The patient's age at the time of initial shunt placement and the time interval since previous surgical revision are important predictors of repeated shunt failures in the multivariable model. Even after adjusting for age at first shunt insertion as well as the cause of hydrocephalus, there is significant association between repeated failure times for individual patients.

Repeated cerebrospinal fluid (CSF) shunt failures in pediatric patients who have undergone neurosurgical procedures are common, and they are a significant cause of morbidity and occasionally mortality. To date, the risk factors for repeated failure have not been established. By performing survival analysis for repeated events, the authors examined the effects of patient characteristics, shunt hardware, and surgical details in a large cohort of patients. During a 10-year period all pediatric patients with hydrocephalus requiring CSF diversionary procedures were included in a prospective single-institution observational study. Patient characteristics were defined as age, gender, weight, head circumference; American Society of Anesthesiology class, and the cause of hydrocephalus. Surgical details included whether the procedure was performed on an emergency or nonemergency basis, use of antibiotics, concurrent other surgical procedures, and the duration of surgical procedure. Details on shunt hardware included the type of shunt, the valve system, whether the shunt system included multiple or complex components, the type of distal catheter, site of the shunt, and side on which the shunt was placed. Repeated shunt failures were assessed with multivariable time-to-event analysis (using the Cox regression model). Conditional models (as established by Prentice, et al.) were formulated for gap times (that is, times between successive shunt failures). There were 1183 shunt failures in 839 patients. Failure time from the first shunt procedure was an important predictor for the second and third episodes of failures, thus establishing an association between the times to failure within individual patients. Age of less than 40 weeks gestation at time of the first shunt implantion carried a hazard ratio (HR) of 2.49 (95% confidence interval [CI] 1.68-3.68) for the first failure and remained high for subsequent episodes of failure. Age of 40 weeks to 1 year (at the time of the initial surgery) also proved to be an important predictor of first shunt malfunctions (HR 1.77, 95% CI 1.29-2.44). The cause of hydrocephalus was significantly associated with the risk of initial failure and, to a lesser extent, later failures. Concurrent other surgical procedures were associated with an increased risk of failure. The patient's age at the time of initial shunt placement and the time interval since previous surgical revision are important predictors of repeated shunt failures in the multivariable model. Even after adjusting for age at first shunt insertion as well as the cause of hydrocephalus there is significant association between repeated failure times for individual patients.

To examine the agreement between two classifications of acute respiratory distress syndrome (ARDS) that are used interchangeably in clinical practice and clinical research, we classified 118 patients taking part in a randomized trial with respect to the presence of ARDS using the North American-European Consensus Committee (NAECC) and the Lung Injury Severity Score (LISS) criteria. The incidence of ARDS using NAECC criteria was 55.1% (95% confidence interval, 46.1% to 64.1%), and using the LISS criteria 61.9% (95% confidence interval, 53.1% to 70.6%). The p value on the difference between these proportions was 0.07. Raw agreement, chance-corrected agreement (kappa), and chance-independent agreement (phi) on the study occurrence of ARDS using the two classifications were, respectively, 0.73 (95% CI, 0.65 to 0.81), 0.46 (95% CI, 0.32 to 0.61), and 0.63 (95% CI, 0.41 to 0.79). No single component of either index contributed to disagreement to an appreciably greater extent than other components. Baseline characteristics and outcomes were similar among patients who developed ARDS according to either classification. We conclude that NAECC and LISS classifications resulted in similar estimates of the incidence of ARDS in this clinical trial, though patients were frequently classified as having ARDS with only one model. These discordant classifications had no prognostic importance.

Our study does not support the notion that published recommendations substantially impact reported use of several ventilator circuit and secretion management strategies. Based on the use of more frequent ventilator circuit changes, closed suctioning systems, heated humidifiers, and respiratory therapists, ventilator circuit and secretion management practice appears more costly in Canada than in France.