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

Highlighting the occurrence of tetraploidy in Acacia senegal (L.) Willd. and genetic variation patterns in its natural range revealed by DNA microsatellite markers

Acacia senegal (L.) Willd. is the main species producing the internationally traded gum arabic. Genetic studies of this species are rare and until now the chromosome number was thought to be diploid (2n = 2x = 26). Here, using chromosome number counting, we demonstrate for the first time that tetraploids (2n = 4x = 52) also occur in A. senegal. Nuclear and chloroplast microsatellite markers were used to estimate and compare genetic variation within this newly described polyploidy complex in the Sudano-Sahelian region in Africa. Genetic diversity was higher in diploids, suggesting that the formation of tetraploids is recent and that mutation-drift equilibrium has not yet been reached. The two cytotypes do not have the same genetic structure and are genetically differentiated. Among tetraploids, populations are greatly differentiated and do not share the same chlorotypes. Based on these results, we discuss recurrent formation of tetraploids from different diploid progenitors across the distribution range of A. senegal in the Sudano-Sahelian zone

La gestion des végétaux en filtres plantés de roseaux - Etat des lieux national

Cet état des lieux de la gestion des végétaux en stations de traitement des eaux usées à filtres plantés de roseaux répond à une demande des gestionnaires de ce type de stations. En effet, les services d’assistances techniques départementaux, Irstea (INRAE) ou l’OIEau sont régulièrement questionnés quant aux techniques d’éradication du liseron, aux traitements contre les pucerons ou encore au devenir des roseaux faucardés chaque année. Or, ces questionnements ne trouvent parfois pas de réponse localement, alors qu’il existe des solutions testées par ailleurs et ayant fait leurs preuves, seules ou combinées, avec une efficacité partielle ou totale. C’est la raison pour laquelle un recueil d’informations au niveau national a été entrepris en 2018, afin de recenser les problématiques et les solutions testées en France métropolitaine de manière exhaustive. Il s'agit dans un premier temps de synthétiser les expériences existantes dans un document diffusé largement par le biais du groupe de travail EPNAC (et sur le site https://epnac.fr/)

Le contrôle républicain du marché. Vignerons et négociants sous la Troisième République

International audienceInitially -in keeping with isues examined by Neil Fligstein- the change around in the market for Burgundy wines to the detriment of the Beaune wine merchants was clearly political in origin: the mass unionization of vineyard owners and the political control exerted by Parliamentarian owners after the republicanization of the countryside enabled them to make the most of republican ideology when reshaping the legal framework of the market although the change had been initiated by the wine merchants. The 1919 statute on denominations of origin and its application attributed the surplus value to the vineyard owners and not to the wine merchants' brands. But this political move alone cannot explain the victory won by the vineyard owners of Nuits-Saint-Georges and Meursault. They subsequently managed to impose an image of a traditional wine tightly bound to the locality. This is where the cultural sphere became involved and the complex work of bringing together the regionalist revival, the invention of traditions, and the promotion of the small vineyard owner as the emblematic figure of the Republic. Burgundy wine together with all the value enhancement of the food economy through terroir and tradition is therefore both a political and a cultural construction.Dans un premier temps, s’inscrivant dans une problématique proche de Neil Fligstein, le retournement du marché des vins de Bourgogne au détriment des négociants de Beaune a clairement une origine politique : la syndicalisation massive des propriétaires, le contrôle politique des propriétaires du Parlement suite à la républicanisation des campagnes leur permet de mettre à profit l’idéologie républicaine lors du cadrage juridique du marché pourtant initié par les négociants. La loi des appellations d’origine de 1919 et son application attribuent la plus value aux propriétaires contre la marque des négociants. Mais cette origine politique ne suffit pas à expliquer la victoire des propriétaires de Nuits-Saint-Georges et de Meursault. Dans un second temps, ces derniers sont parvenus à imposer l’image d’un vin de tradition, ancré dans le terroir. C’est là qu’intervient la sphère culturelle et le travail complexe qui associe renouveau régionaliste, invention des traditions, valorisation du petit propriétaire comme figure emblématique de la République. Le vin de Bourgogne et toute la valorisation par le terroir et la tradition de l’économie alimentaire est donc une construction politique et culturelle

close: Closure of patent foramen ovale, oral anticoagulants or antiplatelet therapy to prevent stroke recurrence: Study design.

RATIONALE: Currently available data do not provide definitive evidence on the comparative benefits of closure of patent foramen ovale, oral anticoagulants and antiplatelet therapy in patients with patent foramen ovale-associated cryptogenic stroke AIM: To assess whether transcatheter patent foramen ovale closure plus antiplatelet therapy is superior to antiplatelet therapy alone and whether oral anticoagulant therapy is superior to antiplatelet therapy, for secondary stroke prevention in patients aged 16 to 60 years with a large patent foramen ovale or a patent foramen ovale associated with an atrial septal aneurysm, and an otherwise unexplained ischaemic stroke or retinal ischaemia. SAMPLE SIZE: Six hundred and sixty-four patients were included in the study. METHODS AND DESIGN: CLOSE is an academic-driven, multicentre, randomized, open-label, three-group, superiority trial with blinded adjudication of outcome events. The trial has been registered with Clinical Trials Register (Clinicaltrials.gov, NCT00562289). Patient recruitment started in December 2007. Patient follow-up will continue until December 2016. Expected mean follow-up = 5.6 years. STUDY OUTCOMES: The primary efficacy outcome is the occurrence of fatal or nonfatal stroke. Safety outcomes include fatal, life-threatening or major procedure- or device-related complications and fatal, life-threatening or major haemorrhagic complications. DISCUSSION: CLOSE is the first specifically designed trial to assess the superiority of patent foramen ovale closure over antiplatelet therapy alone and the superiority of oral anticoagulants over antiplatelet therapy to prevent stroke recurrence in patients with patent foramen ovale-associated cryptogenic stroke