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Cerebral ischemia due to hypoxia is a major cause of secondary brain injury and is associated with higher morbidity and mortality in patients with acute brain injury. Hyperoxia could improve energetic dysfunction in the brain in this setting. Our objectives were to perform a systematic review and meta-analysis of the current literature and to assess the impact of normobaric hyperoxia on brain metabolism by using cerebral microdialysis.We searched Medline and Scopus, following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement; we searched for retrospective and prospective observational studies, interventional studies, and randomized clinical trials that performed a hyperoxia challenge in patients with acute brain injury who were concomitantly monitored with cerebral microdialysis. This study was registered in PROSPERO (CRD420211295223).We included a total of 17 studies, with a total of 311 patients. A statistically significant reduction in cerebral lactate values (pooled standardized mean difference [SMD] - 0.38 [- 0.53 to - 0.23]) and lactate to pyruvate ratio values (pooled SMD - 0.20 [- 0.35 to - 0.05]) was observed after hyperoxia. However, glucose levels (pooled SMD - 0.08 [- 0.23 to 0.08]) remained unchanged after hyperoxia.Normobaric hyperoxia may improve cerebral metabolic disturbances in patients with acute brain injury. The clinical impact of such effects needs to be further elucidated.

Fracture-dislocation of the trapeziometacarpal (TM) joint in adolescent patients is a rare injury, with only 3 cases reported in literature to our knowledge. Its low incidence, together with the complexity of the anatomy and biomechanics of TM joint, may represent a challenge for surgeons in choosing the best treating option. Here, we report a case of a TM fracture dislocation in a 14-year-old boy treated with percutaneous Kirschner wire pinning. The results we obtained endorsed our choice in patients for whom closed reduction is achievable.

The aim of this systematic review is to understand which surgical procedure provides better results in terms of pain relief and function in the treatment of chronic exertional compartment syndrome (CECS) of the forearm. We searched Medline (PubMed), Web of Science, Embase and Scopus databases on 8 July 2020. Twelve studies were included in this review. We assessed the quality of the studies using the Coleman Methodological Score. Data on demographic features, operative readings, diagnostic methods, follow-up periods, type and rates of complications, survivorship of the procedure, return to sport activity, and outcome measures were recorded. In conclusion, compared to the other techniques, endoscopic fasciotomy delivers similar success rates and lower incidence of complications. Cite this article: EFORT Open Rev 2021;6:101-106. DOI: 10.1302/2058-5241.6.200107

The prognostic role of the Pupillary Pain Index (PPI), derived from automated pupillometry, remains unknown in post-anoxic brain injury.Single-center retrospective study in adult comatose cardiac arrest (CA) patients. Quantitative PPI and Neurologic Pupil Index (NPi) were concomitantly recorded on day 1 and day 2 after CA. The primary outcome was to assess the prognostic value of PPI to predict 3-month unfavourable outcome (UO, defined as Cerebral Performance Category of 3-5). Secondary outcome was the agreement between PPI and NPi to predict unfavourable outcome.A total of 102 patients were included; patients with UO (n = 69, 68%) showed a lower NPi (4.2 [3.5-4.5] vs. 4.6 [4.3-4.7]; p 0.01 on day 1-4.3 [3.8-4.7] vs 4.6 [4.3-4.8] on day 2), and PPI (3 [1-6] vs. 6 [3-7]; p 0.01 on day 1-3 [1-6] vs 6 [4-8]; p 0.01 on day 2) than others. A PPI = 1 on day 2 showed a sensitivity of 26 [95% CI 16-38]% and a specificity of 100 [95% CI 89-100]% to predict UO (p = 0.003 vs. NPi ≤ 2). On day 2, a total of 6 patients had concomitant PPI = 1 and NPi ≤ 2, while 12 showed NPi 2 and PPI = 1; the coefficient of agreement was 0.42. Moreover, NPi and PPI values showed a moderate correlation both on day 1 and day 2.In this study, PPI = 1 on day 2 could predict UO in comatose CA patients with 100% specificity, but with a low sensitivity (yet higher than NPi). The agreement between PPI and NPi values was moderate.

Sepsis-associated brain dysfunction is a frequent disorder in septic patients and has a multifactorial pathophysiology. Cholinergic pathways and brainstem dysfunction may result in pupillary alterations. The aim of this study was to evaluate whether early assessment of the Neurological Pupil Index (NPiRetrospective cohort study of adult critically ill septic patients admitted to the intensive care unit of a University Hospital; patients with acute or known brain damage were excluded. Patients' severity was assessed by the daily Sequential Organ Failure Assessment Score and the SOFAinfmax/inf(i.e., highest SOFA Score during the first five days) was computed. The worst NPi (i.e., lowest value from one eye) was collected daily and then computed over the first five days of assessment. Mortality was assessed at hospital discharge.A total of 75 patients were included over the study period (median age 67 [53-75] years and median SOFA Score at admission 10 [8-12]); 64 (85%) presented septic shock; 48 (64%) died at hospital discharge. The worst NPi during the first five days of sepsis was significantly lower in non-survivors compared to survivors (4.4 [3.6-4.6] vs. 4.5 [4.2-4.7]; P=0.042). The worst NPi was also significantly lower in high severity group (i.e., SOFAinfmax/inf≥12) when compared to others (4.4 [3.2- 4.5] vs. 4.5 [4.0-4.7] P=0.01). However, in the multivariate analyses, the NPi value was not independently associated with in-hospital mortality or high SOFAinfmax/inf.In this study, no independent prognostic role of NPi was observed in septic patients. Further larger prospective studies are needed to better evaluate the role of automated pupillometry in this setting.

Background: The Neurologic Pupil Index (NPi), derived from automated pupillometry, can accurately predict poor neurological outcome in post-anoxic brain injury. The prognostic role of another index, called Pupillary Pain Index (PPI), remains unknown in this setting. Methods: Monocentric study in adult comatose cardiac arrest (CA) patients. Quantitative PPI and NPi were concomitantly recorded on day 1 and day 2 after CA. The primary study outcome was to assess the prognostic value of PPI to predict 3-month unfavourable outcome (UO, defined as Cerebral Performance Category of 3–5). Secondary outcome was the agreement between PPI and NPi to predict unfavourable outcome. Results: A total of 102 patients were included; 69 patients (68%) patients had UO. Patients with UO showed a lower NPi (4.2 [3.5-4.5] vs. 4.6 [4.3-4.7]; p2 and PPI=1; the coefficient of agreement was 0.42. Moreover, NPi and PPI values showed a moderate correlation both on day 1 and day 2. Conclusions: In this study, PPI=1 on day 2 could accurately predict UO in comatose CA patients, with 100% specificity and a higher sensitivity than NPi. The agreement between PPI and NPi values was moderate.

High levels of procalcitonin (PCT) have been associated with a higher risk of mortality in COVID-19 patients. We explored the prognostic role of early PCT assessment in critically ill COVID-19 patients and whether PCT predictive performance would be influenced by immunosuppression.Retrospective multicentric analysis of prospective collected data in COVID-19 patients consecutively admitted to 36 intensive care units (ICUs) in Spain and Andorra from March to June 2020. Adult (18 years) patients with confirmed COVID-19 and available PCT values (72 hours from ICU admission) were included. Patients were considered as "no immunosuppression" (NI), "chronic immunosuppression" (CI) and "acute immunosuppression" (AIT if only tocilizumab; AIS if only steroids, AITS if both). The primary outcome was the ability of PCT to predict ICU mortality.Of the 1079 eligible patients, 777 patients were included in the analysis. Mortality occurred in 227 (28%) patients. In the NI group 144 (19%) patients were included, 67 (9%) in the CI group, 66 (8%) in the AIT group, 262 (34%) in the AIS group and 238 (31%) in the AITS group; PCT was significantly higher in non-survivors when compared with survivors (0.64 [0.17-1.44] vs. 0.23 [0.11-0.60] ng/mL; P0.01); however, in the multivariable analysis, PCT values was not independently associated with ICU mortality. PCT values and ICU mortality were significantly higher in patients in the NI and CI groups.PCT values are not independent predictors of ICU mortality in COVID-19 patients. Acute immunosuppression significantly reduced PCT values, although not influencing its predictive value.

Introduction: We evaluated the concordance of the Neurological pupil Index (NPi) with other predictors of outcome after cardiac arrest (CA). Methods: Post hoc analysis of a prospective, international, multicenter study including adult CA patients. Predictors of unfavorable outcome (UO, Cerebral Performance Category of 3–5 at 3 months) included: a) worst NPi ≤ 2; b) presence of discontinuous encephalography (EEG) background; c) bilateral absence of N20 waves on somatosensory evoked potentials (N20ABS); d) peak neuron-specific enolase (NSE) blood levels > 60 mcg/L; e) myoclonus, which were all tested in a subset of patients who underwent complete multimodal assessment (MMM). Results: A total of 269/456 (59 %) patients had UO and 186 (41 %) underwent MMM. The presence of myoclonus was assessed in all patients, EEG in 358 (78 %), N20 in 186 (41 %) and NSE measurement in 228 (50 %). Patients with discontinuous EEG, N20ABS or high NSE had a higher proportion of worst NPi ≤ 2. The accuracy for NPi to predict a discontinuous EEG, N20ABS, high NSE and the presence of myoclonus was moderate. Concordance with NPi ≤ 2 was high for NSE, and moderate for discontinuous EEG and N20ABS. Also, the higher the number of concordant predictors of poor outcome, the lower the observed NPi. Conclusions: In this study, NPi ≤ 2 had moderate to high concordance with other unfavorable outcome prognosticators of hypoxic-ischemic brain injury. This indicates that NPi measurement could be considered as a valid tool for coma prognostication after cardiac arrest.

Intracranial multimodality monitoring (iMMM) is increasingly used in acute brain-injured patients; however, safety and reliability remain major concerns to its routine implementation., info:eu-repo/semantics/published

Neurological outcome and mortality of patients suffering from poor grade subarachnoid hemorrhage (SAH) may have changed over time. Several factors, including patients' characteristics, the presence of hydrocephalus and intraparenchymal hematoma, might also contribute to this effect. The aim of this study was to assess the temporal changes in mortality and neurologic outcome in SAH patients and identify their predictors., info:eu-repo/semantics/published

Alkaline phosphatase (ALP) levels are often elevated in cerebrovascular and cardiovascular disease. Their prognostic role after subarachnoid hemorrhage (SAH) remains to be elucidated.We performed a retrospective single center study of patients with non-traumatic SAH admitted to the intensive care unit (ICU) of Erasme Hospital (Brussels, Belgium) from 2006 to 2019. Exclusion criteria were previous history of liver cirrhosis or malignancies and early death (i.e. within 24 h from ICU admission). Baseline information, clinical data, radiologic data were collected, the occurrence of DCI as well as serum ALP levels during the first 12 days of ICU stay. Unfavorable neurological outcome (UO) at 3 months was defined as a Glasgow Outcome Scale of 1-3.Six hundred and fifty patients were included; ALP levels increased from baseline after day 6 from admission, in particular among patients with an initial poor clinical status. There was no difference in the ALP levels between patients with or without DCI over time. Patients with UO had higher ALP levels over time than others; however, in the multivariable analysis, nor ALP levels on admission or the highest ALP value during the ICU stay were independently associated with UO.The results of this study suggested that ALP levels had no prognostic role in SAH patients. Other possible prognostic biomarkers should be evaluated in this setting.

There is a persistent debate on the optimal target temperature to use during cooling procedures in cardiac arrest survivors. A large randomized clinical trial (RCT) including more than 900 patients showed that targeted temperature management (TTM) at 33 °C had similar mortality and unfavorable neurological outcome (UO) rates as TTM at 36 °C in out-of-hospital cardiac arrest patients with any initial rhythm. Since then, several observational studies have been published on the effects of changes in target temperature (i.e., from 33 to 36 °C) on patients’ outcome. We performed a systematic literature search from 1 January 2014 to 4 December 2020 and identified ten retrospective studies (very low levels of certainty; high risk of bias), including 5509 patients, that evaluated TTM at 33 °C vs. TTM at 36 °C on the occurrence of UO (n = eight studies) and mortality (n = ten studies). TTM at 33 °C was associated with a lower risk of UO when studies assessing neurological outcome with the Cerebral Performance Categories were analyzed (OR 0.80 [95% CIs 0.72–0.98]; p = 0.03). No differences in mortality were observed within the two TTM strategies. These results suggest that an inappropriate translation of TTM protocols from large well-conducted randomized trials into clinical management may result in unexpected effects on patients’ outcome. As for all newly commercialized drugs, epidemiological studies and surveillance programs with an adequate follow-up on large databases are necessary to understand how RCTs are implemented into medical practice.

Introduction Severe coronavirus 2019 disease (CoViD-19) may lead to respiratory failure and mechanical ventilation. Therefore, ventilator associated pneumonia (VAP) may complicate the course of the disease. The aim of the current article was to investigate possible predictive factors for bacterial VAP on a retrospective manner, in a cohort of mechanically ventilated CoViD-19 patients. Additionally, determinant factors of lethality were analyzed. Methods Medical records of patients hospitalized in the intensive care units (ICU) at the university hospital UZ Brussel during the epidemic were reviewed. VAP was defined following the National Healthcare Safety Network 2017 criteria. Univariate and multivariate logistic regressions analyses were performed. Results Among the 39 patients included in the study, 54% were diagnosed with bacterial VAP. Case fatality rate was 44%, but 59% of the deceased patients had a do-not-resuscitate status. Multivariate logistic regression for prediction of VAP showed significant differences in duration of ICU hospitalization and in minimal lung compliance. Additional analyses were performed on CoViD-19 patients who were affected by bacterial respiratory superinfection. The responsible pathogens correspond to the commonly found bacteria in VAP. However, 71% of the isolated germs were multi-drug resistant and bacteraemia was reported in 38%. Multivariate analyses for prediction of lethality found significant difference in SOFA score. Conclusions Mechanically ventilated CoViD-19 patients might frequently develop VAP. Longer ICU hospitalization was associated with pulmonary superinfection in the current cohort. Moreover, decreased minimal lung compliance was correlated to VAP and higher SOFA score at VAP diagnosis was associated with lethality.

Background Fever has been reported as a common symptom in COVID-19 patients. The aim of the study was to describe the characteristics of COVID-19 critically ill patients with fever and to assess if fever management had an impact on some physiologic variables. Methods This is a retrospective monocentric cohort analysis of critically ill COVID-19 patients admitted to the Department of Intensive Care Unit (ICU) of Erasme Hospital, Brussels, Belgium, between March 2020 and May 2020. Fever was defined as body temperature ≥ 38° C during the ICU stay. We assessed the independent predictors of fever during ICU stay. We reported the clinical and physiological variables before and after the first treated episode of fever during the ICU stay. Results A total of 72 critically ill COVID-19 patients were admitted to the ICU over the study period and were all eligible for the final analysis; 53 (74%) of them developed fever, after a median of 4 [0-13] hours since ICU admission. In the multivariable analysis, male gender (OR 5.41 [C.I. 95% 1.34-21.92]; p=0.02) and low PaO2/FiO2 ratio (OR 0.99 [C.I. 95% 0.99-1.00]; p=0.04) were independently associated with fever. After the treatment of the first febrile episode, heart rate and respiratory rate significantly decreased together with an increase in PaO2 and SaO2. Conclusions In our study, male gender and severe impairment of oxygenation were independently associated with fever in critically ill COVID-19 patients. Fever treatment reduced heart rate and respiratory rate and improved systemic oxygenation.

Chronic exertional compartment syndrome of the forearm is a rare disease characterized by the recurrent onset of forearm pain and progressive weakness during exertion. Over the years many surgical techniques have been reported in literature: wide-open fasciotomy, mini-open fasciotomy, fasciotomy associated with fasciectomy, and mini-invasive endoscopic fasciotomy. Compared with traditional open techniques, mini-invasive techniques are characterized by minimal tissue trauma, less postoperative pain, faster recovery to normal activity and better esthetical result. We describe a mini-invasive endoscopic technique for the treatment of forearm chronic exertional compartment syndrome using the SmartRelease endoscopic tissue release system (MicroAire).

The detrimental effects of elevated intra-abdominal pressure (IAP) on kidney function have been known for centuries. However, only recently there has been an increasing focus on the potential role of venous congestion in the development of renal failure, through coexisting repercussions on the heart and abdominal compartment. In contrast with the traditional perception of worsening renal function due to hypoperfusion, this chapter discusses the pathophysiological insights on kidney injury induced by intra-abdominal hypertension (IAH) and the role of IAP in worsening renal function in the setting of decompensated heart failure, introducing the new concept of “cardio-abdominal-renal syndrome” (CARS).

Background: Five-fingered hand (5-FH) with completely developed phalanges is a rare phenotype observed so far only in humans and characterised by three phalanges of the 1st ray. A long-lasting, debated question is if the missing element of the normal hand 1st ray is the metacarpal or the phalanx. In this study, comparative X-rays morphometry of long bones in normal and 5-FH is carried out with the aim to face this question through homology analysis of long bone segments in the transverse and longitudinal line of normal hand and 5-FH. Materials and methods: In the normal hand X-rays (n =20) and in a 5-FH X-rays series (n = 9) the relative length of each segment on the ray total length and the index of growth rate (IGR) were assessed. The calculation of the first parameter in normal hand bi-phalangeal thumb was carried out on the 3rd ray total length in the same hand. Results: The parameters of relative length and the proximal/distal growth rate asymmetry in the post-natal period (assessed through the IGR) confirmed in 5-FH the homology of all the five segment on the transverse line. In the normal control hand, the relative length assessment methodology was biased by the missing segment of the thumb, therefore, the reference to the 3rd ray total length in the same hand (instead of the 1st), allowed the homology analysis of the thumb metacarpal and 1st phalanx with the lateral segments (2nd–5th ray) of the same hand. The 5-FH analysis was used to choose the more appropriate reference ray for the normal hand group. Conclusions: The comparative analysis of relative lengths and IGRs in the two groups suggested homology of the (anatomical) 1st metacarpal with the 2nd–5th proximal phalanges in the same hand and that of the (anatomical) 1st proximal phalanx with the 2nd–5th mid phalanges. These data suggest that the missing segment of the normal hand thumb is the metacarpal.

Fluid therapy is often used as first line therapy in critically ill patients in shock. Among the methods currently available to detect preload responsiveness, the PLR test has been demonstrated to be reliable in many studies and a recent meta-analysis (1,2). According to Monnet and Teboul, five rules need to be taken into account, when performing a PLR (3).

Highlights • Due to the high occurrence of brain complications during COVID-19, monitoring of cerebral functions is necessary. • Clinical examination should be routinely performed in all patients and used to decide for neuro-imaging, whenever necessary. • In heavily sedated or paralyzed patients (i.e. unreliable clinical examination), non-invasive neuromonitoring could provide additional information on cerebral function of these patients. • In daily practice, trained nurses could obtain relevant findings from cerebral ultrasound, cerebral near-infrared spectroscopy, quantified EEG and automated pupillometry to assess cerebral function in COVID-19 critically ill patients

The patterns of longitudinal and peripheral growth were analyzed in human autopod cartilage anlagen (fetal developmental stage 20th-22nd week) through morphometric assessment of chondrocyte parameter size, shape, alignment and orientation between peripheral and central sectors of the anlage transition zone defined by primary ossification center and the epiphyseal basis. The aim was to correlate the chondrocyte dynamics with the longitudinal and peripheral growth. A further comparison was carried out between the corresponding sectors of the postnatal (3-5 months old) growth plate cartilage documenting: (1) the different chondrocyte framework and the new peripheral mechanism; (2) the opposite direction of fetal periosteal ossification versus the Lacroix bone bark. Measurement of multiple parameters (% lac area, % total matrix area, total lac density and mean single lac area), which characterize the cartilage Anlage growth, suggested the following correlations with chondrocyte duplication rate: (a) slow duplication rate ≈ coupled, intralacunar chondrocytes (in central epiphysis); (b) repeated/frequent cell duplications ≈ clusters (in the basal epiphyseal layer); (c) clusters of chondrocytes before becoming hypertrophic were stacked up on the top of each other (both in the Anlage transition zone or in the columns of metaphyseal growth plate); (d) enhanced osteoclastic resorption of the Lacroix bone bark lower end, extended to the more external metaphyseal trabeculae counterbalancing the discrepancy between the epiphyseal and the diaphyseal circumferential growth.

A histological and morphometric analysis of human metacarpal and carpal anlagen between the 16th and 22nd embryonic weeks was carried out with the aim of studying the establishment of the respective anlage architecture. No differences in the pattern of growth were documented between the peripheral and central zones of the metacarpal epiphyses and those of the carpals. The regulation of longitudinal growth in long bone anlagen occurred in the transition zone between the epiphysis and the diaphysis (homologous to the metaphyseal growth plate cartilage in more advanced developmental stage of the bone). Comparative zonal analysis was conducted to assess the chondrocyte density, the mean chondrocyte lacunar area, the paired chondrocyte polarity in the orthogonal longitudinal and transverse planes, and the lacunar shape transformation in the metacarpal. In transition from epiphysis to diaphysis chondrocyte density decreased and mean lacunar area increased. No significant differences in the chondrocyte maturation cycle were observed between proximal/distal metacarpal epiphyses and the carpal anlagen. The number of paired chondrocyte oriented along the growth vector was significantly higher in both proximal/distal transition zones between epiphysis and diaphysis. Human metacarpals shared with experimental models (like mice and nonmammal tetrapods) an early common chondrocyte maturation cycle but with a different timing due to the slower embryonic and fetal developmental rate of human anlagen.