Neurocritical Care Resource Utilization in Pandemics: A Statement by the Neurocritical Care Society

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Lumbar Drainage for the Treatment of Severe Bacterial Meningitis

Objective

To assess the safety and effectiveness of lumbar drains as adjuvant therapy in severe bacterial meningitis, and compare it to standard treatment.

Design

A retrospective cohort study of all patients above the age of 18 years with bacterial meningitis and altered mental status admitted to the Montreal Neurological Hospital Intensive Care Unit from January 2000 to December 2010.

Patients

Thirty-seven patients were identified using clinical and cerebrospinal fluid criteria. Patients were divided into lumbar drain (LD) (n = 11) and conventional therapy (no LD) (n = 26) groups.

Measurements

Outcomes were assessed using meningitis-related mortality and the Glasgow Outcome Scale (GOS) at 1 and 3 months.

Outcomes

All patients received broad-spectrum antibiotic therapy, 84 % received steroids. There was no significant difference in mean age, type of bacteria, or time from arrival in ER to initiation of therapy. There was significantly less co-morbidity (24 % healthy vs. 18.1 %) and coma (GCS < 8 34.6 vs. 54.5 %) in the conventional therapy group, as well as a longer duration of symptoms prior to admission (mean 1.34 ± 1.24 vs. 2.19 ± 2.34 days). The mean opening pressure was high in all patients (20–55 cm H₂O in the LD and 12–60 cm H₂O in the no LD). Mean time from arrival in ER to insertion of the lumbar drain was 37 h. Lumbar drains were set for a maximum drainage of 10 cc/h and an ICP below 10 mmHg. Despite greater clinical severity, the LD group had 0 % mortality and 91 % of the patients achieved a GOS of 4–5. The non-LD group had 15.4 % mortality and only 60 % achieved a GOS of 4–5. No adverse events were associated with LD therapy.

Conclusions

In this study, the use of lumbar drainage in adult patients with severe bacterial meningitis was safe, and likely contributed to the low mortality and morbidity.     

Physiological indicators of salinity stress in the grey mullet,Mugil cephalus,Linnaeus, 1758 juveniles

Grey mullet (Mugil cephalus) juveniles were subjected to salinity stress in order to determine physiological response and recovery. Variations in the most important blood physiological indicators of stress (i.e., cortisol and glucose) were analyzed after application of stress. According to the results, the concentration of cortisol increased significantly 30 min after delivery of fish to water with 15 and 25 ppt salinities. The elevated levels of cortisol returned to basal levels 60 min after application of stress (P?>?0.05). Plasma cortisol and glucose did not show significant changes after delivery of fish to water with 35 ppt salinity (P?>?0.05). The elevation of plasma glucose occurred 30 and 60 min after delivery of fish to water with 15 and 25 ppt salinities (P?>?0.05). Our study demonstrated that low salinities are stressful for grey mullet juveniles.     

Giardia intestinalis in patients with nonulcer dyspepsia

Background and study aimsGiardiasis may present with dyspeptic symptoms that may mimic other gastrointestinal and/or biliary disorders. The objective of this study was to determine the prevalence of giardiasis in stool and duodenal aspirate of patients with NUD, assess symptomatic benefit of therapy, and compare the diagnostic tools for giardiasis utilizing stool and duodenal aspirates microscopic evaluation versus ELISA testing.Patients and methods109 Patients with endoscopic diagnosis of NUD out of 278 consecutive patients with dyspepsia were included. The severity of dyspepsia and the quality of life were assessed utilizing Rome II criteria and SF-36 for Quality of Life and concomitant stool and/or duodenal aspirate samples were submitted for ELISA antigen test for Giardia intestinalis. Those who tested positive for giardiasis (Group 1) were assigned to receive Tinidazole 2.0 g. single dose plus omeprazole for 4 weeks and the remaining patients (Group 2) omeprazole alone for 4 weeks. One month after therapy, both groups were reassessed and Stool ELISA antigen test for G. intestinalis for Group 1, was performed.ResultsELISA testing of stool (19%) and duodenal aspirates (19%) had significantly better results than microscopic ones in stool (11%) or duodenal aspirates (7%). The two groups were well matched with respect to age, sex, initial results on the Glasgow Dyspepsia Severity Score, prevalence of previously prescribed antisecretory-drug therapy, prevalence of smoking, predominant symptom at presentation, and quality of life. The outcome of patients at 1 month, on an intention-to-treat basis, showed that the symptoms were resolved (defined as a score of 0 or 1) in 17 of 21 patients (81%) in Group 1 as compared with 31 of 88 patients (35%) in Group 2 P < 0.001. The scores in both groups were lower than those at base line and there was a highly statistically significant difference between both groups.ConclusionG. intestinalis as a cause of dyspepsia should be considered in patients with negative endoscopy and in those who remain symptomatic in spite of adequate treatment for known upper G.I. disorders. NUD associated with the presence of Giardia, had better symptomatic benefit (81%) with specific treatment than controls (35%). ELISA testing of stool (19%) and duodenal aspirates (19%) had significantly better results than microscopic ones in stool (11%) or duodenal aspirates (7%).