Aims and objectives
To determine the views of nurses and physicians working in intensive care units (ICU) about the aims of glycaemic control and use of their protocols.
Background
Evidence about the ...optimal aims and methods for glycaemic control in ICU is controversial, and current local protocols guiding practice differ between ICUs, both nationally and internationally. The views of professionals on glycaemic control can influence their practice.
Design
Cross‐sectional, multicentre, survey‐based study.
Methods
An online short survey was sent to all physicians and nurses of seven ICUs, including questions on effective glycaemic control, treatment of hypoglycaemia and deviations from protocols’ instructions. STROBE reporting guidelines were followed.
Results
Over half of the 40 respondents opined that a patient spending <75% admission time within the target glycaemic levels constituted poor glycaemic control. Professionals with more than 5 years of experience were more likely to rate a patient spending 50%–74% admission time within target glycaemic levels as poor than less experienced colleagues. Physicians were more likely to rate a patient spending <50% admission time within target as poor than nurses. There was general agreement on how professionals would rate most deviations from their protocols. Nurses were more likely to rate insulin infusions restarted late and incorrect dosage of rescue glucose as major deviations than physicians. Most professionals agreed on when they would treat hypoglycaemia.
Conclusions
When surveyed on various aspects of glycaemic control, ICU nurses and physicians often agreed, although there were certain areas of disagreement, in which their profession and level of experience seemed to play a role.
Relevance to clinical practice
Differing views on glycaemic control amongst professionals may affect their practice and, thus, could lead to health inequalities. Clinical leads and the multidisciplinary ICU team should assess and, if necessary, address these differing opinions.
Rationale, aims, and objectives
The practice of glycaemic control of critically ill patients admitted to intensive care units (ICUs) is guided by clinical management protocols, designed locally by ...the ICUs. These protocols differ significantly in their aims and methods. The aim of this study was to develop a standardized methodology for the systematic and objective analysis and comparison of protocols for glycaemic control implemented in any ICU.
Method
The protocols for glycaemic control implemented in seven ICUs of a UK‐based ICU network were analysed using techniques of inductive content analysis, through an open coding process and the framework method. This involved the identification and classification of protocol instructions for glycaemic control, as well as of the processes and decisions pertaining to each of these instructions. These were used to develop a framework for the structured and systematic description and comparison of the protocols' contents, and to develop a technique for the protocols' graphic visualization.
Results
The following elements were identified or developed: (1) 35 quantifiable variables and 11 non‐quantifiable subjects that could be present in an ICU protocol for glycaemic control, to be used as a framework for the description and comparison of contents; (2) a technique for condensing a protocol into a single, comprehensive flowchart; (3) using these flowcharts, a method for assessing the complexity and comprehensiveness of the protocols.
Conclusions
The methodology developed in this study will allow for any future work analysing the contents of glycaemic control protocols to be carried out in a structured and standardized way. This may be done either as a standalone study, or as the essential first step in any investigation on the impact of new protocols. In turn, the methodology will facilitate the performance of regional, national, and international comparisons, demonstrating the usefulness of this study at a global scale.
ObjectivesTo determine current epidemiology and clinical characteristics of cerebrospinal fluid (CSF) shunt surgery, including revisions.MethodsA retrospective, multicentre, registry-based study was ...conducted based on 10 years’ data from the UK Shunt Registry, including primary and revision shunting procedures reported between 2004 and 2013. Incidence rates of primary shunts, descriptive statistics and shunt revision rates were calculated stratified by age group, geographical region and year of operation.Results41 036 procedures in 26 545 patients were submitted during the study period, including 3002 infants, 4389 children and 18 668 adults. Procedures included 20 947 (51.0%) primary shunt insertions in 20 947 patients, and 20 089 (49.0%) revision procedures. Incidence rates of primary shunt insertions for infants, children and adults were 39.5, 2.4 and 3.5 shunts per 100 000 person-years, respectively. These varied by geographical subregion and year of operation. The most common underlying diagnoses were perinatal intraventricular haemorrhage (35.3%) and malformations (33.9%) in infants, tumours (40.5%) and malformations (16.3%) in children, and tumours (24.6%), post-haemorrhagic hydrocephalus (16.2%) and idiopathic normal pressure hydrocephalus (14.2%) in adults. Ninety-day revision rates were 21.9%, 18.6% and 12.8% among infants, children and adults, respectively, while first-year revision rates were 31.0%, 25.2% and 17.4%. The main reasons for revision were underdrainage and infection, but overdrainage and mechanical failure continue to pose problems.ConclusionsOur report informs patients, carers, clinicians, providers and commissioners of healthcare, researchers and industry of the current epidemiology of shunting for CSF disorders, including the potential risks of complications and frequency of revision.
ABSTRACT Introduction and objectives: This study primary endpoint was to present the in-hospital all-cause mortality of the Spanish TAVI registry from its inception until 2018. Secondary endpoints ...included other in-hospital clinical events, 30-day all-cause mortality, and an assessment of the time trend of this registry. Methods: All consecutive patients included in the Spanish TAVI registry were analyzed. In this time-based analysis, the population was been divided into patients treated before 2014 (cohort A: 2009-2013) and patients treated between 2014 and 2018 (cohort B). Results: From August 2007 to June 2018, 7180 patients were included. The mean age was 81.2 ± 6.5 years and 53% were women. The logistic EuroSCORE was 12% (8-20). Transfemoral access was used in 89%. In-hospital and 30-day all-cause mortality was 4.7% and 5.7%, respectively. On the time-based analyses during the hospital stay, the rate of myocardial infarction, stroke, need for pacemakers, tamponade, coronary obstruction, and vascular complications was similar between both groups. However, cohort B showed less need for conversion to surgery and malapposition of the valve. Also, the implant success rate increased from 93% to 96% (P< .001). In-hospital and 30-day all-cause mortality was significantly lower in cohort B, (OR, 0.65; IC95%, 0.48-0.86; P= .003 and OR, 0.71; IC95%, 0.54-0.92; P= .002, respectively). Conclusions: The time trend analysis of the Spanish TAVI registry showed a change in the patients’ clinical profile and an improvement in the in-hospital clinical outcomes and 30-day all-cause mortality in patients treated more recently.
Background
Vestibular schwannoma (VS) is the most common benign tumour arising in the lateral skull base. Reported incidence rates of VS vary across geographical locations and over time. There is ...scarce updated evidence over the past decade on the epidemiology and mode of presentation of VS.
Objective
To describe the epidemiology and mode of presentation of VS in the East of England between 2013 and 2016.
Methods
A retrospective epidemiological analysis of data from a national VS registry and electronic patient records was conducted, including all newly diagnosed adult patients in a UK tertiary referral centre, between April 1st, 2013, and March 31st, 2016.
Results
There were 391 new cases identified resulting in an overall mean incidence of 2.2 VS cases per 100,000 person-year. The incidence rate for all patients in the <40 age group ranged between 0.3 and 0.7 per 100,000 person-year, increasing to a range of 5.7 to 6.1 per 100,000 person-year in the 60–69 age group. The top three combinations of symptoms on presentation per patient were hearing loss and tinnitus (97, 24.8%), hearing loss alone (79, 20.2%) and hearing loss, tinnitus, and balance symptoms (61, 15.6%). The median duration of symptoms was 12 months, with a wide range from 1.4 to 300 months. Age was negatively correlated with tumour size (r = -0.14 -0.24 to -0.04,
p
=0.01) and positively correlated with symptom duration (r = 0.16 0.03–0.29,
p
=0.02).
Conclusions
The incidence of vestibular schwannoma has increased compared to previous studies in the UK and is similar to incidence rates reported in other countries during the past decade. It peaks in the seventh decade of life, mainly because of an increase in the diagnosis of small tumours with a long duration of audio-vestibular symptoms in older patients, compared to earlier studies.
Background The epidemiology of traumatic brain injury (TBI) is unclear – it is estimated to affect 27–69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries ...(LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment. Objective The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research. Design Multi-centre, international, registry-based, prospective cohort study. Subjects Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence. Methods All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol. Data Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.
Las guías de práctica clínica no mencionan, específicamente, la reparación valvular en pacientes con insuficiencia aórtica y válvula aórtica bicúspide como alternativa al implante protésico. La ...reparación en bicúspides puede exigir técnicas complejas como la utilización de pericardio. Pretendemos analizar la evolución a largo plazo de la reparación en bicúspides y tricúspides.
Análisis prospectivo no-randomizado de 138 pacientes con reparación valvular aórtica (2011-2019). Dos grupos: bicúspides 55 (40%) y tricúspides 83 (60%).
Presentaban: grupo bicúspide: edad media 51,1 ± 13,8 años, 12 (21,8%) mujeres; EuroSCORE Logístico 6,7 ± 4; insuficiencia preoperatoria: I-II (25,4%), III-IV (74,6%). Grupo tricúspide: edad media 62,7 ± 12,6 años, 21 (25,3%) mujeres; 8 (9,6%) emergentes; EuroSCORE-Logístico 10,9 ± 8,1; insuficiencia preoperatoria: I-II (13,2%), III-IV (86,8%). Procedimientos realizados: bicúspides: reimplante valvular (DAVID) 24 (43,6%); remodelado aórtico (Yacoub) 18 (32,7%); tubo supracoronario + plastia aórtica 4 (7,3%); plastia aórtica 9 (16,4%); tricúspides: DAVID 54 (65,1%); Yacoub 4 (4,8%); tubo supracoronario + plastia aórtica 11 (13,3%); plastia aórtica 14 (16,9%). Procedimientos en velos: 56,6% (tricúspides) y 97,3% (bicúspides) p < 0,0001.
Hubo conversión a prótesis intraoperatoria: 15 (18,1%) tricúspides y 1 (1,8%) bicúspides. Fallecieron 8 (5,8%) pacientes en el postoperatorio inmediato (3,9% de electivos).
La mediana de seguimiento fue 42,5 meses. El gradiente pico (mmHg) en seguimiento: bicúspides 16,3 ± 5,4 vs. tricúspides 8,3 ± 1,4 (p < 0,0001).
A nueve años están libres de insuficiencia aórtica ≥ III: 83,5%(serie-entera); 90,4% (tricúspides) vs. 73,9% (bicúspides), p = 0,07; 100% (tricúspides sin plastia pericardio) vs. 70,5% (tricúspides con plastia pericardio), p = 0,001; 92,9% (bicuspides sin plastia pericardio) vs. 57,7% (bicúspides con plastia pericardio), p = 0,009. Libres de reoperación: 88,4% (serie entera); 94,2% (tricúspides) vs. 80,1% (bicúspides), p = 0,086; 100% (tricúspides sin plastia pericardio) vs. 82,1% (tricúspides con plastia pericardio), p = 0,01; 100% (bicúspides sin plastia pericardio) vs. 62,7%(bicúspides con plastia pericardio), p = 0,007.
La válvula bicúspide precisa reparaciones complejas, pero menor conversión a prótesis intraoperatoria; la reparación en bicúspides ofrece resultados no inferiores a tricúspides, con buena durabilidad y hemodinámica; la utilización de pericardio, más frecuente en bicúspides, reduce la durabilidad.
The clinical practice guidelines do not specifically mention valve repair in patients with aortic regurgitation and bicuspid aortic valve as an alternative to prosthesis implantation. Bicuspid repair may require complex techniques such as the use of pericardium. We intend to analyze the long-term evolution of bicuspid and tricuspid repair.
prospective, non-randomized, analysis of 138 patients with aortic valve repair (2011-2019). Two groups: bicuspid valve 55 (40%) and tricuspid valve 83 (60%).
Bicuspid-group: mean age 51.1 ± 13.8 years, 12 (21.8%) women; EuroSCORE-Logistic 6.7 ± 4; preoperative-regurgitation: I-II (25.4%), III-IV (74.6%). Tricuspid-group: mean age 62.7 ± 12.6 years, 21 (25.3%) women; 8 (9.6%) emerging; EuroSCORE-Logistic 10.9 ± 8.1; preoperative-regurgitation: I-II (13.2%), III-IV (86.8%). Procedures performed: bicuspid-group: valve-reimplantation (DAVID) 24 (43.6%); aortic-remodeling (Yacoub) 18 (32.7%); supracoronary-tube + aortic-plasty-4 (7.3%); aortic-plasty 9 (16.4%). Tricuspid-group: DAVID 54 (65.1%); Yacoub 4 (4.8%); supracoronary-tube + aortic-plasty 11 (13.3%); aortic-plasty 14 (16.9%). Leaflet procedures: 56.6% (tricuspid-group) and 97.3% (bicuspid-group) p < 0.0001.
There was conversion to intraoperative prosthesis: 15 (18.1%) tricuspid-group and 1(1.8%) bicuspid-group. Eight (5.8%) patients died in the immediate postoperative period (3.9% of electives).
The median follow-up was 42.5 months. The peak gradient (mmHg) in follow-up: bicuspid-group 16.3 ± 5.4 vs. tricuspid-goup 8.3 ± 1.4 (p < 0.0001).
At 9 years, they are free of aortic regurgitation ≥ III: 83.5% (whole-series); 90.4% (tricuspid-group) vs. 73.9% (bicuspid-group), p = 0.07; 100% (tricuspid-group-without-pericardium-plasty) vs. 70.5% (tricuspid-group-with-pericardium-plasty), p = 0.001; 92.9%(bicuspid-group-without-pericardium-plasty) vs. 57.7% (bicuspid-group-with-pericardium-plasty), p = 0.009. Free of re-operation: 88.4% (whole-series), 94.2% (tricuspid-group) vs. 80.1% (bicuspid-group), p = 0.086; 100%(tricuspid-group-without-pericardium-plasty) vs. 82.1% (tricuspid-group-with-pericardium-plasty), p = 0.01; 100% (bicuspid-group-without-pericardium-plasty) vs. 62.7% (bicuspid-group-with-pericardium-plasty), p = 0.007.
The bicuspid valve requires complex repairs, but less conversion to an intraoperative prosthesis; bicuspid repair offers results not inferior to tricuspid repair, with good durability and hemodynamics; the use of pericardium, more frequent in bicuspid valves, reduces durability.
La miocardiopatía hipertrófica obstructiva es una enfermedad infrecuente, el tratamiento quirúrgico con miectomía septal en grandes centros mejora la clínica y la supervivencia. La miectomía septal ...y, en ocasiones, el reemplazo valvular mitral son las técnicas fundamentales.
Análisis retrospectivo de 30 pacientes con miocardiopatía hipertrófica obstructiva operados en nuestro centro (2007-2017).
El grupo presentaba: edad (media) 67,3±12 años; el 56,7% mujeres; EuroSCORE-LOGÍSTICO 6,3±4,4; septo interventricular 24,9±2,9mm; movimiento sistólico anterior moderado-severo (43,4%); insuficiencia mitral grado iii (46,7%) y iv (33,3%); enfermedad mitral (calcificación, displasia, prolapso) en 17 (56,7%). Procedimientos: miectomía septal (100%); bypass coronario 8 (26,7%), prótesis aórtica 8 (26,7%). El 26,7% (8) recibió reemplazo valvular mitral por enfermedad valvular y persistencia de insuficiencia mitral. Este grupo tenía insuficiencia mitral más severa y peor grado funcional de forma significativa. Hubo una (3,3%) muerte (hemorragia pulmonar) y 2 (6,7%) reoperados por sangrado. El seguimiento medio fue 43,7±36,3 (mediana 30) meses (máximo 116). El grado funcional pasó de: iv (43,3%) y iii (56,7%) precirugía a ii (24,1%) y i (75,9%) poscirugía (p<0,0001). El gradiente intraventricular descendió de 106,1±27,5mmHg (mediana 104,5) a 11,9±7,2mmHg (mediana 10) (p<0,0001). A 10 años la supervivencia es del 93,1%; del 87,5% si recibieron prótesis mitral y del 95,2% sin prótesis mitral (p=0,49).
La degeneración valvular mitral obliga con frecuencia a implante protésico mitral, pero con prótesis mitral o sin ella la cirugía en miocardiopatía hipertrófica obstructiva ofrece buena supervivencia y mejoría clínica a largo plazo.
Obstructive hypertrophic myocardiopathy is an uncommon disease. Surgical treatment with septal myectomy in experienced centres improves clinical outcomes and survival. Septal myectomy and, occasionally, mitral valve replacement are the fundamental techniques.
A retrospective analysis carried out on 30 patients with obstructive hypertrophic myocardiopathy operated in our centre (2007-2017).
The group variables were: age (mean) 67.3±12 years; 56.7% women; mean EuroSCORE-Logistic 6.3±4.4; interventricular septum 24.9±2.9mm; moderate-severe septal anterior movement (43.4%); mitral regurgitation grade III (46.7%) and IV (33.3%); mitral disease (calcification, dysplasia, prolapse) in 17 (56.7%). The procedures performed were: septal myectomy (100%); coronary bypass in 8 (26.7%), and aortic valve replacement in 8 (26.7%). The 26.7% (8) that received mitral valve replacement was due to valvular disease and persistence of mitral regurgitation. This group had more severe mitral regurgitation and a significantly worse functional grade. There was one (3.3%) death due to pulmonary haemorrhage, and 2 (6.7%) patients were re-operated due to bleeding. The mean follow-up was 43.7±36.3 (median 30) months (maximum 116). The functional grade went from: IV (43.3%) and III (56.7%) pre-surgery to II (24.1%) and I (75.9%) post-surgery (P<.0001). The intraventricular gradient decreased from 106.1±27.5mmHg (median 104.5) to 11.9±7.2mmHg (median 10) (P<.0001). At 10 years, survival was 93.1%. It was 87.5% if they received a MVR and 95.2% without MVR (P=.49).
Mitral valve degeneration often requires an implant, but with or without an mitral valve replacement, surgery in obstructive hypertrophic myocardiopathy offers good survival and long-term clinical improvement.
Introduction and objectives: This study primary endpoint was to present the in-hospital all-cause mortality of the Spanish TAVI registry from its inception until 2018. Secondary endpoints included ...other in-hospital clinical events, 30-day all-cause mortality, and an assessment of the time trend of this registry.
Methods: All consecutive patients included in the Spanish TAVI registry were analyzed. In this time-based analysis, the population was been divided into patients treated before 2014 (cohort A: 2009-2013) and patients treated between 2014 and 2018 (cohort B).
Results: From August 2007 to June 2018, 7180 patients were included. The mean age was 81.2 ± 6.5 years and 53% were women. The logistic EuroSCORE was 12% (8-20). Transfemoral access was used in 89%. In-hospital and 30-day all-cause mortality was 4.7% and 5.7%, respectively. On the time-based analyses during the hospital stay, the rate of myocardial infarction, stroke, need for pacemakers, tamponade, coronary obstruction, and vascular complications was similar between both groups. However, cohort B showed less need for conversion to surgery and malapposition of the valve. Also, the implant success rate increased from 93% to 96% (P < .001). In-hospital and 30-day all-cause mortality was significantly lower in cohort B, (OR, 0.65; IC95%, 0.48-0.86; P = .003 and OR, 0.71; IC95%, 0.54-0.92; P = .002, respectively).
Conclusions: The time trend analysis of the Spanish TAVI registry showed a change in the patients’ clinical profile and an improvement in the in-hospital clinical outcomes and 30-day all-cause mortality in patients treated more recently.
Introducción y objetivos: El objetivo primario de este estudio fue presentar la mortalidad total intrahospitalaria del registro español de implante percutáneo de válvula aórtica (TAVI) desde su inicio hasta el año 2018, y como objetivos secundarios otros eventos clínicos intrahospitalarios, la mortalidad total a los 30 días y la evaluación de cuál ha sido la evolución temporal de este registro.
Métodos: Fueron analizados todos los pacientes consecutivos incluidos en el registro español de TAVI. En este análisis temporal se dividió la población en pacientes tratados antes de 2014 (cohorte A: 2009-2013) y pacientes tratados entre los años 2014 y 2018 (cohorte B).
Resultados: Desde agosto de 2007 hasta junio de 2018 se incluyeron 7.180 pacientes. La edad media fue de 81,2 ± 6,5 años y el 53% eran mujeres. El EuroSCORE logístico fue del 12% (8-20). Se utilizó un acceso transfemoral en el 89%. La mortalidad total intrahospitalaria fue del 4,7% y a los 30 días fue del 5,7%. En el análisis temporal durante la fase hospitalaria, las tasas de infarto, accidente cerebrovascular, necesidad de marcapasos, taponamiento, obstrucción coronaria y complicaciones vasculares fueron similares en ambos grupos. Sin embargo, en la cohorte B se observó una reducción de la necesidad de conversión a cirugía y de mala posición de la válvula, y además la tasa de éxito del implante fue mayor (93 frente a 96%; p < 0,001). La mortalidad por cualquier causa ajustada tanto intrahospitalaria como a los 30 días, fue significativamente menor en la cohorte B (odds ratio OR = 0,65; intervalo de confianza del 95% IC95%, 0,48-0,86; p = 0,003; y OR = 0,71; IC95%, 0,54-0,92; p = 0,002, respectivamente).
Conclusiones: En el análisis temporal del registro español de TAVI se observan un cambio en el perfil clínico de los pacientes y una mejora en la evolución clínica tanto intrahospitalaria como a los 30 días en los pacientes tratados en los últimos años.
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