Lower Glasgow Coma Scale Score Research Articles

Risk factors for abusive head trauma in the pediatric population.

Abusive head trauma (AHT) is the leading cause of death from physical child abuse in children younger than 5 years of age in the United States. The mortality rate among patients with AHT is 25%, and the recurrence rate of child abuse rises to 35% when there is a lack of intervention. Thus, identifying child abuse is crucial yet especially challenging for infants and toddlers as they are preverbal. Current guidelines for child abuse do not sufficiently address the specific needs of a younger population. This study aimed to evaluate clinical factors associated with abuse among such populations. The National Trauma Data Bank was queried from 2017 to 2019 for patients younger than 3 years with acute head trauma. Patients who were suspected of having experienced child abuse (suspected child abuse [SCA] group) were propensity score matched with patients who were not suspected of having experienced child abuse (non-SCA group) based on demographics, comorbidities, and Glasgow Coma Scale (GCS) scores. Paired Student t-test and chi-square tests were used to compare differences in hospital outcomes between the two groups. Multivariable regression analysis was used to determine factors associated with SCA (p < 0.05). The authors identified 10,844 patients in the SCA group and 27,912 in the non-SCA group. Regression analysis results showed that patients in the SCA group had higher rates of prematurity (OR 2.30, p < 0.001), GCS scores < 13 (OR 1.79, p < 0.001), congenital disorders (OR 1.56, p < 0.001), and public insurance use (68.38% vs 52.88% p < 0.001). Black and Hispanic patients were more likely to be in the SCA group (OR 1.56, p < 0.001 and OR 1.35, p < 0.001, respectively). Following propensity score matching, SCA patients had a longer length of hospital stay (3.17 vs 1.34 days, p < 0.001) and higher mortality rate (4.89% vs 3.58%, p < 0.001). Acute head injuries in the SCA group were associated with prematurity, congenital disorder, low GCS score, and public insurance use. As such, the current guidelines should implement clinical history and insurance type to better reflect the at-risk patient population when evaluating infants and toddlers for potential abuse. There could be overidentification of child abuse among Black and Hispanic patients, and further research is warranted.

Overall and linked blood pressure variabilities in the first 24 hours and mortality after spontaneous intracerebral hemorrhage: a retrospective study of 1,036 patients.

This study aims to establish the individual contributions of blood pressure variability (BPV) indexes, categorized into overall and linked variability, to mortality following intracerebral hemorrhage (ICH) by examining the risk factors. Patients with spontaneous ICH (n = 1,036) were identified with valid blood pressures (BP) from the first 24-h systolic BP records in the Medical Information Mart for Intensive Care IV version 2.2 database (MIMIC IV). Information on the baseline characteristics, including age, sex, initial Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores, ICH location, Charlson comorbidity index score, and presence of diabetes with or without complications, were collected. Three indexes of BPV-range, standard deviation (SD), and generalized BPV (GBPV)-were calculated using the first 24-h systolic BPs. An automated stepwise variable-selection procedure was used to develop the final logistic model for predicting in-hospital mortality. Out of 1,036 patients, 802 (77.4%) survived and were discharged after spontaneous ICH. Factors associated with mortality included age; male sex; ICH in the brainstem, ventricle, or multiple locations; low GCS score (< 9); high NIHSS score (> 20); and diabetes with complications. Mean systolic BP, SD, and GBPV were also linked to mortality. Higher GBPV notably increased the risk of in-hospital death, with an odds ratio of 3.21 (95% confidence interval, 2.10 to 4.97) for every + 10 mmHg/h change in GBPV. This study underscores the additional impact of GBPV, herein linked to BPV, on mortality following ICH, providing further insights into the management of blood pressure in the early stages of ICH treatment.

Outcome Predictor of Spontaneous Supratentorial Intracerebral Hemorrhage Management

Background: Spontaneous intracerebral hemorrhage (SICH) is responsible for higher morbidity and mortality rates than ischemic stroke. Although SICH is less common than ischemic stroke. Identifying the predictors of outcome after spontaneous supratentorial intracerebral hemorrhage is crucial for a clinical decision-making framework and implementing efficient therapeutic measures. Aims: The study aimed to analyze the clinical profile, assess the outcome, and identify the outcome prognosticators after supratentorial SICH in the Neurosurgery Department of a tertiary care hospital in the southeastern part of Bangladesh. Materials and Methods: This prospective interventional study included 183 patients with computerized tomography (CT) evidence of supratentorial SICH above 18 years of age from the Department of Neurosurgery of Chittagong Medical College Hospital between September 2021 and February 2023.The variables analyzed were age, sex, comorbidities, Glasgow coma scale (GCS) score on admission, radiological features, treatment modality and outcome at 90-day. Glasgow outcome scale (GOS) score was used to assess the outcome. GOS score 4-5 was considered good outcome and GOS score 1-3 was considered as poor outcome. Results: The mean age of the patients was 58.9±14.4 years and 52.5% were male. The 90-day mortality rate was 50.8% and 55.2% patients had poor outcomes. On bivariate analysis, higher age, comorbid CKD state, low GCS score, higher hematoma volume, midline shift, hydrocephalus and intraventricular hematoma (IVH) were associated with poor outcome. Independent predictors of poor outcome included a higher baseline age (OR: 1.07, 95% CI:1.02-1.11, p=0.002), lower GCS on admission (OR: 0.55, 95% CI: 0.39- 0.76, p&lt;0.001), and medical management (OR = 30.56, 95% CI = 7.15-130.69, P &lt;0.001). Conclusions: In conclusion, SICH is associated with high mortality and morbidity. Higher age, low GCS on admission and medical management independently predicted poor outcome in the present study. Patients with a lower age, higher GCS on admission and who were managed surgically were more likely to have a good outcome. Bang. J Neurosurgery 2024; 13(2): 96-103

Risk Factors and Outcome of Acute Kidney Injury in Children with Diabetic Ketoacidosis

Background: Children with diabetic ketoacidosis (DKA) suffer from several complications. Among them acute kidney injury (AKI) is one of the grave complications. Objectives: To determine the risk factors for development of AKI in children (age &lt;15 years) with DKA and observe the outcome of these children. Method: An observational study was done in Department of Paediatrics, BIRDEM General Hospital, Dhaka, Bangladesh from January 2019 to December 2020. During study period, we observed all children with DKA who developed AKI. Data of clinical and biological variables were taken from hospital records and analysed. The parameters of children with AKI were compared with children with DKA who did not develop AKI. Then outcome of the children with AKI were measured. Statistical analysis was done by using SPSS version 23. Results: Among 73 children with DKA, 16 (21.9%) children developed AKI. Children were divided into two groups, DKA with AKI and DKA without AKI. No statistically significant differences were found in demographic features of children in both groups. We observed that, delay in initiation of treatment, low Glasgow Coma Scale (score- &lt;8), haemodynamic failure, severe acidosis and sepsis were significant risk factors of developing AKI. Out of 16 children with AKI, 9(56.2%) patients needed peritoneal dialysis and 7(43.7%) responded to fluid resuscitation. Complete resolution occurred in 13(81.2%). Total mortality in DKA children was 13(17.8%). Among them 84.6% children died due to AKI. Conclusions: This study documented that 21.9% of children with DKA developed AKI. Among them mortality was 84.5%. BANGLADESH J CHILD HEALTH 2023; VOL 47 (1) : 30-33

12264 Myxedema Coma And The Impact Of Treatment Noncompliance

Abstract Disclosure: R. Subramani: None. H. Marasandra Ramesh: None. S. Yavuz: None. Introduction: Myxedema coma represents a critical medical condition marked by a heightened risk of both morbidity and mortality. It manifests as severe hypothyroidism, typically presenting with symptoms like lethargy, altered mental status, or potential obtundation. Various triggering factors, including infections, hypothermia, metabolic imbalances, surgery, and specific medications like amiodarone, lithium, and anesthetics, can precipitate this emergency. Here we outline a classic instance of myxedema coma stemming from non-adherence to levothyroxine treatment in the context of primary hypothyroidism. Case Summary: A 56-year-old woman with a medical history significant for primary hypothyroidism, hyperlipidemia, and mood disorder presented to the hospital exhibiting symptoms suggestive of a stroke. Upon arrival, she had a seizure episode and eventual unresponsiveness. Emergency intubation was performed due to a low Glasgow Coma Scale score and concern for airway protection. Further history revealed non-compliance with levothyroxine therapy. Laboratory findings included TSH of 150 uIu/ml, T4 of 1.1 ng/dl, T3 of 1.17 ng/dl, and cortisol of 21.9 ug/dl. Chest x-ray revealed complete atelectasis of the left lung with mediastinal shift initially before intubation. CT head and neck were unremarkable. A diagnosis of myxedema coma was made based on clinical presentation and a myxedema score of 75. Treatment included IV levothyroxine 50 mcg, increased to 100 mcg, nor-epinephrine drip for hypotension and 1000 mg of levetiracetam for seizures management. Pulmonary edema resolved following levothyroxine initiation. The patient was successfully extubated on day 3, weaned off oxygen, and discharged home after 8 days with counseling on medication adherence. Discussion: While encountering a case of myxedema coma is rare, it is crucial to maintain a low threshold for diagnosing this potentially fatal emergency. Early recognition, facilitated by a comprehensive history, physical examination, and prompt initiation of treatment, is essential for effective management. Despite early intervention, the mortality rate remains high, ranging from 50% to 60%. Wartofsky et al. advocate for the primary treatment approach with T4 alone, emphasizing its efficacy. Supportive measures such as warming, fluid resuscitation, mechanical ventilation, administration of antibiotics, vasopressors, and corticosteroids are also integral components of management. This case report underscores the considerable morbidity and mortality associated with myxedema coma. The most common trigger precipitating myxedema coma is non-compliance with levothyroxine therapy, particularly in elderly females with longstanding hypothyroidism. Therefore, counseling regarding strict adherence to levothyroxine is of paramount importance. Presentation: 6/1/2024

Impact of Glucocorticoid Therapy on 28-Day Mortality in Patients Having Severe Fever with Thrombocytopenia Syndrome in an Intensive Care Unit: A Retrospective Analysis.

The high mortality rate associated with the critical stages of severe fever with thrombocytopenia syndrome (SFTS) does not have effective treatment. We aimed to evaluate the 28-day mortality and potential impact of glucocorticoid therapy in these patients. This retrospective observational study included participants from the intensive care unit between July 2019 and April 2023. The participants were categorized into glucocorticoid (GC) and non-GC groups. Propensity score matching (PSM) was employed to ensure comparability between groups. We used Cox proportional hazard models to examine mortality risk associated with GC use, Kaplan-Meier survival analyses for overall survival, stratified Cox proportional hazard models for subgroup analyses, and likelihood ratio tests to examine interactions between subgroups. Of 218 patients with SFTS (median age, 71 years; male, 49.1%), 61.9% required mechanical ventilation, 58.3% received GC treatment, and the 28-day mortality rate was 61.5%. After PSM, there were 58 patients in each group; post-PSM analysis revealed improved 28-day mortality rates with GC treatment, particularly for patients with Glasgow coma scale (GCS) score <13 (hazard ratio [HR], 95% confidence interval [CI] for GCS score: 9-12: 0.39, 0.17-0.88, p=0.024 and for GCS score: 3-8: 0.09, 0.02-0.35, p=0.001); lactate levels >2mmol/L (0.35, 0.15-0.83, p=0.017); and norepinephrine usage (0.26, 0.13-0.49, p<0.001). Combining antiviral (0.41, 0.22-0.78, p=0.006) or immunoglobulin therapy (0.22, 0.1-0.51, p<0.001) with GC treatment significantly decreased the 28-day mortality rates, compared with GC monotherapy. Using GCs reduced the high 28-day mortality rate in the patients, especially with low GCS score, high lactate levels, norepinephrine intake, and on antiviral or immunoglobulin therapy.

Bacterial profile of wound site infections and evaluation of risk factors for sepsis among road traffic accident patients from Apex Trauma Centre, Northern India.

Background. Among the most significant yet often ignored health issues worldwide are trauma and accidental injuries. India accounts for 11% of global deaths in road accidents, the highest in the world, according to the World Bank report. There are limited data about the bacterial contamination of road traffic accident (RTA) wounds and their antibiotic susceptibility patterns. Materials and Methods. This prospective study was conducted in a tertiary care centre in northern India from January 2023 to January 2024. Wound deep swabs or aspirates were collected from RTA patients with traumatic injuries at different time intervals. Gram stain and culture were performed, and positive aerobic culture was subjected to antibiotic susceptibility testing. Organism identification was done using MALDI-TOF MS and routine biochemical tests. Blood samples were also collected to rule out bloodstream infections during follow-up if the patient became febrile or showed symptoms of systemic infection. Sepsis was defined in those patients who had two or more scores in the systemic inflammatory response syndrome criteria with a positive microbiological culture. Risk factors were evaluated for sepsis on the basis of the patient's vitals, injury characteristics, procalcitonin, Glasgow Coma Scale (GCS) score, need for mechanical ventilation and complete blood count, which were obtained from the patient's admission file. Results. A total of 189 wound samples were collected, of which 99 (52.38%) samples showed the growth of microorganisms. The aerobic isolates included 69 (69.69%) Gram-negative bacilli, of which the majority were Klebsiella pneumoniae, 28 (28.28%) Gram-positive cocci, of which the majority were Staphylococcus aureus and 2 (2.02%) anaerobic isolates. Among the Gram-negative isolates, none of the isolates were resistant to colistin. All S. aureus isolates were susceptible to vancomycin, teicoplanin and levonadifloxacin. Sepsis developed in 50 (26.45 %) patients. Significant risk factors evaluated for sepsis were a raised procalcitonin level, a low GCS score, a higher injury severity score, the need for mechanical ventilation and a raised quick sequential organ failure assessment score. Conclusion. It is essential to ascertain the profile of microorganisms isolated from RTA wounds in order to reduce antibiotic resistance and deliver efficient treatment.

Leakage sign based on contrast-enhanced CT is a predictive marker for hematoma expansion and poor prognosis in primary brainstem hemorrhage

BackgroundAlthough hematoma expansion is a poor prognostic factor in patients with intracerebral hemorrhage (ICH), its effect on primary brainstem hemorrhage (PBSH) remains unclear. Since we previously observed the “leakage sign” (LS) on computed tomography (CT) to be a significant predictor for hematoma expansion, we herein investigated the effect of LS in PBSH. MethodsBetween January 2013 and August 2023, 515 patients with ICH were admitted to our institute. Thirty-six patients with PBSHs met the inclusion criteria, who were then divided into LS-positive (LS+) and LS-negative (LS-) groups based on the presence of LS. We evaluated hematoma expansion and prognosis at discharge. ResultsPatients in the LS+ group had larger baseline hematoma volume and lower Glasgow Coma Scale scores on admission and significantly poor prognosis at discharge. Subgroup analysis revealed that LS was frequently observed within 100 min after the onset of symptoms in patients with a hematoma size of >10 mm3 on CT; additionally, patients in the LS+ group more frequently experienced hematoma expansion and had poor prognosis at discharge. ConclusionLS is a significant predictive marker for disease severity at admission, hematoma expansion, and poor prognosis at discharge.

Acute disseminated encephalomyelitis (ADEM) in a patient with post streptococcal glomerulonephritis (PSGN): A case report.

Concurrent recurrence of acute disseminated encephalomyelitis (ADEM) and poststreptococcal glomerulonephritis (PSGN) in a thalassemia intermedia patient is rare and underscores the complexity of autoimmune disorders. This case emphasizes the importance of considering ADEM in the differential diagnosis of children presenting with PSGN accompanied by neurological symptoms. Post-streptococcal glomerulonephritis (PSGN) is a common group A streptococcal (GAS) infection sequela. The pathophysiology of PSGN involves immune complex deposition, with type 3 hypersensitivity reaction triggered by GAS. Certain neurological conditions may also arise following a GAS infection, possibly due to molecular mimicry in the brain, a pathophysiology similar to rheumatic fever, another common sequel of GAS infection. We present the case of a child with β-thalassemia intermedia who exhibited the classic triad (edema, hypertension, hematuria) of PSGN along with neurological manifestations, including a low glasgow coma scale (GCS) score and seizures. Magnetic resonance imaging (MRI) of the brain indicated changes consistent with acute disseminated encephalomyelitis (ADEM). Initially treated with methylprednisolone, the patient eventually received intravenous immunoglobulin (IVIG) due to lack of response. The patient had a good outcome, with complete resolution of all symptoms and no residual neurological deficits. This case underscores the importance of considering ADEM in the differential diagnosis for patients presenting with neurological signs and symptoms following a recent throat infection with GAS. Furthermore, given the increased risk of infection in thalassemia, patients with thalassemia who have a throat infection and neurological symptoms should be evaluated for the possible presence of ADEM.

Survival status and its predictors among adult victims of road traffic accident admitted to public hospitals of Bahir Bar City, Amhara regional state, Northwest, Ethiopia, 2023: multi center retrospective follow-up study

IntroductionRoad traffic accident is the most common cause of death in adults worldwide. Road traffic accident-related deaths increased from time to time in low- and middle-income countries including Ethiopia; however, there is limited evidence about Survival status and its predictors among adult victims of road traffic accidents admitted to Hospitals in Ethiopia specifically in the study area. Thus, this study aimed to assess Survival status and its predictors among adult victims of road traffic accident admitted to Hospitals.MethodsAn institutional-based retrospective follow-up study was conducted from July 01/2019 to June 30/2022. A total of 402 samples were chosen using simple random sampling. Data was collected by a prepared checklist from the victims’ chart and entered into Epi-Data version 4.6 software and then exported to STATA version 14.1 for analysis. Kaplan-Meier failure function and log-rank test were computed. The assumption was checked by Schoenfeld residual test. All variables in bivariable analysis, p-value < 0.25 were entered into multivariable cox-regression model. Adjusted Hazard Ratio with 95% Confidence Interval was reported to declare the strength of association and statistical significance p-value of < 0.05. Model fitness was checked by using Cox-Snell residual. Data was presented by text, table, and graph.ResultThe median survival time was 504 h. From all, 63(15.6%) deaths, 57% of deaths occurred between 24 and 168 h of follow-up with an overall incidence of 15.34deaths per10, 000 victims-hours observation. According to the Kaplan-Meier failure curve together with the log-rank test, the incidence density rate of death among victims who had a complication during admission was71.86per10,000victims-hour observation (95%, CI:53.66–96.25), which is different from those who did not have complication 5.17per10,000person-hour observation (95%, CI:3.26–8.21). The incidence density rate of death among victims who had low level of arterial oxygen saturation (SPO2 < 95%) during admission was 82.87per10, 000 victims-hour observation (95%, CI: 63.15-108.75), which is different from those who had arterial oxygen saturation ≥ 95% 3.16per10, 000victims -hour observation (95%, CI: 1.75–5.71) Develop complication (AHR = 3.1,95% CI:1.44–6.70), systolic blood pressure measurement value ≤ 89 mmHg (AHR = 2.4,95% CI:1.10–5.19), not admitted intensive care unit (AHR = 0.46,95% CI:0.022–0.97), Glasgow Coma Scale score ≤ 8 (AHR = 2.9,95% CI:1.07–7.75), Glasgow Coma Scale score 9–12(AHR = 3.8,95% CI:1.61–8.97) and, level of arterial oxygen saturation ≤ 95% (AHR = 6.5,95% CI:2.38–17.64) were predictors of outcome variable.Conclusion and recommendationsThe median survival time was short. Complication, low systolic blood pressure measurement value, low Glasgow Coma Scale score, not admit to intensive care unit and low level of arterial oxygen saturation were significant predictors of the outcome variable. So that healthcare providers better give special attention and care to those victims admitted to Hospitals. A further prospective study is recommended.

Correlation of Pseudocholinesterase Level with Clinical, Biochemical Parameters Including Cardiac Profile and the Outcome in Organophosphorus Poisoning.

Poisoning is a significant health hazard and a leading cause of morbidity and mortality worldwide. India, being a predominantly agrarian country, routinely employs organophosphate (OP) pesticides in farming, and they are readily available "over the counter." OPs exert their toxicity by interfering with the normal function of acetylcholine, an essential neurotransmitter throughout the autonomic and central nervous systems. Due to the limited availability of facilities and resources in health-care systems, and economically restraining patients, it is necessary to rely more on clinical features to assess the severity of poisoning and manage the condition properly. It was a hospital-based prospective observational study that included patients aged >13 years in a tertiary care hospital. All patients were clinically evaluated based on their history and examination. The diagnosis was made based on characteristic clinical manifestations or evidence of exposure to organophosphorus compounds (corroborative evidence such as empty containers and the odor of gastric aspirates). Clinical severity was assessed and categorized according to the Peradeniya Organophosphorus Poisoning Scale (POP scale). A score of 0-3 is considered mild poisoning, 4-7 as moderate poisoning, and 8-11 as severe poisoning. Out of the 50 patients enrolled in the study, 17 (34.00%) were aged <20 years, 19 (38%) were in the 20-30 years age group, and 14 (28%) were aged >30 years. Ingestion is the only mode of exposure to poisoning. None of the patients had history of contact or inhalational exposure. Of the 50 cases, 12 (24.0%) were in the mild category, 26 (52.0%) in the moderate category, and 12 (24%) in the severe category on the POP grading. A comparison of the mean serum pseudocholinesterase, troponin-T, and pro-BNP levels with severity was performed. In mild OP poisoning, the mean serum PChE level was 2766.58 ± 1120.44; in moderate, it was 1969.35 ± 1330.07, and in severe, it was 701.83 ± 961.17. Pseudocholinesterase levels decreased progressively with increasing clinical severity from mild-to-severe cases, and this association was statistically significant (P < 0.001). Two-dimensional echocardiography screening done in all patients did not show any significant abnormalities. This study shows that serum PCE is reduced in OP poisoning and correlates with the clinical severity grading done by the POP scale and is also associated with an increase in the duration of intensive care unit stay. No significant evidence of direct cardiac injury was observed in this study. A low Glasgow Coma Scale score and an increased respiratory rate at presentation are associated with poor outcomes.

Resuscitative endovascular balloon occlusion of the aorta provides better survival outcomes for noncompressible blunt torso bleeding below the diaphragm compared to resuscitative thoracotomy

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) serves as a bridging intervention for subsequent definitive haemorrhagic control. This study compared the clinical outcomes of REBOA and resuscitative thoracotomy (RT) in patients with bleeding below the diaphragm. Materials and MethodsThis retrospective cohort study included adult trauma patients who presented to the Trauma Quality Improvement Program between 2020 and 2021 and who underwent either REBOA or RT in the emergency department (ED). Patients with severe head and chest injuries, characterised by an Abbreviated Injury Scale (AIS) score greater than 3, were excluded. The clinical data of patients treated with REBOA and those treated with RT were compared, and multivariable logistic regression (MLR) was employed to identify prognostic factors associated with mortality. ResultsA total of 346 patients were enrolled: 138 (39.9 %) received REBOA, and 208 (60.1 %) received RT at the ED. Patients in the RT group underwent ED cardiopulmonary resuscitation (CPR) more frequently (58.2 % vs. 23.2 %; p < 0.001) and had a higher mortality rate (87.0 % vs. 45.7 %; p < 0.001). Patients who died had lower Glasgow Coma Scale scores (6 [4.5] vs. 11 [4.9]; p < 0.001), underwent more ED CPR (58.6 % vs. 9.8 %; p < 0.001), and received RT more frequently (74.2 % vs. 26.5 %, p < 0.001). The MLR revealed that the major prognostic factors for mortality were systolic blood pressure (odds ratio [OR] 0.988, 95 % confidence interval [CI] 0.978–0.998; p = 0.014), ED CPR (OR 11.111, 95 % CI 4.667–26.452; p < 0.001), abdominal injuries with an AIS score ≥ 4 (OR 4.694, 95 % CI 1.921–11.467; p = 0.001) and RT (OR 5.693, 95 % CI 2.690–12.050; p < 0.001). ConclusionsIn cases of blunt trauma, prompt identification of the bleeding source is crucial. For patients with bleeding below the diaphragm, REBOA led to higher survival rates than did RT. However, it is important to consider the limitations of the database and the necessary exclusions from our analysis.

Risk factors for the development of refeeding syndrome in adults: A systematic review.

Identifying patients with a particularly high risk of refeeding syndrome (RFS) is essential for taking preventive measures. To guide the development of clinical decision-making and risk prediction models or other screening tools for RFS, increased knowledge of risk factors is needed. Therefore, we conducted a systematic review to identify risk factors for the development of RFS. PubMed, EMBASE, Cochrane Library, and Web of Science were searched from January 1990 until March 2023. Studies investigating demographic, clinical, drug use, laboratory, and/or nutrition factors for RFS were considered. The Newcastle-Ottawa Scale was used to appraise the methodological quality of included studies. Of 1589 identified records, 30 studies were included. Thirty-three factors associated with increased risk of RFS after multivariable adjustments were identified. The following factors were reported by two or more studies, with 0-1 study reporting null findings: a previous history of alcohol misuse, cancer, comorbid hypertension, high Acute Physiology and Chronic Health Evaluation II score, high Sequential Organ Failure Assessment score, low Glasgow coma scale score, the use of diuretics before refeeding, low baseline serum prealbumin level, high baseline level of creatinine, and enteral nutrition. The majority of the studies (20, 66.7%) were of high methodological quality. In conclusion, this systematic review informs on several risk factors for RFS in patients. To improve risk stratification and guide development of risk prediction models or other screening tools, further confirmation is needed because there were a small number of studies and a low number of high-quality studies on each factor.

Characteristics, predictors and outcomes of early postoperative cerebral infarction on computed tomography in spontaneous intracerebral hemorrhage

Early postoperative cerebral infarction (ePCI) is a serious complication of spontaneous intracerebral hemorrhage (SICH). Yet, no study has specifically focused on ePCI among SICH patients. Our study aims to investigate the characteristics, predictors, and outcomes of ePCI observed on computed tomography (CT) within 72 h after surgery in patients with supratentorial SICH. Data from a single-center SICH study conducted from May 2015 to September 2022 were retrospectively analyzed. We described the characteristics of ePCI. Predictors were identified through logistic regression analysis, and the impact of ePCI on six-month mortality was examined using a Cox regression model. Subgroup analyses and the “E-value” approach assessed the robustness of the association between ePCI and mortality. A retrospective analysis of 637 out of 3938 SICH patients found that 71 cases (11.1%) developed ePCI. The majority of ePCI cases occurred on the bleeding side (40/71, 56.3%) and affected the middle cerebral artery (MCA) territory (45/71, 63.4%). Multivariable analysis showed that the Glasgow Coma Scale (GCS) score (odds ratio (OR), 0.62; 95% CI, 0.48–0.8; p < 0.001), bleeding volume (per 100 ml) (OR, 1.17; 95% CI, 1.03–1.32; p = 0.016), hematoma volume (per 10 ml) (OR, 1.14; 95%CI, 1.02–1.28; p = 0.023) and bilateral brain hernia (OR, 6.48; 95%CI, 1.71–24.48; p = 0.006) independently predicted ePCI occurrence. ePCI was significantly associated with increased mortality (adjusted hazard ratio (HR), 3.6; 95% CI, 2.2—5.88; p < 0.001). Subgroup analysis and E-value analysis (3.82—6.66) confirmed the stability of the association. ePCI is a common complication of SICH and can be predicted by low GCS score, significant bleeding, large hematoma volume, and brain hernia. Given its significant increase in mortality, ePCI should be explored in future studies.

Correlation of preoperative inflammatory factors and emotional disorders with postoperative delirium in patients with craniocerebral trauma.

Traumatic brain injury (TBI) imposes a substantial societal and familial burden due to its high disability and fatality rates, rendering it a serious public health problem. Some patients with TBI have poor treatment outcomes and are prone to postoperative delirium (POD), which affects their quality of life. Anxiety has been linked to increased POD incidence in some studies, while others have found no correlation. To investigate the correlation of POD risk factors, preoperative inflammatory factors, and mood disorders in patients with TBI. We retrospectively collected data on the treatment of 80 patients with TBI from November 2021 to September 2023. Patients were grouped as POD and non-POD, according to their POD status, and the general data of the two groups were compared. Inflammatory factor levels were detected preoperatively, and the Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA) were used to investigate the risk factors associated with POD in these patients. Logistic regression was used to identify the independent risk factors. Twenty-one patients (26.25%) developed POD, including 7, 10, and 4 cases of the excitatory, inhibitory, and mixed types, respectively. There were 59 cases (73.75%) in the non-POD group. Compared with the non-POD group, the POD group had a significantly higher proportion of patients with low Glasgow Coma Scale (GCS) scores before admission, unilateral mydriasis, preoperative hemorrhagic shock, intraventricular hemorrhage (IVH), and postoperative hyperglycemic hyperosmolar disease (P < 0.05). In the POD group, interleukin-6 (IL-6), human tumor necrosis factor-α (TNF-α), myeloperoxidase levels, HAMA, and HAMD scores were higher than those in the non-POD group (all P < 0.05). Logistic multivariate analysis showed that GCS score at admission, IVH, IL-6, TNF-α, HAMA, and HAMD were independent risk factors for POD in patients with TBI (P < 0.05). Low GCS score at admission, IVH, elevated IL-6 and TNF-α, other inflammatory indicators, anxiety, and depression, can increase the risk of POD in patients with TBI after surgery.

In Search of the Truth: Choice of Ground Truth for Predictive Modeling of Trauma Team Activation in Pediatric Trauma.

Assigning trauma team activation (TTA) levels for trauma patients is a classification task that machine learning models can help optimize. However, performance is dependent on the "ground-truth" labels used for training. Our purpose was to investigate 2 ground truths, the Cribari matrix and the Need for Trauma Intervention (NFTI), for labeling training data. Data were retrospectively collected from the institutional trauma registry and electronic medical record, including all pediatric patients (age <18 years) who triggered a TTA (January 2014 to December 2021). Three ground truths were used to label training data: (1) Cribari (Injury Severity Score >15 = full activation), (2) NFTI (positive for any of 6 criteria = full activation), and (3) the union of Cribari+NFTI (either positive = full activation). Of 1,366 patients triaged by trained staff, 143 (10.47%) were considered undertriaged using Cribari, 210 (15.37%) using NFTI, and 273 (19.99%) using Cribari+NFTI. NFTI and Cribari+NFTI were more sensitive to undertriage in patients with penetrating mechanisms of injury (p = 0.006), specifically stab wounds (p = 0.014), compared with Cribari, but Cribari indicated overtriage in more patients who required prehospital airway management (p < 0.001), CPR (p = 0.017), and who had mean lower Glasgow Coma Scale scores on presentation (p < 0.001). The mortality rate was higher in the Cribari overtriage group (7.14%, n = 9) compared with NFTI and Cribari+NFTI (0.00%, n = 0, p = 0.005). To prioritize patient safety, Cribari+NFTI appears best for training a machine learning algorithm to predict the TTA level.

Efficacy of Ventriculoperitoneal Shunt for Postoperative Central Nervous System Infection Complicated with Hydrocephalus

Abstract Objective Our aim was to assess the efficacy of ventriculoperitoneal shunt (VPS) for treating postoperative central nervous system infection (PCNSI) complicated with hydrocephalus and to identify factors associated with treatment failure. Methods We conducted a retrospective analysis of PCNSI patients with hydrocephalus treated by VPS at the Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, between December 2012 and January 2020. Functional recovery was evaluated during follow-up using the Glasgow Outcome Scale. Results A total of 29 patients (21 males, 8 females) were enrolled in the study (mean age: 56.4 ± 12.0 years, range: 18.0–77.0 years). Seventeen patients were treated successfully by VPS (58.6%). Among the 11 patients with shunt complications (37.9%), 8 (27.6%) presented with fever, 3 (10.3%) with shunt infection, and 3 (10.3%) with shunt obstruction. Univariate analysis identified low Glasgow Coma Scale (GCS) score (3–8) at the time of VPS and post-treatment fever as predictive of shunt failure. Conclusion VPS was effective for treating PCNSI complicated with hydrocephalus. However, patients with low GCS score at the time of VPS or fever post-treatment were at greater risk of shunt failure and poor outcome.

Endoscopic Evacuation of Acute Subdural Hematomas: A New Selection Criterion.

Introduction Acute subdural hematomas (ASDHs) have a high mortality rate and unfavorable outcomes especially in the elderly population even after surgery is performed. The conventional recommended surgeries by the Brain Trauma Foundation in 2006 were craniotomies or craniectomies for ASDH. As the world population ages, and endoscopic techniques improve, endoscopic surgery should be utilized to improve the outcomes in elderly patients with ASDH. Materials and Methods This was a single-center retrospective report on our series of six patients that underwent endoscopic ASDH evacuation (EASE). Demographic data, the contralateral global cortical atrophy (GCA) score, evacuation rates, and outcomes were analyzed. Results All patients' symptoms and Glasgow Coma Scale improved or were similar after EASE with no complications. Good outcome was seen in 4 (66.7%) patients. Patients with poor outcome had initial low Glasgow Coma Scale scores on admission. The higher the contralateral GCA score, the higher the evacuation rate ( r = 0.825, p ≤ 0.043). All the patients had a GCA score of ≥7. Conclusion EASE is at least not inferior to craniotomy for the elderly population in terms of functional outcome for now. Using the contralateral GCA score may help identify suitable patients for this technique instead of just using a cut-off age as a criteria.

Urinary Catheter-Related Meatal Pressure Injury Risk Factors in Male Critical Care Patients: A Prospective Repeated-Measures Study.

Urinary catheter-related meatal pressure injury (UCR-MPI) is a preventable and serious complication of indwelling urinary catheter use. This prospective study aimed to determine the prevalence and risk factors of UCR-MPI in male critical care patients. A total of 138 male patients 18 years and older using an indwelling urinary catheter were included in the study. Participants' perineal areas were assessed daily for the development of MPI. The UCR-MPI prevalence was 26.1% (n = 36/138). Most patients (61.1%) had a grade I UCR-MPI with intact skin and mucosa and nonblanchable erythema. Urinary catheter irrigation (P = .001), lower Braden Scale scores (P = .040), lower Glasgow Coma Scale score (P = .002), higher Itaki Fall Risk Scale score (P = .040), higher dependency level (P = .027), hypoalbuminemia (P = .002), and perineal edema (P = .001) were risk factors for UCR-MPI. The prevalence of UCR-MPI was high in this sample. Providers should take preventive measures to prevent UCR-MPI in patients with a penis including early and frequent risk assessment.

Evaluation of the Use of Phenobarbital and Benzodiazepines in the Management of Alcohol Withdrawal Syndrome in Patients Requiring Neurological/Neurosurgical Critical Care: A Propensity-Matched Analysis.

Objective There is growing interest in the use of phenobarbital for alcohol withdrawal syndrome in critically ill patients, though experience in neurologically injured patients is limited. The purpose of this study was to compare the safety and effectiveness of phenobarbital-containing alcohol withdrawal regimens versus benzodiazepine monotherapy in the neurocritical care unit. Methods We conducted a retrospective cohort study of adult patients admitted to the neurocritical care unit from January 2014 through November 2021 who received pharmacologic treatment for alcohol withdrawal. Treatment groups were defined as benzodiazepine monotherapy versus phenobarbital alone or in combination with benzodiazepines. The primary outcome was the percentage of patients requiring intubation after receiving alcohol withdrawal treatment. Secondary outcomes included all-cause, in-hospital mortality, intensive care unit length of stay, discharge disposition, change in Glasgow Coma Scale (GCS) score, and the use of adjunctive agents. Results We analyzed data from 156 patients, with 77 (49%) in the benzodiazepine group and 79 (51%) in the phenobarbital combination group. The groups were well-balanced for baseline characteristics, though more males (67, 85%) were in the phenobarbital group. Only three (1.9%) patients received phenobarbital monotherapy, and the rest (153, 98.1%) received combination therapy. The percentage of patients requiring mechanical ventilation was significantly higher in the phenobarbital combination group compared to benzodiazepine monotherapy (39% (n=31) versus 13% (n=10); OR: 4.33, 95% CI: 1.94-9.66; p<0.001). The use of adjunctive propofol and dexmedetomidine was higher in the phenobarbital group (propofol 35% (n= 28) versus 9% (n=7) and dexmedetomidine 30% (n=24) versus 5% (n=4), respectively). Patients in the phenobarbital group also had lower GCS scores and higher Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scores during their intensive care unit admission, possibly suggesting more severe alcohol withdrawal. There was no difference in intensive care unit length of stay, all-cause, in-hospital mortality, discharge disposition, or therapeutic adjuncts. Conclusions Combination therapy of phenobarbital plus benzodiazepines was associated with higher odds of requiring mechanical ventilation. Few patients received phenobarbital monotherapy. Additional studies are needed to better compare the effects of phenobarbital monotherapy versus benzodiazepines in neurocritical patients.