Michalopoulos A.,ICU |
Falagas M.E.,Alfa Institute of Biomedical science AIBS
Expert Opinion on Pharmacotherapy | Year: 2010
Importance of the field: Acinetobacter baumannii has emerged as a major cause of healthcare-associated infections. It commonly presents resistance to multiple antimicrobial agents, occasionally including carbapenems and polymyxins, and hence, it is considered the paradigm of multidrug-resistant (MDR) or pandrug-resistant (PDR) bacterium. MDR A. baumannii is a rapidly emerging pathogen, especially in the intensive care setting, causing infections including bacteremia, pneumonia/ventilator-associated pneumonia (VAP), meningitis, urinary tract infection, central venous catheter-related infection, and wound infection. Areas covered in this review: All potential antimicrobial agents that are available for the treatment of Acinetobacter infections are presented. Emphasis was given to the management of nosocomial infections due to MDR A. baumannii and its close relatives, spp. 3 and 13TU. Areas covered include bloodstream infections, pneumonia or VAP, meningitis, urinary tract infection, skin and soft-tissue or wound infections due to Acinetobacter. What the reader will gain: The antibiotics that are usually effective against A. baumannii infections include carbapenems, polymyxins E and B, sulbactam, piperacillin/tazobactam, tigecycline and aminoglycosides. Carbapenems (imipenem, meropenem, doripenem) are the mainstay of treatment for A. baumannii, though carbapenem-resistant Acinetobacter strains have increasingly been reported worldwide in recent years. However, although well-designed trials of new therapeutic approaches are certainly required, the most important factor necessary to guide clinicians in their choice of empirical or targeted therapy should be knowledge of the susceptibility patterns of strains present in their own geographical area. Take home message: Pooled data suggest that infections caused by A. baumannii, especially those with inappropriate treatment, are associated with considerable attributable mortality. The optimal treatment for A. baumannii nosocomial infections has not been established, especially for MDR strains. Therefore, well-designed clinical studies are necessary to guide clinicians on decisions regarding the best therapeutic approach for patients with MDR A. baumannii infections. In addition, new experimental studies are warranted to evaluate the activity and safety of peptides and other novel antibacterial agents for A. baumannii infections. © 2010 Informa UK Ltd. Source
Tridente A.,ICU |
De Luca D.,Catholic University of the Sacred Heart
Acta Paediatrica, International Journal of Paediatrics | Year: 2012
Various light-emitting diode (LED) phototherapy devices have been trialled on the assumption of a more effective spectral distribution of the light emitted. We reviewed the current literature to determine whether LED is more effective than other types of phototherapy. Eligible studies were randomized controlled trials of LED versus other phototherapies. Studies were found to be of medium quality based on a components approach. Data were statistically aggregated within a very homogeneous population (term or late preterm neonates). Results appeared robust at sensitivity analysis. Five hundred and eleven neonates were included in the meta-analysis. LED and other phototherapy devices appeared to be equally effective in reducing total serum bilirubin (TSB) in term or late preterm neonates. The pooled mean TSB rate of decrease was 3.269 μmol/L/h (0.191 mg/dL/h) and 3.074 μmol/L/h (0.18 mg/dL/h) in the LED and conventional arms, respectively [average difference in TSB rate of decrease = 0.194 μmol/L/h (0.011 mg/dL/h) in favour of LED phototherapy; p = 0.378]. Conclusion: No significant difference in TSB rate of decrease was detected between LED and other types of phototherapy. Further randomized controlled trials are needed to ascertain whether LED phototherapy may be more effective when increasing the spectral power, or in certain selected subpopulations. © 2011 The Author(s)/Acta Pædiatrica. Source
News Article | January 7, 2016
One in ten patients is at risk of having new post-traumatic stress disorder (PTSD) related to their ICU experience up to a year post-discharge. This was the finding from a multicenter, prospective cohort research study of veterans and civilians.
Sometimes, the set-up of the transition from fossil fuels is as pretty and impractical as Dr. Doolittle’s Pushmi-Pullyu. The Digest investigates. As you may have noticed in the stories around the launch of the Great Green Fleet, it is a complex maze of relationships when it comes to a technology benefitting from mandates like the Renewable Fuel Standard and the California’s Low Carbon Fuel Standard and various carbon taxes and tax credits. For example, a renewable fuel does not qualify under the Renewable Fuel Standard if it is to be used in an ocean-going vessel, but it can qualify under the California Low Carbon Fuel Standard if it is loaded on ships in California. And, it qualifies for the federal renewable diesel tax credit even though it does not qualify for RINs. Conversely, jet fuel from the same biorefinery can qualify for the Renewable Fuel Standard, but does not qualify under the California Low Carbon Fuel Standard. It does not qualify for the renewable diesel tax credit though it does qualify for RINs. To make matters more complicated, consider the problem of feedstocks. A jet fuel made from eucalyptus oils by the same California biorefinery would not yet qualify for anything — not the RFS, not the LCFS and not the renewable diesel tax credit. Yet, were you to take old branches from eucalyptus trees, grown in Burundi, ship them back to California and convert them into ethanol, you would qualify the fuel under the Renewable Fuel Standard and the California LCFS. Alas, no renewable diesel tax credit. So, by now we should all be completely confused. One might argue that so long as a renewable fuel reduces CO2 emissions and is used within a given jurisdiction, it should qualify as a renewable fuel. Doesn’t work that way. As originally conceived, a mandate, and a tax on the incumbent (or a tax credit for the new entrant) should work well together. First, the mandate should ensure that there is a market available, taking into account that incumbents directly or indirectly control fuel supply (through direct ownership of fueling outlets, or franchising agreements, or the inability of dispensers to handle a new product. The mandating regime can assist the transition away from that old system of ownership and control via incentives or regulations (e.g. the installation of blender pumps, the manufacture of flex-fuel vehicles, or banning agreements that limit fuel selection at any location), or not. In the US, there are limited blender pump incentives, flex-fuel manufacturing incentives that are on the verge of expiring, and that’s about it. That takes care of availability. Initially, renewable volumes are small compared to fossil fuels — yet they are requires to both meet the same ASTM fuel performance spec, and there is limited opportunity for the kind of early-stage performance differentiation that assists the launch of anything from electric cars to iPhones. So, the small refinery has to make essentially the same fuel as the large refinery, and unless there are huge disparities between feedstock costs, the small refinery’s fuel will cost more. We generally attack the resulting production cost problem with tax credits, of which there are three kinds, production credits, investment credits and carbon credits. Production credits are the easiest to understand. You produce a qualifying fuel, you receive a tax credit. The taxing regime gets to decide if it will award the credit to the producer of the fuel, or the marketer that blends and distributes the fuel (known as the Producer’s Credit or the Blender’s Credit) — this past year, the US considered switching from a blender’s credit to a producer’s credit when it comes to biodiesel or renewable diesel. A blender’s credit can benefit, for example, an off-shore producer, while a producer’s credit might narrow the benefit to domestic producers. Then, there are investment tax credits, These always incentivize local producers, who are paid out when they install new production capacity. It’s a lot faster than the production credit, and helps with the capital stack by which these facilities are financed. Investors tend to prefer investment credits for new capacity, because there’s more certainty that they will truly be available. On the other hand, the taxing regime has less certainty that the capacity will be utilized. Carbon credits are the most murky. A federal credit under the Renewable Fuel Standard comes in two flavors. One is a RIN and one is a cellulosic waiver credit. Each obligated party under the RFS has to submit a given number of RINs each year, a mandated percentage of their overall production, for each mandated fuel. Each gallon of renewable fuel comes with a RIN, or a Renewable information Number. The simplest way to comply is to buy the wet gallon, blend it into the fuel supply, and submit the RIN. But obligated parties can also buy RINs on the open market. Sometimes, refiners have excess RINs, so they sell them to obligated parties who are short. The resulting price of the RIN indirectly assists the renewable fuel producer — setting a floor price for a fuel. For example, if gasoline costs $2.00 and a RIN costs $0.75, you can sell a renewable fuel to an obligated party for $2.70, and they’d be delighted to lock in some extra margin. The cellulosic waiver credit works in a similar way. An obligated party can buy a cellulosic waiver credit from the EPA for a given price that is set each year, in lieu of buying or blending a gallon of cellulosic biofuels. In the same way as the RIN example, if gasoline costs $2.00 and a CWC costs $0.75, you can sell a cellulosic fuel to an obligated party for $2.70, and they could lock in some savings compared to distributing gasoline and buying a CWC. So, the theory is sound. There is a mechanism to address the absence of an open market in fuels at the consumer level, and there is a mechanism to address the lask of performance differentiation in fuels that we generally see in new market entires like iPhones. You see, the real performance differentiations between renewable fuels and fossil fuels lie in emissions, energy security and economic development that renewables achieve when they are deployed, by reducing imports and reducing CO2. These are social benefits enjoyed by society as a whole, they do not accrue to the investor in the project, because investment and return in measured in dollars instead of social benefit. The carbon credits internalize the benefits inside the project, monetizing a social benefit such as cleaner air or less dependence on fuels made by unfriendly regimes. Tax credits generally are fuel-specific, for one — so you might have one for ethanol but not biodiesel, or one for biodiesel and renewable diesel but not ethanol. The latter is the case in the US right now. Second, each carbon scheme is based on the idea of pathways. One example would be using a Midwestern dry mill ethanol refinery that uses coal for process energy, and makes ethanol from corn starch. From California’s point of view, a local refinery would have a lower carbon footprint because of the reduced carbon of transporting fuel from the Midwest, Or, a facility that switched to natural gas for process energy would do better on carbon. Better still, biogas. Or, the refinery could switch over to lower-still biomass sorghum. Each of these represents a pathway and they have to be individually and painstakingly approved by the mandating authority. In many cases, California and the US government are simply able to approve pathways at a much slower pace than the pace of innovation, so they fall behind as new feedstocks, technologies and end-uses pop up. For example, algae was not originally included as a feedstock under the RFS. Another thing. Originally, these schemes were designed for road transport. So, marine fuels, jet fuels and the use of molecules to make renewable chemicals were outside of the system of credits. Slowly, the mandating authorities are working through the possibilities. But California has not yet embraced jet fuel for the LCFS, while the US government has not yet embraced marine fuels for the RFS. Chemicals are not yet approved uses, even thought they reduce carbon, and sometimes offer much longer carbon sequestration in a durable good, such as a chair. To give an example, you can qualify for a RIN by making isobutanol and blending it into the fuel supply to be combusted in ICU engines. But, if you sell isobutanol as a blendstock for a renewable chemical, in which case the carbon might be sequestered for a hundred years, you don’t get the credit. On the one hand that makes perfect sense — after all, a durable good is not a renewable fuel and fitting it into the Renewable Fuel Standard is a sketchy proposition. Yet it provides the same (or more) carbon benefit based on the same feedstock, possibly made at the same refinery, such as Butamax or Gevo. And, the producer gets a higher price, generally, for the chemical, which provides more margin and more incentive to build more refineries and reduce carbon faster. So, these are some of the dilemmas that regulators are working through. One way to improve is to shift the way we approve pathways. Right now, we place to burden in EPA to approve a pathway before it can be used. If they get backlogged, innovation stalls and innovative producers can go to the wall. Another way to go forward is to allow producers to use a novel pathway, so long as it meets a basic “first glance” standard based on the producer’s data submissions, subject to EPA review. The EPA review, then, would only be able to shut down a pathway if the data proved to be falsified. Producers could get into the market as fast as they galvanize their own resources to build a data set. Another way to improve is through the use of “pathway” treaties. For example, the US could, by treaty, recognize a California-approved pathway as a US-approved pathway. Or, vice-versa. Saves filing in two regimes for a novel pathway, and prevents cases as with AltAir where the producer is incentivized towards a given pathway not because of reducing more carbon or getting a better margin, but because of differences in the regulatory regimes. Another way to improve is to allow the use of fuels as renewable chemicals, and allow refineries to produce chemicals and qualify them under LCFS and RFS. At the end of the day, both use cases reduce carbon footprints and reduce imports equally. It seems counter-productive and overly complicated that, for example, Gevo could sell isobutanol to an obligated party, and the refiner can sell the RIN if it is used as a fuel blendstock but must retire the RIN if it is used as a chemical feedstock. One final improvement. The EPA decided that RINs would be calculated on energy content and no other factor. Yet, molecules have downstream pathways just as they do upstream pathways. It would be generally acknowledged that higher-ethanol blends incentivize more use of renewable fuels and do more towards achieving aggressive Congressional targets, yet E15 blends (based on a $0.70 RIN) provide no more than a 3.5 cent incentive to the blender compared to E10 blends. That’s not the kind of incentive that breaks through the E10 saturation problem. If higher blends received higher RIN values based on their value in incentivizing a distribution system that could achieve Congressional targets, they would be serving the Congressional purpose.
"A chemical used to make plastic IV tubes and catheters has been linked to attention deficit disorder in children who received treatment for a serious illness, according to a new study. The tubing and catheters contain plastic-softening chemicals, called phthalates, which have been banned from children's toys and products such as teething rings and soft books because of their potential toxic effects. The chemicals are known to disrupt hormones and have been implicated in everything from asthma to autism. "We found a clear match between previously hospitalized children's long-term neurocognitive test results and their individual exposure to the phthalate DEHP during intensive care," lead researcher Soren Verstraete, from Leuven, Belgium, told the Endocrine Society. Verstraete and his colleagues tested 449 children, newborns to age 16, who were treated in pediatric intensive care units and whose care involved between one and 12 medical tubes. They found high levels of phthalates, even among those admitted with only catheters in place. Until the young patients' discharge from the ICU, those levels remained 18 times higher than in a control group of healthy children."