Economic Evaluations in the Diagnosis and Management of Traumatic Brain Injury: A Systematic Review and Analysis of Quality

Clinical decision rules in predicting computed tomography scan findings and need for neurosurgical intervention in mild traumatic brain injury: a prospective observational study

PURPOSE

In this study, we will compare the diagnostic values of head CT decision rules in predicting the findings of CT scans in a prospective multicenter study in university emergency departments in Iran.

METHODS

The primary outcome was any traumatic lesion findings in brain CT scans, and the secondary outcomes were death, the need for mechanical ventilation, and neurosurgical intervention. Decision rules including the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), National Institute for Health and Clinical Excellence (NICE), National Emergency X-Radiography Utilization Study (NEXUS), and Neurotraumatology Committee of the World Federation of Neurosurgical Societies (NCWFNS) were compared for the main outcomes.

RESULTS

In total, 434 mild TBI patients were enrolled in the study. The NCWFNS had the highest sensitivity (91.14%) and the lowest specificity (39.42%) for predicting abnormal finding in CT scan compared to other models. While the NICE obtained the lowest sensitivity (79.75%), it was associated with the highest specificity (66.67%). All model performances were improved when administered to predict neurosurgical intervention among patients with GCS 13-15. NEXUS (AUC 0.862, 95% CI 0.799-0.924) and NCWFNS (AUC 0.813, 95% CI 0.723-0.903) had the best performance among all evaluated models.

CONCLUSION

The NCWFNS and the NEXUS decision rules performed better than the CCHR and NICE guidelines for predicting any lesion in the CT imaging and neurosurgical intervention among patients with mTBI with GCS 13-15. For a subset of mTBI patients with GCS 15, the NOC criteria have higher sensitivity for abnormal CT imaging, but lower specificity and more requested CTs.

Imaging predictors of hemorrhagic progression of a contusion after traumatic brain injury: a systematic review and meta-analysis

The hemorrhagic progression of a contusion (HPC) after Traumatic brain injury (TBI) is one of the important causes of death in trauma patients. The purpose of this meta-analysis was to evaluate the predictive effect of imaging features of Computed tomography (CT) on HPC after TBI. A comprehensive systematic search was performed using PubMed, EMBASE, and WEB OF SCIENCE databases to identify all relevant literature. A total of 8 studies involving 2543 patients were included in this meta-analysis. Meta-analysis showed that subarachnoid hemorrhage (OR 3.28; 95% CI 2.57-4.20), subdural hemorrhage (OR 4.35; 95% CI 3.29-5.75), epidural hemorrhage (OR 1.47;95% CI 1.15-1.89), contrast extravasation (OR 11.81; 95% CI 4.86-28.71) had a predictive effect on the occurrence of HPC. Skull fracture (OR 1.64; 95% CI 0.84-3.19) showed no statistical significance, and midline displacement > 5 mm (OR 4.66; 95% CI 1.87-11.62) showed high heterogeneity. The results of this meta-analysis showed that some imaging features were effective predictors of HPC after TBI. Well-designed prospective studies are needed to more accurately assess the effective predictors of HPC after TBI.

The Association Between Gender and Clinical Outcomes in Patients With Moderate to Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis

INTRODUCTION

Traumatic brain injuries (TBIs) are a significant cause of morbidity and mortality in the United States. but have a disproportionate impact on patients based on gender. This systematic review and meta-analysis aim to compare gender differences in clinical outcomes between male and female adult trauma patients with moderate and severe TBI.

METHODS

Studies assessing gender differences in outcomes following TBIs on PubMed, Google Scholar, EMBASE, and ProQuest were searched. Meta-analysis was performed for outcomes including in-hospital mortality, hospital length of stay, intensive care unit length of stay, and Glasgow outcome scale (GOS) at 6 mo.

RESULTS

Eight studies were included for analysis with 26,408 female and 63,393 male patients. Meta-analysis demonstrated that males had a significantly lower risk of mortality than females (RR: 0.88; 95% CI 0.78, 0.99; P = 0.0001). Females had a shorter hospital length of stay (mean difference -1.4 d; 95% CI - 1.6 d, -1.2 d). No significant differences were identified in intensive care unit length of stay (mean difference -3.0 d; 95% CI -7.0 d, 1.1 d; P = 0.94) or GOS at 6 mo (mean difference 0.2 d; 95% CI -0.9 d, 1.4 d; P = 1).

CONCLUSIONS

Compared to male patients, female patients with moderate and severe TBI had a significantly higher in-hospital mortality risk. There were no significant differences in long-term outcomes between genders based on GOS at 6 mo. These findings warrant further investigation into the etiology of these gender disparities and their impact on additional clinical outcome measures.

Intramural Healthcare Consumption and Costs After Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

Traumatic brain injury (TBI) is a global public health problem and a leading cause of mortality, morbidity, and disability. The increasing incidence combined with the heterogeneity and complexity of TBI will inevitably place a substantial burden on health systems. These findings emphasize the importance of obtaining accurate and timely insights into healthcare consumption and costs on a multi-national scale. This study aimed to describe intramural healthcare consumption and costs across the full spectrum of TBI in Europe. The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) core study is a prospective observational study conducted in 18 countries across Europe and in Israel. The baseline Glasgow Coma Scale (GCS) was used to differentiate patients by brain injury severity in mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS ≤8) TBI. We analyzed seven main cost categories: pre-hospital care, hospital admission, surgical interventions, imaging, laboratory, blood products, and rehabilitation. Costs were estimated based on Dutch reference prices and converted to country-specific unit prices using gross domestic product (GDP)-purchasing power parity (PPP) adjustment. Mixed linear regression was used to identify between-country differences in length of stay (LOS), as a parameter of healthcare consumption. Mixed generalized linear models with gamma distribution and log link function quantified associations of patient characteristics with higher total costs. We included 4349 patients, of whom 2854 (66%) had mild, 371 (9%) had moderate, and 962 (22%) had severe TBI. Hospitalization accounted for the largest part of the intramural consumption and costs (60%). In the total study population, the mean LOS was 5.1 days at the intensive care unit (ICU) and 6.3 days at the ward. For mild, moderate, and severe TBI, mean LOS was, respectively, 1.8, 8.9, and 13.5 days at the ICU and 4.5, 10.1, and 10.3 days at the ward. Other large contributors to the total costs were rehabilitation (19%) and intracranial surgeries (8%). Total costs increased with higher age and greater trauma severity (mild; €3,800 [IQR €1,400-14,000], moderate; €37,800 [IQR €14,900-€74,200], severe; €60,400 [IQR €24,400-€112,700]). The adjusted analysis showed that female patients had lower costs than male patients (odds ratio (OR) 0.80 [CI 0.75-1.85]). Increasing TBI severity was associated with higher costs, OR 1.46 (confidence interval [CI] 1.31-1.63) and OR 1.67 [CI 1.52-1.84] for moderate and severe patients, respectively. A worse pre-morbid overall health state, increasing age and more severe systemic trauma, expressed in the Injury Severity Score (ISS), were also significantly associated with higher costs. Intramural costs of TBI are significant and are profoundly driven by hospitalization. Costs increased with trauma severity and age, and male patients incurred higher costs. Reducing LOS could be targeted with advanced care planning, in order to provide cost-effective care.

Update on Pediatric Mild Traumatic Brain Injury in Rural and Underserved Regions: A Global Perspective

BACKGROUND

Mild traumatic brain injury (MTBI) causes morbidity and disability worldwide. Pediatric patients are uniquely vulnerable due to developmental and psychosocial factors. Reduced healthcare access in rural/underserved communities impair management and outcome. A knowledge update relevant to current gaps in care is critically needed to develop targeted solutions.

METHODS

The National Library of Medicine PubMed database was queried using comprehensive search terms (("mild traumatic brain injury" or "concussion") and ("rural" or "low-income" or "underserved") and ("pediatric" or "child/children")) in the title, abstract, and Medical Subject Headings through December 2022. Fifteen articles on rural/underserved pediatric MTBI/concussion not covered in prior reviews were examined and organized into four topical categories: epidemiology, care practices, socioeconomic factors, and telehealth.

RESULTS

Incidences are higher for Individuals in rural regions, minorities, and those aged 0-4 years compared to their counterparts, and are increasing over time. Rural healthcare utilization rates generally exceed urban rates, and favor emergency departments (vs. primary care) for initial injury assessment. Management guidelines require customization to resource-constrained settings for implementation and adoption. Decreased community recognition of the seriousness of injury is a consensus challenge to care provision by clinicians. Low parental education and income were correlated with decreased MTBI knowledge and worse outcome. Telehealth protocols for triage/consultation and rehabilitation were feasible in improving care delivery to rural and remote settings.

CONCLUSIONS

Pediatric MTBI/concussion patients in rural/underserved regions experience increased risks of injury, geographic and financial healthcare barriers, and poorer outcomes. Globally, under-reporting of injury has hindered epidemiological understanding. Ongoing MTBI education should be implemented for rural caregivers, schools, and low-income populations to improve community awareness. Telehealth can improve care delivery across acuity settings, and warrants judicious inclusion in triage and treatment protocols.

Adherence to the Canadian CT Head Rule in a Nova Scotian Emergency and Trauma Center

Background and aims Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada (CWC), aims to address unnecessary care and tests through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five tests, procedures, and treatments to question within the emergency department setting. The Canadian CT-scan Head Rule (CCHR) has been found to be the most effective clinical decision rule in adults with minor head injuries. This study aimed to better understand the current status of CCHR use in Nova Scotia, we conducted a retrospective audit of patient charts at the Charles V. Keating Emergency and Trauma Center in Halifax, Nova Scotia. Materials and methods Our mixed methods design included a narrative literature review, a retrospective chart audit, and a qualitative audit-feedback component with physicians who work in the emergency department (ED). The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Results Analysis of qualitative data is included here, in parallel with in-depth analysis to contextualize findings from the chart audit. A total of 302 charts of patients presenting to the surveyed site were retrospectively reviewed for this study. Of the 37 cases where the CT head was indicated as per the CCHR, a CT was ordered 32 (86.5%) times. Of the 176 cases where a CT head was not indicated as per the CCHR, a CT was not ordered 155 (88.1%) times. Therefore, the CCHR was followed in 187 (87.8%) of the total 213 cases where the CCHR should be applied. Conclusions Our review revealed that the CCHR was adhered in 87.8% of cases at the surveyed ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical to achieving the goal of reducing unnecessary CTs. This work will be presented to the physician group to engage and understand factors that are enablers in the process of ED minor head injury care.

Prevalence of Computed Tomography Overuse for Mild Head Injury in Adults

INTRODUCTION

The Canadian CT Head Rule (CCHR) is one of many established guidelines for assessing the need for computed tomography (CT) imaging in patients with minor head injuries. Adhering to such criteria would promote the appropriate use of CT imaging, lower healthcare expenses, and prevent harmful radiation exposure. There is no current literature assessing the overuse of CT imaging for minor head injuries in the Kingdom of Bahrain. This study aims to evaluate CT overuse in adult patients with minor head trauma.  Methods: The study was conducted at the Bahrain Defense Force Hospital over 12 months from January to December 2021. All adult patients (>14 years) who sustained a minor head injury and were referred to the emergency department for CT brain imaging were included in the study. Patients presenting for other reasons or suffering from moderate to severe head injuries were excluded. CT reports were retrieved for analysis. The CCHR was used as a reference.  Results: A total of 486 CT scans were performed. Loss of consciousness was the most common symptom on presentation (n = 74 cases). Only 12.1% of CT scans reported positive findings. The prevalence of CT overuse was highest in patients aged 21-30 years. Patients presenting with loss of consciousness showed a high overuse of CT imaging, accounting for 20.3% of all cases. Only 77.4% of cases met the CCHR criteria and 22.6% were defined as overuse, with 95% confidence interval (0.189, 0.266).  Conclusion: When referring to the CCHR, CT imaging for a minor head injury in adults was overused in 22.6% of cases. Further research will be required to reveal the underlying reasons for these findings along with interventions to reduce future overuse.

Intracranial peak pressure as a predictor for perioperative mortality after spontaneous intracerebral hemorrhage evacuation and decompressive craniectomy

BACKGROUND

An optimal intracranial pressure (ICP) management target is not well defined in patients with spontaneous intracerebral hemorrhage. The aim of this study was to explore the association between perioperative ICP monitoring parameters and mortality of patients with spontaneous intracerebral hematoma undergoing emergency hematoma removal and decompressive craniectomy (DC), to provide evidence for a target-oriented ICP management.

METHODS

The clinical and radiological features of 176 consecutive patients with spontaneous intracerebral hemorrhage that underwent emergent hematoma evacuation and DC were reviewed. The Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) scores were assessed 2 weeks after surgery. Multivariate logistic regression analysis was performed to identify predictors for perioperative death.

RESULTS

Forty-four cases (25.0%) were assigned to the ICP group. In patients with an ICP monitor, the median peak ICP value was 25.5 mmHg; 50% of them had a peak ICP value of more than 25 mmHg. The median duration of ICP > 25 mmHg was 2 days. Without a target-specific ICP management, the mortality at 2 weeks after surgery was similar between patients with or without an ICP monitor (27.3% versus 18.2%, p = 0.20). In multivariable analysis, the peak ICP value (OR 1.11, 95% CI 1.004-1.234, p = 0.04) was significantly associated with perioperative death in the ICP group. The area under ROC curve of peak ICP value was 0.78 (95%CI 0.62-0.94) for predicting mortality, with a cut-off value of 31 mmHg.

CONCLUSION

Compared with a persistent hyperintracranial pressure, a high ICP peak value might provide a better prediction for the mortality of patients with spontaneous intracerebral hemorrhage evacuation and DC, suggesting a tailored ICP management protocol to decrease ICP peak value.

Value of Nonpharmacological Interventions for People With an Acquired Brain Injury: A Systematic Review of Economic Evaluations

OBJECTIVES

Acquired brain injury (ABI) has long-lasting effects, and patients and their families require continued care and support, often for the rest of their lives. For many individuals living with an ABI disorder, nonpharmacological rehabilitation treatment care has become increasingly important care component and relevant for informed healthcare decision making. Our study aimed to appraise economic evidence on the cost-effectiveness of nonpharmacological interventions for individuals living with an ABI.

METHODS

This systematic review was registered in PROSPERO (CRD42020187469), and a protocol article was subject to peer review. Searches were conducted across several databases for articles published from inception to 2021. Study quality was assessed according the Consolidated Health Economic Evaluation Reporting Standards checklist and Population, Intervention, Control, and Outcomes criteria.

RESULTS

Of the 3772 articles reviewed 41 publications met the inclusion criteria. There was a considerable heterogeneity in methodological approaches, target populations, study time frames, and perspectives and comparators used. Keeping these issues in mind, we find that 4 multidisciplinary interventions studies concluded that fast-track specialized services were cheaper and more cost-effective than usual care, with cost savings ranging from £253 to £6063. In 3 neuropsychological studies, findings suggested that meditated therapy was more effective and saved money than usual care. In 4 early supported discharge studies, interventions were dominant over usual care, with cost savings ranging from £142 to £1760.

CONCLUSIONS

The cost-effectiveness evidence of different nonpharmacological rehabilitation treatments is scant. More robust evidence is needed to determine the value of these and other interventions across the ABI care pathway.

Effects of the CarFreeMe Traumatic Injuries, a Community Mobility Group Intervention, to Increase Community Participation for People With Traumatic Injuries: A Randomized Controlled Trial With Crossover

Introduction

After traumatic injuries community participation is a common goal, promoting wellbeing and independence. Community mobility and transportation influence an individual's independence in community participation. With the ability to drive safely often compromised after traumatic injuries, the adverse consequences of driving cessation include a loss of identity and reduced participation in chosen activities. In rehabilitation, individualized community mobility intervention is not routinely provided. The primary aim of this trial was to evaluate whether a group-based intervention, the CarFreeMe TI program was more effective than standard intervention, an information sheet of alternative transport, in improving community mobility for people following traumatic injuries. The secondary aim of this study was to evaluate the effect: types of transport used, transport satisfaction, community mobility self-efficacy, quality of life, goal satisfaction and performance, for people following traumatic injuries; and to undertake a preliminary assessment of the potential resource use associated with the intervention, and lessons for implementation.

Design

Prospective, pilot, randomized, blind observer, controlled trial with crossover.

Participants

Twenty individuals with traumatic injuries.

Intervention

Six-week group-based support and education program, the CarFreeMe TI delivered in community settings (intervention) and standard information related to transport options available (control).

Primary Outcome Measures

Community participation using a Global Positioning System device to record the location and number of outings from home.

Secondary Outcome Measures

CarFreeMe TI Transport Questionnaire, Community Mobility Self-efficacy Scale, quality of life measures, Modified Canadian Occupational Performance Measure for goals (importance and satisfaction), participant satisfaction survey results and researcher logs.

Results

Those who received the intervention were more likely to use public transport and transport services and had an improved quality of life, when compared to the control group. The intervention group also reported high levels of improvement in goal performance and satisfaction. Global Positioning System data collection was incomplete, with geolocation data unusable. There was no significant change in number/type of visits away from home.

Conclusions

A group-based community mobility education program promoted modes of active independent transport but did not impact on outings from home. Future research could include passive collection methods using a smartphone to record community participation.

Clinical Trial Registration

https://www.anzctr.org.au/, identifier: ACTRN12616001254482.

Economic evaluations of audit and feedback interventions: a systematic review

BACKGROUND

The effectiveness of audit and feedback (A&F) interventions to improve compliance to healthcare guidelines is supported by randomised controlled trials (RCTs) and meta-analyses of RCTs. However, there is currently a knowledge gap on their cost-effectiveness.

OBJECTIVE

We aimed to assess whether A&F interventions targeting improvements in compliance to recommended care are economically favourable.

METHODS

We conducted a systematic review including experimental, observational and simulation-based economic evaluation studies of A&F interventions targeting healthcare providers. Comparators were a 'do nothing' strategy, or any other intervention not involving A&F or involving a subset of A&F intervention components. We searched MEDLINE, CINAHL, CENTRAL, Econlit, EMBASE, Health Technology Assessment Database, MEDLINE, NHS Economic Evaluation Database, ABI/INFORM, Web of Science, ProQuest and websites of healthcare quality associations to December 2021. Outcomes were incremental cost-effectiveness ratios, incremental cost-utility ratios, incremental net benefit and incremental cost-benefit ratios. Pairs of reviewers independently selected eligible studies and extracted relevant data. Reporting quality was evaluated using CHEERS (Consolidated Health Economic Evaluation Reporting Standards). Results were synthesised using permutation matrices for all studies and predefined subgroups.

RESULTS

Of 13 221 unique citations, 35 studies met our inclusion criteria. The A&F intervention was dominant (ie, at least as effective with lower cost) in 7 studies, potentially cost-effective in 26 and was dominated (ie, the same or less effectiveness and higher costs) in 2 studies. A&F interventions were more likely to be economically favourable in studies based on health outcomes rather than compliance to recommended practice, considering medical costs in addition to intervention costs, published since 2010, and with high reporting quality.

DISCUSSION

Results suggest that A&F interventions may have a high potential to be cost-effective. However, as is common in systematic reviews of economic evaluations, publication bias could have led to an overestimation of their economic value.

Economic Evaluation of In-Hospital Clinical Practices in Acute Injury Care: A Systematic Review

OBJECTIVES

Underuse of high-value clinical practices and overuse of low-value practices are major sources of inefficiencies in modern healthcare systems. To achieve value-based care, guidelines and recommendations should target both underuse and overuse and be supported by evidence from economic evaluations. We aimed to conduct a systematic review of the economic value of in-hospital clinical practices in acute injury care to advance knowledge on value-based care in this patient population.

METHODS

Pairs of independent reviewers systematically searched MEDLINE, Embase, Web of Science, and Cochrane Central Register for full economic evaluations of in-hospital clinical practices in acute trauma care published from 2009 to 2019 (last updated on June 17, 2020). Results were converted into incremental net monetary benefit and were summarized with forest plots. The protocol was registered with PROSPERO (CRD42020164494).

RESULTS

Of 33 910 unique citations, 75 studies met our inclusion criteria. We identified 62 cost-utility, 8 cost-effectiveness, and 5 cost-minimization studies. Values of incremental net monetary benefit ranged from international dollars -467 000 to international dollars 194 000. Of 114 clinical interventions evaluated (vs comparators), 56 were cost-effective. We identified 15 cost-effective interventions in emergency medicine, 6 in critical care medicine, and 35 in orthopedic medicine. A total of 58 studies were classified as high quality and 17 as moderate quality. From studies with a high level of evidence (randomized controlled trials), 4 interventions were clearly dominant and 8 were dominated.

CONCLUSIONS

This research advances knowledge on value-based care for injury admissions. Results suggest that almost half of clinical interventions in acute injury care that have been studied may not be cost-effective.

Use of Magnetic Resonance Imaging in Acute Traumatic Brain Injury Patients is Associated with Lower Inpatient Mortality

Objectives:

While magnetic resonance imaging (MRI) has higher sensitivity than computed tomography for certain types of traumatic brain injury (TBI), it remains unknown whether the increased detection of intracranial injuries leads to improved clinical outcomes in acute TBI patients, especially given the resource requirements involved in performing MRI. We leveraged a large national patient database to examine associations between brain MRI utilization and inpatient clinical outcomes in hospitalized TBI patients.

Material and Methods:

The National Inpatient Sample database was queried to find 3,075 and 340,090 hospitalized TBI patients with and without brain MRI, respectively, between 2012 and 2014 in the United States. Multivariate regression analysis was performed to independently evaluate the association between brain MRI utilization and inpatient mortality rate, complications, and resource requirements.

Results:

The MRI group had a lower unadjusted mortality rate of 0.75% compared to 2.54% in the non-MRI group. On multivariate regression analysis, inpatient brain MRI was independently associated with lower mortality (adjusted OR 0.32, 95% CI 0.12–0.86), as well as higher rates of intracranial hemorrhage (adjusted OR 2.20, 95% CI 1.27–3.81) and non-home discharge (adjusted OR 1.33, 95% CI 1.07–1.67). Brain MRI was independently associated with 3.4 days (P < 0.001) and $8,934 (P < 0.001) increase in the total length and cost of hospital stay, respectively.

Conclusion:

We present the first evidence that inpatient brain MRI in TBI patients is associated with lower inpatient mortality, but with increased hospital resource utilization and likelihood of non-home discharge.

Divergence in the epidemiological estimates of traumatic brain injury in the United States: comparison of two national databases

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in the US, but the true incidence of TBI is unknown.

METHODS

The National Trauma Data Bank National Sample Program (NTDB NSP) was queried for 2007 and 2013, and population-based weighted estimates of TBI-related emergency department (ED) visits, hospitalizations, and deaths were calculated. These data were compared to the 2017 Centers for Disease Control and Prevention (CDC) report on TBI, which used the Healthcare Cost and Utilization Project's National ("Nationwide" before 2012) Inpatient Sample and National Emergency Department Sample.

RESULTS

In the NTDB NSP the incidence of TBI-related ED visits was 59/100,000 in 2007 and 62/100,000 in 2013. However, in the CDC report there were 534/100,000 in 2007 and 787/100,000 in 2013. The CDC estimate for ED visits was 805% higher in 2007 and 1169% higher in 2013. In the NTDB NSP, the incidence of TBI-related deaths was 5/100,000 in 2007 and 4/100,000 in 2013. In the CDC report, the incidence was 18/100,000 in both years. The CDC estimate for deaths was 260% higher in 2007 and 325% higher in 2013.

CONCLUSIONS

The databases disagreed widely in their weighted estimates of TBI incidence: CDC estimates were consistently higher than NTDB NSP estimates, by an average of 448%. Although such a discrepancy may be intuitive, this is the first study to quantify the magnitude of disagreement between these databases. Given that research, funding, and policy decisions are made based on these estimates, there is a need for a more accurate estimate of the true national incidence of TBI.

Pulmonary Hygiene Protocol Reduces Incidence of Lobar Collapse in Severe Traumatic Brain Injury

Background

Traumatic brain injury (TBI) is a common cause of death among injured patients. In addition to neurologic sequelae which may increase mortality risk, trauma patients suffering severe TBI (Glasgow Coma Score≤8) have a predilection for pulmonary complications. We have previously demonstrated that patients with severe TBI who were intubated and mechanically ventilated are at greater risk of radiographic pulmonary lobar collapse that necessitates advanced directional suctioning and/or bronchoscopy. We sought to minimize the potentially deleterious effects of such lobar collapse by using a standardized pulmonary hygiene protocol.

Methods

We performed a retrospective comparison of lobar collapse incidence among three groups over 21 months: patients without severe TBI who were intubated and mechanically ventilated for greater than 24 hours (i.e. “NO TBI”); patients with severe TBI who were intubated and mechanically ventilated for greater than 24 hours who were not treated with a standardized pulmonary hygiene protocol (i.e. historical “CONTROL”); and patients with severe TBI who were intubated and mechanically ventilated for greater than 24 hours and who were treated with a standardized pulmonary hygiene protocol (i.e. “HYGIENE”). Our analysis excluded patients who had any significant neck injury as we had previously found that pulmonary complications are increased in this subpopulation.

Results

We reviewed the charts of 310 trauma patients (NO TBI = 104, CONTROL = 101, HYGIENE = 105) and analyzed demographics, injury severity and outcomes, including the incidence of pulmonary lobar collapse. Pulmonary hygiene protocol demonstrated a significant reduction in the incidence of lobar collapse among the HYGIENE group compared to CONTROL, approximating the incidence among patients with no TBI (11% vs 27% vs 10%, respectively, p = 0.0009). No significant difference was noted in ventilator days, intensive care unit length of stay, hospital length of stay, mortality, nor incidence of pneumonia. 

Conclusion

High-risk TBI patients have a predilection towards the development of pulmonary lobar collapse, which can be significantly reduced by the use of a standardized pulmonary hygiene protocol.

Neuropsychological rehabilitation interventions for people with an acquired brain injury. A protocol for a systematic review of economic evaluation

Background: New emerging evidence has demonstrated the need for effective interventions to help people living with an acquired brain injury (ABI). Evidence on cost-effectiveness, which can help inform use of limited resources, is scarce in this area and therefore the purpose of this systematic review is to critically appraise and consolidate the current evidence on economic evaluations of ABI rehabilitation interventions. Methods: Systematic review methodology will be applied to identify, select and extract data from published economic evaluation studies (trial-based, non-trial based, simulation-based, decision model and trial-based model economic evaluations) of ABI treatment interventions in adults. A systematic literature search will be conducted on the following electronic databases: EMBASE, Econlit, CINAHL, Medline, the National Health Service Economic Evaluation Database and PsyclNFO. This review will only include cost-effectiveness analysis studies (e.g., cost per life year gained), cost-benefit and cost minimisation analyses in which the designs were randomised controlled trials (RCTs), non-RCT studies, cost-utility analyses (e.g., cost per quality-adjusted life year (QALY) gained or cost per disability-adjusted life year averted), cohort studies, and modelling studies. Only studies that were published in the english language, associated with adults who have an ABI will be included. There will be no restrictions on perspective, sample size, country, follow-up duration or setting. The search strategy terms will include the following: acquired brain injury, brain*; cost*; or cost-benefit analysis*. Following data extraction, a narrative summary and tables will be used to summarize the characteristics and results of included studies. Discussion: The findings from this review will be beneficial to health policy decision makers when examining the evidence of economic evaluations in this field. In addition, it is anticipated that this review will identify gaps in the current economic literature to inform future-related research. Systematic review registration: PROSPERO CRD42020187469 (25 th June 2020).

Neuropsychological rehabilitation interventions for people with an acquired brain injury and their caregivers. A protocol for a systematic review of economic evaluation

Background: New emerging evidence has demonstrated the need for effective interventions to help people living with an acquired brain injury (ABI). Evidence on cost-effectiveness, which can help inform use of limited resources, is scarce in this area and therefore the purpose of this systematic review is to critically appraise and consolidate the current evidence on economic evaluations of ABI rehabilitation interventions. Methods: Systematic review methodology will be applied to identify, select and extract data from published economic evaluation studies (trial-based, non-trial based, simulation-based, decision model and trial-based model economic evaluations) of ABI treatment interventions in adults. A systematic literature search will be conducted on the following electronic databases: EMBASE, Econlit, CINAHL, Medline, Econlit, the National Health Service Economic Evaluation Database and PsyclNFO. This review will only include cost-effectiveness analysis studies (e.g., cost per life year gained), cost-benefit and cost minimisation analyses in which the designs were randomised controlled trials (RCTs), non-RCT studies, cost-utility analyses (e.g., cost per quality-adjusted life year (QALY) gained or cost per disability-adjusted life year averted), cohort studies, and modeling studies. Only studies that were published in English, associated with adults who have an ABI will be included. There will be no restrictions on perspective, sample size, country, follow-up duration or setting. The search strategy terms will include the following: acquired brain injury, brain*; cost*; or cost-benefit analysis*. Following data extraction, a narrative summary and tables will be used to summarize the characteristics and results of included studies. Discussion: The findings from this review will be beneficial to health policy decision makers when examining the evidence of economic evaluations in this field. In addition, it is anticipated that this review will identify gaps in the current economic literature to inform future-related research. Systematic review registration: PROSPERO CRD42020187469 (25 th June 2020).

Decreased Risk of Dementia Among Patients With Traumatic Brain Injury Receiving Acupuncture Treatment: A Population-Based Retrospective Cohort Study

OBJECTIVE

We conducted a longitudinal cohort study comparing the effect of acupuncture on the risk of dementia in Taiwanese individuals with traumatic brain injury (TBI).

DESIGN AND PARTICIPANTS

A national health insurance database was used to identify 15 440 newly diagnosed TBI patients 20 to 70 years old between 1998 and 2007. Of the identified patients, 6308 received acupuncture following the onset of TBI (acupuncture users) and 9132 patients did not receive acupuncture (nonacupuncture users).

MEASURES

All enrollees were followed until the end of 2012 to record incident cases of dementia. A Cox proportional hazards regression model was used to compute adjusted hazard ratios for the relationship of acupuncture use with dementia.

RESULTS

During the follow-up period, 249 acupuncture users and 810 nonacupuncture users developed dementia, corresponding to incidence rates of 6.11 and 9.64 per 1000 person-years, respectively. Use of acupuncture was significantly associated with a lower risk of dementia. Those who received more than 5 sessions of acupuncture benefited most from it.

CONCLUSIONS

Adding acupuncture to the clinical management of patients with TBI may benefit these patients by decreasing their risk of developing dementia.

Two latent classes of diagnostic and treatment procedures among traumatic brain injury inpatients

To characterize latent classes of diagnostic and/or treatment procedures among hospitalized U.S. adults, 18-64 years, with primary diagnosis of TBI from 2004-2014 Nationwide Inpatient Samples, latent class analysis (LCA) was applied to 10 procedure groups and differences between latent classes on injury, patient, hospital and healthcare utilization outcome characteristics were modeled using multivariable regression. Using 266,586 eligible records, LCA resulted in two classes of hospitalizations, namely, class I (n = 217,988) (mostly non-surgical) and class II (n = 48,598) (mostly surgical). Whereas orthopedic procedures were equally likely among latent classes, skin-related, physical medicine and rehabilitation procedures as well as behavioral health procedures were more likely among class I, and other types of procedures were more likely among class II. Class II patients were more likely to have moderate-to-severe TBI, to be admitted on weekends, to urban, medium-to-large hospitals in Midwestern, Southern or Western regions, and less likely to be > 30 years, female or non-White. Class II patients were also less likely to be discharged home and necessitated longer hospital stays and greater hospitalization charges. Surgery appears to distinguish two classes of hospitalized patients with TBI with divergent healthcare needs, informing the planning of healthcare services in this target population.

Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study

BACKGROUND

The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI.

METHODS

We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation.

RESULTS

A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%).

CONCLUSION

In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.

Incidence, Risk Factors, and Outcomes of Ventilator-Associated Pneumonia in Traumatic Brain Injury: A Meta-analysis

Ventilator-associated pneumonia (VAP) is one of the most severe complications in patients with traumatic brain injury (TBI) and is considered a risk factor for poor outcomes. However, the incidence of VAP among patients with TBI reported in studies varies widely. What is more, the risk factors and outcomes of VAP are controversial. This study estimates the incidence, risk factors, and outcomes of VAP in patients with TBI and provides evidence for prevention and treatment. PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched from the earliest records to May 2018. Data involving the incidence, risk factors, and outcomes were extracted for meta-analysis. The results showed that the incidence of VAP was 36% (95% confidence interval (CI) 31-41%); risk factors analyses showed that smoking [odds ratio (OR) 2.13; 95% CI 1.16-3.92], tracheostomy (OR 9.55; 95% CI 3.24-28.17), blood transfusion on admission (OR 2.54; 95% CI 1.24-5.18), barbiturate infusion (OR 3.52; 95% CI 1.68-7.40), injury severity score (OR 4.65; 95% CI 1.96-7.34), and head abbreviated injury scale (OR 2.99; 95% CI 1.66-5.37) were related to the occurrence of VAP. When patients developed VAP, mechanical ventilation time (OR 5.45; 95% CI 3.78-7.12), ICU length of stay (OR 6.85; 95% CI 4.90-8.79), and hospital length of stay (OR 10.92; 95% CI 9.12-12.72) were significantly increased. However, VAP was not associated with an increased risk of mortality (OR 1.28; 95% CI 0.74-2.21). VAP is common in patients with TBI. It is affected by a series of factors and has a poor prognosis.

Ability of Fibrin Monomers to Predict Progressive Hemorrhagic Injury in Patients with Severe Traumatic Brain Injury

BACKGROUND

Progressive hemorrhagic injury (PHI) is common in patients with severe traumatic brain injury (TBI) and is associated with poor outcomes. TBI-associated coagulopathy is frequent and has been described as risk factor for PHI. This coagulopathy is a dynamic process involving hypercoagulable and hypocoagulable states either one after the other either concomitant. Fibrin monomers (FMs) are a direct marker of thrombin action and thus reflect coagulation activation. This study sought to determine the ability of FM to predict PHI after severe TBI.

METHODS

We conducted a prospective, observational study including all severe TBI patients admitted in the trauma center. Between September 2011 and September 2016, we enrolled patients with severe TBI into the derivation cohort. Between October 2016 and December 2018, we recruited the validation cohort on the same basis. Study protocol included FM measurements and standard coagulation test at admission and two computed tomography (CT) scans (upon arrival and at least 6 h thereafter). A PHI was defined by an increment in size of initial lesion (25% or more) or the development of a new hemorrhage in the follow-up CT scan. Multivariate logistic regression analysis was applied to identify predictors of PHI.

RESULTS

Overall, 106 patients were included in the derivation cohort. Fifty-four (50.9%) experienced PHI. FM values were higher in these patients (151 [136.8-151] vs. 120.5 [53.3-151], p < 0.0001). The ROC curve demonstrated that FM had a fair accuracy to predict the occurrence of PHI with an area under curve of 0.7 (95% CI [0.6-0.79]). The best threshold was determined at 131.7 μg/ml. In the validation cohort of 54 patients, this threshold had a negative predictive value of 94% (95% CI [71-100]) and a positive predictive value of 49% (95% CI [32-66]). The multivariate logistic regression analysis identified 2 parameters associated with PHI: FM ≥ 131.7 (OR 6.8; 95% CI [2.8-18.1]) and Marshall category (OR 1.7; 95% CI [1.3-2.2]). Coagulopathy was not associated with PHI (OR 1.3; 95% CI [0.5-3.0]). The proportion of patients with an unfavorable functional neurologic outcome at 6-months follow-up was higher in patients with positive FM: 59 (62.1%) versus 16 (29.1%), p < 0.0001.

CONCLUSIONS

FM levels at admission had a fair accuracy to predict PHI in patients with severe TBI. FM values ≥ 131.7 μg/ml are independently associated with the occurrence of PHI.

Developing a framework for evidence-based grading and assessment of predictive tools for clinical decision support

BACKGROUND

Clinical predictive tools quantify contributions of relevant patient characteristics to derive likelihood of diseases or predict clinical outcomes. When selecting predictive tools for implementation at clinical practice or for recommendation in clinical guidelines, clinicians are challenged with an overwhelming and ever-growing number of tools, most of which have never been implemented or assessed for comparative effectiveness. To overcome this challenge, we have developed a conceptual framework to Grade and Assess Predictive tools (GRASP) that can provide clinicians with a standardised, evidence-based system to support their search for and selection of efficient tools.

METHODS

A focused review of the literature was conducted to extract criteria along which tools should be evaluated. An initial framework was designed and applied to assess and grade five tools: LACE Index, Centor Score, Well's Criteria, Modified Early Warning Score, and Ottawa knee rule. After peer review, by six expert clinicians and healthcare researchers, the framework and the grading of the tools were updated.

RESULTS

GRASP framework grades predictive tools based on published evidence across three dimensions: 1) Phase of evaluation; 2) Level of evidence; and 3) Direction of evidence. The final grade of a tool is based on the highest phase of evaluation, supported by the highest level of positive evidence, or mixed evidence that supports a positive conclusion. Ottawa knee rule had the highest grade since it has demonstrated positive post-implementation impact on healthcare. LACE Index had the lowest grade, having demonstrated only pre-implementation positive predictive performance.

CONCLUSION

GRASP framework builds on widely accepted concepts to provide standardised assessment and evidence-based grading of predictive tools. Unlike other methods, GRASP is based on the critical appraisal of published evidence reporting the tools' predictive performance before implementation, potential effect and usability during implementation, and their post-implementation impact. Implementing the GRASP framework as an online platform can enable clinicians and guideline developers to access standardised and structured reported evidence of existing predictive tools. However, keeping GRASP reports up-to-date would require updating tools' assessments and grades when new evidence becomes available, which can only be done efficiently by employing semi-automated methods for searching and processing the incoming information.

The Role of Decompressive Craniectomy in the Context of Severe Traumatic Brain Injury: Summary of Results and Analysis of the Confidence Level of Conclusions From Systematic Reviews and Meta-Analyses

Introduction: Traumatic brain injury (TBI) is a global epidemic. The incidence of TBI in low and middle-income countries (LMICs) is three times greater than in high-income countries (HICs). Decompressive craniectomy (DC) is a surgical procedure to reduce intracranial pressure (ICP) and prevent secondary injury. Multiple comparative studies, and several randomized controlled trials (RCTs) have been conducted to investigate the influence of DC for patients with severe TBI on outcomes such as mortality, ICP, neurological outcomes, and intensive care unit (ICU) and hospital length of stay. The results of these studies are inconsistent. Systematic reviews and meta-analyses have been conducted in an effort to aggregate the data from the individual studies, and perhaps derive reliable conclusions. The purpose of this project was to conduct a review of the reviews about the effectiveness of DC to improve outcomes.

Methods: We conducted a systematic search of the literature to identify reviews and meta-analyses that met our pre-determined criteria. We used the AMSTAR 2 instrument to assess the quality of each of the included reviews, and determine the level of confidence.

Results: Of 973 citations from the original search, five publications were included in our review. Four of them included meta-analyses. For mortality, three reviews found a positive effect of DC compared to medical management and two found no significant difference between groups. The four reviews that measured neurological outcome found no benefit of DC. The two reviews that assessed ICP both found DC to be beneficial in reducing ICP. DC demonstrated a significant reduction in ICU length of stay in the one study that measured it, and a significant reduction in hospital length of stay in the two studies that measured it. According to the AMSTAR 2 criteria, the five reviews ranged in levels of confidence from low to critically low.

Conclusion: Systematic reviews and meta-analyses are important approaches for aggregating information from multiple studies. Clinicians rely of these methods for concise interpretation of scientific literature. Standards for quality of systematic reviews and meta-analyses have been established to support the quality of the reviews being produced. In the case of DC, more attention must be paid to quality standards, in the generation of both individual studies and reviews.

Long-term employment outcomes following moderate to severe traumatic brain injury: a systematic review and meta-analysis

Background: Returning to employment following moderate to severe traumatic brain injury (msTBI) is critical for a survivor's well-being, yet currently there are no systematic reviews that comprehensively describe employment outcomes following msTBI. The objective of this study was to systematically synthesize literature on employment outcomes following msTBI.Methods: Original studies published through April 2018 on MEDLINE/PubMed, PsychINFO, and CINAHL were eligible if the objective was to investigate employment outcomes following msTBI; outcome was measured ≥1 year; participants were ≥15; and size was ≥60. Post-injury employment prevalence and return to pre-injury level of work were summarized through meta-analysis.Results: Of 38 eligible studies, post-injury employment prevalence was most often reported (n = 35), followed by job stability (n = 6), and return to pre-injury level of work (n = 4). Overall post-injury employment prevalence was 42.2%; whereas the return-to-previous-work prevalence was 33.0%. Post-injury employment prevalence appeared to increase over time, from 34.9% at 1 year to 42.1% up to 5 years and 49.9% beyond 5 years.Conclusion: Nearly half of individuals with msTBI were employed post-injury, yet only a third returned to pre-injury level of work. Future researchers are recommended to standardize employment outcome measures to enable better comparison of outcomes across studies.

Grading and assessment of clinical predictive tools for paediatric head injury: a new evidence-based approach

BACKGROUND

Many clinical predictive tools have been developed to diagnose traumatic brain injury among children and guide the use of computed tomography in the emergency department. It is not always feasible to compare tools due to the diversity of their development methodologies, clinical variables, target populations, and predictive performances. The objectives of this study are to grade and assess paediatric head injury predictive tools, using a new evidence-based approach, and to provide emergency clinicians with standardised objective information on predictive tools to support their search for and selection of effective tools.

METHODS

Paediatric head injury predictive tools were identified through a focused review of literature. Based on the critical appraisal of published evidence about predictive performance, usability, potential effect, and post-implementation impact, tools were evaluated using a new framework for grading and assessment of predictive tools (GRASP). A comprehensive analysis was conducted to explain why certain tools were more successful.

RESULTS

Fourteen tools were identified and evaluated. The highest-grade tool is PECARN; the only tool evaluated in post-implementation impact studies. PECARN and CHALICE were evaluated for their potential effect on healthcare, while the remaining 12 tools were only evaluated for predictive performance. Three tools; CATCH, NEXUS II, and Palchak, were externally validated. Three tools; Haydel, Atabaki, and Buchanich, were only internally validated. The remaining six tools; Da Dalt, Greenes, Klemetti, Quayle, Dietrich, and Güzel did not show sufficient internal validity for use in clinical practice.

CONCLUSIONS

The GRASP framework provides clinicians with a high-level, evidence-based, comprehensive, yet simple and feasible approach to grade, compare, and select effective predictive tools. Comparing the three main tools which were assigned the highest grades; PECARN, CHALICE and CATCH, to the remaining 11, we find that the quality of tools' development studies, the experience and credibility of their authors, and the support by well-funded research programs were correlated with the tools' evidence-based assigned grades, and were more influential, than the sole high predictive performance, on the wide acceptance and successful implementation of the tools. Tools' simplicity and feasibility, in terms of resources needed, technical requirements, and training, are also crucial factors for their success.

In-hospital costs after severe traumatic brain injury: A systematic review and quality assessment

Background

The in-hospital treatment of patients with traumatic brain injury (TBI) is considered to be expensive, especially in patients with severe TBI (s-TBI). To improve future treatment decision-making, resource allocation and research initiatives, this study reviewed the in-hospital costs for patients with s-TBI and the quality of study methodology.

Methods

A systematic search was performed using the following databases: PubMed, MEDLINE, Embase, Web of Science, Cochrane library, CENTRAL, Emcare, PsychINFO, Academic Search Premier and Google Scholar. Articles published before August 2018 reporting in-hospital acute care costs for patients with s-TBI were included. Quality was assessed by using a 19-item checklist based on the CHEERS statement.

Results

Twenty-five out of 2372 articles were included. In-hospital costs per patient were generally high and ranged from $2,130 to $401,808. Variation between study results was primarily caused by methodological heterogeneity and variable patient and treatment characteristics. The quality assessment showed variable study quality with a mean total score of 71% (range 48% - 96%). Especially items concerning cost data scored poorly (49%) because data source, cost calculation methodology and outcome reporting were regularly unmentioned or inadequately reported.

Conclusions

Healthcare consumption and in-hospital costs for patients with s-TBI were high and varied widely between studies. Costs were primarily driven by the length of stay and surgical intervention and increased with higher TBI severity. However, drawing firm conclusions on the actual in-hospital costs of patients sustaining s-TBI was complicated due to variation and inadequate quality of the included studies. Future economic evaluations should focus on the long-term cost-effectiveness of treatment strategies and use guideline recommendations and common data elements to improve study quality.

Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox?

BACKGROUND

The decision whether to operate or not in patients with a traumatic acute subdural hematoma (t-ASDH) can, in many cases, be a neurosurgical dilemma. There is a general conception that operating on severe cases leads to the survival of severely disabled patients and is associated with relatively high medical costs. There is however little information on the quality of life of patients after operation for t-ASDH, let alone on the cost-effectiveness.

METHODS

This study retrospectively investigated patient outcome and in-hospital costs for 108 consecutive patients with a t-ASDH. Patient outcome was assessed using the Glasgow Outcome Score (GOS) and the Traumatic Brain Injury (TBI)-specific QOLIBRI questionnaire. The in-hospital costs were calculated using the Dutch guidelines for costs calculation.

RESULTS

Out of 108 patients, 40 were classified as having sustained a mild (Glasgow Coma Scale (GCS) 13-15), 19 a moderate (GCS 9-12), and 49 a severe (GCS 3-8) TBI. As expected, mortality rates increased with higher TBI severity (23%, 47%, and 61% respectively), whereas the chance for favorable outcome (GOS 4-5) decreased (72%, 47%, and 29%). Interestingly, the mean QOLIBRI scores for survivors were quite similar between the TBI severity groups (61, 61, and 64). Healthcare consumption and in-hospital costs increased with TBI severity. In-hospital costs were relatively high (€24,980), especially after emergency surgery (€28,670) and when additional ICP monitoring was used (€36,580).

CONCLUSIONS

Although this study confirms that outcome is often "unfavorable" after t-ASDH, it also shows that "favorable" outcome can be achieved, even in the most severely injured patients. In-hospital treatment costs were substantial and mainly related to TBI severity, with admission and surgery as main cost drivers. These results serve as a basis for necessary future research focusing on the value-based cost-effectiveness of surgical treatment of patients with a t-ASDH.

A technology-enabled electronic incident report to document and facilitate management of sport concussion: A cohort study of youth and young adults

Despite the widespread awareness of concussion across all levels of sport, the management of concussion from youth to college is inconsistent and fragmented. A fundamental gap contributing to inconsistent care is the lack of a scalable, systematic approach to document initial injury characteristics following concussion. The purpose of this study was to determine differences in injury profiles and management of youth, high school, and college athletes using a mobile application for incident report documentation.A cohort study was conducted in which concussion electronic incident report data from 46 high schools and colleges, and Cleveland Clinic ambulatory concussion clinics were gathered and analyzed.In sum, 1421 (N = 88 youth, N = 1171 high school and N = 162 college) athletes with sport-related concussions were included.Despite the relative absence of red flags, youth athletes had a greater probability of being sent to the emergency department than high school and collegiate athletes. Over 60% of athletes were removed from play immediately post-injury. Injury recognition was delayed in 25% of athletes due to delayed symptom reporting (20% of males, 16% of females) or delayed symptom onset (5% of males, 9% of females). A significantly greater incidence of red flags was evident in males, and in high school and collegiate athletes compared to youth athletes.The high frequency of youth athletes sent to the emergency department, despite the absence of red flags, may be a reflection of inadequate medical coverage at youth events, ultimately resulting in unnecessary utilization of emergency medicine services. The relatively high incidence of delayed injury reporting implies that additional educational efforts targeting student-athletes and the utilization of resources to improve injury detection are warranted. The systematic collection of injury-related demographics through the electronic mobile application facilitated interdisciplinary communication and improved the efficiency of managing athletes with concussion.

Community Participation for People with Trauma Injuries: A Study Protocol of a Crossover Randomised Controlled Trial of the Effectiveness of a Community Mobility Group Intervention (CarFreeMe TI)

Background: Following traumatic brain and spinal cord injuries, maximising community participation leads to better physical and mental health outcomes.

Objectives: To determine the effectiveness and health system resource use of a group intervention (CarFreeMe TI) on community participation in people with complex trauma injuries.

Method: Randomised crossover trial of 54 participants, recruited from rehabilitation services in Adelaide, Australia. Inclusion criteria is a trauma injury, unable to return to full driving, aged over 18 years of age, adequate cognition/behavioural/communication abilities to participate in sessions and mobile. Exclusion criterion is living in setting where alternative transport is provided. Participants will be randomly assigned on a 1:1 allocation basis, to receiving Phase 1 CarFreeMe TI-group-based intervention or Phase 2 information related to transport options. Then, crossover to Phase 1 or 2 will occur. Primary outcome measure is community participation using a Global Positioning System. Secondary outcome measures include Community Mobility Self-efficacy Scale; CarFreeMe TI Transport Questionnaire, AQOL, EQ-5D-5L; Carer's Community Mobility Self-efficacy Scale and Modified Carer Strain Index for carers of participants. Outcome assessors will be blinded to group allocation. All analyses will be on an intention to treat basis with difference in community participation between the groups determined via a GLM ANOVA and the significance between groups on other measures using independent sample t-tests. It is hypothesised that the community mobility intervention (CarFreeMeTI) will result in increased community participation.

Discussion: The results will provide proof of concept information on the feasibility and inform allocation of resources for people with complex trauma injuries.

Trial registration: Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12616001254482.

Biomaterial Scaffolds in Regenerative Therapy of the Central Nervous System

The central nervous system (CNS) is the most important section of the nervous system as it regulates the function of various organs. Injury to the CNS causes impairment of neurological functions in corresponding sites and further leads to long-term patient disability. CNS regeneration is difficult because of its poor response to treatment and, to date, no effective therapies have been found to rectify CNS injuries. Biomaterial scaffolds have been applied with promising results in regeneration medicine. They also show great potential in CNS regeneration for tissue repair and functional recovery. Biomaterial scaffolds are applied in CNS regeneration predominantly as hydrogels and biodegradable scaffolds. They can act as cellular supportive scaffolds to facilitate cell infiltration and proliferation. They can also be combined with cell therapy to repair CNS injury. This review discusses the categories and progression of the biomaterial scaffolds that are applied in CNS regeneration.

Neuroprotective effects of estrogen in CNS injuries: insights from animal models

Among the estrogens that are biosynthesized in the human body, 17β-estradiol (estradiol or E2) is the most common and the best estrogen for neuroprotection in animal models of the central nervous system (CNS) injuries such as spinal cord injury (SCI), traumatic brain injury (TBI), and ischemic brain injury (IBI). These CNS injuries are not only serious health problems, but also enormous economic burden on the patients, their families, and the society at large. Studies from animal models of these CNS injuries provide insights into the multiple neuroprotective mechanisms of E2 and also suggest the possibility of translating the therapeutic efficacy of E2 in the treatment SCI, TBI, and IBI in humans in the near future. The pathophysiology of these injuries includes loss of motor function in the limbs, arms and their extremities, cognitive deficit, and many other serious consequences including life-threatening paralysis, infection, and even death. The potential application of E2 therapy to treat the CNS injuries may become a trend as the results are showing significant therapeutic benefits of E2 for neuroprotection when administered into the animal models of SCI, TBI, and IBI. This article describes the plausible mechanisms how E2 works with or without the involvement of estrogen receptors and provides an overview of the known neuroprotective effects of E2 in these three CNS injuries in different animal models. Because activation of estrogen receptors has profound implications in maintaining and also affecting normal physiology, there are notable impediments in translating E2 therapy to the clinics for neuroprotection in CNS injuries in humans. While E2 may not yet be the sole molecule for the treatment of CNS injuries due to the controversies surrounding it, the neuroprotective effects of its metabolite and derivative or combination of E2 with another therapeutic agent are showing significant impacts in animal models that can potentially shape the new treatment strategies for these CNS injuries in humans.

Acute brain trauma, lung injury, and pneumonia: more than just altered mental status and decreased airway protection

Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Even when patients survive the initial insult, there is significant morbidity and mortality secondary to subsequent pulmonary edema, acute lung injury (ALI), and nosocomial pneumonia. Whereas the relationship between TBI and secondary pulmonary complications is recognized, little is known about the mechanistic interplay of the two phenomena. Changes in mental status secondary to acute brain injury certainly impair airway- and lung-protective mechanisms. However, clinical and translational evidence suggests that more specific neuronal and cellular mechanisms contribute to impaired systemic and lung immunity that increases the risk of TBI-mediated lung injury and infection. To better understand the cellular mechanisms of that immune impairment, we review here the current clinical data that support TBI-induced impairment of systemic and lung immunity. Furthermore, we also review the animal models that attempt to reproduce human TBI. Additionally, we examine the possible role of damage-associated molecular patterns, the chlolinergic anti-inflammatory pathway, and sex dimorphism in post-TBI ALI. In the last part of the review, we discuss current treatments and future pharmacological therapies, including fever control, tracheostomy, and corticosteroids, aimed to prevent and treat pulmonary edema, ALI, and nosocomial pneumonia after TBI.

Early neurological wake-up test in intubated brain-injured patients: A long-term, single-centre experience

BACKGROUND

In prehospital setting, a severe traumatic brain injury (TBI) requires tracheal intubation, sedation and mechanical ventilation pending the initial imagery. An early neurological wake-up test (ENWT), soon after the initial imaging assessment, allows a rapid neurological reassessment. This strategy authorises an initial clinical examination of reference with which will be compared the later examinations. The main objective of this study was to describe the characteristics of the patients who underwent an ENWT, and to determine its causes of failure.

METHODS

We conducted a retrospective, observational, single-centre study including all intubated TBI admitted in the trauma centre. An ENWT was defined as cessation of sedation within 24h after TBI. Data concerning patient characteristics, CT-scan results, and outcomes were extracted from a prospective register of all intubated TBI admitted in the ICU. Characteristic of ENWT and causes of failure were retrieved from patient files. A multivariate logistic regression model was developed to determine the risk factors of ENWT failure.

RESULTS

During 7 years, 242 patients with intubated TBI were included. An ENWT was started in 96 patients, for an overall rate at 40%. The ENWT was stopped in 38 patients (39.5%), mostly due to neurological deterioration in 27 cases (71%) or respiratory distress in 10 cases (26%). Significant predictors of ENWT failure were: the presence of subdural hematoma with a thickness >5mm on first imagery (OR=3.2; 95%CI [1.01-10.28]), and an initial GCS score <5 (OR=7.4; 95%CI [1.92-28.43]). Prevalence of poor outcome at 1year was lesser in patients with successful ENWT compared to those with failure or absence of ENWT: 4% vs. 48% and 49% (p<0.0001).

CONCLUSIONS

The ENWT is achieved in 40% of patients, with a success rate of 60.5%. In presence of a subdural hematoma with a thickness >5mm or an initial GCS score <5, an ENWT failure may be expected.

The financial outcome of traumatic brain injury: a single centre study

OBJECTIVES

Severe traumatic brain injury (TBI) is a potentially devastating insult to the brain with high rates of fatality and neurological deficits. TBI can result in substantial costs to the centre providing care. We sought to present the experience of a Major Trauma Centre (MTC) and ascertain the financial implications of this healthcare provision, in particular detailed costs, reimbursement and the surplus or deficit accrued by the centre.

DESIGN

All cranial non-elective neurosurgical admissions with a TBI over 4.5 months (26 October 2014 to 15 March 2015) were analysed retrospectively, excluding cases of chronic subdural haematoma, at an MTC in England. Demographic data were collected alongside detailed cost and income data.

RESULTS

Ninety four patients were identified. The majority of patients presented with more than one diagnosis of cranial trauma. Average length of stay was 18.8 ± 21.6 days. Total deficits as a result of treating this cohort amounted to £558,034. There was a significant association between (i) more complex presentations and (ii) a longer length of stay and the deficit accrued by the centre. The major drivers of the financial outcome were costs associated with wards, medical staffing and overheads.

CONCLUSION

There was a substantial deficit accrued as a result of the management of patients with TBI at an MTC. The more complex the presentation, extensive the intervention, and lengthy the stay, the greater the deficit accrued by the centre. The current tariff payment system is not effectively reflecting the severity of injury or intensity of management of patients with TBI.