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Burke JF, Okonkwo DO, Grugger J, Lowenstein D, Temkin N, Barber J, Foreman B, Ding K, Kim J, Diaz-Arrastia R, Manley GT. Effect of Late Post-traumatic Seizures on Outcomes at One Year After Traumatic Brain Injury. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ene CI, Wang AC, Collins K, Bonow RH, McGrath LB, Durfy S, Barber J, Ellenbogen RG. Duraplasty and Obex Exploration Compared with Bone Only Decompression for Chiari I Malformation in Children. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sen RD, Abecassis IJ, Barber J, Nistal DA, Abecassis ZA, Levitt MR, Kim LJ, Sekhar LN. Ruptured Brain Arteriovenous Malformation Presenting in Extremis. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sen RD, Abecassis IJ, Barber J, Nistal DA, Abecassis ZA, Levitt MR, Kim LJ, Sekhar LN. Impact of Acute Microsurgical Resection for Ruptured Brain Arteriovenous Malformations on Hospital Length of Stay and Clinical Outcomes. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Mac Donald CL, Barber J, Patterson J, Johnson AM, Parsey C, Scott B, Fann JR, Temkin NR. Comparison of Clinical Outcomes 1 and 5 Years Post-Injury Following Combat Concussion. Neurology 2020; 96:e387-e398. [PMID: 33177226 PMCID: PMC7884983 DOI: 10.1212/wnl.0000000000011089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/28/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare 1-year and 5-year clinical outcomes in 2 groups of combat-deployed service members without brain injury to those of 2 groups with combat-related concussion to better understand long-term clinical outcome trajectories. METHODS This prospective, observational, longitudinal multicohort study examined 4 combat-deployed groups: controls without head injury with or without blast exposure and patients with combat concussion arising from blast or blunt trauma. One-year and 5-year clinical evaluations included identical batteries for neurobehavioral, psychiatric, and cognitive outcomes. A total of 347 participants completed both time points of evaluation. Cross-sectional and longitudinal comparisons were assessed. Overall group effect was modeled as a 4-category variable with rank regression adjusting for demographic factors using a 2-sided significance threshold of 0.05, with post hoc Tukey p values calculated for the pairwise comparisons. RESULTS Significant group differences in both combat concussion groups were identified cross-sectionally at 5-year follow-up compared to controls in neurobehavioral (Neurobehavioral Rating Scale-Revised [NRS]; Cohen d, -1.10 to -1.40, confidence intervals [CIs] [-0.82, -1.32] to [-0.97, -1.83] by group) and psychiatric domains (Clinician-Administered PTSD Scale for DSM-IV [CAPS]; Cohen d, -0.91 to -1.19, CIs [-0.63, -1.19] to [-0.76, -1.62] by group) symptoms with minimal differences in cognitive performance. Both combat concussion groups also showed clinically significant decline from 1- to 5-year evaluation (66%-76% neurobehavioral NRS; 41%-54% psychiatric CAPS by group). Both control groups fared better but a subset also had clinically significant decline (37%-50% neurobehavioral NRS; 9%-25% psychiatric CAPS by group). CONCLUSIONS There was an evolution, not resolution, of symptoms from 1- to 5-year evaluation, challenging the assumption that chronic stages of concussive injury are relatively stable. Even some of the combat-deployed controls worsened. The evidence supports new considerations for chronic trajectories of concussion outcome in combat-deployed service members.
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Affiliation(s)
- Christine L Mac Donald
- From the Departments of Neurological Surgery (C.L.M., J.B., J.P., B.S., N.R.T.), Neurology (C.P.), and Psychiatry (J.R.F.), School of Medicine, and Department of Biostatistics (N.R.T.), School of Public Health, University of Washington, Seattle; and Center for Clinical Studies (A.M.J.), Washington University School of Medicine, St. Louis, MO.
| | - Jason Barber
- From the Departments of Neurological Surgery (C.L.M., J.B., J.P., B.S., N.R.T.), Neurology (C.P.), and Psychiatry (J.R.F.), School of Medicine, and Department of Biostatistics (N.R.T.), School of Public Health, University of Washington, Seattle; and Center for Clinical Studies (A.M.J.), Washington University School of Medicine, St. Louis, MO
| | - Jana Patterson
- From the Departments of Neurological Surgery (C.L.M., J.B., J.P., B.S., N.R.T.), Neurology (C.P.), and Psychiatry (J.R.F.), School of Medicine, and Department of Biostatistics (N.R.T.), School of Public Health, University of Washington, Seattle; and Center for Clinical Studies (A.M.J.), Washington University School of Medicine, St. Louis, MO
| | - Ann M Johnson
- From the Departments of Neurological Surgery (C.L.M., J.B., J.P., B.S., N.R.T.), Neurology (C.P.), and Psychiatry (J.R.F.), School of Medicine, and Department of Biostatistics (N.R.T.), School of Public Health, University of Washington, Seattle; and Center for Clinical Studies (A.M.J.), Washington University School of Medicine, St. Louis, MO
| | - Carolyn Parsey
- From the Departments of Neurological Surgery (C.L.M., J.B., J.P., B.S., N.R.T.), Neurology (C.P.), and Psychiatry (J.R.F.), School of Medicine, and Department of Biostatistics (N.R.T.), School of Public Health, University of Washington, Seattle; and Center for Clinical Studies (A.M.J.), Washington University School of Medicine, St. Louis, MO
| | - Beverly Scott
- From the Departments of Neurological Surgery (C.L.M., J.B., J.P., B.S., N.R.T.), Neurology (C.P.), and Psychiatry (J.R.F.), School of Medicine, and Department of Biostatistics (N.R.T.), School of Public Health, University of Washington, Seattle; and Center for Clinical Studies (A.M.J.), Washington University School of Medicine, St. Louis, MO
| | - Jesse R Fann
- From the Departments of Neurological Surgery (C.L.M., J.B., J.P., B.S., N.R.T.), Neurology (C.P.), and Psychiatry (J.R.F.), School of Medicine, and Department of Biostatistics (N.R.T.), School of Public Health, University of Washington, Seattle; and Center for Clinical Studies (A.M.J.), Washington University School of Medicine, St. Louis, MO
| | - Nancy R Temkin
- From the Departments of Neurological Surgery (C.L.M., J.B., J.P., B.S., N.R.T.), Neurology (C.P.), and Psychiatry (J.R.F.), School of Medicine, and Department of Biostatistics (N.R.T.), School of Public Health, University of Washington, Seattle; and Center for Clinical Studies (A.M.J.), Washington University School of Medicine, St. Louis, MO
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Bodien Y, Sherer M, Taylor S, Dikmen S, Yue J, Stein M, Corrigan J, Levin H, Temkin N, Machamer J, Boase K, Vassar M, McCrea M, McAllister T, Whyte J, Barber J, Gardner R, Kramer J, Nelson L, Manley G, Giacino J. Feasibility and Utility of a Flexible Outcome Assessment Battery for Use in Longitudinal Traumatic Brain Injury Research. Arch Phys Med Rehabil 2020. [DOI: 10.1016/j.apmr.2020.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bombardier CH, Dyer JR, Burns P, Crane DA, Takahashi MM, Barber J, Nash MS. A tele-health intervention to increase physical fitness in people with spinal cord injury and cardiometabolic disease or risk factors: a pilot randomized controlled trial. Spinal Cord 2020; 59:63-73. [PMID: 32694748 DOI: 10.1038/s41393-020-0523-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Clinical trial. OBJECTIVES We used a single-blind parallel-group design to test the feasibility and preliminary efficacy of a telehealth-based physical activity counseling intervention to increase physical fitness in people with SCI. SETTING Seattle, Washington, United States. METHODS We recruited under-active, manual wheelchair-using adults at least 1-year post-SCI who had at least two cardiometabolic risk factors/diseases. Participants underwent baseline tests of peak cardiorespiratory fitness; lipids, glucose and insulin; muscle and fat mass; self-reported physical activity, depression, pain and other factors. Participants were assigned 1:1 to treatment vs. usual care (UC) control conditions via concealed computerized randomization. Treatment was delivered via telephone and adapted from the 16-session Diabetes Prevention Program. All baseline tests were repeated at 6 months. Prespecified feasibility goals were to recruit at least nine participants/quarter and retain 85% with complete fitness testing at 6 months. Prespecified efficacy goals were to demonstrate at least a medium treatment effect size (0.50) on fitness, self-reported physical activity, and other outcomes. RESULTS Seven participants were randomized to treatment, 8 to UC over 15 months. Maximum recruitment was only 5.4 participants/quarter. Thirteen (87%) of participants were retained. The effects of treatment on fitness and most cardiometabolic risk factors did not meet expectations, whereas the effects on self-reported physical activity, depression, and pain did meet expectations. CONCLUSIONS The study did not meet key efficacy and feasibility objectives, yet there were some promising effects on self-report measures and lessons to be learned for designing future trials.
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Affiliation(s)
- Charles H Bombardier
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.
| | | | - Patricia Burns
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deborah A Crane
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | | | - Jason Barber
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Mark S Nash
- Departments of Neurological Surgery, Physical Medicine & Rehabilitation and Physical Therapy, University of Miami Miller School of Medicine, Miami, FL, USA
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Abstract
Background Primary CNS lymphoma is a rare and aggressive cancer that can develop in immunocompetent individuals, but little is known about risk factors and causes of disease. Previous studies have demonstrated seasonal patterns for lymphomas and brain tumors. This study examined the seasonal incidence pattern for primary CNSlymphoma. Methods A retrospective review was performed for patients diagnosed with primary CNS lymphoma from 2000 through 2018 at our tertiary referral center. A total of 156 patients were categorized based on month of symptom onset, month of diagnosis, and month of recurrence if they experienced a relapse of their disease. The distributions were then analyzed for seasonal patterns. Results There was a significant, bimodal seasonal incidence pattern based on month of symptom onset (P < .001), with peaks in July (n = 19) and December (n = 23) and troughs in March (n = 4) and September (n = 5). There were no significant differences in patients' sex, age at presentation, length of follow-up, and progression-free survival across months. There were no seasonal patterns based on month of diagnosis (P = .450) or month of disease recurrence (P = .572). Conclusion The incidence of primary CNS lymphoma has bimodal peaks in midsummer and early winter, which could provide insight into causative agents and mechanisms of disease.
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Affiliation(s)
- Alec W Gibson
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Alipi V Bonm
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jerome J Graber
- Department of Neurology, University of Washington, Seattle, Washington, USA.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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Johnson EK, Fraser RT, Lashley S, Barber J, Brandling-Bennett EM, Vossler DG, Miller JW, Caylor L, Warheit-Niemi T. Program of Active Consumer Engagement in Self-Management in Epilepsy: Replication and extension of a self-management randomized controlled trial. Epilepsia 2020; 61:1129-1141. [PMID: 32401339 DOI: 10.1111/epi.16530] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The Program of Active Consumer Engagement in Self-Management in Epilepsy (PACES) is an evidenced-based self-management intervention for adults with epilepsy. Prior randomized controlled trial (RCT) data show that PACES reduces depression and improves self-management, self-efficacy, and quality of life for 6 months postprogram. The objective of this study was to replicate a PACES RCT with key extensions: more diverse patient pool from community-based epilepsy centers; option for telephone-based participation; and longer follow-up (12 months with booster support for intervention group), to examine duration of impact and inform dissemination and implementation. METHODS Participants were adults with chronic epilepsy (n = 101) without serious mental illness or substantive intellectual impairment, recruited from three epilepsy centers. Participants were randomly assigned to intervention or waitlist control groups. Outcomes included the Epilepsy Self-Management Scale (ESMS), Epilepsy Self-Efficacy Scale (ESES), Quality of Life in Epilepsy-31, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7, administered at baseline, postintervention (8 weeks), and 6 and 12 months postintervention. Intervention was an 8-week group of five to eight adults co-led by a psychologist and trained peer with epilepsy that met once per week by teleconference or in person at a hospital for 60-75 minutes. Topics included medical, psychosocial, cognitive, and self-management aspects of epilepsy, as well as community integration and epilepsy-related communication. Treatment group provided program evaluation. RESULTS PACES participants (n = 49) improved relative to controls (n = 52) on the ESES (P < .022) and overall distress composite (P = .008). At 6 months, PACES participants remained improved on the ESES (P = .008) and composite (P = .001), and were improved on the ESMS (P = .005). At 12 months, PACES participants remained improved on the ESMS (P = .006) and were improved on an overall distress composite of combined measures (P = .018). Attrition was low (<6% in each group), and all program satisfaction ratings exceeded 4.0/5.0. SIGNIFICANCE A consumer-generated epilepsy self-management program with broad psychosocial and medical emphasis can be effectively delivered by telephone or in person and facilitates long-term epilepsy self-management, adjustment, and coping up to 1 year after treatment.
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Affiliation(s)
- Erica K Johnson
- Health Promotion Research Center, University of Washington, Seattle, Washington, USA.,Neurology Vocational Services Unit, University of Washington, Seattle, Washington, USA
| | - Robert T Fraser
- Health Promotion Research Center, University of Washington, Seattle, Washington, USA.,Neurology Vocational Services Unit, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.,Department of Neurology, University of Washington, Seattle, Washington, USA.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Steven Lashley
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - David G Vossler
- Department of Neurology, University of Washington, Seattle, Washington, USA.,UW Medicine, Valley Medical Center, Renton, Washington, USA
| | - John W Miller
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Lisa Caylor
- Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Tessala Warheit-Niemi
- Neurology Vocational Services Unit, University of Washington, Seattle, Washington, USA
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Alali AS, Temkin N, Vavilala MS, Lele AV, Barber J, Dikmen S, Chesnut RM. Matching early arterial oxygenation to long-term outcome in severe traumatic brain injury: target values. J Neurosurg 2020; 132:537-544. [PMID: 30738409 DOI: 10.3171/2018.10.jns18964] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 10/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to examine the relationship between early arterial oxygenation thresholds and long-term outcome after severe traumatic brain injury (TBI). METHODS In a post hoc analysis of a randomized trial, adults with severe TBI were classified based on exposure to different levels of arterial oxygenation as measured using the average of arterial partial pressure of oxygen (PaO2) values obtained within 24 hours of admission. Potentially important PaO2 thresholds were defined a priori. The primary outcome was Glasgow Outcome Scale-Extended (GOSE) score at 6 months. Secondary outcomes were cognitive outcomes measured using a battery of 9 neuropsychological tests administered at 6 months, and 6-month mortality. RESULTS In adjusted analyses, oxygenation thresholds of 150 and 200 mm Hg were associated with better functional outcome at 6 months (adjusted OR for better functional outcome on GOSE 1.82 [95% CI 1.12-2.94] and 1.59 [95% CI 1.06-2.37], respectively) and improved cognitive outcome at 6 months (adjusted beta coefficients for better cognitive percentile across 9 neuropsychological tests: 6.9 [95% CI 1.3-12.5] and 6.8 [95% CI 2.4-11.3], respectively). There was no significant association between oxygenation level and 6-month mortality except at a PaO2 threshold of 200 mm Hg (OR for death 0.36, 95% CI 0.18-0.71). Higher or lower oxygenation thresholds were not associated with functional or cognitive outcome. CONCLUSIONS In this observational study, the relationship between early arterial oxygenation and long-term functional and cognitive TBI outcomes appears to be U-shaped. Mild levels of hyperoxemia within the first 24 hours after injury were associated with better long-term functional and cognitive outcomes. These findings highlight the importance of examining balanced oxygen supplementation as a potential strategy to improve TBI outcomes in future research.
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Affiliation(s)
- Aziz S Alali
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and
| | - Nancy Temkin
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and.,Departments of2Biostatistics
| | | | | | - Jason Barber
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and
| | - Sureyya Dikmen
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and.,4Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Randall M Chesnut
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and
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McClelland S, Hayes H, Barber J, Hort A, Baumwol J. Use of Thalidomide for Refractory GI Bleeding in Patients with Continuous Flow Left Ventricular Assist Device (cfLVAD) - The Western Australian (WA) Experience. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Chesnut RM, Temkin N, Videtta W, Petroni G, Lujan S, Pridgeon J, Dikmen S, Chaddock K, Barber J, Machamer J, Guadagnoli N, Hendrickson P, Aguilera S, Alanis V, Bello Quezada ME, Bautista Coronel E, Bustamante LA, Cacciatori AC, Carricondo CJ, Carvajal F, Davila R, Dominguez M, Figueroa Melgarejo JA, Fillipi MM, Godoy DA, Gomez DC, Lacerda Gallardo AJ, Guerra Garcia JA, Zerain GLF, Lavadenz Cuientas LA, Lequipe C, Grajales Yuca GV, Jibaja Vega M, Kessler ME, López Delgado HJ, Sandi Lora F, Mazzola AM, Maldonado RM, Mezquia de Pedro N, Martínez Zubieta JR, Mijangos Méndez JC, Mora J, Ochoa Parra JM, Pahnke PB, Paranhos J, Piñero GR, Rivadeneira Pilacuán FA, Mendez Rivera MN, Romero Figueroa RL, Rubiano AM, Saraguro Orozco AM, Silesky Jiménez JI, Silva Naranjo L, Soler Morejon C, Urbina Z. Consensus-Based Management Protocol (CREVICE Protocol) for the Treatment of Severe Traumatic Brain Injury Based on Imaging and Clinical Examination for Use When Intracranial Pressure Monitoring Is Not Employed. J Neurotrauma 2020; 37:1291-1299. [PMID: 32013721 DOI: 10.1089/neu.2017.5599] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Globally, intracranial pressure (ICP) monitoring use in severe traumatic brain injury (sTBI) is inconsistent and susceptible to resource limitations and clinical philosophies. For situations without monitoring, there is no published comprehensive management algorithm specific to identifying and treating suspected intracranial hypertension (SICH) outside of the one ad hoc Imaging and Clinical Examination (ICE) protocol in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST:TRIP) trial. As part of an ongoing National Institutes of Health (NIH)-supported project, a consensus conference involving 43 experienced Latin American Intensivists and Neurosurgeons who routinely care for sTBI patients without ICP monitoring, refined, revised, and augmented the original BEST:TRIP algorithm. Based on BEST:TRIP trial data and pre-meeting polling, 11 issues were targeted for development. We used Delphi-based methodology to codify individual statements and the final algorithm, using a group agreement threshold of 80%. The resulting CREVICE (Consensus REVised ICE) algorithm defines SICH and addresses both general management and specific treatment. SICH treatment modalities are organized into tiers to guide treatment escalation and tapering. Treatment schedules were developed to facilitate targeted management of disease severity. A decision-support model, based on the group's combined practices, is provided to guide this process. This algorithm provides the first comprehensive management algorithm for treating sTBI patients when ICP monitoring is not available. It is intended to provide a framework to guide clinical care and direct future research toward sTBI management. Because of the dearth of relevant literature, it is explicitly consensus based, and is provided solely as a resource (a "consensus-based curbside consult") to assist in treating sTBI in general intensive care units in resource-limited environments.
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Affiliation(s)
- Randall M Chesnut
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Nancy Temkin
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Walter Videtta
- Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina
| | - Gustavo Petroni
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario, Argentina
| | - Jim Pridgeon
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Sureyya Dikmen
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Kelley Chaddock
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jason Barber
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Joan Machamer
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Peter Hendrickson
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Victor Alanis
- Hospital San Juan de Dios, Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Felipe Carvajal
- Hospital Municipal Eva Peron de Merlo, Provincia Buenos Aires, Argentina
| | - Rafael Davila
- Hospital Universitario Luis Razetti, Barcelona, Venezuela
| | - Mario Dominguez
- Hospital Universitario Provincial "Arnaldo Milián Castro," Santa Clara, Cuba
| | | | | | | | | | | | | | | | | | | | | | | | | | - Hubiel J López Delgado
- Neurosurgery, Critical Care Medicine, CEDIMAT, Plaza de la Salud Juan, Santo Domingo, Dominican Republic
| | | | | | | | | | | | | | - Jacobo Mora
- Hospital Universitario Luis Razetti, Barcelona, Venezuela
| | - Johnny Marcelo Ochoa Parra
- Hospital José Carrasco Arteaga. IESS. Cuenca Facultad de Medicina, Universidad del Azuay, Cuenca, Ecuador
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Wongchareon K, Thompson HJ, Mitchell PH, Barber J, Temkin N. IMPACT and CRASH prognostic models for traumatic brain injury: external validation in a South-American cohort. Inj Prev 2020; 26:546-554. [PMID: 31959626 DOI: 10.1136/injuryprev-2019-043466] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop a robust prognostic model, the more diverse the settings in which the system is tested and found to be accurate, the more likely it will be generalisable to untested settings. This study aimed to externally validate the International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization after Significant Head Injury (CRASH) models for low-income and middle-income countries using a dataset of patients with severe traumatic brain injury (TBI) from the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure study and a simultaneously conducted observational study. METHOD A total of 550 patients with severe TBI were enrolled in the study, and 466 of those were included in the analysis. Patient admission characteristics were extracted to predict unfavourable outcome (Glasgow Outcome Scale: GOS<3) and mortality (GOS 1) at 14 days or 6 months. RESULTS There were 48% of the participants who had unfavourable outcome at 6 months and these included 38% who had died. The area under the receiver operating characteristic curve (AUC) values were 0.683-0.775 and 0.640-0.731 for the IMPACT and CRASH models respectively. The IMPACT CT model had the highest AUC for predicting unfavourable outcomes, and the IMPACT Lab model had the best discrimination for predicting 6-month mortality. The discrimination for both the IMPACT and CRASH models improved with increasing complexity of the models. Calibration revealed that there were disagreement between observed and predicted outcomes in the IMPACT and CRASH models. CONCLUSION The overall performance of all IMPACT and CRASH models was adequate when used to predict outcomes in the dataset. However, some disagreement in calibration suggests the necessity for updating prognostic models to maintain currency and generalisability.
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Affiliation(s)
- Kwankaew Wongchareon
- Adult and Gerontology Nursing, Naresuan University Faculty of Nursing, Phitsanulok, Thailand
| | - Hilaire J Thompson
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Pamela H Mitchell
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Nancy Temkin
- Neurosurgery, University of Washington, Seattle, Washington, USA
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Nguyen V, Brown A, Barber J. OC-019: Contouring of metal artefact for bilateral hip prosthetics in radiation therapy prostate planning. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(20)30425-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Alali AS, Temkin N, Barber J, Pridgeon J, Chaddock K, Dikmen S, Hendrickson P, Videtta W, Lujan S, Petroni G, Guadagnoli N, Urbina Z, Chesnut RM. A clinical decision rule to predict intracranial hypertension in severe traumatic brain injury. J Neurosurg 2019; 131:612-619. [PMID: 30265194 DOI: 10.3171/2018.4.jns173166] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While existing guidelines support the treatment of intracranial hypertension in severe traumatic brain injury (TBI), it is unclear when to suspect and initiate treatment for high intracranial pressure (ICP). The objective of this study was to derive a clinical decision rule that accurately predicts intracranial hypertension. METHODS Using Delphi methods, the authors identified a set of potential predictors of intracranial hypertension and a clinical decision rule a priori by consensus among a group of 43 neurosurgeons and intensivists who have extensive experience managing severe TBI without ICP monitoring. To validate these predictors, the authors used data from a Latin American trial (n = 150; BEST TRIP). To report on the performance of the rule, they calculated sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals. In a secondary analysis, the rule was validated using data from a North American trial (n = 131; COBRIT). RESULTS The final predictors and the clinical decision rule were approved by 97% of participants in the consensus working group. The predictors are divided into major and minor criteria. High ICP would be considered suspected in the presence of 1 major or ≥ 2 minor criteria. Major criteria are: compressed cisterns (CT classification of Marshall diffuse injury [DI] III), midline shift > 5 mm (Marshall DI IV), or nonevacuated mass lesion. Minor criteria are: Glasgow Coma Scale (GCS) motor score ≤ 4, pupillary asymmetry, abnormal pupillary reactivity, or Marshall DI II. The area under the curve for the logistic regression model that contains all the predictors was 0.86. When high ICP was defined as > 22 mm Hg, the decision rule performed with a sensitivity of 93.9% (95% CI 85.0%-98.3%), a specificity of 42.3% (95% CI 31.7%-53.6%), a positive predictive value of 55.5% (95% CI 50.7%-60.2%), and a negative predictive value of 90% (95% CI 77.1%-96.0%). The sensitivity of the clinical decision rule improved with higher ICP cutoffs up to a sensitivity of 100% when intracranial hypertension was defined as ICP > 30 mm Hg. Similar results were found in the North American cohort. CONCLUSIONS A simple clinical decision rule based on a combination of clinical and imaging findings was found to be highly sensitive in distinguishing patients with severe TBI who would suffer intracranial hypertension. It could be used to identify patients who require ICP monitoring in high-resource settings or start ICP-lowering treatment in environments where resource limitations preclude invasive monitoring.Clinical trial registration no.: NCT02059941 (clinicaltrials.gov).
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Affiliation(s)
- Aziz S Alali
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Nancy Temkin
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center.,Departments of2Biostatistics
| | - Jason Barber
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Jim Pridgeon
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Kelley Chaddock
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Sureyya Dikmen
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center.,3Rehabilitation Medicine, and
| | - Peter Hendrickson
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Walter Videtta
- 4Hospital Nacional Profesor Alejandro Posadas, Buenos Aire
| | - Silvia Lujan
- 5Hospital de Emergencias Dr. Clemente Alvarez, Rosario
| | | | - Nahuel Guadagnoli
- 6Hospital Emergencia, Hospital Privado de Rosario, Rosario, Argentina; and
| | | | - Randall M Chesnut
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center.,8Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
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Mac Donald CL, Barber J, Andre J, Panks C, Zalewski K, Temkin N. Longitudinal neuroimaging following combat concussion: sub-acute, 1 year and 5 years post-injury. Brain Commun 2019; 1:fcz031. [PMID: 31915753 PMCID: PMC6935683 DOI: 10.1093/braincomms/fcz031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/07/2019] [Accepted: 10/17/2019] [Indexed: 12/25/2022] Open
Abstract
Questions remain regarding the long-term impact of combat concussive blast exposure. While efforts have begun to highlight the clinical impact, less is known about neuroimaging trajectories that may inform underlying pathophysiological changes post-injury. Through collaborative efforts in combat, following medical evacuation, and at universities in the USA, this study followed service members both with and without blast concussion from the sub-acute to 1-year and 5-year outcomes with quantitative neuroimaging. The following two primary and two exploratory groups were examined: combat-deployed controls without blast exposure history ‘non-blast control’ and concussive blast patients (primary) and combat concussion arising not from blast ‘non-blast concussion’ and combat-deployed controls with blast exposure history ‘blast control’ (exploratory). A total of 575 subjects were prospectively enrolled and imaged; 347 subjects completed further neuroimaging examination at 1 year and 342 subjects completed further neuroimaging examination at 5 years post-injury. At each time point, MRI scans were completed that included high-resolution structural as well as diffusion tensor imaging acquisitions processed for quantitative volumetric and diffusion tensor imaging changes. Longitudinal evaluation of the number of abnormal diffusion tensor imaging and volumetric regions in patients with blast concussion revealed distinct trends by imaging modality. While the presence of abnormal volumetric regions remained quite stable comparing our two primary groups of non-blast control to blast concussion, the diffusion tensor imaging abnormalities were observed to have varying trajectories. Most striking was the fractional anisotropy ‘U-shaped’ curve observed for a proportion of those that, if we had only followed them to 1 year, would look like trajectories of recovery. However, by continuing the follow-up to 5 years in these very same patients, a secondary increase in the number of reduced fractional anisotropy regions was identified. Comparing non-blast controls to blast concussion at each time point revealed significant differences in the number of regions with reduced fractional anisotropy at both the sub-acute and 5-year time points, which held after adjustment for age, education, gender, scanner and subsequent head injury exposure followed by correction for multiple comparisons. The secondary increase identified in patients with blast concussion may be the earliest indications of microstructural changes underlying the ‘accelerated brain aging’ theory recently reported from chronic, cross-sectional studies of veterans following brain injury. These varying trajectories also inform potential prognostic neuroimaging biomarkers of progression and recovery.
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Affiliation(s)
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Jalal Andre
- Department of Radiology, University of Washington, Seattle, WA 98104, USA
| | - Chris Panks
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Kody Zalewski
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA.,Department of Biostatistics, University of Washington, Seattle, WA 98104, USA
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Zahniser E, Temkin NR, Machamer J, Barber J, Manley GT, Markowitz AJ, Dikmen SS. The Functional Status Examination in Mild Traumatic Brain Injury: A TRACK-TBI Sub-Study. Arch Clin Neuropsychol 2019; 34:1165-1174. [PMID: 30608522 PMCID: PMC10576412 DOI: 10.1093/arclin/acy103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 08/11/2018] [Accepted: 12/26/2018] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVE The Functional Status Examination (FSE) is a comprehensive measure of functional status post-traumatic brain injury (TBI) that has primarily been used in studies of moderate-to-severe TBI. The present observational study examines functional status using the FSE among patients who sustained mild TBIs (mTBIs; defined as Glasgow Coma Scale [GCS] = 13-15 at admission) seen in a Level 1 trauma center. Study aims included examining the course of functional status following mTBI, as well as exploring relationships of the FSE and other relevant constructs among those with GCS = 13-15. METHOD Participants were assessed at 2 weeks (n = 112), 3 months (n = 113), 6 months (n = 106), and 12 months (n = 88) post-injury for changes in functional status resulting both (a) from all injuries and (b) from TBI only. RESULTS Among seven domains of day-to-day functioning, participants generally experienced the greatest disruption in their primary activity (work or school) and in leisure and recreation. Subjects' overall functional status tended to improve over time, with sharpest increases in functionality occurring in the first 3 months post-injury. However, some subjects continued to report functional limitations even at 12 months post-injury. Functional status was largely unrelated to neurocognitive functioning, but related strongly to post-traumatic symptoms, life satisfaction, and emotional well-being, particularly at 3 months post-injury and beyond. CONCLUSION Findings indicate that functional impairments related to mTBI may be more likely to persist than widely believed, with those who experience lingering functional deficits at particular risk for emotional health difficulties.
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Affiliation(s)
- Evan Zahniser
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joan Machamer
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Amy J Markowitz
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sureyya S Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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Lim P, Barber J, Sykes J. Evaluation of dual energy CT and iterative metal artefact reduction (iMAR) for artefact reduction in radiation therapy. Australas Phys Eng Sci Med 2019; 42:1025-1032. [PMID: 31602593 DOI: 10.1007/s13246-019-00801-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/19/2019] [Accepted: 09/16/2019] [Indexed: 11/27/2022]
Abstract
Metal artefacts pose a common problem in single energy computed tomography (SECT) images used for radiotherapy. Virtual monoenergetic (VME) images constructed with dual energy computed tomography (DECT) scans can be used to reduce beam hardening artefacts. Dual energy metal artefact reduction is compared and combined with iterative metal artefact reduction (iMAR) to determine optimal imaging strategies for patients with metal prostheses. SECT and DECT scans were performed on a Siemens Somatom AS-64 Slice CT scanner. Images were acquired of a modified CIRS pelvis phantom with 6, 12, 20 mm diameter stainless steel rods and VME images reconstructed at 100, 120, 140 and 190 keV. These were post-reconstructed with and without the iMAR algorithm. Artefact reduction was measured using: (1) the change in Hounsfield Unit (HU) with and without metal artefact reduction (MAR) for 4 regions of interest; (2) the total number of artefact pixels, defined as pixels with a difference (between images with metal rod and without) exceeding a threshold; (3) the difference in the mean pixel intensity of the artefact pixels. DECT, SECT + iMAR and DECT + iMAR were compared. Both SECT + iMAR and DECT + iMAR offer successful MAR for phantom simulating unilateral hip prosthesis. DECT gives minimal artefact reduction over iMAR alone. Quantitative metrics are advantageous for MAR analysis but have limitations that leave room for metric development.
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Affiliation(s)
- P Lim
- School of Physics, University of Sydney, Sydney, Australia.
| | - J Barber
- School of Physics, University of Sydney, Sydney, Australia
- Radiation Oncology, Blacktown Hospital, Sydney West Cancer Network, Sydney, Australia
| | - J Sykes
- School of Physics, University of Sydney, Sydney, Australia
- Radiation Oncology, Blacktown Hospital, Sydney West Cancer Network, Sydney, Australia
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Barber J, Mikhaeel G, Brady J, Mistry A. An Investigation of the Possible Advantages of Treating Lymphoma Stomach Patients in DIBH or EEBH to Reduce Heart Dose. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Nelson LD, Temkin NR, Dikmen S, Barber J, Giacino JT, Yuh E, Levin HS, McCrea MA, Stein MB, Mukherjee P, Okonkwo DO, Robertson CS, Diaz-Arrastia R, Manley GT, Adeoye O, Badjatia N, Boase K, Bodien Y, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson A, Foreman B, Gardner R, Gaudette E, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Korley F, Kramer J, Kreitzer N, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Noel F, Palacios E, Perl D, Puccio A, Rabinowitz M, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Taylor S, Toga A, Valadka A, Vassar MJ, Vespa P, Wang K, Yue JK, Zafonte R. Recovery After Mild Traumatic Brain Injury in Patients Presenting to US Level I Trauma Centers: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study. JAMA Neurol 2019; 76:1049-1059. [PMID: 31157856 DOI: 10.1001/jamaneurol.2019.1313] [Citation(s) in RCA: 210] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Most traumatic brain injuries (TBIs) are classified as mild (mTBI) based on admission Glasgow Coma Scale (GCS) scores of 13 to 15. The prevalence of persistent functional limitations for these patients is unclear. Objectives To characterize the natural history of recovery of daily function following mTBI vs peripheral orthopedic traumatic injury in the first 12 months postinjury using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, and, using clinical computed tomographic (CT) scans, examine whether the presence (CT+) or absence (CT-) of acute intracranial findings in the mTBI group was associated with outcomes. Design, Setting, and Participants TRACK-TBI, a cohort study of patients with mTBI presenting to US level I trauma centers, enrolled patients from February 26, 2014, to August 8, 2018, and followed up for 12 months. A total of 1453 patients at 11 level I trauma center emergency departments or inpatient units met inclusion criteria (ie, mTBI [n = 1154] or peripheral orthopedic traumatic injury [n = 299]) and were enrolled within 24 hours of injury; mTBI participants had admission GCS scores of 13 to 15 and clinical head CT scans. Patients with peripheral orthopedic trauma injury served as the control (OTC) group. Exposures Participants with mTBI or OTC. Main Outcomes and Measures The Glasgow Outcome Scale Extended (GOSE) scale score, reflecting injury-related functional limitations across broad life domains at 2 weeks and 3, 6, and 12 months postinjury was the primary outcome. The possible score range of the GOSE score is 1 (dead) to 8 (upper good recovery), with a score less than 8 indicating some degree of functional impairment. Results Of the 1453 participants, 953 (65.6%) were men; mean (SD) age was 40.9 (17.1) years in the mTBI group and 40.9 (15.4) years in the OTC group. Most participants (mTBI, 87%; OTC, 93%) reported functional limitations (GOSE <8) at 2 weeks postinjury. At 12 months, the percentage of mTBI participants reporting functional limitations was 53% (95% CI, 49%-56%) vs 38% (95% CI, 30%-45%) for OTCs. A higher percentage of CT+ patients reported impairment (61%) compared with the mTBI CT- group (49%; relative risk [RR], 1.24; 95% CI, 1.08-1.43) and a higher percentage in the mTBI CT-group compared with the OTC group (RR, 1.28; 95% CI, 1.02-1.60). Conclusions and Relevance Most patients with mTBI presenting to US level I trauma centers report persistent, injury-related life difficulties at 1 year postinjury, suggesting the need for more systematic follow-up of patients with mTBI to provide treatments and reduce the risk of chronic problems after mTBI.
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Affiliation(s)
| | | | | | | | - Joseph T Giacino
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston
| | | | | | | | - Murray B Stein
- University of California, San Diego, La Jolla.,Veterans Affairs San Diego Healthcare System, San Diego, California
| | | | | | - Claudia S Robertson
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | | | | | | | | | | | - Kim Boase
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | | | - Randall Chesnut
- Department of Neurological Surgery, University of Washington, Seattle
| | | | | | | | | | - V Ramana Feeser
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - Adam Ferguson
- Department of Neurological Surgery, University of California, San Francisco
| | | | - Raquel Gardner
- Department of Neurology, University of California, San Francisco
| | | | | | - Shankar Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | | | | | - Sonia Jain
- University of California, San Diego, La Jolla
| | - Frederick Korley
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
| | - Joel Kramer
- Department of Neurology, University of California, San Francisco
| | | | - Chris Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joan Machamer
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Christopher Madden
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Alastair Martin
- Department of Radiology & Biomedical Imaging, University of California, San Francisco
| | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Randall Merchant
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond
| | - Florence Noel
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Eva Palacios
- Department of Radiology & Biomedical Imaging, University of California, San Francisco
| | - Daniel Perl
- Department of Pathology, Uniformed Services University, Bethesda, Maryland
| | - Ava Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Miri Rabinowitz
- Department of Neurology, University of Pennsylvania, Philadelphia
| | | | - Angelle Sander
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Gabriela Satris
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - David Schnyer
- Department of Psychology, University of Texas at Austin, Austin
| | | | | | - Sabrina Taylor
- Department of Neurological Surgery, University of California, San Francisco
| | - Arthur Toga
- University of Southern California, Los Angeles
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond
| | - Mary J Vassar
- Department of Neurological Surgery, University of California, San Francisco.,Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Paul Vespa
- Department of Neurology, University of California Los Angeles School of Medicine, Los Angeles
| | - Kevin Wang
- Department of Psychiatry, University of Florida, Gainesville
| | - John K Yue
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
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Abecassis IJ, Sen R, Kelly CM, Levy S, Barber J, Ghodke B, Levitt M, Kim LJ, Sekhar LN. Clinical outcomes and cost-effectiveness analysis for the treatment of basilar tip aneurysms. J Neurointerv Surg 2019; 11:1210-1215. [DOI: 10.1136/neurintsurg-2019-014747] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/24/2019] [Accepted: 04/28/2019] [Indexed: 12/27/2022]
Abstract
BackgroundEndovascular treatment of basilar tip aneurysms is less invasive than microsurgical clipping, but requires closer follow-up.ObjectiveTo characterize the additional costs associated with endovascular treatment of basilar tip aneurysms rather than microsurgical clipping.Materials and methodsWe obtained clinical records and billing information for 141 basilar tip aneurysms treated with clip ligation (n=48) or endovascular embolization (n=93). Costs included direct and indirect costs associated with index hospitalization, as well as re-treatments, follow-up visits, imaging studies, rehabilitation, and disability. Effectiveness of treatment was quantified by converting functional outcomes (modified Rankin Scale (mRS) score) into quality-adjusted life-years (QALYs). Cost-effectiveness was performed using cost/QALY ratios.ResultsAverage index hospitalization costs were significantly higher for patients with unruptured aneurysms treated with clip ligation ($71 400 ± $47 100) compared with coil embolization ($33 500 ± $22 600), balloon-assisted coiling ($26 200 ± $11 600), and stent-assisted coiling ($38 500 ± $20 900). Multivariate predictors for higher index hospitalization cost included vasospasm requiring endovascular intervention, placement of a ventriculoperitoneal shunt, longer length of stay, larger aneurysm neck and width, higher Hunt-Hess grade, and treatment-associated complications. At 1 year, endovascular treatment was associated with lower cost/QALY than clip ligation in unruptured aneurysms ($52 000/QALY vs $137 000/QALY, respectively, p=0.006), but comparable rates in ruptured aneurysms ($193 000/QALY vs $233 000/QALY, p=0.277). Multivariate predictors for higher cost/QALY included worse mRS score at discharge, procedural complications, and larger aneurysm width.ConclusionsCoil embolization of basilar tip aneurysms is associated with a lower cost/QALY. This effect is sustained during follow-up. Clinical condition at discharge is the most significant predictor of overall cost/QALY at 1 year.
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Yue JK, Levin HS, Suen CG, Morrissey MR, Runyon SJ, Winkler EA, Puffer RC, Deng H, Robinson CK, Rick JW, Phelps RRL, Sharma S, Taylor SR, Vassar MJ, Cnossen MC, Lingsma HF, Gardner RC, Temkin NR, Barber J, Dikmen SS, Yuh EL, Mukherjee P, Stein MB, Cage TA, Valadka AB, Okonkwo DO, Manley GT. Age and sex-mediated differences in six-month outcomes after mild traumatic brain injury in young adults: a TRACK-TBI study. Neurol Res 2019; 41:609-623. [PMID: 31007155 DOI: 10.1080/01616412.2019.1602312] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Introduction: Risk factors for young adults with mTBI are not well understood. Improved understanding of age and sex as risk factors for impaired six-month outcomes in young adults is needed. Methods: Young adult mTBI subjects aged 18-39 years (18-29y; 30-39y) with six-month outcomes were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study. Multivariable regressions were performed for outcomes with age, sex, and the interaction factor age-group*sex as variables of interest, controlling for demographic and injury variables. Mean-differences (B) and 95% CIs are reported. Results: One hundred mTBI subjects (18-29y, 70%; 30-39y, 30%; male, 71%; female, 29%) met inclusion criteria. On multivariable analysis, age-group*sex was associated with six-month post-traumatic stress disorder (PTSD; PTSD Checklist-Civilian version); compared with female 30-39y, female 18-29y (B= -19.55 [-26.54, -4.45]), male 18-29y (B= -19.70 [-30.07, -9.33]), and male 30-39y (B= -15.49 [-26.54, -4.45]) were associated with decreased PTSD symptomatology. Female sex was associated with decreased six-month functional outcome (Glasgow Outcome Scale-Extended (GOSE): B= -0.6 [1.0, -0.1]). Comparatively, 30-39y scored higher on six-month nonverbal processing speed (Wechsler Adult Intelligence Scale-Processing Speed Index (WAIS-PSI); B= 11.88, 95% CI [1.66, 22.09]). Conclusions: Following mTBI, young adults aged 18-29y and 30-39y may have different risks for impairment. Sex may interact with age for PTSD symptomatology, with females 30-39y at highest risk. These results may be attributable to cortical maturation, biological response, social modifiers, and/or differential self-report. Confirmation in larger samples is needed; however, prevention and rehabilitation/counseling strategies after mTBI should likely be tailored for age and sex.
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Affiliation(s)
- John K Yue
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Harvey S Levin
- c Departments of Neurology and Neurosurgery , Baylor College of Medicine , Houston , TX , USA
| | - Catherine G Suen
- d Department of Neurology , University of Utah , Salt Lake City , UT , USA
| | - Molly Rose Morrissey
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Sarah J Runyon
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Ethan A Winkler
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Ross C Puffer
- e Department of Neurological Surgery , Mayo Clinic , Rochester , MN , USA.,f Department of Neurological Surgery , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Hansen Deng
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Caitlin K Robinson
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Jonathan W Rick
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Ryan R L Phelps
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Sourabh Sharma
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Sabrina R Taylor
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Mary J Vassar
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Maryse C Cnossen
- g Department of Public Health , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Hester F Lingsma
- g Department of Public Health , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Raquel C Gardner
- h Department of Neurology , University of California San Francisco , San Francisco , CA , USA.,i Department of Neurology , Veterans Affairs Medical Center , San Francisco , CA , USA
| | - Nancy R Temkin
- j Departments of Neurological Surgery and Biostatistics , University of Washington , Seattle , WA , USA
| | - Jason Barber
- j Departments of Neurological Surgery and Biostatistics , University of Washington , Seattle , WA , USA
| | - Sureyya S Dikmen
- k Department of Rehabilitation Medicine , University of Washington , Seattle , WA , USA
| | - Esther L Yuh
- b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA.,l Department of Radiology , University of California San Francisco , San Francisco , CA , USA
| | - Pratik Mukherjee
- b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA.,l Department of Radiology , University of California San Francisco , San Francisco , CA , USA
| | - Murray B Stein
- m Departments of Psychiatry and Family Medicine , University of California San Diego , San Diego , CA , USA
| | - Tene A Cage
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
| | - Alex B Valadka
- n Department of Neurological Surgery , Virginia Commonwealth University , Richmond , VA , USA
| | - David O Okonkwo
- f Department of Neurological Surgery , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Geoffrey T Manley
- a Department of Neurological Surgery , University of California San Francisco , San Francisco , CA , USA.,b Brain and Spinal Injury Center , Zuckerberg San Francisco General Hospital , San Francisco , CA , USA
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- o TRACK-TBI Investigators are listed below in alphabetical order by last name
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Barber J, Taylor B, Gaya A, Qureshi A, Thomas C, Hartill C, Staykova V, Sisodia C. EP-2197 EEBH as a method of managing respiratory movement in treating abdominal structures with SABR. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)32617-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abecassis IJ, Sen RD, Barber J, Shetty R, Kelly CM, Ghodke BV, Hallam DK, Levitt MR, Kim LJ, Sekhar LN. Predictors of Recurrence, Progression, and Retreatment in Basilar Tip Aneurysms: A Location-Controlled Analysis. Oper Neurosurg (Hagerstown) 2019; 16:435-444. [PMID: 29905850 DOI: 10.1093/ons/opy132] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/29/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Endovascular treatment of intracranial aneurysms is associated with higher rates of recurrence and retreatment, though contemporary rates and risk factors for basilar tip aneurysms (BTAs) are less well-described. OBJECTIVE To characterize progression, retreatement, and retreated progression of BTAs treated with microsurgical or endovascular interventions. METHODS We retrospectively reviewed records for 141 consecutive BTA patients. We included 158 anterior communicating artery (ACoA) and 118 middle cerebral artery (MCA) aneurysms as controls. Univariate and multivariate analyses were used to calculate rates of progression (recurrence of previously obliterated aneurysms and progression of known residual aneurysm dome or neck), retreatment, and retreated progression. Kaplan-Meier analysis was used to characterize 24-mo event rates for primary outcome prediction. RESULTS Of 141 BTA patients, 62.4% were ruptured and 37.6% were unruptured. Average radiographical follow-up was 33 mo. Among ruptured aneurysms treated with clipping, there were 2 rehemorrhages due to recurrence (6.1%), and none in any other cohorts. Overall rates of progression (28.9%), retreatment (28.9%), and retreated progression (24.7%) were not significantly different between surgical and endovascular subgroups, though ruptured aneurysms had higher event rates. Multivariate modeling confirmed rupture status (P = .003, hazard ratio = 0.14) and aneurysm dome width (P = .005, hazard ratio = 1.23) as independent predictors of progression requiring retreatment. In a separate multivariate analysis with ACoA and MCA aneurysms, basilar tip location was an independent predictor of progression, retreatment, and retreated progression. CONCLUSION BTAs have higher rates of progression and retreated progression than other aneurysm locations, independent of treatment modality. Rupture status and dome width are risk factors for progression requiring retreatment.
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Affiliation(s)
- Isaac Josh Abecassis
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Rakshith Shetty
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Danial K Hallam
- Department of Radiology, University of Washington, Seattle, Washington
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle, Washington.,Department of Mechanical Engineering, University of Washington, Seattle, Washington
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle, Washington
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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Mac Donald CL, Barber J, Wright J, Coppel D, De Lacy N, Ottinger S, Peck S, Panks C, Sun S, Zalewski K, Temkin N. Longitudinal Clinical and Neuroimaging Evaluation of Symptomatic Concussion in 10- to 14-Year-Old Youth Athletes. J Neurotrauma 2019; 36:264-274. [DOI: 10.1089/neu.2018.5629] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Christine L. Mac Donald
- Department of Neurological Surgery, University of Washington, Seattle, Washington
- Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jason Wright
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - David Coppel
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Nina De Lacy
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Steve Ottinger
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Suzanne Peck
- Seattle Children's Research Institute, Seattle, Washington
| | - Chris Panks
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Samantha Sun
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Kody Zalewski
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
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Mac Donald CL, Barber J, Patterson J, Johnson AM, Dikmen S, Fann JR, Temkin N. Association Between 5-Year Clinical Outcome in Patients With Nonmedically Evacuated Mild Blast Traumatic Brain Injury and Clinical Measures Collected Within 7 Days Postinjury in Combat. JAMA Netw Open 2019; 2:e186676. [PMID: 30646193 PMCID: PMC6324322 DOI: 10.1001/jamanetworkopen.2018.6676] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Although previous work has examined clinical outcomes in combat-deployed veterans, questions remain regarding how symptoms evolve or resolve following mild blast traumatic brain injury (TBI) treated in theater and their association with long-term outcomes. OBJECTIVE To characterize 5-year outcome in patients with nonmedically evacuated blast concussion compared with combat-deployed controls and understand what clinical measures collected acutely in theater are associated with 5-year outcome. DESIGN, SETTING, AND PARTICIPANTS A prospective, longitudinal cohort study including 45 service members with mild blast TBI within 7 days of injury (mean 4 days) and 45 combat deployed nonconcussed controls was carried out. Enrollment occurred in Afghanistan at the point of injury with evaluation of 5-year outcome in the United States. The enrollment occurred from March to September 2012 with 5-year follow up completed from April 2017 to May 2018. Data analysis was completed from June to July 2018. EXPOSURES Concussive blast TBI. All patients were treated in theater, and none required medical evacuation. MAIN OUTCOMES AND MEASURES Clinical measures collected in theater included measures for concussion symptoms, posttraumatic stress disorder (PTSD) symptoms, depression symptoms, balance performance, combat exposure intensity, cognitive performance, and demographics. Five-year outcome evaluation included measures for global disability, neurobehavioral impairment, PTSD symptoms, depression symptoms, and 10 domains of cognitive function. Forward selection multivariate regression was used to determine predictors of 5-year outcome for global disability, neurobehavior impairment, PTSD, and cognitive function. RESULTS Nonmedically evacuated patients with concussive blast injury (n = 45; 44 men, mean [SD] age, 31 [5] years) fared poorly at 5-year follow-up compared with combat-deployed controls (n = 45; 35 men; mean [SD] age, 34 [7] years) on global disability, neurobehavioral impairment, and psychiatric symptoms, whereas cognitive changes were unremarkable. Acute predictors of 5-year outcome consistently identified TBI diagnosis with contribution from acute concussion and mental health symptoms and select measures of cognitive performance depending on the model for 5-year global disability (area under the curve following bootstrap validation [AUCBV] = 0.79), neurobehavioral impairment (correlation following bootstrap validation [RBV] = 0.60), PTSD severity (RBV = 0.36), or cognitive performance (RBV = 0.34). CONCLUSIONS AND RELEVANCE Service members with concussive blast injuries fared poorly at 5-year outcome. The results support a more focused acute screening of mental health following TBI diagnosis as strong indicators of poor long-term outcome. This extends prior work examining outcome in patients with concussive blast injury to the larger nonmedically evacuated population.
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Affiliation(s)
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Jana Patterson
- Department of Neurological Surgery, University of Washington, Seattle
| | - Ann M. Johnson
- Center for Clinical Studies, Washington University, Saint Louis Missouri
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Jesse R. Fann
- Department of Psychiatry, University of Washington, Seattle
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
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Gostelow N, Barber J, Gishen F, Berlin A. Flipping social determinants on its head: Medical student perspectives on the flipped classroom and simulated patients to teach social determinants of health. Med Teach 2018; 40:728-735. [PMID: 29457923 DOI: 10.1080/0142159x.2018.1436757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Inequalities in healthcare are increasing. Engaging medical students to tackle this urgent challenge alongside clinical sciences can be demanding. This study examines medical student perceptions of a flipped approach to health inequalities co-designed by faculty and sixth-year students. INNOVATION A flipped learning session was piloted for year 4 medical students combining an online lesson followed by a tutorial with a simulated patient. METHODS A mixed-methods approach collected questionnaire data using 4-point Likert scales and free text answers. A semi-structured group interview was conducted with six voluntary participants. RESULTS Two hundred and eighty-nine students completed questionnaires. 85% (n = 246) completed the online lesson. Students agreed the session helped their understanding of key concepts (mean 3.2), was improved by having an actor (mean = 3.6), and was enjoyable (mean = 3.2). Thematic analysis of qualitative questionnaire and interview data revealed three themes: engagement; structure; and attitudes towards social determinants of health. The simulation increased clinical relevance and students gained understanding of the impact of health inequalities upon individuals. CONCLUSIONS This paper indicates flipped learning can increase clinical relevance and engagement in population health and person-centered care. Further work could assess changes in practice and attitudes of future doctors in tackling such global health challenges.
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Affiliation(s)
- N Gostelow
- a Medical School , University College London Medical School , London , UK
| | - J Barber
- b Department of Primary Care and Population Health , University College London , London , UK
| | - F Gishen
- c University College London Medical School , London , UK
| | - A Berlin
- c University College London Medical School , London , UK
- d Barts and the London School of Medicine and Dentistry , Queen Mary's University , London , UK
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Ozawa T, Arora S, Szulzewsky F, Juric-Sekhar G, Miyajima Y, Bolouri H, Yasui Y, Barber J, Kupp R, Dalton J, Jones TS, Nakada M, Kumabe T, Ellison DW, Gilbertson RJ, Holland EC. A De Novo Mouse Model of C11orf95-RELA Fusion-Driven Ependymoma Identifies Driver Functions in Addition to NF-κB. Cell Rep 2018; 23:3787-3797. [PMID: 29949764 PMCID: PMC6411037 DOI: 10.1016/j.celrep.2018.04.099] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/11/2018] [Accepted: 04/24/2018] [Indexed: 11/30/2022] Open
Abstract
The majority of supratentorial ependymomas (ST-ependymomas) have few mutations but frequently display chromothripsis of chromosome 11q that generates a fusion between C11orf95 and RELA (RELAFUS). Neural stem cells transduced with RELAFUSex vivo form ependymomas when implanted in the brain. These tumors display enhanced NF-κB signaling, suggesting that this aberrant signal is the principal mechanism of oncogenesis. However, it is not known whether RELAFUS is sufficient to drive de novo ependymoma tumorigenesis in the brain and, if so, whether these tumors also arise from neural stem cells. We show that RELAFUS drives ST-ependymoma formation from periventricular neural stem cells in mice and that RELAFUS-induced tumorigenesis is likely dependent on a series of cell signaling pathways in addition to NF-κB.
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Affiliation(s)
- Tatsuya Ozawa
- Division of Human Biology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA; Seattle Tumor Translational Research (STTR), Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA; Alvord Brain Tumor Center, University of Washington, Seattle, WA 98109, USA; Division of Brain Tumor Translational Research, National Cancer Center Research Institute, Tokyo 104-0045, Japan
| | - Sonali Arora
- Division of Human Biology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA
| | - Frank Szulzewsky
- Division of Human Biology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA
| | | | - Yoshiteru Miyajima
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa 252-0374, Japan
| | - Hamid Bolouri
- Division of Human Biology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA
| | - Yoshie Yasui
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa 252-0374, Japan
| | - Jason Barber
- Department of Neurosurgery, University of Washington, Seattle, WA 98109, USA
| | - Robert Kupp
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - James Dalton
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Terreia S Jones
- University of Tennessee Health Science Center, Department of Clinical Pharmacy, Memphis, TN 39103, USA
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Toshihiro Kumabe
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa 252-0374, Japan
| | - David W Ellison
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | | | - Eric C Holland
- Division of Human Biology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA; Seattle Tumor Translational Research (STTR), Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA; Alvord Brain Tumor Center, University of Washington, Seattle, WA 98109, USA; Department of Neurosurgery, University of Washington, Seattle, WA 98109, USA.
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Hammond FM, Sherer M, Malec JF, Zafonte RD, Dikmen S, Bogner J, Bell KR, Barber J, Temkin N. Amantadine Did Not Positively Impact Cognition in Chronic Traumatic Brain Injury: A Multi-Site, Randomized, Controlled Trial. J Neurotrauma 2018; 35:2298-2305. [PMID: 29742960 PMCID: PMC6157374 DOI: 10.1089/neu.2018.5767] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Despite limited evidence to support the use of amantadine to enhance cognitive function after traumatic brain injury (TBI), the clinical use for this purpose is highly prevalent and is often based on inferred belief systems. The aim of this study was to assess effect of amantadine on cognition among individuals with a history of TBI and behavioral disturbance using a parallel-group, randomized, double-blind, placebo-controlled trial of amantadine 100 mg twice-daily versus placebo for 60 days. Included in the study were 119 individuals with two or more neuropsychological measures greater than 1 standard deviation below normative means from a larger study of 168 individuals with chronic TBI (>6 months post-injury) and irritability. Cognitive function was measured at treatment days 0, 28, and 60 with a battery of neuropsychological tests. Composite indices were generated: General Cognitive Index (included all measures), a Learning Memory Index (learning/memory measures), and Attention/Processing Speed Index (attention and executive function measures). Repeated-measures analysis of variance revealed statistically significant between-group differences favoring the placebo group at day 28 for General Cognitive Index (p = 0.002) and Learning Memory Index (p = 0.001), but not Attention/Processing Speed Index (p = 0.25), whereas no statistically significant between-group differences were found at day 60. There were no statistically significant between-group differences on adverse events. Cognitive function in individuals with chronic TBI is not improved by amantadine 100 mg twice-daily. In the first 28 days of use, amantadine may impede cognitive processing. However, the effect size was small and mean scores for both groups were generally within expectations for persons with history of complicated mild-to-severe TBI, suggesting that changes observed across assessments may not have functional significance. The use of amantadine to enhance cognitive function is not supported by these findings.
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Affiliation(s)
- Flora M. Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana
- Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Carolinas HealthCare System, Charlotte, North Carolina
- Address correspondence to:Flora M. Hammond, MDRehabilitation Hospital of Indiana4141 Shore DriveIndianapolis, IN 46254
| | | | - James F. Malec
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana
| | | | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Jennifer Bogner
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio
| | - Kathleen R. Bell
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
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Barber J, Marles RJ. Regulation of Supplemented Foods in Canada: Challenges and Evidence Gaps. Am J Transl Res 2018. [DOI: 10.1055/s-0038-1644936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- J Barber
- Bureau of Nutritional Sciences, Food Directorate, Health Canada, Ottawa, Ontario, Canada
| | - RJ Marles
- Bureau of Nutritional Sciences, Food Directorate, Health Canada, Ottawa, Ontario, Canada
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Hayes H, Barber J, Dembo L, Lam K, Shah A, Dias P, Lambert J, Larbalestier R, Baumwol. J. The World’s Longest-Supported HeartWare TM Ventricular Assist Device Patient 10 Years & Counting: The Western Australian Experience. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Asokendaran M, AL-Ogaili Z, Njue F, Barber J, Hayes H, Lam K. The Role of Gallium Scans in the Diagnosis of Clinically Suspected Left Ventricular Assist Device Infections in Western Australia. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Njue F, Collins K, Hayes H, Barber J, Lam K. Neurohormonal Blockade with Sacubitril/Valsartan in Left Ventricular Assist Device (LVAD) Patients. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.1261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Cooper C, Rapaport P, Robertson S, Marston L, Barber J, Manela M, Livingston G. Relationship between speaking English as a second language and agitation in people with dementia living in care homes: Results from the MARQUE (Managing Agitation and Raising Quality of life) English national care home survey. Int J Geriatr Psychiatry 2018; 33:504-509. [PMID: 28971511 PMCID: PMC5836957 DOI: 10.1002/gps.4786] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/08/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVE As not speaking English as a first language may lead to increased difficulties in communication with staff and other residents, we (1) tested our primary hypotheses that care home residents with dementia speaking English as a second language experience more agitation and overall neuropsychiatric symptoms, and (2) explored qualitatively how staff consider that residents' language, ethnicity, and culture might impact on how they manage agitation. METHODS We interviewed staff, residents with dementia, and their family carers from 86 care homes (2014-2015) about resident's neuropsychiatric symptoms, agitation, life quality, and dementia severity. We qualitatively interviewed 25 staff. RESULTS Seventy-one out of 1420 (5%) of care home residents with dementia interviewed spoke English as a second language. After controlling for dementia severity, age, and sex, and accounting for care home and staff proxy clustering, speaking English as a second language compared with as a first language was associated with significantly higher Cohen-Mansfield Agitation Inventory (adjusted difference in means 8.3, 95% confidence interval 4.1 to 12.5) and Neuropsychiatric inventory scores (4.1, 0.65 to 7.5). Staff narratives described how linguistic and culturally isolating being in a care home where no residents or staff share your culture or language could be for people with dementia, and how this sometimes caused or worsened agitation. CONCLUSIONS Considering a person with dementia's need to be understood when selecting a care home and developing technology resources to enable dementia-friendly translation services could be important strategies for reducing distress of people with dementia from minority ethnic groups who live in care homes.
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Affiliation(s)
- C. Cooper
- UCL Department of Old Age Psychiatry, Division of PsychiatryLondonUK
| | - P. Rapaport
- UCL Department of Old Age Psychiatry, Division of PsychiatryLondonUK
| | | | - L. Marston
- UCL Department of Statistical ScienceGower StreetLondonUK
| | - J. Barber
- UCL Department of Primary Care and Population Health and Priment Clinical Trials UnitUK
| | - M. Manela
- UCL Department of Old Age Psychiatry, Division of PsychiatryLondonUK
| | - G. Livingston
- UCL Department of Old Age Psychiatry, Division of PsychiatryLondonUK
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Lee F, Njue F, Lambert J, Parle N, Barber J, Baumwol J, Shah A, Dembo L. Wearable Cardioverter Defibrillator: Insights from an Australian Advanced Heart Failure and Transplantation Service. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bonow RH, Barber J, Temkin NR, Videtta W, Rondina C, Petroni G, Lujan S, Alanis V, La Fuente G, Lavadenz A, Merida R, Jibaja M, Gonzáles L, Falcao A, Romero R, Dikmen S, Pridgeon J, Chesnut RM. The Outcome of Severe Traumatic Brain Injury in Latin America. World Neurosurg 2017; 111:e82-e90. [PMID: 29229352 DOI: 10.1016/j.wneu.2017.11.171] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) disproportionately affects lower- and middle-income countries (LMIC). The factors influencing outcomes in LMIC have not been examined as rigorously as in higher-income countries. METHODS This study was conducted to examine clinical and demographic factors influencing TBI outcomes in Latin American LMIC. Data were prospectively collected during a randomized trial of intracranial pressure monitoring in severe TBI and a companion observational study. Participants were aged ≥13 years and admitted to study hospitals with Glasgow Coma Scale score ≤8. The primary outcome was Glasgow Outcome Scale, Extended (GOS-E) score at 6 months. Predictors were analyzed using a multivariable proportional odds model created by forward stepwise selection. RESULTS A total of 550 patients were identified. Six-month outcomes were available for 88%, of whom 37% had died and 44% had achieved a GOS-E score of 5-8. In multivariable proportional odds modeling, higher Glasgow Coma Scale motor score (odds ratio [OR], 1.41 per point; 95% confidence interval [CI], 1.23-1.61) and epidural hematoma (OR, 1.83; 95% CI, 1.17-2.86) were significant predictors of higher GOS-E score, whereas advanced age (OR, 0.65 per 10 years; 95% CI, 0.57-0.73) and cisternal effacement (P < 0.001) were associated with lower GOS-E score. Study site (P < 0.001) and race (P = 0.004) significantly predicted outcome, outweighing clinical variables such as hypotension and pupillary examination. CONCLUSIONS Mortality from severe TBI is high in Latin American LMIC, although the rate of favorable recovery is similar to that of high-income countries. Demographic factors such as race and study site played an outsized role in predicting outcome; further research is required to understand these associations.
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Affiliation(s)
- Robert H Bonow
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | | | - Gustavo Petroni
- Hospital de Emergencias Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- Hospital de Emergencias Dr. Clemente Alvarez, Rosario, Argentina
| | - Victor Alanis
- University Hospital San Juan De Dios, Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Antonio Falcao
- Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | | | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - James Pridgeon
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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Wagholikar V, Zhuang H, Jiao Y, Moe N, Ramanan H, Goh L, Barber J, Lee K, Lee H, Fuh J. Modeling cell pair resistance and spacer shadow factors in electro-separation processes. J Memb Sci 2017. [DOI: 10.1016/j.memsci.2017.08.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Okonkwo DO, Shutter LA, Moore C, Temkin NR, Puccio AM, Madden CJ, Andaluz N, Chesnut RM, Bullock MR, Grant GA, McGregor J, Weaver M, Jallo J, LeRoux PD, Moberg D, Barber J, Lazaridis C, Diaz-Arrastia RR. Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II: A Phase II Randomized Trial. Crit Care Med 2017; 45:1907-1914. [PMID: 29028696 PMCID: PMC5679063 DOI: 10.1097/ccm.0000000000002619] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A relationship between reduced brain tissue oxygenation and poor outcome following severe traumatic brain injury has been reported in observational studies. We designed a Phase II trial to assess whether a neurocritical care management protocol could improve brain tissue oxygenation levels in patients with severe traumatic brain injury and the feasibility of a Phase III efficacy study. DESIGN Randomized prospective clinical trial. SETTING Ten ICUs in the United States. PATIENTS One hundred nineteen severe traumatic brain injury patients. INTERVENTIONS Patients were randomized to treatment protocol based on intracranial pressure plus brain tissue oxygenation monitoring versus intracranial pressure monitoring alone. Brain tissue oxygenation data were recorded in the intracranial pressure -only group in blinded fashion. Tiered interventions in each arm were specified and impact on intracranial pressure and brain tissue oxygenation measured. Monitors were removed if values were normal for 48 hours consecutively, or after 5 days. Outcome was measured at 6 months using the Glasgow Outcome Scale-Extended. MEASUREMENTS AND MAIN RESULTS A management protocol based on brain tissue oxygenation and intracranial pressure monitoring reduced the proportion of time with brain tissue hypoxia after severe traumatic brain injury (0.45 in intracranial pressure-only group and 0.16 in intracranial pressure plus brain tissue oxygenation group; p < 0.0001). Intracranial pressure control was similar in both groups. Safety and feasibility of the tiered treatment protocol were confirmed. There were no procedure-related complications. Treatment of secondary injury after severe traumatic brain injury based on brain tissue oxygenation and intracranial pressure values was consistent with reduced mortality and increased proportions of patients with good recovery compared with intracranial pressure-only management; however, the study was not powered for clinical efficacy. CONCLUSIONS Management of severe traumatic brain injury informed by multimodal intracranial pressure and brain tissue oxygenation monitoring reduced brain tissue hypoxia with a trend toward lower mortality and more favorable outcomes than intracranial pressure-only treatment. A Phase III randomized trial to assess impact on neurologic outcome of intracranial pressure plus brain tissue oxygenation-directed treatment of severe traumatic brain injury is warranted.
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Affiliation(s)
- David O Okonkwo
- 1University of Pittsburgh School of Medicine, Pittsburgh, PA. 2Uniformed Services University of the Health Sciences, Bethesda, MD. 3University of Washington, Seattle, WA. 4UT Southwestern Medical Center, Dallas, TX. 5University of Cincinnati College of Medicine, Cincinnati, OH. 6University of Miami, Miller School of Medicine, Miami, FL. 7Stanford University, Stanford, CA. 8Ohio State University College of Medicine, Columbus, OH. 9Temple University, Philadelphia, PA. 10Thomas Jefferson University, Philadelphia, PA. 11Lankenau Medical Center, Wynnewood, PA. 12Moberg Research, Ambler, PA. 13Baylor St. Luke's Medical Center, Houston, TX. 14Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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89
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Chesnut RM, Temkin N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Alanis V, Falcao A, de la Fuenta G, Gonzalez L, Jibaja M, Lavarden A, Sandi F, Mérida R, Romero R, Pridgeon J, Barber J, Machamer J, Chaddock K. A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol. J Neurotrauma 2017; 35:54-63. [PMID: 28726590 DOI: 10.1089/neu.2016.4472] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The imaging and clinical examination (ICE) algorithm used in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) randomized controlled trial is the only prospectively investigated clinical protocol for traumatic brain injury management without intracranial pressure (ICP) monitoring. As the default literature standard, it warrants careful evaluation. We present the ICE protocol in detail and analyze the demographics, outcome, treatment intensity, frequency of intervention usage, and related adverse events in the ICE-protocol cohort. The 167 ICE protocol patients were young (median 29 years) with a median Glasgow Coma Scale motor score of 4 but with anisocoria or abnormal pupillary reactivity in 40%. This protocol produced outcomes not significantly different from those randomized to the monitor-based protocol (favorable 6-month extended Glasgow Outcome Score in 39%; 41% mortality rate). Agents commonly employed to treat suspected intracranial hypertension included low-/moderate-dose hypertonic saline (72%) and mannitol (57%), mild hyperventilation (adjusted partial pressure of carbon dioxide 30-35 mm Hg in 73%), and pressors to maintain cerebral perfusion (62%). High-dose hyperosmotics or barbiturates were uncommonly used. Adverse event incidence was low and comparable to the BEST TRIP monitored group. Although this protocol should produce similar/acceptable results under circumstances comparable to those in the trial, influences such as longer pre-hospital times and non-specialist transport personnel, plus an intensive care unit model of aggressive physician-intensive care by small groups of neurotrauma-focused intensivists, which differs from most high-resource models, support caution in expecting the same results in dissimilar settings. Finally, this protocol's ICP-titration approach to suspected intracranial hypertension (vs. crisis management for monitored ICP) warrants further study.
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Affiliation(s)
- Randall M Chesnut
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Nancy Temkin
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Sureyya Dikmen
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Carlos Rondina
- 2 Hospital Emergencia , Dr. Clemente Alvarez, Rosario, Argentina
| | - Walter Videtta
- 3 Hospital Nacional Professor Alejandro Posadas , Buenos Aires, Argentina
| | - Gustavo Petroni
- 2 Hospital Emergencia , Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- 2 Hospital Emergencia , Dr. Clemente Alvarez, Rosario, Argentina
| | - Victor Alanis
- 4 Hospital San Juan de Dios , Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Freddy Sandi
- 10 Hospital Obrero No 1 de La Paz , La Paz, Bolivia
| | | | | | - Jim Pridgeon
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Jason Barber
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Joan Machamer
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Kelley Chaddock
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
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90
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Stillman MD, Barber J, Burns S, Williams S, Hoffman JM. Complications of Spinal Cord Injury Over the First Year After Discharge From Inpatient Rehabilitation. Arch Phys Med Rehabil 2017; 98:1800-1805. [DOI: 10.1016/j.apmr.2016.12.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/05/2016] [Accepted: 12/18/2016] [Indexed: 11/15/2022]
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91
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Nerva JD, Barber J, Levitt MR, Rockhill JK, Hallam DK, Ghodke BV, Sekhar LN, Kim LJ. Onyx embolization prior to stereotactic radiosurgery for brain arteriovenous malformations: a single-center treatment algorithm. J Neurointerv Surg 2017; 10:258-267. [PMID: 28710086 DOI: 10.1136/neurintsurg-2017-013084] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/08/2017] [Accepted: 05/09/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Embolization before stereotactic radiosurgery (SRS) for brain arteriovenous malformations (BAVMs) is controversial. OBJECTIVE To compare clinical and radiographic outcomes in patients undergoing pre-SRS embolization with ethylene copolymer (Onyx) with outcomes in patients undergoing SRS alone. METHODS Seventy consecutive patients with BAVMs who underwent SRS were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the factors associated with radiographic obliteration and complication. RESULTS Forty-one (59%) patients presented without BAVM rupture and 29 (41%) patients presented with rupture. Pre-SRS embolization was used in 20 patients (28.6%; 7 unruptured and 13 ruptured). Twenty-five of 70 (36%) patients sustained a complication from treatment, including 6 (9%) patients with a post-SRS latency period hemorrhage. Ten (14%) patients had persistent neurological deficits after treatment. Functional outcome (as modified Rankin Scale), complication rate, and radiographic obliteration at last follow-up were not significantly different between embolized and non-embolized groups in both unruptured and ruptured BAVMs. For unruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 23% and 73% for non-embolized patients and 20% and 60% for embolized patients, respectively. For ruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 45% and 72% for non-embolized patients and 53% and 82% for embolized patients, respectively. CONCLUSION Pre-SRS embolization with Onyx was not associated with worse clinical or radiographic outcomes than SRS treatment without embolization. Pre-SRS embolization has a low complication rate and can safely be used to target high-risk BAVM features in carefully selected patients destined for SRS.
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Affiliation(s)
- John D Nerva
- Department of Neurological Surgery, University of Washington, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA.,Department of Mechanical Engineering, University of Washington, Washington, USA
| | - Jason K Rockhill
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiation Oncology, University of Washington, Washington, USA
| | - Danial K Hallam
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
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92
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Hartmann C, Minor L, Terkildsen S, Barber J, Shaughnessy M. ALL TOGETHER NOW: MULTIPLE STAKEHOLDER INSIGHTS ON INTEGRATING QUALITY IMPROVEMENT IN A LARGE SYSTEM. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.3067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- C.W. Hartmann
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts,
- Boston University School of Public Health,
Boston, Massachusetts,
| | - L. Minor
- Geriatrics and Extended Care Operations, Washington, District of Columbia,
| | - S.R. Terkildsen
- Geriatrics and Extended Care Operations, Washington, District of Columbia,
| | - J. Barber
- Geriatrics and Extended Care Operations, Washington, District of Columbia,
| | - M. Shaughnessy
- Office of Geriatrics and Extended Care Policy, Washington, District of Columbia
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93
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Mac Donald CL, Barber J, Jordan M, Johnson AM, Dikmen S, Fann JR, Temkin N. Early Clinical Predictors of 5-Year Outcome After Concussive Blast Traumatic Brain Injury. JAMA Neurol 2017; 74:821-829. [PMID: 28459953 PMCID: PMC5732492 DOI: 10.1001/jamaneurol.2017.0143] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance The long-term clinical effects of wartime traumatic brain injuries (TBIs), most of which are mild, remain incompletely described. Current medical disability cost estimates from world conflicts continually surpass projections. Additional information regarding long-term functional trajectory is needed to reduce this extensive public health burden. Objectives To examine 5-year clinical outcomes leveraging existing clinical data collected at 1 year after injury in the same patients and to identify early risk factors for long-term disability. Design, Setting, and Participants This prospective, longitudinal study enrolled active-duty US military after concussive blast injury (n = 50) in the acute to subacute stage and combat-deployed control individuals (n = 44) in Afghanistan or after medical evacuation to Germany from November 1, 2008, through July 1, 2013. One- and 5-year clinical evaluations were completed in the United States. All concussive blast injuries met the Department of Defense definition of mild, uncomplicated TBI. In-person clinical evaluations included standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden that were essentially identical to the evaluations completed at 1-year follow-up. Data were analyzed from October 1 through November 30, 2016. Main Outcomes and Measures Changes in the in-person standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden from the 1- to 5-year follow-up. Predictive modeling was used to identify early risk factors for long-term disability. Results Among the 94 participants (87 men [93%] and 7 women [7%]; mean [SD] age, 34 [8] years), global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI compared with combat-deployed controls, whereas performance on cognitive measures was no different between groups at the 5-year evaluation. Logistic regression on the dichotomized Extended Glasgow Outcome Scale (GOS-E) at 5 years as a measure of overall disability identified brain injury diagnosis, preinjury intelligence, motor strength, verbal fluency, and neurobehavioral symptom severity at 1 year as risk factors for a poor outcome at 5 years, with an area under the curve of 0.92 indicating excellent prediction strength. Thirty-six of 50 patients with concussive blast TBI (72%) had a decline in the GOS-E from the 1- to 5-year evaluations, in contrast with only 5 of 44 combat-deployed controls (11%). Worsening of symptoms in concussive blast TBI was also observed on measures of posttraumatic stress disorder and depression. Service members with concussive blast TBI experienced evolution, not resolution, of symptoms from the 1- to 5-year outcomes. Conclusions and Relevance Considerable decline was observed in military service members with concussive blast TBI when comparing 1- and 5-year clinical outcomes. These results advocate for new treatment strategies to combat the long-term and extremely costly effect of these wartime injuries.
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Affiliation(s)
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle
| | - Mary Jordan
- Department of Neurological Surgery, University of Washington, Seattle
| | - Ann M Johnson
- Center for Clinical Studies, Washington University, St Louis, Missouri
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Jesse R Fann
- Department of Psychiatry, University of Washington, Seattle
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle5Department of Biostatistics, University of Washington, Seattle
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94
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Abecassis IJ, Hanak B, Barber J, Mortazavi M, Ellenbogen RG. A Single-Institution Experience with Pineal Region Tumors: 50 Tumors Over 1 Decade. Oper Neurosurg (Hagerstown) 2017; 13:566-575. [DOI: 10.1093/ons/opx038] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 02/07/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: Pineal region tumors are rare intracranial tumors that are more common in children than adults. Surgical management of tumors in this region using a tailored approach is a strategy that enhances extent of resection and neurological outcome.
OBJECTIVE: To review our institutional experience with pineal region tumors in children and adults over the past 10 years.
METHODS: Our institutional pathology database and patient records were retrospectively reviewed for details regarding clinical and radiological presentation, surgical management, extent of resection, morbidity, and neurological outcome. Statistical analysis was performed to assess for variables related to functional outcomes.
RESULTS: Fifty patients were identified as having undergone surgical management of a pineal region tumor with at least 1 year of follow-up. Forty-one percent presented with a Karnofsky Performance Scale (KPS) score of 70 or less, all of whom had concomitant hydrocephalus that required urgent treatment. The following variables were statistically significant to KPS score on admission: age, tumor volume, preoperative hydrocephalus, length of hospitalization (total and intensive care unit), and elevations in serum tumor markers. The median postoperative (2 months) KPS score was 90. The following variables were statistically significant with respect to change in KPS score postoperatively: tumor maximum diameter, KPS score on admission, and intensive care unit length of stay. The specific surgical strategy did not correlate to extent of tumor resection, morbidity, immediate neurological outcome, and progression-free survival.
CONCLUSION: Extent of resection, neurological outcome, and progression-free survival in the patients in our series were not related to the specific surgical approach employed and its perioperative complications.
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Affiliation(s)
- Isaac Josh Abecassis
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Brian Hanak
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Martin Mortazavi
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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95
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Mac Donald CL, Barber J, Andre J, Evans N, Panks C, Sun S, Zalewski K, Elizabeth Sanders R, Temkin N. 5-Year imaging sequelae of concussive blast injury and relation to early clinical outcome. Neuroimage Clin 2017; 14:371-378. [PMID: 28243574 PMCID: PMC5320067 DOI: 10.1016/j.nicl.2017.02.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 12/27/2022]
Abstract
Current imaging diagnostic techniques are often insensitive to the underlying pathological changes following mild traumatic brain injury (TBI) or concussion so much so that the explicit definition of these uncomplicated mild brain injuries includes the absence of radiological findings. In the US military, this is complicated by the natural tendency of service members to down play symptoms for fear of removal from their unit particularly in combat making it challenging for clinicians to definitively diagnose and determine course of treatment. Questions remain regarding the long-term impact of these war-time brain injuries. The objective of the current study was to evaluate the long-term imaging sequelae of blast concussion in active-duty US military and leverage previous longitudinal data collected in these same patients to identify predictors of sustained DTI signal change indicative of chronic neurodegeneration. In total, 50 blast TBI and 44 combat-deployed controls were evaluated at this 5-year follow up by advanced neuroimaging techniques including diffusion tensor imaging and quantitative volumetry. While cross-sectional analysis of regions of white matter on DTI images did not reveal significant differences across groups after statistical correction, an approach flexible to the heterogeneity of brain injury at the single-subject level identified 74% of the concussive blast TBI cohort to have reductions in fractional anisotropy indicative of chronic brain injury. Logistic regression leveraging clinical and demographic data collected in the acute/sub-acute and 1-year follow up to determine predictors of these long-term imaging changes determined that brain injury diagnosis, older age, verbal memory and verbal fluency best predicted the presence of DTI abnormalities 5 years post injury with an AUC of 0.78 indicating good prediction strength. These results provide supporting evidence for the evolution not resolution of this brain injury pathology, adding to the growing body of literature describing imaging signatures of chronic neurodegeneration even after mild TBI and concussion. Design: prospective, observational, longitudinal research study Patients: concussive blast (n = 50), combat-deployed control (n = 44) Diffusion tensor imaging analyzed 5 yr post-injury, highly predicted by 1 yr outcomes. Imaging abnormalities appear to evolve from sub-acute, to 1-year, to 5-year scan. Findings indicate chronic neurodegeneration in majority of blast concussion patients.
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Key Words
- A-P, anterior–posterior
- Concussion
- DR-BUDDI, Diffeomorphic Registration for Blip-Up blip-Down Diffusion Imaging
- DTI, Diffusion Tensor Imaging
- Diffusion tensor imaging
- EPI, Echo Planar Imaging
- EPV, events-per-variable
- FA, Fractional Anisotropy
- FLAIR, Fluid attenuation inversion recovery
- MPRAGE, Magnetization prepared rapid gradient-echo
- Neurodegeneration
- TBI, Traumatic Brain Injury
- TORTOISE, Tolerably Obsessive Registration and Tensor Optimization Indolent Software Ensemble
- Traumatic brain injury
- US, United States
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Affiliation(s)
| | - Jason Barber
- University of Washington, Department of Neurological Surgery, Seattle, WA, USA
| | - Jalal Andre
- University of Washington, Department of Radiology, Seattle, WA, USA
| | - Nicole Evans
- University of Washington, Department of Neurological Surgery, Seattle, WA, USA
| | - Chris Panks
- University of Washington, Department of Neurological Surgery, Seattle, WA, USA
| | - Samantha Sun
- University of Washington, Department of Neurological Surgery, Seattle, WA, USA
| | - Kody Zalewski
- University of Washington, Department of Neurological Surgery, Seattle, WA, USA
| | | | - Nancy Temkin
- University of Washington, Department of Neurological Surgery, Seattle, WA, USA; University of Washington, Department of Biostatistics, Seattle, WA, USA
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96
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Abecassis IJ, Nerva JD, Barber J, Rockhill J, Ellenbogen RG, Kim LJ, Sekhar LN. Toward a comprehensive assessment of functional outcomes in pediatric patients with brain arteriovenous malformations: the Pediatric Quality of Life Inventory. J Neurosurg Pediatr 2016; 18:611-622. [PMID: 27540697 DOI: 10.3171/2016.6.peds16103] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (bAVMs) are rare in pediatric patients but represent the most common cause of hemorrhagic stroke in this population. Pediatric patients demonstrate superior outcomes in comparison with adult patients with similar lesions and presentations. Most studies of clinical outcomes of pediatric bAVMs use the modified Rankin Scale (mRS), despite a lack of validation in pediatric patients. METHODS The authors interviewed the parents of 26 pediatric patients who underwent multimodality bAVM treatment and administered the Pediatric Quality of Life Inventory (PedsQL)-a well-validated tool for pediatric outcomes that quantifies performance in a physical, emotional, social, and school domains. They also reviewed clinical information from the patients' medical charts. Statistical analysis was performed using a log-transformed t-test, the Mann-Whitney exact test, the Kruskal-Wallis test, and Spearman correlation. In addition, the literature was reviewed for prior reports of clinical outcome of pediatric cases of bAVM. RESULTS The average PedsQL health-related quality of life score was 71 ± 24, with an average age at diagnosis of 12.5 years and an average follow-up period of 6.8 years. Seventeen patients (65%) presented with hemorrhage and 4 (15%) with seizures. PedsQL scores correlated strongly and at a statistically significant level (p < 0.001) with mRS, Pediatric Overall Performance Category (POPC), Pediatric Cerebral Performance Category (PCPC), and Glasgow Outcome Scale scores. Multivariate modeling validated special education, corrective devices, and cure status as significant predictors of PedsQL scores. Statistically significant risk factors for undergoing placement of a ventriculoperitoneal shunt included lower Glasgow Coma Scale motor scores on admission (p = 0.042), cerebellar location (p = 0.046), and nidus volume (p = 0.017). Neither treatment modality nor location statistically affected clinical outcomes at follow-up. CONCLUSIONS There have been few studies of long-term clinical outcomes of bAVM in pediatric patients, and previously published studies have used conventional metrics that have been validated in the adult population, such as the mRS. Although these metrics can serve as reasonable surrogates, an accurate understanding of overall health-related quality of life is contingent on utilizing validated toolsets, such as the PedsQL.
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Affiliation(s)
| | | | | | | | | | - Louis J Kim
- Departments of 1 Neurological Surgery.,Radiology, University of Washington, Seattle, Washington
| | - Laligam N Sekhar
- Departments of 1 Neurological Surgery.,Radiology, University of Washington, Seattle, Washington
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97
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Birtle A, Barber J. Ten Years on the Juggernaut Keeps on Rolling: Comments on the STAMPEDE Trial from the Front Line. Clin Oncol (R Coll Radiol) 2016; 28:547-9. [DOI: 10.1016/j.clon.2016.04.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
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98
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Richardson EJ, Brooks LG, Richards JS, Bombardier CH, Barber J, Tate D, Forchheimer MB, Fann JR. Changes in pain and quality of life in depressed individuals with spinal cord injury: does type of pain matter? J Spinal Cord Med 2016; 39:535-43. [PMID: 26913786 PMCID: PMC5020591 DOI: 10.1080/10790268.2016.1151145] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To examine the association of neuropathic and nociceptive pain severity and interference with quality of life (QoL) in persons with spinal cord injury (SCI) who underwent a randomized controlled 12-week trial of an antidepressant to treat depression. A secondary objective was to assess the effect of changes in pain on mobility and physical independence. DESIGN Multivariable ANCOVA models controlling for relevant demographic covariates, treatment condition, and baseline pain and QoL were used. SETTING Six rehabilitation centers. PARTICIPANTS Of the 133 persons who were randomized into the trial, 108 provided pain severity and interference ratings through follow-up. INTERVENTIONS Not applicable. OUTCOME MEASURES The Satisfaction with Life Scale and the physical and mental component summary scores of the 12-Item Short-Form Health Survey (SF-12). Secondary outcome measures included the mobility and physical independence subscales of the Craig Handicap Assessment and Reporting Technique (CHART). RESULTS Broadly, few associations between pain and QoL were evident. Results revealed relationships between lower baseline nociceptive pain interference and higher satisfaction with life and mental health-related QoL at 12 weeks. Similarly, lower neuropathic pain interference was associated with change in physical independence, but unrelated to mobility. CONCLUSIONS Pain interference over time may be differentially related to QoL outcomes based on the type of pain following SCI, but overall, there were no extensive relationships between pain and QoL in this sample of depressed persons with SCI.
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Affiliation(s)
- Elizabeth J. Richardson
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA,Correspondence to: Elizabeth J. Richardson, PhD, MSPH, Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, 530 Spain Rehabiltation Center, 1717 6th Ave South, Birmingham, AL 35249, USA.
| | - Larry G. Brooks
- Department of Rehabilitation Medicine, University of Miami, Miami, Florida, USA
| | - J. Scott Richards
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Jason Barber
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Denise Tate
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Martin B. Forchheimer
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Jesse R. Fann
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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99
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Morton RP, Abecassis IJ, Hanson JF, Barber J, Nerva JD, Emerson SN, Ene CI, Chowdhary MM, Levitt MR, Ko AL, Dellit TH, Chesnut RM. Predictors of infection after 754 cranioplasty operations and the value of intraoperative cultures for cryopreserved bone flaps. J Neurosurg 2016; 125:766-70. [DOI: 10.3171/2015.8.jns151390] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The authors' aim was to report the largest study on predictors of infection after cranioplasty and to assess the predictive value of intraoperative bone flap cultures before cryopreservation.
METHODS
They retrospectively examined all cranioplasties performed between March 2004 and November 2014. Throughout this study period, the standard protocol during initial craniectomy was to obtain a culture swab of the extracted autologous bone flap (ABF)—prior to its placement in cytostorage—to screen for microbial contamination. Two consecutive protocols were employed for the use and interpretation of the intraoperative swab culture results: A) From March 2004 through June 2013, any culture-positive ABF (+ABF) was discarded and a custom synthetic prosthesis was implanted at the time of cranioplasty. B) From July 2013 through November 2014, any ABF with a skin flora organism was not discarded. Instead, cryopreservation was maintained and the +ABF was reimplanted after a 10-minute soak in bacitracin irrigation as well as a 3-minute soak in betadine.
RESULTS
Over the 10.75-year period, 754 cranioplasty procedures were performed. The median time from craniectomy to cranioplasty was 123 days. Median follow-up after cranioplasty was 237 days for protocol A and 225 days for protocol B. The overall infection rate after cranioplasty was 6.6% (50 cases) occurring at a median postoperative Day 31. Staphylococcus spp. were involved as the causative organisms in 60% of cases.
Culture swabs taken at the time of initial craniectomy were available for 640 ABFs as 114 ABFs were not salvageable. One hundred twenty-six (20%) were culture positive. Eighty-nine +ABFs occurred during protocol A and were discarded in favor of a synthetic prosthesis at the time of cranioplasty, whereas 37 +ABFs occurred under protocol B and were reimplanted at the time of cranioplasty.
Cranioplasty material did not affect the postcranioplasty infection rate. There was no significant difference in the infection rate among sterile ABFs (7%), +ABFs (8%), and synthetic prostheses (5.5%; p = 0.425). All 3 +ABF infections under protocol B were caused by organisms that differed from those in the original intraoperative bone culture from the initial craniectomy. A cranioplasty procedure ≤ 14 days after initial craniectomy was the only significant predictor of postcranioplasty infection (p = 0.007, HR 3.62).
CONCLUSIONS
Cranioplasty procedures should be performed at least 14 days after initial craniectomy to minimize infection risk. Obtaining intraoperative bone cultures at the time of craniectomy in the absence of clinical infection should be discontinued as the culture results were not a useful predictor of postcranioplasty infection and led to the unnecessary use of synthetic prostheses and increased health care costs.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Timothy H. Dellit
- 2Infection Control, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington
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Ene CI, Xu D, Morton RP, Emerson S, Levitt MR, Barber J, Rostomily RC, Ghodke BV, Hallam DK, Albuquerque FC, McDougall CG, Sekhar LN, Ferreira M, Kim LJ, Chang SW. Safety and Efficacy of Preoperative Embolization of Intracranial Hemangioblastomas. Oper Neurosurg (Hagerstown) 2016; 12:135-140. [PMID: 29506092 DOI: 10.1227/neu.0000000000001014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 07/20/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intracranial hemangioblastomas are highly vascular tumors that account for 1% to 2% of all central nervous system tumors. Preoperative embolization has been proposed to limit the often significant intraoperative blood loss associated with resection and potentially make the tumor more soft/necrotic and thus more amenable to gross total resection. The safety and efficacy of preoperative embolization of intracranial hemangioblastomas, however, are not well characterized. OBJECTIVE To evaluate the safety and efficacy of preoperative endovascular embolization of intracranial hemangioblastomas using a variety of embolic agents. METHODS A retrospective review of all surgically resected intracranial hemangioblastomas treated with preoperative embolization between 1999 and 2014 at 2 high-volume centers was performed. Clinical and radiographic criteria, including von Hippel-Lindau status, magnetic resonance imaging tumor characteristics, embolization-related complications, degree of angiographic devascularization, intraoperative blood loss, ability to obtain gross total resection, transfusion requirements, and operative time, were analyzed. RESULTS A total of 54 patients underwent surgery, with 24 undergoing preoperative embolization followed by surgical resection, and 30 patients undergoing surgical resection alone. Embolization-related neurological complications were seen in 6 patients (25%), including 3 hemorrhages when polyvinyl alcohol particles (P = .04) were used and 3 infarctions when liquid embolic agents were used (P = .27). Permanent neurological deficits were seen in 15%. CONCLUSION Preoperative embolization of intracranial hemangioblastomas should be performed with caution, given the potential for neurological morbidity. Further studies are needed to help guide patient and embolic agent selection.
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Affiliation(s)
- Chibawanye I Ene
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - David Xu
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ryan P Morton
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Samuel Emerson
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Michael R Levitt
- Department of Radiology, University of Washington, Seattle Washington
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Robert C Rostomily
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle Washington
| | - Danial K Hallam
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle Washington
| | - Felipe C Albuquerque
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Cameron G McDougall
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Manuel Ferreira
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle Washington
| | - Steve W Chang
- Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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