The utilization of concentrated solar energy as external heat source for methane steam reforming has been investigated. Molten salts at temperatures up to 550°C can be used as solar heat carrier and storage system, and hydrogen selective membranes can be used to drive reforming reaction at lower temperatures than conventional (<550°C), with hydrogen purification achieved thereby. The combination of new technologies such as membranes and membrane reactors, concentrating solar power (CSP) systems, and molten salt heat carriers, allows a partial decarbonation of the fossil fuel together with the possibility to carry solar energy in the current natural gas grid. Different plant configurations and operating conditions have been analyzed using a mathematical model and AspenPlus simulator. © 2008 American Institute of Chemical Engineers AIChE J, 2008

Treatment of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae infections (KPC-EI) remains a challenge. Combined therapy has been proposed as the best choice, but there are no clear data showing which combination therapy is superior. Our aim was to evaluate the effectiveness of antimicrobial regimens for treating KPC-EI. This was a retrospective cohort study of KPC-EI nosocomial infections (based on CDC criteria) between October 2009 and June 2013 at three tertiary Brazilian hospitals. The primary outcomes were the 30-day mortality for all infections and the 30-day mortality for patients with bacteraemia. Risk factors for mortality were evaluated by comparing clinical variables of survivors and nonsurvivors. In this study, 118 patients were included, of whom 78 had bacteraemia. Catheter-related bloodstream infections were the most frequent (43%), followed by urinary tract infections (n = 27, 23%). Monotherapy was used in 57 patients and combined treatment in 61 patients. The most common therapeutic combination was polymyxin plus carbapenem 20 (33%). Multivariate analysis for all infections (n = 118) and for bacteremic infections (n = 78) revealed that renal failure at the end of treatment, use of polymyxin and older age were prognostic factors for mortality. In conclusion, polymyxins showed suboptimal efficacy and combination therapy was not superior to monotherapy.

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BackgroundPublic hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality.MethodsWe conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance.ResultsWe included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle.ConclusionsQuality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1858-z) contains supplementary material, which is available to authorized users.

artrite reumatóide (AR) é uma doença autoimune de etiologia não esclarecida, caracterizada por inflamação sinovial e erosão óssea e, em alguns casos, com manifestações extra-articulares.Muitos avanços foram obtidos na terapia da AR, com maiores evidências do benefício do tratamento precoce e com uso de drogas como metotrexato, ciclosporina, corticosteróides e leflunomide. Novas opções de tratamento foram desenvolvidas e possivelmente mais benefícios possam ser obtidos com a introdução dos agentes modificadores da resposta biológica, em especial os inibidores do fator de necrose tumoral (TNF).O uso de drogas imunossupressoras (metotrexato, corticoterapia, ciclosporina, azatioprina, etc), tem sido implicado no desenvolvimento de infecções oportunísticas e esta preocupação também deve incluir os agentes anti-TNF. A inibição do TNF-alfa, uma importante citocina na regulação do sistema imunológico, diminui a resistência às infecções causadas por patógenos intracelulares, entre eles o bacilo da tuberculose, especialmente quando associado a outras drogas imunossupressoras, como metotrexato e corticóides. Está bem documentada a associação da tuberculose com o uso de corticosteróides em doses imunossupressoras (> 2mg/kg), enquanto que, com doses baixas de corticóides, a incidência aumentada de infecções estaria mais relacionada quando este se combina com outras drogas (metotrexate, por exemplo).Até (2) . Se considerarmos que a AR tem o pico de incidência entre os 45 e os 65 anos, a preocupação dobra, pois aumenta a incidência de infectados pelo bacilo de Koch. A associação com outras patologias imunossupressoras, como o diabetes, e a forma como a tuberculose se apresenta nessa faixa etária (bem mais insidiosa que nos mais jovens e de mais difícil diagnóstico) também alerta para a importância dessa infecção nos pacientes com AR (3) . Ainda que com atraso, é necessário alertar especialistas e clínicos para cuidados preventivos e de tratamento da tuberculose em pacientes com AR, que necessitem receber terapia imunossupressora.Sugerimos um roteiro, mostrado a seguir, que pode ser usado como guia de investigação e orientação nos pacientes portadores de AR com indicação de imunossupressores, particularmente a terapia anti-TNF.As características clínicas dos casos de tuberculose associados a imunossupressão descritas nos países desenvolvidos (aproximadamente 40% dos casos com a forma extrapulmonar) provavelmente não se aplicam ao Brasil. Como existe alta prevalência de indivíduos bacilíferos, a reinfecção exógena poderá ser um aspecto marcante em nosso meio, enquanto formas de reativação endógena (portanto com maior possibilidade de manifestação extrapulmonar) predominam em países com baixa prevalência da doença.Apresentamos em seguida um roteiro que poderá servir de guia para o diagnóstico da tuberculose infecção (latente) ou doença (ativa) (4,5) .