Data mining techniques for predicting acute kidney injury after elective cardiac surgery

status: publishe

Leakage and boosting effects in environmental governance: a framework for analysis

In an increasingly interconnected world, leakage-broadly understood as unintended displacement of impacts caused by an environmental policy intervention-has become a major governance concern. Yet, leakage remains both loosely conceptualized and poorly understood as a phenomenon in policy making. To fill this gap and broaden the leakage research agenda, we conduct a state-of-the-art review of scientific assessments on leakage (particularly on land use) and combine it with conceptual and analytical frameworks from the environmental governance literature. We then propose a rigorous definition of leakage, discuss frequently overlooked political dimensions, and develop a typology of leakage pathways. Our analysis of leakage through a governance lens yields five core insights: (1) Leakage is not simply a mechanistic phenomenon, but a complex governance issue involving questions of institutional fit, interactions, and political agency. (2) Although the land use literature traditionally focuses on leakage through markets or activity displacement, a governance lens shows that it also occurs through information, motivation, or institutional channels. (3) As policy-makers may act strategically, the unintentionally of leakage should not be assumed but rather become an object of research. (4) A phenomenon not initially regarded as leakage can come to be framed as such through the action of \u27problem brokers\u27 and changes in policy fields. (5) Policy-makers and researchers should broaden their focus from only avoiding leakage to seeking positive spillovers and institutional synergies. These insights are illustrated with examples from two cases relating to land use policy in Brazil and Southeast Asia

Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality

PURPOSE: To provide a practical overview of the management of the potential organ donor in the intensive care unit. METHODS: Seven areas of donor management were considered for this review: hemodynamic management; fluids and electrolytes; respiratory management; endocrine management; temperature management; anaemia and coagulation; infection management. For each subchapter, a narrative review was conducted. RESULTS AND CONCLUSIONS: Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations, or extrapolations from general ICU management strategies, and not on evidence from randomized controlled trials. The cardiorespiratory management of brain-dead donors is very similar to the management of critically ill patients, and the same applies to the management of anaemia and coagulation. Central diabetes insipidus is of particular concern, and should be diagnosed based on clinical criteria. Depending on the degree of vasopressor dependency, it can be treated with intermittent desmopressin or continuous vasopressin, intravenously. Temperature management of the donor is an area of uncertainty, but it appears reasonable to strive for a core temperature of > 35 °C. The indications and controversies regarding endocrine therapies, in particular thyroid hormone replacement therapy, and corticosteroid therapy, are discussed. The potential donor should be assessed clinically for infections, and screening tests for specific infections are an essential part of donor management. Although the rate of infection transmission from donor to receptor is low, certain infections are still a formal contraindication to organ donation. However, new antiviral drugs and strategies now allow organ donation from certain infected donors to be done safely

Paroxysmal sympathetic hyperactivity: the storm after acute brain injury

A substantial minority of patients who survive an acquired brain injury develop a state of sympathetic hyperactivity that can persist for weeks or months, consisting of periodic episodes of increased heart rate and blood pressure, sweating, hyperthermia, and motor posturing, often in response to external stimuli. The unifying term for the syndrome—paroxysmal sympathetic hyperactivity (PSH)—and clear diagnostic criteria defined by expert consensus were only recently established. PSH has predominantly been described after traumatic brain injury (TBI), in which it is associated with worse outcomes. The pathophysiology of the condition is not completely understood, although most researchers consider it to be a disconnection syndrome with paroxysms driven by a loss of inhibitory control over excitatory autonomic centres. Although therapeutic strategies to alleviate sympathetic outbursts have been proposed, their effects on PSH are inconsistent between patients and their influence on outcome is unknown. Combinations of drugs are frequently used and are chosen on the basis of local custom, rather than on objective evidence. New rigorous tools for diagnosis could allow better characterisation of PSH to enable stratification of patients for future therapeutic trials.GM is funded by the Research Foundation, Flanders as senior clinical investigator. DKM is supported by the National Institute for Healthcare Research (NIHR), UK, through the Acute Brain Injury and Repair theme of the Cambridge NIHR Biomedical Research Centre and a NIHR Senior Investigator Award, and is supported by a European Union Framework Program 7 grant (CENTER-TBI; grant agreement no. 602150)

Novel models to predict elevated intracranial pressure during intensive care and long-term neurological outcome after TBI

status: publishe

Improvements in data quality for decision support in intensive care

Nowadays, there is a plethora of technology in hospitals and, in particular, in intensive care units. The clinical data produced everyday can be integrated in a decision support system in real-time to improve quality of care of the critically ill patients. However, there are many sensitive aspects that must be taken into account, mainly the data quality and the integration of heterogeneous data sources. This paper presents INTCare, an Intelligent Decision Support System for Intensive Care in real-time and addresses the previous aspects, in particular, the development of an Electronic Nursing Record and the improvements in the quality of monitored data.Fundação para a Ciência e a Tecnologia (FCT

Feasibility of individualised severe traumatic brain injury management using an automated assessment of optimal cerebral perfusion pressure: the COGiTATE phase II study protocol.

INTRODUCTION: Individualising therapy is an important challenge for intensive care of patients with severe traumatic brain injury (TBI). Targeting a cerebral perfusion pressure (CPP) tailored to optimise cerebrovascular autoregulation has been suggested as an attractive strategy on the basis of a large body of retrospective observational data. The objective of this study is to prospectively assess the feasibility and safety of such a strategy compared with fixed thresholds which is the current standard of care from international consensus guidelines. METHODS AND ANALYSIS: CPPOpt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) is a prospective, multicentre, non-blinded randomised, controlled trial coordinated from Maastricht University Medical Center, Maastricht (The Netherlands). The other original participating centres are Cambridge University NHS Foundation Trust, Cambridge (UK), and University Hospitals Leuven, Leuven (Belgium). Adult severe TBI patients requiring intracranial pressure monitoring are randomised within the first 24 hours of admission in neurocritical care unit. For the control arm, the CPP target is the Brain Trauma Foundation guidelines target (60-70 mm Hg); for the intervention group an automated CPP target is provided as the CPP at which the patient's cerebrovascular reactivity is best preserved (CPPopt). For a maximum of 5 days, attending clinicians review the CPP target 4-hourly. The main hypothesis of COGiTATE are: (1) in the intervention group the percentage of the monitored time with measured CPP within a range of 5 mm Hg above or below CPPopt will reach 36%; (2) the difference in between groups in daily therapy intensity level score will be lower or equal to 3. ETHICS AND DISSEMINATION: Ethical approval has been obtained for each participating centre. The results will be presented at international scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02982122

Representation of decision-making in European agricultural agent-based models

The use of agent-based modelling approaches in ex-post and ex-ante evaluations of agricultural policies has been progressively increasing over the last few years. There are now a sufficient number of models that it is worth taking stock of the way these models have been developed. Here, we review 20 agricultural agent-based models (ABM) addressing heterogeneous decision-making processes in the context of European agriculture. The goals of this review were to i) develop a framework describing aspects of farmers' decision-making that are relevant from a farm-systems perspective, ii) reveal the current state-of-the-art in representing farmers' decision-making in the European agricultural sector, and iii) provide a critical reflection of underdeveloped research areas and on future opportunities in modelling decision-making. To compare different approaches in modelling farmers' behaviour, we focused on the European agricultural sector, which presents a specific character with its family farms, its single market and the common agricultural policy (CAP). We identified several key properties of farmers' decision-making: the multi-output nature of production; the importance of non-agricultural activities; heterogeneous household and family characteristics; and the need for concurrent short- and long-term decision-making. These properties were then used to define levels and types of decision-making mechanisms to structure a literature review. We find most models are sophisticated in the representation of farm exit and entry decisions, as well as the representation of long-term decisions and the consideration of farming styles or types using farm typologies. Considerably fewer attempts to model farmers' emotions, values, learning, risk and uncertainty or social interactions occur in the different case studies. We conclude that there is considerable scope to improve diversity in representation of decision-making and the integration of social interactions in agricultural agent-based modelling approaches by combining existing modelling approaches and promoting model inter-comparisons. Thus, this review provides a valuable entry point for agent-based modellers, agricultural systems modellers and data driven social scientists for the re-use and sharing of model components, code and data. An intensified dialogue could fertilize more coordinated and purposeful combinations and comparisons of ABM and other modelling approaches as well as better reconciliation of empirical data and theoretical foundations, which ultimately are key to developing improved models of agricultural systems.Swiss National Science Foundatio