Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life

NCAM function in the adult brain: lessons from mimetic peptides and therapeutic potential.

International audienceNeural cell adhesion molecules (NCAMs) are complexes of transmembranal proteins critical for cell-cell interactions. Initially recognized as key players in the orchestration of developmental processes involving cell migration, cell survival, axon guidance, and synaptic targeting, they have been shown to retain these functions in the mature adult brain, in relation to plastic processes and cognitive abilities. NCAMs are able to interact among themselves (homophilic binding) as well as with other molecules (heterophilic binding). Furthermore, they are the sole molecule of the central nervous system undergoing polysialylation. Most interestingly polysialylated and non-polysialylated NCAMs display opposite properties. The precise contributions each of these characteristics brings in the regulations of synaptic and cellular plasticity in relation to cognitive processes in the adult brain are not yet fully understood. With the aim of deciphering the specific involvement of each interaction, recent developments led to the generation of NCAM mimetic peptides that recapitulate identified binding properties of NCAM. The present review focuses on the information such advances have provided in the understanding of NCAM contribution to cognitive function