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Purpose The Acute Disease Quality Initiative (ADQI) Workgroup recently released a consensus definition of sepsis-associated acute kidney injury (SA-AKI), combining Sepsis-3 and Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria. This study aims to described the epidemiology of SA-AKI. Methods Retrospective cohort study in 12 intensive care units (ICU) from 2015 to 2021. We studied the incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes of the ADQI SA-AKI definition. Results Of 84,831 admissions, 15,549 met the SA-AKI criteria with its incidence peaking at > 20% in 2021. SA-AKI patients were typically admitted from home via the emergency department (ED) with median time to SA-AKI diagnosis of one day (IQR 1–1) from ICU admission. At diagnosis, most SA-AKI patients had a stage 1 (55%) AKI, mostly due to the low urinary output (UO) criterion only (67%). Compared to diagnosis by creatinine alone, or both UO and creatinine criteria, patients diagnosed by UO alone had lower RRT requirement (3.3% vs 19% vs 51%; p

Background Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care. Methods This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed. Discussion This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units. Trial registration Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268; prospectively registered on 13 March 2018/https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship

Background: Admissions to intensive care units (ICUs) are increasing due to an aging population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations, that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care. Methods: This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60 minute sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.Discussion: This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.Trial registration: Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268; prospectively registered on 13th March 2018 / https://www.anzctr.org.auTrial funding: Metro South Health Research Support Scheme Postgraduate Scholarship

To the Editor: The global coronavirus disease (COVID-19) pandemic has seen a significant increase in the use of preprint services to enable the widespread dissemination of research findings (1). However, whether such facilities influence practice change is currently unknown. Here, we describe the impact of the preprint release and eventual publication of the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial (2) on corticosteroid use in clinical practice in Australian ICUs. The RECOVERY trial tested the efficacy of dexamethasone (6 mg by mouth or intravenously for up to 10 d) in hospitalized patients with clinically suspected or confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and demonstrated a reduction in 28-day mortality, particularly in those receiving either mechanical ventilation or oxygen. Before these results, the Australian and New Zealand Intensive Care Society COVID-19 guidelines recommended against the routine use of corticosteroids (3).

Tekst dotyczy różnicy między dwoma typami dyskursu historiograficznego odnoszącego się do Zagłady, reprezentowanego przez dwa wybitne opracowania tematu. Autor argumentuje, że w przypadku dyskursu bliskiego doświadczeniu świadka rolę odgrywa nie tylko referencja, lecz także specyficzny punkt widzenia i emocje osoby ocalonej, które bierze pod uwagę Saul Friedländer. White analyses the difference between two types of historiographic discourse related to the Holocaust as represented in two outstanding studies on the subject. He argues that in the case of discourses connected to the witness’s experience, it is not only the reference that plays a role but also the specific point of view and emotions of the rescued person. These are taken into account by Saul Friedländer.

Acute brain injury (ABI), including cerebral vascular accidents (CVA) and traumatic brain injury (TBI), are relatively common diseases which may lead to death, significant morbidity and place a heaving burden on health care systems globally, both in suffering and cost. Evidence has emerged from basic science research that ketones (beta-hydroxybutyrate and acetoacetate) which are water-soluble molecules produced by the liver during times of starvation, may have neuroprotective effects. It is therefore theoretically possible that increasing plasma ketone concentrations via intravenous or oral supplementation, may lead to improved outcomes following ABI.This thesis documents a systematic investigation into the possibility that ketone supplementation may lead to benefits in patients with a variety of chronic and acute neurological conditions. While the main emphasis is on ABI, other conditions where ketones may be useful are also reviewed. Beginning with a review of ketones, their potential mechanisms of action and likely neuroprotective roles in disease, this thesis examines the effects of a novel hypertonic intravenous ketone solution on plasma, cerebrospinal fluid (CSF) and brain ketone concentrations in animals, then looks at the hurdles in producing such an intravenous solution as opposed to enteral formulations for humans, before investigating baseline ketone concentrations in patients with ABI and finally culminating in an interventional study where a modified enteral ketone supplement is administered to patients with ABI to determine whether adequate plasma ketone concentrations are attainable.The animal study performed in rats involved the administration of hypertonic saline/ketone solutions of varying concentrations to anaesthetised rats. The results demonstrated that both CSF and beta-hydroxybutyrate (BHB) concentrations increased over time (p

Purpose To determine whether prophylactic inhaled heparin is effective for the prevention and treatment of pneumonia patients receiving mechanical ventilation (MV) in the intensive care unit. Methods A phase 2, double blind randomized controlled trial stratified for study center and patient type (non-operative, post-operative) was conducted in three university-affiliated intensive care units. Patients aged ≥18years and requiring invasive MV for more than 48hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 units in 2mL) or placebo nebulization with 0.9% sodium chloride (2mL) four times daily with the main outcome measures of the development of ventilator associated pneumonia (VAP), ventilator associated complication (VAC) and sequential organ failure assessment scores in patients with pneumonia on admission or who developed VAP. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12612000038897. Results Two hundred and fourteen patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP, using either Klompas criteria (6–7%, P=1.00) or clinical diagnosis (24–26%, P=0.85). There was no difference in the clinical consistency (P=0.70), number (P=0.28) or the total volume of secretions per day (P=.54). The presence of blood in secretions was significantly less in the usual care group (P=0.005). Conclusion Nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.

Purpose To determine whether prophylactic inhaled heparin is effective for the prevention and treatment of pneumonia patients receiving mechanical ventilation (MV) in the intensive care unit. Methods A phase 2, double blind randomized controlled trial stratified for study center and patient type (non-operative, post-operative) was conducted in three university-affiliated intensive care units. Patients aged ≥ 18 years and requiring invasive MV for more than 48 hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 units in 2 mL) or placebo nebulization with 0.9% sodium chloride (2 mL) four times daily with the main outcome measures of the development of ventilator associated pneumonia (VAP), ventilator associated complication (VAC) and sequential organ failure assessment scores in patients with pneumonia on admission or who developed VAP. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12612000038897. Results Two hundred and fourteen patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP, using either Klompas criteria (6–7%, P = 1.00) or clinical diagnosis (24–26%, P = 0.85). There was no difference in the clinical consistency (P = 0.70), number (P = 0.28) or the total volume of secretions per day (P = .54). The presence of blood in secretions was significantly less in the usual care group (P = 0.005). Conclusion Nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.

Thrombosis is a complication of many chronic illnesses. Chronic obstructive pulmonary disease (COPD) and diabetes mellitus are common medical conditions frequently associated with a hypercoagulable state. Acidaemia has been shown to reduce coagulation. COPD and diabetes mellitus during acute deterioration can present with a severe acidaemia. The impact of this acidaemia on coagulation is poorly studied. Patients presenting with a diagnosis of diabetic ketoacidosis or type II respiratory failure from COPD and a pH of less than 7.2 were included in our study. A coagulation screen and a thromboelastograph (TEG) were performed on admission and 24 hours later. The mean pH on admission was 7.07 and mean base excess was -16.3. The activated partial thromboplastin time was associated with pH change but remained within the normal range (26-41 s). All other coagulation and TEG parameters failed to show evidence of association (p>0.05). In the two models of non-haemorrhagic acidosis investigated, coagulation was not altered by the changes in pH. More work is needed to understand the complex relationship between factors affecting coagulation in individual disease processes.

Background Early rehabilitation has been found to prevent delirium and weakness that can hamper the recovery of intensive care unit (ICU) survivors. Integrated clinical practice guidelines for managing patient pain, agitation and delirium (PAD) have been developed. The Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle provides a strategy to implement PAD guidelines into everyday clinical practice. However, there is limited evidence on the effectiveness of the ABCDE bundle in the literature. The purpose of this study was to evaluate the feasibility of conducting a full-scale randomised controlled trial comparing the ABCDE bundle to standard care in an ICU. Trial feasibility was defined as the successful recruitment and retention of trial participants, adherence to the intervention, identification of barriers to the intervention, and the rigorous collection of outcome data. Methods A prospective, single-centre, randomised controlled feasibility study was conducted. Thirty adult mechanically ventilated participants were recruited from an eight-bed ICU in south east Queensland, Australia, between April 2015 and December 2015. Participants were randomised to receive either the ABCDE bundle or standard routine management. The ABCDE bundle integrated prescribed awakening and breathing trials, delirium monitoring and management, and prescribed exercise and mobility regimes. Feasibility outcomes measured included recruitment and retention rates, intervention fidelity, and the feasibility of participant outcome data collection. Outcome measurement assessors were blinded to participant assignment. It was not possible to blind the research team or the participant to group assignment. Results In total, 30 (81.1%) of 37 eligible participants consented and were randomised to the intervention group (n = 15) or the control group (n = 15). Of these, 23 (76.6%) participants successfully completed the 90-day post discharge assessment. A lengthy recruitment period of 8 months was related to overly stringent inclusion and exclusion criteria. Intervention adherence exceeded defined success rates with participation in awakening and breathing trials, delirium monitoring and exercise interventions performed on 80.2, 97.4 and 90.2% of ventilated days respectively. Outcome assessments were successfully and accurately performed at ICU and hospital discharge and 90-day post hospital discharge. Intervention participants were deemed to be delirious on 39.6% of mechanically ventilated days indicating a requirement for a scripted regime to prevent delirium. Conclusions With minor adjustment of inclusion and exclusion criteria, the inclusion of delirium management protocols, and encouragement of family engagement and involvement, a large-scale definitive randomised controlled trial to test the impact of the ABCDEF bundle will be feasible. Trial registration Australian New Zealand Clinical Trials Registry 12614000763640 Date registered 17/08/2014 Electronic supplementary material The online version of this article (10.1186/s40814-017-0224-x) contains supplementary material, which is available to authorized users.

With dengue fever emerging as a global health problem and more Australians travelling to endemic areas, imported dengue infection is on the rise and clinicians need to remain vigilant. Primary cardiac and neurologic involvement in dengue infection has been rarely described in the medical literature and the pathophysiology is poorly understood. A rare and fatal case of primary dengue infection in a 34-yearold woman who returned from Papua New Guinea is reported; the unusual features of this case include severe primary dengue infection, myocarditis, and acute cerebral oedema resulting in death. This case demonstrates that severe atypical manifestations and fatality can occur with primary dengue infection.

Key Clinical Message Idiopathic Systemic Capillary Leak Syndrome is a potentially fatal disorder that is under diagnosed. It commonly presents as recurrent undifferentiated shock with hypotension, hypoalbuminemia and hemoconcentration. There are three distinct phases that define the syndrome; Prodromal, Extravasation and Recovery.

Background: Tracheostomies are commonly performed on critically ill patients requiring prolonged mechanical ventilation. The purpose of this study was to review our experience with surgical and percutaneous tracheostomies and identify factors affecting outcome. Materials and Methods: Patients who underwent tracheostomy between January 1999 and June 2008 were identified on the basis of Diagnostic Related Group coding and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification procedural code. The primary endpoint was in-hospital mortality. Contingency tables were generated for clinical variables and a chi-squared test was used to determine significance. Results: One hundred and sixty-eight patients underwent tracheostomy between January 1999 and 30 June 2008. In-hospital mortality was 22.6%. The probability of death was found to be independent of timing of tracheostomy, technique used (percutaneous vs. surgical), number of failed extubations and obesity. On univariate analysis, the null hypothesis of independence was rejected for age on admission ( P = 0.014), diagnosis of sepsis ( P = 0.0008) or cardiac arrest ( P = 0.0016), Acute Physiology and Chronic Health Evaluation II score ( P = 0.0319) and the Australasian Outcomes Research Tool for Intensive Care calculated risk of death ( P = 0.0432). Conclusion: Although a number of patient factors are associated with worse outcome, tracheostomy appears to be a relatively safe technique in the Intensive Care Unit population.

Ce livre, qui est une histoire de la conscience historique dans l’Europe du xixe siècle, se veut aussi une contribution à la réflexion actuelle sur le problème de la connaissance historique. S’il rend compte de l’évolution de la réflexion historique pendant une période donnée, il offre de surcroît une théorie structurelle d’ensemble du mode de pensée que l’on qualifie d’« historique ». Que veut dire « penser historiquement » ? Qu’est-ce qui différencie la méthode historique des autres types d...

of Ralph Cohen as "master of genres." No one has been more assiduous in the cultivation of genre consciousness; no one has been more liberal in the entertainment of different conceptions of genre. Of course, as a literary scholar, Ralph Cohen has been especially interested in the concept and history of the genres of literary expression. But he has always treated literary genres as a special case of the more general social and cultural activity of identifying, classifying, and relating the classes and species of things both natural and unnatural. Up until the end of the eighteenth century, conformity to the "law of genre" which is supposed to have held that "thou shalt not mix the kinds" was considered a matter of moral, as well as ontological and aesthetic, necessity. The domain of literary genres was only the most cultivated and sophisticated place where the law was applied, tested, and, when necessary, revised. The law of genre was also supposed to preside over the joining of forms with contents. In literary writing, it was forbidden to join a noble form (such as tragedy) with a base content (such as villainy) . But in literature, as in life, Charles Darwin destroyed all that.

[C]riminal organizations, cannily mirroring the practices of their legitimate counterparts, have ex ploited economies of scale, developed worldwide partnerships, and cultivated new markets. As a result, bank fraud, human trafficking, protection rackets, narcotics smuggling, state-sanctioned embezzlement, assassinations, and even old fashioned political corruption are practiced today on a scale previously unimaginable. ?Review of McMafia by Misha Glenny, New Yorker, June 23, 2008, 83

It is now well recognized that low cerebral blood flow (and cerebral perfusion pressure (CPP)) is associated with poor outcome after traumatic brain injury. What is less clear is whether altering cerebral blood flow or CPP will lead to clinical improvement. Initial studies indicated that increasing CPP may be beneficial and the Brain Trauma Foundation acknowledged this by incorporating a target of 70 mm Hg in the 1996 guidelines. However, the lack of a demonstrable benefit and the increased complication rate associated with this approach led to a reduction in the CPP goal to 60 mm Hg. More recently, evidence that autoregulation may be disrupted after traumatic brain injury has led some authors to propose an individualized approach to CPP management. Furthermore, with the advent of advanced neuromonitoring techniques, clinicians are able to more closely monitor the effects of hemodynamic manipulations on cerebral metabolism. As yet, there is no strong outcome evidence to support this approach. Until then, the current debate over the optimal approach to CPP management is likely to continue.

A response to Michael Ann Holly's paper “The Melancholic Art,” which is published in this issue. By referring to art historical writing as “melancholic,” Holly alludes to a psychoanalytic way of explaining the relation between the past and the present, how the past “returns” to, bears on, and colors the present in masked or distorted forms. The notion that the particular scholarly discipline of art history may be inflicted with a psychological malady or syndrome is intriguing, but Holly moots the possibility of history being a science by designating art history as an art. The foremost problem with associating art history with the psychoanalytic concept of loss is that it invariably views loss in terms of the individual subject and, thereby, makes no distinction between actual loss (of an organ or limb, for example) and virtual loss, or the sense of having lost an object that was never actually possessed.

I am grateful to Dirk Moses for taking the time to study my work so assiduously and to comment on it so perspicuously. His essay is eminently well-informed and even-handed, and I have little to add to or correct of his characterization of my many, long on-going, and admittedly flawed attempts to deconstruct modern historical discourse. He understands me well enough and I think that I understand his objections to my position(s). We do not disagree on matters of fact, I think, but we have different notions about the nature of historical discourse and the uses to which historical knowledge can properly be put.

In this commentary I will consider a topical thread that runs through most of the essays comprising this issue of New Literary History and the one before it. The topic is the relation between history and theory in literary studies. In his contribution to this symposium, Michael Prince cites Ralph Cohen's suggestion that both the notion of (literary) genre and genres themselves appear to be "resistant to theory." Prince goes on to suggest that genre's resistance to theoretical consideration tells us more about theory than it does about genre itself. For if, as everyone seems to agree, genre is an essential element or aspect of literarity, then genre's resistance to theory implies that theory itself is inimical to literature and should not, therefore, be brought to bear upon the literary artwork. Indeed, Prince holds that it may be genre's resistance to theory that generates the endless task of literary interpretation, which has the role in criticism of mediating not only between literature and life but also between literature and theory as well. If we hold to interpretation and abandon theory we might be able, Prince tells us, to produce a low-level "theory of genre" "without falling into paradox or self-contradiction." And in his essay on "mauvais genres," he provides a brilliant historical account of how eighteenth-century English thinkers, in their attempt to construct a "theory of genre," met with a kind of resistance by genre that left them in a wasteland of theory and a quagmire of logical contradiction, left them, that is, with little more to do than turn over the question of genre to the newly emerged field of aesthetics, where the paradoxes it generated could be assimi lated to the idea of the sublime. Thus, Michael Prince's alternative to a theoretical approach to the question of genre is a history (in this case, of the failure of one attempt to construct an adequate theory) of genre. This is consistent with Ralph Cohen's historical approach to the study of genre. Cohen's idea that genre is resistant to theory is not itself a theoretical finding; it is a historical or more precisely a historicist one. It is based on the fact that no one has ever produced a compelling theory of genre in spite of the

To describe the technique of continuous jugular venous oxygen saturation (SjVO(2)) monitoring and review its applications in the neurointensive care unit (NICU), with special reference to the management of raised intracranial pressure (ICP) following severe acute brain injury.This narrative review is based on a selection of current literature on SjVO(2) monitoring in conjunction with local experience using this technique.Despite limitations, the use of SjVO(2) monitoring has the potential to impact on patient care in the NICU. The placement of the catheter is relatively simple. Studies have confirmed that abnormalities in cerebral venous oxygen saturation are associated with adverse outcome following traumatic brain injury. There is evidence that SjVO(2) may be a useful adjunct to ICP monitoring of patients with intracranial hypertension. Furthermore, managing cerebral extraction of oxygen in conjunction with cerebral perfusion pressure may result in an improved outcome. Further research in this area is needed. Other indications for SjVO(2) monitoring include subarachnoid hemorrhage, cardiopulmonary bypass and following ischemic stroke.In the past, the management of severe acute brain injury was targeted at ICP and perfusion pressure with little consideration for the metabolic requirements of the injured brain. SjVO(2) monitoring is another tool the intensivist can use to obtain information about the global oxygen requirements of the injured brain on a continuous basis. Whether this will impact on care in the long term remains to be seen.

Objectives The aim of this review is to appraise current research which examines the impact of early rehabilitation practices on functional outcomes and quality of life in adult intensive care unit (ICU) survivors. Review method used A systematic literature search was undertaken; retrieved data was evaluated against a recognised evaluation tool; research findings were analysed and categorised into themes; and a synthesis of conclusions from each theme was presented as an integrated summation of the topic. Data sources Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline and Google Scholar were searched using key search terms ‘ICU acquired weakness’, ‘early rehabilitation’ ‘early mobility’ and ‘functional outcomes’ combined with ‘intensive care’ and ‘critical illness’. Additional literature was sourced from reference lists of relevant original publications. Results Five major themes related to the review objectives emerged from the analysis. These themes included: critically ill patients do not always receive physical therapy as a standard of care; ICU culture and resources determine early rehabilitation success; successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment; early exercise in the ICU prevents the neuromuscular complications of critical illness and improves functional status; early exercise in the ICU is effective, safe and feasible. Conclusions A limited body of research supports early rehabilitation interventions to optimise the short term outcomes and long term quality of life for ICU survivors. Critical care nurses are in an excellent position to drive change within their departments ensuring that early rehabilitation practices are adopted and implemented.

Richards G, White H, Hopley M. Rapid reduction of oxygenation index by employment of a recruitment technique in patients with severe ARDS. J Intensive Care Med 2001;16:193–199. Mechanical ventilation of patients with acute respiratory distress syndrome (ARDS) may contribute to pulmonary injury and systemic inflammation. The objective of this study was to examine the safety and efficacy of a recruitment maneuver that rapidly improves atelectasis and oxygenation, and in so doing may reduce the potential for ventilator-induced lung injury. Nineteen patients with severe ARDS (defined as PaO2:FiO2≤ 150) from diverse etiologies were turned prone and a positive pressure of 40 cmH2O was applied for a period of 90 seconds. This pressure was increased in 5 cmH2O increments in subsequent maneuvers to a maximum of 50 cmH2O if there was an inadequate initial response. Subsequently pressure-limited mechanical ventilation with a PEEP of 15 cmH2O was instituted to prevent derecruitment. Peak pressures were maintained at ≤35 cmH2O. Outcome measures were oxygenation index, PaO2:FiO2 ratio, and alveolar-arterial oxygen difference. The oxygenation index decreased from a median of 31 cmH2O/mmHg to 14 cmH2O/mmHg immediately after recruitment and to 11 cmH2O/mmHg (p < 0.0001) 24 hours later. The A-aDO2 improved from 454 mmHg to 128 mmHg (p < 0.0001) and the PaO2:FiO2 ratio from 75 to 218 (p < 0.0001) 24 hours later. Twenty-five percent of patients had PaO2:FiO2 ratios of more than 300 mmHg at 24 hours. Mean airway pressure increased by 3 cmH2O initially, from 23 cmH2O to 26 cmH2O as a consequence of the increase in PEEP, but this had decreased to 25 cmH2O after 24 hours. There were no significant complications. Rapid reductions in FiO2 can be achieved safely by the implementation of a relatively simple recruitment technique.

This comment on Chris Lorenz’s comment on my work indicates a number of typical failings of reviewers, of which Lorenz’s comments on my talk are typical. One, like most philosophers, Lorenz treats my work as a whole rather than as a congeries of individual works as if they were all written and published at the same time. He finds inconsistencies or contradictions between works written many years apart. My response is that many of these inconsistencies are a result of changes in my point of view over time. Secondly, instead of quoting a passage from my work and criticising it, Lorenz typically paraphrases an argument and then proceeds to criticise his own paraphrase. Often, I do not recognise the paraphrase as a position I hold. Third, I hold that historical writing is often and should be more associative than logical, more poetic than technical. Fourth, about causality in history, I do not think that we have any examples of a universal causal law of historical change or structure. So his demand for a causal law from me is beside the point.

No abstract (available).

Tradução: Arthur Lima de Avila*, Mario Marcello Neto**, Felipe Radünz Krüger***

The past decade has witnessed a resurgence of interest in the use of hypertonic saline for low-volume resuscitation after trauma. Preliminary studies suggested that benefits are limited to a subgroup of trauma patients with brain injury, but a recent study of prehospital administration of hypertonic saline to patients with traumatic brain injury failed to confirm a benefit. Animal and human studies have demonstrated that hypertonic saline has clinically desirable physiological effects on cerebral blood flow, intracranial pressure, and inflammatory responses in models of neurotrauma. There are few clinical studies in traumatic brain injury with patient survival as an end point. In this review, we examined the experimental and clinical knowledge of hypertonic saline as an osmotherapeutic agent in neurotrauma.

Je li prošlost priča? Oko tog kratkog i, na prvi pogled, suvišnoga pitanja vrti se ne samo esej koji je pred nama, već i čitava postmodernistička rasprava o povijesti. U jedno nema sumnje: prošlost predstavljamo kao priču i prošlost rekonstruiramo (uglavnom) na osnovu priča. Ovime smo ukratko opisali povijest kao istraživačku (znanstvenu) djelatnost i jasno predočili njenu povezanost s pričom odnosno pripovijedanjem. Upravo zbog te jasne veze povijesti s pričom, ono pitanje s kojim smo započeli uvod čini nam se suvišnim. Ali povijest ( shvaćena u smislu koji smo prije spomenuli) nije prošlost; ona tek opisuje, prepričava prošle događaje. Jedan od prvih povjesničara koji su počeli ukazivati na spomenutu problematiku bio je Hayden White, američki filozof i povjesničar rođen 1928. godine. Njegova knjiga Metahistory: The Historical Imagination in Nineteenth Century Europe iz 1973. godine predstavljala je pionirski rad u uvođenju problema poznatog kao “lingvistički zaokret” u predmet historiografije. Stavljajući povijesnu znanost kao predmet te iste znanosti on ju ustvari razotkriva kao poetičku djelatnost, čime je pokrenuo raspravu koja do danas nije prestala. U eseju koji je ovdje predstavljen, White na primjeru prikazivanja Holokausta pokazuje presudan utjecaj načina pripovjedanja u prikazivanju prošlosti. Nudi li nam se Holokaust, kao prošli događaj nesumnjive strave i nesreće, sam po sebi kao tragedija, ili ga se može prikazati u nekom dugom pripovjednome modusu? Ako pak tragedija nije jedini mogući način prikazivanja Holokausta, znači li to da narav događaja ne određuje vrstu priče koju možemo uporabiti u njegovu prikazivanju? A što tek reći o stavu na koji se White osobito osvrće u eseju po kojemu Holokaust predstavlja događaj kojeg u potpunosti ne može ispričati nikakav ljudski jezik. Ako je tomu tako, zaključak je jasan: prošlost nije priča. Prošlost dakle nije priča, dok povijest to jest; na taj način kida se veza povjesničarske djelatnosti i njenog predmeta- prošlih zbivanja, veza koju povjesničar u pravilu uzima kao samu po sebi razumljivom.

Although much feared by clinicians, the ability to produce ketones has allowed humans to withstand prolonged periods of starvation. At such times, ketones can supply up to 50% of basal energy requirements. More interesting, however, is the fact that ketones can provide as much as 70% of the brain's energy needs, more efficiently than glucose. Studies suggest that during times of acute brain injury, cerebral uptake of ketones increases significantly. Researchers have thus attempted to attenuate the effects of cerebral injury by administering ketones exogenously. Hypertonic saline is commonly utilized for management of intracranial hypertension following cerebral injury. A solution containing both hypertonic saline and ketones may prove ideal for managing the dual problems of refractory intracranial hypertension and low cerebral energy levels. The purpose of the present review is to explore the physiology of ketone body utilization by the brain in health and in a variety of neurological conditions, and to discuss the potential for ketone supplementation as a therapeutic option in traumatic brain injury.

Introduction To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU). Methods Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically. Results A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the post-pyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 - 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 - 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 - 13.0 hours) compared to 12.3 hours (8.9 - 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 - 288 Kcal) and 3.5 g (0 - 15 g) compared to 167 Kcal (70 - 411 Kcal) and 6.5 g (2.8 - 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar. Conclusions Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complications Trial Registration Clinical Trial: anzctr.org.au:ACTRN12606000367549

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Critical illness is associated with increased oxidant stress. This is manifested by reduced antoxidant potential and an increase in measured oxidant species (ROS). ROS have the capacity to cause cellular injury and to activate NFKB in inflammatory cells. TPN provides a source of lipid for systemic peroxidation particularly in the presence of reduced antoxidant potential. TPN generally contains inadequate nutrient-antoxidants and precursors to glutathione. Total parenteral nutrition (TPN) is also a source of lipid peroxides which are pro-inflammatory.