A concerted effort to tackle the global health problem posed by traumatic brain injury (TBI) is long overdue. TBI is a public health challenge of vast, but insufficiently recognised, proportions. Worldwide, more than 50 million people have a TBI each year, and it is estimated that about half the world's population will have one or more TBIs over their lifetime. TBI is the leading cause of mortality in young adults and a major cause of death and disability across all ages in all countries, with a disproportionate burden of disability and death occurring in low-income and middle-income countries (LMICs). It has been estimated that TBI costs the global economy approximately $US400 billion annually. Deficiencies in prevention, care, and research urgently need to be addressed to reduce the huge burden and societal costs of TBI. This Commission highlights priorities and provides expert recommendations for all stakeholders—policy makers, funders, health-care professionals, researchers, and patient representatives—on clinical and research strategies to reduce this growing public health problem and improve the lives of people with TBI.Additional co-authors: Endre Czeiter, Marek Czosnyka, Ramon Diaz-Arrastia, Jens P Dreier, Ann-Christine Duhaime, Ari Ercole, Thomas A van Essen, Valery L Feigin, Guoyi Gao, Joseph Giacino, Laura E Gonzalez-Lara, Russell L Gruen, Deepak Gupta, Jed A Hartings, Sean Hill, Ji-yao Jiang, Naomi Ketharanathan, Erwin J O Kompanje, Linda Lanyon, Steven Laureys, Fiona Lecky, Harvey Levin, Hester F Lingsma, Marc Maegele, Marek Majdan, Geoffrey Manley, Jill Marsteller, Luciana Mascia, Charles McFadyen, Stefania Mondello, Virginia Newcombe, Aarno Palotie, Paul M Parizel, Wilco Peul, James Piercy, Suzanne Polinder, Louis Puybasset, Todd E Rasmussen, Rolf Rossaint, Peter Smielewski, Jeannette Söderberg, Simon J Stanworth, Murray B Stein, Nicole von Steinbüchel, William Stewart, Ewout W Steyerberg, Nino Stocchetti, Anneliese Synnot, Braden Te Ao, Olli Tenovuo, Alice Theadom, Dick Tibboel, Walter Videtta, Kevin K W Wang, W Huw Williams, Kristine Yaffe for the InTBIR Participants and Investigator

Programme Hospitalier Recherche Clinique, Institut Pasteur, Inserm, French Public Health Agency.

In November 2017, the Lancet Neurology Commission on Traumatic Brain Injury (TBI) highlighted existing deficiencies in epidemiology, patient characterization, identifying best practice, outcome assessment, and evidence generation. The Commission concluded that C needed to address deficiencies in prevention , and made a recommendation for large collaborative studies which could provide the framework for precision medicine and comparative effectiveness research (CER).

These results demonstrate that striking differences in lung morphology, corresponding to different distributions of gas within the lungs, are observed in patients whose respiratory condition fulfills the definition criteria of ARDS.

Computed tomography (CT) assessment of positive end-expiratory pressure (PEEP)-induced alveolar recruitment is classically achieved by quantifying the decrease in nonaerated lung parenchyma on a single juxtadiaphragmatic section (Gattinoni's method). This approach ignores the alveolar recruitment occurring in poorly aerated lung areas and may not reflect the alveolar recruitment of the entire lung. This study describes a new CT method in which PEEP-induced alveolar recruitment is computed as the volume of gas penetrating in poorly and nonaerated lung regions following PEEP. In 16 patients with acute respiratory distress syndrome a thoracic spiral CT scan was performed in ZEEP and PEEP 15 cm H(2)O. According to the new method, PEEP induced a 119% increase in functional residual capacity (FRC). PEEP-induced alveolar recruitment was 499 +/- 279 ml whereas distension and overdistension of previously aerated lung areas were 395 +/- 382 ml and 28 +/- 6 ml, respectively. The alveolar recruitment according to Gattinoni's method was 26 +/- 24 g and no correlation was found between both methods. A significant correlation was found between PEEP-induced alveolar recruitment and increase in Pa(O(2)) only when recruitment was assessed by the new method (Rho = 0.76, p = 0.003), suggesting that it may be more accurate than Gattinoni's method.

The objective of this study was to evaluate incidence and risk factors of postoperative infections, with emphasis on antibiotic prophylaxis, in a series of 4578 craniotomies. A prospective database was implemented for surveillance of postcraniotomy infections. During period A, no antibiotic prophylaxis was prescribed for scheduled, clean craniotomies, lasting less than 4 h, whereas emergency, clean-contaminated or long-lasting craniotomies received cloxacillin or amoxicillin-clavulanate. During period B, prophylaxis was given to every craniotomy. The effect of prophylaxis on craniotomy infections, independently of other risk factors, was studied by multivariate analysis. The overall infection rate was 6.6%. CSF leak, male gender, surgical diagnosis, surgeon, early re-operation, surgical duration and absence of prophylaxis were independent risk factors. CSF leak had the highest odds ratio. Antibiotic prophylaxis decreased infection rate from 9.7% down to 5.8% in the entire population (p<0.0001) mainly by decreasing rates in low risk patients from 10.0% down to 4.6% (p<0.0001). Antibiotic prophylaxis in craniotomy is effective in preventing surgical site infections even in low-risk patients.

In patients with ARDS, the cardiorespiratory effects of PEEP are affected by lung morphology rather than by the cause of the lung injury (primary versus secondary ARDS). The regional distribution of the loss of aeration and the type of atelectasis -- "mechanical" with a massive loss of lung volume, or "inflammatory" with a preservation of lung volume-- characterizing the lower lobes are the main determinants of the cardiorespiratory effects of PEEP.

Selection of the optimal positive end-expiratory pressure level should not only consider optimizing alveolar recruitment, it should also focus on limiting lung overinflation and counterbalancing compression of the lower lobes by maneuvers such as appropriate body positioning. Prone and semirecumbent positions facilitate the reaeration of dependent and caudal lung regions by partially relieving cardiac and abdominal compression and may improve gas exchange.