Expression and Prognostic Evaluation of the Receptor Tyrosine Kinase MET in Canine Malignant Melanoma.

The overexpression and activation of the MET receptor tyrosine kinase has been identified in many human malignancies, but its role in canine cancer has only been minimally investigated. In this study we evaluated the expression of MET in two canine malignant melanoma (CMM) cell lines as well as in 30 CMM tissue samples that were collected from the clinical service at our institution. We were able to confirm the expression of the MET protein in both melanoma cell lines, and we demonstrated MET activation by its ligand, HGF, through phosphorylation, in Western blot analysis. We were also able to demonstrate, by immunohistochemistry, the expression of MET in 63% of the tumor tissue samples analyzed, with the majority demonstrating a relatively low expression profile. We then evaluated the association of MET expression scores with histologic parameters, metastasis, and survival. While statistically significant associations were not found across these parameters, an inverse relationship between MET expression levels and time to lymph node versus distant metastasis was suggested in our cohort. These findings may require assessment in a larger group of specimens to further evaluate the role of MET expression in the homing of metastasis in lymph nodes versus that in distant organs.

Tradução e adaptação cultural para a língua portuguesa falada no Brasil da Canadian survey of mobilization of ICU patients / Traducción y adaptación cultural al portugués brasileño de Canadian survey of mobilization of ICU patients / Translation into Portuguese and cross-cultural adaptation for use in Brazil of the Canadian survey of mobilization of ICU patients

RESUMO Este estudo teve como objetivo traduzir e adaptar culturalmente o questionário Canadian survey of mobilization of intensive care unit patients para a língua portuguesa falada no Brasil. Este instrumento avalia profissionais de unidade de terapia intensiva (UTI) em relação aos conhecimentos sobre a mobilização precoce (MP) e sua importância, as percepções sobre barreiras e as práticas de reabilitação com o paciente crítico. O protocolo incluiu as etapas: autorização e cessão de direitos de uso; tradução do instrumento para a língua portuguesa; reconciliação; retrotradução para a língua original; revisão e harmonização da retrotradução; aprovação da autora principal do questionário original; revisão da versão em português; desdobramento cognitivo; e reconciliação e elaboração da versão final. Devido a algumas diferenças conceituais e culturais entre os dois países, algumas dúvidas foram discutidas com a autora principal do instrumento, a qual concordou com as alterações sugeridas. No desdobramento cognitivo, os 10 profissionais selecionados testaram a clareza, compreensão e aceitabilidade do questionário, e demonstraram suas dificuldades quanto ao conteúdo deste. Muitos entrevistados evidenciaram que o instrumento desperta reflexões importantes sobre as práticas diárias e os benefícios com a realização da MP. O questionário intitulado Pesquisa de mobilização de pacientes em unidade de terapia intensiva: conhecimento, perspectivas e práticas atuais encontra-se traduzido e adaptado culturalmente para a língua portuguesa falada no Brasil, podendo ser utilizado para avaliar aspectos da MP por profissionais que participam deste processo em UTIs adulto e pediátricas. Estudos futuros utilizando esta versão serão necessários para verificar se o questionário fornece medidas reprodutíveis e válidas.

RESUMEN Este estudio tuvo como objetivo traducir y adaptar culturalmente el cuestionario Canadian survey of mobilization of intensive care unit patients al portugués de Brasil. Este instrumento evalúa a los profesionales de la unidad de cuidados intensivos (UCI) en cuanto al conocimiento sobre la movilización temprana (MT) y su importancia, las percepciones sobre las barreras y las prácticas de rehabilitación con pacientes críticos. El protocolo incluyó las siguientes etapas: autorización y cesión de derechos de uso; traducción del instrumento al portugués brasileño; reconciliación; retrotraducción al idioma original; revisión y armonización de la retrotraducción; aprobación de la autora principal al cuestionario original; revisión de la versión al portugués; despliegue cognitivo; y reconciliación y preparación de la versión final. Debido a algunas diferencias conceptuales y culturales entre los dos países, se discutieron algunas dudas con la autora principal del instrumento, quien estuvo de acuerdo con los cambios sugeridos. En el despliegue cognitivo, los 10 profesionales seleccionados probaron la claridad, la comprensión y la aceptabilidad del cuestionario, y demostraron las dificultades de los contenidos. Numerosos entrevistados manifestaron que el instrumento suscita importantes reflexiones sobre las prácticas cotidianas y beneficios de llevar a cabo la MT. El cuestionario titulado Investigación en movilización de pacientes en unidades de cuidados intensivos: conocimientos, perspectivas y prácticas actuales está traducido y adaptado culturalmente al portugués de Brasil, y puede ser utilizado para evaluar aspectos de MT por parte de profesionales que participan en este proceso en UCI de adultos y pediátrica. Se necesitarán estudios futuros que utilicen esta versión para verificar que el cuestionario proporciona la reproducibilidad y la validez de las medidas.

ABSTRACT This study aimed to translate and culturally adapt the "Canadian survey of mobilization of intensive care unit patients" questionnaire to Brazilian Portuguese. This instrument evaluates intensive care unit (ICU) professionals' knowledge about early mobilization and its importance, their perceptions about barriers and rehabilitation practices with critically ill patients. The protocol includes the following steps: authorization and assignment of rights of use; translation of the instrument into Portuguese; reconciliation; back-translation to the original language; revision and harmonization of back-translation; approval from the main author of the original questionnaire; revision of the Portuguese version; cognitive debriefing; reconciliation; and preparation of the final version. Due to some conceptual and cultural differences between the two countries, some questions were discussed with the author of the original instrument, who agreed with the suggested alterations. During cognitive debriefing, the 10 selected professionals tested the questionnaire's clarity, understanding, and acceptability, indicating any difficulties they had regarding its content. Many interviewees reported that the instrument raises important reflections on daily practices and the benefits of early mobilization. The questionnaire entitled "Pesquisa de mobilização de pacientes em unidade de terapia intensiva: conhecimento, perspectivas e práticas atuais" was translated and culturally adapted to Brazilian Portuguese and can be used to evaluate aspects of early mobilization by professionals who participate in this process in adult and pediatric ICUs. Future studies using this version will be necessary to verify that the questionnaire provides reproducible and valid measurements.

Multicentre pilot randomised clinical trial of early in-bed cycle ergometry with ventilated patients.

Introduction: Acute rehabilitation in critically ill patients can improve post-intensive care unit (post-ICU) physical function. In-bed cycling early in a patient's ICU stay is a promising intervention. The objective of this study was to determine the feasibility of recruitment, intervention delivery and retention in a multi centre randomised clinical trial (RCT) of early in-bed cycling with mechanically ventilated (MV) patients. Methods: We conducted a pilot RCT conducted in seven Canadian medical-surgical ICUs. We enrolled adults who could ambulate independently before ICU admission, within the first 4 days of invasive MV and first 7 days of ICU admission. Following informed consent, patients underwent concealed randomisation to either 30 min/day of in-bed cycling and routine physiotherapy (Cycling) or routine physiotherapy alone (Routine) for 5 days/week, until ICU discharge. Our feasibility outcome targets included: accrual of 1-2 patients/month/site; >80% cycling protocol delivery; >80% outcomes measured and >80% blinded outcome measures at hospital discharge. We report ascertainment rates for our primary outcome for the main trial (Physical Function ICU Test-scored (PFIT-s) at hospital discharge). Results: Between 3/2015 and 6/2016, we randomised 66 patients (36 Cycling, 30 Routine). Our consent rate was 84.6 % (66/78). Patient accrual was (mean (SD)) 1.1 (0.3) patients/month/site. Cycling occurred in 79.3% (146/184) of eligible sessions, with a median (IQR) session duration of 30.5 (30.0, 30.7) min. We recorded 43 (97.7%) PFIT-s scores at hospital discharge and 37 (86.0%) of these assessments were blinded. Discussion: Our pilot RCT suggests that a future multicentre RCT of early in-bed cycling for MV patients in the ICU is feasible. Trial registration number: NCT02377830.

Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada.

OBJECTIVE: Early mobilization is safe, feasible, and associated with better outcomes in patients with critical illness. However, barriers to mobilization in clinical practice still exist. The objective of this study was to assess the knowledge and practice patterns of intensive care unit (ICU) clinicians, as well as the barriers and facilitators to early mobilization. DESIGN: Cross-sectional survey. SETTING: Intensive care units of 3 university-affiliated hospitals in Montreal, Canada. PARTICIPANTS: One hundred and thirty-eight ICU clinicians, including nurses, physicians, respiratory therapists, and physiotherapists. INTERVENTIONS: None. MEASUREMENTS: Perceived barriers, facilitators, knowledge, and practice patterns of early mobilization were assessed using a previously validated mobility survey tool. MAIN RESULTS: The overall response rate was 50.0% (138 of 274). Early mobilization was not perceived as a top priority in 49% of respondents. Results showed that clinicians were not fully aware of the benefits of early mobilization as per the current literature. About 58% of clinicians did not feel well trained and informed to mobilize mechanically ventilated patients. Perceptions on patient-level barriers varied with clinicians' professional training, but there was a high degree of interprofessional and intraprofessional disagreement on the permissible maximal level activity in different scenarios of critically ill patients. CONCLUSIONS: Our survey shows limited awareness, among our respondents, of the clinical benefits of early mobilization and high level of disagreement on the permissible maximal level of activity in the critically ill patients. Future studies should evaluate the role of knowledge translation in modifying these barriers and improving early mobilization.

Point Prevalence Study of Mobilization Practices for Acute Respiratory Failure Patients in the United States.

OBJECTIVE: Early mobility in mechanically ventilated patients is safe, feasible, and may improve functional outcomes. We sought to determine the prevalence and character of mobility for ICU patients with acute respiratory failure in U.S. ICUs. DESIGN: Two-day cross-sectional point prevalence study. SETTING: Forty-two ICUs across 17 Acute Respiratory Distress Syndrome Network hospitals. PATIENTS: Adult patients (≥ 18 yr old) with acute respiratory failure requiring mechanical ventilation. INTERVENTIONS: We defined therapist-provided mobility as the proportion of patient-days with any physical or occupational therapy-provided mobility event. Hierarchical regression models were used to identify predictors of out-of-bed mobility. MEASUREMENTS AND MAIN RESULTS: Hospitals contributed 770 patient-days of data. Patients received mechanical ventilation on 73% of the patient-days mostly (n = 432; 56%) ventilated via an endotracheal tube. The prevalence of physical therapy/occupational therapy-provided mobility was 32% (247/770), with a significantly higher proportion of nonmechanically ventilated patients receiving physical therapy/occupational therapy (48% vs 26%; p ≤ 0.001). Patients on mechanical ventilation achieved out-of-bed mobility on 16% (n = 90) of the total patient-days. Physical therapy/occupational therapy involvement in mobility events was strongly associated with progression to out-of-bed mobility (odds ratio, 29.1; CI, 15.1-56.3; p ≤ 0.001). Presence of an endotracheal tube and delirium were negatively associated with out-of-bed mobility. CONCLUSIONS: In a cohort of hospitals caring for acute respiratory failure patients, physical therapy/occupational therapy-provided mobility was infrequent. Physical therapy/occupational therapy involvement in mobility was strongly predictive of achieving greater mobility levels in patients with respiratory failure. Mechanical ventilation via an endotracheal tube and delirium are important predictors of mobility progression.

TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients.

INTRODUCTION: The objective of this study was to assess the safety and feasibility of in-bed cycling started within the first 4 days of mechanical ventilation (MV) to inform a future randomized clinical trial. METHODS: We conducted a 33-patient prospective cohort study in a 21-bed adult academic medical-surgical intensive care unit (ICU) in Hamilton, ON, Canada. We included adult patients (≥ 18 years) receiving MV who walked independently pre-ICU. Our intervention was 30 minutes of in-bed supine cycling 6 days/week in the ICU. Our primary outcome was Safety (termination), measured as events prompting cycling termination; secondary Safety (disconnection or dislodgement) outcomes included catheter/tube dislodgements. Feasibility was measured as consent rate and fidelity to intervention. For our primary outcome, we calculated the binary proportion and 95% confidence interval (CI). RESULTS: From 10/2013-8/2014, we obtained consent from 34 of 37 patients approached (91.9%), 33 of whom received in-bed cycling. Of those who cycled, 16(48.4%) were female, the mean (SD) age was 65.8(12.2) years, and APACHE II score was 24.3(6.7); 29(87.9%) had medical admitting diagnoses. Cycling termination was infrequent (2.0%, 95% CI: 0.8%-4.9%) and no device dislodgements occurred. Cycling began a median [IQR] of 3 [2, 4] days after ICU admission; patients received 5 [3, 8] cycling sessions with a median duration of 30.7 [21.6, 30.8] minutes per session. During 205 total cycling sessions, patients were receiving invasive MV (150 [73.1%]), vasopressors (6 [2.9%]), sedative or analgesic infusions (77 [37.6%]) and dialysis (4 [2.0%]). CONCLUSIONS: Early cycling within the first 4 days of MV among hemodynamically stable patients is safe and feasible. Research to evaluate the effect of early cycling on patient function is warranted. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01885442.

Early mobilization of critically ill adults: a survey of knowledge, perceptions and practices of Canadian physicians and physiotherapists.

BACKGROUND: The promotion of early mobilization following critical illness is tempered by national reports of patient and institutional barriers to this approach. We carried out a survey to assess current knowledge, perceptions and practices of Canadian physicians and physiotherapists with respect to acquired weakness and early mobilization in adults in the intensive care unit (ICU). METHODS: We conducted a cross-sectional, self-administered postal survey among critical care physicians and physiotherapists in all 46 academic ICUs in Canada in 2011-2012. To identify all physicians and physiotherapists working in the ICUs, we contacted division heads and senior physiotherapists by telephone or email. We designed, tested and administered a questionnaire with the following domains: knowledge of ICU-acquired weakness and early mobilization; personal views of, perceived barriers to and adequacy of technical skills for early mobilization; assessments for initiation of early mobilization and permissible activity levels by patient physiologic characteristics, diagnoses and therapies; staffing issues; and sedation practices. RESULTS: The overall response rate was 71.3% (311/436); it was 64.2% (194/302) among physicians and 87.3% (117/134) among physiotherapists. A total of 214 respondents (68.8%) underestimated the incidence of ICU-acquired weakness in the general medical-surgical ICU population, and 186 (59.8%) stated they had insufficient knowledge or skills to mobilize patients receiving mechanical ventilation. Excessive sedation, medical instability, limited staffing, safety concerns, insufficient guidelines and insufficient equipment were common perceived barriers to early mobilization. INTERPRETATION: Physicians and physiotherapists in the ICU underestimated the incidence of ICU-acquired weakness and felt inadequately trained to mobilize patients receiving mechanical ventilation. We identified multiple modifiable barriers to early mobilization at the institutional, health care provider and patient levels that need to be addressed when designing mobilization programs for critically ill adults.

CYCLE pilot: a protocol for a pilot randomised study of early cycle ergometry versus routine physiotherapy in mechanically ventilated patients.

INTRODUCTION: Early exercise with in-bed cycling as part of an intensive care unit (ICU) rehabilitation programme has the potential to improve physical and functional outcomes following critical illness. The objective of this study is to determine the feasibility of enrolling adults in a multicentre pilot randomised clinical trial (RCT) of early in-bed cycling versus routine physiotherapy to inform a larger RCT. METHODS AND ANALYSIS: 60-patient parallel group pilot RCT in 7 Canadian medical-surgical ICUs. We will include all previously ambulatory adult patients within the first 0-4 days of mechanical ventilation, without exclusion criteria. After informed consent, patients will be randomised using a web-based, centralised electronic system, to 30 min of in-bed leg cycling in addition to routine physiotherapy, 5 days per week, for the duration of their ICU stay (28 days maximum) or routine physiotherapy alone. We will measure patients' muscle strength (Medical Research Council Sum Score, quadriceps force) and function (Physical Function in ICU Test (scored), 30 s sit-to-stand, 2 min walk test) at ICU awakening, ICU discharge and hospital discharge. Our 4 feasibility outcomes are: (1) patient accrual of 1-2 patients per month per centre, (2) protocol violation rate <20%, (3) outcome measure ascertainment >80% at the 3 time points and (4) blinded outcomes ascertainment >80% at hospital discharge. Hospital outcome assessors are blinded to group assignment, whereas participants, ICU physiotherapists, ICU caregivers, research coordinators and ICU outcome assessors are not blinded to group assignment. We will analyse feasibility outcomes with descriptive statistics. ETHICS AND DISSEMINATION: Each participating centre will obtain local ethics approval, and results of the study will be published to inform the design and conduct of a future multicentre RCT of in-bed cycling to improve physical outcomes in ICU survivors. TRIAL REGISTRATION NUMBER: NCT02377830; Pre-results.

Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial.

PURPOSE: In shock, hypotension may contribute to inadequate oxygen delivery, organ failure and death. We conducted the Optimal Vasopressor Titration (OVATION) pilot trial to inform the design of a larger trial examining the effect of lower versus higher mean arterial pressure (MAP) targets for vasopressor therapy in shock. METHODS: We randomly assigned critically ill patients who were presumed to suffer from vasodilatory shock regardless of admission diagnosis to a lower (60-65 mmHg) versus a higher (75-80 mmHg) MAP target. The primary objective was to measure the separation in MAP between groups. We also recorded days with protocol deviations, enrolment rate, cardiac arrhythmias and mortality for prespecified subgroups. RESULTS: A total of 118 patients were enrolled from 11 centres (2.3 patients/site/month of screening). The between-group separation in MAP was 9 mmHg (95% CI 7-11). In the lower and higher MAP groups, we observed deviations on 12 versus 8% of all days on vasopressors (p = 0.059). Risks of cardiac arrhythmias (20 versus 36%, p = 0.07) and hospital mortality (30 versus 33%, p = 0.84) were not different between lower and higher MAP arms. Among patients aged 75 years or older, a lower MAP target was associated with reduced hospital mortality (13 versus 60%, p = 0.03) but not in younger patients. CONCLUSIONS: This pilot study supports the feasibility of a large trial comparing lower versus higher MAP targets for shock. Further research may help delineate the reasons for vasopressor dosing in excess of prescribed targets and how individual patient characteristics modify the response to vasopressor therapy.

Corticosteroid use in the intensive care unit: a survey of intensivists.

OBJECTIVE: The efficacy of systemic corticosteroids in many critical illnesses remains uncertain. Our primary objective was to survey intensivists in North America about their perceived use of corticosteroids in clinical practice. DESIGN: Self-administered paper survey. POPULATION: Intensivists in academic hospitals with clinical trial expertise in critical illness. MEASUREMENTS: We generated questionnaire items in focus groups and refined them after assessments of clinical sensibility and test-retest reliability and pilot testing. We administered the survey to experienced intensivists practicing in selected North American centres actively enrolling patients in the multicentre Oscillation for ARDS Treated Early (OSCILLATE) Trial (ISRCTN87124254). Respondents used a four-point scale to grade how frequently they would administer corticosteroids in 14 clinical settings. They also reported their opinions on 16 potential near-absolute indications or contraindications for the use of corticosteroids. MAIN RESULTS: Our response rate was 82% (103/125). Respondents were general internists (50%), respirologists (22%), anesthesiologists (21%), and surgeons (7%) who practiced in mixed medical-surgical units. A majority of respondents reported almost always prescribing corticosteroids in the setting of significant bronchospasm in a mechanically ventilated patient (94%), recent corticosteroid use and low blood pressure (93%), and vasopressor-refractory septic shock (52%). Although more than half of respondents stated they would almost never prescribe corticosteroids in severe community-acquired pneumonia (81%), acute lung injury (ALI, 76%), acute respiratory distress syndrome (ARDS, 65%), and severe ARDS (51%), variability increased with severity of acute lung injury. Near-absolute indications selected by most respondents included known adrenal insufficiency (99%) and suspicion of cryptogenic organizing pneumonia (89%), connective tissue disease (85%), or other potentially corticosteroid-responsive illnesses (85%). CONCLUSIONS: Respondents reported rarely prescribing corticosteroids for ALI, but accepted them for bronchospasm, suspected adrenal insufficiency due to previous corticosteroid use, and vasopressor-refractory septic shock. These competing indications will complicate the design and interpretation of any future large-scale trial of corticosteroids in critical illness.

Early mobilization in critically ill children: a survey of Canadian practice.

OBJECTIVES: While early mobilization is safe and enhances functional recovery in critically ill adults, rehabilitation practices in critically ill children are not well characterized. The objective of this study was to evaluate the knowledge, perceptions, and stated practices of early mobilization among physicians and physiotherapists practicing in Canadian pediatric critical care units. DESIGN AND MEASUREMENTS: A self-administered survey was mailed to 102 physicians and 35 physiotherapists. Survey domains included barriers to early mobilization, the timing, nature and thresholds for rehabilitation, and staffing workload. We assessed for associations using chi-square tests. MAIN RESULTS: The overall response rate was 64.2% (88 of 137), representing 59.8% (61 of 102) physicians and 77.1% (27 of 35) physiotherapists, respectively. Key institutional barriers to early mobilization included a lack of practice guidelines (75.4% physician, 48.1% physiotherapist respondents; p = 0.01) and the need for physician orders prior to initiating physiotherapy (26.2% physician vs 55.6% physiotherapist, p = 0.008). Only 3.4% of respondents reported having local guidelines for early mobilization. Conflicting perceptions regarding the clinical thresholds for early mobilization and the safety of early mobilization were the most commonly reported patient-level barriers. Increasing illness severity was associated with decreased clinician comfort with early mobilization. Respiratory physiotherapy and passive range of motion were the most frequently applied rehabilitation interventions (77.8%), while pregait physiotherapy and ambulation were only sometimes or infrequently (70.4%) used. The type and extent of physiotherapy varied depending on the time of day and week. CONCLUSIONS: There are numerous perceived institutional, patient- and provider-level barriers to early mobilization in Canadian pediatric critical care units, and diverse opinions on the appropriateness of early mobilization. Limited awareness of existing literature and the lack of practice guidelines on early mobilization are not surprising in light of the paucity of pediatric-specific evidence. These results strongly support the need for further research, evaluating the feasibility, safety, and efficacy of early mobilization in critically ill children.

Quality of reporting of surveys in critical care journals: a methodologic review.

OBJECTIVE: Adequate reporting is needed to judge methodologic quality and assess the risk of bias of surveys. The objective of this study is to describe the methodology and quality of reporting of surveys published in five critical care journals. DATA SOURCES: All issues (1996-2009) of the American Journal of Respiratory and Critical Care Medicine, Critical Care, Critical Care Medicine, Intensive Care Medicine, and Pediatric Critical Care Medicine. STUDY SELECTION: Two reviewers hand-searched all issues in duplicate. We included publications of self-administered questionnaires of health professionals and excluded surveys that were part of a multi-method study or measured the effect of an intervention. DATA EXTRACTION: Data were abstracted in duplicate. DATA SYNTHESIS: We included 151 surveys. The frequency of survey publication increased at an average rate of 0.38 surveys per 1000 citations per year from 1996-2009 (p for trend = 0.001). The median number of respondents and reported response rates were 217 (interquartile range 90 to 402) and 63.3% (interquartile range 45.0% to 81.0%), respectively. Surveys originated predominantly from North America (United States [40.4%] and Canada [18.5%]). Surveys most frequently examined stated practice (78.8%), attitudes or opinions (60.3%), and less frequently knowledge (9.9%). The frequency of reporting on the survey design and methods were: 1) instrument development: domains (59.1%), item generation (33.1%), item reduction (12.6%); 2) instrument testing: pretesting or pilot testing (36.2%) and assessments of clarity (25.2%) or clinical sensibility (15.7%); and 3) clinimetric properties: qualitative or quantitative description of at least one of face, content, construct validity, intra- or inter-rater reliability, or consistency (28.5%). The reporting of five key elements of survey design and conduct did not significantly change over time. CONCLUSIONS: Surveys, primarily conducted in North America and focused on self-reported practice, are increasingly published in highly cited critical care journals. More uniform and comprehensive reporting will facilitate assessment of methodologic quality.

Pulmonary artery catheters: evolving rates and reasons for use.

OBJECTIVE: Randomized trials have demonstrated risks and failed to establish a clear benefit for the use of the pulmonary artery catheter. We assessed rates of pulmonary artery catheter use in multiple centers over 5 yrs, variables associated with their use, and how these variables changed over time (2002-2006). DESIGN: A multicenter longitudinal study using the Hamilton Regional Critical Care Database. A two-level multiple logistic regression analysis was used to determine significant variables associated with pulmonary artery catheter use and whether these varied over time. SETTING: Academic intensive care units in Hamilton, Canada. PATIENTS: We identified patients from five intensive care units who received a pulmonary artery catheter within the first 2 days of intensive care unit admission. INTERVENTIONS: Pulmonary artery catheter use over a 5-yr period. MEASUREMENTS AND MAIN RESULTS: Among 15,006 patients, 1,921 (12.8%) had a pulmonary artery catheter. Adjusted rates of pulmonary artery catheter use decreased from 16.4% to 6.5% over 5 yrs. Determinants of pulmonary artery catheter use included Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], 1.05; confidence interval [CI], 1.04-1.06; p < .0001), elective surgical status (OR, 2.82; CI, 2.29-3.48; p < .0001), postabdominal aortic aneurysm repair (OR, 10.91; CI, 8.24-14.45; p < .0001), cardiogenic shock (OR, 5.31; CI, 3.35-8.42; p < .0001), sepsis (OR, 2.83; CI, 1.94-4.13; p < .0001), vasoactive infusion use (OR, 4.04; CI, 3.47-4.71; p < .0001), and mechanical ventilation (OR, 2.21; CI, 1.86-2.63; p < .0001). Physician's base specialty and local intensive care unit were also associated with pulmonary artery catheter use (p < .0001). The determinants of pulmonary artery catheter use did not change over time. CONCLUSIONS: We observed a >50% reduction in the rate of pulmonary artery catheter use over 5 yrs. Patient factors predicting pulmonary artery catheter use were illness severity, specific diagnoses, and the need for advanced life support. Nonpatient factors predicting pulmonary artery catheter use were intensive care unit and the attending physician's base specialty.

Para-aortic arch abscess secondary to Staphylococcus aureus pneumonia.

Staphylococcus aureus is a relatively common pathogen causing pneumonia in the community, hospital ward and intensive care unit. Although pneumonia is responsible for significant morbidity and mortality, especially in elderly and immunocompromised patients, it is usually uncomplicated and resolves without complications. The case of a woman who developed a para-aortic abscess after a community-acquired S aureus pneumonia infection is presented. A number of diagnostic imaging modalities were used to reach the diagnosis. This complication has not been reported previously and it is likely secondary to suppurative lymphadenitis of a station 5 or 6 node. The patient was successfully managed nonsurgically with computed tomography-guided drainage and intravenous antibiotics.

The large Maf factor Traffic Jam controls gonad morphogenesis in Drosophila.

Interactions between somatic and germline cells are critical for the normal development of egg and sperm. Here we show that the gene traffic jam (tj) produces a soma-specific factor that controls gonad morphogenesis and is required for female and male fertility. tj encodes the only large Maf factor in Drosophila melanogaster, an orthologue of the atypical basic Leu zipper transcription factors c-Maf and MafB/Kreisler in vertebrates. Expression of tj occurs in somatic gonadal cells that are in direct contact with germline cells throughout development. In tj mutant gonads, somatic cells fail to inter-mingle and properly envelop germline cells, causing an early block in germ cell differentiation. In addition, tj mutant somatic cells show an increase in the level of expression for several adhesion molecules. We propose that tj is a critical modulator of the adhesive properties of somatic cells, facilitating germline-soma interactions that are essential for germ cell differentiation.