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Thelin EP, Nelson DW, Vehviläinen J, Nyström H, Kivisaari R, Siironen J, Svensson M, Skrifvars MB, Bellander BM, Raj R. Evaluation of novel computerized tomography scoring systems in human traumatic brain injury: An observational, multicenter study. PLoS Med 2017; 14:e1002368. [PMID: 28771476 PMCID: PMC5542385 DOI: 10.1371/journal.pmed.1002368] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/05/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major contributor to morbidity and mortality. Computerized tomography (CT) scanning of the brain is essential for diagnostic screening of intracranial injuries in need of neurosurgical intervention, but may also provide information concerning patient prognosis and enable baseline risk stratification in clinical trials. Novel CT scoring systems have been developed to improve current prognostic models, including the Stockholm and Helsinki CT scores, but so far have not been extensively validated. The primary aim of this study was to evaluate the Stockholm and Helsinki CT scores for predicting functional outcome, in comparison with the Rotterdam CT score and Marshall CT classification. The secondary aims were to assess which individual components of the CT scores best predict outcome and what additional prognostic value the CT scoring systems contribute to a clinical prognostic model. METHODS AND FINDINGS TBI patients requiring neuro-intensive care and not included in the initial creation of the Stockholm and Helsinki CT scoring systems were retrospectively included from prospectively collected data at the Karolinska University Hospital (n = 720 from 1 January 2005 to 31 December 2014) and Helsinki University Hospital (n = 395 from 1 January 2013 to 31 December 2014), totaling 1,115 patients. The Marshall CT classification and the Rotterdam, Stockholm, and Helsinki CT scores were assessed using the admission CT scans. Known outcome predictors at admission were acquired (age, pupil responsiveness, admission Glasgow Coma Scale, glucose level, and hemoglobin level) and used in univariate, and multivariable, regression models to predict long-term functional outcome (dichotomizations of the Glasgow Outcome Scale [GOS]). In total, 478 patients (43%) had an unfavorable outcome (GOS 1-3). In the combined cohort, overall prognostic performance was more accurate for the Stockholm CT score (Nagelkerke's pseudo-R2 range 0.24-0.28) and the Helsinki CT score (0.18-0.22) than for the Rotterdam CT score (0.13-0.15) and Marshall CT classification (0.03-0.05). Moreover, the Stockholm and Helsinki CT scores added the most independent prognostic value in the presence of other known clinical outcome predictors in TBI (6% and 4%, respectively). The aggregate traumatic subarachnoid hemorrhage (tSAH) component of the Stockholm CT score was the strongest predictor of unfavorable outcome. The main limitations were the retrospective nature of the study, missing patient information, and the varying follow-up time between the centers. CONCLUSIONS The Stockholm and Helsinki CT scores provide more information on the damage sustained, and give a more accurate outcome prediction, than earlier classification systems. The strong independent predictive value of tSAH may reflect an underrated component of TBI pathophysiology. A change to these newer CT scoring systems may be warranted.
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Affiliation(s)
- Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David W. Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Juho Vehviläinen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harriet Nyström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Riku Kivisaari
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Markus B. Skrifvars
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Kesmarky K, Delhumeau C, Zenobi M, Walder B. Comparison of Two Predictive Models for Short-Term Mortality in Patients after Severe Traumatic Brain Injury. J Neurotrauma 2017; 34:2235-2242. [PMID: 28323524 DOI: 10.1089/neu.2016.4606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The Glasgow Coma Scale (GCS) and the Abbreviated Injury Score of the head region (HAIS) are validated prognostic factors in traumatic brain injury (TBI). The aim of this study was to compare the prognostic performance of an alternative predictive model including motor GCS, pupillary reactivity, age, HAIS, and presence of multi-trauma for short-term mortality with a reference predictive model including motor GCS, pupil reaction, and age (IMPACT core model). A secondary analysis of a prospective epidemiological cohort study in Switzerland including patients after severe TBI (HAIS >3) with the outcome death at 14 days was performed. Performance of prediction, accuracy of discrimination (area under the receiver operating characteristic curve [AUROC]), calibration, and validity of the two predictive models were investigated. The cohort included 808 patients (median age, 56; interquartile range, 33-71), median GCS at hospital admission 3 (3-14), abnormal pupil reaction 29%, with a death rate of 29.7% at 14 days. The alternative predictive model had a higher accuracy of discrimination to predict death at 14 days than the reference predictive model (AUROC 0.852, 95% confidence interval [CI] 0.824-0.880 vs. AUROC 0.826, 95% CI 0.795-0.857; p < 0.0001). The alternative predictive model had an equivalent calibration, compared with the reference predictive model Hosmer-Lemeshow p values (Chi2 8.52, Hosmer-Lemeshow p = 0.345 vs. Chi2 8.66, Hosmer-Lemeshow p = 0.372). The optimism-corrected value of AUROC for the alternative predictive model was 0.845. After severe TBI, a higher performance of prediction for short-term mortality was observed with the alternative predictive model, compared with the reference predictive model.
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Affiliation(s)
- Klara Kesmarky
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
| | - Cecile Delhumeau
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
| | - Marie Zenobi
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
| | - Bernhard Walder
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
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Braine ME, Cook N. The Glasgow Coma Scale and evidence-informed practice: a critical review of where we are and where we need to be. J Clin Nurs 2017; 26:280-293. [PMID: 27218835 DOI: 10.1111/jocn.13390] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2016] [Indexed: 12/16/2022]
Abstract
AIMS AND OBJECTIVES This paper aims to critically consider the evidence since the Glasgow Coma Scale was first launched, reflecting on how that evidence has shaped practice. It illustrates the lack of clarity and consensus about the use of the tool in practice and draws upon existing evidence to determine the route to clarity for an evidence-informed approach to practice. BACKGROUND The Glasgow Coma Scale has permeated and influenced practice for over 40 years, being well-established worldwide as the key tool for assessing level of consciousness. During this time, the tool has been scrutinised, evaluated, challenged and re-launched in a plethora of publications. This has led to an insight into the challenges, and to some extent the opportunities, in using the Glasgow Coma Scale in practice but has also resulted in a lack of clarity. DESIGN This is a discursive paper that invites readers to explore and arrive at a more comprehensive understanding of the Glasgow Coma Scale in practice and is based on searches of Scopus, Web of Knowledge, PubMed, Science Direct and CINAHL databases. RESULTS While the Glasgow Coma Scale has been rivalled by other tools in an attempt to improve upon it, a shift in practice to those tools has not occurred. The tool has withstood the test of time in this respect, indicating the need for further research into its use and a clear education strategy to standardise implementation in practice. CONCLUSION Further exploration is needed into the application of painful stimuli in using the Glasgow Coma Scale to assess level of consciousness. In addition, a robust educational strategy is necessary to maximise consistency in its use in practice. RELEVANCE TO CLINICAL PRACTICE The evidence illustrates inconsistency and confusion in the use of the Glasgow Coma Scale in practice; this has the potential to compromise care and clarity around the issues is therefore necessary.
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Affiliation(s)
- Mary E Braine
- School of Nursing, Midwifery, Social Work & Social Sciences, University of Salford, Salford, UK
| | - Neal Cook
- School of Nursing, Ulster University, Londonderry, UK
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Scheetz LJ, Horst MA, Arbour RB. Early neurological deterioration in older adults with traumatic brain injury. Int Emerg Nurs 2017; 37:29-34. [PMID: 28082072 DOI: 10.1016/j.ienj.2016.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/14/2016] [Accepted: 11/26/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Traumatic brain injuries (TBIs) and resulting fatalities among older adults increased considerably in recent years. Neurological deterioration often goes unrecognized at the injury scene and patients arrive at emergency departments with near-normal Glasgow Coma Scale (GCS) scores. This study examined the proportion of older adults experiencing early neurological deterioration (prehospital to emergency department), associated factors, and association of the magnitude of neurological deterioration with TBI severity. METHODS This secondary analysis of National Trauma Data Bank Research Datasets included patients who were age ⩾65, sustained a TBI, and transported from the injury scene to an emergency department. Data analysis included chi-square analysis, t-tests, and logistic regression. Long-term anticoagulant/antiplatelet therapy was not associated with deterioration. RESULTS Of the sample of 91,886 patients, 13,913 (15.1%) experienced early neurological deterioration. Adjusting for covariates, age, gender, head AISmax injury severity, and probability of death were associated with early deterioration. Patients with severe and critical head injuries had the highest odds of early neurological deterioration (OR=1.41 [CI=1.22-1.63] and OR=1.98 [CI=1.63-2.40], p<0.001). DISCUSSION/CONCLUSIONS Prehospital providers, nurses, physicians, and other providers have opportunities to optimize outcomes from older adult TBI through early recognition of neurological deterioration, rapid transport to facilities for definitive treatment, and targeted rehabilitation.
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Affiliation(s)
- Linda J Scheetz
- Department of Nursing, Lehman College and The Graduate Center, City University of New York, 250 Bedford Park Blvd West, Bronx, NY 10468, United States.
| | - Michael A Horst
- Research Data & Biostatistics, Lancaster General Research Institute, Lancaster General Hospital, Lancaster, PA, United States
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Padgett CR, Summers MJ, Vickers JC, McCormack GH, Skilbeck CE. Exploring the effect of the apolipoprotein E (APOE) gene on executive function, working memory, and processing speed during the early recovery period following traumatic brain injury. J Clin Exp Neuropsychol 2016; 38:551-60. [PMID: 26898659 DOI: 10.1080/13803395.2015.1137557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION There is evidence that the e4 allele of the apolipoprotein E (APOE) gene is detrimental to cognitive function, but results from traumatic brain injury (TBI) populations are mixed. A possible explanation is that APOEe2 carriers have routinely been incorporated into APOEe4 and non-e4 groups, despite APOEe2 being proposed to have an ameliorative effect. Our primary aim was to investigate the influence of APOEe4 on cognitive impairment during early recovery following TBI, excluding the potential confound of APOEe2 possession. A secondary objective was to explore whether APOEe4 displays more pronounced effects in moderate to severe TBI and to consider the potential postinjury protective influence of the APOEe2 allele. METHOD Participants who recently sustained a TBI (posttraumatic amnesia > 5 minutes) were assessed on measures of information processing speed, executive function, and working memory upon remission of posttraumatic amnesia. APOE genotype was determined by buccal saliva DNA extraction (APOEe4 n = 37, APOEe3 n = 92, APOEe2 n = 13). RESULTS Stepwise multiple regressions were performed to compare APOEe4 carriers to APOEe3 homozygotes, with injury severity, age, and estimated premorbid IQ included in the first step. This model was found to significantly predict performance on all tasks, accounting for 17.3-24.3% of the variance. When APOEe4 status was added for the second step, there were no significant changes on any tasks (additional variance <1%). The effect of APOEe4 in moderate to severe TBI and the effect of APOEe2 were explored by analysis of covariance (ANCOVA), with no significant effects revealed. CONCLUSIONS It is unlikely that APOE genotype influences cognitive function in the initial recovery period following TBI, regardless of injury severity. However, a more nuanced and long-term exploration of the effect of APOE genotype in the TBI population is warranted.
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Affiliation(s)
- Christine R Padgett
- a School of Medicine , University of Tasmania , Launceston , TAS , Australia.,b Tasmanian Neurotrauma Register , Royal Hobart Hospital , Hobart , TAS , Australia
| | - Mathew J Summers
- c School of Social Sciences , University of the Sunshine Coast , Maroochydore , QLD , Australia.,d Wicking Dementia Research and Education Centre , University of Tasmania , Hobart , TAS , Australia
| | - James C Vickers
- d Wicking Dementia Research and Education Centre , University of Tasmania , Hobart , TAS , Australia
| | - Graeme H McCormack
- d Wicking Dementia Research and Education Centre , University of Tasmania , Hobart , TAS , Australia
| | - Clive E Skilbeck
- a School of Medicine , University of Tasmania , Launceston , TAS , Australia.,b Tasmanian Neurotrauma Register , Royal Hobart Hospital , Hobart , TAS , Australia
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Choonthar MM, Raghothaman A, Prasad R, Pradeep S, Pandya K. Head Injury- A Maxillofacial Surgeon's Perspective. J Clin Diagn Res 2016; 10:ZE01-6. [PMID: 26894193 DOI: 10.7860/jcdr/2016/16112.7122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/19/2015] [Indexed: 11/24/2022]
Abstract
Injuries and violence are one of the leading causes of mortality worldwide. A substantial portion of these injuries involve the maxillofacial region. Among the concomitant injuries, injuries to the head and cervical spine are amongst those that demand due consideration on account of their life threatening behaviour. Studies have shown that facial fractures have a strong association with traumatic brain injury. Knowledge of the types and mechanisms of traumatic brain injury is crucial for their treatment. Many a times, facial fractures tend to distract our attention from more severe and often life threatening injuries. Early diagnosis of these intracranial haemorrhage leads to prompt treatment which is essential to improve the outcome of these patients. An oral and maxillofacial surgeon should be able to suspect and diagnose head injury and also provide adequate initial management.
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Affiliation(s)
- Muralee Mohan Choonthar
- Professor, Department of Oral And Maxillofacial Surgery, A.B.Shetty Memorial Institute of Dental Sciences , Mangalore, India
| | - Ananthan Raghothaman
- Consultant Neurosurgeon, Justice K.S.Hegde Charitable Hospital , Mangalore, India
| | - Rajendra Prasad
- Professor, Director of Pg Studies, Department of Oral And Maxillofacial Surgery, A.B.Shetty Memorial Institute of Dental Sciences , Mangalore, India
| | - S Pradeep
- Post Graduate, Department of Oral And Maxillofacial Surgery, A.B.Shetty Memorial Institute of Dental Sciences , Mangalore, India
| | - Kalpa Pandya
- Post Graduate, Department of Oral And Maxillofacial Surgery, A.B.Shetty Memorial Institute of Dental Sciences , Mangalore, India
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Reith FC, Brennan PM, Maas AI, Teasdale GM. Lack of Standardization in the Use of the Glasgow Coma Scale: Results of International Surveys. J Neurotrauma 2016; 33:89-94. [DOI: 10.1089/neu.2014.3843] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Florence C.M. Reith
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Paul M. Brennan
- Department of Neurosurgery, Western General Hospital, Edinburgh, United Kingdom
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Graham M. Teasdale
- Emeritus Professor of Neurosurgery, University of Glasgow, Glasgow, United Kingdom
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Reith FCM, Van den Brande R, Synnot A, Gruen R, Maas AIR. The reliability of the Glasgow Coma Scale: a systematic review. Intensive Care Med 2015; 42:3-15. [PMID: 26564211 DOI: 10.1007/s00134-015-4124-3] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/26/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS. METHODS A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively. RESULTS We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85%, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used. CONCLUSIONS Only 13% of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.
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Affiliation(s)
- Florence C M Reith
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium. .,University of Antwerp, Edegem, Belgium.
| | - Ruben Van den Brande
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
| | - Anneliese Synnot
- Australian & New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Hospital, Level 6, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Russell Gruen
- Central Clinical School, Monash University, Melbourne, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Central Clinical School, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
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Buller LT, Lawrie CM, Vilella FE. A growing problem: acetabular fractures in the elderly and the combined hip procedure. Orthop Clin North Am 2015; 46:215-25. [PMID: 25771316 DOI: 10.1016/j.ocl.2014.11.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Acetabular fractures in the elderly are most frequently the result of low-energy trauma and present unique management challenges to orthopedic surgeons. Evaluation and treatment should be performed in a multidisciplinary fashion with early involvement of internal medicine subspecialists and geriatricians. Distinct fracture patterns and pre-existing osteoarthritis and osteoporosis necessitate careful preoperative planning. The role of total hip arthroplasty should also be considered when surgical treatment is indicated. The outcomes of acetabular fractures in the elderly have improved, but complications remain higher and results less satisfactory than in younger individuals. The lack of randomized controlled trials has limited the ability to establish an evidence-based treatment algorithm.
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Affiliation(s)
- Leonard T Buller
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami, 1400 Northwest 12th Avenue, Miami, FL 33136, USA; Department of Rehabilitation, Jackson Memorial Hospital, University of Miami, 1400 Northwest 12th Avenue, Miami, FL 33136, USA
| | - Charles M Lawrie
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami, 1400 Northwest 12th Avenue, Miami, FL 33136, USA; Department of Rehabilitation, Jackson Memorial Hospital, University of Miami, 1400 Northwest 12th Avenue, Miami, FL 33136, USA
| | - Fernando E Vilella
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Ryder Trauma Center, Jackson Memorial Hospital, University of Miami, 1400 Northwest 12th Avenue, Miami, FL 33136, USA.
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Rzewnicki I, Łebkowski W, Kordecki JK. Evaluation of vestibulo-ocular reflex in patients with damage to the central nervous system (GCS score 5-3). Adv Med Sci 2015; 60:107-11. [PMID: 25638706 DOI: 10.1016/j.advms.2014.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 10/27/2014] [Accepted: 12/01/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of our study was to evaluate the vestibulo-ocular reflex (VOR) in patients with severe damage to the central nervous system (CNS) in the diagnosis of brain death and survival prognosis. MATERIAL AND METHODS The study was conducted in 20 patients with extensive primary central nervous system damage against spontaneous intracranial haemorrhage or craniocerebral trauma and secondary central nervous system damage as a result of cardiac arrest with Glasgow Coma Scale (GCS) score from 3 to 5 treated in the Intensive Care Unit, University Hospital in Bialystok. For labyrinth stimulation we used water at 30°C, recording the reactions with ENG appliance. Records were analyzed in Nathanson-Bergman four-level scale. The first assessment was performed on the second day after the trauma and subsequently the assessments were repeated at 2-day intervals. RESULTS Of the 20 patients studied, the reflex was recorded in nine, which accounted for 45%. In the remaining 11 (55%) patients the reflex was not reported in any test and all of them died. Among patients with recorded VOR, five died and four survived. CONCLUSIONS The results of our study show the usefulness of performing the vestibulo-ocular test in patients with severe brain injury to predict their survival.
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Affiliation(s)
- Ireneusz Rzewnicki
- Department of Otolaryngology, University Hospital, Medical University of Bialystok, Bialystok, Poland
| | - Wojciech Łebkowski
- Department of Neurosurgery, University Hospital, Medical University of Bialystok, Bialystok, Poland
| | - Justyn Ksawery Kordecki
- Department of Diagnostic Radiology, Ministry of Internal Affairs and Administration Hospital, Bialystok, Poland.
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Poon W, Vos P, Muresanu D, Vester J, von Wild K, Hömberg V, Wang E, Lee TMC, Matula C. Cerebrolysin Asian Pacific trial in acute brain injury and neurorecovery: design and methods. J Neurotrauma 2015; 32:571-80. [PMID: 25222349 DOI: 10.1089/neu.2014.3558] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) is one of the leading causes of injury-related death. In the United States alone, an estimated 1.7 million people sustain a TBI each year, and approximately 5.3 million people live with a TBI-related disability. The direct medical costs and indirect costs such as lost productivity of TBIs totaled an estimated $76.5 billion in the U.S. in the year 2000. Improving the limited treatment options for this condition remains challenging. However, recent reports from interdisciplinary working groups (consisting primarily of neurologists, neurosurgeons, neuropsychologists, and biostatisticians) have stated that to improve TBI treatment, important methodological lessons from the past must be taken into account in future clinical research. An evaluation of the neuroprotection intervention studies conducted over the last 30 years has indicated that a limited understanding of the underlying biological concepts and methodological design flaws are the major reasons for the failure of pharmacological agents to demonstrate efficacy. Cerebrolysin is a parenterally-administered neuro-peptide preparation that acts in a manner similar to endogenous neurotrophic factors. Cerebrolysin has a favorable adverse effect profile, and several meta-analyses have suggested that Cerebrolysin is beneficial as a dementia treatment. CAPTAIN is a randomized, double-blind, placebo-controlled, multi-center, multinational trial of the effects of Cerebrolysin on neuroprotection and neurorecovery after TBI using a multidimensional ensemble of outcome scales. The CAPTAIN trial will be the first TBI trial with a 'true' multidimensional approach based on full outcome scales, while avoiding prior weaknesses, such as loss of information through "dichotomization," or unrealistic assumptions such as "normal distribution."
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Affiliation(s)
- Wai Poon
- 1 Division of Neurosurgery, Prince of Wales Hospital, the Chinese University of Hong Kong , Hong Kong, China
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Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol 2014; 13:844-54. [PMID: 25030516 DOI: 10.1016/s1474-4422(14)70120-6] [Citation(s) in RCA: 514] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Since 1974, the Glasgow Coma Scale has provided a practical method for bedside assessment of impairment of conscious level, the clinical hallmark of acute brain injury. The scale was designed to be easy to use in clinical practice in general and specialist units and to replace previous ill-defined and inconsistent methods. 40 years later, the Glasgow Coma Scale has become an integral part of clinical practice and research worldwide. Findings using the scale have shown strong associations with those obtained by use of other early indices of severity and outcome. However, predictive statements should only be made in combination with other variables in a multivariate model. Individual patients are best described by the three components of the coma scale; whereas the derived total coma score should be used to characterise groups. Adherence to this principle and enhancement of the reliable practical use of the scale through continuing education of health professionals, standardisation across different settings, and consensus on methods to address confounders will maintain its role in clinical practice and research in the future.
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Affiliation(s)
- Graham Teasdale
- Mental Health and Wellbeing, Institute of Health and Wellbeing College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Fiona Lecky
- Emergency Medicine Research in Sheffield, Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Beltran E, Platt S, McConnell J, Dennis R, Keys D, De Risio L. Prognostic value of early magnetic resonance imaging in dogs after traumatic brain injury: 50 cases. J Vet Intern Med 2014; 28:1256-62. [PMID: 24814522 PMCID: PMC4857941 DOI: 10.1111/jvim.12368] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/06/2014] [Accepted: 03/20/2014] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The prognostic value of early magnetic resonance imaging (MRI) in dogs after traumatic brain injury (TBI) remains unclear. OBJECTIVES Determine whether MRI findings are associated with prognosis after TBI in dogs. ANIMALS Fifty client-owned dogs. METHODS Retrospective study of dogs with TBI that underwent 1.5T MRI within 14 days after head trauma. MRI evaluators were blinded to the clinical presentation, and all images were scored based on an MRI grading system (Grade I [normal brain parenchyma] to Grade VI [bilateral lesions affecting the brainstem with or without any lesions of lesser grade]). Skull fractures, percentage of intraparenchymal lesions, degree of midline shift, and type of brain herniation were evaluated. MGCS was assessed at presentation. The presence of seizures was recorded. Outcome was assessed at 48 h (alive or dead) and at 3, 6, 12, and 24 months after TBI. RESULTS Sixty-six percent of the dogs had abnormal MRI findings. MRI grade was negatively correlated (P < .001) with MGCS. A significant negative correlation of MRI grade, degree of midline shift, and percentage of intraparenchymal lesions with follow-up scores was identified. The MGCS was lower in dogs with brain herniation (P = .0191). Follow-up scores were significantly lower in dogs that had brain herniation or skull fractures. The possibility of having seizures was associated with higher percentage of intraparenchymal lesions (P = 0.0054) and 10% developed PTE. CONCLUSIONS AND CLINICAL IMPORTANCE Significant associations exist between MRI findings and prognosis in dogs with TBI. MRI can help to predict prognosis in dogs with TBI.
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Affiliation(s)
- E. Beltran
- Centre for Small Animal StudiesAnimal Health TrustNewmarketUK
| | - S.R. Platt
- College of Veterinary MedicineSmall Animal MedicineUniversity of GeorgiaAthensGA
| | - J.F. McConnell
- School of Veterinary ScienceUniversity of LiverpoolLiverpoolUK
| | - R. Dennis
- Centre for Small Animal StudiesAnimal Health TrustNewmarketUK
| | - D.A. Keys
- Independent Statistical ConsultantAthensGA
| | - L. De Risio
- Centre for Small Animal StudiesAnimal Health TrustNewmarketUK
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Reisner A, Chen X, Kumar K, Reifman J. Prehospital Heart Rate and Blood Pressure Increase the Positive Predictive Value of the Glasgow Coma Scale for High-Mortality Traumatic Brain Injury. J Neurotrauma 2014; 31:906-13. [DOI: 10.1089/neu.2013.3128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrew Reisner
- Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiaoxiao Chen
- Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland
| | - Kamal Kumar
- Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland
| | - Jaques Reifman
- Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland
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Boyle CL, Nott MT, Baguley IJ, Ranka JL. Contextual influences on employment of people with dual diagnosis: spinal cord injury and traumatic brain injury. Aust Occup Ther J 2014; 61:335-43. [PMID: 24810135 DOI: 10.1111/1440-1630.12133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND/AIM Research into the paid employment of people with spinal cord injury or traumatic brain injury is prevalent; however, little research has examined the factors that may support employment for adults with a concomitant spinal cord injury and traumatic brain injury (dual diagnosis). This study aimed to determine the level of paid employment reported by people with dual diagnosis and to explore contextual factors that supported paid employment. METHODS This cross-sectional cohort study recruited 30 participants with dual diagnosis from a specialist spinal rehabilitation unit. Interviews were conducted during the first five years post-rehabilitation discharge to determine level of paid employment and contextual factors that supported employment. RESULTS At interview, 47% of participants were in paid employment. Employment type at interview indicated a shift away from more physically intensive jobs. Employed and unemployed participants reported a high level of social support and reported experiencing few physical or attitudinal barriers in their day to day lives. These environmental factors did not differentiate between employed and unemployed participants (z range = -0.98 to -0.17; P value range = 0.33-0.86). The most common facilitator of employment identified by participants was the personal factor - motivation (93% of employed participants). CONCLUSION When considering the impact of contextual factors on paid employment for people with a dual diagnosis of spinal cord injury/traumatic brain injury, personal factors may be of greater influence than environmental factors. Study participants experienced few physical or attitudinal barriers and reported highly supportive interpersonal relationships.
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Affiliation(s)
- Claire L Boyle
- Brain Injury Rehabilitation Service, Westmead Hospital, Sydney, New South Wales, Australia; Moorong Spinal Unit, Royal Rehabilitation Centre Sydney, Albury, New South Wales, Australia
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67
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Walder B, Robin X, Rebetez MML, Copin JC, Gasche Y, Sanchez JC, Turck N. The prognostic significance of the serum biomarker heart-fatty acidic binding protein in comparison with s100b in severe traumatic brain injury. J Neurotrauma 2014; 30:1631-7. [PMID: 23590685 DOI: 10.1089/neu.2012.2791] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The outcome after severe traumatic brain injury (TBI) is largely unfavorable, with approximately two thirds of patients suffering from severe disabilities or dying during the first 6 months. Existing predictive models displayed only limited utility for outcome prediction in individual patients. Time courses of heart-fatty acidic binding protein (H-FABP) and their association with outcome were investigated and compared with S100b. Forty-nine consecutive patients with severe TBI (sTBI; Head component of the Abbreviated Injury Scale [HAIS] >3) with mono and multiple trauma were enrolled in this study. Enzyme-linked immunosorbent assay measured blood concentrations of H-FABP and S100b at 6, 12, 24, and 48 h after TBI. Outcome measures were conscious state at 14 days (Glasgow Coma Scale), disability (Glasgow Outcome Scale Extended; GOSE), and mortality at 3 months. Univariate logistic regression analysis and receiver operating characteristic curves analysis were carried out. Maximal H-FABP and S100b concentrations were observed at 6 h after TBI (34.4±34.0 and 0.64±0.99 ng/mL, respectively). Patients with multi-trauma had significantly higher H-FABP concentrations at 24 and 48 h (22.6±25.6 and 12.4±18.2 ng/mL, respectively), compared to patients with mono trauma (6.9±5.1 and 3.7±4.2 ng/mL, respectively). In the first 48 h, H-FABP and S100b were inversely correlated with the GOSE at 3 months; H-FABP at 48 h predicted mortality with 75% sensitivity and 93% specificity. Early blood levels of H-FABP after sTBI have prognostic significance for survival and disability.
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Affiliation(s)
- Bernhard Walder
- 1 Division of Anaesthesiology, University Hospitals of Geneva , Geneva, Switzerland
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68
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Tohme S, Delhumeau C, Zuercher M, Haller G, Walder B. Prehospital risk factors of mortality and impaired consciousness after severe traumatic brain injury: an epidemiological study. Scand J Trauma Resusc Emerg Med 2014; 22:1. [PMID: 24393519 PMCID: PMC3892077 DOI: 10.1186/1757-7241-22-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 12/28/2013] [Indexed: 12/03/2022] Open
Abstract
Background Severe traumatic brain injury (TBI) is a significant health concern and a major burden for society. The period between trauma event and hospital admission in an emergency department (ED) could be a determinant for secondary brain injury and early survival. The aim was to investigate the relationship between prehospital factors associated with secondary brain injury (arterial hypotension, hypoxemia, hypothermia) and the outcomes of mortality and impaired consciousness of survivors at 14 days. Methods A multicenter, prospective cohort study was performed in dedicated trauma centres of Switzerland. Adults with severe TBI (Abbreviated Injury Scale score of head region (HAIS) >3) were included. Main outcome measures were death and impaired consciousness (Glasgow Coma Scale (GCS) ≤13) at 14 days. The associations between risk factors and outcome were assessed with univariate and multivariate regression models. Results 589 patients were included, median age was 55 years (IQR 33, 70). The median GCS in ED was 4 (IQR 3-14), with abnormal pupil reaction in 167 patients (29.2%). Median ISS was 25 (IQR 21, 34). Three hundred seven patients sustained their TBI from falls (52.1%) and 190 from a road traffic accidents (32.3%). Median time from Out-of-hospital Emergency Medical Service (OHEMS) departure on scene to arrival in ED was 50 minutes (IQR 37-72); 451 patients had a direct admission (76.6%). Prehospital hypotension was observed in 24 (4.1%) patients, hypoxemia in 73 (12.6%) patients and hypothermia in 146 (24.8%). Prehospital hypotension and hypothermia (apart of age and trauma severity) was associated with mortality. Prehospital hypoxemia (apart of trauma severity) was associated with impaired consciousness; indirect admission was a protective factor. Conclusion Mortality and impaired consciousness at 14 days do not have the same prehospital risk factors; prehospital hypotension and hypothermia is associated with mortality, and prehospital hypoxemia with impaired consciousness.
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Affiliation(s)
| | | | | | | | - Bernhard Walder
- Division of Anaesthesiology, University Hospitals of Geneva, Geneva, Switzerland.
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69
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Muñana-Rodríguez J, Ramírez-Elías A. Escala de coma de Glasgow: origen, análisis y uso apropiado. ENFERMERÍA UNIVERSITARIA 2014. [DOI: 10.1016/s1665-7063(14)72661-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Walder B, Haller G, Rebetez MML, Delhumeau C, Bottequin E, Schoettker P, Ravussin P, Brodmann Maeder M, Stover JF, Zürcher M, Haller A, Wäckelin A, Haberthür C, Fandino J, Haller CS, Osterwalder J. Severe traumatic brain injury in a high-income country: an epidemiological study. J Neurotrauma 2013; 30:1934-42. [PMID: 23822874 DOI: 10.1089/neu.2013.2955] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This adult cohort determined the incidence and patients' short-term outcomes of severe traumatic brain injury (sTBI) in Switzerland and age-related differences. A prospective cohort study with a follow-up at 14 days was performed. Patients ≥16 years of age sustaining sTBI and admitted to 1 of 11 trauma centers were included. sTBI was defined by an Abbreviated Injury Scale of the head (HAIS) score >3. The centers participated from 6 months to 3 years. The results are presented as percentages, medians, and interquartile ranges (IQRs). Subgroup analyses were performed for patients ≤65 years (younger) and >65 (elderly). sTBI was observed in 921 patients (median age, 55 years; IQR, 33-71); 683 (74.2%) were male. Females were older (median age, 67 years; IQR, 42-80) than males (52; IQR, 31-67; p<0.00001). The estimated incidence was 10.58 per 100,000 inhabitants per year. Blunt trauma was observed in 879 patients (95.4%) and multiple trauma in 283 (30.7%). Median Glasgow Coma Score (GCS) on the scene was 9 (IQR 4-14; 8 in younger, 12 in elderly) and in emergency departments 5 (IQR, 3-14; 3 in younger, 8 in elderly). Trauma mechanisms included the following: 484 patients with falls (52.6%; younger, 242 patients [50.0%]; elderly, 242 [50.0%]), 291 with road traffic accidents (31.6%; younger, 237 patients [81.4%]; elderly, 54 [18.6%]), and 146 with others (15.8%). Mortality was 30.2% (24.5% in younger, 40.9% in elderly). Median GCS at 14 days was 15 (IQR, 14-15) without differences among subgroups. Estimated incidence of sTBI in Switzerland was low, age was high, and mortality considerable. The elderly had higher initial GCS and a higher death rate, but high GCS at 14 days.
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Affiliation(s)
- Bernhard Walder
- 1 Division of Anesthesiology, University Hospitals of Geneva (HUG) , Geneva, Switzerland
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Abstract
The older adult patient with trauma is becoming a growing part of the overall trauma population. With the world population increasing in age, the rate of the traumatically injured older adult will continue to increase. Recognizing this problem and the fact that the elderly are at higher risk for injury and its complications will be necessary if the increasing volume of patients is to be dealt with. This review discusses these issues, as well as appropriate triage and treatment of injuries and associated comorbidities. Early recognition of injury, even minor, and expedited care using specialized teams will help to improve outcomes for these patients.
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72
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Copin JC, Rebetez MML, Turck N, Robin X, Sanchez JC, Schaller K, Gasche Y, Walder B. Matrix metalloproteinase 9 and cellular fibronectin plasma concentrations are predictors of the composite endpoint of length of stay and death in the intensive care unit after severe traumatic brain injury. Scand J Trauma Resusc Emerg Med 2012; 20:83. [PMID: 23249478 PMCID: PMC3570325 DOI: 10.1186/1757-7241-20-83] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 12/16/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The relationship between severe traumatic brain injury (TBI) and blood levels of matrix metalloproteinase-9 (MMP-9) or cellular fibronectin (c-Fn) has never been reported. In this study, we aimed to assess whether plasma concentrations of MMP-9 and c-Fn could have predictive values for the composite endpoint of intensive care unit (ICU) length of stay (LOS) of survivors and mortality after severe TBI. Secondary outcomes were the state of consciousness measured with the Glasgow Coma Scale (GCS) of survivors at 14 days and Glasgow Outcome Scale Extended (GOSE) at 3 months. METHODS Forty-nine patients with abbreviated injury scores of the head region ≥ 4 were included. Blood was sampled at 6, 12, 24 and 48 hours after injury. MMP-9 and c-Fn concentrations were measured by ELISA. The values of MMP-9 and c-Fn, and, for comparison, the value of the GCS on the field of the accident (fGCS), as predictors of the composite outcome of ICU LOS and death were assessed by logistic regression. RESULTS There was a linear relationship between maximal MMP-9 concentration, measured during the 6-12-hour period, and maximal c-Fn concentration, measured during the 24-48-hour period. The risk of staying longer than 9 days in the ICU or of dying was increased in patients with a maximal early MMP-9 concentration ≥ 21.6 ng/ml (OR = 5.0; 95% CI: 1.3 to 18.6; p = 0.02) or with a maximal late c-Fn concentration ≥ 7.7 μg/ml (OR = 5.4; 95% CI: 1.4 to 20.8; p = 0.01). A similar risk association was observed with fGCS ≤8 (OR, 4.4; 95% CI, 1.2-15.8; p = 0.02). No relationship was observed between MMP-9, c-Fn concentrations or fGCS and the GCS at 14 days of survivors and GOSE at 3 months. CONCLUSIONS Plasma MMP-9 and c-Fn concentrations in the first 48 hours after injury are predictive for the composite endpoint of ICU LOS and death after severe TBI but not for consciousness at 14 days and outcome at 3 months.
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Affiliation(s)
- Jean-Christophe Copin
- Geneva Neuroscience Center, University of Geneva, Geneva, Switzerland
- Division of Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
- Division of Neurosurgery, University Hospitals of Geneva, Geneva, Switzerland
- Centre Médical Universitaire, 1, rue Michel Servet, Genève 4, CH-1211, Switzerland
| | | | - Natacha Turck
- Biomedical Proteomics Research Group, Department of Human Protein Sciences, University of Geneva Medical Center, Geneva, Switzerland
| | - Xavier Robin
- Biomedical Proteomics Research Group, Department of Human Protein Sciences, University of Geneva Medical Center, Geneva, Switzerland
| | - Jean-Charles Sanchez
- Biomedical Proteomics Research Group, Department of Human Protein Sciences, University of Geneva Medical Center, Geneva, Switzerland
| | - Karl Schaller
- Biomedical Proteomics Research Group, Department of Human Protein Sciences, University of Geneva Medical Center, Geneva, Switzerland
| | - Yvan Gasche
- Geneva Neuroscience Center, University of Geneva, Geneva, Switzerland
- Division of Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology, University Hospitals of Geneva, Geneva, Switzerland
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Jacobs B, Beems T, van der Vliet TM, van Vugt AB, Hoedemaekers C, Horn J, Franschman G, Haitsma I, van der Naalt J, Andriessen TMJC, Borm GF, Vos PE. Outcome Prediction in Moderate and Severe Traumatic Brain Injury: A Focus on Computed Tomography Variables. Neurocrit Care 2012; 19:79-89. [DOI: 10.1007/s12028-012-9795-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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74
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Hefny AF, Barss P, Eid HO, Abu-Zidan FM. Motorcycle-related injuries in the United Arab Emirates. ACCIDENT; ANALYSIS AND PREVENTION 2012; 49:245-248. [PMID: 23036401 DOI: 10.1016/j.aap.2011.05.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 03/27/2011] [Accepted: 05/04/2011] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To study the anatomical distribution, severity, outcome, and age by nationality of hospitalized motorcycle-related injured patients in Al-Ain, United Arab Emirates so as to improve preventive measures. METHODS All motorcycle riders involved in a road traffic collision and admitted to Al-Ain Hospital for more than 24 h or who died in hospital after arrival were studied. Patient data were retrieved from Al-Ain Hospital Trauma Registry. Data had been prospectively collected during four and half years (March 2003-October 2007). Demography of patients, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Hospital stay, mortality, nationality, time, day of week, and month of occurrence were analyzed. RESULTS There were 95 patients (93 males). Mean (SD) age was 29.8 (11.5) years. 35% were United Arab Emirates (UAE) nationals. Upper limbs were most frequently involved (54%) followed by lower limbs (48%), head (41%), and face (30%). On arrival at hospital, median (range) ISS was 4.5 (1-36) and median (range) GCS was 15 (3-15). Mean (range) hospital stay was 8.8 (1-79) days. 14 patients (15%) were admitted to the Intensive Care Unit. In-hospital mortality was 6%. UAE national victims were significantly younger and had more abdominal injuries than expatriates, who had lower limb injuries. CONCLUSIONS The most common mechanism of motorcycle crashes was hitting a moving vehicle. Young UAE national motorcyclists are at a higher risk of being injured compared with non UAE nationals. This may be due to risk-taking behavior of young motorcyclists who are mainly riding for leisure. Extremities were the most common injured body region. Severe head injury was the main cause of death. This signifies the need for effective application of motorcycle helmet law in the UAE along with other preventive measures that might include increasing the licensing age.
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Affiliation(s)
- Ashraf F Hefny
- Department of Surgery, Al-Ain Hospital, Al-Ain, United Arab Emirates
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75
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Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. ACTA ACUST UNITED AC 2012; 15:170-83. [DOI: 10.1016/j.aenj.2012.06.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 06/12/2012] [Accepted: 06/15/2012] [Indexed: 10/28/2022]
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76
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Path Dependence and the Persistence of the Glasgow Coma Scale. Ann Emerg Med 2012; 59:559; author reply 559-60. [DOI: 10.1016/j.annemergmed.2011.11.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 11/17/2011] [Accepted: 11/21/2011] [Indexed: 11/23/2022]
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Radvinsky DS, Yoon RS, Schmitt PJ, Prestigiacomo CJ, Swan KG, Liporace FA. Evolution and development of the Advanced Trauma Life Support (ATLS) protocol: a historical perspective. Orthopedics 2012; 35:305-11. [PMID: 22495839 DOI: 10.3928/01477447-20120327-07] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The Advanced Trauma Life Support (ATLS) protocol is a successful course offered by the American College of Surgeons. Once based on didactic lectures and seminars taught by experts in the field, trauma training has evolved to become a set of standardized assessment and treatment protocols based on evidence rather than expert opinion. As the ATLS expands, indices to predict outcome, morbidity, and mortality have evolved to guide management and treatment based on retrospective data. This historical, perspective article attempts to tell the story of ATLS from its inception to its evolution as an international standard for the initial assessment and management of trauma patients.
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Affiliation(s)
- David S Radvinsky
- Department of General Surgery, University of Florida, Gainesville, Florida 32610, USA.
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Adeleye AO, Owolabi MO, Rabiu TB, Orimadegun AE. Physicians' Knowledge of the Glasgow Coma Scale in a Nigerian University Hospital: Is the Simple GCS Still Too Complex? Front Neurol 2012; 3:28. [PMID: 22408634 PMCID: PMC3297815 DOI: 10.3389/fneur.2012.00028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 02/16/2012] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The Glasgow Coma Scale, GCS, is a universal clinical means of quantifying the level of impaired consciousness. Although physicians usually receive undergraduate and postgraduate training in the use of this scale in our university hospital we are aware of studies suggesting that the working knowledge of the GCS among practising physicians might not be adequate. METHODS We carried out a questionnaire-based survey across all specialties and levels of training of physicians in active patient care in a Nigerian university hospital. RESULTS Of the 100 physicians sampled, 98 correctly spelled out what the three-letter abbreviation, GCS, stands for. Ninety-three percent also conceded it to be an important clinical rating scale. However, only 55-89% of the participants correctly identified the three respective clinical variables, (eye opening, verbal response, and motor response), of the GCS. More particularly, the participants' ability to itemize and correctly score all the respective components of each of the three clinical variables ranged from 0 to 35% across specialties and levels of training. Performance was best for the four-item eye opening variable and, worst for the six-item motor response variable. CONCLUSION In our university hospital, practising physicians' working knowledge of the GCS is inadequate and is dependent on the degree of the complexity of each of the three clinical variables of the scale.
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Affiliation(s)
- Amos O Adeleye
- Division of Neurological Surgery, Department of Surgery, College Of Medicine, University of Ibadan Ibadan, Nigeria
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Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. ACTA ACUST UNITED AC 2011; 71:1185-92; discussion 1193. [PMID: 22071923 DOI: 10.1097/ta.0b013e31823321f8] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The Glasgow Coma Scale (GCS) classifies traumatic brain injuries (TBIs) as mild (14-15), moderate (9-13), or severe (3-8). The Advanced Trauma Life Support modified this classification so that a GCS score of 13 is categorized as mild TBI. We investigated the effect of this modification on mortality prediction, comparing patients with a GCS score of 13 classified as moderate TBI (classic model) to patients with GCS score of 13 classified as mild TBI (modified model). METHODS We selected adult TBI patients from the Pennsylvania Outcome Study database. Logistic regressions adjusting for age, sex, cause, severity, trauma center level, comorbidities, and isolated TBI were performed. A second evaluation included the time trend of mortality. A third evaluation also included hypothermia, hypotension, mechanical ventilation, screening for drugs, and severity of TBI. Discrimination of the models was evaluated using the area under receiver operating characteristic curve (AUC). Calibration was evaluated using the Hosmer-Lemershow goodness of fit test. RESULTS In the first evaluation, the AUCs were 0.922 (95% CI, 0.917-0.926) and 0.908 (95% CI, 0.903-0.912) for classic and modified models, respectively. Both models showed poor calibration (p < 0.001). In the third evaluation, the AUCs were 0.946 (95% CI, 0.943-0.949) and 0.938 (95% CI, 0.934-0.940) for the classic and modified models, respectively, with improvements in calibration (p = 0.30 and p = 0.02 for the classic and modified models, respectively). CONCLUSION The lack of overlap between receiver operating characteristic curves of both models reveals a statistically significant difference in their ability to predict mortality. The classic model demonstrated better goodness of fit than the modified model. A GCS score of 13 classified as moderate TBI in a multivariate logistic regression model performed better than a GCS score of 13 classified as mild.
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Cheerio, Laddie! Bidding Farewell to the Glasgow Coma Scale. Ann Emerg Med 2011; 58:427-30. [DOI: 10.1016/j.annemergmed.2011.06.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 06/06/2011] [Accepted: 06/15/2011] [Indexed: 11/21/2022]
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A Critical Analysis of the MND Criteria for Feigned Cognitive Impairment: Implications for Forensic Practice and Research. PSYCHOLOGICAL INJURY & LAW 2011. [DOI: 10.1007/s12207-011-9107-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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82
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Andriessen TMJC, Horn J, Franschman G, van der Naalt J, Haitsma I, Jacobs B, Steyerberg EW, Vos PE. Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study. J Neurotrauma 2011; 28:2019-31. [PMID: 21787177 DOI: 10.1089/neu.2011.2034] [Citation(s) in RCA: 183] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Changes in the demographics, approach, and treatment of traumatic brain injury (TBI) patients require regular evaluation of epidemiological profiles, injury severity classification, and outcomes. This prospective multicenter study provides detailed information on TBI-related variables of 508 moderate-to-severe TBI patients. Variability in epidemiology and outcome is examined by comparing our cohort with previous multicenter studies. Additionally, the relation between outcome and injury severity classification assessed at different time points is studied. Based on the emergency department Glasgow Coma Scale (GCS), 339 patients were classified as having severe and 129 as having moderate TBI. In 15%, the diagnosis differed when the accident scene GCS was used for classification. In-hospital mortality was higher if severe TBI was diagnosed at both time points (44%) compared to moderate TBI at one or both time points (7-15%, p<0.001). Furthermore, 14% changed diagnosis when a threshold (≥6 h) for impaired consciousness was used as a criterion for severe TBI: In-hospital mortality was<5% when impaired consciousness lasted for<6 h. This suggests that combining multiple clinical assessments and using a threshold for impaired consciousness may improve the classification of injury severity and prediction of outcome. Compared to earlier multicenter studies, our cohort demonstrates a different case mix that includes a higher age (mean=47.3 years), more diffuse (Traumatic Coma Databank [TCDB] I-II) injuries (58%), and more major extracranial injuries (40%), with relatively high 6 month mortality rates for both severe (46%) and moderate (21%) TBI. Our results confirm that TBI epidemiology and injury patterns have changed in recent years whereas case fatality rates remain high.
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Hawthorne G, Kaye A, Gruen R, Houseman D, Bauer I. Traumatic brain injury and quality of life: Initial Australian validation of the QOLIBRI. J Clin Neurosci 2011; 18:197-202. [DOI: 10.1016/j.jocn.2010.06.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 06/14/2010] [Indexed: 10/18/2022]
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