Factors associated with an unfavourable outcome in elderly intensive care traumatic brain injury patients. a retrospective multicentre study.

BACKGROUND: Changes in the epidemiology of traumatic brain injury (TBI) in older patients have received attention, but limited data are available on the outcome of these patients after admission to intensive care units (ICUs). The aim of this study was to evaluate the outcomes of patients over 65 years of age who were admitted to an ICU for TBI. METHODS: This was a multicentre, retrospective, observational study conducted from January 2013 to February 2019 in the surgical ICUs of 5 level 1 trauma centres in France. Patients aged ≥ 65 years who were hospitalized in the ICU for TBI with or without extracranial injuries were included. The main objective was to determine the risk factors for unfavourable neurological outcome at 3 months defined as an Extended Glasgow Outcome Scale (GOSE) score < 5. RESULTS: Among the 349 intensive care patients analysed, the GOSE score at 3 months was ≤ 4 and ≥ 5 in 233 (67%) and 116 (33%) patients, respectively. The mortality rate at 3 months was 157/233 (67%), and only 7 patients (2%) fully recovered or had minor symptoms. Withdrawal or withholding of life-sustaining therapies in the ICU was identified in 140 patients (40.1%). Multivariate analysis showed that age (OR 1.09, CI 95% 1.04-1.14), male sex (OR 2.94, CI95% 1.70-5.11), baseline Glasgow Coma Scale score (OR 1.20, CI95% 1.13-1.29), injury severity score (ISS; OR 1.04, CI95% 1.02-1.06) and use of osmotherapy (OR 2.42, CI95% 1.26-4.65) were associated with unfavourable outcomes (AUC = 0.79, CI 95% [0.74-0.84]). According to multivariate analysis, the variables providing the best sensitivity and specificity were age ≥ 77 years, Glasgow Coma Scale score ≤ 9 and ISS ≥ 25 (AUC = 0.79, CI 95% [0.74-0.84]). CONCLUSIONS: Among intensive care patients aged ≥ 65 years suffering from TBI, age (≥ 77 years), male sex, baseline Glasgow coma scale score (≤ 9), ISS (≥ 25) and use of osmotherapy were predictors of unfavourable neurological outcome. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04651803. Registered 03/12/2020. Retrospectively registered.

Discordance of peripheral artery disease diagnosis using exercise transcutaneous oxygen pressure measurement and post-exercise ankle-brachial index.

In patients with exertional limb symptoms and normal ankle-brachial index (ABI) at rest, exercise testing can be used to diagnose lower extremity arterial disease (LEAD). Post-exercise ABI decrease or Exercise transcutaneous oxygen pressure measurement (Exercise-TcPO2) can be used to diagnose LEAD. Objectives were (i) to assess the agreement between both methods (ii) to define the variables associated with the discordance, and (iii) to present results of healthy subjects. In this prospective cross-sectional study, patients with exertional limb symptoms and normal rest ABI were consecutively included. ABI was measured at rest and after standardized exercise protocol as well as Exercise-TcPO2. A kappa coefficient with a 95% confidence interval was used to assess the agreement between the two methods. Logistic regression analysis was performed to outline variables potentially responsible for discordance. Ninety-six patients were included. The agreement between the tests was weak with a k value of 0.23 [0.04-0.41]. Logistic regression analysis found that a medical history of lower extremity arterial stenting (odds ratio 5.85[1.68-20.44]) and age (odds ratio 1.06[1.01-1.11]) were the main cause of discordance. This study suggests that post-exercise ABI and Exercise-TcPO2 cannot be used interchangeably for the diagnosis of LEAD in patients with exertional symptoms and normal rest ABI.

Impact of the complexity of surgical procedures and intraoperative interruptions on neurosurgical team workload.

BACKGROUND: Neurosurgical teams are exposed to various stressors: complexity of surgical procedures, environment, time pressure and interruptions contribute to increasing the perceived workload. OBJECTIVE: This study aimed to evaluate the impact of interruptions and surgical complexity on neurosurgical team workload. METHODS: A prospective observational study was conducted on thirty surgical procedures of graduated complexity recorded in our Department of Neurosurgery. A scale was created and used by neurosurgeons to evaluate the perceived complexity of the surgical procedure. Interruptions and severity of interruptions were noted. The workloads of the neurosurgeon, surgical assistant, scrub nurse and circulating nurse were measured on the Surgery Task Load Index (SURG-TLX) at the end of the procedure. RESULTS: A mean 24.6 interruptions per hour were recorded. The mean interference level of the interruptions was 3.5/7. Mean surgical complexity was 4.3/10. Mean sterile team workload was 43.4/100. The multiple linear regression model showed that sterile team workload increased with surgical complexity (ß=6.692, P=.0002) but decreased in spite of increases in the number of interruptions per hour (ß=-0.855, P=.027). Neurosurgeon and surgical assistant workload increased with surgical complexity (ß=11.53, P<0.0001 and ß=7.42, P=0.0007, respectively). Scrub nurse workload decreased in spite of increases in the number of interruptions per hour (ß=-1.11, P=.026). CONCLUSION: Our study suggests positive effects of some interruptions during elective neurosurgical procedures with strong team familiarity.

[Validation of a questionnaire for standardized-patient assessment of clinical skills]. / Validation d'une grille d'évaluation des compétences cliniques utilisée par des patients standardisés.

BACKGROUND: This study was designed in the context of a new educational program based on standardized-patients (SPs). The study objectives were (1) to evaluate the reliability of the assessment form used by SPs and (2) to compare global ratings to checklists reproducibility. METHOD: History taking, physical examination and communication skills were assessed by SPs at the end of clinical encounters with year 3 medical students, using generic global rating scales and case-specific checklists. The validation process followed four steps: (1) correlation analysis between global rating and their relative checklist of specific items, (2) internal consistency estimation, (3) validation of the questionnaire dimensions, (4) estimation of the reliability of SPs' ratings compared to medical teachers' ratings. RESULTS: A total of 3322 consultations have been performed by 444 year 3 medical students. Statistical analysis showed a good internal reliability (Cronbach α was greater than 0.7) and an acceptable inter-judge reproducibility except for communication skills. Case-specific checklists did not prove to be more reliable than global ratings. Reproducibility was lower with SPs' than with medical teachers' assessment. CONCLUSION: Global rating-based assessment should be preferred to checklists because they are faster and easier to use (shorter duration of SPs training). As SPs proved to be acceptable examiners, no third person seems to be required as external observer.