Objective To evaluate the usefulness of early transcranial Doppler ultrasound (TCD) goal-directed therapy after severe traumatic brain
injury initiated before invasive cerebral monitoring is available.
Design Prospective, observational clinical study.
Setting Surgical intensive care unit, university hospital.
Patients and participants Twenty-four severely brain-injured patients.
Interventions All patients had TCD measurements immediately on admission (T0) and when invasive cerebral monitoring was available (T1).
TCD was considered abnormal when two out of three measured values were outside the following limits: Vm < 30 cm/s, Vd < 20 cm/s,
PI > 1.4. When admission TCD was abnormal, attending physicians modified treatment to increase cerebral perfusion pressure.
Measurements and results Admission TCD was performed 18 ± 11 min (T0) after admission, whereas cerebral inasive monitoring was available 242 ± 116 min
(T1) after admission. At T0, 11 (46%) patients had abnormal TCD values (group 1) and 13 had normal TCD values (group 2); mean
arterial pressure was comparable between groups. All group 1 patients received mannitol and/or norepinephrine. At T1, mean
arterial pressure was increased compared to admission in group 1 (105 ± 17 mmHg vs. 89 ± 15 mmHg, p < 0.05) and only two patients had still an abnormal TCD. Although group 1 patients had higher intracranial pressure than
those of group 2 (32 ± 13 mmHg vs. 22 ± 10 mmHg, p < 0.01), both cerebral perfusion pressure and jugular venous oxygen saturation were comparable between the groups.
Conclusions The use of TCD at hospital admission allows identification of severely brain-injured patients with brain hypoperfusion. In
such high-risk patients, early TCD goal-directed therapy can restore normal cerebral perfusion and might then potentially
help in reducing the extent of secondary brain injury. 相似文献
Knowledge of the distribution of foot‐and‐mouth disease (FMD) is required if control programmes are to be successful. However, data on the seroprevalence and incidence of affected villages in developing countries with endemic disease are scarce. This is partly due to resource constraints as well as the logistical challenges of conducting intensive surveys and diagnostic testing in remote locations. In this study, we evaluated the performance of low resolution national‐scale data against high resolution local survey data to predict the FMD serological status of 168 villages in the Mandalay and Sagaing Regions of central Myanmar using both logistic regression and random forest modelling approaches. Blood samples for ELISA testing were collected from approximately 30 cattle per village in both the 6 to 18 month age range and in the over 18 month age range to distinguish between recent and historical exposure, respectively. The results of the animal level tests were aggregated to the village level to provide the outcome of interest (village positive or not positive for FMD), and three explanatory data sets were constructed: using only nationally available data, using only data collected by survey and using the combined survey and nationally available data. The true seroprevalence of FMD at the village level was 61% when only young animals were included, but increased to 87% when all animals were included. The best performing model was a logistic regression model using the combined national and survey data to predict recent infection in villages. However, this still incorrectly classified 40% of villages, which suggests that using national‐level data were not reliable enough for extrapolating seroprevalence in regions where conducting detailed surveys is impractical. Other methods for collected data on FMD such as the use of local reporting should be explored. 相似文献
World Journal of Surgery - Massive transfusion (MT) is a lifesaving treatment for hemorrhaging patients. Predicting the need for MT is crucial to improve survival. The aim of our study was to... 相似文献
Objective: Attention deficit hyperactivity disorder (ADHD) is common among adult patients with a substance use disorder, yet often goes undetected. This is a qualitative study to explore implementation barriers to a guideline developed in Belgium for the recognition and treatment of ADHD in adult patients with substance use disorder and to gain a better understanding of the strategies to overcome these barriers.
Methods: Focus groups were conducted with caregivers and patients to explore experiences with comorbid substance use disorder and ADHD. The barriers reported in these focus groups became the subject of further study in focus groups with addiction professionals (physicians, psychiatrists, and psychologists) who had tried the guideline and with psychiatrists specializing in addiction but without experience with ADHD.
Results: Our analysis revealed a number of barriers to the implementation of this guideline, including lack of information from the family, pressure from patients and caregivers to make an ADHD diagnosis, and the potential for abuse of ADHD medication. Furthermore, diagnostic instruments for ADHD have not been validated in people with substance use disorder. Although patients with ADHD are usually treated in an outpatient setting, patients with ADHD comorbid with substance use disorder are difficult to identify in an outpatient setting for various reasons. Finally, there is a lack of specific ADHD expertise in substance use treatment organizations.
Conclusions: Despite the availability of an approved guideline for recognizing and treating adult ADHD in patients with a substance use disorder, underdiagnosis and inadequate treatment still persist. As in general substance use treatment, medication only plays a supportive role in the treatment of substance use disorder with comorbid ADHD. An integrated approach and further improvements in the competence of practitioners may help to reduce the resistance to diagnosing ADHD in substance use treatment centers. Practitioners who specialize in addiction medicine and therapists without medical education view the problem from different perspectives and therefore each group needs specific information and training. Targeted interventions need to be developed to keep these patients in treatment. 相似文献
As the general population is aging, surgery in elderly patients has become a major public health issue. This basic question is especially true for liver resection (LR). The aim of this study was to evaluate the operative risks of LR in the elderly.
Methods
Retrospective analysis of a large recent and monocentric database of LR was performed between January 1, 2005 and May 31, 2011. Patients were categorized into three groups (<60, 60–74, and ≥75 years old) to analyze postoperative outcomes and 1-year mortality. Clinicopathologic factors likely to influence outcomes were assessed by univariate and multivariate analysis.
Results
Altogether, 1,001 consecutive LRs were performed in 912 patients (mean age 62 ± 13 years). The distribution of the LR by age was 372 (37.2 %), 477 (47.6 %), and 152 (15.2 %) in patients <60, 60–74, and ≥75 years, respectively. The overall morbidity and mortality rates were 33.3 and 2.5 %, respectively. Age ≥75 years was independently associated with postoperative mortality [odds ratio (OR) 4.75, 95 % confidence interval (CI) 1.5–15.1; p = 0.008] and 1-year mortality (OR 2.8, 95 % CI 1.2–6.6; p = 0.015). The postoperative complication rate (p = 0.216) was not increased, even for major complications (p = 0.09). The other independent risk factors for mortality were a cirrhotic liver (p = 0.017), preoperative arterial chemoembolization (p = 0.001), caval vein clamping (p = 0.001), and intraoperative blood transfusion (p = 0.044).
Conclusions
Age beyond 75 years represent a risk factor of death after LR and should be avoided after chemoembolization or in cirrhotic patients. A specific assessment using geriatric indexes might be the key to success in this population. 相似文献