OBJECTIVES:We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care ...team, including patients and family members, and discusses quality improvement initiatives that require interprofessional collaboration for success.
DATA SOURCES:Studies were identified through MEDLINE search using a variety of search phrases related to interprofessional care, critical care provider types, and quality improvement initiatives. Additional articles were identified through a review of the reference lists of identified articles.
STUDY SELECTION:Original articles, review articles, and systematic reviews were considered.
DATA EXTRACTION:Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles.
DATA SYNTHESIS:“Interprofessional care” refers to care provided by a team of healthcare professionals with overlapping expertise and an appreciation for the unique contribution of other team members as partners in achieving a common goal. A robust body of data supports improvement in patient-level outcomes when care is provided by an interprofessional team. Critical care nurses, advanced practice providers, pharmacists, respiratory care practitioners, rehabilitation specialists, dieticians, social workers, case managers, spiritual care providers, intensivists, and nonintensivist physicians each provide unique expertise and perspectives to patient care, and therefore play an important role in a team that must address the diverse needs of patients and families in the ICU. Engaging patients and families as partners in their healthcare is also critical. Many important ICU quality improvement initiatives require an interprofessional approach, including Awakening and Breathing Coordination, Delirium, Early Exercise/Mobility, and Family Empowerment bundle implementation, interprofessional rounding practices, unit-based quality improvement initiatives, Patient and Family Advisory Councils, end-of-life care, coordinated sedation awakening and spontaneous breathing trials, intrahospital transport, and transitions of care.
CONCLUSIONS:A robust body of evidence supports an interprofessional approach as a key component in the provision of high-quality critical care to patients of increasing complexity and with increasingly diverse needs.
This review describes the management of mechanical ventilation in patients with acute respiratory distress syndrome, including in those with coronavirus disease 2019. Low tidal volume ventilation ...with a moderate to high positive end-expiratory pressure remains the foundation of an evidence-based approach. We consider strategies for setting positive end-expiratory pressure levels, the use of recruitment maneuvers, and the potential role of driving pressure. Rescue therapies including prone positioning and extracorporeal membrane oxygenation are also discussed.
Bulk‐heterojunction organic photovoltaic materials containing nonfullerene acceptors (NFAs) have seen remarkable advances in the past year, finally surpassing fullerenes in performance. Indeed, ...acceptors based on indacenodithiophene (IDT) have become synonymous with high power conversion efficiencies (PCEs). Nevertheless, NFAs have yet to achieve fill factors (FFs) comparable to those of the highest‐performing fullerene‐based materials. To address this seeming anomaly, this study examines a high efficiency IDT‐based acceptor, ITIC, paired with three donor polymers known to achieve high FFs with fullerenes, PTPD3T, PBTI3T, and PBTSA3T. Excellent PCEs up to 8.43% are achieved from PTPD3T:ITIC blends, reflecting good charge transport, optimal morphology, and efficient ITIC to PTPD3T hole‐transfer, as observed by femtosecond transient absorption spectroscopy. Hole‐transfer is observed from ITIC to PBTI3T and PBTSA3T, but less efficiently, reflecting measurably inferior morphology and nonoptimal energy level alignment, resulting in PCEs of 5.34% and 4.65%, respectively. This work demonstrates the importance of proper morphology and kinetics of ITIC → donor polymer hole‐transfer in boosting the performance of polymer:ITIC photovoltaic bulk heterojunction blends.
Three high‐fill‐factor OPV polymers, PTPD3T, PBTI3T, and PBTSA3T are paired with the high performance acceptor, ITIC. A maximum power conversion efficiency of 8.43% is achieved with PTPD3T:ITIC blends due primarily to increased short‐circuit current density. Ultrafast hole‐transfer from ITIC to PTPD3T is observed by femtosecond transient absorption measurements due to the superior blend morphology and improved charge transport versus PBTI3T:ITIC and PBTSA3T:ITIC blends.
OBJECTIVE:Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle ...performance and patient-centered outcomes in critical care.
DESIGN:Prospective, multicenter, cohort study from a national quality improvement collaborative.
SETTING:68 academic, community, and federal ICUs collected data during a 20-month period.
PATIENTS:15,226 adults with at least one ICU day.
INTERVENTIONS:We defined ABCDEF bundle performance (our main exposure) in two ways1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomespatient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.
MEASUREMENTS AND RESULTS:Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomeshospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17–0.62), next-day mechanical ventilation (adjusted odds ratio AOR, 0.28; CI, 0.22–0.36), coma (AOR, 0.35; CI, 0.22–0.56), delirium (AOR, 0.60; CI, 0.49–0.72), physical restraint use (AOR, 0.37; CI, 0.30–0.46), ICU readmission (AOR, 0.54; CI, 0.37–0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51–0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).
CONCLUSIONS:ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.
Canine malignant melanoma, a significant cause of mortality in domestic dogs, is a powerful comparative model for human melanoma, but little is known about its genetic etiology. We mapped the genomic ...landscape of canine melanoma through multi-platform analysis of 37 tumors (31 mucosal, 3 acral, 2 cutaneous, and 1 uveal) and 17 matching constitutional samples including long- and short-insert whole genome sequencing, RNA sequencing, array comparative genomic hybridization, single nucleotide polymorphism array, and targeted Sanger sequencing analyses. We identified novel predominantly truncating mutations in the putative tumor suppressor gene PTPRJ in 19% of cases. No BRAF mutations were detected, but activating RAS mutations (24% of cases) occurred in conserved hotspots in all cutaneous and acral and 13% of mucosal subtypes. MDM2 amplifications (24%) and TP53 mutations (19%) were mutually exclusive. Additional low-frequency recurrent alterations were observed amidst low point mutation rates, an absence of ultraviolet light mutational signatures, and an abundance of copy number and structural alterations. Mutations that modulate cell proliferation and cell cycle control were common and highlight therapeutic axes such as MEK and MDM2 inhibition. This mutational landscape resembles that seen in BRAF wild-type and sun-shielded human melanoma subtypes. Overall, these data inform biological comparisons between canine and human melanoma while suggesting actionable targets in both species.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
A retrospective analysis of longitudinally collected athlete monitoring data was conducted to generate a model of neuromuscular recovery after anterior cruciate ligament (ACL) injury and ...reconstruction (ACLR). Neuromuscular testing data including countermovement jump (CMJ) force‐time asymmetries and knee extensor strength (maximum voluntary contractionext) asymmetries (between‐limb asymmetry index—AI) were obtained from athletes with ACLR using semitendinosus (ST) autograft (n = 29; AI measurements: n = 494), bone patellar tendon bone autograft (n = 5; AI measurements: n = 88) and noninjured controls (n = 178; AI measurements: n = 3188). Explosive strength measured as the rate of torque development was also calculated. CMJ force‐time asymmetries were measured over discrete movement phases (eccentric deceleration phase, concentric phase). Separate additive mixed effects models (additive mixed effects model AMM) were fit for each AI with a main effect for the surgical technique and a smooth term for the time since surgery (days). The models explained between 43% and 91% of the deviance in neuromuscular recovery after ACLR. The mean time course was generated from the AMM. Comparative neuromuscular recovery profiles of an athlete with an accelerated progression and an athlete with a delayed progression after a serious multiligament injury were generated. Clinical Significance: This paper provides a new perspective on the utility of longitudinal athlete monitoring including routine testing to develop models of neuromuscular recovery after ACLR that can be used to characterize individual progression throughout rehabilitation.
The medical management of the critically ill patient focuses predominantly on treatment of the underlying condition (
, sepsis or respiratory failure). However, in the past decade, the importance of ...initiating early prophylactic treatment for complications arising from care in the intensive care unit setting has become increasingly apparent. As survival from critical illness has improved, there is an increased prevalence of postintensive care syndrome-defined as a decline in physical, cognitive, or psychologic function among survivors of critical illness. The Intensive Care Unit Liberation Bundle, a major initiative of the Society of Critical Care Medicine, is centered on facilitating the return to normal function as early as possible, with the intent of minimizing iatrogenic harm during necessary critical care. These concepts are universally applicable to patients seen by nephrologists in the intensive care unit and may have particular relevance for patients with kidney failure either on dialysis or after kidney transplant. In this article, we will briefly summarize some known organ-based consequences associated with critical illness, review the components of the ABCDEF bundle (the conceptual framework for Intensive Care Unit Liberation), highlight the role nephrologists can play in implementing and complying with the ABCDEF bundle, and briefly discuss areas for additional research.
In an effort to protect patientsʼ reproductive rights, many states prohibit health care proxies from serving as surrogate decision makers for pregnancy termination in patients who lack capacity. We ...explore the case of a 24-year-old developmentally delayed woman with intractable seizures and complex psychosocial needs who was found to be pregnant. Her older sister was her health care proxy and declared that an abortion would be in her best interest, medically and socially; the patient herself lacked capacity to make this decision. Legally, her sisterʼs judgment alone was insufficient to move forward with the procedure. Here we describe our multidisciplinary medical, ethical, and legal review of this case and how, despite agreeing with the patientʼs sister, legal barriers hindered our ability to obtain an abortion for this patient. Her situation illustrates the unintended consequences of our current approach to surrogate decision making in pregnancy termination. It highlights the need to reconsider the role of health care proxies in reproductive-choice decisions and emphasizes the value of a holistic evaluation of patientsʼ social circumstances.
Immunosuppressed patients such as solid organ transplant and hematologic malignancy patients appear to be at increased risk for morbidity and mortality due to coronavirus disease 2019 (COVID‐19) ...caused by SARS coronavirus 2 (SARS‐CoV‐2). Convalescent plasma, a method of passive immunization that has been applied to prior viral pandemics, holds promise as a potential treatment for COVID‐19. Immunocompromised patients may experience more benefit from convalescent plasma given underlying deficits in B and T cell immunity as well as contraindications to antiviral and immunomodulatory therapy. We describe our institutional experience with four immunosuppressed patients (two kidney transplant recipients, one lung transplant recipient, and one chronic myelogenous leukemia patient) treated with COVID‐19 convalescent plasma through the Expanded Access Program (NCT 04338360). All patients clinically improved after administration (two fully recovered and two discharged to skilled nursing facilities) and none experienced a transfusion reaction. We also report the characteristics of convalescent plasma product from a local blood center including positive SARS‐CoV‐2 IgG and negative SARS‐CoV‐2 PCR in all samples tested. This preliminary evidence suggest that convalescent plasma may be safe among immunosuppressed patients with COVID‐19 and emphasizes the need for further data on the efficacy of convalescent plasma as either primary or adjunctive therapy for COVID‐19.
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