Prognostication in comatose survivors of cardiac arrest: An advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine.

OBJECTIVES: To review and update the evidence on predictors of poor outcome (death, persistent vegetative state or severe neurological disability) in adult comatose survivors of cardiac arrest, either treated or not treated with controlled temperature, to identify knowledge gaps and to suggest a reliable prognostication strategy. METHODS: GRADE-based systematic review followed by expert consensus achieved using Web-based Delphi methodology, conference calls and face-to-face meetings. Predictors based on clinical examination, electrophysiology, biomarkers and imaging were included. RESULTS AND CONCLUSIONS: Evidence from a total of 73 studies was reviewed. The quality of evidence was low or very low for almost all studies. In patients who are comatose with absent or extensor motor response at ≥72 h from arrest, either treated or not treated with controlled temperature, bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials were identified as the most robust predictors. Early status myoclonus, elevated values of neuron-specific enolase at 48-72 h from arrest, unreactive malignant EEG patterns after rewarming, and presence of diffuse signs of postanoxic injury on either computed tomography or magnetic resonance imaging were identified as useful but less robust predictors. Prolonged observation and repeated assessments should be considered when results of initial assessment are inconclusive. Although no specific combination of predictors is sufficiently supported by available evidence, a multimodal prognostication approach is recommended in all patients.

Regional specificity of MRI contrast parameter changes in normal ageing revealed by voxel-based quantification (VBQ).

Normal ageing is associated with characteristic changes in brain microstructure. Although in vivo neuroimaging captures spatial and temporal patterns of age-related changes of anatomy at the macroscopic scale, our knowledge of the underlying (patho)physiological processes at cellular and molecular levels is still limited. The aim of this study is to explore brain tissue properties in normal ageing using quantitative magnetic resonance imaging (MRI) alongside conventional morphological assessment. Using a whole-brain approach in a cohort of 26 adults, aged 18-85years, we performed voxel-based morphometric (VBM) analysis and voxel-based quantification (VBQ) of diffusion tensor, magnetization transfer (MT), R1, and R2* relaxation parameters. We found age-related reductions in cortical and subcortical grey matter volume paralleled by changes in fractional anisotropy (FA), mean diffusivity (MD), MT and R2*. The latter were regionally specific depending on their differential sensitivity to microscopic tissue properties. VBQ of white matter revealed distinct anatomical patterns of age-related change in microstructure. Widespread and profound reduction in MT contrasted with local FA decreases paralleled by MD increases. R1 reductions and R2* increases were observed to a smaller extent in overlapping occipito-parietal white matter regions. We interpret our findings, based on current biophysical models, as a fingerprint of age-dependent brain atrophy and underlying microstructural changes in myelin, iron deposits and water. The VBQ approach we present allows for systematic unbiased exploration of the interaction between imaging parameters and extends current methods for detection of neurodegenerative processes in the brain. The demonstrated parameter-specific distribution patterns offer insights into age-related brain structure changes in vivo and provide essential baseline data for studying disease against a background of healthy ageing.

Pseudoxanthoma elasticum : evaluation of diagnostic criteria based on molecular data

RÉSUMÉ EN FRANCAIS : Introduction: Le pseudoxanthome élastique (PXE) est une maladie génétique. Les mutations responsables ont été localisées au niveau du gène codant le transporteur transmembranaire ABC-C6. Des calcifications pathologiques des fibres élastiques de la peau, des yeux et du système cardiovasculaire en sont la conséquence. Buts: Evaluer les critères diagnostiques actuels du PXE en se basant sur les données moléculaires. Méthodes: 142 sujets provenant de 10 familles avec une anamnèse familiale positive pour le PXE ont été investiguées sur le plan clinique, histopathologique et génétique. Résultats: 25 sujets se sont avérés être homozygotes pour le gène PXE muté. 23 d'entre eux ont présenté les manifestations cliniques et histopathologique typiques. Les deux autres souffraient d'une élastose et d'une dégénérescence maculaire si importante qu'un diagnostic de PXE ne pouvait pas être confirmé cliniquement. 67 sujets se sont révélés être des porteurs hétérozygotes et 50 ne présentaient pas de mutation. De ces 117 sujets, 116 n'ont montré aucune lésion cutanée ou ophtalmique pouvant correspondre au PXE. Un seul des sujets sans mutation a présenté une importante élastose solaire ainsi qu'une cicatrisation de la rétine, imitant les lésions typiques du PXE. Quatre des 67 sujets hétérozygotes ont eu une biopsie de peau, dont les analyses histopathologique se sont avérées normales. Conclusion: Dans notre cohorte de patients, le PXE était transmis exclusivement de façoh autosomique récessive. La corrélation retrouvée entre le génotype et le phénotype a permis de confirmer les critères diagnostiques majeurs actuels. Le diagnostic clinique peut être difficile, voir impossible, chez des patients atteints d'une élastose solaire importante et/ou d'une dégénérescence maculaire étendue. Dans ces cas, un test moléculaire est nécessaire afin de confirmer le diagnostic de PXE. A notre connaissance, notre étude présentée ici est le premier travail comparant des données cliniques à des données moléculaires dans le domaine du PXE. ABSTRACT : Background: Pseudoxanthoma elasticum (PXE) is a genetic disorder due to mutations in the gene encoding the transmembrane transporter protein adenosine triphosphate binding cassette (ABC)-C6, resulting in calcifications of elastic fibers in the skin, eyes and cardiovascular system. Objectives: To evaluate the diagnostic criteria for PXE based on molecular data. Methods: Of 10 families with a positive history of PXE 142 subjects were investigated for clinical symptoms, histological findings and genetic haplotype analysis. Results: Of these, 25 subjects were haplotypic homozygous for PXE and 23 had typical clinical and histopathological manifestations. Two of the 25 patients showed such marked solar elastosis and macular degeneration that PXE could not be confirmed clinically. Sixty-seven subject were haplotypic heterozygous carriers and 50 haplotypic homozygous unaffected. Of these 117 subjects, 116 showed no cutaneous or ophthalmologic signs of PXE. In one of the 50 haplotypic homozygous unaffected patients important solar elastosis and scaring of the retina mimicked PXE lesions. Only four of the 67 haplotypic heterozygous carriers had biopsies of nonlesional skin; all were histopathologically normal. Conclusions: In our patients, PXE presents as an autosomal recessive genodermatosis. Correlation of haplotype and phenotype confirmed actual major diagnostic criteria. In patients with marked solar elastosis and/ or severe macular degeneration clinical diagnosis can be impossible and molecular testing is needed to confirm the presence of PXE. To the best of our knowledge our large study compares for the first time clinical findings with molecular data.

La pratique basée sur les résultats probants. Partie 1: Origine, définitions, critiques, obstacles, avantages et impact [Evidence-based practice. Part 1: Origins, definitions, critiques, obstacles, advantages and impact].

The increasing popularity of evidence-based practice (EBP) requires that nurses take a stand regarding this type of practice. This positioning rests on knowledge of EBP, however this notion varies by discipline and many definitions exist even within the nursing discipline. An improved understanding of the basic tenets of this type of practice is thus essential. This first, of a series of two articles describes the origin of EBP as well as various definitions, it also presents the major criticisms raised and takes a look at the impact of the increased tendency towards EBP on professional practice.

DEA does not like positive discrimination : a comparison of alternative models based on empirical data

Due to the existence of free software and pedagogical guides, the use of data envelopment analysis (DEA) has been further democratized in recent years. Nowadays, it is quite usual for practitioners and decision makers with no or little knowledge in operational research to run themselves their own efficiency analysis. Within DEA, several alternative models allow for an environment adjustment. Five alternative models, each of them easily accessible to and achievable by practitioners and decision makers, are performed using the empirical case of the 90 primary schools of the State of Geneva, Switzerland. As the State of Geneva practices an upstream positive discrimination policy towards schools, this empirical case is particularly appropriate for an environment adjustment. The alternative of the majority of DEA models deliver divergent results. It is a matter of concern for applied researchers and a matter of confusion for practitioners and decision makers. From a political standpoint, these diverging results could lead to potentially opposite decisions. Grâce à l'existence de logiciels en libre accès et de guides pédagogiques, la méthode data envelopment analysis (DEA) s'est démocratisée ces dernières années. Aujourd'hui, il n'est pas rare que les décideurs avec peu ou pas de connaissances en recherche opérationnelle réalisent eux-mêmes leur propre analyse d'efficience. A l'intérieur de la méthode DEA, plusieurs modèles permettent de tenir compte des conditions plus ou moins favorables de l'environnement. Cinq de ces modèles, facilement accessibles et applicables par les décideurs, sont utilisés pour mesurer l'efficience des 90 écoles primaires du canton de Genève, Suisse. Le canton de Genève pratiquant une politique de discrimination positive envers les écoles défavorisées, ce cas pratique est particulièrement adapté pour un ajustement à l'environnement. La majorité des modèles DEA génèrent des résultats divergents. Ce constat est préoccupant pour les chercheurs appliqués et perturbant pour les décideurs. D'un point de vue politique, ces résultats divergents conduisent à des prises de décision différentes selon le modèle sur lequel elles sont fondées.

Linkage disequilibrium between a melanin-based colour polymorphism and tail length in the barn owl

A linkage disequilibrium between sexually selected and life history traits can be explained by three mutually non-exclusive mechanisms. Genes coding for two traits may be located close on the same chromosome, genes responsible for variation in one of the trait may pleiotropically alter the other, and non-random pairing with respect to two traits may generate a non-physical linkage disequilibrium between their genes. Knowledge of which of these three mechanisms is responsible for a covariation between two traits is of interest to understand why differently ornamented individuals differ in several phenotypic aspects. In Switzerland, barn owls Tyto alba mate randomly with respect to a colour polymorphism generating a large range of variants between reddish-brown and white, males being lighter coloured than females. Several studies have shown that plumage coloration is not neutral with respect to some life history components. To test whether coloration is genetically associated with body size, partial cross-fostering experiments were performed by exchanging some hatchlings between nests. These experiments showed that darker biological fathers produce longer-tailed offspring. This sex-specific pattern is consistent with the hypothesis of non-physical linkage disequilibrium. In line with this hypothesis, darker coloured males were mated with longer-tailed females, whereas female coloration was not associated with tail length of their mate. The finding that dark nestlings had a longer tail than their pale siblings also supports the physical linkage and pleiotropy hypotheses. Therefore, non-random pairing can generate or strengthen a genetic covariation between a secondary sexual character and a morphological trait.

La pratique basée sur les résultats probants. Partie 2: Les étapes du processus [Evidence-based practice: Part 2: Steps in the process].

Evidence-based (EBP) aims for a new distribution of power centered on scientific evidence rather than clinical expertise. The present article describes the operational process of EBP by describing the implementation stages of this type of practise. This stage presentation is essential given that there are many conceptions end models of EBP and that some nurses have a limited knowledge of its rules ans implications. Given that number and formulation of the stages varies by author, the process presented here attempts to integrate the different stages reviewed.