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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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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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Gaither JB, Spaite DW, Bobrow BJ, Barnhart B, Chikani V, Denninghoff KR, Bradley GH, Rice AD, Howard JT, Keim SM, Hu C. EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation. JAMA Surg 2024; 159:363-372. [PMID: 38265782 PMCID: PMC10809136 DOI: 10.1001/jamasurg.2023.7155] [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: 04/07/2023] [Accepted: 09/13/2023] [Indexed: 01/25/2024]
Abstract
Importance The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown. Objective To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV. Design, Setting, and Participants The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023. Exposure Implementation of the evidence-based guidelines for the prehospital care of patient with TBI. Main Outcomes and Measures The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission. Results Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34). Conclusions and Relevance Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.
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Affiliation(s)
- Joshua B. Gaither
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Daniel W. Spaite
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Bentley J. Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, Texas
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
| | - Vatsal Chikani
- Department of Public Health, University of Texas at San Antonio
| | - Kurt R. Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Gail H. Bradley
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Arizona Department of Health Services, Bureau of EMS, Phoenix
| | - Amber D. Rice
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | | | - Samuel M. Keim
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
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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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Tinti L, Lawson T, Molteni E, Kondziella D, Rass V, Sharshar T, Bodien YG, Giacino JT, Mayer SA, Amiri M, Muehlschlegel S, Venkatasubba Rao CP, Vespa PM, Menon DK, Citerio G, Helbok R, McNett M. Research considerations for prospective studies of patients with coma and disorders of consciousness. Brain Commun 2024; 6:fcae022. [PMID: 38344653 PMCID: PMC10853976 DOI: 10.1093/braincomms/fcae022] [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: 05/04/2023] [Revised: 01/04/2024] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilitate a future consensus-based statement (e.g. via a modified Delphi) and series of recommendations. The panel convened weekly online meetings from October 2021 to December 2022. Research considerations addressed the nosographic status of disorders of consciousness, case ascertainment and verification, selection of dependent variables, choice of covariates and measurement and analysis of outcomes and covariates, aiming to promote more homogeneous designs and practices in future observational studies. The goal of this review is to inform a broad community of professionals with different backgrounds and clinical interests to address the methodological challenges imposed by the transition of care from acute to chronic stages and to streamline data gathering for patients with disorders of consciousness. A coordinated effort will be a key to allow reliable observational data synthesis and epidemiological estimates and ultimately inform condition-modifying clinical trials.
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Affiliation(s)
- Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan 20156, Italy
| | - Thomas Lawson
- Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Erika Molteni
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EU, UK
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
| | - Tarek Sharshar
- Neuro-Intensive Care Medicine, Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris 75006, France
| | - Yelena G Bodien
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
| | - Susanne Muehlschlegel
- Department of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke’s Medical Center, Houston, TX 77030, USA
| | - Paul M Vespa
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 1TN, UK
| | - Giuseppe Citerio
- NeuroIntensive Care, IRCSS Fondazione San Gerardo dei Tintori, Monza 20900, Italy
- School of Medicine and Surgery, Università Milano Bicocca, Milan 20854, Italy
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
- Department of Neurology, Johannes Kepler University, Linz 4040, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH 43210, USA
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Mitevska A, Santacruz C, Martin EJ, Jones IE, Ghiacy A, Dixon S, Mostafazadeh N, Peng Z, Kiskinis E, Finan JD. Polyurethane Culture Substrates Enable Long-Term Neuron Monoculture in a Human in vitro Model of Neurotrauma. Neurotrauma Rep 2023; 4:682-692. [PMID: 37908320 PMCID: PMC10615064 DOI: 10.1089/neur.2023.0060] [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: 11/02/2023] Open
Abstract
Human induced pluripotent stem cell (hiPSC)-derived cells can reproduce human-specific pathophysiology, patient-specific vulnerability, and gene-environment interactions in neurological disease. Human in vitro models of neurotrauma therefore have great potential to advance the field. However, this potential cannot be realized until important biomaterials challenges are addressed. Status quo stretch injury models of neurotrauma culture cells on sheets of polydimethylsiloxane (PDMS) that are incompatible with long-term monoculture of hiPSC-derived neurons. Here, we overcame this challenge in an established human in vitro neurotrauma model by replacing PDMS with a highly biocompatible form of polyurethane (PU). This substitution allowed long-term monoculture of hiPSC-derived neurons. It also changed the biomechanics of stretch injury. We quantified these changes experimentally using high-speed videography and digital image correlation. We used finite element modeling to quantify the influence of the culture substrate's thickness, stiffness, and coefficient of friction on membrane stretch and concluded that the coefficient of friction explained most of the observed biomechanical changes. Despite these changes, we demonstrated that the modified model produced a robust, dose-dependent trauma phenotype in hiPSC-derived neuron monocultures. In summary, the introduction of this PU film makes it possible to maintain hiPSC-derived neurons in monoculture for long periods in a human in vitro neurotrauma model. In doing so, it opens new horizons in the field of neurotrauma by enabling the unique experimental paradigms (e.g., isogenic models) associated with hiPSC-derived neurons.
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Affiliation(s)
- Angela Mitevska
- Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Citlally Santacruz
- Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Eric J. Martin
- The Ken & Ruth Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ian E. Jones
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Arian Ghiacy
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Simon Dixon
- Biomer Technology Ltd., Warrington, United Kingdom
| | - Nima Mostafazadeh
- Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Zhangli Peng
- Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Evangelos Kiskinis
- The Ken & Ruth Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Department of Neuroscience, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John D. Finan
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
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Hansson MJ, Elmér E. Cyclosporine as Therapy for Traumatic Brain Injury. Neurotherapeutics 2023; 20:1482-1495. [PMID: 37561274 PMCID: PMC10684836 DOI: 10.1007/s13311-023-01414-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] [Accepted: 07/19/2023] [Indexed: 08/11/2023] Open
Abstract
Drug development in traumatic brain injury (TBI) has been impeded by the complexity and heterogeneity of the disease pathology, as well as limited understanding of the secondary injury cascade that follows the initial trauma. As a result, patients with TBI have an unmet need for effective pharmacological therapies. One promising drug candidate is cyclosporine, a polypeptide traditionally used to achieve immunosuppression in transplant recipients. Cyclosporine inhibits mitochondrial permeability transition, thereby reducing secondary brain injury, and has shown neuroprotective effects in multiple preclinical models of TBI. Moreover, the cyclosporine formulation NeuroSTAT® displayed positive effects on injury biomarker levels in patients with severe TBI enrolled in the Phase Ib/IIa Copenhagen Head Injury Ciclosporin trial (NCT01825044). Future research on neuroprotective compounds such as cyclosporine should take advantage of recent advances in fluid-based biomarkers and neuroimaging to select patients with similar disease pathologies for clinical trials. This would increase statistical power and allow for more accurate assessment of long-term outcomes.
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Affiliation(s)
- Magnus J Hansson
- Abliva AB, Lund, Sweden.
- Department of Clinical Sciences, Mitochondrial Medicine, Lund University, Lund, Sweden.
| | - Eskil Elmér
- Abliva AB, Lund, Sweden
- Department of Clinical Sciences, Mitochondrial Medicine, Lund University, Lund, Sweden
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Banoei MM, Lee CH, Hutchison J, Panenka W, Wellington C, Wishart DS, Winston BW. Using metabolomics to predict severe traumatic brain injury outcome (GOSE) at 3 and 12 months. Crit Care 2023; 27:295. [PMID: 37481590 PMCID: PMC10363297 DOI: 10.1186/s13054-023-04573-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/10/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Prognostication is very important to clinicians and families during the early management of severe traumatic brain injury (sTBI), however, there are no gold standard biomarkers to determine prognosis in sTBI. As has been demonstrated in several diseases, early measurement of serum metabolomic profiles can be used as sensitive and specific biomarkers to predict outcomes. METHODS We prospectively enrolled 59 adults with sTBI (Glasgow coma scale, GCS ≤ 8) in a multicenter Canadian TBI (CanTBI) study. Serum samples were drawn for metabolomic profiling on the 1st and 4th days following injury. The Glasgow outcome scale extended (GOSE) was collected at 3- and 12-months post-injury. Targeted direct infusion liquid chromatography-tandem mass spectrometry (DI/LC-MS/MS) and untargeted proton nuclear magnetic resonance spectroscopy (1H-NMR) were used to profile serum metabolites. Multivariate analysis was used to determine the association between serum metabolomics and GOSE, dichotomized into favorable (GOSE 5-8) and unfavorable (GOSE 1-4), outcomes. RESULTS Serum metabolic profiles on days 1 and 4 post-injury were highly predictive (Q2 > 0.4-0.5) and highly accurate (AUC > 0.99) to predict GOSE outcome at 3- and 12-months post-injury and mortality at 3 months. The metabolic profiles on day 4 were more predictive (Q2 > 0.55) than those measured on day 1 post-injury. Unfavorable outcomes were associated with considerable metabolite changes from day 1 to day 4 compared to favorable outcomes. Increased lysophosphatidylcholines, acylcarnitines, energy-related metabolites (glucose, lactate), aromatic amino acids, and glutamate were associated with poor outcomes and mortality. DISCUSSION Metabolomic profiles were strongly associated with the prognosis of GOSE outcome at 3 and 12 months and mortality following sTBI in adults. The metabolic phenotypes on day 4 post-injury were more predictive and significant for predicting the sTBI outcome compared to the day 1 sample. This may reflect the larger contribution of secondary brain injury (day 4) to sTBI outcome. Patients with unfavorable outcomes demonstrated more metabolite changes from day 1 to day 4 post-injury. These findings highlighted increased concentration of neurobiomarkers such as N-acetylaspartate (NAA) and tyrosine, decreased concentrations of ketone bodies, and decreased urea cycle metabolites on day 4 presenting potential metabolites to predict the outcome. The current findings strongly support the use of serum metabolomics, that are shown to be better than clinical data, in determining prognosis in adults with sTBI in the early days post-injury. Our findings, however, require validation in a larger cohort of adults with sTBI to be used for clinical practice.
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Affiliation(s)
- Mohammad M Banoei
- Department of Critical Care Medicine, University of Calgary, Alberta, Canada
| | - Chel Hee Lee
- Department of Critical Care Medicine, University of Calgary, Alberta, Canada
| | - James Hutchison
- Department of Pediatrics and Critical Care and Neuroscience and Mental Health Research Program, SickKids and Interdepartmental Division of Critical Care and Institute for Medical Science, The University of Toronto, Toronto, ON, Canada
| | - William Panenka
- BC Mental Health and Substance Use Research Institute and the Department of Psychiatry, Faculty of Medicine, University of British Colombia, British Colombia, Canada
| | - Cheryl Wellington
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, British Colombia, Canada
| | - David S Wishart
- Department of Biological Sciences, Computing Sciences and Medicine and Dentistry, University of Alberta, Alberta, Canada
| | - Brent W Winston
- Department of Critical Care Medicine, University of Calgary, Alberta, Canada.
- Department of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, University of Calgary, Health Research Innovation Center (HRIC), Room 4C64, 3280 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada.
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Hutchinson PJ, Adams H, Mohan M, Devi BI, Uff C, Hasan S, Mee H, Wilson MH, Gupta DK, Bulters D, Zolnourian A, McMahon CJ, Stovell MG, Al-Tamimi YZ, Tewari MK, Tripathi M, Thomson S, Viaroli E, Belli A, King AT, Helmy AE, Timofeev IS, Pyne S, Shukla DP, Bhat DI, Maas AR, Servadei F, Manley GT, Barton G, Turner C, Menon DK, Gregson B, Kolias AG. Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma. N Engl J Med 2023; 388:2219-2229. [PMID: 37092792 DOI: 10.1056/nejmoa2214172] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear. METHODS We conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L). RESULTS A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P = 0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group. CONCLUSIONS Among patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group. (Funded by the National Institute for Health and Care Research; RESCUE-ASDH ISRCTN Registry number, ISRCTN87370545.).
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Affiliation(s)
- Peter J Hutchinson
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Hadie Adams
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Midhun Mohan
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Bhagavatula I Devi
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Christopher Uff
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Shumaila Hasan
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Harry Mee
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Mark H Wilson
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Deepak K Gupta
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Diederik Bulters
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Ardalan Zolnourian
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Catherine J McMahon
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Matthew G Stovell
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Yahia Z Al-Tamimi
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Manoj K Tewari
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Manjul Tripathi
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Simon Thomson
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Edoardo Viaroli
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Antonio Belli
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Andrew T King
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Adel E Helmy
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Ivan S Timofeev
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Sarah Pyne
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Dhaval P Shukla
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Dhananjaya I Bhat
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Andrew R Maas
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Franco Servadei
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Geoffrey T Manley
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Garry Barton
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Carole Turner
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - David K Menon
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Barbara Gregson
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
| | - Angelos G Kolias
- From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.)
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Riley RD, Dias S, Donegan S, Tierney JF, Stewart LA, Efthimiou O, Phillippo DM. Using individual participant data to improve network meta-analysis projects. BMJ Evid Based Med 2023; 28:197-203. [PMID: 35948411 PMCID: PMC10313959 DOI: 10.1136/bmjebm-2022-111931] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/04/2022]
Abstract
A network meta-analysis combines the evidence from existing randomised trials about the comparative efficacy of multiple treatments. It allows direct and indirect evidence about each comparison to be included in the same analysis, and provides a coherent framework to compare and rank treatments. A traditional network meta-analysis uses aggregate data (eg, treatment effect estimates and standard errors) obtained from publications or trial investigators. An alternative approach is to obtain, check, harmonise and meta-analyse the individual participant data (IPD) from each trial. In this article, we describe potential advantages of IPD for network meta-analysis projects, emphasising five key benefits: (1) improving the quality and scope of information available for inclusion in the meta-analysis, (2) examining and plotting distributions of covariates across trials (eg, for potential effect modifiers), (3) standardising and improving the analysis of each trial, (4) adjusting for prognostic factors to allow a network meta-analysis of conditional treatment effects and (5) including treatment-covariate interactions (effect modifiers) to allow relative treatment effects to vary by participant-level covariate values (eg, age, baseline depression score). A running theme of all these benefits is that they help examine and reduce heterogeneity (differences in the true treatment effect between trials) and inconsistency (differences in the true treatment effect between direct and indirect evidence) in the network. As a consequence, an IPD network meta-analysis has the potential for more precise, reliable and informative results for clinical practice and even allows treatment comparisons to be made for individual patients and targeted populations conditional on their particular characteristics.
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Affiliation(s)
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Sarah Donegan
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | | | - Lesley A Stewart
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine (ISPMU), University of Bern, Bern, Switzerland
| | - David M Phillippo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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11
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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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12
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Alim-Marvasti A, Kuleindiren N, Tiersen F, Johal M, Lin A, Selim H, Rifkin-Zybutz R, Mahmud M. Hierarchical clustering of prolonged post-concussive symptoms after 12 months: symptom-centric analysis and association with functional impairments. Brain Inj 2023; 37:317-328. [PMID: 36529935 PMCID: PMC10635586 DOI: 10.1080/02699052.2022.2158229] [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: 02/11/2022] [Accepted: 09/27/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Following a concussion, approximately 15% of individuals experience persistent symptoms that can lead to functional deficits. However, underlying symptom-clusters that persist beyond 12 months have not been adequately characterized, and their relevance to functional deficits are unclear. The aim of this study was to characterize the underlying clusters of prolonged post-concussive symptoms lasting more than 12 months, and to investigate their association with functional impairments. METHODS Although hierarchical clustering is ideally suited in evaluating subjective symptom severities, it has not been applied to the Rivermead Post-Concussion Questionnaire (RPQ). The RPQ and functional impairments questions were administered via a smartphone application to 445 individuals who self-reported prolonged post-concussive symptoms. Symptom-clusters were obtained using agglomerative hierarchical clustering, and their association with functional deficits were investigated with sensitivity analyses, and corrected for multiple comparisons. RESULTS Five symptom-clusters were identified: headache-related, sensitivity to light and sound, cognitive, mood-related, and sleep-fatigue. Individuals with more severe RPQ symptoms were more likely to report functional deficits (p < 0.0001). Whereas the headache and sensitivity clusters were associated with at most one impairment, at-least-mild sleeping difficulties and fatigue were associated with four, and moderate-to-severe cognitive difficulties with five (all p < 0.01). CONCLUSIONS Symptom-clusters may be clinically useful for functional outcome stratification for targeted rehabilitation therapies. Further studies are required to replicate these findings in other cohorts and questionnaires, and to ascertain the effects of symptomatic intervention on functional outcomes.
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Affiliation(s)
- Ali Alim-Marvasti
- Research Division, Mindset Technologies Ltd, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | | | | | - Monika Johal
- Research Division, Mindset Technologies Ltd, London, UK
- School of Medicine, Imperial College London, London, UK
| | - Aaron Lin
- Research Division, Mindset Technologies Ltd, London, UK
- University of Birmingham Medical School, Birmingham, UK
| | - Hamzah Selim
- Research Division, Mindset Technologies Ltd, London, UK
| | | | - Mohammad Mahmud
- Research Division, Mindset Technologies Ltd, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
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13
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Shariq S, Cardoso Pinto AM, Budhathoki SS, Miller M, Cro S. Barriers and facilitators to the recruitment of disabled people to clinical trials: a scoping review. Trials 2023; 24:171. [PMID: 36890505 PMCID: PMC9994780 DOI: 10.1186/s13063-023-07142-1] [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: 10/24/2022] [Accepted: 02/07/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Underrepresentation of disabled groups in clinical trials results in an inadequate evidence base for their clinical care, which drives health inequalities. This study aims to review and map the potential barriers and facilitators to the recruitment of disabled people in clinical trials to identify knowledge gaps and areas for further extensive research. The review addresses the question: 'What are the barriers and facilitators to recruitment of disabled people to clinical trials?'. METHODS The Joanna Briggs Institute (JBI) Scoping review guidelines were followed to complete the current scoping review. MEDLINE and EMBASE databases were searched via Ovid. The literature search was guided by a combination of four key concepts from the research question: (1) disabled populations, (2) patient recruitment, (3) barriers and facilitators, and (4) clinical trials. Papers discussing barriers and facilitators of all types were included. Papers that did not have at least one disabled group as their population were excluded. Data on study characteristics and identified barriers and facilitators were extracted. Identified barriers and facilitators were then synthesised according to common themes. RESULTS The review included 56 eligible papers. The evidence on barriers and facilitators was largely sourced from Short Communications from Researcher Perspectives (N = 22) and Primary Quantitative Research (N = 17). Carer perspectives were rarely represented in articles. The most common disability types for the population of interest in the literature were neurological and psychiatric disabilities. A total of five emergent themes were determined across the barriers and facilitators. These were as follows: risk vs benefit assessment, design and management of recruitment protocol, balancing internal and external validity considerations, consent and ethics, and systemic factors. CONCLUSIONS Both barriers and facilitators were often highly specific to disability type and context. Assumptions should be minimised, and study design should prioritise principles of co-design and be informed by a data-driven assessment of needs for the study population. Person-centred approaches to consent that empower disabled people to exercise their right to choose should be adopted in inclusive practice. Implementing these recommendations stands to improve inclusive practices in clinical trial research, serving to produce a well-rounded and comprehensive evidence base.
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Affiliation(s)
- Sameed Shariq
- School of Public Health, Imperial College London, London, UK.
| | | | | | - Marie Miller
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, Imperial College London, London, UK
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Rice AD, Hu C, Spaite DW, Barnhart BJ, Chikani V, Gaither JB, Denninghoff KR, Bradley GH, Howard JT, Keim SM, Bobrow BJ. Correlation between prehospital and in-hospital hypotension and outcomes after traumatic brain injury. Am J Emerg Med 2023; 65:95-103. [PMID: 36599179 DOI: 10.1016/j.ajem.2022.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital]. METHODS Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts. RESULTS Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p < 0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p < 0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)]. CONCLUSION While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (<90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.
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Affiliation(s)
- Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America.
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, United States of America
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America
| | - Bruce J Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ, United States of America
| | - Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America
| | - Gail H Bradley
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ, United States of America
| | - Jeffrey T Howard
- Department of Public Health, University of Texas at San Antonio, United States of America
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, United States of America
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX, United States of America
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The Impact of Preinjury Antiplatelet and Anticoagulant Use on Elderly Patients with Moderate or Severe Traumatic Brain Injury Following Traumatic Acute Subdural Hematoma. World Neurosurg 2022; 166:e521-e527. [PMID: 35843581 DOI: 10.1016/j.wneu.2022.07.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/09/2022] [Accepted: 07/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although it is often assumed that preinjury anticoagulant (AC) or antiplatelet (AP) use is associated with poorer outcomes among those with acute subdural hematoma (aSDH), previous studies have had varied results. This study examines the impact of preinjury AC and AP therapy on aSDH thickness, 30-day mortality, and extended Glasgow Outcome Scale at 6 months in elderly patients (aged ≥65). METHODS A level 1 trauma center registry was interrogated to identify consecutive elderly patients who presented with moderate or severe traumatic brain injury (TBI) and associated traumatic aSDH between the first of January 2013 and the first of January 2018. Relevant demographic, clinical, and radiological data were retrieved from institutional medical records. The 3 primary outcome measures were aSDH thickness on initial computed tomography scan, 30-day mortality, and unfavorable outcome at 6 months (extended Glasgow Outcome Scale). RESULTS One hundred thirty-two elderly patients were admitted with moderate or severe TBI and traumatic aSDH. The mean (±SD) age was 78.39 (±7.87) years, and a majority of patients (59.8%, n = 79) were male. There was a statistically significant difference in mean aSDH thickness, but there were no significant differences in 30-day mortality (P = 0.732) and unfavorable outcome between the AP, AC, combined AP and AC, and no antithrombotic exposure groups (P = 0.342). CONCLUSIONS Further studies with larger sample sizes are necessary to confirm these observations, but our findings do not support the preconceived notion in clinical practice that antithrombotic use is associated with poor outcomes in elderly patients with moderate or severe TBI.
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Keating EM, Sakita F, Mmbaga BT, Nkini G, Amiri I, Tsosie C, Fino N, Watt MH, Staton CA. A cohort of pediatric injury patients from a hospital-based trauma registry in Northern Tanzania. Afr J Emerg Med 2022; 12:208-215. [PMID: 35719184 PMCID: PMC9188958 DOI: 10.1016/j.afjem.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/13/2022] [Accepted: 04/18/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Pediatric injuries in low- and middle-income countries are a leading cause of morbidity and mortality worldwide. Implementing hospital-based trauma registries can reduce the knowledge gap in both hospital care and patient outcomes and lead to quality improvement initiatives. The goal of this study was to create a pediatric trauma registry to provide insight into the epidemiology, outcomes, and factors associated with poor outcomes in injured children. Methods This was a prospective observational study in which a pediatric trauma registry was implemented at a large zonal referral hospital in Northern Tanzania. Data included demographics, hospital-based care, and outcomes including morbidity and mortality. Data were input into REDCap© and analyzed using ANOVA and Chi-squared tests in SAS(Version 9.4)©. Results 365 patients were enrolled in the registry from November 2020 to October 2021. The majority were males (n=240, 65.8%). Most were children 0-5 years (41.7%, n=152), 34.5% (n=126) were 6-11 years, and 23.8% (n=87) were 12-17 years. The leading causes of pediatric injuries were falls (n=137, 37.5%) and road traffic injuries (n=125, 34.5%). The mortality rate was 8.2% (n=30). Of the in-hospital deaths, 43.3% were children with burn injuries who also had a higher odds of mortality than children with other injuries (OR 8.72, p<0.001). The factors associated with in-hospital mortality and morbidity were vital sign abnormalities, burn severity, abnormal Glasgow Coma Score, and ICU admission. Conclusion The mortality rate of injured children in our cohort was high, especially in children with burn injuries. In order to reduce morbidity and mortality, interventions should be prioritized that focus on pediatric injured patients that present with abnormal vital signs, altered mental status, and severe burns. These findings highlight the need for health system capacity building to improve outcomes of pediatric injury patients in Northern Tanzania.
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Affiliation(s)
- Elizabeth M. Keating
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Box 3010, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Box 2240, Moshi, Tanzania
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Box 3010, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Box 2240, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Box 2236, Moshi, Tanzania
| | - Getrude Nkini
- Kilimanjaro Christian Medical Centre, Box 3010, Moshi, Tanzania
| | - Ismail Amiri
- Kilimanjaro Christian Medical Centre, Box 3010, Moshi, Tanzania
| | - Chermiqua Tsosie
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Melissa H. Watt
- Department of Population Health Sciences, Salt Lake City, University of Utah, UT, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Catherine A. Staton
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Surgery, Division of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Medical Center, Durham, NC, USA
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Singh RD, van Dijck JTJM, Maas AIR, Peul WC, van Essen TA. Challenges Encountered in Surgical Traumatic Brain Injury Research: A Need for Methodological Improvement of Future Studies. World Neurosurg 2022; 161:410-417. [PMID: 35505561 DOI: 10.1016/j.wneu.2021.11.092] [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: 10/18/2021] [Accepted: 11/22/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Investigating neurosurgical interventions for traumatic brain injury (TBI) involves complex methodological and practical challenges. In the present report, we have provided an overview of the current state of neurosurgical TBI research and discussed the key challenges and possible solutions. METHODS The content of our report was based on an extensive literature review and personal knowledge and expert opinions of senior neurosurgeon researchers and epidemiologists. RESULTS Current best practice research strategies include randomized controlled trials (RCTs) and comparative effectiveness research. The performance of RCTs has been complicated by the heterogeneity of TBI patient populations with the associated sample size requirements, the traditional eminence-based neurosurgical culture, inadequate research budgets, and the often acutely life-threatening setting of severe TBI. Statistical corrections can mitigate the effects of heterogeneity, and increasing awareness of clinical equipoise and informed consent alternatives can improve trial efficiency. The substantial confounding by indication, which limits the interpretability of observational research, can be circumvented by using an instrumental variable analysis. Traditional TBI outcome measures remain relevant but do not adequately capture the subtleties of well-being, suggesting a need for multidimensional approaches to outcome assessments. CONCLUSIONS In settings in which traditional RCTs are difficult to conduct and substantial confounding by indication can be present, observational studies using an instrumental variable analysis and "pragmatic" RCTs are promising alternatives. Embedding TBI research into standard clinical practice should be more frequently considered but will require fundamental modifications to the current health care system. Finally, multimodality outcome assessment will be key to improving future surgical and nonsurgical TBI research.
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Affiliation(s)
- Ranjit D Singh
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands.
| | - Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Thomas A van Essen
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
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18
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Tas J, Beqiri E, van Kaam RC, Czosnyka M, Donnelly J, Haeren RH, van der Horst ICC, Hutchinson PJ, van Kuijk SMJ, Liberti AL, Menon DK, Hoedemaekers CWE, Depreitere B, Smielewski P, Meyfroidt G, Ercole A, Aries MJH. Targeting Autoregulation-Guided Cerebral Perfusion Pressure after Traumatic Brain Injury (COGiTATE): A Feasibility Randomized Controlled Clinical Trial. J Neurotrauma 2021; 38:2790-2800. [PMID: 34407385 DOI: 10.1089/neu.2021.0197] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Managing traumatic brain injury (TBI) patients with a cerebral perfusion pressure (CPP) near to the cerebral autoregulation (CA)-guided "optimal" CPP (CPPopt) value is associated with improved outcome and might be useful to individualize care, but has never been prospectively evaluated. This study evaluated the feasibility and safety of CA-guided CPP management in TBI patients requiring intracranial pressure monitoring and therapy (TBIicp patients). The CPPopt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) parallel two-arm feasibility trial took place in four tertiary centers. TBIicp patients were randomized to either the Brain Trauma Foundation (BTF) guideline CPP target range (control group) or to the individualized CA-guided CPP targets (intervention group). CPP targets were guided by six times daily software-based alerts for up to 5 days. The primary feasibility end-point was the percentage of time with CPP concordant (±5 mm Hg) with the set CPP targets. The main secondary safety end-point was an increase in therapeutic intensity level (TIL) between the control and intervention group. Twenty-eight patients were randomized to the control and 32 patients to the intervention group. CPP in the intervention group was in the target range for 46.5% (interquartile range, 41.2-58) of the monitored time, significantly higher than the feasibility target specified in the published protocol (36%; p < 0.001). There were no significant differences between groups for TIL or for other safety end-points. Conclusively, targeting an individual and dynamic CA-guided CPP is feasible and safe in TBIicp patients. This encourages a prospective trial powered for clinical outcomes.
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Affiliation(s)
- Jeanette Tas
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ruud C van Kaam
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Roel H Haeren
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Neurosurgery, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Analisa L Liberti
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Anaesthesia and Intensive Care, San Carlo Borromeo Hospital, Milan, Italy
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | | | - Bart Depreitere
- Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, KU Leuven, Leuven, Belgium
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Marcel J H Aries
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
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19
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Poi CH, Koh MYH, Koh TLY, Wong YL, Mei Ong WY, Gu C, Yow FC, Tan HL. Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project. Am J Hosp Palliat Care 2021; 39:667-677. [PMID: 34525873 DOI: 10.1177/10499091211045616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients. METHODS The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients' care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions. RESULTS Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05). CONCLUSIONS Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.
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Affiliation(s)
- Choo Hwee Poi
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Mervyn Yong Hwang Koh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Tessa Li-Yen Koh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Yu-Lin Wong
- Anaesthesiology, Intensive Care and Pain Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Chunguang Gu
- Nursing Service, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Hui Ling Tan
- Anaesthesiology, Intensive Care and Pain Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
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Boase K, Machamer J, Temkin NR, Dikmen S, Wilson L, Nelson LD, Barber J, Bodien YG, Giacino JT, Markowitz AJ, McCrea MA, Satris G, Stein MB, Taylor SR, Manley GT. Central Curation of Glasgow Outcome Scale-Extended Data: Lessons Learned from TRACK-TBI. J Neurotrauma 2021; 38:2419-2434. [PMID: 33832330 PMCID: PMC8390785 DOI: 10.1089/neu.2020.7528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The Glasgow Outcome Scale (GOS) in its original or extended (GOSE) form is the most widely used assessment of global disability in traumatic brain injury (TBI) research. Several publications have reported concerns about assessor scoring inconsistencies, but without documentation of contributing factors. We reviewed 6801 GOSE assessments collected longitudinally, across 18 sites in the 5-year, observational Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. We recorded error rates (i.e., corrections to a section or an overall rating) based on site assessor documentation and categorized scoring issues, which then informed further training. In cohort 1 (n = 1261; February 2014 to May 2016), 24% of GOSEs had errors identified by central review. In cohort 2 (n = 1130; June 2016 to July 2018), acquired after curation of cohort 1 data, feedback, and further training of site assessors, the error rate was reduced to 10%. GOSE sections associated with the most frequent interpretation and scoring difficulties included whether current functioning represented a change from pre-injury (466 corrected ratings in cohort 1; 62 in cohort 2), defining dependency in the home and community (163 corrections in cohort 1; three in cohort 2) and return to work/school (72 corrections in cohort 1; 35 in cohort 2). These results highlight the importance of central review in improving consistency across sites and over time. Establishing clear scoring criteria, coupled with ongoing guidance and feedback to data collectors, is essential to avoid scoring errors and resultant misclassification, which carry potential to result in "failure" of clinical trials that rely on the GOSE as their primary outcome measure.
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Affiliation(s)
- Kim Boase
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Joan Machamer
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Nancy R. Temkin
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Lindsay Wilson
- Division of Psychology, School of Natural Sciences, University of Stirling, Stirling, United Kingdom
| | - Lindsay D. Nelson
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason Barber
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Yelena G. Bodien
- Spaulding Rehabilitation Hospital Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Joseph T. Giacino
- Spaulding Rehabilitation Hospital Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Michael A. McCrea
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gabriela Satris
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Sabrina R. Taylor
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
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21
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Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, Ponsford J, Seppelt I, Reilly P, Wiegers E, Wolfe R. Patient Outcomes at Twelve Months after Early Decompressive Craniectomy for Diffuse Traumatic Brain Injury in the Randomized DECRA Clinical Trial. J Neurotrauma 2021; 37:810-816. [PMID: 32027212 PMCID: PMC7071071 DOI: 10.1089/neu.2019.6869] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Functional outcomes at 12 months were a secondary outcome of the randomized DECRA trial of early decompressive craniectomy for severe diffuse traumatic brain injury (TBI) and refractory intracranial hypertension. In the DECRA trial, patients were randomly allocated 1:1 to either early decompressive craniectomy or intensive medical therapies (standard care). We conducted planned secondary analyses of the DECRA trial outcomes at 6 and 12 months, including all 155 patients. We measured functional outcome using the Glasgow Outcome Scale-Extended (GOS-E). We used ordered logistic regression, and dichotomized the GOS-E using logistic regression, to assess outcomes in patients overall and in survivors. We adjusted analyses for injury severity using the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. At 12 months, the odds ratio (OR) for worse functional outcomes in the craniectomy group (OR 1.68; 95% confidence interval [CI]: 0.96-2.93; p = 0.07) was no longer significant. Unfavorable functional outcomes after craniectomy were 11% higher (59% compared with 48%), but were not significantly different from standard care (OR 1.58; 95% CI: 0.84-2.99; p = 0.16). Among survivors after craniectomy, there were fewer good (OR 0.33; 95% CI: 0.12-0.91; p = 0.03) and more vegetative (OR 5.12; 95% CI: 1.04-25.2; p = 0.04) outcomes. Similar outcomes in survivors were found at 6 months after injury. Vegetative (OR 5.85; 95% CI: 1.21-28.30; p = 0.03) and severely disabled outcomes (OR 2.49; 95% CI: 1.21-5.11; p = 0.01) were increased. Twelve months after severe diffuse TBI and early refractory intracranial hypertension, decompressive craniectomy did not improve outcomes and increased vegetative survivors.
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Affiliation(s)
- D James Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University, Melbourne, Victoria, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Lynnette Murray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yaseen M Arabi
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Andrew R Davies
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia.,Monash-Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia
| | - Ian Seppelt
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Peter Reilly
- Neurosurgery Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eveline Wiegers
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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22
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Roquilly A, Moyer JD, Huet O, Lasocki S, Cohen B, Dahyot-Fizelier C, Chalard K, Seguin P, Jeantrelle C, Vermeersch V, Gaillard T, Cinotti R, Demeure dit Latte D, Mahe PJ, Vourc’h M, Martin FP, Chopin A, Lerebourg C, Flet L, Chiffoleau A, Feuillet F, Asehnoune K. Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury: The COBI Randomized Clinical Trial. JAMA 2021; 325:2056-2066. [PMID: 34032829 PMCID: PMC8150692 DOI: 10.1001/jama.2021.5561] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Fluid therapy is an important component of care for patients with traumatic brain injury, but whether it modulates clinical outcomes remains unclear. OBJECTIVE To determine whether continuous infusion of hypertonic saline solution improves neurological outcome at 6 months in patients with traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS Multicenter randomized clinical trial conducted in 9 intensive care units in France, including 370 patients with moderate to severe traumatic brain injury who were recruited from October 2017 to August 2019. Follow-up was completed in February 2020. INTERVENTIONS Adult patients with moderate to severe traumatic brain injury were randomly assigned to receive continuous infusion of 20% hypertonic saline solution plus standard care (n = 185) or standard care alone (controls; n = 185). The 20% hypertonic saline solution was administered for 48 hours or longer if patients remained at risk of intracranial hypertension. MAIN OUTCOMES AND MEASURES The primary outcome was Extended Glasgow Outcome Scale (GOS-E) score (range, 1-8, with lower scores indicating worse functional outcome) at 6 months, obtained centrally by blinded assessors and analyzed with ordinal logistic regression adjusted for prespecified prognostic factors (with a common odds ratio [OR] >1.0 favoring intervention). There were 12 secondary outcomes measured at multiple time points, including development of intracranial hypertension and 6-month mortality. RESULTS Among 370 patients who were randomized (median age, 44 [interquartile range, 27-59] years; 77 [20.2%] women), 359 (97%) completed the trial. The adjusted common OR for the GOS-E score at 6 months was 1.02 (95% CI, 0.71-1.47; P = .92). Of the 12 secondary outcomes, 10 were not significantly different. Intracranial hypertension developed in 62 (33.7%) patients in the intervention group and 66 (36.3%) patients in the control group (absolute difference, -2.6% [95% CI, -12.3% to 7.2%]; OR, 0.80 [95% CI, 0.51-1.26]). There was no significant difference in 6-month mortality (29 [15.9%] in the intervention group vs 37 [20.8%] in the control group; absolute difference, -4.9% [95% CI, -12.8% to 3.1%]; hazard ratio, 0.79 [95% CI, 0.48-1.28]). CONCLUSIONS AND RELEVANCE Among patients with moderate to severe traumatic brain injury, treatment with continuous infusion of 20% hypertonic saline compared with standard care did not result in a significantly better neurological status at 6 months. However, confidence intervals for the findings were wide, and the study may have had limited power to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03143751.
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Affiliation(s)
- Antoine Roquilly
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Jean Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France
| | - Olivier Huet
- CHU de Brest, Anesthesia and Intensive Care Unit, Brest, France
| | | | - Benjamin Cohen
- CHU de Tours, Anesthesia and Intensive Care Unit, Tours, France
| | | | - Kevin Chalard
- CHU de Montpellier, Anesthesia and Intensive Care Unit, Montpellier, France
| | - Philippe Seguin
- CHU de Rennes, Anesthesia and Intensive Care Unit, Rennes, France
| | - Caroline Jeantrelle
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France
| | | | - Thomas Gaillard
- CHU d’Angers, Anesthesia and Intensive Care Unit, Angers, France
| | - Raphael Cinotti
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Dominique Demeure dit Latte
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Pierre Joachim Mahe
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Mickael Vourc’h
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Florian Pierre Martin
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Alice Chopin
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Celine Lerebourg
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
| | - Laurent Flet
- CHU de Nantes, Service de pharmacie, Hôtel Dieu, Nantes, France
| | - Anne Chiffoleau
- DRCI, Departement promotion, cellule vigilances, CHU Nantes, Nantes, France
| | - Fanny Feuillet
- DRCI, Plateforme de Méthodologie et de Biostatistique, CHU Nantes, Nantes, France
- Université de Nantes, Université de Tours, INSERM, SPHERE U1246, Nantes, France
| | - Karim Asehnoune
- Université de Nantes, CHU Nantes, Pôle anesthésie réanimations, Service d’Anesthésie Réanimation chirurgicale, Hôtel Dieu, Nantes, France
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23
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Brett BL, Kramer MD, Whyte J, McCrea MA, Stein MB, Giacino JT, Sherer M, Markowitz AJ, Manley GT, Nelson LD. Latent Profile Analysis of Neuropsychiatric Symptoms and Cognitive Function of Adults 2 Weeks After Traumatic Brain Injury: Findings From the TRACK-TBI Study. JAMA Netw Open 2021; 4:e213467. [PMID: 33783518 PMCID: PMC8010589 DOI: 10.1001/jamanetworkopen.2021.3467] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/08/2021] [Indexed: 01/01/2023] Open
Abstract
Importance Heterogeneity across patients with traumatic brain injury (TBI) presents challenges for clinical care and intervention design. Identifying distinct clinical phenotypes of TBI soon after injury may inform patient selection for precision medicine clinical trials. Objective To investigate whether distinct neurobehavioral phenotypes can be identified 2 weeks after TBI and to characterize the degree to which early neurobehavioral phenotypes are associated with 6-month outcomes. Design, Setting, and Participants This prospective cohort study included patients presenting to 18 US level 1 trauma centers within 24 hours of TBI from 2014 to 2019 as part of the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. Data were analyzed from January 28, 2020, to January 11, 2021. Exposures TBI. Main Outcomes and Measures Latent profiles (LPs) were derived from common dimensions of neurobehavioral functioning at 2 weeks after injury, assessed through National Institutes of Health TBI Common Data Elements (ie, Brief Symptom Inventory-18, Patient Health Questionnaire-9 Depression checklist, Posttraumatic Stress Disorder Checklist for DSM-5, PROMIS Pain Intensity scale, Insomnia Severity Index, Rey Auditory Verbal Learning Test, Wechsler Adult Intelligence Scale-Fourth Edition Coding and Symbol Search subtests, Trail Making Test, and NIH Toolbox Cognitive Battery Pattern Comparison Processing Speed, Dimensional Change Card Sort, Flanker Inhibitory Control and Attention, and Picture Sequence Memory subtests). Six-month outcomes were the Satisfaction With Life Scale (SWLS), Quality of Life after Brain Injury-Overall Scale (QOLIBRI-OS), Glasgow Outcome Scale-Extended (GOSE), and Rivermead Post-Concussion Symptoms Questionnaire (RPQ). Results Among 1757 patients with TBI included, 1184 (67.4%) were men, and the mean (SD) age was 39.9 (17.0) years. LP analysis revealed 4 distinct neurobehavioral phenotypes at 2 weeks after injury: emotionally resilient (419 individuals [23.8%]), cognitively impaired (368 individuals [20.9%]), cognitively resilient (620 individuals [35.3%]), and neuropsychiatrically distressed (with cognitive weaknesses; 350 individuals [19.9%]). Adding LP group to models including demographic characteristics, medical history, Glasgow Coma Scale score, and other injury characteristics was associated with significantly improved estimation of association with 6-month outcome (GOSE R2 increase = 0.09-0.19; SWLS R2 increase = 0.12-0.22; QOLIBRI-OS R2 increase = 0.14-0.32; RPQ R2 = 0.13-0.34). Conclusions and Relevance In this cohort study of patients with TBI presenting to US level-1 trauma centers, qualitatively distinct profiles of symptoms and cognitive functioning were identified at 2 weeks after TBI. These distinct phenotypes may help optimize clinical decision-making regarding prognosis, as well as selection and stratification for randomized clinical trials.
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Affiliation(s)
- Benjamin L. Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | | | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego, La Jolla
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
- VA San Diego Healthcare System, San Diego, California
| | - Joseph T. Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Mark Sherer
- TIRR Memorial Hermann, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Amy J. Markowitz
- Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
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24
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Cerebrolysin after moderate to severe traumatic brain injury: prospective meta-analysis of the CAPTAIN trial series. Neurol Sci 2021; 42:4531-4541. [PMID: 33620612 DOI: 10.1007/s10072-020-04974-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION This prospective meta-analysis summarizes results from the CAPTAIN trial series, evaluating the effects of Cerebrolysin for moderate-severe traumatic brain injury, as an add-on to usual care. MATERIALS AND METHODS The study included two phase IIIb/IV prospective, randomized, double-blind, placebo-controlled clinical trials. Eligible patients with a Glasgow Coma Score (GCS) between 6 and 12 received study medication (50 mL of Cerebrolysin or physiological saline solution per day for ten days, followed by two additional treatment cycles with 10 mL per day for 10 days) in addition to usual care. The meta-analysis comprises the primary ensembles of efficacy criteria for 90, 30, and 10 days after TBI with a priori ordered hypotheses based on multivariate, directional tests. RESULTS A total 185 patients underwent meta-analysis (mean admission GCS = 10.3, mean age = 45.3, and mean Baseline Prognostic Risk Score = 2.8). The primary endpoint, a multidimensional ensemble of functional and neuropsychological outcome scales indicated a "small-to-medium" sized effect in favor of Cerebrolysin, statistically significant at Day 30 and at Day 90 (Day 30: MWcombined = 0.60, 95%CI 0.52 to 0.66, p = 0.0156; SMD = 0.31; OR = 1.69; Day 90: MWcombined = 0.60, 95%CI 0.52 to 0.68, p = 0.0146; SMD = 0.34, OR = 1.77). Treatment groups showed comparable safety and tolerability profiles. DISCUSSION The meta-analysis of the CAPTAIN trials confirms the safety and efficacy of Cerebrolysin after moderate-severe TBI, opening a new horizon for neurorecovery in this field. Integration of Cerebrolysin into existing guidelines should be considered after careful review of internationally applicable criteria.
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25
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Gaither JB, Spaite DW, Bobrow BJ, Keim SM, Barnhart BJ, Chikani V, Sherrill D, Denninghoff KR, Mullins T, Adelson PD, Rice AD, Viscusi C, Hu C. Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids). Ann Emerg Med 2021; 77:139-153. [PMID: 33187749 PMCID: PMC7855946 DOI: 10.1016/j.annemergmed.2020.09.435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/28/2020] [Accepted: 09/14/2020] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. METHODS The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. RESULTS There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+). CONCLUSION Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.
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Affiliation(s)
- Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ.
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Bruce J Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - Duane Sherrill
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital and Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix, AZ
| | - Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
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26
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Ceyisakar IE, van Leeuwen N, Dippel DWJ, Steyerberg EW, Lingsma HF. Ordinal outcome analysis improves the detection of between-hospital differences in outcome. BMC Med Res Methodol 2021; 21:4. [PMID: 33407167 PMCID: PMC7788719 DOI: 10.1186/s12874-020-01185-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/02/2020] [Indexed: 11/22/2022] Open
Abstract
Background There is a growing interest in assessment of the quality of hospital care, based on outcome measures. Many quality of care comparisons rely on binary outcomes, for example mortality rates. Due to low numbers, the observed differences in outcome are partly subject to chance. We aimed to quantify the gain in efficiency by ordinal instead of binary outcome analyses for hospital comparisons. We analyzed patients with traumatic brain injury (TBI) and stroke as examples. Methods We sampled patients from two trials. We simulated ordinal and dichotomous outcomes based on the modified Rankin Scale (stroke) and Glasgow Outcome Scale (TBI) in scenarios with and without true differences between hospitals in outcome. The potential efficiency gain of ordinal outcomes, analyzed with ordinal logistic regression, compared to dichotomous outcomes, analyzed with binary logistic regression was expressed as the possible reduction in sample size while keeping the same statistical power to detect outliers. Results In the IMPACT study (9578 patients in 265 hospitals, mean number of patients per hospital = 36), the analysis of the ordinal scale rather than the dichotomized scale (‘unfavorable outcome’), allowed for up to 32% less patients in the analysis without a loss of power. In the PRACTISE trial (1657 patients in 12 hospitals, mean number of patients per hospital = 138), ordinal analysis allowed for 13% less patients. Compared to mortality, ordinal outcome analyses allowed for up to 37 to 63% less patients. Conclusions Ordinal analyses provide the statistical power of substantially larger studies which have been analyzed with dichotomization of endpoints. We advise to exploit ordinal outcome measures for hospital comparisons, in order to increase efficiency in quality of care measurements. Trial registration We do not report the results of a health care intervention. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-020-01185-7.
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Affiliation(s)
- I E Ceyisakar
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - N van Leeuwen
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Stroke Center, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - H F Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
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27
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Relationship between health status and functional outcome during two years after a severe trauma. Injury 2020; 51:2953-2961. [PMID: 33008635 DOI: 10.1016/j.injury.2020.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/03/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND With the improved survival rates after trauma, the population of patients with disabilities increased. The knowledge about functional outcome and the relationship between health status and functional outcome is limited. The aim of the present prospective cohort study was to describe the functional outcome and health status over time, and the relationship between both. METHODS Adult severely injured patients (ISS≥16) were included if hospitalised in Noord-Brabant within 48 h after injury between August 2015 and December 2016. The functional outcome (Glasgow Outcome Scale Extended - GOSE) and health status (EQ-5D) were measured at 1, 3, 6, 12 and 24 months after injury. Logistic and linear mixed models were used to examine functional outcome and health status over time. Measurements were divided into short- (1-3 months), mid- (6-12 months) and long-term (24 months). RESULTS In total 239 severely injured patients were included. Functional outcome and health status improved over time. Prognostic factors during two years were a longer hospital length of stay, female gender and Glasgow Coma Scale. Besides age was a prognostic factor for health status and education level for functional outcome. A higher ASA classification was a long-term prognostic factor for a lower functional outcome and a lower health status. The patients with a good functional recovery showed a significant higher EQ-5D utility score and patients with a poor functional recovery reported significant more problems in the EQ-5 domains. CONCLUSION There is a good relationship between the functional outcome and the health status during two years after a severe injury. It appears reliable to use functional outcome in terms of physical impairments in daily clinic to determine patients at risk for both a lower functional outcome and a lower health status over time.
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28
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Fitzgerald E, Hammond N, Tian DH, Bradford C, Flower O, Harbor K, Johnson P, Lee R, Parkinson J, Tracey A, Delaney A. Functional outcomes at 12 months for patients with traumatic brain injury, intracerebral haemorrhage and subarachnoid haemorrhage treated in an Australian neurocritical care unit: A prospective cohort study. Aust Crit Care 2020; 33:497-503. [PMID: 32739245 DOI: 10.1016/j.aucc.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/17/2020] [Accepted: 03/25/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Acute severe brain injury is associated with significant morbidity and mortality. Patients and their families need accurate information regarding expected outcomes. Few studies have reported the long-term functional outcome of patients with acute severe brain injury treated in an Australian neurocritical care unit. OBJECTIVE The objective of this study was to describe 12-month functional outcomes (using the extended Glasgow Outcome Scale) of patients with acute severe brain injury treated in an Australian neurocritical care unit. METHODS This was a single-centre prospective cohort study. Patients with a diagnosis of traumatic brain injury, subarachnoid haemorrhage or intracranial haemorrhage admitted between 2015 and 2019 were enrolled. RESULTS In total, 915 participants were enrolled during the 51-month study period. Of the cohort, 403 (44%) were admitted after traumatic brain injury, 274 (30%) after subarachnoid haemorrhage and 238 (26%) after intracranial haemorrhage. The median duration of intensive care admission was 5 days (interquartile range: 2-13), 458 (50%) received invasive ventilation, 417 (46%) received vasopressor support and 286 (31%) received an external ventricular drain. At discharge from intensive care, 150 of 915 (16.4%) had died, and the in-hospital mortality was seen in 191 of 915 patients (20.9%). Favourable functional outcome, as defined by an extended Glasgow Outcome Scale score of 5-8, was reported in 358 of available 795 patients (45.0%) at six months and in 311 of 672 available patients (46.3%) at 12 months. Those with intracranial haemorrhage reported the highest rates of unfavourable outcomes with 112 of 166 patients (67.4%) at 12 months. CONCLUSIONS In this selected population, admission to a neurocritical care unit was associated with significant resource use. At 12 months after admission, almost half of those admitted to an Australian neurocritical unit with traumatic brain injury, subarachnoid haemorrhage and intracerebral haemorrhage report a good functional outcome.
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Affiliation(s)
- Emily Fitzgerald
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia.
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - David H Tian
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Celia Bradford
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Oliver Flower
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kelly Harbor
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Phil Johnson
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Richard Lee
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Jonathon Parkinson
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia; Department of Neurosurgery, Royal North Shore Hospital, Sydney, Australia
| | - Ashleigh Tracey
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia; Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Ren J, Wu X, Huang J, Cao X, Yuan Q, Zhang D, Du Z, Zhong P, Hu J. Intracranial Pressure Monitoring-Aided Management Associated with Favorable Outcomes in Patients with Hypertension-Related Spontaneous Intracerebral Hemorrhage. Transl Stroke Res 2020; 11:1253-1263. [PMID: 32144586 DOI: 10.1007/s12975-020-00798-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 02/23/2020] [Accepted: 02/26/2020] [Indexed: 01/06/2023]
Abstract
To investigate the effect of intracranial pressure (ICP) monitoring on the functional outcome of patients with hypertension-related spontaneous intracerebral hemorrhage (ICH). We included 196 patients with Glasgow Coma Scale (GCS) scores of 3-12 in this observational study, of which 103 underwent ICP monitors. Binary and ordinal regression analyses were used to estimate the effect of ICP monitoring on the functional outcome. The rate of adverse events, blood pressure control, and length of hospitalization were compared between the two groups. ICP monitoring had a significant impact on the clinical outcome of patients by shifting the Extended Glasgow Outcome Scale (GOS-E) scores in a favorable direction (p = 0.027) and reducing mortality at discharge (p = 0.004) and 6 months later (p = 0.02). The rate of favorable outcome at 6 months was higher in the ICP-monitored group (p = 0.03). However, subgroup analysis showed that no relationship between ICP monitoring and clinical outcome was found for patients with GCS scores of 3-8. For patients with GCS scores of 9-12, the distribution of GOS-E scores at 6 months shifted in a favorable direction in the ICP-monitored group (p = 0.001). The rate of favorable outcome at 6 months was higher in the ICP-monitored group (p = 0.01). The mortality at discharge and 6 months later was also lower in the ICP-monitored group. Thus, our study supports the value of ICP monitoring in hypertension-related ICH patients with GCS scores of 3-12, especially those with GCS scores of 9-12.
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Affiliation(s)
- Junwei Ren
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiongwei Huang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xudong Cao
- Department of Neurosurgery, Tibet Autonomous Region People's Hospital, Lhasa, Tibet, China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Dalong Zhang
- Department of Emergency, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhuoying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Ping Zhong
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
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Hurwitz M, Lucas S, Bell KR, Temkin N, Dikmen S, Hoffman J. Use of Amitriptyline in the Treatment of Headache After Traumatic Brain Injury: Lessons Learned From a Clinical Trial. Headache 2020; 60:713-723. [PMID: 31943197 DOI: 10.1111/head.13748] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The primary outcome of this study was to assess the efficacy and safety of preventive treatment with amitriptyline on headache frequency and severity after mild traumatic brain injury (mTBI). BACKGROUND Despite the fact that headache is the most common and persistent physical symptom after TBI, there has been little research on the longitudinal course or pharmacologic treatment of this disorder. Of those who have headache after injury, about 60% continue to complain of headache at 3 months post injury, with higher levels of disability than those without headache. There have been no prospective, randomized, controlled trials of a pharmacologic agent for headache after TBI. Additionally, a brain-injured population may be more susceptible to side effects of medication. DESIGN This is a single-center phase II trial of amitriptyline to prevent persistent headache after an mTBI. Medication dose was gradually increased from 10 to 50 mg daily. RESULTS Fifty participants were enrolled and 33 who completed the 90-day assessment were included in the final analysis. In order to detect a possible cognitive impact of the study drug, 24 participants were randomly assigned to start amitriptyline immediately after study enrollment and 26 were assigned to start 30 days after enrollment. Forty-nine percent (18/37) of those assigned to take medication took none throughout the study period, with less compliance in younger participants with mean ages of 32.7 in those who did not take any medication, 33.4 who were less than 80% compliant, and 42.3 who were compliant (P = .013). Compliance in keeping a daily headache diary was low, with 29/50 participants (58%) meeting daily entry completion, and only 10 participants maintaining 100% diary completion. No differences were found between those who started medication immediately vs at day 30 in headache frequency or severity. CONCLUSIONS While headache is the most common symptom following mTBI, current evidence does not support a specific treatment. No differences were noted in headache frequency compared to our prior study. However, the current sample had significantly lower headache severity (15% vs 36% with pain rating of 6 or above, P = .015) compared to our prior study. Our current study was not able to determine whether there is any benefit for the use of amitriptyline as a headache preventive because of difficulty with study recruitment and compliance. The challenges with recruitment and retention in the mTBI population were instructive, and future research in this area will need to identify strategies to improve recruitment, diary compliance, and medication adherence in this population.
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Affiliation(s)
- Max Hurwitz
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Sylvia Lucas
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.,Department of Neurological Surgery, University of Washington, Seattle, WA, USA.,Department of Neurology, University of Washington, Seattle, WA, USA
| | - Kathleen R Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, TX, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.,Department of Neurological Surgery, University of Washington, Seattle, WA, USA.,Department of Psychiatry and Behavioral Medicine, University of Washington, Seattle, WA, USA
| | - Jeanne Hoffman
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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Efficacy and safety of cerebrolysin in neurorecovery after moderate-severe traumatic brain injury: results from the CAPTAIN II trial. Neurol Sci 2020; 41:1171-1181. [PMID: 31897941 DOI: 10.1007/s10072-019-04181-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The objective of this trial was to evaluate the efficacy and safety of Cerebrolysin in treating patients after moderate to severe traumatic brain injury (TBI) as an adjunct to standard care protocols. The trial was designed to investigate the clinical effects of Cerebrolysin in the acute (neuroprotective) stage and during early and long-term recovery as part of a neurorestorative strategy. MATERIALS AND METHODS The study was a phase IIIb/IV single-center, prospective, randomized, double-blind, placebo-controlled clinical trial. Eligible patients with a Glasgow Coma Score (GCS) between 7 and 12 received study medication (50 ml of Cerebrolysin or physiological saline solution per day for 10 days, followed by two additional treatment cycles with 10 ml per day for 10 days) in addition to standard care. We tested ensembles of efficacy criteria for 90, 30, and 10 days after TBI with a priori ordered hypotheses using a multivariate, directional test, to reflect the global status of patients after TBI. RESULTS The study enrolled 142 patients, of which 139 underwent formal analysis (mean age = 47.4, mean admission GCS = 10.4, and mean Baseline Prognostic Risk Score = 2.6). The primary endpoint, a multidimensional ensemble of 13 outcome scales, indicated a "small-to-medium"-sized effect in favor of Cerebrolysin, statistically significant at day 90 (MWcombined = 0.59, 95% CI 0.52 to 0.66, P = 0.0119). Safety and tolerability observations were comparable between treatment groups. CONCLUSION Our trial confirms previous beneficial effects of the multimodal, biological agent Cerebrolysin for overall outcome after moderate to severe TBI, as measured by a multidimensional approach. Study findings must be appraised and aggregated in conjunction with existing literature, as to improve the overall level of insight regarding therapeutic options for TBI patients. The widely used pharmacologic intervention may benefit from a large-scale observational study to map its use and to establish comparative effectiveness in real-world clinical settings.
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Nelson LD, Brett BL, Magnus BE, Balsis S, McCrea MA, Manley GT, Temkin N, Dikmen S. Functional Status Examination Yields Higher Measurement Precision of Functional Limitations after Traumatic Injury than the Glasgow Outcome Scale-Extended: A Preliminary Study. J Neurotrauma 2019; 37:675-679. [PMID: 31663425 DOI: 10.1089/neu.2019.6719] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The Glasgow Outcome Scale-Extended (GOSE) is one of the most widely used measures of functional limitations after traumatic brain injury (TBI), and is the primary outcome measure used in clinical trials of acute TBI treatment. However, the GOSE appears insensitive to the full spectrum of TBI-related functional limitations, which may limit its potential to capture treatment effects or correlate with other variables that impact outcome. The Functional Status Examination (FSE) was designed to improve on the assessment of injury-related functional limitations using a standardized assessment and wider possible score range. The aim of this pilot study was to employ item response theory (IRT) to test the hypothesis that the FSE yields more precise estimation of functional outcome than the GOSE. Traumatically injured patients (n = 100, 77 TBI, 23 orthopedic injuries) were interviewed at 3 months post-injury using both the GOSE and FSE structured interviews. IRT was used to quantify and compare the tests' information functions, which reflect the degree to which each instrument precisely measures functional limitations across the severity spectrum. Findings were consistent with predictions: the FSE yielded stronger measurement of functional limitations (i.e., higher test information) across a wider range of severity than the GOSE, whether scoring the GOSE from all interview items or using the traditional GOSE overall score. Although the FSE appears to be a promising alternative measure to the GOSE, further research is needed to cross-validate these findings in a larger sample and understand how to best deploy it in clinical and translational research.
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Affiliation(s)
- Lindsay D Nelson
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Benjamin L Brett
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brooke E Magnus
- Department of Psychology, Marquette University, Milwaukee, Wisconsin
| | - Steve Balsis
- Department of Psychology, University of Massachusetts Lowell, Boston, Massachusetts
| | - Michael A McCrea
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, and the Brain and Spinal Injury Center, University of California San Francisco, San Francisco, California
| | - Nancy Temkin
- Department of Neurological Surgery and Biostatistics and University of Washington, Seattle, Washington
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
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Poon W, Matula C, Vos PE, Muresanu DF, von Steinbüchel N, von Wild K, Hömberg V, Wang E, Lee TMC, Strilciuc S, Vester JC. Safety and efficacy of Cerebrolysin in acute brain injury and neurorecovery: CAPTAIN I-a randomized, placebo-controlled, double-blind, Asian-Pacific trial. Neurol Sci 2019; 41:281-293. [PMID: 31494820 DOI: 10.1007/s10072-019-04053-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of Cerebrolysin as an add-on therapy to local standard treatment protocol in patients after moderate-to-severe traumatic brain injury. METHODS The patients received the study medication in addition to standard care (50 mL of Cerebrolysin or physiological saline solution daily for 10 days, followed by two additional treatment cycles with 10 mL daily for 10 days) in a prospective, randomized, double-blind, placebo-controlled, parallel-group, multi-centre phase IIIb/IV trial. The primary endpoint was a multidimensional ensemble of 14 outcome scales pooled to be analyzed by means of the multivariate, correlation-sensitive Wei-Lachin procedure. RESULTS In 46 enrolled TBI patients (Cerebrolysin 22, placebo 24), three single outcomes showed stand-alone statistically significant superiority of Cerebrolysin [Stroop Word/Dots Interference (p = 0.0415, Mann-Whitney(MW) = 0.6816, 95% CI 0.51-0.86); Color Trails Tests 1 and 2 (p = 0.0223/0.0170, MW = 0.72/0.73, 95% CI 0.53-0.90/0.54-0.91), both effect sizes lying above the benchmark for "large" superiority (MW > 0.71)]. While for the primary multivariate ensemble, statistical significance was just missed in the intention-to-treat population (pWei-Lachin < 0.1, MWcombined = 0.63, 95% CI 0.48-0.77, derived standardized mean difference (SMD) 0.45, 95% CI -0.07 to 1.04, derived OR 2.1, 95% CI 0.89-5.95), the per-protocol analysis showed a statistical significant superiority of Cerebrolysin (pWei-Lachin = 0.0240, MWcombined = 0.69, 95% CI 0.53 to 0.85, derived SMD 0.69, 95% CI 0.09 to 1.47, derived OR 3.2, 95% CI 1.16 to 12.8), with effect sizes of six single outcomes lying above the benchmark for "large" superiority. Safety aspects were comparable to placebo. CONCLUSION Our trial suggests beneficial effects of Cerebrolysin on outcome after TBI. Results should be confirmed by a larger RCT with a comparable multidimensional approach.
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Affiliation(s)
- W Poon
- Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - C Matula
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - P E Vos
- Department of Neurology, Slingeland Hospital, Doetinchem, The Netherlands
| | - D F Muresanu
- Department of Clinical Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania. .,RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364, Cluj-Napoca, Romania.
| | - N von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Centre Göttingen, Göttingen, Germany
| | - K von Wild
- Medical Faculty, Westphalia Wilhelm's University, Münster, Germany
| | - V Hömberg
- Department of Neurology, SRH Gesundheitszentrum Bad Wimpfen GmbH, Bad Wimpfen, Germany
| | - E Wang
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - T M C Lee
- State Key Laboratory of Brain and Cognitive Sciences and Laboratory of Neuropsychology, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - S Strilciuc
- Department of Clinical Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364, Cluj-Napoca, Romania
| | - J C Vester
- Department of Biometry and Clinical Research, idv Data Analysis and Study Planning, Krailling, Germany
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Spaite DW, Bobrow BJ, Keim SM, Barnhart B, Chikani V, Gaither JB, Sherrill D, Denninghoff KR, Mullins T, Adelson PD, Rice AD, Viscusi C, Hu C. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg 2019; 154:e191152. [PMID: 31066879 PMCID: PMC6506902 DOI: 10.1001/jamasurg.2019.1152] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/03/2019] [Indexed: 12/27/2022]
Abstract
Importance Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival. Objective To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures Primary: survival to hospital discharge; secondary: survival to hospital admission. Results Of the included patients, the median age was 45 years, 14 666 (67.1%) were men, 7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21 852 met inclusion criteria for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P = .40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P < .001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P < .001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P = .02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P < .001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P = .02). Conclusions and Relevance Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines. Trial Registration ClinicalTrials.gov identifier: NCT01339702.
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Affiliation(s)
- Daniel W. Spaite
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Bentley J. Bobrow
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Samuel M. Keim
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Joshua B. Gaither
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Duane Sherrill
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
| | - Kurt R. Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - P. David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital, Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix
| | - Amber D. Rice
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
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Dyhrfort P, Shen Q, Clausen F, Thulin M, Enblad P, Kamali-Moghaddam M, Lewén A, Hillered L. Monitoring of Protein Biomarkers of Inflammation in Human Traumatic Brain Injury Using Microdialysis and Proximity Extension Assay Technology in Neurointensive Care. J Neurotrauma 2019; 36:2872-2885. [PMID: 31017044 PMCID: PMC6761596 DOI: 10.1089/neu.2018.6320] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Traumatic brain injury (TBI) is followed by secondary injury mechanisms strongly involving neuroinflammation. To monitor the complex inflammatory cascade in human TBI, we used cerebral microdialysis (MD) and multiplex proximity extension assay (PEA) technology and simultaneously measured levels of 92 protein biomarkers of inflammation in MD samples every three hours for five days in 10 patients with severe TBI under neurointensive care. One μL MD samples were incubated with paired oligonucleotide-conjugated antibodies binding to each protein, allowing quantification by real-time quantitative polymerase chain reaction. Sixty-nine proteins were suitable for statistical analysis. We found five different patterns with either early (<48 h; e.g., CCL20, IL6, LIF, CCL3), mid (48–96 h; e.g., CCL19, CXCL5, CXCL10, MMP1), late (>96 h; e.g., CD40, MCP2, MCP3), biphasic peaks (e.g., CXCL1, CXCL5, IL8) or stable (e.g., CCL4, DNER, VEGFA)/low trends. High protein levels were observed for e.g., CXCL1, CXCL10, MCP1, MCP2, IL8, while e.g., CCL28 and MCP4 were detected at low levels. Several proteins (CCL8, -19, -20, -23, CXCL1, -5, -6, -9, -11, CST5, DNER, Flt3L, and SIRT2) have not been studied previously in human TBI. Cross-correlation analysis revealed that LIF and CXCL5 may play a central role in the inflammatory cascade. This study provides a unique data set with individual temporal trends for potential inflammatory biomarkers in patients with TBI. We conclude that the combination of MD and PEA is a powerful tool to map the complex inflammatory cascade in the injured human brain. The technique offers new possibilities of protein profiling of complex secondary injury pathways.
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Affiliation(s)
- Philip Dyhrfort
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Qiujin Shen
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Fredrik Clausen
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Måns Thulin
- Department of Statistics Uppsala University, Uppsala, Sweden.,School of Mathematics and Maxwell Institute for Mathematical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Masood Kamali-Moghaddam
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Lars Hillered
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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36
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Yamal JM, Hannay HJ, Gopinath S, Aisiku IP, Benoit JS, Robertson CS. Glasgow Outcome Scale Measures and Impact on Analysis and Results of a Randomized Clinical Trial of Severe Traumatic Brain Injury. J Neurotrauma 2019; 36:2484-2492. [PMID: 30973053 DOI: 10.1089/neu.2018.5939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The original unstructured Glasgow Outcome Scale (uGOS) and the newer structured interviews GOS and the Extended GOS (GOS-E) have been used widely as outcomes in severe traumatic brain injury (TBI) trials. We compared outcome categories (ranging from dead [D] to good recovery [GR]) for each measure in a randomized trial of transfusion threshold and the implications of measure choice and analysis methods for the results of the trial. We planned to explore patient symptomology possibly driving any discrepancies between the patient's uGOS and GOS scores. Category correspondence between uGOS and GOS scores occurred in 160 (88.4%) of the 181 analyzed cases. The GOS-E and GOS instruments incorporated more behavioral/cognitive/social and other components, leading to a worse outcome in some cases than for the uGOS. Choice of outcome measure and analysis led to incongruous conclusions. Dichotomizing uGOS into favorable outcome (GR and moderate disability [MD] categories) versus unfavorable (severe disability [SD], vegetative state [VS], and D categories), we observed a significant effect of transfusion threshold (odds ratio [OR] = 0.51, p = 0.03; adjusted OR = 0.40, p = 0.02). For the same dichotomization of GOS and GOS-E, the effect was not statistically significant but the ORs were similar (ORs between 0.57 and 0.68, p > 0.15 for all). An effect was not detected using ordinal logistic regression or sliding dichotomy method for all three measures. Differences in categorizations of subjects between moderate and severe disability among the scales impacted conclusions of the trial. In future studies, particular attention should be given to implementing GOS measures and describing the methodology for how outcomes were ascertained.
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Affiliation(s)
- Jose-Miguel Yamal
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, The University of Texas School of Public Health, Houston, Texas
| | - H Julia Hannay
- Department of Psychology, University of Houston, Houston, Texas.,Texas Institute for Measurement Evaluation and Statistics (TIMES), University of Houston, Houston, Texas
| | - Shankar Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Imoigele P Aisiku
- Harvard Medical School/Brigham and Women's Hospital, Boston, Massachusetts
| | - Julia S Benoit
- Texas Institute for Measurement Evaluation and Statistics (TIMES), University of Houston, Houston, Texas.,Department of Basic Vision Sciences, University of Houston, Houston, Texas
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van Leeuwen N, Walgaard C, van Doorn PA, Jacobs BC, Steyerberg EW, Lingsma HF. Efficient design and analysis of randomized controlled trials in rare neurological diseases: An example in Guillain-Barré syndrome. PLoS One 2019; 14:e0211404. [PMID: 30785890 PMCID: PMC6382155 DOI: 10.1371/journal.pone.0211404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/14/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) pose specific challenges in rare and heterogeneous neurological diseases due to the small numbers of patients and heterogeneity in disease course. Two analytical approaches have been proposed to optimally handle these issues in RCTs: covariate adjustment and ordinal analysis. We investigated the potential gain in efficiency of these approaches in rare and heterogeneous neurological diseases, using Guillain-Barré syndrome (GBS) as an example. METHODS We analyzed two published GBS trials with primary outcome 'at least one grade improvement' on the GBS disability scale. We estimated the treatment effect using logistic regression models with and without adjustment for prognostic factors. The difference between the unadjusted and adjusted estimates was disentangled in imbalance (random differences in baseline covariates between treatment arms) and stratification (change of the estimate due to covariate adjustment). Second, we applied proportional odds regression, which exploits the ordinal nature of the GBS disability score. The standard error of the estimated treatment effect indicated the statistical efficiency. RESULTS Both trials were slightly imbalanced with respect to baseline characteristics, which was corrected in the adjusted analysis. Covariate adjustment increased the estimated treatment effect in the two trials by 8% and 18% respectively. Proportional odds analysis resulted in lower standard errors indicating more statistical power. CONCLUSION Covariate adjustment and proportional odds analysis most efficiently use the available data and ensure balance between the treatment arms to obtain reliable and valid treatment effect estimates. These approaches merit application in future trials in rare and heterogeneous neurological diseases like GBS.
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Affiliation(s)
- Nikki van Leeuwen
- Centre for Medical Decision Making, Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Christa Walgaard
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pieter A. van Doorn
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bart C. Jacobs
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ewout W. Steyerberg
- Centre for Medical Decision Making, Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hester F. Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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DeWitt DS, Hawkins BE, Dixon CE, Kochanek PM, Armstead W, Bass CR, Bramlett HM, Buki A, Dietrich WD, Ferguson AR, Hall ED, Hayes RL, Hinds SR, LaPlaca MC, Long JB, Meaney DF, Mondello S, Noble-Haeusslein LJ, Poloyac SM, Prough DS, Robertson CS, Saatman KE, Shultz SR, Shear DA, Smith DH, Valadka AB, VandeVord P, Zhang L. Pre-Clinical Testing of Therapies for Traumatic Brain Injury. J Neurotrauma 2018; 35:2737-2754. [PMID: 29756522 PMCID: PMC8349722 DOI: 10.1089/neu.2018.5778] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Despite the large number of promising neuroprotective agents identified in experimental traumatic brain injury (TBI) studies, none has yet shown meaningful improvements in long-term outcome in clinical trials. To develop recommendations and guidelines for pre-clinical testing of pharmacological or biological therapies for TBI, the Moody Project for Translational Traumatic Brain Injury Research hosted a symposium attended by investigators with extensive experience in pre-clinical TBI testing. The symposium participants discussed issues related to pre-clinical TBI testing including experimental models, therapy and outcome selection, study design, data analysis, and dissemination. Consensus recommendations included the creation of a manual of standard operating procedures with sufficiently detailed descriptions of modeling and outcome measurement procedures to permit replication. The importance of the selection of clinically relevant outcome variables, especially related to behavior testing, was noted. Considering the heterogeneous nature of human TBI, evidence of therapeutic efficacy in multiple, diverse (e.g., diffuse vs. focused) rodent models and a species with a gyrencephalic brain prior to clinical testing was encouraged. Basing drug doses, times, and routes of administration on pharmacokinetic and pharmacodynamic data in the test species was recommended. Symposium participants agreed that the publication of negative results would reduce costly and unnecessary duplication of unsuccessful experiments. Although some of the recommendations are more relevant to multi-center, multi-investigator collaborations, most are applicable to pre-clinical therapy testing in general. The goal of these consensus guidelines is to increase the likelihood that therapies that improve outcomes in pre-clinical studies will also improve outcomes in TBI patients.
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Affiliation(s)
- Douglas S. DeWitt
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | - Bridget E. Hawkins
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | - C. Edward Dixon
- Department of Neurological Surgery, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William Armstead
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cameron R. Bass
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
| | - Helen M. Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miami, Florida
| | - Andras Buki
- Department of Neurosurgery, Medical University of Pécs, Pécs, Hungary
| | - W. Dalton Dietrich
- The Miami Project to Cure Paralysis, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Adam R. Ferguson
- Weill Institute for Neurosciences, Brain and Spinal Injury Center (BASIC), Department of Neurological Surgery, University of California, San Francisco (UCSF), San Francisco, California
| | - Edward D. Hall
- Spinal Cord and Brain Injury Research Center (SCoBIRC), University of Kentucky Medical Center, Lexington, Kentucky
| | - Ronald L. Hayes
- University of Florida, Virginia Commonwealth University, Banyan Biomarkers, Inc., Alachua, Florida
| | - Sidney R. Hinds
- United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | | | - Joseph B. Long
- Blast-Induced Neurotrauma Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - David F. Meaney
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stefania Mondello
- Department of Neurosciences, University of Messina, Via Consolare Valeria, Messina, Italy
| | - Linda J. Noble-Haeusslein
- Departments of Neurology and Psychology, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Samuel M. Poloyac
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Donald S. Prough
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | | | - Kathryn E. Saatman
- Spinal Cord and Brain Injury Research Center (SCoBIRC), University of Kentucky, Lexington, Kentucky
| | - Sandy R. Shultz
- Department of Medicine, Melbourne Brain Center, The University of Melbourne, Parkville, Victoria, Australia
| | - Deborah A. Shear
- Brain Trauma Neuroprotection Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Douglas H. Smith
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alex B. Valadka
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Pamela VandeVord
- Department of Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
| | - Liying Zhang
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan
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Bathke AC, Friedrich S, Pauly M, Konietschke F, Staffen W, Strobl N, Höller Y. Testing Mean Differences among Groups: Multivariate and Repeated Measures Analysis with Minimal Assumptions. MULTIVARIATE BEHAVIORAL RESEARCH 2018; 53:348-359. [PMID: 29565679 PMCID: PMC5935051 DOI: 10.1080/00273171.2018.1446320] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
To date, there is a lack of satisfactory inferential techniques for the analysis of multivariate data in factorial designs, when only minimal assumptions on the data can be made. Presently available methods are limited to very particular study designs or assume either multivariate normality or equal covariance matrices across groups, or they do not allow for an assessment of the interaction effects across within-subjects and between-subjects variables. We propose and methodologically validate a parametric bootstrap approach that does not suffer from any of the above limitations, and thus provides a rather general and comprehensive methodological route to inference for multivariate and repeated measures data. As an example application, we consider data from two different Alzheimer's disease (AD) examination modalities that may be used for precise and early diagnosis, namely, single-photon emission computed tomography (SPECT) and electroencephalogram (EEG). These data violate the assumptions of classical multivariate methods, and indeed classical methods would not have yielded the same conclusions with regards to some of the factors involved.
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Affiliation(s)
- Arne C. Bathke
- Department of Mathematics, University of Salzburg; Department of Statistics, University of Kentucky
| | | | | | | | - Wolfgang Staffen
- Department of Neurology, Christian Doppler Medical Centre and Centre for Cognitive Neuroscience, Paracelsus Medical University
| | - Nicolas Strobl
- Department of Neurology, Christian Doppler Medical Centre and Centre for Cognitive Neuroscience, Paracelsus Medical University
| | - Yvonne Höller
- Department of Neurology, Christian Doppler Medical Centre and Centre for Cognitive Neuroscience, Paracelsus Medical University
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Gorji N, Zador Z, Poon S. A Configurational Analysis of Risk Patterns for Predicting the Outcome After Traumatic Brain Injury. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2018; 2017:780-789. [PMID: 29854144 PMCID: PMC5977564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Exploring relationships between admission variables and outcome using regression models has been the focus of Traumatic Brain Injury (TBI) research. Although practical and well established, these approaches do not evaluate interactions between predictors. We therefore applied a set-theoretic logical analysis to the Corticosteroid Randomization after Significant Head Injury (CRASH) trial database. Complete data analysis of 6945 patients demonstrated 9 different configurations of admission variables were sufficient for favorable outcome in 87.5% of all cases and explained 57% of favorable outcomes (moderate disability or good outcome). We also evaluated the contrasting configurations for unfavorable versus favorable outcome. Results are largely in line with findings of previous studies however the influence of age fell behind GCS components, which is unexpected. Specifying a combination of admission parameters that are likely to translate into a given clinical outcome is appealing from a clinician's perspective therefore our results have considerable translational value.
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Affiliation(s)
- Niku Gorji
- School of Information Technologies, The University of Sydney, NSW, Australia
| | - Zsolt Zador
- Department of Neurosurgery, Salford Royal Foundation Trust, Salford, Greater Manchester, United Kingdom
- Institute of Cardiovascular Sciences, Centre for Vascular and Stroke Research, University of Manchester, Manchester, United Kingdom
| | - Simon Poon
- School of Information Technologies, The University of Sydney, NSW, Australia
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Meisner A, Parikh CR, Kerr KF. Using ordinal outcomes to construct and select biomarker combinations for single-level prediction. Diagn Progn Res 2018; 2:8. [PMID: 31093558 PMCID: PMC6460803 DOI: 10.1186/s41512-018-0028-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/16/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Biomarker studies may involve an ordinal outcome, such as no, mild, or severe disease. There is often interest in predicting one particular level of the outcome due to its clinical significance. METHODS A simple approach to constructing biomarker combinations in this context involves dichotomizing the outcome and using a binary logistic regression model. We assessed whether more sophisticated methods offer advantages over this simple approach. It is often necessary to select among several candidate biomarker combinations. One strategy involves selecting a combination based on its ability to predict the outcome level of interest. We propose an algorithm that leverages the ordinal outcome to inform combination selection. We apply this algorithm to data from a study of acute kidney injury after cardiac surgery, where kidney injury may be absent, mild, or severe. RESULTS Using more sophisticated modeling approaches to construct combinations provided gains over the simple binary logistic regression approach in specific settings. In the examples considered, the proposed algorithm for combination selection tended to reduce the impact of bias due to selection and to provide combinations with improved performance. CONCLUSIONS Methods that utilize the ordinal nature of the outcome in the construction and/or selection of biomarker combinations have the potential to yield better combinations.
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Affiliation(s)
- Allison Meisner
- 0000 0001 2171 9311grid.21107.35Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Chirag R. Parikh
- 0000000419368710grid.47100.32Program of Applied Translational Research, Department of Medicine, Yale School of Medicine, New Haven, CT USA
- Department of Internal Medicine, Veterans Affairs Medical Center, West Haven, CT USA
| | - Kathleen F. Kerr
- 0000000122986657grid.34477.33Department of Biostatistics, University of Washington, Seattle, WA USA
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IMPACT Score for Traumatic Brain Injury: Validation of the Prognostic Tool in a Spanish Cohort. J Head Trauma Rehabil 2018; 33:46-52. [DOI: 10.1097/htr.0000000000000292] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Asehnoune K, Lasocki S, Seguin P, Geeraerts T, Perrigault PF, Dahyot-Fizelier C, Paugam Burtz C, Cook F, Demeure dit latte D, Cinotti R, Mahe PJ, Fortuit C, Pirracchio R, Feuillet F, Sébille V, Roquilly A. Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury - a multicentre prospective cohort study and systematic review. Crit Care 2017; 21:328. [PMID: 29282104 PMCID: PMC5745762 DOI: 10.1186/s13054-017-1918-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/05/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Intracranial hypertension (ICH) is a major cause of death after traumatic brain injury (TBI). Continuous hyperosmolar therapy (CHT) has been proposed for the treatment of ICH, but its effectiveness is controversial. We compared the mortality and outcomes in patients with TBI with ICH treated or not with CHT. METHODS We included patients with TBI (Glasgow Coma Scale ≤ 12 and trauma-associated lesion on brain computed tomography (CT) scan) from the databases of the prospective multicentre trials Corti-TC, BI-VILI and ATLANREA. CHT consisted of an intravenous infusion of NaCl 20% for 24 hours or more. The primary outcome was the risk of survival at day 90, adjusted for predefined covariates and baseline differences, allowing us to reduce the bias resulting from confounding factors in observational studies. A systematic review was conducted including studies published from 1966 to December 2016. RESULTS Among the 1086 included patients, 545 (51.7%) developed ICH (143 treated and 402 not treated with CHT). In patients with ICH, the relative risk of survival at day 90 with CHT was 1.43 (95% CI, 0.99-2.06, p = 0.05). The adjusted hazard ratio for survival was 1.74 (95% CI, 1.36-2.23, p < 0.001) in propensity-score-adjusted analysis. At day 90, favourable outcomes (Glasgow Outcome Scale 4-5) occurred in 45.2% of treated patients with ICH and in 35.8% of patients with ICH not treated with CHT (p = 0.06). A review of the literature including 1304 patients from eight studies suggests that CHT is associated with a reduction of in-ICU mortality (intervention, 112/474 deaths (23.6%) vs. control, 244/781 deaths (31.2%); OR 1.42 (95% CI, 1.04-1.95), p = 0.03, I 2 = 15%). CONCLUSIONS CHT for the treatment of posttraumatic ICH was associated with improved adjusted 90-day survival. This result was strengthened by a review of the literature.
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Affiliation(s)
- Karim Asehnoune
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
- CHU de Nantes, Service d’Anesthésie Réanimation, 1 place Alexis Ricordeau, 44093 Nantes, Cedex 1, France
| | - Sigismond Lasocki
- Department of Anaesthesiology and Critical Care Department, University Hospital of Angers, Angers, France
| | - Philippe Seguin
- Intensive Care Unit, Anaesthesia and Critical Care Department, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Thomas Geeraerts
- Anaesthesia and Critical Care Department, University Hospital of Toulouse, Toulouse, France
| | - Pierre François Perrigault
- Intensive Care Unit, Anaesthesia and Critical Care Department, Gui Chauliac University Hospital of Montpellier, Montpellier, France
| | - Claire Dahyot-Fizelier
- Neuro-Intensive Care Unit, Anaesthesia and Critical Care Department, Poitiers, University Hospital of Poitiers, Poitiers, France
| | - Catherine Paugam Burtz
- Intensive Care Unit, Anaesthesia and Critical Care Department, Beaujon, University Hospital of Beaujon (AP-HP), Beaujon, France
| | - Fabrice Cook
- Intensive Care Unit, Anaesthesia and Critical Care Department, Henri Mondor, University Hospital of Créteil (AP-HP), Créteil, France
| | | | - Raphael Cinotti
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
| | - Pierre Joachim Mahe
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
| | - Camille Fortuit
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
| | - Romain Pirracchio
- Department of Anesthesia and Critical care Medicine, Hôpital Européen Georges Pompidou, Paris 5 Descartes, Sorbonne Paris Cité, Paris, France
- NSERM UMR-S1153, Team ECSTRA, Hôpital Saint Louis, Paris, France
| | - Fanny Feuillet
- UMR 1246 SPHERE “methodS in Patients-centered outcomes and HEalth ResEarch”, Nantes University, Nantes, France
| | - Véronique Sébille
- UMR 1246 SPHERE “methodS in Patients-centered outcomes and HEalth ResEarch”, Nantes University, Nantes, France
- Plateforme de Biométrie, Département Promotion de la Recherche Clinique, University Hospital of Nantes, Nantes, France
| | - Antoine Roquilly
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
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Abstract
Vulnerable groups are often excluded from clinical research on the basis of scientific, ethical and practical reasons. Although intended to protect vulnerable people and maintain study integrity, exclusion of vulnerable groups from research through use of standard exclusion criteria may not always be necessary and may result in findings that are not generalisable. Achieving a balance between the competing needs to protect vulnerable people and to make progress in our understanding of disorders and their management through research requires a reconsideration of exclusion criteria and consent processes to ensure vulnerable people are appropriately represented in clinical research. Reasons for development of broad exclusion criteria include both concrete barriers and intangible discouraging factors. This paper examines this situation and its consequences, perceived and real barriers to inclusion of vulnerable people in research, and suggests methods for overcoming these barriers and applying thoughtful exclusion criteria.
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Synnot A, Chau M, Pitt V, O'Connor D, Gruen RL, Wasiak J, Clavisi O, Pattuwage L, Phillips K. Interventions for managing skeletal muscle spasticity following traumatic brain injury. Cochrane Database Syst Rev 2017; 11:CD008929. [PMID: 29165784 PMCID: PMC6486165 DOI: 10.1002/14651858.cd008929.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI. OBJECTIVES To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI. SEARCH METHODS In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data. MAIN RESULTS We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes. AUTHORS' CONCLUSIONS The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.
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Affiliation(s)
- Anneliese Synnot
- Monash UniversityCochrane Australia, School of Public Health and Preventive MedicineL4 551 St Kilda RdMelbourneVictoriaAustralia3004
- National Trauma Research Institute, Alfred Hospital, Monash UniversityLevel 4, 89 Commercial RoadMelbourneVictoriaAustralia3004
| | - Marisa Chau
- National Trauma Research Institute, Alfred Hospital, Monash UniversityLevel 4, 89 Commercial RoadMelbourneVictoriaAustralia3004
| | - Veronica Pitt
- Australian & New Zealand Intensive Care Research Centre (ANZIC‐RC), Monash UniversityLevel 6, The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Denise O'Connor
- Monash UniversitySchool of Public Health and Preventive MedicineThe Alfred Centre99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Russell L Gruen
- Nanyang Technological UniversityLee Kong Chian School of Medicine11 Mandalay RoadSingaporeSingapore308232
| | - Jason Wasiak
- University of MelbourneMelbourne School of Health SciencesGrattan Street, ParkvilleMelbourneVictoriaAustralia
| | - Ornella Clavisi
- MOVE muscle, bone & joint health263‐265 Kooyong Rd ElsternwickMelbourneVICAustralia3185
| | - Loyal Pattuwage
- Centre for Evidence and ImplementationEast MelbourneVICAustralia3175
| | - Kate Phillips
- Monash UniversitySchool of Public Health & Preventive MedicineThe Alfred Centre99 Commercial RoadMelbourneVictoriaAustralia3004
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Roquilly A, Lasocki S, Moyer JD, Huet O, Perrigault PF, Dahyot-fizelier C, Seguin P, Sharshar T, Geeraerts T, Remerand F, Feuillet F, Asehnoune K. COBI (COntinuous hyperosmolar therapy for traumatic Brain-Injured patients) trial protocol: a multicentre randomised open-label trial with blinded adjudication of primary outcome. BMJ Open 2017; 7:e018035. [PMID: 28947465 PMCID: PMC5623466 DOI: 10.1136/bmjopen-2017-018035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/19/2017] [Accepted: 09/04/2017] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a major cause of death and severe prolonged disability. Intracranial hypertension (ICH) is a critical risk factor of bad outcomes after TBI. Continuous infusion of hyperosmolar therapy has been proposed for the prevention and the treatment of ICH. Whether an early administration of continuous hyperosmolar therapy improves long-term outcomes of patients with TBI is uncertain. The aim of the COBI study (number clinicaltrial.gov 03143751, pre-results stage) is to assess the efficiency and the safety of continuous hyperosmolar therapy in patients with TBI. METHODS AND ANALYSIS The COBI (COntinuous hyperosmolar therapy in traumatic Brain-Injured patients) trial is a multicentre, randomised, controlled, open-label, two-arms study with blinded adjudication of primary outcome. Three hundred and seventy patients hospitalised in intensive care unit with a TBI (Glasgow Coma Scale ≤12 and abnormal brain CT scan) are randomised in the first 24 hours following trauma to standard care or continuous hyperosmolar therapy (20% NaCl) plus standard care. Continuous hyperosmolar therapy is maintained for at least 48 hours in the treatment group and continued for as long as is necessary to prevent ICH. The primary outcome is the score on the Extended Glasgow Outcome Scale at 6 months. The treatment effect is estimated with ordinal logistic regression adjusted for prespecified prognostic factors and expressed as a common OR. ETHICS AND DISSEMINATION The COBI trial protocol has been approved by the ethics committee of Paris Ile de France VIII and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. The COBI trial is the first randomised controlled trial powered to investigate whether continuous hyperosmolar therapy in patients with TBI improve long-term recovery. TRIAL REGISTRATION NUMBER Trial registration number is NCT03143751.
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Affiliation(s)
- Antoine Roquilly
- Anaesthesia Intensive Care Unit, Centre Hospitalier Universitaire, Nantes, France
| | - Sigismond Lasocki
- Anaesthesia Intensive Care Unit, Centre Hospitalier Universitaire, Angers, France
| | - Jean Denis Moyer
- Anaesthesia Intensive Care Unit, Centre Hospitalier Universitaire de Beaujon (AP/HP), Beaujon, France
| | - Olivier Huet
- Intensive Care Unit, Anaesthesia, Centre Hospitalier Universitaire, Brest, France
| | | | | | - Philippe Seguin
- Anaesthesia and Intensive Care Unit, Centre Hospitalier Universitaire, Rennes, France
| | - Tarek Sharshar
- Anaesthesia and Intensive Care Unit, Hôpital Saint Anne (AP/HP), Paris, France
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, TONIC (Toulouse NeuroImaging Center), University Toulouse 3-Paul Sabatier, Inserm, France
| | - Francis Remerand
- Service anesthésie Réanimation 2, Centre Hospitalier Régional Universitaire de Tours, Université F Rabelais, Tours, France
| | - Fanny Feuillet
- Département Promotion, Centre Hospitalier Universitaire de Nantes, Plateforme de Méthodologie et de Biostatistique, Direction de la Recherche, Nantes, France
- Université de Nantes, Université de Tours, INSERM, SPHERE U1246, Nantes, France
| | - Karim Asehnoune
- Anaesthesia Intensive Care Unit, Centre Hospitalier Universitaire, Nantes, France
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DelSignore LA, Tasker RC. Treatment options for severe traumatic brain injuries in children: current therapies, challenges, and future prospects. Expert Rev Neurother 2017; 17:1145-1155. [PMID: 28918666 DOI: 10.1080/14737175.2017.1380520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Severe traumatic brain injury (TBI) afflicts many children and adults worldwide, resulting in high rates of morbidity and mortality. Recent therapeutic advances have focused on both surgical and medical treatment options, but none have been proven to reduce overall morbidity and mortality in this population. Areas covered: Several emerging therapies are addressed that focus on treating related secondary injuries and other clinical sequelae post-TBI during the acute injury phase (defined by authors as up to four weeks post-injury). Information and data were obtained from a PubMed search of recent literature and through reputable websites (e.g. Centers for Disease Control, ClinicalTrials.gov). Peer-reviewed original articles, review articles, and clinical guidelines were included. Expert commentary: The ongoing challenges related to conducting rigorous clinical trials in TBI have led to largely inconclusive findings regarding emerging beneficial therapies.
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Affiliation(s)
- Lisa A DelSignore
- a Department of Pediatrics, Division of Critical Care Medicine , Tufts Floating Hospital for Children, Tufts Medical School , Boston , MA , USA
| | - Robert C Tasker
- b Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Critical Care Medicine , Boston Children's Hospital, Harvard Medical School , Boston , MA , USA.,c Department of Neurology , Boston Children's Hospital, Harvard Medical School , Boston , MA , USA
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Peterson RL, Vock DM, Powers JH, Emery S, Cruz EF, Hunsberger S, Jain MK, Pett S, Neaton JD. Analysis of an ordinal endpoint for use in evaluating treatments for severe influenza requiring hospitalization. Clin Trials 2017; 14:264-276. [PMID: 28397569 PMCID: PMC5528156 DOI: 10.1177/1740774517697919] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background/Aims A single best endpoint for evaluating treatments of severe influenza requiring hospitalization has not been identified. A novel six-category ordinal endpoint of patient status is being used in a randomized controlled trial (FLU-Intravenous Immunoglobulin - FLU-IVIG) of intravenous immunoglobulin. We systematically examine four factors regarding the use of this ordinal endpoint that may affect power from fitting a proportional odds model: (1) deviations from the proportional odds assumption which result in the same overall treatment effect as specified in the FLU-IVIG protocol and which result in a diminished overall treatment effect, (2) deviations from the distribution of the placebo group assumed in the FLU-IVIG design, (3) the effect of patient misclassification among the six categories, and (4) the number of categories of the ordinal endpoint. We also consider interactions between the treatment effect (i.e. factor 1) and each other factor. Methods We conducted a Monte Carlo simulation study to assess the effect of each factor. To study factor 1, we developed an algorithm for deriving distributions of the ordinal endpoint in the two treatment groups that deviated from proportional odds while maintaining the same overall treatment effect. For factor 2, we considered placebo group distributions which were more or less skewed than the one specified in the FLU-IVIG protocol by adding or subtracting a constant from the cumulative log odds. To assess factor 3, we added misclassification between adjacent pairs of categories that depend on subjective patient/clinician assessments. For factor 4, we collapsed some categories into single categories. Results Deviations from proportional odds reduced power at most from 80% to 77% given the same overall treatment effect as specified in the FLU-IVIG protocol. Misclassification and collapsing categories can reduce power by over 40 and 10 percentage points, respectively, when they affect categories with many patients and a discernible treatment effect. But collapsing categories that contain no treatment effect can raise power by over 20 percentage points. Differences in the distribution of the placebo group can raise power by over 20 percentage points or reduce power by over 40 percentage points depending on how patients are shifted to portions of the ordinal endpoint with a large treatment effect. Conclusion Provided that the overall treatment effect is maintained, deviations from proportional odds marginally reduce power. However, deviations from proportional odds can modify the effect of misclassification, the number of categories, and the distribution of the placebo group on power. In general, adjacent pairs of categories with many patients should be kept separate to help ensure that power is maintained at the pre-specified level.
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Affiliation(s)
- Ross L Peterson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - John H Powers
- School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | - Sean Emery
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Eduardo Fernandez Cruz
- Departamento de Microbiología I, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Departamento de Inmunología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Sally Hunsberger
- Biostatistics Research Branch (BRB), National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Mamta K Jain
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sarah Pett
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
- CRG, Research Department of Infection and Population Health and The MRC Clinical Trials Unit (MRC CTU) at UCL, University College London, London, UK
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Braun M, Vaibhav K, Saad NM, Fatima S, Vender JR, Baban B, Hoda MN, Dhandapani KM. White matter damage after traumatic brain injury: A role for damage associated molecular patterns. Biochim Biophys Acta Mol Basis Dis 2017; 1863:2614-2626. [PMID: 28533056 DOI: 10.1016/j.bbadis.2017.05.020] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/09/2017] [Accepted: 05/16/2017] [Indexed: 12/12/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of mortality and long-term morbidity worldwide. Despite decades of pre-clinical investigation, therapeutic strategies focused on acute neuroprotection failed to improve TBI outcomes. This lack of translational success has necessitated a reassessment of the optimal targets for intervention, including a heightened focus on secondary injury mechanisms. Chronic immune activation correlates with progressive neurodegeneration for decades after TBI; however, significant challenges remain in functionally and mechanistically defining immune activation after TBI. In this review, we explore the burgeoning evidence implicating the acute release of damage associated molecular patterns (DAMPs), such as adenosine 5'-triphosphate (ATP), high mobility group box protein 1 (HMGB1), S100 proteins, and hyaluronic acid in the initiation of progressive neurological injury, including white matter loss after TBI. The role that pattern recognition receptors, including toll-like receptor and purinergic receptors, play in progressive neurological injury after TBI is detailed. Finally, we provide support for the notion that resident and infiltrating macrophages are critical cellular targets linking acute DAMP release with adaptive immune responses and chronic injury after TBI. The therapeutic potential of targeting DAMPs and barriers to clinical translational, in the context of TBI patient management, are discussed.
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Affiliation(s)
- Molly Braun
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Kumar Vaibhav
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States; Department of Medical Laboratory, Imaging & Radiologic Sciences, College of Allied Health Science, Augusta University, Augusta, GA, United States
| | - Nancy M Saad
- Department of Oral Biology, Dental College of Georgia, Augusta University, Augusta, GA, United States
| | - Sumbul Fatima
- Department of Medical Laboratory, Imaging & Radiologic Sciences, College of Allied Health Science, Augusta University, Augusta, GA, United States
| | - John R Vender
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Babak Baban
- Department of Oral Biology, Dental College of Georgia, Augusta University, Augusta, GA, United States; Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Md Nasrul Hoda
- Department of Medical Laboratory, Imaging & Radiologic Sciences, College of Allied Health Science, Augusta University, Augusta, GA, United States; Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Krishnan M Dhandapani
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States.
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50
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Brunner M, Hemsley B, Togher L, Palmer S. Technology and its role in rehabilitation for people with cognitive-communication disability following a traumatic brain injury (TBI). Brain Inj 2017; 31:1028-1043. [DOI: 10.1080/02699052.2017.1292429] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Melissa Brunner
- Speech Pathology, Faculty of Education and Arts, University of Newcastle, Newcastle, Australia
| | - Bronwyn Hemsley
- Speech Pathology, Faculty of Education and Arts, University of Newcastle, Newcastle, Australia
| | - Leanne Togher
- Speech Pathology, Faculty of Health Sciences, University of Sydney, Sydney, Australia
- NHMRC Centre of Research Excellence in Brain Recovery, Sydney, Australia
| | - Stuart Palmer
- Faculty of Science, Engineering & Built Environment, Deakin University, Geelong, Australia
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