Use Of Restrictive Criteria Research Articles

Recurrence of Hepatocellular Carcinoma After Liver Transplantation: Risk Factors and Predictive Models.

Liver transplantation (LTx) is the best treatment for patients with early-stage hepatocellular carcinoma (HCC). The Milan criteria positively influenced results of liver transplantation and were adopted by the majority of cancer centers, becoming the criterion standard treatment for early-stage HCC. Despite the use of restrictive criteria, recurrence is still high, affecting between 8% and 20% of cases, and is a significant predictor of survival after LTx.The diagnosis of both micro-and macro-invasion of vessels, which are significant factors in determining the frequency of recurrence and overall survival, significantly decreases the success of transplantation, causing an increase in mortality of 50% in comparison to recipients with no vascular invasion.The risk of recurrence depends on several factors, which are discussed in this review. The authors also discuss the clinical presentation and treatment methods of recurrence and its prognosis. In addition, the role of different models developed to identify groups of patients with high versus low risk of recurrence is discussed, enabling the planning of recommendations and screening protocols after transplantation to help early diagnosis and guide effective treatment. In the era of an increasing numbers of liver transplants due to HCC, the need to create robust screening tools is urgent.

Hepatocellular carcinoma recurrence after liver transplantation: Risk factors, screening and clinical presentation.

Liver transplantation is the best treatment option for cirrhotic patients with early-stage hepatocellular carcinoma, but it faces the problem of scarcity of donors and the risk of tumor recurrence, which affects between 15% and 20% of the cases, despite the use of restrictive criteria. The risk of recurrence depends on a number of factors, related to the tumor, the patient, and the treatment, which are discussed in this review. Some of these factors are already well established, such as the histopathological characteristics of the tumor, Alpha-fetoprotein (AFP) levels, and waiting time. Other factors related to the biological behavior of the tumor and treatment should be recognized because they can be used in the refinement of the selection criteria of transplant candidates and in an attempt to reduce recurrence. This review also discusses the clinical presentation of recurrence and its prognosis, contributing to the identification of a subgroup of patients who may have better survival, if they are timely identified and treated. Development of recurrence after the first year, with AFP levels ≤ 100 ng/mL, and single site capable of locoregional therapy are associated with better survival after recurrence.

Life-sustaining treatment limitation criteria upon admission to the intensive care unit: Results of a Spanish national multicenter survey

ObjectiveTo determine the life-sustaining treatment limitation (LSTL) predisposition upon patient admission to the Intensive Care Unit (ICU), the criteria upon which such predisposition is based, and whether these decisions are related to structural factors of the surveyed hospitals. DesignA descriptive multicenter study was made in 2010, involving the conduction of a survey in 90 hospitals, with a view to documenting the usual practise referred to LSTL upon admission in these centers. SettingSpanish ICUs. InterventionOpinion survey. Main variables of interestType of hospital, number of hospital beds, ICU and semicritical patient beds, usual bed availability in the ICU, use of restrictive admission criteria, use of LSTL criteria upon admission, and type of criterion used to decide LSTL. ResultsA total of 43 (48%) hospitals participated in the study, with LSTL being a common practise in these centers (93%). LSTL was fundamentally decided on the basis of the presence of prior severe chronic disease (95%), observation of previously declared patient will (95%), prior functional limitation (85%), and qualitative futility of care (82%). Frequent ICU bed availability (77% of the hospitals) and the use of restrictive criteria (79% of the hospitals) were also associated to patient admission with LSTL. ConclusionsAdmission to ICU with LSTL is a generalized practise in Spanish Hospitals. LSTL is decided not only based on physiological futility from an objective medical point of view, but also in observance of ethical and moral implications based on the qualitative futility of medical care.

Criterios para limitar los tratamientos de soporte vital al ingreso en unidad de cuidados intensivos: resultados de una encuesta multicéntrica nacional

ObjectiveTo determine the life-sustaining treatment limitation (LSTL) predisposition upon patient admission to the intensive care unit (ICU), the criteria upon which such predisposition is based, and whether these decisions are related to structural factors of the surveyed hospitals. DesignA descriptive multicenter study was made in 2010, involving the conduction of a survey in 90 hospitals, with a view to documenting the usual practice referred to LSTL upon admission in these centers. SettingSpanish ICUs. InterventionOpinion survey. Main variables of interestType of hospital, number of hospital beds, ICU and semicritical patient beds, usual bed availability in the ICU, use of restrictive admission criteria, use of LSTL criteria upon admission, and type of criterion used to decide LSTL. ResultsA total of 43 (48%) hospitals participated in the study, with LSTL being a common practice in these centers (93%). LSTL was fundamentally decided on the basis of the presence of prior severe chronic disease (95%), observation of previously declared patient will (95%), prior functional limitation (85%), and qualitative futility of care (82%). Frequent ICU bed availability (77% of the hospitals) and the use of restrictive criteria (79% of the hospitals) were also associated to patient admission with LSTL. ConclusionsAdmission to ICU with LSTL is a generalized practice in Spanish Hospitals. LSTL is decided based on physiological futility from an objective medical point of view, but also in observance of ethical and moral implications based on the qualitative futility of medical care.

Emergency skull radiography: the effect of restrictive criteria on skull radiography and CT use.

A prospective study was performed to determine the effect of restrictive criteria on the use of emergency skull radiography and computed tomography (CT) of the head. Emergency skull radiography required the completion of a special requisition form. Emergency CT of the head was done at the request of senior consultants and was available on a full-time basis. Over 1 year, 2,758 skull studies were performed, a decrease of 39.1% when compared with the year before restrictive criteria were instituted, during which 4,587 skull examinations were done. In the same period, the number of emergency CT scans of the head increased by 45.7%, from 471 in the control year to 686 in the experimental year. With the use of restrictive criteria, a net savings of +164,000 was achieved. Our results suggest that the use of restrictive criteria is a cost-effective means of limiting skull radiography when CT of the head is readily available.