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BACKGROUND The survival benefit of chemotherapy compared to best supportive care (BSC) after percutaneous transhepatic biliary drainage (PTBD) was evaluated in patients with pancreatic or biliary tract cancer. PATIENTS AND METHODS A retrospective registry study was conducted at a tertiary-level university hospital. The endpoint was survival measured from the PTBD and the initiation of chemotherapy. RESULTS Among 158 patients (mean age=74 years, range=43-93 years; 51.9% women), 82 (51.9%) had pancreatic cancer and 76 (48.1%) had biliary tract cancer. After PTBD, 32 (20.3%) patients received chemotherapy and had a median survival of 11.7 months; 126 (79.7%) patients received only BSC resulting in a median survival of 1.7 months. The hazard ratio for survival at 1 year for patients who received chemotherapy compared to BSC was 0.22 (95% confidence interval=0.12-0.41, p

Background: Echinocandins are recommended as a first-line empiric treatment for fungal infections of patients in an intensive care unit (ICU) with critical illness. The primary aim of the study was to compare outcomes among ICU patients treated with empiric anidulafungin (ANI), caspofungin (CASPO), or micafungin (MICA). Methods: A retrospective cohort study in a mixed adult ICU. Patient demographics, reason for ICU admission, ICU risk scores and organ support therapies were analyzed. Outcome parameters included ICU and hospital stay, 30-day mortality and 1-year mortality. Results: Empiric echinocandin therapy was given to 367 patients (ANI; 73 patients, CASPO; 84 patients, and MICA; 210 patients) with a median duration of 3 days in an ICU. Patient median age was 60.7 years. As a first-line therapy, 52% of patients received fluconazole. Positive Candida cultures were found in the following samples: blood, 16 (4.4%); central line, 27 (7.4%); deep site, 92 (25.1%). Median ICU stay (ANI 6.4 days, CASPO 5.3 days, MICA 8.1 days), hospital stay (ANI 33 days, CASPO 30 days, MICA 30 days), 30-day mortality (ANI 27%, CASPO 32%, MICA 32%), and 1-year mortality (ANI 33%, CASPO 44%, MICA 45%) did not differ between the groups. The cost of antifungal therapy during the ICU period was similar in the three echinocandin groups (ANI; €1 872, CASPO; €1 799, and MICA; €1783). Conclusion: Our results show that ICU, hospital stay, and mortality (hospital, 30-day and 1-year) did not differ among patients with empiric anidulafungin, caspofungin, or micafungin treatment in a mixed adult ICU.

A previous study showed that classical building-related symptoms (BRS) were related to indoor dust and microbial toxicity via boar sperm motility assay, a sensitive method for measuring mitochondrial toxicity. In this cross-sectional study, we analyzed whether teachers' most common work-related non-literature-known BRS (nBRS) were also associated with dust or microbial toxicity. Teachers from 15 schools in Finland completed a questionnaire evaluating 20 nBRS including general, eye, respiratory, hearing, sleep, and mental symptoms. Boar sperm motility assay was used to measure the toxicity of extracts from wiped dust and microbial fallout samples collected from teachers' classrooms. 231 teachers answered a questionnaire and their classroom toxicity data were recorded. A negative binomial mixed model showed that teachers' work-related nBRS were 2.9-fold (95% CI: 1.2-7.3) higher in classrooms with highly toxic dust samples compared to classrooms with non-toxic dust samples (p = 0.024). The RR of work-related nBRS was 1.8 (95% CI: 1.1-2.9) for toxic microbial samples (p = 0.022). Teachers' BRS appeared to be broader than reported in the literature, and the work-related nBRS were associated with toxic dusts and microbes in classrooms.

Background During the past decades, epidemiologic data of independent predictors of multiple organ failure (MOF), incidence, and mortality have changed. The aim of the study was to assess the potential changes in the incidence and outcomes of MOF for one decade (2008-2017). In addition, resource utilization was considered. Methods Patients were eligible for inclusion if they were adults, admitted to the ICU between January 1, 2008 and December 31, 2017, and had complete data sets regarding MOF. MOF was defined as organ failure separately with and without central nervous system (CNS) failure. The onset of MOF was defined as being early (≤48 h of ICU admission) and late (>48 h after ICU admission). Results Of a total of 13,270 patients enclosed in this study, 44.6% of the patients developed MOF with and 31.4% without CNS failure. MOF-related mortality decreased in patients with (adjusted IRR 0.972 [95% CI 0.948 to 0.996], P=0.022) and without (adjusted IRR 0.957 [95% CI 0.931 to 0.983], P=0.0013) CNS failure. In addition, the incidence (adjusted IRR 0.970 [95% CI 0.950 to 0.991], P=0.006) and mortality (adjusted IRR 0.968 [95% CI 0.940 to 0.996], P=0.025) of early-onset MOF decreased, while the incidence and mortality of late-onset MOF remained constant. The length of ICU (P=0.024) and hospital (P=0.032) stays decreased while the length of mechanical ventilation remained constant (P=0.41). Conclusions Despite all improvements in intensive care during the last decades, the incidence of late-onset MOF remains a resource-intensive, morbid, and lethal condition. More research on etiologies, signs of organ failure, and where and when to start treatment is needed to improve the prognosis of late-onset MOF.

Background Hospital managers play an essential role in implementing strategies to promote good hand hygiene (HH) among health care workers. We investigated the managers’ views on their roles, challenges and developmental ideas in promoting good HH practice. Methods A descriptive cross-sectional study with an online survey of both medical and nursing managers was conducted within a single tertiary care hospital in Finland. Three open-ended questions were analyzed using inductive content analysis. Results A total of 78 managers out of 168 responded to the survey (response rate 46%). Managers helped promote HH practices by enabling the proper environment for adherence to good HH, visible commitment, and using various means to instruct staff about HH. Challenges included the acute hospital setting and practical problems related to the managers’ numerous responsibilities. Developmental ideas included information communication technology applications for monitoring HH as an indicator of the quality of care, versatile responses to HH audits, and clarifying the roles of different management levels. Conclusions Managers are committed to and use various methods to promote HH. Managers would benefit from information communication technology applications to provide easy and targeted information regarding compliance with HH.

Summary Background Nurse understaffing and increased nursing workload have been associated with increased risk of adverse patient outcomes and even mortality. Aim To determine whether nurse staffing and nursing workload are associated with ventilator-associated pneumonia and mortality. Methods This prospective, observational cohort study was conducted in a single tertiary-level teaching hospital in Finland during 2014–2015. The association between nurse staffing, nursing workload and prognosis was determined using daily nurse-to-patient ratios, Therapeutic Intervention Scoring System and Intensive Care Nursing Scoring System scores, and Intensive Care Nursing Scoring System indices. Ventilator-associated pneumonia was defined according to the Centers for Disease Control and Prevention criteria. Findings Evaluable data was available for 85 patients. The overall ventilator-associated pneumonia and 28-day mortality rates were 23.5% and 35.3%, respectively. Nurse staffing, measured as the daily lowest nurse-to-patient ratio (P = 0.006) and median Intensive Care Nursing Scoring System index (P = 0.046), were significantly lower in patients with ventilator-associated pneumonia. In addition, nursing workload, measured as median scores obtained by the Therapeutic Intervention Scoring System (P = 0.009) and Intensive Care Nursing Scoring System (P = 0.03), was significantly higher in infected patients. The median (P = 0.02) and daily highest (P = 0.03) Intensive Care Nursing Scoring System scores were significantly higher in non-survivors. Conclusions Lower nurse staffing and increased nursing workload are associated with ventilator-associated pneumonia and mortality, demonstrating that adequate staffing is a prerequisite for the availability and quality of critical care services.

Background Neuroinflammation often develops in sepsis along with increasing permeability of the blood-brain barrier (BBB), which leads to septic encephalopathy. The barrier is formed by tight junction structures between the cerebral endothelial cells. We investigated the expression of tight junction proteins related to endothelial permeability in brain autopsy specimens in critically ill patients deceased with sepsis and analyzed the relationship of BBB damage with measures of systemic inflammation and systemic organ dysfunction. Methods The case series included all (385) adult patients deceased due to sepsis in the years 2007–2015 with available brain specimens taken at autopsy. Specimens were categorized according to anatomical location (cerebrum, cerebellum). The immunohistochemical stainings were performed for occludin, ZO-1, and claudin. Patients were categorized as having BBB damage if there was no expression of occludin in the endothelium of cerebral microvessels. Results Brain tissue samples were available in 47 autopsies, of which 38% (18/47) had no expression of occludin in the endothelium of cerebral microvessels, 34% (16/47) developed multiple organ failure before death, and 74.5% (35/47) had septic shock. The deceased with BBB damage had higher maximum SOFA scores (16 vs. 14, p = 0.04) and more often had procalcitonin levels above 10 μg/L (56% vs. 28%, p = 0.045) during their ICU stay. BBB damage in the cerebellum was more common in cases with C-reactive protein (CRP) above 100 mg/L as compared with CRP less than 100 (69% vs. 25%, p = 0.025). Conclusions In fatal sepsis, damaged BBB defined as a loss of cerebral endothelial expression of occludin is related with severe organ dysfunction and systemic inflammation.

Malignant biliary obstruction is a challenging problem for cancer patients. Here we evaluate predictive factors for survival following percutaneous drainage for malignant biliary obstruction in patients in whom endoscopic drainage was unsuccessful or insufficient. A retrospective register study in a tertiary-level university hospital. A total of 643 cancer patients (317 females and 326 males) with malignant biliary obstruction were treated with percutaneous drainage at our hospital between 1999 and 2016. Their median overall survival rate was 2.6 months, with a 95% confidence interval (CI) of 2.2–3.0. Independent factors predicting poor outcome were metastatic cancer, with a hazard ratio (HR) of 2.2 (95% CI 1.8–2.7); Eastern Cooperative Oncology Group performance status (ECOG PS) of 2 (HR 2.3; 95% CI 1.8–2.8); ECOG PS of 3–4 (HR 3.5; 95% CI 2.8–4.4), American Society of Anesthesiologists physical status classification (ASA) of 4 (HR 2.1; 95% CI 1.5–2.9); and bilirubin of ≥60.0 µmol/L within 30 days post-drainage (HR 1.3; 95% CI 1.1–1.6). During the time periods 1999–2004 and 2005–2010, patients had poorer outcomes (HR 1.4; 95% CI 1.1–1.7 and HR 1.4; 95% CI 1.2–1.8) than during the last period 2011–2016. Patients with cancer who underwent percutaneous biliary drainage for biliary obstruction had a poor median overall survival. The usefulness of biliary drainage, especially in patients with metastatic cancer, poor ECOG PS, and high ASA class, should be critically considered.

BACKGROUNDIn 2013, the Centers for Disease Control and Prevention released a novel surveillance concept called the “ventilator-associated event,” which focused surveillance on objective measures of complications among patients that underwent invasive ventilations.OBJECTIVETo evaluate the concordance and possible differences in efficacy (ie, disease severity and outcomes) between 2 surveillance paradigms: (1) infection-related ventilator-associated complications (iVAC) and (2) on conventional ventilator-associated pneumonia (VAP).DESIGNProspective, observational, single-center cohort study.PATIENTSThis study included 85 adult patients that received invasive ventilation for at least 2 consecutive calendar days in a 22-bed, adult, mixed medical-surgical intensive care unit in Finland between October 2014 and June 2015.RESULTSAmong these patients, 9 (10.1 per 1,000 days of mechanical ventilation) developed iVAC (10.6%) and 20 (22.4 per 1,000 days of mechanical ventilation) developed conventional VAP (23.5%). The iVAC indicators were most often caused by atelectasis and fluid overload. Compared with patients with conventional VAP, patients with iVAC had significantly worse respiratory status but no other differences in disease severity or outcomes.CONCLUSIONSThe incidence of conventional VAP was >2-fold that of iVAC, and the surveillance paradigms for VAP and iVAC capture different patterns of disease. Our results suggest that this novel surveillance concept, although based on objective measures of declining oxygenation, actually identified deteriorations of oxygenation due to noninfectious causes.Infect Control Hosp Epidemiol 2017;38:983–988

Introduction Indoor microbial toxicity is suspected to cause some building-related symptoms, but supporting epidemiological data are lacking. Objective We examined whether the in vitro toxicity of indoor samples from school buildings was associated with work-related health symptoms (building-related symptoms, BRS). Methods Administrators of the Helsinki City Real Estate Department selected 15 schools for the study, and a questionnaire on symptoms connected to work was sent to the teachers in the selected schools for voluntary completion. The cellular toxicity of classroom samples was determined by testing substances extracted from wiped indoor dust and by testing microbial biomass that was cultured on fallout plates. Boar sperm cells were used as indicator cells, and motility loss was the indicator for toxic effects. The effects were expressed as the half maximal effective concentration (EC 50 ) at which >50% of the exposed boar sperm cells were immobile compared to vehicle control. Results Completed symptom questionnaires were received from 232 teachers [median age, 43 years; 190 (82.3%) women] with a median time of 6 years working at their school. Samples from their classrooms were available and were assessed for cellular toxicity. The Poisson regression model showed that the impact of extracts of surface-wiped school classroom dust on teacher work-related BRS was 2.8-fold (95% CI: 1.6–4.9) higher in classrooms with a toxic threshold EC 50 of 6 µg ml −1 versus classrooms with insignificant EC 50 values (EC 50 >50 µg ml −1 ); P Conclusions Teachers working in classrooms where the samples showed high sperm toxicity had more BRS. The boar sperm cell motility inhibition assay appears promising as a tool for demonstrating the presence of indoor substances associated with BRS.

To determine changes in hand-hygiene compliance after the introduction of direct observation of hand-hygiene practice for doctors and nurses, and evaluate the relationship between the changes and the incidence of health-care-associated infections.We conducted an internal audit survey in a tertiary-care hospital in Finland from 2013 to 2018. Infection-control link nurses observed hand-hygiene practices based on the World Health Organization's strategy for hand hygiene. We calculated hand-hygiene compliance as the number of observations where necessary hand-hygiene was practised divided by the total number of observations where hand hygiene was needed. We determined the incidence of health-care-associated infections using a semi-automated electronic incidence surveillance programme. We calculated the Pearson correlation coefficient (The link nurses made 52 115 hand-hygiene observations between 2013 and 2018. Annual hand-hygiene compliance increased significantly from 76.4% (2762/3617) in 2013 to 88.5% (9034/10 211) in 2018 (The compliance of doctors and nurses with hand-hygiene practices improved with direct observation and feedback, and this change was associated with a decrease in the incidence of health-care-associated infections. Further studies are needed to evaluate the contribution of hand hygiene to reducing health-care-associated infections.Identifier les changements dans l'application des mesures d'hygiène des mains après l'introduction d'un système d'observation directe des pratiques en la matière chez les médecins et infirmiers. Évaluer le rapport entre ces changements et le nombre d'infections liées aux soins de santé.Nous avons effectué un audit interne au sein d'un hôpital de soins tertiaires en Finlande entre 2013 et 2018. Les infirmières chargées du contrôle des infections ont jugé les pratiques d'hygiène en se basant sur la stratégie d'hygiène des mains de l'Organisation mondiale de la Santé. Nous avons défini dans quelle mesure le personnel respectait les consignes d'hygiène des mains en divisant le nombre de cas où le niveau d'hygiène requis était respecté par le nombre total de cas où l'hygiène des mains était nécessaire. Nous avons également déterminé le nombre d'infections liées aux soins de santé à l'aide d'un programme de surveillance électronique semi-automatique. Enfin, nous avons calculé le coefficient de corrélation de Pearson (Les infirmières ont observé 52 115 cas d'hygiène des mains entre 2013 et 2018. La moyenne annuelle du respect des mesures a considérablement augmenté, passant de 76,4% (2762/3617) en 2013 à 88,5% (9034/10 211) en 2018 (Les observations directes et retours ont encouragé les médecins et infirmiers à mieux respecter les consignes d'hygiène des mains. Ce changement a entraîné une baisse du nombre d'infections liées aux soins de santé. D'autres études sont cependant nécessaires pour évaluer l'impact de l'hygiène des mains sur la diminution des infections liées aux soins de santé.Determinar los cambios del cumplimiento de la higiene de las manos tras las observaciones directas en las prácticas de higiene de las manos que realizan los médicos y las enfermeras, además de evaluar la relación entre los cambios y la incidencia de las infecciones relacionadas con la atención médica.Se realizó una encuesta de auditoría interna en un hospital de atención terciaria en Finlandia de 2013 a 2018. Las enfermeras de control de infecciones observaron las prácticas de higiene de las manos según la estrategia de la Organización Mundial de la Salud para la higiene de las manos. Se estimó que el cumplimiento de la higiene de las manos equivalía a dividir el número de las observaciones en las que era necesario practicar la higiene de las manos por el número total de observaciones en las que se requería la higiene de las manos. Se determinó la incidencia de las infecciones relacionadas con la atención médica mediante un programa semiautomatizado y electrónico de vigilancia de la incidencia. Se calculó la correlación de Pearson (Las enfermeras realizaron 52 115 observaciones de higiene de las manos entre 2013 y 2018. El cumplimiento anual de la higiene de las manos aumentó significativamente del 76,4 % (2762/3617) en 2013 al 88,5 % (9034/10 211) en 2018 (El cumplimiento de las prácticas de higiene de las manos que realizan los médicos y las enfermeras mejoró con la observación directa y la retroalimentación, lo que se asoció a una disminución de la incidencia de las infecciones relacionadas con la atención médica. Se requieren más estudios para evaluar la contribución de la higiene de las manos a la reducción de las infecciones relacionadas con la atención médica.الغرض تحديد التغيرات في الالتزام بنظافة اليدين بعد تطبيق الملاحظة المباشرة لممارسات نظافة اليدين لدى الأطباء والممرضات، وتقييم العلاقة بين التغيرات وحدوث حالات العدوى المرتبطة بالرعاية الصحية. الطريقة قمنا بإجراء مسح تدقيقي داخلي في مستشفى رعاية فوق الثانوي في فنلندا خلال الفترة من 2013 إلى 2018. قام ممرضو مكافحة العدوى بملاحظة ممارسات نظافة اليدين بناءً على استراتيجية منظمة الصحة العالمية الخاصة بنظافة اليدين. قمنا باحتساب الالتزام بنظافة اليدين بعدد الملاحظات حيث تم ممارسة نظافة اليدين الضرورية، مقسومًا على إجمالي عدد الملاحظات حيث كانت هناك حاجة إلى نظافة اليدين. لقد قررنا حدوث حالات العدوى المرتبطة بالرعاية الصحية باستخدام برنامج مراقبة إلكتروني شبه آلي لحدوث العدوى. قمنا بحساب معامل ارتباط Pearson (在直接观察医生和护士的手部卫生习惯之后确定手部卫生合规性的变化，并且评估这些变化与卫生保健相关性感染发生率之间的关系。.从 2013 年至 2018 年，我们在芬兰的一家三级医院进行了内部审核调查。感染控制专科护士根据世界卫生组织的手部卫生策略观察了手部卫生习惯。我们计算手部卫生合规性的方法为：采取了必要手部卫生措施的观察次数除以需要保持手部卫生的观察总数。我们使用半自动化的电子发生率监测程序来确定卫生保健相关性感染的发生率。我们计算了皮尔逊相关系数 (在 2013 年至 2018 年之间，护士进行了 52,115 次手部卫生观察。年度手部卫生合规性从 2013 年的 76.4％ (2762/3617) 显著提升至 2018 年的 88.5％ (9034/10 211) (通过直接观察和反馈改善了医生与护士在手部卫生习惯方面的合规性，并且这种变化与医疗保健相关性感染的发生率降低相关。需要进一步的研究来评估手部卫生对减少卫生保健相关性感染的有利因素。.Выявить изменения в соблюдении правил гигиены рук с момента введения непосредственного наблюдения за гигиеной рук для врачей и медицинских сестер и оценить взаимосвязь между данными изменениями и заболеваемостью внутрибольничными инфекциями.Авторы проводили опросы во время внутренних проверок в больнице третичной медицинской помощи в Финляндии в период с 2013 по 2018 год. Медицинские сестры отделения инфекционного контроля наблюдали за осуществлением на практике гигиены рук в соответствии с правилами, определенными Всемирной организацией здравоохранения. Авторы рассчитали коэффициент соответствия требованиям гигиены рук как соотношение количества наблюдений, в ходе которых правила гигиены рук соблюдались, к общему количеству наблюдений, в ходе которых соблюдение таких правил было необходимо. Авторы также определили показатель заболеваемости внутрибольничными инфекциями с применением полуавтоматической программы электронного надзора за заболеваемостью. Был рассчитан коэффициент корреляции Пирсона (В период с 2013 по 2018 год медицинские сестры выполнили 52 115 наблюдений за гигиеной рук. Ежегодный показатель соблюдения правил гигиены рук значительно вырос: с 76,4% (2762 случая из 3617) в 2013 году до 88,5% (9034 из 10 211 случаев) в 2018 году (Соблюдение врачами и медицинскими сестрами правил гигиены рук улучшилось с момента введения прямого наблюдения и отчетов о результатах, и это изменение связано со снижением показателей заболеваемости внутрибольничными инфекциями. Для оценки роли гигиены рук в снижении заболеваемости внутрибольничными инфекциями необходимо проведение дальнейших исследований.

Background: An association between fungal exposure at work and asthma onset has been shown, but a causal relationship between them has not beTanle en established. Methods: The study describes an asthma cluster in workers in a building under renovation. Before renovation the work site had significant water damage, technical deficiencies, and ventilation problems. Worker protection was insufficient during renovation. In the building, toxicity was determined from dust as well as from cultured dust. Toxicity analysis was conducted in vitro using the boar spermatozoa motility assay. Results: During the 8-month renovation period, among 290 workers, 21 (7.2%) experienced new-onset asthma (9 women, 42.9%, 12 men, 57.1%, median age, 43 years (range, 30&ndash, 60 years)). At the renovation site, they had been exposed to areas where remarkable toxicity was demonstrated in vitro. One year later, 13 (61.9%) of them still had moderate disease, and three (14.8%) had severe disease. Most patients had a poor response to inhaled corticosteroids. Conclusions: This study documents a clear temporal association between occupational exposure during renovation of a water-damaged building and a cluster of 21 new occupational asthma cases. In addition, dust and cultured dust from their work spaces showed remarkable toxicity based on inhibition of boar sperm motility in vitro.

Aims To determine whether nurse staffing and nursing workload are associated with multiple organ failure and mortality. Design A cross-sectional study. Methods This study was conducted in a single tertiary-level teaching hospital during 2008-2017. The association between nurse staffing, nursing workload and prognosis was determined using daily nurse-to-patient ratios, Therapeutic Intervention Scoring System scores, Intensive Care Nursing Scoring System scores and Intensive Care Nursing Scoring System indexes. In addition, the timing of intensive care unit admission was considered. Multiple organ failure was defined according to the Sequential Organ Failure Assessment score. Results During the study period, 10,230 patients were included in the final analysis. Generally, the mean daily highest Therapeutic Intervention Scoring System score and Intensive Care Nursing Scoring System score were significantly higher in patients with multiple organ failure and in non-survivors. The proportion of understaffing was significantly more common in patients with multiple organ failure than in those without. The mean daily lowest nurse-to-patient ratio and the mean daily highest Intensive Care Nursing Scoring System index did not differ between survivors and non-survivors. The levels of nursing associated with workload and understaffing were at their worst on weekends. Conclusions The proportion of understaffing and increased nursing workload are associated with multiple organ failure, demonstrating that an adequate level of nurse staffing in relation to patient complexity is a prerequisite for the availability and quality of critical care services. The proportion of understaffing did not differ between survivors and non-survivors. Impact This is the first study that evaluates nurse staffing and nursing workload as potential risk factors for multiple organ failure and mortality. There is a need to ensure that intensive care units are consistently staffed based on real patient needs, 7 days a week and that personnel and services are available at all times for high-risk patients.

In Europe few studies have analyzed the costs of treating aseptic revisions and prosthetic joint infections with either debridement, antibiotics and implant retention or two-stage revision, as compared to the cost of a primary total joint arthroplasty.The purpose was to analyze the costs of total joint arthroplasties, aseptic revisions and prosthetic joint infections treated with debridement, antibiotics and implant retention or a two-stage revision. We conducted a retrospective cohort study of patients who had a total joint arthroplasty in the Oulu University Hospital during the three-year period from 2013 to 2015. The costs were divided to specific services (e.g. procedure costs, ward care costs, laboratory). Actual costs obtained from the hospital's financial database were used for analysis.There were 1708 total joint arthroplasties without complications, 18 aseptic revisions and 42 prosthetic joint infections eligible for analysis. The mean cost of a total joint arthroplasty was €7200, the excess cost of an aseptic revision was €10,900 and the excess cost of a prosthetic joint infection was €18,900 (total joint arthroplasty vs. infection, p .0001). The excess cost was €12,800 for debridement, antibiotics and implant retention treatment and €44,600 for a two-stage revision (p .0001). The two most expensive services were ward care and procedures.Infection tripled the cost of a total joint arthroplasty. The cost of two-stage revisions were triple that of debridement, antibiotics and implant retention treatment.

Background Implementation of evidence-based oral care protocols, nurse education programmes and assessment tools may reduce the risk of developing ventilator-associated pneumonia by increasing critical care nurses' knowledge and skills in adhering to current oral care recommendations. Aims To evaluate the longitudinal effects of single-dose simulation education with structured debriefing and verbal feedback on critical care nurses' knowledge and skills in adhering to current oral care recommendations. Design A randomized controlled trial with repeated measurements. Method The data for the study were collected in a single academic centre in a 22-bed adult, mixed, medical-surgical intensive care unit in Finland from February 2012 to March 2014. The effectiveness of simulation education was evaluated through the validated Ventilator Bundle Questionnaire and Observation Schedule at baseline (n = 30) and 24 months (n = 17) after simulation education. Data were analysed using a linear mixed model and intention-to-treat analyses. Results During the study period, the average knowledge score in the intervention group increased significantly (44·0% to 56·0% of the total score) in the final post-intervention measurement (pt = 0·51, pg = 0·002, pt*g = 0·023). However, single-dose simulation education with structured debriefing and verbal feedback had no impact on critical care nurses' skill scores. Conclusion Single-dose simulation education had only a minimal effect on critical care nurses' knowledge and skills in adhering to current oral care recommendations. Despite increased awareness, there was no significant difference in oral care practices between the study groups after simulation education. Relevance for clinical practice The need for regularly repeated educational sessions with theoretical training and practical exercises and direct feedback is evident. Certain aspects of oral care, such as prevention of microaspiration of oropharyngeal secretions and moistening of oral mucosa and lips, require more reinforcement than others.

Background To evaluate how critical nurses' knowledge of and adherence to current care hand hygiene (HH) guidelines differ between randomly allocated intervention and control groups before and after simulation education in both a simulation setting and clinical practice during a 2-year follow-up period. It was hypothesized that intervention group knowledge of and adherence to current HH guidelines might increase compared with a control group after simulation education. Methods A prospective, parallel, randomized controlled trial with repeated measurements was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Oulu, Finland. Thirty out of 40 initially randomized critical care nurses participated in the baseline measurements; of these, 17 completed all the study procedures. Participants' HH adherence was observed only in high-risk contact situations prior to and postendotracheal suctioning events using a direct, nonparticipatory method of observation. Participants' HH knowledge was evaluated at the end of each observational session. Results The overall HH adherence increased from a baseline value of 40.8% to 50.8% in the final postintervention measurement at 24 months ( P = .002). However, the linear mixed model did not identify any significant group ( P = .77) or time-group interactions ( P = .17) between the study groups after 2 years of simulation education. In addition, simulation education had no impact on participants' HH knowledge. Conclusions After a single simulation education session, critical care nurses' knowledge of and adherence to current HH guidelines remained below targeted behavior rates.

Background Considerable discrepancies have been observed in the implementation of strategies to liberate patients from mechanical ventilation. The aim of this study was to describe critical care nurses’ knowledge of and self-reported and documented adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate and evaluate how these practices differ between patients with and without ventilator-associated pneumonia and between survivors and nonsurvivors. Methods The survey was conducted in a tertiary-level hospital in Finland from October 2014 to June 2015. Actual adherence was evaluated based on documentation of performed practices. Results A total of 86 critical care nurses responded to the survey, and 85 patients were followed. The levels of knowledge of and self-reported adherence to low tidal ventilation were 84.5% and 90.2%, respectively, and the median tidal volume was at a target level in 74.4% of patients. Regarding daily sedation interruption, the level of knowledge was 85.7%, the level of self-reported adherence was 77.3%, and documented adherence was 33.3%. The levels of knowledge and self-reported adherence regarding spontaneous breathing trials were 61.9% and 71.6%, respectively. Adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate did not differ between patients with (n = 20) and without (n = 65) ventilator-associated pneumonia and between survivors (n = 55) and nonsurvivors (n = 30). Conclusions Lung-protective ventilation, including low-tidal ventilation and avoidance of high inspiratory plateau pressures, was well implemented and adhered to. The levels of knowledge and self-reported adherence versus documented adherence regarding daily sedation interruption and spontaneous breathing trial demonstrated insufficient implementation of local guidelines. There was no effect on the outcome.

Summary Background Point prevalence surveillance is widely used to monitor healthcare-associated infections (HAIs). Incidence surveillance offers more accurate information than point prevalence surveillance, but is more time consuming. Electronic surveillance systems may allow for more widespread incidence surveillance. Aim To determine the incidence of HAI in a tertiary care hospital in Finland over a three-year period from 2011 to 2013 using an automated electronic IS programme, linked to all of the hospital's electronic databases. Methods The programme identified cases of HAI prospectively from initiation of antibiotic treatment. All of the cases were verified manually after discharge. In order to evaluate the sensitivity of the electronic method for the identification of surgical site infections, the medical records of all patients who underwent cardiac surgery or total joint arthroplasty were evaluated retrospectively. Findings In total, 78,211 patients, covering 321,974 patient-days, were admitted to the wards during the study period, and 29,694 antibiotic treatment initiations were registered. After manual review, 5089 (17.1%) of these were found to be for HAIs. The total time needed to undertake the surveillance for the whole hospital (353 hospital beds) was 255 days, which is the approximate total annual working time for one nurse. Sensitivity evaluation showed that the number of surgical site infections identified by manual and electronic methods was identical. The three-year incidence of HAI was 15.8 per 1000 patient-days and 4.9% of all discharged patients. Conclusions Continuous electronic incidence surveillance based on initiation of antibiotic treatment may be a practical means of measuring hospital-wide incidence of HAI, but this method still requires personnel resources.

Background Leukocyte surface molecules may improve sepsis diagnostics. Our aim was to study whether monocyte and neutrophil CD11b and CD64 expression differs between patients with severe sepsis (including septic shock) and intensive care unit (ICU) controls, and also to investigate the expression kinetics in patient groups. Methods Monocyte and neutrophil CD11b and CD64 expression was analyzed in 27 patients with severe sepsis, 7 off-pump coronary artery bypass (OPCAB) patients, and 8 ICU patients without systemic inflammation in the beginning of the treatment using quantitative flow cytometry. Blood samples were collected within 48 h of the beginning of severe sepsis, at admission to the ICU for non-systemic inflammatory response syndrome patients, and on the day of surgery before the skin incision for OPCAB patients, and on 2 consecutive days for all patients. Ten healthy individuals served as controls. Results Monocyte and neutrophil CD11b and neutrophil CD64 expression was higher in severe sepsis patients compared with the other groups (P

Background A high prevalence of delirium is observed in sepsis, yet specific markers for this brain dysfunction in sedated patients are still lacking. Cytoplasmic low molecular weight calcium-binding protein, S-100β, is a commonly used nonspecific marker for brain injury. Here, we evaluated whether delirium is associated with increases in S-100β levels. Methods This observational study included 22 patients with septic shock. Delirium was assessed by CAM-ICU and blood samples were obtained to measure inflammatory (CRP, PCT, IL-6, IL-17, TNF-α) and cerebral biomarkers (S-100β, NSE, HAB42, SUBP). Patients were categorized according to the presence of delirium. Results Delirium was present in 10/22 of the patients (45.5%). Serum S-100β levels were above the laboratory cutoff value of 0.15 μg/L in 13/22 (59.1%) of the patients. The odds ratio for risk of developing delirium in cases with an S-100β >0.15 μg/L was 18.0 (95%CI, 1.7-196.3, P = 0.011). Patients with delirium had higher plasma levels of IL-6 compared to those without; 138.3 pg/mL [28.0-296.7] vs 53.6 pg/mL [109.3-505, P = 0.050]. There was a positive correlation between S100 β and IL-6 levels (r = 0.489, P = 0.021). Delirium patients had higher SOFA scores; 10 [5-9] vs 7[8-10.5], P = 0.036. Conclusions Delirium in septic shock was associated with an elevated protein S-100β when using a laboratory cutoff value of 0.15 μg/L and with more severe organ dysfunction during the ICU stay.

Background Abnormal permeability and extensive epithelial injury are characteristic of colon wall damage complicating critical illness, such as sepsis, and associated with mortality. To assess mechanisms of such colon epithelial disruption, we studied expression of markers of innate immunity and intercellular junctions in patients with critical illness. Methods Emergency colectomy samples from 38 intensive care unit patients with sepsis, fulminant C. difficile colitis, or colon ischemia were studied. Expression of tight junction proteins (claudin‑1, claudin‑2, occludin) and Toll-like receptors (TLRs) (TLR2, TLR4, TLR5, and TLR9) was studied in samples representing histologically verified damaged segments of the colon, and compared with normal colon (N.=28). Results As compared with normal epithelium, histologically damaged samples showed decreased claudin‑1 (P=0.002) expression. Expression of TLR2, TLR4, and TLR5 was similar in patients and controls, but TLR9 expression was up-regulated in the histologically damaged region (P=0.03). The expression of other markers (claudin‑1, claudin‑2, occludin, TLR2,TLR4, TLR5 and TLR9) did not differ between survivors and non-survivors. Conclusions Down-regulation of claudin‑1 and up-regulation of TLR9 suggest that epithelial barrier dysfunction and innate immunity activation are involved in the pathogenesis of colon epithelial injury in patients with critical illness.

Two-stage revision is widely used for the treatment of prosthetic joint infections. However, the duration of antibiotic treatment between stages and role of reimplantation microbiology are controversial. The purpose of this study was to evaluate the outcome and influence of the reimplantation microbiology of two-staged revisions with 6 weeks of antibiotic treatment. We retrospectively reviewed 107 patients treated with two-stage revision between 2001 and 2009. The overall treatment success rate was 94.4%. The reimplantation cultures were positive in 5/97 (5.2%) cases, and only one of them failed. Therefore, we achieved excellent results with a 6-week course of antibiotics between stages in two-stage revision. Positive reimplantation cultures do not seem to be associated with worse outcomes.

Background. The role of viral infections in the etiology of severe community-acquired pneumonia (SCAP) was prospectively evaluated from 2008 to 2012 at a university-level intensive care unit. Methods. Clinical data and microbiological tests were assessed: blood cultures, urine pneumococcal and legionella antigens, Mycoplasma pneumoniae and Chlamydia pneumoniae antibodies from paired serums, and respiratory virus detection by multiplex, real-time polymerase chain reaction (PCR) from nasopharyngeal swabs and lower tracheal specimens via intubation tube. Results. Of 49 mechanically ventilated SCAP patients (21 men and 28 women; median age, 54 years), the etiology was identified in 45 cases (92%). There were 21 pure bacterial infections (43%), 5 probably pure viral infections (10%), and 19 mixed bacterial–viral infections (39%), resulting in viral etiology in 24 patients (49%). Of 26 viruses, 21 (81%) were detected from bronchial specimens and 5 (19%) from nasopharyngeal swabs. Rhinovirus (15 cases, 58%) and adenovirus (4 cases, 15%) were the most common viral findings. The bacterial–viral etiology group had the highest peak C-reactive protein levels (median, 356 [25th–75th percentiles, 294–416], P = .05), whereas patients with probably viral etiology had the lowest peak procalcitonin levels (1.7 [25th–75th percentiles, 1.6–1.7]). The clinical characteristics of pure bacterial and mixed bacterial–viral etiologies were comparable. Hospital stay was longest among the bacterial group (17 vs 14 days; P = .02). Conclusions. Viral findings were demonstrated in almost half of the SCAP patients. Clinical characteristics were similar between the pure bacterial and mixed bacterial–viral infections groups. The frequency of viral detection depends on the availability of PCR techniques and lower respiratory specimens.

Background There is a current lack of valid and reliable instruments that can be used to examine critical care nurses' knowledge and skills in adhering to ventilator bundles. The aim of this study was to develop and psychometrically test a ventilator bundle questionnaire (VBQ) and ventilator bundle observation schedule (VBOS). Methods The VBQ and VBOS consisted of a list of pharmacologic and nonpharmacologic nurse-led interventions taken from the literature and supported by various levels of evidence. After content validation, stability and equivalence reliabilities of the VBOS were determined in a randomly selected sample of critical care nurses from a single academic center in Finland. Results The final VBQ contained 49 multiple-choice questions, and the VBOS had 86 dichotomous items, whose overall content validity ranged from 0.99 to 1.0. The overall intraclass correlation coefficient of the VBOS ranged from 0.93 to 1.0. Conclusions The VBQ and VBOS have acceptable psychometric properties and could be used to objectively assess whether evidence-based guidelines regarding ventilator bundles are being used in clinical practice. Further testing with diverse samples is needed to strengthen the validity and reliability of these instruments.

Background: We compared in a single mixed intensive care unit (ICU) patients with influenza A(H1N1) pdm09 between pandemic and postpandemic periods. Methods: Retrospective analysis of prospectively collected data in 2009–2016. Data are expressed as median (25th–75th percentile) or number (percentile). Results: Seventy-six influenza A(H1N1) pdm09 patients were admitted to the ICU: 16 during the pandemic period and 60 during the postpandemic period. Postpandemic patients were significantly older (60 years vs. 43 years, p

Purpose We were interested in whether C-reactive protein (CRP) and procalcitonin (PCT) distinguish sepsis from non-septic controls and whether a combination of CRP, PCT, and neutrophil CD64 improves identification of sepsis in the intensive care unit (ICU). Materials and methods We analyzed the CRP and PCT concentrations from 27 patients with sepsis and 15 ICU controls. In addition, CD64 on neutrophils was measured using quantitative flow cytometry. We present a multiple marker analysis for sepsis diagnostics combining neutrophil CD64, CRP, and PCT using post-test analysis. Results The CRP and PCT values separated sepsis and non-septic ICU patients. In post-test analysis, CRP provided a positive probability of 0.48 and a negative probability of 0.053 for sepsis in the ICU; while, the corresponding values were 0.35 and 0.0059, respectively, for PCT and 0.62 and 0.0013, respectively, for neutrophil CD64. When neutrophil CD64 was analyzed with PCT and CRP, the probabilities were 0.98 and Conclusions Neutrophil CD64 expression was superior to PCT and CRP for the identification of sepsis in ICU. Positive post-test probability for any combinations of simultaneously analyzed CRP, PCT and CD64 showed improved diagnostic accuracy for sepsis. This approach may be useful for guiding antibiotic treatment in ICU.

Background This study aimed to compare the outcome of patients with severe community-acquired pneumonia (SCAP) treated with the combination of either β-lactam–quinolone (βQ) or β-lactam–macrolide (βM) antibiotics. Methods We retrospectively studied a cohort of patients with SCAP treated from January 2000 to December 2010 at a mixed university-level intensive care unit (ICU). APACHE II score, SCAP severity assessed by IDSA/ATS score, first antibiotic treatment initiated during the initial 24 h of admission, ICU and hospital length of stay (LOS), and ICU, hospital, 30 and 60-day mortalities were assessed. Results Altogether, 210 patients with SCAP were analyzed, 104 in the βQ arm and 106 in the βM arm. Median APACHE II scores on admission were higher in the βM group (22 vs. 18, P = 0.003). More patients in the βQ group required mechanical ventilation (63.1% vs. 42.5%, P = 0.004) and fulfilled IDSA/ATS SCAP criteria (n = 87; 83.7%) than those in the βM group (n = 73; 68.9%; P = 0.015). Thirty-day mortality was 16.3% in the βQ group and 24.5% in the βM group (P = 0.17), and with septic shock mortality was 19.6% and 32.6%, respectively (P = 0.16). On APACHE II and IDSA/ATS SCAP score adjusted multivariate logistic regression analysis, the βM group had a slightly higher but not significant odds ratio (OR) for a 30-day mortality compared to the βQ group (OR 1.4; 95% CI, 0.62–3.0; P = 0.44). Conclusion Thirty-day mortality rate of SCAP patients did not differ whether they were treated with either βQ or βM combination.

The aim of the present study was to investigate whether expression of monocyte and lymphocyte surface molecules differs between patients with severe sepsis and non-septic patients treated in the intensive care unit (ICU). The expression of monocyte CD14, CD40, CD80 and HLA-DR, and lymphocyte CD69 were analyzed using quantitative flow cytometry on three consecutive days in 27 patients with severe sepsis and in 15 non-septic patients. Receiver operating characteristic analyses were performed and each corresponding area under the curve (AUC) was determined. The results showed that the expression levels of CD40 on monocytes and CD69 on CD4+ T cells and on natural killer (NK) cells were highest in patients with severe sepsis (p < 0.05). Monocyte CD40 and NK cell CD69 expression levels were higher in patients with severe sepsis and positive blood culture compared with those with negative blood culture (p < 0.05). The highest values of AUC for severe sepsis detection were 0.836 for CD40, 0.872 for CD69 on NK cells, and 0.795 for CD69 on CD4+ T cells. These findings suggest that monocyte CD40 and CD69 on NK cells and CD4+ T cells could prove useful for new approaches in the identification of severe sepsis in the ICU.

Our purpose was to analyse the association of pneumonia types with hospital and long-term outcomes of intensive care unit (ICU)-treated pneumonia patients.The occurrence of pneumonia was retrospectively evaluated among prospectively registered patients admitted into a mixed university-level ICU during a 14-month period. Their age, severity of underlying disease, malignancy, immunosuppressive therapy and organ dysfunctions were recorded, as well as the length of hospital stay and short- and long-term mortalities.There were 117 severe community-acquired pneumonia (SCAP), 66 hospital-acquired pneumonia (HAP) and 25 ventilator-associated pneumonia (VAP) cases among the 817 patients admitted. ICU and hospital mortality did not differ between pneumonia groups. VAP and HAP patients had more malignant underlying diseases than SCAP patients (P0.001). HAP patients were older than SCAP and VAP patients (P = 0.023). The admission Acute Physiology and Chronic Health Evaluation II scores did not differ between the groups (P0.90). The patients with VAP had higher Sequential Organ Failure Assessment maximum scores compared with patients with SCAP and HAP (P0.001). In an adjusted multivariate logistic regression model, there were no significant differences in odds ratios for hospital mortality between the three pneumonia types. Mortality among the hospital survivors during the 12-month follow-up period was 18% (16/89) in the SCAP group, 35% (18/51) in the HAP group and 41% (7/17) in the VAP group (P = 0.023).The type of pneumonia (i.e. SCAP, HAP or VAP) had no significant association with hospital mortality, whereas the SCAP patients had the lowest 1-year mortality.

Background Previous studies have reported chest radiographic findings of consolidation and ground-glass opacity in patients with swine-origin influenza A (H1N1). However, most of these studies include both hospitalized and outpatients. Purpose To evaluate initial chest radiographic and CT findings of hospitalized swine flu patients, adults and children, confirmed with a real-time reverse transcriptase polymerase chain reaction (PCR) assay for H1N1 virus. Material and Methods All PCR-verified swine flu patients admitted to the Department of Emergency Medicine (October 1 to December 15, 2009) at Oulu University Hospital, in Northern Finland, who underwent frontal chest radiography within 24 hours of presentation and who were hospitalized, were included. The radiographs and CT scans were assessed for the presence of pneumonia and characterized by pattern and distribution. The patients' medical records were analyzed for demographics, underlying medical conditions, the admission to the intensive care unit (ICU), initiation of mechanical ventilation or non-invasive ventilation support (NIV) and death. Results Of 159 H1N1 influenza patients, 135 (85%) underwent chest radiographs at admission; 113 adults and 22 children. Findings of pulmonary infiltrates were detected in 62% (70/113) of adults and 64% (14/22) of children, being bilateral in 67% of adults and 64% of the children. The anatomic location of infiltrates was more often peripheral in adults; 42/70 (60%) vs. 4/14 (29%), P = 0.041, and diffuse among children; 9/14 (64%) vs. 26/70 (37%), P = 0.078. When the ICU and NIV patients were compared to less severe cases, on their chest radiographs four or five lobes were more often affected (65%, 11/17 vs. 34% 23/67, P = 0.029 ). The predominant radiographic findings were consolidation (93% of all patients, 91% of adults and 100% of children) and ground-glass opacity (74% of all, 77% of adults and 57% of children). Pulmonary emboli were detected by CT in 2/9 (22%) patients. Conclusion The pandemic 2009 swine influenza causes common and widely distributed infiltrates on chest radiographs among hospitalized patients, which are not peculiar to usual respiratory viral infections, and these findings can not be differentiated from usual bacterial pneumonia.

Background: There is a lack of studies showing the overall impact of multi-detector computed tomography (MDCT) on the treatment of critically ill patients in a general intensive care unit (ICU) setting. Methods: A prospective observational study on the effects of MDCT on the treatment of patients in a 12-bed medical–surgical ICU in a university hospital providing tertiary care. Results: During the 9-month study period, there were 343 admissions with ICU length of stay longer than 48 h. Of these patients, 64 (19%) had had inconclusive findings with other modalities of radiological imaging, and they underwent altogether 82 MDCT examinations. Fifty examinations (61%) resulted in a change of treatment. The changes included 22 surgical interventions, 16 percutaneous or paranasal interventions, 15 changes of antimicrobial therapy, three withdrawals of active treatment, and four other changes of treatment. Eight patients underwent two and one patient underwent three changes of treatment. Twenty examinations (24%) were regarded as otherwise necessary for clinical decision-making, although no change in the treatment was indicated. Twelve examinations (15%) failed to provide any additional information relevant to the patient's treatment. Conclusion: Sixty-one percent of the MDCT examinations led to a change of treatment, and 24% of them otherwise contributed to or supported clinical decision-making, suggesting that MDCT examination is helpful in the case of general ICU patients, with inconclusive findings with other imaging modalities.

To evaluate the effect of various chemotherapy courses on the rate of bloodstream infections (BSI) during therapy-related neutropenia, all infection episodes of adult patients with acute myeloid leukaemia (AML) during 7 y were retrospectively analysed in a university hospital. Of the 182 infection episodes in 76 AML patients, 37% (n = 68) were BSI. The riskratio (RR) of BSI was highest after regimens containing high-dose cytarabine (2.4 with 95% confidence interval (CI) 1.3-4.4) and lowest after thioguanine-containing courses (RR: 0.2, 95% CI 0.2-0.5). Chemotherapy courses per se may have an influence on the rate of BSI during neutropenia.

We evaluated the longitudinal effects of single-dose simulation education with structured debriefing and verbal feedback on critical care nurses' endotracheal suctioning knowledge and skills. To do this we used an experimental design without other competing intervention. Twenty-four months after simulation education, no significant time and group differences or time × group interactions were identified between the study groups. The need for regularly repeated educational interventions with audiovisual or individualized performance feedback and repeated bedside demonstrations is evident.

Background The value of early chest computed tomography (CT) was evaluated among severe community-acquired pneumonia (SCAP) patients. Methods The study population consisted of 65 of 457 SCAP patients with concomitant chest CT and radiograph performed within 48 h of ICU admission. Each image pair was re-evaluated by two radiologists. The type of pneumonia, the presence of pleural fluid and atelectasis were assessed. Therapeutic and diagnostic procedures induced by CT results were analysed together with clinical, microbiological and outcome data. Results Alveolar pneumonia was observed in 72.3% of patients by radiograph and in 75.4% of patients by CT. Pleural fluid was detected via chest radiograph and CT in 17 (26.2%) and 41 cases (63.1%), (P < 0.001) and atelectasis in 10 (15.4%) and 22 cases (33.8%), (P = 0.002), respectively. In 34 patients (52.3%), the CT revealed 38 new findings (58.5%) not shown in plain chest radiograph. Out of these 34 patients, therapeutic interventions or procedures were performed in 26 (76.5%). The number of infected lobes correlated negatively with the lowest PaO2/FiO2 ratio (ρ = −0.326, P = 0.008) for chest CT scans. Conclusion Compared with chest radiograph, chest CT generated new findings in nearly 60% of SCAP patients, leading to new procedures or changes in medical treatment in nearly 75% of those patients. Chest CT better describes the pulmonary involvement and severity of oxygenation disorder compared to a plain chest radiograph.

Pneumonia is recognised in patients suffering from acute cough or deteriorated general condition. Patients with acute cough without pneumonia-related symptoms or clinical findings do not benefit from antimicrobial treatment. Those with suspected or confirmed pneumonia are treated with antibiotics, amoxicillin being the first choice. Most patients with pneumonia can be treated at home. Those with severe symptoms are referred to hospital. Patients are always encouraged to contact his/her physician if the symptoms worsen or do not ameliorate within 2-3 days. Patients aged 50 years or older and smokers are controlled by thoracic radiography in 6-8 weeks.

Background Critical care nurses' knowledge and skills in adhering to evidence-based guidelines for avoiding complications associated with intubation and mechanical ventilation are currently limited. We hypothesized that single simulation education session would lead to a long-lasting higher level of skills among critical care nurses. Material and methods A randomized controlled trial was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Finland during the period February 2012-March 2014. Thirty out of 40 initially randomized critical care nurses participated in a 24-month follow-up study. Behavior and cognitive development was evaluated through a validated Ventilator Bundle Observation Schedule and Questionnaire at the baseline measurement and repeated 3 times during simulation and real-life clinic settings. Results After simulation education, the average skills score increased from 46.8%-58.8% of the total score in the final postintervention measurement ( P time P time × group = .040, and P group = .11). The average knowledge scores within groups did not change significantly. The average between-group difference in skills scores was significant only at the measurement taken at 6 months ( P = .006). Conclusions Critical care nurses' skills in adhering to evidence-based guidelines improved in both groups over time, but the improvements between the study groups was significantly different only at 6 months and was no longer evident after 2 years following a single simulation education.

The reported success rates of debridement, antibiotics, and implant retention (DAIR) for prosthetic joint infections (PJIs) vary widely. Several risk factors have been described for treatment failure, but they vary between studies. The purpose of this study was to evaluate the predictors of DAIR failure in PJI treatment and to assess the efficacy of rifampin combined with ciprofloxacin versus rifampin combined with other antibiotics in staphylococcal PJIs.Patients with PJI that underwent DAIR for the first time between February 2001 and August 2009 were identified retrospectively in the hospital's patient databases. A total of 113 PJI cases with early postoperative or acute haematogenous PJI were followed for up to two years from the start of treatment.In univariate analysis, variables significantly associated with treatment failure were acute haematogenous infections (p = 0.022), leucocyte count at admission 10 × 10(9)/l (p 0.01), pain in the joint (p 0.01), and ineffective empirical antibiotics (p 0.01). In a multivariate Cox model, leucocyte count 10 × 10(9)/l and ineffective empirical antibiotics were significant risk factors for failure. Compared to rifampin-ciprofloxacin, the hazard ratio (HR) for treatment failure was significantly increased in the rifampin-other antibiotics group (HR 6.0, 95% CI 1.5-28.8, p = 0.014) and the group treated without rifampin (HR 14.4, 95% CI 3.1-66.9, p 0.01).Rifampin-ciprofloxacin combination therapy was significantly more effective than rifampin combined with other antibiotics. Effective empirical antibiotics are essential for successful PJI treatment.

Data from a six-year period were retrospectively retrieved from medical records and an intensive care unit data management system to study the impact of infections on patients with status epilepticus. Out of 161 admitted patients, 33 had a community-acquired infection and 35 acquired an infection during their hospital stay, 10 while in a ward before admission to the intensive care unit and 25 while in an intensive care unit, giving an infection rate of 42% of all admissions (68 patients). The patients with intensive care unit-acquired infection had three times longer stays in the intensive care unit than those without any infection (P In conclusion, the infection rate of status epilepticus patients was high and nosocomial infections were associated with more severe illness, treatment escalation, prolonged hospital stay and enhanced resource utilization.

We have observed the efficiency of antibiotic-releasing polylactide-co-glycolide (PLGA) 80/20 in preventing Staphylococcus epidermidis attachment and biofilm formation in vitro. The aim of the present study was to evaluate the effect of self-reinforced (SR) implants with enhanced antibiotic release on bacterial attachment and biofilm formation rates, and also on growth inhibition of Staphylococcus epidermidis. Cylindrical SR-PLGA+AB specimens (length 30 mm, diameter 3 mm) were examined by scanning electron microscopy (SEM) for attachment of S. epidermidis ATCC 35989 on biomaterial surface and formation of biofilm, after incubating with bacterial suspension of ca. 105 cfu/mL for 1, 3, 7, 14 and 21 days. SR-PLGA and SR-PLGA+AB implants were tested on agar plates by measuring the inhibition distance around implants. On the surface of SR-PLGA+AB, at days 1, 3, 7, 14 and 21, the percentage of areas with not a single bacteria attached, was 88.6%, 71.1%, 73.7%, 73.7%, and 68.4%, respectively. On the areas where bacteria were detected, the number of bacterial cells remained low during whole study period, and no significant increase by time was seen. There was no biofilm observed on 97-99% of the examined areas during the whole study period on SR-PLGA+AB. In agar plates, the SR-PLGA+AB showed inhibition of bacterial growth, with (mean) 53.2 mm diameter of inhibition area with peeled implants and 50.5 mm with non-peeled implants. There was no inhibition seen around implants without ciprofloxacin. Bioabsorbable ciprofloxacin-releasing self-reinforced PLGA (SR-PLGA+AB) was superior to plain SR-PLGA in preventing bacterial attachment, biofilm formation, and also the growth of Staphylococcus epidermidis.

To evaluate the spectrum of infections, co-morbidities and outcome of patients admitted into an intensive care unit (ICU) due to community- (CAI) or hospital-acquired infections (HAI).A 14-month prospective study in a medical-surgical ICU in a tertiary level teaching hospital.Three hundred and thirty-five patients were included, of whom 74.9% had an infection on admission; 59.3% had CAI and 40.7% HAI, while 84 patients did not have any infection (NI). The most common infections in the CAI and HAI groups (G) were pneumonia and gastrointestinal infections. Secondary bacteremia (p0.001), severe sepsis and septic shock (p=0.048) were more prevalent in CAIG, while histories of transient ischaemic attack or stroke (p=0.03), immunosuppressive medications (p=0.009) or malignancies (p0.001) were more common in HAIG. APACHE II scores and ICU or hospital mortalities did not differ between the groups. The median hospital stay was longer in HAIG (24 days) than in CAIG (15) or NIG (17.5), p0.001.Patients in CAIG had more often secondary bacteremia or severe sepsis or septic shock, whereas HAIG patients had more often a history of cerebrovascular problems, malignancies and immunosuppressive treatments. Eighty percent of these infection patients requiring ICU treatment survived.

Purpose: To survey the prevalence and type of lung patterns detectable at high-resolution CT (HRCT) in a primary care population seeking help for cough and fever. Material and Methods: The HRCT patterns of 103 patients obtained at the primary visit to a municipal health centre for cough and fever were evaluated. Forced expiratory examinations were obtained in 93 patients. Results: Lower respiratory tract infection (LRTI)-related findings (present at inclusion, healed at follow-up, not explained by any other factor) were seen in 19 patients (18.7%), of whom 11 also showed opacities, even though of lesser extent, at conventional chest radiography. The following patterns were found: ground-glass opacity (58%), discrete consolidations (52%), confluent consolidations (16%; 1 case with an air bronchogram), air space nodules (10%), peribronchovascular thickening (37%), tree-in-bud pattern (26%), free pleural fluid (5%), and septal thickening (5%). An expiratory mosaic pattern was seen in 19 (20%) out of 93 patients. In addition, lymph node enlargement (>1 cm) was recorded in 7 patients out of 103. Conclusion: HRCT is more sensitive than chest radiography in detecting LRTI-related lung lesions in a primary care population. The pattern typically comprises subtle scattered polymorphous opacities with varying attenuation affecting several lung segments. LRTI-related HRCT pattern deserves consideration as a differential diagnostic alternative in patients examined due to any lower respiratory tract symptoms.