Validation of an ICD-Code-Based Case Definition for Psychotic Illness Across Three Health Systems.

BACKGROUND AND HYPOTHESIS: Psychosis-associated diagnostic codes are increasingly being utilized as case definitions for electronic health record (EHR)-based algorithms to predict and detect psychosis. However, data on the validity of psychosis-related diagnostic codes is limited. We evaluated the positive predictive value (PPV) of International Classification of Diseases (ICD) codes for psychosis. STUDY DESIGN: Using EHRs at 3 health systems, ICD codes comprising primary psychotic disorders and mood disorders with psychosis were grouped into 5 higher-order groups. 1133 records were sampled for chart review using the full EHR. PPVs (the probability of chart-confirmed psychosis given ICD psychosis codes) were calculated across multiple treatment settings. STUDY RESULTS: PPVs across all diagnostic groups and hospital systems exceeded 70%: Mass General Brigham 0.72 [95% CI 0.68-0.77], Boston Children's Hospital 0.80 [0.75-0.84], and Boston Medical Center 0.83 [0.79-0.86]. Schizoaffective disorder PPVs were consistently the highest across sites (0.80-0.92) and major depressive disorder with psychosis were the most variable (0.57-0.79). To determine if the first documented code captured first-episode psychosis (FEP), we excluded cases with prior chart evidence of a diagnosis of or treatment for a psychotic illness, yielding substantially lower PPVs (0.08-0.62). CONCLUSIONS: We found that the first documented psychosis diagnostic code accurately captured true episodes of psychosis but was a poor index of FEP. These data have important implications for the case definitions used in the development of risk prediction models designed to predict or detect undiagnosed psychosis.

Validation of an ICD-code-based case definition for psychotic illness across three health systems.

Background and Hypothesis: Early detection of psychosis is critical for improving outcomes. Algorithms to predict or detect psychosis using electronic health record (EHR) data depend on the validity of the case definitions used, typically based on diagnostic codes. Data on the validity of psychosis-related diagnostic codes is limited. We evaluated the positive predictive value (PPV) of International Classification of Diseases (ICD) codes for psychosis. Study Design: Using EHRs at three health systems, ICD codes comprising primary psychotic disorders and mood disorders with psychosis were grouped into five higher-order groups. 1,133 records were sampled for chart review using the full EHR. PPVs (the probability of chart-confirmed psychosis given ICD psychosis codes) were calculated across multiple treatment settings. Study Results: PPVs across all diagnostic groups and hospital systems exceeded 70%: Massachusetts General Brigham 0.72 [95% CI 0.68-0.77], Boston Children's Hospital 0.80 [0.75-0.84], and Boston Medical Center 0.83 [0.79-0.86]. Schizoaffective disorder PPVs were consistently the highest across sites (0.80-0.92) and major depressive disorder with psychosis were the most variable (0.57-0.79). To determine if the first documented code captured first-episode psychosis (FEP), we excluded cases with prior chart evidence of a diagnosis of or treatment for a psychotic illness, yielding substantially lower PPVs (0.08-0.62). Conclusions: We found that the first documented psychosis diagnostic code accurately captured true episodes of psychosis but was a poor index of FEP. These data have important implications for the development of risk prediction models designed to predict or detect undiagnosed psychosis.

Patient Experiences Completing Patient Reported Outcome Measures in Behavioral Health Within a Health Safety-Net Setting.

Measurement based care (MBC), a practice that uses patient reported outcome measures (PROMs), is not widely used in behavioral health settings and little is known about the patient experience with MBC in safety-net settings. This study aimed to understand patient experiences completing PROMs on paper when presenting to an outpatient, behavioral health setting within a public safety-net hospital. Semi-structured interviews were conducted with 22 participants in English and Spanish. Participants were 42 years old (SD = 12.7), mostly white (36.4%) and Black (31.8%). Thematic analysis was used to analyze findings. Overall, participants were engaged with PROMs and described them as helpful for themselves and their clinicians. Participants also expressed themes focused on PROMs user-friendliness, including formatting, time to complete measures, and participant characteristics such as attention and literacy. These findings are important to consider to ensure equitable access to MBC when implemented in behavioral health in the health safety-net setting.

Patient Perspectives of the Hospital Discharge Process: A Qualitative Study.

Care transitions after hospitalization require communication across care teams, patients, and caregivers. As part of a quality improvement initiative, we conducted qualitative interviews with a diverse group of 53 patients who were recently discharged from a hospitalization within a safety net hospital to explore how patient preferences were included in the hospital discharge process and differences in the hospital discharge experience by race/ethnicity. Four themes emerged from participants regarding desired characteristics of interactions with the discharge team: (1) to feel heard, (2) inclusion in decision-making, (3) to be adequately prepared to care for themselves at home through bedside teaching, (4) and to have a clear and updated discharge timeline. Additionally, participants identified patient-level factors the discharge planning team should consider, including the social context, family involvement, health literacy, and linguistic barriers. Lastly, participants identified provider characteristics, such as a caring and empathetic bedside manner, that they found valuable in the discharge process. Our findings highlight the need for shared decision-making in the discharge planning process to improve both patient safety and satisfaction.

A participatory study of college students' mental health during the first year of the COVID-19 pandemic.

Introduction: The COVID-19 pandemic has negatively impacted college students' mental health and wellbeing. Even before the pandemic, young adults reported high mental health morbidity. During the pandemic, young adult college students faced unprecedented challenges, including campus closure and a pivot to fully online education. Methods: This study employed a novel participatory approach to a Course-based Undergraduate Research Experience (CURE) in an introductory epidemiology course to examine factors students considered important regarding their experience during the pandemic. Two groups of undergraduate students enrolled in this course (one in Fall 2020 and another in Spring 2021) and participated in the CURE. A sub-group of these students continued after the class and are authors of this article. Through repeated cross-sectional surveys of college students' peer groups in northern California in October 2020 and March 2021, this student/faculty collaborative research team evaluated depression, anxiety, suicidal ideation and several other topics related to mental health among the students' young adult community. Results: There was a high prevalence of anxiety (38.07% in October 2020 and 40.65% in March 2021), depression (29.85% in October 2020 and 27.57% in March 2021), and suicidal ideation (15.94% in October 2020 and 16.04% in March 2021). In addition, we identified the significant burden of loneliness for college students, with 58.06% of students reporting feeling lonely at least several days in the past two weeks. Strategies that students used to cope with the pandemic included watching shows, listening to music, or playing video games (69.01%), sleeping (56.70%), taking breaks (51.65%), and connecting with friends (52.31%) or family (51.21%). Many reported distressing household experiences: more than a third reporting loss of a job or income (34.27%) in the first year of the pandemic. We explain the participatory research approach and share empirical results of these studies. Discussion: We found this participatory CURE approach led to novel, experience-based research questions; increased student motivation; real-world benefits such as combatting imposter syndrome and supporting graduate school intentions; integration of teaching, research, and service; and development of stronger student-faculty relationships. We close with recommendations to support student wellbeing and promote student engagement in research.

Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team.

Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.

Características clínicas de pacientes con sepsis en una unidad de cuidados intensivos pediátricos de un hospital de segundo nivel

Introducción: En los últimos años, tanto la morbilidad como la mortalidad por sepsis se han incrementado paulatinamente. Objetivo: Caracterizar variables clínicas de los pacientes con sepsis ingresados en una unidad de cuidados intensivos pediátricos del hospital Morón. Metodología: Se realizó un estudio descriptivo prospectivo de los pacientes pediátricos ingresados en la Unidad de Cuidados Intensivos por una Sepsis en el periodo comprendido entre enero de 2015 a diciembre 2018. El universo fue de 298 niños y la muestra de 113, los cuales se distribuyen en diferentes variables. Resultados: Predominan las edades de entre 2 y 5 años con 36 pacientes (31,9 %) y el sexo femenino en 63 casos (55,7 %). En la distribución de los estadíos al diagnóstico predominó fue la sepsis con 53 casos para un 46,9 %, y el tiempo transcurrido entre la infección y la aparición de la sepsis fue de 0 a 3 horas en 43 casos. Existió asociación entre el shock séptico y dosis de volumen administrado a 60ml/Kg de peso. La estadía que predominó en la serie fue entre 3 y 7 días en 41 pacientes. Conclusiones: Se realizó una caracterización clínica de los pacientes pediátricos con sepsis ingresados en la unidad de cuidados intensivos en el hospital Morón, que se clasifica dentro de los hospitales de segundo nivel de atención, durante 4 años, dentro de las variables principales se encuentra el predominio del estadio sepsis y la relación entre el choque séptico y la dosis de volumen a 60ml/Kg de peso.

Introduction: In recent years, both morbidity and mortality from sepsis have increased gradually. Objective: To characterize clinical variables of patients with sepsis admitted to a pediatric intensive care unit of the Morón hospital. Methods: A prospective descriptive study was carried out of pediatric patients admitted to the Intensive Care Unit for Sepsis in the period from January 2015 to December 2018. The universe consisted of 298 children and the sample of 113, of whom they are distributed in different variables. Results: Ages between 2 and 5 years old predominate with 36 patients (31.9%) and female sex in 63 cases (55.7%). In the distribution of the stages at diagnosis, sepsis predominated with 53 cases for 46.9 %, and the time elapsed between infection and the appearance of sepsis was 0 to 3 hours in 43 cases. There was an association between septic shock and the volume dose administered at 60ml/Kg of body weight. The stay that predominated in the series was between 3 and 7 days in 41 patients. Conclusions: A clinical characterization of pediatric patients with sepsis admitted to the intensive care unit at Morón hospital was carried out, which is classified within second-level care hospitals, for 4 years, among the main variables is the predominance of the sepsis stage and the relationship between septic shock and the volume dose at 60ml/Kg of body weight.

Presión positiva al final de la espiración, presión intracraneal y presión de perfusión cerebral en el paciente pediátrico crítico con traumatismo craneoencefálico grave / Positive end expiration pressure, intracranial pressure and cerebral perfusion pressure in the severe traumatic brain injury in child / Pressão positiva ao final da expiração, pressão intracraniana e pressão de perfusão cerebral em pacientes pediátricos criticamente enfermos com traumatismo cranioencefálico grave

Resumen: Introducción: el uso de presión positiva al final de la espiración mejora la oxigenación y recluta alvéolos, aunque también provoca alteraciones hemodinámicas e incrementa la presión intracraneal. Material y métodos: se realizó un estudio preexperimental de un solo grupo en pacientes pediátricos aquejados de traumatismo craneoencefálico grave, con hipoxemia asociada, tratados con diferentes niveles de presión positiva al final de la espiración, a los que se les monitorizó la presión intracraneal y la presión de perfusión cerebral para evaluar el efecto de esta maniobra ventilatoria en las variables intracraneales. Resultados: predominaron las edades entre cinco y 17 años, 14 (73.68%) y la escala de coma de Glasgow al ingreso de ocho a nueve puntos (47.36%). La presión intracraneal aumenta cuando la presión positiva al final de la espiración supera los 12 cmH2O. La escala de coma de Glasgow al ingreso de ocho puntos se asoció con secuelas ligeras o ausencia de secuelas (47.36%), todos los niños con tres puntos fallecieron. Conclusiones: el empleo de presión positiva al final de la espiración en el traumatismo craneoencefálico grave requiere de monitorización continua de la presión intracraneal. Corregir la hipertensión intracraneal y la inestabilidad hemodinámica son condiciones necesarias previas al tratamiento.

Abstract: Introduction: the use of positive end expiratory pressure improves oxygenation and recruits pulmonary alveoli, however at the same time it leads to hemodynamic changes and increase intracranial pressure. Material and methods: a prospective descriptive study was done with pediatric patients afflicted with severe traumatic brain injury associated with hypoxemia and treated with different levels of positive end expiratory pressure, to whom the intracranial pressure and cerebral perfusion pressure were monitored so as to evaluate the effect of this ventilation maneuver over the intracranial variables. Results: patients with age between 5-17 years old as well as male sex, 14 (73.68%) were predominant. 9 (47.36%) showed Glasgow coma scale of 8 points on admission. Intracranial pressure starts to rise when the positive end expiratory pressure exceeds 12 cmH2O. Glasgow coma scale with 8 points was associated with mild disability or no disability (47.36%). All the patients that scored 3 points died. Conclusions: the use of positive end expiratory pressure to correct hypoxemia was an applicable therapeutic alternative as long as continuous intracranial pressure monitoring was available in a systematic and personalized way. The correction of intracranial hypertension and hemodynamic instability were a necessary condition before using the ventilatory maneuver in these patients.

Resumo: Introdução: o uso de pressão positiva no final da expiração melhora a oxigenação e recruta alvéolos, embora também cause alterações hemodinâmicas e aumente a pressão intracraniana. Material e métodos: realizou-se um estudo pré-experimental de um único grupo em pacientes pediátricos vítimas de traumatismo cranioencefálico grave, com hipoxemia associada, tratados com diferentes níveis de pressão positiva ao final da expiração, nos quais foram monitoradas a pressão intracraniana e a pressão de perfusão cerebral, para avaliar o efeito desta manobra ventilatória em variáveis intracranianas. Resultados: predominou a faixa etária entre 5-17 anos, 14 (73.68%) e a escala de coma de Glasgow na admissão de 8 pontos, 9 (47.36%). A pressão intracraniana aumenta quando a pressão positiva no final da expiração excede 12 cmH2O. A escala de coma de Glasgow na admissão de 8 pontos foi associada a sequelas leves ou sem sequelas (47.36%), todas as crianças com 3 pontos morreram. Conclusões: a utilização de pressão positiva no final da expiração no TCE grave requer monitorização contínua da pressão intracraniana. A correção da hipertensão intracraniana e da instabilidade hemodinâmica são condições necessárias prévias ao tratamento.

Presión de perfusión cerebral en pacientes pediátricos con traumatismo craneoencefálico grave

RESUMEN Introducción: La mortalidad por traumatismo craneoencefálico grave (TCE g) en el paciente pediátrico, crece de forma directamente proporcional con la severidad de la injuria inicial. Se estima entre el 1 y 7 % de menores de 18 años afectados por dicha enfermedad en el mundo. La incidencia de muerte por esta causa oscila entre 2,8 y 3,75 por cada 100 000 niños anualmente. Metodología: Se realizó un estudio descriptivo de tipo correlacional en el servicio de cuidados intensivos pediátricos del Hospital General Docente "Roberto Rodríguez" de Morón, Ciego de Ávila, Cuba, en el período entre enero de 2003 y diciembre de 2017. Se incluyeron pacientes menores de 18 años. Las intervenciones fueron monitorización continua de la presión intracraneal, a través de una ventriculostomía al exterior y de la presión de perfusión cerebral y las variables presión intracraneal y presión de perfusión cerebral. Resultados: Se estudiaron 41 niños. Predominaron aquellos entre 5 y 17 años con 35 casos (85,3 %). La presión de perfusión cerebral en menores de 1 año fue >47mmhg en los dos casos estudiados, de 1-4 años >47mmhg en 2 casos y de 50mmhg en 23 casos (65,7 %) y 50mmhg se asoció con el grado V de la escala de resultados de Glasgow. Discusión: El control de la presión de perfusión cerebral con valores diferentes ajustados a los diferentes grupos de edades, a través de la manipulación de la presión intracraneal y la presión arterial media en el niño, mostró una adecuada relación con los resultados favorables.

ABSTRACT Introduction: Mortality from severe head injury (TBI g) in pediatric patients increases in direct proportion to the severity of the initial injury. It is estimated between 1 and 7% of children under 18 years of age affected by this disease in the world. The incidence of death from this cause ranges from 2.8 to 3.75 per 100,000 children annually. Methodology: A correlational descriptive study was carried out in the pediatric intensive care service of the General Teaching Hospital "Roberto Rodríguez" in Morón, Ciego de Ávila, Cuba, in the period between January 2003 and December 2017. Minor patients were included of 18 years. The interventions were continuous monitoring of intracranial pressure, through an external ventriculostomy and cerebral perfusion pressure and the variable intracranial pressure and cerebral perfusion pressure. Results: 41 children were studied. Those between 5 and 17 years old predominated with 35 cases (85.3%). Cerebral perfusion pressure in children under 1 year of age was> 47mmhg in the two cases studied, from 1-4 years> 47mmhg in 2 cases and 50mmhg in 23 cases (65.7%) and 50mmhg was associated with grade V on the Glasgow Outcome Scale. Discussion: The control of cerebral perfusion pressure with different values adjusted to the different age groups, through the manipulation of intracranial pressure and mean arterial pressure in the child, showed an adequate relationship with the favorable results.

The intratumor microbiome predicts prognosis across gender and subtypes in papillary thyroid carcinoma.

While the intratumor microbiome has become increasingly implicated in cancer development, the microbial landscape of papillary thyroid carcinoma (PTC) is essentially uninvestigated. PTC is characterized by varied prognosis between gender and cancer subtype, but the cause for gender and subtype-based dissimilarities is unclear. Women are more frequently diagnosed with PTC, while men suffer more advanced-staged PTC. In addition, tall cell variants are more aggressive than classical and follicular variants of PTC. We hypothesized that intratumor microbiome composition distinctly alters the immune landscape and predicts clinical outcome between PTC subtypes and between patient genders. Raw whole-transcriptome RNA-sequencing, Level 3 normalized mRNA expression read counts, and DNA methylation 450 k sequencing data for untreated, nonirradiated tumor, and adjacent normal tissue were downloaded from the Genomic Data Commons (GDC) legacy archive for 563 thyroid carcinoma patients. Microbe counts were extracted using Pathoscope 2.0 software. We correlated microbe abundance to clinical variables and immune-associated gene expression. Gene-set enrichment, mutation, and methylation analyses were conducted to correlate microbe abundance to characterize microbes' roles. Overall, PTC tumor tissue significantly lacked microbes that are populated in adjacent normal tissue, which suggests presence of microbes may be critical in controlling immune cell expression and regulating immune and cancer pathways to mitigate cancer growth. In contrast, we also found that microbes distinctly abundant in tall cell and male patient cohorts were also correlated with higher mutation expression and methylation of tumor suppressors. Microbe dysbiosis in specific PTC types may explain observable differences in PTC progression and pathogenesis. These microbes provide a basis for developing specialized prebiotic and probiotic treatments for varied PTC tumors.

Características anatómicas y fisiológicas que influyen en la presión intracraneal y la presión de perfusión cerebral en el paciente pediátrico con traumatismo craneoencefálico grave

RESUMEN La lesión cerebral traumática, es la de mayor potencial para el desarrollo de secuelas devastadoras de todos los tipos de trauma en los niños. La hipertensión intracraneal está presente en más del 65% de los que sufren de un TCE grave y se relaciona con más de la mitad de las muertes por esta causa. No existe consenso sobre los valores normales de PIC y PPC en los niños, se estima que son dependientes de la edad, pero es un tema en controversia en la actualidad. El objetivo es identificar los elementos anatómicos y fisiológicos en el compartimiento craneal y su contenido en los niños que influyen en las posibles variaciones de los valores de presión intracraneal y de la presión de perfusión cerebral en el paciente menor de 18 años con traumatismo craneoencefálico grave. Las características anatómicas y fisiológicas del paciente pediátrico en sus diferentes etapas de desarrollo definen valores de presión intracraneal y de presión de perfusión cerebral diferentes a los valores en el adulto. Se aborda un tema controversial, que permite identificar aspectos anatómicos y fisiológicos importantes que pueden influir sobre el tratamiento del traumatismo craneoencefálico pediátrico.

ABSTRACT Traumatic brain injury is one with the greatest potential for the development of devastating sequelae of all types of trauma in children. Intracranial hypertension is present in more than 65% of those who suffer from a severe TBI and is related to more than half of deaths from this cause. There is no consensus on the normal values of ICP and CPP in children, it is estimated that they are dependent on age, but it is currently a controversial issue. The objective was to identify the anatomical and physiological characteristics in the cranial compartment and its content in children that influence the possible variations in intracranial pressure and cerebral perfusion pressure in patients less than 18 years of age with severe head injury. The anatomical and physiological characteristics of the pediatric patient in their different stages of development define values of intracranial pressure and cerebral perfusion pressure different from those in adults. A controversial issue is addressed, which allows identifying important anatomical and physiological aspects that may influence the treatment of pediatric head trauma.

Comportamiento de los trastornos hipertensivos gestacionales, en el policlínico René Ávila Reyes, Holguín, Cuba, desde el año 2015 al 2016 / Gestational hypertension behavior from 2015 to 2016, at René Ávila Reyes Polyclinic, Holguín, Cuba

Introducción: la hipertensión arterial se encuentra entre las enfermedades más frecuentes del embarazo y el puerperio. Objetivo: caracterizar el comportamiento de los trastornos hipertensivos gestacionales, en el Policlínico René Ávila Reyes. Método: se realizó un estudio de los casos, de enero del 2015 a diciembre de 2016, en el Policlínico René Ávila Reyes, de Holguín, Cuba. El universo quedó conformado por 215 gestantes, que recibieron atención prenatal, y la muestra por 68 pacientes, con enfermedad hipertensiva gestacional. La información se obtuvo de la revisión del carné obstétrico de las gestantes, y del registro estadístico del área de salud. Resultados: 45 pacientes presentaron hipertensión arterial crónica, para un 66,17%; 15 mayores de 35 años, para el 22,06%, y el 47,06% con sobrepeso. Solo el 13,24% tenía pre- eclampsia, y el 69,12% exceso de peso corporal. Las nulíparas representaron un 58,82%, y 61 recién nacidos estuvieron por encima de 2500 g (89,71%). Conclusiones: predominó la hipertensión arterial crónica en las mujeres mayores de 35 años. No existieron pacientes con eclampsia ni hipertensión transitoria. El mayor porcentaje de casos estuvo constituido por pacientes sobrepeso. Las nulíparas, independientemente de su edad, aportaron el mayor número de casos. Los trastornos hipertensivos no tuvieron repercusión sobre el peso del recién nacido, con predominio del peso al nacer por encima de los 2500 g, en su mayoría asociados a la hipertensión arterial crónica.

Introduction: hypertension is one of the most frequent diseases during pregnancy and puerperium. Objective: to characterize gestational hypertension behavior in patients, from January 2015 to December 2016. Methods: from January 2015 to December 2016, a study was carried out on 215 pregnant women, which received prenatal care at René Ávila Reyes Polyclinic. A 68 gestational hypertension sample, was independently diagnosed. Information was obtained from the Maternal Program and the obstetric clinical records. Results: forty five patients (66.17%) showed chronic arterial hypertension. At the same group, 15 (22.06%) were over 35 years old, and 47.06% were overweight. Only 13.24% of patients suffered from preeclampsia and 69.12% were excess weight. Nulliparous women represented the 58.82% and 61 newborns birth weights were above 2500 g (89.71%). Conclusions: overweight and chronic hypertension prevailed, over 36 year's old women. There were no patients with eclampsia or transitional hypertension. Most cases were nulliparital women, no matter their age. Hypertensive disorders did not affect newborn's weight. Birth weight over 2500g was associated to chronic hypertension.

Neuromonitorización en el trauma craneoencefálico grave en pediatría / Neuromonitoring of severe craniocerebral trauma in paediatric patients

Introducción: El traumatismo craneoencefálico (TCE) grave representa una de las principales causas de incapacidad y muerte en la población pediátrica de todo el mundo. La neuromonitorización multimodal en estos pacientes en Cuba no se encuentra generalizada en las unidades de cuidados intensivos pediátricos y no existe un protocolo de actuación estandarizado para su uso en estas unidades. Material y métodos: Se realizó un estudio longitudinal prospectivo de tipo correlacional, con enfermos pediátricos que presentaron el diagnóstico de TCE grave, en el período entre enero del 2003 y diciembre del 2014. Se realizó neuromonitorización continua de parámetros como la presión intracraneal y la presión de perfusión cerebral. Resultados: Se encontró correlación entre las imágenes de TAC al ingreso y el grado de luxación de las estructuras de línea media con los resultados. Se observó la existencia de una relación directamente proporcional entre la presión intracraneal y los resultados, los valores normales para cada grupo de edad se asociaron a mejores resultados y viceversa. La utilización de la CD precoz facilitó el rápido control de la hipertensión intracraneal en los pacientes con TCE grave y se evidencia la relación entre los valores normales de presión de perfusión cerebral para cada grupo de edad y las secuelas ligeras o ausencia de estas en la ERG

Conclusiones: La neuromonitorización aporta información indispensable para adoptar una postura terapéutica en el manejo de los pacientes pediátricos con un TCE grave. Introduction: Severe craniocerebral trauma is the main cause of morbidity and mortality in children worldwide. Neuromonitoring of these patients in Cuba is not routine in paediatric intensive cares units, and there is no standardised protocol for its use in these units. Materials and methods: A correlational longitudinal prospective study was conducted on all patients admitted to the paediatric intensive care unit with the diagnosis of severe craniocerebral trauma in the period between January 2003 and December 2014. Continuous neuromonitoring of intracranial pressure and cerebral perfusion pressure was carried out. Results: The results showed that there was a correlation between the initial images of CT scan and the grade of shift of the half line structures. There was a direct relationship between intracranial pressure and the outcomes. The use of early decompressive craniectomy facilitated the rapid control of the intracranial hypertension. Conclusions: Continuous neuromonitoring contributes to adopt a therapeutic posture in the handling of the paediatric patients with severe head trauma

Endoscopic evacuation of spontaneous supratentorial intracerebral hemorrhage

Introduction: Spontaneous intracerebral hemorrhage (SICH) constitutes a major public health problem worldwide, despite active research it is still a leading cause of morbidity, disability, and death. In Cuba cerebrovascular disease represents the 3rd cause of death and in the last decade, the number of deaths for this cause has increased and the mortality rate is about 41/100,000/year. Method: We have carried out a descriptive study of 14 patients admitted in the intensive care unit of Moron General Hospital in Ciego de Avila, Cuba, with diagnosis of Spontaneous Supratentorial Intracerebral Hemorrhage (SSICH), who were treated with endoscopic surgical evacuation in the period from January of 2013 to December of 2014. Results: All patients underwent surgery within 12 hours of ictus and 10 (71.43 percent) underwent surgery within 6 hours. The mean time from SSICH onset to surgery was 7.6 hours. The mean operative time was 90 minutes. Endoscopy was successfully completed in all cases and the hematoma evacuation rate was 97 percent- 100 percent in all patients. The mortality rate was 5 patients (35.71 percent). Six months after clot endoscopic evacuation, six cases (42.86 percent) had poor results (Grade IV-VI) and 8 (57.14 percent) had goodrecovery (Grade 0-III). Conclusions: Early endoscope-assisted SSICH evacuation is safe, effective and feasible method in hematoma evacuation.

[Neuromonitoring of severe craniocerebral trauma in paediatric patients]. / Neuromonitorización en el trauma craneoencefálico grave en pediatría.

INTRODUCTION: Severe craniocerebral trauma is the main cause of morbidity and mortality in children worldwide. Neuromonitoring of these patients in Cuba is not routine in paediatric intensive cares units, and there is no standardised protocol for its use in these units. MATERIALS AND METHODS: A correlational longitudinal prospective study was conducted on all patients admitted to the paediatric intensive care unit with the diagnosis of severe craniocerebral trauma in the period between January 2003 and December 2014. Continuous neuromonitoring of intracranial pressure and cerebral perfusion pressure was carried out. RESULTS: The results showed that there was a correlation between the initial images of CT scan and the grade of shift of the half line structures. There was a direct relationship between intracranial pressure and the outcomes. The use of early decompressive craniectomy facilitated the rapid control of the intracranial hypertension. CONCLUSIONS: Continuous neuromonitoring contributes to adopt a therapeutic posture in the handling of the paediatric patients with severe head trauma.

Tratamiento quirúrgico en las hemorragias intracerebrales lobares espontáneas supratentoriales sin extensión ventricular / Surgical treatment for supratentorial spontaneous lobarintracerebral hemorrhage without ventricular extension

Objetivo: Evaluar los resultados en el manejo de pacientes con hemorragias intracerebrales lobares espontaneas, supratentoriales y sin extensión ventricular a través de la comparación entre el tratamiento quirúrgico y el tratamiento médico. Material y Método: Se realizó un estudio de casos y controles en el Hospital General “Roberto Rodríguez Fernández” de Morón, Ciego de Ávila, Cuba, en el período comprendido entre enero de 2009 y diciembre de 2013. La muestra quedó conformada por aquellos que reunieron los siguientes criterios de inclusión: 1) Edad de 18-60 años; 2) 48 horas de inicio de las manifestaciones clínicas; 3) volumen de la hemorragia entre 20 y 60 cm3 ; 4) Escala de coma de Glasgow al ingreso superior a 4 puntos. Se constituyeron dos grupos, en el Grupo I fueron incluidos los enfermos que recibieron tratamiento quirúrgico y médico. En el Grupo II se incluyeron los que recibieron tratamiento médico solamente. La inclusión en uno de los dos grupos quedó sujeta al criterio del médico que recibió al paciente en el departamento de emergencias, no existió aleatorización en el proceso. Resultados: Se incluyeron en el estudio un total de 147 pacientes 54 (36,73 por ciento) en el Grupo I y 93 (63,27 por ciento) en el Grupo II. En el Grupo I la mortalidad a los seis meses del egreso fue de 16 pacientes (29,64 por ciento), mientras que en el grupo II murieron 33 (35,48 por ciento). Conclusiones: Se obtuvo un discreto pero relevante predominio de los resultados satisfactorios en el grupo de pacientes operados y la mortalidad fue también menor en este grupo.

The aim of this paper was to evaluate the surgical versus medical treatment in patients with supratentorial spontaneous intracerebral hemorrhage without ventricular extension. Methods: A case-control study was carried out in the “Roberto Rodríguez Fernández” general hospital in Moron, Ciego de Avila, Cuba, in the period between January 2009 and December 2013. The sample was conformed by those patients that gathered the following inclusion criteria: 1) Age of 18-60 years; 2) 48 hours of beginning of clinical manifestation; 3) Volume of the hemorrhage between 20-60 cm3; 4) GCS superior to 4 points. Two groups were constituted. In the group I the patients whom received medical and surgical treatment were included. In the group II were included patients whom received medical treatment only. The inclusion in one of the two groups was subject to the doctor´s criteria in the emergency department, randomization didn’t exist in the process. Results: They were included in the study a total of 147 patients, 54 (36,73 percent) in the Group I and 93 (63,27 percent) in the Group II. The mortality at 6 month of discharge was 29,64 percent in Group I and 35,48 percent in Group II. Conclusions: A discreet but outstanding of the satisfactory results was obtained in the group of operated patients and the mortality was also smaller in this group.

Infecciones relacionadas con la atención sanitaria en Unidad de Terapia Intensiva Pediátrica / Infections related to health care in Pediatric Intensive Care Unit

Introducción: Las infecciones relacionadas con la atención sanitaria son consideradas un gran problema de salud a nivel mundial y son aquellas que aparecen después de 48 horas de estadía hospitalaria. Los pacientes que necesitan cuidados intensivos van a ser los más vulnerables. Método: Se realizó un estudio longitudinal retrospectivo de los pacientes pediátricos que ingresaron por una infección relacionada con la atención sanitaria o que desarrollaron un proceso infeccioso intrahospitalario en la Unidad de Cuidados Intensivos pediátricos, en el periodo de enero del 2011 al 31 de diciembre de 2013. El universo fue de 945 pacientes y la muestra de 70 niños de 1 mes de nacidos a 17 años 11 meses y 29 días.Resultados: En la serie analizada predominó el grupo de edad menor de un año con 37.1 por ciento, el 45.7 por ciento se infectaron dentro de la unidad de cuidados intensivos pediátricos; el 34.3 por ciento ingresó con el diagnóstico de enfermedades respiratorias. Al 74.3 por ciento de los casos se les realizaron abordajes venosos profundos y este fue el sitio de infección más frecuente con 31.4 por ciento; el cultivo de secreciones informó 79 muestras negativas; dentro de los gérmenes predominó la Klebsiella Pneumoniae en 12.6 por ciento; el antibiótico más utilizado fue la ciprofloxacina en 51.4 por ciento y la tasa de infección nosocomial en el servicio fue de 7.4 por ciento.Conclusiones: Las infecciones relacionadas con la atención sanitaria representan un problema para los servicios pediátricos de atención al grave, relacionado principalmente con las características microbiológicas del medio que rodea al paciente y los procedimientos invasivos a que son sometidos por su estado clínico(AU)

Introduction: Health care-related infections are considered a major global health problem and are those that appear after 48 hours of hospital stay. Patients who need intensive care will be the most vulnerable. Method: A retrospective longitudinal study of pediatric patients that were admitted by an infection related to health care or who developed an in-hospital infectious process in the pediatric intensive care unit was carried out, in the period of January 2011 to December 31, 2013. The universe was 945 patients and the sample was 70 children from babies to 17 years old, 11 months and 29 days. Results: In the analyzed series predominated the Group of age less than one year old with 37.1 percent; the 45.7 percent of them were infected within the pediatric intensive care unit; the 34.3 percent was admitted with respiratory diseases. To the 74.3 percent of the cases were performed deep venous approaches and this was the most frequent infection site with 31.4 percent; the secretion cultures reported 79 negative samples;within the germs predominated the Klebsiella Pneumoniae in 12.6 percent; the most commonly used antibiotic was ciprofloxacin in 51.4 percent and the rate of nosocomial infection was 7.4 percent. Conclusions: Healthcare-associated infections represent a problem for attention to the severe pediatric services, mainly related to the microbiological characteristics of the environment that surrounds the patient and invasive procedures to which are subjected by its clinical status(AU)

Cirugía extra temporal para resección del foco en epilepsia parcial intratable de causa no tumoral poco frecuente. Informe de 2 casos / Extra temporal sugery for focal resection in intractable epilepsy of no tumor cause. Two cases report

La epilepsia es una de las enfermedades neurológicas crónicas más comunes, con una prevalencia aproximada entre 0.5 y 1 por ciento, ocasiona una sustancial morbilidad, mortalidad y elevados gastos económicos. El trauma cráneo encefálico es la causa más frecuente de epilepsia sintomática tardía en las edades comprendidas entre 15 y 34 años, representa aproximadamente el 30 por ciento de los casos, sin embargo no se conoce qué proporción de estas se convierten en intratables. Las calcificaciones intracraneales son hallazgos frecuentes en los exámenes imagenológicos en la edad adulta y causa de crisis comiciales, pero igualmente su relación con la intratabilidad médica no está clara. Se presentan dos casos con epilepsia intratable, de origen no tumoral y con causas poco frecuente en el medio, que recibieron tratamiento quirúrgico para resección extra temporal del foco (AU)

Epilepsy is one of the commonest chronic neurological diseases, affects nearly 0,5-1 percent people, causing substantial morbidity, mortality, and economic costs. Head trauma is the most common cause of remote symptomatic epilepsy in the 15–34-year-old age range, making up approximately 30 percent of cases; nevertheless it is not clear what proportions of these patients develop medically intractable epilepsy. Intracranial calcifications are a frequent chance finding in many neuroimaging tests in adults but its relation with intractable epilepsy is unclear. Two cases are showing with intractable epilepsy of traumatic and intracranial calcification origin that were operated on for extra temporal focal resection (AU)

Uso del metilfenidato en pacientes pediátricos con traumatismo craneoencefálico grave / Methylphenidate use in pediatric patients with severe head trauma

Se realizó un estudio descriptivo y retrospectivo de todos los pacientes pediátricos que sufrieron un traumatismo craneoencefálico grave, en el período entre enero de 2003 a enero de 2012, a los que después de controlada la hipertensión endocraneana y las patologías asociadas, entre 15 y 21 días, se les administró metilfenidato para mejorar el estado de vigilia. El universo fue de 20 casos y la muestra de 13. Se comienza con una dosis mínima que se incrementa hasta obtener la respuesta deseada. Predominó el sexo masculino y el grupo de edades entre 6 y 11 años, en 69.2 por ciento los pacientes presentaron una escala de coma de Glasgow de 8 puntos al ingreso, el mayor número no padecían de enfermedades previas al evento (11), y el 76.9 por ciento presentaban sintomatología previa a la administración del medicamento. Dentro de los síntomas más observados con su uso está la ansiedad en 46.2m por ciento, seguido de la hipertensión arterial ligera y la taquicardia. La mejoría del estado de vigilia aparece entre 3 y 7 días de iniciado el tratamiento en 69.23 por ciento de los casos, este se prolonga por 10 a 15 días. Se necesitó una dosis diaria de 2 tabletas para controlar la hipersomnia (AU)

A descriptive and retrospective study of all pediatric patients who were admitted on the pediatric intensive care unit suffering a severe head trauma was carried out from January 2003 to January 2012. After been controlled the intracranial hypertension and associated pathologies between 15 and 21 days, methylphenidate was administered to improve the wakefulness state. The universe was composed by 20 cases and the sample 13. It was begun with a minimum dose that was increased until obtaining the wished answer. Masculine sex predominated and the age group between 6 and 11 years. 62 patients presented a Glasgow Coma Scale of 8 points to the entrance, the greater number did not suffer previous diseases to the event (11) and 76.9 percent of them presented prevoius symptomatology to medicine administration. Within the most observed symptoms with its use it is the anxiety in 46.2 percent, followed by the slight arterial hypertension and the tachycardia. The improvement of the wakefulness state appears between 3 and 7 days starting the treatment in 69.23 percent of cases, this one extends by 10 to 15 days. It was necessary a daily doses of 2 tablets to control the hypersomnia (AU)