scholarly journals Multimodal Neuromonitoring: Current Scenario in Neurocritical Care

2019 ◽  
Vol 06 (02) ◽  
pp. 062-071
Author(s):  
Keshav Goyal ◽  
Ankur Khandelwal ◽  
Shweta Kedia
Keyword(s):  
Neurocritical Care ◽  
Clinical Care ◽  
Cerebral Hemodynamics ◽  
Therapeutic Interventions ◽  
Secondary Brain Injury ◽  
Brain Physiology ◽  
Therapeutic Decisions ◽  
The Status ◽  
Monitoring Modality ◽  
Neurological Insult

AbstractMultimodal neuromonitoring (NM) is the concept of integrating various tools and data to understand brain physiology and guide therapeutic interventions to prevent secondary brain injury. There exists a range of invasive/noninvasive and global/regional monitors of cerebral hemodynamics, oxygenation, metabolism, and electrophysiology that can be used to guide treatment decisions after neurological insult. No single monitoring modality is ideal for all patients. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows individualized patient care. The ability to analyze these advanced data for real-time clinical care, however, remains intuitive and primitive. Advanced informatics is promising and may provide us a supportive tool to interpret physiological events and guide pathophysiological-based therapeutic decisions. Available literature is not robust regarding multimodality NM and favorable patient outcome. This narrative review is undertaken to know the status and recent advancement of multimodal NM in neurocritical care.

Multimodality Neuromonitoring in Adult Traumatic Brain Injury

2018 ◽  
Vol 128 (2) ◽  
pp. 401-415 ◽  
Author(s):  
Martin Smith
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Patient Management ◽  
Cerebral Hemodynamics ◽  
Expert Consensus ◽  
Therapeutic Interventions ◽  
Secondary Brain Injury ◽  
Consensus Guidelines ◽  
Individualized Approach ◽  
Simultaneous Assessment

Abstract Neuromonitoring plays an important role in the management of traumatic brain injury. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows an individualized approach to patient management in which therapeutic interventions intended to prevent or minimize secondary brain injury are guided by monitored changes in physiologic variables rather than generic thresholds. This narrative review describes various neuromonitoring techniques that can be used to guide the management of patients with traumatic brain injury and examines the latest evidence and expert consensus guidelines for neuromonitoring.

scholarly journals Role of CMR Imaging in Diagnostics and Evaluation of Cardiac Involvement in Muscle Dystrophies

2021 ◽  
Author(s):  
Edyta Blaszczyk ◽  
Jan Gröschel ◽  
Jeanette Schulz-Menger
Keyword(s):  
Clinical Care ◽  
Fatty Infiltration ◽  
Severe Heart Failure ◽  
Diffuse Fibrosis ◽  
Muscular Dystrophies ◽  
Invasive Technique ◽  
Myocardial Tissue ◽  
Therapeutic Decisions ◽  
Cardiovascular Evaluation ◽  
Unique Capability

Abstract Purpose of Review This review aims to outline the utility of cardiac magnetic resonance (CMR) in patients with different types of muscular dystrophies for the assessment of myocardial involvement, risk stratification and in guiding therapeutic decisions. Recent Findings In patients suffering from muscular dystrophies (MD), even mild initial dysfunction may lead to severe heart failure over a time course of years. CMR plays an increasing role in the diagnosis and clinical care of these patients, mostly due to its unique capability to precisely characterize subclinical and progressive changes in cardiac geometry, function in order to differentiate myocardial injury it allows the identification of inflammation, focal and diffuse fibrosis as well as fatty infiltration. CMR may provide additional information in addition to the physical examination, laboratory tests, ECG, and echocardiography. Summary Further trials are needed to investigate the potential impact of CMR on the therapeutic decision-making as well as the assessment of long-term prognosis in different forms of muscular dystrophies. In addition to the basic cardiovascular evaluation, CMR can provide a robust, non-invasive technique for the evaluation of subclinical myocardial tissue injury like fat infiltration and focal and diffuse fibrosis. Furthermore, CMR has a unique capability to detect the progression of myocardial tissue damage in patients with a preserved systolic function.

Severe Traumatic Brain Injury

2018 ◽  
Author(s):  
Ryan Martin ◽  
Lara Zimmermann ◽  
Kee D. Kim ◽  
Marike Zwienenberg ◽  
Kiarash Shahlaie
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Severe Traumatic Brain Injury ◽  
Neurocritical Care ◽  
Secondary Brain Injury ◽  
Brain Oxygenation ◽  
Barbiturate Coma ◽  
Blast Traumatic Brain Injury ◽  
Penetrating Traumatic Brain Injury

Traumatic brain injury remains a leading cause of death and disability worldwide. Patients with severe traumatic brain injury are best treated with a multidisciplinary, evidence-based, protocol-directed approach, which has been shown to decrease mortality and improve functional outcomes. Therapy is directed at the prevention of secondary brain injury through optimizing cerebral blood flow and the delivery of metabolic fuel (ie, oxygen and glucose). This is accomplished through the measurement and treatment of elevated intracranial pressure (ICP), the strict avoidance of hypotension and hypoxemia, and in some instances, surgical management. The treatment of elevated ICP is approached in a protocolized, tiered manner, with escalation of care occurring in the setting of refractory intracranial hypertension, culminating in either decompressive surgery or barbiturate coma. With such an approach, the rates of mortality secondary to traumatic brain injury are declining despite an increasing incidence of traumatic brain injury. This review contains 3 figures, 5 tables and 69 reference Key Words: blast traumatic brain injury, brain oxygenation, cerebral perfusion pressure, decompressive craniectomy, hyperosmolar therapy, intracranial pressure, neurocritical care, penetrating traumatic brain injury, severe traumatic brain injury

Maintaining Clinical Tissue Archives and Supporting Human Research: Challenges and Solutions

2011 ◽  
Vol 135 (3) ◽  
pp. 347-353
Author(s):  
Caterina Giannini ◽  
Michael M Oelkers ◽  
William D Edwards ◽  
Marie Christine Aubry ◽  
Maureen M Muncil ◽  
...  
Keyword(s):  
Translational Research ◽  
Tracking System ◽  
Clinical Care ◽  
First Year ◽  
Research Needs ◽  
Robust Tracking ◽  
Policies And Procedures ◽  
The Status ◽  
Loan System ◽  
New System

Abstract Context.—The increasing number of requests for use of clinically archived tissue in translational research poses unique challenges. Conflicts may arise between pathologists who are responsible for overseeing and preserving the tissues and investigators who need these materials for research purposes. Objectives.—To evaluate the status of our institution's Tissue Registry Archive and to develop updated written policies and procedures to support a new modern and robust tracking system with features of a library loan system. Design.—An observational study was performed. Results.—We found the existing process for managing loans of tissue (slides and paraffin blocks) to be insufficient for the complexity and volume of this task. After extensive customization, a new tracking system was implemented in January 2008. Analysis of the first year of the system's use (2008) showed that of the 206 330 slides and 51 416 blocks loaned out in 2008, 92% and 94%, respectively, were returned by the due date. These rates were markedly improved from those before the new system: 61% and 47%, respectively, in 2005. Material permanently “lost” in 2008 represented only 0.02% of slides and 0.05% of blocks, none of which was the only diagnostic material for the case. Conclusions.—With expanding needs for archived tissues for clinical care and growing demands for translational research, it is essential that pathology departments at institutions with large tissue-based research endeavors have a tracking and management system in place to meet clinical, educational, and research needs, as well as legal requirements.

scholarly journals Digital Health Applications for Pharmacogenetic Clinical Trials

Genes ◽  
2020 ◽  
Vol 11 (11) ◽  
pp. 1261
Author(s):  
Hetanshi Naik ◽  
Latha Palaniappan ◽  
Euan A. Ashley ◽  
Stuart A. Scott
Keyword(s):  
Clinical Trials ◽  
Trial Design ◽  
Digital Health ◽  
Clinical Care ◽  
Vital Signs ◽  
Medication Administration ◽  
Therapeutic Interventions ◽  
Participant Engagement ◽  
Patient Reported ◽  
Health Related

Digital health (DH) is the use of digital technologies and data analytics to understand health-related behaviors and enhance personalized clinical care. DH is increasingly being used in clinical trials, and an important field that could potentially benefit from incorporating DH into trial design is pharmacogenetics. Prospective pharmacogenetic trials typically compare a standard care arm to a pharmacogenetic-guided therapeutic arm. These trials often require large sample sizes, are challenging to recruit into, lack patient diversity, and can have complicated workflows to deliver therapeutic interventions to both investigators and patients. Importantly, the use of DH technologies could mitigate these challenges and improve pharmacogenetic trial design and operation. Some DH use cases include (1) automatic electronic health record-based patient screening and recruitment; (2) interactive websites for participant engagement; (3) home- and tele-health visits for patient convenience (e.g., samples for lab tests, physical exams, medication administration); (4) healthcare apps to collect patient-reported outcomes, adverse events and concomitant medications, and to deliver therapeutic information to patients; and (5) wearable devices to collect vital signs, electrocardiograms, sleep quality, and other discrete clinical variables. Given that pharmacogenetic trials are inherently challenging to conduct, future pharmacogenetic utility studies should consider implementing DH technologies and trial methodologies into their design and operation.

Multimodality Monitoring in Neurocritical Care: Decision-Making Utilizing Direct And Indirect Surrogate Markers

2018 ◽  
Vol 34 (6) ◽  
pp. 449-463 ◽  
Author(s):  
Fawaz Al-Mufti ◽  
Megan Lander ◽  
Brendan Smith ◽  
Nicholas A. Morris ◽  
Rolla Nuoman ◽  
...  
Keyword(s):  
Brain Injury ◽  
Neurocritical Care ◽  
Delayed Cerebral Ischemia ◽  
Neurological Injury ◽  
Innovative Technology ◽  
Secondary Brain Injury ◽  
Neurologic Injury ◽  
Irreversible Damage ◽  
Traumatic Intracranial Hemorrhage ◽  
Substantial Progress

Substantial progress has been made to create innovative technology that can monitor the different physiological characteristics that precede the onset of secondary brain injury, with the ultimate goal of intervening prior to the onset of irreversible neurological damage. One of the goals of neurocritical care is to recognize and preemptively manage secondary neurological injury by analyzing physiologic markers of ischemia and brain injury prior to the development of irreversible damage. This is helpful in a multitude of neurological conditions, whereby secondary neurological injury could present including but not limited to traumatic intracranial hemorrhage and, specifically, subarachnoid hemorrhage, which has the potential of progressing to delayed cerebral ischemia and monitoring postneurosurgical interventions. In this study, we examine the utilization of direct and indirect surrogate physiologic markers of ongoing neurologic injury, including intracranial pressure, cerebral blood flow, and brain metabolism.

scholarly journals Protocol for development and validation of a clinical prediction model for adverse pregnancy outcomes in women with gestational diabetes

BMJ Open ◽  
2020 ◽  
Vol 10 (11) ◽  
pp. e038845
Author(s):  
Shamil D. Cooray ◽  
Jacqueline A. Boyle ◽  
Georgia Soldatos ◽  
Javier Zamora ◽  
Borja M. Fernández Félix ◽  
...  
Keyword(s):  
Gestational Diabetes ◽  
Prediction Model ◽  
Pregnancy Outcomes ◽  
Absolute Risk ◽  
Clinical Care ◽  
Adverse Pregnancy Outcomes ◽  
Therapeutic Interventions ◽  
Multivariable Logistic Regression Model ◽  
Adverse Pregnancy ◽  
Development And Validation

IntroductionGestational diabetes (GDM) is a common yet highly heterogeneous condition. The ability to calculate the absolute risk of adverse pregnancy outcomes for an individual woman with GDM would allow preventative and therapeutic interventions to be delivered to women at high-risk, sparing women at low-risk from unnecessary care. The Prediction for Risk-Stratified care for women with GDM (PeRSonal GDM) study will develop, validate and evaluate the clinical utility of a prediction model for adverse pregnancy outcomes in women with GDM.Methods and analysisWe undertook formative research to conceptualise and design the prediction model. Informed by these findings, we will conduct a model development and validation study using a retrospective cohort design with participant data collected as part of routine clinical care across three hospitals. The study will include all pregnancies resulting in births from 1 July 2017 to 31 December 2018 coded for a diagnosis of GDM (estimated sample size 2430 pregnancies). We will use a temporal split-sample development and validation strategy. A multivariable logistic regression model will be fitted. The performance of this model will be assessed, and the validated model will also be evaluated using decision curve analysis. Finally, we will explore modes of model presentation suited to clinical use, including electronic risk calculators.Ethics and disseminationThis study was approved by the Human Research Ethics Committee of Monash Health (RES-19–0000713 L). We will disseminate results via presentations at scientific meetings and publication in peer-reviewed journals.Trial registration detailsSystematic review proceeding this work was registered on PROSPERO (CRD42019115223) and the study was registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12620000915954); Pre-results.

scholarly journals The Prehospital Evaluation and Care of Moderate/Severe TBI in the Austere Environment

2020 ◽  
Vol 185 (Supplement_1) ◽  
pp. 148-153
Author(s):  
Jennifer M Gurney ◽  
Paul E Loos ◽  
Mayumi Prins ◽  
David W Van Wyck ◽  
Randall R McCafferty ◽  
...  
Keyword(s):  
Brain Injury ◽  
Patient Outcomes ◽  
Resource Constraints ◽  
Therapeutic Interventions ◽  
Definitive Treatment ◽  
Secondary Brain Injury ◽  
Severe Tbi ◽  
Assessment And Monitoring ◽  
Austere Environment ◽  
Monitoring Devices

Abstract Increased resource constraints secondary to a smaller medical footprint, prolonged evacuation times, or overwhelming casualty volumes all increase the challenges of effective management of traumatic brain injury (TBI) in the austere environment. Prehospital providers are responsible for the battlefield recognition and initial management of TBI. As such, targeted education is critical to efficient injury recognition, promoting both provider readiness and improved patient outcomes. When austere conditions limit or prevent definitive treatment, a comprehensive understanding of TBI pathophysiology can help inform acute care and enhance prevention of secondary brain injury. Field deployable, noninvasive TBI assessment and monitoring devices are urgently needed and are currently undergoing clinical evaluation. Evidence shows that the assessment, monitoring, and treatment in the first few hours and days after injury should focus on the preservation of cerebral perfusion and oxygenation. For cases where medical management is inadequate (eg, evidence of an enlarging intracranial hematoma), guidelines have been developed for the performance of cranial surgery by nonneurosurgeons. TBI management in the austere environment will continue to be a challenge, but research focused on improving evidence-based monitoring and therapeutic interventions can help to mitigate some of these challenges and improve patient outcomes.

scholarly journals Alive but not well: the limited validity but continued utility of the concept of schizophrenia

2017 ◽  
Vol 48 (2) ◽  
pp. 245-246 ◽  
Author(s):  
Anthony W. Zoghbi ◽  
Jeffrey A. Lieberman
Keyword(s):  
Classification System ◽  
Clinical Care ◽  
Diagnostic Category ◽  
Status Quo ◽  
Biological Research ◽  
Negative Effects ◽  
New Classification ◽  
The Status ◽  
Poor Outcomes ◽  
The Many

AbstractGuloksuz & van Os boldly challenge the status quo as pertains to schizophrenia. In ‘The Slow Death of the Concept of Schizophrenia, and the Painful Birth of the Psychosis Spectrum’ (Guloksuz & van Os, 2017) they thoughtfully review long-standing concerns about this diagnostic category and present a new conceptualization. The authors question the validity of the schizophrenia concept citing variable clinical outcomes, transdiagnostic manifestations of psychosis, and the difficulty in identifying biomarkers, among other concerns. They also point toward the over-representation of schizophrenia in the psychosis literature and lament that patients and clinicians have come to associate this illness with predominantly poor outcomes. Finally, they propose removing the diagnosis of schizophrenia from the diagnostic nomenclature and instituting a broad new classification system, ‘psychosis spectrum disorder’ (PSD), to capture the many manifestations of psychosis. In this commentary, we advise against the institution of a psychosis spectrum due to the potential negative effects this framework would have on clinical care and progress in biological research.

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