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BACKGROUND: Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. OBJECTIVE: To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. METHODS: We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. RESULTS: Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. CONCLUSION: Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions. ispartof: Neurosurgery vol:93 issue:2 pages:399-408 ispartof: location:United States status: published

Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a “nihilism guard.” More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.

This study aimed at surveying lower secondary schools in southern Italy, in a highly polluted area. A community close to an industrial area and three villages in rural areas was investigated. Indoor temperature, relative humidity (RH), gaseous pollutants (CO 2 and NO 2 ), selected biological pollutants in indoor dust, and the indoor/outdoor mass concentration and elemental composition of PM 2.5 were ascertained. Temperature and RH were within, or close to, the comfort range, while CO 2 frequently exceeded the threshold of 1000ppm, indicating inadequate air exchange rate. In all the classrooms, median NO 2 levels were above the WHO threshold value. Dermatophagoides p. allergen concentration was below the sensitizing threshold, while high endotoxin levels were detected in the classrooms, suggesting schools may produce significant risks of endotoxin exposure. Concentration and solubility of PM 2.5 elements were used to identify the sources of indoor particles. Indoor concentration of most elements was higher than outdoors. Resuspension was responsible for the indoor increase in soil components. For elements from industrial emission (Cd, Co, Ni, Pb, Sb, Tl, V), the indoor concentration depended on penetration from the outside. For these elements, differences in rural vs industrial concentrations were found, suggesting industrial sources may influence indoor air quality nearby schools.

Background: The British Thoracic Society (BTS) guidelines for community-acquired pneumonia (CAP) suggest a repeat chest radiograph 6 weeks after treatment for patients over the age of 50 to screen for lung malignancy. The benefit of this practice is not well determined. Method: We conducted a retrospective study involving patients from the community over 50 years old with consolidations on chest radiography. These patients presented in Mater Dei Hospital, Gozo General Hospital and Maltese Health Centres during the months of January 2013-2017 and August 2013-2016. The occurrence of follow-up imaging and subsequent diagnosis of lung malignancy was documented. All chest radiographs were reviewed by a radiologist. Results: 402 patients met our inclusion criteria. Follow-up imaging was done in 214 patients (53.2%) within 12 weeks. There was no statistical significance in the follow-up rates when matched for the presenting month, whether radiologists recommended repeat imaging, whether patients were admitted to hospital, and for the patients’ age and gender. The diagnostic yield of lung malignancy was 1.74% (7 patients) within 12 weeks with all malignancies being at an advanced stage at diagnosis (lowest stage being IIIA) when detected. All seven patients had a smoking history. Conclusion: 53.2% of community-acquired pneumonia patients over the age of 50 had follow-up imaging within 12 weeks. No clinical variables explaining this low rate could be identified. This practice results in a low diagnostic yield. Moreover, the diagnosis of lung malignancy is achieved at an advanced stage, making it a poor screening tool., peer-reviewed

Introduction: Seasonal influenza may be associated with a high morbidity and mortality rate. Efforts at promoting effective influenza vaccination in the general population and amongst health-care workers have been of increasing importance over recent years. Aim: To assess use of influenza vaccine amongst doctors and nurses working in the medical wards at Mater Dei Hospital. Method: Data was collected using questionnaires supplied to nurses on the wards and posted online to doctors. Results: A total of 130 questionnaires were completed. Results showed underutilization of the vaccine, with only 34% of respondents taking the vaccine in 2015. 43% of doctors (n=76) and 20% of nurses (n=54) confirmed taking the vaccine. 44% of senior doctors (HST level and above; n=27), were compliant with the vaccination; 43% of the junior doctors (n=49) took the vaccine, of which foundation-year doctors formed the larger portion (FY 55%; BST 19%). In the case of nurses, 25% of the 8 senior nurses took the vaccine, and 19% of the 46 staff nurses were compliant. The commonest reasons for non-compliance to vaccination included doubt about its beneficial effects and fear of side effects. The most effective method for promoting the influenza vaccine included nurses handing out the vaccine on site Conclusion: The influenza vaccination coverage-rate in Malta amongst health-care workers during the 2015-2016 season was estimated to be 33.8%. The audit was limited by its small sample size and selection bias. Improved education about the beneficial effects of the vaccine is recommended in order to improve outcomes., peer-reviewed

Aim of the study was to evaluate the influence of living in highly polluted areas in Malta and in Sicily on reported allergic respiratory diseases in children. Malta has a very high population density while the petrochemical industry located close to Gela is one of the main sources of industrial air pollution in Sicily. In the context of RESPIRA Project, we evaluated 2,047 schoolchildren (972 M), aged 10-15 yrs, selected from 12 junior high schools of Southern Sicily (n=1,189 evaluated subjects) and 6 of Malta (n=858). Children′s parents fulfilled an ISAAC respiratory questionnaire. Rhinitis in the last 12 months was reported by 6.6% in Italy and 7.9% in Malta (p=.05); wheeze in the last 12 months (W12m) by 7.4% in Italy and 12.7% in Malta (p, N/A

RESPIRA Study showed living in Malta (urban), Gela (industrial) is a risk for respiratory symptoms compared to rural south Sicily. Aim: To chemically analyze outdoor PM2.5 in these locations. Method: FAI pumps at 10l/min and Teflon(Whatman) filters collected PM2.5 for 48 hours, Malta(n=54), Gela(n=42) and rural areas (n=42), including schools and homes. The ionic component of ICP-MS extraction was measured at CNR Rome. Aeroqual IQM60 measured PM2.5 levels in Malta. PM2.5 in Sicily was calculated from filter weights. Results: Outdoor PM2.5 Malta(n=53) Mean41.1 µg/m3, Median29.7, Q1-13.9, Q3-57.7, p, N/A

Pollutants in particulate matter (PM) are associated with respiratory disorders. Data on indoor concentration of elemental chemical pollutants in highly polluted areas is scanty. In the context of RESPIRA Project, we evaluated both outdoor and indoor concentrations of air pollutants in the Mediterranean area. Gravimetric samples of PM with aerodynamic diameter, N/A

Introduction: The RESPIRA study (EU Funded-Italia-Malta) was performed in the district of Gela (Southern Sicily) and Malta in 2012/3 in 10-15 years old schoolchildren (n=2,047) by means of standard respiratory questionnaires (ISAAC),and clinical exam of case and control subjects. Aims and Objectives: To measure total serum IgE levels in cases (n=127, males=45) and controls (n=142, Males=64), specific IgEs in cases (n=90, Males=53), and controls (n=82, Males=38). Materials and Methods: Cases reported wheeze and/or use of asthma medications in the last 12 months, while controls answered negatively to both and rhinitis. Results: Total Serum IgE (n=269) was raised (>144 IU/l) in 70/127 cases vs 25/142 controls (p=.0001). In males 30/76 of cases vs 11/64 controls (p=.005), while in females cases 15/51 vs 14/78, (p=.14). Positive specific IgE (>0.34 U/ml) was noted for at least one allergen in 54/90 cases vs 30/82 controls (p=.002). House dust mite (HDM) was positive in 27/90 cases vs 12/82 controls (p=.0001), Parietaria positive 12/90 cases vs 2/82 controls (p=.011), cat 22/90 vs 13/82 controls (p=.19), while in male subgroup 14/53 of cases were positive vs 4/38 controls (p=.06). Dog 9/90 cases vs 8/82 controls (NS). Olive positive in 13/90 cases vs 8/82 controls (NS). Alternaria positive in 6/90 cases vs 2/82 controls (NS). Goldenrod Solidago Virgaurea positive in 2/90 cases vs 1/82 controls, and Cladosporium 0/90 cases, 1/82 controls. Conclusion: Positive Total serum IgE and specific IgE to HDM and Parietaria in all patients and cat in males only were higher in cases than in controls., peer-reviewed

The RESPIRA study (EU-funded Italia-Malta) was performed in the District of Gela (Southern Sicily) and Malta in 2012/3 in 10-15 years children (n=2,047) by questionnaires and clinical exam of cases and controls. Aims: To assess sensitivity to common allergens in these southern Mediterranean islands. Cases (n=137, M=84) reported wheeze and/or use of asthma medications in the last 12 months, while controls (n=159, M=70) answered negatively to both and rhinitis in the last 12 months. A positive SPT (>=3mm) for at least one allergen tested was found in 80/137 cases and 51/159 controls (p=0.0001). House Dust Mite (cases 62/137, controls 28/159, p=0.001), Parietaria (22/137, 10/159, p=0.008), Alternaria (19/137, 9/159, p=0.018), and Blattella (12/137, 5/159, p=0.046) were more frequently positive in cases than in controls. Olive (25/137, 19/159, p=0.142), cat (17/137, 11/159, P=0.116), and dog (9/137, 5/159, p=0.182) did not show a significant difference . Grass pollen sensitization was slightly higher in controls (10/137, 13/159). There was a significant difference by gender in a 2x4 chi2 comparing positive subjects amongst cases and controls. HDM: Males (cases 41/84 Controls 15/70), females (cases 21/53, controls 13/89) p=0.011; Olive: in Males (cases 19/84, controls 10/70) Females (cases 6/53, controls 9/89) p=0.007; Cat: Males (cases.12/84, controls 6/70) Females (cases.5/53 and 5/89) p=0.019; Dog: Males (cases 7/84 and 2/70) and Females (Cases 2 /53 and 4/89) p=0.017. SPT sensitivity to common Mediterranean aero-allergens in asthma patients vs controls was significantly higher in 10-15 year old Males when compared to females., N/A

Background: The Respira Project is an EU funded Italia-Malta project, whose main aim is to monitor air quality and respiratory Health in schools amongst children aged 11-14. Aim: In this preliminary analysis, airborne or gaseous pollutants in 2 classrooms in two different schools were monitored for 48 hours during the scholastic year. Method: An aeroqual IQM60 was used to measure PM 1, PM2.5, PM 10 particulate levels, Ozone, Carbon Dioxide, Carbon monoxide, Nitrogen Dioxide, and Volatile organic compound levels. Levels were monitored every 2 minutes for 48 hours Results: Levels for Ozone, Carbon Monoxide, Volatile organic carbons and nitrogen dioxide, were all well below the maximum recommended levels of indoor air quality in both classes. In school 1, class 1, Carbon dioxide levels rose from baseline 356pp/million, rose to mean of 875pp/million with a peak of 1397 pp/million with students present from 08:00 to 10:00 AM. Similarly PM2.5 and PM10 levels rose from a baseline of 25.1 µg/m3 and 25.5 µg/m3 to a mean of 43.4 and 54.0 µg/m3 with peaks of 58.5 and 76.9 µg/m3 respectively. However mean PM1 dropped from mean 25.3 µg/m3 to mean 12.9 with a nadir of 11.37 µg/m3. School 2, Classroom 2 baselines were CO2 356ppm, PM1 30.5, PM2.5 30.7, PM10 30.0 µg/m3 Classroom values from 9.00 to 11.00 AM with students present were CO2 mean 587, peak 981 ppm, Mean PM 2.5 and PM 10 rose to 43.8 and 55.9, with peaks of 96.8 and 134.7 µg/m3 respectively. PM1dropped from mean of 30.5 µg/m3 dropped to mean 19.75 with a nadir of 11.37 µg/m3. Conclusion: Rreliminary results indicated that the presence of students in the classroom significantly alters airborne particulate matter concentrations., N/A

Rock from the "soll" seams of the Lower Globigerina Limestone Formation is distinguishable from 'franka" because of its characteristic honeycomb weathering. However, when freshly quarried, "soll" limestone, aninferior building material, is not so readily recognizable. This study was aimed at characterizing "soll" on the basis of its inorganic geochemistry. It is shown that "soll" has a significantly higher silicon content than normal "franka". The silica content of "soll', which is a measure of its clay content, is typically less than 5%. Therefore, the traditional belief that "soll" is a limestone which is rich in clay is untenable. The silicon content may be useful in differentiating "soll" limestone from 'franka ". Besides that in silicon, other elemental anomalies are found associated with the "soll" facies of the Lower Globigerina and also with "soll ahdar ", a stratigraphically related grey-green variety., peer-reviewed

Objective: Tonic-clonic activity (TCA) at onset complicates 3% to 21% of cases of subarachnoid hemorrhage (SAH). The impact of onset TCA on in-hospital complications, including seizures, remains unclear. One study associated onset TCA with poor clinical outcome at 6 weeks after SAH, but to our knowledge no other studies have confirmed this relationship. This study aims to assess the impact of onset TCA on in-hospital complications, poor functional outcome, mortality, and epilepsy at 3 months. Methods: Analysis of a prospective study cohort of 1479 SAH patients admitted to Columbia University Medical Center between 1996 and 2012. TCA within 6 hours of hemorrhage onset was identified based on accounts of emergency care providers or family witnesses. Results: TCA at onset was described in 170 patients (11%). Patients with onset TCA were younger (P = 0.002), presented more often with poor clinical grade (55% vs. 26%, P

Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM2.5 and heavy metals, 73 children were investigated by parental questionnaire and skin prick tests. The houses of residence of 41 "cases" and 32 "controls" (children with and without respiratory symptoms, respectively) were evaluated by 48-hours PM2.5 indoor/outdoor monitoring. PM2.5 mass concentration was determined by gravimetry; the extracted and mineralized fractions of elements (As, Cd, Ce, La, Mn, Pb, Sb, Sr, Tl) were evaluated by ICP-MS. PM2.5 and Ce, La, Cd, and Tl indoor concentrations were higher in smoker dwellings. When corrected for confounding factors, PM2.5, Ce, La, Cd, and Tl were associated with more likely presence of respiratory symptoms in adolescents. We found that: i) indoor smoking is associated with increased levels of PM2.5, Ce, La, Cd, and Tl and ii) the latter with increased presence of respiratory symptoms in children