BackgroundThe demand for specialized medical services such as critical care often exceeds availability, thus rationing of intensive care unit (ICU) beds commonly leads to difficult triage decisions. Many factors can play a role in the decision to admit a patient to the ICU, including severity of illness and the need for specific treatments limited to these units. Although triage decisions would be based solely on patient and institutional level factors, it is likely that intensivists make different decisions when there are fewer ICU beds available. The objective of this study is to evaluate the characteristics of patients referred for ICU admission during times of limited beds availability.MethodsA single center, prospective, observational study was conducted among consecutive patients in whom an evaluation for ICU admission was requested during times of ICU overcrowding, which comprised the months of April and May 2014.ResultsA total of 95 patients were evaluated for possible ICU admission during the study period. Their mean APACHE-II score was 16.8 (median 16, range 3 - 36). Sixty-four patients (67.4%) were accepted to ICU, 18 patients (18.9%) were triaged to SDU, and 13 patients (13.7%) were admitted to hospital wards. ICU had no beds available 24 times (39.3%) during the study period, and in 39 opportunities (63.9%) only one bed was available. Twenty-four patients (25.3%) were evaluated when there were no available beds, and eight of those patients (33%) were admitted to ICU. A total of 17 patients (17.9%) died in the hospital, and 15 (23.4%) expired in ICU.ConclusionICU beds are a scarce resource for which demand periodically exceeds supply, raising concerns about mechanisms for resource allocation during times of limited beds availability. At our institution, triage decisions were not related to the number of available beds in ICU, age, or gender. A linear correlation was observed between severity of illness, expressed by APACHE-II scores, and the likelihood of being admitted to ICU. Alternative locations outside the ICU in which care for critically ill patients could be delivered should be considered during times of extreme ICU-bed shortage.
Early cancer detection by cell-free DNA faces multiple challenges: low fraction of tumor cell-free DNA, molecular heterogeneity of cancer, and sample sizes that are not sufficient to reflect diverse patient populations. Here, we develop a cancer detection approach to address these challenges. It consists of an assay, cfMethyl-Seq, for cost-effective sequencing of the cell-free DNA methylome (with > 12-fold enrichment over whole genome bisulfite sequencing in CpG islands), and a computational method to extract methylation information and diagnose patients. Applying our approach to 408 colon, liver, lung, and stomach cancer patients and controls, at 97.9% specificity we achieve 80.7% and 74.5% sensitivity in detecting all-stage and early-stage cancer, and 89.1% and 85.0% accuracy for locating tissue-of-origin of all-stage and early-stage cancer, respectively. Our approach cost-effectively retains methylome profiles of cancer abnormalities, allowing us to learn new features and expand to other cancer types as training cohorts grow.
Background and Aims: The sensitivity of current surveillance methods for detecting early-stage hepatocellular carcinoma (HCC) is suboptimal. Extracellular vesicles (EVs) are promising circulating biomarkers for early cancer detection. In this study, we aim to develop an HCC EV-based surface protein assay for early detection of HCC.Approach and Results: Tissue microarray was used to evaluate four potential HCC-associated protein markers. An HCC EV surface protein assay, composed of covalent chemistry-mediated HCC EV purification and real-time immuno-polymerase chain reaction readouts, was developed and optimized for quantifying subpopulations of EVs. An HCC EV ECG score, calculated from the readouts of three HCC EV subpopulations (EpCAM + CD63 + , CD147 + CD63 + , and GPC3 + CD63 + HCC EVs), was established for detecting early-stage HCC. A phase 2 biomarker study was conducted to evaluate the performance of ECG score in a training cohort (n = 106) and an independent validation cohort (n = 72). Overall, 99.7% of tissue microarray stained positive for at least one of the four HCC-associated protein markers (EpCAM, CD147, GPC3, and ASGPR1) that were subsequently validated in HCC EVs. In the training cohort, HCC EV ECG score demonstrated an area under the receiver operating curve (AUROC) of 0.95 (95% confidence interval [CI], 0.90-0.99) for distinguishing early-stage HCC from cirrhosis with a sensitivity of 91% and a specificity of 90%. The AUROCs of the HCC EV ECG score remained excellent in the validation cohort (0.93; 95% CI, 0.87-0.99) and in the subgroups by etiology (viral: 0.95; 95% CI, 0.90--1.00; nonviral: 0.94; 95% CI, 0.88-0.99). Conclusion: HCC EV ECG score demonstrated great potential for detecting early-stage HCC. It could augment current surveillance methods and improve patients' outcomes.
Drug use and abuse continue to be a large public health concern worldwide. Over the past decade, novel or atypical drugs have emerged and become increasingly popular. In the recent past, compounds similar to tetrahydrocannabinoid (THC), the active ingredient of marijuana, have been synthetically produced and offered commercially as legal substances. Since the initial communications of their abuse in 2008, few case reports have been published illustrating the misuse of these substances with signs and symptoms of intoxication. Even though synthetic cannabinoids have been restricted, they are still readily available across USA and their use has been dramatically increasing, with a concomitant increment in reports to poison control centers and emergency department (ED) visits. We describe a case of acute hypoxemic/hypercapnic respiratory failure as a consequence of acute congestive heart failure (CHF) developed from myocardial stunning resulting from a non-ST-segment elevation myocardial infarction (MI) following the consumption of synthetic cannabinoids.
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