Empiric Antimicrobial Therapy in Patients with Healthcare-Associated, Hospital-Acquired, or Ventilator-Associated Pneumonia in Septic Shock: Does Antimicrobial Reuse Influence Outcomes?

Appropriate empiric antimicrobial selection is crucial to the survival of septic shock patients. It is suspected that the use of inadequate empiric therapy occurs commonly in practice. The primary objective of this study was to determine if there is a difference in intensive care unit (ICU) length of stay (LOS) among septic shock patients with pneumonia who received adequate versus inadequate empiric antimicrobials. Adequate was defined as a lack of exposure to the same antimicrobial class and absence of previous cultures reporting resistance to the antimicrobial in the last 90 days. This was a retrospective cohort study of adult patients who were diagnosed with septic shock and pneumonia, received IV antimicrobials, and admitted to an ICU at St. Francis Indianapolis between March 1, 2011 and September 30, 2015. Forty-four patients were identified to be included in the study after screening. Of these patients, 13 patients (29.5%) received adequate therapy and 31 patients (70.5%) received inadequate therapy. ICU LOS was found to have a median of 8.5 days (IQR=7) in adequate group and 7 days (IQR=10) in the inadequate group (p=0.776). This study showed that inadequate antimicrobial therapy occurred commonly in this patient sample. A larger sample size is needed to determine the true consequences of inadequate antimicrobial therapy in the septic shock patient population. Enhancements in real time electronic alerts within the electronic medical record may be a method that can be utilized to ensure appropriate empiric antimicrobials are initiated in septic shock patients

Nurse migration: a challenge for the profession and health-care systems

Introduction and questions of exploration: In a first step this paper outlines the global context of and international influences on nurse migration. Liberalization of health markets is identified as a trigger point steering movements of nurses globally. Facts and figures concerning nurse migration are highlighted in a second section focusing on developments in the USA and UK, which are recruiting nurses from Europe and overseas on a large scale, and adding the latest European approaches and policies concerning this issue. Projections are presented that highlight growing demands for the next 2 decades. The third part explores the impact of nurse migration on nursing care and professional standards. Methods: The article is based on an extensive literature review and the analysis of quality issues in the nursing field. Results: The number of nurse migrations in the last decades show that the issue of nurse migration is already of high importance for many countries. This will be enhanced by future accelerated development of nursing shortages in many countries. Boosted global recruitment of nurses will be the consequence.The paper concludes that the recruitment of international nurses has not yet taken quality issues and indicators in health-care settings profoundly into consideration. Economical gains by not training nurses and recruiting them from abroad might have a severe impact on already existing problems concerning patient safety issues and nurse-sensitive outcomes in health-care settings

Water Resources Adaptation to Climate and Demand Change in the Potomac River

The effects of climate change are increasingly considered in conjunction with changes in water demand and reservoir sedimentation in forecasts of water supply vulnerability. Here, the relative effects of these factors are evaluated for the Washington, DC metropolitan area water supply for the near (2010 to 2039), intermediate (2040-2069), and distant future (2070 to 2099) by repeated water resources model simulations. This system poses water management challenges due to long water delivery travel times that increase uncertainty, multiple water jurisdictions that constrain potential decisions, and future scenarios that simultaneously increase demand and decrease water supply during the critical summer period. Adaptation strategies were developed for the system using a multi-objective evolutionary algorithm. Optimized reservoir management policies were compared using six distinct objectives, ranging from reservoir storage to environmental and recreational benefits. Simulations of future conditions show water stress increasing with time. Reservoir sedimentation is projected to more than double (114% increase) the severity of reservoir storage failures by 2040. Increases in water demand and climate change are projected to further stress the system, causing longer periods of low flow and a loss of recreational reservoir storage. The adoption of optimized rules mitigates some of these effects, most notably returning simulations of 2070-2099 climate to near historical levels. Modifying the balance between upstream and downstream reservoirs improved storage penalties by 20.7% and flowby penalties by 50%. Changing triggers for shifting load to off-line reservoirs improved flowby (8.3%) and environmental (4.1%) penalties slightly, while changing demand restriction triggers provided only moderate improvements, but with little adverse effects

Valorization of hydrolysis lignin from a spruce-based biorefinery by applying -valerolactone treatment

Hydrolysis lignin, i.e., the hydrolysis residue of cellulosic ethanol plants, was extracted with the green solvent γ-valerolactone (GVL). Treatments at 170–210 ◦C were performed with either non-acidified GVL/water mixtures (NA-GVL) or with mixtures containing sulfuric acid (SA-GVL). SA-GVL treatment at 210 ◦C resulted in the highest lignin solubilization (64% (w/w) of initial content), and 76% of the solubilized mass was regenerated by water induced precipitation. Regenerated lignins were characterized through compositional analysis with sulfuric acid, as well as using pyrolysis–gas chromatography/mass spectrometry (Py-GC/MS), high-performance size-exclusion chromatography (HPSEC), solid-state cross-polarization/magic angle spinning 13C nuclear magnetic resonance (CP/MAS 13C NMR) spectroscopy, 1 H–13C heteronuclear single-quantum coherence NMR (HSQC NMR), and Fourier-transform infrared (FTIR) spectroscopy. The characterization revealed that the main difference between regenerated lignins was their molecular weight. Molecular weight averages increased with treatment temperature, and they were higher and had broader distribution for SA-GVL lignins than for NA-GVL lignins.publishedVersio

Field Evaluation of Hydrologic and Water Quality Benefits of Grass Swales for Managing Highway Runoff

Due to growing awareness of non-point source pollution treatment, the performance of grass swales as a highway runoff treatment and the effect of including a grass filter strip pretreatment area adjacent to the swale were evaluated using a field-scale input/output study on a Maryland highway. Results of this comparison for 22 rainfall events over 1.5 years show significant peak reduction (50-53%), delay of the peak flow (33-34 min) and reduction of total volume (46-54%). The grass swales exhibited statistically significant removals by mean concentration of total suspended solids (41-52%), nitrite (56-66%) and zinc (30-40%), lead (3-11%), copper (6-28%) and cadmium. Other monitored nutrients (nitrate, TKN, and total phosphorus) exhibited variable removal capabilities (-1-60%), while the swales exported chloride (216-499 mg/l) at a significant level. Results suggest the pretreatment grass filter strip imparts no significant water quantity or quality improvement and that the swale itself is the most important treatment mechanism

Spent mushroom substrates for ethanol production – Effect of chemical and structural factors on enzymatic saccharification and ethanolic fermentation of Lentinula edodes-pretreated hardwood

Spent mushroom substrates (SMS) from cultivation of shiitake (Lentinula edodes) on three hardwood species were investigated regarding their potential for cellulose saccharification and for ethanolic fermentation of the produced hydrolysates. High glucan digestibility was achieved during enzymatic saccharification of the SMSs, which was related to the low mass fractions of lignin and xylan, and it was neither affected by the relative content of lignin guaiacyl units nor the substrate crystallinity. The high nitrogen content in SMS hydrolysates, which was a consequence of the fungal pretreatment, was positive for the fermentation, and it ensured ethanol yields corresponding to 84–87% of the theoretical value in fermentations without nutrient supplementation. Phenolic compounds and acetic acid were detected in the SMS hydrolysates, but due to their low concentrations, the inhibitory effect was limited. The solid leftovers resulting from SMS hydrolysis and the fermentation residues were quantified and characterized for further valorisation

Monthly Paleostreamflow Reconstruction from Annual Tree-Ring Chronologies

Paleoclimate reconstructions are increasingly used to characterize annual climate variability prior to the instrumental record, to improve estimates of climate extremes, and to provide a baseline for climate-change projections. To date, paleoclimate records have seen limited engineering use to estimate hydrologic risks because water systems models and managers usually require streamflow input at the monthly scale. This study explores the hypothesis that monthly streamflows can be adequately modeled by statistically decomposing annual flow reconstructions. To test this hypothesis, a multiple linear regression model for monthly streamflow reconstruction is presented that expands the set of predictors to include annual streamflow reconstructions, reconstructions of global circulation, and potential differences among regional tree-ring chronologies related to tree species and geographic location. This approach is used to reconstruct 600 years of monthly streamflows at two sites on the Bear and Logan rivers in northern Utah. Nash-Sutcliffe Efficiencies remain above zero (0.26–0.60) for all months except April and Pearson’s correlation coefficients (R) are 0.94 and 0.88 for the Bear and Logan rivers, respectively, confirming that the model can adequately reproduce monthly flows during the reference period (10/1942 to 9/2015). Incorporating a flexible transition between the previous and concurrent annual reconstructed flows was the most important factor for model skill. Expanding the model to include global climate indices and regional tree-ring chronologies produced smaller, but still significant improvements in model fit. The model presented here is the only approach currently available to reconstruct monthly streamflows directly from tree-ring chronologies and climate reconstructions, rather than using resampling of the observed record. With reasonable estimates of monthly flow that extend back in time many centuries, water managers can challenge systems models with a larger range of natural variability in drought and pluvial events and better evaluate extreme events with recurrence intervals longer than the observed record. Establishing this natural baseline is critical when estimating future hydrologic risks under conditions of a non-stationary climate

Assessing Data Availability and Research Reproducibility in Hydrology and Water Resources

There is broad interest to improve the reproducibility of published research. We developed a survey tool to assess the availability of digital research artifacts published alongside peer-reviewed journal articles (e.g. data, models, code, directions for use) and reproducibility of article results. We used the tool to assess 360 of the 1,989 articles published by six hydrology and water resources journals in 2017. Like studies from other fields, we reproduced results for only a small fraction of articles (1.6% of tested articles) using their available artifacts. We estimated, with 95% confidence, that results might be reproduced for only 0.6% to 6.8% of all 1,989 articles. Unlike prior studies, the survey tool identified key bottlenecks to making work more reproducible. Bottlenecks include: only some digital artifacts available (44% of articles), no directions (89%), or all artifacts available but results not reproducible (5%). The tool (or extensions) can help authors, journals, funders, and institutions to self-assess manuscripts, provide feedback to improve reproducibility, and recognize and reward reproducible articles as examples for others

Evaluation of the Use of Superconducting 380 kV Cable

This study describes the design of superconducting cables for use in the 380 kV three-phase network and explains general aspects of the use of such cables in the extra-high voltage grid. It compares the superconducting technology with other line technologies under many different criteria