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No abstract available. Article truncated at 150 words. A 62 year old male was recently diagnosed with Stage 4 squamous cell left lung cancer with metastases to the pleura, brain and mediastinum. He also had known chronic obstructive pulmonary disease (COPD) with a FEV1 = 1.96 L and a known left side pleural effusion (see Figure 1). Figure 1. Baseline chest radiograph showing left pleural effusion (red arrow). He was seen as an outpatient for symptomatic shortness of breath and underwent real time ultrasound guided left sided thoracentesis removing 500 ml of straw-colored fluid. The procedure was uneventful except that near the end, the patient started to cough. He denied any symptoms post procedure apart from some minor puncture site pain. A routine post procedure chest x-ray was performed (Figure 2). Figure 2. Post-thoracentesis x-ray (Panel A) and its negative image (Panel B). What new abnormality is identified on the post-procedure chest x-ray?1.Left pneumothorax2.Right pneumothorax …

Background Clinical practice guidelines are developed to assist in patient care but the evidence basis for many guidelines has been called into question. Methods We conducted a literature review using PubMed and analyzed the overall quality of evidence and made strength of recommendation behind 8 Institute of Health Care (IHI) guidelines for prevention of central line associated blood stream infection (CLABSI). Quality of evidence was assessed by the American Thoracic Society (ATS) levels of evidence (levels I through III). We also examined data from our intensive care units (ICUs) for evidence of a correlation between guideline compliance and the development of VAP.Results None of the guidelines was graded at level I. Two of the guidelines were graded at level II and the remaining 6 at level III. Despite the lack of evidence, 2 of the guidelines (hand hygiene, sterile gloves) were given a strong recommendation. Chlorhexidine and use of nonfemoral sites were given a moderate recommendation. In our ICUs compliance with the use of chlorhexidine correlated with a reduction in CLABSI (p

No abstract available. Article truncated at 150 words. Dr. Raschke took a well-deserved vacation, and in his absence we did another quick-fire critical care journal club reviewing 7 articles.Davies AR, Morrison SS, Bailey MJ, Bellomo R, Cooper DJ, Doig GS, Finfer SR, Heyland DK; for the ENTERIC Study Investigators and the ANZICS Clinical Trials Group. A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness. Crit Care Med 2012;40:2342-8. (Click here for abstract)This was a randomized control trial, which enrolled 181 patients from multiple medical-surgical ICUs to receive either nasojejunal or nasogastric nutrition. The number of patients selected for this study provided an 80% power to detect a 12% difference in mean energy delivery. Inclusion criteria for the study were patient that were admitted to the ICU, needing mechanically ventilated, narcotic drips for sedation as well as elevated gastric residuals (>150ml). Patients were excluded if patient had abnormal anatomy or imminent death…

Chantier qualité GA; International audience; Transport losses (dead and nonambulatory pigs) present animal welfare, legal, and economic challenges to the US swine industry. The objectives of this review are to explore 1) the historical perspective of transport losses; 2) the incidence and economic implications of transport losses; and 3) the symptoms and metabolic characteristics of fatigued pigs. In 1933 and 1934, the incidence of dead and nonambulatory pigs was reported to be 0.08 and 0.16%, respectively. More recently, 23 commercial field trials (n = 6,660,569 pigs) were summarized and the frequency of dead pigs, nonambulatory pigs, and total transport losses at the processing plant were 0.25, 0.44, and 0.69% respectively. In 2006, total economic losses associated with these transport losses were estimated to cost the US pork industry approximately $46 million. Furthermore, 0.37 and 0.05% of the nonambulatory pigs were classified as either fatigued (nonambulatory, noninjured) or injured, respectively, in 18 of these trials (n = 4,966,419 pigs). Fatigued pigs display signs of acute stress (open-mouth breathing, skin discoloration, muscle tremors) and are in a metabolic state of acidosis, characterized by low blood pH and high blood lactate concentrations; however, the majority of fatigued pigs will recover with rest. Transport losses are a multifactorial problem consisting of people, pig, facility design, management, transportation, processing plant, and environmental factors, and, because of these multiple factors, continued research efforts are needed to understand how each of the factors and the relationships among factors affect the well-being of the pig during the marketing process.