Medical Bulletin 14/October/2023

New Guideline Updates Brain Death Determination for Adults and Children

In a significant development, the American Academy of Neurology (AAN) has released an updated guideline that redefines the criteria for determining brain death or death by neurologic criteria (BD/DNC). This comprehensive guideline is designed to encompass both adults and children, clarifying the process of BD/DNC determination in a single framework.

The primary objective of this guideline is to provide a much-needed revision to the 2010 AAN BD/DNC guideline for adults and the 2011 guideline for infants and children, issued by the American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine. The revised guideline incorporates the latest advancements and medical practices, including the evaluation of BD/DNC in cases involving extracorporeal membrane oxygenation, targeted temperature management, and primary infratentorial injury.

The expert panel behind this guideline comprises members from various medical societies, and they relied on a unique evidence-informed consensus process due to the lack of high-quality evidence in this area. The panel used their extensive knowledge of BD/DNC literature to formulate preliminary recommendations. These recommendations underwent a rigorous vetting process involving a modified Delphi method, consistent with the 2017 AAN Clinical Practice Guideline Process Manual.

In total, the updated guideline encompasses 85 recommendations. These recommendations cover a wide range of crucial aspects related to BD/DNC evaluation, including general principles, qualifications for conducting BD/DNC evaluations, prerequisites for BD/DNC determination, components of the neurologic examination, apnea testing, ancillary testing, and special considerations for BD/DNC determination.

Ref: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline

Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM

David M. Greer et al, Neurology Oct 2023, 10.1212/WNL.0000000000207740; DOI: 10.1212/WNL.0000000000207740

Common drug offers hope for painful Hand Osteoarthritis

Relief may be on the horizon for those suffering from painful hand osteoarthritis, thanks to a groundbreaking study led by Monash University and Alfred Health. Published in The Lancet, this research has uncovered an affordable and readily available drug methotrexate, that has shown promise in alleviating symptoms in patients with hand osteoarthritis, a condition for which there has been no effective treatment until now.

The drug methotrexate is a well-established and cost-effective treatment commonly used to manage inflammatory joint conditions such as rheumatoid arthritis and psoriatic arthritis. Hand OA is a debilitating condition that brings about pain and hinders normal hand function, impacting daily activities like dressing and eating. Until now, no effective medications existed to manage this condition.

It was a randomized, double-blind, placebo-controlled trial involving 97 participants. It aimed to determine whether a weekly 20 mg dosage of methotrexate could reduce pain and improve function in patients with symptomatic hand OA and synovitis (inflammation) over a six-month period.

The study found that a 20mg weekly oral dose of methotrexate over six months had a moderate effect in reducing pain and stiffness in patients with symptomatic hand OA. According to Professor Cicuttini, the improvement in pain for the methotrexate group was twice as much as for the placebo group. For patients with hand OA and inflammation, the effects of methotrexate were noticeable at around three months, and by six months, it became evident whether the treatment was effective.

Ref:Methotrexate to treat hand osteoarthritis with synovitis (METHODS): an Australian, multisite, parallel-group, doubleblind, randomised, placebo-controlled trial, The Lancet, DOI 10.1016/S0140-6736

Enhanced Recovery Protocol Reduces Postoperative Infections After Robotic-Assisted Radical Cystectomy

In a significant development in the field of urology, the implementation of an enhanced recovery after surgery (ERAS) protocol has led to a substantial reduction in postoperative infections following robotic-assisted radical cystectomy (RARC). Despite the significant improvements in morbidity associated with RARC, infectious complications, including sepsis, urinary tract infections (UTIs), wound infections (WIs), and intra-abdominal infections (AIs), have remained a concern.

Researchers conducted a retrospective analysis of patients undergoing RARC between 2014 and 2022 at a tertiary care institution, categorizing them into two groups based on adherence to a modified ERAS protocol. The modified ERAS group included intracorporeal urinary diversion (ICUD) and antibiogram-directed antimicrobial prophylaxis, while the unmodified ERAS group followed extracorporeal urinary diversion (UD) and guideline-recommended prophylaxis.

The study aimed to assess the impact of these protocol modifications on infection rates post-surgery.

The analysis involved 396 patients, with the modified-ERAS group comprising 258 patients and the unmodified-ERAS group comprising 138 patients. The modified-ERAS group showed a significant reduction in the rates of both 30-day and 90-day UTIs as well as 30-day wound infections.Multivariate regression analysis confirmed that the modified-ERAS protocol was associated with a significantly lower risk of UTIs and WIs.

Ref: Antibiogram-directed Prophylaxis and Intracorporeal Urinary Diversion for Robot-assisted Radical Cystectomy, Jordan M. Rich et al,European Urology Focus