Molecular mechanisms of traumatic brain injury: the missing link in management.

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.Head injury is common, sometimes requires intensive care unit admission, and is associated with significant mortality and morbidity. A gap still remains in the understanding of the molecular mechanism of this condition. This review is aimed at providing a general overview of the molecular mechanisms involved in traumatic brain injury to a busy clinician. It will encompass the pathophysiology in traumatic brain injury including apoptosis, the role of molecules and genes, and a brief mention of possible pharmacological therapies

Perioperative care of a patient with stroke.

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.Strokes and TIAs, with their high cumulative mortality and morbidity rates, are occurring with increasing frequency in western population 14. As such, it is vital for clinicians to provide optimal medical management in the perioperative period for those patients with this common neurological problem. This review aims to highlight the importance of the perioperative period and the stages of pre-optimization that can be taken by the multi-disciplinary team to aid this 171819. The evidence suggests that there are significant physiological advantages to early invasive monitoring and high dependency care in these complex patients. These cohort of patients are at increased risk of development of respiratory, gastrointestinal, nutritional and electrolyte disturbances so a constant vigil should be exercised in early recognition and treatment

Exploratory Analysis of Preoperative and Postoperative Risk Stratification Tools to Identify Acute Kidney and Myocardial Injury in Patients Undergoing Surgery for Chronic Subdural Haematoma.

Perioperative statistical risk stratification is widespread. Such tools inform intraoperative and postoperative care as part of the National Emergency Laparotomy Audit (NELA)1. Patients with chronic subdural haematomas (cSDH) are often elderly with significant comorbidity2. Despite this, there is a paucity of literature pertaining to risk stratification models in this cohort3. At our centre, as part of a multidisciplinary improvement initiative (the ‘Improving Care in Elderly Neurosurgery Initiative’ (ICENI)4) (Project ID:PRN7705) we demonstrated a significant association between postoperative complications and length of stay2. As a further analysis within this cohort of operated cSDH, we explore the potential of using retrospective electronic health record (EHR) data to generate prognostic statistical models for the identification of two end-organ complications (myocardial injury –troponin above the upper limit of normal and acute kidney injury (AKI) –a rise in serum creatinine of ≥ 1.5 times baseline). Outcomes were chosen based on data availability and veracity as well as clinical relevance. The integrated nature of our EHR permitted incorporation of variables reflecting intraoperative management. This enabled an exploratory analysis of models that, analogous to NELA, could be used preoperatively and updated postoperatively

Identification of factors associated with morbidity and postoperative length of stay in surgically managed chronic subdural haematoma using electronic health records: a retrospective cohort study.

INTRODUCTION: Chronic subdural haematoma (cSDH) tends to occur in older patients, often with significant comorbidity. The incidence and effect of medical complications as well as the impact of intraoperative management strategies are now attracting increasing interest. OBJECTIVES: We used electronic health record data to study the profile of in-hospital morbidity and examine associations between various intraoperative events and postoperative stay. DESIGN, SETTING AND PARTICIPANTS: Single-centre, retrospective cohort of 530 cases of cSDH (2014-2019) surgically evacuated under general anaesthesia at a neurosciences centre in Cambridge, UK. METHODS AND OUTCOME DEFINITION: Complications were defined using a modified Electronic Postoperative Morbidity Score. Association between complications and intraoperative care (time with mean arterial pressure <80 mm Hg, time outside of end-tidal carbon dioxide (ETCO2) range of 3-5 kPa, maintenance anaesthetic, operative time and opioid dose) on postoperative stay was assessed using Cox regression. RESULTS: 53 (10%) patients suffered myocardial injury, while 24 (4.5%) suffered acute renal injury. On postoperative day 3 (D3), 280 (58% of remaining) inpatients suffered at least 1 complication. D7 rate was comparable (57%). Operative time was the only intraoperative event associated with postoperative stay (HR for discharge: 0.97 (95% CI: 0.95 to 0.99)). On multivariable analysis, postoperative complications (0.61 (0.55 to 0.68)), anticoagulation (0.45 (0.37 to 0.54)) and cognitive impairment (0.71 (0.58 to 0.87)) were associated with time to discharge. CONCLUSIONS: There is a high postoperative morbidity burden in this cohort, which was associated with postoperative stay. We found no evidence of an association between intraoperative events and postoperative stay.Wellcome Trust Studentshi

Feasibility of fully automated closed-loop glucose control using continuous subcutaneous glucose measurements in critical illness: a randomized controlled trial.

INTRODUCTION: Closed-loop (CL) systems modulate insulin delivery according to glucose levels without nurse input. In a prospective randomized controlled trial, we evaluated the feasibility of an automated closed-loop approach based on subcutaneous glucose measurements in comparison with a local sliding-scale insulin-therapy protocol. METHODS: Twenty-four critically ill adults (predominantly trauma and neuroscience patients) with hyperglycemia (glucose, ≥10 mM) or already receiving insulin therapy, were randomized to receive either fully automated closed-loop therapy (model predictive control algorithm directing insulin and 20% dextrose infusion based on FreeStyle Navigator continuous subcutaneous glucose values, n = 12) or a local protocol (n = 12) with intravenous sliding-scale insulin, over a 48-hour period. The primary end point was percentage of time when arterial blood glucose was between 6.0 and 8.0 mM. RESULTS: The time when glucose was in the target range was significantly increased during closed-loop therapy (54.3% (44.1 to 72.8) versus 18.5% (0.1 to 39.9), P = 0.001; median (interquartile range)), and so was time in wider targets, 5.6 to 10.0 mM and 4.0 to 10.0 mM (P ≤ 0.002), reflecting a reduced glucose exposure >8 and >10 mM (P ≤ 0.002). Mean glucose was significantly lower during CL (7.8 (7.4 to 8.2) versus 9.1 (8.3 to 13.0] mM; P = 0.001) without hypoglycemia (<4 mM) during either therapy. CONCLUSIONS: Fully automated closed-loop control based on subcutaneous glucose measurements is feasible and may provide efficacious and hypoglycemia-free glucose control in critically ill adults. TRIAL REGISTRATION: ClinicalTrials.gov Identifier, NCT01440842

Can compliment and complaint data inform the care of individuals with chronic subdural haematoma (cSDH)?

OBJECTIVES: To explore the frequency and nature of complaints and compliments reported to Patient Advice and Liaison (PALS) in individuals undergoing surgery for a chronic subdural haematoma (cSDH). DESIGN: A retrospective study of PALS user interactions. SUBJECTS: Individuals undergoing treatment for cSDH between 2014 and 2019. METHODS: PALS referrals from patients with cSDH between 2014 and 2019 were identified. Case records were reviewed and data on the frequency, nature and factors leading up to the complaint were extracted and coded according to Healthcare Complaints Analysis Tool (HCAT). RESULTS: Out of 531 patients identified, 25 (5%) had a PALS interaction, of which 15 (3%) were complaints and 10 (2%) were compliments. HCAT coding showed 8/15 (53%) of complaints were relationship problems, 6/15 (33%) a management problem and 1/15 (7%) other. Of the relationship problems, 6 (75%) were classed as problems with communication and 2 (25%) as a problem with listening. Of the compliments, 9/10 (90%) related to good clinical quality and 1/10 (10%) to staff-patient relationship. Patients were more likely to register a compliment than family members, who in turn were more likely to register a complaint (p<0.005). Complaints coded as a relationship problem had 2/8 (25%) submitted by a patient and 6/8 (75%) submitted by a relative. CONCLUSIONS: Using the HCAT, routinely collected PALS data can easily be coded to quantify and provide unique perspective on tertiary care, such as communication. It is readily suited to quality improvement and audit initiatives.NIHR Clinical Doctoral Research Fellowshi