The Role of Ketone Bodies in Treatment Individualization of Glioblastoma Patients.

Glioblastoma is the most common and aggressive primary brain tumor in adults. According to the 2021 WHO CNS, glioblastoma is assigned to the IDH wild-type classification, fulfilling the specific characteristic histopathology. We have conducted a prospective observational study to identify the glucose levels, ketone bodies, and the glucose-ketone index in three groups of subjects: two tumoral groups of patients with histopathological confirmation of glioblastoma (9 male patients, 7 female patients, mean age 55.6 years old) or grade 4 astrocytoma (4 male patients, 2 female patients, mean age 48.1 years old) and a control group (13 male patients, 9 female patients, mean age 53.9 years old) consisting of subjects with no personal pathological history. There were statistically significant differences between the mean values of glycemia (p value = 0.0003), ketones (p value = 0.0061), and glucose-ketone index (p value = 0.008) between the groups of patients. Mortality at 3 months in glioblastoma patients was 0% if the ketone levels were below 0.2 mM and 100% if ketones were over 0.5 mM. Patients with grade 4 astrocytoma and the control subjects all presented with ketone values of less than 0.2 mM and 0.0% mortality. In conclusion, highlighting new biomarkers which are more feasible to determine such as ketones or glucose-ketone index represents an essential step toward personalized medicine and survival prolongation in patients suffering from glioblastoma and grade 4 astrocytoma.

Improving Clinical Performance of an Interprofessional Emergency Medical Team Through a One-day Crisis Resource Management Training.

INTRODUCTION: Errors are frequent in health care and Emergency Departments are one of the riskiest areas due to frequent changes of team composition, complexity and variety of the cases and difficulties encountered in managing multiple patients. As the majority of clinical errors are the results of human factors and not technical in nature or due to the lack of knowledge, a training focused on these factors appears to be necessary. Crisis resource management (CRM), a tool that was developed initially by the aviation industry and then adopted by different medical specialties as anesthesia and emergency medicine, has been associated with decreased error rates. THE AIM OF THE STUDY: To assess whether a single day CRM training, combining didactic and simulation sessions, improves the clinical performance of an interprofessional emergency medical team. MATERIAL AND METHODS: Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through two in situ simulated exercises. The exercises were videotaped and were evaluated by two assessors who were blinded as to whether it was the initial or the final exercise. Objective measurement of clinical team performance was performed using a checklist that was designed for each scenario and included essential assessment items for the diagnosis and treatment of a critical patient, with the focus on key actions and decisions. The intervention consisted of a one-day training, combining didactic and simulation sessions, followed by instructor facilitated debriefing. All participants went through this training after the initial assessment exercises. RESULTS: An improvement was seen in most of the measured clinical parameters. CONCLUSION: Our study supports the use of combined CRM training for improving the clinical performance of an interprofessional emergency team. Empirically this may improve the patient outcome.

Improving nontechnical skills of an interprofessional emergency medical team through a one day crisis resource management training.

Errors are frequent in healthcare, but Emergency Departments are among the highest risk areas due to frequent changes in team composition, complexity and variety of cases, and difficulties encountered in managing multiple patients simultaneously.Crisis resource management (CRM) training has been associated with decreased error rates in the aviation industry as well as in certain areas of acute medical care, such as anesthesia and emergency medicine. In this study, we assessed whether a single day CRM training, combining didactic and simulation sessions, improves nontechnical skills (NTS) of interprofessional emergency medical teams.Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through 2 in situ simulated exercises. The exercises were videotaped and were evaluated by 2 assessors who were blinded as to whether it was the initial or the final exercise. They used a new tool designed specifically for the assessment of emergency physicians' NTS. The intervention consisted of one-day training, combining didactic and simulation sessions, followed by an instructor facilitated debriefing. All participants went through this training after the initial assessment exercises.A significant improvement (P < 0.05) was shown for all the NTS assessed, in all professional categories involved, regardless of the duration of prior work experience in the Emergency Department.This study shows that even a short intervention, such as a single day CRM training, can have a significant impact in improving NTS, and can potentially improve patient safety.

Moving Toward a Universal Digital Era in Mass Casualty Incidents and Disasters: Emergency Personnel's Perspective in Romania.

BACKGROUND: Despite a recognized need for improved communications and logistics in high acuity situations, the integration of telemedicine services into the mainstream health services has been difficult. This study reports on the opinions of Romanian professional responders to mass casualty incidents and disasters regarding the use and requirements of specific electronic medical documentation solutions. MATERIALS AND METHODS: Doctors, nurses, paramedics, and fire department officers participated in a customized online structured questionnaire. To assess factors associated with the current use of information technology and the willingness to adopt an exclusive optimized electronic system, a multivariate analysis was performed. Logistic regression was used for free input key elements regarding the most useful technical and operative improvements and medical documentation solutions for large-scale events. RESULTS: A total of 536 respondents provided answers between the second half of the year 2014 and the first half of the year 2015. Doctors and nurses were the most frequent users of documentation techniques, especially if they were employed at a high-level emergency care center. Professionals' duties were perceived as increasingly impaired by the use of current electronic systems as those duties became more complex. All respondents favored an optimized large-scale event electronic solution, emphasizing the need for enhanced communications, technical equipment, cooperation, and workflow mainly by integrating mobile devices, dedicated software, remote databases, and interlink capabilities. CONCLUSIONS: Professionals support the implementation of an integrated electronic system for large-scale events if outlined requirements are met to maximize user acceptance.

Gangliocytic paraganglioma: a rare cause of gastrointestinal bleeding.

Duodenal neuroendocrine tumors (NETs) are rare tumors, consisting of five different types of tumors. In many cases, they may be asymptomatic, leading to delay in diagnosis. Clinical symptoms are related to local tumor growth and mucosal ulceration. We report a 38-year old man with duodenal gangliocytic paraganglioma causing overt upper gastrointestinal bleeding and anemia. We describe specific clinical and histopathological features of the tumor, and review the diagnostic and therapeutic strategy. Gangliocytic paragangliomas are regarded as benign tumors. However, the disease recurrence and the malignant potential of the tumor have also been reported.

Narrow-band imaging with magnifying endoscopy for the evaluation of gastrointestinal lesions.

Narrow band imaging (NBI) endoscopy is an optical image enhancing technology that allows a detailed inspection of vascular and mucosal patterns, providing the ability to predict histology during real-time endoscopy. By combining NBI with magnification endoscopy (NBI-ME), the accurate assessment of lesions in the gastrointestinal tract can be achieved, as well as the early detection of neoplasia by emphasizing neovascularization. Promising results of the method in the diagnosis of premalignant and malignant lesions of gastrointestinal tract have been reported in clinical studies. The usefulness of NBI-ME as an adjunct to endoscopic therapy in clinical practice, the potential to improve diagnostic accuracy, surveillance strategies and cost-saving strategies based on this method are summarized in this review. Various classification systems of mucosal and vascular patterns used to differentiate preneoplastic and neoplastic lesions have been reviewed. We concluded that the clinical applicability of NBI-ME has increased, but standardization of endoscopic criteria and classification systems, validation in randomized multicenter trials and training programs to improve the diagnostic performance are all needed before the widespread acceptance of the method in routine practice. However, published data regarding the usefulness of NBI endoscopy are relevant in order to recommend the method as a reliable tool in diagnostic and therapy, even for less experienced endoscopists.

Gastric carcinoids and therapeutic options. Case report and review of the literature.

Neuroendocrine tumors (carcinoids) are tumors originating from neuroendocrine cells. The distinction between different types of gastric carcinoids is important for their management. We present the case of a 38-year old woman with type 1 gastric neuroendocrine tumors (NETs) associated with autoimmune atrophic gastritis. The management of these tumors has not been yet codified and different therapeutic strategies have been suggested. A proper evaluation before therapy is indicated in order to rule out both the malignant transformation as well as the presence of synchronous lesions, such as dysplasia or gastric adenocarcinoma. We describe our diagnostic and therapeutic strategies with references to previously published reports.

Epidemiology of assault and self-harm injuries treated in a large Romanian Emergency Department.

OBJECTIVES: Intentional injury, including interpersonal violence and self-harm, is one of the world's leading causes of preventable injury. In Europe alone, nearly 1.5 million individuals receive medical treatment each year for a violence-related injury. We examined violent injuries treated in the largest Emergency Department (ED) in Tîrgu Mures County, Romania, with a catchment area of approximately 580 000 residents to describe the epidemiology of assault and self-harm injuries. METHODS: Data were collected as part of the European Injury Database project, from a sample of patients who presented with a violence-related injury and received care from the ED of the Mures County Emergency Hospital, Romania. The data were collected for 9 months by two trained emergency physicians. Information about individual demographics; mechanism, nature, place, and activity of injury; injury types, and body regions affected; and discharge state were compared for assault and self-harm injuries. RESULTS: Of the 380 patients treated for violence-related injuries, 88.7% were for assault and 11.3% were for self-harm. For both types of injuries, the majority of patients were between the ages of 15 and 44. Assaults frequently occurred in the home, on streets and highways, or in public places; and men (80.4%) were far more likely than women (19.6%) to be treated for this type of injury; a slightly higher proportion of men (55.8%) than women (44.2%) were treated for self-harm, most of which occurred in homes. DISCUSSION: Of all injuries treated in the Tîrgu Mures ED, one out of five was violence related. One out of 10 patients that suffered an injury as a consequence of a violent event and treated in the ED required admission to a hospital for further medical care, leading to a significant health care burden. These data suggest that prevention strategies should focus on young adults, and particularly men. Interventions that focus on detection and treatment of psychological illness, reduction of alcohol use and associated aggression, and family and intimate partner violence are suggested as priorities.

The BRAIN TRIAL: a randomised, placebo controlled trial of a Bradykinin B2 receptor antagonist (Anatibant) in patients with traumatic brain injury.

BACKGROUND: Cerebral oedema is associated with significant neurological damage in patients with traumatic brain injury. Bradykinin is an inflammatory mediator that may contribute to cerebral oedema by increasing the permeability of the blood-brain barrier. We evaluated the safety and effectiveness of the non-peptide bradykinin B2 receptor antagonist Anatibant in the treatment of patients with traumatic brain injury. During the course of the trial, funding was withdrawn by the sponsor. METHODS: Adults with traumatic brain injury and a Glasgow Coma Scale score of 12 or less, who had a CT scan showing an intracranial abnormality consistent with trauma, and were within eight hours of their injury were randomly allocated to low, medium or high dose Anatibant or to placebo. Outcomes were Serious Adverse Events (SAE), mortality 15 days following injury and in-hospital morbidity assessed by the Glasgow Coma Scale (GCS), the Disability Rating Scale (DRS) and a modified version of the Oxford Handicap Scale (HIREOS). RESULTS: 228 patients out of a planned sample size of 400 patients were randomised. The risk of experiencing one or more SAEs was 26.4% (43/163) in the combined Anatibant treated group, compared to 19.3% (11/57) in the placebo group (relative risk = 1.37; 95% CI 0.76 to 2.46). All cause mortality in the Anatibant treated group was 19% and in the placebo group 15.8% (relative risk 1.20, 95% CI 0.61 to 2.36). The mean GCS at discharge was 12.48 in the Anatibant treated group and 13.0 in the placebo group. Mean DRS was 11.18 Anatibant versus 9.73 placebo, and mean HIREOS was 3.94 Anatibant versus 3.54 placebo. The differences between the mean levels for GCS, DRS and HIREOS in the Anatibant and placebo groups, when adjusted for baseline GCS, showed a non-significant trend for worse outcomes in all three measures. CONCLUSION: This trial did not reach the planned sample size of 400 patients and consequently, the study power to detect an increase in the risk of serious adverse events was reduced. This trial provides no reliable evidence of benefit or harm and a larger trial would be needed to establish safety and effectiveness. TRIAL REGISTRATION: This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN23625128.