Purpose
The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life ...care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear.
Methods
We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries.
Results
Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies.
Conclusion
Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.
Abstract Objectives In a time of exponential growth of new evidence supporting clinical decision-making, combined with a labor-intensive process of selecting this evidence, methods are needed to ...speed up current processes to keep medical guidelines up-to-date. This study evaluated the performance and feasibility of active learning to support the selection of relevant publications within medical guideline development and to study the role of noisy labels. Design We used a mixed-methods design. Two independent clinicians’ manual process of literature selection was evaluated for 14 searches. This was followed by a series of simulations investigating the performance of random reading versus using screening prioritization based on active learning. We identified hard-to-find papers and checked the labels in a reflective dialogue. Main outcome measures Inter-rater reliability was assessed using Cohen’s Kappa ( ĸ ). To evaluate the performance of active learning, we used the Work Saved over Sampling at 95% recall (WSS@95) and percentage Relevant Records Found at reading only 10% of the total number of records (RRF@10). We used the average time to discovery (ATD) to detect records with potentially noisy labels. Finally, the accuracy of labeling was discussed in a reflective dialogue with guideline developers. Results Mean ĸ for manual title-abstract selection by clinicians was 0.50 and varied between − 0.01 and 0.87 based on 5.021 abstracts. WSS@95 ranged from 50.15% (SD = 17.7) based on selection by clinicians to 69.24% (SD = 11.5) based on the selection by research methodologist up to 75.76% (SD = 12.2) based on the final full-text inclusion. A similar pattern was seen for RRF@10, ranging from 48.31% (SD = 23.3) to 62.8% (SD = 21.20) and 65.58% (SD = 23.25). The performance of active learning deteriorates with higher noise. Compared with the final full-text selection, the selection made by clinicians or research methodologists deteriorated WSS@95 by 25.61% and 6.25%, respectively. Conclusion While active machine learning tools can accelerate the process of literature screening within guideline development, they can only work as well as the input given by human raters. Noisy labels make noisy machine learning.
Even though data suggest that palliative care (PC) improves patient quality of life, caregiver burden, cost, and intensive care unit (ICU) length of stay, integration of PC in the ICU is far from ...being universally accepted. Poor understanding of what PC provides is one of the barriers to the widespread implementation of their services in ICU. Evidence suggests that the availability of specialist PC is lacking in most European countries and provided differently depending on geographical location. The aim of this systematic review is to compare the numbers and types of PC interventions and gauge their impact on stakeholder outcomes and ICU resource utilisation.
We will undertake a systematic review of the published peer-reviewed journal articles; our search will be carried out MEDLINE, Embase, Cochrane, CINAHL, and PsycINFO. The search strategy will include variations in the term 'palliative care' and 'intensive care'. All studies with patient populations undergoing palliative care interventions will be selected. Only full-text articles will be considered, and conference abstracts excluded. There will be no date restrictions on the year of publications or on language. The primary aim of the present study is to compare the numbers and types of PC interventions in ICU and their impact on stakeholder (patient, family, clinician, other) outcomes. Reporting of findings will follow the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
This review will provide insight into the implementation of palliative care in ICU, elucidate differences between countries and health systems, reveal most effective models, and contribute to identifying research priorities to improve outcomes.
International Prospective Register of Systematic reviews PROSPERO ( CRD42018094315 ).
Elevated total plasma homocysteine (tHcy) concentrations are considered a risk factor for neural tube defects (NTD) and cardiovascular disease. Supplementation with folic acid decreases the risk of ...women having children with NTD. In both sexes, it decreases tHcy levels. We investigated the efficacy of natural dietary folate in improving folate and homocysteine status. We performed a 4-wk dietary controlled, parallel design intervention trial with 66 healthy subjects (18-45 y) divided into 3 treatment groups: the dietary folate group, the folic acid group and the placebo group. Each day each group was fed a different diet. The dietary folate group received a diet high in vegetables and citrus fruit (total folate content approximately 560 microgram) plus a placebo tablet. The folic acid group received a diet naturally low in folate (approximately 210 microgram) plus 500 microgram folic acid and placebo tablet on alternate days, i.e., 250 microgram folic acid/d. And the placebo group received the same low-folate diet as the folic acid group plus a placebo tablet. After 4 wk of intervention, folate status improved, and tHcy concentrations decreased in both the dietary folate and the folic acid groups. From the amount of additional folate (350 microgram/d) and folic acid (250 microgram/d) consumed, the relative bioavailability of dietary folate compared to folic acid was calculated to be 60-98%, depending on the endpoint used. In conclusion, increasing the consumption of vegetables and citrus fruit, both good sources of folate, will improve folate status and decrease tHcy concentrations. This may contribute to the prevention of cardiovascular disease and NTD in the general population
An elevated plasma total homocysteine concentration is a risk factor for cardiovascular disease and neural tube defects. A high daily intake of supplemental folic acid is known to decrease total ...homocysteine concentrations.
We studied the effect of low-dose folic acid administration (250 or 500 (microgram/d) for 4 wk on plasma total homocysteine concentrations and folate status. We also investigated whether total homocysteine concentrations and blood folate concentrations returned to baseline after an 8-wk washout period.
In this placebo-controlled study, 144 healthy women aged 18-40 y received 500 microgram folic acid/d, 500 microgram folic acid every second day (250 microgram/d), or a placebo tablet with their habitual diet (mean dietary folate intake: 280 microgram/d).
Administration of 250 and 500 microgram folic acid/d for 4 wk significantly increased folate concentrations in plasma (P < 0.001) and red blood cells (P < 0.01). Total homocysteine concentrations decreased significantly (P < 0.001) in women (n = 50) who took 250 microgram folic acid/d mean (+/-SEM) deviation from baseline: - 11.4 +/- 198% and in women (n = 45) who took 500 microgram folic acid/d (-21.8 + 1.49%). Eight weeks after the end of the intervention period (week 12), plasma total homocysteine concentrations in the folic acid-supplemented groups had not returned to baseline (week 0).
Doses of folic acid as low as 250 microgram/d, on average, in addition to usual dietary intakes of folate significantly decreased plasma total homocysteine concentrations in healthy, young women. An 8-wk washout period was not sufficient for blood folate and plasma total homocysteine concentrations to return to baseline concentrations.
To gain more insight into the relation between vegetable consumption and the risk of chronic diseases, it is important to determine the bioavailability of carotenoids from vegetables and the effect ...of vegetable consumption on selected biomarkers of chronic diseases.
To assess the bioavailability of β-carotene and lutein from vegetables and the effect of increased vegetable consumption on the ex vivo oxidizability of LDL.
Over 4 wk, 22 healthy adult subjects consumed a high-vegetable diet (490 g/d), 22 consumed a low-vegetable diet (130 g/d), and 10 consumed a low-vegetable diet supplemented with pure β-carotene (6 mg/d) and lutein (9 mg/d).
Plasma concentrations of vitamin C and carotenoids (ie, α-carotene, β-carotene, lutein, zeaxanthin, and β-cryptoxanthin) were significantly higher after the high-vegetable diet than after the low-vegetable diet. In addition to an increase in plasma β-carotene and lutein, the pure carotenoid–supplemented diet induced a significant decrease in plasma lycopene concentration of −0.11 μmol/L (95% CI: −0.21, −0.0061). The responses of plasma β-carotene and lutein to the high-vegetable diet were 14% and 67%, respectively, of those to the pure carotenoid–supplemented diet. Conversion of β-carotene to retinol may have attenuated its plasma response compared with that of lutein. There was no significant effect on the resistance of LDL to oxidation ex vivo.
Increased vegetable consumption enhances plasma vitamin C and carotenoid concentrations, but not resistance of LDL to oxidation. The relative bioavailability of lutein from vegetables is higher than that of β-carotene.
An elevated plasma total homocysteine (tHcy) concentration is a risk factor for cardiovascular disease and for having offspring with a neural-tube defect. Folate is a methyl donor in the ...remethylation of homocysteine into methionine. Although folic acid supplementation decreases tHcy concentrations, effects of folic acid supplementation on plasma methionine concentrations are unclear. There is also concern that folic acid supplementation negatively affects vitamin B(12) status. We studied effects of low-dose folic acid supplementation on methionine and vitamin B(12) concentrations in plasma. We also investigated whether baseline plasma methionine and tHcy concentrations correlated with the baseline folate and vitamin B(12) status. For a period of 4 weeks, 144 young women received either 500 micrograms folic acid each day, or 500 micrograms folic acid and placebo tablets on alternate days, or a placebo tablet each day. Plasma methionine, tHcy and plasma vitamin B(12) concentrations were measured at start and end of the intervention period. Folic acid supplementation had no effect on plasma methionine or plasma vitamin B(12) concentrations although it significantly decreased tHcy concentrations. Plasma methionine concentrations showed no correlation with either tHcy concentrations (Spearman r(s)-0.01, P = 0.89), or any of the blood vitamin variables at baseline. Baseline tHcy concentrations showed a slight inverse correlation with baseline concentrations of plasma vitamin B(12) (r(s)-0.25, P < 0.001), plasma folate (r(s) - 0.24, P < 0.01) and erythrocyte folate(r(s) - 0.19, P < 0.05). In conclusion, low-dose folic acid supplementation did not influence plasma methionine or plasma vitamin B(12) concentrations. Furthermore, no correlation between plasma methionine concentrations and the blood folate and vitamin B(12) status was shown.
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