RESUMO
BACKGROUND: Traumatic brain injuries (TBIs) are one of the leading causes of death or long-term disability around the world. As a result of improvements in supportive care, patients are surviving more severe insults with more pronounced dependency on their families, hospitals, and long-term care facilities. The introduction of brain tissue oxygenation (PbtO2) monitoring aims to recognize episodes of reduced cerebral perfusion with and without associated increased intracranial pressure (ICP). AIM: The aim of this review is to determine the impact of PbtO2 on the Glasgow Outcome Scale/Glasgow Outcome Scale Extended (GOS/GOSE) in patients with moderate to severe TBI. DESIGN: Systematic review with narrative and meta-analysis. All original research in which adult patients undergoing PbtO2 were compared with a control group of traditional ICP/cerebral perfusion pressure (CPP) monitoring. Both randomized controlled trials and observational studies were included in this review. METHODS: Databases were searched in September 2022. The primary outcome of the review was the impact of PbtO2 monitoring on GOS/GOSE, while secondary outcomes were mortality and length of stay (LOS) in the intensive care unit (ICU). RESULTS: Seven studies with a combined number of 770 patients were included in the review. These patients were adults ≥16 years of age. Only two of the studies included found a statistically significant association between PbtO2 monitoring and improved long-term neurological outcomes in patients with TBI (p = .01, p < .01). A meta-analysis of the secondary outcomes identified an associated reduction of mortality in favour of the group treated with PbtO2 monitoring (p < .0001). Results from studies examining LOS in ICU have demonstrated an associated increase of LOS in ICU in patients treated with PbtO2-guided therapy. CONCLUSION: From the studies included in this review, only two found a statistically significant association between PbtO2 monitoring and long-term outcomes. It is unclear whether PbtO2 goal-directed therapy has a positive impact on the long-term neurological functions and mortality of patients suffering from TBI. A multicentre randomized controlled trial may provide further evidence, but not necessarily conclusive. RELEVANCE TO CLINICAL PRACTICE: Further research is warranted to determine the efficacy of the introduction of this new monitoring system to guide local policy change.
RESUMO
Three criteria for diagnosing specific language impairment (SLI) are defined in the literature: exclusionary definitions, inclusionary definitions, and qualitative markers. However, the assessment and diagnosis of this complex impairment in clinical practice can be challenging. The aims of this research were twofold: (1) to make explicit the current assessment procedures which speech and language therapists (SLTs) use when they diagnose children with SLI in Ireland, and (2) to explore SLT's perceptions and experiences of the process of diagnosing children with SLI. Both quantitative and qualitative methods were used in this study. A survey of 199 SLTs in Ireland was carried out to address aim one and a focus group was conducted to address the second aim. The findings were that SLTs use exclusionary and inclusionary definitions of SLI, and qualitative markers when assessing children who they suspect may have SLI. SLTs in Ireland consider a diagnosis of SLI when children present with a verbal-performance discrepancy, a positive family history, word finding difficulties and lack of progress in therapy. The results of the qualitative strand indicated that assessment and diagnosis of children with SLI is a complex, time-consuming process involving other professionals. What emerged was a complex picture with tensions between therapists' professional judgements, policy, evidence-based practice and resources.