REDACS: Regional emergency-driven adaptive cluster sampling for effective COVID-19 management.

As COVID-19 is spreading, national agencies need to monitor and track several metrics. Since we do not have perfect testing programs on the hand, one needs to develop an advanced sampling strategies for prevalence study, control and management. Here we introduce REDACS: Regional emergency-driven adaptive cluster sampling for effective COVID-19 management and control and justify its usage for COVID-19. We show its advantages over classical massive individual testing sampling plans. We also point out how regional and spatial heterogeneity underlines proper sampling. Fundamental importance of adaptive control parameters from emergency health stations and medical frontline is outlined. Since the Northern hemisphere entered Autumn and Winter season (this paper was originally submitted in November 2020), practical illustration from spatial heterogeneity of Chile (Southern hemisphere, which already experienced COVID-19 winter outbreak peak) is underlying the importance of proper regional heterogeneity of sampling plan. We explain the regional heterogeneity by microbiological backgrounds and link it to behavior of Lyapunov exponents. We also discuss screening by antigen tests from the perspective of "on the fly" biomarker validation, i.e., during the screening.

Protocolised thromboelastometric-guided haemostatic management in patients with traumatic brain injury: a pilot study.

Coagulopathy in patients with traumatic brain injury is associated with an increase in morbidity and mortality. Although timely and aggressive treatment of coagulopathy is of paramount importance, excessive transfusion of blood products has been linked with poor long-term outcomes in patients with traumatic brain injury. A point-of-care thromboelastometric-guided algorithm could assist in creating a more individually tailored approach to each patient. The aim of this study was to evaluate the feasibility of implementing a thromboelastometric-guided algorithm in centres that were formerly naïve to thromboelastometry. Hence, we developed such an algorithm and provided training to four centres across Europe to direct the haemostatic management of patients with severe traumatic brain injury. The primary outcome was adherence to the algorithm and timing of the availability of relevant results. Thirty-two patients were included in the study. Complete adherence to the algorithm was observed in 20 out of 32 cases. The availability of thromboelastometric results after hospital admission was reported significantly earlier than conventional coagulation tests (median (IQR [range]) 33 (20-40 [14-250]) min vs. 71 (51-101 [32-290]) min; p = 0.037). Although only 5 out of 32 patients had abnormalities of conventional coagulation tests, 21 out of 32 patients had a coagulopathic baseline thromboelastometric trace. Implementing a thromboelastometric-guided algorithm for the haemostatic therapy of traumatic brain injury is feasible in centres formerly naïve to this technology and may lead to more rapid and precise coagulation management. Further large-scale studies are warranted to confirm the results of this pilot trial and evaluate clinical outcomes.

Care gap: a comprehensive measure to quantify unmet needs in mental health.

AIM: Treatment gap refers to the percentage of individuals who require treatment in a country or a defined community but do not receive it due to various reasons. There is widespread acceptance of 'treatment gap' as a measure of unmet needs in mental health. However, the term 'treatment' carries a medical connotation and implies biomedical treatment (or lack of it) of mental illness and is often interpreted by policymakers, planners and researchers, as well as by non-professional stakeholders as exclusively referring to curative clinical psychiatric interventions. This common interpretation results in the exclusion of a range of effective psychosocial interventions available today. Treatment gap also does not include physical health services for persons with mental illness, a major concern due to the relative frequent yet highly unattended physical comorbidity and early mortality of persons with severe mental illness. METHODS & RESULTS: We, therefore, propose a more comprehensive measure of unmet needs.

Point prevalence study of antimicrobial usage in acute care hospitals in the Slovak Republic.

BACKGROUND: Antimicrobial use and resultant resistance is still increasing worldwide. Close monitoring and strict implementation of policies are important to tackle this issue. AIM: To assess the use of antimicrobials in acute care hospitals in the Slovak Republic. METHODS: Antimicrobial use was monitored as part of a point prevalence survey (PPS) of healthcare-associated infections. Surveillance was performed in 40 hospitals in the Slovak Republic according to the standardized methodology developed by the European Centre for Disease Prevention and Control. Data were collected according to a standard protocol. FINDINGS: In total, 8397 patients in 40 Slovak hospitals were surveyed. Of these, 30.7% were receiving antibiotics at the time of the survey. In 630 cases, patients were receiving more than one antimicrobial agent. The prevalence of antimicrobial use was highest in intensive care units (54.3%). Antimicrobials were prescribed most frequently for treatment of community-acquired infections (48.1%) and healthcare-associated infections (11.4%). Surgical prophylaxis was the indication for 22.2% of all prescribed antimicrobials, and exceeded 24h in 81.5% of cases. The antimicrobials used most often were fluoroquinolones (20.9%), especially for non-surgical prophylaxis (26.8%) and treatment (21.9%). The antimicrobials prescribed most frequently for surgical prophylaxis were first-generation cephalosporins (23.0%), fluoroquinolones (14.7%) and second-generation cephalosporins (11.4%). The use of antimicrobials was higher in patients with invasive medical devices. CONCLUSION: This study found excessive use of broad-spectrum antibiotics, prolonged surgical prophylaxis, frequent use of parenteral antibiotics and inadequate documentation of the indication for prescription. These findings present opportunities for improving the management of antimicrobials in Slovak hospitals.

The impact of body mass index on severity, patterns and outcomes after traumatic brain injuries caused by low level falls.

PURPOSE: Low level falls are a common cause of traumatic brain injuries (TBI) and are associated with significant mortality and disability. The aim of this study was to analyse whether BMI, height and weight of patients were related to severity, patterns and outcomes of TBI caused by low level falls. METHODS: Data on patients with TBI where cause of injury was a low level fall (fall < 3 m) with known body mass index (BMI) (N = 683) were analysed. Patients were categorized into underweight, normal, pre-obese and obese based on BMI and demographic characteristics, injury severity, patterns and outcomes were compared. In addition, physiological status, comorbidities and length of hospitalization were analysed in a subset of patients where this information was available. RESULTS: The median BMI was 25.6. About 1/10 of patients were obese. The mean age and proportion of male sex of patients was increasing with increasing BMI. The patients in all BMI groups were of similar injury severity and neurological status. There was also no difference in mortality and functional outcome based on patient's BMI. Obese and pre-obese patients required longer stay at ICU and in hospital. CONCLUSION: We found no associations between BMI and severity or outcome of TBI caused by low level falls. More detailed data and further studies are needed to fully elucidate these complex relationships.

Timing and duration of intracranial hypertension versus outcomes after severe traumatic brain injury.

BACKGROUND: The goal of this paper was to investigate the association between patterns of intracranial hypertension (IH) and outcomes, to describe the treatment of patients with different patterns of IH, and to examine whether IH is an independent predictor of mortality and unfavourable outcome, respectively. METHODS: A retrospective analysis of data collected prospectively in 9 central European centers is presented. 204 patients with severe TBI who had intracranial pressure (ICP) monitoring were coded as having either early (within first 2 days), late (after first 2 days), or no IH. IH was defined as >60 min of ICP >20 mmHg/day. The total number of hours/day of IH was recorded. Treatment was followed closely for the first 10 days using the therapy intensity level (TIL) score. Associations between types of IH and demographic factors, trauma severity, or treatment factors as well as outcomes were analysed. RESULTS: Patients in the early IH group were the most severely injured. They had the highest TIL levels, had the highest mortality (48%) and the highest rate of unfavourable outcome (65%) followed by the late IH group (20% and 57%) and the no IH group (23% and 36%). Duration of IH correlated significantly with hospital mortality. IH was an independent predictor of mortality and unfavourable outcome after adjusting for age, Glasgow Coma Scale score, and Abbreviated Injury Score "head". CONCLUSION: Intracranial hypertension with early onset is independently associated with significantly worse outcome in patients with severe TBI. The total duration of IH shows a significant correlation to mortality.

Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury.

OBJECTIVE: To analyse the association between the Glasgow Coma Scale (GCS) score at intensive care unit (ICU) discharge and the 1-year outcome of patients with severe traumatic brain injury (TBI). DESIGN: Retrospective analysis of prospectively collected observational data. PATIENTS: Between 01/2001 and 12/2005, 13 European centres enrolled 1,172 patients with severe TBI. Data on accident, treatment and outcomes were collected. According to the GCS score at ICU discharge, survivors were classified into four groups: GCS scores 3-6, 7-9, 10-12 and 13-15. Using the Glasgow Outcome Scale (GOS), 1-year outcomes were classified as "favourable" (scores 5, 4) or "unfavourable" (scores <4). Factors that may have contributed to outcomes were compared between groups and for favourable versus unfavourable outcomes within each group. MAIN RESULTS: Of the 538 patients analysed, 308 (57 %) had GCS scores 13-15, 101 (19 %) had scores 10-12, 46 (9 %) had scores 7-9 and 83 (15 %) had scores 3-6 at ICU discharge. Factors significantly associated with these GCS scores included age, severity of trauma, neurological status (GCS, pupils) at admission and patency of the basal cisterns on the first computed tomography (CT) scan. Favourable outcome was achieved in 74 % of all patients; the rates were significantly different between GCS groups (93, 83, 37 and 10 %, respectively). Within each of the GCS groups, significant differences regarding age and trauma severity were found between patients with favourable versus unfavourable outcomes; neurological status at admission and CT findings were not relevant. CONCLUSION: The GCS score at ICU discharge is a good predictor of 1-year outcome. Patients with a GCS score <10 at ICU discharge have a poor chance of favourable outcome.

One-year outcome and course of recovery after severe traumatic brain injury.

GOAL: To describe the outcome of patients with severe traumatic brain injury (TBI) 3, 6 and 12 months after trauma. METHODS: Between January 2001 and December 2005, 13 European centres enrolled 1,172 patients with severe TBI defined as Glasgow Coma Scale (GCS) score < 9. Demographic data, trauma severity, results of computed tomography (CT) scans, data on status, treatment and outcome were recorded. The five-level Glasgow Outcome Scale (GOS) score was used to classify patients as having a "favourable" (GOS scores 5 and 4) or an "unfavourable outcome" (GOS scores 3, 2 and 1). RESULTS AND CONCLUSIONS: Of the 1,172 patients, 37% died in the intensive care unit (ICU) and 8.5% died after ICU discharge. At 12 months after trauma, almost half of the outcomes (46.6%) were classified as "favourable" (33% "good recovery", 13.6% "moderate disability") and 7.9% were classified as "unfavourable" (6.1% "severe disability", 1.8% "vegetative status"). As in previous studies, long-term outcomes were influenced by age, severity of trauma, first GCS score, pupillary status and CT findings (e.g. subdural haematoma and closed basal cistern on the first CT scan). Patients with "good recovery" had a high likelihood to remain in that category (91%). Patients with "moderate disability" had a 50% chance to improve to "good recovery". Patients with "severe disability" had a 40% chance to improve and had a 4% chance of death. Patients with "vegetative status" were more likely to die (42%) than to improve (31%). Changes were more likely to occur during the first than during the second half-year after trauma.

Evaluation of traumatic brain injury guidelines using AGREE instrument.

BACKGROUND: This study aims to assess the quality of four selected traumatic brain injuries management guidelines used mainly in the US and in Europe. METHODS: The instrument Appraisal of Guidelines Research & Evaluation was selected to provide a framework for guidelines appraisal. Four guidelines addressing a specific topic related to the treatment of traumatic brain injury were selected for evaluation: three developed in the United States of America and one from the United Kingdom. A trauma surgeon, one anaesthesiologist, one emergency physician and a public health specialist evaluated the guidelines. RESULTS: In the overall assessment of all guidelines, the United Kingdom guidelines attracted the best score, achieving the highest score of all four guidelines in five of six domains. The scientific quality of collected evidence was excellent and well documented in all four guidelines. Overall, the domains of Stakeholder involvement and Applicability were the lowest scoring for all the guidelines. CONCLUSION: A Broad spectrum of stakeholders should be represented in the brain trauma management guidelines development. The potential organizational and financial barriers for the application of guidelines need to be considered during their development. The paper provides suggestions for those who develop new guidelines for the management of patients with head injuries (Tab. 8, Ref. 29). Full Text (Free, PDF) www.bmj.sk.

Stakeholder approach in strengthening the patients' rights in the Slovak Republic.

OBJECTIVES: The described project aimed to promote patients' rights in the Slovak Republic that are stipulated by law but in practice not observed fully. BACKGROUND: The project was based on a bi-lateral agreement between The Netherlands and the Slovak Republic in the framework of European Union pre-accession program and implemented in the period from January 2002 to June 2003. METHODS: Successful Dutch models of patients' rights promotion were used. They were applied under Slovak conditions and focused on the areas in the greatest need of attention, such as information campaigning and public awareness of patients' rights issues. The initiation of a cooperation of various stakeholders active in healthcare and national patients' right forums was among the most positive aspects of the project. RESULTS: The information campaign was constructed in order to educate citizens about their entitlements and rights within healthcare. Healthcare professionals were trained on respecting the rights of their clients. Pilots were started in several hospitals and in Healthy City projects, and patients' rights modules were made available at educational centers and various private and health organizations. Some of the cooperating healthcare professionals expressed their fear that the public might misuse the gained advocacy skills. This idea has originated from the current situation in Slovak healthcare, where inadequate financing, education, and management is a barrier in the physician's ability to serve the patient's best interest. CONCLUSIONS: The implemented project started wide public discussion on patients' rights and stimulated a cooperation of a large number of stakeholders in the promotion of patients' rights (Tab. 2, Ref. 13). Full Text (Free, PDF) www.bmj.sk.