Acceptance and validity of the methods used to implement a competency based medical education programme in an Intensive Care Department of a teaching referral center

OBJECTIVES

1. To determine the satisfaction of tutors and residents with a specific methodology used to implement CoBaTrICE. 2. To determine the reliability and validity of the global rating scales designed ad hoc to assess the performance of the residents for training purposes.

DESIGN

Prospective cohort study.

PARTICIPANTS

All the residents and tutors of the ICU Department of the Hospital Universitario y Politécnico la Fe de Valencia.

INTERVENTION

CoBaTrICE implementation started in March 2016, it was based on: (1) Training the tutors in feedback techniques; (2) Performing multiple objective and structured work based assessments to achieve the competences of the program; and (3) The use of an electronic portfolio to promote learning reflection and to collect the evidence that learning was taking place.

METHODS

The acceptance of CoBaTrICE was explored through a satisfaction survey conducted after 9 months of implementation of the training program. The 15 residents and 5 tutors of the ICU Department were asked about the methodology of the formative assessments, the quality of the feedback, self-learning regulation and the electronic portfolio usefulness. The validity of the global rating scales was assessed through the tests alfa de Cronbach, reliability and generalizability indexes, and intraclass correlation coefficient.

RESULTS

The implementation of CoBaTrICE was satisfactory in all the dimensions studied. The global rating scales used for formative purposes showed reliability and validity.

CONCLUSIONS

The methodology used to implement CoBaTrICE was highly valued by tutors and residents. The global rating scales used for formative purposes showed reliability and validity.

Transcriptome analysis of severely active chronic spontaneous urticaria shows an overall immunological skin involvement

BACKGROUND

The knowledge about chronic spontaneous urticaria (CSU) phenotypes is based on its clinical characteristics, associated comorbidities, course of the disease, and its response to the available effective drugs. Genotype expression and its further correlation with CSU phenotypes are still unknown. We describe the cutaneous transcriptome of patients suffering a severely active CSU refractory to antihistamine treatment.

METHODS

Through the bioinformatic analysis of the whole Human Genome with Oligo Microarrays and quantitative real-time polymerase chain reaction (qPCR), relevant genes expressed in nonlesional (NLS-CSU) and lesional skin (LS-CSU) and peripheral blood were identified in 20 patients suffering from severely active CSU and 10 healthy controls (HCs).

RESULTS

From 39 genes differentially expressed in NLS-CSU when compared with HCs, 31 (79.48%) were confirmed by qPCR corresponding to genes involved in epidermal homeostasis and dermal repair. From the analysis comparing LS-CSU with NLS-CSU, a selection of 142 genes was studied with qPCR, and 103 (72.53%) were confirmed. Differentially expressed genes in the phenomenon of wheal development are involved in a variety of biological functions as, epidermal differentiation, intracellular signal function, transcriptional factors cell cycle differentiation, inflammation, or coagulation. Differentially expressed genes that uniformly increase or decrease along the skin worsening until the wheal appearance is shown.

CONCLUSION

The skin of CSU patients with a severely active disease shows an overall immunological skin involvement showing a peculiar gene profile.

Characteristics and outcomes of patients admitted to Spanish ICU: A prospective observational study from the ENVIN-HELICS registry (2006-2011)

OBJECTIVE

To describe the case-mix of patients admitted to intensive care units (ICUs) in Spain during the period 2006-2011 and to assess changes in ICU mortality according to severity level.

DESIGN

Secondary analysis of data obtained from the ENVN-HELICS registry. Observational prospective study.

SETTING

Spanish ICU.

PATIENTS

Patients admitted for over 24h.

INTERVENTIONS

None.

VARIABLES

Data for each of the participating hospitals and ICUs were recorded, as well as data that allowed to knowing the case-mix and the individual outcome of each patient. The study period was divided into two intervals, from 2006 to 2008 (period 1) and from 2009 to 2011 (period 2). Multilevel and multivariate models were used for the analysis of mortality and were performed in each stratum of severity level.

RESULTS

The study population included 142,859 patients admitted to 188 adult ICUs. There was an increase in the mean age of the patients and in the percentage of patients >79 years (11.2% vs. 12.7%, P<0.001). Also, the mean APACHE II score increased from 14.35±8.29 to 14.72±8.43 (P<0.001). The crude overall intra-UCI mortality remained unchanged (11.4%) but adjusted mortality rate in patients with APACHE II score between 11 and 25 decreased modestly in recent years (12.3% vs. 11.6%, odds ratio=0.931, 95% CI 0.883-0.982; P=0.008).

CONCLUSION

This study provides observational longitudinal data on case-mix of patients admitted to Spanish ICUs. A slight reduction in ICU mortality rate was observed among patients with intermediate severity level.

Intensive care practices in brain death diagnosis and organ donation

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

Urethral catheter-related urinary infection in critical patients admitted to the ICU. Descriptive data of the ENVIN-UCI study

OBJECTIVE

To describe trends in national catheter-related urinary tract infection (CRUTI) rates, as well as etiologies and multiresistance markers.

DESIGN

An observational, prospective, multicenter voluntary participation study was conducted from 1 April to 30 June in the period between 2005 and 2010.

SETTING

Intensive Care Units (ICUs) that participated in the ENVIN-ICU registry during the study period.

PATIENTS

We included all patients admitted to the participating ICUs and patients with urinary catheter placement for more than 24 hours (78,863 patients).

INTERVENTION

Patient monitoring was continued until discharge from the ICU or up to 60 days.

VARIABLES OF INTEREST

CRUTIs were defined according to the CDC system, and frequency is expressed as incidence density (ID) in relation to the number of urinary catheter-patients days.

RESULTS

A total of 2329 patients (2.95%) developed one or more CRUTI. The ID decreased from 6.69 to 4.18 episodes per 1000 days of urinary catheter between 2005 and 2010 (p<0.001). In relation to the underlying etiology, gramnegative bacilli predominated (55.6 to 61.6%), followed by fungi (18.7 to 25.2%) and grampositive cocci (17.1 to 25.9%). In 2010, ciprofloxacin-resistant E. coli strains (37.1%) increased, as well as imipenem-resistant (36.4%) and ciprofloxacin-resistant (37.1%) strains of P. aeruginosa.

CONCLUSIONS

A decrease was observed in CRUTI rates, maintaining the same etiological distribution and showing increased resistances in gramnegative pathogens, especially E. coli and P. aeruginosa.

Depth of focus increase by multiplexing programmable diffractive lenses

A combination of several diffractive lenses written onto a single programmable liquid crystal display (LCD) is proposed for increasing the Depth of Focus (DOF) of the imaging system as a whole. The lenses are spatially multiplexed in a random scheme onto the LCD. The axial irradiance distribution produced by each lens overlaps with the next one producing an extended focal depth. To compare the image quality of the multiplexed lenses, the Modulation Transfer Function (MTF) is calculated. Finally we obtain the experimental Point Spread Functions (PSF) for these multiplexed lenses and experimental results in which an extended object is illuminated under spatially incoherent monochromatic light. We compare the images obtained in the focal plane and in some defocused planes with the single lens and with three multiplexed lenses. The experimental results confirm that the multiplexed lenses produce a high increase in the depth of focus.

Distinct requirements for IFNs and STAT1 in NK cell function

NK cell functions were examined in mice with a targeted mutation of the STAT1 gene, an essential mediator of IFN signaling. Mice deficient in STAT1 displayed impaired basal NK cytolytic activity in vitro and were unable to reject transplanted tumors in vivo, despite the presence of normal numbers of NK cells. IL-12 enhanced NK-mediated cytolysis, but poly(I:C) did not, and a similar phenotype occurred in mice lacking IFNalpha receptors. Molecules involved in activation and lytic function of NK cells (granzyme A, granzyme B, perforin, DAP10, and DAP12) were expressed at comparable levels in both wild-type and STAT1(-/-) mice, and serine esterase activity necessary for CTL function was normal, showing that the lytic machinery was intact. NK cells with normal cytolytic activity could be derived from STAT1(-/-) bone marrow progenitors in response to IL-15 in vitro, and enhanced NK lytic activity and normal levels of IFN-gamma were produced in response to IL-12 treatment in vivo. Despite these normal responses to cytokines, STAT1(-/-) mice could not reject the NK-sensitive tumor RMA-S, even following IL-12 treatment in vivo. Whereas in vitro NK cytolysis was also reduced in mice lacking both type I and type II IFN receptors, these mice resisted tumor challenge. These results demonstrate that both IFN-alpha and IFN-gamma are required to maintain NK cell function and define a STAT1-dependent but partially IFN-independent pathway required for NK-mediated antitumor activity.

STAT1 affects lymphocyte survival and proliferation partially independent of its role downstream of IFN-gamma

Lymphocytes derived from mice deficient in STAT1 showed reduced apoptosis and enhanced proliferation in vitro. To understand the involvement of STAT1 in the observed reduction in apoptosis, we examined the levels of caspase and bcl-2 family genes that are involved in cell survival and/or apoptosis. The levels of caspase 1 and 11, two enzymes involved in both cytokine protein processing and induction of apoptosis, were reduced in STAT1-/- cells compared with wild-type. However, the levels of bcl-2 genes were comparable in both mice. STAT1-/- cells also displayed an enhanced proliferation following TCR stimulation. This hyperproliferation could not be ascribed completely to the loss of IFN-gamma-mediated antiproliferation. First, similar phenotypes were also observed in fibroblasts and pre-B cells derived from STAT1-/- mice, which do not produce IFN-gamma. Second, comparisons with cells lacking the gene for IFN-gamma or with cells treated with neutralizing Abs to IFN-gamma only partially mimicked the STAT1-/- phenotype. Interestingly, the kinetics of degradation of p27kip1, a CDK inhibitor, following TCR ligation were faster, and, concomitantly, the up-regulation of CDK2 kinase activity and protein levels were increased in stimulated T cells of STAT1-/- mice relative to those of wild-type mice. Furthermore, STAT1-/- animals were more susceptible to carcinogen-induced thymic tumors, a possible consequence of altered T cell growth and/or survival. These results demonstrate an essential role for STAT1 for lymphocyte survival and proliferation that is only partially dependent on IFN-gamma signaling.

LST1 is a SEC24 homologue used for selective export of the plasma membrane ATPase from the endoplasmic reticulum

In Saccharomyces cerevisiae, vesicles that carry proteins from the ER to the Golgi compartment are encapsulated by COPII coat proteins. We identified mutations in ten genes, designated LST (lethal with sec-thirteen), that were lethal in combination with the COPII mutation sec13-1. LST1 showed synthetic-lethal interactions with the complete set of COPII genes, indicating that LST1 encodes a new COPII function. LST1 codes for a protein similar in sequence to the COPII subunit Sec24p. Like Sec24p, Lst1p is a peripheral ER membrane protein that binds to the COPII subunit Sec23p. Chromosomal deletion of LST1 is not lethal, but inhibits transport of the plasma membrane proton-ATPase (Pma1p) to the cell surface, causing poor growth on media of low pH. Localization by both immunofluorescence microscopy and cell fractionation shows that the export of Pma1p from the ER is impaired in lst1Delta mutants. Transport of other proteins from the ER was not affected by lst1Delta, nor was Pma1p transport found to be particularly sensitive to other COPII defects. Together, these findings suggest that a specialized form of the COPII coat subunit, with Lst1p in place of Sec24p, is used for the efficient packaging of Pma1p into vesicles derived from the ER.

Signal transducer and activator of transcription 1 in human muscle: implications in inflammatory myopathies

Polymyositis (PM) and dermatomyositis (DM) are two major and distinct inflammatory myopathies. Cytokines, implicated in the immune process, have been recognized in the muscle tissue from PM and DM patients, but their functional in situ role has not been identified. We analyzed the expression of the signal transducer and activator of transcription 1 (STAT1), a molecule whose up-regulation indicates the interaction of cytokines, or growth factors, with their target receptors in muscle fibers and inflammatory infiltrates in PM and DM. An immunohistochemical analysis was performed using monoclonal antibodies to STAT1 in 57 muscle biopsies from 10 patients with DM, 10 with PM, and 37 controls. The profile of STAT1 up-regulation was also investigated in cultured muscle stimulated by interferon-gamma, epidermal growth factor, platelet-derived growth factor, and interleukin-2, using semiquantitative polymerase chain reaction and Western blot. High STAT1 expression was observed in many perifascicular atrophic muscle fibers from DM patients in 10/10 biopsies. In contrast, only a few muscle fibers undergoing necrosis were STAT1 positive in 2/10 patients with PM and in 2/37 controls. STAT1 reactivity was noted in most cells of the infiltrates in DM, PM, and controls. In vitro, STAT1 was stimulated by interferon-gamma but not by the other molecules studied. These results suggest that in DM, but not in PM, there is distinctive functional local cytokine activity able to increase STAT1 expression in muscle fibers. As interferon-gamma specifically activates STAT1 in vitro, this cytokine in conjunction with ischemia is probably involved in perifascicular muscle fiber pathology in DM.

The two isoforms of the 90-kDalton nucleolus organizer region autoantigen (upstream binding factor) bind with different avidity to DNA modified by the antitumor drug cisplatin

It has been previously described that some proteins containing HMG boxes are able to bind more strongly to DNA modified with cis-diamminedichloroplatinum (II) (cisplatin) than to unmodified DNA. In the present study, we analyzed the interaction of cisplatin-modified DNA with the human autoantigen NOR-90 (UBF), a transcription factor that contains several HMG boxes. Using autoantibodies against NOR-90 to perform ELISA and immunoprecipitation, it was confirmed that NOR-90 (UBF) was able to bind cisplatin-modified DNA more avidly than unmodified DNA or trans-diamminedichloroplatinum(II) (transplatin) modified DNA. Moreover, by Southwestern, we observed that the 97 kDalton isoform of NOR-90 (UBF1) was able to bind cisplatin-modified DNA more strongly than the 94 kDalton isoform (UBF2); binding of unmodified DNA or transplatin-modified DNA was not detected with either isoform. Sera containing autoantibodies against NOR-90 did not inhibit, but increased the binding of NOR-90 to cisplatin-modified DNA.

Stat1 implication in the immune response to superantigens in vivo

We analyzed the activation and changes in the protein level of STAT1 as a consequence of in vivo treatment with superantigens. Ninety minutes after i.p. injection of the staphylococcal enterotoxin B (SEB), a complex containing STAT1 that was able to specifically bind to DNA containing GAS-like sequences was activated in mouse splenocytes. This complex had the same characteristics as that induced by IFN-gamma in several in vitro systems. Activation of the complex was inhibited by cyclosporin A, and Abs against IFN-gamma severely decreased the amount of complex detected. When splenocytes were analyzed 24 h after SEB treatment, a high increase in the amount of the STAT1 isoforms, STAT91 and STAT84, was observed by Western analysis, but binding to GAS-like sequences was clearly decreased when compared with analysis at 90 min. Nevertheless, when SEB was injected a second time 24 h after the first injection, the binding of STAT1 to GAS-like sequences had risen again. This approach corroborates the implication of IFN-gamma in the response to superantigens in vivo and shows the relevance of analysis of transcription factors in defining the molecular events involved in the immune response.

Stat1 implication in the immune response to superantigens in vivo

We analyzed the activation and changes in the protein level of STAT1 as a consequence of in vivo treatment with superantigens. Ninety minutes after i.p. injection of the staphylococcal enterotoxin B (SEB), a complex containing STAT1 that was able to specifically bind to DNA containing GAS-like sequences was activated in mouse splenocytes. This complex had the same characteristics as that induced by IFN-gamma in several in vitro systems. Activation of the complex was inhibited by cyclosporin A, and Abs against IFN-gamma severely decreased the amount of complex detected. When splenocytes were analyzed 24 h after SEB treatment, a high increase in the amount of the STAT1 isoforms, STAT91 and STAT84, was observed by Western analysis, but binding to GAS-like sequences was clearly decreased when compared with analysis at 90 min. Nevertheless, when SEB was injected a second time 24 h after the first injection, the binding of STAT1 to GAS-like sequences had risen again. This approach corroborates the implication of IFN-gamma in the response to superantigens in vivo and shows the relevance of analysis of transcription factors in defining the molecular events involved in the immune response.

Long-term behavior of bovine collagen membrane used as vascular substitute. Experimental study in rats

The aim of the present study was to evaluate the sequence of the immediate and the mid/long-term organization of the blood interface of a collagenous membrane used as vascular substitute in rats. The implants were prepared from calf skin type I insoluble collagen, obtained after acidic dispersion, in absence of chemical or tanning treatment. They were used to patch an aortic defect by means of microsurgical techniques. The animals were sequentially sacrificed for immediate hemocompatibility studies at 10 s, 30 s, 10 min, 3 h, and 6 h, for long-term analyses of the organization of the blood material interface at the 7th, 15th, 45th, 60th, 90th day following the surgery and each month until 14 months after aortic replacement. The superficial immediate events at the blood patch interface demonstrated erythrocytes heavily engulfed in a thin but dense fibrin mesh both at the patch and at the adjacent aortic wall surfaces. Neither adherent platelet nor platelet aggregate were detectable on the collagen patch surface. This fibrinoerythrocytic membrane covered the patch completely at 60 s and at 3 h the deposit was limited to 5-6 erythrocyte layers as confirmed by histology. It did not further develop on the 7th day. At the blood-collagen interface there progressively developed a tissue composed of active myofibroblasts, collagen bundles, and elastic fibers. After 4 months, nests of fibroendothelial cells were present, and between 6 and 14 months surface cell differentiation, although complete on the adjacent aorta was still incomplete on the bovine collagen patch, amorphous fibers, and fibroendothelial cells coexisting. Heterologous patch debris were still present 14 months after implantation and were associated with macroscopic and ultrastructural calcification, which need further investigations concerning the exact nature and mechanism of mineralization of vascular substitutes of biological nature.