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Importance Many patients with coronavirus disease 2019 (COVID-19) are critically ill and require care in the intensive care unit (ICU). Objective To evaluate the independent risk factors associated with mortality of patients with COVID-19 requiring treatment in ICUs in the Lombardy region of Italy. Design, Setting, and Participants This retrospective, observational cohort study included 3988 consecutive critically ill patients with laboratory-confirmed COVID-19 referred for ICU admission to the coordinating center (Fondazione IRCCS [Istituto di Ricovero e Cura a Carattere Scientifico] Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy) of the COVID-19 Lombardy ICU Network from February 20 to April 22, 2020. Infection with severe acute respiratory syndrome coronavirus 2 was confirmed by real-time reverse transcriptase–polymerase chain reaction assay of nasopharyngeal swabs. Follow-up was completed on May 30, 2020. Exposures Baseline characteristics, comorbidities, long-term medications, and ventilatory support at ICU admission. Main Outcomes and Measures Time to death in days from ICU admission to hospital discharge. The independent risk factors associated with mortality were evaluated with a multivariable Cox proportional hazards regression. Results Of the 3988 patients included in this cohort study, the median age was 63 (interquartile range [IQR] 56-69) years; 3188 (79.9%; 95% CI, 78.7%-81.1%) were men, and 1998 of 3300 (60.5%; 95% CI, 58.9%-62.2%) had at least 1 comorbidity. At ICU admission, 2929 patients (87.3%; 95% CI, 86.1%-88.4%) required invasive mechanical ventilation (IMV). The median follow-up was 44 (95% CI, 40-47; IQR, 11-69; range, 0-100) days; median time from symptoms onset to ICU admission was 10 (95% CI, 9-10; IQR, 6-14) days; median length of ICU stay was 12 (95% CI, 12-13; IQR, 6-21) days; and median length of IMV was 10 (95% CI, 10-11; IQR, 6-17) days. Cumulative observation time was 164 305 patient-days. Hospital and ICU mortality rates were 12 (95% CI, 11-12) and 27 (95% CI, 26-29) per 1000 patients-days, respectively. In the subgroup of the first 1715 patients, as of May 30, 2020, 865 (50.4%) had been discharged from the ICU, 836 (48.7%) had died in the ICU, and 14 (0.8%) were still in the ICU; overall, 915 patients (53.4%) died in the hospital. Independent risk factors associated with mortality included older age (hazard ratio [HR], 1.75; 95% CI, 1.60-1.92), male sex (HR, 1.57; 95% CI, 1.31-1.88), high fraction of inspired oxygen (Fio2) (HR, 1.14; 95% CI, 1.10-1.19), high positive end-expiratory pressure (HR, 1.04; 95% CI, 1.01-1.06) or low Pao2:Fio2ratio (HR, 0.80; 95% CI, 0.74-0.87) on ICU admission, and history of chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.28-2.19), hypercholesterolemia (HR, 1.25; 95% CI, 1.02-1.52), and type 2 diabetes (HR, 1.18; 95% CI, 1.01-1.39). No medication was independently associated with mortality (angiotensin-converting enzyme inhibitors HR, 1.17; 95% CI, 0.97-1.42; angiotensin receptor blockers HR, 1.05; 95% CI, 0.85-1.29). Conclusions and Relevance In this retrospective cohort study of critically ill patients admitted to ICUs in Lombardy, Italy, with laboratory-confirmed COVID-19, most patients required IMV. The mortality rate and absolute mortality were high.

Question What are the baseline characteristics and outcomes of patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to intensive care units (ICUs) in Lombardy, Italy? Findings In this retrospective case series that involved 1591 critically ill patients admitted from February 20 to March 18, 2020, 99% (1287 of 1300 patients) required respiratory support, including endotracheal intubation in 88% and noninvasive ventilation in 11%; ICU mortality was 26%. Meaning In this case series of critically ill patients admitted to ICUs in Lombardy, Italy, with laboratory-confirmed coronavirus disease 2019 (COVID-19), a high proportion required mechanical ventilation and ICU mortality was 26% as of March 25, 2020.Importance In December 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) emerged in China and has spread globally, creating a pandemic. Information about the clinical characteristics of infected patients who require intensive care is limited. Objective To characterize patients with coronavirus disease 2019 (COVID-19) requiring treatment in an intensive care unit (ICU) in the Lombardy region of Italy. Design, Setting, and Participants Retrospective case series of 1591 consecutive patients with laboratory-confirmed COVID-19 referred for ICU admission to the coordinator center (Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy) of the COVID-19 Lombardy ICU Network and treated at one of the ICUs of the 72 hospitals in this network between February 20 and March 18, 2020. Date of final follow-up was March 25, 2020. Exposures SARS-CoV-2 infection confirmed by real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay of nasal and pharyngeal swabs. Main Outcomes and Measures Demographic and clinical data were collected, including data on clinical management, respiratory failure, and patient mortality. Data were recorded by the coordinator center on an electronic worksheet during telephone calls by the staff of the COVID-19 Lombardy ICU Network. Results Of the 1591 patients included in the study, the median (IQR) age was 63 (56-70) years and 1304 (82%) were male. Of the 1043 patients with available data, 709 (68%) had at least 1 comorbidity and 509 (49%) had hypertension. Among 1300 patients with available respiratory support data, 1287 (99% [95% CI, 98%-99%]) needed respiratory support, including 1150 (88% [95% CI, 87%-90%]) who received mechanical ventilation and 137 (11% [95% CI, 9%-12%]) who received noninvasive ventilation. The median positive end-expiratory pressure (PEEP) was 14 (IQR, 12-16) cm H2O, and Fio(2) was greater than 50% in 89% of patients. The median Pao(2)/Fio(2) was 160 (IQR, 114-220). The median PEEP level was not different between younger patients (n = 503 aged = 64 years) (14 [IQR, 12-15] vs 14 [IQR, 12-16] cm H2O, respectively; median difference, 0 [95% CI, 0-0]; P = .94). Median Fio(2) was lower in younger patients: 60% (IQR, 50%-80%) vs 70% (IQR, 50%-80%) (median difference, -10% [95% CI, -14% to 6%]; P = .006), and median Pao(2)/Fio(2) was higher in younger patients: 163.5 (IQR, 120-230) vs 156 (IQR, 110-205) (median difference, 7 [95% CI, -8 to 22]; P = .02). Patients with hypertension (n = 509) were older than those without hypertension (n = 526) (median [IQR] age, 66 years [60-72] vs 62 years [54-68]; P < .001) and had lower Pao(2)/Fio(2) (median [IQR], 146 [105-214] vs 173 [120-222]; median difference, -27 [95% CI, -42 to -12]; P = .005). Among the 1581 patients with ICU disposition data available as of March 25, 2020, 920 patients (58% [95% CI, 56%-61%]) were still in the ICU, 256 (16% [95% CI, 14%-18%]) were discharged from the ICU, and 405 (26% [95% CI, 23%-28%]) had died in the ICU. Older patients (n = 786; age >= 64 years) had higher mortality than younger patients (n = 795; age

Background The long pentraxin PTX3 is a key component of the humoral arm of innate immunity related to sepsis severity and mortality. We evaluated the clinical and prognostic significance of circulating PTX3 in the largest cohort ever reported of patients with severe sepsis or septic shock. Design Plasma PTX3 was measured on days 1, 2 and 7 after randomization of 958 patients to albumin or crystalloids for fluid resuscitation in the multicenter Albumin Italian Outcome Sepsis (ALBIOS) trial. We tested the association of PTX3 and its changes over time with clinical severity, prevalent and incident organ dysfunctions, 90-day mortality, and treatment. Results PTX3 was high at baseline (72 [33-186] ng/mL) and rose with the severity and number of organ dysfunctions (p

ObjectivesA number of studies have shown that the airborne transmission route could spread some viruses over a distance of 2 meters from an infected person. An epidemic model based only on respiratory droplets and close contact could not fully explain the regional differences in the spread of COVID-19 in Italy. On March 16th 2020, we presented a position paper proposing a research hypothesis concerning the association between higher mortality rates due to COVID-19 observed in Northern Italy and average concentrations of PM10exceeding a daily limit of 50 µg/m3.MethodsTo monitor the spreading of COVID-19 in Italy from February 24th to March 13th (the date of the Italian lockdown), official daily data for PM10levels were collected from all Italian provinces between February 9th and February 29th, taking into account the maximum lag period (14 days) between the infection and diagnosis. In addition to the number of exceedances of the daily limit value of PM10, we also considered population data and daily travelling information for each province.ResultsExceedance of the daily limit value of PM10appears to be a significant predictor of infection in univariate analyses (p10levels, while 62 out of 66 Southern provinces presented low PM10concentrations (p0>6.0, comparable with the highest values estimated for China.ConclusionA significant association has been found between the geographical distribution of daily PM10exceedances and the initial spreading of COVID-19 in the 110 Italian provinces.

’Purrpose: To investigate long-term intraocular pressure trends after uncomplicated pars plana vitrectomy for idiopathic epiretinal membrane. Methods: Three hundred and sixty-eight eyes of 368 consecutive patients were enrolled. Changes in intraocular pressure 1, 3, 6, and 12 months after surgery and during the fi nal follow-up visit were evaluated in vitrectomized eyes and nonvitrectomized fellow eyes. Results: The median follow-up period was 36 months (range 12 – 92 months). Longitudinal data analysis evidenced a 2.5-mmHg (2.2 mmHg; 2.7 mmHg, 95% con fi dence interval) statis- tically signi fi cant difference in intraocular pressure 30 days after surgery between treated and fellow untreated eyes, gradually recovering to a not signi fi cant 0.2-mmHg ( 2 0.1 mmHg; 0.4 mmHg, 95% con fi dence interval) difference within 26 months. The incidence of late-onset ocular hypertension was 5.7% (21 over 347, 2%; 12%, 95% con fi dence interval) without difference between the treated eyes and the group control. No signi fi cant difference in the incidence of late-onset ocular hypertension and sex, lens status, or gauge of vitrectomy instru- ments was detected. Only patient ’ sagewassigni fi cantly higher (mean difference 4.2 years; 0.1 – 8.0 years, Monte Carlo, 95% con fi dence interval) in those who de veloped late-onset ocular hypertension in the vitrectomized eye. Conclusion: Uncomplicated pars plana vitrectomy for idiopathic epiretinal membrane seems not to increase the risk of late-onset ocular hypertension or open-angle glaucoma development. R

Study Objective Preliminary data on the effects of prophylactic bilateral salpingectomy (PBS) show that postoperative ovarian function is preserved up to 3 months after surgery. The confirmation of PBS safety on ovarian function even many years after surgery is essential to reassure the medical community that this new strategy, recently proposed for the prevention of ovarian cancer, is at least able to avoid the risk of premature surgical menopause. We investigated whether the addition of PBS during total laparoscopic hysterectomy (TLH) causes long-term effects on ovarian function. Design An observational study (Canadian Task Force classification II-3). Setting Department of Obstetrics and Gynecology, “Magna Graecia” University, Catanzaro, Italy. Patients Seventy-nine patients who underwent TLH plus salpingectomy between September 2010 and September 2012 at our institution have been recalled to be submitted to ovarian reserve evaluation in February 2015. Eight of 79 women refused to participate in this follow-up study. Interventions The ovarian age of PBS patients has been determined through OvAge (OvAge sr., Catanzaro, Italy), a statistical model that combines antimullerian hormone, follicle-stimulating hormone, 3-dimensional antral follicle count, vascular index, flow index, and vascular flow index values. The control group consisted of a large population of 652 healthy women (with intact uterus and adnexa) previously enrolled to build the OvAge model. Comparisons between ovarian ages of PBS patients and the control group have been assessed by analysis of covariance linear statistical modeling. Measurements and Main Results The main outcome measurement was the differences in the behavior within OvAge/age relation between PBS and control women. Descriptive statistics of those 71 enrolled PBS patients are the following: age, 49.61 ± 2.15 years; OvAge, 49.22 ± 2.57 years; follicle-stimulating hormone, 43.02 ± 19.92 mU/mL; antimullerian hormone, 0.12 ± 0.20 ng/mL; 3-dimensional antral follicle count, 1.91 ± 1.28; vascular index, 2.80% ± 5.32%; flow index, 19.37 ± 5.88; and vascular flow index, 0.56 ± 1.12. Analysis of covariance disclosed that PBS and control women do not exhibit different behaviors (p = .900) within OvAge/age relation. Conclusion According to our model, the addition of PBS to TLH in the late reproductive years does not modify the ovarian age of treated women up to 3 to 5 years after surgery.

Purpose To demonstrate in a two-compartment heterogeneous mechanical model of the lung how different loads applied to one compartment, while the other is kept constant, would modify gas distribution between the two pathways under high-frequency percussive ventilation (HFPV). Additionally, these results were compared with those generated in the same model by pressure-controlled ventilation (PCV). Methods Analysis was based on a Siemens lung simulator, representing a fixed branch of the system with an elastance equal to 45 cmH2O/L and a resistance of 20 cmH2O/L/s, and a single-compartment lung simulator, representing a variable pathway of the model, presenting three elastic loads varying between 35 and 85 cmH2O/L and three resistive loads varying between 5 and 50 cmH2O/L/s. Each simulator represented one compartment of the model connected to a central airway that was ventilated with either a volumetric diffusive respirator (VDR-4; Percussionaire Corporation, Sandpoint, ID, USA) or a Siemens Servo 900c ventilator. Flow and pressures were measured in each branch of the model under nine conditions representing the combinations of three elastic and three resistive loads (variable branch) while the loads in the other pathway were kept constant. Results HFPV was able to avoid hyperinflation and reduce tidal volume in a bicompartmental heterogeneous lung model. Under HFPV, gas distribution between the two compartments was not constrained by their time constants. PCV yielded gas distribution as determined by the time constant of each compartment. Conclusions HFPV accommodated volume distribution without overinflating compartments with low time constants, thus possibly presenting a potential protective behavior in mechanically heterogeneous lungs.

Study objective: The aim of this prospective observational study was to evaluate the utility of derived dead space indexes to predict survival in mechanically ventilated patients with acute lung injury (ALI) and ARDS. Study population: Thirty-six patients with ALI (Murray score, > or =1; Pao(2)/fraction of inspired oxygen [Fio(2)] ratio, < 300) in critical care departments at two separate hospitals entered the study. MEASUREMENTS: At ICU admission, 24 h, and 48 h, we measured the following: simplified acute physiologic score II; Pao(2)/Fio(2) ratio; respiratory system compliance; and capnographic indexes (Bohr dead space) and physiologic dead space (Enghoff dead space [Vdphys/Vt]), expired normalized CO(2) slope, carbon dioxide output, and the alveolar ejection volume (Vae)/tidal volume fraction (Vt) ratio. RESULTS: The best predictor was the Vae/Vt ratio at ICU admission (Vae/Vt-adm) and after 48 h (Vae/Vt-48 h) [p = 0.013], with a sensitivity of 82% and a specificity of 64%. The difference between Vae/Vt-48 h and Vae/Vt-adm show a sensitivity of 73% and a specificity of 93% with a likelihood ratio (LR) of 10.2 and an area under the receiver operating characteristic (ROC) curve of 0.83. The interaction between the Pao(2)/Fio(2) ratio and Vae/Vt-adm predict survival (p = 0.003) with an area under the ROC curve of 0.84, an LR of 2.3, a sensitivity of 100%, and a specificity of 57%. The Vdphys/Vt after 48 h predicted survival (p = 0.02) with an area under the ROC curve of 0.75, an LR of 8.8, a sensitivity of 63%, and a specificity of 93%. Indexes recorded 24 h after ICU admission were not useful in explaining outcome. CONCLUSIONS: Noninvasive measures of Vae/Vt at ICU admission and after 48 h of mechanical ventilation, associated with Pao(2)/Fio(2) ratio provided useful information on outcome in critically ill patients with ALI.

Candidemia represents an important cause of morbidity and mortality. To-date, the highest rates of candidemia occur in elderly patients, but there are few data on such patient population. The aims of this study were to evaluate the epidemiology, treatment and outcome of candidemia in an elderly patient population.Nosocomial candidemia episodes occurring in a university general hospital were included in this study. Demographic, clinical, and Candida susceptibility testing data were retrospectively collected. Potential risk factors for 30-day crude mortality rate including host factors, Candida species, concomitant bacteremia, severity of sepsis, and management of fungemia were assessed by hazard risk (HR) analyses.145 consecutive episodes of candidemia occurring in 140 patients with a median age of 81 years (interquartile range, 78-86 years) were analyzed. At the onset of candidemia, 98 (67.6 %) cases were hospitalized in medical wards. Candida albicans accounted for 55 % of all candidemia episodes. Overall, resistance to fluconazole was detected in 8.0 % of Candida isolates. Crude hospital mortality at 30 days was 46 %. Failure to receive adequate antifungal therapy was the significant risk factor for death on multivariable analysis (adjusted HR 1.87, 95 % CI 0.94-2.79).Over two-thirds of elderly patients with candidemia are admitted to medical wards in our series. 30-day crude mortality is high and seems to be related to inadequate antifungal therapy. Increased awareness of the burden of this disease also in medical wards is strongly required to recognize and treat properly this severe infection.

PurposeThis paper aims to present an innovative model to evaluate the quality of the learning outcome in vocational education and training (VET) considering a wide approach that includes, in particular, stakeholders' expectations and perceptions.Design/methodology/approachThe Expero model was implemented in various kinds of vocational schools and educational institutions in different European countries.FindingsThe model was validated through review by several international experts and by translation into a quality standard certification model.Research limitations/implicationsExpero needs a larger testing phase in non‐European countries to validate its appropriateness. Different vocational systems in non‐EU countries could enrich and widen the model in terms of transferability and sustainability as well as fostering cross‐educational requirements and needs that may impact the quality of the learning outcome. The Expero model is mainly dedicated to vocational education and, in its current form, is not suitable to be applied to other levels of education (i.e. primary or secondary). Meanwhile, it seems promising in terms of its application in higher education institutions, in workplace learning, and in continuous professional training.Practical implicationsExpero permits analysis of the quality of the learning outcome, which constitutes the prior mission of a school. Being dedicated to the vocational sector, Expero is based on stakeholder evaluation, including school personnel, trainees, industries, companies and external bodies interested in a school's results. Applying the Expero model, a school can analyse its strengths and weaknesses in a systematic way; strengthening – or even creating – a collaborative network with its stakeholders finalised in improving learning outcome.Originality/valueAmong the various opportunities a school has to perform a quality assessment (ISO 9000, EFQM, CAF), Expero is the first model focused on the quality of the learning outcome based on multi‐stakeholder data analysis.

Purpose Ineffective respiratory efforts during expiration (IEE) are a problem during mechanical ventilation (MV). The goal of this study is to validate mathematical algorithms that automatically detect IEE in a computerized (Better Care®) system that obtains and processes data from intensive care unit (ICU) ventilators in real time. Methods The Better Care® system, integrated with ICU health information systems, synchronizes and processes data from bedside technology. Algorithms were developed to analyze airflow waveforms during expiration to determine IEE. Data from 2,608,800 breaths from eight patients were recorded. From these breaths 1,024 were randomly selected. Five experts independently analyzed the selected breaths and classified them as IEE or not IEE. Better Care® evaluated the same 1,024 breaths and assigned a score to each one. The IEE score cutoff point was determined based on the experts’ analysis. The IEE algorithm was subsequently validated using the electrical activity of the diaphragm (EAdi) signal to analyze 9,600 breaths in eight additional patients. Results Optimal sensitivity and specificity were achieved by setting the cutoff point for IEE by Better Care® at 42%. A score >42% was classified as an IEE with 91.5% sensitivity, 91.7% specificity, 80.3% positive predictive value (PPV), 96.7% negative predictive value (NPV), and 79.7% Kappa index [confidence interval (CI) (95%) = (75.6%; 83.8%)]. Compared with the EAdi, the IEE algorithm had 65.2% sensitivity, 99.3% specificity, 90.8% PPV, 96.5% NPV, and 73.9% Kappa index [CI (95%) = (71.3%; 76.3%)]. Conclusions In this pilot, Better Care® classified breaths as IEE in close agreement with experts and the EAdi signal.

PURPOSE: To evaluate the role of uterine fundal pressure during the second stage of labor (Kristeller maneuver) on pelvic floor dysfunction (urinary and anal incontinence, genital prolapse, pelvic floor strength). METHODS: 522 primiparous women, enrolled 3 months after vaginal delivery, were divided in two groups: group A (297 women) identifies the women who received Kristeller maneuvers with different indications (e.g. fetal distress, failure to progress, mother exhaustion), group B (225 women) the women without maneuver. Participants were questioned about urogynecological symptoms and examined by Q-tip test, digital test, vaginal perineometry and uroflowmetric stop test score. RESULTS: Mediolateral episiotomies, dyspareunia and perineal pain were significantly higher in Kristeller group, whereas urinary and anal incontinence, genital prolapse and pelvic floor strength were not significantly different between the groups. CONCLUSIONS: Kristeller maneuver does not modify puerperal pelvic floor function but increases the rate of episiotomies.

Background: Hypoxemia in acute lung injury/acute respiratory distress syndrome (ALI/ARDS) patients represents a common finding in the intensive care unit (ICU) and frequently does not respond to standard ventilatory techniques. Objective: To study whether the early short-term application of high-frequency percussive ventilation (HFPV) can improve gas exchange in hypoxemic patients with ALI/ARDS or many other conditions in comparison to conventional ventilation (CV) using the same mean airway pressure (Paw), representing the main determinant of oxygenation and hemodynamics, irrespective of the mode of ventilation. Methods: Thirty-five patients not responding to CV were studied. During the first 12 h after admission to the ICU the patients underwent CV. Thereafter HFPV was applied for 12 h with Paw kept constant. They were then returned to CV. Gas exchange was measured at: 12 h after admission, every 4 h during the HFPV trial, 1 h after the end of HFPV, and 12 h after HFPV. Thirty-five matched patients ventilated with CV served as the control group (CTRL). Results: Pao2/Fio2 and the arterial alveolar ratio (a/A Po2) increased during HFPV treatment and a Pao2/Fio2 steady state was reached during the last 12 h of CV, whereas both did not change in CTRL. Paco2 decreased during the first 4 h of HFPV, but thereafter it remained unaltered; Paco2 did not vary in CTRL. Respiratory system compliance increased after HFPV. Conclusions: HFPV improved gas exchange in patients who did not respond to conventional treatment. This improvement remained unaltered until 12 h after the end of HFPV.

Background and objective. Tuberculosis (TB) occurring in immigrants and resistance to drugs are major problems for TB control in Western countries. Directly observed therapy (DOT) reduces disease transmission, but this approach may have poor results among illegal immigrants. Our aim was to evaluate a prolonged hospitalisation programme to improve early outcome of TB treatment in high risk patients. Methods. All the consecutive adult patients with sputum smear-positive pulmonary TB admitted to 2 Italian referral TB Centres were evaluated. Hospital-based DOT was provided to high risk patients up-to smear conversion. Demographic, microbiological and clinical conditions, as potential factors associated with confirmed smear conversion at 60 and 90 days of anti-tuberculous therapy were evaluated. Results. 122 patients were studied, 45.9% of them were immigrants (20% illegal) from high-prevalence TB countries. HIV testing was negative in all cases. Twelve patients had M. tuberculosis resistant to ≥ 1 first-line anti-tuberculous agents. The rate of defaulting from TB treatment was 7.3%. Sputum smear became negative in 84.4% cases after 60 days and 93.3% cases after 90 days. At such time, smear conversion rates were similar among different high risk subgroups such as illegal immigrants (95.9%), legal foreign-born (92.5%) and Italian persons (94.8%). Persistent sputum smear positivity was independently correlated with the extent of pulmonary lesions at 60 (p

PURPOSE: Because the use of IgM and IgA enriched polyclonal intravenous immunoglobulins (eIg) is a standard of care in critically ill patients admitted to our intensive care unit (ICU) with the diagnosis of severe sepsis or septic shock, we investigated if the delay from the onset of severe sepsis and septic shock and their administration could influence the outcome. MATERIALS AND METHODS: The medical records of all patients with severe sepsis or septic shock admitted to our ICU from July 2004 through October 2009 and treated with eIg (Pentaglobin®; Biotest, Dreieich, Germany) were retrospectively examined. RESULTS: A total of 129 adult patients with severe sepsis or septic shock were considered eligible. Thirty-two percent of patients died during the ICU stay. Survivors were given eIg significantly earlier than nonsurvivors (23 vs 63 hours, P < .05). The delay in the administration of eIg and the Simplified Acute Physiology Score II were the only variables that entered stepwise a propensity score-adjusted logistic model. The delay in the administration of eIg was a significant predictor of the odds of dying during the ICU stay (odds ratio for 1 hour of delay, 1.007; P < .01; 99% confidence interval from 1.001 to 1.010) and proved to be independent from the Simplified Acute Physiology Score II and other variables. CONCLUSIONS: The efficacy of eIg, being maximal in early phases of severe sepsis and/or septic shock, is probably time dependent.

PurposeDuring work as reviewers and editors of journals authors are often faced the same types of problems in many articles. The purpose of this piece is to give some guidelines on typical problems that lead to rejection, and how to avoid these.Design/methodology/approachThe paper discusses journal article design and offers some methodology viewpoints; in particular about the differences between a PhD thesis aim and a scientific journal article. It focuses on some typical mistakes found in reviewing papers.FindingsThe paper finds that the main criteria to getting published are that the article must include original, empirical research.Originality/valueFollowing these guidelines the review process of articles will be smoother and the amount of rejects should diminish. Especially young researchers can find good suggestions about how to write a paper for the Journal of Workplace Learning.

Objective: During thoracotomy, positive end-expiratory pressure is applied to the dependent lung and continuous positive airway pressure (CPAP) inflates the nondependent lung to avoid hypoxemia. These methods do not allow the removal of produced secretions. We hypothesized that high-frequency percussive ventilation (HFPV) can improve both conditions and reduce hospital length of stay in these patients. Design: Randomized prospective study. Setting: University Hospital. Patients: Fifty-three consecutive patients undergoing elective pulmonary partial resection were enrolled. Nine were excluded because of surgical reasons. Interventions: The nondependent lung was ventilated with HFPV in 22 patients and other 22 received CPAP. In both groups, the dependent lung was ventilated with continuous mechanical ventilation. Measurement and Main Results: Cardiocirculatory variables and blood gas analysis were measured during surgery. Postoperatively, all patients underwent chest physiotherapy, and Spo2, body temperature, the amount of sputum produced, and chest radiography were recorded. Before nondependent lung re-expansion, HFPV patients presented higher Pao2 than CPAP group (p = 0.020). The amount of secretions was higher in chronic obstructive pulmonary disease patients treated with HFPV than in those who received CPAP (199 and 64 mL, respectively, p = 0.028). HFPV increased by 5.28 times the chance of sputum production by chronic obstructive pulmonary disease patients (χ2 = 46.66, p < 0.0001; odds ratio = 5.28). A patient treated with HFPV had a 3.14-fold larger chance of being discharged earlier than a CPAP-treated subject (likelihood ratio = 11.5, p = 0.0007). Conclusions: Under the present settings, HFPV improved oxygenation in one-lung ventilation during pulmonary resection. Postoperatively, it decreased the length of stay and increased the removal of secretions in comparison with CPAP.

Objective: To test the effects of positive expiratory pressure onthe leakage of fluid around cuffs of different tracheal tubes, inmechanically ventilated patients and in a benchtop model.Design: Randomized clinical trial and experimental in vitrostudy.Setting: Intensive care unit of a university hospital.Patients: Forty patients recovering in the intensive care unitwere ventilated in volume-controlled mode. Twenty patients wererandomly intubated with Hi-Lo tubes (HL group), whereas theremaining 20 subjects were intubated with SealGuard tubes (SGgroup).Interventions: Immediately after intubation and cuff inflationwith 30 cm H2O, Evans blue was applied onto the cephalic surfaceof the tracheal tube cuff. A 5-cm H2O positive expiratory pressurewas used during the first 5 hrs of stay, and thereafter it wasremoved. Bronchoscopy verified whether the dye leaked aroundthe cuff. The experiment lasted 12 hrs. Leakage was also testedin vitro with the same tracheal tubes with incremental level ofpositive expiratory pressure.Measurements and Main Results: At 1 hr, 5 hrs, and thereafterhourly until 12 hrs, bronchoscopy was used to test the presenceof dye on the trachea caudal to the cuff. At the fifth hour, twopatients of the HL group failed the test. One hour after positiveexpiratory pressure removal, all subjects in group HL exhibited adyed lower trachea. On the other hand, one patient in group SGpresented a leak at the eighth hour, and at the 12th hour three ofthem were still sealed. In vitro, the same level of positive expiratorypressure delayed the passage of dye around the cuff; after30 mins positive expiratory pressure was removed, and in 10 minsall dye leaked only in the Hi-Lo tube.Conclusions: We found that 5 cm H2O positive expiratorypressure was effective in delaying the passage of fluid around thecuffs of tracheal tubes both in vivo and in vitro. The SealGuardtube proved to be more resistant to leakage than Hi-Lo