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Young AMH, Guilfoyle MR, Fernandes H, Garnett MR, Agrawal S, Hutchinson PJ. The application of adult traumatic brain injury models in a pediatric cohort. J Neurosurg Pediatr 2016; 18:558-564. [PMID: 27564785 DOI: 10.3171/2016.5.peds15427] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is increasing interest in the use of predictive models of outcome in adult head injury. Two international models have been identified to be reliable modalities for predicting outcome: the Corticosteroid Randomisation After Significant Head Injury (CRASH) model, and the International Mission on Prognosis and Analysis of randomized Controlled Trials in TBI (IMPACT) model. However, these models are designed only to identify outcomes in adult populations. METHODS A retrospective analysis was performed on pediatric patients with severe traumatic brain injury (TBI) admitted to the pediatric intensive care unit (PICU) of Addenbrooke's Hospital between January 2009 and December 2013. The individual risk of 14-day mortality was calculated using the CRASH-Basic and -CT models, and the risk of 6-month mortality calculated using the IMPACT-Core and -Extended (including CT findings) models. Model accuracy was determined by standardized mortality ratio (SMtR; observed/expected deaths), discrimination was evaluated as the area under the receiver operating curve (AUROC), and calibration assessed using the Hosmer-Lemeshow χ2 test. RESULTS Ninety-four patients with an average age of 7.3 years were admitted to the PICU with a TBI. The mortality rate was 12.7% at 14 days and at 6 months. For the CRASH-Basic model, the SMtR was 1.42 and both calibration (χ2 = 6.1, p = 0.64) and discrimination (AUROC = 0.92) were good. For the IMPACT-Core model, the SMtR was 1.03 and the model was also well calibrated (χ2 = 8.99, p = 0.34) and had good discrimination (AUROC = 0.85). Poor outcome was observed in 17% of the cohort and identified with the CRASH-Basic and IMPACT-Core models to varying degrees: standardized morbidity ratio = 0.89 vs 0.67, respectively; calibration = 6.5 (χ2) and 0.59 (p value) versus 8.52 (χ2) and 0.38 (p value), respectively; and discrimination (AUROC) = 0.92 versus 0.83, respectively. CONCLUSIONS Adult head injury models may be applied with sufficient accuracy to identify predictors of morbidity and mortality in pediatric TBI.
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Affiliation(s)
- Adam M H Young
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, and
| | - Mathew R Guilfoyle
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, and
| | - Helen Fernandes
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, and
| | - Matthew R Garnett
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, and
| | - Shruti Agrawal
- Department of Paediatric Intensive Care, Addenbrooke's Hospital, University of Cambridge, United Kingdom
| | - Peter J Hutchinson
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, and
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Zhang H, Zhang XN, Zhang HL, Huang L, Chi QQ, Zhang X, Yun XP. Differences in cognitive profiles between traumatic brain injury and stroke: A comparison of the Montreal Cognitive Assessment and Mini-Mental State Examination. Chin J Traumatol 2016; 19:271-274. [PMID: 27780506 PMCID: PMC5068208 DOI: 10.1016/j.cjtee.2015.03.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To investigate the profiles of cognitive impairment through Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) in patients with chronic traumatic brain injury (TBI) or stroke and to evaluate the sensitivity of the two scales in patients with TBI. METHODS In this cohort study, a total of 230 patients were evaluated, including TBI group (n = 103) and stroke group (n = 127). The cognitive functions of two groups were evaluated by designated specialists using MoCA (Beijing version) and MMSE (Chinese version). RESULTS Comparedwith the patientswith stroke, the patientswith TBI received significantly lower score in orientation subtest and recall subtest in both tests.MoCA abnormal rates in the TBI group and stroke group were 94.17% and 86.61% respectively,whileMMSE abnormal rateswere 69.90% and 57.48%, respectively. In the TBI group, 87.10% patientswith normalMMSE score had abnormalMoCA score and in the stroke group, about 70.37% patients with normal MMSE score had abnormal MoCA score. The diagnostic consistency of two scales in the TBI group and the stroke group were 72% and 69%, respectively. CONCLUSION In our rehabilitation center, patients with TBI may have more extensive and severe cognitive impairments than patients with stroke, prominently in orientation and recall domain. In screening post- TBI cognitive impairment, MoCA tends to be more sensitive than MMSE.
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Affiliation(s)
- Hao Zhang
- Neurorehabilitation Department, Beijing Bo'ai Hospital, China Rehabilitation Research Center, School of Rehabilitation, Capital Medical University, Beijing 100068, China
| | - Xiao-Nian Zhang
- Neurorehabilitation Department, Beijing Bo'ai Hospital, China Rehabilitation Research Center, School of Rehabilitation, Capital Medical University, Beijing 100068, China
| | - Hui-Li Zhang
- Rehabilitation Evaluation Department, Beijing Bo'ai Hospital, China Rehabilitation Research Center, School of Rehabilitation, Capital Medical University, Beijing 100068, China
| | - Liang Huang
- Rehabilitation Department, Huabei Oil Field Huayuan Hospital, Hejian 062450, Hebei, China
| | - Qian-Qian Chi
- Neurorehabilitation Department, Beijing Bo'ai Hospital, China Rehabilitation Research Center, School of Rehabilitation, Capital Medical University, Beijing 100068, China
| | - Xin Zhang
- Neurorehabilitation Department, Beijing Bo'ai Hospital, China Rehabilitation Research Center, School of Rehabilitation, Capital Medical University, Beijing 100068, China
| | - Xiao-Ping Yun
- Rehabilitation Evaluation Department, Beijing Bo'ai Hospital, China Rehabilitation Research Center, School of Rehabilitation, Capital Medical University, Beijing 100068, China,Corresponding author.
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203
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Corrigan F, Arulsamy A, Teng J, Collins-Praino LE. Pumping the Brakes: Neurotrophic Factors for the Prevention of Cognitive Impairment and Dementia after Traumatic Brain Injury. J Neurotrauma 2016; 34:971-986. [PMID: 27630018 DOI: 10.1089/neu.2016.4589] [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: 12/14/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of disability and death worldwide, affecting as many as 54,000,000-60,000,000 people annually. TBI is associated with significant impairments in brain function, impacting cognitive, emotional, behavioral, and physical functioning. Although much previous research has focused on the impairment immediately following injury, TBI may have much longer-lasting consequences, including neuropsychiatric disorders and cognitive impairment. TBI, even mild brain injury, has also been recognized as a significant risk factor for the later development of dementia and Alzheimer's disease. Although the link between TBI and dementia is currently unknown, several proposed mechanisms have been put forward, including alterations in glucose metabolism, excitotoxicity, calcium influx, mitochondrial dysfunction, oxidative stress, and neuroinflammation. A treatment for the devastating long-term consequences of TBI is desperately needed. Unfortunately, however, no such treatment is currently available, making this a major area of unmet medical need. Increasing the level of neurotrophic factor expression in key brain areas may be one potential therapeutic strategy. Of the neurotrophic factors, granulocyte-colony stimulating factor (G-CSF) may be particularly effective for preventing the emergence of long-term complications of TBI, including dementia, because of its ability to reduce apoptosis, stimulate neurogenesis, and increase neuroplasticity.
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Affiliation(s)
- Frances Corrigan
- Translational Neuropathology Lab, Discipline of Anatomy and Pathology, School of Medicine, University of Adelaide , Adelaide, Australia
| | - Alina Arulsamy
- Translational Neuropathology Lab, Discipline of Anatomy and Pathology, School of Medicine, University of Adelaide , Adelaide, Australia
| | - Jason Teng
- Translational Neuropathology Lab, Discipline of Anatomy and Pathology, School of Medicine, University of Adelaide , Adelaide, Australia
| | - Lyndsey E Collins-Praino
- Translational Neuropathology Lab, Discipline of Anatomy and Pathology, School of Medicine, University of Adelaide , Adelaide, Australia
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Okazaki T, Hifumi T, Kawakita K, Nakashima R, Matsumoto A, Shishido H, Ogawa D, Okauchi M, Shindo A, Kawanishi M, Tamiya T, Kuroda Y. Association Between Comorbidities, Nutritional Status, and Anticlotting Drugs and Neurologic Outcomes in Geriatric Patients with Traumatic Brain Injury. World Neurosurg 2016; 93:336-40. [DOI: 10.1016/j.wneu.2016.06.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 10/21/2022]
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Schoell SL, Weaver AA, Talton JW, Baker G, Doud AN, Barnard RT, Stitzel JD, Zonfrillo MR. Functional outcomes of motor vehicle crash head injuries in pediatric and adult occupants. TRAFFIC INJURY PREVENTION 2016; 17 Suppl 1:27-33. [PMID: 27586099 PMCID: PMC6211837 DOI: 10.1080/15389588.2016.1201203] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/07/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The objective of the study was to develop a disability-based metric for motor vehicle crash (MVC) injuries, with a focus on head injuries, and compare the functional outcomes between the pediatric and adult populations. METHODS Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System (NTDB-RDS) for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 3, 4, and 5 head injuries in NASS-CDS 2000-2011. Pediatric (ages 7-18), adult (19-45), middle-aged (46-65), and older adult (66+) patients with an FIM score available who were alive at discharge and had an AIS 3, 4, or 5 injury were included in the study. The NTDB-RDS contains a truncated form of the FIM instrument, including 3 items (self-feed, locomotion, and verbal expression), each graded on a scale of 1 (full functional dependence) to 4 (full functional independence). Patients within each age group were classified as disabled or not disabled based on the FIM scale. The DR was calculated for each age group by dividing the number of patients who sustained a specific injury and were disabled by the number of patients who sustained the specific injury. To account for the impact of more severe associated coinjuries, a maximum AIS (MAIS) adjusted DR (DRMAIS) was also calculated for each injury. DR and DRMAIS ranged from 0 (0% disability risk) to 1 (100% disability risk). RESULTS An analysis of the most frequent FIM components associated with disabling MVC head injuries revealed that disability across all 3 items (self-feed, locomotion, and expression) was the most frequent for pediatric and adult patients. Only locomotion was the most frequent for middle-aged and older adults. The mean DRMAIS for MVC head injuries was 35% for pediatric patients, 36% for adults, 38% for middle-aged adults, and 44% for older adults. Further analysis was conducted by grouping the head injuries into 8 groups based on the structure of injury and injury type. The pediatric population possessed higher DRMAIS values for brain stem injuries as well as loss of consciousness injuries. Older adults possessed higher DRMAIS values for contusion/hemorrhage injuries, epidural hemorrhage, intracerebral hemorrhage, skull fracture, and subdural/subarachnoid hemorrhage. CONCLUSION At-risk populations such as pediatric and older adult patients possessed higher DRMAIS values for different head injuries. Disability in pediatric patients is critical due to loss of quality life years. Disability risk can supplement severity metrics to improve the ability of such metrics to discriminate the severity of different injuries that do not lead to death. Understanding of age-related differences in injury outcomes when compared to adults could inform future age-specific modifications to the AIS.
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Affiliation(s)
- Samantha L. Schoell
- Virginia Tech–Wake Forest University Center for Injury Biomechanics, Winston–Salem, North Carolina
- Wake Forest School of Medicine, Winston–Salem, North Carolina
| | - Ashley A. Weaver
- Virginia Tech–Wake Forest University Center for Injury Biomechanics, Winston–Salem, North Carolina
- Wake Forest School of Medicine, Winston–Salem, North Carolina
| | - Jennifer W. Talton
- Wake Forest School of Medicine, Division of Public Health Sciences, Winston–Salem, North Carolina
| | - Gretchen Baker
- Virginia Tech–Wake Forest University Center for Injury Biomechanics, Winston–Salem, North Carolina
| | - Andrea N. Doud
- Wake Forest School of Medicine, Winston–Salem, North Carolina
| | - Ryan T. Barnard
- Wake Forest School of Medicine, Division of Public Health Sciences, Winston–Salem, North Carolina
| | - Joel D. Stitzel
- Virginia Tech–Wake Forest University Center for Injury Biomechanics, Winston–Salem, North Carolina
- Wake Forest School of Medicine, Winston–Salem, North Carolina
| | - Mark R. Zonfrillo
- Alpert Medical School of Brown University and Hasbro Children’s Hospital, Providence, Rhode Island
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206
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Prognostic factors of early outcome and discharge status in patients undergoing surgical intervention following traumatic intracranial hemorrhage. J Clin Neurosci 2016; 31:152-6. [DOI: 10.1016/j.jocn.2016.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/08/2016] [Indexed: 12/27/2022]
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207
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Frazzitta G, Zivi I, Valsecchi R, Bonini S, Maffia S, Molatore K, Sebastianelli L, Zarucchi A, Matteri D, Ercoli G, Maestri R, Saltuari L. Effectiveness of a Very Early Stepping Verticalization Protocol in Severe Acquired Brain Injured Patients: A Randomized Pilot Study in ICU. PLoS One 2016; 11:e0158030. [PMID: 27447483 PMCID: PMC4957764 DOI: 10.1371/journal.pone.0158030] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/07/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Verticalization was reported to improve the level of arousal and awareness in patients with severe acquired brain injury (ABI) and to be safe in ICU. We evaluated the effectiveness of a very early stepping verticalization protocol on their functional and neurological outcome. METHODS Consecutive patients with Vegetative State or Minimally Conscious State were enrolled in ICU on the third day after an ABI. They were randomized to undergo conventional physiotherapy alone or associated to fifteen 30-minute sessions of verticalization, using a tilt table with robotic stepping device. Once stabilized, patients were transferred to our Neurorehabilitation unit for an individualized treatment. Outcome measures (Glasgow Coma Scale, Coma Recovery Scale revised -CRSr-, Disability Rating Scale-DRS- and Levels of Cognitive Functioning) were assessed on the third day from the injury (T0), at ICU discharge (T1) and at Rehab discharge (T2). Between- and within-group comparisons were performed by the Mann-Whitney U test and Wilcoxon signed-rank test, respectively. RESULTS Of the 40 patients enrolled, 31 completed the study without adverse events (15 in the verticalization group and 16 in the conventional physiotherapy). Early verticalization started 12.4±7.3 (mean±SD) days after ABI. The length of stay in ICU was longer for the verticalization group (38.8 ± 15.7 vs 25.1 ± 11.2 days, p = 0.01), while the total length of stay (ICU+Neurorehabilitation) was not significantly different (153.2 ± 59.6 vs 134.0 ± 61.0 days, p = 0.41). All outcome measures significantly improved in both groups after the overall period (T2 vs T0, p<0.001 all), as well as after ICU stay (T1 vs T0, p<0.004 all) and after Neurorehabilitation (T2 vs T1, p<0.004 all). The improvement was significantly better in the experimental group for CRSr (T2-T0 p = 0.033, T1-T0 p = 0.006) and (borderline) for DRS (T2-T0 p = 0.040, T1-T0 p = 0.058). CONCLUSIONS A stepping verticalization protocol, started since the acute stages, improves the short-term and long-term functional and neurological outcome of ABI patients. TRIAL REGISTRATION clinicaltrials.gov NCT02828371.
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Affiliation(s)
- Giuseppe Frazzitta
- Department of Brain Injury and Parkinson Disease Rehabilitation, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Ilaria Zivi
- Department of Brain Injury and Parkinson Disease Rehabilitation, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Roberto Valsecchi
- Department of Intensive Care, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Sara Bonini
- Department of Brain Injury and Parkinson Disease Rehabilitation, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Sara Maffia
- Department of Brain Injury and Parkinson Disease Rehabilitation, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Katia Molatore
- Department of Brain Injury and Parkinson Disease Rehabilitation, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Luca Sebastianelli
- Department of Brain Injury and Parkinson Disease Rehabilitation, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Alessio Zarucchi
- Department of Brain Injury and Parkinson Disease Rehabilitation, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Diana Matteri
- Department of Brain Injury and Parkinson Disease Rehabilitation, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Giuseppe Ercoli
- Department of Brain Injury and Parkinson Disease Rehabilitation, Ospedale “Moriggia-Pelascini”, Gravedona ed Uniti (CO), Italy
| | - Roberto Maestri
- Department of Biomedical Engineering, Scientific Institute of Montescano, Fondazione S. Maugeri IRCCS, Montescano (PV), Italy
| | - Leopold Saltuari
- Research Unit for Neurorehabilitation South Tyrol, Landeskrankenhaus Hochzirl-Natters, Zirl, Austria
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The role of cardiac troponin I in prognostication of patients with isolated severe traumatic brain injury. J Trauma Acute Care Surg 2016; 80:477-83. [PMID: 26910044 DOI: 10.1097/ta.0000000000000916] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac dysfunction is frequently observed after severe traumatic brain injury (sTBI); however, its significance is poorly understood. Our study sought to elucidate the association of cardiac troponin I (cTnI) elevation with all-cause in-hospital mortality following isolated sTBI (brain Abbreviated Injury Scale score ≥3 and admission Glasgow Coma Scale score ≤8, no Abbreviated Injury Scale score ≥3 to any other bodily regions). METHODS We retrospectively reviewed all adult patients (aged ≥18 years) with isolated sTBI admitted to a Level I trauma center between June 2007 and January 2014. Patients must have cTnI values within 24 hours of admission. Mortality risks were examined by Cox proportional hazard model. RESULTS Of 580 patients identified, 30.9% had detectable cTnI in 24 hours of admission. The median survival time was 4.19 days (interquartile range, 1.27-11.69). When adjusted for potential confounders, patients in the highest cTnI category (≥0.21 ng/mL) had a significantly higher risk of in-hospital mortality (hazard ratio, 1.39; 95% confidence interval, 1.04-1.88) compared with patients with undetectable cTnI. Mortality risk increased with higher troponin levels (p < 0.0001). This association was more pronounced in patients aged 65 years or younger (hazard ratio, 2.28; 95% confidence interval, 1.53-3.40; p < 0.0001) while, interestingly, insignificant in those older than 65 years (p = 0.0826). CONCLUSION Among patients with sTBI, cTnI elevation is associated with all-cause in-hospital mortality via a nonlinear positive trend. Age modified the effect of cTnI on mortality. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Cho YE, Latour LL, Kim H, Turtzo LC, Olivera A, Livingston WS, Wang D, Martin C, Lai C, Cashion A, Gill J. Older Age Results in Differential Gene Expression after Mild Traumatic Brain Injury and Is Linked to Imaging Differences at Acute Follow-up. Front Aging Neurosci 2016; 8:168. [PMID: 27468266 PMCID: PMC4942460 DOI: 10.3389/fnagi.2016.00168] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/23/2016] [Indexed: 12/21/2022] Open
Abstract
Older age consistently relates to a lesser ability to fully recover from a traumatic brain injury (TBI); however, there is limited data to explicate the nature of age-related risks. This study was undertaken to determine the relationship of age on gene-activity following a TBI, and how this biomarker relates to changes in neuroimaging findings. A young group (between the ages of 19 and 35 years), and an old group (between the ages of 60 and 89 years) were compared on global gene-activity within 48 h following a TBI, and then at follow-up within 1-week. At each time-point, gene expression profiles, and imaging findings from both magnetic resonance imaging (MRI) and computed tomography were obtained and compared. The young group was found to have greater gene expression of inflammatory regulatory genes at 48 h and 1-week in genes such as basic leucine zipper transcription factor 2 (BACH2), leucine-rich repeat neuronal 3 (LRRN3), and lymphoid enhancer-binding factor 1 (LEF1) compared to the old group. In the old group, there was increased activity in genes within S100 family, including calcium binding protein P (S100P) and S100 calcium binding protein A8 (S100A8), which previous studies have linked to poor recovery from TBI. The old group also had reduced activity of the noggin (NOG) gene, which is a member of the transforming growth factor-β superfamily and is linked to neurorecovery and neuroregeneration compared to the young group. We link these gene expression findings that were validated to neuroimaging, reporting that in the old group with a MRI finding of TBI-related damage, there was a lesser likelihood to then have a negative MRI finding at follow-up compared to the young group. Together, these data indicate that age impacts gene activity following a TBI, and suggest that this differential activity related to immune regulation and neurorecovery contributes to a lesser likelihood of neuronal recovery in older patients as indicated through neuroimaging.
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Affiliation(s)
- Young-Eun Cho
- National Institute of Nursing Research, National Institutes of Health, Bethesda MD, USA
| | - Lawrence L Latour
- National Institute of Neurological Disorders, National Institutes of Health, Bethesda MD, USA
| | - Hyungsuk Kim
- National Institute of Nursing Research, National Institutes of Health, Bethesda MD, USA
| | - L Christine Turtzo
- National Institute of Neurological Disorders, National Institutes of Health, Bethesda MD, USA
| | - Anlys Olivera
- National Institute of Nursing Research, National Institutes of Health, Bethesda MD, USA
| | - Whitney S Livingston
- National Institute of Nursing Research, National Institutes of Health, Bethesda MD, USA
| | - Dan Wang
- National Institute of Nursing Research, National Institutes of Health, Bethesda MD, USA
| | - Christiana Martin
- National Institute of Nursing Research, National Institutes of Health, Bethesda MD, USA
| | - Chen Lai
- National Institute of Nursing Research, National Institutes of Health, Bethesda MD, USA
| | - Ann Cashion
- National Institute of Nursing Research, National Institutes of Health, Bethesda MD, USA
| | - Jessica Gill
- National Institute of Nursing Research, National Institutes of Health, Bethesda MD, USA
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You W, Feng J, Tang Q, Cao J, Wang L, Lei J, Mao Q, Gao G, Jiang J. Intraventricular intracranial pressure monitoring improves the outcome of older adults with severe traumatic brain injury: an observational, prospective study. BMC Anesthesiol 2016; 16:35. [PMID: 27401211 PMCID: PMC4940906 DOI: 10.1186/s12871-016-0199-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 06/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring is widely used in the management of patients with severe traumatic brain injury (TBI). However, there is limited evidence about the efficacy of ICP monitoring in older subjects (aged ≥65 years). This study evaluated the effect of intraventricular ICP monitoring on the outcome of older adults suffering from a severe TBI. METHODS This prospective, observational study included 166 older TBI patients (aged ≥65 years) with Glasgow Coma scale (GCS) scores lower than 9 at admission. The study cohort was divided into two groups, intraventricular ICP monitoring and non-ICP monitoring. The primary outcome was in-hospital mortality. The secondary outcomes included the Glasgow Outcome Scale (GOS) score 6 months after injury, the ICU and total hospital lengths of stay, and mechanical ventilation days. RESULTS There were 80 patients in the intraventricular ICP monitoring group and 86 patients in non-ICP monitoring group. There was no statistical difference between groups in demographics and severity of head injury. Patients treated with intraventricular ICP monitoring had lower in-hospital mortality (33.8 % vs 51.2 %, P < 0.05), a higher 6-month GOS score (3.0 ± 1.4 vs 2.5 ± 1.2 P < 0.05), and a lower dosage (514 ± 246 g vs 840 ± 323 g, P < 0.0001) and shorter duration (7.2 ± 3.6 days vs 8.4 ± 4.3 days, P < 0.01) of mannitol use. However, the ICU length of stay (14.3 ± 6.4 days vs 11.6 ± 5.8 days, P < 0.01) and mechanical ventilation days (6.7 ± 3.5 days vs 5.6 ± 2.4 days, P < 0.05) were longer in the ICP monitoring group. The total length of hospital stay did not differ between the two groups (28.5 ± 12.1 days vs 26.1 ± 13.5 days, P = 0.23). CONCLUSIONS Intraventricular ICP monitoring may have beneficial effects on the decreased in-hospital mortality and improved 6-month outcome of older patients with severe TBI. However, given that this was an observational study conducted in a single institution, further well-designed randomized control trials are needed to evaluate the effect of intraventricular ICP monitoring on the outcome of older severe TBI patients.
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Affiliation(s)
- Wendong You
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Junfeng Feng
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Qilin Tang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Jun Cao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Lei Wang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Jin Lei
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Qing Mao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China.
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China.
| | - Jiyao Jiang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
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Abstract
OBJECTIVE Traumatic brain injury (TBI) is the single largest cause of death and disability following injury worldwide. The aim of this study was to determine the demographic, clinical, medical and accident related trends for patients with TBI hospitalized in an urban level 1 Trauma Centre. METHODS Data were retrospectively collected on individuals (n = 5,642) who were admitted to the Traumatic Brain Injury Program of the McGill University Health Centre - Montreal General Hospital from 2000 to 2011. RESULTS Regression analysis showed a significant upward trend in the yearly number of cases as well as an upward trending by year in the proportion of TBI cases aged 70-years-old or more. The Injury Severity Scale scores were positively associated with year indicating a slight increase in injury severity over the years and there was an increase in patient psychological, social and medical premorbid complexity. In addition, the Extended Glasgow Outcome Scale score tended to become more severe over the years. There was a slight decrease in the proportion of discharges home and in the proportion of deaths. CONCLUSIONS These results will help to understand the impact of TBI in an urban Canadian level 1 Trauma Centre. This information should be used to develop public prevention strategies and to educate the community about the risk of TBI especially the risk of falls in the ageing population. These findings can also provide information to help health policy makers plan for future resources.
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Osier ND, Bales JW, Pugh B, Shin S, Wyrobek J, Puccio AM, Okonkwo DO, Ren D, Alexander S, Conley YP, Dixon CE. Variation in PPP3CC Genotype Is Associated with Long-Term Recovery after Severe Brain Injury. J Neurotrauma 2016; 34:86-96. [PMID: 27225880 DOI: 10.1089/neu.2015.4343] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
After experimental traumatic brain injury (TBI), calcineurin is upregulated; blocking calcineurin is associated with improved outcomes. In humans, variation in the calcineurin A-gamma gene (PPP3CC) has been associated with neuropsychiatric disorders, though any role in TBI recovery remains unknown. This study examines associations between PPP3CC genotype and mortality, as well as gross functional status assessed at admission using the Glasgow Coma Scale (GCS) and at 3, 6, and 12 months after severe TBI using the Glasgow Outcome Score (GOS). The following tagging single nucleotide polymorphisms (tSNPs) in PPP3CC were genotyped: rs2443504, rs2461491, rs2469749, and rs10108011. The rs2443504 AA genotype was univariately associated with GCS (p = 0.022), GOS at 3, 6, and 12 months (p = 0.002, p = 0.034, and p = 0.004, respectively), and mortality (p = 0.007). In multivariate analysis controlling for age, sex, and GCS, the AA genotype of rs2443504 was associated with GOS at 3 (p = 0.02), and 12 months (p = 0.01), with a trend toward significance at 6 months (p = 0.05); the AA genotype also was associated with mortality in the multivariate model (p = 0.04). Further work is warranted to better understand the role of calcineurin, as well as the genes encoding it and their relevance to outcomes after brain injury.
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Affiliation(s)
- Nicole D Osier
- 1 Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania.,3 School of Nursing, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - James W Bales
- 2 Department of Neurosurgery, University of Washington , Seattle, Washington
| | - Bunny Pugh
- 1 Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania.,4 Safar Center for Resuscitation Research, Seton Hill University , Greensburg, Pennsylvania
| | - Samuel Shin
- 1 Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Julie Wyrobek
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Ava M Puccio
- 6 Department of Neurological Surgery, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - David O Okonkwo
- 6 Department of Neurological Surgery, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Dianxu Ren
- 3 School of Nursing, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Sheila Alexander
- 3 School of Nursing, University of Pittsburgh , Pittsburgh, Pennsylvania.,7 School of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Yvette P Conley
- 3 School of Nursing, University of Pittsburgh , Pittsburgh, Pennsylvania.,8 Department of Human Genetics, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - C Edward Dixon
- 1 Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania.,6 Department of Neurological Surgery, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania.,9 VA Pittsburgh Healthcare System , Pittsburgh, Pennsylvania
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Tracheostomy is associated with decreased hospital mortality after moderate or severe isolated traumatic brain injury. Wien Klin Wochenschr 2016; 128:397-403. [PMID: 27220338 PMCID: PMC4916187 DOI: 10.1007/s00508-016-1004-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 03/22/2016] [Indexed: 12/18/2022]
Abstract
Background Data regarding the impact and timing of tracheostomy in patients with isolated traumatic brain injury (TBI) are ambiguous. Our goal was to evaluate the impact of tracheostomy on hospital mortality in patients with moderate or severe isolated TBI. Materials and Methods We performed a retrospective cohort analysis of data prospectively collected at 87 Austrian intensive care units (ICUs). All patients continuously admitted between 1998 and 2010 were evaluated for the study. In total, 4,735 patients were admitted to ICUs with isolated TBI. Of these patients, 2,156 had a moderate or severe TBI (1,603 patients were endotracheally intubated only, 553 patients underwent tracheostomy). Epidemiological data (trauma severity, treatment, and outcome) of the two groups were compared. Results Patients with moderate or severe isolated TBI undergoing tracheostomy had a similar Glasgow Coma Scale score, median (interquartile range): 6 (3–8) vs 6 (3–8); p = 0.90, and Simplified Acute Physiology Score II, 45 (37–54) vs 45 (35–56); p = 0.86, compared with intubated patients not undergoing tracheostomy. Furthermore, patients undergoing tracheostomy exhibited higher Abbreviated Injury Scale Head scores and had a longer ICU stay for survivors, 30 (22–42) vs 9 (3–17) days; p < 0.0001). In contrast, risk-adjusted mortality was lower in patients undergoing tracheostomy compared with patients who remained intubated, observed-to-expected mortality ratio (95 % confidence interval): 0.62 (0.53–0.72) vs 1.00 (0.95–1.05) respectively. Conclusions Despite the greater severity of head injury, patients with isolated TBI who underwent tracheostomy had a lower risk-adjusted mortality than patients who remained intubated. Reasons for this difference in outcome may be multifactorial and require further investigation.
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214
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Psychometric Properties of the Functional Independence Measure (FIM) in Iranian Patients With Traumatic Brain Injury. Trauma Mon 2016. [DOI: 10.5812/traumamon.25534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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215
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Thompson WH, Thelin EP, Lilja A, Bellander BM, Fransson P. Functional resting-state fMRI connectivity correlates with serum levels of the S100B protein in the acute phase of traumatic brain injury. Neuroimage Clin 2016; 12:1004-1012. [PMID: 27995066 PMCID: PMC5153599 DOI: 10.1016/j.nicl.2016.05.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 04/21/2016] [Accepted: 05/05/2016] [Indexed: 12/20/2022]
Abstract
The S100B protein is an intra-cellular calcium-binding protein that mainly resides in astrocytes in the central nervous system. The serum level of S100B is used as biomarker for the severity of brain damage in traumatic brain injury (TBI) patients. In this study we investigated the relationship between intrinsic resting-state brain connectivity, measured 1-22 days (mean 8 days) after trauma, and serum levels of S100B in a patient cohort with mild-to-severe TBI in need of neuro-intensive care in the acute phase. In line with previous investigations, our results show that the peak level of S100B acquired during the acute phase of TBI was negatively correlated with behavioral measures (Glasgow Outcome Score, GOS) of functional outcome assessed 6 to 12 months post injury. Using a multi-variate pattern analysis-informed seed-based correlation analysis, we show that the strength of resting-state brain connectivity in multiple resting-state networks was negatively correlated with the peak of serum levels of S100B. A negative correspondence between S100B peak levels recorded 12-36 h after trauma and intrinsic connectivity was found for brain regions located in the default mode, fronto-parietal, visual and motor resting-state networks. Our results suggest that resting-state brain connectivity measures acquired during the acute phase of TBI is concordant with results obtained from molecular biomarkers and that it may hold a capacity to predict long-term cognitive outcome in TBI patients.
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Affiliation(s)
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anders Lilja
- Section of Neuroradiology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Fransson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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216
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Elderly Patients with Severe Traumatic Brain Injury Could Benefit from Surgical Treatment. World Neurosurg 2016; 89:147-52. [DOI: 10.1016/j.wneu.2016.01.084] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 11/20/2022]
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217
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McDonald SJ, Sun M, Agoston DV, Shultz SR. The effect of concomitant peripheral injury on traumatic brain injury pathobiology and outcome. J Neuroinflammation 2016; 13:90. [PMID: 27117191 PMCID: PMC4847339 DOI: 10.1186/s12974-016-0555-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/18/2016] [Indexed: 01/08/2023] Open
Abstract
Background Traumatic injuries are physical insults to the body that are prevalent worldwide. Many individuals involved in accidents suffer injuries affecting a number of extremities and organs, otherwise known as multitrauma or polytrauma. Traumatic brain injury is one of the most serious forms of the trauma-induced injuries and is a leading cause of death and long-term disability. Despite over dozens of phase III clinical trials, there are currently no specific treatments known to improve traumatic brain injury outcomes. These failures are in part due to our still poor understanding of the heterogeneous and evolving pathophysiology of traumatic brain injury and how factors such as concomitant extracranial injuries can impact these processes. Main body Here, we review the available clinical and pre-clinical studies that have investigated the possible impact of concomitant injuries on traumatic brain injury pathobiology and outcomes. We then list the pathophysiological processes that may interact and affect outcomes and discuss promising areas for future research. Taken together, many of the clinical multitrauma/polytrauma studies discussed in this review suggest that concomitant peripheral injuries may increase the risk of mortality and functional deficits following traumatic brain injury, particularly when severe extracranial injuries are combined with mild to moderate brain injury. In addition, recent animal studies have provided strong evidence that concomitant injuries may increase both peripheral and central inflammatory responses and that structural and functional deficits associated with traumatic brain injury may be exacerbated in multiply injured animals. Conclusions The findings of this review suggest that concomitant extracranial injuries are capable of modifying the outcomes and pathobiology of traumatic brain injury, in particular neuroinflammation. Though additional studies are needed to further identify the factors and mechanisms involved in central and peripheral injury interactions following multitrauma and polytrauma, concomitant injuries should be recognized and accounted for in future pre-clinical and clinical traumatic brain injury studies.
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Affiliation(s)
- Stuart J McDonald
- Department of Physiology, Anatomy and Microbiology, La Trobe University, Melbourne, VIC, Australia.
| | - Mujun Sun
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Denes V Agoston
- Department of Anatomy, Physiology, and Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sandy R Shultz
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.
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Emami P, Czorlich P, Fritzsche FS, Westphal M, Rueger JM, Lefering R, Hoffmann M. Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study. J Neurosurg 2016; 126:760-767. [PMID: 27035177 DOI: 10.3171/2016.1.jns152385] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI. METHODS A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIShead) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIShead score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0-15 years old) and adults (16-55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale. RESULTS A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240-5.435) and fixed pupils (OR 4.197, 95% CI 3.271-5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282-3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421-0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively). CONCLUSIONS This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.
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Affiliation(s)
| | | | | | | | - Johannes M Rueger
- Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg; and
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Michael Hoffmann
- Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg; and
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Rezaei S, Dehnadi Moghadam A, Khodadadi N, Rahmatpour P. Functional Independence Measure in Iran: A Confirmatory Factor Analysis and Evaluation of Ceiling and Floor Effects in Traumatic Brain Injury Patients. ARCHIVES OF TRAUMA RESEARCH 2016; 4:e25363. [PMID: 26848469 PMCID: PMC4733519 DOI: 10.5812/atr.25363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 03/05/2015] [Accepted: 06/30/2015] [Indexed: 11/16/2022]
Abstract
Background: The functional independence measure (FIM) is one of the most important assessment instruments for motor and cognitive dependence in rehabilitation medicine; however, there is little data about its confirmatory factor analysis (CFA) and ceiling/floor effects from other countries and also in Iranian patients. Objectives: The aim of this study was to evaluate a two-factor model (motor and cognitive independence as latent variables) and ceiling/floor effects for FIM in Iranian patients with traumatic brain injuries (TBI). Patients and Methods: In this cross-sectional study, 185 subacute TBI patients were selected from emergency and neurosurgery departments of Poursina Hospital (the largest trauma hospital in northern Iran, Rasht) using the consecutive sampling method and were assessed for functional independence. Results: The results of this study showed that the floor effect was not observed; however, ceiling effects were observed for the FIM total score and its subscales. The confirmatory factor analysis showed that the chi-square/df ratio was 2.8 for the two-factor structure and the fit indices for this structural model including root mean square error of approximation (RMSEA) = 0.099, normed fit index (NFI) = 0.96, tucker lewis index (TLI) = 0.97, comparative fit index (CFI) = 0.97 were close to standard indices. Conclusions: Although ceiling effects should be considered for rehabilitation targets, the two-factor model of FIM (motor and cognitive independence) has an eligible fitness for Iranian patients with TBI.
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Affiliation(s)
- Sajjad Rezaei
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
- Corresponding author: Sajjad Rezaei, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, IR Iran. Tel: +98-9113390785, Fax: +98-1333338373, E-mail:
| | - Anoush Dehnadi Moghadam
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
- Department of Anesthesiology and Intensive Care Unit, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Naeima Khodadadi
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
- Department of Nursing, Faculty of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Pardis Rahmatpour
- Department of Nursing, Faculty of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, IR Iran
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220
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Promising clinical outcome of elderly with TBI after modern neurointensive care. Acta Neurochir (Wien) 2016; 158:125-33. [PMID: 26577639 DOI: 10.1007/s00701-015-2639-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The increasing number of elderly patients with traumatic brain injury (TBI) leads to specific neurointensive care (NIC) challenges. Therefore, elderly subjects with TBI need to be further studied. In this study we evaluated the demographics, management and outcome of elderly TBI patients receiving modern NIC. METHODS Patients referred to our NIC unit between 2008 and 2010 were included. Patients were divided in two age groups, elderly (E) ≥65 years and younger (Y) 64-15 years. Parameters studied were the dominant finding on CT scans, neurological motor skills and consciousness, type of monitoring, neurosurgical procedures/treatments and Glasgow Outcome Scale Extended score at 6 months after injury. RESULTS Sixty-two E (22 %) and 222 Y (78 %) patients were included. Falls were more common in E (81 %) and vehicle accidents were more common in Y patients (37 %). Acute subdural hematoma was significantly more common in E (50 % of cases) compared to Y patients (18 %). Intracranial pressure was monitored in 44 % of E and 57 % of Y patients. Evacuation of significant mass lesions was performed more common in the E group. The NIC mortality was similar in both groups (4-6 %). Favorable outcome was observed in 72 % of Y and 51 % of E patients. At the time of follow-up 25 % of E and 7 % of Y patients had died. CONCLUSIONS The outcome of elderly patients with TBI was significantly worse than in younger patients, as expected. However, as much as 51 % of the elderly patients showed a favorable outcome after NIC. We believe that these results encourage modern NIC in elderly patients with TBI. We need to study how secondary brain injury mechanisms differ in the older patients and to identify specific outcome predictors for elderly patients with TBI.
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Petkus V, Krakauskaitė S, Preikšaitis A, Ročka S, Chomskis R, Ragauskas A. Association between the outcome of traumatic brain injury patients and cerebrovascular autoregulation, cerebral perfusion pressure, age, and injury grades. Medicina (B Aires) 2016; 52:46-53. [DOI: 10.1016/j.medici.2016.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 01/15/2016] [Indexed: 11/24/2022] Open
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Ryu JI, Kim CH, Kim JM, Cheong JH. Assessment of the Clinical and the Radiological Prognostic Factors that Determine the Management of a Delayed, Traumatic, Intraparenchymal Hemorrhage (DTIPH). JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.4.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Je Il Ryu
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Choong Hyun Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
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223
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Predictors of Outcomes in Traumatic Brain Injury. World Neurosurg 2015; 90:525-529. [PMID: 26721615 DOI: 10.1016/j.wneu.2015.12.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 12/12/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The purpose of this study was to retrospectively evaluate patients treated for traumatic brain injuries (TBI) to determine how multiple organ trauma (MOT) and lung injuries sustained at the time of initial injury affect outcome. METHODS A single institution retrospective review of all patients diagnosed with TBI at a level I trauma center from 2000 to 2014 was conducted. Clinical outcome was based on Glasgow Outcome Scale at hospital discharge. Lung injury was defined as the presence of pulmonary contusions, pneumothorax, hemothorax, rib fractures, or diaphragmatic rupture proven by x-ray or computed tomography scan. MOT was defined as trauma to one body region with an Abbreviated Injury Scale (AIS) score ≥3 plus trauma to 2 additional body regions with AIS scores ≥1. Regression analysis was conducted with SPSS 21. RESULTS There were 409 patients reviewed. The majority of patients were male (73%), average age was 46 years (range, 16-94 years), average Glasgow Coma Scale (GCS) score was 7, and 71% had a severe TBI (GCS ≤8). Thirty percent of patients had poor outcome (Glasgow Outcome Scale = 1-2) Regression analysis indicated age (odds ratio [OR] 1.03, P < 0.001), initial GCS (OR 0.88, P < 0.001), Injury Severity Score (OR 1.03, P = 0.021), and head AIS ≥5 (OR 0.55, P = 0.019) were significant independent predictors of poor outcome. Sex, MOT, lung injury, and lung injury severity were not significant predictors of outcome. CONCLUSIONS Age, GCS, Injury Severity Score, and critical head injuries (AIS ≥5) were significant tools in predicting outcome in this patient cohort. MOT and traumatic lung injury may cause significant damage to a patient suffering from a severe TBI, but these injuries do not predict mortality in this patient population.
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Brennan JH, Bernard S, Cameron PA, Olaussen A, Fitzgerald MC, Rosenfeld JV, Mitra B. Ethanol exposure and isolated traumatic brain injury. J Clin Neurosci 2015; 22:1928-32. [DOI: 10.1016/j.jocn.2015.05.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 05/09/2015] [Indexed: 11/26/2022]
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Nakae R, Takayama Y, Kuwamoto K, Naoe Y, Sato H, Yokota H. Time Course of Coagulation and Fibrinolytic Parameters in Patients with Traumatic Brain Injury. J Neurotrauma 2015; 33:688-95. [PMID: 26414158 DOI: 10.1089/neu.2015.4039] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) has long been associated with coagulopathy; however, the time course of coagulation/fibrinolytic parameters in the acute phase of TBI remains unclear. The purpose of the study was to analyze the time course of coagulation/fibrinolytic parameters in the acute phase of TBI and to elucidate parameter relationships to prognosis. We retrospectively evaluated 234 patients with severe isolated TBI with initial blood samples obtained no more than 1 h after injury. Platelet count, prothrombin time, activated partial thromboplastin time (aPTT), plasma levels of fibrinogen, and D-dimer were measured on arrival in the emergency department and 3, 6, and 12 h after injury. Multivariate logistic regression analysis was performed to identify risk factors for poor prognosis at each time point. From hospital admission to 12 h after injury, an elevated D-dimer level was a significant negative prognostic indicator (admission: p < 0.0001; 3 h after injury: p = 0.0005; 6 h after injury: p = 0.005; 12 h after injury: p = 0.0009). An upward trend of aPTT on admission and 3 h after injury was also a significant negative prognostic indicator (admission: p = 0.0011; 3 h after injury: p = 0.013). On multivariate logistic regression analysis, which included all initial variables, independent risk factors for poor prognosis included older age (p = 0.0005), low Glasgow Coma Scale score (p < 0.0001), high Abbreviated Injury Score (p = 0.015), aPTT >30.2 sec (p = 0.019), and elevated D-dimer level (p = 0.0005). We concluded that D-dimer is the best coagulation/fibrinolytic parameter to monitor for prediction of outcome.
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Affiliation(s)
- Ryuta Nakae
- 1 Emergency and Critical Care Center, Kawaguchi Municipal Medical Center , Saitama, Japan
| | - Yasuhiro Takayama
- 2 Department of Emergency and Critical Care Medicine, Nippon Medical School , Tokyo, Japan
| | - Kentaro Kuwamoto
- 2 Department of Emergency and Critical Care Medicine, Nippon Medical School , Tokyo, Japan
| | - Yasutaka Naoe
- 1 Emergency and Critical Care Center, Kawaguchi Municipal Medical Center , Saitama, Japan
| | - Hidetaka Sato
- 2 Department of Emergency and Critical Care Medicine, Nippon Medical School , Tokyo, Japan
| | - Hiroyuki Yokota
- 2 Department of Emergency and Critical Care Medicine, Nippon Medical School , Tokyo, Japan
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Fu TS, Jing R, McFaull SR, Cusimano MD. Recent trends in hospitalization and in-hospital mortality associated with traumatic brain injury in Canada: A nationwide, population-based study. J Trauma Acute Care Surg 2015; 79:449-54. [PMID: 26535433 DOI: 10.1097/ta.0000000000000733] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is the leading cause of traumatic death and disability worldwide.We examined nationwide trends in TBI-related hospitalizations and in-hospital mortality between April 2006 and March 2011 using a nationwide, population based database that is mandatory for all hospitals in Canada. METHODS Trends in hospitalization rates for all acute hospital separations in Canada were analyzed using linear regression. Independent predictors of in-hospital mortality were evaluated using logistic regression. RESULTS Hospitalization rates remained stable for children and young adults but increased considerably among elderly adults (age Q65 years). Falls and motor vehicle collisions (MVCs) were the most common causes of TBI hospitalizations. TBIs caused by falls increased by 24% (p = 0.01), while MVC-related hospitalization rates decreased by 18% (p = 0.03). Elderly adults were most vulnerable to falls and experienced the greatest increase (29%) in fall-related hospitalization rates. Young adults (ages, 15Y24 years) were most at risk for MVCs but experienced the greatest decline (28%) in MVC-related admissions. There were significant trends toward increasing age, injury severity, comorbidity, hospital length of stay, and rate of in-hospital mortality.However, multivariate regression showed that odds of death decreased over time after controlling for relevant factors. Injury severity, comorbidity, and advanced age were the most important predictors of in-hospital mortality for TBI inpatients. CONCLUSION Hospitalizations for TBI are increasing in severity and involve older populations with more complex comorbidities. Although preventive strategies for MVC-related TBI are likely having some effects, there is a critical need for effective fall prevention strategies, especially among elderly adults.
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Kang J, Hong S, Hu C, Pyen J, Whang K, Cho S, Kim J, Kim S, Oh J. Clinical Analysis of Delayed Surgical Epidural Hematoma. Korean J Neurotrauma 2015; 11:112-7. [PMID: 27169075 PMCID: PMC4847500 DOI: 10.13004/kjnt.2015.11.2.112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 09/16/2015] [Accepted: 10/12/2015] [Indexed: 11/25/2022] Open
Abstract
Objective A small epidural hematoma (EDH) that has been diagnosed to be nonsurgical by initial brain computed tomography (CT) can increase in size and need surgical removal, resulting in a poor prognosis. However, there have been few studies, which focused delayed operated EDH. Therefore, we analyzed the clinical factors to determine the predicting factors of delayed operated EDH. Methods Between January 2011 and January 2014, 90 patients, who were admitted due to EDH, were enrolled in this study. None of the patients were indicated for operation initially. Based on the presence of surgery, we classified the patients into a delayed-surgery group (DG) and a non-surgical group (NG). Additionally, we analyzed them according to the following: time interval between the trauma and the initial CT, gender, age, medical history, drinking, change of mean arterial pressure (MAP), volume of EDH and other traumatic brain lesion. Results Among the 90 patients, the DG was 19 patients. Compared with NG, the DG revealed increased MAP, less presence of drinking, and a short time interval (DG vs. NG: +9.684 mm Hg vs. -0.428 mm Hg, 5.26% vs. 29.58%, 1.802 hours vs. 5.707 hours, respectively, p<0.05). Analyzing the time interval with receiver operating characteristic, there was 88.2% sensitivity and 68.3% specificity at the 2.05-hour cut-off value (area under the curve=0.854). Conclusion According to our results, the time interval between the trauma and the initial CT along with blood pressure change are potential predicting factors in the cases of delayed operation of EDH.
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Affiliation(s)
- Jiin Kang
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Soonki Hong
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Chul Hu
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Jinsoo Pyen
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Sungmin Cho
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Jongyeon Kim
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Sohyun Kim
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Jiwoong Oh
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
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228
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Timaru-Kast R, Herbig EL, Luh C, Engelhard K, Thal SC. Influence of Age on Cerebral Housekeeping Gene Expression for Normalization of Quantitative Polymerase Chain Reaction after Acute Brain Injury in Mice. J Neurotrauma 2015; 32:1777-88. [PMID: 26102571 DOI: 10.1089/neu.2014.3784] [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: 11/12/2022] Open
Abstract
To prevent methodological errors of quantitative PCR (qPCR) normalization with reference genes is obligatory. Although known to influence gene expression, impact of age on housekeeping gene expression has not been determined after acute brain lesions such as traumatic brain injury (TBI). Therefore, expression of eight common control genes was investigated at 15 min, 24 h, and 72 h after experimental TBI in 2- and 21-month-old C57Bl6 mice. Expression of β2-microglobulin (B2M), β-actin (ActB), and porphobilinogen deaminase (PBGD) increased after TBI in both ages. β2M demonstrated age-dependent differences and highest inter- and intragroup variations. Expression of cyclophilin A, glyceraldehyde-3-phosphate dehydrogenase (GAPDH), hypoxanthine ribosyltransferase (HPRT), S100B, and 18SrRNA remained stable. Cyclophilin A and HPRT demonstrated strongest inter- and intragroup stability. The data indicate that the expression of most but not all control genes is stable during aging. The correct choice of housekeeping genes is of key importance to ensure adequate normalization of qPCR data. With respect to insult and age, normalization strategies should consider cyclophilin A as a single normalizer. Normalization with two reference genes is recommended with cyclophilin A and HPRT in young mice and in mixed age studies and with cyclophilin A and GAPDH in old mice. In addition, the present study suggests not to use β2-microglobulin, β-actin or PBGD as single control genes because of strong regulation after CCI in 2- and 21-month-old mice.
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Affiliation(s)
- Ralph Timaru-Kast
- Department of Anesthesiology, Medical Center of Johannes Gutenberg-University , Mainz, Germany
| | - Elina L Herbig
- Department of Anesthesiology, Medical Center of Johannes Gutenberg-University , Mainz, Germany
| | - Clara Luh
- Department of Anesthesiology, Medical Center of Johannes Gutenberg-University , Mainz, Germany
| | - Kristin Engelhard
- Department of Anesthesiology, Medical Center of Johannes Gutenberg-University , Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, Medical Center of Johannes Gutenberg-University , Mainz, Germany
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Lichte P, Andruszkow H, Kappe M, Horst K, Pishnamaz M, Hildebrand F, Lefering R, Pape HC, Kobbe P. Increased in-hospital mortality following severe head injury in young children: results from a nationwide trauma registry. Eur J Med Res 2015; 20:65. [PMID: 26272597 PMCID: PMC4536600 DOI: 10.1186/s40001-015-0159-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/05/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In the current literature, the outcome of paediatric brain injury is controversially discussed. According to the majority of the studies, there seems to be a decreased mortality but worse recovery in paediatric, traumatic brain injury in comparison with adults. However, there is a lack of information concerning the differences in various stages of development in patients younger than 18 years. The aim of our study was to verify the in-hospital outcome of different paediatric age groups in comparison to adults with respect to the treatment strategy. METHODS We performed a retrospective analysis of the TraumaRegister DGU(®) from 2002 to 2012. Inclusion criteria were an Abbreviated Injury Scale (AIS) head ≥3 points and an AIS ≤2 points of the remaining body regions. The collective was divided into different subgroups according to age (1-3, 4-6, 7-10, 11-14, 15-17) and an adult control group aged between 18 and 55 years. We descriptively analysed the endpoint rate of sepsis, multiple organ failure, and mortality. Additionally, the Glasgow Outcome Scale (GOS) at discharge was observed. RESULTS Overall, 1110 children and 6491 adult control patients were included. Comparing the rate of intubation on-scene, the rate of cranial CT scans, the rate of craniotomies, and the rate and length of intensive care treatment, we could only identify minor differences between the age groups. The treatment after discharge from hospital was markedly different due to a very low rate of in-patient rehabilitation treatment in children. On one hand, the rate of systemic complications, such as sepsis and multiple organ failure increased with increasing age. On the other hand, we found a significantly increased mortality in children younger than 7 years after very (AIS head = 5) severe brain injury. The in-hospital functional outcome in survivors, according to the GOS, was beneficial for younger children in comparison to adolescents and adults. CONCLUSIONS We were unable to identify marked age-related differences in the therapeutic approach. Nevertheless, we were able to demonstrate marked differences of outcome. Children younger than 7 years significantly die more often due to direct impact of severe trauma. But if they survive, they seem to develop less systemic complications and profit from a better functional outcome.
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Affiliation(s)
- Philipp Lichte
- Department of Orthopaedic Trauma Surgery, University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Hagen Andruszkow
- Department of Orthopaedic Trauma Surgery, University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Miriam Kappe
- Department of Orthopaedic Trauma Surgery, University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Klemens Horst
- Department of Orthopaedic Trauma Surgery, University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany. .,Harald Tscherne Research Laboratory for Orthopedic Trauma, Department of Orthopaedic Trauma Surgery, University Hospital RWTH Aachen, Aachen, Germany.
| | - Miguel Pishnamaz
- Department of Orthopaedic Trauma Surgery, University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany. .,Harald Tscherne Research Laboratory for Orthopedic Trauma, Department of Orthopaedic Trauma Surgery, University Hospital RWTH Aachen, Aachen, Germany.
| | - Frank Hildebrand
- Department of Orthopaedic Trauma Surgery, University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany.
| | - Hans-Christoph Pape
- Department of Orthopaedic Trauma Surgery, University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Philipp Kobbe
- Department of Orthopaedic Trauma Surgery, University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
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Henninger N, Izzy S, Carandang R, Hall W, Muehlschlegel S. Severe leukoaraiosis portends a poor outcome after traumatic brain injury. Neurocrit Care 2015; 21:483-95. [PMID: 24752459 DOI: 10.1007/s12028-014-9980-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE It is now well accepted that traumatic white matter injury constitutes a critical determinant of post-traumatic functional impairment. However, the contribution of preexisting white matter rarefaction on outcome following traumatic brain injury (TBI) is unknown. Hence, we sought to determine whether the burden of preexisting leukoaraiosis of presumed ischemic origin is independently associated with outcome after TBI. METHODS We retrospectively analyzed consecutive, prospectively enrolled patients of ≥50 years (n = 136) who were admitted to a single neurological/trauma intensive care unit. Supratentorial white matter hypoattenuation on head CT was graded on a 5-point scale (range 0-4) reflecting increasing severity of leukoaraiosis. Outcome was ascertained according to the modified Rankin Scale (mRS) and Glasgow outcome scale (GOS) at 3 and 12 months, respectively. RESULTS After adjustment for other factors, leukoaraiosis severity was significantly associated with a poor outcome at 3 and 12 months defined as mRS 3-6 and GOS 1-3, respectively. The independent association between leukoaraiosis and poor outcome remained when the analysis was restricted to patients who survived up to 3 months, had moderate-to-severe TBI [enrollment Glasgow Coma Scale (GCS) ≤12; p = 0.001], or had mild TBI (GCS 13-15; p = 0.002), respectively. CONCLUSION We provide first evidence that preexisting cerebral small vessel disease independently predicts a poor functional outcome after closed head TBI. This association is independent of other established outcome predictors such as age, comorbid state as well as intensive care unit complications and interventions. This knowledge may help improve prognostic accuracy, clinical management, and resource utilization.
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Affiliation(s)
- Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North, Worcester, MA, 01655, USA,
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Al Nimer F, Thelin E, Nyström H, Dring AM, Svenningsson A, Piehl F, Nelson DW, Bellander BM. Comparative Assessment of the Prognostic Value of Biomarkers in Traumatic Brain Injury Reveals an Independent Role for Serum Levels of Neurofilament Light. PLoS One 2015; 10:e0132177. [PMID: 26136237 PMCID: PMC4489843 DOI: 10.1371/journal.pone.0132177] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 06/10/2015] [Indexed: 11/18/2022] Open
Abstract
Traumatic brain injury (TBI) is a common cause of death and disability, worldwide. Early determination of injury severity is essential to improve care. Neurofilament light (NF-L) has been introduced as a marker of neuroaxonal injury in neuroinflammatory/-degenerative diseases. In this study we determined the predictive power of serum (s-) and cerebrospinal fluid (CSF-) NF-L levels towards outcome, and explored their potential correlation to diffuse axonal injury (DAI). A total of 182 patients suffering from TBI admitted to the neurointensive care unit at a level 1 trauma center were included. S-NF-L levels were acquired, together with S100B and neuron-specific enolase (NSE). CSF-NF-L was measured in a subcohort (n = 84) with ventriculostomies. Clinical and neuro-radiological parameters, including computerized tomography (CT) and magnetic resonance imaging, were included in the analyses. Outcome was assessed 6 to 12 months after injury using the Glasgow Outcome Score (1-5). In univariate proportional odds analyses mean s-NF-L, -S100B and -NSE levels presented a pseudo-R2 Nagelkerke of 0.062, 0.214 and 0.074 in correlation to outcome, respectively. In a multivariate analysis, in addition to a model including core parameters (pseudo-R2 0.33 towards outcome; Age, Glasgow Coma Scale, pupil response, Stockholm CT score, abbreviated injury severity score, S100B), S-NF-L yielded an extra 0.023 pseudo-R2 and a significantly better model (p = 0.006) No correlation between DAI or CT assessed-intracranial damage and NF-L was found. Our study thus demonstrates that S-NF-L correlates to TBI outcome, even if used in models with S100B, indicating an independent contribution to the prediction, perhaps by reflecting different pathophysiological processes, not possible to monitor using conventional neuroradiology. Although we did not find a predictive value of NF-L for DAI, this cannot be completely excluded. We suggest further studies, with volume quantification of axonal injury, and a prolonged sampling time, in order to better determine the connection between NF-L and DAI.
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Affiliation(s)
- Faiez Al Nimer
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Eric Thelin
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Stockholm, Sweden
| | - Harriet Nyström
- Department of Clinical Neuroscience, Section of Neuroradiology, Karolinska Institutet, Stockholm, Sweden
| | - Ann M Dring
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anders Svenningsson
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Stockholm, Sweden
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232
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Functional Recovery and Life Satisfaction in the First Year After Severe Traumatic Brain Injury. J Head Trauma Rehabil 2015; 30:E38-49. [DOI: 10.1097/htr.0000000000000080] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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233
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Willyerd FA, Empey PE, Philbrick A, Ikonomovic MD, Puccio AM, Kochanek PM, Okonkwo DO, Clark RSB. Expression of ATP-Binding Cassette Transporters B1 and C1 after Severe Traumatic Brain Injury in Humans. J Neurotrauma 2015; 33:226-31. [PMID: 25891836 DOI: 10.1089/neu.2015.3879] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Adenosine triphosphate-binding cassette (ABC) transport proteins ABCC1 and ABCB1 (also known as multidrug resistance-associated protein 1 and p-glycoprotein, respectively), are key membrane efflux transporters of drugs and endogenous substrates, including in the brain. The impact of traumatic brain injury (TBI) on ABCC1 and ABCB1 expression in humans is unknown. We hypothesized that ABCC1 and ABCB1 expression would be altered in brain tissue from patients acutely after severe TBI. Archived TBI samples (n=10) from our Brain Trauma Research Center and control samples (n=7) from our Alzheimer Disease Research Center were obtained under Institutional Review Board approval. Protein was extracted from fresh frozen cortical brain tissue for Western blot analysis and sections were obtained from fixed cortical tissue for immunohistochemistry. Relative abundance of ABCC1 was increased in samples from TBI versus controls (2.8±2.5 fold; p=0.005). ABCC1 immunohistochemistry was consistent with Western blot data, with increased immunoreactivity in cerebral blood vessel walls, as well as cells with the morphological appearance of neurons and glia in TBI versus controls. Relative abundance of ABCB1 was similar between TBI and controls (p=0.76), and ABCB1 immunoreactivity was primarily associated with cerebral blood vessels in both groups. These human data show that TBI increases ABCC1 expression in the brain, consistent with possible implications for both patients receiving pharmacological inhibitors and/or substrates of ABCC1 after TBI.
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Affiliation(s)
- F Anthony Willyerd
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.,7 Phoenix Children's Children's Hospital, Critical Care, and the University of Arizona , Phoenix, Arizona
| | - Philip E Empey
- 2 Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania.,6 Clinical and Translational Science Institute, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Ashley Philbrick
- 2 Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Milos D Ikonomovic
- 3 Department of Neurology, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Ava M Puccio
- 4 Department of Neurological Surgery, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Patrick M Kochanek
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.,5 Department of Pediatrics, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - David O Okonkwo
- 4 Department of Neurological Surgery, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Robert S B Clark
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.,5 Department of Pediatrics, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.,6 Clinical and Translational Science Institute, University of Pittsburgh School of Medicine , the Safar Center for Resuscitation Research and the Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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234
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Jawa RS, Shapiro MJ, McCormack JE, Huang EC, Rutigliano DN, Vosswinkel JA. Preadmission Do Not Resuscitate advanced directive is associated with adverse outcomes following acute traumatic injury. Am J Surg 2015; 210:814-21. [PMID: 26116324 DOI: 10.1016/j.amjsurg.2015.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 04/17/2015] [Accepted: 04/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Do Not Resuscitate (DNR) orders have been associated with poor outcomes in surgical patients. There is limited literature on admitted trauma patients with advanced directives indicating DNR status before admission (preadmission DNR [PADNR]). METHODS A retrospective review of the trauma registry of a suburban county was carried out for admitted trauma patients with age ≥41 years, who were admitted between 2008 and 2013. RESULTS Of 7,937 admitted patients, 327 had a preadmission advanced directive indicating DNR. PADNR patients were significantly older (87 vs 69 years), with more frequent comorbidities, and were more often admitted after a fall (94.2% vs 65.8%). PADNR patients had a higher Injury Severity Score (14 vs 11). They also had significantly increased rates of pneumonia, sepsis, myocardial infarction, and death (33.6% vs 5.9%). On multivariate logistic regression, the presence of a preadmission advanced directive indicating DNR status was independently associated with a 5.2-fold increased odds of mortality. CONCLUSION An advanced directive indicating DNR is associated with adverse outcomes following trauma.
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Affiliation(s)
- Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA.
| | - Marc J Shapiro
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Jane E McCormack
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Daniel N Rutigliano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
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235
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Herou E, Romner B, Tomasevic G. Acute Traumatic Brain Injury: Mortality in the Elderly. World Neurosurg 2015; 83:996-1001. [DOI: 10.1016/j.wneu.2015.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 02/07/2015] [Accepted: 02/11/2015] [Indexed: 11/29/2022]
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236
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Serum ubiquitin C-terminal hydrolase L1 as a biomarker for traumatic brain injury: a systematic review and meta-analysis. Am J Emerg Med 2015; 33:1191-6. [PMID: 26087705 DOI: 10.1016/j.ajem.2015.05.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Serum ubiquitin C-terminal hydrolase L1 (UCH-L1) has been proposed as a biomarker of traumatic brain injury (TBI). However, previous studies on levels of UCH-L1 in serum remain inconsistent. This systematic review and meta-analysis were conducted on observational studies that reported the association between serum UCH-L1 levels and TBI. METHODS Studies were identified by searching PubMed and ISI Web of Science up to February 2015. For the continuous outcomes, we calculated the weighted mean difference and 95% confidence interval. The statistical analysis was performed by RevMan 5.1 and Stata 12 software. Only case-control studies were included if they had data on serum UCH-L1 levels in TBI patients and healthy controls. Funnel plot and Egger's regression test were applied to assess the potential publication bias. RESULTS Of the 145 selected studies, 11 observational studies (including 9 case-control and 2 case-crossover studies) met the selection criteria, containing a total of 1138 TBI cases and 1373 controls. Finally, 5 case-control studies (including 673 TBI and 1004 controls) were eligible for the present meta-analysis. The results of our study showed that there was a significant increase in serum UCH-L1 levels in patients with TBI compared to controls (weighted mean difference, 0.96; 95% confidence interval, 0.31-1.61; P = .004). CONCLUSION In conclusion, TBI cases had higher serum UCH-L1 concentrations than matched controls. This reinforces the conceptualization of UCH-L1 as a potential biomarker of TBI.
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237
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Zhao FZ, Wolf SE, Nakonezny PA, Minhajuddin A, Rhodes RL, Paulk ME, Phelan HA. Estimating Geriatric Mortality after Injury Using Age, Injury Severity, and Performance of a Transfusion: The Geriatric Trauma Outcome Score. J Palliat Med 2015; 18:677-81. [PMID: 25974408 PMCID: PMC4522950 DOI: 10.1089/jpm.2015.0027] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A tool to determine the probability of mortality for severely injured geriatric patients is needed. OBJECTIVE We sought to create an easily calculated geriatric trauma prognostic score based on parameters available at the bedside to aid in mortality probability determination. METHODS All patients ≥ 65 years of age were identified from our Level I trauma center's registry between January 1, 2000 and December 31, 2013. Measurements included age, Injury Severity score (ISS), units of packed red blood cells (PRBCs) transfused in the first 24 hours, and patients' mortality status at the end of their index hospitalization. As a first step, a logistic regression model with maximum likelihood estimation and robust standard errors was used to estimate the odds of mortality from age, ISS, and PRBCs after dichotomizing PRBCs as yes/no. We then constructed a Geriatric Trauma Outcome (GTO) score that became the sole predictor in the re-specified logistic regression model. RESULTS The sample (n = 3841) mean age was 76.5 ± 8.1 years and the mean ISS was 12.4 ± 9.8. In-hospital mortality was 10.8%, and 11.9% received a transfusion by 24 hours. Based on the logistic regression model, the equation with the highest discriminatory ability to estimate probability of mortality was GTO Score = age + (2.5 × ISS) + 22 (if given PRBCs). The area under the receiver operating characteristic curve (AUC) for this model was 0.82. Selected GTO scores and their related probability of dying were: 205 = 75%, 233 = 90%, 252 = 95%, 310 = 99%. The range of GTO scores was 67.5 (survivor) to 275.1 (died). CONCLUSION The GTO model accurately estimates the probability of dying, and can be calculated at bedside by those possessing a working knowledge of ISS calculation.
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Affiliation(s)
- Frank Z Zhao
- 1 Department of General Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
| | - Steven E Wolf
- 2 Division of Burns/Trauma/Critical Care, Department of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
| | - Paul A Nakonezny
- 3 Division of Biostatistics, Department of Clinical Sciences, UT Southwestern Medical Center , Dallas, Texas
| | - Abu Minhajuddin
- 3 Division of Biostatistics, Department of Clinical Sciences, UT Southwestern Medical Center , Dallas, Texas
| | - Ramona L Rhodes
- 4 Division of Geriatrics and Palliative Care, Department of Internal Medicine, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
| | - M Elizabeth Paulk
- 5 Division of Palliative Care, Department of Internal Medicine, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
| | - Herb A Phelan
- 2 Division of Burns/Trauma/Critical Care, Department of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
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238
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Reuter-Rice K, Krebs M, Eads JK. Head Injuries in School-Age Children Who Play Golf. J Sch Nurs 2015; 32:132-7. [PMID: 25899097 DOI: 10.1177/1059840515579084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in children. We conducted a prospective study, which examined injury characteristics and outcomes of school-age children of 5.0-15.0 years (N = 10) who were admitted to hospital for a TBI. This study evaluated the role of age, gender, the Glasgow Coma Scale, mechanisms and severity of injury, and functional outcomes. Seventy percent of the children sustained a TBI from a fall. We also found that playing golf was associated with 40% of the TBIs, with three (30%) children being unrestrained passengers in a moving golf cart and another one (10%) was struck by a golf club. Injury awareness could have benefited or prevented most injuries, and school nurses are in the best position to provide preventative practice education. In golf-centric communities, prevention of golf-related injuries should include education within the schools.
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Affiliation(s)
- Karin Reuter-Rice
- School of Nursing, Duke University, Durham, NC, USA School of Medicine, Duke University, Durham, NC, USA Department of Pediatrics, Duke Institute for Brain Sciences, Duke University, Durham, NC, USA
| | - Madelyn Krebs
- College of Arts & Sciences, University of North Carolina, Chapel Hill, NC, USA
| | - Julia K Eads
- School of Nursing, Duke University, Durham, NC, USA
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Dang Q, Simon J, Catino J, Puente I, Habib F, Zucker L, Bukur M. More fateful than fruitful? Intracranial pressure monitoring in elderly patients with traumatic brain injury is associated with worse outcomes. J Surg Res 2015; 198:482-8. [PMID: 25972315 DOI: 10.1016/j.jss.2015.03.092] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/16/2015] [Accepted: 03/27/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND In an expanding elderly population, traumatic brain injury (TBI) remains a significant cause of death and disability. Guidelines for management of TBI, according to the Brain Trauma Foundation (BTF), include intracranial pressure (ICP) monitoring. Whether ICP monitoring contributes to outcomes in the elderly patients with TBI has not been explored. METHODS This is a retrospective study extracted from the National Trauma Database 2007-2008 research datasets. Patients were included if aged >55 y and they met BTF indications for ICP monitoring. Patients that had nonsurvivable injuries (any body region, abbreviated injury score = 6), were dead on arrival, had withdrawal of care, or length of stay <48 h were excluded. Outcomes were then stratified based on ICP monitoring. The primary outcomes were inhospital mortality and favorable discharge. Logistic regression was used to analyze the effect of ICP monitoring on outcomes. RESULTS A total of 4437 patients were included with 11.2% having an ICP monitor placed. Patients requiring an ICP monitor were younger overall, more likely to present hypertensive, had higher injury severity, and more likely to require operative intervention. Median initial Glasgow coma scale (3) was similar between groups. Of those patients with ICP monitoring, overall mortality was significantly higher, and they were less likely to have favorable discharge status. Craniotomy itself was not associated with increased mortality (P = 0.450). CONCLUSIONS Our findings suggest that the use of ICP monitoring according to BTF guidelines in elderly TBI patients does not provide outcomes superior to treatment without monitoring. The ideal group to benefit from ICP monitor placement remains to be elucidated.
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Affiliation(s)
- Quoc Dang
- Department of Surgery, Larkin Community Hospital, South Miami, Florida; Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida.
| | - Joshua Simon
- Department of Surgery, Larkin Community Hospital, South Miami, Florida; Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida
| | - Joe Catino
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care, Broward General Hospital, Fort Lauderdale, Florida
| | - Ivan Puente
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care, Broward General Hospital, Fort Lauderdale, Florida
| | - Fahim Habib
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care, Broward General Hospital, Fort Lauderdale, Florida
| | - Lloyd Zucker
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida
| | - Marko Bukur
- Division of Trauma and Critical Care, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care, Broward General Hospital, Fort Lauderdale, Florida
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240
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Bajwa SJS. Clinical conundrums and challenges during geriatric orthopedic emergency surgeries. Int J Crit Illn Inj Sci 2015; 5:38-45. [PMID: 25810963 PMCID: PMC4366827 DOI: 10.4103/2229-5151.152342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Despite so many advancements and innovations in anesthetic techniques, expectations and challenges have also grown in plenty. Cardiac, pediatric, obstetric and neuro-anesthesia have perfectly developed to fulfill the desired needs of respective patient population. However, geriatric anesthesia has been shown a lesser interest in teaching and clinical practices over the years as compared with other anesthetic sub-specialties. The large growing geriatric population globally is also associated with an increase number of elderly patients presenting for orthopedic emergency surgeries. Orthopedic emergency surgery in geriatric population is not only a daunting clinical challenge but also has numerous socio-behavioral and economic ramifications. Decision making in anesthesia is largely influenced by the presence of co-morbidities, neuro-cognitive functions and the current socio-behavioral status. Pre-anesthetic evaluation and optimization are extremely important for a better surgical outcome but is limited by time constraints during emergency surgery. The current review aims to highlight comprehensively the various clinical, social, behavioral and psychological aspects during pre-anesthetic evaluation associated with emergency orthopedic surgery in geriatric population.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
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241
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Katzenberger RJ, Chtarbanova S, Rimkus SA, Fischer JA, Kaur G, Seppala JM, Swanson LC, Zajac JE, Ganetzky B, Wassarman DA. Death following traumatic brain injury in Drosophila is associated with intestinal barrier dysfunction. eLife 2015; 4. [PMID: 25742603 PMCID: PMC4377547 DOI: 10.7554/elife.04790] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 03/05/2015] [Indexed: 12/15/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Unfavorable TBI outcomes result from primary mechanical injuries to the brain and ensuing secondary non-mechanical injuries that are not limited to the brain. Our genome-wide association study of Drosophila melanogaster revealed that the probability of death following TBI is associated with single nucleotide polymorphisms in genes involved in tissue barrier function and glucose homeostasis. We found that TBI causes intestinal and blood–brain barrier dysfunction and that intestinal barrier dysfunction is highly correlated with the probability of death. Furthermore, we found that ingestion of glucose after a primary injury increases the probability of death through a secondary injury mechanism that exacerbates intestinal barrier dysfunction. Our results indicate that natural variation in the probability of death following TBI is due in part to genetic differences that affect intestinal barrier dysfunction. DOI:http://dx.doi.org/10.7554/eLife.04790.001 Traumatic brain injury (TBI) caused by a violent blow to the head or body and the resultant collision of the brain against the skull is a major cause of disability and death in humans. Primary injury to the brain triggers secondary injuries that further damage the brain and other organs, generating many of the detrimental consequences of TBI. However, despite decades of study, the exact nature of these secondary injuries and their origin are poorly understood. A better understanding of secondary injuries should help to develop novel therapies to improve TBI outcomes in affected individuals. To obtain this information, in 2013 researchers devised a method to inflict TBI in the common fruit fly, Drosophila melanogaster, an organism that is readily amenable to detailed genetic and molecular studies. This investigation demonstrated that flies subjected to TBI display many of the same symptoms observed in humans after a brain injury, including temporary loss of mobility and damage to the brain that becomes worse over time. In addition, many of the flies die within 24 hr after brain injury. Now Katzenberger et al. use this experimental system to investigate the secondary injuries responsible for these deaths. First, genetic variants were identified that confer increased or decreased susceptibility to death after brain injury. Several of the identified genes affect the structural integrity of the intestinal barrier that isolates the contents of the gut—including nutrients and bacteria—from the circulatory system. Katzenberger et al. subsequently found that the breakdown of this barrier after brain injury permits bacteria and glucose to leak out of the intestine. Treating flies with antibiotics did not increase survival, whereas reducing glucose levels in the circulatory system after brain injury did. Thus, Katzenberger et al. conclude that high levels of glucose in the circulatory system, a condition known as hyperglycemia, is a key culprit in death following TBI. Notably, these results parallel findings in humans, where hyperglycemia is highly predictive of death following TBI. Similarly, individuals with diabetes have a significantly increased risk of death after TBI. These results suggest that the secondary injuries leading to death are the same in flies and humans and that further studies in flies are likely to provide additional new information that will help us understand the complex consequences of TBI. Important challenges remain, including understanding precisely how the brain and intestine communicate, how injury to the brain leads to disruption of the intestinal barrier, and why elevated glucose levels increase mortality after brain injury. Answers to these questions could help pave the way to new therapies for TBI. DOI:http://dx.doi.org/10.7554/eLife.04790.002
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Affiliation(s)
- Rebeccah J Katzenberger
- Department of Cell and Regenerative Biology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, United States
| | | | - Stacey A Rimkus
- Department of Cell and Regenerative Biology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, United States
| | - Julie A Fischer
- Department of Cell and Regenerative Biology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, United States
| | - Gulpreet Kaur
- Department of Cell and Regenerative Biology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, United States
| | - Jocelyn M Seppala
- Department of Cell and Regenerative Biology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, United States
| | - Laura C Swanson
- Department of Cell and Regenerative Biology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, United States
| | - Jocelyn E Zajac
- Department of Cell and Regenerative Biology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, United States
| | - Barry Ganetzky
- Laboratory of Genetics, University of Wisconsin-Madison, Madison, United States
| | - David A Wassarman
- Department of Cell and Regenerative Biology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, United States
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de Guise E, LeBlanc J, Dagher J, Tinawi S, Lamoureux J, Marcoux J, Maleki M, Feyz M. Traumatic brain injury in the elderly: A level 1 trauma centre study. Brain Inj 2015; 29:558-64. [PMID: 25625679 DOI: 10.3109/02699052.2014.976593] [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: 11/13/2022]
Abstract
OBJECTIVE To explore the characteristics and outcome of patients with TBI over 65 years old admitted to an acute care Level 1 Trauma centre in Montreal, Canada. METHODS Data were retrospectively collected on patients (n = 1812) who were admitted post-TBI to the McGill University Health Centre-Montreal General Hospital from 2000-2011. The cohort was composed of four groups over 65 years old (65-75; 76-85; 86-95; and 96 and more). Outcome measures used were the extended Glasgow Outcome Scale (GOSE) as well as discharge destination. RESULTS As the patients got older, the odds of having a poor outcome increased (OR = 2.344 for those 75-85 years old, 4.313 for those 86-95 years of age and 3.465 for those aged 96 years of age or older). Also, the proportion of patients going home or going home with out-patient rehabilitation decreased as age increased (p = 0.001 and p < 0.001, respectively). In contrast, the proportion of patients being discharged to long-term care facilities increased significantly as age increased (p < 0.001). CONCLUSION This descriptive study provides a better understanding of characteristics and outcome of different age groups of patients with TBI all over 65 years old in Montreal, Canada.
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Affiliation(s)
- Elaine de Guise
- Neurology and Neurosurgery Department, McGill University Health Centre , Montreal, Quebec , Canada
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Maas AI, Lingsma HF, Roozenbeek B. Predicting outcome after traumatic brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 128:455-74. [DOI: 10.1016/b978-0-444-63521-1.00029-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Gómez PA, de-la-Cruz J, Lora D, Jiménez-Roldán L, Rodríguez-Boto G, Sarabia R, Sahuquillo J, Lastra R, Morera J, Lazo E, Dominguez J, Ibañez J, Brell M, de-la-Lama A, Lobato RD, Lagares A. Validation of a prognostic score for early mortality in severe head injury cases. J Neurosurg 2014; 121:1314-22. [DOI: 10.3171/2014.7.jns131874] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Traumatic brain injury (TBI) represents a large health and economic burden. Because of the inability of previous randomized controlled trials (RCTs) on TBI to demonstrate the expected benefit of reducing unfavorable outcomes, the IMPACT (International Mission on Prognosis and Analysis of Clinical Trials in TBI) and CRASH (Corticosteroid Randomisation After Significant Head Injury) studies provided new methods for performing prognostic studies of TBI. This study aimed to develop and externally validate a prognostic model for early death (within 48 hours). The secondary aim was to identify patients who were more likely to succumb to an early death to limit their inclusion in RCTs and to improve the efficiency of RCTs.
Methods
The derivation cohort was recruited at 1 center, Hospital 12 de Octubre, Madrid (1990–2003, 925 patients). The validation cohort was recruited in 2004–2006 from 7 study centers (374 patients). The eligible patients had suffered closed severe TBIs. The study outcome was early death (within 48 hours post-TBI). The predictors were selected using logistic regression modeling with bootstrapping techniques, and a penalized reduction was used. A risk score was developed based on the regression coefficients of the variables included in the final model.
Results
In the validation set, the final model showed a predictive ability of 50% (Nagelkerke R2), with an area under the receiver operating characteristic curve of 89% and an acceptable calibration (goodness-of-fit test, p = 0.32). The final model included 7 variables, and it was used to develop a risk score with a range from 0 to 20 points. Age provided 0, 1, 2, or 3 points depending on the age group; motor score provided 0 points, 2 (untestable), or 3 (no response); pupillary reactivity, 0, 2 (1 pupil reacted), or 6 (no pupil reacted); shock, 0 (no) or 2 (yes); subarachnoid hemorrhage, 0 or 1 (severe deposit); cisternal status, 0 or 3 (compressed/absent); and epidural hematoma, 0 (yes) or 2 (no). Based on the risk of early death estimated with the model, 4 risk of early death groups were established: low risk, sum score 0–3 (< 1% predicted mortality); moderate risk, sum score 4–8 (predicted mortality between 1% and 10%); high risk, sum score 9–12 (probability of early death between 10% and 50%); and very high risk, sum score 13–20 (early mortality probability > 50%). This score could be used for selecting patients for clinical studies. For example, if patients with very high risk scores were excluded from our study sample, the patients included (eligibility score < 13) would represent 80% of the original sample and only 23% of the patients who died early.
Conclusions
The combination of Glasgow Coma Scale score, CT scanning results, and secondary insult data into a prognostic score improved the prediction of early death and the classification of TBI patients.
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Affiliation(s)
| | - Javier de-la-Cruz
- 2Clinical Research Unit, IMAS12-CIBERESP, University Hospital 12 Octubre, Medical Faculty Complutense University, Madrid
| | - David Lora
- 2Clinical Research Unit, IMAS12-CIBERESP, University Hospital 12 Octubre, Medical Faculty Complutense University, Madrid
| | | | | | - Rosario Sarabia
- 4Department of Neurosurgery, Clinical University Hospital Río Ortega, Valladolid
| | - Juan Sahuquillo
- 5Department of Neurosurgery, Clinical University Hospital Val d′Hebrón, Barcelona
| | - Roberto Lastra
- 5Department of Neurosurgery, Clinical University Hospital Val d′Hebrón, Barcelona
| | - Jesus Morera
- 6Department of Neurosurgery, Clinical University Hospital Dr. Negrín, Las Palmas de Gran Canaria
| | - Eglis Lazo
- 7Department of Neurosurgery, Clinical University Hospital Virgen de la Candelaria, Tenerife
| | - Jaime Dominguez
- 7Department of Neurosurgery, Clinical University Hospital Virgen de la Candelaria, Tenerife
| | - Javier Ibañez
- 8Department of Neurosurgery, Clinical University Hospital Son Dureta, Palma de Mallorca; and
| | - Marta Brell
- 8Department of Neurosurgery, Clinical University Hospital Son Dureta, Palma de Mallorca; and
| | - Adolfo de-la-Lama
- 9Department of Neurosurgery, Clinical University Hospital, Hospital Xeral, Vigo, Spain
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Gardizi E, Hanks RA, Millis SR, Figueroa MJ. Comorbidity and Insurance as Predictors of Disability After Traumatic Brain Injury. Arch Phys Med Rehabil 2014; 95:2396-401. [DOI: 10.1016/j.apmr.2014.06.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/23/2014] [Accepted: 06/06/2014] [Indexed: 11/25/2022]
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Lingsma HF, Yue JK, Maas AIR, Steyerberg EW, Manley GT. Outcome prediction after mild and complicated mild traumatic brain injury: external validation of existing models and identification of new predictors using the TRACK-TBI pilot study. J Neurotrauma 2014; 32:83-94. [PMID: 25025611 DOI: 10.1089/neu.2014.3384] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Although the majority of patients with mild traumatic brain injury (mTBI) recover completely, some still suffer from disabling ailments at 3 or 6 months. We validated existing prognostic models for mTBI and explored predictors of poor outcome after mTBI. We selected patients with mTBI from TRACK-TBI Pilot, an unselected observational cohort of TBI patients from three centers in the United States. We validated two prognostic models for the Glasgow Outcome Scale Extended (GOS-E) at 6 months after injury. One model was based on the CRASH study data and another from Nijmegen, The Netherlands. Possible predictors of 3- and 6-month GOS-E were analyzed with univariate and multi-variable proportional odds regression models. Of the 386 of 485 patients included in the study (median age, 44 years; interquartile range, 27-58), 75% (n=290) presented with a Glasgow Coma Score (GCS) of 15. In this mTBI population, both previously developed models had a poor performance (area under the receiver operating characteristic curve, 0.49-0.56). In multivariable analyses, the strongest predictors of lower 3- and 6-month GOS-E were older age, pre-existing psychiatric conditions, and lower education. Injury caused by assault, extracranial injuries, and lower GCS were also predictive of lower GOS-E. Existing models for mTBI performed unsatisfactorily. Our study shows that, for mTBI, different predictors are relevant as for moderate and severe TBI. These include age, pre-existing psychiatric conditions, and lower education. Development of a valid prediction model for mTBI patients requires further research efforts.
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Affiliation(s)
- Hester F Lingsma
- 1 Erasmus Medical Center-University Medical Center , Rotterdam, The Netherlands
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248
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Seifman MA, Gomes K, Nguyen PN, Bailey M, Rosenfeld JV, Cooper DJ, Morganti-Kossmann MC. Measurement of serum melatonin in intensive care unit patients: changes in traumatic brain injury, trauma, and medical conditions. Front Neurol 2014; 5:237. [PMID: 25477861 PMCID: PMC4235080 DOI: 10.3389/fneur.2014.00237] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/01/2014] [Indexed: 12/16/2022] Open
Abstract
Melatonin is an endogenous hormone mainly produced by the pineal gland whose dysfunction leads to abnormal sleeping patterns. Changes in melatonin have been reported in acute traumatic brain injury (TBI); however, the impact of environmental conditions typical of the intensive care unit (ICU) has not been assessed. The aim of this study was to compare daily melatonin production in three patient populations treated at the ICU to differentiate the role of TBI versus ICU conditions. Forty-five patients were recruited and divided into severe TBI, trauma without TBI, medical conditions without trauma, and compared to healthy volunteers. Serum melatonin levels were measured at four daily intervals at 0400 h, 1000 h, 1600 h, and 2200 h for 7 days post-ICU admission by commercial enzyme linked immunosorbent assay. The geometric mean concentrations (95% confidence intervals) of melatonin in these groups showed no difference being 8.3 (6.3–11.0), 9.3 (7.0–12.3), and 8.9 (6.6–11.9) pg/mL, respectively, in TBI, trauma, and intensive care cohorts. All of these patient groups demonstrated decreased melatonin concentrations when compared to control patients. This study suggests that TBI as well as ICU conditions, may have a role in the dysfunction of melatonin. Monitoring and possibly substituting melatonin acutely in these settings may assist in ameliorating long-term sleep dysfunction in all of these groups, and possibly contribute to reducing secondary brain injury in severe TBI.
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Affiliation(s)
- Marc A Seifman
- National Trauma Research Institute, The Alfred , Melbourne, VIC , Australia ; Department of Surgery, Monash University , Melbourne, VIC , Australia ; Department of Neurosurgery, The Alfred , Melbourne, VIC , Australia
| | - Keith Gomes
- National Trauma Research Institute, The Alfred , Melbourne, VIC , Australia ; Department of Neurosurgery, The Alfred , Melbourne, VIC , Australia
| | - Phuong N Nguyen
- National Trauma Research Institute, The Alfred , Melbourne, VIC , Australia
| | - Michael Bailey
- Department of Epidemiology, Monash University , Melbourne, VIC , Australia ; Australian New Zealand Intensive Care Research Centre , Melbourne, VIC , Australia
| | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University , Melbourne, VIC , Australia ; Department of Neurosurgery, The Alfred , Melbourne, VIC , Australia
| | - David J Cooper
- Department of Epidemiology, Monash University , Melbourne, VIC , Australia ; Australian New Zealand Intensive Care Research Centre , Melbourne, VIC , Australia ; Intensive Care Unit, The Alfred , Melbourne, VIC , Australia
| | - Maria Cristina Morganti-Kossmann
- Department of Epidemiology, Monash University , Melbourne, VIC , Australia ; Australian New Zealand Intensive Care Research Centre , Melbourne, VIC , Australia ; Department of Child Health, Barrow Neurological Institute, University of Arizona , Phoenix, AZ , USA
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Wasserman EB, Shah MN, Jones CMC, Cushman JT, Caterino JM, Bazarian JJ, Gillespie SM, Cheng JD, Dozier A. Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center. PREHOSP EMERG CARE 2014; 19:202-12. [PMID: 25290953 DOI: 10.3109/10903127.2014.959225] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. METHODS We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. RESULTS We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales -level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) -may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. CONCLUSIONS Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.
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250
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Ulfarsson T, Lundgren-Nilsson Å, Blomstrand C, Jakobsson KE, Odén A, Nilsson M, Rosén T. Ten-year mortality after severe traumatic brain injury in western Sweden: A case control study. Brain Inj 2014; 28:1675-81. [DOI: 10.3109/02699052.2014.947625] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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