Context:The role of electrical muscle stimulation in intensive care has not previously been systematically reviewed. Objectives:To identify, evaluate, and synthesize the evidence examining the effectiveness and the safety of electrical muscle stimulation in the intensive care, and the optimal intervention variables. Data Sources:A systematic review of articles using eight electronic databases (Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Excerpta Medica Database, Expanded Academic ASAP, MEDLINE, Physiotherapy Evidence Database, PubMed, and Scopus) personal files were searched, and cross-referencing was undertaken. Eligibility Criteria:Quantitative studies published in English, assessing electrical muscle stimulation in intensive care, were included. Data Extraction and Data Synthesis:One reviewer extracted data using a standardized form, which were cross-checked by a second reviewer. Quality appraisal was undertaken by two independent reviewers using the Physiotherapy Evidence Database and Newcastle–Ottawa scales, and the National Health and Medical Research Council Hierarchy of Evidence Scale. Preferred Reporting Items for Systematic Reviews guidelines were followed. Results:Nine studies on six individual patient groups of 136 participants were included. Eight were randomized controlled trials, with four studies reporting on the same cohort of participants. Electrical muscle stimulation appears to preserve muscle mass and strength in long-stay participants and in those with less acuity. No such benefits were observed when commenced prior to 7 days or in patients with high acuity. One adverse event was reported. Optimal training variables and safety of the intervention require further investigation. Conclusions:Electrical muscle stimulation is a promising intervention; however, there is conflicting evidence for its effectiveness when administered acutely. Outcomes measured are heterogeneous with small sample sizes.
Rationale:Despite recommendations supporting the importance of clinician-family communication in the ICU, this communication is often rated as suboptimal in frequency and quality. We employed a multifaceted behavioral-change intervention to improve communication between families and clinicians in a statewide collaboration of ICUs. Objectives:Our primary objective was to examine whether the intervention resulted in increased compliance with process measures that targeted clinician-family communication. As secondary objectives, we examined the ICU-level characteristics that might be associated with increased compliance (open vs closed, teaching vs nonteaching, and medical vs medical-surgical vs surgical) and patient-specific outcomes (mortality, length of stay). Methods:The intervention was a multifaceted quality improvement approach targeting process measures adapted from the Institute of Health Improvement and combined into two "bundles" to be completed either 24 or 72 hours after ICU admission. Measurements and Main Results:Significant increases were seen in full compliance for both day 1 and day 3 process measures. Day 1 compliance improved from 10.7% to 83.8% after 21 months of intervention (p < 0.001). Day 3 compliance improved from 1.6% to 28.8% (p < 0.001). Improvements in compliance varied across ICU type with less improvement in open, nonteaching, and mixed medical-surgical ICUs. Patient-specific outcome measures were unchanged, although there was a small increase in patients discharged from ICU to inpatient hospice (p = 0.002). Conclusions:We found that a multifaceted intervention in a statewide ICU collaborative improved compliance with specific process measures targeting communication with family members. The effect of the intervention varied by ICU type.
BACKGROUND:Technological advances have resulted in diminishing perioperative complications reported during carotid artery stenting (CAS) trials. Because trial experience lags behind technological advances, an understanding of the incidence of perioperative complications after CAS remains in flux. OBJECTIVE:In this single-arm, observational study, a contemporary experience of CAS at a high-volume academic training center for neuroendovascular surgeons was reviewed to assess perioperative morbidity. METHODS:A prospectively maintained database of all neuroendovascular procedures was queried for all CAS procedures performed for stenotic atherosclerotic disease between 2009 and 2011. Each case was assessed for major perioperative (30 day) adverse events, including new acute ischemic stroke, postoperative symptomatic intracranial hemorrhage, myocardial infarction (MI), and mortality. RESULTS:A total of 474 patients were identified. Perioperative adverse events were noted in 13 patients (2.7%). These included 4 ischemic strokes, 4 intracranial hemorrhages, 3 MIs, and 5 deaths. Most perioperative events occurred in symptomatic patients (10 of 239 symptomatic patients with events, 4.2% event incidence), whereas these events occurred rarely in asymptomatic patients (3 of 235 asymptomatic patients with events, 1.3% event incidence). CONCLUSION:In this retrospective analysis of consecutive patients treated with CAS, the perioperative incidence of stroke (0.9%), MI (0.6%), and death (1.1%) was favorable. ABBREVIATIONS:CAS, carotid artery stentingCEA, carotid endarterectomyCREST, Carotid Revascularization Endarterectomy versus Stenting TrialMI, myocardial infarctionNASCET, North American Symptomatic Carotid Endarterectomy TrialNIHSS, National Institutes of Health Stroke scaleDepartment of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA.
Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to reducing risk and to measuring and improving outcomes. The authors performed a review of patterns and frequencies of adverse events in neurosurgery as background for future efforts directed at the improvement of quality and safety in neurosurgery. They found 6 categories of contributory factors in neurosurgical adverse events, categorizing the events as influenced by issues in surgical technique, perioperative medical management, use of and adherence to protocols, preoperative optimization, technology, and communication. There was a wide distribution of reported occurrence rates for many of the adverse events, in part due to the absence of definitive literature in this area and to the lack of standardized reporting systems. On the basis of their analysis, the authors identified 5 priority recommendations for improving outcomes for neurosurgical patients at a population level: 1) development and implementation of a national registry for outcome data and monitoring; 2) full integration of the WHO Surgical Safety Checklist into the operating room workflow, which improves fundamental aspects of surgical care such as adherence to antibiotic protocols and communication within surgical teams; and 3-5) activity by neurosurgical societies to drive increased standardization for the safety of specialized equipment used by neurosurgeons (3), more widespread regionalization and/or subspecialization (4), and establishment of data-driven guidelines and protocols (5). The fraction of adverse events that might be avoided if proposed strategies to improve practice and decrease variability are fully adopted remains to be determined. The authors hope that this consolidation of what is currently known and practiced in neurosurgery, the application of relevant advances in other fields, and attention to proposed strategies will serve as a basis for informed and concerted efforts to improve outcomes and patient safety in neurosurgery.
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Objective:Increasing evidence, including publication of the Transfusion Requirements in Critical Care trial in 1999, supports a lower hemoglobin threshold for RBC transfusion in ICU patients. However, little is known regarding the influence of this evidence on clinical practice over time in a large population-based cohort. Design:Retrospective population-based cohort study. Setting:Thirty-five Maryland hospitals. Patients:Seventy-three thousand three hundred eighty-five nonsurgical adults with an ICU stay greater than 1 day between 1994 and 2007. Interventions:None. Measurements and Main Results:The unadjusted odds of patients receiving an RBC transfusion increased from 7.9% during the pre-Transfusion Requirements in Critical Care baseline period (1994–1998) to 14.7% during the post-Transfusion Requirements in Critical Care period (1999–2007). A logistic regression model, including 40 relevant patient and hospital characteristics, compared the annual trend in the adjusted odds of RBC transfusion during the pre- versus post-Transfusion Requirements in Critical Care periods. During the pre-Transfusion Requirements in Critical Care period, the trend in the adjusted odds of RBC transfusion did not differ between hospitals averaging > 200 annual ICU discharges and hospitals averaging ≤ 200 annual ICU discharges (odds ratio, 1.07 [95% CI, 1.01–1.13] annually and 1.03 [95% CI, 0.99–1.07] annually, respectively; p = 0.401). However, during the post-Transfusion Requirements in Critical Care period, the adjusted odds of RBC transfusion decreased over time in higher ICU volume hospitals (odds ratio, 0.96 [95% CI, 0.93–0.98] annually) but continued to increase in lower ICU volume hospitals (odds ratio, 1.10 [95% CI, 1.08–1.13] annually), p < 0.001. Conclusions:In this population-based cohort of ICU patients, the unadjusted odds of RBC transfusion increased in both higher and lower ICU volume hospitals both before and after Transfusion Requirements in Critical Care publication. After adjusting for relevant characteristics, the odds continued to increase in lower ICU volume hospitals in the post-Transfusion Requirements in Critical Care period, but it decreased in higher ICU volume hospitals. This suggests that evidence supporting restrictive RBC transfusion thresholds may not be uniformly translated into practice in different hospital settings.From: Sociedade Brasileira de Neurocirurgia <sbn@sbn.com.br>Subject: NotĂcias on-line da SBN | Publicação 16/2013Date: September 25, 2013 5:47:54 AM PDTTo: J�lio Leonardo Barbosa Pereira <juliommais@yahoo.com.br>Reply-To: Sociedade Brasileira de Neurocirurgia <sbn@sbn.com.br>
NotĂcias on-line da SBN | Publicação 16/2013 – 25/09/2013
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à brasileiro o vice-presidente da WFNS. O professor Hildo Azevedo é também o primeiro latino-americano a ocupar o cargo.
Congress of Neurological Surgeons . O encontro anual serå em outubro na Califórnia. As inscriçÔes estão abertas.
Tel.: (31) 3658-3235 | Email:secretaria@sbn.com.br
Secretaria Permanente: Rua AbĂlio Soares, 233 - cj. 143 - ParaĂso - CEP 04005-001 - SĂŁo Paulo/SP
Tel.: (11) 3051-6075 | Email:sbn@sbn.com.br
Bioengineering Group, National Research Council (CSIC), Carretera Campo Real, km 0.200, 28500, Madrid, Spain jc.moreno@csic.es
A neurobot (NR) is a mechatronic wearable robot that can be applied to drive a paralyzed limb. Through the application of controllable forces, a NR can assist, replace, or retrain a certain motor function. Robotic intervention in rehabilitation of motor disorders has a potential to improve traditional therapeutic interventions. Because of its flexibility, repeatability and quantifiability, NRs have been more and more applied in neurorehabilitation. Furthermore, combination of NRs with functional electrical stimulation/therapy constitutes a trend to overcome a number of practical limitations to widespread the application of NRs in clinical settings and motor control studies. In this review, we examine the motor learning principles, robotic control approaches and novel developments from studies with NRs and hybrid systems, with a focus on rehabilitation of the lower limbs.
The post Neurorobotic and hybrid management of lower limb motor disorders: a review. appeared first on NEUROSURGERY BLOG.
 Nature World News | Fatal rare brain disease confirmed in NH patient; 15 possibly exposed NBCNews.com A neurosurgery patient treated at a New Hampshire hospital this spring did have a rare brain disorder known as Creutzfeldt-Jakob Disease, health officials confirmed Friday. That means that 15 other people in three states may have been exposed to the ... Rare, fatal brain disease confirmed in New Hampshire patient Case of Creutzfeldt-Jakob Disease Confirmed in New Hampshire Rare brain disease confirmed in New Hampshire |
The pseudotumor cerebri syndrome (PTCS) may be primary (idiopathic intracranial hypertension) or arise from an identifiable secondary cause. Characterization of typical neuroimaging abnormalities, clarification of normal opening pressure in children, and features distinguishing the syndrome of intracranial hypertension without papilledema from intracranial hypertension with papilledema have furthered our understanding of this disorder. We propose updated diagnostic criteria for PTCS to incorporate advances and insights into the disorder realized over the past 10 years.
Rationale:Despite recommendations supporting the importance of clinician-family communication in the ICU, this communication is often rated as suboptimal in frequency and quality. We employed a multifaceted behavioral-change intervention to improve communication between families and clinicians in a statewide collaboration of ICUs. Objectives:Our primary objective was to examine whether the intervention resulted in increased compliance with process measures that targeted clinician-family communication. As secondary objectives, we examined the ICU-level characteristics that might be associated with increased compliance (open vs closed, teaching vs nonteaching, and medical vs medical-surgical vs surgical) and patient-specific outcomes (mortality, length of stay). Methods:The intervention was a multifaceted quality improvement approach targeting process measures adapted from the Institute of Health Improvement and combined into two "bundles" to be completed either 24 or 72 hours after ICU admission. Measurements and Main Results:Significant increases were seen in full compliance for both day 1 and day 3 process measures. Day 1 compliance improved from 10.7% to 83.8% after 21 months of intervention (p < 0.001). Day 3 compliance improved from 1.6% to 28.8% (p < 0.001). Improvements in compliance varied across ICU type with less improvement in open, nonteaching, and mixed medical-surgical ICUs. Patient-specific outcome measures were unchanged, although there was a small increase in patients discharged from ICU to inpatient hospice (p = 0.002). Conclusions:We found that a multifaceted intervention in a statewide ICU collaborative improved compliance with specific process measures targeting communication with family members. The effect of the intervention varied by ICU type.
Objectives:To determine the impact of rapid response team implementation on the outcome of patients transferred from the regular hospital ward and nonward locations to the ICU. Design:Retrospective before–after cohort study. Setting:The study was performed in two ICUs, one surgical and one medical, of a tertiary medical center. Patients:We included 4,890 patients transferred from the hospital ward to two ICUs and 15,855 patients admitted from nonward locations. Interventions:None. Measurements and Main Results:Data on each patient were abstracted from the Acute Physiology and Chronic Health Evaluation III and the administrative hospital and rapid response team databases. The study period was divided into pre–rapid response team and rapid response team. A 24/7 critical care consult service and cardiac arrest teams were available for ward patient care during both periods. A total of 20,745 patients were admitted to the two study ICUs, of whom 4,890 were from the ward (2,466 and 2,424 during the pre–rapid response team and rapid response team periods, respectively). The first ICU day severity of illness was higher for the pre–rapid response team period. A multiple logistic regression model that included predicted mortality as a covariate suggested that availability of rapid response team was associated with an increased risk of hospital death in patients transferred to the ICU from the regular ward, odds ratio (95% CI) of 1.273 (1.089–1.490). For the nonward patients, the availability of rapid response team was similarly associated with increased risk of death. The ICU length of stay was shorter during the rapid response team period both in ward transfer and in nonward transfer patients. Conclusions:Rapid response team implementation is associated with increased numbers of ICU admissions and rates, and transfer from the ward of less severely ill patients. However, rapid response team implementation did not improve the severity-of-illness-adjusted outcome of patients transferred from the ward. Implementation of rapid response team in an institution with a 24/7 ICU consult service may have unforeseen costs without obvious benefit. Our findings highlight that institutions should evaluate the impact of rapid response team on patient outcome and make modifications specific to their practices.
Objectives:To compare the quality of care delivered to critically ill and injured children receiving telemedicine, telephone, or no consultation in rural emergency departments. Design:Retrospective chart review with concurrent surveys. Setting and Participants:Three hundred twenty patients presenting in the highest triage category to five rural emergency departments with access to pediatric critical care consultations from an academic children's hospital. Measurements and Main Results:Quality of care was independently rated by two pediatric emergency medicine physicians applying a previously validated 7-point implicit quality review tool to the medical records. Quality was compared using multivariable linear regression adjusting for age, severity of illness, and temporal trend. Referring physicians were surveyed to evaluate consultation-related changes in their care. Parents were also surveyed to evaluate their satisfaction and perceived quality of care. In the multivariable analysis, with the no-consultation cohort as the reference, overall quality was highest among patients who received telemedicine consultations (n = 58; ÎČ = 0.50 [95% CI, 0.17–0.84]), intermediate among patients receiving telephone consultation (n = 63; ÎČ = 0.12 [95% CI, −0.14 to 0.39]), and lowest among patients receiving no consultation (n = 199). Referring emergency department physicians reported changing their diagnosis (47.8% vs 13.3%; p < 0.01) and therapeutic interventions (55.2% vs 7.1%; p < 0.01) more frequently when consultations were provided using telemedicine than telephone. Parent satisfaction and perceived quality were significantly higher when telemedicine was used, compared with telephone, for six of the seven measures. Conclusions:Physician-rated quality of care was higher for patients who received consultations with telemedicine than for patients who received either telephone or no consultation. Telemedicine consultations were associated with more frequent changes in diagnostic and therapeutic interventions, and higher parent satisfaction, than telephone consultations.Neurosurgery Blog just shared an Instagram photo with you:
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BACKGROUND:Genetic risk factors for intracranial aneurysms may influence the size of aneurysms. OBJECTIVE:To assess the association between genetic risk factors and the size of aneurysms at the time of rupture. METHODS:Genotypes of 7 independent single-nucleotide polymorphisms (SNPs) of the 6 genetic risk loci identified in genome-wide association studies of patients with intracranial aneurysms were obtained from 700 Dutch patients with an aneurysmal subarachnoid hemorrhage (1997-2007) previously genotyped in the genome-wide association studies; 255 additional Dutch patients with an aneurysmal subarachnoid hemorrhage (2007-2011) were genotyped for these SNPs. Aneurysms were measured on computerized tomography angiography or digital subtraction angiography. The mean aneurysm size (with standard error) was compared between patients with and without a genetic risk factor by the use of linear regression. The association between SNPs and size was assessed for single SNPs and for the combined effect of SNPs by using a weighted genetic risk score. RESULTS:Single SNPs showed no association with aneurysm size, nor did the genetic risk score. CONCLUSION:The 6 genetic risk loci have no major influence on the size of aneurysms at the time of rupture. Because these risk loci explain no more than 5% of the genetic risk, other genetic factors for intracranial aneurysms may influence aneurysm size and thereby proneness to rupture. ABBREVIATIONS:aSAH, aneurysmal subarachnoid hemorrhageCTA, computerized tomography angiogramDSA, digital subtraction angiogramGRS, genetic risk scoreGWAS, genome-wide association studiesSAH, subarachnoid hemorrhageSE, standard errorSNP, single-nucleotide polymorphism
