High frequency oscillatory ventilation for respiratory failure due to RSV bronchiolitis

Objective: To describe the time course of high frequency oscillatory ventilation (HFOV) in respiratory syncytial virus (RSV) bronchiolitis. Design: Retrospective charts review. Setting: A tertiary paediatric intensive care unit. Patients and participants: Infants with respiratory failure due to RSV infection. Intervention: HFOV. Measurements and results: Pattern of lung disease, ventilatory settings, blood gases, infant's vital parameters, sedation and analgesia during the periods of conventional mechanical ventilation (CMV, 6 infants), after initiation of HFOV (HFOVi, 9 infants), in the middle of its course (HFOVm), at the end (HFOVe) and after extubation (Post-Extub) were compared. All infants showed a predominant overexpanded lung pattern. Mean airway pressure was raised from a mean (SD) 12.5 (2.0) during CMV to 18.9 (2.7) cmH2O during HFOVi (P<0.05), then decreased to 11.1(1.3) at HFOVe (P<0.05). Mean FiO2 was reduced from 0.68 (0.18) (CMV) to 0.59 (0.14) (HFOVi) then to 0.29 (0.06) (P<0.05) at HFOVe and mean peak to peak pressure from 44.9 (12.4) cmH2O (HFOVi) to 21.1 (7.7) P<0.05 (HFOVe) while mean (SD) PaCO2 showed a trend to decrease from 72 (22) (CMV) to 47 (8) mmHg (HFVOe) and mean infants respiratory rate a trend to increase from 20 (11) (HFOVi) to 34 (14) (HFOVe) breaths/min. With usual doses of sedatives and opiates, no infant was paralysed and all were extubated to CPAP or supplemental oxygen after a mean of 120h. Conclusion: RSV induced respiratory failure with hypercapnia can be managed with HFOV using high mean airway pressure and large pressure swings while preserving spontaneous breathin

Surfactant use based on the oxygenation response to lung recruitment during HFOV in VLBW infants

Purpose: Early lung recruitment (ELR) during high-frequency oscillatory ventilation (HFOV) in combination with prophylactic surfactant use has been reported to reduce mortality, improve respiratory outcomes, and reduce the need for repeated surfactant dosing, suggesting that surfactant might be used more selectively in very low birth weight (VLBW) infants on HFOV than generally recommended. We report our first experience from such a selective early rescue use of surfactant in VLBW infants on HFOV. Methods: After a deliberate ELR maneuver and "optimal” continuous distending pressure (CDP) finding during HFOV, used as primary ventilation mode for VLBW infants with respiratory distress syndrome (RDS), surfactant was only given when an unsatisfactory oxygenation response to lung recruitment (as defined by CDP×FiO2>5) was observed. Results: Out of 144 VLBW infants on HFOV, 84 (58.3%) received surfactant and 60 (41.7%) did not. Duration of required oxygen supplementation (37.4±44.9 vs. 46.2±35.4days; P=0.031) and respiratory support (i.e., n-CPAP and/or mechanical ventilation; 22.3±19.3 vs. 38.2±24.3days; P=0.001) was shorter for infants who did not receive surfactant than for those who did. The incidence and severity of bronchopulmonary dysplasia was similar in both groups, and there was no difference in survival rates between groups. Subgroup analysis for infants of less than 28weeks of gestation revealed similar results. Conclusions: First intention HFOV combined with an early attempt at lung volume optimization might allow surfactants to be used more selectively (in relation to disease severity) in VLBW infants presenting with RDS at birth without negatively influencing the outcom

Effect of crew resource management training in a multidisciplinary obstetrical setting

Objective To assess the effect of a Crew Resource Management (CRM) intervention specifically designed to improve teamwork and communication skills in a multidisciplinary obstetrical setting. Method Design-A before-and-after cross-sectional study designed to assess participants' satisfaction, learning and change in behaviour, according to Kirkpatrick's evaluation framework for training programmes. Setting-Labour and delivery units of a large university-affiliated hospital. Participants-Two hundred and thirty nine midwives, nurses, physicians and technicians from the department of anaesthesia, obstetrics and paediatrics. Intervention-All participants took part in a CRM-based training programme specifically designed to improve teamwork and communication skills. Principal measures of outcome-We assessed participants' satisfaction by means of a 10-item standardized questionnaire. A 36-item survey was administered before and after the course to assess participants' learning. Behavioural change was assessed by a 57-item safety attitude questionnaire measuring staff's change in attitude to safety over 1 year of programme implementation. Results Most participants valued the experience highly and 63-90% rated their level of satisfaction as being very high. Except for seven items, the 36-item survey testing participants' learning demonstrated a significant change (P < 0.05) towards better knowledge of teamwork and shared decision making after the training programme. Over the year of observation, there was a positive change in the team and safety climate in the hospital [odds ratio (OR) 2.9, 95% confidence interval (CI) (1.3-6.3) to OR 4.7, 95% CI (1.2-17.2)]. **There was also improved stress recognition [OR 2.4, 95% CI (1.2-4.8) to OR 3.0, 95% CI (1.0-8.8)]. Conclusion The implementation of a training programme based on CRM in a multidisciplinary obstetrical setting is well accepted and contributes to a significant improvement in interprofessional teamwor

The frequency of genes encoding three putative group B streptococcal virulence factors among invasive and colonizing isolates

BACKGROUND: Group B Streptococcus (GBS) causes severe infections in very young infants and invasive disease in pregnant women and adults with underlying medical conditions. GBS pathogenicity varies between and within serotypes, with considerable variation in genetic content between strains. Three proteins, Rib encoded by rib, and alpha and beta C proteins encoded by bca and bac, respectively, have been suggested as potential vaccine candidates for GBS. It is not known, however, whether these genes occur more frequently in invasive versus colonizing GBS strains. METHODS: We screened 162 invasive and 338 colonizing GBS strains from different collections using dot blot hybridization to assess the frequency of bca, bac and rib. All strains were defined by serotyping for capsular type, and frequency differences were tested using the Chi square test. RESULTS: Genes encoding the beta C protein (bac) and Rib (rib) occurred at similar frequencies among invasive and colonizing isolates, bac (20% vs. 23%), and rib (28% vs. 20%), while the alpha (bca) C protein was more frequently found in colonizing strains (46%) vs, invasive (29%). Invasive strains were associated with specific serotype/gene combinations. CONCLUSION: Novel virulence factors must be identified to better understand GBS disease

Innate Immune Deficiency of Extremely Premature Neonates Can Be Reversed by Interferon-γ

Background: Bacterial sepsis is a major threat in neonates born prematurely, and is associated with elevated morbidity and mortality. Little is known on the innate immune response to bacteria among extremely premature infants. Methodology/Principal Findings: We compared innate immune functions to bacteria commonly causing sepsis in 21 infants of less than 28 wks of gestational age, 24 infants born between 28 and 32 wks of gestational age, 25 term newborns and 20 healthy adults. Levels of surface expression of innate immune receptors (CD14, TLR2, TLR4, and MD-2) for Grampositive and Gram-negative bacteria were measured in cord blood leukocytes at the time of birth. The cytokine response to bacteria of those leukocytes as well as plasma-dependent opsonophagocytosis of bacteria by target leukocytes was also measured in the presence or absence of interferon-c. Leukocytes from extremely premature infants expressed very low levels of receptors important for bacterial recognition. Leukocyte inflammatory responses to bacteria and opsonophagocytic activity of plasma from premature infants were also severely impaired compared to term newborns or adults. These innate immune defects could be corrected when blood from premature infants was incubated ex vivo 12 hrs with interferon-c. Conclusion/Significance: Premature infants display markedly impaired innate immune functions, which likely account for their propensity to develop bacterial sepsis during the neonatal period. The fetal innate immune response progressivel

Tipping points in the dynamics of speciation.

Speciation can be gradual or sudden and involve few or many genetic changes. Inferring the processes generating such patterns is difficult, and may require consideration of emergent and non-linear properties of speciation, such as when small changes at tipping points have large effects on differentiation. Tipping points involve positive feedback and indirect selection stemming from associations between genomic regions, bi-stability due to effects of initial conditions and evolutionary history, and dependence on modularity of system components. These features are associated with sudden 'regime shifts' in other cellular, ecological, and societal systems. Thus, tools used to understand other complex systems could be fruitfully applied in speciation research

Colonial Archives and the Arts of Governance

Anthropologists engaged inpost-colonial studies are increasingly adoptingan historical perspective and using archives. Yet their archival activity tends to remain morean extractive than an ethnographic one.Documents are thus still invokedpiecemeal to confirm the colonial invention ofcertain practices or to underscore culturalclaims, silent. Yet such mining of the content of government commissions,reports, and other archival sources rarely paysattention to their peculiar placement and form .Scholars need to move fromarchive-as-source to archive-as-subject. Thisarticle, using document production in the DutchEast Indies as an illustration, argues thatscholars should view archives not as sites ofknowledge retrieval, but of knowledgeproduction, as monuments of states as well assites of state ethnography. This requires asustained engagement with archives as culturalagents of ``fact'' production, of taxonomies inthe making, and of state authority. What constitutes thearchive, what form it takes, and what systemsof classification and epistemology signal atspecific times are (and reflect) critical featuresof colonial politics and state power. The archive was the supreme technology of thelate nineteenth-century imperial state, arepository of codified beliefs that clustered(and bore witness to) connections betweensecrecy, the law, and power.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41825/1/10502_2004_Article_5096461.pd

Potential origins of 400-500 kyr periodicities in the ocean carbon cycle: A box model approach

International audienc

Multi-level analysis of electronic health record adoption by health care professionals: A study protocol

<p>Abstract</p> <p>Background</p> <p>The electronic health record (EHR) is an important application of information and communication technologies to the healthcare sector. EHR implementation is expected to produce benefits for patients, professionals, organisations, and the population as a whole. These benefits cannot be achieved without the adoption of EHR by healthcare professionals. Nevertheless, the influence of individual and organisational factors in determining EHR adoption is still unclear. This study aims to assess the unique contribution of individual and organisational factors on EHR adoption in healthcare settings, as well as possible interrelations between these factors.</p> <p>Methods</p> <p>A prospective study will be conducted. A stratified random sampling method will be used to select 50 healthcare organisations in the Quebec City Health Region (Canada). At the individual level, a sample of 15 to 30 health professionals will be chosen within each organisation depending on its size. A semi-structured questionnaire will be administered to two key informants in each organisation to collect organisational data. A composite adoption score of EHR adoption will be developed based on a Delphi process and will be used as the outcome variable. Twelve to eighteen months after the first contact, depending on the pace of EHR implementation, key informants and clinicians will be contacted once again to monitor the evolution of EHR adoption. A multilevel regression model will be applied to identify the organisational and individual determinants of EHR adoption in clinical settings. Alternative analytical models would be applied if necessary.</p> <p>Results</p> <p>The study will assess the contribution of organisational and individual factors, as well as their interactions, to the implementation of EHR in clinical settings.</p> <p>Conclusions</p> <p>These results will be very relevant for decision makers and managers who are facing the challenge of implementing EHR in the healthcare system. In addition, this research constitutes a major contribution to the field of knowledge transfer and implementation science.</p