Impact of non-neurological complications in severe traumatic brain injury outcome

Introduction: Non-neurological complications in patients with severe traumatic brain injury (TBI) are frequent, worsening the prognosis, but the pathophysiology of systemic complications after TBI is unclear. The purpose of this study was to analyze non-neurological complications in patients with severe TBI admitted to the ICU, the impact of these complications on mortality, and their possible correlation with TBI severity. Methods: An observational retrospective cohort study was conducted in one multidisciplinary ICU of a university hospital (35 beds); 224 consecutive adult patients with severe TBI (initial Glasgow Coma Scale (GCS) < 9) admitted to the ICU were included. Neurological and non-neurological variables were recorded. Results: Sepsis occurred in 75% of patients, respiratory infections in 68%, hypotension in 44%, severe respiratory failure (arterial oxygen pressure/oxygen inspired fraction ratio (PaO2/FiO(2)) < 200) in 41% and acute kidney injury (AKI) in 8%. The multivariate analysis showed that Glasgow Outcome Score (GOS) at one year was independently associated with age, initial GCS 3 to 5, worst Traumatic Coma Data Bank (TCDB) first computed tomography (CT) scan and the presence of intracranial hypertension but not AKI. Hospital mortality was independently associated with initial GSC 3 to 5, worst TCDB first CT scan, the presence of intracranial hypertension and AKI. The presence of AKI regardless of GCS multiplied risk of death 6.17 times (95% confidence interval (CI): 1.37 to 27.78) (P < 0.02), while ICU hypotension increased the risk of death in patients with initial scores of 3 to 5 on the GCS 4.28 times (95% CI: 1.22 to15.07) (P < 0.05). Conclusions: Low initial GCS, worst first CT scan, intracranial hypertension and AKI determined hospital mortality in severe TBI patients. Besides the direct effect of low GCS on mortality, this neurological condition also is associated with ICU hypotension which increases hospital mortality among patients with severe TBI. These findings add to previous studies that showed that non-neurological complications increase the length of stay and morbidity in the ICU but do not increase mortality, with the exception of AKI and hypotension in low GCS (3 to 5)

Laboratori d'habilitats: aprenentatge i avaluació dels continguts pràctics de Fisiologia Humana

Podeu consultar la Vuitena trobada de professorat de Ciències de la Salut completa a: http://hdl.handle.net/2445/66524Un dels reptes en els ensenyaments amb docència pràctica és avaluar els coneixements i les habilitats que els estudiants adquireixen al laboratori. En aquest sentit, els estudiants de Ciències Mèdiques Bàsiques, actualment Ciències Biomèdiques, durant els cursos 11-12 i 13-14 van participar en el laboratori d’habilitats de l’assignatura Fisiologia Humana I i II. El laboratori d’habilitats consisteix en un laboratori que disposa dels equips i materials que es fan servir a les pràctiques de l’assignatura i que està a lliure disposició dels estudiants en un horari concret. Un cop realitzades les pràctiques, els estudiants poden participar lliurement en el laboratori d’habilitats per consultar dubtes i practicar les habilitats que han adquirit durant el normal desenvolupament de les pràctiques i que seran objecte d’avaluació. L’avaluació es realitza en el mateix laboratori d’habilitats i consisteix en un examen escrit i oral sobre els continguts de pràctiques, a més d’una demostració de les habilitats adquirides. Les habilitats ponderen un 10% en l’avaluació continuada i són avaluades mitjançant una rúbrica que permet al professorat puntuar objectivament l’estudiant. Un cop realitzat l’examen pràctic els estudiants van ser enquestats per tal de conèixer la seva opinió respecte al “laboratori d’habilitats” i al nou sistema d’avaluació de la docència pràctica. La majoria d’estudiants creuen que el laboratori d’habilitats els ha fet treballar i comprendre millor els continguts de les pràctiques (obtenint una puntuació de 4.2 de mitjana dels dos cursos, sobre 5), prefereixen aquest mètode d’avaluació enfront al tradicional, basat en preguntes a l'examen teòric (4.6 sobre 5), els ha resultat interessant (4.4 sobre 5) i globalment l’experiència els ha resultat satisfactòria (4.5 sobre 5). Les puntuacions obtingudes en l’examen d’habilitats han estat de 8,5 sobre 10 (de mitjana en els darrers 2 cursos). Així, es pot concloure que aquesta metodologia docent, àmpliament acceptada pels estudiants, permet reforçar i avaluar les habilitats treballades al laboratori

Combined intermittent hypobaric hypoxia and muscle electro-stimulation: a method to increase circulating progenitor cell concentration?

Our goal was to test whether short-term intermittent hypobaric hypoxia (IHH) at a level well tolerated by healthy humans could, in combination with muscle electro-stimulation (ME), mobilize circulating progenitor cells (CPC) and increase their concentration in peripheral circulation. Nine healthy male subjects were subjected, as the active group (HME), to a protocol involving IHH plus ME. IHH exposure consisted of four, three-hour sessions at a barometric pressure of 540 hPa (equivalent to an altitude of 5000 m). These sessions took place on four consecutive days. ME was applied in two separate 20-minute periods during each IHH session. Blood samples were obtained from an antecubital vein on three consecutive days immediately before the experiment, and then 24 h, 48 h, 4 days, 7 days and 14 days after the last day of hypoxic exposure. Four months later a control study was carried out involving seven of the original subjects (CG), who underwent the same protocol of blood samples but without receiving any special stimulus. In comparison with the CG the HME group showed only a non-significant increase in the number of CPC CD34+ cells on the fourth day after the combined IHH and ME treatment. CPC levels oscillated across the study period and provide no firm evidence to support an increased CPC count after IHH plus ME, although it is not possible to know if this slight increase observed is physiologically relevant. Further studies are required to understand CPC dynamics and the physiology and physiopathology of the hypoxic stimulus

Physiological and biological responses to short-term intermittent hypobaric hypoxia exposure: from sports and mountain medicine to new biomedical applications

In recent years, the altitude acclimatization responses elicited by short-term intermittent exposure to hypoxia have been subject to renewed attention. The main goal of short-term intermittent hypobaric hypoxia exposure programs was originally to improve the aerobic capacity of athletes or to accelerate the altitude acclimatization response in alpinists, since such programs induce an increase in erythrocyte mass. Several model programs of intermittent exposure to hypoxia have presented efficiency with respect to this goal, without any of the inconveniences or negative consequences associated with permanent stays at moderate or high altitudes. Artificial intermittent exposure to normobaric hypoxia systems have seen a rapid rise in popularity among recreational and professional athletes, not only due to their unbeatable cost/efficiency ratio, but also because they help prevent common inconveniences associated with high-altitude stays such as social isolation, nutritional limitations, and other minor health and comfort-related annoyances. Today, intermittent exposure to hypobaric hypoxia is known to elicit other physiological response types in several organs and body systems. These responses range from alterations in the ventilatory pattern to modulation of the mitochondrial function. The central role played by hypoxia-inducible factor (HIF) in activating a signaling molecular cascade after hypoxia exposure is well known. Among these targets, several growth factors that upregulate the capillary bed by inducing angiogenesis and promoting oxidative metabolism merit special attention. Applying intermittent hypobaric hypoxia to promote the action of some molecules, such as angiogenic factors, could improve repair and recovery in many tissue types. This article uses a comprehensive approach to examine data obtained in recent years. We consider evidence collected from different tissues, including myocardial capillarization, skeletal muscle fiber types and fiber size changes induced by intermittent hypoxia exposure, and discuss the evidence that points to beneficial interventions in applied fields such as sport science. Short-term intermittent hypoxia may not only be useful for healthy people, but could also be considered a promising tool to be applied, with due caution, to some pathophysiological states

Circulating progenitor cells during exercise, muscle electro-stimulation and intermittent hypobaric hypoxia in patients with traumatic brain injury. A pilot study

BACKGROUND: Circulating progenitor cells (CPC) treatments may have great potential for the recovery of neurons and brain function. OBJECTIVE: To increase and maintain CPC with a program of exercise, muscle electro-stimulation (ME) and/or intermittent-hypobaric-hypoxia (IHH), and also to study the possible improvement in physical or psychological functioning of participants with Traumatic Brain Injury (TBI). METHODS: Twenty-one participants. Four groups: exercise and ME group (EEG), cycling group (CyG), IHH and ME group (HEG) and control group (CG). Psychological and physical stress tests were carried out. CPC were measured in blood several times during the protocol. RESULTS: Psychological tests did not change. In the physical stress tests the VO2 uptake increased in the EEG and the CyG, and the maximal tolerated workload increased in the HEG. CPC levels increased in the last three weeks in EEG, but not in CyG, CG and HEG. CONCLUSIONS: CPC levels increased in the last three weeks of the EEG program, but not in the other groups and we did not detect performed psychological test changes in any group. The detected aerobic capacity or workload improvement must be beneficial for the patients who have suffered TBI, but exercise type and the mechanisms involved are not clear

Variables que inciden en la morbimortalidad de los pacientes con traumatismo craneoencefálico grave y su relación con la tomografía computarizada. Un estudio de pacientes consecutivos ingresados en las unidades de críticos del hospital universitario de Bellvitge.

A) Introducción: Los pacientes que sufren un traumatismo craneoencefálico (TCE) grave tienen una elevada morbimortalidad, y a menudo, permanecen discapacitados durante meses y años, por secuelas físicas, psíquicas y/o sociales.B) Objetivos: Estudiar las variables clínicas y radiológicas de la tomografía computarizada (TC), que afecten a la supervivencia y a la morbilidad de los pacientes con TCE grave. Además, se analiza la evolución a los seis y doce meses y las complicaciones a corto plazo.C) Material y métodos: Se incluyeron 224 pacientes adultos con TCE en coma Glasgow Coma Score (GCS) D) Resultados:La edad mediana fue de 36 años (amplitud intercuartil 23-55), la mayoría hombres (84%) y el mecanismo de lesión más frecuente fue el accidente de tráfico (66%). Los factores de mal pronóstico iniciales fueron la edad, el GCS, las pupilas alteradas y la TC, y, en la regresión logística, las variables independientes fueron la edad. el GCS y la TC. Los factores de mal pronóstico durante el ingreso fueron la hipertensión intracraneal, la presión de perfusión cerebral baja (PPC Las escalas de GOS y GOSE mejoraron, significativamente, de los 6 meses al año tras el TCE grave y esta mejoría fue mayor en el grupo de GCS inicial 6-8 que en el de GCS3-5. Las características de la TC que se asociaron a la mortalidad fueron: las contusiones cerebrales múltiples, las lesiones bihemisféricas, la hemorragia subaracnoidea (HSA), las contusiones de tronco y la clasificación de la TC del "Traumatic Coma Data Bank" (TCDB). La hemorragia intraventricular se asoció a una mala evolución, aunque no a un aumento de mortalidad. Los hematomas epidurales se asociaron a menor mortalidad. En la regresión logística, la clasificación de la TC del TCDB, la HSA y el número de territorios afectados por contusiones fueron las variables independientes pronósticas.Las características individuales de la TC no se asociaron a la mejoría del GOS y GOSE de los 6 meses al año, con la excepción de la HSA que se asoció a una menor mejoría del GOSE. La clasificación del TCDB se asoció a la mejoría del GOS/GOSE, mejorando los tipos I, II y masa evacuable más que los tipos III, IV y masa no evacuable.E) Conclusiones: Las características epidemiológicas y los factores pronóstico al ingreso fueron los conocidos y descritos en la literatura. Se deben evitar las complicaciones neurológicas y extraneurológicas durante el ingreso en fase aguda que empeoran notablemente el pronóstico. La valoración de la evolución se debería realizar también al año del traumatismo, ya que se produce una mejoría considerable desde los seis meses al año. Las variables de la TC independientes que influyeron en la evolución fueron la clasificación del TCDB de la TC, la hemorragia subaracnoidea y el número de territorios afectados. Además, las contusiones de tronco y la bilateralidad de las contusiones se asociaron a una peor evolución. La clasificación de la TC del TCDB y la HSA se asociaron a la mejoría del GOS y GOSE de seis meses al año, pero, no las características individuales.a) Objective: To analyze the association between clinical and computerized tomography (CT) variables, and mortality and morbidity. Analyze early complications and outcome at six and twelve months.b) Material and Methods: We studied 224 adult patients with severe traumatic brain injury (TBI) with Glasgow Coma Scale (GCS) c) Results: Median age was 36 years, predominantly male and traffic accidents were the main mechanism of injury. Initial risk factors for bad outcome were age, GCS, abnormal pupils and CT, and in the logistic regression, independent variables were age, GCS and CT. Risk factors during admission, in the logistic regression, were independent variables: intracranial hypertension, severe respiratory failure, septic shock and renal failure.GOS and GOSE scores significantly improved between six and twelve months, this improvement being greater in high GCS score (6-8) at admission group than in the low score (3-5) group.CT characteristics associated with mortality were: multiple contusions, bilateral contusions, subarachnoid hemorrhage (SAH), brainstem contusions and Traumatic Coma Data Bank (TCDB)CT classification, being independent TCDB CT classification, SAH and the number of contusions.Subarachnoid hemorrhage showed a negative association with GOSE improvement between six and twelve months. TCDB CT classification was associated with GOS and GOSE improvement, type I, II and evacuated mass improving more than type III, IV and non-evacuated mass.d) Conclusions: Epidemiologic characteristics and prognostic factors were the same described in the literature. Neurological and non-neurological complications should be avoided during admission in acute phase, because it clearly impairs prognosis. Outcome measure should be done also at one year, because GOS and GOSE scores improve between six and twelve months after severe TBI. TCDB CT scan classification, SAH and number of contusions were associated with mortality. Brainstem and bilateral contusions were associated with worse outcome. TCDB CT classification and SAH were associated with GOS/GOSE improvement from six to twelve months, but individual CT abnormalities were not associated

Variables incidence in the mortality and morbidity of severe traumatic brain injured patients and its relation with computerized tomography

[spa] A) Introducción: Los pacientes que sufren un traumatismo craneoencefálico (TCE) grave tienen una elevada morbimortalidad, y a menudo, permanecen discapacitados durante meses y años, por secuelas físicas, psíquicas y/o sociales.B) Objetivos: Estudiar las variables clínicas y radiológicas de la tomografía computarizada (TC), que afecten a la supervivencia y a la morbilidad de los pacientes con TCE grave. Además, se analiza la evolución a los seis y doce meses y las complicaciones a corto plazo.C) Material y métodos: Se incluyeron 224 pacientes adultos con TCE en coma Glasgow Coma Score (GCS) < 9, que ingresaron en las unidades de críticos del Hospital Universitario de Bellvitge de forma consecutiva. Se excluyeron los pacientes con signos de enclavamiento o de muerte inminente. Las secuelas se midieron mediante las escalas de "Glasgow Outcome Scale" (GOS) y GOS extendido (GOSE).D) Resultados:La edad mediana fue de 36 años (amplitud intercuartil 23-55), la mayoría hombres (84%) y el mecanismo de lesión más frecuente fue el accidente de tráfico (66%). Los factores de mal pronóstico iniciales fueron la edad, el GCS, las pupilas alteradas y la TC, y, en la regresión logística, las variables independientes fueron la edad. el GCS y la TC. Los factores de mal pronóstico durante el ingreso fueron la hipertensión intracraneal, la presión de perfusión cerebral baja (PPC < 60 mm Hg), la hipotensión arterial, la necesidad de aminas vasoactivas, el shock séptico, el síndrome de distres respiratorio del adulto, la insuficiencia respiratoria grave (PaO2/FiO2 < 200), las hemorragias y la insuficiencia renal. En la regresión logística, las variables independientes fueron la hipertensión intracraneal, la insuficiencia respiratoria grave, el shock séptico y la insuficiencia renal.Las escalas de GOS y GOSE mejoraron, significativamente, de los 6 meses al año tras el TCE grave y esta mejoría fue mayor en el grupo de GCS inicial 6-8 que en el de GCS3-5. Las características de la TC que se asociaron a la mortalidad fueron: las contusiones cerebrales múltiples, las lesiones bihemisféricas, la hemorragia subaracnoidea (HSA), las contusiones de tronco y la clasificación de la TC del "Traumatic Coma Data Bank" (TCDB). La hemorragia intraventricular se asoció a una mala evolución, aunque no a un aumento de mortalidad. Los hematomas epidurales se asociaron a menor mortalidad. En la regresión logística, la clasificación de la TC del TCDB, la HSA y el número de territorios afectados por contusiones fueron las variables independientes pronósticas.Las características individuales de la TC no se asociaron a la mejoría del GOS y GOSE de los 6 meses al año, con la excepción de la HSA que se asoció a una menor mejoría del GOSE. La clasificación del TCDB se asoció a la mejoría del GOS/GOSE, mejorando los tipos I, II y masa evacuable más que los tipos III, IV y masa no evacuable.E) Conclusiones: Las características epidemiológicas y los factores pronóstico al ingreso fueron los conocidos y descritos en la literatura. Se deben evitar las complicaciones neurológicas y extraneurológicas durante el ingreso en fase aguda que empeoran notablemente el pronóstico. La valoración de la evolución se debería realizar también al año del traumatismo, ya que se produce una mejoría considerable desde los seis meses al año. Las variables de la TC independientes que influyeron en la evolución fueron la clasificación del TCDB de la TC, la hemorragia subaracnoidea y el número de territorios afectados. Además, las contusiones de tronco y la bilateralidad de las contusiones se asociaron a una peor evolución. La clasificación de la TC del TCDB y la HSA se asociaron a la mejoría del GOS y GOSE de seis meses al año, pero, no las características individuales.[eng] a) Objective: To analyze the association between clinical and computerized tomography (CT) variables, and mortality and morbidity. Analyze early complications and outcome at six and twelve months.b) Material and Methods: We studied 224 adult patients with severe traumatic brain injury (TBI) with Glasgow Coma Scale (GCS) < 9 consecutively admitted to Intensive Care Unit. Patients with signs of imminent death were excluded. The sequelae were measured with Glasgow Outcome Scale (GOS) and extended GOS (GOSE) at six and twelve months.c) Results: Median age was 36 years, predominantly male and traffic accidents were the main mechanism of injury. Initial risk factors for bad outcome were age, GCS, abnormal pupils and CT, and in the logistic regression, independent variables were age, GCS and CT. Risk factors during admission, in the logistic regression, were independent variables: intracranial hypertension, severe respiratory failure, septic shock and renal failure.GOS and GOSE scores significantly improved between six and twelve months, this improvement being greater in high GCS score (6-8) at admission group than in the low score (3-5) group.CT characteristics associated with mortality were: multiple contusions, bilateral contusions, subarachnoid hemorrhage (SAH), brainstem contusions and Traumatic Coma Data Bank (TCDB)CT classification, being independent TCDB CT classification, SAH and the number of contusions.Subarachnoid hemorrhage showed a negative association with GOSE improvement between six and twelve months. TCDB CT classification was associated with GOS and GOSE improvement, type I, II and evacuated mass improving more than type III, IV and non-evacuated mass.d) Conclusions: Epidemiologic characteristics and prognostic factors were the same described in the literature. Neurological and non-neurological complications should be avoided during admission in acute phase, because it clearly impairs prognosis. Outcome measure should be done also at one year, because GOS and GOSE scores improve between six and twelve months after severe TBI. TCDB CT scan classification, SAH and number of contusions were associated with mortality. Brainstem and bilateral contusions were associated with worse outcome. TCDB CT classification and SAH were associated with GOS/GOSE improvement from six to twelve months, but individual CT abnormalities were not associated

Impact of non-neurological complications in severe traumatic brain injury outcome

Introduction: Non-neurological complications in patients with severe traumatic brain injury (TBI) are frequent, worsening the prognosis, but the pathophysiology of systemic complications after TBI is unclear. The purpose of this study was to analyze non-neurological complications in patients with severe TBI admitted to the ICU, the impact of these complications on mortality, and their possible correlation with TBI severity. Methods: An observational retrospective cohort study was conducted in one multidisciplinary ICU of a university hospital (35 beds); 224 consecutive adult patients with severe TBI (initial Glasgow Coma Scale (GCS) < 9) admitted to the ICU were included. Neurological and non-neurological variables were recorded. Results: Sepsis occurred in 75% of patients, respiratory infections in 68%, hypotension in 44%, severe respiratory failure (arterial oxygen pressure/oxygen inspired fraction ratio (PaO2/FiO(2)) < 200) in 41% and acute kidney injury (AKI) in 8%. The multivariate analysis showed that Glasgow Outcome Score (GOS) at one year was independently associated with age, initial GCS 3 to 5, worst Traumatic Coma Data Bank (TCDB) first computed tomography (CT) scan and the presence of intracranial hypertension but not AKI. Hospital mortality was independently associated with initial GSC 3 to 5, worst TCDB first CT scan, the presence of intracranial hypertension and AKI. The presence of AKI regardless of GCS multiplied risk of death 6.17 times (95% confidence interval (CI): 1.37 to 27.78) (P < 0.02), while ICU hypotension increased the risk of death in patients with initial scores of 3 to 5 on the GCS 4.28 times (95% CI: 1.22 to15.07) (P < 0.05). Conclusions: Low initial GCS, worst first CT scan, intracranial hypertension and AKI determined hospital mortality in severe TBI patients. Besides the direct effect of low GCS on mortality, this neurological condition also is associated with ICU hypotension which increases hospital mortality among patients with severe TBI. These findings add to previous studies that showed that non-neurological complications increase the length of stay and morbidity in the ICU but do not increase mortality, with the exception of AKI and hypotension in low GCS (3 to 5)

Impact of non-neurological complications in severe traumatic brain injury outcome

Introduction: Non-neurological complications in patients with severe traumatic brain injury (TBI) are frequent, worsening the prognosis, but the pathophysiology of systemic complications after TBI is unclear. The purpose of this study was to analyze non-neurological complications in patients with severe TBI admitted to the ICU, the impact of these complications on mortality, and their possible correlation with TBI severity. Methods: An observational retrospective cohort study was conducted in one multidisciplinary ICU of a university hospital (35 beds); 224 consecutive adult patients with severe TBI (initial Glasgow Coma Scale (GCS) < 9) admitted to the ICU were included. Neurological and non-neurological variables were recorded. Results: Sepsis occurred in 75% of patients, respiratory infections in 68%, hypotension in 44%, severe respiratory failure (arterial oxygen pressure/oxygen inspired fraction ratio (PaO2/FiO(2)) < 200) in 41% and acute kidney injury (AKI) in 8%. The multivariate analysis showed that Glasgow Outcome Score (GOS) at one year was independently associated with age, initial GCS 3 to 5, worst Traumatic Coma Data Bank (TCDB) first computed tomography (CT) scan and the presence of intracranial hypertension but not AKI. Hospital mortality was independently associated with initial GSC 3 to 5, worst TCDB first CT scan, the presence of intracranial hypertension and AKI. The presence of AKI regardless of GCS multiplied risk of death 6.17 times (95% confidence interval (CI): 1.37 to 27.78) (P < 0.02), while ICU hypotension increased the risk of death in patients with initial scores of 3 to 5 on the GCS 4.28 times (95% CI: 1.22 to15.07) (P < 0.05). Conclusions: Low initial GCS, worst first CT scan, intracranial hypertension and AKI determined hospital mortality in severe TBI patients. Besides the direct effect of low GCS on mortality, this neurological condition also is associated with ICU hypotension which increases hospital mortality among patients with severe TBI. These findings add to previous studies that showed that non-neurological complications increase the length of stay and morbidity in the ICU but do not increase mortality, with the exception of AKI and hypotension in low GCS (3 to 5)