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Zimmerman A, Elahi C, Hernandes Rocha TA, Sakita F, Mmbaga BT, Staton CA, Vissoci JRN. Machine learning models to predict traumatic brain injury outcomes in Tanzania: Using delays to emergency care as predictors. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002156. [PMID: 37856444 PMCID: PMC10586611 DOI: 10.1371/journal.pgph.0002156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/13/2023] [Indexed: 10/21/2023]
Abstract
Constraints to emergency department resources may prevent the timely provision of care following a patient's arrival to the hospital. In-hospital delays may adversely affect health outcomes, particularly among trauma patients who require prompt management. Prognostic models can help optimize resource allocation thereby reducing in-hospital delays and improving trauma outcomes. The objective of this study was to investigate the predictive value of delays to emergency care in machine learning based traumatic brain injury (TBI) prognostic models. Our data source was a TBI registry from Kilimanjaro Christian Medical Centre Emergency Department in Moshi, Tanzania. We created twelve unique variables representing delays to emergency care and included them in eight different machine learning based TBI prognostic models that predict in-hospital outcome. Model performance was compared using the area under the receiver operating characteristic curve (AUC). Inclusion of our twelve time to care variables improved predictability in each of our eight prognostic models. Our Bayesian generalized linear model produced the largest AUC, with a value of 89.5 (95% CI: 88.8, 90.3). Time to care variables were among the most important predictors of in-hospital outcome in our best three performing models. In low-resource settings where delays to care are highly prevalent and contribute to high mortality rates, incorporation of care delays into prediction models that support clinical decision making may benefit both emergency medicine physicians and trauma patients by improving prognostication performance.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Cyrus Elahi
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Catherine A. Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
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2
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Kaplan ZR, van der Vlegel M, van Dijck JT, Pisică D, van Leeuwen N, Lingsma HF, Steyerberg EW, Haagsma JA, Majdan M, Polinder S. Intramural Healthcare Consumption and Costs After Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma 2023; 40:2126-2145. [PMID: 37212277 PMCID: PMC10541942 DOI: 10.1089/neu.2022.0429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023] Open
Abstract
Traumatic brain injury (TBI) is a global public health problem and a leading cause of mortality, morbidity, and disability. The increasing incidence combined with the heterogeneity and complexity of TBI will inevitably place a substantial burden on health systems. These findings emphasize the importance of obtaining accurate and timely insights into healthcare consumption and costs on a multi-national scale. This study aimed to describe intramural healthcare consumption and costs across the full spectrum of TBI in Europe. The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) core study is a prospective observational study conducted in 18 countries across Europe and in Israel. The baseline Glasgow Coma Scale (GCS) was used to differentiate patients by brain injury severity in mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS ≤8) TBI. We analyzed seven main cost categories: pre-hospital care, hospital admission, surgical interventions, imaging, laboratory, blood products, and rehabilitation. Costs were estimated based on Dutch reference prices and converted to country-specific unit prices using gross domestic product (GDP)-purchasing power parity (PPP) adjustment. Mixed linear regression was used to identify between-country differences in length of stay (LOS), as a parameter of healthcare consumption. Mixed generalized linear models with gamma distribution and log link function quantified associations of patient characteristics with higher total costs. We included 4349 patients, of whom 2854 (66%) had mild, 371 (9%) had moderate, and 962 (22%) had severe TBI. Hospitalization accounted for the largest part of the intramural consumption and costs (60%). In the total study population, the mean LOS was 5.1 days at the intensive care unit (ICU) and 6.3 days at the ward. For mild, moderate, and severe TBI, mean LOS was, respectively, 1.8, 8.9, and 13.5 days at the ICU and 4.5, 10.1, and 10.3 days at the ward. Other large contributors to the total costs were rehabilitation (19%) and intracranial surgeries (8%). Total costs increased with higher age and greater trauma severity (mild; €3,800 [IQR €1,400-14,000], moderate; €37,800 [IQR €14,900-€74,200], severe; €60,400 [IQR €24,400-€112,700]). The adjusted analysis showed that female patients had lower costs than male patients (odds ratio (OR) 0.80 [CI 0.75-1.85]). Increasing TBI severity was associated with higher costs, OR 1.46 (confidence interval [CI] 1.31-1.63) and OR 1.67 [CI 1.52-1.84] for moderate and severe patients, respectively. A worse pre-morbid overall health state, increasing age and more severe systemic trauma, expressed in the Injury Severity Score (ISS), were also significantly associated with higher costs. Intramural costs of TBI are significant and are profoundly driven by hospitalization. Costs increased with trauma severity and age, and male patients incurred higher costs. Reducing LOS could be targeted with advanced care planning, in order to provide cost-effective care.
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Affiliation(s)
- Z.L. Rana Kaplan
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Jeroen T.J.M. van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & HAGA Teaching Hospital, Leiden/The Hague, The Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nikki van Leeuwen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Juanita A. Haagsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, Trnava, Slovakia
| | - Suzanne Polinder
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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3
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Allen BC, Cummer E, Sarma AK. Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature. J Neurotrauma 2023; 40:602-619. [PMID: 36424896 DOI: 10.1089/neu.2022.0068] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Low- and middle-income countries (LMICs) experience the majority of traumatic brain injuries (TBIs), yet few studies have examined the epidemiology and management strategies of TBI in LMICs. The objective of this narrative review is to discuss the epidemiology of TBI within LMICs, describe the adherence to Brain Trauma Foundation (BTF) guidelines for the management of severe TBI in LMICs, and document TBI management strategies currently used in LMICs. Articles from January 1, 2009 to September 30, 2021 that included patients with TBI greater than 18 years of age in low-, low middle-, and high middle-income countries were queried in PubMed. Search results demonstrated that TBI in LMICs mostly impacts young males involved in road traffic accidents. Within LMICs there are a myriad of approaches to managing TBI with few randomized controlled trials performed within LMICs to evaluate those interventions. More studies are needed in LMICs to establish the effectiveness and appropriateness of BTF guidelines for managing TBI and to help identify methods for managing TBI that are appropriate in low-resource settings. The problem of limited pre- and post-hospital care is a bigger challenge that needs to be considered while addressing management of TBI in LMICs.
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Affiliation(s)
- Beddome C Allen
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Elaina Cummer
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anand K Sarma
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Neurology, Division of Neurocritical Care, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, 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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5
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Zimmerman A, Fox S, Griffin R, Nelp T, Thomaz EBAF, Mvungi M, Mmbaga BT, Sakita F, Gerardo CJ, Vissoci JRN, Staton CA. An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country. PLoS One 2020; 15:e0240528. [PMID: 33045030 PMCID: PMC7549769 DOI: 10.1371/journal.pone.0240528] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022] Open
Abstract
Background Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting. Methods We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes. Results Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery. Conclusions Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Samara Fox
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Randi Griffin
- Department of Evolutionary Anthropology, Duke University, Durham, North Carolina, United States of America
| | - Taylor Nelp
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Mark Mvungi
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Charles J Gerardo
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Catherine A Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
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van Dijck JTJM, Dijkman MD, Ophuis RH, de Ruiter GCW, Peul WC, Polinder S. In-hospital costs after severe traumatic brain injury: A systematic review and quality assessment. PLoS One 2019; 14:e0216743. [PMID: 31071199 PMCID: PMC6508680 DOI: 10.1371/journal.pone.0216743] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/28/2019] [Indexed: 12/19/2022] Open
Abstract
Background The in-hospital treatment of patients with traumatic brain injury (TBI) is considered to be expensive, especially in patients with severe TBI (s-TBI). To improve future treatment decision-making, resource allocation and research initiatives, this study reviewed the in-hospital costs for patients with s-TBI and the quality of study methodology. Methods A systematic search was performed using the following databases: PubMed, MEDLINE, Embase, Web of Science, Cochrane library, CENTRAL, Emcare, PsychINFO, Academic Search Premier and Google Scholar. Articles published before August 2018 reporting in-hospital acute care costs for patients with s-TBI were included. Quality was assessed by using a 19-item checklist based on the CHEERS statement. Results Twenty-five out of 2372 articles were included. In-hospital costs per patient were generally high and ranged from $2,130 to $401,808. Variation between study results was primarily caused by methodological heterogeneity and variable patient and treatment characteristics. The quality assessment showed variable study quality with a mean total score of 71% (range 48% - 96%). Especially items concerning cost data scored poorly (49%) because data source, cost calculation methodology and outcome reporting were regularly unmentioned or inadequately reported. Conclusions Healthcare consumption and in-hospital costs for patients with s-TBI were high and varied widely between studies. Costs were primarily driven by the length of stay and surgical intervention and increased with higher TBI severity. However, drawing firm conclusions on the actual in-hospital costs of patients sustaining s-TBI was complicated due to variation and inadequate quality of the included studies. Future economic evaluations should focus on the long-term cost-effectiveness of treatment strategies and use guideline recommendations and common data elements to improve study quality.
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Affiliation(s)
- Jeroen T. J. M. van Dijck
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
- * E-mail:
| | - Mark D. Dijkman
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Robbin H. Ophuis
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Godard C. W. de Ruiter
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Wilco C. Peul
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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7
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Rubiano AM, Maldonado M, Montenegro J, Restrepo CM, Khan AA, Monteiro R, Faleiro RM, Carreño JN, Amorim R, Paiva W, Muñoz E, Paranhos J, Soto A, Armonda R, Rosenfeld JV. The Evolving Concept of Damage Control in Neurotrauma: Application of Military Protocols in Civilian Settings with Limited Resources. World Neurosurg 2019; 125:e82-e93. [PMID: 30659971 DOI: 10.1016/j.wneu.2019.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/02/2019] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aim of the present review was to describe the evolution of the damage control concept in neurotrauma, including the surgical technique and medical postoperative care, from the lessons learned from civilian and military neurosurgeons who have applied the concept regularly in practice at military hospitals and civilian institutions in areas with limited resources. METHODS The present narrative review was based on the experience of a group of neurosurgeons who participated in the development of the concept from their practice working in military theaters and low-resources settings with an important burden of blunt and penetrating cranial neurotrauma. RESULTS Damage control surgery in neurotrauma has been described as a sequential therapeutic strategy that supports physiological restoration before anatomical repair in patients with critical injuries. The application of the concept has evolved since the early definitions in 1998. Current strategies have been supported by military neurosurgery experience, and the concept has been applied in civilian settings with limited resources. CONCLUSION Damage control in neurotrauma is a therapeutic option for severe traumatic brain injury management in austere environments. To apply the concept while using an appropriate approach, lessons must be learned from experienced neurosurgeons who use this technique regularly.
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Affiliation(s)
- Andres M Rubiano
- Institute of Neurosciences and Neurosurgery, El Bosque University, Bogotá, Colombia; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; INUB MEDITECH Research Group, MEDITECH Foundation, Cali, Colombia; MEDITECH Foundation, Cali Valle, Colombia.
| | - Miguel Maldonado
- School of Medicine, Central Military Hospital, Nueva Granada Military University, Bogota, Colombia
| | - Jorge Montenegro
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; Department of Research, INUB-MEDITECH Research Group, MEDITECH Foundation, Cali, Colombia; Puerto Asís Hospital, Puerto Asís, Colombia
| | - Claudia M Restrepo
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; Department of Research, INUB-MEDITECH Research Group, MEDITECH Foundation, Cali, Colombia; Central Military Hospital, Nueva Granada Military University, Bogota, Colombia
| | - Ahsan Ali Khan
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; Department of Research, INUB-MEDITECH Research Group, MEDITECH Foundation, Cali, Colombia; Department of Neurosurgery, Neurotrauma, and Global Surgery, MEDITECH Foundation, Barrow Neurological Institute, University of Cambridge, Cambridge, United Kingdom
| | - Ruy Monteiro
- Neurological Surgery Service, Hospital Municipal Miguel Couto, Río de Janeiro, Brazil
| | - Rodrigo M Faleiro
- Department of Neurosurgery, Hospital Sao Joao XXIII, Belo Horizonte, Minas Gerais, Brazil
| | - José N Carreño
- Neurointensive Care Unit, Santa Fe Foundation University Hospital, Bogotá, Colombia; Central Military Hospital, Nueva Granada Military University, Bogotá, Colombia
| | - Robson Amorim
- Emergency Neurosurgery Service, Hospital das Clínicas, University of São Paulo Medical School, Manaus, Brazil
| | - Wellingson Paiva
- Neurosurgical Intensive Care Unit, Department of Neurology, University of São Paulo, São Paulo, Brazil
| | - Erick Muñoz
- Neurological Surgery Service, Central Military Hospital, Nueva Granada Military University, Bogotá, Colombia
| | - Jorge Paranhos
- Intensive Care Unite and Neuroemergency Service, Santa Casa de Misericordia Hospital, São João del Rei-Minas Gerais, Brazil
| | - Alvaro Soto
- Neurosurgery Service, San Antonio Hospital, Pitalito, Huila, Colombia
| | - Rocco Armonda
- Department of Neuroendovascular Surgery, Med-Star Washington Hospital Center, Med-Star Georgetown University Hospital, Washington, DC, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia; Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
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8
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Clavijo A, Khan AA, Mendoza J, Montenegro JH, Johnson ED, Adeleye AO, Rubiano AM. The Role of Decompressive Craniectomy in Limited Resource Environments. Front Neurol 2019; 10:112. [PMID: 30863354 PMCID: PMC6399379 DOI: 10.3389/fneur.2019.00112] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/28/2019] [Indexed: 12/12/2022] Open
Abstract
Decompressive craniectomy (DC) is a neurosurgical procedure useful to prevent and manage the impact of high intracranial pressure (ICP) that leads to brain herniation and brain's tissue ischemia. In well-resourced environment this procedure has been proposed as a last tier therapy when ICP is not controlled by medical therapies in the management of different neurosurgical emergencies like traumatic brain injury (TBI), stroke, infectious diseases, hydrocephalus, tumors, etc. The purpose of this narrative review is to discuss the role of DC in areas of low neurosurgical and neurocritical care resources. We performed a literature review with a specific search strategy in web repositories and some local and regional journals from Low and Middle-Income Countries (LMICs). The most common publications include case reports, case series and observational studies describing the benefits of the procedure on different pathologies but with several types of biases due to the absence of robust studies or clinical registries analysis in these kinds of environments.
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Affiliation(s)
- Angélica Clavijo
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Ahsan A Khan
- MEDITECH Foundation, Clinical Research, Cali, Colombia.,Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Juliana Mendoza
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Jorge H Montenegro
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Erica D Johnson
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Amos O Adeleye
- Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom.,College of Medicine, University of Ibadan, and University College Hospital (UCH), Ibadan, Nigeria
| | - Andrés M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Cali, Colombia.,Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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9
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Sundaram PK, Arora P, Ramalingam J, D'Costa J. Is Mechanical Ventilation Mandatory for the Management of Severe Head Injury? Outcome in 53 Medically Managed Severe Head Injury Patients, Without Ventilatory Support: A Prospective Study. Asian J Neurosurg 2018; 13:18-22. [PMID: 29492115 PMCID: PMC5820882 DOI: 10.4103/ajns.ajns_221_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Severe head injury (SHI) is a major cause of mortality and morbidity across the world. The current paradigm of management of SHI involves admission in Intensive Care Unit (ICU), mechanical ventilation (MV), and intracranial pressure (ICP) monitoring. Such resources are expensive and often unavailable in the developing world. Objective: MV or ICP monitoring was unavailable for our patients due to the scarcity of resources. Hence, other alternatives were considered to prevent secondary brain injury due to hypoxia. This study assessed the outcome after SHI when managed with an early tracheostomy (ET). Methods: This prospective observational study over 13 months included all medically managed SHI patients without MV or ICP monitoring. The Glasgow outcome scale (GOS) was assessed at discharge and compared with published historical data reported after treatment in an ICU environment. Results: Our study included 53 unoperated patients with SHI among 1862 patients with traumatic brain injury. Overall mortality was 24.5% (13/53) and compared favorably with reported mortality of 25%–40% reported from centers using intensive management. At discharge, the favorable outcome with a GOS of 4 or 5 was seen in 39.6% (21/53). Conclusion: With ET, the results of management of SHI in our patients were comparable to results reported after MV in an ICU environment. Hence, ET is a cost-effective alternative when resources are scarce. MV should be used if hypoxia persists after tracheostomy. Although MV effectively prevents hypoxia, it has complications. We conclude that although MV was unavailable for our patients, they did not have the complications associated with it.
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Affiliation(s)
| | - Pankaj Arora
- Department of Neurosurgery, Goa Medical College, Bambolim, Goa, India
| | | | - Jorson D'Costa
- Department of Neurosurgery, Goa Medical College, Bambolim, Goa, India
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10
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Gupta S, Klaric K, Sam N, Din V, Juschkewitz T, Iv V, Shrime MG, Park KB. Impact of helmet use on traumatic brain injury from road traffic accidents in Cambodia. TRAFFIC INJURY PREVENTION 2018; 19:66-70. [PMID: 28699848 DOI: 10.1080/15389588.2017.1342821] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 06/12/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Rapid urbanization and motorization without corresponding increases in helmet usage have made traumatic brain injury due to road traffic accidents a major public health crisis in Cambodia. This analysis was conducted to quantify the impact of helmets on severity of injury, neurosurgical indication, and functional outcomes at discharge for motorcycle operators who required hospitalization for a traumatic brain injury following a road traffic accident in Cambodia. METHODS The medical records of 491 motorcycle operators who presented to a major tertiary care center in Cambodia with traumatic brain injury were retrospectively analyzed using multivariate logistic regression. RESULTS The most common injuries at presentation were contusions (47.0%), epidural hematomas (30.1%), subdural hematomas (27.9%), subarachnoid hemorrhages (12.4%), skull fractures (21.4%), and facial fractures (18.5%). Moderate-to-severe loss of consciousness was present in 36.3% of patients. Not wearing a helmet was associated with an odds ratio of 2.20 (95% confidence interval [CI], 1.15-4.22) for presenting with moderate to severe loss of consciousness compared to helmeted patients. Craniotomy or craniectomy was indicated for evacuation of hematoma in 20.0% of cases, and nonhelmeted patients had 3.21-fold higher odds of requiring neurosurgical intervention (95% CI, 1.25-8.27). Furthermore, lack of helmet usage was associated with 2.72-fold higher odds of discharge with functional deficits (95% CI, 1.14-6.49). In total, 30.1% of patients were discharged with severe functional deficits. CONCLUSIONS Helmets demonstrate a protective effect and may be an effective public health intervention to significantly reduce the burden of traumatic brain injury in Cambodia and other developing countries with increasing rates of motorization across the world.
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Affiliation(s)
| | - Katherine Klaric
- b Asia Injury Prevention Foundation , Chamka Mom District , Phnom Penh , Cambodia
| | - Nang Sam
- c Department of Neurosurgery , Preah Kossamak Hospital , Phnom Penh , Cambodia
| | - Vuthy Din
- c Department of Neurosurgery , Preah Kossamak Hospital , Phnom Penh , Cambodia
| | - Tina Juschkewitz
- d Department of Neurology , Asklepios Klinikum Heidberg Nord , Hamburg , Germany
| | - Vycheth Iv
- c Department of Neurosurgery , Preah Kossamak Hospital , Phnom Penh , Cambodia
| | - Mark G Shrime
- e Department of Otolaryngology , Massachusetts Eye and Ear Infirmary , Boston , Massachusetts
- f Program in Global Surgery and Social Change , Harvard Medical School , Boston , Massachusetts
| | - Kee B Park
- c Department of Neurosurgery , Preah Kossamak Hospital , Phnom Penh , Cambodia
- f Program in Global Surgery and Social Change , Harvard Medical School , Boston , Massachusetts
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Ziaeirad M, Alimohammadi N, Irajpour A, Aminmansour B. Association between Outcome of Severe Traumatic Brain Injury and Demographic, Clinical, Injury-related Variables of Patients. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2018; 23:211-216. [PMID: 29861760 PMCID: PMC5954643 DOI: 10.4103/ijnmr.ijnmr_65_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Traumatic brain injury (TBI) is a main health problem among communities. There exists a variety of effective factors on the outcome of patients with TBI. We describe the demographic, clinical, and injury related variables of the patients with severe TBI, and determine the predictors of outcome. Materials and Methods: We did this cross-sectional study on all 267 adult patients with severe TBI admitted to three trauma centers of Isfahan University of Medical Sciences (IUMS) from March 20, 2014 to March 19, 2015. Data were extracted from patients' profiles. We considered the patients' outcome as discharged and died. We analyzed the collected data using descriptive (frequency, mean, and standard deviation) and analytical (independent t-test, Mann–Whitney U-test, Kruskal–Wallis test and logistic regression) statistics in Statistical Package for the Social Sciences (SPSS) 16.0. We considered p < 0.05 as the significance level. Results: The mean (SD) age of patients was 43.86 (18.40) years. The majority of the population was men (87.27%). Road traffic accidents (RTAs) were the most common mechanism of trauma (79.40%). The mean (SD) of Glasgow coma scale (GCS) was 6.03 (3.11). In 50.19% of the patients, the pupillary reflex was absent. One hundred and twenty-four patients (46.44%) died before discharge. We found age, gender, GCS, pupillary reflex, hypernatremia, and increased intracranial pressure (IICP) as the predictors of death in severe TBI. Conclusions: In this study, the mortality rate of patients with severe TBI was high. In addition, some factors were determined as the significant predictors of outcome. The findings can assist in planning to enhance the quality of care and reduce the mortality rate in the patients with severe TBI.
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Affiliation(s)
- Marzieh Ziaeirad
- Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.,Department of Nursing, Nursing and Midwifery Faculty, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran
| | | | - Alireza Irajpour
- Department of Critical Care Nursing, Nursing and Midwifery Care Research Center, Nursing and Midwifery Faculty, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahram Aminmansour
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Landes M, Venugopal R, Berman S, Heffernan S, Maskalyk J, Azazh A. Epidemiology, clinical characteristics and outcomes of head injured patients in an Ethiopian emergency centre. Afr J Emerg Med 2017; 7:130-134. [PMID: 30456124 PMCID: PMC6234141 DOI: 10.1016/j.afjem.2017.04.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 01/20/2017] [Accepted: 04/12/2017] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Head injury is a leading cause of mortality in Africa. We characterise the epidemiology and outcomes of head injury at an Ethiopian emergency centre. METHODS We conducted a prospective cohort study of all head injured patients presenting to the Emergency Centre of Tikur Anbessa Specialised Hospital, Addis Ababa. Data was collected via a standardised form from the patient's chart, radiology reports and operative reports. Patients were followed until discharge, facility transfer, death, or 7 days in hospital. Consent was obtained from the patient or substitute decision maker. RESULTS Among 204 head injured patients enrolled, the majority were <30 years old (51.0%) and male (86.8%). Forty-one percent of injuries occurred from road traffic accidents (RTAs). A significant number of patients had at least one indicator of severe injury on presentation: 51 (25.0%) had a GCS < 9, 53 (26.0%) had multi-system trauma, 95 (46.6%) had ≥1 abnormal vital sign and of the 133 patients with data available, 37 (27.8%) had a Revised Trauma Score (RTS) < 6. Patients injured by RTA were more likely to have indicators of severe injury than other mechanisms, including multi-system trauma (OR 3.2, 95% CI 1.7-6.2, p = 0.00), GCS < 9 (OR 3.7, 95% CI 1.8-7.4, p = 0.00), ≥1 abnormal vital sign (OR 2.5, 95% CI 1.4-4.6, p = 0.00) or an RTS score < 6 (OR 3.6, 95% CI 1.6-8.1, p = 0.00). Overall, 149 (73.0%) patients were discharged from hospital, 34 (16.7%) were transferred to another hospital, and 21 patients died (10.3%). In multivariable analysis, death was significantly associated with age over 60 years (aOR 68.8, 95% CI 2.0-2329.0, p = 0.02), GCS < 9 (aOR 14.8, 95% CI 2.2-99.5, p = 0.01), fixed bilateral pupils (aOR 39.1, 95% CI 4.2-362.8, p < 0.01) and hypoxia (oxygen saturation <90%; aOR 14.2%, 95% CI 2.6-123.9, p = 0.01). CONCLUSION Head injury represents a significant risk for morbidity and mortality in Ethiopia, of which RTA's increase injury severity. Targeted approaches to improving care of the injured may improve outcomes.
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Krebs E, Gerardo CJ, Park LP, Nickenig Vissoci JR, Byiringiro JC, Byiringiro F, Rulisa S, Thielman NM, Staton CA. Mortality-Associated Characteristics of Patients with Traumatic Brain Injury at the University Teaching Hospital of Kigali, Rwanda. World Neurosurg 2017; 102:571-582. [PMID: 28336445 PMCID: PMC5681277 DOI: 10.1016/j.wneu.2017.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of death and disability. Patients with TBI in low and middle-income countries have worse outcomes than patients in high-income countries. We evaluated important clinical indicators associated with mortality for patients with TBI at University Teaching Hospital of Kigali, Kigali, Rwanda. METHODS A prospective consecutive sampling of patients with TBI presenting to University Teaching Hospital of Kigali Accident and Emergency Department was screened for inclusion criteria: reported head trauma, alteration in consciousness, headache, and visible head trauma. Exclusion criteria were age <10 years, >48 hours after injury, and repeat visit. Data were assessed for association with death using logistic regression. Significant variables were included in a multivariate logistic regression model and refined via backward elimination. RESULTS Between October 7, 2013, and April 6, 2014, 684 patients were enrolled; 14 (2%) were excluded because of incomplete data. Of patients, 81% were male with mean age of 31 years (range, 10-89 years; SD 11.8). Most patients (80%) had mild TBI (Glasgow Coma Scale [GCS] score 13-15); 10% had moderate (GCS score 9-12) and 10% had severe (GCS score 3-8) TBI. Multivariate logistic regression determined that GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were significantly associated with death. CONCLUSIONS GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were associated with mortality. These findings inform future research that may guide clinicians in prioritizing care for patients at highest risk of mortality.
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Affiliation(s)
- Elizabeth Krebs
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Charles J Gerardo
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Lawrence P Park
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Division of Global Neurosurgery and Neurosciences, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | - Stephen Rulisa
- University Teaching Hospital of Kigali, Kigali, Rwanda; School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Catherine A Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA; Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Division of Global Neurosurgery and Neurosciences, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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14
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Mild induced hypothermia for patients with severe traumatic brain injury after decompressive craniectomy. J Crit Care 2017; 39:267-270. [DOI: 10.1016/j.jcrc.2016.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/01/2016] [Accepted: 12/10/2016] [Indexed: 11/21/2022]
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15
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Impact of Helmet Use on Severity of Epidural Hematomas in Cambodia. World Neurosurg 2017; 100:267-270. [DOI: 10.1016/j.wneu.2016.12.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 12/21/2016] [Accepted: 12/23/2016] [Indexed: 11/18/2022]
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Reynolds TA, Stewart B, Drewett I, Salerno S, Sawe HR, Toroyan T, Mock C. The Impact of Trauma Care Systems in Low- and Middle-Income Countries. Annu Rev Public Health 2017; 38:507-532. [DOI: 10.1146/annurev-publhealth-032315-021412] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Injury is a leading cause of death globally, and organized trauma care systems have been shown to save lives. However, even though most injuries occur in low- and middle-income countries (LMICs), most trauma care research comes from high-income countries where systems have been implemented with few resource constraints. Little context-relevant guidance exists to help policy makers set priorities in LMICs, where resources are limited and where trauma care may be implemented in distinct ways. We have aimed to review the evidence on the impact of trauma care systems in LMICs through a systematic search of 11 databases. Reports were categorized by intervention and outcome type and summarized. Of 4,284 records retrieved, 71 reports from 32 countries met inclusion criteria. Training, prehospital systems, and overall system organization were the most commonly reported interventions. Quality-improvement, costing, rehabilitation, and legislation and governance were relatively neglected areas. Included reports may inform trauma care system planning in LMICs, and noted gaps may guide research and funding agendas.
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Affiliation(s)
- Teri A. Reynolds
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva CH-1211, Switzerland;, ,
| | - Barclay Stewart
- Department of Surgery, University of Washington, Seattle, Washington 98105
| | - Isobel Drewett
- School of Medicine, Monash University, Melbourne 3800, Australia
| | - Stacy Salerno
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva CH-1211, Switzerland;, ,
| | - Hendry R. Sawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam 11103, Tanzania
| | - Tamitza Toroyan
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva CH-1211, Switzerland;, ,
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, Washington 98105
- Department Global Health, University of Washington, Seattle, Washington 98105
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Peeters S, Blaine C, Vycheth I, Nang S, Vuthy D, Park KB. Epidemiology of Traumatic Brain Injuries at a Major Government Hospital in Cambodia. World Neurosurg 2016; 97:580-589. [PMID: 27773857 DOI: 10.1016/j.wneu.2016.09.127] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/26/2016] [Accepted: 09/29/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a critical public health problem worldwide with a significant socioeconomic burden. Although improved safety regulations in high-income countries have resulted in a decline in traffic-related TBI, the incidence of TBI in low-income countries is on the rise. We illustrate the trends and factors involved in TBI in a large Cambodian governmental hospital in Phnom Penh. In addition, suggestions for improvement of the country's road traffic safety are discussed. METHODS This is a cross-sectional study of all patients who presented with traumatic brain injury to Department of Neurosurgery at Preah Kossamak Hospital in Phnom Penh, Cambodia between November 2013 and March 2016. RESULTS TBIs in Cambodia are on the rise; 34% occur during rush hour, 5-9 pm, and 40% during the weekend. The vast majority (74%) occur as the result of road traffic accidents, of which 81% are motorcycle related. Helmet wear remains low at 13%, and recent alcohol use was reported as 38%. The most common diagnosis is skull fracture. The subdural to epidural hematoma ratio was 1:1.05. Lastly, in both subdural and epidural hematomas the frontal lobe was most commonly involved, with 60% of epidural hematomas associated with a lucid interval. CONCLUSIONS Our study suggests prevention and management of TBIs can have a measurable public health impact in Cambodia. Initiative examples include helmet safety awareness campaigns, stricter penalties, improvement of prehospital care, and more efficient triage. A high proportion of unhelmeted motorcycle accidents correlates with an increase in epidural hematomas.
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Affiliation(s)
- Sophie Peeters
- University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Neurosurgery, Preah Kossamak Hospital, Phnom Penh, Cambodia, USA.
| | - Caitlin Blaine
- Department of Neurosurgery, Preah Kossamak Hospital, Phnom Penh, Cambodia, USA
| | - Iv Vycheth
- Department of Neurosurgery, Preah Kossamak Hospital, Phnom Penh, Cambodia, USA
| | - Sam Nang
- Department of Neurosurgery, Preah Kossamak Hospital, Phnom Penh, Cambodia, USA
| | - Din Vuthy
- Department of Neurosurgery, Preah Kossamak Hospital, Phnom Penh, Cambodia, USA
| | - Kee B Park
- Department of Neurosurgery, Preah Kossamak Hospital, Phnom Penh, Cambodia, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Khalili H, Sadraei N, Niakan A, Ghaffarpasand F, Sadraei A. Role of Intracranial Pressure Monitoring in Management of Patients with Severe Traumatic Brain Injury: Results of a Large Level I Trauma Center in Southern Iran. World Neurosurg 2016; 94:120-125. [DOI: 10.1016/j.wneu.2016.06.122] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 06/27/2016] [Accepted: 06/28/2016] [Indexed: 02/01/2023]
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Abstract
Traumatic brain injury (TBI) is the greatest cause of death and severe disability in young adults; its incidence is increasing in the elderly and in the developing world. Outcome from severe TBI has improved dramatically as a result of advancements in trauma systems and supportive critical care, however we remain without a therapeutic which acts directly to attenuate brain injury. Recognition of secondary injury and its molecular mediators has raised hopes for such targeted treatments. Unfortunately, over 30 late-phase clinical trials investigating promising agents have failed to translate a therapeutic for clinical use. Numerous explanations for this failure have been postulated and are reviewed here. With this historical context we review ongoing research and anticipated future trends which are armed with lessons from past trials, new scientific advances, as well as improved research infrastructure and funding. There is great hope that these new efforts will finally lead to an effective therapeutic for TBI as well as better clinical management strategies.
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Affiliation(s)
- Gregory W J Hawryluk
- Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA
| | - M Ross Bullock
- Neurotrauma, Department of Neurosurgery, Miller School of Medicine, Lois Pope LIFE Center, University of Miami, 1095 NW 14th Terrace, Miami, FL 33136, USA.
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Staton CA, Msilanga D, Kiwango G, Vissoci JR, de Andrade L, Lester R, Hocker M, Gerardo CJ, Mvungi M. A prospective registry evaluating the epidemiology and clinical care of traumatic brain injury patients presenting to a regional referral hospital in Moshi, Tanzania: challenges and the way forward. Int J Inj Contr Saf Promot 2015; 24:69-77. [DOI: 10.1080/17457300.2015.1061562] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Catherine A. Staton
- Duke Division of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | | | | | | | - Rebecca Lester
- London School of Tropical Medicine and Hygiene, London, United Kingdom
| | - Michael Hocker
- Duke Division of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Charles J Gerardo
- Duke Division of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Mark Mvungi
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
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Severity, Causes and Outcomes of Traumatic Brain Injuries Occurring at Different Locations: Implications for Prevention and Public Health. Cent Eur J Public Health 2015; 23:142-8. [DOI: 10.21101/cejph.a4025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 04/17/2015] [Indexed: 11/15/2022]
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Girisgin AS, Kalkan E, Ergin M, Keskin F, Dundar ZD, Kebapcioglu S, Kocak S, Cander B. An experimental study: does the neuroprotective effect increase when hypothermia deepens after traumatic brain injury? IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e21233. [PMID: 26023335 PMCID: PMC4443303 DOI: 10.5812/ircmj.17(4)2015.21233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 10/16/2014] [Accepted: 11/09/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Experimental approaches have been promising with the use of therapeutic hypothermia after Traumatic Brain Injury (TBI) whereas clinical data have not supported its efficacy. OBJECTIVES This study aimed to investigate whether using selective deeper brain cooling correlates with a more neuroprotective effect on Intracranial Pressure (ICP) increments following TBI in rats. MATERIALS AND METHODS Adult male Sprague-Dawley rats (mean weight = 300 g; n = 25) were subjected to brain injury using a modified Marmarou method. Immediately after the onset of TBI, rats were randomized into three groups. Selective brain cooling was applied around the head using ice packages. Intracranial Temperature (ICT) and ICP were continuously measured at 0, 30, 60, 120, and 180 minutes and recorded for all groups. Group 1 (n = 5) was normothermia and was assigned as the control group. Group 2 (n = 10) received moderate hypothermia with a target ICT of between 32°C - 33°C and Group 3 (n = 10) was given a deeper hypothermia with a target ICT of below 32°C. RESULTS All subjects reached the target ICT by the 30th minute of hypothermia induction. The ICT was significantly different in Group 2 compared to Group 1 only at the 120th minute (P = 0.017), while ICP was significantly lower starting from the 30th minute (P = 0.015). The ICT was significantly lower in Group 3 compared to Groups 1 and 2 starting from the 30th minute (P = 0.001 and P = 0.003, respectively). The ICP was significantly lower in Group 3 compared to Group 1 starting from 30th minute (P = 0.001); however, a significant difference in ICP between Group 3 and Group 2 was observed only at the 180th minute (P = 0.047). CONCLUSIONS Results of this study indicate that selective brain cooling is an effective method of decreasing ICP in rats; however, the deeper hypothermia caused a greater decrease in ICP three hours after hypothermia induction.
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Affiliation(s)
- Abdullah Sadik Girisgin
- Department of Emergency Medicine, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Erdal Kalkan
- Department of Neurosurgery, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Mehmet Ergin
- Department of Emergency Medicine, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Fatih Keskin
- Department of Neurosurgery, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Zerrin Defne Dundar
- Department of Emergency Medicine, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Sedat Kebapcioglu
- Department of Emergency Medicine, Medicine Faculty, Mevlana University, Konya, Turkey
| | - Sedat Kocak
- Department of Emergency Medicine, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Basar Cander
- Department of Emergency Medicine, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
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Imen RB, Olfa C, Kamilia C, Meriam B, Hichem K, Adel C, Mabrouk B, Noureddine R. Factors predicting early outcome in patients admitted at emergency department with severe head trauma. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/s2221-6189(14)60087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma 2014; 31:531-40. [PMID: 23962031 PMCID: PMC3949434 DOI: 10.1089/neu.2013.3094] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.
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Affiliation(s)
- Terje Sundstrøm
- 1 Department of Biomedicine, University of Bergen , Bergen, Norway
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Álvarez XA, Figueroa J, Muresanu D. Peptidergic drugs for the treatment of traumatic brain injury. FUTURE NEUROLOGY 2013. [DOI: 10.2217/fnl.12.95] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Traumatic brain injury (TBI) is a devastating medical condition that has an enormous socioeconomic impact because it affects more than 10 million people annually worldwide and is associated with high rates of hospitalization, mortality and disability. Although TBI survival has improved continuously for decades, particularly in developing countries, implementation of an effective drug therapy for TBI represents an unmet clinical need. All confirmatory trials conducted to date with drugs targeting a single TBI pathological pathway failed to show clinical efficacy, probably because TBI pathophysiology involves multiple cellular and molecular mechanisms of secondary brain damage. According to current scientific evidence of the participation of peptide-mediated mechanisms in the processes of brain injury and repair after TBI, peptidergic drugs represent a multimodal therapy alternative to improve acute outcome and long-term recovery in TBI patients. Preliminary randomized-controlled clinical trials and open-label studies conducted to date with the peptidergic drug Cerebrolysin® (Ever Neuro Pharma GmbH, Unterach, Austria) and with the endogenous neuropeptides progesterone and erythropoietin, showed positive clinical results. Cerebrolysin-treated patients had a faster clinical recovery, a shorter hospitalization time and a better long-term outcome. Treatment with progesterone showed advantages over placebo regarding TBI mortality and clinical outcome, whereas erythropoietin only reduced mortality. Further validation of these promising findings in confirmatory randomized-controlled clinical trials is warranted. This article reviews the scientific basis and clinical evidence on the development of multimodal peptidergic drugs as a therapeutic option for the effective treatment of TBI patients.
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Affiliation(s)
| | - Jesús Figueroa
- Rehabilitation Department, Santiago University Hospital, Santiago de Compostela, Spain
| | - Dafin Muresanu
- Department of Neurology, University of Medicine & Pharmacy ‘Iuliu Hatieganu’, Cluj-Napoca, Romania
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