ABSTRACT
Importance: In 2018, the combination of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) levels became the first US Food and Drug Administration-approved blood test to detect intracranial lesions after mild to moderate traumatic brain injury (MTBI). How this blood test compares with validated clinical decision rules remains unknown. Objectives: To compare the performance of GFAP and UCH-L1 levels vs 3 validated clinical decision rules for detecting traumatic intracranial lesions on computed tomography (CT) in patients with MTBI and to evaluate combining biomarkers with clinical decision rules. Design, Setting, and Participants: This prospective cohort study from a level I trauma center enrolled adults with suspected MTBI presenting within 4 hours of injury. The clinical decision rules included the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), and National Emergency X-Radiography Utilization Study II (NEXUS II) criteria. Emergency physicians prospectively completed data forms for each clinical decision rule before the patients' CT scans. Blood samples for measuring GFAP and UCH-L1 levels were drawn, but laboratory personnel were blinded to clinical results. Of 2274 potential patients screened, 697 met eligibility criteria, 320 declined to participate, and 377 were enrolled. Data were collected from March 16, 2010, to March 5, 2014, and analyzed on August 11, 2021. Main Outcomes and Measures: The presence of acute traumatic intracranial lesions on head CT scan (positive CT finding). Results: Among enrolled patients, 349 (93%) had a CT scan performed and were included in the analysis. The mean (SD) age was 40 (16) years; 230 patients (66%) were men, 314 (90%) had a Glasgow Coma Scale score of 15, and 23 (7%) had positive CT findings. For the CCHR, sensitivity was 100% (95% CI, 82%-100%), specificity was 33% (95% CI, 28%-39%), and negative predictive value (NPV) was 100% (95% CI, 96%-100%). For the NOC, sensitivity was 100% (95% CI, 82%-100%), specificity was 16% (95% CI, 12%-20%), and NPV was 100% (95% CI, 91%-100%). For NEXUS II, sensitivity was 83% (95% CI, 60%-94%), specificity was 52% (95% CI, 47%-58%), and NPV was 98% (95% CI, 94%-99%). For GFAP and UCH-L1 levels combined with cutoffs at 67 and 189 pg/mL, respectively, sensitivity was 100% (95% CI, 82%-100%), specificity was 25% (95% CI, 20%-30%), and NPV was 100%; with cutoffs at 30 and 327 pg/mL, respectively, sensitivity was 91% (95% CI, 70%-98%), specificity was 20% (95% CI, 16%-24%), and NPV was 97%. The area under the receiver operating characteristic curve (AUROC) for GFAP alone was 0.83; for GFAP plus NEXUS II, 0.83; for GFAP plus NOC, 0.85; and for GFAP plus CCHR, 0.88. The AUROC for UCH-L1 alone was 0.72; for UCH-L1 plus NEXUS II, 0.77; for UCH-L1 plus NOC, 0.77; and for UCH-L1 plus CCHR, 0.79. The GFAP biomarker alone (without UCH-L1) contributed the most improvement to the clinical decision rules. Conclusions and Relevance: In this cohort study, the CCHR, the NOC, and GFAP plus UCH-L1 biomarkers had equally high sensitivities, and the CCHR had the highest specificity. However, using different cutoff values reduced both sensitivity and specificity of GFAP plus UCH-L1. Use of GFAP significantly improved the performance of the clinical decision rules, independently of UCH-L1. Together, the CCHR and GFAP had the highest diagnostic performance.
Subject(s)
Brain Concussion , Brain Injuries, Traumatic , Adult , Biomarkers , Brain Concussion/diagnosis , Brain Injuries, Traumatic/diagnostic imaging , Canada , Clinical Decision Rules , Cohort Studies , Female , Humans , Male , Prospective Studies , Tomography, X-Ray ComputedABSTRACT
BACKGROUND: Waveform capnography is considered the gold standard for verification of proper endotracheal tube placement, but current guidelines caution that it is unreliable in low-perfusion states such as cardiac arrest. Recent case reports found that long-deceased cadavers can produce capnographic waveforms. The purpose of this study was to determine the predictive value of waveform capnography for endotracheal tube placement verification and detection of misplacement using a cadaveric experimental model. METHODS: We conducted a controlled experiment with two intubated cadavers. Tubes were placed within the trachea, esophagus, and hypopharynx utilizing video laryngoscopy. We recorded observations of capnographic waveforms and quantitative end-tidal carbon dioxide (ETCO2) values during tracheal versus extratracheal (i.e., esophageal and hypopharyngeal) ventilations. RESULTS: 106 and 89 tracheal ventilations delivered to cadavers one and two, respectively (n=195) all produced characteristic alveolar waveforms (positive) with ETCO2 values ranging 2-113mmHg. 42 esophageal ventilations (36 to cadaver one and 6 to cadaver two), and 6 hypopharyngeal ventilations (4 to cadaver one and 2 to cadaver two) all resulted in non-alveolar waveforms (negative) with ETCO2 values of 0mmHg. Esophageal and hypopharyngeal measurements were categorized as extratracheal (n=48). A binary classification test showed no false negatives or false positives, indicating 100% sensitivity (NPV 1.0, 95%CI 0.98-1.00) and 100% specificity (PPV 1.0, 95%CI 0.93-1.00). CONCLUSION: Though current guidelines question the reliability of waveform capnography for verifying endotracheal tube location during low-perfusion states such as cardiac arrest, our findings suggest that it is highly sensitive and specific.
Subject(s)
Capnography/standards , Intubation, Intratracheal , Cadaver , Capnography/methods , Female , Humans , Models, Theoretical , Sensitivity and SpecificityABSTRACT
Introducción: el diagnóstico de corioamnionitis se basa en criterios clínicos que no alcanzan una sensibilidad mayor al 60%, y que tienen poca utilidad para predecir el compromiso fetal. El ultrasonido surge como una alternativa útil en el diagnóstico. Al mejorar el diagnóstico con la búsqueda de marcadores ecográficos de infección fetal podemos impactar en la morbimortalidad perinatal al poder intervenir de forma temprana a las gestantes en riesgo de compromiso fetal, especialmente corioamnionitis con curso subclínico. El objetivo de esta revisión es conocer la evidencia que soporta la asociación entre los hallazgos ecográficos del ultrasonido y la presencia de corioamnionitis e infección fetal in utero. Materiales y métodos: se realizó una revisión de la literatura existente en las bases de datos medline, ovid, ebsco, ProQuest, lilacs, SciELO desde enero de 1985 hasta octubre de 2012. Se incluyeron los artículos de revisión e investigaciones originales.Resultados: en las gestantes con parto pretérmino y ruptura prematura de membranas ovulares el acortamiento cervical, la presencia de "sludge", el oligohidramnios y la involución del timo son los marcadores que han mostrado mayor asociación con infección amniótica.Conclusiones: el ultrasonido es una herramienta por considerar en el diagnóstico de infección materna y fetal in utero.
Introduction: A diagnosis of chorioamnionitis is based on clinical criteria which only manage 60% sensitivity and have little usefulness in predicting fetal compromise. Ultrasound emerges as a useful diagnostic alternative. An impact might be made on perinatal morbimortality by improving diagnosis through the search for echographic markers of fetal infection, thereby enabling early intervention in pregnant women at risk of fetal compromise, especially regarding subclinical chorioamnionitis. This review was aimed at providing evidence supporting an association between ultrasounds echographic findings and the presence of chorioamnionitis in in utero (congenital) fetal infection.Materials and methods: A review of the existing literature was made in medline, ovid, ebsco, ProQuest, lilacs and scielo databases from January 1985 to October 2012. Original research and review articles were included. Results: Cervical length shortening, the presence of sludge, oligohydramnios and thymus involution are the markers which have been shown to have the greatest association with intra-amniotic infection.Conclusions: Ultrasound is a tool to be considered when diagnosing in utero maternal and fetal infection.
Subject(s)
Female , Pregnancy , Cervix Uteri , Chorioamnionitis , Fetal Heart , Oligohydramnios , Prenatal Diagnosis , Respiration , Thymus Gland , Ultrasonography , Ultrasonography, DopplerABSTRACT
Objetivo: realizar el reporte de una serie de casos evaluados a través de ecografía convencional y Examen Tridimensional Extendido (3DXI), y realizar una revisión de la literatura respecto a las imágenes más frecuentes de la ecografía de 2 y 3D, y métodos diagnósticos complementarios. Materiales y métodos: se presenta el reporte de tres casos evaluados en la Unidad de Medicina Materno-Fetal de la Clínica Colsubsidio Orquídeas, centro de referencia de nivel III que atiende población embarazada de alto riesgo obstétrico perteneciente al régimen contributivo. Ninguno de los casos se asoció con hallazgo de malformaciones y su evolución fue favorable. Se realizó una revisión de la literatura con base en las palabras clave: colelitiasis fetal, vesícula biliar fetal, barro biliar fetal y diagnóstico prenatal, en las bases de datos Pubmed, Ebsco, Ovid, Proquest desde el año 1980 al 2011. Se incluyeron artículos de revisión, reporte de casos, estudios de validez diagnóstica o estudios de corte transversal publicados durante el mismo periodo. Resultados: se encontraron 41 artículos de los cuales se incluyeron 25 correspondientes a: series de casos (9), revisiones (9), estudios de exactitud diagnóstica (7). El diagnóstico de colelitiasis se hace durante el final del segundo o inicio del tercer trimestre de gestación en el examen de vigilancia y crecimiento fetal, y requiere que sea corroborado posnatalmente. No se han documentado complicaciones asociadas a este diagnóstico en vida posnatal. Generalmente tiene buena evolución prenatal y posnatal, sin secuelas en el futuro y con resolución espontánea. Solo un estudio refiere la resonancia nuclear magnética como una opción posnatal. Los métodos tipo resonancia magnética dinámica (DMR) y 3DXI no fueron referidos en la literatura. Conclusión: la colelitiasis fetal es un hallazgo incidental aunque el diagnóstico generalmente se realiza con ecografía 2D; el examen tridimensional extendido podría ser una nueva herramienta diagnóstica para tener en cuenta como alternativa complementaria en el diagnóstico prenatal.
Objective: Reporting a series of cases which were evaluated by conventional echography and 3D eXtended imaging (3DXI) and reviewing the pertinent literature regarding the most frequent 2D and 3D ultrasound images and complementary diagnostic methods. Materials and methods: Three cases are reported which were evaluated in the Maternal-Fetal Medicine Unit at the Clínica Colsubsidio Orquídeas (a reference centre) which attends a high obstetric risk pregnant population from the contributory health insurance system. None of the cases were associated with findings of malformations and they all had favorable evolution. A literature review was made of Pubmed, Ebsco, Ovid and Proquest data-bases from 1980 to 2011 based on the following key words: fetal cholelithiasis, fetal biliary gallbladder, fetal biliary mud, prenatal diagnosis; review articles, case reports, diagnostic validity/accuracy studies or cross-sectional studies published during the same period were included. Results: 25 of the 41 articles found were included: 9 case series, 9 reviews and 7 diagnostic accuracy studies. Cholelithiasis was usually diagnosed during the end of the second or third trimester of pregnancy during fetal growth and welfare ultrasound exam. Diagnosis must be postnatally corroborated. Complications associated with a diagnosis of cholelithiasis during postnatal life have not been documented. Cases usually have good prenatal and postnatal evolution without future sequelae and usually have spontaneous resolution. Only one study referred to nuclear magnetic resonance as being a postnatal option. DMR and 3DXI-type methods were not referred to in the literature. Conclusion: Fetal cholelithiasis is an incidental finding; even though diagnosis is usually made by 2D echography, 3D eXtended imaging could provide a new diagnostic tool as a complementary alternative in prenatal diagnosis.
Subject(s)
Adult , Female , Pregnancy , Cholelithiasis , Gallbladder , Prenatal DiagnosisABSTRACT
Material educativo e informativo para estudiantes a nivel secundaria, donde se presenta un amplio panorama sobre la salud ambiental, dando a conocer datos sobre la contaminación en sus diferentes tipos y algunas medidas para preservar el medio ambiente, así como sugerencias para trabajos en grupo, excursiones, visitas de campo y a instituciones ligadas al quehacer ecológico. El documento está dividido por cuatro unidades: 1. Contaminación producida por desechos materiales 2. Contaminación atmosférica 3. Alteraciones del equilibrio ecológico por la deforestación 4. Consumismo y medio ambiente 5. Apéndices
