Associated Risk Factors and Impact in Clinical Outcomes of Multiorgan Failure in Patients with TBI.

BACKGROUND: Individual extracerebral organ dysfunction is common after severe traumatic brain injury (TBI) and impacts outcomes. However, multiorgan failure (MOF) has received less attention in patients with isolated TBI. Our objective was to analyze the risk factors associated with the development of MOF and its impact in clinical outcomes in patients with TBI. METHODS: This was an observational, prospective, multicenter study using data from a nationwide registry that currently includes 52 intensive care units (ICUs) in Spain (RETRAUCI). Isolated significant TBI was defined as Abbreviated Injury Scale (AIS) ≥ 3 in the head area with no AIS ≥ 3 in any other anatomical area. Multiorgan failure was defined using the Sequential-related Organ Failure Assessment as the alteration of two or more organs with a score of ≥ 3. We analyzed the contribution of MOF to crude and adjusted mortality (age and AIS head) by using logistic regression analysis. A multiple logistic regression analysis was performed to analyze the risk factors associated with the development of MOF in patients with isolated TBI. RESULTS: A total of 9790 patients with trauma were admitted to the participating ICUs. Of them, 2964 (30.2%) had AIS head ≥ 3 and no AIS ≥ 3 in any other anatomical area, and these patients constituted the study cohort. Mean age was 54.7 (19.5) years, 76% of patients were men, and ground-level falls were the main mechanism of injury (49.1%). In-hospital mortality was 22.2%. Up to 185 patients with TBI (6.2%) developed MOF during their ICU stay. Crude and adjusted (age and AIS head) mortality was higher in patients who developed MOF (odds ratio 6.28 [95% confidence interval 4.58-8.60] and odds ratio 5.20 [95% confidence interval 3.53-7.45]), respectively. The logistic regression analysis showed that age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring were significantly associated with MOF development. CONCLUSIONS: MOF occurred in 6.2% of patients with TBI admitted to the ICU and was associated with increased mortality. MOF was associated with age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring.

SIMUNEO: Control and Monitoring System for Lung Ultrasound Examination and Treatment of Neonatal Pneumothorax and Thoracic Effusion.

Training with real patients is a critical aspect of the learning and growth of doctors in training. However, this essential step in the educational process for clinicians can potentially compromise patient safety, as they may not be adequately prepared to handle real-life situations independently. Clinical simulators help to solve this problem by providing real-world scenarios in which the physicians can train and gain confidence by safely and repeatedly practicing different techniques. In addition, obtaining objective feedback allows subsequent debriefing by analysing the situation experienced and learning from other people's mistakes. This article presents SIMUNEO, a neonatal simulator in which professionals are able to learn by practicing the management of lung ultrasound and the resolution of pneumothorax and thoracic effusions. The article also discusses in detail the hardware and software, the main components that compose the system, and the communication and implementation of these. The system was validated through both usability questionnaires filled out by neonatology residents as well as through follow-up sessions, improvement, and control of the system with specialists of the department. Results suggest that the environment is easy to use and could be used in clinical practice to improve the learning and training of students as well as the safety of patients.

Role of medical comorbidity in the association between psychiatric disorders and mortality among patients with COVID-19.

We examined whether excess chronic medical comorbidity mediated excess COVID-19 inpatient mortality among people with mental disorders in the early phase of the pandemic, a question with important implications for public health and clinical decision-making. Using records of 2599 COVID-19 hospitalized patients, we conducted a formal causal mediation analysis to estimate the extent to which chronic comorbidity mediates the association between mental disorders and COVID-19 mortality. The Odds Ratio (95% CI) for Natural Indirect Effect and Controlled Direct Effect were 1.07(1.02, 1.14) and 1.40 (1.00, 1.95), respectively, suggesting that a large proportion of excess COVID-19 mortality among people with mental disorders may be explained by factors other than comorbidity.

Screening Protocol and Prevalence of Venous Thromboembolic Disease in Hospitalized Patients With COVID-19.

BACKGROUND: SARS-CoV-2 disease (COVID-19) induces endothelial damage and sustained hypoxia and facilitates immobilization as factors of hypercoagulability. OBJECTIVES: The objective of our study was to assess the prevalence of venous thromboembolic disease (VTD) in COVID-19 patients and the usefulness of VTD screening based on age-adjusted D-dimer and point-of-care ultrasound (POCUS). PATIENTS/METHODS: We conducted a single cohort, prospective observational study in 102 consecutive hospitalized patients. RESULTS: A total of 102 POCUS and 39 pulmonary computed tomography angiography (PCTA) were performed diagnosing 27 VTD (26.5%): 17 deep vein thrombosis (DVT) (16.6% positive POCUS) and 18 pulmonary embolism (PE) (46.2% positive PCTA). COVID-19 patients with VTD were older (P < .030), had higher D-dimer (P < .001), higher International Society on Thrombosis and Hemostasis score (P < .001), and higher mortality (P = .025). However, there were no differences in inflammatory laboratory parameters neither in the cytokine storm syndrome (CSS) development. The ROC curve for D-dimer showed an AUC of 0.91. We have evidenced that patients with D-dimer between 2000 and 6000 ng/mL could benefit from a screening strategy with POCUS given the high sensitivity and specificity of the test. Furthermore, patients with D-dimer ≥6000 ng/mL should undergo POCUS and PCTA to rule out DVT and PE, respectively. CONCLUSIONS: In our cohort, 26.5% of the patients presented VTD. Screening strategy based on age-adjusted D-dimer and POCUS proved high sensitivity and specificity. Future trials focused on screening strategies are necessary to early detect the presence of DVT and PE and determine thromboprophylaxis strategies in patients with COVID-19.

A New Immersive Virtual Reality Station for Cardiopulmonary Resuscitation Objective Structured Clinical Exam Evaluation.

The Objective Structured Clinical Exam (OSCE) is an assessment tool used as a reliable method for clinical competence evaluation of students. This paper presents an investigation focused on the chain of survival, its related exploration, management, and technical skills, and how Virtual Reality (VR) can be used for the creation of immersive environments capable of evaluating students' performance while applying the correct protocols. In particular, the Cardiopulmonary Resuscitation (CPR) procedure is studied as an essential step in the development of the chain of survival. The paper also aims to highlight the limitations of traditional methods using mechanical mannequins and the benefits of the new approaches that involve the students in virtual, immersive, and dynamic environments. Furthermore, an immersive VR station is presented as a new technique for assessing CPR performance through objective data collection and posterior evaluation. A usability test was carried out with 33 clinicians and OSCE evaluators to test the viability of the presented scenario, reproducing conditions of a real examination. Results suggest that the environment is intuitive, quick, and easy to learn and could be used in clinical practice to improve CPR performance and OSCE evaluation.

Critical Care Requirements Under Uncontrolled Transmission of SARS-CoV-2.

Objectives. To estimate the critical care bed capacity that would be required to admit all critical COVID-19 cases in a setting of unchecked SARS-CoV-2 transmission, both with and without elderly-specific protection measures.Methods. Using electronic health records of all 2432 COVID-19 patients hospitalized in a large hospital in Madrid, Spain, between February 28 and April 23, 2020, we estimated the number of critical care beds needed to admit all critical care patients. To mimic a hypothetical intervention that halves SARS-CoV-2 infections among the elderly, we randomly excluded 50% of patients aged 65 years and older.Results. Critical care requirements peaked at 49 beds per 100 000 on April 1-2 weeks after the start of a national lockdown. After randomly excluding 50% of elderly patients, the estimated peak was 39 beds per 100 000.Conclusions. Under unchecked SARS-CoV-2 transmission, peak critical care requirements in Madrid were at least fivefold higher than prepandemic capacity. Under a hypothetical intervention that halves infections among the elderly, critical care peak requirements would have exceeded the prepandemic capacity of most high-income countries.Public Health Implications. Pandemic control strategies that rely exclusively on protecting the elderly are likely to overwhelm health care systems.

Design and Development of a Hemorrhagic Trauma Simulator for Lower Limbs: A Pilot Study.

One of the main preventable leading causes of death after a trauma injury is the hemorrhagic shock. Therefore, it is extremely important to learn how to control hemorrhages. In this paper, a hemorrhagic trauma simulator for lower limb has been developed and a pilot study has been accomplished to trail the simulator. Four different bleeding scenarios have been tested per participant, gathering information about the manual pressure exerted to control the bleeding. Data, altogether, from 54 hemorrhagic scenarios managed by final year medical students and doctors were gathered. Additionally, a post-simulation questionnaire, related to the usability of the simulator, was completed. All the participants managed to control the simulated bleeding scenarios, but the pressure exerted to control the four different scenarios is different depending if the trainee is a student or a doctor, especially in deep venous hemorrhages. This research has highlighted the different approach to bleeding control treatment between medical students and doctors. Moreover, this pilot study demonstrated the need to deliver a more effective trauma treatment teaching for hemorrhagic lesions and that hemorrhagic trauma simulators can be used to train and evaluate different scenarios.

Design and Development of an Interactive Web-Based Simulator for Trauma Training: A Pilot Study.

Trauma is the leading cause of death in people under 45 years old and one of the leading causes of death in the world. Therefore, specific trauma training during medical school as well as after it is crucial. Web-based learning is an important tool in education, offering the possibility to create realistic trauma scenarios. A web-based simulator has been developed and a pilot study has been accomplished to trial the simulator. A pelvic trauma scenario was created and 41 simulations were performed, 28 by medical students and 13 by doctors. The data analyzed are the actions taken to treat the trauma patient, the evolution of the vital signs of the patient, the timing spent on deciding which action to take, when each action was performed and the consequence that it had on the patient. Moreover, a post-simulation questionnaire was completed related to the usability of the simulator. The clinical treatment performance of doctors is better than the performance of medical students performing more actions correctly and in the right sequence as per ATLS recommendations. Moreover, significant differences are obtained in the time response provided to the patients which is key in trauma. With respect to the usability of the tool, responses provide a positive usability rating. In conclusion, this pilot study has demonstrated that the web-based training developed can be used to train and evaluate trauma management. Moreover, this research has highlighted a different approach to trauma treatment between medical students and doctors.

Efficacy and safety of high-dose intravenous iron as the first-choice therapy in outpatients with severe iron deficiency anemia.

BACKGROUND: Asymptomatic severe iron deficiency anemia is a common finding in subjects admitted to the outpatient anemia clinic. Although the condition can be easily be reversed with intravenous iron (IVI) therapy and several guidelines have suggested a restrictive threshold for using transfusion in hemodynamically stable patients, transfusion is often the rule in clinical practice. This study describes clinical practice results of IVI therapy without transfusion. STUDY DESIGN AND METHODS: In this multicenter retrospective observational study, data of severely anemic outpatients treated only with high-dose IVI with ferric carboxymaltose were collected. Inclusion criteria were hemoglobin (Hb) level of less than 7.0 g/dL and ferritin level of less than 30 ng/mL or mean corpuscular volume of less than 75 fL. RESULTS: Overall, 303 patients referred to the anemia clinic mainly from primary health care centers (46.2%) or the emergency department (28.7%) met the inclusion criteria. Median (interquartile range [IQR]) age was 47 (37-62) years and 84.5% were female. The median (IQR) Hb concentration at first visit was 6.5 (6.1-6.8) g/dL, 64 patients (21.1%) presented with a Hb level of less than 6.0 g/dL at diagnosis, and 11 of them (3.6%) had extreme anemia (Hb ≤ 5 g/dL). Gynecologic and gastroenteric bleeding were the main cause. After a mean IV administration of 1500 mg of iron, the Hb increased by a median of 5.7 g/dL. Thirteen patients experienced only mild side effects. CONCLUSIONS: In chronic very severe sideropenic anemias, third-generation IVI is effective and safe for quick correction and avoidance of red blood cell transfusion. These results suggest that more specific guidelines for this clinical setting are warranted.

Results of a Prospective Study to Evaluate the Impact of Point-of-Care Ultrasound in the Enhancement of Gastrointestinal Bleeding Risk Scores.

OBJECTIVES: Gastrointestinal (GI) bleeding is a common illness seen in the emergency department. The prognosis varies from self-limited to potentially life threatening. Currently available GI bleeding risk scores have only a modest predictive value, limiting their wide implementation. The aim of this study was to assess the association and capability of point-of-care ultrasound (POCUS) used by emergency physicians to improve common GI bleeding scores for predicting complications and long-term outcomes of patients with GI bleeding, which to our knowledge have never been studied. METHODS: Between August 2015 and April 2017, 203 hemodynamically stable patients with acute GI bleeding admitted to the emergency department were prospectively investigated. Using ultrasound, we measured the inferior vena cava diameter, cardiac output with surrogate markers such as the velocity time integral before and after the passive leg-raising test, and the presence of systolic obliteration of the left ventricle. The Rockall and Glasgow-Blatchford scores were calculated for patients with upper GI bleeding and the Velayos score for lower GI bleeding. The patients had follow-up during hospitalization and 30 days later to assess for early and late adverse events (AEs). Then we integrated the ultrasound findings of hypovolemia into the GI bleeding scores, assessing the capability to detect AEs. RESULTS: In our cohort, patients with upper GI bleeding who showed left ventricle kissing walls had a worse evolution, with a greater presence of late AEs (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.32-10.96; P = .01). Patients with lower GI bleeding who showed a collapse of the inferior vena cava (>50%) after passive leg raising had a greater presence of early AEs (OR, 3.6; 95% CI, 1.46-9.00; P = .004). The predictive performance of the Rockall score (receiver operating characteristic analysis: area under the curve [AUC], 77.6%; 95% CI, 66.3%-88.8%) increased with POCUS (AUC, 80.3%; 95% CI, 69.5%-91.1%); that of the Glasgow-Blatchford score (AUC, 72.5%; 95% CI, 59.9%-85.2%) increased with POCUS (AUC, 73.2%; 95% CI, 61.1%-85.4%); and that of Velayos score (AUC, 55.7%; 95% CI, 42.5%-69.0%) also increased with POCUS (AUC, 72.2%; 95% CI, 61.1%-83.3%). CONCLUSIONS: The use of POCUS in GI bleeding is feasible and enhances common GI bleeding risk scores, showing better predictive performance in detecting AEs.

IMPACT Score for Traumatic Brain Injury: Validation of the Prognostic Tool in a Spanish Cohort.

BACKGROUND: The aim of this work was to validate the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials in TBI) model in a Spanish cohort of patients with moderate-severe TBI (traumatic brain injury). SETTING: Two level I neurotrauma centers. PARTICIPANTS: Patients admitted to these hospitals between 2011 and 2014 with a diagnosis of TBI and a Glasgow Coma Scale score of 12 or less. DESIGN: Prospective observational study. MAIN MEASURES: We collected prospectively the clinical variables included in the IMPACT models. Outcome evaluation was prospectively done at 6-month follow-up according to the Glasgow Outcome Scale. RESULTS: A total of 290 patients were included in the study. Forty-seven patients (16.2%) died within 6 months post-TBI, and 74 patients (25.5%) had an unfavorable outcome. The Hosmer-Lemeshow test revealed that there was no difference between observed and predicted outcomes; hence, the 3 models displayed adequate calibration for predicting 6-month mortality or unfavorable outcome. The receiver operating characteristic curve indicated that the 3 models (Core, Extended, and Lab) could accurately discriminate between favorable and unfavorable outcomes, as well as between survival and mortality (P < .001). CONCLUSION: The IMPACT model validates prediction of 6-month outcomes in a Spanish population of moderate-severe TBI. IMPACT Lab model is the one that presents a higher discriminative capacity. These results encourage the implementation of the IMPACT model as a prognostic tool in the management of patients with TBI.

Validation of S100B use in a cohort of Spanish patients with mild traumatic brain injury: a multicentre study.

INTRODUCTION: The aim of this study was to validate the S100B protein as a diagnostic tool for ruling out the presence of intracranial lesion (IL) after mild traumatic brain injury (mTBI). Subjects with a Glasgow Coma Scale (GCS) score of 15 and at least one neurological symptom post-trauma were selected from a large Spanish cohort. METHODS: A number of 260 patients with mTBI were enrolled. Blood samples were extracted within 6 h and CT scan performed within 24 h post-injury. Blood samples were also drawn from 18 healthy subjects. RESULTS: CT scan revealed the presence of IL in 22 patients (8.5%). Patients with mTBI had higher S100B serum levels (p = 0.008) than the healthy subjects (p < 0.001). The ROC analysis of S100B discriminated between patients with and without IL (AUC: 0.671; 95%CI: 0.574-0.769; p = 0.008). The multivariate analysis identified male gender (OR: 5.39; 95%CI: 1.45-20.10; p = 0.012), age > 65 (OR: 2.97; 95%CI: 1.04-8.44; p = 0.041) and S100B level >0.10 µg/L (OR: 7.93; 95%CI: 1.03-60.76; p = 0.046) as independent risk factors for IL in patients with mTBI. CONCLUSION: Measurement of S100B within 6 h of mTBI accurately predicts risk of IL in patients with a GCS score of 15 and at least one neurological symptom.

[Causes for consultation in the emergency room among patients with systemic autoimmune diseases]. / Motivos de consulta de pacientes con enfermedades autoinmunes sistémicas en el servicio de urgencias de un hospital terciario.

BACKGROUND: The causes of acute decompensations of patients with systemic autoimmune diseases are not well known. AIM: To describe the causes for consultation in an emergency room of patients with systemic autoimmune diseases. MATERIAL AND METHODS: Review of medical records of patients with systemic autoimmune diseases, aged over 14 years, consulting in an emergency room of a general hospital during three months. RESULTS: In the study period, 166 patients with systemic autoimmune diseases consulted in the emergency room, of a total of 18,153 consultations (0.9%). Patients with rheumatoid arthritis were those that consulted with higher frequency (37%) followed by patients with systemic lupus erythematosus (21%). The most common causes for consultation were cardiovascular diseases in 25%, followed by digestive disorders in 15%. The most common diagnosis was chest pain with suspected ischemic heart disease in 36%. No differences in cardiovascular risk factors were observed between those patients consulting for cardiovascular diseases and those consulting for other causes. CONCLUSIONS: The most common cause of consultation in the emergency room of patients with systemic autoimmune diseases is cardiovascular.

Antithrombotic Use Patterns in COVID-19 Patients from Spain: A Real-World Data Study.

Antithrombotics have been widely used to treat and prevent COVID-19-related thrombosis; however, studies on their use at population levels are limited. We aimed to describe antithrombotic use patterns during the pandemic in Spanish primary care and hospital-admitted patients with COVID-19. Methods: A real-world data study was performed. Data were obtained from BIFAP's electronic health records. We investigated the antithrombotic prescriptions made within ±14 days after diagnosis between March 2020 and February 2022, divided their use into prior and new/naive groups, and reported their post-discharge use. Results: We included 882,540 individuals (53.4% women), of whom 78,499 were hospitalized. The median age was 44.7 (IQR 39-59). Antithrombotics were prescribed in 37,183 (4.6%) primary care subjects and 42,041 (53.6%) hospital-admitted patients, of whom 7505 (20.2%) and 20,300 (48.3%), respectively, were naive users. Prior users were older and had more comorbidities than new users. Enoxaparin was the most prescribed antithrombotic in hospitals, with higher prescription rates in new than prior users (2348.2, IQR 2390-3123.1 vs. 1378, IQR 1162-1751.6 prescriptions per 10,000 cases, p = 0.002). In primary care, acetylsalicylic acid was the most used antithrombotic, with higher use rates in prior than in naïve users. Post-discharge use occurred in 6686 (15.9%) subjects (median use = 10 days, IQR 9-30). Conclusions: Our study identified a consensus on prescribing antithrombotics in COVID-19 patients, but with low use rates in hospitals.

Epidemiology, use, and practice of the intraosseous route in an out-of-hospital emergency department: a retrospective cross-sectional study.

Introduction: The Spanish Emergency Medical Services, according to the model we know today, were formed during the 80s and 90s of the 20th century. The Health Emergency Service (EMS), 061 La Rioja, began to assist the population of La Rioja in November 1999. An essential part of the mission of the SES is the provision of care and the transfer of critical patients using advanced life support unit (ALSU) techniques. In daily practice, out-of-hospital emergency services are faced with situations in which they must deal with the care of serious or critically ill patients, in which the possibility of being able to channel peripheral vascular access as part of ALSU quickly may be difficult or impossible. In these cases, cannulation of intraosseous (IO) vascular access may be the key to early and adequate care. Aim: This study aimed to determine the incidence and epidemiology use of IO vascular access in SES 061 La Rioja during the year 2022. Matherial and methods: We performed observational retrospective cross-sectional studies conducted in 2022. It included a population of 4.364 possible patients as a total of interventions in the community of La Rioja in that year. Results: A total of 0.66% of patients showed a clinical situation that required the establishment of IO vascular access to enable out-of-hospital stabilization; this objective was achieved in 41.3%. A total of 26.1% of patients who presented with cardiorespiratory arrest (CA) were stabilized, while 100% presented with shock and severe trauma. Discussion: IO vascular access provides a suitable route for out-of-hospital stabilization of critically ill patients when peripheral vascular access is difficult or impossible.

Approximation to the economic cost of healthcare for hypertensive patients diagnosed with COVID-19.

Introduction: Many researchers have focused their studies on hypertension due to its over-representation among COVID-19 patients. Both retrospective and observational studies conducted close to the Wuhan area have reported that hypertension is the most common comorbidity observed in patients affected by COVID-19. Objective: Our objective is that patients with arterial hypertension have a worse prognosis in terms of evolution leading to higher costs. Methods: A retrospective cross-sectional study was conducted. A total of 3,581 patients from La Paz University Hospital (LPUH) during the period between 15 July 2020 and 31 July 2020 were included in this study. Results: It should be noted that 40.71% of the patients were hypertensive. As expected, hypertension was associated with men, among whom we observed a higher prevalence and a higher age (median age of 77 years (IQI: 65-85) versus 52 years (IQI: 37-64), p-value < 0.001). Hypertensive patients had a higher prevalence of dyspnea (52.14% vs. 47.15%, p-value = 0.004) and altered awareness (14.89% vs. 4.30%, p-value <0.001). The non-parametric Kaplan-Meier curve estimates the survival of patients in the two study groups. We can see how patients with hypertension have a higher associated mortality, with the difference being statistically significant, p-value (log-rank) = 0.004. Only for the appearance of complications during hospitalization, the group of hypertensive patients reached the figure of €1,355,901.71 compared to the total of 421,403.48 € for normotensive patients. Conclusion: Our study shows the worse clinical evolution of patients with COVID-19 in terms of associated morbidity and mortality. It also shows that the cost of managing patients with hypertension is greater than that of managing normotensive patients.

[Acute massive pulmonary embolism with thrombus entrapped in patent foramen ovale]. / Tromboembolismo pulmonar agudo masivo con trombo atrapado en foramen oval permeable.

Thromboembolic disease is a potentially severe pathology, which can represent a life threat if it is not diagnosed early, especially when the cardiopulmonary backup is limited. When its clinical feature implies a massive occlusion of the arterial pulmonary tree and a cardiac failure is ensued, it can be seriously life threatening, even for young patients. Less frequent features as right or left atrium thrombosis could increase de morbidity and mortality of this disease. We present the case of a young woman with severe respiratory insufficiency. The CT pulmonary angiography revealed an acute massive pulmonary embolism, with a right atrium thrombus extending towards the left atrium, through a patent foramen ovale. We discuss the imaging characteristics and the importance of the precise information obtained with the CT pulmonary angiography, essential in the rapid establishment of a given treatment protocol and an outcome prognosis for the patient.

Modified Needleman-Wunsch algorithm for trauma management performance evaluation.

BACKGROUND: Trauma injuries are one of the leading causes of death in the world, representing approximately 8 % of all deaths. Therefore, trauma management training is of great importance and new training courses have arisen during the last decades. However, actual training courses do not typically analyze compliance with the protocols and guidelines available in the literature. Considering general trauma management guidelines such as the Advanced Trauma Life Support (ATLS) manual and the expertise of trauma specialists, a trauma management automated evaluation system has been designed in this paper. METHODS: A modification to the Needleman-Wunsch (NW) algorithm is developed, including all relevant aspects of trauma management to automatically evaluate how a trauma intervention has been implemented according to trauma protocols. This allows to consider more information with respect to the order of the actions taken and the type of actions performed than current evaluation methods, such as checklists or videos recorded in simulation. A web-based trauma simulator is used so that it can be used at any setting with internet connection. Final-year medical students and first- and second-year residents performed an experimental test, where a trauma score is obtained with the modified NW algorithm. This automatic score relates to how similar the actions are to trauma protocols. RESULTS: The results show the best combination of the scores used for the modified NW variables. This combination has an error, for the different case scenarios created, below 0.07 which verifies the values obtained. Additionally, trauma experts verified the results obtained showing a median difference of 0 between the protocol adherence evaluation using the algorithm and the one provided by the trauma experts. CONCLUSIONS: The best set of score values to apply to the modified NW algorithm show that the modified NW algorithm provides a successful objective measurement with respect to the protocol compliance.

NLRP3 Inflammasome Overactivation in Patients with Aneurysmal Subarachnoid Hemorrhage.

Aneurysmal subarachnoid hemorrhage (aSAH) is an uncommon and severe subtype of stroke leading to the loss of many years of productive life. We analyzed NLRP3 activity as well as key components of the inflammasome cascade in monocytes and plasma from 28 patients with aSAH and 14 normal controls using flow cytometry, western blot, ELISA, and qPCR technologies. Our data reveal that monocytes from patients with aSAH present an overactivation of the NLRP3 inflammasome, which results in the presence of high plasma levels of interleukin (IL)-1ß, IL-18, gasdermin D, and tissue factor. Although further research is needed, we propose that serum tissue factor concentration might be a useful prognosis biomarker for clinical outcome, and for Tako-Tsubo cardiomyopathy and cerebral vasospasm prediction. Remarkably, MCC-950 inhibitor effectively blocks NLRP3 activation in aSAH monocyte culture and supresses tissue factor release to the extracellular space. Finally, our findings suggest that NLRP3 activation could be due to the release of erythrocyte breakdown products to the subarachnoid space during aSAH event. These data define NLRP3 activation in monocytes from aSAH patients, indicating systemic inflammation that results in serum TF upregulation which in turns correlates with aSAH severity and might serve as a prognosis biomarker for aSAH clinical outcome and for cerebral vasospasm and Tako-Tsubo cardiomyopathy prediction.