion up to 50 ml kg−1 on either side, measurements at baseline and after fluid loading were repeated. Cardiac output, stroke volume, central venous pressure (CVP) and pulmonary occlusion pressure (PAOP) were obtained by pulmonary thermodilution, whereas GEDV was determined by transpulmonary thermodilution. SVV and PPV were monitored continuously by pulse contour analysis. Results: Pleural effusion was associated with significant changes in lung compliance, peak airway pressure and stroke volume in both responders and non-responders. At baseline, SVV, PPV and GEDV reliably predicted fluid responsiveness (area under the curve 0.85 (p<0.001), 0.88 (p<0.001), 0.77 (p = 0.007). After induction of pleural effusion the ability of SVV, PPV and GEDV to predict fluid responsiveness was well preserved and also PAOP was predictive. Threshold values for SVV and PPV increased in presence of pleural effusion. Conclusions: In this porcine model, bilateral pleural effusion did not affect the ability of SVV, PPV and GEDV to predict fluid responsiveness

A more realistic representation of overshoot at the base of the solar convective envelope as seen by helioseismology

The stratification near the base of the Sun's convective envelope is governed by processes of convective overshooting and element diffusion, and the region is widely believed to play a key role in the solar dynamo. The stratification in that region gives rise to a characteristic signal in the frequencies of solar p modes, which has been used to determine the depth of the solar convection zone and to investigate the extent of convective overshoot. Previous helioseismic investigations have shown that the Sun's spherically symmetric stratification in this region is smoother than that in a standard solar model without overshooting, and have ruled out simple models incorporating overshooting, which extend the region of adiabatic stratification and have a more-or-less abrupt transition to subadiabatic stratification at the edge of the overshoot region. In this paper we consider physically motivated models which have a smooth transition in stratification bridging the region from the lower convection zone to the radiative interior beneath. We find that such a model is in better agreement with the helioseismic data than a standard solar model.Comment: 18 pages, 4 tables, 24 figures - to appear in MNRAS (version a: equation 9 corrected

Glutamine supplementation

Intravenous glutamine supplementation is standard care when parenteral nutrition is given for critical illness. There are data of a reduced mortality when glutamine supplementation is given. In addition, standard commercial products for parenteral nutrition do not contain any glutamine due to glutamine instability in aqueous solutions. For the majority of critical ill patients who are fed enterally, the available evidence is insufficient to recommend glutamine supplementation. Standard formulation of enteral nutrition contains some glutamine: 2-4 g/L. However, this dose is insufficient to normalize glutamine plasma concentration

Detection of Plant DNA in the Bronchoalveolar Lavage of Patients with Ventilator-Associated Pneumonia

BACKGROUND: Hospital-acquired infections such as nosocomial pneumonia are a serious cause of mortality for hospitalized patients, especially for those admitted to intensive care units (ICUs). Despite the number of the studies reported to date, the causative agents of pneumonia are not completely known. Herein, we found by molecular technique that vegetable and tobacco DNA may be detected in the bronchoalveolar lavage from patients with ventilator-associated pneumonia (VAP). METHODOLOGY/PRINCIPAL FINDINGS: In the present study, we studied bronchoalveolar lavage (BAL) from patients admitted to ICUs with ventilator-associated pneumonia. BAL fluids were assessed with molecular tests, culture and blood culture. We successfully identified plant DNA in six patients out of 106 (6%) with ventilator-associated pneumonia. Inhalation was confirmed in four cases and suspected in the other two cases. Inhalation was significantly frequent in patients with plant DNA (four out of six patients) than those without plant DNA (three out of 100 patients) (P<0.001). Nicotiana tabacum chloroplast DNA was identified in three patients who were smokers (cases 2, 3 and 6). Cucurbita pepo, Morus bombycis and Triticum aestivum DNA were identified in cases 1, 4 and 5 respectively. Twenty-three different bacterial species, two viruses and five fungal species were identified from among these six patients by using molecular and culture techniques. Several of the pathogenic microorganisms identified are reported to be food-borne or tobacco plant-associated pathogens. CONCLUSIONS/SIGNIFICANCE: Our study shows that plants DNA may be identified in the BAL fluid of pneumonia patients, especially when exploring aspiration pneumonia, but the significance of the presence of plant DNA and its role in the pathogenesis of pneumonia is unknown and remains to be investigated. However, the identification of these plants may be a potential marker of aspiration in patients with pneumonia

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine.

OBJECTIVE: Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock. METHODS: The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575-590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit ? (2) Should we monitor preload and fluid responsiveness in shock ? (3) How and when should we monitor stroke volume or cardiac output in shock ? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock ? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock ? Four types of statements were used: definition, recommendation, best practice and statement of fact. RESULTS: Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring. CONCLUSIONS: This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock