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Leung CH, Rizoli SB, Trypcic S, Rhind SG, Battista AP, Ailenberg M, Rotstein OD. Effect of remote ischemic conditioning on the immune-inflammatory profile in patients with traumatic hemorrhagic shock in a randomized controlled trial. Sci Rep 2023; 13:7025. [PMID: 37120600 PMCID: PMC10148877 DOI: 10.1038/s41598-023-33681-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/17/2023] [Indexed: 05/01/2023] Open
Abstract
Resuscitation induced ischemia/reperfusion predisposes trauma patients to systemic inflammation and organ dysfunction. We investigated the effect of remote ischemic conditioning (RIC), a treatment shown to prevent ischemia/reperfusion injury in experimental models of hemorrhagic shock/resuscitation, on the systemic immune-inflammatory profile in trauma patients in a randomized trial. We conducted a prospective, single-centre, double-blind, randomized, controlled trial involving trauma patients sustaining blunt or penetrating trauma in hemorrhagic shock admitted to a Level 1 trauma centre. Patients were randomized to receive RIC (four cycles of 5-min pressure cuff inflation at 250 mmHg and deflation on the thigh) or a Sham intervention. The primary outcomes were neutrophil oxidative burst activity, cellular adhesion molecule expression, and plasma levels of myeloperoxidase, cytokines and chemokines in peripheral blood samples, drawn at admission (pre-intervention), 1 h, 3 h, and 24 h post-admission. Secondary outcomes included ventilator, ICU and hospital free days, incidence of nosocomial infections, 24 h and 28 day mortality. 50 eligible patients were randomized; of which 21 in the Sham group and 18 in the RIC group were included in the full analysis. No treatment effect was observed between Sham and RIC groups for neutrophil oxidative burst activity, adhesion molecule expression, and plasma levels of myeloperoxidase and cytokines. RIC prevented significant increases in Th2 chemokines TARC/CCL17 (P < 0.01) and MDC/CCL22 (P < 0.05) at 24 h post-intervention in comparison to the Sham group. Secondary clinical outcomes were not different between groups. No adverse events in relation to the RIC intervention were observed. Administration of RIC was safe and did not adversely affect clinical outcomes. While trauma itself modified several immunoregulatory markers, RIC failed to alter expression of the majority of markers. However, RIC may influence Th2 chemokine expression in the post resuscitation period. Further investigation into the immunomodulatory effects of RIC in traumatic injuries and their impact on clinical outcomes is warranted.ClinicalTrials.gov number: NCT02071290.
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Affiliation(s)
- C H Leung
- The Keenan Research Centre for Biomedical Science and the Department of Surgery, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Li Ka Shing Knowledge Institute 3-305, Toronto, ON, M5B 1W8, Canada
| | - S B Rizoli
- The Keenan Research Centre for Biomedical Science and the Department of Surgery, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Li Ka Shing Knowledge Institute 3-305, Toronto, ON, M5B 1W8, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - S Trypcic
- The Keenan Research Centre for Biomedical Science and the Department of Surgery, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Li Ka Shing Knowledge Institute 3-305, Toronto, ON, M5B 1W8, Canada
| | - S G Rhind
- The Defence Research and Development Canada, Toronto Research Centre, Toronto, Canada
| | - A P Battista
- The Defence Research and Development Canada, Toronto Research Centre, Toronto, Canada
| | - M Ailenberg
- The Keenan Research Centre for Biomedical Science and the Department of Surgery, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Li Ka Shing Knowledge Institute 3-305, Toronto, ON, M5B 1W8, Canada.
| | - O D Rotstein
- The Keenan Research Centre for Biomedical Science and the Department of Surgery, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Li Ka Shing Knowledge Institute 3-305, Toronto, ON, M5B 1W8, Canada.
- Department of Surgery, University of Toronto, Toronto, Canada.
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McGeary DD, Penzien DB, Resick PA, McGeary CA, Jaramillo CA, Eapen BC, Young-McCaughan S, Nabity PS, Moring JC, Houle TT, Keane TM, Peterson AL. Study design for a randomized clinical trial of cognitive-behavioral therapy for posttraumatic headache. Contemp Clin Trials Commun 2021; 21:100699. [PMID: 33490706 PMCID: PMC7806520 DOI: 10.1016/j.conctc.2021.100699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/06/2020] [Accepted: 01/01/2021] [Indexed: 11/29/2022] Open
Abstract
Posttraumatic headache (PTH) is a common debilitating condition arising from head injury and is highly prevalent among military service members and veterans with traumatic brain injury (TBI). Diagnosis and treatment for PTH is still evolving, and surprisingly little is known about the putative mechanisms that drive these headaches. This manuscript describes the design of a randomized clinical trial of two nonpharmacological (i.e., behavioral) interventions for posttraumatic headache. Design of this trial required careful consideration of PTH diagnosis and inclusion criteria, which was challenging due to the lack of standard clinical characteristics in PTH unique from other types of headaches. The treatments under study differed in clinical focus and dose (i.e., number of treatment sessions), but the trial was designed to balance the treatments as well as possible. Finally, while the primary endpoints for pain research can vary from assessments of pain intensity to objective and subjective functional measures, this trial of PTH interventions chose carefully to establish clinically relevant endpoints and to maximize the opportunity to detect significant differences between groups with two primary outcomes. All these issues are discussed in this manuscript.
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Key Words
- AUDIT, Alcohol Use Disorders Identification Test-Self Report
- B-IPF, Brief Inventory of Psychosocial Functioning
- CAP, Consortium to Alleviate PTSD
- CAPS-5, Clinician-Administered PTSD Scale for DSM-5
- CBT, cognitive-behavioral therapy
- CCBT, clinic-based cognitive-behavioral therapy intervention for headache
- CEQ, Credibility and Expectancy Questionnaire
- CGRP, calcitonin gene-related peptide
- CPRS, Computerized Patient Record System
- CPT, Cognitive Processing Therapy
- CRIS, Community Reintegration of Injured Service Members
- DRRI-2-D, Deployment Risk and Resilience Inventory-2-Deployment Environment
- DRRI-2-P, Deployment Risk and Resilience Inventory-Postbattle Experiences
- DSI-SS, Depressive Symptom Index-Suicide Subscale
- DoD, U.S. Department of Defense
- GAD-7, Generalized Anxiety Disorder Screener
- GLM, general linear mixed
- HIPAA, Health Insurance Portability and Accountability Act
- HIT-6, Headache Impact Test
- HMSE, Headache Management Self-Efficacy Scale
- HSLC, Headache-Specific Locus of Control Scale
- Headache
- ICHD-2, International Classification of Headache Disorders, 2nd Edition
- ICHD-3, International Classification of Headache Disorders, 3rd Edition
- IRB, institutional review board
- ISI, Insomnia Severity Index
- ITT, intent to treat
- LEC-5, Life Events Checklist for DSM-5
- NIH, National Institutes of Health
- NSI, Neurobehavioral Symptom Inventory
- OSU TBI-ID-SF, Ohio State University TBI Identification Method-Interview Form
- PCL-5, PTSD Checklist for DSM-5
- PHQ-15, Patient Health Questionnaire-15
- PHQ-9, Patient Health Questionnaire-9 Item
- PP, per protocol
- PRC, Polytrauma Rehabilitation Center
- PROMIS, Patient-Reported Outcomes Measurement Information System
- PTCI, Posttraumatic Cognitions Inventory
- PTH, posttraumatic headache
- PTHA Study, posttraumatic headache and PTSD study
- PTSD
- PTSD, posttraumatic stress disorder
- Polymorbidity
- QDS, Quick Drinking Screen
- RSES, Response to Stressful Experiences Scale
- SDIH-R, Structured Diagnostic Interview for Headache-Revised, Brief Version
- SITBI, Self-Injurious Thoughts and Behaviors Interview – Short Form
- STOP, Snoring, Tired, Observed, Blood Pressure
- TAU, treatment as usual
- TBI, traumatic brain injury
- Traumatic brain injury
- VA, U.S. Department of Veterans Affairs
- VHCS, Veterans Health Care System
- VR-12, Veterans RAND 12-Item Health Survey
- Veterans
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Affiliation(s)
- Donald D. McGeary
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Rehabilitation Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Donald B. Penzien
- Departments of Psychiatry and Behavioral Medicine & Neurology, Wake Forest University, Winston-Salem, NC, USA
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Cindy A. McGeary
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Carlos A. Jaramillo
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Rehabilitation Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Blessen C. Eapen
- Greater Los Angeles Veterans Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, PM&R, Los Angeles, CA, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Paul S. Nabity
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - John C. Moring
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Timothy T. Houle
- Department of Anaesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Terence M. Keane
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA
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