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To study the impact of duration of mechanical ventilation, hospitalization and multiple ventilation episodes on the development of pneumonia while accounting for extubation as a competing event.
A multicenter data base from a Spanish surveillance network was used to conduct a retrospective analysis of prospectively collected intensive care patients followed from admission to discharge.
Spanish intensive care units (ICUs).
Mechanically ventilated adult patients from 158 ICUs with 45,486 admissions, 48,705 ventilation episodes, and 314,196 ventilator days.
Competing-risk models were applied to account for extubation plus 48 hours as a competing event for acquiring ventilator-associated pneumonia (VAP).
Time in the ICU before mechanical ventilation was associated with an increased VAP hazard rate and with longer intubation time. This indirect prolongation of intubation increased the cumulative risk to eventually acquire VAP. For instance, comparing 3–4 versus 0 days, the adjusted VAP hazard ratio was 1.40 (95% confidence interval [CI], 1.19–1.64) and the adjusted extubation hazard ratio was 0.64 (95% CI, 0.61–0.68), which leads to an adjusted VAP subdistribution hazard ratio (sHR) of 2.13 (95% CI, 1.83–2.50). Similarly, due to prolonged intubation, multiple ventilation episodes increase the risk for VAP; the adjusted sHR is 1.52 (95% CI, 1.35–1.72) for the second episode compared to the first episode, and the adjusted sHR is 1.54 (95% CI, 1.03–2.30) for the third episode compared to the first episode. The Kaplan-Meier method produced an upward biased estimated cumulative risk for VAP.
A competing-risk analysis is necessary to receive unbiased risk estimates and to quantify the indirect effect of intubation time on the cumulative VAP risk. Our findings may guide physicians to improve medical decisions related to the harms and benefits of the duration of ventilation.
The fraction of organic matter present affects the fragmentation behavior of sialoliths; thus, pretherapeutic information on the degree of mineralization is relevant for a correct selection of lithotripsy procedures. This work proposes a methodology for in vivo characterization of salivary calculi in the pretherapeutic context. Sialoliths were characterized in detail by X-ray computed microtomography (μCT) in combination with atomic emission spectroscopy, Fourier transform infrared spectroscopy, X-ray diffraction, scanning electron microscopy, and transmission electron microscopy. Correlative analysis of the same specimens was performed by in vivo and ex vivo helical computed tomography (HCT) and ex vivo μCT. The mineral matter in the sialoliths consisted essentially of apatite (89 vol%) and whitlockite (11 vol%) with average density of 1.8 g/cm3. In hydrated conditions, the mineral mass prevailed with 53 ± 13 wt%, whereas the organic matter, with a density of 1.2 g/cm3, occupied 65 ± 10% of the sialoliths’ volume. A quantitative relation between sialoliths mineral density and X-ray attenuation is proposed for both HCT and μCT.
Competing risks are a necessary consideration when analyzing risk factors for nosocomial infections (NIs). In this article, we identify additional information that a competing risks analysis provides in a hospital setting. Furthermore, we improve on established methods for nested case-control designs to acquire this information.
Using data from 2 Spanish intensive care units and model simulations, we show how controls selected by time-dynamic sampling for NI can be weighted to perform risk-factor analysis for death or discharge without infection. This extension not only enables hazard rate analysis for the competing risk, it also enables prediction analysis for NI.
The estimates acquired from the extension were in good agreement with the results from the full (real and simulated) cohort dataset. The reduced dataset results averted any false interpretation common in a competing-risks setting.
Using additional information that is routinely collected in a hospital setting, a nested case-control design can be successfully adapted to avoid a competing risks bias. Furthermore, this adapted method can be used to reanalyze past nested case-control studies to enhance their findings.
The Spanish National Network (REDETS) is a group of eight agencies, units and services, depending on National and Regional Governments that coordinate their work within a common methodological framework, guided by the principles of mutual recognition and cooperation. The necessity of considering a Quality Management System has been detected and, consequently, a common tool for all the members needs to be developed. We describe in this study the process to achieve that goal.
Based on both a review of previous literature and the proposal for a self-evaluating tool, a group of experts from each agency through consensus have developed a tool for self-evaluation in Health Technology Assessment (HTA) agencies. Through the structure described in the handbook of the Andalusian Agency for Healthcare Quality (ACSA), each standard should have a statement or proposal that needs to also include evidence or good practices, and the corresponding evaluation questions. In separate workgroups, the definition of these proposals, evidence and evaluation questions were developed. One face-to-face meeting and two meetings via teleconference were necessary to achieve a final document with all the quality standards.
From a proposed structure of sixty-six standards, the titles, definitions, statements and evidence as well as good practices and evaluation questions were established in workgroups with consensus among all of the members (1 - 3). The final version of the self-assessment tool was composed of sixty-eight standards, grouped in twelve quality criteria structured in four dimensions: I Responsibility, II Clients and Stakeholders, III Production Process, and IV Resources.
Quality management requires an evaluation tool and this version, based on a systematic review and consensus, is a useful and practical instrument for developing a handbook by each member of REDETS. An online version of the tool is in process of development.
Despite the higher proportion of foreclosures and home evictions executed in Spain, compared to other countries, and the known link between social exclusion and mental health problems, studies exploring this association in Spain remain scarce. This study investigated the link between the process of home eviction and the appearance of symptomatology of post-traumatic stress disorder (PTSD), anxiety, depression, and perceived stress. Two hundred and five people affected by the process of home eviction were assessed using a structured interview that included three validated assessment instruments for PTSD, perceived stress, anxiety and depression. Analysis involved comparison with the normative groups that formed the validation studies together with regression analysis to determine the major psychological and socio-demographic predictors of perceived stress. Of the participants, 95.1% reported that they were experiencing the process of home eviction with fear, helplessness, or horror. In PTSD symptomatology, they scored higher than the normative PTSD group in symptoms of avoidance (t = 5.01; p < .05), activation (t = 5.48; p < .01), and total score (t = 4.15; p < .05). Of this subgroup, 72.5% fulfilled the DSM-IV symptom criteria for PTSD. The major predictor of perceived stress was PTSD symptomatology (B = .09; p < .001). The process of home eviction in Spain is having an alarming impact on mental health of affected people calling for effective measures to provide psychological and social support.
Mass balance and climate sensitivity of Glaciar Perito Moreno (GPM), one of the main outlet glaciers of Hielo Patagónico Sur (southern Patagonia icefield), were investigated. Field measurements were carried out from 1995 to 2003, including ice ablation and velocity at stakes, seismic profiling, bathymetry of the lake near the calving fronts and meteorological data. The database was complemented by satellite observations, to derive the motion field by interferometric data, map glacier boundaries and snowlines from multi-year time series of radar images, and obtain glacier topography from the Shuttle Radar Topography Mission. In September 2003, GPM started to dam the southern arm of Lago Argentino, resulting in a maximum rise of the lake level of 9.35 m before the dam burst in March 2004. The ice dam formed again in August 2005, bursting in March 2006. Analysis of mass fluxes indicates no long-term trend in mass balance. This behaviour, contrasting with most retreating glaciers in the vicinity, can be attributed to a particular glacier geometry. Monthly climate sensitivity characteristics for glacier mass balance were derived using a degree-day model, showing similar importance of both temperature and precipitation. Also, the reconstruction of the mass balance for the last 50 years from local climate data shows a near-steady-state condition for GPM, with some small fluctuations, such as a slightly positive balance after 1998, that may have triggered the minor advance leading to damming events in 2003 and 2005.
Objectives: The methodological quality of an economic evaluation performed alongside a clinical trial can be underestimated if the paper does not report key methodological features. This study discusses methodological assessment issues on the example of a systematic review on cost-effectiveness of physiotherapy for knee osteoarthritis.
Methods: Six economic evaluation studies included in the systematic review and related clinical trials were assessed using the 10-question check-list by Drummond and the Physiotherapy Evidence Database (PEDro) scale.
Results: All economic evaluations were performed alongside a clinical trial but the studied interventions were too heterogeneous to be synthesized. Methodological quality of the economic evaluations reported in the papers was not free of drawbacks, and in some cases, it improved when information from the related clinical trial was taken into account.
Conclusions: Economic evaluation papers dedicate little space to methodological features of related clinical trials; therefore, the methodological quality can be underestimated if evaluated separately from the trials. Future economic evaluations should follow more strictly the recommendations about methodology and the authors should pay special attention to the quality of reporting.
To determine the effects of lipid-based nutrient supplements (LNS) on children’s Hb, linear growth and development, compared with supplementation with micronutrient powder (MNP).
The study was a two-arm parallel-group randomized controlled trial, where participants received either LNS or MNP for daily consumption during 6 months. Supplements were delivered by staff at government-run health centres. Hb, anthropometric, motor development, language development and problem-solving indicators were measured by trained research assistants when children were 12 months of age.
The study was conducted in five rural districts in the Province of Ambo in the Department of Huánuco, Peru.
We enrolled 6-month-old children (n 422) at nineteen health centres.
Children who received LNS had a higher mean Hb concentration and lower odds of anaemia than those who received MNP. No significant differences in height-for-age, weight-for-height or weight-for-age Z-score, or stunting and underweight prevalence, were observed. Provision of LNS was associated with a higher pre-verbal language (gestures) score, but such effect lost significance after adjustment for covariates. Children in the LNS group had higher problem-solving task scores and increased odds of achieving this cognitive task than children in the MNP group. No significant differences were observed on receptive language or gross motor development.
LNS between 6 and 12 months of age increased Hb concentration, reduced anaemia and improved cognitive development in children, but showed no effects on anthropometric indicators, motor or language development.
The Union of the Iberian Crowns (1580–1640) promoted a wider cultural exchange between Portuguese and Spanish Asian settlements in Asia. This paper identifies the remarkable circulation of artisans and patrons and the development of new building techniques during this period, which allowed for a shared cultural dialogue that may be best described as forms of mestizage. So, it tries to address the mobility of patrons and architects, which helps explain the diffusion of techniques and models. The first case shows how cultural dialogue promoted new techniques from local traditions and materials, which were later used in neighbouring settlements. The second demonstrates the role these mixed solutions played in the creation of the image of a pure state, in the form of public palaces, a mestizo society, mainly in urban houses, and a local cultural resistance, keeping traditional housing forms in the native quarters. Thanks to this approach, the currently preserved built heritage can be seen not only as a European cultural transfer but also as the result of a fruitful global dialogue.
In today's context of disseminating research internationally, the need to publish research papers in English-medium journals has become ever more pressing, not only for those scholars who seek to make their research visible to a wider audience and gain international recognition, but also for those who intend to obtain academic promotion and professional benefits, such as research funding and salary increment (Lillis & Curry, 2010; Moreno, 2010; Hanauer & Englander, 2011; Martin, Rey-Rocha, Burgess & Moreno, 2014). This is particularly the case in disciplinary areas such as the health sciences, where the number of scientific journals published in languages other than English has diminished dramatically over the last few years to almost total extinction.
Aside from geopolitical considerations related to the dominance of English (see, for example, Ammon, 2001, 2012; Ferguson, 2007), it is a fact that the writing up of a research paper generally involves difficulties, especially for inexperienced writers and users of English as an Additional Language [EAL]. In order to get their papers accepted, scholars have to demonstrate to the other members of their particular disciplinary communities, especially the editors and reviewers of international English language journals, that they have mastered the established rhetorical conventions which have been institutionalised in a specific research genre, such as the research article [RA]. In response to this situation, many English for Research Publication Purposes [ERPP] researchers and practitioners have put their energies into providing support to these scholars, including the analysis of the structural organisation of experimental RAs. Many of these studies have revealed that the typical macro-structure of experimental papers adheres to the IMRD [Introduction, Methods, Results and Discussion] pattern, not only across disciplines but also across languages. Other authors, such as Cargill and O'connor (2013) and Burgess and Cargill (2013), have also noted a slight variation to this prevalent pattern in terms of the order in which these sections appear throughout the paper [IRDM], which consists in presenting the methods section at the end of the RA.
Understanding the drivers of macroevolutionary trends through the Phanerozoic has been a central question in paleobiology. Increasingly important is understanding the regional and environmental variation of macroevolutionary patterns and how they are reflected at the global scale. Here we test the role of biotic interactions on regional ecological patterns during the Mesozoic marine revolution. We test for escalatory trends in Jurassic marine benthic macroinvertebrate ecosystems using occurrence data from the Paleobiology Database parsed by region and environment. The escalation hypothesis posits that taxonomic groups that could adapt to intense predation and bioturbation proliferated, whereas groups unable to adapt were reduced in diversity and abundance or driven to extinction. We tested this hypothesis in five regions during Jurassic stages and among four depositional environments in Europe. Few escalatory trends were detected, although at least one escalatory trend was observed in every region, with the greatest number and strongest trends observed in Europe. These trends include increases in shallow infauna and cementing epifauna and occurrences of facultatively mobile invertebrates and decreases in pedunculate, free-lying, and sessile epifauna. Within Europe, escalatory trends occur in shallow-water environments but also in deeper-water environments, where they are predicted not to occur. When regional trends are aggregated, trends in Europe drive the global signal. The results of this study suggest that while evidence of escalation is rare globally, it is plausible that escalation drove macroevolutionary patterns in Europe. Furthermore, these results underline the need to dissect global fossil data at the regional scale to understand global macroevolutionary dynamics.
Lithotripsy methods show relatively low efficiency in the fragmentation of sialoliths compared with the success rates achieved in the destruction of renal calculi. However, the information available on the mechanical behavior of sialoliths is limited and their apparently tougher response is not fully understood. This work evaluates the hardness and Young’s modulus of sialoliths at different scales and analyzes specific damage patterns induced in these calcified structures by ultrasonic vibrations, pneumoballistic impacts, shock waves, and laser ablation. A clear correlation between local mechanical properties and ultrastructure/chemistry has been established: sialoliths are composite materials consisting of hard and soft components of mineralized and organic nature, respectively. Ultrasonic and pneumoballistic reverberations damage preferentially highly mineralized regions, leaving relatively unaffected the surrounding organic matter. In contrast, shock waves leach the organic component and lead to erosion of the overall structure. Laser ablation destroys homogeneously the irradiated zones regardless of the mineralized/organic nature of the underlying ultrastructure; however, damage is less extensive than with mechanical methods. Overall, the present results show that composition and internal structure are key features behind sialoliths’ comminution behavior and that the organic matter contributes to reduce the therapeutic efficiency of lithotripsy methods.
In this note, we consider the problem of introducing variables in temporal logic programs under the formalism of Temporal Equilibrium Logic, an extension of Answer Set Programming for dealing with linear-time modal operators. To this aim, we provide a definition of a first-order version of Temporal Equilibrium Logic that shares the syntax of first-order Linear-time Temporal Logic but has different semantics, selecting some Linear-time Temporal Logic models we call temporal stable models. Then, we consider a subclass of theories (called splittable temporal logic programs) that are close to usual logic programs but allowing a restricted use of temporal operators. In this setting, we provide a syntactic definition of safe variables that suffices to show the property of domain independence – that is, addition of arbitrary elements in the universe does not vary the set of temporal stable models. Finally, we present a method for computing the derivable facts by constructing a non-temporal logic program with variables that is fed to a standard Answer Set Programming grounder. The information provided by the grounder is then used to generate a subset of ground temporal rules which is equivalent to (and generally smaller than) the full program instantiation.
We present studies using different observational techniques, along different frequencies, aiming to resolve and investigate jets, outflows, as well as compact and innermost regions of asymmetric planetary nebulae (PNe) and objects in transition to PN. All the information gathered allow us to explore the kinematics and other important properties of the structures that play a crucial role in the shaping of complex PNe morphologies, in particular, we explore the role of disks/tori as collimating engine of extreme axisymmetric PNe.
Despite the ecological relevance of tropical reefs, information on species composition and coverage on sandstone reefs is very scarce. Most studies on reef systems have been conducted for true coral reefs, ecosystems that show calcareous formations with extensive coral cover and diversity. The aim of this study was to analyse the coverage of benthic assemblages in a submerged sandstone reef (22–24 m) in a relatively non-explored region (Tropical South-western Atlantic). In this area, filamentous algae (43.6%) and sponges (19.6%) are the main components of the benthic reef assemblages. Other benthic reef fauna (ascidians, corals and zoanthids) showed lower coverage, although their importance may vary depending on the area. A negative correlation between filamentous algae and slow-growing reef-building organisms (calcareous algae) was observed. High sand coverage (19.6%) over the reef revealed a high rate of silting. A low coral diversity (only two resilient species) was quantified, and most of the coral colonies were small-sized. The results provide a baseline assessment for a poorly known ecosystem with turbid-water benthic communities and higher sea-surface temperatures near the Earth's equator.