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Zhu S, Liu X, Lu X, Liao Q, Luo H, Tian Y, Cheng X, Jiang Y, Liu G, Chen J. Biomaterials and tissue engineering in traumatic brain injury: novel perspectives on promoting neural regeneration. Neural Regen Res 2024; 19:2157-2174. [PMID: 38488550 PMCID: PMC11034597 DOI: 10.4103/1673-5374.391179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/13/2023] [Accepted: 11/20/2023] [Indexed: 04/24/2024] Open
Abstract
Traumatic brain injury is a serious medical condition that can be attributed to falls, motor vehicle accidents, sports injuries and acts of violence, causing a series of neural injuries and neuropsychiatric symptoms. However, limited accessibility to the injury sites, complicated histological and anatomical structure, intricate cellular and extracellular milieu, lack of regenerative capacity in the native cells, vast variety of damage routes, and the insufficient time available for treatment have restricted the widespread application of several therapeutic methods in cases of central nervous system injury. Tissue engineering and regenerative medicine have emerged as innovative approaches in the field of nerve regeneration. By combining biomaterials, stem cells, and growth factors, these approaches have provided a platform for developing effective treatments for neural injuries, which can offer the potential to restore neural function, improve patient outcomes, and reduce the need for drugs and invasive surgical procedures. Biomaterials have shown advantages in promoting neural development, inhibiting glial scar formation, and providing a suitable biomimetic neural microenvironment, which makes their application promising in the field of neural regeneration. For instance, bioactive scaffolds loaded with stem cells can provide a biocompatible and biodegradable milieu. Furthermore, stem cells-derived exosomes combine the advantages of stem cells, avoid the risk of immune rejection, cooperate with biomaterials to enhance their biological functions, and exert stable functions, thereby inducing angiogenesis and neural regeneration in patients with traumatic brain injury and promoting the recovery of brain function. Unfortunately, biomaterials have shown positive effects in the laboratory, but when similar materials are used in clinical studies of human central nervous system regeneration, their efficacy is unsatisfactory. Here, we review the characteristics and properties of various bioactive materials, followed by the introduction of applications based on biochemistry and cell molecules, and discuss the emerging role of biomaterials in promoting neural regeneration. Further, we summarize the adaptive biomaterials infused with exosomes produced from stem cells and stem cells themselves for the treatment of traumatic brain injury. Finally, we present the main limitations of biomaterials for the treatment of traumatic brain injury and offer insights into their future potential.
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Affiliation(s)
- Shihong Zhu
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaoyin Liu
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiyue Lu
- Department of Anesthesiology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Qiang Liao
- Department of Pharmacy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Huiyang Luo
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
- Department of Anesthesiology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Yuan Tian
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Xu Cheng
- Department of Anesthesiology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Yaxin Jiang
- Out-patient Department, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Guangdi Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Jing Chen
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
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Zhang L, Wu C, Liu T, Tian Y, Wang D, Wang B, Yin Y. Propofol Protects the Blood-Brain Barrier After Traumatic Brain Injury by Stabilizing the Extracellular Matrix via Prrx1: From Neuroglioma to Neurotrauma. Neurochem Res 2024; 49:2743-2762. [PMID: 38951281 DOI: 10.1007/s11064-024-04202-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/15/2024] [Accepted: 06/19/2024] [Indexed: 07/03/2024]
Abstract
The purpose of this study is to explore the shared molecular pathogenesis of traumatic brain injury (TBI) and high-grade glioma and investigate the mechanism of propofol (PF) as a potential protective agent. By analyzing the Chinese glioma genome atlas (CGGA) and The Cancer Genome Atlas (TCGA) databases, we compared the transcriptomic data of high-grade glioma and TBI patients to identify common pathological mechanisms. Through bioinformatics analysis, in vitro experiments and in vivo TBI model, we investigated the regulatory effect of PF on extracellular matrix (ECM)-related genes through Prrx1 under oxidative stress. The impact of PF on BBB integrity under oxidative stress was investigated using a dual-layer BBB model, and we explored the protective effect of PF on tight junction proteins and ECM-related genes in mice after TBI. The study found that high-grade glioma and TBI share ECM instability as an important molecular pathological mechanism. PF stabilizes the ECM and protects the BBB by directly binding to Prrx1 or indirectly regulating Prrx1 through miRNAs. In addition, PF reduces intracellular calcium ions and ROS levels under oxidative stress, thereby preserving BBB integrity. In a TBI mouse model, PF protected BBB integrity through up-regulated tight junction proteins and stabilized the expression of ECM-related genes. Our study reveals the shared molecular pathogenesis between TBI and glioblastoma and demonstrate the potential of PF as a protective agent of BBB. This provides new targets and approaches for the development of novel neurotrauma therapeutic drugs.
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Affiliation(s)
- Lan Zhang
- Department of Anesthesiology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Chenrui Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yu Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Bo Wang
- Department of Neurosurgery, Tianjin University Huanhu Hospital, Tianjin, China.
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China.
| | - Yiqing Yin
- Department of Anesthesiology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China.
- Tianjin's Clinical Research Center for Cancer, Tianjin, China.
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.
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Dantan E, Foucher Y, Simon-Pimmel J, Léger M, Campfort M, Lasocki S, Lakhal K, Bouras M, Roquilly A, Cinotti R. Long-term survival of traumatic brain injury and intra-cerebral haemorrhage patients: A multicentric observational cohort. J Crit Care 2024; 83:154843. [PMID: 38875914 DOI: 10.1016/j.jcrc.2024.154843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 05/13/2024] [Accepted: 06/06/2024] [Indexed: 06/16/2024]
Abstract
PURPOSE Mortality is often assessed during ICU stay and early after, but rarely at later stage. We aimed to compare the long-term mortality between TBI and ICH patients. MATERIALS AND METHODS From an observational cohort, we studied 580 TBI patients and 435 ICH patients, admitted from January 2013 to February 2021 in 3 ICUs and alive at 7-days post-ICU discharge. We performed a Lasso-penalized Cox survival analysis. RESULTS We estimated 7-year survival rates at 72.8% (95%CI from 67.3% to 78.7%) for ICH patients and at 84.9% (95%CI from 80.9% to 89.1%) for TBI patients: ICH patients presenting a higher mortality risk than TBI patients. Additionally, we identified variables associated with higher mortality risk (age, ICU length of stay, tracheostomy, low GCS, absence of intracranial pressure monitoring). We also observed anisocoria related with the mortality risk in the early stage after ICU stay. CONCLUSIONS In this ICU survivor population with a prolonged follow-up, we highlight an acute risk of death after ICU stay, which seems to last longer in ICH patients. Several variables characteristic of disease severity appeared associated with long-term mortality, raising the hypothesis that the most severe patients deserve closer follow-up after ICU stay.
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Affiliation(s)
- E Dantan
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, F-44000 Nantes, France.
| | - Y Foucher
- Poitiers Université, CHU de Poitiers, CIC INSERM 1402, Poitiers, France
| | - J Simon-Pimmel
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, F-44000 Nantes, France
| | - M Léger
- Department of Anaesthesiology and Critical Care, Angers University, CHU Angers, Angers, France
| | - M Campfort
- Department of Anaesthesiology and Critical Care, Angers University, CHU Angers, Angers, France
| | - S Lasocki
- Department of Anaesthesiology and Critical Care, Angers University, CHU Angers, Angers, France
| | - K Lakhal
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Laennec, Nantes F-44093, France
| | - M Bouras
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR, 1064 Nantes, France; CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC0004, 1413 Nantes, France
| | - A Roquilly
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR, 1064 Nantes, France; CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC0004, 1413 Nantes, France
| | - R Cinotti
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, F-44000 Nantes, France; Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes F-44093, France
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Park M, Shim Y, Choo YH, Kim HS, Kim J, Ha EJ. Should Hypertonic Saline Be Considered for the Treatment of Intracranial Hypertension? A Review of Current Evidence and Clinical Practices. Korean J Neurotrauma 2024; 20:146-158. [PMID: 39372110 PMCID: PMC11450342 DOI: 10.13004/kjnt.2024.20.e35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Revised: 09/12/2024] [Accepted: 09/14/2024] [Indexed: 10/08/2024] Open
Abstract
Intracranial hypertension (IH) is a critical neurological emergency that requires prompt intervention because failure to treat it properly can lead to severe outcomes, including secondary brain injury. Traditionally, mannitol (MNT) has been the cornerstone of hyperosmolar therapy. However, the use of hypertonic saline (HTS) has become increasingly important because of its unique advantages. Both HTS and MNT effectively reduce intracranial pressure by creating an osmotic gradient that draws fluid from brain tissue. However, unlike MNT, HTS does not induce diuresis or significantly lower blood pressure, making it more favorable for maintaining cerebral perfusion. Additionally, HTS does not cause rebound edema and carries a lower risk of renal injury than MNT. However, it is important to note that the use of HTS comes with potential risks, such as hypernatremia, hyperchloremia, and fluid overload. Due to its unique properties, HTS is a crucial agent in the management of IH, and understanding its appropriate use is essential to optimize patient outcomes.
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Affiliation(s)
- Moowan Park
- Department of Neurosurgery, Armed Force Yangju Hospital, Yangju, Korea
| | - Youngbo Shim
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jungook Kim
- Gachon University Gil Hospital Regional Trauma Center, Incheon, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Zoerle T, Beqiri E, Åkerlund CAI, Gao G, Heldt T, Hawryluk GWJ, Stocchetti N. Intracranial pressure monitoring in adult patients with traumatic brain injury: challenges and innovations. Lancet Neurol 2024; 23:938-950. [PMID: 39152029 DOI: 10.1016/s1474-4422(24)00235-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 05/15/2024] [Accepted: 05/28/2024] [Indexed: 08/19/2024]
Abstract
Intracranial pressure monitoring enables the detection and treatment of intracranial hypertension, a potentially lethal insult after traumatic brain injury. Despite its widespread use, robust evidence supporting intracranial pressure monitoring and treatment remains sparse. International studies have shown large variations between centres regarding the indications for intracranial pressure monitoring and treatment of intracranial hypertension. Experts have reviewed these two aspects and, by consensus, provided practical approaches for monitoring and treatment. Advances have occurred in methods for non-invasive estimation of intracranial pressure although, for now, a reliable way to non-invasively and continuously measure intracranial pressure remains aspirational. Analysis of the intracranial pressure signal can provide information on brain compliance (ie, the ability of the cranium to tolerate volume changes) and on cerebral autoregulation (ie, the ability of cerebral blood vessels to react to changes in blood pressure). The information derived from the intracranial pressure signal might allow for more individualised patient management. Machine learning and artificial intelligence approaches are being increasingly applied to intracranial pressure monitoring, but many obstacles need to be overcome before their use in clinical practice could be attempted. Robust clinical trials are needed to support indications for intracranial pressure monitoring and treatment. Progress in non-invasive assessment of intracranial pressure and in signal analysis (for targeted treatment) will also be crucial.
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Affiliation(s)
- Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Guoyi Gao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thomas Heldt
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Gregory W J Hawryluk
- Cleveland Clinic Akron General Hospital, Uniformed Services University, Cleveland, OH, USA
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Martin FP, Goronflot T, Moyer JD, Huet O, Asehnoune K, Cinotti R, Gourraud PA, Roquilly A. Predictive Models of Long-Term Outcome in Patients with Moderate to Severe Traumatic Brain Injury are Biased Toward Mortality Prediction. Neurocrit Care 2024:10.1007/s12028-024-02082-3. [PMID: 39138720 DOI: 10.1007/s12028-024-02082-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 07/26/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND The prognostication of long-term functional outcomes remains challenging in patients with traumatic brain injury (TBI). Our aim was to demonstrate that intensive care unit (ICU) variables are not efficient to predict 6-month functional outcome in survivors with moderate to severe TBI (msTBI) but are mostly associated with mortality, which leads to a mortality bias for models predicting a composite outcome of mortality and severe disability. METHODS We analyzed the data from the multicenter randomized controlled Continuous Hyperosmolar Therapy in Traumatic Brain-Injured Patients trial and developed predictive models using machine learning methods and baseline characteristics and predictors collected during ICU stay. We compared our models' predictions of 6-month binary Glasgow Outcome Scale extended (GOS-E) score in all patients with msTBI (unfavorable GOS-E 1-4 vs. favorable GOS-E 5-8) with mortality (GOS-E 1 vs. GOS-E 2-8) and binary functional outcome in survivors with msTBI (severe disability GOS-E 2-4 vs. moderate to no disability GOS-E 5-8). We investigated the link between ICU variables and long-term functional outcomes in survivors with msTBI using predictive modeling and factor analysis of mixed data and validated our hypotheses on the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. RESULTS Based on data from 370 patients with msTBI and classically used ICU variables, the prediction of the 6-month outcome in survivors was inefficient (mean area under the receiver operating characteristic 0.52). Using factor analysis of mixed data graph, we demonstrated that high-variance ICU variables were not associated with outcome in survivors with msTBI (p = 0.15 for dimension 1, p = 0.53 for dimension 2) but mostly with mortality (p < 0.001 for dimension 1), leading to a mortality bias for models predicting a composite outcome of mortality and severe disability. We finally identified this mortality bias in the IMPACT model. CONCLUSIONS We demonstrated using machine learning-based predictive models that classically used ICU variables are strongly associated with mortality but not with 6-month outcome in survivors with msTBI, leading to a mortality bias when predicting a composite outcome of mortality and severe disability.
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Affiliation(s)
- Florian P Martin
- Nantes Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMR 1064, Center for Research in Transplantation and Translational Immunology (CR2TI), 22 Boulevard Bénoni Goullin, 44200, Nantes, France.
- Department of Anesthesiology and Surgical Intensive Care Unit, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France.
| | - Thomas Goronflot
- CHU Nantes, Pôle Hospitalo-Universitaire 11: Santé Publique, Clinique Des Données, INSERM, Nantes Université, Nantes, France
| | - Jean D Moyer
- Department of Anesthesia and Critical Care, Départements Médico-Universitaires Parabol, Assistance Publique-Hôpitaux de Paris Nord, Beaujon Hospital, Paris, France
| | - Olivier Huet
- Anesthesia and Intensive Care Unit, CHU Brest, Brest, France
| | - Karim Asehnoune
- Nantes Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMR 1064, Center for Research in Transplantation and Translational Immunology (CR2TI), 22 Boulevard Bénoni Goullin, 44200, Nantes, France
- Department of Anesthesiology and Surgical Intensive Care Unit, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | - Raphaël Cinotti
- Department of Anesthesiology and Surgical Intensive Care Unit, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
- Methods in Patient-Centered Outcomes and Healthy Research (SPHERE), INSERM, UMR 1246, Nantes Université, Université de Tours, Nantes, France
| | - Pierre A Gourraud
- Nantes Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMR 1064, Center for Research in Transplantation and Translational Immunology (CR2TI), 22 Boulevard Bénoni Goullin, 44200, Nantes, France
- CHU Nantes, Pôle Hospitalo-Universitaire 11: Santé Publique, Clinique Des Données, INSERM, Nantes Université, Nantes, France
| | - Antoine Roquilly
- Nantes Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMR 1064, Center for Research in Transplantation and Translational Immunology (CR2TI), 22 Boulevard Bénoni Goullin, 44200, Nantes, France
- Department of Anesthesiology and Surgical Intensive Care Unit, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
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Codorniu A, Charbit E, Werner M, James A, Hanouz JL, Jost D, Severin A, Lang E, Pottecher J, Favreau M, Weiss E, Abback PS, Moyer JD. Comparison of mannitol and hypertonic saline solution for the treatment of suspected brain herniation during prehospital management of traumatic brain injury patients. Eur J Emerg Med 2024; 31:287-293. [PMID: 38691014 DOI: 10.1097/mej.0000000000001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND AND IMPORTANCE Occurrence of mydriasis during the prehospital management of traumatic brain injury (TBI) may suggest severe intracranial hypertension (ICH) subsequent to brain herniation. The initiation of hyperosmolar therapy to reduce ICH and brain herniation is recommended. Whether mannitol or hypertonic saline solution (HSS) should be preferred is unknown. OBJECTIVES The objective of this study is to assess whether HSS, compared with mannitol, is associated with improved survival in adult trauma patients with TBI and mydriasis. DESIGN/SETTING AND PARTICIPANTS A retrospective observational cohort study using the French Traumabase national registry to compare the ICU mortality of patients receiving either HSS or mannitol. Patients aged 16 years or older with moderate to severe TBI who presented with mydriasis during prehospital management were included. OUTCOME MEASURES AND ANALYSIS We performed propensity score matching on a priori selected variables [i.e. age, sex and initial Coma Glasgow Scale (GCS)] with a ratio of 1 : 3 to ensure comparability between the two groups. The primary outcome was ICU mortality. The secondary outcomes were regression of pupillary abnormality during prehospital management, pulsatility index and diastolic velocity on transcranial Doppler within 24 h after TBI, early ICU mortality (within 48 h), ICU and hospital length of stay. RESULTS Of 31 579 patients recorded in the registry between 2011 and 2021, 1417 presented with prehospital mydriasis and were included: 1172 (82.7%) received mannitol and 245 (17.3%) received HSS. After propensity score matching, 720 in the mannitol group matched 240 patients in the HSS group. Median age was 41 years [interquartile ranges (IQR) 26-60], 1058 were men (73%) and median GCS was 4 (IQR 3-6). No significant difference was observed in terms of characteristics and prehospital management between the two groups. ICU mortality was lower in the HSS group (45%) than in the mannitol group (54%) after matching [odds ratio (OR) 0.68 (0.5-0.9), P = 0.014]. No differences were identified between the groups in terms of secondary outcomes. CONCLUSION In this propensity-matched observational study, the prehospital osmotherapy with HSS in TBI patients with prehospital mydriasis was associated with a lower ICU mortality compared to osmotherapy with mannitol.
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Affiliation(s)
- Anais Codorniu
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris
| | - Emilie Charbit
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris
| | - Marie Werner
- Department of Anesthesiology and Critical Care, APH-HP, Bicêtre Hôpitaux Universitaires Paris-Saclay, Université Paris Saclay, Le Kremlin Bicêtre
| | - Arthur James
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris
| | - Jean-Luc Hanouz
- Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, Avenue de la cote de Nacre, Caen
| | - Daniel Jost
- Emergency Medical Department, Fire Brigade of Paris
| | - Armelle Severin
- SAMU des Hauts-de-Seine - SMUR Raymond Poincaré, Raymond Poincaré Hospital, Paris Saclay University, Assistance Publique-Hôpitaux de Paris (APHP)
| | - Elodie Lang
- Department of Anaesthesia and Critical Care, AP-HP, Hôpital Européen Georges Pompidou, Paris Cité University, Paris
| | - Julien Pottecher
- Department of Anaesthesiology, Critical Care and Perioperative Medicine, Fédération de Médecine Translationnelle de Strasbourg, ER 3072, Strasbourg University Hospital, Strasbourg
| | - Malory Favreau
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris
| | - Paer Selim Abback
- Department of Anesthesiology and Critical Care Medicine, CHU Tours, Tours University Hospital, Tours, France
| | - Jean-Denis Moyer
- Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, Avenue de la cote de Nacre, Caen
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Khasiyev F, Hakoun A, Christopher K, Braun J, Wang F. Safety and Effect on Intracranial Pressure of 3% Hypertonic Saline Bolus Via Peripheral Intravenous Catheter for Neurological Emergencies. Neurocrit Care 2024; 41:202-207. [PMID: 38379103 DOI: 10.1007/s12028-024-01941-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/05/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Elevated intracranial pressure (ICP) is a neurological emergency in patients with acute brain injuries. Such a state requires immediate and effective interventions to prevent potential neurological deterioration. Current clinical guidelines recommend hypertonic saline (HTS) and mannitol as first-line therapeutic agents. Notably, HTS is conventionally administered through central venous catheters (CVCs), which may introduce delays in treatment due to the complexities associated with CVC placement. These delays can critically affect patient outcomes, necessitating the exploration of more rapid therapeutic avenues. This study aimed to investigate the safety and effect on ICP of administering rapid boluses of 3% HTS via peripheral intravenous (PIV) catheters. METHODS A retrospective cohort study was performed on patients admitted to Sisters of Saint Mary Health Saint Louis University Hospital from March 2019 to September 2022 who received at least one 3% HTS bolus via PIV at a rate of 999 mL/hour for neurological emergencies. Outcomes assessed included complications related to 3% HTS bolus and its effect on ICP. RESULTS Of 216 3% HTS boluses administered in 124 patients, complications occurred in 8 administrations (3.7%). Pain at the injection site (4 administrations; 1.9%) and thrombophlebitis (3 administrations; 1.4%) were most common. The median ICP reduced by 6 mm Hg after 3% HTS bolus administration (p < 0.001). CONCLUSIONS Rapid bolus administration of 3% HTS via PIV catheters presents itself as a relatively safe approach to treat neurological emergencies. Its implementation could provide an invaluable alternative to the traditional CVC-based administration, potentially minimizing CVC-associated complications and expediting life-saving interventions for patients with neurological emergencies, especially in the field and emergency department settings.
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Affiliation(s)
- Farid Khasiyev
- Department of Neurology, Saint Louis University, St. Louis, MO, USA
| | - Abdullah Hakoun
- Department of Neurology, Saint Louis University, St. Louis, MO, USA
| | - Kara Christopher
- Department of Neurology, Saint Louis University, St. Louis, MO, USA
| | - James Braun
- Department of Pharmacy, Sisters of Saint Mary Health Saint Louis University Hospital, 1008 S. Spring Ave, St. Louis, MO, 63110, USA
| | - Fajun Wang
- Department of Neurology, Saint Louis University, St. Louis, MO, USA.
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Pardo M, Spencer E, Odunayo A, Ramirez ML, Rudloff E, Shafford H, Weil A, Wolff E. 2024 AAHA Fluid Therapy Guidelines for Dogs and Cats. J Am Anim Hosp Assoc 2024; 60:131-163. [PMID: 38885492 DOI: 10.5326/jaaha-ms-7444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
Fluids are drugs used in veterinary patients capable of producing beneficial therapeutic or inadvertent harmful effects within the body's intravascular, interstitial, and intracellular fluid spaces. The individualized design of a fluid therapy plan requires careful patient assessment and targeted selection of proper fluid types, administration routes, and rates, along with adjustments during therapy tailored specifically as per the individual patient's fluid requirement and therapeutic response. Personalized fluid prescriptions and vigilant patient monitoring help avoid patient morbidity from body fluid deficiencies, fluid excess, and electrolyte derangements and support better patient outcomes. These guidelines provide an overview of fluid dynamics within the fluid spaces of the body, describe various types of fluids and their uses, and outline recommendations for fluid administration for resuscitation, rehydration, and maintenance purposes. The guidelines also outline approaches to fluid therapy for anesthetized patients and reiterate the recommendations of reduced fluid rates in this population of patients. Additionally, the guidelines include practical fluid therapy strategies for patients with various common disorders. The goal of these guidelines is to help veterinary professionals safely and effectively prescribe and administer fluid therapy for canine and feline patients.
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Affiliation(s)
- Mariana Pardo
- Critical Care Veterinarian Consulting, Pleasantville, New York (M.P.)
| | - Erin Spencer
- Veterinary Emergency Group, Derry, New Hampshire (E.S.)
| | | | - Mary L Ramirez
- North Dallas Veterinary Emergency and Specialty Hospital, Frisco, Texas (M.L.R.)
| | - Elke Rudloff
- Blue Pearl Pet Hospice, Milwaukee, Wisconsin (E.R.)
| | - Heidi Shafford
- Veterinary Anesthesia Specialists, Gladstone, Oregon (H.S.)
| | - Ann Weil
- Purdue University, West Lafayette, Indiana (A.W.)
| | - Ewan Wolff
- Blue Pearl NE Portland, Portland, Oregon (E.W.)
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10
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Ye Z, Li Z, Zhong S, Xing Q, Li K, Sheng W, Shi X, Bao Y. The recent two decades of traumatic brain injury: a bibliometric analysis and systematic review. Int J Surg 2024; 110:3745-3759. [PMID: 38608040 PMCID: PMC11175772 DOI: 10.1097/js9.0000000000001367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/10/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a serious public health burden worldwide, with a mortality rate of 20-30%; however, reducing the incidence and mortality rates of TBI remains a major challenge. This study provides a multidimensional analysis to explore the potential breakthroughs in TBI over the past two decades. MATERIALS AND METHODS The authors used bibliometric and Latent Dirichlet Allocation (LDA) analyses to analyze publications focusing on TBI published between 2003 and 2022 from the Web of Science Core Collection (WOSCC) database to identify core journals and collaborations among countries/regions, institutions, authors, and research trends. RESULTS Over the past 20 years, 41 545 articles on TBI from 3043 journals were included, with 12 916 authors from 20 449 institutions across 145 countries/regions. The annual number of publications has increased 10-fold compared to previous publications. This study revealed that high-income countries, especially the United States, have a significant influence. Collaboration was limited to several countries/regions. The LDA results indicated that the hotspots included four main areas: 'Clinical finding', 'Molecular mechanism', 'Epidemiology', and 'Prognosis'. Epidemiological research has consistently increased in recent years. Through epidemiological topic analysis, the main etiology of TBI has shifted from traffic accidents to falls in a demographically aging society. CONCLUSION Over the past two decades, TBI research has developed rapidly, and its epidemiology has received increasing attention. Reducing the incidence of TBI from a preventive perspective is emerging as a trend to alleviate the future social burden; therefore, epidemiological research might bring breakthroughs in TBI.
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Affiliation(s)
- Ziyin Ye
- Department of Neurosurgery, The Fourth Hospital of China Medical University, Huanggu
| | - Zhi Li
- Department of Oncology, The First Hospital of China Medical University, Heping
| | - Shiyu Zhong
- Department of Neurosurgery, The Fourth Hospital of China Medical University, Huanggu
| | - Qichen Xing
- Department of Neurosurgery, The Fourth Hospital of China Medical University, Huanggu
| | - Kunhang Li
- Department of Neurosurgery, The Fourth Hospital of China Medical University, Huanggu
| | - Weichen Sheng
- Department of Neurosurgery, The Fourth Hospital of China Medical University, Huanggu
| | - Xin Shi
- School of Health Management, China Medical University, Shenyang, People’s Republic of China
| | - Yijun Bao
- Department of Neurosurgery, The Fourth Hospital of China Medical University, Huanggu
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11
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Arabi YM, Belley-Cote E, Carsetti A, De Backer D, Donadello K, Juffermans NP, Hammond N, Laake JH, Liu D, Maitland K, Messina A, Møller MH, Poole D, Mac Sweeney R, Vincent JL, Zampieri FG, AlShamsi F. European Society of Intensive Care Medicine clinical practice guideline on fluid therapy in adult critically ill patients. Part 1: the choice of resuscitation fluids. Intensive Care Med 2024; 50:813-831. [PMID: 38771364 DOI: 10.1007/s00134-024-07369-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/20/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on resuscitation fluids in adult critically ill patients. This part addresses fluid choice and the other two will separately address fluid amount and fluid removal. METHODS This guideline was formulated by an international panel of clinical experts and methodologists. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision. RESULTS For volume expansion, the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general (moderate certainty of evidence), in patients with sepsis (moderate certainty of evidence), in patients with acute respiratory failure (very low certainty of evidence) and in patients in the perioperative period and patients at risk for bleeding (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis (very low certainty of evidence). The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general (low certainty of evidence), in patients with sepsis (low certainty of evidence) and in patients with kidney injury (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using isotonic crystalloids rather than small-volume hypertonic crystalloids in critically ill patients in general (very low certainty of evidence). CONCLUSIONS This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Emilie Belley-Cote
- Divisions of Cardiology and Critical Care, McMaster University, Riyadh, Saudi Arabia
| | - Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, Verona, Italy
- Anaesthesia and Intensive Care B Unit, AOUI-University Hospital Integrated Trust of Verona, Verona, Italy
| | - Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health and UNSW, Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Kathryn Maitland
- Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK
| | - Antonio Messina
- IRCCS Humanitas Research Hospital, Department of Anesthesia and Intensive Care Medicine, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, København, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | - Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Fernando G Zampieri
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Fayez AlShamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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12
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Labib H, Tjerkstra MA, Coert BA, Post R, Vandertop WP, Verbaan D, Müller MCA. Sodium and Its Impact on Outcome After Aneurysmal Subarachnoid Hemorrhage in Patients With and Without Delayed Cerebral Ischemia. Crit Care Med 2024; 52:752-763. [PMID: 38206089 PMCID: PMC11008454 DOI: 10.1097/ccm.0000000000006182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
OBJECTIVES To perform a detailed examination of sodium levels, hyponatremia and sodium fluctuations, and their association with delayed cerebral ischemia (DCI) and poor outcome after aneurysmal subarachnoid hemorrhage (aSAH). DESIGN An observational cohort study from a prospective SAH Registry. SETTING Tertiary referral center focused on SAH treatment in the Amsterdam metropolitan area. PATIENTS A total of 964 adult patients with confirmed aSAH were included between 2011 and 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 277 (29%) developed DCI. Hyponatremia occurred significantly more often in DCI patients compared with no-DCI patients (77% vs. 48%). Sodium levels, hyponatremia, hypernatremia, and sodium fluctuations did not predict DCI. However, higher sodium levels were significantly associated with poor outcome in DCI patients (DCI onset -7, DCI +0, +1, +2, +4, +5, +8, +9 d), and in no-DCI patients (postbleed day 6-10 and 12-14). Also, hypernatremia and greater sodium fluctuations were significantly associated with poor outcome in both DCI and no-DCI patients. CONCLUSIONS Sodium levels, hyponatremia, and sodium fluctuations were not associated with the occurrence of DCI. However, higher sodium levels, hypernatremia, and greater sodium fluctuations were associated with poor outcome after aSAH irrespective of the presence of DCI. Therefore, sodium levels, even with mild changes in levels, warrant close attention.
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Affiliation(s)
- Homeyra Labib
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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13
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Bagg MK, Hicks AJ, Hellewell SC, Ponsford JL, Lannin NA, O'Brien TJ, Cameron PA, Cooper DJ, Rushworth N, Gabbe BJ, Fitzgerald M. The Australian Traumatic Brain Injury Initiative: Statement of Working Principles and Rapid Review of Methods to Define Data Dictionaries for Neurological Conditions. Neurotrauma Rep 2024; 5:424-447. [PMID: 38660461 PMCID: PMC11040195 DOI: 10.1089/neur.2023.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to develop a health informatics approach to collect data predictive of outcomes for persons with moderate-severe TBI across Australia. Central to this approach is a data dictionary; however, no systematic reviews of methods to define and develop data dictionaries exist to-date. This rapid systematic review aimed to identify and characterize methods for designing data dictionaries to collect outcomes or variables in persons with neurological conditions. Database searches were conducted from inception through October 2021. Records were screened in two stages against set criteria to identify methods to define data dictionaries for neurological conditions (International Classification of Diseases, 11th Revision: 08, 22, and 23). Standardized data were extracted. Processes were checked at each stage by independent review of a random 25% of records. Consensus was reached through discussion where necessary. Thirty-nine initiatives were identified across 29 neurological conditions. No single established or recommended method for defining a data dictionary was identified. Nine initiatives conducted systematic reviews to collate information before implementing a consensus process. Thirty-seven initiatives consulted with end-users. Methods of consultation were "roundtable" discussion (n = 30); with facilitation (n = 16); that was iterative (n = 27); and frequently conducted in-person (n = 27). Researcher stakeholders were involved in all initiatives and clinicians in 25. Importantly, only six initiatives involved persons with lived experience of TBI and four involved carers. Methods for defining data dictionaries were variable and reporting is sparse. Our findings are instructive for AUS-TBI and can be used to further development of methods for defining data dictionaries.
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Affiliation(s)
- Matthew K. Bagg
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health Sciences, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Amelia J. Hicks
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Sarah C. Hellewell
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
| | - Jennie L. Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Natasha A. Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Terence J. O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter A. Cameron
- National Trauma Research Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - D. Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Belinda J. Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
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14
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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15
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Hall KE, Tucker C, Dunn JA, Webb T, Watts SA, Kirkman E, Guillaumin J, Hoareau GL, Pidcoke HF. Breaking barriers in trauma research: A narrative review of opportunities to leverage veterinary trauma for accelerated translation to clinical solutions for pets and people. J Clin Transl Sci 2024; 8:e74. [PMID: 38715566 PMCID: PMC11075112 DOI: 10.1017/cts.2024.513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 08/10/2024] Open
Abstract
Trauma is a common cause of morbidity and mortality in humans and companion animals. Recent efforts in procedural development, training, quality systems, data collection, and research have positively impacted patient outcomes; however, significant unmet need still exists. Coordinated efforts by collaborative, translational, multidisciplinary teams to advance trauma care and improve outcomes have the potential to benefit both human and veterinary patient populations. Strategic use of veterinary clinical trials informed by expertise along the research spectrum (i.e., benchtop discovery, applied science and engineering, large laboratory animal models, clinical veterinary studies, and human randomized trials) can lead to increased therapeutic options for animals while accelerating and enhancing translation by providing early data to reduce the cost and the risk of failed human clinical trials. Active topics of collaboration across the translational continuum include advancements in resuscitation (including austere environments), acute traumatic coagulopathy, trauma-induced coagulopathy, traumatic brain injury, systems biology, and trauma immunology. Mechanisms to improve funding and support innovative team science approaches to current problems in trauma care can accelerate needed, sustainable, and impactful progress in the field. This review article summarizes our current understanding of veterinary and human trauma, thereby identifying knowledge gaps and opportunities for collaborative, translational research to improve multispecies outcomes. This translational trauma group of MDs, PhDs, and DVMs posit that a common understanding of injury patterns and resulting cellular dysregulation in humans and companion animals has the potential to accelerate translation of research findings into clinical solutions.
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Affiliation(s)
- Kelly E. Hall
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
| | - Claire Tucker
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- One Health Institute, Office of the Vice President of Research and Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
| | - Julie A. Dunn
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- Medical Center of the Rockies, University of Colorado Health North, Loveland, CO, USA
| | - Tracy Webb
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
| | - Sarah A. Watts
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- CBR Division, Medical and Trauma Sciences Porton Down, Salisbury, WI, UK
| | - Emrys Kirkman
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- CBR Division, Dstl Porton Down, Salisbury, WI, UK
| | - Julien Guillaumin
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
| | - Guillaume L. Hoareau
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
- Emergency Medicine Department and Nora Eccles-Harrison Cardiovascular Research and Training Institute and Biomedical Engineering Department, University of Utah, Salt Lake City, UT, USA
| | - Heather F. Pidcoke
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
- Translational Trauma Research Alliance (TeTRA-Med), Fort Collins, CO, USA
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16
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Mustafa AFM, Ab Mukmin L, Mazlan MZ, Ghani ARI, Wan Hassan WMN, Hassan MH. Analysis on Short-Term Outcomes for Cerebral Protection Treatment in Post Severe Traumatic Brain Injury Patients: A Single Neurosurgical Centre Study. Malays J Med Sci 2024; 31:142-152. [PMID: 38694580 PMCID: PMC11057832 DOI: 10.21315/mjms2024.31.2.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/29/2023] [Indexed: 05/04/2024] Open
Abstract
Background Severe traumatic brain injury (TBI) is a leading cause of disability worldwide and cerebral protection (CP) management might determine the outcome of the patient. CP in severe TBI is to protect the brain from further insults, optimise cerebral metabolism and prevent secondary brain injury. This study aimed to analyse the short-term Glasgow Outcome Scale (GOS) at the intensive care unit (ICU) discharge and a month after ICU discharge of patients post CP and factors associated with the favourable outcome. Methods This is a prospective cohort study from January 2021 to January 2022. The short-term outcomes of patients were evaluated upon ICU discharge and 1 month after ICU discharge using GOS. Favourable outcome was defined as GOS 4 and 5. Generalised Estimation Equation (GEE) was adopted to conduct bivariate GEE and subsequently multivariate GEE to evaluate the factors associated with favourable outcome at ICU discharge and 1 month after discharge. Results A total of 92 patients with severe TBI with GOS of 8 and below admitted to ICU received CP management. Proportion of death is 17% at ICU discharge and 0% after 1 month of ICU discharge. Proportion of favourable outcome is 26.1% at ICU discharge and 61.1% after 1 month of ICU discharge. Among factors evaluated, age (odds ratio [OR] = 0.96; 95% CI: 0.94, 0.99; P = 0.004), duration of CP (OR = 0.41; 95% CI: 0.20, 0.84; P = 0.014) and hyperosmolar therapy (OR = 0.41; CI 95%: 0.21, 0.83; P = 0.013) had significant association. Conclusion CP in younger age, longer duration of CP and patient not receiving hyperosmolar therapy are associated with favourable outcomes. We recommend further clinical trial to assess long term outcome of CP.
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Affiliation(s)
- Ahmad Fikri Muhammad Mustafa
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Laila Ab Mukmin
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Mohd Zulfakar Mazlan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Abdul Rahman Izaini Ghani
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Wan Mohd Nazaruddin Wan Hassan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Mohamad Hasyizan Hassan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
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17
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Nguyen TL, Simon DW, Lai YC. Beyond the brain: General intensive care considerations in pediatric neurocritical care. Semin Pediatr Neurol 2024; 49:101120. [PMID: 38677799 DOI: 10.1016/j.spen.2024.101120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/29/2024] [Accepted: 03/10/2024] [Indexed: 04/29/2024]
Abstract
Managing children with critical neurological conditions requires a comprehensive understanding of several principles of critical care. Providing a holistic approach that addresses not only the acute interactions between the brain and different organ systems, but also critical illness-associated complications and recovery is essential for improving outcomes in these patients. The brain reacts to an insult with autonomic responses designed to optimize cardiac output and perfusion, which can paradoxically be detrimental. Managing neuro-cardiac interactions therefore requires balancing adequate cerebral perfusion and minimizing complications. The need for intubation and airway protection in patients with acute encephalopathy should be individualized following careful risk/benefit deliberations. Ventilatory strategies can have profound impact on cerebral perfusion. Therefore, understanding neuro-pulmonary interactions is vital to optimize ventilation and oxygenation to support a healing brain. Gastrointestinal dysfunction is common and often complicates the care of patients with critical neurological conditions. Kidney function, along with fluid status and electrolyte derangements, should also be carefully managed in the acutely injured brain. While in the pediatric intensive care unit, prevention of critical illness-associated complications such as healthcare-associated infections and deep vein thrombosis is vital in improving outcomes. As the brain emerges from the acute injury, rehabilitation and management of delirium and paroxysmal sympathetic hyperactivity is paramount for optimal recovery. All these considerations provide a foundation for the care of pediatric patients with critical neurological conditions in the intensive care unit.
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Affiliation(s)
- Thao L Nguyen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, McGovern Medical School, UT Health Houston, Houston, TX
| | - Dennis W Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yi-Chen Lai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
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Bernhardt K, McClune W, Rowland MJ, Shah A. Hypertonic Saline Versus Other Intracranial-Pressure-Lowering Agents for Patients with Acute Traumatic Brain Injury: A Systematic Review and Meta-analysis. Neurocrit Care 2024; 40:769-784. [PMID: 37380894 PMCID: PMC10959781 DOI: 10.1007/s12028-023-01771-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023]
Abstract
Acute traumatic brain injury (TBI) is a major cause of mortality and disability worldwide. Intracranial pressure (ICP)-lowering is a critical management priority in patients with moderate to severe acute TBI. We aimed to evaluate the clinical efficacy and safety of hypertonic saline (HTS) versus other ICP-lowering agents in patients with TBI. We conducted a systematic search from 2000 onward for randomized controlled trials (RCTs) comparing HTS vs. other ICP-lowering agents in patients with TBI of all ages. The primary outcome was the Glasgow Outcome Scale (GOS) score at 6 months (PROSPERO CRD42022324370). Ten RCTs (760 patients) were included. Six RCTs were included in the quantitative analysis. There was no evidence of an effect of HTS on the GOS score (favorable vs. unfavorable) compared with other agents (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.48-1.40; n = 406; 2 RCTs). There was no evidence of an effect of HTS on all-cause mortality (RR 0.96, 95% CI 0.60-1.55; n = 486; 5 RCTs) or total length of stay (RR 2.36, 95% CI - 0.53 to 5.25; n = 89; 3 RCTs). HTS was associated with adverse hypernatremia compared with other agents (RR 2.13, 95% CI 1.09-4.17; n = 386; 2 RCTs). The point estimate favored a reduction in uncontrolled ICP with HTS, but this was not statistically significant (RR 0.52, 95% CI 0.26-1.04; n = 423; 3 RCTs). Most included RCTs were at unclear or high risk of bias because of lack of blinding, incomplete outcome data, and selective reporting. We found no evidence of an effect of HTS on clinically important outcomes and that HTS is associated with adverse hypernatremia. The included evidence was of low to very low certainty, but ongoing RCTs may help to the reduce this uncertainty. In addition, heterogeneity in GOS score reporting reflects the need for a standardized TBI core outcome set.
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Affiliation(s)
| | | | - Matthew J Rowland
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
- Cardiovascular, Renal, and Metabolism Group, Novartis, London, UK
| | - Akshay Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
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Peng C, Chi L, Chen M, Peng L, Yang F, Shao L, Bo L, Jin Z. Effect of continuous hypertonic saline infusion on clinical outcomes in patients with traumatic brain injury. Neurosurg Rev 2024; 47:78. [PMID: 38340147 DOI: 10.1007/s10143-024-02316-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 02/12/2024]
Abstract
Osmotic therapy has been recognized as an important treatment option for patients with traumatic brain injury (TBI). Nevertheless, the effect of hypertonic saline (HTS) remains unknown, as findings are primarily based on a large database. This study aimed to elucidate the effect of HTS on the clinical outcomes of patients with TBI admitted to the intensive care unit (ICU). We retrospectively identified patients with moderate-to-severe TBI from two public databases: Medical Information Mart for Intensive Care (MIMIC)-IV and eICU Collaborative Research Database (eICU-CRD). A marginal structural Cox model (MSCM) was used, with time-dependent variates designed to reflect exposure over time during ICU stay. Trajectory modeling based on the intracranial pressure evolution pattern allowed for the identification of subgroups. Overall, 130 (6.65%) of 1955 eligible patients underwent HTS. MSCM indicated that the HTS significantly associated with higher infection complications (e.g., urinary tract infection (HR 1.88, 95% CI 1.26-2.81, p = 0.002)) and increased ICU LOS (HR 2.02, 95% CI 1.71-2.40, p < 0.001). A protective effect of HTS on GCS was found in subgroups with medium and low intracranial pressure. Our study revealed no significant difference in mortality between patients who underwent HTS and those who did not. Increased occurrence rates of infection and electrolyte imbalance are inevitable outcomes of continuous HTS infusion. Although the study suggests slight beneficial effects, including better neurological outcomes, these results warrant further validation.
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Affiliation(s)
- Chi Peng
- Department of Health Statistics, Naval Medical University, No. 800 Xiangyin Road, Shanghai, 200433, China
| | - Lijie Chi
- Department of Vascular and Endovascular Surgery, Hainan Hospital of PLA General Hospital, Sanya, 572000, China
| | - Mengjie Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, 710038, China
| | - Fan Yang
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, (Army Medical University) and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Liangjing Shao
- Department of Hematology, General Hospital Eastern Theater Command of PLA, Nanjing, 210002, China
| | - Lulong Bo
- Department of Anesthesiology, The First Affiliated Hospital of Naval Medical University, No. 168, Changhai Road, Yangpu District, Shanghai, 200433, China.
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, No. 800 Xiangyin Road, Shanghai, 200433, China.
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Bernhardt K, McClune W, Rowland MJ, Shah A. Response to "Letter to the Editor for 'Hypertonic Saline Versus Other Intracranial-Pressure-Lowering Agents for Patients with Acute Traumatic Brain Injury: A Systematic Review and Meta-analysis'". Neurocrit Care 2024; 40:377-378. [PMID: 37957417 DOI: 10.1007/s12028-023-01876-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/04/2023] [Indexed: 11/15/2023]
Affiliation(s)
| | | | - Matthew J Rowland
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
- Cardiovascular, Renal, and Metabolism Group, Novartis, London, UK
| | - Akshay Shah
- Nuffield Department of Clinical Neurosciences, Level 6 West Wing, John Radcliffe Hospital, University of Oxford, Oxford, UK.
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Han W, Zhang H, Feng L, Dang R, Wang J, Cui C, Jiang P. The emerging role of exosomes in communication between the periphery and the central nervous system. MedComm (Beijing) 2023; 4:e410. [PMID: 37916034 PMCID: PMC10616655 DOI: 10.1002/mco2.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 11/03/2023] Open
Abstract
Exosomes, membrane-enclosed vesicles, are secreted by all types of cells. Exosomes can transport various molecules, including proteins, lipids, functional mRNAs, and microRNAs, and can be circulated to various recipient cells, leading to the production of local paracrine or distal systemic effects. Numerous studies have proved that exosomes can pass through the blood-brain barrier, thus, enabling the transfer of peripheral substances into the central nervous system (CNS). Consequently, exosomes may be a vital factor in the exchange of information between the periphery and CNS. This review will discuss the structure, biogenesis, and functional characterization of exosomes and summarize the role of peripheral exosomes deriving from tissues like the lung, gut, skeletal muscle, and various stem cell types in communicating with the CNS and influencing the brain's function. Then, we further discuss the potential therapeutic effects of exosomes in brain diseases and the clinical opportunities and challenges. Gaining a clearer insight into the communication between the CNS and the external areas of the body will help us to ascertain the role of the peripheral elements in the maintenance of brain health and illness and will facilitate the design of minimally invasive techniques for diagnosing and treating brain diseases.
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Affiliation(s)
- Wenxiu Han
- Translational Pharmaceutical LaboratoryJining First People's HospitalShandong First Medical UniversityJiningP. R. China
- Institute of Translational PharmacyJining Medical Research AcademyJiningP. R. China
| | - Hailiang Zhang
- Translational Pharmaceutical LaboratoryJining First People's HospitalShandong First Medical UniversityJiningP. R. China
- Institute of Translational PharmacyJining Medical Research AcademyJiningP. R. China
| | - Lei Feng
- Department of NeurosurgeryJining First People's HospitalShandong First Medical UniversityJiningP. R. China
| | - Ruili Dang
- Translational Pharmaceutical LaboratoryJining First People's HospitalShandong First Medical UniversityJiningP. R. China
- Institute of Translational PharmacyJining Medical Research AcademyJiningP. R. China
| | - Jing Wang
- Translational Pharmaceutical LaboratoryJining First People's HospitalShandong First Medical UniversityJiningP. R. China
- Institute of Translational PharmacyJining Medical Research AcademyJiningP. R. China
| | - Changmeng Cui
- Department of NeurosurgeryAffiliated Hospital of Jining Medical UniversityJiningP. R. China
| | - Pei Jiang
- Translational Pharmaceutical LaboratoryJining First People's HospitalShandong First Medical UniversityJiningP. R. China
- Institute of Translational PharmacyJining Medical Research AcademyJiningP. R. China
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Hossain I, Rostami E, Marklund N. The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies. Curr Opin Crit Care 2023; 29:650-658. [PMID: 37851061 PMCID: PMC10624411 DOI: 10.1097/mcc.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours. RECENT FINDINGS Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials. SUMMARY Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.
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Affiliation(s)
- Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala
- Department of Neuroscience, Karolinska institute, Stockholm
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
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Wu H, Li X, Zhao L, Yuan J, Xing Y, Bai M, Sun S. Risk factors for mortality in brain injury patients who have severe hypernatremia and received continuous venovenous hemofiltration. Heliyon 2023; 9:e21792. [PMID: 38027977 PMCID: PMC10663868 DOI: 10.1016/j.heliyon.2023.e21792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/06/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Background and objectives The mortality rate for people with brain injuries is increased when hypernatremia is present. Patients with severe hypernatremia, who have a significant short-term mortality rate, were shown to benefit from continuous venovenous hemofiltration (CVVH), which has been indicated to be successful. Exploring the risk factors for short-term mortality in brain injury patients who underwent CVVH and had severe hypernatremia was the aim of the current study. Materials and methods Retrospective screening was performed on patients with brain injuries who underwent CVVH at Xijing Hospital between 1 December 2010 and 31 December 2021 and who have a diagnosis of severe hypernatremia. The outcomes included 28-day patient mortality and hospital stay duration. The patient survival rate was examined using the Kaplan-Meier survival curve. To determine the risk factors for short-term death for patients, univariate and multivariate Cox regression analysis models were used. Results Our current study included a total of 83 individuals. The included patients had a median age of 49 (IQR 35-59) years. Of the included patients, 58 patients (69.9 %) died within 28 days. The median length of hospital stay for the patient was 13 (IQR 7-21) days. The APACHE II score, SOFA score, GCS, PLT count, INR, stroke, mechanical ventilation, and vasopressor reliance were related to 28-day mortality according to the univariate Cox analysis. INR (HR = 1.004, 95 % Cl: 1.001-1.006, P = 0.008), stroke (HR = 1.971, 95 % Cl: 1.031-3.768, P = 0.04), mechanical ventilation (HR = 3.948, 95 % Cl: 1.090-14.294, P = 0.036), and vasopressor dependency (HR = 2.262, 95 % Cl: 1.099-4.655, P = 0.027) were independently associated with the risk of 28-day death rates, according to multivariate Cox regression analysis. Conclusions Brain injuries who have severe hypernatremia requires CVVH, which has high short-term patient mortality. Mechanical ventilation, INR increase, stroke, and vasopressor dependence are independently associated with increased patient mortality risk.
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Affiliation(s)
- Hao Wu
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
- Xi'an Medical University, Xi 'an, Shanxi, China
| | - Xiayin Li
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
- Xi'an Medical University, Xi 'an, Shanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
| | - Jinguo Yuan
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
| | - Yan Xing
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, Shanxi, 710032, China
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Figaji A. An update on pediatric traumatic brain injury. Childs Nerv Syst 2023; 39:3071-3081. [PMID: 37801113 PMCID: PMC10643295 DOI: 10.1007/s00381-023-06173-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) remains the commonest neurological and neurosurgical cause of death and survivor disability among children and young adults. This review summarizes some of the important recent publications that have added to our understanding of the condition and advanced clinical practice. METHODS Targeted review of the literature on various aspects of paediatric TBI over the last 5 years. RESULTS Recent literature has provided new insights into the burden of paediatric TBI and patient outcome across geographical divides and the severity spectrum. Although CT scans remain a standard, rapid sequence MRI without sedation has been increasingly used in the frontline. Advanced MRI sequences are also being used to better understand pathology and to improve prognostication. Various initiatives in paediatric and adult TBI have contributed regionally and internationally to harmonising research efforts in mild and severe TBI. Emerging data on advanced brain monitoring from paediatric studies and extrapolated from adult studies continues to slowly advance our understanding of its role. There has been growing interest in non-invasive monitoring, although the clinical applications remain somewhat unclear. Contributions of the first large scale comparative effectiveness trial have advanced knowledge, especially for the use of hyperosmolar therapies and cerebrospinal fluid drainage in severe paediatric TBI. Finally, the growth of large and even global networks is a welcome development that addresses the limitations of small sample size and generalizability typical of single-centre studies. CONCLUSION Publications in recent years have contributed iteratively to progress in understanding paediatric TBI and how best to manage patients.
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Affiliation(s)
- Anthony Figaji
- Division of Neurosurgery and Neurosciences Institute, University of Cape Town, Cape Town, South Africa.
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Cinotti R, Chopin A, Moyer JD, Huet O, Lasocki S, Cohen B, Dahyot-Fizelier C, Chalard K, Seguin P, Martin FP, Lerebourg C, Guitteny M, Chenet A, Perrouin-Verbe B, Asehnoune K, Feuillet F, Sébille V, Roquilly A. Anxiety and depression symptoms in relatives of moderate-to-severe traumatic brain injury survivors - A multicentre cohort. Anaesth Crit Care Pain Med 2023; 42:101232. [PMID: 37054915 DOI: 10.1016/j.accpm.2023.101232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/06/2023] [Accepted: 03/21/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION The prevalence and risk factors of anxiety and depression symptoms in relatives of moderate to severe traumatic brain injury (TBI) survivors have not been thoroughly investigated. METHODS Ancillary study of a multicentric prospective randomized-controlled trial in nine university hospitals in 370 moderate-to-severe TBI patients. TBI survivor-relative dyads were included in the 6th month of follow-up. Relatives responded to the Hospital Anxiety and Depression Scale (HADS). The primary endpoints were the prevalence of severe symptoms of anxiety (HADS-Anxiety ≥ 11) and depression (HADS-Depression ≥ 11) in relatives. We explored the risk factors of severe anxiety and depression symptoms. RESULTS Relatives were predominantly women (80.7%), spouse-husband (47.7%), or parents (39%). Out of the 171 dyads included, 83 (50.6%) and 59 (34.9%) relatives displayed severe symptoms of anxiety and depression, respectively. Severe anxiety symptoms in relatives were independently associated with the patient's discharge at home (OR 2.57, 95%CI [1.04-6.37]) and the patient's higher SF-36 Mental Health domain scores (OR 1.03 95%CI [1.01-1.05]). Severe depression symptoms were independently associated with a lower SF-36 Mental Health domain score (OR = 0.98 95%CI [0.96-1.00]). No ICU organization characteristics were associated with psychological symptoms in relatives. DISCUSSION There is a high prevalence of anxiety and depression symptoms among relatives of moderate-to-severe TBI survivors at 6 months. Anxiety and depression were inversely correlated with the patient's mental health status at 6 months. CONCLUSIONS Long-term follow-up must provide psychological care to relatives after TBI.
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Affiliation(s)
- Raphaël Cinotti
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093 France; Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-centered outcomes and HEalth Research (SPHERE), F-44000 Nantes, France.
| | - Alice Chopin
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093 France
| | - Jean Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP, Nord, Paris, France
| | - Olivier Huet
- Centre Hospitalier Universitaire De Brest, Anesthesia and Intensive Care Unit, Brest, France
| | - Sigismond Lasocki
- Centre Hospitalier Universitaire d'Angers, Anesthesia and Intensive Care Unit, Angers, France
| | - Benjamin Cohen
- Centre Hospitalier Universitaire De Tours, Anesthesia and Intensive Care Unit, Tours, France
| | - Claire Dahyot-Fizelier
- Centre Hospitalier Universitaire De Potiers, Anesthesia and Intensive Care Unit, Poitiers, France
| | - Kevin Chalard
- Centre Hospitalier Universitaire De Montpellier, Anesthesia and Intensive Care Unit, Montpellier, France
| | - Philippe Seguin
- Centre Hospitalier Universitaire De Rennes, Anesthesia and Intensive Care Unit, Rennes, France
| | - Florian Pierre Martin
- CRT2I Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Nantes, F-44000, France
| | - Céline Lerebourg
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093 France
| | - Marie Guitteny
- Nantes Université, CHU Nantes, Department of Addictology and Liaison Psychiatry, Consultation-Liaison Psychiatry Unit, Hôtel Dieu, Nantes, F-44093, France
| | - Amandine Chenet
- Nantes Université, CHU Nantes, Médecine Physique et Réadaptation Neurologique, Hôpital Saint-Jacques, Nantes, F-44093, France
| | - Brigitte Perrouin-Verbe
- Nantes Université, CHU Nantes, Médecine Physique et Réadaptation Neurologique, Hôpital Saint-Jacques, Nantes, F-44093, France
| | - Karim Asehnoune
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093 France
| | - Fanny Feuillet
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-centered outcomes and HEalth Research (SPHERE), F-44000 Nantes, France; Nantes Université, CHU Nantes, Plateforme de Méthodologie et Biostatistique, Direction Recherche et Innovation, Nantes, F-44000, France
| | - Véronique Sébille
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-centered outcomes and HEalth Research (SPHERE), F-44000 Nantes, France; Nantes Université, CHU Nantes, Plateforme de Méthodologie et Biostatistique, Direction Recherche et Innovation, Nantes, F-44000, France
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44093 France; Nantes Université, CHU Nantes, Médecine Physique et Réadaptation Neurologique, Hôpital Saint-Jacques, Nantes, F-44093, France
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Sébille V, Dubuy Y, Feuillet F, Blanchin M, Roquilly A, Cinotti R. Does Differential Item Functioning Jeopardize the Comparability of Health-Related Quality of Life Assessment Between Patients and Proxies in Patients with Moderate-to-Severe Traumatic Brain Injury? Neurocrit Care 2023; 39:339-347. [PMID: 36977961 DOI: 10.1007/s12028-023-01705-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/22/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Health-related quality of life (HRQoL) is clearly recognized as a patient-important outcome in patients with traumatic brain injury (TBI). Patient-reported outcomes are therefore often used and supposed to be directly reported by the patients without interpretation of their responses by a physician or anyone else. However, patients with TBI are often unable to self-report because of physical and/or cognitive impairments. Thus, proxy-reported measures, e.g., family members, are often used on the patient's behalf. Yet, many studies have reported that proxy and patient ratings differ and are noncomparable. However, most studies usually do not account for other potential confounding factors that may be associated with HRQoL. In addition, patients and proxies can interpret some items of the patient-reported outcomes differently. As a result, item responses may not only reflect patients' HRQoL but also the respondent's (patient or proxy) own perception of the items. This phenomenon, called differential item functioning (DIF), can lead to substantial differences between patient-reported and proxy-reported measures and compromise their comparability, leading to highly biased HRQoL estimates. Using data from the prospective multicenter continuous hyperosmolar therapy in traumatic brain-injured patients study (240 patients with HRQoL measured with the Short Form-36 (SF-36)), we assessed the comparability of patients' and proxies' reports by evaluating the extent to which items perception differs (i.e., DIF) between patients and proxies after controlling for potential confounders. METHODS Items at risk of DIF adjusting for confounders were examined on the items of the role physical and role emotional domains of the SF-36. RESULTS Differential item functioning was evidenced in three out of the four items of the role physical domain measuring role limitations due to physical health problems and in one out of the three items of the role emotional domain measuring role limitations due to personal or emotional problems. Overall, despite an expected similar level of role limitations between patients who were able to respond and those for whom proxies responded, proxies tend to give more pessimistic responses than patients in the case of major role limitations and more optimistic responses than patients in the case of minor limitations. CONCLUSIONS Patients with moderate-to-severe TBI and proxies seem to have different perceptions of the items measuring role limitations due to physical or emotional problems, questioning the comparability of patient and proxy data. Therefore, aggregating proxy and patient responses may bias HRQoL estimates and alter medical decision-making based on these patient-important outcomes.
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Affiliation(s)
- Véronique Sébille
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France.
- DRCI, Methodology and Biostatistic Department, CHU Nantes, Nantes, France.
- SPHERE, Nantes Université, IRS2 22 Boulevard Bénoni Goullin, 44200, Nantes, France.
| | - Yseulys Dubuy
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France
| | - Fanny Feuillet
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France
- DRCI, Methodology and Biostatistic Department, CHU Nantes, Nantes, France
| | - Myriam Blanchin
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- Surgical Intensive Care Unit, Hôtel Dieu, CHU Nantes, Nantes, France
| | - Raphaël Cinotti
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France
- Surgical Intensive Care Unit, Hôtel Dieu, CHU Nantes, Nantes, France
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Dolmans RGF, Harary M, Nawabi N, Taros T, Kilgallon JL, Mekary RA, Izzy S, Dawood HY, Stopa BM, Broekman MLD, Gormley WB. External Ventricular Drains versus Intraparenchymal Pressure Monitors in the Management of Moderate to Severe Traumatic Brain Injury: Experience at Two Academic Centers over a Decade. World Neurosurg 2023; 178:e221-e229. [PMID: 37467955 DOI: 10.1016/j.wneu.2023.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE The choice between external ventricular drain (EVD) and intraparenchymal monitor (IPM) for managing intracranial pressure in moderate-to-severe traumatic brain injury (msTBI) patients remains controversial. This study aimed to investigate factors associated with receiving EVD versus IPM and to compare outcomes and clinical management between EVD and IPM patients. METHODS Adult msTBI patients at 2 similar academic institutions were identified. Logistic regression was performed to identify factors associated with receiving EVD versus IPM (model 1) and to compare EVD versus IPM in relation to patient outcomes after controlling for potential confounders (model 2), through odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Of 521 patients, 167 (32.1%) had EVD and 354 (67.9%) had IPM. Mean age, sex, and Injury Severity Score were comparable between groups. Epidural hemorrhage (EDH) (OR 0.43, 95% CI 0.21-0.85), greater midline shift (OR 0.90, 95% CI 0.82-0.98), and the hospital with higher volume (OR 0.14, 95% CI 0.09-0.22) were independently associated with lower odds of receiving an EVD whereas patients needing a craniectomy were more likely to receive an EVD (OR 2.04, 95% CI 1.12-3.73). EVD patients received more intense medical treatment requiring hyperosmolar therapy compared to IPM patients (64.1% vs. 40.1%). No statistically significant differences were found in patient outcomes. CONCLUSIONS While EDH, greater midline shift, and hospital with larger patient volume were associated with receiving an IPM, the need for a craniectomy was associated with receiving an EVD. EVD patients received different clinical management than IPM patients with no significant differences in patient outcomes.
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Affiliation(s)
- Rianne G F Dolmans
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Maya Harary
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Noah Nawabi
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Trenton Taros
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John L Kilgallon
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rania A Mekary
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, Massachusetts, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hassan Y Dawood
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittany M Stopa
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marike L D Broekman
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - William B Gormley
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Dong X, Tang Y, Zhou Y, Feng Z. Stimulation of vagus nerve for patients with disorders of consciousness: a systematic review. Front Neurosci 2023; 17:1257378. [PMID: 37781261 PMCID: PMC10540190 DOI: 10.3389/fnins.2023.1257378] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/06/2023] [Indexed: 10/03/2023] Open
Abstract
Purpose The purpose of this study is to evaluate the efficacy and safety of stimulating the vagus nerve in patients with disorders of consciousness (DOCs). Methods A comprehensive systematic review was conducted, encompassing the search of databases such as PubMed, CENTRAL, EMBASE and PEDro from their inception until July 2023. Additionally, manual searches and exploration of grey literature were performed. The literature review was conducted independently by two reviewers for search strategy, selection of studies, data extraction, and judgment of evidence quality according to the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) Study Quality Scale. Results A total of 1,269 articles were retrieved, and 10 studies met the inclusion criteria. Among these, there were three case reports, five case series, and only two randomized controlled trials (RCTs). Preliminary studies have suggested that stimulation of vagus nerve can enhance the levels of DOCs in both vegetative state/unresponsive wakefulness state (VS/UWS) and minimally conscious state (MCS). However, due to a lack of high-quality RCTs research and evidence-based medical evidence, no definitive conclusion can be drawn regarding the intervention's effectiveness on consciousness level. Additionally, there were no significant adverse effects observed following stimulation of vagus nerve. Conclusion A definitive conclusion cannot be drawn from this systematic review as there was a limited number of eligible studies and low-quality evidence. The findings of this systematic review can serve as a roadmap for future research on the use of stimulation of vagus nerve to facilitate recovery from DOCs.
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Affiliation(s)
| | | | | | - Zhen Feng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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29
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Beynon C, Bernhard M, Brenner T, Dietrich M, Fiedler MO, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Focus neurosurgical intensive care medicine : Summary of selected intensive medical care studies]. DIE ANAESTHESIOLOGIE 2023; 72:518-525. [PMID: 37195500 DOI: 10.1007/s00101-023-01287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Christopher Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - Maximilian Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Mascha O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christian Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christopher J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - Dominik Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Christine Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Moyer JD, Elouahmani S, Codorniu A, Abback PS, Jeantrelle C, Goutagny S, Gauss T, Sigaut S. External ventricular drainage for intracranial hypertension after traumatic brain injury: is it really useful? Eur J Trauma Emerg Surg 2023; 49:1227-1234. [PMID: 35169869 DOI: 10.1007/s00068-022-01903-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 01/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSES External ventricular drainage (EVD) is frequently used to control raised intracranial pressure after traumatic brain injury. However, the available evidence about its effectiveness in this context is limited. The aim of this study is to evaluate the effectiveness of EVD to control intracranial pressure and to identify the clinical and radiological factors associated with its success. METHODS For this retrospective cohort study conducted in a Level 1 traumacenter in Paris area between May 2011 and March 2019, all patients with intracranial hypertension and treated with EVD were included. EVD success was defined as an efficient and continuous control of intracranial hypertension avoiding the use of third tier therapies (therapeutic hypothermia, decompressive craniectomy, and barbiturate coma) or avoiding a decision to withdraw life sustaining treatment due to both refractory intracranial hypertension and severity of brain injury lesions. RESULTS 83 patients with EVD were included. EVD was successful in 33 patients (40%). Thirty-two patients (39%) required a decompressive craniectomy, eight patients (9%) received barbiturate coma. In ten cases (12%) refractory intracranial hypertension prompted a protocolized withdrawal of care. Complications occurred in nine patients (11%) (three cases of ventriculitis, six cases of catheter occlusion). Multivariate analysis identified no independent factors associated with EVD success. CONCLUSION In a protocol-based management for traumatic brain injury, EVD allowed intracranial pressure control and avoided third tier therapeutic measures in 40% of cases with a favorable risk-benefit ratio.
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Affiliation(s)
- Jean-Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France.
| | - Saida Elouahmani
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Anais Codorniu
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Paer-Selim Abback
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Caroline Jeantrelle
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Stéphane Goutagny
- Department of Neurosurgery, Assistance Publique Hôpitaux de Paris, Beaujon Hospital, Clichy, France
- Université de Paris, UFR de Médecine Paris Nord, Paris, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Stéphanie Sigaut
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
- Université de Paris, UFR de Médecine Paris Nord, Paris, France
- NeuroDiderot, Inserm U1141, Université de Paris, Paris, France
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Kang JH, Jang M, Seo SJ, Choi A, Shin D, Seo S, Lee SH, Kim HN. Mechanobiological Adaptation to Hyperosmolarity Enhances Barrier Function in Human Vascular Microphysiological System. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2206384. [PMID: 36808839 PMCID: PMC10161024 DOI: 10.1002/advs.202206384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/27/2023] [Indexed: 05/06/2023]
Abstract
In infectious disease such as sepsis and COVID-19, blood vessel leakage treatment is critical to prevent fatal progression into multi-organ failure and ultimately death, but the existing effective therapeutic modalities that improve vascular barrier function are limited. Here, this study reports that osmolarity modulation can significantly improve vascular barrier function, even in an inflammatory condition. 3D human vascular microphysiological systems and automated permeability quantification processes for high-throughput analysis of vascular barrier function are utilized. Vascular barrier function is enhanced by >7-folds with 24-48 h hyperosmotic exposure (time window of emergency care; >500 mOsm L-1 ) but is disrupted after hypo-osmotic exposure (<200 mOsm L-1 ). By integrating genetic and protein level analysis, it is shown that hyperosmolarity upregulates vascular endothelial-cadherin, cortical F-actin, and cell-cell junction tension, indicating that hyperosmotic adaptation mechanically stabilizes the vascular barrier. Importantly, improved vascular barrier function following hyperosmotic exposure is maintained even after chronic exposure to proinflammatory cytokines and iso-osmotic recovery via Yes-associated protein signaling pathways. This study suggests that osmolarity modulation may be a unique therapeutic strategy to proactively prevent infectious disease progression into severe stages via vascular barrier function protection.
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Affiliation(s)
- Joon Ho Kang
- Brain Science InstituteKorea Institute of Science and TechnologySeoul02792Republic of Korea
| | - Minjeong Jang
- Brain Science InstituteKorea Institute of Science and TechnologySeoul02792Republic of Korea
| | - Su Jin Seo
- Brain Science InstituteKorea Institute of Science and TechnologySeoul02792Republic of Korea
- Department of Chemical EngineeringKwangwoon UniversitySeoul01897Republic of Korea
| | - Andrew Choi
- Brain Science InstituteKorea Institute of Science and TechnologySeoul02792Republic of Korea
| | - Daeeun Shin
- Brain Science InstituteKorea Institute of Science and TechnologySeoul02792Republic of Korea
- School of Mechanical EngineeringSungkyunkwan UniversitySuwon16419Republic of Korea
| | - Suyoung Seo
- Brain Science InstituteKorea Institute of Science and TechnologySeoul02792Republic of Korea
- Program in Nano Science and TechnologyGraduate School of Convergence Science and TechnologySeoul National UniversitySeoul08826Republic of Korea
| | - Soo Hyun Lee
- Brain Science InstituteKorea Institute of Science and TechnologySeoul02792Republic of Korea
- Division of Bio‐Medical Science & TechnologyKIST SchoolUniversity of Science and Technology (UST)Seoul02792Republic of Korea
| | - Hong Nam Kim
- Brain Science InstituteKorea Institute of Science and TechnologySeoul02792Republic of Korea
- Division of Bio‐Medical Science & TechnologyKIST SchoolUniversity of Science and Technology (UST)Seoul02792Republic of Korea
- School of Mechanical EngineeringYonsei UniversitySeoul03722Republic of Korea
- Yonsei‐KIST Convergence Research InstituteYonsei UniversitySeoul03722Republic of Korea
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Hourmant Y, Huard D, Demeure Dit Latte D, Bouras M, Asehnoune K, Pirrachio R, Roquilly A. Effect of continuous infusion of hypertonic saline solution on survival of patients with brain injury: a systematic review and meta-analysis. Anaesth Crit Care Pain Med 2023; 42:101177. [PMID: 36436787 DOI: 10.1016/j.accpm.2022.101177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/16/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objective was to determine the effects of continuous infusion of hypertonic saline solutions on outcomes of patients with brain injury. METHODS Preferred Reported Items for Systemic Reviews and Meta-Analysis guidelines were followed. We searched the MEDLINE and COCHRANE clinical trials register (through December 2021) and reference lists of articles. We included all clinical trials conducted in brain-injured patients hospitalized in intensive care units evaluating continuous infusion of hypertonic saline solution (osmolarity above 308 mOsm/L). Two reviewers extracted data that were checked by two others. The primary outcome was the in-hospital mortality rate. The main secondary outcomes were the rates of intracranial hypertension, an unfavorable neurological outcome at day 90, and adverse events. RESULTS We identified 23 clinical trials reporting the use of continuous infusion of hypertonic saline solution in brain-injured patients. The primary outcome was available in 10 studies (n = 1883 patients). The odds ratio (OR) for in-hospital death with the intervention was 0.68 (95% confidence interval (CI), 0.54-0.85, I2 = 0%). In the subgroup of studies including only traumatic brain-injured patients (7 studies, n = 1521 patients), the OR for the primary outcome was 0.74 (95%CI 0.57-0.95) with the intervention. The OR for intracranial hypertension and unfavorable neurological outcome at day 90 were 0.66 (95%CI 0.49-0.88, I2 = 42%, n = 787 patients) and 0.61 (95%CI 0.46-0.81, I2 = 15%, n = 956 patients), respectively. Regarding safety, the OR of acute kidney injury and severe hypernatremia were 0.82 (95%CI 0.47-1.44, I2 = 0%) and 3.38 (95%CI 2.16-5.27, I2 = 24%). CONCLUSIONS Continuous hypertonic saline solution infusion reduced in-hospital mortality without increasing the risk of unfavorable neurological outcome at day 90 in brain-injured patients hospitalized in intensive care units. Given the inclusion of observational and heterogeneous studies, further randomized studies are needed before developing recommendations for implementation at the bedside. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021221367. Registered 13 May 2021.
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Affiliation(s)
- Yannick Hourmant
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Donatien Huard
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Dominique Demeure Dit Latte
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Marwan Bouras
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Karim Asehnoune
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France
| | - Romain Pirrachio
- Department of Anesthesia and Perioperative Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, United States of America
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, INSERM CIC 0004 Immunologie Et Infectiologie, Nantes, F-44093 France.
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Marchesini N, Fernández Londoño LL, Boaro A, Kuhn I, Griswold D, Sala F, Rubiano AM. Hyperosmolar therapies for neurological deterioration in mild and moderate traumatic brain injury: A scoping review. Brain Inj 2023:1-9. [PMID: 36929819 DOI: 10.1080/02699052.2023.2191010] [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: 03/18/2023]
Abstract
OBJECTIVE To explore the available evidence on hyperosmolar therapies(HT) in mild and moderate traumatic brain injury(TBI) and to evaluate the effects on outcomes.A scoping review was conducted according to the Joanna Briggs Institute methodology. Inclusion criteria: (a)randomized controlled trials(RCTs), prospective and retrospective cohort studies and case-control studies; (b)all-ages mild and moderate TBIs; (c)HT administration; (d)functional outcomes recorded; (e)comparator group. RESULTS From 4424 records, only 3 respected the inclusion criteria. In a retrospective cohort study of adult moderate TBIs, the Glasgow Coma Scale(GCS) remained the same at 48 hours in those treated with hypertonic saline(HTS) while it worsened in the non-treated. A trend toward increased pulmonary infections and length of stay was found. In an RCT of adult severe and moderate TBIs, moderate TBIs treated with HTS showed a trend toward better secondary outcomes than standard care alone, with similar odds of adverse effects. An RCT enrolling children with mild TBI found a significant improvement in concussive pain immediately after HTS administration and after 2-3 days. No adverse events occurred. CONCLUSIONS A gap in the literature about HTs' role in mild and moderate TBI was found. Some benefits may exist with limited side effects and further studies are desirable.
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Affiliation(s)
| | | | - Alessandro Boaro
- Department of Neurosciences, Biomedicine and Movement, Section of Neurosurgery, University of Verona, Verona, Italy.,Clinical and Translational Science Institute, University of Utah, Logan, Utah, USA
| | - Isla Kuhn
- University of Cambridge Medical Library, Cambridge, UK
| | - Dylan Griswold
- NIHR Group on Neurotrauma, University of Cambridge, Cambridge, UK.,Stanford School of Medicine, Stanford, California, USA
| | - Francesco Sala
- Department of Neurosciences, Biomedicine and Movement, Section of Neurosurgery, University of Verona, Verona, Italy
| | - Andrés M Rubiano
- Neuroscience Institute, Universidad El Bosque, Bogotá, Colombia.,NIHR Group on Neurotrauma, University of Cambridge, Cambridge, UK.,Meditech Foudation, Cali, Colombia
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Michel C, Warming S, Neto AS, Abeygunawardana V, Fisher C, Kishore K, Warrillow S, Bellomo R. Early and prolonged continuous hypertonic saline infusion in patients with acute liver failure. J Crit Care 2023; 76:154289. [PMID: 36933387 DOI: 10.1016/j.jcrc.2023.154289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/15/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To study patient characteristics, physiological changes, and outcomes associated with prolonged continuous hypertonic saline (HTS) infusion in acute liver failure (ALF). MATERIALS AND METHODS Retrospective observational cohort study of adult patients with ALF. We collected clinical, biochemical, and physiological data six hourly for the first week, daily until day 30 or hospital discharge, and weekly, when documented, until day 180. RESULTS Of 127 patients, 85 received continuous HTS. Compared with non-HTS patients they were more likely to receive continuous renal replacement therapy (CRRT) (p < 0.001) and mechanical ventilation (p < 0.001). Median HTS duration was 150 (Interquartile range (IQR): 84-168) hours, delivering a median 2244 (IQR: 979-4610) mmol sodium load. Median peak sodium concentration was 149 mmol/L vs 138 mmol/L in non-HTS patients (p < 0.001). The median rate of sodium increase with infusion was 0.1 mmol/L/h and median rate of decrease during weaning was 0.1 mmol/L every 6 h. Median lowest pH value was 7.29 vs. 7.35 in non-HTS patients. Survival of HTS patients was 72.9% overall and 72.2% without transplantation. CONCLUSIONS In ALF patients, the prolonged administration of HTS infusion was not associated with severe hypernatremia or rapid shifts in serum sodium upon commencement, delivery, or weaning.
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Affiliation(s)
- Claire Michel
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Scott Warming
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
| | | | - Caleb Fisher
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Kartik Kishore
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
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Stefanou Ε, Karvelas N, Bennett S, Kole C. Cerebrovascular Manifestations of SARS-CoV-2: A Comprehensive Review. Curr Treat Options Neurol 2023; 25:71-92. [PMID: 36950279 PMCID: PMC9984763 DOI: 10.1007/s11940-023-00747-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2023] [Indexed: 03/06/2023]
Abstract
Purpose of review The risks of cerebrovascular manifestations due to SARS-CoV-2 infection are significantly increased within the first 6 months of the infection. Our work aims to give an update on current clinical aspects of diagnosis and treatment of cerebrovascular manifestations during acute and long-term SARS-CoV-2 infection. Recent findings The incidence of acute ischemic stroke and haemorrhagic stroke during acute SARS-CoV-2 patients is estimated at 0.9 to 4.6% and 0.5-0.9%, respectively, and were associated with increased mortality. The majority presented with hemiparesis, dysarthria, sensory deficits, and a NIHSS score within 5-15. In addition, beyond the first 30 days of infection people with COVID-19 exhibited increased risk of stroke. During acute phase, age, hypertension, diabetes, and medical history of vascular disease were increased in patients with COVID-19 with new onset of cerebrovascular manifestations, while during long-COVID-19, the risk of cerebrovascular manifestations were found increased regardless of these factors. The management of patients with large-vessel ischemic stroke fulfilling the intravenous thrombolysis criteria are successfully treated according to the guidelines, while hyperosmolar therapy is typically administered in 4- to 6-h intervals. In addition, prophylaxis of anticoagulation therapy is associated with a better prognosis and low mortality during acute and post hospital discharge of patients with COVID-19. Summary In this work, we provide a comprehensive review of the current literature on acute and post-acute COVID-19 cerebrovascular sequelae, symptomatology, and its pathophysiology mechanisms. Moreover, we discuss therapeutic strategies for these patients during acute and long-term care and point populations at risk. Our findings suggest that older patients with risk factors such as hypertension, diabetes, and medical history of vascular disease are more likely to develop cerebrovascular complications.
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Affiliation(s)
- Εleni Stefanou
- Artificial Kidney Unit, General Hospital of Messinia, Kalamata, Greece
| | - Nikolaos Karvelas
- Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Christo Kole
- Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Cardiology Department, Sismanoglio General Hospital of Attica, Athens, Greece
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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McNamara R, Meka S, Anstey J, Fatovich D, Haseler L, Jeffcote T, Udy A, Bellomo R, Fitzgerald M. Development of Traumatic Brain Injury Associated Intracranial Hypertension Prediction Algorithms: A Narrative Review. J Neurotrauma 2023; 40:416-434. [PMID: 36205570 PMCID: PMC9986028 DOI: 10.1089/neu.2022.0201] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic intracranial hypertension (tIH) is a common and potentially lethal complication of moderate to severe traumatic brain injury (m-sTBI). It often develops with little warning and is managed reactively with the tiered application of intracranial pressure (ICP)-lowering interventions administered in response to an ICP rising above a set threshold. For over 45 years, a variety of research groups have worked toward the development of technology to allow for the preemptive management of tIH in the hope of improving patient outcomes. In 2022, the first operationalizable tIH prediction system became a reality. With such a system, ICP lowering interventions could be administered prior to the rise in ICP, thus protecting the patient from potentially damaging tIH episodes and limiting the overall ICP burden experienced. In this review, we discuss related approaches to ICP forecasting and IH prediction algorithms, which collectively provide the foundation for the successful development of an operational tIH prediction system. We also discuss operationalization and the statistical assessment of tIH algorithms. This review will be of relevance to clinicians and researchers interested in development of this technology as well as those with a general interest in the bedside application of machine learning (ML) technology.
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Affiliation(s)
- Robert McNamara
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Medicine, Curtin University, Bentley, Western Australia, Australia
| | - Shiv Meka
- Data Innovation Laboratory, Western Australian Department of Health, Perth, Western Australia, Australia
| | - James Anstey
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Daniel Fatovich
- Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Luke Haseler
- Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
| | - Toby Jeffcote
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Udy
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Data Analytics Research and Evaluation, Austin Hospital, Melbourne, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, Western Australia, Australia
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Salasky VR, Chang WTW. Neurotrauma Update. Emerg Med Clin North Am 2023; 41:19-33. [DOI: 10.1016/j.emc.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Huet O, Chapalain X, Vermeersch V, Moyer JD, Lasocki S, Cohen B, Dahyot-Fizelier C, Chalard K, Seguin P, Hourmant Y, Asehnoune K, Roquilly A. Impact of continuous hypertonic (NaCl 20%) saline solution on renal outcomes after traumatic brain injury (TBI): a post hoc analysis of the COBI trial. Crit Care 2023; 27:42. [PMID: 36707841 PMCID: PMC9881296 DOI: 10.1186/s13054-023-04311-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/07/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND To evaluate if the increase in chloride intake during a continuous infusion of 20% hypertonic saline solution (HSS) is associated with an increase in the incidence of acute kidney injury (AKI) compared to standard of care in traumatic brain injury patients. METHODS In this post hoc analysis of the COBI trial, 370 patients admitted for a moderate-to-severe TBI in the 9 participating ICUs were enrolled. The intervention consisted in a continuous infusion of HSS to maintain a blood sodium level between 150 and 155 mmol/L for at least 48 h. Patients enrolled in the control arm were treated as recommended by the latest Brain Trauma foundation guidelines. The primary outcome of this study was the occurrence of AKI within 28 days after enrollment. AKI was defined by stages 2 or 3 according to KDIGO criteria. RESULTS After exclusion of missing data, 322 patients were included in this post hoc analysis. The patients randomized in the intervention arm received a significantly higher amount of chloride during the first 4 days (intervention group: 97.3 ± 31.6 g vs. control group: 61.3 ± 38.1 g; p < 0.001) and had higher blood chloride levels at day 4 (117.9 ± 10.7 mmol/L vs. 111.6 ± 9 mmol/L, respectively, p < 0.001). The incidence of AKI was not statistically different between the intervention and the control group (24.5% vs. 28.9%, respectively; p = 0.45). CONCLUSIONS Despite a significant increase in chloride intake, a continuous infusion of HSS was not associated with AKI in moderate-to-severe TBI patients. Our study does not confirm the potentially detrimental effect of chloride load on kidney function in ICU patients. TRIAL REGISTRATION The COBI trial was registered on clinicaltrial.gov (Trial registration number: NCT03143751, date of registration: 8 May 2017).
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Affiliation(s)
- Olivier Huet
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, Boulevard Tanguy Prigent, 29609, Brest, France.
| | - Xavier Chapalain
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, Boulevard Tanguy Prigent, 29609, Brest, France
| | - Véronique Vermeersch
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, Boulevard Tanguy Prigent, 29609, Brest, France
| | - Jean-Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France
| | - Sigismond Lasocki
- Department of Anesthesia and Intensive Care Unit, Angers Hospital, Angers, France
| | - Benjamin Cohen
- Department of Anesthesia and Intensive Care Unit, Tours Hospital, Tours, France
| | | | - Kevin Chalard
- Department of Anesthesia and Intensive Care Unit, Montpellier Hospital, Montpellier, France
| | - P Seguin
- Department of Anesthesia and Intensive Care Unit, Rennes Hospital, Rennes, France
| | - Y Hourmant
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, CHU Nantes, Nantes, France
| | - Karim Asehnoune
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, CHU Nantes, Nantes, France
| | - Antoine Roquilly
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, CHU Nantes, Nantes, France
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40
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Cinotti R, Roquilly A, Chopin A, Martin FP, Morato Y, Lerebourg C, Moyer JD, Huet O, Lasocki S, Cohen B, Dahyot-Fizelier C, Chalard K, Seguin P, Chenet A, Perrouin-Verbe B, Sinha D, Asehnoune K, Feuillet F, Sébille V. Relationship between health-related quality-of-life and functional outcome 6 months after moderate to severe TBI. Ann Phys Rehabil Med 2023; 66:101715. [PMID: 36652785 DOI: 10.1016/j.rehab.2022.101715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 09/20/2022] [Accepted: 10/08/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Raphaël Cinotti
- CHU Nantes, Nantes Université, Department of Anaesthesia and critical care, Hôtel Dieu, F-44000 Nantes, France; UMR 1246 SPHERE "MethodS in Patients-centered outcomes and HEalth Research", University of Nantes, University of Tours, INSERM, IRS2 22 Boulevard Benoni Goulin, 44200 Nantes, France.
| | - Antoine Roquilly
- CHU Nantes, Nantes Université, Department of Anaesthesia and critical care, Hôtel Dieu, F-44000 Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000 Nantes, France
| | - Alice Chopin
- CHU Nantes, Nantes Université, Department of Anaesthesia and critical care, Hôtel Dieu, F-44000 Nantes, France
| | - Florian Pierre Martin
- CHU Nantes, Nantes Université, Department of Anaesthesia and critical care, Hôtel Dieu, F-44000 Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000 Nantes, France
| | - Yoanna Morato
- CHU Nantes, Nantes Université, Department of Anaesthesia and critical care, Hôtel Dieu, F-44000 Nantes, France
| | - Céline Lerebourg
- CHU Nantes, Nantes Université, Department of Anaesthesia and critical care, Hôtel Dieu, F-44000 Nantes, France
| | - Jean Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris
| | - Olivier Huet
- Centre Hospitalier Universitaire de Brest, Anaesthesia and Intensive Care Unit, Brest, France
| | - Sigismond Lasocki
- Centre Hospitalier Universitaire d'Angers, Anaesthesia and Intensive Care Unit, Angers, France
| | - Benjamin Cohen
- Centre Hospitalier Universitaire de Tours, Anaesthesia and Intensive Care Unit, Tours, France
| | - Claire Dahyot-Fizelier
- Centre Hospitalier Universitaire de Potiers, Anaesthesia and Intensive Care Unit, Poitiers, France
| | - Kevin Chalard
- Centre Hospitalier Universitaire de Montpellier, Anaesthesia and Intensive Care Unit, Montpellier, France
| | - Philippe Seguin
- Centre Hospitalier Universitaire de Rennes, Anaesthesia and Intensive Care Unit, Rennes, France
| | - Amandine Chenet
- CHU Nantes, Nantes Université, Department of Rehabilitation, Hôpital Saint-Jacques, F-44000 Nantes, France
| | - Brigitte Perrouin-Verbe
- CHU Nantes, Nantes Université, Department of Rehabilitation, Hôpital Saint-Jacques, F-44000 Nantes, France
| | - Debajyoti Sinha
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000 Nantes, France
| | - Karim Asehnoune
- CHU Nantes, Nantes Université, Department of Anaesthesia and critical care, Hôtel Dieu, F-44000 Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000 Nantes, France
| | - Fanny Feuillet
- UMR 1246 SPHERE "MethodS in Patients-centered outcomes and HEalth Research", University of Nantes, University of Tours, INSERM, IRS2 22 Boulevard Benoni Goulin, 44200 Nantes, France; Plateforme de Méthodologie et Biostatistique, Direction Recherche et Innovation, CHU Nantes, France
| | - Véronique Sébille
- UMR 1246 SPHERE "MethodS in Patients-centered outcomes and HEalth Research", University of Nantes, University of Tours, INSERM, IRS2 22 Boulevard Benoni Goulin, 44200 Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000 Nantes, France
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Almuqamam M, Novi B, Rossini CJ, Mammen A, DeSanti RL. Association of hyperchloremia and acute kidney injury in pediatric patients with moderate and severe traumatic brain injury. Childs Nerv Syst 2023; 39:1267-1275. [PMID: 36595084 DOI: 10.1007/s00381-022-05810-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/14/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Acute kidney injury (AKI) is an established complication of adult traumatic brain injury (TBI) and known risk factor for mortality. Evidence demonstrates an association between hyperchloremia and AKI in critically ill adults but studies in children are scarce. Given frequent use of hypertonic saline in the management of pediatric TBI, we believe the incidence of hyperchloremia will be high and hypothesize that it will be associated with development of AKI. METHODS Single-center retrospective cohort study was completed at an urban, level 1 pediatric trauma center. Children > 40 weeks corrected gestational age and < 21 years of age with moderate or severe TBI (presenting GCS < 13) admitted between January 2016 and December 2021 were included. Primary study outcome was presence of AKI (defined by pediatric Kidney Disease: Improving Global Outcomes criteria) within 7 days of hospitalization and compared between patients with and without hyperchloremia (serum chloride ≥ 110 mEq/L). RESULTS Fifty-two children were included. Mean age was 5.75 (S.D. 5.4) years; 60% were male (31/52); and mean presenting GCS was 6 (S.D. 2.9). Thirty-seven patients (71%) developed hyperchloremia with a mean peak chloride of 125 (S.D. 12.0) mEq/L and mean difference between peak and presenting chloride of 16 (S.D. 12.7) mEq/L. Twenty-three patients (44%) developed AKI; of those with hyperchloremia, 62% (23/37) developed AKI, while among those without hyperchloremia, 0% (0/15) developed AKI (difference 62%, 95% CI 42-82%, p < 0.001). Attributable risk of hyperchloremia leading to AKI was 62.2 (95% CI 46.5-77.8, p = 0.0015). CONCLUSION Hyperchloremia is common in the management of pediatric TBI and is associated with development of AKI. Risk appears to be associated with both the height of serum chloride and duration of hyperchloremia.
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Affiliation(s)
- Mohamed Almuqamam
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Brian Novi
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Connie J Rossini
- Department of Surgery, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Ajit Mammen
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Ryan L DeSanti
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA. .,Department of Critical Care Medicine, St. Christopher's Hospital for Children, 160 East Erie Avenue, Third Floor Suite, Office A3-20k, Philadelphia, PA, 19143, USA.
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Neurotrauma and Intracranial Pressure Management. Crit Care Clin 2023; 39:103-121. [DOI: 10.1016/j.ccc.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Launey Y, Coquet A, Lasocki S, Dahyot-Fizelier C, Huet O, Le Pabic E, Roquilly A, Seguin P. Factors associated with an unfavourable outcome in elderly intensive care traumatic brain injury patients. a retrospective multicentre study. BMC Geriatr 2022; 22:1004. [PMID: 36585608 PMCID: PMC9801582 DOI: 10.1186/s12877-022-03651-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/24/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Changes in the epidemiology of traumatic brain injury (TBI) in older patients have received attention, but limited data are available on the outcome of these patients after admission to intensive care units (ICUs). The aim of this study was to evaluate the outcomes of patients over 65 years of age who were admitted to an ICU for TBI. METHODS This was a multicentre, retrospective, observational study conducted from January 2013 to February 2019 in the surgical ICUs of 5 level 1 trauma centres in France. Patients aged ≥ 65 years who were hospitalized in the ICU for TBI with or without extracranial injuries were included. The main objective was to determine the risk factors for unfavourable neurological outcome at 3 months defined as an Extended Glasgow Outcome Scale (GOSE) score < 5. RESULTS Among the 349 intensive care patients analysed, the GOSE score at 3 months was ≤ 4 and ≥ 5 in 233 (67%) and 116 (33%) patients, respectively. The mortality rate at 3 months was 157/233 (67%), and only 7 patients (2%) fully recovered or had minor symptoms. Withdrawal or withholding of life-sustaining therapies in the ICU was identified in 140 patients (40.1%). Multivariate analysis showed that age (OR 1.09, CI 95% 1.04-1.14), male sex (OR 2.94, CI95% 1.70-5.11), baseline Glasgow Coma Scale score (OR 1.20, CI95% 1.13-1.29), injury severity score (ISS; OR 1.04, CI95% 1.02-1.06) and use of osmotherapy (OR 2.42, CI95% 1.26-4.65) were associated with unfavourable outcomes (AUC = 0.79, CI 95% [0.74-0.84]). According to multivariate analysis, the variables providing the best sensitivity and specificity were age ≥ 77 years, Glasgow Coma Scale score ≤ 9 and ISS ≥ 25 (AUC = 0.79, CI 95% [0.74-0.84]). CONCLUSIONS Among intensive care patients aged ≥ 65 years suffering from TBI, age (≥ 77 years), male sex, baseline Glasgow coma scale score (≤ 9), ISS (≥ 25) and use of osmotherapy were predictors of unfavourable neurological outcome. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04651803. Registered 03/12/2020. Retrospectively registered.
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Affiliation(s)
- Y Launey
- grid.414271.5Service de Réanimation Chirurgicale. CHU de Rennes. Hôpital Pontchaillou. 2, Rue Henri Le Guilloux, 35033 Rennes Cedex, France
| | - A Coquet
- grid.414271.5Service de Réanimation Chirurgicale. CHU de Rennes. Hôpital Pontchaillou. 2, Rue Henri Le Guilloux, 35033 Rennes Cedex, France
| | - S Lasocki
- grid.411147.60000 0004 0472 0283Département d’Anesthésie Réanimation, CHU de Angers, Angers, France
| | - C Dahyot-Fizelier
- grid.411162.10000 0000 9336 4276Département d’Anesthésie Réanimation, CHU de Poitiers, Poitiers, France
| | - O Huet
- grid.411766.30000 0004 0472 3249Département d’Anesthésie Réanimation, CHU de Brest, Brest, France
| | - E Le Pabic
- grid.411154.40000 0001 2175 0984Centre d’Investigation Clinique, CHU de Rennes, 2 Rue Henri Le Guilloux, 35000 Rennes, France
| | - A Roquilly
- grid.277151.70000 0004 0472 0371Département d’Anesthésie Réanimation, CHU de Nantes, Nantes, France
| | - P Seguin
- grid.414271.5Service de Réanimation Chirurgicale. CHU de Rennes. Hôpital Pontchaillou. 2, Rue Henri Le Guilloux, 35033 Rennes Cedex, France
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DeHoff G, Lau W. Medical management of cerebral edema in large hemispheric infarcts. Front Neurol 2022; 13:857640. [PMID: 36408500 PMCID: PMC9672377 DOI: 10.3389/fneur.2022.857640] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/26/2022] [Indexed: 09/08/2024] Open
Abstract
Acute ischemic stroke confers a high burden of morbidity and mortality globally. Occlusion of large vessels of the anterior circulation, namely the intracranial carotid artery and middle cerebral artery, can result in large hemispheric stroke in ~8% of these patients. Edema from stroke can result in a cascade effect leading to local compression of capillary perfusion, increased stroke burden, elevated intracranial pressure, herniation and death. Mortality from large hemispheric stroke is generally high and surgical intervention may reduce mortality and improve good outcomes in select patients. For those patients who are not eligible candidates for surgical decompression either due timing, medical co-morbidities, or patient and family preferences, the mainstay of medical management for cerebral edema is hyperosmolar therapy. Other neuroprotectants for cerebral edema such as glibenclamide are under investigation. This review will discuss current guidelines and evidence for medical management of cerebral edema in large hemispheric stroke as well as discuss important neuromonitoring and critical care management targeted at reducing morbidity and mortality for these patients.
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Affiliation(s)
- Grace DeHoff
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | - Winnie Lau
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
- Department of Neurosurgery, University of North Carolina, Chapel Hill, NC, United States
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Zhao J, Song C, Li D, Yang X, Yu L, Wang K, Wu J, Wang X, Li D, Zhang B, Li B, Guo J, Feng W, Fu F, Gu X, Qian J, Li J, Yuan X, Liu Q, Chen J, Wang X, Liu Y, Wei D, Wang L, Shang L, Yang F, Jiang W. Efficacy and safety of glibenclamide therapy after intracerebral haemorrhage (GATE-ICH): A multicentre, prospective, randomised, controlled, open-label, blinded-endpoint, phase 2 clinical trial. EClinicalMedicine 2022; 53:101666. [PMID: 36177443 PMCID: PMC9513728 DOI: 10.1016/j.eclinm.2022.101666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/30/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Glibenclamide is a promising agent for treating brain oedema, but whether it improves clinical outcomes in patients with intracerebral haemorrhage (ICH) remains unclear. In this study, we aimed to explore the efficacy and safety of glibenclamide treatment in patients with acute ICH. METHODS The Glibenclamide Advantage in Treating Oedema after Intracerebral Haemorrhage (GATE-ICH) study was a randomised controlled phase 2 clinical trial conducted in 26 hospitals in the northwest of China, recruiting patients with acute ganglia ICH no more than 72 h after onset from Dec 12, 2018 to Sept 23, 2020. During the first 7 days after enrolment, patients randomly assigned to the glibenclamide group were given glibenclamide orally (1.25 mg, 3/day) and standard care, while patients randomly assigned to the control group were given standard care alone. The computer-generated randomisation sequence was prepared by a statistician not involved in the rest of the study. Randomisation was computer-generated with a block size of four. The allocation results were unblinded to participants and investigators. The primary outcome was the percentage of patients with poor outcome (defined as modified Rankin Scale [mRS] score of ≥3) at day 90. The trial was registered at ClinicalTrials.gov (NCT03741530). FINDINGS 220 participants were randomised and 200 participants (mean [standard deviation] age, 56 [11] years; sex, 128 [64.0%] male and 72 [36.0%] female) were included in the final analysis, with 101 participants randomly assigned to the control group and 99 to the glibenclamide group. The incidence of poor outcome at day 90 was 20/99 (20.2%) in glibenclamide group and 30/101 (29.7%) in control group (absolute difference, 9.5%; 95% confidence interval [CI], -3.2%-21.8%; P = 0.121) with adjusted odds ratios of 0.54 (95% CI, 0.24-1.20; P = 0.129). No significant difference was found in the overall rates of adverse events or serious adverse events between groups. However, the incidence of asymptomatic hypoglycaemia was significantly higher in glibenclamide group than control group (15/99 [15.2%] vs 0/101 [0.0%]; absolute difference, 15.2%; 95% CI, 7.5%-24.1%; P < 0.001). INTERPRETATION Our study provides no evidence that glibenclamide (1.25 mg, 3/day) significantly reduces the proportion of poor outcome at day 90 after ICH. In addition, glibenclamide could result in higher incidence of hypoglycaemia. Larger trials of glibenclamide with optimised medication regimen are warranted. FUNDING Shaanxi Province Key Research and Development Project (2017DCXL-SF-02-02) and Shaanxi Province Special Support Program for Leading Talents in Scientific and Technological Innovation (tzjhjw).
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Affiliation(s)
- Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Changgeng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Deshuai Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiai Yang
- Department of Neurology, Ankang Central Hospital, Ankang 725000, China
| | - Liping Yu
- Department of Neurology, The First People's Hospital of Xianyang, Xianyang 712000, China
| | - Kangjun Wang
- Department of Neurology, Hanzhong Central Hospital, Hanzhong 723000, China
| | - Jun Wu
- Department of Neurology, Xianyang Central Hospital, Xianyang 712000, China
| | - Xiaofeng Wang
- Department of Neurosurgery, The PLA 987 Hospital, Baoji 721000, China
| | - Dongsong Li
- Department of Neurology, Ankang People's Hospital, Ankang 725000, China
| | - Bo Zhang
- Department of Neurology, Shangluo Central Hospital, Shangluo 726000, China
| | - Binyong Li
- Department of Neurology, Xixiang Hospital, Hanzhong 723000, China
| | - Jun Guo
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Weikui Feng
- Department of Neurology, Shaanxi Province Mianxian Hospital, Hanzhong 723000, China
| | - Feng Fu
- Department of Neurology, 215 Hospital of Shaanxi NI, Xianyang 712021, China
| | - Xinrong Gu
- Department of Neurology, Tianjin Hospital of Ningqiang, Hanzhong 723000, China
| | - Jian Qian
- Department of Neurology, Xi'an No.4 Hospital, Xi'an 710004, China
| | - Jialong Li
- Department of Neurology, Baoji No.3 Hospital, Baoji 721000, China
| | - Xiangjun Yuan
- Department of Neurology, Weinan Central Hospital, Weinan 714000, China
| | - Qiuwu Liu
- Department of Neurology, Xi'an 141 Hospital, Xi'an 710499, China
| | - Jiang Chen
- Department of Neurology, Shaanxi Aerospace Hospital, Xi'an 710025, China
| | - Xiaocheng Wang
- Department of Neurology, Yulin No.2 Hospital, Yulin 719000, China
| | - Yi Liu
- Department of Neurology, Ankang Central Hospital, Ankang 725000, China
| | - Dong Wei
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Ling Wang
- Department of Health Statistics, Fourth Military Medical University, Xi'an, China
| | - Lei Shang
- Department of Health Statistics, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
- The Shaanxi Cerebrovascular Disease Clinical Research Centre, Xi'an 710032, China
- Corresponding authors at: Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
- The Shaanxi Cerebrovascular Disease Clinical Research Centre, Xi'an 710032, China
- Corresponding authors at: Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
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Yan XJ, Zhan CP, Lv Y, Mao DD, Zhou RC, Xv YM, Yu GF. Utility of serum nuclear factor erythroid 2-related factor 2 as a potential prognostic biomarker of severe traumatic brain injury in adults: A prospective cohort study. Front Neurol 2022; 13:1013062. [PMID: 36388174 PMCID: PMC9663921 DOI: 10.3389/fneur.2022.1013062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 10/10/2022] [Indexed: 12/01/2022] Open
Abstract
Objective Nuclear factor erythroid 2-related factor 2 (Nrf2) may harbor endogenous neuroprotective role. We strived to ascertain the prognostic significance of serum Nrf2 in severe traumatic brain injury (sTBI). Methods This prospective cohort study included 105 controls and 105 sTBI patients, whose serum Nrf2 levels were quantified. Its relations to traumatic severity and 180-day overall survival, mortality, and poor prognosis (extended Glasgow Outcome Scale score 1–4) were discerned using multivariate analysis. Results There was a substantial enhancement of serum Nrf1 levels of patients (median, 10.9 vs. 3.3 ng/ml; P < 0.001), as compared to controls. Serum Nrf2 levels were independently correlative to Rotterdam computed tomography (CT) scores (ρ = 0.549, P < 0.001; t = 2.671, P = 0.009) and Glasgow Coma Scale (GCS) scores (ρ = −0.625, P < 0.001; t = −3.821, P < 0.001). Serum Nrf2 levels were significantly higher in non-survivors than in survivors (median, 12.9 vs. 10.3 ng/ml; P < 0.001) and in poor prognosis patients than in good prognosis patients (median, 12.5 vs. 9.4 ng/ml; P < 0.001). Patients with serum Nrf2 levels > median value (10.9 ng/ml) had markedly shorter 180-day overall survival time than the other remainders (mean, 129.3 vs. 161.3 days; P = 0.002). Serum Nrf2 levels were independently predictive of 180-day mortality (odds ratio, 1.361; P = 0.024), overall survival (hazard ratio, 1.214; P = 0.013), and poor prognosis (odds ratio, 1.329; P = 0.023). Serum Nrf2 levels distinguished the risks of 180-day mortality and poor prognosis with areas under receiver operating characteristic curve (AUCs) at 0.768 and 0.793, respectively. Serum Nrf2 levels > 10.3 ng/ml and 10.8 ng/ml discriminated patients at risk of 180-day mortality and poor prognosis with the maximum Youden indices of 0.404 and 0.455, respectively. Serum Nrf2 levels combined with GCS scores and Rotterdam CT scores for death prediction (AUC, 0.897; 95% CI, 0.837–0.957) had significantly higher AUC than GCS scores (P = 0.028), Rotterdam CT scores (P = 0.007), or serum Nrf2 levels (P = 0.006) alone, and the combination for poor outcome prediction (AUC, 0.889; 95% CI, 0.831–0.948) displayed significantly higher AUC than GCS scores (P = 0.035), Rotterdam CT scores (P = 0.006), or serum Nrf2 levels (P = 0.008) alone. Conclusion Increased serum Nrf2 levels are tightly associated with traumatic severity and prognosis, supporting the considerable prognostic role of serum Nrf2 in sTBI.
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Turgeon AF, Fergusson DA, Clayton L, Patton MP, Zarychanski R, English S, Docherty A, Walsh T, Griesdale D, Kramer AH, Scales D, Burns KEA, Boyd JG, Marshall JC, Kutsogiannis DJ, Ball I, Hébert PC, Lamontagne F, Costerousse O, St-Onge M, Lessard Bonaventure P, Moore L, Neveu X, Rigamonti A, Khwaja K, Green RS, Laroche V, Fox-Robichaud A, Lauzier F. Haemoglobin transfusion threshold in traumatic brain injury optimisation (HEMOTION): a multicentre, randomised, clinical trial protocol. BMJ Open 2022; 12:e067117. [PMID: 36216432 PMCID: PMC9557781 DOI: 10.1136/bmjopen-2022-067117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the leading cause of mortality and long-term disability in young adults. Despite the high prevalence of anaemia and red blood cell transfusion in patients with TBI, the optimal haemoglobin (Hb) transfusion threshold is unknown. We undertook a randomised trial to evaluate whether a liberal transfusion strategy improves clinical outcomes compared with a restrictive strategy. METHODS AND ANALYSIS HEMOglobin Transfusion Threshold in Traumatic Brain Injury OptimizatiON is an international pragmatic randomised open label blinded-endpoint clinical trial. We will include 742 adult patients admitted to an intensive care unit (ICU) with an acute moderate or severe blunt TBI (Glasgow Coma Scale ≤12) and a Hb level ≤100 g/L. Patients are randomly allocated using a 1:1 ratio, stratified by site, to a liberal (triggered by Hb ≤100 g/L) or a restrictive (triggered by Hb ≤70 g/L) transfusion strategy applied from the time of randomisation to the decision to withdraw life-sustaining therapies, ICU discharge or death. Primary and secondary outcomes are assessed centrally by trained research personnel blinded to the intervention. The primary outcome is the Glasgow Outcome Scale extended at 6 months. Secondary outcomes include overall functional independence measure, overall quality of life (EuroQoL 5-Dimension 5-Level; EQ-5D-5L), TBI-specific quality of life (Quality of Life after Brain Injury; QOLIBRI), depression (Patient Health Questionnaire; PHQ-9) and mortality. ETHICS AND DISSEMINATION This trial is approved by the CHU de Québec-Université Laval research ethics board (MP-20-2018-3706) and ethic boards at all participating sites. Our results will be published and shared with relevant organisations and healthcare professionals. TRIAL REGISTRATION NUMBER NCT03260478.
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Affiliation(s)
- Alexis F Turgeon
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Dean A Fergusson
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lucy Clayton
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Centre de Recherche du CHU Sainte-Justine, Montréal, Québec, Canada
| | - Marie-Pier Patton
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Hematology/Oncology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Shane English
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Annemarie Docherty
- Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Timothy Walsh
- Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Center for Clinical Epidemiology & Evaluation, Vancouver General Hospital, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Andreas H Kramer
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Damon Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Ontario, Canada
| | - John Gordon Boyd
- Department of Medicine, Division of Neurology, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, Division of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Ian Ball
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Paul C Hébert
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Centre de Recherche du CHU de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Olivier Costerousse
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
| | - Maude St-Onge
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec City, Québec, Canada
| | - Paule Lessard Bonaventure
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Surgery, Division of Neurosurgery, Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec City, Québec, Canada
| | - Xavier Neveu
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
| | - Andrea Rigamonti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kosar Khwaja
- Department of Critical Care Medicine, McGill University, Montréal, Québec, Canada
| | - Robert S Green
- Departments of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vincent Laroche
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Medicine, Université Laval, Québec City, Québec, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Francois Lauzier
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
- Department of Medicine, Université Laval, Québec City, Québec, Canada
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Salted or sweet? Hypertonic saline or mannitol for treatment of intracranial hypertension. Curr Opin Anaesthesiol 2022; 35:555-561. [PMID: 35787533 DOI: 10.1097/aco.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW The aim of this review article is to present current recommendations regarding the use of hypertonic saline and mannitol for the treatment of intracranial hypertension. RECENT FINDINGS In recent years, a significant number of studies have been published comparing hypertonic saline with mannitol in patients with acute increased intracranial pressure, mostly caused by traumatic brain injury. Albeit several randomized controlled trials, systematic reviews and meta-analysis support hypertonic saline as more effective than mannitol in reducing intracranial pressure, no clear benefit in regards to the long-term neurologic outcome of these patients has been reported. SUMMARY Identifying and treating increased intracranial pressure is imperative in neurocritical care settings and proper management is essential to improve long-term outcomes. Currently, there is insufficient evidence from comparative studies to support a formal recommendation on the use of any specific hyperosmolar medication in patients with acute increased intracranial pressure.
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Moyer JD, Lee P, Bernard C, Henry L, Lang E, Cook F, Planquart F, Boutonnet M, Harrois A, Gauss T. Machine learning-based prediction of emergency neurosurgery within 24 h after moderate to severe traumatic brain injury. World J Emerg Surg 2022; 17:42. [PMID: 35922831 PMCID: PMC9351267 DOI: 10.1186/s13017-022-00449-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/27/2022] [Indexed: 12/03/2022] Open
Abstract
Background Rapid referral of traumatic brain injury (TBI) patients requiring emergency neurosurgery to a specialized trauma center can significantly reduce morbidity and mortality. Currently, no model has been reported to predict the need for acute neurosurgery in severe to moderate TBI patients. This study aims to evaluate the performance of Machine Learning-based models to establish to predict the need for neurosurgery procedure within 24 h after moderate to severe TBI. Methods Retrospective multicenter cohort study using data from a national trauma registry (Traumabase®) from November 2011 to December 2020. Inclusion criteria correspond to patients over 18 years old with moderate or severe TBI (Glasgow coma score ≤ 12) during prehospital assessment. Patients who died within the first 24 h after hospital admission and secondary transfers were excluded. The population was divided into a train set (80% of patients) and a test set (20% of patients). Several approaches were used to define the best prognostic model (linear nearest neighbor or ensemble model). The Shapley Value was used to identify the most relevant pre-hospital variables for prediction. Results 2159 patients were included in the study. 914 patients (42%) required neurosurgical intervention within 24 h. The population was predominantly male (77%), young (median age 35 years [IQR 24–52]) with severe head injury (median GCS 6 [3–9]). Based on the evaluation of the predictive model on the test set, the logistic regression model had an AUC of 0.76. The best predictive model was obtained with the CatBoost technique (AUC 0.81). According to the Shapley values method, the most predictive variables in the CatBoost were a low initial Glasgow coma score, the regression of pupillary abnormality after osmotherapy, a high blood pressure and a low heart rate. Conclusion Machine learning-based models could predict the need for emergency neurosurgery within 24 h after moderate and severe head injury. Potential clinical benefits of such models as a decision-making tool deserve further assessment. The performance in real-life setting and the impact on clinical decision-making of the model requires workflow integration and prospective assessment. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00449-5.
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Affiliation(s)
- Jean-Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
| | - Patrick Lee
- Capgemini Invent, Insight Driven Enterprise, Focused on Data and Artificial Intelligence Services, Paris, France
| | - Charles Bernard
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Lois Henry
- Department of Anesthesiology and Critical Care, Lille, France
| | - Elodie Lang
- Department of Anesthesiology and Critical Care, Hôpital Européen Georges Pompidou, Paris, France
| | - Fabrice Cook
- Department of Anesthesiology and Critical Care, Hôpital Henri Mondor, Créteil, France
| | - Fanny Planquart
- Department of Anesthesiology and Critical Care, Strasbourg, France
| | - Mathieu Boutonnet
- Intensive Care Unit, Percy Military Teaching Hospital, 101 Avenue Henri Barbusse, 92140, Clamart, France.,Val de Grace Academy, Place Alphonse Laveran, 75005, Paris, France
| | - Anatole Harrois
- Department of Anesthesiology and Critical Care, APH-HP, Bicêtre Hôpitaux Universitaires Paris-Sud, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Tobias Gauss
- Déchocage- Bloc des urgences, Pole Anesthésie- Réanimation, CHU Grenoble Alpes, La Tronche, France
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Fitzgerald M, Ponsford J, Lannin NA, O'Brien TJ, Cameron P, Cooper DJ, Rushworth N, Gabbe B. AUS-TBI: The Australian Health Informatics Approach to Predict Outcomes and Monitor Intervention Efficacy after Moderate-to-Severe Traumatic Brain Injury. Neurotrauma Rep 2022; 3:217-223. [PMID: 35919508 PMCID: PMC9279124 DOI: 10.1089/neur.2022.0002] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Predicting and optimizing outcomes after traumatic brain injury (TBI) remains a major challenge because of the breadth of injury characteristics and complexity of brain responses. AUS-TBI is a new Australian Government–funded initiative that aims to improve personalized care and treatment for children and adults who have sustained a TBI. The AUS-TBI team aims to address a number of key knowledge gaps, by designing an approach to bring together data describing psychosocial modulators, social determinants, clinical parameters, imaging data, biomarker profiles, and rehabilitation outcomes in order to assess the influence that they have on long-term outcome. Data management systems will be designed to track a broad range of suitable potential indicators and outcomes, which will be organized to facilitate secure data collection, linkage, storage, curation, management, and analysis. It is believed that these objectives are achievable because of our consortium of highly committed national and international leaders, expert committees, and partner organizations in TBI and health informatics. It is anticipated that the resulting large-scale data resource will facilitate personalization, prediction, and improvement of outcomes post-TBI.
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Affiliation(s)
- Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Nedlands, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Monash Epworth Rehabilitation Research Centre–Epworth Healthcare, Richmond, Victoria, Australia
| | - Natasha A. Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Terence J. O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - D. James Cooper
- Australian and New Zealand Intensive Care Research Centre Recovery Program (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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