Clinical practice guideline. Fitness to drive in cognitive impairment and dementia

El deterioro de las funciones cognitivas puede afectar a las habilidades de conducción vehicular representando un riesgo de salud pública al incrementar los accidentes de tránsito. El deterioro cognitivo leve y las demencias se caracterizan por presentar alteraciones cognitivas que afectan, en mayor o menor grado, a las actividades instrumentales de la vida diaria e influyen en la conducción segura. El Grupo de Trabajo de Neurología de la Conducta y Neurociencias Cognitivas de la Sociedad Neurológica Argentina ha elaborado esta Guía de práctica clínica para facilitar a los profesionales médicos la evaluación de pacientes en quienes se sospecha deterioro cognitivo o demencia y para detectar y prevenir eventuales conductas de riesgo.Cognitive impairment may compromise driving skills and represent a public health risk by increasing traffic accidents. Mild Cognitive Impairment and Dementia are characterized by cognitive impairment affecting to a greater or lesser degree the instrumental activities of daily living and fitness to drive. The Argentine Neurologic Society Working Group on Behavioural Neurology and Cognitive Neurosciences has prepared this clinical practice guideline to help physicians evaluate patients suspected to present cognitive impairment or dementia and detect and prevent risky behaviors.Fil: Allegri, Ricardo Francisco. Sociedad Neurológica Argentina. Buenos Aires; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Arizaga, Raúl Luciano. Sociedad Neurológica Argentina; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Bavec, Claudia Veronica. Sociedad Neurológica Argentina; ArgentinaFil: Barreto, María Dolores. Sociedad Neurológica Argentina; ArgentinaFil: Brusco, Luis Ignacio. Sociedad Neurológica Argentina; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Colli, Liliana Patricia. Sociedad Neurológica Argentina; ArgentinaFil: Demey, Ignacio. Sociedad Neurológica Argentina; ArgentinaFil: Fernandez, Maria Cecilia. Sociedad Neurológica Argentina; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Frontera, Silvana A.. Sociedad Neurológica Argentina; ArgentinaFil: Garau, Maria Laura. Sociedad Neurológica Argentina; ArgentinaFil: Gimenez, Julio Jorge. Sociedad Neurológica Argentina; ArgentinaFil: Golimstok, Angel. Sociedad Neurológica Argentina; ArgentinaFil: Kremer, Janus. Sociedad Neurológica Argentina; ArgentinaFil: Labos, Luisa Edit. Sociedad Neurológica Argentina; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Leis, Adriana Mónica. Sociedad Neurológica Argentina; ArgentinaFil: Lopez Llano, María Luz. Sociedad Neurológica Argentina; ArgentinaFil: Mangone, Carlos Alberto. Sociedad Neurológica Argentina; ArgentinaFil: Ollari, Juan Alberto. Sociedad Neurológica Argentina; ArgentinaFil: Rojas, Zenón Galeno. Sociedad Neurológica Argentina; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Russo, María Julieta. Sociedad Neurológica Argentina; ArgentinaFil: Serrano, Mariela Cecilia. Sociedad Neurológica Argentina; ArgentinaFil: Somale, Maria Veronica. Sociedad Neurológica Argentina; ArgentinaFil: D. Souza, Leandro. Sociedad Neurológica Argentina; ArgentinaFil: Ure, Jorge Alberto. Sociedad Neurológica Argentina; ArgentinaFil: Zuin, Daniel Raul. Sociedad Neurológica Argentina; Argentin

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status