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To explore the possibility of identifying skull fracture, with or without clinical signs, as a predictor of positive CT scans in mild traumatic brain injury (mTBI).Prospective cohort study, matched 1:1 for five potential confounding variables (age, sex, symptoms, mechanism of injury and extracranial trauma severity).The study was performed on patients with mTBI (Glasgow Coma Scale 15-14), with or without radiologically demonstrated skull fracture. The cohort with skull fracture included 155 patients selected from a sample of 5097 mTBI patients treated during 1998 at the Critical Care and Emergency Department of the Trauma Centre. The cohort without skull fracture was prospectively recruited from patients with mTBI treated in the same department from 2002-2005.The percentage of patients with intracranial lesion (IL) was significantly higher in mTBI patients with skull fracture than in those without. The risk of requiring neurosurgery was 5-fold higher when skull fracture was present. Of mTBI patients with skull fracture and IL, 63.2% showed no clinical signs of bone injury.Skull fracture, with or without clinical signs, in mTBI patients is associated with an increased risk of neurosurgically-relevant intracranial lesion.

Objectives: To determine the attributable mortality and excess length of stay (LOS) associated with the use of inadequate empirical antimicrobial therapy in patients with sepsis at admission to the intensive care unit (ICU). Methods: A retrospective matched cohort study was performed using a prospectively collected database at a 40 bed general ICU at a university public hospital. Patients who received inadequate antimicrobial therapy at admission to the ICU (exposed) were matched with controls (unexposed) on the basis of origin of sepsis, inflammatory response at admission, surgical or medical status, hospital- or community-acquired sepsis, APACHE II score (+ +2 points) and age (+ +10 years). Clinical outcome was assessed by in-hospital mortality, and this analysis was also performed in those pairs without nosocomial infection in the ICU. Results: Eighty-seven pairs were successfully matched. Fifty-nine exposed patients died [67.8% mortality (95% CI, 58.0‐77.6%)] and 25 unexposed controls died [28.7% mortality (95% CI, 19.2‐ 38.2%)] (P < 0.001). Excess in-hospital mortality was estimated to be 39.1%. The rate of nosocomial infection was significantly higher in patients with inadequate empirical therapy (16.1%) than in those treated empirically with adequate antibiotics (3.4%) (P 5 0.013). Excess in-hospital mortality was 31.4% after excluding those 17 pairs that developed a nosocomial infection in the ICU. Inadequate antimicrobial therapy was associated with a significant increment in duration of hospitalization (15 days in surviving pairs). Conclusions: Inadequate antimicrobial therapy at admission to the ICU with sepsis is associated with excess mortality and increases LOS.

Objective To analyse the repair of lesions of articular cartilage with periosteum-free implants and follow-up at 6 months. Design Thirty-six New Zealand rabbits, 4–6 weeks old, were used. Full-thickness articular cartilage defects in the medial femoral condyle were created. Spontaneous evolution occurred in 18 animals; the other 18 animals were treated with a free autogenous periosteal tibial implant fixed with Tissucol ® . Animals were killed in groups of six at 8, 12 and 24 weeks. Macroscopic, histologic and histochemical results were evaluated and analysed statistically using the Mann-Whitney U-test. Results The spontaneous evolution of the lesion did not lead to complete repair in any case. The periosteum-free implant provided complete repair of the lesion and statistically significant restoration of the articular surface. Conclusions In the rabbit, this study confirms the incomplete spontaneous repair of articular cartilage and the chondrogenic potential of tibial periosteum-free implants, with long-term maintenance of the macroscopic, histologic and histochemical characteristics of neo-cartilage. This raises the possibility of its use as an alternative method in the repair of circumscribed osteochondral lesions in young patients.

Echinocandins are the treatment of choice for patients with severe forms of candidaemia, including neutropenic patients and those episodes presenting with shock. There is little distinction between the three available echinocandins (caspofungin, anidulafungin and micafungin), but there is more clinical experience with caspofungin. Identifying patients who will benefit from early antifungal therapy using clinical tools such as the 'Candida Score' is an interesting strategy that may reduce the high mortality in critically ill patients with invasive fungal infections.

Introduccion. Los cambios que fisiologicamente tienen lugar en la circulacion cerebral durante la gestacion y el puerperio se conocen todavia poco. El Doppler transcraneal (DTC), por su inocuidad, es un metodo de estudio adecuado. Objetivo. Conocer la velocimetria DTC al final de la gestacion y en el puerperio precoz de gestantes sanas. Sujetos y metodos. Mediante DTC se estudiaron bilateralmente las arterias cerebrales anterior (ACA), media (ACM) y posterior (ACP). Ademas, se midieron la presion arterial y el hematocrito. En el analisis estadistico se utilizaron las variables velocidad media (VM), indice de pulsatilidad (IP), presion arterial media y hematocrito. Se compararon los resultados de 44 gestantes normotensas al final de la gestacion (semana 33 a termino) con los de un grupo control de 58 mujeres de similar edad, no gestantes y normotensas. A las gestantes se les repitio el estudio en el puerperio precoz (cinco primeros dias posparto), y se compararon los resultados en ambos tiempos. Resultados. La edad y la PAM fueron similares en los grupos gestante y no gestante. El hematocrito fue significativamente mas bajo en las primeras (p < 0,001). Las VM fueron significativamente mas bajas en las gestantes en todas las arterias (p < 0,001), mientras que los IP tambien fueron significativamente mas bajos en cuatro de los seis territorios estudiados (p < 0,005). En el puerperio se observo un aumento significativo de las VM en todas las arterias (p < 0,001) y de los IP en tres de ellas (p < 0,05). En esta fase aumento la presion arterial media (p < 0,05), mientras disminuyo el hematocrito (p < 0,001). Conclusiones. Las VM e IP bajos que se observan al final de la gestacion son compatibles con una vasodilatacion cerebral. En el puerperio precoz se incrementan las VM, probablemente en relacion con una relativa hiperperfusion.

Objetivos. Conocer los valores normales de Doppler transcraneal (DTC) en puerperas normotensas (PNT) en nuestro medio. Evaluar la influencia de diferentes variables sobre el flujo sanguineo cerebral. Pacientes y metodos. Se realizaron 100 estudios DTC en PNT, y se sonorizaron seis arterias intracraneales. Se recogieron diversas variables como presion arterial, hematocrito y datos clinicos referidos al embarazo y parto. Se realizo un analisis descriptivo en el caso de las variables cualitativas, y las variables cuantitativas se expresaron como media mas desviacion estandar (DE). Se compararon las velocidades medias (VM) de cada arteria segun la lateralidad hemisferica, y su relacion con las cifras tensionales, el hematocrito y el resto de las variables. Resultados. Las VM expresadas como media y DE fueron: ACM derecha 73,10±14,33; ACM izquierda 75,68±15,84; ACA derecha 57,61±12,92; ACA izquierda 60,14±14,35; ACP derecha 42,77± 9,28; ACP izquierda 45,54±9,58. Se comprobo un aumento de VM en las arterias de lateralidad izquierda con respecto a las de lateralidad derecha, estadisticamente significativo. Ninguna de las variables del estudio influyo en los valores de flujo sanguineo cerebral. Conclusion. Los valores de VM fueron mas altos en el hemisferio izquierdo. Resulta util conocer valores de referencia puerperales en mujeres asintomaticas para poder identificar alteraciones hemodinamicas cerebrales propias de estados patologicos, como eclampsia tardia y angiopatia cerebral posparto