Cervical spondylotic myelopathy with concomitant ex vacuo hydrocephalus in the differential diagnosis of idiopathic normal pressure hydrocephalus

Introduction: Idiopathic normal pressure hydrocephalus (iNPH) is a syndrome of gait disturbance with enlargement of the cerebral ventricles, not justified by another cause. It frequently occurs with cognitive dysfunction and overactivity of the bladder’s detrusor muscle, resulting in dementia and urinary incontinence. We report a case in which the patient´s gait and initial image suggested iNPH, posteriorly found to be a cervical spondylotic myelopathy (CSM). Objectives: To report a CSM with concomitant ex vacuo hydrocephalus case resembling iNPH and to discuss the biases of the initial diagnosis. Case presentation: A 78 year-old woman, previously diagnosed with hypertension and type 2 diabetes mellitus, presented to our ambulatory with a long history of progressive gait disturbance, radiating pain to the right arm and several episodes of falls. The relatives referred possible cognitive deficits in attention and memory, as well as urinary urgency. Given the peculiar unstable wide-based gait and history, an iNPH was suspected. At the outpatient unit, a transcranial ultrasound examination revealed large cerebral ventricles, compatible with hydrocephalus. A brain magnetic resonance imaging (MRI) obtained at another facility suggested iNPH. The patient was then hospitalized at our hospital for investigation of iNPH and had a lumbar tap test scheduled. The complete neurological examination revealed: an unstable wide-based gait, with head and neck leaning forward, marche à petit pas, and prolonged Timed Up and Go Test; positive Romberg’s test; spasticity of the lower limbs; globally reduced muscular strength, especially at distal lower limbs and right hand (compatible with C6 and C7 myotomes); global preserved or enhanced reflexes; Hoffman and Tromner signs bilaterally; inversion of the right bicipital due to enlargement of the reflexive area of the ipsilateral tricipital; cutaneous plantar reflexes in flexion; impaired sensations on the right hand, especially on the index and middle fingers, with normal sensations on the left hand; loss of vibratory sensation at distal lower limbs; positive Spurling’s test; normal cranial nerves; normal coordination. Frontal Assessment Battery, Mini Mental State Examination and Montreal Cognitive Assessment showing no signs of cognitive impairment. As the neurological examination added a possible spinal cord syndrome differential diagnosis, the tap test was postponed and both brain and cervical MRIs ordered. The cervical MRI revealed a serious and extensive CSM compressing the spinal cord at C3 through C5. The brain MRI obtained at our institution showed hydrocephalus with no ventricular or acqueductal flow void, normal callosal angle and diffuse signs of brain atrophy, suggesting ex vacuo hydrocephalus. The patient then awaits for cervical decompressive neurosurgery. We bring this case to shed light on the differential diagnosis between these conditions, a case infrequently found in medical literature. The atypical presentation of CSM with longstanding parkinsonian-like gait, urinary disturbance and vague cognitive complaints, aside with the first mistaken MRI report, allowed the attending clinicians to search for iNPH. Whilst, notwithstanding the importance of complementary exams, its high accountability may lead to diagnostic error and unnecessary invasive procedures. This report emphasizes the importance of a complete neurologic examination to highlight a correct topographic and nosological diagnosis

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

Quantitative NMR as a tool for analysis of new psychoactive substances

Several New Psychoactive Substances (NPS) have appeared on the drug market, following a new trend of drug consumption. Nuclear Magnetic Resonance (NMR) has been used, especially in the case of forensic analysis, as a tool for unambiguous structure determination of unknown NPS. The quantification of NPS in complex mixtures is, however, a very challenging task, especially in the absence of certified reference materials (CRM). In this work, we applied a quantitative 1H NMR (1H-qNMR) methodology performed without certified analytes for quantification of twelve NPS samples seized by the Brazilian Federal Police. The molecular structure of NPS samples were first confirmed by mono and bidimensional 1H and 13C NMR with unequivocally assigned signals, which allowed for the discrimination of constitutional isomers. A detailed compilation of NMR spectroscopic data showed that these NPS samples belong to cathinones, phenethylamines, and tryptamines groups. The quantitative analyses showed high precision (RSD = 2.67%) and low uncertainty (from 0.44% to 0.37%, with k = 2, 95% confidence). The NPS samples exhibited sufficient stability for a period of 48 h, which is longer than the experimental time frame and, therefore, assures the reliability and validity of the obtained results. Evaluation of some other figures of merit (selectivity, limits of quantification and detection) was also performed and confirmed the proposed method presents suitable and reproducible results. These achievements suggest the present methodology is highly adequate for forensic purposes, attaining excellent precision and accuracy, even in the absence of CRM