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Contains fulltext : 218566pub.pdf (Publisher’s version ) (Closed access) Contains fulltext : 218566pos.pdf (Author’s version postprint ) (Open Access) BACKGROUND: Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study. METHODS: We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality. RESULTS: We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47). CONCLUSION: PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.

Introduction Neurocritical care focuses on the care of critically ill patients with an acute neurologic disorder and has grown significantly in the past few years. However, there is a lack of data that describe the scope of practice of neurointensivists and epidemiological data on the types of patients and treatments used in neurocritical care units worldwide. To address these issues, we designed a multicenter, international, point-prevalence, cross-sectional, prospective, observational, non-interventional study in the setting of neurocritical care (PRINCE Study). Methods In this manuscript, we analyzed data from the initial phase of the study that included registration, hospital, and intensive care unit (ICU) organizations. We present here descriptive statistics to summarize data from the registration case report form. We performed the Kruskal–Wallis test followed by the Dunn procedure to test for differences in practices among world regions. Results We analyzed information submitted by 257 participating sites from 47 countries. The majority of those sites, 119 (46.3%), were in North America, 44 (17.2%) in Europe, 34 (13.3%) in Asia, 9 (3.5%) in the Middle East, 34 (13.3%) in Latin America, and 14 (5.5%) in Oceania. Most ICUs are from academic institutions (73.4%) located in large urban centers (44% > 1 million inhabitants). We found significant differences in hospital and ICU organization, resource allocation, and use of patient management protocols. The highest nursing/patient ratio was in Oceania (100% 1:1). Dedicated Advanced Practiced Providers are mostly present in North America (73.7%) and are uncommon in Oceania (7.7%) and the Middle East (0%). The presence of dedicated respiratory therapist is common in North America (85%), Middle East (85%), and Latin America (84%) but less common in Europe (26%) and Oceania (7.7%). The presence of dedicated pharmacist is highest in North America (89%) and Oceania (85%) and least common in Latin America (38%). The majority of respondents reported having a dedicated neuro-ICU (67% overall; highest in North America: 82%; and lowest in Oceania: 14%). Conclusion The PRINCE Study results suggest that there is significant variability in the delivery of neurocritical care. The study also shows it is feasible to undertake international collaborations to gather global data about the practice of neurocritical care. Electronic supplementary material The online version of this article (10.1007/s12028-019-00750-3) contains supplementary material, which is available to authorized users.

Quarantines may exacerbate the presence of emotional symptoms or anxiety.To explore the relation between time spent in lockdown and development of depressive and anxiety symptoms.A survey including the GAD anxiety and PHQ-9 depression scores was answered online by 1,488 subjects aged 36 ± 14 years (74% women), invited to participate through social networks. Both scores are validated for the Chilean population.Most responders had a private health insurance system. Sixty seven percent had clinically significant depressive symptoms and 39% had anxiety symptoms. Spending four or more weeks of lockdown (quarantine) was associated with 1.6 times higher risk of developing depressive symptoms and 2.9 times higher risk of developing anxiety symptoms. Difficulties in access to health care increased 3.3 times the risk of developing depression. Suffering a respiratory disease increased 2.39 times the risk of developing anxiety.There was a direct association between depressive and anxious symptoms, and the time spent of quarantine.

The Chilean Academy of Medicine convened a commission to evaluate the status of HIV epidemic and the national response to it, regarding its achievements, gaps and challenges, aiming to recommend actions to optimize assessment quality and national response. This publication summarizes the agreed upon opinion of its members. The epidemic is overwhelmingly sexually transmitted, predominant in homo/bisexual men. Vertical transmission is very low. An increasing number of new diagnoses is occurring, with relative over representation of foreign people lately. There is a legal guarantee of confidentiality, nondiscrimination and treatment for those affected, both in the private and public sector. All public health services have active HIV care units. Modern antiviral drugs and monitoring tests are also available. Despite these clear achievements, insufficient, occasionally inadequate public policies and certain rigid regulations thwart optimal effectivity and efficiency of the programs, contributing to the slow and incomplete compliance with international commitments. Shortcomings worth highlighting are: suboptimal educational and preventive programs directed to youngsters, vulnerable and general population; persistent underdiagnosis of infected population; cumbersome requirements to request and inform diagnostic tests, thus discouraging testing; excessive centralization and long latency of diagnosis confirmation and monitoring tests; incomplete epidemiologic analysis and public reporting of findings; non flexibility and slow updating of therapeutic guidelines; insufficient adaptation of care and drug delivery modalities to patients' needs; excessive administrative requirements at care centers and restrictive legislation for outcome and interventional clinical research. Recommendations to deal with these issues were proposed.

Background: MRI is assumed to be valid for distinguishing metastatic vertebral fractures (MVFs) from osteoporotic vertebral fractures (OVFs). This study assessed (1) concordance between the image-based diagnosis of MVF versus OVF and the reference (biopsy or follow-up of >6 months), (2) interobserver and intraobserver agreement on key imaging findings and the diagnosis of MVF versus OVF, and (3) whether disclosing a patient's history of cancer leads to variations in diagnosis, concordance, or agreement. Patients and Methods: This retrospective cohort study included clinical data and imaging from 203 patients with confirmed MVF or OVF provided to 25 clinicians (neurosurgeons, radiologists, orthopedic surgeons, and radiation oncologists). From January 2018 through October 2018, the clinicians interpreted images in conditions as close as possible to routine practice. Each specialist assessed data twice, with a minimum 6-week interval, blinded to assessments made by other clinicians and to their own previous assessments. The kappa statistic was used to assess interobserver and intraobserver agreement on key imaging findings, diagnosis (MVF vs OVF), and concordance with the reference. Subgroup analyses were based on clinicians' specialty, years of experience, and complexity of the hospital where they worked. Results: For diagnosis of MVF versus OVF, interobserver agreement was fair, whereas intraobserver agreement was substantial. Only the latter improved to almost perfect when a patient's history of cancer was disclosed. Interobserver agreement for key imaging findings was fair or moderate, whereas intraobserver agreement on key imaging findings was moderate or substantial. Concordance between the diagnosis of MVF versus OVF and the reference was moderate. Results were similar regardless of clinicians' specialty, experience, and hospital category. Conclusions: When MRI is used to distinguish MVF versus OVF, interobserver agreement and concordance with the reference were moderate. These results cast doubt on the reliability of basing such a diagnosis on MRI in routine practice.

Four taxa are added to the fossil history of catfishes based on new identifications and descriptions of material from the Miocene Urumaco Formation in northwestern Venezuela. Three of the fossil catfishes belong to the family Doradidae (thorny catfishes); one, Doras dioneae, represents a new species, the first fossil doradid to be formally named, and the other two, Doraops cf. zuloagai and Rhinodoras cf. thomersoni, are referred to modern taxa endemic to the Maracaibo basin. The fourth fossil catfish belongs to the family Pimelodidae (long-whiskered catfishes) and is assigned to Platysilurus, a modern genus that occurs in the Maracaibo, Orinoco, Amazon, and large rivers of the Guianas. These fossil taxa inhabited the paleo-Amazon-Orinoco, a large ancient river system that drained the South American continent northward prior to the uplift of the Eastern Andes and Coastal Cordilleras and concomitant isolation of the Maracaibo basin in the Late Miocene (ca. 8 Ma). Species novum: Doras dioneae Sabaj ...

Determinations were made of total soil organic matter (SOM), stable and labile organic fractions, biomass carbon (C), and chemical composition of several humus‐soil‐fractions in Chilean volcanic soils, Andosols and Ultisols. Their physico‐chemical properties and humification degree at different stages in edaphic evolution were also assessed. In addition, organic matter models were obtained by chemical and biological syntheses and the structures and properties of natural and synthetic humic materials were compared with SOM. Results indicate that Andosols have higher SOM levels than Ultisols, but the fraction distribution in the latter suggests a shift of the more stable fractions to the more labile ones. Moreover, contents of humines, and humic and fulvic acids suggest that Chilean volcanic soil SOM is highly humified. On the other hand, among the SOM labile fractions, carbohydrate and biomass are about 15% of the SOM which are one of the most important fractions in soil fertility.

Influenza (FLU) es una enfermedad aguda, altamente transmisible, que evoluciona en brotes anuales. La diversidad de los reservorios naturales y la capacidad de reordenamiento genético del virus FLU A, hacen que el potencial de pandemia por una nueva cepa esté presente. Las medidas de prevención incluyen el uso de vacunas inactivadas, las que están indicadas en lactantes entre 6 a 24 meses de vida, pacientes con enfermedades cardíacas y pulmonares crónicas, pacientes inmunocomprometidos, adultos sobre 65 años de edad, personal de salud y mujeres embarazadas. La vacuna atenuada nasal tiene indicación restringida a los grupos de edad entre 5 y 49 años. La profilaxis con fármacos antivirales está indicada en brotes y contactos de pacientes con factores de riesgo. El manejo considera el uso de fármacos antivirales en los casos graves. Ante una eventual pandemia se deben reforzar las medidas de prevención y hacer un uso racional de antivirales, tanto en profilaxis como en tratamiento

Se presenta el caso de un hombre de 69 años, etílico crónico, diabético, con antecedentes de cirrosis hepática y colecistectomía. Ingresó por cuadro de ascitis y derrame pleural izquierdo masivo asociado a insuficiencia respiratoria. El estudio de ambos fluidos fue categórico para el diagnóstico de quilotórax y quiloascitis. No había antecedentes traumáticos ni de neoplasia conocida. El estudio de imágenes fue negativo para cáncer. El paciente egresó en relativas buenas condiciones luego de terapia depletiva y evacuadora parcial de ambos derrames, con franco alivio de la disnea. Se prescribió régimen oral libre de grasas. El paciente reingresó un mes después en falla respiratoria secundaria a neumonía grave sin lograr recuperarse. El informe de la autopsia reveló una lesión del conducto torácico a nivel abdominal posiblemente relacionado a la cirugía previa. La asociación de quilotórax y quiloascitis es extraordinariamente infrecuente, generalmente asociada a traumatismos, neoplasias o complicaciones postoperatorias, aunque ocasionalmente puede deberse a cirrosis hepática, insuficiencia cardíaca y síndrome nefrótico

El sindrome pulmonar por hantavirus (SPH) es una enfermedad emergente en Chile, 123 casos de SPH se confirmaron entre 1993 y julio de 2000, incluyendo 5 casos estudiados retrospectivamente. Esta enfermedad ha afectado especialmente a personas jovenes (26 anos promedio edad), en su mayoria hombres (75%). Los casos se han presentado en personas residentes de comunidades rurales que realizaban actividades agricolas-forestales o actividades relacionadas con el hogar. La letalidad global ha sido de 49,6%, variando desde 60% en 1997 a 43% en el ano 2000. Los casos se han presentado desde la VI a XI regiones del pais, los riesgos mas altos han ocurrido en Aysen (1997-1998) y Araucania (1998 y 2000), destacando la ocurrencia de conglomerados de casos, en las Regiones de la Araucania, Bio Bio, Los Lagos y Aysen. El SPH es una enfermedad de presentacion endemica con aumento de casos en los meses de primavera y verano

Eye-safety requirements in important applications like LIDAR or Free Space Optical Communications make specifically interesting the generation of high power, short optical pulses at 1.5 um. Moreover, high repetition rates allow reducing the error and/or the measurement time in applications involving pulsed time-of-flight measurements, as range finders, 3D scanners or traffic velocity controls. The Master Oscillator Power Amplifier (MOPA) architecture is an interesting source for these applications since large changes in output power can be obtained at GHz rates with a relatively small modulation of the current in the Master Oscillator (MO). We have recently demonstrated short optical pulses (100 ps) with high peak power (2.7 W) by gain switching the MO of a monolithically integrated 1.5 um MOPA. Although in an integrated MOPA the laser and the amplifier are ideally independent devices, compound cavity effects due to the residual reflectance at the different interfaces are often observed, leading to modal instabilities such as self-pulsations.

Although infrequent, non-inflammatory nodules are potential complications associated with dermal filler injections. There is a lack of consensus in the literature regarding potential treatments to help resolve nodules associated with calcium hydroxylapatite (CaHA) filler injections. This case report describes the successful treatment of a non-inflammatory nodule related to CaHA injection using a combination of 5-fluorouracil, dexamethasone, and triamcinolone. Copyright © 2016 Journal of Drugs in Dermatology. All Rights Reserved.

BACKGROUND: Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. OBJECTIVE: To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. METHODS: We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. RESULTS: Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. CONCLUSION: Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions. ispartof: Neurosurgery vol:93 issue:2 pages:399-408 ispartof: location:United States status: published

Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a “nihilism guard.” More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.