Neuronal desertification after a direct lightning strike: a case report

Background: Lightning strike is a rare but dramatic cause of injury. Patients admitted to intensive care units (ICUs) with lightning strike frequently have a high mortality and significant long-term morbidity related to a direct brain injury or induced cardiac arrest (CA). Case presentation: A 50-year-old Caucasian man was admitted to our hospital after being struck by lightning resulting in immediate CA. Spontaneous circulation was initially restored, and the man was admitted to the ICU, but ultimately died while in hospital due to neurological injury. The computer tomography scan revealed a massive loss of grey-white matter differentiation at the fronto-temporal lobes bilaterally. Somatosensory-evoked potentials demonstrated bilateral absence of the cortical somatosensory N20-potential, and the electroencephalogram recorded minimal cerebral electrical activity. The patient died on day 10 and a post-mortem study revealed a widespread loss of neurons. Conclusion: This case study illustrates severe brain injury caused by a direct lighting strike, with the patient presenting an extraordinary microscopic pattern of neuronal desertification

Metastatic pancreatic cancer: is gemcitabine still the best standard treatment?

Pancreatic ductal adenocarcinoma is the fourth cause of death in the Western world. Surgery remains the only treatment offering an advantage in terms of overall survival (5-year survival range, 15-25%), but unfortunately only 10-20% of patients present resectable disease at the time of diagnosis. Hence chemotherapy, possibly combined with radiation therapy, remains the only treatment option aimed at palliation of symptoms and ensuring a better quality of life. Notwithstanding the efforts to find more effective therapies for the treatment of pancreatic cancer, significant results have not yet been achieved. Increasing interest has focused on integrated treatments, i.e. chemotherapy combined with targeted therapies, and a better selection of patients. This study examines the principal clinical trials that will help give clinicians an overview of the progress made in the systemic therapy for advanced pancreatic cancer patients in recent years

Sanguinamenti gastrointestinali alti non varicosi: i risultati dell'embolizzazione arteriosa come trattamento

E' stata valutata l'efficacia della procedura di embolizzazione arteriosa in 31 pazienti affetti da emorragia arteriosa gastrointestinale alta non controllabile con endoscopi

Intra-Arrest Therapeutic Hypothermia and Neurologic Outcome in Patients Admitted after Out-of-Hospital Cardiac Arrest: A Post Hoc Analysis of the Princess Trial

Background: Despite promising results, the role of intra-arrest hypothermia in out-of-hospital cardiac arrest (OHCA) remains controversial. The aim of this study was to assess the effects of trans-nasal evaporative cooling (TNEC) during resuscitation on neurological recovery in OHCA patients admitted alive to the hospital. Methods: A post hoc analysis of the PRINCESS trial, including only patients admitted alive to the hospital, either assigned to TNEC or standard of care during resuscitation. The primary endpoint was favorable neurological outcome (FO) defined as a Cerebral Performance Category (CPC) of 1–2 at 90 days. The secondary outcomes were overall survival at 90 days and CPC 1 at 90 days. Subgroup analyses were performed according to the initial cardiac rhythm. Results: A total of 149 patients in the TNEC and 142 in the control group were included. The number of patients with CPC 1–2 at 90 days was 56/149 (37.6%) in the intervention group and 45/142 (31.7%) in the control group (p = 0.29). Survival and CPC 1 at 90 days was observed in 60/149 patients (40.3%) vs. 52/142 (36.6%; p = 0.09) and 50/149 (33.6%) vs. 35/142 (24.6%; p = 0.11) in the two groups. In the subgroup of patients with an initial shockable rhythm, the number of patients with CPC 1 at 90 days was 45/83 (54.2%) in the intervention group and 27/78 (34.6%) in the control group (p = 0.01). Conclusions: In this post hoc analysis of admitted OHCA patients, no statistically significant benefits of TNEC on neurological outcome at 90 days was found. In patients with initial shockable rhythm, TNEC was associated with increased full neurological recovery

Pain pupillary index to prognosticate unfavorable outcome in comatose cardiac arrest patients

Background: The prognostic role of the Pupillary Pain Index (PPI), derived from automated pupillometry, remains unknown in post-anoxic brain injury. Methods: Single-center retrospective study in adult comatose cardiac arrest (CA) patients. Quantitative PPI and Neurologic Pupil Index (NPi) were concomitantly recorded on day 1 and day 2 after CA. The primary outcome was to assess the prognostic value of PPI to predict 3-month unfavourable outcome (UO, defined as Cerebral Performance Category of 3 & ndash;5). Secondary outcome was the agreement between PPI and NPi to predict unfavourable outcome. Results: A total of 102 patients were included; patients with UO (n = 69, 68%) showed a lower NPi (4.2 [3.5 & ndash;4.5] vs. 4.6 [4.3 & ndash;4.7]; p < 0.01 on day 1 & ndash;4.3 [3.8 & ndash;4.7] vs 4.6 [4.3 & ndash;4.8] on day 2), and PPI (3 [1 & ndash;6] vs. 6 [3 & ndash;7]; p < 0.01 on day 1 & ndash;3 [1 & ndash;6] vs 6 [4 & ndash;8]; p < 0.01 on day 2) than others. A PPI =1 on day 2 showed a sensitivity of 26 [95% CI 16 & ndash;38]% and a specificity of 100 [95% CI 89 & ndash;100]% to predict UO (p = 0.003 vs. NPi < 2). On day 2, a total of 6 patients had concomitant PPI = 1 and NPi < 2, while 12 showed NPi > 2 and PPI = 1; the coefficient of agreement was 0.42. Moreover, NPi and PPI values showed a moderate correlation both on day 1 and day 2. Conclusions: In this study, PPI = 1 on day 2 could predict UO in comatose CA patients with 100% specificity, but with a low sensitivity (yet higher than NPi). The agreement between PPI and NPi values was moderate

Venous Thromboembolism and Port-Related Thrombosis in Metastatic Colorectal Cancer Patients: A Monocenter Experience

Venous thromboembolism (VTE) may occur during the natural history of neoplastic disease and is a common cause of mortality and morbidity in cancer patients. Major risk factors for VTE in cancer patients include surgery, immobilization, hospitalization, and the administration of granulopoietic and/or erythropoietic (stimulatory) agents. Chemotherapy is a supplementary independent risk factor for VTE and the use of central venous catheters (CVC) in clinical practice has increased the risk of thromboembolic events. We conducted a retrospective study to evaluate CVC-related thrombosis and the VTE rate in 145 consecutive metastatic colorectal cancer patients. We observed only 2 cases of symptomatic CVC- related thrombotic events (1.38%) and 10 cases of thromboembolic events (6.9%) in our series. Only surgery for metastases was found to be significantly related to the development of VTE, with an incidence of 16.1% vs. 4.4 in patients who did not undergo surgery (p = 0.037). In addition, a history of VTE seems to be a supplementary risk factor for CVC-related thrombosis (p = 0.055)

The impact of perfusion computed tomography on the diagnosis and outcome of delayed cerebral ischemia after subarachnoid hemorrhage.

Delayed cerebral ischemia (DCI) is a preventable cause of poor neurological outcome in aneurysmal subarachnoid hemorrhage (aSAH). Advances in radiological methods, such as cerebral perfusion computed tomography (CTP), could help diagnose DCI earlier and potentially improve outcomes in aSAH. The objective of this study was to assess whether the use of CTP to diagnose DCI early could reduce the risk of infarction related to DCI.info:eu-repo/semantics/publishe

Automated Pupillometry for Prediction of Electroencephalographic Reactivity in Critically Ill Patients: A Prospective Cohort Study

Background: Electroencephalography (EEG) is widely used to monitor critically ill patients. However, EEG interpretation requires the presence of an experienced neurophysiologist and is time-consuming. Aim of this study was to evaluate whether parameters derived from an automated pupillometer (AP) might help to assess the degree of cerebral dysfunction in critically ill patients. Methods: Prospective study conducted in the Department of Intensive Care of Erasme University Hospital in Brussels, Belgium. Pupillary assessments were performed using the AP in three subgroups of patients, concomitantly monitored with continuous EEG: “anoxic brain injury”, “Non-anoxic brain injury” and “other diseases”. An independent neurologist blinded to patient's history and AP results scored the degree of encephalopathy and reactivity on EEG using a standardized scale. The mean value of Neurologic Pupil Index (NPi), pupillary size, constriction rate, constriction and dilation velocity (CV and DV) and latency for both eyes, obtained using the NPi®-200 (Neuroptics, Laguna Hills, CA, USA), were reported. Results: We included 214 patients (mean age 60 years, 55% male). EEG tracings were categorized as: mild (n = 111, 52%), moderate (n = 65, 30%) or severe (n = 16, 8%) encephalopathy; burst-suppression (n = 19, 9%) or suppression background (n = 3, 1%); a total of 38 (18%) EEG were classified as “unreactive”. We found a significant difference in all pupillometry variables among different EEG categories. Moreover, an unreactive EEG was associated with lower NPi, pupil size, pupillary reactivity, CV and DV and a higher latency than reactive recordings. Low DV (Odds ratio 0.020 [95% confidence intervals 0.002–0.163]; p < 0.01) was independently associated with an unreactive EEG, together with the use of analgesic/sedative drugs and high lactate concentrations. In particular, DV values had an area under the curve (AUC) of 0.86 [0.79–0.92; p < 0.01] to predict the presence of unreactive EEG. In subgroups analyses, AUC of DV to predict unreactive EEG was lower (0.72 [0.56–0.87]; p < 0.01) in anoxic brain injury than Non-anoxic brain injury (0.92 [0.85–1.00]; p < 0.01) and other diseases (0.96 [0.90–1.00]; p < 0.01). Conclusions: This study suggests that low DV measured by the AP might effectively identify an unreactive EEG background, in particular in critically ill patients without anoxic brain injury.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Neck circumference as reliable predictor of mechanical ventilation support in adult inpatients with COVID-19: a multicentric prospective evaluation

Aims: COVID-19 is especially severe for elderly subjects with cardio-metabolic and respiratory comorbidities. Neck circumference (NC) has been shown to be strongly related to cardiometabolic and respiratory illnesses even after adjustment for body mass index (BMI). We performed a prospective study to investigate the potential of NC to predict the need for invasive mechanical ventilation (IMV) in adult COVID-19 inpatients. Materials and methods: we prospectively and consecutively enrolled COVID-19 adult patients admitted to dedicated medical wards of two Italian hospitals from March 25th to April seventh 2020. On admission, clinical, biochemical and anthropometric data, including BMI and NC were collected. As primary outcome measure, the maximum respiratory support received was evaluated. Follow-up time was 30 days from hospital admission. Results: we enrolled 132 subjects (55.0-75.8 years, 32% female). During the study period, 26 (19.7%) patients underwent IMV. In multivariable logistic regression analyses, after adjusting for age, sex, diabetes, hypertension and COPD, NC resulted independently and significantly associated with IMV risk (adjusted OR 1.260 - per 1 cm increase 95% CI:1.120-1.417; P 40.5 cm (>37.5 for females and > 42.5 for males) showed a higher and earlier IMV risk compared to subjects with lower NC (Log-rank test:P < 0.001). Conclusions: NC is an easy to measure parameter able to predict the need for IMV in adult COVID-19 inpatients

Hypothermia versus normothermia after out-of-hospital cardiac arrest

BACKGROUND Targeted temperature management is recommended for patients after cardiac arrest, but the supporting evidence is of low certainty. METHODS In an open-label trial with blinded assessment of outcomes, we randomly assigned 1900 adults with coma who had had an out-of-hospital cardiac arrest of presumed cardiac or unknown cause to undergo targeted hypothermia at 33°C, followed by controlled rewarming, or targeted normothermia with early treatment of fever (body temperature, ≥37.8°C). The primary outcome was death from any cause at 6 months. Secondary outcomes included functional outcome at 6 months as assessed with the modified Rankin scale. Prespecified subgroups were defined according to sex, age, initial cardiac rhythm, time to return of spontaneous circulation, and presence or absence of shock on admission. Prespecified adverse events were pneumonia, sepsis, bleeding, arrhythmia resulting in hemodynamic compromise, and skin complications related to the temperature management device. RESULTS A total of 1850 patients were evaluated for the primary outcome. At 6 months, 465 of 925 patients (50%) in the hypothermia group had died, as compared with 446 of 925 (48%) in the normothermia group (relative risk with hypothermia, 1.04; 95% confidence interval [CI], 0.94 to 1.14; P = 0.37). Of the 1747 patients in whom the functional outcome was assessed, 488 of 881 (55%) in the hypothermia group had moderately severe disability or worse (modified Rankin scale score ≥4), as compared with 479 of 866 (55%) in the normothermia group (relative risk with hypothermia, 1.00; 95% CI, 0.92 to 1.09). Outcomes were consistent in the prespecified subgroups. Arrhythmia resulting in hemodynamic compromise was more common in the hypothermia group than in the normothermia group (24% vs. 17%, P<0.001). The incidence of other adverse events did not differ significantly between the two groups. CONCLUSIONS In patients with coma after out-of-hospital cardiac arrest, targeted hypothermia did not lead to a lower incidence of death by 6 months than targeted normothermia. (Funded by the Swedish Research Council and others; TTM2 ClinicalTrials.gov number, NCT02908308.)