Critical care management of severe traumatic brain injury in adults

Traumatic brain injury (TBI) is a major medical and socio-economic problem, and is the leading cause of death in children and young adults. The critical care management of severe TBI is largely derived from the "Guidelines for the Management of Severe Traumatic Brain Injury" that have been published by the Brain Trauma Foundation. The main objectives are prevention and treatment of intracranial hypertension and secondary brain insults, preservation of cerebral perfusion pressure (CPP), and optimization of cerebral oxygenation. In this review, the critical care management of severe TBI will be discussed with focus on monitoring, avoidance and minimization of secondary brain insults, and optimization of cerebral oxygenation and CPP

COVID-19 research in critical care: the good, the bad, and the ugly

The extraordinary pace of research on coronavirus disease 2019 (COVID-19) has been one of the major success stories of the pandemic. Therapeutic trials involving thousands of patients, which usually take years to complete, have been reported in a matter of months. National and international registries and networks have reported on tens of thousands of patients in near real time. However, there have also been many challenges: hundreds of trials have been underpowered, duplicated, or of poor quality; excessive bureaucracy has complicated study initiation; and only a small percentage of eligible patients worldwide have been enrolled in studies, while many others have been treated with off-label, unproven therapies. All of this has been complicated by an “infodemic” of low-quality medical information, accelerated by social media.info:eu-repo/semantics/publishedVersio

Analysis of the Healthcare MERS-CoV Outbreak in King Abdulaziz Medical Center, Riyadh, Saudi Arabia, June–August 2015 Using a SEIR Ward Transmission Model

Middle East respiratory syndrome coronavirus (MERS-CoV) is an emerging zoonotic coronavirus that has a tendency to cause significant healthcare outbreaks among patients with serious comorbidities. We analyzed hospital data from the MERS-CoV outbreak in King Abdulaziz Medical Center, Riyadh, Saudi Arabia, June–August 2015 using the susceptible-exposed-infectious-recovered (SEIR) ward transmission model. The SEIR compartmental model considers several areas within the hospital where transmission occurred. We use a system of ordinary differential equations that incorporates the following units: emergency department (ED), out-patient clinic, intensive care unit, and hospital wards, where each area has its own carrying capacity and distinguishes the transmission by three individuals in the hospital: patients, health care workers (HCW), or mobile health care workers. The emergency department, as parameterized has a large influence over the epidemic size for both patients and health care workers. Trend of the basic reproduction number (R0), which reached a maximum of 1.39 at the peak of the epidemic and declined to 0.92 towards the end, shows that until added hospital controls are introduced, the outbreak would continue with sustained transmission between wards. Transmission rates where highest in the ED, and mobile HCWs were responsible for large part of the outbreak

Association of corticosteroids use and outcomes in COVID-19 patients: A systematic review and meta-analysis

BackgroundTo systematically review the literature about the association between systemic corticosteroid therapy (CST) and outcomes of COVID-19 patients. MethodsWe searched Medline, Embase, EBM Reviews, Scopus, Web of Science, and preprints up to July 20, 2020. We included observational studies and randomized controlled trials (RCT) that assessed COVID-19 patients treated with CST. We pooled adjusted effect estimates of mortality and other outcomes using a random effect model, among studies at low or moderate risk for bias. We assessed the certainty of evidence for each outcome using the GRADE approach. ResultsOut of 1067 citations screened for eligibility, one RCT and 19 cohort studies were included (16,977 hospitalized patients). Ten studies (1 RCT and 9 cohorts) with 10,278 patients examined the effect of CST on short term mortality. The pooled adjusted RR was 0.92 (95% CI 0.69–1.22, I2 = 81.94%). This effect was observed across all stages of disease severity. Four cohort studies examined the effect of CST on composite outcome of death, ICU admission and mechanical ventilation need. The pooled adjusted RR was 0.41(0.23−0.73, I2 = 78.69%). Six cohort studies examined the effect of CST on delayed viral clearance. The pooled adjusted RR was 1.47(95% CI 1.11–1.93, I2 = 43.38%). ConclusionIn this systematic review, as of July 2020, heterogeneous and low certainty cumulative evidence based on observational studies and one RCT suggests that CST was not associated with reduction in short-term mortality but possibly with a delay in viral clearance in patients hospitalized with COVID-19 of different severities. However, the discordant results between the single RCT and observational studies as well as the heterogeneity observed across observational studies, call for caution in using observational data and suggests the need for more RCTs to identify the clinical and biochemical characteristics of patients’ population that could benefit from CST

Patient Outcomes at Twelve Months after Early Decompressive Craniectomy for Diffuse Traumatic Brain Injury in the Randomized DECRA Clinical Trial

Functional outcomes at 12 months were a secondary outcome of the randomized DECRA trial of early decompressive craniectomy for severe diffuse traumatic brain injury (TBI) and refractory intracranial hypertension. In the DECRA trial, patients were randomly allocated 1:1 to either early decompressive craniectomy or intensive medical therapies (standard care). We conducted planned secondary analyses of the DECRA trial outcomes at 6 and 12 months, including all 155 patients. We measured functional outcome using the Glasgow Outcome Scale-Extended (GOS-E). We used ordered logistic regression, and dichotomized the GOS-E using logistic regression, to assess outcomes in patients overall and in survivors. We adjusted analyses for injury severity using the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. At 12 months, the odds ratio (OR) for worse functional outcomes in the craniectomy group (OR 1.68; 95% confidence interval [CI]: 0.96-2.93; p = 0.07) was no longer significant. Unfavorable functional outcomes after craniectomy were 11% higher (59% compared with 48%), but were not significantly different from standard care (OR 1.58; 95% CI: 0.84-2.99; p = 0.16). Among survivors after craniectomy, there were fewer good (OR 0.33; 95% CI: 0.12-0.91; p = 0.03) and more vegetative (OR 5.12; 95% CI: 1.04-25.2; p = 0.04) outcomes. Similar outcomes in survivors were found at 6 months after injury. Vegetative (OR 5.85; 95% CI: 1.21-28.30; p = 0.03) and severely disabled outcomes (OR 2.49; 95% CI: 1.21-5.11; p = 0.01) were increased. Twelve months after severe diffuse TBI and early refractory intracranial hypertension, decompressive craniectomy did not improve outcomes and increased vegetative survivors

Clinical characteristics, sepsis interventions and outcomes in the obese patients with septic shock: an international multicenter cohort study

La calidad educativa de los centros de hoy depende del nivel de competencias adquirido por sus educadores (Perrenoud, 2002). En este sentido, debemos apostar por un equipo humano formado por sujetos que sepan superarse permanentemente, aptos para ejercer tareas dinámicas y cambiantes y que compartan alternativas para crecer en todos los sentidos. Más todavía, debemos apostar por profesionales capaces de identificar y dominar los procesos que se deben realizar actuando con decisión y responsabilidad. La adquisición de competencias comporta aptitud y actitud para utilizar conocimientos, más concretamente, habilidades y valores, de manera interdisciplinaria, transversal e interactiva en contextos y situaciones que requieren la intervención de contenidos vinculados a las diferentes áreas del currículum (Lleixà, 2007), sin exclusividad, en este caso, del área de Educación Física. Presentamos una propuesta metodológica, el «Paradigma Estratégico para el desarrollo de habilidades competenciales», cuya ejecución implica comprensión, reflexión y discernimiento, teniendo en cuenta la dimensión social de cada situación. El estudio se ha llevado a cabo en la Universidad de Lleida con 40 alumnos de tercer curso de la asignatura «Educación Física y su didáctica». Se pretende valorar el impacto que provoca la implementación del programa «Paradigma estratégico para la adquisición de habilidades competenciales» sobre sus propias percepciones competenciales intrapersonales, antes y después de la aplicación de dicho programa