Triage decisions for ICU admission: Report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine

Demand for intensive care unit (ICU) resources often exceeds supply, and shortages of ICU beds and staff are likely to persist. Triage requires careful weighing of the benefits and risks involved in ICU admission while striving to guarantee fair distribution of available resources. We must ensure that the patients who occupy ICU beds are those most likely to benefit from the ICU's specialized technology and professionals. Although prognosticating is not an exact science, preference should be given to patients who are more likely to survive if admitted to the ICU but unlikely to survive or likely to have more significant morbidity if not admitted. To provide general guidance for intensivists in ICU triage decisions, a task force of the World Federation of Societies of Intensive and Critical Care Medicine addressed 4 basic questions regarding this process. The team made recommendations and concluded that triage should be led by intensivists considering input from nurses, emergency medicine professionals, hospitalists, surgeons, and allied professionals. Triage algorithms and protocols can be useful but can never supplant the role of skilled intensivists basing their decisions on input from multidisciplinary teams. Infrastructures need to be organized efficiently both within individual hospitals and at the regional level. When resources are critically limited, patients may be refused ICU admission if others may benefit more on the basis of the principle of distributive justice.     

31P solid-state NMR based monitoring of permeation of cell penetrating peptides into skin

The main objective of the current study was to investigate penetration of cell penetrating peptides (CPPs: TAT, R₈, R₁₁, and YKA) through skin intercellular lipids using ³¹P magic angle spinning (MAS) solid-state NMR. In vitro skin permeation studies were performed on rat skin, and sections (0–60, 61–120, and 121–180 μm) were collected and analyzed for ³¹P NMR signal. The concentration-dependent shift of 0, 25, 50, 100, and 200 mg/ml of TAT on skin layers, diffusion of TAT, R₈, R₁₁, and YKA in the skin and time dependent permeation of R₁₁ was measured on various skin sections using ³¹P solid-state NMR. Further, CPPs and CPP-tagged fluorescent dye encapsulate liposomes (FLip) in skin layers were tagged using confocal microscopy. The change in ³¹P NMR chemical shift was found to depend monotonically on the amount of CPP applied on skin, with saturation behavior above 100 mg/ml CPP concentration. R₁₁ and TAT caused more shift in solid-state NMR peaks compared to other peptides. Furthermore, NMR spectra showed R₁₁ penetration up to 180 μm within 30 min. The results of the solid-state NMR study were in agreement with confocal microscopy studies. Thus, ³¹P solid-state NMR can be used to track CPP penetration into different skin layers.     

Migration and Maternity: Insights of Context,Health Policy,and Research Evidence on Experiences and Outcomes From a Three Country Preliminary Study Across Germany,Canada, and the United Kingdom

A group from Germany, Canada, and the United Kingdom undertook country-specific scoping reviews and stakeholder consultations before joining to holistically compare migration and maternity in all three countries. We examined four interlinking dimensions to understand how international migrant/minority maternal health might be improved upon using transnational research: (a) wider sociopolitical context, (b) health policy arena, (c) constellation, outcomes, and experiences of maternity services, and (d) existing research contexts. There was clear evidence that the constellation and delivery of services may undermine good experiences and outcomes. Interventions to improve access and quality of care remain small scale, short term, and lacking in rigorous evaluation.     

Actualizaciones sobre colonoscopia en el cribado,seguimiento y tratamiento del cáncer colorrectal y sus lesiones precursoras

Colonoscopy is the gold standard for the diagnosis and treatment of diseases of the colon and, in particular, for the screening and surveillance of colorectal cancer. In Digestive Disease Week 2010 in New Orleans, the results of highly interesting studies on diagnostic and therapeutic colonoscopy were presented. As key points, the utility of quality indicators in colonoscopy and the need for constant surveillance were stressed and new quality indicators such as the polyp detection rate were proposed. In addition, new therapeutic regimens for anterograde preparation were evaluated, showing once again that the split dose and administration shortly before the examination are determining factors. There is increasing evidence on the advantages of propofol over other products in sedation and administration by gastroenterologists or specially trained nurses is becoming widespread. Several ingenious methods concerning the endoscopic technique were presented. These methods aim to improve the performance of colonoscopy and include the new colon capsule, the water method or cap technique, as well as narrowband imaging and confocal endomicroscopy. Lastly, the results presented reinforce the use of advanced digestive endoscopic techniques for the treatment of large colorectal lesions, whether benign or early malignant lesions.     

Diagnostic Yield of Coronary Angiography in Asymptomatic Orthotopic Liver Transplantation Candidates

BackgroundThe ideal cardiac risk stratification strategy for orthotopic liver transplantation (OLT) is unknown. Our institution performed coronary angiography for asymptomatic OLT candidates at high risk for CAD: ≥65 years of age, diabetic and ≥55 years of age or diagnosed ≥5 years, abnormal stress test, or at the discretion of the OLT committee.MethodsThe analysis included 301 consecutive, asymptomatic OLT candidates who underwent coronary angiography. The primary outcome was the prevalence of obstructive CAD.ResultsAt 2-year follow-up, OLT was performed in 44.9%, and 42.2% died. The prevalence of obstructive CAD, involvement of the proximal or mid LAD, and 3-vessel CAD were 10.3%, 6.6%, and 0.7%, respectively. Percutaneous and surgical revascularization were performed in 7.0% and 1.3%, respectively. Stress test was performed in 54.8%. The sensitivity and specificity of stress testing were 0% and 87.1%, respectively. The negative and positive predictive values of stress testing were 91.4% and 0%, respectively. Chest computed tomography (CT) was performed in 83.1%. Moderate or severe coronary artery calcification (CAC) was present in 47.8%. The sensitivity and specificity of moderate or severe CAC were 88.9% and 57.3%, respectively. The negative and positive predictive values of moderate or severe CAC were 97.7% and 20.2%, respectively. Multivariate analysis demonstrated that CAC was an independent predictor of obstructive CAD (HR 10.7; 95% CI 3.2–37.9; p < 0.001).ConclusionsThe prevalence of obstructive CAD in asymptomatic OLT candidates at high risk was uncommon. Alternative diagnostic strategies may be preferred to coronary angiography.     

Dutch Melanoma Treatment Registry: Quality assurance in the care of patients with metastatic melanoma in the Netherlands

BackgroundIn recent years, the treatment of metastatic melanoma has changed dramatically due to the development of immune checkpoint and mitogen-activated protein (MAP) kinase inhibitors. A population-based registry, the Dutch Melanoma Treatment Registry (DMTR), was set up in July 2013 to assure the safety and quality of melanoma care in the Netherlands. This article describes the design and objectives of the DMTR and presents some results of the first 2 years of registration.MethodsThe DMTR documents detailed information on all Dutch patients with unresectable stage IIIc or IV melanoma. This includes tumour and patient characteristics, treatment patterns, clinical outcomes, quality of life, healthcare utilisation, informal care and productivity losses. These data are used for clinical auditing, increasing the transparency of melanoma care, providing insights into real-world cost-effectiveness and creating a platform for research.ResultsWithin 1 year, all melanoma centres were participating in the DMTR. The quality performance indicators demonstrated that the BRAF inhibitors and ipilimumab have been safely introduced in the Netherlands with toxicity rates that were consistent with the phase III trials conducted. The median overall survival of patients treated with systemic therapy was 10.1 months (95% confidence interval [CI] 9.1–11.1) in the first registration year and 12.7 months (95% CI 11.6–13.7) in the second year.ConclusionThe DMTR is the first comprehensive multipurpose nationwide registry and its collaboration with all stakeholders involved in melanoma care reflects an integrative view of cancer management. In future, the DMTR will provide insights into challenging questions regarding the definition of possible subsets of patients who benefit most from the new drugs.