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Background Following the publication of 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic.1 Gaps in prior pandemic planning were identified and require modification in the midst of ongoing surge throughout the world. Methods The Task Force for Mass Critical Care (TFMCC) adopted a modified version of established rapid guideline methodologies from the World Health Organization2 and the Guidelines International Network-McMaster Guideline Development Checklist.3 With a consensus development process incorporating expert opinion to define important questions and extract evidence, TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, “gray” evidence from lay media sources, and anecdotal experiential evidence. Results Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. Intensive care unit (ICU) surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and avoid crisis triage, with early transfer strategies to further load-balance care. We suggest intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in intensive care units (ICUs). Conclusions A subcommittee from the Task Force for Mass Critical Care offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands from COVID-19.

The prevalence of mental health disorders is higher among justice-involved youth than youth in the general population. Despite mental health being a pressing contemporary issue in the juvenile justice system, fewer than half of the states in the United States mandate the use of a mental health screening for youth in the juvenile justice system. The need to utilize a mental health screening tool in all 50 states should be a national priority. The Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) is the recommended screening tool that should be adopted nationally. Currently, 21 of the 24 states that mandate the use of a screening tool utilize MAYSI-2. Furthermore, it is recognized as having the most empirical evidence as an instrument at the juvenile justice system’s entry and transitional points.

Background Early in the COVID-19 pandemic, there was serious concern that the United States (US) would encounter a short fall of mechanical ventilators. In response, the US government, utilizing the Defense Production Act ordered the development of 200,000 ventilators from 11 different manufacturers. These ventilators have different capabilities and it is not evident whether all are able to support COVID-19 patients. Research question Evaluate ventilator requirements for affected COVID-19 patients, assess the clinical performance of current SNS ventilators employed during the pandemic, and finally compare ordered ventilators functionality based on COVID-19 patient needs. Study design and methods Current published literature, publicly available documents, and lay press articles were reviewed by a diverse team of disaster experts. Data was assembled into tabular format which formed the basis for analysis and future recommendations. Results COVID-19 patients often develop severe hypoxemic acute respiratory failure and ARDS requiring high levels of ventilator support. Current SNS ventilators were unable to fully support all COVID-19 patients, and only about half of newly ordered ventilators have the capacity to support the most severely affected patients; ventilators with less capacity for providing high level support are still of significant value in caring for many patients. Interpretation Current SNS ventilators and those on order are capable of supporting most but not all COVID-19 patients. Technologic, logistic, and educational challenges encountered from current SNS ventilators are summarized, with potential next generation SNS ventilator updates offered. Clinical trial registration N/A.

Critical drug shortages have been widely documented during the coronavirus disease 2019 (COVID-19) pandemic, particularly for IV sedatives used to facilitate mechanical ventilation. Surges in volume of patients requiring mechanical ventilation coupled with prolonged ventilator days and the high sedative dosing requirements observed quickly led to the depletion of "just-in-time" inventories typically maintained by institutions. This manuscript describes drug shortages in the context of global, manufacturing, regional and institutional perspectives in times of a worldwide crisis such as a pandemic. We describe etiologic factors that lead to drug shortages including issues related to supply (eg, manufacturing difficulties, supply chain breakdowns) and variables that influence demand (eg, volatile prescribing practices, anecdotal or low-level data, hoarding). In addition, we describe methods to mitigate drug shortages as well as conservation strategies for sedatives, analgesics and neuromuscular blockers that could readily be applied at the bedside. The COVID-19 pandemic has accentuated the need for a coordinated, multi-pronged approach to optimize medication availability as individual or unilateral efforts are unlikely to be successful.

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

El objetivo de este estudio retrospectivo fue describir los resultados de aislados bacterianos y determinar los factores de riesgo involucrados en la presentación de bacteriuria en gatos con enfermedad del tracto urinario inferior (FLUTD). Se recolectaron 102 historias clínicas de pacientes felinos a los cuales se les realizó análisis de orina y urocultivo. Se consideraron las variables edad, sexo, estado reproductivo, raza, peso, estación del año, color de orina, olor de orina, densidad urinaria, pH, glucosa, proteínas, sangre, leucocitos, eritrocitos, cristales y tipo de cristales. En el 60.8% (62/102) de las muestras se llegó a aislar bacterias en orina, entre ellas E. coli 40.3% (25/62), Klebsiella sp 12.9% (8/62), Staphylococcus sp 12.9% (8/62), Proteus sp 8.1% (5/62), Enterobacter sp 8.1% (5/62) y Staphylococcus epidermidis 6.4% (4/62). La edad, densidad urinaria y presencia de sangre fue estadísticamente significativa. Además, se determinó que, la densidad urinaria, el color rojo de la orina, la presencia de leucocitos y de cristales representan factores de riesgo (p

Improving the provision of supportive care for patients with Ebola is an important quality improvement initiative. We designed a simulated Ebola Treatment Unit (ETU) to assess performance and safety of healthcare workers (HCWs) performing tasks wearing personal protective equipment (PPE) in hot (35 °C, 60% relative humidity) or thermo-neutral (20 °C, 20% relative humidity) conditions. In this pilot phase to determine the feasibility of study procedures, HCWs in PPE were non-randomly allocated to hot or thermo-neutral conditions to perform peripheral intravenous (PIV) and midline catheter (MLC) insertion and endotracheal intubation (ETI) on mannequins. Eighteen HCWs (13 physicians, 4 nurses, 1 nurse practitioner, 2 with prior ETU experience, 10 in hot conditions) spent 69 (10) (mean (SD)) minutes in the simulated ETU. Mean (SD) task completion times were 16 (6) min for PIV insertion, 33 (5) min for MLC insertion, and 16 (8) min for ETI. Satisfactory task completion was numerically higher for physicians vs. nurses. Participants’ blood pressure was similar, but heart rate was higher (p = 0.0005) post-simulation vs. baseline. Participants had a median (range) of 2.0 (0.0–10.0) minor PPE breaches, 2.0 (0.0–6.0) near-miss incidents, and 2.0 (0.0–6.0) health symptoms and concerns. There were eight health-assessment triggers in five participants, of whom four were in hot conditions. We terminated the simulation of two participants in hot conditions due to thermal discomfort. In summary, study tasks were suitable for physician participants, but they require redesign to match nurses’ expertise for the subsequent randomized phase of the study. One-quarter of participants had a health-assessment trigger. This research model may be useful in future training and research regarding clinical care for patients with highly infectious pathogens in austere settings.

Introduction Alopecia areata (AA) is an autoimmune disorder causing sudden, non-scarring hair loss. There are currently no drugs approved for AA treatment. This study assessed prevalence of comorbidities, treatments, and healthcare costs and resource utilization among patients with AA in the USA. Methods Patients diagnosed with AA between January 2011 and December 2018 were identified in IBM MarketScan® Research Databases. Eligible patients had no other hair loss-related disorders and were continuously enrolled with medical and pharmacy benefits at least 12 months before and after AA diagnosis. Descriptive statistics were used to summarize comorbid conditions, treatments related to AA or other autoimmune/inflammatory conditions, and all-cause and AA-specific healthcare costs and resource utilization identified from claims data. Results A total of 68,121 patients with AA were identified. Mean (SD) age was 40.3 (17.8) years and 61.0% were female. The most common comorbidities included hyperlipidemia (22.4%), hypertension (21.8%), thyroid disorders (13.1%), contact dermatitis or eczema (10.8%), depression (9.5%), and anxiety (8.4%). Comorbid autoimmune diseases included atopic dermatitis (2.8%), psoriasis (2.1%), chronic urticaria (1.5%), and rheumatoid arthritis (1.1%). During the 12-month follow-up period, 37,995 patients (55.8%) were prescribed treatment for their AA or other comorbid autoimmune/inflammatory disease; 44.9% of treated patients were prescribed therapy within 7 days of AA diagnosis. Of patients receiving treatment, 80.3% received topical steroids and 30.0% received oral steroids. Mean (SD) total healthcare costs were $11,241.21 ($43,839.69) for all-causes and $419.12 ($1534.99) for AA. AA-related expenses were driven by outpatient and prescription costs. Conclusion Patients with AA have a high comorbidity burden and lack of treatment. Current AA treatments, including systemic therapies other than oral steroids, were not frequently utilized in this study population. Healthcare costs incurred by patients with AA went beyond AA-related expenses. Longitudinal data are needed to better understand treatment trajectories and the disease burden in patients with AA. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01845-0.

Annular pancreas is defined by a ring of pancreatic tissue encircling the descending portion of the duodenum. It is exceptionally rare in adults and commonly diagnosed during the investigation of symptoms arising due to its complications. Treatment usually involves the surgical correction with a duodenoduodenostomy, gastrojejunostomy or duodenojejunostomy. We discuss the case of a 66-year-old male patient who presented with symptoms of gastric outlet obstruction and was found to have an annular pancreas encircling the pylorus and the first and second portions of the duodenum and was treated by performing a gastrojejunostomy. Upper gastrointestinal series, computerized tomography (CT) scans, and magnetic resonance cholangeopancreatographys can all be used for preoperative diagnosis; however, endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic modality of choice. Nonetheless, many patients may only be diagnosed intraoperatively, especially those who cannot undergo an ERCP due to stenosis proximal to the duodenum or patients in whom the annulus may not be visible on CT scan.

Mechanical ventilation in helicopter emergency medical service (HEMS) environments is a procedure which carries a significant risk of complications. Limited data on the quality and performance of mechanical ventilation in HEMS are available in the literature.We conducted an international survey to evaluate mechanical ventilation infrastructure in HEMS and collect data of transported ventilated patients. From June 20-22, 2019, the participating HEMS bases were asked to provide data via a web-based platform. Vital parameters and ventilation settings of the patients at first patient contact and at handover were compared using non-parametric statistical tests.Out of 215 invited HEMS bases, 53 responded. Respondents were from Germany, Denmark, United Kingdom, Luxembourg, Austria and Switzerland. Of the HEMS bases, all teams were physician staffed, mainly anesthesiologists (79%), the majority were board certified (92.5%) and trained in intensive care medicine (89%) and had a median (range) experience in HEMS of 9 (0-25) years. HEMS may provide a high level of expertise in mechanical ventilation whereas the majority of ventilators are able to provide pressure controlled ventilation and continuous positive airway pressure modes (77%). Data of 30 ventilated patients with a median (range) age of 54 (21-100) years and 53% male gender were analyzed. Of these, 24 were primary missions and 6 interfacility transports. At handover, oxygen saturation (p 0.01) and positive end-expiratory pressure (p = 0.04) of the patients were significantly higher compared to first patient contact.In this survey, the management of ventilated HEMS-patients was not associated with ventilation related serious adverse events. Patient conditions, training of medical crew and different technical and environmental resources are likely to influence management. Further studies are necessary to assess safety and process quality of mechanical ventilation in HEMS.The survey was prospectively registered at Research Registry ( researchregistry2925 ).

OBJECTIVE: When healthcare systems are overwhelmed, accurate assessments of patients’ predicted mortality risks are needed to ensure effective allocation of scarce resources. Organ dysfunction scores can serve this essential role, but their evaluation in this context has been limited so far. In this study, we sought to assess the performance of three organ dysfunction scores in both critically ill adults and children at clinically-relevant mortality thresholds and timeframes for resource allocation and compare it to two published prioritization schemas. DESIGN, SETTING AND PATIENTS: Retrospective observational cohort study of critically ill patients in three large academic medical centers in the US. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We calculated the daily Sequential Organ Failure Assessment score (SOFA) in adults and the Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score and the Pediatric SOFA (pSOFA) score in children. There were 49,290 adults (11.6% mortality), and 19,983 children (2.5% mortality) included in the analysis. Both the SOFA and pSOFA scores had adequate discrimination across relevant timeframes and adequate distribution across relevant mortality thresholds. Additionally, we found that the only published state prioritization schema that includes pediatric and adult patients had poor alignment of mortality risks, giving adults a systematic advantage over children. CONCLUSIONS: In the largest analysis of organ dysfunction scores in a general population of critically ill adults and children to date, we found that both the SOFA and pSOFA scores had adequate performance across relevant mortality thresholds and timeframes for resource allocation. Published prioritization schemas that include both pediatric and adult patients may put children at a disadvantage. Furthermore, the distribution of patient and mortality risk in the published schemas may not adequately stratify patients for some high-stakes allocation decisions. This information may be useful to bioethicists, healthcare leaders, and policy makers who are developing resource allocation policies for critically ill patients.

BackgroundThe extent to which Point-of-care of ultrasound (POCUS) is used in different European helicopter EMS (HEMS) is unknown. We aimed to study the availability, perception, and future aspects of POCUS in the European HEMS using an online survey.MethodA survey about the use of POCUS in HEMS was conducted by a multinational steering expert committee and was carried out from November 30, 2020 to December 30, 2020 via an online web portal. Invitations for participation were sent via email to the medical directors of the European HEMS organizations including two reminding notes.ResultsDuring the study period, 69 participants from 25 countries and 41 different HEMS providers took part in the survey. 96% (n = 66) completed the survey. POCUS was available in 75% (56% always when needed and 19% occasionally) of the responding HEMS organizations. 17% were planning to establish POCUS in the near future. Responders who provided POCUS used it in approximately 15% of the patients. Participants thought that POCUS is important in both trauma and non-trauma-patients (73%, n = 46). The extended focused assessment sonography for trauma (eFAST) protocol (77%) was the most common protocol used. A POCUS credentialing process including documented examinations was requested in less than one third of the HEMS organizations.ConclusionsThe majority of the HEMS organizations in Europe are able to provide different POCUS protocols in their services. The most used POCUS protocols were eFAST, FATE and RUSH. Despite the enthusiasm for POCUS, comprehensive training and clear credentialing processes are not available in about two thirds of the European HEMS organizations. Due to several limitations of this survey further studies are needed to evaluate POCUS in HEMS.

Purpose: Local and regional policies to guide the allocation of scarce critical care resources have been developed, but the views of prospective users are not understood. We sought to investigate the perspectives of Canadian acute care physicians towards triaging scarce critical care resources in the COVID-19 pandemic. Methods: We rapidly deployed a brief survey to Canadian emergency and critical care physicians in April 2020 to investigate current attitudes towards triaging scarce critical care resources and identify subsequent areas for improvement. Descriptive and between-group analyses along with thematic coding were used.Results: The survey was completed by 261 acute care physicians. Feelings of anxiety related to the pandemic were common (65%), as well as fears of psychological distress if required to triage scarce resources (77%). Only 49% of respondents felt confident in making resource allocation decisions. Both critical care and emergency physicians favored multidisciplinary teams over single physicians to allocate scarce critical care resources. Critical care physicians were supportive of decision making by teams not involved in patient care (3.4/5 vs 2.9/5 p=0.04), whereas emergency physicians preferred to maintain their involvement in such decisions (3.4/5 vs 4.0/5 p=0.007). Free text responses identified five themes for subsequent action including the need for further guidance on existing triage policies, ethical support in decision making, medico-legal protection, additional tools for therapeutic communications, and healthcare provider psychological support. Conclusion: There is an urgent need for collaboration between policymakers and frontline physicians to develop critical care resource triage policies that wholly consider the diversity of provider perspectives across practice environments.

Background Early in a pandemic, outcomes are biased towards patients with shorter durations of critical illness. We describe 60-day outcomes for patients critically ill with confirmed COVID-19 and explore the potential bias in the weekly reported data by ICNARC. Methods First 200 consecutive patients with confirmed COVID-19, admitted for critical care in England, Wales and Northern Ireland, followed-up for a minimum of 60 days from admission. Outcomes included survival and duration of critical care, receipt/duration of organ support in critical care and hospital survival . Results Mean age was 62.6 years, 70.5% were male, 52.0% were white, 39.2% obese and 9.0% had serious comorbidities. Median APACHE II score was 16 (IQR 12, 19). After 60 days, 83 (41.5%) patients had been discharged from hospital, 15 (7.5%) had been discharged from critical care but remained in hospital, 1 (0.5%) was still receiving critical care, 90 (45.0%) had died while receiving critical care and 11 (5.5%) had died in hospital after discharge from critical care. Median duration of critical care was 14.0 days (IQR 6.1, 23.0) for survivors and 10.0 days (IQR 5.0, 16.0) for non-survivors of critical care. Overall, 158 (79.0%) patients received advanced respiratory support for a median of 13 (IQR 8, 20) calendar days. Compared with weekly reports during the pandemic, critical care mortality started higher than but then decreased below that of the first 200 consecutive patients. Duration of critical care, for both survivors and non-survivors increased over time; however, both were still lower than those for the first 200 consecutive patients. Receipt and duration of organ support increased to values similar to those for the first 200 consecutive patients. Conclusion COVID-19 in critical care has high mortality and places a large burden on resources. Analysis of preliminary data with limited follow-up should be interpreted with caution, particularly for future planning in a pandemic.

Objective Helicopter emergency medical services play an important role in the prehospital care of critically ill and injured patients, providing enhanced interventions and direct transfer to specialist centers. Essex & Herts Air Ambulance (EHAAT) delivers prehospital critical care to patients in Essex, Hertfordshire, and the surrounding areas. Historically, EHAAT's resources have not operated during the night. This study aimed to ascertain demand for prehospital critical care in Essex and Hertfordshire during night hours. Methods A prospective observational design was used. Data were collected by 11 critical care paramedics during night shifts on a critical care desk using an online survey. Details were recorded for incidents in Essex and Hertfordshire between 21:00 and 07:00 deemed appropriate for a prehospital critical care response. Results A total of 108 incidents were recorded across 52 nights, equating to an average of 2.08 incidents per night. For 52 incidents, there was no critical care resource available to attend. The majority of incidents fell in closer proximity to EHAAT's North Weald base than its Earls Colne base. Conclusion The findings suggest a potential need for prehospital critical care during night hours in Essex and Hertfordshire and support the operation of a resource from EHAAT's North Weald base.

Supplemental Digital Content is available in the text., Objectives: Coronavirus disease 2019 patients are currently overwhelming the world’s healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. Data Sources: PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. Study Selection: Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. Data Extraction: References and data were based on relevance and author consensus. Data Synthesis: We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. “First come, first served” is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. Conclusions: Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.

BackgroundThis study aimed to determine the rate of scalpel cricothyroidotomy conducted by a physician–paramedic prehospital trauma service over 20 years and to identify indications for, and factors associated with the intervention.MethodsA retrospective observational study was conducted from 1 January 2000 to 31 December 2019 using clinical database records. This study was conducted in a physician–paramedic prehospital trauma service, serving a predominantly urban population of approximately 10 million in an area of approximately 2500 km2.ResultsOver 20 years, 37 725 patients were attended by the service, and 72 patients received a scalpel cricothyroidotomy. An immediate ‘primary’ cricothyroidotomy was performed in 17 patients (23.6%), and ‘rescue’ cricothyroidotomies were performed in 55 patients (76.4%). Forty-one patients (56.9%) were already in traumatic cardiac arrest during cricothyroidotomy. Thirty-two patients (44.4%) died on scene, and 32 (44.4%) subsequently died in hospital. Five patients (6.9%) survived to hospital discharge, and three patients (4.2%) were lost to follow-up. The most common indication for primary cricothyroidotomy was mechanical entrapment of patients (n=5, 29.4%). Difficult laryngoscopy, predominantly due to airway soiling with blood (n=15, 27.3%) was the most common indication for rescue cricothyroidotomy. The procedure was successful in 97% of cases. During the study period, 6570 prehospital emergency anaesthetics were conducted, of which 30 underwent rescue cricothyroidotomy after failed tracheal intubation (0.46%, 95% CI 0.31% to 0.65%).ConclusionsThis study identifies a number of indications leading to scalpel cricothyroidotomy both as a primary procedure or after failed intubation. The main indication for scalpel cricothyroidotomy in our service was as a rescue airway for failed laryngoscopy due to a large volume of blood in the airway. Despite high levels of procedural success, 56.9% of patients were already in traumatic cardiac arrest during cricothyroidotomy, and overall mortality in patients with trauma receiving this procedure was 88.9% in our service.

Given the rapidly changing nature of COVID-19, clinicians and policy makers require urgent review and summary of the literature, and synthesis of evidence-based guidelines to inform practice. The WHO advocates for rapid reviews in these circumstances. The purpose of this rapid guideline is to provide recommendations on the organizational management of intensive care units caring for patients with COVID-19 including: planning a crisis surge response; crisis surge response strategies; triage, supporting families, and staff. Electronic supplementary material The online version of this article (10.1007/s00134-020-06092-5) contains supplementary material, which is available to authorized users.

A global health emergency has been declared by the World Health Organization as the 2019-nCoV outbreak spreads across the world, with confirmed patients in Canada. Patients infected with 2019-nCoV are at risk for developing respiratory failure and requiring admission to critical care units. While providing optimal treatment for these patients, careful execution of infection control measures is necessary to prevent nosocomial transmission to other patients and to healthcare workers providing care. Although the exact mechanisms of transmission are currently unclear, human-to-human transmission can occur, and the risk of airborne spread during aerosol-generating medical procedures remains a concern in specific circumstances. This paper summarizes important considerations regarding patient screening, environmental controls, personal protective equipment, resuscitation measures (including intubation), and critical care unit operations planning as we prepare for the possibility of new imported cases or local outbreaks of 2019-nCoV. Although understanding of the 2019-nCoV virus is evolving, lessons learned from prior infectious disease challenges such as Severe Acute Respiratory Syndrome will hopefully improve our state of readiness regardless of the number of cases we eventually manage in Canada.

Brain metastases (BRM) occur frequently in non-small-cell lung cancer (NSCLC) and present a substantial unmet medical need. Previous literature on global BRM prevalence, treatment patterns, costs, and outcomes typically has described a subset of these factors. The primary objective of this systematic literature review was to summarize BRM-related epidemiology, treatment patterns, costs, and survival of patients with NSCLC in the United States, European Union, and Japan. The study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. Literature searches were conducted in PubMed, Ovid MedLine, and Embase to identify studies published between 2003 and 2014. Peer-reviewed, English language, and human observational studies of patients with NSCLC and BRM were identified. Demographic characteristics, treatment patterns, histology subtype, costs, and survival data were extracted into Microsoft Excel and descriptively analyzed using SAS version 9.2 (SAS Institute, Inc). Of 8257 studies, 243 were eligible. Data from 46,422 patients with NSCLC and 27,907 patients with BRM were summarized. Radiation therapy was used by 70.7% (n = 19,736) of the total BRM population, followed by systemic therapy (8.9%, n = 2497), and surgery (6.1%, n = 1690). Reported median survival was 9.78 months ranging from 2.5 to 38 months. Radiation therapy had the best outcome at 10.0 months with 41.6% (n = 101) of the studies reporting the use of stereotactic radiosurgery. Highly variable median survival and treatment patterns were reported between countries. Costs and histology subtype data were not reported for most countries, highlighting the need for additional research to describe the economic burden of BRM and improve the diagnosis, prognosis, and prescription of effective therapies.

Development of pharmacotherapies that promote remyelination are a high priority for multiple sclerosis (MS) due to their potential for neuroprotection and restoration of function through repair of demyelinated lesions. A novel preparation of clean-surfaced, faceted gold nanocrystals demonstrated robust remyelinating activity in response to demyelinating agents in both chronic cuprizone and acute lysolecithin rodent animal models. Furthermore, oral delivery of gold nanocrystals improved motor functions of cuprizone-treated mice in both open field and kinematic gait studies. Gold nanocrystal treatment of oligodendrocyte precursor cells in culture resulted in oligodendrocyte maturation and expression of key myelin differentiation markers. Additional in vitro data demonstrated that these gold nanocrystals act via a novel energy metabolism pathway involving the enhancement of key indicators of aerobic glycolysis. In response to gold nanocrystals, co-cultured central nervous system cells exhibited elevated levels of the redox coenzyme nicotine adenine dinucleotide (NAD+), elevated total ATP levels, elevated extracellular lactate levels, and upregulation of myelin-synthesis related genes, collectively resulting in functional myelin generation. Based on these preclinical studies, clean-surfaced, faceted gold nanocrystals represent a novel remyelinating therapeutic for multiple sclerosis.One Sentence SummaryNanocatalytic activity of clean-surfaced, faceted gold nanocrystals results in robust remyelinating activity in demyelination animal models of multiple sclerosis.

INTRODUCTION: Local and regional policies to guide the allocation of scarce critical care resources have been developed, but the views of prospective users are not understood We sought to investigate the perspectives of acute care physicians towards triaging scarce critical care resources in the COVID-19 pandemic METHODS: We rapidly deployed a brief survey to Canadian emergency and critical care physicians in April 2020 to investigate current attitudes towards triaging scarce critical care resources and identify subsequent areas for improvement Descriptive and between-group analyses along with thematic coding were used RESULTS: The survey was completed by 261 acute care physicians Feelings of anxiety related to the pandemic were common (65%), as well as fears of psychological distress if required to triage scarce resources (77%) Only 49% of respondents felt confident in making resource allocation decisions Both critical care and emergency physicians favored multidisciplinary teams over single physicians to allocate scarce critical care resources Critical care physicians were supportive of decision making by teams not involved in patient care (3 4/5 vs 2 9/5 p=0 04), whereas emergency physicians preferred to maintain their involvement in such decisions (3 4/5 vs 4 0/5 p=0 007) Free text responses identified five themes for subsequent action including the need for further guidance on existing triage policies, ethical support in decision making, medico-legal protection, additional tools for therapeutic communications, and healthcare provider psychological support CONCLUSIONS: There is an urgent need for collaboration between policymakers and frontline physicians to develop critical care resource triage policies that wholly consider the diversity of provider perspectives across practice environments

Objectives Prior studies examining the sensitivity of cranial computed tomography (CT) for the detection of subarachnoid hemorrhage (SAH) have used the final radiology report as the reference standard. However, optimal sensitivity may have been underestimated due to misinterpretation of reportedly normal cranial CTs. This study aims to estimate the incidence of missed CT evidence of SAH among a cohort of patients with aneurysmal SAH (aSAH). Methods We performed a retrospective chart review of emergency department (ED) encounters within an integrated health delivery system between January 2007 and June 2013 to identify patients diagnosed with aSAH. All initial noncontrast CTs from aSAH cases diagnosed by lumbar puncture (LP) and angiography following a reportedly normal noncontrast cranial CT (CT-negative aSAH) were then reviewed in a blinded, independent fashion by two board-certified neuroradiologists to assess for missed evidence of SAH. Reviewers rated the CT studies as having definite evidence of SAH, probable evidence of SAH, or no evidence of SAH. Control patients who underwent a negative evaluation for aSAH based on cranial CT and LP results were also included at random in the imaging review cohort. Results A total of 452 cases of aSAH were identified; 18 (4%) were cases of CT-negative aSAH. Of these, seven (39%) underwent cranial CT within 6 hours of headache onset, and two (11%) had their initial CTs formally interpreted by board-certified neuroradiologists. Blinded independent CT review revealed concordant agreement for either definite or probable evidence of SAH in nine of 18 (50%) cases overall and in five of the seven (71%) CTs performed within 6 hours of headache onset. Inter-rater agreement was 83% for definite SAH and 72% for either probable or definite SAH. Conclusions CT evidence of SAH was frequently present but unrecognized according to the final radiology report in cases of presumed CT-negative aSAH. This finding may help explain some of the discordance between prior studies examining the sensitivity of cranial CT for SAH.

In the twentieth century, rarely have mass casualty events yielded hundreds or thousands of critically ill patients requiring definitive critical care. However, future catastrophic natural disasters, epidemics or pandemics, nuclear device detonations, or large chemical exposures may change usual disaster epidemiology and require a large critical care response. This article reviews the existing state of emergency preparedness for mass critical illness and presents an analysis of limitations to support the suggestions of the Task Force on Mass Casualty Critical Care, which are presented in subsequent articles. Baseline shortages of specialized resources such as critical care staff, medical supplies, and treatment spaces are likely to limit the number of critically ill victims who can receive life-sustaining interventions. The deficiency in critical care surge capacity is exacerbated by lack of a sufficient framework to integrate critical care within the overall institutional response and coordination of critical care across local institutions and broader geographic areas.

Congenital Zika syndrome (CZS) was identified following a large Zika virus (ZIKV) outbreak in Brazil in 2015. Two children with clinical presentations consistent with CZS, ages 7 and 8 years old, are described. Both mothers lived in Cambodia, a region with known ZIKV, during their pregnancies and reported fever and rash in the second trimester. The infants were born with severe microcephaly. Testing for congenital infection at birth and genetic testing were unremarkable. In 2017, serologic testing for both mothers were consistent with prior ZIKV infection. Review of infant neuroimaging demonstrated ventriculomegaly, severe cerebral atrophy, and subcortical calcifications consistent with CZS. Given the maternal symptoms suggesting ZIKV infection during pregnancy and the combination of clinical and radiological features unique to CZS, CZS is strongly suspected in these children, suggesting that CZS occurred before the 2013-2014 French Polynesia outbreak. As such, CZS should be considered in older children with congenital microcephaly of unknown etiology and a history consistent with possible ZIKV exposure.

In the setting of international disaster response, an important challenge is determining when it is appropriate to withdraw deployed assets as the acute disaster response transitions to recovery and rebuilding. We describe our experience with realtime data collection during our medical response to Typhoon Haiyan as a means to guide military aid mission parameters.The operational medical headquarters prospectively developed a database for use in this mission. Mobile medical teams (MMTs) were deployed to provide primary care, and the nurse designated to each MMT was responsible for entering and transmitting data daily to the medical headquarters. Data collected included the MMT location, basic patient demographics, the primary reason for the encounter and any treatment provided. These encounters were then classified as disaster, acute or chronic.Between Nov. 16 and Dec. 16, 2013, medical care was provided to 6596 local nationals; 238 (3.6%) had disaster-related illness or injury, 4321 (65.5%) had acute postdisaster medical conditions and 2037 (30.9%) sought medical care for chronic conditions. Of the 257 patients with traumatic injuries, 28 (11%) had disaster-related injuries and 214 (83%) had acute injuries that occurred postdisaster.The data collected during the mission to the Phillippines was compiled with performance metrics from the other Disaster Assistance Response Team components to help advise the Canadian government regarding mission duration. We recommended that data collection continue on all future missions and be modified to provide further information to larger disaster coordination teams, such as the United Nations Office for the Coordination of Humanitarian Affairs.Dans le domaine de l’intervention internationale en cas de catastrophe, il est souvent difficile de déterminer le moment approprié pour retirer les ressources déployées alors que l’on passe de la première intervention d’urgence à la période de rétablissement et de reconstruction. Nous décrirons ici notre expérience de collecte de données en temps réel durant notre intervention médicale après le typhon Haiyan, dans le but d’orienter les paramètres de mission de l’aide militaire.Le quartier général des opérations médicales avait préparé d’avance la base de données qui a été utilisée lors de cette mission. Des équipes médicales mobiles ont été déployées pour fournir des soins de base, et une infirmière ou un infirmier désigné dans chaque équipe était chargé d’entrer et de transmettre les données quotidiennement au quartier général des opérations médicales. Les données recueillies comprenaient la position de l’équipe médicale mobile, des données démographiques de base sur les patients, la raison première de la rencontre et les traitements fournis. Ces rencontres étaient ensuite classées comme catastrophiques, aiguës ou chroniques.Du 16 novembre au 16 décembre 2013, des soins médicaux ont été prodigués à 6596 Philippins; 238 personnes (3,6 %) avaient des maladies ou des blessures liées au typhon, 4321 personnes (65,5 %) avaient des problèmes médicaux aigus d’après catastrophe et 2037 personnes (30,9 %) avaient besoin de soins pour des affections chroniques. Des 257 patients ayant subi des lésions traumatiques, 28 (11 %) avaient des blessures liées à la catastrophe et 214 (83 %) avaient des blessures aiguës reçues après la catastrophe.Les données recueillies durant la mission aux Philippines ont été compilées avec les indicateurs de rendement des autres composantes de l’équipe d’intervention en cas de catastrophe pour conseiller le gouvernement canadien au sujet de la durée des missions. Nous recommandons que la collecte de données se poursuive durant toutes les missions futures et soit modifiée afin de fournir plus de renseignements aux plus grandes équipes de coordination des interventions en cas de catastrophe, comme le Bureau de la coordination des affaires humanitaires de l’Organisation des Nations Unies.

To provide clinicians with practical considerations for care of children with Ebola virus disease in resource-rich settings.Review of the published medical literature, World Health Organization and government documents, and expert opinion.There are limited data regarding Ebola virus disease in children; however, reported case-fatality proportions in children are high. Ebola virus may affect immune regulation and endothelial function differently in children than adults. Considerations for care of children with Ebola virus disease are presented.Ebola virus disease is a severe multisystem disease with high mortality in children and adults. Hospitals and clinicians must prepare to provide care for patients with Ebola virus disease before such patients present for care, with particular attention to rigorous infection control to limit secondary cases. Although there is no proven specific treatment for Ebola virus disease, meticulous supportive care offers patients the best chance of survival.

Background On a global scale scabies is one of the most common dermatological conditions, imposing a considerable economic burden on individuals, communities and health systems. There is substantial epidemiological evidence that in tropical regions scabies is often causing pyoderma and subsequently serious illness due to invasion by opportunistic bacteria. The health burden due to complicated scabies causing cellulitis, bacteraemia and sepsis, heart and kidney diseases in resource-poor communities is extreme. Co-infections of group A streptococcus (GAS) and scabies mites is a common phenomenon in the tropics. Both pathogens produce multiple complement inhibitors to overcome the host innate defence. We investigated the relative role of classical (CP), lectin (LP) and alternative pathways (AP) towards a pyodermic GAS isolate 88/30 in the presence of a scabies mite complement inhibitor, SMSB4. Methodology/Principal findings Opsonophagocytosis assays in fresh blood showed baseline immunity towards GAS. The role of innate immunity was investigated by deposition of the first complement components of each pathway, specifically C1q, FB and MBL from normal human serum on GAS. C1q deposition was the highest followed by FB deposition while MBL deposition was undetectable, suggesting that CP and AP may be mainly activated by GAS. We confirmed this result using sera depleted of either C1q or FB, and serum deficient in MBL. Recombinant SMSB4 was produced and purified from Pichia pastoris. SMSB4 reduced the baseline immunity against GAS by decreasing the formation of CP- and AP-C3 convertases, subsequently affecting opsonisation and the release of anaphylatoxin. Conclusions/Significance Our results indicate that the complement-inhibitory function of SMSB4 promotes the survival of GAS in vitro and inferably in the microenvironment of the mite-infested skin. Understanding the tripartite interactions between host, parasite and microbial pathogens at a molecular level may serve as a basis to develop improved intervention strategies targeting scabies and associated bacterial infections., Author summary The molecular mechanisms that underpin the link between scabies and bacterial pathogens were unknown. We proposed that scabies mites play a role in the establishment, proliferation and transmission of opportunistic pathogens. We investigated here the synergy between mites and one of the most recognised mite associated pathogens, Streptococcus pyogenes. As part of the innate immune response mammals have a pre-programmed ability to recognise and immediately act against substances derived from fungal and bacterial microorganisms. This is mediated through a sequential biochemical cascade involving over 30 different proteins (complement system) which as a result of signal amplification triggers a rapid killing response. The complement cascade produces peptides that attract immune cells, increases vascular permeability, coats (opsonises) the surfaces of a pathogen, marking it for destruction, and directly disrupts foreign plasma membranes. To prevent complement mediated damage of their gut cells, scabies mites secrete several classes of complement inhibiting proteins into the mite gut and excrete them into the epidermal mite burrows. Furthermore, these inhibitors also provide protection for S. pyogenes. We verified here specifically the impact of the mite complement inhibitor SMSB4, to identify the molecular mechanisms behind the long recognised tendency of S. pyogenes to infect mite-induced skin lesions.

BACKGROUND Natural disasters, industrial accidents, terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government officials. The field of disaster medicine does not have the required body of evidence needed to undergo a traditional guideline development process. In result, consensus statement-development methodology was used to capture the highest-caliber expert opinion in a structured, scientific approach. METHODS Task Force Executive Committee members identified core topic areas regarding the provision of care to critically ill or injured patients from pandemics or disasters and subsequently assembled an international panel for each identified area. International disaster medicine experts were brought together to identify key questions (in a population, intervention, comparator, outcome [PICO]-based format) within each of the core topic areas. Comprehensive literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions that are presented in this supplement using a modified Delphi process. RESULTS A total of 315 suggestions were drafted across all topic groups. After two rounds of a Delphi consensus-development process, 267 suggestions were chosen by the panel to include in the document and published in a total of 12 manuscripts composing the core chapters of this supplement. Draft manuscripts were prepared by the topic editor and members of the working groups for each of the topics, producing a total of 11 papers. Once the preliminary drafts were received, the Executive Committee (Writing Committee) then met to review, edit, and promote alignment of all of the primary drafts of the manuscripts prepared by the topic editors and their groups. The topic editors then revised their manuscripts based on the Executive Committee's edits and comments. The Writing Committee subsequently reviewed the updated drafts and prepared the final manuscripts for submission to the Guidelines Oversight Committee (GOC). The manuscripts subsequently underwent review by the GOC, including external review as well as peer review for the journal publication. The Writing Committee received the feedback from the reviewers and modified the manuscripts as required. CONCLUSIONS Based on a robust and transparent process, this project used rigorous methodology to produce clinically relevant, trustworthy consensus statements, with the aim to provide needed guidance on treatment and procedures for practitioners, hospital administrators, and public health and government officials when addressing the care of critically ill or injured patients in disasters or pandemics.

Bioterrorism is not only a reality of the times in which we live but bioweapons have been used for centuries. Critical care physicians play a major role in the recognition of and response to a bioterrorism attack. Critical care clinicians must be familiar with the diagnosis and management of the most likely bioterrorism agents, and also be adequately prepared to manage a mass casualty situation. This article reviews the epidemiology, diagnosis, and treatment of the most likely agents of biowarfare and bioterrorism.

ObjectivesTo assess local, state, federal, and global pandemic influenza preparedness by identifying pandemic plans at the local, state, federal, and global levels, and to identify any information technology (IT) systems in these plans to support critical care triage during an influenza pandemic in the Canadian province of Ontario.MethodsThe authors used advanced MEDLINE and Google search strategies and conducted a comprehensive review of key pandemic influenza Web sites. Descriptive data extraction and analysis for IT systems were conducted on all of the included pandemic plans.ResultsA total of 155 pandemic influenza plans were reviewed: 29 local, 62 state, 63 federal, and 1 global. We found 70 plans that examined IT systems (10 local, 33 state, 26 federal, 1 global), and 85 that did not (19 local, 29 state, 37 federal). Of the 70 plans, 64 described surveillance systems (10 local, 32 state, 21 federal, 1 global), 2 described patient data collection systems (1 state, 1 federal); 4 described other types of IT systems (4 federal), and none were intended for triage.ConclusionsAlthough several pandemic plans have been drafted, the majority are high-level general documents that do not describe IT systems. The plans that discuss IT systems focus strongly on surveillance, which fails to recognize the needs of a health care system responding to an influenza pandemic. The best examples of the types of IT systems to guide decision making during a pandemic were found in the Kansas and the Czech Republic pandemic plans, because these systems were designed to collect both patient and surveillance data. Although Ontario has yet to develop such an IT system, several IT systems are in place that could be leveraged to support critical care triage and medical response during an influenza pandemic. (Disaster Med Public Health Preparedness. 2013;7:287-291)

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.

Purpose. The objectives were to describe the management and outcomes of acute leukemia (AL) patients admitted to the ICU and to identify predictors of ICU mortality.Methods. Data was retrospectively collected from the medical records of all patients with AML or ALL admitted to the Mount Sinai Hospital ICU from August 2009 to December 2012.Results. 151 AL patients (117 AML, 34 ALL) were admitted to the ICU. Mean age was 54 (SD 15) years, median APACHE II score was 27 (IQR 22–33), and 50% were female. While in ICU, 128 (85%) patients had sepsis and 56 (37%) had ARDS. The majority of patients required invasive organ support: 94 (62%) required mechanical ventilation while 23 (15%) received renal replacement therapy. Multivariable analysis identified SOFA score (OR 1.18, 95% CI 1.01–1.38) and invasive ventilation (OR 9.64, 95% CI 3.39–27.4) as independent predictors of ICU mortality. Ninety-four (62%) patients survived to ICU discharge. Only 39% of these 94 patients discharged were alive 12 months after ICU admission.Conclusions. AL patients admitted to the ICU had a 62% ICU survival rate; yet only 25% of cohort patients were alive 12 months after ICU admission. Higher admission SOFA scores and invasive ventilation are independently associated with a greater risk of dying in the ICU.

Despite the widespread popularity of tattoos in the U.S. and worldwide, little consideration has been given to the occupational risk factors that tattoo artists face. Tattoo artists are exposed to many of the same risk factors faced by occupations such as dentistry and cosmetology, including prolonged static work postures and sustained gripping of hand held tools. However, no research has evaluated the extent to which the tattooing profession is adversely affected by its occupational demands. Utilizing a survey of tattoo artists, this research sought to benchmark the prevalence of symptoms commonly associated with the development of musculoskeletal disorders. The survey results revealed that tattoo artists experience high levels of discomfort in the lower back, neck, shoulders, and upper extremities and that these levels significantly exceed discomfort reported in professions that expose workers to similar ergonomic risk factors.

The bakers' yeast Saccharomyces cerevisiae utilizes a high affinity Ca(2+) influx system (HACS) to survive assaults by mating pheromones, tunicamycin, and azole-class antifungal agents. HACS consists of two known subunits, Cch1 and Mid1, that are homologous and analogous to the catalytic α-subunits and regulatory α2δ-subunits of mammalian voltage-gated calcium channels, respectively. To search for additional subunits and regulators of HACS, a collection of gene knock-out mutants was screened for abnormal uptake of Ca(2+) after exposure to mating pheromone or to tunicamycin. The screen revealed that Ecm7 is required for HACS function in most conditions. Cycloheximide chase experiments showed that Ecm7 was stabilized by Mid1, and Mid1 was stabilized by Cch1 in non-signaling conditions, suggesting they all interact. Ecm7 is a member of the PMP-22/EMP/MP20/Claudin superfamily of transmembrane proteins that includes γ-subunits of voltage-gated calcium channels. Eleven additional members of this superfamily were identified in yeast, but none was required for HACS activity in response to the stimuli. Remarkably, many dozens of genes involved in vesicle-mediated trafficking and protein secretion were required to prevent spontaneous activation of HACS. Taken together, the findings suggest that HACS and calcineurin monitor performance of the membrane trafficking system in yeasts and coordinate compensatory processes. Conservation of this quality control system in Candida glabrata suggests that many pathogenic species of fungi may utilize HACS and calcineurin to resist azoles and other compounds that target membrane biosynthesis.

We have previously observed that stepwise replacement of amino acid residues in the nascent base-pair binding pocket of RB69 DNA polymerase (RB69pol) with Ala or Gly expanded the space in this pocket, resulting in a progressive increase in misincorporation. However, in vivo results with similar RB69pol nascent base-pair binding pocket mutants showed that mutation rates, as determined by the T4 phage rI forward assay and rII reversion assay, were significantly lower for the RB69pol S565G/Y567A double mutant than for the Y567A single mutant, the opposite of what we would have predicted. To investigate the reasons for this unexpected result, we have determined the pre-steady-state kinetic parameters and crystal structures of relevant ternary complexes. We found that the S565G/Y567A mutant generally had greater base selectivity than the Y567A mutant and that the kinetic parameters for dNMP insertion, excision of the 3'-terminal nucleotide residue, and primer extension beyond a mispair differed not only between these two mutants but also between the two highly mutable sequences in the T4 rI complementary strand. Comparison of the crystal structures of these two mutants with correct and incorrect incoming dNTPs provides insight into the unexpected increase in the fidelity of the S565G/Y567A double mutant. Taken together, the kinetic and structural results provide a basis for integrating and interpreting in vivo and in vitro observations.

Infectious diseases following natural disasters tend to occur as a result of the prolonged secondary effects of the disaster, mostly when there is an interruption of public health measures resulting from destruction of the local infrastructure. This article will review the infectious risks that occur as a result of natural disasters, with a focus on the mechanism of disease spread, infectious diseases after specific disasters, and various evidence-based interventions.(Disaster Med Public Health Preparedness. 2010;4:232-238)

Family engagement in home visiting (HV) is challenging. This study related attachment security of home visitors (n=48) and mothers (n=328) to family engagement in an HV program to prevent child maltreatment. Attachment security was assessed by using the Attachment Style Questionnaire to measure attachment anxiety and attachment avoidance. Family engagement was defined as receipt of a high dose of visits and home visitor response to intimate partner violence (IPV) and poor maternal mental health as measured via record review and by maternal report of trust in the home visitor. Home visitors had lower attachment anxiety and avoidance than mothers. Families were likely to receive a high dose of services if either the mother or home visitor was high on attachment anxiety. Home visitors high on attachment anxiety were less likely to respond to IPV and poor maternal mental health; home visitors high on attachment avoidance were more likely to respond to these issues. Mothers with high attachment anxiety were less trusting of highly anxious home visitors and more trusting of avoidant home visitors. HV programs should consider the influence of both home visitor and maternal attachment style on family engagement. © 2010 Wiley Periodicals, Inc.

Faced with increased demands for critical care services as a result of the novel H1N1 pandemic, hospitals must prepare a surge response in an attempt to manage these needs. In preparing for a surge response, factors to consider are staff, stuff (supplies and equipment), space, and systems necessary to respond to the event. This article uses this general framework to discuss surge issues in the context of H1N1 challenges that we are facing currently and to provide specific advice for hospitals. Particular attention is given to how hospitals can estimate the potential impact of H1N1 and pharmaceutical stockpiling.

Purpose To provide recommendations and standard operating procedures for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with a specific focus on critical care triage.

Background: Few published data exist with respect to current implementation of interventions that increase patient safety in intensive care units (ICUs) Furthermore, even less published data exist that address implementation of outcome-related methodologies of patient safety interventions in ICUs. Objective: The purpose of this study was threefold: (1) to increase implementation rates of known, evidence-based interventions in the Dartmouth Hitchcock Medical Center (DHMC) ICU that have been demonstrated to reduce morbidity and mortality in critically ill patients; (2) to develop a durable and reproducible intervention model that can be applied not only to various aspects of ICU medicine but to any healthcare microsystem that is process oriented; and (3) to design an “ICU-specific” value compass. Design: Using a before/after study design, the interventions involved: (1) establishing a systematic approach to integrate the delivery of proven ICU safety measures; (2) using the design of the various tools to develop a method for team communication and team building; (3) incorporating prompts into a ICU progress note for the healthcare team to address three evidence-based measures on a daily basis; and (4) using a data wall to demonstrate progress and to provide “real-time” feedback for error correction. Setting and participants: In the before and after study, two groups of 40 consecutive patients admitted to DHMC’s Intensive Care Unit were evaluated. The first group of patients was admitted between April and May of 2003. The second group of 40 patients was admitted between May and June of 2004. To ensure process stability, control data were also collected on patients at an interval time point between these two groups. Main outcome measures: Three evidence-based interventions were identified that reduce the likelihood of adverse events resulting simply from an ICU stay: (1) prophylaxis against venous thrombo-embolic disease (venous thromboembolism or deep vein thrombosis); (2) prophylaxis against ventilator-associated pneumonia (VAP); and (3) prophylaxis against stress-ulcers (SU). Two data points were obtained per patient per day corresponding to the work shift schedule in the ICU. The unit of measure was patient-shift observation. A limited data set was collected before implementing the change package to ensure system stability. Results: Both traditional statistical analysis and statistical process control (SPC) were used to evaluate the results. For each metric, it was possible to demonstrate an increase in the measure of the mean, reduced point-to-point variation as well as a substantial narrowing of the control limits indicating improved process control. Limitations: By virtue of the involvement of the researcher in the data collection for the control group, the potential existed for methodological bias by acting on the information collected. There was also the lack of a cohesive data structure from which to collect information (ie, the hospital computer speaks one language, the ventilator a second and the monitoring systems a third). Conclusions: A model for changing the ICU microsystem at DHMC was created that enabled successful implementation of evidence-based measures by maximising the natural flow of work and fostering a team-based culture to improve patient safety. Unique to this method and unlike currently available methods that define only the delivery of the appropriate intervention as success, system success was defined in terms of both true positives, namely delivering care when it is indicated, as well as true negatives, not delivering care when there is none indicated, to offer a more comprehensive system review. Additionally, the method of data collection allowed simplified defect analysis, thereby eliminating a resource-consuming audit of data after the fact. This approach, therefore, provides a basis for adapting and redesigning the PDSA cycle so as to specifically apply this type of “disciplinary” work.

Background Mass numbers of critically ill disaster victims will stress the abilities of health-care systems to maintain usual critical care services for all in need. To enhance the number of patients who can receive life-sustaining interventions, the Task Force on Mass Critical Care (hereafter termed the Task Force ) has suggested a framework for providing limited, essential critical care, termed emergency mass critical care (EMCC). This article suggests medical equipment, concepts to expand treatment spaces, and staffing models for EMCC. Methods Consensus suggestions for EMCC were derived from published clinical practice guidelines and medical resource utilization data for the everyday critical care conditions that are anticipated to predominate during mass critical care events. When necessary, expert opinion was used. Task Force major suggestions The Task Force makes the following suggestions: (1) one mechanical ventilator that meets specific characteristics, as well as a set of consumable and durable medical equipment, should be provided for each EMCC patient; (2) EMCC should be provided in hospitals or similarly equipped structures; after ICUs, postanesthesia care units, and emergency departments all reach capacity, hospital locations should be repurposed for EMCC in the following order: (A) step-down units and large procedure suites, (B) telemetry units, and (C) hospital wards; and (3) hospitals can extend the provision of critical care using non-critical care personnel via a deliberate model of delegation to match staff competencies with patient needs. Discussion By using the Task Force suggestions for adequate supplies of medical equipment, appropriate treatment space, and trained staff, communities may better prepare to deliver augmented essential critical care in response to disasters.

Background Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources. Task Force suggestions In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.

Background Plausible disasters may yield hundreds or thousands of critically ill victims. However, most countries, including those with widely available critical care services, lack sufficient specialized staff, medical equipment, and ICU space to provide timely, usual critical care for a large influx of additional patients. Shifting critical care disaster preparedness efforts to augment limited, essential critical care (emergency mass critical care [EMCC]), rather than to marginally increase unrestricted, individual-focused critical care may provide many additional people with access to life-sustaining interventions. In 2007, in response to the increasing concern over a severe influenza pandemic, the Task Force on Mass Critical Care (hereafter called the Task Force ) convened to suggest the essential critical care therapeutics and interventions for EMCC. Task Force suggestions EMCC should include the following: (1) mechanical ventilation, (2) IV fluid resuscitation, (3) vasopressor administration, (4) medication administration for specific disease states ( eg , antimicrobials and antidotes), (5) sedation and analgesia, and (6) select practices to reduce adverse consequences of critical illness and critical care delivery. Also, all hospitals with ICUs should prepare to deliver EMCC for a daily critical care census at three times their usual ICU capacity for up to 10 days. Discussion By using the Task Force suggestions for EMCC, communities may better prepare to deliver augmented critical care in response to disasters. In light of current mass critical care data limitations, the Task Force suggestions were developed to guide preparedness but are not intended as strict policy mandates. Additional research is required to evaluate EMCC and revise the strategy as warranted.

2008;133;1S-7S Chest Geiling and Lewis Rubinson Asha Devereaux, Michael D. Christian, Jeffrey R. Dichter, James A. * 27, 2007 − January 26 Force for Mass Critical Care Summit, Summary of Suggestions From the Task http://chestjournal.chestpubs.org/content/133/5_suppl/1S.full.html services can be found online on the World Wide Web at: The online version of this article, along with updated information and ISSN:0012-3692 ) http://chestjournal.chestpubs.org/site/misc/reprints.xhtml ( written permission of the copyright holder. this article or PDF may be reproduced or distributed without the prior Dundee Road, Northbrook, IL 60062. All rights reserved. No part of Copyright2008by the American College of Chest Physicians, 3300 Physicians. It has been published monthly since 1935. is the official journal of the American College of Chest Chest