ObjectTo establish and compare normative metabolite concentrations in 2nd and 3rd trimester human amniotic fluid samples in an effort to reveal metabolic biomarkers of fetal health and development.Materials and methodsTwenty-one metabolite concentrations were compared between 2nd (15–27 weeks gestation, N = 23) and 3rd (29–39 weeks gestation, N = 27) trimester amniotic fluid samples using 1H high resolution magic angle spinning (HR-MAS) spectroscopy. Data were acquired using the electronic reference to access in vivo concentrations method and quantified using a modified semi-parametric quantum estimation algorithm modified for high-resolution ex vivo data.ResultsSixteen of 21 metabolite concentrations differed significantly between 2nd and 3rd trimester groups. Betaine (0.00846±0.00206 mmol/kg vs. 0.0133±0.0058 mmol/kg, P <0.002) and creatinine (0.0124±0.0058 mmol/kg vs. 0.247±0.011 mmol/kg, P <0.001) concentrations increased significantly, while glucose (5.96±1.66 mmol/kg vs. 2.41±1.69 mmol/kg, P <0.001), citrate (0.740±0.217 mmol/kg vs. 0.399±0.137 mmol/kg, P <0.001), pyruvate (0.0659±0.0103 mmol/kg vs. 0.0299±0.286 mmol/kg, P <0.001), and numerous amino acid (e.g. alanine, glutamate, isoleucine, leucine, lysine, and valine) concentrations decreased significantly with advancing gestation. A stepwise multiple linear regression model applied to 50 samples showed that gestational age can be accurately predicted using combinations of alanine, glucose and creatinine concentrations.ConclusionThese results provide key normative data for 2nd and 3rd trimester amniotic fluid metabolite concentrations and provide the foundation for future development of magnetic resonance spectroscopy (MRS) biomarkers to evaluate fetal health and development.

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Central line-associated bloodstream infections (CLABSIs) and ventilator-associated events (VAEs) are among the most prevalent and morbid health careassociated infections (HAIs) encountered in the ICU. The past decade has seen concerted efforts to reduce the cost of these infections, both fiscal and physical, but the evidence underlying these efforts varies in quality. Whereas the data supporting interventions to reduce CLABSI are robust and reproducible, the evidence for ventilator-associated pneumonia has suffered from inconsistencies. CLABSIs are well defined, may be confirmed by laboratory testing, and are amenable to active surveillance programs. In contrast, the clinical definition of ventilator-associated pneumonia lacks specificity and the diagnosis is confounded by inter-observer variability, thus complicating efforts to reduce its prevalence. In this context, we review recommendations for reducing these HAIs, and describe efforts to standardize surveillance definitions for VAE. These interventions are presented alongside our institution's 5-year CLABSI and VAE data with notes on our changing practice over time. As intensivists, enacting current practice recommendations are among the best available measures to limit the incidence of HAIs in our ICUs.

Familiarity with and adherence to the above principles may not make you claim or judgment proof, but they should improve patient care in your office and decrease your exposure to medico-legal interventions. Always bear in mind that medical practice is not a right conferred upon you by virtue of your medical degree, but rather a privilege granted you by state statute and licensure.

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