Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline.

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

OBJECTIVES: To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU. DESIGN: A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics. METHODS: The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results. RESULTS: The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written. CONCLUSIONS: This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

Induction of brown cells in Venerupis philippinarum exposed to benzo(a)pyrene.

Benzo(a)pyrene is an important polycyclic aromatic hydrocarbon (PAH) commonly present in the marine environment and responsible for carcinogenic, teratogenic and mutagenic effects in various animal species. In the present study, we investigated by both histochemical and immunohistochemical approaches the effect of an acute exposure to different concentrations of B(a)P in the Manila clam Venerupis philippinarum. The general morphology of the different clam tissues, which was investigated histologically, evidenced a significant increase in the number of intestinal brown cells after B(a)P exposure. An increasing trend response to B(a)P was detected. The histochemical analysis for lipofuscin revealed the presence of lipofuscin-like substances inside the cytoplasm of intestinal brown cells. The same cells exhibited a PAS positivity and a reactivity to Schmorl's solution for melanin pigment. Moreover, intestinal brown cells exhibited an immunopositivity to HSP70 antibody confirming the increasing trend response to B(a)P detected by the histochemical analysis. Our results suggest that histological tissue changes resulting from exposure to B(a)P can be an useful marker in biomonitoring studies.

Histopathology and stress biomarkers in the clam Venerupis philippinarum from the Venice Lagoon (Italy).

The aim of this study was to evaluate the histomorphology and the stress response in the bivalve Venerupis philippinarum sampled in four differently polluted sites of the Venice Lagoon (Palude del Monte, Marghera, Ca' Roman and Val di Brenta). This species is often used as bioindicator of environmental pollution since it can bioaccumulate a large variety of pollutants because of its filter feeding. Chemical analyses for heavy metals (Cd, Cu, Hg and Pb) and polycyclic aromatic hydrocarbons (PAHs) were performed on whole soft tissues of V. philippinarum. The histological evaluation of clams revealed the presence of Perkinsus sp. infection in animals from all sites, although a very high prevalence of parasites was evidenced in clams from Ca' Roman. Perkinsus sp. were systemically distributed in the mantle, in the intestine and digestive gland, in gonads and gills. The trophozoites of Perkinsus sp. were found isolated or in cluster surrounded by a heavy hemocitical response. Haemocytes always exhibited an immunopositivity to cytochrome P4501A (CYP1A), heat shock protein 70 (HSP70), 4-hydroxy-2-nonenal (HNE) and nitrotyrosine (NT) antibodies. The digestive gland of animals from Palude del Monte showed the highest malondialdehyde (MDA) concentration, whereas clams from Ca' Roman exhibited the highest quantity of metallothioneins.

Executive Summary: Criteria for Critical Care of Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

This is an executive summary of the 2019 update of the 2004 guidelines and levels of care for PICU. Since previous guidelines, there has been a tremendous transformation of Pediatric Critical Care Medicine with advancements in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution of resources and training in the provision of care through the PICU. Outcome and quality research related to admission, transfer, and discharge criteria as well as literature regarding PICU levels of care to include volume, staffing, and structure were reviewed and included in this statement as appropriate. Consequently, the purposes of this significant update are to address the transformation of the field and codify a revised set of guidelines that will enable hospitals, institutions, and individuals in developing the appropriate PICU for their community needs. The target audiences of the practice statement and guidance are broad and include critical care professionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatric surgical subspecialists; pediatric imaging physicians; and other members of the patient care team such as nurses, therapists, dieticians, pharmacists, social workers, care coordinators, and hospital administrators who make daily administrative and clinical decisions in all PICU levels of care.

Expression of CYP4 and GSTr genes in Venerupis philippinarum exposed to benzo(a)pyrene.

Bivalve molluscs, such as Venerupis philippinarum, are often used as bioindicators of environmental pollution since they can bioaccumulate a large variety of pollutants because of their filter feeding. The Polycyclic Aromatic Hydrocarbon (PAH) benzo(a)pyrene (B(a)P) is an important contaminant, commonly present in the marine environment. Pollutants are generally metabolized by enzymes of phase I, mainly CYPs enzymes, and by conjugation enzymes of phase II like GST. In this study, we investigated by Real Time PCR the expression of CYP4 and GSTr (GST class rho) in the digestive gland of V. philippinarum exposed to different concentrations of B(a)P for 24 h and after a 24 h depuration period. Accumulation of B(a)P by clams has been confirmed by the HPLC-FLD analyses. Moreover, HPLC-FLD analyses evidenced that after depuration, B(a)P concentrations decreased in animals subjected to 0.03 mg/l and 0.5mg/l exposures but did not decrease in animals subjected to 1mg/l exposure. B(a)P exposure and depuration did not cause histopathological lesions in the different organs. The analysis of GSTr expression in the digestive gland showed a significant increase in mRNA in animals subjected to 1 mg/l exposure, whereas the analysis of CYP4 expression did not evidence differences among treatments. Moreover, the expression of both genes did not exhibit any differences after the purification treatment. The results demonstrate that B(a)P significantly affects the expression of GSTr mRNA in the digestive gland of V. philippinarum and suggest that GSTr gene could play an important role in the biotransformation of B(a)P.