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Wang HE, Hu C, Barnhart BJ, Jansen JO, Moeller K, Spaite DW. Changes in neurologic status after traumatic brain injury in the Resuscitation Outcomes Consortium Hypertonic Saline trial. J Am Coll Emerg Physicians Open 2024; 5:e13107. [PMID: 38486833 PMCID: PMC10938931 DOI: 10.1002/emp2.13107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 03/17/2024] Open
Abstract
Objectives Traumatic brain injury (TBI) is an important public health problem resulting in significant death and disability. Emergency medical services (EMS) personnel often provide initial treatment for TBI, but only limited data describe the long-term course and outcomes of this care. We sought to characterize changes in neurologic status among adults with TBI patients enrolled in the Resuscitation Outcomes Consortium Hypertonic Saline (ROC-HS) trial. Methods We used data from the TBI cohort of the ROC-HS trial. The trial included adults with TBI, with Glasgow Coma Scale (GCS) ≤8, and excluded those with shock (systolic blood pressure [SBP] ≤70 or SBP 71-90 with a heart rate [HR] ≥108). The primary outcome was Glasgow Outcome Scale-Extended (GOS-E; 1 = dead, 8 = no disability) determined at (a) hospital discharge and (b) 6-month follow-up. We assessed changes in GOS-E between hospital discharge and 6-month follow-up using descriptive statistics and Sankey graphs. Results Among 1279 TBI included in the analysis, GOS-E categories at hospital discharge were as follows: favorable (GOS-E 5-8) 220 (17.2%), unfavorable (GOS-E 2-4) 664 (51.9%), dead (GOS-E 1) 321 (25.1%), and missing 74 (5.8%). GOS-E categories at 6-month follow-up were as follows: favorable 459 (35.9%), unfavorable 279 (21.8%), dead 346 (27.1%), and missing 195 (15.2%). Among initial TBI survivors with complete GOS-E, >96% followed one of three neurologic recovery patterns: (1) favorable to favorable (20.0%), (2) unfavorable to favorable (40.3%), and (3) unfavorable to unfavorable (36.0%). Few patients deteriorated from favorable to unfavorable neurologic status, and there were few additional deaths. Conclusions Among TBI receiving initial prehospital care in the ROC-HS trial, changes in 6-month neurologic status followed distinct patterns. Among TBI with unfavorable neurologic status at hospital discharge, almost half improved to favorable neurologic status at 6 months. Among those with favorable neurologic status at discharge, very few worsened or died at 6 months. These findings have important implications for TBI clinical care, research, and trial design.
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Affiliation(s)
- Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Chengcheng Hu
- Department of BiostatisticsMel and Enid Zuckerman College of Public HealthThe University of ArizonaTucsonArizonaUSA
| | - Bruce J. Barnhart
- Department of Emergency MedicineThe University of Arizona College of Medicine‐PhoenixPhoenixArizonaUSA
| | - Jan O. Jansen
- Division of Trauma, Burns and Critical CareDepartment of SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Kim Moeller
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Daniel W. Spaite
- Department of Emergency MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
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Scheenen ME, van der Horn HJ, de Koning ME, van der Naalt J, Spikman JM. Identification of At-Risk Patients That Need More Intensive Treatment Following mTBI: Post-Hoc Insights From the UPFRONT-Study. J Head Trauma Rehabil 2024:00001199-990000000-00128. [PMID: 38453626 DOI: 10.1097/htr.0000000000000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To investigate which factors within an at-risk group make patients less likely to benefit from preventive treatment following mild traumatic brain injury (mTBI). SETTING Inclusion in 3 level I trauma centers in the Netherlands. Data collection through surveys as outpatients. PARTICIPANTS mTBI patients (18-66 years), reporting 3 or more complaints 2 weeks postinjury (at-risk status). Eighty-four patients included and randomized (39 patients cognitive behavioral therapy, 45 patients telephonic counseling). Eighty patients filled out the questionnaires 12 months postinjury. Post hoc analysis investigating 80 patients as 1 at-risk group receiving psychological treatment. DESIGN Post hoc study of a randomized controlled trial (RCT). Binomial logistic regression performed determining which variables 2 weeks postinjury contributed strongly to unsuccessful return to work/study (RTW) and unfavorable outcome at 12 months. MAIN MEASURES RTW and functional outcome as measured with the Glasgow Outcome Scale-Extended (GOSE) at 12 months postinjury. RESULTS Out of 80 patients, 43 (53.8%) showed a favorable functional outcome at 12 months, and 56 (70%) patients had a full RTW. Patients with unfavorable outcome had a higher age and higher reports of anxiety, depression at 2 weeks and 12 months postinjury. Patients with an unsuccessful RTW had a higher age and higher reports of depression, and posttraumatic stress disorder at 2 weeks and 12 months postinjury. A logistic regression model for functional outcome (GOSE) was statistically significant (χ²7 = 40.30, P < .0001). Of 6 predictor variables, 3 were significant: anxiety, depression, and treatment condition. For RTW, logistic regression was also statistically significant (χ²7 = 19.15, P = .008), with only 1 out of 6 predictor variables (ie, age) being significant. CONCLUSION Main findings comprise differences in demographic and psychological measures between patients with favorable and unfavorable outcomes and patients with RTW versus no RTW. Prediction models of outcome and RTW showed several psychological measures at 2 weeks greatly determining patients' likelihood benefitting from the preventive treatment. Results suggest that from the beginning there are some patients for whom a short preventive treatment is not sufficient. Selection and treatment of at-risk patients might be better based on psychological symptoms instead of posttraumatic complaints.
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Affiliation(s)
- Myrthe E Scheenen
- Author Affiliations: Departments of Neuropsychology (Dr Scheenen and Ms Spikman) and Neurology (Dr van der Horn and Ms van der Naalt), University of Groningen, University Medical Center Groningen, Groningen, Netherlands; and Department of Medical Psychology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands (Dr de Koning)
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Wei C, Wang J, Yu J, Tang Q, Liu X, Zhang Y, Cui D, Zhu Y, Mei Y, Wang Y, Wang W. Therapy of traumatic brain injury by modern agents and traditional Chinese medicine. Chin Med 2023; 18:25. [PMID: 36906602 PMCID: PMC10008617 DOI: 10.1186/s13020-023-00731-x] [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: 10/28/2022] [Accepted: 02/27/2023] [Indexed: 03/13/2023] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of disability and death, and the social burden of mortality and morbidity caused by TBI is significant. Under the influence of comprehensive factors, such as social environment, lifestyle, and employment type, the incidence of TBI continues to increase annually. Current pharmacotherapy of TBI mainly focuses on symptomatic supportive treatment, aiming to reduce intracranial pressure, ease pain, alleviate irritability, and fight infection. In this study, we summarized numerous studies covering the use of neuroprotective agents in different animal models and clinical trials after TBI. However, we found that no drug has been approved as specifically effective for the treatment of TBI. Effective therapeutic strategies for TBI remain an urgent need, and attention is turning toward traditional Chinese medicine. We analyzed the reasons why existing high-profile drugs had failed to show clinical benefits and offered our views on the research of traditional herbal medicine for treating TBI.
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Affiliation(s)
- Chunzhu Wei
- Department of Integrated Traditional and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jingbo Wang
- Department of Integrated Traditional and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jintao Yu
- Department of Otolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qing Tang
- Department of Integrated Traditional and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinjie Liu
- Department of Integrated Traditional and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanlong Zhang
- Department of Integrated Traditional and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dandan Cui
- Department of Integrated Traditional and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanqiong Zhu
- Department of Integrated Traditional and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanli Mei
- Department of Integrated Traditional and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanjun Wang
- Department of Otolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Wenzhu Wang
- Department of Integrated Traditional and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Eagle SR, Nwachuku E, Elmer J, Deng H, Okonkwo DO, Pease M. Performance of CRASH and IMPACT Prognostic Models for Traumatic Brain Injury at 12 and 24 Months Post-Injury. Neurotrauma Rep 2023; 4:118-123. [PMID: 36895818 PMCID: PMC9989509 DOI: 10.1089/neur.2022.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
The Corticoid Randomization after Significant Head Injury (CRASH) and International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) prognostic models are the most reported prognostic models for traumatic brain injury (TBI) in the scientific literature. However, these models were developed and validated to predict 6-month unfavorable outcome and mortality, and growing evidence supports continuous improvements in functional outcome after severe TBI up to 2 years post-injury. The purpose of this study was to evaluate CRASH and IMPACT model performance beyond 6 months post-injury to include 12 and 24 months post-injury. Discriminative validity remained consistent over time and comparable to earlier recovery time points (area under the curve = 0.77-0.83). Both models had poor fit for unfavorable outcomes, explaining less than one quarter of the variation in outcomes for severe TBI patients. The CRASH model had significant values for the Hosmer-Lemeshow test at 12 and 24 months, indicating poor model fit past the previous validation point. There is concern in the scientific literature that TBI prognostic models are being used by neurotrauma clinicians to support clinical decision making despite the goal of the models' development being to support research study design. The results of this study indicate that the CRASH and IMPACT models should not be used in routine clinical practice because of poor model fit that worsens over time and the large, unexplained variance in outcomes.
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Affiliation(s)
- Shawn R Eagle
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Enyinna Nwachuku
- Department of Neurological Surgery, Cleveland Clinic, Akron, Ohio, USA
| | - Jonathan Elmer
- Department of Clinical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew Pease
- Department of Neurological Surgery, Memorial Sloan Kettering, New York, New York, USA
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Haddam M, Kubacsi L, Hamada S, Harrois A, James A, Langeron O, Boutonnet M, Holleville M, Garrigue D, Leclercq M, Hanouz JL, Pottecher J, Audibert G, Cardinale M, Vinour H, Zieleskiewicz L, Resseguier N, Leone M. Withholding and withdrawal of life-sustaining therapy in 8569 trauma patients: A multicentre, analytical registry study. Eur J Anaesthesiol 2022; 39:418-426. [PMID: 35166244 DOI: 10.1097/eja.0000000000001671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to determine the prevalence of withholding or withdrawal of life-sustaining therapy (WLST) decisions in trauma ICU patients, using a large registry. We hypothesised that this prevalence is similar to that of the general population admitted to an ICU. As secondary aims, it sought to describe the trauma patients for whom the decision was made for WLST and the factors associated with this decision. DESIGN This observational study assessed data from 14 French centres listed in the TraumaBaseTM registry. All trauma patients hospitalised for more than 48 h were pro-spectively included. RESULTS Data from 8569 trauma patients, obtained from January 2016 to December 2018, were included in this study. A WLST decision was made in 6% of all cases. In the WLST group, 67% of the patients were older men (age: 62 versus 36, P < 0.001); more often they had a prior medical history and higher median severity scores than the patients in the no WLST decision group; SAPS II 58 (46 to 69) versus 21 (13 to 35) and ISS 26 (22 to 24) versus 12 (5 to 22), P < 0.001. Neurological status was strongly associated with WLST decisions. The geographic area of the ICUs affected the rate of the WLST decisions. The ICU mortality was 11% (n = 907) of which 47% (n = 422) were preceded by WLST decisions. Fourteen percent of WLST orders were not associated to the death. CONCLUSION Among 8569 patients, medical history, trauma severity criteria, notably neurological status and geographical areas were associated with WLST. These regional differences deserve to be investigated in future studies.
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Affiliation(s)
- Malik Haddam
- From the Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Department of Anaesthesia and Intensive Care, Hôpital Nord (MH, LK, LZ, ML), Support Unit for Clinical Research and Economic Evaluation, Assistance Publique-Hôpitaux de Marseille - CERESS, Aix Marseille University, Marseille (NR), Kremlin Bicêtre University Hospital, Assistance Publique Hôpitaux de Paris, Department of Anaesthesia and Intensive Care, Le Kremlin-Bicêtre (AH), Department of Anaesthesia and Intensive Care, Assistance Publique Hôpitaux de Paris, Pitié Salpêtrière University Hospital (AJ), Department of Anaesthesia and Intensive Care, Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou University Hospital, Paris (SH, ML), Department of Anaesthesia and Intensive Care, Henri Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Créteil (OL), Department of Anaesthesiology and Critical Care Medicine, DMU Parabol, Beaujon Hospital, APHP. Nord-Université de Paris, 100 Bd du General Leclerc 92110 Clichy (MHo), Department of Anaesthesia and Intensive Care, Clamart Army Training Hospital Percy, Clamart (MB), Toulon Army Training Hospital Sainte-Anne, Toulon (MC), Department of Anaesthesia and Intensive Care, Toulouse University Hospital, Toulouse (HV), Department of Anesthesia and Critical Care Medicine, Université de Lorraine, CHRU Nancy, Nancy (GA), Lille University Hospital, Pôle de l'Urgence, Pôle d'Anesthésie Réanimation, Lille (DG), Department of Anaesthesia and Intensive Care, Reims University Hospital, Reims (MLec), Department of Anaesthesia and Intensive Care, Caen University Hospital, Caen (JLH) and Department of Anaesthesia and Perioperative Medicine, Strasbourg University Hospital, Strasbourg, France (JP)
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Krueger EM, DiGiorgio AM, Jagid J, Cordeiro JG, Farhat H. Current Trends in Mild Traumatic Brain Injury. Cureus 2021; 13:e18434. [PMID: 34737902 PMCID: PMC8559421 DOI: 10.7759/cureus.18434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/02/2021] [Indexed: 12/12/2022] Open
Abstract
In this review, we provide an overview of the current research and treatment of all types of traumatic brain injury (TBI) before illustrating the need for improved care specific to mild TBI patients. Contemporary issues pertaining to acute care of mild TBI including prognostication, neurosurgical intervention, repeat radiographic imaging, reversal of antiplatelet and anticoagulation medications, and cost savings initiatives are reviewed. Lastly, the effect of COVID-19 on TBI is addressed.
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Affiliation(s)
- Evan M Krueger
- Neurological Surgery, Carle Foundation Hospital, Urbana, USA
| | - Anthony M DiGiorgio
- Neurological Surgery, University of California San Francisco, San Francisco, USA
| | - Jonathan Jagid
- Neurological Surgery, University of Miami, Coral Gables, USA
| | | | - Hamad Farhat
- Neurological Surgery, Advocate Aurora Health Care, Downers Grove, USA
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Wijdicks EFM, Hwang DY. Predicting Coma Trajectories: The Impact of Bias and Noise on Shared Decisions. Neurocrit Care 2021; 35:291-296. [PMID: 34426900 PMCID: PMC8382106 DOI: 10.1007/s12028-021-01324-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
Coma trajectories are characterized by quick awakening or protracted awakening. Outcome is bookended by restored functionality or permanent cognitively and physically debilitated states. Given the stakes, prognostication cannot be easily questioned as a judgment call, and a scientific underpinning is elemental. Conventional wisdom in determining coma-outcome trajectories posits that (1) predictive models are better than personal experiences, (2) self-fulfilling prophesy is unchecked and driven by nihilism, with little regard for prior probability outcomes, and (3) recovery is impacted by patients’ prior wishes and preexisting medical conditions—but also by what families are told about the patient’s state and anticipated clinical course. Moreover, a predicted good outcome can be offset by a major subsequent complication, or a predicted poor outcome can be offset by aggressive care. This article examines some of these concepts, including how we decide on aggressiveness of care, how we judge quality of life, and the impact on outcome. Most patients who awaken quickly do well and can resume their pretrauma injury lives. In worse off, slow-to-awaken patients, outcomes are a mixed bag of limited innate resilience, depleted cognitive and physical reserves, and adjusted quality of life. Bias and noise are factors not easily measured in outcome prediction, but their influence on recovery trajectories raises some troubling issues.
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Affiliation(s)
- Eelco F M Wijdicks
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA. .,Yale New Haven Hospital, New Haven, CT, USA. .,Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - David Y Hwang
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA.,Yale New Haven Hospital, New Haven, CT, USA
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Affiliation(s)
- Jennifer A Kim
- Division of Neurocritical Care, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Kevin N Sheth
- Division of Neurocritical Care, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Biegon A. Considering Biological Sex in Traumatic Brain Injury. Front Neurol 2021; 12:576366. [PMID: 33643182 PMCID: PMC7902907 DOI: 10.3389/fneur.2021.576366] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 01/08/2021] [Indexed: 11/23/2022] Open
Abstract
Published epidemiological studies of traumatic brain injury (TBI) of all severities consistently report higher incidence in men. Recent increases in the participation of women in sports and active military service as well as increasing awareness of the very large number of women who sustain but do not report TBI as a result of intimate partner violence (IPV) suggest that the number of women with TBI is significantly larger than previously believed. Women are also grossly under-represented in clinical and natural history studies of TBI, most of which include relatively small numbers of women, ignore the role of sex- and age-related gonadal hormone levels, and report conflicting results. The emerging picture from recent studies powered to detect effects of biological sex as well as age (as a surrogate of hormonal status) suggest young (i.e., premenopausal) women are more likely to die from TBI relative to men of the same age group, but this is reversed in the 6th and 7th decades of life, coinciding with postmenopausal status in women. New data from concussion studies in young male and female athletes extend this finding to mild TBI, since female athletes who sustained mild TBI are significantly more likely to report more symptoms than males. Studies including information on gonadal hormone status at the time of injury are still too scarce and small to draw reliable conclusions, so there is an urgent need to include biological sex and gonadal hormone status in the design and analysis of future studies of TBI.
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Affiliation(s)
- Anat Biegon
- Department of Radiology and Neurology, Stony Brook University School of Medicine, Stony Brook, NY, United States
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