24 research outputs found
Risk factors for developing ventilator-associated lower respiratory tract infection in patients with severe COVID-19:a multinational, multicentre study, prospective, observational study
Around one-third of patients diagnosed with COVID-19 develop a severe illness that requires admission to the Intensive Care Unit (ICU). In clinical practice, clinicians have learned that patients admitted to the ICU due to severe COVID-19 frequently develop ventilator-associated lower respiratory tract infections (VA-LRTI). This study aims to describe the clinical characteristics, the factors associated with VA-LRTI, and its impact on clinical outcomes in patients with severe COVID-19. This was a multicentre, observational cohort study conducted in ten countries in Latin America and Europe. We included patients with confirmed rtPCR for SARS-CoV-2 requiring ICU admission and endotracheal intubation. Only patients with a microbiological and clinical diagnosis of VA-LRTI were included. Multivariate Logistic regression analyses and Random Forest were conducted to determine the risk factors for VA-LRTI and its clinical impact in patients with severe COVID-19. In our study cohort of 3287 patients, VA-LRTI was diagnosed in 28.8% [948/3287]. The cumulative incidence of ventilator-associated pneumonia (VAP) was 18.6% [610/3287], followed by ventilator-associated tracheobronchitis (VAT) 10.3% [338/3287]. A total of 1252 bacteria species were isolated. The most frequently isolated pathogens were Pseudomonas aeruginosa (21.2% [266/1252]), followed by Klebsiella pneumoniae (19.1% [239/1252]) and Staphylococcus aureus (15.5% [194/1,252]). The factors independently associated with the development of VA-LRTI were prolonged stay under invasive mechanical ventilation, AKI during ICU stay, and the number of comorbidities. Regarding the clinical impact of VA-LRTI, patients with VAP had an increased risk of hospital mortality (OR [95% CI] of 1.81 [1.40-2.34]), while VAT was not associated with increased hospital mortality (OR [95% CI] of 1.34 [0.98-1.83]). VA-LRTI, often with difficult-to-treat bacteria, is frequent in patients admitted to the ICU due to severe COVID-19 and is associated with worse clinical outcomes, including higher mortality. Identifying risk factors for VA-LRTI might allow the early patient diagnosis to improve clinical outcomes. Trial registration: This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable
The global retinoblastoma outcome study : a prospective, cluster-based analysis of 4064 patients from 149 countries
DATA SHARING : The study data will become available online once all analyses are complete.BACKGROUND : Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival. METHODS : We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models. FINDINGS : The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0â36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8â100·0) for children from high-income countries, 91·2% (89·5â93·0) for children from upper-middle-income countries, 80·3% (78·3â82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76â50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44â18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23â1·56). For children aged 3â7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope). INTERPRETATION : This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.The Queen Elizabeth Diamond Jubilee Trust and the Wellcome Trust.https://www.thelancet.com/journals/langlo/homeam2023Paediatrics and Child Healt
Lâhistoire des disciplines : un champ de recherche en mutation
Trente ans aprĂšs la publication par AndrĂ© Chervel dâun article novateur sur lâhistoire des disciplines scolaires, ce dossier veut mettre en perspective les mutations et les tendances actuelles de ce champ de recherche, aujourdâhui marquĂ© par un intĂ©rĂȘt croissant pour les acteurs, câest-Ă -dire pour ceux qui « produisent » les disciplines. Il cherche Ă expliciter les aspects Ă©pistĂ©mologiques et mĂ©thodologiques de cette Ă©volution, en la resituant dans le champ, plus large de la recherche sur les contenus dâenseignement. Lâintroduction pose donc, sur cet objet prĂ©cis, la question dâune spĂ©cificitĂ© de lâapproche historique sur les phĂ©nomĂšnes Ă©ducatifs, par rapport aux regards croisĂ©s des autres sciences humaines et sociales. Portant sur lâenseignement secondaire (puis du second degrĂ©) français au XXe siĂšcle, le dossier articule ainsi perspectives disciplinaires et perspectives curriculaires. Il sâattache Ă mettre en lumiĂšre la multiplicitĂ© des acteurs impliquĂ©s dans la fabrication comme dans lâorganisation des disciplines ou des champs disciplinaires, depuis les enseignants de terrain jusquâaux cabinets ministĂ©riels, ainsi que la variĂ©tĂ© de leurs actions, individuelles ou collectives. Il met plus particuliĂšrement lâaccent sur le rĂŽle des enseignants dans la dĂ©finition des contenus dâenseignement comme dans lâaffirmation de la lĂ©gitimitĂ© de leurs disciplines dans le champ scolaire. Thirty years after AndrĂ© Chervelâs innovative article on the history of school subjects, this special issue aims to put into perspective the recent changes and trends in this field of research, which is now characterised by a growing interest in actors, i.e. those who "produce" the disciplines. It seeks to clarify the epistemological and methodological aspects of this evolution, resituating it in the broader field of research on curriculum and teaching content. The introduction thus questions the specificity of French historical scholarship in this research field, compared with the contributions of other disciplinary approaches, in France and abroad. Focusing on French post-elementary and secondary education in the 20th century, the special issue combines disciplinary and curricular perspectives. It seeks to highlight the multiplicity of actors involved in the design and organisation of school subjects or disciplinary fields - from practising teachers to ministerâs advisers - as well as their different actions, both individual and collective. It places particular emphasis on the role of teachers in developing curricula and in asserting the legitimacy of their subjects in the school arena
First-in-class inhibitor of the T cell receptor for the treatment of autoimmune diseases
Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes
Objective To compare the clinical characteristics and outcomes of
patients with acute heart failure (AHF) according to clinical profiles
based on congestion and perfusion determined in the emergency department
(ED).
Methods and results Overall, 11 261 unselected AHF patients from 41
Spanish EDs were classified according to perfusion (normoperfusion =
warm; hypoperfusion = cold) and congestion (not = dry; yes = wet).
Baseline and decompensation characteristics were recorded as were the
main wards to which patients were admitted. The primary outcome was
1-year all-cause mortality; secondary outcomes were need for
hospitalisation during the index AHF event, in-hospital all-cause
mortality, prolonged hospitalisation, 7-day post-discharge ED revisit
for AHF and 30-day post-discharge rehospitalisation for AHF. A total of
8558 patients (76.0%) were warm+ wet, 1929 (17.1%) cold+ wet, 675
(6.0%) warm+ dry, and 99 (0.9%) cold+ dry; hypoperfused (cold)
patients were more frequently admitted to intensive care units and
geriatrics departments, and warm+ wet patients were discharged home
without admission. The four phenotypes differed in most of the baseline
and decompensation characteristics. The 1-year mortality was 30.8%, and
compared to warm+ dry, the adjusted hazard ratios were significantly
increased for cold+ wet (1.660; 95% confidence interval 1.400-1.968)
and cold+ dry (1.672; 95% confidence interval 1.189-2.351).
Hypoperfused (cold) phenotypes also showed higher rates of index episode
hospitalisation and in-hospital mortality, while congestive (wet)
phenotypes had a higher risk of prolonged hospitalisation but decreased
risk of rehospitalisation. No differences were observed among phenotypes
in ED revisit risk.
Conclusions Bedside clinical evaluation of congestion and perfusion of
AHF patients upon ED arrival and classification according to phenotypic
profiles proposed by the latest European Society of Cardiology
guidelines provide useful complementary information and help to rapidly
predict patient outcomes shortly after ED patient arrival
A stacked record of relative geomagnetic paleointensity for the past 270 kyr from the western continental rise of the Antarctic Peninsula
Paleomagnetic and rock magnetic investigations were carried out on four gravity cores recovered from the western continental rise
of the Antarctic Peninsula during the SEDANO II cruise of RV OGS-Explora. The studied cores, each about 6.5 m-long, were
collected at a depth of 3700â4100 m below the sea level, on the distal gentle side of sediment Drift 7, and consist of very fine-grained
sediments spanning through various glacialâinterglacial cycles. Detailed analysis of the paleomagnetic and rock magnetic data
allowed to reconstruct relative paleointensity (RPI) records (NRM20 mT/ARM20 mT) for each core.We established a refined age model
for the studied sequences by correlating individual SEDANO RPI curves to the global RPI stack SINT-800 [Y. Guyodo, J.-P. Valet,
Global changes in intensity of the Earth's magnetic field during the past 800 kyr, Nature 399 (1999) 249â252]. The individual
normalized SEDANO RPI records are in mutual close agreement; they were thus merged in a RPI stacking curve spanning the last
270 kyr and showing a low standard deviation. This study also points out that RPI records may provide a viable tool to date otherwise
difficult-to-date sedimentary sequences, such as those deposited along peri-Antarctic margins. The new RPI chronology indicates that
the sampled sedimentary sequence is younger than previously thought and allows a new high-resolution correlation to oxygen isotope
stages. Furthermore, we recognized variations in the rock magnetic parameters that appear to be climatically-driven, with changes in
the relative proportion of two magnetic mineral populations with distinct coercivities. Rock magnetic and lithological trends observed
in the SEDANO cores indicate that during the climatic cycles of the Late Pleistocene this sector of the peri-Antarctic margin was
subjected to subtle, yet identifiable, environmental changes, confirming a relatively higher instability of theWest Antarctic ice sheet
with respect to the East Antarctic counterpart