The Perceived Likelihood of Outcome of Critical Care Patients and Its Impact on Triage Decisions: A Case-Based Survey of Intensivists and Internists in a Canadian,Quaternary Care Hospital Network

Introduction

There is high variability amongst physicians’ assessments of appropriate ICU admissions, which may be based on potential assessments of benefit. We aimed to examine whether opinions over benefit of ICU admissions of critically ill medical inpatients differed based on physician specialty, namely intensivists and internists.

Materials and Methods

We carried out an anonymous, web-based questionnaire survey containing 5 typical ICU cases to all ICU physicians regardless of their base specialty as well as to all internists in 3 large teaching hospitals. For each case, we asked the participants to determine if the patient was an appropriate ICU admission and to assess different parameters (e.g. baseline function, likelihood of survival to ICU discharge, etc.). Agreement was measured using kappa values.

Results

21 intensivists and 22 internists filled out the survey (response rate = 87.5% and 35% respectively). Predictions of likelihood of survival to ICU admission, hospital discharge and return to baseline were not significantly different between the two groups. However, agreement between individuals within each group was only slight to fair (kappa range = 0.09–0.22). There was no statistically significant difference in predicting ICU survival and prediction of survival to hospital discharge between both groups. The accuracy with which physicians predicted actual outcomes ranged between 35% and 100% and did not significantly differ between the two groups. A greater proportion of internists favoured non resuscitative measures (24.6% of intensivists and 46.9% internists [p = 0.002]).

Conclusion

In a case-based survey, physician specialty base did not affect assessments of ICU admission benefit or accuracy in outcome prediction, but resulted in a statistically significant difference in level of care assignments. Of note, significant disagreement amongst individuals in each group was found.     

Simulium spp. control program in Rio Grande do Sul, Brazil

Insects of the Simuliidae family have been the object of control in Rio Grande do Sul since the 70s. Their constant attacks became a social-economical problem as well as a problem of Public Health, with serious consequences to men and to the economy of the areas in which the insects develop. At first, the control was done with a chemical larvicide Themephos ABATE 500 E, but an imperfect measuring of outflow to determine the quantity of the product made Simulium spp. resistant to it. From 1983 on, following a study of a new method for the outflow measuring, we started to use a biological larvicide Bacillus thuringiensis serovar israelensis based. The biological control uses the new method in 36.4% of the state area, assisting about 3,500,000 inhabitants.     

Resource cost comparison of implant-based breast reconstruction versus TRAM flap breast reconstruction

Relatively little has been published to date comparing the resource costs of transverse rectus abdominis musculocutaneous (TRAM) flap and prosthetic breast reconstruction. The data that have been published reflect the experience at just one medical center with a previously known clear preference for autologous breast reconstruction. The goal of this study was to compare the resource costs of TRAM flap and prosthetic reconstruction in an institution where both procedures continue to be performed using modern techniques and at a relatively equivalent frequency. All available medical records were reviewed for patients who had completed their breast reconstruction between 1987 and 1997. Records of patients who had undergone TRAM flap or prosthetic reconstruction were reviewed to compare resource costs, including hospital stay, operating room time, anesthesia time, prosthetic devices, and physician's fees. Of 835 patients reviewed who had completed breast reconstruction, a total of 140 suitable patients were identified who had all the necessary financial information available. The patient population comprised 64 patients who received TRAM flaps and 76 patients who had undergone prosthetic reconstruction. The length of stay for the TRAM flap group, including all subsequent admissions for each patient, ranged from 2 to 24 days (mean, 6.25 days), and that for the prosthetic reconstruction group ranged from 0 to 20 days (mean, 4.36 days). Operating room time for the complete multistage reconstructive process for a TRAM flap ranged from 5 hours, 20 minutes to 12 hours, 25 minutes (mean, 7 hours, 34 minutes); with implant-based reconstruction, operating time ranged from 1 hour, 45 minutes to 8 hours, 56 minutes (mean, 4 hours, 6 minutes). With prostheses costing from $600 to $1200, a surgeon's fee of $160/hour, and an assistant's fee of $45/hour, the average cost of TRAM flap reconstructions was $19,607 (range, $11,948 to $49,402), compared with $15,497 for prosthetic reconstructions (range, $6422 to $40,015). The results were statistically significant (p < 0.001). Several factors weigh into the decision as to which reconstructive operation best suits the patient's needs. These factors include surgical risk, potential morbidity, and aesthetic results. On the basis of this review of autologous and prosthetic breast reconstruction in an institution where both are performed frequently, during a 10-year period with a mean time elapsed since reconstruction of 7.45 years, prosthetic reconstruction was significantly less expensive.     

Insect epidermis: polarity patterns after grafting result from divergent cell adhesions between host and graft tissue

Insect epidermal cells display planar polarity (i.e. polarity in the plane of the cell sheet) by secreting oriented cuticular denticles and bristles before each moult. We investigate how cell polarities in an abdominal segment are uniformly oriented towards the posterior of the animal. Recently we have shown for the cotton bug Dysdercus that, in 180 degrees-rotated grafts pretreated with colchicine, graft cells tend to adopt the orientation prevailing in surrounding host cells via an intermediate stage with outward oriented denticles (Nübler-Jung and Grau, 1987). Here we show that, in untreated grafts that were transposed along the anteroposterior segment axis, the denticles also always tend to point outwards. This independence of the polarity pattern from the direction of transposition is compatible neither with a gradient model for polarity control, nor with the assumption that epidermal cells orient according to the local sequence of distinctly differentiated cells. Instead we found that outward orientation of graft denticles correlates with an elongation of epidermal cells along a host-graft border with divergent cell adhesiveness. We therefore propose that outward orientation in a graft results from a combination of two factors: epidermal cells stretch along an interface with divergent cell adhesiveness, and they form a denticle perpendicular to their long axis. By analogy, the normal anteroposterior orientation of denticles in a segment may result because epidermal cells tend to elongate parallel to the segment boundary and to form denticles perpendicular to this mediolateral cell elongation, i.e. along the anteroposterior segment axis.     

Specific cleavage of beta-LPH and ACTH by tonin: release of an opiate-like peptide beta-LPH (61-78).

Tonin, a rat enzyme capable of cleaving angiotensinogen, the tetradecapeptide renin substrate and angiotensin I directly to antiotensin II is also shown to cleave beta-lipotropin into beta-LPH 1–50, 1–51, 51–60, 52–60, 61–78 and 79–91, thereby selectively releasing the opiate-like segment beta-LPH 61–78. Its action on ACTH was similar, releasing ACTH 1–8, 1–7, 3–8, 3–7 and 9–39. In both situations the cleavages are of a selective tryptic-chymotryptic type at specific arginine, phenylalanine residues. Comparison of the tonin cleavage with those of trypsin, trypsin in combination with citraconylation of the lysine residues of beta-LPH is made. The data presented show that tonin does not cleave Met-enkephalin and can be used as an enzyme to study the presence of endorphin-like sequences in polypeptides.