The ethics of the Global Kidney Exchange programme

The Global Kidney Exchange (GKE) programme seeks to facilitate kidney transplants by matching donor-recipient pairs across high-income, medium-income, and low-income countries. The GKE programme pays the medical expenses of people in medium-income and low-income countries, thus enabling them to receive a kidney transplantation they otherwise could not afford. In doing so, the programme increases the global donor pool, and so benefits people in high-income countries by improving their chances of finding a donor match. Nevertheless, the GKE has been accused of being a form of organ trafficking, exploiting the poor, and involving coercion and commodification of donors. We refute these claims, arguing that the GKE promotes global justice and reduces the potential for people in need of kidneys in low-income and medium-income countries to be exploited. Misguided objections should not be allowed to prevent the GKE from realising its potential to reduce suffering and save the lives of rich and poor patients alike.

Chronic non-bacterial osteomyelitis: a comparative study between children and adults

BACKGROUND

To compare clinical presentation, diagnostic and treatment strategies, and outcome between pediatric and adult patients with chronic non-bacterial osteomyelitis (CNO).

METHODS

Retrospective single-centre comparative study of pediatric and adult patients diagnosed with chronic recurrent multifocal osteomyelitis (CRMO)/CNO or synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome treated at the Medical University of Graz.

RESULTS

24 pediatric patients diagnosed with CRMO/CNO and 10 adult patients diagnosed with SAPHO syndrome were compared. Median age at diagnosis was 12.3 years (range 7.9-18.9) in the pediatric group and 32.5 years (range 22-56) in the adult group. Median time to diagnosis was shorter in children than in adults (0.3 vs. 1.0 years). Initial clinical presentation, laboratory and histopathological findings were similar in children and adults. Mean numbers of bone lesions were comparable between pediatric and adult patients (3.1 vs. 3.0), as were rates of skin involvement (33% vs. 30%). Sternal involvement was more frequent in adults whereas involvement of clavicle and long bones was more frequent in children (41.7% vs.10, 33% vs. 10%). Computerized tomography (CT) was used more often in adults, whereas whole-body magnetic resonance imaging (MRI) was used only in children. Bisphosphonates were applied more often in children and outcome was better in children than in adults (62.5% vs.30%).

CONCLUSION

Results of our study suggest that CNO/CRMO and SAPHO syndrome in children and adults might represent a single clinical syndrome that needs a similar diagnostic and therapeutic approach.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community

RATIONALE

This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings.

METHODS

In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications.

RESULTS

A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

CONCLUSION

A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community

RATIONALE

This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings.

METHODS

In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications.

RESULTS

A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

CONCLUSION

A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

Validation of carbon dioxide production (VCO2) as a tool to calculate resting energy expenditure (REE) in mechanically ventilated critically ill patients: a retrospective observational study

BACKGROUND

Indirect calorimetry (IC) measurement is considered the gold standard for the assessment of resting energy expenditure (REE). It is based on the measurement of oxygen and carbon dioxide consumption (VO2 and VCO2, respectively). However, its use is limited by cost and technical issues. It has been proposed that, in critically ill patients, the analysis of VCO2 obtained from the ventilator alone may be used as an accurate method to assess REE in ventilated patients. This retrospective study aimed to assess the accuracy of VCO2 measurement alone in the determination of REE.

METHODS

This was a retrospective study conducted at the general intensive care unit of a single university-affiliated tertiary medical center. Patients included were invasively ventilated and their REE was measured by using IC. The respiratory quotients (RQs) were set at 0.8, 0.85, and 0.89. Data were collected from computerized patient files. REE obtained from the ventilator by using VCO2 (REE-VCO2) alone was compared with REE obtained from IC (REE-IC).

RESULTS

Measurements were obtained for 80 patients, and 497 REE-IC measurements were compared with REE-VCO2 obtained at the same time. The mean REE-IC was 2059.5 ± 491.7 kcal/d. The mean REE-RQs corresponding to RQs of 0.80, 0.85, and 0.89 were 1936.8 ± 680.0, 2017.8 ± 708.8, and 2122.1 ± 745.4 kcal/d, respectively. REE-VCO2 derived from an RQ of 0.85 had the lowest mean difference from REE-IC. Whereas accuracy was higher using an RQ of 0.85, agreement (between 85% and 115%) was highest using an RQ of 0.89.

CONCLUSIONS

The level of agreement of REE obtained from VCO2 readings with REE obtained from IC was generally low. IC continues to be the recommended method for REE assessment.

Randomised clinical trial: 2% taurolidine versus 0.9% saline locking in patients on home parenteral nutrition

BACKGROUND

The catheter lock solutions 2% taurolidine and 0.9% saline are both used to prevent catheter-related bloodstream infections (CRBSIs) in home parenteral nutrition patients.

AIMS

To compare the effectiveness and safety of taurolidine and saline.

METHODS

This multicentre double-blinded trial randomly assigned home parenteral nutrition patients to use either 2% taurolidine or 0.9% saline for 1 year. Patients were stratified in a new catheter group and a pre-existing catheter group. Primary outcome was the rate of CRBSIs/1000 catheter days in the new catheter group and pre-existing catheter group, separately.

RESULTS

We randomised 105 patients, of which 102 were analysed as modified intention-to-treat population. In the new catheter group, rates of CRBSIs/1000 catheter days were 0.29 and 1.49 in the taurolidine and saline arm respectively (relative risk, 0.20; 95% CI, 0.04-0.71; P = 0.009). In the pre-existing catheter group, rates of CRBSIs/1000 catheter days were 0.39 and 1.32 in the taurolidine and saline arm respectively (relative risk, 0.30; 95% CI, 0.03-1.82; P = 0.25). Excluding one outlier patient in the taurolidine arm, mean costs per patient were $1865 for taurolidine and $4454 for saline (P = 0.03). Drug-related adverse events were rare and generally mild.

CONCLUSIONS

In the new catheter group, taurolidine showed a clear decrease in CRBSI rate. In the pre-existing catheter group, no superiority of taurolidine could be demonstrated, most likely due to underpowering. Overall, taurolidine reduced the risk for CRBSIs by more than four times. Given its favourable safety and cost profile, taurolidine locking should be considered as an additional strategy to prevent CRBSIs.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT01826526.

Viability Test Device for anisakid nematodes

Up to now the visual inspection of mobility of isolated anisakid larvae serves as a measure of viability and possible risk of infection. This paper presents a new method to rule out unreliability – caused by the temporary immobility of the larvae and by the human uncertainty factor of visual observation. By means of a Near infrared (NIR) imaging method, elastic curvature energies and geometric shape parameters were determined from contours, and used as a measure of viability. It was based on the modelling of larvae as a cylindrical membrane system. The interaction between curvatures, contraction of the longitudinal muscles, and inner pressure enabled the derivation of viability from stationary form data. From series of spectrally signed images within a narrow wavelength range, curvature data of the larvae were determined. Possible mobility of larvae was taken into account in statistical error variables. Experiments on individual living larvae, long-term observations of Anisakis larvae, and comparative studies of the staining method and the VTD measurements of larvae from the tissue of products confirmed the effectiveness of this method. The VTD differentiated clearly between live and dead nematode larvae isolated from marinated, deep-frozen and salted products. The VTD has been proven as excellent method to detect living anisakid nematode larvae in fishery products and is seen as useful tool for fish processing industry and control authorities.