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 11·0–36·5). 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 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) 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 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 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

L’histoire des disciplines : un champ de recherche en mutation

Trente ans après la publication par André Chervel d’un article novateur sur l’histoire des disciplines scolaires, ce dossier veut mettre en perspective les mutations et les tendances actuelles de ce champ de recherche, aujourd’hui marqué par un intérêt croissant pour les acteurs, c’est-à-dire pour ceux qui « produisent » les disciplines. Il cherche à expliciter les aspects épistémologiques et méthodologiques de cette évolution, en la resituant dans le champ, plus large de la recherche sur les contenus d’enseignement. L’introduction pose donc, sur cet objet précis, la question d’une spécificité de l’approche historique sur les phénomènes éducatifs, par rapport aux regards croisés des autres sciences humaines et sociales. Portant sur l’enseignement secondaire (puis du second degré) français au XXe siècle, le dossier articule ainsi perspectives disciplinaires et perspectives curriculaires. Il s’attache à mettre en lumière la multiplicité des acteurs impliqués dans la fabrication comme dans l’organisation des disciplines ou des champs disciplinaires, depuis les enseignants de terrain jusqu’aux cabinets ministériels, ainsi que la variété de leurs actions, individuelles ou collectives. Il met plus particulièrement l’accent sur le rôle des enseignants dans la définition des contenus d’enseignement comme dans l’affirmation de la légitimité de leurs disciplines dans le champ scolaire. Thirty years after André Chervel’s 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 minister’s 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

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 3700–4100 m below the sea level, on the distal gentle side of sediment Drift 7, and consist of very fine-grained sediments spanning through various glacial–interglacial 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) 249–252]. 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