Apache II score as a predictor of length of stay and outcome in our ICUs

The APACHE II (acute physiology and chronic health evaluation) is used widely for predicting probability of hospital mortality and length of stay in the ICU. APACHE II forms were available to all ICU residents within 24 hours of admission, and a score was assigned to them. Based on our results the APACHE II score has reliably predicted an outcome of the least amount of length of stay (LOS) in the ICU as well as a 100% probability of being shifted out of the ICU for a score of \u3c 10 (according to international benchmarks). This reliable scoring system can be used for predicting mortality and length of stay and therefore, resource allocation, antibiotic use and ethical decisions regarding counseling families about end of life decisions--all within 24 hours of admissions

Marshallov sindrom – izazov u kliničkoj praksi

Marshall syndrome (periodic fever, adenitis, pharyngitis, aphthae, PFAPA syndrome) is characterized by recurrent episodes of fever associated with aphthous stomatitis, cervical adenitis or pharyngitis. Although it is the most common cause of recurrent fever in children, the diagnosis is rarely established. The aim of this study was to describe a group of Romanian children with Marshall syndrome. In seven children with PFAPA, the following methods were used: patient history, clinical examination, and determination of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and tumor necrosis factor α (TNF-α). The treatment consisted in prednisone at a dose of 1 mg/kg. The age at onset was 2.2 years and at diagnosis 4.8 years. The mean interval between episodes was 3.1 weeks and the duration per febrile episode was 3.7 days. The patients presented with pharyngitis (100%), adenitis (100%) and aphthous lesions (57.1%). The mean ESR value was 31 mm/h, CRP 7.8 mg/dL and leukocytes 17700/mm3 . TNF-α remained elevated between febrile episodes. Six patients treated with prednisone had favorable evolution. In conclusion, PFAPA should be suspected in children with periodic fever associated with pharyngitis, cervical adenitis and aphthous stomatitis.Marshallov sindrom (periodična groznica, adenitis, faringitis, afte, sindrom PFAPA) obilježen je opetovanim epizodama groznice udružene s aftoznim stomatitisom, cervikalnim adenitisom ili faringitisom. Iako je to najčešći uzrok opetovane groznice u djece, ova se dijagnoza rijetko postavlja. Cilj ovoga ispitivanja bio je opisati skupinu rumunjske djece s Marshallovim sindromom. U sedmoro djece s PFAPA primijenjene su sljedeće metode: anamneza, klinički pregled te određivanje sedimentacije eritrocita (SE), C-reaktivnog proteina (CRP) i faktora tumorske nekroze alfa (TNF-α). Liječenje je provedeno prednisonom u dozi od 1 mg/kg. Dob pri nastupu PFAPA bila je 2,2 godine, a pri dijagnozi 4,8 godina. Srednja vrijednost intervala među epizodama PFAPA bila je 3,1 tjedan, a trajanja pojedine febrilne epizode 3,7 dana. Bolesnici su imali faringitis (100%), adenitis (100%) i aftozne promjene (57,1%). Srednja vrijednost SE bila je 31 mm/h, CRP 7,8 mg/dL i leukocita 17700/mm3 . TNF-α je ostao povišen između febrilnih epizoda. Povoljan ishod zabilježen je u šestoro bolesnika liječenih prednisonom. U zaključku, na PFAPA treba posumnjati u djece s periodičnim groznicama udruženim s faringitisom, cervikalnim adenitisom i aftoznim stomatitisom

Effect of Boiling on the Antioxidant Potential of Cabbage Varieties

The aim of this study was to investigate the effect of boiling cooking method on the total polyphenolic content, ascorbic acid concentration, pigments amount and total antioxidant activity of four cabbage varieties (De Buzau cabbage, Buzoiana cabbage, Magura cabbage and De Isalnita cabbage) from Buzau, Romania. As we expect, fresh vegetables presented greater antioxidant capacity than boiled vegetables. For all cooked vegetables, the parameters (polyphenols, ascorbic acid, chloropyll, carotenoids and antioxidant activity) decrease with increase of boiling time. After 15 minutes of boiling, content in nutrients fell below 50%

Mitigating cache associativity and coherence scalability constraints for many-core chip multiprocessors

University of Technology Sydney. Faculty of Engineering and Information Technology.Chip Multi-Processor (CMP) designs have become dominant in the processor market. The evaluation and development of CMPs is essential for product improvement. Up to date, CMPs have presented many challenges for system designers, including cache memory system scalability. My research aims to implement a highly scalable CMP cache memory system using an associative cache, with enhanced replacement policy and a scalable cache coherent protocol. This thesis establishes a novel Adaptive Hashing and Replacement Cache (AHRC) design, which can maintain high associativity with an advanced method of replacement policy. The AHRC design can improve associativity and keep the possible number of locations of each block (or ways) to a minimum. For the AHRC, the Adaptive Reuse Interval Prediction (ARIP) replacement policy was used because of its ability to resist both scan and thrash. This research involved simulating several workloads on a large-scale CMP with AHRC as the last-level cache. The results demonstrated that AHRC has better energy efficiency and higher performance than conventional caches. Additionally, larger caches that utilise AHRC are the most suitable in many-core CMPs, as they support scalability as opposed to smaller caches. Scalable cache coherence protocols are essential for CMPs systems, in order to satisfy the requirement for more dominant high-performance chips with shared memory. However, the limited size of the directory cache, associated with larger systems, may result in recurrent directory entries, evictions and invalidations of cached blocks thus compromising system performance. This thesis proposes the Private/Shared, Read-Only/Read-Write, Invalid/Valid scalable coherence protocol called PROI. This novel protocol implements a slight modification on the caches’ tags, allowing it to differentiate between the private and shared data on a block granularity level. Also, PROI employs a dynamic writing policy with self-invalidation and self-downgrade for each L1 cache and can sustain system coherence and performance, scale with the raised number of cores and reduce area, energy, and performance associated costs with the coherence mechanism. The result indicates that PROI can reduce various variables, including the miss ratio of the private L1 cache by 17%, the network traffic, application runtime of approximately 6%, and energy consumption by about 35%. Therefore, utilising AHRC, ARIP, and PROI can mitigate the cache scalability constraints significantly and maintain the performance level while enhancing energy consumption of the CMP cache

Outcome of home mechanical ventilation

OBJECTIVE: To determine the outcome of patients discharged home on portable ventilator. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi from January 2000 to December 2004. PATIENTS AND METHODS: All ventilator-dependent patients discharged home were contacted. Survivors were administered the EQ-5D Quality-of-Life instrument. SPSS version 13 was used to analyze data. RESULTS: Eleven patients were discharged home on invasive ventilation. Mean age was 49 years (range 10-98 years). Cause of ventilatory failure were cervical spine trauma in 36%, primary neurological disease in 27%, critical illness neuropathy and respiratory failure in 18% each. Survival rate was 73%, with three deaths. Mean duration of ventilation was 9.45 months (95% CI 3.24, 15.67). Rate of successful weaning after discharge was 36%, with 4 patients off all forms of ventilatory support and 2 on only nocturnal support. A 2.8 (95% CI 0.5, 16.6) relative risk towards successful weaning was associated with the presence of a family member as the primary care giver. Mean scores on the EQ-5D descriptive tool were; mobility 2 (-/+0.82), self-care 2 (-/+0.82), usual activities 1.86 (-/+0.69), pain/discomfort 1.43(-/+0.79), anxiety/depression 1.29 (-/+0.76). Mean score on the EQ-VAS was 48.2(-/+ 27.3). CONCLUSION: In carefully selected patients, home ventilation is a viable option with the expectation of successful weaning and survival. Patients discharged home on ventilation reported a reasonably good quality of life with proportionately more problems related to independence compared to overall well-being

Impact of antibiotic restriction on broad spectrum antibiotic usage in the ICU of a developing country

Objective: To reduce rates of nosocomial pneumonia and cost of antibiotic therapy. Methods: By means of a policy implementation the following broad spectrum antibiotics were restricted to usage in the ICU for 72 hours: Cefepime, Meropenem, Imipenem, Tazocin, Polymixin B and Vancomycin, after an institutional based pharmacy and therapeutic committee approval. The ICU pharmacist would alert the ICU residents or consultants after 48 hours of the computer based antibiotic entry that the order would expire within hours. Telephone approval was obtained followed by a formal consultation if deemed necessary by the ID specialist or primary team. Antibiotic usage was standardized by defined daily doses (DDDs) per 1000/patient-days. Results: A cumulative 34% reduction was seen in the use of all broad spectrum antibiotics in our ICU after the enforcement of the antibiotic restriction policy. The largest reduction was seen in the use of Tazocin (190 DDDs) and Meropenem (60 DDDs). The policy resulted in a reduction by 40% of overall broad spectrum antibiotic pharmacy costs. The number of multidrug resistant organisms has remained static but the ventilator associated pneumonia rates have declined.Conclusion: Streamlining the formulary to control antibiotic choices and the creation of a restriction program using the expertise of infectious disease physicians resulted in significant reductions in the use of and expenditure for broad spectrum antibiotics (JPMA 57:484:2007)

Training in critical care echocardiography

Echocardiography is useful for the diagnosis and management of hemodynamic failure in the intensive care unit so that competence in some elements of echocardiography is a core skill of the critical care specialist. An important issue is how to provide training to intensivists so that they are competent in the field. This article will review issues related to training in critical care echocardiography

Perioperative echocardiography-guided hemodynamic therapy in high-risk patients:a practical expert approach of hemodynamically focused echocardiography

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy