This pilot study aims to investigate the differences between varying lengths of bundles in structure and function by comparing the 100 most frequent three-, four-, and five-word bundles in a self-built corpus of dissertations which contains about 3.5 million words. The findings reveal considerable variances between bundles of different lengths in terms of both structure and function. In general, the variances between three-and four-word bundles are greater than those between four-and five-word bundles, and three-and five-word bundles. Structurally, three-and four-word bundles differ significantly in all six main categories. Four-and five-word bundles vary in five categories, while three-and five-word bundles are only different in four categories. Functionally, noticeable variances were observed in research-, text- and participant-oriented bundles between three-and four-word bundles, and three-and five-word bundles. However, four-and five-word bundles only differ significantly in text- and participant-oriented bundles. Interestingly, bundles of varying lengths also vary in patterns that are used to perform the same functions. The results of this study might inform researchers that they need to take bundle lengths into consideration when making generalizations of their findings or comparing bundles between various studies.

Promoting land use planning through ecosystem service (ES) protection is a crucial approach for maintaining landscape sustainability. Identifying ES bundles to serve landscape functional zoning can provide a new perspective for sustainable land use planning. Taking the Beijing metropolitan region as a study area, we quantitatively assessed the spatiotemporal distributions of multiple ESs, from 1980 to 2017, based on land use changes. By combining ES patterns and comprehensive ecosystem service (CES), distinct ES bundles were identified through the clustering method. Based on the ES bundles, landscape functional zones were then established. We further developed improved land use scenarios to conserve ESs in selected towns of different functional zones by exploring dominant factors influencing ESs. Results showed that most of ESs decreased due to the expansion of developed lands. According to the classification of ES bundles, Beijing can be classified into three landscape functional zones at town level: the ecological conservation region (ECR), food production region (FPR), and urban development region (UDR). For each landscape functional zone, the town with the greatest decline in CES value was selected. Associated with the influencing factors of ESs, local land use patterns, and ecological protection policies, corresponding multi-step improved land use scenarios were designed. These scenarios were demonstrated to be effective in conserving ESs in the selected towns: (1) the agricultural expansion scenario, which enhanced food provision services in the ECR; (2) the forest conservation scenario, which enhanced habitat and recreational services in the FPR; and (3) the developed land optimization scenario, which enhanced a range of regulating services in the UDR. Overall, this study used landscape functional zoning as a nexus to connect ES patterns and land use management. The optimized land use strategies can provide references for conserving ESs and enhancing landscape sustainability in Beijing and other similar metropolitan areas worldwide.

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Rationale: Compliance with sepsis bundles is associated with better outcomes, but information to support structural actions that might improve compliance is scarce. Few studies have evaluated bundle compliance in different time periods, with conflicting results.Objectives: To evaluate the association of sepsis identification during the daytime versus during the nighttime and on weekdays versus weekends with 3-hour sepsis treatment bundle compliance.Methods: This was an observational, multicenter study including patients with sepsis admitted between 2010 and 2017 to 10 hospitals in Brazil. Our exposures of interest were daytime (7:00 a.m.-6:59 p.m.) versus nighttime (7:00 p.m.-6:59 a.m.) and weekdays (Monday 7:00 a.m.-Friday 6:59 p.m.) versus weekends (Friday 7:00 p.m.-Monday 6:59 a.m.). Our primary outcome was full compliance with the 3-hour sepsis treatment bundles. We adjusted by potential confounding factors with multivariable logistic regression models.Results: Of 11,737 patients (8,733 sepsis and 3,004 septic shock), 3-hour bundle compliance was 79.1% and hospital mortality was 24.7%. The adjusted odds ratio (adjOR) for 3-hour full bundle compliance for patients diagnosed during the daytime versus during the nighttime was 1.35 (95% confidence interval [CI], 1.23-1.49; P < 0.001) and was more pronounced in the emergency department (adjOR, 1.55; 95% CI, 1.35-1.77; P < 0.001) than in nonemergency areas (adjOR, 1.19; 95% CI, 1.04-1.37; P = 0.014). Overall, there was no association between diagnosis on the weekends versus on weekdays and 3-hour full bundle compliance (adjOR, 1.08; 95% CI, 0.98-1.19; P = 0.115), although there was an association among those diagnosed in nonemergency areas (adjOR, 1.15; 95% CI, 1.00-1.32; P = 0.047). The lower compliance observed for sepsis diagnosed during the nighttime was more evident 2 years after implementation of the quality improvement initiative.Conclusions: Compliance with sepsis bundles was associated with the moment of sepsis diagnosis. The place of diagnosis and the time from campaign implementation were factors modifying this association. Our results support areas for better design of quality improvement initiatives to mitigate the influence of the period of sepsis diagnosis on treatment compliance.

We conducted two event-related potentials (ERP) experiments to investigate consumers\' responses to different types of food bundles. In Experiment 1, the participants were instructed to indicate their wanting of a three-yogurt bundle when their neural activity was recorded. The results of self-report wanting scores revealed that the participants wanted bundles consisting of their favorite yogurt products more than those of disliked products. Such a difference in self-report scores was also indexed by the N2 in frontal brain and the P1 in the left hemisphere. By contrast, bundles consisting of three different yogurt products elicited a smaller amplitude of the N2 than bundles consisting of two favorite products and one disliked product, but these two types of bundles received comparable wanting scores. Moreover, we asked the participants in Experiment 2 to perform a visual discrimination task on these bundles, and did not found these effects on the N2 or the P1. Collectively, these results revealed neural activities underlying consumers\' responses to food rewards, and demonstrated the role of individuals\' variety-seeking tendency in wanting process.

BACKGROUND: Age has been traditionally considered a risk factor for mortality in elderly patients admitted to intensive care units. The aim of this prospective, observational, multicenter cohort study is to determine the risk factors for mortality in elderly and very elderly critically ill patients with sepsis.
RESULTS: A total of 1490 patients with ≥ 65 years of age were included in the study; most of them 1231 (82.6%) had a cardiovascular failure. The mean age (± SD) was 74.5 (± 5.6) years, and 876 (58.8%) were male. The patients were divided into two cohorts: (1) elderly: 65-79 years and (2) very elderly: ≥ 80 years. The overall hospital mortality was 48.8% (n = 727) and was significantly higher in very elderly compared to elderly patients (54.2% vs. 47.4%; p = 0.02). Factors independently associated with mortality were APACHE II score of the disease, patient location at sepsis diagnosis, development of acute kidney injury, and thrombocytopenia in the group of elderly patients. On the other hand, in the group of very elderly patients, predictors of hospital mortality were age, APACHE II score, and prompt adherence of the resuscitation bundle.
CONCLUSIONS: This prospective multicenter study found that patients aged 80 or over had higher hospital mortality compared to patients between 65 and 79 years. Age was found to be an independent risk factor only in the very elderly group, and prompt therapy provided within the first 6 h of resuscitation was associated with a reduction in hospital mortality in the very elderly patients.

BACKGROUND: The aim of this study was to evaluate the effectiveness and safety of a new three-component \'bundle\' for insertion and management of centrally inserted central catheters (CICCs), designed to minimize catheter-related bloodstream infections (CRBSIs) in critically ill children.
METHODS: Our \'bundle\' has three components: insertion, management, and education. Insertion and management recommendations include: skin antisepsis with 2% chlorhexidine; maximal barrier precautions; ultrasound-guided venipuncture; tunneling of the catheter when a long indwelling time is expected; glue on the exit site; sutureless securement; use of transparent dressing; chlorhexidine sponge dressing on the 7th day; neutral displacement needle-free connectors. All CICCs were inserted by appropriately trained physicians proficient in a standardized simulation training program.
RESULTS: We compared CRBSI rate per 1000 catheters-days of CICCs inserted before adoption of our new bundle with that of CICCs inserted after implementation of the bundle. CICCs inserted after adoption of the bundle remained in place for a mean of 2.2 days longer than those inserted before. We found a drop in CRBSI rate to 10%, from 15 per 1000 catheters-days to 1.5.
CONCLUSIONS: Our data suggest that a bundle aimed at minimizing CR-BSI in critically ill children should incorporate four practices: (1) ultrasound guidance, which minimizes contamination by reducing the number of attempts and possible break-down of aseptic technique; (2) tunneling the catheter to obtain exit site in the infra-clavicular area with reduced bacterial colonization; (3) glue, which seals and protects the exit site; (4) simulation-based education of the staff.

BACKGROUND: Public 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.
METHODS: We 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.
RESULTS: We 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.
CONCLUSIONS: Quality 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.

Sepsis management in the Emergency Department remains a daily challenge. The Surviving Sepsis Campaign (SSC) has released three-hour bundle. The implementation of these bundles in European Emergency Departments remains poorly described. The main objective was to assess the compliance with the Severe Sepsis Campaign 3-h bundle (blood culture, lactate dosage, first dose of antibiotics and 30 ml/kg fluid challenge). Secondary objectives were the analysis of the delay of severe sepsis recognition and description of the population.
In accordance with STROBE statement, we performed a retrospective study in two French University Hospital Emergency Departments from February to August 2015. Patients admitted during the study period were screened using the electronic files of the hospital databases. Patient\'s files were reviewed and included in the study if they met severe sepsis criteria. Demographics, comorbities, treatments were recorded. Delays from admission to severe sepsis diagnosis, fluid loading onset and antibiotics administration were calculated.
One hundred thirty patients were included (76 men, mean age 71 ± 14 years). Blood culture, lactate dosage, antibiotics and 30 ml/kg fluid loading were performed within 3 hours in % [95% confidence interval] 100% [96-100%], 62% [54-70%], 49% [41-58%] and 19% [13-27%], respectively. 25 patients out of 130 (19% [13-27%]) fulfilled each criteria of the 3-h bundle. The mean fluid loading volume was 18 ± 11 ml/kg. Mean delay between presentation and severe sepsis diagnosis was 200 ± 263 min, from diagnosis to fluid challenge and first antibiotic dose, 10 ± 27 min and 20 ± 55 min, respectively.
Compliance with SSC 3-h bundle and delay between admission and sepsis recognition have to be improved. If confirmed by other studies, an improvement program might be deployed.

OBJECTIVE: Whether the entire posterior cruciate ligament (PCL) should be retained during cruciate-retaining total knee arthroplasty (CR TKA) is controversial. The goal of this study was to compare the early clinical outcomes of partial versus intact PCL-retaining TKA.
METHODS: Ninety-two patients who had undergone unilateral CR TKA from March 2012 to June 2013 were enrolled in this study. Forty-six of these patients were randomly selected to undergo intact PCL-retaining TKA (intact group), whereas the remaining 46 patients underwent tibial osteotomy together with anterolateral bundle and bone island resection (partial group). All operations were performed by a senior orthopedic surgeon and the PCL was released to some extent in both groups. After TKA, active and passive flexion and extension exercises of the knee and lower limb strength exercises were maintained until at least 3 months after surgery. Before surgery and 6, 12, and 24 months after surgery, range of motion, Knee Society Clinical Rating System scores (including clinical and functional scores of the knee) and maximum anteroposterior (AP) displacement of the knee at 30° and 90° of knee flexion were evaluated in both groups.
RESULTS: Fourteen patients were rejected from the final analysis because of loss to follow-up or development of complications. Thus, 40 patients from the partial group and 38 from the intact group were followed up for 24-41 months (mean 32.8 months). Knee functional scores were significantly higher in the intact than in the partial group (88.1 vs. 84.8 points) 24 months after surgery There were no significant differences in range of motion or knee clinical scores between the two groups at any time point. However, 12 and 24 months after surgery, the mean maximum AP displacement of the knee in 90° knee flexion was significantly greater in the partial than in the intact group (12 months: 6.3 vs. 5.7 mm; 24 months: 7.0 vs. 6.2 mm).
CONCLUSIONS: Double-bundle PCL plays an important role in maintaining knee stability; the entire PCL should therefore be retained during CR TKA.