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In the intensive care setting, delirium is a common occurrence; however, the impact of the level of alertness has never been evaluated. Therefore, this study aimed to assess the delirium characteristics in the drowsy, as well as the alert and calm patient.
In this prospective cohort study, 225 intensive care patients with Richmond Agitation and Sedation Scale (RASS) scores of −1 — drowsy and 0 — alert and calm were evaluated with the Delirium Rating Scale-Revised-1998 (DRS-R-98) and the Diagnostic and Statistical Manual 4th edition text revision (DSM-IV-TR)-determined diagnosis of delirium.
In total, 85 drowsy and 140 alert and calm patients were included. Crucial items for the correct identification of delirium were sleep–wake cycle disturbances, language abnormalities, thought process alterations, psychomotor retardation, disorientation, inattention, short- and long-term memory, as well as visuo-spatial impairment, and the temporal onset. Conversely, perceptual disturbances, delusions, affective lability, psychomotor agitation, or fluctuations were items, which identified delirium less correctly. Further, the severities of inattentiveness and visuo-spatial impairment were indicative of delirium in both alert- or calmness and drowsiness.
Significance of results
The impairment in the cognitive domain, psychomotor retardation, and sleep–wake cycle disturbances correctly identified delirium irrespective of the level alertness. Further, inattentiveness and — to a lesser degree — visuo-spatial impairment could represent a specific marker for delirium in the intensive care setting meriting further evaluation.
The biggest advantage of Additive Manufacturing is the individualization of products. Mass Customization is well known as a promising future application. The use of Additive Manufacturing for assembly groups is mostly not reasonable, however combining it with conventional manufacturing processes can lead to new opportunities.
This paper works out concepts to join, by using similar material combinations, an injection molded part with an additive deposited geometry by the Fused-Deposition-Modeling (FDM) process. Therefore, two of the main industrially used polymers, acrylonitrile butadiene styrene (ABS) and polypropylene (PP), are selected for further study. In particular, this investigation focuses on the procedural potentials and surface preparation of the injection molded part. By the variation of adhesive bonding, the fusion of similar materials can be identified and tested in several series of testing.
First in general a direct joining function by the FLM process will be tested. After proving this hypothesis, the results will be summarised in a recommendation of joining similar materials, which are manufactured in different ways.
The importance of the proper identification of delirium, with its high incidence and adversities in the intensive care setting, has been widely recognized. One common screening instrument is the Intensive Care Delirium Screening Checklist (ICDSC); however, the symptom profile and key features of delirium dependent on the level of sedation have not yet been evaluated.
In this prospective cohort study, the ICDSC was evaluated versus the Diagnostic and Statistical Manual, 4th edition, text revision, diagnosis of delirium set as standard with respect to the symptom profile, and correct identification of delirium. The aim of this study was to identify key features of delirium in the intensive care setting dependent on the Richmond Agitation and Sedation Scale levels of sedation: drowsiness versus alert and calmness.
The 88 delirious patients of 225 were older, had more severe disease, and prolonged hospitalization. Irrespective of the level of sedation, delirium was correctly classified by items related to inattention, disorientation, psychomotor alterations, inappropriate speech or mood, and symptom fluctuation. In the drowsy patients, inattention reached substantial sensitivity and specificity, whereas psychomotor alterations and sleep-wake cycle disturbances were sensitive lacked specificity. The positive prediction was substantial across items, whereas the negative prediction was only moderate. In the alert and calm patient, the sensitivities were substantial for psychomotor alterations, sleep-wake cycle disturbances, and symptom fluctuations; however, these fluctuations were not specific. The positive prediction was moderate and the negative prediction substantial. Between the nondelirious drowsy and alert, the symptom profile was similar; however, drowsiness was associated with alterations in consciousness.
Significance of results
In the clinical routine, irrespective of the level of sedation, delirium was characterized by the ICDSC items for inattention, disorientation, psychomotor alterations, inappropriate speech or mood and symptom fluctuation. Further, drowsiness caused altered levels of consciousness.
Similar to delirium, its subsyndromal form has been recognized as the cause of diverse adverse outcomes. Nonetheless, the nature of this subsyndromal delirium remains vastly understudied. Therefore, in the following, we evaluate the phenomenological characteristics of this syndrome versus no and full-syndromal delirium.
In this prospective cohort study, we evaluated the Delirium Rating Scale–Revised, 1998 (DRS–R–98) versus the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM–IV–TR) diagnostic criteria and examined the diagnosis of delirium with respect to phenomenological distinctions in the intensive care setting.
Out of 289 patients, 36 with subsyndromal delirium versus 86 with full-syndromal and 167 without delirium were identified. Agreement with respect to the DSM–IV–TR diagnosis of delirium was perfect. The most common subtype in those with subsyndromal delirium was hypoactive, in contrast to mixed subtype in those with full-syndromal delirium versus no motor alterations in those without delirium. By presence and severity of delirium symptoms, subsyndromal delirium was intermediate. The ability of the DRS–R–98 items to discriminate between either form of delirium was substantial. Between subsyndromal and no delirium, the cognitive domain and sleep–wake cycle were more impaired and allowed a distinction with no delirium. Further, between full- and subsyndromal delirium, the prevalence and severity of individual DRS–R–98 items were greater. Although the differences between these two forms of delirium was substantial, the items were not very specific, indicating that the phenomenology of subsyndromal delirium is closer to full-syndromal delirium.
Significance of results:
Phenomenologically, subsyndromal delirium was found to be distinct from and intermediate between no delirium and full-syndromal delirium. Moreover, the greater proximity to full-syndromal delirium indicated that subsyndromal delirium represents an identifiable subform of full-syndromal delirium.
In the intensive care setting, delirium is a common occurrence that comes with subsequent adversities. Therefore, several instruments have been developed to screen for and detect delirium. Their validity and psychometric properties, however, remain controversial.
In this prospective cohort study, the Confusion Assessment Method for the Intensive Care Unit (CAM–ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were evaluated versus the DSM–IV–TR in the diagnosis of delirium with respect to their validity and psychometric properties.
Out of some 289 patients, 210 with matching CAM–ICU, ICDSC, and DSM–IV–TR diagnoses were included. Between the scales, the prevalence of delirium ranged from 23.3% with the CAM–ICU, to 30.5% with the ICDSC, to 43.8% with the DSM–IV–TR criteria. The CAM–ICU showed only moderate concurrent validity (Cohen's κ = 0.44) and sensitivity (50%), but high specificity (95%). The ICDSC also reached moderate agreement (Cohen's κ = 0.60) and sensitivity (63%) while being very specific (95%). Between the CAM–ICU and the ICDSC, the concurrent validity was again only moderate (Cohen's κ = 0.56); however, the ICDSC yielded higher sensitivity and specificity (78 and 83%, respectively).
Significance of Results:
In the daily clinical routine, neither the CAM–ICU nor the ICDSC, common tools used in screening and detecting delirium in the intensive care setting, reached sufficient concurrent validity; nor did they outperform the DSM–IV–TR diagnostic criteria with respect to sensitivity or positive prediction, but they were very specific. Thus, the non-prediction by the CAM–ICU or ICDSC did not refute the presence of delirium. Between the CAM–ICU and ICDSC, the ICDSC proved to be the more accurate instrument.
The management of and prognosis for delirium are affected by its subtype: hypoactive, hyperactive, mixed, and none. The DMSS–4, an abbreviated version of the Delirium Motor Symptom Scale, is a brief instrument for the assessment of delirium subtypes. However, it has not yet been evaluated in an intensive care setting.
We performed a prospective/descriptive cohort study in order to determine the internal consistency, reliability, and validity of the relevant items of the DMSS–4 versus the Delirium Rating Scale–Revised-98 (DRS–R-98) and the original DMSS in a surgical intensive care setting.
A total of 289 elderly, predominantly male patients were screened for delirium, and 122 were included in our sample. The internal consistency of the DMSS–4 items was excellent (Cronbach's α = 0.92), and between the DMSS–4 and DRS–R-98 the overall concurrent validity was substantial (Cramer's V = 0.67). Within individual motor subtypes, concurrent validity remained at least substantial (Cohen's κ = 0.65–0.81) and sensitivity high (69.8 to 82.2%), in contrast to those of the no-motor subtype, with less validity and sensitivity (κ = 0.28, 22%). Similarly, total concurrent validity between the DMSS–4 and the original DMSS reached perfection (Cramer's V = 0.83), as did agreement between the subtypes (κ = 0.83–0.92), while sensitivity remained high (88.2–100%). Only in those with delirium with no-motor subtype was agreement moderate (κ = 0.56) and sensitivity lower (67%). Specificity was high across all subtypes (91.2–99.1%). The DMSS–4 yielded very sensitive ratings, particularly for hypoactive and hyperactive motor symptoms, and interrater agreement was excellent (Fleiss's κ = 0.83).
Significance of Results:
We found the DMSS–4 to be a most reliable and valid brief assessment of delirium in characterizing the subtypes of delirium in an intensive care setting, with increased sensitivity to hypoactive and hyperactive motor alterations.
Inpatients with blood cultures positive for Staphylococcus aureus, Enterococcus faecalis, E. faecium, Streptococcus pneumoniae, S. pyogenes, S. agalactiae, S. anginosus, Streptococcus spp., and Listeria monocytogenes during the 6 months before and after implementation of Verigene Gram-positive blood culture microarray (BC-GP) with an antimicrobial stewardship intervention.
Before the intervention, no rapid diagnostic technology was used or antimicrobial stewardship intervention was undertaken, except for the use of peptide nucleic acid fluorescent in situ hybridization and MRSA agar to identify staphylococcal isolates. After the intervention, all Gram-positive blood cultures underwent BC-GP microarray and the antimicrobial stewardship intervention consisting of real-time notification and pharmacist review.
In total, 513 patients with bacteremia were included in this study: 280 patients with S. aureus, 150 patients with enterococci, 82 patients with stretococci, and 1 patient with L. monocytogenes. The number of antimicrobial switches was similar in the pre–BC-GP (52%; 155 of 300) and post–BC-GP (50%; 107 of 213) periods. The time to antimicrobial switch was significantly shorter in the post–BC-GP group than in the pre–BC-GP group: 48±41 hours versus 75±46 hours, respectively (P<.001). The most common antimicrobial switch was de-escalation and time to de-escalation, was significantly shorter in the post-BC-GP group than in the pre–BC-GP group: 53±41 hours versus 82±48 hours, respectively (P<.001). There was no difference in mortality or hospital length of stay as a result of the intervention.
The combination of a rapid microarray diagnostic test with an antimicrobial stewardship intervention improved time to antimicrobial switch, especially time to de-escalation to optimal therapy, in patients with Gram-positive blood cultures.
Various transmission routes contribute to spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) in hospitalized patients. Patients with readmissions during which CRKP is again isolated (“CRKP readmission”) potentially contribute to transmission of CRKP.
To evaluate CRKP readmissions in the Consortium on Resistance against Carbapenems in K. pneumoniae (CRaCKLe).
Cohort study from December 24, 2011, through July 1, 2013.
Multicenter consortium of acute care hospitals in the Great Lakes region.
All patients who were discharged alive during the study period were included. Each patient was included only once at the time of the first CRKP-positive culture.
All readmissions within 90 days of discharge from the index hospitalization during which CRKP was again found were analyzed. Risk factors for CRKP readmission were evaluated in multivariable models.
Fifty-six (20%) of 287 patients who were discharged alive had a CRKP readmission. History of malignancy was associated with CRKP readmission (adjusted odds ratio [adjusted OR], 3.00 [95% CI, 1.32–6.65], P<.01). During the index hospitalization, 160 patients (56%) received antibiotic treatment against CRKP; the choice of regimen was associated with CRKP readmission (P=.02). Receipt of tigecycline-based therapy (adjusted OR, 5.13 [95% CI, 1.72–17.44], using aminoglycoside-based therapy as a reference in those treated with anti-CRKP antibiotics) was associated with CRKP readmission.
Hospitalized patients with CRKP—specifically those with a history of malignancy—are at high risk of readmission with recurrent CRKP infection or colonization. Treatment during the index hospitalization with a tigecycline-based regimen increases this risk.
Infect. Control Hosp. Epidemiol. 2016;37(3):281–288
We report on localised patches of cellular hexagons observed on the surface of a magnetic fluid in a vertical magnetic field. These patches are spontaneously generated by jumping into the neighbourhood of the unstable branch of the domain-covering hexagons of the Rosensweig instability upon which the patches equilibrate and stabilise. They are found to coexist in intervals of the applied magnetic field strength parameter around this branch. We formulate a general energy functional for the system and a corresponding Hamiltonian that provide a pattern selection principle allowing us to compute Maxwell points (where the energy of a single hexagon cell lies in the same Hamiltonian level set as the flat state) for general magnetic permeabilities. Using numerical continuation techniques, we investigate the existence of localised hexagons in the Young–Laplace equation coupled to the Maxwell equations. We find that cellular hexagons possess a Maxwell point, providing an energetic explanation for the multitude of measured hexagon patches. Furthermore, it is found that planar hexagon fronts and hexagon patches undergo homoclinic snaking, corroborating the experimentally detected intervals. Besides making a contribution to the specific area of ferrofluids, our work paves the ground for a deeper understanding of homoclinic snaking of two-dimensional localised patches of cellular patterns in many physical systems.
The activities and some research progress of IAU Commission 19 (C19) - Rotation of the Earth - in the past triennial term (2012-2015) is reported in this paper, including the scientific session and business meeting of C19, as well as a business meeting of the IAU/IAG Joint Working Group of “Theory of Earth Rotation” (JWG_ThER) during the XXIX IAU General Assembly in Hawaii, USA. Three reports of JWG_ThER progress, IERS and IAG, eleven reports of national projects and individual institutions, a short summary of the history and heritage of C19, and an Overview of the status and outlook of new Commission A2 are also presented.
To determine the rates of and risk factors for tigecycline nonsusceptibility among carbapenem-resistant Klebsiella pneumoniae (CRKPs) isolated from hospitalized patients
Multicenter prospective observational study
Acute care hospitals participating in the Consortium on Resistance against Carbapenems in Klebsiella pneumoniae (CRaCKle)
A cohort of 287 patients who had CRKPs isolated from clinical cultures during hospitalization
For the period from December 24, 2011 to October 1, 2013, the first hospitalization of each patient with a CRKP during which tigecycline susceptibility for the CRKP isolate was determined was included. Clinical data were entered into a centralized database, including data regarding pre-hospital origin. Breakpoints established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) were used to interpret tigecycline susceptibility testing.
Of 287 patients included in the final cohort, 155 (54%) had tigecycline-susceptible CRKPs. Of all index isolates, 81 (28%) were tigecycline-intermediate and 51 (18%) were tigecycline resistant. In multivariate modeling, independent risk factors for tigecycline nonsusceptibility were (1) admission from a skilled nursing facility (OR, 2.51; 95% CI, 1.51–4.21; P=.0004), (2) positive culture within 2 days of admission (OR, 1.82; 95% CI, 1.06–3.15; P=.03), and (3) receipt of tigecycline within 14 days (OR, 4.38, 95% CI, 1.37–17.01, P=.02).
In hospitalized patients with CRKPs, tigecycline nonsusceptibility was more frequently observed in those admitted from skilled nursing facilities and occurred earlier during hospitalization. Skilled nursing facilities are an important target for interventions to decrease antibacterial resistance to antibiotics of last resort for treatment of CRKPs.
Recently it has been demonstrated that there are differences between sheep and goats in respect to adaptation to a calcium-restricted diet. It was the aim of the present study to evaluate whether species-specific peculiarities also occur when calcium homoeostasis is challenged by lactation. Therefore, we investigated the time courses of plasma parameters related to calcium homoeostasis (calcium, phosphate, calcitriol, the bone resorption marker CrossLaps® and the bone formation marker osteocalcin) during the transition period in multiparous animals of both species and compared the results to data from a former study carried out with dairy cows. As in cows, plasma calcium and the ratio of bone formation to bone resorption decreased at parturition in goats while plasma calcitriol increased. On day 10 post partum the bone parameters of goats reached prepartum values again, which was not the case in cows. Sheep were found to experience a challenge of calcium homoeostasis already 10 d before parturition, reflected by a very low ratio of bone formation to bone resorption, which was not accompanied by an increase in plasma calcitriol. Additionally, sheep and goats which had been in milk for 3 months were sampled, dried-off and sampled again 6 weeks later. In dried-off animals there were no detectable differences in parameters of bone metabolism. In conclusion we could show that the contribution of bone mobilisation to the compensation for the enhanced calcium demand due to lactation differs between the three ruminant species.
Hans Blumenberg's early historical examination of the metaphorology of the shipwreck, Schiffbruch mit Zuschauer (Shipwreck with spectator), lays out the existential import this image held for Western thought from antiquity through to philosophical modernism. For Blumenberg, the metaphor of the ocean voyage assumes a place along-side that of air flight and the Promethean theft of fire as one of the staple concretizations of human arrogance in its attempts to challenge and tame the laws of nature (14–15). The sea voyage in particular encapsulates, according to Blumenberg, a paradigmatic moment of human blasphemy, codified in the attempt to transgress those natural conditions that bind human existence to terra firma, and to venture out into that element that paradigmatically embodies the forces of incalculability, lawlessness, and total lack of orientation: the infinitely vast and wholly unpredictable ocean (10). Blumenberg identifies precisely that liminal space between terra firma and the immeasurable expanse of the ocean as the place that embodies and symbolically invokes this constant human drive toward transgression of its existential limitations. Blumenberg's language points immediately to the relevance this model holds specifically for Faust in part 2 of Goethe's drama: “Daß hier, an der Grenze vom festen Land zum Meer, zwar nicht der Sündenfall, aber doch der Verfehlungsschritt ins Ungemäße und Maßlose zuerst getan wurde, ist von der Anschaulichkeit, die dauerhafte Topoi trägt” (11; The fact that this border between firm land and the sea marks the place where, to be sure, not the fall from grace per se, but the first transgressive step into inexpedience and immoderation was taken, has the vividness that only lasting topoi possess).
What does it mean to think “I,” to say “I,” to write “I”? These foundational questions of subjectivity inform Annette von Droste-Hulshoff's literary production to such an extent that one might arguably define her oeuvre in terms of the early German Romantic notion of autopoiesis, the self-reflexive, self-critical self-creation of the subject, das Ich (the I), in and through poesy. Yet in contradistinction to the unitary structure of early Romantic subjectivity, for Droste the self frequently is presented as an object, an object often watched by—and at times watching—the subject, an object that is irreconcilable with the subject. significantly, many of these scenes of objectified self-definition are explicitly presented as aesthetic events, indicating their programmatic status in Droste's poetics, and they recur emblematically throughout her writing.
The following analysis seeks to elucidate Droste's object-driven conception of subjectivity and poetic production through a series of examples. The first section considers the early prose fragment Ledwina (1818/19–26). The second presents brief readings of a selection of her more famous poems and ballads, written between 1840 and 1844: “Das Spiegelbild” (The mirror image), “Im Moose” (In the moss), “Das Fraulein von Rodenschild” (Lady von Rodenschild), “Das erste Gedicht” (The first poem), “Das alte schloss” (The old castle), “Im Grase” (In the grass), “Die todte Lerche” (The dead lark), “Die Taxuswand” (The yew wall), “Die Mergelgrube” (The marl pit) and “Lebt wohl” (Farewell).