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Book
The Glasgow Coma Scale at 40 years: standing the test of time
Since 1974, the Glasgow Coma Scale has provided a practical method for bedside assessment of impairment of conscious level, the clinical hallmark of acute brain injury. The scale was designed to be easy to use in clinical practice in general and specialist units and to replace previous ill-defined and inconsistent methods. 40 years later, the Glasgow Coma Scale has become an integral part of clinical practice and research worldwide. Findings using the scale have shown strong associations with those obtained by use of other early indices of severity and outcome. However, predictive statements should only be made in combination with other variables in a multivariate model. Individual patients are best described by the three components of the coma scale; whereas the derived total coma score should be used to characterise groups. Adherence to this principle and enhancement of the reliable practical use of the scale through continuing education of health professionals, standardisation across different settings, and consensus on methods to address confounders will maintain its role in clinical practice and research in the future.
Journal Article
Dealing with missing standard deviation and mean values in meta-analysis of continuous outcomes: a systematic review
Background
Rigorous, informative meta-analyses rely on availability of appropriate summary statistics or individual participant data. For continuous outcomes, especially those with naturally skewed distributions, summary information on the mean or variability often goes unreported. While full reporting of original trial data is the ideal, we sought to identify methods for handling unreported mean or variability summary statistics in meta-analysis.
Methods
We undertook two systematic literature reviews to identify methodological approaches used to deal with missing mean or variability summary statistics. Five electronic databases were searched, in addition to the Cochrane Colloquium abstract books and the Cochrane Statistics Methods Group mailing list archive. We also conducted cited reference searching and emailed topic experts to identify recent methodological developments. Details recorded included the description of the method, the information required to implement the method, any underlying assumptions and whether the method could be readily applied in standard statistical software. We provided a summary description of the methods identified, illustrating selected methods in example meta-analysis scenarios.
Results
For missing standard deviations (SDs), following screening of 503 articles, fifteen methods were identified in addition to those reported in a previous review. These included Bayesian hierarchical modelling at the meta-analysis level; summary statistic level imputation based on observed SD values from other trials in the meta-analysis; a practical approximation based on the range; and algebraic estimation of the SD based on other summary statistics. Following screening of 1124 articles for methods estimating the mean, one approximate Bayesian computation approach and three papers based on alternative summary statistics were identified. Illustrative meta-analyses showed that when replacing a missing SD the approximation using the range minimised loss of precision and generally performed better than omitting trials. When estimating missing means, a formula using the median, lower quartile and upper quartile performed best in preserving the precision of the meta-analysis findings, although in some scenarios, omitting trials gave superior results.
Conclusions
Methods based on summary statistics (minimum, maximum, lower quartile, upper quartile, median) reported in the literature facilitate more comprehensive inclusion of randomised controlled trials with missing mean or variability summary statistics within meta-analyses.
Journal Article
النقاط الحاكمة : (نقطة. مفصل الورك) : أساسيات تصميم السيارة وتعبئتها
كان تصميم السيارات جزءا من البرامج التعليمية في مركز الفنون حتى العام 1930 ؛ مما حث الخريجين على الانضمام إلى دعم النشاط التصميمي الجديد بشركة جنرال موتورز. وفي عام 1948، عندما انضم ستروثر ماكمين إلى مركز الفنون، تم صياغة البرنامج. وكان التركيز على تخطيط السيارة بالكامل أو الهندسة المعمارية لها، لتكون جزءا مهما من التعليم منذ البداية.صناعة السيارات والنقل في زمن التغيير العميق : اختلط فيه دور المصمم مع العديد من التقنيات، وكذلك التأثير على التسويق والابتكار في مجال الأعمال. وقد صمم هذا الكتاب لمساعدة طلاب مركز الفنون ؛ ليكونوا مصممين ناجحين ومبتكرين، من خلال التعرف الكامل على جميع بنيات سياراتهم وطبقاتها. ونحن على ثقة أن هذا الكتاب سيكون مفيدا أيضا للعديد من المهتمين.
BOOK
Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension
In a trial comparing decompressive craniectomy with medical therapy in patients with traumatic brain injury and raised intracranial pressure refractory to medical therapy, decompressive craniectomy resulted in lower mortality and higher rates of vegetative state and severe disability.
After traumatic brain injury (TBI), intracranial pressure can be elevated owing to a mass effect from intracranial hematomas, contusions, diffuse brain swelling, or hydrocephalus.
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Intracranial hypertension can lead to brain ischemia by reducing the cerebral perfusion pressure.
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Intracranial hypertension after TBI is associated with an increased risk of death in most studies.
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The monitoring of intracranial pressure and the administration of interventions to lower intracranial pressure are routinely used in patients with TBI, despite the lack of level 1 evidence.
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Decompressive craniectomy is a surgical procedure in which a large section of the skull is removed and the underlying . . .
Journal Article
حلول الاستثمار : تعلم إدارة أموالك وحماية مستقبلك المالي
يحتوي هذا الكتاب ثمانية فصول الفصل الأول قرار افعلها بنفسك وأما الفصل الثاني قرار توزيع الأصول والفصل الثالث قرار التنويع والفصل الرابع قرار الاستثمار النشط مقابل الاستثمار الساكن والفصل الخامس قرار إعادة التوازن والفصل السادس مقارنة بماذا والفصل السابع ماذا عن البدائل وأخيرا الفصل الثامن يمكن لأي شخص أن ينجح.
Book
Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial
The balance of risk and benefit from early neurosurgical intervention for conscious patients with superficial lobar intracerebral haemorrhage of 10–100 mL and no intraventricular haemorrhage admitted within 48 h of ictus is unclear. We therefore tested the hypothesis that early surgery compared with initial conservative treatment could improve outcome in these patients.
In this international, parallel-group trial undertaken in 78 centres in 27 countries, we compared early surgical haematoma evacuation within 12 h of randomisation plus medical treatment with initial medical treatment alone (later evacuation was allowed if judged necessary). An automatic telephone and internet-based randomisation service was used to assign patients to surgery and initial conservative treatment in a 1:1 ratio. The trial was not masked. The primary outcome was a prognosis-based dichotomised (favourable or unfavourable) outcome of the 8 point Extended Glasgow Outcome Scale (GOSE) obtained by questionnaires posted to patients at 6 months. Analysis was by intention to treat. This trial is registered, number ISRCTN22153967.
307 of 601 patients were randomly assigned to early surgery and 294 to initial conservative treatment; 298 and 291 were followed up at 6 months, respectively; and 297 and 286 were included in the analysis, respectively. 174 (59%) of 297 patients in the early surgery group had an unfavourable outcome versus 178 (62%) of 286 patients in the initial conservative treatment group (absolute difference 3·7% [95% CI −4·3 to 11·6], odds ratio 0·86 [0·62 to 1·20]; p=0·367).
The STICH II results confirm that early surgery does not increase the rate of death or disability at 6 months and might have a small but clinically relevant survival advantage for patients with spontaneous superficial intracerebral haemorrhage without intraventricular haemorrhage.
UK Medical Research Council.
Journal Article
النقاط الحاكمة : (نقطة. مفصل الورك) : أساسيات تصميم السيارة وتعبئتها
وقد صمم هذا الكتاب لمساعدة طلاب مركز الفنون؛ ليكونوا مصممين ناجحين ومبتكرين، من خلال التعرف الكامل على جميع بنيات سياراتهم وطبقاتها ونحن على ثقة أن هذا الكتاب سيكون مفيدًا أيضًا للعديد من المهتمين وكان تصميم السيارات جزءا من البرامج التعليمية في مركز الفنون حتى العام 1930 مما حث الخريجين على الانضمام إلى دعم النشاط التصميمي الجديد بشركة جنرال موتورز. وفي عام 1948، عندما انضم ستروثر ماكمين إلى مركز الفنون، تم صياغة البرنامج.
BOOK
Hypothermia for Intracranial Hypertension after Traumatic Brain Injury
In this randomized trial involving patients with traumatic brain injury and elevated intracranial pressure, therapeutic hypothermia plus standard care to reduce intracranial pressure did not result in outcomes better than those with standard care alone.
In Europe, traumatic brain injury is the most common cause of permanent disability in people younger than 40 years of age, with the annual cost exceeding €33 billion (approximately $37.5 billion in U.S. dollars).
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Recent statistics show a 21% increase in the incidence of traumatic brain injury during the past 5 years — three times greater than the increase in population. Despite this, management of traumatic brain injury has been underrepresented in medical research as compared with other health problems.
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Consequently, there are few data to support the commonly used stage 2 interventions (Figure 1) for the management of . . .
Journal Article