Co-production opportunities seized and missed in decision-support frameworks for climate-change adaptation in agriculture – How do we practice the “best practice”?

To contribute to building sustainable and effective climate change adaptation solutions avoiding usability gap, it is largely recommended to engage in the process of co-production, integrating expertise and knowledge from various academic and non-academic actors. We want to learn if and how co-production, believed to effectively link knowledge and decision-making, and thus suggested as the best practice in building decision-support frameworks, is really applied in the frameworks that are being implemented on the ground. A literature review allowed us to identify integrated decision-support frameworks for climate-change adaptation in agriculture developed and used over the period of the last 10 years and involving non-academic stakeholders. To analyse them, we chose as an assessment tool the four co-production principles proposed by Norström and colleagues: context-based, pluralistic, goal-oriented and interactive. The useful entry points for incorporating co-production in the design of decision-support that we found in the reviewed frameworks include among the others adequate participants selection strategy, building on existing interaction spaces, developing a theory of change with the participants, and involving participants in the design of different elements of the method. The architectures of the analyzed frameworks contained more elements that responded to pluralistic and interactive principles than to context-based and goal oriented principles, we have also identified gaps in the design, such as taking into account the personal characteristics of researchers that could strengthen a framework's implementation and its impact, or attempts at bridging different levels of decision making, to cover the triad of science, policy and practice. A detailed look at the decision-frameworks that are actually being applied allows for a critical reflection whether and how we as researchers use what we preach as an effective way of responding to sustainability challenges in agriculture. Co-production principles turn out to be a useful tool for analysis and we suggest they can be used as a check-list when designing decision-support frameworks for climate-change adaptation. This papers offers useful examples of how to shift the research-led processes of decision-support towards more co-production with non-academic actors, to increase chances of bridging the gaps between science, policy and practice

Interet du NIRS dans le monitorage de l'oxygenation cerebrale lors d'une hyperventilation chez les traumatises craniens graves en htic refractaire

Introduction : Lors d'une hypertension intracrânienne (HTIC) secondaire à un traumatisme crânien grave (TCG), l'hypocapnie contrôlée peut entrainer, par vasoconstriction des artères cérébrales, une ischémie responsable de lésions secondaires. Toutefois, au cours d'une HTIC réfractaire survenant dans un contexte d'hyperhémie, l'hyperventilation pourrait permettre de diminuer rapidement la pression intracrânienne (PIC). Dans ce contexte, un monitorage de l'oxygénation cérébrale est indispensable. Il peut être réalisé de façon invasive par la mesure de la saturation veineuse jugulaire en oxygène (SjO2). Le NIRS, spectroscopie dans le proche infrarouge, pourrait approcher cette valeur de façon non-invasive. L'objectif de l'étude était de comparer les valeurs de NIRS et SjO2 au cours d'une manoeuvre d'hyperventilation chez les TCG en HTIC avec hyperhémie cérébrale. Matériel et méthodes : Etude prospective observationnelle monocentrique incluant des patients TCG en HTIC > 20mmHg malgré un traitement médico-chirurgical optimal et une hyperhémie cérébrale définie sur des critères de doppler transcrânien. Une électrode de NIRS était placée du coté de la SjO2 (veine dominante). On recueillait et comparait avant (T0) et après hyperventilation (T1) les valeurs de SjO2, NIRS, lactate jugulaire et les paramètres du doppler transcrânien. Les relations entre la SjO2 et le NIRS ont été étudiées par une relation de corrélation et méthode graphique de Bland-Altman. Résultats : 13 patients ont bénéficié d'une hyperventilation (PaCO2 à 5,1+- 0,6 à T0 vs 4,1 +- 0,5 kPa à T1) avec une diminution de la PIC observée chez tous les patients (de 27 [22-35] mmHg à 12 [9-17] mmHg ; p < 0,001). Les valeurs doppler homolatérales sont restées comparables entre T0 et T1. Il n'y a pas eu de SjO2 < 50% et 3 patients ont eu une SjO2 entre 55 et 60% à T1. Ces trois patients étaient les seuls ayant un NIRS < 60% à T1. L'étude de corrélation entre SjO2 et NIRS montrait un r à 0,77 (p < 0,0001) à T0 et à 0,70 (p = 0,0004) à T1. L'analyse du Bland-Altman comparant SjO2 et NIRS montrait un biais plus étroit à T0 qu'à T1 : -5,3 [-15,3 ; 4,8] et, à T1, 2 [-11,8 ; 15,8]. Conclusion : Il existe une corrélation satisfaisante et intéressante sur le plan clinique entre NIRS et SjO2 dans le contexte de la traumatologie crânienne au cours d'une hypocapnie contrôlée. Le seuil délétère de diminution de l'oxygénation cérébrale est probablement une valeur de NIRS < 60.BORDEAUX1-Bib.electronique (335229901) / SudocSudocFranceF

Comparaison de l'index bispectral (BIS-SPtm) et de l'électroencéphalogramme chez des patients traumatisés crâniens sévères lors d'un traitement induisant un coma barbiturique

Les traumatisés crâniens sévères (TCS) avec hypertension intracrânienne sont parfois traités par les barbituriques. L'objectif de la sédation est d'obtenir un EEG avec des burst suppression (2à 5/min). Le BIS-XP donne en temps réel des données issues de l'EEG : le BIS et le RS (ratio de suppression). Le but de cette étude est de rechercher si un iveau de BIS ou de RS peut être utilisé pour prédire une intoxication barbiturique ou une sédation profonde chez les TCS traités par barbituriques. Tous les TCS traités par barbituriques en réanimation chirurgicale sont inclus prospectivement en 2003. Des EEG numériques sont réalisés quotidiennement pendant une heure et relus par un neurologue. Toutes les 5 minutes une minute est gardée pour compter le nombre de burst et le pourcentage de temps en silence électrique (RS/EEG). La relation entre les 2 valeurs est étudiée avec un test de corrélation et une méthode graphique selon BLand et Altman. Une analyse en terme de sensibilité (Se), spécificité (Sp) et valeur prédictive positive et négative (VPP et VPN) est réalisée pour différents niveaux de BIS ou de RS. 12 patients étudiés, 31 EEG enregistrés, 372 valeurs retenues pour l'analyse. Il existe une importante corrélation entre RS et RS/EEG : coefficient de 0,97, p89. Pour une sédation adéquate, les indicateurs pourraient être un BIS entre 6 et 15 ou un RS entre 89 et 65.BORDEAUX2-BU Santé (330632101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Subclavian central venous catheter-related thrombosis in trauma patients: incidence, risk factors and influence of polyurethane type.

International audienceINTRODUCTION: The incidence of deep venous thrombosis (DVT) related to a central venous catheter varies considerably in ICUs depending on the population included. The aim of this study was to determine subclavian central venous catheter (SCVC)-related DVT risk factors in severely traumatized patients with regard to two kinds of polyurethane catheters. METHODS: Critically ill trauma patients needing a SCVC for their usual care were prospectively included in an observational study. Depending on the month of inclusion, patients received one of the two available products in the emergency unit: either an aromatic polyurethane SCVC or an aliphatic polyurethane SCVC. Patients were screened weekly by ultrasound for SCVC-related DVT. Potential risk factors were collected, including history-related, trauma-related and SCVC-related characteristics. RESULTS: A total of 186 patients were included with a median Injury Severity Sore of 30 and a high rate of severe brain injuries (21% of high intracranial pressure). Incidence of SCVC-related DVT was 37% (95% confidence interval: 26 to 40) in patients or 20/1,000 catheter-days. SCVC-related DVT occurred within 8 days in 65% of cases. There was no significant difference in DVT rates between the aromatic polyurethane and aliphatic polyurethane SCVC groups (38% vs. 36%). SCVC-related DVT independent risk factors were age >30 years, intracranial hypertension, massive transfusion (>10 packed red blood cell units), SCVC tip position in the internal jugular or in the innominate vein, and ipsilateral jugular catheter. CONCLUSION: SCVC-related DVT concerned one-third of these severely traumatized patients and was mostly clinically silent. Incidence did not depend on the type of polyurethane but was related to age >30 years, intracranial hypertension or misplacement of the SCVC. Further studies are needed to assess the cost-effectiveness of routine screening in these patients in whom thromboprophylaxis may be hazardous

Higher than standard dosing regimen are needed to achieve optimal antibiotic exposure in critically ill patients with augmented renal clearance receiving piperacillin-tazobactam administered by continuous infusion

Purpose To determine whether augmented renal clearance (ARC) impacts negatively on piperacillin-tazobactam unbound concentrations in critically ill patients receiving 16 g/2 g/day administered continuously. Material and methods Fifty nine critically ill patients without renal impairment underwent 24-h creatinine clearance (Cr CL ) measurement and therapeutic drug monitoring during the first three days of antimicrobial therapy by piperacillin-tazobactam. The main outcome was the rate of piperacillin underexposure, defined by at least one of three samples under 16 mg/L. Monte Carlo simulation was performed to predict the distribution of piperacillin concentrations for various Cr CL and minimal inhibitory concentration (MIC) values. Results The rate of piperacillin underexposure was 19%, significantly higher in ARC patients (0 vs. 31%, p = .003). A threshold of Cr CL ≥ 170 mL/min had a sensitivity and specificity of 1 (95%CI: 0.79–1) and 0.69 (95%CI: 0.61–0.76) to predict piperacillin underexposure. In ARC patients, a 20 g/2.5 g/24 h PTZ dosing regimen was associated with the highest probability to reach the 16 mg/L empirical target, without risk of excessive dosing. Conclusions When targeting a theoretical MIC at the upper limit of the susceptibility range, the desirable target (100%fT >16 ) may not be achieved in patients with Cr CL ≥ 170 mL/min receiving PTZ 16 g/2 g/day administered continuously

Assessment of White Matter Injury and Outcome in Severe Brain Trauma: A Prospective Multicenter Cohort

BACKGROUND:: Existing methods to predict recovery after severe traumatic brain injury lack accuracy. The aim of this study is to determine the prognostic value of quantitative diffusion tensor imaging (DTI). METHODS:: In a multicenter study, the authors prospectively enrolled 105 patients who remained comatose at least 7 days after traumatic brain injury. Patients underwent brain magnetic resonance imaging, including DTI in 20 preselected white matter tracts. Patients were evaluated at 1 yr with a modified Glasgow Outcome Scale. A composite DTI score was constructed for outcome prognostication on this training database and then validated on an independent database (n = 38). DTI score was compared with the International Mission for Prognosis and Analysis of Clinical Trials Score. RESULTS:: Using the DTI score for prediction of unfavorable outcome on the training database, the area under the receiver operating characteristic curve was 0.84 (95% CI: 0.75-0.91). The DTI score had a sensitivity of 64% and a specificity of 95% for the prediction of unfavorable outcome. On the validation-independent database, the area under the receiver operating characteristic curve was 0.80 (95% CI: 0.54-0.94). On the training database, reclassification methods showed significant improvement of classification accuracy (P < 0.05) compared with the International Mission for Prognosis and Analysis of Clinical Trials score. Similar results were observed on the validation database. CONCLUSIONS:: White matter assessment with quantitative DTI increases the accuracy of long-term outcome prediction compared with the available clinical/radiographic prognostic score