The management of pediatric severe traumatic brain injury: Italian guidelines

Introduction: the aim of the work was to update the “guidelines for the Management of severe traumatic Brain Injury” published in 2012, to reflect the new available evidence, and develop the Italian national guideline for the management of severe pediatric head injuries to reduce variation in practice and ensure optimal care to patients. eViDeNce acQUisitioN: MeDliNe and eMBase were searched from January 2009 to october 2017. inclusion criteria were english language, pediatric populations (0-18 years) or mixed populations (pediatric/adult) with available age subgroup analyses. the guideline development process was started by the Promoting group that composed a multidisciplinary panel of experts, with the representatives of the Scientific Societies, the independent expert specialists and a representative of the Patient associations. the panel selected the clinical questions, discussed the evidence and formulated the text of the recommendations. the documentarists of the University of Florence oversaw the bibliographic research strategy. a group of literature reviewers evaluated the selected literature and compiled the table of evidence for each clinical question. EVIDENCE SYNTHESIS: The search strategies identified 4254 articles. We selected 3227 abstract (first screening) and, finally included 67 articles (second screening) to update the guideline. This Italian update includes 25 evidence-based recommendations and 5 research recommendations. coNclUsioNs: in recent years, progress has been made on the understanding of severe pediatric brain injury, as well as on that concerning all major traumatic pathology. this has led to a progressive improvement in the clinical outcome, although the quantity and quality of evidence remains particularly low

Safety profile of enhanced thromboprophylaxis strategies for critically ill COVID-19 patients during the first wave of the pandemic: observational report from 28 European intensive care units

Introduction: Critical illness from SARS-CoV-2 infection (COVID-19) is associated with a high burden of pulmonary embolism (PE) and thromboembolic events despite standard thromboprophylaxis. Available guidance is discordant, ranging from standard care to the use of therapeutic anticoagulation for enhanced thromboprophylaxis (ET). Local ET protocols have been empirically determined and are generally intermediate between standard prophylaxis and full anticoagulation. Concerns have been raised in regard to the potential risk of haemorrhage associated with therapeutic anticoagulation. This report describes the prevalence and safety of ET strategies in European Intensive Care Unit (ICUs) and their association with outcomes during the first wave of the COVID pandemic, with particular focus on haemorrhagic complications and ICU mortality. Methods: Retrospective, observational, multi-centre study including adult critically ill COVID-19 patients. Anonymised data included demographics, clinical characteristics, thromboprophylaxis and/or anticoagulation treatment. Critical haemorrhage was defined as intracranial haemorrhage or bleeding requiring red blood cells transfusion. Survival was collected at ICU discharge. A multivariable mixed effects generalised linear model analysis matched for the propensity for receiving ET was constructed for both ICU mortality and critical haemorrhage. Results: A total of 852 (79% male, age 66 [37\u201385] years) patients were included from 28 ICUs. Median body mass index and ICU length of stay were 27.7 (25.1\u201330.7) Kg/m2 and 13 (7\u201322) days, respectively. Thromboembolic events were reported in 146 patients (17.1%), of those 78 (9.2%) were PE. ICU mortality occurred in 335/852 (39.3%) patients. ET was used in 274 (32.1%) patients, and it was independently associated with significant reduction in ICU mortality (log odds = 0.64 [95% CIs 0.18\u20131.1; p = 0.0069]) but not an increased risk of critical haemorrhage (log odds = 0.187 [95%CI 12 0.591 to 12 0.964; p = 0.64]). Conclusions: In a cohort of critically ill patients with a high prevalence of thromboembolic events, ET was associated with reduced ICU mortality without an increased burden of haemorrhagic complications. This study suggests ET strategies are safe and associated with favourable outcomes. Whilst full anticoagulation has been questioned for prophylaxis in these patients, our results suggest that there may nevertheless be a role for enhanced / intermediate levels of prophylaxis. Clinical trials investigating causal relationship between intermediate thromboprophylaxis and clinical outcomes are urgently needed

Longitudinal river zonation in the tropics: examples of fish and caddisflies from endorheic Awash river, Ethiopia

Primary Research PaperSpecific concepts of fluvial ecology are well studied in riverine ecosystems of the temperate zone but poorly investigated in the Afrotropical region. Hence, we examined the longitudinal zonation of fish and adult caddisfly (Trichoptera) assemblages in the endorheic Awash River (1,250 km in length), Ethiopia. We expected that species assemblages are structured along environmental gradients, reflecting the pattern of large-scale freshwater ecoregions. We applied multivariate statistical methods to test for differences in spatial species assemblage structure and identified characteristic taxa of the observed biocoenoses by indicator species analyses. Fish and caddisfly assemblages were clustered into highland and lowland communities, following the freshwater ecoregions, but separated by an ecotone with highest biodiversity. Moreover, the caddisfly results suggest separating the heterogeneous highlands into a forested and a deforested zone. Surprisingly, the Awash drainage is rather species-poor: only 11 fish (1 endemic, 2 introduced) and 28 caddisfly species (8 new records for Ethiopia) were recorded from the mainstem and its major tributaries. Nevertheless, specialized species characterize the highland forests, whereas the lowlands primarily host geographically widely distributed species. This study showed that a combined approach of fish and caddisflies is a suitable method for assessing regional characteristics of fluvial ecosystems in the tropicsinfo:eu-repo/semantics/publishedVersio

Dying brain

Dying brain Editor—Ancillary tests used to confirm clinically diagnosed brain death may substantially influence the time of diagnosis, as in the following case. A 48-yr-old woman was shot to the head and was admitted to the hospital at 01:00 a.m. with a Glasgow Coma Scale (GCS) of 1 (eye), 5 (motor), 1 (verbal); brain tissue oxygen tension measured with an intraparenchymal catheter was 12 mm Hg (normal range 15–35 mm Hg), and the intracranial pressure was 25 mm Hg. At 07:00 a.m., GCS score was 3 with absent brainstem reflexes. Brain CT revealed massive cerebral oedema, the brain tissue oxygen tension was zero, and the intracranial pressure was 81 mm Hg with a cerebral perfusion pressure of zero. EEG showed a persistent low amplitude theta activity at the vertex and transcranial Doppler (TCD) a persistent cerebral blood flow in middle cerebral arteries (systolic flow velocity: 30 cm s–1) (Fig. 1A). At 09:00 a.m. of the next day, EEG was flat, and the 6 h observation period required by the Italian law to declare brain death was started; however, a TCD still showed a very low systolic flow velocity and a residual diastolic flow velocity (Fig. 1B). At 03:00 p.m., deep coma, absent reflex motor response and brainstem reflexes, and flat EEG persisted. Brain death was declared. TCD showed a reverberating flow indicating cerebral circulatory arrest (Fig. 1C). There is widespread acceptance of the concept of brain death in the Western hemisphere,1 and a fairly uniform agreement in Europe regarding the clinical criteria.2 There is, however, considerable variation in the use of additional confirmatory tests.1 2 These include flat EEG and determination of cerebral circulatory arrest by means of cerebral angiography, brain CT or MRI angiography, TCD, or cerebral scintigraphy. In the UK,1 only clinical criteria are used and brain death is defined as the complete, irreversible loss of brainstem function. In Sweden,1 cerebral angiography is the facultative ancillary test to confirm brain death; in Italy, EEG is mandatory, while cerebral angiography, brain CT angiography, TCD, or cerebral scintigraphy are all permitted methods to document cerebral circulatory arrest in children of ,1 yr of age, or if a complete and reliable clinical evaluation is not possible

Aneurysmal Subarachnoid Hemorrhage in Pregnancy - Case Series, Review, and Pooled Data Analysis

Background: Aneurysmal subarachnoid haemorrhage (aSAH) during pregnancy represents an important cause of maternal and foetal morbidity and mortality. Approaches to diagnostics and treatment are still controversial and there are only a limited number of cases described in the literature. Our study examines the management of aSAH in pregnant patients creating a case series by combining patients from our hospital records with those from the limited available literature