The contribution of international health volunteers to the health workforce in sub-Saharan Africa

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Variation in Structure and Process of Care in Traumatic Brain Injury: Provider Profiles of European Neurotrauma Centers Participating in the CENTER-TBI Study.

INTRODUCTION: The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. METHODS: We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions. RESULTS: All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers. CONCLUSION: Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches

Variation in general supportive and preventive intensive care management of traumatic brain injury: a survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study

Abstract Background General supportive and preventive measures in the intensive care management of traumatic brain injury (TBI) aim to prevent or limit secondary brain injury and optimize recovery. The aim of this survey was to assess and quantify variation in perceptions on intensive care unit (ICU) management of patients with TBI in European neurotrauma centers. Methods We performed a survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We analyzed 23 questions focused on: 1) circulatory and respiratory management; 2) fever control; 3) use of corticosteroids; 4) nutrition and glucose management; and 5) seizure prophylaxis and treatment. Results The survey was completed predominantly by intensivists (n = 33, 50%) and neurosurgeons (n = 23, 35%) from 66 centers (97% response rate). The most common cerebral perfusion pressure (CPP) target was > 60 mmHg (n = 39, 60%) and/or an individualized target (n = 25, 38%). To support CPP, crystalloid fluid loading (n = 60, 91%) was generally preferred over albumin (n = 15, 23%), and vasopressors (n = 63, 96%) over inotropes (n = 29, 44%). The most commonly reported target of partial pressure of carbon dioxide in arterial blood (PaCO2) was 36–40 mmHg (4.8–5.3 kPa) in case of controlled intracranial pressure (ICP) < 20 mmHg (n = 45, 69%) and PaCO2 target of 30–35 mmHg (4–4.7 kPa) in case of raised ICP (n = 40, 62%). Almost all respondents indicated to generally treat fever (n = 65, 98%) with paracetamol (n = 61, 92%) and/or external cooling (n = 49, 74%). Conventional glucose management (n = 43, 66%) was preferred over tight glycemic control (n = 18, 28%). More than half of the respondents indicated to aim for full caloric replacement within 7 days (n = 43, 66%) using enteral nutrition (n = 60, 92%). Indications for and duration of seizure prophylaxis varied, and levetiracetam was mostly reported as the agent of choice for both seizure prophylaxis (n = 32, 49%) and treatment (n = 40, 61%). Conclusions Practice preferences vary substantially regarding general supportive and preventive measures in TBI patients at ICUs of European neurotrauma centers. These results provide an opportunity for future comparative effectiveness research, since a more evidence-based uniformity in good practices in general ICU management could have a major impact on TBI outcome

Hyponatrémie aux urgences

IntroductionL’hyponatrémie (HNa) est une des anomalies hydro-électrolytiques les plus fréquentes. Une seule étude prospective a été réalisée aux urgences montrant une prévalence de l’HNa de 3.8%. L’impact de l’HNa sur la mortalité et la morbidité des patients admis aux urgences reste toutefois inconnu.Objectifs :Evaluer la fréquence et les complications associées à l’ HNa chez des patients admis dans le service des urgences d’un hôpital universitaire bruxellois.Patients et MéthodesNous avons rétrospectivement identifié les dossiers de tous les patients admis aux urgences entre le 1er juin 2009 et le 30 mars 2010 grâce à un système informatique (E-Care). Les patients présentant un sodium plasmatique < 130mmol/l ont été identifiés via le laboratoire central de l’hôpital ;cette liste a été confrontée avec celle de tous les patients sur le système E-Care pour identifier ceux dont la prise de sang avaient été effectuée aux urgences (le groupe « cas »). Nous avons par la suite créé un groupe « contrôle », en appariant pour l’âge et le sexe, un même nombre de patients admis aux urgences durant la même période n’ayant pas d’HNa (appariement 1 :1). Nous avons collecté les donnés démographiques (âge, sexe et date d’admission), cliniques (motif d’admission, signes et symptômes), biologiques (sodium plasmatique, urée, créatinine, sodium, osmolarité et créatinine urinaire, diurèse de 24 heures) ainsi que les co-morbidités. Nous avons aussi enregistré les médicaments que les patients prenaient avant l’admission (corticoïdes, antidépresseurs, antiépileptiques, immunosuppresseurs, diurétiques, inhibiteurs de l’enzyme de conversion ou les antagonistes du récepteur à l’angiotensine II). Les variables d’intérêt étaient :l’admission à l’hôpital, l’admission aux Soins Intensifs, la survenue de complications respiratoires (pneumonie, syndrome de détresse respiratoire aigu - SDRA), cardio-vasculaires (œdème pulmonaire aigu, syndrome coronarien aigu), neurologiques (épilepsie, coma), du système uro-gynécologique (infection urinaire, avortement, insuffisance rénale aiguë), digestives (diarrhée, hémorragie digestive), orthopédiques (fracture, douleur ostéo-tendineuse) ou de sepsis ;la mortalité hospitalière.RésultatsParmi les 36036 patients admis aux urgences dans la période d’étude, 10816 ont eu une prise de sang, dont 183 avaient une HNa (1.7%). Les patients dans le group HNa avaient plus fréquemment des tumeurs solides (29/183 vs. 12/183 p = 0.03) et recevaient plus de diurétiques que les patients « contrôles » (68/183 vs. 47/183 p = 0.04). Le tableau clinique à l’admission n’était pas différent entre les groupes. Seulement 59 patients (32%) avec HNa avaient eu une récolte des urines de 24 heures et/ou une analyse du sodium, de l’osmolarité et de la créatinine urinaires permettant une démarche diagnostique pour identifier la cause d’HNa. L’admission à l’hôpital ou à l’USI était significativement plus fréquente chez les patients HNa que les contrôles (163/183 vs. 99/183 - p = 0.001, 25/183 vs. 7/183, p = 0.01, respectivement). La durée d’hospitalisation était de 11 jours [6-16] dans le groupe HNa et de 8 jours [4-14] dans le groupe contrôle (p = 0.01). Les patients HNa présentaient plus fréquemment au moins une complication pendant leur séjour (44 vs. 10%, p<0.001), et plus spécifiquement plus de complications respiratoires (13 vs. 4%, p = 0.01), uro-gynécologiques (15 vs. 5%, p = 0.01), digestives (18 vs. 4%, p < 0.001), orthopédiques (4 vs. 0%, p = 0.01) et de sepsis (17 vs. 0%, p < 0.001). La mortalité hospitalière n’était pas différente entre les deux groupes (9 vs. 5%, p = 0.23).ConclusionL’HNa est une pathologie peu fréquente aux urgences. Elle est associée à un risque plus élevé de séjour à l’hôpital ou aux soins intensifs. L’HNa est aussi associée plus fréquemment à la survenue de différentes complications, mais pas à un risque accru de mortalité. Le rôle de l’HNa comme marqueur de risque aux urgences devrait être prospectivement confirmé dans des études futures.info:eu-repo/semantics/publishe

Improving policy-making process through bottom-up planning: what are the keys to success?

Since the beginning of development cooperation with low-income countries, bottom-up approaches have been promoted in order to increase the effectiveness of aid. But they have been generally limited to simple consultation with beneficiaries and main stakeholders, without any real impact over decision-making and policy implementation. Since the 1990s, several reforms have been engaged to enhance national ownership, good governance and stakeholders’ empowerment. But these concepts seem overused. Indeed, these “participatory” and “empowering” approaches have hardly been accompanied by a real change in behaviour: donors and policy-makers generally go on working according to linear top-down logics, using logical frameworks and looking for short terms results and their attribution. Then, an implementation gap often persists between (inter)national strategies and reality on the ground. In this presentation, we define a more ambitious bottom-up approach, one where policy planning is based on realistic, systemic, inclusive and self-learning mechanisms and which includes paradigm shift and behaviour change. To be effective, the policy process should be organised through learning dynamics: for every phase of the process, operational stakeholders should be involved, their need and particular context taken into account, their capacities strengthened, their experiences and local evidence used as inputs for planning new policies and programmes. Stakeholders at all levels should accept the complexity of development, the fact that a strategy can take many paths and the possibility of failure. Results should also be expected on a longer term. This is an introduction to the session. Based on field experiences and extensive literature review, we present and discuss the main determinants and constraints of a successful bottom-up approach to improve policy-making process.info:eu-repo/semantics/nonPublishe

THE BELGIAN BRAIN COUNCIL. WHAT FOR ?

The Belgian Brain Council (BBC) is a registered association with statutes published in the Moniteur Belge. BBC was created 10 years ago on the initiative of Pr. Jean Schoenen. BBC is an independent National Brain Council (NBC) but aligned with the main goals of the European Brain Council (EBC). BBC is unique and a multidisciplinary platforms which UNITE scientific organizations of neuroscientists, psychiatrists and research workers, patients' associations and pharmaceutical/device companies. The BBC aims are : • To improve the quality of life of persons living with neurological and mental disorders, • To raise awareness of this subject, stimulate research, • To foster exchange between the different disciplines and associations, and • To lobby government for enhancing research and treatments. BBC is a need for : • To speak with one voice to be strong enough to influence policy makers and budget holders at the national level • To act at national research programs, in which the greatest part of overall funds is available • National research policies should be aligned with the EU policies: NBCs are the best bottom instruments to approach such challenge BBC achievements : • Use to diffuse information through a web page since 2007 regularly updated and consulted more than 900.000 times with an overall nibbler scoring of 5.6 (for instance the EBC web site has a score of 6.2 and ULB a score of 6.3) • Coordinate the belgian Brain Awareness Week, a yearly worldwide event • Organized scientifically and logistically already 5 national conferences gathering each time 250 participants. A unique platform gathering and creating interactions between all the stakeholders. The next meeting will in MONS at the MICX, OCTOBER 8, 2016 • Realized studies and publications about the cost of brain diseases in Belgium • Submit to the Belgian Government a memorandum and recommendations focused on « What future for brain research in Belgium ?status: publishe

Weak MGMT gene promoter methylation confers a clinically significant survival benefit in patients with newly diagnosed glioblastoma : a retrospective cohort study

Introduction: Quantitative methylation specific PCR (qMSP) is a frequently used technique to assess MGMT gene promoter methylation in glioblastoma patients. The optimal technical cut-off value to distinguish methylated from unmethylated samples is nevertheless still undetermined. In literature, a "grey zone" of diagnostic uncertainty has been described. Methods: We performed a retrospective analysis of newly diagnosed glioblastoma patients treated according to the Stupp protocol. Epidemiological data were gathered from the individual patient files. MGMT gene promoter methylation status was determined on stored tumour samples using qMSP. A strong, weak or absent promoter methylation was determined based on Cq values (quantification value) of the MGMT and ACTB primers as well as a positive control sample. Results: In total, 181 patient files were reviewed and included for statistical analysis. MGMT promoter hypermethylation was detected in 38.7% of glioblastoma patients. The median overall survival of unmethylated and strongly methylated patients was 10.1 months and 19.7 months respectively. Furthermore, 11% of the total patient cohort had a weak MGMT gene promoter methylation. The median OS in this subgroup was 15.4 months, significantly better compared to the unmethylated cohort (P < 0.001). Multivariate Cox regression analysis showed weak MGMT promoter methylation as an independent prognostic parameter for overall survival. Conclusion: Glioblastoma patients with weak promoter methylation show a statistically significant longer overall survival when compared to clearly unmethylated patients. Patients with grey zone qMSP test results should receive additional molecular analysis in future to further direct individual therapy strategies

Endoscopic treatment of temporal arachnoid cysts in 34 patients

INTRODUCTION: Arachnoid cysts are lesions present in 1% of the population and usually found in the temporal fossa. Clinical and radiologic presentations can differ greatly. Despite intensive research, it is still debatable which patients will benefit from surgery. OBJECTIVE: This study aims to investigate the pretreatment parameters influencing the outcome after neuroendoscopic treatment of temporal arachnoid cysts. MATERIALS AND METHODS: A retrospective analysis of 34 patients who underwent an endoscopic fenestration of a temporal arachnoid cyst between July 1991 and December 2013 was performed. RESULTS: In symptomatic patients, there was a clinical improvement in 76.4% of cases. The best results were found in treating symptoms related to intracranial hypertension, acute neurologic defects, and macrocrania. Patients with temporal lobe epilepsy improved after cyst fenestration in 33.3% of cases. Behavioral problems and psychomotor retardation remained largely unchanged. Patients with a complex neurologic presentation, often from a congenital syndrome and combined with an intellectual disability, had the least benefit from endoscopic surgery. Radiologic follow-up showed a cyst volume decrease in 91.2% of cases. Complications were present in 29.4%, but were mostly minor and transient. CONCLUSION: This study demonstrates that patients with symptoms related to intracranial hypertension, acute neurologic deficits, and macrocrania have the best postoperative outcome. Also, patients with ipsilateral temporal lobe epilepsy seem to be good candidates for endoscopic arachnoid cyst fenestrations. In complex neurologic disorders without one of the previously mentioned symptoms, endoscopy remains less successful