Interrater reliability of surveillance for ventilator-associated events and pneumonia

OBJECTIVETo compare interrater reliabilities for ventilator-associated event (VAE) surveillance, traditional ventilator-associated pneumonia (VAP) surveillance, and clinical diagnosis of VAP by intensivists.DESIGNA retrospective study nested within a prospective multicenter quality improvement study.SETTINGIntensive care units (ICUs) within 5 hospitals of the Centers for Disease Control and Prevention Epicenters.PATIENTSPatients who underwent mechanical ventilation.METHODSWe selected 150 charts for review, including all VAEs and traditionally defined VAPs identified during the primary study and randomly selected charts of patients without VAEs or VAPs. Each chart was independently reviewed by 2 research assistants (RAs) for VAEs, 2 hospital infection preventionists (IPs) for traditionally defined VAP, and 2 intensivists for any episodes of pulmonary deterioration. We calculated interrater agreement using κ estimates.RESULTSThe 150 selected episodes spanned 2,500 ventilator days. In total, 93–96 VAEs were identified by RAs; 31–49 VAPs were identified by IPs, and 29–35 VAPs were diagnosed by intensivists. Interrater reliability between RAs for VAEs was high (κ, 0.71; 95% CI, 0.59–0.81). Agreement between IPs using traditional VAP criteria was slight (κ, 0.12; 95% CI, −0.05–0.29). Agreement between intensivists was slight regarding episodes of pulmonary deterioration (κ 0.22; 95% CI, 0.05–0.39) and was fair regarding whether episodes of deterioration were attributable to clinically defined VAP (κ, 0.34; 95% CI, 0.17–0.51). The clinical correlation between VAE surveillance and intensivists’ clinical assessments was poor.CONCLUSIONSProspective surveillance using VAE criteria is more reliable than traditional VAP surveillance and clinical VAP diagnosis; the correlation between VAEs and clinically recognized pulmonary deterioration is poor.Infect Control Hosp Epidemiol 2017;38:172–178</jats:sec

Stratification of single-vessel coronary stenosis by ischemic threshold at the onset of wall motion abnormality during continuous monitoring of left ventricular function by semisupine exercise echocardiography.

peer reviewedWe studied the relation between the ischemic threshold at the onset of wall motion abnormality on exercise echocardiography (EE) and the severity of coronary stenosis in patients with 1-vessel coronary artery disease (CAD). We screened 216 consecutive patients who underwent coronary angiography and EE for suspected CAD. Ninety-five (74 men; age, 56 +/- 12 years) satisfied the study criteria, that is, the presence of 1-vessel disease or no evidence of CAD on angiography and a normal baseline echocardiogram. Eighty-seven patients had 1-vessel CAD on angiography, and exercise-induced wall motion abnormality occurred in 73 (77%). Optimal cutoff values of percent diameter stenosis and minimal lumen diameter for predicting a positive EE were 61% (sensitivity and specificity of 76%) and 1.12 mm (sensitivity and specificity of 74%). Among patients with positive EE, heart rate-blood pressure product at ischemic threshold was correlated with quantitative coronary stenosis (r = -0.72, P <.001). The ischemic threshold from continuous monitoring of left ventricular function during semisupine EE is correlated with the severity of coronary stenosis among patients with 1-vessel disease and a normal resting echocardiogram

Zero-bias anomalies and boson-assisted tunneling through quantum dots

We study resonant tunneling through a quantum dot with one degenerate level in the presence of a strong Coulomb repulsion and a bosonic environment. Using a real-time approach we calculate the spectral density and the nonlinear current within a conserving approximation. The spectral density shows a multiplet of Kondo peaks split by the transport voltage and boson frequencies. As a consequence we find a zero-bias anomaly in the differential conductance which can show a local maximum or minimum depending on the level position. The results are compared with recent experiments.Comment: 4 pages, revtex, 5 postscript figures, submitted to Phys. Rev. Let

The Anderson Model out of equilibrium: Time dependent perturbations

The influence of high-frequency fields on quantum transport through a quantum dot is studied in the low-temperature regime. We generalize the non crossing approximation for the infinite-U Anderson model to the time-dependent case. The dc spectral density shows asymmetric Kondo side peaks due to photon-assisted resonant tunneling. As a consequence we predict an electron-photon pump at zero bias which is purely based on the Kondo effect. In contrast to the resonant level model and the time-independent case we observe asymmetric peak amplitudes in the Coulomb oscillations and the differential conductance versus bias voltage shows resonant side peaks with a width much smaller than the tunneling rate. All the effects might be used to clarify the question whether quantum dots indeed show the Kondo effect.Comment: 13 pages, REVTEX 3.0, 5 figure

ESC core curriculum for the general cardiologist (2013)

[No abstract available

Resonant tunneling through ultrasmall quantum dots: zero-bias anomalies, magnetic field dependence, and boson-assisted transport

We study resonant tunneling through a single-level quantum dot in the presence of strong Coulomb repulsion beyond the perturbative regime. The level is either spin-degenerate or can be split by a magnetic field. We, furthermore, discuss the influence of a bosonic environment. Using a real-time diagrammatic formulation we calculate transition rates, the spectral density and the nonlinear $I-V$ characteristic. The spectral density shows a multiplet of Kondo peaks split by the transport voltage and the boson frequencies, and shifted by the magnetic field. This leads to zero-bias anomalies in the differential conductance, which agree well with recent experimental results for the electron transport through single-charge traps. Furthermore, we predict that the sign of the zero-bias anomaly depends on the level position relative to the Fermi level of the leads.Comment: 27 pages, latex, 21 figures, submitted to Phys. Rev.

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data

OBJECTIVE: To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. DESIGN: Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. DATA SOURCES: Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. RESULTS: Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). CONCLUSIONS: In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42012002780

Revisiting Zitterbewegung

The Dirac wave equation for the electron soon lead to the recognition of the Zitterbewegung. This was studied both by Schrodinger and Dirac. Later there were further elegant and sometimes dissenting insights, from different authors. We briefly review some of these developments. However in more recent times with dark energy and noncommutative spacetime coming to centre stage, the earlier studies of Zitterbewegung become questionable.Comment: 14 pages; late