Routine ward admission for patients undergoing elective craniotomies with selective ICU admission appears safe; however, approximately 2% of patients may require a direct postoperative unplanned ICU admission. Patients with anticipated long operation times, extensive blood loss, and high anesthetic risks should be selected for postoperative ICU admission, but further study is needed to determine the preoperative factors that can aid in identifying and caring for these groups of patients.

Glioblastoma multiforme (GBM) is one of the most lethal primary central nervous system cancers with a median overall survival of only 12–15 months. The best documented treatment is surgical tumor debulking followed by chemoradiation and adjuvant chemotherapy with temozolomide, but treatment resistance and therefore tumor recurrence, is the usual outcome. Although advances in molecular subtyping suggests GBM can be classified into four subtypes, one concern about using the original histology for subsequent treatment decisions is that it only provides a static snapshot of heterogeneous tumors that may undergo longitudinal changes over time, especially under selective pressure of ongoing therapy. Liquid biopsies obtained from bodily fluids like blood and cerebro-spinal fluid (CSF) are less invasive, and more easily repeated than surgery. However, their deployment for patients with brain cancer is only emerging, and possibly suppressed clinically due to the ongoing belief that the blood brain barrier prevents the egress of circulating tumor cells, exosomes, and circulating tumor nucleic acids into the bloodstream. Although brain cancer liquid biopsy analyses appear indeed challenging, advances have been made and here we evaluate the current literature on the use of liquid biopsies for detection of clinically relevant biomarkers in GBM to aid diagnosis and prognostication.

Functional outcomes at 12 months were a secondary outcome of the randomized DECRA trial of early decompressive craniectomy for severe diffuse traumatic brain injury (TBI) and refractory intracranial hypertension. In the DECRA trial, patients were randomly allocated 1:1 to either early decompressive craniectomy or intensive medical therapies (standard care). We conducted planned secondary analyses of the DECRA trial outcomes at 6 and 12 months, including all 155 patients. We measured functional outcome using the Glasgow Outcome Scale-Extended (GOS-E). We used ordered logistic regression, and dichotomized the GOS-E using logistic regression, to assess outcomes in patients overall and in survivors. We adjusted analyses for injury severity using the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. At 12 months, the odds ratio (OR) for worse functional outcomes in the craniectomy group (OR 1.68; 95% confidence interval [CI]: 0.96-2.93; p = 0.07) was no longer significant. Unfavorable functional outcomes after craniectomy were 11% higher (59% compared with 48%), but were not significantly different from standard care (OR 1.58; 95% CI: 0.84-2.99; p = 0.16). Among survivors after craniectomy, there were fewer good (OR 0.33; 95% CI: 0.12-0.91; p = 0.03) and more vegetative (OR 5.12; 95% CI: 1.04-25.2; p = 0.04) outcomes. Similar outcomes in survivors were found at 6 months after injury. Vegetative (OR 5.85; 95% CI: 1.21-28.30; p = 0.03) and severely disabled outcomes (OR 2.49; 95% CI: 1.21-5.11; p = 0.01) were increased. Twelve months after severe diffuse TBI and early refractory intracranial hypertension, decompressive craniectomy did not improve outcomes and increased vegetative survivors.

Safety and error reduction in medical care is crucial to the future of medicine. This study evaluates trauma patients dying at a level 1 trauma centre to determine the adequacy of care. All trauma deaths at a level 1 trauma centre between 1996 and 2003 were reviewed by an eight-member multidisciplinary death review panel. Errors in care were classified according to their location, nature, impact, outcome and whether the deaths were avoidable or non-avoidable. Avoidable deaths were categorized as potentially, probably and definitely avoidable. Between 1996 and 2003, there were 17 157 trauma admissions, including 307 trauma deaths. The mean patient age was 47.7 years -24.8 years, mean injury severity score 38.1 -19.6. Of all deaths, 69 (22.5%) were deemed avoidable. Of the avoidable deaths, 61 (88%) were potentially avoidable, 7 (10%) probably avoidable and 1 (1.4%) definitely avoidable. Avoidable deaths were associated with patients with increased age, lower injury severity score, admissions to intensive care unit, longer hospital stay and treatment by a non-trauma surgeon (P < 0.05). Of the 307 trauma deaths, 271 (89.3%) patients experienced a total of 1063 errors, an overall error rate of 3.5 per patient. The error rate in the non-avoidable group was 2.9 per patient and 5.3 per patient in the avoidable group (P < 0.0001). Most errors occurred in the resuscitation area. Age, severity of injury, hospital length of stay and care by a non-trauma surgeon are factors associated with avoidable deaths. A new approach to trauma and injury care is required.