Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Automated diagnosis of intestinal parasites: A new hybrid approach and its benefits

Intestinal parasites are responsible for several diseases in human beings. In order to eliminate the error-prone visual analysis of optical microscopy slides, we have investigated automated, fast, and low-cost systems for the diagnosis of human intestinal parasites. In this work, we present a hybrid approach that combines the opinion of two decision-making systems with complementary properties: (DS₁) a simpler system based on very fast handcrafted image feature extraction and support vector machine classification and (DS₂) a more complex system based on a deep neural network, Vgg-16, for image feature extraction and classification. DS₁ is much faster than DS₂, but it is less accurate than DS₂. Fortunately, the errors of DS₁ are not the same of DS₂. During training, we use a validation set to learn the probabilities of misclassification by DS₁ on each class based on its confidence values. When DS₁ quickly classifies all images from a microscopy slide, the method selects a number of images with higher chances of misclassification for characterization and reclassification by DS₂. Our hybrid system can improve the overall effectiveness without compromising efficiency, being suitable for the clinical routine - a strategy that might be suitable for other real applications. As demonstrated on large datasets, the proposed system can achieve, on average, 94.9%, 87.8%, and 92.5% of Cohen's Kappa on helminth eggs, helminth larvae, and protozoa cysts, respectively.

Evaluation of TeO2 content on the optical and spectroscopic properties of Yb3+-doped calcium borotellurite glasses

This paper reports the synthesis and the characterization of Yb³⁺-doped calcium borotellurite (CaBTeX) glasses with composition 10CaF₂-(29.5-0.4x)CaO-(60-0.6x)B₂O₃-xTeO₂-0.5Yb₂O₃ (x=10, 16, 22, 31 and 54mol%). The results of XRD confirm the amorphous character of all the samples. The density, molar volume, refractive index and electronic polarizability values show an increase with TeO₂ content. Otherwise, the optical band gap energy shows a decrease with the increase of TeO₂ content. The replacement of CaO and B₂O₃ by TeO₂ changes the glass structure, which decreases the excited Yb³⁺/cm³ and, consequently, the luminescence intensity. The temperature dependence of luminescence was studied for all the samples up to 420K. The fluorescence lifetime does not change significantly due to TeO₂ addition. In addition, absorption and emission cross section were calculated and present high values as compared to other tellurite and phosphate glasses.

Evaluation of the amount of nanoparticles emitted in welding fume from stainless steel using different shielding gases

The primary objective of this study was to correlate the emission of macro and nanoparticles released during the process of metal inert gas/metal active gas (MIG/MAG) of stainless steel with different gas mixtures. Using different gas mixtures with different heat inputs, it was possible to determine fume formation rates and surface areas of nanoparticles with alveolar lung deposition capacity. It was found, how the various transfer modes and the type of gas protection, in particular, the percentage of active elements in the chemical composition of the gas, affect the amount of fumes generated and also the generation of nanoparticles with a high capacity of deposition. The spray transfer mode always shows higher values of nanoparticles surface area, unlike the fume formation rates. Among the tested mixtures 82%Ar + 18%CO₂ generates higher emissions of nanoparticles as well as fume formation rates.

Determination of "safe" and "critical" nanoparticles exposure to welders in a workshop

The present study examined consequences of "safe" versus "critical" exposure to nanoparticles (NP) released during welding operations. With this aim in mind, a set of measurements regarding NP emissions was undertaken in a workshop during welding by metal active gas of carbon steel using different mixtures of argon (Ar) and carbon dioxide (CO₂) as well as different process parameters which might influence emission of (NP). If these measurements were conducted in several locations away from the welding sources, the graphical representation of the obtained observations with time enabled definition of "safe" and "critical" regions within a welding workshop in terms of welder's exposure. This information may be combined with the results of risk analysis derived by control banding and helps to categorize the sites where regulatory measures such as operation containment or dedicated exhaust ventilation need to be implemented.

Characterization of airborne particles generated from metal active gas welding process

This study is focused on the characterization of particles emitted in the metal active gas welding of carbon steel using mixture of Ar + CO2, and intends to analyze which are the main process parameters that influence the emission itself. It was found that the amount of emitted particles (measured by particle number and alveolar deposited surface area) are clearly dependent on the distance to the welding front and also on the main welding parameters, namely the current intensity and heat input in the welding process. The emission of airborne fine particles seems to increase with the current intensity as fume-formation rate does. When comparing the tested gas mixtures, higher emissions are observed for more oxidant mixtures, that is, mixtures with higher CO2 content, which result in higher arc stability. These mixtures originate higher concentrations of fine particles (as measured by number of particles by cm(3) of air) and higher values of alveolar deposited surface area of particles, thus resulting in a more severe worker's exposure.

Emission of nanoparticles during friction stir welding (FSW) of aluminium alloys

Friction stir welding (FSW) is now well established as a welding process capable of joining some different types of metallic materials, as it was (1) found to be a reliable and economical way of producing high quality welds, and (2) considered a "clean" welding process that does not involve fusion of metal, as is the case with other traditional welding processes. The aim of this study was to determine whether the emission of particles during FSW in the nanorange of the most commonly used aluminum (Al) alloys, AA 5083 and AA 6082, originated from the Al alloy itself due to friction of the welding tool against the item that was being welded. Another goal was to measure Al alloys in the alveolar deposited surface area during FSW. Nanoparticles dimensions were predominantly in the 40- and 70-nm range. This study demonstrated that microparticles were also emitted during FSW but due to tool wear. However, the biological relevance and toxic manifestations of these microparticles remain to be determined.

Determination of airborne nanoparticles in elderly care centers

According to numerous studies, airborne nanoparticles have a potential to produce serious adverse human health effects when deposited into the respiratory tract. The most important parts of the lung are the alveolar regions with their enormous surface areas and potential to transfer nanoparticles into the blood stream. These effects may be potentiated in case of the elderly, since this population is more susceptible to air pollutants in general and more to nanoparticles than larger particles. The main goal of this investigation was to determine the exposure of institutionalized elders to nanoparticles using Nanoparticle Surface Area Monitor (NSAM) equipment to calculate the deposited surface area (DSA) of nanoparticles into elderly lungs. In total, 193 institutionalized individuals over 65 yr of age were examined in four elderly care centers (ECC). The occupancy daily pattern was achieved by applying a questionnaire, and it was concluded that these subjects spent most of their time indoors, including the bedroom and living room, the indoor microenvironments with higher prevalence of elderly occupancy. The deposited surface area ranged from 10 to 46 μm(2)/cm(3). The living rooms presented significantly higher levels compared with bedrooms. Comparing PM10 concentrations with nanoparticles deposited surface area in elderly lungs, it is conceivable that living rooms presented the highest concentration of PM10 and were similar to the highest average DSA. The temporal distribution of DSA was also assessed. While data showed a quantitative fluctuation in values in bedrooms, high peaks were detected in living rooms.

Exposure to airborne ultrafine particles from cooking in Portuguese homes

Cooking was found to be a main source of submicrometer and ultrafine aerosols from gas combustion in stoves. Therefore, this study consisted of the determination of the alveolar deposited surface area due to aerosols resulting from common domestic cooking activities (boiling fish, vegetables, or pasta, and frying hamburgers and eggs). The concentration of ultrafine particles during the cooking events significantly increased from a baseline of 42.7 microm2/cm3 (increased to 72.9 microm2/cm3 due to gas burning) to a maximum of 890.3 microm2/cm3 measured during fish boiling in water and a maximum of 4500 microm2/cm3 during meat frying. This clearly shows that a domestic activity such as cooking can lead to exposures as high as those of occupational exposure activities.

IMPLICATIONS

The approach of this study considers the determination of alveolar deposited surface area of aerosols generated from cooking activities, namely, typical Portuguese dishes. This type of measurement has not been done so far, in spite of the recognition that cooking activity is a main source of submicrometer and ultrafine aerosols. The results have shown that the levels of generated aerosols surpass the outdoor concentrations in a major European town, which calls for further determinations, contributing to a better assessment of exposure of individuals to domestic activities such as this one.

Assessment of exposure to airborne ultrafine particles in the urban environment of Lisbon, Portugal

The aim of this study was the assessment of exposure to ultrafine in the urban environment ofLisbon, Portugal, due to automobile traffic, and consisted of the determination of deposited alveolar surface area in an avenue leading to the town center during late spring. This study revealed differentiated patterns for weekdays and weekends, which could be related with the fluxes of automobile traffic. During a typical week, ultrafine particles alveolar deposited surface area varied between 35.0 and 89.2 microm2/cm3, which is comparable with levels reported for other towns such in Germany and the United States. These measurements were also complemented by measuring the electrical mobility diameter (varying from 18.3 to 128.3 nm) and number of particles that showed higher values than those previously reported for Madrid and Brisbane. Also, electron microscopy showed that the collected particles were composed of carbonaceous agglomerates, typical of particles emitted by the exhaustion of diesel vehicles.

A simulation study on the abatement of CO2 emissions by de-absorption with monoethanolamine

Because of the adverse effect of CO2 from fossil fuel combustion on the earth's ecosystems, the most cost-effective method for CO2 capture is an important area of research. The predominant process for CO2 capture currently employed by industry is chemical absorption in amine solutions. A dynamic model for the de-absorption process was developed with monoethanolamine (MEA) solution. Henry's law was used for modelling the vapour phase equilibrium of the CO2, and fugacity ratios calculated by the Peng-Robinson equation of state (EOS) were used for H2O, MEA, N2 and O2. Chemical reactions between CO2 and MEA were included in the model along with the enhancement factor for chemical absorption. Liquid and vapour energy balances were developed to calculate the liquid and vapour temperature, respectively.

Characterisation of non-condensable sulphur containing gases from Kraft pulp mills

This paper describes work performed on the sampling and analysis of non-condensable gases (NCG) emitted from diffuse sources of a Portuguese Kraft pulp mill, which is the background information for a NCG collection, treatment and disposal system. The variability found in the composition of the gaseous compounds showed the existence of gaseous streams other than typical total reduced sulphur (TRS) compounds as usually described. From the measured TRS concentrations and the gas flow rate from each source it was possible to calculate the emission flow rate, E, of each source. These emission flow rates were then divided into three categories which are quite useful to identify significant sources and to choose abatement techniques. The methodology presented allows for a precise quantification of sources so that similar emissions can be grouped for treatment purposes. Sources with an emission flow rate bigger than 1 kg/h have a marked effect on the overall TRS emissions of the mill, as they are major contributors. It was also found that a new analytical procedure using Restek columns is more easy to use and overcomes operational problems noticed previously, namely a run time of 20-25 min instead of 50-60 min.

Assessment of opacimeter calibration according to International Standard Organization 10155

This paper compares the calibration method for opacimeters issued by the International Standard Organization (ISO) 10155 with the manual reference method for determination of dust content in stack gases. ISO 10155 requires at least nine operational measurements, corresponding to three operational measurements per each dust emission range within the stack. The procedure is assessed by comparison with previous calibration methods for opacimeters using only two operational measurements from a set of measurements made at stacks from pulp mills. The results show that even if the international standard for opacimeter calibration requires that the calibration curve is to be obtained using 3 x 3 points, a calibration curve derived using 3 points could be, at times, acceptable in statistical terms, provided that the amplitude of individual measurements is low.

Pollutant atmospheric emissions from Portuguese Kraft pulp mills

This paper describes systematic work done in the field of atmospheric emissions from Portuguese Kraft pulp mills. This study led to the determination of emission factors from stationary sources that proved to be an important tool in assessing the need for investment in air pollution abatement equipment.

Use of computer- and teacher-delivered prompts in discrimination training with individuals who have mental retardation

Individuals with mental retardation received training on a series of 16 visual discrimination problems. Eleven subjects received computer-delivered instruction with a stimulus-fading procedure and 11 were trained with verbal and nonverbal prompts delivered by a human teacher. We found that (a) the teacher's prompts were effective with more subjects than was the computer-based fading procedure; (b) transfer to stimulus control to task stimuli was poor with the teacher's prompts but nearly perfect when fading was effective; and (c) subjects learned more discrimination problems with the computer-delivered fading procedure. These results suggest that the computer could be a useful tool to assist in discrimination training in special-education settings.